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Rad Onc Oral Boards > Mini Humans > Flashcards

Mini Humans Flashcards

1
Q

Peds brain tumors which ones do we not resect

A

Germinoma, NGGCT, Optic and brainstem Glioma

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2
Q

Only Peds CNS to biopsy

A

Germinoma

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3
Q

Only CNS peds tumor that doesnt go to 54 Gy

A

Germinoma

Carbo/etop x 4

M0: whole WVRT 21 Gy + boost to 30 Gy (36 PR)

M1: CSI 24 Gy -> boost to 45 Gy

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4
Q

Posterior Fossa Syndrome

A

PF syndrome (24-48 hrs after surgery):
-15% after craniotomy
SAME
- Swallowing dysfxn
- Ataxia (truncal)
- Mutism (cerebellar)
- Emotional lability

  • can also have respiratory failure
  • do NOT delay RT – improves over 1-6 months
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5
Q

Medulloblastoma imaging timing

A

Imaging:
MRI brain pre-op and 24-72 hr post-op
MRI total spine; then 10-14 days post (false positive if too early)

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6
Q

Medulloblastoma treatment algorithm

A

Imaging -> do not get CSF or biopsy -> straight to MSR-> CRT within 31 days post-op -> adj chemo (GTR achieved 90% of time)

Don’t forget post-op MRI within 48 hrs and spine MRI at day 10 followed by CSF

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7
Q

Medulloblastoma prognosis subtype

A

: WNT > group 4 > SHH > Group 3 bad

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8
Q

Medullo standard risk adjuvant treatment

A

Standard risk:
CSI 23.4 Gy + tumor bed boost (IF) to 54 Gy with concurrent vincristine (1.5 mg/m2 q week)
Adjuvant chemo

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9
Q

Medullo High risk adjuvant treatment

A

High risk: M+, STR, anaplasia
CSI 36 Gy + IF boost to 54 Gy with concurrent vincristine
Adjuvant chemo
Boosts:
Focal at/above cord: 45
Focal below cord: 50.4
Diffuse: CSI to 39.6

Adjuvant chemo: platinum, CCNU, vincristine x 8 cycles – NOT PCV (procarbazine)

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10
Q

Medullo High risk criteria

A

M+, STR, anaplasia

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11
Q

Medullo < 3 yo

A

Infant:
If <3 yo: max safe resection  chemo alone (Head Start)
- Reserve RT for salvage or progression
- If you have to treat with RT, use IFRT 54 Gy (1 cm margin supratentorral, 1.5 cm margin infratentorial)

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12
Q

CSI script Medullo

A

1) CT based simulation - will fuse pre-op and post-op MRI
2) Prone immobilization with Aquaplast mask – also make mold in supine position – head extended to avoid divergence into the mandible, shoulders down – BBs on mask, shoulders, lumbosacral spine
-anesthesia if <11 years
3) Scan vertex to mid femur (2.5 mm slices thru brain, 5 mm elsewhere)
4) Contour globes, lenses, brain (including cribriform plate), cauda
5) Set spine field first
Sup: C7 (as low as possible without going through shoulders)
Inf: thecal sac (S2/S3)
Lat: 1 cm lat to vertebral body;
spade at sacrum to include SI joints
- use a single field if length < 40 cm
- if > 36 cm, can either:
a. Treat at 120 cm SSD
b. Use two fields
6) If using two fields, match anterior to cord (post edge of vertebral body) with skin gap equation
7) Next set-up the brain field. Parallel opposed laterals (or RAO/LAO to minimize divergence into C/L eye). Iso at mid plane (in same coronal plane as spine field).
8) Rotate collimator to match the divergence of the spine field
9) Kick the couch toward the gantry to match divergence of brain field
Note: theoretical underdose of cribiform
Brain – use RAO/LAO to avoid divergence of brain field into contralateral retina
10) Feather all junctions by increasing middle field and decreasing brain and inf spinal fields by 0.5 cm after every 9 Gy (1 week)
11) Image WBRT field daily, apply z shifts with table indexing for lower field isocenters
12) Image all fields weekly
13) Boost

