Oral Boards Flashcards
GBM: RT fields and dose
CTV 46Gy - T2 + 2cm
CTV 60Gy - T1 post / cavity + 2cm
GBM: temozolomide dosing during/after RT
during RT: 75mg/m2 daily
after RT: 150-200mg/m2 days 1-5 on q28day cycle for 6 months
GBM: max dose constraints for chiasm, brainstem, optic nerves, retina, and lenses
chiasm 55Gy brainstem 60Gy optic nerves 55Gy retina 50Gy lenses 7Gy
GBM: follow up
MRI one month after RT then ever 3 months thereafter
GBM: simulation
supine, mask, fuse preop and postop MRIs
GBM: RT options for elderly or poor KPS
Roa - 40Gy/15fxs, age > 60 and KPS > 50
Bauman - 30Gy/10fxs, age > 65 and KPS < 50
(French trial showed improved MS with RT compared to observation)
WHO 3 glioma: RT fields and dose
CTV 5940 - GTV/cavity + T2 flair + 2cm
WHO 3 glioma: chemotherapy
PCV: procarbazine, lomustine, vincristine
given either before or after course of RT, possibly omit if 1p 19q codeletion is present
WHO 3 glioma: max dose constraints for chiasm, brainstem, optic nerves, retina, and lenses
chiasm 55Gy brainstem 60Gy optic nerves 55Gy retina 36Gy lenses 5Gy
WHO 3 glioma: follow up
MRI one month after RT then ever 3 months thereafter
WHO 2 glioma: RT fields and dose
CTV 54Gy - GTV / T2 FLAIR + 2cm
Anal T2N0: RT fields and dose
CTV 42 - primary site, mesorectum, presacral, inguinal, external iliac, internal iliac
CTV 50.4 - GTV + anal canal + 2.5cm
PTV - 1cm margin
Anal T3-4N0: RT fields and dose
CTV 45 - primary site, mesorectum, presacral, inguinal, external iliac, internal iliac
CTV 54 - GTV + anal canal + 2.5cm (consider 60Gy if T4)
PTV - 1cm margin
Anal N+: doses
45Gy to elective nodal regions
50.4Gy to nodal regions with nodes <3cm
54Gy to primary and nodal regions with nodes >3cm
Anal: chemotherapy
two cycles at a 4 week interval:
5FU 1000mg/m2 daily x 4 days
mitomycin 10mg/m2 x 1 day
Anal: workup
H&P: LN eval, DRE, anal sphincter tone, sexual history, HIV, HPV, IBD history, Gyn exam
Labs: CBC, HIV if risk factors
Proctoscopy with bx. FNA of inguinal nodes. MRI or EUS.
CT/MRI of A/P. CXR or CT chest
Rectal: criteria for WLE
T1, <3 cm, <30% circumference, margins >3mm, within 8 cm of anal verge, grade 1-2, no LVSI/PNI
Rectal: RT fields and dose (T3-4 or N+)
CTV 45 - mesorectum, presacrals, internal iliacs, obturators
CTV 50.4 - tumor/mesorectum + 2cm sup/inf
Rectal: 2D fields
AP: L5/S1 down to bottom of obturator foramen or 3 cm below tumor, whichever is more inferior (anal verge for tumors close to anal verge), lat 2 cm on pelvic brim
lat: want ant behind pubic symphysis and 3cm in front of sacral promontory, post 1cm behind sacrum
If T4 with anterior structure invasion - move ant border in front of sacrum
Rectal: chemotherapy
preop with concurrent capecitabine 825mg bid M-F
adjuvant treatment for T3/4 or N+ is FOLFOX x 6 months
what are the components of FOLFOX
leucovorin (FOLinic acid)
5FU
Oxaliplatin
what are the treatment options for early stage esophageal cancer (Tis, T1a, T1b, T2)?
Tis/T1a - endoscopic resection + ablation
T1b - esophagectomy
T2 - esophagectomy alone if noncervical, <2cm, well differentiated
definition of anal margin
area below anal verge encompassing 6cm of skin around anus, consists of keratinizing epithelum
definition of anal verge
area near end of anus where nonkeratinizing epithelium becomes keratinizing epithelium
anal cancer target coverage
primary PTV: 90/100
nodal ptv: 85/100
max dose 115%
anal cancer constraints for small bowel, bladder, and femoral heads
small bowel: V45 < 20cc, Dmax 50Gy
bladder: V50 < 5%
femoral heads: V44 < 5%
rectal cancer constraints for small bowel, and bladder
small bowel: V45 < 35cc, Dmax 50Gy
bladder: mean < 40Gy
rectal cancer pCR rate
15-20%
treatment paradigm for T1-2 rectal cancer not meeting criteria for WLE
surgical resection (APR/LAR with TME) give adjuvant CRT for pT3-4 or N+
concurrent chemo for esophageal cancer
weekly taxol 50 and carbo AUC 2
esophageal cancer OAR constraints per RTOG 1010 (lung and heart)
lung V5 < 50, V20 < 25
heart V40 < 50, mean < 30
what nodes are treated for T3N0 gastric cancer
perigastric nodes
what nodes are treated for N+ gastric cancer arising from proximal 1/3 (cardia)?
perigastric, celiac/PA, splenic, suprapancreatic
what nodes are treated for N+ gastric cancer arising from middle 1/3 (body)?
perigastric, celiac, splenic, suprapancreatic, pancreatoduodenal, porta hepatic
what nodes are treated for N+ gastric cancer arising from the distal 1/3 (antrum/pylorus)?
