Medical Oncology Module 2

A 52-year-old postmenopausal woman with stage IIB oestrogen receptor-positive (ER+), progesterone receptor-positive (PR+), HER2-negative invasive ductal carcinoma undergoes breast-conserving surgery followed by adjuvant radiotherapy. She is commenced on tamoxifen 20 mg daily as adjuvant endocrine therapy.

She has a longstanding history of major depressive disorder, which has been well controlled with antidepressant therapy for several years. During a routine oncology review, her oncologist notes that one of her antidepressants may significantly reduce the effectiveness of tamoxifen by inhibiting its metabolic activation.

Which of the following antidepressants should be avoided in patients receiving tamoxifen?

A 64-year-old postmenopausal woman is diagnosed with stage II oestrogen receptor-positive (ER+) and HER2-negative invasive breast cancer. She undergoes surgical resection followed by adjuvant radiotherapy. Given her postmenopausal status, she is commenced on an aromatase inhibitor (AI) as adjuvant endocrine therapy.

Which of the following is a recognised adverse effect of aromatase inhibitor therapy?

A 67-year-old postmenopausal woman is diagnosed with a 2.5 cm invasive ductal carcinoma of the breast. She undergoes lumpectomy with clear surgical margins and sentinel lymph node biopsy, which shows no nodal involvement. Histopathology demonstrates:

• Oestrogen receptor (ER): strongly positive
• Progesterone receptor (PR): positive
• HER2: negative
• Ki-67: low proliferation index

Following completion of local therapy, which of the following is the most appropriate adjuvant systemic therapy to reduce the risk of breast cancer recurrence?

A 46-year-old female patient presents to the clinic with a diagnosis of stage IV breast cancer, characterized by supraclavicular and axillary lymph node involvement as well as liver metastases. The tumor is HER2 positive, and the patient maintains a good functional status.

What is the most appropriate initial treatment approach for this patient?

A 42-year-old premenopausal woman presents with metastatic breast cancer. Biopsy of a liver metastasis confirms invasive ductal carcinoma with the following receptor profile:

• Oestrogen receptor (ER): strongly positive
• Progesterone receptor (PR): strongly positive
• HER2: negative

She has not previously received endocrine therapy. Given that her tumour is hormone receptor-driven, endocrine therapy is planned as the initial systemic treatment.

In a premenopausal woman with ER-positive, PR-positive metastatic breast cancer, which of the following is the most effective intervention to reduce oestrogen stimulation of the tumour?

Which of the following tumor characteristics confers a poor prognosis in patients with breast cancer?

A 56-year-old woman is diagnosed with stage III oestrogen receptor-positive (ER+) breast cancer. She undergoes surgical resection followed by adjuvant chemotherapy with doxorubicin and cyclophosphamide, and is subsequently commenced on tamoxifen as endocrine therapy.

Six months into treatment, she presents with acute onset dyspnoea and pleuritic chest pain. CT pulmonary angiography confirms a pulmonary embolism.

Which of the following medications is most strongly associated with an increased risk of venous thromboembolism (VTE) in this patient?

A 55-year-old patient with a history of non-Hodgkin’s lymphoma undergoes high-dose chemotherapy as part of a preparative regimen for an autologous bone marrow transplant. Within a week following the administration of the chemotherapy, the patient presents with acute onset of dyspnea, chest pain, and palpitations.

The chest pain is described as sharp and worsens with deep breaths and when lying down, but slightly improves when sitting forward.

On physical examination, the patient exhibits signs of distress with tachypnea and tachycardia. A friction rub is audible on cardiac auscultation.

The ECG shows diffuse ST-segment elevations, and an echocardiogram reveals a small-to-moderate sized pericardial effusion without signs of cardiac tamponade. Laboratory findings include elevated cardiac biomarkers and inflammatory markers. The patient’s renal function and electrolytes are within normal limits, and there is no evidence of infection.

Given this clinical presentation, the patient is diagnosed with acute pericarditis and pericardial effusion following high-dose chemotherapy.

Based on the clinical scenario, which chemotherapeutic agent is most likely responsible for the patient’s pericarditis and pericardial effusion?

What is the mechanism of action of aprepitant?

A 23-year-old man with non-Hodgkin’s lymphoma had just completed chemotherapy 10 days ago and now presents with neutropenic sepsis but without any features of systemic compromise. He has a history of anaphylaxis with penicillin.

What would be the antibiotic of choice?

What is the mechanism of action of ondansetron?

Which of the following serotonin antagonist has the highest affinity for the 5-HT3 receptor?

What is the rationale for reducing the dose of dexamethasone when given in combination with aprepitant in the treatment of chemotherapy-induced nausea and vomiting (CINV)?

A cancer patient is planned to have intravenous vincristine for the first time.

What is the recommended antiemetic regimen before starting chemotherapy?

Among the following malignancies, which has the strongest and most consistently established association with menopausal hormone therapy (HRT), particularly combined oestrogen–progestogen therapy?

