Flashcards in Colon Deck (72)
Time and percent of Colonic Adenomas that develop into adenocarcinoma?
5% over 10-20 years
Three pathways to colon cancer development
CpG island methylator phenotype
Colon Cancer: Sporadic v Familial percentage
75% v 25%
US Preventative Services Task Force CRC screening Reccomendations
Age 50-75. Individualized from 75-85.
Stool-based screening tests and intervals are as follows:
Guaiac-based fecal occult blood test (FOBT), every year
Fecal immunochemical test (FIT), every year
FIT-DNA, every 1 or 3 years
Direct visualization screening tests and intervals are as follows:
Colonoscopy, every 10 years
Computed tomographic (CT) colonography, every 5 years
Flexible sigmoidoscopy, every 5 years
Flexible sigmoidoscopy with FIT; sigmoidoscopy every 10 years, with FIT every year
Indications and benefits of adjuvant chemo for CRC
All stage III
cuts distant recurrence by 50%
Is there a benefit for adding oxaliplatin to 5-FU for CRC? (name 2 studies and metric)
MOSAIC and NSABP-C06 demonstrated improved 3-year DFS.
Is there a benefit for adding irinotecan to 5-FU for CRC? (name two studies and outcome)
No difference in outcome. CALGB 89803 and PETACC 3
Non-inferiority of capecitabine to 5-FU
XACT study in stage III
XELOX (capecitabine +oxaliplatin) v FOLFOX
accrued but not resulted.
Adjuvant chemo for stage II CRC?
20-30% recurrence/5 year mortality makes consensus opinion difficult.
QUASAR study for CRC
A large European trial with small but significant benefit (3.6%) 5-year OS for those patients who received fluorouracil/leucovorin versus those in the control group
What tumor factor are clinical trials using to select against chemotherapy in Stage II CRC?
Microsatellite stable patients.
Median survival of metastatic CRC (all comers)?
Failed to show a difference in Stage II/III CRC when added to FOLFOX
Anti-angiogenic; 1st and second line when combined with chemo for mCRC.
Cetuximab is a chimeric monoclonal antibody against EGFR that is approved for treatment of KRAS mutation–negative (wild-type), EGFR-expressing, metastatic colorectal cancer
Cetuximab combinations (3)
2. Cetuximab + Irinotecan (Camptosar) (2nd line p FOLFOX)
3. Cetuximab + FOLFIRI
What is the trial for KRAS + FOLFIRI
Panitumumab is a fully human monoclonal antibody against EGFR for combination use in second line CRC.
Panitumumab + FOLFOX trial
The PRIME trial (phase III) patients with wild-type KRAS tumors had significant improved PFS 9.6 versus 8.0 months, P=0.02) and a nonsignificant improvement in OS (23.9 versus 19.7 months, P =0.07).
Nivolumab +/- Ipilimumab in second line mCRC?
CheckMate 142 phase 2 study, nivolumab, with or without ipilimumab,
disease control rate 48.4%
1 year OS 73.8%
Pembrolizumab in mCRC
KEYNOTE phase2. multiple MSI-H tumors.
Regorafinib in mCRC
multikinase inhibitor approved 2012. 2-3rd line after anti VEGF treatments in mCRC
Ziv-aflibercept in mCRC
VEGF/PIGF decoy receptor.
improves OS compared to FOLFIRI alone 13.5 v 12 months.
Hepatic artery yttrium-90 resin microspheres (SIR-Spheres) in mCRC
Imrpoves pfs from 2.1 to 5.5 months for liver confined disease compared to 5FU alone.
J Clin Oncol. 2010; 28(23):3687-94 (ISSN: 1527-7755)
Surveilance for CRC afte resection of stage II/III disease
Visit q3 months for years 0-3 q 6 months years 4-5.
CEA every visit
CT CAP every other visit.
Colonoscopy at years 1,3,5.
Survival after salvage APR for failed Nigro protocol?
When to examine patient after Nigro protocol?
8 to 12 weeks
Loss of MLH1 and PMS2 on immunohistochemistry? (2 mechanisms)
sporadic loss of MLH1 by hypermethylation of promoter
This is usually secondary to a BRAF mutation
Test genes directly to look for Lynch Syndrome
Importance of MSI-high CRC for therapy?
They do not respond to 5-FU adjuvant chemo alone
sacral mass with myxoid architechture
treatment for sacral chordoma
wide local excision with post-op XRT
Pattern of failure for sacral chordoma?
