Upper GI Flashcards
post-op therapy for esophageal SCC?
no systemic until progression.
GE cancer with positive supraclavicular node?
unresectable per NCCN guidelines
Longterm survival of T1b GE cancer?
Not good, need agressive surveilance or go to esophagectomy
Esophageal Stent at the diagnosis of GEJ cancer?
Only if patient will never be a surgical candidate or if they cannot swallow their own saliva.
Ideal lymph nodes for GE cancer staging?
15 if no preop therapy
undefined after neoadjuvant therapy but try for 15
Anatomic definition of proximal location of resectable esophageal cancer?
any tumor >5cm from the cricopharyngeus
What % of patients tolerate chemo/RT after GE junction resection?
Only a little over half the patients in MacDonald completed therapy.
What test before starting systemic therapy for esophageal adeno?
check HER2 status
Level of evidence for endoscopic resection of esophageal cancer?
large institutional data, no level I, but accepted.
Follow-up for gastric cancer?
Would get serial CT scans, but little evidence to support.
EGD surveillance after endoscopic resection/ablation of esophageal cancer?
start with q3month deescalate to yearly after 3 years
EUS after nonsurgical therapy for gastroesophageal cancer?
considered less reliable
[nccn 2019]
Trastuzumab for HER2 GEJ cancer?
add to chemo for all stage IV
[NCCN 2019]
Things to check before starting neoadjuvant therapy for GEJ cancer?
nutrition status and think about a j-tube
When is endoscopic resection likely to be fully therapeutic? (esophageal SCC - 5)
lesion <2cm lesion fully removed well to moderate differentiation superficial to submucosa no LVI
Value of PET for gastroesophageal cancer?
No evidence it is superior to CT scan for staging.
Radiation Oncology uses for treatment planning.
Criteria to conservatively manage a thoracic esophageal leak?
<1/3 of circumpherence of esophagus
No evidence of ischemia.
When to do endoscopic resection?
Any nodular lesion <2cm.
If it is not therapeutic then it is more diagnostic of T stage than EUS
NCCN 2019
Does everyone get dumping syndrome after gastrectomy?
no!
do not put on low glucose diet until they get symptoms.
Longterm survival of Tis and T1a GE cancer?
close to non-cancer patients
NCCN guidelines for neoadjuvant therapy for SCC?
all T3 or N+,
can offer to all T1b or above.
Outcomes for robotic v open gastrectomy?
4 Asian RCTs suggest equivalent and on MSKCC study (V. Strong)
Number of chemo agents for GEJ cancer
double agents preferred to triple agent outside of a trial or high volume center
[NCCN 2019]
Progressive oligometastatic GIST on Gleevec?
Resect! still good survival in carefully selected patients.
[retrospective data - Raut Brigham]
when to start surveilance endoscopy after definitive radiation for esophageal cancer?
at least 6 weeks
[nccn 2019]
No residual disease after radiation of endoscopy, what next?
still do four quadrant blind biopsy of neomucosa. Residual dysplasia may be below the mucosa.
[nccn 2019]
Three types gastric carcinoids?
I - solitary larger mass
II - associated with achlorohydrea
III- associated with gastrinoma.
Is there utility in getting peritoneal washings for gastric cancer?
no, very rarely positive in absence of clinically detectable mets. retrospective series
Endoscopic Surveillance for Fanconi’s anemia
Consider immediately at diagnosis
may be limited by other conditions
Endoscopic therapy for esophageal adenocarcinoma?
up to superficial T1b
Classic start to work-up of dysphagia?
Do a barium swallow if not immediately a diagnosis of cancer.
Difference between linear and circular stapled anastomosis in GE surgery?
No difference in leak, some higher rate of stenosis with circular stapler.
Fanconi’s Anemia
multiple genes - DNA repair deficiency
anemia
bleeding
SCC of multiple locations
When to not offer chemo for Stage IV esophageal SCC?
