Lung Cancer Flashcards

1
Q

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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

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

A

Atezolizumab, but you can still offer them Pembro.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

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?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

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

A

Alectinib for stages II-IIIB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

When is adjuvant Atezolizumab indicated in early stage NSCLC?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When is adjuvant Osimertinib indicated for NSCLC?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

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

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Adjuvant chemotherapy is indicated for what stages?

A

Stage IIA w/high risk features
Stages IIB-IIIA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

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

A

Durvalumab or Osimertinib if EGFR mutation is present.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

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

A

It has CNS activity

19
Q

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

A

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

20
Q

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

A

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.

21
Q

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

A

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

22
Q

What is the preferred tx options for RET mutated NSCLC?

A

Selpercatinib and Pralsetinib.

23
Q

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

A

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

24
Q

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

A

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

25
Q

How do you approach Her2+ metastatic NSCLC patients?

A

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

26
Q

When can Ipi/Nivo be used in metastatic NSCLC?

A

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.

27
Q

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

A

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.

28
Q

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

A

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

29
Q

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

A

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!

30
Q

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

A

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

31
Q

What is the preferred chemo for epithelioid mesothelioma?

A

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

32
Q

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

A

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

33
Q

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!

A

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.

34
Q

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

A

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

35
Q

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!

A

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

36
Q

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

A

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

37
Q

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

A

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.

38
Q

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

A

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.

39
Q

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

A

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

40
Q

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

A

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

41
Q

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

A

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

42
Q

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

A

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.

43
Q

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.

A
44
Q

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

A

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).