Lecture 9 - Lung cancer Flashcards by Patryk Lasiuk

Who is considered “high risk” for lung cancer screening

50+ yrs old and 20+ pack per year history of smoking cigarettes

Low dose CT = highly sensitive and can have false results

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Lung cancer risk factors

cigarette smoking hx
radon exposure
occupational exposure
cancer hx
family hx in 1st degree relative
disease hx, COPD or pulmonary fibrosis
Second-hand smoke exposure

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Small cell lung cancer info

centrally located
rapid doubling time, ~ 30 days
High growth fraction
early development of widespread metastases
more closely linked to smoking

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Adenocarcinoma info

most common, n most common among non-smokers
inc incidence
peripheral lesions
doubling time ~ 160 days

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Squamous Cell carcinoma info

most resectable
centrally located
common among smokers
targetable mutations uncommon
slow grow, ~ 88 days doubling time
late development of metastases

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Large Cell carcinoma info

incidence declining
peripherally located
often bulky in size and quickly spread
longer doubling time, ~ 86 days

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How is SCLC staged

using VA Lung Study group classification system, rather than TNM

Limited vs Extensive

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“Limited” SCLC

confined to ipsilateral hemithorax, which can be safely encompassed within a radiation field

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“Extensive” SCLC

beyond ipsilateral hemithorax, including malignant pleural or pericardial effusion or hematogenous metastases

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biomarker testing recommendations with non-squamous NSCLC

EGFR
ALK
ROS1
BRAF
MET
PD-L1
NTRK
RET
ERBB2

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biomarker testing recommendations with squamous NSCLC

EGFR
ALK
ROS1
BRAF in select pts

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NSCLC Stage I/II txm

resection if possible, goal is negative margins

Chemo after resection

chemoradiation combo, cisplatin based doublet is go to

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point of neoadjuvant therapy NSCLC Stage I/II

shrink tumor and improve operability
convert inoperable to operable

after surgery = intention to cure/improve survival

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Cisplatin (Platinol) toxicity

N/V/ nephrotoxicity, peripheral neuropathy, mild myelosuppresion, ototoxicity, hypokalemia, hypomagnesemia

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Cisplatin (Platinol) toxicity prevention

Adequate Pre-/Post hydration
Mannitol
electrolyte replacement
Antiemetics

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Carboplatin (Paraplatin) toxicity

myelosuppresion, neutropenia, thrombocytopenia, anemia, Nausea, vomiting, nephrotoxicity

Based on Calvert Formula*

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Calvert Formula

AUC X (CrCl + 25)

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Stage 3B disease info

concurrent chemo w/ radiation, typically cisplatin based followed by consolidate therapy

if unresectable w/ no progression after 2 cycles, can do Durvalumab Q2wk for 12 month*

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Who is EGFR+ NSCLC more common in?

women
non-smokers w/ adenocarcinomas
asians

Only drug that hits EGFR+ T790M mutation n all others is….

Osimertinib

Which EGFR drugs need to be on empty stomach

Afatinib (Gilotrif)
Erlotinib (Tarceva)= no PPI***

rest can be taken w/ or without

EGFR Rash and Management

worsening rash had better overall survival

non-pharm: moisturize dry areas BID, minimize sunlight exposure, use SPF 30, wash w/ bath or shower oil to trap moisture

Some EGFR toxicities

inc eyelash length
Diarrhea
paronychia = periungual inflammation develops months later

If ALK+, usually resistant to….

EGFR agents

preferred agents for ROS Rearrangement

Crizontinib Entrectinib = better CNS pen but more toxicity than Crizontinib

ALK/ROS1 options

Alectinib = ALK+ Brigatinib = ALK+ Ceritinib = ALK+ Crizotinib = ALK/ROS1+ Entrectinib = ROS1+ Lorlatinib = ALK+

BRAF mutation therapy

Dabrafenib + trametinib is recommended, V effective V600E mutation = better prognosis

MET EXON14 skipping mutation 1st line

Capmatinib

RET Rearrangement mutation 1st line

Selpercatinib (wt based dosing) or pralsetinib

NTRK Fusion mutation 1st line

Larotrectinib or entrectinib

Immune checkpoint inhibitors are first line in pts that...

cant identify driver mutation Atezolizumab, Nivolumab and Pembrolizumab Durvalumab can be used as adjuvant

PD-L1 testing rec for....

all pts with metastatic disease

PD-L1 > 50%, Non-squamous preferred agents....

Pembrolizumab Pembrolizumab + pemetrexed + carboplatin or cisplatin Atezolizumab Cemiplimab-rwlc

PD-L1 > 50%, Squamous preferred agents...

Pembrolizumab + carboplatin +paclitaxel

PD-L1 1-49%, non-squamous preferred agents....

Pembrolizumab + pemetrexed + carboplatin or cisplatin

PD-L1 1-49%, squamous preferred agents...

Pembrolizumab + carboplatin +paclitaxel

PD-L1 < 1%, non squamous preferred agents...

Pembrolizumab + pemetrexed + carboplatin or cisplatin

PD-L1 < 1%, squamous preferred agents....

Pembrolizumab + carboplatin + paclitaxel Pembrolizumab + carboplatin + albumin-bound paclitaxel

immune checkpoint inhibitors

Atezolizumab = Tecentriq Nivolumab = Opdivo Pembrolizumab = Keytruda, req PDL1 testing

immune checkpoint inhibitors ADE

can happens months to years later within month = skin 2 months = GI 3 months = endocrine 4 month = lung

VEG-F inhibitors

Bevacizumab Ramucirumab

Bevacizumab info

1st line in select pts with non squamous NSCLC

Ramucirumab info

1st line or subsequent therapy in select pts

Limited stage SCLC therapy

Cisplatin Day 1 + etoposide days 1-3, every 21 days for 4-6 cycles with radiation

Extensive Stage SCLC therapy

Platinum/etoposide or platinum/irinotecan for 4-6 cycles

Carboplatin advantages n disadvantages

Less N/V Less neuropathy Less nephropathy More myelosuppresion not as well clinically evaluated

immunotherapy in extensive stage SCLC

Atezolizumab w/ carboplatin Durvalumab w/ either platinum