Exam 2: Colorectal Cancer Flashcards
(55 cards)
1
Q
Presentation of Colorectal
A
- Asymptomatic
- rectal bleeding
- change in bowel habit
- N/V
2
Q
Cause of CRC
A
DNA mismatch repair system
3
Q
dMMR or MSI-H tumor predicts a _____ benefit from adjuvant 5-FU therapy for stage __ disease
A
decreased, II
4
Q
_____ patients with dMMR or MSI-H disease can _______ from adjuvant 5-FU
A
Stage III, benefit
5
Q
Which patients with colon cancer should be tested for mismatch repair or microsatellite instability
A
all patients
6
Q
When is surgery an option in CRC
A
- early stage disease
- palliative setting
7
Q
When is radiation a treatment option in CRC
A
- more controversal
- can be used to alleviate pain
- can decrease bleeding
8
Q
Which stages are considered potentially curable
A
I - III
9
Q
Which stages is localized therapy indicated for
A
I and II
10
Q
Treatment for localized therapy
A
- surgery alone is definitive therapy
11
Q
Chemo in stage I and II
A
- recommended against
- can recommend if patient is high risk
- if MSI-H or dMMR, then will not benefit from chemo
12
Q
Chemo options for high risk or intermediate risk stable II patients
A
FOLFOX
CapeOXF
13
Q
FOLFOX
A
- 5-FU
- Leucovorin
- Oxaliplatin
14
Q
CapeOX
A
- capecitabine
- oxaliplatin
15
Q
Standard therapy for Stage III disease
A
- surgery including regional lymph node removal AND
- chemo
16
Q
What medications do not play a role in Stage III disease
A
- bevacizumab
- cetuximab
- panitumumab
- rinotecan
17
Q
Ajuvant Chemo options for Stage II disease
A
- mFOLFOX6
- CapeOX
18
Q
IDEA trial
A
CapeOX for 3 months was noninferior to 6 months
19
Q
Stage III Low risk
A
- CapeOx x 3 months
- FOLFOX x 6 months, consider 3 months
20
Q
Stage III High Risk
A
- CapeOx 6 months, consider 3 months
- FOLFOX x 6 months
21
Q
Regimen Considerations FOLFOX
A
- requires port
- 2 day pump
- more infusions
- increased myelosuppression and mouth sores
22
Q
CapeOx Regiment Considerations
A
- Port not required
- less infusions overall
- increased hand foot syndrome
- increased diarrhea
- Capecitabine needs renal dose adjustments, more expensive, more interactions
23
Q
Mainstay of therapy for metastatic disease
A
- chemo
- palliative RT
- surgery can play a role in isolated
24
Q
Co-morbities that may determine therapy
A
- neuropathy
- UGT1A1 deficiency (irinotecan)
- 1 vs 2 vs 3 drug
25
PDL-1 Inhibitor benefit
- pembro and nivolumab shown benefit in metastatic setting
-should be tested for dMMR/MSI status first
26
KRAS
- mutations predict lack of response to anti-EGFR monoclonal antiboidies
27
Which medications should you not use in the setting of a KRAS mutation
- cetuximab and panitumumab
28
BRAF
- test all patients in metastatic setting
29
1st line metastatic disease with no targetable mutations
- FOLFOX
- CapeOx
- FOLFIRI
- FOLFIRINOX
+ bevacizumab
30
1st line metastatic disease with Kras wild type, left sided
- FOLFOX OR
- CapeOx + Cetuximab or Panitumumab OR
- FOLFIRI Cetuximab or Panitumumab
31
1st line metastatic disease with dMMR/MSI-H
- Nivolumab + ipilimumab OR
- Pembrolizumab
32
1st line metastatic disease with HER2+
trastuzumab + pertuzumab or lapatinib
OR
fam-trastuzumab deruxtecan-nxki
33
FOLFIRI
- Irinotecan
- Leucovorin
- Fluorouracil
34
FOLFIRINOX
- oxaliplatin
- Leucovorin
- Irinotecan
- Fluorouracil
35
1st Line Metastatic Disease with no targetable mutations in someone who can not tolerate intensive chemo
- Infusional 5-FU + leucovorin
OR
- capecitabine ± bevacizumab
36
1st Line Metastatic Disease with KRAS WT, left sided in someone who can not tolerate intensive chemo
- Cetuximab OR
- Panitumumab
37
1st Line Metastatic Disease with dMMR/MSI-H in someone who can not tolerate intensive chemo
- nivolumab ± ipilimumab OR
- pembro
38
1st Line Metastatic Disease with HER2+ in someone who can not tolerate intensive chemo
trastuzumab + (pertuzumab or lapatinib or tucatinib)
39
Second line therapy for metastatic Disease progression with prior oxaliplatin therapy
FOLFIRI or irinotecan based
40
Second line therapy for metastatic Disease progression with prior irinotecan-based therapy
FOLFOX or Capox regiments
+ bevacizumab or cetuximab or panitumumab
41
Tests to primarily detect colon cancer
- fecal immunochemical test (FIT)
- FIT DNA
- Endoscopy
42
Colon Cancer Screening
- > 45 years old
- Family history = 40
- HNPCC = 20-25
- FAP = 10-12
43
If BRAF Positive Second line therapy metastatic
- Encorafenib + cetuximab or panitumuab
44
Average Risk Screening
- Annual FOBT or
- annual FIT or
- multi-target stool DNA test every 3 years
OR
- flexible sigmoidoscopy every 5 years
- colonoscopy every 10 years or
- CT colonography every 5 years
45
Colon Cancer Prevention
- celecoxib
- NSAIDs
- aspirin
- colectomy
46
F-FU
- converted to FUTP and FdUMP
- FdUMP binds to thymidylate synthase and reduces rate of DNA synthesis, replication, and repair
47
Leucovorin
- given in combo with 5-FU to enhance binding of FdUMP to TS
48
Irinotecan
- pro-drug of SN-38
- topo I
- Diarrhea
- UGT1A1 increases diarrhea by preventing SN-38 conversion
49
Oxaliplatin
- cross links DNA, inhibiting DNA replication
- cold intolerances
50
Capecitabine
- oral pro-drug of 5-FU
- hand foot syndrome
- diarrhea
51
Cetuximab
- binds to extracellular domain of the EGFR
- only in KRAS wild type
- acneform rash
- hypomagnesemia
- premedicate with H1 antagonist
52
Panitumumab
- binds to EGFR
- acneform rash
- hypomagnesemia
53
Bevacizumab
- binds to VEGF
- given in combo with 5-FU, leucovorin, irinotecan
- signficant toxicity: bleeding
- many black box warnings
54
Regorafenib
- Multi-kinase inhibitor targeting angiogenesis (VEGF 1-3, BRAF)
- can use in patients with KRAS mutations
- take with high fat meals
55
TAS-102 (Trifluridine/Tipiracil)
- used after patients fail
- better tolerated than regorafenib
