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oral boards > misc thoracic CA/tumors (meso, thymoma, chest wall, etc) > Flashcards

misc thoracic CA/tumors (meso, thymoma, chest wall, etc) Flashcards

1
Q

NCCN guideline mesothelioma re-staging after induction chemo

A

CT chest with contrast ± PET-CT

NCCN: PET “for mediastinal assessment based on CT or other evidence of advanced disease”

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2
Q

NCCN guideline mgmt of residual [lung] nodule(s)/mass(es) in seminoma

A

with post-tx (1st-line chemo) CT C/A/P with contrast &
with αFP & β-hCG WNL
- ≤3cm ⇒ surveil
- >3cm ⇒ PET-CT (≥6w post-chemo) ￫ bx/resxn if PET⊕ ￫ 2nd-line chemo if ⊕viable seminoma ￫ same mgmt cycle but this time resect if PET⊕

with progressive dz (￪ αFP & β-hCG OR nodule/mass growing)
- 2nd-line chemo

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3
Q

NCCN guideline mgmt of residual [lung] nodule(s)/mass(es) in non-seminomatous germ cell tumor after 1st-line chemo

A

with αFP & β-hCG levels:
- WNL ⇒ resect
- ￬ ⇒ resect
- ∅∆ (still ￪) ⇒ resect (UpToDate) v surveil (NCCN)
- ￪ ⇒ 2nd-line chemo (NCCN)

(normalized v decreased v stable elevated v increased)

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4
Q

NCCN guideline mgmt after resxn of residual [lung] nodule(s)/mass(es) in non-seminomatous germ cell tumor (after 1st-line chemo)

A

if resxn pathology shows:
- teratoma or necrosis ⇒ surveil
- residual GCT ⇒ more chemo

chemo = non-BEP 1st-line or 2nd-line (EP/TIP/VIP/VeIP)

NCCN Preferred Regimens
EP = Etoposide/cisplatin
TIP = Paclitaxel/ifosfamide/cisplatin
VIP = Etoposide/ifosfamide/cisplatin
VeIP = Vinblastine/ifosfamide/cisplatin

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5
Q

Do serum tumor markers have to normalize to consider resxn in seminoma?

A

YES
if not, give more chemo

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6
Q

Do serum tumor markers have to normalize to consider resxn in non-seminomatous germ cell tumor?

A

NO

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7
Q

Are mixed seminoma/non-seminoma germ cell tumors treated as seminoma or NSGCT?

A

treated as non-seminomatous germ cell tumor

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8
Q

NCCN guideline 1st-line systemic tx regimen for germ cell tumors (both seminoma & non-seminomatous)

A
  1. BEP (platinum-based triplet): bleomycin + etoposide + cisplatin (Platinol)
  2. EP: etoposide + cisplatin OR
    VIP(/IEP) (platinum-based triplet): etoposide (VP16) + ifosfamide + cisplatin (Platinol)
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9
Q

NCCN guideline mgmt of unicentric Castleman dz

A
  • resectable: surgery
  • unresectable: rituximab ± chemo ￫ resect
  • incomplete resxn:
    asx = observe v
    sx = back to unresectable pathway
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10
Q

strongest predictor of metastatic potential of an pleuropulmonary SFT (solitary fibrous tumor)

A

>4 mitoses / 10 high-power fields

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11
Q

predictor(s) of risk of recurrence/metastasis of pleuropulmonary SFT (solitary fibrous tumor)

A
  • high mitotic rate (SESATS: >4 mitoses / 10 HPF)
  • +tumor necrosis
  • T>10cm
  • mets @ dx
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12
Q

indication(s) for adjuvant RT after resxn of pleuropulmonary SFT

A

NONE

if >R0: re-resect
if high-risk: surveil & re-resect
(UpToDate)

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13
Q

indication(s) for adjuvant systemic tx after resxn of pleuropulmonary SFT

A

NONE

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14
Q

indication(s) for neoadjuvant tx before resxn of pleuropulmonary SFT

A

maybe neoadj RT to aid resectability (prob not in chest)

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15
Q

surveillance after resxn of pleuropulmonary SFT

A

CT Q1Y xforever

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16
Q

required margin for resection of a pedunculated visceral pleura-based pleuropulmonary SFT

A

negative
(wedge of stalk base is adequate for small tumors)

UpToDate: “Pedunculated tumors can generally be resected with a wedge resection, but large sessile tumors and those with ipsilateral intrapleural metastases may occasionally require a lobectomy, pneumonectomy, or a chest wall or diaphragm resection to achieve negative (R0) margins.”

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17
Q

What proportion of pleuropulmonary SFTs occur on the parietal v visceral pleura?

