1
Q
Define Lymphoma
A
Malignancy of immune cells mostly in lymphoid tissues
2
Q
Define HL Classification of Lymphoma
A
- Very Curable
- 2 Subtypes: cHL and NLPHL
- Similar Presentation
3
Q
Define NHL Classification of Lymphoma
A
- Variable Cure Rates
- Many Subtypes
- Variable Presentation
4
Q
Define cHL: Classical Hodgkin Lymphoma
A
- Bimodal Age Distribution
- Very Curable
- REED-Sternbery Cells = Owl Eyes
5
Q
What are the typical immunophenotype on IHC in cHL?
A
- CD30+
- CD20-
- PDL1 and PDL2
6
Q
What are the symptoms of Lymphoma?
A
- Lymphadenopathy
- Hepatosplenomegaly
- Fatigue/Malaise
- Whole-Body Pruritus (HL Especially)
- EtOH Induced Lymph Node Pain
- B Symptoms
7
Q
What are the B Symptoms seen in Lymphoma Presentation?
A
- Fever >100.4
- Drenching Night Sweats
- Unintentional Weight Loss >10% over past 6 months
8
Q
What things are needed the diagnosis, staging, and prognostication of Lymphoma?
A
- Lymph/Bone Marrow Biopsy
- Pathology
- PET/CT
- Labs
9
Q
Initial cHL Treatment Considerations
A
- CURABLE INTENT
- Chemotherapy +/- Radiation
- Response Adapted Treatment
10
Q
Stage I-II Favorable Initial cHL Treatment
A
ABVD x 2-4 cycles +/- Radiation
11
Q
Stage I-II Unfavorable Initial cHL Treatment
A
- ABVD x 4 cycles + Radiation
- ABVD x 2 cycles —> AVD x 4 cycles
12
Q
Stage III-IV Initial cHL Treatment
A
ABVD x 2 cycles —> AVD x 4 cycles
Escalated BEACOPP
A + AVD x 6 cycles
13
Q
What is ABVD for cHL aka the Standard Care?
A
- Adriamycin
- Bleomycin
- Vinblastine
- Dacarbazine
14
Q
When is ABVD given in a 28 day cycle treatment plan?
A
Day 1 and Day 15
15
Q
Adriamycin aka Doxorubicin MOA and Cell Cycle
A
DNA intercalation + Topoisomerase II
Cell Cycle SPECIFIC
16
Q
What are the dose-limiting toxicities of Adriamycin/Doxorubicin?
A
- Myelosupression
- Cardiotoxicity
17
Q
What are the AEs of Adriamycin/Doxorubicin?
A
- Alopecia
- Urine Discoloration
- GI Effects
- Secondary AML
- Sterility
18
Q
What is the vesicant for Adriamycin/Doxorubicin?
A
Cold + DMSO
19
Q
What is the MOA and Cell Cycle of Bleomycin?
A
- DNA strand breakage
- Cell Cycle SPECIFIC G2 + M Phase
20
Q
What is the dose limiting toxicity of Bleomycin?
A
Pulmonary Toxicity
21
Q
What should Bleomycin NOT be used with due to increased risk of Pulmonary Toxicity?
A
- GCSF
- Brentuximab Vedotin
22
Q
What is the MOA and Cell Cycle of Vinblastine?
A
- Binds to tubular and inhibits microtubule formation
- Cell Cycle SPECIFIC M Phase
23
Q
What is the dose limiting toxicity and AE of Vinblastine?
A
- Myelosuppression
- Constipation
24
Q
What is the vesicant for Vinblastine?
A
HOT + Hyaluronidase
25
What is a concern with administering Vinblastine?
Do NOT Administer Intrathecally
26
What is the MOA and Cell Cycle of Dacarbazine?
1. Addition to Guanine, DNA break, Apoptosis
2. Cell Cycle NONSPECIFIC
27
What is the dose limiting toxicity and emetic potential of Dacarbazine?
1. Myelosuppression
2. High Potential
28
What is Subsequent Therapy for Refractory/Relapsed (R/R) cHL?
Brentuximab Vedotin (mono therapy or combo)
29
What is the MOA of Brentuximab +/- Bendamustine?
Targeted Therapy +/- Alkylating Agent
30
What is the dose limiting toxicity of Brentuximab +/- Bendamustine?
Peripheral Neuropathy and Myelosuppression
31
What is the Indication for Brentuximab Vedotin?
1. Advanced cHL
2. R/R cHL
3. Consolidation after
32
What is the MOA and dose limiting toxicities of Brentuximab Vedotin?
1. Binds CD30
2. Neutropenia and Peripheral Neuropathy
33
Can Bleomycin be used with Brentixumab Vedotin?
NO
34
What is the MOA and Cell Cycle for Bendamustine?
1. Single and double strand cross linking
2. Cell Cycle NONSPECIFIC
35
What is the dose limiting toxicity for Bendamustine?
Delayed Myelosuppression (nadir ~D21)
36
What is ICE and when is it used?
1. Ifosfamide
2. Carboplatin
3. Etoposide
Refractory R/R cHL
37
What is GemOx and when is it used?
1. Gemcitabine
2. Oxaliplatin
Refractory R/R cHL
38
ICE therapy requires growth factor support due to high NF risk, but what are the other AE concerns?
1. CNS Neurotoxicity (ifosfamide)
2. Nephrotoxicity (ifosfamide)
3. Infusion Rxn
4. EtOH (etoposide)
39
GemOx therapy requires growth factor support due to high NF risk, but what are the other AE concerns?
1. Toxicity with Infusion Rate (gemcitabine)
2. Cold Induced Neuropathy (oxaliplatin)
40
What is the MOA of Pembrolizumab + GVD, and what is GVD?
Immunotherapy + Chemotherapy for TRANSPLANT Eligible patients
1. Gemcitabine
2. Vinorelbine
3. Liposomal Doxorubicin
41
What is the dose limiting toxicity of Pembrolizumab + GVD?
Myelosuppression
42
What are the risk factors for Non-Hodgkin Lymphoma NHL?
1. Increased age, more common in white men
2. EBV/HIV/HEP C Infections
3. Prior exposure to radiation and alkylating agents
43
What types of NHL are consider INCIDENT and what is the presentation?
FL Grade 1 and 2
1. Wax and Wane Adenopathy
44
What types of NHL are consider AGRESSIVE and what is the presentation?