IF boost
CTV = pre-op tumor + tumor bed + 1.5 cm (cropped at tentorium and bone)
Anatomically confined to the posterior fossa, trim inside tent/bones
PTV = CTV + 0.3-0.5 cm

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13
Q

Medullo what to check before treatment

A

Before RT, check that ANC > 1000 and plt > 100K.
If not, start with boost then do CSI after

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14
Q

Germ cell tumor
AFP or high B-HCG (>50)

A

indicates NGGCT
Embryonal – bHCG (> 50) + AFP (>10)
Yolk sac – AFP
Chorio - >> bHCG

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15
Q

Germ cell when to biopsy

A

Pure germinoma if markers elevated do not have to

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16
Q

Germinoma treatment M0

A

Chemo -> (biopsy if incomplete response) -> whole ventricle 21 Gy boost IF 30 (36 PR)

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17
Q

Germinoma treatment M1

A

M1:
Chemo -> 21 Gy CSI boost to 36 if CR

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18
Q

NGGCT treatment

A

Chemo x 6 -> restage
-chemo: alternating cis/etoposide and ifos/etop

If CR: RT
If < CR: max safe resection -> post-op RT

-RT: CSI 36 Gy + boost 54 Gy

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19
Q

Pineoblastoma

A

treat like high risk medullo:

CSI 36 Gy + IF boost to 54 Gy with concurrent vincristine
Adjuvant chemo
Boosts:
Focal at/above cord: 45
Focal below cord: 50.4
Diffuse: CSI to 39.6

Adjuvant chemo: cisplatinum, lomustine, vincristine x 8 cycles

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20
Q

Ependymoma workup

A

MRI brain/spine
-pre-op and 10-14 days post-op
LP 10-14 days post-op and after MRI spine
-contraindicated pre-op for posterior fossa mass for risk of herniation

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21
Q

Ependymoma
MRI spine/LP negative: treatment

A

MRI spine/LP negative:
Max safe resection (be aggressive!) -> post-op IFRT to 54)
-goal is GTR –chemo then re-resecting if needed to achieve GTR

Historically no role for chemo unless < 3 yrs s/p GTR to delay RT

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22
Q

Ependymoma
MRI spine/LP positive: treatment

A

MRI spine/LP positive:
Max safe resection -> post-op CSI to 36 Gy
-boost spine dz to 45, 50.4-59.4 if below cord
-boost intracranial primary to 59.4

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23
Q

Ependymoma start within

A

56 days

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24
Q

Ependymoma volumes and dose

A

GTV=tumor bed + residual + tissues originally involved w tumor
CTV=GTV + 5 mm
PTV=CTV + 5 mm

Dose: 59.4/1.8

25
Q

Optic Glioma workup

A

Fundoscopic and CN exam
Visual field testing
No biopsy!!

26
Q

Optic Glioma treatment

A

< 10 yo:
Observation w close surveillance
-Carbo/vincristine at radiographic or sx progression
-RT if progresses post-chemo

>10 yo:
RT to 54/1.8 Gy (confirm not 50.4)

27
Q

craniopharyngioma presentation and workup

A

Arise from remnants of Rathke’s pouch

H&P – present w DI, growth failure, behavior issues, visual field defects

Labs – pituitary panel

Imaging – MRI brain – solid calcified nodule with cyst filled w crankcase oil

Biopsy – not necessary

Other:
Audiometry
Ophtho exam

28
Q

Cranio treatment

A

Max safe resection
If GTR -> observe (20% recurrence)
if STR (70% recurrence) -> adjuvant RT to 54/1.8 Gy

Decompress cyst prior to RT
MRI q 1-2 wks to assess cyst growth requiring replanning. Daily CBCT can guide too.

