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Hematology, oncology > Colorectal cancer 2 > Flashcards

Colorectal cancer 2 Flashcards

1
Q

Recommended interval for c-scope in surveillance setting

A

1 year, then 3 years if normal, then 5 years if normal

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2
Q

clinical features of palmar-plantar erythrodysesthesia

A

redness, swelling, skin peeling and pain on the palms of the hands and/or the soles of the feet.

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3
Q

Tumor marker for CRC

A

CEA

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4
Q

What is the idea of total neoadjuvant therapy (TNT) in rectal cancer?

A

Using all systemic chemo + radiation in preoperative setting to downstage rectal cancer

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5
Q

Neoadjuvant vs. surgery concept for CRC

A
  • Surgery is the only curative modality, so if patient has resectable disease and are anticipated to have negative margins, they should proceed to surgery rather than upfront chemo.
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6
Q

What is the goal of adjuvant chemotherapy for colon cancer?

A

Eradicate micrometastases

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7
Q

Duration of adjuvant therapy

A

6 months (BUT IDEA collaboration which involved 6 trials suggest that you lose some disease free survival with 3 months but it is suitable in patients with low risk disease)

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8
Q

high risk stage II features per ASCO and NCCN

A

1) fewer than 12 nodes sampled
2) ***T4 tumor
3) perforated
3) obstruction
4) poorly differentiated tumor histology
5) LVI
6) PNI
7) close/indeterminate margins

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9
Q

Therapy that is controversial for use in older people

A

Oxaliplatin

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10
Q

Access for 5 Fu

A

Need central access

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11
Q

Role for RT in rectal vs colon

A

Postop RT not used for colon, as opposed to rectal

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12
Q

most common distant metastatic sites

A

Liver, lungs, lymph nodes, peritoneum

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13
Q

Survival in metastatic CRC

A

30 months (around 3 years)

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14
Q

In what sites can metastasectomy be performed

A

Liver and lung

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15
Q

Is long term survival possible with metastasectomy?

A

Yes, but most people are alive at 5 years with active disease

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16
Q

How to predict 5 year survival rate for solid tumors

A

Memorial sloan kettering has nomograms on their websites

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17
Q

What does presence of synchronous CRC cancers suggest?

A

Lynch syndrome or FAP

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18
Q

Clinical significance of microsatelite instability

A
  • Predicts lack of response to fluoropyrimidine therapy

- Predicts response to CPIs

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19
Q

Liver test abnormality associated with liver mets

A

Elevated alk phos
- Elevated liver enzymes are not a reliable marker for exclusion of liver involvement (may be normal in the setting of small hepatic mets)

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20
Q

When do you start adjuvant chemo in stage III?

A

Await until recovery following surgery (typically 6-8 weeks)

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21
Q

FOLFOX vs CAPEOX in terms of toxicity

A

CAPEOX probably more toxic

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22
Q

Biochem interaction and physiology of PD-1 and PD-L1

A

PD-1 is upregulated on activated T cells, and upon recognition of tumor via the T cell receptor, PD-1 engagement by programmed death ligand 1 (PD-L1) results in T cell inactivation.

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23
Q

Initial combination or single chemo for mCRC?

A

initial combination chemo

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24
Q

What is “conversion therapy”?

A

Giving chemo with the hope of converting unresectable mets to resectable

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25
Q

Best metric for response to therapy in palliative setting

A

PFS (trying to delay tumor progression for as long as possible)

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26
Q

Is chemo typically modified in obese patients?

A

Doses are often reduced because of concern for excess toxicity due to a larger body surface area (guidelines recommend against this for mCRC though)

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27
Q

Response assessment in mCRC

A

Scans every 2-3 months + CEA every 1-3 months

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28
Q

Management of rising CEA level in mCRC

A

Confirm disease progression with scan prior to changing therapy

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29
Q

Clinical utility of PET/CT for CRC

A

Low, not indicated generally

Can be considered in Stage IV for potentially curable M1 disease

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30
Q

Stage II adjuvant treatment options

A 
*Depends on risk factors
Capecitabine
5-Fu
FOLFOX
CAPEOX
Observation
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31
Q

Imaging if recurrence suggested by elevated CEA

A

Chest/abdomen/pelvis CT with contrast

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32
Q

Next step if elevated CEA prompts imaging in surveillance and imaging is negative

A

Consider PET/CT

Re-evaluate chest/abdomen/pelvis CT with contrast in 3 months

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33
Q

Surveillance imaging for stage II and III

A

Chest, abdomen, pelvis CT q6 months for a total of 5 years

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34
Q

Surveillance imaging for stage I

A

Imaging only if symptomatic

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35
Q

Surveillance imaging for stage IV

A

chest/abdomen/pelvis CT q3 months x 2 years, then q6 months for total 5 years

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36
Q

When MRI is indicated for liver mets

A

Indeterminate, potentially resectable mets

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37
Q

What is tumor budding + clinical significance

A

ON path – single or cluster of cells at advancing edge of invasive carcinoma.
Negative prognostic factor