DLBCL FL Grade 3
1. B symptoms
2. Obstruction Adenopathy
45
What types of NHL are consider VERY AGRESSIVE and what is the presentation?
Double/Triple Hit, DLBCL, and Burkitt's
1. Rapidly growing mass
2. B symptoms
46
What is the most common NHL?
Diffuse Large B cell Lymphoma DLBCL
47
What is the typical immunophenotype of DLBCL?
1. CD20+
2. CD19+
3. CD79a/b+
48
What is the standard therapy for DLBCL?
R-CHOP
49
Define R-CHOP
1. Rituximab on Day 1
2. Cyclophosphamide on Day 1
3. Doxorubicin on Day 1
4. Oncovin (VINCRISTINE) on Day 1
5. Prednisone on Day 1-5
50
Rituximab is a Anti-20 agent, what are the points to know about it's role in R-CHOP?
1. NO DLT
2. Infusion rxns
3. Can reactivate Hep B
4. PRETREAT
51
What medications must you pretreat with for Rituximab?
1. APAP
2. Diphenydramine
Given before each dose
52
Cyclophosphamide is an Alkylating agent, what are the points to know about it's role in R-CHOP?
1. Interstand DNA strand cross linking
2. DLT = Myelosuppression
3. AE =Alopecia, Infertility, and SIADH
4. Emetic Potential = HIGH, acute & delayed
53
Vincristine is an Vinca Alkaloid, what are the points to know about it's role in R-CHOP?
1. DLT = Neurotoxicity (peripheral neuropathy)
2. Hepatic Metabolism
3. Vesicant = HOT
4. Do not administer intrathecally
54
What is the MAX Weekly Dose for Vincristine?
2 mg
55
What is Double and Triple Hit (HGBL DLBCL) Lymphoma?
Translocations of MYC + BCL2 +/- BCL6
56
Is there a poor or good prognosis of HGBL DLBCL with R-CHOP and what is the standard of care?
POOR, no standard of care yet
57
For R/R DLBCL, if >12 months from the last line of chemotherapy, for 2nd line chemotherapy if responsive consider what?
AutoHSCT
58
For R/R DLBCL, if >12 months from the last line of chemotherapy, for 2nd line chemotherapy if unresponsive consider what?
CART
59
For R/R DLBCL, if <12 months from the last line of chemotherapy or primary refractory consider what?
CART +/- Bridging Therapy
60
What therapy regimen is Preferred for R/R DLBCL 2nd line setting?
RGemOx or RICE
AKA Adding Rituximab to the original GemOc or ICE
61
CART therapy cause cytotoxicity of the tumor cells, but what are the adverse reactions of this therapy used for R/R DLBCL Lymphoma?
1. CRS
2. ICANS
62
What is used in the treatment of CRS/ICANS?
Corticosteroids and/or Tocilizumab
63
What is used for 2nd Line Option +/- Bridging Therapy for R/R DLBCL?
Polatuzumab Vedotin w/ Bendamustine + Rituximab
64
Polatuzumab Vedotin targets CD79b as its MOA but what are the AEs of the agent?
1. Myelosuppression
2. Neuropathy
3. Hepatotoxicity
65
Polatuzumab Vedotin requires what prophylaxis before starting treatment?
1. PJP -- bactrim
2. HSV -- acyclovir
66
What is the indication and MOA of Tafastimab + Lenalidomide?
1. 2nd Line Option, potential option for patients not sutiable for intense chemotherapy (BRIDGE to autoHSCT or CART)
2. Targeted drug therapy + iMID oral therapy
67
What is the indication and MOA of Loncastuximab Tesirine?
1. 3rd Line Option, potential option for patients not suitable for intense chemotherapy
2. Targeted drug therapy, alkylating agent
68
What are the AEs of Lenalidomide?
Myelosuppression and VTE
69
Use of Lenalidomide requires what?
ASA 81 mg QD
70
What are the AEs of Loncastuximab Tesirine?
Myelosuppression, Infection, and Edema
71
Use of Loncastuximab Tesirine requires what?
Dexamethasone to prevent edema
72
What is the 2nd most common form of NHL?
Follicular Lymphoma
73
What is the typical immunophenotype of Follicular Lymphoma FL?
CD20+
74
What is the therapy for Grade 1&2; Stage I&II FL?
1. Watch and Wait
2. Radiation +/- Rituximab
3. Rituximab Monotherapy
75
What is therapy for Grade 1&2; Stage III&IV Grade 3a? FL?
1. Rituximab or Obinutuzumab + Bendamustine
2. RCHOP
3. Rituximab + Lenalidomide
76
What is therapy for Grade 3b FL?
1. RCHOP
77
What is maintenance therapy for FL?
1. Rituximab q2-3 months x 2 years
2.Obinutiuzumab q2months x 12 doses
78
What is the MOA of Obinutuzumab?
Anti-CD20
79
What is the required study prior to initiating Obinutuzumab?
HepB Serologies
80
What are the Non-Modifiable Risk Factors of Breast Cancer?
1. Genetics
2. Age >60
3. Endogenous Estrogen Exposure
4. Breast Cancer
5. Benign Thoracic Irradiation
6. Personal FH
81
What are the Modifiable Risk Factors of Breast Cancer?
1. Obesity/BMI
2. Physical Activity
3. Alcohol
4. Exogenous Estrogen Exposure
82
A decrease in weight in premenopausal women would increase their risk of breast cancer true or false?
True
83
What are the 2 Risk Assessment Models commonly used for Breast Cancer?
1. Gail Model
2. Modified Gail Model
84
When are annual mammograms recommended?
Average Risk Women >40 yrs
85
What deems a patient high risk of Breast Cancer?
1. Prior History
2. Lifetime Risk >20
3. Prior RT
4. 5y Gail MR
5. BRCA1/2 Mutation
6. FH of BRCA Mutation
86
What are forms of Primary Prevention for Breast Cancer?
1. Mastectomy (90%)
2. B/I Oophorectomy (50%)
3. Tamoxifen
4. Raloxifene
5. Aromatase Inhibitors
87
When would Tamoxifen be used in Primary Prevention of Breast Cancer and what is the concern with its use?
Used for PRE and POST menopausal women
1. Increased Endometrial Cancer
2. Increased VTE
88
When would Raloxifene and Aromatase Inhibitors be used in Primary Prevention of Breast Cancer?
POSTmenopausal women
89
What are the 4 Types of Breast Cancer?
