Lung Cancer: MCQ bank

Which paraneoplastic syndrome is most characteristic of squamous cell carcinoma of the lung?

1. AEctopic ACTH (Cushing) syndrome
2. BAnti-Hu sensory neuronopathy
3. CHypercalcaemia due to PTH-related peptide
4. DLambert-Eaton myasthenic syndrome
5. ESIADH

A 58-year-old smoker has right shoulder and arm pain, wasting of the small muscles of the hand and ptosis with miosis on the right. The most likely diagnosis is:

1. ASyringomyelia
2. BCarpal tunnel syndrome
3. CFrozen shoulder
4. DCervical spondylotic myelopathy
5. ESuperior sulcus (Pancoast) tumour

A 30-year-old woman who has never smoked has an EGFR-mutant lung adenocarcinoma. Her sister asks whether she should be tested for the EGFR mutation. The correct advice is:

1. ARelatives should have BRCA testing
2. BRelatives should have yearly CT from age 25
3. CRelatives should take a preventive EGFR inhibitor
4. DTumour EGFR mutations are acquired, so relatives do not need EGFR testing
5. EAll first-degree relatives need germline EGFR testing

Which statement about lung cancer in India is most accurate?

1. AA substantial share of patients, especially women, have never smoked
2. BSquamous carcinoma is now the commonest type
3. CAlmost all patients are heavy smokers over 70
4. DBiomass smoke has no association with lung cancer
5. EMost cases are diagnosed at stage I

A smoker's chest X-ray shows right upper lobe collapse with a convex bulge at the hilum, forming a reversed S-shaped fissure. What does this “Golden S sign” indicate?

1. APneumothorax
2. BA central hilar mass obstructing the right upper lobe bronchus
3. CPleural effusion
4. DNormal variant
5. EMiddle lobe pneumonia

Exposure to which pair shows a multiplicative (synergistic) effect on lung cancer risk?

1. ACaffeine and smoking
2. BAsbestos and cigarette smoking
3. CAlcohol and radon
4. DObesity and asbestos
5. EMobile phones and smoking

Hypertrophic pulmonary osteoarthropathy (clubbing, painful periostitis of long bones) is most associated with:

1. ACarcinoid tumour
2. BSmall cell lung cancer
3. CNon-small cell lung cancer, particularly adenocarcinoma
4. DTuberculosis only
5. EMesothelioma only

The histological type of lung cancer most common in never-smokers is:

1. AAdenocarcinoma
2. BCarcinoid
3. CSquamous cell carcinoma
4. DLarge cell carcinoma
5. ESmall cell carcinoma

The schematic H&E drawing shows nests of polygonal cells with concentric pink structures. Which immunostain is expected to be positive?

1. ASynaptophysin
2. Bp40
3. CCD20
4. DNapsin A
5. ETTF-1

Which population was shown to benefit from low-dose CT screening in randomised trials (NLST, NELSON)?

1. AOlder current or former heavy smokers
2. BAdults with asthma
3. CNever-smoking women with biomass exposure
4. DPatients with treated tuberculosis
5. EAll adults over 40

A 6 mm solid incidental nodule is found on CT in a 45-year-old never-smoker with no risk factors. According to Fleischner 2017, the recommended action is:

1. AImmediate PET-CT
2. BCT at 6–12 months, then consider CT at 18–24 months
3. CCT-guided biopsy
4. DSurgical wedge resection
5. ENo follow-up at all

Brain MRI is recommended routinely in all of the following EXCEPT:

1. ASmall cell lung cancer of any stage
2. BStage III NSCLC planned for curative treatment
3. CAny lung cancer patient with headache or focal signs
4. DAsymptomatic stage IA peripheral NSCLC
5. EStage IV NSCLC

Which node station is classically NOT reachable by cervical mediastinoscopy?

1. AStation 7 (subcarinal)
2. BStation 4R
3. CStation 2R
4. DStation 5 (aortopulmonary window)
5. EStation 4L

Which patients with advanced NSCLC should have broad molecular testing?

1. AOnly patients under 50
2. BOnly patients who fail chemotherapy
3. CAll non-squamous NSCLC, and squamous NSCLC in never- or light smokers
4. DOnly women who have never smoked
5. EOnly adenocarcinomas with brain metastases

The most frequent actionable driver in Indian lung adenocarcinoma is:

1. ABRAF V600E
2. BALK fusion
3. CEGFR mutation
4. DKRAS G12C
5. ERET fusion

An EGFR exon 20 insertion is found in metastatic NSCLC. Which first-line treatment is supported by a phase 3 trial?

1. ACrizotinib
2. BAmivantamab plus carboplatin–pemetrexed
3. COsimertinib monotherapy
4. DErlotinib
5. EGefitinib

The schematic H&E drawing shows malignant glands. Before treating this tumour as metastatic disease, which test is essential?