A

1/3 parietal v 2/3 visceral
(usu pedunculated v sessile/broad-based respectively)

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18
Q

paraneoplastic syndromes a/w pleuropulmonary SFT

A
  • IGF-2 secretion ⇒ refrx hypoGlc = Doege-Potter syndrome (<5%)
  • clubbing + periostitis + synovial effusions = hypertrophic pulmonary osteoarthropathy (HPO) = Pierre-Marie-Bamberger syndrome

IGF-2 = insulin-like growth factor 2

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19
Q

[pleuropulmonary] SFT histopathology

A

spindle cell neoplasm
- characterized by dense collagenous background, often with hyalinized or thick collagen bands
- variably atypical spindled cells arrayed haphazardly within this stroma
in a storiform configuration or in randomly oriented fascicles characteristically referred to as “patternless pattern”
- less and more cellular areas alternate
- thin-walled, branching capillaries are always present but may not be prominent

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20
Q

Which are more common: bronchogenic or esophageal duplication cysts?

A

bronchogenic

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21
Q

indication(s) to resect bronchogenic or esophageal duplication cysts

A

infxn
ppx for cx like infxn (?)
sxs

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22
Q

Do bronchogenic duplication cysts typically communicate with the airway?

A

NO
(So if you see an air-fluid level, you should suspect infection.)

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23
Q

Do esophageal duplication cysts typically communicate with the GI tract?

A

NO

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24
Q

location predilection of esophageal duplication cysts

A

R mediastinum

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25
Q

common presenting sxs in bronchogenic duplication cyst

A

incidental
compression
infxn

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26
Q

common presenting sxs in esophageal duplication cyst

A

incidental
bleeding (2/2 ectopic gastric mucosa)
dysphagia (2/2 esophageal compression)

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27
Q

bx of a middle mediastinal mass shows pseudostratified columnar epithelium

A

esophageal duplication cyst

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28
Q

bx of a middle mediastinal mass shows normal respiratory epithelium

A

bronchogenic duplication cyst

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29
Q

rounded fluid or soft tissue density mass in middle mediastinum with layering milk of calcium

A

bronchogenic duplication cyst

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30
Q

Are posterior mediastinal tumors in adults usually benign or malignant?

A

most are BENIGN
(v most malignant e.g. neuroblastoma in <10yo)

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31
Q

most common etiology anterior mediastinal mass in ♀ <40yo

A

lymphoma

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32
Q

most common etiology anterior mediastinal mass in ♀ >40yo

A

thymoma

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33
Q

% of thymoma pts with MG

A

~50%

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34
Q

% of MG pts with thymoma

A

~15%

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35
Q

Do thymic cysts have solid components?

A

NOa
if mixed, ddx: thymoma, lymphoma, germ cell tumor

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36
Q

anterior mediastinal mass with mixed cystic & solid components with enhancing septae

A

germ cell tumor

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37
Q

Are internal calcs in a thymic mass a/w more or less aggressive behavior/etiology?

A

MORE aggressive
a/w thymic CA
thymic CA is MORE likely to have calcs than thymoma
- stippled calcs within the mass = thymic CA
- curvilear peripheral/capsular calcs = calcified thymomas

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38
Q

Which is more aggressive: mucoepidermoid carcinoma OR adenoid cystic carcinoma?

A

adenoid cystic CA = aggressive
mucoepidermoid CA = meek

ACC more likely to spread longitudinally(submucosal)/perineural/lymphatic AND more likely to invade mediastinum/outside trachea

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39
Q

most common 1° tracheal tumor

A

SCC (50-60%)

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40
Q

most common tracheobronchial sites of:
- SCC
- adenoid cystic CA
- mucoepidermoid CA

A
  • SCC = distal 2/3 trachea + prox mainstem bronchi
  • ACC = prox 1/3 trachea
  • MEC = bronchi
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41
Q

posterior mediastinal mass ddx

A
  1. neurogenic tumor
  2. sarcoma
  3. SFT
  4. desmoid
    (SESATS)
    order of most common after neurogenic??? correct???
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42
Q

most common neurogenic tumor type

A

nerve sheath tumors (40-65%)

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43
Q

most common nerve sheath tumor type

A

Schwannoma

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44
Q

% of nerve sheath tumors that are malignant

A

5%

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45
Q

mgmt of neurogenic tumors

A

resxn

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46
Q

indication(s) for adjuvant tx for neurogenic tumors

A

NONE

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47
Q

indication(s) for RT for neurogenic tumors

A

NONE
(RT not effective)

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48
Q

frequency of neural foramen/spinal canal invasion by neurogenic tumors

A

10%

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49
Q

preop w/u for neurogenic tumors

A

CT scan
bx
MRI chest/spine

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50
Q

minimum relative tracheal luminal narrowing to cause obstructive sxs

A

50-74%

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51
Q

absolute tracheal luminal size threshold to cause exertional dyspnea as obstructive sx

A

8mm

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52
Q

absolute tracheal luminal size threshold to cause rest dyspnea as obstructive sx

A

5mm

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53
Q

tracheal tumor that most commonly causes or p/w hemoptysis

A

SCC

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54
Q

max resectable length of trachea

A

usu 4cm
absolute limit is 1/2 of trachea ≈ 6cm (normal trachea 11-12cm)

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55
Q

strongest prognostic factor for osteosarcoma OS

A

histologic grade
(like all sarcoma)

