GI malignancy case review

Tuesday, August 27, 2019

Daniel G. Haller, MD, of the University of Pennsylvania, Philadelphia, joins Blood & Cancer host David H. Henry, MD, also of the University of Pennsylvania, to discuss two real-world gastrointestinal cancer cases and how the latest research should influence the approach to care.

Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University talks about pressure from patients to overtreat indolent cancer.

Patient case #1: Patient presents with a T2 tumor with right-sided colon cancer with invasion of a large right vessel. What is the best management?

  • The IDEA collaboration: Large analysis to evaluate CAPOX vs. FOLFOX therapy for colorectal cancer and to determine 3 months vs. 6 months of therapy. Researchers at the 2019 American Society of Clinical Oncology annual meeting presented an evaluation of the treatments in stage II colon cancer with high-risk features (Abstract 3501).
    • Definition of high risk: T4, inadequate nodal harvest, poorly differentiated, obstruction, perforation or vascular/perineural invasion.
      • Difficult for pathologists to diagnose T4 disease. The definition of high-risk disease was slightly different in each individual trial.
    • T stage makes the most difference of all.
    • Overall data:

Patient case #2: A 38-year old woman with past medical history of diverticulitis presents with left lower quadrant pain and is treated with antibiotics but does not improve. She was referred for colonoscopy, which reveals sigmoid polyp; pathology shows moderately differentiated adenocarcinoma. A CT scan is performed, which reveals a lesion that is transmural, circumferential in the sigmoid, and requires surgery. Sigmoid is colectomy performed for a large tumor and serosal and pericolic and immediately adjacent retroperitoneal soft tissue is noted. Other notable features included lymphovascular invasion but no metastases. Genetic testing shows RAS/BRAF negative and MMR analysis notes PMS2 negative.

  • Concern for Lynch syndrome given right-sided disease, female, large tumor; therefore, genetic testing for Lynch syndrome is recommended. This is important because patient requires more frequent colonoscopies.
  • Work with surgeons to recommend keeping clips in place to minimize area that gets radiation.
  • Approach to treatment: Dr. Haller recommends the “sandwich approach,” in which the patient receives chemotherapy, then radiation, then more chemotherapy. FOLFOX or CAPOX are both chemotherapy options.

Show notes by Ronak Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.

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Ilana Yurkiewicz on Twitter: @ilanayurkiewicz

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David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.



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