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Rad Onc Oral Boards Quick > GI > Flashcards

GI Flashcards

1
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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2
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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3
Q

Esoph T1a Management

A

Endoscopic Mucosal Resection +/- ablation

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4
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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5
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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6
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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7
Q

Esoph T1b-T2<3cm management

A

esophagectomy

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8
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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9
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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10
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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11
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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12
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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13
Q

Panc resectable management

A

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

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14
Q

Borderline resectable management:

A

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

Cord<36
Kidneys mean <12

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15
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

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16
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

17
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)

18
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

19
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

20
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
21
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

22
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

23
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)

24
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.

25
Q

HCC SBRT constraints

A

50/5

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

26
Q

Rectal Screening

A

Screening at age > 50 if no fam hx

27
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

28
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

29
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

30
Q

Rectal T3 or N+

A

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

31
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

32
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)
33
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%

34
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

35
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

36
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

37
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

38
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

39
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%*

Rad Onc Oral Boards Quick (11 decks)

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