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56
Q

osteosarcoma (all malignant chest wall masses???) margins

A

2-4cm

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57
Q

incidence of delayed (several weeks postop) mesh infxn in chest wall reconstruction

A

10%
esp if +RT

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58
Q

Masaoka staging

A
  • I: encapsulated
    “macroscopically & microscopically completely encapsulated”
  • II: pericapsular (incl fat/pleura)
    IIA = “microscopic transcapsular invasion”
    IIB = “macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium”
  • III: adjacent (mediastinal) structures
    “macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)”
    IIIA = ⊖great vessels
    IIIB = ⊕great vessels
  • IVA: pleura/pericardium
    “pleural or pericardial dissemination” (implants)
  • IVB: distant mets
    “lymphogenous or hematogenous metastasis”
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59
Q

Masaoka stage:
completely encapsulated without invasion

A

I
(encapsulated:
“macroscopically & microscopically completely encapsulated”)

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60
Q

Masaoka stage:
microscopic invasion through the capsule

A

IIA
(II: pericapsular (incl fat/pleura)
IIA = “microscopic transcapsular invasion”
IIB = “macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium”)

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61
Q

Masaoka stage:
invasion into surrounding fat

A

IIB
(II: pericapsular (incl fat/pleura)
IIA = “microscopic transcapsular invasion”
IIB = “macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium”)

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62
Q

Masaoka stage:
invasion into mediastinal pleura

A

IIB
(II: pericapsular (incl fat/pleura)
IIA = “microscopic transcapsular invasion”
IIB = “macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium”)

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63
Q

Masaoka stage:
invasion into pericardium

A

IIIA
(III: adjacent (mediastinal) structures
“macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)”
IIIA = ⊖great vessels
IIIB = ⊕great vessels)

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64
Q

Masaoka stage:
invasion into SVC

A

IIIB
(III: adjacent (mediastinal) structures
“macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)”
IIIA = ⊖great vessels
IIIB = ⊕great vessels)

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65
Q

Masaoka stage:
invasion into lung

A

IIIA
(III: adjacent (mediastinal) structures
“macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)”
IIIA = ⊖great vessels
IIIB = ⊕great vessels)

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66
Q

Masaoka stage:
invasion into innominate artery

A

IIIA
(III: adjacent (mediastinal) structures
“macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)”
IIIA = ⊖great vessels
IIIB = ⊕great vessels)

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67
Q

Masaoka stage:
invasion into Ao

A

IIIB
(III: adjacent (mediastinal) structures
“macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)”
IIIA = ⊖great vessels
IIIB = ⊕great vessels)

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68
Q

Masaoka stage:
invasion into pulmonary pleura / pleural implants

A

IVA
(pleura/pericardium:
“pleural or pericardial dissemination”)

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69
Q

Masaoka stage:
pericardial implants

A

IVA
(pleura/pericardium:
“pleural or pericardial dissemination”)

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70
Q

Masaoka stage:
distant mets (outside pleura or pericardium)

A

IVB
(distant mets:
“lymphogenous or hematogenous metastasis”)

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71
Q

thymoma/thymic CA

cutoff criteria between I & II & III(A&B)

TNM

A

T-size:
T1 / T2 / T3 / T4

all N0 M0

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72
Q

thymoma/thymic CA

IIIA v IIIB

TNM

A

T3 v T4
i.e. resectable v potentially un-resectable structures

all N0 M0

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73
Q

basis of T-stage in thymoma/thymic CA

A

level of invasion
(NO SIZE critera)

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74
Q

thymoma/thymic CA

T1

A

within mediastinum:
encapsulated OR into mediastinal fat ± mediastinal pleura

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75
Q

thymoma/thymic CA

T1a

A

⊖mediastinal pleura invasion
(encapsulated OR into mediastinal fat)

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76
Q

thymoma/thymic CA

T1b

A

⊕mediastinal pleura invasion

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77
Q

thymoma/thymic CA

T2

A

⊕pericardium invasion
(either partial OR full-thickness)

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78
Q

thymoma/thymic CA

T3

A

⊕invasion of readily resectable structures:
- lung
- innominate vein
- SVC
- phrenic
- chest wall
- hilar/extrapericardial pulm vessels (PA or PV)

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79
Q

thymoma/thymic CA

T4

A

⊕invasion of potentially un-resectable structures:
- Ao (asc/arch/desc)
- arch vessels
- intrapericardial PA
- myocardium (heart)
- trachea
- esophagus

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80
Q

thymoma/thymic CA

N0

A

self-explanatory

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81
Q

thymoma/thymic CA

N1

A

anterior/perithymic LNs

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82
Q

thymoma/thymic CA

N2

A

deep intrathoracic or cervical LNs

83
Q

NCCN guideline adjuvant systemic tx indication(s) after resxn of thymoma/thymic CA

A

R>0 (incomplete resxn) only
chemo 1st-line only
R1 thymic CA (RT ± chemo)
R2 thymoma/thymic CA (definitive chemoRT)

