Lung Cancer

Question 1

What is the screening guideline for lung cancer depending on the smoking history?

Answer 1

This is indicated for patients aged 50-80 years of age who have a 20 pack year smoking history and currently smoke or quit smoking within 15 years ago. They need yearly CT scans.

Question 2

When giving Pembro or Atezolizumab in the adjuvant setting for early stage lung cancer which one is assoc with a larger survival benefit?

Answer 2

Atezolizumab, but you can still offer them Pembro.

Question 3

What neoadjuvant regimens can be given for early stage lung cancer and what stages is this indicated for?

Answer 3

Nivolumab w Cisplatin w/Carbo/Paclitaxel (any histology), or Pemetrexed (non-squamous), or Gemcitabine (squamous), or Paclitaxel (any histology). You consider this treatment for tumors 4cm or more and/or N+ dx Stage IIA or higher.

Question 4

For those that you want to give Nivolumab and chemo to in the the neoadjuvant setting what if they can’t tolerate Cisplatin what can you do?

Answer 4

Carboplatin/Gemcitabine (squamous) or you can do Carboplatin/Pemetrexed (non-squamous)

Question 5

What are the regimens for neoadjuvant/adjuvant chemo/Pembro immunotherapy and what stages are this indicated for?

Answer 5

Here you give Pembro with chemo and then after surgery you give Pembro alone for a year. Pembro w/Cisplatin/Gemcitabine (squamous) or Pembro w/Cisplatin/Pemetrexed (non-squamous). Stages IIB-IIIB. Benefit is for those with CPS of 1 or higher

Question 6

What are the indications to give adjuvant chemo for early stage NSCLC?
Stage IIA-T2bN0
T2b lesion is 4-5cm
Stage IIB-T1a-c,N1 T2a-2b,N1 T3,N0

Answer 6

Stage IIA-w/high risk features such as poorly diff, vascular invasion, wedge resection, visceral pleura dx, unknown lymph nodes
Stages IIB-IIIA

Question 7

What ALK inhibitor is approved for early stage NSCLC in the adjuvant setting and for what stages?

Answer 7

Alectinib for stages II-IIIB

Question 8

When is adjuvant Atezolizumab indicated in early stage NSCLC?

Answer 8

High risk Stage IIA or stages IIB-IIIB with CPS of 1 or higher and no ALK or EGFR mutation

Question 9

When is adjuvant Osimertinib indicated for NSCLC?

Answer 9

For stages IB-IIIB after adjuvant chemo or after surgery if adjuvant chemo is not indicated. You give for a total of 3 years.

Question 10

This is a freebie, but remember that Durvalumab can be added to chemo before surgery and then Durvalumab for a year after for Stage IIB-IIIB

Question 11

What are the different ways you can get Stage IIB disease? You will use this flash card to help you remember the stage for adjuvant chemo based off the T/N stage only

Answer 11

T1abc-T2a,N1
T3,N0
T2b,N1
T1: less than 3cm
T2: 3-5 cm
T3: 5-7cm
N1: peribronchial and/or ipsilateral hilar and intrapulmonary
N2: ipsilateral subcarinal and mediastinal

Question 12

Adjuvant chemotherapy is indicated for what stages?

Answer 12

Stage IIA w/high risk features
Stages IIB-IIIA

Question 13

For Stage IIIB disease that is treated with chemo/RT what are the adjuvant tx options?

Answer 13

Durvalumab or Osimertinib if EGFR mutation is present.

Question 14

What EGFR inhibitors are approved for metastatic NSCLC that has a EGFR exon 19 mutation or 21 L858R mutation? Focus on the preferred options

Answer 14

Osimertinib (preferred)
Other options: Osimertinib w/Cisplatin/Carboplatin and Pemetrexed (Cat 1) or Amivantamab+Lazertinib (Cat 1).

Question 15

What is the preferred option for EGFR exon 20 mutation for metastatic NSCLC?

