14 Lung Cancer and Mesothelioma

Siddhartha Devarakonda and Saiama N. Waqar

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered response that is BEST in each case.

Question 14.1 A 40-year-old never-smoker woman was diagnosed with adenocarcinoma of the lung a year ago. Molecular testing of her tumor revealed an exon 19 deletion in EGFR. She was started on erlotinib and had a partial response. However, her most recent scan suggested significant progression in her disease burden with multiple new liver and lung metastases. Her tumor was rebiopsied. Which of the following alterations is most likely to explain the tumor’s resistance to erlotinib?

A. L858R

B. MET amplification

C. T790M

D. The biopsy is likely to reveal transdifferentiation to small cell lung cancer (SCLC).

Question 14.2 Sequencing the lung adenocarcinoma of a 54-year-old man with a 60 pack-year smoking history is likely to reveal which of the following features?

A. EML4-ALK translocation

B. An excess of C>T transitions

C. Co-mutation of TP53 and RB1

D. An excess of G>T transversions

Question 14.3 A 55-year-old man with a 30 pack-year history of smoking, presents to the emergency room with shortness of breath. Chest radiograph demonstrates a right upper lobe opacity. Computed tomography (CT) scan reveals a 3.5-cm spiculated mass in the peripheral right upper lobe, which is suspicious for malignancy, without any hilar or mediastinal lymphadenopathy. What is the next best step in management?

A. Bronchoscopy and biopsy of the mass

B. CT-guided biopsy of the mass

C. Brain MRI

D. Refer to thoracic surgeon for resection.

Question 14.4 A 65-year-old man with a 40 pack-year history of smoking, presents to the emergency room with shortness of breath. Chest radiograph demonstrates a left lower lobe mass and left pleural effusion. CT reveals a 3-cm left lower lobe mass, left hilar fullness, and a moderate left pleural effusion. Biopsy of the mass and thoracentesis are both positive for adenocarcinoma. Staging studies do not reveal any distant metastases. Which of the following is the next best step in his management?

A. Referral to a thoracic surgeon

B. Radiation to the chest

C. Concurrent chemotherapy and radiation

D. Platinum-based doublet therapy

Question 14.5 A 66-year-old man, with a 30 pack-year history of smoking, presents to your office for consultation regarding chemotherapy options for metastatic non–small cell lung cancer (NSCLC), squamous histology. He has no significant medical problems and the performance status (PS) is 1. Laboratory studies reveal normal blood counts, liver enzymes, and kidney function. Which of the following treatment regimens would you recommend?

A. Cisplatin and pemetrexed

B. Carboplatin, paclitaxel, and bevacizumab

C. Carboplatin and paclitaxel

D. Carboplatin and erlotinib

Question 14.6 A 55-year-old Asian woman, who is a never smoker, completed four cycles of front-line carboplatin and paclitaxel, for metastatic NSCLC. Imaging studies done after completion of therapy show stable disease. She is very active and has continued to work as a nurse throughout her treatment. Her PS is 0 and she has tolerated the treatment well, other than grade I neuropathy. Her tumor EGFR status is wild type. She wants “the best treatment possible” and desires further treatment. What would you recommend?

A. Treatment break, erlotinib at the time of disease progression

B. Stopping carboplatin, continuing paclitaxel till disease progression

C. Continuing carboplatin and paclitaxel for four additional cycles

D. Pemetrexed maintenance therapy

Question 14.7 A 58-year-old man, with a 40 pack-year history of smoking is referred to you by a radiation oncologist for management of limited-stage SCLC. What treatment would you recommend?

A. Cisplatin and etoposide chemotherapy

B. Cisplatin and etoposide chemotherapy with concurrent thoracic radiation

C. Cisplatin and etoposide chemotherapy, followed by PCI if response to chemotherapy

D. Cisplatin and etoposide chemotherapy with concurrent thoracic radiation, followed by PCI if response to treatment

Question 14.8 Which of the following statement(s) is/are CORRECT regarding the role of adjuvant chemotherapy after resection for NSCLC?

A. Adjuvant chemotherapy benefits patients with stage IA disease.

B. Adjuvant chemotherapy benefits patients with node-positive disease.

C. Adjuvant chemotherapy may benefit patients with stage IB disease, who have primary tumors less than 4 cm in size.

D. All of the above.

Question 14.9 Which of the following statements is CORRECT regarding pulmonary carcinoid tumors?

A. Patients usually present with carcinoid syndrome.

B. Surgery has a curative potential for resectable localized tumors.

C. Adjuvant chemotherapy is the standard of care following complete surgical resection.

D. Most pulmonary carcinoids are atypical carcinoids.

Question 14.10 Which of the following statement is TRUE regarding first-line therapy with EGFR tyrosine kinase inhibitors (TKIs) in patients with EGFR-mutated lung adenocarcinoma?

A. Response rates with TKIs are similar to that achieved with chemotherapy, although they are more durable.

B. TKIs have consistently shown superior overall survival compared to chemotherapy.

C. TKIs when combined with chemotherapy yield better outcomes than treatment with either modality alone.

D. TKIs show better response rates and progression-free survival compared to chemotherapy.

Question 14.11 A 60-year-old man with a 45 pack-year history of smoking, presents with chest pain. Chest x-ray reveals a right upper lobe mass. CT scan of the chest demonstrates a 4-cm right upper lobe lung mass, with right hilar and multiple ipsilateral enlarged mediastinal lymph nodes. Bronchoscopy and biopsy of the mass reveals NSCLC. PET scan demonstrates increased FDG-uptake in the lung mass, right hilar and mediastinal lymph nodes, but no other site of metastatic disease. CT of the abdomen and brain MRI are unremarkable. Mediastinoscopy and biopsy reveals NSCLC. His cancer is staged as T2aN2M0, stage IIIA NSCLC. His PS is 1 and he is otherwise in good health. Which of the following is the best management for this patient?