KPS <60
ECOG >3 limited self care, sedentary >50% of time
[NCCN]
Management of cT4b SSC of the esophagus?
definitive chemoradiation
Can peritoneal washings change in response to neoadjuvant therapy?
yes
FLOT regimen
5FU over 24 hours
Leucovorin
Oxaliplatin
Docetaxel
14 day cycles
4 cycles preop
4 cycles post-op
Endoscopic Surveillance for Familial Barrett’s
After age 40
reresect recurrent esophageal SCC?
yes if feasible per NCCN
Esophageal endoscopic resection v. ablation?
nodular lesion - needs ER for staging
flat lesion <2cm - can do either, (ER prefered)
flat lesion >2cm - ablation is safer
Treatment for cancer in cervical esophagus?
definitive chemo radiation
Dilate an obstructing tumor to complete and EUS?
associated with perforation, would not do
What to do before starting neoadjuvant therapy for Gastric cancer?
Do staging laparoscopy and peritoneal cytology
M1 cytology has 60-80% chance of progressing during therapy. Need to consider surgery only as part of a trial.
surveillance for complete clinical response for neoadjuvant chemoRT for esophageal SCC?
accepted by NCCN, but probably wouldn’t do
Endoscopic Surveillance for Tylosis
After age 20
Level I evidence for surveillance after definitive therapy for GEJ cancer?
none
High risk genetic conditions for GE cancer?
Tylosis
Familial Barrett’s Esophagus
Bloom Syndrome
Fanconi’s Anemia
Neoadjuvant dosing of FOLFOX for GEJ cancer?
Continuous 5FU for first 48 hours of each cycle.
Oxaliplatin and Leucovorin on day 1
Cycle every 2 weeks x 3 cycles with RT
3 more cycles after RT
incidence of gastric cancer in <40 year olds?
Is increasing similar to that of CRC, unclear mechanism
NCCN statement of systemic therapy for GEJ cancers
Most systemic therapies can be considered interchangeable
Rainbow trial?
established VEGF + FOLFOX second line for gastric cancer.
Acute bleeding from an esophageal tumor, nccn statement
may represent a pre-terminal event from aorto-esophageal fistulazation.
Use endoscopy cautiously, recurrent bleeding is high.
Chronic bleeding from an esophageal tumor
palliative radiation
What test to order right after an esophageal stent is placed?
swallow study to ensure no leaks.
EGD surveillance after definitive chemoradiation of esophageal cancer?
EGD every 3-6 months for 2 years
Annual for next 3 (years 3-5)
GE junction cancer invading the liver or spleen?
unresectable per NCCN guidelines
Timeframe of “actionable” GEJ recurrences?
90% within 2 years.
[NCCN 2019]
Minimal esophageal biopsies?
6-8 biopsies with standard to large forcepts
Treatment for esophageal cancer within 5 cm of the cricopharyngeus?
definitive chemoradiation
Additional biomarkers/targets to test for for stage IV GE cancer?
MSI and PDL-1 testing
can be done of FFPE tissue
What is main toxicity of ECF?
hand foot syndrome
neuropathy
Bloom’s Syndrome
BLM gene
AML, ALL and esophageal SCC at age 20
EUS biopsy esophageal nodes?
Yes for all unless there is a blood vessel in the way (check flow with doppler)
What is response rate for dose escalation of Imatinib 400 to 800?
33% in metastatic progression.
Neoadjuvant chemoradiation for Siewert III lesions?
generally not; if you do it use the gastric guidelines.
complete response rate of esophageal SCC to definitive chemoradiation?
~60%
Tylosis
RHBDF2 gene
high risk of esophageal SCC
TOGA trial?
14 months OS with FOLFOX+ Herceptin v
11 months with FOLFOX alone for gastric cancer
reconstruction after gastrectomy?
always a roux limb.
