ONCO

BREAST CANCER: In a 55-year-old patient with cytologically verified adenocarcinoma in the left breast, clinically measuring 3 cm, the most appropriate next step is: a.) Immediate surgery – mastectomy and sentinel lymph node biopsy. b.) Mammography and, in case of a solitary lesion, tumorectomy and sentinel lymph node biopsy. c.) Core needle biopsy of the tumor, mammography, ultrasound of the left axilla, and further management based on the findings. d.) Neoadjuvant systemic therapy. e.) Neoadjuvant radiotherapy.

BREAST CANCER: What are considered adequate surgical margins after breast-conserving surgery (lumpectomy) for invasive breast cancer?. a.) No tumor on ink (surgical margins are not infiltrated with tumor cells). b.) 1 mm. c.) 2 mm. d.) 5 mm. e.) 10 mm.

BREAST CANCER: In a 40-year-old patient with a 3 cm triple-negative breast cancer in the right breast and negative axillary lymph nodes, the most appropriate treatment sequence is: a.) Surgery, followed by systemic chemotherapy and immunotherapy, and in case of breast-conserving surgery, also radiotherapy. b.) Neoadjuvant systemic chemotherapy and immunotherapy, surgery, and in case of breast-conserving surgery, also radiotherapy. c.) (Neo)adjuvant systemic chemotherapy and immunotherapy, surgery, continuation of systemic therapy according to histological findings, and in case of breast-conserving surgery, also radiotherapy. d.) Neoadjuvant systemic chemotherapy and immunotherapy and, in case of a clinical complete response (tumor not visible on MRI), radiotherapy only. e.) Neoadjuvant systemic chemotherapy and immunotherapy and, in case of a clinical complete response (tumor not visible on MRI), no further treatment.

BREAST CANCER: A 55-year-old postmenopausal patient with a 1.5 cm invasive ductal carcinoma, ER+ HER2-, in the upper outer quadrant of the right breast underwent breast-conserving surgery. Is adjuvant radiotherapy indicated?. a.) Yes, because adjuvant radiotherapy has been shown to improve locoregional control and survival in patients with invasive breast cancer. b.) No, because adjuvant radiotherapy does not improve survival in patients with invasive breast cancer. c.) Yes, because all patients with non-metastatic breast cancer receive adjuvant radiotherapy. d.) No, because radiotherapy may cause severe pneumonitis. e.) Yes, because adjuvant radiotherapy eliminates the need for adjuvant endocrine therapy.

GIT/CC1: The primary care physician referred a 56-year-old patient for an abdominal ultrasound after an injury in the forest. The radiologist described a 2.5 cm lesion in segment 8 of the liver, in otherwise cirrhotic liver. The patient denies any symptoms. 1. Which examinations are needed first?. a) Medical history, clinical examination, laboratory tests. b) CT angiography. c) PET CT. d) No examinations are performed; the patient is urgently sent to the nearest emergency center.

GIT/CC1: In the history, the patient denies alcohol abuse, but on clinical examination, he appears intoxicated and has enlarged liver. Laboratory results show elevated gamma-GT, decreased albumin, while other parameters are normal. 2. What is the next step in management?. a) Priority referral for abdominal CT and AFP sampling. b) Urgent referral to internal medicine department. c) Urgent referral to a liver surgeon. d) Referral for PET CT.

GIT/CC1: CT scan shows a 2.5 cm tumor in segment 8 of the liver, with a smaller nodule less than one centimeter, which also enhances in the venous phase. 3. Which disease do you suspect?. a) Cholangiocarcinoma of the liver. b) Liver metastases. c) Hepatocellular carcinoma (HCC). d) Hepatoblastoma.

GIT/CC1: The primary care physician referred a 56-year-old patient for an abdominal ultrasound after an injury in the forest. The radiologist described a 2.5 cm lesion in segment 8 of the liver, in otherwise cirrhotic liver. The patient denies any symptoms. 4. Is cytological or histological verification of the lesions necessary if they enhance with contrast on CT?. a) Yes. b) No. c) Yes, because there are two lesions. d) Yes, because the liver is cirrhotic.

GIT/CC1: The primary care physician referred a 56-year-old patient for an abdominal ultrasound after an injury in the forest. The radiologist described a 2.5 cm lesion in segment 8 of the liver, in otherwise cirrhotic liver. The patient denies any symptoms. 5. What is the correct approach for the primary care physician in such patients?. a) Referral to surgical emergency. b) Referral to internal medicine department. c) Schedule patient for PET CT. d) Referral to the appropriate specialist.

