YouYOUNG good doctor voice fierce competition, each show style! Suwan Station advanced colorectal cancer cases are coming

*For medical professionals only

"Excellent YOUNG good medical voice" Suwan station wonderful case speech hit hard!

Colorectal cancer (CRC) seriously endangers the health of Chinese residents, and advanced CRC seriously affects the quality of life of

On September 3, 2022, the Colorectal Cancer Committee of the Chinese Society of Clinical Oncology (CSCO) jointly held the "Excellent YOUNG Good Medical Voice | Advanced colorectal cancer full management case speech" - Suwan Station meeting was held

Professor Qian Xiaoping of the Affiliated Drum Tower Hospital of Nanjing University School of Medicine and Professor He Yifu of the First Affiliated Hospital of the University of Science and Technology of China are invited to serve as the presidents of

Figure 1 Professor Qian Xiaoping, President of the Conference

Figure 2 Professor He Yifu, President of the Conference

Stand in the present and look to the future

New advances in anti-angiogenesis combined with immunotherapy for mCRC

Subsequently, the conference entered the academic sharing session, which was presided over by Professor Zhu Chunrong of the First Affiliated Hospital of Soochow

Professor Sun Yubei introduced that immunotherapy has a clear benefit in patients with microsatellite high instability (MSI-H), but most of the mCRCs are non-inflammatory "cold tumors" with limited efficacy of immunotherapy alone, so more combination therapies need to be explored

Figure 3 Professor Sun Yubei shared her academic work

Fruquintinib can highly selectively inhibit VEGFR1/2/3, and PD-1 monoclonal antibody can play a synergistic antitumor effect ^[2
].

Professor Sun Yubei introduced that not only that, fruquintinib can also promote the release of immune cytokines, induce T cell infiltration and activation, reduce the proportion of Treg cells, regulate macrophage M1/M2 balance, and ultimately restore tumor immunity
.

The results of a phase I.
b/II study of fruquintinib plus cidilizumab in the treatment of advanced CRC showed that the objective response rate (ORR) of fruquintinib 5 mg intermittent treatment group (fruquintinib 5 mg discontinued for 1 week + xindilizumab 200 mg Q3W) was 27.
3%, the median progression-free survival (mPFS) was 6.
9 months, and the disease control rate (DCR) was 95.
5% ^[3].


Another study also confirmed the excellent antitumor effect of fruquintinib plus PD-1 monoclonal antibody in the treatment regimen of fruquintinib plus genolumab, and the results showed that the ORR was 26.
7% and DCR was up to 80%, of which the ORR in the Phase II recommended dose (RP2D) group was 33.
3%, suggesting that fruquintinib plus genolimumab also has a good application prospect for patients with third-line advanced CRC ^[4].

。

Professor Ma Tai of the First Affiliated Hospital of Anhui Medical University, Professor Su Fang of the First Affiliated Hospital of Bengbu Medical College, Professor Tan Jie of Suzhou Municipal Hospital (East District), Professor Wu Pingping of Jiangsu Provincial Cancer Hospital, and Professor Yang Weichun of Huainan Chaoyang Hospital participated in the discussion session
.

After intense discussion, the participating experts agreed that fruquintinib combined immunotherapy showed a certain anti-tumor effect compared with immunomonotherapy and had good application prospects, but the combination needs to be individualized, and for advanced patients, more attention should be paid to the safety of
the drug.

The third-line treatment of advanced colorectal cancer should consider the quality
of life of patients while taking into account the anti-tumor effect.

Figure 4 Expert discussion session

Fierce competition, ignited the whole audience - wonderful diagnosis and treatment case speech

The meeting entered the case speech session, which was presided over
by Professor Zhang Congjun of the First Affiliated Hospital of Anhui Medical University and Professor Duan Aixiong of Anqing Municipal Hospital.

Professor Qian Hesheng of Fuyang Cancer Hospital, Professor Liu Yong of Xuzhou Central Hospital, Professor Han Gaohua of Taizhou People's Hospital, Professor Liu Min of the Second Affiliated Hospital of Anhui Medical University and Professor Zhao Lu of the General Hospital of Anhui North Coal and Power Group served as the jury
.

