ESMO EXAMINATION – Answers to trial questions

Type A – Single choice

The correct answers are marked in bold

A1
A 45-year-old patient, who has been treated for metastatic BRAF-wildtype melanoma for 6 weeks, presents in the emergency
department with severe fatigue, elevated temperature (37.9 °C) and abdominal discomfort. On examination he has a
performance status ECOG 2, oxygen saturation of 96 %, blood pressure 105/70 mmHg, heart rate 102/min and a normal
examination of chest and abdomen. Lab values show sodium 132 mmol/L (normal 135-145), potassium 4.6 mmol/L (normal
3.6-4.8), creatinine 67 μmol/l (0.8 mg/dl; < upper limit of normal),
CRP 26 mg/L (normal 0-10).
Which diagnostic step will most likely reveal the underlying problem?
A) ACTH stimulation test

B) Blood cultures

C) CT scan of the abdomen

D) Electrocardiogram and serum troponin

E) Serum TSH

A2
While you are on emergency duty, a 57-year-old patient, who started treatment for metastatic colorectal cancer three weeks
ago, presents with an itching rash (see picture). As recommended, he used daily moisturizing cream and protected the skin
from the sun. However, he forgot to take the daily pills that your colleague prescribed.
Which „pills“is he most likely referring to?
 A) Capecitabine

B) Ciprofloxacin

C) Doxycycline

D) Magnesium/calcium tablets

E) Vitamin B complex

A3
A 34-year-old woman, desiring future fertility, presents with newly diagnosed breast cancer (cT3 N+ M0, ER-positive, PR-
positive, HER2-negative). She’s scheduled to be treated with neoadjuvant anthracycline- and taxane-based chemotherapy,
breast surgery, adjuvant radiotherapy and endocrine therapy.
What is important regarding fertility?
A) An LHRH agonist during chemotherapy increases post-chemo pregnancy rates

B) Her age does not influence a future pregnancy

C) Initiating adjuvant endocrine therapy can safely be postponed for pregnancy

D) Ovarian stimulation with tamoxifen or an aromatase inhibitor for oocyte cryopreservation is recommended before
starting chemotherapy

E) Resuming menses is a reliable indicator for preserved fertility

A4
Regarding the metabolism of the 5-fluorouracil, which statement is correct?
A) Assessment of DPYD mutations can predict 5-FU toxicity

B) Dihydropyrimidine dehydrogenase (DPD) is a key enzyme in the metabolic catabolism of 5-FU but not of capecitabine

C) DPD activity is not a predictive biomarker of potential toxicity when using 5-FU

D) In patients with complete DPD deficiency, fluoropyrimidines could be used with an adapted posology

E) Patients with known partial DPD deficiency do not benefit from dose adaptation of their 5-FU therapy

A5
You see a new patient with metastatic cancer of unknown primary origin. Immunohistochemical work-up shows a CK7- and
CK 20-negative tumour.
Which of the following is the most probable origin?
A) Colorectal cancer

B) Merkel cell cancer

C) Ovarian cancer

D) Renal cell cancer

E) Urothelial cancer
A6
An 82-year-old woman with metastatic HER2-positive, hormone receptor-negative breast cancer suffers from dyspnoea on
exertion from pulmonary metastases. Concomitant diseases are well-controlled diabetes mellitus and arterial hypertension.
Cardiac, renal and hepatic function are normal for her age. ECOG performance status is 1.
Which is the best management for this patient?
A) Best supportive care

B) Trastuzumab, pertuzumab and lapatinib

C) Trastuzumab and fulvestrant

D) Trastuzumab and capecitabine

E) Trastuzumab and epirubicin

A7
An 82-year-old patient with metastatic castration-resistant prostate cancer has progressive disease upon first-line treatment
with enzalutamide. CT scan reveals new bone metastases, multiple enlarged lymph nodes and suspicion of a liver metastasis.
He has ischemic heart disease (with a left ventricular ejection fraction of 35 %), diabetes type II with a chronic diabetic foot
ulcer, chronic renal insufficiency (glomerular filtration rate of 40 ml/min), and minor cognitive impairment. He needs to rest
most of the day.
Which of the following treatment strategies is most appropriate?
A) Abiraterone acetate and prednisone

B) Best supportive care

C) Cabazitaxel

D) Docetaxel

E) Radium 223

A8
A 62-year-old patient with metastatic renal cell carcinoma was treated with third-line cabozantinib for 6 weeks and presented
to the emergency department with confusion, polydipsia and constipation. He uses oxycodone 30 mg twice daily for painful
bone metastases.
Blood pressure was 102/73 mmHg, heart rate 96/min, temperature 36.5˚ Celsius. Blood analyses show a haemoglobin of
89 g/L (normal 120-160), leucocytes 23 x109/L (normal 3.5-10), creatinine 126 µmol/L (normal 50-105), GFR 51 ml/min,
C-reactive protein 112 mg/L (normal <10), albumin 27 g/L (normal 35-50) and
calcium 3.10 mmol/L (normal 2.28-2.65).
Which of the following options is the most likely diagnosis and proposed treatment?
A) Anaemia: Blood transfusion is indicated

B) Infection: Broad-spectrum antibiotics are indicated

C) Hypercalcaemia: Isotonic saline infusion and bisphosphonates are indicated

D) Side effect from cabozantinib: Treatment should be interrupted

E) Side effect from oxycodone: Naloxone is indicated

A9
In patients with metastatic cancer, what is correct about pain management?
A) Analgesics for chronic pain should be prescribed on an ‘as required’ schedule

B) Fentanyl and buprenorphine are the safest opioids in patients with severely impaired renal function

C) In patients with recurrent bone pain re-irradiation should not be offered

D) Intravenous administration is the first-choice alternative for patients unable to receive oral or transdermal opioids

E) The opioid of first choice for moderate to severe cancer pain is fentanyl

A10
A 56-year-old man with metastatic urothelial carcinoma shows tumour progression under first-line chemotherapy with
platinum/gemcitabine.
Which of the following drugs improves survival in second-line treatment?
A) Atezolizumab

B) Methotrexate

C) Paclitaxel

D) Pembrolizumab

E) Vinorelbine
A11
An 82-year-old, otherwise healthy and very fit patient had an amputation of the 5th finger of the left hand because of a
melanoma 2 years ago. Histology showed pT3 pN0 (0/1) sn, Breslow 3.3 mm, BRAF wildtype. Now he is diagnosed with
symptomatic brain metastases; and asymptomatic soft tissue and lung metastases. He experiences resolution of the
neurological symptoms with
4 mg dexamethasone/day.
Which treatment is recommended?

