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GI Flashcards

1
Q

History questions for esophageal cancer

A
  • Dysphagia (solids/liquids)
  • Odynophagia
  • Wt loss and nutrition habits
  • Cough
  • Pain
  • Smoking/drinking
  • H/o GERD
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2
Q

PE maneuvers for esophageal cancer

A
  • Abdominal exam
  • SCV nodes
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3
Q

Workup for suspected esophagus cancer

A
  • EGD w biopsy of primary - to determine distance from incisors / obstructing or not
  • Staging EUS to determine T stage and abnormal periesophgeal nodes
  • Bronchoscopy if tumor is above carina to rule out fistula
  • Imaging
    • CT CAP with oral and IV contrast
    • PET
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4
Q

Necessary referrals for newly diagnosed esophagus cancer

A
  • Nutrition assessment for consideration of PEG (if nutritionally deficient)
  • Speech/swallow
  • Smoking cessation
  • PFTs
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5
Q

Cervical esophageal cancer, distance from incisors

A

15-18 cm

Below cricoid cartilage

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6
Q

Upper esophageal cancer, distance from incisors

A

18-24

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7
Q

Mid esophageal cancer, distance from incisors

A

24-32

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8
Q

Lower esophageal cancer, distance from incisors

A

32-40 cm

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9
Q

GEJ esophageal cancer, distance from incisors

A

~40 cm

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10
Q

Siewert I classification

A

Originates in the distal esophaus (distal 5 cm from GEJ)

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11
Q

Siewert II classification

A

originates in true GEJ (esophageal cancer)

-1 cm from GEJ to 2 cm into stomach

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12
Q

Siewert III classification

A

Originates in stomach between 2 and 5 cm from the GEJ

technically gastric cancer

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13
Q

What are the surgery techniques for esophageal cancer

A
  • Transthoracic, Ivor-Lewis esophagectomy
  • Transhiatal
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14
Q

Which esophagectomy better for distal tumors

A

Transhiatal

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15
Q

Describe Ivor-Lewis esophagectomy

A
  • Two incisions, one in the upper abdomen and R lateral thoracotomy
  • Reconnects residual esophagus and stomach
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16
Q

Pros/cons of Ivor-Lewis

A
  • Pros
    • Oncologic procedure
    • Less leaks
    • Better for proximal tumors
  • Cons
    • Heartburn common
    • Tight proximal margins
    • Pulmonary and mediastinal complications can be severe
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17
Q

Describe transhiatal esophagectomy

A
  • Two incisions
    • L neck
    • Uppe abdominal laparotomy
  • Cervical anastomosis of the cervical esophagus to stomach
  • Better for distal tumors
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18
Q

Pros/cons of transhiatal esophagectomy

A
  • Pros
    • Less morbid and pain
    • Avoids thoracotomy
    • Leks less dangerous in he neck and are more easily managed
    • Clear proximal margin
    • Less heartburn
  • Cons
    • Can’t see upper tumors
    • LND only by blunt dissection
    • Can’t access level 7
    • More leaks
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19
Q

How many LN should be removed from esophagectomy

A

At least 15

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20
Q

What would make an esophageal tumor inoperable

A
  • T4b disease
  • Multifocality including GEJ and SCV nodes
  • Bulky multistation mediastinal nodes
  • Distant mets
  • Medically inoperable
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21
Q

Nodal drainage of upper esophagus

A
  • Superior mediastinum
  • SCV
  • Cervical neck
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22
Q

Nodal drainage of Mid esophagus

A

Either superior or inferior in paraesophageal nodes

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23
Q

Nodal drainage of lower 1/3 esophagus

A

Lower mediastinum

Celiac nodes

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24
Q

What share of tumors are adenoca

A

75% and rising

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25
Q

T1 esophagus

A

Mucosa, lamina propria, submucosa

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26
Q

T2 esophagus

A

Muscularis propria (40% are N+)

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27
Q

T3 esophagus

A

Invades adventitia

**No serosa for esophagus**

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28
Q

T4a esophagus

A
  • Invades adjacent structures but is still resectable (pleura, pericardium, diaphragm)
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29
Q

T4b esophagus

A

Not resectable

Invades aorta, vertebral body, trachea, adjacent organs

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30
Q

Describe nodal staging for esophagus

A

N1 = 1-2 nodes

N2 = 3-6 nodes

N3 = 7+ nodes

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31
Q

Management of cTis or cT1 tumors

A

Options include

  • Endoscopic mucosal resection +/- ablation
  • Esophagectomy if extensive disease
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32
Q

Which esophageal tumors can be managed with esophagectomy alone?

A
  • cTis
  • cT1
  • cT2N0 - small <3 cm, low risk features (well diff)
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33
Q

Options for Operable Locally Advanced Esophageal Cancer

A
  • Neoadjuvant CRT –> PET 5-8 weeks post completion –> EUS –> Esophagectomy
  • Definitive CRT (lower)
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34
Q

What is the dose for preop RT for locally advanced esophagus

A

50.4 Gy in 28 fractions of 1.8 Gy

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35
Q

What are the concurrent chemo options for neoadjuvant CRT for locally advanced esophageal

A
  • Carboplatin (AUC 2) and taxol (50 mg/m2) weekly x 5 weeks
  • Cisplatin (75 mg/m2) D1 and 5FU (1000 mg/m2) q4w x2 cycles
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36
Q

What is the management of inoperable esophageal cancer

A

50.4 Gy with concurrent carbo/taxol or cis/5FU

consider 2 cycles of adjuvant FOLFOX

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37
Q

Management of cervical esophageal cancer

A
  • Definitive CRT
  • 45 Gy to larger volume including SCV nodes
  • Primary tumor to 66-70 Gy meeting constraints
  • Chemo is weekly carbo-taxol
    • Carbo AUC 2
    • Taxol 50 mg/m2
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38
Q

Treatment of stage IV esophageal cancer

A
  • Palliative RT - 30/10 for dysphagia and relief
  • Trastuzumab for HER2+ adenocarcinoma
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39
Q

What about RT alone for esophageal cancer

A

Palliative, (0% 5 year OS)

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40
Q

Doses for preop, postop and definitive RT for esophagus ca

A
  • Preop: 50.4 Gy (in case not surgical candidate)
  • Postop: 50.4
  • Definitive: 50.4 or 66 for cervical esophagus cancer
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41
Q

