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46 Cards in this Set

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NSCLC - Genetic susceptibility loci

6p21, 15q25

Which carry a worse prognosis - mucinous or non mucinous BAC?

Mucinous

NSCLC - T stage>

T1 - <3 (Ia <2, Ib 2-3), T2 - 3-7, (2a 3-5, 2b 5-7), T3 - >7, <2cm carina, invasive, seperate tumor in same lobe


T4 - invasive, carina, different ipsi lobe



NSCLC - stage IIIB is? IIIA?

IIIB - N3, T4N2

IIIA - T0-3N2, T3-4N1, T4N0


NSCLC - stage IIB? IIA? IB?

IIB - T3N0, T2bN1


IIA - T2bN0 T1-T2aN1


IB - T2aN0

NSCLC - newly diagnosed, which patients should undergo PET?

Every newly diagnosed patient

NSCLC - EUS can detect lesions in which stations?

2,4,5,7,8.


Cannot asses 3 or 6


(3mm)

NSCLC - CME can detect lesions at which stations. What are the indications for performing CME and when you can forego it?

CME 2,3,4,7,10.


CME indicated for clinical stage II/III, particulary those potentially requiring pneumonectomy.


Forego in clinical stage I if PET negative for mediastinum

NSCLC - what is the strategy for sampling a patient who might need induction therapy?

EBUS/EUS and if negative CME

NSCLC - when do you use VATS?

For stations which cannot be assessed by CME, for T4 lesions

NSCLC - which patients are classicaly inoperable?

N3, T4 (esp. with N2)

NSCLC - strategy for screening patients prior to surgery

FEV1/DLCO >60% no further testing.


FEV1/DLCO <60% --> V/Q scans to assess postop capacity. Postop capacity <40% --> exercise testing --> predicted VO2 max >15ml/kg can undergo surgery

NSCLC -data regarding IMRT?

IMRT reduces G3-4 rad pnemo 1y 32%-->8%


V5<70% predictive for greater risk of pneumonitis

NSCLC - for early stages, is MLND recommended?>

controversial, but book states it does not increase mortality.


Consider for all cancers except small peripheral ones with PET negative medaistinum

VATS vs thoractomy regarding results and survival?

comparable

NSCLC - centrally located tumors (T3 <2cm carina), whats the preferred surgical approach?

Sleeve lobectomy (rather than pneumonectomy) -- lower mortality, better QOL

NSCLC - minimal N2 vs clinical N2 disease

Minimal - single station, microscopic foci not found on clinical staging,

NSCLC PORT - PORT meta analysis, Italian and Austrian studies. To whom currently recommended

PORT Meta analysis - detremintal effect on survival 2y 55%-->48% (LR rate improved thuogh),


Italian study (stage I) - improved 5yOS 58-->67%


Austrian study (stage I-III) improved 5y recurrence free survival 16-->27%, no OS.


local recurrences improved across trials.


Recommended for positive margins, ECE, inadequate mediastinal resection

NSCLC -adjuvant chemo meta-analysis, CI significant for which stages?


Whats the recommeneded regimen?

5yOS benefit 5%, CI significant only for II and up

Recommended regimen cis-navelbine(mostly studied)

NSCLC - adjuvant chemo IALT - stages, regimens, results

I-IIIA, various cis-based, 5yOS 5% 40->45, 7.5yOS NS(!!), but DFS still.



NSCLC - adjuvant chemo BR10, stages, regimen, results 5y, 9y

IB-II, cis-navelbine, 5yOS 56-->67%, significant only for Ib>4cm.


Note 9yOS and DFS remain significant only for N1 disease

NSCLC - adjuvant chemo ANITA, stages, regimen, results

IB-IIIA, cis navelbine, 5yOS 8.6% benefit, mOS 20 months!!!! 43-->65m

NSCLC -adjuvant chemo CALGB 9633, stages, regimen, results

Ib only, carbo-taxol q3w, long follow up no OS or DFS. subset analysis OS benefit for Ib >4cm

NSCLC - Neoadjuvant CRT for IIIA/IIIB

In general, improve mediastinal clearance and margins but does not affect PFS or OS

NSCLC - definitive CRT vs neoadjuvant CRT+surgery for IIIA disease

Int 0139 - PFS better for surgery 11->21%


EORTC 08941 found no benefit

NSCLC - locally advanced, preferred CRT regimen, benefit

Concurrent CRT (2-4 cycles of platinum baesd, 60Gy), benefit in OS 5% at 3y (18-->23%)

NSCLC - locally advanced, whats the mOS and 5yOS with CRT?

