Lung Cancer-1

Summary:

  1. B. Yes, she is a candidate for an annual chest CT
  2. d. Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV Days 1-3 and atezolizumab 1200 mg IV Day 1 Q 21 days x 4 cycles followed by atezolizumab 1200 mg IV Day 1 Q 21 days
  3. a. Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV days 1-3 every 21 days
  4. A. Lurbinectedin 3.2 mg/m2 IV Day 1 Q 21 days (for relapsed/refractory SCLC)
  5. B. Refer to Radiation Oncology for possible stereotactic brain radiation
  6. c. Cisplatin and pemetrexed
  7. a. Pembrolizumab
  8. a. Drain the fluid
  9. C. Cisplatin and pemetrexed for 4 cycles, followed by atezolizumab for 1 year
  10. d. EGFR:Osimertinib
  11. C. Ondansetron 8 mg IV plus dexamethasone 12 mg PO plus olanzapine 5 mg PO (Acute)
  12. B. Dexamethasone 8 mg PO daily on days 2 to 4 plus olanzapine 5 mg PO daily on days 2 to 4 (Prevention)
  13. A. Metoclopramide 10 mg PO every 6 hours
  14. B. Dexamethasone 8 mg PO daily days 5 and 6 (Delayed)
  15. C. Poor nausea control with prior chemotherapy
  16. A. Palonosetron 0.25 mg IV plus dexamethasone 12 mg PO plus olanzapine 5 mg PO (Acute)
  17. B. Dexamethasone 8 mg PO daily on days 2 to 4 plus olanzapine 5 mg PO daily on days 2 to 4 (Prevention)
  18. A. Lorazepam 0.5 mg PO every 6 hours
  19. C. Alectinib: Myalgias
  20. A. Cemiplimab
  21. D. Concomitant use of proton pump inhibitors with sotorasib should be avoided.
  22. C. Docetaxel and ramucirumab
  23. C. Dexamethasone, diphenhydramine, and acetaminophen
  24. A) B.carotene & selenium has a no rule in lung cancer prevention
  25. B. Carboplatin + pemetrexed + pembrolizumab × 4 cycles followed by maintenance pemetrexed + pembrolizumab
  26. A. Tobacco use
  27. D.Nivolumab plus ipilimumab
  28. B. patient should receive vit B12 IV/IM every 9 weeks plus folic acid 350 mcg PO daily 3 weeks before treatment and continue these medications for 3 weeks after treatment
  29. D. Do not give cisplatin until CrCl ≥60 ml/min
  30. C. stop drug if baseline SBP is 135 and it decreased to 100 after 5 mins of infusion (Amifostine)
  31. A Hold pembrolizumab until AD’s symptoms return to baseline. Start levothyroxine and recheck TSH/T4 in 6 weeks (55%)
  32. B Lorlatinib (35%)
  33. A Carboplatin/paclitaxel (76%)
  34. C Ceritinib (62%)
  35.  D (All of the above)
  36. B Lung cancer (94%)
  37. A Pembrolizumab, Carboplatin, Pemetrexed (48%)
  38. C Cisplatin/etoposide (62%)
  39.  Carboplatin/paclitaxel/bevacizumab (66%)
  40. D Chemotherapy and radiation (61%)
  41. B Surgery and adjuvant cisplatin/ vinorelbine (68%)
  42. A Crizotinib (91%)
  43. B 10–15% (34%)
EXAM QUESTIONS

MD is a 66-year-old retired schoolteacher, caring for her father with Alzheimer’s disease. At her annual visit to her primary care provider, her provider discusses lung cancer screening options with MD. MD started smoking at age 14, and quit at age 64 when she moved her father into her home. She smoked approximately 1 pack per day.

Is MD a candidate for lung cancer screening?

  • A. Yes, she is a candidate for an annual chest X-ray
  • B. Yes, she is a candidate for an annual chest CT
  • C. No, she stopped smoking two years ago
  • D. No, because she smoked < 2 packs per day

The correct answer is B

MD should be commended on her decision to stop smoking. The risk of lung cancer decreases over time after smoking cessation. MD is also a candidate for annual screening for lung cancer with CT based on the USPTF and NCCN guideline criteria. She meets the inclusion criteria, similar to patients included in the NLST trial: her age is 66 years old and she has a 50 pack year smoking history. She does not have any unmanaged comorbid conditions and appears motivated to seek treatment. While screening will not help to prevent MD from developing lung cancer, it could reduce her risk of mortality due to the possibility of early detection of disease.

MD is a 69-year-old retired nurse who is at her annual wellness visit with her primary care provider. Her provider discusses lung cancer screening options with MD.

MD started smoking at age 20 and quit smoking at age 42. She smoked 1 pack per day at the time when she quit.

Is MD a candidate for lung cancer screening based on the NCCN Lung Cancer Screening Guidelines?

  • A. Yes, she is a candidate for an annual chest X-ray
  • B. Yes, she is a candidate for an annual chest CT
  • C. No, she stopped smoking
  • D. D. No, because she smoked < 2 packs per day

The correct answer is B

MD quit smoking and she should be commended for her decision to stop smoking and continue smoking cessation. The risk of lung cancer decreases over time after smoking cessation.

MD is also a candidate for annual screening for lung cancer with CT based on the NCCN© guideline criteria. She is greater than 50 years of age and has a greater than 20 pack year history of smoking at 22 pack-year history. Chest X-rays are not recommended as screening strategies and she would meet NCCN guideline screening recommendations.

HN is a 62-year-old man in the emergency room.

HPI: HN’s family brings him to the ED because he is disoriented. His family reports he received azithromycin for bronchitis 2 weeks ago, hasn’t been eating, and has experienced a 15-pound weight loss in the last 3 weeks.

  • PMH: Hypertension
  • FH/SH: Smoked two packs and a day for 25 years, quit 7 years ago. Social alcohol use.
  • Physical Exam: ECOG performance status 1
  • Normal except for:
    • General: Confused
    • Neck: Extensive lymphadenopathy
    • Lung: Normal respiratory effort, speaking in full sentences. (+) Rhonchi with expiratory wheezes.
    • Neuro: Alert and oriented x 1, gait is unstable

Laboratory: Na 126, Cl 104, WBC 6.5, K 4.6 BUN 18, ANC 3.4, SCr 0.86, Bilirubin 1.2, Platelets 238, ALT 68, AST 45

CT further reveals 4.3 x 3.2 x 4.6 cm right lower lobe mass, extensive lymphadenopathy throughout the neck and chest as well as innumerable liver metastasis. He undergoes a MRI which is negative. Based on the CT findings, a lung biopsy was performed and pathology results were conclusive for SCLC. He has extensive stage SCLC due to the presence extensive lymphadenopathy within the neck as well as innumerable liver metastasis.

Which treatment option is most appropriate for HN at this time?