What is the benefit of preop CRT

A

IMproves path CR rate

Improves OS

Improves R0 resection and N+ rates

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42
Q

What incremental benefit does surgery provide after CRT

A

10% LC

No OS benefit

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43
Q

What is the advantage to dose escalation for esophagus cancer

A

None (but most deaths occured before pt got to escalation component)

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44
Q

What is the simulation strategy for esophagus tumors

A
  • NPO 2-4h prior to sim and treatment
  • 4DCT sim with IV and po contrast
  • Supine, arms up in a alpha cradle if lower tumor
  • Supine, arms down, 5 pt mask if upper tumor
  • Scan from cricoid to L3
  • PET/CT fusion
  • Daily KV imaging
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45
Q

Type of RT to utilize for esophagus cancer

A
  • Use IMRT to reduce heart and lung (but watch V5)
  • If not, 3DCRT using 4 field (AP/PA and RPO/LPO)
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46
Q

Define GTV, CTV, PTV for esophagus cancer

A
  • GTV = gross tumor and enlarged nodes by CT, PET, EGD information
  • ITV = GTV plus motion
  • CTV =
    • GTV + 4 cm superior and inferior, 1 cm radially on primary
    • GTV nodes + 1cm
    • Elective nodal coverage
    • Respect anatomic boundaries of heart, liver, vert bodies
  • PTV
    • CTV + 1 cm
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47
Q

What is the elective nodal coverage for esophagus tumors

A
  • Cervical: SCV
  • Mid esophagus: paraesophageal
  • Distal: celiac and lesser curvature (located in gastrohepatic ligament)
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48
Q

If ITV is large, other strategies

A

Adbominal compression

Respiratory gating

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49
Q

Lung constraints for esophageal cancer

A
  • V20 < 20%
  • V5 < 50%
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50
Q

Cord constraint for esophageal cancer

A

MPD of 45 Gy

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51
Q

Heart constraint for esophageal cancer

A

V30 < 30%

Mean <26 Gy

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52
Q

Kidney constraint for esophageal cancer

A

V20 < 33%

Mean dose to both kidneys < 18 Gy

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53
Q

Liver constraint for esophageal cancer

A

V20 < 30%

V30 < 20%

Mean < 25 Gy

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54
Q

5 year OS for stage I esophagus

A

80%

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55
Q

5 year OS for stage II esophagus

A

50%

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56
Q

5 year OS for stage III esophagus

A

20%

N1 or N2

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57
Q

5 year OS for stage IV esophagus

A

<5%

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58
Q

Acute toxicities of esophageal cancer treatment

A

esophagitis

weight loss

fatigue

anorexia

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59
Q

Late SE of esophageal cancer

A
  • Perforation or fistula (5-10% if invading trachea)
  • Pneumonitis
  • Late strictures (20-40%)
  • Pericarditis
  • CAD
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60
Q

What are the layers of the stomach on EUS

A
  • Superficial mucosa
  • Deep mucosa (hypoechoic)
  • Submucosa
  • Muscularis propria
  • Subserosa

Alternate hyper and hypoechoic

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61
Q

History questions about gastric cancer

A

Abdominal pain

N/V

Early satiety

Dyspepsia

Melena
Coffee ground emesis

Risk factors of H Pylori, FAP, HNPCC, Peutz-Juegers

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62
Q

Physical exam for gastric

A

Abdominal exam

Nodes check cervical, SCV, periumbilical

Hepatomegaly or ascites

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63
Q

Labs for gastric

A

CBC

COMP

LFT

CEA (elevated in 1/3)

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64
Q

Imaging and other workup for suspected gastric cancer

A
  • EGD + random biopsies
  • EUS + biopsies
  • CT CAP w contrast OR PET/CT
  • Staging laparoscopy in T1b+
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65
Q

When should staging laparoscopy be considered

A

T1b+

If unresectable

Before/after neoadjuvant therapy (25% will be positive)

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66
Q

For esophagus and gastric, what is the nutritional consideration

A
  • If part of stomach likely to be removed or moved, go with J-tube
  • If stomach unlikely to move, PEG ok
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67
Q

What are the goals for gastrectomy?

A
  • >5 cm margin
  • >15 LN dissected
  • D2 nodal resection
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68
Q

Types of gastrectomies

A
  • Total gastrectomy required for cardia, fundal, greater curvature tumors
  • Partial gastrectomy - ok for distal tumors of antrum or body
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69
Q

What is the connection of a total gastrectomy?

A
  • Roux en Y with connection of esophageal stump to jejunum
  • Used for proximal tumors (cardia, fundus, greater curvature)
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70
Q

What is the connection of the partial gastrectomy?

A

Gastric remnant to jejunum

End to end or end to side

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71
Q

D1 dissection

A

Just perigastric nodes

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72
Q

D2 dissection

A
  • D1 nodes
  • Celiac plus three branches:
    • Common hepatic
    • Splenic
    • L gastric
  • Modified D2 doesn’t remove spleen or distal panc
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73
Q

D3 dissection

A

D2 plus PA nodes

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74
Q

T1 gastric

A

Lamina propria

Muscularis mucosa

Submucosa

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75
Q

T2 gastric

A

Muscularis propria

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76
Q

T3 gastric

A

Subserosa

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77
Q

T4a gastric

A

Serosa (visceral peritoneum)

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78
Q

T4b gastric

A

Adjacent structures

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79
Q

N1 gastric

A

1-2 nodes

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80
Q

N2 gastric

A

3-6 nodes

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81
Q

N3a gastric

A

7-15

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82
Q

N3b gastric

A

>15 nodes

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83
Q

Tricks for gastric staging

A
  • IA adds to 1
  • IB adds to 2
  • IIA adds to 3
  • IIB adds to 4
  • Anything greater is stage III
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84
Q

Two histologies of gastric cancer

A
  • Intestinal: H pylori, better prognosis
  • Diffuse: linitis plastica, poorly differentiated
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85
Q

Treatment of T1N0 stomach cancer

A

Gastrectomy

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86
Q

What patients are candidates for postop RT

A

Really only R1 or R2

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87
Q

If a patient has operable cT2+ or N+ what are the management options?

