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RO Clinical Boards > GI > Flashcards

GI Flashcards

1
Q

Risk factors for cholangiocarcinoma

A
  1. PSC
  2. Hep C
  3. Liver fluke
  4. Lynch Syndrome II
  5. Congenital polycystic liver conditions
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2
Q

Esophageal- role of EUS if PET+

A

If +LN on PET no need for EUS

If -LN proceed to staging EUS

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3
Q

What other workup needed for upper esophageal mass

A

Bronch to eval for tracheal fistula

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4
Q

Major risk factor for SCC esophageal ca

A

tobacco

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5
Q

Risk factors for esophageal adeno

A
  1. Barrett’s/GERD
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6
Q

Share of adeno/SCC which express Her2

A

15-30% adeno

5-13% of SCC

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7
Q

What does Her2 overexpression mean for prognosis

A

Associated with increased risk of LN mets and poor prognosis

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8
Q

Upper thoracic: distance from incisors

A

20-25 cm

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9
Q

Mid thoracic: distance from incisors

A

25-30 cm

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10
Q

Lower thoracic: distance from incisors

A

30-40 cm

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11
Q

GEJ: distance from incisors

A

within 5 cm of GE junction

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12
Q

Distance to sternal notch

A

15 cm

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13
Q

Distance to carina

A

25 cm

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14
Q

Upper thoracic: antomic

A

sternal notch to azygos

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15
Q

Mid thoracic: anatomc

A

azygos to inferior pulm vein

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16
Q

Lower thoracic: anatomic

A

inferior pulm vein to GEJ

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17
Q

Cure rate for T1N0 esophagus with surgery

A

70-90%

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18
Q

Ivor-Lewis esophagectomy

A

R thoracotomy and abdominal incision –> visualized dissection but more heartburn

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19
Q

Standard preop chemoRT dose

A

50.4 in 28 fractions

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20
Q

Esophagus T1

A

invades lamina propria, muscularis mucosa or submucosa

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21
Q

Esophagus T2

A

invades muscularis propria

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22
Q

Esophagus T3

A

Invades adventitia

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23
Q

Esophagus T4

A

invades other structures

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24
Q

Esophagus N1

A

1-2 regional lymph nodes

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25
Q

Esophagus N2

A

3-6 regional lymph nodes

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26
Q

Esophagus N3

A

7+ regional nodes

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27
Q

MAGIC trial design

A

RCT of 503 patients randomized to 3 cycles preop ECF –> surgery –> 3 cycles ECF vs. surgery alone

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28
Q

Results of MAGIC

A

Periop chemo decreased tumor size and significantly improved PFS/OS

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29
Q

CROSS study design

A

RCT of surgery vs. chemoRT –> surgery

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30
Q

What chemo used in CROSS

A

carbo/taxol

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31
Q

What RT used in CROSS

A

41.4 Gy

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32
Q

Histologic breakdown in CROSS

A

75% adeno

25% SCC

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33
Q

Results of CROSS

A

significant OS advantage to CRT –> surgery, 49 mos vs. 24 months median survival

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34
Q

What was pCR rate in CROSS

A

30%

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35
Q

Which histology benefited most from CROSS regimen

A

SCC (47% pCR) but adeno did benefit

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36
Q

Most common complication in CROSS arms

A 
#1 - pulmonary complications
#2 - anastomotic leak
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37
Q

KEYNOTE 181

A

Study of pembro vs. chemo, included CPS>10

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38
Q

Which patients did better with pembro

A

Asian, SCC

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39
Q

Margins for CTV 45

A

3.5 cm sup/inf

2 cm radially

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40
Q

Margins for CTV 50.4

A

GTV+ 1.5 cm radial

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41
Q

What nodal area covered for distal tumors

A

celiac axis area

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42
Q

Main prognostic factors for gastric ca

A

locoregional tumor extent

nodal involvement

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43
Q

Stomach name for GEJ

A

cardia

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44
Q

Top of stomach known as

A

fundus

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45
Q

Pre-pyloric region of stomach

A

antrum

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46
Q

Cure rate of surgery if node negative

A

80%

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47
Q

D1 nodal resection

A

All perigastric nodes (15 LN)

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48
Q

D2 nodal resection

A

D1 nodes plus left gastric, common hepatic, celiac, splenic, splenic hilum (30 LN)

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49
Q

What was population in MAGIC trial

A

resectable adenocarcinoma of GEJ or stomach

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50
Q

What chemo used in MAGIC

A

ECF (epirubicin, cisplatin, 5FU)

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51
Q

What was result of MAGIC

A

Improvement in 5 year OS with preop chemo (36% vs. 23%)

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52
Q

What were the treatment arms in FLOT4 trial

A

Periop chemo study

  1. ECF 3 cycles
  2. FLOT 4 cycles
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53
Q

What is FLOT?

