GI Flashcards
When to give neoadjuvant or adjuvant chemo in gastric cancer
Neoadjuvant: If >T1 (T2=invading muscularis propia)
Adjuvant: If T3/T4 and N+
High risk stage II colon cancer
T4 tumors, high grade or poorly differentiated histology (signet ring or mucinous histologies), close/inderminate positive surgical margins, hjigh preop CEA, <12 regional LNs assessed, perineural invasion, lymphovascular invasion, bowel obstruction, bowel perforation
1st line metastatic anal cancer (squamous)
1st line: cisplatin/5-FU or carbo/taxol
2nd line: pembro or nivo
CRM in rectal cancer
> 1mm
1st line localized rectal cancer treatment if T1-T2 only, or N+ or T3 and above
T1-T2: surgery and observation
N+ or T3 and above:
chemoRT > re-stage > resection > adjuvant chemo for 12-16 weeks
OR
chemoRT > neoadjuvant chemo 12-16 weeks > re-stage > surgery
Adjuvant therapy pancreatic cancer if not given neoadjuvant
FOLFIRINOX or Gem/Cap or Gem alone if poor PS
T4 pancreatic cancer
involves celiac axis, SMA, and/or common hepatic artery; regardless of size. Makes it stage 3. Chemo or chemoRT first.
imaging of HCC
triple phase CT: arterial = increased enhancement; venous = decreased enhancement; delayed phase = persistent wash out
Barcelona Clinic Liver Cancer Algorithm - early stage A
single or 3 nodules <3cm, PS 0, if transplantable - proceed with transplant and if not - locoregional therapy
Milan Criteria
single tumor 5cm or less
3 tumors 3cm or less
no macrovascular invasion
no extrahepatic invasion
Child-pughs Score
Encephalopathy Ascites Albumin PT Bili
A: 5-6 points
B: 7-9 points
C: 10=15 points
Neuroendocrine tumors - grade 1 versus grade 3
Grade 1: well differentiated AND <2 mitotic rate AND Ki-67 <2%
Grade 2: not 1 or 3
NEC (neuroendocrine CARCINOMA)
Grade 3: poorly differentiated OR >20 mitotic rate OR Ki-67 >20%
Risk factors for cholangiocarcinoma
Risk Factors → chronic inflammation Gallstones Porcelain gallbladder DM Obesity Smoking Women > Men Infections (HCV > HBV, Salmonella, Liver Fluke)
Adjuvant Treatment for cholangiocarcinoma
T1a clear margins –> observation
Anything more –> adjuvant chemo; if R1 then post-op chemoRT
T2 in gastric and colon cancer
invading muscularis propria
Metastatic R sided versus L sided colon cancer treatment
R sided –> BRAF (worse prognosis)
L sided and KRAS WT –> EGFR inhibitor
Colon cancer adjuvant therapy guidelines
T1-T2 –> none
T3N0 –> +/- chemo (no benefit if MSI-high)
T4N0 –> chemo
N1 (<3 LN) –> 3 months FOLFOX/CAPOX
N2 (>3LN) –> 6 months FOLFOX or CAPOX or 3 months CAPOX
If age > 70 - benefit of oxaliplatin unclear
Metastatic gastroesophageal cancer treatment
folfox or capox + ICI if
+Nivolumab if CPS 5-9
+Pembrolizumab or Nivolumab if CPS ≧ 10)
Add HER2 agent if HER2+
Chemotherapy for perioperative setting gastric cancer
FLOT (superior to ECF/ECX)
Can give FOLFOX to debilitated patient
metastatic treatment BRAF mutated colon cancer - 2nd line
2nd line BRAFV600E Mutated
Encorafenib + cetuximab (2nd line)
Dabrafenib + trametinib (2nd line)
DPYD versus UGT1a
DPD deficiency - mainly neutropenia and mucositis
UGT1a1 allele variants - diarrhea and neutropenia and are unlikely to have severe mucositis. UGT1a1 variant alleles can be associated with elevated baseline bilirubin levels
Mutation seen in MSI tumors
BRAF V600E mutations are frequent in MSI tumors (~47% of cases)