A
  • Perioperative chemotherapy (chemo –> surgery –> chemo)
  • Surgery –> postop CRT
  • Surgery –> chemo
  • Preop CRT –> Surgery (this is category 2B, not recommended)
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88
Q

If periop chemo approach selected, what chemo regimen?

A

FLOT

5-FU

Leukovorin

Oxaliplatin

Taxotere

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89
Q

How is FLOT given for gastric cancer

A
  • 4 cycles of chemo –> surgery –> 4 cycles of chemo
  • All agents are given on D1
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90
Q

If surgery and postCRT is selected, what chemo?

A
  • Capecitabine 1000 mg/m2 BID D1-14
  • Cape 825 mg/m2 BID D1-5 qweekly with RT (5 cycles)
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91
Q

What is the treatment approach if surgery –> adjuvant CRT?

A
  • Gastrectomy
  • Adjuvant cape x 1 cycle (1000 mg/m2 BID)
  • CRT with cape and 45 Gy (825 mg/m2 BID)
  • 2 cycles of adjuvant cape (1000 mg/m2 BID)
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92
Q

What patients should be considered for adjuvant CRT

A
  • No upfront chemo/RT
  • T3-T4 or N+ with R0 resection (if less than D2)
  • R1 resection
  • R2 resection
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93
Q

For gastric ca, if surgery –> chemo strategy, which chemo

A

Capecitabine and oxaliplatin

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94
Q

If patient had T4N+ disease with R0 resection what should be adjuvant therapy

A
  • Depends on extent of LN dissection
  • If D1 –> CRT
  • If D2 –> chemo
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95
Q

Treatment options for medically inoperable gastric ca

A
  • CRT to 45 Gy with capecitabine or 5-FU
  • Chemo (cape or 5-FU)
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96
Q

How to simulate patients for gastric cancer

A
  • Supine, alpha cradle, arms up
  • Empty stomach (NPO 3-4 hrs)
  • 4DCT with IV and oral contrast
  • Fuse preop PET and CT
  • Daily KV
  • Go with CBCT if unresectable or preop or boosting >45 Gy
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97
Q

What is the CTV for postop gastric volumes

A
  • Pre-op stomach or tumor bed + gastric remnant and duodenal stump
  • Surgical clips and anastomosis
  • Nodes
    • Celiac and branches
    • Perigastric
    • Suprapancreatic
    • Porta hepatis
    • Splenic
  • If distal, no need to cover splenic, but add subpyloric
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98
Q

PTV margin for gastric

A

1 cm

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99
Q

Dose for R0 resection gastric

A

45 Gy

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100
Q

Dose for R1 resection gastric

A

50.4 Gy in 28 daily 1.8 Gy fractions

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101
Q

Dose for R2 resection gastric

A

54 Gy in 30 daily 1.8 Gy fx

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102
Q

If a boost is being done, what is the volume

A

Conedown after 45 Gy

Volume is GTV + 1.5 cm

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103
Q

What is the RT approach

A

4 fields, AP/PA heavily weighted with RAO/LPO

IMRT only if constrained by heart and kidney

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104
Q

Borders for gastric field

A
  • Sup: T10
  • Inf L3
  • L Lateral: 2/3 L diaphragm to cover splenic nodes
  • R lateral: 3-4 cm on R vertebral body to cover porta hepatis
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105
Q

What should you draw before commiting to 3D fields

A
  • Location of the kidneys
  • Preop stomach
  • Stomach remnant
  • Anastomosis
  • Celiac
  • Porta hepatis
  • SMA
  • Splenic
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106
Q

What vertebral level is celiac

A

T12

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107
Q

What vertebral level is SMA

A

L1

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108
Q

What is location of porta hepatis

A

2 cm to R of T11/L1

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109
Q

Small bowel constraint with conventional fx

A
  • MPD < 55 Gy
  • V45 < 40 cc
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110
Q

Stomach constraint with conventional fx

A

MPD < 60 Gy

V50 < 40 cc

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111
Q

Median OS for gastric patients getting surgery –> CRT

A

36 mos

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112
Q

Acute toxicities of gastric cancer treatment

A

nausea

vomiting

fatigue

myelosuppression

GERD - give PPI

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113
Q

Late toxicities of gastric cancer treatment

A

Radiation gastritis

Ulcers

Dyspepsia

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114
Q

Follow-up vitamin supplementation after gastric cancer treatment

A

B12 (loss of IF)

Ca2+ and iron supplementation due to loss of stomach acid

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115
Q

History questions for pancreas ca

A
  • nausea
  • vomiting
  • early satiety
  • greasy stools
  • jaundice
  • pain
  • weight loss
  • migratory thrombophlebitis (DVT)
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116
Q

Risk factors for pancreas cancer

A

Smoking

DM2

FHx (Peutz-Jeghers, BRCA 1/2, HNPCC)

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117
Q

Physical exam for pancreas ca

A
  • Jandice/Scleral icterus
  • Abdominal exam
  • Weight loss
  • Palpable gallbladder (Courvorsier’s sign)
  • Virchow node (L SCV)
  • Sister Mary Joseph node (periumbilical)
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118
Q

Labwork for suspected pancreas cancer

A
  • CBC
  • COMP
  • LFTs
  • Amylase
  • Lipase
  • CA-19-9
  • CEA
  • HgbA1c
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119
Q

Imaging for suspected pancreas ca

A
  • CT CAP with pancreas protocol (IV contrast for early arterial, late arterial, portal venous with thin slices)
  • MRI abdomen to rule out liver mets
  • PET/CT for high risk patients
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120
Q

Best approach for tissue sampling for pancreas cancer

A

EUS with FNA (less risk of seeding over CT guided)

ERCP with stenting if biliary obstruction

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121
Q

Surgical options for pancreas cancer

A
  • If proximal pancreas –> Whipple procedure
  • If distal pancreas –> distal pancreatectomy
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122
Q

Describe the Whipple procedure

A
  • Removes the head of pancreas
  • Duodenum
  • Gallbladder and distal CBD
  • Pylorus is spared to prevent dumping syndrome
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123
Q

Anastomoses for Whipple

A
  • Gastrojeujeunostomy
  • CBD to jeujeunum
  • Pancreas to jeujunum
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124
Q

Which margin is most often positive for Whipple

A

RP most common

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125
Q

Pancreas is at what vertebral level

A

L1/L2

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126
Q

T1 pancreas

A

<2 cm

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127
Q

T2 pancreas

A

2-4 cm

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128
Q

T3 pancreas

A

>4 cm

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129
Q

T4 pancreas

A

Involvement of celiac artery, SMA, CHA

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130
Q

N1 pancreas

A

1-3 nodes

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131
Q

N2 pancreas

A

4+ nodes

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132
Q

What makes stage III pancreas

A

T4 or N2 disease

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133
Q

At diagnosis, what is the split of resectable, unresectable, metastatic

A
  • Resectable - 20%
  • LA/unresectable - 40%
  • Metastatic - 40%
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134
Q

What are the criteria for resectable pancreas ca?