84
Q

NCCN guideline 1st-line adjuvant systemic tx regimen for thymoma/thymic CA

A

thymoma = CAP(/CCD)
(platinum-based triplet):
cyclophosphamide + doxorubicin (Adriamycin) + cisplatin (Platinol)

thymic CA = carbo/taxel
(platinum-based doublet):
carboplatin + paclitaxel

85
Q

NCCN guideline 1st-line adjuvant systemic tx regimen for thymoma

A

thymoma = CAP(/CCD)
(platinum-based triplet):
cyclophosphamide + doxorubicin (Adriamycin) + cisplatin (Platinol)

86
Q

NCCN guideline 1st-line adjuvant systemic tx regimen for thymic CA

A

thymic CA = carbo/taxel
(platinum-based doublet):
carboplatin + paclitaxel

87
Q

NCCN guideline 2nd-line adjuvant systemic tx regimen for thymoma/thymic CA

A

thymoma = chemo
e.g. etoposide, everolimus, gemcitabine ± capecitabine

thymic CA = IO/TT/chemo
pembro OR sunitinub or lenvatinib OR gemcitabine ± capecitabine

(basically all same agents except can ONLY use IO/TT in thymic CA)

88
Q

NCCN guideline 2nd-line adjuvant systemic tx regimen for thymoma

A

thymoma = chemo
e.g. etoposide, everolimus, gemcitabine ± capecitabine

(basically all same agents as thymic CA except canNOT use IO/TT in thymoma)

89
Q

NCCN guideline 2nd-line adjuvant systemic tx regimen for thymic CA

A

thymic CA = IO/TT/chemo
pembro OR sunitinub or lenvatinib OR gemcitabine ± capecitabine

(basically all same agents except can ONLY use IO/TT in thymic CA)

90
Q

NCCN guideline neoadjuvant RT indication(s) for thymoma/thymic CA

A

NONE

91
Q

NCCN guideline neoadjuvant systemic tx indication(s) for thymoma/thymic CA

A

borderline resectability

92
Q

NCCN guideline adjuvant RT indication(s) after resxn of thymoma/thymic CA

A

consider in Masaoka>I & give in R>0
- Masaoka II-IV R0: ±RT (“consider”)
- R1: ⊕RT (± chemo for thymic CA)
- R2: ⊕RT (definitive chemoRT)

93
Q

thymoma/thymic CA

M0

A

self-explanatory

94
Q

thymoma/thymic CA

M1

A

pleural/pericardial/distant mets

95
Q

thymoma/thymic CA

M1a

A

pleural or pericardial implants
(separate nodules)

96
Q

thymoma/thymic CA

M1b

A

pulmonary intraparenchymal or distant mets

97
Q

thymoma/thymic CA

IVA v IVB

TNM

A

N1 OR M1a v N2 OR M1b

98
Q

thymoma/thymic CA

I

TNM stage criteria

A

T1N0M0
(within mediastinum)

99
Q

thymoma/thymic CA

II

TNM stage criteria

A

T2N0M0
(into pericardium)

100
Q

thymoma/thymic CA

IIIA

TNM stage criteria

A

T3N0M0
(resectable structures)

101
Q

thymoma/thymic CA

IIIB

TNM stage criteria

A

T4N0M0
(potentially un-resectable structures)

102
Q

thymoma/thymic CA

IVA

TNM stage criteria

A

N1 OR M1a
(anterior/perithymic LNs OR pleural or pericardial implants)

regardless of T

103
Q

thymoma/thymic CA

IVB

TNM stage criteria

A

N2 OR M1b
(deep intrathoracic or cervical LNs OR pulmonary intraparenchymal or distant mets)

regardless of T

104
Q

thymoma/thymic CA

minimum T & overall stage:
within mediastinum:
encapsulated OR into mediastinal fat ± mediastinal pleura

A

thymoma/thymic CA

T1 / I

105
Q

thymoma/thymic CA

minimum T & overall stage:
⊖mediastinal pleura invasion
(encapsulated OR into mediastinal fat)

A

thymoma/thymic CA

T1a / I

106
Q

thymoma/thymic CA

minimum T & overall stage:
⊕mediastinal pleura invasion

A

thymoma/thymic CA

T1b / I

107
Q

thymoma/thymic CA

minimum T & overall stage:
⊕pericardium invasion
(either partial OR full-thickness)

A

thymoma/thymic CA

T2 / II

108
Q

thymoma/thymic CA

minimum T & overall stage:
⊕invasion of:
- lung
- innominate vein
- SVC
- phrenic
- chest wall
- hilar/extrapericardial pulm vessels (PA or PV)

A

thymoma/thymic CA

T3 / IIIA

109
Q

thymoma/thymic CA

minimum T & overall stage:
⊕invasion of:
- Ao (asc/arch/desc)
- arch vessels
- intrapericardial PA
- myocardium (heart)
- trachea
- esophagus