A) Brain surgery followed by immunotherapy

B) Brain surgery followed by radiotherapy

C) Immediate immunotherapy

D) Stereotactic radiotherapy followed by immunotherapy

E) Whole-brain radiotherapy followed by immunotherapy

A12
Which of the following criteria is required for a complete remission (CR) according to the International Myeloma Working
Group (IMWG) in multiple myeloma?
A) >90% reduction of soft tissue manifestation

B) Absence of clonal plasma cells by Next Generation Sequencing (NGS) on bone marrow aspirate

C) Negative immunofixation on serum and urine

D) Normalization of free light chain (FLC)-ratio

E) Plasma cells <10% on bone marrow aspirate

A13
A 70-year-old man was diagnosed with a lung cancer of 8 cm diameter and infiltration of the right N. laryngeus recurrens.
PET-CT showed multiple enlarged hypermetabolic bilateral mediastinal lymph nodes but no distant metastasis. Histological
and immunohistological evaluation revealed adenocarcinoma with
PD-L1 expression of 55 % in the tumour tissue. The patient has a good performance status (ECOG 1) and normal renal
function.
Which is the optimal approach for this patient?
A) Cisplatin-based induction chemotherapy followed by sequential radiotherapy and immunotherapy with
pembrolizumab for one year

B) Cisplatin-based neoadjuvant chemotherapy followed by surgery, adjuvant radiotherapy and maintenance

immunotherapy with durvalumab

C) Definitive concurrent cisplatin-based chemo-/radiotherapy followed by one year of immunotherapy with durvalumab

D) Palliative immuno-/chemotherapy with pembrolizumab and carboplatin/pemetrexed for 4-6 cycles followed by
maintenance immunotherapy with durvalumab

E) Palliative immunotherapy with pembrolizumab

A14
A 75-year-old man with a 30-year smoking history is diagnosed with metastatic adenocarcinoma of the lung. Performance
status is ECOG 1.
Molecular analysis reveals no driver mutation or translocation in EGFR, ALK, ROS-1 and BRAF genes. PD-L1 expression is 80 %.
Which is the most appropriate treatment?
A) Combination therapy with carboplatin and paclitaxel

B) Combination therapy with cisplatin and pemetrexed

C) Combination therapy with cisplatin, pemetrexed and nivolumab

D) Monotherapy with pembrolizumab

E) Monotherapy with pemetrexed

A15
Which mutated gene is associated with HNPCC (hereditary non-polyposis colon cancer)-syndrome?
A) BRCA1

B) K-RAS

C) MLH1

D) Rb

E) TP53

A16
You are going to manage a 42-year-old man who underwent R0 resection for early stage pancreatic ductal adenocarcinoma.
He is otherwise healthy with ECOG performance status 1 and good organ functions.
What is the most appropriate adjuvant treatment?
A) 5-FU plus nano-liposomal irinotecan

B) Gemcitabine plus capecitabine

C) Gemcitabine plus erlotinib

D) mFOLFIRINOX

E) Nab-paclitaxel and gemcitabine

A17
Which statement regarding Temozolomide is correct?
A) It increases the risk of opportunistic infections

B) It is a 5-fluorouracil analogue

C) It is administered as monotherapy as a one week on, one week off scheme

D) It is less active in glioblastoma with methylated MGMT promoter

E) It prolongs QTc-time in ECG

A18
A 63-year-old woman is diagnosed with a high-grade, serous adenocarcinoma of the ovary, FIGO stage IIIC. She received
optimal debulking and recovered well from surgery. She has no concomitant diseases. ECOG performance status is 1. She is a
known carrier of a BRCA-1 mutation.
What is the best management for this patient to prevent progression?
A) Hyperthermic intraperitoneal chemotherapy

B) Regular follow-up and monitor CA-125 in the serum

C) Six cycles of carboplatin/paclitaxel

D) Six cycles of carboplatin/paclitaxel followed by bevacizumab maintenance

E) Six cycles of carboplatin/paclitaxel followed by olaparib maintenance

A19
A 60-year-old man was diagnosed with a tumour in the rectum (5.5 cm in diameter), 2 mm from the anal sphincter. Biopsy
revealed a mesenchymal tumour, spindle cell type, DOG1 and CD117 positive. Staging with PET/CT showed no evidence of
metastatic lesions but a high FDG uptake of the rectal mass.
What is the most appropriate treatment strategy?
A) Neoadjuvant imatinib, surgery and adjuvant imatinib

B) Neoadjuvant sunitinib, surgery and adjuvant sunitinib

C) Surgery (rectal amputation)

D) Surgery and adjuvant imatinib

E) Surgery and adjuvant sunitinib

A20
A 67-year-old woman has symptomatic progression of her metastatic liposarcoma after treatment with doxorubicin.
What is the preferred second-line treatment?