A
  • Clear fat plane around celiac, hepatic artery, SMA, common hepatic artery
  • <180 degree contact and no distortion of the SMV or portal vein
  • No tumor thrombus
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135
Q

Borderline resectable pancreas ca criteria

A
  • <180 degree contact of SMA, CA
  • CHA contact but reconstructable
  • >180 contact of SMV/PV or thrombus
  • Contact of IVC
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136
Q

Management of resectable pancreas cancer

A
  • Surgery
  • Restage with CT CAP, CA-19-9, germline testing
  • Chemotherapy
  • Restage with CT CAP, CA-19-9
  • CRT if R1/R2
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137
Q

Systemic therapy options for adjuvant pancreatic cancer

A
  • mFOLFIRINOX
  • Gem-Cape
  • Gem alone if poor performance status
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138
Q

What is mFOLFIRINOX and how is it given?

A
  • Leucovorin
  • 5-FU CI
  • Irinotecan
  • Oxaliplatin
  • q2w x 12 cycles
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139
Q

How is gem-cape given?

A

q4w x 6 cycles

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140
Q

If CRT is offered adjuvantly to pancreas surgery, when should it start?

A

After 4-6 months of chemo

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141
Q

What are the chemo options for CRT with pancreas cancer

A
  • RT to 50.4 Gy in 28 fractions of 1.8 Gy
  • Capecitabine 825 mg/m2 BID
  • 5-FU CI 250 mg/m2 per day
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142
Q

What is the treatment strategy for borderline resectable pancreatic cancers?

A
  • Start with chemo (mFOLFIRINOX for 4-8 cycles)
  • Restage with CT CAP
  • CRT with 2.4 x 15 = 36 Gy
  • Restage
  • Surgery if feasible
  • Consider adjuvant chemo
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143
Q

What percentage of patients will be converted from borderline resectable to resectable with neoadjuvant therapy?

A

30%

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144
Q

What is the criteria for unresectable pancreatic cancer?

A

>180 degree contact with SMA, CA

Unreconstructable SMV or portal vein occlusion with tumor

Aortic invasion

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145
Q

Treatment of unresectable pancreas cancer

A
  • Chemo (4-8 months of mFOLFIRINOX)
  • Restage
  • CRT to 50.4 Gy
  • Restage
  • Adjuvant chemo

**If there is pain, local obstruction or chance of converting, start with CRT

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146
Q

What should be done if a patient is deemed unresectable at time of pancreas surgery?

A
  • Biopsy
  • Duodenal bypass or stent
  • Celiac plexus nerve block if pain
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147
Q

How to sim pancreas patient?

A
  • Supine
  • Arms up
  • Alpha cradle
  • 4DCT with IV and oral contrast
  • Empty stomach (3-4 hr NPO)
  • Fuse preop imaging
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148
Q

RT dose for preop pancreas

A
  • 2.4 Gy x 15 = 36 Gy
149
Q

Volumes for Preop pancreas

A

GTV and grossly affected nodes

150
Q

Dose for postop pancreas

A
  • 50.4 in 1.8 Gy x 28
  • Concurrent capecitabine 825 mg/m2 BID or 5-FU
151
Q

Contouring strategy for postop pancreas

A
  • GTV - any residual disease
  • CTV
    • Postop bed, clips, original tumor with 2 cm margin
    • PJ/HJ anastomosis (0.5-1 cm margin)
    • Elective nodes
  • PTV = 5 mm
152
Q

CTV elective nodes for pancreatic head lesions

A
  • Cover Celiac, SMA, Peripancreatic, Porta hepatis and para-aortic LN
  • Contour celiac, SMA, PV with 1 cm expanion
  • Contour aorta from celiac down to bottom of L2 with asymmetric expansion
    • R: 2.5 - 3 cm
    • L: 1 cm
    • Anterior: 2.5 cm
    • Post: 0.2 cm
153
Q

Elective nodes to cover for pancreatic tail lesions

A
  • Celiac
  • SMA
  • Suprapancreatic (lateral)
  • Splenic hilum
154
Q

Contouring strategy for unresectable pancreas cancer

A
  • Gross disease + 2 cm
  • ITV
  • ITV to CTV of 1.5 cm
  • CTV to PTV of 0.5 cm

No ENI since 95% of failures are in PTV

Consider boosting to 54 Gy if able to meet constraints

155
Q

Liver constraint for pancreas cancer

A

Mean < 24 Gy

156
Q

Kidney constraints for pancreas cancer

A
  • V18 < 33% if 2 kidneys
  • Mean kidney dose < 18 Gy if 2 kidneys
  • V18 < 15% if 1 kidney
157
Q

Small bowel constraint for pancreas cancer

A

Target V45 < 40 cc

If unable to meet coverage, <15%

MPD 55 Gy

158
Q

Spinal cord max for pancreas cancer

A

<45 Gy

159
Q

What is importance of CA-19-9 post op?

A

It is prognostic, post op level >90 associated with low survival

160
Q

Toxicity of 5-FU

A

Mucositis

Hand foot syndrome

If bolus - diarrhea, bone marrow suppression

161
Q

Toxicities of capecitabine

A

Diarrhea

Hand foot syndrome

Mucositis

162
Q

Where is cholangiocarcinoma derived from?

