GI cancers Flashcards
GEJ adenocarcinoma type of treatment
multimodality approach chemoradiation f/b surgery even if lymph nodes (mediastinal and celiac). Not if RP. Also even if extends to other organs.
Adenocarcinoma is treated with chemoradiation f/b surgery.
SCC sometimes try to avoid surgery (especially MSKCC)
nasopharyngeal carcinoma staging
MRI given the anatomic location of the nasopharynx, this tumor has a propensity for skull base invasion, bone destruction and parapharyngeal space involvement, and involvement of retropharyngeal lymph nodes which have treatment and prognostic implications.
Recurrent symptomatic CLL after treatment with fludarabine?
Can do fludarabine again if greater than 12 months. Alemtuzumab is approved for use in patients with disease refractory to fludarabine. In such patients, the response rate was 33%, including a 2% rate of complete response. Response rates varied with a number of clinical factors, and were markedly lower in patients with enlarged lymph nodes. Bendamustine is a bifunctional alkylator that provides responses in 70-80% of patients with recurrent CLL, including those with enlarged lymph nodes.
surgery in mesothelioma
good performance status and the pulmonary reserve to tolerate surgery, an extrapleural pneumonectomy should be attempted. Patients with negative mediastinal nodes and an epithelial histology are most likely to benefit from surgery.
indolent HL
Nodular lymphocyte-predominant
Breast cancer under 30 genetics?
BRCA1 or TP53 TP53 is associated with leukemia and sarcoma
When to do RPLND for residual mass in seminoma?
complete a PET scan at least 6 weeks after completion of chemotherapy, and proceed with surgical resection only if there is a residual mass ≥ 3 cm that is FDG avid consistent with persistent viable seminoma
when do you use in anthracycline in APL?
when patient is defined as high risk with wbc >10 are at risk for potentially fatal differentiation syndrome and benefit from cytoreduction using anthracycline or gemtuzamab.
criteria for multiple myeloma
MM Clonal BMPC ≥10% or biopsy proven bony or extra-medullary plasmacytoma, AND ≥1 of the following myeloma defining events (MDE): - Evidence of end organ damage attributed to PC proliferative disorder: serum Ca ≥ 11 mg/dL, renal insufficiency (creatinine ≥ 2mg/dL/creatinine clearance ˂ 40mL/min, anemia (Hb ˂10 g/dL), lytic bone lesions - ≥ 1 of the following Clonal bone marrow plasma cell percentage ≥ 60% Involved:un-involved serum free light chain ratio ≥ 100 ˃1 focal lesion on MRI
smoldering multiple myeloma criteria
SMM Must meet both of the following criteria: - Serum monoclonal protein ≥ 3g/dL or urine monoclonal protein ≥ 500 mg/24 hour, and/or BMPC 10 to 60% - Absence of MDEs and amyloidosis
MGUS definition
-Serum monoclonal protein <30 g/L Bone marrow plasma cells <10% Absence of myeloma defining events or amyloidosis (or Waldenström macroglobulinemia in the case of IgM MGUS)
Older head and neck patients:
Surgery, radiation, and chemoradiation appear to be equally efficacious in older and younger patients The available data suggest that patient-reported quality of life is not significantly reduced after treatment in older patients with HNC. However, we do not recommend using these data to inform patient counseling and treatment decisions. Older patients with HNC require more supportive care. We recommend prophylactic feeding tubes. We also recommend coordinating care with the patient’s other general practitioners and specialists.
HPV related oropharyngeal cancer in unresectable cancer treatment?
Randomized phase III studies comparing sequential chemotherapy and RT to concurrent chemotherapy RT alone are ongoing and have not demonstrated a convincing survival benefit with incorporation of induction chemotherapy. Cisplatin based induction chemotherapy followed by high-dose every 3 weeks cisplatin chemoradiation is not recommended due to toxicity concerns. After induction chemotherapy, multiple options can be used for RT based portion of therapy including carboplatin or cetuximab.
capecitabine and anticoagulation
increased anti-coagulant activity of warfarin
second line chemo for advanced gastric cancer
phase III Rainbow trial found that the addition of ramucirumab to paclitaxel improved response rate, progression-free survival and OS among patients who had previously received a platinum and fluoropyrimidine. Neither cetuximab nor bevaziumab improve survival in metastatic gastric cancer and are not part of routine care.
