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Panc, Liver, Biliary, Misc. Flashcards

1
Q

What was the pt population and randomization for the BILCAP trial?

A
  • Intra- or extrahepatic cholangiocarcinoma or GB carcinoma (all stages)
    – s/p macroscopic complete resection
  • Randomization:
    – adj capecitabine x6 mos
    – obs
  • Primary endpoint: OS
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2
Q

What were the main results for the BILCAP trial?

A

Adj. cape vs. obs.
- ITT: OS 51.1 vs. 36.4 mos, p=0.097
- Per Protocol: OS 53 vs. 36 mos, p=0.028
– RFS 24.4 vs 17.5 mos
- Serious AE in 21% vs 10%”

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3
Q

Which cancers are linked to HNPCC?

A

The ECOGs:
- Endometrial
- Colorectal
- Ovarian
- Gastric

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4
Q

Which cancers are linked to ataxia-telangiectasia?

A
  • Lymphomas
  • Leukemias
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5
Q

Which cancers are linked to FAP (Familial Adenomatous Polyposis)?

A
  • Commonly 2/2 mutations in the APC
  • Almost all carriers will develop colorectal cancer
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6
Q

Which cancers are linked to WA (Wiskott-Aldrich)?

A
  • Lymphoma
  • Leukemia
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7
Q

How do the segments of the liver appear on axial CT scan slices?

A
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8
Q

Where does the rectum end and anal canal begin on a coronal MRI slice?

A

Anal canal originates where peri-rectal fat can no longer be seen

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9
Q

What are the components of the Child Pugh Score?

A
  • Estimates Cirrhosis Mortality
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10
Q

Per the NCCN, what is the preferred tx for unresectable HCC cases?

A
  • Unresectable/Untransplantable 2/2 comorbidities, disease progression,
    – Locoregional, arterially directed, or radiation therapy
    — SBRT
    — Microwave ablation
    — Radioembolization
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11
Q

What was the pt population of the PREOPANC-1 trial for pancreatic cancer?

A
  • Resectable pancreatic cancer
  • Borderline resectable pancreatic cancer
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12
Q

What were the arms of the PREOPANC-1 trial for pancreatic cancer?

A
  • Surgery → adjuvant gem x6
  • 🏆 gem 1000 mg/m2 x3 cycles + 36 Gy/ 15 fx during cycle 2 → surgery → adjuvant gem x4
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13
Q

What were the main results of the ‘22 publication of PREOPANC-1 trial?

A
  • Upfront Surg vs. neoadjuvant CRT
    – ITT R0 28% vs. 41%
    – DFS and LRF also improved
    – 5-yr OS 7% vs. 21%
    – Median OS 14.3 vs. 15.7 mos
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14
Q

What are the caveats to the PREOPANC-1 trial?

A
  • FOLFIRINOX (not gem) is the preferred regimen
  • PREOPANC2 will test neoadj FOLFIRINOX vs. neoadj CRT with gem from PREOPANC
  • A trial testing pre-op FOLFIRINOX plus RT would also be of interest.
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15
Q

What vertebral level corresponds to the HOPanc?

A
  • L1-2
  • Same as the end of spinal cord!
  • Panc tail is higher up
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16
Q

What vertebral level corresponds to the origin of celiac axis?

A

T12

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17
Q

What vertebral level corresponds to the origin of SMA?

A

L1

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18
Q

What vertebral level corresponds to the origin of IMA?

A

L3

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19
Q

What is the T staging for pancreatic cancer?

A
  • T1 - confined to pancreas, ≤2 cm
    – T1a: ≤0.5 cm
    – T1b: >0.5 cm and ≤ 1.0 cm
    – T1c: 1-2 cm
  • T2: >2 cm and ≤4 cm
  • T3: >4 cm
  • T4: Unresectable, invades:
    – SMA
    – Celiac axis
    – common hepatic artery
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20
Q

What is the N staging for pancreatic cancer?

