Procedures Flashcards
1
Q
mammary glands are composed of
A
glandular tissue, subcutaneos fat, fibrous stroma
2
Q
mammary glands are supported by
A
deep fascia overlying the pectoral muscle (pectoralis major and minor)
3
Q
the protuberant portion of the adult breast is located
A
between the 2nd and 6th ribs in the sagittal plane and extends from the sternochondral junctions to the midaxillary line in the axial plane
4
Q
2/3 of the breast rest on
A
the deep pectoral fascia that overlies the pectoralis major
5
Q
1/3 of the breast rests on
A
fascia that covers the serratus anterior
6
Q
the suspensory ligaments of cooper runs from the
A
pectoral fascia and branch out through and around breast tissue to connect to the skin overlying the breast (
7
Q
what supports the breast and helps it maintain its shape
A
suspensory ligament of cooper
8
Q
breast paraenchyma consists of
A
15-20 sections or lobes that are embedded in adipose tissue
9
Q
what type of breast cancer originates in the lactiferous ducts
A
ductal carcinoma
10
Q
type of breast cancer that originates from the lobules of the breast
A
lobular carcinoma
11
Q
conical prominence in the center of the areola that is composed mostly of smooth muscle fibers that compress the lactiferous ducts
A
nipple
12
Q
the breast does not contain
A
fat, hair, or sweat glands
13
Q
in young nulliparous women the nipple is usually located
A
at the level of the 4th intercostal spaces
14
Q
the areola contains
A
numerous subaceous glands
15
Q
arterial supply of the breast is derived from
A
the medial mammary branches and anterior intercostal branches of the intermal mammary artery medially AND the lateral thoracic and thoracoacromial artery branches of the axillary artery and the posterior intercostal arteries laterally
16
Q
venous drainage of the breast is mainly
A
to the axillary vein through the lateral thoracic and lateral mammary veins
17
Q
Medially, the internal mammary vein is responsible for
A
venous drainage through its perforating branches
18
Q
the nerves of the breast derive from the
A
anterior and lateral cutaneous branches of the fourth through sixth intercostal nerves
19
Q
intramammary lymph nodes are located
A
within the breast parenchyma (although they can be involved with metastasis, they are not part of the nodal staging)
20
Q
to describe the extent of lymph node metastasis in breast cancer
A
number and location of the regional lymph nodes involved are considered (axillary, supraclavicular/infraclavicular, internal mammary)
21
Q
primary deep lymphatic drainage of the breast occur to the
A
ipsilateral axilla
22
Q
how many nodes are in each axilla
A
10-38
23
Q
level I lymph nodes of the axilla are located
A
in the caudal and lateral of the pectoralis minor and are the most superficial node in the axilla (often first station of drainage from breast)
24
Q
level II lymph nodes in axilla
A
located beneath the muscle
25
level III lymph nodes in the axilla
infraclavicular lymph nodes, located cranial and medial to the pectoralis minor
26
order of spread of tumor cells for breast cancer
from level I to III is common but skip metastasis can occur rarely
27
internal mammary lymph nodes are located
in the parasternal space, embedded in fat in the intercostal spaces, and run alongside the corresponding artery and vein.
28
most mammary nodes are
in the first, second, and third intercostal spaces
29
inner quadrant tumors have a higher risk of
internal mammary lymph node involvement, 30% of patients have drainage localized to these nodes
30
supraclavicular lymph nodes are located within the
supraclavicular fossa
31
supraclavicular fossa
a space defined by the omohyoid muscle and tendon laterally and superiorly, the internal jugular vein medially, and the clavicle and subclavian vein inferiorly
32
supraclavicular lymph nodes provide drainage to
internal mamary nodes, axillary lymph node chain, small number of breast tumors (centrally located)
33
21% of all breast cancers
DCIS
34
5 subtypes of DCIS
1) comedo type-characterized by prominent necrosis in the centerof the involved spaces
2) cribroform type-characterized by formation of back to back glands without intervening stroma
3) micropapillary type and 4) papillary type-both show projection of tumor cells into the lumen
5) solid type-shows no significant necrosis, gland formation, or projections of tumor cells
35
estrogen receptor positivity is associated ith
90% of low- grade DCIS and 25% of high-grade DCIS
36
most common invasive cancer
invasive ductal carcinoma (accounts for 70%-80% of invasive lesions and 50% of invasive ductal carcinomas include a DCIS component
37
second most invasive breast cancer
invasive lobular carcinoma (5%-10% of all invasive lesions)
38
invasive lobular carcinoma originates?
from the glands, or lobules of the breast
39
under a microscope invasive lobular carcinoma cells are characterized by
small cells that infiltrate the surrounding tissues ina single file pattern, often growing in a target like configuration around the healthy breast ducts
40
invasive lobular carcinoma have a higher frequency of
bilateral breast involvement compared to invasive-DCIS
41
how is breast cancer staged
TNM
42
for clinical T stage in breast cancer
the larger the tumor is the higher the T stage
43
for breast cancer with tumor extention into the chest wall or skin it would be classified as
t$
44
what has the highest T staging classification of breast cancer
t4d (inflammatory cancer)
45
clinical N stage is based off of
location and extent of regional lymph node involvement (involvement of the typical first drainage station lymph node is a lower N stage ) ex: axillary lymph node is N1
46
T1 breast
20mm or less in size
47
T2 breast
20mm-50mm in size
48
T3 breast
more than 55mm in size
49
T4 breast
tumor of any size without direct extention to the chest wall or to the skin
50
receives 85% of drainage from breast
axillary node
51
procedure where injection of radioactive colloid or blue dye is injected into the breast tissue in the vicinity of the tumor. tracers then enter the lymphatic channel and flow to the lymph nodes that are first in line to receive the drainage from the tumor. lymph nodes are then identified and removed
sentinel lymph node biopsy
52
in patients with mets involving 3 or more sentinel lymph nodes what is recommended
axillary dissection
53
neoadjuvant therapy
systemic therapy given before surgery
54
most patients with locally advanced breast cancer receive
neoadjuvant therapy
55
side effects of breast RT
skin changes, fatigue, lymphedema, fibrosis, cardiotoxicity, pneumonitis
56
most common cancer in US and cause
lung; smoking
57
lung cancers spread via
local extention to other parts of the lung, and the ribs, heart, and other structures
58
lung cancers classified as
small cell and non-small cell carcinomas (small cell more likely to met early
59
usual tx for lung cancer
RT combied with chemo or surgery
60
what is used to define the extent of non-small cell carcinomas
PET & CT
61
death rate of lung cancer
4.5x greater for males
62
respiratory system includes the
nose, pharynx, larynx, trachea, and both lungs
63
name of where the trachea divides into 2 branches and location
carina; T5
64
hilium
area of the lung where the blood, lymphatic vessels, and nerves enter and exit each lung
65
mediastinum
anatomy between the lungs including the heart, thymas, great vessels, and other structures that help positionthe lung on either side of the midline
66
one of the principal routes of regional spread in lung cancer
lymphatic
67
the superior mediastinal nodes include
upper paratracheal, lower paratracheal, and tracheobronchial angle nodes
68
inferior mediastinal nodes include
subcarinal, paraesophageal and pulmonar ligament nodes
69
most common form of lung cancer in north america
adenocarcinoma; more common in women and arise in the bronchioles or alveoli
70
lung cancer thats prone to early spread, and 3 year survival is 10-15%
SCLC
71
lung caner with 15-20% 5 year survival
NSCLC
72
how is lung cancer staged
TNM
73
tumors of the lung are more likely to extend to
other parts of the lung, ribs, heart, esophagus, and vertebral column
74
tumors of the lung that are not encapsulated have the ability
to invade and attach themselves to local tructures such as the chest wall, diaphragm, pleura, paricardium
75
lung cancer direct extention can occur through
visceral pleura into the pleural cavity
76
a tumor at the midline of the lung can grow
directly into the hilum of the other lung
77
primary lymphatics that drain the lungs
mediastinal and intrapulmonic channels
78
the thoracic duct drains
the left side of the body
79
commons site of mets for lung tumors
cervical lymph node, liver, brain, bones, adrenal glands, kidneys, and contralateral lung
80
critical structures of concern when treating lung cancer
spinal cord, esophagus, heart, and the healthy ung
81
spinal cord tolerance
4500-5500 cgy
82
pneumonitis occurs
1-3 mos following tx
83
fibrosis occurs
2-4 mos following tx
84
other strutures included in the lung field that arent as critical
esophagus, bone marrow, skin, and sometimes liver with right lower lobe tumors
85
simplest field when treating lung cancer that included primary tumor volume and adjacent mediastinum
anterior posterior parallel opposed mediastinal fields
86
used to deliver high dose to a small volume
boost field
87
dose for definitive tx of SCLC
4500-6000 cGy a 180-200 cGy per fraction
88
dose for definitive tx of NSCLC
6000-6600 cGy at 180-200 cGy daily dose fractions
89
initial field arrangement dose for lung
4000-4500 cGy
90
conventional fractionation uses
180 cGy-200 cGy dose given once per day
91
what part of the lung are primary SCC usually found
centrally
92
the incidence of distant mets is greatest with tumors of
the nasopharynx and hypopharynx
93
most common site of distant mets in H&N cancer?
lungs
94
most common part of the aerodigestive tract affected
oral cavity, phayrnx, paranasal sinuses, larynx, thyroid gland, and salivary gland
95
etiologic risks for h&n cancer
tobacco and alcohol use, ultraviolet light, viral infection, environmental exposure
96
3 divisions of the pharynx
nasopharynx, oropharynx, and laryngopharynx
97
how do you stage and classify H&N cancer?
based on involvement of subsites
98
respiratory tubes
nasopharynx
99
digestive tubes
oropharynx and hypopharynx
100
location of cervical vertebral body
first cervical vertebra- C1- lies at the inferior margin of the nasopharynx, whereas C2-C3 contain the oropharynx.
