GI Tumor Board 70yo F without significant PMH presents w/3 months of - PDF document

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #1 GI Tumor Board • 70yo F without significant PMH presents w/3 months of diarrhea and Edward Kim George Poultsides RLQ abdominal pain Naseem Esteghamat Kenzo Hirose • CT: cecal mass with mesenteric adenopathy, no distant disease May Cho Alan Venook • Colonoscopy: partially obstructing tumor in cecum biopsy positive for Arta Monjazeb Margaret Tempero adenocarcinoma George Fisher Andrew Ko • Undergoes right hemicolectomy. Daniel Chang Thomas Semrad • Surgical path: 8.5cm low grade adenocarcinoma pT3/pN2a 6/53 LN Sisi Haraldsdottir positive, negative margins, MSI‐high. 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach IDEA Case #1 Question #1 What is the next step in management? 1. Test expanded RAS and BRAF 2. Treat with adjuvant FOLFOX for 3 months 3. Treat with adjuvant FOLFOX for 6 months 4. Treat with adjuvant CAPOX for 3 months 5. Treat with adjuvant CAPOX for 6 months 1

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Low risk High risk 3m vs 6m 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach FOLFOX CAPOX Low risk High risk FOLFOX CAPOX 2

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #1 Question #2 In this patient with stage III colon cancer, would BRAF status change your approach to adjuvant therapy? IDEA Clinical Consensus: Risk-based approach to adjuvant chemotherapy in stage III colon cancer 1. Yes 2. No 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #1 continued Case #1 Question #3 What is the next step in management? • Patient completed 6 months of adjuvant FOLFOX with discontinuation of 1. Surgical resection of liver metastasis oxaliplatin after cycle 9 due to sensory 2. Liver directed therapy (eg SIRT, RFA, SBRT) neuropathy 3. FOLFIRI • CT scan 2 months after completion of 4. PD‐1 inhibitor adjuvant FOLFOX reveals a 1.8cm liver lesion which on retrospect review may have been faintly present on pre‐ operative imaging • Molecular profiling reveals RAS wt, BRAF wt, MSI‐high 3

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #1 Take Home Points • In patients with T1‐T3,N1 disease, consider 3 months of adjuvant therapy. Pre‐planned subgroup analysis showed non‐inferiority of 3 vs 6 months of adjuvant therapy. • For patients with T4 or N2 disease, discuss risks and benefits of 3 vs 6 months of adjuvant therapy. Non‐inferiority was not met in this subgroup • 3 months confers significantly less neurotoxicity • Consider toxicity profiles when deciding between CAPOX AND FOLFOX 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #2 Case #2 Question #1 What is the next step in management? A 62yo M w/no significant PMH presents with 3 month history of epigastric pain 1. Start FOLFIRINOX with associated anorexia. 2. Start gemcitabine/nab‐paclitaxel ‐ CT reveals hypodense mass 3. Radiation oncology consultation in pancreatic head with 4. Surgical oncology consultation >180 0 encasement of the superior mesenteric artery ‐ EUS‐FNA confirms pancreatic adenocarcinoma. 4

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #2 Clinical Course Case #2 Question #2 What is the next step in management? • Patient receives 6 months of gemcitabine/nab‐paclitaxel • CT scans after 2 and 4 months of treatment showed stable disease 1. Surgical resection 2. Chemoradiation • Patient developed grade 3 sensory neuropathy and nab‐paclitaxel is 3. SBRT discontinued during cycle 6 4. Continue chemotherapy with gemcitabine alone • CT scan after 6 th month still showed stable disease and no evidence of 5. Continue chemotherapy but change regimen distant disease 6. Treatment break 5

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach LAP07 LAP07 • Assess OS with chemotherapy vs chemoradiotherapy in locally advanced pancreatic cancer with progression‐free disease after gemcitabine based therapy • Evaluate effect of Erlotinib on OS in locally advanced pancreatic cancer • Gemcitabine vs Gemcitabine + Erlotinib Hammel, P et al. “2016. JAMA. 315(17); 1844‐1853. 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #2 Clinical Course Case #2 Question #3 What is the next step in management? • Patient elected to take a break from chemotherapy • Subsequent imaging about 4 months later shows metastatic 1. FOLFIRNOX progression to the liver and peritoneum 2. FOLFIRI 3. FOLFOX • He continues to have symptomatic sensory neuropathy 4. 5FU/nanoliposomal‐irinotecan 6

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach NAPOLI‐1 NAPOLI‐1 ‐ OS 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #3 Case #2 Take Home Points • There is no standard of care best option for locally advanced pancreatic • 63yo woman presents with fatigue and adenocarcinoma jaundice • • Both frontline regimens of FOLFIRINOX and Gem/nab‐paclitaxel are reasonable options CT scan reveals biliary dilation and mass based on extrapolation from randomized trial data in the metastatic setting distally • ERCP confirms a CBD stricture and • Chemoradiotherapy has not been proven to improve OS compared to chemotherapy brushings are positive for adenocarcinoma alone in locally advanced pancreatic cancer following gemcitabine based therapy • ECOG PS 0 • Nanoliposomal Irinotecan in combination with fluorouracil extends survival in patients with metastatic pancreatic ductal adenocarcinoma who previously received gemcitabine‐based chemotherapy – compared to fluorouracil. 7

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #3 followup Case #3 Question #2 What is the next step in management? • Patient undergoes whipple resection • 1. Chemotherapy – gemcitabine and cisplatin Pathology confirms a 2.5cm moderately differentiated extrahepatic cholangiocarcinoma 2. Chemoradiation with capecitabine • 1/18 Lymph nodes are positive 3. Surgery • Negative margins 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach BILCAP Case #3 Question #2 What is the next step in management? 1. Chemotherapy – capecitabine 2. Chemotherapy – gemcitabine and cisplatin 3. Chemotherapy with gemcitabine/capecitabine ‐> chemoradiation with capecitabine 4. Chemoradiation with capecitabine 8

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach BILCAP Future directions • ACTICCA‐1 – adjuvant therapy for resected cholangio or GB cancer original design = gem/cis vs placebo ‐> based on BILCAP ‐> gem/cis vs capecitabine Primary endpoint ‐ DFS 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach Case #3 Take Home Points Case #4 • 62 yo woman presents with upper GI bleeding • Capecitabine improves median overall survival compared to • EGD reveals a large ulcerative gastric mass positive for surveillance in patients with biliary tract cancer following adenocarcinoma macroscopic complete resection • EUS reveals T3N1 disease • Unclear whether multi‐drug regimens and incorporation of • Diagnostic laparoscopic evaluation with cytology of peritoneal chemoradiation add benefit in the adjuvant setting washings is negative 9

3/8/2018 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach MAGIC Trial – Perioperative Chemotherapy Case #4 Question #1 What is the next step in management? 1. Surgery 2. ECF 3. EOX 4. FOLFOX 5. FLOT 6. chemoradiation 18 th Multidisciplinary Management of Cancers: A Case‐based Approach 18 th Multidisciplinary Management of Cancers: A Case‐based Approach MAGIC ‐> FLOT FLOT TFLO OLFT LFTO FLTO TFOL OLTF LFOT FTLO TLOF OTLF LTOF FTOL TLFO OTFL LTFO FOLT TOLF OFLT LOTF FOTL TOFL OFTL LOFT 10