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Oral Boards > Thoracic > Flashcards

Thoracic Flashcards

1
Q

NCCN recommendation for screening

A
  • Annual low dose CT for high risk patients
  • “Shared decision making”
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2
Q

Who are eligible pts for screening CT?

A
  • >30 pack year history
  • Current or former smoker within 15 years
  • age 55-74
  • age 50+ with other risk factors (radon, occupational exposures, Fhx of lung cancer, COPD/fibrosis)
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3
Q

In the National Lung Screening Trial, how much did CT screening reduce mortality?

A

20%

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4
Q

Solid nodules > X or part solid nodules > Y deserve CT at 3 months, PET or biopsy

A

Solid > 8 mm

Semi-solid > 6

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5
Q

Plan for solid nodules 6-8 mm in size

A

CT at 6 months

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6
Q

Plan for single ground glass opacitiy

A

If > 6 mm, CT at 6 months to confirm no growth or development of solid component –> q2y for 5 years

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7
Q

Plan for multiple subsolid nodules

A

CT in 3-6 months

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8
Q

What history should be asked for thoracic patient

A
  • Pulm symptoms
  • Weight loss
  • Fevers
  • Hemoptysis
  • Shoulder pain/dysufunction
  • Neuro exam/headaches
  • Paraneoplastic questions
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9
Q

What labs and tests should be ordered for a thoracic patient

A
  • CBC
  • CMP
  • LDH
  • PFTs
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10
Q

How best to pathologically diagnosis central lesion

A

Bronch and EBUS

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11
Q

How best to pathologically diagnose peripheral lesion

A

CT guided biopsy

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12
Q

Pneumothorax risk with CT-guided bx

A

20%

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13
Q

How to manage a pleural effusion

A

Perform thoracentesis with US

Obtain 50 cc of fluid and send for culture and cytology

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14
Q

Diagnostic yield of pleural cytology

A

50%, increases to 70% if 2 performed

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15
Q

Which patients are exempt from mediastinal sampling?

A

NCCN says patients with solid lesions <1cm or non-solid <3 cm, especially if PERIPHERAL

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16
Q

How many stations should be sampled on a good mediastinal review

A

3 stations, including 7

Try to hit all involved stations

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17
Q

Level 2 thoracic

A

High paratracheal

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18
Q

Level 3 lymph nodes

A

Retrotracheal or prevascular

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19
Q

Level 4 nodes

A

Paratracheal

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20
Q

Level 5 nodes

A

AP window

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21
Q

Level 6 nodes

A

Para-aortic nodes

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22
Q

Level 7 nodes

A

Subcarinal

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23
Q

Level 8 nodes

A

para-esophageal

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24
Q

Level 10 nodes

A

Hilar

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25
Q

Level 11 nodes

A

Interlobar

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26
Q

What levels are obtained with cervical mediastinoscopy

A
  • 1 - high mediastinal
  • 2 - high paratracheal
  • 3 - prevascular
  • 4 - low paratracheal
  • 7 - subcarinal
  • 10 - hilar
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27
Q

What levels are obtained with EBUS

A

1, 2, 4, 7, 10, 11, 12

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28
Q

What levels obtained with chamberlain procedure

A

5 - AP window

6 - para-aortic

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29
Q

Principles of lung cancer imaging

A
  • CT chest w contrast - compare with prior
  • CT AP - look at adrenals
  • PET CT
  • MRI brain if stage IB or greater
  • MRI spine or brachial plexus if Pancoast
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30
Q

MRI brain should be ordered for which stages

A

IB or greater

T2b or higher

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31
Q

T1 lung cancer

A

<3 cm

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32
Q

T1a lung cancer

A

<1 cm

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33
Q

T1b lung cancer

A

1-2 cm

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34
Q

T1c lung cancer

A

2-3 cm

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35
Q

T2 lung cancer

A

3-5 cm

Involvement of mainstem bronchus or visceral pleura

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36
Q

T2a lung cancer

A

3-4 cm

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37
Q

T2b lung cancer

A

4-5 cm

Involvement of mainstem bronchus

Involvement of visceral pleura

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38
Q

T3 lung cancer

A

5-7 cm OR

Invasion of

  • Parietal pleura
  • Chest wall
  • Phrenic nerve
  • Parietal pericardium
  • Separate tumor nodules in same lobe as primary
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39
Q

