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444-Oncology and Neurology > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

what is the leading cause of death from cancer

A

lung cance

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2
Q

RF for lung cancer

A

smoking (↑20x), second hand smoking (↑20-30%), asbestos, hx COPD/ TB/ lupus, immunosuppression, occupational exposure to certain chemicals, exposure to radiation, beta carotene with smoking, outdoor air pollution

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3
Q

S/S of lung cancer

A

cough, dyspnea, weight loss, chest pain, sx more likely in pts who already have COPD

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4
Q

lung cancer diagnosis requries

A

CXR, chest CT or PET, bronchoscopy, sputum cytology from cough or bronchoscopy, biopsy via bronchoscopy or fine needle or excisional or from surgery

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5
Q

year for 3 years
lung cancer workup includes

A

lab tests, consider bone scale, CT/MRI head, CT chest/ abdomen for bone/ brain/ liver/ adrenal metastasis, pulmonary fxn tests

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6
Q

CTFPHC recommends screening with low dose CT every _____in adults who: Are _____yrs, current or former smokers who quit in the last __yrs, min ______ year hx of smoking

A

every year for 3 years
55-74yrs
15 yrs
30 pack year

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7
Q

lung cancer is divided into 2 histologic types

A

non small cell lung cancer
small cell lung cancer

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8
Q

prognosis of stage 1 NSCLC

A

80% 5yr survival

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9
Q

prognosis of stage 4 NSCLC

A

10% 5yr survival

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10
Q

NSCLC is further divided into

A

adenocarcinoma (nonsequamous)
squamous cell (epidermoid)
other (large cell)

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11
Q

what is the most common type of NSCLC in nonsmokers

A

adenocarcinoma (nonsquamous)

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12
Q

what type of cells do adenocarcinomas affect

A

glandular cells

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13
Q

what type of cells do squamous cell NSCLC affect

A

squamous cells

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14
Q

treatment for stage 1-3A resectable disease

A

resection preferred, but pt has to be fit for surgery
+ adjuvant chemo if => stage 2
+ adjuvant radiation or reresecting after adjuvant chemo if + margins

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15
Q

what proportion of pts have nonresectable lung cancer

A

2/3- includes those who refuse or are unfit for surgery

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16
Q

options for stage 2-3 unresectable disease

A

concurrent radiation + chemo - if good response on stage 3A = give durvalumab
intense focused radiation, followed by adjuvant chemo
neoadjuvant chemo, surgery, adjuvant radiation

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17
Q

what is a platinum doublet

A

platinum + other drug

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18
Q

recommendation for stage 1-3A, ECOG 3-4

A

palliative radiation

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19
Q

cisplatin MOA

A

covalently binds DNA and disrupts function

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20
Q

cisplatin SEs

A

ototoxicity, nephrotoxicity, hypokalemia, hypomagnesemia, myelosuppression, N/V

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21
Q

what should be given with cisplatin infusions

A

K and Mg supplementation + IV fluid

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22
Q

what is dosed based on the carvert formula

A

carboplatin

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23
Q

what is the benefit of carboplatin over cispatin

A

less ototoxic and nephrotoxic

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24
Q

what is the downside of carboplatin over cisplatin

A

more myelosuppressive

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25
Q

what is often used for pts who can’t tolerate cisplatin due to renal insuff?

A

carboplatin

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26
Q

vinorelbine is a

A

semisynthetic vinca alkaloid

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27
Q

vinorelbine MOA

A

inhibits cell growth by binding to tubulin on nitotic MT

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28
Q

vinorelbine SEs

A

bone marrow suppression
changes in bowel habits (constipation>diarrhea)
sensory neuropathy
alopecia

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29
Q

pemetrexed is an

A

antifolate antimetabolite

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30
Q

pemetrexed is an antifolate antimetabolite that primarily

A

inhibits thymidylate synthase which leads to reduced thymidine for DNA synthesis

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31
Q

pemetrexed SEs

A

bone marrow suppression
diarrhea
mucositis
fatigue
skin rash (less if pretreat with dex)

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32
Q

how to prevent pemetrexed bone marrow suppression, diarrhea, mucositis

A

folic acid 0.4mg po daily starting 1 wk before first dose + cont 3 wks after last dose
vit B12 1000mcg IM q9wks with first inj 1 wk before first dose, end 3 wks after last dose

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33
Q

gemcitabine MOA

A

pyrimidine analog whos active metabolites are incorporated into DNA = inhibition of DNA synthesis + induction of apoptosis

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34
Q

gemcitabine AEs

A

bone marrow suppression
elevated liver enzymes
pulmonary toxicity

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35
Q

durvalumab is indicated in pts that are (3)