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38
Q

Number of lymph nodes required to pathologically stage nodal status of CRC

A

12

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39
Q

Clinical significance of KRAS or NRAS mutations

A

No treatment with cetuximab or panitumumab

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40
Q

Clinical significance of BRAF mutation

A

Response to panitumumab or cetuximab is highly unlikely unless given with a BRAF inhibitor

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41
Q

How testing for MSI status is performed

A

PCR or NGS

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42
Q

Testing for HER2

A

IHC, FISH, or NGS

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43
Q

Is re-resection of lung mets possible?

A

Can be considered in selected patients

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44
Q

Role for bevacizumab

A

Usually added to FOLFOX or CAPEOX

45
Q

Indication for cetuximab or panitumumab

A

KRAS/NRAS/BRAF WT + left-sided only

46
Q

Bevacizumab formulation

A

IV

47
Q

What does m in mFOLFOX stand for?

A

Modified FOLFOX

48
Q

Percentage of cases of CRC associated with familial clustering

A

20%

49
Q

How is a malignant polyp defined?

A

Cancer invading the submucosa

50
Q

Surgical management of lymph nodes for resectable non-metastatic CRC

A

Colectomy with en bloc removal of the regional lymph nodes

51
Q

Adjuvant therapy for Stage II depends on

A

Depends on risk (low vs high)

52
Q

Adjuvant therapy options for low-risk stage II?

A

Observation OR
capecitabine OR
5-FU/leucovorin

53
Q

Adjuvant therapy options for low-risk stage III disease

A

3 months CAPEOX
3-6 months FOLFOX
IF oxaliplatin inappropriate –> single agent capecitabine or 5-FU/LV

54
Q

Adjuvant therapy options for high-risk stage III disease

A

6 months FOLFOX

3-6 months CAPEOX CONFIRM

55
Q

MSI classification

A

MSI-High or MSI-low

56
Q

NCI preferred FOLFOX regimen for adjuvant and metastatic treatment?

A

mFOLFOX

57
Q

Reversibility of peripheral neuropathy with oxalaplatin

A

Reversible in most patients, irreversible in a small percentage

58
Q

Cause of death in most patients with mCRC

A

Metastatic liver disease

59
Q

Local therapies for metastases

A

Surgical resection is the standard of care, but in patients who aren’t surgical candidates, image-guided ablation is used. SBRT is an option for patients who can’t be ablated.

60
Q

Goal of treatment of peritoneal metastases

A

Palliative

61
Q

What is HIPEC?

A

Hyperthermic intraperitoneal chemotherapy

  • treatment fit or peritoneal metastases
  • works but morbidity high and didn’t change long term survival
62
Q

Potential upside + downside to neoadjuvant chemo as

A
  • elimination of micro metastatic disease

- may miss “window of opportunity” for resection

63
Q

Why don’t you test for EGFR?

A

Hasn’t been shown to predict response to EGFR inhibitors

64
Q

When should you drop oxaliplatin?

A

After 3 months of therapy or sooner if unacceptable neurotoxicity

65
Q

EGFR-targeted therapies for CRC

A

cetuximab, panitumumab

66
Q

Need to rebiopsy tumor if metastatic recurrence and retest mutational status?

A

No (RAS mutations occur early in carcinogenesis so mutation status of primary tumor and subsequent recurrence are very concordant)

67
Q

Stage III means

A

Mets to local-regional lymph nodes

68
Q

Stage IIIC means

A

Mets to four or more nodes

69
Q

epidemiology of CRC

A
  • incidence is going down due to screening but incidence of early onset is rising
70
Q

who among CRC patients are tested for Lynch syndrome?

A

everyone

71
Q

*Indications for adjuvant therapy

A

High risk Stage II

Stage III

72
Q

Duration of adjuvant treatment for Stage III

A
  • Intermediate risk = 3 months CAPOX or 6 months FOLFOX
  • High risk = 6 months FOLFOX or 3-6 months CAPOX
  • so 6 months except data for 3 months CAPOX with intermediate risk
73
Q

Adjuvant therapy regimens and duration for Stage II

A

3 months CAPOX
OR
5-Fu/LV
OR capecitabine

74
Q

Stage II patients who you should avoid giving chemo to in CRC

A

MSI-H patients

75
Q

CEA level that is thought to predict adverse impact on survival

A

Equal to or greater than 5

76
Q

Initial management of CRC presenting with hepatic mets

A
  • SURGERY – hemicolectomy + surgical resection of liver disease, followed by adjuvant chemo
  • NO biopsy (hepatic mets in CRC are diagnosed by noninvasive imaging and tumor markers. Hepatic biopsy adds little diagnostic information and may reduce long term survival)
77
Q

Contraindications to surgery for hepatic mets

A
  • inadequate liver reserve for resection
  • extensive liver mets (greater than 70%, over 6 segments, involving all 3 hepatic veins)
  • vascular involvement: involvement of hepatic artery, major bile ducts, or main portal vein
78
Q

Clinical significance of dMMR tumors in CRC

A

1) Patients experience clinical benefit from PD-1 inhibitors and can have durable responses
2) chemo resistant

79
Q

IO for GBCs?

