1
Q
History questions for esophageal cancer
A
- Dysphagia (solids/liquids)
- Odynophagia
- Wt loss and nutrition habits
- Cough
- Pain
- Smoking/drinking
- H/o GERD
2
Q
PE maneuvers for esophageal cancer
A
- Abdominal exam
- SCV nodes
3
Q
Workup for suspected esophagus cancer
A
- EGD w biopsy of primary - to determine distance from incisors / obstructing or not
- Staging EUS to determine T stage and abnormal periesophgeal nodes
- Bronchoscopy if tumor is above carina to rule out fistula
- Imaging
- CT CAP with oral and IV contrast
- PET
4
Q
Necessary referrals for newly diagnosed esophagus cancer
A
- Nutrition assessment for consideration of PEG (if nutritionally deficient)
- Speech/swallow
- Smoking cessation
- PFTs
5
Q
Cervical esophageal cancer, distance from incisors
A
15-18 cm
Below cricoid cartilage
6
Q
Upper esophageal cancer, distance from incisors
A
18-24
7
Q
Mid esophageal cancer, distance from incisors
A
24-32
8
Q
Lower esophageal cancer, distance from incisors
A
32-40 cm
9
Q
GEJ esophageal cancer, distance from incisors
A
~40 cm
10
Q
Siewert I classification
A
Originates in the distal esophaus (distal 5 cm from GEJ)
11
Q
Siewert II classification
A
originates in true GEJ (esophageal cancer)
-1 cm from GEJ to 2 cm into stomach
12
Q
Siewert III classification
A
Originates in stomach between 2 and 5 cm from the GEJ
technically gastric cancer
13
Q
What are the surgery techniques for esophageal cancer
A
- Transthoracic, Ivor-Lewis esophagectomy
- Transhiatal
14
Q
Which esophagectomy better for distal tumors
A
Transhiatal
15
Q
Describe Ivor-Lewis esophagectomy
A
- Two incisions, one in the upper abdomen and R lateral thoracotomy
- Reconnects residual esophagus and stomach
16
Q
Pros/cons of Ivor-Lewis
A
- Pros
- Oncologic procedure
- Less leaks
- Better for proximal tumors
- Cons
- Heartburn common
- Tight proximal margins
- Pulmonary and mediastinal complications can be severe
17
Q
Describe transhiatal esophagectomy
A
- Two incisions
- L neck
- Uppe abdominal laparotomy
- Cervical anastomosis of the cervical esophagus to stomach
- Better for distal tumors
18
Q
Pros/cons of transhiatal esophagectomy
A
- Pros
- Less morbid and pain
- Avoids thoracotomy
- Leks less dangerous in he neck and are more easily managed
- Clear proximal margin
- Less heartburn
- Cons
- Can’t see upper tumors
- LND only by blunt dissection
- Can’t access level 7
- More leaks
19
Q
How many LN should be removed from esophagectomy
A
At least 15
20
Q
What would make an esophageal tumor inoperable
A
- T4b disease
- Multifocality including GEJ and SCV nodes
- Bulky multistation mediastinal nodes
- Distant mets
- Medically inoperable
21
Q
Nodal drainage of upper esophagus
A
- Superior mediastinum
- SCV
- Cervical neck
22
Q
Nodal drainage of Mid esophagus
A
Either superior or inferior in paraesophageal nodes
23
Q
Nodal drainage of lower 1/3 esophagus
A
Lower mediastinum
Celiac nodes
24
Q
What share of tumors are adenoca
A
75% and rising
25
T1 esophagus
Mucosa, lamina propria, submucosa
26
T2 esophagus
Muscularis propria (40% are N+)
27
T3 esophagus
Invades adventitia
\*\*No serosa for esophagus\*\*
28
T4a esophagus
* Invades adjacent structures but is still resectable (pleura, pericardium, diaphragm)
29
T4b esophagus
Not resectable
Invades aorta, vertebral body, trachea, adjacent organs
30
Describe nodal staging for esophagus
N1 = 1-2 nodes
N2 = 3-6 nodes
N3 = 7+ nodes
31
Management of cTis or cT1 tumors
Options include
* Endoscopic mucosal resection +/- ablation
* Esophagectomy if extensive disease
32
Which esophageal tumors can be managed with esophagectomy alone?