Patient on CAPEOX with significant myelotoxicity and, to a lesser extent, GI toxicity
highly suspicious for him being homozygous for the germline UGT1A1*28 polymorphism. educed clearance of SN-38 (the active metabolite of irinotecan), resulting in excessive neutropenia and, possibly to a lesser extent, diarrhea.
Patient receives 5FU and develops myelotoxicity and GI toxicity
DPYD
Lobular breast cancer, particularly under the age of 50, and diffuse gastric cancer (also known as signet ring carcinoma, linitus plasticus) should b tested for??
CDH1, located on 16q22.1, with autosomal dominance inheritance, codes for the E-Cadherin protein, involved in cellular adhesion
head and neck cancer receiving moderate dose radiation therapy (up to 50 Gy),
Benzydamine mouthwash
grade 3 mucositis
prevents the patient from eating any solids
Palifermin
has been shown to improve oral mucositis symptoms in patients undergoing hematopoietic cell transplantation.
Hemicolectomy for Incidentally found carcinoids of the appendix?
recommended for patients with tumors over 2 cm in maximum dimension. For small (< 1) cm lesions the risk of recurrence is so small as to not warrant additional follow-up testing or surveillance.
Pathway has shown activity in the treatment of low-grade ovarian cancer
MAP-kinase with selumetinib
Venetoclax MOA
B-cell lymphoma 2 (BCL-2) inhibitor. CLL who have a 17p deletion and have been treated with at least one prior therapy.
Primary mediastinal B-cell lymphoma (PMBL)
It can present similar to classical Hodgkin lymphoma (HL) in clinical presentation and on imaging. The role of the pathologist is important in making the distinction. PBML is derived from a thymic B-cell and expresses pan B-cell markers such as CD20 and CD79a. Pax5 is also positive. CD30 can be negative or dim and CD15 is negative. This is in comparison to Hodgkin lymphoma which shows Reed-Sternberg cells morphologically and expresses CD15 and strong expression of CD30. In addition, CD20 and Pax5 are negative in HL. The majority of these patients are young, with a female predominance. PMBL is curable and patients are expected to have a normal life span. It is best to avoid radiation if possible to prevent long term complications. Dose-adjusted EPOCH-R has been shown to have a 5 year event-free survival of 93% and is given without radiation. Alternatively, R-CHOP x 6 can be given but must be followed with radiation and has worse outcomes.
Standard of care for patient has clinical T1N0 small cell lung cancer (SCLC)
clinical T1-2 N0 SCLC is to perform mediastinoscopy and if pathological mediastinal staging is negative then proceed with surgical resection (lobectomy is preferred). Patients subsequently should still receive adjuvant chemotherapy regardless of the T staging. Adjuvant radiation therapy is considered if a positive lymph node is identified (in particular unexpected N2). There is no role for neoadjuvant treatment prior to surgery in clinical T1-2 N0 cases. Definitive concurrent chemoradiation is the standard of care for any patient with limited stage in excess of T1-2, N0 SCLC
osteosarcoma prognostic factor
Less than 90% necrosis to neoadjuvant chemotherapy has been found to significantly impact survival from osteosarcoma.
Ph1-negative standard-risk young patients with ALL
Stem cell transplantation adds nothing to overall prognosis Rituximab enhances results in such patients.
MSI-high tumors expression
CK7+ and CK20- as opposed to the opposite for microsatellite stable tumors. retain CDX staining
adjuvant chemo in colon cancer
Adjuvant chemotherapy with fluoropyrimidine plus oxaliplatin for six months decrease risk of relapse and improves survival in these patients per MOSAIC and NSABP C-07 trials. The IDEA (International Duration Evaluation of Adjuvant Chemotherapy) was a joint effort of investigators from six randomized phase 3 trials that evaluated 3 versus 6 months of adjuvant chemotherapy (FOLFOX or CAPOX). For low risk patients (T3N1) 3 months of treatment was non inferior (3yDFS 83.3 vs 83.1%, HR=1.01, 95% CI 0.9-1.12). However, for high risk patients (T4N2) non-inferiority could not be confirmed In addition, for FOLFOX treated patients, 3 months was statistically inferior (3yDFS 6 vs 3m = 76 vs 73.6 %, HR=1.16, 95% CI 1.06-1.26). However, non-inferiority was proven for CAPOX 3 months
MEN1 cancers
3 Ps. Pituitary tumor, parathyroid tumor, PNET
MEN2 cancers
MPH Medullary thyroid, hyperparathyroid, pheochromocytomas
Li-Fraumeni
SBLA syndrome sarcoma, breast cancer, leukemia, adrenocortical tumors
Peutz-jeghers syndrome
GI cancers, breast, ovarian, and hyperpigmented mucosal lesions
GEJ cancer work-up
includes CT C/AP and PET (not gastric work-up)
If met, look at HER2 status.
