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Rad Onc Oral Boards > GI > Flashcards

GI Flashcards

1
Q

Esoph H/P

A
  • History: dysphagia, odynophagia, wt loss/nutrition, cough, pain, smoking/EtOH, GERD
  • Physical: abdomen, SCV nodes
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2
Q

Workup Esoph

A
  • 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)
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3
Q

Landmarks by distance from incisors:

A

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

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4
Q

Transthoracic (Ivor-Lewis)

A

Transthoracic (Ivor-Lewis) - better for proximal

  • 2 incisions – upper abdominal, right lateral
  • Pro: Oncologic procedure
  • Con: Heartburn, tight proximal margin, pulmonary complications, mediastinal leak
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5
Q

Trans-hiatal surgery

A

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
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6
Q

Esophagus # of cases

A

16,000

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7
Q

Esoph nodal drainage

A

Upper 1/3: sup mediastinum, SCV, cervical;
mid 1/3: either
lower 1/3: lower mediastinum or celiac

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8
Q

Esoph T/N/M stage

A 
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)

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9
Q

Esoph Overall stage

A 
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
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10
Q

Siewart Stages

A

I: +5 to +1 cm
II: +1 to -2 cm
III: -2 to -5 cm

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11
Q

Esoph T1a Management

A

Endoscopic Mucosal Resection +/- ablation

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12
Q

Esoph cT2-T4a, N0-N+ (operable) Management

A

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!!!!

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13
Q

Inoperable T2+ or N+ Esoph Managment

A

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
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14
Q

Cervical esophagus management

A

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
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15
Q

Esoph T1b-T2<3cm management

A

esophagectomy

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16
Q

Esoph Sim

A
  • 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
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17
Q

Esoph volumes and fields

A

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)!
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18
Q

Esoph Constraints

A

Total Lung
V40<10%
V20<20%
V5<50%

Cord Max 45

Heart
V30<30
Mean <26

Kidney
V18<33%

Liver
Mean<25 Gy

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19
Q

Esoph 5 yr OS

A 
5yr OS:
I – 60%
II – 30%
III – 20%
IV - < 5%
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20
Q

Gastric # of cases

A

~28k cases/yr

2nd leading cause of cancer death worldwide after lung

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21
Q

Stomach EUS layers

A

EUS 5 layers: alt hyper-hypoechoic

1: superficial mucosa (hyper)
2: deep mucosa (hypo)
3: submucosa
4: muscularis propria
5: subserosa

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22
Q

Gastrectomy

A

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
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23
Q

Gastric dissections

A

Dissections (often D1 in US):
D1: peri-gastric
D2: D1 + celiac + 3 branches (common hepatic, splenic, L gastric)
D3: D2 + PA nodes

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24
Q

Gastric Staging TNM

A

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

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25
Q

Gastric overall stage

A 
IA: add to 1
IB: add to 2
IIA: add to 3
IIB: add to 4
III: all else
IV: M1
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26
Q

Intestinal vs. Diffuse

A

Intestinal vs. Diffuse
Intestinal: H. pylori, better prognosis
Diffuse: familia, linitis plastica, poorly differentiated, signet ring

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27
Q

Gastric Operable clinical T2+ or N+ Management

A

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)

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28
Q

Gastric inoperable

A

CRT or chemo -> restage -> eval for surgery

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29
Q

Gastric Post-op

A

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

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30
Q

Gastric Sim/Volumes

A
  • 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
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31
Q

Gastric Dose and fields

A 
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

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32
Q

ANATOMIC LANDMARKS:

celiac, SMA, Porta hepatis

A

ANATOMIC LANDMARKS:

Celiac T12
SMA L1
Porta hepatis 2cm to R of T11/L1

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33
Q

Pancreas # cases

A

54k cases/45k deaths

4th leading cause of cancer deaths

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34
Q

Pancreas H/P

A
  • 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

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35
Q

Panc Imaging

A
  • 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

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36
Q

Whipple

A

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)

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37
Q

Panc T/N Stage

A 
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

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38
Q

Panc Overall stage

A 
IA, T1: < 2cm
IB: T2: >2cm
IIA: T3: >4
IIB: N1: 1-3
III: T4 or N2: 4+ Nodes
IV: M1
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39
Q

Panc Resectability

A

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

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40
Q

Panc resectable management

A

Resectable: surgery -> chemo mFOLFIRINOX -> restage -> CRT (if positive margin)

41
Q

Borderline resectable management:

A

Borderline: FOLFIRINOX x 8 cycles -> 36/15 chemoRT with capecitabine -> surgery

Cord<36
Kidneys mean <12

42
Q

Panc Sim

A
  • 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)
43
Q

Panc constraints

A

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

44
Q

Panc OS, MS, LC, DM

A 
Resectable:
3yr OS 30%
MS 28 mo 
LC 70%
DM 70%

Borderline: MS 18 mo

Unresectable:
MS 10 months
2yr OS 20%

45
Q

Panc OS, MS, LC, DM

A 
Resectable:
3yr OS 30%
MS 28 mo 
LC 70%
DM 70%

Borderline: MS 18 mo

Unresectable:
MS 10 months
2yr OS 20%

46
Q

Panc long term side effects

A

LATE:

ulceration, stricture formation, obstruction, pancreatic exocrine dysfunction

47
Q

Panc long term side effects

A

LATE:

ulceration, stricture formation, obstruction, pancreatic exocrine dysfunction

48
Q

Panc Follow up

A

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)

