Lower GI Flashcards
Dutch trial of HIPEC v 5FU alone
22.3 mo v 12.6 mo survival
Peritoneal Cancer Index scores
0 - no tumor
1 - tumors <0.5 cm
2 - tumors < 5 cm
3 - tumors > 5 cm
Drug for secondary prevention of CRC?
aspirin 325 daily.
Colonoscopy at what age for Lynch?
20
Can you use stage to select lateral margin on an APR?
yes
T1-T2 intrasphincteric dissection
T3 Extralevator dissection (ELAPE)
T4 ischeoanal dissection.
Peritoneal Cancer Index regions
0-8 are 3 x 3 grid of abdominal wall
9-12 small bowel
AJCC/CAP reccomended minimum lymph nodes in rectal cancer?
12
may not be achievable after preoperative therapy
mutations to check for on all stage IV CRC?
kras/nras mutation
BRAF V600E
Lynch mutations individual risk?
each changes cancer risk, but c-scope reccomendations don’t change
Screening for anal cancer in high risk populations?
anoscopy and anal cytology
NCCN position on lap v open rectal surgery?
Prefer open for threatened TME
can you just establish peritoneal access for HIPEC?
No, you need to clear all adhesions to get good exposure
second line for stage IV SCC after chemo
Nivolumab or pembrolizumab
What is short course radiation for rectal cancer?
European standard of care, usually for all patients:
5 Gy x 5 days, OR next week
PET recommended for CRC surveillance?
No (unles CEA up and CT negative)
Sensitivity of staging modalities for nodal disease in rectal cancer?
ultrasound and MRI are both ~70% sensitive
Other cancers with Lynch and screening?
Pancreatic - no screening Breast - no extra screening Prostate - no extra screening Endometrial - some doing transvaginal US Ovarian - some doing transvaginal US
Definition of a malignant polyp?
cancer invading thru the muscularis mucosa into the submucosa (T1)
Transanal Local Excision for Rectal Cancer
< 30% of circumpherence <3 cm tumor >3 mm margin Mobile 8cm from the anus T1 full thickness excision no lymphadenopathy
Radiation dose for anal SCC
54-59 Gy to tumor unless T1N0
30-36 Gy to inguinal lymph nodes
When is PROSPECT trial results expected?
at half accrual in 2019
What is rate of CRC pelvic sidewall node positivity?
In retrospective Japanese series with no RT and routine sidewall dissection, rate is 7%.
When to do serial CTs for SCC?
T3 or N+
management of stage IV mucinous appendiceal tumor if not a HIPEC candidate?
do a biopsy to establish grade. no chemo for low grade
can still live 10 years in stage IV
T staging of anal SCC
T1: <2cm
T2: 2-5cm
T3: >5cm
T4: invades vagina, bladder, urethra
Unresectable rectal cancer
Sacral involvement above S2
Acetabular involvement
Common or external iliac involvement
Solid Mucinous appendiceal tumor in two locations?
Stage IV and not a HIPEC candidate since it is beyond peritoneal spread.
Where is radiation given for rectal cancer?
include tumor with a 2-5 cm margin, presacral nodes and internal iliac nodes.
Include perineal incision in an APR
“German Rectal Trial”
JCO 2012 - post-op rectal radiation had more local recurrence than preop
which is worse prognosis for CRC portal nodes v aortic nodes?
aortic nodes.
which is worse, peritoneal mets or omental mets?
omental mets
Chemo for stage II MSI high rectal cancer?
no!
How does rectal irradiation effect continence rates?
doubles rate of incontinence.
Local recurrence rate for Rectal cancer, CME v non CME?
8% v 20%
4 RCTs comparing lap to open colectomy for CRC?
Classic
Corean
Color2
ACOSOGZ605/ALaCarte
NCCN watch and wait for complete clinical response rectal cancer statement?
may be considered in experienced centers if negative on DRE, MRI and endoscopy.
Should involve careful discussion, and risks not adequately characterized.
How do you treat a rectal cancer patient with extensive pelvic lymphadenopathy?
Cite japanese data re: >3LN
3 months FOLFOX -> restage
Pelvic chemoradiation -> pelvic MRI
Surgery, to include pelvic sidewall dissection.
Rate of local recurrence for colon cancer, all comers?
6%
Favorable histologic features for a colon polyp?
gade 1 or 2
no angiolymphatic invasion
negative margins
what % of patients will have long term side effects from oxalliplatin?
20%
Data on overall survival benefit of CME?
Danish national retrospective data showed clear OS benefit for stage I and II, but not stage III.
Response rate for FOLFOX/cetuximab in stage IV
30%
SCC anal cancer with metastatic disease
still do RT give FOLFOX
When is CRC pelvic nodal disease stage IV?
In retrospective Japanese series, 3 or more positive pelvic nodes has same survival as stage IV disease.
use this to support systemic chemo upfront for patients with extensive pelvic nodal disease.