A

thymoma/thymic CA

T4 / IIIB

110
Q

thymoma/thymic CA

minimum N & overall stage:
anterior/perithymic LNs

A

thymoma/thymic CA

N1 / IVA

111
Q

thymoma/thymic CA

minimum N & overall stage:
deep intrathoracic or cervical LNs

A

thymoma/thymic CA

N2 / IVB

112
Q

thymoma/thymic CA

minimum M & overall stage:
pleural or pericardial implants
(separate nodules)

A

thymoma/thymic CA

M1a / IVA

113
Q

thymoma/thymic CA

minimum M & overall stage:
pulmonary intraparenchymal or distant mets

A

thymoma/thymic CA

M1b / IVB

114
Q

thymoma/thymic CA

T1N0M0
(within mediastinum)

A

thymoma/thymic CA

I

115
Q

thymoma/thymic CA

T2N0M0
(into pericardium)

A

thymoma/thymic CA

II

116
Q

thymoma/thymic CA

T3N0M0
(resectable structures)

A

thymoma/thymic CA

IIIA

117
Q

thymoma/thymic CA

T4N0M0
(potentially un-resectable structures)

A

thymoma/thymic CA

IIIB

118
Q

thymoma/thymic CA

N1 OR M1a
(anterior/perithymic LNs OR pleural or pericardial implants)

A

thymoma/thymic CA

IVA

regardless of T

119
Q

thymoma/thymic CA

minimum stage:
N2 OR M1b
(deep intrathoracic or cervical LNs OR pulmonary intraparenchymal or distant mets)

A

thymoma/thymic CA

IVB

regardless of T

120
Q

thymoma/thymic CA

anatomic definition/region of anterior/perithymic (N1) LNs

A

prevascular compartment along thymus + anterior cervical (adjacent to anterior/lateral trachea)

121
Q

thymoma/thymic CA

anatomic definition/region(s) of deep thoracic/cervical (N2) LNs

A

visceral compartment + lateral cervical + mammary

122
Q

10y DFS by WHO classification of thymoma

A

A = medullary, spindle-shaped epithelial cells, ∅/￬TdT+ = 100%
AB = mixed: spindle-shaped epi cells, ￪TdT+ = 100%
B1 = organoid, predom cortical + medullary islands, ￪TdT+, <3 contiguous epi cells = 83%
-————————–
B2 = cortical, ￪epi cells, ￪TdT+ = 83%
B3 = epithelial: sheets of mild-mod atypical epi cells, ∅/￬TdT+, well-diff thymic CA = 35%
C = thymic CA = 28%

TdT+ = immature T cells: ∅/￬=absence/paucity, ￪=abundance;
organoid = thymus-like architecture & cytology

https://drive.google.com/file/d/17c3vabwRLy8AUshgKT1cb4cfTydc5Dfy/view
https://drive.google.com/file/d/17nyEZxdkQS4en_1SyLaWdCqs-z1J6ian/view

123
Q

NCCN guideline postop surveillance after R0 resxn of thymoma/thymic CA

A

thymoma: CT chest Q6mo x2y ￫ Q1Y x7y/til 10y
thymic CA: CT chest Q3-6mo x2y ￫ Q1Y x3y/til 5y

124
Q

NCCN guideline duration of surveillance for thymoma

A

10y (or forever)

125
Q

NCCN guideline duration of surveillance for thymic CA

A

5y

126
Q

NCCN guideline initial/dx w/u for mesothelioma

A
  • pleural bx (VATS preferred; Abrams needle/CNBx acceptable)
  • thoracentesis if ⊕effusion (usu p/w)
  • CT chest with contrast
  • ± soluble mesothelin-related peptide
127
Q

NCCN guideline preop/staging w/u for mesothelioma

A

[dx:
- pleural bx (VATS preferred; Abrams needle/CNBx acceptable)
- thoracentesis if ⊕effusion (usu p/w)
- CT chest with contrast
- ± soluble mesothelin-related peptide]

staging:
CT C/A/P with contrast ￫
cI-IIIA AND epithelioid:
- PFTs incl DLCO
- PET-CT
- invasive mediastinal staging
- V/Q scan if considering EPP (for FEV1>80%)
- cardiac stress test
- ± chest MRI
- ± VATS/lap staging
cIIIB-IV OR sarcomatoid/biphasic:
no further w/u

128
Q

NCCN guideline mgmt of cI-IIIA epithelioid meso

A

systemic tx
OR
obs
OR
trimodality tx
- surgery (PD or EPP)
- chemo with platinum-based doublet: cis/pem (cisplatin>carboplatin + pemetrexed)
- hemithoracic RT:
±pleural IMRT if PD or ⊕RT if EPP
in any order
(but generally RT is last)

129
Q

my NCCN guideline-based mgmt of cI-IIIA epithelioid meso

A

systemic tx
OR
1. induction chemo with platinum-based doublet cis/pem (cisplatin>carboplatin + pemetrexed)
2. re-staging (CT chest wtih contrast ± PET-CT)
3. surgical exploration: resectable ￫ PD
4. ± hemithoracic pleural IMRT

130
Q

NCCN guideline 1st-line induction/adjuvant systemic tx regimen for epithelioid meso

A

platinum-based doublet cis/pem (cisplatin>carboplatin + pemetrexed)