A

Bile duct epithelium

163
Q

What is a Klatskin Tumor

A

Extrahepatic cholangio at the confluence of the R and L hepatic ducts

Most common cholangio location (60-70%)

Best prognosis

164
Q

What is the workup for cholangiocarcinoma

A
  • Labs: CBC, COMP, LFTs, CEA, CA-19-9
  • RUQ ultrasound
  • Liver MRI
  • MRCP
  • ERCP or EUS and Bx for diagnosis
165
Q

Failure patterns of cholangiocarcinomas

A
  • Hilar tends to fail locally (RT important)
  • Gallbladder tends to fail distantly
166
Q

What forms the common bile duct

A

Common hepatic duct (from R and L hepatic)

Cystic duct (from gallbladder)

167
Q

Management strategy of resectable cholangiocarcinoma

A
  • Eval for liver transplant if needed
  • Surgical resection with regional LND
  • Adjuvant therapy as indicated
168
Q

Adjuvant therapy for IHCC

A
  • R0, N0 - observe or chemo
  • R1, N+ - chemo alone or CRT
  • R2 - treat as unresectable
169
Q

Adjuvant therapy for EHCC

A
  • R0, N0 - observe, chemo, or CRT
  • R1, N+ - CRT
  • R2 - treat as unresectable
170
Q

What is the adjuvant chemo option for cholangiocarcinoma

A

Gem/Cape for 4-6 months q3w

171
Q

Treatment recommendations for cholangiocarcinoma

A
  • Resection (if T2+, N+, margin+)
  • 4 cycles of gem/cape q3 weeks
  • CRT with concurrent cape 825 mg/m2 BID
    • 45 Gy to LNs (retropancreaticoduodenal, celiac and portal vein)
    • 59.4 Gy to tumor bed (1.8 x 33)
172
Q

Which cholangio pts benefit the most for adjuvant tx

A

LN+

R1 surgery

173
Q

Characteristics of HCC on CT

A

Early arterial enhancement

Early washout

174
Q

Imaging for HCC workup

A

Triphasic CT or MRI liver

Chest imaging

175
Q

What labs should be obtained for liver mass?

A

AFP, CBC, CMP, LDH, LFTs, PT/iNR, hep panel

176
Q

What constitues a positive AFP for HCC?

A

>100

177
Q

What goes into Child Pugh score

A

Encephalitis

Ascites

Albumin

INR

Bili

178
Q

T1 HCC

A

Solitary, no vascular invasion

179
Q

T2 HCC

A

Vascular invasion or many small tumors (<5 cm)

180
Q

T3a HCC

A

Many tumors > 5 cm

181
Q

T3b HCC

A

Portal or hepatic vein involvement

182
Q

T4 HCC

A

adjacent structures

visceral peritoneum involvement

183
Q

Radiographic features of HCC

A

Intense early arterial enhancement and early/rapid washout with rim/capsule which persists

184
Q

Treatment options for resectable HCC

A
  • Partial hepatectomy (CP A, no portal HTN, 20-40% liver remnant)
    • Other local therapies as needed
  • Liver transplant - only curative treatment
    • Consider bridge therapy of RFA, TACE, Y90
185
Q

Milan criteria for liver transplant

A

1 lesion <5 cm or

3 lesions < 3 cm each

No macrovascular involvement

186
Q

Treatment options for unresectable HCC

A
  • Ablation (RFA, cryo, microwave) - caution if close to large vessel
  • TACE (50% response)
  • Y90 (50-80% response)
  • Systemic therapy (atezo and bev)
  • RT (SBRT or conventional)
187
Q

RT strategy for liver mass

A

SBRT - 50 Gy in 5 fx

188
Q

Sim strategy for liver tumors

A
  • IV and PO contrast
  • Supine, alpha cradle
  • DIBH
  • NPO for 4 hrs
  • Fuse diagnostic imaging
189
Q

Contouring for liver tumors

A
  • GTV
  • ITV if using 4dct
  • PTV = ITV +0.5cm
190
Q

Dose for extensive liver mets

A

8x1 to majority of liver with dex 1 hr prior

191
Q

Liver constraint for SBRT

A

Preserve at least 700 cc as having < 15 Gy

192
Q

Small bowel dose constraint for liver SBRT

A

MPD 30 Gy

193
Q

When does RILD occur

A

2-3 months post RT

194
Q

Symptoms of RILD

A

Fatigue

RUQ pain

Ascites

Hepatomegaly

LFT and transaminitis

Veno-occlusive dsiease leading to hepatocyte atrophy

195
Q

Treatment of RILD

A

Supportive - steroids, pain meds, lasix, paracentesis

196
Q

When should colon cancer screening begin if no FHx

A

Age 50

197
Q

What is normal screening paradigm for colon cancer

A

Colonoscopy q10years

Flex sig with FOBT q5years

CT colonscopy q5years

198
Q

What delineates the anal verge

A

Lack of hair

199
Q

How long is the anal canal

A

4 cm, dentate line is midway

200
Q

Low rectum is X cm from anal verge

A

4-8 cm

201
Q

Mid rectum is x cm from anal verge

A

8-12

202
Q

High rectum is x cm from anal verge

A

12-15

203
Q

What is superior extent of the rectum

A

Peritoneal reflection, usually 12-15 cm from verge

204
Q

What is the muscle around the rectum

A

puborectalis

205
Q

What is the risk of CRC with FAP and HNPCC

A

FAP: 95%

HNPCC: 80%

206
Q

What is risk of CRC with IBD

A

15-50%

207
Q

What is risk of >1 cm polyp becoming CRC

A

20%

208
Q

History to ask rectal cancer patient

A
  • Nausea
  • Vomiting
  • Diahrrea
  • Stool change
  • BRBPR
  • Pain
  • History of UC, Crohn’s, HNPCC
209
Q

Physical exam for rectal patient

A
  • Abdominal
  • Pelvic
  • Female gyn exam
  • Fixed/tethered mass
  • Circumferential involvement
  • Location from verge
  • Sphincter function
  • Proctoscopy to determine distance from verge
210
Q

Additional workup for rectal cancer

A
  • Refer to GI for colonscopy with biopsies
  • EUS or pelvic MRI to determine depth of invasion
  • CT CAP with oral and IV contrast

NO ROLE FOR PET

211
Q

What is needed to be visualized on colonscopy

A

ileocecal ring (since 7% have synchronous primary)

212
Q

On MRI, what is the color of the muscularis

A

BLACK/Dark

213
Q

Surgical options for rectal cancer

A
  1. LAR - low anterior resection for mid-upper lesions
  2. APR - abdominoperineal resection for low lying lesions
214
Q

If patient getting LAR has temporary ostomy, when will it be reversed

A

4-6 months post surgery

215
Q

With either LAR or APR what is the extent of the surgery

A

TME - total mesorectal excision

216
Q

What is removed with TME?

