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WorksheetsStevich - Lung Cancer
Total questions: 52
Worksheet time: 52mins
Different molecular abnormalities in the pathogenesis of lung cancer
KRAS
EGFR
ALK
Mutations causing
Activation of proto-oncogenes
Inhibition of tumor suppressor genes
Production of autocrine (self-stimulatory) growth factors
Non-Small Cell Lung Cancer (NSCLC)
Overexpresses C-KIT, a protein tyrosine kinase receptor that is specific for stem cell factor
Different mutations acting as targets in: EGFR and ALK
Epidermal Growth Factor Receptor (EGFR)
Anaplastic Lymphoma Kinase (ALK)
Small Cell Lung Cancer (SCLC)
Overexpresses C-KIT, a protein tyrosine kinase receptor that is specific for stem cell factor
Different mutations acting as targets in: EGFR and ALK
Epidermal Growth Factor Receptor (EGFR)
Anaplastic Lymphoma Kinase (ALK)
EGFR inhibitors used to treat NSCLC and offer potential method of lung cancer chem-prevention include:
Erlotininb
Gefitinib
Afatinib
Dacometininb
Osimertinib
Drugs that target the EML4-ALK pathway important for treatment of NSCLC adenocarcinoma
Erlotininb
Crizotinib
Ceritinib
Alectinib
Brigatinib
Less common, can drive tumor growth, can be targeted with TKIs
BRAF
NTRK
ROS1
ALK
Different agents tested for screening
NSAIDs
retinoids
inhaled glucocorticoids
Vitamin E
Selenium
Two major types of lung cancer
Non-Small Cell Lung Cancer (NSCLC)
Small-Cell Lung Cancer (SCLC)
Non-Small Cell Lung Cancer
Slower growth rate and doubling time than SCLC
Different types and subtypes
Small cells with round to oval nuclei
Aggressive and rapidly growing
Small Cell Lung Cancer (SCLC)
Slower growth rate and doubling time than SCLC
Different types and subtypes
Small cells with round to oval nuclei
Aggressive and rapidly growing
Paraneoplastic syndrome
Weight loss, hypercalcemia
Cushing's syndrome
Syndrome of inappropriate secretion of antidiuretic hormone
Pulmonary hypertrophic osteoarthropathy
Anemia
Paraneoplastic syndrome: Commonly in small cell lung cancer
Weight loss, hypercalcemia
Cushing's syndrome
Syndrome of inappropriate secretion of antidiuretic hormone
Pulmonary hypertrophic osteoarthropathy
Anemia
Extrapulmonary signs and symptoms
Bone pain and/or pathologic fractures
Liver dysfunction
Neurologic deficits
Spinal cord compression
Diagnosis and staging of lung
History and physical examination
Laboratory testing
Tissue sampling for pathologic assessment: Sputum cytology, biopsy
Radiologic imaging: Endobronchial Ultrasound, Computed Tomography (CT), Positron Emission Tomography (PET), integrated CT-PET
Diagnosis and staging of lung cancer: Non-Small Cell Lung Cancer
TNM staging
Stages l-lV
Limited stage
Extensive stage
Diagnosis and staging of lung cancer: Small Cell Lung Cancer
TNM staging
Stages l-lV
Limited stage
Extensive stage
Metastatic sites
Lymph
Brain
Bone
Liver
Adrenal Gland
Non-Small Cell Lung Cancer
More common than SCLC
Less common than SCLC
Slower growing
Moderately sensitive to radiation
Low sensitivity to chemotherapy
Non-Small Cell Lung Cancer common histologic types
Adenocarcinoma
Squamous cell
Large cell carcinoma
Small cell carcinoma
NSCLC: Stage 1A and 1B treated with
Surgery alone
If complete resection achieved --> adjuvant therapy is not routinely recommended
May receive adjuvant chemotherapy
Primary treatment is surgery and follow by adjuvant chemotherapy
Most positive data with platinum-based regimens: cisplatin/etoposide, cisplatin/vinorelbine, cisplatin/paclitaxel, cisplatin/pemetrexed
NSCLC: 1B tumors and high risk features
Surgery alone
If complete resection achieved --> adjuvant therapy is not routinely recommended
May receive adjuvant chemotherapy
Primary treatment is surgery and follow by adjuvant chemotherapy
Most positive data with platinum-based regimens: cisplatin/etoposide, cisplatin/vinorelbine, cisplatin/paclitaxel, cisplatin/pemetrexed
NSCLC: Stage llA and llB
Surgery alone
If complete resection achieved --> adjuvant therapy is not routinely recommended
May receive adjuvant chemotherapy
Primary treatment is surgery and follow by adjuvant chemotherapy
Most positive data with platinum-based regimens: cisplatin/etoposide, cisplatin/vinorelbine, cisplatin/paclitaxel, cisplatin/pemetrexed
NSCLC: Stage lll locally advanced disease
Treatment best planned by multidisciplinary team
Highly individualized
Patient's preferences considered
Optimal outcomes utilizes multimodality therapy including systemic chemotherapy
NSCLC: Stage lll locally advanced disease is an option is radiation instead of surgery?
