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Oral Boards > Lung/Sarcoma > Flashcards

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
Q

Thymoma: workup

A

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

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26
Q

Thymoma: indications for radiation

A

complete resection and stage II-IV, incomplete resection, unresectable, or after neoadjuvant chemo and surgery, thymic carcinoma

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27
Q

Thymoma: xrt doses

A

preop 45Gy

R0 resecton 50.4Gy

R1 resection 54 Gy

R2 resection 60 Gy

unresectable 70 Gy

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28
Q

Thymoma: Masaoka staging

A

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

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29
Q

Thymoma: target volumes

A

GTV: gross residual tumor

CTV: remaning thymus, surgical clips, areas at risk per surgeon. Must review CTV with surgeon.

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30
Q

Thyoma: heart constraint

A

heart mean <30Gy, as low as possible as patients are often young

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31
Q

Thymoma: 5yr OS for stage I-IV

A

I: 90%

II: 80%

III: 70%

IV: 50%

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32
Q

Thymoma: recurrence rate for stage II-III with complete resection

A

40% recurrence without RT

10% recurrence with RT

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33
Q

Mesothelioma: workup

A

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

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34
Q

Mesothelioma: surgical options

A

extrapleural pneumonectomy: removes lung, pleura, pericardium, diaphragm. MS node dissection and diaphragm reconstruction

pleurectomy and decortication: removal of pleural and tumor, mainly palliative

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35
Q

Mesothelioma: treatment paradigm

A

induction chemo with cisplatin/pemetrexed

extrapleural pneumonectomy (when possible)

consider adjuvant xrt for epithelial or mixed histology (sarcomatoid get chemo only)

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36
Q

Mesothelioma: sim

A

Prior: PFTs, pacemaker card

supine position, arms up, wire scars, drain sites, wingboard, 4DCT, abdominal compression

37
Q

Mesothelioma: radiation doses

A

54 Gy for negative margins

60Gy for positive margins

consider 21Gy/3fx for drain sites only if negative margins

20Gy/5fxs for palliation

38
Q

Mesothelioma: 3D fields

A

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
Q

Mesothelioma: 2D fields

A

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
Q

Mesothelioma: dose constraints for lung, esophagus,

A

contralateral lung:

MLD<8.5 Gy

V5<50%

V20<10%

esophagus V60 Gy<1/3

Kidney mean dose < 12 Gy

41
Q

Mesothelioma: MS for stage I/II and stage III/IV

A

stage I/II: 34mo

stage III/IV: 10mo

42
Q

Soft tissue sarcoma: workup

A

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
Q

Soft tissue sarcoma: mutations for synovial, clear cell, myxoid round cell liposarcoma, and Ewing/PNET

A

Synovial: X;18

Clear cell: 12;22

Myxoid round cell liposarcoma: 12;16

Ewing/PNET: 11;22

44
Q

Extremity sarcoma: indications for radiation

A

positive margin and/or grade 3

close margin and grade 3

or maybe just use MSKCC nomogram

45
Q

Extremity sarcoma: doses

A

Pre-op: 50Gy

Post-op R0/1: 50Gy + 16Gy boost

Post-op R2: 50Gy + 20Gy boost

46
Q

Extremity sarcoma: sim

A

Wire scars. Use vac loc to stabilize extremity. Aquaplast fixation device is ideal (ORFIT).

Clamshell and fertility testing in lower extremity in men

47
Q

Extremity sarcoma: pre-op fields

A

(Per RTOG atlas) CTV 1.5 cm radial margin, 3 cm sup/inf margin plus T2 edema on MRI.

48
Q

Extremity sarcoma: post-op fields

A

Give first 50 Gy according to pre-op, then boost to surgical bed, clips, scar + 2 cm

49
Q

Extremity sarcoma: dose constraints

A

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
Q

Retroperitoneal sarcoma: dose and field

A

50Gy/25fxs (heavily prefer pre-op; rarely post-op unless positive margin)

GTV + 1.5cm CTV + 0.5cm PTV

51
Q

Lung T1b

A

1-2cm

52
Q

Lung T1c

A

2-3cm

53
Q

Lung T2

A

involves main bronchus (excluding carina)

visceral pleura

atelectasis extending to hilum

3-5cm (T2a 3-4cm, T2b 4-5cm)

54
Q

Lung T3

A

5-7cm

parietal pleura/pericardium

chest wall

phrenic nerve

separate nodules in same lobe

55
Q

Lung T4

A

>7cm

diaphragm

mediastinum (heart, great vessels, trachea, recurrent laryngeal, esophagus, vertebra)

carina

nodules in separate ipsilateral lobes

56
Q

Lung stage IA1-3

A

IA1: T1aN0

IA2: T1bN0

IA3: T1cN0

57
Q

Lung stage IB

A

T2aN0

58
Q

Lung stage IIA

A

T2bN0

59
Q

Lung stage IIB

A

T1-2N1

T3N0

60
Q

Lung stage IIIA

A

T1-2N2

T3N1

T4N0-1

61
Q

Lung stage IIIB

A

T1-2N3

T3-4N2

62
Q

Lung stage IIIC

A

T3-4N3

63
Q

Mesothelioma T1

A

limited to ipsilateral pleura

64
Q

Mesothelioma T2

A

diaphragmatic muscle

lung parenchyma

65
Q

Mesothelioma T3

A

endothoracic fascia

mediastinal fat

solitary, resectable extension into chest wall

non-trasmural pericardium

66
Q

Mesothelioma T4

A

diffuse chest wall invasion

transdiaphragmatic extension to peritoneum

contralateral pleura

mediastinal organs

spine

transmural pericardial extension

67
Q

Mesothelioma N2

A

contralateral mediastinal nodes

supraclavicular nodes

68
Q

Mesothelioma stage IB

A

T2-3N0

69
Q

Mesothelioma stage II

A

T1-2N1

70
Q

Mesothelioma stage IIIA

A

T3N1

71
Q

Mesothelioma stage IIIB

A

T4 or N2

72
Q

Thymus T2

A

pericardium

73
Q

Thymus T3

A

lung, brachiocephalic vein, vena cava, phrenic nerve, chest wall, exrapericardial pulmonary vessels

74
Q

Thymus T1

A

mediastinal fat and/or mediastinal pleura

75
Q

Thymus T4

A

aorta, arch vessels, intrapericardial pulonary vessels, myocardium, trachea, esophagus

76
Q

Thymus N1

A

anterior mediastinal lymph nodes

77
Q

Thymus N2

A

deep intrathoracic or cervical lymph nodes

78
Q

Thymus stage II

A

T2N0

79
Q

Thymus stage IIIA

A

T3N0

80
Q

Thymus stage IIIB

A

T4N0

81
Q

Thymus stage IVA

A

N1 or M1a

82
Q

Head/Neck soft tissue sarcoma T2

A

2-4cm

83
Q

Head/neck soft tissue sarcoma T4a

A

orbit, skull base, dura, facial bones, pterygoid muscles

84
Q

Extremity/retroperitoneal sarcoma T2

A

5-10cm

85
Q

Extremity/retroperitoneal sarcoma T4

A

15cm+

86
Q

Extremity/retroperitoneal sarcoma stage II

A

T1N0, grade 2-3

87
Q

Extremity/retroperitoneal sarcoma stage IIIA

A

T2N0, grade 2-3

88
Q

Extremity/retroperitoneal sarcoma stage IIIB

A

T3-4N0, grade 2-3

89
Q
A

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