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Rad Onc Oral Boards Quick > GU > Flashcards

GU Flashcards

1
Q

Prostate T Staging

A

T1a-c: clinically inapparent, detected by bx
T2a: ½ of 1 lobe or less
T2b: more than ½ of one of the lobes
T2c: both lobes
T3a: ECE and micro bladder neck
T3b: SV
T4: bladder, levator, pelvic wall
N1: regional nodes
M1a: non-regional nodes
M1b: bone
M1c: other sites

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2
Q

Prostate overall stage

A

I: T1-T2a, PSA <10, GG1 (LR)
IIA: GG 1 and either T2b-c or PSA 10-20
IIB: GG 2
IIC: GG 3-4, T1-2, PSA < 20
IIIA: PSA > 20
IIIB: T 3-4
IIIC: GG 5
IVA: N1
IVB : M1

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3
Q

Life expectancy
20
10
5

A

20y: 62
10y: 76
5y: 86

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4
Q

Favorable intermediate age cutoffs

A

<5: Observation
5-10y: Observation preferred, EBRT or brachy
>10y: AS, EBRT or brachy, RP

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5
Q

Unfavorable intermediate age cutoffs

A

Unfavorable intermediate age cutoffs
>10: RP or EBRT+ADT +/- brachy
5-10: EBRT or obs

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6
Q

High risk age cutoffs

A

>5 or symptomatic: treat
<5 and asymptomatic: obs, or ADT or EBRT

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7
Q

Brachy procedure

A

Brachy – IODINE 125 (half life 60 days) = 145 Gy
Pre-op
-1 week prior to implant bring pt in for volume study of prostate, determination of favorable anatomy (no pubic arch interference), and creation of preplan to order seeds
-gen med or cardiac clearance
-Flomax 1-2 weeks before
-bowel prep day before
-stop ASA, Plavix, 7 days before; NSAIDS 2-3 days

Day of:

  • bring pt to OR with GA
  • placed in lithotomy position in stir-ups
  • perineum is prepped with betadine
  • foley catheter is placed – 120 cc in bladder
  • 4 mg Decadron intra-op
  • TRUS is secured to table
  • insert TRUS: make sure prostate is centered on template (base = 0.0), with urethra in central sagittal plane
  • scan prostate
  • contour bladder, prostate, rectum, urethra
  • make plan based on this contour
  • contruct needles with seeds and spacers
  • place contructed needles based on plan
  • while inserting needles under ultrasound guidance, visualize in the desired plane (rotating bevel can help visualize). Verify position with sagittal and transverse US.
  • post-implant room survey
  • pt discharged after urinating
  • discharge with Flomax, NSAIDs, Pyridium, and Bactrim x 3 days
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8
Q

Brachy planning goals and constraints

A

D90>95%
V100>95%
V200<20%

Urethra V125% < 1cc
Rectal V100% < 1cc

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9
Q

Prostate 70/28 constraints

A

Rectum/Bladder:
V45 < 45%
V65 < 15%

Bowel/Heads: max 52

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10
Q

Prostate conventional constraints

A

Rectum/Bladder:
V45 < 50%
V70 < 15%

Bowel/Heads max 52

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11
Q

Salvage CTV volumes

A

The CTV would be the prostate bed defined as:

  • Superior: SV or vas deferens; or 3 cm above pubis
  • Inferior: at the top of the penile bulb or 1 cm below the vesicourethral anastomosis, 1 cm below urine

Below pubic symphysis

  • Anterior: just posterior to pubic symphysis
  • Posterior: anterior border of rectal wall
  • Lateral: medial border of levator ani

Above pubic symphysis

  • Anterior: 1-2 cm of bladder
  • Posterior: mesorectal fascia
  • Lateral: sacrorectogenitopubic fascia

INCLUDE RETAINED SVs if involved

PTV= 1 cm (5 mm posteriorly) with daily CBCT

Dose: 66Gy / 46Gy

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12
Q

Salvage Constraints

A

Bladder-CTV:
V65<50%;

Rectum:
V65<35%;

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13
Q

What to do after surgery for Testicular

A

Staging is based on POST-ORCHIECTOMY labs/etc.:

  • CT abd/pelvis
  • CT chest if positive CT a/p or abnl CXR
  • repeat b-HCG, AFP, LDH
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14
Q

Testicular S stage

A

S0: normal
S1: LDH <1.5 ULN, hCG <5,000, AFP <1,000
S2: LDH 1.5-10 ULN, hCG 5,000-50,000, AFP 1,000-10,000
S3: LDH >10 ULN, hCG >50,000, AFP >10,000

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15
Q

Testicular T/N/M staging

A

T1: testis, epididymis, tunica albuginea
T1a <3cm
T1b >3cm
T2: LVSI or tunica vaginalis or hilar invasion
T3: spermatic cord
T4: scrotum

N1: LN 0.1-2 cm, ≤5 LNs
N2: 2.1-5cm or >5 LNs (or pECE)
N3: > 5cm
(>= 10 mm short axis  37% sensitivity, 100% spec)

M1a: nonRP nodal or pulm mets
M1b: nonpulm visceral mets

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16
Q

Testicular overall stage

A

IA: T1
IB: T2-4
IS: N0 S+
IIA: N1 S0-1
IIB: N2 S0-1
IIC: N3 S0-1
IIIA: M1a, S0-1
IIIB: [N+ or M1a] AND S2
IIIC: ([N+ or M1a] AND S3) OR any M1b

17
Q

IA/B: Seminoma (AFP neg) adj treatment

A

IA/B: Seminoma (AFP neg)

