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Gastric Cancer > Background and recommendations > Flashcards

Background and recommendations Flashcards

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1
Q

How do you develop CTV for tumors of antrum of stomach postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, 1st portion of the duodenal loop, gastric remnant and regional nodal regions

Regional nodes add: Porta hepatis, periduondenal, suprapancreatic, splenic, pancreaticoduodenal

Boost gross residual: CTV = GTV + 2 cm margin

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2
Q

Late toxicities of gastrectomy?

A 
Dumping syndrome (diarrhea, cramping, palpitations, reactive hypoglycemia)
Malabsorption: B12, iron, calcium
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3
Q

Beam techniques used?

A

4 field plan
or
IMRT

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4
Q

How do you develop CTV for tumors of body of stomach postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, gastric remnant and regional nodal regions

Regional nodes add: Suprapancreatic, Splenic, pancreaticoduodenal, porta hepatis, splenic hilum

Boost gross residual: CTV = GTV + 2 cm margin

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5
Q

How do you develop CTV for tumors of proximal stomach postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, surgical clips, anastomoses, gastric remnant, regional nodal regions

Regional nodes: Suprapancreatic, Splenic, pancreaticoduodenal, porta hepatis, splenic hilum

Boost gross residual: CTV = GTV + 2 cm margin

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6
Q

How do you develop CTV for tumors of GE junction postoperatively?

A

CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, gastric remnant and regional nodal regions

Regional nodes add: mediastinal, peripesophgeal

Boost gross residual: CTV = GTV + 2 cm margin

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7
Q

What is the relapse pattern after surgery alone?

A

50% of patients fail distantly

54% of patients experience locoregional recurrence

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8
Q

What are the minimum surgical margins on gross tumor and minimum number of nodes removed?

A

5 cm margins

15 nodes

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9
Q

Kidney dose constraint?

A

Mean dose < 18 Gy

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10
Q

Heart dose constraint?

A

V40<30%

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11
Q

Spinal cord dose constraint?

A

Max dose < 45 Gy

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12
Q

T1a

A

Invades lamina propria or muscularis mucosa

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13
Q

T1b

A

Invades submucosa

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14
Q

T2

A

Invades muscularis propria

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15
Q

T3

A

Tumor penetrates subserosa without invasion of the visceral peritoneum (serosa)

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16
Q

T4a

A

Invasion of the serosa, visceral peritoneum

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17
Q

T4b

A

Tumor invades adjacent structures including extension into gastrocolic or gastrohepatic ligaments or greater or lesser omentum

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18
Q

N1

A

1-2 regional nodes

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19
Q

N2

A

3-6 regional nodes

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20
Q

N3

A

N3a: 7-15 nodes
N3b: > 15 nodes

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21
Q

Stage IIA

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A

T1 N2
T2 N1
T3 N0

22
Q

Stage IIB

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A

T2 N2
T3 N1
T4a N0
T1 N3

23
Q

Stage IA

24
Q

Stage IB

25
Stage III
A) T4a N2, T3 N2, T2 N3 B) T4b N0, T4b N1, T4a N2, T3 N3 C) T4b N2, T4 N3
26
Stage IV
M1
27
What is OS for patients with node positive disease?
5-10%
28
D1 LND
Perigastric nodes
29
D2 LND
D1+ portal +periarterial (left gastric, hepatic, celiac, splenic)
30
D3 LND
D2+hepatoduodenal, peripancreatic, mesenteric root, portcaval, PA nodes, middle colic
31
For what stages is gastrectomy alone appropriate?
``` T1 T2 N0 (no LVSI, D2 LND) ```
32
In the standard PORCT regimen, what is the course of chemo?
1. Neoadjuvant: 5FU + leucovorin x 1 (425/20 mg/m2 q 4 weeks) 2. Concurrent: 5FU + leucovorin x 2 (400/20 mg/m2q4 weeks) 3. Adjuvant: 5FU + leucovorin x 2 (425/20 mg/m2 q 4 weeks)
33
What elements of the history and physical should you explore at work up?
History: anorexia, early satiety, abdominal pain, weight loss, fatigue, nasuea, melena, KPS Physical: Abdominal exam evaluating for any palpable masses or ascites, examine for adenopathy left SCL, periumblical, and left axillary regions
34
What imaging and labs are needed at diagnosis?
Imaging: CT scan of the chest/abdomen/pelvis with contrast Labs: CBC, CMP (includes LFTs)
35
What are the two major strategies for management of stomach cancer?
1. Surgery + Chemo+CRT+Chemo | 2. Chemo + surgery + chemo
36
What special studies are needed during work up?
1. EGD with biopsy with H. pylori test
37
What determines whether a total gastrectomy is needed?
1. Total: proximal lesions | 2. Distal: subtotal gastrectomy
38
What anastomosis is done after resection?
Gastrojejuonostomy or esophagojejunostomy
39
What dose of RT do you deliver?
45 Gy and boost to 50.4 for gross residual
40
What is the ECF chemo regimen?
Epirubicin 50/60/200 mg/m2 x 3 cycles q 21 days Cisplatin 5FU
41
What is median OS? 5 year OS with surgery+POCRT?
Median OS 27 months | 5 year OS: 39-52%
42
CT simulation
1. Supine 2. NPO for 3 hours 3. IV contrast 4. Arms above head 5. 4D scan if delivering preop
43
What are the 4 anatomic sections of the stomach?
1. Cardia: begins at the GEJ junction 2. Fundus: Most caudad and up against diaphragm 3. Body: central 4. Antrum: gateway to the pylorus
44
What is the porta hepatis?
The site of entry of the portal vein, hepatic artery, hepatic ducts and hepatic nerve plexus and lymphatic vessels
45
What studys supports post-op chemoRT?
INT 0116 Macodonald Surgery vs. Surgery + Chemo+CRT+Chemo CMT improved 3 year OS ARTIST Trial Post-op Chemo vs. CRT CRT trended to improving OS overall and did improve OS in patients with node positive disease.
46
What patients can have preoperative chemoradiation?
GE junction tumors | Borderline resectable tumors at presentation
47
What study supports perioperative chemo therapy?
MAGIC trial ECF x 3 cycles + surgery + ECF x 3 cycles vs. Surgery alone Chemo improved 5 year OS by 13%. No difference in curative resection rates.
48
Small bowel constraint?
V45 < 150 cc | V30 < 300 cc
49
What are the branches of the celiac artery?
1. Common hepatic 2. Left gastric 3. Splenic artery
50
What nodal regions do you always treat electively?
1. Celiac 2. Perigastric: greater and lesser curvature 3. Paraaortic

Gastric Cancer (1 decks)

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