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ROQs > [ROQs] GI, Panc, Liver, Biliary, Misc. > Flashcards

[ROQs] GI, Panc, Liver, Biliary, Misc. Flashcards

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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
What is the nodal drainage pattern of the HOP?
- Anterior and posterior pancreaticoduodenal nodes -Hepatoduodenal ligament nodes (including porta hepatis nodes) - Superior mesenteric artery
26
What is the nodal drainage pattern of the pancreatic tail?
- Splenic artery nodes - Celiac nodes - Superior mesenteric artery nodes - Paraaortic nodes - Inferior pancreatic nodes
27
What dx tests should be performed for an intial dx of pancreatic ca?
- 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
28
What resected pancreatic cancer, what is the role of adjuvant gemcitabine vs. observation?
- 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%
29
When is adjuvant CCRT considered for a post-op pancreatic cancer pt?
- 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
What was the R0 resection rate in the '20 publication of PREOPANC-1 trial?
- Upfront Surg vs. neoadjuvant CRT -- 40% vs. 71%
31
What is the patient positioning for simulation of a post-op pancreatic ca pt?
Supine w/ arms up
32
Who was included in PRODIGE 24 pancreatic cancer trial and what was the randomization?
- Resected pancreatic cancer - Randomization -- adj gem x 24 wks --🏆 adj mFOLFIRINOX x 24 wks
33
What were the 5-yr results of the PRODIGE 24 pancreatic cancer trial and what was the randomization?
- 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
How is adjuvant mFOLFIRINOX given for pancreatic ca pt's per the PRODIGE 24 trial?
q14 days x 12C (24 wks)
35
What was the pt population and randomization for the LAP07 trial for pancreatic cancer?
- locally advanced pancreatic -- induction gem -- induction gem + erlotinib - if disease controlled at 4 mos -- further chemo -- 54 Gy 3DCRT w/ capecitabine ## Footnote LAP: Locally Advanced Pancreas
36
What were the main results of the LAP07 trial for pancreatic cancer?
- **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
What was the pt population and randomization for the Alliance trial for pancreatic cancer?
- 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
What were the main results of the Alliance trial for pancreatic cancer?
- 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
What was the randomization for the Stanford retrospective analysis (Miller et al, IJORBP 2021) of neoadjuvant SBRT to gross disease ± ENI for pancreatic cancer?
- Randomization: -- SBRT alone to gross disease -- SBRT + ENI - Dose: -- Gross disease: 40 Gy in 5 fx -- ENI 25Gy in 5 fx
40
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?
- 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
What was the randomization for the ESPAC-4 trial for pancreatic cancer?
- Pt population: -- 730 pts. RO/R1 -- 80% N+ -- 40% R0, 60% R1. - Randomization: -- Surgery→ Gem x6C ± Cape x6C
42
What were the main findings of the ESPAC-4 trial for pancreatic cancer?
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
What were 3-yr the results of the PRODIGE 24 pancreatic cancer trial and what was the randomization?
- 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
What % of pancreatic cancers are resectable at dx?
20%
45
What % of pancreatic cancers are unresectable but non-metastatic at dx?
30%
46
What % of pancreatic cancers are metastatic at dx?
50%
47
What is a standout negative prognostic factor for pancreatic neuroendocrine tumors?
- Surgical margin status heavily impacts survival -- +margin → OS 13 mos -- -margin → OS 71 mos
48
What is the main mode of tx of neuroendocrine pancreatic tumors?
- Surgical resection - CHT or RT or CRT is not recommended for completely resected casesW
49
What are the common pancreatic cancer histologies?
- Adenocarcinoma: 85% - Neuroendocrine: 5% - Adenosquamous ~4% - Mucinous non-cystic: ~2% - Intraductal papillary mucinous neoplasm a/w invasive cancer
50
What is the T staging for pancreatic cancer?
- 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
What is the N staging for pancreatic cancer?
- N0 - N1: 1-3 - N2 - ≥4 - NX - Cannot be assessed
52
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?
- 94% - Compare to 71% in PREOPANC trial
53
What is the patient population and randomization for the GITSG 9173 trial for pancreatic cancer?
- 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
What were the main results of the GITSG 9173 trial for pancreatic cancer?
- 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
Why is the GITSG 9173 trial for pancreatic cancer noteworthy?
Only trial to demonstrate OS benefit w/ CRT!
56
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?
41%
57
What are the AP/PA borders of a classic 4 field for post-op pancreas?
- 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
What are the borders of the lateral fields in a classic 4 field plan for post-op pancreas?
- Sup: T10/11 interspace - Inf: L3/4 interspace - Ant: 2-3cm ant to pre-operative GTV - Post: splits the vertebral bodies
59
What is the standard contouring guide for post-op pancreas?
RTOG 0848
60
What was the pt population and randomization for the LAP07 trial for pancreatic cancer?
- Locally advanced pancreatic - 2X2 randomization - Induction -- Gem -- Gem + Erlotinib - if disease controlled -- further chemo -- 54 Gy 3D CRT w/ capecitabine
61
What were the main results of the LAP07 trial for pancreatic cancer?
- 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
What is the most common age at dx of pancreatic cancer?
- **7**0 - MNEMONIC: Pancreatic enzymes work in a neutral pH
63
What clinical questions did ESPAC-3 trial for pancreatic cancer address?
Is there a benefit to gemcitabine over 5-FU for adjuvant chemotherapy?
64
What was the pt population, randomization, and primary endpoint for the Jang st al. (Korean) study for pancreatic cancer?
- 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
What were the results of the Jang st al. (Korean) study for pancreatic cancer?
- 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
What is the tumor marker for a non-functioning neuroendocrine tumor of the pancreas?
- Elevated Chromogranin A - WNL Gastrin, Insulin, GLucagon
67
What is a standout positive prognostic factor for pancreatic neuroendocrine tumors?
Functional tumors do better than non-functional tumors
68
What is removed during the Whipple procedure?
- Head of the pancreas - Distal stomach - Duodenum - Proximal jejunum - Gallbladder - Distal common bile duct - Regional lymph nodes
69
What structures are contoured within the CTV for a post-op pancreas volume?
- Gross disease or tumor bed - Portal vein - Celiac axis - Superior mesenteric artery - The pancreaticojejunostomy - Aorta
70
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?
- ~40 mos - 3.33 yrs
71
Encasement of which artery is not a contraindication to pancreatic cancer resection?
Spelnic Artery (but NOT splenic vein!)

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