The epiglottis is in line wih C3, whereas the true vocal cord lie opposite C4
101
cranial Nerve I
olfactory-smell
102
cranial Nerve II
optic-site
103
cranial nerve III
oculomotor-eye movement (up and down)
104
cranial nerve IV
trochlear-eye movement (side to side)
105
cranial nerve V
trigeminal-sensory (facial) and motor (jaw)
106
cranial nerve VI
abducens-eye movement (lateral)
107
cranial nerve VII
facial (masticator)- expressions, muscle contractions, and mouthing
108
cranial nerve VIII
acoustic-hearing
109
cranial nerve IX
glossopharyngeal- tongue and throat movement
110
crania nerve x
vagus-talking and sound
111
crania nerve xi
spinal accessory-movement of shoulders and head
112
cranial nerve XII
hypoglossal-movement of tongue and chewing
113
most H&N tumors are
infiltrating lesions in the EPITHELIAL lining
114
endophytic tumors
more aggressing h&n and spread and harder to control locally
115
exophytic tumors
noninvasive neopplasms characterized by raised, elevated borders with 60% of patients reporting otalgia (ear pain)
116
nearly 1/3 of the bodies lymph nodes are located
in the H&N
117
lymph drainage in H&N
mainly ipsilateral but
| soft palate, tonsils, base of tongue, posterior phayngeal wall, and especially nasopharynx drain bilerally
118
jugolodigastric lymph node also called
subdigastic node
119
node of Rouviere also called
lateral retropharyngeal node
120
spinal accessory node also called
posterior cervical lymph node chain
121
mastoid node is also called
retroauricular node
122
more than 80% of H&N cancers arrise from
the surface of the epithelium of the mucousal linings of the upper digestive tract (mostly SCC)
123
SCC in H&N are often seen in the
lymphoepithelial, spingle cell carcinoma, and undifferentated carcinoma
124
lymphoepithelioma occurs in places of
abundance lymphoid tissue ( i.e. nasopharynx, tonsil, and base of tongue) **patients w this type have better cure rate than SCC**
125
to a lesser extent in H&N adenocarcinomas are found
in the salivary glands
126
staging for H&N is based on
manual for staging cancer by the AJCC.
127
for H&N the inferior cervical node are positive in
6%-23% of cases
128
75 % of all H&N cancers recur
locally or regionally abov the clavicle
129
oral cavity tumor symptom
swelling or ulcer that doesnt heal
130
oropharnx tumor symptom
painful swallowing ad referred otalgia. pain in the ear originating from somewhere else
131
nasopharyn tumor symptom
bloody discharge, difficulty hearing
132
hypopharynx tumor symptom
dysphagia, painful neck node
133
larynx tumor symphtom
hoarseness
134
nose/sinus tumor sympyom
obstruction, discharge, facial pain, diplopia (double vision), local swelling
135
SCC of neck tx
200 cgy per day 5x/week usually 6.5-7.5 weeks
136
histopath of oral tongue cancer
90-95% SCC either well differentiated or moderatelly well differentiated
137
oral cavity cancer metastatic behaviorq
cervical lymph node involvement is rare
lowest incidence (except glottic) of nodal mets in H&N region
less than 20% bloodborne spread
138
tx dose oral cavity cancer
IMRT-all gross disease 70 Gy (7000 cGY)
| with a 0-5mm expansion for PTV
139
the lymphatic of the upper lip drain into
the submandubular and preauricular nodal beds
140
lymphatics from the mid-lower lip and anterior floor of mouth drain into
submental nodal group
141
lymphatics from the oral tongue drain into
anterior cervical chin
142
lip cancers are treated the same as
the skin (less than 2cm 200-300 cgy/day X 4-6 weeks.....larger tmors 5000-6000cgy)
143
triangular space behind the last molar tooth
retromolar trigone (carcinomas are rare here)
144
3 part of the pharynx
oropharynx, nasopharynx, and hypopharynx (A.K.A laryngopharynx.
145
location of nasopharynx
located behind the nose and extending from the posterior nares to the level of the soft palate
146
oropharynx location
behind the mouth from the soft palate above to the level of the hyoid bone below
147
larygopharynx/hypopharynx
extends from the hyoid bone to its termination in the esophagus
148
clinical presentation pharynx cancer
persistent sore throat painful swallowing, referred otalgia. often enlarged cervical nodes are present.
for advanced disease- fetororis, dyspnea, dysphagia, hoarseness, dysarthria, nd hypersalvation
149
histopath of pharynx cancer
90% SCC
150
pharynx cancer mets behavior
with oropharyngeal carcinoma-cervical lymph node involvement is common
151
hypopharynx is composed of
pyriform sinus, postcricoid and lower posteriorpharyngeal walls below base of tongue. anatomically located between the vertebral bodies C3 and C6. the cricoid cartilage represents the inferior border, and the epiglottis is the superior border.
152
site of highest incidence of hypopharyngeal cancer
pyriform sinus (highest rate of nodal mets in pyriform sinus tumor-70-75%)
153
nasopharynx region includes
posteriosuperior pharyngeal wall, lateral pharyngeal wall, eustacian tube orfice, and adenoids
154
nasopharynx structure
cuboidal structure that lies on a line from the zygomatic arch to the external auditory meatus. lies behind the nasal cavities and above the level of the soft palate
155
larynx location
extends from the tip of the epiglottis at the level of the lower border of the C3 vertebra to the lower border of the cricoid cartilege at the level of the C6 vertebra.
156
larynx is subdivided into 3 sites
the glottis, supraglottis and subglottis
157
glottic cancer accounts for roughly
65% of larynx cancer
158
30% of glottic cancer site
supraglottic region
159
5% of glottic cancer site
subglottic
160
most common cancer of the upper aerodigestive tract
larynx
161
spinal cord location
starts in the brain (medulla) and ends approx. L1-L2 in adults (does not extend the entire length of the spinal column)
162
cauda equina loc
starts at approx L1 and ends at the coccyx
163
most spinal cord tumors originate
outside the dura mater (extra dural) and are metastatic
164
primary spinal tumors
intra sural spine tumors (rare)
165
cerebrum function
interpretation of sensory impulses and voluntary muscular activities (center for memory, learning, reasoning, judgement, intelligence, and emotions
166
cerebellum
part of the brain that plays a role in the coordination of voluntary muscular movement
167
20-40% of people with cancer eventually have
brain mets
168
most common primary brain tumor
gliomas which include 2 most common types of tumor-astrocytoma nd gliobasloma multiforme
169
astrocytoma
most common type of brain tumor in children, originated in the brain tem, cerebellum, white matter of the cerebrum, or spinal cord
170
glioblastoma multiforme (GBM)
most common type of brain tumor in adults, originates in the glial cells in the cerebrum. HIGH GRADE TUMOR WITH POOR PROGNOSIS
171
brainstem glioma
originates in the medulla, pons, or midbrain. diffucult to biopsy due to location. overall bad prognosis
172
schwannoma
originates in the Schwann cell which surrounds the cranial nerves or other nerves responsible for hearing and balance. usually benign
173
ependymoma
originates in the ependymal cells which line the ventricles. may block the exit of cerebrospinal fluid causing the ventricles to enlarge. avg age 21 y.o
174
medulloblastoma
2nd most common type of brain tumor in children. originates in the 4th cerebral ventricle an the cerebellum. often invades the meninges
175
oligodendrolioma
originates in the brain cells called oligodendrocyetes. benign, slow growing tumors. usually occur in the frontal lobe
176
secondary (metastatic) brain tumors
more common than primary brain tumors
177
in adults most common cancers that spread to brain are
lung, breast, melanomas, and G.I
178
route of spread for primary tumors of the CNS
rarely spread outside CNS. they can spread via local invasion and CSF seeding
179
wilms tumor
nephroblastoma (lungs most common site of mets)
180
most common renal tumor in children, usually occurs between 2-5 years old
wilms tumor
181
outer cover that protects the brain
cranial bone, meninges, CSF
182
a fold of dura matter that is the outer covering of the brain
tentorium
183
where does the blood supply to the brain come from?
internal carotid arteries and vertebral arteries via the circle of Willis
184
how do gliomas spread
invasively because they do not form a natural capsule that inhibits growth. they rarely met outside of the CNS; expand through local invasion
185
common route of spread for medulloblastoma and primitive neuroectodermal tumors (PNET)
seeding via CSF into spinal and intracranial subarachnoid spaces
186
screening tests for CNS tumor?
none, must show symptoms first`
187
PET (positron emission tomography) is a beneficial took that ay be useful in determining what?
necrosis and malignancy, which are associated with areas of high metabolism
188
intracranial tumors are considered
locally malignant based on the limited space for expansion in the cranium
189
most importan prognostic factor for CNS tumor
histopathology diagnosis; benign lesions have a better progosis
190
what approach is used to treat the whole brain for palliative reasons
lateral port fields; inferior margins of the field may intersect the superior orbital ridge and external auditory meatus.
