NSCLC

Question 1

Lung cancer screening indication

Answer 1

Age 55-80 with > 30 pack years and currently smoking or quit in past 15 years

Question 2

Stage IA definition

Answer 2

T1 N0 M0

T1 = tumor < 3cm

Question 3

Stage IA treatment

Answer 3

Lobectomy with LND preferred, no adjuvant chemo

RT used if surgery medically contraindicated

Question 4

Pancoast (superior sulcus) tumor treatment

Answer 4

Neoadjuvant cisplatin + etoposide x2 cycles with concurrent RT

• -> surgical resection
• -> consolidation chemo with platinum doublet x2 cycles

Question 5

Adjuvant chemotherapy indications

Answer 5

Give for all stage IIB-IIIB (T1-3 N1-2)

Consider for high risk stage IB/IIA (T2a-2b N0)
T2a = 3-4cm
T2b = 4-5 cm

Question 6

Adjuvant chemotherapy regimens

Answer 6

Non-squamous: cisplatin + pemetrexed x 4 cycles

Squamous: cisplatin + gemcitabine or docetaxel x 4 cycles

Question 7

Adjuvant osimertinib indication

Answer 7

Completely resected stage IIB-IIIA or high risk IB-IIA with EGFR mutation
Given after adjuvant chemo or alone in patients ineligible for platinum chemo for up to 3 years

FDA approved based on DFS but no OS data yet

Question 8

Unresectable stage II/III treatment

Answer 8

Definitive chemoRT
Consolidation durvalumab for up to 1 year (for patients who complete at least 2 cycles of chemoRT and don’t progress)

Non-squamous:
Carbo/pemetrexed

Squamous:
Carbo/paclitaxel

*If unresectable and not candidate for definitive chemoRT and PD-L1 >= 1%, can give pembro

Question 9

Definitive chemoRT regimens

Answer 9

Weekly carbo/paclitaxel (+/- 2 cycles of carbo/palictaxel after finishing RT)
Cisplatin/etoposide

Question 10

Clinicopathologic features associated with EGFR mutation

Answer 10

Female
East Asian
Never/light smoker
Adenocarcinoma

Question 11

Metastatic squamous cell 1st line treatment (no driver mutation)

Answer 11

PD-L1 >= 50%:

• single agent pembro/atezo/cemiplimab
• carbo/paclitaxel + pembro

PD-L1 < 50%:

• carbo/paclitaxel + pembro
• carbo/paclitaxel + ipi/nivo

Ineligible for IO:
-carbo/cis + gemcitabine/paclitaxel

If response or stable disease, continue IO as maintenance for up to 2 years

Question 12

Metastatic adenocarcinoma 1st line treatment (no driver mutation)

Answer 12

PD-L1 >= 50%:

• single agent pembro/atezo/cemiplimab
• carbo/cis + pemetrexed + pembro
• carbo + paclitaxel + bev + atezo

PD-L1 < 50%:

• carbo/cis + pemetrexed + pembro
• carbo + paclitaxel + bev + atezo

Ineligible for IO:

• carbo + paclitaxel + bev
• carbo/cis + pemetrexed

If response or stable disease, drop carbo/cis/paclitaxel and continue the rest as maintenance for up to 2 years

Question 13

Metastatic adenocarcinoma 2L+ treatment

Answer 13

• Nivo, pembro, or atezo monotherapy if no prior IO
• Docetaxel +/- ramucirumab
• Pemetrexed
• Gemcitabine

Question 14

Metastatic squamous cell 2L+ treatment

Answer 14

• Nivo, pembro, or atezo monotherapy if no prior IO
• Docetaxel +/- ramucirumab
• Gemcitabine

Question 15

Stage for separate tumor nodule in same lobe as primary

Answer 15

T3

Question 16

Stage for separate tumor nodule in ipsilateral lung but different lobe from primary

Answer 16

T4

Question 17

Stage for separate tumor nodule in contralateral lobe

Answer 17

M1a

Question 18

Stage for malignant pleural or pericardial effusion

Answer 18

M1a

Question 19

High risk features for stage IB/IIA

Answer 19

Poorly differentiated histology, including large cell neuroendocrine
Tumor > 4cm
Vascular invasion
Visceral pleural involvement
Wedge resection

Question 20

Pancoast (superior sulcus) tumor T stage

Answer 20

T3

Question 21

Stage IB/IIA definition

Answer 21

IB = T2a N0
IIA = T2b N0

Question 22

N1 definition

Answer 22

Ipsilateral peribronchial, hilar, and intrapulmonary nodes

Question 23

N2 definition

Answer 23

Ipsilateral mediastinal and subcarinal nodes

Question 24

N3 definition

Answer 24

Contralateral mediastinal or hilar, any side scalene or supraclavicular nodes