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Oral Boards > GI > Flashcards

GI Flashcards

1
Q

Rectal cancer: criteria for transanal excision

A

<3 cm

<30% circumference

margin >3mm

within 8 cm of anal verge

T1

mobile

grade 1-2

no LVSI or PNI

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2
Q

Anal Cancer: workup

A

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

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3
Q

Perianal Cancer: criteria for WLE

A

T1

well differentiated

>1cm margins

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4
Q

Anal Canal: sup/inf borders

A

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

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5
Q

Perianal region: boundaries

A

starts at anal verge and includes the perianal skin over a 5cm radius (from the squamous mucocutaneous junction)

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6
Q

Anal canal cancer: criteria for excision

A

superficially invasive

<3mm basement membrane invasion

horizontal spread <7mm

negative margins

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7
Q

Anal cancer: adjuvant treatment for T1 negative margins

A

45Gy to anal region and inguinals, +/- chemo

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8
Q

Anal cancer: adjuvant treatment for T1 positive margins

A

45Gy to anal region and inguinals

boost anal region to 50.4Gy

+/- chemo

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9
Q

Anal cancer: adjuvant treatment for T2

A

45Gy to anal region and inguinals

boost anal region to 50.4Gy

concurrent chemo

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10
Q

Anal cancer: T1-2N0 definitive radiation dose and fields

A

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

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11
Q

Anal cancer: simulation

A

supine, frog leg, vac loc, oral contrast, full bladder, bead marker at anal verge

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12
Q

Anal cancer: RTOG 0529 constraints small bowel, bladder, femoral heads, and external genitalia

A

small bowel: V45 < 20cc, Dmax < 50

bladder: V50 < 5%, V35 < 50%

femoral heads: V40 < 5%

external genitalia: V40 < 5%

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13
Q

Anal cancer: T3-4N0 fields and dose

A

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

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14
Q

Anal cancer: concurrent chemo dosing

A

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

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15
Q

Anal cancer: 5yr OS for stage I-IV

A

stage I 80%

stage II 75%

stage III 50%

stage IV 10%

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16
Q

Anal cancer: local control for T1, T2, T3

A

T1 95%

T2 75%

T3 50%

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17
Q

Anal cancer: N+ fields and dose

A

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

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18
Q

Anal cancer: considerations for HIV+ patients

A

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

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19
Q

Rectal cancer: workup

A

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

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20
Q

Rectal cancer: simulation

A

PRONE, belly board, anal marker, oral contrast two hours before, full bladder

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21
Q

Rectal cancer: classic fields

A

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

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22
Q

Rectal cancer: concurrent chemotherapy dosing

A

capecitabine 800mg BID M-F

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23
Q

Rectal cancer: adjuvant chemotherapy

A

FOLFOX q2wks for 6 months

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24
Q

Rectal cancer: adjuvant radiation dose if positive margin

A

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

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25
Q

Rectal cancer: treatment paradigm with short course radiation

A

T3-4N0-2 patients

25Gy/5fxs to pelvis without concurrent chemotherapy

surgery 4-8 weeks after radiation (better than 1 week on Stockholm III)

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26
Q

Rectal cancer: outcomes if inoperable or refuses surgery

A

treat tumor to 60Gy with concurrent chemo

complete response rate is 80%

for patients with complete response, 1yr LR is 16%

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27
Q

Esophageal cancer: workup

A

H&P. Smoking cessation

Labs: CBC, CMP, liver panel

Imaging: EGD with biopsy, EUS, CT, PET

consider J tube

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28
Q

Esophageal cancer: simulation

A

supine, wingboard, small amount of oral contrast

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29
Q

Esophageal cancer: fields and dose

A

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

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30
Q

Esophageal cancer: concurrent chemo dosing

A

carboplatin AUC 2 weekly

paclitaxel 50mg/m2 weekly

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31
Q

Esophageal cancer: NCCN constraints for lung, heart, liver, stomach

A

Lung: V20 < 20%, V5 < 50%

Heart: V30 < 25%, mean < 30Gy

Liver: V20 < 30%, mean < 25Gy

Stomach: mean < 30Gy (excluding PTV)

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32
Q

Esophageal cancer: MS and 5yr OS with trimodality treatment

A

MS 49mo

5yr OS 47%

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33
Q

Gastric cancer: workup

A

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)

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34
Q

Gastric cancer: surgical approaches

A

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

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35
Q

Gastric cancer: simulation

A

supine, 4DCT, wingboard, empty stomach, small amount of oral contrast

treat daily on empty stomach (clearly, only if subtotal gastrectomy was performed)

