GI Flashcards
1
Q
Risk factors for cholangiocarcinoma
A
- PSC
- Hep C
- Liver fluke
- Lynch Syndrome II
- Congenital polycystic liver conditions
2
Q
Esophageal- role of EUS if PET+
A
If +LN on PET no need for EUS
If -LN proceed to staging EUS
3
Q
What other workup needed for upper esophageal mass
A
Bronch to eval for tracheal fistula
4
Q
Major risk factor for SCC esophageal ca
A
tobacco
5
Q
Risk factors for esophageal adeno
A
- Barrett’s/GERD
6
Q
Share of adeno/SCC which express Her2
A
15-30% adeno
5-13% of SCC
7
Q
What does Her2 overexpression mean for prognosis
A
Associated with increased risk of LN mets and poor prognosis
8
Q
Upper thoracic: distance from incisors
A
20-25 cm
9
Q
Mid thoracic: distance from incisors
A
25-30 cm
10
Q
Lower thoracic: distance from incisors
A
30-40 cm
11
Q
GEJ: distance from incisors
A
within 5 cm of GE junction
12
Q
Distance to sternal notch
A
15 cm
13
Q
Distance to carina
A
25 cm
14
Q
Upper thoracic: antomic
A
sternal notch to azygos
15
Q
Mid thoracic: anatomc
A
azygos to inferior pulm vein
16
Q
Lower thoracic: anatomic
A
inferior pulm vein to GEJ
17
Q
Cure rate for T1N0 esophagus with surgery
A
70-90%
18
Q
Ivor-Lewis esophagectomy
A
R thoracotomy and abdominal incision –> visualized dissection but more heartburn
19
Q
Standard preop chemoRT dose
A
50.4 in 28 fractions
20
Q
Esophagus T1
A
invades lamina propria, muscularis mucosa or submucosa
21
Q
Esophagus T2
A
invades muscularis propria
22
Q
Esophagus T3
A
Invades adventitia
23
Q
Esophagus T4
A
invades other structures
24
Q
Esophagus N1
A
1-2 regional lymph nodes
25
Esophagus N2
3-6 regional lymph nodes
26
Esophagus N3
7+ regional nodes
27
MAGIC trial design
RCT of 503 patients randomized to 3 cycles preop ECF --> surgery --> 3 cycles ECF vs. surgery alone
28
Results of MAGIC
Periop chemo decreased tumor size and significantly improved PFS/OS
29
CROSS study design
RCT of surgery vs. chemoRT --> surgery
30
What chemo used in CROSS
carbo/taxol
31
What RT used in CROSS
41.4 Gy
32
Histologic breakdown in CROSS
75% adeno
| 25% SCC
33
Results of CROSS
significant OS advantage to CRT --> surgery, 49 mos vs. 24 months median survival
34
What was pCR rate in CROSS
30%
35
Which histology benefited most from CROSS regimen
SCC (47% pCR) but adeno did benefit
36
Most common complication in CROSS arms
```
#1 - pulmonary complications
#2 - anastomotic leak
```
37
KEYNOTE 181
Study of pembro vs. chemo, included CPS>10
38
Which patients did better with pembro
Asian, SCC
39
Margins for CTV 45
3.5 cm sup/inf
| 2 cm radially
40
Margins for CTV 50.4
GTV+ 1.5 cm radial
41
What nodal area covered for distal tumors
celiac axis area
42
Main prognostic factors for gastric ca
locoregional tumor extent
| nodal involvement
43
Stomach name for GEJ
cardia
44
Top of stomach known as
fundus
45
Pre-pyloric region of stomach
antrum
46
Cure rate of surgery if node negative
80%
47
D1 nodal resection
All perigastric nodes (15 LN)
48
D2 nodal resection
D1 nodes plus left gastric, common hepatic, celiac, splenic, splenic hilum (30 LN)
49
What was population in MAGIC trial
resectable adenocarcinoma of GEJ or stomach
50
What chemo used in MAGIC
ECF (epirubicin, cisplatin, 5FU)
51
What was result of MAGIC
Improvement in 5 year OS with preop chemo (36% vs. 23%)
52
What were the treatment arms in FLOT4 trial
Periop chemo study
1. ECF 3 cycles
2. FLOT 4 cycles
53
What is FLOT?
