GI Flashcards
Esoph H/P
- History: dysphagia, odynophagia, wt loss/nutrition, cough, pain, smoking/EtOH, GERD
- Physical: abdomen, SCV nodes
Workup Esoph
- Labs: CBC, CMP, LFTs
- EGD w/ biopsy: distance from incisors, obstructing
- Initial imaging:
- CT c/a/p with oral/IV contrast
- PET/CT – recommended by NCCN
- Staging EUS (no M1); FNA LNs
- EUS accuracy T, 80-90%; N, 50-80%
Other
- Nutritional assessment for J-tube placement (PEG only for cervical lesions)
- Smoking cessation
- PFTs
- Bronchosocpy if at or above carina to r/o fistula
- Her2 if mets adeno (10% amp)
Landmarks by distance from incisors:
Landmarks by distance from incisors:
15-20 cm cervical (cricoid)
20-25 cm Upper thoracic (sternal notch to azygous)
25-35 cm Mid thoracic (Azygous to Pulmonary vein)
35-40 cm Lower Thoracic (Pulm Vein to GEJ)
40-45 cm GE junction
Transthoracic (Ivor-Lewis)
Transthoracic (Ivor-Lewis) - better for proximal
- 2 incisions – upper abdominal, right lateral
- Pro: Oncologic procedure
- Con: Heartburn, tight proximal margin, pulmonary complications, mediastinal leak
Trans-hiatal surgery
Trans-hiatal - better for distal
- 2 incisions: L neck, laparotomy – cervical anastomosis (cervical esophagus to stomach)
- Pros: Less morbid/pain, avoids thoracotomy, leaks are less dangerous in neck- easily managed and no mediastinitis, clear proximal margin, less heartburn
- Cons: Can’t see upper/mid-thoracic tumor, LND only via blunt dissection, can’t access subcarinal LN, more anastomotic leaks
- > 15 LN should be removed
Esophagus # of cases
16,000
Esoph nodal drainage
Upper 1/3: sup mediastinum, SCV, cervical;
mid 1/3: either
lower 1/3: lower mediastinum or celiac
Esoph T/N/M stage
T1: mucosa and submucosa *T1a: lamina propria, MM (7% N+) *T1b: submucosa (20% N+) T2: muscularis propria (40% N+) T3: adventitia (note: no serosa) T4: adj structures *T4a: still resectable (pleura, pericardium, diaphragm) *T4b: not resectable (aorta, vertebral body, trachea, adj organs [liver, panc, lung, spleen])
Nodal staging (by number, not by location)
N1: 1-2
N2: 3-6
N3: 7+
M1: distant including retroperitoneal, PA nodes, positive peritoneal cytology (most common sites = liver, lung, bone, adrenals, pleural, kidneys)
Esoph Overall stage
Adeno: I : T1N0 IIA: T1N1 IIB: T2N0 III: T2N1, T3-4aN0-1 IVA: N2-3 or T4b IVB: M1
Sqcc: I: T1 N0-1 II: T2 N0-1 or T3 N0 III: T3 N1 or N2 IVA: T4 or N3 IVB M1
Siewart Stages
I: +5 to +1 cm
II: +1 to -2 cm
III: -2 to -5 cm
Esoph T1a Management
Endoscopic Mucosal Resection +/- ablation
Esoph cT2-T4a, N0-N+ (operable) Management
cT2-T4a, N0-N+ (operable)
-CRT -> PET/CT -> surgery (3-6 wks after CRT) -> Nivolumab! for residual disease
-RT: 50.4 Gy
-Chemo:
Cis 75mg/m2 and 5FU 1000mg/m2 weeks 1 and 4
Dont forget Nivolumab!!!!