A) Ifosfamide

B) Gemcitabine and dacarbazine

C) Gemcitabine and docetaxel

D) Olaratumab

E) Trabectedin

A21
A 57-year-old patient was diagnosed with a cT3 N0, ER positive (25 %), PR negative (0 %), HER2-positive breast cancer. Staging
evaluation showed 6 bone metastases, confirmed by histopathologic examination. The patient is asymptomatic.
For which first-line treatment improved overall survival was demonstrated?
A) Anastrozol plus palbociclib

B) Capecitabine plus trastuzumab

C) Docetaxel plus trastuzumab plus pertuzumab

D) Lapatinib plus trastuzumab

E) Trastuzumab emtansine (TDM-1)

A22
A 68-year-old man is newly diagnosed with a prostate cancer showing the following features: Cancer in 6 of 12 core biopsies,
bilaterally, Gleason score 4+5=9,
PSA 10.4 ng/dl, CT and bone scan without evidence of lymphadenopathy or distal metastases.
What is the most appropriate treatment plan?
A) Active surveillance with yearly biopsies and PSA assessment

B) Brachytherapy

C) External beam radiotherapy and short-term androgen-deprivation therapy (ADT)

D) External beam radiotherapy and long-term ADT

E) Radical prostatectomy
A23
Based on randomised controlled trials, which adjuvant therapy is recommended for a healthy patient with completely
resected stage III, BRAF mutant (V600E) malignant melanoma?
A) Dabrafenib and trametinib for 12 months

B) Dacarbazine for 6 months

C) Interferon gamma for 24 months

D) Ipilimumab for 4 months

E) Nivolumab for 24 months

A24
A 59-year-old woman presents with dizziness, disorientation, imbalance and large cervical and axillary lymphnodes up to
7 cm. Laboratory analyses show abnormalities in leucocytes 34 x109/L (normal 3.5-10), haemoglobin 91 g/L (normal 120-160),
platelets 66 x109/L (normal 150-450), total protein 112 g/L (normal 64-83) and
IgM-concentration 64.5 g/L.
The neurological symptoms are most likely due to:
A) Anaemia

B) Cerebellar lymphoma involvement

C) Cerebral haemorrhage

D) Hyperviscosity

E) Meningeosis lymphomatosa

A25
A 43-year-old patient is newly diagnosed with HIV infection. In addition, a stage IIA diffuse large B-cell lymphoma (DLBCL) is
diagnosed.
What is correct?
A) Antiretroviral therapy should be initiated

B) Chemotherapy doses should be reduced by 25 %

C) Involved field radiotherapy should be given

D) No treatment for the DLBCL is necessary, if full immune-reconstitution is achieved

E) Primary G-CSF prophylaxis with R-CHOP 21 is indicated

A26
A patient is treated with FOLFOXIRI plus bevacizumab for metastatic BRAF-mutated adenocarcinoma of the colon. After the
second course the patient loses all his hair within 4 days.
Which drug is most likely the cause?
A) 5-fluorouracil

B) Bevacizumab

C) Ifosfamide

D) Irinotecan

E) Oxaliplatin
A27
A 65-year-old patient with jaundice is diagnosed with adenocarcinoma of the pancreas. CT scan shows no distant metastases.
Infiltration of which structure is most critical in limiting resectability?
A) Ampulla vateri

B) Duodenum

C) Portal vein

D) Splenic artery

E) Superior mesenteric artery

A28
A 60-year-old man presented with a left renal mass. Renal biopsy showed clear cell carcinoma. A CT scan revealed lung and
bone metastases. Blood test were normal, except for a haemoglobin of 97 g/L (normal 120-160).
What is the best approach for this patient?
A) Atezolizumab-bevacizumab

B) Cytoreductive nephrectomy followed by sunitinib

C) Cytoreductive nephrectomy followed by ipilimumab-nivolumab

D) Ipilimumab-nivolumab

E) Sunitinib

A29
Which of the following factors most prominently increases the fracture risk in postmenopausal women with breast cancer?
A) 25 pack-years of smoking

B) Bone mineral density (BMD) T-score of ≤ 1.5

C) High body mass index (BMI) (> 30 kg/m2)

D) History of oral corticosteroid use for 2 months

E) Tamoxifen treatment

A30
A 53-year-old patient with metastatic clear cell renal cell carcinoma is treated with nivolumab after prior progression on
sunitinib. He comes for his fourth 2-weekly infusion and complains of diarrhoea for the past few days with 8 liquid stools in
the last 24 hours. His blood pressure is 95/60 mmHg, heart rate 103/min and temperature 36.8 ˚C. The patient is admitted for
i.v. infusion. Stool examination rule out infection and a colonoscopy is planned.
Besides withholding nivolumab treatment, which of the following treatments should be initiated?
A) Antibiotics

B) Infliximab 5 mg/kg

C) Loperamide

D) (Methyl)prednisolone 2 mg/kg

E) Mycophenolate mofetil 500 mg 2x/day

A31
A 67-year-old man with metastatic low-grade small bowel neuroendocrine tumour and carcinoid syndrome receives
treatment with octreotide LAR 30 mg every 4 weeks. CT scan and radionuclide examination demonstrate progression of liver
and retroperitoneal metastases.
Which of the following treatments has been shown to significantly improve progression-free survival in such patients?
A) 177-Lutetium-dotatoc

B) High dose octreotide

C) Lanreotide

D) Sunitinib

E) Temozolomide, capecitabine

A32
A premenopausal 45-year-old woman underwent breast-sparing surgery with sentinel lymph node biopsy. A grade 1 invasive
ductal carcinoma of 7 mm diameter and negative sentinel lymph nodes were found, ER positive/PR positive, HER2-negative.
Which of the following approaches is most appropriate?
A) Adjuvant aromatase inhibitor and ovarian suppression

B) Adjuvant fulvestrant

C) Adjuvant raloxifene

D) Adjuvant tamoxifen

E) Follow-up only

A33
Which of the following therapies has the best outcome in a 45-year-old patient with chronic HCV liver cirrhosis, Child-Pugh
class A, and hepatocellular carcinoma (one nodule of 2 cm in each lobe; T2 N0 M0)?
A) Chemo-embolization

B) Liver transplantation

C) Nivolumab

D) Radio-embolization

E) Sorafenib

A34
What statement is correct about soft-tissue sarcoma (STS)?
A) Anthracycline and trabectedin are the backbone of systemic therapy in patients with metastatic STS

