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Lung/Sarcoma Flashcards

1
Q

Lung cancer: workup

A

H&P (smoking history and cessation, exposure to chemicals), performance status (weight loss)

Labs:CBC, CMP

Imaging: CXR, CT with contrast. Biopsy with CT guidance, EBUS of mediastinum (could need mediastinoscopy for anterior nodes). Thoracentesis if pleural effusion seen on CXR

Distant imaging: PET, MRI brain for stage ≥II or neuro symptoms

Functional: PFTs, bronchoscopy

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2
Q

Lung cancer: simulation for conventional radiation

A

Prior: PFTs, pacemaker card

supine with 4DCT and vac loc

contour on MIP

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3
Q

Lung cancer: constraints for conventional radiation

A

cord max 45Gy

lungs V20<35% (per RTOG, whole lung-CTV)

lung mean < 20Gy

lung V5<70%

brachial plexus <66 Gy

esophagus mean <34 Gy

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4
Q

NSCLC: criteria for operability

A

pre-op FEV1 >1.5 L and >FEV1 80% for lobectomy

post-op predicted FEV1 > 40% and DLCO > 40%

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5
Q

NSCLC: indications for adjuvant chemo after surgery

A

N1, poorly differentiated, >4cm, vascular invasion, wedge resection, visceral pleural involvement, incomplete nodal dissection

cisplatin and vinorelbine/etoposide

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6
Q

Lung SBRT: doses

A

54Gy/3fxs: peripheral location

50Gy/5fxs: central location or <2cm from chest wall

70Gy/10fxs: ultracentral location

3D treatment planning with 3-6 non-coplanar beams and 2-4 arcs

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7
Q

Lung SBRT: 3fx constraints

A

spinal cord: 18Gy

esophagus: 27Gy
heart: 30Gy

trachea/bronchus: 30Gy

skin: 24Gy

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8
Q

Lung SBRT: 5fx constraints

A

spinal cord: 30Gy

esophagus: 105%
heart: 105%

trachea/bronchus: 105%

skin: 32Gy

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9
Q

Lung SBRT: target dosimetry

A

95% of dose to 100% of volume

Min dose: 99% of PTV receives minimum 90% dose

Conformity index <1.2

R50% and D2cm limited per protocol charts based on PTV size

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10
Q

Lung cancer: options for improving lung dose with conventional fractionation

A

increase AP/PA weighting

reduce margins of CTV

4DCT

IMRT

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11
Q

NSCLC definitive chemoradiation: chemo regimen

A

concurrent cisplatin 50mg/m2 on D1, 8, 29, 36

etoposide 50 mg/m2 n d1-5 and 29-33

RTOG 0617: weekly carbo AUC 2 and paclitaxel 45mg/m2, then adjuvant 2 cycles carbo AUC 6 and paclitaxel 200 mg/m2

adjuvant durvalumab after chemoRT (PACIFIC)

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12
Q

RTOG 0617: MS and local failure

A

MS 29mo

local failure 30%

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13
Q

Definition of superior sulcus tumor

A

1) apical tumor with Pancoast syndrome with or without invasion chest wall or spine
2) superior or sulcus tumors with inv of chest wall, spine, or subclavian vessels

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14
Q

Superior sulcus tumor: symptoms of Pancoast syndrome and Horners syndrome

A

Pancoast: nerve symptoms in ulnar distribution, possibly atrophic hand muscles

Horners: ptosis, miosis, anhydrosis

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15
Q

Superior sulcus tumor: treatment paradigm

A

MRI to confirm potential resectability

45Gy with concurrent chemo

restage and repeat MRI also to determine resectability

surgery if resectable

chemoradiation to 60Gy if unresectable (and may reevaluate afterward)

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16
Q

Superior sulcus tumors: pCR and OS

A

pCR 30%

pCR or minimal residual 55%

5yr OS 45%

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17
Q

NSCLC: criteria for PORT

A

N2, positive margin, ECE

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18
Q

NSCLC: PORT doses

A

54Gy for negative margin, ECE

60G for positive margin

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19
Q

LS-SCLC: treatment paradigm with surgery

A

N0: adjuvant chemo, then PCI

N+: treat like typical limited stage with chemoradiation and PCI

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20
Q

SCLC: workup

A

Difference from NSCLC:

No mediastinal staging

Labs: LDH;Consider bone marrow biopsy

All get MRI. Restage before PCI.

