Sarcomas Flashcards

Question 1

Q

SDH deficient GIST

Answer

A

Insensitive to imatinib- use sunitinib or regorafenib

Question 2

Q

Localized, clinically resectable, extremity and superficial trunk soft tissue sarcoma
(Tx overview)

Answer

A

Grade 1: surgery +/- radiation

Grade 2-3: surgery +/- radiation and chemo before and after surgery

Question 3

Q

Localized, clinically unresectable, extremity and superficial trunk soft tissue sarcoma
(Tx overview)

Answer

A

Neoadjuvant chemo +/- RT
—-> surgery if now resectable, otherwise tx as advance dx

Question 4

Q

Advanced/metastatic clinically resectable soft tissue sarcoma
(Tx overview)

Answer

A

Isolated Mets: surgery +/- chemo

Mx Mets: tx as advance unresectable

Question 5

Q

Advanced/metastatic, unresectable soft tissue sarcoma
(Non-specific histology)

Answer

A

Chemo, options are:
1. Doxorubicin (better for less fit patients)
2. Doxorubicin + ifos + Mesna (AIM)

*give with g-CSF

Others:
-doxorubicin + Dacarbazine (AD)
- ifos + Epirubicin + Mesna
-liposomal dox
-Epirubicin

Question 6

Q

Advanced/metastatic, unresectable soft tissue sarcoma
(Non-specific histology)
And cannot tolerate doxorubicin

Answer

A

Gemcitabine + docetaxel (or Vinorelbine or dacarbazine)

infuse Gemcitabine at 10 mg/m2/min -increases efficacy has not been proven but this is how it was studied

Question 7

Q

Advanced/metastatic, unresectable soft tissue sarcoma. non-liposomal
(Non-specific histology)
SECOND LINE

Answer

A

Pazopanib

Question 8

Q

Advanced/metastatic, unresectable soft tissue sarcoma. Liposomal
(Non-specific histology)

Answer

A

Eribulin or trabectedin

(use 2 lines of therapy first including anthracycline)

Question 9

Q

Advanced/metastatic, unresectable soft tissue sarcoma. Leimyosarcoma.
(Non-specific histology)

Answer

A

Trebectedin

Question 10

Q

Soft tissue sarcoma neoadjuvant

Answer

A

Dox + ifos + Mesna (AIM)

(Or Epirubicin instead of dox)

*give with g-CSF

Question 11

Q

Soft tissue sarcoma neoadjuvant
Unable to do doxorubicin

Answer

A

Gemcitabine + docetaxel

Question 12

Q

Soft tissue sarcoma: Desmoid tumors (aggressive fibromatosis)

Answer

A

Observation!!!

-Sorafenib (cat 1)
-nirogacestat (cat 1)

Others:
-Mtx + vin
-imatinib
-liposomal dox
-dox + Dacarbazine
-Pazopanib

Associated with Gardner syndrome (APC gene mutation)

Question 13

Q

Soft tissue sarcoma: non-pleomorphic rhabdomyosarcoma

Answer

A

Vincristine + dactinomycin + cyclophosphamide (VAC)

Question 14

Q

Soft tissue sarcoma: alveolar soft part sarcoma

Answer

A

-sunitinib
-Pazopanib
-pembrolizumab
-pembro + axitinib
-atezolizumab

Question 15

Q

Soft tissue sarcoma: angiosarcoma

Answer

A

Paclitaxel

Or doxorubicin

Question 16

Q

Soft tissue sarcoma: dermatofibrosarcoma transformation (DFSP)

Question 17

Q

Soft tissue sarcoma: Epithelioid sarcoma

Answer

A

Early stage: surgical resection

Metastatic: Tazometostat 800 PO BID

Question 18

Q

Extra skeletal osteosarcoma

Answer

A

-ifos
- or doxorubicin + cisplatin

“I am a CD”

Question 19

Q

Dedifferentiated chordoma

Answer

A

Treat as general soft tissue sarcoma (anthracycline OR Gemcitabine based regimens )

Question 20

Q

Soft tissue sarcoma: inflammatory myofibroblastic tumor (IMT) with anaplastic lymphoma kinase (ALK) translocation

Answer

A

-alectinib
-Brigatinib
-ceritinib
-crizotinib
-lorlatinib

Question 21

Q

Soft tissue sarcoma: malignant perivascular epitheloid cell tumor (PEComa)

Answer

A

Albumin based sirolimus

Question 22

Q

Recurrent angiomyolipoma

OR

lymphangioleiomyomatosis

Answer

A

-sirolimus
-everolimus
-temsirolimus

Question 23

Q

Soft tissue sarcoma: solitary fibrous tumor

Answer

A

-bevacizumab + temozolomide
-sunitinib
-sorafenib
-pazopanib

Question 24

Q

Tenosynovial giant cell tumor/pigmented villonodular synovitis

Answer

A

Pexidartinib

Question 25

Q

Retroperitoneal well differentiated or dedifferentiated liposarcoma

Answer

A

Palbociclib

Question 26

Q

Soft tissue sarcoma: uterine leiomyosarcoma

Answer

A

Gemcitabine + docetaxel

Question 27

Q

Myxoid liposarcoma

Answer

A

-dox
-dox + dacarbazine (AD)

Question 28

Q

Soft tissue sarcoma: pleomorphic liposarcoma

Answer

A

Doxorubicin

Question 29

Q

Synovial sarcoma

Answer

A

Doxorubicin + ifos

afamitresgene autoleucel

Question 30

Q

Bone sarcoma: giant cell tumor of bone

Answer

A

First line: surgery or serial arterial embolization

RT if recurrence or inoperable

Denosumab

-interferon/peginterfeuron can be options

Question 31

Q

Bone sarcoma: osteosarcoma
Neoadjuvant/adjuvant or metastatic
First line

Answer

A

If >40 y/o: cisplatin + doxorubicin

If <40 y/o: high dose MTX (12 g/m2) + cisplatin + doxorubicin (MAP)

neoadjuvant *2-6 cycles—>surgery —>
Adjuvant 2-12 cycles

MTX 12 g/m2!!!- probably cap at 20 g!!!

Same regimens used for metastatic just no surgery

Question 32

Q

Bone sarcoma: osteosarcoma
Second line or relapsed/refractory

Answer

A

-Ifosfamide (high dose) +/- etoposide (cat 2A)
-regorafenib (cat 1)!!
-sorafenib (cat 2A)

Question 33

Q

Bone sarcoma: Ewing sarcoma
First line: adjuvant/Neoadjuvant/primary)

Answer

A

-NEOADJUVANT!!! vincristine + doxorubicin + cyclophosphamide alternating with ifosfamide + etoposide (VDC/IE)- every 2 weeks

*give with g-CSF

-surgery after chemo
-very radiosensitive but RT reserved for when we can’t do surgery
-follow with adjuvant chemo

Metastatic
-HD-chemo—>ASCT

Question 34

Q

Bone sarcoma: Ewing sarcoma
Primary therapy

Answer

A

-Surgery and neoadjuvant/adjuvant chemo (RT option if can’t do surgery- radiosensitive but toxicities)

-Vincristine + dox + cyclophosphamide alternative w/ ifos + etop (VDC/IE)- every 2 weeks

-vincristine + dox + ifos + dactinomycin (VAIA)

-vincristine + ifos + dox + etoposide (VIDE)

-vincristine + dox + cyclophosphamide (VDC)

*give these with g-CSF

*neoadjuvant, can also do adjuvant

Question 35

Q

Bone sarcoma: Ewing sarcoma
Second line for relapsed refractory or metastatic dx

Answer

A

-Cyclophosphamide + topotecan
-irinotecan + temozolomide +- vincristine

Question 36

Q

Bone sarcoma: chordoma

Answer

A

-primary therapy is surgery
-if unresectable- RT is primary therapy

-imatinib
-dasatinib
-sunitinib

Dedifferentiated should be tx as STS

Question 37

Q

Sarcoma: GIST
Neoadjuvant for resectable dx

Answer

A

KIT or PDGFRA (except exon 18 including D842V)
-Imatinib
-Note: no proven role for neoadjuvant at this time, usually adjuvant for 1-3 years

PDGFRA exon 18 D842V mutation
-Avapritinib 300 mg daily on empty stomach

Question 38

Q

Sarcoma: GIST
Neoadjuvant, resectable or metastatic
NTRK gene fusionpositive

Answer

A

-larotrectinib
-entrectinib

FOR FUSIONS, NOT MUTATIONS

Question 39

Q

Sarcoma: GIST
Neoadjuvant, resectable dx or metastatic
SDH deficient

Answer

A

Sunitinib

Question 40

Q

Sarcoma: GIST
Neoadjuvant, resectable, or metastatic
BRAF V600E mutated

Answer

A

Dabrafenib + trametinib

Question 41

Q

Sarcoma: GIST Resectable
Adjuvant therapy

Answer

A

High risk: imatinib x3 yr

Low risk: imatinib x 1yr

400 mg daily

Note: for resectable dx usually adjuvant not neoadjuvant

Question 42

Q

Sarcoma: GIST metastatic

Answer

A

First line: Imatinib
Second line: sunitinib
Third line: regorafenib
Fourth line: ripretinib

PDGFRA exon 18 mutation including PDGFRA D842V- Avapritinib (notice also used as neoadjuvant in resectable dx)

Question 43

Q

Sarcoma: GIST metastatic
Exon 9 mutation

Answer

A

Imatinib 800 mg/day 400 mg BID

Question 44

Q

Sarcoma: GIST

PDGFRA exon 18 mutation including PDGFRA D842V

Answer

A

Avapritinib- neoadjuvant if resectable and also for metastatic/unresectable

Second line: dasatinib

Question 45

Q

WHO grade II glioma (astrocytoma, or oligodendroglioma)

Answer

A

Initial tx
Surgery —->RT—->PCV x6
(Procarbazine + lomustine + vincristine)
**(category 1 for high risk (>40 y or subtotal resection) **

Recurrent
Surgery again + RT and concurrent or adjuvant PCV or TMZ

-TMZ is alternative if pt can’t take PCV
-Ivosidenib if chemo not preffered and IDH mutated

Useful in certain circumstances: ivosidenib

Question 46

Q

Grade III oligodendroglioma- with co-deletion of 1p/19q

Answer

A

Surgery—>RT + neoadjuvant or adjuvant PCV (Category 1)

(Procarbazine + lomustine + vincristine)

TMZ is alternative if pt can’t take PCV

Useful in certain circumstances: ivosidenib

Question 47

Q

Grade III astrocytoma

Anaplastic astrocytoma?

Answer

A

Surgery—>RT + adjuvant TZM

Anaplastic: EBRT

Question 48

Q

Grade IV glioma
(Glioblastoma, IDH wildtype astrocytoma)

Answer

A

Surgery —>RT m-f + TMZ 75 mg/m2 QD—> month break
—>TMZ 150–>200 mg/m2 QD x 5d q28d x6 cycles (start at 150mg/m2)

-give pjp ppx with TMZ
-if >70 can use Hypofractionated RT
-if MGMT methylated and >70y and/or PFS<60: TMZ alone
-if MGMt methylated and <70y and KPS >60 can: RT + concurrent lomustine and TMZ
-+/- electric field therapy
-regardless of methylation status

Note: we often see pseudo progression in first 3 months due to tx with RT!!

Question 49

Q

Primary CNS lymphoma Induction

Answer

A

RMT
HD MTX 8 g/m2 + rituximab +/- TMZ

Consolidate with etoposide + Cytarabine +/- WBRT

Or

RMPV
HD MTX 3.5 g/m2 + rituximab + vincristine + Procarbazine

Consolidate with Cytarabine —>ASCT

Note: we give MTX as short infusion (not continuous) bc it actually doesn’t have great CNS penetration (hydrophilic) so we need high peak concentrations for it to diffuse through the CNS

Note:
-organ transplant pts- try tapering immunosuppressants to get spontaneous remission
-HIV pts- poor prognosis, give ART

Question 50

Q

Primary CNS lymphoma consolidation

Answer

A

Consider archiving this card (consolidation discussed on other pcnsl notecard)

HD systemic therapy w/ stem cell rescue
-Cytarabine + thiotepa—> carmustine + thiotepa
-thiotepa + busulfan + cyclophosphamide
-HD Cytarabine + etoposide
-HD Cytarabine

Question 51

Q

Adult medulloblastoma

Answer

A

Weekly vincristine during craniospinal RT —>
-cisplatin + cyclophosphamide + vincristine
Or
-cisplatin + lomustine + vincristine

Question 52

Q

Meningioma (benign)

Answer

A

No preferred regimen- usually just surgery —-> adjuvant RT

Systemic therapy only if anaplastic, or progression despite above tx
-bevacizumab (2A)
-sunitinib (2B)
-bevacizumab +/-everolimus (2B)

Question 53

Q

Non-muscle invasive bladder CA
(Tx overview)

Answer

A

TURBT—>intravesical BCG or chemo x1—>induction x1-2—> maintenance (for intermediate (1y) or high (3y) risk

Question 54

Q

Muscle invasive bladder CA (T2 or above)
(Tx overview )

Answer

A

TURBT—>Neoadjuvant cisplatin (dd-MVAC preferred) based chemo——->cystectomy—->adjuvant nivolumab? (For high risk: T3-4a or N+ and not eligible/declines adjuvant chemo)

-some patients can consider bladder sparing approach

-note: can do split cisplatin for borderline renal function (40 ml/min)

Question 55

Q

Metastatic bladder CA
(Tx overview)

Answer

A

Chemo. Immunotherapy. Targeted therapy

Can do in addition to local treatments or start with chemo alone. But note for non-metastatic chemo is typically neoadjuvant and followed by surgery unless trying to do bladder sparing approach

Question 56

Q

NMIBC- low risk

Answer

A

TURBT—>one immediate (within 24h, ideally 6h) instillation of intravesical chemo then observation

Low risk= Ta (low grade) solitary and </=3cm, no CIS (carcinoma in situ)

*intravesical chemo with Gemcitabine or mitomycin

Notice- using chemo here, not BCG

Recurrent or persistent
-can repeat induction x1, after that switch to a different agent

Note: muscularis MUCOSA is Non-muscle invasive (unlike muscularis propria)

Question 57

Q

NMIBC- intermediate risk

Answer

A

TURBT—> immediate intravesical chemo (NOT BCG) —>intravesical chemo for max 1 yr OR BCG x1 yr (start BCG 3-4 weeks after TURBT)

Note: BCG induction (weekly x6) for max 2 inductions (12 weeks)*, maintenance is x1yr

Intermediate=
Ta (low grade) recurrent, >3 cm, or multifocal;
Ta (high grade) <3cm
T1 low grade

*chemo w/ intravesical Gemcitabine or mitomycin

Notice, chemo or BCG acceptable here unlike with low/high risk

Recurrent or persistent
-can repeat induction x1, after that switch to a different agent

Note: muscularis MUCOSA is Non-muscle invasive (unlike muscularis propria)

Question 58

Q

NMIBC-high risk

Answer

A

TURBT——>BCG (start 3-4 weeks after TURBT) x3 yrs OR radical cystectomy (NO immediate intravesical therapy after surgery)

Note: BCG induction (weekly x6) for max 2 inductions (12 weeks), maintenance is x3 yr

High risk=
Ta (high grade): recurrent, >3cm, or multifocal
T1 (high grade)
Tis

notice, use BCG, NOT chemo for tumor is situ and high risk, may use mitomycin if unable to tolerate BCG for other high risk

Recurrent or persistent
-can repeat induction x1, after that switch to a different agent

Note: muscularis MUCOSA is Non-muscle invasive (unlike muscularis propria)

Question 59

Q

NMIBC- very high risk

Answer

A

Radical cystectomy OR BCG induction and 3 years of maintence

Highest risk=
-T1 G3/HG associated with concurrent bladder CIS
-mx and/or large T1 G3/HG and/or recurrent T1 G3/HG with CIS in the prostatic urethra
-some forms of variant histology or prostatic urothelial carcinoma, lymphovascular invasion

Note: muscularis MUCOSA is Non-muscle invasive (unlike muscularis propria)

Question 60

Q

High risk NMIBC- carcinoma in situ (CIS) who are BCG unresponsive and do not want radical cystectomy

