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Rad Onc Oral Boards > Lung > Flashcards

Lung Flashcards

1
Q

Lung LN Stations 2-14

A

LN stations:

2: upper paratracheal
3: retro tracheal/prevasc
4: lower paratracheal
5: AP window
6: paraaortic
7: subcarinal
8: paraesophageal
9: pulmonary ligament
10: hilar
11: interlobar
12: lobar
13: segmental
14: subsegmental

  • picture
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2
Q

Lung Workup

A

Imaging:

  • Prior chest imaging for comparison!!!
  • CT chest & upper abdomen (liver, adrenals) w IV cont
  • PET/CT (eval liver/adrenals)
  • brain MRI (for Stage IB (consider) definite if above 1B) NSCLC, all SCLC)

Biopsy:

  • Central – broch/EBUS; peripheral – CT-guided; effusion – thora
  • EGFR, KRAS, ALK, ROS-1, BRAF, PD-1 for NSCLC
  • mediastinal sampling for NSCLC

Other:
- PFTs

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3
Q

Lung Screening

A

Screening (USPSTF-2021): annual low dose CT for high risk (age 50-80, >20 pack year, quit <15 years ago)

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4
Q

When do you not need Mediastinal LN staging

A

Med LN staging necessary unless
peripheral solid <1cm or
non-solid <3cm that are negative on imaging

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5
Q

Bronch LNs

A

Bronch (EBUS w FNA):

  • can access central primary
  • LN 2, 4, 7, 10+
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6
Q

EUS LNs

A

EUS

- LN 4, 7, 8, 9

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7
Q

Cervical mediastinoscopy LNs

A

Cervical mediastinoscopy: recommend this if cannot see any nodes

  • incision 1 cm above suprasternal notch
  • LN 2, 4, 7, 10 – maybe
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8
Q

Chamberlin Procedure LNs

A

Chamberlin (anterior mediastinoscopy):

  • incision at left 2nd intercostal space
  • LN 4, 5, 6, 7
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9
Q

Lung Simulation

A

CT simulation: Supine, arms up, vac lock bag, wingboard. 4D CT with IV contrast from cricoid to L2
Iso at carina
PET/CT fusion (PET within 4 wks of treatment planning)

Use 6 MV beams in lung

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10
Q

If not meeting constraints (esp V20):

A

If not meeting constraints (esp V20):

  • 3D->IMRT or Protons
  • 4D planning to reduce margin
  • Inspiration Breath hold
  • Add non-coplanar beams
  1. Shrink margins (IGRT)
  2. Conedown or adaptive replan after 40 Gy
  3. Inc weighting of AP/PA vs. oblique
  4. Add extra beams (consider IMRT but watch V5)
  5. Neoadj chemo
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11
Q

Pneumonitis presentation and treatment

A

Pneumonitis:

  • 6 wks to 4 months post RT
  • sx: fever, dyspnea, tachycardia, and hypoxia
Grade 1: radiographic
Grade 2: minor sx/steroids
Grade 3: O2
Grade 4: hospitalized
Grade 5: death
  • Tx: Pred 1 mg/kg/day tapered over 2-3 months + Bactrim and PPI; monitor PFTs
  • Diffusion capacity dec in early phase, radiographically diffuse inhomogeneous opacification in tx field
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12
Q

Adeno markers - 50%

A

periph; TTF-1, napsin; EGFR overexpress in 30%

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13
Q

SCC markers - 30%

A

SCC – central; p63, CK5/6; EGFR in 80%

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14
Q

Lung Ca # cases and deaths

A

240,000 cases

130,000 deaths

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15
Q

squamous cell paraneoplastic

A

Hypercalcemia (SCC)

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16
Q

medical operability

A

PFTs:
FEV1 and DLCO predicted post op: >40%

FEV1/FVC>75%,
DLCO>40% (post-op), >80% pre-op,
FEV1>1.2L (lobectomy) or 2L (pneumonectomy), post-op 0.8
-no severe pulm HTN, end-organ damage, severe vascular disease, severe chronic cardiac dz