1. ABone marrow biopsy
2. BBronchial washings for TB only
3. CSerum CEA only
4. DSputum cytology
5. EMolecular testing for actionable drivers (EGFR, ALK, ROS1 and others) plus PD-L1

A fit 60-year-old has a 1.6 cm peripheral solid adenocarcinoma, node-negative on staging. Which operation is supported by JCOG0802 as at least as good as lobectomy for overall survival?

1. ASleeve lobectomy
2. BAnatomical segmentectomy with nodal assessment
3. CObservation
4. DWedge resection without nodal assessment
5. EPneumonectomy

An 80-year-old with severe COPD has biopsy-proven stage IA NSCLC and is not fit for surgery. The preferred treatment is:

1. APneumonectomy after pulmonary rehabilitation
2. BErlotinib
3. CConventional radiotherapy over 6 weeks with chemotherapy
4. DObservation only
5. EStereotactic ablative radiotherapy (SBRT)

A 48-year-old never-smoker has metastatic adenocarcinoma with EGFR exon 19 deletion. Which first-line drug improved overall survival over gefitinib or erlotinib in FLAURA?

1. ADocetaxel
2. BBevacizumab
3. COsimertinib
4. DCrizotinib
5. EPembrolizumab

Which first-line treatment is preferred for metastatic ALK-positive NSCLC?

1. ADocetaxel
2. BAlectinib or lorlatinib
3. CCrizotinib only after chemotherapy
4. DPembrolizumab monotherapy
5. EGefitinib

Metastatic non-squamous NSCLC with no driver and PD-L1 TPS 75%, ECOG 1. A standard first-line option is:

1. ABest supportive care only
2. BSingle-agent docetaxel
3. CPembrolizumab monotherapy
4. DGefitinib
5. EAlectinib

For squamous metastatic NSCLC without a driver, which chemotherapy partner is NOT appropriate with pembrolizumab?

1. APemetrexed
2. BCarboplatin–nab-paclitaxel
3. CCisplatin–gemcitabine
4. DCarboplatin–paclitaxel
5. ECarboplatin–gemcitabine

Unresectable stage III NSCLC without a driver responds to concurrent chemoradiation. PACIFIC supports:

1. AErlotinib for 2 years
2. BProphylactic cranial irradiation
3. CPneumonectomy
4. DObservation
5. EDurvalumab for 12 months

Early palliative care integrated with oncology care in metastatic NSCLC (Temel et al.) led to:

1. AMore aggressive end-of-life chemotherapy
2. BShorter survival
3. CBetter quality of life and mood, and longer median survival
4. DNo change in quality of life
5. EHigher hospital costs without benefit

Pemetrexed, used in non-squamous NSCLC, works mainly by:

1. AStabilising microtubules
2. BCross-linking DNA
3. CInhibiting topoisomerase I
4. DInhibiting folate-dependent enzymes such as thymidylate synthase
5. EBlocking EGFR

After curative resection of NSCLC, recommended surveillance imaging is:

1. ACT chest every 6 months for 2–3 years, then yearly low-dose CT
2. BPET-CT every 3 months for life
3. CTumour markers every month
4. DChest X-ray every month
5. ENo imaging after 1 year

Approximately what proportion of patients with small cell lung cancer have extensive-stage disease at diagnosis?

1. AAbout half are stage I
2. BAbout two thirds
3. CAlmost all
4. DAbout one quarter
5. EAbout 10%

Small cell lung cancer arises predominantly in:

1. APatients with asbestosis, in the pleura
2. BPatients with EGFR mutations as the primary driver
3. CNever-smoking young women, in the periphery
4. DChildren
5. ECurrent or former heavy smokers, usually in central airways

Which microscopic description fits small cell carcinoma of the lung?

1. ASmall round cells with scant cytoplasm, finely granular chromatin, absent nucleoli and nuclear moulding
2. BGlandular structures with mucin
3. CSpindle cells with storiform pattern
4. DUniform cells in nests with low mitotic rate
5. ELarge cells with prominent nucleoli and keratin pearls

Which immunohistochemical panel supports neuroendocrine differentiation in small cell carcinoma?

1. ACalretinin and WT1
2. Bp40 and CK5/6
3. CSynaptophysin, chromogranin, CD56 (and INSM1)
4. DCD20 and CD3
5. EHMB-45 and S100

Which electrolyte disturbance is the classic paraneoplastic feature of small cell lung cancer?

