FC Rad Onc(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the
College of Radiation Oncologists of South Africa

19 August 2013

Paper 1 Tumour Pathology and General Oncology (3 hours)

All questions to be answered. Each question to be answered in a separate book (or books if more than one is required
for the one answer)

1 A 55-year-old man with no co-morbidities is diagnosed with a prostate adeno carcinoma, PSA
12.3, 52cc volume, Gleason score 4+3, out of 6 cores involved
1.1 a) What is the role of neo-adjuvant Goserelin? (1)
b) What class of drug is Goserelin? (1)
c) Describe the feedback mechanism effect of Goserelin on prostate carcinoma cells.
(2)
1.2 a) What methods could you use to ensure adequate immobilisation and set-up accuracy?
(2)
b) Describe your CTV and PTV for a 3-D conformal plan. (2)
c) What are the tolerance doses as per Quantec for your organs at risk? (2)
d) i) What is the ratio for the prostate ?
ii) What are the benefits and disadvantages of hypofractionation in prostate
cancer treatment? (3)
e) What is the difference between step-and-shoot and dynamic IMRT techniques? (2)

1.3 a) i) A brachytherapy boost with seed implants is planned for the patient, what
isotopes may be used in this process?
ii) What are their respective half-lives? (3)
b) What specific late effects may occur as a result of prostate brachytherapy? (2)

1.4 The patient recurs 2 years later with bone metastases, a bone scan shows both lytic and
sclerotic bone lesions
a) Describe the physiological mechanisms for both lesions on the bone scan. (2)
b) What are the most common symptoms of hypercalcaemia? (1)
c) What are suggested physiological mechanisms of hypercalcaemia of malignancy?
(2)
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2 a) Define phase I, II, III and IV research studies. What do you base your treatment
decisions on? (4)
b) Define what informed consent entails. (6)
c) Tabulate what primary components have to be assessed in a palliative care patient.
(3)
d) How do you approach pain management in the palliative patient and what methods of
management can be used? (6)
e) Patients with which tumours have a risk of developing tumor lysis syndrome? (2)
PTO/Page 2 Question 2f)
-2-

f) Tabulate the laboratory indicators of tumour lysis syndrome. (2)
g) How would you prevent and treat tumour lysis syndrome? (2)
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3 a) A 22-year-old male is diagnosed with a nasopharyngeal malignancy. Tabulate the
possible histo-pathological options and subtypes. (3)
b) Some of the above mentioned histologies are associated with a possible underlying
viral aetiology. Tabulate the viruses and a method for testing. (3)
c) This is a carcinoma. What staging tests have to be done on this patient? (2)
d) With the initial evaluation of a patient with prostate cancer, tabulate the information
needed for risk stratification by an experienced clinician. (4)
e) What information on a radical prostatectomy histology report can influence the
prognosis of the patient? (2)
f) Tabulate a basic risk stratification used for the treatment of prostate cancer. (4)
g) Tabulate the prognostic factors for malignant melanoma which you will find on the
pathology report. (5)
h) Name a mutation identified/under investigation in malignant melanoma and name
molecular targeted therapies for this mutation. (2)
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4 a) A 33-year-man presents with rectal bleeding and is found on colonoscopy to have a
grade 2 adenocarcinoma of the rectum. His older brother was diagnosed with rectal
carcinoma at the age of 39
i) Describe the path of an invasive rectal tumour from Stage Tis to T3. (4)
ii) What imaging will you perform to assess local disease and name two
radiological criteria of this test that will help you decide on operability of the
tumour. (2)
iii) Name 2 genetic syndromes that may be the cause of this man's colorectal
cancer and the associated genetic defect. (4)
b) i) Name 5 histological subtypes of ductal breast carcinoma. (2.5)
ii) Describe the subclassification of a T4 breast carcinoma. (2)
iii Name the molecular subcategories of breast tumour types. (2)
iv) Name the malignancies that may occur in families who are BRCA2 carriers in
addition to endometrial, breast and ovarian cancer. (2)
v) What is the risk of developing breast cancer in a BRCA2 carrier? (0.5)
c) i) What are the histological subtypes of epithelial ovarian carcinoma? (2)
ii) Name a targeted agent used in the treatment of metastatic cervical carcinoma
and it's mode of action. (2)
iii) Describe your clinical management of ascites in the palliative setting. (2)
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FC Rad Onc(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the
College of Radiation Oncologists of South Africa

