Thread by @TumorBoardTues

1/12 #TumorBoardTuesday

🔬🧬Discussion on #ColonCancer and BRAFv600E disease w dMMR led by @FlavioRochaMD
➡️Here is this week's Thurs Case🎀

👉👉 Don’t forget to pick up🆓 #CME credit by answering 2 quick ❓
ALL CME 🔗: integrityce.com/tbt
Now…we’re off to the races!

2/11 #TumorBoardTuesday
Thurs Case🎀

Take🏠messages:
#CRC 🚫one disease!
✅Diff 🧬subtypes that define tx sensitivity
✅BRAFv600E is bad–but may be ⬆️sensitive to IO w MLH1 meth
✅Neoadj tx: 🦊FOXTROT= poss benefit, depends on subgroup
✅Keynote177: IO= way to go in dMMR!

3/12 #TumorBoardTuesday
Thurs Case🎀

Take🏠messages (cont’d):

✅ATOMIC will help answer ❓chemo/IO combo upfront is best in dMMR and BRAFv600E
✅POLEM trial also looking at adjuv IO in dMMR @shafiarahman_

📚We captured the discussion in this moment: twitter.com/i/events/15212…

4/12 #TumorBoardTuesday
Thurs Case🎀

MOST IMPORTANTLY: Performance status (PS) is key, but have to meet pt where they are- 💥everyone is an individual!💥

📌 Do no harm--but also recognize when therapy could improve PS - requires lots of discussion with patient!🤝

5/12 #TumorBoardTuesday
Thurs Case🎀

@FlavioRochaMD presented a case of a 👩w anemia & 🥱
10 cm right sided, non-obstruct colon tumor w BRAFv600E mut and loss of MLH1.
Prev w breast ca; 👨‍👩‍👧‍👧w uterine, prostate, breast. Unfortunately, pt PS= 2!

➡️What, if any, chemo upfront?

6/12 #TumorBoardTuesday
Thursday Case🎀

😱Given PS of 2, pt not a candidate for cytotoxic chemo or for ✂️ upfront. BUT- dMMR. And w 🧬BRAF mutation!

🤔What now❓
💡Consensus- attempt IO, watching closely for toxicity. Can IO be a bridge to improved PS ➡️surgery?

7/12 #TumorBoardTuesday
Thurs Case🎀

dMMR in #CRC = big changes in tx, based on Keynote 177.

@ShimagavimiMD also brought BEACON to the group’s attention- BRAF, MEK inhib + EGFR inhib beat cytotox chemo in BRAFv600E

nejm.org/doi/full/10.10…

8/12 #TumorBoardTuesday
Thurs Case🎀
@FlavioRochaMD discussed what drives #CRC.

🔑: 4+ molec subtypes, each different!
✳️CMS1: Immune- dMMR (15% of pts)--💪IO benefit!
✳️CMS2: Canonical (37%)
✳️CMS3: Metabolic (13%); mixed MSI status
✳️CMS4: Mesenchymal (23%)
✳️Other (12%)

9/12 #TumorBoardTuesday
Thursday Case🎀

For dMMR, IO seems 🗝️. Unclear whether familial, or sporadic- Keynote 177 includes both, as well as BRAF/MLH1
✅IO significantly outperforms chemo for dMMR
✅ATOMIC will eval whether there’s benefit to combining w chemo upfront

10/12 #TumorBoardTuesday
Thurs Case🎀
…which raises a good❓Germline or sporadic?
Pt w strong FH and personal hx of breast ca, suggests Lynch syndrome.

As @HHampel1 points out, methylation MLH1 promoter common w BRAFv600E mutation= sporadic dMMR.

🤔Could our pt have both?

11/12 #TumorBoardTuesday
Thurs Case🎀

@FlavioRochaMD also took us through 🦊FOXTROT (neoadj chemo).
✅Slight survival ⬆️w neoadjuvant–BUT–much better rate of R0 resection (& fewer complications)
✅However- no substantial benefit in dMMR group (with cytotoxic neoadj chemo)

12/12 #TumorBoardTuesday
Case🎀

Back to pt: pembro x 4 months. Symptoms resolved!
⬆️PS👉surgery👉adjuvant FOL🦊!

🙏Sometimes PS is improved by tx

➡️Did you👂? We’re weekly! Join on May 17: @PTarantino presents a case of 2nd line HER2 tx in breast ca😀

Remember #TumorBoardTuesday continues to offer AMA & now MOC credit for FREE! Don’t forget to answer the polls👇🏽
Then click this link to easily request your credit!
ALL CME eval🔗: integrityce.com/tbteval

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