Answer

A

-radical cystectomy (preferred)
-Pembrolizumab

Intravesical options
-valrubicin
-Gemcitabine
-nadifaragene firadenovec (select patients)

Question 61

Q

MIBC-not metastatic (stage II-III)

Answer

A

TURBT—>neoadjuvant ddMVAC (preferred, 3-6 cycles) OR GC (4 cycles) —>radical cystectomy w/ pelvic lymph node dissection

consider adjuvant ddMVAC if they didn’t get neoadjuvant, or *nivolumab- evidence not great for adjuvant (Dont confuse with avelumab in metastatic setting)

ddMVAC- dose sense MTX + Vinblastine + dox + cisplatin (must give w/ G-CSF)

GC- Gemcitabine + cisplatin

Do no sub cisplatin with Carboplatin for non-metastatic MIBC (better to just not give any chemo if can’t get cisplatin)

Note: ddMVAC probably preferred in this setting

Question 62

Q

Metastatic bladder cancer
Cisplatin eligible

Answer

A

Preffered
-Pembro + enfortumab vedotin

Other
-ddMVAC (mtx + Vinblastine + dox + cis)
OR
-GC (gem + cisplatin)
Above two FOLLOWED BY—> avelumab maintenance (if no progression w/ first line)

-GC (gem + cisplatin) + nivo —> nivo maintenance

Note: cisplatin eligibility:
-crcl>60
-ECOG PS 0 or 1
-adequate hearing

Question 63

Q

Metastatic bladder CA
Cisplatin ineligible

Answer

A

Preffered
-pembro + enfortumab vedotin

Other
Gemcitabine + Carboplatin
FOLLOWED BY avelumab

Question 64

Q

Metastatic bladder CA
Platinum ineligible

Answer

A

I THINK THIS CARD SHOULD BE ARCHIVED FOR NOW

-Pembrolizumab (platinum ineligible regardless of PD-L1 expression)

-pembro + enfortumab

-atezolizumab (cisplatin ineligible if PD-L >5%, or platinum ineligible regardless of PD-L1 status)

Answer 64

A

Prior chemo
Pembrolizumab (category 1) (notice preferable to give alone NOT with Enfortumab vedotin-combo is 2B)

Prior ICI-cisplatin eligible
-Gemcitabine + cisplatin
-ddMVAC
-erdifinitib (If FGFR2 or FGFR3 alterations)

Prior ICI- cisplatin ineligible
-enfortumab vedotin (2a, usually 3rd line)
-Gemcitabine + Carboplatin
-erdafitinib

can repeat platinum based therapy if PFS>12 months

Answer 65

A

Enfortumab vedotin

Or erdafinitib if FGRF 2/3 mutation

Answer 66

A

-cisplatin alone
-low dose gemcitabine
-5-FU and mitomycin

Given with RT after TURBT for bladder preservation (or not cystectomy Candidate) with stage II and IIIa MIBC

Reqs:
-lack of hydro nephro sis
-lack of extensive or multi focal TIS
-tumor size <6 cm

Answer 67

A

T1a
-Partial nephrectomy (preferred) OR
-ablative techniques (<3 cm) OR
-active surveillance Or
-radical nephrectomy (select pts)

T1b
-partial nephrectomy OR
-radical nephrectomy OR
-active surveillance (select pts) OR

Answer 68

A

-Partial nephrectomy OR
-radical nephrectomy

If grade 4 clear cell +/- sarcomatoid features- *adjuvant pembrolizumab x1 yr

Answer 69

A

-radical nephrectomy OR
-partial nephrectomy (select pts)

—> adjuvant Pembrolizumab x1 yr or sunitinib is an option (not a good option) or surveillance

If non-clear cell: surveillance or clinical trial

Answer 70

A

Category 1 options:
-axitinib + Pembrolizumab
-cabozantinib (40 mg) + nivolumab
-lenvatinib + Pembrolizumab

*first assess for active surveillance or cytoreductive nephrectomy

-adjuvant pembro x 1yr following metastectomy within 1 yr of nephrectomy

Answer 71

A

Category 1 options
-axitinib + pembrolizumab
-cabozantinib (40 mg) + nivolumab
-lenvatinib + pembrolizumab
-ipilimumab + nivolumab

Other:
Cabozantinib If can’t take ICI (60 mg daily)

*first assess for active surveillance or cytoreductive nephrectomy

-adjuvant pembro x1 yr following metastectomy within 1 yr of nephrectomy

Note: ICI + ICI has limited duration- opposed to TKI which is continued indefinitely

Answer 72

A

temsirolimus for poor prognosis (at least 3 risk fxs)*
otherwise:
-cabozantinib (preferred)
-clinical trial OR
-sunitinib OR

-papillary RCC- Cabozantinib is preferred TKI
-FH deficient RCC- bevacizumab + erlotinib
- Chromophobe RCC- bevacizumab/lenvatinib + everolimus
-renal medullary carcinoma and collecting duct carcinoma- platinum based chemo
-SDH deficient RCC- VegF TKI

Answer 73

A

Favorable or intermediate risk, limited or no dx symptoms, favorable histologic profile, long interval b/w nephrectomy and development of Mets, limited burden of Mets

Answer 74

A

-Good PFS
-lung only Mets
-good prognosis risk

Answer 75

A

Preferred
-Cabozantinib (cat 1)
-nivolumab (cat 1)
-lenvatinib + everolimus

Other
-axitinib (cat 1)
-tivozanib (cat 1 if 2 prior regimens)
-belzutifan (if prior pd1 and vegf)
-all first line options
-Pazopanib
-sunitinib
-axitinib + avelumab (cat 3)

Answer 76

A

-bone directed RT
-bisphosphonate or rank-L
-cabozantinib containing regimen

Answer 77

A

-brain directed RT and/or surgery

Answer 78

A

-ipilimumab + nivolumab has strongest evidence OR
-ICI + TKI

Answer 79

A

Very low risk

Expected survival
<10y: observation
10-20y: active surveillance
>20y: active surveillance, RT, or RP (+/- EBRT +/- ADT)

Notice don’t use ADT alone unless very short life expectancy

Answer 80

A

Low risk

Expected survival
-<10y: observation
->10y: active surveillance, RT, RP (+/- EBRT +/- ADT)

Notice don’t use ADT alone unless very short life expectancy

Answer 81

A

Intermediate risk

Life expectancy
<5y: observation

Favorable: 1 of above risk factors, grade group 1-2, <50% bx cores pos
-5-10y: observation, RT
->10y: active surveillance, RT, or RP +/- PLND (+/- EBRT +/- ADT)

Unfavorable: 2-3 of above factors, grade group 3, >50% bx cores pos
-5-10y: observation, EBRT + ADT, or EBRT + brachy +/- ADT
-10y: RP + PLND (+/- EBRT +/- ADT), or EBRT + ADT, or EBRT + brachy +/- ADT

Notice don’t use ADT alone unless very short life expectancy

Answer 82

A

High risk

Life expectancy
-<5 y and asymptomatic: observation or ADT or EBRT
->5 y or symptoms: EBRT + 1.5-3y ADT, or EBRT + brachy + 1-3y ADT (cat 1), or RP + PLND (+/- EBRT +/- ADT)

Notice don’t use ADT alone unless very short life expectancy

Answer 83

A

Very High risk

Life expectancy
-<5 y and asymptomatic: observation or ADT or EBRT
->5 y or symptoms: EBRT + 1.5-3y ADT + abiraterone, or EBRT + brachy + 1-3y ADT (cat 1), or RP + PLND (+/- EBRT +/- ADT)

notice we’re not using second gen antiandrogens here

Prednisone is once daily with abiraterone in this setting

Answer 84

A

Regional

Life expectancy:
-<5y: observation or ADT
->5y: ADT + EBRT + abiraterone (preferred), or ADT + EBRT, or ADT +/- abiraterone, or RP + PLND (+- EBRT +- ADT)

Notice don’t use ADT alone unless very short life expectancy

Prednisone is once daily with abiraterone in this setting

Answer 85

A

-if short PSA doubling time (<12 months) or long life expectancy: ADT or enzalutamide +/- ADT (PSADT <9 mo, psa >2 over nadir after RT or 1 after RP)

-if long PSA doubling time or short life expectancy: monitoring

Consider intermittent ADT

Answer 86

A

Continue ADT

-monitoring (preferred)
-other secondary HT

Answer 87

A

continue ADT

Preferred:
-novel (second gen) antiandrogens: (apalutamide, enzalutamide, darolutamide)

*note darolutamide ok here but for metastatic you need to give it with docetaxel

Other:
-secondary HT
-androgen withdrawal
-dex or pred
-ketoconazole (give w/ hydrocortisone)

Answer 88

A

-ADT + (abiraterone OR apalutamide OR enzalutamide)

-ADT + docetaxel + (abiraterone OR darolutamide)

*triplet therapy better if need faster response (high volume (viseceral mets or 4+ bone Mets with 1 outside vertebral column) or symptomatic from mets))

abiraterone only for de novo metastatic dx *in CS setting (can still add later)

docetaxel- in *castration sensitive dx only for de novo high volume dx

Notice we don’t use PARP inhibitors unless mCRPC- not used in m0 or mCSPC

Answer 89

A

-docetaxel OR
-abiraterone OR
- enzalutamide

BRCA mutation
-Olaparib + abiraterone
-Niraparib + abiraterone

HRR mutation
-talazaparib + enzalutamide

Answer 90

A

Docetaxel

BRCA mutation
-Niraparib + abiraterone
-Rucaparib (preferred)

HRR mutation
-Olaparib (preferred)
-talazoparib + Enzalutamide

Answer 91

A

Category 1
-abiraterone
-enzalutamide

Other:
Cabazitaxel

BRCA mutation
-Olaparib + abiraterone
-Niraparib + abiraterone

HRR mutation
-talazaparib + enzalutamide

Answer 92

A

Category 1
-cabazitaxel
-Lu-177-PSMA-617 (if PSMA +)

Other:
-Docetaxel rechallenge (if no prior progression)

-mitoxantrone + prednisone (last line if no other options)

BRCA mutation
-Rucaparib

HRR mutation
-Olaparib

Answer 93

A

Radium-223

If no visceral mets

Answer 94

A

Cabazitaxel + Carboplatin

add GCSF

Answer 95

A

continue ADT

Pembrolizumab

Answer 96

A

this is mCRPC only

Olaparib- indicated after androgen receptor directed therapy (enzalutamide or abiraterone)- any HRR mutation (except PPP2R2A)

Rucaparib- indicated after androgen receptor directed therapy and taxane BRCA mutation only

Note: it might be better to use chemo first in eligible patients (not clear cut)

Answer 97

A

Olaparib- indicated after androgen directed therapy

Note: it might be better to use chemo first in eligible patients (not clear cut)

Answer 98

A

-alendronate 70 mg weekly
-zolendronate 5 mg yearly or 4 mg q6 months
-denosumab 60 mg q6 month

Also calcium and vit D

Notice for prostate we need risk score, we don’t just tx, but for AI, tamoxifen or LHRH don’t need risk assessment score (I think, but in module still lists these tools as a way to determine who needs BMA in breast cancer)

Answer 99

A

-denosumab 120 mg q4wk (preferred)
+ calcium and vit D
-or zolendronate q3-4 wks or q3 mo (but denosumab is superior here)

This is for reductionis SRE in patients with bone Mets!!!

Not for CSPC EVEN IF PATIENT HAS BONE METS

Answer 100

A

Can use atezolizumab first line in cisplatin ineligible patients- but this requires PD-L1 expression (>5%). Can use atezolizumab and pembro in platinum ineligible pts regardless of PD-L1.

Also doesn’t matter for second line I don’t think.

Double check this answer at some point

also atezolizumab no longer indicated for bladder cancer but still in NCCN guidelines

Answer 101

A

Augmentin + cipro

Others:
-augmentin + levo
-moxifloxacin

Note: if pt was getting FQ ppx they will NOT be a candidate for PO abx

Answer 102

A

levofloxacin

Others:
-bactrim
-3rd gen CEPH

Answer 103

A

BEP q21 days x 3
-bleomycin 30 mg IV weekly
-etoposide 100 mg/m2 d1-5
-cisplatin 20 mg/m2 d1-5

EP q21 days x 4
-etoposide 100 mg/m2 d1-5
-cisplatin 20 mg/m2 d1-5
*good risk, stage 2, or viable germ cell tumor at surgery following first line chemo

Other:
VIP q21 days- WITH G-CSF
-etoposide 75 mg/m2 d1-5
-ifosfamide 1200 mg/m2 d1-5 (w Mesna)
-cisplatin 20 mg/m2 d1-5
*for int or poor risk or for pts with viable germ cell tumor at surgery following first line chemo

Answer 104

A

Conventional dose
1. TIP q21 days x4- WITH G-CSF
-paclitaxel + ifosfamide + cisplatin

VeIP q21 days x4- WITH G-CSF
-Vinblastine + ifosfamide + cisplatin

High dose chemo then ASCT
1. Carboplatin + etoposide
2. Paclitaxel + ifosfamide + Carboplatin + etoposide

Answer 105

A

Carboplatin 700 mg/m2 + etoposide 750 mg/m2
Paclitaxel + ifosfamide + Carboplatin + etoposide

These are myeloablative ASCT regimens

followed by ASCT

Answer 106

A

Gemcitabine + paclitaxel + oxaliplatin
Gemcitabine + Oxaliplatin
Gemcitabine + paclitaxel
Etoposide (oral)

this is more palliative

Answer 107

A

Stage 1A/1B
-RIO —>surveillance (preferred)
-adjuvant RT
-Adjuvant carbo AUC 7 x1-2

Stage IS
-re-image

Stage IIA/IIB
-BEP x3, EP x4
-RT (non-bulky <3cm)

Stage IIC/III
RIO—> chemo
-good risk: BEP x3, EPx4
-int: BEP x4, VIP x4

Following chemo for IIC/III
-No or <3cm residual dx and normal tumor marker: surveillance
-Residual mass >3cm and normal markers—> PET scan >6 wks after chemo (unlike non-seminoma which does surgery)
-if positive: RPLND, TIP, VIP
-if complete resection of residual dx: EP, TIP, VIP, VeIP x2
-if incomplete resection of residual dx: full course second line
-if progression: second line or ASCT

DONT DOSE REDUCE CHEMO UNLESS ANC <500 or scr >1.5

Answer 108

A

Stage 1
-Surveillance (preferred if no risk fx for relapse)
-nerve sparing RPLND
-BEP x1 (unless pure teratoma)

Stage IS
-EP x4, BEP x3

Stage IIA/IIB
-Normal post orchiectomy tumor markers:
-RPLND
-EP x4, BEP x3
-Elevated post orchiectomy tumor markers:
-EP x4, BEP x3

After stage IIA/IIB
-negative tumor markers and no residual dx or <1cm:
-surveillance
-RPLND (select pts)
-negative tumor markers and residual dx >1cm: nerve sparing RPLND
-after RPLND:
-N0: surveilllance
-N1-2: EP x2, BEP c2
-N3: EP x4, BEP x3

Stage IIC/ IIIA (good risk)
-EP x4, BEP x3

Stage IIIB (int risk)/ IIIC (poor risk)
-BEP x4, VIP x 4
-EP x4, BEP x3 ok if intermediate risk and LDH is the only reason

Risk for relapse: lymphovascular, spermatic cord, or scrotum invasion
********
After primary chemo
-CR and negative tumor markers: Surveillance or RPLND (unlike seminoma which does PET scan)-bc it’s usually teratoma so can’t do chemo
-PR, residual mass, normal tumor markers: EP, TIP, VIP, VeIP x2 (or surveillance if teratoma or necrosis)
-PR residual mass, abnormal tumor markers
-elevated and rising: second line
-elevated and stable: surveillance
-mildly elevated and normalizing:
-surgical resection
- surveillance if teratoma or necrosis
-other histology: EP, TIP, VIP, VeIP x2

DONT DOSE REDUCE CHEMO unless ANC <500 or scr>1.5

Answer 109

A

Primary therapy is surgery

-dasatinib
-Pazopanib
-ivosidenib (IDH1 mutation)

If unresectable, metastatic of de-differentiated- tx like osteosarcoma

If mesenchymal- tx like Ewings

Answer 110

A

Osteosarcoma like regimen for neoadjuvant and adjuvant chemo

*UPS

Answer 111

A

Doxorubicin

Answer 112

A

Surgery (radical orchiectomy) only

*older men and rarely metabolize

Answer 113

A

Surgery only

Answer 114

A

Optimal cytoreduction: <1 cm residual dx
Suboptimal: > 1cm residual dx

*note: can do fertility sparing surgery for stage 1A and 1B

Answer 115

A

Stage 1A/1B low grade serous or grade 1-2 endometrioid
-Surgery alone -> observation

Stage 1A/1B high grade serous or grade 2-3 endometrioid, stage 1C
-Paclitaxel 175 mg/m2 + Carboplatin AUC 5-6 q3w

Others:
-Liposomal dox + Carboplatin
-docetaxel + carboplatin

Note
-3 cycles only for low grade, high grade serous gets 6 cycles

Answer 116

A

<70 years old
-Paclitaxel 175 mg/m2 + Carboplatin AUC 5-6
-Paclitaxel 175 mg/m2 + Carboplatin AUC 5-6 + bevacizumab + bevacizumab maintenance

>70 years old or comorbidities
-Paclitaxel 135 mg/m2 + Carboplatin AUC 5
-paclitaxel 60 mg/m2 + Carboplatin AUC 2 weekly (instead of every 3 weeks)

Other options (<70y)
-docetaxel + Carboplatin
-liposomal doxorubicin + Carboplatin

Notes:
-we still do surgery
-6 cycles of chemo (q21 days)
-for stage 3 HIPEC (hyperthermia IP chemo) w/ cisplatin 100 mg/m2 is and option at time of IDS

Answer 117

A

-5FU + leucovorin + Oxaliplatin (FOLFOX)
-capecitabine + Oxaliplatin (CAPOX)
-paclitaxel + Carboplatin

*can add bevacizumab for stages II-IV Is this supposed to be stage III-IV? NO!