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17
Q

Most common involved LN NSCLC

A

level 4(R/L) except LUL: 5, 6

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18
Q

Lung TNM Staging

A

T1a: up to 1 cm
T1b: > 1 – 2 cm
T1c: > 2 – 3 cm

T2a: 3.1 – 4 cm
T2b: 4.1 – 5 cm
-or mainstem bronchus, not carina
-visceral pleura
-atelectasis, obstructive pneumonitis to hilar region

T3: >5 – 7 cm

  • separate nodule in same lobe
  • chest wall, phrenic nerve, pericardium, parietal pleura

T4: >7cm

  • mediastinum, heart, great vessels, carina, trachea, spine, esophagus, recurrent laryngeal, diaphragm
  • separate nodule in different I/L lobe

N1: hilar
N2: ipsi mediastinal
N3: contralat med, supraclav

M1a: sep nodule in contralat lobe, pleur/pericard nodules, pleural effusion
M1b: single extrathoracic metastasis
M1c: multiple extrathoracic mets

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19
Q

Lung Overall Stage

A

Think about node neg and node positive separately, for N- go straight down the stages IA1-IIIA, N+ T1-2 and T3-4 go together

IA1: T1a 85% OS
IA2: T1b
IA3: T1c
IB: T2a (70%)
IIA: T2b (65%)
IIB: T3N0, T1-2N1 (55%)

IIIA (5yrOS 40%):

  • T1-2N2
  • T3-4N1, T4N0

IIIB: T3-4N2, T1-2N3 (5yrOS 25%)
IIIC: T3-4N3 (10-15%)

IVA: M1a-1b (5yrOS 0-10%)
IVB: M1c (0%)

T1a: up to 1 cm
T1b: > 1 – 2 cm
T1c: > 2 – 3 cm

T2a: 3.1 – 4 cm
T2b: 4.1 – 5 cm
-or mainstem bronchus, not carina
-visceral pleura
-atelectasis, obstructive pneumonitis to hilar region

T3: >5 – 7 cm

  • separate nodule in same lobe
  • chest wall, phrenic nerve, pericardium, parietal pleura

T4: >7cm

  • mediastinum, heart, great vessels, carina, trachea, spine, esophagus, recurrent laryngeal, diaphragm
  • separate nodule in different I/L lobe

N1: hilar
N2: ipsi mediastinal
N3: contralat med, supraclav

M1a: sep nodule in contralat lobe, pleur/pericard nodules, pleural effusion
M1b: single extrathoracic metastasis
M1c: multiple extrathoracic mets

*picture

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20
Q

SBRT dose

A

SBRT, peripheral lesion: 18 Gy x 3
-tumor < 5 cm, > 2 cm from proximal bronchial tree (which includes mainstem bronchi, upper lobe bronchi, right middle lobe bronchus, left lingual bronchus, and lower lobe bronchi), node negative

SBRT apical, or chest wall: 10 Gy x 5 (say if can’t meet CW for 18 x 3)

(BED>100 Gy)

SBRT, central lesions: 10 Gy x 5, or if can’t meet constraints, then see alternative below

Alternatives:
4 Gy x 15 fx (NCIC)
7 Gy x 10 fx (MDACC)

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21
Q

SBRT sim/technique and volumes

A

Supine in full body vac bag immobilizer; consider abdominal compression if moving >1 cm

ITV = GTV + resp motion
PTV = ITV + 0.5 cm
  • There is no CTV
  • If using free-breathing scan, PTV margins 1 cm sup/inf and 0.5 cm radially
  • 6 MV
  • 7-10 non-opposing, non-coplanar fields
  • Field aperture from beam’s eye view should be PTV (no extra margin for dose buildup) except for small lesions
  • Prescribe to IDL covering PTV – usually normalize to 80%
  • Treat every other day (minimum 40 hours apart per RTOG 0236)
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22
Q

SBRT dose constraints 3 fraction

A

SBRT constraints for 3 fx (per NCCN): 6-8-10

  • Cord: 6/fx :18 Gy
  • Plexus/Skin/Esophagus: 8/fx: 24 Gy
  • Rib/Heart/Trach/Bronchi: 10/fx: 30 Gy
  • Total Lung - GTV: V20 <10%
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23
Q