T4 lung cancer

A
  • >7 cm
  • Involvement of
    • Diaphragm
    • Mediastinum
    • Heart
    • Great Vessels
    • Trachea
    • Recurrent laryngeal nerve
    • Esophagus
    • Vertebral body
  • Separate nodules in ipsilateral lung but different lobe
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40
Q

Separate nodule in different lobe IPSILATERAL is

A

T4

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41
Q

Separate nodule in same lobe IPSILATERAL

A

T3

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42
Q

Separate nodule in diff lobe CONTRALATERAL

A

M1a

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43
Q

N1 lung cancer

A

Ipsilateral 10-14

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44
Q

N2 disease

A

Ipsilateral 1-9

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45
Q

N3 lung cancer

A

Contralateral mediastinal or hilar nodes

Ipsi or contra SCV nodes

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46
Q

What is sens/spec of PET for nodes

A

~80%

more false positives with central tumors

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47
Q

How many are surgically upstaged in terms of nodal disease?

A

10-20%

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48
Q

M1a lung cancer

A

Separate tumor nodule in contralateral lobe

Tumor with pleural or pericardial nodules

Malignant pleural effusion

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49
Q

M1b lung cancer

A

single extrathoracic met

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50
Q

T1 N0 lung cancer is stage X

A

IA

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51
Q

T2N0 lung cancer is stage X

A

IB or IIA

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52
Q

Criteria for IIIA disease

A

T1 or T2 N2

T3N1

T4 N0

T4 N1

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53
Q

Criteria for IIIB cancer

A

T1 or T2 N3

T3 N2

T4 N2

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54
Q

Criteria for stage IIIC lung cancer

A

T3 N3

T4 N3

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55
Q

OS at 5 years of stage I lung cancer

A

70-90%

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56
Q

5 year OS of stage II lung cancer

A

50-60%

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57
Q

OS at 5 years of stage IIIA lung cancer

A

35-40%

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58
Q

5 year OS of stage IIIB lung cancer

A

25%

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59
Q

5 year OS of stage IIIC lung cancer

A

12%

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60
Q

Medically inoperable DLCO

A

<50%

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61
Q

Medically inoperable FEV1

A

<50%

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62
Q

Medically inoperable FEV1/FVC

A

< 75%

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63
Q

If pneumonectomy planned, FEV1 must be

A

>2L (preoperative)

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64
Q

If lobectomy planned, FEV1 should be

A

1.2 L (preoperative)

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65
Q

Other medical inoperable characteristics

A

Severe pulm HTN

DM with severe end organ damage

Severe vascular or cardiac disease

Patient refusal

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66
Q

What is preferred surgical approach

A
  • Lobectomy (periop mortality 3%)
  • Pneumonectomy if near proximal bronchus (periop mortality 6%)
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67
Q

When is wedge resection ok

A

Tumor < 2cm, margin > 2cm

LRR is 18% (vs. 6% for lobectomy)

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68
Q

Paraneoplastic syndrome with squamous

A

HyperCa

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69
Q

Paraneoplastic syndrome with adenocarcinoma

A

Hypercoagulable state

Hypertrophic osteoarthropathy

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70
Q

Paraneoplastic syndromes with SCLC

A

SIADH

Ectopic ACTH

Lambert-Eaton

Cerebellar ataxia

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71
Q

SIADH symptoms

A

Hypo Na

HA

N/V

Confusion

Seizures

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72
Q

Lambert-Eaton symptoms

A

Proximal muscles weak

Ptosis

Improves with exercise

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73
Q

Cerebellar ataxia symptoms

A

Gait instability

Dysphagia

Dysarthria

Diplopia

Retinopathy

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74
Q

What is stage IIB NSCLC

A

T1N1

T2N1

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75
Q

What is the management for stage I or II NSCLC (resectable)

A
  • Surgery if option
  • Risk adapted adjuvant therapy
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76
Q

What are high risk features warranting adjuvant chemo for resected NSCLC?

A
  • Poor diff
  • LVI
  • Wedge resection
  • >4 cm (T2b)
  • Visceral pleural involvement
  • N2 disease
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77
Q

What are adjuvant chemo options?