The correct answer is D

HN does not have limited stage SCLC, where concurrent chemotherapy with radiation therapy would be the treatment of choice, so option C is incorrect. He should receive chemotherapy with immunotherapy followed by immunotherapy maintenance because this is considered to be a category 1, preferred regimen in the NCCN Guidelines, making options A incorrect Option B contains combination chemotherapy with immunotherapy, however the dosing schedule is incorrect for the combination with chemotherapy and should be every 21 days followed by durvalumab 1500 mg IV day 1 every 28 days. A carboplatin-based regimen was preferred due to the SIADH diagnosis. HN tolerated chemotherapy well after receiving appropriate antiemetics. No G-CSF was used. His SIADH improved with chemotherapy.

HN completed 4 cycles of chemoimmunotherapy and was restaged with a PET/CT which showed stable disease. He proceed with immunotherapy maintenance with atezolizumab every 21 days. 10 months into maintenance therapy, HN called the clinic complaining of increasing shortness of breath. CT confirms disease recurrence.

Given disease progression after 10 months of therapy, what is the appropriate treatment regimen for HN?

The correct answer is A

Now HN has recurrent extensive stage SCLC with performance status of 0. He is to receive carboplatin AUC 5 IV day 1 and etoposide 100 mg/m2 IV days 1-3. Plan for 4 cycles, then reassess.

A. He may be re-treated with a platinum agent and etoposide since 10 months had elapsed since his last chemotherapy, indicating his disease is platinum sensitive. Since HN progressed on maintenance atezolizumab therapy, he would not be eligible for additional immunotherapy. There is no data to support switching to an alternate immunotherapy at the point of recurrence on maintenance therapy with a different immunotherapy agent.

Use of irinotecan or cisplatin/irinotecan is not the best answer as HN’s recurrence was > 6 months from first-line therapy, it would be preferred to repeat that previous regimen.

HN’s CT scan after 4 cycles showed a partial response to therapy, and he elected to undergo active surveillance.

He returns 1 month later after completing his fourth cycle of treatment with new complaints of cough, blood-tinged sputum, dyspnea, and chest pain. Upon work-up, it is determined that HN has disease progression within the chest and liver. His ECOG performance status remains 1-2.

What is the most appropriate treatment option for HN’s recurrent extensive stage SCLC?

The correct answer is A

Lurbinectidin is approved for relapsed/refractory SCLC. Topotecan, both oral and intravenous formulations, is recommended as an option for single agent therapy for relapsed disease that is platinum resistant, however the dose recommended in option D is for IV administration and not PO administration. Options B and C are incorrect as HN should not receive another platinum-based doublet as he has seen 2 cycles with platinum therapy and he is now has platinum resistant disease. Option C is incorrect and he has already received etoposide therapy twice and switching to a different active agent would be most appropriate.

Plan for salvage therapy with lurbinectedin 3.2 mg/m2 IV day 1 every 21 days. Monitoring to include complete blood count checks prior to each cycle to ensure that HN has an ANC of greater than or equal to 1500/mm3 and platelets greater than or equal to 100,000/mm3. Additionally close monitoring of LFTs given the patients baseline liver disease in addition to recommended dose reductions associated with observed liver elevations while receiving lurbinectedin.

SJ is a 72-year-old man in the emergency room. HPI: SJ’s family brings him to the ED because he is disoriented. His family reports he received azithromycin for bronchitis 2 weeks ago, hasn’t been eating, and has experienced a 15-pound unitentional weight loss in the last 3 weeks.

  • PMH: Hypertension
  • FH/SH: Smoked two packs and a day for 20 years, recently decreased to ½ a pack per day in the last month. Social alcohol use.
  • Physical Exam: Wt: 72 kg Ht: 165 cm ECOG performance status 1
  • Normal except for:
    • General: Confused
    • Neck: Extensive lymphadenopathy
    • Lung: Normal respiratory effort, speaking in full sentences. (+) Rhonchi with expiratory wheezes.
  • Neuro: Alert and oriented x 2
  • Laboratory: Na 126, Cl 104, WBC 6.5, K 4.6, BUN 28, ANC 3.4, SCr 1.5, Bilirubin 1.2, Platelets 238, ALT 68, AST 45, CrCL (using C-G) 45 mL/min

CT abdomen/pelvis/chest further reveals 3.3 x 3.2 x 4.6 cm right lower lobe mass, extensive lymphadenopathy throughout the neck and chest as well as innumerable liver metastases. He undergoes a brain MRI which is negative for metastatic lesions. Based on the CT findings, a lung biopsy was performed and pathology results were conclusive for small cell lung cancer. He has extensive stage SCLC due to the presence of extensive lymphadenopathy within the neck as well as innumerable liver metastases.

Which treatment option is most appropriate for HN at this time?

The correct answer is D.

  • SJ does not have limited stage SCLC, where concurrent chemotherapy with radiation therapy would be the treatment of choice, so option A is incorrect.
  • He should receive chemotherapy with immunotherapy followed by immunotherapy maintenance because this is considered to be a category 1, preferred regimen in the NCCN Guidelines, making options B incorrect.
  • HN also has impaired kidney function with an estimated CrCL of 45 mL/min making cisplatin a less than optimal option in the extensive stage setting.
  • Option C contains combination chemotherapy with immunotherapy, however the dose of etoposide should be adjusted for the patient’s current kidney function of less than 50 mL/min warranting a 25% dose reduction, as well as the schedule is incorrect for the combination with chemotherapy and should be every 21 days followed by durvalumab 1500 mg IV day 1 every 28 days.
  • A carboplatin-based regimen was preferred due to the SIADH diagnosis and current kidney function. HN tolerated chemotherapy well after receiving appropriate antiemetics. No G-CSF was used. His SIADH improved with chemotherapy.

SJ completed 4 cycles of chemoimmunotherapy and was restaged with a PET/CT, which showed stable disease. He proceeded with immunotherapy maintenance with atezolizumab every 21 days. He developed pneumonitis following his 6th cycle of atezolizumab and immunotherapy was stopped while continuing with regular CT scans for evaluation of disease progression.

4 months after stopping his immunotherapy treatment a routine CT scan shows stable disease in the lungs and liver but SJ shares in the office his balance is altered and has daily headaches. A brain MRI was obtained and found to have 4 lesions in his brain with localized edema surrounding the lesions.

Given his most recent CT and Brain MRI, what is the most appropriate treatment for SJ at this time?

The correct answer is B.

Now SJ has recurrent extensive stage SCLC. SJ has symptomatic brain metastasis with stable systemic disease. The most appropriate treatment at this time would be to refer SJ to radiation oncology for evaluation for stereotactic radiation treatment and following with routine CT scans. The addition of etoposide chemotherapy at this time would not be recommended as his progression is localized at this time to the brain. The role of lurbinectedin is in patients with disease relapse less than or equal to 6 months and SJ has continued to have stable disease 6 months after immunotherapy discontinuation. Additionally, lurbinectedin was studied in patients without brain metastasis and given this patient has disease progression exclusively in the brain this therapy would not be appropriate. Restarting chemoimmunotherapy at this time would not be recommended given the only site of disease progression is in the brain, in addition to having to hold immunotherapy treatment secondary to Grade 3 pneumonitis

He returns 3 months after completing his stereotactic radiation to his 4 brain lesions and shares new complaints of cough, blood-tinged sputum, dyspnea, and chest pain. Upon work-up, it is determined that SJ has disease progression within the chest and liver. His ECOG performance status remains 1.

