Lung Cancer (Snap Review)

Non-Small Cell Lung Cancer (NSCLC)

• T1 

• T2: 3 cm

• T3: 5 cm

• T4: 7 cm

• N1: Hilar nodes

• N2: Ipsilateral

• N3: Contralateral or supraclavicular

Stage I: N0

Stage Ia: T1  (<3 cm, No NGS)

Stage Ib: T2a (3-4 cm):

             Alectinib if ALK mutated

             Osimertinib if EGFR exon 19 deletion or L858R

Stage II: >N1

If unresectable: 

            Radiation

If resectable:

Alectinib if ALK mutated

Osimertinib if EGFR exon 19 deletion or L858R

Chemotherapy:

• Platinum/Taxol x4

• Platinum/Pemetrexed x4

Immunotherapy: (No adjuvant IO if EGFR+)

• Pembrolizumab x1 year (regardless of PD-L1)

• Atezolizumab x1 year if PD-L1 1% or higher

Stage III:

• If resectable: same as stage II

• If unresectable:

         Definitive concurrent chemo-RT followed by consolidation Durvalumab x1 year 

         If EGFR+ after definitive chemo-RT: Adjuvant Osimertinib 80 mg PO once daily

Neoadjuvant Therapies for Resectable NSCLC:

• Nivo + Chemo x3 cycles → surgery → option chemotherapy

• Nivo + Chemo x3 cycles → surgery → Nivo (if R0) x6 months

• Pembro + Chemo           → surgery → Pembro

• Durvalumab + Chemo     → surgery → Durvalumab

Stage IV:

NGS, Check for driver mutations and PD-L1 

• Chemo + IO: if no driver mutations/ large burden of disease and need for quick robust response

• Carboplatin + Pemetrexed + Pembro

• Carboplatin + Taxol + Pembro

• Pembrolizumab: if PD-L1 >50%

• Second Line agents:

  • Docetaxel + Ramucirumab, Pemetrexed, Gemcitabine, Abraxane, Vinorelbine

• EGFR Exon 21 L858R or Exon del 19 

• Osimertinib monotherapy

• Osimertinib + Chemotherapy

• Amivantamab + Lazertinib

• EGFR Exon 20 mutation

• Amivantamab

• ALK fusion

  • Alectinib, Brigatinib, Crizontinib, Lorlatinib

• RET fusion

  • Selpercatinib

• ROS1 fusion 

  • Repotrectinib, Entrectinib, Crizontinib, Lorlatinib

• KRAS G12C

  • Sotorasib and Adagrasib for 2L

• MET Exon 14 Skipping Mutation

• Capmatinib, Crizotinib, Tepotinib

• BRAF V600E

• Dabrafenib/Trametinib

• HER2

• Fam-trastuzumab deruxtecan (Enhertu)

• NTRK

  • Repotrectinib

  • Larotrectinib

  • Entrectinib

• NRG1

  • Zenocutuzumab

    
    

Small Cell Lung Cancer (SCLC)

Limited stage-SCLC:

• T1-2 only: Surgery → adjuvant chemo (Cisplatin and etoposide)

• > T2:         ChemoRT

• Consider:  ChemoRT → consolidation Durvalumab 

• Consider PCI in LS-SCLC

Extended stage-SCLC:

• No radiation or surgery

• MRI brain: If brain mets: WBRT + steroids

• Chemo (carboplatin/cisplatin + etoposide x4 cycles) + IO (Atezolizumab or Durvalumab)

Relapsed SCLC

• If relapse >6 months: re-challenge with Carboplatin + etoposide

• If relapse < 6 months: Lurbinectedin and Topotecan

• Talratamab (bispecific Ab)

May present with SVC Syndrome

• IR consult to get tissue and Rad-Onc for chemoRT

  
  

Mesothelioma

Types:

Epithelioid Mesothelioma (better prognosis)

Non-Epithelioid Mesothelioma (Sarcomatoid or Biphasic)

For 1L: 

• Ipilimumab + Nivo  (prefered for sarcomatoid)

• Cisplatin + Pemetrexed

• Cisplatin + Pemetrexed + bevacizumab

For 2L: 

• If immunotherapy used in first line: use chemo

• If chemo used in first line: use ipi/nivo