A

stage 3A NSCLC and
have received concurrent chemo + radiation and
has good response to tx (no progression)

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36
Q

durvalumab is an ________ that blocks ________

A

immune checkpoint inhibitor that blocks PD-L1

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37
Q

how to treat advanced (stage 3B, C) or metastatic lung disease if ECOG 3-4

A

radiation alone

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38
Q

how to treat advanced (stage 3B, C) or metastatic lung disease if ECOG is 1-2

A

chemo +/- radiation- platinum doublet
targeted oral therapies - EGFR TKis, ALK TKis, ROS1 TKIs
immune checkpoint inhibitors

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39
Q

Genetic mutations and molecular targets can be identified through _____.
______ can detect presence of PD-L1 in tissues

A

PCR, FISH, NGS
IHC

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40
Q

NSCLC adenocarcinoma can be further detailed into

A

EFGR mutation
ALK fusion oncogene
ROS1 rearrangement positive
KRAS mutation

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41
Q

T or F: the overlap between NSCLC is rare

A

T <3%

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42
Q

common EFGR sensitizing mutations are ______ or _______

A

deletion exon 19
point mutation exon 21

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43
Q

what is a less common EGFR mutation

A

T790M

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44
Q

what is true about T790M? select all that apply
1. is a less common EGFR mutation
2. is a common ALK fusion mutation
3. tends to be hereditary
4. tends to be acquired during treatment

A

1,4

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45
Q

sensitizing EGFR gene mutations are more common in _____ and ______

A

smokers and females

46
Q

what are the first gen EGFR TKIs

A

erlotinib and gefitinib

47
Q

what is the second gen EGFR TKi

A

afatinib

48
Q

what is the third gen EGFR TKi

A

osimertinib

49
Q

all EGFR TKis have activity on ______ or ______

A

exon 19 del or exon 21

50
Q

what is the only EGFR TKi that has activity on T790M

A

osimertinib

51
Q

what EGFR TKi is funded as first line for EGFR sensitizing mutation in alberta

A

osimertinib

52
Q

osimertinib benefits

A

better penetration to brain- passes BBB
only EGFR TKi that targets T790M

53
Q

AEs for EGFR TKis

A

fatigue, rash, diarrhea, hepatic dysfunction or increase in liver transaminases, interstitial lung disease

54
Q

what are 2 ALK fusion oncogene TKis

A

alactinib and brigatinib

55
Q

name 3 ALK TKi AEs

A

GI toxicities - diarrhea (50% with brig), constipation (35% with alect)
N/V (30% with brig)
hepatotoxicity or elevation in transaminases and/or bilirubin
hyperglycemia with brig (initiate appropriate AHG meds)
myalgia with alectinib
symptomatic bradycardia
QTc prolongation
HPTN with brig
CK elevation

56
Q

ROS1 encodes a _____ and is a _____

A

Transmembrane receptor
protooncogene

57
Q

what are 2 ROS TKis

A

entrectinib and crizotinib

58
Q

which of the following is true about the KRAS mutation
1. it happens in about 40% of all lung NSCLC adenocarcinoma
2. if it is present, there is likely problems with either EGFR, ALK, ROS1
3. is a good prognostic marker
4. if it is present, EGFR, ALK, ROS1 are unlikely to have mutations too
5. EGFR targets may help

A

4

59
Q

entrectinib is a

A

ROS1 fusion TKi

60
Q

osimertinib is a

A

EGFR TKi

61
Q

which of the following should be taken with or without food
1. osimertinib
2. entrectinib
3. crizotinib
4. alectinib
5. brigatinib

A

1, 2, 5

62
Q

which of the following should be taken with food
1. osimertinib
2. entrectinib
3. crizotinib
4. alectinib
5. brigatinib

A

4

63
Q

which of the following has pH dependent solubility
1. osimertinib
2. entrectinib
3. crizotinib
4. alectinib
5. brigatinib

A

2

64
Q

osimertinib, entrectinib, crizotinib, alectinib, and brigatinib are major CYP ____ substrates

A

3A4

65
Q

crizotinib is a TKi for

A

ROS1

66
Q

alectinib is a TKi for

A

ALK

67
Q

brigatinib is a TKi for

A

ALK

68
Q

because erlotinib, gefitinib, osimertinib, entrectnib, crizotinib, alectinib, brigatinib = major CYP3A4 substrate, what should be avoided? what should be monitored?