5-FU, Leucovorin, Oxaliplatin, Docetaxel
54
Results of FLOT4 trial
FLOT had significantly improved OS compared to ECF periop chemo
55
Intergroup 116 trial
Demonstrated benefit to postop CRT compared to surgery alone
56
What regimen used in Intergroup 116 trial
surgery --> 5FU/LV --> 45 Gy --> 5FU/LV x2
57
ARTIST trial design
RCT comparing postop chemo to postop CRT in patients with D2 resected gastric ca
58
Result of ARTIST
Significant improvement in DFS for CRT in patients with N+ disease and intestinal subtype
59
ARTIST II trial
postop chemo (SOX) vs. postop SOX-RT. Closed early due to futility of CRT
60
POET trial design
Preop chemo (Cis/5-Fu) --> Surgery vs. Cis/5-FU --> concurrent CRT (30/15 with cis/etop) --> surgery
61
Patients included in POET trial
T3/T4 lower esophagus or gastric cardia ADENO
62
Advantages of CRT in POET trial
Increased path CR rate, suggestion of improved OS but underpowered
63
CRITICS trial design
Arm 1: 3 cycles of ECF like chemo --> surgery --> chemo
| Arm 2: 3 cycles of ECF like chemo --> surgery --> chemoRT to 45/25 with cis/capecitabine
64
What resection was done in CRITICS
D1
65
Results of CRITICS
No difference in OS with postop CRT
66
What is mutated in >95% of pancreatic cancers
KRAS
67
What gene portends increased risk of distant mets with pancreatic cancer
SMAD4
68
How many pancreatic tumors are resectable
15-20%
69
Borderline resectable criteria - SMA
up to 180 degrees
70
Borderline resectable criteria - CHA
contact without extension to celiac artery or HA bifurcation
71
Borderline resectable criteria - SMV/PV
>180 contact
72
Unresectable criteria - SMA
>180 degrees
73
Treatment paradigm for resectable pancreatic cancer
If R0: mFOLFIRINOX
| If R1: postop CRT --> mFOLFIRINOX
74
CONKO study
RCT to surgery vs. surgery + adjuvant gemcitabine
75
Results of CONKO study
Improvement in 5 year OS from 10% to 20%
76
GI PRODIGE study
RCT of adjuvant mFOLFIRINOX vs. gemcitabine
77
Results of PRODIGE
OS advantage for mFOLFIRINOX
78
PREOPANC study design
RCT of (borderline) resectable patients randomized to
1. Surgery
2. Preop CRT with 3 cycles of gem
79
RT dose used in PREOPANC
36/15
80
Results of PREOPANC - R0 resections
Improved with CRT 71% vs. 40%
81
Results of PREOPANC - pN+
Improved with CRT 33% vs. 78%
82
Results of PREOPANC - OS
no difference
83
Results of PREOPANC - DFS/LRFS
Improved with CRT
84
LAP07 trial design
RCT with 2x2
First randomization: gem vs. gem/erlotinib
Second randomization: continued chemo vs. 54Gy + cape
85
LAP07 results
1. No significant diff in OS
| 2. Improvement in local control 46% local progression (chemo) --> 32% (CRT)
86
What share of liver cancers are HCC?
70-85%
87
CT findings of HCC during arterial phase
brightly enhancing
88
CT findings of HCC during venous phase
washed out
89
CT appearance of cholangiocarcinoma
delayed enhancement, capsular retraction, focal internal calcs
90
What biomarker is associated with HCC
AFP
91
What level of AFP suggestive of HCC
>400
92
What factors go into Childs-Pugh class
1. Ascites
2. Bilirubin level
3. Albumin
4. INR
5. Encephalopathy
93
What is point range of Childs-Pugh class
5-15
| Lower = better liver function
94
Childs-Pugh A
5-6 points
95
Childs-Pugh B
7-9 points
96
Childs-Pugh C
10-15 points
97
Components of MELD score
1. INR
2. Bilirubin
3. Creatinine
4. Sodium
98
What is 5 year OS for liver transplant for HCC and hilar cholangio
70-85%
99
What are criteria for liver transplant?