* cTis
* cT1
* cT2N0 - small \<3 cm, low risk features (well diff)
33
Options for Operable Locally Advanced Esophageal Cancer
* Neoadjuvant CRT --\> PET 5-8 weeks post completion --\> EUS --\> Esophagectomy
* Definitive CRT (lower)
34
What is the dose for preop RT for locally advanced esophagus
50.4 Gy in 28 fractions of 1.8 Gy
35
What are the concurrent chemo options for neoadjuvant CRT for locally advanced esophageal
* Carboplatin (AUC 2) and taxol (50 mg/m2) weekly x 5 weeks
* Cisplatin (75 mg/m2) D1 and 5FU (1000 mg/m2) q4w x2 cycles
36
What is the management of inoperable esophageal cancer
50.4 Gy with concurrent carbo/taxol or cis/5FU
consider 2 cycles of adjuvant FOLFOX
37
Management of cervical esophageal cancer
* Definitive CRT
* 45 Gy to larger volume including SCV nodes
* Primary tumor to 66-70 Gy meeting constraints
* Chemo is weekly carbo-taxol
* Carbo AUC 2
* Taxol 50 mg/m2
38
Treatment of stage IV esophageal cancer
* Palliative RT - 30/10 for dysphagia and relief
* Trastuzumab for HER2+ adenocarcinoma
39
What about RT alone for esophageal cancer
Palliative, (0% 5 year OS)
40
Doses for preop, postop and definitive RT for esophagus ca
* Preop: 50.4 Gy (in case not surgical candidate)
* Postop: 50.4
* Definitive: 50.4 or 66 for cervical esophagus cancer
41
What is the benefit of preop CRT
IMproves path CR rate
Improves OS
Improves R0 resection and N+ rates
42
What incremental benefit does surgery provide after CRT
10% LC
No OS benefit
43
What is the advantage to dose escalation for esophagus cancer
None (but most deaths occured before pt got to escalation component)
44
What is the simulation strategy for esophagus tumors
* NPO 2-4h prior to sim and treatment
* 4DCT sim with IV and po contrast
* Supine, arms up in a alpha cradle if lower tumor
* Supine, arms down, 5 pt mask if upper tumor
* Scan from cricoid to L3
* PET/CT fusion
* Daily KV imaging
45
Type of RT to utilize for esophagus cancer
* Use IMRT to reduce heart and lung (but watch V5)
* If not, 3DCRT using 4 field (AP/PA and RPO/LPO)
46
Define GTV, CTV, PTV for esophagus cancer
* GTV = gross tumor and enlarged nodes by CT, PET, EGD information
* ITV = GTV plus motion
* CTV =
* GTV + 4 cm superior and inferior, 1 cm radially on primary
* GTV nodes + 1cm
* Elective nodal coverage
* Respect anatomic boundaries of heart, liver, vert bodies
* PTV
* CTV + 1 cm
47
What is the elective nodal coverage for esophagus tumors
* Cervical: SCV
* Mid esophagus: paraesophageal
* Distal: celiac and lesser curvature (located in gastrohepatic ligament)
48
If ITV is large, other strategies
Adbominal compression
Respiratory gating
49
Lung constraints for esophageal cancer
* V20 \< 20%
* V5 \< 50%
50
Cord constraint for esophageal cancer
MPD of 45 Gy
51
Heart constraint for esophageal cancer
V30 \< 30%
Mean \<26 Gy
52
Kidney constraint for esophageal cancer
V20 \< 33%
Mean dose to both kidneys \< 18 Gy
53
Liver constraint for esophageal cancer
V20 \< 30%
V30 \< 20%
Mean \< 25 Gy
54
5 year OS for stage I esophagus
80%
55
5 year OS for stage II esophagus
50%
56
5 year OS for stage III esophagus
20%
N1 or N2
57
5 year OS for stage IV esophagus
\<5%
58
Acute toxicities of esophageal cancer treatment
esophagitis
weight loss
fatigue
anorexia
59
Late SE of esophageal cancer
* Perforation or fistula (5-10% if invading trachea)
* Pneumonitis
* Late strictures (20-40%)
* Pericarditis
* CAD
60
What are the layers of the stomach on EUS
* Superficial mucosa
* Deep mucosa (hypoechoic)
* Submucosa
* Muscularis propria
* Subserosa
Alternate hyper and hypoechoic
61
History questions about gastric cancer
Abdominal pain
N/V
Early satiety
Dyspepsia
Melena
Coffee ground emesis
Risk factors of H Pylori, FAP, HNPCC, Peutz-Juegers
62
Physical exam for gastric
Abdominal exam
Nodes check cervical, SCV, periumbilical
Hepatomegaly or ascites
63
Labs for gastric
CBC
COMP
LFT
CEA (elevated in 1/3)
64
Imaging and other workup for suspected gastric cancer
* EGD + random biopsies
* EUS + biopsies
* CT CAP w contrast OR PET/CT
* Staging laparoscopy in T1b+
65
When should staging laparoscopy be considered
T1b+
If unresectable
Before/after neoadjuvant therapy (25% will be positive)
66
For esophagus and gastric, what is the nutritional consideration
* If part of stomach likely to be removed or moved, go with J-tube
* If stomach unlikely to move, PEG ok
67
What are the goals for gastrectomy?
* \>5 cm margin
* \>15 LN dissected
* D2 nodal resection
68
Types of gastrectomies
* Total gastrectomy required for cardia, fundal, greater curvature tumors
* Partial gastrectomy - ok for distal tumors of antrum or body
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69
What is the connection of a total gastrectomy?
* Roux en Y with connection of esophageal stump to jejunum
* Used for proximal tumors (cardia, fundus, greater curvature)
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70
What is the connection of the partial gastrectomy?
Gastric remnant to jejunum
End to end or end to side
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71
D1 dissection
Just perigastric nodes
72
D2 dissection
* D1 nodes
* Celiac plus three branches:
* Common hepatic
* Splenic
* L gastric
* Modified D2 doesn't remove spleen or distal panc
73
D3 dissection
D2 plus PA nodes
74
T1 gastric
Lamina propria
Muscularis mucosa
Submucosa
75
T2 gastric
Muscularis propria
76
T3 gastric
Subserosa
77
T4a gastric
Serosa (visceral peritoneum)
78
T4b gastric
Adjacent structures
79
N1 gastric
1-2 nodes
80
N2 gastric
3-6 nodes
81
N3a gastric
7-15
82
N3b gastric
\>15 nodes
83
Tricks for gastric staging
* IA adds to 1
* IB adds to 2
* IIA adds to 3
* IIB adds to 4
* Anything greater is stage III
84
Two histologies of gastric cancer
* Intestinal: H pylori, better prognosis
* Diffuse: linitis plastica, poorly differentiated
85
Treatment of T1N0 stomach cancer
Gastrectomy
86
What patients are candidates for postop RT
Really only R1 or R2
87
If a patient has operable cT2+ or N+ what are the management options?