Threatment for painful oxaliplatin neuropathy?
duloxetine
(serotonin-norepinephrine reuptake inhibitor)
doesnt work for non-painful neuropathy
How do you do a pelvic sidewall dissection?
Would get preop stents in the ureter
Do rectal dissection in CME plain,
localize and place vessel loop around the ureter
obtain vascular control of the interal iliac and obterator.
ligate the internal iliac at its origin
Ligate the internal iliac and obterator at the exit points of the pelvis.
Take all nodal tissue from the region staying just superficial to the obturator nerve and sacral plexus.
CRC with BRAF V600E mutation?
automatically not Lynch disease, even with MLH1 abscence
Transanal excision of rectal carcinoid?
OK for low-grade tumors <1cm
Do you need to biopsy pelvic lymphnodes for CRC recurrence?
divided opinion, but PET avid nodes with high CEA is reasonable enough evidence
Ostomy support group
send the referral, maybe that scores one point.
Which two Lynch genes are highest risk for CRC?
MLH and MSH2 have 80% lifetime risk
Lynch syndrome genes
MLH1 MSH2 MSH6 PMS2 EPCAM
Radiographic response rate of CRC to FOLFOX?
40%
rectal ca surveillance Stage II-IV
Visit q3 months for 2 years then q 6 months for 3 years
CEA every visit
Scan every other visit
How often to asymptomatic CRC patients become symptomatic during neoadjuvant?
<15% of patients
Definition of Clear CRM
greater than 1 mm from the mesorectal fascia, levator muscles and not invading the intersphincteric plane.
How do you divide the lateral rectal ligament?
close to rectal wall to avoid nervous injury.
Give local RT in stage IV SCC?
generally yes unless poor life expectancy and disseminated metastatic disease.
Can do 5 Gy x 5 treatments in extreme palliative situations.
Response rate of FOLFOX in stage IV if already got as adjuvant?
15%
MRI shows 6mm pelvic sidewall lymph node after neoadjuvant chemoradiation for rectal cancer?
would add pelvic sidewall dissection for any nodal disease > 5mm.
Appendix NETs?
Tumor < 2 cm at tip - appendectomy
Tumor < 2 cm with local invasion or poor histology - R hemicolectomy
Tumor > 2 cm - right hemicolectomy.
Isolated inguinal recurrence of SCC?
Inguinal LND
add chemoradiation if groin did not previously get it.
Lymphatic spread in rectal cancer?
above the peritoneal reflection goes to abdominal mesenteric nodes.
below the peritoneal reflection goes to abdominal mesentery and pelvic nodes.
Rectal carcinoid?
< 1cm and well differentiated - transanal excision
> 2cm or T2 - LAR/APR
appendix cancer, who gets HIPEC?
low grades with cellular mucin
intermediate and high grade
TNT trial
for the “really bad” rectal cancers where poor outcomes are expected (5 cm from anal verge T3N+)
8 Cycles of FOLFOX
5FU/XRT (with experimental arms for targeted therapies)
Then surgery
When to do radiation for rectal cancer with liver mets?
controversial; favor systemic therapy.
Is there a demonstrated benefit to extralevator dissection (ELAPE) on an APR?
not demonstrated, does increase morbidity.
Persistent SCC after Nigro Protocol?
continue to examine every 4 weeks for up to 26 months. Biopsy if progressing and restage.
[ACT-II RCT Lancet Oncology 2013]
bevacizumab warnings
do not use 6 weeks before or after surgery
increased risk of stroke and arterial events
Is there good literature on extended nodal management of CRC nodes?
hard to find good literature…
Many studies lump synchronous and metachronous nodal disease.
Japanese have extensive retrospective data on routine pelvic side wall dissection
Two things to add to consent for HIPEC
development of short gut with lifelong TPN
permanent Ostomy
Is there a higher rate of complications with CME?
some retrospective series say yes, hard to tell if there is a learning curve issue here
Differences in response to American v “Short Course” RT for rectal cancer?
No downstaging or cPR rate with short course since you operate one week later.
Toxicity of mitomycin-c (HIPEC)
can cause acute pulmonary toxicity during HIPEC
can cause neutropenia post-op
Change chemo plans based on HIV status?
no!
Treatment for pT1-2N0 rectal cancer after resection?
observation
Resect fibrolamellar HCC with +LN or limited carcinomatosis?
limited retrospective data supports.
When to do 5-FU over capecitabine?
only reason to have to do 5FU is non-compliance with oral capecitabine.
Treatment options for T3 N any with involved CRM rectal cancer?
same as for clear CRM but must restage after chemoRT and go to FOLFOX (12-16wks) if CRM still involved.
Sessile rectal polyp with T1 adenocarcinoma and clear margins?
observation may be considered, but do much worse than pedunculated lesions.
Need endorectal gel or coils for staging MRI?
no!
Radiosensitive structure for pelvic radiation?
