GI Flashcards
Rectal cancer: criteria for transanal excision
<3 cm
<30% circumference
margin >3mm
within 8 cm of anal verge
T1
mobile
grade 1-2
no LVSI or PNI
Anal Cancer: workup
H&P: LN eval, DRE, anal sphincter tone, sexual history, HIV, HPV, IBD history, Gyn exam. Family history
Labs: CBC, HIV if risk factors
Anoscopy/colonoscopy with bx. FNA of inguinal nodes. EUS.
CT chest, CT/MRI of A/P. PET scan not required but can be ordered for treatment delineation
Perianal Cancer: criteria for WLE
T1
well differentiated
>1cm margins
Anal Canal: sup/inf borders
sup: upper border of anal sphincter and puborectalis muscles
inf: anal verge (aka squamous mucocutaneous junction, aka lower edge of anal sphincter)
approximately 3-5cm in length
Perianal region: boundaries
starts at anal verge and includes the perianal skin over a 5cm radius (from the squamous mucocutaneous junction)
Anal canal cancer: criteria for excision
superficially invasive
<3mm basement membrane invasion
horizontal spread <7mm
negative margins
Anal cancer: adjuvant treatment for T1 negative margins
45Gy to anal region and inguinals, +/- chemo
Anal cancer: adjuvant treatment for T1 positive margins
45Gy to anal region and inguinals
boost anal region to 50.4Gy
+/- chemo
Anal cancer: adjuvant treatment for T2
45Gy to anal region and inguinals
boost anal region to 50.4Gy
concurrent chemo
Anal cancer: T1-2N0 definitive radiation dose and fields
42Gy/28fxs with SIB to 50.4Gy, concurrent chemo
CTV 50.4 = GTV plus anal canal with a 2 cm CTV margin, entire mesorectum
CTV 42 = mesorectal, bilateral inguinal, ext, and int iliacs with 7mm margin
PTV is 1cm
Anal cancer: simulation
supine, frog leg, vac loc, oral contrast, full bladder, bead marker at anal verge
Anal cancer: RTOG 0529 constraints small bowel, bladder, femoral heads, and external genitalia
small bowel: V45 < 20cc, Dmax < 50
bladder: V50 < 5%, V35 < 50%
femoral heads: V40 < 5%
external genitalia: V40 < 5%
Anal cancer: T3-4N0 fields and dose
45Gy/30fxs with SIB to 54Gy, concurrent chemo
CTV 54 = GTV plus anal canal with a 2 cm CTV margin, entire mesorectum
CTV 45 = mesorectal, bilateral inguinal, ext, and int iliacs with 7mm margin
PTV is 1cm
Anal cancer: concurrent chemo dosing
capecitabine 825mg/m2 BID M-F
mitomycin 10mg/m2 on day 1 and day 29 or just 12mg/m2 on day 1
5FU 1000mg/m2 daily x 4 days
Anal cancer: 5yr OS for stage I-IV
stage I 80%
stage II 75%
stage III 50%
stage IV 10%
Anal cancer: local control for T1, T2, T3
T1 95%
T2 75%
T3 50%
Anal cancer: N+ fields and dose
54/50.4/45 Gy in 30 fx (1.8/1.68/1.5 daily)
54 to primary and nodal regions with nodes>3 cm
50.4 to nodal regions with nodes<3 cm
45 to negative nodal regions
Anal cancer: considerations for HIV+ patients
Test CD4 and consider treatment de-escalation if CD4 count < 200
May decrease dose to 50Gy or reduce superior field border to bottom of SI joints
Ensure patient is following with ID and is on HAART
Consider concurrent cisplatin instead of mitomycin
Rectal cancer: workup
H&P. Ask about incontinence. Family history, history of IBD, genetic or hereditary disorders
DRE: distance from anal verge, size, circumference, tone. Pelvic exam if female.
Labs: CBC, CMP, CEA.