A
  • Sharp dissecion of entire mesrectum (perirectal fat, presacral space) which reduced radial margin positive rate
217
Q

What is benefit of TME?

A

Reduced LR by 50% (11 vs. 25%)

218
Q

What is the goal for margin negativity for rectal surgery?

A

4-5 cm if possible

1-2 cm is acceptable if low lying

219
Q

What is the goal for nodal sampling for TME

A

12-14 LN

220
Q

What is the nodal drainage for the rectum?

A
  • Proximal –> IMA –> portal circulation –> liver mets
  • Distal –> internal iliac –> IVC –> lung mets
  • Anal canal –> inguinals
221
Q

T1 rectum

A

Submucosa

222
Q

T2 rectum

A

Muscularis mucosa

223
Q

T3 rectum

A

Serosa or peri-rectal fat

224
Q

T4a rectum

A

Visceral peritoneum

225
Q

T4b rectum

A

adjacent organs

226
Q

N1a rectum

A

1 node

227
Q

N1b rectum

A

2-3 nodes

228
Q

N1c rectum

A

tumor deposits in subserosa

229
Q

N2a

A

4-6 LN

230
Q

N2b

A

7+ nodes

231
Q

M1a rectum

A

Solitary nonregional node or single site

232
Q

M1b rectum

A

More than one site

233
Q

M1c rectum

A

peritoneal mets

234
Q

Stage I rectum

A

T1-2N0

235
Q

Stage II Rectum

A

T3 or T4 N0

236
Q

Stage III rectum

A

N+

237
Q

Stage IV rectum

A

M1a-M1c

238
Q

Treatment option for T1N0 rectum

A
  • Start with transanal excision –> close FU
  • Need full thickness WLE
  • This should be the best actors
    • <3 cm
    • >3 mm negative margin
    • <30% circumference
    • Well-diff
    • Within 8 cm of anal verge
239
Q

What are higher risk features after transanal excision

A
  • Large size (>3 cm)
  • T2
  • Deep T1 (deep 1/3 of submucosa)
  • Grade 3
  • LVI
  • Positive margins
240
Q

What is the concern with higher risk lesions after transanal excision

A

Greater risk of local failure (15-20%)

241
Q

What is next step if high risk lesion after transanal excision?

A
  • Recommend oncologic surgery (LAR or APR)
  • If refusing, do CRT
242
Q

Treatment options for T2N0 rectum

A
  • LAR or APR is preferred
  • If close to anus, can try CRT to downstage
  • No adjuvant therapy recommended
243
Q

When would adjuvant therapy be offered after LAR or APR for T2N0 tumor

A

If found to be T3+ or N+

244
Q

Treatment options for T3 or N+ rectal cancer

A
  • There are several options
    • Neoadjuvant therapy
      • Long course CRT or Short course RT
      • Restaging MRI
      • Resection
      • 4 months of FOLFOX
    • Total neoadjuvant therapy
      • 4 months of FOLFOX
      • Long course CRT or Short course RT
      • Restaging MRI
      • Resection
245
Q

If preop CRT, what is the dose of RT and chemo drugs utilized

A
  • 50.4 Gy in 28 daily fractions of 1.8 Gy
  • Choice of chemotherapy
    • 5-FU 225 mg/m2 CI for 5-7 days
    • Capecitabine 825 mg/m2 BID 5 days a week x 5 weeks
246
Q

When should surgery be performed after completion of RT

A
  • Restaging 8 weeks post therapy
  • Perform surgery 6-12 weeks post RT
247
Q

If neoadjuvant therapy is utilized what is the adjuvant chemo program

A

FOLFOX x 4 months

q2 weeks

248
Q

What is FOLFOX

A
  • 5-FU
  • Oxaliplatin
  • Leucovorin
249
Q

Which patients might be good candidates for total neoadjuvant therapy

A

T4 tumors

Locally unresectable

Close to mesorectal fascia

250
Q

What are the advantages of preop CRT?

A
  • Downstaging
  • Sphincter preservation
  • Assess response to neoadjuvant therapy
  • Toxicity better
  • Possibility for Non operative mgmt in future (on protocol)
251
Q

What is the downside of preop CRT?

A

Over treat T1-T2 since wee don’t know the true path

No OS improvement

252
Q

What is the treatment option for oligometastatic rectal ca with liver or lung mets

A
  • FOLFOX x 3 months
  • Short course RT to rectum
  • LAR and liver resection
  • FOLFOX x 3 months
253
Q

What is the treatment of colon cancer

A

Colectomy and LND

Adjuvant FOLFOX for stage III+

254
Q

What would be the indications of RT for colon cancer

A
  • Fixed T4
  • pN0 with close or positive margins
  • Perforation
255
Q

Dose of RT for colon cancer

A

50.4 Gy in 1.8 Gy daily fractions

256
Q

From German trial, how many patients converted from APR to LAR?

A

40%

257
Q

Simulation for rectal cancer

A
  • CT simulation with IV and oral contrast
  • Prone on belly board
  • Wire scars for APR
  • Marker at anal verge
  • Vaginal marker
  • Full bladder
  • CT from L1 to mid femur
258
Q

What is the CTV for rectal cancer

A
  • Two dose levels 45 Gy to pelvis and then 50.4 to the gross tumor with margin
259
Q

What is CTV 45 for rectal cancer

A
  • Includes
    • Mesorectum,
    • presacral space
    • Internal iliac nodes
    • +/-external iliac
    • +/- inguinals
260
Q

When would external iliacs be included in rectal field

A

Involvement of anterior structures: bladder, prostate, vagina

261
Q

When would inguinals be included in the CTV 45 for rectal

A

Involvement of anal canal

262
Q

What is CTV 50.4 for rectal cancer

A
  • GTV (or preop tumor) with
    • 2 cm radial margin
    • 2 cm sup/inf margin
    • Presacral LN
    • Full mesorectum at levels of tumor
    • 1 cm of posterior bladder
  • GTV nodes with 1 cm margin
263
Q

What is CTV to PTV margin for rectal ca

A

7 mm

264
Q

How should rectal cancer RT be delivered?