131
Q

NCCN guideline 1st-line definitive systemic tx regimen for epithelioid meso

A
  • platinum-based doublet cis/pem (cisplatin>carboplatin + pemetrexed)
  • cis/pem + bevacizumab
  • nivo+ipi
132
Q

NCCN guideline 1st-line definitive systemic tx regimen for sarcomatoid meso

A
  • nivo+ipi
133
Q

NCCN guideline definition of PD for meso

A

complete removal of the pleura and all gross tumor ± en-bloc resection of pericardium and/or diaphragm with reconstruction
(+ MLND x3+ stations)

134
Q

NCCN guideline definition of EPP for meso

A

en-bloc resection of the pleura, lung, ipsilateral diaphragm, and often pericardium
(+ MLND x3+ stations)

135
Q

NCCN guideline goals of surgery/resectability for meso

A

complete gross cytoreduction of the tumor / “macroscopic complete resection” / removal of ALL visible or palpable tumors
(if can “remove MOST gross dz to help with postop mgmt with minimal impact on morbidity”, can continue)

“The goal of surgery is complete gross cytoreduction of the tumor. The goal of cytoreductive surgery is “macroscopic complete resection”—in other words, removal of ALL visible or palpable tumors. In cases where this is not possible, such as in multiple sites of chest wall invasion, surgery should be aborted. If it is possible to remove most of the gross disease to help with postoperative management, with a minimal impact on morbidity, then surgery should be continued.”

136
Q

contrandications to surgery in meso

A
  • sarcomatoid (or biphasic) histology
  • N2
137
Q

MARS 1 trial

A

???

138
Q

MARS 2 trial

A

???

139
Q

NCCN guideline recommendatoins re: bx for suspected [chest wall] bone CA

A

“Biopsy diagnosis is necessary prior to any surgical procedure or fixation of primary site.”
- “Prior to biopsy, consultation should be obtained with an orthopedic oncologist regarding appropriate prebiopsy imaging.”
- “Biopsy is optimally performed at a center that will do definitive management.”
- “Placement of biopsy is critical.”
- “Biopsy should be core needle or surgical biopsy.”
- “Fresh tissue may be needed for molecular studies and tissue banking.”

140
Q

NCCN guideline 1st-line systemic tx for resectable [chest wall] chondrosarcoma

A

NONE for grade 1-3

141
Q

NCCN guideline 1st-line systemic tx for resectable [chest wall] Ewing sarcoma

A

non-platinum-based triplet
VDC/IE: vincristine + doxorubicin + cyclophosphamide alternating with ifosfamide + etoposide

142
Q

NCCN guideline 1st-line systemic tx for resectable [chest wall] osteosarcoma

A

platinum-based doublet:
- cisplatin + doxorubicin
- MAP = high-dose MTX + doxorubicin (Adriamycin) + cisplatin (Platinol)

143
Q

NCCN guideline 1st-line systemic tx for resectable [chest wall] giant cell tumor

A

denosumab

144
Q

NCCN guideline dx w/u of [chest wall] bone tumors/CA

A
  • <40yo ⇒ “refer to ortho onc”; bx @ tx institution
  • ≥40yo ⇒ w/u as potential met ￫ if no apparent 1°, “refer to ortho onc”; bx @ tx institution
145
Q

NCCN guideline dx w/u of [chest wall] chrondosarcoma

A

NOT SPECIFIED

146
Q

NCCN guideline mgmt of localized resectable [chest wall] chondrosarcoma

A

WLE

147
Q

NCCN guideline mgmt of localized unresectable [chest wall] chondrosarcoma

A

RT

148
Q

NCCN guideline mgmt of metastatic potentially resectable (oligometastatic) [chest wall] chondrosarcoma

A
  • surgery (excision) all sites > RT for unresectable sites
  • ± clinical trial
149
Q

NCCN guideline mgmt of metastatic unresectable [chest wall] chondrosarcoma

A
  • surgery and/or RT and/or ablation for sx sites
  • ± dasatinib/pazopanib
150
Q

NCCN guideline surveillance for resected [chest wall] chondrosarcoma

A

CT chest with contrast Q3-6mo x5y ￫ Q1Y x10y

151
Q

NCCN guideline dx w/u of [chest wall] Ewing sarcoma

A
  • MRI with contrast
  • CT chest with contrast
  • PET-CT
  • cytogenetics/molecular studies
  • LDH
  • ± bone marrow bx
    (re-stage with CT chest non-con ± PET-CT)
152
Q

NCCN guideline mgmt of resectable [chest wall] Ewing sarcoma

A
  1. chemo ≥9w
  2. re-stage with CT chest non-con ± PET-CT, if stable/improved (else pall):
  3. WLE OR definitive chemoRT
  4. if resxn, adjuvant chemo
153
Q

NCCN guideline surveillance for resected [chest wall] Ewing sarcoma

A

CT chest non-con Q2-3mo ± PET-CT Q?? x2y ￫ “￪ interval”?? x3y/til 5y ￫ Q1Y xforever