1. AHypophosphataemia from FGF23
2. BHypercalcaemia from PTHrP
3. CHyperkalaemia
4. DHypermagnesaemia
5. EHyponatraemia from SIADH

Lambert-Eaton myasthenic syndrome associated with small cell lung cancer is caused by antibodies against:

1. AMuscle-specific kinase
2. BAquaporin-4
3. CPotassium channels
4. DP/Q-type voltage-gated calcium channels
5. EAcetylcholine receptors

Ectopic ACTH production by small cell lung cancer typically presents with:

1. AHyperkalaemia
2. BHypercalcaemia
3. CWeight gain with striae over many years
4. DHypokalaemic metabolic alkalosis, oedema and hyperglycaemia, often without classic Cushingoid features
5. EHypoglycaemia

A bronchoscopic biopsy from a central mass in a heavy smoker shows the appearance in the schematic H&E drawing. The most likely diagnosis is:

1. AHamartoma
2. BSmall cell carcinoma
3. CCarcinoid tumour
4. DAdenocarcinoma
5. ESquamous cell carcinoma

Limited-stage small cell lung cancer is best defined as disease that:

1. AIs confined to one hemithorax and regional nodes and can be encompassed in a tolerable radiotherapy field
2. BHas only one distant metastasis
3. CHas no lymph node involvement
4. DCan be removed by pneumonectomy
5. EIs under 3 cm in size

The main purpose of prophylactic cranial irradiation (PCI) in small cell lung cancer is to:

1. AReduce the incidence of symptomatic brain metastases in patients who responded to initial treatment
2. BShrink the primary tumour
3. CTreat existing large brain metastases
4. DPrevent bone metastases
5. EReplace chemotherapy

The standard chemotherapy backbone for small cell lung cancer is:

1. ASingle-agent paclitaxel
2. BPlatinum (cisplatin or carboplatin) plus etoposide
3. CPemetrexed plus carboplatin
4. DGemcitabine plus docetaxel
5. EImatinib

A 52-year-old bidi smoker has received 3 months of antituberculous treatment for a right upper zone opacity. Sputum was never tested. He has lost more weight and now has haemoptysis. What is the most appropriate next step?

1. AStart a course of broad-spectrum antibiotics only
2. BSwitch to second-line TB drugs empirically
3. CRepeat chest X-ray after 3 months
4. DContinue antituberculous treatment for 6 more months
5. EContrast CT chest and tissue diagnosis, with sputum NAAT

An EGFR-mutant adenocarcinoma responding to osimertinib for 18 months now progresses rapidly with liver metastases and a rising neuron-specific enolase. What is the most important next step?

1. ADouble the dose of osimertinib
2. BBiopsy a progressing lesion to look for small-cell transformation
3. CAdd pembrolizumab to osimertinib
4. DSwitch to gefitinib
5. EStart whole-brain radiotherapy

A 64-year-old smoker with 2 months of cough. Based on the schematic chest X-ray shown, what is the most likely diagnosis and next step?

1. ARight upper lobe pneumonia: antibiotics and repeat X-ray in 6 weeks only
2. BRight pneumothorax: chest drain
3. CPleural effusion: thoracentesis
4. DNormal X-ray: reassure
5. ERight upper lobe collapse from a central hilar mass (Golden S sign): contrast CT and bronchoscopy

A 58-year-old bidi smoker has right shoulder pain radiating down the inner arm and a right Horner syndrome. The schematic X-ray is shown. Which is the best next imaging test to plan treatment?

1. AMRI of the thoracic inlet and brachial plexus, plus CT and PET-CT staging
2. BCervical spine X-ray only
3. CShoulder ultrasound
4. DBarium swallow
5. ERepeat chest X-ray in 3 months

A patient has a 4 cm right upper lobe mass, an enlarged subcarinal node and a right pleural effusion. Which first diagnostic procedure gives both diagnosis and the highest stage?

1. AWedge resection of the mass
2. BBronchial washings
3. CSputum cytology
4. DPleural fluid cytology with cell block
5. ECT-guided biopsy of the lung mass

In an Indian patient with suspected lung cancer, PET-CT shows uptake in mediastinal nodes. Before denying surgery, the clinician should:

1. ARepeat PET after 6 weeks of antibiotics
2. BOrder tumour markers
3. CStart chemoradiation immediately
4. DConfirm nodal involvement by EBUS-TBNA
5. EAccept the PET result as proof of N2 disease

Before right lower lobectomy (5 of 19 segments), a patient has FEV1 and DLCO of 70% predicted, giving predicted post-operative values of about 52%. Following the ACCP approach, the next step is:

1. AProceed to surgery with no further testing
2. BFormal cardiopulmonary exercise testing straight away
3. CDeclare inoperable and refer for SBRT
4. DA low-technology exercise test (stair climb or shuttle walk)
5. EArterial blood gas analysis to decide

A 56-year-old man smoked 15 cigarettes a day from age 18 to 54 and quit 2 years ago. Is he eligible for low-dose CT screening under the USPSTF 2021 criteria?