A
  • Cis 75 mg/m2 or carbo AUC 5 + pemetrexed 500 mg (ADENO)
  • Docetaxel 75 mg (SQUAMOUS)
  • q3w
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78
Q

How many cycles of adjuvant chemo should there be?

A

4 cycles

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79
Q

What is the benefit of adjuvant chemo?

A

Probably 5-10% OS advantage

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80
Q

When should PORT be considered?

A
  • N1/N2 - ONLY if no chemo planned
  • Positive margin - favor re-resection or CRT
  • Stage III, R1: PORT –> chemo
  • Stage III, R2: CRT
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81
Q

Per LungART, what is the benefit of PORT for N2 disease

A

Reduces mediastinal relapse 50%

Other outcomes similar

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82
Q

What stages are considered potentially resectable NSCLC

A
  • Stage IIIA (T1-T2bN2 or T3N1)
  • Stage IIIB (T3N2)
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83
Q

Treatment options for potentially resectable NSCLC

A
  • Trimodality therapy: CRT –> surgery (if lobectomy)
  • Definitive CRT
  • Chemo –> surgery –> +/- PORT
  • Surgery –> chemo +/- PORT (in either order)
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84
Q

If resection if planned, what should be the CRT strategy

A
  • Platnium doublet chemo (cis/etoposide or carbo/taxol)
  • Plan for 45-54 Gy neoadjuvant
    *
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85
Q

If contemplating trimodality therapy, what surgery is preferred?

A

Lobectomy

If pneumonectomy is required, discuss with surgeons and consider definitive CRT given excess mortality risk

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86
Q

What is the benefit of chemotherapy?

A

5% OS improvement

Same if pre or post operative

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87
Q

Definition of superior sulcus tumors

A
  • Apical tumor with chest wall or rib invasion
  • Pancoast syndrome
    • Shoulder pain
    • Brachial plexopathy
    • Horner’s syndrome
  • Usually T4N0 or N1
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88
Q

Horner syndrome

A

Ptosis

Myosis

Anhidrosis

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89
Q

Additional workup required for Pancoast tumor

A
  • MRI brain
  • MRI brachial plexus
  • Rule out other sources of pain (cardiac)
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90
Q

Strategy to treat superior sulcus tumors

A
  • Neoadjuvant cis-etoposide plus 45 Gy
  • Restage with MRI brachial plexus after 45 Gy
    • If good response –> surgery
    • If poor response –> continue to 60-66 Gy with concurrent chemo
    • In either scenario: 2 more cycles of chemo and/or durva
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91
Q

What is the brachial plexus consideration for superior sulcus tomor

A

Dmax <60 (66 is necessary)

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92
Q

For medically inoperable early stage tumors, local control of SBRT

A

95% local

90% local/lobar

93
Q

For medically inoperable early stage tumors, local control of hypofractionation

A

75% LC

94
Q

For medically inoperable early stage tumors, local control of conventional fx

A

50-60%

95
Q

What are the RT options for medically inoperable stage I/II tumors?

A
  • SBRT (goal BED > 100)
  • Moderate hypofractionation (60/15)
  • RT alone to 60-66 Gy

Consider post RT chemo for >IA based on risk factors

96
Q

What tumors are eligible for SBRT

A
  • <5 cm
  • >2 cm from central structures
97
Q

Definition of central tumor for SBRT

A

tumor in the no fly zone (2 cm expansion of distal 2 cm of carina through mainstem bronchi to lobar bronchi)

98
Q

Dose of RT for central tumor

A

10 Gy x 5

99
Q

Definition of ultracentral tumor for SBRT

A
  • PTV abuts major airway, pulm vein, pulm artery, mediatinum
100
Q

Dose of SBRT for ultracentral malignancies

A

7.5 Gy x 8 QOD

101
Q

Characteristics for unresectable stage III tumors

A
  • Medically inoperable
  • T4 (unresectable)
  • N3 disease
  • High N2 or contralateral N2 disease
  • Bulky or multi-station N2
    • Pneumonectomy (relative)
102
Q

Treatment options for inoperable Stage III NSCLC

A
  1. Concurrent chemoRT (to 60-66 Gy)
  2. Sequential chemo –> RT (or hypofractionated RT)
  3. Sequential RT –> chemo (if very symptomatic or obstructive)
  4. Consider adjuvant durva following chemoRT
103
Q