A

5-FU, Leucovorin, Oxaliplatin, Docetaxel

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54
Q

Results of FLOT4 trial

A

FLOT had significantly improved OS compared to ECF periop chemo

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55
Q

Intergroup 116 trial

A

Demonstrated benefit to postop CRT compared to surgery alone

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56
Q

What regimen used in Intergroup 116 trial

A

surgery –> 5FU/LV –> 45 Gy –> 5FU/LV x2

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57
Q

ARTIST trial design

A

RCT comparing postop chemo to postop CRT in patients with D2 resected gastric ca

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58
Q

Result of ARTIST

A

Significant improvement in DFS for CRT in patients with N+ disease and intestinal subtype

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59
Q

ARTIST II trial

A

postop chemo (SOX) vs. postop SOX-RT. Closed early due to futility of CRT

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60
Q

POET trial design

A

Preop chemo (Cis/5-Fu) –> Surgery vs. Cis/5-FU –> concurrent CRT (30/15 with cis/etop) –> surgery

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61
Q

Patients included in POET trial

A

T3/T4 lower esophagus or gastric cardia ADENO

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62
Q

Advantages of CRT in POET trial

A

Increased path CR rate, suggestion of improved OS but underpowered

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63
Q

CRITICS trial design

A

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

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64
Q

What resection was done in CRITICS

A

D1

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65
Q

Results of CRITICS

A

No difference in OS with postop CRT

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66
Q

What is mutated in >95% of pancreatic cancers

A

KRAS

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67
Q

What gene portends increased risk of distant mets with pancreatic cancer

A

SMAD4

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68
Q

How many pancreatic tumors are resectable

A

15-20%

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69
Q

Borderline resectable criteria - SMA

A

up to 180 degrees

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70
Q

Borderline resectable criteria - CHA

A

contact without extension to celiac artery or HA bifurcation

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71
Q

Borderline resectable criteria - SMV/PV

A

> 180 contact

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72
Q

Unresectable criteria - SMA

A

> 180 degrees

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73
Q

Treatment paradigm for resectable pancreatic cancer

A

If R0: mFOLFIRINOX

If R1: postop CRT –> mFOLFIRINOX

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74
Q

CONKO study

A

RCT to surgery vs. surgery + adjuvant gemcitabine

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75
Q

Results of CONKO study

A

Improvement in 5 year OS from 10% to 20%

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76
Q

GI PRODIGE study

A

RCT of adjuvant mFOLFIRINOX vs. gemcitabine

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77
Q

Results of PRODIGE

A

OS advantage for mFOLFIRINOX

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78
Q

PREOPANC study design

A

RCT of (borderline) resectable patients randomized to

  1. Surgery
  2. Preop CRT with 3 cycles of gem
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79
Q

RT dose used in PREOPANC

A

36/15

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80
Q

Results of PREOPANC - R0 resections

A

Improved with CRT 71% vs. 40%

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81
Q

Results of PREOPANC - pN+

A

Improved with CRT 33% vs. 78%

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82
Q

Results of PREOPANC - OS

A

no difference

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83
Q

Results of PREOPANC - DFS/LRFS

A

Improved with CRT

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84
Q

LAP07 trial design

A

RCT with 2x2
First randomization: gem vs. gem/erlotinib
Second randomization: continued chemo vs. 54Gy + cape

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85
Q

LAP07 results

A
  1. No significant diff in OS

2. Improvement in local control 46% local progression (chemo) –> 32% (CRT)

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86
Q

What share of liver cancers are HCC?

A

70-85%

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87
Q

CT findings of HCC during arterial phase

A

brightly enhancing

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88
Q

CT findings of HCC during venous phase

A

washed out

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89
Q

CT appearance of cholangiocarcinoma

A

delayed enhancement, capsular retraction, focal internal calcs

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90
Q

What biomarker is associated with HCC

A

AFP

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91
Q

What level of AFP suggestive of HCC

A

> 400

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92
Q

What factors go into Childs-Pugh class

A
  1. Ascites
  2. Bilirubin level
  3. Albumin
  4. INR
  5. Encephalopathy
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93
Q

What is point range of Childs-Pugh class

A

5-15

Lower = better liver function

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94
Q

Childs-Pugh A

A

5-6 points

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95
Q

Childs-Pugh B

A

7-9 points

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96
Q

Childs-Pugh C

A

10-15 points

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97
Q

Components of MELD score

A
  1. INR
  2. Bilirubin
  3. Creatinine
  4. Sodium
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98
Q

What is 5 year OS for liver transplant for HCC and hilar cholangio

A

70-85%

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99
Q

What are criteria for liver transplant?