What is the most appropriate treatment option for HN’s recurrent extensive stage SCLC?

The correct answer is B

  • Pembrolizumab is incorrect as the dose/schedule is incorrect and should be either 200 mg every 21 days or 400 mg every 42 days. Additionally caution should be taken with resuming immunotherapy following a prior discontinuation of treatment secondary to pneumonitis with the initial treatment.
  • Lurbinectedin is a treatment option for patients who relapse following initial treatment as another recommended regimen per the NCCN guidelines. Given the patient’s good performance status and length of response with initial platinum doublet therapy and no contraindications for use at this time it would be preferred to rechallenge with Carboplatin and Etoposide.
  • Topotecan, both oral and intravenous formulations, is recommended as an other recommended regimen by NCCN guidelines for single agent therapy for relapsed disease that is platinum resistant and relapses less than or equal to 6 months following treatment, however the dose provided is for the IV route rather than the oral route and this patient’s disease would be classified as platinum sensitive.

FS is a 48- year--old woman with complaints of a persistent dry cough that has not improved with antibiotics and cough suppressants.

  • HPI: FS presented to her family practice physician 1 month ago with same complaints, treated for bronchitis with levofloxacin for 7 days.
  • PMH: Hypothyroidism
  • FH/SH: Smoked - 12 pack year history, quit 10 years ago. Social alcohol use.
  • Drug History: NKDA, levothyroxine 88 mcg PO daily
  • ECOG: 0
  • Laboratory: Serum creatinine (SCr) 0.55
  • Patient work-up:
    • CXR: Left lower lobe mass
    • CT scan – chest 1.4 cm x 2.2 cm left lower lobe density
    • CT scan of abdomen, pelvis: negative
    • Brain MRI: negative
    • Bone scan: negative

CT guided biopsy of left lower lobe lung nodule revealed poorly differentiated non-small cell carcinoma, adenocarcinoma histology. Tumor tissue was negative for any driver mutations.

Staging: T1bN1M0 (one positive ipsilateral hilar lymph node); Stage IIA

Treatment: Curative intent resection

Based on the data, which adjuvant treatment regimen would be most appropriate for FS?

The correct answer is C

  • Adjuvant chemotherapy for stage II should be cisplatin-based. A carboplatin-based doublet would be appropriate in the palliative setting or in patients that are unable to tolerate cisplatin.
  • Option D is incorrect based on the use of carboplatin, rather than cisplatin.
  • Option B is incorrect as immunotherapy in the setting of early stage disease is not recommended.
  • Option A is also incorrect as observation is not supported by NCCN guidelines given the stage of disease and the FS’s performance status suggesting adjuvant chemotherapy would be appropriate.

Stage IIA NSCLC – first-line treatment with cisplatin 75 mg/m2 and pemetrexed 500 mg/m2 IV Day 1 every 21 days X 4 cycles after surgical resection.

CT scan at 3 months post adjuvant therapy demonstrates disease recurrence in the right lung, Bone scan shows multiple bony lesions in the ribs, pelvis and lumbar spine, Repeat biopsy reveals: Adenocarcinoma (EGFR negative, ALK negative, PD-L1 80%). FS now has recurrent, metastatic NSCLC.

What is the most appropriate next line of treatment for FS?

Answer A is the best answer

  • She is negative for mutations. The next best option is treatment with PD-1 directed therapy as her repeat biopsy was evaluated for PD-L1 expression and found to be greater than 50%. Based on KEYNOTE-024, single-agent pembrolizumab is appropriate to administer for this patient.
  • Option B is incorrect since the patient received pemetrexed in the first line setting and has progressive disease, so pemetrexed in the second line setting would not be appropriate.
  • Option C is incorrect as the use of nivolumab in the first line setting for a newly metastatic NSCLC patient is not indicated.
  • Option D is incorrect as immunotherapy with nivolumab has been shown to improve median PFS over docetaxel therapy and she has yet to fail an immunotherapy agent.

FS returns to the office following initiation of immunotherapy. She reports increased symptoms of shortness of breath as well as rib pain. A chest x-ray is obtained to rule out pneumonia, immune-mediated pneumonitis as well as potential pleural effusion. The radiologist calls the clinic to let the team know that her x-ray shows a new pleural effusion.

What plan would you recommend for FS?

  • a. Drain the fluid
  • b. Placement of chest tube on wall suction
  • c. Place a small pigtail catheter in the chest wall
  • d. Pleurodesis with doxycycline

Answer A is correct.

Thoracentesis is appropriate for initial management of the effusion. The need for a chest tube or pleurodesis with doxycycline would be determined by the rate and volume of further fluid re-accumulation.

A therapeutic tap was performed and fluid was sent for gram stain, cytology, hematology, and chemistry. The results showed the fluid to be exudative in nature (LDH 240) and the cytology was consistent with lung cancer. 1 liter total is drained and FS experiences good symptomatic relief. FS is discharged to continue receiving chemotherapy in the outpatient setting.

EM is a 58-year-old woman with complaints of a persistent dry cough that has not improved with antibiotics and cough suppressants.

  • HPI: EM presented to her family practice physician 1 month ago with same complaints, treated for bronchitis with levofloxacin for 7 days.
  • PMH: Hypothyroidism
  • FH/SH: 10 pack-year smoking history, quit 20 years ago. Social alcohol use.
  • Drug History: NKDA, levothyroxine 88 mcg PO daily
  • ECOG: 0
  • Laboratory: Serum creatinine (SCr) 0.55
  • Patient work-up:
    • CXR: Left lower lobe mass
    • CT scan – chest 1.4 cm x 2.2 cm left lower lobe density
    • CT scan of abdomen, pelvis: negative
    • Brain MRI: negative
    • Bone scan: negative

CT guided biopsy of left lower lobe lung nodule revealed poorly differentiated non-small cell carcinoma, adenocarcinoma histology. Tumor tissue was negative for ALK rearrangements, EGFR pathogenic alterations and PD-L1 was 50%.

Staging: T1bN1M0 (one positive ipsilateral hilar lymph node); Stage IIA

Treatment: Curative intent resection

Based on the data, which adjuvant treatment regimen would be most appropriate for FS?

The correct answer is C.

Adjuvant chemotherapy for stage II should be cisplatin-based. A carboplatin-based doublet would be appropriate in the palliative setting or in patients that are unable to tolerate cisplatin. Option D is incorrect based on the use of carboplatin, rather than cisplatin. Option B is incorrect as nivolumab in combination with chemotherapy is only approved for neoadjuvant treatment, not adjuvant treatment. Option A is also incorrect as osimertinib is only approved in the adjuvant setting for patients with EGFR (exon 19del, L858R) positive disease, EM is not EGFR positive. EM is a candidate for adjuvant chemotherapy and the use of cisplatin in combination with pemetrexed followed by atezolizumab would be most appropriate as the patient has PD-L1 of 50% which is ≥ 1%. Based on IMpower010 the addition of atezolizumab following adjuvant chemotherapy improved disease free survival.