191
most complex CNS tx
craniospinal axis- radiation needs to encompass the entire brain and spinal cord simultaneously (most common tx for medulloblastoma)
192
GTV
gross tumor volume-gross tumor seen on the MRI, CT, or other imaging study
193
CTV
clinical tumor volume-central nervous system tissue with suspected microscopic tumor- usually extends 1-3 CM beyond GTV
194
PTV
planning target volume-margin beyond GTV & CTVand account for factors such as internal organ motion, setup variation, and patient movement. USUALLY CONTAINT AND EXTENDS 0.5-1 CM BEYOND GTV AND CTV
195
TV
TREATMENT VOLUME- volume enclosed by the desired prescription isodose line (usually greater than 95%); this contains GTV, CTV, and PTV)
196
IR
irradiate volume- tissue volume that receives a significant dose of radiation and contains the GTV, CTV, and PTV
197
PRV
planning risk volume for OAR(organs at risk)
198
when treating cranium temporary hair loss occurs with doses ranging from
2000-4000cGy
199
permanent hair loss can occur with doses higher than
4000cGy
200
whole brain tolerance dose
4500-500 cGy
201
partial brain tolerance dose
6000 cGy
202
spinal cord tolerance dose
4500-5000 Cgy
203
what isotope is mostly used or brachytherapy
I-125
204
SRS is used with
isolated CNS tumors and solitary brain mets
205
set up for SRS
pt. positioned in a Halo device to immoblize them. TV is spherical and only up to 3 CM at max dimenson. Gives a high (necrosing) local dose to the tumor and spares surrounding tissue.
206
cervix
lower 1/3 of the uterus,
| divided into 2 parts: the cervix and the body (fundus)
207
common risk factor or cervical cancer
HPV,
early age intercourse,
large # of pregnancies,
35-55 years old
208
signs and symptoms of cervical cancer
increased menstrual bleeding, foul smelling discharge, bleeding following intercourse, pain, and urinary/rectal symptoms in late stage
209
common histopath and route of spread for cervical cancer
SCC, direct extension and lymphatics
210
3 layers of the cervix in order
Inner-Endometrium (mucous membrane), Middle-myometrium (smoothe muscles), Outer- perimetrium (parietal peritoneum)
211
extending laterally from the superior uterus is the
fallopian tubes
212
3rd most common malignancy in women worldwide
cervical cancer
213
outer most portion of the female genitalia
vulva
214
parts of the vulva
labia majora, labia minora, the clitoris, and the area bound by these three is called the vestibule
215
vestibule
triangular space that is located anterior to the vaginal opening and contains the opening of the female urethra
216
perineum
area between the vaginal and anus in females and scrotum an anus in males
217
signs & symptoms vulva cancer
red, white, or pink bumps. itching, bleeding, discharge
218
signs & symptoms vagina cancer
bleeding, discharge, mass, pain during intercourse, painful urination
219
vagina
musculartube that extends 6-8 inches from the cervix of the uterus to the vulva
220
common histopath of vagina and vulva cancer
SCC
221
fornices
where cervix project through the vaginal wall and formed a circular sulcus that serves as an anatomical landmark that surrounds the superior portion of the vagina
222
lowest part of the uterus where it connects with the superior portion of the vagina
cervix
223
2 primary types of cervical cancer
80-90% is SCC
| 10-20% is adenocarcinoma
224
Cervical intraepithelial neoplasm (CIN)
precancerous cndition in which Squamous cells that line the cervix become dysplastic
225
staging system for cervical cancer
TNM & FIGO (International Federal Gynecology and Obstetrics) staging systems (two staging systems are very similar except FIGO does not have a stage 0)
226
most significant prognostic factor in patients with invasive carcinoma of the cervix
staging (other factors may be age, race, socioeconimical status, tumr size, location, lymph nde involvement)
227
cervical cancer route of spread
direct extension into the uterus, vagina, parametrium, abdomen, pelvis, rectum, and bladder. (can also spread via hematogenous routes)
228
most common distant site of met
lungs, liver, and bone
229
cervical cancer lymphtic involvement
usually ordrly, involving parametrial nodes, followed by pelvic, common, illiac, periaortic, an even supraclavicular node. ***with periaortic nodal invovlement a 35% risk exists for supraclavicular spread***`
230
cervical cancer tx
RT used for all stages, surgery resrved for pt w medicall operable stges (in situ, Ia, Ib1, IIa)
231
cerical tx setup
whole pelvis is initially tx with a 4-field (minimum 16MV photon) technique. The lower border generally falls at the inferior aspect of the foramen, unless the vagina is involved. Upper border is usually at the top or bottom of L5, lateral borders are 1.5-2cm lateral to the pelvis sidewall in the AP/PA plame
232
most common gynecological malignncy and 4th most common cancer overall in women in the USA
endometrium (hormone related cancer)
233
histopath endometrium cancer
adenocarcinoma (80%) and arise in the lining of the uterus and grow and invade the uterine wall
234
most definitive method of diagnosis for endimetrial cancer
D&C dilation and curetage
235
uterus is located
in the pelvis between the bladder and rectum
236
endometrial cancers affects mostly...
post menopausal 55+ year old women, cases are higher in white women but more deaths in black women.
237
risk factors for endometrial
postmenopausal, nulliparity, hormone-replacement therapy, late menopause, early menarche, irregular menstration, diabetes, and history of infertility.
238
screening for endometrial cancer?
none
239
mets for endomatrial cancer
pelvic, para-aortic nodes. lymphatic spread occurs initially to the intenal and external iliac pelvic nodes (stage 1-10% nodal involvement, 25-35% stage II nodal involvement,
240
tx and sim for endometrial cancer
for lower stages a vaginal cylinder is used for tx, 60-70Gy brachytherapy surface dose in 2 sessions or a high dose brachy. of 7 Gy to a 0.5 cm depth for 3 sessions. for higher stages pelvic irradiation is done, with fields similar to cervical fields. Heyman capsule technique or intrauterine tandems can be used is uterus is still present pelvic nodal tx volume is 4-50 Gy with boostins up to 65 Gy for gross involvement.
241
endometrial cavity can be treated up to
75-90 Gy with combines xternal beam therapy and low dos brachytherapy, but the bladder and rectum must be kept to65-75 Gy and the small bowel kept at or below 45-50Gy if tx w RT alone.
242
5th most common cancer among women in the US an d leading cause of death in gyn. cancers
ovarian cancer
243
what are the ovaries
almond shaped bodies attached to both sides of the uterus. their function is to produce an egg (ova) and 2 hormones (estrogen and progesterone). they are attached to the uterus by the utero-ovarian ligaments,
244
common cause ovarian cancer
nulliparity, intertility, family hx, estrogen hormone replacement therapy
245
signs and symptoms ovarian cancer
back pain, fatigue, bloating, constipation, abdominal pain, urinary frequency
later symptoms include:swelling of the abdomen, cramping, pressure, vaginal bleeding, and back pain
246
most common histopath ovarian cancer
epithelial carcinoma(most common) or malignant germ cell tumor (more prevalent in younger women)
247
staging for ovarian cancer
FIGO & AJCC TNM staging
248
ovarian route of spread
direct extention to surrounding organs, peritoneal fluid, or lymph nodes. hematagenous spead is rare. 80% of pt.. w ovarian cancer present with abdominal involvement
249
most common malignancy in males in the US (excluding skin cancer)
prostate
250
prostate location
inferior to the bladder and anterior to the rectum
prostate gland surrounds the male urethra between the base of the bladder and the urogenital diaphragm
251
where does prostate cancer originate
periphery of the gland
252
2nd leading cause of cancer deaths in males
prostate
253
lymphatic spread from the prostate
in order - periprostatic and obturator nodes, followed by external iliac hypogastric, common iliac, and periaortic
254
most malignant tumors of the prostate are
adenocarcinoma
255
location of bladder
when empty lies entirely within the true pelvis. the apex of the bladder is directed toward the upper part of the pubic symphysis and is joined to the umbilicus by the middle umbilical ligament (the urachal remnant)
256
in males what seperates the bladder from the rectum
rectovesical puch
257
the lymphatics of the bladder form 2 plexuses
one in the submucosa and one in the muscular layer
258
most bladder cancers are
epithelial (99%), in the western hemisphere 98% of epithelial tumors are transitional cell carcinoma, 6-7% SCC, and 1-2% adenocarcinoma
259
morphology of bladder cancer
1. papillary, 2. papillary infiltrating, 3. solid infiltrating, 4. nonpapillary, non infiltrating, or carcinoma in situ. (at the time of diagnosis 70% of these cancers are papillary, 25% show papillary or solid infiltration, and 3-5% indicate carcinoma in situ)
260
bladder cancr is staged using
TNM
261
bladder cancer route of spread
direct extention into or through the wall of the bladder
262
tx for bladder carcinoma in situ
radical cystectomy (usually curative)
263
bladder tx set up
include total bladder and TV, prostate and prostatic urethra, and pelvic lymph nodes. a 4-field pelvic technique ap/pa. fields extend 1 cm inferiorly to the caudal border of the obturator foramen and superiorly to just below the sacral promontory or just below S1-L5. *****(portals are usuall 12x12 cm to include the EMPTY bladder)**88
264
bladder dose
larger pelvic fields that include the bladder and pelvic lymph nodes is generally tx to dose of 45-50 Gy and 180 cGy/day, which requires 5-5.5 week of tx
265
most common malignancy in men age 20-34 (although it is still considered rare)
testicular cancer
266
testis anatomy
contained in the scrotum and suspended by the spermatic cords. Left is usually longer than the right. it is invested by the tunica vaginalis, tunica albuginea, and tunica vasculosa. testis produce testosterone.
