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Clinical > Upper GI: esoph, gastric, pancreas > Flashcards

Upper GI: esoph, gastric, pancreas Flashcards

1
Q

What is unresectable pancreas? (Not borderline)

A

Involvement or >180 of SMA, hepatic artery and CA.
Short segment tumor abutment of SMV and PV.
SMV and PV can be grafted.

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2
Q 
Annual # esophageal cancer in US?
# annual deaths?
A

17,500 yearly

15,000 annual deaths

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3
Q

What is not a risk factor in esophageal ca?

A

H.pylori is protective, ESP adenos

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4
Q

what cm from incisors does mid-thoracic esophagus begin?
cervical?
upper and lower thoracic?

A

25-30cm
cervical: 15-20cm (distal hypopharyx to sternal notch)
upper thoracic: 20-25cm (sternal notch to azygos)
middle thoracic: 25-30cm (azygous to inferior pulm vein)
lower thoracic: 30-40cm. (IPV to GEJ)

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5
Q

3cm distal esophagus adeno, invades muscularis propria, +2 regional LN. Stage?

A

T2N1M0, stage IIB
N1=1-2 regional LN+. N2= 3-6LN+
T1a= lamina propria or muscularis mucosa
T1b= submucosa
T3=adventitia
T4a=resectable involving pleura, pericardium or diaphram
T4b=unresectable involving aorta, vertebral body, trachea

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6
Q

what is a component of a transhiatal esophagectomy

A

cervical anastomosis, gastric conduit in esophageal bed, celiotomy.
a thoracotomy is not done to avoid the thoracoabdominal incision and mediastinitis and anastomotic leak.

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7
Q

CALGB 9781 (Tepper) trial randomized to surgery alone vs neoadj chemoRT followed by surgery. what was the 5yr OS benefit with neoadj chemoRT?

A

23%. used cis/5FU and 50.4. 5yr OS improved from 16% to 39%. MS from 1.8 to 4.5yrs. pCR 40%.

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8
Q

what was chemo and RT dose in CALGB 9781 (Tepper trial)?

pCR rate?

A

cis/5FU and 50.4Gy.
100mg/m2 bolus IV cis on days 1 and 29.
5FU 1,000 mg/m2/day CI days 1-4 and 29-32.
pCR=40%

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9
Q 
RTOG 8501 (Herskovic) randomized esophageal ca pts to? What was the control dose of RT?
This is why we do not use RT alone
5Yr OS in control arm?
A

chemoRT to RT alone.
cis/5FU and 50Gy vs 64Gy/2Gy fx
chemoRT imrpoved MS (14 vs 9mos), 5yr OS (0 vs 26%)
5yr OS was 0% in the 64Gy arm.

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10
Q

What esophageal ca dose escalation study did not show a benefit?
What dose did they use?

A

INT 0123, Minsky.
cis/5FU chemoRT with 50 or 64.8Gy
both arms went to 50Gy to large field and a boost volume to 64.8. this arm had higher tx related deaths,11 but 7 occurred before 50.4Gy

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11
Q

What was the randomization of the neoadj tx for esophageal ca by Walsh?
What was the RT dose/fx?
pCR rate?

A

cis/5FU, RT then surgery.
majority ADENOCA, got 40Gy15fx and slightly less chemo dose than Tepper trial. pCR was 22%. compared to 40% in Tepper. MS improved 11 to 16mos. 3yr OS from 6 to 32%. compared to Tepper 5yr OS was 16 to 39%. Tepper seems like a more solid trial.

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12
Q

CROSS (van Hagen) randomized what?
what neoadj tx did they use?
what was the median OS advantage?
pCR rate?

A 
randomization resectable T2-3N0-1 esoph or GEJ: surgery vs neoadj carbo/paclitaxel+ 41.4Gy
weekly carbo (AUC2), taxol 50mg/m2.
OS improved 49 vs 24 mos. 92% had R0 (complete) vs 69% in surgery only. pCR=29% (Walsh 22%, Tepper 40%)
leukopenia was G3 toxicity.
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13
Q

GITSG for LA gastric ca, RT improved what?

A

OS. N+ or T4 gastric in GITSG got chemo alone vs chemoRT. OS improved from 7 to 18%.

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14
Q

MAGIC (Cunningham) randomization?

