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

3 April 2013

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)

1 A 41-year-old lady has a left mastectomy for a pathological 40mm ductal carcinoma
involving skin, lympho-vascular invasion positive, Grade 3, oestrogen receptor negative,
node negative. She receives 6 cycles of anthracycline chemotherapy and is planned for
chest wall radiation. At planning it is noted that the field separation is 30cm.
a) Should this patient be planned on the simulator with 2-D fields or CT planned?
J ustify your choice. (2)
b) What is the ideal beam energy for this treatment? Why is this? (2)
c) For 3-D conformal planning for a patient that has undergone left sided breast
conserving surgery
i) Define your target volumes. (3)
ii) What field arrangement and technique will be used for the whole breast? (2)
iii) What prescription point will be used and what is the isodose at this
prescription point? (1)
d) What is your dose prescription in conventional fractionation and in a
hypofractionated regimen? Please give total dose/dose per fraction and number of
fractions (2)
e) Would you add bolus for the patient that underwent a mastectomy and what
thickness would you use? (2)
f) What are the organs at risk and Quantec dose constraints,? Are there any additional
factors to take into account for this patient and why? (4)
g) Name two advanced radiation planning techniques that may be used in place of 3-D
conformal RT. (2)
h) Describe patient immobilisation and the reasons for the technique used. (2)
i) Why is an inclined plane (approximately 15 degrees) sometimes used to position the
patient? (1)
j) How would you verify that the beams are administered accurately? (1)
k) How will the therapy radiographers ensure the patient receives the correct dose? (1)
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2 a) A 60-year-old male patient with unresectable stage III non small cell lung cancer is
treated with 60 Gy in 30 fractions (5x/week) and concurrent chemotherapy. He
develops oesphoagitis during week 3 of his treatment.
i) Explain the clinical and biological rationale behind using concurrent radiation
and chemotherapy to improve local control of disease. (4)
ii) What patient and treatment factors predict for a higher incidence of
oesophagitis? (4)
PTO/Page 2 Question 2a) iii)...
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iii) Describe grade 2, 3 and 4 oesophagitis according to the common terminology
criteria. (3)
iv) What is the anticipated incidence of grade 3 oesophagitis after the above
therapy? (1)
v) How is radiation oesophagitis treated? (1)
b) i) Briefly discuss testosterone metabolism from its production in the testis up to
its effect on the nucleus of its target cell? (4)
ii) What is the mechanism for the feedback regulation of testosterone production
by the hypothalamic pituitary- testicular axis in males? (4)
iii) What is the function of testosterone in the adult? (4)
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3 a) A biopsy of a 7-year-old childs bone and bone marrow reveals small round blue cells.
i) Give a differential diagnosis. (6)
ii) What tests are used to render a diagnosis? (5)
iii) A neuroblastoma is diagnosed. What clinical features are common with this
diagnosis? (5)
b) Name the AIDS-defining malignancies. (5)
c) What virus infections commonly occur in HIV infected patients that could lead to
malignancies? (4)
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4 A 60-year-old male presents with a T4NxM1 (liver) rectal carcinoma. The rectal tumour
infiltrates the presacral fat and prostate. He has multiple liver metastases, ECOG 1
a) What test would you expect your pathologist to do on the histology sample
that would guide you in your treatment of this Stage 4 rectum carcinoma patient? (1)
b) How would the results influence your choice of treatment? (4)
c) Describe the mechanism of action for the targeted therapies used in colorectal
cancer (7)
d) This patients local disease progresses on the systemic treatment with sacral plexus
infiltration. He experiences severe pain. His pain is not controlled on non-opioids or
opioid medication. What treatment options would you consider? (5)
e) This patient is now in for terminal care. How would you manage each of these
symptoms in this patient?
i) Severe loss of appetite.
ii) Dehydration.
iii) Constipation.
iv) Nausea and vomiting.
v) Ascites. (5)
f) Name risk factors for developing non-melanoma skin cancers. (3)
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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