Answer 118

A

Stage 2-3
-optimal cytoreduction (<1 cm)
-no bowel obstruction or bowel surgery
-good PFS
-normal renal function
-no pre-existing neuropathy

paclitaxel 135 mg/m2 IV —> cisplatin 75 mg/m2 IP—>paclitaxel 60 mg/m2 IP
-warm IP fluids, aggressive hydration (prevent renal function), aggressive antiemetics *(highly emetogenic regimen before day 2 cisplatin)

Note: paclitaxel is given over 3 hours NOT 24h and cisplatin is 75 mg not 100 mg

Answer 119

A

Bulky stage 3-4 unlikely to be optimally cytoreduced (<1 cm with surgery) and/or poor surgical candidate

Assess for interval debunking surgery after 3 cycles (3 cycles—> surgery—> 3 more cycles…could technically do all 6 then surgery then more chemo)

Same regimens except no IP. And hold bevacizumab cycle before and after surgery

Answer 120

A

Note: HRD+ means homologous recombinant DEFICIENT (ya little dumbass)

Notice the word ”REGARDLESS doesn’t mean “wild type”

Bevacizumab:
-regardless of HRD and BRCA wildtype
-must have used in upfront regimen

Bevacizumab + Olaparib
-PR/CR to 1st line chemo
-Germline/somatic BRCA mutation when bevacizumab used in upfront (cat 1) OR
-BRCA wild type but HRD+ (mychoice CDx score 42+) when used upfront

Olaparib
-PR/CR to 1st line chemo
-germline/somatic BRCA mutation

Niraparib (preferred over Rucaparib bc has fda and NCCN approval)
-PR/CR to 1st line chemo
-regardless of BRCA or HRD
-unless BRCA wildtype and Bev was used- use Bev maintenance

Rucaparib
-PR/CR to 1st line chemo
-Regardless of BRCA or HRD
-unless BRCA wildtype and Bev was used- use Bev maintenance

Usually continue for 2 years, dx progression, or unacceptable toxicity. Except Niraparib: 36 months and bevacizumab: 15 months

”stable disease” is not CR/PR and does not qualify for PARP maintenance

Answer 121

A

-carbo + gemzar +/- bevacizumab
-carbo + paclitaxel +/- bevacizumab
-carbo + Liposomal dox +/- bevaciz
-cisplatin + gemcitabine

Targeted therapy:
-bevacizumab

Note: don’t retreat for biochemical recurrence (CA-125), wait for measurable or symptomatic disease

Answer 122

A

-docetaxel
-oral etoposide
-Gemcitabine
-liposomal dox +/- bevacizumab
-paclitaxel (weekly) +/- bevacizumab
-topotecan +/- bevacizumab
-oral cyclophosphamide + bevacizuma

Targeted:
Bevacizumab

Other:
-Mirvetuximab (FRa positive- >75%)
-pembro: msi-h, dMMR, TMB-h and no satisfactory alternatives

Note: don’t retreat for biochemical recurrence (CA-125), wait for measurable or symptomatic disease

Answer 123

A

no PARP inhibitors for platinum resistant recurrence

Olaparib:
-PR/CR to 2+ line therapy
-regardless of BRCA

Rucaparib:
-PR/CR to 2+ line therapy
-must have BRCA mutation

Niraparib:
-PR/CR to 2+ line therapy
-must have germline BRCA mutation
-if starting at a reduced dose, may increase back if no worsening thrombocytopenia

bevacizumab:
-PR/CR to 2+ line therapy
-if used in therapy for recurrent dx

*continue until dx progression or unacceptable toxicity

Answer 124

A

BRFA V600E: Dabrafenib + trametinib

NTRK: entrectinib, larotrectinib

RET: Selpercatinib

MSI-H, dMMR, TMB-H: pembro (only
If no other treatment options left)

TMB-H: dostarlimab for recurrent

Answer 125

A

Stage I-IIA
-Surgery + RT

Stage IIB-IVA, recurrent, metastatic
RT most important:
Chemo radiation:
-cisplatin + etoposide + RT

(Can use carbo is cis intolerant)

Answer 126

A

Pretty much just surgery (TH/BSO) followed by observation or RT (pelvic EBRT and/or vaginal brachytherapy NOT whole pelvic RT)

Note: bx proven grade I endometrioid limited to endometrium can skip surgery for fertility sparing and just do HT (continuous progesterone therapy with megestrol, medroxyprogesterone, or levonorgestrel IUD)

Could consider systemic therapy for stage II or IB (grade 3)

For high risk (serous carcinoma, clear cell carcinoma, undifferentiated/Dedifferentiated carcinoma, carcinosarcoma) use systemic therapy much earlier- stage 1, more like ovarian

Note: early stage endometrial is the most curable gyn CA

Answer 127

A

Surgery—>chemo—> +/- RT

Chemo: Carboplatin + paclitaxel + pembro/dostarlimab (regardless of MMR) OR + trastuzumab (HER-2+ uterine serous or carcinosarcoma)

Chemo-Radiation
-cisplatin + RT—> carbo + paclitaxel

Endocrine therapy:
(For ER/PR+, low grade endometrial only- use instead of chemo)
-tamoxifen, AI, fulvestrant, progestin products

Notice we don’t start chemo
Until stage III- unlike ovarian (stage 1) and cervical (stage IIB)

Answer 128

A

Local recurrence
Surgery and/or RT-pelvic EBRT + brachytherapy (Look at what was previously given)

Distant recurrence
Chemo:
Carboplatin + paclitaxel +/- pembro/dostarlimab (regardless of MMR) + trastuzumab (if HER-2+ uterine *serous or carcinosarcoma)

Endocrine therapy:
(For ER/PR+, low grade endometrial only- use instead of chemo)
-tamoxifen, AI, fulvestrant, progestin products

Other:
-lenvatinib + pembro (NOT MSI-H or dMMR) (Category 1)
-pembro, nivo, dostarlimab, avelumab alone (MSI-H /dMMR or TMB-H)
-single agents therapy: cis, carbo, dox, paclitaxel

Answer 129

A

Recurrent or metastatic
-Megestrol/ tamoxifen alternating
-everolimus + letrozole

Uterine limited dx and fertility sparing
-levonorgestrel IUD

ER/PR+, low grade endometrioid, instead of chemo

Answer 130

A

-dex + vincristine + calaspargase

Note: dex in 10+ y/o increases fungal infxns and osteonecrosis

Answer 131

A

-steroid (dex <10, pred 10+), vincristine, calaspargase, anthracycline

Note: dex in 10+ y/o increases fungal infxns and osteonecrosis

Answer 132

A

Diagnostic LP with IT Cytarabine given on or before induction LP

Then intermittent IT chemo

need plt >/= 100k

Cytarabine d.o.c bc active in ALL and AML

Answer 133

A

Peg: >21 y/o
Cal: </= 21 y/o

Answer 134

A

Standard backbone:
-daily mercaptopurine (6MP) PO + weekly PO MTX+ intermittent pulses of vincristine + corticosteroid

-increase (if sustained >6-8 weeks) 6MP and MTX doses by 25% to maintain ANC 500-1500
-if ANC <500, hold both until recovery and restart at lower dosing

Answer 135

A

Homozygous wild type (normal metabolizer- 1/1): normal dose

Heterozygous (intermediate- 1/2, 3A, 3B, 3C, or 4): 30-80% of normal dose

Homozygous deficient (poor- *2/3A, 3C/4): 10% full dose (3 times per week per lecture but not NCCN)

*if int for both NUDT15 and TPMT give further dose adjustment

Answer 136

A

Homozygous wildtype (normal metabolizer- 1/1): normal dose

Heterozygous (intermediate- 1/2, *3, or 9):
-6MP: 30-80% *of full dose

Homozygous deficient (poor- 2/3):
-6MP: 10 mg/m2/day
-6TG: 25% dosing

*if int for both NUDT15 and TPMT give further dose adjustment

Answer 137

A

COPAD x2
(Cyclophosphamide, vincristine, prednisone, doxorubicin)

no IT or HD-MTX needed

no reduction or consolidation like group B/C and no maintenance like group C

Answer 138

A

-COP x1 (cyclophosphamide + vincristine + prednisone)-REDUCTION

-COPADM x2 (cyclophosphamide + vincristine + prednisone + doxorubicin + HD-MTX)-INDUCTION

-CYM x2 (Cytarabine + HD-MTX)-CONSOLIDATION

No maintenance like group C

Answer 139

A

-COP x1 (cyclophosphamide + vincristine + prednisone)-REDUCTION

-COPADM x2 (cyclophosphamide + vincristine +prednisone + doxorubicin + HD-MTX)-INDUCTION

-CYVE x2 (HD-Cytarabine + etoposide)-CONSOLIDATION

Maintenance x2-4 cycles

Answer 140

A

Average Risk
-surgery + reduced dose RT + weekly vincristine —> chemo x8

Chemo is:
-cisplatin + vincristine + cyclophos OR
-cisplatin + vincristine + lomustine

High Risk
3+ y/o: surgery + standard dose RT + weekly vincristine —> chemo (VCP x8 (vincristine + lomustine + prednisone)

<3 y/o: surgery + chemo +/- HCT (avoid RT in <3y)

Give RT within 4 weeks post surgery

Answer 141

A

Induction: surgery + RT
Chemo= CAV cycle 1,2,4,6 (cyclophos , dox, vinc) and cis + etop cycle 3 and 5

Consolidation: myeloablative chemo + tandem autologous stem cell transplant

Maintenance: isotretinoin +/-Dinutuximab
___________________________________

Note: low risk (stage 1-2) dx is tx with surgery alone

GM-CSF: potentials antibody dependent cell mediated toxicity

Hyperdiploid is favorable risk

Answer 142

A

-surgery is mainstay
-RT for stage III or greater
-chemo
-low risk (Stage II) EE-4A (dactinomycin + vinc)
-standard-high risk (stage III+): DD-4A (dactinomycin + vinc + dox)
-sometimes add cyclophos for higher risk

*this is a type of kidney cancer- almost always in children

LOH at chromosomes 1p and 16q is poor prognostic fx- seen in standard and high risk

Answer 143

A

-ddMVAC preferred in neoadjuvant setting, either in metastatic setting

Answer 144

A

Indications withdrawn!! Still in NCCN guidelines

Answer 145

A

Large tumors (>10cm) or high grade

Answer 146

A

Stage I-IIA
-Surgery + RT

Stage IIB-IVA
Chemo radiation:
-cisplatin + RT (EBRT + brachy)
(carbo if cisplatin intolerant)
-cisplatin dose is 40 mg/m2 q7d x5-6 weeks
-may cap dose at 70 mg

Notice IVA NOT IVB

If chemo alone
-cisplatin + paclitaxel +/- bevacizumab +/- pembro (PD-L1 pos)

Answer 147

A

-Cisplatin (or carbo) + paclitaxel +/- bevacizumab + pembrolizumab (if PD-L1 positive: (CPS 1+)- q3wk

-paclitaxel + topotecan + bevacizumab

If above fails
-Tisotumab-vedotin
-pembro (cps 1+, MSI-H/TMB-H)
-cemiplimab
-paclitaxel
-fam-trastuzumab deruxtecan (HER-2+)

Notice IVB NOT IVA

Answer 148

A

Astrocytomas/brain stem
-Carboplatin + vincristine OR
-thioguanine + Procarbazine + lomustine + vincristine

-surgery is primary- reserve chemo for symptomatic, progressive, or recurrent dx
-RT often avoided if possible

High grade gliomas
-3+: RT + TMZ —> Adjuvant TMZ + lomustine

-<3:
-cyclophos + vinc + cis + etop
-vinc + carbo + TMZ

Answer 149

A

-Low dose cyclophos + vincristine + pred
-goal to decrease by 20% to reduce TLS risk

Answer 150

A

Intraocular
ICIR group A: focal therapy only
ICIR group B: systemic VC: vinc + Carbo x8 (and focal)
ICIR group C-D: systemic VEC- vinc + etop+ Carbo x6 (and focal)
ICIR group E: enucleation
-note: intra-arterial chemo is an option here (unlike extraocular)

Extraocular
-Orbital/locoregional: enucleation, systemic chemo, EBRT
-metastatic: systemic chemo, maybe enucleation and EBRT, maybe ASCT

-Consider intra-arterial chemo (carbo, Melphalan, or topotecan )
-for group E and extraocular dx you will need systemic chemo and likely enucleation
-focal therapy: photocoagulation, cryotherapy
-highly radiosensitive: consider EBRT

Metastatic (rare)
-induction chemo (cyclo, cisplatin, vincristine, etoposide)—> consolidation with HD chemo and ASCT

Answer 151

A

-T< 0.5 cm and N0: ET or observation
-T >0.5 cm or LN+:
-PS<26: ET
-PS 26+: ET + chemo
-LN 4+ (N2/N3): ET + chemo

Answer 152

A

-T<0.5 cm: ET or observation
-T>0.5 cm:
-PS 16+: ET + chemo
-PS <16: ET

Notice: is premenopausal women there is the exception and you can use OncotypeDx in LN negative rather than 1-3 LN like post menopausal m

Answer 153

A

ET + chemo

Answer 154

A

ET + chemo + trastuzumab (if chemo given)

could be less aggressive if small tumor (<0.5 cm) but chemo still and option

Answer 155

A

ET + chemo + trastuzumab and Pertuzumab

Answer 156

A

-HER-2 (+):chemo + trastuzumab
-HER-2 (-):chemo (nothing if LN (-) AND T<0.5cm)

can be less aggressive for smaller tumors (usually <0.5cm) chemo is still an option if HER-2+

Answer 157

A

LN +: Chemo

**</=0.5cm AND LN (-): no adjuvant therapy **

Answer 158

A

Chemo + trastuzumab and pertuzumab

Answer 159

A

Tamoxifen +/- OAS x5 years, THEN
-still premenopause: tamoxifen x5 more years
-post-menopause: 5 more years with AI

OAS for higher risk recurrence (young age, high grade tumor, LN involvement)- *unlike metastatic in which premenopausal women always get OAS with hormone therapy

Note: don’t confuse with BC prevention which has a duration of 5 years total

Notice we don’t differentiate b/w HER-2+ vs HER-2 negative like in the metastatic setting (although HER-2+ will also get HER-2 therapy IF CHEMO IS ALSO GIVEN)***

Tamoxifen preferred in men

Answer 160

A

AI x5 years—> consider continuing for total of 7.5-10y (10 years for LN+)

Note: don’t confuse with BC prevention which has a duration of 5 years total

Notice we don’t differentiate b/w HER-2+ vs HER-2 negative like in the metastatic setting (although HER-2+ will also get HER-2 therapy-IF CHEMO IS GIVEN)

Answer 161

A

HR+, HER-2 (-), LN (+):
-ki-67 20%+
-4+ LN
-1-3 LN + (grade 3, OR T= 5+ cm (T3), OR ki67 20%+

Answer 162

A

-dose dense (q2week) Dox + cyclo—-> paclitaxel (weekly) (maybe better if grade 3 or LN 4+)- 4 cycles of each
-docetaxel + cyclophosphamide (TC)- if can’t take anthracycline

STAGE II-III TNBC: (for stage I TNBC need to use above regimens):
NEOADJUVANT not adjuvant
taxane (paclitaxel) + Carboplatin +/- pembrolizumab x4 followed by AC (cyclo + dox/epirubicin) + pembro x4 follow by more pembro in adjuvant setting x9 (only pembro alone is adjuvant)

Answer 163

A

early stage
-inflammatory BC
-dx likely to be converted to respectable after chemo
-reduce extent of surgery
-preferable to delay surgery
-TNBC: LN+, or at least T1c
-HER-2+: LN + or high risk LN (-)
-pre-menopausal LN+ (fellow on call)

stage IIIa or higher (locally advanced) will probably get it? YES!