Case 1: Keep hope, the good will come as scheduledThe case is provided by Suzhou Municipal Hospital (East District) as a supervisor: Professor Tan Jie; Case speaker: Dr.
Wang Chenjie Case summary: The patient is a 55-year-old male, postoperative pathological tips: (right half colon) differentiation adenocarcinoma, invasion of the whole layer, two incisions and appendix no cancer involvement, see tubular adenoma, lymph nodes see cancer metastasis (11/14), see also cancer nodules
.

The immunohistochemistry results showed MLH1(+), PMS2(+), MSH6(+), MSH2(+), indicating that the microsatellite was stable, Her2(1+), Ki-67 (30-40%)
.

Diagnosis was postoperative for liver metastasis of transverse colon cancer (T3N2bM1a stage IV, MSS type, Her-2 negative
).

From December 2019 to April 2020, 6 courses of oxaliplatin + capecitabine chemotherapy were performed, and the disease progressed
in mid-August 2020.

The tumor marker CA-199 was 610.
80 U/ml, which was modified for postoperative diagnosis of transverse colon cancer after liver metastasis (T3N2bM1a stage IV.
, MSS type, Her-2 negative).


First-line therapy, starting in September 2020, is given FOLFIRI plus bevacizumab for 5 cycles, during which CA-199 decreases to 100 U/ml
.

Efficacy assessment achieved partial remission (PR) in November 2020, but liver function was affected
.

In December 2020, the patient entered the second-line treatment, and now bevacizumab plus ratitidrexed treatment for 4 cycles, the efficacy is evaluated to maintain PR status, and at the same time, the patient still has more severe liver injury side effects
.

In March 2021, the third-line treatment was started, and the targeted therapy of fruquintinib (5mg/day for 3 weeks and 1 week) was used, and the efficacy in the treatment was stable, and it has been more than 1 and a half years now, and the tumor control effect is good
.

Drug toxicity side effects are small, and transaminases are always within the normal range
.

This case suggests that for patients with poor liver function, fruquintinib not only provides good anti-tumor therapeutic activity, but also a better treatment option
with excellent safety.

Figure 5 Dr.
Wang Chenjie of Suzhou Municipal Hospital (East District) made a case report

Case 2: It is difficult to go astray, the long wind and waves This case is provided by the First Affiliated Hospital of Bengbu Medical College: Professor Su Fang; Case Speaker: Doctor Case Summary: The patient is a 70-year-old male who visited the hospital in September 2020 due to "finding liver occupancy for more than half a month", and abdominal color ultrasound showed low-density intrahepatic shadows, considering multiple metastases
of the liver.

Genetic test results showed that KRAS, NRAS, BRAF wild-type MSS type; Diagnosis of left colon adenocarcinoma with multiple liver metastases (cTxNxM1 stage IV).


First-line therapy is initiated in October 2020 with cetuximab plus FOLFIRI regimen, and through July 2021, patients continue PR
.

Efficacy was evaluated as disease progression (PD) in September 2021, and no significant reduction
was seen in CA-199 and CEA throughout first-line treatment.

Bevacizumab in combination with oxaliplate and capecitabine chemotherapy will be given in September 2021 until the end of December 2021, and the efficacy will be evaluated as PD
.

In December 2021, a therapeutic regimen of fruquintinib (5 mg d1-14) combined with xindilizumab (200 mg) was started, and after 3 cycles of treatment, the disease progressed
.

The patient entered the four-line therapy and was given cetuximab plus irinotecan and raltitrexed chemotherapy, and the overall survival time of the patient was about 2 years
.

This case demonstrates the importance of the full management of advanced colorectal cancer and the selection of
appropriate treatment strategies.

Figure 6 The First Affiliated Hospital of Bengbu Medical College used to meet doctors to make case reports

Case 3: Posterior line fruquintinib brings "intestine" for a long time The case is provided by the First Affiliated Hospital of Anhui Medical University: Professor Ma Tai; Case Speaker: Dr.
Yu Hanqing's Case Summary:

The patient is a 58-year-old male who was diagnosed with adenocarcinoma at the direct B junction in April 2020, and underwent multiple low-density foci of the liver on enhanced CT examination, considered metastasis, and underwent a course
of chemotherapy 1 with the "CapeOx" regimen.