B) CT chest is mandatory for staging

C) Imatinib is standard of care in leiomyosarcoma

D) Primary site of metastases in STS are the lymph nodes

E) Risk of relapse in high-risk STS is highest in years 5-6 after initial diagnosis
A35
A 65-year-old heavy smoker was diagnosed with a pathological vertebral fracture. He complains about shortness of breath
when tying his shoes, swollen neck and frequent headaches. A fine-needle aspiration of a supraclavicular lymph node reveals
small cell cancer cytology.
What is the next procedure?
A) Biopsy of the supraclavicular lymph node

B) Concomitant chemoradiotherapy

C) Platinum-based palliative chemotherapy

D) Radiotherapy

E) Stent in superior vena cava

A36
A 53-year-old, otherwise healthy patient was diagnosed with a rectal cancer, 15 cm above the anal verge. CT and MRI staging
showed T3 N1 M0, negative circumferential resection margin (CRM).
What is the correct treatment strategy?
A) Neoadjuvant radiotherapy (5x5Gy) followed by surgery

B) Neoadjuvant chemoradiotherapy followed by surgery and adjuvant chemotherapy

C) Neoadjuvant chemoradiotherapy followed by surgery

D) Surgery followed by adjuvant chemotherapy

E) Surgery followed by adjuvant chemoradiotherapy

A37
A 51-year-old otherwise healthy woman presents with a pelvic mass. Surgical staging and optimal debulking reveals a 2 cm
epithelial serous ovarian tumour of low malignant potential in the right ovary, with capsule rupture and multiple peritoneal
implants without evidence of invasion.
What is the adequate management?
A) Observation

B) Six cycles of carboplatin/paclitaxel

C) Six cycles of carboplatin/paclitaxel and bevacizumab followed by 6 months of bevacizumab maintenance therapy

D) Six cycles of intraperitoneal cisplatin and i.v. paclitaxel

E) Three cycles of carboplatin/paclitaxel

A38
Which result in a randomized trial proves that a cancer screening test "saves lives"?
A) 5-year survival rates in cancer patients detected by screening are better than in cancer patients from the unscreened
population

B) More cancers are detected in the screened population than in the unscreened population

C) Mortality rates are lower among screened persons vs. unscreened persons

D) Screening detects cancer at an earlier stage

A39
A biomarker is a measurement variable that is associated with disease outcome.
The following graphs show a biomarker that is:

A) Both prognostic and predictive

B) Neither prognostic nor predictive

C) Predictive only

D) Prognostic only
A40
Which of the following targeted therapies represents standard of care for patients with metastatic or locally advanced basal
cell carcinoma that is not amenable to treatment with surgery or radiation therapy?

A) Dabrafenib

B) Dasatinib

C) Erlotinib

D) Trametinib

E) Vismodegib

A41
A 38-years-old patient is diagnosed with metastatic, neuroendocrine tumour (NET) of the lung. Ki-67 is 2%. All lesions show
avid uptake in somatostatin receptor-based diagnostic imaging. No neuroendocrine symptoms are present.
What is the most appropriate first-line treatment?
A) Everolimus

B) Lutetium-177 dotatate

C) Somatostatin analogue (SSA)

D) Cisplatin plus etoposide

E) Temozolomide plus capecitabine

A42
A 42-year-old man in a very good performance status (PS ECOG 0), noticed a large soft tissue mass (20 cm diameter) on his
right thigh. Histology revealed a high-grade pleomorphic sarcoma. The multidisciplinary team judged the tumour as
marginally resectable.
What is the most appropriate treatment strategy?
A) Chemotherapy followed by surgery and radiotherapy

B) Chemotherapy and radiotherapy followed by surgery

C) Surgery followed by radiotherapy

D) Surgery followed by radiotherapy and chemotherapy

E) Surgery alone
A43
A 69-year-old man is diagnosed with an adenocarcinoma of the right colon with multiple liver metastases (RAS wildtype, BRAF
mutated [V600E], microsatellite-stable [MSS]). Imaging during first-line treatment with FOLFOXIRI plus bevacizumab shows
disease progression.
What is the most appropriate second-line treatment?
A) Irinotecan plus bevacizumab

B) Nivolumab

C) Dabrafenib plus trametinib

D) Cetuximab plus Encorafenib

E) Nivolumab plus ipilimumab

A44
Which of the following criteria is recommended to assess treatment response in brain tumours?
A) RANO criteria

B) RECIST criteria

C) iRECIST criteria

D) Choi criteria

E) PERCIST criteria

A45
Fatigue is a frequent complaint of cancer patients, ranging from tiredness to exhaustion.
Which of the following approaches is recommended by the ESMO guidelines?
A) Dexamethason

B) Aerobic exercise

C) Methylphenidate

D) Acupuncture

E) L-carnitine
A46
The standard treatment for locally advanced anal cancer is chemoradiotherapy (CRT).
What is true concerning this curative approach?
A) Reduced local relapse rate is seen with dose intensification by radiation boost

B) Maintenance chemotherapy after CRT prolongs overall survival

C) Standard chemotherapy consists of mitomycin C plus 5-fluorouracil

D) More than 40% of patients require salvage surgery

E) Response assessment 11 weeks after CRT is best done by biopsy

A47
A 74-year-old man presents to his family doctor with progressive dysphagia and weight loss (-4kg in the past 6 weeks). He
drinks one bottle of wine every day and has a smoking history of 40 pack-years. Medical history: Coronary artery disease with
a stent placement 1 year ago and chronic obstructive pulmonary disease. Diagnostic tests (upper endoscopy with biopsies,
endoscopic ultrasound and PET-CT) reveal a squamous cell carcinoma in the mid oesophagus, cT3 cN1 M0.
Which is the most appropriate treatment strategy for this patient?
A) Oesophagectomy followed by adjuvant chemotherapy