If suspecting Lambert Eaton syndrome: Ab for voltage gated Ca channels and EMG (positive in 85%)

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21
Q

LS-SCLC: BID xrt planning

A

45 Gy in 1.5 Gy BID (preferred). For 3D, PM treatment is off cord starting on week 2. IMRT is another option.

0.5 cm CTV on gross disease plus 0.5 cm PTV, consider ipsilateral hilum

spinal cord max <36Gy

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22
Q

LS-SCLC: chemo dose/schedule

A

cis/etop 60/120 q4 weeks, 4-6 cycles

cisplatin given on day 1 only and etoposide on days 1-3

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23
Q

LS-SCLC: 5yr OS on Turrisi

A

5yr OS 26%

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24
Q

ES-SCLC: chemo dose/schedule

A

cis/etop 75/100, q4 weeks, 4-6 cycles

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25
Thymoma: workup
H&P, progressive muscle weakness (myasthenia gravis), smoking history, exposure to toxins, B symptoms Imaging: CT with contrast Biopsy: CT guided biopsy or mediastinoscopy Surgery: total thymectomy and complete excision Labs: CBC (pure red cell aplasia), CMP, Ach rececptor Ab, BHCG, AFP, LDH
26
Thymoma: indications for radiation
complete resection and stage II-IV, incomplete resection, unresectable, or after neoadjuvant chemo and surgery, thymic carcinoma
27
Thymoma: xrt doses
preop 45Gy R0 resecton 50.4Gy R1 resection 54 Gy R2 resection 60 Gy unresectable 70 Gy
28
Thymoma: Masaoka staging
I: intact capsule II: microscopic invasion into mediastinal pleura or fat III: macroscopic invasion into adjacent organs or vessels IVA: pleural or pericardial implants IVB: distant mets
29
Thymoma: target volumes
GTV: gross residual tumor CTV: remaning thymus, surgical clips, areas at risk per surgeon. Must review CTV with surgeon.
30
Thyoma: heart constraint
heart mean \<30Gy, as low as possible as patients are often young
31
Thymoma: 5yr OS for stage I-IV
I: 90% II: 80% III: 70% IV: 50%
32
Thymoma: recurrence rate for stage II-III with complete resection
40% recurrence without RT 10% recurrence with RT
33
Mesothelioma: workup
H&P, asbestos exposure Imaging: CT chest and abdomen, PET, mediastinoscopy/EBUS of mediastinum, (consider chest MRI if needed) Special: consider VATS or laparoscopy if contralateral or peritoneal disease suspected. Consider pleural cath Functional: PFTs, VQ scan, cardiac stress test Resectable if T1-T3 Treat inoperable with chemo only
34
Mesothelioma: surgical options
extrapleural pneumonectomy: removes lung, pleura, pericardium, diaphragm. MS node dissection and diaphragm reconstruction pleurectomy and decortication: removal of pleural and tumor, mainly palliative
35
Mesothelioma: treatment paradigm
induction chemo with cisplatin/pemetrexed extrapleural pneumonectomy (when possible) consider adjuvant xrt for epithelial or mixed histology (sarcomatoid get chemo only)
36
Mesothelioma: sim
Prior: PFTs, pacemaker card supine position, arms up, wire scars, drain sites, wingboard, 4DCT, abdominal compression
37
Mesothelioma: radiation doses
54 Gy for negative margins 60Gy for positive margins consider 21Gy/3fx for drain sites only if negative margins 20Gy/5fxs for palliation
38
Mesothelioma: 3D fields
Targets: hemithorax, surgical incision, drain sites, positive margins 3D: After 45 Gy, come off cord and ipsilateral kidney. Can block kidney, liver, stomach initially and supplement these missing pleural areas with electron fields to start off if desired, per some techniques. For left sided, block out heart at 19.8 Gy. Block cord at 41.4 Gy. Boost areas of prior macroscopic disease with electrons to 54 Gy with 153 cGy per day (expected that 15% of photon field will be there with scatter). Used electrons opposed to photon field to do this
39
Mesothelioma: 2D fields
2D: Top of T1 to bottom of L2, medial border of contralateral edge of vertabral body to lateral flash. If positive nodes, go 1.5-2 cm beyond contralateral side of vertebral body to catch mediastinum
40
Mesothelioma: dose constraints for lung, esophagus,
contralateral lung: MLD\<8.5 Gy V5\<50% V20\<10% esophagus V60 Gy\<1/3 Kidney mean dose \< 12 Gy