Tumor markers CEA 387.
2 ng/ml, CA72-4 19.
16 U/ml, CA-199 622.
7 U/ml, CA125, AFP(-); Genetic test results: KRAS, NRAS, BRAF are all wild-type, MSS
.

The final diagnosis was adenocarcinoma at the direct B junction with multiple metastases of the liver, (stage IV, KRAS, NRAS, BRAF are all wild-type, MSS, ECOG 1 points).


In May 2020, cetuximab plus CapeOx regimen was treated for 8 courses, during which multiple metastases of the liver were reduced compared with before, and the efficacy was evaluated PR
.

First-line maintenance therapy with cetuximab plus capecitabine regimen
is initiated in January 2021.

In April 2021, tumor markers were significantly elevated, and the efficacy was evaluated for PD
.

After 4 courses of treatment with bevacizumab plus FOLFIRI regimen in April 2021, multiple metastases in the liver increased again than before, new lesions appeared, tumor markers were significantly elevated, and the efficacy was evaluated PD
.

In July 2021, entering the third-line treatment, using fruquintinib (5 mg/4 mg) regimen, multiple metastases in the liver during treatment were reduced compared with before the drug, tumor markers decreased compared with before, the safety was good, the efficacy evaluation was SD, and the current patients continued to benefit, with an overall survival of more than 28 months
.

The diagnosis and treatment process of this case suggests that the anti-tumor efficacy of fruquintinib single-agent third-line therapy is objective, the safety is tolerable, and the patient can bring sustained benefits
.

Figure 7 Dr.
Yu Hanqing of the First Affiliated Hospital of Anhui Medical University made a case report

Case 4: Success is achieved without giving up

The case was provided by Jiangsu Provincial Cancer Hospital

Supervisor: Professor Wu Pingping; Case Speaker: Dr.
Pan Xuan

Case summary:

The patient is a 60-year-old man who was admitted to the hospital and diagnosed with sigmoidoid adenocarcinoma with lung metastases (cTNM: T4N1M1; ECOG, 1 point) Genetic testing prompts: KRAS mutation, NRAS wild type, BRAF wild type; The immunohistochemical results are: MLH1(+), PMS2(+), MSH2(+), MSH6(+
).

In March 2015, the patient underwent "laparoscopic assisted total colonectomy rectal anastomosis and terminal ileostomy" and underwent 6 cycles
of intravenous chemotherapy with the Folfox4 regimen.

After regular review, no recurring metastases were observed
.

In June 2018, a follow-up CT showed that the lesions of pulmonary nodules had increased compared with the previous ones, and metastasis
was considered.

In July 2018, bevacizumab combined with irinotecan and ratitizai was treated with 12 cycles of chemotherapy, and the re-examination of lung metastases every two months did not change much compared with the previous one, and in January 2019, bevacizumab plus ratitricex monotherapy was carried out for 3 cycles
.

In April 2019, the right lung metastases were checked for enlargement, and bevacizumab combined with oxaliplatin and raltetraxe regimens were treated for 4 cycles
.

The CT in June 2019 showed that the intrapulmonary nodule did not change much from the previous one, and metastasis was still considered
.

From June to July 2019, pelvic and chest irradiation DT:PGTV:37.
5Gy/15f and PGTV2:37.
5Gy/15
, respectively.

Oral fruquintinib plus capecitabine was started in October 2019, with fruquintinib slowly increasing from 3 mg, 4 mg to 5 mg
.

The patient discontinued oral administration of drugs due to toxic side effects such as hand-foot syndrome and discontinued the drug on his own in January 2021, when PFS was 15 months
.

In March 2021, the patient had a right lung metastasis nodule that was enlarged and the disease progressed, and the disease metastasized after three cycles of treatment with fruquintinib (3 mg qd) plus TAS-102 dual oral regimen, and the disease progressed after 12 months, and in April 2022, the disease metastasized
after three cycles of treatment with tiralimizumab plus sulfatinib.