Try to limit dose to the femoral heads to reduce radio-osteonecrosis.
Appendiceal carcinoid >2cm incidental on appendectomy?
Do systemic staging if not done.
Right hemicolectomy?
workup for SCC anal cancer
DRE and physical exam of inguinal nodes
Full body CT, can consider PET (helps Rad/Onc aim)
Anoscopy
HIV testing
GYN exam to test for concurrent cervical cancer.
Is there a survival benefit for the addition of oxaliplatin for elderly colon cancer patients?
Has never been proved for patients >70 yo.
Is there a benefit to using FOLFOX during rectal RT?
No!
5 seperate RCTs have investigated and all showed no benefit and increased toxicity
Summary of lap v open RCTs for CRC
Statistical proof of non-inferiority has never been reached, but outcomes are generally within a few percent/months to make differences clinically insignificant.
Many early studies did not to a good job standardizing surgical quality on MIS operations and there were learning curve factors.
Trying neoadjuvant for CRC and “really need a response”?
FOLFOXIRI has a 60% response rate;
would be hesitant to add if planning a liver resection
anal recurrence of SCC?
APR +/- Inguinal LND
Treatment for pT4 or pN+ rectal cancer after resection
Chemotherapy (FOLFOX prefered), then chemoradiation.
Risk factors for fibrolamellar variant of HCC?
Young women;
no association with Hep B/C
Treatment options for T3 N any with clear CRM rectal cancer?
Chemoradiation -> surgery -> systemic chemo
syst. chemo -> cheomrads -> surgery
Is there a consensus on a “negative margin” for polyp removal?
No!
most conservative is tumor cells within 2 mm
rectal ca surveillance Stage I or below
C scope at 1, 3 and 5 years
What to do for young patient before pelvic radiation?
council on infertility and offer egg and sperm banking.
First degree relative with CRC, when to start c-scopes?
age 40.
appendix cancer, who gets systemic chemo?
All high grade and intermediate
Should you ever do a “node plucking” operation for CRC nodes?
no
PET for resectable rectal cancer?
specifically not indicated per NCCN
Resectable colon cancer with obstruction?
Attempt preoperative stent first.
follow-up after initial treatment of SCC?
DRE/exam in 3 months then q 3-6 months for 5 y
Anoscopy q 6-12 months for 5 years
What do you do with complete radiographic response for CRC mets? (cPR rate?)
still need to resect; cPR is 25% in setting of complete radiologic response.
Evidence for adding bevacizumab to chemo for stage III colorectal cancer?
multiple negative RCTs
Pedunculated rectal polyp with T1 adenocarcinoma and clear margins?
observe
PROSPECT trial?
not-resulted
1:1 randomization of rectal cancer to FOLFOX instead of chemo/RT;
skip chemoRT if tumor responds to FOLFOX
What is median OS on non-surgical management of isolated CRC nodal disease?
2-3 years
MRI definition of rectum [nccn]
between a virtual line from the sacral promontory to the pubic symphysis
Why do you need 5 cm distal on rectal margin?
to get remaining rectal nodes
NCCN guidelines for distal margin on rectal cancer?
if above 5 cm, then take 5 cm distally
if in last 5 cm then get a 2 cm margin and check a frozen.
Most common location of pelvic CRC metastasis?
Internal iliac and obterator nodes
What is a D3 resection for right sided colon cancer?
skeletonize the SMA/SMV; very limited evidence to support and high morbidity
Key MERCURY study finding
tumor within 1mm of CME margin on MRI predicts a positive radial margin after surgery.
surveillance after transanal excision of rectal cancer
add MRI or EUS q 6 months for 5 years.
Is there an OS benefit to Adj/NeoAdj RT for rectal cancer?
Debated on individual studies, but Cochrain Review suggests yes
Presacral tumor?
Should be able to make the diagnosis based on MRI features.
Do DRE, if you can reach your finger above it, remove it from a perineal approach.
Surveillance for Lynch syndrome patient?
colonoscopy every 1-2 years starting at age 20
Need to revise an ultra low colorectal anastomosis
pursestring the rectal stump closed transanally. Redeploy the circular stapler.
perianal scc
within 5cm of anal verge
T1N0 well differentiated - local excision to negative margins. (1 cm clinical)
>T1N0 well diff -> capecitabine/mitomycin +RT
Treatment for pT3N0 rectal cancer after resection?
chemoradiation (5FU/RT) followed by 5FU chemo alone
What to do after 5 years of NED from CRC
no more routine CEA or CT scans
Colonoscopy starts at age?
45
[new nccn 2019]
systemic targets for fibrolamellar HCC/
There is a known common gene fusion that may eventually become a target, but currently no cell lines and no clinical evidence.
watch and wait a complete clinical response for adeno CRC on boards?
Only on trial.
operative points for a small bowel carcinoid?
examine liver
run the bowel to look for synchronous tumor (25% of cases in some series)