A
  • N0: no LNs
  • N1: 1-3 regional LNs
  • N2: ≥4 regional LNs
  • NX: LNs cannot be assessed
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21
Q

What are the NCCN criteria for clearly resectable pancreatic cancer?

A
  • No distant metastases
  • No arterial tumor contact
    – celiac axis (CA)
    – superior mesenteric artery (SMA)
    – common hepatic artery (CHA)
  • No tumor contact with the superior mesenteric vein (SMV) or portal vein (PV) or ≤ 180°
    contact without vein contour irregularity
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22
Q

What are the NCCN criteria for borderline resectable pancreatic cancer?

A
  • Involvement of SMV/portal vein of >180° OR ≤180° with contour irregularity of veins
  • SMV/Portal impingement (distortion/narrowing/occlusion/thrombosis), which can be resected/reconstructed
  • Head/uncinate process tumor:
    – Involvement of common hepatic artery without celiac axis or hepatic bifurcation involved.
    – Abutment of SMA of ≤180°.
    – Contact with anatomic arterial variant (e.g., replaced or accessory artery).
  • Body/Tail tumors: Involvement of ≤180° of celiac axis or >180° without aorta involvement and uninvolved gastroduodenal artery
  • Limited involvement of IVC
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23
Q

What are the NCCN criteria for unresectable pancreatic cancer?

A
  • Distant metastases, including LNs beyond field of resection
  • Contact with first jejunal SMA branch for head/uncinate process lesions OR contact with celiac axis and aortic involvement for body/tail lesions.
  • Involvement with >180 degrees of celiac axis
  • Unreconstructable SMV/portal vein occlusion due to tumor involvement or occlusion (even bland thrombus)
  • Aortic invasion or encasement
  • Contact with proximal draining jejunal branch into SMV for head/uncinate process tumors.
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24
Q

In general, how does single-agent adjuvant CHT compare to multi-agent adjuvant CHT for pancreatic cancer?

A
  • Multi-agent CHT is a/w an OS benefit
    – mFOLFIRINOX vs. Gem (PRODIGE-24): 54.5 mo vs. 35 mo (p = 0.003)
    – Gem/Cape vs, Gem (ESPAC-4); OS 25.5 mo vs. 28 mo (p = 0.032)
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25
Q

What is the nodal drainage pattern of the HOP?

A
  • Anterior and posterior pancreaticoduodenal nodes
    -Hepatoduodenal ligament nodes (including porta hepatis nodes)
  • Superior mesenteric artery
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26
Q

What is the nodal drainage pattern of the pancreatic tail?

A
  • Splenic artery nodes
  • Celiac nodes
  • Superior mesenteric artery nodes
  • Paraaortic nodes
  • Inferior pancreatic nodes
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27
Q

What dx tests should be performed for an intial dx of pancreatic ca?

A
  • H&P
  • CT panc protocol (triphasic contrast CT A/P)
  • CT chest
  • EUS/EGD
    – ERCP if biliary obstruction with stent placement
  • Liver function tests
  • CA 19-9 (following adequate biliary drainage)
    – predicts response
  • Considerations:
    – Laparoscopy is limited to select cases
    – No current role for PET
    – If deemed resectable, consider forgoing bx 2/2 increased risk of peritoneal metastases if bx is done before surgery
    – If biopsy is needed, do it via ERCP
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28
Q

What resected pancreatic cancer, what is the role of adjuvant gemcitabine vs. observation?

A
  • CONKO-001: Adjuvant Gem improves OS
    – 23 mo. vs. 20 mo.
    – 5-yr OS: 20.7% vs. 10.4%
    – 10-yr OS: 12.2% vs. 7.7%
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29
Q

When is adjuvant CCRT considered for a post-op pancreatic cancer pt?

A
  • Recommend 6 mo adjuvant chemo for all patients who did not receive pre-op therapy
  • Consider adjuvant CCRT for R1+ w/ no pre-op therapy or who have residual disease after 4-6m of systemic chemo
30
Q

What was the R0 resection rate in the ‘20 publication of PREOPANC-1 trial?

