GI Flashcards
(39 cards)
Esoph T/N/M stage
T1: mucosa and submucosa
*T1a: lamina propria, MM (7% N+)
*T1b: submucosa (20% N+)
T2: muscularis propria (40% N+)
T3: adventitia (note: no serosa)
T4: adj structures
*T4a: still resectable (pleura, pericardium, diaphragm)
*T4b: not resectable (aorta, vertebral body, trachea, adj organs [liver, panc, lung, spleen])
Nodal staging (by number, not by location)
N1: 1-2
N2: 3-6
N3: 7+
M1: distant including retroperitoneal, PA nodes, positive peritoneal cytology (most common sites = liver, lung, bone, adrenals, pleural, kidneys)
Esoph Overall stage
Adeno:
I : T1N0
IIA: T1N1
IIB: T2N0
III: T2N1, T3-4aN0-1
IVA: N2-3 or T4b
IVB: M1
Sqcc:
I: T1 N0-1
II: T2 N0-1 or T3 N0
III: T3 N1 or N2
IVA: T4 or N3
IVB M1
Esoph T1a Management
Endoscopic Mucosal Resection +/- ablation
Esoph cT2-T4a, N0-N+ (operable) Management
cT2-T4a, N0-N+ (operable)
-CRT -> PET/CT -> surgery (3-6 wks after CRT) -> Nivolumab! for residual disease
-RT: 50.4 Gy
-Chemo:
Cis 75mg/m2 and 5FU 1000mg/m2 weeks 1 and 4
Dont forget Nivolumab!!!!
Inoperable T2+ or N+ Esoph Managment
Inoperable T2+ or N+: Definitive CRT
- RT: 50.4 Gy
- Chemo: Cis 75 and 5FU 1000 weeks 1, 4, 8, 11
- consider chemo alone for T4b SCC invading trachea, great vessels, heart
Cervical esophagus management
Cervical esophagus: Definitive CRT
- 45 Gy to larger volume including SCV -> 50.4 or mid 60s (2 RCTs showing no difference between CRT alone vs. surgery, both went to mid 60s – higher dose to achieve surgical equivalency)
- chemo is carbo/tax (CROSS – 49% pCR) or FOLFOX (French trial, showed less toxicity than cis/5-FU)
- sup extension likely <5 cm, up to level III
Esoph T1b-T2<3cm management
esophagectomy
Esoph volumes and fields
4 field plan (AP/PA + RPO/LPO) weighted AP-PA or 3 field
GTV: gross tumor and enlarged nodes – defined by CT, PET, EGD/EUS
CTV: GTV + 3-4 cm sup/inf, 1 cm radial on primary and nodes; respecting anatomic boundaries (cut out of heart, liver, vertebral body)
-ENI: cervical – SCV; proximal – para-esophageal; distal – celiac, lesser curvature (located in gastrohepatic ligament)
PTV: CTV + 1 cm
*if using 4DCT, contour on average
*Can use IMRT (MDACC) to spare the heart and lungs but pay attention to lung V5 and dose to uninvolved stomach (which will be used for anastomosis) – MDACC Lin IJROBP 2012 showed similar acute tox but improved OS w IMRT (due to less cardiac deaths)!
Esoph Constraints
Total Lung
V40<10%
V20<20%
V5<50%
Cord Max 45
Heart
V30<30
Mean <26
Kidney
V18<33%
Liver
Mean<25 Gy
Panc T/N Stage
T1a: <0.5cm
T1b 0.5-1.0cm
T1c: >1cm-2cm
T2: 2-4 cm
T3: >4cm
T4: +celiac, SMA, CHA
N1: 1-3 nodes
N2: 4+ nodes
Panc Overall stage
IA, T1: < 2cm
IB: T2: >2cm
IIA: T3: >4
IIB: N1: 1-3
III: T4 or N2: 4+ Nodes
IV: M1
Panc Resectability
Ask about CA, SMA, Common Hepatic, Aorta, SMV/PV
Resectable:
no Arterial contact
<180 Vein without vein contour irregularity
Borderline resectable:
<180 Arterial
Reconstructable Venous contact
Unresectable:
>180 SMA or CA
Unreconstructable SMV/PV
Panc resectable management
Resectable: surgery -> chemo mFOLFIRINOX -> restage -> CRT (if positive margin)
Borderline resectable management:
Borderline: FOLFIRINOX x 8 cycles -> 36/15 chemoRT with capecitabine -> surgery
Cord<36
Kidneys mean <12
Panc constraints
RTOG 0848:
Liver: Mean liver <24 Gy
Kidney: V18 <33% and mean < 18 Gy if 2 kidneys.
