Lung Cancer

Question 1

Calvert equation for carboplatin dosing

Answer 1

Total dose (mg)= (AUC) * (CrCl+25)

Question 2

When to use IBW vs. ABW vs. AdjABW in CrCl formula

Answer 2

Use AdjABW when ABW/IBW >1.2
Use IBW when ABW/IBW <1.2
Use ABW when ABW < IBW

Question 3

Lung cancer immunotherapy-related AE grade treatment plan: Grade 1

Answer 3

continue immunotherapy

Question 4

Lung cancer immunotherapy-related AE grade treatment plan: Grade 2

Answer 4

hold immunotherapy and CONSIDER corticosteroid administration

Question 5

Lung cancer immunotherapy-related AE grade treatment plan: Grade 3 and higher

Answer 5

hold immunotherapy and administer corticosteroid

Question 6

Lung cancer immunotherapy-related AE grade treatment plan: refractory cases

Answer 6

Add infliximab, MMF

Question 7

Corticosteroid dosing

Answer 7

Prednisone 0.5-2mg/kg/day or equivalent until resolution to Grade 1 followed by taper over at least 1 month

Question 8

NSCLC treatment goal: Stages I and II

Answer 8

Cure!

Question 9

Stage 1 NSCLC treatment

Answer 9

surgery and surveillance

Question 10

Stage 2 NSCLC treatment

Answer 10

surgery, adjuvant therapy

Question 11

NSCLC adjuvant therapy (mainstay of treatment)

Answer 11

Platinum-based regimen x4 cycles

Question 12

Platinum-based regimens

Answer 12

Cisplatin/etoposide
Cisplatin/vinorelbine
Carboplatin/paclitaxel
Cisplatin/pemetrexed

Question 13

Platinum-based regimens are for what kind of histology?

Answer 13

Nonsquamous

Question 14

Cisplatin and carboplatin AEs

Answer 14

Myelosuppression
N/V/D
Constipation
Mucositis
Alopecia
Nephrotoxicity
Ototoxicity
Peripheral neuropathy

Question 15

Carboplatin has less what compared to cisplatin (in terms of AEs)

Answer 15

N/V, nephrotoxicity, ototoxicity, peripheral neuropathy

Question 16

Cisplatin nephrotoxicity

Answer 16

Hypokalemia, hypomagnesmia

Question 17

Carboplatin myelosuppression

Answer 17

Thrombocytopenia

Question 18

Adjuvant therapy in EGFR+ NSCLC

Answer 18

osimertinib for up to 3 years or until disease progression or unacceptable toxicity

Question 19

Adjuvant therapy in PD-L1 ≥1% NSCLC

Answer 19

Atezolizumab following completion of platinum-based chemo x1 year

Question 20

Neoadjuvant therapy for NSCLC for operable, but difficult to resect tumors

Answer 20

Platinum-based regimen +/- nivolumab x4 cycles

Question 21

Radiation therapy in NSCLC

Answer 21

Reserved in conjunction with chemo (platinum-based) in patients who are medically inoperable
Positive margins after initial resection if unable to undergo resection
Concurrent rather than sequential chemo is preferred

Question 22

NSCLC treatment goals: Stages III and IV

Answer 22

prolongation of survival

Question 23

Stage IIIA NSCLC treatment

Answer 23

Neoadjuvant chemo +/- nivolumab x4 cycles followed by surgery or RT
Adjuvant osimertinib (EGFR+) or atezolizumab (PD-L1 ≥1%) similar to stage II
Concurrent chemoradiotherapy for non-surgical candidates

Question 24

Stage IIIB-IIIC NSCLC treatment

Answer 24

Considered UNRESECTABLE DISEASE

Concurrent chemoradiation is the mainstay for up to 6 cycles or until progression or unacceptable toxicity

Durvalumab maintenance x1 year upon response to chemoradiotherapy

Question 25

Stage IV NSCLC: targetable genetic mutation treatment

Answer 25

Kinase inhibitor targeted to the mutation

Question 26

Stage IV NSCLC: PD-L1 positive ≥1%

Answer 26

PD-1/PD-L1 inhibitor +/- chemo

Question 27

Stage IV NSCLC: PD-L1 <1%

Answer 27

PD-1/PD-L1 inhibitor + chemo

Question 28

PD-L1+ and Nonbiomarker Driven NSCLC treatment: PD-L1 ≥50%

Answer 28

pembrolizumab, atezolizumab, cemiplimab

Question 29

PD-L1+ and Nonbiomarker Driven NSCLC treatment: PD-L1 1-49% or <1% with squamous histology

Answer 29

cisplatin or carboplatin + *paclitaxel* + pembrolizumab OR nivolumab AND ipilimumab

Question 30

PD-L1+ and Nonbiomarker Driven NSCLC treatment: PD-L1 1-49% or <1% with nonsquamous histology

Answer 30

cisplatin or carboplatin + *pemetrexed* + pembrolizumab OR nivolumab AND ipilimumab

Question 31

PD-L1+ and Nonbiomarker Driven NSCLC treatment: PD-L1 1-49% or <1% with squamous histology AND CIs EXIST

Answer 31

Cisplatin + gemcitabine

Question 32

PD-L1+ and Nonbiomarker Driven NSCLC treatment: PD-L1 1-49% or <1% with nonsquamous histology AND CIs EXIST

Answer 32

Carboplatin + pemetrexed

Question 33

SCLC treatment goal: limited stage

Answer 33

cure

Question 34

SCLC treatment goal: extensive stage

Answer 34

prolongation of survival

Question 35

First-line treatments for limited stage SCLC

Answer 35

Cisplatin OR carboplatin PLUS etoposide

Question 36

First-line treatments for extensive stage SCLC

Answer 36

Cisplatin OR carboplatin PLUS atezolizumab OR durvalumab

Question 37

Osimertinib AEs

Answer 37

**Skin rash** **Dry skin** **Diarrhea** Fatigue Stomatitis **Nail toxicity** Myelosuppression QTc prolongation Conjunctivitis (rare)

Question 38

Osimertinib clinical pearls (4 of them: CNS activity, tolerability, substrate of what CYP enzyme, pH-dependent absorption?)