DG is 73- year-old female (never smoker) that presents to the ED with a chronic cough and progressive shortness of breath.

HPI: Chest X-ray shows large spiculated mass in the right upper lobe suspicious for lung cancer

Based on the data given, which of the following mutations is DG most at risk for and has the most appropriate first- line treatment for said mutation according to NCCN guidelines?

DG is 73-year-old female (never smoker) that presents to the ED with a chronic cough and progressive shortness of breath.

HPI: Chest X-ray shows large spiculated mass in the right upper lobe suspicious for lung cancer

Pathology: consistent with NSCLC (adenocarcinoma)

Based on the data given, which of the following mutations is most likely associated with DG’s cancer and has the most appropriate first- line treatment for said mutation according to NCCN© guidelines?

The correct answer is D (EGFR: Osimertinib)

Patient is a female, never smoker which are common patient characteristics of the EGFR mutation. Non-smokers are associated with the development of ALK and ROS1 gene rearrangements as well, but since this patient is 73-years old, the likelihood of these mutations is decreased. ROS1 can be managed with lorlatinib however first line therapy would be either crizotinib or entrectinib. Capmatinib is approved for patients with MET exon 14 skipping mutations. EGFR first line preferred therapy is osimertinib, and afatinib is listed as “other recommended”.

DM is a 37-year-old female (never smoker) that presents to the ED with progressive shortness of breath and overall feeling unwell. Two weeks ago she completed a half marathon with no issues. An infectious workup was completed and all results were negative. A CT scan was obtained and shows innumerable lung lesions and pleural effusion concerning for metastatic disease.

Pathology was obtained and she is found to have NSCLC, adenocarcinoma (EGFR mutation negative, ALK rearrangement positive, RET rearrangement negative, MET 14 skipping mutation negative, PD-L1 55%)

Based on the data given, which of the following is the most appropriate first line treatment for DM and is matched with the appropriate adverse effect?

The correct answer is C (Alectinib:Myalgias)

The most appropriate first line treatment for ALK positive metastatic NSCLC would be lorlatinib, alectinib, or brigatnib as preferred, category 1 NCCN guideline recommendations.

  • Crizotinib is an option as other recommended first line treatment for ALK positive NSCLC however this patient has not contraindications to preferred first line treatment.
  • Lorlatinib is inappropriately associated with acneiform rash which is a common adverse effect of EGFR therapy and not ALK therapy. Crizotinib does have a warning/precaution for bradycardia, however would not be preferred treatment for this patient.
  • Brigatinib has not been associated with mood disorders, rather lorlatinib has a warning/precaution for CNS effects. Alectinib has an overall incidence of > 29% and myalgias.

SW is a 65-year-old male with newly diagnosed Stage IV NSCLC. He presents to the medical oncologist for discussion of treatment options and final results from his pathology. A year ago his PCP recommended he obtain a LD-CT as part of lung cancer screening where he was found to have a suspicious lesion. He was lost to follow-up and returned to his PCP 3 weeks ago with worsening cough and shortness of breath and new hip pain. A CT was obtained and found to have continued growth in the previously identified lung lesion as well as several lytic bone lesions and liver metastasis. He has completed palliative radiation to the hip lesion given his reports of severe pain.

Pathology: Squamous NSCLC (EGFR negative, ALK negative, EGFR exon 20 mutation negative, KRAS G12C positive, RET rearrangement negative, MET skipping mutation negative, PD-L1 88%)

What is the most appropriate treatment for SW at this time?

Answer A is the best answer.

He is negative for first line targetable mutations. The next best option is treatment with PD-1 directed therapy as his biopsy was evaluated for PD-L1 expression and found to be greater than 50% at 88%. Based on EMPOWER-Lung 1, single-agent cemiplimab is appropriate to administer for this patient. Option B is incorrect since the patient has squamous cell histology and would not benefit from pemetrexed based chemotherapy additionally the use of bevacizumab is contraindicated in a squamous cell lung cancer patient given the observed increased rates of bleeding complications. Carboplatin, nab-paclitaxel and atezolizumab is not an approved combination and would not be appropriate. While this patient is found to have a KRAS G12C mutation, sotorasib use in the first line setting is not recommended.

He returns to clinic after receiving 9 months of single-agent cemiplimab. His routine CT scan demonstrated increased size in his lung lesion as well as worsening liver metastasis. Given his pathology results at diagnosis, he was started on sotorasib treatment.

Which of the following is true regarding sotorasib treatment?

  • A. More than 50% of patients observed an objective response while taking sotorasib on the CodeBreaK 100 trial.
  • B. Sotorasib is effective for several KRAS mutations given its broad binding effect with the RAS pathway
  • C. Sotorasib can cause QTc prolongation and should be monitored closely if taking with other QT prolonging medications.
  • D. Concomitant use of proton pump inhibitors with sotorasib should be avoided.

Answer D is the best answer.

CodeBreaK100 trial demonstrated for the first time that KRAS targeting with sotorasib improved ORR. While an improvement in ORR was observed it was only 37.1% (95% CI: 28.6 – 46.2) which makes option A incorrect as it was not more than 50% ORR. Sotorasib has a very unique mechanism of action and at this time is only active against KRAS G12C. While it is a RAS inhibitor it only irreversibly and covalently binds with KRAS G12C making other KRAS mutations unlikely to respond to sotorasib therapy. Sotorasib has not been reported to effect QTc and/or prolong the QT interval, which makes C incorrect. Sotorasib and proton pump inhibitors should be avoided together based on package labeling and is the most appropriate answer at this time.

SW returns to clinic after two months of sotorasib therapy. He reports in the last month having severe diarrhea and has held treatment twice with two dose reductions but continues to have intolerance to the treatment. He requests stopping treatment.

He returns 3 months later with a repeat CT scan and is found to have continued disease progression.

Based on SWs continued disease progression, what treatment would be most appropriate to recommend at this time?

Answer C is the best answer.

SW returns to the office following initiation of immunotherapy. He reports increased symptoms of shortness of breath as well as rib pain. A chest x-ray is obtained to rule out pneumonia, immune-mediated pneumonitis as well as potential pleural effusion. The radiologist calls the clinic to let the team know that her x-ray shows a new pleural effusion.

What plan would you recommend for SW?

  • A. Drain the fluid
  • B. Placement of chest tube on wall suction
  • C. Place a small pigtail catheter in the chest wall
  • D. Pleurodesis with doxycycline

Answer A is correct.

Thoracentesis is appropriate for initial management of the effusion. The need for a chest tube or pleurodesis with doxycycline would be determined by the rate and volume of further fluid re-accumulation.

A therapeutic tap was performed and fluid was sent for gram stain, cytology, hematology, and chemistry. The results showed the fluid to be exudative in nature (LDH 240) and the cytology was consistent with lung cancer. 1 liter total is drained and SW experiences good symptomatic relief.

SW is discharged to continue receiving immunotherapy in the outpatient setting.

JR is a previously treated, stage IV, NSCLC patient who was recently found to have disease progression. On repeat review of his pathology, next generation sequencing (NGS) performed on the diagnostic tissue showed an EGFR exon 20 insertion mutation. He is starting amivantamab treatment today in the treatment room.

