FRANZCR Examination Phase 2 Radiation Oncology

Past Examination Papers

February / March Series 2011
RADIATION THERAPY 1
Time Allowed: 3 Hours
There are a total of SIX (6) questions.

Question 1
A fit 21 year old man has undergone a right inguinal orchidectomy for a 3 cm pure seminoma of the testicle. A CT scan
of the chest, abdomen and thorax are normal.
a)

What are his options for further management, giving evidence to support each option?
(3 marks)

b)

What are the factors that you would consider when advising him of the option(s) suitable for his situation?
(4 marks)

He decides to proceed with adjuvant radiation therapy.

c)

Describe a suitable technique and dose prescription for his treatment.

(2 marks)

d)

Justify the target volume described in (c) above.

(1 mark)

Question 2
A previously very fit 30 year old man presents with a 5 cm mass in the head of the pancreas. It is inoperable due to its
proximity to major arterial vessels. A biopsy confirms adenocarcinoma. Staging investigations show no nodal or distant
metastases.
a)

What treatment options are available for this man? Justify your answer.
(4 marks)

The decision has been made to give chemotherapy followed by radiation therapy.
b)

Describe a suitable technique and dose prescription for his treatment.

(4 marks)

During treatment this patient develops significant nausea.

c)

How would you manage this problem?

(2 marks)

Phase 2 Exam Written Papers

2011

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Question 3
A 70 year old man presents with increasing dyspnoea and cough. A CT scan confirms a 5 cm mass in the right middle
lobe of the lung with enlarged mediastinal lymph nodes. Bronchoscopy and biopsy confirm small cell lung carcinoma.
The patient has an ECOG performance status of 1.
a)

Describe your initial management of this patient.

(2 marks)

Further imaging shows no evidence of metastatic disease.

b)

Describe the treatment you would recommend, giving the rationale and evidence to support this.
(2 marks)

c)

Describe a suitable technique and dose prescription for treatment with radical chemoradiation. Include in your
answer, the normal tissue dose constraints you would apply and the potential toxicities of this treatment.
(4 marks)

d)

What are the indications for prophylactic cranial irradiation? If this were recommended for this man, give the
dose/fractionation schedule you would prescribe.
(2 marks)

Question 4
A 65 year old woman has a history of a Clarkes level IV melanoma of the left thigh excised 5 years ago. She presents
with a groin mass which is excised. Histology shows metastatic melanoma. Physical examination and staging
investigations do not reveal any other evidence of disease.
a)

What are the indications for postoperative radiation therapy following lymph node dissection in melanoma?
Justify your answer.
(3 marks)

The decision is made to give her postoperative radiation therapy.

b)

Describe a suitable technique and dose prescription for her treatment.

(3 marks)

c)

What would be the expected tumour-related outcome from this treatment?

(1 mark)

d)

Describe the potential acute and late toxicities of this treatment, and how these might be minimised.
(3 marks)

Question 5
A 55 year old post-menopausal woman underwent a left modified radical mastectomy and axillary dissection for breast
cancer. The pathology report described a 55 mm grade 2 infiltrating ductal carcinoma with clear margins. Six of fifteen
(6/15) axillary lymph nodes were involved by metastatic disease. The tumour was strongly oestrogen and progesterone
receptor positive and HER-2 positive.
a)

What features in the pathology report would assist you in deciding whether to recommend post-mastectomy
radiation therapy?
(2 marks)

b)

What is the evidence for the benefit of post-mastectomy radiation therapy in this setting?
(3 marks)

c)

Describe a suitable radiation therapy technique and dose prescription.

(3 marks)

d)

What potential toxicities would you discuss with this patient?

(2 marks)

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2011

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Question 6
A 44 year old woman presents with a painful left infra-orbital swelling. CT and MRI show a
3 cm soft tissue mass arising from the lateral wall of the maxillary antrum. There is no extension to the orbit or to other
paranasal sinuses on imaging.
a)

In this woman, what malignant tumours might present in this way?

(2 marks)

A biopsy reveals this to be a plasmacytoma.

b)

What other investigations would you perform and why?

(2 marks)

This lesion was confirmed as being a solitary plasmacytoma. The decision is made to treat her with definitive radiation
therapy.
c)

Describe a suitable treatment technique and dose prescription to treat this tumour.
(4 marks)

d)

What would be the expected tumour outcomes following this treatment?

