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Gastric Cancer > Background and recommendations > Flashcards

Background and recommendations Flashcards

1
Q

How do you develop CTV for tumors of antrum of stomach postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, 1st portion of the duodenal loop, gastric remnant and regional nodal regions

Regional nodes add: Porta hepatis, periduondenal, suprapancreatic, splenic, pancreaticoduodenal

Boost gross residual: CTV = GTV + 2 cm margin

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2
Q

Late toxicities of gastrectomy?

A 
Dumping syndrome (diarrhea, cramping, palpitations, reactive hypoglycemia)
Malabsorption: B12, iron, calcium
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3
Q

Beam techniques used?

A

4 field plan
or
IMRT

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4
Q

How do you develop CTV for tumors of body of stomach postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, gastric remnant and regional nodal regions

Regional nodes add: Suprapancreatic, Splenic, pancreaticoduodenal, porta hepatis, splenic hilum

Boost gross residual: CTV = GTV + 2 cm margin

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5
Q

How do you develop CTV for tumors of proximal stomach postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, surgical clips, anastomoses, gastric remnant, regional nodal regions

Regional nodes: Suprapancreatic, Splenic, pancreaticoduodenal, porta hepatis, splenic hilum

Boost gross residual: CTV = GTV + 2 cm margin

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6
Q

How do you develop CTV for tumors of GE junction postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, gastric remnant and regional nodal regions

Regional nodes add: mediastinal, peripesophgeal

Boost gross residual: CTV = GTV + 2 cm margin

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7
Q

What is the relapse pattern after surgery alone?

A

50% of patients fail distantly

54% of patients experience locoregional recurrence

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8
Q

What are the minimum surgical margins on gross tumor and minimum number of nodes removed?

A

5 cm margins

15 nodes

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9
Q

Kidney dose constraint?

A

Mean dose < 18 Gy

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10
Q

Heart dose constraint?

A

V40<30%

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11
Q

Spinal cord dose constraint?

A

Max dose < 45 Gy

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12
Q

T1a

A

Invades lamina propria or muscularis mucosa

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13
Q

T1b

A

Invades submucosa

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14
Q

T2

A

Invades muscularis propria

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15
Q

T3

A

Tumor penetrates subserosa without invasion of the visceral peritoneum (serosa)

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16
Q

T4a

A

Invasion of the serosa, visceral peritoneum

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17
Q

T4b

A

Tumor invades adjacent structures including extension into gastrocolic or gastrohepatic ligaments or greater or lesser omentum

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18
Q

N1

A

1-2 regional nodes

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19
Q

N2

A

3-6 regional nodes

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20
Q

N3

A

N3a: 7-15 nodes
N3b: > 15 nodes

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21
Q

Stage IIA

A

T1 N2
T2 N1
T3 N0

22
Q

Stage IIB

A

T2 N2
T3 N1
T4a N0
T1 N3

23
Q

Stage IA

A

T1 N0

24
Q

Stage IB

A

T1 N1

T2 N0

25
Q

Stage III

A

A) T4a N2, T3 N2, T2 N3

B) T4b N0, T4b N1, T4a N2, T3 N3

C) T4b N2, T4 N3

26
Q

Stage IV

A

M1

27
Q

What is OS for patients with node positive disease?

A

5-10%

28
Q

D1 LND

A

Perigastric nodes

29
Q

D2 LND

A

D1+ portal +periarterial (left gastric, hepatic, celiac, splenic)

30
Q

D3 LND

A

D2+hepatoduodenal, peripancreatic, mesenteric root, portcaval, PA nodes, middle colic

31
Q

For what stages is gastrectomy alone appropriate?

A 
T1
T2 N0 (no LVSI, D2 LND)
32
Q

In the standard PORCT regimen, what is the course of chemo?

A
  1. Neoadjuvant: 5FU + leucovorin x 1 (425/20 mg/m2 q 4 weeks)
  2. Concurrent: 5FU + leucovorin x 2 (400/20 mg/m2q4 weeks)
  3. Adjuvant: 5FU + leucovorin x 2 (425/20 mg/m2 q 4 weeks)
33
Q

What elements of the history and physical should you explore at work up?

A

History: anorexia, early satiety, abdominal pain, weight loss, fatigue, nasuea, melena, KPS

Physical: Abdominal exam evaluating for any palpable masses or ascites, examine for adenopathy left SCL, periumblical, and left axillary regions

34
Q

What imaging and labs are needed at diagnosis?

A

Imaging: CT scan of the chest/abdomen/pelvis with contrast

Labs: CBC, CMP (includes LFTs)

35
Q

What are the two major strategies for management of stomach cancer?

A
  1. Surgery + Chemo+CRT+Chemo

2. Chemo + surgery + chemo

36
Q

What special studies are needed during work up?

A
  1. EGD with biopsy with H. pylori test
37
Q

What determines whether a total gastrectomy is needed?

A
  1. Total: proximal lesions

2. Distal: subtotal gastrectomy

38
Q

What anastomosis is done after resection?

A

Gastrojejuonostomy or esophagojejunostomy

39
Q

What dose of RT do you deliver?

A

45 Gy and boost to 50.4 for gross residual

40
Q

What is the ECF chemo regimen?

A

Epirubicin 50/60/200 mg/m2 x 3 cycles q 21 days
Cisplatin
5FU

41
Q

What is median OS? 5 year OS with surgery+POCRT?

A

Median OS 27 months

5 year OS: 39-52%

42
Q

CT simulation

A
  1. Supine
  2. NPO for 3 hours
  3. IV contrast
  4. Arms above head
  5. 4D scan if delivering preop
43
Q

What are the 4 anatomic sections of the stomach?

A
  1. Cardia: begins at the GEJ junction
  2. Fundus: Most caudad and up against diaphragm
  3. Body: central
  4. Antrum: gateway to the pylorus
44
Q

What is the porta hepatis?

A

The site of entry of the portal vein, hepatic artery, hepatic ducts and hepatic nerve plexus and lymphatic vessels

45
Q

What studys supports post-op chemoRT?

A

INT 0116 Macodonald

Surgery vs. Surgery + Chemo+CRT+Chemo

CMT improved 3 year OS

ARTIST Trial

Post-op Chemo vs. CRT

CRT trended to improving OS overall and did improve OS in patients with node positive disease.

46
Q

What patients can have preoperative chemoradiation?

A

GE junction tumors

Borderline resectable tumors at presentation

47
Q

What study supports perioperative chemo therapy?

A

MAGIC trial

ECF x 3 cycles + surgery + ECF x 3 cycles

vs.

Surgery alone

Chemo improved 5 year OS by 13%. No difference in curative resection rates.

48
Q

Small bowel constraint?

A

V45 < 150 cc

V30 < 300 cc

49
Q

What are the branches of the celiac artery?

A
  1. Common hepatic
  2. Left gastric
  3. Splenic artery
50
Q

What nodal regions do you always treat electively?

A
  1. Celiac
  2. Perigastric: greater and lesser curvature
  3. Paraaortic

Gastric Cancer (1 decks)

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