Lower GI:

Question 1

% anal ca presenting with DM?

% with pelvic LN?

Answer 1

DM <5%. PA LN+ is M1. usually DM in liver or lung

pelvic LN 30%.

Question 2

Anal ca, + R inguinal node and L internal iliac N stage is?

What about R inguinal node and perirectal N?

Answer 2

N2. inguinal node can either be ipsilat or contralat. dont need iliac involvement for N2 if inguinal +. For second question: N3.
N3 Is inguinal and perirectal
N3 is b/l internal iliac.
N3 is inguinal, perirectal and b/l internal iliac

Question 3

what is the anatomic boundary of the anal canal?

Answer 3

superiorly: puborectalis sling, this is 1-2cm proximal to the dentate line and ends inferiorly at the perianal skin or inferior portion of the internal sphincter muscle.

Question 4

What is the 5yr OS of Stage I anal?

Answer 4

85%

II-IV= 75%, 50%, 5%.

Question 5

On Nigro trial what was pCR rate with chemoRT?

Answer 5

5FU, MMC RT 93% cPR rate.

Question 6

RTOG 9811 randomized what in anal ca?

Improvement in what?

Answer 6

induction 5FU/cis with concurrent 5FU/cis+RT vs RU/MMC+RT.
improvement in colostomy free rate with MMC. 10 vs 19%*. at the cost of bad heme toxicity in MMC. Same 5yr DFS, OS, LRF and DM.

Question 7

RTOG 0529 what dose do you need for 3cm anal primary and inguinal node 3.5cm?

Answer 7

54 Gy to both. T2N2.

Question 8

4cm rectal adeno, invasion into muscularis propria and one LN 1.5cm. Stage?

Answer 8

T2N1.  from lumen: lamina propria, submucosa, muscularis propria, serosa.
T1: submucosa
T2: muscularis propria
T3: pericolorectal tissue
T4a: surface of visceral peritoneum
T4b: adherent to other organs/structures
N1: 1-3 regional nodes. N2: 4-6LN

Question 9

German Rectal compared what?
what was the diff in OS?, LR? toxicity? sphincter preserving rates?
pCR?

Answer 9

preop vs postop chemoRT in rectal, 823pts with cT3-4 or N+ randomized to TME+ adj chemoRT(55.8Gy) and 5FU vs preo chemoRT(50.4Gy)+TME wtih 5FU.
preop chemoRT improved LF 6 vs 13%, in 2012 now 7 vs 10%. Same OS, DFS. 39 vs 19% had sphincter preserving surgery with neoadj chemoRT.
postop chemo RT had higher rates of chronic diarrhea and strictures at the anastomotic site.
pCR rate was 8%

Question 10

What study required TME?

Answer 10

Dutch trial. this randomized preopRT (25Gy in 5) TME or TME alone. better 2yr LC (2 vs 8%). 92% in MRC CR07 got TME. Swedish did not require TME.

Question 11

What did the MRC CR07 trial show?

Answer 11

short course(5x5) preopRT vs surgery with selective postop 5FUchemoRT(45Gy/25fx) with +margin. 92% got TME. 
preop RT showed better 3yr LR 4 vs 11%. better 3yr DFS 77 vs 71%. OS no change.

Question 12

Dutch trial showed what for preop RT vs TME alone for toxicity?

Answer 12

preop RT had higher rates of fecal incontinence, 62% vs 38%. same rates of stoma function, urinary fxn and hospital rates.

Question 13

UKCC ACTII for anal cancer randomization?

Answer 13

RT vs chemoRT. 2x2 randomization. 1) 50.4Gy+5FU/cis, 2) 50.4Gy+5FU/MMC, then randomized to +/- maintenance chemo cis/5FU or nothing. CR, 95%, was the same between MMC and cis. maintenance chemo did not impact OS, RFS nor reversal of colostomy. same outcomes May 2013, updated.

Question 14

what did RTOG 8704 show?

What does MMC benefit?

Answer 14

anal ca randomized to 45-50.5Gy+5FU vs 45-50.4Gy+5FU/MMC.
need MMC, it decreases the colostomy rate and the LC at the cost of increased toxicity. colostomy rate was lower in MMC, 9 vs 22%. LC better 16 vs 34%. CFS was also higher 71 vs 59%. same OS.

Question 15

T3N1 rectal adeno received chemoRT then APR. what is the next step in tx?
If she recurrs in 2 mos, waht do you do?

Answer 15

adj 5FU/LV x 6 mos, FOLFOX or xeloda+/- oxaliplatin.

if recurrence, then try to repeat hyperfx RT or chemoRT, then surgery.

Question 16

what must be covered in T4 GI lesions?

Answer 16

External iliac nodes.
T3 can place the anterior part of the laterals block behind the pubic symphysis. for T4 place the block in front of the pubic symphysis

Question 17

what age do you start colon ca screen in average risk pts?

Answer 17

age 50. colonoscopy q 10 yrs or flex sign, dc barian enema or CT colonograph q 5 yrs.

Question 18

for metastatic rectal adeno, mutated KRAS means?

Answer 18

poor response to tx wtih cetuximab tx.

cetuximab (antibody for epidermal growth factor receptor) is more effective in wild type KRAS.

Question 19

GITSG 7175 for adj tx in rectal cancer showed?

Answer 19

4 arm study to determine optimal adj tx. 1)surgery, 2)surgery+40 or 48Gy, 3) surgery +chemo, 4) surgery+chemoRT. chemo was 5FU and MeCCNU. lowest recurrence rate in adj chemoRT 33% vs 55% with surgery alone. There was an OS benefit with chemoRT vs observation, 45 vs 27%

Question 20

what did MOSAIC trial in adj chemo for resected colon cancer show?

Answer 20

Stage I/II colon cancer s/p surgery got FOLFOX or 5FU/LV. OS benefit in stage III, not stage II. but improved DFS in all wtih folfox.

Question 21

after skin cancers, rectal cancer is the __ most common cancer in the US?

Answer 21

3rd!

40,000 cases annually, incidence is decreasing due to screening