(2 marks)

RADIATION THERAPY 2
Time Allowed: 2 Hours
There are a total of FOUR (4) questions.
Question 1
A 55 year old man had a low anterior resection 3 years ago for an early rectal adenocarcinoma. No adjuvant treatment
was given at that time. He now presents with severe anal and sacral pain, as well as PR bleeding. He is otherwise well.
Assessment and imaging reveals a 4 cm fixed recurrence at the anastamosis with involvement of multiple pelvic and
paraaortic lymph nodes up to the level of L3.
a)

What would be the goals of treatment when managing this patient?

(3 marks)

b)

What treatment options are available to this patient now?

(2 marks)

After discussion, the patient decides to proceed with radiation therapy.

c)

Describe a suitable technique and dose prescription for his treatment.

(3 marks)

d)

What general supportive measures would you organise for this man during and after his radiation therapy?
(2 marks)

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2011

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Question 2
A 64 year old male presents with hoarseness of the voice, progressive dysphagia and recent weight loss. Examination
reveals a 3 cm exophytic mass involving the right piriform fossa, and a 4 cm right Level IV neck node. Staging
investigations show no disease elsewhere. Biopsy of the lesion confirms a moderately differentiated squamous cell
carcinoma (SCC). He has an ECOG performance status of 0.
a)

What are the treatment options for this patient, giving the advantages and disadvantages of each?
(3 marks)

The decision is made to treat this patient with chemoradiation.

b)

How would you assess this patient prior to treatment?

(3 marks)

c)

Describe a suitable radiation therapy technique and dose prescription for this man.
(3 marks)

d)

What would be the expected tumour outcome from this treatment?

(1 mark)

Question 3
A 68 year old man was investigated for haematuria. A cystoscopy and Trans-Urethral Resection of Bladder Tumour
(TURBT), show urothelial carcinoma (TCC) of the bladder.
a)

What further information and investigations would help you to decide on a treatment recommendation for him?
(3 marks)

The cystoscopy report described the tumour as being solitary and on the right bladder wall. The histology report
confirmed high grade urothelial carcinoma with deep muscle invasion. Staging showed no evidence of extra-vesical
spread or distant metastases. He has opted for a bladder-preserving treatment approach.
b)

Would you include chemotherapy as part of his treatment program? Justify your answer.
(2 marks)

c)

Describe a suitable technique and dose prescription for his treatment.

(2 marks)

d)

What are the potential side effects and expected treatment outcomes?
(2 marks)

e)

What follow-up regimen would you recommend and why?

(1 mark)

Question 4
A 28 year old woman presents with a 6 month history of lethargy, progressive shortness of breath and non-productive
cough. A chest CT scan demonstrates an 8 cm mass in the anterior mediastinum.
A core biopsy is performed. Histopathology demonstrates a diffuse large B-cell lymphoma.
a)

What further investigations would you organise?

(1 mark)

Staging investigations demonstrate no disease outside the mediastinum.

b)

What would you recommend as management for this patient now? Justify your answer.
(2 marks)

c)

If her management was to include radiation therapy, describe a suitable technique and dose prescription for
delivering this treatment.
(3 marks)

d)

What are the potential acute and late toxicities, and how might these be minimised?
(4 marks)

Phase 2 Exam Written Papers

2011

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CLINICAL ONCOLOGY
Time Allowed: 3 Hours
There are a total of SIX (6) questions.
Question 1
A 6 year old boy presents with headache and recent right lower limb weakness. An MRI demonstrates a 4cm lesion in
his left cerebral hemisphere. A biopsy shows a WHO grade 2 glioma. His case is discussed in a paediatric meeting and
the decision is made to recommend definitive radiation therapy.
a)

What are the main points you would discuss with this childs parents about the rationale for radiation therapy,
side effects and potential late complications.
(4 marks)

b)

Discuss how you would follow this boy after treatment, assuming you are managing this aspect of his care.
(3 marks)

c)

In general, for primary CNS tumours in children, what factors would you consider when making a decision
about treatment with radiation therapy? Justify your answer.
(3 marks)

Question 2
PET scanning is now commonly used in cancer management.
a)

Describe how PET scans can be employed in oncological practice. Illustrate your answer with three examples
from different tumour sites.
(4 marks)

b)

What are the advantages and disadvantages of using PET scans in radiation therapy planning?
(4 marks)

c)

Name a commonly employed radiotracer and describe its biological characteristics.