1. Solitary tumor <5cm
| 2. 3 tumors all <3 cm
100
What tumors amenable to RFA
<3cm, not near large vessels
101
Other options for HCC (nonoperative candidates)
SBRT
| Proton therapy
102
What dose of proton therapy for HCC
67.5 in 15
103
Local control for hypofractionted proton therapy
95% at 2 years
104
Control rates with RFA
90% for tumors <3cm
| 50% for tumors >3 cm
105
What is TACE?
Most often irinotecan eluting beads injected trans-arterially
106
What share of HCC comes from hepatic artery
80%
107
Where does normal liver parenchyma derive most of blood flow
portal vein
108
Does TACE have survival benefit?
yes, compared to best supportive care
109
Contraindications to TACE
1. Thrombus in PV
2. Encephalopathy
3. Biliary obstruction
4. Childs Pugh B/C
110
RILD
Elevation of AP
| Anicteric hepatomegaly
111
What is predictor of RILD
Mean liver dose
112
What is the typical liver reserve needed for RT
700cc
113
SHARP trial
sorafenib vs. placebo, improves OS by 3 months, 3% response rate
114
mechanism of sorafenib
multikinase inhibitor (mostly VEGF)
115
side effects of sorafenib
hand-foot-mouth, diarrhea, mucositis
116
SWOG S0809 trial
single arm for gallbladder ca: looking at gem-cape --> surgery --> postop chemoRT
117
dose of postop RT used in SWOG study
45/54-59.4 Gy with cape
118
What imaging sequence should be used to visualize liver mets
use portal venous (liver is bright, tumors are hypointense)
119
What imaging sequence should be used for HCC
late arterial phase
120
Syndromes associated with colorectal cancer
1. Lynch
2. FAP
3. IBD
121
Why do Lynch patients have better prognosis?
respond to PD-1 blockers
122
Which form of IBD has increased risk of CRC
chronic UC
123
What mutation is seen in 70% of CRC
APC
124
BRAF mutations like which area of colon
Right
125
If FAP, how often to get flex sig
q 1 year [often require colectomy]
126
HNPCC
colonoscopy q2y
127
What is most important determinant of OS for CRC
pathologic extent of disease
128
What is the uppermost portion of the rectum
peritoneal reflection
129
Length of rectum
15 cm
130
Distance for lower third of rectum
0-6 cm
131
Distance for upper third of rectum
12-16 cm
132
For men with newly diagnosed rectal ca they should also have what checked
PSA
133
What is the requirement for LAR
At least 2 cm distal margin on rectum
| Sphincter needs to be functional
134
What are the indications for neoadjuvant chemoRT for rectal cancer
uT3/T4 or N+
135
What was research question in German Rectal Cancer Study?
preop CRT vs. postop CRT
136
What are the two arms of German study?
1. preop: 50.4/28 with 5-FU days 1-5 weeks 1 and 5
| 2. postop: 55.8/31 with same chemo
137
Findings of German rectal study?
Preop had several advantages:
1. lower rates of local failure (6% vs. 13%)
2. lower rates of acute toxicity
3. increased conversion to sphincter preservation surgery
138
Swedish rectal cancer trial design
RCT of 25/5 --> surgery vs. surgery
139
Swedish rectal cancer trial results
1. Decreased LRR from 27% to 12%
| 2. Improved 5 year OS
140
What was unique about Swedish study?
only one to show survival benefit
141
Why did Swedish study show OS benefit
no TME
142
Dutch CKVO trial
RCT of TME vs. 25/5 --> TME [improved LRR]
143
GTV for rectal cancer
mesorectum + internal iliac
144
Dose for rectal cancer
45 Gy to pelvis
| 5.4 Gy boost to GTV + 2 cm
145
CTVA definition
internal iliac, pre-sacral, perirectal
146
CTVB definition
external iliac
147
CTVC
inguinal
148
superior border of rectal field
L5-S1
149
inferior border of rectal field
below ischial tuberosity
150
How far below rectal tumor should you go
2.5-3 cm
151
Anterior-posterior border of rectal field
behind sacrum, behind pubic symphysis
152
What is the histology of anal cancer
75-80% SCC
153
how long is anus
4 cm
154
What HPV strains associated with anal cancer
```
16
18
31
33
35
```
155
T1 anal cancer
2cm
156
T2 anal cancer
2-5 cm
157
T3 anal cancer
>5 cm
158
T4 anal cancer
invades adjacent structures
159
What chemo regimen is used for definitive CRT for anal cancer
5-FU + mitomycin
160
Dose of 5-FU
1000 mg/m2 continuous infusion D1-4 and 29-32
161
Dose of mitomycin
10 mg/m2 bolus day 1, 29
162
RTOG 05-29 dose for T2N0
42 Gy to elective nodes
| 50.4 to anal tumor
163
RTOG 05-29 design
dose painting IMRT single arm phase II designed
164
endpoint for RTOG 05-29
combined G2+ GI/GU toxicities
165
dose for T3-T4 or N1-3
45 Gy to elective nodes
50.4 to nodes <3cm
54 to nodes >3 cm
54 to primary
166
What did IMRT improve?