NCCN guidelines for CRC survivors: CEA levels
q3 months for 2 years then
q6 months for 3 years
What do you order for a rising CEA if CT and Colonoscopy are negative?
distal margin for mid-rectal CRC
5 cm to achieve full TME
distal margin for distal CRC
1 cm gross is acceptable
Other type of pouch if a j-pouch wont reach?
Other maneuvers to help a j-pouch reach? (2)
incise the peritoneum along the SMA;
divide the secondary arcade vessels of the pouch
High Risk Stage II CRC criteria (NCCN; 7)
1. poor differentiation without MSI
2. lymphovascular invasion
3. perineural invasion
4. bowel obstruction
5. tumor perforation
6. close or indeterminate margins
7. less than 12 nodes removed
Decrease in local recurrence due to chemoradiation for rectal cancer?
13% to 6% (about half)
FOLFOX after rectal cancer?
Current NCCN guidelines recommend FOLFOX for all rectal cancer patients who got chemo/RT up front. Benefit may only be for node positive patients. Keep checking guidelines.
Indications for local excision (trans rectal) of rectal cancer
size < 3cm
less than 1/3 of the circumference.
Treatment for pelvic sidewall CRC
Neoadj chemoRT followed by LAR/APR and SELECTIVE iliac nodal dissection
Haggitt system for pedunculated polyps (0-4)
0 - Carcinoma in-situ
1- limited the the head of the polyp
3 - stalk
4 - into stalk but above the muscularis propria
Need surgery for what polyps?
Still havent found a simple rule, but all Haggitt 4 lesions; all sessile polyps and any polyp with LVI.
Side effects of 5-FU?
Dihydropyrimidine dehydrogenase deficiency (DPD)
5-10% of people
higher in African Americans
fast and severe 5FU toxicity at first infusion
Need to stop infusion immediately
30 center european non-inferiority trial;
showed faster recovery for laparoscopic surgery and no difference for margin positivity and 3 year RFS
ACOSOG Z6051 and ALaCaRT
Rectal Cancer lap v open trials. Both failed to demonstrate non-inferiority with ~200 patients in each arm. but showed no difference between lap and open rectal cancer surgery for radial margin, number of lymph nodes and TME
Looked at MRI for Rectal cancer to avoid Neoadj
showing a 1mm clearance of the mesorectal fascia with no evidence of extramural invasion and tumors <5mm from the bowel wall ("early T3") had good outcomes with 3.3% local recurrence and 68% OS.
Systemic Staging for ANAL SCC?
CT scan of C/A/P for everyone
Anal epidermoid carcinoma
is the same as SCC
What do you do if SCC is still there 6 weeks after completing Nigro protocol?
keep watching, reexamine every six weeks. Complete regression reported as late as 26 weeks.
Indications for formal resection of a carcinoid (v endscopic)
Operation for a rectal cancer with fecal incontinence?
APR, you are never going to make the incontinence better
Survival after R. colectomy/whipple for T4 CRC?
52% at 5 years.
Neoadjuvant chemo for T4 CRC (OxMdG) improved R0 rate of resection; pilot was small and this is not yet standard of care
TILs is a colorectal cancer path report suggests:
DNA mismatch repair deficiency/Lynch syndrome
Systemic agents for Desmoids
Number of polyps on a Colonoscopy to send a patient for genetic testing?
30 (attenuated FAP)
need 100 to get diagnosis of FAP
gene for FAP and attenuated FAP
both APC, depends on the severity of the mutation
MYH associated polyposis; autosomal recessive; behaves like attenuated FAP
TME should dissect between
the mesorectal fascia (fascia propria) and
the preperitoneal fascia
Isolated oligometastatic CRC (inguinal lymph nodes)
4 cycles of FOLFIRI then ILND
Pouch procedure and fertility?
Better with laparoscopic surgery in retrospective European studies.
Operation for presacral tumors?
Posterior approach for all below S3.
landmark establishment of adjuvant FOLFOX for CRC
on subgroup analysis, no clear benefit for stage II patients.
NSABP C03 and C04
first trials establishing 5FU for CRC in the 1990s
small UK study sometimes used to justify adjuvant chemo for stage II CRC patients.
adjuvant irinotecan/5FU for CRC?
has been shown ineffective by multiple studies