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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 2012

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)
Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is
vir n vraag) geskryf word

1 A 65-year man is diagnosed with an adenoid cystic carcinoma of his left parotid. He
undergoes a parotidectomy and ipsilateral neck dissection. Pathology shows a 5cm
tumour, high grade with perineural invasion, positive margins and 2 out 7 nodes
positive
a) (i) How is the extent of residual tumour after surgical excision described in
the WHO staging system? (2)
(ii) What is the difference between prognostic factors and predictive indices?
Mention an example of a prognostic indicator and a predictive indicator
for any disease in Oncology (eg breast cancer). Would response to
treatment be a prognostic indicator or a predictive indicator? (3)
b) (i) Briefly discuss patient positioning, immobilisation and imaging acquisition
process for the radical post-operative treatment of the above patient.
What further imaging will be of assistance during the planning process?
(3)
(ii) Define the ICRU term PTV. How does it differ from the CTV? (1)
(iii) Briefly describe beam verification in the above case. (3)
c) (i) Name the Dmax in cm for cobalt 60, and for 6 MV and16 MV photons
from a Linac. What is the beam energy of choice for this patient? (2)
(ii) In Medical Physics, what is the main type of interaction between photons
and tissue with megavoltage irradiation. Why is the CT scan the imaging
modality of choice for radiotherapy treatment planning? (3)
(iii) How does IMRT affect the integral dose and dose gradients compared to
conventional 3D-CRT? What are the clinical significances of these
differences with IMRT? (3)
d) (i) How would a treatment gap of 5 days caused by machine breakdown
affect the tumour cure probability of a patient with squamous carcinoma
of the oral cavity? (2)
(ii) What is the mechanism of the late effects of irradiation on normal tissue?
(3)
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1 n 65-Jarige-man is gediagnoseer met n adenoied sistiese karsinoom van die linker
parotis. n Parotidektomie en ipsilaterale nekdisseksie word gedoen. Histopatologie
loon n 5 em tumor, hoe graads met perineurale infiltrasie, positiewe snyrande en 2
uit 7 limfnodes is positief
a) (i) Hoe word die omvang van die oorblywende tumor na chirugie in die WHO
stadieringsisteem beskryf? (2)
(ii) Wat is die verskil tussen prognostiese faktore en
voorspelbaarheidsindekse? Dui 'n voorbeeld aan van 'n prognostiese
aanwyser en 'n voorspellende aanwyser vir enige siektetoestand in
Onkologie (bv. borskanker). Sal respons op behandeling 'n prognostiese
aanwyser of 'n voorspellende aanwyser wees (3)
b) (i) Bespreek kortliks pasient posisionering, immobilisasie en die proses van
verkryging van beelding vir die radikale, post-operatiewe genoemde
pasient. Walter verdere beelding sal behulpsaam wees
beplanningsproses. (3)
(ii) Definieer die ICRU term PTV. Hoe verskil dit van die CTV? (1)
(iii) Beskryf kortliks bundelverifikasie in bogenoemde geval. (3)
c) (i) Noem die Dmaks in sentimeter vir Kobalt 60 en vir 6 MV en 16 MV
fotone vanaf. (2)
(ii) In mediese fisika, wat is die hooftipe interaksie tussen fotone en weefsel
met keuse vir bestralingsbeplanning? (3)
(iii) Hoe beinvloed IMRT die integrale dosis en dosisgradiente in vergelyking
met van hierdie verskille met IMRT? (3)
d) (i) Hoe sal 'n onderbreking van 5 dae in behandeling, wat veroorsaak is deur
n Versneller wat gebreek het, die tumor genesingswaarskynlikheid van n
pasient met plaveiselkarsinoom van die mondholte beinvloed? (2)
(ii) Wat is die meganisme van laat effekte van bestraling op normale
weefsel? (3)
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2 A patient has a 3 cm follicular cancer of the thyroid treated by subtotal
thyroidectomy. She is to have the thyroid remnant ablated by I-131
a) (i) How is iodine stored in the thyroid after uptake? (2)
(ii) How is iodine excreted from the body? (1)
(iii) Discuss the regulation of thyroid hormone secretion. (2)
(iv) What is the half-life of I-131 and what are the types of irradiation which
results from its decay? (2)
(v) What is the approximate tissue penetration of the particle irradiation
which results from I 131 decay and what is the energy of the photon
radiation emitted relative to technetium? (2)
(vi) After thyroid ablation, the patient is put on thyroxin. What is the aim of the
thyroxin? (2)
b) A patient present with the features of Cushings syndrome.
(i) What are the causes of Cushings syndrome? (3)
(ii) What are the symptoms and signs of Cushings syndrome? (4)
c) (i) Draw a graph showing tumour cure probability with an increase in
radiation dose. (2)
(ii) What radiobiological parameters do you need to calculate the acute and
late biological effects on normal tissue (eg mucosa and associated sub-
mucosa), of a hypo-fractionated course of irradiation to compare it with
conventional fractionation? (5)
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2 n Pasient het n 3 em follikulere tiroiedkarsinoom wat behandel is deur middel van
n subtotale tiroiedektomie.
a) (i) Hoe word jodium in die tiroied gestoor na opname? (2)
(ii) Hoe word jodium uitgeskei deur die liggaam? (2)
(iii) Bespreek die regulering van tiroied hormoon vrystelling. (2)
(iv) Wat is die halfleeftyd van I-131

