2B treatment summaries Flashcards
Anal T1N0
Dose & volumes
T1N0
50.4Gy/28#
No elective nodal volume
GTV - Gross primary anal tumour
CTV - GTV + 1cm
Cover Anal canal, verge, internal and external anal sphincters.
Edit from bone & muscle.
PTV-P = CTV +10mm
Anal T2N0
Dose & volumes
T2 (<4cm) N0:
50.4Gy/28# to anal tumour
40Gy/28# to elective nodal volume
GTV-A = primary tumour
CTV A = GTV +10mm, entire anal canal & internal and external sphincters
Elective volume = from bifurcation of common iliac vessles (L5/S1) or 1.5cm above GTV
incl inguinal, femoral, int & ext iliac, obturator, pre-sacral nodes and perirectal nodes.
Include lower 5cm of the mesorectum, or whole mesorectum if tumour extends into it
Include ischiorectal fossa if >5mm infiltration outside levators, puborectalis muscle, external anal sphincter or anal verge, or into the ischiorectal fossa either clinically or on diagnostic imaging, or if skin involvement
PTV-P = CTV +10mm
PTV -elective = 5mm
Anal T2 >4cm, T3-4 / N+
Dose & volumes
T3-4 (&T2 >4cm) or N+:
53.2Gy/28# to primary tumour and nodes >3cm, 50.4Gy to positive nodes <3cm
40Gy to elective volume
GTV-P = primary tumour; CTV-P = GTV +15mm;
PTV-P = 10mm
GTV-N = positive nodes; CTV-N = GTV +5mm;
PTV-N = CTV+5mm
Elective volume = from 2cm above SI joint (L5/S1) or 1.5cm above GTV, inguinal, femoral, int & ext iliac, obturator, pre-sacral nodes and perirectal nodes, but not including mesorectal nodes.
Include lower 5cm of the mesorectum, or whole mesorectum if tumour extends into it
Include ischiorectal fossa if >5mm infiltration outside levators
PTV-P = CTV +10mm
PTV-N & -elective = 5mm
Anal - adj treatment
Indication: close or positive margin and no further resection possible
41.4Gy in 23# - Cover scar plus 1cm margin with MMC & Capecitabine
Include elective nodal volume if primary ≥T2 (similar to treating primary)
Breast - whole breast field borders
Whole breast - borders:
1.5cm into lung, 1cm anterior clearance
midline to mid axillary line
1cm below breast tissue (or inferior aspect of medial head of clavicle) to 1cm above breast tissue
Breast - axilla field borders
Axilla - 5-7° couch twist, single isocentre technique; borders:
Lateral border of humeral head
Med - 1cm lateral to midline
Sup - 3cm above clavicle
Inf - match to whole breast tangent, half beam blocked
Breast - SCF field borders
SCF - borders:
(Humeral head shielding unless treating axilla)
Lateral: 2/3 along clavicle
Med - 1cm lateral to midline
sup - 3cm above clavicle
Inf - matched to whole breast, 0.5cm below clavicular head
Breast - partial breast
Indications: >50 & low risk
Partial breast - Tumour bed +15mm; cropped 5mm of skin and chest wall
PTV 10mm, respecting 5mm from skin but unmodified posteriorly
Covered with tangential fields
Breast - boost
Indications: all <50, >50 & high risk (G3, LVSI+, N+, HER2+)
Boost:
CTV = tumour bed & clips, not grown for CTV, and wired scar
PTV = 5mm
Breast - chest wall
Indication: T3-4, N2, high risk N1, positive margins, residual disease after NACT
Chest wall - wire scar, include skin flaps & entire scar, underlying muscle and ribcage
Breast - whole breast and int mammary nodes
IMN (whole breast and IMN by IMRT):
Ant - 5mm from skin
Post - deep fascia
Inf - breast tissue
Sup - inferior medial clavicular head