A new infusion nurse comes to the pharmacy as she is about to start JR on amivantamab treatment. He is starting cycle 1 day 1 and she would like to verify what would be most appropriate premedication for her patient at this time?

Answer C is the best answer.

Amivantamab commonly causes an infusion-related reaction. IRRs occurred in approximately two-thirds of patients treated with amivantamab, particularly with the first infusion. The proposed mechanism is non-dose-related, immunologic the overall onset is rapid with a median time to onset of 1 hours after the start of the infusion. Per package labeling acetaminophen and diphenhydramine are to be administered prior to all amivantamab infusions. Glucocorticoids should be administered prior to week 1, days 1 and 2 doses, and are option for subsequent doses. Montelukast and famotidine are not required premedications for patients starting amivantamab.

Which of the following is correct?

  • A) B.carotene & selenium has a no rule in lung cancer prevention
  • B) smoking cessation showed benefits in healthy individuals only
  • C) no relation between smoking cessation and response to treatment
  • D) trials of acetylcystein showed significant reduction in lung cancer patients

Answer: A) β-carotene & selenium has a no role in lung cancer prevention

Trials like the ATBC and CARET actually showed increased lung cancer risk with β-carotene supplementation in smokers. Selenium also did not show benefit. Therefore, supplements are not recommended for prevention.

A 60-year-old man with an 80 pack-year smoking history presents to the ED with right upper quadrant abdominal pain. CT of the abdomen shows multiple masses within the liver suspicious for metastatic disease. CT of the chest is notable for a left lower lobe 5.5 cm mass, multiple small bilateral pulmonary nodules, and enlarged ipsilateral hilar and mediastinal lymph nodes. MRI of the brain does not show any intracranial metastases. Percutaneous biopsy of a liver lesion reveals adenocarcinoma of lung primary. Next-generation sequencing for driver mutations reveals mutations in p53, ATM, and STK11. PD-L1 expression is present in 5% of tumor cells. His pain is controlled with hydrocodone–acetaminophen 10 to 325 mg as needed and his Eastern Cooperative Oncology Group (ECOG) performance status is 1. What is the most appropriate first-line therapy for this patient’s disease?

Answer: B. Carboplatin + pemetrexed + pembrolizumab × 4 cycles followed by maintenance pemetrexed + pembrolizumab

Explanation: This patient has metastatic non-squamous non-small cell lung cancer (NSCLC) (adenocarcinoma) with no targetable driver mutations found (p53, ATM, and STK11 are not directly targetable with standard therapy). His PD-L1 expression is low at 5%. According to current guidelines, the standard first-line treatment for metastatic non-squamous NSCLC without an actionable driver mutation is platinum-doublet chemotherapy (carboplatin) combined with pemetrexed and a checkpoint inhibitor (pembrolizumab). This combination has shown a survival benefit regardless of PD-L1 status, though the benefit is more pronounced in higher expressors. Option A includes bevacizumab, which is not typically first-line with immunotherapy here and offers no clear advantage. Option C (pembrolizumab alone) is only indicated for first-line use if PD-L1 expression is ≥50%. Option D is a targeted therapy for BRAF V600E mutations, which this patient does not have.

A 72-year-old retired pipefitter presents with progressive exertional dyspnea, chest wall pain, and cough. He has smoked one pack per day for 54 years. His medical history is notable for Hodgkin lymphoma in his 30s treated with chemotherapy and mantle field radiation with no evidence of recurrence. He has a family history of mesothelioma in a paternal uncle and ocular melanoma in his father. CT scan shows a left-pleural-based mass with a moderate left pleural effusion. Percutaneous pleural biopsy confirms malignant sarcomatoid mesothelioma. Which of the following is not a risk factor for the development of mesothelioma?

  • A. Tobacco use
  • B. Radiation exposure
  • C. Family history of mesothelioma
  • D. Occupational asbestos exposure

Answer: A. Tobacco use

Explanation: The primary and overwhelmingly most common risk factor for mesothelioma is asbestos exposure (D). Radiation exposure (B), particularly mantle radiation for Hodgkin's lymphoma as in this patient's history, is a well-documented risk factor. A family history (C) can be a risk factor due to potential genetic predispositions (e.g., BAP1 mutation syndrome) or shared environmental exposure to asbestos. However, tobacco smoking (A) is not a risk factor for the development of mesothelioma. While smoking synergistically increases the risk of lung cancer in people exposed to asbestos, it does not independently increase the risk for mesothelioma.

A 67-year-old previously healthy man presents with progressive dyspnea, chest discomfort, fatigue, and peripheral edema. He has a blood pressure of 94/60, heart rate of 116, and respiratory rate of 28. His neck veins are distended, and his heart sounds are distant with an audible rub. Echocardiogram shows a large pericardial effusion with early tamponade physiology. He undergoes pericardiocentesis with temporary catheter placement, and cytologic evaluation of pericardial fluid reveals mesothelioma.CT shows diffuse left pleural thickening and a small pleural effusion with enlarged left hilar and mediastinal lymph nodes. After pericardial drainage, he is hemodynamically stable with a good performance status. What is the best next step in management?

Correct answer: D. Nivolumab plus ipilimumab

The best next step in management for a patient with mesothelioma presenting with pericardial effusion, post-pericardiocentesis, and hemodynamic stability is systemic immunotherapy with nivolumab plus ipilimumab. This combination is currently recommended as first-line therapy for malignant mesothelioma in patients with good performance status according to the latest clinical guidelines and evidence

A 58-year-old woman with a history of cardiac transplantation and chronic renal insufficiency due to tacrolimus(immunosuppression), is evaluated for shortness of breath and diffuse left chest pain. A CT of the chest is notable for extensive nodular right pleural thickening that extends into the major fissure without frank chest wall invasion. There are multiple enlarged right hilar, paratracheal, and cardiophrenic lymph nodes. CT abdomen shows no evidence of metastatic disease. PET/CT shows intense fluorodeoxyglucose (FDG) avidity diffusely within the right pleura and in hilar and mediastinal lymph nodes. CT-guided pleural biopsy reveals malignant mesothelioma with sarcomatoid histology. She has a good performance status and is motivated for therapy.

What is the best next step in management?

Answer: B. Nivolumab plus ipilimumab

Explanation: This patient has metastatic mesothelioma (involving lymph nodes) with sarcomatoid histology. Based on the CheckMate 743 trial, first-line dual immunotherapy with nivolumab plus ipilimumab (B) has become the standard of care for unresectable malignant mesothelioma, as it demonstrated a significant overall survival benefit compared to standard chemotherapy (cisplatin/carboplatin + pemetrexed). This benefit was particularly pronounced in the non-epithelioid (which includes sarcomatoid) histology group. Her immunosuppression is a relative contraindication but her good performance status and motivation for therapy make her a candidate. Chemotherapy (A) is an option but is inferior to immunotherapy in this context. Surgery (C) is not appropriate for unresectable, advanced disease. Tumor-treating fields (D) are approved for use with chemotherapy, not as first-line monotherapy.

