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Colorectal Cancer FRCR CO2A Flashcards

1
Q

Types of malignant CRC

A
  1. ADenocarcinoma
  2. CArcinoid tumor
  3. Anal zone carcinoma

Mesenchymal tumors: Leiomyosarcoma
Liposarcoma
Kaposi’s sarcoma

Others: Lymphoma

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2
Q

Peak Incidence of CRC

A

60 to 70 yrs

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3
Q

Which is more common Colon Vs Rectum cancer?

A

Colon&raquo_space; Rectum by 3:2

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4
Q

RFs for CRC

A
  1. Family Hx
  2. IBD like UC and crohn’s colitis
  3. diet low in indigestible starch, high in refined carbs and fat content
  4. decreased intake of fruits and Vegetables
  5. Low physical activity
  6. High BMI (23 to 30 kg/m2)
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5
Q

Family Hx and CRC

A

1st degree relative < 40 yrs, increased risk,
Genetic causes 15% of all CRCs

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6
Q

what are 2 well recognised inherited CRC syndrome

A
  1. Lynch Syndrome
  2. Familial Adenomatous Polyposis (FAP)
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7
Q

How is Lynch Syndrome a/w CRC?

A

2% of CRCs, affected gene carriers have 80% of lifetime risk of CRC

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8
Q

what type of CRC is a/w Lynch syndrome

A

Autosomal Dominant

RIGHT SIDED, MUCIN PRODUCING, LESS AGGRESSIVE

Other associated factors include: 1. endometrial
2. ovarian
3. gastric
4. pancreatic
5. Renal malignancies

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9
Q

How is Lynch Syndrome diagnosed?

A

Modified Amsterdam Criteria

after assessment for MSI, the dx is confirmed by lab testing for MSH1&2 and PMS1&2

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10
Q

What is FAP?

A

Autosomal Dominant Condition
Defects in the adenomatous polyposis coli (APC) gene on Chromosome 5

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11
Q

what are 3 variants of FAP?

A
  1. Garder’s syndrome
  2. Turcot’s syndrome
  3. Attenuated FAP
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12
Q

what is Turcot’s syndrome?

A

Colonic polyps a/w CNS tumors, including ependymomas and medulloblastomas

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13
Q

How to prevent CRC?

A
  1. Diet high in fish and low in red meat
  2. High Fibre Diet
  3. Chemoprevention: Aspirin
  4. Exercise
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14
Q

How is screening done for CRC?

A

Faecal Occult Blood (routine in UK between age 60 to 75)

Sigmoidoscopy and colonoscopy: at 55 yrs

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15
Q

what prevention strategy can be applied for pts with IBD?

A

Screening with regular colonoscopies and prophylactic pan proctocolectomy in selected cases

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16
Q

How the risk of cancer varies with size of polyp?

A

< 1 cm: < 1% risk
1 to 2 cm: 10 % risk
> 2 cm : 50%

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17
Q

Regional LNs for Rectum

A
  1. Pararectal LNs,
  2. Nodes at bifurcation of the infr mesenteric artery
  3. the hypogastric nodes
  4. Presacral Nodes
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18
Q

Distant Metastatic site of CRC

A

Liver
Lungs
Bones

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19
Q

Right Sided Colon Cancer S/S

A

unexplained Anemia

Ill defined abdominal pain

abdominal mass

weight loss

Rectal Bleeding

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20
Q

Left Sided Colon Cancer S/S

A

changes in bowel habit

obstruction

rectal bleeding

tenesmus

mucoid discharge

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21
Q

Staging Ix for CRC

A
  1. FBC
  2. LFTs
  3. CEA
  4. Colonoscopy
  5. CT Thorax Abdomen and Pelvis
  6. PET CT only when resection of metastasis is considered
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22
Q

CEA in CRC

A

raised in 85% of CRC

higher values : worse prognosis

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23
Q

Local Staging for rectal CAncer

A

DRE
EUS and

MRI (established by MERCURY trial)

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24
Q

How is MRI helpful in rectal cancer local staging?

A
  1. identify the MRF and
  2. Clearance at CRM
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25
Q

Treatment of M0 colon cancer

A

Surgery as an elective procedure

if presents at EMR, defunctioning colostomy/stenting f/b elective definitive Sx

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26
Q

what structures are removed in Surgery for Colon Cancer?