1. ANo: he must be over 60
2. BNo: he must have at least 30 pack-years
3. COnly if he has symptoms
4. DNo: former smokers are excluded
5. EYes: about 27 pack-years, age 50–80, quit within 15 years

CT shows a new 2.2 cm spiculated solid nodule with a pleural tag in the right upper lobe of a 64-year-old smoker; a CT 2 years ago was normal. The next step is:

1. APET-CT and tissue diagnosis with staging, aiming at curative treatment
2. BRepeat CT in 12 months
3. CTumour markers
4. DAntibiotics and repeat X-ray
5. EReassure because it is under 3 cm

Planned right pneumonectomy: preoperative DLCO is 60% predicted and perfusion scintigraphy shows the right lung receives 55% of total flow. The predicted post-operative DLCO is about:

1. A45%: proceed without further tests
2. B33%: stair climb only
3. CCannot be calculated
4. D60%: low risk
5. E27%: cardiopulmonary exercise testing is needed

A lymphocytic exudative pleural effusion in a 58-year-old smoker has an ADA of 18 U/L; one cytology sample is negative. The best next step is:

1. ATalc pleurodesis immediately
2. BDischarge with follow-up
3. CRepeat cytology with a cell block and, if negative, thoracoscopic pleural biopsy
4. DStart antituberculous treatment
5. EClosed (blind) pleural biopsy only

A patient has a right upper lobe mass and a 2 cm hard node in the left supraclavicular fossa. Which first biopsy is best?

1. ABronchoscopic biopsy of the primary
2. BCT-guided biopsy of the lung mass
3. CUltrasound-guided biopsy of the supraclavicular node
4. DMediastinoscopy
5. EWait for PET results before any biopsy

An incidental CT (lung window, schematic) in a 62-year-old ex-smoker shows the lesion illustrated, new since a scan 3 years ago. Which feature most raises suspicion of malignancy?

1. ACentral popcorn calcification
2. BSmooth margins with laminated calcification
3. CFat density within the lesion
4. DSpiculated margins with a pleural tag
5. ESize stable for 2 years

The schematic CT shows a right pleural effusion with nodular pleural thickening in a patient with a known lung mass. How does this finding change stage if proven malignant?

1. AIt does not affect stage
2. BIt makes the disease M1a (stage IVA), changing intent from cure to control
3. CIt is N2 disease
4. DIt makes the disease M1c2
5. EIt is T3 disease

Which drug–target pairing is INCORRECT?

1. ALorlatinib – ALK fusion
2. BOsimertinib – EGFR exon 19 deletion
3. CCapmatinib – MET exon 14 skipping
4. DSelpercatinib – ROS1 fusion
5. ESotorasib – KRAS G12C

After 20 months on first-line osimertinib, re-biopsy of progressing disease shows the original EGFR exon 19 deletion plus a new EGFR C797S mutation. What does C797S do?

1. AIt is a germline variant needing family testing
2. BIt removes the cysteine to which osimertinib binds covalently, causing resistance
3. CIt sensitises the tumour to immunotherapy
4. DIt predicts benefit from rechallenge with osimertinib
5. EIt indicates small-cell transformation

In concurrent chemoradiation for stage III NSCLC, RTOG 0617 showed that escalating the radiation dose to 74 Gy compared with 60 Gy:

1. AReduced pneumonitis
2. BEliminated the need for chemotherapy
3. CImproved overall survival
4. DWorsened overall survival
5. EWas equivalent with fewer side effects

A patient with EGFR-mutant NSCLC has three asymptomatic brain metastases under 1 cm. A reasonable initial approach is:

1. AStart a brain-penetrant EGFR TKI and repeat MRI at 6–8 weeks
2. BNeurosurgical resection of all three lesions
3. CSteroids alone
4. DImmediate whole-brain radiotherapy before any systemic therapy
5. EChemotherapy with pembrolizumab

A 66-year-old with idiopathic pulmonary fibrosis (FVC 72%, DLCO 55%) has a 1.8 cm peripheral adenocarcinoma, cT1b N0. Which statement is most appropriate?

1. APneumonectomy is preferred to remove all fibrotic lung
2. BLung-sparing (sublobar) surgery is favoured; radiotherapy and immunotherapy carry a higher risk of severe pneumonitis
3. CObservation is mandatory because ILD makes cancer treatment futile
4. DSBRT is clearly safer than surgery in ILD
5. EPerioperative chemo-immunotherapy is standard because ILD patients were well represented in the trials

A patient with metastatic NSCLC and a KRAS G12C mutation has three asymptomatic brain metastases (largest 1.5 cm) without mass effect. The usual first step is:

1. AWhole-brain radiotherapy is contraindicated
2. BSotorasib alone with MRI in 6–8 weeks
3. CRadiotherapy to the brain metastases, then systemic therapy
4. DObservation of the brain lesions until symptoms develop
5. EOsimertinib

JCOG0802 tested segmentectomy against lobectomy in a non-inferiority design. What does “non-inferiority” mean here?

1. ANon-inferiority trials cannot affect practice
2. BThe aim was to show segmentectomy is not unacceptably worse than lobectomy within a pre-set margin
3. CThe trial showed the two operations are identical
4. DThe aim was to prove segmentectomy is superior
5. ELobectomy was found inferior

An Indian patient with EGFR-mutant metastatic NSCLC cannot afford osimertinib. Which regimen improved overall survival over gefitinib alone in a randomised trial from Tata Memorial Centre?

