Zachary Risch Profile picture
Mar 22 29 tweets 201 min read
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance 1/22 #TumorBoardTuesday #ColonCancerAwarenessMonth #OncTwitter @shafiarahman_

62 yo 👨🏼‍🦳 asymptomatic
🔦 Screening colonoscopy - sigmoid mass
🔬Biopsy + for pMMR/MSS adenocarcinoma
🩻Staging CT + for unresectable liver mets

🤨What first line systemic treatment would you choose?
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ 2/22 #TumorBoardTuesday @MPishvaian @JohnEbbenMDPhD #CRCAwarenessMonth

👨🏼‍🦳started on first line FOLFOX
🧪NGS testing
KRAS/BRAF WT
TMB low
ERBB2 negative
ATM mutation
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ 3/22 #TumorBoardTuesday #GI23 #CRCAwareness
👩🏻‍🏫Mini tweetorial 1👨🏻‍🏫

↩️Left side tumors more common:
BRAF WT
KRAS WT
HER2 amp

↪️Right side tumors enriched for
BRAF V600E mutation
KRAS Mut
MSI-H
📚@ASCO
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO 4/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 2👨🏻‍🏫

📌RAS Mutation = resistance to anti-EGFR therapy

📌KRAS muts:🕵🏻 detected by NGS- tissue or liquid bx #ctDNA

≈49% of #CRC= KRAS/NRAS muts
KRAS codons 12 (30%) & 13 (~8%) of exon 2. NRAS (exons 2, 3, 4)
📚pubmed.ncbi.nlm.nih.gov/26189770/
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO 5/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 3
🥇Tissue test “gold standard” but liquid bx⬆️concordance (80-93%)
⚡Fast
💁Concordance highest with liver mets> peritoneal >🫁in mCRC
📚Corcoran, RB @NatureMedicine doi.org/10.1038/s41591…
📚@YoshinoriKagawa aacrjournals.org/clincancerres/…
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa 6/22 #TumorBoardTuesday
#ColonCancer
Back to case🔎
👨🏼‍Pmab added to FOLFOX after 1 cycle

📌Data for 1L Anti-EGFR inhibitor
👍🏽Several prior trials signal OS benefit of anti-EGFR tx in L side KRAS WT
❓Is frontline anti-EGFR essential in fit unresectable👨🏾‍ given clinical➕💰tox
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa @MGHCancerCenter @CathyEngMD @GillSharlene @BasselElRayesMD @aparna1024 @gabe_a_brooks @the_danielahn @ShaalanBeg @MadhuEluri @OncBrothers @KristenCiombor @cancerassassin1 @CelsoMello15 @MariloMediano @mgfakih 7/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 4👨🏻‍🏫

✨FIRE-3

📌Ph 3 RCT, untreated, unresectable KRAS exon 2 WT #CRC
📍592 pt 🎲 FOLFIRI + Cetux vs FOLFIRI + Bev

1° objective: ORR not met (62% vs 52%)
2° analysis: improved OS with anti-EGFR vs anti-VEGF for RAS WT
@TheLancetOncol
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa @MGHCancerCenter @CathyEngMD @GillSharlene @BasselElRayesMD @aparna1024 @gabe_a_brooks @the_danielahn @ShaalanBeg @MadhuEluri @OncBrothers @KristenCiombor @cancerassassin1 @CelsoMello15 @MariloMediano @mgfakih @TheLancetOncol 8/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 5👨🏻‍🏫

✨CALGB/SWOG 80405

📌Phase III RCT
📍1137 patients with untreated, unresectable KRAS WT #CRC
mFOLFOX6 or FOLFIRI backbone
🎲Randomized to cetux or bev
Similar OS (32 vs 31.2 mos)
📚@HJLenz59 doi.org/10.1001/jama.2…
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa @MGHCancerCenter @CathyEngMD @GillSharlene @BasselElRayesMD @aparna1024 @gabe_a_brooks @the_danielahn @ShaalanBeg @MadhuEluri @OncBrothers @KristenCiombor @cancerassassin1 @CelsoMello15 @MariloMediano @mgfakih @TheLancetOncol @HJLenz59 @OncSTATdoc 10/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 7👨🏻‍🏫
✨PARADIGM

📌Phase III, multi-center, RCT
📍604 pts with L sided RAS WT untreated, unresectable #CRC
🎲Randomized to mFOLFOX6 + Pan vs Bev
👍🏽OS improved with Pan (37.9 vs 34.3 mos)
📚doi.org/10.1200/jco.20…
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa @MGHCancerCenter @CathyEngMD @GillSharlene @BasselElRayesMD @aparna1024 @gabe_a_brooks @the_danielahn @ShaalanBeg @MadhuEluri @OncBrothers @KristenCiombor @cancerassassin1 @CelsoMello15 @MariloMediano @mgfakih @TheLancetOncol @HJLenz59 @OncSTATdoc 11/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 8👨🏻‍🏫
✨STRATEGIC-1

📌Phase III, RCT
📍263 pts with untreated, unresectable, RAS/RAF WT CRC (86% left side 1°)
💪🏽A: FOLFIRI-Cetux then mFOLFOX6-Bev
💪🏽B: OPTIMOX-Bev then FOLFIRI-Bev then EGFR mab +/- irinotecan
ascopubs.org/doi/10.1200/JC…
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa @MGHCancerCenter @CathyEngMD @GillSharlene @BasselElRayesMD @aparna1024 @gabe_a_brooks @the_danielahn @ShaalanBeg @MadhuEluri @OncBrothers @KristenCiombor @cancerassassin1 @CelsoMello15 @MariloMediano @mgfakih @TheLancetOncol @HJLenz59 @OncSTATdoc 12/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 9👨🏻‍🏫

✨FIRE-3, CALGB/SWOG 80405, PEAK

📌 AE’s

Anti-EGFR
⬆️ acneiform rash
🧃 electrolyte disorders
🥱 fatigue
🚽 diarrhea
💰 Financial toxicity

Anti-VEGF
⬆️ thrombosis
🫀 hypertension
@TumorBoardTues @MPishvaian @JohnEbbenMDPhD @CCAlliance @shafiarahman_ @ASCO @NatureMedicine @YoshinoriKagawa @MGHCancerCenter @CathyEngMD @GillSharlene @BasselElRayesMD @aparna1024 @gabe_a_brooks @the_danielahn @ShaalanBeg @MadhuEluri @OncBrothers @KristenCiombor @cancerassassin1 @CelsoMello15 @MariloMediano @mgfakih @TheLancetOncol @HJLenz59 @OncSTATdoc 13/22 #TumorBoardTuesday
👩🏻‍🏫Mini tweetorial 10👨🏻‍🏫

Is tumor side🗝️to select tx?
@KoheiShitara/✨PARADIGM

🩸🧬ctDNA alterations & relation to anti-EGFR tx resistance
🔹hyperselected pts, RAS wt via ctDNA=
⬆️OS w PAN vs BEV regardless of tumor side
HR 0.76 - 0.82 w mOS 6.6-8.0 mo

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