Colonoscopy, consideration for diversion with colostomy if incontince, EUS or MRI, CT abdomen/pelvis
Rectal cancer: simulation
PRONE, belly board, anal marker, oral contrast two hours before, full bladder
Rectal cancer: classic fields
sup: L5/S1
inf: bottom of obturator foramen or 3 cm below tumor, whichever is more inferior
lat: 2 cm beyond pelvic brim
ant: behind pubic symphysis and 3cm in front of sacral promontory
post: 1 cm behind sacrum
Rectal cancer: concurrent chemotherapy dosing
capecitabine 800mg BID M-F
Rectal cancer: adjuvant chemotherapy
FOLFOX q2wks for 6 months
Rectal cancer: adjuvant radiation dose if positive margin
same dose as neoadjuvant but boost area of positive margin to 59.4Gy
If LAR, 1 cm below anastamosis or rectal stump
If APR, extend inferior border down to scar
Rectal cancer: treatment paradigm with short course radiation
T3-4N0-2 patients
25Gy/5fxs to pelvis without concurrent chemotherapy
surgery 4-8 weeks after radiation (better than 1 week on Stockholm III)
Rectal cancer: outcomes if inoperable or refuses surgery
treat tumor to 60Gy with concurrent chemo
complete response rate is 80%
for patients with complete response, 1yr LR is 16%
Esophageal cancer: workup
H&P. Smoking cessation
Labs: CBC, CMP, liver panel
Imaging: EGD with biopsy, EUS, CT, PET
consider J tube
Esophageal cancer: simulation
supine, wingboard, small amount of oral contrast
Esophageal cancer: fields and dose
CTV 45: primary with 4 cm sup/inf margin and 1 cm radial margin, plus nodes with a 1 cm margin, with volume enlarged to cover celiac if GEJ
CTV 50.4: GTV
PTV: 0.5cm
Esophageal cancer: concurrent chemo dosing
carboplatin AUC 2 weekly
paclitaxel 50mg/m2 weekly
Esophageal cancer: NCCN constraints for lung, heart, liver, stomach
Lung: V20 < 20%, V5 < 50%
Heart: V30 < 25%, mean < 30Gy
Liver: V20 < 30%, mean < 25Gy
Stomach: mean < 30Gy (excluding PTV)
Esophageal cancer: MS and 5yr OS with trimodality treatment
MS 49mo
5yr OS 47%
Gastric cancer: workup
History and physical
Labs: CBC, CMP, liver panel
Upper GI with biopsy and H pylori testing, EUS, CT A/P, consider PET
Functional testing: J tube consult if Kcal <1500, renal perfusion scan (not needed if planning for IMRT)
Gastric cancer: surgical approaches
Subtotal gastrectomy, 5 cm margin on tumor with D2 dissection removing >15 LNs, ex lap to look for peritoneal disease
Total gastrectomy for large or proximal/fundus lesions
Ivor-Lews esophagectomy if tumor at GEJ, Seweirt III
Gastric cancer: simulation
supine, 4DCT, wingboard, empty stomach, small amount of oral contrast
treat daily on empty stomach (clearly, only if subtotal gastrectomy was performed)
Gastric cancer: adjuvant capecitabine dose/schedule
capecitabine 825mg/m2, BID, days 1-14, q28days for one cycle before RT and 2 cycles after RT
capecitabine 825mg/m2 BID M-F during RT
start RT one month after surgery
Gastric cancer: constraints for heart, kidneys, liver, small bowel
heart V40 < 30%
2/3 of one kidney < 20Gy
liver V30 < 60%
small bowel V45 < 20cc, max < 54Gy
Gastric cancer: MS and 5yr OS on MacDonald trial
MS 36mo
5yr OS 44%
Gastric cancer: considerations for follow up
if proximal stomach was removed, supplement with B12, calcium, and iron
Gastric cancer: dose and general targets for T3N0
45Gy/25fxs
T3N0: treat anastomosis, whole stomach (except for GEJ tumors), and perigastric nodes
Gastric cancer: nodal targets for T4 or N+
perigastric, celiac, paraaortic, superior mesenteric, porta hepatic, periesophageal, suprapancreatic, pancreaticoduodenal
only include splenic for tumor in proximal (cardia) or middle (body) location
