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21 Cards in this Set

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Describe the 4 field technique for post-op pancreas
External-beam four-field technique for body of pancreas lesion. A: Computed tomography (CT) scan showing right tumor extent of lesion marked with clips. B: CT scan of same patient showing left tumor extent marked with clips. The lesion extends posteriorly; note proximity of the tumor to the posterior wall of the stomach anteriorly. The normal glandular appearance of the head of the pancreas and its relation to the duodenum can be seen. C: The anteroposterior/posteroanterior (AP/PA) field showing lesion as reconstructed from CT and clips (broken line) and head of pancreas (dotted line). The field is extended to the left to get a 3- to 5-cm margin of uninvolved pancreas and additional nodal coverage (suprapancreatic with or without splenic). Although the pancreaticoduodenal and porta hepatis nodes are included, the entire duodenal loop does not need to be treated, and at least two thirds of the right kidney can be shielded. (From Gunderson LL, Margolis AR, Burhenne HJ, eds. Alimentary tract radiology, 3rd ed. St. Louis: C.V. Mosby, 1982, with permission.)

Post-op fields as per RTOG 9704
As general guidelines...
Superior intervertebral space T10-T11 or midT11
Inferior intervertebral space L3-L4, depending on pre-op studies
Right edge A margin of 2-3 cm is maintained on preoperative primary tumor extent. In tumors of the body or tail region the right edge may be moved to a minimum of 2 cm from the right edge of the vertebral bodies, as long as a margin of 2-3 cm is maintainted on preoperative primary tumor extent, to allow sparing of the right kidney while covering nodal areas at high risk.
Left edge A margin of 2-3 cm from the preoperative primary tumor extent or 2 cm from the left edge of the vertebral bodies, whichever is most lateral
Posterior split the vertebral bodies in half
Anterior 1.5-2 cm anterior to anterior aspect of the primary tumor as defined on preoperative CT scan and at least 3.5-4 cm anterior to the anterior edge of the vertebral bodies, whichever is most anterior (or 1.5-2 cm anterior to nodal volumes as reconstructed from CT scan information and outlined on simulator films (recommended, but not required))
Boost Field a single field reduction at 45 Gy is required encompassing the preoperative primary tumor volume only with a field edge margin of 1.5-2 cm on all fields
Describe this image.
Pancreatic cancer. Computerized tomographic scan showing a pancreatic adenocarcinoma of the pancreatic head. The gallbladder (gb) is distended because of biliary obstruction. The superior mesenteric artery (sma) is surrounded by tumor, making this an unresectable T4 lesion.
Name four appropriate procedures to obtaining tissue from a suspicious pancreatic mass?
4 ways to obtain tissue for PCA dx: 1. EUS-guided FNA. 2. CT-guided FNA. 3. ERCP. 4. Pancreatic resection, i.e. histologic dx not required before surgery. EUS-directed FNA biopsy is preferable to a CT-guided FNA in patients with resectable disease because of better diagnostic yield, safety,
and potentially lower risk of peritoneal seeding with EUS FNA when compared with the percutaneous approach. Biopsy proof of malignancy is
not required before surgical resection and a non-diagnostic biopsy should not delay surgical resection when the clinical suspicion for
pancreatic cancer is high.
What is work-up for suspected PCA?
Workup for suspected PCA is H+P, CBC, CMP, CA 19-9, triphasic, thin sliced CT of abdomen (pancreas protocol), chest imaging, +/- ERCP/EUS FNA for diagnosis and/or stent placement
Per NCCN, what three criteria are necessary for a primary pancreatic tumor to be resectable?
NCCN resectability for PCA is defined by:
1. Patent SMV-portal vein confluence (splenic vn and SMV join to form portal vn at the confluence).
2. Clear fat plane around celiac and SMA.
3. No nodal mets or other mets beyond the field of resection.
What is the standard total dose and fractionation for PCA after surgical resection?
Standard adjuvant RT volumes and doses for adjuvant PCA: Tumor bed and at risk regional nodes plus a 1-2 cm margin for motion and set-up error to 45Gy. Conedown to tumor bed and a margin to 50.4-54Gy in 1.8 Gy fractions.
In pts with adenoCa of the pancreatic head receiving adjuvant chemoRT, what structures and regional nodes should be covered by RT field?
Classic adjuvant fields for head lesions cover tumor bed, pancreaticoduodenal nodes, local suprapancreatic nodes (not entire pancreas), celiac nodes, porta hepatic nodes, SMA/SMV nodes. For unresectable tumors or neoadjuvant treatment the trend is now towards smaller fields which treat the tumor plus a small margin (McGinn et al. JCO 2001).
What are the expected acute and late radiation toxicities associated with treatment of resected and unresectable PCA?
Acute toxicities: nausea, diarrhea, small bowel obstruction, weight loss.
Late toxicities: small bowel obstruction/stenosis/perforation, gastric/small bowel ulceration and/or bleeding, biliary stenosis obstruction, second malignancies.
In the absence of 3D planning, what are the borders for the initial AP and Lateral radiation fields for PCA of the head?