Answer 15

Amivantamab w/Carboplatin and Pemetrexed (non-squamous only). Or you can consider other typical regimens for Squamous/Adenocarcinoma

Question 16

What are the preferred options for EGFR S7681, L861Q, G719X mutation in metastatic NSCLC?

Answer 16

Preferred options are Osimertinib and Afatinib. You can consider Erlotinib, Gefitinib, or Dacomitinib.

Question 17

What are the Cat 1 recs for ALK mutation metastatic NSCLC?

Answer 17

Alectinib, Brigatinib, Lorlatinib. Lorlatinib and Alectinib are the newest ones that work the best.

Question 18

What is the unique benefit of Lorlatinib in ALK metastatic NSCLC?

Answer 18

It has CNS activity

Question 19

What are the preferred options for ROS1 mutated metastatic NSCLC? Which two have the best CNS penetration?

Answer 19

Entrectinib, Crizotinib, repotrectinib. Entrecrinib and Repotrectinib have the highest CNS penetration.

Question 20

When patients have a KRASG12C mutation in metastatic NSCLC what is the first line tx option?

Answer 20

KRAS med given after progression on chemo/immuno. If PDL1 less than 1% you give Carbo or Cisplatin w/Pemetrexed and Pembro. Or for squamous you give Carbo/Paclitaxel w/Pembro or Cemiplimiab. Can exchange Cemiplimab for Pembro. If 1% or higher and under 49% you give the options above. If 50% or higher you give Pembro alone, Atezolizumab alone, or Cemiplimiab alone.

Question 21

When giving KRAS inhibitors in the 2nd line setting for the G12C mutation, what agents are used?

Answer 21

Sotarasib or Adagrasib. The reason it is given in the 2nd line setting is the response rate is 37 and 43% respectively.

Question 22

What is the preferred tx options for RET mutated NSCLC?

Answer 22

Selpercatinib and Pralsetinib.

Question 23

What are the first line options for BRAF-V600E metastatic NSCLC?

Answer 23

Dabrafenib/Trametinib or Encorafenib/Binimetinib. You can do Vemurafenib or Dabrafenib alone if the combo would be too toxic.

Question 24

What are the preferred first line options for MET 14 skipping mutated metastatic NSCLC?

Answer 24

Capmatinib or Tepotinib are the preferred options. Can you use Crizotinib for PS of 0-4, ie for those w/poor PS.

Question 25

How do you approach Her2+ metastatic NSCLC patients?

Answer 25

You first give traditional chemo/IO options and only after progression do you use Trastuzumab-Deruxtecan (preferred) or TDM-1.

Question 26

When can Ipi/Nivo be used in metastatic NSCLC?

Answer 26

It can be used in the front line setting for both adeno and squamous although the response is better in adeno. PDL1 should be 1% or more although in NCCN it doesn’t say this, but this is how the trial was done.

Question 27

Platinum doublet chemo can be combined with Ipi/Nivo particularly in what type of patient?

Answer 27

You can give Ipi/Nivo plus Carbo/Pemetrexed or w/Carbo/Paclitaxel in those that want a less chemo intense option, but note their PS has to be 0-1.

Question 28

What are options for disease progression with metastatic NSCLC after they have received upfront IO?

Answer 28

Docetaxel, Pemetrexed (adeno), Gemcitabine, Ramucirumab/Docetaxel, Nab-paclitaxel, TDXT-IHC 3+

Question 29

For mesothelioma what stages of disease can be resected? What is the general tx approach?

Answer 29

Stage I-IIIA and epitheliod dx can be respected T3,N1 T3-endothoracic fascia, extension to mediastinal fat, solitary tumor in soft tissues of chest wall, non transmural involvement of pericardium
N1-ipsilateral nodes N2-contralateral nodes
Stage IIIB: T4,any N T1-3,N2-cannot be respected
Know that besides going to surgery right away you have the option of giving chemo followed by surgery or just chemo alone or observation-this is the answer for a patient w/minimal disease and symptoms!

Question 30

What are the adjuvant options for those that undergo pleurectomy/decortication vs EPP in mesothelioma?