A
  1. Solitary tumor <5cm

2. 3 tumors all <3 cm

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100
Q

What tumors amenable to RFA

A

<3cm, not near large vessels

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101
Q

Other options for HCC (nonoperative candidates)

A

SBRT

Proton therapy

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102
Q

What dose of proton therapy for HCC

A

67.5 in 15

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103
Q

Local control for hypofractionted proton therapy

A

95% at 2 years

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104
Q

Control rates with RFA

A

90% for tumors <3cm

50% for tumors >3 cm

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105
Q

What is TACE?

A

Most often irinotecan eluting beads injected trans-arterially

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106
Q

What share of HCC comes from hepatic artery

A

80%

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107
Q

Where does normal liver parenchyma derive most of blood flow

A

portal vein

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108
Q

Does TACE have survival benefit?

A

yes, compared to best supportive care

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109
Q

Contraindications to TACE

A
  1. Thrombus in PV
  2. Encephalopathy
  3. Biliary obstruction
  4. Childs Pugh B/C
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110
Q

RILD

A

Elevation of AP

Anicteric hepatomegaly

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111
Q

What is predictor of RILD

A

Mean liver dose

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112
Q

What is the typical liver reserve needed for RT

A

700cc

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113
Q

SHARP trial

A

sorafenib vs. placebo, improves OS by 3 months, 3% response rate

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114
Q

mechanism of sorafenib

A

multikinase inhibitor (mostly VEGF)

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115
Q

side effects of sorafenib

A

hand-foot-mouth, diarrhea, mucositis

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116
Q

SWOG S0809 trial

A

single arm for gallbladder ca: looking at gem-cape –> surgery –> postop chemoRT

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117
Q

dose of postop RT used in SWOG study

A

45/54-59.4 Gy with cape

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118
Q

What imaging sequence should be used to visualize liver mets

A

use portal venous (liver is bright, tumors are hypointense)

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119
Q

What imaging sequence should be used for HCC

A

late arterial phase

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120
Q

Syndromes associated with colorectal cancer

A
  1. Lynch
  2. FAP
  3. IBD
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121
Q

Why do Lynch patients have better prognosis?

A

respond to PD-1 blockers

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122
Q

Which form of IBD has increased risk of CRC

A

chronic UC

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123
Q

What mutation is seen in 70% of CRC

A

APC

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124
Q

BRAF mutations like which area of colon

A

Right

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125
Q

If FAP, how often to get flex sig

A

q 1 year [often require colectomy]

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126
Q

HNPCC

A

colonoscopy q2y

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127
Q

What is most important determinant of OS for CRC

A

pathologic extent of disease

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128
Q

What is the uppermost portion of the rectum

A

peritoneal reflection

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129
Q

Length of rectum

A

15 cm

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130
Q

Distance for lower third of rectum

A

0-6 cm

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131
Q

Distance for upper third of rectum

A

12-16 cm

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132
Q

For men with newly diagnosed rectal ca they should also have what checked

A

PSA

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133
Q

What is the requirement for LAR

A

At least 2 cm distal margin on rectum

Sphincter needs to be functional

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134
Q

What are the indications for neoadjuvant chemoRT for rectal cancer

A

uT3/T4 or N+

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135
Q

What was research question in German Rectal Cancer Study?

A

preop CRT vs. postop CRT

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136
Q

What are the two arms of German study?

A
  1. preop: 50.4/28 with 5-FU days 1-5 weeks 1 and 5

2. postop: 55.8/31 with same chemo

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137
Q

Findings of German rectal study?

A

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
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138
Q

Swedish rectal cancer trial design

A

RCT of 25/5 –> surgery vs. surgery

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139
Q

Swedish rectal cancer trial results

A
  1. Decreased LRR from 27% to 12%

2. Improved 5 year OS

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140
Q

What was unique about Swedish study?

A

only one to show survival benefit

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141
Q

Why did Swedish study show OS benefit

A

no TME

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142
Q

Dutch CKVO trial

A

RCT of TME vs. 25/5 –> TME [improved LRR]

