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Metho > Skin And Breast > Flashcards

Skin And Breast Flashcards

1
Q

What are the types of non melanoma skin cancers

A
  • basal cell carcinoma
  • squamous cell carcinoma
  • mycosis fungoides
  • kaposi’s sarcoma
  • merkel cell
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2
Q

How many of cancers diagnosed are skin

A

1/3

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3
Q

What is the ratio of male to female of those diagnosed with skin cancers

A

2:1

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4
Q

What are the most common reasons for skin cancer

A

Fair skin
History of excessive sun exposure

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5
Q

Which skin cancer is most common

A

Basal cell carcinoma

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6
Q

Where do basal cell carcinomas arise from

A

Basal layer of epidermis

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7
Q

Where do basal cell carcinomas occur most

A

Head and neck

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8
Q

Compare the likely hood of metastasis from BCC to SCC

A

BCC (rare) and SCC (likely)

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9
Q

Where do SCCn arise from

A

Epidermal keratinizing cells

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10
Q

What is a SCC in situ known as

A

Bowen’s diease

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11
Q

What is a benign SCC known as

A

Keratocanthoma

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12
Q

What reasons would surgery be preferred over RT

A
  • four small lesions and primary closure is possible
  • mainly preferred over Rt
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13
Q

Why would RT be preferred over surgery

A
  • cosmetically or functionally sensitive area (nose, canthus of the eye)
  • comorbid disease
  • primary closure not possible
  • patient preference
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14
Q

What are the advantages of radiotherapy in skin cancers

A
  • better for older and in poor health
  • better for people on anticoagulants with bleeding tendency
  • preserves anatomic contour
  • no reconstructive surgery required
  • no anesthesia required
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15
Q

What are the disadvantages of radiotherapy in skin cancers

A
  • potential cataract or carcinogenesis in the young patient
  • many visits for optimal cosmetic result
  • some degree of chronic effects expected which worsen with time
  • takes 3-4 weeks to heal (acute morbidity)
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16
Q

What would be a reason to choose RT

A
  • improve local control ( post operative positive margin , extensive nodal disease found at dissection)
  • used as a primary where lesion could be deep
  • lesion could be nose, lip, eyelid, ear
  • to preserve normal tissue contours
  • if margins were not examined microscopically
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17
Q

What are some reasons for RT that are not primary or local control related

A
  • large primary size >5cm
  • recurrent disease
  • incompletely excised primary (positive surgical margins)
  • perineural invasion, lymphovascular invasion
  • regional nodal involvement
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18
Q

What are some reasons RT would not be used

A
  • young age (scar worsens with time)
  • area is exposed to other hazards (sunlight, poor blood supply, trauma/friction)
  • hair hearing skin
  • previous high dose RT
  • peripheral limb lesions in an edematous leg or with vasculopathy
  • fair fragile or damaged skin
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19
Q

What are the most common sites XRT will be used

A
  • eyelids
  • lip
  • nasal pyramid
  • canthal regions
  • pinna of the ear
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20
Q

Once radiation is chosen, what are the 8 steps that are taken to choose the treatment

A
  1. Determine extent and size of lesion
  2. Delineate surface depth/size
  3. Select beam type and energy
  4. Tailor field defining devices (margins)
  5. Tailor beam blocking devices if any
  6. +/- bolts
  7. Tailor immobilization / machine / set up
  8. Document all of the above
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21
Q

How’d you determine extent, size, and depth of the lesion

A

palpation
- bidigital (assess depth but is imprecise and requires safety margins)
- CT / MRI (assess depth of invasion (infiltrative/perineural))

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22
Q

What is the T staging for BCC and SCC

A

T1 - greater and equal to 2cm
T2 - 2-5cm
T3 - greater than 5 cm
T4 - tumour involves deep structures (cartilage, muscle, bone)

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23
Q

What are the CTV margins for BCC

A

< 2cm = 5mm
> 2cm or distinct/morphea or recurrent = 1cm
> and equal to 6cm plus advanced grade = 2cm

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24
Q

What is the margin for SCC

A

1 cm or more

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25
Q

What are the types of XRT used for skin

A

Superficial / ortho photons (single SSD field)
Electrons with bolus
Brachy
MV external beam

