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oncology > lung cancer > Flashcards

lung cancer Flashcards

1
Q

histologic types of lung cancer

A

Non small cell lung cancer (NSCLC): adenocarcinoma, squamous, others

Small cell lung cancer (SCLC)

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2
Q

which details guide treatment options in NSCLC?

A

non-squamous or squamous
surgically resected or unresectable
PD-L1 testing result

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3
Q

which details guide treatment options in SCLC?

A

limited or extensive stage?
recurrent?

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4
Q

what is the most important factor in deciding treatment for Stage I, II, III NSCLC

A

is it resectable or not?

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5
Q

what does positive margin mean?

A

there is tumor left over at the edge of resected tissue (not good)

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6
Q

what does negative margin mean?

A

there is no tumor present in the normal tissue (Good)

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7
Q

general outline of treatment for stages I, II, III RESECTABLE NSCLC?

A

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)

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8
Q

when to use osimertinib for stage I-III resectable NSCLC?

A

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

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9
Q

when to use atezolizumab for stage I-III resectable NSCLC?

A

completely resected (negative margin)
PD-L1 >/= 1%
adjuvant: IV chemotherapy first then atezolizumab for 1 year

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10
Q

when to use pembrolizumab for stage I-III resectable NSCLC?

A

completely resected (negative margin)
regardless of PD-L1 status
adjuvant: IV chemotherapy first then pembrolizumab for 1 year

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11
Q

general outline for treatment of UNRESECTABLE stage I-III NSCLC?

A

if there is possible resection: neoadjuvant chemo +/- immunotherapy THEN surgery.

no possible resection: radiation, chemoradiation

stage III unresectable: chemoradiation + consolidation therapy with durvalumab

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12
Q

when there is a possible resection: what is used as neoadjuvant therapy to make the tumor small enough to resect?

A

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

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13
Q

what are the platin toxicities?

A

cisplatin: ototoxicity, nephrotoxicity, n/v. patients receive more fluids so avoid in fluid-restricted patients

carboplatin: hematologic toxicities (anemia, leukopenia, neutropenia, thrombocytopenia)

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14
Q

what is the place in therapy for pemetrexed?

A

non-squamous ONLY

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15
Q

what premeds are required for pemetrexed

A

steroids to reduce skin reactions (rash)
supplemental vitamins to reduce hematologic toxicities

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16
Q

what are the immune-related toxicities from checkpoint inhibitors?

A

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

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17
Q

how are immune-related toxicities managed?

A

high dose-steroid then slowly taper off over 4-6 weeks

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18
Q

what are the checkpoint inhibitor drugs

A

PD-1: pembrolizumab, nivolumab, cemiplimab
PD-L1: atezolizumab, durvalumab
CTLA-4: ipilimumab, tremelimumab

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19
Q

what are side effects from radiation?

A

common: fatigue, hair loss, skin problems, low blood count
less common: sore throat, swallowing problems, loss of appetite, cough, SOB, heart complications, radiation pneumonitis

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20
Q

general approach to stage IV (metastatic) NSCLC

A

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

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21
Q

osimnertinib target

A

EGFR exon 19 deletion or 21 L858R

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22
Q

amivantamab target

A

EGFR + MET

23
Q

alectinib target

A

ALK + RET
2nd line

24
Q

dabrafenib/trametinib target

A

dabrafenib: BRAF V600E
trametinib: MEK

25
Q

entrectinib target

A

ROS1, NTRK

26
Q

larotrectinib target

A

NTRK

27
Q

tepotinib, capmatinib target

A

MET exon 14 skipping mutation

28
Q

sotorasib target

A

KRAS G12C
2nd line

29
Q

Fam-Trastuzumab Deruxtecan (Enhertu) target

A

HER2
2nd line

30
Q

Ado-Trastuzumab Emtansine target

A

HER2
2nd line

31
Q

what if there are no targetable mutations for stage IV metastatic NSCLC?