en noem die t ipes bestraling wat Volg op
die veraI daarvan. (2)
(v) Wat is die geskatte weefsel penetrasie van die partikel bestraling wat volg
op 1
131
verval en wat is die energie van die foton uitstraling relatief tot
technesium. (2)
(iv) Pasiente word op tiroksien geplaas na tiroied ablasie. Wat is die Doel
van die tiroksien? (2)
b) n Pasient presenteer met die beeld van Cushing se sindroom.
(i) Wat is die oorsake van Cushing se sindroom? (3)
(ii) Wat is die simptome en tekens van Cushing se sindroom? (4)
c) (i) Teken n grafiek wat tumor genesings waarskynlikheid uitbeeld met n
toename in bestralingsdosis. (2)
(ii) Walter radiobiologiese parameters benodig u om die akute en laat
biologiese effekte op normale weefsel (bv. Mukosa en onderliggende sub-
mukosa) te bereken vir 'n hipo fraksionasie bestralings kursus sodat dit
vergelyk kan word met konvensionele fraksionisasie? (5)
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3 a) Tabulate 5 cancers induced by Tobacco. (5)
b) Tabulate 3 cancer susceptibility syndromes and name the mutations in either
caretaker or gatekeeper genes responsible. (7)
c) Tabulate 5 viruses implicated in aetiology of malignancy and the type of
malignancy it is related to. (5)
d) Tabulate 5 chronic inflammatory predisposing conditions associated with
tumour development and the cancers associated. (5)
e) Name 3 other etiological factors for cancer. (3)
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3 a) Tabuleer vyf kankers wat deur tabak induseer word. (5)
b) Tabuleer drie kanker-vatbaarheid sindrome en noem die mutasies. (7)
c) Tabuleer vyf virusse wat impliseer word in die etiologie van en die tipe
maligniteite wat daarmee verbind word. (5)
d) Tabuleer vyf chroniese inflammatoriese predisponerende wat met tumor
ontwikkeling geassosieer word asook die kankers. (5)
e) Noem drie ander etiologiese faktore vir die ontwikkeling van kanker. (3)
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4 a) What components does the pathologist have to report on in a percentage
form when evaluating Nephroblastoma histologically and why? (5)
b) What clinico pathological features influence the staging of nephroblastoma?
(7)
c) What are SIOP working classification of renal tumours of childhood divided
into? (3)
d) What treatment modalities are used to treat nephroblastoma? (2)
e) Discuss the biological agents which are active in the treatment of adult renal
cell carcinoma. Mention with each where it acts in the cell and where would
you place it in the treatment of renal cell carcinoma. (5)
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4 a) Walter komponente moet n patoloog persentasie gewys rapporteur wanneer
n nefroblastoom histologies evalueer word en hoekom? (5)
b) Walter klinies-patologiese eienskappe beinvloed die stadiering van
nefroblastome? (7)
c) Waarin verdeel die SlOP werkende klassifikasie nier tumore in pediatriese
pasiente? (3)
d) Uit watter modaliteite bestaan die behandeling van nefroblastome? (2)
e) Bespreek die biologiese middels met aktiwiteit in die behandeling van
volwassenes met renaalsel karisinoom. Meld in elke geval die werkings
meganisme en waar in die behandeling dit gebruik behoort te word. (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 2012

Paper 2 Radiotherapy & Cancer Chemotherapy (3 hours)

