Colorectal cancer

Question 1

What is the effect of leucovorin and mechanism?

Answer 1

• enhances effect of 5-Fu by stabilizing and binding to thymydilate synthase , preventing bolus 5-Fu from being metabolized

Question 2

DPD deficiency inheritance pattern

Answer 2

autosomal recessive

Question 3

1) Management of patient with DPD who’s symptomatic after 5-Fu 2) mechanism of drug

Answer 3

• uridine triacetate
• competitive inhibitor of 5-Fu

Question 4

CrCl precluding capecitabine

Answer 4

less than 30

Question 5

Oxaliplatin and renal insufficiency?

Answer 5

Requires renal dosing for crcl less than 30

Question 6

Oxaliplatin SE’s

Answer 6

hypersensitivity reactions (after sensitization)

Question 7

Irinotecan mechanism

Answer 7

topoisomerase I inhibitor

Question 8

Gene deficiency associated with irinotecan metabolization

Answer 8

UGT1A1

Question 9

UGT1A1 inheritance pattern

Answer 9

autosomal recessive

Question 10

Tumors on which side are more aggressive?

Answer 10

Right sided

Question 11

Cetuximab/EGFR SE’s

Answer 11

diarrhea
rash
*long eyelashes
hypersensitivity reactions

Question 12

Second line for BRAF mutant mCRC

Answer 12

encorafenib + cetuximab (it’s MEK + EGFR)

Question 13

1) Second line HER2 regimens in mCRC 2) Preferred regimen

Answer 13

Tucatinib + trastuzumab (Preferred - MOUNTAINEER – ORR 38%, PFS 8.2 mo) (Multiple HER2 regimens without head to head comparison, Best CNS penetration)
trastuzumab + lapatinib
trastuzumab + pertuzumab.

Question 14

NTRK targeted drugs

Answer 14

Larotrectinib
Others

Question 15

regorafenib SE’s

Answer 15

• hand foot syndrome
• diarrhea
• HTN

Question 16

Fruquintinib mechanism

Answer 16

VEGF inhibition

Question 17

How long bev needs to be held prior to surgery

Answer 17

At least 6 weeks

Question 18

Which regimens in mCRC can you substitute capecitabine for 5-Fu?

Answer 18

Capeox
*CapeIRI not used in

Question 19

Age for screening of CRC now

Answer 19

45

Question 20

Pattern of MSI testing suggestive of sporadic MSI-H in which you need to send BRAF

Answer 20

Loss of MLH1 + PMS2
*Or loss of either of above alone

Question 21

Lymph nodes required for staging of localized disease

Answer 21

12

Question 22

T4 or N1 disease worse?

Answer 22

Depth of invasion is higher risk so some Stage II pts have worse prognosis than stage III

Question 23

High risk features of Stage II

Answer 23

• T4
• less than 12 lymph nodes examined
• obstruction
• perforation
• LVI
• PNI
• poorly differentiated histology

Question 24

Management of localized MSI disease

Answer 24

neoadjuvant immunotherapy (now NCCN)

Question 25

Approved adjuvant systemic therapy regimens

Answer 25

- 5-Fu - capecitabine - oxali **not irinotecan or targeted therapies. Boards commonly try to trick you on this point.

Question 26

Clinical benefit of oxaliplatin addition in stage II colon cancer

Answer 26

Hasn't demonstrated OS benefit

Question 27

Indications for adjuvant in Stage II CRC

Answer 27

1) T3 AND >2 high-risk features *IF 1 high-risk features, risk/benefit/individualized decision 2) T4, NO

Question 28

When shorter course Capeox can be used per IDEA trial

Answer 28

- Stage II: high risk stage II (low risk isn't treated) - Low risk Stage III - NOt high risk stage III

Question 29

What is low risk localized?

Answer 29

T1-3, N1

Question 30

Stage I surveillance

Answer 30

- c-scope 1 year after IF adenomas, repeat in 1 year, IF none, repeat in 3 years, then 5 years

Question 31

Stage II/III c-scope surveillance interval

Answer 31

Colonoscopy in 1 year after surgery except if no preoperative colonoscopy due to obstructing lesion, colonoscopy in 3–6 mo If advanced adenoma, repeat in 1 y. If no advanced adenoma, repeat in 3 y, then every 5 yrs

Question 32

Recommended scan interval for Stage II/III + duration of imaging screening

Answer 32

Chest/abdominal/pelvic CT every 6-12 mo (category 2B for frequency <12 mo) from date of surgery for a total of 5 y

Question 33

Age cutoff at which oxali can be held

Answer 33

70

Question 34

5-fu mechanism

Answer 34

inhibits thymydilate synthesis

Question 35

Benefit of avastin addition in MCRC

Answer 35

OS benefit

Question 36

FAP inheritance pattern

Answer 36

autosomal dominant

Question 37

4 genes associated with Lynch

Answer 37

MSH6 MSH2 MLH1 PMS2

Question 38

Duration for single agent adjuvant

Answer 38

Always 6 months, no data for shortening duration

Question 39

Why neoadjuvant CRT is preferred in rectal

Answer 39

- better tolerated - lower recurrence rates - increased rate of sphincter preserving surgery

Question 40

T1NO rectal management

Answer 40

local transanal excsion

Question 41

What is T4 disease (need to know since high risk feature)

Answer 41

T4a = invades through peritoneum T4b = adheres to adjacent structures

Question 42

INdications for TNT

Answer 42

T3 any N with clear CRM OR T1-2, N1-2 and low-lying (<5 cm from anal verge) *Need to know because they will just say distance from anal verge

Question 43

What is stage I CRC?

Answer 43

T1-2NO *T3 thus = Stage II

Question 44

Board answer to young fit pt with metastatic right sided CRC

Answer 44

triple w/ bev (FOLFOXIRI)

Question 45

What is stage II CRC?

Answer 45

T2

Question 46

Regorafenib lab monitoring

Answer 46

LFT's