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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
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
26
Mesothelioma: treatment paradigm
induction chemo with cisplatin/pemetrexed extrapleural pneumonectomy (when possible) consider adjuvant xrt for epithelial or mixed histology (sarcomatoid get chemo only)
27
NSCLC: criteria for operability
pre-op FEV1 \>1.5 L and \>FEV1 80% for lobectomy post-op predicted FEV1 \> 40% and DLCO \> 40%
28
Mesothelioma stage IB
T2-3N0
29
Mesothelioma stage IIIA
T3N1
30
Superior sulcus tumors: pCR and OS
pCR 30% pCR or minimal residual 55% 5yr OS 45%
31
Lung SBRT: 3fx constraints
spinal cord: 18Gy esophagus: 27Gy heart: 30Gy trachea/bronchus: 30Gy skin: 24Gy
32
Extremity sarcoma: doses
Pre-op: 50Gy Post-op R0/1: 50Gy + 16Gy boost Post-op R2: 50Gy + 20Gy boost
33
Lung stage IIIB
T1-2N3 T3-4N2
34
Lung stage IIIC
T3-4N3
35
Mesothelioma N2
contralateral mediastinal nodes supraclavicular nodes
36
Thymus T2
pericardium
37
Extremity/retroperitoneal sarcoma stage IIIA
T2N0, grade 2-3
38
Soft tissue sarcoma: workup
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
Mesothelioma: sim
Prior: PFTs, pacemaker card supine position, arms up, wire scars, drain sites, wingboard, 4DCT, abdominal compression
40
Extremity/retroperitoneal sarcoma T4
15cm+
41
Lung cancer: workup
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
Thymus N2
deep intrathoracic or cervical lymph nodes
43
Head/Neck soft tissue sarcoma T2
2-4cm
44
Lung T3
5-7cm parietal pleura/pericardium chest wall phrenic nerve separate nodules in same lobe
45
ES-SCLC: chemo dose/schedule
cis/etop 75/100, q4 weeks, 4-6 cycles
46
Lung T4
\>7cm diaphragm mediastinum (heart, great vessels, trachea, recurrent laryngeal, esophagus, vertebra) carina nodules in separate ipsilateral lobes
47
Lung SBRT: 5fx constraints
spinal cord: 30Gy esophagus: 105% heart: 105% trachea/bronchus: 105% skin: 32Gy
48
Lung stage IIIA
T1-2N2 T3N1 T4N0-1
49
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
50
Mesothelioma stage II
T1-2N1
51
Superior sulcus tumor: symptoms of Pancoast syndrome and Horners syndrome
Pancoast: nerve symptoms in ulnar distribution, possibly atrophic hand muscles Horners: ptosis, miosis, anhydrosis
52
Thymoma: Masaoka staging
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
Thymus T3
lung, brachiocephalic vein, vena cava, phrenic nerve, chest wall, exrapericardial pulmonary vessels
54
RTOG 0617: MS and local failure
MS 29mo local failure 30%
55
Mesothelioma T3
endothoracic fascia mediastinal fat solitary, resectable extension into chest wall non-trasmural pericardium
56
Lung stage IA1-3
IA1: T1aN0 IA2: T1bN0 IA3: T1cN0
57
Extremity/retroperitoneal sarcoma stage IIIB
T3-4N0, grade 2-3
58
Mesothelioma T1
limited to ipsilateral pleura
59
Lung cancer: constraints for conventional radiation
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
Thymoma: target volumes
GTV: gross residual tumor CTV: remaning thymus, surgical clips, areas at risk per surgeon. Must review CTV with surgeon.
61
Lung stage IB
T2aN0
62
Lung T1c
2-3cm
63
Thymoma: workup
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
Thymus T1
mediastinal fat and/or mediastinal pleura
65
Extremity sarcoma: pre-op fields
(Per RTOG atlas) CTV 1.5 cm radial margin, 3 cm sup/inf margin plus T2 edema on MRI.
66
Thymus stage IIIB
T4N0
67
NSCLC: PORT doses
54Gy for negative margin, ECE 60G for positive margin
68
LS-SCLC: chemo dose/schedule
cis/etop 60/120 q4 weeks, 4-6 cycles cisplatin given on day 1 only and etoposide on days 1-3
69
Extremity sarcoma: post-op fields
Give first 50 Gy according to pre-op, then boost to surgical bed, clips, scar + 2 cm
70
Mesothelioma: MS for stage I/II and stage III/IV
stage I/II: 34mo stage III/IV: 10mo
71
Thymoma: recurrence rate for stage II-III with complete resection
40% recurrence without RT 10% recurrence with RT
72
Lung SBRT: target dosimetry
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
Extremity sarcoma: dose constraints
Skin: 2cm strip V20\<50% Joint: V50\<50% Bone: V50\<50% Anus/vulva: V30\<50% Testis fertility preservation: V3\<50%
74
NSCLC: indications for adjuvant chemo after surgery
N1, poorly differentiated, \>4cm, vascular invasion, wedge resection, visceral pleural involvement, incomplete nodal dissection cisplatin and vinorelbine/etoposide
75
SCLC: workup
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
Definition of superior sulcus tumor
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
Thymoma: xrt doses
preop 45Gy R0 resecton 50.4Gy R1 resection 54 Gy R2 resection 60 Gy unresectable 70 Gy
78
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
79
Lung cancer: simulation for conventional radiation
Prior: PFTs, pacemaker card supine with 4DCT and vac loc contour on MIP
80
Lung stage IIB
T1-2N1 T3N0
81
Thyoma: heart constraint
heart mean \<30Gy, as low as possible as patients are often young
82
LS-SCLC: 5yr OS on Turrisi
5yr OS 26%
83
Superior sulcus tumor: treatment paradigm
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
Lung stage IIA
T2bN0
85
Thymus stage IVA
N1 or M1a
86
LS-SCLC: BID xrt planning
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
Extremity/retroperitoneal sarcoma T2
5-10cm
88
Thymus stage IIIA
T3N0
89
Lung cancer: options for improving lung dose with conventional fractionation
increase AP/PA weighting reduce margins of CTV 4DCT IMRT

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