(2 marks)

Question 3
A 60 year old man with a 3 month history of back pain now presents with leg weakness and urinary retention. Plain
films demonstrate a lytic lesion at T10.
a)

Describe how you would evaluate this patient.

(3 marks)

b)

What factors would you consider in deciding on the management of this man?
Justify your answer.
(4 marks)

The patient is confirmed to have malignant spinal cord compression at T10 and is treated with palliative radiation
therapy alone.
c)

Describe the general supportive measures you would organise for this man during and after his treatment.
(3 marks)

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2011

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Question 4
In relation to waiting times prior to commencing a course of radiation treatment:
a)

Describe the potential problems of delayed commencement of radiation therapy:

i)

with respect to clinical outcomes, giving at least 4 specific examples.

(3 marks)
ii) with respect to other adverse effects for the treatment centre
(2 marks)
b)

If your centre had unacceptable waiting times for radiation treatment, what measures could be used to
manage this?
(5 marks)

Question 5
You have been asked to chair a committee charged with the development of an Early Breast Cancer Treatment
Guidelines document.
a)

Describe the process you would employ to develop such guidelines.

(5 marks)

b)

What is meant by levels of evidence?

(1 mark)

c)

Define the system of levels of evidence that you would use within your guidelines document.
(4 marks)

Question 6
Part 1 - With regard to tumour lysis syndrome:
a)

What are the patho-physiological and clinical features of tumour lysis syndrome?
(3 marks)

b)

What measures can be used to reduce the risk of tumour lysis syndrome?
(2 marks)

Part 2 - With regard to statistical methods:

c)

What is a meta-analysis and why are meta-analyses performed?

(2 marks)

d)

What are the advantages and disadvantages of a meta-analysis over a single randomised controlled trial?
(3 marks)

Phase 2 Exam Written Papers

2011

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PATHOLOGY
Time Allowed: 3 Hours
There are a total of FIVE (5) questions.
Question 1
A 70 year old smoker presents with a lung mass and mediastinal lymphadenopathy. Histology from the transbronchial
biopsy shows features consistent with a primary lung cancer.
a)

Describe the microscopic and immunhistochemical features that would assist in distinguishing between the four
most common histological subtypes of lung cancer?
(5 marks)

b)

Define paraneoplastic syndrome. Write notes on the paraneoplastic syndromes that can be associated with lung
cancer.
(5 marks)

Question
A 35 year old female has a right mastectomy and axillary dissection for an invasive breast cancer
a)
List the factors in the pathology report that are required for you to make a decision on the recommendation for
adjuvant radiation therapy. Indicate how each of these factors influences your decision to recommend adjuvant
radiation therapy in this patient.
(6 marks)
b)

The analysis of gene expression is being increasingly used in invasive breast cancer. Describe the 21 gene
recurrence score (Oncotype Dx) and the Amsterdam 70 gene profile (Mammaprint). Explain the utility of these.
(4 marks)

Question 3
a)
Describe the histological features of cervical intraepithelial neoplasia (CIN).
(4 Marks)
b)

Describe the pathogenesis of cervical intraepithelial neoplasia (CIN).

(6 Marks)

Question 4
A 48 year old man with a history of a low grade glioma presents with headache, nausea and vomiting. A MRI scan
shows features that suggest the low grade glioma has transformed into a high grade glioma. Biopsy of the mass
confirms Glioblastoma Multiforme.
a)

List the WHO classification of gliomas.

(3 marks)

b)

Describe the histological features of gliomas.

(5 marks)

c)

Discuss the molecular genetic changes that are associated with the malignant progression from a low grade to
high grade glioma.
(2 marks)

Phase 2 Exam Written Papers

2011

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Question 5
Write short notes on:
a)

The pathology and biological behaviour of chordomas.

(2.5 marks)

b)

The morphology, immunophenotype and the predisposing conditions associated with mucosa-associated
lymphoid tissue (MALT) lymphoma.
(2.5 marks)

c)

The pathogenesis and histological features of radiation-induced fibrosis of the skin and subcutaneous tissue.
(2.5 marks)

d)

The risk factors and epidemiology of hepatocellular carcinoma.