B) Definitive radiochemotherapy

C) Neoadjuvant radiochemotherapy followed by oesophagectomy

D) Neoadjuvant chemotherapy followed by oesophagectomy

E) Best supportive care

A48
What is the treatment of choice for patients with locally advanced cutaneous squamous cell carcinoma not amenable to local
treatment?
A) Cisplatin plus 5-fluorouracil

B) Carboplatin plus paclitaxel

C) Ipilimumab plus nivolumab

D) Cemiplimab

E) Cetuximab
A49
A 64-year-old patient with metastatic bladder cancer has been treated with 6 cycles of cisplatin plus gemcitabine with a
partial remission. Performance status is good (ECOG 1) with normal organ functions.
What is the most appropriate next step?
A) Gemcitabine maintenance

B) Durvalumab maintenance

C) Avelumab maintenance

D) Tremelimumab maintenance

E) No maintenance treatment

A50
A 68-year-old woman with metastatic breast cancer (ER/PR positive, HER2 negative) has been treated with letrozole and
palbociclib as first-line treatment. Now, she experiences disease progression with multiple bone metastases and 4 liver
metastases up to 2 cm in diameter. Her performance status is good (ECOG 1), organ functions are normal. Genomic analyses
of tumour tissue reveal a PIK3CA mutation.
What is the most appropriate second-line treatment?
A) Everolimus plus exemestane

B) Alpelisib plus exemestane

C) Alpelisib plus fulvestrant

D) Ribociclib plus fulvestrant

E) Chemotherapy

A51
A 72-year-old man was newly diagnosed with metastatic prostate cancer and staged as cT3b cN1 cM1 (at least 5 bone
metastases: 3 vertebrae, left femur and ribs; 3 lung metastases). Gleason score is 9 (4+5), PSA 378 ng/ml. The patient has no
symptoms from the primary tumour.
Which answer is NOT correct?
A) According to CHAARTED definition this man has high-volume disease

B) According to LATITUDE definition this man has high-risk disease

C) Androgen deprivation therapy (ADT) plus docetaxel is a treatment option

D) ADT plus abiraterone/prednisolone is a treatment option

E) Radiation therapy to the primary tumour plus systemic therapy is recommended

A52
Which first-line treatment for advanced hepatocellular carcinoma (HCC) has shown the longest progression-free (PFS) and
overall survival (OS) in clinical trials?
A) Sorafenib

B) Lenvatinib

C) Cabozantinib

D) Atezolizumab plus bevacizumab

E) Ipilimumab plus nivolumab

A53
A 42-year-old patient was diagnosed with a malignant melanoma on his back (superficial spreading melanoma, Breslow
thickness of 1.2 mm, no ulceration). Sentinel node biopsy (left axilla) was negative.
Based on current guidelines, which management is appropriate?
A) Complete lymph node dissection of the left axilla

B) Adjuvant radiotherapy of the left axilla

C) Adjuvant nivolumab or pembrolizumab

D) Adjuvant interferon-alpha

E) Regular follow-up

A54
A 45-year-old patient with metastatic melanoma is treated with 3-weekly pembrolizumab. Serum analyses after 6 cycles are
shown here:
TSH: 0.043 mIU/l (normal 0.500 – 4.20)
fT4: 30 pmol/l (normal 10-25)
basal cortisol: 0.48 µmol/l (normal 0.15 - 0.70)

The patient has no symptoms. Blood pressure is 130/70 mmHg, heart rate 80/min.
What is the diagnosis and the most appropriate management?
A) Hyperthyroidism. Withhold immunotherapy and start prednisolone 0.5 mg/kg

B) Hypothyroidism. Withhold immunotherapy and start prednisolone 0.5 mg/kg in combination with thyroxine

C) Hyperthyroidism. Continue immunotherapy

D) Hypothyroidism. Continue immunotherapy, initiate thyroxine

E) Hypophysitis. Withhold immunotherapy and start prednisolone 1 mg/kg

A55
Which of the following drugs is associated with the highest risk for infertility in male patients?
A) Cyclophosphamide

B) Methotrexate

C) Bleomycin

D) Etoposide

E) Gemcitabine

A56
After complete resection of the primary tumour and of a single liver metastasis in a patient with metastatic colon cancer,
stage pT3 pN1 pM1, you receive the pathology report.
Which of the following results is associated with the worst prognosis?
Report Localization of primary KRAS NRAS BRAF MSI

A) right colon mut wt wt high

B) right colon wt wt mut low

C) left colon mut wt wt low

D) transverse colon wt mut wt low

E) distal colon (Sigma) mut wt wt high

wt: wildtype; mut: mutated, MSI: microsatellite-instability (by immunohistochemistry)

A) Report A

B) Report B

C) Report C

D) Report D

E) Report E
A57
A 32-year-old woman is diagnosed with stage IVB Burkitt lymphoma. Lymphoma affects supra-clavicular, mediastinal (bulk)
and inguinal lymph nodes and the liver (diffuse infiltration).
The patient has a long-term partner, with whom she plans to have children. The extension of the disease requires immediate
start of highly gonadotoxic treatment (within the next 10 days).
According to the ESMO guidelines, which is the best strategy for fertility preservation?
A) Ovarian stimulation (letrozole) - embryo cryopreservation

B) Embryo cryopreservation - tamoxifen during chemotherapy

C) Ovarian tissue preservation - GnRh analogue during chemotherapy

D) There are no effective fertility preservation measures in this emergency situation

E) Reduce cumulative dose of alkylating agents

A58
A 60-year-old patient has undergone complete resection of an adenocarcinoma of the head of the pancreas. He recovered
well from surgery. His only other condition is a longstanding diabetes with grade 3 polyneuropathy. Renal function is normal.
According to the ESMO guidelines, what is the most appropriate further management?
A) No adjuvant treatment, regular follow-up