Inoperable T2+ or N+ Esoph Managment
Inoperable T2+ or N+: Definitive CRT
- RT: 50.4 Gy
- Chemo: Cis 75 and 5FU 1000 weeks 1, 4, 8, 11
- consider chemo alone for T4b SCC invading trachea, great vessels, heart
Cervical esophagus management
Cervical esophagus: Definitive CRT
- 45 Gy to larger volume including SCV -> 50.4 or mid 60s (2 RCTs showing no difference between CRT alone vs. surgery, both went to mid 60s – higher dose to achieve surgical equivalency)
- chemo is carbo/tax (CROSS – 49% pCR) or FOLFOX (French trial, showed less toxicity than cis/5-FU)
- sup extension likely <5 cm, up to level III
Esoph T1b-T2<3cm management
esophagectomy
Esoph Sim
- NPO 2-4 hours if distal tumor
- 4D CT simulation with IV and oral contrast
- supine, arms up in wingboard/vac lock (if above carina, do arms down and S-frame)
- scan from cricoid to L3 (below celiac)
- PET/CT fusion
- Daily KV imaging
Esoph volumes and fields
4 field plan (AP/PA + RPO/LPO) weighted AP-PA or 3 field
GTV: gross tumor and enlarged nodes – defined by CT, PET, EGD/EUS
CTV: GTV + 3-4 cm sup/inf, 1 cm radial on primary and nodes; respecting anatomic boundaries (cut out of heart, liver, vertebral body)
-ENI: cervical – SCV; proximal – para-esophageal; distal – celiac, lesser curvature (located in gastrohepatic ligament)
PTV: CTV + 1 cm
- if using 4DCT, contour on average
- Can use IMRT (MDACC) to spare the heart and lungs but pay attention to lung V5 and dose to uninvolved stomach (which will be used for anastomosis) – MDACC Lin IJROBP 2012 showed similar acute tox but improved OS w IMRT (due to less cardiac deaths)!
Esoph Constraints
Total Lung
V40<10%
V20<20%
V5<50%
Cord Max 45
Heart
V30<30
Mean <26
Kidney
V18<33%
Liver
Mean<25 Gy
Esoph 5 yr OS
5yr OS: I – 60% II – 30% III – 20% IV - < 5%
Gastric # of cases
~28k cases/yr
2nd leading cause of cancer death worldwide after lung
Stomach EUS layers
EUS 5 layers: alt hyper-hypoechoic
1: superficial mucosa (hyper)
2: deep mucosa (hypo)
3: submucosa
4: muscularis propria
5: subserosa
Gastrectomy
Gastrectomy:
-goal is > 5 cm margin, >15 LN
Total – proximal (cardia, greater curvature, fundus) with roux en y; J tube
Subtotal – distal (antrum/body)
Both are G-J anastomosis:
Billroth I: end to end; J tube
Billroth II: end to side; J tube (below)
- picture
Gastric dissections
Dissections (often D1 in US):
D1: peri-gastric
D2: D1 + celiac + 3 branches (common hepatic, splenic, L gastric)
D3: D2 + PA nodes
Gastric Staging TNM
Close enough to esophagus
T1a: mucosa, lamina propria T1b: submucosa T2: muscularis propria T3: subserosa T4a: serosa (visceral peritoneum) T4b: adjacent structures
Nodal staging has changed: N1: 1-2 N2: 3-6 N3a: 7-15 N3b: >15 Dissect minimum 15
M1: includes involvement of distant nodes (portal, mesenteric, retropancreatic, para-aortic, RP) and positive cytology
Gastric overall stage
IA: add to 1 IB: add to 2 IIA: add to 3 IIB: add to 4 III: all else IV: M1
Intestinal vs. Diffuse
Intestinal vs. Diffuse
Intestinal: H. pylori, better prognosis
Diffuse: familia, linitis plastica, poorly differentiated, signet ring
Gastric Operable clinical T2+ or N+ Management
Operable clinical T2+ or N+: similar to esophagus
1) Periop chemo [chemo x 4 > surgery > chemo x 4]
- chemo = FLOT (5-FU, leucovorin, oxaliplatin, taxotere)
Gastric inoperable
CRT or chemo -> restage -> eval for surgery
Gastric Post-op
If no preop chemo:
R0: T3-4 or N+:
chemo ->CRT->chemo for D1