49
Q

Panc Post op volumes

A

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

50
Q

Panc intact volumes

A 
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)
51
Q

Cholangiocarcinoma cell type

A

Cholangiocarcinoma – bile duct epithelium

52
Q

Klatskin Tumor

A

Klatskin Tumor – extrahepatic cholangiocarcinoma at confluence of R and L hepatic ducts; best prognosis

53
Q

Cholangio Workup

A 
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
54
Q

Intrahepatic Ddx

A

Intrahepatic Ddx: HCC, liver mets (need biliary epithelium stains to distinguish)

55
Q

Cholangio T staging

A 
T1a – lamina propia
T1b – muscle
T2 – connective tissue
T3 – serosa, invades adj organs
T4 – portal vein, hepatic artery, 2+ adj sites
56
Q

Bile duct anatomy

A

*picture

57
Q

Cholangio treatment when resectable

A

• Surgery, cholecystectomy with partial hepatectomy -> adjuvant capecitabine (preferred)

CRT is an option as well

Adjuvant chemo: 4-6 months

58
Q

Cholangio Unresectable

A

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
59
Q

Cholangio survival

A

5yr OS
GB:
50% for T1N0
MS overall 10 months

IHC:
20-40%

EHC:
30-50%

60
Q

HCC Risk factors, screening

A

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)

61
Q

HCC MRI findings

A

Radiographic features: intense early arterial enhancement and early/rapid washout (rim/capsule that persists)

  • ask about vascular invasion
  • distant disease
  • other lesions
62
Q

Child Pugh score

A

Child Pugh score:

Encephalopathy
Ascites
Albumin
INR
Bilirubin
63
Q

HCC Staging

A 
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

64
Q

HCC UNOS Criteria

A

UNOS transplant criteria: one lesion < 5 cm or 3 lesions < 3 cm each, AFP<1000, no macrovascular invasion

65
Q

Resectable HCC treatment

A

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

66
Q

Unresectable HCC treatment

A

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)

67
Q

HCC Sim

A 
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
68
Q

HCC volumes and dose

A

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.

69
Q

HCC SBRT constraints

A

50/5

Cord max 30 Gy
Liver 700 ml < 20 Gy
-small bowel/stomach max 30 Gy

70
Q

HCC 5yr OS

LC

A

I – 50-60%
II – 30-40%
III – 10-20%
IV - <10%

LC 90%

71
Q

RILD

A

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

72
Q

Rectal Screening

A

Screening at age > 50 if no fam hx

73
Q

Rectum anatomy distances

A

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

74
Q

Rectal Workup

A

-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
75
Q

Rectal Surgery

A

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

76
Q

Rectal LN drainage

A

LN drainage:

  • Proximal: IMA  portal (liver mets)
  • Distal: int iliac  IVC (lung mets)
  • Anus/sphincter: inguinals
77
Q

Rectal TNM

A 
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

78
Q

Rectal Overall Stage

A

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

79
Q

Rectal Stage I treatment

A

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

80
Q

Rectal T3 or N+

A

TNT

Long course or Short Course w/ capecitabine -> 12 weeks FOLFOX - > Restage -> Surgery

81
Q

Rectal Stage IV with solitary liver or lung met

A

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

82
Q

Rectal if surgery first

A

Rectal, if surgery first:

  • pT1- observation
  • pT2N0: LAR
  • pT3-4, or N1+: chemo (FOLFOX) -> chemoRT or in reverse same as TNT
83
Q

Rectal Volumes and fields

A
  • 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:

  1. 4 pre-op (45 Gy then conedown)
  2. 4 post-op
  3. 4 definitive (refuse surgery, not resectable)
84
Q

Rectal Constraints

A

Bowel (bag)
V45 < 200 cc
Point dose max 54

Bladder:
max < 50 Gy
V40 < 40

Femoral head:
max < 50 Gy
V45 < 25%

85
Q

Rectal OS

A

OS:
I – 90%
II – 80%
III –40- 60%

86
Q

Rectal Followup

A

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
87
Q

Anal H/P

A
  • 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.

88
Q

Anal Workup

A
  • 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

89
Q

Anal Canal anatomy

A

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

90
Q

Anal TNM

A

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

91
Q

Anal Overall Stage

A

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

92
Q

Anal Stage I-III treatment

A 
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

93
Q

Anal Margin Ca Cancer treatment

A

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

94
Q

Anal Sim

A
  • 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
95
Q

IMRT dose/volumes anal

A 
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

96
Q

Aanl Constraints

A

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%

97
Q

Anal OS

A 
5 yr OS:
I – 90-95%
II – 70-80%
III – 40-50%
IV - 10%
98
Q

Anal Side effects

A

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
99
Q

Anal follow-up

A

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

Rad Onc Oral Boards (11 decks)

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