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OB2 > Lung/Sarcoma > Flashcards

Lung/Sarcoma Flashcards

1
Q

Lung T1b

A

1-2cm

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2
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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3
Q
A
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4
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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5
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

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6
Q

Mesothelioma T4

A

diffuse chest wall invasion

transdiaphragmatic extension to peritoneum

contralateral pleura

mediastinal organs

spine

transmural pericardial extension

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7
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

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8
Q

Mesothelioma stage IIIB

A

T4 or N2

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9
Q

Thymoma: 5yr OS for stage I-IV

A

I: 90%

II: 80%

III: 70%

IV: 50%

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10
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

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11
Q

Thymus stage II

A

T2N0

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12
Q

Extremity sarcoma: indications for radiation

A

positive margin and/or grade 3

close margin and grade 3

or maybe just use MSKCC nomogram

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13
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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14
Q

Mesothelioma: workup

A

H&P, family history, smoking history and cessation, asbestos exposure, performance status (weight loss)

Labs:CBC, CMP, PFTs, cardiac stress test, VQ scan

Imaging: CT chest/abdomen, PET

Percutaneous biopsy

EBUS biopsy or mediastinoscopy

Thoracentesis or pleural cath if pleural effusion

consider VATS or laparoscopy if contralateral or peritoneal disease suspected

Resectable if T1-T3

Treat inoperable with chemo only

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15
Q

Thymus T4

A

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

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16
Q

Extremity/retroperitoneal sarcoma stage II

A

T1N0, grade 2-3

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17
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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18
Q

Mesothelioma T2

A

diaphragmatic muscle

lung parenchyma

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19
Q

Head/neck soft tissue sarcoma T4a

A

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

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20
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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21
Q

NSCLC: criteria for PORT

A

N2, positive margin, ECE

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22
Q

Thymus N1

A

anterior mediastinal lymph nodes

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23
Q

Lung T2

A

involves main bronchus (excluding carina)

visceral pleura

atelectasis extending to hilum

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

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24
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

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25
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

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26
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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27
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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28
Q

