GI Flashcards
Which laboratory test abnormality is MOST frequently associated with a rectal adenocarcinoma?
A. CEA
B. CA 19-9
C. CA 125
D. AFP
A. CEA
Carcinoembryonic antigen (CEA) is the classical tumor marker for colorectal cancer. CA 19-9 levels also have low specificity. CA 19-9 is frequently elevated in patients with pancreatic cancers as well various benign pancreaticobiliary disorders. CA 125, an ovarian cancer tumor marker. AFP can be elevated in patients with hepatocellular carcinoma and testicular germ cell tumors.
For patients with resectable non-metastatic rectal adenocarcinoma, what is an acceptable treatment regimen?
A. Short course chemoRT (25 Gy in 5 Fx with concurrent 5-FU) followed by surgery within 1 week
B. Short course RT (25 Gy in 5 Fx without concurrent 5-FU) followed by surgery within 1 week
C. Long course chemoRT (50 Gy in 25 Fx with concurrent 5-FU) followed by surgery within 1 week
D. Long course RT (50 Gy in 25 Fx without concurrent 5-FU) followed by surgery after 4-8 weeks
B. Short course RT (25 Gy in 5 Fx without concurrent 5-FU) followed by surgery within 1 week
In the Stockholm III trial (Erlandsson, Lancet 2017), patients with resectable non-metastatic rectal adenocarcinoma were randomly assigned to receive short course radiation therapy (25 Gy in 5 fractions) followed by surgery within 1 week OR short course radiation therapy (25 Gy in 5 fractions) followed by surgery after 4-8 weeks OR long course radiation therapy (50 Gy in 25 fractions) with surgery after 4–8 weeks.
What is the local failure rate at 10 years for patients with stage II-III rectal cancer who undergo neoadjuvant chemoRT (50.4 Gy in 28 Fx)?
A. <5%
B. 5 - 10%
C. 11 - 15%
D. 16 - 20%
B. 5 - 10%
The 10-year cumulative incidence of local relapse was 7.1% in the pre-operative arm of the German Rectal Cancer Trial. Other trials have showed similar results, with local failure rates of 5-10% at 10 years.
Which chemotherapy regimen and radiation dose were administered for a 7 cm anal cancer tumor with a single 2 cm inguinal node in RTOG 05-29?
A. 5-FU and Cisplatin, with a dose of 54 Gy to the primary tumor and 50.4 Gy to the involved node
B. 5-FU and Cisplatin, with a dose of 50.4 Gy to the primary tumor and 45 Gy to the involved node
C. 5-FU and Mitomycin C with a dose of 54 Gy to the primary tumor and 50.4 Gy to the involved node
D. 5-FU and Mitomycin C with a dose of 50.4 Gy to the primary tumor and 45 Gy to the involved node
C. 5-FU and Mitomycin C with a dose of 54 Gy to the primary tumor and 50.4 Gy to the involved node
In the RTOG 05-29 trial, two cycles of 5FU (1000 mg/m2/d as a 96-hour infusion, days 1-5 and 29-33) and MMC (10 mg/m2 bolus, days 1 and 29) were administered concurrently with radiation therapy. T2-4N0-3M0 anal cancer patients received 5FU and MMC days 1 and 29 of DP-IMRT, prescribed per stage - T2N0: 42Gy elective nodal and 50.4Gy anal tumor planning target volumes (PTVs) in 28 fractions; T3-4N0-3: 45Gy elective nodal, 50.4Gy ≤ 3cm or 54Gy > 3cm metastatic nodal and 54Gy anal tumor PTVs in 30 fractions.
What was the RT prescription dose scheme for a patient with T2N0 anal cancer enrolled on RTOG 0529?
A. 50.4 Gy to the primary tumor and 42 Gy to the elective lymph nodes
B. 54 Gy to the primary tumor and 42 Gy to the elective lymph nodes
C. 45 Gy to the primary tumor and 45 Gy to the elective lymph nodes
D. 54 Gy to the primary tumor and 45 Gy to the elective lymph nodes
A. 50.4 Gy to the primary tumor and 42 Gy to the elective lymph nodes
In the RTOG 05-29 study, patients with cT2N0 anal cancer received 50.4Gy to the primary tumor and 42 Gy to the elective lymph nodes in 28 fractions using dose-painted IMRT.