A

then IV chemo selection is based on histology: non squamous or squamous

32
Q

first line treatment for non-squamous, stage IV metastatic NSCLC

A

PD-L1>/= 50%: pembrolizumab, cemiplimab, or atezolizumab

regardless of PD-L1 status:
1. PEMETREXED + pembrolizumab + platin
2. BEVACIZUMAB + atezolizumab + platin + paclitaxel
(pemetrexed and bevacizumab can be used with IV chemo & immunotherapy for non squamous ONLY)

33
Q

second line treatment for non-squamous, stage IV metastatic NSCLC

A
  1. immunotherapy (if not previously given): nivolumab, pembrolizumab (PD-L1>/= 1%), atezolizumab
  2. chemotherapy (if not previously given): ramucirumab + docetaxel
34
Q

MOA of ramucirumab & bevacizumab

A

mAbs: VEGF inhibition

35
Q

ADEs of the VEGF inhibitors ramucirumab & bevacizumab

A

hemorrhage!!!
GI perforation, heart failure,hTN, thromboembolism, wound healing complication, proteinuria

36
Q

first line treatment of squamous stage IV metastatic NSCLC

A

if PD-L1>/= 50%: pembrolizumab, cemiplimab, atezolizumab

regardless of PD-L1 status: a variety of checkpoint inhibitor and platin combos – but notice there is no option for pemetrexed or bevacizumab for squamous

37
Q

options for maintenance treatment of squamous stage IV metastatic NSCLC

A

pembrolizumab
nivolumab & ipilimumab
cemiplimab
atezolizumab
durvalumab

38
Q

2nd line treatment of squamous stage IV metastatic NSCLC

A
  1. immunotherapy (if not previously given): nivolumab, pembrolizumab (PD-L1 >/= 1%), atezolizumab
  2. chemo: gemcitabine/docetaxel, ramucirumab/docetaxel
39
Q

how is small cell lung cancer (SCLC) categorized for treatment?

A

limited stage
extensive stage
relapse

40
Q

how is limited stage SCLC treated?

A

cisplatin + etoposide + RT
or
carboplatin + etoposide + RT
(pref cisplatin)
x 4-6 cycles
prophylactic cranial radiation given after chemoradiation

41
Q

how is extensive stage SCLC treated?

A

carboplatin + etoposide + atezolizumab
platin + etoposide + durvalumab
x4-6 cycles
(durvalumab & atezolizumab get continued as maintenance therapy after 4 cycles)
palliative radiation for symptom control

42
Q

how is a relapse in SCLC approached?

A

relapse >6 months: repeat initial regimen
relapse <6 months: second line treatment (clinical trial, topotecan, lurbinectedin)

43
Q

MOA, place in therapy, and side effects of lurbinectedin

A

2nd line, alkylating agent for relapse <6 months SCLC
better tolerated than topotecan. ADEs include bone marrow suppression, n/v/d, constipation, hepatotoxicity, fatigue.

44
Q

MOA, place in therapy of trilaciclib

A

for supportive care to prevent bone marrow suppression for a carboplatin/etoposide containing regimen (with or without atezolizumab) or for a topotecan containing regimen in SCLC.

is a CDK4/8 inhibitor that arrests the cell cycle so the cell doesn’t get that much damage from chemo.

45
Q

osimertinib side effects

A

rash diarrhea ILD

46
Q

amivantamab side effects

A

infusion rxn

47
Q

alectinib side effects

A

hepatotoxicity
bradycardia
CPK elevation

48
Q

dabrafenib/trametinib side effects

A

FEVER
n/v/d

49
Q

entrectinib side effects

A

QT prolonging
vision
CHF
hepatotoxicity
hyperuricemia

50
Q

larotrectinib

A

delirium, memory
hepatotoxicity

51
Q

tepotinib, capmatinib side effects

A

peripheral edema, pneumonitis, n/v/d

52
Q

sotorasib side effects

A

diarrhea
hepatotoxicity
ILD
muscle pain

53
Q

fam-trastuzumab deruxtecan side effects

A

bone marrow suppression
cardiotoxicity
pulm toxicity
GI

54
Q

ado-trastuzumab emtansine side effects

A

bone marrow suppression
cardiotoxicity
pulm toxicity
neuropathy

oncology (19 decks)

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