Mesothelioma stage IB

A

T2-3N0

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29
Q

Mesothelioma stage IIIA

A

T3N1

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30
Q

Superior sulcus tumors: pCR and OS

A

pCR 30%

pCR or minimal residual 55%

5yr OS 45%

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31
Q

Lung SBRT: 3fx constraints

A

spinal cord: 18Gy

esophagus: 27Gy
heart: 30Gy

trachea/bronchus: 30Gy

skin: 24Gy

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32
Q

Extremity sarcoma: doses

A

Pre-op: 50Gy

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

Post-op R2: 50Gy + 20Gy boost

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33
Q

Lung stage IIIB

A

T1-2N3

T3-4N2

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34
Q

Lung stage IIIC

A

T3-4N3

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35
Q

Mesothelioma N2

A

contralateral mediastinal nodes

supraclavicular nodes

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36
Q

Thymus T2

A

pericardium

37
Q

Extremity/retroperitoneal sarcoma stage IIIA

A

T2N0, grade 2-3

38
Q

Soft tissue sarcoma: workup

A

H&P, family history, 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

39
Q

Mesothelioma: sim

A

Prior: PFTs, pacemaker card

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

40
Q

Extremity/retroperitoneal sarcoma T4

A

15cm+

41
Q

Lung cancer: workup

A

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

Labs:CBC, CMP, PFTs

Imaging: CT with contrast, PET, MRI

Percutaneous biopsy

EBUS biopsy or mediastinoscopy

Thoracentesis if pleural effusion

42
Q

Thymus N2

A

deep intrathoracic or cervical lymph nodes

43
Q

Head/Neck soft tissue sarcoma T2

A

2-4cm

44
Q

Lung T3

A

5-7cm

parietal pleura/pericardium

chest wall

phrenic nerve

separate nodules in same lobe

45
Q

ES-SCLC: chemo dose/schedule

A

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

46
Q

Lung T4

A

>7cm

diaphragm

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

carina

nodules in separate ipsilateral lobes

47
Q

Lung SBRT: 5fx constraints

A

spinal cord: 30Gy

esophagus: 105%
heart: 105%

trachea/bronchus: 105%

skin: 32Gy

48
Q

Lung stage IIIA

A

T1-2N2

T3N1

T4N0-1

49
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

50
Q

Mesothelioma stage II

A

T1-2N1

51
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

52
Q

Thymoma: Masaoka staging

A

I: intact capsule, no invasion

IIA: capsular invasion

IIB: surrounding fat or mediastinal pleura

IIIA: lung, pericardium

IIIB: great vessels

IVA: pleural or pericardial disssemination

IVB: nodes or mets

53
Q

Thymus T3

A

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

54
Q

RTOG 0617: MS and local failure

A

MS 29mo

local failure 30%

55
Q

Mesothelioma T3

A

endothoracic fascia

mediastinal fat

solitary, resectable extension into chest wall

non-trasmural pericardium

56
Q

Lung stage IA1-3

A

IA1: T1aN0

IA2: T1bN0

IA3: T1cN0

57
Q

Extremity/retroperitoneal sarcoma stage IIIB

A

T3-4N0, grade 2-3

58
Q

Mesothelioma T1

A

limited to ipsilateral pleura

59
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

60
Q

Thymoma: target volumes

A

GTV: gross residual tumor

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

61
Q

Lung stage IB

A

T2aN0

62
Q

Lung T1c

A

2-3cm

63
Q

Thymoma: workup

A

H&P, family history, progressive muscle weakness (myasthenia gravis), smoking history, exposure to toxins, B symptoms

Labs: CBC w/ diff, CMP, bHCG, LDH, AFP, ACH receptor antibody

Imaging: CT with contrast

Biopsy: CT guided biopsy or mediastinoscopy

Surgery: total thymectomy and complete excision

64
Q

Thymus T1

A

mediastinal fat and/or mediastinal pleura

65
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.

66
Q

Thymus stage IIIB

A

T4N0

67
Q

NSCLC: PORT doses

A

54Gy for negative margin, ECE

60G for positive margin

68
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

69
Q

Extremity sarcoma: post-op fields

A

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

70
Q

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

A

stage I/II: 34mo

stage III/IV: 10mo

71
Q

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

A

40% recurrence without RT

10% recurrence with RT

72
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

73
Q

Extremity sarcoma: dose constraints

A

Skin: 2cm strip V20<50%

Joint: V50<50%

Bone: V50<50%

Anus/vulva: V30<50%

Testis fertility preservation: V3<50%

74
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

75
Q

SCLC: workup

A

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

Labs:CBC, CMP, LDH, PFTs

Imaging: CT with contrast, PET, MRI

Percutaneous biopsy

EBUS biopsy or mediastinoscopy

Thoracentesis if pleural effusion

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

76
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

77
Q

Thymoma: xrt doses

A

preop 45Gy

R0 resecton 50.4Gy

R1 resection 54 Gy

R2 resection 60 Gy

unresectable 70 Gy

78
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

79
Q

Lung cancer: simulation for conventional radiation

A

Prior: PFTs, pacemaker card

supine with 4DCT and vac loc

contour on MIP

80
Q

Lung stage IIB

A

T1-2N1

T3N0

81
Q

Thyoma: heart constraint

A

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

82
Q

LS-SCLC: 5yr OS on Turrisi

A

5yr OS 26%

83
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)

84
Q

Lung stage IIA

A

T2bN0

85
Q

Thymus stage IVA

A

N1 or M1a

86
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

87
Q

Extremity/retroperitoneal sarcoma T2

A

5-10cm

88
Q

Thymus stage IIIA

A

T3N0

89
Q

Lung cancer: options for improving lung dose with conventional fractionation

A

increase AP/PA weighting

reduce margins of CTV

4DCT

IMRT

OB2 (10 decks)

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