Medical Oncology Practice Set

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Medical Oncology Practice Set

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Practice Set of Medical Oncology

1. Identify the CORRECT statement.
(1) Patients age 70 and above with stage 1, ER+ breast cancer treated by lumpectomy and tamoxifen alone have no difference in locoregional recurrence rates relative to those who receive whole breast radiation in addition.
(2) Preoperative chemotherapy has a long-term survival advantage relative to adjuvant chemotherapy.
(3) Concurrent use of pertuzumab with trastuzumab and chemotherapy is appropriate in women receiving preoperative chemotherapy for HER2+ breast cancer.
(4) All of the above.

2. Identify the CORRECT statement.
(1) A maximum duration of 5 years is the only duration for which safety and efficacy data exists for an aromatase inhibitor.
(2) Ovarian suppression in combination with tamoxifen has no benefit relative to tamoxifen alone in high-risk premenopausal women with breast cancer.
(3) Concurrent use of an aromatase inhibitor and tamoxifen is appropriate therapy for high risk node-positive breast cancer patients.
(4) All patients treated with aromatase inhibitors should undergo monitoring of bone mineral density and treatment with denosumab when osteoporosis is detected.

3. Identify the CORRECT statement regarding the use of taxanes in the adjuvant setting:
(1) Concurrent administration of docetaxel/doxorubicin/cyclophosp hamide chemotherapy is better tolerated than sequential dose dense AC followed by paclitaxel due to lower rates of neutropenia.
(2) Weekly paclitaxel is associated with increased grade 3 and 4 neutropenia relative to dose dense paclitaxel.
(3) Weekly paclitaxel is associated with increased grade 3 and 4 neuropathy relative to dose dense paclitaxel.
(4) Incorporation of gemcitabine into adjuvant anthracyclines- and taxanes-based chemotherapy improves efficacy.

4. With regard to the clinical and pathologic characteristics of male breast cancer, which of the following is TRUE?
(1) Male breast cancer is found, more often than female breast cancer, to be estrogen receptor negative, and the older a man is with breast cancer, the more likely the cancer is estrogen-receptor negative.
(2) Liver cirrhosis and mumps orchitis are associated with a decreased risk of male breast cancer
(3) The median age of onset is 10 years younger than the median age of onset for females.
(4) Sentinel node biopsy is the preferred treatment for clinically node-negative patients.

5. Regarding breast cancer and bone metastases, which of the following is TRUE?
(1) The optimal duration of RANK ligand inhibition is 2 years.
(2) Intravenous bisphosphonates and RANK-ligand inhibitors lessen the pain associated with bone metastases.
(3) Bone directed therapies in patients with widespread bone metastases improve overall survival.
(4) Only patients with asymptomatic sclerotic bone metastases benefit from bone-directed therapies.

6. Primary (de novo) glioblastoma multiforme (GBM) is commonly associated with which of the following?
(1) PTEN inactivation
(2) Loss of heterozygosity of chromosomes Ip and 19q
(3) IDHI mutation
(4) Median age <40 years

7. Which gene mutation identified in GBM is frequently seen in younger patients, and is associated with better prognosis:
(1) EGFR
(2) p53
(3) IDHI
(4) Gain in chromosome

8. Patients with GBM have a higher likelihood of responding to therapy with epidermal growth factor receptor tyrosine kinase (EGFR-TK) inhibitors if which of the following biomarkers is present?
(1) Methyl guanine methyl transferase (MGMT) gene methylation
(2) Activated EGFRvIII
(3) Retained PTEN function
(4) (2) and (3)

9. The primary CNS neoplasm that is associated with Epstein-Barr virus (EBV) is:
(1) Primary CNS lymphoma.
(2) Ependymoma.
(3) Oligodendroglioma.
(4) GBM.

10. A 45-year-old man presents’ with generalized seizures, and MRI of the brain reveals a non-enhancing mass measuring 7 cm. Biopsy is done, and the tumor histology is reported as grade II astrocytoma. The patient undergoes surgery, and a partial (85% to 90%) tumor resection is achieved. Further treatment should include:
(1) Watchful waiting.
(2) Chemotherapy with temazolamide and bevacizumab
(3) Radiotherapy with 50.4 Gy in 1.8 Gy fractions.
(4) Radiotherapy with chemotherapy (procarbazine, CCNU, and vincristine).

11. Which of the following are TRUE about radiation-induced sarcomas?
(1) Cancer history usually includes breast cancer, lymphoma, and cervical cancer.
(2) They usually occur 10 to 30 years after radiation exposure.
(3) Osteogenic sarcoma, undifferentiated pleomorphic sarcoma (UPS), angiosarcoma, and lymphangiosarcoma are the usual histologic subtypes.
(4) All of the Above.