chemo for D2
R1-2: CRT with 5-FU
If pre-op chemo:
R0: chemo
R1-2: CRT
Gastric Sim/Volumes
- 4D CT simulation with IV and oral contrast
- empty stomach (fast 3 hrs prior)
- supine, arms up, vac-lock bag for immobilization
- fuse pre-op CT
- Daily KV imaging
- Use CBCT if unresectable/pre-op, concern w kidney or heart constraints, or boosting > 45 Gy
- CTV = 1) pre-op stomach/tumor bed/ remnant,
2) surgical clips and anastomoses,
3) nodes (celiac and branches, perigastric, suprapancreatic, porta hepatis, splenic) - if distal – no splenic, add subpyloric
- PTV= CTV+1 cm
Gastric Dose and fields
Dose: R0 45 Gy R1 boost to 50.4 R2 boost to 54 (if boosting, conedown after 45 to GTV + 1.5 cm)
4 fields (AP/PA, RAO/LPO) - mixed energy, weight AP-PA heavily IMRT only if constrained by heart/kidney
Classic 4 field borders are:
AP-PA
sup-inf: T10-L3
lat: 2/3 L diaphragm to cover splenic nodes and 3-4 cm on R vertebral body to cover porta hepatis
LAT: post - split verteb bod, ant abd wall
*Before drawing: ask for location of both kidneys, pre-op stomach, remaining stomach, anastomoses, celiac, porta hepatis, SMA, splenic
ANATOMIC LANDMARKS:
celiac, SMA, Porta hepatis
ANATOMIC LANDMARKS:
Celiac T12
SMA L1
Porta hepatis 2cm to R of T11/L1
Pancreas # cases
54k cases/45k deaths
4th leading cause of cancer deaths
Pancreas H/P
- History: n/v, satiety, pale, greasy stools, jaundice, pain, wgt loss, migratory thrombophlebitis, DVT (trousseau’s sign)
- risk factors: smoking, diabetes, family history (Peutz-Jeghers, BRCA 1/2, HNPCC)
- Physical: jaundice, abd exam, weight loss (common triad) palable gallbladder (Courvoisier’s sign)
FH: BRCA1/2, PeutzJeghers
Panc Imaging
- Imaging:
- CT c/a/p w panc protocol (triphasic: arterial, late arterial, portal venous; thin slice, 3D recon); could get MRI primary as well
- EUS w FNA biopsy –preferred per NCCN; lower risk of seeding than CT guided FNA
- ERCP with stenting if biliary obs
Pancreas lies at L1/L2
Whipple
Whipple:
•Distal stomach (can have pyloric sparing to prevent dumping syndrome)
•Duodenum & prox jejunum
•Head lesion: partial body of pancreas; tail lesion: remove body/tail spleen
•GB, distal CBD
•Anastomosis:
Pancreas → Jejunum
Chole → Jejunum
Gastro → Jejunum
Goal is R0 resection – +margin has poor survival (+RP margin most common)
Panc T/N Stage
T1a: <0.5cm T1b 0.5-1.0cm T1c: >1cm-2cm T2: 2-4 cm T3: >4cm T4: +celiac, SMA, CHA
N1: 1-3 nodes
N2: 4+ nodes
Panc Overall stage
IA, T1: < 2cm IB: T2: >2cm IIA: T3: >4 IIB: N1: 1-3 III: T4 or N2: 4+ Nodes IV: M1
Panc Resectability
Ask about CA, SMA, Common Hepatic, Aorta, SMV/PV
Resectable:
no Arterial contact
<180 Vein without vein contour irregularity
Borderline resectable:
<180 Arterial
Reconstructable Venous contact
Unresectable:
>180 SMA or CA
Unreconstructable SMV/PV
Panc resectable management
Resectable: surgery -> chemo mFOLFIRINOX -> restage -> CRT (if positive margin)
Borderline resectable management:
Borderline: FOLFIRINOX x 8 cycles -> 36/15 chemoRT with capecitabine -> surgery
Cord<36
Kidneys mean <12
Panc Sim
- 4D CT simulation with IV and oral contrast, empty stomach
- scan carina to top of femoral heads
- supine, arms up, arm shuttle
- fuse pre-op CT (PET for definitive)
- Daily KV imaging, CBCT if unresectable/borderline (gross dz)
Panc constraints
RTOG 0848:
Liver: Mean liver <24 Gy
Kidney: V18 <33% and mean < 18 Gy if 2 kidneys.
V18 <15% if 2 kidney.
