GI Flashcards
1
Q
Colorectal T4a
A
invades serosa (visceral peritoneum)
2
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
3
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
4
Q
Gastric yp Stage II
A
adds to 3 or 4 (excluding T4bN0)
5
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)
6
Q
Anal cancer: simulation
A
supine, frog leg, vac loc, oral contrast, full bladder, bead marker at anal verge
7
Q
Perianal Cancer: criteria for WLE
A
T1
well differentiated
>1cm margins
8
Q
Distal bile duct T4
A
celiac axis, SMA, common hepatic artery
9
Q
Colorectal N1c
A
negative nodes with tumor deposits in the subserosa, mesentery, or perirectal/mesorectal tissues
10
Q
Gallbladder T2b
A
invades perimuscular connective tissue on hepatic side
11
Q
Colorectal Stage IIIC
A
T4aN2a, T3-4aN2b, T4bN+
12
Q
Anal canal cancer: criteria for excision
A
superficially invasive
<3mm basement membrane invasion
horizontal spread <7mm
negative margins
13
Q
Gastric Pathological Stage IIB
A
T1N3a, T2N2, T3N1, T4aN0 (adds to 4)
14
Q
Pancreatic cancer: adjuvant chemo
A
concurrent capecitabine 825mg/m2 BID
then adjuvant gemcitabine / capecitabine
15
Q
Esophagus yp Stage II
A
T3N0
16
Q
Colorectal Stage IIIA
A
T1-2N1, T1N2
17
Q
Esophageal Adeno clincical Stage IIA
A
T1N1
18
Q
Gastric Pathological Stage IIIB
A
T1-2N3b, T3-4aN3a, T4bN1-2
19
Q
Rectal cancer: simulation
A
PRONE, belly board, anal marker, oral contrast two hours before, full bladder
20
Q
Gastric Clinical Stage IVA
A
T4b
21
Q
Intrahepatic Bile Duct Stage II
A
T2
22
Q
Distal bile duct T2
A
tumor invades bile duct wall 5-12mm
23
Q
Anus Stage IIIA
A
T1-2N1
24
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)
25
Rectal cancer: concurrent chemotherapy dosing
capecitabine 800mg BID M-F
26
Colorectal M1c
peritoneal metastasis
27
Gallbladder T2a
invades perimuscular connective tissue on peritoneal side
28
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
29
Anus Stage IIIC
T3-4N1
30
Gastric T3
invades subserosal connective tissue
31
Gallbladder Stage IIIA
T3
32
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)
33
Esophageal cancer: concurrent chemo dosing
carboplatin AUC 2 weekly
paclitaxel 50mg/m2 weekly
34
Esophageal Adeno clincical Stage IVA
T4b or N2-3
35
Gastric T2
invades muscularis propria
36
Intrahepatic Bile Duct Stage IIIA
T3
37
Gastric cancer: nodal targets for T4 or N+
CP5S2 (+/- splenic):
## Footnote
* celiac
* pancreaticoduodenal
* paraaortic
* periesophageal
* perigastric
* portahepatic
* superior mesenteric
* suprapancreatic
only include splenic for tumor in proximal (cardia) or middle (body) location
38
Anus N1a
inguinal, mesorectal, or internal iliac nodes
39
Colorectal Stage IIC
T4bN0
40
Pancreatic cancer: criteria for borderline resectability
SMV/PV \> 180
CA/SMA \< 180
CHA/IVC contact
41
Intrahepatic Bile Duct Stage IIIB
T4 or N1
42
Gastric cancer: constraints for kidneys and liver
2/3 of one kidney \< 20Gy
liver V30 \< 60%
43
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
44
Intrahepatic Bile Duct Stage IV
M1
45
Gallbladder T3
serosa (visceral peritoneum), liver, and/or one other structure
46
Anus Stage IIA
T2N0
47
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%
48
Colorectal N2a
4-6 nodes
49
Gallbladder Stage IVA
T4
50
Gastric Pathological Stage IIA
T1N2, T2N1, T3N0 (adds to 3)
51
Esophageal SCCa clinical Stage IVA
T4 or N3
52
Gastric Clinical Stage III
T3N+, T4N+
53
Esophageal SCCa Middle Location
azygous vein to inferior pulmonary vein (lower border)
54
Intrahepatic Bile Duct N1
positive node(s)
55
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)
56
Gastric cancer: workup
H&P, family history, nutrition/weight loss, IBD
Labs: CBC, CMP
Upper GI with biopsy and H pylori testing, EUS, CT A/P, consider PET
consider J-tube and nutrition eval, renal perfusion scan (if not doing IMRT)
57
Gallbladder Stage IIB
T2b
58
Anus N1b
external iliac nodes
59
Colorectal M1a
metastasis to one site without peritoneal metastasis
60
Esophageal Adeno clincical Stage III
T2N1 or T3-4aN0-1
61
Colorectal M1b
metastasis to two or more sites without peritoneal metastasis
62
Pancreatic cancer: simulation
supine, wingboard, abdominal compression, 4DCT, oral contrast, IV contrast