Classic pancreatic head fields receive 45Gy in 1.8 Gy fractions.
AP Superior- T10-11 interspace
AP Inferior- L3-L4 interspace
AP Left - 2cm from left border of vertebral body
AP Right – 2cm to right of pre-op duodenum
Lateral Superior/Inferior – same as AP
Lateral Posterior – 2 cm into vertebral body
Lateral Anterior -- 2 cm anterior to pre-op gross dz or duodenum.
Whipple procedure is the surgery for removal of pancreatic head cancer. Describe.
en bloc removal of the antrum (distal stomach), first and second portions of the duodenum, head of pancreas, common bile duct and gallbladder. There is then anastomosis performed with attaching the pancreas to the jejunum (pancreatojejunostomy) and hepatic ducts to the jejunum (hepaticojejunostomy) and attachment of the remaining stomach to the jejunum (gastrojejunostomy).
Describe the regimen for unresectable pancreas ca.
definitive concurrent chemotherapy and radiation to 54 Gy (45 to a large field followed by 9 Gy to the tumor plus a 2 cm margin) with concurrent protracted infusional 5-FU of 250 mg per meter squared per day.
For pts with resected pancreatic adenoCa, local failure is the site of first failure for what % of pts treated with adjuvant chemo/RT? Distant failure as first site?
Based on RTOG 9704, local failure is site of first failure in 23-28% and distant failure is first site in 71-77%.
Compare survival in pancreas cancer for pts that are unresectable and get no treatment vs those who get chemo/rt vs those who are resected with adjuvant treatment.
Unresectable disease/no treatment – <6 mo MST
Unresectable diease/CTX-RT – 10 mo
Resectable disease/postop tx – 10-18 months
Depends on margins, T stage, LN stage/involvement
What intervention can help the jaundiced patient/
If patients present with biliary obstruction (jaundice/elevated direct bilirubin), plastic or metal stents should be placed prior to initiation of RT.
A percutaneous drain can also be used if ERCP stent placement is unsuccessful.
Describe the CTV in adjuvant pancreas treatment.
For adjuvant cases, a CTV
includes high risk peri-pancreatic lymph nodes, anastomoses, pancreatic tumor bed derived from pre-surgical imaging and strategicallyplaced
surgical clips. CTV expansions are needed to include possible microscopic disease. Further expansion to PTV includes ITV for
target/breathing motion and additional margin for patient set-up error
What is the standard dose fractionation for unresectable and adjuvant pancreatic cancer?
5040 in 28 fractions is standard for both unresectable and adjuvant
What is the AJCC T and N staging for PCA?
T1- limited to pancreas and 2cm or less
T2- limited to pancreas and > 2cm
T3- extends beyond pancreas but without celiac axis or SMA involvement
T4- celiac axis or SMA involvement
N1- regional nodal involvement
What American RCT first reported a benefit of adjuvant chemoRT vs no additional treatment for resected PCA? Describe the arms of this study and the major results.
The Gastrointestinal Tumor Study Group (GITSG 91-73) trial first reported benefit to adjuvant chemo/RT for PCA in 1985. Standard arm was post-op observation. Experimental arm was split course RT to 40 Gy (2 week break after 20 Gy) with intermittent bolus 5-FU followed by 2 full years of adjuvant 5 FU alone. Adjuvant chemo/RT arm had improved median survival (20 mo vs 11 mo) and 2 yr OS (42% vs 15%). (Kalser MH et al., Arch Surg, 1985).
Did ESPAC-1 study on PCA support or contest benefit of adjuvant chemo/RT?
The ESPAC-1 included pts with grossly resected adenoCa of the pancreas. 2x2 factorial design. Surgery +/- chemo/RT and +/- adjuvant chemo. Adjuvant chemo/RT was similar to GITSG. Adjuvant chemo was 6 months of 5-FU. Median OS 15 mo (chemo/RT) vs 16 mo (no chemo/RT), not signif.; median OS 20 mo (chemo) vs 14 mo (no chemo), p=0.0005. Criticisms: physicians could randomize into 2x2 or directly into one of the two randomizations. “Background treatment” allowed, i.e. observation pts may have received chemo and/or RT. No central RT QA. (Neoptolemos JP et al., Lancet 2001). Note: Analysis of 2x2 subset suggest that chemo/RT had deleterious effect, 5 yr OS 10% (chemo/RT) vs 20% (no chemo/RT), p = 0.05.
What neoadjuvant chemoRT regimen would you use for borderline resectable PCA?
No standard neoadjuvant treatment for PCA. Use similar paradigms as for locally advanced: (1) 5-FU/RT, (2) Gem/RT, (3) induction GTX (Gemcitabine, Taxotere, Xeloda) 5-FU/RT. RT to 45-50.4Gy in 1.8-2Gy fxs or 30Gy in 3Gy fractions per MD Anderson paradigm (Breslin TM et al., Ann Surg Oncol 2001)
In pancreas surgery, goal is always GTR with negative margins. Which margin is most likely to be positive?
retroperitoneal margin is highest risk.