Med - ipsilateral edge of sternum
Lat - thoracic vessels or breast tissue
PTV = 5mm
Breast - int mammary vessels
Int mammary vessels from where artery comes off subclavian artery, for first 3 ribspaces (node negative) or first 5 (IMN node positive)
CTV = 5mm, clipped from lung edge
PTV = 5mm
Bladder
55Gy/20#
CTV = whole bladder + 1cm (F) / 1.5cm (M) of urethra if base of bladder involvement
PTV = 1.5cm (2cm if dome of bladder)
Cervix
Ph1: 45Gy/25#
Ph2: 20Gy/10# EBRT boost or 21-28Gy/3-4# by IGBT
1° CRT:
GTVp = macroscopic disease on fused MRI
HR-CTV = remaining cervix
LR-CTV = CTV-HR, bilateral parametria, uterus, prox 2cm of vagina or 2cm below disease, uterosacral ligaments (& mesorectum if uterosacral ligaments involved)
ITV45 = LR-CTV + 10mm ant/post, 10mm sup/inf & 5mm laterally, and elective nodal volume
Elective nodal volume - from L5/S1 for common iliacs, and renal vessels for para-aortics - CI, II, EI, PS, O
GTV-N = positive nodes; CTV-N = GTV-N +5mm
PTV = ITV +5mm
Ph2 boost - GTVp +2cm
Chordoma
70Gy
Protons
Include whole clivus & vertebral body if affected
CNS - Glioma
Glioma
CTV = GTV +1.5cm for low and high grade
High grade planned on T1 post contrast
Low grade planned on T2
Temporal lobe lesion - include whole temporal lobe
PTV = 3mm margin
60/30
40/15
59.4/33
54/30
30/6
35/10 for re-irradiation
CNS lymphoma
CNS lymphoma
4x matrix then WBRT (if not for SCT) - 36/20 +/- 9Gy boost for partial response; Shield lens and anterior chamber after 36Gy
CR after chemo - 23.4/13#
GTV = residual tumour post chemo, CTV = 2cm, PTV = 3mm
Haem - 1° testicular lymphoma
1° testicular lymphoma - 30Gy/15# to contralateral testis
Meningioma
Adj RT - 54/30; GTV = residual tumour and reconstructed pre-op imaging for contact points of tumour. CTV = 1cm along the dura; PTV = 3mm
Radical - Gr1 - 50/30; Gr2 - 55/33; Gr3 - 60/30
GTV = primary tumour; CTV = 1cm along dura (2cm if Gr 3); PTV = 3mm
Haem - marginal zone
Marginal zone - 24Gy/12# to whole stomach, fasted for reproducibility
CTV = whole stomach +1cm and include perigastric nodes
PTV = 1cm
Haem - NK/T cell lymphoma
NK/T cell lymphoma - gelox x2 then 50/25 then Gelox x2
CTV = GTV + whole nasal cavity, maxillary antra and 1-2cm beyond
Haem - mycosis fungoides
Mycosis fungoides - 8Gy/2#, electrons treated to 1cm depth; PTV = 1cm
Haem - solitary plasmacytoma
solitary plasmacytoma: 45Gy/25# if <5cm; 50Gy/25# if >5cm
CTV = whole vertebra and soft tissue, +2cm extension
Adjuvant CTV = GTV +10mm and include metalwork
PTV = 5mm
H&N SEP - GTV = primary + nodes; CTV = 15mm; PTV 10mm
haem - conjunctival lymphoma
Conjunctival lymphoma - 24Gy/12#
CTV is whole conjunctiva with lead contact lens for shielding. 300kV photons
If posterior orbit lesion - 30/15 planned photons prescribed to midplane
haem - Hodgkin’s lymphoma
CTV = Whole nodal compartment radially, +1.5cm sup/inf
PTV = 5mm
Primary testicular lymphoma - contralateral scrotal RT
9MeV electrons, with bolus
Scrotum on a block, penis taped up
30Gy/15#
Frog leg position
Endometrium - adjuvant treatment
Post TAH/BSO
45/25Gy +/- 7Gy single fraction dobbie if cervical invasion
CTV1 (Tumour bed)
Whole Parametrium and 2.5cm upper vagina
CTV2 (nodes)
From bifurcation of common iliac - internal iliac, ext iliac, obturator and pre-sacral nodes.
