colorectal

Question 1

colorectal imaging

Answer 1

CT CAP (enhanced) preferred, MRI alternative, PET/CT NOT

Question 2

PET/CT in colorectal

Answer 2

High false-positive and false-negative, bad for post-op anastamoses and mucinous

Question 3

first line metastatic colorectal

Answer 3

FOLFIRI or FOLFOX, 56% ORR, ~8mo TTP

Question 4

infusional 5-FU versus bolus

Answer 4

infusional MORE effective and less toxic

Question 5

FOLFOX or FOLFIRI?

Answer 5

discuss toxicities with patients to decide. equal. Irinotecan–>greater alopecia; oxali–>cold sensitivity

Question 6

CapeOx v. FOLFOX for metastatic

Answer 6

PFS equal, but Cape is not more convenient, because you need oxali ANYway. Fine to use either if compliance assured.

Question 7

Capecitabine in elderly

Answer 7

difficult–> increased age, decreased CrCl, toxicites (not a problem with 5-FU)

Question 8

scheduling of FOLFOX

Answer 8

Optimox study–> you can drop the oxali after 6 cycles (3 months), to make chemo more managable with no change in PFS.

Question 9

+bev to FOLFOX/CapeOx for metastatic

Answer 9

improved PFS by only 1.4 months in one study. NO benefit in shrinking tumors; you can add for PFS benefit, but not to shrink tumor more (if need surgery, don’t give, 21d T1/2)

Question 10

bevacizumab toxicities

Answer 10

THN, GI perf (death rate 0.25%), arterial events, impaired wound healing, albuminuria–> clinically irrelevant if metastatic disease

Question 11

aflibercept data

Answer 11

VELOUR study–> survival 13.5 v 12mo (42d benefit). however more expensive and same benefit as continuing bev.

Question 12

bev beyond progression?

Answer 12

1.4mo OS increase if you continue bev when switch.

Question 13

cetuximab/panitumumb for metastatic?

Answer 13

if ANY RAS mutation or BRAF mutation, do not give (may accelerate), if no mutation, then small PFS benefit in first line setting.

Question 14

EGFR inhibitor or VEGF inhibitor in first line?

Answer 14

SWOG80405–>randomize FOLFORI/FOLFOX with either cetux or bev–> IDENTICAL. Response rate is equal (FIRE 3 study)

Question 15

deciding factor or cetuximiab, bev, or neither for first line FOLFOX/FOLFIRI

Answer 15

cetuximab rash is HORRIBLE and required for benefit. but people when have rash that doesn’t mean they will benefit.

Question 16

cetuximab v. best supportive care

Answer 16

benefit of cetuximab is real, in later lines of therapy

Question 17

should you combine bev+cetux+capeox

Answer 17

NO? worse PFS to just bev alone (CAIRO2 study)

Question 18

BRAF mutation in colon cancer

Answer 18

8% of patients–>bad actor. more often in serrated adenoma, associated with somatic MSI, poor prognosis, resistant to EGFR

Question 19

vemurafenib for BRAF in colon

Answer 19

NO! only 1 pt with ORR out of 21. probably related to EGFR feedback. maybe combination therapy would be worthwhile

Question 20

regorafenib for colorectal

Answer 20

TKI with VEGFi activity, 1.4 months OS benefit versus supportive care. a LOT of fatigue, hand/foot. consider it and discuss. 1% response rate

Question 21

regorafenib response rate

Answer 21

1%, don’t give to shrink. only for palliative control of disease.

Question 22

adjuvant infusional 5-FU v. FOLFOX4

Answer 22

only stage III patients had benefit for FOLFOX in 3-yr DFS. Incremental benefit of oxali is with higher risk disease, majority of benefit from 5-FU

Question 23

OS benefit from adjuvant FOLFOX

Answer 23

4.4% OS benefit for stage III with FOLFOX, stage II FOLFOX=5-FU benefit.

Question 24

risk factors with stage II disease to promote FOLFOX use

Answer 24

LVI+, colon perforation

Question 25

adjuvant therapy for stage II colon

Answer 25

only 5-FU/cape, or observation, unless high risk features

Question 26

adjuvant for elderly with colorectal cancer

Answer 26

use physiologic age, not chronologic age

Question 27

adjuvant options: CapeOx v. FOLFOX for colorectal

Answer 27

either CapeOx or FOLFOX okay, same outcome, equally acceptible, consider the issues with pills, etc.

Question 28

how much adjuvant therapy is needed for colorectal

Answer 28

12 doses of Oxali is TOO much. Neurotox worsens for 4 months following discontinuation (because platinum circulates for 2 months). Everyone gets 12 doses 5-FU, and 6 cycles of oxali is enough.

Question 29

oxali toxicity

Answer 29

30% of patients have some degree after 1 year, 15% at 4 years. however only like 1% grade III, 5% grade II

Question 30

FOLFIRI for adjuvant therapy

Answer 30

NO- no benefit of irinotecan addition to 5-FU!

Question 31

bev for adjuvant therapy

Answer 31

NO- no benefit of addition

Question 32

cetux for adjuvant therapy

Answer 32

NO- no benefit of addition

Question 33

MSI high patients adjuvant therapy

Answer 33

good prognostic factor in stage II disease--observation recommended, no benefit from chemotherapy. stage III still some modest benefit from chemo.

Question 34

MSI test

Answer 34

IHC for MMR proteins, or PCR

Question 35

rectal exam standard

Answer 35

get CT CAP plus rectal MRI or ERUS, no pet

Question 36

stage I rectal

Answer 36

surgery only

Question 37

stage II/III rectal

Answer 37

cape/RT -->surgery-->FOLFOX (or) FOLFOX/Capeox-->surgery-->CapeRT

Question 38

high risk stage II colorectal

Answer 38

5-FU alone, no clear benefit for addition of oxali

Question 39

maintenance therapy for colorectal

Answer 39

OPTIMOX strategy-->maintain with 5-FU okay.

Question 40

Irinotecan for micrometastatic disease

Answer 40

NO benefit!