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1
Q

Rectal cancer: criteria for transanal excision

A

<3 cm

<30% circumference

margin >3mm

within 8 cm of anal verge

T1

mobile

grade 1-2

no LVSI or PNI

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2
Q

Anal Cancer: workup

A

H&P: LN eval, DRE, anal sphincter tone, sexual history, HIV, HPV, IBD history, Gyn exam. Family history

Labs: CBC, HIV if risk factors

Anoscopy/colonoscopy with bx. FNA of inguinal nodes. EUS.

CT chest, CT/MRI of A/P. PET scan not required but can be ordered for treatment delineation

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3
Q

Perianal Cancer: criteria for WLE

A

T1

well differentiated

>1cm margins

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4
Q

Anal Canal: sup/inf borders

A

sup: upper border of anal sphincter and puborectalis muscles
inf: anal verge (aka squamous mucocutaneous junction, aka lower edge of anal sphincter)

approximately 3-5cm in length

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5
Q

Perianal region: boundaries

A

starts at anal verge and includes the perianal skin over a 5cm radius (from the squamous mucocutaneous junction)

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6
Q

Anal canal cancer: criteria for excision

A

superficially invasive

<3mm basement membrane invasion

horizontal spread <7mm

negative margins

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7
Q

Anal cancer: adjuvant treatment for T1 negative margins

A

45Gy to anal region and inguinals, +/- chemo

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8
Q

Anal cancer: adjuvant treatment for T1 positive margins

A

45Gy to anal region and inguinals

boost anal region to 50.4Gy

+/- chemo

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9
Q

Anal cancer: adjuvant treatment for T2

A

45Gy to anal region and inguinals

boost anal region to 50.4Gy

concurrent chemo

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10
Q

Anal cancer: T1-2N0 definitive radiation dose and fields

A

42Gy/28fxs with SIB to 50.4Gy, concurrent chemo

CTV 50.4 = GTV plus anal canal with a 2 cm CTV margin, entire mesorectum

CTV 42 = mesorectal, bilateral inguinal, ext, and int iliacs with 7mm margin

PTV is 1cm

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11
Q

Anal cancer: simulation

A

supine, frog leg, vac loc, oral contrast, full bladder, bead marker at anal verge

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12
Q

Anal cancer: RTOG 0529 constraints small bowel, bladder, femoral heads, and external genitalia

A

small bowel: V45 < 20cc, Dmax < 50

bladder: V50 < 5%, V35 < 50%

femoral heads: V40 < 5%

external genitalia: V40 < 5%

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13
Q

Anal cancer: T3-4N0 fields and dose

A

45Gy/30fxs with SIB to 54Gy, concurrent chemo

CTV 54 = GTV plus anal canal with a 2 cm CTV margin, entire mesorectum

CTV 45 = mesorectal, bilateral inguinal, ext, and int iliacs with 7mm margin

PTV is 1cm

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14
Q

Anal cancer: concurrent chemo dosing

A

capecitabine 825mg/m2 BID M-F

mitomycin 10mg/m2 on day 1 and day 29 or just 12mg/m2 on day 1

5FU 1000mg/m2 daily x 4 days

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15
Q

Anal cancer: 5yr OS for stage I-IV

A

stage I 80%

stage II 75%

stage III 50%

stage IV 10%

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16
Q

Anal cancer: local control for T1, T2, T3

A

T1 95%

T2 75%

T3 50%

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17
Q

Anal cancer: N+ fields and dose

A

54/50.4/45 Gy in 30 fx (1.8/1.68/1.5 daily)

54 to primary and nodal regions with nodes>3 cm

50.4 to nodal regions with nodes<3 cm

45 to negative nodal regions

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18
Q

Anal cancer: considerations for HIV+ patients

A

Test CD4 and consider treatment de-escalation if CD4 count < 200

May decrease dose to 50Gy or reduce superior field border to bottom of SI joints

Ensure patient is following with ID and is on HAART

Consider concurrent cisplatin instead of mitomycin

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19
Q

Rectal cancer: workup

A

H&P. Ask about incontinence. Family history, history of IBD, genetic or hereditary disorders

DRE: distance from anal verge, size, circumference, tone. Pelvic exam if female.

Labs: CBC, CMP, CEA.