1. AAfatinib plus cetuximab
2. BGefitinib at a double dose
3. CGefitinib plus bevacizumab
4. DGefitinib plus pemetrexed–carboplatin
5. EErlotinib plus pembrolizumab

A patient completed adjuvant chemotherapy and atezolizumab for stage IIIA NSCLC (no driver) and relapses with liver metastases 4 months later. How should this relapse be treated?

1. AOsimertinib
2. BAs second-line disease: docetaxel ± ramucirumab or another non-cross-resistant option
3. CObservation until symptomatic
4. DAs first-line disease: repeat platinum doublet with a checkpoint inhibitor
5. ERestart atezolizumab alone

In PACIFIC, 5-year overall survival was about 43% with durvalumab and 33% with placebo. Approximately how many patients must be treated for one additional patient to be alive at 5 years?

1. A3
2. B100
3. C10
4. D43
5. E33

A trial reports an overall-survival hazard ratio of 0.77 (95% CI 0.61–0.96). The best interpretation is:

1. A23 patients must be treated to save one life
2. B23% more patients were alive at 5 years
3. CAt any time point, the risk of death was about 23% lower with the experimental treatment
4. DMedian survival was 23% longer by definition
5. EThe result is not statistically significant

A randomised trial of a new drug shows a large progression-free survival benefit, but overall survival is similar; most control patients crossed over to the new drug at progression. The most reasonable reading is:

1. AThe control arm was inferior from the start
2. BThe trial was negative and should be ignored
3. CProgression-free survival is always the more important end point
4. DCrossover may dilute an overall-survival difference; sequencing the drug later may give similar survival
5. EThe drug is ineffective

A patient with PD-L1 85% NSCLC received one dose of pembrolizumab before NGS returned an EGFR exon 19 deletion. What is the best approach?

1. AStop pembrolizumab and start EGFR-directed therapy, watching closely for pneumonitis
2. BGive radiotherapy only
3. CSwitch to nivolumab
4. DContinue pembrolizumab alone
5. EAdd osimertinib to pembrolizumab

On ipilimumab plus nivolumab, a patient develops fatigue, headache and hyponatraemia; morning cortisol and ACTH are both low, while TSH and free T4 are also low. The most likely diagnosis is:

1. AImmune-related hypophysitis
2. BPrimary adrenal insufficiency
3. CHyperthyroidism
4. DBrain metastases
5. ESIADH from the tumour

Eight months after chemoradiation and durvalumab, an Indian patient develops a new cavitating lesion in the opposite lung. The best next step is:

1. ARestart durvalumab
2. BStart second-line chemotherapy immediately
3. CAssume radiation fibrosis
4. DStart empirical antituberculous treatment without tests
5. ESputum NAAT and tissue sampling before calling it progression

Which feature best distinguishes Lambert-Eaton myasthenic syndrome from myasthenia gravis?

1. AThymoma on CT
2. BResponse only to thymectomy
3. CPtosis that worsens through the day
4. DStrength and reflexes improve briefly after sustained exercise, with dry mouth
5. EPositive acetylcholine-receptor antibodies

A lung tumour contains small cell carcinoma mixed with an adenocarcinoma component. How is it classified and treated?

1. ALarge-cell neuroendocrine carcinoma
2. BTwo separate primaries
3. CCombined small cell carcinoma, treated as small cell lung cancer
4. DAdenocarcinoma, treated with EGFR testing only
5. ECarcinoid tumour

Which patient with small cell lung cancer needs invasive mediastinal staging before treatment?

1. AA patient with a malignant pleural effusion
2. BA patient with liver metastases
3. CA patient with a 2.5 cm peripheral tumour and no nodal disease on PET-CT, being considered for surgery
4. DA patient with bulky mediastinal nodes on CT
5. EA patient with brain metastases

An EGFR exon 19-deleted adenocarcinoma transforms into small cell carcinoma on osimertinib. Re-biopsy will most likely show:

1. ASmall cell histology that retains the original EGFR mutation, often with TP53 and RB1 loss
2. BA germline EGFR mutation
3. CLoss of the EGFR mutation and a new KRAS mutation
4. DSquamous transformation with PD-L1 100%
5. EAn ALK fusion

A patient with limited-stage small cell lung cancer presents with superior vena cava obstruction. The standard treatment is:

1. AStenting and best supportive care
2. BSteroids alone
3. CSurgery first
4. DPalliative radiotherapy alone
5. EConcurrent chemotherapy with definitive thoracic radiotherapy, with curative intent

A patient with SIADH from small cell lung cancer has sodium 118 mmol/L and mild confusion. Which statement is correct?