12. Which clonal cytogenetic abnormality is associated with the CORRECT sarcoma subtype?
(1) Ewing sarcoma and t(11;22) (q24;q12)
(2) Synovial sarcoma and. t(12;16) (q13;p11)
(3) Myxoid liposarcoma and t(X;18)(p11;q11)
(4) Alveolar rhabdomyosarcoma and t(17;22) (q22;q13)

13. A 52-year-old man underwent resection of a 3-cm mass from the lateral left thigh. Pathology revealed a high-grade leiomyosarcoma, and the lateral surgical margin was positive. The most appropriate next step in the treatment of this patient’s cancer would be:
(1) Radiation.
(2) Adjuvant chemotherapy.
(3) Re-resection.
(4) Observation.

14. A 68-year-old woman presented with a purplish nodular lesion in the occipital scalp. Resection revealed an angiosarcoma measuring 3 cm. Surgical margins were negative. What Is the most appropriate next step in the treatment of this patient’s cancer?
(1) Radiologic imaging to look for nodal metastases and referral for adjuvant radiation
(2) Monitoring
(3) Adjuvant chemotherapy with an anthracycline
(4) Adjuvant chemotherapy with paclitaxel

15. A 65-year-old woman presented with abdominal pain and iron-deficiency anemia. Workup revealed a gastric mass and multiple large intra-abdominal masses and liver hypodensities. Biopsy of the gastric mass revealed a spindle cell neoplasm thought to be a leiomyosarcoma. After three cycles of doxorubicin and ifosfamide, imaging showed disease progression. The appropriate next step in the management of this patient’s cancer would be:
(1) Docetaxel and gemcitabine.
(2) Dacarbazine.
(3) Request the pathologist to perform a CD117 (c-Kit) stain.
(4) Palliative radiation.

16. What is the most prevalent significantly mutated gene in cutaneous melanoma?
(1) BRAF V600K
(2) BRAF V600R
(3) BRAF V600E

17. A 40-year-old woman with a history of ulcerative colitis, mitral valve prolapse, eczema, and stage cutaneous melanoma presents with right inguinal adenopathy. Physical examination confirms a 4-cm node and core biopsy confirms malignant melanoma. BRAF mutational analysis is requested and BRAF V600E mutation is detected. Brain MRI is unremarkable; however, CT examination reveals numerous (>10) bilateral pulmonary metastases with the largest lesion measuring 1.2 cm in the left upper lobe. No other sites of distant metastases are evident and you conclude that this patient has stage IV, Mlb disease. What is the best initial treatment for this individual?
(1) Ipilimumab
(2) BRAF inhibitor
(3) MEK inhibitor
(4) BRAF and MEK inhibitor combination

18. An 8-year-old child is brought to clinic by his mother due to a jaw lump that has been increasing in size over the past month. Physical examination reveals a child in moderate distress with a left jaw mass that displaces teeth and is impinging on the trachea. Biopsy reveals sheets of atypical lymphocytes with areas of necrosis and hemorrhage. Ki-67 is 99%. Flow cytometry shows B-cell markers as well as CD10 and BCL-6. CD5, BCL-2, and TdT are absent. Which of the following is the most common translocation in this malignancy?
(1) t(1;14)
(2) t(2;8)
(3) t(8;14)
(4) t(8;22)

19. A 69-year-old man presents to his primary care doctor for persistent nausea associated with non-bloody, non-bilious emesis, loss of appetite, and 30-lb weight loss over approximately 1 year. He also recalls having occasional dark stools. Physical examination reveals splenomegaly. PET/CT reveals FDG avidity of intra-abdominal lymph nodes as well as uptake in the stomach and small and large bowel. Upper and lower endoscopy reveals a non-bleeding gastric ulcer and diffuse polyps in the colon. Biopsies are performed. Cells express surface IgM and IgD along with CD5, CDI9, and CD20. Cytogenetics reveals t(11;14). Which of the following statement is INCORRECT regarding the next step in management?
(1) Consolidation with autologous stem cell transplantation in first remission is an approach often considered for fit patients.
(2) Treatment with ibrutinib in the upfront setting is limited because of its association with peripheral neuropathy.
(3) Front-line therapy for elderly patients with good performance status includes bendamustine and rituximab.
(4) Hyper-CVAD with rituximab may be administered to patients with more aggressive disease.

