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1
Q

CNS dose max for 1.8/2Gy fx:
1) Retina
2) Optic Nerves
3) Optic chiasm
4) cochlea
5) Brainstem
6) Spinal cord
7) Lens
8) Whole brain-PTV

A

1) <50Gy
2) <54Gy
3) <54Gy
4) <45Gy mean
5) <54Gy, D1cc <59, Dmax <60-64 if needed
6) <52Gy
7) 7Gy
8) 60Gy

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2
Q

1fx, 3fx, and 5fx contraints for:
1) Optics
2) Brainstem
3) Brain-GTV
4) Cochlea mean
5) Spinal Cord

A

1) Optics: <8Gy, 17Gy, 25Gy
3) Spinal cord: <14Gy, <22Gy, <30Gy
2) Brainstem: <15Gy, <23Gy, <31Gy
4) Brain-GTV: V10<12cc, V20<20cc, V24<20cc
5) Coclea mean: <4-9Gy, <17Gy, <18Gy

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3
Q

What histology features make up the grade for gliomas?

A

AMEN: atypica, mitosis, endothelial proliferation, necrosis

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4
Q

1) OS for G2 Oligo vs Astro?
2) OS for G3 Olgio vs Astro?

A

1) 18yrs vs 8yrs
2) 10yrs vs 3yrs

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5
Q

What were high risk patients on RTOG 9802? What did this trial show?

A

Age >=40 or STR; RT vs RT+PCV; PCV increased 10yr OS 62% vs 41%.

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6
Q

What are PCV and TMZ? How are they given?

A

1) procarbazine, lomustine, vincristine q8wks x 6 cycles adjuvantly or neoadjuvantly.

2) TMZ 75mg/m2 daily during RT (7d wk) then D28 150mg/m2 for 5 days —> 200mg/m2 5d x 12 mos.

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7
Q

What are the Pignotti criteria? When helpful to use them?

A

SATAN:
Size >6cm
Age >=40
Tumor crosses midline
Astrocytoma
Neuro deficits

Use deciding obs vs RT for G2 astrocytoma. Need 3+ criteria (astro is already one, so two more).

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8
Q

What defines GBM?

A

IDHwt, ATRX retained, AND:
necrosis/MVP, TERTmut, EGFR, +7/10-

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9
Q

Meningioma GI,II, III criteria?

A

WHO I: <4 mitosis per 10 hpf
WHO II: 4-20 mitosis, clear cell, choroid, brain invasion.
WHO III: 20+ mitosis, anaplastic, TERTmut, CDKN2A loss.

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10
Q

What is Group III meningioma per RTOG 0539 and how do you treat it?

A

Recurrent WHO grade II or new WHO grade II s/p STR or WHO grade III of any resection extent:

GTV = Nodular enhancing tissues and tumor bed (if post-op).
Do not include cerebral edema (T2 or FLAIR MRI hyperintensity) or dural tail
CTV 54 = GTV + 2 cm, but reduce to 1 cm around bones (unless radiographic evidence of invasion or hyperostosis, then use 2 cm) and other natural barriers to spread
CTV 60 = GTV + 1 cm
PTV = CTV + 3-5mm

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11
Q

Epidural spine cord compression scale?

A

1a, epidural impingement, without deformation of the thecal sac;
1b, deformation of the thecal sac, without spinal cord abutment;
1c, deformation of the thecal sac with spinal cord abutment, but without cord compression;
2, spinal cord compression, but with CSF visible around the cord;
3, spinal cord compression, no CSF visible around the cord.

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12
Q

General tx paradigm for pituitary adenoma?

A
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13
Q

Labs for pituitary tumor?

A

Examine respective secretory status with TSH, T3/T4,
ACTH, 24-hour urinary free cortisol, PRL, IGF-1.

bHCG, AFP, LDH

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14
Q

Doses for Secretory vs Nonsecretory Pituitory Tumors? SRS vs EBRT?

A

Nonsecretory: 16Gy, 50.4Gy
Secretory: 20Gy, 54Gy

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15
Q

How do you treat a vestibular schwannoma?

A

If small and asymptomatic can observe.

50.4Gy/28fx or 12.5Gy in 1 fx.

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16
Q

How do you treat an AVM? Bleeding risk if untreated? If treated?

A

If <3cm then 21Gy, if >3cm 18Gy.

2% risk per year untreated

Reduce bleeding risk 50% during latency periodi (1-4yrs to scar down) then decreased 85%.