1. ASIADH is unrelated to the tumour
2. BGive large volumes of normal saline
3. CCorrect sodium slowly and start chemotherapy promptly, which treats the SIADH
4. DDelay chemotherapy until sodium is normal for a month
5. ECorrect sodium to normal within 6 hours

A woman with extensive-stage small cell lung cancer has three small asymptomatic brain metastases. The usual approach is:

1. AWhole-brain radiotherapy before any systemic therapy
2. BStart chemo-immunotherapy, then treat remaining brain lesions with radiosurgery or whole-brain radiotherapy after induction
3. CObservation only
4. DThoracic radiotherapy first
5. ENeurosurgery for all three lesions

A 70-year-old with newly diagnosed extensive-stage small cell lung cancer is bed-bound (ECOG 3) because of liver metastases and breathlessness; before the illness he was fully active. What is the best plan?

1. ABest supportive care only, because of ECOG 3
2. BWait until performance status improves
3. CRadiotherapy to the liver
4. DOffer chemotherapy promptly, with careful supportive care, because responses are often rapid
5. EImmunotherapy alone

After four cycles of chemo-immunotherapy for extensive-stage disease, a patient has a good response at distant sites but a residual 3 cm hilar mass. A reasonable addition is:

1. AConsolidative thoracic radiotherapy
2. BStopping maintenance immunotherapy
3. CPneumonectomy
4. DWhole-brain radiotherapy
5. ESwitching to tarlatamab

During the first tarlatamab infusion, a patient develops fever 39 °C and hypotension responding to fluids. The most likely cause is:

1. ASepsis from neutropenia
2. BTumour lysis syndrome
3. CAdrenal crisis from immunotherapy
4. DAnaphylaxis to etoposide
5. ECytokine release syndrome

A 14 mm part-solid nodule has persisted for 4 months with a 7 mm solid component. The best interpretation is:

1. ABenign because it has not grown
2. BA pure ground-glass nodule needing no follow-up
3. CAlmost certainly infection; repeat in 2 years
4. DA hamartoma
5. EHighly suspicious for adenocarcinoma; plan tissue diagnosis or resection

Under the IASLC 9th edition TNM, a 2.5 cm tumour with metastasis to a single ipsilateral mediastinal node station and no distant spread is staged as:

1. AT1c N2 M0, stage IIIA
2. BT2a N2b M0, stage IIIB
3. CT1c N2a M0, stage IIIA
4. DT1c N2a M0, stage IIB
5. ET1c N1 M0, stage IIB

Which finding makes a lung cancer M1c2 under the 9th edition?

1. AA single brain metastasis
2. BMultiple metastases confined to the liver
3. CMetastases in more than one extrathoracic organ system
4. DA malignant pleural effusion
5. EA separate nodule in the contralateral lung

A 55-year-old never-smoker has the 18 mm lesion shown on CT (schematic), persistent after 3 months, with a 7 mm solid component. What is the most likely pathology?

1. ASquamous carcinoma
2. BSmall cell carcinoma
3. CHamartoma
4. DAdenocarcinoma (minimally invasive or invasive) arising from a ground-glass precursor
5. EHealed tuberculous granuloma

A plasma ctDNA NGS test in a never-smoker with metastatic adenocarcinoma shows no driver. The correct interpretation is:

1. AThe tumour is squamous
2. BPD-L1 testing is now unnecessary
3. CA driver is not excluded; test tissue as well
4. DRepeat plasma testing monthly
5. ENo driver is present; start chemo-immunotherapy at once

Single-gene EGFR PCR is negative in a never-smoker with metastatic adenocarcinoma. ALK IHC is negative. What should be done?

1. ANGS with RNA for fusions (ROS1, RET, NTRK) and other drivers
2. BRepeat EGFR PCR on the same block
3. CConclude that there is no driver
4. DStart EGFR TKI empirically
5. EStart pembrolizumab monotherapy regardless of PD-L1

At progression on lorlatinib after alectinib, which test result would best guide the next step?

1. ARe-biopsy or ctDNA for ALK resistance mutations and bypass pathways
2. BRepeat ALK IHC on the diagnostic sample
3. CPD-L1 on the original biopsy
4. DGermline ALK testing
5. ESerum CEA

For first-line treatment of ROS1-positive metastatic NSCLC with brain metastases, which choice best reflects current evidence?

1. ACrizotinib, because of superior brain penetration
2. BTaletrectinib or repotrectinib
3. COsimertinib
4. DSelpercatinib
5. EPembrolizumab monotherapy

A patient with metastatic NSCLC and an activating HER2 (ERBB2) mutation progresses after chemo-immunotherapy. Which option has phase 2 evidence as an oral targeted therapy?

