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Surgical Oncology > Colon > Flashcards

Colon Flashcards

1
Q

Time and percent of Colonic Adenomas that develop into adenocarcinoma?

A

5% over 10-20 years

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2
Q

Three pathways to colon cancer development

A

Chromosomal Instability
Microsatellite instability
CpG island methylator phenotype

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3
Q

Colon Cancer: Sporadic v Familial percentage

A

75% v 25%

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4
Q

US Preventative Services Task Force CRC screening Reccomendations

A

Age 50-75. Individualized from 75-85.

Stool-based screening tests and intervals are as follows:
Guaiac-based fecal occult blood test (FOBT), every year
Fecal immunochemical test (FIT), every year
FIT-DNA, every 1 or 3 years

Direct visualization screening tests and intervals are as follows:
Colonoscopy, every 10 years 
Computed tomographic (CT) colonography, every 5 years 
Flexible sigmoidoscopy, every 5 years 
Flexible sigmoidoscopy with FIT; sigmoidoscopy every 10 years, with FIT every year
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5
Q

Indications and benefits of adjuvant chemo for CRC

A

All stage III

cuts distant recurrence by 50%

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6
Q

Is there a benefit for adding oxaliplatin to 5-FU for CRC? (name 2 studies and metric)

A

MOSAIC and NSABP-C06 demonstrated improved 3-year DFS.

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7
Q

Is there a benefit for adding irinotecan to 5-FU for CRC? (name two studies and outcome)

A

No difference in outcome. CALGB 89803 and PETACC 3

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8
Q

Non-inferiority of capecitabine to 5-FU

A

XACT study in stage III

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9
Q

XELOX (capecitabine +oxaliplatin) v FOLFOX

A

accrued but not resulted.

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10
Q

Adjuvant chemo for stage II CRC?

A

20-30% recurrence/5 year mortality makes consensus opinion difficult.

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11
Q

QUASAR study for CRC

A

A large European trial with small but significant benefit (3.6%) 5-year OS for those patients who received fluorouracil/leucovorin versus those in the control group

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12
Q

What tumor factor are clinical trials using to select against chemotherapy in Stage II CRC?

A

Microsatellite stable patients.

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13
Q

Median survival of metastatic CRC (all comers)?

A

22 months.

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14
Q

Adjuvant Bevacizumab?

A

Failed to show a difference in Stage II/III CRC when added to FOLFOX

NASBP C-08

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15
Q

Bevacizumab

A

Anti-angiogenic; 1st and second line when combined with chemo for mCRC.

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16
Q

Cetuximab

A

Cetuximab is a chimeric monoclonal antibody against EGFR that is approved for treatment of KRAS mutation–negative (wild-type), EGFR-expressing, metastatic colorectal cancer

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17
Q

Cetuximab combinations (3)

A
  1. monotherapy
  2. Cetuximab + Irinotecan (Camptosar) (2nd line p FOLFOX)
  3. Cetuximab + FOLFIRI
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18
Q

What is the trial for KRAS + FOLFIRI

A

CRYSTAL

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19
Q

Panitumumab

A

Panitumumab is a fully human monoclonal antibody against EGFR for combination use in second line CRC.

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20
Q

Panitumumab + FOLFOX trial

A

The PRIME trial (phase III) patients with wild-type KRAS tumors had significant improved PFS 9.6 versus 8.0 months, P=0.02) and a nonsignificant improvement in OS (23.9 versus 19.7 months, P =0.07).

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21
Q

Nivolumab +/- Ipilimumab in second line mCRC?

A

CheckMate 142 phase 2 study, nivolumab, with or without ipilimumab,

ORR 31%
disease control rate 48.4%
1 year OS 73.8%

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22
Q

Pembrolizumab in mCRC

A

KEYNOTE phase2. multiple MSI-H tumors.

ORR 39.6%
CR 7.4%

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23
Q

Regorafinib in mCRC

A

multikinase inhibitor approved 2012. 2-3rd line after anti VEGF treatments in mCRC

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24
Q

Ziv-aflibercept in mCRC

A

VEGF/PIGF decoy receptor.

improves OS compared to FOLFIRI alone 13.5 v 12 months.

