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oncology > lung cancer > Flashcards

lung cancer Flashcards

1
Q

etiology and patho

A

acquire molecular lesions (tobacco smoke, environmental respiratory carcinogens, inherited genetic risk factors)–> inhibition of tumor suppressor genes ,production of autocrine growth factors, immune system evasion, activation of proto-oncogenes –> malignant transformation

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2
Q

common metastatic sites for NCLC and SCLC

A

contralateral lung
lymp nodes
liver
adrenal glands
bone
CNS

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2
Q

clinical presentation

A

pulmonary symptoms: cough, dyspnea, chest pain or discomfort, with or without hemoptysis
extra-pulmonary symptoms: fatigue, weight loss, anorexia
SVC syndrome- tumor blocks blood flow–> swelling in face + neck
Paraneoplastic syndromes- hypercalcemia and SIADH (most common in SCLC)

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2
Q

SCLC

A

faster growing, worse prognosis, sensitive to chemo and radiation

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3
Q

risk factors

A

smoking
secondhand smoke
asbestos exposure
metal exposure
radiation
air pollution

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4
Q

pack years

A

pack years= years of smoking * number of packs/day smoked

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5
Q

screening (who)

A

adults age 50-80 yrs
current or former smoker who quit within the last 15 years AND
20 pack-year smoking history or longer

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6
Q

screening (what)

A

yearly low dose CT
advantages:
20% lower risk of dying from lung cancer
7% overall mortality decrease
disadvantages:
false positives, unnecessary stress/biopsies
will not find all lung cancer
cost
radiation exposure

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7
Q

Diagnosis

A

Step 1: radiologic evaluation
-computed tomography (CT) scan of chest and upper abdomen
Step 2: Lung tissue biopsy
-confirms presence of active malignancy
-determines specific tumor type
-provides sample for molecular analysis (PD-L1 expression, genetic mutations)

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8
Q

SCLC limited stage

A

spread: confined to one lung
lymph node involvement: same side of chest

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9
Q

SCLC extensive stage

A

spread: involves both lungs
lymph node involvement: both sides of chest
extrapulmonary metastases

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10
Q

NSCLC treatment goals

A

Stage I-III: cure
stage IV: prolong survival

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11
Q

SCLC treatment goals

A

limited stage: cure
extensive stage: prolongation of survival

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12
Q

NSCLC stage 1

A

surgical resection
unresectable- RT alone

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13
Q

NSCLC stage 2

A

surgical resection +/- neoadjuvant therapy, adjuvant therapy

unresectable- concurrent ChemoRT

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14
Q

NSCLC stage 3

A

surgical resection, neoadjuvant therapy, adjuvant therapy. +/- RT

unresectable- concurrent ChemoRT, durvalumab maintenance

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15
Q

perioperative therapy

A

treatment before, after or both surgical intervention

16
Q

neoadjuvant regimens

A

nivolumab + platinum-based: chemotherapy for 3 cycles
pembrolizumab + cisplatin-based chemotherapy for 4 cycles - continue pembrolizumab adjuvant therapy
platinum based chemotherapy for 4 cycles (if not a candidate for immune checkpoint inhibitor)

17
Q

adjuvant regimens

A

osimertinib daily for up to 3 years- must be EGFR +
atezolizumab for up to 1 year
pembrolizumab for up to 1 year
platinum based chemo for 4 cycles (if not candidate for immune checkpoint inhibitor)

18
Q

calvert equation

A

total dose= target AUC x (CrCl +25)
*CrCl used should not exceed 125 ml/min

19
Q

taxanes- paclitaxel, docetaxel

A

MOA: inhibits mitosis through disruption of microtubule depolymerization
PK: CYP3A4 substrate and CYP2C8 (paclitaxel only)
ADEs: myelosuppression, alopecia, peripheral neuropathy, hypersensitivity reaction (solvent related)- pre med w dexamethasone, famotidine, diphenhydramine, peripheral edema (docetaxel)- pre med with dexamethasone day before, of and after infusion

20
Q

pemetrexed

A

*non squamous histology only
MOA: inhibits dihydrofolate reductase and thymidylate synthase, thereby depleting DNA building blocks
PK: primarily renal elimination
ADEs: myelosuppression, erythematous/pruritic skin rash
-folic acid and vitamin B12 supplement proph
-dexamethasone day before, or and after for skin rash

