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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
Q

Hepatic artery yttrium-90 resin microspheres(SIR-Spheres) in mCRC

A

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)

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26
Q

Surveilance for CRC afte resection of stage II/III disease

A 
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.
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27
Q

Survival after salvage APR for failed Nigro protocol?

A

39-64%

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28
Q

When to examine patient after Nigro protocol?

A

8 to 12 weeks

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29
Q

Loss of MLH1 and PMS2 on immunohistochemistry? (2 mechanisms)

A

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
Q

Importance of MSI-high CRC for therapy?

A

They do not respond to 5-FU adjuvant chemo alone

31
Q

sacral mass with myxoid architechture

A

sacral chordoma

32
Q

treatment for sacral chordoma

A

wide local excision with post-op XRT

chemo resistant

33
Q

Pattern of failure for sacral chordoma?

A

local recurrence

34
Q

NCCN guidelines for CRC survivors: CEA levels

A

q3 months for 2 years then

q6 months for 3 years

35
Q

What do you order for a rising CEA if CT and Colonoscopy are negative?

36
Q

distal margin for mid-rectal CRC

A

5 cm to achieve full TME

37
Q

distal margin for distal CRC

A

1 cm gross is acceptable

38
Q

Other type of pouch if a j-pouch wont reach?

39
Q

Other maneuvers to help a j-pouch reach? (2)

A

incise the peritoneum along the SMA;

divide the secondary arcade vessels of the pouch

40
Q

High Risk Stage II CRC criteria (NCCN; 7)

A
  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
Q

Decrease in local recurrence due to chemoradiation for rectal cancer?

A

13% to 6% (about half)

42
Q

FOLFOX after rectal cancer?

A

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
Q

Indications for local excision (trans rectal) of rectal cancer

A

size < 3cm
low grade
T1
less than 1/3 of the circumference.

44
Q

Treatment for pelvic sidewall CRC

A

Neoadj chemoRT followed by LAR/APR and SELECTIVE iliac nodal dissection

45
Q

Haggitt system for pedunculated polyps (0-4)

A 
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
Q

Need surgery for what polyps?

A

Still havent found a simple rule, but all Haggitt 4 lesions; all sessile polyps and any polyp with LVI.

47
Q

Side effects of 5-FU?

A 
nausea
loose stool
mucositis
anorexia
photophobia
metallic taste
cytopenia
48
Q

Dihydropyrimidine dehydrogenase deficiency (DPD)

A

5-10% of people
higher in African Americans
fast and severe 5FU toxicity at first infusion
Need to stop infusion immediately

49
Q

COLOR-II Study

A

30 center european non-inferiority trial;

showed faster recovery for laparoscopic surgery and no difference for margin positivity and 3 year RFS

50
Q

ACOSOG Z6051 and ALaCaRT

A

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
Q

MERCURY study

A

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
Q

Systemic Staging for ANAL SCC?

A

CT scan of C/A/P for everyone

53
Q

Anal epidermoid carcinoma

A

is the same as SCC

54
Q

What do you do if SCC is still there 6 weeks after completing Nigro protocol?

A

keep watching, reexamine every six weeks. Complete regression reported as late as 26 weeks.

55
Q

Indications for formal resection of a carcinoid (v endscopic)

56
Q

Operation for a rectal cancer with fecal incontinence?

A

APR, you are never going to make the incontinence better

57
Q

Survival after R. colectomy/whipple for T4 CRC?

A

52% at 5 years.

58
Q

FOXTROT trial

A

Neoadjuvant chemo for T4 CRC (OxMdG) improved R0 rate of resection; pilot was small and this is not yet standard of care

59
Q

TILs is a colorectal cancer path report suggests:

A

DNA mismatch repair deficiency/Lynch syndrome

60
Q

Systemic agents for Desmoids

A
  1. Suldinac
  2. Tamoxifen
  3. doxorubicin/dacarbazine
61
Q

Number of polyps on a Colonoscopy to send a patient for genetic testing?

A

30 (attenuated FAP)

need 100 to get diagnosis of FAP

62
Q

gene for FAP and attenuated FAP

A

both APC, depends on the severity of the mutation

63
Q

MAP

A

MYH associated polyposis; autosomal recessive; behaves like attenuated FAP

64
Q

TME should dissect between

A

the mesorectal fascia (fascia propria) and

the preperitoneal fascia

65
Q

Isolated oligometastatic CRC (inguinal lymph nodes)

A

4 cycles of FOLFIRI then ILND

66
Q

Pouch procedure and fertility?

A

Better with laparoscopic surgery in retrospective European studies.

67
Q

Operation for presacral tumors?

A

Posterior approach for all below S3.

68
Q

MOSAIC trial

A

landmark establishment of adjuvant FOLFOX for CRC

on subgroup analysis, no clear benefit for stage II patients.

69
Q

NSABP C03 and C04

A

first trials establishing 5FU for CRC in the 1990s

70
Q

QUASAR study

A

small UK study sometimes used to justify adjuvant chemo for stage II CRC patients.

71
Q

adjuvant irinotecan/5FU for CRC?

A

has been shown ineffective by multiple studies

72
Q

N10407 study

A

adding Cetuximab to adjuvant FOLFOX for stage III CRC.

Showed no additional survival benefit

Surgical Oncology (23 decks)

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