-same regimens as adjuvant unless TNBC MAY use taxane + Carboplatin +/- pembro
-AC—>T may be better than TC if LN positive
-can use pembro with chemo neoadjuvant in TNBC- (and give more pembro adjuvantly)

Can do ET for postmenopausal women

Answer 164

A

Capecitabine- start after RT

-if no residual dx just observation of pembro x9 cycles (only if given neoadjuvant already)

Answer 165

A

Neoadjuvant: chemo (carbo + taxane) + pembro
Adjuvant: pembro

*pd-l1 expression not required here (it is required in metastatic setting)

Answer 166

A

-Trastuzumab + paclitaxel (T1, N0, LN-)

-THC (docetaxel + carbo + trastuzumab)

-TCHP (docetaxel + carbo + trastuzumab + pertuzumab)

*pertuzumab if T>2cm or LN+- double check the 2 cm

Answer 167

A

Trastuzumab + paclitaxel (T1, N0, LN-)

-THC (docetaxel + carbo + trastuzumab)

-TCHP (docetaxel + carbo + trastuzumab + pertuzumab)

*pertuzumab if T>2cm or LN+

Answer 168

A

-if no residual dx or no neoadjuvant treatment: complete 1 year of trastuzumab +/- pertuzumab

-if residual dx: ado-trastuzumab emtansine x14 cycles

Answer 169

A

Neratinib x1 year after trastuzumab in pts with high risk recurrence (usually means LN+ and HR+ and HER2+)

Answer 170

A

For Risk reduction of distant Mets in POST-MENOPAUSAL with LN+ or high risk LN(-) (irrespective of HR or HER-2)

-Zolendronate 4 mg IV q6months x3 y or q3months x2 y
-or clodronate or ibandronate

note this is for risk reduction of mets in patients with EARLY STAGE BC……..DONT CONFUSE WITH REDUCTION OF SRE IN PATIENTS WHO ALREADY HAVE BONE METS

Menopause can be natural or induced (LHRH agonists)

Not for men, not for premenopausal, don’t use denosumab

Answer 171

A

HER-2+: chemo + anti-her2 therapy

HER-2(-): chemo (+ pembrolizumab if TNBC and pd-l1 cps >10% or PARP if appropriate

*olaparib or talazoparib if germline BRCA

notice we’re not doing ET even if HR+ (can add on after chemo when appropriate)

Answer 172

A

HER-2+: chemo + anti-her-2 (could do ET instead of chemo if HR+)

HER-2(-):
-HR+: ET
-HR(-): chemo + pembro (if pd-l1>10%)

*olaparib or talazoparib if germline BRCA

*basically the same is last notecard expect you can get away with ET instead of chemo for HR+/HER-2(-)

Answer 173

A

-CDK 4/6-I (ribociclib preferred) + AI

-CDk 4/6-I (ribociclib or abemeciclib preferred) + fulvestrant

Second line*
-CDk 4/6-I (ribociclib or abemeciclib preferred) + fulvestrant
-alpelisib + fulvestrant (PIK3CA)
-capivasertib + fulvestrant (PIK3CA or AKT1/PTEN)

OAS required if premenopausal

Duration: continue until dx progression (unlike early stage)

Treat men the same as women here

Answer 174

A

-ER+/HER-2(-), ESR1 mutated - progression following 1 or more lines of ET
-post-menopause
-given alone

Answer 175

A

-Metastatic breast cancer HR+/HER-2(-) with PIK3CA mutation after progression on ET
-post-menopause or premenopausal with OAS
-given with fulvestrant

Answer 176

A

First line: chemo or PARP-I (if BRCA)

Second line:
-fam-trastuzumab deruxtecan (if HER-2 low)
-chemo or sacituzumab govitecan (if HER-2(-)
-Notice no PARP-I in second line like with TNBC)

Answer 177

A

First line:
-chemo + pembro (cps>10%)
-chemo
-PARP-I (germline BRCA) or platinum-unlike HR+/HER-2 neg (germline BRCA)

Second line:
-PARP-I (germline BRCA) (unlike HR+/HER-2(-)) NOT PLATINUM LIKE IN FIRST LINE
-fam-traztuzumab deruxtecan (HER-2 low)
-chemo
-sacituzumab govitecan

Chemo options with pembro:
-paclitaxel or nab-paclitaxel
-Gemcitabine + Carboplatin

Answer 178

A

single agent:
Use one of these first:
-doxorubicin
-liposomal doxorubicin
-paclitaxel

Failed taxane and anthracycline
-capecitabine
-Eribulin

other
-Gemcitabine
-Vinorelbine

TNBC w/ BRCA mutation
-platinum (no taxane here like with early stage) (first line only)

Trick: In metastatic setting: HER-2+ drop the platinum, TNBC drop the taxane

Chemo options with pembro for TNBC
-paclitaxel or nab-paclitaxel
-Gemcitabine + Carboplatin

Answer 179

A

Notice AI is ok for premenopausal -especially if progressed while on tamoxifen

-AI +/- trastuzumab
-AI +/- lapatinib
-AI +/- lapatinib + trastuzumab
-fulvestrant +/- trastuzumab
-tamoxifen +/- trastuzumab

*pre or post menopause

OAS required if premenopausal

use fulvestrant or steroidal AI if not sensitive to AI (less than a year since use)

non-steroidal AI

Note: if progressing on these you can do things like: change to steroidal AI, SERD, elacestrant, alpelesib, capivasertib (these 3 are actually HER-2 neg, but you get the idea) etc. After this we go to PARP-we only go to chemo when we have visceral crisis or after all these ET agents and PARP if applicable

Duration: continue until dx progression (unlike early stage)

Answer 180

A

First line:
-THP: pertuzumab + trastuzumab + taxane (docetaxel preferred)

Second line:
-fam-trastuzumab deruxtecan

Third line:
-tucatinib + trastuzumab + capecitabine (especially if Brain Mets- after 1 prior line)
-ado-trastuzumab emtansine

Fourth line:
-margetuximab?

notice we give both traztuzumab and Pertuzumab for metastatic

Trick: In metastatic setting: HER-2+ drop the platinum, TNBC drop the taxane

Note: don’t switch therapy d/t presence of brain Mets if systemic dx is stable

Answer 181

A

-pamidronate 90 mg over 2 hours iv q3-4 wk
-zolendronate 4 mg iv q3-4 or q12 wks
-denosumab 120 mg iv q4 weeks

Answer 182

A

DXA -1.5 to -2 consider it and definitely for -2+ or FRAX 10y major fx risk >20% or hip fx >3%

HT or ADT

Use osteoporosis dosing

Answer 183

A

Give chemo first, then RT

*notice that chemo is adjuvant not neoadjuvant

Answer 184

A

Definitely neoadjuvant (category 1), but also can give adjuvantly

*Ewings also gets neoadjuvant

Answer 185

A

Neoadjuvant reserved for clinical trials, or highly select pts to avoid more aggressive surgery or amputation

Adjuvant- no proven role but DECREASES RECURRENCE

Answer 186

A

-No definitive role for neoadjuvant: consider if surgical morbidity can be reduced by giving it

-Usually it’s just adjuvant

Answer 187

A

Neoadjuvant chemo (if applicable) + HER-2
Surgery
Adjuvant chemo + HER-2
RT and ET +/- abemeciclib (2y)
Then PARP-I at least 2 weeks after RT
Neratinib x1y following trastuzumab x1y

Note: RT given after chemo to avoid radiation recall

Start chemo within 30 days of surgery

Note: neoadjuvant HT is an option for post-menopausal HR+/HER-2(-)

Answer 188

A

Pembrolizumab

Answer 189

A

Pre menopause: Tamoxifen 20 mg daily- 5 years

Post menopause: tamoxifen, Raloxifene (SERM), AI. -5 years

raloxifene is better than AI in postmenopausal women if low BMD and better than tamoxifen if pt has intact uterus

5 YEAR DURATION!!!

Dont confuse with HT therapy for tx of early stage BC which is often 10 years

Answer 190

A

-antidepressants (venlafaxine preferred)
-gabapentin (preferred)
-pregabalin
-clonidine
-oxybutynin

Answer 191

A

Epogen

*don’t give if epo lvl>500

Dose is 300 units/kg three times a week

do before luspatercept

Answer 192

A

Luspatercept

15%+ ring sideroblasts or 5%+ with SF3B1 mutation

Answer 193

A

Lenalidomide

can use Lenalidomide in non-del(5q) after using (or ruling out) luspatercept and epo, but before moving on the HMAs

Dont use if ch 7 abnormality

Answer 194

A

Immunosuppression: ATG, cyclosporin, corticosteroids, eltrombopag (various combinations), ATGAM

Answer 195

A

HMAs: azacitadine, decitabine

use Lenalidomide even in non-del(5q) pts before moving on the HMAs

Failure: significant thrombocytopenia, or neutropenia or increased marrow blasts

Answer 196

A

HMA:
azacitadine (preferred), or decitabine

Answer 197

A

Allogeneic HCT (only cure for MDS)

-Can bridge with HMA
-can do high intensity chemo with AML regimen before HCT (poor response rate if complex karyotype or del(7q)

R/R:
-Ivosidenib

Answer 198

A

(7 (Cytarabine) + 3 (Idarubicin 12 mg/m2/d or daunorubicin))

-If FLT3-ITD mutation: add midostaurin or quizartinib
-If FLT-TKD mutation: add midostaurin

-if core binding fx (inv(16), t(16;16), t(8;21) (don’t need CD33+): add Gemtuzumab ozagamicin

Daunorubicin dose is 60-90mg/m2/day x 3 days, 60 if combo with Gemtuzumab or midostaurin or quizartinib- wolverheme like dauno 90 in FLT-3 pts

Cytarabine dose is 100 mg/m2- don’t confuse with HIDAC

Notice IDH inhibitors are not used here

Note: AML induction is 28 days

Note: goal is blast <5% “hypoplasia”

Answer 199

A

CPX-351 (Liposomal Daunorubicin and Cytarabine)

Note: AML induction is 28 days

Answer 200

A

Preffered (more middle road)
-S.O.C: HMA (Aza cat 1) + venetoclax (could ignore FLT3 in this case)- middle of the road regimen
-HMA (aza cat 1) + Ivosidenib (If IDH-1 mutation)

Other (less intense than above)
-Ivosidenib (IDH-1 mutation)
-enasidenib (IDH-2 mutation)
-Gemtuzumab (CD33+)
-Glasdegib + LDAC
-venetoclax + LDAC
-LDAC
-HMA
-HMA + FLT3-I (probably not-see below)

unlike with young/fit pts, don’t act on FLT3 mutations

Notice IDH inhibitors are only used in older pts unfit for intensive therapy

continue therapies on indefinitely (unlike fit induction)

Answer 201

A

Favorable Risk
-High dose Cytarabine (2-4 cycles)
-OR carry forward whatever was used initially
-can follow with allo HCT- BUT DONT GENERALLY NEED THIS FOR CURE!

Poor risk or consider for intermediate risk
-Allogeneic HCT (also give if CR2-takes 2 rounds of induction chemo)

Start consolidation within 2 weeks of hematologic recovery AND bone marrow showing CR

Bone marrow at day 14 to see that blasts <5%, then upon recovery (ANC >1000, plt>100k) repeat marrow to confirm still at blast <5%, then you can do consolidation- if refractory may need salvage

Answer 202

A

Consider oral azacitadine in int/poor risk cytogenetics in pts who previously got intensive induction chemo and can’t go on to allo HCT for consolidation. >55y/o

Begin while pt is in CR:
-ANC >1000
-plt >100
-transfusion independent
-marrow blasts <5%
-no extramedullary dx

Answer 203

A

-allo HCT if eligible (only cure for R/R)
-look for targetable mutations

Re-induction (often if relapse more than 1 yr, or before HCT)
-salvage chemo (hiDAC based: FLAG +/-IDA, MEC (mitoxantrone based), G-CLAC, CLA(+/-M) AKA CLAG (these are all HD-Cytarabine regimens with (mitoxantrrone/clofarabine/cladrabine/Fludarabine)
-5+2
-can repeat same regimen if remission >12 months

Low intensity for salvage
-Gemtuzumab (CD33+)
-gilteritinib (if FLT3-ITD or TKD mutation)
-Ivosidenib or olutasidenib (IDH-1)
-enasidenib (IDH-2)

Low intensity (used in practice but not great data)
-HMA +/- venetoclax
-LDAC +/- venetoclax

Note: refractory is pts who either don’t respond of relapse within 6 months

Answer 204

A

Use Differentiating agents:
-all-trans-retinoids acid (ATRA) +arsenic trioxide

Maintenance: observation or ATRA + arsenic x1-2y

chemo free

Dont add a FLT-3-I even if FLT-3 mutation- don’t get tripped up

-PLT transfusion to goal fibrinogen of 30-50
-cryoprecipitate to goal of 100-150

Answer 205

A

Use differentiating agent AND chemo:

Induction and consolidation:
-ATRA +/- arsenic + Idarubicin or Gemtuzumab ozogamicin
-consider IT therapy

Maintenance:
-ATRA + MTX + 6MP for 1-2y

Note: NCCN recommends differentiation syndrome ppx w/ pred 0.5 mg/kg/d or dex 10 mg q12 is high risk pts WBC>10

Dont add a FLT-3-I even if FLT-3 mutation- don’t get tripped up

-PLT transfusion to goal of 30-50
-cryoprecipitate to goal fibrinogen of 100-150

Answer 206

A

Dex 10 mg IV q12h x3-5d followed by 14 day taper

-continue differentiating agents if mild, hold if really bad (cardio respiratory)- except hold right away for olutasidenib

-causes by ATRA, arsenic, IDH-I, FLT3-I (AML drugs!)

all blasts mature into granulocytes at once and there’s a ton of cytokines and inflammatory processes. Lots of edema happens ~10-12days after first dose

(Dyspnea, peripheral and pulmonary edema, unexplained fever, hypotension, AKI)

Answer 207

A

-Inotuzumab ozogamicin +/- TKI
-blinatumomab ozogamicin +/- TKI
-tisagenlecleucel (less 26 y/o)
-brexucabtagene autoleucel
-allogenic HCT if you can achieve CR

Answer 208

A

-5FU + mitomycin
-cisplatin alone
-low dose Gemcitabine

Others:
-cisplatin + 5FU
-cisplatin + paclitaxel

For MIBC- given with RT after TURBT for bladder preservation

Reqs:
-lack of hydro nephro sis
-lack of extensive or multi focal TIS
-tumor size <6 cm

Answer 209

A

-CALGB 10403-Daunorubicin + vincristine + pred + pegAsparginase

-DFCI protocol 00-01-doxorubicin + vincristine + pred + HD-MTX + pegAsparginase

T-cell:
-COG AALL0434

Answer 210

A

WTF HAPPENED TO THIS CARD! It’s supposed to be ECOG1910!!