Which of the following is correct regarding pemetrexed support?

  • A. patient should receive vit B12 PO daily plus leucovorin 15 mcg IV daily 3 weeks before treatment and continue these medications for 3 weeks after treatment
  • B. patient should receive vit B12 IV/IM every 9 weeks plus folic acid 350 mcg PO daily 3 weeks before treatment and continue these medications for 3 weeks after treatment
  • C. patient should receive vit B12 IV/IM every 9 weeks 3 weeks before treatment and continue these medication for 3 weeks after treatment
  • D. patient should receive folic acid 350 mcg PO daily 3 weeks before treatment and continue these medication for 3 weeks after treatment

Answer: B. patient should receive vit B12 IV/IM every 9 weeks plus folic acid 350 mcg PO daily 3 weeks before treatment, and continue these medications for 3 weeks after treatment

Explanation: Pemetrexed is an antifolate chemotherapy drug that can cause severe hematologic and gastrointestinal toxicity. To reduce these side effects, vitamin supplementation is mandatory. The correct regimen, per clinical protocols, is:

  • Folic acid (350–1000 mcg) orally daily, starting 1–2 weeks before the first dose of pemetrexed and continuing until 3 weeks after therapy ends.
  • Vitamin B12 (1000 mcg) intramuscularly (IM) 1–2 weeks before the first dose of pemetrexed and then every 9 weeks thereafter.
  • Option B correctly states this regimen. Options A, C, and D are incorrect because they omit one vitamin, use the wrong vitamin (leucovorin), or have the wrong frequency or route.

PN is 55 years old patient who was diagnosed by Stage III B adenocarcinoma of the lung, he received 1 cycle of Cisplatin+pemetrexede CCRth, before his 2nd cycle his CrCl was 50 ml/min which of the following is correct ?

  • A. give cisplatin at 75 mg/m2 and Pemetrexade at 500 mg/m2
  • B. give cisplatin at 60 mg/m2 and Pemetrexade at 300 mg/m2
  • C. give cisplatin at 37.5 mg/m2 and Pemetrexade at 500 mg/m2
  • D. Do not give cisplatin until CrCl ≥60 ml/min

Answer: D. Do not give cisplatin until CrCl ≥ 60 ml/min

Explanation: Cisplatin is contraindicated in patients with a creatinine clearance (CrCl) below 60 mL/min due to its high nephrotoxicity. Administering it with impaired renal function could cause permanent, severe kidney damage. The standard dose for cisplatin in lung cancer regimens is 75 mg/m², but this is only given if renal function is adequate. If renal function drops during treatment, the correct action is to hold the cisplatin until renal function recovers or to switch to a non-nephrotoxic platinum agent like carboplatin (which is dosed based on AUC and CrCl). Pemetrexed also requires dose adjustment for renal impairment, but the primary concern is holding the cisplatin.

Which of the following is correct regarding amifostine?

  • A. use is encouraged with adjuvant cisplatin to maximize dose and efficacy
  • B. dose is 910 mg/m2 over 30 mins, </=30 mins before cisplatin
  • C. stop drug if baseline SBP is 135 and it decreased to 100 after 5 mins of infusion
  • D. BP must be monitored 20 mins after infusion

Answer: C. stop drug if baseline SBP is 135 and it decreased to 100 after 5 mins of infusion

Explanation: Amifostine is a cytoprotective agent used to reduce toxicity from chemotherapy (e.g., cisplatin-induced nephrotoxicity) and radiation (e.g., xerostomia). Its use is limited by significant side effects, primarily hypotension.

  • A) is incorrect. Amifostine is used to reduce toxicity, not to maximize dose or efficacy. Its use is not "encouraged" but rather considered in specific scenarios to mitigate side effects.
  • B) is incorrect. The standard dose is 910 mg/m², but it is infused over 15 minutes, not 30. It must be completed 15-30 minutes before chemotherapy.
  • C) is correct. Hypotension is a major adverse effect. The infusion should be interrupted if systolic blood pressure (SBP) decreases significantly from baseline (e.g., a drop of 20-40 mm Hg, or as described in this option) and should be stopped if it does not resolve quickly.
  • D) is incorrect. Blood pressure must be monitored before and every 5 minutes during the infusion, not just 20 minutes after.

NY is a 66-year-old with newly diagnosed Stage IV lung cancer. On pathologic review, it was determined to be adenocarcinoma non-small cell lung cancer(NSCLC) type and also EGFR, ALK, KRAS negative. His PD-L1 expression is over 50%. His ECOG performance status is 1, and all labs are unremarkable. His past medical history includes diabetes mellitus and rheumatoid arthritis. Which one of the following regimens would be the preferred regimen for this patient?

Correct Answer: B (Pembrolizumab/cisplatin / pemetrexed)

Explanation:

The key factor that dictates the first-line treatment choice for this patient is the high PD-L1 expression of over 50%.

Why not the others?

A, C, and D (Cisplatin-based doublets without immunotherapy): These are all chemotherapy-only regimens. While they were the historical standard of care, for a patient with such high PD-L1 expression, immunotherapy alone or in combination with chemotherapy is significantly more effective and is now the standard first-line approach. The percentages in parentheses (e.g., 75%) likely represent an answer distribution from a test bank and confirm that A is a common distractor but not the best answer for this specific biomarker profile.

Additional Context from the Case: The patient's history of rheumatoid arthritis is a note of caution regarding the use of immunotherapy, as it can exacerbate autoimmune conditions. However, this history is not an absolute contraindication, and the strength of the biomarker (PD-L1 ≥ 50%) still makes an immunotherapy-based regimen the preferred choice, though it would require very close monitoring. The negative EGFR, ALK, and KRAS testing rules out targeted therapies for those mutations.

AS is a 66 year old with newly diagnosed Stage IV lung cancer. On pathologic review, it was determined to be adenocarcinoma non-small cell lung cancer (NSCLC) type and also EGFR. ALK, KRAS negative. His performance status - 1 and all labs are unremarkable. Which one of the following regimens would be the preferred regimen for this patient?

Correct Answer: D. Cisplatin + pemetrexed

You are caring for a 59-year-old female (weight 50 kg) with NSCLC who is started on pembrolizumab. After four weeks, she begins experiencing extreme fatigue and weakness, weight gain, hair loss, and constipation. Although her TSH is 15 mlU/L and her T4 is 5.1 mcg/dL, she is otherwise stable. Which of the following recommendations is most appropriate?

