For each question, choose the answer you think is correct. See the end of this page for the answers.
Dual modality case study – patient H.N.
H.N. is a 47 year old male diagnosed with locally advanced squamous cell carcinoma of the oropharynx (related to HPV). He is scheduled to start a combination treatment with cisplatin and radiation therapy as per the HNLAPRT dual modality protocol.
Lab results taken 24 hours prior to starting treatment:
| Lab value | Patient's labs | Normal range |
| WBC | 5.1 | 4 – 10 x 109/L |
| ANC | 7.3 | 2 – 7.5 x 109/L |
Hgb
| 152 | 115 – 155 g/L |
| Plt | 244 | 150 – 400 x 109/L |
| SCr | 145 | 45 – 90 umol/L |
| Calculated CrCl | 74 | ≥ 60 mL/min/1.73m2 |
| Calcium | 2.31 | 2.10 – 2.60 mmol/L |
| Magnesium | 0.92 | 0.64 – 0.98 mmol/L |
| Sodium | 140 | 135 – 145 mmol/L |
| Potassium | 4.8 | 3.5 – 5.0 mmol/L |
| Albumin | 46 | 35 – 50 g/L |
| ALT | 61 | <50 U/L |
| Alk Phos | 88 | 40 – 145 U/L |
| Total bilirubin | 3 | <17 umol/L |
| LDH | 206 | <225 U/L |
| Random blood glucose | 10.4
| 3.3 – 11 umol/L |
Urea
| 5.5
| 2 – 9 mmol/L
|
Weight = 93.5 Kg, Height = 178.6 cm ECOG = 1
Choose ONE best answer:
- Cisplatin is a radiosensitizer
- Cisplatin is a chemosensitizer
- Cisplatin is effective only when used in combination with radiation therapy
- All of the above
- Netupitant-palonosetron 300 mg-0.5 mg PO 30 to 60 minutes prior to cisplatin
- Ondansetron 8 mg 30 – 60 minutes prior to cisplatin and then 8 mg every 12 hours x 6 doses
- Dexamethasone 12 mg 30 – 60 minutes prior to cisplatin and then 4 mg every 12 hours x 6 doses
- Options 1 and 3 only
- All of the above
- Placement of a feeding tube for nutritional needs
- Oral hygiene treatment with sodium bicarbonate mouth rinse or antifungals and antibiotics prn
- Pre and post hydration with D5W-1/2NS along with potassium chloride and magnesium sulfate
- Dry mouth treatment with pilocarpine tablets
- All of the above
- 215 mg once every 3 weeks for up to 3 cycles
- 215 mg once every week for up to 3 cycles
- 172 mg once every 3 weeks for up to 3 cycles
- 172 mg once every week for up to 3 cycles
- 7000 centigrays in 35 weeks
- 7000 grays in 35 weeks
- 7000 centigrays in 35 doses
- 7000 grays in 35 doses
- ANC and platelets are within normal range; continue 100% dose as prescribed
- ANC is low but platelets are within normal range; continue 100% dose as prescribed
- ANC is low, reduce cisplatin dose to 75%; proceed with RT as prescribed
- ANC is low, delay cisplatin and RT. Repeat weekly CBC
- 215 mg
- 172 mg
- 129 mg
- No dose change required
- 207 mg
- 155 mg
- 124 mg
- No dose change required
- 3D Conformal Radiation Therapy (3DCRT)
- Intensity Modulated Radiation Therapy (IMRT)
- Volumetric Modulated Arc Therapy (VMAT)
- Stereotactic Radiation Therapy
- Spinal cord, brainstem, optic nerves, optic chiasm
- Parotid glands, submandibular glands
- Auditory apparatus, brachial plexus
- All of the above
- None of the above
The correct answer is 1.
Rationale: Cisplatin is a radiosensitizer
The correct answer is 4.
Rationale: Either aprepitant and ondansetron OR netupitant-palonosetron (without ondansetron) along with dexamethasone are required premedications as per the HNLAPRT protocol.
The correct answer is 5.
Rationale: As per the supportive care section of the HNLAPRT protocol, patients may require the placement of a feeding gastrostomy tube prior to treatment if there has been significant weight loss (ie. greater than 10% from baseline). They may also require use of standard oral hygiene during treatment (sodium bicarbonate mouth rinse, nystatin/fluconazole for fungal infections, antibiotics for documented infections). Pilocarpine (SALAGEN®) tablets may be used during radiation (usual dose 5 mg PO tid) to treat xerostomia.
The correct answer is 1.
Rationale: As per the BC Cancer protocol HNLAPRT treatment section, cisplatin 100 mg/m2 is given every 3 weeks for up to 3 cycles during concurrent RT.
The correct answer is 3.
Rationale: As per the BC Cancer protocol HNLAPRT treatment section, 7000 cGy RT is given in 35 fractions (doses).
The correct answer is 3.
Rationale: As per the BC Cancer protocol HNLAPRT dose modification section, if patient's ANC is 1.0 to less than 1.5 x 109/L OR platelets are 75 to less than 100 x 109/L, cisplatin dose should be reduced to 75% (161 mg). RT continues as planned.
The correct answer is 3.
Rationale: Using the Cockcroft-Gault formula, his calculated creatinine clearance is 53 mL/min. As per the BC Cancer protocol HNLAPRT dose modification section, if patient's calculated creatinine clearance is 45 to less than 60 mL/min, cisplatin dose should be reduced to 80% of previous dose. Dose of cisplatin at Cycle 2 was 161 mg, so 80% of that dose would be 129 mg. RT continues as planned.
The correct answer is 4.
Rationale: As the weight loss is less than 10% from baseline and does not lead to a 5% variance from the prescribed dose, a dose reduction/change is not required.
The correct answer is 2.
Rationale: As per the radiation therapy treatment section of the HNLAPRT protocol, for locally advanced head and neck cancer, radiation is delivered using the IMRT technique.
The correct answer is 4.
Rationale: As per the radiation therapy treatment section of the HNLAPRT protocol, critical organs-at-risk include spinal cord, brainstem, optic nerves and optic chiasm, parotid glands, submandibular glands, auditory apparatus, and brachial plexus.