A
  1. Appropriate bowel segment and its mesentery
  2. Vascular pedicle
  3. draining LNs
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27
Q

Adjuvant Rx for T1/2N0, pMMR/MSS

A

Observation

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28
Q

Adjuvant Rx for T3N0, pMMR/MSS or higher stages

A

CAPEOX 3 months to 6 months
FOLFOX 3 to 6 months

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29
Q

Poor Risk features in N0 colon cancer

A
  1. Serosal involvement
  2. Perforated tumors
  3. Extramural Vascular invasion
  4. < 12 LNs examined
  5. involved CRM
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30
Q

Adjuvant Rx for dMMR/MSI H (T1-4a N0)

A

observation

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31
Q

Adjuvant Rx for dMMR/MSI H (>T4a or N+)

A

CAPEOX 3 to 6 months
FOLFOX 3 to 6 months

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32
Q

whats the status of bevacizumab and cetuximab as adjuvant therapy?

A

No significant benefit (AVANT and FFCD. PETACC 8 trial)

33
Q

when to add Aspirin in adjuvant setting for colon cancer?

A

If PIK3CA
mutation,
add aspirin
100-162 mg
PO daily for
3 years for
stage II-III
disease

34
Q

what are 3 risk categories as per MRI in rectal cancer (MERCURY) study?

A

1 .Favourable rT1 or rT3a, N0 (min exxtension into rectum)

  1. unfavourable >rT3a (significant mesorectal contamination), or N+ve with margin not at risk
  2. Advanced T4 or CRM < 1 mm
35
Q

when is pre-op RT indicated in Ca Rectum?

A

predicted to be likely to recur after surgery

36
Q

surgery in rectal cancer?

A

Challenging due to narrow pelvis

Very Low tumors: APR

Higher tumors: anterior resection

TME is standard for rectal cancer surgery

37
Q

what surgery is standard in early stage rectal cancer?

A

local excision an alternative to APR in low rectal cancers

38
Q

what’s the mc approach for local excision?

A

TEM (Trans anal endoscopic microsurgery).

39
Q

Adjuvant Chemo for Rectal cancer

A

same adjuvant systemic therapy as colon cancer, stage for stage

40
Q

Pre op Vs Post Op RT in Rectal Cancer

A

Sauer Study
Pre op Vs Post op Long Course CRT
Local Control Rate 13 % Vs 6% in favor of pre op

more toxicity in post op

Pre op CRT standard in UK

41
Q

Pre Op SCRT (25 Gy/ 5#) trials

A

Dutch TME trial

No survival benefit but increased local control

42
Q

what if N+ but CRM -

A

Give Post op RT, LCR improved (MRC CR 07 study)

43
Q

In UK, when is post op RT done in rectal cancer

A

CRM + and no PRE OP RT

in N+, role of post op RT is less certain

44
Q

which trial defines UK standard for REctal CAncer RT Volumes?

A

UK ARISTOTLE Trial

45
Q

CT simulation for Rectal Cancer

A

Supine
Radio opaque marker at the anal verge

Gastrografin (oral contrast) 20 ml in 1 L of water 45 to 60 minutes b4 simulation

46
Q

CT simulation Scan Field

A

Supr: Supr aspecct of L5

Infr: 4 cm below marker or the infr extent of tumor

48
Q

slice thickness of simulation CT

49
Q

CTV in Rectal Cancer

A
  1. GTV + 1 cm
  2. Mesorectum, Presacral Space and Internal iliac nodes
  3. Levator muscle invasion, 1 cm lateral and postr margin is applied
50
Q

Should uninvolved Ext Iliac LNs be included in RT field

51
Q

RT Field Arrangement for Rectal Cancer

A

3/4 fields

1 postr, 2 lateral
or 2 postr, 2 lateral

45 degree wedges of lateral fields

52
Q

SCRT approaches for Rectal Cancer

A
  1. 25 Gy/ 5# f/b surgery at 1 week
  2. 45 Gy/ 25# f/b surgery at 6 weeks
53
Q

Post op RT dose:

A

45 to 50 Gy in 25#

Residual disease: Boost of 10 to 15 Gy in 5 to 7 fractions

54
Q

What is ICRU Reference Point?