  • A Hold pembrolizumab until AD’s symptoms return to baseline. Start levothyroxine and recheck TSH/T4 in 6 weeks (55%)
  • B Hold pembrolizumab until AD’s symptoms return to baseline. Start levothyroxine and prednisone 50 mg/day, then recheck TSH/T4 in 6 weeks (18%)
  • C Hold pembrolizumab until AD’s symptoms return to baseline. Start prednisone 50 mg/day, then recheck TSH/T4 in 6 weeks (12%)
  • D Continue pembrolizumab at a reduced dose. Monitor TSH/T4 every 6 weeks (13%)"

Answer: A (Hold pembrolizumab until AD’s symptoms return to baseline. Start levothyroxine and recheck TSH/T4 in 6 weeks)

Explanation:

The patient is presenting with classic symptoms and lab findings of hypothyroidism (elevated TSH, low-normal T4, fatigue, weight gain, hair loss, constipation). This is a common immune-related adverse event (irAE) associated with pembrolizumab and other immune checkpoint inhibitors. The management for immune-related endocrinopathies like hypothyroidism is hormone replacement (e.g., levothyroxine). Immunosuppression with high-dose steroids (e.g., prednisone) is not indicated for isolated hypothyroidism, as it is typically a permanent condition that is easily managed. The immunotherapy (pembrolizumab) is often held until symptoms improve but can typically be resumed once the endocrine issue is managed. Dose reduction for immunotherapy is not standard practice for managing irAEs.

EL is a 59year female is diagnosed with metastatic adenocarcinoma of the lung. She has a 1 month history of DVT. EL is currently taking lisinopril dalteparin and furosemide Which of the following is best treatment for her lung cancer?

Answer: C (Cisplatin/pemetrexed)

Explanation:

The patient has metastatic adenocarcinoma (non-squamous NSCLC). The standard first-line chemotherapy for non-squamous NSCLC without targetable mutations is a platinum agent (cisplatin or carboplatin) combined with pemetrexed. The critical factor ruling out other options is her history of a recent DVT (1 month) and her current use of dalteparin (a low molecular weight heparin). Bevacizumab (Avastin), an anti-angiogenic agent in option B, is contraindicated in patients with a recent history of thrombosis or who require full-dose anticoagulation (like therapeutic dalteparin) due to a significantly increased risk of severe or fatal bleeding. Erlotinib (option D) is an EGFR inhibitor, which is not indicated without a confirmed EGFR mutation.

A 60-year-old male was diagnosed last year with ALK-positive metastatic squamous non-small cell lung cancer (NSCLC). He began first-line treatment with crizotinib but progressed after five months. He was then started on alectinib and has been on it for ten months. His most recent PET/CT shows progression with brain metastases. Which agent should be used as subsequent therapy?

Answer: B (Lorlatinib)

Explanation:

This patient has ALK-positive NSCLC. The standard sequence of therapy after progression on first-generation (crizotinib) and second-generation (alectinib) ALK inhibitors is a third-generation ALK inhibitor, lorlatinib. Lorlatinib has particularly high CNS penetration and is the preferred choice for patients with ALK-positive NSCLC who progress on earlier ALK inhibitors, especially with brain metastases. Entrectinib (A) is primarily used for NTRK or ROS1 gene fusions, not ALK. Erlotinib (C) is for EGFR mutations. Observation (D) is not appropriate as there are effective next-line targeted therapies available.

PK is a 62 year old male presented with increasing cough and weight loss. He also has right hip pain for about 3 weeks now. Total body scan reveals metastasis to the right iliac bone. PK is then diagnosed with squamous cell lung cancer. Which of the following is the best chemotherapy treatmentfor him?

Answer: A (Carboplatin/paclitaxel)

Explanation:

The patient has metastatic squamous cell lung cancer. The standard first-line chemotherapy regimen for squamous NSCLC is a platinum agent (carboplatin or cisplatin) combined with a taxane (e.g., paclitaxel) or gemcitabine. Bevacizumab is an anti-angiogenic agent that is contraindicated in squamous cell histology due to a high risk of life-threatening pulmonary hemorrhage. Regimens containing doxorubicin (B, D) are not standard for NSCLC.

CL is a 65-year-old man who presents to his oncologist with a new diagnosis of non-small cell lung cancer, adenocarcinoma. He has a history of hyperlipidemia for 5 years, hypertension for 10 years, and arthritic pain for 10 years. His medications include lisinopril 2o mg daily, atorvastatin 10 mg daily, and meloxicam 15 mg daily. He states his arthritis has been acting up, and he has been using hydrocodone/acetaminophen 2-3 times a day. His labs are within normal limits except for a creatinine of 1.5 mg/dL and an alkaline phosphatase of 244 IU/L. He has difficulty finding transportation to bring him to the clinic. He states he has a ride twice a month if needed. Which of the following is the best chemotherapy option for him?

Answer: C (Carboplatin and paclitaxel)

Explanation:

Several patient factors guide this decision:

Renal Impairment: His elevated creatinine (1.5 mg/dL) indicates renal insufficiency. Cisplatin (options A and B) is highly nephrotoxic and requires vigorous hydration, making it a poor choice. Carboplatin is renally cleared but is less nephrotoxic and is dose-adjusted based on renal function.

Transportation/Lifestyle: He has significant difficulty with transportation, only able to come to the clinic twice a month. A carboplatin/paclitaxel regimen is typically given on a 3-week (once-every-three-weeks) cycle, which aligns with his availability. Pemetrexed (option A, which must be paired with carboplatin, not cisplatin, in this case) requires vitamin B12 and folate supplementation and is also given every 3 weeks, but the renal issue is the primary contraindication for cisplatin.

Carboplatin/paclitaxel is the best balance of efficacy, reduced nephrotoxicity, and a feasible schedule for this patient.

Which reference should the oncologist use to review the most current treatment recommendations for the common malignancies?

  • A Devita's Cancer Principles and Practice of Oncology textbook (3%)
  • B National Comprehensive Cancer Network guidelines found at wwwNCCNorg (89%)
  • C American Cancer Society found at wwwecancerorg (6%)
  • D Micromedex online ctinical reference (2%)"

Answer: B (National Comprehensive Cancer Network guidelines found at www.NCCN.org)

Explanation:

The National Comprehensive Cancer Network (NCCN) Guidelines are the gold standard for up-to-date, evidence-based, and consensus-driven cancer treatment protocols. They are continuously updated (sometimes multiple times a year) to incorporate the latest research and drug approvals. While textbooks like Devita's (A) are excellent foundational resources, they become outdated quickly. The American Cancer Society (C) is a superb resource for patient education and support but does not create detailed treatment guidelines for clinicians. Micromedex (D) is a valuable resource for drug information but does not provide comprehensive cancer treatment algorithms.

GV is 56-year-old mate who has progressed after receiving crizotinib for ALK positive, EGFR negative metastatic lung adenocarcinoma. Which of the following treatments is most appropriate for GV a this time?

Answer: C (Ceritinib)

Explanation:

The patient has ALK-positive NSCLC and has progressed on the first-generation ALK inhibitor crizotinib. The standard of care after progression on crizotinib is to switch to a second-generation ALK inhibitor. Ceritinib is a second-generation ALK inhibitor approved for this exact scenario. Osimertinib (D) is a third-generation EGFR inhibitor, used for EGFR-mutated lung cancer, not ALK. Chemotherapy regimens like A or immunotherapy like B (nivolumab) may be used later in the treatment sequence but are not the preferred next step after progression on a targeted therapy when an effective next-line targeted agent exists.

"Which of the following drugs are NCCN guideline recommended options for maintenance therapy in patients with squamous cell non-small cell lung cancer (NSCLC)?