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143
Q

GTV for rectal cancer

A

mesorectum + internal iliac

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144
Q

Dose for rectal cancer

A

45 Gy to pelvis

5.4 Gy boost to GTV + 2 cm

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145
Q

CTVA definition

A

internal iliac, pre-sacral, perirectal

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146
Q

CTVB definition

A

external iliac

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147
Q

CTVC

A

inguinal

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148
Q

superior border of rectal field

A

L5-S1

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149
Q

inferior border of rectal field

A

below ischial tuberosity

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150
Q

How far below rectal tumor should you go

A

2.5-3 cm

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151
Q

Anterior-posterior border of rectal field

A

behind sacrum, behind pubic symphysis

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152
Q

What is the histology of anal cancer

A

75-80% SCC

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153
Q

how long is anus

A

4 cm

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154
Q

What HPV strains associated with anal cancer

A 
16
18
31
33
35
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155
Q

T1 anal cancer

A

2cm

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156
Q

T2 anal cancer

A

2-5 cm

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157
Q

T3 anal cancer

A

> 5 cm

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158
Q

T4 anal cancer

A

invades adjacent structures

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159
Q

What chemo regimen is used for definitive CRT for anal cancer

A

5-FU + mitomycin

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160
Q

Dose of 5-FU

A

1000 mg/m2 continuous infusion D1-4 and 29-32

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161
Q

Dose of mitomycin

A

10 mg/m2 bolus day 1, 29

162
Q

RTOG 05-29 dose for T2N0

A

42 Gy to elective nodes

50.4 to anal tumor

163
Q

RTOG 05-29 design

A

dose painting IMRT single arm phase II designed

164
Q

endpoint for RTOG 05-29

A

combined G2+ GI/GU toxicities

165
Q

dose for T3-T4 or N1-3

A

45 Gy to elective nodes
50.4 to nodes <3cm
54 to nodes >3 cm
54 to primary

166
Q

What did IMRT improve?

A

skin toxicity, severe GI tox, heme tox

167
Q

Follow-up for anal cancer

A

many who do not have CR at 11 weeks respond by 26 weeks

168
Q

When do you biopsy residual disease for anal cancer

A

only if progression. re-eval q4w until CR

169
Q

Sim parameters for gastric

A
  1. NPO 3-4 h
  2. Small amount of PO contrast 30 mins prior to scan
  3. Arms up
  4. 4DCT
170
Q

German rectal study subjects

A

823 patients
uT3/T4 or N+
Resectable

171
Q

What surgery was performed in German rectal study?

A

TME

172
Q

Pancreatic T1

A

<2 cm

173
Q

Pancreatic T2

A

2-4 cm

174
Q

Pancreatic T3

A

> 4 cm

175
Q

Pancreatic T4

A

Invades SMA, celiac axis, CHA regardless of size

176
Q

Pancreatic N1

A

1-3 regional nodes

177
Q

Pancreatic N2

A

> 3 nodes

178
Q

When should capecitabine be given wrt radiation

A

1 hr before

179
Q

What is typical capecitabine dose

A

825 mg/m2

180
Q

What were two arms in POET study

A
  1. Chemo (Cis/5-FU/LV) –> Surgery

2. Chemo (Cis/5-FU/LV) –> CRT (30/15) with cis/etop –> surgery

181
Q

Patients in POET study

A

uT3/T4 lower esophagus or gastric cardia

182
Q

Major critique of POET

A

underpowered as only enrolled 119/197

183
Q

Path CR rates POET

A

15% CRT vs. 2%

184
Q

At 5 years what was significantly better with CRT

A

locoregional relapse
local PFS
?OS (p=0.055),

185
Q

POET: What was 5 year OS with chemoRT

A

39% vs. 24.4% (p=0.055)

186
Q

Rates of colostomy for anal with definitive RT at 5 years

A

12% (per RTOG 9811)

187
Q

RTOG 98-11 design

A

chemo study

  1. 5-FU/MMC
  2. induction 5-FU/Cisplatin (2 cycles) –> 5-FU+MMC
188
Q

Minimum # of LN to be removed for colon cancer surgery to be deemed adequate

A

12

189
Q

Which pelvic nodes are regional for rectal ca in USA

A

only internal iliac

NOT obturator, external iliac, common iliac

190
Q

best chemo regimen for intrahepatic cholangio

A

gem-cis

191
Q

Chinese esophagus study (NEOCRTEC5010)

A

RCT of:

  1. Surgery (excellent technique with mediastinal sampling)
  2. Preop CRT (40Gy/20 with cis-vinorelbine) –> surgery
192
Q

What histology in Chinese esophagus study

A

SCC

193
Q

What improved in Chinese esophagus study

A
  1. OS
  2. DFS
  3. R0 resection
  4. Pathologic downstaging
194
Q

What LN are covered in rectal ca?

A

perirectal
presacral
internal iliac

195
Q

when would external iliac LN be covered for rectal?

A

if invasion into Gyn/GU structure

196
Q

Spinal level of SMA

A

L1

197
Q

Spinal level of IMA

A

L3

198
Q

What were the arms of the Polish II trial

A

short course (5x5) and 3 cycles of FOLFOX vs. long course (1.8 x 28) with concurrent 5-FU and oxali

199
Q

Which patients included in Polish trial

A

cT3 (fixed) or T4

200
Q

Short term results of Polish trial

A
  1. No difference in local recurrence or pCR
  2. Lower toxicity
  3. Improved OS at 3 years (73% vs. 65%)
201
Q

What changed in long-term follow-up of Polish rectal trial

A

OS difference no longer significant,
No difference in DFS
No difference in toxicity