20 August 2013

Paper 2 Radiation and Medical Oncology (3 hours)

All questions to be answered. Each question to be answered in a separate book (or books if more than one is required
for the one answer)

1 a) Name 5 risk factors for breast cancer in women among the general population. (5)
b) The DBCG (Danish Breast Cancer Trial Group) reported a 9% increase in absolute
Survival rate, with irradiation for all node positive mastectomy (Modified Radical
Mastectomy) patients. What other prognostic factors would sway you to add chest wall
radiotherapy to Modified Radical Mastectomy patients? (5)
c) What neo-adjuvant chemotherapy regime will you consider as first line for a 39-year-
old HER-2 negative breast cancer patient? (5)
d) Choose one of above mentioned drugs and discuss possible side effects to be
considered. (5)
e) List 4 genetic mutations or a histology report, where you may advise a patient to
consider risk reduction bilateral mastectomy. (4)
f) What other surgery would you recommend or consider with a patient with a strong
family history of breast cancer? (1)
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2 a) Define FIGO Stage 1 Cervix cancer. (5)
b) What is your suggested treatment approach for a Stage IB2 Squamous Carcinoma of
Cervix? (5)
c) What investigations would you do on a patient after histological diagnosis of the Cervix
Cancer? (5)
d) If a patient presents with Cervix intraepithelial neoplasia (CIN) what 5 treatment
options will you consider? (5)
e) What is a "Pelvic Exenteration", and give an example of a case where you may discuss
it with your Gynecologist colleague. (5)
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3 a) A 63-year-old male referred with T2N2 Cancer of the oropharynx has been prescribed
radical chemo radiation
i) Define T2N2 cancer of the oropharynx. (2)
ii) He has 4 weeks of therapy and reports when reviewed that he has difficulty in
swallowing. What factors contribute to this? (3)
b) A 65-year-old man with a 20 pack year history of smoking presents with proptosis of
the left eye. Clinical examination reveals opthalmoplegia of the left eye and CT shows
a tumour of the maxillary antrum. Biopsy confirms a poorly differentiated squamous
cell carcinoma

PTO/Page 2 Question 3i)
-2-

i) What further investigations are indicated? (1)
ii) What would your treatment intent be? What factors would you take into
consideration in deciding on the therapeutic plan? (4)
iii) Would you add radiation? (1)
iv) Describe a suitable radiation technique. (4)
v) Describe the dose prescription. (5)
vi) What normal tissue dose constraints would you use? (5)
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4 a) Discuss the indications, advantages and contra-indications of a PEG (percutaneous
endoscopic gastrostomy) vs. the nasogastric tube as adjuncts to the treatment of
patients receiving radical chemo-radiation for head and neck cancers. (5)
b) Which lymph node groups would you be concerned about in the evaluation of a patient
with cancer of the body of the stomach? Illustrate by means of a diagram which nodes
should be considered in planning radiation treatment. (5)

A 50-year-old female presents with a 5 cm mass in the pancreas. Biopsy shows
Adenocarcinoma and it is deemed to be inoperable due to its proximity of major vessels
including the coeliac axis. Staging investigations show no nodal or distant disease. The
patient planned for chemo radiation
c) How do you stage this patient? (1)
d) Describe the organs at risl< (OAR) and dose constraints you will take into
consideration when planning treatment. (4)
e) What side effects do you expect? (5)
f) What precautions should be taken to support the patient during the radiation? (5)
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FC Rad Onc(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the
College of Radiation Oncologists of South Africa

21 August 2013

Paper 3 Radiation and Medical Oncology (3 hours)

All questions to be answered. Each question to be answered in a separate book (or books if more than one is required
for the one answer)