Low intensity:
-vinc + steroids
-POMP

Moderate:
-GMALL
-GRAALL
-EWALL
-PETHEMA ALLOLD07
-modified DFCI 91-01
-mini-hyper-CVD + Inotuzumab

High:
-hyper-CVAD (dose reduced Cytarabine)
-CALGB 9111
-ECOG1910

Answer 211

A

Low intensity:
-vinc + steroids
-POMP

Moderate:
-GMALL
-GRAALL
-EWALL
-PETHEMA ALLOLD07
-modified DFCI 91-01
-mini-hyper-CVD + Inotuzumab

High:
-hyper-CVAD (dose reduced Cytarabine)
-CALGB 9111

Answer 212

A

-EsPhALL: TKI + (cyclo + vinc + dauno + dex + Cytarabine + MTX + peg + pred)
-TKI + hyper-CVAD
-TKI + steroid
-TKI + vincristine + dex
-CALGB 10701 (TKI + dex + vinc + dauno + etop + MTX + Cytarabine)
-blinatumomab + TKI

Note: Same as adult <65 except EsPhALL is an additional option here

Answer 213

A

-TKI + hyper-CVAD alternating with HD-MTX and Cytarabine
-TKI + steroid
-TKI + vinc + dex
-CALBG 10701 (TKI + dex + vinc + dauno + MTX + etop + Cytarabine)
-blinatumomab +/- TKI

Note: Same as AYA except no EsPhALL

Answer 214

A

Low intensity:
-TKI + steroids
-TKI + vinc + dex

Moderate:
-EWALL (TKI + mx agent chemo)
-CALGB 10701 (TKI + mx agent chemo)

High:
-TKI + hyper-CVAD (dose reduced Cytarabine)
-Blinatumomab +/- TKI

pretty much same as AYA and adult except no Esphall (like in AYA), and added EWALL)

Answer 215

A

Blinatumomab at ~3month mark if MRD+, follow with allo HCT (regardless of whether or not MRD+ after blinatumomab)

3 months!!!/3 cycles!! Not just after induction!!

Answer 216

A

Tocilizumab +/- dex

*be more aggressive if CAR-T. If blinatumomab you can just stop infusion for mild reactions

Answer 217

A

Grade 1: supportive care
Grade 2: dex x1
Grade3-4: Dexamethasone 10 mg IV Q6h or Methylprednisolone 1 mg/kg iv q12h

no tocilizumab

Ppx CAR-T therapy pts with keppra x30 days

Answer 218

A

MDS requiring >20 transfusions and serum ferritin >2500 ng/mL

goal ferritin <1000

Answer 219

A

-Backbone of 6MP + weekly MTX with periodic vincristine or prednisone
-continue for 1-2y
-omit for mature B-cell ALL

Answer 220

A

Neuroblastoma, Ewings, brain tumors, germ cell, testicular

Answer 221

A

preferred
-Acalabrutinib +/- obinutuzumab
-venetoclax + obinutuzumab
-zanubrutinib

other
-ibrutinib (cat 1)
-consider chemo immunotherapy (bendamustine, Chlorambucil, obinutuzumab)

IGHV mutation >2%, <65 y, and fit
-FCR (Fludarabine, cyclophos, rituxan)

Note: don’t need to start rx right away I’m asymptomatic patients RAI stage 0 or Binet stage A

Note: venetoclax based is fixed duration (1 yr) as opposed to indefinite like BTK inhibitors
-obinutuzumab is only 6 months when given with BTK-I

Answer 222

A

preferred
-Acalabrutinib
-venetoclax (2y) + rituximab (6 mo)
-zanubrutinib

other
-ibrutinib (cat 1)
-venetoclax
-consider repeating ven + obin if remission achieved in first line
-chemo-immunotherapy (BR, R2, FCR, obinutuzumab)

Note: venetoclax based is fixed duration (2 yr) as opposed to indefinite like BTK inhibitors

Use opposite of what you used before (BTK-I vs venetoclax)

Answer 223

A

Without del(17P)TP53 mutation
-pirtobrutinib
PI3K inhibitors
-duvelisib
-idelalisib +/- rituximab

Chemotherapy or immunotherapy
-bendamustine + rituxan (<65 and fit)
-FCR (<65 and fit)
-Lenalidomide +/- rituximab
-obinutuzumab

With del(17P)TP53 mutation
-pirtobrutinib
PI3K inhibitors:
-duvelisib
-idelalisib +/- rituximab
-alemtuzumab +/- rituximab
-HDMP + anti-CD20 mAb
-Lenalidomide +/- rituximab

Lisocabtagene

Allo HCT???

Answer 224

A

preferred
-Acalabrutinib +/- obinutuzumab
-venetoclax + obinutuzumab
-zanubrutinib

no chemo-immunotherapy

Note: don’t need to start rx right away I’m asymptomatic patients RAI stage 0 or Binet stage A

Note: venetoclax based is fixed duration (1 yr) as opposed to indefinite like BTK inhibitors
-obinutuzumab is only 6 months when given with BTK-I

Answer 225

A

preferred
-Acalabrutinib
-venetoclax + rituximab
-venetoclax
-zanubrutinib

Note: venetoclax based is fixed duration (1 yr) as opposed to indefinite like BTK inhibitors

Use opposite of what you used before (BTK-I vs venetoclax)

Answer 226

A

Consider in CLL when serum IgG <500 mg/dL AND recurrent (2+ in 6
Months) sinopulmonary infections requiring IV ABX or hospitalization

Does not improve OS

Multiple myeloma IgG<400 and recurrent life threatening infections

may cause false positive hep b core antibody

Answer 227

A

If tx is indicated
-cladrabine +/- rituximab
-pentostatin

If unable to tolerate purine analog (frail or active infection): vemurafebib +/- obinutuzumab

Don’t forget pjp and hsv ppx

Remember BRAFV600E mutation

Answer 228

A

Relapse >2 years:
-cladrabine + rituximab
-pentostatin + rituximab
-Rituximab

Relapse <2 years:
-alternative purine analog + rituximab
-vemurafenib +/- rituximab (preferred if BRAF mutation)
-Dabrafenib + trametinib (also preferred is BRAF mutation and not already tx with BRAF-I)

Third line

-vemurafenib +/- rituximab (preferred if BRAF mutation)
-Dabrafenib + trametinib (also preferred is BRAF mutation and not already tx with BRAF-I)
-ibrutinib
-zanubrutinib
-venetoclax +/- rituximab

Note: moxetumomab removed from market in July 2023

Answer 229

A

Low risk:
-imatinib 400 QD
-dasatinib 100 QD
-nilotinib 300 bid
-bosutinib 400 QD

Intermediate-high risk (same doses)
-dasatinib
-nilotinib
-bosutinib
-imatinib but only one that isn’t cat 1

base choice on ADRs and comorbidities

Note: maybe prefer a second gen over imatinib in woman who want a rapid and deeper response with eventual TKI discontinuation for family planning purposes

Answer 230

A

-nilotinib, dasatinib, bosutinib
(Switch to a different one if used before)

not imatinib

Same doses as first line

Answer 231

A

-omacetaxine mepesuccinate
-Ponatinib 15-45 mg QD
-asciminib 40 bid or 80 QD
-allogenic HCT

Answer 232

A

-ponatinib (preferred)
-omacetaxine
-asciminib 200 BID (use instead of Ponatinib if CV risk fxs)
-allogenic HCT

Note: this mutation is associated with secondary TKI resistance

Answer 233

A

basically tx like second or third line chronic phase- except NO ASCIMINIB, and doses are different

-second gen TKI or alternate second gen TKI
-Ponatinib if no other tki indicated
-omacetaxine if resistant to 2+ tki-NOT FOR DE NOVO ACCELERATED PHASE (don’t get tripped up)
-allo HCT (if able to first achieve chronic phase)

Doses
-imatinib 600-800 QD (probably wouldn’t use though)
-dasatinib 140 QD
-nilotinib 400 bid
-bosutinib 500 QD
-Ponatinib 45 QD

Answer 234

A

BCR-ABL TKI + induction tx of respective type of acute leukemia (could be ALL or AML)
-DONT USE IMATINIB UNLESS NO OTHER CHOICE

-if second chronic phase is achieved- allogenic HCT

-CNS ppx if lymphoid type
-dasatinib preferred in CNS of lymphoid type

Answer 235

A

-BCS +/- RT or total mastectomy +/- reconstruction

Follow by: endocrine therapy x 5y (if for BCS and HR+)- decreases risk or ipailateral or contralateral BC

notice BCS does not require RT here

2 mm margin

Answer 236

A

If BCS
If total mastectomy:
-LN+ OR T>5 cm (T3)
-no RT if negative margins

give RT after chemo if chemo is given

-no RT if TP53 mutation

Answer 237

A

Venetoclax based regimen preferred over BTK inhibitor

Answer 238

A

Avoid Ponatinib and dasatinib

Answer 239

A

ISRT preferred

Could do ISRT +/- (mAb +/- chemo)

Answer 240

A

Anti-CD20 mAb +/- chemo +/- ISRT

Answer 241

A

-bendamustine + rituximab/obinutuzumab (probably choose over R-CHOP)

-CHOP + rituximab/obinutuzumab (for more aggressive dx or grade 3)

-CVP + rituximab/obinutuzumab

-Lenalidomide + rituximab (frail pts)

Elderly/infirm
-rituximab x4 weekly doses (low tumor burden, elderly/infirm) preferred
-Chlorambucil + rituxan
-cyclophos + rituxan

Follow with maintenance if response to frontline therapy:
-Rituximab q8week x2 years (12 doses) (unlike MCL which is 3 yrs) (note only 4 doses of tx with rituxan alone)
-obinutuzumab 1000 mg q8wk x2yr (12 doses)

Answer 242

A

Grade 3A: controversial

Grade 3B: Tx like DLBCL- (R-CHOP)

Answer 243

A

Whatever CD-20 mAb was given frontline

-Rituximab q8week x2 years (12 doses) (unlike MCL which is 3 yrs) (note only 4 doses of tx with rituxan alone)
-obinutuzumab 1000 mg q8wk x2yr (12 doses)

if response to frontline therapy

Answer 244

A

same as stage III-IV (grade 1-2)

-bendamustine + rituximab/obinutuzumab

-CHOP + rituximab/ obinutuzumab

-CVP + rituximab/obinutuzumab

-Lenalidomide + rituximab

choose depending on fitness, prior tx, and early vs late relapse: *early relapse (<2y AKA POD24) or fitter pts should be tx more aggressively

Elderly/infirm
-rituximab x4
-Chlorambucil +/- rituximab
-cyclophosphamide +/- rituximab
-tazametostat (second line only)

Consolidation
-rituximab - EVERY 12 WEEKS (unlike 1st line-q8wk) x 2 yr
-obinutuzumab every 8 weeks x2yr
-autoor allo HCT

Note: ensure FL is not transforming to a more aggressive lymphoma

Answer 245

A

-Copanlisib (PI3K) (NOT others)-(withdrawn)
-CAR-T (axicabtagene, tisagenlecleucel, lisocabtagene)
-tazametostate (irrespective of EZH2 mutation)
-BiTE (mosotuzumab, epcoritamab)

Answer 246

A

-stage I-II (non-bulky): R-CHOP x3
Then interim staging:
-CR: R-CHOP x1 or ISRT
-PR: R-CHOP x1-3 +/- ISRT
Or Pola-R-CHP (smIPI>1)

-stage I-II (bulky): R-CHOP x6 +/- ISRT
Or Pola-R-CHP (smIPI>1)

-stage II (extensive mesenteric dx or stage III-IV: R-CHOP x6
Or Pola-R-CHP (IPI 2+)

no maintenance rituximab (unlike follicular lymphoma)

we still do interim staging after ~3 cycles for all stages, but this doesn’t effect tx like it does for stage 1-2 non-bulky

Negative prognostic fxs:
-age > 60
-st III-IV
-extranodal dx > 1 site
-ECOG 2+
-high LDH

Answer 247

A

Poor LVEF:
-DA-R-EPOCH (keep dox at base dose)
-R-CDOP
-R-CEPP
-R-CEOP
-R-GCVP

>80 w/ comorbidities
-R-CDOP
-R-CEPP
-R-mini-CHOP
-R-GCVP

Answer 248

A

-DA-R-EPOCH (not appropriate for everyone)
-R-hyper-CVAD
-R-CODOX-M/R-IVAC
-R-mini-CHOP (elderly/frail)

May need auto HCT

give CNS ppx

R-CHOP has inferior outcomes

Note: R-EPOCH has higher rates of neuropathy and febrile neutropenia than R-CHOP

Answer 249

A

Ppx: IT MTX x4, systemic MTX x2, or Cytarabine
-DLBCL with IPI score of 4+
-high grade B-cell lymphoma
-Burkitts lymphoma
-HIV lymphoma
-testicular
-MYC, BCL2/6
-primary cutaneous DLBCL
-stage le DLBCL of breast

Tx: systemic MTX +/- IT MTX or Cytarabine

If parenchymal dx tx with systemic HD-MTX

Answer 250

A

>12 months HCT eligible:
-R-ICE, R-DHAP, R-GDP, other: R-ESHAP, R-gem-ox, R-MINE
-if response: auto HCT +/- ISRT
-if partial response: auto HCT or car-T (all 3 CAR-T ok here)

>12 months HCT ineligible:
Preffered
NOTE: can omit rituximab in below regimens if relapse after <6 months

-polatuzumab vedotin +/- bendamustine +/- rituximab
-tafasitimab + Lenalidomide
-lisocabtagene

Other
-gem/ox +/- R
-GDP +/- R
-CEOP +/- R
-Rituximab
-Lenalidomide + rituximab

<12 months or primary refractory
CAR-T (may need something else in interim)
-axicabtagen ciloleucel
-lisocabtagene maraleucel

Answer 251

A

CAR-T
-axicabtagene
-lisocabtagene
-tisagenlecleucel (not second line option like the other two)

BiTE- AFTER 2 LINES IF THERAPY
-epcoritamab
-Glofitamab

Others
-Loncastuximab tesirine
-Selinexor (after transplant or CAR-T)

Answer 252

A

induction
-R-DHA + platinum, followed By R-CHOP in no CR (Lyma regimen)
-alternating R-CHOP/R-DHAP
-Nordic regimen (R-maxi chop alt w/ HDAC)
-R-HyperCVAD (“other” regimen)
-BR —> R + HD-Cytarabine
-Triangle (alt R-CHOP, BTK-I/DHA, platinum)

Consolidation
-ASCT

Maintenance (start after ASCT)
-* covalent BTK-I (ibrutinib preferred) x2y* + rituximab q8 weeks x 3 years (unlike FL which is 2 years)

-notice how this differs from non-aggressive tx where you only do rituximab if they got R-CHOP and there no BTK-I

Answer 253

A

induction
-BR
-VR-CAP
-R-CHOP
-Lenalidomide + rituximab
-Other: RBAC500 (Ritux, bendamustine, Cytarabine)

consolidation
-rituximab q8 weeks x2-3y (only if they got R-CHOP, cat 2 if given after BR)!!!!! (unlike FL, and aggressive tx of MCL)

Notice no ASCT like with aggressive

Answer 254

A

Low risk:
-CODOX- M +/- R x3 cycles
-DA-R-EPOCH (x3 min, 1 additional after CR)
-R-HyperCVAD alternating with R-MTX/Cytarabine, lnclude IT MTX

High risk:
-CODOX-M alternating w/ IVAC +/- R x4 cycles
-hyperCVAD alternating with R-MTX/Cytarabine, include IT MTX
-DA-R-EPOCH (if can’t take aggressive tx)

>60 years old:
-DA-R-EPOCH (x3 min, 1 additional after CR)

CNS PPX

Second line
-clinical trial preferred
-DA-R-EPOCH
-R-ICE
-R-IVAC
-R-GDP
-HiDAC + rituximab
-HCT

Note: if CNS dx- it should be addressed with initial regimen (give CNS portion first)

Answer 255

A

Pruritis:
-topical moisturizer/emollients
-topical steroid
-TCA, gabapentin, antihistamine
-refractory: aprepitant, naltrexone, mirtazapine, SSRI

Infection ppx:
-avoid central lines
-diluted bleach bath (1tsp/gal or 1/2 cup)—>moisturize
-mupirocin, dicloxacillin, cephalexin if staph colonization
-HSV/VZV reactivation (consider ppx)
-gram negative rods in necrotic tumors
-empiric ABX could include gram neg and gram pos

Stage IA
-topicals: steroid, mechlorethamine, retinoids (bexarotene, tazarotene), imiquimod, phototherapy, RT

Stage IB-IIA
-phototherapy (PUVA), total skin electron beam therapy,
May need systemic tx

Stage IIB-IV
-various combos
Systemic therapy includes:
-alemtuzumab
-bexarotene
-Brentuximab
-Gemcitabine
-interferon
-mogamulizumab
-liposomal dox
-pralatrexate
-romidepsin
-vorinostat

Notice: single agents preferred (unlike peripheral T-cell lymphomas which often require combo

Answer 256

A

-CHOP-21
-CHOEP
-DA-EPOCH
-CHP + Brentuximab vedotin (preferred regimen if CD30+, category 1 for ALCL- anaplastic large cell lymphoma)

no rituximab- there’s no CD20

First line consolidation
-consider HD chemo and ASCT

Second line Relapsed, or 1st line palliative
-Belinostat
-Brentuximab vedotin (if CD30+)
-romidepsin
-pralatrexate

Answer 257

A

favorable (non-bulky)
ABVD x2 followed by:
-ISRT
-AVD x4 (deauville 1-3)
-ABVD x1-2 +/-ISRT (deauville 4-5)
-biopsy (deauville 4-5)
-***Elderly/low PFS: A(B)VD x2 +/- AVD x2 + ISRT (preferred)
-CHOPx4 + ISRT

unfavorable (bulky or B-symptoms, and other)
ABVD x2 followed by:
-AVD x4 (deauville 1-3)
-ABVD x2 + ISRT (deauville 4-5, NCCN says 1-3)
-BEACOPP x2-4 +/- ISRT (deauville 4-5)

-Elderly/poor pfs: A(B)VD x2 -> AVD x4 if pet neg
-BV->AVD, conditionally followed by BV
-CHOP x6 +/- ISRT

Note: don’t dose reduce if low counts

Avoid BEACOPP and Brentuximab vedotin in pts >60

Bulky is >10 cm

Answer 258

A

ABVDx2 followed by:
-AVD x4 (good response-deauville 1-3)
-BEACOPP x3-4 +/- ISRT (if poor response- deauville 4-5)
A + AVD (Brentuximab vedotin + AVD) give with G-CSF- not for pts >60 or with baseline neuropathy

Nivo + AVD?

