| What does SBRT aim to achieve in terms of radiation delivery? | deliver high doses of radiation at bigger doses per fraction (hypofractionation) to a small target volume with tight margins and steep dose gradients | Technological advances include respiratory motion management, image-guidance, better treatment planning and delivery systems. Treatment of gross disease with margins, excluding elective nodal coverage has shown improved toxicity whilst maintaining local control rates (137-141). Stereotactic body radiation therapy (SBRT) is fast evolving as a very effective local treatment modality, as it is well-tolerated and can be given as a shortened course of radiotherapy, with minimal interruption in systemic therapy (111). SBRT aims to deliver high doses of radiation at bigger doses per fraction (hypofractionation) to a small target volume with tight margins and steep dose gradients. Respiratory | 531 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | SBRT aims to deliver high doses of radiation at bigger doses per fraction (hypofractionation) to a small target volume with tight margins and steep dose gradients. | 35 | page=35,block=11 | 0.700 | valid |
| What does induction chemotherapy address in LAPC patients? | potential systemic disease (ie microscopic metastases) | 22 ICMR Consensus Document for Management of Pancreatic Cancer LAPC – Induction Chemotherapy Before CRT Up to 30% of patients with LAPC develop metastatic disease within 3 months, induction chemotherapy for 3–4 months could potentially select a subgroup of patients without early metastatic course who could benefit from CRT, as suggested by 2 large retrospective studies (128, 129). This strategy helps, firstly, address potential systemic disease (ie microscopic metastases) and secondly, limits the radiation therapy to a subgroup of patients with well controlled tumours (128, 129). An international phase III trial, LAP07, has investigated this sequential approach of induction chemotherapy followed by CRT. The trial, although initially planned to include 722 patients with LAPC, was stopped for futility after recruiting 449 patients (130). | 423 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | This strategy helps, firstly, address potential systemic disease (ie microscopic metastases) and secondly, limits the radiation therapy to a subgroup of patients with well controlled tumours (128, 129). |
| What does the T4 stage indicate about tumour involvement? | Tumour involves the celiac axis or the superior mesenteric artery (unresectable primary tumour) | pT stage Description T1 Maximum Tumour diameter < 2 cm T2 Maximum Tumour diameter > 2 ≤ 4 cm T3 Maximum Tumour diameter > 4 cm T4 Tumour involves the celiac axis or the superior mesenteric artery (unresectable primary tumour) Grossing technique Currently, several different techniques are employed for dissecting PD specimens both with its attendant merits and limitations. First involves bi-valving of the specimen through the Ampulla of Vater with resultant two mirror image slices through the pancreatic and CBD. The second technique which is discussed below involves the axial dissection method which has several advantages. It is easy to perform, and allows key anatomical structures (e.g. ampulla, common bile duct, main pancreatic duct) to be seen in the same slices, and facilitates radial sampling of margins with respect to tumour. | 130 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | pT stage Description T1 Maximum Tumour diameter < 2 cm T2 Maximum Tumour diameter > 2 ≤ 4 cm T3 Maximum Tumour diameter > 4 cm T4 Tumour involves the celiac axis or the superior mesenteric artery (unresectable primary tumour) Grossing technique Currently, several different techniques are employed for dissecting PD specimens both with its attendant merits and limitations. |
| What is BRPC used to describe in pancreatic cancer? | pancreatic cancer with limited involvement of some vasculature, such that any resection, although possible, is likely to result in positive surgical margins (R1 resection). | For patients aged 18-79 years, 21-84 days after R0 or R1 resection, WHO Performance status 1, adequate hematologic and renal function, and no cardiac ischaemia, mFOLFIRINOX has not only been shown to be safe, but associated with a significantly better DFS and OS compared to Gemcitabine. Borderline Resectable Pancreatic Cancer (BRPC) BRPC is used to describe pancreatic cancer with limited involvement of some vasculature, such that any resection, although possible, is likely to result in positive surgical margins (R1 resection). R1 resection is recognized as a negative prognostic factor for overall survival in patients with pancreatic cancer (101). neo-adjuvant therapy may lead to a R0 resection and promote long-term survival, and is | 360 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | Borderline Resectable Pancreatic Cancer (BRPC) BRPC is used to describe pancreatic cancer with limited involvement of some vasculature, such that any resection, although possible, is likely to result in positive surgical margins (R1 resection). R1 resection is recognized as a negative prognostic factor for overall survival in patients with pancreatic cancer (101). |
| What is a characteristic feature of undifferentiated carcinoma with osteoclastic giant cells? | pleomorphic mononuclear cells with scattered osteoclastic giant cells | 33 ICMR Consensus Document for Management of Pancreatic Cancer Undifferentiated (anaplastic) carcinomas are highly lethal carcinomas which lack any ductal differentiation are composed of large pleomorphic cells, anaplastic, sarcomatous, or rhabdoid cells that grow in poorly cohesive formations supported by scanty fibrous stroma. High mitotic activity as well as perineural, lymphatic, and blood vessel invasion is seen in most cases (152). Undifferentiated carcinoma with osteoclastic giant cells has pleomorphic mononuclear cells with scattered osteoclastic giant cells; latter mark with histiocytic markers. Mixed ductal-endocrine carcinoma is characterized by an admixture of ductal and endocrine cells. By definition, the endocrine cells should comprise at least 1/3rd to 1/2 of the entire tumour. | 504 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | Undifferentiated carcinoma with osteoclastic giant cells has pleomorphic mononuclear cells with scattered osteoclastic giant cells; latter mark with histiocytic markers. | 46 |