* Perioperative chemotherapy (chemo --\> surgery --\> chemo)
* Surgery --\> postop CRT
* Surgery --\> chemo
* Preop CRT --\> Surgery (this is category 2B, not recommended)
88
If periop chemo approach selected, what chemo regimen?
FLOT
5-FU
Leukovorin
Oxaliplatin
Taxotere
89
How is FLOT given for gastric cancer
* 4 cycles of chemo --\> surgery --\> 4 cycles of chemo
* All agents are given on D1
90
If surgery and postCRT is selected, what chemo?
* Capecitabine 1000 mg/m2 BID D1-14
* Cape 825 mg/m2 BID D1-5 qweekly with RT (5 cycles)
91
What is the treatment approach if surgery --\> adjuvant CRT?
* Gastrectomy
* Adjuvant cape x 1 cycle (1000 mg/m2 BID)
* CRT with cape and 45 Gy (825 mg/m2 BID)
* 2 cycles of adjuvant cape (1000 mg/m2 BID)
92
What patients should be considered for adjuvant CRT
* No upfront chemo/RT
* T3-T4 or N+ with R0 resection (if less than D2)
* R1 resection
* R2 resection
93
For gastric ca, if surgery --\> chemo strategy, which chemo
Capecitabine and oxaliplatin
94
If patient had T4N+ disease with R0 resection what should be adjuvant therapy
* Depends on extent of LN dissection
* If D1 --\> CRT
* If D2 --\> chemo
95
Treatment options for medically inoperable gastric ca
* CRT to 45 Gy with capecitabine or 5-FU
* Chemo (cape or 5-FU)
96
How to simulate patients for gastric cancer
* Supine, alpha cradle, arms up
* Empty stomach (NPO 3-4 hrs)
* 4DCT with IV and oral contrast
* Fuse preop PET and CT
* Daily KV
* Go with CBCT if unresectable or preop or boosting \>45 Gy
97
What is the CTV for postop gastric volumes
* Pre-op stomach or tumor bed + gastric remnant and duodenal stump
* Surgical clips and anastomosis
* Nodes
* Celiac and branches
* Perigastric
* Suprapancreatic
* Porta hepatis
* Splenic
* If distal, no need to cover splenic, but add subpyloric
98
PTV margin for gastric
1 cm
99
Dose for R0 resection gastric
45 Gy
100
Dose for R1 resection gastric
50.4 Gy in 28 daily 1.8 Gy fractions
101
Dose for R2 resection gastric
54 Gy in 30 daily 1.8 Gy fx
102
If a boost is being done, what is the volume
Conedown after 45 Gy
Volume is GTV + 1.5 cm
103
What is the RT approach
4 fields, AP/PA heavily weighted with RAO/LPO
IMRT only if constrained by heart and kidney
104
Borders for gastric field
* Sup: T10
* Inf L3
* L Lateral: 2/3 L diaphragm to cover splenic nodes
* R lateral: 3-4 cm on R vertebral body to cover porta hepatis
105
What should you draw before commiting to 3D fields
* Location of the kidneys
* Preop stomach
* Stomach remnant
* Anastomosis
* Celiac
* Porta hepatis
* SMA
* Splenic
106
What vertebral level is celiac
T12
107
What vertebral level is SMA
L1
108
What is location of porta hepatis
2 cm to R of T11/L1
109
Small bowel constraint with conventional fx
* MPD \< 55 Gy
* V45 \< 40 cc
110
Stomach constraint with conventional fx
MPD \< 60 Gy
V50 \< 40 cc
111
Median OS for gastric patients getting surgery --\> CRT
36 mos
112
Acute toxicities of gastric cancer treatment
nausea
vomiting
fatigue
myelosuppression
GERD - give PPI
113
Late toxicities of gastric cancer treatment
Radiation gastritis
Ulcers
Dyspepsia
114
Follow-up vitamin supplementation after gastric cancer treatment
B12 (loss of IF)
Ca2+ and iron supplementation due to loss of stomach acid
115
History questions for pancreas ca
* nausea
* vomiting
* early satiety
* greasy stools
* jaundice
* pain
* weight loss
* migratory thrombophlebitis (DVT)
116
Risk factors for pancreas cancer
Smoking
DM2
FHx (Peutz-Jeghers, BRCA 1/2, HNPCC)
117
Physical exam for pancreas ca
* Jandice/Scleral icterus
* Abdominal exam
* Weight loss
* Palpable gallbladder (Courvorsier's sign)
* Virchow node (L SCV)
* Sister Mary Joseph node (periumbilical)
118
Labwork for suspected pancreas cancer
* CBC
* COMP
* LFTs
* Amylase
* Lipase
* CA-19-9
* CEA
* HgbA1c
119
Imaging for suspected pancreas ca
* CT CAP with pancreas protocol (IV contrast for early arterial, late arterial, portal venous with thin slices)
* MRI abdomen to rule out liver mets
* PET/CT for high risk patients
120
Best approach for tissue sampling for pancreas cancer
EUS with FNA (less risk of seeding over CT guided)
ERCP with stenting if biliary obstruction
121
Surgical options for pancreas cancer
* If proximal pancreas --\> Whipple procedure
* If distal pancreas --\> distal pancreatectomy
122
Describe the Whipple procedure
* Removes the head of pancreas
* Duodenum
* Gallbladder and distal CBD
* Pylorus is spared to prevent dumping syndrome
123
Anastomoses for Whipple
* Gastrojeujeunostomy
* CBD to jeujeunum
* Pancreas to jeujunum
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124
Which margin is most often positive for Whipple
RP most common
125
Pancreas is at what vertebral level
L1/L2
126
T1 pancreas
\<2 cm
127
T2 pancreas
2-4 cm
128
T3 pancreas
\>4 cm
129
T4 pancreas
Involvement of celiac artery, SMA, CHA
130
N1 pancreas
1-3 nodes
131
N2 pancreas
4+ nodes
132
What makes stage III pancreas
T4 or N2 disease
133
At diagnosis, what is the split of resectable, unresectable, metastatic
* Resectable - 20%
* LA/unresectable - 40%
* Metastatic - 40%
134
What are the criteria for resectable pancreas ca?