Which of the following is NOT used in calculating a patient’s Child-Pugh Score?
A. Ascites
B. Bilirubin
C. Creatinine
D. Albumin
C. Creatinine
The Child-Pugh score consists of five clinical features and is used to assess the prognosis of chronic liver disease and cirrhosis. The five clinical features include: bilirubin, PT/INR, albumin, ascites, hepatic encephalopathy. Each item is graded from a scale of 1 (best) to 3 (worst) and the scores across all five features are then summed to create a total score from 5-15. The Child-Pugh score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices. In addition to being used with the Model for End-Stage Liver Disease (MELD) to determine priority for liver transplantation, The Child Pugh Score can also risk stratify patients for liver SBRT.
Which of the following best defines non-classic radiation-induced liver disease (RILD)?
A. Increase in ALBI grade by 1 or more points
B. Increase in Child Pugh score from baseline by 2 or more points
C. Progressive abdominal pain and weight loss
D. Progressive fatigue, bruising and itching
A. Increase in ALBI grade by 1 or more points
B. Increase in Child Pugh score from baseline by 2 or more points
A & B NOTE: This item was double-keyed for scoring purposes upon post-exam statistical item analysis.
In the current era of more precise radiotherapy planning and avoidance of whole liver radiotherapy, non-classic RILD is much more common that classic RILD. Non-classic RILD manifests as markedly elevated serum transaminases (>5X upper limit of normal), and jaundice. The most commonly used criteria in cirrhotic patients is an increase in Child Pugh score greater than or equal to 2.
What is the approximate local control rate at 1 year for a 2 cm hepatocellular carcinoma treated with SBRT to BED > 100 Gy?
A. 85 - 100%
B. 70 - 84%
C. 55 - 69%
D. 40 - 54%
A. 85 - 100%
Prospective clinical trials of liver SBRT have demonstrated high rates of local control, defined as no progression of disease per RECIST criteria, ranging from approximately 85% to 100% at 1-3 years (Mendez-Romero, 2006, Phase I/II; Kang, 2012, Phase II; Bujold, 2013, Phase I/II; Culleton, 2014, Phase I/II; Lasely, 2015, Phase I/II; Hong, 2016, Phase II). Progression elsewhere in the liver and distantly is common unfortunately, as is death from underlying liver dysfunction, which can be exacerbated by radiation therapy.
Which of the following would be the LEAST acceptable fractionation regimen for definitive radiation therapy for a 4 cm hepatocellular carcinoma, presuming all liver constraints can be met?
A. 60 Gy in 3 Fx
B. 67.5 Gy in 15 Fx
C. 48 Gy in 3 Fx
D. 40 Gy in 5 Fx
This item was 0-weighted for scoring purposes upon post-exam statistical item analysis (did not count for or against candidate in calculation of test scores)
Doses of 54 Gy and higher in 3 fractions, or radiobiological equivalents, may be more suitable for treatment of metastatic lesions wherein underlying liver dysfunction is less of a concern. 48 Gy in 3 fractions is considered one of the acceptable doses for patients with Child Pugh A liver function, while 40 Gy in 5 fractions may be more appropriate for those with B7 and B8 disease. Phase II study on proton beam radiotherapy for unresectable HCC or intrahepatic cholangiocarcinoma used 67.5 Gy RBE in 15 fractions
What is the MINIMUM volume of uninvolved liver that must be spared from receiving a critical dose threshold in liver SBRT?
A. 400 cc
B. 700 cc
C. 900 cc
D. 1500 cc
B. 700 cc
For liver SBRT, the fundamental premise is that to preserve adequate liver function, a minimum volume of normal liver must be spared from receiving a dose that might render it nonfunctional. This minimum “critical volume” was estimated from partial hepatectomy series to be 700 mL; the maximum dose allowed to this critical volume was estimated to be 15 Gy in three fractions (based on LQ conversion, α/β = 3 Gy). When SBRT is given according to these constraints, the risk of radiation induced liver disease is very low.