GIT/CC1: The primary care physician referred a 56-year-old patient for an abdominal ultrasound after an injury in the forest. The radiologist described a 2.5 cm lesion in segment 8 of the liver, in otherwise cirrhotic liver. The patient denies any symptoms. 6. Which is NOT optimal treatment for this patient?. a) Surgical resection of both nodules. b) Hormonal therapy. c) Targeted therapy. d) RFA, MWA. e) SBRT.

GIT/CC2: A 59-year-old woman, who 10 years ago was treated with surgery, radiation, postoperative chemotherapy, and postoperative hormonal therapy for breast cancer, comes to her primary care physician due to newly developed jaundice and itchy skin. She has no other symptoms. On clinical examination, she is icteric, and laboratory results show markedly elevated bilirubin. 1. How should the primary care physician proceed?. a) Issue a referral for an abdominal ultrasound with high priority. b) Issue a referral for a CT scan of the abdomen and chest with high priority. c) Refer the patient to internal medicine for jaundice urgently. d) Urgently refer the patient to the oncologist who treated her for breast cancer.

GIT/CC2: A 59-year-old woman, who 10 years ago was treated with surgery, radiation, postoperative chemotherapy, and postoperative hormonal therapy for breast cancer, comes to her primary care physician due to newly developed jaundice and itchy skin. She has no other symptoms. On clinical examination, she is icteric, and laboratory results show markedly elevated bilirubin. 2. Further diagnostic evaluation reveals a tumor in the head of the pancreas without invasion into major vessels and without distant metastases. Who should provide an opinion on the proposed treatment?. a) Oncologist. b) Abdominal surgeon. c) Radiologist. d) Multidisciplinary tumor board.

GIT/CC2: A 59-year-old woman, who 10 years ago was treated with surgery, radiation, postoperative chemotherapy, and postoperative hormonal therapy for breast cancer, comes to her primary care physician due to newly developed jaundice and itchy skin. She has no other symptoms. On clinical examination, she is icteric, and laboratory results show markedly elevated bilirubin. 3. Surgery is performed, and the tumor is removed with negative margins (R0). Histology confirms pancreatic adenocarcinoma T3N0M0. What is the recommended follow-up management?. a) Adjuvant chemotherapy to reduce the risk of distant metastases, if the patient’s performance status and comorbidities allow. b) Adjuvant radiotherapy to reduce the risk of local recurrence. c) Only follow-up with the surgeon, since recurrence is unlikely due to absence of nodal metastases. d) Treatment with medical cannabis.

GIT/CC2: A 59-year-old woman, who 10 years ago was treated with surgery, radiation, postoperative chemotherapy, and postoperative hormonal therapy for breast cancer, comes to her primary care physician due to newly developed jaundice and itchy skin. She has no other symptoms. On clinical examination, she is icteric, and laboratory results show markedly elevated bilirubin. 4. Postoperatively, the patient receives 6 months of adjuvant chemotherapy with the mFOLFIRINOX regimen and is regularly followed. Two years later, a CT scan shows a new solitary lesion in the liver suggestive of metastasis. Tumor markers are not clearly elevated. What is the appropriate next step?. a) Initiate chemotherapy for metastatic pancreatic cancer. b) Core needle biopsy of the liver metastasis to confirm the origin and present the results at a multidisciplinary tumor board. c) Initiate hormonal therapy for metastatic breast cancer. d) Radical surgery of the liver metastasis.

GIT/CC2: A 59-year-old woman, who 10 years ago was treated with surgery, radiation, postoperative chemotherapy, and postoperative hormonal therapy for breast cancer, comes to her primary care physician due to newly developed jaundice and itchy skin. She has no other symptoms. On clinical examination, she is icteric, and laboratory results show markedly elevated bilirubin. 5. Core needle biopsy confirms metastasis of adenocarcinoma, immunohistochemically consistent with pancreatic origin. The multidisciplinary tumor board recommends systemic oncologic therapy. Considering her history of pancreatic and prior breast cancer, the oncologist advises oncologic genetic counseling. Which gene mutation is most likely in this patient based on her history?. a) VHL. b) TP53. c) BRCA2. d) APC.

GIT/CC2: A 59-year-old woman, who 10 years ago was treated with surgery, radiation, postoperative chemotherapy, and postoperative hormonal therapy for breast cancer, comes to her primary care physician due to newly developed jaundice and itchy skin. She has no other symptoms. On clinical examination, she is icteric, and laboratory results show markedly elevated bilirubin. 6. The patient receives platinum-based chemotherapy, with good response, but one year later the disease progresses with new liver metastases, local recurrence at the previous surgery site, and bone metastases. Severe pain develops. How can the patient be helped?. a) Initiate and appropriately titrate analgesic therapy, including opioids. b) Palliative radiotherapy for painful metastases is possible. c) If the patient still has adequate performance status, changing systemic oncologic therapy may help reduce disease symptoms. d) The correct answers are a, b, and c.