267
testis lymphatic drainage
lymphatics from the hilum of the testes accompany the spermatic cord up to the internal inguinal ring along the cords of the testicular-spermatic veins. these then drain into the retroperitoneal lymph nodes between the level of T11 and L4 but are concentrated at the level of the L1 -L3 vertebrae
268
most common type of testicular cancer
seminoma
269
3 subtype of seminoma
classic, anaplastic, and spermatocytic
270
nonseminomatous tumors are
embryonal carcinoma, teratoma, choriocarcinoma. yolk sac.
271
most common single cell type testicular cancer
embryonal carcinoma
272
histopath of testicular cancer
germ cell
273
route of spread for testicular cancer
pure seminomas have a higher chance to remain localized, or involve only one lymph node. non-seminomatous germ cell tumors may spread via lymphatics of hematogenous routes.
274
order of spread for seminoma
lymph nodes in the retroperitoneum, then to the next echelon of draining lymphatics in the mediastinum and supraclavicular fossa (stage III). only rarely and late does pure seminoma spread hematogenousy to involve the lung paraenchyma, bone, .iver. or brain (stage IV)
275
non- seminoma met sites
if met outside the lymph nodes usually spreads to lungs and liver.
276
standardized radiation dose for seminoma
2500 cGy/fraction
277
initial tx for nonseminoma
radical inguinal orchiectomy, followed by cisplatin-based chemo
278
RT set up seminoma
MV irradiation to the paraaortic or paraaortic and ipsilateral pelvic lymph nodes. top of the portal should be at T10-T12. inferior border should be at the bottom of L5 or at the top of the obturator foramen. the lateral b orders must include the para-ortic lymph nodes and ipsilateral renal hilum.
279
location of kidneys and ureters
kidney, ureter, and their vascular supply and lympatics are located in the retroperitoneal space between the parietalperitoneum and the posterior abdominal wall.
280
kidney loction
located at the level of between the 11th rib and the transverse process of the 3rd lumbar vertebra. the renal axis is parallel to the lateral margin of the psoas muscle. yeach kidney is 10-12 in length and the right kidney sits 1-2 cm lower than the left
281
lymphatic drainage of the kidney and renal pelvis
occurs along the vessels in the renal hilum to the para-aortic and paracaval nodes.
282
lymphatic drainage of the ureters
is it segmented and diffuse and involves any of the following renal hilar, abdominal para-aortic, paracaval, common iliac, internal iliac, or external iliac.
283
tissue of origin for renal cell carinoa
proximal tubular epithelium
284
2 cell types for renal and ureter cancer
transitional cell carcinoma -more than 90%
SCC- 7-8%
***adenocarcinoma of the upper urothelial tract is rare***
**SCC ofthe renal pelvis is often deeply invasive and is associated with a worse prognosis than transitional cell carcinoma**
285
route of spread for kidney cancer
via local infiltration through the lung 75%, soft tissue 36%, bone 20%, liver 18%, cutaneous area 8% and CNS 8%
286
upper urinary tract carcinoma i a multifocal process meaning/
patients with cancer at one site in the upper urinary tract are at greater risk of dev. of tumors elsewhere in the urinary tract
287
transitional cell carcinoma of the upper urothelial tract may spread via
direct extention, blood, or lymphatics
288
standardized tx for pt with localized renal cell cracinoma T1 amd T2
radical nephrectomy (complete removal of the infact Garota's fascia and its contents, including kidney, adrenal gland, and perinephric fat. **regional lymphadenectomy is often performed at the time of radical nephrectomy**
289
when is RT often performed for renal cell carcinoma
postoperatively, for a tumor left behind after sx or for reoccurence
290
TV for renal cell carcinoma includes
renal fossa, and site of gross reoccurence, if present along with the para-aortic nodal drainage sites in the adjuvant setting.
291
post-op RT for renal cell carcinoma range
4500-5000 cGy, the usual recommended dose that can be given safely to the upper abdomen with an acceptable complication rate of 5040 Cgy at 180 cGy/fraction over 5-6 weeks
***a boost of 540 cGy in 3 fractions to smaller volume may be dded, with special care, to bringthe TD to 5580 cGy***
292
for prostate tx bladder should be
full
293
for bladder tx bladder should be
empty when entire bladder is being tx. During boost field bladder should be full to reduce the amount of bladdr tx to the boost field
294
normal adult pulse
60-100 beats per min
295
normal adult respirations
12-18 breaths per min
296
normal adult BP
90-140 mm Hg
| 60-80 mm Hg
297
systolic BP
when the heartbeat disappears
298
diastolic BP
when heartbeat reappears after releasing the cuff
299
2nd leading cause of overall cancer deaths in US
colorectal (affects men more than women)
300
causes of colorectal cancer
diet high in animal fat, obesity, smoking, excessive drinking, NSAID, chronic ulcerative colitis
301
Gardner's syndrome
hereditary disease where pt. have adenamatous polyposis of the large bowel and other abnormal growths, such as upper G.I. polyps, periampullary tumors, lipomas, and fibromas.
302
colon is divided into 8 regions
cecum, ascending colon, descending colon, splenic flexure, hepatic flexure, transverse colon, sigmoid, and rectum.
303
what parts of the colon are considered freely mobile
located intraperitoneally, the cecum, transverse colon, and sigmoids, and they have a complete mesentary and serosa
304
what parts of the colon are immobile
located retroperitoneally, the ascending and descending colon, and the hepatic and splenic flexures are considered immobile
305
the rectum is continuous with the sigmoid and begins at
he level of the 3rd sacral vertebra and like the sigmoid is covered by the peritoneum
306
the lower 2/3 of the rectum is located
retroperitoneally
307
3 transverse folds ivide the rectum into areas known as
upper valve, middle valve. ad lower valve or ampulla
308
rectum middle valve loc.
11 cm superiorly from the anal verge
309
large bowel has 4 main layers:
the mucosa, submucosa, muscularis propria, and serosa (these layers are used in the staging system to define the amount of involvement through the bowel)
310
innermost layer of large bowel
mucosa-forms the lumen of the bowel and consists of 2 supporting layers: the lamina propria and the muscularis mucosa.
311
2nd layer from the inside of the large bowel
the submucosa- rich in blood vessels and lymphatics
312
3rd layer from the inside of the large bowel
muscularis propria-contains 2 muscle layers: one circular are one longitudinal which are responsible for peristalsis (beneath the muscularis layer is a layer of sat called the subserosal layer)
313
oter most layer of the large bowel
serosa (not all segments oft he colon have a serosal layer)
314
lymphatic drainage of the colon
(follows the mesenteric vessels) right colon follows the superior mesenteric vessel and includes the ileocolic and righ colic nodes and the left colon follows the inferior mesenteric vessels and includes the regional node termed the midcolin, inferor mesenteric, and left colic.
315
sigmoid region drains into the
inferior mesenteric system but also includes the nodes along the superior rectal, sigmoidal, and sigmoidal mesenteric system.
