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 Stage 1 disease defined as and what is the tx?

Answer 2

T2,N0-no adjuvant tx is indicated.

Question 3

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

Answer 3

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 4

What is the tx of high risk Stage IIa (T3,N0) or Stage IIb (T4,N0) colon cancer?
T1-invades through the submucosa
T2-it invades to the muscularis propria
T3-invades through the muscularis prorpria
T4-invades the visceral peritoneum or adjacent organs

Answer 4

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

Question 5

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

Answer 5

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

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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 8

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

Answer 8

6 months of CAPOX or FOLFOX

Question 9

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

Answer 9

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 10

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

Answer 10

H&P w/CEA level every 3-6 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 11

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

Answer 11

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 12

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 12

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

Question 13

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

Answer 13

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

Question 14

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

Answer 14

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 15

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

Answer 15

Nivo+/-Ipi, Pembro, or Dostarlimab

Question 16

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

Answer 16

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 17

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

Answer 17

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 18

What are the chemo options available for 2nd line tx if they had prior Oxaliplatin use?

Answer 18

FOLFIRI or Irinotecan alone. FOLFIRI or Irinotecan +/-Bevacizumab (preferred), Ziv Aflibercept, or Ramucirumab. If KRAS/NRAS WT: FOLFIRI+Cetuximab or Panitumumab
Cetuximab or Panitumumab +/- Irinotecan

Question 19

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

Answer 19

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

Question 20

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

Answer 20

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 21

For stage I rectal tumors is adjuvant therapy indicated?

Answer 21

NO!

Question 22

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-L/pMMR?

Answer 22

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 23

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

Answer 23

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 24

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 24

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 25

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 25

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).

Question 26

What is the first line tx for metastatic anal cell carcinoma?

Answer 26

Carbo/Paclitaxel
2nd line options: FOLFCIS, mFOLFOX6, 5-FU/Cisplatin (Cat 2B), DCF (Cat 2B)

Question 27

What are your 2nd line options for metastatic anal cell carcinoma?

Answer 27

Nivo, Pembro, Retifanlamb

Question 28

For chemo/RT for anal cell what are the regimens?

Answer 28

5-FU/mitomycin or Capecitabine/mitomycin. Can also use 5-FU/Cisplatin (Cat 2B).