pancreatic

Question 1

pancreatic cancer mutations

Answer 1

p16 80%; p53 70%; SMAD4 55%; K-RAS 90%; the more the worse

Question 2

risk factor pancreatic cancer

Answer 2

A-A, male, tobacco (RR 2.5), obesity, fat/alcohol, chronic pancreatitis, diabetes, chronic hep B/C, cirrhosis

Question 3

familial pancreatic cancer

Answer 3

10% of patients; BRCA, peutz-jegher, HNPCC (MLH1,MSH2), ataxia telangiectasia

Question 4

resectable pancreatic cancer treatment

Answer 4

2 options: up front surgery versus NACT +/- chemorad

Question 5

borderline resectable pancreatic treatment

Answer 5

favor neoadjuvant with chemoradiation (one of only situations where chemorad is used)

Question 6

pancreaticoduodenectomy

Answer 6

mortality 2-4% morbidity 30%, high volume center maximizes outcome

Question 7

post-op chemo for pancreatic

Answer 7

CONKO-001: gem v. observation–> doubling of OS; 10yr OS 12.2 v 7.7%; ESPAC-3: compare to 5-FU: no difference, gemcitabine better because of improved toxicity

Question 8

gemcitabine complications

Answer 8

HUS, pneumonitis

Question 9

adjuvant chemoradiation in addition to adjuvant therapy?

Answer 9

NO, inferior

Question 10

adjuvant 2 versus one chemo?

Answer 10

all pending trials

Question 11

adjuvant S1 v. gem?

Answer 11

70 v 53% 2yr OS in favor of S1! but was non-inferiority endpoint

Question 12

pancreatic adeno thromboembolic events

Answer 12

20-50% rate

Question 13

metastatic: gem v. 5-FU

Answer 13

gem 18% 1yr OS v. 2%

Question 14

chemo metastatic setting

Answer 14

addition to 5-FU or platinum to gem might be better

Question 15

Prodige 4-ACCORD 11

Answer 15

ECOG0-1, FOLFIRINOX v. gemcitabine–> 11.1 v 6.8mo, delays worsening quality of life; ORR rate 31 v 9.4%,

Question 16

FOLFIRINOX tox

Answer 16

neuropathy, febrile neurtopenia 5%, thrombocytopenia, neuropathy, diarrhea 13%, vomiting 14%

Question 17

MPACT

Answer 17

KPS 70-100; Nab-pac + gem v. gem; OS 8.5 v 6.7mo, worsening neuropenia,fatigue,neuropathy

Question 18

erlotinib data in pancreatic

Answer 18

PA.3–> 6.24mo v 5.9mo median OS but significant. FDA APPROVED WITH GEMZAR!

Question 19

GERCOR phase III trial- locally advanced

Answer 19

gem +/- erlotinib, then +/-chemoRT–> adding erlotinib worse; chemoradiation not clearly better

Question 20

well-diff neuroendocrine tumor

Answer 20

mostly aerodigestive tract (carcinoid)

Question 21

PNET

Answer 21

pancreatic neuroendocrine; only <20% functional

Question 22

behavior of NE tumors

Answer 22

look at differentiation and Ki67 and grade (high grade >20mit/HPF and 20%ki67

Question 23

PROMID study

Answer 23

octreotide v. placebo: 14.3mo time to tumor progression v 6mo

Question 24

genetic mutations in pancreatic

Answer 24

KRas, P16, p53, SMAD4, BRCA1/2 (5%), MMR, STK11(Peutz-Jeghers), FANCC/FANCG (fanconi)

Question 25

Whipple surgery for pancreas

Answer 25

mortality <.5% in major institutions, median survival 2years. complicated by leaks, fistula

Question 26

borderline resectable pancrease cancer

Answer 26

significant venous involvement, but not arterial. favor neoadjuvant therapy and re-staging. may require vascular resection

Question 27

adjuvant chemo for pancreas

Answer 27

CONKO-001 trial- gem v. observation, doubling of DFS, 2.6month improved OS. doubling of 5yr survival (20v.10), 12% 10-year survival. if gem not tolerated (pneumonitis), can complete adjuvant therapy with bolus 5-FU which has same survival.