41
Mesothelioma: MS for stage I/II and stage III/IV
stage I/II: 34mo stage III/IV: 10mo
42
Soft tissue sarcoma: workup
H&P, examination of limb motor, neurologic, and vascular function, skin. PMH of diabetes or poor wound healing Labs: CBC, BMP, ESR, LDH Longitudinal incisional biopsy. Sometimes CNB if deep tumor. Immnumohistochemistry, cytogenetics, molecular testing Imaging: CT/MRI of the primary, x-ray of primary, CT chest, (CT abdomen if myxoid liposarcoma; MRI brain if alveolar) Oncologic surgery to remove tumor without contaminating incision, ideally en bloc
43
Soft tissue sarcoma: mutations for synovial, clear cell, myxoid round cell liposarcoma, and Ewing/PNET
Synovial: X;18 Clear cell: 12;22 Myxoid round cell liposarcoma: 12;16 Ewing/PNET: 11;22
44
Extremity sarcoma: indications for radiation
positive margin and/or grade 3 close margin and grade 3 or maybe just use MSKCC nomogram
45
Extremity sarcoma: doses
Pre-op: 50Gy Post-op R0/1: 50Gy + 16Gy boost Post-op R2: 50Gy + 20Gy boost
46
Extremity sarcoma: sim
Wire scars. Use vac loc to stabilize extremity. Aquaplast fixation device is ideal (ORFIT). Clamshell and fertility testing in lower extremity in men
47
Extremity sarcoma: pre-op fields
(Per RTOG atlas) CTV 1.5 cm radial margin, 3 cm sup/inf margin plus T2 edema on MRI.
48
Extremity sarcoma: post-op fields
Give first 50 Gy according to pre-op, then boost to surgical bed, clips, scar + 2 cm
49
Extremity sarcoma: dose constraints
Always spare 1.5 to 2 cm of skin (3D) spare joint IMRT joint V50\<50% bone V50\<50% How do you spare skin with IMRT? Skin longituginal stripe V20\<50% anus/vulva V30\<50% testis fertility preservation: V3\<50%, max\<18 Gy femoral heads V60\<5%
50
Retroperitoneal sarcoma: dose and field
50Gy/25fxs (heavily prefer pre-op; rarely post-op unless positive margin) GTV + 1.5cm CTV + 0.5cm PTV
51
Lung T1b
1-2cm
52
Lung T1c
2-3cm
53
Lung T2
involves main bronchus (excluding carina) visceral pleura atelectasis extending to hilum 3-5cm (T2a 3-4cm, T2b 4-5cm)
54
Lung T3
5-7cm parietal pleura/pericardium chest wall phrenic nerve separate nodules in same lobe
55
Lung T4
\>7cm diaphragm mediastinum (heart, great vessels, trachea, recurrent laryngeal, esophagus, vertebra) carina nodules in separate ipsilateral lobes
56
Lung stage IA1-3
IA1: T1aN0 IA2: T1bN0 IA3: T1cN0
57
Lung stage IB
T2aN0
58
Lung stage IIA
T2bN0
59
Lung stage IIB
T1-2N1 T3N0
60
Lung stage IIIA
T1-2N2 T3N1 T4N0-1
61
Lung stage IIIB
T1-2N3 T3-4N2
62
Lung stage IIIC
T3-4N3
63
Mesothelioma T1
limited to ipsilateral pleura
64
Mesothelioma T2
diaphragmatic muscle lung parenchyma
65
Mesothelioma T3
endothoracic fascia mediastinal fat solitary, resectable extension into chest wall non-trasmural pericardium
66
Mesothelioma T4
diffuse chest wall invasion transdiaphragmatic extension to peritoneum contralateral pleura mediastinal organs spine transmural pericardial extension
67
Mesothelioma N2
contralateral mediastinal nodes supraclavicular nodes
68
Mesothelioma stage IB
T2-3N0
69
Mesothelioma stage II
T1-2N1
70
Mesothelioma stage IIIA
T3N1
71
Mesothelioma stage IIIB
T4 or N2
72
Thymus T2
pericardium
73
Thymus T3
lung, brachiocephalic vein, vena cava, phrenic nerve, chest wall, exrapericardial pulmonary vessels
74
Thymus T1
mediastinal fat and/or mediastinal pleura
75
Thymus T4
aorta, arch vessels, intrapericardial pulonary vessels, myocardium, trachea, esophagus
76
Thymus N1
anterior mediastinal lymph nodes
77
Thymus N2
deep intrathoracic or cervical lymph nodes
78
Thymus stage II
T2N0
79
Thymus stage IIIA
T3N0
80
Thymus stage IIIB
T4N0
81
Thymus stage IVA
N1 or M1a
82
Head/Neck soft tissue sarcoma T2
2-4cm
83
Head/neck soft tissue sarcoma T4a
orbit, skull base, dura, facial bones, pterygoid muscles
84
Extremity/retroperitoneal sarcoma T2
5-10cm
85
Extremity/retroperitoneal sarcoma T4
15cm+
86
Extremity/retroperitoneal sarcoma stage II
T1N0, grade 2-3
87
Extremity/retroperitoneal sarcoma stage IIIA
T2N0, grade 2-3
88
Extremity/retroperitoneal sarcoma stage IIIB
T3-4N0, grade 2-3
89

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