Colon Cancer

Question 1

What are the high risk features you need to look for in stage II colon cancer? T3, N0

Answer 1

Poorly differentiated/undifferentiated, lymphovascular invasion, bowel obstruction, less than 12 lymph nodes, perineural invasion, localized perforation, close/indeterminate/positive margins, visceral involvement.

Question 2

What is the tx for low risk Stage II (T3,N0) colon cancer?

Answer 2

Low risk Stage II: either observation OR 6 months of 5-FU or Capecitabine. Remember studies did not show a benefit of adding Oxaliplatin to Stage II patients.

Question 2

What is the tx of high risk Stage II (T3,N0) or (T4,N0) colon cancer?

Answer 2

5-FU or Capectiabine for 6 months OR FOLFOX for 6 months or CAPOX for 3 months OR observation.

Question 3

What is the tx for low risk Stage III colon cancer (T1-3,N1)?

Answer 3

Preferred options: CAPOX for 3 months or FOLFOX for 3-6 months or you can do Capecitabine or 5-FU for 6 months.

Question 4

What is the tx for high risk colon cancer that is Stage III (T4,N1-2) or (T any stage,N2)?

Answer 4

CAPEOX for 3-6 months or FOLFOX for 6 months OR 5-FU for 6 months or Capecitabine for 6 months

Question 5

What is the tx of metastatic liver only or lung only colon cancer?

Answer 5

So the preferred option is to proceed with a synchronous colon resection with liver resection or staged colon resection. Or you can do 2-3 months of neoadjuvant FOLFOX or CAPOX followed by surgery. OR you can do colectomy followed by chemo and then resection of mets. All are preferred.

Question 6

For those who have undergone surgery for metastatic lung or liver only colon cancer what adjuvant therapy do you do?

Answer 6

6 months of CAPOX or FOLFOX

Question 7

What is the f/u for Stage I colon cancer?

Answer 7

Repeat colonoscopy at 1 year, if adenoma repeat in 1 year. If neg for this then you do repeat in 3 years and then in 5 years

Question 8

What is the follow up for Stage II and II colon cancer?

Answer 8

H&P w/CEA level every 6 months for 2 years and then every 6 months for 5 years. CT scan every 6-12 months from date of surgery for a total of 5 years. Colonoscopy 1 year after surgery.

Question 9

What is the f/u for fully treated Stage IV colon cancer?

Answer 9

H&P w/CEA every 3-6 months for 2 years followed by every 6 months for 5 years. CT scan every 3-6 months for 2 years followed by every 6-12 months for 5 years.

Question 10

What is the first line tx for metastatic tumors that are right sided? (regardless of the RAS mutation!) These are all regimens for intense therapy

Answer 10

You give FOLFOX or CAPEOX +/- Bev or you can do FOLFIRI or FOLFIRINOX +/- Bev

Question 11

What is the tx for metastatic colon cancer that is left sided and KRAS/NRAS WT? If its KRAS/NRAS mutated then what?

Answer 11

FOLFOX, FOLFIRI, CAPEOX w/ Panitumumab or Cetuximab. KRAS/NRAS mutated-just give chemo w/o EGFR inhibitor

Question 12

What are less intense regimens you give as first line tx in metastatic colon cancer?

Answer 12

So you can do 5FU or Capecitabine +/- Bev or you can do Panitumumab or Cetuximab alone for those that are KRAS/NRAS WT (CAT2B rec). Also you have Trastuzumab w/Pertuzumab, lapatinib, or tucatinib in HER2+

Question 13

What are the IO therapy options for metastatic colon cancer is the dMMR/MSI-H?

Answer 13

Nivo+/-Ipi, Pembro, or Dostarlimab

Question 14

Take note that for HER2 directed therapy for metastatic colon cancer when is this therapy indicated first line vs second line?

Answer 14

So for HER2+ dx you can use this in the first line setting only for those patients who are not candidates for intense therapy. Otherwise you give it in the 2nd line setting.

Question 15

Name the options for targeted directed therapy in the 2nd line setting? (only used in 2nd line, exception with HER2)

Answer 15

BRAF: Encorafenib+(Cetuximab or Panitumumab)
HER2-Trastuzumab Deruxtecan or you can do Trastuzumab w/Pertuzumab, Lapatinib, or Tucatinib
RET-Selpercatinib
KRAS: Sotorasib or Adagrasib+Cetuximab or Panitumumab
NTRK-Larotrectinib, Entrectinib, Repotrectinib

Question 16

What are your options for metastatic colon cancer that has progressed using both Irinotecan and Oxaliplatin?

Answer 16

Fruqutinib, Regorafenib, or Lonsurf +/- Bevacizumab (preferred to be given with Bev).
Fruquitinib is a VEGF Kinase inhibitor

Question 17

What stage of rectal cancers can be treated w/surgery upfront?

Answer 17

Stage I (T1,N0)-Endoscopic resection or transanal
Stage I (T1-2,N0)-Trans-abdominal resection
Stage II (T3,N0) high rectal tumors-Can do Trans-abdominal resection, but some may need chemo/RT depending on where they are located

Question 18

For stage I rectal tumors is adjuvant therapy indicated?

Answer 18

NO!

Question 19

For those with inoperable Stage II rectal cancer (because of the location within the rectum and invasion of MSF) or stage III tumors, what is the tx assuming they are MSI-H/pMMR?

Answer 19

TNT which means you give long course chemo/RT followed by chemo and then surgery or the other way around. Chemo you can use? CAPEOX, FOLFOX, or FOLFIRINOX. W/RT-5-FU or Capecitabine.

Question 20

What is tx for inoperable Stage II or Stage III rectal cancer that is MSI-H/dMMR?

Answer 20

So you can give Pembro, Dostarlimab, Nivolumab for up to 6 months or you can consider TNT therapy, but IO therapy is preferred here.

Question 21

If patients who undergo IO therapy for early stage rectal cancer have a CR, what do you do next? What if they didn’t have a CR?

Answer 21

If they have a CR then you can do surveillance. If they didn’t you can consider using long course chemo/RT or short course. If they have a good response you can do surveillance or you can take to surgery. If after surgery they have a CR you can do surveillance or chemo (12-16wks of CAPEOX or FOLFOX). They have good prognosis even when tx w/chemo!

Question 22

For those T1 lesions in rectal cancer that are treated with transanal excision, what additional treatment is done for those with high risk features and what are they?

Answer 22

So if they have high risk features you then do trans-abdominal resection (preferred) or chemo/RT followed by surveillance if no evidence or disease or you can do chemo (FOLFOX/CAPEOX) or if they have residual dx do surgery followed by chemo. High risk features-positive margins, LSVI, poorly diff, S3 invasion (lower third submucosa invasion).