-Elderly/poor pfs: A(B)VD x2 -> AVD x4 if pet neg
-BV->AVD, conditionally followed by BV
-CHOP x6 +/- ISRT

Note: don’t dose reduce if low counts

Avoid BEACOPP and Brentuximab vedotin in pts >60

Answer 259

A

Goal is still CURE!

Chemo +/- ASCT —> followed by Brentuximab vedotin in high risk pts

Chemo options are:
-ICE
-IGEV
-ESHAP
-MINE
-GVD
-bendamustine
-Brentuximab vedotin +/- bendamustine (unless BV was used in frontline)
-Brentuximab vedotin maintenance x1y
-nivo or pembro after ASCT +/- Brentuximab vedotin or if can’t get ASCT (EBV and Reed-sternberg cells express PD-L1)

Other options include: everolimus, Lenalidomide, nivolumab +/- BV, pembro +/- GVD

Answer 260

A

Stage IA, IIA, (non-bulky)
-ISRT (preferred)
-observation

Stage IB, IIB, or IA, IIA (bulky), III, IV
-R-ABVD + ISRT
-R-CHOP + ISRT
-RCVbP + ISRT
-rituximab

rituximab if CD-20 (only time it’s used in HL

no Brentuximab vedotin (no CD30)

R/R
-rituximab
-R-bendamustine
-R-DHAP
-R-ICE
-R-IGEV

-Indolent course and late relapse (decades later)
-no Reed-Sternberg cell

Note: bulky is >10 cm

Good Prognosis

Answer 261

A

-Don’t need tx right away! Even for later stage!

-unless early stage- give RT bc it may actually be curable

Indications to tx:
-symptomatic dx
-end organ dysfunction
-cytopenias
-massive bulk or splenomegaly
-steady progression over 6 months
-recurrent infxns
-pt preferred

If asymptomatic don’t tx

Answer 262

A

Dont need to tx right away (like FL), see below

-BR (bendamustine + rituximab)
-bortezomib + dex + rituximab (other)
-ibrutinib +/- rituximab (cat 1)
-zanubrutinib (cat 1)

Second line
-any of the above options
-rituximab + cyclophos + dex

Indications to tx
-recurrent fevers, night sweats, wt loss, hyperviscocity, bulk lymphadenopathy, dx related peripheral neuropathy, splenomegaly, hepatomegaly, organomegaly, symptomatic cryoglobulinemia, symptomatic cold agglutin anemia, autoimmune hemolytic anemia, thrombocytopenia (median time to these symptoms in asymptomatic pts (25%) is >10 years)
-level of IgM alone is not enough to start tx
-note can use plasmapheresis if needed to Decrease IgM

Note: pts stratified based on age, B2-microglobulin, LDH, and albumin

Don’t use rituximab alone with IgM>4000 (flare)

hyper-viscosity is often a big issue

Answer 263

A

Tx similarly to follicular lymphoma

-if EMZL gastric lymphoma- eradicate h. Pylori
-use anti HCV if HCV associated
-SMLZ- rituximab alone is preferred initial option

edit this card if more info from workbook

Answer 264

A

Observation

Answer 265

A

-VRd: bortezomib + Lenalidomide + dex
-KRd: cardilzomib + Lenalidomide + dex (would use if pt has neuropathy)
-consider 2 drug regimen if old/frail

Other:
Daratumumab + VRd (unlike HCT ineligible)

if renal impairment
-CyBorD- cyclophos + bortezomib + dex
-thalidomide based regimen

Follow with ASCT (Melphalan based)
-if we can get them to at least PR with <10% plasma cells
.
**Then maintenance **
-Lenalidomide 10 mg daily (cat 1)
-bortezomib QOweek (alternative)
-Lenalidomide + velcade? (Consider for high risk)

weekly and SQ velcade preferred

Answer 266

A

category 1
-VRd: bortezomib + Lenalidomide + dex
-daratumumab + lenalidomide + dex
-consider 2 drug regimen if old/frail

Other cat 1s
-KRD
-dara + bort + Melphalan + pred

Others (more frail pts)
-bortezomib + dex
-Lenalidomide + low dose dex
-VRd-lite

Others:
-CyBorD (or thalidomide based if renal issues)
-KcyD
-cyclo+ Len + dex

followed by maintenance
-Lenalidomide 10 mg daily (cat 1)
-bortezomib QOweek (alternative)
-Lenalidomide + velcade? (Consider for high risk)

weekly and SQ velcade preferred

Answer 267

A

Progression is Increase in M protein of 25%, FLC ratio increase of 10+, or new lesions

-Many options
-ask what has pt already gotten (refractory to) or intolerant to
-can repeat drugs if >6 months later

Early relapse (1-3 prior therapy)
-think second gen PI and IMiDs
-think triple therapy with anti-CD38
-venetoclax + dex t(11;14)

Late relapse and >4 prior therapies
-CAR-T or BiTE (after 4 therapy including PI, IMiD, and anti-CD38)
-ciltacabtagene, idecabtagene, teclistimab, talquetamab, elrantamab
-Selinexor/dex (after 4 therapy- refractory to 2 PI, 2 IMiD, and antiCD38)
-Other: bendamustine based (after 3 therapies)
-Other: belantamab (via compassionate use program)

REMOVED FROM MARKET
-belantamab
-panobinostat

Answer 268

A

Second line
-Acalabrutinib
-ibrutinib +/- rituximab (not preferred)
-zanubrutinib
-Lenalidomide + rituximab (If BTK CI)
-Radiotherapy if localized relapse (rare)- most radiosensitive NHL FYI

Third line
-brexucabtagene (after BTK and chemoimmunitherapy)
-lisocabtagene
-pirtobrutinib

Consolidation
-consider allogenic HCT (unlike 1st line which is ASCT)

Answer 269

A

Surgery: all stages

RT: limited role, mostly palliation

Answer 270

A

Stage I-IIA
-observation or clinical trial

Stage IIB-IIC
-pembrolizumab (IIB -IIIC) OR NIVOLUMAB (adjuvant)

-clinical trial
-observation
-locoregional RT

notice no BRAF here

Answer 271

A

-nivolumab
-pembrolizumab
-Dabrafenib + trametinib (BRAF V600 E or K mutation) IIIA with SLN met >1 mm or st IIIB/C, notice not used before this stage
-observation

Note: BRAF + MEK may have faster onset and benefit than ICI (4-6 wks vs 3 months)

Could also do neoadjuvant if you want

Answer 272

A

Talimogene laherparepvec (T-Vec)

Satellite: visible cutaneous or SubQ met within 2 cm of primary

In transit: regional cutaneous or SubQ met >2 cm from primary

Answer 273

A

-nivolumab (cat 1)
-pembrolizumab (cat 1)
-nivolumab + ipilimumab (cat 1) (preferred if asymptomatic with brain mets)
-nivolumab/relatlimab
-pembro + low dose ipilimumab (cat 2B)

BRAF V600 (E or K) mutation
-START WITH IPI/nivo followed by: (unless symptomatic/rapidly growing)
-Dabrafenib + trametinib
-vemurafenib + Cobimetinib
-encorafenib + binimetinib

Note: use BRAF + MEK combo first if needed for high volume symptomatic dx d/t faster onset and benefit (4-6 wks vs 3 months with ICI)

Answer 274

A

Progression defined as 25% increase in tumor burden- 2 observations 4 wk apart

-pembrolizumab
-nivolumab
-nivolumab + ipilimumab
-pembro and low dose ipilimumab

BRAF V600 mutation
-Dabrafenib + trametinib
-vemurafenib + Cobimetinib
-encorafenib + binimetinib

if short relapse use different agents from different class. If progression on monotherapy, try combination. If late relapse after a PR/CR/SD (>3 months) you can repeat same drug or class

Chemo-dont really use ever
-Dacarbazine
-Temozolomide( maybe good if brain Mets) -preferred
-taxanes
-carbo + pacli- preferred (not better than pacli alone but maybe give after TMZ or dacarbazine)

Answer 275

A

-KIT: imatinib
-NRAS: binimetinib
-NTRK: larotrectenib or entrectinib

Answer 276

A

LN positive or T>5cm

-if BCS (as opposed to mastectomy)
-consider if close/positive margins

Answer 277

A

-young age, high grade, LN+
-stage II-III eligible for adjuvant chemo
-metastatic with ET- always if premenopausal
-If AI is used in premenopausal or male patient (male pts we prefer tamoxifen alone)

Note: high rates of ADRs/hard to tolerate

Note: Duration is 5 years! After 5 years can continue another 5 of tamoxifen or AI but drop the OAS

Answer 278

A

Need GERMLINE BRCA mutation also obviously!!!

Notice: Don’t use if HER-2+, don’t get tripped up

After neoadjuvant
-TNBC: residual dx
-HR+, HER-2(-): residual dx and CPS EG score 3+

After adjuvant
-TNBC: pT2+, pN1+ (like neoadjuvant req)
-HR+, HER-2(-): LN+ 4+

TNBC
Neoadjuvant: residual dx
Adjuvant: pT2+, pN1+

HR+/HER-2(-)
Neoadjuvant: residual dx and CPS EG score 3+
Adjuvant: LN+ 4+

Answer 279

A

-under investigation: there are deeper responses but we don’t know how long the response will last and if we are wasting our daratumumab up front

-Dara- VRD
-Dara-VTD
-Dara-KRD

Update: probably a good idea in younger pts but in older is probably bad bc of increased deaths.

May be good in high risk features

May use dara- len- dex in older pts

Answer 280

A

Chemo-radiation
-RT + cisplatin 100 mg/m2 q3weeks x2-3 doses (cat 1)
-RT + Carboplatin + 5FU infusion (cat 1)

Nasopharyngeal
Induction (category 1 for EBV associated nasopharyngeal, but could use for non-nasopharyngeal)
-TPF (Taxane (docetaxel) + cisplatin + 5FU) followed by weekly carbo (low dose) + RT
-Gemcitabine + cisplatin (nasopharyngeal only)

Nasopharyngeal non-induction
-cisplatin + RT —> cisplatin + 5FU

Note: more neutropenia with induction

Answer 281

A

Surgery and RT

Chemo-RT with cisplatin + RT ONLY IF
1. Extracapsular nodal extension OR
2. Positive mucosal margins

Answer 282

A

preferred first line
-carbo/cisplatin + 5FU + pembro (non-nasopharyngeal)
-pembro alone (cps 1+) (non-nasopharyngeal)
-cisplatin + Gemcitabine (nasopharyngeal)
-cisplatin + Gemcitabine + pembro/nivo (nasopharyngeal)
-cisplatin + Gemcitabine + toripalimab (nasopharyngeal)
-pembrolizumab (Cat 1 if CPS >1)

other first line
-carbo/cisplatin + 5FU + cetuximab (non-nasopharyngeal)

second line
-nivolumab (non-nasopharyngeal)
-pembrolizumab (non-nasopharyngeal)
-Note: ICI is an option for nasopharyngeal but less strong rec and nivo only for non-keratinizing and pembro needs PD-L1 +

RT

If ECOG 2+ use single agent
-non-nasopharyngeal: pembro, cisplatin, carbo, paclitaxel, docetaxel, 5FU, MTX, capecitabine, cetuximab, afatinib (cat 2)
-nasopharyngeal: all of the same except: add gemzar, subtract pembro and afatinib

Answer 283

A

first line
-surgery (thyroidectomy v lobecetomt) followed by RAI

second line
-active surveillance* (if asymptomatic and no brain Mets)
-sorafenib
-lenvatinib (preferred)

subsequent
-cabozantinib

Use these after RAI instead of above recs if applicable
-RET: pralsetinib, Selpercatinib
-BRAFV600E: vemurafenib, Dabrafenib +/- trametinib (Dabrafenib + trametinib combo is preferred)
-(TMB 10+): pembro
-NTRK: larotrectinib, entrectinib

Answer 284

A

ALL of the following: LOW RISK
-classic papillary carcinoma
-largest primary tumor <2 cm
-intrathyroidal
-unifocal or multifocal primary papillary tumor 1 cm or less
-no detectable Tg- antibodies
-post-op un-stimulated Tg< 1
-negative post-op ultrasound

Any of the following
-gross extra thyroidal extension
-primary tumor >4 cm
-post-op unstimulated Tg>10
-indicates biochemical recurrence
-bulky or >5 LN +

Answer 285

A

-surgery- total thyroidectomy (DTC can often get away with just lobectomy)
-RT for residual dx

Recurrent or advanced
-RET-wild type:
-cabozantinib CAPSULES
-Vandetanib-REMS
-RET-mutant:
-Selpercatinib
-pralsetinib

Answer 286

A

Preferred
-Dabrafenib + trametinib (BRAFV600E mutation)
-Selpercatinib, pralsetinib (REt fusion)

Other
-Carboplatin + paclitaxel
-docetaxel + doxorubicin
-paclitaxel
-doxorubicin

Clinical trials if able

Answer 287

A

High risk recurrence or residual dx
-goal <0.1

Low risk dx recurrence (no e/o dx on imaging)
-goal 0.1-0.5

-use levothyroxine
-don’t do this for MTC
-supplement with calcium 1200 mg/day and vit D 1000 units/day

Answer 288

A

-Start with LHRH agonist (or antagonist). Add antiandrogen later (CAB) if necessary.
-don’t use antiandrogen monotherapy
-note: first generation antiandrogens are usually only used to prevent tumor flare (1 week before and ~2 weeks after starting LHRH agonist)

Answer 289

A

ADT: LN positive at time of surgery

Abiraterone: very high risk: 2 of 3 criteria
-PSA >40
-extra-prostatic extension
-Gleason of 8 or more

Answer 290

A

-surgery (in some cases- T1-T2w/o mediastinal pathology, T3 based on size, N0, may consider)

-RT + cisplatin + etoposide x4 cycles
-ppx cranial RT for pts in CR/PR (THIS IS SOC UNLIKE IN extensive stage)

Notice just cisplatin here (unlike extensive stage which is carbo or cisplatin)

