Sarcomas Flashcards

Question

Retroperitoneal well differentiated or dedifferentiated liposarcoma

Answer 1

Palbociclib

Answer 2

Gemcitabine + docetaxel

Answer 3

-dox -dox + dacarbazine (AD)

Answer 4

Doxorubicin

Answer 5

Doxorubicin + ifos afamitresgene autoleucel

Answer 6

First line: surgery or serial arterial embolization RT if recurrence or inoperable Denosumab -interferon/peginterfeuron can be options

Answer 7

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***

Answer 8

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

Answer 9

-***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

Answer 10

-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

Answer 11

-Cyclophosphamide + topotecan -irinotecan + temozolomide +\- vincristine

Answer 12

-primary therapy is surgery -if unresectable- RT is primary therapy -imatinib -dasatinib -sunitinib Dedifferentiated should be tx as STS

Answer 13

***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

Answer 14

-larotrectinib -entrectinib ***FOR FUSIONS, NOT MUTATIONS***

Answer 15

Dabrafenib + trametinib

Answer 16

High risk: imatinib x3 yr Low risk: imatinib x 1yr 400 mg daily Note: for resectable dx usually adjuvant not neoadjuvant

Answer 17

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)

Answer 18

Imatinib 800 mg/day ***400 mg BID***

Answer 19

Avapritinib- neoadjuvant if resectable and also for metastatic/unresectable Second line: dasatinib

Answer 20

***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

Answer 21

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

Answer 22

Surgery—>RT + adjuvant TZM Anaplastic: EBRT

Answer 23

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!!

Answer 24

***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

Answer 25

***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

Answer 26

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

Answer 27

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)

Answer 28

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

Answer 29

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)

Answer 30

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

Answer 31

TURBT—>one immediate (within ***24h, ideally 6h***) instillation of intravesical ***chemo*** then ***observation*** Low risk= Ta (low grade) solitary and

Answer 32

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)***

Answer 33

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)***

Answer 34

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)***

Answer 35

-radical cystectomy (preferred) -Pembrolizumab ***Intravesical options*** -valrubicin -Gemcitabine -nadifaragene firadenovec ***(select patients)***

Answer 36

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

Answer 37

***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

Answer 38

***Preffered*** -pembro + enfortumab vedotin ***Other*** Gemcitabine + Carboplatin FOLLOWED BY avelumab

Answer 39

***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 40

***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 41

Enfortumab vedotin Or erdafinitib if FGRF 2/3 mutation

Answer 42

-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 43

***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 44

-Partial nephrectomy OR -radical nephrectomy *If grade 4 clear cell +/- sarcomatoid features- ***adjuvant pembrolizumab x1 yr***

Answer 45

-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 46

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 47

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 48

**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 49

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 50

-Good PFS -lung only Mets -good prognosis risk

Answer 51

***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 52

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

Answer 53

-brain directed RT and/or surgery

Answer 54

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

Answer 55

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 56

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 57

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 58

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 59

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 60

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 61

-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 62

***Continue ADT*** -monitoring (preferred) -other secondary HT

Answer 63

***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 64

-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 65

-docetaxel OR -abiraterone OR - enzalutamide ***BRCA mutation*** -Olaparib + abiraterone -Niraparib + abiraterone ***HRR mutation*** -talazaparib + enzalutamide

Answer 66

Docetaxel ***BRCA mutation*** -Niraparib + abiraterone -Rucaparib ***(preferred)*** ***HRR mutation*** -Olaparib ***(preferred)*** -talazoparib + Enzalutamide

Answer 67

Category 1 -abiraterone -enzalutamide Other: Cabazitaxel ***BRCA mutation*** -Olaparib + abiraterone -Niraparib + abiraterone ***HRR mutation*** -talazaparib + enzalutamide

Answer 68

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 69

Radium-223 If no visceral mets

Answer 70

Cabazitaxel + Carboplatin - add GCSF

Answer 71

***continue ADT*** Pembrolizumab

Answer 72

***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 73

Olaparib- indicated after androgen directed therapy Note: it might be better to use chemo first in eligible patients (not clear cut)

Answer 74

-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 75

-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 76

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 77

***Augmentin + cipro*** Others: -augmentin + levo -moxifloxacin ***Note: if pt was getting FQ ppx they will NOT be a candidate for PO abx***

Answer 78

levofloxacin Others: -bactrim -3rd gen CEPH

Answer 79

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 80

Conventional dose 1. TIP q21 days x4- WITH G-CSF -paclitaxel + ifosfamide + cisplatin 2. VeIP q21 days x4- WITH G-CSF -Vinblastine + ifosfamide + cisplatin High dose chemo then ASCT 1. Carboplatin + etoposide 2. Paclitaxel + ifosfamide + Carboplatin + etoposide

Answer 81

1. Carboplatin 700 mg/m2 + etoposide 750 mg/m2 2. Paclitaxel + ifosfamide + Carboplatin + etoposide These are myeloablative ASCT regimens ***followed by ASCT***