A
  • Upfront Surg vs. neoadjuvant CRT
    – 40% vs. 71%
31
Q

What is the patient positioning for simulation of a post-op pancreatic ca pt?

A

Supine w/ arms up

32
Q

Who was included in PRODIGE 24 pancreatic cancer trial and what was the randomization?

A
  • Resected pancreatic cancer
  • Randomization
    – adj gem x 24 wks
    –🏆 adj mFOLFIRINOX x 24 wks
33
Q

What were the 5-yr results of the PRODIGE 24 pancreatic cancer trial and what was the randomization?

A
  • mFOLFIRINOX improves DFS, DM, and OS
    – Median DFS 12.8 mos vs. 21.4 mos
    – 5-yr DFS 19% vs. 26%
    – Median OS 35.5 mos vs. 53.5 mos
    – 5-yr OS 31% vs. 43%
    – Median DMFS 17.7 mos vs. 29.4 mos
    – 5-yr DM 54% vs. 37%
    – Median CSS 36.3 mos vs. 54.7 mos
34
Q

How is adjuvant mFOLFIRINOX given for pancreatic ca pt’s per the PRODIGE 24 trial?

A

q14 days x 12C (24 wks)

35
Q

What was the pt population and randomization for the LAP07 trial for pancreatic cancer?

A
  • locally advanced pancreatic
    – induction gem
    – induction gem + erlotinib
  • if disease controlled at 4 mos
    – further chemo
    – 54 Gy 3DCRT w/ capecitabine

LAP: Locally Advanced Pancreas

36
Q

What were the main results of the LAP07 trial for pancreatic cancer?

A
  • RT randomization
    – No difference in OS
    — Median OS 16.5 mos chemo vs. 15.2 mos chemoRT, p=0.83
    – RT improved LC, 68% vs. 54%, p=0.03
    – PFS 9.9 mos RT vs. 8.4 mos, p=.06
    – No increase in Grade 3-4 toxicity with RT except for nausea
  • Erlotinib randomization
    – No improvement in OS
    – Toxicity was increased
37
Q

What was the pt population and randomization for the Alliance trial for pancreatic cancer?

A
  • Borderline resectable pancreatic cancer
    –🏆induction mFOLFIRINOX x8 → surgery → FOLFOX x4
    –induction mFOLFIRINOX x7 → SBRT (33-40 Gy/5 fx) or hypofractioned IGRT (25 Gy/5 fx) → surgery → FOLFOX x4
38
Q

What were the main results of the Alliance trial for pancreatic cancer?

A
  • Interim analysis mandated closure of RT arm due to low R0. The chemo only arm proceeded to full enrollment
  • CHT vs. CRT
    – Overall R0: 57% and 33%
    – Proceeded to surgery: 58% and 51%
    – Of those who underwent surgery:
    – R0: 88% and 74%
    – pCR: 0 and 2%
    – 18-mo OS: 67% and 47% (unpowered)
    – Median OS: 29.8 and 17.1 mos
    – Median EFS: 15.0 and 10.2 mos
39
Q

What was the randomization for the Stanford retrospective analysis (Miller et al, IJORBP 2021) of neoadjuvant SBRT to gross disease ± ENI for pancreatic cancer?

A
  • Randomization:
    – SBRT alone to gross disease
    – SBRT + ENI
  • Dose:
    – Gross disease: 40 Gy in 5 fx
    – ENI 25Gy in 5 fx
40
Q

What were the main findings of the Stanford retrospective analysis (Miller et al, IJORBP 2021) of neoadjuvant SBRT to gross disease ± ENI for pancreatic cancer?

A
  • Median radiographic FU ~ 28 mos.
    – 2-yr LR progression favored the SBRT + ENT (22.6% vs 44.6% for SBRT-alone, absolute reduction = 22% and hazard ratio = 0.39, p=0.021)
    – Comparable overall acute and late toxicity, except acute G1-2 nausea significantly higher in SBRT + ENI cohort (60% vs 20%, P<0.001).
41
Q

What was the randomization for the ESPAC-4 trial for pancreatic cancer?