1. ALapatinib
2. BErlotinib
3. CZongertinib
4. DTrastuzumab alone
5. EImatinib

After complete (R0) resection of pN2 NSCLC and adjuvant chemotherapy, the Lung ART trial showed that postoperative radiotherapy:

1. ADoubled overall survival
2. BImproved disease-free survival only in squamous cancers
3. CReduced brain metastases
4. DWas required for all pN2 patients
5. EDid not improve disease-free survival and increased cardiopulmonary deaths

On cardiopulmonary exercise testing before lobectomy, a patient's VO2 max is 9 mL/kg/min. The best interpretation is:

1. ARepeat spirometry only
2. BHigh risk: consider sublobar resection, SBRT or other non-surgical options
3. CVO2 max is irrelevant to lung resection
4. DLow risk: proceed with lobectomy
5. EModerate risk: proceed with pneumonectomy

In FLAURA2, adding platinum–pemetrexed to first-line osimertinib in EGFR-mutant NSCLC:

1. AWorsened overall survival
2. BWas only tested in exon 20 insertions
3. CReduced haematological toxicity
4. DHad no effect on progression-free survival
5. EImproved progression-free and, at final analysis, overall survival, with more toxicity

In KEYNOTE-042 (pembrolizumab vs chemotherapy for PD-L1 ≥1%), the overall survival benefit was:

1. ALargest in PD-L1 1–49%
2. BLimited to squamous tumours
3. CSeen only in EGFR-positive patients
4. DAbsent in all subgroups
5. EDriven mainly by patients with PD-L1 ≥50%

After resection of stage II EGFR exon 19-deleted NSCLC and adjuvant chemotherapy, ADAURA showed that osimertinib for 3 years:

1. AHad no effect
2. BWas inferior to adjuvant pembrolizumab
3. CWas only beneficial for stage IA
4. DImproved disease-free and overall survival
5. EImproved disease-free survival but worsened overall survival

A resectable stage IIIA (single-station N2) adenocarcinoma has no EGFR/ALK alteration. Which approach is supported by phase 3 trials such as KEYNOTE-671 and CheckMate 77T?

1. ANeoadjuvant radiotherapy alone
2. BNeoadjuvant chemo-immunotherapy, surgery, then adjuvant immunotherapy
3. CObservation until symptoms
4. DOsimertinib before surgery
5. ESurgery alone

Why should durvalumab not be given after chemoradiation for EGFR-mutant stage III NSCLC?

1. AIt is contraindicated in all women
2. BDurvalumab is not approved for stage III disease
3. CEGFR mutations predict durvalumab-induced haemorrhage
4. DIt causes hypercalcaemia
5. ELittle benefit, and osimertinib after immunotherapy raises pneumonitis risk; LAURA supports osimertinib instead

Which statement about KRAS G12C-mutant metastatic NSCLC is correct?

1. AKRAS G12C predicts benefit from osimertinib
2. BKRAS mutations are inherited
3. CKRAS G12C tumours do not respond to immunotherapy
4. DSotorasib doubled overall survival in CodeBreaK 200
5. EChemo-immunotherapy is used first; sotorasib improved progression-free but not overall survival versus docetaxel

A completely resected stage IIA (pT2b N1) RET fusion-positive adenocarcinoma has received adjuvant chemotherapy. Which next step has randomised evidence?

1. AAdjuvant osimertinib
2. BAdjuvant bevacizumab
3. CAdjuvant alectinib
4. DAdjuvant selpercatinib
5. ENo further therapy is ever indicated

Resectable stage II EGFR exon 19-deleted NSCLC in a patient whose surgeon wants downstaging before lobectomy. Which induction option is supported by a phase 3 trial?

1. ARadiotherapy alone
2. BNivolumab plus chemotherapy (CheckMate 816)
3. CAlectinib
4. DDurvalumab alone
5. EOsimertinib with or without chemotherapy (NeoADAURA)

In PD-L1-negative (TPS <1%) metastatic NSCLC without a driver, which strategy is thought to add most beyond a single PD-1 inhibitor with chemotherapy?

1. ABevacizumab alone
2. BAdding CTLA-4 blockade (nivolumab + ipilimumab, or durvalumab + tremelimumab) with chemotherapy
3. CPembrolizumab monotherapy
4. DObservation
5. EOsimertinib

The risk of a second primary lung cancer after resection of NSCLC is approximately:

1. A1–2% per year, persisting long term
2. BZero after 5 years
3. C20% per year
4. D0.01% per year
5. EOnly in the first year

Which molecular finding is almost universal in small cell lung cancer?

1. AALK fusion
2. BInactivation of both TP53 and RB1
3. CKRAS G12C mutation
4. DBRAF V600E
5. EEGFR exon 19 deletion

Which statement about DLL3 in small cell lung cancer is correct?