Answer 82

1. Gemcitabine + paclitaxel + oxaliplatin 2. Gemcitabine + Oxaliplatin 3. Gemcitabine + paclitaxel 4. Etoposide (oral) ***this is more palliative***

Answer 83

***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 84

***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 85

Primary therapy is surgery -dasatinib -Pazopanib -ivosidenib (IDH1 mutation) If unresectable, metastatic of de-differentiated- tx like osteosarcoma If mesenchymal- tx like Ewings

Answer 86

Osteosarcoma like regimen for neoadjuvant and adjuvant chemo *UPS

Answer 87

Doxorubicin

Answer 88

Surgery (radical orchiectomy) only *older men and rarely metabolize

Answer 89

Surgery only

Answer 90

Optimal cytoreduction: <1 cm residual dx Suboptimal: ***> 1cm*** residual dx *note: can do fertility sparing surgery for stage 1A and 1B

Answer 91

***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 92

***<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 93

-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 94

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 95

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 96

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 97

-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 98

-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 99

**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 100

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 101

***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 102

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 103

***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 104

***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 105

***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 106

-dex + vincristine + calaspargase ***Note: dex in 10+ y/o increases fungal infxns and osteonecrosis***

Answer 107

-steroid (dex <10, pred 10+), vincristine, calaspargase, anthracycline ***Note: dex in 10+ y/o increases fungal infxns and osteonecrosis***

Answer 108

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 109

Peg: >21 y/o Cal:

Answer 110

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 111

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 112

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 113

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 114

-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 115

-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 116

***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 117

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 118

-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 119

-ddMVAC preferred in neoadjuvant setting, either in metastatic setting

Answer 120

Indications withdrawn!! Still in NCCN guidelines

Answer 121

Large tumors (>10cm) or high grade

Answer 122

***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 123

-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 124

***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 125

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

Answer 126

***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 127

-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 128

-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 129

ET + chemo

Answer 130

ET + chemo + trastuzumab ***(if chemo given)*** could be less aggressive if small tumor (<0.5 cm) ***but chemo still and option***

Answer 131

ET + chemo + trastuzumab and Pertuzumab

Answer 132

-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 133

LN +: Chemo ***

Answer 134

Chemo + trastuzumab and pertuzumab

Answer 135

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 136

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 137

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

Answer 138

-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 139

***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 140

Capecitabine- start ***after RT*** -if no residual dx just observation of pembro x9 cycles (only if given neoadjuvant already)

Answer 141

Neoadjuvant: chemo (carbo + taxane) + pembro Adjuvant: pembro *pd-l1 expression not required here (it is required in metastatic setting)

Answer 142

***-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 143

***Trastuzumab + paclitaxel (T1, N0, LN-)*** -THC (docetaxel + carbo + trastuzumab) -TCHP (docetaxel + carbo + trastuzumab + pertuzumab) *pertuzumab if T>2cm or LN+

Answer 144

-if no residual dx or no neoadjuvant treatment: complete 1 year of trastuzumab +/- pertuzumab -if residual dx: ado-trastuzumab emtansine x14 cycles

Answer 145

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

Answer 146

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 147

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 148

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 149

-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 150

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

Answer 151

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

Answer 152

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 153

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 154

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 155

***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 156

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 157

-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 158

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 159

Give chemo first, then RT *notice that chemo is adjuvant not neoadjuvant

Answer 160

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

Answer 161

Neoadjuvant reserved for clinical trials, or highly select pts to avoid more aggressive surgery or amputation Adjuvant- no proven role but ***DECREASES RECURRENCE***

Answer 162

-No definitive role for neoadjuvant: consider if surgical morbidity can be reduced by giving it -Usually it’s just adjuvant

Answer 163

1. Neoadjuvant chemo (if applicable) + HER-2 2. Surgery 3. Adjuvant chemo + HER-2 4. RT and ET +/- abemeciclib (2y) 5. Then PARP-I at least 2 weeks after RT 6. 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 164

Pembrolizumab

Answer 165

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 166

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

Answer 167

Epogen *don’t give if epo lvl>500 Dose is 300 units/kg three times a week ***do before luspatercept***

Answer 168

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

Answer 169

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 170

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

Answer 171

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 172

HMA: azacitadine ***(preferred)***, or decitabine

Answer 173

***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 174

(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 175

CPX-351 (Liposomal Daunorubicin and Cytarabine) Note: AML induction is 28 days

Answer 176

***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 177

***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 178

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 179

-***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 180

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 181

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 182

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 183

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

Answer 184

-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 185

-***CALGB 10403***-Daunorubicin + vincristine + pred + pegAsparginase -***DFCI protocol 00-01***-doxorubicin + vincristine + pred + HD-MTX + pegAsparginase T-cell: -COG AALL0434