* Clear fat plane around celiac, hepatic artery, SMA, common hepatic artery
* \<180 degree contact and no distortion of the SMV or portal vein
* No tumor thrombus
135
Borderline resectable pancreas ca criteria
* \<180 degree contact of SMA, CA
* CHA contact but reconstructable
* \>180 contact of SMV/PV or thrombus
* Contact of IVC
136
Management of resectable pancreas cancer
* Surgery
* Restage with CT CAP, CA-19-9, germline testing
* Chemotherapy
* Restage with CT CAP, CA-19-9
* CRT if R1/R2
137
Systemic therapy options for adjuvant pancreatic cancer
* mFOLFIRINOX
* Gem-Cape
* Gem alone if poor performance status
138
What is mFOLFIRINOX and how is it given?
* Leucovorin
* 5-FU CI
* Irinotecan
* Oxaliplatin
* q2w x 12 cycles
139
How is gem-cape given?
q4w x 6 cycles
140
If CRT is offered adjuvantly to pancreas surgery, when should it start?
After 4-6 months of chemo
141
What are the chemo options for CRT with pancreas cancer
* RT to 50.4 Gy in 28 fractions of 1.8 Gy
* Capecitabine 825 mg/m2 BID
* 5-FU CI 250 mg/m2 per day
142
What is the treatment strategy for borderline resectable pancreatic cancers?
* Start with chemo (mFOLFIRINOX for 4-8 cycles)
* Restage with CT CAP
* CRT with 2.4 x 15 = 36 Gy
* Restage
* Surgery if feasible
* Consider adjuvant chemo
143
What percentage of patients will be converted from borderline resectable to resectable with neoadjuvant therapy?
30%
144
What is the criteria for unresectable pancreatic cancer?
\>180 degree contact with SMA, CA
Unreconstructable SMV or portal vein occlusion with tumor
Aortic invasion
145
Treatment of unresectable pancreas cancer
* Chemo (4-8 months of mFOLFIRINOX)
* Restage
* CRT to 50.4 Gy
* Restage
* Adjuvant chemo
\*\*If there is pain, local obstruction or chance of converting, start with CRT
146
What should be done if a patient is deemed unresectable at time of pancreas surgery?
* Biopsy
* Duodenal bypass or stent
* Celiac plexus nerve block if pain
147
How to sim pancreas patient?
* Supine
* Arms up
* Alpha cradle
* 4DCT with IV and oral contrast
* Empty stomach (3-4 hr NPO)
* Fuse preop imaging
148
RT dose for preop pancreas
* 2.4 Gy x 15 = 36 Gy
149
Volumes for Preop pancreas
GTV and grossly affected nodes
150
Dose for postop pancreas
* 50.4 in 1.8 Gy x 28
* Concurrent capecitabine 825 mg/m2 BID or 5-FU
151
Contouring strategy for postop pancreas
* GTV - any residual disease
* CTV
* Postop bed, clips, original tumor with 2 cm margin
* PJ/HJ anastomosis (0.5-1 cm margin)
* Elective nodes
* PTV = 5 mm
152
CTV elective nodes for pancreatic head lesions
* Cover Celiac, SMA, Peripancreatic, Porta hepatis and para-aortic LN
* Contour celiac, SMA, PV with 1 cm expanion
* Contour aorta from celiac down to bottom of L2 with asymmetric expansion
* R: 2.5 - 3 cm
* L: 1 cm
* Anterior: 2.5 cm
* Post: 0.2 cm
153
Elective nodes to cover for pancreatic tail lesions
* Celiac
* SMA
* Suprapancreatic (lateral)
* Splenic hilum
154
Contouring strategy for unresectable pancreas cancer
* Gross disease + 2 cm
* ITV
* ITV to CTV of 1.5 cm
* CTV to PTV of 0.5 cm
No ENI since 95% of failures are in PTV
Consider boosting to 54 Gy if able to meet constraints
155
Liver constraint for pancreas cancer
Mean \< 24 Gy
156
Kidney constraints for pancreas cancer
* V18 \< 33% if 2 kidneys
* Mean kidney dose \< 18 Gy if 2 kidneys
* V18 \< 15% if 1 kidney
157
Small bowel constraint for pancreas cancer
Target V45 \< 40 cc
If unable to meet coverage, \<15%
MPD 55 Gy
158
Spinal cord max for pancreas cancer
\<45 Gy
159
What is importance of CA-19-9 post op?
It is prognostic, post op level \>90 associated with low survival
160
Toxicity of 5-FU
Mucositis
Hand foot syndrome
If bolus - diarrhea, bone marrow suppression
161
Toxicities of capecitabine
Diarrhea
Hand foot syndrome
Mucositis
162
Where is cholangiocarcinoma derived from?