Gastric cancer: 3D fields
AP/PA FIELD:
sup: top of T9
inf: bottom of L3
left lateral: include two thirds of left diaphragm
right lateral: 4cm lateral to vertebral bodies
LATERAL FIELD:
ant: abdominal wall
post: split vertebral bodies
Pancreatic cancer: workup
H&P
Labs: CBC, CMP, CEA, CA-19-9, amylase, lipase, liver panel
EUS (preferred) with biopsy, CT C/A/P with contrast in 3 phases per pancreatic protocol. Only do ERCP/MRCP if no mass seen. Can consider PET, but not a substitute for high quality CT
Pancreatic cancer: 3 phase CT anatomy
Noncontrast phase: shows calcifications that could otherwise be confused with contrast
Early arterial phase, 20 seconds, shows arterial anatomy
Late arterial/early portal phase, 40 seconds, shows optimal attenuation between enhancing parenchyma and tumor
Late portal/venous phase, 80 seconds, shows lymph nodes, liver mets, peritoneal implants
Pancreatic cancer: simulation
supine, wingboard, abdominal compression, 4DCT, oral contrast, IV contrast
Pancreatic cancer: adjuvant dose and contouring targets
CTV 50.4:
tumor bed + 2cm
PJ, SMA, celiac, protal vein and clips + 1cm
aorta from T11 to L3 + 3cm right, 2cm ant, 1cm left, and 0.2cm post
Pancreatic cancer: adjuvant 3D fields
AP/PA FIELD:
sup: top of T11
inf: bottom of L3
left lateral: 1.5cm lateral to vertebral body
right lateral: 2cm lateral to vertebral bodies
LATERAL FIELD:
ant: 2cm anterior to preop GTV
post: split vertebral bodies
Pancreatic cancer: adjuvant chemo
concurrent capecitabine 825mg/m2 BID
then adjuvant gemcitabine / capecitabine
Pancreatic cancer: 3yr OS, 3yr LF, and MS (RTOG 9704)
3yr OS 30%
3yr LF 30%
MS 21mo
Pancreatic cancer: criteria for borderline resectability
CA < 180
SMA < 180
SMV > 180
PV > 180
contact with CHA
contact with IVC
Borderline resectable pancreatic cancer: treatment paradigm with concurrent radiation
induction FOLFIRINOX or gemcitabine/nab-paclitaxel
scan to assess for progression
concurrent chemoradiation (capecitabine 825mg BID, 50.4Gy)
scan to assess for resectability
surgery if possible
Pancreatic cancer: constraints for stomach, duodenum, small intestine, liver, and kidney
stomach / duodenum / small intestine max dose < 54Gy
liver mean < 25Gy
single kidney D30% < 18Gy
Unresectable pancreatic cancer: MS and LC with chemo/xrt
MS 16 months
LC 45%
(results from LAP 07 which showed LC benefit but no OS benefit)
Liver SBRT (HCC and mets): simulation
supine, arms up, SBRT body fix, abdominal compression, 4DCT, IV contrast in portal venous phase, contour on MIN, fiducials if doing cyberknife
SBRT for liver mets: dose
20Gy/3fxs
50Gy/5fxs if close to critical structures
(1 yr LC 95%)
SBRT for liver mets: constraints for liver, small bowel, cord, and kidney
liver 700cc < 15Gy
small bowel max < 26Gy
cord max < 28Gy
kidney V18 < 66%
hepatocellular carcinoma: workup
History: alcohol abuse, bleeding, esophageal varices, encephalopathy, lactulose, lasix, ascites
Imaging: triple phase MRI liver (CT can also be done) (MRI results should be diagnostic. Bx not needed. Enhances on arterial phase and washout on venous phase), CT abdomen
Labs: AFP, liver labs, hepatitis panel, INR, plt, albumin
Calculate Child Pugh Score (if C, may not be worth treating). Scoring factors include bilirubin, albumin, INR, ascites, encephalophaty
hepatocellular carcinoma: dose
40Gy/5fxs (consider lowering dose if needed)
Cholangiocarcinoma: workup and treatment paradigm
CT/MRI, chest CT, cholangiography, consider CEA and CA 19-9, amylase, lipase, LFTs, EUS
Distal extrahepatic: whipple
For extrahepatic R1/R2 can give RT+4FU OR cis/gem
Intrahepatice R1 give chemoRT.