SBRT dose constraints 5 fraction

A

SBRT constraints for 5 fx:
- Cord: 30 Gy
- Plexus/Skin: 32 Gy
All others: 105%

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24
Q

SBRT Planning Objectives

A

High dose spillage:
CI = 100% iso/PTV < 1.2

50% dose to be constrained within 2 cm – rapid fall-off

R50 – ratio of 50% isodose line to PTV < 3 to 4 (depending on PTV size)

95% PTV gets 100% dose
99% PTV gets >90% dose

25
Q

SBRT 3 yr LC, OS

A

LC 90-95%
10% regional recurrence
55% OS

26
Q

NSCLC Medically operative workup

A

Pre-thoracotomy LN sampling (for stage IB and above) -> lobectomy + mediastinal dissection/sampling

27
Q

NSCLC Adjuvant chemo indication

A

N+
>4cm

chemo + atezolizumab

28
Q

NSCLC PORT indications

A

PORT indications (54/2 or 1.8 – per ART):

-positive margin:
up to stage IIB(N1): re-resect-> chemo, consider CRT
Stage III: CRT(boost to 60)

Volumes: treat bronchial stump, ipsilateral hilum(10), ipsilateral lower paratracheal(4), subcarinal(7), + involved

29
Q

STAGE III NSCLC treatment

A

definitive CRT -> adjuvant Durvalumab

concurrent cisplatin 50mg/m2 on D1, 8, 29, 36
etoposide 50 mg/m2 on d1-5 and 29-33
-start at same time as RT

Durvalumab (10mg/kg q2 wk for 12 months)

30
Q

Definitive Lung NSCLC constraints

A

Cord: max < 50 Gy

Total lung - GTV:
V20 < 37%
MLD < 20 Gy
V5 < 60%

Esophagus
mean dose < 34

Brachial plexus max < 66 Gy

Heart
Mean dose < 20 Gy
V30 < 50%

95% of PTV gets 95% of dose

31
Q

Stage III Lung PFS and OS

A

PFS: 33%
OS: 43%

32
Q

Horner’s Syndrome

A

ptosis (falling eyelid), miosis (constricted pupil), anhidrosis (no sweating), can also see facial flushing, arm neuro exam, atrophy

33
Q

Pancoast/Superior Sulcus treatment

A

Resectable: pre-op ChemoRT (re-image during last week of 45 Gy to see if resectable/non-metastatic) -> surgery (2-4 wks after) -> chemo + atezolizumab

  • RT: 45/1.8 (but plan to 63 if not sure whether will be resectable)
  • Chemo: cis 50/etop 50 q 3-4 week
  • Adj chemo: cis/etop x 2
    (i. e. EP 50/50 x 4 cycles total)

Unresectable: Def ChemoRT
- RT: 63/1.8 -> adj Durvalumab

Target = tumor + ipsi SCV
- did not include mediastinum/hilum

Plexus max 66 Gy

34
Q

Bronchial Alveolar Carcinoma (BAC), Adenocarcinoma in Situ

A
  • now called adenocarcinoma in situ (AIS)
  • lepidic spread: spread along alveolar structure; do not invade stroma, pleura, or lymphatic spaces
  • subtypes: mucinous, non-mucinous, mixed
  • diffuse, multifocal have high rate of EGFR/ALK mutation

Lobectomy + mediastinal LN dissection/sampling

Targeted agent if mutation present

35
Q

Pancoast/ Superior Sulcus definition

A

Pancoast/ Superior Sulcus
Superior sulcus = apex
Pancoast = Horners, shoulder pain, muscle wasting; and/or radiographic ribs/periosteum (above 2nd), brachial plexus, sympathetic chain, subclav vessels

T3 – chest wall, brachial plexus
T4 – subclavian, vertebral body

36
Q

Carcinoid tumor workup and treatment

A

Med LN eval only for pts with abnormal LN on CT
Ocrtreotide scan if secreting

Carcinoid syndrome (5HIAA) – flushing, diarrhea, right sided valve issues, cough/wheezing