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26
Q

What are superficial X rays energy

A

50-150 Kip

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27
Q

Fill in these blanks for superficial x rays
Useful for _____ T_ lesions
Maximum dose on surface with ____% of dose is at ___mm of depth
___ dose fall off at ___ depth
After ___ mm dose drops off significantly
- excellent for _____ tumours

A
  • small T1
  • 90% at 5mm
  • rapid at 5mm
  • 5mm
  • superficial
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28
Q

What is the energy range for ortho

A

150-400 Kip

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29
Q

Fill in the blanks for ortho voltage x rays
Useful for
- more ____ disease T__
- involvement of ___ or ____
- involved _____
- maximum dose on ____
- additional _______ power
- 90% of dose at ____ depth
- excellent for lesions ________ the skin surface

A
  • bulky disease T1/2
  • bone or cartilage
  • lymph nodes
  • surface
  • penetrating
  • 2.0 cm
  • slightly below
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30
Q

What are the advantages of orthovoltage

A
  • easy shielding
  • narrow penumbra
  • relatively flat beam
  • low cost
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31
Q

What are the disadvantages of orthovoltage

A
  • F factor (increases absorption in bone compared to soft)
  • dose drop off (dose not uniform for thick tumour)
  • significant dose to underlying normal tissues, bone
  • availability of orthovoltage units
  • Dosimetry issues with small/shielded fields
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32
Q

When are ortho and electron preferred to one another

A
  • superficial/ortho are for T1-T2
  • superficial/ortho are for tumours greater than 4cm and 1cm thick
  • electrons are favoured for T2-T4 tumours and tumours on scalp to reduce exit dose to brain
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33
Q

What is now being more frequency being chose for T4 lesions

A

Megavoltage

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34
Q

Where at the isodose line is the therapeutic range given

A

90%

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35
Q

What are the advantages of electrons

A
  • good for deeper skin tumours as uniformity is better at depth than orhtovoltage
  • bolus can be utilized to increase surface dose
  • rapid dose drop off at desired depth
  • very available
  • lower absorption in cartiledge and bone
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36
Q

What are the disadvantages of electrons

A
  • wide field margin
  • lateral scatter of electrons makes shielding difficult
  • air spaces are harder to treat
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37
Q

Why is a wider field margin needed for electrons

A

Bowing of isodose lines

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38
Q

What does more side scatter at shallow depths and less at deeper depths result in

A

Higher isodose lines shifting more to surface. Decreasing therapeutic depth of beam

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39
Q

Is RBE lower or higher for electrons compared to low energy photons

A

Lower

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40
Q

What would be a sample dose for electrons with bolus? Include energy of beam

A

55/20 and 6 or 9 MeV

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41
Q

How much does dose need to be increased by if megavoltage is being used compared to superficial photons

A

10-20%

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42
Q

What would be the common fractionation for megavoltage T4 tumours

A

60/30

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43
Q

What would clinicians balance to determine fractionation ? What do each favour

A
  • convenience (short regimen)
  • retards proliferation (short regimen)
  • better cosmesis (longer regimen)
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44
Q

What is the general fractionation for small superficial tumours

A

20 in one fraction

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45
Q

What is the general fractionation for <3 cm, cosmesis unimportant ?

A

30-35 Gy/5

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46
Q

What is the general fractionation for <5 cm, cosmesis unimportant ?

A

45 GY/10-25fx

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47
Q

What is the general fractionation for most indications and is also the preferred

A

50/15-20

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48
Q

What is the general fractionation for a large volume with nodal areas

A

60-70/30-35

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49
Q

What is the minimum dose for SCC for all lesions

A

50gy

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50
Q

What is the TD5/5 for 10/10cm

A

70 GY (necrosis)

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51
Q

What is the electron fractionation schedule for less than or equal to 5cm

A

45/10

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52
Q

What is the electron fractionation schedule for less than or equal to 8cm

A

50/20

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53
Q

What is the electron fractionation schedule for greater than 8cm (large)

A

60-70/30-35

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54
Q

What is the electron fractionation schedule for post adjuvant RT

A

50/25

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55
Q

How much transmission should field defining devices allow

A

No more than 5%

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56
Q

How is orthovoltage therapy shielded

A

Pb cutout behind tumour as well

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57
Q

What are some examples of orthovoltage eye shielding

A

Lead (1.4-1.7 +coating)
Gold (18 Karat , 2.0mm)