1. Lobular Carcinoma in SITU (LCIS)
2. Ductal Carcinoma in SITU (DCIS)
3. Invasive Lobular Carcinoma (ILC)
4. Invasive Ductal Carcinoma (IDC)
90
What two forms of "Breast Cancer" are not malignant but are considered PRE-Cancer?
1. LCIS
2. DCIS
91
What is TNM Staging in Breast Cancer?
T = Size of main tumor
N = Lymph node spread
M = Metastasis
92
Where are the most common sites of tumors in Stage IV Breast Cancer?
1. Bones
2. Lungs
3. Liver
4. Brain
93
What are the 3 markers for Breast Cancer?
1. ER = estrogen receptor
2. PR = progesterone receptor
3. HER2 = her2 neu protein
94
Normal Cells HER2 gene number
2-5 copies of HER2 gene
Up to 20,000 HER2 receptors
95
Breast Cancer Cells HER2 gene number
20-25 copies of HER2 gene
Up to 2 million HER2 receptors
96
IHC Score for HER2 Breast Cancer
0-1+ = negative
2+ = equivocal
3+ = positive
97
What are the Prognostic Factors of Breast Cancer?
1. Response to Systemic Chemotherapy
2. Estrogen Receptor ER/Progesterone Receptor PR Status
3. Grade
4. Proliferation Rate Ki-67
5. HER2 Amplification/Overexpression
98
For Response to Systemic Chemotherapy (prognostic factor in breast cancer), is Primary Resistance a good or poor prognosis?
POOR
99
For ER/PR Status (prognostic factor in breast cancer), is a Positive Status a bad prognosis true or false?
FALSE
Positive = GOOD prognosis
100
For a <50 yo woman with a <15 RS or >50 yo woman with <25 RS, what should be recommended?
Endocrine/Hormone Therapy
101
For a <50 yo woman with >15 RS or >50 yo woman with >25 RS, what should be recommended?
Chemoendocrine/Chemotherapy + Hormone Therapy
102
Oncotype Prognostic Tools predicts recurrence with EBC and benefit from chemotherapy, must demonstrate what to use these tools
ER+,, HER2-, and LN-
103
<25 RS vs >25 RS EBC means what in terms of chemotherapy?
>25 = chemo + hormone
>25 = NO chemo benefit
104
What role does Surgery have in treatment of BC?
Role in Stage I-III
105
What is BCS (Lumpectomy)?
Increase in loco regional recurrence >5cm
106
What role does Radiation have in treatment of BC?
With BCS or Mastectomy
107
What is Neoadjuvant?
Before Surgery
108
What is Adjuvant?
After surgery, prevent micrometastatic disease from progressing
109
When would you use Adjuvant Chemo?
1. LN Positive
2. HER2 Positive
3. TNBC
4. Oncotype Score
110
When would you use Adjuvant Hormone Therapy?
ER/PR+ or following cytotoxic chemo
111
What is TNBC?
Triple Negative
112
What 3 Categories fall under Early BC?
1. HER2+ (HR+/-)
2. TNBC
3. HR+/HER2-
113
What are the 3 Therapy Regimens for HER2+ BC?
1. TCH
2. TCHP
3. Weekly Paclitaxel, Trastuzumab +/- Pertuzumab
114
What is TCH Regimen?
1. Docetaxel
2. Carboplatin
3. Tratuzumab
115
What is TCHP Regimen?
1. Docetaxel
2. Carboplatin
3. Trastuzumab
4. Pertuzumab
116
What drugs should be avoided with Trastuzumab?
AVOID Anthracycline: rubicins
117
What is AC-T?
A = Doxorubicin
C = Cyclophosphamide
T = Paclitaxel
118
What is recommended ACT-T or TCHP for HER2+ EBC?
TCHP, ACT-T has increased CHF and heart issues
119
Why add Pertuzumab to TCH or Weekly Paclitaxel+Tratsuzumab for EBC HER2+?
Improved invasive disease free survival
120
For HER2+ Treatment EBC, Start with TCHP or Weekly Pac+Trast (HP) then followed by surgery, what is recommended if the patient has NO residual disease?
Tratsuzumab +/- Pertuzumab
121
For HER2+ Treatment EBC, Start with TCHP or Weekly Pac+Trast (HP) then followed by surgery, what is recommended if the patient has residual disease?
Ado-Trastuzumab Emtansine or continue with Pac + Trast (HP) for 1 yr
122
What are the treatment options for HR+/HER2- EBC?
1. Dose Dense AC-T
2. Dose Dense AC + T
3. TC
123
What is Dose Dense AC-T?
1. Doxorubicin
2. Cyclophosphamide
3. Paclitaxel q2weeks
124
What is Dose Dense AC + T?
1. Doxorubicin
2. Cyclophosphamide
3. Paclitaxel weekly
125
What is TC?
1. Docetaxel
2. Cyclophosphamide
126
What drugs are preferred in HR+ HER2- EBC?
Anthracyclines, reduce recurrence by 25%
127
What are the treatment regimen options for TNBC EBC?
-Neoadjuvant Pembrolizumab + [TC] Carboplatin + [TC] Paclitaxel followed by
-Pembrolizumab + [AC] Doxorubicin + [AC] Cyclophosphamide followed by
-Surgery + Pembrolizumab +/- Capcitabine
128
What is the treatment considerations for Metastatic Breast Cancer?
1. Bone Disease
2. ER/PR+, HER2-
3. TNBC
4. HER2+
5. HER2 LOW +1/2/FISH Non-Amplified
129
For patients with MBC Bone Metastasis, what bone modifying agents can be added to current regimen?
1. Pamidronate
2. Zoledronic Acid
3. Denosumab --> preferred
130
What is the treatment therapy plan for ER/PR+, HER2- NO Visceral Crisis MBC?
1. Change Endocrine = Tamoxifen, Letrozole, Anastrozole, Exemesane, Fulvestrant
2. Premenopause = Tamoxifen --> AI [aromatase inhibitor]+OAS [ovarian ablation]
3. Fulvestrant + Alpelisib for PIK3 mutated MBC
131
What is the treatment therapy plan for ER/PR+, HER2- Visceral Crisis MBC?
1. IV Chemo
2. Combination? --> increased toxicity and no OS benefit
3. Treat with previous agents is okay for TAXANES!!
132
What is the treatment agent options for HER2- MBC?
