GI

Question 1

If doing SBRT in 5fx pancrease, what constraints for bowel? Liver? How do you do volumes?

Answer 1

Bowel, stomach: V33Gy<0.5cc, V30Gy<5cc. Use 3mm PRV.
Liver 700cc<15Gy.

GTV: 40/5fx then SIB 25/5fx to at risk vasculature (celiac, SMA).

Question 2

What is the name of the post-op atlas for pancreas?

Answer 2

RTOG 0848 has post-op atlas.

Question 3

T staging for rectal cancer? N stage?

Answer 3

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ, intramucosal carcinoma (involvement of lamina propria with no extension through muscularis mucosae)

T1 Tumor invades the submucosa (through the muscularis mucosa but not into the muscularis propria)

T2 Tumor invades the muscularis propria

T3 Tumor invades through the muscularis propria into pericolorectal tissues

T4a Tumor invades* through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
T4b Tumor directly invades* or adheres** to adjacent organs or structures

(N stage same as pancreas)
N1: 1-3 nodes
N2: >=4-6 nodes

Question 4

N staging for rectal cancer?

Answer 4

○ N1a: 1 LN
○ N1b: 2-3
○ N1c: tumor deposits
○ N2a: 4-6
○ N2b: 7 or more LNs

Question 5

BCLC Staging for HCC?

Answer 5

Question 6

For anal cancer what dose to primary and nodes:

1) T1N1 (<3cm)
2) T3N0
3) T2N2 (>3cm)
4) T2N0

Answer 6

1) 54/30_p, 50.4/30_n, and 45/30_LNs
2) 54/30_p and 45/30_LNs
3) 54/30_p, 54/30_n, and 45/30_LNs
4) 50.4/28_p and 42/28_LNs

Question 7

Anal canal, anal verge, anal margin?

Answer 7

The anal canal is 4 cm long and extends proximally from anal verge (palpable junction between non–hair-bearing and hair-bearing squamous epithelium) to dentate line (line between simple columnar epithelium proximally to stratified squamous epithelium distally). Anal margin is skin within 5 cm of anal verge. Canal is surrounded by internal and external anal sphincter.

Question 8

Which anal cancer patients can get WLE?

Answer 8

T1N0 well or moderatley differentiated.

Question 9

Outcomes in anal cancer? 5yr OS and LRF?

Answer 9

Question 10

What dose contraints for anal cancer? Bowel, femoral heads, genitalia?

Answer 10

Question 11

How do you f/u anal cancer after chemoRT?

Answer 11

DRE and anoscopy 8-12wks after. If persistant disease, MRI/PET at 4wks then every 3 months until CR or progression.

Once CR:
* Inguinal node palpation every 3–6 mo for 5y
* Chest/abdomen/pelvis CT with contrast or chest CT without contrast and abdomen/pelvis MRI with contrast annually for 3 y
* FDG-PET/CT is not
indicated

Question 12

F/u after CR for anal cancer.

Answer 12

DRE 3-6 months, Inguial node eval 3-6 months, Anoscopy 6-12 months, CT TAP and MRI a/p annually for 3 years.

Question 13

Colonoscopy screening guidelines?

Answer 13

Average Risk (USPSTF): Broad screening options (stool tests, colonoscopy), starts at 45, less frequent for colonoscopy (10 years).

IBD (ACG): Colonoscopy only, starts 8–10 years post-diagnosis, more frequent (1–5 years), focuses on dysplasia surveillance due to chronic inflammation

Question 14

HCC cancer staging? 5cm solitary tumor?

Answer 14

Question 15

Liver contraint for 50/5 to liver met or HCC?

Answer 15

MLD <13Gy

Question 16

Esophagus contraints for lungs, bowel, heart, kidney, liver, stomach?

Answer 16

Lungs: V40<10, V20<20, V10<40, mean <20
Bowel: Max <54Gy, V45<195cc
Heart: V30<30, mean <30
Kidney: V20<33%, mean <18Gy
Liver: V30<33%, mean <25
Somach: mean <45Gy, max <54Gy

Question 17

What SBRT contraints for liver?

Answer 17

Question 18

What is the treatment paradigm for T1N0 and T2N0 rectal cancer?

Answer 18

T1: transanal excision –> obs; can do if <3cm, <30% circumference, within 8cm verge, G1-2, LVSI-, margin >3mm.

T2: LAR/APR + TME –> obs

Question 19

Follow up schedule for rectal?

Answer 19

HP 3-6 months for 2y and then q6months for 5y.
CEA every 3-6 months.
CT-TAP q6-12 months for 5yrs.
Colonoscopy in 1 year, then 3yr, then 5yr (Villous polyp, polyp >1 cm, or high-grade dysplasia then repeat in 1yr).

Question 20

How long after TNT in OPRA were patients re-staged? How? Describe WW approach?

Answer 20

8-12 weeks
DRE, endoscopy, MRI rectum and CT TAP
WW: DRE & Flex sig q4 mos + MRI q 6mos for first 2 year
DRE & Flex sig q6 mos for up + MRI q12 mos for 3 years

Question 21

What follow up for anal cancer?

Answer 21

DRE+anosocpy to assess response at 8 – 12 weeks after completion –> monthly until CR is achieved

Once CR is achieved:
DRE + inguinal node exam q3-6 months for 5 yrs.
Anoscopy q6-12 months for 1st 3 yrs
CT TAP q1 yr for 1st 3 yrs

Question 22

What is the SOC for unresectable HCC?

Answer 22

Atezo/Bevacuzimab or Durvalumab/Tremilimumab

Question 23

5fx and 15fx dose contraints for HCC and Cholangio.