skin toxicity, severe GI tox, heme tox
167
Follow-up for anal cancer
many who do not have CR at 11 weeks respond by 26 weeks
168
When do you biopsy residual disease for anal cancer
only if progression. re-eval q4w until CR
169
Sim parameters for gastric
1. NPO 3-4 h
2. Small amount of PO contrast 30 mins prior to scan
3. Arms up
4. 4DCT
170
German rectal study subjects
823 patients
uT3/T4 or N+
Resectable
171
What surgery was performed in German rectal study?
TME
172
Pancreatic T1
<2 cm
173
Pancreatic T2
2-4 cm
174
Pancreatic T3
>4 cm
175
Pancreatic T4
Invades SMA, celiac axis, CHA regardless of size
176
Pancreatic N1
1-3 regional nodes
177
Pancreatic N2
>3 nodes
178
When should capecitabine be given wrt radiation
1 hr before
179
What is typical capecitabine dose
825 mg/m2
180
What were two arms in POET study
1. Chemo (Cis/5-FU/LV) --> Surgery
| 2. Chemo (Cis/5-FU/LV) --> CRT (30/15) with cis/etop --> surgery
181
Patients in POET study
uT3/T4 lower esophagus or gastric cardia
182
Major critique of POET
underpowered as only enrolled 119/197
183
Path CR rates POET
15% CRT vs. 2%
184
At 5 years what was significantly better with CRT
locoregional relapse
local PFS
?OS (p=0.055),
185
POET: What was 5 year OS with chemoRT
39% vs. 24.4% (p=0.055)
186
Rates of colostomy for anal with definitive RT at 5 years
12% (per RTOG 9811)
187
RTOG 98-11 design
chemo study
1. 5-FU/MMC
2. induction 5-FU/Cisplatin (2 cycles) --> 5-FU+MMC
188
Minimum # of LN to be removed for colon cancer surgery to be deemed adequate
12
189
Which pelvic nodes are regional for rectal ca in USA
only internal iliac
| NOT obturator, external iliac, common iliac
190
best chemo regimen for intrahepatic cholangio
gem-cis
191
Chinese esophagus study (NEOCRTEC5010)
RCT of:
1. Surgery (excellent technique with mediastinal sampling)
2. Preop CRT (40Gy/20 with cis-vinorelbine) --> surgery
192
What histology in Chinese esophagus study
SCC
193
What improved in Chinese esophagus study
1. OS
2. DFS
3. R0 resection
4. Pathologic downstaging
194
What LN are covered in rectal ca?
perirectal
presacral
internal iliac
195
when would external iliac LN be covered for rectal?