1. Liposomal Doxorubicin
2. Weekly Paclitaxel
3. Oral Capecitabine
4. Gemcitabine
5. Vinorelbine
6. Eribulin
7. Ixabepilone
8. Albumin-Bound Paclitaxel
9. Carboplain + Gemcitabine
133
Sacituzumab is approved ONLY for what type of MBC?
TNBC
134
What is first line therapy for HER2+ MBC?
1. Trastuzumab + Pertuzumab + Docetaxel or Paclitaxel
135
What is second line therapy for HER2+ MBC?
1. Ado-Tratuzumab Emtansine
2. Fam-Tratuzumab Emtansine
136
What is the BBW and Max Lifetime Dose of Doxorubicin which inhibits Topoisomerase II?
Cardiomyopathy
MAX = 550 mg/m2
137
What is the Monitoring and AEs of Doxorubicin?
1. ECHO/MUGA at baseline
2. Cardiotoxcitiy, Discoloration of Bodily Fluids
138
If CHF develops from Doxorubicin there is a 50% mortality rate, what is used for the prevention of cardiomyopathy and treatment of extravasation of Doxorubicin?
Dexrazoxane
139
What is Doxorubicin and Cyclophosphamide used for?
AC and AC-T therapy regimens in HR+/HER2- EBC
140
What is the AE of Cyclophosphamide that is an alkylating agent preventing cell division by cross linking DNA strands?
Hemorrhagic Cystitis
141
Are Doxorubicin and Cyclophosphamide highly emetic agents true or false?
True
142
Paclitaxel is used in AC-T for HR+/HER2- EBC, what is its AEs?
1. Infusion Reactions --premedicate (famotidine/dex/diphen)
2. Peripheral Neuropathy -- EXAM
143
Docetaxel is used in TC [HR+/HER2-] and TCHP [HER2+], what is its AEs?
1. Neurotoxicity
2. Edema
144
What must you premeditate with for Docetaxel to prevent Fluid Retention?
Dexamethasone 8 mg PO BID x 3 days
145
Carboplatin is used in TC+Pem [TNBC] and TCHP [HER2+], what is its AEs?
1. N/V
2. Neuropathy
146
What is the CrCl cutoff for Carboplatin?
CrCl <50 = dose reductions
147
Gemcitabine is only used in MBC and inhibits ribonucleotide reductase, when do you dose reduce with Gemcitabine?
Bilirubin >1.6 mg/dL
148
Vinorelbine is a single agent that inhibits microtubule formation for HER2- MBC what do you have to monitor for?
1. Neuropathy/Pulmonary sis
Neurotoxicity = AE
149
Eribulin inhibits formation of mitotic spindles and used as a single agent for HER2- MBC, what is its AEs?
Peripheral Neuropathy
150
Ixabepilone inhibits formation of mitotic spindles and used as a single agent for HER2- MBC, what is its AEs?
1. Neuropathy
2. Arthralgia/Myalgia
3. Infusion Reactions
151
Albumin Bound Paclitaxel is used as a single agent for HER2- MBC, what is its AEs?
Neuropathy
152
What is the MOA of Sacituzumab Govitecan-hziy?
Antibody Drug Conjugate: humanized anti-trophoblast cell surface antigen (Trop-2) + Topoisomerase 1 Inhibitor SN-38
(used for TNBC following 2 prior therapies)
153
What is the main AE of Sacituzumab Govitecan-hziy?
Diarrhea
154
Tratuzumab is used in TCHP HER2+ EBC, what is its BBWs and AEs?
BBW = Cardiomyopathy, Infusion Rxn, Pulmonary Toxicity
AE DECREASED LVEF
155
What are 3 forms of resistance to Trastuzumab?
1. Steric Effects
2. Alternate Elevations
3. Intracellular Alteration Signaling
156
What is the MOA of Pertuzumab used in TCHP HER2+ EBC?
Binds to dimerization domain of HER2 protein, inhibits dimerization = apoptosis
157
What are the AEs of Pertuzumab?
1. Diarrhea
2. DECREASED LVEF
158
Pertuzumab can ONLY be given with Trastuzumab, not as monotherapy or with any other agent true or false?
True
159
What is the MOA of Ado-Tratuzumab Emtansine?
1. Tratuzumab MOA: binds HER2 and inhibits proliferation
2. Microtubule Inhibitor DM1 = apoptosis
160
What is the BBW/AEs of Ado-Trastuzumab Emtansine?
BBW = cardiomyopathy, hepatotoxicity
AE = DECREASED LVEF
161
What is the MOA and USE of Fam-Trastuzumab Deruxtecan?
1. Tratuzumab MOA: binds HER2 and inhibits proliferation
2. Topoisomerase I Inhibitor = apoptosis
USED in HER+ MBC after failure of 2 previous lines of treatment
162
What is the AEs of Fam-Trastuzumab Deruxtecan?
1. Cardiotoxicity
2. Pulmonary Toxicity
163
What is the indication of Margetuximab?
HER2+ MBC, in combination with chemotherapy = 3rd Line
164
What is the Adjuvant Endocrine Therapy options for Normal Risk/HER2+ patients?
1. Endocrine Therapy: AIs
2. SERM: Tamoxifen
165
What is the Adjuvant Endocrine Therapy options for High Risk of Recurrence patients?
Abemaciclib + Endocrine Therapy
166
Low Levels of ER, ER/PR, and BC = better outcomes true or false?
False, you want HIGH levels
167
Do Aromatase Inhibitors AIs work well in younger patients?
NO, they target fat tissues and convert androgen to estrogen
168
What is the Indication and MOA of Tamoxifen?
1. Hormone Receptor HR + BC; use independent of menopausal status
2. Selective Estrogen Receptor Modulator SERM, that competitively binds to estrogen receptors
169
What is the dosing for Tamoxifen?
20 mg po d, x 5-10 yrs
170
Tamoxifen acts as an ER Agonist where and what are the effects?
1. Bone = strengthens bone aka GOOD
2. Uterine ER = increased risk of uterine cancer aka BAD
171
Tamoxifen acts as an ER Antagonist where and what are the effects?
Breast = reduces breast cancer recurrence aka GOOD
172
What is the trial and dose for Anastrozole that determined initial therapy?
ATAC Trial
1 mg po qd x 5 years
173
What is the trial and dose for Letrozole that determined initial therapy?
BIG 1-98
2.5 mg po qd x 5 yrs
174
What is the trial for Exemestane that determined initial therapy?
