Upper GI Flashcards
Distance from incisors
Cervical: 18cm
Upper 1/3: 24cm
Middle 1/3: 32 cm
Lower 1/3 : 40cm
What is the histology of a tumour at the cervical esophagus
Squamous cell carcinoma
Out of all the upper GI tumours, which location has the best prognosis
Cervical esophagus
What is the histology of a tumour at the thoracic esophagus
Combination of squamous and adenocarcinoma
What is the histology of the esophageal junction
Adenocarcinomas
What are the main histologies of the upper GI
Adenocarcinoma
Squamous cell carcinoma
What are the other lesser histologies of the upper GI
Muceoepidermoid
Adenoid cystic carcinoma
Melanoma
Small cell carcinoma
What are some risk factors that contribute to upper GI tumours
- smoking alcohol
- Barrett’s esophagus
- tylosis
- Plummer Vinson / Patterson Kelly syndrome
- caustic injury
- achalasia
- heliobacter infection
- Previous aerodigestive tract malignancy
Name the countries have the most occurrences of upper GI cancer to the lowest
- Iran / northern china
- Sri Lanka / India / South Africa / France / Switzerland
- japan / Great Britain / Canada
- USA
What age is upper GI most likely diagnosed
Age 60-80
What are the local / regional symptoms of a tumour in the esophagus
- dysphagia
- odynophagia
- Melena, hematochezia
What are the local / regional symptoms of a tumour in the airway
- cough
- shortness of breath
- pneumonia (TE fistula)
- stridor
What are the local / regional symptoms of a tumour in the mediastinum
- retrosternal pain
- hoarseness of voice
- SVC obstruction
- hemorrhage (erosion into aorta)
What are systemic symptoms caused by metastatic involvement in the esophagus
Cough
Shortness of breath
Bone pain
Headache
Where are systemic constitutional symptoms of upper GI
- weight loss
- anorexia
- fatigue
- fever
What are some tools for diagnosis for esophageal cancer
- barium swallow
- upper endoscopy / esophagogastroscopy (EGD) + biopsy
What are some staging procedures for esophagus
- CT chest / abdo
- OGD / EGD
- EUS
- PET
- Bronchoscopy
- Nasolaryngoscopy
- Bone scan
- CXR
What are the layers of the lumen
- mucosa
- submucosa
- muscularis propia
- adventia
If a tumour’s epicenter is within 2 cm of the esophagogastric junction and extends into the esophagus, what is it classified and staged as
Esophageal scheme
If a tumours epicenter involves the esophagogastric junction and is within the proximal 2cm of the cardiac what is it staged as
Esophageal
If a cancer’s epicenter is more than 2cm distal from the EGJ, what will they be staged as
Stomach cancer
What are forms of esophagus surgery
- transhiatal esophagectomy
- transthoracic esophagetcomy
- en bloc esophagectomy
What are the fractionations of esophageal cancer with chemotherapy
Cervical : 70/35
Resectable: 41.4 / 23
Unresectable concurrent: 50 / 25 , 50.4 / 28
XRT alone : 50/20 , 60/30
What are the fractionations of esophageal cancer with RT alone
50 / 20
60 / 30
What radiation therapy techniques are used in esophageal cancer
IMRT / VMAT
Inhaling and exhaling will move the gtv in which direction
Exhale (sup)
Inhale (inf)
What are some acute side effects of treatment for esophageal cancer
- esophagitis
- skin erythema/ dry desquamation
- tracheotomy
- pneumonitis
- gastritis
- fatigue
What are some late side effects of treatment for esophageal cancer
- stricture, fistula
- pulmonary fibrosis
- ischemic heart disease, pericarditis
- spinal cord myelopathy
- gastric ulcer
What are fractionations for palliative care of esophagus cancer
30/10
20/5
8/1
What are some predisposing conditions of gastric cancer
- nutritional (salt, nitrate, low vitamin A/C, smoked foods
- occupational (rubber coals)
- smoking
- HPV, EBV
- radiation exposure
- prior gastric surgery for ulcers
- genetic : type A blood, pernicious anemia, HNCC, Li fraumeni,
- precursor : adenomatous polyps, chronic gastritis
What counties is gastric cancer most common
Japan, South America, Eastern Europe, Middle East
What are stomach local/regional symptoms of gastric cancer
- dysphagia
- vomiting
- early satiety
- melena, hematochezia
What are abdominal local/regional symptoms of gastric cancer
- bowel obstruction
- malignant fistula
What are metastatic (systemic) symptoms that occur in gastric cancer AND esophageal cancer
- cough
- shortness of breath
- bone ache
- headache
What are constitutional (systemic) symptoms that occur in gastric cancer
- weight loss
- anorexia
- fatigue
- fever
What are some classic signs of stomach cancer (types of spread)
Peritoneal
Nodal
What are some examples of peritoneal spread
Krukenberg’s tumoru
Blumer’s shelf
Melena, hematochezia
What are some examples of nodal spread in stomach cancer
Left supraclavicular node
Left axilla
Periumbilical nodal deposit
What are the histologies of stomach cancer
Adenocarcinoma carcinoma
SCC
Adenocanthoma
Carcinoid
Lymphoma
Leiomyosarcoma
TNM staging for stomach cancer : T
1a: invade lamina propia, muscularis mucosae
1b: submucosa
2: muscularis propria
3: subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