B) Adjuvant FOLFIRINOX

C) Adjuvant radiotherapy to the pancreatic region

D) Adjuvant gemcitabine plus capecitabine

E) Adjuvant gemcitabine plus olaparib

A59
A 72-year-old man with extensive disease small-cell lung cancer (SCLC) is treated with cisplatin plus etoposide. His ECOG
performance status is 1. During the first cycle a severe anaphylactic reaction to etoposide occurs.
Which of the following is the best option to replace etoposide in a platinum-based doublet?
A) Paclitaxel

B) Vinorelbine

C) Irinotecan

D) Pemetrexed

E) Gemcitabine
A60
Which of the following targeted agents used in advanced breast cancer treatment is associated with an increased risk of
venous thromboembolism (VTE)?
A) Abemaciclib

B) Everolimus

C) Alpelisib

D) Olaparib

E) Neratinib

A61
A 69-year-old man is newly diagnosed with metastatic, EGFR-mutated non-small-cell lung cancer with PDL-1 expression of
60%.
What is the most appropriate first-line treatment?
A) Pembrolizumab

B) Carboplatin, pemetrexed and pembrolizumab

C) Gefitinib and pembrolizumab

D) Osimertinib

E) Osimertinib and pembrolizumab

A62
The Follicular Lymphoma International Prognostic Index (FLIPI) allows a prognostic differentiation in 3 risk categories
concerning the risk of relapse.
Which is NOT a risk factors in this score?
A) Elevated serum LDH

B) Age > 60 years

C) Haemoglobin < 120 g/L

D) Splenomegaly

E) > 4 lymph node regions affected

A63
A 79-year-old man is diagnosed with diffuse large B-cell lymphoma (DLBCL), Ann Arbor stage IIIA. Comorbidities are diabetes
mellitus, arterial hypertension. He suffered a stroke 5 years ago without persisting neurological deficit. Left ventricular
ejection fraction is 55%, creatinine clearance is 55 ml/min. A geriatric assessment shows the following:
Co-medication 4 different drugs/day

Weight - 2kg over past 6 months

Appetite decreased

Mental health good, stable

Cognitive function tests normal

Social network strong support by family (lives nearby)

Mobility independent (daily shopping by foot)

Which is the most appropriate therapy?

A) R-CHOP

B) Best supportive care

C) Obinutuzumab plus bendamustine

D) Radiation therapy

E) Etoposide monotherapy

A64
A 75-year-old man presented to his family doctor due to progressive fatigue. The laboratory analyses reveal a lymphocytosis
of 100 x109/L (normal 1.0-4.8), haemoglobin of 85 g/L (normal 120-160) and platelets of 60 x109/L (normal 150-450). Further
studies confirm the diagnosis of a chronic lymphatic leukaemia (CLL).
Which of the following factors is associated with a very good clinical outcome?
A) IGHV wild type

B) del 13q 14

C) del(17p)

D) TP53 mutation

E) Stage Binet C
A65
A 30-year-old previously healthy woman presents with shortness of breath and chest pain. She also reports night sweats for
the past three weeks. On physical exam, she has mild lymphadenopathy of the left cervical chain, no hepatosplenomegaly.
Her labs were normal. A CT scan reveals a 7 cm mediastinal mass and left cervical lymphadenopathy. A biopsy of the
mediastinum was performed and shows classical Hodgkin lymphoma. Availability of PET and CT at the treating centre are no
issue.
According to the PET-guided approach of the ESMO guidelines, at what intervals should PET and CT scans be done for this
patient?
A) PET after cycle 4 and at the end of treatment. CT scan every 6 months for the first 2 years

B) PET after cycle 2, 4 and at the end of treatment. CT scan every 3-4 months for the first 2 years

C) PET at the end of treatment. CT scan every 3-4 months for the first 2 years

D) PET after cycle 2 and at the end of treatment. CT scan as clinically indicated

E) PET at the end of treatment. CT scan as clinically indicated

A66
A 64-year-old man with a locally advanced laryngeal carcinoma underwent total laryngectomy. Due to extracapsular spread
he received adjuvant chemoradiation. He completed his therapy 10 months ago. In the follow-up consultation he complains
about severe fatigue, forgetfulness and dry skin. He has a dry mouth, but he can eat solid food.
Which of the following is the most appropriate next step?
A) PET-CT scan to rule out brain metastases

B) Explain to patient that this is a normal part of recovery

C) Start patient on amphetamines

D) Refer patient to psychiatrist to evaluate for possible depression

E) Check TSH and free T4/T3

A67
A 67-year-old patient with newly diagnosed chronic lymphocytic leukaemia (CLL) with a deletion del(17p) and several
comorbidities needs a first-line treatment.
What is the most appropriate treatment?
A) Fludarabine, cyclophosphamide plus rituximab

B) Ibrutinib monotherapy

C) Bendamustine plus rituximab

D) Obinutuzumab plus chlorambucil

E) Alemtuzumab plus high-dose steroids

A68
A 55-year-old man with newly diagnosed non-small-cell lung cancer (NSCLC) of the left upper lobe reports constant sweating
of the left forehead.
Which lesion explains this patient‘s symptom?
A) C7 cervical spinal cord compression

B) Impingement of the left sympathetic trunk

C) Impingement of the left parasympathetic trunk

D) Right cervical ganglion infiltration

E) Left cervical ganglion infiltration

A69
Which of the following are the best validated prognostic factors for GIST?
A) Mitotic rate, tumour size and tumour site

B) Mitotic rate and lymphovascular invasion

C) Tumour size and surgical resection margins

D) Tumour size and tumour rupture

E) Mitotic rate and tumour rupture

A70
A 54-year-old woman presents with chest pain and shortness of breath. CT scan showed multiple pleural and lung
metastases. A biopsy of an enlarged axillary lymph node was performed and showed an ER negative, PR negative, HER2
positive breast cancer.
Which is the most appropriate first-line therapy?
A) Docetaxel, trastuzumab plus pertuzumab

