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Question: Good morning Dr Cervantes. I am a young tunisian medical oncologist, also one of your biggest fans and I hope that you are doing well. I have two questions please about the possibility of use of Pembrolizumab for patients with CRC with lung metastasis MSI-H. 1/ Is a MSI-H on IHC is sufficient for prescription of Pembro or a PCR is mandatory required? 2/ If patient have a chronic ulcerative colitis or corhn disease, can we prescribe Pembro? if YES what are in practice precautions for use? I thank you very much, Emna Trigui
Answer: Dear Colleague, IHC with loss of one of the mismatched repair proteins is enough to consider that tumor as MSI high and therefore a good candidate for check point inhibitors. If the los is in MSH1, please consider determining BRAF mutational status. You may remember that MSH1 promotor hypermethylation is related to BRAF mutations. PCR is not superior to IHC and has high concordance with IHC. In patients with bowel inflammatory disease there is no major contraindication, excepting when they have active disease and they need corticoids for controlling it. If there is no active inflammatory bowel disease, check point inhibitors are safe and can be udes. Best regards, Andres
Question: . I would like to ask you a question about a young patient who came to consult us today. She was operated for an adenocarcinoma of the rectosigmoid hinge by anterior laparoscopic resection. And it was a pT2bN0M0 but the removal of the anapath only brought back 4 lymph nodes which were all reactive. Is it normal to have only 4 nodes in some patients? Could this be due to the laparoscopic approach? Is that lymph node removal considered insufficient in a stage I colon cancer? What exactly should be done in this case?
Answer: Dear Colleague, An appropriate lymphonodal yield is essential to stage localized colon cancer and a minimum number of 12 lymp nodes is requested for a minimum quality staging. Getting 12 or more lymph nodes is a balance between the skills of the surgeon able to remove enough mesocolic tissue for assessment and the dedication of the pathologists to properly examine all nodes around. Please check ESMO guidelines for localized colon cancer recently published in Annals of Oncology. I would advise discussing this point with your patient, who is staged as a T2NX. T2N0 is stage IB and does not require treatment, but t2N1 is stage IIIA, a subset with good prognosis but requiring adjuvant treatment. Six months capecitabine could be a sensible option for him, Best regards, Andres