A

Use 3DCRT with 3 field orientation

PA,

2 Lateral beams

265
Q

What is superior border of rectal cancer 3 field technique

A

L5/S1

266
Q

What is inferior border of rectal cancer 3 field technique

A

3 cm below tumor or bottom of obturator foramen

267
Q

What is lateral border of rectal cancer 3 field technique

A

2 cm lateral to pelvic brim

268
Q

What is posterior border of rectal cancer 3 field technique

A

1 cm behind sacrum

269
Q

What is anterior border of rectal cancer 3 field technique

A

Normally behind pubic symphysis

1 cm anterior for T4 tumors (to cover external iliac)

270
Q

What dose should be utilized for definitive rectal

A

59.4 if can achieve constraints

271
Q

When should IMRT be considered for rectal cancer

A
  • A lot of small bowel
  • Covering external iliac or inguinal nodes to reduce dose to genitals
  • Reirradiation
272
Q

Dose for rectal reirradiation

A

39 Gy

1.5 x 26 fractions BID

273
Q

Bowel constraint for rectal cancer

A
  • V45 < 40 cc
  • V45 < 150-200 cc for bowel bag
  • MPD of 55 Gy
274
Q

Bladder constraint for rectal cancer

A

V40 < 40

275
Q

Femoral head constraint for rectal cancer

A

MPD < 50 Gy

V45 < 25%

276
Q

5 year OS for stage I rectal

A

90%

277
Q

5 year OS for stage II rectal cancer

A

80%

278
Q

5 year OS for stage III rectal cancer

A

60%

279
Q

Acute toxicities of rectal cancer treatment

A

Diarrhea

Proctitis

Thrombocytopenia

Dysuria

280
Q

Late toxicities of rectal cancer treatment

A

Persistent bowel issues

Proctitis

Anastomotic structures

SBO <5%

Incontinence

Impotence/sterility

Vaginal stenosis (dilators)

281
Q

Surveillance after rectal cancer treatment

A

H&P and CEA if elevated every 3 months for 2 years

Colonscopy in year 1 and then @ 3 years and 5 years

CT CAP yearly for stage III, q6m for stage IV

282
Q

Dentate line above/below

A
  • 2/3 above is non-keratinizing columnar epithelium and venous drainage is hepatic portal vein (via IMA)
  • 1/3 below is keratinized SCC and venous supply is systemic
283
Q

History points for anal cancer

A
  • Bleeding
  • Anal discomfort
  • Pruritis
  • Rectal bleeding
  • Sexual history
  • HIV
  • HPV
  • History of AIN
284
Q

What share of anal cancers are due to HPV

A

85%

285
Q

Physical exam for anal cancer

A
  • Abdominopelvic exam
  • Bilateral inguinals
  • Proctoscopy for distance from anal verge
  • DRE for sphincter tone
  • Gyn exam with Pap smear
286
Q

What are special workup considerations for anal cancer?

A
  • Men - sperm banking
  • Female - gyn referral with Pap, fertility referral
287
Q

Labs for anal cancer

A
  • CBC
  • CMP
  • LFT
  • LDH
  • HPV
  • HIV
  • Pap Smear
288
Q

Imaging for anal cancer

A
  • Anoscopy with biopsy
  • CT CAP
  • MRI pelvis
  • PET/CT for T3/T4 or N+
289
Q

What should be biopsied in anal cancer

A

Primary mass

Any suspicious inguinal nodes with FNA since only 50% of clinically N+ are pN+

290
Q

What is the pathology of most anal cancers

A

80-90% SCC

291
Q

What are the high risk HPV strains

A

16, 18, 31, 33

292
Q

What is the skin margin around anus

A

5 cm around the anus

293
Q

T1 anus

A

<2 cm

294
Q

T2 anus

A

2-5 cm

295
Q

T3 anus

A

>5 cm

296
Q

T4 anus

A

adjacent organ invasion not including rectum, perirectal skin, anal sphincter

297
Q

N1a anal cancer

A

inguinal

mesorectal

internal iliac

298
Q

N1b anal cancer

A

external iliac

299
Q

N1c anal cancer

A

external iliac and N1a nodes

300
Q

M1 anal cancer

A

mets including PA nodes

301
Q

What is stage III anal cancer

A

N+

302
Q

What is the preferred treatment for stage I-III anal cancer?

A

Definitive CRT

303
Q

What is the RT dose for anal cancer

A

Depends on size

T1: 45 Gy

T2: 50.4

T3/T4/N+: 54 Gy

304
Q

What is the dose for locally advanced anal cancer

A

54 Gy

305
Q

What is the chemo used for CRT for anal cancer

A

Mitomycin plus 5-FU

306
Q

What is the dose of MMC for anal cancer

A

10 mg/m2 on day 1 and 29

307
Q

What is dose of 5-FU for anal cancer

A

1000 mg/m2 day 1-4 and day 29-32

308
Q

What is the management of stage IV anal cancer

A

Cisplatin + 5FU +/- RT

309
Q

How to treat anal margin cancer

A
  • If well-differentiated T1 can do WLE with 1 cm margins
  • If T2-T4 or N+ do defintiive chemoRT as for anal canal, if surgery, then do post op RT similar to anal canal
310
Q

How to approach anal adenocarcinoma

A

Approach like rectal cancer

311
Q

How to approach if HIV and CD4 <200

A

Consider reduced dose chemo

Use cisplatin

Lower top border of RT field to bottom of SI joint

RT dose reduction

312
Q

How to approach if gross fecal incontinence

A

Go straight to APR with possibility of postop RT

Or get temporary diverting ileostomy and then do definitive CRT

313
Q

Indications for APR for anal cancer

A

Salvage after CRT

Sphincter dysfunction

Prior pelvic RT

Unable to tolerate chemo

Adenocarcinoma

314
Q

How to approach anal ca with solitary liver met

A

Definitive CRT with 5-FU and cisplatin

Consider restaging and then SBRT to liver

315
Q

How to sim anal cancer?

