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Colon Flashcards

1
Q

CEA

A

not sufficient to sufficient or initiate Tx

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2
Q

CEA>20

A

99% chance of cancer

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3
Q

CEA 5-10

A

50% FP rate, repeat in 4-6 wk

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4
Q

first line Tx

A

FOLFOX or FOLFIRI, equal OS and PFS

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5
Q

when to stop oxali

A

3 months is equivalent to continuing

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6
Q

oxali neuropathy

A

gets worse for 3 months; 12% permenant

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7
Q

addition of bev

A

no statistically sig placebo controlled proof of added benefit. maybe increase PFS but no RR change

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8
Q

bev tox

A

HTN, albuminuria, GI perf, thrombotic events, impaired wound healing

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9
Q

albuminuria with bev

A

don’t bother looking

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10
Q

GI perf

A

1.5%,

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11
Q

when to stop beva prior to surg

A

6-8wk

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12
Q

aflibercept

A

fusion of VEGF1,2R to IgG Fx

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13
Q

VELOUR study

A

2nd line FOLFIRI +/- aflibercept –> OS 13.5 v. 12mo, p=0.003

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14
Q

beg beyond progression in 2nd line

A

TML trial: continue with switch in chemo or no, Lancet Oncol 2013; 1.4mo survival benefit

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15
Q

aflibercept following bev

A

NO: not new lines, only replacement

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16
Q

cetuximab front line

A

FOLFIRI +/- cetux: PFS 1month increase; 37d improvement in kras wt. OS benefit, but you don’t have to start it in first line

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17
Q

RAS mutations

A

genotype for exon 2(12,13), and NRAS, non-exon2 as they confer resistance

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18
Q

BRAF in CRC

A

doesn’t work

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19
Q

FOLFIRI/bev v. FOLFIRI/cetux

A

no difference in response rate, no PFS benefit

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20
Q

cetuximab rash

A

no rash no benefit, d/c after 6 wks

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21
Q

perioperative FOLFOX/cetux

A

addition of cetux did worse

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22
Q

CAIRO-2 study

A

cape/ox/bev +/- cetux–> combined did worse

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23
Q

regorafenib

A

TKI against VEGF, dirty: CORRECT trial: regorefenib v. placebo in ECOG 0-1 PS–> 1.4mo OS benefit; difficult drug 2/2 fatigue at 160mg; 1% PR, 43% stablization

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24
Q

Adjuvant options

A

FOLFOX or CapeOX (both acceptable), HlLWE SX

25
Stage II adjuvant
no benefit to oxaliplatin in MOSAIC study
26
Stage III benefit adjuvant
4.4%
27
higher risk stage 2
MOSAIC didn't show benefit to oxali; think about it and discuss with patient. maybe if 2+ risk factor you can add
28
adjuvant oxali in older
Don't do if age 70+, no benefit
29
do we need 12 doses FOLFOX?
probably not; complete 6months 5-FU, d/c oxali based on tox
30
MMR deficiency and adjuvant or PCR
more common in stage 2 patients; majority of patients do better. if stage 2 and deficient, do not give adjuvant therapy. observe, do not treat with adjuvant; stage III--> still give adjuvant, treat with FOLFOX
31
rectal cancer
TME- total mesorectal excision is right surgery: sharp excision outside fascia, remove all relevant encased lymph nodes
32
rectal management
pre-op staging CT CAP, endorectal US or MRI, PET not recommended;
33
stage I rectal
surgery alone
34
stage II/III
standard: preop chemo/RT-->surg-->4mo CAPEOX/FOLFOX
35
rectal chemorad
Sauer NEJM 2004: pre-op better than post-op
36
chemorad rectal regimen
either cape or infusional 5-FU, oxaliplatin adds toxicity and not benefit
37
colon cancer survival endpoings
3-year DFS is a surrogate for 5-yr OS
38
adjuvant therapy colon
5-FU for stage II, FOLFOX for high risk stage II (undid, T4, perf, obstruct,
39
adjuvant options
FOLFOX, FLOX(bolus 5-FU + ox) or XELOX x 6 months
40
adjuvant in elderly colon
MOSAIC trial: less benefit in >70y for Oxali.
41
stage II adjuvant chemo for colon
can use adjuvantonline or mayo clinic tool. individualize decision to the patient
42
associations with colon cancer recurrence
increased exercise, avoidance of western diet, ASA/COX2 inhibitors, increased vitD all associated with reduced risk,
43
ASA for prevention of colon cancer recurrence
profound effect in PIK3CA mutation carriers (12% of cancers)
44
leukovorin mechansim
binds 5-FU that permits prolonged inhibition of thymidylaste synthase.
45
capecitabine mechanism
converted to 5-FU in 3 cteps. same efficacy as 5-FU, slightly higher response rate.
46
irinotecan for colon ca
superior to infusional 5-FU;
47
metastatic colon ca
bolus 5-FU + irinotecan regimens are superior to 5-FU alone. FOLFOX comparable to FOLFIRI, but FOLFOX>IFL (non-infusional)
48
FOLFOXIRI for colon
only for exceptional cases when rapid shrinkage necessary (borderline resectable liver mets)
49
bevacizumab mechanism
binds VEGF-A, prevents binding to VEGF-R1/R2. R2 more significant effect
50
metastatic colon ca for elderly
5-FU + bev is an option based on dramatic PFS benefit compared to 5-FU alone. use in pts with contraindicated oxali/irino
51
how long to give bevacizumab in metastatic CRC
prolonged maintenance with 5-FU is standard. drop the oxali. can also continue at progression with another agent (improved survival)
52
cetuximab for mCRC
can give with irino at progression (benefit even if irino-experienced)
53
cetuximab anaphylaxis
pre-existing IgE antibodies to galactose-alpha-1,3-galactos (found in Fab of cetuximab). 21% of pts in tennessee, versus 1% in boston
54
KRAS in CRC
1) occur early in oncogenesis; 2) binary variable; 3) robust biomarkers; 4) 40% frequency (exon 2 mutation). exon 3,4 or NRAS mutations also confer EGFRi resistance
55
BRAF mutant colon cancers
5-10% of CRC, poor prognosis, early data that FOLFOXIRI+bev may be beneficial
56
regorafenib use in CRC
1.4 month survival benefit to placebo. hand-food, fatigue, diarrhea, HTN. only for people treated with all other options
57
ligand to EGFR
amphiregulin, epiregulin
58
bevacizumab surgical considerations
must wait 6 weeks
59
irinotecan metabolism
metabolized to SN-38(potent topoI inhibitor), inactivated by glucorinidation by UGT1A1 enzyme. Polymorphism of UGT1A1 -->reduced expression-->Gilbert's. If homozygous, need irinotecan dose reduction.

GI (7 decks)

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