Patient's Query
Hi doctor,
I am sending the medical reports of my relative. A month back, he had vomiting and abdominal pain. He went to the doctor, and they diagnosed him with cancer in the jejunum. They have done a PET SCAN and found the tumor is not metastatic, so he was operated on accordingly. I am attaching his discharge summary and also the biopsy reports. After seeing his present reports, please guide:-
1. Now, does he require chemotherapy?
2. If you say yes, which combination should be selected?
3. How many cycles of chemotherapy are needed?
4. Since he was operated on ten days ago, when can they start the first cycle of chemotherapy?
Please guide.
Thank you.
Hello,
Welcome to icliniq.com.
I have gone through the reports you have provided as well as the records of Sx (surgery) (attachment removed to protect patient identity). Based on this, my diagnosis is as follows. The patient is a 59-year-old male without prior comorbidities suffering from cancer in the jejunum. (Ca Jejunum with p/Sx, pT3N0 and LN - 0/9).
I would advocate adjuvant chemotherapy in his case, as there is inadequate LN (lymph node) dissection. A minimum of 12 LNs (lymph node dissection) needs to be harvested for it to be adequate Sx. He should receive a total of six months of adjuvant CapOx (Capecitabine and Oxaliplatin) or Folfox (5-Fluorouracil, Leucovarin and Oxaliplatin) based treatment.
Chemotherapy can be started after three to four weeks of completion of Sx, provided he is medically and surgically fit.
If you have any other questions, you can always revert here.
Thank you.
Patient's Query
Hi doctor,
Thank you for your reply.
The above patient met a medical oncologist. Both of his prescriptions are attached. The first doctor suggested adjuvant chemotherapy of 12 cycles within fifteen days and prescribed the plan in his prescription. From there, he went to another doctor. He met a local oncologist again, and his prescription is also attached. However, his advice differed from the first doctor's opinion. He wants to treat the patient with oral chemotherapy of a minimum of four cycles, and if affordable, then a maximum of eight cycles has been advised.
He does not recommend any high-dose treatment in this case as the lymph nodes are free and the MSI status remains unknown. Now, the patient has some treatment options. So they seek valuable advice from you.
1. Which prescribed treatment must be followed, or do you recommend?
2. What medicines or injections of chemotherapy should be used as per your advice?
3. How many cycles and intervals remain between two cycles?
4. Should they need to ask MSI about the block?
5. What is your opinion about the NGS test for this patient?
6. If you recommend NGS, where should it be done?
7. Does NGS have to be done from a blood sample or a block?
Would you please reply step by step to understand better?
Thank you.
Hello,
Welcome back to icliniq.com.
First, I will tell what I would do in such a case based on the evidence. As LN (lymph node) dissection is inadequate, he comes under the high-risk stage 2 intestinal cancer. ESMO (European Society for Medical Oncology) guidelines suggest adjuvant doublet treatment (both 5FU or Capecitabine and Oxaliplatin should be given).
If FolFox is chosen, then completing twelve cycles every two weeks is needed. If Capox is chosen, then four cycles every three weeks are needed. The choice between CapOx and FolFox is decided after looking at the patient's fitness and co-morbidity. In his case, a medical oncologist has chosen FolFOX because CapOx is a difficult regimen to tolerate. Not all patients can take it, and they may leave the treatment in between. FolFOX is better tolerated than CapOX, especially if the patient's age is above 60 years.
Now, the second oncologist is not a medical oncologist. He is a radiation oncologist, so I would not consider his treatment plan based on the recent knowledge. Only single-agent oral treatment is given for intermediate-risk disease based on MSI (microsatellite instability) status. It is always given for eight cycles and never for four cycles. Before starting single-agent treatment, MSI testing is mandatory. So the final conclusion is-
1. Folfox is the preferred option every two weeks for twelve cycles (total six months of t/t).
2. CapOx every three weeks for four cycles (total three months of t/t) is the second option.
3. MSI testing will not give additional information in high-risk cases, as we are already treating with doublet treatment. But I would recommend doing it for a different purpose, as it can act as a screening test for three percent of cases of hereditary colon cancer.
4. What is the purpose behind doing NGS in stage 2 intestinal cancer?
Treatment is not decided as per NGS, so NGS is not recommended for deciding treatment. If you are doing it as a part of genetic testing for hereditary cancer because of a positive family history, you should do it.
5. For hereditary cancer testing, NGS is always done on a blood sample and not on a tissue block.
Treatment plan:
The treatment advised is adjuvant chemotherapy with FolFOX for six months or CapOX for three months.
I think this should answer your questions.
If you have any more queries, you can always revert here.
Thank you.
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Answered byDr. Pawar Satyajit Jalinder
Medically reviewed byDr. K. Shobana
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