Typical, resectable: Lobectomy + LN dissection/sampling -> observe

Typical, unresectable: RT alone

Atypical: I-IIIA: lobectomy + mediastinal LN sampling

  • if stage I, observe
  • if stage II-III, adj chemo (EP) +/- RT

Stage IIIB or unresectable: definitive CRT w/ concurrent EP 50/50

Large cell – treat like NSCLC

Consider octreotide if secreting

37
Q

SCLC pathology

A

Path:

  • small round blue cells
  • crush artifact on path
  • if mixed SCLC/ NSCLC, tx like SCLC
38
Q

Diff Dx small round blue cells

A

Diff Dx small round blue cells:

  • SCLC
  • lymphoma
  • ALL
  • Ewing sarcoma
  • rhabdomyosarc
  • neuroblastoma
  • neuroepithelio.
  • medulloblasto.
  • retinoblastoma
39
Q

Limited Stage SCLC treatment

A

Early concurrent CRT (cycle 1-2)-> restage chest/brain ->PCI

RT: 45/1.5 BID or 70/2 QD – bc CONVERT 45 looked better and was 66
Chemo: Cis 60 day 1 & Etop 120 day 1-3 q 3 wks x 4 cycles
- No GM-CSF w/ CRT

PCI (4-6 wks post-CRT): 25/2.5

40
Q

Extensive Stage SCLC treatment

A

Chemo -> +/- PCI 25 Gy +/- thoracic RT 30 Gy for responders

Chemo:
Carbo or cisplatin /Etop/atezolizumab x 4-6c (cat 1) – doses
Cis 80 & Etop 80 x 4-6 cycles

41
Q

SCLC constraints

A
  • Cord max
    BID: 41 Gy (36 Gy on Turrisi)
    QD: 45-50.5 Gy
  • Lung-CTV: V20<30% (up to 40% by CALGB)
  • Total lung mean < 20 Gy
  • Esophagus (cricoid to GEJ): mean <34 (up to 10 cm can get 60 Gy)
  • Heart (starts at origin of ascending aorta): V30 < 50%; mean 26 Gy

PTV: > 99% volume receives > 95% prescribed dose. No more than 2 cc getting 120%

42
Q

Mesothelioma types

A
  • Epithelial (best), sarcomatoid (worst), and biphasic

- > 80% due to asbestos (smoking not a risk fx)

43
Q

Mesothelioma surgery types

A

EPP: En-bloc resection of entire pleura, lung, diaphragm, pericardium (peri-op mortality 6-30%)

Radical pleurectomy:
Removal of pleura and gross tumor (note: decort is palliative)

44
Q

Mesothelioma additional Workup

A

CBC prognostic

Additional w/u:

  • MRI chest/abd to rule diaphragm invasion
  • PET/CT
  • Pleural bx: VATS (needle biopsy can track)

If surgery planned:

  • Med/EBUS of nodes
  • cardiac stress test
45
Q

Mesothelioma Staging

A

T1: pleura
T2: diaphragm or lung parenchyma
T3: locally adv resectable (focal chest wall, mediastinal FAT, pericardium)
T4: technically unresectable
(transdiaphr extension, unresectable CW, mediastin organs, spine)

N1: I/L hilar or med (int mam and peri-diaphragmatic nodes are mediastinal)
N2: C/L med or any SCV

I: T1-3N0
II: T1-2N1
III: T3N1, T1-3N2, T4
IV: M1

46
Q

Mesothelioma T1-3N0-1 w/ epith hist, predicted post-op FEV1>1L

A

1) EPP -> RT -> chemo
- RT: hemi-thorax 54/1.8 Gy
- Chemo: cisplatin 75/pemtrexed 500 q 3 wks

  • if not doing hemithoracic RT, consider drain/biopsy sites get RT 21/7
    2) Radical pleurectomy/decortication -> chemo (will not give RT after P/D)
47
Q

Mesothelioma T4, N2, M1, sarcomatoid or medically inoperable

A

T4, N2, M1, sarcomatoid or medically inoperable: chemo alone (cis/pem)