Answer 30

P/D-Pemetrexed w/Cisplatin or Carbo and consider sequential hemithoracic pleural IMRT
EPP-chemo as above with hemithoracic RT

Question 31

What is the preferred chemo for epithelioid mesothelioma?

Answer 31

Cisplatin/Pemetrexed
Cisplatin/Pemetrexed+Bevacizumab
Ipi/Nivo All of these are Cat 1 recs!

Question 32

Please take note of this, what is the preferred regimen for Sarcomatoid/biphasic pathology for mesothelioma?

Answer 32

Ipi/Nivo!
Other options: Cisplatin/Pemetrexed (Cat 1) and the above chemo w/Bevacizumab which is Cat 1 too.

Question 33

For limited Stage I-IIA small cell (T1-2, N0, M0) what is the tx approach? Take note that they have negative nodes so surgery is an option!

Answer 33

If mediastinal staging is negative and they can get surgery you proceed with a lobectomy. If they cant get surgery you do SABR followed by Cis/Etop or concurrent chemo/RT.

Question 34

For limited Stage I-IIA (T1-2,N0) small cell lung cancer, what adjuvant tx do they receive?

Answer 34

If R0,N0 you do Cisplatin/Etoposide for 4 cycles. If they have N+, you do Cisplatin/Etoposide w/concurrent or sequential mediastinal RT. R1/R2: chemo/concurrent RT

Question 35

What is tx for limited stage IIB-IIIC (T3-4,N0 or T1-4,N1-3) small cell lung cancer? Take note here that anyone with N+ dx cannot go for surgery!

Answer 35

PS of 0-2: Cisplatin/Etoposide w/concurrent RT
PS of 3-4: Cisp/Etop +/- concurrent RT or sequential

Question 36

After primary treatment for early stage small cell lung CA, what is the indication for Durvalumab?

Answer 36

You only give it to patients who a CR or PR or stable disease with limited stage disease who did not undergo surgery!

Question 37

For early stage small cell lung CA, what is the guideline regarding PCI?

Answer 37

For limited stage disease that had a CR or PR it says you can either consider giving PCI OR you can do MRI surveillance. You must give PCI before starting Durvalumab. PCI has a survival benefit ONLY in limited stage.

Question 38

For extended stage small cell that had a CR or PR, what is the guideline about giving PCI and thoracic RT in this setting?

Answer 38

It says at minimum you need to do MRI brain for surveillance +/-consider giving PCI and Thoracic RT. But please take note a study in Japan showed that PCI in those with neg imaging had worse survival outcomes. One study showed a benefit, but they didn’t do baseline MRI imaging.

Question 39

What are the chemo regimens used in extended stage small cell lung CA?

Answer 39

You can do Carbo/Etop plus Atezolizumab followed by Atezo maintenance. Or you can do Carbo/Etop plus Durvalumab followed by Durvalumab maintenance.

Question 40

What are the 2nd line options for extended stage small cell if the recurrence is greater than 6 months?

Answer 40

The preferred options are consider a clinical trial or you can do a retrial with a platinum regimen

Question 41

What are the 2nd line options for extended stage small cell if the recurrence is less than 6 months?

Answer 41

Clinical trial, Lurbinectedin, Topotecan PO or IV, Irinotecan, Tarlatamab, retreatment w/Platinum agent if recurrence happened within 3-6 months

Question 42

In extended stage disease what is the sequence of chemo and RT in those with asymptomatic and symptomatic brain mets?

Answer 42

Asymptomatic-start systemic therapy first followed by brain RT. Symptomatic-Brain RT followed by systemic therapy, must give steroids right away. This goes for spinal mets/compression too.

Question 43

According to NCCN you still do MRI brain monitoring in those with stable disease that did not respond to tx in those with limited and extended stage disease.

Question 44

What are the paraneoplastic syndromes that can present in small cell?

Answer 44

Hyponatremia of malignancy due to SIADH ( due to Arginine vasopressin and atrial naturitetic peptide), Hypercalcemia (due to PTH related hormone peptide), ectopic ACTH (Cushings), and Acromegaly (due to growth hormone).