Small bowel/ Stomach: Max dose ≤54 Gy. V45 <15%
Spinal Cord: Max 0.03 cc ≤45 Gy
Panc OS, MS, LC, DM
Resectable: 3yr OS 30% MS 28 mo LC 70% DM 70%
Borderline: MS 18 mo
Unresectable:
MS 10 months
2yr OS 20%
Panc OS, MS, LC, DM
Resectable: 3yr OS 30% MS 28 mo LC 70% DM 70%
Borderline: MS 18 mo
Unresectable:
MS 10 months
2yr OS 20%
Panc long term side effects
LATE:
ulceration, stricture formation, obstruction, pancreatic exocrine dysfunction
Panc long term side effects
LATE:
ulceration, stricture formation, obstruction, pancreatic exocrine dysfunction
Panc Follow up
Follow-up:
-HP, CA 19-9 and CT q6 months for 2 years, then annually
-Ca 19-9 prognostic – post-op > 90 has low survival (RTOG 9704)
Panc Post op volumes
Post-op: 50.4 Gy (RTOG 0848)
Target: fuse pre-op CT to planning CT
CTV = tumor bed (clips; discuss w/surgeon + op-note) + pancreatico-jejunostomy + nodal groups = P3SC (Peri-pancreatic, Porta Hepatis, P-A, SMA/SMV, celiac)
CTV Target volumes (RTOG atlas) -Celiac: Most proximal 1.5 cm -SMA: Most proximal 3 cm (3 letters) -PV: segment of PV slightly to right of, anterior to and antero-medial to IVC (patient’s right). Contour PV from just above its junction w/SMV and go superior and lateral until center of PV width has moved past R lateral edge of IVC stop. Expand celiac, SMA, PV and PJ by 1 cm
-Aorta: start at most superior of celiac, PJ or PV and then cover down to L2.
Expand off aorta: 2.5 cm to right, 2.5 cm anterior, 1 cm to left and 0.2 cm posterior
-Aortic expansion should be as high as PJ or PV expansion
-If there is a pancreatico-gastrostomy, DO NOT include it (b/c food will go through)
-Crop CTV from liver or stomach
PTV = CTV + 0.5 cm w/daily IGRT
Panc intact volumes
Definitive (Intact): CTV = GTV + 1.5 cm PTV = CTV + 0.5 cm -No elective nodes (95% failures in PTV) -Boost to 54 if meeting normal tissue constraints (can use IMRT)
Cholangiocarcinoma cell type
Cholangiocarcinoma – bile duct epithelium
Klatskin Tumor
Klatskin Tumor – extrahepatic cholangiocarcinoma at confluence of R and L hepatic ducts; best prognosis
Cholangio Workup
Same w/u as pancreas +: -CEA -Abd U/S -Liver MRI -MRCP for EHC (MRCP is non-invasive, while ERCP is) -ERCP or percutaneous biopsy for diagnosis
Intrahepatic Ddx
Intrahepatic Ddx: HCC, liver mets (need biliary epithelium stains to distinguish)
Cholangio T staging
T1a – lamina propia T1b – muscle T2 – connective tissue T3 – serosa, invades adj organs T4 – portal vein, hepatic artery, 2+ adj sites
Bile duct anatomy
*picture
Cholangio treatment when resectable
• Surgery, cholecystectomy with partial hepatectomy -> adjuvant capecitabine (preferred)
CRT is an option as well
Adjuvant chemo: 4-6 months
Cholangio Unresectable
Chemo or
• Neoadjuvant gem/cis -> liver RT (4.5 x 15 = 67.5, avoid conventional fractionation)
- max mucosal pt dose 42
- mean liver = liver-GTV<20Gy
Cholangio survival
5yr OS
GB:
50% for T1N0
MS overall 10 months
IHC:
20-40%
EHC:
30-50%
HCC Risk factors, screening
Risk Factors; Cirrhosis due to Hep B/C, EtOH, hemochromatosis, NASH, PBC, A1AT deficiency; Hep B/C carrier status
