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Rad Onc Oral Boards Quick > 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

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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3
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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4
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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5
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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6
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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7
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

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8
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

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9
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)

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10
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

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11
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

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12
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

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13
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

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14
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%

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15
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

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16
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)
17
Q

Mesothelioma T4, N2, M1, sarcomatoid or medically inoperable

A

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

18
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%

19
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

20
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
21
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
22
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

Rad Onc Oral Boards Quick (11 decks)

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