TEAM
175
What is the max amount of years for AI use?
7 years
176
What is the MOA of AIs: Letrozole, Anastrozole, and Exemestane?
Selective aromatase inhibitor; inhibits peripheral conversion of androgens to estrogen
177
What are the AEs of AI agents?
1. Bone Loss
--Recommend Calcium + Vitamin D +/- Denosumab
178
Endocrine Therapy can caused related Hot Flashes, what is the preferred treatment of choice to treat this symptom?
Antidepressants = VENLAFAXINE
179
What Endocrine Therapy is used in postmenopausal metastatic women ONLY?
Fluvestrant
180
What is the MOA and Route of Fluvestrant?
Estrogen receptor antagonist, causes down regulation of estrogen receptors
IV ONLY
181
What agents are CDK4/6 Inhibitors used in HR+, HER2- BC?
1. Palbociclib
2. Ribociclib
3. Abemaciclib
182
CDK4/6 Inhibitors are indicated for what type of BC?
HR+, HER2-
183
What is the AE of Palbociclib and Ribociclib?
Neutropenia
184
What is the AE of Abemaciclib?
1. Diarrhea
2. Neutropenia
3. Nausea
4. Fatigue
5. VTE
185
What is the monitoring for CDK4/6 Inhibitors?
1. CBC
2. CMP
Neutropenia concerns
186
What is the special monitoring parameters for Ribociclib and Abemaciclib?
1. Ribociclib = ECG Baseline = QT Prolongation
2. Abemaciclib = VTE
187
What is the MOA of mTOR Inhibitors?
Macrolide immunosuppressant and a mechanistic target of rapamycin inhibitor aka anti proliferative and antiangiogenic (inhibit VEGF)
188
Everolimus is an mTOR Inhibitor used in HR+, HER2- BC, what are its AEs?
1. Stomatitis
2. Diarrhea
189
What is the MOA and Indication of PI3K Inhibitors?
PI3K inhibitor inhibits Act-signaling, cellular transformation, and tumor generation
Indicated for:
1. PI3KCA mutated HR+ MBC in combo with Fulvestrant
190
Aleplisib is the PI3K inhibitor used in HR+ MBC, what is its AEs?
Hyperglycemia
191
Capecitabine is used as a single agent 5-FU for BC, what are its AEs?
1. Palmar Plantar Erythrodysethesia
2. Diarrhea
3. Stomatitis
192
What drugs are PARP Inhibitors used for BRCA Mutation MBC HER2-?
1. Olaparib
2. Talazoparib
193
What is the MOA and Indication of Lapatinib?
Tyrosine kinase inhibitor inhibits EGFR and HER2 blocking cell proliferation
Used after Trastuzumab FAILURE
194
Is Lapatinib an Oral or IV medication?
ORAL
195
What is the MOA and Indication of Tucatinib?
Tyrosine Kinase Inhibitor, inhibits cell proliferation
Used with and without BRAIN Metastases
196
What is the AE of Tucatinib?
Hepatotoxicity
197
What drug is given if BC reaches Bone Metastases?
Zolendronic Acid
198
Define Leukemia
Immature proliferating leukemia cells (BLASTS) inhibit normal cellular maturation in bone marrow = crowding out
199
Leukemia can result in what 3 diseases?
1. Anemia
2. Neutropenia
3. Thrombocytopenia
200
What are the types of Leukemia?
1. Acute Myeloid Leukemia AML
2. Acute Lymphoblastic Leukemia ALL
3. Chronic Myeloid Leukemia CML
4. Chronic Lymphocytic Leukemia CLL
201
What is the Etiology of Leukemia?
No balance between proliferation and differentiation leads to cells not differentiating past particular stage of hematopoiesis
202
What are common Lab Findings for the types of Leukemia?
1. Thrombocytopenia = all leukemias
2. Leukocytes = AML/ALL/CML
3. Lymphocytosis = CLL/ALL
4. Disseminated Intravascular Coagulation =APL
203
What are 3 Risk Factors of Acute Myeloid Leukemia AML?
1. Prior exposure to Topo II Inhibitors
2. Prior exposure to Cytotoxic/Alkylating Agents
3. Prior Radiation
204
What are the 4 Categories of AML?
1. AML with recurrent cytogenetic abnormalities
2. AML with myelodysplasia related changes
3. Therapy related myeloid neoplasms
4. AML not otherwise specified [NOS]
205
What is the short term goal for AML treatment?
Complete Response CR
206
What is the long term goal for AML treatment?
5 years considered cured
207
What is the treatment algorithm for AML?
1. Induction
2. Achieve CR
3. Determine Risk
4. Favorable = Consolidation
5. Unfavorable = Stem Cell Transplant
208
What is Induction Therapy for AML?
7+3 Regimen
7 days Cytarabine
3 Days Anthracycline (idarubicin or daunorubicin)
209
What should be the dose for Daunorubicin in induction therapy for AML in patients <65 yrs?
INTENSE = 90
210
What is Consolidation Therapy for AML?
HIGH DOSE Cytarabine = 3 grams
211
Is Maintenance Therapy, low dose chemo for 1-3 years used in AML?
NO, used in APL
212
What is the MOA/Class of Cytarabine?
1. Antimetabolite S Phase Specific
2. Inhibits DNA polymerase halting chain synthesis
213
What is the dose limiting toxicity of Cytarabine?
1. Leukopenia
2. Thrombocytopenia
214
What should be given with Cytarabine to prevent Conjunctivitis?
Dexamethasone Eye Drops 0.1% q6hrs and continues 24hrs after last dose
215
What is Vyxeos?
Liposomal Daunorubicin and Cytarabine
216
What is the indication of Vyxeos?
Treatment of patients with newly diagnosed therapy related AML or AML with myelodysplasia related changes
217
Vyxeos does not work for the general public due to risks that are what?
It accumulates in bone marrow with preferential uptake by leukemia cells = PROLONGED CYTOPENIAS
218
What is Mylotarg?
Gemtuzumab = CD33
Ozogamicin = dna strand breaks
219
What is the toxicity associated with Mylotarg that would cause patients to immediately seek care?
Liver Toxicity
220
The goal of treatment in Acute Lymphoblastic Leukemia ALL is what?
Cure
221
What agents are used in Induction of Adult ALL?