(2.5 marks)

Phase 2 Exam Written Papers

2011

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FRANZCR Examination Phase 2 Radiation Oncology

Past Examination Papers
July / August Series 2011
RADIATION THERAPY 1
Time Allowed: 3 Hours
There are a total of SIX (6) questions.
Question 1
A 54 year old woman with good performance status presents with a two month history of cough and small volume
haemoptysis. A CT scan demonstrates a 5cm mass in the right lower lobe with subcarinal adenopathy. A biopsy shows
adenocarcinoma. A PET scan demonstrates uptake in the right lower lobe lesion, and subcarinal nodes only. The
patients lung function is excellent.
a)

What is your treatment recommendation for this patient? Provide evidence to justify your answer.
(2 marks)

b)

In general, what methods can be used to evaluate and account for respiratory movement when radiation
therapy is used in the definitive management of non-small cell lung cancer?
(2 marks)

c)

Describe a suitable radiation technique and dose prescription for treating this patient with curative intent.
(4 marks)

d)

Outline what you would do if the dose-volume constraints you have stipulated for the lungs cannot be met.
(2 marks)

Question 2
A fit 65 year old man has a routine health check and is found to have an elevated PSA of 6.5 ng/ml. Digital rectal
examination by the GP is normal. He undergoes TRUS-guided biopsies and is found to have adenocarcinoma of the
prostate; Gleason 3+4=7 disease in 4 of 12 cores, all on the right side.
a)

What factors would you consider in advising this man about his treatment options? Explain how these might
influence your recommendations.
(3 marks)

He opts for treatment with external beam radiation therapy alone.

b)

Describe a suitable radiation therapy technique and dose prescription for treating this man, using conformal
radiation therapy (3D-CRT).
(2 marks)

c)

Discuss methods and/or measures for ensuring accuracy of treatment delivery in this setting.
(3 marks)

d)

What potential acute and late toxicities would you discuss with this patient? Include a risk estimate for each
side effect.
(2 marks)

Phase 2 Exam Written Papers

2011

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Question 3
A 42 year old man is referred to you with a mass in his left thigh. A CT scan reveals a heterogenous tumour measuring
13 x 10 x 8cm in the proximal anterior compartment of his left thigh, suggestive of a soft tissue sarcoma.
a)

Describe the initial assessment and work-up of this man, including the purpose of any further investigations.
(2 marks)

A biopsy shows high grade leiomyosarcoma. Staging investigations do not show any metastatic disease.
b)

What are the management options for this man now? Include in your answer the potential advantages and
disadvantages of each approach.
(3 marks)

Preoperative radiation therapy is considered the optimal approach for treating this man.
c)

Describe a suitable radiation technique and dose prescription for this mans treatment.
(3 marks)

d)

What are potential toxicities and how would you manage them?
(2 marks)

Question 4
A 69 year old man is admitted to emergency with acute confusion. A brain MRI shows two lesions adjacent to the
lateral ventricle, with a moderate degree of surrounding oedema. There are no other clinical signs. He has complete
resolution of confusion within 24 hours of commencing dexamethasone. Stereotactic biopsy of one brain lesion shows
non-Hodgkins lymphoma (NHL). A CT scan of the chest, abdomen and pelvis is normal, as is bone marrow biopsy.
a)

What further investigations and/or work up would you perform prior to treatment?
(2 marks)

The NHL appears to be confined to the brain. The decision has been made to treat this patient with chemotherapy and
radiation therapy.
b)

What chemotherapy is usually employed and how would you schedule this with radiation therapy?
(2 marks)

c)

Discuss the potential long term side effects of this treatment.

(2 marks)

d)

Describe a suitable radiation technique and dose prescription for treating this patient. (4 marks)

Question 5
A 56 year old man was found to have a solitary 3cm lesion in the right upper lobe on a chest X-ray done for insurance
purposes. He has a past history of rectal carcinoma treated with an anterior resection. He is asymptomatic.
a)

What further information would you require to make a decision regarding further management?
(5 marks)

b)

What additional tests would you request and why?