4 April 2013

Paper 2 Radiation and Clinical 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) Discuss the prognostic indicators of Ductal Carcinoma in Situ (DCIS). (3)
b) Discuss the treatment options for DCIS. (4)
c) Indicate the principles for use of the Van Nuys prognostic index. (4)
d) What are the prognostic implications of a diagnosis of lobular carcinoma in situ
(LCIS)? (3)
e) Discuss treatment approach to LCIS. (2)
f) Name the indications for MRI investigations in patients with breast cancer. (4)
g) Discuss the indications for screening in breast cancer based on evidence and expert
consensus opinion. (5)
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2 a) Name 5 of the WHO broad classification subtypes for ovarian cancer (5)
b) The sub group Malignant epithelial tumours account for 90% of ovarian
cancers name 5 subtypes. (5)
c) What investigational and staging tests will you do for a cancer patient presenting with
a pelvic mass? (5)
d) Describe FIGO stage IIB ovarian cancer. (2)
e) Discuss chemotherapy for patients with epithelial- carcinoma. (3)
f) Discuss precautions and side effects for this regimen. (5)
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3 a) Discuss endocrine tumours of the pancreas. (5)
b) List risk factors of gastric cancer. (5)
c) A patient with dysphagia has the diagnosis of cancer of the oesophagus made on
endoscopy. Discuss indications for
i) Surgery. (2)
ii) Chemotherapy. (2)
iii) Radiotherapy. (2)
iv) Combinations of these modalities. (4)
d) List organ at risk dosages OAR dosages you would define in the planning of
treatment for a cancer of the oesophagus. (5)
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PTO/Page 4 Question 4
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4 a) Describe the lymphatic drainage of the ano- rectum. (5)
b) Discuss chemotherapy for anal cancer. (5)
c) Describe the radiotherapy for a patient with T3a, middle third rectal cancer under
the headings
i) Setup and margins for planning. (5)
ii) Prescription and field arrangements. (5)
d) Discuss dose fractionation regiments used in the treatment of rectal cancer. (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

5 April 2013

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 seventy-year-old male patient presents with PSA 10ng/ml of 10.
i) List the differential diagnoses. (3)
ii) How would you investigate this patient further? (3)
iii) What types of radiation treatment may of value for bone metastases? (2)
iv) What dose of EBRT might you use to treat painful bone metastases in a
patient with Ca Prostate? (2)
v) List all types of hormone treatment which may be used in the treatment of
prostate cancer. (3)
(13)

b) A twenty-year-old male presents with a hard lump in his testis.
i) How would you make a definitive diagnosis? (2)
ii) List two broad categories of common testicular cancers for this age group and
mention any blood markers which may aid in diagnosis and follow up. (4)
iii) Discuss the broad principles of management in a patient with Stage 1 disease
of each category mentioned above. (6)
(12)
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2 A patient presents with an anterior mediastinal mass and new onset of ptosis with
fatiguability.
a) What is the most likely diagnosis? (1)
b) Name the commonest para-neoplastic disorders which may be associated with this
diagnosis. (3)
c) Give a list of differential diagnoses for a patient with an anterior mediastinal mass.
How would you make the diagnosis? (4)
d) How is the distinction made histologically between thymoma and thymic carcinoma?
(3)
e) Discuss the role and doses of radiotherapy used in the management of thymic
carcinoma. (3)
f) Which techniques of radiotherapy might be used? List 4. (2)





PTO/Page 2 Question 2g)...

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g) Please define and describe the following for a patient receiving post-operative
radiotherapy for thymic carcinoma
i) GTV. (1)
ii) CTV. (1)
iii) PTV. (1)
in OAR (Include dose constraints). (4)
What is your prescription for 3-D conformal RT for a patient with
v) Positive margins(microscopic)? (1)
vi) Negative margins? (1)
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3 A 36-year-old man is referred to you with a slightly painful, rapidly enlarging mass over the
left trapezius muscle on the right shoulder. He is fit and has no other medical history and no
other symptoms. CT scan shows a soft tissue mass involving the muscle and soft tissue,
but not involving the bone. A biopsy is performed
a) If the biopsy reveals the mass to be a myxoi d liposarcoma
i) Please discuss what further investigations you would request on this patient
and why? (3)
ii) If the investigations show a localised myxoidliposarcoma with no signs of
bony involvement or neurovascular invasion and no metastases, briefly
outline what treatment you would offer to this patient. (Detailed treatment
regimens are NOT required.) (7)
iii) If the investigations reveal myxoidliposarcoma with 3 lung soft tissue nodules
suspicious for metastases in the left upper lobe of the lung and no other
metastases, briefly outline the treatment that you would offer to this patient.(6)
b) If the biopsy reveals the mass to be aggressive fibromatosis
i) Give another name for this type of tumour. (1)
ii) With which genetic disorder can this tumour be associated? (1)
iii) The surgeon feels that the mass is resectable, however the tumour is large
and surgery would require a flap and carry significant morbidity with the
possibility of brachial plexus injury. There is also no guarantee of complete
resection. The patient is not keen, and consults you to find out if there are any
other treatment options, and the likelihood of long term tumour control
compared to surgery. Please outline how you would answer this patients
query. (7)
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4 a) Please name the commonest presenting symptoms for a child with
Craniopharyngioma. (3)
b) A 5-year-old child with subtotal resection of a localised posterior fossa grade 2
ependymoma is referred to you.
i) What further treatment would you advise and why? (2)
ii) If radiotherapy is to be given, please describe the radiotherapy technique
used, in terms of positioning, volumes, and dose. (6)
c) A 46-year-old patient is referred to you with a presumed acoustic neuroma. A 2cm
left sided cerebello-pontine mass is seen on MRI scan.
i) What treatment options would you discuss with this patient, and which would
you recommend, and why? (4)
ii) How effective is this treatment and what side effects could this patient expect?
(4)
iii) Briefly describe the procedure mentioned in the question above. (6)
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