Localized Lullabies
This is the treatment for colon cancer which invades into the submucosa or muscularis propria (but not through) without nodal involvement
What is no chemotherapy!
Stage 1 colon cancer does not require treatment. 5 year survival rate is 90-95%
This biologic agent was added to FOLFOX or FOLFIRI in the CRYSTAL and PRIME trials in RAS wild type tumors
What are anti-EGFR therapies (cetuximab/panitumumab)?
SE - rash, long eye lashes, diarrhea
5FU inhibits this enzyme
What is thymidylate synthase?
This landmark trial demonstrated survival benefit of adjuvant 5-FU in Stage III colon cancer (FOLFOX > bolus 5-FU)
What is the MOSAIC trial?
FOLFOX vs bolus FU - increase DFS in stage III, lower risk reduction in stage II high risk, low risk stage II did not see benefit, OS no change in stage II, but did not benefit stage III; can stop oxaliplatin in patients > 70 to reduce this toxicity
Loss of these genes are associated with Lynch Syndrome
What are loss of MSH6, MSH2, PMS1, MLH1, PMS2 (at least one)
IF only loss of MLH1, PMS2 - check BRAF - if positive then sporadic not germline
This indicates T2 disease and thus referral to an oncologist for consideration of chemotherapy
What is invasion into the muscularis propria?
T/F Right sided tumors are more likely to be aggressive, MSI high, BRAF/RAS mutated and have benefit from Bevacizumab
What is True?
Left sided - more HER2, benefit from EGFR2 and VEGF inhibition
Capecitabine cannot be given under this creatinine clearance
What is Cr Cl < 30?
Dose reduce oxaliplatin at this level as well
This international pooled analysis compared 3 vs. 6 months of adjuvant chemo in Stage III colon cancer.
What is the IDEA trial?
Capeox vs FOLFOX 3 or 6 months - stage III
DFS of 3 vs 6 months was not proven for FOLFOX
CAPEOX did have non inferiority in 3 months vs 6 months
OS was inferior in 3 months of FOLFOX
Stage III
Low risk - T1-3, N1 - CAPEOX x 3 months or FOLFOX X 6 months
High risk - T4 or N2 - need 6 months of whatever
What are MMR deficient?
These are high risk features for stage II colon cancer
What are T4, inadequate nodal sampling (<12 nodes), lymphovascular invasion, perineural invasion, poorly differentiated and clinical obstruction or perforation?
These mutations can lead to toxicities in 5-FU and irinotecan respetively
What are DPD deficiency and UGT1A deficiency?
T/F There is no interaction between warfarin and capecitabine
False - capecitabine is a P450 inhibitor - decreases the clearance of warfarin - choose a diff AC if possible!
The NICHE study showed benefit of neoadjvuant immunotherapy for this population of patients.
What is nonmetastatic - stage I, II mostly stage III- MMR deficient?
Ipi/nivo and then surgery within 6 weeks; pathologic response in 99% (major and complete)
This mutation is mutually exclusive from KRAS and confers a poor prognosis and worse prognosis with EGFR inhibitors alone.
What is BRAF?
These are high risk features for stage III colon cancer
What are T4 (Tumor invades* the visceral peritoneum or invades or adheres** to adjacent organ or structure) or N2 (4+ lymph nodes involved)?
What is the common name for triflurodine tipiracil
What is LONSURF?
inhibits thymidilate phosphoryalse
SE - cytopenias, GI toxicity, fatigue;
Sunlight trial - ALSO adding BEVACIZUMAB to lonsurf - OS improved, PFS doubled
This medication is given empirically with irinotecan to prevent acute diarrheal episodes?
What is atropine?
Late diarrhea occurs after 24 hours of Irinotecan exposure. Loperamide and fluoroquinolone can be given to help control this phase of diarrhea.
The FRESCO 2 trial approved this oral VEGF inhibitor after many lines of therapy and lonsurf/regorafenib
What is fruquitinib?
This electrolyte abnormality is commonly found from patient's who take cetuximab
What is hypomagnesemia, followed by secondary hypokalemia and hypocalcemia?
This is the surveillance strategy after treatment of stage II/III colon cancer
What is colonoscopy 1year after surgery, H and P 3-6 months for 2 years, then every 6 months to year 5, tumor markers every 3-6 months for first 2 years, every 6 months to year 5, CT A/P every 6 months to year 5 (consider yearly)
The CODEBREAK 300 trial approved this combination as second line in patients with a KRAS G12C mutation
What is sodarasenib + panitumumab?
This is the treatment for 5-FU overdose
What is Uridine triacetate
Uridine nucleotides reduce the incorporation of 5-FU into the DNA of non-cancer cells. It is administered as 10 grams q6 hours x 20 doses. Treatment is initiated within 96 hours following the end of treatment of fluorouracil.
The Breakwater trial established this regimen as first line therapy for BRAFV600 Patients
What is Enco/cetux/FOLFOX first line - ORR 60.9 % vs 40% with chemo alone.
BEACON - encorafenib, bimintienb + cetuximb vs doublet enco/cetux vs chemo/cetux - ORR triplet 27%, 20% doublet, 2% in control, median OS was 9.3, 9.3, 5.9 control
This is the neurotoxicity associated with 5-FU
What is toxic leukoencephalopathy?
There is no definitive treatment for toxic leukoencephalopathy. Immediately stopping the offending agent along with supportive therapy with corticosteroids, antioxidants such as coenzyme Q, vitamin E and vitamin C may lead to improvement.