Chemo options for NSCLC definitive CRT

A
  • Cis/etoposide
  • Carbo/pemetrexed
  • Weekly carbo-taxol
104
Q

Dose of cis and etoposide for definitive CRT

A
  • Cisplatin 50 mg/m2 days 1,8, 29, 36
  • Etoposide 50 mg/m2 days 1-5 and 29-33
105
Q

Dose of carbo pemetrexed for definitive CRT

A
  • Only for non squamous histologies!
  • Carbo AUC 2 day 1
  • Pemetrexed 500 mg/m2 day 1 and 21
106
Q

Dose of weekly carbo taxol

A
  • Carbo AUC 2
  • Taxol 50 mg/m2 weekly
107
Q

Adjuvant immunotherapy option for definitive CRT, NSCLC

A

durvalumab 10 mg/kg, q2weeks

Start within 2-6 weeks post CRT

Get restaging scan after CRT!

108
Q

What is the benefit of PCI for NSCLC

A

Decreased number of mets but no difference in OS or DFS

109
Q

What is 5 year OS for concurrent vs. sequential CRT for NSCLC (no durva)

A
  • CRT - 16%
  • Sequential 10%
110
Q

What is the benefit of induction chemo for pts planned for definitive CRT

A
  • No benefit to induction chemo –> CRT
  • Consider if significant bulk and would be beneficial to shrink fields to meet constraints
111
Q

Treatment options for oligometastatic disease

A
  • Per Gomez et al - pts with NSCLC with 1-3 mets with lack of progression after 1L systemic therapy randomized to local consolidation therapy (surgery or SBRT) or maintenance treatment , PFS and OS favors local therapy
112
Q

First line treatments for metastatic NSCLC

A
  • If PDL1 > 50%: Pembro
  • If PDL1 < 50%: Pembro + Carbo + Pemetrexed
113
Q

Second line therapies for stage IV NSCLC

A

Pembro (if PDL1 >1%)

Nivo

Atezolizumab

Chemo

114
Q

High risk CT features after RT

A
  • Enlarging opacity (after 12 months)
  • Craniocaudal growth
  • Sequential enlargement
  • Loss of linear margins
  • Bulging margins
  • Loss of air bronchograms

FOR THESE CONSIDER PET –> BX

115
Q

Dose and targets for definitive RT of NSCLC

A
  • 60 Gy in 2 Gy fractions
  • Treat the primary and affected nodal disease
    • >1 cm
    • PET+
    • Bx+
  • No elective nodal irradiation
116
Q

Simulation setup for lung treatment

A
  • Supine
  • Arms raised
  • Alpha cradle
  • CT sim with IV contrast, small amount of esophageal contrast
  • Image from cricoid to below diaphragm
117
Q

Volumes for definitive lung

A
  • GTV = tumor and involved nodes
  • ITV = tumor + nodes with motion accounted per 4DCT
  • CTV = ITV + 7 mm (subtract from esophagus, bone)
  • PTV = CTV + 5 mm setup
118
Q

What is a 4DCT

A

Multiple images in thin section, the images are sorted into each breathing phase and reconstructed into a 4D movie, if the tumor is ever in that location during breathing, it is included in the ITV

119
Q

Treatment volumes for PORT

A
  • +Margin
  • Treatment stump
  • For N2, include the high risk or involved nodal stations
    • Ipsilateral level 4, 7, hilum
120
Q

Doses for PORT

A
  • If negative margin: 50.4 Gy in 28 fractions
  • If microscopic margin: 54 Gy in 30 fractions
  • If R2 margin or ENE: 60 Gy in 30 fractions
121
Q

What is the coverage objective for lung plans?

A
  • V100% > 95%
  • V90% > 99%
122
Q

What is the benefit of IMRT over 3DCRT for conventional lung plans?