20. 63-year-old woman with a past medical history of HIV presents to the emergency room with shortness of breath. She notes that it has been worsening over the past 3 to 4 months, but became unbearable over the past week. Review of systems is positive for involuntary weight loss of 30 Ib over 4 months and pedal edema. Physical examination reveals pitting edema to the knees bilaterally. PET/CT scan shows diffuse adenopathy of the mediastinum and the pelvis, with the largest nodes measuring 2.5 cm. No extra-nodal disease is appreciated. Excisional biopsy reveals proliferating large and small lymphocytes. Ki-67 is 85%. Flow cytometry reveals cells that are CD19, CD20, and CD22 positive and negative for CD10 and BCL-6. Which of the following statements regarding management Is accurate?
(1) R-CHOP chemotherapy is appropriate.
(2) ABVD chemotherapy is preferred as first-line management.
(3) Allogeneic stem cell transplant is the treatment of choice if the patient were to relapse with chemosensitive disease.
(4) Rituximab with CHOP confers greater benefits in patients who lack BCL-6 expression, based on the GELA R-CHOP trial.

Practice Set MCQs
Quiz Questions and Answers

21. A 43-year-old woman presents to a dermatologist with a diffuse skin rash, described as red and itchy with associated thickening of the palms and soles that has been slowly progressing for the past 4 years. Physical examination reveals erythematous plaques on 20% of the body surface area. FDG PET reveals absence of extra-cutaneous disease. Skin biopsy reveals Pautrier microabscesses. Immunophenotyping reveals expression of CD2, CD3, CD5, andCD7. What is the next best step in management?
(1) EPOCH chemotherapy combined with pentostatin and fludarabine with interferon alpha
(2) Extracorporeal photochemotherapy
(3) Locally applied denileukin diftitox with or without vorinostat
(4) Topical carmustine or mechlorethamine, bexarotene, or ultraviolet B with or without interferon alpha

22. Which of the following accurately describes an aspect of primary CNS lymphoma (PCNSL)?
(1) AIDS patients tend to have large, invasive unifocal masses that rapidly progress without HAART therapy.
(2) Incidence has decreased fivefold from 1985 to 1997 due to advances in treatment of immune suppressed patients.
(3) Many masses are periventricular, allowing tumor cells access to cerebrospinal fluid.
(4) Presents most commonly in the occipital lobe, manifesting as vision changes and gait abnormalities.

23. Which of the following statements best characterizes nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) in contrast to classic Hodgkin lymphoma (cHL)?
(1) Approximately 80% of patients with NLPHL have stage I to II disease at the me of diagnosis.
(2) Bone marrow involvement is frequent with stage III to IV disease.
(3) Disease presentation manifests predominantly in thoracic nodes before spreading to the mediastinum.
(4) NLPHL cells express CD30 and CD45 as well as B-cell antigens

24. A 24-year-old GIPO woman presents to her physician with fever, neck pain, fatigue, and 10-lb weight loss during the first trimester of pregnancy. She is concerned about the health of her fetus. Physical examination reveals non-tender cervical adenopathy, leading to a biopsy, which reveals cells that are positive for CDI5 and CD30 and negative for CD3, CD7, CD20, and CD45. Morphology its pertinent for Reed-Sternberg cells in a background of inflammatory cells. Which of the following accurately describe(s) an aspect of care for such patients?
(1) BEACOPP chemotherapy its preferred to ABVD for treatment during the first trimester due to the lack of anti-metabolites in the regimen.
(2) MRI scanning is preferred for staging because it is non-teratogenic.
(3) Long-term survival of treated pregnant women is inferior to that of non-pregnant women with the disease.
(4) Radiation therapy with abdominal shielding can be safely used for bulky disease above the diaphragm.

25. You are caring for a 25-year-old woman with AML-M2 and normal cytogenetics. She receives 7+3 induction therapy, and her day-14 bone marrow biopsy is ablated. She returns to clinic and her day-45 bone marrow shows normal hematopoiesis. However, she relapses after 18 months. Which of the following likely contributed to her relapse?
(1) DNMT3A mutation
(2) CEBPA mutation
(3) NPM mutation without FLT3-ITD
(4) Her age

26. Which of the following is a poor prognostic factor in adult ALL?
(1) Age <55 years
(2) WBC<10,000
(3) Diploid chromosomes on karyotyping
(4) t(4;11)

27. A 30-year-old, otherwise healthy woman is diagnosed with AML. Cytogenetics reveal inv(16). She undergoes induction therapy. Day-14 bone marrow biopsy shows an ablated marrow. Her day-45 marrow shows restored cellularity without evidence of disease. Repeat cytogenetics do not reveal the inv(16) rearrangement. What would be most appropriate consolidation therapy for this patient?
(1) Allogeneic transplant if a matched sibling donor is available.
(2) High-dose cytarabine (HIDAC) 3 g/m2 every 12 hours on days 1, 3, and 5 for four 28- day cycles.
(3) Intermediate-dose cytarabine (IDAC) 300 mg/m2 every 12 hours on days 1, 3, and 5 for four 28-day cycles.
(4) Arsenic 0.15 mg/kg on days 1 to 5 for four 28-day cycles.

