Exam 2: Lung Cancer Flashcards
EGFR Mutations: Lung Cancer
- can predict sensitivity to TKI therapy
KRAS mutations: Lung Cancer
- can predict resistance to TKIs
- exclusive to smokers
ALK inhibition: Lung cancer
- present in non/light smokers, younger age, adenocarcinoma
ROS-1 mutations: Lung Cancer
- encodes receptor kinase related to ALK
- present in never/light smoker, adenocarcinomas, younger patients
BRAF V600E
- typically current or former smokers
- recommended to test in 1st line metastatic setting for NSCLC
PD-L1 Status
- patients with EGFR, ALK, or ROS-1 mutation rearrangements typically done have PD1 expression
- testing not recommended for SCLC
When to check PD-L1 status
1st line metastatic setting setting
NSCLC Histology Adenocarcinoma
- 50% adenocarcinoma
- most common in non-smokers
- tend to be located peripherally in the lung
NSCLC Histology Squamous
- 30%
- clearly related to smoking
- tend to be located centrally in lung
NSCLC Histology Large Cell
- 5%
- tend to be located peripherally in the lung
- tend to be a diagnosis of exlusion
SCLC Histology
- 15%
- related to smoking
- fast growing and rapidly progressive
- can have presence of paraneoplastic syndrome
NSCLC Characteristics
- slower growth fraction
- moderatly sensitive to radiation
- marginal sensitivity to chemo
- 50% present with metastases
SCLC Characteristics
- clear relationship to smoking
- paraneoplastic syndromes common
- rapid cell growth fraction
- highly sensitive to radiation and chemotherapy
- two thirds present with matastases
Presentation of Lung Cancer
- very nonspecific
- cough
- spitting up blood
- dyspnea
SCLC Limited Stage
tumor is confined to hemithorax and contained in a radiation port
SCLC Extensive Stage
- tumor not confined to hemithorax or origin
- not contained in a radiation port
- distant metastasis
Is surgery a therapeutic option in SCLC
no
Limited Stage SCLC treatment
- curative intent
- radiation + combo chemo
- radiation given concurrently daily
Chemo regimen in limited stage SCLC
- platinum doublet
- Cisplatin and Etoposide w/daily radiation
Extensive stage SCLC treatment
- rarely curative
- platinum based combo chemo without radiation
- cisplatin or carboplatin-based combo
- etoposide or irinotecan
When is radiation appropriate for extensive stave SCLC
- prophylactic cranial radiation if a patient achieves a response in the chest
- if brain metastases present, whole brain radiation should be given
- if symptomatic, whole brain radiation should be started prior to chemo
- if asymptomatic, initiate radiation after chemo
Immunotherapy SCLC Extensive Stage
Atezolizumab + Carboplatin + Etoposide
Durvalumab + Carboplatin + Etoposide
Platin-based regimen toxicity
- myelosupression
- nephrotoxicity
PD-1 Inibitors SCLC
- option for metastatic SCLC patients who have progressed on or after platinum based chemo and at least 1 prior line of therapy
- regardless of PD-1 status
NSCLC Treatment Modalities
- moderately sensitive to radiation
- low sensitivity to chemo
- Surgery is most efficacious
- radiation for early stage when surgery cannot be performed
Neoadjuvant Treatment of Resectable NSCLC
- nivolumab + platinum doublet with tumors ≥ 4 cm or node positive and no contraindications
Preferred non squamous resectable NSCLC Adjuvant Therapy Option
- Cisplatin + pemetrexed
Preferred squamous NSCLC resectable Treatment
Cisplatin +
- gemcitabine
- docetaxel
- vinorelbine
- etop
Alternative adjuvant NSCLC resectable therapy option for those not able to tolerate cisplatin
Carboplatin +
- paclitaxel
- gemcitibine
- Pemetrexed (nonsquamous only)
ALK positive and early stage resectable NSCLC
- alectinib
EGFR mutation exon 19/21 resectable NSCLC treatment
osimertinib
Additional adjuvant resectable NSCLC treatment
- atezolizumab
- pembrolizumab
Treatment for Unresectable Nonsquamous NSCLC (Stage IIIB/IV)
- treatment considered palliative
- platinum doublet chemo + radiation
- cisplatin/carboplatin + pemetrexed/paclitaxel/etop
Treatment for Unresectable squamous NSCLC (Stage IIIB/IV)
- Paclitaxel + carboplatin (fewer toxicities)
- cisplatin + etoposide
Stage III unresectable NSCLC Immunotherapy
- pembrolizumab an option for non-candidates for surgery or chemo/radiation
- durvalumab for disease that has not progressed following chemo/radiation
Utilizing TKIS in metastatic adenocarcinoma NSCLC
- if patient has targetable mutation and is PD-L1+, it is preferred to use the oral therapies first and then move to immunotherapy
EGFR Targeted therapies in metastatic adenocarcinoma NSCLC
Osimertinib (T790 Mutation)
BRAF Targeted therapies in metastatic adenocarcinoma NSCLC
Dabrafenib + Trametinib
KRAS G12C Targeted therapies in metastatic adenocarcinoma NSCLC
Sotorasib
If no mutation found in metastatic NSCLC adenocarcionma or if targeted oral chemo have been exhausted for a positive mutation
- check PDL1 status
- if positive, Keytruda
Mutation negative nonsquamous NSCLC
- carboplatin + pemetrexed + pembrolizumab
Treatment for Metastatic squamous NSCLC if no contraindication to immunotherapy
- pembro OR
- pembro + chemo OR
- Atezolizumab or Nivolumab or Cemiplimab-rwlc
Treatment for Metastatic squamous NSCLC if contraindication to immunotherapy
- platinum doublet regardless of PDL1 status
First line for Squamous Cell NSCLC
- platinum doublet
Carboplatin is typically paired with
- gemcitabine OR
- paclitaxel OR
- nab-paclitaxel OR
- Docetaxel
Squamous NSCLC standard 3 drug regiment
- pembro + carboplatin + paclitaxel (or albumin bound paclitaxel)
Next line of therapy for metastatic squamous cell NSCLC
- TKI if positive
- Immunotherapy or non-platinum therapy
Immunotherapy toxicities
- rare and serious
- pneumonitis
- colitis
- hepatitis
- nephritis
- endocrine (thyroid/pituitary)
Lung Cancer Screening
- can consider screening in patients considered high risk
- no effective screening methods
- false positives
- no cost-effectiveness data