A
  • Supine in alpha cradle
  • Frog leg with full bladder
  • Wire nodes
  • Place anal BB
  • IV and oral contrast
  • Consider vaginal dilator for sim/treatment
  • CT from L1 to mid femur
316
Q

Contouring for anal cancer - GTV

A
  • GTV-A: primary tumor
  • GTV-N50: involved nodes < 3 cm
  • GTV-N54: involved nodes >3 cm
317
Q

Contouring for anal cancer - CTV A

A
  • GTV primary
  • Full anal canal (4 cm)
  • Expand
    • 2.5 cm sup/inf
    • 1.5 cm radial
    • Subtract out bone and air
  • Create nodal CTVs which are affected nodes with 1 cm margin
318
Q

What are the elective nodal regions for anal cancer

A

Mesorectum

Presacral

Internal iliac, external iliac, inguinal

319
Q

What is the CTV to PTV expansion for anal cancer

A

1 cm for primary

7 mm for nodes

320
Q

PTV doses for T2N0 rectal

A
  • Primary gets 50.4 Gy in 1.8 x 28
  • N0 nodes get 42 Gy in 1.5 x 28
321
Q

What is elective nodal dose in T2N0 anal cancer

A

42 Gy

1.5 x 28

322
Q

What is the PTV doses for locally advanced anal cancer

A
  • Primary (PTVA) - 54 Gy in 30 fractions of 1.8
  • N0 nodes - 45 Gy in 30 fractions of 1.5
  • LN < 3 cm: 50.4 Gy in 30 fractions of 1.68
  • LN > 3 cm: 54 Gy in 30 fractions of 1.8
323
Q

Elective nodal dose for anal cancer

A

Depends on size of primary

  • T2 - 42 Gy
  • T3-T4-N+ : 45 Gy
324
Q

Small bowel tolerance for anal cancer

A

V45 < 20 cc (lower due to MMC)

V30 < 200 cc

325
Q

Genitalia tolerance for anal cancer

A

MPD < 40 Gy

V20 < 50%

326
Q

Femoral neck tolerance for anal cancer

A

<45 Gy

327
Q

Bladder tolerance for anal cancer

A

V40 < 40%

328
Q

Anal sphincter tolerance

A

60-65 Gy

329
Q

5 year OS for early stage anal cancer

A

90-95%

330
Q

5 year OS for stage II anal cancer

A

70-80%

331
Q

5 year OS for stage III anal cancer

A

40-50%

332
Q

5 year OS for stage IV anal cancer

A

10%

333
Q

How long should anal cancer be completed

A

50 days

No breaks prior to 45 days

334
Q

Colostomy rate after definitive CRT for anal cancer

A

25%

335
Q

Side effects of MMC

A

Myelosuppression

Hemolytic uremic syndrome

336
Q

Acute side effects of anal cancer treatment

A

Dermatitis

Cystitis

Proctitis

Diarrhea

337
Q

Late side effects of anal cancer therapy

A

10% risk of femoral neck fracture

Vaginal stenosis (dilator)

Sterility/impotence

Anorectal dysfunction

338
Q

Follow-up for anal cancer

A

8-12 weeks post CRT, doe DRE

If CR –> DRE q3-6 months and anoscopy q6-12 mos

CT CAP annually

339
Q

What to do if anal cancer not CR in 2-3 months post CRT

A

Re-eval in 4 weeks

Contunue in 3 month intervals

Reimage and bx if progressive disease and consider APR if local failure

340
Q

How to approach local anal recurrence

A

APR

50% local control

341
Q

How to approach groin recurrence for anal cancer

A

Inguinal dissection

342
Q

Other chemo option for anal cancer

A

capecitabine 825 mg/m2 BID instead of 5-FU

343
Q

Why use IMRT for anal cancer

A

Reduce GU/GI/dematitis

344
Q

Where do inguinal nodes start

A

Top of femoral head

345
Q

What is the stomach constraint for esophageal ca?

A

mean of 30 Gy (stomach - PTV)

346
Q

How to achieve better stomach mean for esophagus

A

reduce inferior margins

accept lower dose (CROSS did 41.4)

3D –> IMRT

switch from 4D to compression or DIBH

347
Q

If residual esophageal disease after CRT and esophagectomy, next step

A

1 year of nivolumab

348
Q

Boost dose for cervical esophagus

A

Treat SCV, upper mediastinum and paraesophageals to 50.4 then boost tumor + 2 cm to 59.4 Gy

349
Q

Approach to TE fistula

A

stent to block the fistula

Abx for pneumonia

Proceed to definitive CRT

350
Q

What is a safe answer for postop gastric

A

If R0 and D2 resection –> adjuvant chemo alone

If R1/R2, consider 1 cycle of cape –> RT to 45 Gy, boost to 54 to positive margin and then 2 cycles of cape

351
Q

How to choose chemo regimen for pancreatic

A

Use performance status

  • If ECOG 0-1: mFOLFIRINOX
  • If ECOG 2+: gem-abraxane
352
Q

How many months of chemo before you switch to RT for pancreatic

A

4-6 months

353
Q

For CRC liver mets what is preferred strategy

A

Resection

354
Q

If resection of CRC mets is not possible what are other acceptable options

A
  1. RFA
  2. SBRT
355
Q

Contours for liver mets

A

Use DIBH with fiducial if possible

If not, 4DCT with abdominal compression

5 mm radial margin

1 cm sup/inf

356
Q

What is preferred strategy for gastric cancer

A

Periop FLOT4

4 cycles of FLOT –> gastrectomy –> 4 cycles of FLOT

357
Q

What is FLOT

A

5-FU with leucovorin

Oxaliplain

Docetaxel

358
Q

Implication of portal vein thrombus

A

rules out surgery, transplant and makes liver-directed therapies challenging so do SBRT

359
Q

What is the term for the space between disease and resection edge for rectal cancer

A

circumferential resection margin

360
Q

If CRM is threatened, what is best first step

A

TNT

50.4 Gy CRT with concurrent cape and then 4-8 cycles of FOLFOX

361
Q

For which rectal patients might it be ok to avoid RT

A

T3N0 high rectal

Especially in young woman hoping to preserve potency

362
Q

What is suitable for transanal excision?

A

T1N0

<30% circumference

<3 cm

>3 mm margin

Accessible from anal verge

363
Q

What do you do if T1N0 gets transanal –> pT2N0

A

Go to TME

Do not do CRT

364
Q

How to approach rectal obstruction

A

Divert –> PREOP TNT

365
Q
A
366
Q
A
367
Q
A
368
Q
A
369
Q
A

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