28. Which of the following targeted agents have been shown to be beneficial in adult ALL?
(1) Imatinib
(2) Alemtuzumab
(3) Gemtuzumab ozogamicin
(4) Sunitinib

29. For which of the following patients would you consider myeloablative stem cell transplantation in CR1?
(1) A 30-year-old woman with inv( 16) AML-M4 with eosinophilia
(2) A 50-year-old man with complex cytogenetics AML-MI
(3) A 65-year-old man with complex cytogenetics AML-MI
(4) A 50-year-old woman with t(15;17) AML-M3

30. A 69-year-old male with a history of COPD, coronary artery disease and diabetes mellitus was diagnosed with chronic-phase chronic myeloid leukemia (CML). What is the most appropriate therapeutic intervention?
(1) Imatinib 400 mg QD
(2) Dasatinib 100 mg QD
(3) Nilotinib 300 mg BID
(4) Ponatinib 30 mg QD

31. A 60-year-old female has been under your care for chronic-phase CML for the past 2 years. She achieved complete response on nifotinib. She subsequently developed thrombocytopenia with elevated RQ-PCR and a bone marrow biopsy showed 42% Ph-positive metaphases. Mutational analysis showed T3151 mutation in the ABL domain. What is the appropriate treatment for this patient?
(1) Imatinib
(2) Ponatinib
(3) Dasatinib
(4) Bosutinib

32. With the advent of tyrosine kinase inhibitors (TKIs), allogeneic stem cell transplantation (allo-HCT), once a primary therapy for CML, is now reserved for specific CML patients. What are the indications for allo-HCT in CML?
(1) Progression to CML accelerated/blast phase
(2) Resistance to first-line TKIs but continues to be in chronic phase
(3) Availability of a matched sibling donor
(4) Young patients (<50 years of age)

33. Minimal residual disease assessment is NOT the standard-of-care for which haematological malignancy as of date?
(1) Acute Lymphoblastic leukemia
(2) Chronic Myeloid leukemia
(3) Multiple Myeloma
(4) Acute Myeloid leukemia

34. A 56-year-old man was recently diagnosed with Rai stage 0 CLL. He is professor of chemical engineering in one of the IITs, has read about newer therapies and wanted to know when he can start treatment. Which of the following findings would be an indication for initiation of systemic therapy?
(1) Availability of newer treatment modalities such as ibrutinib, idelalisib, and CAR-T cells
(2) An increase in his absolute lymphocyte count from 25 x 109/L to 40 x 109/L over the last 2 years
(3) Recent diagnosis of hypo-gammaglobulinemia
(4) Fever of 38°C for the last 2 weeks without evidence of infection

35. A 61-year-old female with a history of CLL and 17p deletion was treated with six cycles of FCR and subsequently achieved complete remission. One year later, she started noticing increased diffuse lymph node swelling and progressive unintentional weight loss. Initial workup demonstrated WBC count of 1.2 x 105 cu mL and a platelet count of 65,000 cumL. A repeat lymph node biopsy showed CLL. What is the next best treatment?
(1) Ibrutinib 420 mg PO Q daily
(2) Ibrutinib 840 mg PO Q daily
(3) Ofatumumab
(4) Fludarabine + cyclophosphamide + rituximab

36. A 25-year-old female, bank employee, presented with severe upper back pain and dry cough. No significant prior history, 4 kg weight loss, No night sweats. Physical examination: WHO Performance status 2, Right pleural effusion, right supra clavicular and right axillary LN palpable Laboratory results: normal blood count, increased lactate dehydrogenase. XRC-Mediastinal mass Lymph node excision biopsy, anaplastic large cell lymphoma (ALCL), CD30+ Which is the most important prognostic THC biomarker in ALCL?
(1) Expression of MYC
(2) Expression of ALK
(3) Expression of TP53
(4) Expression of BCL2

