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Pancreas Cancer > Background and recommendations > Flashcards

Background and recommendations Flashcards

1
Q

What veins form the portal vein?

A

SMV, Left gastric and Splenic

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2
Q

T1

A

Tumor limited to pancreas and 2 cm or less in size

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3
Q

T2

A

tumor limited to the pancreas, but more than 2 cm

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4
Q

T3

A

Tumor extends beyond the pancreas but without involvement of the celiac axis or SMA

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5
Q

T4

A

Tumor involves the celiac axis, or SMA

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6
Q

N1

A

Regional nodal metastases

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7
Q

Stage IA

A

T1 N0

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8
Q

Stage IB

A

T2 N0

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9
Q

Stage IIA

A

T3 N0

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10
Q

Stage IIB

A

T1-2 N1

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11
Q

Stage III

A

T4 Any N

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12
Q

Stage IV

A

M1 including positive cytology of ascites

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13
Q

What are the key parts of the exam?

A
  1. Abdominal exam
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14
Q

Imaging needed at diagnosis?

A

CT scan of chest, abdomen and pelvis with IV contrast

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15
Q

What labs are needed at diagnosis?

A
  1. CBC
  2. BMP
  3. Ca 19-9
  4. LFTs
  5. Amylase/lipase
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16
Q

How do you get a tissue diagnosis?

A

EUS with FNA biopsy of pancreatic mass

or

CT guided biopsy

or

ERCP

or

pancreatic resection

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17
Q

Treatment paradigm for resectable tumors?

A
  1. Pylorus preserving pancreatocduondenectomy
  2. Gemzar followed by CRT (5FU and RT) (50.4 Gy) followed by Gemzar

or

  1. Adjuvant gemzar alone

or

  1. Adjuvant CRT (5FU based) followed by maintenance gemzar
  2. Adjuvant 5Fu followed by CRT (5FU) followed by 5FU alone

or

  1. Observation
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18
Q

What is the treatment paradigm for borderline resectable tumors?

A
  1. Staging laparoscopy
  2. Concurrent 5FU based chemo+RT
  3. Restage and if resectable, proceed to surgical resection
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19
Q

What is the treatment paradigm for unresectable tumors?

A

Biliary stent placement

  1. Gemzar 600 mg/m2 x weekly for 6 weeks. Concurrent RT to total dose 50.4 Gy at 1.8 Gy/fx. 4 weeks of rest then 5 months of weekly gemzar with 1 week of rest per month

ECOG 4201

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20
Q

What are the treatment options for patients with metastatic disease?

A
  1. FOLFIRINOX (5FU, leucovorin, irinoteca, oxaliplatin)

or

  1. Gemzar
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21
Q

CT simulation definitive

A
  1. Supine Arms up
  2. Indexed Mold
  3. IV contrast
  4. Oral contrast (gastrgaffin)
  5. Empty stomach
  6. 4D CT for unresectable tumors
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22
Q

Definitive Dose Prescription

A
  1. Initial: 45 Gy at 1.8 Gy
  2. Boost: 5.4 to 9 Gy at 1.8 Gy/fx
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23
Q

Post-op Prescription

A
  1. Initial 45 Gy at 1.8 Gy/fx (post-op bed and regional nodes)
  2. Boost: 5.4 to 9 Gy (post-op bed)
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24
Q

What is included in the Post-op or Preop-CTV? Boost volume?

A
  1. Post-op bed based on initial tumor location on preop imaging and op report and surgical clips delineating areas of gross disease or close margins, gross disease
  2. Regional nodal regions: around proximal 1 cm celiac, proximal 2 cm of SMA, portal vein anterior to IVC, preop GTV, pancreaticojejunostomy and paraaortic region (Most cephalad contour to bottom of L2)

Expand everything 1 cm except for the paraaortic area which should be expanded 2cm to the right and anterior, 1 cm to the left, 0.2 cm posteriorly

GTV or Post-op bed + 2 cm

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25
Q

Unresectable Volumes

A
  1. GTV: gross disease on CTV scan with contrast
  2. ITV=GTV+ motion on 4D scan
  3. CTV=ITV+1 cm
  4. PTV=CTV+ 0.5 cm
26
Q

At what vertebral level does the pancreas sit?

27
Q

What dose is provided to the PTV in post-op cases?

A

50.4 Gy at 1.8 Gy/fraction

28
Q

Which patients have borderline resectable disease?

A
  1. Abutment or encasement of SMV/PV
  2. Tumor abutment of SMA does not exceed 180 degrees
  3. Short segment encasement of the common hepatic artery encasement up to hepatic artery
  4. No celiac artery abutment
29
Q

What dose is provided for neoadjuvant chemoRT?

A

45 Gy at 1.8 Gy/fx

30
Q

Stomach constraint?

A

V45 < 150 cc

V30 < 300 cc

31
Q

Liver Constraints?

A
  1. V30 < 60%
  2. Mean dose < 25 Gy
32
Q

Kidney Dose Constraint?

A
  1. Bilateral Mean dose < 18 Gy
  2. Unilateral mean dose < 18 Gy
  3. Unilateral V6 < 30%
33
Q

Bowel dose constraints?