154
Q

NCCN guideline mgmt of unresectable [chest wall] Ewing sarcoma

A
  1. chemo ≥9w
  2. re-stage with CT chest non-con ± PET-CT
  3. WLE OR RT for local control @ 1° (pall) + more chemo
    OR pall RT for sxs
155
Q

NCCN guideline dx w/u of [chest wall] giant cell tumor

A
  • MRI with & without contrast
  • CT chest
  • ± bone scan
  • bx
    (re-stage with CT chest non-con ± PET-CT)
156
Q

NCCN guideline mgmt of resectable [chest wall] giant cell tumor

A

excision

157
Q

NCCN guideline surveillance for resected [chest wall] giant cell tumor

A

CT chest with contrast Q6-12mo x4y ￫ Q1Y xforever? (“as clinically indicated”)

158
Q

NCCN guideline mgmt of localized borderline/unresectable [chest wall] giant cell tumor

A
  1. denosumab (preferred) and/or serial embo (preferred) and/or RT
  2. re-stage with CT with contrast
  3. resectable: excision (else: surveillance)
159
Q

NCCN guideline mgmt of metastatic potentially resectable (at least the 1°) [chest wall] giant cell tumor

A

same as for localized borderline/unresectable dz:
1. denosumab (preferred) and/or serial embo (preferred) and/or RT
2. re-stage with CT with contrast
3. resectable: excision 1° ± mets (else: surveillance)

160
Q

NCCN guideline mgmt of metastatic unresectable [chest wall] giant cell tumor

A
  • denosumab
  • RT
  • obs
161
Q

NCCN guideline dx w/u of [chest wall] osteosarcoma

A
  • MRI with contrast
  • CT chest with contrast
  • PET-CT
  • LDH, alk phos
    (re-stage with CT chest non-con ± PET-CT)
162
Q

NCCN guideline mgmt of low-grade resectable [chest wall] osteosarcoma

A
  1. WLE
  2. high-grade ⇒ chemo / low-grade ⇒ surveillance
163
Q

NCCN guideline mgmt of periosteal resectable [chest wall] osteosarcoma

A
  1. ± chemo
  2. WLE
  3. high-grade ⇒ chemo / low-grade ⇒ surveillance
164
Q

NCCN guideline mgmt of high-grade resectable [chest wall] osteosarcoma

A
  1. chemo ≥9w
  2. re-stage with CT chest non-con ± PET-CT, if resectable (else RT and/or? chemo):
  3. WLE
  4. tx response: good ⇒ chemo / poor ⇒ chemo (cont preop or change)
165
Q

NCCN guideline mgmt of metastatic potentially/treatable resectable [chest wall] osteosarcoma

A
  1. chemo ≥9w
  2. re-stage with CT chest non-con ± PET-CT, if resectable (else RT and/or? chemo):
  3. WLE + metastasectomy OR SBRT > ablation (if pulm metastasectomy not possible)
  4. tx response: good ⇒ chemo / poor ⇒ chemo (cont preop or change)
166
Q

NCCN guideline surveillance for resected [chest wall] osteosarcoma

A

CT chest non-con ± PET-CT Q3mo x2y ￫ Q4mo x1y/til 3y ￫ Q6mo x2y/til 5y ￫ Q1Y xforever? (“as clinically indicated”

167
Q

NCCN guideline mgmt of unresectable [chest wall] osteosarcoma

A
  • chemo
  • RT
  • re-assess 1° for local control as approp
168
Q

NCCN guideline for [chest wall] bone CA tumor “wide excision”

A

“should achieve histologically negative surgical margins”

169
Q

mesothelioma

T1

A

ipsilateral pleura:
ipsilateral parietal and/or visceral pleura

170
Q

mesothelioma

T2

A

ipsilateral pleura
⊕invasion of ≥1 of:
- diaphragm (muscle)
- pulmonary parenchyma

171
Q

mesothelioma

T3

A

ipsilateral pleura
locally advanced but potentially resectable
⊕invasion of ≥1 of:
- endothoracic fascia
- mediastinal fat
- chest wall ± rib destrxn (solitary/resectable)
- pericardium (non-transmural)

172
Q

mesothelioma

T4

A

ipsilateral pleura
locally advanced & technically un-resectable
⊕invasion of ≥1 of:
- chest wall ± rib destrxn (diffuse or multifocal/unresectable)
- peritoneum (direct transdiaphragm extension)
- contralateral pleura
- mediastinal organs (esophagus, trachea, heart, great vessels)
- spine (vertebra/neural foramen/spinal cord)
- brachial plexus
- pericardium (transmural ± pericardial effusion) ± myocardium

173
Q

mesothelioma

N0

A

self-explanatory

174
Q

mesothelioma

N1

A

ipsilateral intrathoracic LNs
incl ipsi levels 2-14, peridiaphragm, pericardial, intercostal, internal mammary

7 counts as ipsi

incl bronchopulmonary, hilar, subcarinal, paratracheal, aortopulmonary, paraesophageal, peridiaphragmatic, pericardial, intercostal, internal mammary

