LWBK1006-18 LWW-Govindan-Review November 24, 2011 11:24
212 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Reviewpresentation. Ninety percentage of pulmonary carcinoids are typical,
while 10% are atypical carcinoids. Surgery is the primary treatment for
carcinoid tumors. There is no role for adjuvant chemotherapy, following
complete resection for carcinoid tumors.Answer 18.11. The answer is A.
Erlotinib is a small molecule EGFR–tyrosine kinase inhibitor. Though it
is approved in the second-line setting for treatment of NSCLC, its benefit
appears to be mainly in patients with activating mutations in the tyrosine
kinase domain of EGFR (exon 19 deletion or exon 21 point mutation
L858R). Patients with exon 19 deletion respond better to erlotinib, than
patients with L858R mutations. The presence of dermatologic toxicity
from erlotinib therapy correlates with response to treatment. Resistance to
erlotinib therapy is mediated through two main mechanisms: acquisition
of a second mutation in EGFR (T790M), or through MET oncogene
amplification.Answer 18.12. The answer is C.
This patient has locally advanced NSCLC. Chemotherapy in addition
to radiation has been shown to improve survival over radiation alone,
and concurrent chemotherapy and radiation has been demonstrated to be
superior to sequential therapy. Chemotherapy alone would be indicated
for palliation of metastatic disease and is not appropriate in this setting.
Concurrent chemotherapy and radiation would provide the best chance
for cure.Answer 18.13. The answer is A.
LNEC accounts for 3% of surgically resected lung cancers. They are
diagnosed based on the following criteria: neuroendocrine morphology
with rosette-like structures, high mitotic rate, NSCLC features, such as
large cell size, low nuclear/cytoplasmic ratio, nucleoli, or vesicular chro-
matin and finally, neuroendocrine differentiation by immunohistochem-
istry. They are not associated with paraneoplastic syndromes or ectopic
hormone secretion. They have an aggressive natural history, though are
less chemosensitive than SCLCs. They are managed according to the same
treatment algorithm as NSCLC, stage for stage, though they carry a worse
prognosis.Answer 18.14. The answer is D.
In patients with EGFR mutations, initial therapy with an EGFR TKI
results in longer time to progression compared with chemotherapy,
though overall survival is similar in both groups. Though EGFR TKI ther-
apy does not confer a survival benefit in the first-line setting, most patients
prefer oral therapy, and the toxicities of EGFR TKI therapy (diarrhea and
acneform rash) compare more favorably than conventional chemother-
apy. However, first-line EGFR TKI therapy in patients with EGFR wild-
type tumors, or tumors with unknown EGFR status is less efficacious
than chemotherapy. Both erlotinib and gefitinib have been studied in