202
Q

Recommended interval of surgery after preop CRT for rectal cancer

A

5-12 weeks

203
Q

OS in the CROSS trial for neoadjuvant CRT

A

49 months

204
Q

Sister Mary Joseph nodule

A

Periumbilical met through falciform ligament

205
Q

Virchow’s node

A

L supraclav mass through thoracic duct

206
Q

Krukenberg tumor

A

ovarian met

207
Q

Irish node

A

L axillary mass

208
Q

Blumer’s shelf

A

tumor spread to rectouterine pouch of Douglas

209
Q

Dosing of carbo in CROSS Trial

A

AUC 2

210
Q

Chemo used in CROSS trial

A

Paclitaxel + Carbo

211
Q

Dosing of carbo for NSCLC

A

AUC 5

212
Q

How was carbo given in CROSS

A

weekly

213
Q

Polish I study- when did patients have surgery after short course

A

<7d

214
Q

Arms of Polish I trial

A
  1. 5x5 –> surgery within 7 days

2. 50.4 with 5-FU/LV –> surgery 4-6 weeks later

215
Q

What was significant in Polish I trial

A

Early tox higher in chemoRT arm
pCR higher in chemoRT arm
NO DIFF in DFS, OS

216
Q

What was pCR rate in long course CRT

A

16%

217
Q

What determines pCR rates for rectal treatment

A

timing of surgery

218
Q

T1 [Liver]

A

Solitary tumor <2 or >2 without vascular invasion

219
Q

T2 [Liver]

A

Solitary tumor > 2 with vascular invasion

Multiple tumors, none >5 cm

220
Q

T3 [Liver]

A

Multiple tumors, one >5 cm

221
Q

T4 [Liver]

A

Involves major branch of portal vein or hepatic vein or direct invasion to gallbladder

222
Q

CRITICS trial studied which intervention

A

Gastric/GEJ

Postop Chemo vs. Postop CRT (45/25 in

223
Q

What is main message of CRITICS

A

Postop CRT is very poorly tolerated for gastric only about 50% completed therapy

224
Q

Results of CRITICS trial

A

No difference in OS or EFS

225
Q

Other postop CRT trials for GASTRIC

A
  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
Q

What about ARTIST II

A

Resected, N+ gastric cancer

Chemo (S vs. SOX vs. SOX-RT to 45 Gy)

227
Q

What were results of ARTIST II

A

No difference in EFS at 3 years, stopped early

228
Q

Pancreatic tumor with contact to IVC is considered

A

borderline resectable

229
Q

MAGIC trial results: OS

A

5 year OS 36 vs 23% favoring periop chemo

230
Q

INT 0116 trial results OS:

A

3 year OS 50 vs 41% favoring postop CRT

231
Q

Margins used in LAP-07

A

GTV and involved nodes 1 cm or more

PTV: GTV + 3cm sup/inf, 1.5 cm all other dimension

232
Q

What was the only thing significant in LAP-07

A

local control better with CRT

233
Q

PREOPANC study design

A

RCT of

  1. Immediate surgery
  2. Preop CRT to 36/15 with gem (3 cycles)
234
Q

Which groups had improved OS with preop CRT in PREOPANC

A
  1. Cohort who proceeded with surgery and adjuvant chemo

2. BORDERLINE resectable

235
Q

Siewert Type I

A

Distal esophagus within 1-5 cm from GEJ

236
Q

Siewert Type II

A

Originates in either:

  1. 1 cm proximal from GEJ
  2. Within 2 cm from GEJ in gastric cardia
237
Q

Siewert Type III

A

Originates 2-5 cm from GEJ in gastric cardia

238
Q

Describe chemo from Intergroup 116 trial

A

1 cycle 5FU/LV (day 1-5) then concurrent 5FU on first four/last 3 days of RT then 2 cycles 5FU-LV

239
Q

Why give LV with 5-FU

A

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
Q

RTOG 9704

A

Both arms postop chemo/CRT

5-FU –> CRT –> 5-FU vs. Gemcitabine –> CRT –> Gemcitabine

241
Q

RTOG 9704 results

A

trend towards improved OS for pancreatic head lesions (fully resected)

242
Q

Milan criteria for transplant

A
  1. single tumor <5 cm
  2. 2-3 tumors all <3 cm
  3. no vascular invasion
243
Q

When to evaluate anal cancer results

A

DRE at 8-12 weeks then q4 weeks until CR

244
Q

Dose of 5FU for continuous infusion

A

225 for 5-7 days a week during RT

245
Q

Dose of 5FU for bolus

A

400 over 4 days week 1 and 5 of RT

246
Q

Dose of xeloda for rectal

A

825 BID for 5 days a week during RT

247
Q

Which 5FU form needs LV

A

bolus

248
Q

Should bladder be full or empty for anal SCC setup?