A. Definitive radiation to the chest

B. Radiation to the chest, followed by platinum-based chemotherapy

C. Concurrent radiation to the chest and platinum-based chemotherapy

D. Platinum-based chemotherapy

Question 14.12 When treating a patient with metastatic ALK rearranged adenocarcinoma of the lung, disease progression was noted after 9 months of treatment with crizotinib. Which of the following is/are valid treatment option(s) for this patient?

A. Treatment with a second-generation ALK inhibitor such a ceritinib

B. Treatment with chemotherapy

C. Treatment with local ablative techniques for oligo-progression

D. All of the above

Question 14.13 A 45-year-old Asian woman, who is a never smoker, presents to your office for consultation regarding systemic therapy for metastatic adenocarcinoma of the lung. Her tumor has an activating EGFR mutation. Which of the following is a valid first-line treatment option for this patient?

A. Cetuximab

B. Afatinib

C. Necitumumab

D. Crizotinib

Question 14.14 A 65-year-old Caucasian man, who is a never smoker, presents to your office for consultation regarding therapy for metastatic adenocarcinoma of the lung. Genotyping of his tumor revealed a gene fusion involving ROS1. The patient is interested in knowing more about this alteration and if he would qualify for treatment with any of the currently approved TKIs. Which of the following response is CORRECT?

A. While ROS1 alterations are seen in nearly 15% of adenocarcinomas, but there are no TKIs known to be active in this setting

B. ROS1 rearrangements are seen in 5% of adenocarcinomas, and these tumors respond well to treatment with erlotinib.

C. ROS1 rearrangements are seen in nearly 2% of adenocarcinomas, and these tumors respond well to treatment with crizotinib.

D. ROS1 rearrangements are seen in 15% of all adenocarcinomas, and these tumors can respond to crizotinib.

Question 14.15 A 65-year-old man, who is a former smoker presents for consultation regarding management of unresectable stage IIIB adenocarcinoma of the lung. He has a PS of 0 and adequate blood counts, hepatic, and renal function. Which of the following would you recommend?

A. Concurrent definitive cisplatin and etoposide therapy, no consolidation therapy, no PCI

B. Concurrent definitive cisplatin and etoposide therapy, consolidation docetaxel therapy, no PCI

C. Concurrent definitive cisplatin and etoposide therapy, consolidation gefitinib therapy, no PCI

D. Concurrent definitive cisplatin and etoposide therapy, consolidation gefitinib therapy, followed by PCI

Question 14.16 A 44-year-old woman presents with a newly diagnosed adenocarcinoma of the lung located at the apex of the left lung and involving the brachial plexus and first rib. She undergoes a PET scan that reveals no other nodal involvement or distant sites of FDG uptake. The preferred treatment strategy in this situation would be?

A. Definitive treatment with concurrent chemoradiation

B. Surgical resection followed by adjuvant chemotherapy

C. Palliative chemotherapy

D. Concurrent chemoradiation followed by surgical resection

Question 14.17 Which of the following is a characteristic genomic feature of small cell lung cancer?

A. Recurrent alterations in EGFR and ALK

B. Recurrent alterations in TP53 and RB1

C. Recurrent mutations in DDR2

D. Recurrent KRAS mutations.

Question 14.18 A 45-year-old male was diagnosed with stage II adenocarcinoma of the right lung. Staging revealed ipsilateral hilar lymph-node involvement and no distant metastatic disease. Patient underwent a sleeve resection of the tumor and his postoperative recovery was uneventful. Which is the next preferred step in the management of his disease?

A. No further treatment, observation only.

B. Adjuvant chemotherapy with a doublet containing cisplatin

C. Adjuvant chemotherapy with a doublet containing carboplatin

D. Prophylactic cranial irradiation

Question 14.19 What is the most common histologic subtype of malignant mesotheliomas?

A. Epithelial

B. Sarcomatoid

C. Poorly differentiated

D. Biphasic

Question 14.20 Which of the following immunohistochemistry markers is present in malignant mesotheliomas?

A. CEA

B. TTF-1

C. Moc-31

D. Calretinin

Question 14.21 Which of the following is an indicator of poor prognosis in malignant mesothelioma?

A. Anemia

B. Epithelial histology

C. Female gender

D. Thrombocytopenia

Question 14.22 Which of the following finding(s) indicate an unresectable pleural mesothelioma?

A. Direct extension into the spine

B. Extension into the internal surface of the pericardium without pleural effusion

C. Direct transdiaphragmatic extension to the peritoneum

D. All of the above

Question 14.23 Frequent alteration of which of the following novel tumor suppressor genes is seen in mesothelioma?

A. RBL1

B. APC

C. RB1

D. BAP1

Question 14.24 Which of the following statements is applicable to peritoneal mesotheliomas?

A. It is not associated with airborne asbestos fiber exposure.

B. Median age of presentation is 50 years.

C. Pleural plaques are observed in approximately 50% of patients.

D. It is more common in females.

Question 14.25 A 60-year-old man was recently diagnosed with metastatic pleural mesothelioma. Assuming that this patient has no other significant comorbidities, which of the following chemotherapy regimens would be most preferable in the first-line setting?

A. Cisplatin and gemcitabine

B. Carboplatin and gemcitabine

C. Single agent pemetrexed

D. Cisplatin and pemetrexed

Stay updated, free articles. Join our Telegram channel

Join