A
  1. Bowel space V45 < 150 cc
34
Q

Acute complications

A

Nausea, vomiting, diarrhea

35
Q

Late complications of RT

A

Ulceration, Stricture, obstruction, perforation

36
Q

Complications related to surgery

A

Exocrine and endocrine dysfunction

37
Q

What is the pattern of failure after surgery alone?

A

LRR: 50-85%

38
Q

What are the levels of the important organs and vessels?

A
  1. Pancreas: L1-2
  2. Celiac axis: T12
  3. SMA: L1
39
Q

What is included in the CTV for intact pancreatic head lesions?

A

Duodenual loop, Tumor with 2-3 cm margin

  1. Pancreaticoduodenal
  2. Suprapancreatic
  3. Celiac nodes
  4. Porta hepatis
  5. Duodenum
40
Q

What is included in the CTV for pancreatic body/tail lesions?

A
  1. pancreaticoduodenal, lateral suprapancreatic, celiac nodes, splenic hilum, and gross disease with 2-3 cm margin
41
Q

What dose of 5FU is used pre and post CRT?

A

Pre: 250 mg/m2/day for 21 days

Post: 250 mg/m2/day for 3 months

42
Q

What are the anastomoses performed after a whipple?

A
  1. Pancreaticojejuonstomy
  2. Choldochojejunostomy
  3. Gastrojejunostomy
43
Q

Follow up schedule?

A

H&P every 3 months for 2 years, with CA19-9 and CT scan of the chest/abdomen and pelvis, then every 6 months for 3 years

44
Q

After surgery+adjuvant CRT, what are the first sites of failure?

A

LF: 25%

DF: 75%

45
Q

Overall survival for resectable tumors treated with surgery + CRT? 3 year OS?

A

MS: 22 months

3 year OS:36-44%

46
Q

Median OS for patients with unresectable tumors?

A

With CRT, 9 months

1 year OS: 20%

47
Q

What are 3 ways to provide relief from tumor associated biliary obstruction?

A
  1. Endoscopic biliary stent
  2. Percutaneous biliary stent drainage
  3. Open biliary-enteric bypass
48
Q

Describe the 1st portion of the duodenum?

A

It is starts at the pylorus and it is retroperitoneal after the 1st 5 cm where is is suspended by the hepatoduodenal ligament

49
Q

Between what structures does the uncinate process lie?

A

Between the SMV and SMA anteriorly and IVC and Aorta posteriorly

50
Q

What is the second portion of the duodenum?

A

It starts at the superior duodenal flexure and it is attached to the head of the pancreas. It is 7.5 cm long and located to the right of the IVC at levels L1-L3.

51
Q

What is the second portion of the duodenum?

A

It crosses in front of the aorta and IVC and is posterior to the SMA and SMV. It is about 10 cm and marks the end of the C-loop.

52
Q

What study supports adjuvant gemzar alone?

53
Q

What trial supports adjuvant CRT for pancreas?

A

GITSG 9173

54
Q

What trial supports post-op CRT following resection?

A

GITSG Trial

  1. Surgery alone
    vs.
  2. Surgery 5 FU +RT split course 40 Gy folowed by 5FU

Surgery + CRT improved OS. Median OS improved from 11 to 21 months.

55
Q

What trial do not support CRT following surgery?

A
  1. EORTC trial (Garofalo): CRT did not improve OS to a SS degree over observation
  2. ESPAC-1: Adjuvant CRT worsened OS compared to adjuvant chemo
56
Q

What are the criticisms of the ESPAC trial?

A
  1. Choice was allowed for which design arm to enroll patients
  2. 1/3rd or chemo arm recieved CRT and vice versa
  3. RT fields and design were not standardized, up to 60 Gy was allowed
57
Q

What study supports adjuvant chemo after surgery?

A
  1. EORTC
  2. CONKO-01: Gemzar improved median OS by 2 months and 3 year OS by 17%
58
Q

What trial supports the use of Gemzae given before CRT and after CRT?

A

RTOG 9704:

  1. Gemzar+CRT + Gemzar
  2. 5FU+CRT+5FU

For patients with pancreatic head masses, Gemzar improved 3 year OS by 9%.

59
Q

What dose of Gemzar is used pre and post CRT?

A

Pre: Gemzar 1000 mg/m2 weekly for 3 weeks

Post: Gemzar Gemzar 1000 mg/m2 weekly for 3 months

60
Q

Trial supporting Chemo+RT for unresectable tumors?

A

GITSG 9273

61
Q

What study supports CRT + adjuvant chemo for unresectable?

A

ECOG 4201

  1. Gemzar 1000 mg/m2 weekly for 6 weeks, 1 week of rest then 5 months of weekly gemzar with 1 week of rest per month
  2. Gemzar 600 mg/m2 x weekly for 6 weeks. Concurrent RT to total dose 50.4 Gy at 1.8 Gy/fx. 4 weeks of rest then 5 months of weekly gemzar with 1 week of rest per month

CRT + adjuvant chemo improved 2 year OS by 8%

62
Q

What study supports IMRT for pancreas in comparison to 3D conformal?

A

RR: Yovino in Red Journal 2011

Decreased stomach, kidney and bowel dose and produced less GI toxicity

Pancreas Cancer (1 decks)

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