Early Stage
For a patient with newly diagnosed early stage NSCLC, what mutations or testing would you test for?
EGFR, ALK, and PDL-1
Is the locally advanced and unresectable setting considered curable or uncurable?
Curable
This mutation is typically found in what demographic?
Asian female non smokers
Amongst people with ALK mutations, what typical demographic do you see?
young, non-smoker or light smoker, typically 1/3 of patients have CNS at baseline and many will develop CNS disease over their disease course
How would you rank the following in terms of incidence in NSCLC? EGFR, ALK, KRAS, MET, RET, ROS1, BRAFV600E, NTRK?
1. EGFR - 10-20% but can be up to 50% in asian women
2. KRAS - 25-30% but KRASG12C up to 10-13%
3. ALK rearrangements - 4-8%
4. MET exon 14 skip mutations- 3-4%
5. ROS1, RET, BRAF
6. NTRK
What stages of NSCLC would unequivocally warrant adjuvant chemotherapy in a healthy and fit patient?
Stages II - III
What stage should a perioperative immunotherapy approach be absolutely considered?
Medically operable stage III
What are the two most common EGFR mutations that together make up >80% of all EGFR mutations?
Bonus Question: what EGFR mutation is inherently resistance to EGFR TKIs?
Exon 19 deletions and L858R point mutations are the two most common EGFR mutations. EGFR exon 20 insertions are inherently resistant to oral EGFR TKIs.
Patient is a 65 year old female with newly diagnosed lung adenocarcinoma, UCSF500 shows an ALK rearrangement. What treatment would you start?
Alectinib (ALEX) or Lorlatinib (CROWN)
In NSCLC, what histology would you use a gemcitabine based regimen and what histology would you use a pemetrexed based regimen?
Nonsquamous (Adenocarcinoma) - use platinum doublet with pemetrexed
Squamous - use platinum doublet with gemcitabine
Patient has stage IIB adenocarcinoma of the RLL with complete resection of the RLL followed by negative margins. What adjuvant chemotherapy and doses would you recommend? Patient is a 50 year old M, fit, with normal creatinine function and no comorbidities. PDL-1 testing of tumor showed PDL-1 50% and no targetable mutations.
Cisplatin 75mg/m2 + pemetrexed 500 mg/m2 x4 cycles followed by 1 year of atezolizumab
Patient is a 75 year old M with stage IIIB unresectable NSCLC. Patient has a KRAS mutation but no other targetable mutations with a PDL1 status of 30%. What would the best course of treatment be?
Chemoradiation with weekly carboplatin AUC 2 and paclitaxel 45mg/m2 x7-8 cycles followed by durvalumab consolidation x1 year per PACIFIC trial
Patient is a 62 year old female with newly diagnosed lung adenocarcinoma, mutation status and PDL1 status is pending following biopsy but patient is fairly symptomatic and wants to start urgently on treatment. What treatment would you start?
Carboplatin AUC 5 + Pemetrexed 500 mg/m2
Patient is a 65 year old female with ALK+ lung adenocarcinoma who has been on alectinib for the past 3 years with CNS and lung progression, what would be the patient's next treatment choice?
Lorlatinib
Patient is a 65 year old male with new diagnosed metastatic lung adenocarcinoma, UCSF500 found a KRAS G12C mutation and PDL1 status of 50%. What would be this patient's choices for treatment?
1. Carboplatin/Pemetrexed/Pembrolizumab (KEYNOTE-189)
2. Carboplatin/Pemetrexed/Ipi/Nivo (CHECKMATE9LA)
3. Carboplatin/Pemetrexed/Trem/Durva (POSEIDON)
Patient has stage IIB adenocarcinoma of the RLL with complete resection of the RLL followed by negative margins. What would you recommend next for their treatment plan? Patient is a 50 year old M, fit, with normal creatinine function and no comorbidities. PDL-1 testing of tumor showed PDL-1 50% with an EGFR exon 19 deletion
Cisplatin 75mg/m2 + pemetrexed 500mg/m2 x 4 cycles followed by 3 years of osimertinib per ADAURA
Patient has stage IIIA adenocarcinoma of the RLL and after following consultation with thoracic surgery, would like to consider decreasing tumor burden prior to resection. What would you recommend? Patient is a 50 year old M, fit, with normal creatinine function and no comorbidities. PDL-1 testing of tumor showed PDL-1 20% and no targetable mutations.
Perioperative chemoimmunotherapy with Cisplatin/Pemetrexed/Pembrolizumab x 4 cycles followed by pembrolizumab to complete 1 year of adjuvant treatment per KEYNOTE-671
Patient is a 68 year old female with newly diagnosed metastatic NSCLC with an EGFR exon 19 deletion. What are 3 options of treatment based on what trials?
1. Osimertinib (FLAURA)
2. Osimertinib + Chemo (FLAURA2)
3. Amivantamab + Lazertinib (MARIPOSA)
Patient is a 65 year old female with ALK+ lung adenocarcinoma who subsequently progressed on lorlatinib (been on for 2 years). What would be the next line of treatment?
2. Carboplatin AUC 6 + Paclitaxel 200 mg/m2 + Bevacizumab 15 mg/kg + Atezolizuamb 1200 mg q3 weeks (IMPOWER150)
Patient is a 80 year old female with newly diagnosed lung adenocarcinoma, UCSF500 shows no actionable mutations and PDL1 status is 50% following biopsy What treatment would you start?
1. Pembrolizumab monotherapy (KEYNOTE-024)
2. Carbo/Pem/Pembro (KEYNOTE189)
Patient has stage IIIA adenocarcinoma of the LLL with complete resection of the LLL followed by negative margins. What would you recommend next for their treatment plan? Patient is a 70 year old M, fit, with normal creatinine function and no comorbidities. PDL-1 testing of tumor showed PDL-1 0% with an ALK rearrangement
Alectinib x 2 years per ALINA trial
Patient is a 75 year old M with stage IIIB unresectable NSCLC. Patient has a EGFR mutation but no other targetable mutations with a PDL1 status of 90%. What would the best course of treatment be?
Chemoradiation with weekly carboplatin AUC 2 and paclitaxel 45mg/m2 x7-8 cycles followed by osimertinib per LAURA trial
Patient is a 65 year old male has metastatic NSCLC with EGFR L858R mutation and has been on osimertinib x 3 years with stable disease. Most recent CT scans show disease progression in multiple sites (liver and bone progression). Biopsy of the osseous site shows a MET amplification. What would you do as the oncologist?
1. Amivantamab + Chemotherapy (MARIPOSA-2)
2. Osimertinib + Tepotinib (INSIGHT-2)
Patient is a 65 year old female with ALK+ lung adenocarcinoma who subsequently progressed on lorlatinib (been on for 2 years from 2020-2022) and subsequently received carboplatin/pemetrexed x4 cycles in 2022 and been on pemetrexed maintenance since. What would be the next line of treatment?
Docetaxel 75mg/m2 + Ramucirumab 10mg/kg every 3 weeks (REVEL trial)
Patient is a 60 year old female with newly diagnosed squamous carcinoma of the lung, mutation status is negative for any actionable mutations and PDL1 status is 10% following biopsy. What treatment would you start?
1. Carbo/Taxol/Pembro or Carbo/Abraxane/Pembro (KEYNOTE-407)
2. Carbo/Taxol/Ipi/Nivo (CHECKMATE-9LA)
3. Carbo/Abraxane/Trem/Durva or Carbo/Gemcitabine/Trem/Durva (POSEIDON)