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36
Q

Gastric cancer: adjuvant capecitabine dose/schedule

A

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

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37
Q

Gastric cancer: constraints for heart, kidneys, liver, small bowel

A

heart V40 < 30%

2/3 of one kidney < 20Gy

liver V30 < 60%

small bowel V45 < 20cc, max < 54Gy

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38
Q

Gastric cancer: MS and 5yr OS on MacDonald trial

A

MS 36mo

5yr OS 44%

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39
Q

Gastric cancer: considerations for follow up

A

if proximal stomach was removed, supplement with B12, calcium, and iron

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40
Q

Gastric cancer: dose and general targets for T3N0

A

45Gy/25fxs

T3N0: treat anastomosis, whole stomach (except for GEJ tumors), and perigastric nodes

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41
Q

Gastric cancer: nodal targets for T4 or N+

A

perigastric, celiac, paraaortic, superior mesenteric, porta hepatic, periesophageal, suprapancreatic, pancreaticoduodenal

only include splenic for tumor in proximal (cardia) or middle (body) location

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42
Q

Gastric cancer: 3D fields

A

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

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43
Q

Pancreatic cancer: workup

A

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

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44
Q

Pancreatic cancer: 3 phase CT anatomy

A

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

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45
Q

Pancreatic cancer: simulation

A

supine, wingboard, abdominal compression, 4DCT, oral contrast, IV contrast

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46
Q

Pancreatic cancer: adjuvant dose and contouring targets

A

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

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47
Q

Pancreatic cancer: adjuvant 3D fields

A

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

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48
Q

Pancreatic cancer: adjuvant chemo

A

concurrent capecitabine 825mg/m2 BID

then adjuvant gemcitabine / capecitabine

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49
Q

Pancreatic cancer: 3yr OS, 3yr LF, and MS (RTOG 9704)

A

3yr OS 30%

3yr LF 30%

MS 21mo

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50
Q

Pancreatic cancer: criteria for borderline resectability

A

CA < 180

SMA < 180

SMV > 180

PV > 180

contact with CHA

contact with IVC

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51
Q

Borderline resectable pancreatic cancer: treatment paradigm with concurrent radiation

A

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

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52
Q

Pancreatic cancer: constraints for stomach, duodenum, small intestine, liver, and kidney

A

stomach / duodenum / small intestine max dose < 54Gy

liver mean < 25Gy

single kidney D30% < 18Gy

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53
Q

Unresectable pancreatic cancer: MS and LC with chemo/xrt

A

MS 16 months

LC 45%

(results from LAP 07 which showed LC benefit but no OS benefit)

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54
Q

Liver SBRT (HCC and mets): simulation

A

supine, arms up, SBRT body fix, abdominal compression, 4DCT, IV contrast in portal venous phase, contour on MIN, fiducials if doing cyberknife

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55
Q

SBRT for liver mets: dose

A

20Gy/3fxs

50Gy/5fxs if close to critical structures

(1 yr LC 95%)

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56
Q

SBRT for liver mets: constraints for liver, small bowel, cord, and kidney

A

liver 700cc < 15Gy

small bowel max < 26Gy

cord max < 28Gy

kidney V18 < 66%

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57
Q

hepatocellular carcinoma: workup

A

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

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58
Q

hepatocellular carcinoma: dose

A

40Gy/5fxs (consider lowering dose if needed)

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59
Q

Cholangiocarcinoma: workup and treatment paradigm

A

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

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60
Q

Treatment paradigm for extrahepatic cholangiocarcinoma and gallbladder carcinoma on SWOG 0809

A

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

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61
Q

SWOG 0809 dose and field

A

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)

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62
Q

SWOG 0809: MS

A

MS 35mo

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63
Q

Esophagus T1a

A

invades mucosa (lamina propria or muscularis mucosa)

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64
Q

Esophagus T1b

A

invades submucosa

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65
Q

Esophagus T2

A

invades muscularis propria

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66
Q

Esophagus T3

A

invades adventitia

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67
Q

Esophagus T4a

A

pleura, pericardium, peritoneum, azgous vein, diagphragm

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68
Q

Esophagus T4b

A

aorta, vertebral body, airway (unresectable tumor)

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69
Q

Esophagus N1

A

1-2 regional nodes

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70
Q

Esophagus N2

A

3-6 regional nodes

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71
Q

Esophagus N3

A

7 or more regional nodes

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72
Q

Esophageal SCCa Upper Location

A

cervical esophagus to azygous vein (lower border)