Bile duct epithelium
163
What is a Klatskin Tumor
Extrahepatic cholangio at the confluence of the R and L hepatic ducts
Most common cholangio location (60-70%)
Best prognosis
164
What is the workup for cholangiocarcinoma
* Labs: CBC, COMP, LFTs, CEA, CA-19-9
* RUQ ultrasound
* Liver MRI
* MRCP
* ERCP or EUS and Bx for diagnosis
165
Failure patterns of cholangiocarcinomas
* Hilar tends to fail locally (RT important)
* Gallbladder tends to fail distantly
166
What forms the common bile duct
Common hepatic duct (from R and L hepatic)
Cystic duct (from gallbladder)
167
Management strategy of resectable cholangiocarcinoma
* Eval for liver transplant if needed
* Surgical resection with regional LND
* Adjuvant therapy as indicated
168
Adjuvant therapy for IHCC
* R0, N0 - observe or chemo
* R1, N+ - chemo alone or CRT
* R2 - treat as unresectable
169
Adjuvant therapy for EHCC
* R0, N0 - observe, chemo, or CRT
* R1, N+ - CRT
* R2 - treat as unresectable
170
What is the adjuvant chemo option for cholangiocarcinoma
Gem/Cape for 4-6 months q3w
171
Treatment recommendations for cholangiocarcinoma
* Resection (if T2+, N+, margin+)
* 4 cycles of gem/cape q3 weeks
* CRT with concurrent cape 825 mg/m2 BID
* 45 Gy to LNs (retropancreaticoduodenal, celiac and portal vein)
* 59.4 Gy to tumor bed (1.8 x 33)
172
Which cholangio pts benefit the most for adjuvant tx
LN+
R1 surgery
173
Characteristics of HCC on CT
Early arterial enhancement
Early washout
174
Imaging for HCC workup
Triphasic CT or MRI liver
Chest imaging
175
What labs should be obtained for liver mass?
AFP, CBC, CMP, LDH, LFTs, PT/iNR, hep panel
176
What constitues a positive AFP for HCC?
\>100
177
What goes into Child Pugh score
Encephalitis
Ascites
Albumin
INR
Bili
178
T1 HCC
Solitary, no vascular invasion
179
T2 HCC
Vascular invasion or many small tumors (\<5 cm)
180
T3a HCC
Many tumors \> 5 cm
181
T3b HCC
Portal or hepatic vein involvement
182
T4 HCC
adjacent structures
visceral peritoneum involvement
183
Radiographic features of HCC
Intense early arterial enhancement and early/rapid washout with rim/capsule which persists
184
Treatment options for resectable HCC
* Partial hepatectomy (CP A, no portal HTN, 20-40% liver remnant)
* Other local therapies as needed
* Liver transplant - only curative treatment
* Consider bridge therapy of RFA, TACE, Y90
185
Milan criteria for liver transplant
1 lesion \<5 cm or
3 lesions \< 3 cm each
No macrovascular involvement
186
Treatment options for unresectable HCC
* Ablation (RFA, cryo, microwave) - caution if close to large vessel
* TACE (50% response)
* Y90 (50-80% response)
* Systemic therapy (atezo and bev)
* RT (SBRT or conventional)
187
RT strategy for liver mass
SBRT - 50 Gy in 5 fx
188
Sim strategy for liver tumors
* IV and PO contrast
* Supine, alpha cradle
* DIBH
* NPO for 4 hrs
* Fuse diagnostic imaging
189
Contouring for liver tumors
* GTV
* ITV if using 4dct
* PTV = ITV +0.5cm
190
Dose for extensive liver mets
8x1 to majority of liver with dex 1 hr prior
191
Liver constraint for SBRT
Preserve at least 700 cc as having \< 15 Gy
192
Small bowel dose constraint for liver SBRT
MPD 30 Gy
193
When does RILD occur
2-3 months post RT
194
Symptoms of RILD
Fatigue
RUQ pain
Ascites
Hepatomegaly
LFT and transaminitis
Veno-occlusive dsiease leading to hepatocyte atrophy
195
Treatment of RILD
Supportive - steroids, pain meds, lasix, paracentesis
196
When should colon cancer screening begin if no FHx
Age 50
197
What is normal screening paradigm for colon cancer
Colonoscopy q10years
Flex sig with FOBT q5years
CT colonscopy q5years
198
What delineates the anal verge
Lack of hair
199
How long is the anal canal
4 cm, dentate line is midway
200
Low rectum is X cm from anal verge
4-8 cm
201
Mid rectum is x cm from anal verge
8-12
202
High rectum is x cm from anal verge
12-15
203
What is superior extent of the rectum
Peritoneal reflection, usually 12-15 cm from verge
204
What is the muscle around the rectum
puborectalis
205
What is the risk of CRC with FAP and HNPCC
FAP: 95%
HNPCC: 80%
206
What is risk of CRC with IBD
15-50%
207
What is risk of \>1 cm polyp becoming CRC
20%
208
History to ask rectal cancer patient
* Nausea
* Vomiting
* Diahrrea
* Stool change
* BRBPR
* Pain
* History of UC, Crohn's, HNPCC
209
Physical exam for rectal patient
* Abdominal
* Pelvic
* Female gyn exam
* Fixed/tethered mass
* Circumferential involvement
* Location from verge
* Sphincter function
* Proctoscopy to determine distance from verge
210
Additional workup for rectal cancer
* Refer to GI for colonscopy with biopsies
* EUS or pelvic MRI to determine depth of invasion
* CT CAP with oral and IV contrast
NO ROLE FOR PET
211
What is needed to be visualized on colonscopy
ileocecal ring (since 7% have synchronous primary)
212
On MRI, what is the color of the muscularis
BLACK/Dark
213
Surgical options for rectal cancer
1. LAR - low anterior resection for mid-upper lesions
2. APR - abdominoperineal resection for low lying lesions
214
If patient getting LAR has temporary ostomy, when will it be reversed
4-6 months post surgery
215
With either LAR or APR what is the extent of the surgery
TME - total mesorectal excision
216
What is removed with TME?
