GI Flashcards
anastamoses after gastrectomy
Distal gastrectomy:
1) biroth i: duodenal stump to stomach (anastamosis at risk)
2) bilroth II: Jejenum to stomach (anastamosis at risk)
3) Roux en y: proximal gastrojejunal, distal jejunojejunal (neither anastamoses are at risk)
complications after gastrectomy
1) dumping syndrome (diarrhea, cramping, reactive hypoglycemia)
2) malabsorption: B12, iron, calcium
Gastric nodal levels
D1: 1-6
1+2) right and left paracardial
3+4) lesser/greater curvature
5: suprapyloric, 6: infrapyloric
D2: 7-11
7: left gastric
8: common hepatic
9: celiac trunk
11: splenic artery
10: splenic hilum
Note: anything else (D3/4 is metastatic).
Should have a D2 resection with gastrectomy and at least 15 nodes removed
HCC workup imaging and what are the characteristic findings for HCC
Usually multiphasic CT first but better evaluation with multiphasic MRI (this is what you should use LiRADS for but I think both work): BOTH MUST BE MULTIPHASIC
o LIRADS: major criteria: THIS IS FOR HEPATOCELLULAR CARCINOMA:
- Arterial hyperenhancement really important, and if like one of these other ones then for sure HCC LIRADS-5
- Non-peripheral washout (on portal venous phase is hypointense)
- Enhancing pseudocapsule in venous phase (≥50% growth in 6 months)
- Threshold growth
o Venous phase is good for metastases: enhance on venous phase
Whipple: what is removed and what are the anastamoses
for pancreatic head tumors, remove head/uncinate process of pancreas, duodenum, proximal jejunum, distal stomach, gallbladder, CBD.
1) pancreaticojejunostomy
2) cholodochojejunostomy (CBD to jejunum)
3) gastrojejunostomy (stomach to jejunum)
Also remove lymph nodes duh
Note: all of these anastamoses are at risk! include in CTV for post-op - LOL which we do not do anymore. But also cover the celiac and SMA vessel and portal vein
common definition of pancreas resectable:
1) not touching CA, SMA, or hepatic artery (aka not touching arteries)
2)not distorting SMV or PV
3) no mets
Note: We just need to know what is resectable because unresectable/borderline will just get the same treatment, +/- surgery
Think (maybe not true): veins have low BP and can be repaired better than arteries
Pancreas: treatment and benefit
1) resectable
2) borderline resectable
3) unresectable
1) surgery -> folfirinox x 6 (5yr OS 40%)
2) folfirinox x 4 -> CRT 50.4/28 with concurrent gemcitabine 40mg/m2 THEN: restage: if resectable and no progression; surgery) (5yr OS 20%): CRT offers survival benefit.
3) folfirinox x 4 -> CRT 50.4/28 with concurrent gemcitabine 40mg/m2 but obviously no resection (MOS 15 months). CRT only improves LC, not survival benefit (LAP07) in unresectable setting: can argue to do chemotherapy alone.
Pancreas: RC case
1) which BW on workup (4)
2) which imaging most useful for planning
3) which chemo are most often given with XRT
4) unresectable. Given pre-op chemo then CRT. What is the CTV? PTV
5) 3 things to do during sim/planning to help with target delineation?
1) CBC, LFTs, CA 19-9, Lipase (if ddx is uncertain), bilirubin if juandiced
2) Staging done. Which single modality of imaging helps most with radiation planning?
Thin Slice Multiphase CT Abdomen with IV contrast (NOT MRI)
3) 5-Fu, gemcitabine
4) CTV = GTV + 1cm, PTV = ITV + 0.5mm (4dCT) otherwise 1cm.
5) CTsim fusion with MRI
CTsim with IV contrast and
oral contrast
4DCT
5Yr OS for resected, unresectable
1) resected: 25%
2) unresectable: 5%
McDonald:
1) Chemo used
2) CTV/PTV
2.5) Alternative q: list 3 anatomical structures which are in-situ within post-op bed CTV
3) 2 benefits from adjuvant treatment
1) Chemo used: 5FU+ LV x 1 -> 5FU/LV with 45Gy/25# -> 5FU/LV x 2
2) CTV includes all of following with 1cm margin: (note: Do 4dCT, PTV has 1cm margin because stomach moves a lot)
- anastamosis
- Gastric remnant
- post-op bed
- loco-regional nodes (D1+D2)
- Include porta hepatis, upper para-aortic nodes
2.5) stomach, duodenum, pancreas, celiac artery, portal vein outside liver
3) improved OS with CRT vs surgery alone, decreased local recurrence with CRT vs surgery alone
OARS: (can say for pancreas, gastsric, esophagus)
- Mean liver dose <30Gy
- Bowel peritoneal contour: V45 < 195cc
- Kidney mean <18Gy (bilateral)
- Spinal cord Dmax <Rx dose (or 50Gy)
- Heart mean <26Gy (for pericarditis)
- Lung (esophagus): V20<30%
GEJ adenocarcinoma with tumor extending into cardia!
1) two most important staging investigations
2) additional investigations
3) 4 potentially curative treatment options with names of chemo:
1) PET, EUS
2) CBCs, LFTs, CT C/A/P, PFTs, lytes, cea, etc.
3)
- ChemoRT -> Sx (carboplatin, cross)
- Definitive CRT: 50/25 with 5-Fu/cisplatin
- FLOTx4-> Sx -> FLOT x 4
- sx -> adjuvant CRT 45/25 with 5Fu/LV
What is in FLOT chemo
5-Fu, leucovorin, oxaliplatin, docetaxel (think: dose-etaxel is the last letter; bc David couldn’t get his last dose)
Pancreas:
1) which vessels are most important in determining resettability
2) OS for not resectable at presentation
3) how do you improve tumor delineation at time of Sim
1) common hepatic artery, celiac axis, SMA, SMV/portal vein
2) 5% (20% for resectable with sx -> chemo)
3) thin slice multiphasic CT with IV contrast, oral contrast, fusion of pre-op imaging, MRI fusion
Esophagus:
1) 3 staging investigations other than imaging
2) 3 treatment doses for RT
3) 5 RX options
4) 5Yr OS
1) Endoscopy, EUS, bronch (note: for others you also want PET/CT, CT CAP, PFTs)
2) 41.4/23, 50/25, 50.4/28
3) CRT -> Sx
Definitive CRT
Surgery -> adjuvant CRT
Definitive EBRT alone
EBRT + brachytherapy
