Mini Humans Flashcards
Peds brain tumors which ones do we not resect
Germinoma, NGGCT, Optic and brainstem Glioma
Only Peds CNS to biopsy
Germinoma
Only CNS peds tumor that doesnt go to 54 Gy
Germinoma
Carbo/etop x 4
M0: whole WVRT 21 Gy + boost to 30 Gy (36 PR)
M1: CSI 24 Gy -> boost to 45 Gy
Medulloblastoma treatment algorithm
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
Medullo standard risk adjuvant treatment
Standard risk:
CSI 23.4 Gy + tumor bed boost (IF) to 54 Gy with concurrent vincristine (1.5 mg/m2 q week)
Adjuvant chemo
Medullo High risk adjuvant treatment
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)
Medullo High risk criteria
M+, STR, anaplasia
CSI script Medullo
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
Germinoma treatment M0
Chemo -> (biopsy if incomplete response) -> whole ventricle 21 Gy boost IF 30 (36 PR)
Germinoma treatment M1
M1:
Chemo -> 21 Gy CSI boost to 36 if CR
NGGCT treatment
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
Rhabdo Favorable sites
• Favorable sites: BONG
Biliary
Orbit
Non parameningeal HN
GU (non bladder/prostate)
Rhabdo Unfavorable sites
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
RMS Staging
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
RMS Grouping
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
Rhabdo Risk group
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
RMS overall treatment paradigm
Surgery* -> chemo -> RT -> chemo
RMS low risk paradigm
Low-risk: Surgery then
- VAC (vincristine/actinomycin D/cyclophos) wk 1-12
- RT at week 12 w chemo
- VA wk 13-24
RMS Int-risk paradigm
Int-risk (UH)
- VAC wk 1-42
-RT at week 12
** no actinomycin during RT **
RMS high risk
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
RT Doses by Group and Histology RMS
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
RMS constraints
Optic nerve & chiasm < 46.8 Gy (per RMS protocol)
Contralat whole kidney < 14.4
Whole Liver < 23.4
Neuroblastoma risk cat
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
Neuroblastoma treatment
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
Neuroblastoma dose
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
Neuroblastoma constraints
Liver V9 < 50% ; V18< 25%
Ipsilateral kidney < 14.4
Lung V15 < 30%
Wilms stage
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*
Wilms overall treatment
Surgery - > Chemo - > +/- RT
Flank field
Flank Field: pre-op tumor +1.5cm anatomically modified, include vertebral bodies