if invasion into Gyn/GU structure
196
Spinal level of SMA
L1
197
Spinal level of IMA
L3
198
What were the arms of the Polish II trial
short course (5x5) and 3 cycles of FOLFOX vs. long course (1.8 x 28) with concurrent 5-FU and oxali
199
Which patients included in Polish trial
cT3 (fixed) or T4
200
Short term results of Polish trial
1. No difference in local recurrence or pCR
2. Lower toxicity
3. Improved OS at 3 years (73% vs. 65%)
201
What changed in long-term follow-up of Polish rectal trial
OS difference no longer significant,
No difference in DFS
No difference in toxicity
202
Recommended interval of surgery after preop CRT for rectal cancer
5-12 weeks
203
OS in the CROSS trial for neoadjuvant CRT
49 months
204
Sister Mary Joseph nodule
Periumbilical met through falciform ligament
205
Virchow's node
L supraclav mass through thoracic duct
206
Krukenberg tumor
ovarian met
207
Irish node
L axillary mass
208
Blumer's shelf
tumor spread to rectouterine pouch of Douglas
209
Dosing of carbo in CROSS Trial
AUC 2
210
Chemo used in CROSS trial
Paclitaxel + Carbo
211
Dosing of carbo for NSCLC
AUC 5
212
How was carbo given in CROSS
weekly
213
Polish I study- when did patients have surgery after short course
<7d
214
Arms of Polish I trial
1. 5x5 --> surgery within 7 days
| 2. 50.4 with 5-FU/LV --> surgery 4-6 weeks later
215
What was significant in Polish I trial
Early tox higher in chemoRT arm
pCR higher in chemoRT arm
NO DIFF in DFS, OS
216
What was pCR rate in long course CRT
16%
217
What determines pCR rates for rectal treatment
timing of surgery
218
T1 [Liver]
Solitary tumor <2 or >2 without vascular invasion
219
T2 [Liver]
Solitary tumor > 2 with vascular invasion
| Multiple tumors, none >5 cm
220
T3 [Liver]
Multiple tumors, one >5 cm
221
T4 [Liver]
Involves major branch of portal vein or hepatic vein or direct invasion to gallbladder
222
CRITICS trial studied which intervention
Gastric/GEJ
| Postop Chemo vs. Postop CRT (45/25 in
223
What is main message of CRITICS
Postop CRT is very poorly tolerated for gastric only about 50% completed therapy
224
Results of CRITICS trial
No difference in OS or EFS
225
Other postop CRT trials for GASTRIC
1. Int 116 - CRT vs. observation, CRT had improved OS
| 2. ARTIST - postop chemo vs. CRT, significant improvent in DFS for N+/intestinal for CRT
226
What about ARTIST II
Resected, N+ gastric cancer
| Chemo (S vs. SOX vs. SOX-RT to 45 Gy)
227
What were results of ARTIST II
No difference in EFS at 3 years, stopped early
228
Pancreatic tumor with contact to IVC is considered
borderline resectable
229
MAGIC trial results: OS
5 year OS 36 vs 23% favoring periop chemo
230
INT 0116 trial results OS:
3 year OS 50 vs 41% favoring postop CRT
231
Margins used in LAP-07
GTV and involved nodes 1 cm or more
| PTV: GTV + 3cm sup/inf, 1.5 cm all other dimension
232
What was the only thing significant in LAP-07
local control better with CRT
233
PREOPANC study design
RCT of
1. Immediate surgery
2. Preop CRT to 36/15 with gem (3 cycles)
234
Which groups had improved OS with preop CRT in PREOPANC
1. Cohort who proceeded with surgery and adjuvant chemo
| 2. BORDERLINE resectable
235
Siewert Type I
Distal esophagus within 1-5 cm from GEJ
236
Siewert Type II
Originates in either:
1. 1 cm proximal from GEJ
2. Within 2 cm from GEJ in gastric cardia
237
Siewert Type III
Originates 2-5 cm from GEJ in gastric cardia
238
Describe chemo from Intergroup 116 trial
1 cycle 5FU/LV (day 1-5) then concurrent 5FU on first four/last 3 days of RT then 2 cycles 5FU-LV
239
Why give LV with 5-FU
When given in combination with Leucovorin, Leucovorin can enhance the binding of fluorouracil to an thymidylate synthase (TS) inhibitor. As a result fluorouracil may stay in the cancer cell longer and exert its anti-cancer effect on the cells.
240
RTOG 9704
Both arms postop chemo/CRT
| 5-FU --> CRT --> 5-FU vs. Gemcitabine --> CRT --> Gemcitabine
241
RTOG 9704 results
trend towards improved OS for pancreatic head lesions (fully resected)
242
Milan criteria for transplant
1. single tumor <5 cm
2. 2-3 tumors all <3 cm
3. no vascular invasion
243
When to evaluate anal cancer results
DRE at 8-12 weeks then q4 weeks until CR
244
Dose of 5FU for continuous infusion
225 for 5-7 days a week during RT
245
Dose of 5FU for bolus
400 over 4 days week 1 and 5 of RT
246
Dose of xeloda for rectal
825 BID for 5 days a week during RT
247
Which 5FU form needs LV
bolus
248
Should bladder be full or empty for anal SCC setup?