48
Q

Mesothelioma treatment technique

A

3D technique: supine, arms akimbo
54 Gy / 1.8
•AP/PA covering entire hemithorax T1-L2, inclusive, covers across contralateral vertebral body (add 1.5 cm if positive mediastinum)
•Day 1 block liver, stomach, kidney, humeral head
•After 19.8 Gy block heart
•After 41.4 Gy block spinal cord by moving medial border to ipsilateral side of vertebral body
•Bolus scars, biopsy, and drain sites
•Supplement blocked area with electrons prescribed at depth of pleura, typically 1.53 Gy/Fx (+15% scatter)
•Can boost macroscopic residual to 60

IMRT technique (Harvard Allen 2007) – can we just say IMRT?
GTV=gross tumor + clips
CTV=GTV + entire pleural surface + incision sites
ENI not recommended
(restriced field technique) 9 fields with superior portion of PTV using only 3-4 fields
- note: their prior study showed almost 50% fatal pneumonitis w IMRT (need to have V20<7%). This was a dosi study.

49
Q

Mesothelioma constraints

A 
MLD <8.0 Gy
V20 <10% (<7% if IMRT)
V5 <50% 
Esophagus V55<30%
Liver V30 <30%
Kidney V15 <20%
Heart V40 <50%
50
Q

SCLC paraneoplastic

A

SIADH, ANP syndrome, Cushings, Lambert Eaton

51
Q

Thymoma WHO histology

A

WHO Histology:
A – epithelial/spindle
AB – same as A, but with immature T cells
B1 – immature T cells
B2 – B1, but also clustered dendritic epithelial cells
B3 – sheets of polygonal (atypical) apithelial cells

C – thymic carcinoma

A best, C worst

52
Q

-Anterior mediastinal mass Ddx:

A
  • Anterior mediastinal mass Ddx: 4 Ts
    1. thymoma
    2. thyroid
    3. teratoma
    4. terrible lymphoma
53
Q

Thymoma paraneoplastic

A

Paraneoplastic:

  • MG: autoab to postsynaptic Ca++ channels. Weaker w activity. 40% thymoma have MG vs 15% MG with thymoma (anti-ACH receptor Ab 100% sensitive)
  • Pure red cell aplasia (10%)
  • Hypogammaglob (5%)

*make sure MG under control before surgery

54
Q

Thymoma Masaoka Stage

A

I: no caps inv

II: transcapsular inv into fat or adherent to but not thru mediastinal pleura or pericardium (A: micro B: macro)

III: macro invasion into surrounds organs (A vs. B is without vs. w/ great vessel invasion)

IVA: pleural, pericardial dissemination

IVB: LN or distant

  • picture
55
Q

Thymoma Resectable treatment

A

Resectable: Surgery (total thymectomy)

  • RT for III, R1/R2, thymic carcinoma (or carcinoid)
  • add chemo for thymic carcinoma or R2 thymoma
56
Q

Thymoma Unresectable treatment

A

Unresectable: neoadj chemo -> re-eval for surgery -> adjuvant RT if resectable; (cis)RT if unresectable

Chemo:

  • thymoma: CAP (cyclophos 500, adria 50, cisplatinum 50) q 3 wks
  • thymic carcinoma: carbo 6 /taxol 225 q 3 wks
57
Q

Thymoma radiation dose

A 
R0: 50.4 Gy
R1: 54 Gy
R2: 60 Gy
Unresectable: 60-70 Gy
Pre-op: 45 Gy
GTV = any gross disease
CTV = any gross disease + pre-op tumor bed + clips + thymus (if left behind) + 1.5 cm (review w surgeon)
PTV = CT + 0.5 cm

No elective LN treatment

Techniques:

  • Wedge pair
  • 3-field (2 ant, 1 PA, non-coplanar)
  • AP/PA weighed heavily AP
  • IMRT

Total Heart <30 Gy

58
Q

Thymoma OS

A 
5-yr OS
I – 95%
II – 85%
III – 70%
IV – 50%

Rad Onc Oral Boards (11 decks)

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