4a: serous (visceral peritoneum)
4b: adjacent structures/organs
TNM staging for stomach cancer : N
1: 1-2
2: 3-6
3a: 7-15 nodes
3b: 16 or more nodes
What are the regional nodes of the stomach
- perigastric
- nodes along lesser and greater curvature
- left gastric
- common hepatic
- splenic
- cardiac arteries
- hepatodeodenal nodes
Regional nodes of the GE junction
- pericardial, left gastric, celiac, diaphragmatic, lower esophageal
What its the 5 year survival for node negative and positive
- : 40-60%
+ : 10-30%
What is the chance of local regional failure after resected gastric cancer
70-90%
What is the dose constraint of the spinal cord
< 5% receives > 45gy
0% receives > 50gy
What lymphnodes are included in the CTV post surgery
- gastric
- gastroepiploic
-celiac - porta hepatis
- subpyloric
- paraaortic
- gastroduodenal
- suprapancreatic
What part of the stomach is included in the CTV (what sites)
- proximal 1/3
For proximal T3/4 lesions a what part of the hemidiaphragm is included in the CTV
The medial 2/3 - 3/4 left hemidiaphragm
What part of the CTV is included for tumours invading the GE junction with positive lymphnodes
Distal 4cm of esophagus and periesophageal lymph nodes will be included
What part of the CTV is included for tumours in the distal 2/3 of the stomach
Retropancreaticduodenal lymphnodes (inferior boarder of L3/4)
What are some risk factors of pancreatic cancer
- smoking
- diet
- prior radiation
- genetic (10%) - BRCA2
- occupational exposure (chlorinated hydrocarbons, formaldehyde, pesticides)
- predisposing illnesses (chronic pancreatitis, diabetes)
Which races have the highest prevalence of pancreatic factors
US, black 12 / 100, 000
Japan, Europe, USA 9 / 100, 000
Hong Kong, Spain, Singapore 4 / 100, 000
What is the common histology of pancreatic cancer
Ductal adenocarcinoma
What are the other histologies of pancreatic cancer
Acinar cell
Adenosquamous carcinoma
Cystasquamous carcinoma
Cystadenocarcinoma
Papillary mucinous carcinoma
Signet ring carcinoma
Undifferentiated carcinoma
Giant cell carcinoma
Mixed type
Small cell type carcinoma
Unclassified
Pancreatoblastoma
What are some clinical manifestations of pancreatic cancer . And what percentage of these are present in patients
- pain jaundice
- weight loss
- epigastric pain
- diabetes
70-95%
How is pancreatic cancer staged
- CBC, lytes, CA19-9
- CT chest/abdomen/pelvis
- MRI pancreas
- ERCP/MRCP with biopsy
- endoscopic ultrasound with biopsy
What is the TNM staging for pancreatic cancer : T
T1: tumour is <2cm
T1a: tumour is < 0.5 cm in greatest dimension
T1b: tumour is between 0.5 and 1cm
T1c: tumour is 1-2cm
T2: tumour is between 2 and 4 cm
T3: tumour is greater than 4 cm
T4: tumour involves celiac axis, superior mesenteric artery, and or common hepatic artery regardless of size
What is the 5 year survival rate for PDAC
Pancreatic ductal adenocarcinoma <10%
What are the clinical challenges of PDAC
Few symptoms / late diagnosis
Early locoregional invasion and distant metastasis
Post operative recurrence
Resistant to chemotherapy and radiotherapy
What is the percentage of are patients resectable at diagnosis
Less than 20%
What are the major advances of PDAX
FOLFIRINOX
Gemcitabine/abraxane
SBRT
What is the treatment process of an SBRT pancreas
- EUS guided fiducial placement
- 33-40 in 5 fractions every other day
- need to be off chemo for 2 weeks then resume 2 weeks after SBRT
What is the 5th most common solid organ and 3rd most common cause of cancer death globally
Hepatocellular carcinoma
What is the gender ratio for hepatocellular carcinoma
Male to female 3:1
What is the percentage of hepatocellular carcinoma in less developed regions of the world
> 80%
What are the most common regions to have hepatocellular carcinoma
East Asia, Africa (middle, east, then west)
What age is hepatocellular carcinoma most common
6th decade of life
What is the 5 year survival rate for HCC
<12%
What are the screening tools for HCC for high risk patients
- liver U/S 6-12 months
- AFP 6-12 months (high false positive)
What are diagnostic tools for HCC
CBC, LFTs, Cr, coagulation profile, hepatitis profile, AFP
Triphasic CT or MRI
Calculate child Pugh score
Staging CT chest/abdomen/pelvis to rule out distant metastasis Post
Biopsy
What are curative options of HCC
- partial hepatectomy
- liver transplant
What are the Milan criteria
- Single tumour less than 5 cm
- Not more than three foci of tumour each one not exceeding 3cm
- No Angiovasion
- No extrahepatic involvement
What are some locoregional therapies of HCC
Tumour ablation (RFA)
TACE
SBRT
What RT modality is good for locally advanced HCC
- SBRT
What are some side effects to SBRT
Fatigue
RUQ pain
Nausea
Decline in liver function
Liver disease
What is the percentage of patients that have a recurrence in 5 years after partial hepatectomy
75%
What is the histology of liver cancer
Well differentiated or poorly differentiated
What is the treatment for cervical esophagus (and chemo and dosage pls!)