A
  • frequency of dMMR tumors is around 5% for GBC
  • pembro is FDA approved for MSI-H tumors for tumors progressing following prior treatment
  • PD-L1 may predict response
80
Q

what is the pathophysiologic mechanism of VEGF inhibitors?

A
  • angiogenesis inhibitors (vascular endothelial growth factor)
81
Q

Clinical relevance of MSI – MMR status

A

1) eligibility for checkpoint inhibitor immunotherapy

2) predicts responsiveness to fluoropyrimidines,

82
Q

Benefit of chemo with stage II colon cancer

A
  • somewhat muted. NCCN basically accepts relative benefit of adjuvant therapy in stage III disease
83
Q

prognostic + clinical relevance of MSI status in Stage II colon cancer

A

1) MSI-High patients do not benefit from adjuvant fluoropyrimidines
2) Responsive to immunotherapy

84
Q

clinical significance of MSI-H**

A

1) Response to immunotherapy

2) Unresponsive to fluoropyrimidines

85
Q

When is adjuvant chemotherapy indicated in stage II disease indicated

A

pT3 with high risk features
pT4 disease
*must be pMMR

86
Q

what defines stage II colon cancer

A

Any T stage

No nodal involvement

87
Q

EGFR inhibitors you can add to front line systemic therapy

A

Cetuximab
OR
*panitumumab

88
Q

when EGFR inhibitors are indicated

A

KRAS + NRAS + BRAF wild type

89
Q

Efficacy of capecitabine vs. 5-Fu

A

EQUIVALENT, choose based on SE profile

90
Q

second line for colon after first line FOLFOX

A

FOLFIRI (if FOLFOX first line)

91
Q

High risk features for Stage II colon cancer

A
  • bowel obstruction
  • less than 12 lymph nodes sampled
  • LVI
  • close/positive margins
  • PNI
  • *poorly differentiated histology
  • perforation
92
Q

N1c disease in CRC

A
  • nodal deposits in the subserosa, mesentery, pericolic, perirectal, mesorectal tissues
93
Q

significance of tumor deposits in the subserosa, mesentery, pericolic, perirectal, mesorectal tissues in CRC

A

Stage III disease, not metastatic

94
Q

High risk features of Stage III colon cancer

A

1) T4 disease w/ N1-2
2) T any, N2

95
Q

Differences in duration of treatment for low and high risk stage III colon

A

Capeox 3 months for low risk, noninferiority of 3 months of FOLFOX vs. 6 months has not been shown

96
Q

What is pseudomyxoma peritonei?

A

Diffuse mucinous peritoneal involvement from appendiceal cancer. This is not peritoneal carcinomatosis.

97
Q

Are hepatic mets typically biopsied with CRC?

A

NO biopsy (hepatic mets in CRC are diagnosed by noninvasive imaging and tumor markers. Hepatic biopsy adds little diagnostic information and may reduce long term survival)

98
Q

Utility of PET/CT in colon cancer

A

Not indicated

99
Q

When is neoadjuvant therapy indicated aside from nonresectable disease?

A

T4b disease

100
Q

What has been shown to reduce risk of colon cancer recurrence?

A

Exercise

101
Q

Second line for BRAF V600 mutant metastatic colon

A

encorafenib + cetuximab

102
Q

What is high risk in Stage III

A

T4 and or N2 disease

103
Q

Abnormality associated with severe symptoms from 5-Fu

A

dihydropyrimidine dehydrogenase (DPD; encoded by DPYD) deficiency.

104
Q

MSI vs. MMR in terms of testing

A

dMMR = loss of expression on IHC
MSI-H = PCR

105
Q

Med contraindicated with capecitabine

A

PPIs

106
Q

Adjuvant therapy for low risk

A

3 months FOLFOX or CAPOX

107
Q

Continue Bev at progression in second line?

A

Yes, shown to have a benefit of a couple months

108
Q

Mutation associated with delayed clearance of irinotecan

A

UGT1a1

109
Q

Colonoscopy recommended surveillance interval

A
  • 1 yr after curative resesction
  • 3 years later if no high-risk adenomas

Hematology, oncology (218 decks)

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