Answer: D (All of the above)

Explanation:

For patients with squamous cell NSCLC who have not progressed on first-line platinum-based chemotherapy:

  • Pembrolizumab (A) is an option for maintenance if it was part of the first-line regimen and the patient has achieved disease control.
  • Gemcitabine (B) is a recommended option for continuation maintenance (continuing one of the non-platinum drugs from the initial regimen).
  • Docetaxel (C) is a recommended option for switch maintenance (switching to a different drug after completing initial platinum-based therapy).
  • Therefore, all three agents (A, B, and C) are recognized by NCCN guidelines as potential options for maintenance therapy in squamous cell NSCLC.

Cancer prevention depends on knowledge of modifiable risk factors. Which of the below cancers can be effectively prevented by behavior and life-style change?

Answer: B (Lung cancer)

Explanation:

Lung cancer has the strongest and most well-established link to modifiable risk factors. The overwhelming majority of cases are directly caused by tobacco smoking, a behavioral and lifestyle choice. Avoiding tobacco can prevent the vast majority of lung cancer cases. While diet and lifestyle may play a minor role in the other cancers listed (A, C, D), the link is not nearly as direct or powerful as it is for lung cancer. The primary risk factors for prostate cancer (age, family history, race), CML (a genetic translocation), and multiple myeloma (largely unknown) are not effectively modifiable through behavior change.

A 72-year-old female was recently diagnosed with stage IV non-small cell lung cancer (NSCLC). The patient has no other comorbidities, and ECOG is a Histology report shows adenocarcinoma. Molecular mutations show the patient is EGFR, ALK, ROS1, and BRAF negative, with PD-L1 expression positive at 1% (tumor proportion score [TPS]). What would be an appropriate therapy to begin the patient on?

Correct Answer: A. Pembrolizumab + Carboplatin + Pemetrexed

Explanation

SE is a 53 year old female with history of smoking who presents with increasing cough and worsening shortness of breath. Her A CT scan of chest was positive for lesions on right upper lobe and left lower lobe. Furthermore, the CT scan also suggested significant pleural effusion at the base of the left lung and lesion at right adrenal gland. After, fine needle biopsy of right adrenal lesion she received diagnosis of small cell lung cancer. Which of the following is the best therapy for SE?

Answer: C (Cisplatin/etoposide)

Explanation:

The patient has extensive-stage small cell lung cancer (ES-SCLC), as evidenced by metastases to the adrenal gland and a malignant pleural effusion. The historic and still fundamental standard first-line treatment for ES-SCLC is platinum-based chemotherapy (cisplatin or carboplatin) combined with etoposide. While the current standard of care now often adds immunotherapy to this backbone, the correct choice among the given options is C (Cisplatin/Etoposide). Paclitaxel-based regimens (A, D) are not standard for SCLC. Definitive radiation (A, B) is not a primary treatment for extensive-stage disease, though it may be used later for palliative purposes or consolidatively for limited metastatic burden.

NT is a 64 year old male who recently received a diagnosis of stage IV non-small cell lung cancer, The histology of his cancer revealed adenocarcinoma. Based on the histology. which ofthe following is the best chemotherapy regimen for hs lung cancer?

Answer: C (Carboplatin/paclitaxel/bevacizumab)

Explanation:

The patient has metastatic adenocarcinoma (non-squamous NSCLC). For patients with non-squamous NSCLC, good performance status, and no contraindications (e.g., no significant history of bleeding, thrombosis, or need for anticoagulation), the regimen of platinum (carboplatin) + paclitaxel + bevacizumab is a historically significant and NCCN-listed regimen. Bevacizumab is an anti-angiogenic agent approved for use specifically in non-squamous histology; it is contraindicated in squamous cell due to risk of severe bleeding. While pemetrexed-based regimens are also preferred for non-squamous, this is the best choice among the options given. Regimens containing doxorubicin (B, D) are not standard for NSCLC.

SL is a 58year old male who presents with right middle ob mass. The biopsy of this mass is positive for small cell lung cancer. CT scans of chest. abdomen. pelvis and brain are negative for any other area of cancer involvement Which of the following is the best therapy for SL?

Answer: D (Chemotherapy and radiation)

Explanation:

The scans show the cancer is confined to one lung without distant metastasis. This defines limited-stage small cell lung cancer (LS-SCLC). The standard of care and potentially curative treatment for LS-SCLC is concurrent chemotherapy and thoracic radiation therapy. Surgery (options A and C) is very rarely an option for SCLC due to its aggressive and early metastatic nature; it is almost exclusively reserved for the rare instance of a very small, node-negative tumor. Chemotherapy alone (B) is inferior to the combination of chemo and radiation for limited-stage disease.

BF is a 56 year old male presents with stage ll non-small cell lung cancer, He has an ECOG performance status of 1 What is the most appropriated course of treatment?

Answer: B (Surgery and adjuvant cisplatin/vinorelbine)

Explanation:

For Stage II NSCLC in a patient with a good performance status (ECOG 1), the standard of care is surgical resection followed by adjuvant platinum-based chemotherapy (e.g., cisplatin with vinorelbine or another partner drug). This has been proven to improve overall survival by reducing the risk of recurrence. Surgery alone (A) is inadequate for Stage II due to a high risk of micrometastatic disease. Adjuvant radiotherapy (C) is not standard after a complete resection for this stage; it is used for positive margins or N2 disease. Starting with radiotherapy (D) is not the standard approach for a resectable Stage II tumor.

ST is a 72-year-old female who presents to her oncologist with a diagnosis of stage IV non-small cell cancer (NSCLC) Her tumor biology shows that the adenocarcinoma tumor is EML4-ALK positive and EGFR negative. Which of the following agents would be most appropriate for ST at this time?

Answer: A (Crizotinib)

Explanation:

The patient has Stage IV (metastatic) NSCLC with a confirmed ALK gene rearrangement (EML4-ALK). The preferred first-line treatment for ALK-positive metastatic NSCLC is targeted therapy with an ALK inhibitor. Crizotinib was the first-generation ALK inhibitor approved for this specific biomarker. While newer ALK inhibitors (e.g., alectinib) are now often preferred first-line, crizotinib remains a correct and targeted answer for an ALK-positive tumor. Erlotinib (B) is for EGFR mutations. Chemotherapy (C) or bevacizumab (D) would be less effective first-line options when a highly effective targeted therapy is available.

Up to what percentage of Caucasian non-small cell lung cancer (NSCLC) patients are EGFR positive?

  • A 0–5% (23%)
  • B 10–15% (34%)
  • C 45–50% (42%)
  • D 85–90% (1%)

Answer: B (10–15%)

Explanation:

The frequency of EGFR mutations in NSCLC is highly dependent on ethnicity and smoking status. In Caucasian populations, which have a much higher rate of smoking-related lung cancer, the prevalence of EGFR mutations is approximately 10-15%. This contrasts sharply with East Asian populations, where the prevalence can be 40-50% (making C a common distractor for those not noting the "Caucasian" specification). Options A is too low, and D is far too high and represents the prevalence in a different context (e.g., response rate to TKIs in mutated patients, not the mutation rate itself).

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