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73
Q

Esophageal SCCa Middle Location

A

azygous vein to inferior pulmonary vein (lower border)

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74
Q

Esophageal SCCa Lower Location

A

inferior pulmonary vein to stomach

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75
Q

Esophageal SCCa clinical Stage I

A

T1N0-1

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76
Q

Esophageal SCCa clinical Stage II

A

T2N0-1

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77
Q

Esophageal SCCa clinical Stage III

A

T3 or N2

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78
Q

Esophageal SCCa clinical Stage IVA

A

T4 or N3

79
Q

Esophageal SCCa clinical Stage IVB

A

M1

80
Q

Esophageal Adeno clincical Stage I

A

T1N0

81
Q

Esophageal Adeno clincical Stage IIA

A

T1N1

82
Q

Esophageal Adeno clincical Stage IIB

A

T2N0

83
Q

Esophageal Adeno clincical Stage III

A

T2N1 or T3-4aN0-1

84
Q

Esophageal Adeno clincical Stage IVA

A

T4b or N2-3

85
Q

Esophageal Adeno clincical Stage IVB

A

M1

86
Q

Esophagus yp Stage I

A

T0-2N0

87
Q

Esophagus yp Stage II

A

T3N0

88
Q

Esophagus yp Stage IIIA

A

T0-2N1

89
Q

Esophagus yp Stage IIIB

A

T3N1, T0-3N2, T4aN0

90
Q

Esophagus yp Stage IVA

A

T4aN1-2, T4b, N3

91
Q

Esophagus yp Stage IVB

A

M1

92
Q

Gastric T1a

A

invades mucosa (lamina propria or muscularis mucosa)

93
Q

Gastric T1b

A

invades submucosa

94
Q

Gastric T2

A

invades muscularis propria

95
Q

Gastric T3

A

invades subserosal connective tissue

96
Q

Gastric T4a

A

invades serosa (visceral peritoneum)

97
Q

Gastric T4b

A

invades adjacent structures

98
Q

Gastric N1

A

1-2 nodes

99
Q

Gastric N2

A

3-6 nodes

100
Q

Gastric N3a

A

7-15 nodes

101
Q

Gastric N3b

A

16+ nodes

102
Q

Gastric Clinical Stage I

A

T1-2N0

103
Q

Gastric Clinical Stage IIA

A

T1-2N2-3

104
Q

Gastric Clinical Stage IIB

A

T3-4aN0

105
Q

Gastric Clinical Stage III

A

T3N+, T4N+

106
Q

Gastric Clinical Stage IVA

A

T4b

107
Q

Gastric Clinical Stage IVB

A

M1

108
Q

Gastric Pathological Stage IA

A

T1N0

109
Q

Gastric Pathological Stage IB

A

T1N1, T2N0 (adds to 2)

110
Q

Gastric Pathological Stage IIA

A

T1N2, T2N1, T3N0 (adds to 3)

111
Q

Gastric Pathological Stage IIB

A

T1N3a, T2N2, T3N1, T4aN0 (adds to 4)

112
Q

Gastric Pathological Stage IIIA

A

T2N3a, T3N2, T4aN1-2, T4bN0

113
Q

Gastric Pathological Stage IIIB

A

T1-2N3b, T3-4aN3a, T4bN1-2

114
Q

Gastric Pathological Stage IVC

A

T3N3b, any T4N3

115
Q

Gastric Pathological Stage IV

A

M1

116
Q

Gastric yp Stage II

A

adds to 3 or 4 (excluding T4bN0)

117
Q

Colorectal Tis

A

invades mucosa (lamina propria or muscularis mucosa)

118
Q

Colorectal T1

A

invades submucosa

119
Q

Colorectal T2

A

invades muscularis propria

120
Q

Colorectal T3

A

invades through muscularis propria into pericolorectal tissue

121
Q

Colorectal T4a

A

invades serosa (visceral peritoneum)

122
Q

Colorectal T4b

A

invades adjacent structures

123
Q

Colorectal N1a

A

1 node

124
Q

Colorectal N1b

A

2-3 nodes

125
Q

Colorectal N1c

A

negative nodes with tumor deposits in the subserosa, mesentery, or perirectal/mesorectal tissues