A

full to displace bowel sup

249
Q

What is research question in Minsky esophagus study (Intergroup 0123)

A

benefit of dose escalation for definitive esophagus treatment

250
Q

Two arms of Minsky trial

A

64.8 vs. 50.4 both with cis/5FU

251
Q

Findings of Minsky trial

A

No benefit to dose escalation in terms of OS or LRF

252
Q

Which trial showed OS benefit to adjuvant CRT for resected pancreas

A

GITSG (40/20 split course with 5FU)

253
Q

ESPAC-1 trial

A

2x2 factorial design for resected pancreatic cancer with 4 arms

  1. Chemo alone
  2. CRT (20 Gy)
  3. Chemo + CRT
  4. Observation
254
Q

Findings of ESPAC-1

A

chemo significantly improved OS

CRT associated with adverse OS

255
Q

What circumference of bowel ok for trans-anal excision

A

<30%

256
Q

What max size for trans-anal excision

A

3 cm

257
Q

How far from anal verge ok for trans-anal excision

A

<8 cm

258
Q

Is adjuvant gem+cape superior to gem for resected pancreatic cancer

A

yes, superior OS, especially for margin negative tumors

259
Q

Acceptable chemo options for resected pancreatic cancer

A
  1. Gem-cape

2. mFOLFIRINOX

260
Q

Preferred chemo regimen for cholangio

A

gem-cis

261
Q

What is the proportion of rectal preservation after total neoadjuvant therapy with cCR

A

80%

262
Q

What is the concern to nonoperative mgmt

A

Inferior outcomes (OS) compared to patients who had pCR at time of TME

263
Q

Findings of Dutch D1D2 trial

A
  1. Improved local recurrence
  2. Improved regional recurrence
  3. Improved gastric cancer mortality
    NOT OS
264
Q

What is worse with D2 resection in Dutch trial

A

higher postop mortality, morbidity and reoperation rates

265
Q

Is D2 preferred operation for resectable gastric cancer

A

yes, spleen sparing

266
Q

Liver constraint for SBRT

A

at least 700 cc receives < 15 Gy

267
Q

Adjuvant chemo regimen for locally advanced rectal

A

6 months of FOLFOX q2w

268
Q

What is N1c for rectal cancer

A

tumor deposits in the subserosa, mesentery or nonperitoneal pericolic or perirectal tissues without regional nodal mets

269
Q

What is N2a for rectal cancer

A

4-6 LN

270
Q

What is N2b for rectal cancer

A

7 or more LN

271
Q

What is the typical boost field for preop rectal

A

2-3 cm on GTV plus full sacral hollow

272
Q

How far lateral should AP fields go for rectum

A

2 cm lateral to widest point of bony pelvis

273
Q

What is posterior extent of lateral rectal field for T3 tumor

A

2 cm posterior to presacrum

274
Q

What is posterior extent of lateral rectal field for T4 tumor

A

1 cm posterior to sacrum

275
Q

What is anterior extent of lateral rectal field

A

1 cm anterior to symphysis for anterior wall

Mid symphysis for posterior lesions

276
Q

How many nodes equate to N2 for pancreas ca

A

4 or more

277
Q

How many randomizations in LAP07

A

2

278
Q

What was first LAP07 randomization

A

gem (1000 mg/m2) vs. gem/erlotinib

279
Q

What was second LAP07 randomization

A

If no POD after 4 months chemo –>

  1. 2 months of gem
  2. CRT (54 Gy in 30 with concurrent cape)
280
Q

What was local tumor progression for chemo alone arm for LAP07

A

46%

281
Q

What was local tumor progression for CRT arm for LAP07

A

32%

282
Q

ESPAC-3 question

A

5FU or gemcitabine for adjuvant chemo

283
Q

ESPAC-3 result

A

no difference in OS but improved tox with gemcitabine

284
Q

ESPAC-4 question

A

gemcitabine-cape vs. gemcitabine alone for adjuvant chemo

285
Q

Major criticism of 98-11 anal trial (cis vs. MMC)

A

cis arm got induction chemo

286
Q

Findings of 98-11

A

Lower colostomy rate with MMC arm (10% vs. 19% with cis)

Improved DFS/OS for MMC arm

287
Q

What does SCV node reflect for esophagus cancer

A

M1 disease

288
Q

How many Whipples per year are considered high volume

A

15-20

289
Q

What histology included in POET trial

A

GEJ adenocarcinoma

290
Q

What was POET design

A
  1. cis-FU –> surgery

2. cis-FU (2 cycles) –> CRT (30/15 with cis/etop) –> surgery

291
Q

Major flaw with POET

A

underpowered, only enrolled part of patients

292
Q

Ultimately on POET, what was improved with CRT

A

Locoregional relapse
Local PFS
5 Yr OS (borderline, p=0.055)

293
Q

Anal N1a nodes

A

Inguinal
Mesorectal
Internal Iliac

294
Q

Anal N1b nodes

A

External iliac

295
Q

Anal N1c nodes

A

N1a and external iliac

296
Q

Chemo used in PREOPANC

A

gemcitabine days 1, 8, 15

297
Q

Which groups benefited from preopCRT (in terms of OS)