- primary treatment: XRT
- concurrent CRT
70/35 with cisplatin - advanced is palliation
What is the treatment for upper,middle, and lower esophagus (and chemo and dosage pls!) for resectable
Primary : surgery
Standard: resectable
- Neoadjuvant CRT (carboplatin and paclitaxel with 41.4/23)
What is the treatment for upper,middle, and lower esophagus (and chemo and dosage pls!) for unresectable
Primary: surgery
- concurrent CRT (50/25 or 50.4/28 with cisplatin and 5FU)
XRT alone = 50g/20 or 60/30
What is the diagnostic procedure for gastric cancer
- OGD/EGD + biopsy
What is the staging procedure for gastric cancer
- upper GI series (barium meal)
- OGD/EGD
- CT chest / abdomen
- laparoscopy
- bone scan
- CXR
What is the primary treatment for gastric cancer
Surgery
What is the treatment procedure for gastric cancer ? Doses pls
- surgery
- concurrent CRT
- chemo on 1st and last 3 days of XRT
- XRT dose: 45/25
- 1 month rest
- 2 more cycles of chemotherapy
- sometimes preoperative chemo to shrink tumour before surgery
Diagnostic procedures for pancreatic cancer
- CT abdo
- upper endoscopy
- biopsy
What is the staging procedures for gastric cancer
- ERCP
- MRI
CT chest/ abdo - bone scan
- CXR
How is M category defined in pancreatic cancer
- NCCN
Findings on imaging
Resectable, boarderline resectable, locally advanced unresectable, metastatic
What is the primary treatment for pancreatic cancer
- surgery
What is the primary treatment for pancreatic cancer
- surgery
What is the treatment procedure for resectable pancreatic cancer (chemo and doses included)
- adjuvant chemo
- adjuvant CRT if positive margins
- XRT : 45-54gy/25-30 with gemcitabine or 5FU)
What is the treatment procedure for resectable pancreatic cancer (chemo and doses included)
- adjuvant chemo
- adjuvant CRT if positive margins
- XRT : 45-54gy/25-30 with gemcitabine or 5FU)
What is the treatment procedure for boarder line resectable pancreatic cancer (chemo and doses included)
- Neoadjuvant (4-6 cycles of FOLFIRINOX)
- restage during chemo if no response : CRT (45-54/25/30 + gemcitabine)
- then surgery
What is the treatment procedure for boarder line resectable pancreatic cancer (chemo and doses included)
- Neoadjuvant (4-6 cycles of FOLFIRINOX)
- restage during chemo if no response : CRT (45-54/25/30 + gemcitabine)
- then surgery
What is the treatment procedure for locally advanced unresectable pancreatic cancer (chemo and doses included)
- indication chemo (4-6 months)
- concurrent CRT 50.4/28 + capecitabine
- SBRT 33-40gy/5
Primary: surgery
What are the diagnostic procedure for liver cancer
- triphasic CT
What are the staging procedures for liver
- triquad phasic CT
- MRI
- CT chest abdo pelvis
- Child Pugh score
- bloodwork
What is the treatment procedure for liver cancer
- primary : surgery Standard
- radiotherapy for bridging treatment before transplant or local control or if not suitable for surgery
- palliative : 8gy /1
What is the treatment procedure for liver cancer
- primary : surgery Standard
- radiotherapy for bridging treatment before transplant or local control or if not suitable for surgery
- palliative : 8gy /1