126
Q

Colorectal N2a

A

4-6 nodes

127
Q

Colorectal N2b

A

7+ nodes

128
Q

Colorectal M1a

A

metastasis to one site without peritoneal metastasis

129
Q

Colorectal M1b

A

metastasis to two or more sites without peritoneal metastasis

130
Q

Colorectal M1c

A

peritoneal metastasis

131
Q

Colorectal Stage I

A

T1-2N0

132
Q

Colorectal Stage IIA

A

T3N0

133
Q

Colorectal Stage IIB

A

T4aN0

134
Q

Colorectal Stage IIC

A

T4bN0

135
Q

Colorectal Stage IIIA

A

T1-2N1, T1N2

136
Q

Colorectal Stage IIIB

A

T3-4aN1, T2-3N2a, T1-2N2b

137
Q

Colorectal Stage IIIC

A

T4aN2a, T3-4aN2b, T4bN+

138
Q

Anus T1

A

<2cm

139
Q

Anus T2

A

2-5cm

140
Q

Anus T3

A

>5cm

141
Q

Anus T4

A

invading adjacent organ

142
Q

Anus N1a

A

inguinal, mesorectal, or internal iliac nodes

143
Q

Anus N1b

A

external iliac nodes

144
Q

Anus N1c

A

external iliac nodes AND inguinal/mesorectal/internal iliac

145
Q

Anus Stage I

A

T1N0

146
Q

Anus Stage IIA

A

T2N0

147
Q

Anus Stage IIB

A

T3N0

148
Q

Anus Stage IIIA

A

T1-2N1

149
Q

Anus Stage IIIB

A

T4N0

150
Q

Anus Stage IIIC

A

T3-4N1

151
Q

Liver T1a

A

solitary tumor <2cm

152
Q

Liver T1b

A

solitary tumor >2cm without vascular invasion

153
Q

Liver T2

A

solitary tumor >2cm with vascular invasion or multiple tumors <5cm

154
Q

Liver T3

A

mulitple tumors with one >5cm

155
Q

Liver T4

A

major branch of portal vein or hepatic vein, adjacent organs (excluding gallbladder), perforation of visceral peritoneum

156
Q

Liver N1

A

positive node(s)

157
Q

Liver Stage IA

A

T1a

158
Q

Liver Stage IB

A

T1b

159
Q

Liver Stage II

A

T2

160
Q

Liver Stage IIIA

A

T3

161
Q

Liver Stage IIIB

A

T4

162
Q

Liver Stage IVA

A

N1

163
Q

Liver Stage IVB

A

M1

164
Q

Intrahepatic Bile Duct T1a

A

solitary tumor <5cm without vascular invasion

165
Q

Intrahepatic Bile Duct T1b

A

solitary tumor >5cm without vascular invasion

166
Q

Intrahepatic Bile Duct T2

A

solitary tumor with intrahepatic vascular invasion or multiple tumors

167
Q

Intrahepatic Bile Duct T3

A

perforating visceral peritoneum

168
Q

Intrahepatic Bile Duct T4

A

local extrahepatic structures

169
Q

Intrahepatic Bile Duct N1

A

positive node(s)

170
Q

Intrahepatic Bile Duct Stage IA

A

T1a

171
Q

Intrahepatic Bile Duct Stage IB

A

T1b

172
Q

Intrahepatic Bile Duct Stage II

A

T2

173
Q

Intrahepatic Bile Duct Stage IIIA

A

T3

174
Q

Intrahepatic Bile Duct Stage IIIB

A

T4 or N1

175
Q

Intrahepatic Bile Duct Stage IV

A

M1

176
Q

Gallbladder T1a

A

invades lamina propria

177
Q

Gallbladder T1b

A

invades muscular layer

178
Q

Gallbladder T2a

A

invades perimuscular connective tissue on peritoneal side

179
Q

Gallbladder T2b

A

invades perimuscular connective tissue on hepatic side

180
Q

Gallbladder T3

A

serosa (visceral peritoneum), liver, and/or one other structure

181
Q

Gallbladder T4

A

main portal vein, hepatic artery, or two or more extrahepatic structures

182
Q

Gallbladder N1

A

1-3 nodes

183
Q

Gallbladder N2

A

4+ nodes

184
Q

Gallbladder Stage I

A

T1

185
Q

Gallbladder Stage IIA

A

T2a

186
Q

Gallbladder Stage IIB

A

T2b

187
Q

Gallbladder Stage IIIA

A

T3

188
Q

Gallbladder Stage IIIB

A

N1

189
Q

Gallbladder Stage IVA

A

T4

190
Q

Gallbladder Stage IVB

A

N2 or M1

191
Q

Distal bile duct T2

A

tumor invades bile duct wall 5-12mm

192
Q

Distal bile duct T4

A

celiac axis, SMA, common hepatic artery

193
Q

Distal bile duct N2

A

4+ regional nodes

Oral Boards (11 decks)

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