Answer 38

Improved CNS activity compared to other EGFR targeting agents Tolerability is better compared to other EGFR targeting agents CYP3A4 substrate No pH-dependent absorption

Question 39

ALK inhibitors (just the drugs)

Answer 39

Brigatinib, alectinib, lorlatinib

Question 40

Brigatinib AEs

Answer 40

Diarrhea Fatigue Interstitial lung disease/pneumonitis Myalgia HTN

Question 41

Brigatinib clinical pearls (4 of them: it vs. chemo, substrate of what CYP enzyme, pH-dependent absorption, dose reduction)

Answer 41

Demonstrated to be superior to chemo 2nd and 3rd gen > 1st gen CYP3A4 substrate No pH-dependent absorption Dose reduction required for severe renal and hepatic impairment

Question 42

Alectinib AEs

Answer 42

Constipation Fatigue LFT abnormalities Peripheral edema Myalgia Anemia

Question 43

Alectinib pearls (4: it vs. chemo, substrate of what CYP enzyme, pH-dependent absorption, dose reduction)

Answer 43

Demonstrated to be superior to chemo 2nd and 3rd gen > 1st gen CYP3A4 substrate No pH-dependent absorption Dose reduction required for severe hepatic impairment

Question 44

Lorlatinib AEs

Answer 44

Fatigue Peripheral edema Mood disorders Neuropathy Cognitive effects Arthralgia Dyslipidemia/weight gain

Question 45

Lorlatinib pearls (5 of them: it vs. chemo, substrate of what enzymes, pH dependent absorption, CNS activity, dose reduction)

Answer 45

Demonstrated to be superior to chemo 2nd and 3rd gen > 1st gen CYP3A4 and P-gp substrates No pH-dependent absorption Better CNS penetration, so more cognitive AEs Dose reduction required for severe renal impairment

Question 46

KRAS inhibitors

Answer 46

Sotorasib, adagrasib

Question 47

Sotorasib AEs

Answer 47

Diarrhea Nausea Fatigue LFT abnormalities Musculoskeletal pain Decreased Hgb/lymphocytes

Question 48

Sotorasib pearls (2: substrate and inhibitor of what enzymes, DDI with PPI and H2RAs)

Answer 48

CYP3A4 substrate, strong P-gp inhibitor Avoid coadministration with PPIs and H2RAs (4 hours before, 10 hours after)

Question 49

Adagrasib AEs

Answer 49

Same as sotorasib, plus Renal impairment Edema QT prolongation Interstitial lung disease/pneumonitis

Question 50

Adagrasib pearls (3: substrate of what, inhibitor of what, pH-dependent absorption)

Answer 50

CYP3A4 substrate; inhibits its own metabolism at Css Moderate CYP2B6, 2C9, P-gp inhibitor No pH-dependent absorption

Question 51

VEGF inhibitors

Answer 51

Bevacizumab, ramucirumab

Question 52

AEs of VEGF inhibitors

Answer 52

Acute: HTN Delayed: thromboembolic events, epistaxis, major bleeds, GI perforation, proteinuria, diarrhea (ramucirumab)

Question 53

VEGF inhibitor pearls (avoid in what?)

Answer 53

Avoid Avastin in patients with squamous histology Avoid in patients with recent hemoptysis, on therapeutic anticoagulation for new onset VTE, recent surgical procedure

Question 54

Taxanes used in NSCLC

Answer 54

Paclitaxel, docetaxel

Question 55

Taxane AEs

Answer 55

Myelosuppression Alopecia *Peripheral neuropathy (premedicate with 8mg dexa BID day before, day of, and day after infusion of docetaxel)* Mucositis Diarrhea N/V Hypersensitivity reaction: premedicate with dexa, famotidine, diphenhydramine

Question 56

Taxane and CYP enzymes

Answer 56

CYP3A4 substrate; paclitaxel is a 2C8 substrate too

Question 57

Pemetrexed AEs

Answer 57

Myelosuppression Erythematous/pruritic skin rash Fatigue Diarrhea N/V

Question 58

Pemetrexed pearls (4: CrCl, NSAIDs, folic acid and B12, dexamethasone)

Answer 58

Avoid if CrCl <45ml/min NSAIDs decrease clearance Folic acid and B12 supplementation Dexa 4mg BID day before, day of, and day after infusion decreases incidence of skin rash

Question 59

Etoposide AEs

Answer 59

**Myelosuppression** N/V Stomatitis Alopecia

Question 60

Topotecan AEs

Answer 60

**Myelosuppression (neutropenia)** N/V/D Fatigue Alopecia

Question 61

Lurbinectedin AEs

Answer 61

**Fatigue** **Hepatic enzyme elevations** **Extravasation** **Nausea** Myelosuppression Increased SCr Musculoskeletal pain

Question 62

PD-L1+ and Nonbiomarker Driven NSCLC treatment: PD-L1 >=1-49%

Answer 62

Nivolumab and ipilimumab Pembrolizumab

Question 63

PD-L1+ and Nonbiomarker Driven NSCLC treatment: nonsquamous and PD-L1 <1%

Answer 63

Carboplatin + paclitaxel + atezolizumab + bevacizumab