63
Distal bile duct N2
4+ regional nodes
64
Colorectal N1a
1 node
65
Anus T4
invading adjacent organ
66
Gastric cancer: considerations for follow up
if proximal stomach was removed, supplement with B12, calcium, and iron
67
Esophagus N2
3-6 regional nodes
68
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
69
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
70
Intrahepatic Bile Duct T2
solitary tumor with intrahepatic vascular invasion or multiple tumors
71
Esophageal Adeno clincical Stage IIB
T2N0
72
Anal cancer: 5yr OS for stage I-IV
stage I 80%
stage II 75%
stage III 50%
stage IV 10%
73
Esophagus yp Stage I
T0-2N0
74
Anus N1c
external iliac nodes AND inguinal/mesorectal/internal iliac
75
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
76
Esophageal cancer: workup
H&P, assess nutritional status / weight loss, Family history, IBD, smoking history (cessation)
Labs: CBC, CMP
Imaging: EGD with biopsy, EUS, CT, PET
consider J tube and dietary eval
77
Gallbladder N2
4+ nodes
78
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
79
Gastric Pathological Stage IIIA
T2N3a, T3N2, T4aN1-2, T4bN0
80
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
81
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)
82
Esophagus N3
7 or more regional nodes
83
Gastric T4a
invades serosa (visceral peritoneum)
84
Rectal cancer: workup
H&P, family history, genetic or hereditary disorders, IBD, DRE (distance from verge, size, circumference, sphincter tone), GYN exam
Labs: CBC, CMP, CEA.
Colonoscopy with biopsy, MRI pelvis, CT A/P
85
Esophagus yp Stage IIIB
T3N1, T0-3N2, T4aN0
86
Anus Stage IIB
T3N0
87
Gastric Pathological Stage IVC
T3N3b, any T4N3
88
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
89
Gallbladder T4
main portal vein, hepatic artery, or two or more extrahepatic structures
90
Gastric N3b
16+ nodes
91
Anus T2
2-5cm
92
Gastric Clinical Stage IIB
T3-4aN0
93
Anus Stage IIIB
T4N0
94
Esophageal SCCa clinical Stage II
T2N0-1
95
Esophagus yp Stage IVA
T4aN1-2, T4b, N3
96
Intrahepatic Bile Duct T3
perforating visceral peritoneum
97
Colorectal T4b
invades adjacent structures
98
Pancreatic cancer: adjuvant dose and contouring targets
CTV 50.4:
tumor bed + 2cm
PJ, HJ, SMA, CA, PV, and clips + 1cm
aorta from T11 to L3 + 3cm right, 2cm ant, 1cm left, and 0.2cm post
99
Esophageal SCCa Lower Location
inferior pulmonary vein to stomach
100
Esophageal SCCa Upper Location
cervical esophagus to azygous vein (lower border)
101
Esophageal SCCa clinical Stage III
T3 or N2
102
Gallbladder Stage IIIB
N1
103
Esophagus T4b
aorta, vertebral body, airway (unresectable tumor)
104
Pancreatic cancer: workup
H&P, family history, weight loss / nutrition, abdominal exam
Labs: CBC, CMP, CEA, CA-19-9, amylase, lipase
EUS 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
105
Anal cancer: concurrent chemo dosing
capecitabine 825mg/m2 BID M-F
mitomycin 12mg/m2 on day 1
106
Gastric cancer: dose and general targets for T3N0
45Gy/25fxs
T3N0: treat anastomosis, whole stomach (except for GEJ tumors), and perigastric nodes
107
Esophagus T4a
pleura, pericardium, peritoneum, azgous vein, diagphragm
108
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
109
Colorectal T3
invades through muscularis propria into pericolorectal tissue
110
Intrahepatic Bile Duct T4
local extrahepatic structures
111
Colorectal N1b
2-3 nodes
112
Esophagus yp Stage IIIA
T0-2N1
113
SWOG 0809: MS
MS 35mo
114
Anal Cancer: workup
H&P, sexual history, HIV risk factors, IBD, family history, LN eval, DRE, anal sphincter tone, GYN exam
Labs: CBC, CMP, HIV if risk factors
Anoscopy/colonoscopy with bx. FNA of inguinal nodes.
PET/CT
115
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
116
Esophageal cancer: simulation
supine, wingboard, small amount of oral contrast
117
Gallbladder Stage IVB
N2 or M1
118
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
119
Colorectal Stage IIIB
T3-4aN1, T2-3N2a, T1-2N2b
120
Anus T3
\>5cm
121
Colorectal N2b
7+ nodes
122
Rectal cancer: adjuvant chemotherapy
FOLFOX q2wks for 6 months
123
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
124
Gastric N2
3-6 nodes
125
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