Colonoscopy, consideration for diversion with colostomy if incontince, EUS or MRI, CT abdomen/pelvis

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20
Q

Rectal cancer: simulation

A

PRONE, belly board, anal marker, oral contrast two hours before, full bladder

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21
Q

Rectal cancer: classic fields

A

sup: L5/S1
inf: bottom of obturator foramen or 3 cm below tumor, whichever is more inferior
lat: 2 cm beyond pelvic brim
ant: behind pubic symphysis and 3cm in front of sacral promontory
post: 1 cm behind sacrum

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22
Q

Rectal cancer: concurrent chemotherapy dosing

A

capecitabine 800mg BID M-F

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23
Q

Rectal cancer: adjuvant chemotherapy

A

FOLFOX q2wks for 6 months

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24
Q

Rectal cancer: adjuvant radiation dose if positive margin

A

same dose as neoadjuvant but boost area of positive margin to 59.4Gy

If LAR, 1 cm below anastamosis or rectal stump

If APR, extend inferior border down to scar

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25
Rectal cancer: treatment paradigm with short course radiation
T3-4N0-2 patients 25Gy/5fxs to pelvis without concurrent chemotherapy surgery 4-8 weeks after radiation (better than 1 week on Stockholm III)
26
Rectal cancer: outcomes if inoperable or refuses surgery
treat tumor to 60Gy with concurrent chemo complete response rate is 80% for patients with complete response, 1yr LR is 16%
27
Esophageal cancer: workup
H&P. Smoking cessation Labs: CBC, CMP, liver panel Imaging: EGD with biopsy, EUS, CT, PET consider J tube
28
Esophageal cancer: simulation
supine, wingboard, small amount of oral contrast
29
Esophageal cancer: fields and dose
CTV 45: primary with 4 cm sup/inf margin and 1 cm radial margin, plus nodes with a 1 cm margin, with volume enlarged to cover celiac if GEJ CTV 50.4: GTV PTV: 0.5cm
30
Esophageal cancer: concurrent chemo dosing
carboplatin AUC 2 weekly paclitaxel 50mg/m2 weekly
31
Esophageal cancer: NCCN constraints for lung, heart, liver, stomach
Lung: V20 \< 20%, V5 \< 50% Heart: V30 \< 25%, mean \< 30Gy Liver: V20 \< 30%, mean \< 25Gy Stomach: mean \< 30Gy (excluding PTV)
32
Esophageal cancer: MS and 5yr OS with trimodality treatment
MS 49mo 5yr OS 47%
33
Gastric cancer: workup
History and physical Labs: CBC, CMP, liver panel Upper GI with biopsy and H pylori testing, EUS, CT A/P, consider PET Functional testing: J tube consult if Kcal \<1500, renal perfusion scan (not needed if planning for IMRT)
34
Gastric cancer: surgical approaches
Subtotal gastrectomy, 5 cm margin on tumor with D2 dissection removing \>15 LNs, ex lap to look for peritoneal disease Total gastrectomy for large or proximal/fundus lesions Ivor-Lews esophagectomy if tumor at GEJ, Seweirt III
35
Gastric cancer: simulation
supine, 4DCT, wingboard, empty stomach, small amount of oral contrast treat daily on empty stomach (clearly, only if subtotal gastrectomy was performed)
36
Gastric cancer: adjuvant capecitabine dose/schedule
capecitabine 825mg/m2, BID, days 1-14, q28days for one cycle before RT and 2 cycles after RT capecitabine 825mg/m2 BID M-F during RT start RT one month after surgery
37
Gastric cancer: constraints for heart, kidneys, liver, small bowel
heart V40 \< 30% 2/3 of one kidney \< 20Gy liver V30 \< 60% small bowel V45 \< 20cc, max \< 54Gy
38
Gastric cancer: MS and 5yr OS on MacDonald trial
MS 36mo 5yr OS 44%
39
Gastric cancer: considerations for follow up