Screening: U/S and AFP 12m (positive AFP is >100)
HCC MRI findings
Radiographic features: intense early arterial enhancement and early/rapid washout (rim/capsule that persists)
- ask about vascular invasion
- distant disease
- other lesions
Child Pugh score
Child Pugh score:
Encephalopathy Ascites Albumin INR Bilirubin
HCC Staging
T1 – solitary, no vasc inv T2 – vasc inv, or many small tumors (< 5cm) T3a – many tumors> 5 cm T3b – portal or hepatic vein T4 – adj structures, visceral peritoneum
IVA – N1
IVB – M1
HCC UNOS Criteria
UNOS transplant criteria: one lesion < 5 cm or 3 lesions < 3 cm each, AFP<1000, no macrovascular invasion
Resectable HCC treatment
Resectable:
1) Partial hepatectomy (CPA, no portal htn, 20-40% liver remnant)
2) Liver transplant (Milan criteria: one lesion < 5 cm or 3 lesions < 3 cm each
Unresectable HCC treatment
Eval for transplant, if not a canddiate:
Local therapy(preferred): Ablation Arterial directed SBRT: 50/5: liver 700cc < 20 Gy 30/3: liver 700cc < 17.5 Gy
Chemo: Sorafenib or Atezolizumab/Bevacizumab (Class A only)
HCC Sim
Consider fiducial markers Supine in custom mold, arms up IV and PO contrast, NPO for 4 hours 4D-CT simulation with IV contrast -Fusion to diagnostic MRI or CT -CT tends to overestimate GTV for HCC Respiratory management with breath hold, abdominal compression or gating PPI/H2 blocker given to all patients
HCC volumes and dose
GTV=gross tumor
PTV=ITV+0.5 cm
- CPA: 16 Gy x 3
- CPB: 8 Gy x 5
15 fx to 67.5 – TH
Probably safe to say 50/5 then deescalate to meet constraints
-RTOG – starts at 50 Gy in 5 fractions, de-escalated based on liver dose (700cc and Veffective), lowest is 27.5/5
Volume receiving <20 Gy more than 700cc – 5 fraction.
Volume receiving <15 Gy more than 700cc – 3 fraction.
HCC SBRT constraints
50/5
Cord max 30 Gy
Liver 700 ml < 20 Gy
-small bowel/stomach max 30 Gy
HCC 5yr OS
LC
I – 50-60%
II – 30-40%
III – 10-20%
IV - <10%
LC 90%
RILD
RILD
- 2-8 wks after RT
- fatigue, RUQ pain, ascites, hepatomegaly
- transaminitis
- Veno-occlusive disease leading to hepatocyte atrophy
-non-classic RILD – 30%, bump in CP by 2 points
Rectal Screening
Screening at age > 50 if no fam hx
Rectum anatomy distances
Anal verge: no hair
Anal canal (~4 cm) – dentate line is mid-point
Low rectum: 4-8 cm from verge
Mid rectum: 8-12 cm from verge
High rectum: >12 cm from verge
Superior margin: peritoneal reflection, typically 12-15 cm from verge
Muscle around rectum: puborectalis
Rectal Workup
-Labs: CBC, CMP, LFTs, CEA (normal <3), PSA
- Imaging/Biopsy:
- Proctoscopy – distance from anal verge
- Colonoscopy with biopsy – make sure ileocecal valve visualized (7% synchronous primary)
- EUS or MRI (depth of invasion) – muscularis propria is BLACK – EUS if can’t get MRI
- CT c/a/p w oral and IV contrast
Rectal Surgery
Sugery:
- LAR: low anterior resection for mid-upper lesions -> spares sphincter
- APR: abdominoperioneal resection for low-lying lesions
- TME: sharp dissection of entire mesorectum (peri-rectal fat, pre-sacral space) – reduces positive radial margin rate
All get TME: LR 11 vs 25 %
-4-5 cm margin (can be1-2 cm if low-lying)