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25
Hepatic artery yttrium-90 resin microspheres (SIR-Spheres) in mCRC
Imrpoves pfs from 2.1 to 5.5 months for liver confined disease compared to 5FU alone. J Clin Oncol.  2010; 28(23):3687-94 (ISSN: 1527-7755)
26
Surveilance for CRC afte resection of stage II/III disease
``` Hybrid ASCO/NCCN Visit q3 months for years 0-3 q 6 months years 4-5. CEA every visit CT CAP every other visit. Colonoscopy at years 1,3,5. ```
27
Survival after salvage APR for failed Nigro protocol?
39-64%
28
When to examine patient after Nigro protocol?
8 to 12 weeks
29
Loss of MLH1 and PMS2 on immunohistochemistry? (2 mechanisms)
sporadic loss of MLH1 by hypermethylation of promoter This is usually secondary to a BRAF mutation germline mutations. Test genes directly to look for Lynch Syndrome
30
Importance of MSI-high CRC for therapy?
They do not respond to 5-FU adjuvant chemo alone
31
sacral mass with myxoid architechture
sacral chordoma
32
treatment for sacral chordoma
wide local excision with post-op XRT | chemo resistant
33
Pattern of failure for sacral chordoma?
local recurrence
34
NCCN guidelines for CRC survivors: CEA levels
q3 months for 2 years then | q6 months for 3 years
35
What do you order for a rising CEA if CT and Colonoscopy are negative?
PET-CT
36
distal margin for mid-rectal CRC
5 cm to achieve full TME
37
distal margin for distal CRC
1 cm gross is acceptable
38
Other type of pouch if a j-pouch wont reach?
S pouch
39
Other maneuvers to help a j-pouch reach? (2)
incise the peritoneum along the SMA; | divide the secondary arcade vessels of the pouch
40
High Risk Stage II CRC criteria (NCCN; 7)
1. poor differentiation without MSI 2. lymphovascular invasion 3. perineural invasion 4. bowel obstruction 5. tumor perforation 6. close or indeterminate margins 7. less than 12 nodes removed
41
Decrease in local recurrence due to chemoradiation for rectal cancer?
13% to 6% (about half)
42
FOLFOX after rectal cancer?
Current NCCN guidelines recommend FOLFOX for all rectal cancer patients who got chemo/RT up front. Benefit may only be for node positive patients. Keep checking guidelines.
43
Indications for local excision (trans rectal) of rectal cancer
size < 3cm low grade T1 less than 1/3 of the circumference.
44
Treatment for pelvic sidewall CRC
Neoadj chemoRT followed by LAR/APR and SELECTIVE iliac nodal dissection
45
Haggitt system for pedunculated polyps (0-4)
``` 0 - Carcinoma in-situ 1- limited the the head of the polyp 2- neck 3 - stalk 4 - into stalk but above the muscularis propria ```
46
Need surgery for what polyps?
Still havent found a simple rule, but all Haggitt 4 lesions; all sessile polyps and any polyp with LVI.
47
Side effects of 5-FU?
``` nausea loose stool mucositis anorexia photophobia metallic taste cytopenia ```
48
Dihydropyrimidine dehydrogenase deficiency (DPD)
5-10% of people higher in African Americans fast and severe 5FU toxicity at first infusion Need to stop infusion immediately
49
COLOR-II Study
30 center european non-inferiority trial; | showed faster recovery for laparoscopic surgery and no difference for margin positivity and 3 year RFS
50
ACOSOG Z6051 and ALaCaRT
Rectal Cancer lap v open trials. Both failed to demonstrate non-inferiority with ~200 patients in each arm. but showed no difference between lap and open rectal cancer surgery for radial margin, number of lymph nodes and TME
51
MERCURY study
Looked at MRI for Rectal cancer to avoid Neoadj showing a 1mm clearance of the mesorectal fascia with no evidence of extramural invasion and tumors <5mm from the bowel wall ("early T3") had good outcomes with 3.3% local recurrence and 68% OS.
52
Systemic Staging for ANAL SCC?
CT scan of C/A/P for everyone
53
Anal epidermoid carcinoma
is the same as SCC
54
What do you do if SCC is still there 6 weeks after completing Nigro protocol?
keep watching, reexamine every six weeks. Complete regression reported as late as 26 weeks.
55
Indications for formal resection of a carcinoid (v endscopic)
> 2cm
56
Operation for a rectal cancer with fecal incontinence?
APR, you are never going to make the incontinence better
57
Survival after R. colectomy/whipple for T4 CRC?
52% at 5 years.
58
FOXTROT trial
Neoadjuvant chemo for T4 CRC (OxMdG) improved R0 rate of resection; pilot was small and this is not yet standard of care
59
TILs is a colorectal cancer path report suggests:
DNA mismatch repair deficiency/Lynch syndrome
60
Systemic agents for Desmoids
1. Suldinac 2. Tamoxifen 3. doxorubicin/dacarbazine
61
Number of polyps on a Colonoscopy to send a patient for genetic testing?
30 (attenuated FAP) | need 100 to get diagnosis of FAP
62
gene for FAP and attenuated FAP
both APC, depends on the severity of the mutation
63
MAP
MYH associated polyposis; autosomal recessive; behaves like attenuated FAP
64
TME should dissect between
the mesorectal fascia (fascia propria) and | the preperitoneal fascia
65
Isolated oligometastatic CRC (inguinal lymph nodes)
4 cycles of FOLFIRI then ILND
66
Pouch procedure and fertility?
Better with laparoscopic surgery in retrospective European studies.
67
Operation for presacral tumors?
Posterior approach for all below S3.
68
MOSAIC trial
landmark establishment of adjuvant FOLFOX for CRC | on subgroup analysis, no clear benefit for stage II patients.
69
NSABP C03 and C04
first trials establishing 5FU for CRC in the 1990s
70
QUASAR study
small UK study sometimes used to justify adjuvant chemo for stage II CRC patients.
71
adjuvant irinotecan/5FU for CRC?
has been shown ineffective by multiple studies
72
N10407 study
adding Cetuximab to adjuvant FOLFOX for stage III CRC. Showed no additional survival benefit

Surgical Oncology (23 decks)

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