| What is a characteristic of borderline resectable pancreatic cancers? | a higher likelihood of incomplete resection and positive surgical margins | a more clinically relevant way to classify pancreatic cancer is into the following categories: •• Potentially curable Resectable. Borderline resectable. •• Unresectable, locally advanced. •• Metastatic. At the time of diagnosis, pancreatic ductal adenocarcinoma is resectable in only 15%-20% cases. These are the only potentially curable patients, but even in this category 5-year survival rates are around 20% after surgical resection. The subcategory of borderline resectable carcinomas include potentially curable patients in whom there is a higher likelihood of incomplete resection and positive surgical margins, when surgery is used as the initial treatment (23). Anatomic definitions of borderline resectable cancers are generally well accepted now (24). These patients may be considered for neoadjuvant treatment in preference to upfront surgical resection. | 551 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | The subcategory of borderline resectable carcinomas include potentially curable patients in whom there is a higher likelihood of incomplete resection and positive surgical margins, when surgery is used as the initial treatment (23). |
| What is a key feature of adenosquamous carcinoma? | the presence of variable proportions of glandular and squamous components | Medullary carcinomas are characterized by solid syncitial growth pattern and a rich intratumoural lymphoid infiltrate. These variants are likely to display microsatellite instability and display a better prognosis. Acinar cell carcinomas are aggressive tumours however exhibit a slightly better prognosis than conventional PDAC. Adenosquamous carcinoma is a rare neoplasm characterized by the presence of variable proportions of glandular and squamous components. The squamous component should account for at least 30% of the tumour tissue (152). | 389 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | Adenosquamous carcinoma is a rare neoplasm characterized by the presence of variable proportions of glandular and squamous components. | 45 | page=45,block=8 | 0.700 | valid |
| What is classified as lymph node metastasis in pancreatic cancer management? | Direct infiltration of the primary tumour into lymph nodes | 36 ICMR Consensus Document for Management of Pancreatic Cancer i. Celiac (sent separately) j. Hilar and peripancreatic nodes (distal pancreatectomy) All of the lymph nodes dissected from the specimen should be examined histologically. Direct infiltration of the primary tumour into lymph nodes is also classified as lymph node metastasis. Use of IHC for detecting metastasis in a histologically negative node is not currently recommended for routine practice. Tumour regression grading score As neoadjuvant therapy is increasingly being administered in borderline resectable pancreatic cancer patients, specimens with prior therapy related changes are becoming common. Hyalinization, necrosis, foam cells, calcification and inflammation in the tumour area are histologic features of tumour regression/ response. | 236 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | Hilar and peripancreatic nodes (distal pancreatectomy) All of the lymph nodes dissected from the specimen should be examined histologically. Direct infiltration of the primary tumour into lymph nodes is also classified as lymph node metastasis. |
| What is the SMA margin on the uncinate process? | a rough area on the uncinate process | Herein, the SMV indents the pancreatic surface which is identifiable as a smooth, curvilinear tract, referred to as ‘the SMV groove’ (also referred to as SMV margin, see under section -margins). The SMA courses to the left of SMV and is closely applied to the uncinate process. During pancreaticoduodenectomy (PD), a surgeon has to sharply dissect the SMA off the uncinate process which produces a rough area on the uncinate process which is referred to as the ‘SMA margin’. This surface/margin has also been referred to previously as ‘the retroperitoneal margin’ or the ‘uncinate margin’ by different authors. b) Pancreatic head surfaces The head of pancreas encompasses four important landmarks which are relevant to evaluation of PD resections for pancreatic cancer: 1. Anterior surface, which is smooth bulging anterior face of the pancreatic head. 2. | 396 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | During pancreaticoduodenectomy (PD), a surgeon has to sharply dissect the SMA off the uncinate process which produces a rough area on the uncinate process which is referred to as the ‘SMA margin’. | 44 |
| What is the purpose of the Task Force on Management of Cancers? | to formulate the guidelines for management of cancer sites | The Consensus Document on Management of Pancreatic Cancer is a concerted outcome of effort made by experts of varied disciplines of oncology across the nation. The Indian Council of Medical Research has constituted various sub committees to formulate the document for management of different cancer sites. The Task Force on Management of Cancers has been constituted to formulate the guidelines for management of cancer sites. The sub-committees were constituted to review to review the literature related to management and treatment practices being adopted nationally and internationally of different cancer sites. The selected cancer sites are that of lung, breast, oesophagus, cervix, uterus, stomach, gallbladder, soft tissue sarcoma and osteo-sarcoma, tongue, acute myeloid leukaemia, ALL, CLL, NHL- high grade, NHL-low grade, HD, MM, MDS, and paediatric lymphoma. | 367 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/consensu_3.pdf | The Task Force on Management of Cancers has been constituted to formulate the guidelines for management of cancer sites. | 8 |