Notice no immunotherapy here, unlike extensive stage

Smoking is #1 risk factor

Can now consolidate with Durvalumab like NSCLC

Answer 291

A

-cisplatin/carbo + etoposide +/- immunotherapy q21 days x4-6 cycles followed by immunotherapy maintenance (notice not using RT here like in limited stage)
-consider ppx cranial radiation (consider adding memantine during and after)- NOT SOC LIKE LIMITED STAGE

Notice both carbo and cisplatin okay here (unlike limited stage- just cisplatin

-use atezolizumab or Durvalumab
-Durvalumab changed from q21d to q28d in maintence
-consider chest RT for residual thoracic dx
-if positive brain Mets: (RT before chemo if symptomatic, otherwise chemo first

Second line
-if recurrence only in brain and systemic dx stable- refer to radiation!!
-rechallenge with same regimen (minus ICI)!!! If CHEMO FREE x6 months (consider for 3-6 mo)
-lurbinectedin 3.2 mg/m2- (NO BRAIN METS!)
-topotecan 1.5 IV or 2.3 PO mg/m2
-Irinotecan
-clinical trial
-pacli, doc, TZM, CAV, etop, Vinorelbine, gem, nivo, pembro
-avoid immunotherapy if progressed on maintenance!! Just repeat platium doublet if chemo sensitive

Note: CSFs not recommended in patients receiving thoracic RT with chemo (cat 1 rec)- increased risk of pulmonary toxicity

Smoking is #1 risk factor

Answer 292

A

Stage IA
N: observation
P: resection

Stage IB-IIA
N: observation, chemo for high risk, or osimertinib
P: re-resection or RT +/- chemo

stage IIB
N: chemo FOLLOWED BY atezolizumab, OR osimertinib
P: resection + chemo, or chemoradiation

Stage IIIA
N: chemo + atezolizumab, OR osimertinib, OR sequential chemo and consider RT
P: chemoradiation

-N- negative margins
-P- positive margins
-Osimertinib- use when EGFR exon 19 deletion or exon 21 L858R, tx x3 yrs
-chemo is platinum doublet
-non-squamous: cis + pem
-squamous: cis + gem, or cis + doc
-IB-IIA high risk: poorly differentiated, vascular invasion, wedge resection, tumor >4cm, visceral pleural involvement, unknown LN status

Atezolizumab: completely resected IIB-IIIA or high risk IIA w/ PDL1 1%+
Pembro: also and option now, for high risk IIA-IIIA regardless of PDL1- give AFTER chemo

-osimertinib- give AFTER chemo unless ineligible for chemo

Durvalumab consolidation x12 months for unresectable stage II or III

_______________________________________
-If supracalvicular or contralateral LN positive can NOT do surgery
-R0 is goal after surgery (no residual dx), or R1 or R2 there’s dx left over (positive margins essentially)
-in LN +, or if >4cm LN negative we will usually need some adjuvant tx

Answer 293

A

For resectable tumors: 4+ cm OR LN positive
-Nivolumab + platinum doublet q3 weeks x3 cycles
-Any histology: carbo + pacli
-Non-squamous: cis + Pemetrexed
-Squamous: cis + Gemcitabine

Pembro + platinum doublet every 3 weeks x4 cycles—> adjuvant pembro
-Non-squamous: cis + Pemetrexed
-Squamous: cis + Gemcitabine

Dostarlimab + platinum doublet every 3 weeks x4 cycles
-non-squamous: cis/pem
-squamous: carbo/pacli, cis/gem

Answer 294

A

Chemo + radiation (I.e., no surgery like earlier stages)

Non-squamous:
-cisplatin/carbo + pemetrexed + RT

All histologies:
-carbo + paclitaxel + RT
-cisplatin + etoposide + RT

Durvalumab consolidation x12 months for unresectable stage II or III

Answer 295

A

Durvalumab consolidation x12 months for unresectable stage II or III -PFS 0-1
-No dx progression after 2+ cycles of definitive chemoradiation

Answer 296

A

Non-squamous- AAAHHH WTF DONT MISS THIS!!
First line:
-EGFR Exon 20 insertion: Amivantamab + Carboplatin + pemetrexed (amivantamab monotherapy if progression on this)
-EGFR exon 19 del- osimertinib (option to give with platinum doublet if nonsquamous)
-EGFR L85R- osimertinib
-EGFR S768I, L861Q, or G719x- afatinib or osimertinib
-ALK- alectinib, Brigatinib, lorlatinib
-ROS1- entrectinib (esp if brain Mets) crizotinib, repotrectinib
-MET exon 14 skipping- capmatinib, tepotinib
-RET-Selpercatinib, pralsetinib, (Cabozantinib sometimes)
-BRAFV600E- Dabrafenib + trametinib or encorafenib + binimetinib
-NTRK: larotrectinib, entrectinib
-PDL1 (other mutations take precedence)!!!!!

SECOND LINE (failed 1st line targeted):
-SYMPTOMATIC after osimertinib: amivantamab, Carboplatin, pemetrexed (Cat 1)

-EGFR: erlotinib +/- bevacizumab or ramucirumab, afatinib, dacomitinib, gefitinib —>chemo (NOT ICI) if further progression

-ALK: lorlatinib (progressed on alectinib, Brigatinib, ceritinib
-progressed on crizotinib: alec, lorlat, brigat, ceritinib
-progressed on two ALK: lortalinib (but —>after that we need chemo +/- ICI)

ROS1: if progressed on entrectinib, crizotinib, ceritinib, consider lorlatinib
-progressed on crizotinib- entrectinib
-Reprotrectinib- prior ROS1

MET exon 14 skip: if progress on above go to chemo +/- ICI

NTRK: if progress on above go to chemo+/- ICI

BRAF: if progress on above go to chemo +/- ICI

-Further progression warrants change to ICI +/- chemo for all classes except EGFR (just chemo)

-don’t use ICI with targeted therapy

Squamous-AHHH WTF DONT MISS THIS!!
First line:
-PDL1

Answer 297

A

PD-L1 50%+
-monotherapy: pembro, atezolizumab, of cemiplimab
-CAN ALSO USE COMBOS BELOW

PD-L1 1-49% (or regardless of PDL1)
-platinum doublet with (pemetrexed, bevacizumab, nab-paclitaxel) + pembro/cemip followed by I/O maintenance (see maintenance notecard)
-ipilimumab + nivolumab + pemetrexed + platinum —>IPI/nivo
-ipilimumab + nivolumab (ASCO disagrees)

Notice, atezolizumab only used as monotherapy, not PREFERRED in combos! (There is one cat 1 option for atezolizumab/bevacizumab/carbo/paclitaxel—unlike squamous), this is also the only regimen BEVACIZUMAB is used with ICI)

Note: cisplatin/carbo + pemetrexed + pembro—>pembro is preffered

Category 2 options
Tremelimumab + Durvalumab + chemo (platinum doublet) followed by tramelimumab x1 and Durvalumab q4wk

Note: if there is an actionable mutation, always target this first before ICI

Contraindication to ICI
-platinum doublet with (paclitaxel, nab-paclitaxel, docetaxel, etoposide, Gemcitabine, pemetrexed) +/- bevacizumab (w/ pem or pacli regimen)
-Gemcitabine + (docetaxel or Vinorelbine)

Answer 298

A

PD-L1 50%+
-monotherapy: pembro, atezolizumab, of cemiplimab
-CAN ALSO USE COMBOS BELOW

PD-L1 1-49% (or regardless of PDL1)
-platinum doublet with (paclitaxel, nab-paclitaxel) + cemiplimab/pembro followed by I/O maintenance (see maintenance notecard)
-ipilimumab + nivolumab + paclitaxel + platinum —>IPI/nivo
-ipilimumab + nivolumab (ASCO disagrees)

notice no Pemetrexed or bevacizumab for squamous

Notice, atezolizumab only used as monotherapy, not in combos! (unlike non-squamous where there are a few exceptions)

Note: cisplatin/carbo + pacli or nab-pacli + pembro is preffered

Category 2 options
Tremelimumab + Durvalumab + chemo (platinum doublet, could use Gemcitabine for squamous) followed by tramelimumab x1 and Durvalumab q4wk

Contraindication to ICI
-platinum doublet with (paclitaxel, nab-paclitaxel, docetaxel, etoposide, Gemcitabine)
-Gemcitabine + (docetaxel or Vinorelbine)

Answer 299

A

After 4-6 cycles of chemo in pts with response or stable dx

Continuation: (continue part of initial regimen)
-pembro +/- pemetrexed
-bevacizumab
-pemetrexed +/- bevacizumab
-atezolizumab +/- bevacizumab
-cemiplimab +/- pemetrexed
-ipi + nivo
-there are other options but these are category 1

Switch:
- Pemetrexed

NOTE: maintenance is ONLY for STAGE IV, unlike consolidation with Durvalumab which is stage II-III

Answer 300

A

These are given after CHEMO

ERBB2 (HER-2): fam-trastuzumab deruxtecan
-other: ado-trastuzumab emtansine

KRAS G12C: sotorasib, adagrasib

Exon 20 insertion: amivantamab if not already used is an option

After initial therapy but before chemo +/- ICI
-T790M: osimertinib (if not used first line) (resistance mutation)

-EGFR mutated leptomeningeal dx: osimertinib

don’t use ICI with targeted therapy

Answer 301

A

No prior I/O-chemo only (unlikely):
-nivolumab (regardless of PD-L1
-pembro (PD-L1 >1%)
-atezolizumab (regardless of PD-L1)

Regardless of prior I/O
-pemetrexed (non-squamous)
-docetaxel
-nab-paclitaxel
-Gemcitabine
-docetaxel + ramucirumab (unlike gastric/esophageal which is pacli)
-trastuzumab deruxtecan (HER-2+)

Dont repeat immunotherapy if progressed on immunotherapy

Note: if progression on EGFR inhibitor-second line chemo preferred over ICI

Answer 302

A

Resectable
-resection—> OBSERVATION (no adjuvant tx)

Unresectable
-transplant (AFP<1000 AND <5 cm or 2-3 tumors <3 cm)
-locoregional therapy (if transplant ineligible)- ablation, arterial embolization +/- chemo, radiotherapy
-systemic therapy
-supportive care

Answer 303

A

First line
-atezolizumab + bevacizumab (child Pugh A only)
-Tremelimumab x1 + Durvalumab q4wk

Other category 1
-sorafenib (child Pugh A or B7)
-lenvatinib (child pugh A) (less palmar-plantar erythro… than sorafenib)
-durvalumab
-tislelizumab

Subsequent (all child Pugh A)
-regorafenib
-Cabozantinib (tablets)
-ramucirumab (AFP>400)

Note: beware of bevacizumab if variceal bleeding!/Varices!

Answer 304

A

Adjuvant (resectable)
-mFOLFIRINOX (ECOG 0-1) (notice it’s modified)
-Gemcitabine + capecitabine
Other cat 1:
-Gemcitabine
-5FU/leucovorin

Neoadjuvant (borderline resectable)- 4-6 cycles
-FOLFIRINOX/ mFOLFIRINOX (option for BRCA1/2 or PALB2 mutations)
-Gemcitabine + nab-paclitaxel
-Gemcitabine + cisplatin (only for BRCA 1/2 or PALB2 mutations)

-give 2-6 cycles
-may follow with chemoradiation

Answer 305

A

Good PFS- ECOG 0-1
-FOLFIRINOX/ mFOLFIRINOX (option for BRCA1/2 or PALB2 mutation)
-NALFIROX (as above but uses liposomal irinotecan)
-Gemcitabine + nab-paclitaxel
-Gemcitabine + cisplatin (only BRCA 1/2 or PALB2 mutation)

-other:
Gemcitabine + erlotinib (metastatic)- highly toxic (cat 1)
-Gemcitabine (metastatic)- (cat 1)

Intermediate PFS
-Gemcitabine + nab-paclitaxel (ECOG 2)
-capecitabine
-Gemcitabine

Poor PFS
-Gemcitabine (standard (cat1)or FDR)
-capecitabine (cat 2B)
-continuous infusion 5FU (cat 2B)

Follow with maintenance if response or stable dx x4-6 months- us PARP if BRCA of PALB2, or carry forward part of original regimen

Answer 306

A

Prior platinum containing regimen
-Olaparib (if germline BRCA 1/2 mutation)
-Rucaparib (if germline or somatic BRCA 1/2 or PALB2)

First line FOLFINOX/ mFOLFIRINOX
-capecitabine (Preferred)
-5FU +/- irinotecan
-FOLFOX

First line Gemcitabine + nab-paclitaxel
-modified Gemcitabine + nab-paclitaxel
-Gemcitabine

maintenance is after response or stable dx x4-6 months (16 weeks) each cycle of chemo is 2 weeks

Answer 307

A

Prior fluoropyrimidine based
-Gemcitabine
-Gemcitabine + nab-paclitaxel
-Gemcitabine + cisplatin (BRCA 1/2 or PALB 2 only)
-Gemcitabine + erlotinib
-5FU + liposomal irinotecan (no prior irinotecan)
-Gemcitabine + nab-paclitaxel + cisplatin (cat 2B)

Prior Gemcitabine based
-5FU + liposomal irinotecan (cat 1)
-FOLFIRI
-FOLFIRINOX/ mFOLFIRINOX
-fluoropyimidine + Oxaliplatin
-capecitabine
-continuous 5FU

Targetable
-pembro (MSI-H, dMMR, TMB 10+)
preferred
-larotrectinib, entrectinib (NTRK)-(preferred)
-Dabrafenib + trametinib (BRAFV600E)
-Selpercatinib (RET)
-Adagrasib/ sotorasib (KRASG12C)
-chemoradiation (other)- locally advanced

Note:
-pembro or NTRK preferred over chemo if appropriate
-single agent chemo if poor PFS

Answer 308

A

T2+ or any LN involvement

Peri-operative chemo:
-FLOT (5FU + leucovorin + Oxaliplatin + docetaxel) (preferred cat 1)
-fluoropyrimidine + Oxaliplatin (preferred)
-5FU + cisplatin

Note: can also consider the following but NOT category 1
-pre or post-operative chemo-RT
-neoadjuvant or perioperative immunotherapy (MSI-h/dMMR)
-post-operative chemo: CAPOX is cat 1 (if D2 LN dissection)

Answer 309

A

Pre-operative Chemoradiation
Preferred
-Carboplatin + paclitaxel- weekly
-5FU + Oxaliplatin (FOLFOX)
Other category 1 regimens
-5FU + cisplatin

Definitive chemoradiation (IF NOT MEDICALLY FIT FOR SURGERY
Preferred
-Carboplatin + paclitaxel
-5FU + Oxaliplatin (FOLFOX)
Other category 1 regimens
-5FU + cisplatin

Peri-operative chemo (ADENO ONLY)
Preferred
-FLOT (5FU + leucovorin + Oxaliplatin + docetaxel) (category 1)
-fluoropyrimidine + Oxaliplatin
Other category 1 regimen
-5FU + cisplatin

Post-operative
-nivolumab (after perioperative chemo-radiation with R0 resection and residual dx)

Note: can also do neoadjuvant or perioperative immunotherapy but not category 1- (MSI-h/dMMR)

oxaliplatin preferred over cisplatin

Answer 310

A

HER-2 positive
-fluoropyrimidine + oxaliplatin (preferred)/cisplatin + trastuzumab + pembrolizumab (if CPS 1+)

HER-2 negative
-Fluoropyrimidine + Oxaliplatin (preferred)/cisplatin + pembro (if CPS 1+, cat 1 if 10+)/or nivo (if CPS 5+)

MSI-H/dMMR (regardless of CPS
-pembro
-dostarlimab
-nivolumab + ipilimumab
-fluoropyrimidine + oxaliplatin + nivo/pembro

notice difference in CPS rec for nivo compared to esophagel adeno-otherwise it’s the same

For her-2+ cisplatin is category 1 BUT oxaliplatin preferred d/t better tolerability

Answer 311

A

HER-2 positive
-fluoropyrimidine + oxaliplatin (preferred)/cisplatin + trastuzumab + pembrolizumab (if CPS 1+)

HER-2 negative
-Fluoropyrimidine + Oxaliplatin (preferred)/cisplatin + pembro (if CPS 1+, cat 1 if 10+)/or nivo (cat 1 if CPS 5+, 2B if CPS<5)