Answer 23

40-50/5fx, Child Pugh A: mean liver <13Gy and 700cc<15; stomach, duo, bowel <32Gy max.

67.5Gy/15fx, Child Pugh A: Mean liver <20Gy; Dmax <42Gy stomach, duo/bowel <45Gy.

Question 24

How would you treat unresectable cholangio? Add anything if extrahepatic?

Answer 24

Durva + gem + cis

67.5Gy/15 if >1cm from bowel and 75/25 if <1cm. Use 37.5/15fx to elective volume

Question 25

When can anal cancer get WLE?

Answer 25

T1N0, anal margin (not in anal canal), can get >1cm margin, not high grade, no LVI/PNI

Question 26

What's the follow up for anal cancer?

Answer 26

DRE every 3–6 mo for 5 y * Inguinal node palpation every 3–6 mo for 5 y * Anoscopy every 6–12 mo x 3 y * Chest/abdomen/pelvis CT with contrast or chest CT without contrast and abdomen/pelvis MRI with contrast annually for 3 y (stage II–III)

Question 27

Can you get a PET scan for rectal cancer?

Answer 27

NO! Not indicated.

Question 28

Which gastric cancer pts need RT?

Answer 28

If D1 dissection and pT3/4 or N+, or R1/2. Or if pT2 and poorly differentiated or higher grade cancer, lymphovascular invasion (LVI), neural invasion, or <50 years of age or patients who did not undergo D2 lymph node dissection.

Question 29

NCCN resectable criteria for pancreas?

Answer 29

Question 30

Who is elegible for liver transplant?

Answer 30

* Patients meeting the UNOS criteria ([AFP level ≤1000 ng/mL and single lesion ≥2 cm and ≤5 cm, or 2 or 3 lesions ≥1 cm and ≤3 cm]

Question 31

What areas should be covered in a post-op gastric case?

Answer 31

1) Tumor/gastric bed, anastomosis/stumps, and peritenent nodal groups.

Question 32

How do you treat esophageal T1a and superficial T1b?

Answer 32

ER + ablation.

Question 33

Who can get esphagetcomy alone?

Answer 33

T2, well diff, <3cm, no LVI

Question 34

Describe beam setup and weighting for 3D rectal plan.

Answer 34

2 lateral and PA, with lateral wedges heels posterior. Weighted 2:1:1 (posterior to lats)

Question 35

Small bowel constraints for rectal cancer?

Answer 35

Small bowel max point dose should be limited to Dmax 55 Gy, V45 Gy should be ≤150 cc, or V50 should be ≤30 cc for individual small bowel loops

Question 36

What rectal cancer patients can get a transanal local excision?

Answer 36

<30% circumference of bowel; <3 cm in size; clear surgical margin (>3 mm); mobile, nonfixed; within 8 cm of anal verge; T1 only; endoscopically removed polyp with cancer or indeterminate pathology; no lymphovascular invasion or PNI; well to moderately differentiated; no evidence of lymphadenopathy on pretreatment imaging.

Question 37

Dose constraints for 5fx rectal?

Answer 37

Bowel (maximum dose < 25 Gy, V20Gy < 50 cc); bladder and femoral head V25 <15%.

Question 38

Treatment for liver or lung only mets in rectal cancer?

Answer 38

FOLFOX-->Restage--> Short course RT--> staged or synchronous resection of mets and and TME.

Question 39

What surgery is done for hilar cholangio tumor? Then what after that?

Answer 39

Adj gem/cap x 4 cycles followed by adj RT with concurrent cape. Treat to 45/25 with tumor bed boost to 55Gy if R1.

Question 40

What are the criteria for RILD?

Answer 40

Hepatomegaly, anicertic ascites, alk phos elevation.

Question 41

What is the workup for gastric cancer?

Answer 41

CBC, CMP, H. pylori, EGD/EUS, Diagnostic laparoscopy for peritoneal implants/cytology, PET or CT TAP.

Question 42

When do you need adj chemoRT for gastric cancer?

Answer 42

I) Surgery shows pT2 and high-risk features include poorly differentiated or higher grade cancer, lymphovascular invasion (LVI), neural invasion, or <50 years of age or patients who did not undergo D2 lymph node dissection. II) Surgery shows pT3-4 or N+, then Fluoropyrimidine (fluorouracil or capecitabine) then fluoropyrimidine-based chemoradiation then fluoropyrimidine (fluorouracil or capecitabine) if less than a D2 dissection. III) R1 or R2 then chemoRT.

Question 43

What are components of LIRADS 5?

Answer 43

Arterial phase hyperenhancement (APHE) Washout on portal venous phase Size > 1cm Enhancing venous pseudo-capsule Growth >50% in <6 months

Question 44

Review Barcelona Clinic Liver Cancer Staging

Answer 44

Question 45

F/u after SBRT for HCC

Answer 45

Imaging and AFP q3-6 months for 2y, then every 6 mo

Question 46

What dose constraints for 36/15fx preopanc?

Answer 46

Bowel max 42Gy, kidney mean <18, V18<33%, liver mean <24Gy

Question 47

Central bile ducts constraint 1.5cm ?

Answer 47

5fx: V40<21cc 15fx: Dmax<70

Question 48

Prospect trial?

Answer 48

PROSPECT Trial: mid-upper rectum, cT2-3, clear MRF 3mm, N0-N1, planned for surgery with LAR. ○ DFS and OS, no different ○ 6c FOLFOX > Sx > 6 cycles of FOLFOX Must have>20% reduction in tumor or CRT