1. BJ is a 62-year-old with newly diagnosed metastatic gastric adenocarcinoma. The molecular profile shows the tumor is HER2-negative (IHC 1+), PD-L1 CPS = 10, and is microsatellite-stable (MSS). What would be most appropriate course of action?

2. Which of the following organ systems requires routine laboratory monitoring for immune-related toxicities in a patient with hypertension, GERD, and hyperlipidemia?

3. LG is a 52-year-old patient with metastatic gastric adenocarcinoma who presents to clinic for toxicity evaluation prior to the next cycle of chemotherapy. LG has received 9 cycles of FOLFOX + nivolumab. In clinic, LG complains of itching, fatigue and RUQ pain and tenderness; LG is slightly jaundiced. Liver function tests reveals ALT = 521 mg/dL (12x ULN), AST = 694 mg/dL (14x ULN), Tbili = 3.1 mg/dL. You suspect immunotherapy induced hepatitis. What is the appropriate next step for LG?

4. FT is a 71-year-old patient who received cycle 1 of FOLFOX + trastuzumab for HER2-positive metastatic gastric adenocarcinoma. At today's toxicity check appointment, the molecular profiling on FT's tumor resulted with a PD-L1 CPS = 20. The oncologist would like to add pembrolizumab to cycle #2 today. Choose the correct immunotherapy counseling statement:

5. JM is an active 33-year-old woman with metastatic gastric adenocarcinoma who is brought to the ER by her friend. Her friend indicates that the patient has shown increasing generalized fatigue to the point that it is difficult for her to get out of bed. The patient has been receiving immunotherapy for the last few months without any issues. Temperature 100.2, and her vitals are pulse 116, BP 77/palp, and 92% on 6 L. Blood and urine cultures are collected. One-view CXR does not show definite infiltrates or ground-glass opacities. EKG shows sinus tachycardia without definite ST/T changes. She is placed on a ventilator, and fluids, pressors, and IV antibiotics are started. ALT and AST are 1400 and 1200, respectively. What is the next best step in management?

6. ST is a 75-year-old man with metastatic gastric cancer whose disease has previously progressed after 4 months on FOLFOX, and he is now on ramucirumab/paclitaxel, which was started about 4 weeks ago. He is tolerating therapy well. New test results return indicating that his tumor, collected at baseline about 6 months ago, shows a loss of MLH1 expression, but intact expression of MSH2, MSH6, and PMS2. PD-L1 expression status is pending. HER2 tests show IHC 2+ with nonamplification on FISH. What is the next best step in management?

7. MG is a 66-year-old man with metastatic HER2-positive gastric cancer. His tumor has progressed on FOLFOX + trastuzumab + pembrolizumab. What is the next best step in management?

8. PT, a 69-year-old woman, presents to the emergency room with a nonproductive cough and mild dyspnea on exertion. Her symptoms began about 10 days ago and have been steadily worsening. She has been receiving FOLFOX + nivolumab for the last 2 months and tolerating all agents well. A CXR in the ER shows 2 ground glass opacities in the right lung and three such opacities in the left lung. Her O2 saturation is 91% on room air. Temperature is 100.3. Pulse 89 and BP 120/87. Her labs are unremarkable, including a WBC of 8.2. Antibiotics are started. What is the next best additional step in management?

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