For intrahepatic R2 give cis/gem category 1, or chemoRT.
For anything unresectable give cis/gem. RT+5FU also an option
Treatment paradigm for extrahepatic cholangiocarcinoma and gallbladder carcinoma on SWOG 0809
surgical resection (pT2-4, N+, or positive margin)
adjuvant induction capecitabine/gemcitabine x 4 cycles
adjuvant concurrent capecitabine with radiation (45Gy with boost to 54-59.4Gy
SWOG 0809 dose and field
CTV 45: tumor bed and portal vein nodes, consider pancreatic and celiac nodes
CTV54-59.4: tumor bed +1.5cm margin
PTV: 0.5 radial, 0.7 sup/inf (if contouring ITV on 4DCT)
SWOG 0809: MS
MS 35mo
Esophagus T1a
invades mucosa (lamina propria or muscularis mucosa)
Esophagus T1b
invades submucosa
Esophagus T2
invades muscularis propria
Esophagus T3
invades adventitia
Esophagus T4a
pleura, pericardium, peritoneum, azgous vein, diagphragm
Esophagus T4b
aorta, vertebral body, airway (unresectable tumor)
Esophagus N1
1-2 regional nodes
Esophagus N2
3-6 regional nodes
Esophagus N3
7 or more regional nodes
Esophageal SCCa Upper Location
cervical esophagus to azygous vein (lower border)
Esophageal SCCa Middle Location
azygous vein to inferior pulmonary vein (lower border)
Esophageal SCCa Lower Location
inferior pulmonary vein to stomach
Esophageal SCCa clinical Stage I
T1N0-1
Esophageal SCCa clinical Stage II
T2N0-1
Esophageal SCCa clinical Stage III
T3 or N2
Esophageal SCCa clinical Stage IVA
T4 or N3
Esophageal SCCa clinical Stage IVB
M1
Esophageal Adeno clincical Stage I
T1N0
Esophageal Adeno clincical Stage IIA
T1N1
Esophageal Adeno clincical Stage IIB
T2N0
Esophageal Adeno clincical Stage III
T2N1 or T3-4aN0-1
Esophageal Adeno clincical Stage IVA
T4b or N2-3
Esophageal Adeno clincical Stage IVB
M1
Esophagus yp Stage I
T0-2N0
Esophagus yp Stage II
T3N0
Esophagus yp Stage IIIA
T0-2N1
Esophagus yp Stage IIIB
T3N1, T0-3N2, T4aN0
Esophagus yp Stage IVA
T4aN1-2, T4b, N3
Esophagus yp Stage IVB
M1
Gastric T1a
invades mucosa (lamina propria or muscularis mucosa)
Gastric T1b
invades submucosa
Gastric T2
invades muscularis propria
Gastric T3
invades subserosal connective tissue
Gastric T4a
invades serosa (visceral peritoneum)
Gastric T4b
invades adjacent structures
Gastric N1
1-2 nodes
Gastric N2
3-6 nodes
Gastric N3a
7-15 nodes
Gastric N3b
16+ nodes
Gastric Clinical Stage I
T1-2N0
Gastric Clinical Stage IIA
T1-2N2-3
Gastric Clinical Stage IIB
T3-4aN0
Gastric Clinical Stage III
T3N+, T4N+
Gastric Clinical Stage IVA
T4b
Gastric Clinical Stage IVB
M1
Gastric Pathological Stage IA
T1N0
Gastric Pathological Stage IB
T1N1, T2N0 (adds to 2)
Gastric Pathological Stage IIA
T1N2, T2N1, T3N0 (adds to 3)
Gastric Pathological Stage IIB
T1N3a, T2N2, T3N1, T4aN0 (adds to 4)
Gastric Pathological Stage IIIA
T2N3a, T3N2, T4aN1-2, T4bN0
Gastric Pathological Stage IIIB
T1-2N3b, T3-4aN3a, T4bN1-2
Gastric Pathological Stage IVC
T3N3b, any T4N3
Gastric Pathological Stage IV
M1
Gastric yp Stage II
adds to 3 or 4 (excluding T4bN0)
Colorectal Tis
invades mucosa (lamina propria or muscularis mucosa)
Colorectal T1
invades submucosa
Colorectal T2