1. Anthracycline
2. Vincristine
3. Corticosteroid
4. Asparginase
222
Is Maintenance chemotherapy recommended in ALL? Such as Methotrexate + Vincristine once a month
YES
223
What corticosteroids are used in ALL?
1. Prednisone
2. Dexamethasone
224
What toxicities are of concern with corticosteroid treatment?
Infection, should be on PJP prophylaxis with bactrim
225
Patients with Heterozygous TPMT genotype tend to experience moderate to severe what when using 6-Mercaptopurine for ALL?
Myelosuppression
226
What is the Pearl/DDI for 6-MP used for ALL?
1. Take on an empty stomach
2. Allopurinol reduced 6-MP by 75%
227
Asparaginase is used for ALL, what is the MOA/Toxicity?
1. Depletion of asparaginase in leukemia cells
2. Allegic Rxns
228
What is the MOA of Blinatumomab?
1. Monoclonal antibody designed to direct cytotoxic T Cells
2. Targets CD19
229
What is the indication for Blinatumomab?
1. R/R ALL
2. Consolidation for <65 yrs without substantial comorbidity MRD+
230
What are the pearls for Blinatumomab?
Do NOT flush infusion line
231
What are the AEs of Blinatumomab?
1. Cytokine Release Syndrome CRS
2. Neurological Toxicities
3. Infections
232
What is the MOA of Inotuzumab Ozogamicin?
Binds CD22, induced dna strand breaks/apoptosis
233
What drugs are considered CART?
1. Tisagenlecleucel-T
2. Brexucabtagene Autoleucel
234
What is an Actionable Mutation?
Isocitrate Dehydrogenase (IDH) mutations occur in 15-20% of AML
235
FLT3 Mutations occur in 30-35% of AML, what is FLT3?
FMS-Like Tyrosine Kinase 3
-Transmembrane protein leads to uncontrolled proliferation in bone marrow
236
What is FLTL3-ITD?
Internal Tandem Duplication, prevents ASSOCIATION
237
What is FLT3-TKD?
Tyrosine Kinase Doman, occurs in ACTIVATING LOOP
238
What agents are FLT3 Inhibitors?
1. Midostaurin = 1st gen
2. Fliterinib = 2nd gen
239
What is the indication and dose of Midostaurin?
1. AML with FLT3 mutation in combination with chemotherapy
2. Take with food
240
What are the common AEs of Midostaurin?
1. Neutropenia
2. N/V/D
241
What are the DDIs of Midostaurin?
1. Strong 3A4 Inhibitros = fluconazole
2. QTc prolonging drugs
242
What is the MOA of Gilteritinib?
FLT3 TKI that is highly selective
243
What is the dose/indication of Gilteritinib?
1. R/R AML with FLT3 Mutation
2. 120 mg once daily for 6 months minimum
244
What are the AEs of Gilteritinib?
1. Prolonged QTc
2. Differentiation Syndrome (cytokine)
245
What is the Treatment for Differentiation Syndrome?
1. Stop therapy causing differentiation
2. >48 hrs later if symptoms persist start steroid therapy
3. Start dexamethasone 10 mg BID x 3 days
246
What are IDH Mutations?
IDH = Isocitrate Dehydrogenase = leads to imapired differentiation
IDH1, IDH2, IDH3
247
What is the MOA/Indication of Enasidenib?
1. Used for R/R AML
2. Selective IDH2 Inhibitor
248
What is the dose/BBW of Enasidenib?
1. Treat for 6 months minimum
2. Differentiation Syndrome
249
What are the AEs of Enasidenib?
Indirect Hyperbilirubinemia -> off target UGT1A1 inhibition
250
What is the MOA/Indication of Ivosidenib?
1. Used for R/R AML
2. Selective IDH1 Inhibitor
251
What is the dose/warning of Ivosidenib?
1. treat 6 months minimum
2. QTc Prolongation
3. Differentiation Syndrome
252
What drugs are Hypomethylating Agents that directly incorporate into DNA?
1. Azacitidine
2. Decitabine
253
What is the MOA of Venetoclax for AML?
1. Selective BCL-2 Inhibitor
2. Anti-Apoptic B Cell Lymphoma Protein
254
What is the Indication for Ventoclax in AML?
Combinatoin with Azactidine of Decitabine for treatment of NEW diagnosed AML patients >75 yrs OR >65 yrs patients with comorbidites that preclude use of intensive induction chemo
255
For Dose Escalation of Venetoclax, what should be administered with it?
1. Hydration
2. Allopurinol
256
Reduce Ventoclax by 50% or 75% with what?
50% with fluconazole/isavuconazole
75% with voriconazole/posaconazole
257
What is the most curable AMLsubtype and is associated with high incidence of disseminated intravascular coagulation DIC?
Acute Promyelocytic Leukemia APL
258
APL has what genetic problems?
1. t(15;17) results in promyeloctic gene with retinoic acid receptor alpha
2. PML-RARa causes failure to differentiate and blocks apoptosis
259
What is used in HIGH Risk WBC >10k APL Induction Therapy?
1. ATRA (Tretinoin)
2. Anthracycline (danuo or idarub)
3. Arsenic -- ONLY for those that cannot receive anthracyclines
260
What is used in LOW Risk WBC <10k APL Induction Therapy?
1. ATRA Tretinoin
2. Arsenic ATO
261
What is the treatment regimen for APL Consolidation?
1. ATRA
2. Anthra = high risk
3. Or Arsenic = low risk
262
What is the treatment regimen for APL Maintenance?
1. ATRA
2. 6-MP
3. Methotrexate
1-2 years
263
What is the MOA of ATRA, Tretinoin?
Allows for differentiation of leukemic cells
264
What is the MOA of Arsenic Trioxide?
1. Damages or Degrades the fusion protein PML-RAR Alpha
2. Allows differentiation of promyelocytic cells
265
Arsenic Trioxide can cause QTc Prolongation, when should you DC or Reinitiate therapy?
>500 msec or irregular heartbeat = DC
<460 msec = Reinitate
266
What is the Etiology of Chronic Myeloid Leukemia?
Philadelphia Chromosome
267
What are the 3 Classifications for CML?
1. Chronic Phase CP = Benign
2. Accelerated Phase AP = Aggressive
3. Blast Crisis BC = Very Aggressive
268
What is the MOA/Indication of Imatinib?
1. Initial or Salvage Therapy for CP/BC CML
2. Binds to ATP binding site on BCR-ABL inhibits phosphorylation
269
What is the toxicities of Imatinib?