316
lymphatic drainage of the upper rectum follows the
superior rectal vessels into the inferior mesenteric system
317
middle and lower rectum lymphatic drainagw
is along the middle rectal vessels with the principal nodal group that comprises the internal iliac nodes
318
other nodal groups at risk for involvement with rectal cncer
perirectal, lateral sacral, and presacral nodes.
low rectal lesions that entend into the anal canal can drain into the inguinal nodes
319
most common malignancy of the large bowel
adenocarcinoma (90-95%)
(other types include mucinous adenocarcinoma, signer-ring cell carcinoma, and SCC
320
staging used to large bowel cancer
TNM set by the AJCC
321
route of spread for large bowel
usually spread via direct extension, lymphatics, and hematogenous spread
* *direct extension of the tumor is typically in a radial fashion, with penetration into the bowel wall rather than longitudinally
* *lymphatic spread occurs if the tumar has invaded the submucosal layer of the boel (lymphatics spread orderly, the initial node invovled is perirectal node
* *blood-borne spread to the liver is the most common type of distant mets
322
2nd most common site of distant spread for largebowel cancer
lung
323
tx of choice for large bowel
surgery
324
for rectal cancer the 2 most common procedures are
low anterior resection (LAR) and the abdominoperineal resection (APR)
325
what is low anterior resection
removal of the tumor plus a margin and immediately adjacent lymph nodes (used on pt with rectal cancer in the lower 3rd of the rectum)
326
RT is most commonly used as what for rectal cancer
adjuvant therapy (before or after surgery)
327
preoperative RT is commonly used technique on patients
who have large rectal cancers that have invaded through the muscle layer (T3) or who have imaging studies (MRI) that show enlarged lymph nodes that indicate N1 or N2 disease. (goal is sphincter preservation)
328
sphincter-preserving procedure done for curative intent in a select group of pt. with lower-third to middle-third rectal cancers that are confined to the bowel wall.
endocavitary RT
329
for rectal cancer most reoccurences occur?
posterior aspect of the pelvis, including metastasis to the internal iliac and presacral lymph nodes
330
OAR for RT of the pelvis
small bowel (dose should be less than 45 Gy
331
tx/sim set up for rectal cancer
a 3 field technique where pt is prone (PA and opposed laterals wedged), which allows homogenous dose to the tumor bed while sparing of anterior structures such as the prostate or vagina
332
dose limiting structures for tx of ascending or descending colon cancer include the
kidney and small bowel
333
pt who undergo IORT may receive a dose of
1000-2000 cGy of electrons in a single fractions
334
IORT dose is calculated at the
90% isodose line
335
leukopenia
abnormal reduction in white blood cell count
336
thrombocytopenia
abnormal decrease in platelet count
337
anal canal is how long
3-4 CM long and extends from the anal verge to the anorectal ring at the junction of the anus and rectum
338
lymphatic spread of the anal canal
occurs initially to the periretal and anorectal lymph nodes
**if the tumor extends above the dentate line, the nodal groups at risk are in the internal iliac and lateral sacral nodes; this is similar to rectal cancer
339
anal cancer histology
SCC 80% of cases, the next most common is basaloid, or cloagenic
340
perianal cancers are typically
SCC or basal cell carcinoma (consistent w skin cncer)
341
route of spread anal tumor
most frequently direct extention into the adjacent soft tissues. lymphatic spread occurs relatively early to pelvic nodes but more commonly to inguinal lymph nodes, hematogenous spread to the liver or lungs is less common
342
tx setup/sim for anal cancer
IMRT static or VMAT with a 4-field AP/PA pelvic field with electron field to the inguinal nodes including a boost to the tumor bed with a perineal electon field or another multifield technique. the pelvic field extends from the lumbosacral-sacroiliac regiom to 3 CM distal to the lowest extent of the tumor . the inf erior border typically flashes the perineum. the lateral border may extend to include tx of the inguinal nodes on the AP field only. tthe PA field is kept narrower because the anteriorly located inguinal nodesdo not receive much contribution from the posterior field
343
OAR for anal cancer tx
femoral head and neck, genitalia/perineum, small bowel, and bladder
344
the most severe and life-threatening complication from irradiation to the pelvis and the 5-FU and mitomycin reginment for anal cancer
bone marrow suppression
345
standard of care for tx of anal cancer
RT combines w chemo provides sphincter preservtion and better cure rates
346
accounts for 1% o all cancers in the US, 3-4x more common in men, and diagnosed between age 55-85
esophageal cancer (has nearly uniformly fatal death rate)
347
cancer of the esophagus occurs more in
northern china, northern iran, and south africa
348
factors that increase the risk of esophogeal cancr
tobacco, excessive alcohol, Barrett esophagus, GERD (associated with 30% of esophageal cancer), diets low in fresh fruit and veggies and high in nitrates, obesity
349
Barrett esophagus
condition in which distal esophagus is lines with a columnar epithelium rather than a stratified epithelium
350
achalasia
disorder in which the lower 2/3 of the esophagus loses its normal peristaltic activity
351
what is the esophagus
a thin-walled 25 cm long tube lones with stratified squamous epithelium. begins at the level of C6 and traverses through the thoracic case to terminate at the esophageal gastric junction (T10-T11)
352
esophagus is divided into 3 regions
upper thoracic, middle thoracic, and lower thoracic (or GE junction)
353
staging system for esophagus cancer is based on
pathology: SCC or adenocacinoma
354
the esophagus lies directly
posterior to the trachea and is anterior to the vertebral column.
355
located laterally and to the left of the esophagus is the
aortic arch. the descending aorta is situated lateral and posterior to the esophagus
356
layers of the esophagus
adventitia (outer layer, consisting of thin loose connective tissue, mucosa, submucosa, and muscular layers
357
lymph drainage of esophagus
lymph fluid cn travel the entire length f the esophagus and drain into any adjacent draining nodal bed, which places the entire esophagus at risk for skip mets and nodal involvement
358
the upper third (cervical area) of the esophagus drains into
internal jugular, cervical, paraesophageal, and supraclav. nodes
359
upper and middle thoracic portion of the esophagus drain into
paratracheal, hilar, subcarinal, paraesophageal, and paracardial nodes
360
principal draining lymphatics for the distal or lower thirs of the esophagus include the
celiac axis, left gastric nodes, nodes of the lesser curvature of the stomach
361
most common pathological type of esophageal cancer
SCC and adenocarcinoma ***SCC is more common in black people and adenocarcinoma is more common in white people**
362
rare type of esophagus cancer
non-epithelial which is Leiomyosarcoma (a tumor of the smooth muscles)-this is the most common nonepithelil tumor
363
route of spread of esophagus cancer
spread is usually longitudinal. occassionally skip lesions my be present at a significant distance from the primary lesion (up to 5cm)
364
standard tx of esophageal cancer
RT and concomitant chemo or preoperative chemoradiation followed by curative surgery (RT w/ chemo is considered the current nonsurgical tx of choice)
365
nodes at risk for esophageal RT
cervical, supraclavicular, paraesophageal, amd subdiaphragmatic (celiac axis), lymph node region are at risk
366
CTV esophageal cancer
includes regional lymphatics and encompasses the primary tumor with a 3 cm to 4 cm margin above and below the GTV and a 1 cm radial margin. the margin for the nodes should be expanded 0.5-1.5 cm from the GTV. the PTV is also expanded 0.5-1cm for radial or lateral margins.
367
lesions of the upper third of the esophagus are treated with what type field set up
a field that begins at the level of the thyroid cartilage and ends at the level of the carina to include the supraclav, low anterior cervical, and mediastinal lymph nodes
368
tumors of the distal third esophagus field set up
the inferior margin must include the celiac-axis lymph node, which are located at the T12-L1 vertebral level. the superior extent of the tx field should include the paraesophageal nodes and mediastinal nodes because they are a low risk of being involved.
369
RT technique for esophageal cancer
3D conformal fields (AP/PA, laterals, or obliques), step and shoot IMRT fields and VMAT
370
OAR for esophageal RT
lung, heart, spinal cord, kidneys, and liver
371
TX dose for RT for esophageal cancer
60-65 Gy (6000-6500cGy)
| if combined with chemo total dose should be 41.4-50.4 Gy
372
RT tolerance dose of spinal cord
45-50 Gy
373
Sim set up esophagus tx
-standard supine position. pts arms are often above the head, w pt. clasping the elbows or wrist. immobilization devices are used to help maintain position
(if pt. cant put arms above head, place arms along their sides with elbows slighty bend so marks can be placed)
-a 3 point set up is used. a thermoplastic mold may be used to maintain shoulder and headposition.
-a set of 3 marks are placed on the lower thoracic cage and are used to establish isocenter
374
4th leading cancer-related death in the US
pancreatic (more common in men than women, and greater in blacks than white)
375
cause of pancreatic cancer
no known cause
376
location of pancreas
located retroperitoneally at the L1-L2 level and lies transversely in the upper abdomen.
377
pancreas is divided into 3 anatomic regions
the head, body, and tail
378
location of the head of the pancreas
C-loop of the duodenum
379
location of the body of the pancreas
lies just posterior to the stomach near the midline and is anterior to the IVC.
380
location of the tail of the pancreas
extends laterally to the left of the pancreas body, the tail terminates at the splenic hilum
381
what does the pancreas come in direct contact with and often invade what?
duodenum, jejunum, stomach, major vessels (IVC), spleen, kidney (usually unresectable at the time of diagnosis)
382
lymph nodes that drain the pancreas
main lymph node group includes the superior and inferior pancreaticoduodenal nodes, porta hepatis, suprapancreaetic nodes, and para-aortic nodes
383
tumors that arise in the tail of the pancreas drain to the
splenic hilar nodes
384
4 common symptoms of pancreatic cancr
jaundice, abdominal pain, anorexia, and weight loss
385
tumors that arise in the head of the pancrease can obstruct
the biliary system, resultng in jaundice. it causes excess bilirubin to be excreted in urine and less bilirubin to enter the bowel, which result in dark urine and light color stool.