full to displace bowel sup
249
What is research question in Minsky esophagus study (Intergroup 0123)
benefit of dose escalation for definitive esophagus treatment
250
Two arms of Minsky trial
64.8 vs. 50.4 both with cis/5FU
251
Findings of Minsky trial
No benefit to dose escalation in terms of OS or LRF
252
Which trial showed OS benefit to adjuvant CRT for resected pancreas
GITSG (40/20 split course with 5FU)
253
ESPAC-1 trial
2x2 factorial design for resected pancreatic cancer with 4 arms
1. Chemo alone
2. CRT (20 Gy)
3. Chemo + CRT
4. Observation
254
Findings of ESPAC-1
chemo significantly improved OS
| CRT associated with adverse OS
255
What circumference of bowel ok for trans-anal excision
<30%
256
What max size for trans-anal excision
3 cm
257
How far from anal verge ok for trans-anal excision
<8 cm
258
Is adjuvant gem+cape superior to gem for resected pancreatic cancer
yes, superior OS, especially for margin negative tumors
259
Acceptable chemo options for resected pancreatic cancer
1. Gem-cape
| 2. mFOLFIRINOX
260
Preferred chemo regimen for cholangio
gem-cis
261
What is the proportion of rectal preservation after total neoadjuvant therapy with cCR
80%
262
What is the concern to nonoperative mgmt
Inferior outcomes (OS) compared to patients who had pCR at time of TME
263
Findings of Dutch D1D2 trial
1. Improved local recurrence
2. Improved regional recurrence
3. Improved gastric cancer mortality
NOT OS
264
What is worse with D2 resection in Dutch trial
higher postop mortality, morbidity and reoperation rates
265
Is D2 preferred operation for resectable gastric cancer
yes, spleen sparing
266
Liver constraint for SBRT
at least 700 cc receives < 15 Gy
267
Adjuvant chemo regimen for locally advanced rectal
6 months of FOLFOX q2w
268
What is N1c for rectal cancer
tumor deposits in the subserosa, mesentery or nonperitoneal pericolic or perirectal tissues without regional nodal mets
269
What is N2a for rectal cancer
4-6 LN
270
What is N2b for rectal cancer
7 or more LN
271
What is the typical boost field for preop rectal
2-3 cm on GTV plus full sacral hollow
272
How far lateral should AP fields go for rectum
2 cm lateral to widest point of bony pelvis
273
What is posterior extent of lateral rectal field for T3 tumor
2 cm posterior to presacrum
274
What is posterior extent of lateral rectal field for T4 tumor
1 cm posterior to sacrum
275
What is anterior extent of lateral rectal field
1 cm anterior to symphysis for anterior wall
| Mid symphysis for posterior lesions
276
How many nodes equate to N2 for pancreas ca
4 or more
277
How many randomizations in LAP07
2
278
What was first LAP07 randomization
gem (1000 mg/m2) vs. gem/erlotinib
279
What was second LAP07 randomization
If no POD after 4 months chemo -->
1. 2 months of gem
2. CRT (54 Gy in 30 with concurrent cape)
280
What was local tumor progression for chemo alone arm for LAP07
46%
281
What was local tumor progression for CRT arm for LAP07
32%
282
ESPAC-3 question
5FU or gemcitabine for adjuvant chemo
283
ESPAC-3 result
no difference in OS but improved tox with gemcitabine
284
ESPAC-4 question
gemcitabine-cape vs. gemcitabine alone for adjuvant chemo
285
Major criticism of 98-11 anal trial (cis vs. MMC)
cis arm got induction chemo
286
Findings of 98-11
Lower colostomy rate with MMC arm (10% vs. 19% with cis)
| Improved DFS/OS for MMC arm
287
What does SCV node reflect for esophagus cancer
M1 disease