A
  • Reduce pneumonitis risk
123
Q

What is the V20 goal for conventional lung plans

A
  • Consider lung minus GTV
  • V20 < 37%
124
Q

Strategies to reduce V20

A
  • Switch from 3D to IMRT/IGRT
  • Reduce CTV margin
  • Induction chemo
  • Consider DIBH to reduce ITV
  • Replan after 40-45 Gy
125
Q

V5 goal for conventional lung plans

A

<65%

126
Q

Mean lung dose for conventional lung plans

A

<20 Gy

127
Q

Spinal cord constraint for conventional lung plans

A

<50 Gy

128
Q

Heart constraints for conventional lung plans

A
  • Mean < 35 Gy
  • V45 < 60%
  • V60 < 30%
129
Q

Esophagus constraint for conventional lung plans

A
  • Mean < 34 Gy
  • MPD < 105%
130
Q

Brachial plexus constraint

A

MPD < 66 Gy

131
Q

SBRT planning considerations

A
  • 7-10 non opposing, non coplanar beams
  • Heterogeneity corrections
  • 100% IDL covering the PTV
132
Q

SBRT lung coverage goals

A
  • D95% > 100%
  • MPD < 115%
  • <105% dose outside of PTV
  • Max dose >2 cm from PTV < 50%
  • No hot spots in OARs
133
Q

Acute toxicities of lung RT

A
  • Dermatitis
  • Esophagitis
  • Cough
  • Fatigue
  • Cytopenias (weekly CBC if on CRT)
134
Q

Late toxicities from lung RT

A
  • Brachial plexopathy
  • Pericarditis
  • Pulmonary fibrosis –> cor pulmonale
  • Dyspnea
  • Respiratory failure
135
Q

Time course for RT pneumonitis

A

subacute, 6w to 6mos

136
Q

Symptoms of pneumonitis

A
  • Fever
  • SOB
  • Opacities in treatment field
  • Hypoxia
  • Tachycardia
137
Q

Workup for pneumonitis

A
  • Rule out other causes - COVID, PNA
  • Cardiac dx
  • POD
  • GI causes
  • Get PFTs to follow (DLCO might be reduced)
138
Q

Treatment of pneumonitis

A
  • Prednisone 60 mg daily
  • Slow taper over 2-3 months
  • PPI + Bactrim
  • O2 if needed
  • Pulm c/s
139
Q

For SCLC volumes, how to approach if post chemo

A
  • Ok to limit GTV to post induction volumes
  • Initially involved nodal regions should be covered (not volumes)
140
Q

Spinal cord constraint if doing 45 Gy in BID fractions

A

MPD < 41 Gy

141
Q

Workup for suspected SCLC

A
  • H&P
  • CXR –> CT w contrast (including adrenals)
  • Labs
  • Bronch or mediastinoscopy
  • PET
  • MRI brain
  • PFTs
  • BM bx
  • Thoracentesis if effusion
142
Q

When to do BMBx for SCLC

A

Evidence of nucleated RBC or cytopenias

143
Q

Definition of extensive stage SCLC

A
  • “Can’t fit within one radiation portal”
  • N3 disease
  • Pleural or pericardial effusions
  • Distant mets or bone marrow involvement
144
Q

Treatment strategy for ES SCLC

A
  • Chemoimmunotherapy is standard
  • Cis-etoposide x 4-6 cycles with atezolizumab or durvalumab
  • Followed by maintenace atezo (q3w) or durva (q2w)
  • Consolidation of chest disease if good response to chemoimmuno
145
Q

Dose for consolidation lung RT for ES-SCLC

A
  • 30 Gy in 10 fx
146
Q

How to manage brain disease in pts with ES-SCLC

A
  • If symptomatic: WBRT –> chemo
  • If asymptomatic: chemo –> WBRT (if persistent)
147
Q

5 year OS rates for ES-SCLC

A

<10%

148
Q

What is the management approach for LS-SCLC

A
  • Can consider surgery for very select early stage pts with N0 disease (T1/T2N0)
  • If N+ at time of surgery –> abort and go to CRT
  • Definitive CRT is SOC
  • Consider PCI
149
Q

Which patients could you consider surgery for LS-SCLC

A
  • Select T1/T2 N0 by mediastinoscopy
  • Recommend lobectomy + MLND + chemo
150
Q

What is the most preferred CRT regimen for LS-SCLC

A
  • 45 Gy in 30 fractions of 1.5 Gy delivered BID
  • Concurrent cis-etoposide x 4 cycles
151
Q

Dose of chemo for LS-SCLC

A
  • Cisplatin: 60 mg/m2 day 1
  • Etoposide: 120 mg/m2 day 1-3
  • 4 cycles q3w
152
Q

