Treatment of specific cancers AB

Question 1

What is the management of resectable gastric cancer?

Answer 1

Staging including laparoscopy is routine
Radical surgery with curative intent
Preoperative chemotherapy
Post-operative chemotherapy and radiotherapy

Question 2

What is the management of metastatic gastric cancer?

Answer 2

Chemotherapy:
- platinums, taxanes, irinotecan, 5FU

Targeted therapy:

• Possible role for VEGF inhibitors in 2nd line (Ramicrumumab, Regorafenib)
• Trastuzumab added to chemotherapy in the 10-15% who are HER2 positive (improved median survival)

Question 3

CRC - what is the management of stage I and II disease?

Answer 3

Resection

Adjuvant CTx for stage II is controversial

Question 4

CRC - what is the management for stage III disease?

Answer 4

Adjuvant CTx (proven survival benefit)

• 5FU or Capecitabine (pyrimidine analogues)
• Folinic acid (Leucovorin)
• Oxaliplatin

Targeted therapy:

• Bevacizumab (first line) in combenation with CAPEOX
• Irenotecam (second line)
• Cetixumab (third line, if KRAS wild type)

Question 5

CRC - what is the management for stage IV disease?

Answer 5

Palliative chemotherapy - increases OS and PFS

Question 6

Rectal cancer - what is the treatment?

Answer 6

Surgery - remove the mesorectal envelope including the fascia

CTx and RTx do not improve survival but do reduce local recurrence rate

Question 7

Anal cancer - what is the treatmetn?

Answer 7

Unlike rectal cancer, anal cancer is treated initially with combination RTx and CTx (Mitomycin + 5FU)

Surgery is NOT indicated as primary treatment. Only for recurrence.

Question 8

Seminoma - what is the treatment of stage 1 disease?

Answer 8

Orchidectomy followed by surveillance

Adjuvant CTx: Carboplatin
NO RTx

Question 9

NSGCT - what is the treatment of stage 1 disease?

Answer 9

Radical inguinal orchidectomy followed by active surveillance

Adjuvant BEP (done in US, not Au for stage 1)

Question 10

Testicular cancer - what is the management of metastatic disease?

Answer 10

BEP and Resection

BEP = Bleomycin, Etoposide, Cisplatiin

Question 11

Testicular cancer - what is the management of relapsed/refractory diseae?

Answer 11

TIP (Paclitaxel, Ifosfamide, Cisplatin) - high dose with stem cell support

Seminoma does better than NSGCT

Question 12

What is the first line treatment for metastatic prostate cancer?

Answer 12

GnRH + Docetaxel

If bony mets, need to start testosterone antagonist 7 days before and until 7 days after to prevent flare phenomenon
Improves PF + OS

Question 13

When is Gefitinib indicated in the treatment of lung cancer?

Answer 13

Lung adenocarcinoma with EGFR mutation (wild type)

Use as single agent

Question 14

When is Crizotinib indicated in the treatment of lung cancer?

Answer 14

Lung adenocarcinoma when ALK fusion oncogene positive.

Use first line as single agent or for relapsed disease.

Also can be used in ROS1 fusion

Question 15

What are the main adverse effects of Gefitinib?

Answer 15

Acneiform skin rash
GI symptoms
Interstitial lung disease (rare but severe)

Question 16

What are the main adverse effects of Crizotinib?

Answer 16

Visual disturbance (shadowing)
GI symptoms
Bradycardia (resolves when drug ceased)

Question 17

What is the treatment of small cell lung cancer?

Answer 17

Concurrent chemo and radiotherapy (if in one radiation field)

CTx: Platinum + Etoposide

Question 18

What is the treatment of Mesothelioma?

Answer 18

Palliative chemotherapy (Cisplatin + Pemetrexed) improves survival.

Radical treatment: extrapleural pneumonectomy

Question 19

Targeted therapy for BRAF positive melanomas?

Answer 19

Dabrafenib - inhibits all V600 mutations
- As good as WBRT

Vemurafenib - selective V600E mutations
- No CNS penetration

Question 20

Targeted therapy against MEK in melanoma?

Answer 20

Trametinib

Question 21

Targeted therapy against cKIT in melanoma?

Answer 21

Imatinib

Question 22

Immunotherapy in melanoma?

Answer 22

Ipilimumab (CTLA4 mAb)

Nivolumab (PD-1 mAb)

Question 23

What are the indications for chemotherapy in breast cancer?

Answer 23

Node positive
Triple negative
Younger, premenopausal
Large, high grade tumour

Question 24

What is the treatment of ovarian cancer?

Answer 24

If resectable, surgery followed by chemotherapy (Taxane + Platinum) at all stages

High risk = add Bevacizumab to first line therapy

Question 25

What is the first line treatment of GIST?

Answer 25

Imatinib

Question 26

What is the treatment of unresectable NET?

Answer 26

Somatostain analogues
PRRT if uptake on gallium DOTATATE
Targeted agents: Sunitinib, Everolimus

Question 27

What is the treatment of unresectable pancreatic cancer?

Answer 27

Early stage + locally advanced - Gemcitabine

Metastatic - Gemcitabine + Abraxane (pegylated paclitaxel)