invades muscularis propria
Colorectal T3
invades through muscularis propria into pericolorectal tissue
Colorectal T4a
invades serosa (visceral peritoneum)
Colorectal T4b
invades adjacent structures
Colorectal N1a
1 node
Colorectal N1b
2-3 nodes
Colorectal N1c
negative nodes with tumor deposits in the subserosa, mesentery, or perirectal/mesorectal tissues
Colorectal N2a
4-6 nodes
Colorectal N2b
7+ nodes
Colorectal M1a
metastasis to one site without peritoneal metastasis
Colorectal M1b
metastasis to two or more sites without peritoneal metastasis
Colorectal M1c
peritoneal metastasis
Colorectal Stage I
T1-2N0
Colorectal Stage IIA
T3N0
Colorectal Stage IIB
T4aN0
Colorectal Stage IIC
T4bN0
Colorectal Stage IIIA
T1-2N1, T1N2
Colorectal Stage IIIB
T3-4aN1, T2-3N2a, T1-2N2b
Colorectal Stage IIIC
T4aN2a, T3-4aN2b, T4bN+
Anus T1
<2cm
Anus T2
2-5cm
Anus T3
>5cm
Anus T4
invading adjacent organ
Anus N1a
inguinal, mesorectal, or internal iliac nodes
Anus N1b
external iliac nodes
Anus N1c
external iliac nodes AND inguinal/mesorectal/internal iliac
Anus Stage I
T1N0
Anus Stage IIA
T2N0
Anus Stage IIB
T3N0
Anus Stage IIIA
T1-2N1
Anus Stage IIIB
T4N0
Anus Stage IIIC
T3-4N1
Liver T1a
solitary tumor <2cm
Liver T1b
solitary tumor >2cm without vascular invasion
Liver T2
solitary tumor >2cm with vascular invasion or multiple tumors <5cm
Liver T3
mulitple tumors with one >5cm
Liver T4
major branch of portal vein or hepatic vein, adjacent organs (excluding gallbladder), perforation of visceral peritoneum
Liver N1
positive node(s)
Liver Stage IA
T1a
Liver Stage IB
T1b
Liver Stage II
T2
Liver Stage IIIA
T3
Liver Stage IIIB
T4
Liver Stage IVA
N1
Liver Stage IVB
M1
Intrahepatic Bile Duct T1a
solitary tumor <5cm without vascular invasion
Intrahepatic Bile Duct T1b
solitary tumor >5cm without vascular invasion
Intrahepatic Bile Duct T2
solitary tumor with intrahepatic vascular invasion or multiple tumors
Intrahepatic Bile Duct T3
perforating visceral peritoneum
Intrahepatic Bile Duct T4
local extrahepatic structures
Intrahepatic Bile Duct N1
positive node(s)
Intrahepatic Bile Duct Stage IA
T1a
Intrahepatic Bile Duct Stage IB
T1b
Intrahepatic Bile Duct Stage II
T2
Intrahepatic Bile Duct Stage IIIA
T3
Intrahepatic Bile Duct Stage IIIB
T4 or N1
Intrahepatic Bile Duct Stage IV
M1
Gallbladder T1a
invades lamina propria
Gallbladder T1b
invades muscular layer
Gallbladder T2a
invades perimuscular connective tissue on peritoneal side
Gallbladder T2b
invades perimuscular connective tissue on hepatic side
Gallbladder T3
serosa (visceral peritoneum), liver, and/or one other structure
Gallbladder T4
main portal vein, hepatic artery, or two or more extrahepatic structures
Gallbladder N1
1-3 nodes
Gallbladder N2
4+ nodes
Gallbladder Stage I
T1
Gallbladder Stage IIA
T2a
Gallbladder Stage IIB
T2b
Gallbladder Stage IIIA
T3
Gallbladder Stage IIIB
N1
Gallbladder Stage IVA
T4
Gallbladder Stage IVB
N2 or M1
Distal bile duct T2
tumor invades bile duct wall 5-12mm
Distal bile duct T4
celiac axis, SMA, common hepatic artery
Distal bile duct N2
4+ regional nodes