A

used for reporting dose, ideally located at the center of the PTV and near the intersection of beam axes

55
Q

Concurrent ChT in Rectal Cancer

A

Capecitabine @ 900 mg/m2 BD on RT days

5 FU 200mg/m2 per day through out RT treatment

55
Q

C/I for RT in rectal cancer

A
  1. IBD
  2. Diverticular disease
  3. DM
56
Q

Acute S/E of CRT:

A

tiredness
diarrhea
cystitis
Severe and painful perineal reaction (low tumors) and Cardiac toxicity
myelosuppression

57
Q

Late S/E of RT (rectal cancer)

A
  1. Menopause (in females)
  2. Infertility/sterility
  3. impotence
  4. bowel dysfunction
  5. urge incontinence
58
Q

Mx of RT induced diarrhoea

A

Imodium and low residue diet and close monitoring

59
Q

Rx of Advanced/inoperable local disease REctal cancer

A

RT with/without Chemo: useful palliation

s/times converted to operable

DEfunctioning colostomy

60
Q

palliative RT indications?

A

medically unfit for Surgery

symptoms of local pain, discharge or bleeding

61
Q

Dose of Palliative RT

A

8 Gy SF
25 Gy/ 5#
20 Gy/ 4 #

Fitter Pts: 45 Gy/ 25# with capecitabine ChT

62
Q

pall RT in caecal tumors purpose

A

bleeding and recurrent anaemia

63
Q

Palliative SUrgery

A

better than just bypass, increased survival and better QOL

64
Q

Recurrent Disease

A

CRT f/b assessment for Sx, if RT not given previously

65
Q

Does resection of oligo liver mets increase survival?

A

yes, 31 Vs 11 months

66
Q

when is liver mets not recommended for Sx?

A
  1. extends outside the liver
  2. Hepatic veins are involved, all
  3. not enough viable liver tissue left
67
Q

what about NACT for metastatic disease

A

evidence supports the use of preoperative ChT prior to resection in Pts with potentially operable liver mets

68
Q

metastatic Rectal Cancer
1st L

A
  • FOLFOX ± bevacizumab
  • KRAS/NRAS/BRAF WTi
    :
    FOLFOX + (cetuximab or panitumumab)j

CAPEOX + (cetuximab or panitumumab)j
FOLFIRI
+ (cetuximab or panitumumab)j
* BRAF V600E mutation positive
:
Encorafenib + (cetuximab or panitumumab) + FOLFOX

69
Q

Targeted therapy for rectal cancer (metastatic)

A

BRAF V600E mutation positive:
Encorafenib + (cetuximab or panitumumab)

(Encorafenib + [cetuximab or panitumumab]FOLFOXe)

  • HER2-amplified and RAS and BRAF WTj
    (Trastuzumab + [pertuzumab or lapatinib or tucatinib])k
  • HER2-amplified (IHC 3+)
    Fam-trastuzumab deruxtecan-nxkit
  • KRAS G12C mutation positive

(Sotorasib or adagrasib)u + (cetuximab or panitumumab)

  • NTRK gene fusion-positive
    Entrectinib
    Larotrectinib

RET gene fusion-positive
Selpercatinib

70
Q

mCRC dMMR/MSI-H
1st L

A

nivolumab ± ipilimumab,

pembrolizumab, dostarlimab-gxly,

cemiplimab-rwlc,

retifanlimab-dlwr,

toripalimab-tpzi, or

tislelizumab-jsgr.

70
Q

Predictors of prognosis when starting chemo

A
  1. poor P.S
  2. Low serum albumin
  3. High ALP
  4. Liver Involvement
71
Q

Role of Bevacizumab as single agent as a maintenance therapy

A

No benefit

72
Q

Bevacizumab S/Es

A
  1. HTN
  2. Proteinuria
  3. Bowel Perforation
73
Q

when is cetuximab or panitumumab used?

A

monotherapy in wt RAS as the last line or

in combination with irinotecan or oxaliplatin in 1st/2nd Line

74
Q

S/Es of cetuximab

A

skin rash

paronychia

splitting in the pulps of fingers and toes

75
Q

follow up duration in CRC

A

3 monthly in 1st year

every 6 months thereafter and then annual

76
Q

Status of Regorafenib in CRC

A

last Line, not approved by NICE

FRCR CO2A (20 decks)

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