288
How many Whipples per year are considered high volume
15-20
289
What histology included in POET trial
GEJ adenocarcinoma
290
What was POET design
1. cis-FU --> surgery
| 2. cis-FU (2 cycles) --> CRT (30/15 with cis/etop) --> surgery
291
Major flaw with POET
underpowered, only enrolled part of patients
292
Ultimately on POET, what was improved with CRT
Locoregional relapse
Local PFS
5 Yr OS (borderline, p=0.055)
293
Anal N1a nodes
Inguinal
Mesorectal
Internal Iliac
294
Anal N1b nodes
External iliac
295
Anal N1c nodes
N1a and external iliac
296
Chemo used in PREOPANC
gemcitabine days 1, 8, 15
297
Which groups benefited from preopCRT (in terms of OS)
1. Those who were resected and started adjuvant chemo
| 2. Borderline resectable disease
298
Neuroendocrine tumors - better outcomes with functional or non-functional
functional
299
Recommendations for resected biliary tract cancer
1. If neg margins: adjuvant cape x 6 months
| 2. If R1: CRT [gem-cape --> RT to 54-59.4 with cape]
300
Timeline for surgery after short course RT for rectal
within 1 week or delayed 6-8 weeks
301
What did esophageal meta-analysis conclude OS benefit for neoadjuvant CRT
9% all cause mortality benefit for both adenocarcinoma AND SCC
302
What did esophageal meta-analysis conclude OS benefit for neoadjuvant chemo
5% all cause mortality benefit for adenocrcinoma ONLY
303
On CROSS study, share of CRT patients who had R0 resection
92%
304
In CROSS study, share of surgery patients who had R0 resection
69%
305
RTOG 85-01 design (herskovic)
Radiation alone vs. CRT
1. RT alone (64/32)
2. 50/25 with cis/5FU
306
Importance of 85-01
established superiority of preop CRT to RT alone (OS advantage)
307
For rectal if margin involved after CRT what is next step
Total neoadjuvant therapy (12-16 weeks of FOLFOX or CAPEOX)
308
5 year OS on Herskovic study RTOG 85-01 for CRT
26%
309
5 year OS on Herskovic study RTOG 85-01 for RT
0%
310
Acute grade 3/4 tox in German rectal study
27% (preop)
| 40% (postop)
311
Late grade 3/4 tox in German rectal study
14% (preop)
| 24% (postop)
312
Pancreas T1a
<0.5
313
Pancreas T1b
0.5-1
314
Pancreas T1c
1-2
315
Pancreas T2
2-4
316
Pancreas T3
>4
317
Pancreas T4
invades SMA, CA, CHA
318
Pancreas N1
1-3
319
Pancreas N2
>4
320
Arms on NETTER-1 trial
Lu-Dotatate vs. somatastatin
321
PFS advantage for Lu-Dotatate
55%
322
Gallbladder T1a
lamina propria
323
Gallbadder T1b
Muscle layer
324
Gallbladder T2
Perimuscular connective tissue
325
Gallbladder T3
perforates serosa, directly invades liver or other adjacent structures
326
Gallbladder T4
invades main portal vein or hepatic artery or 2 extrahepatic organs
327
Esophagus N1
1-2 regional nodes
328
For esophagus, there are different staging systems by what
Histology - adeno and SCC
| But not yp - same for both
329
For esophagus, anatomic location of tumor is defined by what feature of tumor
epicenter (used to be top)
330
What anal lesions should get consideration of 59.4
T3/T4
Residual disease after 45 gy
N+
331
What patients included in Intergroup 116 trial
R0 resection of gastric or GEJ
332
Rectal N1a
1
333
Rectal N1b
2-3
334
Rectal N1c
tumor deposits in subserosa, mesentery, perirectal tissues
335
Rectal N2a
4-6
336
Rectal N2b
>7
337
RTOG 0822 (Hong study) design
Using IMRT (45 Gy) followed by boost to 50.4 (3DCRT) to reduce grade 2+ GI tox
338
What chemo used on 0822
Cape-Ox
339
Why didn't 0822 achieve endpoint?
