NSCLC Flashcards
Second line for NSCLC
docetaxel +/- ramucirumab
First line for BRAF mutant NSCLC
BRAF/MEK
First line for RET mutant NSCLC
RET inhibitors - Selpercatinib (Libretto 431) + pralsetinib
First line for MET mutant NSCLC
MET inhibitors - capmatinib vs. tepotinib
Osimertinib SE’s
cardiomyopathy
long QT syndrome
amivantimab targets?
EGFR + MET
First line ALK targeted therapies
alectinib
brigatinib
Lorlatinib
*Ceritinib (not preferred but also category 1)
*crizotinib (not preferred but also category 1)
Class effect ALK inhibitor SE’s to know
bradycardia
pneumonitis
Drugs targeted ROS1
Crizotinib
entrectinib
repotrectinib
crizotinib SE’s to know
- visual dysfunction
- hepatotoxicity
- low testosterone
RET fusion targeting drugs
selpercatinib
pralsetinib
Drugs targeting MET
tepotinib
capmatinib
Amivantimab
Class effect of MET inhibitors to know
- peripheral edema
NTRK targeting drugs
entrectinib
lorlectinib
KRAS g12c targeting drugs
Sotorasib
Adagrasib
First line for KRAS
Chemoimmunotherapy
Line of therapy for which HER2 is approved in NSCLC
second line or subsequent
Stains for adeno
***CK7
Napsin A
TTF1
CK20 positive suggests what tissue origin
GI tract primary
T3 NSCLC
1)Tumor >5 cm but ≤7 cm in greatest dimension
2)or associated with separate tumor nodule(s) in the same lobe as the primary tumor
3) or directly invades any of the following structures: chest wall (including the parietal pleura and superior sulcus tumors), phrenic nerve, parietal pericardium
T2 NSCLC
1)Tumor >3 cm but ≤5 cm
2)or tumor with any of the following features:Δ
Involves main bronchus regardless of distance from the carina but without involvement of the carina
Invades visceral pleura
3)Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lung
T staging that indicates adjuvant chemo
Greater than 4 cm is T2b
N3 disease
Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
N2 disease
Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N1 disease
Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
IA vs. IB
T2 qualifies as IB
*Important since changes management
Adjuvant immunotherapy indication
- atezo if PD-L1 positive
- pembro regardless (approval, but benefit unknown)
ALK drug studied in Alina for adjuvant of ALK mutant NSCLC
Alectinib
Necessary FEV1 post-op for determining surgical candidacy
1.5L for lobectomy
Greater than 2L for pneumonectomy
*board question may state this and answer will be radiation over surgery
Management of unresectable superior sulcus tumor
Chemoradiation followed by adjuvant durvalumab
typical first line regimen for squamous and nonsquamous
adeno - carbo/pem/pem
squam - carbo/taxol/pembro
adeno stains
CK7
TTF1
squam stains
P63
P40
TTF1 negative
*impt to know since may just give stains
Concurrent chemoradiation regimens for 1) nonsquamous 2) squamous
Nonsquamous:
- carbo/pem
- cis/pem
- carbo/taxol
Squamous:
- carbo/taxol
- cisplatin/etoposide
Nonresectable superior sulcus tumor management
Definitive CRT followed by durvalumab
Board answer to patient to CR to pembro and NED at 2 years
Stop treatment
Management of oligometastatic NSCLC with PR
Local therapy (XRT) to sites of residual disease
Indication for adjuvant immunotherapy
- same as for chemo (tumors of 4 cm or larger)
Indication for adjuvant atezo
- Stage II-IIIA
- PDL1 greater than 1%
Answer to adjuvant for visceral pleural invasion on boards
If multiple high risk features (poorly differentiated, vascular invasion, wedge resection, visceral pleural invasion, unknown nodal status), give adjuvant cehmo
Approved line of therapy for KRAS targeted therapy
Second line
Second line for small cell
*REMEMBER, depends on platinum sensitivity (relapse after 3-6 months considered platinum sensitive)
Line of therapy for RET in solid tumor
- second line or later for any solid tumor (tissue agnostic)
Line of therapy for RET targeted therapy
Firstline
Indication for lung cancer screening
- age 50-85
- 20 pack-year smoking history
- currently smoke or have quit within 15 years
Standard radiation dose for NSCLC CRT
60 Gy
EGFR exon 20 drugs approved for second line
*Mobicertinib
Amivantamab
Management of localized sarcomatoid mesothelioma
Ipi/nivo
*No surgical cytoreduction (aggressive disease biology)
Characteristics of malignant pleural effusion per Light certiera
- pleural fluid protein to serum protein ratio >0.5
- pleural fluid LDH to serum LDH >0.6
- OR pleural fluid LDH > 2/3’s of ULN of serum LDH
*rapid recurrence
CrCl threshold for pemetrexed
CrCl>45
Staging of thymoma
Stage 1 - completely encapsulated
Stage 2 - transcapsular invasion and/or extension to surrounding tissue
Stage 3 - Extension to neighboring organ
Stage 4 - pleural, pericardial, lymphogenous, hematogenous dissemination
First line for metastatic thymoma
cisplatin, doxorubin, cyclophosphamide, and prednisone for 6 cycles
Management of grade 1 mucositis per boards
“sodium bicarbonate mouthwash with local anesthetics and antiulcer medication”
First line options for epitheliod mesothelioma
- nivo/ipi
- platinum/pemetrexed +/- bev
Most common SE of selpercatinib + second most common
1) HTN most commonly
2) Elevated liver enzymes
CNS activity of ROS1 TKI’s
- entrectinib and repotrectinib have good CNS activity
Line of therapy for ROS1 TKI’s
First line
First line for thymic carcinoma
carbo/taxol
Stage IIIB requires
T3-4 N2 OR N3 disease
Second line for thymoma
Pemetrexed
How is cervical adenopathy staged in NSCLC?
M1
Other high emetic risk drugs
- ACT
- carbo AUC >4
- cytoxan >1500
- dacarbazine
- TDxd
- ifosfamide
- melphalaen
- sacituzumab