A
  • Pt population:
    – 730 pts. RO/R1
    – 80% N+
    – 40% R0, 60% R1.
  • Randomization:
    – Surgery→ Gem x6C ± Cape x6C
42
Q

What were the main findings of the ESPAC-4 trial for pancreatic cancer?

A

Gem (G) vs. Gem + Cape (GC)
- MS 25.5 → 28 mo (p=0.032)
– R1 + G: OS 23.0 mos
– R0 + G: OS 27.9 mos
– R1 + GC: OS 23.7 mos
– R0 + GC: OS 39.5 mos
- 5y OS 16.3 → 28.8%.
- 5y PFS 12→ 19%.
- G3-4 toxicity 53 → 63%.
- LR ~66%.

43
Q

What were 3-yr the results of the PRODIGE 24 pancreatic cancer trial and what was the randomization?

A
  • Median FU ~ 34 mos
  • mFOLFIRINOX vs. gem
    – 3-year DFS: 40% vs. 21% (P<0.001)
    – 3-year OS: 63% vs. 49% (P=0.003)
    – G 3-4 AEs: 75.9% vs. 52.9%
44
Q

What % of pancreatic cancers are resectable at dx?

A

20%

45
Q

What % of pancreatic cancers are unresectable but non-metastatic at dx?

A

30%

46
Q

What % of pancreatic cancers are metastatic at dx?

A

50%

47
Q

What is a standout negative prognostic factor for pancreatic neuroendocrine tumors?

A
  • Surgical margin status heavily impacts survival
    – +margin → OS 13 mos
    – -margin → OS 71 mos
48
Q

What is the main mode of tx of neuroendocrine pancreatic tumors?

A
  • Surgical resection
  • CHT or RT or CRT is not recommended for completely resected casesW
49
Q

What are the common pancreatic cancer histologies?

A
  • Adenocarcinoma: 85%
  • Neuroendocrine: 5%
  • Adenosquamous ~4%
  • Mucinous non-cystic: ~2%
  • Intraductal papillary mucinous neoplasm a/w invasive cancer
50
Q

What is the T staging for pancreatic cancer?

A
  • T1 - confined to pancreas, ≤2 cm
    – T1a - tumor ≤0.5 cm
    – T1b - >0.5 cm and ≤1.0 cm
    – T1c: 1-2 cm
  • T2: >2 cm and ≤4 cm
  • T3: >4 cm
  • T4 - invades superior mesenteric artery, celiac axis, and/or common hepatic artery regardless of size (unresectable primary tumor)
51
Q

What is the N staging for pancreatic cancer?

A
  • N0
  • N1: 1-3
  • N2 - ≥4
  • NX - Cannot be assessed
52
Q

In the MDACC series (Katz, 2008), what was the R0 resection rate for borderline resectable pancreatic cancer s/p CRT f/b surgery if no evidence of progression?

A
  • 94%
  • Compare to 71% in PREOPANC trial
53
Q

What is the patient population and randomization for the GITSG 9173 trial for pancreatic cancer?

A
  • Designed to compare obs. v s. adjuvant CRT for resected pancreatic cancer w/ -margins
    – 28% were LN+, 95% pancreatic head
  • Randomized to:
    – Surgery alone
    – Surgery → 40 Gy split course (2 wk break after 20 Gy) + concurrent bolus 5FU –> maintenance 5FU x 2y
54
Q

What were the main results of the GITSG 9173 trial for pancreatic cancer?

A
  • Adj CRT vs. obs.
    – Median OS 21.0 months vs. 10.9 months
    – 2-yr OS 46% vs. 18%
  • Only trial to demonstrate OS benefit w/ CRT!
55
Q

Why is the GITSG 9173 trial for pancreatic cancer noteworthy?