1. AIt is an inhibitory Notch ligand expressed on most small cell cancers and is the target of tarlatamab
2. BIt predicts response to EGFR inhibitors
3. CIt is a germline cancer-predisposition gene
4. DIt is a driver mutation requiring NGS before treatment
5. EIt is expressed mainly on normal lung epithelium

In limited-stage small cell lung cancer, CONVERT compared twice-daily 45 Gy over 3 weeks with once-daily 66 Gy over 6.5 weeks and found:

1. AOnce-daily was clearly superior
2. BNeither improved on chemotherapy alone
3. CNo significant difference in survival; both are acceptable
4. DOnce-daily caused more oesophagitis
5. ETwice-daily was clearly superior

In extensive-stage small cell lung cancer, the Japanese randomised trial of PCI versus MRI surveillance (Takahashi) found:

1. APCI eliminated all brain metastases
2. BA large survival benefit from PCI
3. CNo overall-survival benefit from PCI when patients had regular brain MRI
4. DPCI improved cognition
5. EMRI surveillance worsened survival

The landmark Turrisi (INT 0096) trial in limited-stage small cell lung cancer showed that twice-daily thoracic radiotherapy (45 Gy in 3 weeks) compared with once-daily 45 Gy over 5 weeks:

1. AImproved 5-year survival, with more oesophagitis
2. BWorsened survival
3. CAllowed omission of chemotherapy
4. DHad no effect on survival but reduced oesophagitis
5. EReplaced the need for PCI

In limited-stage small cell lung cancer without progression after chemoradiation, ADRIATIC showed that durvalumab:

1. AHad no effect
2. BWas harmful when given after PCI
3. CImproved overall survival (median about 56 vs 33 months)
4. DShould replace thoracic radiotherapy
5. EOnly improved response rate

Small cell lung cancer relapses 6 weeks after completing platinum–etoposide with atezolizumab. A preferred option supported by a phase 3 trial is:

1. APlatinum–etoposide rechallenge
2. BTarlatamab
3. COsimertinib
4. DPemetrexed
5. EObservation

A 62-year-old has a resected 2.4 cm small cell carcinoma, pT1c N0 after negative invasive mediastinal staging. What is recommended next?

1. AAdjuvant platinum–etoposide chemotherapy, with PCI or MRI surveillance
2. BDurvalumab alone
3. CObservation only
4. DThoracic radiotherapy alone
5. EOsimertinib

In extensive-stage disease, adding lurbinectedin to atezolizumab maintenance after induction (IMforte) is best suited to:

1. APatients with symptomatic brain metastases
2. BLimited-stage disease after chemoradiation
3. CPatients with ECOG 3
4. DPatients who progressed during induction
5. EFit patients without brain metastases who responded to chemo-atezolizumab induction

In IMpower133 and CASPIAN, adding a PD-L1 antibody to platinum–etoposide in extensive-stage small cell lung cancer improved median overall survival by about:

1. A12 months
2. BNo difference
3. C2–3 months, with a small group of long-term survivors
4. D1 week
5. E6 months but only in PD-L1-high tumours

A patient with ALK-positive NSCLC on lorlatinib has a serum cholesterol of 340 mg/dL and triglycerides of 480 mg/dL at 2 months. What is the best approach?

1. AStart immunotherapy instead
2. BIgnore: lipids do not matter in cancer
3. CStart lipid-lowering therapy and continue lorlatinib with monitoring
4. DStop lorlatinib permanently
5. ESwitch to crizotinib immediately

On day 3 of brigatinib, a patient develops new breathlessness and hypoxia with bilateral ground-glass change. The most likely cause is:

1. APulmonary embolism is the only possibility
2. BRadiation pneumonitis
3. CEarly-onset pulmonary events typical of brigatinib
4. DALK-positive disease progression
5. EExpected TKI response

A patient on dabrafenib plus trametinib for BRAF V600E NSCLC develops fever of 39 °C without a source. What is the correct first step?

1. AHold the BRAF/MEK treatment, give antipyretics and restart when the fever settles
2. BContinue treatment and start broad antibiotics only
3. CSwitch to osimertinib
4. DStop treatment permanently
5. EAdd high-dose steroids and continue

A patient on capmatinib for MET exon 14 NSCLC has a rise in creatinine from 0.9 to 1.3 mg/dL with normal cystatin C and no symptoms. The best interpretation is:

1. AAcute tubular necrosis needing dialysis
2. BInhibition of renal creatinine transporters, not true loss of kidney function
3. CDehydration from diarrhoea is certain
4. DTumour lysis syndrome
5. EImmune nephritis

Six weeks after starting pembrolizumab, a 66-year-old has chest pain, ptosis, proximal weakness, troponin elevation and CK 4200 U/L. What is the most urgent action?

1. AStart thyroxine
2. BStop immunotherapy permanently and start high-dose IV steroids with cardiology input for immune myocarditis–myositis
3. COrder a bone scan
4. DGive oral steroids and continue immunotherapy
5. EContinue pembrolizumab and repeat troponin in a week

A patient with ALK-positive NSCLC on lorlatinib is diagnosed with pulmonary TB. Which treatment issue is most important?

1. AStop lorlatinib permanently
2. BRifampicin markedly lowers TKI levels and with lorlatinib can cause severe hepatotoxicity: plan a rifabutin-based or non-rifamycin regimen with the TB team
3. CIsoniazid alone for 2 months is adequate
4. DDouble the lorlatinib dose
5. ENo interaction exists between TB drugs and TKIs