If no distant mets EUS and FNAB.
Chemo regimen for GEJ junction tumors and other treatment tidbidts
Both Magic and Cross trial showed benefit of neoadj chemo. In MAGIC it was ECF.
Other studies have shown that carbo/taxol is effective and less toxic than 5FU/taxol
ChemoRT for nonsurgical candidates
CROSS trial which used carboplatin (area under the curve (AUC) 2) and paclitaxel (50 mg/m^2 intravenous) weekly chemotherapy along with 41.4 Gy of concurrent radiation followed by surgery. This showed a pathologic complete response rate of 29% and an R0 resection rate of 92%. Median overall survival was 49.4 months in the chemotherapy and radiation arm as compared to the surgery alone arm. The CROSS regimen appears to be better tolerated than cisplatin and 5-fluorouracil.
early stage gastric cancer treatment options
magic trial also showed benefit of preop chemo here.
Surgery critical
can do periop chemo or adjuvant chemo
can do sandwich chemo, chemo rt, chemo as well
treatment for metastatic gastric/GEJ junction tumors
2 vs 3 drugs
3 may have small benefit
Do 5FU/platinum or ECF (epirubicin, cis, 5FU) or DCF (taxol, cis 5FU)
FOr gastric can do EOX or FOLFIRI as irinitecan is active for non platinum candidates
Add HER2! ToGa trial
Second line metastatic GEJ/gastric cancer?
taxol/ram
Unresectable pancreatic cancers?
>180 celiac axis or SMA
aortic invasion
metastatic pancreatic cancer treatment options?
gem/abraxane
FOLFIRINOX
gem
gem + elortinib
adjuvant treatment for pancreatic cancer?
ESPAC2
gem/cape
or gem
BRCA mutated pancreatic cancer treatment metastatic?
can do gem/cis
HCC treatment
usually local treatments.
If advanced and Child Pugh A then sorafenib and second line nivo
cholangiocarcinoma treatment early and late stage
early if positive margins after surgery then chemo/RT. If positive LN then chemo RT and chemo
advanced disease = gem/cis
Colon cancer staging review
T1 - submucosa and muscularis propria
T2 - invades in the serosa
T3 - into visceral periotneum
T4 through visceral peritoneum
1-3 nodes is N1
4 or more N2
Any N is automatically sstage 3 same goes for rectal.
Not stage 3 until nodal involvement.
colon cancer treatment for stage II
LOOK FOR HIGH RISK FEATURES - LVI/PNI/POOR DIFF/T4
then cosnider 5FU or cape only. High risk folfox
If MSI-HI no response to 5FU
colon cancer stage III
adjuvant mFOLFOX or capeOX
Over 70 no benefit from Ox
IDEA trial 3 months if low risk (T3 or N1)
rectal cancer treatment
If T1 or T2 muscularis propria and no lymph nodes - can do surgery only.
If not trimodality treatment
EGFR inhibitors
and
VEGF inhibitors
EGFR - cetuximab and panitumimab
Don’t give if mutated KRAS/NRAS/BRAF
VEGF - bev and ziv-aflibercept
Anal cancer treatment
metastatic 5FU/Cis
locally advanced - chemoRT with mitomycin/cape or cis
If 5FU vasospasm
Then stop all treatment?
risk factors for esopageal cancer
adnenocarcinoma: barretts and obesity.
Prior gastrectomy, atrophic gastritis, and HPV infection are risk factors for squamous cell carcinoma, but not esophageal adenocarcinoma.
NSAID use appears to possibly be protective against esophageal carcinoma.
lung toxicity gem/abraxane in met pancreatic cancer
can be related to either treatment.
stop and switch regimen
Patients known to be homozygous for the UGT1A1*28 allele
dose reduce irinotecan by 25% at least
cholangiocarcinoma + margins treatment?
cholangio + LN treatment?
+margins = chemo RT
LN+ = chemoRT + chemo (gem/cis)
pnet second line after octreotide?
sunitnib and everolimus
MSI HI early stage disease does not benefit from?
5FU
Right sided colon cancer
no benefit from cetuximab