A Phase III trial randomizing patients with unresectable hepatocellular carcinoma to atezolizumab plus bevacizumab versus sorafenib showed which of the following?
A. The combination of atezolizumab and bevacizumab was associated with no difference in PFS or OS as compared to sorafenib
B. The combination of atezolizumab and bevacizumab was associated with improved PFS as compared to sorafenib, but no difference in OS
C. The combination of atezolizumab and bevacizumab was associated with worse OS and PFS as compared to sorafenib
D. The combination of atezolizumab and bevacizumab was associated with improved OS and PFS as compared to sorafenib
D. The combination of atezolizumab and bevacizumab was associated with improved OS and PFS as compared to sorafenib
In a phase 3 trial, patients with unresectable hepatocellular carcinoma who had not previously received systemic treatment were randomly assigned in a 2:1 ratio to receive either atezolizumab plus bevacizumab or sorafenib. Results showed that the hazard ratio for death with atezolizumab-bevacizumab as compared with sorafenib was 0.58 (95% confidence interval [CI], 0.42 to 0.79; P<0.001). Overall survival at 12 months was 67.2% (95% CI, 61.3 to 73.1) with atezolizumab-bevacizumab and 54.6% (95% CI, 45.2 to 64.0) with sorafenib. Median progression-free survival was 6.8 months (95% CI, 5.7 to 8.3) and 4.3 months (95% CI, 4.0 to 5.6) in the respective groups (hazard ratio for disease progression or death, 0.59; 95% CI, 0.47 to 0.76; P<0.001).
Which concurrent chemotherapy regimen is MOST appropriate for preoperative chemoRT to 50.4 Gy in a HER2+ T3N1 adenocarcinoma of the distal esophagus?
A. Carboplatin, paclitaxel, and trastuzumab
B. Carboplatin and paclitaxel
C. Carboplatin, paclitaxel, and erlotinib
D. Carboplatin, paclitaxel, and capecitabine
B. Carboplatin and paclitaxel
The NRG/RTOG 1010 trial randomized HER2+ esophageal adenocarcinoma patients to receive standard preoperative chemoradiation with or without concurrent trastuzumab. The study demonstrated no benefit in disease-free survival with the addition of trastuzumab.
Which perioperative therapy for locally advanced adenocarcinoma of the GE junction is the LEAST appropriate?
A. Preoperative chemoRT with carboplatin and paclitaxel
B. Preoperative chemoRT with fluorouracil and cisplatin
C. Perioperative chemotherapy with fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT)
D. Preoperative chemotherapy with carboplatin and paclitaxel
D. Preoperative chemotherapy with carboplatin and paclitaxel
Preoperative carboplatin and paclitaxel alone have not been demonstrated to improve survival in esophageal cancer. Choices A) and B) have proven efficacious in the CROSS and RTOG 8501 trials respectively, and Choice C) has proven effective in the FLOT 4 trial when compared to perioperative ECF/ECX chemotherapy.
For esophageal cancer, which lymph node station is considered nonregional or distant?
A. Lower paratracheal nodes (level 4)
B. Celiac nodes (level 20)
C. Pulmonary hilar nodes (level 10)
D. Lower cervical/supraclavicular nodes (level 1)
C. Pulmonary hilar nodes (level 10)
In the 8th edition AJCC staging manual, regional nodes are found in the peri-esophageal tissue from the upper esophageal sphincter to the celiac artery. Pulmonary hilar nodes are regional nodes for lung cancer but would not be considered regional nodes for esophageal cancer.
What is an indication for postoperative chemoRT following total gastrectomy for localized node negative gastric adenocarcinoma?
A. D1 lymph node dissection
B. Negative surgical margins
C. D2 lymph node dissection
D. Diffuse-type adenocarcinoma
A. D1 lymph node dissection
The Intergroup 0116 trial showed that postoperative chemoradiation improved survival compared to surgery alone in a population of patients who mostly received D0 or D1 lymph node dissections, which is now considered suboptimal compared to D2 dissection. Subsequent randomized trials have since suggested that postoperative chemoradiation does not improve survival compared to chemotherapy alone in patients who undergo margin-negative, D2 dissections. However, patients who receive