Used oxaliplatin which has baseline rate of high GI tox
340
Most common tumor of appendix
carcinoid
341
ACT II trial design
2x2 factorial
First randomization: Concurrent CRT to 50.4 Gy with 5-FU/MMC or 5-FU/Cis
Second randomization: Maintenance 5-FU/cis or observation
342
When did ACT II assess CR for anal cancer
26 weeks
343
What did ACT II conclude about outcomes
5-FU/MMC should remain SOC, no advantage to maintenance chemo
344
What dose of CRT did ACT II use
50.4 Gy
345
How many lymph nodes is aspirational for gastric cancer resection
at least 15
346
RTOG 87-04 design (Flam)
Anal SCC 45-50.4 Gy randomized to
a) 5-FU
b) 5-FU + MMC
347
What were differences in MMC arm
Increased rates of
1. Local control
2. Colostomy free survival
3. Disease free survival
348
Does MMC have OS advantage
No
349
Does MMC add toxiciy
yes, 23% vs 7% grade 4/5 tox
350
new cases of anal cancer per year
8,500
351
new cases of rectal ca per year
40,000
352
new cases of colon ca per year
100,000
353
stomach t1a
lamina propria or muscularis mucosa
354
stomach t1b
submucosa
355
stomach t2
muscularis propria (wall)
356
stomach t3
penetrates subserosal connective tissue
357
stomach N1
1-2
358
stomach N2
3-6
359
Stomach N3a
7-15
360
Stomach N3b
>16
361
What is optimal way to give 5FU for rectal cancer
continuous infusion 225 mg/m2
362
RAPIDO trial
RCT of locally advanced rectal
1. 5x5 --> CAPEOX or FOLFOX --> surgery
2. 50.4 with cape
363
Findings of RAPIDO
short course improved
- -pCR rate
- -disease related failure
- -distant met free survival
364
Chemo used in ARTIST trial
capecitabine and cisplatin
365
What surgery was done in ARTIST trial
D2 resection
366
NCCN recs for margins on gastric surgery
no tumor on ink
367
Primary prevention
interventions applied before any evidence of disease
368
Secondary prevention
treatment of precancerous conditions
369
Tertiary prevention
diagnosis and early/effective treatment of invasive cancer
370
Chemo recommendation for resected low risk stage III disease (T1-T3/N1)
3 months of adjuvant CAPOX
| 3-6 months of adjuvant FOLFOX
371
Chemo rec for resected high risk stage III disease (T4N2)
3-6 months of adjuvant CAPOX
| 6 months of adjuvant FOLFOX
372
Adjuvant treatment recs for pancreatic NETs
No adjuvant treatment for completely resected tumors (even if mets too)
373
Primary mgmt of pancreatic NETs
Surgery to primary and mets
374
Number of colon cancer cases per year
100000
375
Number of colorectal cancer cases per year
140000
376
CROSS trial: R0 resection for CRT arm
92%
377
CROSS trial: R0 resection for surgery alone arm
69%
378
Staging for newly diagnosed rectal cancer
1. Colonoscopy
2. Pelvic MRI
3. CT CAP
379
Rectal ca doses for preop cases
45 Gy to whole pelvis
| Tumor bed boost to 5.4 Gy
380
Rectal ca doses for postop cases
45 Gy to whole pelvis
| Tumor bed boost to 5.4-9 Gy
381
Klatskin tumor
perihilar cholangio involving confluence of left and right bile ducts
382
What did Garcia-Aguilar TNT trial show?
Dose dependent increase in pCR rates for each additional cycle of FOLFOX
383
What is downside of TNT
increased heme toxicity
384
What is PFS of definitive CRT for anal cancer
75% at 3 years
385
Rate of pCR after neoadjuvant CRT on German Rectal Study
8%
386
What MRI sequence is utilized for rectal cancer staging
T2
387
Is muscularis hypointense or hyperintense on T2 MRI
hypointense
388
What chemo is used for ACC
mitotane (inhibitor of steroidogenesis)
389
What is role of postop RT for ACC
Decreased LRR
| No difference in PFS/OS
390
What esophagus preop CRT study enrolled just SCC
EORTC
391
What esophagus preop CRT study enrolled just adenocarcinoma
Walsh (Irish)
392
Swedish Rectal Trial
RCT of:
1. Preop RT (5x5)
2. Surgery alone
393
What type of surgery in Swedish rectal trial
Non-TME
394
Results of Swedish rectal trial
Improvements in OS, cancer specific survival, local recurrence
395
CR rate for anus using 5-FU/MMC vs. 5-FU/cis
91% vs. 90% at 26 weeks
396
OS in Swedish Rectal Trial
38% (RT, 5x5)
| 30% (surgery, non-TME)
397
What did CONKO study show?
improved OS for gemcitabine vs. observation for R0/R1 pancreas resection
398
When does RILD develop
2 weeks to 8 months post RT, most commonly within 3 months
399
Main lab abnormality with RILD
elevated AP
400
Clinical presentation with RILD
anicteric, painful hepatomegaly
401
BED should be above ___ to improve LC and OS for cholangiocarcinoma
80.5
402
Dose of paclitaxel for CROSS
50 mg/m2
