Lung Flashcards
Lung LN Stations 2-14
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
If not meeting constraints (esp V20):
If not meeting constraints (esp V20):
- 3D->IMRT or Protons
- 4D planning to reduce margin
- Inspiration Breath hold
- Add non-coplanar beams
- Shrink margins (IGRT)
- Conedown or adaptive replan after 40 Gy
- Inc weighting of AP/PA vs. oblique
- Add extra beams (consider IMRT but watch V5)
- Neoadj chemo
Lung TNM Staging
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
Lung Overall Stage
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
SBRT dose
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)
SBRT dose constraints 5 fraction
SBRT constraints for 5 fx:
- Cord: 30 Gy
- Plexus/Skin: 32 Gy
All others: 105%
SBRT Planning Objectives
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
NSCLC PORT indications
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
STAGE III NSCLC treatment
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)
Definitive Lung NSCLC constraints
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
Pancoast/Superior Sulcus treatment
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
Limited Stage SCLC treatment
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
Extensive Stage SCLC treatment
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
SCLC constraints
- 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%
Mesothelioma Staging
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
Mesothelioma T1-3N0-1 w/ epith hist, predicted post-op FEV1>1L
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)
Mesothelioma T4, N2, M1, sarcomatoid or medically inoperable
T4, N2, M1, sarcomatoid or medically inoperable: chemo alone (cis/pem)
Mesothelioma constraints
MLD <8.0 Gy
V20 <10% (<7% if IMRT)
V5 <50%
Esophagus V55<30%
Liver V30 <30%
Kidney V15 <20%
Heart V40 <50%
Thymoma Masaoka Stage
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
Thymoma Resectable treatment
Resectable: Surgery (total thymectomy)
- RT for III, R1/R2, thymic carcinoma (or carcinoid)
- add chemo for thymic carcinoma or R2 thymoma
Thymoma Unresectable treatment
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
Thymoma radiation dose
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