Six-line treatment with tirelizumab plus bevacizumab regimen, followed up until August 2022, the right lung metastases are slightly smaller than before, and the mediastinal and right hilar enlarged lymph nodes are smaller
than before.

Up to now, the total OS of patients has exceeded 4 years and the quality of life is better
.

This case suggests that for patients with advanced colorectal cancer, improving quality of life, prolonging survival time, and maintaining cancer survival are our main treatment goals
.

In the course of treatment, the combination of fruquintinib has brought significant clinical benefits
to patients.

Figure 8 Dr.
Pan Xuan of Jiangsu Provincial Cancer Hospital made a case report

Case 5: Life goes on, I hope not only this case is provided by Huainan Chaoyang Hospital as a mentor: Professor Yang Weichun; Case Speaker: Dr.
Li Bin Case Summary:

The patient in this case is a 65-year-old woman who was admitted to the hospital in September 2020 for "confirmed rectal cancer nearly 3 months, palliative chemotherapy", and the ultrasound endoscopic diagnosis was rectal cancer uT3cN2b uCRM and MRF (positive).


Colonoscopy pathology: low-differentiation adenocarcinoma; Immunotyping: MSS
.

KRAS 2 exon missense mutation (abundance 13.
54%), NRAS, BRAF mutation not detected
.

The final diagnosis was: rectal hypodifferentiated adenocarcinoma (cT3N2M1, stage IV, MSS type, KRAS 2 exon mutation) with liver metastases and lung metastases
.

In November 2020, bevacizumab was treated with the combination of oxaliplatin and capecitabine regimens, during which CEA was normal and CT was evaluated for SD
.

In May 2021, "transverse colon binocula" was performed, followed by treatment with fruquintinib (4 mg qd) plus capecitabine until the disease progressed in September 2021, and continued treatment with fruquintinib (4 mg qd) plus capecitabine was continued, and PD was evaluated again after two cycles
.

Begin 2 weeks of SBRT treatment for liver metastases in November 2021, DT: 40Gy
.

During the period of oral treatment with fruquintinib and capecitabine in combination, re-evaluated 3 months later, bone metastases
were found.

Local radiation therapy
for metastases from the left acromi, scapula, and humerus began in March 2022.

After 2 cycles of immunotherapy with fruquintinib (4 mg qd) and xindilizumab (200 mg q3w) during radiotherapy, the patient's left shoulder pain improved significantly after the above treatment
.

This case suggests that a combination of fruquintinib treatment strategies is a future treatment trend
for advanced colorocarcinoma.

Figure 9 Dr.
Li Bin of Huainan Chaoyang Hospital reported the case

Through the wonderful case speeches, the five doctors fully demonstrated their personal style and the thinking and choices
of the diagnosis and treatment team in the treatment of the above-mentioned real-world cases.

In the end, after the review and approval of the jury, Dr.
Yu Hanqing from the First Affiliated Hospital of Anhui Medical University performed well and won the excellent case
.

summary

At the end of the meeting, Professor Qian Xiaoping and Professor He Yifu, chairmen of the conference, made a wonderful summary, saying that the case speeches of the five doctors were very wonderful, the slides were exquisitely made, the speech typhoons were good, the case diagnosis and treatment process was clearly described, and the speculation process was reasonable and well-founded, and it can be seen that the young doctors have solid basic skills
.

In the future, it is also necessary to emphasize humanistic care, bring efficacy to patients, pay attention to the quality of life and mental health of patients, and benefit patients with advanced colorocoloral cancer in
an all-round way.

References:

[1].
Fukumura D, Kloepper J, Amoozgar Z, et al.
Enhancing cancer immunotherapy using antiangiogenics: opportunities and challenges.
Nat Rev Clin Oncol.
2018 May; 15(5):325-340.

[2].
Huang Y, Goel S, Duda DG,et al.
Vascular normalization as an emerging strategy to enhance cancer immunotherapy.
Cancer Res.
2013 May 15; 73(10):2943-8.

[3].
Ye Guo, 2021, ASCO.

[4].
J clin oncol 39, 2021.
(suppl 15, Abstr e15551)

*This article is for the sole purpose of providing scientific information to medical professionals and does not represent the views of this platform