37. A 28-year-old man was found to have stage IV Burkitt’s lymphoma. His renal function was normal and a staging CT scan had shown no abnormality of the renal tract. Three days later, when he was about to start chemotherapy, he developed a temperature of 39.0°C with rigors and was treated with imipenem. Investigations (the following day):
* serum sodium 138 mmol/L (137-144)
* serum potassium 6.2 mmol/L (3.5-4.9)
* serum creatinine 215 µmol/L (60-110)/2.43 mg/dL (0.6-1.2)
* serum corrected calcium 1.60 mmol/L (2.20-2.60) / 6.4 mg/dL (8.5 – 10.2)
* serum phosphate 1.52 mmol/L (0.8-1.4)/4.71 mg/dL (3.0 – 4.5)
* serum lactate dehydrogenase 1238 U/L (10-250)
* serum urate 0.69 mmol/L (0.19-0.36)/ 11.6 mg/dL (2.4 – 6.0)
What is the most likely cause of the renal impairment?
(1) imipenem toxicity
(2) intravenous contrast, toxicity
(3) septic shock
(4) tumour lysis syndrome

38. A 40-year-old woman presented with post-coital bleeding. Investigations revealed a 2-cm grade 1, stage IB1 squamous cell carcinoma of the cervix. There was no evidence of lymphovascular space invasion. She had completed her family. What is the most appropriate treatment?
(1) Brachytherapy
(2) chemo-radiotherapy
(3) excision cone biopsy only
(4) radical hysterectomy

39. A 52-year-old man, heavy tobacco chewer, presented with vomiting and 4-kg weight loss. His performance status was 1. He was found to have a pre-pyloric gastric carcinoma with gastric outlet obstruction. A CT scan showed no metastases. What is the most appropriate next step?
(1) chemo-radiation
(2) neoadjuvant chemotherapy
(3) palliative bypass
(4) radical resection

40. A 62-year-old man, presented with recent change in bowel habits and intermittent rectal bleeding, was found to have an anterior rectal cancer at 2 cm from the anal verge. A CT scan of chest, abdomen and pelvis showed no evidence of metastatic disease. An MR scan of pelvis showed an anterior tumour abutting the prostate gland, radiologically staged as a T3, NI, MO cancer. What is the most appropriate next step in management?
(1) abdominoperineal resection
(2) chemotherapy
(3) long-course chemoradiation
(4) short-course radiotherapy

41. A 48-year-old man presented with a 1 month history of altered personality, incontinence and seizures. An MR scan of brain demonstrated an enhancing lesion in the right frontal lobe. Histology revealed a grade 3 oligodendroglioma, with loss’ of heterozygosity of Ip/19q. What is the most appropriate treatment?
(1) chemoradiation with temozolomide
(2) cranial irradiation
(3) procarbazine, vincristine and lomustine (PCV)
(4) temozolomide

42. A 45-year-old woman with early breast cancer, T2NIMO, triple negative, presented with fever and fatigue to the accident and emergency department on day 7 of her first adjuvant chemotherapy cycle with the TAC (docetaxel, doxorubicin, cyclophosphamide) regimen. On examination, her temperature was 38.5°C, her pulse was 110 beats per minute and her blood pressure was 110/70 mmHg. A full blood count was requested. What is the most appropriate next step?
(1) await full blood count result
(2) intravenous broad-spectrum antibiotics
(3) intravenous broad-spectrum antibiotics and granulocyte colony-stimulating factor
(4) oral broad-spectrum antibiotics and G-CSF

43. A 35-year-old man sought advice about the increased risk of cardiac complications following chemotherapy. Eight years previously, he had been successfully treated for Hodgkin’s disease with six cycles of doxorubicin, bleomycin, vinblastine and dacarbazine, and mediastinal radiotherapy. For how many years from the end of treatment will this increased risk persist?
(1) 6-10
(2) 1-15
(3) 16-20
(4) >20

44. A 55-year-old woman presented with hot flushes. Her last menstrual period had been 1 year previously. She was treated with ethinylestradiol and medroxyprogesterone acetate. Which potential consequence of oestrogen therapy is most reduced by co-prescription of a progestogen?
(1) breast cancer
(2) breast pain
(3) endometrial cancer
(4) mood changes

45. A 59-year-old man was referred because of a change 1n bowel habit. He had noticed no alteration in stool calibre, gastrointestinal bleeding or unintended weight loss. There was no family history of colonic polyps or gastrointestinal malignancy. Physical examination was normal. A rectal examination revealed no masses. A sigmoidoscopy revealed a 4-mm polyp in the mid-rectum, which was removed with forceps, and histology revealed a tubular adenoma. What is the most appropriate next step in management?
(1) barium enema now
(2) colonoscopy in 3 years
(3) colonoscopy in 5 years
(4) colonoscopy now