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Oral Boards > Sarcoma > Flashcards

Sarcoma Flashcards

1
Q

Site of metastatic disease

A
  • For extremity: lung, bone, soft tissue
  • For retroperitoneal: liver
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2
Q

Histologies with higher risk of nodal metastases

A

CARE

  • Clear cell
  • Angiosarcoma
  • Rhabdomyosarcoma
  • Epithelioid
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3
Q

Physical exam features for sarcoma

A
  • ROM
  • Pain
  • Swelling
  • Neurologic dysfunction
  • Pulses
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4
Q

Necessary workup

A

Try to obtain imaging prior to biopsy –CT/MRI –+/-PET –Plain film of chest or CT chest –Special imaging

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5
Q

What other imaging does myxoid sarcoma require

A

MRI spine

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6
Q

What other imaging does alveolar soft part sarcoma or angiosarcoma require

A

MRI brain

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7
Q

After imaging of sarcoma –> next step

A

Biopsy

  • Core is preferred
  • Incisional
  • Excision is lowest priority given risk of non-oncologic surgery
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8
Q

When would an RP sarcoma get biopsied

A

If preop RT is planned

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9
Q

What dictates sarcoma grade

A
  • Mitoses
  • Atypia
  • Necrosis
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10
Q

Sarcoma T1

A

<5 cm

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11
Q

Sarcoma T2

A

5-10 cm

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12
Q

Sarcoma T3

A

10-15 cm

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13
Q

Sarcoma T4

A

>15 cm

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14
Q

Stage IA sarcoma

A

T1 G1

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15
Q

Stage IB sarcoma

A

T2-T4 G1

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16
Q

Stage II sarcoma

A

T1 G2 or G3

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17
Q

Stage III

A

T2-T4 G2-3

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18
Q

Management of stage I tumors

A
  • Several options
    • Surgery alone with observation (preferred for T1)
    • Surgery plus adjuvant RT if close or positive margins (more if IB)
    • Pre-op RT –> surgery
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19
Q

Principles of sarcoma surgery

A
  • Limb sparing
  • Wide local excision with 1-2 cm of margins
  • Place clips at any area of concerning margin
  • Resect biopsy and scar
  • Closer or positive margins are acceptable at major nerves/vessel/bone or areas that cause functional deficits
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20
Q

Indications for neoadjuvant RT

A
  • Amputation would be necessary with surgery
  • Poor functional outcomes anticipated
  • Concerns about margin +
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21
Q

Indications for postop RT

A
  • Close or positive margins (<1 cm) and reresection not possible
  • Larger size (T2+)
  • Higher grade (G2-G3)
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22
Q

What is the benefit of RT for sarcomas

A

Improves local control (70% –> 90%)

No difference in OS

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23
Q

Management of stage II tumors

A
  • Surgery +/- Adjuvant RT
  • Pre-op RT –> surgery
  • Brachytherapy
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24
Q

What is the management of stage III sarcomas?

A
  • Preop RT –> surgery
  • Surgery –> RT + chemo
  • Brachytherapy
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25
Q

What chemo regimen is recommended for sarcomas?

A

doxorubicin containing regimen, single or multi-agent

26
Q

What is the preop dose for sarcomas?

A

50 Gy in 25 daily fractions of 2 Gy

27
Q

What is the postop dose for extremity sarcomas?

A
  • Negative margins: 60 Gy
  • Microscopic margins: 66 Gy
  • Gross positive margins: 70 Gy
28
Q

What is the benefit/tradeoff of preop RT

A
  • Benefits
    • More defined targets
    • Smaller targets
    • Lower dose
    • Less fibrosis/joint stiffness and edema
    • Less hypoxia
  • Downside
    • More wound complications post op, especially LE
    • Delays surgery
29
Q