1. Myelosuppression
2. N/V
3. Myalgias
270
What are the Pearls of Imatinib?
1. Take with food
2. Limit APAP to 1300 mg/day due to liver toxicity
271
What is the MOA/Indication of Dasatinib?
1. Inhibits BCR-ABL
2. Initial chronic phase or resistant CML
272
What are the DDIs/dose limiting toxicities of Dasatinib?
1. AVOID PPI/H2RA
2. DLT = Pleural Effusions
273
What is the MOA/Indication for Nilotinib?
1. CP/AP CML
2. Inhibits BCR-ABL
274
What is the DDI/DLT of Nilotinib?
1. AVOID PPIs
2. DLT= QTc prolongation
275
How do you take Nilotinib?
With an EMPTY stomach
276
What is the MOA/Indication for Bosutinib?
1. CP or R/R CML, not 1st or 2nd line
2. Inhibit BCR-ABL
277
What are the DDIs/Toxicities of Bosutinib?
1. AVOID PPI
2. Diarrhea
278
How do you take Bosutinib?
WITH FOOD
279
What is the MOA/Indication of Ponatinib?
1. Last line R/R CML
2. Inhibits BCR/ABL
280
What are the toxicities associated with Ponatinib?
1. Peripheral/Arterial Thrombosis
2. HF
3. VTE
4. Hepatic
281
What is used first line in CML?
Imatinib
or Dasatinib, Nilotinib, Bosutinib
282
Therapy for CLL Upfront without Deletion of 17p for Frail or >65 yrs or with Comorbidity CrCl <70 or <65 yrs without comorbidity is what?
1. Acalabrutinib +/- Obinutuzumab
2. Venetoclax +
3. Obinutuzumab +
4. Zanabrutunub
283
Therapy for CLL R/R without Deletion of 17p for Frail or >65 yrs or with Comorbidity CrCl <70 or <65 yrs without comorbidity is what?
1. Acalabrutinib +
2. Zanabrutinib
3. Venetoclax +
4. Rituximab
284
Therapy for CLL Upfront WITH Deletion of 17p is what?
1. Acalabrutinib +/- Obinutuzumab
2. Venetoclax +
3. Obinutuzumab +
4. Zanabrutunub
285
Therapy for CLL R/R WITH Deletion of 17p is what?
1. Acalabrutinib +
2. Venetoclax +
3. Rituximab
4. Zanabrutinib
286
What is the MOA of Obinutuzumab used in CLL without deletion?
1. Anti CD20
2. Type II Antibodies induce apoptosis without cross-linking antibody
287
What drugs are BCR inhibitors?
1. Ibrutinib
2. Acalabrutinib
3. Zanabrutinib
288
What is the preferred frontline treatment of CLL with 17p deletion?
Ibrutinib
289
What are AEs of Ibrutinib?
Lymphocytosis
290
What is the target of Idelalisib?
Used in CLL
Inhibits PI3K
291
Acalabrutinib is highly potent, has a DDI with CYP3A4 substrates, and is used in CLL, what is the most common AE associated with this agent?
Headaches
292
Zanabrutinib is better tolerated but has what AEs?
Lymphocytosis
293
Fludarabine is an Antimetabolite, what toxicities does it have?
1. Myelosuppression
2. Tumor Lysis Sundrome
3. CNS Toxicity
294
Fludrarabine requires prophylaxis for myelosuppresion AE, what are the premedications?
1. Acyclovir
2. Bactrim
295
Deleted 17p in CLL leaned what?
Loss of TP53 gene, decreased survival and chemotherapy resistance
296
What are the Risk Factors associated with Lung Cancer?
1. Cigarette Smoking
2. Older Age
3. Radium 226 Decay
4. Occupational exposure to carcinogens
5. Radiation Therapy
297
When is Low Dose Chest CT [LDCT] Recommended for Screeningn of Lung Cancer?
High Risk Individuals: adults age 50-80 yrs who have a 20 pack year smoking history and currently smoke or have quit within the past 15 years
298
Define Small Cell Lung Cancer SCLC
1. Strong correlation with smoking
2. More agresive
3. Highly sensitive to chemo/RT
4. Poor prognosis, long term survival rare
299
Define Non Small Cell Lung Cancer NSCLC
1. Genetic
2. 3 Subtypes: adenocarcinoma, squamous cell, large cell
3. Squamous Cell NSCLC CORRELATED WITH SMOKING
4. Less aggressive
300
What are 2 symptoms associated with Lung Cancer?
1. Superior Vena Cava SVC Syndrome
2. Paraneoplastic Syndrome = SCLC
301
What is the treatment standard for Limited Staged SCLC?
Systemic Chemo [Platinum Doublet] + RT
302
What is the Platinum Doublet used in SCLC Limited Stage?
CISPLATIN + Etoposide
Use Carboplatin if Cisplatin not tolerated
303
What is the treatment standard for Extensive Staged SCLC?
Systemic Chemo [Platinum Doublet] + Immunotherapy
304
What is the Platinum Doublet used in SCLC Extensive Stage?
Carboplatin + Etoposide
305
What is the immunotherapy in Extensive Stage SCLC?
Atzeolizumab
306
Whole Brain Radiation WBRT, is given in what type of SCLC?
Extensive Stage
307
Define Localized SCLC
There is no sign that the cancer has spread outside the lung
308
Define Regional SCLC
The cancer has spread outside the lung to nearby structures or lymph nodes
309
What is the Preferred Regimen for Relapse SCLC <6 Months? Platinum Resistance
1. Topotecan
2. Lubrinectedin
310
What is Preferred Regimen for Relapse SCLC >6 Months? Platinum Sensitive
Use same platinum doublet regimen
311
What are 3 reasons to not be a candidate for Cisplatin therapy?
1. Renal Failure
2. Ototoxicity
3. Neuropathy
312
What type of mutations are categorized as NSCLC?
1. KRAS Mutations
2. EGFR Mutations
3. ALK Rearrangements
313
What Exon mutations are EGFR Mutations?
Exon 19 deletions
Exon 21 Point mutation
314
What is the MOA/Indication of Pemetrexed?
1. Inhibits multiple enzymes
2. Preferred in Non-Squamous and AVOID in Squamous NSCLC
315
Pemetrexed has toxicities that are myelosuppression (DLT) and N/V/D, what should be given to decrease these?