B) TDM-1

C) Tucatinib plus pertuzumab

D) Capecitabine plus trastuzumab

E) Trastuzumab deruxtecan
A71
A 75-year-old man was referred because of an elevated PSA serum level (16 ng/ml). He has no specific complaints.
Which is the most appropriate first diagnostic procedure?
A) Transrectal biopsy

B) CT scan

C) PSMA-PET-CT scan

D) FDG-PET-CT scan

E) Multi-parametric MRI

A72
Which of the following statements about adrenocortical carcinoma (ACC) is FALSE?
A) ACC is rare with an estimated incidence of ∼0.5-2 new cases per million people per year

B) In cases of suspected ACC, an extensive steroid hormone workup is recommended

C) Pre-operative biopsy to confirm suspected ACC is indicated

D) Complete en-bloc resection of ACC is the mainstay of a potentially curative approach

E) Adjuvant mitotane is recommended in patients at high risk of recurrence

A73
Which is NOT a typical side effect of bleomycin?
A) Peripheral neuropathy

B) Flu-like symptoms

C) Pneumonitis

D) Nausea

E) Hyperpigmentation
A74
A 64-years-old patient with metastatic ER positive, PR positive, HER2 negative breast cancer is treated with fulvestrant and a
CDK4/6-inhibitor. After 8 months of stable disease, re-staging shows progression with 5 new liver metastases and unchanged
bone metastases. ECOG performance status is 1. Laboratory values are normal except for mildly increased serum levels of
ASAT and ALAT (1.8xULN).
What is the most appropriate next step?
A) Taxane-based combination chemotherapy

B) Biopsy of liver metastasis

C) Surgical consultation regarding resectability of liver metastases

D) Single-agent chemotherapy (taxane or anthracycline)

E) Switch to aromatase inhibitor and CDK4/6 inhibitor

A75
A patient with small and fragile veins needs to start systemic treatment in the outpatient setting. Peripheral vein access for iv-
infusion is difficult, but usually possible after two or three attempts. The patient is reluctant to obtain a central venous access.
For planned repeated administration of which of the following drugs is a central venous access strongly recommended
despite the patient’s reluctance?
A) Methotrexate

B) Pertuzumab

C) Carboplatin

D) Ipilimumab

E) Epirubicin

A76
Many orally administered drugs should not be taken together with grapefruit juice.
Which pharmacokinetic process is mainly affected by this interaction?
A) Drug absorption (gastric pH)

B) Drug formulation stability (liberation)

C) Drug distribution

D) Drug metabolism

E) Drug excretion
A77
Adjuvant chemotherapy should be offered to fully staged patients with early stage ovarian cancer (stage I–IIA), EXCEPT:
A) Low-grade serous carcinoma, stage IA

B) Grade 1 and 2 endometrioid carcinoma, stage IIA

C) Grade 1 and 2 mucinous carcinoma, stage IIA (expansile invasion)

D) High-grade serous carcinoma, stage IA

E) Germ-cell cancer, stage IIA

A78
Which of the following is the most reliable indicator of pain?
A) Physical examination

B) Patients' self-report

C) Basal cortisol serum level

D) Functional assessment

E) Neurological assessment

A79
Regarding Hodgkin lymphoma, what is correct?
A) The peak incidence in the general population is between the ages 10 and 20 years

B) «Nodular sclerosis» is the most common histological subtype

C) The risk of Hodgkin lymphoma in HIV-positive patients is similar to the risk in the general population

D) The standard chemotherapeutic regimen is the CHOP regimen

E) Human Papilloma Virus (HPV) is one of the risk factors in young people
A80
Which of the following skin toxicities is NOT typically observed during single-agent treatment with an anti-EGFR monoclonal
antibody?
A) Hand-foot syndrome

B) Paronychia

C) Photosensitivity

D) Pruritus

E) Xerosis
Type K – Quadruple
Correct (T)
Incorrect (F)
The correct answers are marked in bold

K1
A 51-year-old perimenopausal woman was diagnosed with breast cancer (invasive ductal adenocarcinoma G2, ER/PR positive,
HER2 negative) in a core biopsy triggered by a finding on screening mammography. She is asymptomatic and otherwise
healthy.
Which assessment(s) is/are indicated as next step(s) for further treatment decisions?
A) PET/CT scan

B) Serum oestradiol/FSH

C) Serum CA 15-3

D) Ultrasound of axilla ultrasound of axilla

K2
According to the ESMO Guidelines which of the following statements concerning gastrointestinal (GI) toxicity of immune
checkpoint inhibitors is/are correct?
A) Calcium/vitamin D supplementation and pneumocystis prophylaxis is recommended for systemic steroid use > 4
weeks

B) Intense immunosuppression with infliximab for severe GI toxicity is associated with decreased treatment efficacy

C) Median time to onset of severe GI toxicity with PD1- or PD-L1-inhibitor monotherapy is 12 weeks

D) Tapering of corticosteroids after response to initial 4-day intravenous treatment with 1-2 mg/kg methylprednisolone
for grade 3 diarrhoea is recommended over 6-8 weeks

K3
Which statement(s) is/are correct?
Microsatellite instability (MSI)
A) is associated with good prognosis in early stage colorectal cancer.

B) is found in 20 % of patients with stage IV colon cancer.

C) is a condition of genetic hypomutability.

D) results from defects of the mismatch repair system.