(2 marks)

The lung lesion is confirmed to be an adenocarcinoma. The patient declines treatment and is lost to follow-up for 12
months. He then re-presents to the clinic with severe perineal pain and an ECOG performance status of 2. Further
staging investigations now show a 6cm recurrence in the pre-sacral region. He has limited lung and liver metastases.
He is considered unfit for chemotherapy. The decision has been made to give radiation therapy to the pelvis for pain
control.
c)

Describe a suitable radiotherapy technique and dose prescription for his treatment, justifying your choice of
approach.
(3 marks)

Phase 2 Exam Written Papers

2011

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Question 6
A 19 year old female university student presents with a 3cm right supraclavicular (SCF) mass. Aged 6, she was treated
for acute lymphoblastic leukaemia. She remained well until the current presentation. Biopsy of the SCF lymph node
confirms Nodular Sclerosing Hodgkins Disease. Staging investigations (CT and PET scans) show the SCF mass and
another 4cm mass in the superior mediastinum.
a)

What other factors would you take into consideration prior to deciding upon your treatment recommendation for
this woman?
(4 marks)

This patient has been discussed at the multidisciplinary meeting and a decision has been made to treat her with ABVD
chemotherapy followed by radiation therapy.
b)

What would you tell this patient about the potential toxicities of chemo-radiation in this setting?
(3 marks)

c)

Assuming that the patient has not had any radiation therapy in the past, describe in detail a suitable technique
and dose prescription, including dose constraints to organs at risk.
(3 marks)

RADIATION THERAPY 2
Time Allowed: 2 Hours
There are a total of FOUR (4) questions.
Question 1
A 75 year old caucasian man presents with a 3cm erythematous nodule in the infra-orbital right cheek. Further
examination reveals generally sun-damaged skin and a solitary 2cm lymph node in the right pre-auricular region. A
biopsy of the lesion and the lymph node shows histology consistent with Merkel cell carcinoma.
a)

In general, what is the role of radiation therapy in the management of Merkel cell carcinoma. Provide
justification for your answer.
(3 marks)

b)

What further information would you require before making a treatment recommendation for this patient?
(2 marks)

This mans case is discussed at a multidisciplinary meeting. The decision is made to treat him with radiation therapy
alone.
c)

Describe a suitable radiation technique and dose prescription to treat this man.
(4 marks)

d)

What is the expected outcome of treatment with respect to this cancer?

(1 mark)

Phase 2 Exam Written Papers

2011

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Question 2
A 69 year old man presents with a 4cm mass in the base of his tongue. He has a 2.5cm palpable lymph node in the left
upper cervical neck, and another 3cm node in the left mid cervical neck.
a)

How would you assess this patient further, explaining the reasons for any investigations you would order?
(2 marks)

Subsequent investigations reveal a squamous cell carcinoma which is HPV-negative. CT scan and PET scan
demonstrate the primary and neck nodes, as previously described. The decision has been made to treat with
concurrent chemo-radiation.
b)

Describe a suitable radiation therapy technique and dose prescription to treat this
man.
(3 marks)

c)

What advantages might the use of IMRT confer for this patients treatment? Give evidence and reasons to
support your answer.
( 2 marks)

d)

What are the epidemiological and clinical differences between HPV-positive and HPV -negative head and neck
cancers?
(3 marks)

Question 3
A 68 year old man presents with a 4cm mass in the distal oesophagus. Biopsy reveals adenocarcinoma. Endoscopic
ultrasound shows invasion beyond the muscularis propria (T3). CT and PET scans reveal no nodal or distant
metastases.
a)

Describe the curative treatment options available for this man. What is the rationale and evidence supporting
each approach?
(6 marks)

The decision has been made to treat with concurrent chemotherapy and radiation therapy.
b)

Describe a suitable radiation technique and dose prescription for this mans treatment; include an outline of a
suitable chemotherapy regimen.
(4 marks)

Question 4
A 4 year old boy had a left nephrectomy and regional lymph node dissection for a favourable histology Wilms tumour.
The pathology showed that the primary was completely removed but there was involvement of some left para-aortic
lymph nodes. There was no tumour spill or peritoneal involvement.
a)

In general, what are the indications for radiation therapy for a child with Wilms tumour?
(2 marks)

b)

Describe a suitable radiation technique and dose prescription for treating this boy.
(3 marks)

c)

What toxicities would you discuss with his parents?