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58
Q

How much transmission goes through each beam with eye shielding

A

225 kv 4%
100 kv < 4%
75 kv <4%

59
Q

What is the dose threshold for cataract formation

A

5-10Gy (or 0-0.08)

60
Q

What is the usual lead thickness for ortho and what does it depend on

A

1-3 mm over possible energy range and depends on filter type in beam

61
Q

What should high atomic number shielding be coated with

A
  • aluminum
  • dental acrylic
  • paraffin wax
62
Q

What is the eyeshielding for electrons

A

Tungsten with thickness of 2.8 mm coated with acrylic with 9MeV

63
Q

How is bolus different to tantalum wire mesh

A

Bolus: acts as a tissue equivalent and shifts isodose lines superficially
Wire: increases scatter to skin surface and dose not shift isodose lines

64
Q

What is the atomic number and density of wire mesh

A

73
16.6g/cc

65
Q

How thick is the wire and open area fraction

A

T= 0.51
F = 0.706

66
Q

What is the distance between wires in tantalum wire

A

3.2 mm

67
Q

What are examples of measurements and setup references

A
  • ink marks on skin
  • written set up instructions
  • photos of treatment setup
  • acetate template
    -patient data
  • orientation
  • scar
  • moles
  • previous tattoos
68
Q

What is positive and negative standoff

A

Positive: skin lesion is below the surface
Negative: skin lesion is above the surface

69
Q

How do you compensate for ISL in ortho

A
  • longer FSD
  • compensating attenuator
70
Q

What is mucous is fungoides a common form of

A

Cutaneous T cell lymphoma

71
Q

What is a common fractionation for mycosis fungoides / T cell lymphoma (cutaneous)

A
  • 10/5 with 3MeV
72
Q

What is a common fractionation for mycosis fungoides / T cell lymphoma (cutaneous) with multiple lesions

A
  • total body electron therapy (TBE)
  • extended SSD : 120cm
  • 45x45 field using 3MeV
  • 30/10 fractions biweekly
73
Q

What does TSET stand for and what is it also known as

A

Total skin electron therapy is also known as total body electrons TBE

74
Q

Where is the gantry and what is the position of the patient in TSET

A
  • 270 degrees
  • patient is standing
  • modified flattening filter
75
Q

What is the presentation of kaposi’s sarcoma

A

Multiple flat or raised purple lesions

76
Q

What is the fractionation of kaposi’s sarcoma

A

3 MeV: 10gy /1
TBE: 4Gy per week for 6-8 weeks with an average of 30Gy

77
Q

What is the fractionation of kaposi’s sarcoma

A

3 MeV: 10gy /1
TBE: 4Gy per week for 6-8 weeks with an average of 30Gy

78
Q

What is the use of RT in melanoma

A
  • palliation, bleeding, ulceration
79
Q

What is the fractionation of melanoma with and without nodal involvement

A

Without: 30 giving 6-8 weekly
With: 50/25

80
Q

How is ocular melanoma treated if the disease is inside the eye and outside

A

Inside: enucleation. Conservative RT treatment with some chemo
Outside: brachytherapy or proton

81
Q

What does ABCDE stand for

A

Asymmetry
Boarders
Colour
Diameter
Evolving or elevation

82
Q

Where is the breast sitatuated approx

A
  • superiority 2nd rib
  • inferiority 6th rib
  • medial lateral sternum
  • laterally- mid axillary line
    Anterior - skin
    Post - Pectoralis major
83
Q

What is the biggest prognostic factor of the breast

A

Nodal involvement

84
Q

Describe the pathway of nodal involvement starting with level I (axilla level)

A

Axilla level I (lateral axillary lymphnode)
Mid axillary II (central axillary lymphnode)
High axillary III (apical axillary lymphnode)
Supraclavicular
Internal mammary chain

85
Q

Define each stage in breast cancer

A

I: tumour confines to the breast or at least one micromet
II: tumour is greater than 5cm in diameter or spread is to 1-3 movable ipsilateral axillary node
III: tumour is greater than 5cm or has spread to skin or chest wall or IMC nodules are involved or more than 3 axillary lymphs or SC nodes are involved
IV: metastasis present

86
Q

Is RT needed is risk recurrence is less than 5%

A

No

87
Q

What is the role of radiaiton in early breast cancer

A

Conserving
Reduce local recurrence following lumpectomy

88
Q

What is the typical treatment for stage I

A

Lumpectomy + sentinel node biopsy
RT to ipsilateral breast
Hormone treatment if hormone positive
Chemo if high risk