K4
A 73-year-old female never smoker is diagnosed with metastatic adenocarcinoma of the left upper lobe of the lung.
Performance status is ECOG 0. PD-L1 expression is 70 %. Molecular analyses reveal a translocation in the ALK gene.
Which is/are the appropriate treatment(s)?
A) Alectinib

B) Crizotinib

C) Nivolumab

D) Pemetrexed-containing chemotherapy
K5
Patients with asymptomatic, stable advanced follicular lymphoma (FL) do not require immediate treatment but should be
followed closely.
Which of the following is/are clear indication(s) to start therapy?
A) Age ≤ 60 years

B) Elevated LDH and beta-2 microglobulin

C) Night sweats

D) Symptomatic extranodal disease

K6
Concerning human papilloma virus (HPV) positive oropharyngeal cancer (OPC), which of the following statements is/are
correct?
A) HPV-positive OPCs have a favourable prognosis

B) HPV positivity is sufficiently defined by immunohistochemistry of P16

C) HPV status is part of the current AJCC classification system

D) Radiotherapy in combination with cetuximab is a validated de-escalation strategy in locally-advanced disease

K7
In a phase III trial, patients with metastatic cancer are randomized between standard treatment and the new drug Esmolalib.
Median survival (primary endpoint) with 800 included patients is 7.5 months for Esmolalib and 7 months for the standard
treatment; HR = 0.88 (95% CI 0.79 – 0.97); p-value 0.04.
Which of statement(s) is/are correct?
A) 200 patients on standard treatment have died within 7 months of randomization

B) Based on this trial, Esmolalib is the new standard of care

C) The standard treatment and Esmolalib are equally effective

D) There is a 4% chance that the results are random

K8
A 33-year-old male patient is diagnosed with a melanoma on his back (Breslow 2.3 mm with ulceration, BRAF wildtype) and a
positive sentinel node biopsy (> 1 mm).
Which of the following statements is/are correct for this patient?
A) A complete lymph node dissection improves overall survival

B) Adjuvant local radiotherapy is indicated

C) Adjuvant immunotherapy with nivolumab improves recurrence-free survival

D) Adjuvant treatment with dabrafenib and trametinib improves overall survival

K9
What is correct for radiotherapy in non-metastatic soft tissue sarcomas (STS)?
A) It is of benefit after a full compartmental resection

B) It is indicated for STS after a R1 resection, if further resection is not feasible

C) It should be offered, in addition to surgery, for cases with a deep low-grade STS

D) Preoperative vs. postoperative radiotherapy results in similar local control

K10
Typical side effect(s) of 2nd and 3rd generation Tyrosine Kinase Inhibitors (dasatinib, nilotinib, bosutinib, ponatinib) in Chronic
Myeloid Leukaemia (CML) is/are:
A) Cardiovascular complications

B) Diarrhoea

C) Mucositis

D) Pleural effusion

K11
According to the ESMO guidelines adjuvant chemotherapy is recommended in patients with high-risk features of stage II
colorectal cancer.
Which of the following characteristics is/are considered ‘high-risk’?
A) T3

B) Tumour perforation

C) Number of examined lymph nodes < 10

D) Tumour grade 3

K12
Which of the following statements about denosumab is/are true?
A) Serum calcium levels should be monitored, especially during the first few months of treatment, and vitamin D levels
assessed before starting treatment

B) In patients with bone metastases denosumab should be administered every 4 weeks

C) After discontinuation of denosumab an increase in bone turnover markers and a rapid decrease in bone mineral
density (BMD) have been observed

D) The incidence of osteonecrosis of the jaw is about 10% per year on treatment
K13
Regarding triple negative breast cancer (TNBC) what is true?
A) Surgery is the first step in treating T3N0 disease

B) TNBC is more likely to recur within the first 5 years than other breast cancer subtypes

C) TNBC is the most common breast cancer subtype in BRCA1 mutation carriers

D) Bone metastases occur more frequently than in other breast cancer subtypes

K14
Concomitant radiochemotherapy after surgery of locally advanced squamous cell carcinoma of the head and neck (SCCHN) is
indicated in which of the following situations?
A) pT4

B) R1 resection

C) Perineural infiltration

D) Extracapsular spread

K15
Open oesophagectomy (transthoracic en bloc oesophagectomy with an extended two-field lymphadenectomy and
anastomosis in the upper chest with the use of a gastric conduit) for operable, oesophageal carcinoma of the middle and
lower oesophagus is a standard of care.
What is correct?
A) Mortality rate in experienced centres is around 5%

B) Major pulmonary events are the most common complications (in about 25% of patients)

C) Perioperative chemotherapy significantly increases the rate of major surgical complications

D) Postoperative mobilisation occurs at day 1

K16
Which statement/s about systemic treatment of malignant pleural mesothelioma (MPM) is/are true?
A) Debulking surgery followed by pemetrexed plus cisplatin is standard of care for unresectable disease without distant
metastases

B) Cisplatin is the most active cytotoxic drug in MPM

C) Vitamin B12 and folate are co-administered with pemetrexed

D) Ipilimumab plus nivolumab combination treatment in first line prolongs overall survival as compared to
chemotherapy
K17
Which of the following statements about opioids is/are correct?
A) Fentanyl can be safely used in patients with chronic kidney disease (estimated glomerular filtration rate < 30 mL/min)

B) The average relative potency ratio of oral to i.v. morphine is 1:1

C) A breakthrough dose of opioids is usually equivalent to 10% - 15% of the total daily dose

D) i.v. administration is an option for opioid titration when rapid pain control is needed

K18
A 49-year-old patient is diagnosed with a pure seminoma stage I. The tumour measures 6.2 cm and shows infiltration of the
rete testis. According to the ESMO guidelines, which treatment option/s is/are to be considered?
A) Active surveillance

B) Paraaortal radiotherapy with a total dose of 48Gy

C) Chemotherapy with two cycles of BEP (bleomycin, etoposide, cisplatin)

D) Chemotherapy with one cycle of carboplatin AUC7

K19
Neuropathic pain (NP) occurs in up to 40% of cancer patients.
Which of the following drugs is/are recommended for the treatment of NP?
A) Opioids

B) Levetiracetam

C) Gabapentin

D) Duloxetine

K20
A patient with metastatic castration resistant prostate cancer who has not received prior chemotherapy is progressing with
mildly symptomatic new bone metastasis and lymph nodes of 5cm diameter in his pelvis. Possible next treatment options are:
A) Abiraterone acetate plus steroids

B) Cabazitaxel plus steroids

C) Docetaxel plus steroids

D) RAD-223