CRT for locally advanced -mOS 17m, 5yOS 20%

NSCLC - metastatic, benefit of chemotherapy vs BSC, recommendations by PS

Metanalysis - y1OS 9% benefit 20-->29%, mOS benefit 1.5m 4.5-->6m.


PS 0-1 platinum doublet


PS 2 single agent


PS 3-4 BSC

NSCLC - metastatic, 4 factors impacting response to chemo

PS, Age>70, female, LDH-Calcium-HB

NSCLC - metastatic, Cis-navelbine vs Cis, Cis-taxol vs Cis-VP, Cis-gemzar vs taxol-gemzar, carbo-taxol vs taxol

Cis-navelbine vs cis 2 months 6->8m


Cis taxol vs cis-vp 2 month 8-10m


Cis gemzar vs taxol gemzar 2 months 7-9m


carbo-taxol vs taxol improved mOS (q3w)

NSCLC- metastatic, carbo-taxol weekly or 3-weekly

same results, weekly less toxic

NSCLC - metastatic TAX 326 taxotere carbo/cis vs cis navelbine

Same survival. better QOL and RR for taxotere regimens

NSCLC - metastatic, cis-alimta vs cis-gemzar

non inferior for general poplulation, for adenocarcinoma alimta benefit 1.5m 10.5-->12m, for SCC alimta detrimental 1.5m 11-->9.5

NSCLC -metastatic, carbo-taxol-avastin, cis-gemzar-avastin

Avastin improved OS, TTP, RR. note 15 treatment related deatsh and 5 fatal pulmonary hemorrhages. Also more hematologic toxicity with avastin.


Cis-gemzar-avastin no OS benefit

NSCLC -metastatic FELX study cis-navelbine-cetuximab

OS benefit 1m, more G3-4 diarrhea, rash.


NOT FDA APPROVED in the book.

NSCLC - metastatic, exclusions for avastin threapy

SCC, brain mets, hemoptysis, PS >1

NSCLC -metastatic IPASS study for Gefitinib vs carbo-taxol. Stratification by EGFR mutation

Asian patients, light/never smokers. non inferiority trial for PFS. 1yPFS 7-->25% for gefitinib.


EGFR mutants significantly longer PFS, EGFR WT significantly worse PFS with gefitinib.

NSCLC - metastatic, old patients and chemotherapy?

Still beneficia. data suggests lower doses of platinum doublets are effective.

NSCLC - metastatic, 6 cycles vs 4 improve what?


Whats the strategy in the book for assessing response during chemo?

TTP. Assess response every 2 cycles

NSCLC metastatic - Maintenance therapy with alimta

Improves PFS 2m and OS 3m 10-13 in adeno only (patients not progressing after induction)

NSCLC metastatic - SATURN study for erlotinib maintenance . Stratification by stable disease or reponse after induction

improves RR(12%), improves OS by 1m (11-12) for general population. Patients with SD after induction benefited OS 9.5-->12 but not those with response 12-12.5m.


FDA approved for non progressors, EMEA approved for SD only

NSCLC - metastatic, 2nd line therapy, whats approved and whats the benefit?

Taxotere, Alimta, oral topotecan - roughly 3m for OS 4.5-->7.5m

NSCLC - metastatic, IDEAL-2 trial - RR, speed of response, also results of trial 2nd-3rd line vs BSC

2nd-3rd line gefitinib , RR 11%, response within 8 days/. When compared to BSC no benefit in OS or PFS

NSCLC -metastatic, BR21 trial erlotinib vs BSC

2nd-3rd line, RR 9% vs 1%, OS benefit 2m 4.5-->6.5m

NSCLC - metastatic, INTEREST study gefitinib vs docetaxel 2nd line. also stratification by EGFR mutation

gefitinib non inferior in RR, OS. better QOL with gefitinib. When stratified by mutation - EGFR mutatnts PFS 3m advantage 4-7m


NSCLC - EGFR relation with KRAS, ALK. response by specific mutations

EGFR mutation mutually exclusive with KRAS or ALK mutation. Exon 19del better response and survival than L858R exon 21.