When to do esophagectomy for T1a SCC?
extensive disease, especially nodular disease not controlled by ablation.
What to do with progression of metastatic GIST?
Dose escalate from Imatinib 400 to Imatinib 800.
NCCN position on peritoneal washings for GE cancer?
“consider” for T3 or N+ disease
Complete clinical response to neoadjuvant thererapy for gastric adeno?
still need surgery, do not let them trap you into watch and wait.
Goal gross margins for gastric cancer?
> 4 cm
15 lymph nodes
Older patient with difficult to localized pylorus?
Can always do upper endoscopy intraop.
hand foot syndrome
occurs during capecitabine or 5-FU.
hand and foot erythema, blistering and skin peeling
no treatment
gradually improves once chemo stopped/reduced
Who could you potentially omit staging laparoscopy on for gastric cancer?
T2 or lower
no nodal involvement.
EGD Surveillance after esophagectomy?
as needed unless Barrets left over, then start with q3 month endoscopy
Linitis plastica on pathology?
Always do a total gastrectomy and be prepared to chase the superior margin into the chest.
What early gastric cancers should not get an endoscopic mucosal resection?
poorly differentiated
ulcerated on endoscopy
Siewert Classification
I is 1-5 cm above GE junction
II is 1 cm above or 2 cm below the GE junction
III is more than 2cm below, treat as gastric.
How do you do Endoscopic Lumen restoration for complete lumen restoration with an esophageal cancer?
Via anteriograde and retrograde (via gastrostomy) endoscopy.
[NCCN guidelines]
Was diagnostic laparoscopy routine for Magic study?
no! may have worsened results.
Cutoff for endoscopic resection of esophageal SCC?
T1a or lower. (tumor invades muscularis mucosa)
What do you do before starting neoadjuvant chemo for gastric cancer?
Diagnostic laparoscopy in addition to standard staging.
Familial Barret’s
numerous genes associated
Staging after diagnosis of GE cancer?
start with CT C/A/P
if no M1 disease go on to PET and EUS
Endoscopic Surveillance for Blooms Syndrome
After age 20
When do you do adjuvant chemoradiation after esophagectomy (SCC)?
only for R1 resection
esophageal SCC invading trachea, great vessels of heat?
consider chemotherapy alone
Supplements needed after total gastrectomy? (3)
Vit D
Iron
B12
NCCN imaging surveillance after esophagectomy by stage?
Stage I (T1N0) - only with symptoms Stage II - III - imaging only (unless Barrets)
PAtient has M1 cytology and then good response to palliative chemo; repeat cytology is M0?
You have probably already passed the room, this is the population to look at clinical trials of HIPEC.
Assessment of HER2 status of GE cancers?
do if unresectable and planning for systemic therapy
may still be equivocal and need FISH, just like breast cancer.
Three main theoretic benefits of neoadjuvant RT
improved tissue oxygenation
Smaller defined field (helps rad/onc aim)
increase rate of R0 resection
Signet ring cell gastric cancer
more diffuse spread
presents at higher stage
more chemo-resistant
associated with CDH1 mutations
multiple low grade gastric NETs?
check a gastrin level
check for achlorohydria (gastric pH)
pericardial invasion of GE cancer?
still resectable, take the pericardium
Operation for esophageal leak?
try to save the conduit if no necrosis.
debride edges
cover defect with an intercostal or pleural flap
cervical diversion.
treatment of goblet cell of the appendix
R0N0 - right hemicolectomy
N+ add FOLFOX
M1 - FOLFOX v HIPEC
median survival of mucinous appendiceal tumors?
16 years
adjuvant therapy for low grade mucinous appendiceal tumor?
HIPEC only for cellular mucin,
no chemo,
no radiation
most common complication of HIPEC?
prolonged ileus
survival benefit to doing right hemicolectomy at the time of rupture of a appendiceal mucinous neoplasm?
no, only if you do HIPEC at the same time as resection.