Question 28

pancreatic cancer sequelae

Answer 28

50% thrombolic,

Question 29

prognosis pancreatic

Answer 29

ECOG2 2.8mo OS, 0 OS 8mo

Question 30

first line metastatic pancreas

Answer 30

gem>5, 1yr OS 18% v. 2%

Question 31

FOLFIRINOX for pancreatic ca

Answer 31

FOLFIRINOX v. gem- PS0-1, improved OS 11.1 v. 6.8mo, delays worsening of QOL,

Question 32

FOLFIRINOX toxicities

Answer 32

myelosuppression, GI tox, need for GMCSF, LFTs, 9% neuropathy. age limit 70, only ECOG 0-1

Question 33

nab-taxol + gem v. gem for pancreatic

Answer 33

improved OS 8.5 v. 6.7mo, significant,

Question 34

locally advanced pancreatic

Answer 34

if no progression after chemo, may consider switching to chemoRT with 5-FU based regimen but no data to support

Question 35

second line chemo for pancreatic

Answer 35

FOLFOX, what you didn't get

Question 36

well-diff PNET when to tx

Answer 36

treat if uncontrolled Sx, or progression under observation

Question 37

when to resect a PNET

Answer 37

can debulk if a lot of symptoms with some benefit. if resectable, can resect

Question 38

treatment of PNET options

Answer 38

octreotide v. placebo- time to progression 14.3 v. 6mo; lanreotide is subQ monthly, improved PFS.

Question 39

other tx for PNET

Answer 39

temozolamide, strep/dox, 5-FU, regional approaches, pancreas-sunitinib, everolimus, maybe somatostatin analogues

Question 40

Peutz-Jehgers

Answer 40

STK11/LKB1 gene mutation. mucocutaneous lesions, hamartomas of GI tract, pancreatic cancer, breast, lung, ovarian

Question 41

adjuvant radiation for pancreas

Answer 41

no definitive data, can give adj chemo+5-U +/- gemcitabine (pre and post)

Question 42

unresectable pancreatic cancer

Answer 42

standard is infusional 5-FU/RT --> gem alone. Alternative is gem alone (no RT). no data yet on nab/gem or FOLFIRINOX

Question 43

MENI

Answer 43

pancreatic neuroendocrine tumors, pituitary tumors, parathyroid tumors (men 1)

Question 44

MENII

Answer 44

RET gene- parathyroid tumors, pheo, and medullary thyroid [2 is worse]

Question 45

carcinoid tumor prognossi

Answer 45

great if resected and LN-negative. latent mets frequent if LN-positive

Question 46

appendix carcinoid management

Answer 46

appendectomy if

Question 47

intestinal carcinoids

Answer 47

only have systemic symptoms if liver mets (due to liver first pass clearance)

Question 48

carcinoid evlauation

Answer 48

if long disease course, need echo to look for R side of heart. PET is bad. get octreotide scan or CT/MRI

Question 49

carcinoid/PNET resections

Answer 49

can be complete, or palliative for debulking

Question 50

therapies for carcinoid

Answer 50

octreotide, interferon alpha (superior to streptozocin/5-FU)

Question 51

standardtherapy for non-carcinoid PNET tumor

Answer 51

streptozosin + doxorubicin

Question 52

poorly differentiated gut neuroendocine tumors therapy

Answer 52

small cell regimens: etoposide/cisplatin

Question 53

PNET alternative therapies

Answer 53

sunitib, everolimus. NOT effective for carcinoids

Question 54

high grade neuroendocrine/carcinoid

Answer 54

TREATED AS SMALL CELL/LARGE CELL-- chemo