* Sharp dissecion of entire mesrectum (perirectal fat, presacral space) which reduced radial margin positive rate
217
What is benefit of TME?
Reduced LR by 50% (11 vs. 25%)
218
What is the goal for margin negativity for rectal surgery?
4-5 cm if possible
1-2 cm is acceptable if low lying
219
What is the goal for nodal sampling for TME
12-14 LN
220
What is the nodal drainage for the rectum?
* Proximal --\> IMA --\> portal circulation --\> liver mets
* Distal --\> internal iliac --\> IVC --\> lung mets
* Anal canal --\> inguinals
221
T1 rectum
Submucosa
222
T2 rectum
Muscularis mucosa
223
T3 rectum
Serosa or peri-rectal fat
224
T4a rectum
Visceral peritoneum
225
T4b rectum
adjacent organs
226
N1a rectum
1 node
227
N1b rectum
2-3 nodes
228
N1c rectum
tumor deposits in subserosa
229
N2a
4-6 LN
230
N2b
7+ nodes
231
M1a rectum
Solitary nonregional node or single site
232
M1b rectum
More than one site
233
M1c rectum
peritoneal mets
234
Stage I rectum
T1-2N0
235
Stage II Rectum
T3 or T4 N0
236
Stage III rectum
N+
237
Stage IV rectum
M1a-M1c
238
Treatment option for T1N0 rectum
* Start with transanal excision --\> close FU
* Need full thickness WLE
* This should be the best actors
* \<3 cm
* \>3 mm negative margin
* \<30% circumference
* Well-diff
* Within 8 cm of anal verge
239
What are higher risk features after transanal excision
* Large size (\>3 cm)
* T2
* Deep T1 (deep 1/3 of submucosa)
* Grade 3
* LVI
* Positive margins
240
What is the concern with higher risk lesions after transanal excision
Greater risk of local failure (15-20%)
241
What is next step if high risk lesion after transanal excision?
* Recommend oncologic surgery (LAR or APR)
* If refusing, do CRT
242
Treatment options for T2N0 rectum
* LAR or APR is preferred
* If close to anus, can try CRT to downstage
* No adjuvant therapy recommended
243
When would adjuvant therapy be offered after LAR or APR for T2N0 tumor
If found to be T3+ or N+
244
Treatment options for T3 or N+ rectal cancer
* There are several options
* Neoadjuvant therapy
* Long course CRT or Short course RT
* Restaging MRI
* Resection
* 4 months of FOLFOX
* Total neoadjuvant therapy
* 4 months of FOLFOX
* Long course CRT or Short course RT
* Restaging MRI
* Resection
245
If preop CRT, what is the dose of RT and chemo drugs utilized
* 50.4 Gy in 28 daily fractions of 1.8 Gy
* Choice of chemotherapy
* 5-FU 225 mg/m2 CI for 5-7 days
* Capecitabine 825 mg/m2 BID 5 days a week x 5 weeks
246
When should surgery be performed after completion of RT
* Restaging 8 weeks post therapy
* Perform surgery 6-12 weeks post RT
247
If neoadjuvant therapy is utilized what is the adjuvant chemo program
FOLFOX x 4 months
q2 weeks
248
What is FOLFOX
* 5-FU
* Oxaliplatin
* Leucovorin
249
Which patients might be good candidates for total neoadjuvant therapy
T4 tumors
Locally unresectable
Close to mesorectal fascia
250
What are the advantages of preop CRT?
* Downstaging
* Sphincter preservation
* Assess response to neoadjuvant therapy
* Toxicity better
* Possibility for Non operative mgmt in future (on protocol)
251
What is the downside of preop CRT?
Over treat T1-T2 since wee don't know the true path
No OS improvement
252
What is the treatment option for oligometastatic rectal ca with liver or lung mets
* FOLFOX x 3 months
* Short course RT to rectum
* LAR and liver resection
* FOLFOX x 3 months
253
What is the treatment of colon cancer
Colectomy and LND
Adjuvant FOLFOX for stage III+
254
What would be the indications of RT for colon cancer
* Fixed T4
* pN0 with close or positive margins
* Perforation
255
Dose of RT for colon cancer
50.4 Gy in 1.8 Gy daily fractions
256
From German trial, how many patients converted from APR to LAR?
40%
257
Simulation for rectal cancer
* CT simulation with IV and oral contrast
* Prone on belly board
* Wire scars for APR
* Marker at anal verge
* Vaginal marker
* Full bladder
* CT from L1 to mid femur
258
What is the CTV for rectal cancer
* Two dose levels 45 Gy to pelvis and then 50.4 to the gross tumor with margin
259
What is CTV 45 for rectal cancer
* Includes
* Mesorectum,
* presacral space
* Internal iliac nodes
* +/-external iliac
* +/- inguinals
260
When would external iliacs be included in rectal field
Involvement of anterior structures: bladder, prostate, vagina
261
When would inguinals be included in the CTV 45 for rectal
Involvement of anal canal
262
What is CTV 50.4 for rectal cancer
* GTV (or preop tumor) with
* 2 cm radial margin
* 2 cm sup/inf margin
* Presacral LN
* Full mesorectum at levels of tumor
* 1 cm of posterior bladder
* GTV nodes with 1 cm margin
263
What is CTV to PTV margin for rectal ca
7 mm
264
How should rectal cancer RT be delivered?