21
Q

advanced NSCLC targetable genetic mutation

A

Mutation in EGFR, ALK, ROSI, BRAF, NTRK, RET, MET
-kinase inhibitor targeted to mutation

22
Q

advanced NSCLC PD-LI positive: >1%

A

PD-I/PD-LI +/- chemotherapy

23
Q

advanced NSCLC PD-L1 <1%

A

PD-I/PD-LI inhibitor + chemotherapy

24
Q

EGFR inhibitors

A

most prevalent in adenocarcinomas and nonsmokers
1st gen: erlotinib, gefitinib, afatinib
2nd gen: dacomitinib
2nd gen»1st
3rd gen: osimertinib (first line)
significantly improved PFD and OS
improved CNS activity compared to other EGFR targeting agents
better tolerability

25
Q

EGFR inhibitor rash management

A

prevention
-SPF 25
-gentle skin care: loose fitting clothing, pH neutral baths/bath oil, avoidance of hot showers, avoidance of OTC acne products, hydrophilic creams

treatment
-topical or systemic steroids
-topical or systemic antibiotics

26
Q

ALK inhibitors

A

superior to chemo
1st gen: crizotinib, ceritinib
2nd: alectinib, brigatinib
3rd: lorlatinib
2nd and 3rd preferred
alectinib improvement in overall survival
lorlatinib improved potency + penetration of the BBB

27
Q

KRAS inhibitor

A

more commonly associated with cigarette smoking
confers poor disease prognosis
indicated for advanced or metastatic NSCLC and KRAS G12C mutation after receipt of one prior therapy
*sotorasib- avoid coadministration with PPIs and H2RAs
*adagrasib- pH independent absorption

28
Q

immunotherapy single agent

A

pembrolizumab, atezolizumab, cemiplimab

29
Q

immunotherapy + chemo (squamous)

A

carboplatin + paclitaxel (or albumin bound paclitaxel) + pembrolizumab
cisplatin or carboplatin + placlitaxel + cemiplimab

30
Q

immunotherapy + chemo (non-squamous)

A

cisplatin or carboplatin + pemetrexed + pembrolizumab
cisplatin or carboplatin + pemetrexed + cemiplimab

31
Q

NSCLC 2nd line no previous checkpoint inhibitors

A

pembrolizumab
nivolumab
atezolizumab

32
Q

NSCLC 2nd line previous checkpoint inhibitor

A

docetaxel + ramucirumab (preferred over single agent)
docetaxel
gemcitabine
albumin-bound paclitaxel
pemetrexed (nonsquamous)

33
Q

VEGF inhibitors

A

NSCLC specific agents: bevacizumab, ramucirumab
avoid in pts with squamous histology (bev), recent hemoptysis, on therapeutic anticoagulation for new onset VTE, recent surgical procedure (hold 28 days)

34
Q

SCLC

A

treatment of choice is chemotherapy +/- radiation
disease recurrence usually occurs within 6-8 months after complete response

35
Q

1st line SCLC limited stage treatment

A

carboplatin (or cisplatin)+ etoposide + concurrent RT

36
Q

1st line SCLC extensive stage treatment

A

carboplatin + etoposide + atezolizumab ( extensive-stage only)
carboplatin + etoposide + durvalumab (extensive-stage only)
cisplatin + etoposide + durvalumab (extensive stage only)

37
Q

2nd line SCLC treatment

A

topotecan (oral or IV)
lurbinectedin
clinical trials

38
Q

etoposide

A

MOA: topoisomerase II inhibitor–> leads to double stranded DNA breaks
AE; myelosuppression, N/V, stomatitis, alopecia

39
Q

topotecan

A

MOA: topoisomerase I inhibitor–> leads to single stranded DNA breaks
reduce dose by 50% if CrCl 20-39 mL/min and avoid if CrCl < 20 mL/min
AE; myelosuppression (neutropenia), diarrhea, nausea, vomiting fatigue, alopecia

40
Q

lurbinectedin

A

MOA: alkylates DNA residues that ultimately result in DNA damage and cell death
PK: substrate of CYP3A4
AE: fatigue, hepatic enzyme elevations, extravasation, nausea, myelosuppression, increase in SCr, musculoskeletal pain
pretreatment with dexamethasone ( decreased hepatic enzyme elevations) and 5-HT3 antagonist for antiemetic purposes

oncology (9 decks)

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