Lung Cancer - Block 4

Question 1

RF of lung cancer?

Answer 1

1. Smoking
2. Environmental respiratory carcinogens
3. 1st degree relative
4. Inflammaotry dx (COPD asthma)

Question 2

How do screen for lung cancer?

Answer 2

Low dose computer tomography

Question 3

How meets the criteria for lung cancer screening?

Answer 3

1. 55-74 YO
2. ≥30 ppy
3. Have quit smoking less than 15 years ago

Question 4

What are the presentations of lung cancer?

Answer 4

1. Cough
2. Hemoptysis
3. Dyspnea/wheezing
4. Chest pain/discomfort
5. Rust streaked or purulent sputum
6. Chest, shoulder, arm pain
7. Dysphagia
8. ANemia, weight loss fatigue

Question 5

Diagnostic tools for lung cancer?

Answer 5

1. Imaging
2. Biopsy (squamous cell, adenocarcinoma, large cell, small cell)

Question 6

What are the small cell lung cancer?

Answer 6

1. Small cell carcinoma
2. Combined cell carcinoma

Question 7

What are the non-small cell lung cancer?

Answer 7

1. Adenocarcinoma
2. Large cell carcinoma
3. Squamous cell

Question 8

Characteristics of SCLC?

Answer 8

1. Very aggressive
2. Rapidly growing
3. Early development of metastases
4. Always associated with smoking

Question 9

What is the difference between limited and extensive SCLC?

Answer 9

Limited: tumor confined to the lung
* Limited or no nodal involvement
* Stages 1-2

Extensive:
* Any progression beyond limited
* Stage 3-4

Question 10

Tx for limited stage?

Answer 10

1. Surgery (limited use unless solitary nodules)
2. Radiation is preferred over surgery
3. Radiation therapy + chemo
4. Prophylactic cranial irradiation (PCI) offered to pts with complete response and prevention of recurrence

Question 11

Chemo used with radiation for SCLC?

Answer 11

Etoposide and cisplatin for 4-6 cycles
* May use carboplatin if ADRs of cisplatin are too severe

Question 12

What are the outcomes of recurrent dx?

Answer 12

Less responsive to chemo after recurrence
* Tx based on time between induction therapy and relapse
* < 3 months -> unlikely to respone to tx
* > 3 months -> 25% chance of response, use 2nd line tx

Question 13

TX for extensive SCLC?

Answer 13

1. Chemotherapy alone
2. EP (Etoposide plus cisplatin or carboplatin)

Question 14

What is considered 2nd line “first line” for recurrance dx?

Answer 14

Topotecan IV/PO
OR irinotecan, gemcitabine, pacitaxel, doxetaxel, vinorelbine

Question 15

What are the tx option for NSCLC?

Answer 15

1. Surgery tx of choice
2. Radiation
3. Chemotherapy
4. Targeted therapies

Question 16

What are the types of NSCLC?

Answer 16

1. Adenocarcinomas (non-smokers)
2. Squamous cell carcinomas
3. Large cell carcinomas

Question 17

Describe the staging of NSCLC?

Answer 17

Stage 1: Tumor confined to lung
2: Large tumors or tumors with initial lymph node involvement
3: more extensive nodual or regional involvement
IV: contralateral lung, metastatic dx or pleural effusion

Question 18

Stage 1 tx for NSCLC?

Answer 18

Negative margins:
* Observation after surgery
* Chemo for high-risk patients

Positive margins:
* Re-resection (preferred) +/- chemo
* Radiation therapy +/- chemotherapy

Question 19

Stage 2 tx for NSCLC?

Answer 19

Negative margins: Chemo
Positive margins:
* Re-resection (preferred) + chemotherapy
* Chemoradiation (sequential or concurrent)

Question 20

Stage 3 tx for NSCLC?

Answer 20

Negative margins:
* Chemotherapy OR
Chemoradiation (before or after surgery)

Tx based on genetic findings:
* Crizotinib for ALK +
* Erlotinib for EGFR +

Positive margins:
* Re-resection (preferred) + chemotherapy
* Chemoradiation (sequential or concurrent)

Question 21

Biomarkers you look for in NSCLC?

Answer 21

EGFR mutation (EGFR inhibitors)
EML4-ALK mutation (ALK inhibitors)
KRAS

Question 22

EGFR inhibitors?

Answer 22

Erlotinib
Gefitinib
Afatanib

Question 23

ALK inhibitors?

Answer 23

Crizotinib
Certinib
Alectinib

Question 24

Chemo used for NSCLC?

Answer 24

1. Cisplatin/etoposide
2. Cisplatin/Vinorelbine
3. Carboplatin/pacitaxel
4. Cisplatin/pemetrexed

Question 25

ADRs of EGFR inhibitors?

Answer 25

Intestinal lung dx

Question 26

DDI of EGFR inhibitors?

Answer 26

Warfarin for gefitinib or erlotinib May need topical or oral therapy for rash as with erlotinib and afatinib

Question 27

Counseling for gefitinib and erlotinib?

Answer 27

PPIs, antacids, H2RAs decrease absorption (Avoid if possible) CYP3A4 substrates

Question 28

First line for ALK+ NSCLC?

Answer 28

Crizotinib

Question 29

ADRs of crizotinib?

Answer 29

Vision disorders   Diarrhea, nausea Infections Elevated LFTs Severe pneumonitis **QTc prolongation**

Question 30

ADR of Ceritinib?

Answer 30

Diarrhea Hepatotoxicity Visual impairment Interstitial lung disease QTc prolongation

Question 31

# eritinib ADR of alectinib?

Answer 31

Elevated LFT’s Myalgias Photosenstivity Interstitial lung disease

Question 32

Tx for Stage IV lung cancer non squamous?

Answer 32

**EGFR +:** erlotinib, afatinib, gefitinib **ALK +:** Crizotinib **EGFR/ALK mutation negative (PS 0-1):** Cisplatin or carboplatin/pemetrexed * Platinum doublet ±  Bevacizumab **EGFR/ALK mutation negative (PS 2):** Carboplatin/pemetrexed Single agent therapy **EGFR mutation negative PS 3-4:** Best supportive care

Question 33

Tx for Stage IV lung cancer squamous cell?

Answer 33

**EGFR/ALK mutation negative (PS 0-2):** * NO BEVACIZUMAB * Cisplatin/gemcitabine **EGFR/ALK mutation negative (PS 3-4):** Best supportive care