lung cancer Flashcards
histologic types of lung cancer
Non small cell lung cancer (NSCLC): adenocarcinoma, squamous, others
Small cell lung cancer (SCLC)
which details guide treatment options in NSCLC?
non-squamous or squamous
surgically resected or unresectable
PD-L1 testing result
which details guide treatment options in SCLC?
limited or extensive stage?
recurrent?
what is the most important factor in deciding treatment for Stage I, II, III NSCLC
is it resectable or not?
what does positive margin mean?
there is tumor left over at the edge of resected tissue (not good)
what does negative margin mean?
there is no tumor present in the normal tissue (Good)
general outline of treatment for stages I, II, III RESECTABLE NSCLC?
radiation if disease left behind after surgery (positive margin)
IV chemotherapy (platinum based backbone)
additional adjuvant therapy: osimertinib, atezolizumab, pembrolizumab (have specific when to use)
when to use osimertinib for stage I-III resectable NSCLC?
completely resected (negative margin)
Previously untreated EGFR mutation-positive exon 19 deletions or exon 21 L858R mutations
adjuvant: IV chemotherapy first then osimertinib for 3 years
when to use atezolizumab for stage I-III resectable NSCLC?
completely resected (negative margin)
PD-L1 >/= 1%
adjuvant: IV chemotherapy first then atezolizumab for 1 year
when to use pembrolizumab for stage I-III resectable NSCLC?
completely resected (negative margin)
regardless of PD-L1 status
adjuvant: IV chemotherapy first then pembrolizumab for 1 year
general outline for treatment of UNRESECTABLE stage I-III NSCLC?
if there is possible resection: neoadjuvant chemo +/- immunotherapy THEN surgery.
no possible resection: radiation, chemoradiation
stage III unresectable: chemoradiation + consolidation therapy with durvalumab
when there is a possible resection: what is used as neoadjuvant therapy to make the tumor small enough to resect?
IV chemo is platinum-based (cisplatin or carboplatin)
and nivolumab can be used REGARDLESS of PD-L1 status
after 3 cycles of this, patients proceed with resection
what are the platin toxicities?
cisplatin: ototoxicity, nephrotoxicity, n/v. patients receive more fluids so avoid in fluid-restricted patients
carboplatin: hematologic toxicities (anemia, leukopenia, neutropenia, thrombocytopenia)
what is the place in therapy for pemetrexed?
non-squamous ONLY
what premeds are required for pemetrexed
steroids to reduce skin reactions (rash)
supplemental vitamins to reduce hematologic toxicities
what are the immune-related toxicities from checkpoint inhibitors?
skin problems: rash, itch, blister, sores, ulcers
GI tract problems (diarrhea, bloody stool, severe abdominal pain/cramping, nausea/vomiting)
hormone glands (pituitary, thyroid)- excessive sleepiness, weight gain/loss, changes in mood/behavior, hair loss, feeling cold, constipation, excessive thirst or urination
how are immune-related toxicities managed?
high dose-steroid then slowly taper off over 4-6 weeks
what are the checkpoint inhibitor drugs
PD-1: pembrolizumab, nivolumab, cemiplimab
PD-L1: atezolizumab, durvalumab
CTLA-4: ipilimumab, tremelimumab
what are side effects from radiation?
common: fatigue, hair loss, skin problems, low blood count
less common: sore throat, swallowing problems, loss of appetite, cough, SOB, heart complications, radiation pneumonitis
general approach to stage IV (metastatic) NSCLC
surgery & radiation usually not helpful :(
need to do molecular testing to see if patient has targetable mutations: EGFR, ALK, BRAF/MET, HER2, etc etc etc
osimnertinib target
EGFR exon 19 deletion or 21 L858R
amivantamab target
EGFR + MET
alectinib target
ALK + RET
2nd line
dabrafenib/trametinib target
dabrafenib: BRAF V600E
trametinib: MEK