Radiation: local treatment modality combined with chemotherapy
True
False
NSCLC: Stage lll locally advanced disease
lllA not surgical candidates or if tumor that cannot be resected, and almost all stage lllB patients
lllB not surgical candidates or if tumor that cannot be resected, and almost all stage lllA patients
NSCLC: Stage lll locally advanced disease --> lllA not surgical candidates or if tumor that cannot be resected, and almost all stage lllB patients
True
False
NSCLC: Stage lll locally advanced disease......What considered unresectable?
Stages lllB and lllC
Stages lllA and lllB
NSCLC: Stage lll locally advanced disease......If no surgical candidates
Then concurrent chemotherapy and radiation
Treat like stage lV disease
NSCLC: Stage lll locally advanced disease......If not candidates for radiation
Then concurrent chemotherapy and radiation
Treat like stage lV disease
NSCLC: Stage lll locally advanced disease......If not candidates for radiation
Followed by consolidation therapy with durvalumab (PD-L1 inhibitor)
Durvalumab not used if patient undergoes surgical resection
NSCLC: Stage lV and relapsed disease.
For ECOG performance status of 2 or significant comorbidities recommended less intensive therapy (eg single agent therapy)
True
False
NSCLC: Stage lV and relapsed disease.
Three pathways identified for advanced NSCLC
1. Immune sensitive (PD-L1+)
2. Targetable genetic mutation-driven divided based on the mutation (EGFR, ALK, BRAF, NTRK, and ROS1)
3. Nonbiomarker-driven treatment divided into squamous histology or nonsquamous histology due to drug toxicity and efficacy
NSCLC: Stage lV and relapsed disease.
Squamous histology usually ____ targetable genetic mutation; testing for mutations optional
Not have
Have
NSCLC: Stage lV and relapsed disease.
No mutations/PD-L1 negative main chemotherapy is platinum-based (cisplatin or carboplatin with docetaxel or vinorelbine)
True
False
NSCLC: Stage lV and relapsed disease.
_____ for nonsquamous histology
Bevacizumab
Vinorelbine
NSCLC: Treatment - Genomics
-PD-L1 inhibitors
Pembrolizumab
Atezolizumab
Cemiplimab
Nivolumab + Ipilimumab
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-EGFR Exon 19 Deletion or EGFR l858R mutation:
Afatinib
Osimertinib
Erlotinib
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-ALK rearrangements
Alectinib
Brigatinib
Loraltinib
Crizotinib
Enterctinib
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-ROS1 rearrangements
Alectinib
Brigatinib
Loraltinib
Crizotinib
Enterctinib
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-BRAF V600E mutation
Trametinib
Dabrafenib
Capmatinib
Tepotinib
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-RET rearrangement
Selpercatinib
Pralsetinib
Larotrectinib
Sotorasib
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-NTRK Gene Fusion Positive
Selpercatinib
Pralsetinib
Larotrectinib
Sotorasib
NSCLC: Treatment - Selected Oral Therapies for Advanced, Mutation Driven NSCLC.
-KRAS G12C Mutation
Selpercatinib
Pralsetinib
Larotrectinib
Sotorasib
Small Cell Lung Cancer Treatment: Limited Stage
Radiation preferred over surgery
Radiation combined with concurrent chemotherapy
Chemotherapy: Cisplatin-etoposide
Can substitute cisplatin for carboplatin
Carboplatin less N/V, nephrotoxicity, neurotoxicity, more myelosuppression (thrombocytopenia)
SCLC treatment: Side effect nephrotoxicity
Cisplatin
Etoposide
Bevacizumab
PD/PD-L1 inhibitor
SCLC treatment: Side effect hypotension
Cisplatin
Etoposide
Bevacizumab
PD/PD-L1 inhibitor
SCLC treatment: VEGF inhibitor --> side effects: bleeding, impaired wound healing, hypertension, proteinuria
Cisplatin
Etoposide
Bevacizumab
PD/PD-L1 inhibitor
SCLC treatment: VEGF inhibitor --> immunotherapies and side effects: immune reactions
Cisplatin
Etoposide
Bevacizumab
PD/PD-L1 inhibitor
What is the difference between Non-Small Cell Lung Cancer (NSCLC) and Small Cell Lung Cancer (SCLC)
NSCLC staged using TNM staging system and there are four stages (l-lV)
NSCLC is staged only in two stages limited and extensive stage
Bevacizumab should be used for the treatment of non-small cell lung cancer with which of the following?
Nonsquamous histology
Squamous histology
A 76 YO patient is diagnosed with non-small cell lung cancer with expression of ROS1 rearrangements. This patient is a candidate for which of the following targeted agents for the treatment of lung cancer?
Crizotinib
Erlotinib