89
Q

What is the typical treatment for stage II

A

Lumpectomy + sentinel node biopsy +- axillary lymphnode dissection if positive sentinel nodes
Cx
RT to ipsilateral breast +- regional nodes
Hormone treatment if hormone positive

90
Q

What are some immobilization accessories for breast cancer

A

Vacuum bags
Immobolization uvex cast
Breast board
Raised styrofoam board

91
Q

What are breast “immobilization” devices (large pendulous breast)

A

Aquaplast
Thermoplastic shell
Styrofoam wedge
Wireless bra
Sock

92
Q

If patient is in breath hold should it be inhale or exhale

A

Inhale: moves chest wall away from heart

93
Q

How to do breath hold

A
  • ABC
  • reflective marker
  • VBH
  • surface rendering
94
Q

What are the typical breast techniques

A
  • 2 beams
  • tangential field
95
Q

What is the most common technique

A
  • isocenter is, half beam, parallel opposed tangential technique
96
Q

What are the tattoos on the breast patient (not diamond)

A
  1. ASU (medial C/A)
  2. Straightening Tattoo
  3. Lateral boarder C/A
  4. Levelling Tattoo
97
Q

What are the tattoos on the breast patient (diamond)

A
  1. Medial
  2. Inferior CAX (1.5-2cm inf to palpable breast tissue)
  3. Lateral TTH (medial of TTH)
  4. Sup CAX (1.5-2cm inf to palpable breast tissue)
98
Q

What is the commonality between both tattoo setups on breast

A

Tattoos placed on stable surfaces to localize
the breast tissue
Laterals may be on one
side or on both sides

99
Q

What are the typical boarders of a standard tangent field

A

SUP: SSN (1.5-2.0cm sup to breast)
INF: 2cm inf to inframammary fold
MED: midline
LAT :mid axillary line

100
Q

What are the typical boarders of a standard tangent field

A

SUP: SSN (1.5-2.0cm sup to breast)
INF: 2cm inf to inframammary fold
MED: midline
LAT :mid axillary line

101
Q

What does the CTV include in a breast

A

entire breast with 2cm clearance
Chest wall with 1-3cm lung volume included
Field boarders must include
- tumour bed (surgical clips)
- surgical scar (scar marked by wire)
- margins to ensure a 2cm margin beyond

102
Q

When does moist desquamation occur

A

4000 Cgy or earlier for larger breasts

103
Q

When does acute pericarditis with subsequent fibrosis occur

A

4000cgy

104
Q

For average size patients with separation between 18-21cm, what would the energy be

A

4-6MV photons

105
Q

What MV should be used for separations over 22cm

A

10-18MV

106
Q

When would beam energies be mixed in breast cases

A
  • ensure adequate dosage to entire breast
  • improve cosmesis
107
Q

What are the common dose regimes for breast

A

4240 (4256) cGy/16#/3.5 weeks
•265 (266) cGy / day

4005 cGy/15#/3.5 weeks
•267 cGy / day

5000 cGy/25#/5weeks
•200 cGy / day

•Latest one 2600 cGy/5#/1week

108
Q

Where is the isocenter located in a breast setup

A

Mid way along posterior field border

109
Q

How is collimator angle beam aligned

A

Slope of chest

110
Q

How is field width defined

A

Asymmetrically by anterior jaw

111
Q

What are the everyday checks

A
  • covering all breast tissue with anterior clearance
  • covering lumpectomy scar
  • arm out of field
  • separations or depth
    Reference to tattoos
    Acccessories
    Lung volume with portal imaging
112
Q

What are some set up correction strategies

A

Gantry
Vertical
Vert and lat
Tape

113
Q

What are some other techniques used to treat breast cancer (RT)

A

Intraopertive (irradiate open cavity with 20/1)
Breast permanent seed implant (u/s guided)
Accelerated partial breast irradiation (EBRT 30/5 , 38.5/10) brachy HDR

114
Q

What is APBI and what does it stand for . What is the dose regime

A
  • CBCT guided non co planar beams for early stage patients with no LVI, great margins
  • uses 38.5/10 BID
  • accelerated partial breast irradiation
115
Q

What is the fractionation for post tangent radiotherapy boosts for EBRT

A

10-16Gy in 4-5 fractions for EBRT

116
Q

What are the types of seroma.tumour bed boosts

A

Electron beam
Electron / photon
Cone down photon
Non co planar photon
Boost with interstitial implant