Use 3DCRT with 3 field orientation
PA,
2 Lateral beams
265
What is superior border of rectal cancer 3 field technique
L5/S1
266
What is inferior border of rectal cancer 3 field technique
3 cm below tumor or bottom of obturator foramen
267
What is lateral border of rectal cancer 3 field technique
2 cm lateral to pelvic brim
268
What is posterior border of rectal cancer 3 field technique
1 cm behind sacrum
269
What is anterior border of rectal cancer 3 field technique
Normally behind pubic symphysis
1 cm anterior for T4 tumors (to cover external iliac)
270
What dose should be utilized for definitive rectal
59.4 if can achieve constraints
271
When should IMRT be considered for rectal cancer
* A lot of small bowel
* Covering external iliac or inguinal nodes to reduce dose to genitals
* Reirradiation
272
Dose for rectal reirradiation
39 Gy
1.5 x 26 fractions BID
273
Bowel constraint for rectal cancer
* V45 \< 40 cc
* V45 \< 150-200 cc for bowel bag
* MPD of 55 Gy
274
Bladder constraint for rectal cancer
V40 \< 40
275
Femoral head constraint for rectal cancer
MPD \< 50 Gy
V45 \< 25%
276
5 year OS for stage I rectal
90%
277
5 year OS for stage II rectal cancer
80%
278
5 year OS for stage III rectal cancer
60%
279
Acute toxicities of rectal cancer treatment
Diarrhea
Proctitis
Thrombocytopenia
Dysuria
280
Late toxicities of rectal cancer treatment
Persistent bowel issues
Proctitis
Anastomotic structures
SBO \<5%
Incontinence
Impotence/sterility
Vaginal stenosis (dilators)
281
Surveillance after rectal cancer treatment
H&P and CEA if elevated every 3 months for 2 years
Colonscopy in year 1 and then @ 3 years and 5 years
CT CAP yearly for stage III, q6m for stage IV
282
Dentate line above/below
* 2/3 above is non-keratinizing columnar epithelium and venous drainage is hepatic portal vein (via IMA)
* 1/3 below is keratinized SCC and venous supply is systemic
283
History points for anal cancer
* Bleeding
* Anal discomfort
* Pruritis
* Rectal bleeding
* Sexual history
* HIV
* HPV
* History of AIN
284
What share of anal cancers are due to HPV
85%
285
Physical exam for anal cancer
* Abdominopelvic exam
* Bilateral inguinals
* Proctoscopy for distance from anal verge
* DRE for sphincter tone
* Gyn exam with Pap smear
286
What are special workup considerations for anal cancer?
* Men - sperm banking
* Female - gyn referral with Pap, fertility referral
287
Labs for anal cancer
* CBC
* CMP
* LFT
* LDH
* HPV
* HIV
* Pap Smear
288
Imaging for anal cancer
* Anoscopy with biopsy
* CT CAP
* MRI pelvis
* PET/CT for T3/T4 or N+
289
What should be biopsied in anal cancer
Primary mass
Any suspicious inguinal nodes with FNA since only 50% of clinically N+ are pN+
290
What is the pathology of most anal cancers
80-90% SCC
291
What are the high risk HPV strains
16, 18, 31, 33
292
What is the skin margin around anus
5 cm around the anus
293
T1 anus
\<2 cm
294
T2 anus
2-5 cm
295
T3 anus
\>5 cm
296
T4 anus
adjacent organ invasion not including rectum, perirectal skin, anal sphincter
297
N1a anal cancer
inguinal
mesorectal
internal iliac
298
N1b anal cancer
external iliac
299
N1c anal cancer
external iliac and N1a nodes
300
M1 anal cancer
mets including PA nodes
301
What is stage III anal cancer
N+
302
What is the preferred treatment for stage I-III anal cancer?
Definitive CRT
303
What is the RT dose for anal cancer
Depends on size
T1: 45 Gy
T2: 50.4
T3/T4/N+: 54 Gy
304
What is the dose for locally advanced anal cancer
54 Gy
305
What is the chemo used for CRT for anal cancer
Mitomycin plus 5-FU
306
What is the dose of MMC for anal cancer
10 mg/m2 on day 1 and 29
307
What is dose of 5-FU for anal cancer
1000 mg/m2 day 1-4 and day 29-32
308
What is the management of stage IV anal cancer
Cisplatin + 5FU +/- RT
309
How to treat anal margin cancer
* If well-differentiated T1 can do WLE with 1 cm margins
* If T2-T4 or N+ do defintiive chemoRT as for anal canal, if surgery, then do post op RT similar to anal canal
310
How to approach anal adenocarcinoma
Approach like rectal cancer
311
How to approach if HIV and CD4 \<200
Consider reduced dose chemo
Use cisplatin
Lower top border of RT field to bottom of SI joint
RT dose reduction
312
How to approach if gross fecal incontinence
Go straight to APR with possibility of postop RT
Or get temporary diverting ileostomy and then do definitive CRT
313
Indications for APR for anal cancer
Salvage after CRT
Sphincter dysfunction
Prior pelvic RT
Unable to tolerate chemo
Adenocarcinoma
314
How to approach anal ca with solitary liver met
Definitive CRT with 5-FU and cisplatin
Consider restaging and then SBRT to liver
315
How to sim anal cancer?