386
pancreatic cancers occur most frequently in the
head and neck of the pancreas
387
symptoms of tumor in body of tail of the pancrease
severe back pain and weight loss
388
2 contraindications for pancrease tumor resection
liver mets and involvement of superior mesenteric artery or other major vessel
389
hisopath of pancreatic tumor
adenocarcinoma (80%), other types include islet cell tumor, acinar cell carcinoma, and cystadenocarcinoma
390
staging system for pancreas
TNM
391
route of spread pancreas tumor
invade locally. lymph node involvement or direct extension into the duodenum, stomach, an colon is not uncommon at time of diagnosis,
hematogenous spread to the liver via the portal vein is also common
392
tx of choice for pancreatic tumor
sx though often un-resectable.
most common potentially curative sx is the Whipple procedure (pancreaticodenectomy), involves a resection of the head of the pancreas, entire duodenum, distal stomach, gallbladder, and common bile duct
393
tx set up for pancreatic cancer
4-field technique that encompasses the primary tumor ed. a dose of 45-50 Gy is delivered in 1.8 Gy fractions with high energy photons
394
OAR for pancreatic tx
kidney, liver, stomach, small bowel. spinal cord
395
typical AP/PA field set up for head of the pancreas
extend approx. from T10-T11 for inclusion of the tumor ned, draining lymphatics, and celiac axis (T12-L1). width of the field should encompass the entire duodenal loop and the margin that extends across the midline to the left. the lateral fields are designed to provide a 1.5 cm-2cm margin anteriorly beyond the tumor. posteriorly, the field extends 1.5 behind the anterior vertebral body for adequate coverage of the para-aortic nodes.
396
sim set up for pancreatic tumor
supine position, with armsabove head for easier placement of lateral isocenter marks. an immobilization device is used. for sim with pt having SBRT a full-body immibolization device is used. patients have to drink a contrast 30min-1hr beforethe 4D-CT due to large amount of movement associated w the pancreas
397
non melanoma is used to describe
basal (80%) and SCC (20%)
398
most common malignancy in humans
skin cancer
399
skin cancer that occurs in sites typically not exposed to the sun and is often aggressive
SCC
400
junctional melanocytic nevi
uniformly brown or black, circular, well-circumscribed, flat, small (less than 6mm)
401
compound nevi
contain melanocyte clusters in the dermis and epidermis, small, well circumscribed, slightly raised papules that often contain excess hair. the surfce is rough an color ranges from tan to brown
402
intradermal nerci
small, well-circumscribed, dome shaped lesion, only found in dermal layer.
403
dysplastic nevi
atyppical mole
404
people with family history of melanoma are
8x more likely to get the disease
405
largest organ in the body
skin (covers 17-20ft on the avg person)
406
function of the skin
regular temp, acts as a barrier, participates in the production of vitamin D, provides eceptores for external stimuli
407
connective tissue lyer of the skin
epidermis
408
deeper layer of the skin composed of connective tissue that contains blood and lymhatic vessels, nervesm nerve ending, sweat glands, and hair follices
dermis
409
layer below the dermis that contains nerves, blood vessels, adipose tissue, areolar connective tissue
subcutaneous layer
410
epidermis is the extremely thin outer later of the skin that is composed of what layers
1. stratum basale (base layer)-produces keratinocytes
2. stratum spinosum (spiny layer)-contains rows of keratinocytes which have a spiney appearence microscopiclly
3. stratum granulosum (granular layer)-contains 305 rows of somewhat flattened cells
4. stratum lucidum (clear layer)-found typically ony in areas w/ thick skin (soles and palms), contains 3-5 rows of clear, flat cells that contain eleidin
5. stratum corneum (horny layer) - forms the skin surface nd contains thicker rows of flat, dead, scaly squamous cells that are completely filled w keratin that have lost all their internal organelles including nuclei
411
slow growing skin cancer that does not typically met. arises from stem cells and if left untreated can cause extensive damage
basal cell carcinoma
412
faster growing cancer with higher chance for mets. arises from more mature keratinocytes of the upper layers of the Dermis
squamous cell carcinoma
413
rare tumor thought to arise from Merkel (tactile) cells. known for high-rates of recurrence after surgical excision. frequently involves lymph nodes and and distant mets and cn lead to death
merkel cell carcinoma
414
skin melanoma characteristics
asymmetric, notched uneven borders, diff shades of black, brown, or tan, have a diameter greater than 6mm
415
melanomas are classified base on
growth pattern nd histological appearence
416
superficial spreading melanomas
most common melanoma subtype. 70%
417
nodular melanpmas
15% of melanomas, tend t be raised throughout and vary in color from dark brown, black, blue, or blue-black
418
lentigo maligna melanomas
5% of melanomas. minimal elevation, tend to occur on sun exosed skin in older white females
419
acral lentiginous melanomas
10% of melanomas. found mostly on palms, poles, nail beds, or mucous membranes.
420
stage I tumor
low risk
421
stage II -IIIA
intermediate risk
422
stage III B
high risk
423
stage IIIC and IV
very high risk
424
stomach tolerance dose
4500 cgy
425
small bowel tolerance dose
4500 cgy
426
liver tolerance dose
3000-3200 cgy
427
kidney tolerance dose
1500-1800 cgy
428
area where liver tumors appear
right upper quadrant
429
large bowel tolerance dose
5500 cgy
430
histopath stomach cancer
adenocarcinoma
431
route of spread stomach cancer
gastric cancers spread via direct extension and also through the rich lymphatics network
432
rectum tolerance dose
6000cgy
433
femoral head tolerance dose
5400cgy
434
bladder tolerance dose
6500cgy
435
6 sections of the stomach
cardia, fundus, body, greater curvature, lesser curvature, pylorus
436
histopath stomach csncer
90-95% adenocarcinoma
| Leiomyosarcomas and lymphomas 5-8%
437
route of spread stomach
- 1/3 have distant mets at diagnosis
- may spread through lymph, blood, or direct
- more likely o spread to bowel, omenta, pancreas, colon, regional nodes, peritoneum
- will take blood route to the liver and lung since portal systems is in close proximity.
438
stomach lymph drainage
drainage is tohe nodes along the greater and lesser curvature, then splenic, celiac, and hepatic nodes
439
stomach staging
TNM
440
rt Tx delivery for stomach
4-field box technique with beam shapers, use IMRT
441
divisions of the small bowel
duodenum,jejunum,ileum
442
histology of small bowel
adenocarcinoma (in duodenum and jejunum), sarcomas, lymphomas, carcinoid
443
small bowel route of spread
regional lymph nodes and neighboring organ
444
small bowel staging
classified y histological site and TNM
445
small bowel Rt set up
irradiate whole abdomen for lymphomas, and csrcinoids
| usually donde post-op. 20-25 Gy in 1-1.25 Gy fractions (limits dose to other organs in absomen)
446
causes of liver cancer
hep B, hep C, cirrhosis, aflatoxin B (toxic metabolite of fungi that can grow in stored grain and peanuts)
447
causes of gallbladder cancer
Cholelithiasis (stones irritate or bile acid is carcinogenic)
448
histology liver cancer
Hepatocellular (HCC) (most common)
449
histology of gallbladder cancer
adenocarcinoma (most common)
450
lymph drainage for liver and gallbladder
regional lymph nodes including porta hepatic, celiac, cystic, pericholeductal, and hilar nodes
451
route of spread for liver
can spread throughout the liver, may invade the portal vein, hepatic vein, or diaphragm. 1/3 of HCC have regional spread at diagnosis, then spread to regional nodes and then to lung, brain, or muscle tissue in absomen.
452
gallbladder spread
40-50% of gallbladder carcinomas have distant spread at diagnosis, usually to liver or peritoneum
453
liver/gallbladder staging and grading
grading is used, 1-2=low grade, 3-4 high grade.