if proximal stomach was removed, supplement with B12, calcium, and iron
40
Gastric cancer: dose and general targets for T3N0
45Gy/25fxs T3N0: treat anastomosis, whole stomach (except for GEJ tumors), and perigastric nodes
41
Gastric cancer: nodal targets for T4 or N+
perigastric, celiac, paraaortic, superior mesenteric, porta hepatic, periesophageal, suprapancreatic, pancreaticoduodenal only include splenic for tumor in proximal (cardia) or middle (body) location
42
Gastric cancer: 3D fields
AP/PA FIELD: sup: top of T9 inf: bottom of L3 left lateral: include two thirds of left diaphragm right lateral: 4cm lateral to vertebral bodies LATERAL FIELD: ant: abdominal wall post: split vertebral bodies
43
Pancreatic cancer: workup
H&P Labs: CBC, CMP, CEA, CA-19-9, amylase, lipase, liver panel EUS (preferred) with biopsy, CT C/A/P with contrast in 3 phases per pancreatic protocol. Only do ERCP/MRCP if no mass seen. Can consider PET, but not a substitute for high quality CT
44
Pancreatic cancer: 3 phase CT anatomy
Noncontrast phase: shows calcifications that could otherwise be confused with contrast Early arterial phase, 20 seconds, shows arterial anatomy Late arterial/early portal phase, 40 seconds, shows optimal attenuation between enhancing parenchyma and tumor Late portal/venous phase, 80 seconds, shows lymph nodes, liver mets, peritoneal implants
45
Pancreatic cancer: simulation
supine, wingboard, abdominal compression, 4DCT, oral contrast, IV contrast
46
Pancreatic cancer: adjuvant dose and contouring targets
CTV 50.4: tumor bed + 2cm PJ, SMA, celiac, protal vein and clips + 1cm aorta from T11 to L3 + 3cm right, 2cm ant, 1cm left, and 0.2cm post
47
Pancreatic cancer: adjuvant 3D fields
AP/PA FIELD: sup: top of T11 inf: bottom of L3 left lateral: 1.5cm lateral to vertebral body right lateral: 2cm lateral to vertebral bodies LATERAL FIELD: ant: 2cm anterior to preop GTV post: split vertebral bodies
48
Pancreatic cancer: adjuvant chemo
concurrent capecitabine 825mg/m2 BID then adjuvant gemcitabine / capecitabine
49
Pancreatic cancer: 3yr OS, 3yr LF, and MS (RTOG 9704)
3yr OS 30% 3yr LF 30% MS 21mo
50
Pancreatic cancer: criteria for borderline resectability
CA \< 180 SMA \< 180 SMV \> 180 PV \> 180 contact with CHA contact with IVC
51
Borderline resectable pancreatic cancer: treatment paradigm with concurrent radiation
induction FOLFIRINOX or gemcitabine/nab-paclitaxel scan to assess for progression concurrent chemoradiation (capecitabine 825mg BID, 50.4Gy) scan to assess for resectability surgery if possible
52
Pancreatic cancer: constraints for stomach, duodenum, small intestine, liver, and kidney
stomach / duodenum / small intestine max dose \< 54Gy liver mean \< 25Gy single kidney D30% \< 18Gy
53
Unresectable pancreatic cancer: MS and LC with chemo/xrt
MS 16 months LC 45% (results from LAP 07 which showed LC benefit but no OS benefit)
54
Liver SBRT (HCC and mets): simulation
supine, arms up, SBRT body fix, abdominal compression, 4DCT, IV contrast in portal venous phase, contour on MIN, fiducials if doing cyberknife
55
SBRT for liver mets: dose
20Gy/3fxs 50Gy/5fxs if close to critical structures (1 yr LC 95%)
56
SBRT for liver mets: constraints for liver, small bowel, cord, and kidney
liver 700cc \< 15Gy small bowel max \< 26Gy cord max \< 28Gy kidney V18 \< 66%
57
hepatocellular carcinoma: workup
History: alcohol abuse, bleeding, esophageal varices, encephalopathy, lactulose, lasix, ascites Imaging: triple phase MRI liver (CT can also be done) (MRI results should be diagnostic. Bx not needed. Enhances on arterial phase and washout on venous phase), CT abdomen Labs: AFP, liver labs, hepatitis panel, INR, plt, albumin Calculate Child Pugh Score (if C, may not be worth treating). Scoring factors include bilirubin, albumin, INR, ascites, encephalophaty