A

avoid grapefruit juice
monitor INR for pts on warfarin

69
Q

what are 4 treatment options for NSCLC nonsquamous with out driver mutations

A

platinum doublet
ICI monotherapy
platinum doublet with one ICI therapy
platinum doublet with 2 ICI therapies

70
Q

Regardless of PD-L1 expression levels, immunotherapy is less effective for__________- if there is a driver in metastatic disease, use that as a target first

A

tumors with driver mutations (EGFR+, ALK+)

71
Q

if a tumor has high PD-L1 levels and an EGFR mutation, which would be more appropriate therapy
1. osimertanib
2. entrectinib
3. pembrolizumab
4. platinum doublet
5. imilimumab

A

1- EGFR TKi
always target driver mutations first, before using immunotherapy agents

72
Q

where are PD-1 receptors present?

A

activated cytotoxic T cells

73
Q

where are PD-L1 ligands present

A

cancer cells

74
Q

PD-1 inhibit MAbs include

A

nivolumab, pembrolizumab

75
Q

PD-L1 inhibitors include

A

atezolizumab, durvalumab

76
Q

what is a tumor proportion score?

A

% of viable tumor cells showing any PD-L1 staining (not the same as somatic genetic mutation)

77
Q

what is the best for predicting response to pembrolizumab in metastatic NSCLC

A

PD-L1TPS

78
Q

the TPS predicts response of metastatic NSCLC to ______
1. pembro
2. nivo
3. atezo
4. durvalu
5. more than one of the above

A

1

79
Q

which of the following is true about PD-L1
1. TPS is a measure of the % of tumor cells with PD-L1 staining
2. >50% is a high expression and chooses pembro as second line therapy
3. expression is continuously variable and dynamic, hence cut offs are arbitrary
4. >1% is high expression = pembro is second line therapy

A

3

80
Q

if PD-L1 expression is >50% without other driver mutations, what is first line therapy?

A

pembrolizumab

81
Q

in order to use immune checkpoint inhibitors like pembrolizumab, pts must have ______

A

ECOG <2

82
Q

what is the only PD-1/PD-L1 inhibitor used with a curative intent

A

durvalumab for stage 3A

83
Q

pembrolizumab may be combined with __________ for improved 1 yr survival compared to chemo alone

A

platinum doublet for improved 1yr survival compared to chemo alone

84
Q

when may pembrolizumab be second line

A

after progression if the pt did not receive pembro before and PD-L1 =>1

85
Q

nivolumab is a

A

PD-1i

86
Q

nivolumab is used with ______ intent

A

palliative for advanced/ metastatic

87
Q

nivolumab is used as first line in combo with

A

ipilmumab and platinum doublet if no mutations

88
Q

is PD-L1 score required if nivo is used as first line in combo with ipilumab and platinum coublet?

A

no

89
Q

when is nivo indicated as second line tx

A

after progression on chemo alone

90
Q

when is atezolizumab used

A

for palliation after advanced/ metastatic + second line only after rpogression on chemo alone

91
Q

durvalumab can be used for

A

curative intent for stage 3A and consolidation (prevent recurrance)
adjuvant- after good response on concurrent chemo + radiation

92
Q

B7 is present on

A

dendritic cells

93
Q

CD28 is on

A

T cells

94
Q

CTLA4 is an

A

immune checkpoint

95
Q

______ is a CTLA4i

A

ipilimumab

96
Q

ipilimumab is synergistic with

A

PD1 targeting MAbs like nivolumab

97
Q

data supports the combo of ipilimumab + _______ + ______

A

nivolumab + chemo

98
Q

what is a spectrum of SEs caused by general immunologic enhancement

A

immune mediated AEs

99
Q

what is considered limited SCLC

A

cancer contained in single area that can be treated with radiotherapy

100
Q

can limited SCLC be treated with curative intent?

A

yes- if pt is fit

101
Q

what is considered extensive SCLC

A

cancer has spread to other lung or lymph nodes further away from cancer
distance metastasis present
may be in pleural fluid

102
Q

extensive SCLC is treat with ____ intent

A

palliative

103
Q

SCLC is highly linked to

A

smokign

104
Q

which spreads and grows faster? NSCLC or SCLC?

A

SCLC

105
Q

SCLC usually starts in cells that

A

line the bronchi (center of lung)

106
Q

describe stage 1 SCLC

A

3.5% pts diagnosed here, 5yr survival of 30%

107
Q

should you push stage 1 SCLC pts to quit smoking?

A

yes- 5 yr survival doubles if they stop smoking after dx

108
Q

describe stage 4 SCLC

A

67% dx here, 5yr survival 2%, most survive for 7-11mths after

109
Q

treatment of limited stage SCLC

A

concurrent chemo + radiation for pts with ECOG 0-1
prophylactic cranial radiation for brain metastasis

110
Q

treatment of extensive stage SCLC

A

platinum doublet chemo 4-6 cycles + durvalumab
+ durvalumab maintenance

111
Q

etoposide is used in lung cancer in

A

SCLC

444-Oncology and Neurology (22 decks)

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