454
grading
based on appearance, shows degree of differentiation at a cellular level, can be a major prognostic factor
455
brain (limited) tolerance dose
6000cgy
456
while brain tolerance dose
4500cgy
457
brain stem tolerance dose
5000cgy
458
optic nerve tolerance dose
5000cgy
459
retina tolerance dose
4500cgy
460
ear tolerance dose
3000-5500cgy
461
HD is determined by the presence of what
Reed-sternberg cells (large lymphoid cells that contain multiple nnuclei
462
HD spread
spreads in a systemic pattern through the lymph nodes and lymph vessels
463
HD & NHL staging
Ann Arbor Lymphoma Staging
numbers I-IV designates the extent of the disease.
the lettes A & B designate the presence (B) or absence (A) of symptoms
B symptoms:unexplained weight loss (10%+), feverrs greater than 101, drenching night sweats
464
major lymph nodes
1. Waldeyers ring (tonsillar lymp tissue that surrounds the nasopharynx and orophrynx) and cervical, preauricular, andoccupital lymph nodes
2. supraclavicular (near jugular on neck) and infraclavicular lymph node(by collar bone)
3. axillary lymph nodes (arm pit)
4. thorax(includes hilar and mediastinal nodes)
5. abdominal cavity (includes para-aortic nodes[middle of stomach])
6. pelvic cavity (includes iliac node [side/lower abdomen], an Peyer's patches in the distal ileum
the spleen, thymus, tonsils, adenoids, and bone marrow are all parts of the lympatics also`
465
risk factor for HD
epstein-barr, mono, reed-sternberg cells, HIV
466
most common sin of HD
painless mass above the diaphragm
467
route of spread HD
contigous pattern of spread that mimics the route of spread of the lymphtic system. if disease ifs found outside the lymphtic system, it is next to the involved site. the rate of progression is not redictable
468
tx tech. for HD
chemo
469
RT setup for HD
most often delivered to the neck, chest, and axilla or to para-aortic lymph nodes and spleen. sme pt receive also to pelvic nodes.
470
mantle field for HD
tx fields to the neck, chest, and axilla (includes cervical,submandibular, axillary, supraclav, infraclav, mediastinal, and hilar nodes)
471
for HD if the pelvic and para-aortic fields are tx together its called
inverted Y
472
when all 3 HD fields are tx together (mantle, pelvic and para-aortic[inverted y]) it is called
total nodal RT
473
tx areas that only encompass the areas of known disease for HD is called
involved field radiation
474
HD tx that includes areas of known disease and contiguous uninvolved lymph nodes
Extended field RT
475
mantle field set up
large field size. pt is supine with hands above their head or akimbo with their hands on their hipsand elbows turned outwards. with chin extention to prevent exposure to mouth. tx with a AP/PA approach
476
border for mantle field
superior: lower mandible or mastoid tip
inferior: T9-T10 interspace
lateral: flash beyond the axillary nodes
477
tx of mantle and abdominal fields w/o pelvic portion is termed
subtotal nodal irradiation
478
abdominal or para-aortic field setup
the spleen, para-aortic, and retroperitoneal nodes are tx AP/PA abdominal field. (if spleen is tx left kidney must be protected because right kidney receives dose).
479
Borders for abdominal HD tx
superior- Mid T10-T11
inferior- L4-L5
lateral- 9cm-10cm wide midline
480
when tx pelvic field for HD when is shielded
bone marrow, bowel, bladder, ovaries, testicles
481
borders for pelvic HD tx
superior L-5
inferior 2 cm below ischial tuberosity
lateral- 2cm beyond pelvic inlet
482
tx dose for HD
35-44 Gy to areas free of disease with 6 MV to 10 MV photon. the area of initial nodal involvement is tx from 25-30 Gy.
483
NHL seperated into 2 groups
indolent (slow-growing) and aggressive
484
pathology of NHL
B-cell (85% of NHL, arrises from abnormal B lymphocytes)
| T-cell 15% NHL, arrises from abnormal T Lymphocytes)
485
primary tx for NHL
chemo, rt, immunotherapy, and stem cell transplant. chemo is most affective.
486
tx field dose NHL
35-45 Gy and includes involved site and related drainage nodal clusters
487
indolent NHL in stages I and II can be tx with
RT alone
488
NHL accounts for what portion of pediatric cancers (undr 20 years old)
7%
489
side effects NHL RT tx
can vary because tx sites can be found all along he body. can tleast expect fatigue, alopecia, and skin erythema
490
what is multiple myeloma
- malignant disease of the plasma cells . arrises in the B-cell lymphocytes of the bone marrow
- makes up approx. 10% of all hematologic malignancies.
- usually seen in middle-aged or older adults
- more common in men and blacks than women and whites
491
mycosis fungoides
disease of the lymphocytes that can resemble eczema or other inflammatory conditions and tends to remain localized to the skin for long periods. tx using TBI
492
tomotherapy
tx delivery system where tx is given slice by slice
493
bone marrow transplant
- harvesting of healthy marrow from matched donor
- diseased marrow must first be destroyed or ablated by chemo or TBI
- harvested marrow then injected back into patient
- transplanted marrow then finds its way into bone marrow cavities and begins supplyingthe pt w/ normal, helthy hematopoietic cells.
- failues in transplant are leukemia and graft-versus-host disease
494
tumors of the primary bone include
osteosarcoma, chondrosarcoma, fibrosarcoma, malignant histiocytoma, malignant giant cell tumors, multiple myeloma, and metastatic bone disease.
495
what 3 cancers affect bone and soft tissue
[fibrosarcoma and malignant histiocytoma(both these tumors are considered malignant fibrous histiocytoma MFH)], ewing sarcoma (not an MFH)
496
most common osseous malignant bone tumor in children(56% of all pediatric primary skeletal tumors)(more common in males than females)
osteosarcoma
497
2nd most common type of primary bone tumor in adults, involves the long bones of the extremities (knee joint), and jaw
osteosarcoma
498
most common primary bone tumor in adults but is rare in children (6%pediatric primary bone tumors and 40% of adult)
chondrosarcoma
499
primary bone tumor that involves the pelvis, ribs, vertebrae, long bones (proximal part), usually diagnosed at 60 years or older
chondrosarcoma
500
most malignant bone lesion
metastatic bone disease, occurs mostly in spine and pelvis (lesions are less common farther from the trunk)
501
most common primary site to met to bone
lung, followed by prostate, breast, lung, kidney, and thyroid
502
risk factors for osteosarcoma
genetics (RB! and TP53), higher birth weight, tall, rapid bone growth in fetal and adolescence, Pagets disease, Werner syndrome, Bloom syndrome, and hereditary retinoblastoma.
503
most common site of primary bone sarcoma is near
growth plates
504
typical long bone consists of
diaphysis (main shaft of the bone), 2 epiphyses (knoblike portions at either end of the bone), the cartilage cap (covers the articular surface), and the periosteum (hard, dense covering of the bone)
505
bone tumor found commonly is the distal femur, followed by the proximal tibia and proximal humerus
osteosarcoma
506
chondrosarcomas are commonly found in the
pelvis and femur
507
fibrosarcomas 9MFH) and GCTBs typically arise in the
metaphysics and epiphysis of the long bone, including the distal femur, proximal tibia, an distal radius.
508
ewing sarcoma is most freq. seen in the
appendicular skeleton. 25% in the pelvis, 17% in the femur. can occur in any part of the bone most most commonly seen in the diaphysis
509
most common oncological disease of bone
multiple myeloma, can occur in any bone and is characterized by osteolytic lesions
510
metastatic bone disease often involves the
spine, pelvis, femur, humerus (it is not uncommon for met. disease to affect ribs and skull)
511
the most common cancers to mets to bone ate advanced diseases of the
lung, breast, prostate. (nearly 40% of pt. w NSCLC and 70% with prostate are affected, 20-30% with breast cancer)
512
multiple myeloma causes
bone loss, which results in painful bony lesions (can cause fractures)
513
one of the few emergency procedures in RT
partial or complete spinal cord blockage-must be tx early to prevent paralysis and sensory loss
514
osteosarcoma histopathology
poorly differentiated, subtypes include osteoblastic, chondroblastic, fibroblastic, or mixed chondroblastic
515
tumor that arises from the mesenchymal elements of the bone
chondrosarcoma
516
originate in te mesenchymal tissue and osten have the appearance of normal fibroblasts but are malignant
fibrosarcoma
517
cell of origin for MFH tumors
histiocyte or the macrophage, usually undifferentiated pleomorphic
518
multiple myeloma is characterized by
neoplastic proliferation of a single clone of plasma cells. these cells produce a monoclonal protein that, along with the proliferation of plasma cells , leads to the destruction of bone
519
bone sarcoma staging and grading
```
stage IA-grade low=<8cm
stage IB-grade low =>8cm
stage IIA-grade high=<8cm
stage IIB-grade high=>8cm
stage III any tumor grade, skip mets
stage IV- any tumor grde, any tumor size, distant mets
```
520
tumors are classified based on
grade, tumor size, presence or absence of mets
521
route of spread sarcomas
- most sarcomas met. hematologically to lungs. occasionally, osteosarcoma, MFH, and chondrosarcoma met to other sites like bone, liver, brain
- lymphatic spread is not usually of concern
* *90% of pt. w high-grade osteosarcoma have lung mets**
522
osteosarcomas may also have what kind of met
skip mets (a second-smaller focus of the cancer in the same bone or a 2nd bone lesion on the opposing side of the joint face)
523
osteosarcoma tx
surgery. very chemo and rad. resistant
524
primary tx for chondrosarcoma
sx
525
primary tx for fibrosarcoma
aggressive surgery with wide or radical excision. post op RT can be done 66-70 Gy wit ha shrinking field technique
526
MFH tx
surgery, if inoperable 46-66 Gy external beam and single fractions of 15-20 Gy intraoperatively
527
tx for multiple myeloma
chemo w/ RT usually 30 Gy in 10-15 treatments
528
Ewing sarcoma tx
sx, RT, chemo (very sensitive to chemo) tx w/55-60 Gy with a 2 cm margin around the soft tissue component and entire bone
529
part of the classification of solid tumors that arise from the mesenchymal cells
soft tissue sarcomas (STS), rare but more common than bone
530
`STS locations
connective tissue, including adipos, muscle, nerve, nerve sheath, and blood vessels
531
most common STS in kids
rhabdomyosarcoma
532
most common STS adults
```
pleomorphic sarcoma (malignant fibrous histiocytoma), gastrointestinal stromal tumor (Gist)
liposarcoma (malignant)
leiomyosarcoma (malignant)
synovial sarcoma (malignant)
peripheral nerve sheath tumor
```
533
local growth pattern of STS
follows the lines of least resistance in the longitudinal axis of the primary site compartment
534
primary site compartment
consists of the natural anatomic boundaries that surround the STS primary-composed of common fascia planes of muscles, bone, joint, skin, subcutaneous tissues, and major neuromuscular structures.