All questions are 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) What is the Oncotype DX, and which breast cancer patients are eligible for its
use? (5)
b) i) Name the 5 most common histologic subtypes of DCIS. (2.5)
ii) Which histologic subtype of DCIS has the worst and 2
nd
worst
prognosis? (2.5)
c) What is Phyllodes tumour of the breast and discuss the therapeutic
approach? (5)
d) What are the major side effects of
i) Tamoxifen. (2.5)
ii) Aromatase Inhibitors (AIs) (2.5)
e) i) What are some absolute contra-indications for Breast Conserving
Therapy (BCT) in patients with early breast cancer? (2.5)
ii) Discuss some relative contra-indications for BCT in patients with early
stage breast cancer. (2.5)
[25]

1 a) Wat is Oncotype DX en watter mamma karsinoom pasinte kwalifiseer vir die
gebruik daarvan? (5)
b) i) Benoem 5 algemene histologiese subtipes van DCIS. (2.5)
ii) Watter histologiese subtipes van DCIS het die swakste en 2de
swakste prognose? (2.5)
c) Wat is phylloides tumor van die mamma en bespreek die terapeutiese
benadering. (5)
d) Wat is die hoof newe effekte van
i) Tamoxifen. (2.5)
ii) Aromatase inhibitors (Als). (2.5)
e) i) Wat is die absolute kontra indikasies van borsbewarende terapie
(BBT) in pasinte met vroe mamma karsinoom. (2.5)
ii) Bespreek relatiewe kontra indikasies vir BBT in pasinte met
vroe stadium mamma karsinoom. (2.5)
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2 a) i) What % of cervical cancers is caused by HPV 16 and 18? (1)
ii) What HPV subtypes cause most cases of benign warts? (1)
iii) Name 3 histologic subtypes of adenocarcinoma of the cervix. (3)
b) i) Where is point A, and what should it correspond to anatomically? (2.5)
ii) Where is point B, and what should it correspond to anatomically?
How does the dose to point B typically relate to the dose to point A?
(2.5)
c) i) What RT dose can cause ovarian failure? What about sterility? (2)
ii) What should be the dose to point A in RT for cervical cancer (sum of
EBRT +brachytherapy) for each stage of disease? (3)
d) i) What are the regional lymph node drainage routes from the ovaries?
(2.5)
ii) What is CA 125, and what is its utility in ovarian cancer? (2.5)
e) i) What is the primary treatment modality for endometrial cancer? (1)
ii) What is resected in a total abdominal hysterectomy? (2)
iii) What is resected in a modified radical hysterectomy? (2)
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2 a) i) Watter % van serviks kankers word veroorsaak deur HPV 16 en 18?
(1)
ii) Watter HPV subtipe veroorsaak meeste gevalle van benige vratte? (1)
iii) Benoem 3 histologiese subtipes van adenokarsinoom van die serviks.
(3)
b) i) Waar is punt A en met watter anatomiese landmerke stem dit ooreen?
(2.5)
ii) Waar is punt B en met watter anatomiese landmerke stem dit ooreen?
Wat is die verhouding tussen die dosis van punt B tot die dosis by
punt A? (2.5)
c) i) Watter bestralings dosis kan ovarile versaking veroorsaak? en
steriliteit? (2)
ii) Wat moet die dosis by punt A in bestraling van serviks kanker wees
(som van EBRT + bragiterapie) vir elke stadium? (3)
d) i) Wat is die streeks limf dreinerings roetes van die ovaria? (2.5)
ii) Wat is CA 125, en wat is sy nut in ovarile kanker? (2.5)
e) i) Wat is die primre behandelings modaliteit vir endometrile kanker?
(1)
ii) Wat word resekteer in n totale abdominale histerektomie? (2)
iii) Wat word resekteer in n gemodifiseerde radikale histerektomie? (2)
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3 a) How do you manage a 30-year-old white male with a base tongue T2N2BM0
tumour? (5)
b) How does HPV effect the management of Oropharyngeal tumours? (5)
c) How do you do risk stratification of Oropharyngeal tumours? (5)
d) What are the characteristics of patient with HPV +ive tumour? (5)
e) What is the Prognostic Factors for a Base of tongue tumour? (5)
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3 a) Hoe hanteer jy n 30 jaar oue wit man met n T2N2bM0 tong basis tumor? (5)
b) Hoe benvloed HPV die hantering van Orofaringeale tumour? (5)
c) Hoe doen jy risiko stratifisering van Orofaringeale tumore? (5)
d) Wat is die eie*nskappe van n pasint met n HPV positiewe tumor? (5)
e) Wat is die prognostiese faktore vir n tongbasis tumor? (5)
[25]

4 a) What are different radiotherapy treatment options in rectal cancers? (5)
b) What is the rationale of preoperative radiotherapy? (5)
c) Discuss short versus conventional course preoperative radiation therapy. (5)
d) Discuss preoperative versus postoperative radiation therapy for rectal
cancers. (5)
e) Discuss the influence of timing of radiotherapy on sphincter preservation. (5)
[25]

