Lung Cancer

Question 1

common metastatic sites for NSCLC and SCLC

Answer 1

contralateral lung, lymph nodes, liver, adrenal glands, bone, CNS

Question 2

clinical presentation

Answer 2

cough, dyspnea, chest pain, hemoptysis, repeat prescriptions for pneumonia/bronchitis/chronic cough**

Question 3

risk factors

Answer 3

smoking**, second hand smoke, asbestos exposure, metal exposure (arsenic), radiation, air pollution

Question 4

pack years

Answer 4

years of smoking * pack per day smoked
(1 pack = 20 cigs)

Question 5

diagnosis

Answer 5

1. radiologic evaluation (CT)
2. lung tissue biopsy

Question 6

treatment goals

Answer 6

NSCLC stage 1-3: cure
NSCLC stage 4: prolong survival
SCLC limited: cure
SCLC extensive: prolong survival

Question 7

SCLC neoadjuvant therapy

Answer 7

-immunotherapy (nivolumab, pembrolizumab, durvalumab) + platinum based chemo x4 cycles
-platinum based chemo x4 cycles if not candidate for immune

Question 8

SCLC adjuvant therapies

Answer 8

-osimertinib qd x3yrs (EGFR+)
-alectinib bid x2yrs (ALK+)
-atezolizumab x1yr
-pembrolizumab x1yr
-nivolumab x1yr
-durvalumab x1ye
-platinum based chemo x4 cycles

Question 9

platinum based chemo for non-squamous

Answer 9

-cisplatin/pemetrexed
*qd x21d x4 cycles

Question 10

platinum based chemo for squamous

Answer 10

-cisplatin/docetaxel
-cisplatin/gemcitabine
*both qd x21d x4c

Question 11

platinum based chemo for non-cisplatin candidates

Answer 11

-carboplatin/paclitaxel
-carboplatin/gemcitabine
-carboplatin/pemetrexed (non-squamous only)
*all qd x21d x4c

Question 12

cisplatin* vs carboplatin

Answer 12

myelosuppression: less than
N/V: yes
diarrhea/constipation: yes
nephrotoxicity: hypokalemia, hypomagnesemia
ototoxicity: yes
peripheral neuropathy: yes

Question 13

cisplatin vs. carboplatin*

Answer 13

myelosuppression: thrombocytopenia
N/V: less than
Diarrhea/constipation: yes
nephrotoxicity: less than
ototoxicity: less than
peripheral neuropathy: less than

Question 14

carboplatin dosing Calvert equation

Answer 14

total dose (mg) = target AUC x (CrCl + 25)

Question 15

Calvert equation pearls

Answer 15

-CrCl should not exceed 125 mL/min
-max dose = target AUC x 150 mL/min

Question 16

NSCLC chemo agents

Answer 16

taxanes (paclitaxel, docetaxel) and pemetrexed

Question 17

pemetrexed

Answer 17

-NSCLC chemo
-non squamous only
-depletes purine and pyrimidine
-avoid if CrCl <45 (renal elim)
-myelosuppression, rash, fatigue, diarrhea, N/V
-fa and B12 prophylaxis + dexamethasone 4mg bid for rash

Question 18

advanced NSCLC with targetable genetic mutation

Answer 18

EGFR, ALK, ROSI, BRAF, NTRK, RET, MET, NRGI, HER2, KRAS

Question 19

EGFR inhibitors

Answer 19

erlotinib, gefitinib, afatinib, dacomitinib, osimertinib*, lazertinib

Question 20

osimertinib (first line EGFR)

Answer 20

dose: 80 mg qd
DDIs: CYP3A4
pH dependent?: no

Question 21

osimertinib (first line EGFR) AEs

Answer 21

skin rash, dry skin, diarrhea, fatigue, nail toxicity, stomatitis, myelosuppression, QTc prolongation, cardiomyopathy, conjunctivitis