535
as STS progress and grow, they push away other structures andform
pseudocapsules (areas of compressed healthy and fibrotic tissue
536
STS tumors of this area are generally high grade and end to invade adjacent muscle groups
trunk, head, neck
537
extremity STS tend to invade how
spread along the longitudinal axis of muscular compartments.
538
incidence of STS is _____, but mortality rate is ____
low incidence, high mortality
539
etiology of STS is
unknown
540
embryonic origin of STS begins in the
primitive mesoderm
541
sarcomas are classified by
histology and named according to the tissue in which they arise (more than 50 types of STS are known)
542
most common STS in adults
MFH 28% (arise in bone and soft tissue), leiomyosarcoma (12%), liposarcoma (15%), synovial sarcoma (10%), and malignant peripheral nerve sheath tumors (6%)
543
most common pediatric STS
rhabdomyosarcoma
544
primary staging system for STS
French Federation of Cancer Centers Sarcoma Group (FNCLCC) and National Cancer Institute System
545
STS spread pattern
aggressive and invade along local, anatomically defined planes composed of neuromuscular structures, fascia, and muscle bundles. lymphatic extension is NOT common.
-hematologic pathway are the primary routes of spread
546
STS common met site
lung, followed by the bones, liver, and skin
547
Tx for STS requires
multidisciplimary approach (sx, chemo, and RT)
- surgical resection
- Rt may be delivered w/ external beam radiation, brachytherapy, IORT, or a combo of those. more common approach is either pre or post-op
548
carcinoma
75-85% of tumors
- originate in the epithelium
- SCC, glandular cell (adenocarcinoma)
- generally spread via lymphatics
549
sarcomas
-10-15% of tumors
-originate in bone, connective, or soft tissue
most common met site is lungs
550
benign tumors
- non cancerous
- normal to slightly increased growth
- encapsulated
- well differentiated
- not usually life threatening
551
malignant tumors
- cancerous
- normal to increased mitotic rate
- can met.
- well differentiated to anapestic (undifferentiated)
- life threatening
552
tumor classifications
benign or malignant
553
etiology
study of the cause of the disease
| carcinogens, genetic, etc
554
epidemiology
study of the incidence of the disease (age, gender, race, occupation, geographic location)
555
TNM described
T-describes the size and invasiveness of the primary tumor (the numerical value(1-4) is added to the T and increases w/ the extent of the normal
T1-small lesion confined to the organ of origin
T2-larger tumor size or deeper extention
T3-extention beyond the organ of origin, but confined tothe region
T4-invasion into another organ or viscera
N-describes the presence or absence of nodal involvement
M-describes the presence or absence of met.
556
transverse plan or axial
cuts body into upper and lower through belly bottom
```
O
\|/
-----------------------------
|
/ \
```
557
sagittal plane or longitudinal
cuts body in half into left and right portions
558
frontal plane or coronal plane
cuts body into front and back options
559
contrast media may be given
oral, iv, intrathecally, intraarteriorly
560
types of contrast
barium (not water-soluble)
| Iv contrast is usually iodine-based
561
Scan field of view (SFOV)
area for which projection data are collected for a CT scan
562
first image acquired during CT
tomogram (scouts, etc)
563
isocenter localization procedure
1. external skin fiducially
2. computing isocenter based on field border placement
3. placement of isocenter based on Tx volume or contour info
564
2 main body cavities
posterior/dorsal and anterior/ventral (front and back)
565
dorsal cavity can be divided into
1. spinal or vertebral city (contains spine)
| 2. cranial cavity (contains brain)
566
thoracic cavity is devided into
1. pericardial cavity (contains the heart)
| 2. two pleural cavities (includes left and right lung)
567
abdominopelvic cavity has 2 sections
1. upper absomincal cavity
2. lower pelvic cavity
(abdominopelvic cavity iis large and divided into 4 quadrants; right upper, left upper, right lower, left lower)
568
principle structures in the abdominal cavity
peritoneum, liver, gallbladder, pancreas, spleen, stomach, most of the large and small intestine
569
structures in the pelvic cavity
rest of the large intestine, rectum, urinary bladder, internal reproductive system
570
how many cervical vertebrae
7
571
how many thoracic vertebae
12
572
how many lumbar vertebrae
5
573
an electron has a negative charge and a mass......
approx. 2000x smaller than that of a proton
574
for water, energy loss by collission is approx
2mev/cm in the energy range of 1-100 MeV
575
the dose at the surface begins at approx.
85% of maximum and builds up to 100% in the first few CM before the surface
576
iodine-125 half life
59.4 days
577
palladium-103 half life
17 days
578
cesium-137 half life
30 years
579
iridium-192 half life
73.8 days
580
strontium-90 half life
28.8 years
581
Iodine-131 half life
8 days
582
what is the characteristic shape of the electron beam isodose curve
it is described as a lateral bulge or ballooning of the isodose curve
583
mean energy of the electron be a in MeV at the surface
depth in centimeters of 50% isodose line divided by 2.4
584
the practical range in CM in tissue
(mean energy at surface) divided by 2
585
the depth of the 80% isodose line in CM in tissue
(mean energy at surface) divided by 3
| example: 80%isodose=MeV/3
586
gradient
the rate of change of a value (dose) with a change in position
587
the depth of the 90% isodose curve may be approximated by:
dividing the energy of the electron beam in Mev by 4
90% isodose=MeV/4
588
electron beam characteristics at the surface
-surface dose is 0.5 cm on the central axis of the electron beam
surface dose values for electron beams in the 6 MEv-20MeV rate vary from 75%-100%
589
in megavoltage photo beams, increased energy of the treatment beam results in a
decrease in surface dose
590
as the energy of the electron beam increases
the surface dose and percent depth dose also increase (because of backscatter)
591
why is the use of bolus materials in electron beam therapy is somewhat more complicated than in photon beam therapy
a decrease in dose is possible in an electron beam setup with use of bolus. for this reason "a partial bolus should never be used with electrons"
592
with increasing electron beam energy the ballooning of the isodose lines
decrease
593
What percent of cells are killed with a dosage of 5 Gy delivered?
50%
- 100,000 cells with 5 Gy delivered there will be 50,000 killed
594
Why are modern radiation therapy treatments given in fractions during an extended period (6-8 weeks)?
so that a high total dose is given to the tumor while ideally sparing normal tissues. known as fractionation
595
What determines the total dose, size, and number of fractions, and treatment duration?
The tumor type and tolerance of normal tissue in the tx field
596
What size of fractionation scheme is typical for daily tx?
180 to 200 cGy given 5 days a week for 6 weeks
- this totals a dose ranging in 5400 cGy to 6000 cGy
597
What is hyperfractionated radiation therapy?
schedules for radiation include tx BID (twice a day) and TID (3 times a day)
598
What is hypofractionated radiation therapy?
involves the use of dose fractions substantially larger than the conventional level of around 2 Gy
599
What are the four R's of radiation biology?
1. Repopulation
2. Redistribution
3. Repair
4. Reoxygenation
The biologic effects of tissue from fractionated radiation therapy depend on the "four R's" of radiation biology
600
What does Repopulation from the "four R's" mean?
the hope of repopulating of normal cells during tx. normal cells dividing, thus repopulating is highly desirable because it decreases the risk of late effects
601
What does Redistribution from the "four R's" mean?
known as partial synchronization, results in a redistribution or reassortment of surviving cells after irradiation. the ideal clinical situation for radiation treatment exists when tumor cells have moved into a sensitive phase and normal cells have moved into a resistant phase
602
What does Repair from the "four R's" mean?
repair of sublethal damage occurs within hours of radiation exposure in normal and tumor cells. is oxygen dependent because a portion of tumor cells are thought to be hypoxic therefor making tumors incapable of repairing sublethal radiation damage as efficiently as normal tissues
603
What does Reoxygenation from the "four R's" mean?
applies only to tumor cells, which is the process by which hypoxic cells gain access to oxygen and become more radiosensitive between fractions
604
What are the types of radiation?
alpha, beta, neutron, gamma, and x-rays
