Colon Flashcards
incidence and epidemiology -3
VIDEO**
2nd leading cause of death in men AND women
5 yr OS 64%
median dx age 70 (63% >65)
risk factors -8
age
hereditary nonpolyposis colon CA (HNPCC) or
Lynch Syndrome (5-10%, age 30 on)
familial adenomatosis polyposis (FAP) (0.5%, total colectomy when polyps appear after age 10-12 on)
IBDz (UC or crohn’s)
Polyps
Diet (high fat, low fiber, EtOH, high BMI)
FH
Prevention -3
diet (high fiber, low fat, fruits, veg, Ca++, vit D)
NSAIDs and Cox-2 inhibitors (>equal 2 tabs/wk RR 0.79)
colectomy
Screening -6
fecal occult blood testing (FOBT) - high false neg, use in combo
fecal immunochemical test (FIT)
DRE
endoscopy - flex sigmoidoscopy (lower 60% of bowel), colonoscopy (entire bowel, remove pre-malignant lesions)
barium enema
tumor markers (CEA) - inc in many GI tumors and pancreatitis, hepatitis, renal failure, smoking->use to watch chemo response
ACS screening guidelines - average risk -5
annual DRE AND FOBT or FIT after 50 + one of the following:
sigmoidoscopy q5y
colonoscopy q10y
barium enema q5y
CT colonoscopy q5y
ACS screening guidelines - family hx -1
start at age 35-40
ACS screening guidelines - HNPCC -1
start at age 30
ACS screening guidelines - FAP -1
start at age 10-12
staging - TNM -4
FAIRLY SIMPLISTIC COMPARED TO OTHER CANCERS
HUGE DIFFERENCE IN OS BY STAGING
I: local dz, no muscular mucosa invasion 5yr OS 90.1%
II: muscular mucosa invasion, no extracolonic
III: lymph node involvement (any N) 5yr 69% OS
IV: mets (liver, lung, bone) 5yr OS 11.7%
signs and symptoms 4
changes in bowel habits
blood in stool
anorexia, abd pain
weakness, wt loss
surgery - stage I or II -2
curative intent, 50% cure rate overall for all stages
partial or total colectomy +resection of primary and regional LN
surgery - stage III or IV -2
palliation/debulking (mostly)
decrease bleeding, relieve obstruction, inc QOL
surgery - isolated mets to lung or liver -1
20-25% cure rate if all mets can be resected
treatment - XRT -2
controvesial in colon CA, well established in rectal CA
OFTEN AN INCORRECT TEST ANSWER
chemotherapy - stage II -3
NOTE stage I - NO ADJ CHEMO
controversy - NOT on test
oxaliplatin OS benefit unproven
PROBABLY STRATEGY IS HIGH RISK VS STD RISK - MAY THINK IF NOT ENOUGH NODES SAMPLED THEN MAY BENEFIT FROM CHEMO - NEED 12 NODES - IF SURGERY DOES NOT EXAMINE 12 NODES OFFER CHEMO
chemotherapy- adjuvant - stage III (LYMPH NODE (+))- locally advanced dz - TOC - MOSAIC trial AND NO16968 trial -3
NOTE CHEMO DIFFERENT FOR STAGE IV
PAY ATTENTION TO AGE RESTRICTION OF BENEFIT
1 FOLFOX4 (cat 1) vs 5fu/lv is SOC:
==surgery + adjuvant 5-FU based chemo/leucovorin==
5yr DFS 73 vs 67%, subset of age 70-75yr did not benefit
OS ADVANTAGE ONLY IN STAGE 3
3yr DFS 70.9 vs 66.5%,
No OS benefit,
ADR: HFS, PN (cape-ox) vs neutropenia/NF)
chemotherapy- adjuvant - stage III - locally advanced dz: FLOX vs bolus 5FU -2
NOT PREFERRED
PAY ATTENTION TO AGE RESTRICTION OF BENEFIT
FLOX (=bolus 5FU +ox)
higher tox than FOLFOX (D and neurotox) - REASON NOT USED
inc 5yr DFS,
possible inc OS if <70yr
chemotherapy - stage III - locally advanced dz: X-ACT trial -3
PAY ATTENTION TO AGE RESTRICTION OF BENEFIT
Cape vs bolus 5FU, trend towards inc DFS and OS
chemotherapy- adjuvant - stage III - intra-arterial (portal) hepatic regional chemo -2
FUDR (floxuridine) peri-op
chemotherapy- adjuvant - stage III - mFOLFOX6 vs mFOLFOX6 +bev -3
ADRs significantly inc in BEV arm (HTN, pain, proteinuria, wound complications)
DO NOT USE
chemotherapy- adjuvant - stage III - targeted therapies and irinotecan -1
At this time cetuximab, bevacizumab or irinotecan are NOT approved for adjuvant use
chemotherapy - stage IV - resectable synchronous liver only AND/OR lung only== 3 CHOICES
- colectomy+resection->adj ???,
- neoadj ???->colecotomy+resection->adj???,
- colectomy->mix neoadj/adj chemo???->resection->adj??? -7
ALL METASTATIC DRUGS STILL COME IN TO PLAY
1 FOLFOX or CapeOx