EBRT
GTV (just post-op GTV) = tumor + cyst wall
(can use 0.5 cm CTV)
PTV = GTV + 0.5 cm

Dose: 54 Gy

29
Q

DIPG

A

DIPG
Steroids and RT to 54 Gy

GTV=FLAIR + 1.5 cm
CTV=entire brainstem (midbrain to C1)
PTV=CTV+0.5 cm

30
Q

LGG

A

GTR – obs

NF-1 indolent

<10 yo vincristine carbo to delay RT

RT-54Gy

31
Q

HGG

A

High Grade Glioma: MGMT bad, H3.3 K27M bad, IDH better

Surgery, RT 54-60Gy

32
Q

Rhabdo Favorable sites

A

• Favorable sites: BONG
Biliary
Orbit
Non parameningeal HN
GU (non bladder/prostate)

33
Q

Rhabdo Unfavorable sites

A

Unfavorable sites:
• Parameningeal (MMNNOOPP):
Middle ear,
Mastoid region,
Nasal Cavity,
Nasopharynx,
Pterygopalatine fOssa,
Infratemporal fOssa,
Paranasal Sinus,
Parapharyngeal region
• Bladder/prostate
• Extremities
• Other: Trunk/retroperitoneum

34
Q

RMS Staging

A

Simple RMS Staging

Stage=Site

1 Favorable (any size/N)
2 Unfavorable, small and N0
3 Unfavorable, large or N+ (or both)
4 Distant Mets

35
Q

RMS Grouping

A

Simple RMS Grouping

Group = Surgical Group

Based on surgical status prior to chemo start.
I GTR, margins –
II GTR, + microscopic disease
III Gross residual
IV Mets

36
Q

Rhabdo Risk group

A

Low – (all others): based on histology
FH, fav site, group 1-3 (no met)
FH, unfav site, group 1-2

Int –
unfav site & group 3(gross disease) or UH

High – mets

37
Q

RMS overall treatment paradigm

A

Surgery* -> chemo -> RT -> chemo

38
Q

RMS low risk paradigm

A

Low-risk: Surgery then

  • VAC (vincristine/actinomycin D/cyclophos) wk 1-12
  • RT at week 12 w chemo
  • VA wk 13-24
39
Q

RMS Int-risk paradigm

A

Int-risk (UH)
- VAC wk 1-42
-RT at week 12
** no actinomycin during RT **

40
Q

RMS high risk

A

High-risk

  • VAC + IE (ifos/etop) wk 1-20
  • RT at week 20 to primary and mets
  • VAC + IE wk 20-52 Gy

If compression etc can start with chemo

41
Q

RT Doses by Group and Histology RMS

A

RT Doses by Group and Histology
Group. FH. UH.
1(neg marg) 0 36
+margin 36 36
node+ 41.4 41.4
3(gross) 50.4* 50.4*
(*45 Gy if orbit; **36 Gy if delayed primary excision)

FH: Embryonal
UH: Alveolar

Basically:

UH or + margin: 36 Gy

Node + 41.4

Gross: 50.4

42
Q

RMS volumes

A

Pre-chemo, pre-surgical GTV based on the gross disease on MR.

CTV = GTV + 1 cm 
PTV = CTV + 5 mm

Lung mets:
15/1.5 Gy
Boost if gross disease to 50.4 Gy

43
Q

RMS constraints

A

Optic nerve & chiasm < 46.8 Gy (per RMS protocol)

Contralat whole kidney < 14.4

Whole Liver < 23.4

44
Q

Ewing’s Workup

A

H&P: w neuro and MSK exam
Labs: CBC, CMP, LDH, ESR

Imaging:

  • MRI primary (T1 enhancing)
  • PET with diagnostic CT
  • CT chest
  • Bone scan

Biopsy:

  • Bx primary site – longitudinal incisional bx
  • BM biopsy (25% have BM+!!!)
45
Q

Ewing’s treatment

A

Chemo -> local therapy (surgery vs RT) -> chemo

1) VDC-IE q 2 wks x 6 cycles (wk 1-12)

2) local therapy at wk 14:
- surgery preferred for “expendable” bones
- otherwise RT + chemo (minus adriamycin)

45 Gy to pre-chemo volume (bone and soft tissue) + 2 cm
55.8 Gy boost to post-chemo soft tissue + pre-chemo bone + 2 cm

No elective nodes
-if vertebral body, do 45 then 5.4 to 50.4 total

46
Q

Ewing dont forget

A

CLAM SHELL IF MALE!!!!!!!
OVARIAN transposition for women if RT to pelvis.