A
  1. Those who were resected and started adjuvant chemo

2. Borderline resectable disease

298
Q

Neuroendocrine tumors - better outcomes with functional or non-functional

A

functional

299
Q

Recommendations for resected biliary tract cancer

A
  1. If neg margins: adjuvant cape x 6 months

2. If R1: CRT [gem-cape –> RT to 54-59.4 with cape]

300
Q

Timeline for surgery after short course RT for rectal

A

within 1 week or delayed 6-8 weeks

301
Q

What did esophageal meta-analysis conclude OS benefit for neoadjuvant CRT

A

9% all cause mortality benefit for both adenocarcinoma AND SCC

302
Q

What did esophageal meta-analysis conclude OS benefit for neoadjuvant chemo

A

5% all cause mortality benefit for adenocrcinoma ONLY

303
Q

On CROSS study, share of CRT patients who had R0 resection

A

92%

304
Q

In CROSS study, share of surgery patients who had R0 resection

A

69%

305
Q

RTOG 85-01 design (herskovic)

A

Radiation alone vs. CRT

  1. RT alone (64/32)
  2. 50/25 with cis/5FU
306
Q

Importance of 85-01

A

established superiority of preop CRT to RT alone (OS advantage)

307
Q

For rectal if margin involved after CRT what is next step

A

Total neoadjuvant therapy (12-16 weeks of FOLFOX or CAPEOX)

308
Q

5 year OS on Herskovic study RTOG 85-01 for CRT

A

26%

309
Q

5 year OS on Herskovic study RTOG 85-01 for RT

A

0%

310
Q

Acute grade 3/4 tox in German rectal study

A

27% (preop)

40% (postop)

311
Q

Late grade 3/4 tox in German rectal study

A

14% (preop)

24% (postop)

312
Q

Pancreas T1a

A

<0.5

313
Q

Pancreas T1b

A

0.5-1

314
Q

Pancreas T1c

A

1-2

315
Q

Pancreas T2

A

2-4

316
Q

Pancreas T3

A

> 4

317
Q

Pancreas T4

A

invades SMA, CA, CHA

318
Q

Pancreas N1

A

1-3

319
Q

Pancreas N2

A

> 4

320
Q

Arms on NETTER-1 trial

A

Lu-Dotatate vs. somatastatin

321
Q

PFS advantage for Lu-Dotatate

A

55%

322
Q

Gallbladder T1a

A

lamina propria

323
Q

Gallbadder T1b

A

Muscle layer

324
Q

Gallbladder T2

A

Perimuscular connective tissue

325
Q

Gallbladder T3

A

perforates serosa, directly invades liver or other adjacent structures

326
Q

Gallbladder T4

A

invades main portal vein or hepatic artery or 2 extrahepatic organs

327
Q

Esophagus N1

A

1-2 regional nodes

328
Q

For esophagus, there are different staging systems by what

A

Histology - adeno and SCC

But not yp - same for both

329
Q

For esophagus, anatomic location of tumor is defined by what feature of tumor

A

epicenter (used to be top)

330
Q

What anal lesions should get consideration of 59.4

A

T3/T4
Residual disease after 45 gy
N+

331
Q

What patients included in Intergroup 116 trial

A

R0 resection of gastric or GEJ

332
Q

Rectal N1a

A

1

333
Q

Rectal N1b

A

2-3

334
Q

Rectal N1c

A

tumor deposits in subserosa, mesentery, perirectal tissues

335
Q

Rectal N2a

A

4-6

336
Q

Rectal N2b

A

> 7

337
Q

RTOG 0822 (Hong study) design

A

Using IMRT (45 Gy) followed by boost to 50.4 (3DCRT) to reduce grade 2+ GI tox

338
Q

What chemo used on 0822

A

Cape-Ox

339
Q

Why didn’t 0822 achieve endpoint?

A

Used oxaliplatin which has baseline rate of high GI tox

340
Q

Most common tumor of appendix

A

carcinoid

341
Q

ACT II trial design

A

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
Q

When did ACT II assess CR for anal cancer

A

26 weeks

343
Q

What did ACT II conclude about outcomes

A

5-FU/MMC should remain SOC, no advantage to maintenance chemo

344
Q

What dose of CRT did ACT II use

A

50.4 Gy

345
Q

How many lymph nodes is aspirational for gastric cancer resection

A

at least 15

346
Q

RTOG 87-04 design (Flam)

A

Anal SCC 45-50.4 Gy randomized to

a) 5-FU
b) 5-FU + MMC

347
Q

What were differences in MMC arm

A

Increased rates of

  1. Local control
  2. Colostomy free survival
  3. Disease free survival
348
Q

Does MMC have OS advantage

A

No

349
Q

Does MMC add toxiciy

A

yes, 23% vs 7% grade 4/5 tox

350
Q

new cases of anal cancer per year

A

8,500

351
Q

new cases of rectal ca per year

A

40,000

352
Q

new cases of colon ca per year

A

100,000

353
Q

stomach t1a

A

lamina propria or muscularis mucosa

354
Q

stomach t1b

A

submucosa

355
Q

stomach t2

A

muscularis propria (wall)