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17
Q

How would you treat a brainstem met? What dose constraints to the brainstem?

A

Higher total Dmax (31–33 Gy) spread over 5 fractions (6–6.6 Gy/fx), better for larger lesions or re-irradiation. Slightly more forgiving on volume (V23 Gy <0.5 cc) due to repair between fractions.

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18
Q

Hippocampus dose constraints for HA-WBRT?

A

D100% (Max Dose to 100% of Hippocampus): ≤ 9–10 Gy over 10 fractions.

This ensures no part of the hippocampus exceeds this threshold.
Dmax (Maximum Point Dose): ≤ 16–17 Gy over 10 fractions.

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19
Q

Breakdown group I, II, III for meningoma.

A

I) Grade 1 GTR or STR
II) Recurrent G1 GTR and STR; New G2 GTR
III) New G2 STR; Recurrent G2 GTR or SRT; G3 GTR or STR.

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20
Q

What are the Simpson grades?

A
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21
Q

Recurrent GBM dose constraints?

A
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22
Q

What do you constrain chiasm, brainstem, optic nerves to in 5fx?

A

22-25Gy.

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23
Q

What is the conformality index?

A

100% Isodose/ PTV volume want <2.

24
Q

LC for for BM <2cm, 2-3 cm, and 3-4cm?

A

90%, 80-90%, 60-70%.