58
hepatocellular carcinoma: dose
40Gy/5fxs (consider lowering dose if needed)
59
Cholangiocarcinoma: workup and treatment paradigm
CT/MRI, chest CT, cholangiography, consider CEA and CA 19-9, amylase, lipase, LFTs, EUS Distal extrahepatic: whipple For extrahepatic R1/R2 can give RT+4FU OR cis/gem Intrahepatice R1 give chemoRT. For intrahepatic R2 give cis/gem category 1, or chemoRT. For anything unresectable give cis/gem. RT+5FU also an option
60
Treatment paradigm for extrahepatic cholangiocarcinoma and gallbladder carcinoma on SWOG 0809
surgical resection (pT2-4, N+, or positive margin) adjuvant induction capecitabine/gemcitabine x 4 cycles adjuvant concurrent capecitabine with radiation (45Gy with boost to 54-59.4Gy
61
SWOG 0809 dose and field
CTV 45: tumor bed and portal vein nodes, consider pancreatic and celiac nodes CTV54-59.4: tumor bed +1.5cm margin PTV: 0.5 radial, 0.7 sup/inf (if contouring ITV on 4DCT)
62
SWOG 0809: MS
MS 35mo
63
Esophagus T1a
invades mucosa (lamina propria or muscularis mucosa)
64
Esophagus T1b
invades submucosa
65
Esophagus T2
invades muscularis propria
66
Esophagus T3
invades adventitia
67
Esophagus T4a
pleura, pericardium, peritoneum, azgous vein, diagphragm
68
Esophagus T4b
aorta, vertebral body, airway (unresectable tumor)
69
Esophagus N1
1-2 regional nodes
70
Esophagus N2
3-6 regional nodes
71
Esophagus N3
7 or more regional nodes
72
Esophageal SCCa Upper Location
cervical esophagus to azygous vein (lower border)
73
Esophageal SCCa Middle Location
azygous vein to inferior pulmonary vein (lower border)
74
Esophageal SCCa Lower Location
inferior pulmonary vein to stomach
75
Esophageal SCCa clinical Stage I
T1N0-1
76
Esophageal SCCa clinical Stage II
T2N0-1
77
Esophageal SCCa clinical Stage III
T3 or N2
78
Esophageal SCCa clinical Stage IVA
T4 or N3
79
Esophageal SCCa clinical Stage IVB
M1
80
Esophageal Adeno clincical Stage I
T1N0
81
Esophageal Adeno clincical Stage IIA
T1N1
82
Esophageal Adeno clincical Stage IIB
T2N0
83
Esophageal Adeno clincical Stage III
T2N1 or T3-4aN0-1
84
Esophageal Adeno clincical Stage IVA
T4b or N2-3
85
Esophageal Adeno clincical Stage IVB
M1
86
Esophagus yp Stage I
T0-2N0
87
Esophagus yp Stage II
T3N0
88
Esophagus yp Stage IIIA
T0-2N1
89
Esophagus yp Stage IIIB
T3N1, T0-3N2, T4aN0
90
Esophagus yp Stage IVA
T4aN1-2, T4b, N3
91
Esophagus yp Stage IVB
M1
92
Gastric T1a
invades mucosa (lamina propria or muscularis mucosa)
93
Gastric T1b
invades submucosa
94
Gastric T2
invades muscularis propria
95
Gastric T3
invades subserosal connective tissue
96
Gastric T4a
invades serosa (visceral peritoneum)
97
Gastric T4b
invades adjacent structures
98
Gastric N1
1-2 nodes
99
Gastric N2
3-6 nodes
100
Gastric N3a
7-15 nodes
101
Gastric N3b
16+ nodes
102
Gastric Clinical Stage I
T1-2N0
103
Gastric Clinical Stage IIA
T1-2N2-3
104
Gastric Clinical Stage IIB
T3-4aN0
105
Gastric Clinical Stage III
T3N+, T4N+
106
Gastric Clinical Stage IVA
T4b
107
Gastric Clinical Stage IVB
M1
108
Gastric Pathological Stage IA
T1N0
109
Gastric Pathological Stage IB
T1N1, T2N0 (adds to 2)
110
Gastric Pathological Stage IIA
T1N2, T2N1, T3N0 (adds to 3)
111
Gastric Pathological Stage IIB
T1N3a, T2N2, T3N1, T4aN0 (adds to 4)
112
Gastric Pathological Stage IIIA
T2N3a, T3N2, T4aN1-2, T4bN0
113
Gastric Pathological Stage IIIB
T1-2N3b, T3-4aN3a, T4bN1-2
114
Gastric Pathological Stage IVC
T3N3b, any T4N3
115
Gastric Pathological Stage IV
M1