Answer 186

***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 187

***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 188

-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 189

-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 190

***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 191

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 192

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

Answer 193

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 194

MDS requiring >20 transfusions and serum ferritin >2500 ng/mL ***goal ferritin <1000***

Answer 195

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

Answer 196

Neuroblastoma, Ewings, brain tumors, germ cell, testicular

Answer 197

***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 198

***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 199

***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 200

***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 201

***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 202

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 203

***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 204

***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 205

***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 206

-nilotinib, dasatinib, bosutinib (Switch to a different one if used before) ***not imatinib*** Same doses as first line

Answer 207

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

Answer 208

-***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 209

***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 210

***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 211

-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 212

1. If BCS 2. 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 213

Venetoclax based regimen preferred over BTK inhibitor

Answer 214

Avoid Ponatinib and dasatinib

Answer 215

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

Answer 216

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

Answer 217

-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 218

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

Answer 219

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 220

***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 -***auto***or allo HCT Note: ensure FL is not transforming to a more aggressive lymphoma

Answer 221

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

Answer 222

-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 223

***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 224

-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 225

***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 226

***>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 227

***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 228

***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 229

***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 230

***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 231

***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 232

-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 233

***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 234

1. ABVDx2 followed by: -AVD x4 (good response-deauville 1-3) -BEACOPP x3-4 +/- ISRT (if poor response- deauville 4-5) 2. 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 235

***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 236

***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 237

-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 238

***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 239

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 240

Observation

Answer 241

-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 242

***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 243

***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 244

***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 245

Surgery: all stages RT: limited role, mostly palliation

Answer 246

***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 247

-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 248

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 249

-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 250

***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 251

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

Answer 252

***LN positive or T>5cm*** -if BCS (as opposed to mastectomy) -consider if close/positive margins

Answer 253

-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 254

***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 255

-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 256

***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 257

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

Answer 258

***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 259

***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 260

***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 261

-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 262

***Preferred*** -Dabrafenib + trametinib (BRAFV600E mutation) -Selpercatinib, pralsetinib (REt fusion) ***Other*** -Carboplatin + paclitaxel -docetaxel + doxorubicin -paclitaxel -doxorubicin ***Clinical trials if able***

Answer 263

***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 264

-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 265

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 266

-surgery (in some cases- ***T1-T2***w/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 267

-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 268

***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 269

***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 270

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 271

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

Answer 272

***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 273

***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 274

***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 275

***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 276

***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 277

***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 278

***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 279

***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 280

***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 281

***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 282

***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 283

***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 284

***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 285

***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 286

***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 287

***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 288

***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 289

***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 290

***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 291

***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 292

***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 293

***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 294

***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 295

***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 296

***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 297

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 298

***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 299

***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 300

***These are grade 1*** BRAF V600E ***mutation*** -Dabrafenib + trametinib -vemurafenib + Cobimetinib BRAF ***Fusion*** -selumetinib ***Subependymal giant cell astrocytoma*** -everolimus

Answer 301

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 302

-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 303

***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 304

Pembro (also for TMB >10) or dostarlimab ***Nivo +/-*** in colorectal Atezolizumab not indicated Other: -NTRK -BRAF V600E: Dabrafenib + trametinib -RET fusion: ***Selpercatinib***

Answer 305

***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 306

Lomustine Double check this

Answer 307

-R-EPOCH -RCHOP (may need RT for residual dx) R/R: -pembro -nivo +/- Brentuximab vedotin

Answer 308

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

Answer 309

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

Answer 310

Bromocriptine - D2 AGONIST, inhibits prolactin release Note: Cushing’s is a common complication of this tumor

Answer 311

NCCN doesn’t discuss- ongoing research Osimertinib has been used after tmz

Answer 312

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 313

Chordoma: imatinib, dasatinib, sunitinib Chondrosarcoma: dasatinib, Pazopanib, ivosidenib (IDH mutation) UPS of bone: osteosarcoma like (AP, MAP)

Answer 314

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 315

***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 316

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

Answer 317

-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 318

Interferon Alfa

Answer 319

Carboplatin + paclitaxel

Answer 320

***Adjuvant*** -capecitabine ***Unresectable or metastatic*** -Gemcitabine + cisplatin + (Durvalumab or pembrolizumab) (preferred) -Gemcitabine + cisplatin ***Subsequent*** -FOLFOX ***Targeted*** -FGFR inhibitors

Answer 321

-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 322

-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 323

No treatment We do prevention strategies like surgery or tamoxifen/ AI ***No RT***

Answer 324

No treatment We do prevention strategies like surgery or tamoxifen/ AI

Answer 325

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

Answer 326

Think SCLC Platinum + etoposide +/- IO

Answer 327

Doxorubicin + Dacarbazine

Answer 328

Treat like small cell lung cancer Mitotic rate or ki67 >20

Answer 329

-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 330

TIP (paclitaxel, ifosfamide, cisplatin)

Answer 331

TIP (paclitaxel, ifosfamide, cisplatin)