V18 <15% if 2 kidney.
Small bowel/ Stomach: Max dose ≤54 Gy. V45 <15%
Spinal Cord: Max 0.03 cc ≤45 Gy
Panc Post op volumes
Post-op: 50.4 Gy (RTOG 0848)
Target: fuse pre-op CT to planning CT
CTV = tumor bed (clips; discuss w/surgeon + op-note) + pancreatico-jejunostomy + nodal groups = P3SC (Peri-pancreatic, Porta Hepatis, P-A, SMA/SMV, celiac)
CTV Target volumes (RTOG atlas)
-Celiac: Most proximal 1.5 cm
-SMA: Most proximal 3 cm (3 letters)
-PV: segment of PV slightly to right of, anterior to and antero-medial to IVC (patient’s right). Contour PV from just above its junction w/SMV and go superior and lateral until center of PV width has moved past R lateral edge of IVC stop.
Expand celiac, SMA, PV and PJ by 1 cm
-Aorta: start at most superior of celiac, PJ or PV and then cover down to L2.
Expand off aorta: 2.5 cm to right, 2.5 cm anterior, 1 cm to left and 0.2 cm posterior
-Aortic expansion should be as high as PJ or PV expansion
-If there is a pancreatico-gastrostomy, DO NOT include it (b/c food will go through)
-Crop CTV from liver or stomach
PTV = CTV + 0.5 cm w/daily IGRT
Panc intact volumes
Definitive (Intact):
CTV = GTV + 1.5 cm
PTV = CTV + 0.5 cm
-No elective nodes (95% failures in PTV)
-Boost to 54 if meeting normal tissue constraints (can use IMRT)
Cholangio T staging
T1a – lamina propia
T1b – muscle
T2 – connective tissue
T3 – serosa, invades adj organs
T4 – portal vein, hepatic artery, 2+ adj sites
Cholangio treatment when resectable
• Surgery, cholecystectomy with partial hepatectomy -> adjuvant capecitabine (preferred)
CRT is an option as well
Adjuvant chemo: 4-6 months
Cholangio Unresectable
Chemo or
• Neoadjuvant gem/cis -> liver RT (4.5 x 15 = 67.5, avoid conventional fractionation)
- max mucosal pt dose 42
- mean liver = liver-GTV<20Gy
HCC Staging
T1 – solitary, no vasc inv
T2 – vasc inv, or many small tumors (< 5cm)
T3a – many tumors> 5 cm
T3b – portal or hepatic vein
T4 – adj structures, visceral peritoneum
IVA – N1
IVB – M1
Resectable HCC treatment
Resectable:
1) Partial hepatectomy (CPA, no portal htn, 20-40% liver remnant)
2) Liver transplant (Milan criteria: one lesion < 5 cm or 3 lesions < 3 cm each
Unresectable HCC treatment
Eval for transplant, if not a canddiate:
Local therapy(preferred):
Ablation
Arterial directed
SBRT: 50/5: liver 700cc < 20 Gy
30/3: liver 700cc < 17.5 Gy
Chemo: Sorafenib or Atezolizumab/Bevacizumab (Class A only)
HCC volumes and dose
GTV=gross tumor
PTV=ITV+0.5 cm
- CPA: 16 Gy x 3
- CPB: 8 Gy x 5
15 fx to 67.5 – TH
Probably safe to say 50/5 then deescalate to meet constraints
-RTOG – starts at 50 Gy in 5 fractions, de-escalated based on liver dose (700cc and Veffective), lowest is 27.5/5
Volume receiving <20 Gy more than 700cc – 5 fraction.
Volume receiving <15 Gy more than 700cc – 3 fraction.