Should try to get at least 14 nodes for complete LN evaluation
Rectal LN drainage
LN drainage:
- Proximal: IMA portal (liver mets)
- Distal: int iliac IVC (lung mets)
- Anus/sphincter: inguinals
Rectal TNM
T1: submucousa T2: muscularis T3: serosal, peri-rectal T4a: visceral peritoneum T4b: adjacent organs
N1a: 1 N1b: 2-3 N1c: tumor deposits in subserosa, etc N2a: 4-6 N2b: 7+
M1a: solitary nonregional node or single site (liver, lung, ovary)
M1b: More than one site
M1c: peritoneal mets
Rectal Overall Stage
I: T1-2 N0
IIA: T3N0
IIB: T4aN0
IIC: T4bN0
III: N+
IIIA:T1-2,N1, T1N2a
IIIB:T3-4aN1, T2-3N2a, T1-2, N2b
IIIC: T4aN2a-b,T3N2b, T4bN1-2
IVA: M1a
IVB: M1b
Rectal Stage I treatment
I: T1-T2N0
T1N0: transanal excision -> close f/u
-need FULL THICKNESS WLE
- <3cm, negative margin (> 3 mm), <30% circumference, well-diff (grade 1-2), no LVI, within 8 cm of anal verge (rule of 3s)
-if path shows T2 or bad T1 (deep 1/3 of T1, Grade 3, LVI, or positive margins) -> LF > 15-20% > recommend oncologic surgery (LAR/APR) and if refuse, post-op chemoRT
T2N0: LAR/APR – give risk of lymphatics 20% - if just give chemo, LR 20% (CALGB, Bleday BWH) – continuous tail
-if tumor close to anus, can downstage with chemoRT
Rectal T3 or N+
TNT
Long course or Short Course w/ capecitabine -> 12 weeks FOLFOX - > Restage -> Surgery
Rectal Stage IV with solitary liver or lung met
IV: solitary liver met
CRM clear-FOLFOX x 3 > 5 Gy x 5 > LAR and liver resection
CRM compromised->Folfox x 3-> Long course-> surgery
short course max dose 27.8 to everything
surgery 1 week after RT
Rectal if surgery first
Rectal, if surgery first:
- pT1- observation
- pT2N0: LAR
- pT3-4, or N1+: chemo (FOLFOX) -> chemoRT or in reverse same as TNT
Rectal Volumes and fields
- CTV_45 Gy: all gross disease, entire mesorectum, presacral, internal iliac nodes (external if T4 – such as invasion of prostate)
- CTV_50.4: GTV (or pre-op tumor) + 2.5 cm + presacral LN and mesorectum/sacral hollow
3 field technique: PA-laterals Sup: L5/S1 Inf: 2 cm below tumor Lat: 2cm on brim Post: 1cm behind sacrum and Ant: 1cm behind pubic symphysis
-if invading prostate cover external iliacs
T4:
1) Lats: anterior border is >1 cm anterior to pubic symphysis (to cover external iliacs)
Lateral wedges with posterior heel
Dose:
- 4 pre-op (45 Gy then conedown)
- 4 post-op
- 4 definitive (refuse surgery, not resectable)
Rectal Constraints
Bowel (bag)
V45 < 200 cc
Point dose max 54
Bladder:
max < 50 Gy
V40 < 40
Femoral head:
max < 50 Gy
V45 < 25%
Rectal OS
OS:
I – 90%
II – 80%
III –40- 60%
Rectal Followup
Follow-up:
- NCCN: q3 month H+P exam, CEA if elevated at onset x 2 years, then q6 month for total 5 years, colonoscopy in 1 year and then every 5 years, CT C/A/P annually for 3-5 years
- do NOT do PET/CT
Anal H/P
- History: bleeding, anal discomfort, pruritis, rectal urgency
- sexual history, HIV, HPV (85% anal ca’s) and h/o anal intraepithelial neoplasia.
-Physical: exam with bilateral inguinal exam and proctoscopy. DRE for sphincter tone, mobility, distance from anal verge. If female, gyn exam (with pap!). If male, sperm banking.