1. Folic Acid qd
2. Vitamin B12 IM
316
Pemetrexed can cause cutaneous reactions, what should be used for premedications to avoid this toxicity?
Dexamethasone x3 days
317
Pemtrexed is cleared by the kidneys, and should be AVOIDED when?
1. USE with NSAIDS (avoid NSAIDs)
2. CrCl 45-79
318
What two drugs are Anti-Angiogenic Inhibitors used in NSCLC?
1. Bevacizumab
2. Ramucirumab
319
What is the MOA of Ramucirumab?
Inhibits VEGF2 by binding to it and blocks ligand binding
320
What drugs are PDL1 Inhibitors and are recommended for first line NSCLC?
1. Atezolizumab
2. Avelumab
3. Durvalumab
321
What drugs are PD-1 Inhibitors for NSCLC?
1. Cemiplimab
2. Desterlimab
322
What is the Management of irAE Colitis: diarrhea, abdominal pain, blood in stool?
1. Supportive Care
2. Antidiarrheals
3. Corticosteroids
4. Infliximab if refractory
323
What is the Management of irAE Pneumonitis: dyspneaa, dry cough, SOB?
1. Corticosteroids
2. Infliximab
3. IVIG
4. Mycophenolate Mofetil if refractory
324
What is the Management of irAE Hepatitis: ALT/AST, Bilirubin elevation?
1. Corticosteroids
2. Mycophenolate Mofetil if refractory
AVOID Infliximab
325
What is the Management of irAE Dermatitis: rash, SJS, TEN?
1. Topical bethamethasone/antihistamine
2. Corticosteroids
326
What is the Management of irAE Neuropathy: myasthenia graves?
Corticosteroids
327
What is the Management of irAE Endocrinpathy: hypo/hyper-thryoidism, gonadism, cushing's?
Hormone Replacement
328
If irAEs present do you dose adjust immunotherapy?
NO, stop and go approach
329
Grade 1 irAE Steroid Dosing
NO, supportive care
330
Grade 2 irAE Steroid Dosing
0.5-1 ng/kg prednisone
331
Grade 3 irAE Steroid Dosing
1-2 mg/kg prednisone
332
Grade 4 irAE Steroid Dosing
1-2 mg/kg methylprednisolone
333
What mutations indicates RESPONSIVENESS to EGFR Tyrosine Kinase Inhibitors TKIs?
1. Exon 19 Deletion
2. Exon 21 L858R
334
What mutation indicates RESISTANCE to EGFR TKIs?
Exon 20
335
What mutation is acquired while on 1st-2nd gen EGFR TKIs, but is susceptible to Osimertinib?
T90M
336
What drugs are EGFR TKI 1st gen?
1. Getitinib
2. Erlotinib
Reversible binding
337
What drugs are EGFR TKI 2nd gen?
1. Afatinib
2. Dacomitinib
Irreversible binding
338
What drugs are EGFR TKI 3rd gen?
Osimertinib
339
What is the most common AE of EGFR Inhibitors?
Cuatneous Acneiform Rash
340
What EGFR TKIs need to be taken on an Empty Stomach?
1. Afatinib
2. Erlotinib
341
What EGFR TKI has an AE of cardiotoxicity?
1. Afatinib
2. Osimertinib
342
What EGFR TKI has an AE of hyperglycemia?
Dacomitinib
343
What EGFR TKI has an DDI of AVOIDING: PPI/H2 antagonist/Antacids?
1. Erlatinib
2. Gefitinib
344
What protein leads to constitutive activation of downstream pathways leading to inhibition of apoptosis?
EML-4-ALK
Anaplastic Lymphoma Kinase ALK
345
List the ALK Inhibitors
1. Alectinib
2. Brigatinib
3. Ceritinib
4. Crizotinib
5. Lorlatinib
346
List the AEs of Alectinib
1. Myalgia/CPK elevation
2. Photosensitivity
347
List the AEs of Brigatinib
1. HTN
2. CPK up
3. Elevated pancreatic enzyme
4. Hyperglycemia
5. Pulmonary toxicity
6. Photosensitivity
348
List the AEs of Certinib
1. Diarrhea
2. Hyperglycemia
3. Pancreatitis
4. QTc prolongation
349
List the Aes of Crizotinib
1. Ocular toxicity
2. QTc prolongation
350
List the AEs of Lorlatinib
1. CNS effects
2. Hyperlipidemia
3. PR interval prolongation
4. AV Block
351
What is the preferred ALK Inhibitor?
Alectinib, take with food, and monitor CPK
352
What is the indication for Sotorasib?
Treatment of KRAS G12C mutated locally advanced or metastatic NSCLC in patients ho have received at least 1 prior systemic therapy
353
What is the dose for Sotorasib?
960 mg qd
354
What are the DDIs of Sotorasib?
AVOID PPIs, H2RAs, Apixaban, and Rivaroxaban
355
What is the recommended therapy for Stage IA of NSCLC?
Surgery alone
356
What ist he recommended therapy for Stage IB, II, IIIA of NSCLC?
Sugery + Chemo [platinum doublet]
357
What is the timeline for Osimertinib for adjuvant therapy?
3 years
358
What agent is used as adjuvant therapy for patietns with completely resected stage IIB-IIIA or high risk stage IIA PDL1 >1% for up to 1 year?
Atezolizimab
359
What are the 3 histogolic classifications of NSCLC?
1. Squamous Cell Carcinoma SCC
2. Adenocarcinoma
3. Large Cell
360
When do you AVOID Bevacizumab and Pemetrexed?
SCC NSCLC
361
When is Pemetrexed Preferred treatment?
1. Adenocarcinoma
2. Large Cell
362
SCC NSCLC patients have improved survival with what therapy?
Cisplatin/Gemcitabine
363
What is preferred therapy for Unresectable Stage III NSCLC?
Paclitaxel + Carboplatin + RT + followed by Durvalumab
364
What 2 mutations have targetable drugs but only in the 2nd Line setting?
1. Exon 20
2. KRAS G12C
365
If patients received immunotherapy monotherapy then can go on to receive what for NSCLC?
Histology based on platinum doublet
366
If patients progressed on immunotherapy + chemotherapy, upon progession they can receive what in NSCLC?
Docetaxel +/- Ramucirumab
367
MOA of Platinum Agents
DNA crosslinks to cause damage
368
MOA of Lurbinectedin
Alkylating agent and binds to guanine resides in DNA
Hem/Onc Module
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