A 50-year-old patient, with a history of receiving radiotherapy for head and neck cancer, presents to the oncology clinic with a new-onset rash. The rash is localized to the area that previously underwent radiotherapy and appeared following the initiation of a new chemotherapy regimen. The patient reports no other new medications or changes in their routine. The physical examination reveals erythematous, desquamating skin changes confined to the irradiated region.

Which chemotherapy agent is most likely responsible for the development of the rash in this patient?

A 48-year-old woman is diagnosed with a 6 cm HER2-positive invasive ductal carcinoma of the breast with biopsy-proven axillary lymph node involvement. The multidisciplinary team recommends neoadjuvant systemic therapy before surgery.

What is the primary purpose of neoadjuvant chemotherapy in this patient?

A 17-year-old man recently completed chemotherapy for rhabdomyosarcoma.

On routine testing the following results were obtained:

• Serum sodium 134 mmol/L [135-145],
• creatinine 39 mmol/L [18-58],
• potassium 3.4 mmol/L [3.5-5.0],
• calcium 2.46 mmol/L [2.20-2.70],
• chloride 114 mmol/L [97-109],
• phosphate 0.44 mmol/L [1.07-2.03],
• bicarbonate 13.9 mmol/L [20.0-28.0],
• magnesium 0.93 mmol/L [0.65-1.05],
• urea 4.9 mmol/L [2.1-8.4],
• albumin 42 g/L [33-49].
• Urinalysis: protein ++, glucose +++.

The drug most likely to have caused these abnormalities is:

In assessment of cancer patients, the Karnofsky performance scale (KPS) best correlates with:

Which type of primary tumor is most commonly associated with the syndrome of inappropriate antidiuretic hormone (SIADH)?

The occurrence of gynecomastia in patients with testicular cancer is most likely to arise through which one of the following mechanisms?

An adolescent 16-year-old female has been treated successfully with radiotherapy for Hodgkin disease.

Which of the following tumors is most likely to occur when she reaches adulthood (after more than 10 years following treatment)?

A 57-year-old female, with a history of right mastectomy for breast cancer performed three years prior, reports to the clinic complaining of progressive discomfort in her lower back. Her neurological examination is largely unremarkable, with the exception of an equivocal right plantar reflex. Functions of the bowel and bladder remain intact.

Radiographic imaging reveals a generalized increase in bone lucency along with a diminished height in two of the lumbar vertebrae. Subsequent MRI imaging confirms the presence of spinal cord compression. The patient’s Eastern Cooperative Oncology Group (ECOG) performance status is classified as 1.

What is the most appropriate course of action for managing this patient’s condition?

A 58-year-old postmenopausal woman is diagnosed with invasive ductal carcinoma of the left breast after detecting a painless breast lump during self-examination. She undergoes breast-conserving surgery with sentinel lymph node biopsy.

Histopathology confirms a 2.8 cm, grade 2 invasive ductal carcinoma with clear surgical margins. Immunohistochemistry demonstrates ER-positive, PR-positive, HER2-negative disease.

At the multidisciplinary meeting, the team discusses the pathological factors that will have the greatest impact on her long-term prognosis and guide recommendations for adjuvant therapy.

Which of the following is the single most important prognostic factor in patients with operable breast cancer?

A 35-year-old woman attends the breast clinic seeking advice about her future risk of developing breast cancer. She has no personal history of breast disease and has no known pathogenic genetic mutation. She asks which factors in her medical and family history are most strongly associated with an increased lifetime risk of breast cancer.

Which of the following would place her at the greatest risk of developing breast cancer?

A 63-year-old woman with metastatic breast cancer with skeletal metastases presents with dry cough and shortness of breath. Six weeks ago she completed palliative radiotherapy to her T5 vertebra because of painful metastatic involvement. She is currently receiving tamoxifen. On examination, she is afebrile and her chest auscultation reveals fine crepitations in the left upper zone. Her chest X-ray is shown below.

The most appropriate next step in her management is to:

A 45-year-old perimenopausal woman with osteopenia is considering raloxifene for fracture prevention and breast cancer risk reduction. She has no history of venous thromboembolism and is otherwise well.

Which of the following factors is NOT considered an absolute contraindication for raloxifene?

A 62-year-old woman with a 1.8 cm, node-negative, oestrogen receptor-positive invasive ductal carcinoma undergoes breast-conserving surgery (lumpectomy) with clear surgical margins. The multidisciplinary team recommends adjuvant whole-breast irradiation.

What is the primary benefit of adjuvant whole-breast irradiation following breast-conserving surgery?

A 36-year-old woman with a history of right breast invasive ductal carcinoma underwent surgical resection one year ago. She now presents with multiple liver metastases consistent with recurrent metastatic breast cancer. 

Which of the following tumour characteristics would most strongly predict benefit from treatment with trastuzumab deruxtecan (T-DXd)?