Anal Workup
- Labs: CBC, CMP, LFT, LDH, HPV, HIV
- Pap smear
- Imaging:
- Anoscopy with bx of mass
- Colonoscopy (10% synchronus)
- CT c/a/p
- PET/CT for T3/T4 or N+
- EUS or MRI for transanal nodes
- Biopsy:
- FNA of clinically + inguinal nodes
- Only 50% cN+ are malignant
80-90% SCC
HPV 16,18,31,33
Anal Canal anatomy
Anal canal 4 cm long from anal verge to anorectal ring
Dentate line transition from nonkeratinized squamous epithelium to colorectal columnar mucosa
- Above drains to peri-rectal and internal iliac
- Below inguinal, external iliac
Anal margin is 5 cm skin around the anus
Note: mostly a locoregional disease. Distant mets uncommon
Anal TNM
T1: ≤2cm
T2: 2.1-5 cm
T3: > 5cm
T4: adjacent organ invasion (not including rectum, peri-rectal skin, anal sphincter)
N1a: inguinal, mesorectal, internal iliac
N1b: external iliac
N1c: external iliac and N1
M1: mets including PA nodes
Anal Overall Stage
I: T1 N0
IIA: T2 N0
IIB: T3 N0
IIIA: T1-2N1
IIIB: T4N0
IIIC: T3-4N1
IV: M1
T1: ≤2cm
T2: 2.1-5 cm
T3: > 5cm
T4: adjacent organ invasion (not including rectum, peri-rectal skin, anal sphincter)
N1a: inguinal, mesorectal, internal iliac
N1b: external iliac
N1c: external iliac and N1
M1: mets including PA nodes
Anal Stage I-III treatment
Stage I-III
Def chemoRT
-IMRT: T2: 50.4, T3: 54
-Chemo: day 1 and 29
5-FU: 1000mg/m2 (1-4, 29-32)
Mitomycin: 10 mg/m2
Stage IV: Cisplatin/5FU +/- RT
Anal Margin Ca Cancer treatment
Anal margin – must be MARGIN (5cm) – if T1N0 anal canal, do chemoRT
- Well differentiated T1 (<2 cm): WLE with >1 cm margin; if margins inadequate, re-excise or RT+5FU/cape
- T2-T4 or N+: definitive chemoRT as for anal canal; if had surgery then post-op RT similar to anal canal
Adeno: treat like rectal
Anal Sim
- Sim supine, frog-leg, full bladder, vac lack bag. Wire nodes, anal marker.
- Give oral contrast 2 hours prior
- CT from L1 to mid femur
IMRT dose/volumes anal
T2N0: • PTVA (primary tumor): 50.4 Gy in 28 fx of 1.8 Gy • N0 nodes (all nodal regions receives): 42 Gy in 28 fx of 1.5 Gy
T3-4N0 or N+: • PTVA 54 Gy in 30 fx of 1.8 • N0 nodes or uninvolved nodes: 45 Gy in 30 fx of 1.5 Gy • LN ≤ 3 cm + 1 cm: 50.4 Gy in 30 fx of 1.68 Gy • LN > 3 cm + 1 cm: 54 Gy in 30 fx of 1.8 Gy
Nodes:
mesorectum, presacrum, internal iliac, external iliac, inguinal
Aanl Constraints
Small bowel (diff because of MMC):
V30 < 200 cc
Vulva/penis:
Max < 40 Gy
Femoral neck:
Max < 45 Gy
Bladder:
V40<40%
colostomy rate is 10%
Anal OS
5 yr OS: I – 90-95% II – 70-80% III – 40-50% IV - 10%
Anal Side effects
Acute:
- MitoC – low plt (hold if plt<50) and hemolytic uremic syndrome. Check labs 2x/week. Pulm fibrosis
- 5-FU: mucositis and hand-foot syndrome
- RT: skin rxn, proctitis, diarrhea, cystitis
Late:
- 10% risk of femoral neck fracture at 54 Gy
- remember vaginal dilator
- sterility, impotence
Anal follow-up
Follow-up:
8-12 weeks: exam + DRE
If complete remission > DRE every 3-6 months for 5 years, anoscopy every 6-12 months x 3 years, CT chest/abdomen/pelvis annually for 3 years
-note PET/CT not in NCCN
If persistent disease > re-evaluate in 4 weeks, continue at 3 month intervals
-per ACT II, disease may continue to regress even at 26 weeks
-if mass persistent then, biopsy
If progressive disease (biopsy proven) > restage > APR if local, chemo+/- RT if metastatic
-salvage APR: 5-year DFS 40-50%, OS 50-60%
If local recurrence: APR salvage (w colostomy); LC 50%
If groin recurrence: groin dissection