4 a) Wat is verskillende bestralings behandelings opsies vir rektale kanker? (5)
b) Wat is die rasionaal vir pre-operatiewe bestraling? (5)
c) Bespreek kort- versus konvensionele kursus pre-operatiewe bestraling. (5)
d) Bespreek pre-operatiewe versus postoperatiewe bestraling vir rektale
kankers. (5)
e) Bespreek die invloed van die tydsberekening van radio terapie op sfinkter
behoud. (5)
[25]


















































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

22 August 2012

Paper 3 Radiation and Medical Oncology (3 hours)

All questions are 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) A 3-year-old girl presents with a hard lump near umbilicus. This is not
painful. A large 8 x 8 cm hard mass is palpable in the left flank. Laboratory
evaluation of the blood counts, urine-analysis, serum electrolytes, liver and
renal function tests are normal.
i) What investigations apart from the above will you do? (5)
b) This is a Wilms tumour. Table the National Wilms tumour Group Staging
(NWTGS). (8)
c) Discuss your treatment of Wilms tumour of stage IV disease to lung under
headings
i) Surgery. (3)
ii) Chemotherapy. (5)
iii) Radiotherapy. (2)
d) If vertebral bodies are irradiated how much of body of vertebra will be
included in radiation field and why? (2)
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1 a) n 3-Jarige-dogtertjie presenter met n harde knop naby die umbilikus. n
Groot 8 x 8 cm harde massa is tasbaar in die linker flank. Laboratorium
evaluasie van die bloedtellings, urine-analise, serum elektroliete, lewer en
nier funksie is normal. (5)
b) Dit is n Wilms tumor. Tabuleer die Nasionale Willms tumor Groep
Stadiring (NWTGS). (8)
c) Bespreek jou behandeling van Wilms tumor stadium 4 na die long onder die
volgende hoofde
i) Chirurgie. (3)
ii) Chemoterapie. (5)
iii) Bestraling. (2)
d) As vertebrale liggame bestraal word hoeveel van die vertebrale liggaam
moet ingesluit word in die bestralingsveld en waarom? (2)
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2 a) An 18-year-old male presented with a swelling of the lower leg. This is an
Ewing sarcoma of the tibia. List your investigations to reach above
diagnosis. (8)
b) When do you schedule chemotherapy in your treatment plan? (1)
c) Give chemotherapy regimes plus dos. (10)
d) Give the portals and doses for the radiotherapy treatment. (5)
e) What is the role of surgery.? (1)
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2 a) n 18-Jarige man presenteer met swelling van sy onderbeen. Dit is n Ewing
sarkoom van die tibia. Tabuleer die ondersoeke wat sal lei tot bogenoemde
diagnose. (8)
b) Wanneer word chemoterapie in u behandelingsplan geskeduleer? (1)
c) Tabuleer chemoterapie regimes plus dosisse. (10
d) Skryf kort notas oor die bestralingsvelde en die dosis van bestraling. (5)
e) Wat is die rol van chirurgie? (1)
[25]

3 a) The development of some paediatric brain tumours is related to certain
genetic syndromes. Name 3 such genetic syndromes and the tumours they
may be responsible for causing. (3)
b) What are the commonest presenting symptoms of medulloblastoma? (2)
c) Discuss the staging of medulloblastoma. (5)
d) i) Glioblastoma multiforme is commonly treated with combined
chemoradiation. What molecular test can be done to determine the
likelihood of responding to Temozolomide chemotherapy? (1)
ii) Discuss the mechanism of chemoresistance which forms the basis for
this test. (5)
e) Non-Pituitary adenomas with significant residual tumour following surgery
are frequently treated with post-operative radiotherapy
i) What dose and fractionation of radiotherapy would you use to treat
such a patient? (2)
ii) Name 4 organs at risk which would be contoured prior to planning
such treatment? (2)
iii) What would be your most likely beam energies and beam
configuration? (3)
iv) If the tumour was small enough, and far away enough from the
chiasm to be treated with stereotactic radiosurgery, what would be
your dose and fractionation? (2)
[25]

