Dr. Pawar Satyajit Jalinder
Medical oncology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I am sending the medical reports of my relative. A month back, he had vomiting and abdomen pain. He went to the doctor, and they diagnosed him with cancer in Jejunum. They have done 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, and then which combination should be selected?
3. How many cycles of chemotherapy are needed?
4. Since he was operated on ten days back, when can they start the first cycle of chemotherapy? Please guide sir.
Hello,
Welcome to icliniq.com.
I have gone through reports you have provided as well as records of Sx (surgery) (attachment removed to protect patient identity). Based on which my diagnosis is as follows. The patient is a 59-year-old male without prior comorbidities suffering from cancer in 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. Minimum 12 LNs (lymph node dissection) need to be harvested for it to be adequate Sx. He should receive total six month of adjuvant CapOx (Capecitabine and Oxaliplatin) or Folfox (5-Fluorouracil, Leucovarin and Oxaliplatin) based treatment. Chemotherapy can be started after three to four week of completion of Sx, provided he is medically and surgically fit. If you have any other questions, you can always revert back here. Thank you.
Patient's Query
Thank you doctor,
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. But his advice was different 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 lymph nodes are free and MSI status remains unknown. Now, the patient got some treatment options. So they seek valuable advice from you.
1. Which prescribed treatment must be followed, or do you recommend?
2. What are medicines or injections of chemotherapy should be used as per your advice?
3. How many number of cycles and intervals remain between two cycles?
4. Should they need to ask MSI from 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. Do NGS has to be done from a blood sample or block? Would you please reply step by step to understand better?
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 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 complete twelve cycles every two weeks are 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 stating 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 positive family history, you should do it.
5. For hereditary cancer testing, NGS is always done on a blood sample and not on tissue block. I think this should answer your questions. If you have any more queries, you can always revert here. Thank you.
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