* Supine in alpha cradle
* Frog leg with full bladder
* Wire nodes
* Place anal BB
* IV and oral contrast
* Consider vaginal dilator for sim/treatment
* CT from L1 to mid femur
316
Contouring for anal cancer - GTV
* GTV-A: primary tumor
* GTV-N50: involved nodes \< 3 cm
* GTV-N54: involved nodes \>3 cm
317
Contouring for anal cancer - CTV A
* GTV primary
* Full anal canal (4 cm)
* Expand
* 2.5 cm sup/inf
* 1.5 cm radial
* Subtract out bone and air
* Create nodal CTVs which are affected nodes with 1 cm margin
318
What are the elective nodal regions for anal cancer
Mesorectum
Presacral
Internal iliac, external iliac, inguinal
319
What is the CTV to PTV expansion for anal cancer
1 cm for primary
7 mm for nodes
320
PTV doses for T2N0 rectal
* Primary gets 50.4 Gy in 1.8 x 28
* N0 nodes get 42 Gy in 1.5 x 28
321
What is elective nodal dose in T2N0 anal cancer
42 Gy
1.5 x 28
322
What is the PTV doses for locally advanced anal cancer
* Primary (PTVA) - 54 Gy in 30 fractions of 1.8
* N0 nodes - 45 Gy in 30 fractions of 1.5
* LN \< 3 cm: 50.4 Gy in 30 fractions of 1.68
* LN \> 3 cm: 54 Gy in 30 fractions of 1.8
323
Elective nodal dose for anal cancer
Depends on size of primary
* T2 - 42 Gy
* T3-T4-N+ : 45 Gy
324
Small bowel tolerance for anal cancer
V45 \< 20 cc (lower due to MMC)
V30 \< 200 cc
325
Genitalia tolerance for anal cancer
MPD \< 40 Gy
V20 \< 50%
326
Femoral neck tolerance for anal cancer
\<45 Gy
327
Bladder tolerance for anal cancer
V40 \< 40%
328
Anal sphincter tolerance
60-65 Gy
329
5 year OS for early stage anal cancer
90-95%
330
5 year OS for stage II anal cancer
70-80%
331
5 year OS for stage III anal cancer
40-50%
332
5 year OS for stage IV anal cancer
10%
333
How long should anal cancer be completed
50 days
No breaks prior to 45 days
334
Colostomy rate after definitive CRT for anal cancer
25%
335
Side effects of MMC
Myelosuppression
Hemolytic uremic syndrome
336
Acute side effects of anal cancer treatment
Dermatitis
Cystitis
Proctitis
Diarrhea
337
Late side effects of anal cancer therapy
10% risk of femoral neck fracture
Vaginal stenosis (dilator)
Sterility/impotence
Anorectal dysfunction
338
Follow-up for anal cancer
8-12 weeks post CRT, doe DRE
If CR --\> DRE q3-6 months and anoscopy q6-12 mos
CT CAP annually
339
What to do if anal cancer not CR in 2-3 months post CRT
Re-eval in 4 weeks
Contunue in 3 month intervals
Reimage and bx if progressive disease and consider APR if local failure
340
How to approach local anal recurrence
APR
50% local control
341
How to approach groin recurrence for anal cancer
Inguinal dissection
342
Other chemo option for anal cancer
capecitabine 825 mg/m2 BID instead of 5-FU
343
Why use IMRT for anal cancer
Reduce GU/GI/dematitis
344
Where do inguinal nodes start
Top of femoral head
345
What is the stomach constraint for esophageal ca?
mean of 30 Gy (stomach - PTV)
346
How to achieve better stomach mean for esophagus
reduce inferior margins
accept lower dose (CROSS did 41.4)
3D --\> IMRT
switch from 4D to compression or DIBH
347
If residual esophageal disease after CRT and esophagectomy, next step
1 year of nivolumab
348
Boost dose for cervical esophagus
Treat SCV, upper mediastinum and paraesophageals to 50.4 then boost tumor + 2 cm to 59.4 Gy
349
Approach to TE fistula
stent to block the fistula
Abx for pneumonia
Proceed to definitive CRT
350
What is a safe answer for postop gastric
If R0 and D2 resection --\> adjuvant chemo alone
If R1/R2, consider 1 cycle of cape --\> RT to 45 Gy, boost to 54 to positive margin and then 2 cycles of cape
351
How to choose chemo regimen for pancreatic
Use performance status
* If ECOG 0-1: mFOLFIRINOX
* If ECOG 2+: gem-abraxane
352
How many months of chemo before you switch to RT for pancreatic
4-6 months
353
For CRC liver mets what is preferred strategy
Resection
354
If resection of CRC mets is not possible what are other acceptable options
1. RFA
2. SBRT
355
Contours for liver mets
Use DIBH with fiducial if possible
If not, 4DCT with abdominal compression
5 mm radial margin
1 cm sup/inf
356
What is preferred strategy for gastric cancer
Periop FLOT4
4 cycles of FLOT --\> gastrectomy --\> 4 cycles of FLOT
357
What is FLOT
5-FU with leucovorin
Oxaliplain
Docetaxel
358
Implication of portal vein thrombus
rules out surgery, transplant and makes liver-directed therapies challenging so do SBRT
359
What is the term for the space between disease and resection edge for rectal cancer
circumferential resection margin
360
If CRM is threatened, what is best first step
TNT
50.4 Gy CRT with concurrent cape and then 4-8 cycles of FOLFOX
361
For which rectal patients might it be ok to avoid RT
T3N0 high rectal
Especially in young woman hoping to preserve potency
362
What is suitable for transanal excision?
T1N0
\<30% circumference
\<3 cm
\>3 mm margin
Accessible from anal verge
363
What do you do if T1N0 gets transanal --\> pT2N0
Go to TME
Do not do CRT
364
How to approach rectal obstruction
Divert --\> PREOP TNT
365
366
367
368
369
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