CRC 2 Flashcards
Mutation and inheritance in familial adenomatous polyposis
AD mutation in APC gene
Who should be tested for HNPCC/Lynch syndrome?
All CRC patients, regardless of stage or age
How do you screen for HNPCC?
Mismatch repair protein ICH or MSI testing (PCR)
What genes are implicated in HNPCC? (4)
MSH2
MSH6
MLH1
PMS2
What is difference about MLH1 mutations compared to other mutations seen in MMR-deficient CRC?
MLH1 mutation can be sporadic. If it is seen in MLH1 hypermethylation or BRAF mutation, then it is sporadic, not germline
At what age should CRC screening begin?
45
T stage in colorectal cancer
T1: submucosal invasion
T2: Invasion muscularis propria
T3: Invades through muscularis propria or subseroa
T4: Directly invades other structures
N stage in CRC
N1: 1-3 LNs
N2: 4+ LNs
Adjuvant treatment for intermediate risk stage III CRC
3 months CAPEOX
6 months FOLFOX
Adjuvant treatment for high risk stage II CRC?
3 months CAPEOX
6 months FOLFOX
6 months 5-FU or Cape
What designates someone as high risk Stage III?
T4 and/or N2
Adjuvant treatment for high-risk stage III CRC? (2)
6 months CAPEOX
6 months FOLFOX
Adjuvant Treatment for low-risk stage III CRC
3 months CAPEOX
3-6 months FOLFOX
if can’t tolerate doublet, 6 months 5-FU or Cape
What classifies someone as high risk stage II CRC (6)
T4
Less than 12 LNs
Obstruction/perforation
LVI
PNI
Poor differentiation
Adjuvant treatment for a patient with stage II MSI-H/MMR-D CRC?
No adjuvant chemotherapy, unless high risk features
For stage T3Nx rectal cancer, what is the preferred treatment paradigm?
Preoperative chemoradiation with 5-FU, then surgery, then adjuvant chemotherapy with CAPEOX or FOLFOX maybe
What is the benefit of preoperative chemoRT compared to postoperative RT in rectal cancer?
Less toxic, less local recurrence, more sphincter sparing surgeries, no change in distant mets
For rectal cancer, what is the difference in short course preoperative radiation compared to chemoRT?
short course radiation had more locoregional recurrence
In patients with upper rectal cancer who wish to avoid radiation, what is their option?
Preoperative FOLFOX can allow people to avoid chemoRT 90% of the time
Management of T1N0 rectal cancer
Local transanal excision
Management of T2N0 rectal cancer
upfront resection
High T2N0 rectal cancer management
Upfront surgery
What does a KRAS mutation mean for treatment of metastatic CRC?
They will not respond to EGFR inhibitors
What is the definition of left sided colon cancer?
Splenic flexure to rectum
What sided colon cancers respond well to EGFR inhibitors?
Left
Treatment for left sided KRASwt metastatic colon cancer? (2)
FOLFOX + Cetuximab/Panitumumab
FOLFIRI + Cetuximab/Panitumumab
Could do Bev instead of EGFR mAb
Treatment for right sided KRASwt metastatic colon cancer?
FOLFOX + Bev
FOLFIRI + Bev
Right sided colon cancer should NOT receive what type of systemic therapy?
EGFR inhibitors
Who should not receive EGFR inhibitors? (2)
Right sided cancer
RAS/BRAF mutated
-Also those who have resectable liver mets
BRAF V600E mutations have what prognosis in metastatic colon cancer?
Poor
What is the indication for encorafenib and cetuximab in colon cancer?
2nd line metastatic BRAF V600E mutated
What is the indication for Trastuzumab + Tucatinib?
2nd line or later mCRC with HER2 amplification
What is the specific metastatic pattern for BRAF mutated CRC?
RP LNs and peritoneum
3rd line treatment options for mCRC without driver mutations (3)
Regorafenib
Tirpacil fluoracil (Lonsurf) +/- Bevacizumab
Fruquitinib
Treatment for 1L MSI-H/dMMR mCRC?
Pembrolizumab
Treatment for 2L MSI-H/dMMR mCRC? (2)
Pembrolizumab
Nivolumab
Ipi/Nivo
Dostarlimab
Treatment paradigm for liver-only mCRC?
Perioperative FOLFOX (3 months prior), surgery, then 3 months adjuvant FOLFOX
What are poor prognostic signs in anal cancer (4)
Tumor >5 cm
LN mets
Male
HPV ctDNA + after chemoRT
Standard of care for locally advanced anal cancer?
Concurrent 5-FU/Mitomycin + RT
Treatment of 1L metastatic anal cancer?
Carboplatin + Paclitaxel
Treatment of 2L metastatic anal cancer?
Nivolumab
Pembrolizumab
Treatment for perianal cancer T1 or T2 that doesn’t involve the anal sphincter?
Surgical excision
Treatment of perianal cancer that is T1N0 and poorly differentiated
5-FU/Mitomycin + Rt
Treatment of perianal cancer that is T2-T4 or N+
5-FU/MItomycin + RT
Preferred treatment for locoregional recurrence of anal cancer after chemoRT?
Surgical resection (APR), though could consider IO prior to surgery
Patient with T2N0 rectal cancer undergoes up front resection and surgery upstages them to T3. What now?
Adjuvant CAPEOX or FOLFOX then chemoRT
or vice versa
Preferred treatment paradigm for locally advanced rectal cancer
Total neoadjuvant therapy
ChemoRT, then FOLFOX or CAPEOX x3-4 months, then restage. If a great response, can observe and avoid surgery.
Indications for ICI in rectal cancer?
In dMMR/MSI-H rectal cancer:
T3Nany
T1-2, N1-2
T4Nx
Locally unresectable
Medically inoperable
In what patient population can you safely omit oxaliplatin from adjuvant therapy?
Stage II, Older than 70
Low risk stage III older than 70
T2N0 is what stage colon cancer?
Stage I
Treatment for BRAF mutated metastatic colon cancer that has progressed on FOLFOX + Bev?
Encorafenib + Cetuximab (or Panitumumab)