perigastric, celiac, suprapancreatic, pancreatoduodenal, porta hepatic
AP/PA field borders for gastric cancer
superior: top of T9
inferior: bottom of L3
left lateral: include two thirds of left hemidiaphragm
right lateral: 4cm lateral to vertebral bodies
lateral field borders for gastric cancer (if using 4 field)
superior: top of T9
inferior: bottom of L3
anterior: abdominal wall
posterior: half of vertebral bodies
concurrent chemo dose for adjuvant gastric cancer
capecitabine 825mg BID
gastric cancer OAR constraints (small bowel, liver, kidney)
small bowel: max < 54Gy
liver: V30 < 60%
kidney: one kidney with V20 < 33%
“three phase contrast narrative” for pancreatic cancer
Inject 120-150 mL contrast. Noncontrast phase: Will show calcifications that could otherwise be confused with contrast
1) Early arterial phase, 20 sec. Will show arterial anatomy
2) late arterial/early portal phase. Scan delay of 35-50 seconds. Optimal attenuation between enhancing parenchyma and tumor in this phase.
3) Late portal, venous phase: scan delay of 70-80 seconds. Shows lymph nodes, liver mets, peritoneal implants
criteria for very low risk prostate cancer
GS 6 in 1-2 cores, <50% of core,
contraindications to prostate brachy
AUA score > 12, size >60cc or <30cc, prior TURP, large median lobe, prior RT, inflammatory bowel disease
prostate brachy dose, energy, half-life for I-125 and Pd-103
I-125: 144Gy, 0.028MeV, 60 days
Pd-103: 125Gy, 0.021MeV, 17 days
dosimetric criteria for prostate brachy with modified peripheral loading (D90, V100, V150, V200, urethral Dmax, urethral Dmax, rectal D2cc)
D90 > 90% (goal of 130%) V100 > 98% V150 < 40% V200 < 10% urethral Dmax < 120 rectal D2cc < 100%
treatment options for stage I seminoma
OBSERVATION (preferred)
carbo AUC 7 x 1 cycle
RT
stage I seminoma dose and field (if forced to treat)
20Gy/10fxs
superior: top of T12
inferior: bottom of L5
lateral: transverse processes
management of stage IIA, IIB, and IIC seminoma
IIA - RT
IIB - cisplatin/etoposide x 4 cycles (preferred), RT also an option
IIIC - BEP chemotherapy, no RT
stage IIA/B seminoma dose(s) and field
20Gy/10fxs with 10Gy boost to IIA nodes (<2cm) or 16Gy boost to IIB nodes (2-5cm)
field is modified dog leg
superior: top of T12
inferior: top of acetabulum
seminoma kidney constraints
single kidney D50 < 8Gy
bilateral kidney mean dose < 9Gy
criteria for bladder preservation
T2-T4a, no hydronephrosis, no extensive CIS, able to undergo maximal TURBT
Sedlis criteria for postop cervix
need two:
LVSI
size > 4cm
stromal invasion > 2/3
Peters criteria for postop cervix
positive nodes, positive margins, parametrial invasion
components of radical hysterectomy
mobilization of ureters, bladder, and rectum , dissect parametria out to pelvic sidewall, remove upper half of vagina
postop cervix dose and fields
45Gy/25fxs EBRT + vaginal cuff HDR 5Gy x 2 to surface
field: L4/5 to bottom of obturator foramen, 2cm on pelvic brim, anterior border in front of pubic symphysis, posterior covers entire sacrum
definitive cervix dose and fields
45 Gy in 25 fx with 4-field, inf at least 3 cm below disease or upper 2/3 vag, as well as HDR with tandem and ovoids with a dose of 6 Gy x 5 (5x6 Gy for EQD2 of 84) = 80-90 Gy to Point A. Treatments delivered 1-2 times per week Rx to point A. Boost gross nodes to 60 Gy.
definitive cervix whole pelvic fields
L4/L5 to bottom of obturator foramen or 3 cm from lowest vaginal involvment, 2 cm on pelvic brim, ant is in front of pubic symphysis, post covers whole sacrum with extra 1 cm to cover uterosacral ligaments
definitive cervix fields for positive PA nodes
PA nodes: If node positive, include periaortic node chain up to T11/T12. In current 0724 protocol, if common iliac nodes are positive then PA nodes are treated up to L1/L2. If PA nodes are positive, treated up to T11/T12.
tandem and ovoid OAR constraints for bladder, rectum, and sigmoid (45Gy/25 EBRT + 30Gy/5fx HDR)
bladder: 90Gy EQD2, 9Gy per fx
rectum: 75Gy EQD2, 6Gy per fx
sigmoid: 75Gy EQD2, 6Gy per fx
inoperable endometrial cancer staging
Stage IA <8 cm uterine cavity sound Stage IB >8 cm Stage II involves corpus and cervix Stage III parametrium, vagina, adnexa Stage IV A local structures B metastatic
describe tandem and ovoid procedure
I would take the patient to the OR place them in the dorsal lithotomy position and administer general anesthesia. I’d perform and EUA to assess response. After prepping the patient with betadine, a gold seed would be placed at the anterior cervix. A foley catheter would then be inserted to drain the bladder and the foley bulb inflated with 7cc half saline half contrast. I would inject 200 mL of saline into the bladder and clamp the foley. The uterus would be sounded to assess distance to the fundus and flexion, and the appropriate tandem inserted with the largest ovoids that could be accommodated. Packing would be placed anteriorly and posteriorly to the device with gauze soaked with contrast and clindamycin ointment to pack away from the bladder and rectum. I would then take AP and lateral orthogonal films to ensure adequate positioning and packing.