25
What is treatment paradigm for germinoma?
Biopsy -> Induction chemo -> EBRT Localized: 1.5 Gy per fraction No chemo: 24 Gy WVI plus 21 Gy boost Partial response: 24 Gy WVI plus 12 Gy boost Complete response: 18 Gy WVI plus 12 Gy boost Metastatic: No chemo: 24 Gy CSI plus 21 Gy boost With chemo: 24 Gy CSI plus 12 Gy boost
26
How do you treat diabetes insipidus?
Desmopressin, Vasopressin analog.
27
Describe CSI?
28
What does CDKN2A/B homozygous deletion affects what?
Oligos become G3 Astro become G4
29
What is ATRX?
Exclusive with 1p19q, so associated with astrocytomas.
30
Workup for CNS lymphoma?
Full ophthalmologic exam including slit lamp eye exam * Lumbar puncture if safe * Spine MRI if clinically indicated * Lactate dehydrogenase (LDH) test * HIV status * Complete blood count (CBC), comprehensive metabolic panel * Whole body PET/CT scan or contrast-enhanced chest/abdomen/pelvis CT * Bone marrow biopsy (category 2B) * Consider testicular ultrasound for patients >60 yk (category 2B) * Initiate steroids as clinically indicated
31
PCNSL chemo regimen?
R-MPV: rituxin, methotrexate, procarbazine, vincristine. Give 5c if not CR then 2 more cycles. Then consolidate WBRT or ASCT
32
If partial response to chemo for CNS lymphoma, then what RT dose? What's the 5yr OS?
WBRT 30Gy with boost to gross disease to 45Gy.
33
Differential for dura tail lesions? If diagnostic doubts what can you order?
Cats like spilled milk Chloroma Lymphoma Sarcoid Meningioma *Order octreotide or DOTATATE PET/MRI
34
For treated high risk meningiomas, what are the outcomes?
3yr LC only ~70%, OS 80%.
35
How do you tx trigeminal neuralgia?
40Gy to the 50% iosodose line with brainstem max of 16Gy.
36
What combo of exam findings point to sensorineural loss?
Rinne: shows air better than bone conduction on affected side Weber: shows bone conduction only quiter in the affected ear.
37
For vestigular schwannomas with % are stable or regress without tx? How would you follow with obs? Do you treat with RT if more hearing loss? Dose? Constraints? Koos grades?
50% if <2cm MRI and Audiometry q1yr No, only tx for growth. 50-60% hearing loss with RT. Brainstem max 12Gy, cochlea max 4Gy Koos grade: I intracanicular, II CPA no contact w brainstem, III CP cistern, IV brainstem compression
38
AVM risk factors for bleed; mortality and severe impairment risk if bleed? Risk factors for bleed? What does Spetlzer-Martin grade predict; what grade should avoid microsurgery?
3% per year, mortality 5-10% but 50% survivors w severe deficit Prior bleed, location, depth of venous drainage Neuro deficit after surgery; GIII
39
What labs need to be orderd for pituitary mass? What % PA are functioning?
Serum prolactin; tx with bromocriptine or cabergoline GH and EGF-1; test with glucose suppresison, insulin intolerance, TRH stimulation; tx with octreotide ACTH; random coritsol, 24hr urine, and dex suppression test; tx w ketoconazole FSH, LH, estradiolo, testosterone TSH, T3, T4 AFP, bHCG, LDH 75% functioning
40
What scan for paraganglioma?
68Ga DOTATE PET
41
Bilksy and SINS scores?
**Bilsky:** grade 0: bone-only disease grade 1: epidural extension without cord compression 1a: epidural extension only (no deformation of the thecal sac) 1b: deformation of thecal sac, without spinal cord abutment 1c: deformation of the thecal sac, with spinal cord abutment grade 2: spinal cord compression, with cerebrospinal fluid (CSF) visible around the cord grade 3: spinal cord compression, no CSF visible around the cord **SINS; 6 components:** Location Pain: mechanical vs oncologic Lytic vs blastic Alignment Vertebral body collapse Posterolateral involvement **Risk stratification** 0-6 stable, 7-12 potentially unstable, 13+ unstable & require surgical stabilization
42
Risk of progression after GTR for G2 glioma? How often do you repeat brain MRIs?
50% at 5yrs and q3-6 months.
43
For G3 glioma what is the GTV and CTV?
* GTV = residual FLAIR changes, resection cavity and any residual enhancement on T1 postcontrast * CTV = GTV + 10-15 mm expansion * PTV = CTV + 3-5 mm expansion
44
Vertebrae anatomy
45
Describe a flair vs T1 image.
46
Ring enhancing lesion?
Abscess Primary brain tumor/high grade glioma Metastasis CNS lymphoma infarct, contusion, demyelinating disease, radiation necrosis, or resolving hematoma
47
Hypofractionation options for GBM if MGMT-meth vs not.
45/15+TMZ or 34/10 alone.
48
Treatment of recurrent GBM?
35Gy/10fx +bev 10mg/kg q2wks until progression. Median survival time was 10.1 versus 9.7 months for BEV + RT versus BEV alone. The median PFS for BEV + RT was 7.1 versus 3.8 months for BEV, hazard ratio, 0.73; 95% CI, 0.53 to 1.0; P = .05.
49
GBM survival Stupp, TTF, MGMT meth, elderly?
Stupp: MS 14.6mo, 2y OS 27%, 5y OS 2% MGMT+/- 22mo vs 15mo TTF: 21 mos vs 16mos without Eldery 6-12 months, concurrent TMZ+40/15=9 mos.
50
Hippocampal constraints and memantine?
Hippocampi D100 <9Gy, Dmax <16Gy Memantine dosing? Starting d1 of WBRT 5mg qd x1wk 5mg bid x1wk 10mg + 5mg x1wk 10mg bid for total 24wk
51
Workup for CNS lymphoma? What if intraocular? 5yr OS?
PET, CSF, slip lamp, testicular US if >60, HIV, LDH, slit lamp, MRI spine if indicated, BMB consider. Consider intraocular chemo? 5yr OS 30%
52
Treatment of M+ germinoma?
CSI 24Gy boost to 45Gy no chemo if with chemo then boost 36.
53
What do you call an old intrinsinc pontine glioma? Mutation? OS with RT vs steroids?
Diffuse midline glioma; H3 K37M 2-3 mos vs 9-12 mos
54
Optic glioma is associated with what genetic mutation? Skin association? Tx?
NF-1 Cafe au lait, axillary freckling Obs, chemo (carbo/vincristine), RT 50.4Gy
55
ATRT tx paradigm?
ATRT: 1. MRI brain --> maximal safe resection --> post-op MRI (w/i 48 hours) --> MRI spine 10 days post-op --> LP after MRI spine Induction chemotherapy x 2 cycles --> RT --> adjuvant chemotherapy x 3 cycles with PBSC rescue M0: IFRT to 54 Gy If < 3 yo, IFRT to 50.4 Gy, but try to avoid If > 3 yo, can consider CSI - but controversial GTV = pre-op GTV + tumor bed CTV = GTV + 1 cm cropped at bone and tentorium M1: CSI 36 Gy + IFRT 54 + spinal boost 45 If < 3 yo, no RT
56
Spine ependymoma in adults?
GTR for G1-2: obs GTR for G3: RT RT for any capsule violation.

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