356
Q

stomach t3

A

penetrates subserosal connective tissue

357
Q

stomach N1

A

1-2

358
Q

stomach N2

A

3-6

359
Q

Stomach N3a

A

7-15

360
Q

Stomach N3b

A

> 16

361
Q

What is optimal way to give 5FU for rectal cancer

A

continuous infusion 225 mg/m2

362
Q

RAPIDO trial

A

RCT of locally advanced rectal

  1. 5x5 –> CAPEOX or FOLFOX –> surgery
  2. 50.4 with cape
363
Q

Findings of RAPIDO

A

short course improved

  • -pCR rate
  • -disease related failure
  • -distant met free survival
364
Q

Chemo used in ARTIST trial

A

capecitabine and cisplatin

365
Q

What surgery was done in ARTIST trial

A

D2 resection

366
Q

NCCN recs for margins on gastric surgery

A

no tumor on ink

367
Q

Primary prevention

A

interventions applied before any evidence of disease

368
Q

Secondary prevention

A

treatment of precancerous conditions

369
Q

Tertiary prevention

A

diagnosis and early/effective treatment of invasive cancer

370
Q

Chemo recommendation for resected low risk stage III disease (T1-T3/N1)

A

3 months of adjuvant CAPOX

3-6 months of adjuvant FOLFOX

371
Q

Chemo rec for resected high risk stage III disease (T4N2)

A

3-6 months of adjuvant CAPOX

6 months of adjuvant FOLFOX

372
Q

Adjuvant treatment recs for pancreatic NETs

A

No adjuvant treatment for completely resected tumors (even if mets too)

373
Q

Primary mgmt of pancreatic NETs

A

Surgery to primary and mets

374
Q

Number of colon cancer cases per year

A

100000

375
Q

Number of colorectal cancer cases per year

A

140000

376
Q

CROSS trial: R0 resection for CRT arm

A

92%

377
Q

CROSS trial: R0 resection for surgery alone arm

A

69%

378
Q

Staging for newly diagnosed rectal cancer

A
  1. Colonoscopy
  2. Pelvic MRI
  3. CT CAP
379
Q

Rectal ca doses for preop cases

A

45 Gy to whole pelvis

Tumor bed boost to 5.4 Gy

380
Q

Rectal ca doses for postop cases

A

45 Gy to whole pelvis

Tumor bed boost to 5.4-9 Gy

381
Q

Klatskin tumor

A

perihilar cholangio involving confluence of left and right bile ducts

382
Q

What did Garcia-Aguilar TNT trial show?

A

Dose dependent increase in pCR rates for each additional cycle of FOLFOX

383
Q

What is downside of TNT

A

increased heme toxicity

384
Q

What is PFS of definitive CRT for anal cancer

A

75% at 3 years

385
Q

Rate of pCR after neoadjuvant CRT on German Rectal Study

A

8%

386
Q

What MRI sequence is utilized for rectal cancer staging

A

T2

387
Q

Is muscularis hypointense or hyperintense on T2 MRI

A

hypointense

388
Q

What chemo is used for ACC

A

mitotane (inhibitor of steroidogenesis)

389
Q

What is role of postop RT for ACC

A

Decreased LRR

No difference in PFS/OS

390
Q

What esophagus preop CRT study enrolled just SCC

A

EORTC

391
Q

What esophagus preop CRT study enrolled just adenocarcinoma

A

Walsh (Irish)

392
Q

Swedish Rectal Trial

A

RCT of:

  1. Preop RT (5x5)
  2. Surgery alone
393
Q

What type of surgery in Swedish rectal trial

A

Non-TME

394
Q

Results of Swedish rectal trial

A

Improvements in OS, cancer specific survival, local recurrence

395
Q

CR rate for anus using 5-FU/MMC vs. 5-FU/cis

A

91% vs. 90% at 26 weeks

396
Q

OS in Swedish Rectal Trial

A

38% (RT, 5x5)

30% (surgery, non-TME)

397
Q

What did CONKO study show?

A

improved OS for gemcitabine vs. observation for R0/R1 pancreas resection

398
Q

When does RILD develop

A

2 weeks to 8 months post RT, most commonly within 3 months

399
Q

Main lab abnormality with RILD

A

elevated AP

400
Q

Clinical presentation with RILD

A

anicteric, painful hepatomegaly

401
Q

BED should be above ___ to improve LC and OS for cholangiocarcinoma

A

80.5

402
Q

Dose of paclitaxel for CROSS

A

50 mg/m2

RO Clinical Boards (13 decks)

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