Was there improvement in LC, PFS or OS?

A

surgery vs surgery with periop ECF (epirubicin, cis, 5FU). 74% were adeno stomach, 11% GEJ.
5yr OS benefit with chemo, 23 vs 36%.
PFS benefit 0.66. same toxicity. Significant tumor downstaging from 5 to 3cm dm of tumor.

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15
Q

SWOG 9008/INT 0116 (MacDonald) randomization?
rate of D2 resection? D0?
RT dose? chemo?
what was improved? OS? RFS?

A

surgery alone vs surgery with adj chemoRT.
582pts with R0 gastric (T3+, N+) or GEJ.
D2= 10%
D0=50%
D1= 40$
1 cycle of chemo prior to starting chemoRT. (5FU/LV + 45Gy/25Fx)
postopchemoRT improved mOS 26 vs 35 mos. 3yr OS 41 vs 50%. diffuse type did not benefit much with chemoRT

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16
Q

what is Imatinib? what is the target?

which mutation responds best?

A

used in GIST, target is KIT, it is a competitive inhibitor.

Exon 11 responds best, exon 9 does not.

17
Q

what vertebral body does the pancreas lie? most common genetic mutation in pancreas?
what lab value is important in pancreas?
what % are resectable? what % present with DM?
Stain for seminomas?
NSGCT?

A

L1-L2. common mutation is kras.

CA 19-9. best if

18
Q

GITSG 9173, randomized R0 postop pancreas to observation and adj chemoRT. what was the 2yr OS benefit?
RT dose?

A

2yr OS was 42 vs 15% with benefit in adj chemoRT. 5FU split course RT 40Gy with 2 wk break over 6 wks. maintenance 5FU given. MS improved 11 to 20mos.

19
Q

What was randomization in RTOG 9704, resected pancreas?
3yr OS?
was there any SS to OS or MS?
how often was tx completed in experimental arm?

A

resection then obs vs induction gem x3wks, then adj gem x 3 mos then adj 5Fu or gem with 5FU+50.4 Gy.
3yr OS improvement: 22 vs 31%, NS
MS improved 17 to 20mos, NS
both groups completed tx >85%.

20
Q 
CONKO 001 (Neuhas) randomization?
what did it show?
A

R0 surgery then gem alone vs obs.
improvement in DFS but not OS with adj gem postop. DFS improved 7 to 13mos*.
OS 20 vs 22 mos, NS

21
Q

GITSG 9273 randomized unresectable pancreas to what 3 arms?
which arm was the best?
improvement in MS? OS?

A

194 pts LAPC, 1) 60Gy split course, 2) 40Gy spit course with 5FU, 3) 60Gy split course with 5FU.
Maintenance 5FU.
MS improved in chemoRT60Gy 7.6mos. 7mos with 40/5FU and 3 mos with 60Gy alone.
1yr OS best with 46% vs 35% and 10%.

22
Q

ESPAC (Neoptolemos)for adj resected pancreatic 2x2 designed to obs, chemoRT, chemo alone or both. RT dose?
conclusions?

A

RT was 20 Gy.
541 pts resected pancreas randomized to obs vs chemoRT vs chemo only vs chemoRT+chemo. chemoRT was 5FU 500mg/m2 D1-3. chemo alone was 5FU/LV x 5days.
survival benefit for adj chemo only MS 20m.
critiques: bad RT technique, low dose, poor QA.

23
Q

what do do you include in pancreatic head RT bed?

what can you exclude in tail of pancreas?

A

duodenal bed, peripancreatic, CA, SMA, PA, porta hepatis, PD lymph nodes. anastomoses: PJ and or choledochol or hepatojejunal. not the splenic hilum.
in tail of pancreas, can exclude duodenal bed.

24
Q

what is the staging for HCC measuring 4.2cm with single +LN?

A

IVA.

Any LN+ HCC is stage IV. <5cm w/ vascular invasion is T2. DM is IVB.

25
Q

most common site of extrahepatic cholangiocarcinoma?

A

bifurcation of the common hepatic duct. aka Klatskin tumor. EHCC are difficult to resect and have poor prognosis. PD, ampulla of Vater are all EHCC locations. Papillary is the most curable, sclerosing is the most common type of bile duct adeno but less resectable.

Clinical (5 decks)

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