175
Q

mesothelioma

N2

A

ipsilateral supraclavicular LNs and/or
contralateral intrathoracic LNs

incl contralat supraclav

176
Q

mesothelioma

M0

A

self-explanatory

177
Q

mesothelioma

M1

A

distant mets

178
Q

mesothelioma

IA v IB

A

T1 v T2-3
(all N0M0)

179
Q

mesothelioma

IIIA v IIIB

A

T3N1 v T4 OR N2

180
Q

mesothelioma

IA

A

T1N0M0
(ipsi pleura)

181
Q

mesothelioma

IB

A

T2-3N0M0
(diaphragm/pulm parenchyma - locally adv resectable)

182
Q

mesothelioma

I

A

localized, resectable, N0
- IA: **T1**N0M0
(ipsi pleura)
- IB: **T2-3**N0M0
(diaphragm/pulm parenchyma - locally adv resectable)

183
Q

mesothelioma

II

A

T1-2N1M0
(ipsi pleura - diaphragm/pulm parenchyma + ipsi intrathoracic LNs)

184
Q

mesothelioma

IIIA

A

T3N1M0
(resectable + N1)

185
Q

mesothelioma

IIIB

A

T4NanyM0 OR T1-3N2M0
(unresectable)

186
Q

mesothelioma

III

A

borderline/poorly resectable d/t N1 OR unresectable d/t N2 OR invasion, M0
- IIIA: **T3N1**M0
(resectable + N1)
- IIIB: **T4**NanyM0 OR T1-3N2M0
(unresectable)

regardless of T

187
Q

mesothelioma

IV

A

M1

regardless of T

188
Q

basis of T-stage in mesothelioma

A

level/extent of invasion
(NO SIZE critera)

189
Q

mesothelioma

minimum T-stage:
invades ipsilateral parietal and/or visceral pleura

A

mesothelioma

T1

190
Q

mesothelioma

minimum T-stage:
ipsilateral pleura + invades
- diaphragm (muscle)
- pulmonary parenchyma

A

mesothelioma

T2

191
Q

mesothelioma

ipsilateral pleura
locally advanced but potentially resectable
⊕invasion of ≥1 of:
- endothoracic fascia
- mediastinal fat
- chest wall ± rib destrxn (solitary/resectable)
- pericardium (non-transmural)

A

mesothelioma

T3

192
Q

mesothelioma

ipsilateral pleura
locally advanced & technically un-resectable
⊕invasion of ≥1 of:
- chest wall ± rib destrxn (diffuse or multifocal/unresectable)
- peritoneum (direct transdiaphragm extension)
- contralateral pleura
- mediastinal organs (esophagus, trachea, heart, great vessels)
- spine (vertebra/neural foramen/spinal cord)
- brachial plexus
- pericardium (transmural ± pericardial effusion) ± myocardium

A

mesothelioma

T4

193
Q

mesothelioma

ipsilateral intrathoracic LNs
incl ipsi levels 2-14, peridiaphragm, pericardial, intercostal, internal mammary

7 counts as ipsi

incl bronchopulmonary, hilar, subcarinal, paratracheal, aortopulmonary, paraesophageal, peridiaphragmatic, pericardial, intercostal, internal mammary

A

mesothelioma

N1

194
Q

mesothelioma

ipsilateral supraclavicular LNs and/or
contralateral intrathoracic LNs

incl contralat supraclav

A

mesothelioma

N2

195
Q

mesothelioma

distant mets

A

mesothelioma

M1

196
Q

mesothelioma

T1N0M0
(ipsi pleura)

A

mesothelioma

IA

197
Q

mesothelioma

T2-3N0M0
(diaphragm/pulm parenchyma - locally adv resectable)

A

mesothelioma

IB

198
Q

mesothelioma

localized, resectable, N0
- IA: **T1**N0M0
(ipsi pleura)
- IB: **T2-3**N0M0
(diaphragm/pulm parenchyma - locally adv resectable)

A

mesothelioma

I

199
Q

mesothelioma

T1-2N1M0
(ipsi pleura - diaphragm/pulm parenchyma + ipsi intrathoracic LNs)

A

mesothelioma

II

200
Q

mesothelioma

T3N1M0
(resectable + N1)

A

mesothelioma

IIIA

201
Q

mesothelioma

T4NanyM0 OR T1-3N2M0
(unresectable)

A

mesothelioma

IIIB

202
Q

mesothelioma

borderline/poorly resectable d/t N1 OR unresectable d/t N2 OR invasion, M0
- IIIA: **T3N1**M0
(resectable + N1)
- IIIB: **T4**NanyM0 OR T1-3N2M0
(unresectable)

regardless of T

A

mesothelioma

III

203
Q

mesothelioma

M1

regardless of T

A

mesothelioma

IV

204
Q

required labs as part of w/u of middle or posterior mediastinal mass along the vertebra

A

plasma ± urine catecholamines/metanephrines
± MIBG scan
± preop embo
(c/f paraganglionoma, which can be hormonally active & highly vascular)

oral boards (15 decks)

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