1) Surveillance (NCCN preferred for pT1-3):
- H&P and labs q 3 mo x yr 1, q 6 mo x yrs 2-3, then annual
- CT a/p @3, 6, 12mo, then annually through 5 yrs
- CXR as clinically indicated
- relapse rate 15-20% at 5 yrs-stop surveillance at 5 years

2) PA RT 20/2 Gy (midplane)
- used to be recommend for rete testis invasion or tumor > 4 cm, but is no longer (Chung JCO 2010)

3) Carboplatin AUC 7 x 1
- who to treat: in jail, in 60s

18
Q

IS testicular

A

Repeat workup, treat accordingly

19
Q

Seminoma IIA

A

IIA: N1 S0-1

  1. RT : DL 20/2 + 10/2 boost = 30 Gy
  2. Chemo alone: BEP x 3
    - bleomycin 30, etoposide 100, cisplatin 20 q 3 weeks
20
Q

Seminoma IIB

A

IIB: N2 S0-1

  1. RT: DL 20/2 + 16/2 boost = 36 Gy
  2. Chemo alone (NCCN preferred): BEP x 3
21
Q

NSGCT treatment

A

NSGCT (elevated AFP):
IA: orchiectomy + surveillance
IB/IIA: orchiectomy + open nerve-sparing RPLND  BEP X 2-3
IIB: BEP chemo x 3
IIC+: BEP chemo

RPLND for post-chemo residual mass > 1 cm (no PET needed)

22
Q

Seminoma PA field

A

PA radiation:
CTV=(IVC+1 cm) + (aorta + 2 cm)
PTV=CTV+0.5 cm
Daily KV imaging
Goal is targeting para-aortic, paracaval, and preaortic nodes
*dogleg if prior pelvic surgery*

Fields
-T11/T12 – L5/S1
-lateral transverse process or 2 cm on nodes
* no longer need to cover renal hilar nodes

23
Q

seminoma DL field

A

Modified DL Radiation
CTV=(IVC+1 cm) + (aorta + 2 cm)+ (ipsilat common, external, and prox int iliac + 1 cm)
-nodes down to top of acetabulum
CTV_boost=GTV+1 cm
PTV=CTV+0.5 cm
(2 cm to block edge for boost)

Fields:
T11/12 to L5-S1 then diagonal down to top of acetabulum or top of obturator foramen

Full DL Radiation:
Modified DL + inguinals

Use CLAMSHELL: reduces dose by ~2-3x
PA w/ clamshell = 0.6 cGy
Dogleg w/clamshell = 1.5 cGy

24
Q

Seminoma constraint

A

Kidney: D50% < 8 Gy (no more than 50% of each kidney can receive 8 Gy or higher). If only one kidney, D15% < 20 Gy

V20<70%
Stomach
Bowel

25
Q

Bladder Staging

A

Ta: non-invasive papillary
Tis: CIS (flat)

T1: lamina propria

T2: invades muscularis propria
T2a: inner 1/2
T2b: outer 1/2

T3: invades perivesicular tissue
T3a: microscopic
T3b: macro, ie-extravesicular mass)

T4: adjacent organs
a-prostate, uterus, vagina
b-pelvic or abdominal sidewall

N1: single pelvic below common iliac
N2: multiple pelvic below common iliac
N3: common iliac

M1a: LN beyond com. iliac
M1b: non-LN distant met

I – T1
II – T2
IIIA – T3-T4a and/or N1
IIIB – N2-3
IVA – T4b and/or M1a
IVB – M1b

26
Q

Bladder Non muscle invasive TX

A

Non-invasive:
Ta:
Low gr: TURBT
High gr: TURBT -> BCG
T1:
Low gr: TURBT -> BCG
High gr: TURBT -> BCG
Tis: TURBT -> BCG 50 mg q wk x 6
-other adj intravesicular agents include MMC

27
Q

Muscle invasive (cT2-T4aN0) treatment

A

Muscle invasive (cT2-T4aN0):

  1. Neoadj gem/cis x 4 -> radical cystectomy w LND
    - Neoadj gem/cis x 4 -> partial cystectomy if unifocal T2 without CIS or trigone involvement that can be removed w/ 2 cm margin
    - if neo-adj chemo not given, give adj chemo for pT3-4 or N+
  2. Bladder preservation for the best players**
    - max TURBT (+/- fiducials)
    - Cisplatin + RT 55/20
    - re-cysto at 3 months. If PR, salvage cystectomy or BCG if small. If CR, surveillance
28
Q

Bladder T4b, N+, or Medically inoperable:

A

T4b, N+, or Medically inoperable:
1. Definitive chemoRT
55/20 w/ cisplatin
2. Cis/Gem x3-> if response, cystectomy or chemoRT
3. Chemo alone

29
Q

Bladder Sim, Volumes

A

-Ensure maximal TURBT performed, and bladder mapping

*****only treat nodes if N+****

CT simulation
-supine, immobilized, empty bladder, CT w/ contrast

GTV=gross tumor on CT/MRI/TUBRT map

(CTV_44=GTV+ whole bladder + prostate + LN (ext iliac, int iliac, obturator – not common)
PTV_44=CTV + 1.5 ant, 1 cm post/lat, 0.5 inf, 2 cm sup)

CTV_55=GTV+ whole bladder + 1 cm
PTV_55=CTV + 0.5 cm
Exclude bowel from PTV

30
Q

Bladder Constraints

A

Rectum
- V50 <10%

Bowel: exclude from PTV
-max 53 Gy

Rad Onc Oral Boards Quick (11 decks)

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