47
Q

Osteosarcoma

A

Chemo -> surgery -> chemo
-Chemo: MAP (MTX, adria, cisplatin)

RT if:

  • inoperable (70 Gy)
  • R1/R2 resection (60 Gy)
48
Q

Neuroblastoma workup

A

Labs: blood catecholamines Urine catecholamines (inc in 90%): VMA, HMV

  • Imaging:
    CT c/a/p - calcs
    MIBG scan
    Bone scan (if MIBG neg)

-Biopsy
Bilateral BM biopsy
Biopsy primary and involved nodes: do NOT biopsy primary until wilms ruled out

Homer-Wright pseudorosettes

49
Q

Neuroblastoma risk cat

A

Low: Stage I:

  • -unilateral GTR or R1
  • -Stage II: STR, R2, ipsi LN

Int: all others

High Risk:

  • -N-Myc
  • -Mets >18mo
  • -Stage III UH >18mo: cross midline, contralateral LN, unresectable
50
Q

Neuroblastoma presentation

A

Young 2 and under, sick
pushes kidney out of the way,
urine catecholamines +, skeletal mets are common(MIBG scan)
MS is mets in <18months

calcifications in mass

Neural crest cells of the sympathetic ganglion

51
Q

Neuroblastoma treatment

A

Low – surgery alone
-chemo for persistence or recurrence

Int
Max safe resection -> chemo

High
Make sure you have biopsy!
1) Induction CAPE x 5 months (cisplatin-based regimen)
2) Repeat MIBG
3) max safe resection
4) tandem transplant (ABMT x 2)
5) RT day 28 to primary and persistent MIBG+ sites
5) maintenance cis-retinoic acid x 6 months and immune tx x 5 months

52
Q

Neuroblastoma dose

A

Primary site & mets: 21.6/1.8 Gy

Post-induction, pre-op volume with 2 cm margin (1.5 cm CTV, 0.5 cm PTV)
Cover entire vertebral body to prevent scoliosis.

4S liver palliation causing respiratory distress (Pepper syndrome) give 1.5 Gy x 3 fx

Symptomatic cord compression:
Try chemo first! RT if persistent
<3yo: 9/1.8 Gy
>3yo: 21.6/1.8

53
Q

Neuroblastoma constraints

A

Liver V9 < 50% ; V18< 25%

Ipsilateral kidney < 14.4
Lung V15 < 30%

54
Q

Wilms histology

A

FH: (90%) – no anaplasia or sarcomatous features
UH: (10%) anaplastic (focal or diffuse), clear cell, rhabdoid

55
Q

Wilms workup

A

Labs – CBC, Chem7, LFTs, UA w catecholamines (to r/o NB)

Imaging -
Abd U/S
CT/MRI of primary
CT chest
For clear cell: add bone scan, MRI brain, BM bx
For rhabdoid: add MRI brain

DO NOT BIOPSY (unless bilateral or unresectable)

56
Q

Wilms stage

A

I: completely resected, confined to kidney
II: completely resected, but beyond capsule, or vessel
III:
SLURPP-Bx
Spillage
LN+
Unresectable
Residual tumor
Positive margins
Peritoneal implants
Biopsy performed
IV: mets or LN+ outside abd/pelvis
V: bilateral (stage each side separately)

*pre-op chemo=Stage III*

57
Q

Wilms overall treatment

A

Surgery - > Chemo - > +/- RT

58
Q

Flank field

A

Flank Field: pre-op tumor +1.5cm anatomically modified, include vertebral bodies

59
Q

Pediatric Hodgkins treatment

A

Low risk: AVPC x 3 c -> ISRT 21/1.5 Gy (AHOD 0431)

-adria, vincristine, pred, cyclo

Int risk: AVPC-BE x 4-6 c -> ISRT to 21/1.5 Gy

-adria, bleo, vincristine, etop, pred, cyclophos

High risk: ABPC-BE x 6-8 c -> ISRT 21/1.5

Ann Arbor staging

Low risk:

Favorable stage I-II (no B sx, non-bulky, no extranodal extension, 1-2 sites)

Int risk:

Unfav stage I-II

Stage IIIA (no B sx)

High risk:

Stage IIIB or IV

Rad Onc Oral Boards (11 decks)

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