MSI-H/dMMR (regardless of CPS)
-pembro
-dostarlimab
-nivolumab + ipilimumab
-fluoropyrimidine + oxaliplatin + nivo/pembro

notice difference in CPS rec for nivo compared to gastric cancer, otherwise it’s the same

For her-2+ cisplatin is category 1 BUT oxaliplatin preferred d/t better tolerability

Answer 312

A

Preferred
-fluoropyrimidine + Oxaliplatin (preferred)/cisplatin +/- nivolumab (cat1)/ pembro (cat 2)
-nivolumab + ipilimumab

MSI-H (regardless of CPS)
-pembro
-dostarlimab
-nivolumab + ipilimumab
-fluoropyrimidine + Oxaliplatin + nivo/pembro

Notice no HER-2 here
oxaliplatin preferred over cisplatin

Answer 313

A

Second line
Preferred
-ramucirumab + paclitaxel (cat 1) (unlike NSCLC which is docetaxel)
-fam-trastuzumab deruxtecan (HER-2)- (prior tx w/ trastuzumab)
-docetaxel (cat 1)
-paclitaxel (cat 1)
-irinotecan (cat 1)
-5FU + irinotecan
Other
-ramucirumab (cat 1)

Third line
-trifluridine/tipiracil (Lonsurf) (cat 1)

Answer 314

A

Preferred
-Nivolumab (cat 1)
-pembro if CPS 10+ (cat 1)
-docetaxel (cat 1)
-paclitaxel (cat 1)
-irinotecan (cat 1)
-tislelizumab (cat 1)
-5FU + irinotecan

Maybe prefer chemo over ICI if given both options

Answer 315

A

Risk fxs- cumulative sun exposure, age
Other: immunosupression (SCC esp.), hpv, merkel cell polyoma virus (MCC), arsenic, RT, chronic skin inflammation, genetic conditions

-Actinic keratosis: premalignant scc lesion- Tx with retinoids
-nicotinamide: Dec risk SCC

Seems like surgery (Mohs, curettage and electrodessication, excision) is first when able and RT (CI in SLE and XP) if can’t do surgery, then below

CSCC and BCC local
-low risk: curettage + electrodesiccation or excision or RT
-high risk: Excision or Mohs or RT
-topical imiquimod or 5FU if can’t do RT
-chemo not usually used (cisplatin sometimes for CSCC)

BCC locally advanced or metastatic
-vismodegib oral
-sonidegib oral
-cemiplimab (after hedgehog-I)
-note sunscreen does NOT decrease risk for BCC

CSCC locally advanced
-cemiplimab
-pembro
-chemo if can’t do ICI (carbo + pacli)
-cetuximab
-Dont give ICI if transplant patient

MCC
Local:
-adjuvant cisplatin/carbo +/- etoposide in select cases

Advanced:
-clinical trial (preferred)
-avelumab
-pembro
-nivolumab
-chemo if can’t do ICI
-carbo +/- etoposide, teniposide, or CAV

Short answer for advance dx: CSCC and MCC use ICI, BCC use hedgehog

Answer 316

A

Stage I or contingious stage II
-ISRT alone
-Less aggressive induction +/- ISRT

Stage II non-contiguous
-Less aggressive induction +/- ISRT
-observation (highly select cases)

Answer 317

A

All stages: I, II, III
-surgery (partial colectomy and minimum of 12 LN)

Stage I
-surgical resection followed by surveillance

Stage II
dMMR/MSI-H:
-SURGERY ONLY!! no adjuvant therapy
No high risk factors:
-surgery only (consider adjuvant single agent 5FU or capecitabine)
High risk factors:
-surgery followed by
-capecitabine or 5FU/LV x6 months, or CAPOX X3 mo, FOLFOX x6 mo

Stage III
-surgery followed by
Low risk:
-CAPOX x3 or FOLFOX x3-6 months
High risk (T4 or N2- 4 LN+)
-CAPOX x3-6 or FOLFOX x6 months

-can use neoadjuvant immunotherapy (pembro or nivo +/- ipi) if dMMR/MSI-H (T4b tumors)

Stage 2 high risk factors
-poorly or undifferentiated
-lymphatic/vascular invasion
-bowel obstruction
-<12 LN surgically examined
-perineural invasion
-localized perforation
-close, intermediate, or positive margins
-tumor budding
-T4??
-Note: these risk fxs were not created in the modern era and not everyone agrees that these people need chemo

Note: in high risk stage III there is data supporting stopping Oxaliplatin early after 3 months and ok continue monotherapy to complete 6 months

Answer 318

A

Clinical stage I
-Surgery followed by observation or adjuvant chemo or adjuvant chemo RT

Clinical stage II and III
-TNT (preferred)->surgery->observation
-Neoadjuvant RT->surgery->adjuvant chemo
-Consider neoadjuvant dostarlimab, pembro, nivo for dMMR/MSI-H- THIS IS NOW STANDARD!!

Chemo options
-CAPOX or FOLFOX
-Consider 5FU/LV or capecitabine
-FOLFIRINOX: consider if pT4 or N+

ChemoRadiation options
-RT + capecitabine or 5FU CIVI
-RT + bolus 5FU (consider- NOT PREFERRED)
-Notice no Oxaliplatin with chemo given with RT

note: TNT is neoadjuvant chemo and chemo-RT/or RT

Note: equipoise on whether long or short course RT in TNT is best

Answer 319

A

First line- INTENSIVE THERAPY
-FOLFOX or CAPOX +/- bevacizumab
-FOLFIRI +/- bevacizumab
-FOLFIRINOX +/- bevacizumab (more aggressive, e.g., R-sided or BRAF)
-FOLFOX (NOT CAPOX) or FOLFIRI + cetuximab or panitumumab (Left sided and RAS/RAF wild type)- EGFR instead of bev (don’t need EGFR mutation)
-pembrolizumab, dostarlimab- NOT NIVO (dMMR/MSI-H)- or IPI/nivo (not preferred)

First line- NON-INTENSIVE THERAPY
-5FU/LV or capecitabine +/- bevacizumab
-cetuximab or panitumumab (Left sided and RAS/RAF wild type)
-pembrolizumab (dMMR/MSI-H)-or IPI/nivo-not preferred
-trastuzumab + (Pertuzumab/ lapatinib/ or tucatinib) (***HER-2+ RAS/RAF wild type)

Note: if single metastatic site to liver or lung: you could do surgery and try to cure- use metastatic regimens though, not typical adjuvant regimens- use CAPOX OR FOLFOX

Notice: FOLFIRINOX NOT FOLFOXIRI

Note: pick EGFR inhibitor over bev if candidate for it

Answer 320

A

This card is actually important so don’t skip it

-bevacizumab (can continue from 1st line)
-ziv-afilbercept or ramucirumab: with FOLFIRI or irinotecan (but bevacizumab is preferred)
-cetuximab or panitumumab (RAS/RAF wild type) (unless used in front line)- alone or with FOLFOX or FOLFIRI or irinotecan
-encorafenib + (cetuximab or panitumumab) (BRAF V600E)-need both drugs here (unless used in frontline)
-trastuzumab + (Pertuzumab/ lapatinib/ or tucatinib) (HER-2+ and no prior anti-HER-2 therapy)
-fam-trastuzumab deruxtecan (regardless of prior HER-2 therapy)- progressed on 2 or more likes of therapy!!
-pembro, nivo +/- ipi, or dostarlimab (dMMR/MSI-H and have not used prior ICI)
-adagrasib/sotorasib +/- cetuximab/panitumumab (KRAS G12C)
-entrectinib/larotrectinib (NTRK)
-Selpercatinib (RET)
-others: regorafenib, fruquintinib (RAS/RAF wildtype), or trifluridine/tipiracil (preferred with bevacizumab)

Answer 321

A

Aspirin - this was rescinded in 2022- (can consider if lynch syndrome)

USPSTF says insufficient evidence, NCCN acknowledges this but still has it in guidelines to consider it

Answer 322

A

Epithelioid (best prognosis)
-cisplatin + pemetrexed +/- bevacizumab —> bevacizumab maintenance)
-ipilimumab + nivolumab

Biphasic/Mixed or Sarcomatoid
-ipilimumab + nivolumab (Preffered)
-cisplatin/carbo + pemetrexed +/- (bevacizumab —> bevacizumab maintenance)

Subsequent
-pemetrexed (if not used first line or if good response in first line)
-ipilimumab + nivolumab

Main risk fx is asbestos

-Screening is NOT recommended
-BAP1 is the the mutation we see
-second line switch to what you didn’t give before (ICI vs chemo)

Answer 323

A

Localized
-5FU/capecitabine + mitomycin + RT (Nigro protocol)

Locally progressive or recurrent
-abdominoperineal resection (WILL NEED COLOSTOMY)

Metastatic
-carbo + paclitaxel (cat 1)
-cisplatin + 5FU
-FOLFCIS
-FOLFOX
-DCF (doc + cis + 5FU)

Subsequent
-nivo or pembro (regardless of PDL1)
-platinum (if given first line)

Risk fx: hpv, HIV, smoking hx, anal intercourse

Note: may take up to 26 weeks for complete response

Answer 324

A

These are grade 1

BRAF V600E mutation
-Dabrafenib + trametinib
-vemurafenib + Cobimetinib

BRAF Fusion
-selumetinib

Subependymal giant cell astrocytoma
-everolimus

Answer 325

A

Siewart classification:
Types I-II: Tx as esophageal cancer
Type III: Tx as gastric cancer

I think also you can look at histology and if adenocarcinoma you can treat more like gastric- example: traztuzumab can be used in her-2+ EGJ adenocarcinoma

Answer 326

A

-anemia or thrombocytopenia
-autoimmune cytopenias even after tx with rituximab and high dose steroids
-B- symptoms
-threatened end organ function
-symptomatic lymphadenopathy
-symptomatic extranodal involvement
-lymphocyte doubling time of less than 6 months (maybe)

Even if really high WBC bc we are not worried about leukostasis like with acute leukemias

Answer 327

A

Early relapse (<6 months) after ATRA + anthracycline, or prior arsenic
-arsenic +/- ATRA +/- Gemtuzumab

Late relapse (>6 months) after arsenic
-Arsenic +/- ATRA +/- anthracycline

Transplant
-auto if MRD negative
-allo if CR but MRD positive

Answer 328

A

Pembro (also for TMB >10) or dostarlimab

Nivo +/- in colorectal

Atezolizumab not indicated

Other:
-NTRK
-BRAF V600E: Dabrafenib + trametinib
-RET fusion: Selpercatinib

Answer 329

A

Limited stage SCLC
-cisplatin + etoposide (+RT)

Extensive stage SCLC
-cisplatin/carboplatin* + etoposide

NSCLC IIA (high risk)-IIIA
-squamous: cisplatin + (gemzar or docetaxel)
-Non- Squamous: cisplatin + pemetrexed

NSCLC neoadjuvant
-any histology: carbo + paclitaxel
-non-squamous: cisplatin + pemetrexed
-squamous: cisplatin + Gemcitabine

NSCLC IIIB
-Non-squamous: cisplatin/carbo + pemetrexed + RT
-All histologies: carbo + paclitaxel + RT

NSCLC Advanced
-Squamous: (paclitaxel, nab-paclitaxel) + cemiplimab/pembro followed by I/O maintenance
-ipilimumab + nivolumab + paclitaxel + platinum —>IPI/nivo
-Non-Squamous: carbo/cis + (pemetrexed, bevacizumab, nab-paclitaxel) + atezolizumab/pembro followed by I/O maintenance

Answer 330

A

Lomustine

Double check this

Answer 331

A

-R-EPOCH
-RCHOP (may need RT for residual dx)

R/R:
-pembro
-nivo +/- Brentuximab vedotin

Answer 332

A

Isotretinoin- can’t do long term d/t toxicity

Answer 333

A

Isotretinoin- can’t do long term d/t toxicity

Answer 334

A

Bromocriptine - D2 AGONIST, inhibits prolactin release

Note: Cushing’s is a common complication of this tumor

Answer 335

A

NCCN doesn’t discuss- ongoing research

Osimertinib has been used after tmz

Answer 336

A

Note: pseudo progression from RT in first 3 months scans look worse

No established second line:
-resection (if able)
-re-irradiation (if able)
-bevacizumab +/- chemo
-TMZ
-nitrosurea (carmustine or lomustine)
-PCV
-regorafenib
-tumor treating fields (alt electric fields)

Answer 337

A

Chordoma: imatinib, dasatinib, sunitinib

Chondrosarcoma: dasatinib,
Pazopanib, ivosidenib (IDH mutation)

UPS of bone: osteosarcoma like (AP, MAP)

Answer 338

A

Uterine leimyosarcoma: Gemcitabine + docetaxel

Myxoid liposarcoma: dox or dox + Dacarbazine

Pleomorphic liposarcoma: dox

Differentiated liposarcoma: dox

Angiosarcoma: dox, Liposomal dox, or paclitaxel

Synovial sarcoma: dox + ifos

Perivascular epithelioid differentiation: nab-sirolimus

Epitheloid sarcoma: tazemetostat

Tenosynovial giant cell tumor/pigmented villonodular synovitis: Pexidartinib

Perivascular epitheloid cell neoplasm (PEComas): nab-sirolimus

Desmoid: observation—> sorafenib

Leimyosarcoma: dox + Dacarbazine

Answer 339

A

Vascular tumor associated with human herpes virus-8 (aka KS herpes virus)

Usually associated with HIV- manage this with ART

Often visible on skin

Limited cutaneous disease
-topicals (imiquimod, alitretinoin)
-intralesional Vinblastine
-RT, local excision, cryotherapy

Advanced disease
-liposomal doxorubicin (preferred)
-sirolimus (transplant Ks)
-paclitaxel

Relapsed/refractory
-pomalidomide (give with ASA)

Avoid steroids- causes flare

Answer 340

A

Lenalidomide, luspatercept, epoetin, then Lenalidomide if none apply, then hma

Answer 341

A

-if >3 yr can repeat regimen
-FLAG-IDA, FLAM, MOAD, augmented hyper-CVAD, clofarabine based (CLOVE), nelarabine based (NECTAR), inotuzumab, blinatumomab
-CAR-T: tisagenlecleucel (up to 25 y/o), brexucabtagene
-allogenic HCT if you can achieve CR

Answer 342

A

Interferon Alfa

Answer 343

A

Carboplatin + paclitaxel

Answer 344

A

Adjuvant
-capecitabine

Unresectable or metastatic
-Gemcitabine + cisplatin + (Durvalumab or pembrolizumab) (preferred)
-Gemcitabine + cisplatin

Subsequent
-FOLFOX

Targeted
-FGFR inhibitors

Answer 345

A

-Surgery
-adjuvant chemo for advanced dx need mitotane +/- (cisplatin/carbo + etoposide)
-unresectable:
-mitotane + EDT (etop, dox, platinum)

-We check mitotane lvls (14-20)
-mitotane can cause aldosterone deficiency

Answer 346

A

-Surgery (localized)
-adjuvant chemo for advanced dx need mitotane +/- (cisplatin/carbo + etoposide)
-unresectable:
-mitotane + EDT (etop, dox platinum)

-We check mitotane lvls (14-20)
-mitotane can cause aldosterone deficiency

Answer 347

A

No treatment

We do prevention strategies like surgery or tamoxifen/ AI

No RT

Answer 348

A

No treatment

We do prevention strategies like surgery or tamoxifen/ AI

Answer 349

A

-chemo in second trimester or post partum
-no RT or ET
-chemo regimens:
-FAC (5FU, dox, cyclo)

Answer 350

A

Think SCLC

Platinum + etoposide +/- IO

Answer 351

A

Doxorubicin + Dacarbazine

Answer 352

A

Radiation

Answer 353

A

Treat like small cell lung cancer

Mitotic rate or ki67 >20

Answer 354

A

Pazopanib

Answer 355

A

-Surgery if possible
-somatastatin analongs
-everolimus
-luteum 177 gotatade (mid-gut NET)
-MSI-H, high TMB: pembro
-lots of other crap depending on location

Mitotic rate and ki67 <2

Answer 356

A

TIP (paclitaxel, ifosfamide, cisplatin)

Answer 357

A

TIP (paclitaxel, ifosfamide, cisplatin)

Brainscape's Knowledge GenomeTM

Sarcomas Flashcards

Brainscape's Knowledge Genome^TM