116
Gastric yp Stage II
adds to 3 or 4 (excluding T4bN0)
117
Colorectal Tis
invades mucosa (lamina propria or muscularis mucosa)
118
Colorectal T1
invades submucosa
119
Colorectal T2
invades muscularis propria
120
Colorectal T3
invades through muscularis propria into pericolorectal tissue
121
Colorectal T4a
invades serosa (visceral peritoneum)
122
Colorectal T4b
invades adjacent structures
123
Colorectal N1a
1 node
124
Colorectal N1b
2-3 nodes
125
Colorectal N1c
negative nodes with tumor deposits in the subserosa, mesentery, or perirectal/mesorectal tissues
126
Colorectal N2a
4-6 nodes
127
Colorectal N2b
7+ nodes
128
Colorectal M1a
metastasis to one site without peritoneal metastasis
129
Colorectal M1b
metastasis to two or more sites without peritoneal metastasis
130
Colorectal M1c
peritoneal metastasis
131
Colorectal Stage I
T1-2N0
132
Colorectal Stage IIA
T3N0
133
Colorectal Stage IIB
T4aN0
134
Colorectal Stage IIC
T4bN0
135
Colorectal Stage IIIA
T1-2N1, T1N2
136
Colorectal Stage IIIB
T3-4aN1, T2-3N2a, T1-2N2b
137
Colorectal Stage IIIC
T4aN2a, T3-4aN2b, T4bN+
138
Anus T1
\<2cm
139
Anus T2
2-5cm
140
Anus T3
\>5cm
141
Anus T4
invading adjacent organ
142
Anus N1a
inguinal, mesorectal, or internal iliac nodes
143
Anus N1b
external iliac nodes
144
Anus N1c
external iliac nodes AND inguinal/mesorectal/internal iliac
145
Anus Stage I
T1N0
146
Anus Stage IIA
T2N0
147
Anus Stage IIB
T3N0
148
Anus Stage IIIA
T1-2N1
149
Anus Stage IIIB
T4N0
150
Anus Stage IIIC
T3-4N1
151
Liver T1a
solitary tumor \<2cm
152
Liver T1b
solitary tumor \>2cm without vascular invasion
153
Liver T2
solitary tumor \>2cm with vascular invasion or multiple tumors \<5cm
154
Liver T3
mulitple tumors with one \>5cm
155
Liver T4
major branch of portal vein or hepatic vein, adjacent organs (excluding gallbladder), perforation of visceral peritoneum
156
Liver N1
positive node(s)
157
Liver Stage IA
T1a
158
Liver Stage IB
T1b
159
Liver Stage II
T2
160
Liver Stage IIIA
T3
161
Liver Stage IIIB
T4
162
Liver Stage IVA
N1
163
Liver Stage IVB
M1
164
Intrahepatic Bile Duct T1a
solitary tumor \<5cm without vascular invasion
165
Intrahepatic Bile Duct T1b
solitary tumor \>5cm without vascular invasion
166
Intrahepatic Bile Duct T2
solitary tumor with intrahepatic vascular invasion or multiple tumors
167
Intrahepatic Bile Duct T3
perforating visceral peritoneum
168
Intrahepatic Bile Duct T4
local extrahepatic structures
169
Intrahepatic Bile Duct N1
positive node(s)
170
Intrahepatic Bile Duct Stage IA
T1a
171
Intrahepatic Bile Duct Stage IB
T1b
172
Intrahepatic Bile Duct Stage II
T2
173
Intrahepatic Bile Duct Stage IIIA
T3
174
Intrahepatic Bile Duct Stage IIIB
T4 or N1
175
Intrahepatic Bile Duct Stage IV
M1
176
Gallbladder T1a
invades lamina propria
177
Gallbladder T1b
invades muscular layer
178
Gallbladder T2a
invades perimuscular connective tissue on peritoneal side
179
Gallbladder T2b
invades perimuscular connective tissue on hepatic side
180
Gallbladder T3
serosa (visceral peritoneum), liver, and/or one other structure
181
Gallbladder T4
main portal vein, hepatic artery, or two or more extrahepatic structures
182
Gallbladder N1
1-3 nodes
183
Gallbladder N2
4+ nodes
184
Gallbladder Stage I
T1
185
Gallbladder Stage IIA
T2a
186
Gallbladder Stage IIB
T2b
187
Gallbladder Stage IIIA
T3
188
Gallbladder Stage IIIB
N1
189
Gallbladder Stage IVA
T4
190
Gallbladder Stage IVB
N2 or M1
191
Distal bile duct T2
tumor invades bile duct wall 5-12mm
192
Distal bile duct T4
celiac axis, SMA, common hepatic artery
193
Distal bile duct N2
4+ regional nodes

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