What is anticipated rate of wound complications preop vs. postop

A
  • Preop: 35%
  • Postop: 17%
30
Q

What are the 5 year OS rates for stage I-III tumors

A
  • stage I: 85-90%
  • stage II: 70-80%
  • stage III: 70-80%
31
Q

Downside of postop RT

A

More fibrosis, joint stiffness, edema

32
Q

Management of N1 or M1 sarcoma

A

Doxorubicin containing chemo

SBRT or surgery for up to 4 spine or lung mets

33
Q

General principles of STS RT treatment

A
  • CT and MRI sim if possible or fuse T1 post contrast and T2 sequences
  • Spare >1 cm of limb cross section to reduce edema risk
  • Treat < 50% of bone circumference if possible
  • Avoid joint space or exclude after 40-45 Gy
34
Q

What RT approach should be used for STS

A

IMRT with faily KV/CBCT

35
Q

CTV margins for preop RT

A
  • If GTV >8 cm
    • CTV = gross disease + T2 edema + 3cm longitudinal, 1.5 cm radial
  • If GTV <8 cm
    • CTV = gross disease + T2 edema + 2cm longitudinal, 1 cm radial
36
Q

CTV margins from GTV for large sarcomas

A

3 cm longitudinal

1.5 cm radial

37
Q

When should postop RT start?

A

10-20 days postop for healing

38
Q

What is the contouring strategy for postop RT for STS?

A
  • CTV50: tumor bed, scar, drain sites + 4 cm longitudinal, 1.5 cm radial
  • CTVboost: tumor bed + 2 cm longitudinal, 1.5 cm radial
39
Q

Boost doses for postop RT

A

If R0: 60 Gy

If R1: 66 Gy

If R2: 70 Gy

40
Q

Strategy if preop given and then margin positive

A

Give boost dose post op

srugical margin + 1 cm

41
Q

Anus/vulva constraint

A

V30 <50%

42
Q

Testis constraint

A

V3 < 50%

43
Q

Femoral neck

A

V60 < 5%

44
Q

Joint constraint

A

V50 < 50%

45
Q

Skin strip constraint

A

V20 < 50%

46
Q

PTV coverage goal for sarcomas

A
  • V97% = 99%
  • V110% <20%
47
Q

Follow-up recs for sarcomas

A

MRI primary and CT chest q3m x 2years –> q6m x 2-5 years –> annual

48
Q

Complications for STS

A

Wound complictions

Fibrosis and decreased ROM

Weakening of bone/fracture

Limb length discrepancies

Lymphedema

Dermatitis, hyperpig, telangiectasia

5% risk of second malig

Compartment syndrome (dex and fasciotomy)

49
Q

Staging of RP sarcomas

A

same as extremity

50
Q

Management of RP sarcomas

A

In general, if resectable should go to surgery straight

If concern about margin–> core needle biopsy –> neoadjuvant RT (45-50 Gy) –> maximal safe surgery

51
Q

What is the rate of local failure for RP sarcoma

A

50-80%

52
Q

What is 5 year OS for RP sarcoma

A

30-60%

53
Q

What histology for RP sarcoma has poorest outcomes

A

leiomyosarcoma (highest rate of DM)

54
Q

What is the controversey of preop RT

A

Recent trial demonstrated no difference in abdominal RFS but this was a controversial primary otucome.

The LF was significant reduced (50%) with RT

55
Q

When should postop RT be done for RP sarcoma

A

Maybe +margin but very discouraged due to high GI toxicity

56
Q

Simulation for RP sarcoma

A

Supine, alpha cradle, 4dCT, PO/IV contrast, fuse with diagnostic CT and MRI

57
Q

Contouring for RP sarcoma

A
  • GTV = gross disease
  • ITV = accounting for motion
  • CTV = 1.5 cm expansion (edit of organs, bones), with only 5 mm extension into bowel
  • PTV = 5 mm expansion, daily CBCT
58
Q

Management of desmoid tumors

A

Surgery is best with wide margins (2cm+)

If R1: 50 Gy if re-resection not possible

If R2: re-resect or RT (50 Gy)

59
Q

What if desmoid is unresectable?

A

56 Gy or systemic therapy

Use wide margins

60
Q
A

Oral Boards (12 decks)

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