3 a) Die ontwikkeling van sommige pediatriese breintumore hou verband met
sekere Genetiese sindrome. Tabuleer 3 sulke genetiese sindrome en die
tumour wat hulle kan veroorsaak. (3)
b) Wat is die algemeenste simptome waarmee medulloblastoom presenteer. (2)
c) Bespreek die stadiring van medulloblastoom. (5)
d) i) Glioblastoma multiforme word gewoonlik behandel met
gekombineerde chemo-irradiasie. Watter molekulre toets kan
gedoen word om waarskynlikheid van respons op99 Temozolomide
chemoterapie te bepaal? (1)
ii) Bespreek die meganisme van chemoweerstandigheid wat die basis
vorm vir hierdie toets. (5)
e) Non-Pitutre adenoma met betekenisvolle residuele tumor na chirurgie word
dikwels behandel met post-operatiewe bestraling.
i) Watter dosis en fraksionasie van bestraling sal u gebruik vir so n
pasint. (2)
ii) Noem 4 kritieke organe wat ingeteken moet word voordat hierdie
behandeling beplan word. (2)
iii) Wat sal die mees waarskynlike bundel energie en konfigurasie wees?
(3)
iv) Wat sal jou dosis en fraksionasie wees indien die tumor klein genoeg,
en ver genoeg van die chiasma af wees om behandeling met
stereotaktiese radiochirugie te regverdig. (2)
[25]

4 a) i) Which 2 systemic treatment agents have shown a survival benefit
when used in the setting of metastatic melanoma? (1)
ii) Describe each agent's mechanism of action. (2)
iii) Name 1 side effect of each? (2)
b) A 40-year-old pilates instructor presents 3 months post partum with a mass in
the anterior abdominal wall just above her caesarean section scar.
The mass is 3X4 cm, painful and purplish in colour. It is excised by a surgeon
and histology comes back as a dermatofibro sarcoma protruberans. The
margins are close but clear. The surgeon elects to watch, but unfortunately
the lesion recurs 6 months later with 2 lesions noted both above and below
the C/S scar. The diameter measures about 8cm in total. Biopsy confirms
DFSP again
i) What treatment options should be considered now? (2)
ii) Which treatment would you recommend? Give reasons for this
recommendation. (3)
c) i) Give the indications for the use of 131-Iodine in thyroid carcinoma. (3)
ii) Describe side effects of treatment with 131-Iodine. (2)
d) i) Discuss the typical radiological features of localised Ewings sarcoma.
(3)
ii) Treatment of localised Ewings sarcoma is typically multi-modal. Give a
brief treatment timetable for systemic therapy and local therapy.
Please include names and schedule of chemotherapy drugs used
(doses not required) as well as a brief description of local treatment.(5)
iii) What is the prognosis (5 yr disease-free survival) for localised Ewings
sarcoma? (1)
iv) What is the risk for second malignancy in a Ewings patient who has
had multi-modality treatment? (1)
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4 a) i) Watter twee sistemiese behandeling middels het bewese oorlewings
voordeel in metastatiese melanoom? (1)
ii) Beskryf bogenoemde twee middles se werkingsmeganisme. (2)
iv) Noem een new-effek van elk van bogenoemde middels. (2)
b) n Veertig-jarige pilates Instrukteur presenteer 3 maande post-partum met n
anterior buikwand massa net bo die keisersnit litteken. Die massa meet 3 x 4
cm, is pynlik en is perskleurig. n Chirurg eksideer dit en die histologie toon
n dermatofibrosarkoom protuberans. Die chirurgiese snyrandte is naby
maar skoon. Die chirurg besluit om dit net op te volg maar ses maande later
herhaal die letsel met twee letsels beide bo en onder die keisersnit litteken.
Die totale afmeting daarvan is ongeveer 8 cm. Biopsie bevestig DFSP
herhaling.
i) Watter behandelingsopsies behoort nou oorweeg te word? (2)
ii) Watter behandelingsopsies sou u aanbeveel? Verskaf redes vir
u aanbeveling. (3)
c) i) Gee die indikasies vir die gebruik van jodium-131 in tiroied karsinoom.
(3)
ii) Beskryf die newe-effekte van behandeling met jodium -131. (2)
d) i) Bespreek die kenmerkende radiologiese eienskappe van
gelokaliseerde Ewing sarkoom. (3)
ii) Behandeling van gelokaliseerde Ewing sarkoom is gewoonlik multi-
modaal. Gee n kort behandelingsprogram vir sistemiese en locale
behandeling. Sluit name en skedulering van chemoterapie middles in
(u kan dosis weglaat) asook n kort beskrywing van lokale
behandeling. (5)
iii) Wat is die prognose (5jaar siekte-vrye oorlewing) van gelokaliseerde
Ewing sarkoom? (1)
iv) Wat is die risiko vir sekondre maligniteite in n Ewing pasint
wie met multi-modaliteit behandeling behandel is? (1)
[25]