Cover one nodal level above those involved
PTV1 -CTV1 + 10mm
PTV2 - CTV2 + 8mm
Lung - SCLC
Small cell:
Concurrent - 45Gy/30#/3wks +cis(60)/etopo(100 IV d1, 200mg PO D2-3) starting C1
Seq - cis(80)/etopo(100 & 200) x4 followed by 40Gy/15#/3wks
4D planned - GTV is post chemo primary and pre-chemo LN in all phases of respiration and grown by 5mm to form ITV; PTV = 5mm
PCI = 25Gy/10# within 4-6wks
Lung - NSCLC
NSCLC:
55Gy/20#/4wks +cis(80)/vinorelbine(15mg - D1 & 8) starting C2
4D planned - GTV is post chemo primary and pre-chemo LN in all phases of respiration and grown by 5mm to form ITV; PTV = 5mm
SABR - 54/3; 55/5; 60/8
4D planned - GTV = ITV; PTV = 5mm
Parotid
Sup: zygomatic arch
Inf: hyoid bone
Ant border of masseter to mastoid
Pituitary
Pituitary
45/25 or 54/30 if functioning
GTV = tumour; CTV = pituitary fossa; PTV = 3-5mm
craniopharyngioma
Craniopharyngioma
1° & adjuvant - 54/30
GTV = residual mass + reconstructed primary; CTV = 5mm, including all areas contacted by tumour
PTV = 3mm
Rectum
LC-CRT - 45/25 +/- 5Gy SIB (GTV +2cm)
SC = 25/5/5 days
GTVp = gross tumour or whole lumen
ICTVp = GTV+10mm (15mm anteriorly for high rectal tumours)
GTVn = positive nodes;
ICTVn = 5mm margin
ICTV elective = mesorectum +1cm anteriorly (starts at S2/3 or bifurcation of the IMA), or 2cm above most positive node, & nodal volume (int iliac, presacral, obturator)
ICTV = ICTVp + ICTVn +ICTV elective
Edit off bone and muscle, but not off the sacrum, and edited off muscle but not obturator internus if obturator node positive
PTV = 10mm margin
H&N - nasopharynx
70-63-57
T1-2:
CTV70 = GTV +5mm;
CTV-63 = GTV +10mm, entire nasopharynx
T3-4:
CTV70 = GTV +5mm;
CTV-63 = GTV +10mm, entire nasopharynx
Adjuvant - reconstruct GTV & grow by 1-2cm
H&N - non-nasopharynx
CTV-65 = GTV+5mm (10mm if poorly defined)
CTV-60 = GTV+10mm
CTVn = GTVn +5mm (10mm if >3cm or local invasion & include whole muscle)
PTV 3-5mm
prostate
60/20, 48/20 to SV, 44/20 to nodes
CTV = prostate + prox 2cm of SV if ≤T3a, whole SV if T3b
PTVp = 5mm; PTVsv = 10mm
prostate bed
Prostate bed:
52.5Gy/20#
Vol - below SP: whole bladder to 8mm below VUA / 5mm above penile bulb
Above SP: posterior 1/3 of bladder for 3cm above SP +SV volume
PTV = 1cm
Penile
Penis: CTV = GTV +2cm & 20Gy/10 boost to primary and positive nodes
Treating POP with wax block
No PTV expansion
Elective volume, inguinal and pelvic nodes; and involved nodes
Pancreas
40/5 SABR following folfirinox
GTV primary + nodes
4D planned, ITV = GTV in all phases
PTV = 5mm
Oesophagus
NA - 41.4/23 with carboplatin AUC2 & paclitaxel 50
Definitive - 50/25 - cisplatin (75) / 5FU (1000) starting C2-3
50Gy/16# - <5cm
55Gy/20# - >5cm
Thymoma - primary tx
Radical RT - 60/30
CTV = GTV +10mm; Ptv = 10mm
Thymoma - Adj
Adj RT if macroscopic invasion of mediastinum (st 2b) or high grade
45Gy/25# (R0) or 50.4/28 (R1) +/- boost to 60Gy
GTV = surgical bed, CTV = 5mm, PTV = 5mm radially and 8mm sup/inf
Testicular
IGCN - 20Gy/10# to contralateral testis
Stage 1 if no carboplatin given - 20Gy/10# - 30Gy/15# to PA strip, T11-L5, out to transverse process and include ipsilateral renal hilum.
dog leg to mid obturator fossa if prev inguinal surgery.
Shield remaining testicle
AP/PA field based prescribed to mid plane
Stomach
R1 resection
45Gy/25#- CTV is tumour bed + residual
PTV = 1cm
Skin - Merkel
Merkel - 60/30, of adj 50/25 (if positive margin, >2cm or node positive)
Sarcoma
Wire lump or scar
Neoadjuvant - 50/25, 3cm sup/inf and 2cm radially
Adjvant - 60-66/30-33; 50/25 then 10-16/5-8#, ph1 grown by 5cm sup/inf & 2cm radially, phase 2 by 2cm all round
vulva - primary
45/25 to elective nodal volume & GTV +1cm
SIB to primary and positive nodes to 60Gy, or Ph2 EBRT 20/10 boost
CTVn = GTVn +3mm
PTV 3mm
vulva - adj
Adjuvant = scar +1cm, remaining vulva, mons and elective nodes
thyroid
65 (macroscopic disease)/60/54/30#
GTV = residual tumour + positive nodes
CTV = 1cm and thyroid bed
Hyoid to sternal notch, laterally to carotid sheaths tracheo-oesophageal groove to front of vertebral body
CTV54 = bilat level 2-6