A

Only trial to demonstrate OS benefit w/ CRT!

56
Q

In MDACC series (Katz et al 2008), how many borderline resectable pancreatic cancer pts were able to complete neoadjuvant CHT → CRT and proceed to surgery?

A

41%

57
Q

What are the AP/PA borders of a classic 4 field for post-op pancreas?

A
  • Sup: T10/11 interspace
  • Inf: L3/4 interspace
  • Lat: includes the hepatic hilum, pancreatic remnant, and 1.5-2cm off the vertebral bodies to cover the PAs
58
Q

What are the borders of the lateral fields in a classic 4 field plan for post-op pancreas?

A
  • Sup: T10/11 interspace
  • Inf: L3/4 interspace
  • Ant: 2-3cm ant to pre-operative GTV
  • Post: splits the vertebral bodies
59
Q

What is the standard contouring guide for post-op pancreas?

A

RTOG 0848

60
Q

What was the pt population and randomization for the LAP07 trial for pancreatic cancer?

A
  • Locally advanced pancreatic
  • 2X2 randomization
  • Induction
    – Gem
    – Gem + Erlotinib
  • if disease controlled
    – further chemo
    – 54 Gy 3D CRT w/ capecitabine
61
Q

What were the main results of the LAP07 trial for pancreatic cancer?

A
  • CHT vs. CRT
    – No difference in OS
    – Median OS 16.5 mos vs. 15.2 mos, p=0.83
    – LC 54% vs. 68%, p=0.03
    – PFS 9.9 mos RT vs. 8.4 mos, p=.06
    – No increase in Grade 3-4 toxicity with RT except for nausea
  • ± Erlotinib
    – No improvement in OS
    – Toxicity was increased
62
Q

What is the most common age at dx of pancreatic cancer?

A
  • 70
  • MNEMONIC: Pancreatic enzymes work in a neutral pH
63
Q

What clinical questions did ESPAC-3 trial for pancreatic cancer address?

A

Is there a benefit to gemcitabine over 5-FU for adjuvant chemotherapy?

64
Q

What was the pt population, randomization, and primary endpoint for the Jang st al. (Korean) study for pancreatic cancer?

A
  • Borderline resectable pancreatic cancer
  • Randomization:
    – Gemcitabine-based pre-op CRT (54 Gy / 30 fx) → surgery
    – Surgery → CRT
    – All patients received maintenance gemcitabine chemotherapy for 4 monthly cycles.
  • Endpoint: 2-yr OS
65
Q

What were the results of the Jang st al. (Korean) study for pancreatic cancer?

A
  • Pre-op vs. post-op CRT
    – 2-yr OS: 41% vs. 26% (p=0.028)
    – Median OS: 21 mos vs. 12 mos (p=0.028)
    – RO resection rate: 52% vs. 26% (p=0.004)
    – Mean # of positive LNs: 0.5 vs. 1.9 (p=0.01)
66
Q

What is the tumor marker for a non-functioning neuroendocrine tumor of the pancreas?

A
  • Elevated Chromogranin A
  • WNL Gastrin, Insulin, GLucagon
67
Q

What is a standout positive prognostic factor for pancreatic neuroendocrine tumors?

A

Functional tumors do better than non-functional tumors

68
Q

What is removed during the Whipple procedure?

A
  • Head of the pancreas
  • Distal stomach
  • Duodenum
  • Proximal jejunum
  • Gallbladder
  • Distal common bile duct
  • Regional lymph nodes
69
Q

What structures are contoured within the CTV for a post-op pancreas volume?

A
  • Gross disease or tumor bed
  • Portal vein
  • Celiac axis
  • Superior mesenteric artery
  • The pancreaticojejunostomy
  • Aorta
70
Q

In the MDACC series (Katz, 2008), what was the MS of pt’s who completed induction CHT f/b CRT f/b surgery if no evidence of progression for pancreatic cancer?

A
  • ~40 mos
  • 3.33 yrs

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