Question 22

EGFRi rash management prevention

Answer 22

-sun safety: spf 25
-gentle skin care

Question 23

EGFRi rash management treatment for grade 1 (mild)

Answer 23

-continue anticancer regimen
-hydrocortisone 2.5% cream
or
-clindamycin 1% gel

Question 24

EGFRi rash management treatment for grade 2 (moderate)

Answer 24

-continue anticancer agent
-hydrocortisone 2.5% cream and doxycycline/minocycline 100 mg po bid

Question 25

EGFRi rash management treatment for grade 3 (severe)

Answer 25

-delay treatment for 1-2 weeks and dose reduce per package insert -mild and moderate interventions plus -po prednisone 0.5 mg/kg/d x7d

Question 26

ALK inhibitors

Answer 26

crizotinib, ceritinib, brigatinib, alectinib, lorlatinib, ensartinib

Question 27

brigatinib (ALK)

Answer 27

dose: 90 mg qd x7d > 180 mg qd DDIs: CYP3A4 -dose reduce in hepatic and renal failure

Question 28

brigatinib (ALK) AEs

Answer 28

diarrhea, fatigue, ILD/pneumonitis, myalgia, hypertension

Question 29

alectinib (ALK)

Answer 29

dose: 600 mg bid DDIs: CYP3A4 dose reduce in hepatic

Question 30

alectinib (ALK) AEs

Answer 30

constipation, fatigue, LFT abnormalities, peripheral edema, myalgia, anemia

Question 31

lorlatinib (ALK)

Answer 31

dose: 100 mg qd DDIs: CYP3A4, pgp dose adjust in renal

Question 32

lorlatinib (ALK) AEs

Answer 32

fatigue, peripheral edema, mood disorders, neuropathy, cognitive effects, arthralgia, dyslipidemia, weight gain

Question 33

ensartinib (ALK)

Answer 33

dose: 225 mg qd DDIs: CYP3A4, pgp no dose adjustments

Question 34

ensartinib (ALK) AEs

Answer 34

constipation, N/V, fatigue, LFT abnormalities, peripheral edema, ILD/pneumonitis, myalgia, arthralgia

Question 35

KRAS inhibitors

Answer 35

-25% of adenocarcinomas, more common with cigs, poor prognosis -indicated after receipt of one prior therapy -sotorasib and adagrasib

Question 36

sotorasib (KRAS)

Answer 36

-960 mg qd -avoid co-admin with PPIs and H2RAs -adagrasib: 600 mg bid

Question 37

immunotherapy AE management

Answer 37

grade 1: continue immunotherapy grade 2: hold immunotherapy and consider corticosteroid admin grade >/3: hold immunotherapy and admin corticosteroids

Question 38

corticosteroids for immunotherapy related AE

Answer 38

prednisone 0.5-2 mg/kg/day or equivalent until resolution to grade 1 followed by taper over at least 1 month

Question 39

SCLC first line limited stage regimens

Answer 39

-cisplatin + etoposide + concurrent RT +/- durvalumab -carboplatin +etoposide + concurrent RT +/- durvalumab

Question 40

SCLC first line extensive stage regimens

Answer 40

-carboplatin + etoposide + atezolizumab -carboplatin + etoposide + durvalumab -cisplatin + etoposide + durvalumab

Question 41

tarlatamab-dlle dosing

Answer 41

cycle 1: -day 1: 1 mg -day 8: 10 mg -day 15: 10 mg cycle 2: -days 1 + 15: 10 mg

Question 42

tarlatamab-dlle boxed warnings

Answer 42

cytokine release syndrome (CRS): fever, hypoxia, hypotension, tachycardia neurotoxicity: ams, unresponsiveness, seizures

Question 43

summary

Answer 43

-NSCLC is more common and less aggressive than SCLC -management of NSCLC is driven by targetable biomarkers -SCLC mainstay of treatment is platinum chemo -immunotherapy may require halt in therapy and/or steroid admin