1 a) Name the 2 most frequently altered cellular pathways in Non-Small cell Lung Cancer
(NSCLC) (2)
b) Which group of patients have a survival benefit for annual screening with low dose
CT scan of the chest? (1)
c) Is there a role for high dose beta-carotene supplementation in prevention of lung
cancer? (1)
d) i) What is a paraneoplastic syndrome? (2)
ii) Name 3 para-neoplastic syndromes associated with NSCLC. (3)
e) Name 2 prognostic biomarkers for lung adenocarcinoma. (2)
f) Describe the Tumour and Node definitions for T2N2MO staging in NSCLC. (3)
g) Which chemotherapy doublet is the standard first-line therapy for advanced or
metastatic adenocarcinoma of lung (EGFR status not known)? Which doses and
scheduling are commonly used? (4)
h) Give radiotherapy doses and fractionation for stage IIIA (N2 positive) NSCLC. (2)
i) When would maintenance therapy be considered in patients with locally advanced or
metastatic disease? (1)
j) Name 3 drugs, which can be used as maintenance therapy in patients with locally
advanced or metastatic disease, with a Non-squamous histology? (3)
k) The EML4-ALK fusion oncogene predicts response to which biological drug? (1)
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2 a) A patient presents with a right sided testicular seminoma. He has been staged as
having pT2N3 Ml b disease
i) Briefly describe what each component of his TNM classification means. (3)
ii) Based on the above TNM category, what would his stage grouping be? (1)
iii) Briefly describe his management plan. (2)
iv) Which investigations would you use to assess response at the end of
treatment? (2)
v) If a 4 cm residual tumour remains in mid para-aortic region, how would you
manage this patient further? (3)
b) i) List 3 familial syndromes associated with Renal Cell carcinoma (RCC). (1.5)
ii) List 3 histological subtypes of RCC. (1.5)
iii) Define stage IV RCC. (1)
iv) When is surgery indicated in stage IV RCC? (2)
v) List 6 targeted agents available for RCC and give the target on which they act.
(6)
vi) What are the indications for radiotherapy in RCC? (2)
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-2-

3 a) A 5-year-old child presents with visual problems and an MRI scan is done. A brightly
enhancing mass involving the optic chiasm and optic tracts is found and radiological
diagnosis of an optic pathway glioma is made
i) With which genetic condition is optic pathway glioma commonly associated?
(0.5)
ii) What type and grade of glioma is this likely to be? (0.5)
iii) Discuss your approach to treatment if this child is found to have the underlying
genetic condition mentioned in (a) above. (3)
b) A 48-year-old woman presents with a basal cell carcinoma (BCC) of the face
i) Name 4 anatomical areas of the face that are considered high risk for
recurrence of BCC. (2)
ii) Why are these areas high risk for recurrence? (1)
iii) Apart from site, name 3 other high risk factors for recurrence of BCCs of the
face. (1.5)
iv) Give 2 surgical treatments used commonly in the treatment of BCC, and state
when they may be used. (2)
v) Name 2 topical agents used for treatment of BCC, and briefly explain their
mechanism of action. (4)
vi) Name the 2 commonest types of thyroid cancer and briefly outline what the
further management of a patient with well-differentiated thyroid cancer after
surgery will entail. (3)
c) i) What is the primary treatment for Prolactinoma? (1)
ii) When is radiotherapy indicated for non-functional pituitary adenoma? (2)
iii) When is radiotherapy indicated pituitary adenoma? (2)
iv) Describe the likely side effects of 3-D conformal radiotherapy for pituitary
adenoma, as well as when they are likely to occur. (2.5)
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4 a) i) Describe the differences in presentation between a child with Osteosarcoma
and a child with Ewings sarcoma. (3)
ii) Your multi-disciplinary team elects to treat a child with Osteosarcoma with neo-
adjuvant chemotherapy consisting of Adriamycin and Cisplatin, followed by
surgery and further chemotherapy. What points would you discuss with the
parents when obtaining informed consent for the chemotherapy? (3)
iii) What supporting drugs and fluids would you prescribe as a pre-med for the
chemotherapy and why? (3)
iv) What is the interval between cycles in this regimen? (0.5)
v) If this interval is persistently prolonged due to neutropenia, would you be
concerned about this, and if so, why and how would you manage it? (3)
vi) How soon after the surgery should chemotherapy re-commence? (0.5)
b) i) Which patients presenting with spinal cord compression qualify for emergency
radiotherapy? (3)
ii) What are the indications for emergency surgical decompression in patients
with spinal cord compression? (2)
iii) Does choice of treatment influence prognosis? If so, how? (1)
iv) Describe the fields and dose of radiotherapy you would use to treat a patient
with advanced lung cancer and spinal cord compression. (3)
v) The patient is a 55-year-old female, not known to oncology previously, and the
acute spinal cord compression is treated with emergency surgical
decompression followed by radiotherapy. This histology shows
adenocarcinoma. The patient is performance status 1. Are any further
investigations required? If so, what? (3)
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