117
Q

What are the types of seroma.tumour bed boosts

A

Electron beam
Electron / photon
Cone down photon
Non co planar photon
Boost with interstitial implant

118
Q

What is the typical energy for an electron boost to the breast and to which isodose line

A

10-16 MeV

To 90%

119
Q

When are cone down photons used and what are they also known as

A
  • aka mini tangents
  • reduced to only include the tumour with a 1-2cm margin
    Suited for large deep seromas
120
Q

What is the margin for a non co planar photon/vmat

A
  • 2cm
121
Q

What are the characteristics of iridium 192 as a boost
- fractionation
- type of catheter
- advantage

A
  • 10/2
  • interstitial or intracavity balloon
  • improved cosmetic result
122
Q

How many lymphnodes in each axilla

A

10-38 or more

123
Q

What percentage drain to the axilla and IM chain

A

> 75% : axillary
<25% : IM

124
Q

About how much breast cancer occurs in the outer upper quadrant

A

40%

125
Q

How many breast cancer cases are locally advanced

A

10-15%

126
Q

What makes a breast locally advanced ? How is it usually cured

A

More advanced - large tumour, nodal disease, extension onto chest wall or skin, inflammatory
Cured through with multimodality therapy

127
Q

What is axillary node sampling

A
  • small number of nodes removed (minimum of 4)
128
Q

What is axillary lymphnode clearance

A

Removal of the first two levels of lymph nodes

129
Q

What is______ for XRT in locally advanced breast cancer
Intent
Beam arrangement / energy
Dose:
Dose homogeneity

A

Radical / curative intent
Tangential obliques / 4-6MV or mixed with 10-18MV / AP and PA pair to cover supclav and axilla
5000/25 for 5 weeks with a boost
Wedges/IMRT , bolus

130
Q

What is the scan range for LABC

A
  • mandible to cover entire thorax plus 4cm inf
131
Q

What’s is the four field technique

A
  • 2 AP PA POP to supraclav and axilla
  • 2 POP tangents to breast and chest wall
132
Q

What are the advantages of dual asymmetry

A

Perfect match line
Equivalent field definition
Superior absorption
Cost effective
Minimal junction inconsistency

133
Q

4 field dual asymmetric technique isocenter s

A

1 iso centre: tangents and supraclavicular
2 isocenter: tangents/anterior field and posterior field
3: tangents, ant supraclavicular and post supraclavicular

134
Q

What is the fraciationation and beam energy for axilla and supraclav fields

A

5000/25
4-6MV

135
Q

What are the boarders of the supraclavicular field

A

Medial : 1cm of M/L cord
Lateral: cover humeral head and surgical neck
Sup: thryocricoid groove
Inf: inf clavicular head

136
Q

What are the boarders of a four field tangent field

A

Med: approx: M/L
Lateral: cover breast tissue
Sup: inf clavicular head
Inf: 2cm inf to fold

137
Q

How do you define post border for 2 and 4 field tangents

A

2: rotate collimator and half beam block , non divergent posterior boarder
4: do not rotate and and defined using MLC , divergent posterior boarder

138
Q

How do you define post border on chest wall

A

With bolus

139
Q

What are the setup correction strategies for tangents and supraclav

A
  • couch shifts
  • gantry rotation (3 degrees for SC)
140
Q

What are the pros and cons to RT to the IMC with photons using wide tangents

A

Pro: treats IMC, technique is easy and no field matching
Cons: treats more normal tissue

141
Q

What are the boarders for a separate IMC field

A

Sup: abutting the inf boarder of the SC field
Right boarder: 1cm across midline
Left boarder: 4cm lateral to midline
Inferior: xiphoid or 4th intercostal space to spare heart

142
Q

Describe each for the separate IMC field
- energy for electrons
- dose
Critical structures

A

12-16MeV
5000/25
Ipsilateral lung and heart

143
Q

What is the isocentric, half beam, parallel opposed tangential technique ?

A
  • eliminates beam divergence into underlying lung and contralateral breast
  • most common
  • affords optimal coverage of breast tissue and chest wall
144
Q

What are some challenges in bilateral breast cancer

A
  • large breasts
  • immobilization
  • confusing references
  • gap between volumes

Metho (2 decks)

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