(2 marks)

d)

In general, what factors are important to consider in minimizing the risk of long term toxicity from radiation
therapy in paediatric patients?
(3 marks)

Phase 2 Exam Written Papers

2011

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CLINICAL ONCOLOGY
Time Allowed: 3 Hours
There are a total of SIX (6) questions.

Question 1
Combined chemo-radiation is increasingly used in the management of gliomas.
Discuss the use of combined chemo-radiation in the management of:
a)

Glioblastoma Multiforme

b)

Anaplastic Astrocytoma

c)

Oligodendroglioma

Include in your answer the rationale and evidence for, and potential toxicities of, treatment.
A detailed radiation therapy technique is NOT required.
(10 marks)
Question 2
Peer review or audit of clinical practice is now a routine function in radiation oncology departments.
a)

What are the purposes of review of clinical practice by peers?

(3 marks)

b)

Describe the essential and desirable elements of a peer review process in radiation oncology.
(4 marks)

c)

What are possible disadvantages of, and/or problems with, conducting peer review?
(3 marks)

Question 3
A 68 year old woman presents with bony pain. A whole body bone scan shows extensive skeletal metastases including
lesions in the thoracic spine, right greater trochanter and multiple ribs. She has no prior history of cancer.
a)

Describe your initial management of this patient.

(4 marks)

Biopsy of a palpable supraclavicular lymph node confirms adenocarcinoma with positive ER- staining. Other imaging
does not show an obvious primary, or any other metastatic disease.
b)

What treatment options does this woman have at this time? Describe the indications for each option, giving
your reasons.
(3 marks)

She has severe pain in the left anterior 9th rib, in T10, T11 and T12, and in the proximal right thigh. Pain is not
controlled on narcotic analgesics.
c)

Describe a suitable radiation therapy technique and dose prescription to treat each of these areas.
(3 marks)

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2011

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Question 4
Follow-up clinics are commonly undertaken in cancer treatment centres.
Evaluate the usefulness of follow-up clinics from the perspective of patients of all ages, and of staff. Include in your
answer the potential benefits and problems arising from the conduct of such clinics. Give three specific examples
where follow-up of cancer patients has value, in your opinion.
(10 marks)
Question 5
With regard to the management of cervical cancer in a pregnant woman, what guiding principles and factors would you
consider?
A detailed radiation treatment technique is NOT required.
(10 marks)
Question 6
Fatigue and cachexia are commonly seen in cancer patients.
a)

Define cancer-related fatigue, and discuss its causes, mechanisms and management.
(7 marks)

b)

Write notes on cancer-related cachexia, including its assessment and management.

(3 marks)

PATHOLOGY
Time Allowed: 3 Hours
There are a total of FIVE (5) questions.
Question 1
For testicular germ cell tumours, describe:
a)

The risk factors for their development.

(2.5 marks)

b)

The related serum tumour markers and their clinical application.

(5 marks)

c)

The histopathological features of seminoma and its subtypes.

(2.5 marks)

Question 2
Write short notes on:
a)

The histopathological features of rhabdomyoscarcoma.

(2.5 marks)

b)

The pathogenesis of radiation-induced nephropathy.

(2.5 marks)

c)

Hereditary non-polyposis colorectal cancer (HNPCC).

(2.5 marks)

d)

The basal-like intrinsic subtype of breast cancer.

(2.5 marks)

Phase 2 Exam Written Papers

2011

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Question 3
For vulvar cancer describe:
a)

The histological subtypes.

(3 marks)

b)

The epidemiology, risk factors and pathogenesis of squamous cell carcinoma.

(3 marks)

A 70 year old woman undergoes a radical vulvectomy and bilateral inguinofemoral lymphadenectomy for a vulvar
carcinoma.
c)

Describe the features in the pathology report that would assist you in determining her prognosis and in the
decision making process.
(4 marks)

Question 4
Compare and contrast the risk factors, the biological behaviour and the histopathological features of:
a)

small cell lung carcinoma (classical variant).

(5 marks)

b)

bronchoalveolar carcinoma.
(5 marks)

Question 5
Many malignant tumours exhibit haematogenous spread. Describe the sequential steps involved in this process.
(10 marks)

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2011

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