Field designs for LS-SCLC

A
  • Primary: post chemo vols (after 1 cycle)
  • Nodes - include:
    • Ipsi hilum
    • Involved levels (pre chemo)
    • Use post-chemo vols
    • Ipsi SCV if involved
153
Q

When should RT begin for LS-SCLC

A

With cycle 1 or 2 of chemo (needs to start within 30d)

154
Q

Is there an alternative CRT regimen for LS-SCLC

A

60-70 Gy in daily 2 Gy fractions

concurrent Cis/Etoposide

155
Q

What is the 5 year OS estimate for LS-SCLC with definitive CRT

A

25-30%

156
Q

What is the ancitipated rate of G3 esophagitis from definitive CRT for LS-SCLC

A

26% (requiring feeding tube or IVF)

157
Q

Who is a candidate for PCI?

A
  • Restrict to LS-SCLC with CR or good PR
158
Q

What should be done first if considering PCI?

A
  • Restage with MRI brain
  • Restage with CT CAP
159
Q

Dose of PCI

A

25 Gy in 10 fractions

160
Q

When should PCI be given?

A

4-6 weeks after completion of chemo

161
Q

What is the DDx for anterior mediastinal mass?

A
  • Thymoma
  • Teratoma
  • Lymphoma
  • Thymic carcinoma
  • Thyroid lesions
162
Q

What are the borders of the anterior mediastinum

A

Anterior: sternum

Posterrior: heart and great vessels

Laterally: pleural surfaces

163
Q

What is the workup for an anterior mediastinal mass

A
  • H&P focusing on paraneoplastic symptoms
  • CXR
  • CT chest w con or MRI chest
  • Labs (CBC, CMP, LDH, bHCG, AFP)
  • PFTs
  • Core/open bx if not resectable
164
Q

What is the preferred first step for thymic tumor

A

Median sternotomy and en block thymectomy

165
Q

What are the histologic subtypes of thymoma

A
  • Type A - benign
  • Type AB or B1-3: moderately malignant
  • Type C: very malignant (thymic carcinoma)
166
Q

Symptoms of myesthenia gravis

A
  • fatiguing of voluntary muscles
  • bulbar muscle fatigue
167
Q

What percent of MG patients have thymoma?

A

10-15%

168
Q

What percent of thymoma pts have MG?

A

50%

169
Q

What paraneoplastic syndromes are present in thymoma?

A
  • MG (40-50%)
  • Pure red cell aplasia (10%)
  • Hypogammaglob (5%)
  • Addison’s or Cushing’s
170
Q

What happens to MG after treatment of thymoma?

A

50% will improve

171
Q

Stage I thymoma

A

No capsule invasion

172
Q

Stage IIA thymoma

A

microscopic transcapsular invasion

173
Q

Stage IIB thymoma

A

macroscopic invasion into fatty tissues or mediastinal pleura

174
Q

Stage III thymoma

A

invades adjacent organs including pericardium, great vessels or lung

175
Q

Stage IVA thymoma

A

pleural or pericardial mets

176
Q

Stage IVB thymoma

A

distant mets

177
Q

Treatment of earlier stage thymoma

A
  • Surgery
  • Get multiD involvement, if resectable, do not attempt bx and go for thymectomy
  • All patients going for surgery need preop AchE inhibition (neostigmine)
178
Q

What should be studied on the path report for thymic tumor?

A
  • Path - carcinoma vs. thymoma, WHO subtype
  • Invasion of capsule
  • Pleural involvement
  • Organ invasion
  • Margin status
179
Q

What is the intent of PORT for thymoma

A

Improves LC and decreases risk of relapse

180
Q

For thymic tumors, indication of PORT for stage I

A
  • If thymoma, R0 - obs
  • If thymic carcinoma, R0 - obs
  • If thymoma R1 or R2 - consider PORT
  • If thymic cancer R1 or R2 - PORT
181
Q

For thymic tumors, indication for PORT for stage II

A
  • For thymoma: consider for all, especially if B2-B3 histology
  • For thymic carcinoma - consider PORT for all
182
Q

For stage III or IV thymic tumors, which should get PORT

A

All, dose determined by margins

183
Q

Dose of PORT for stage II thymomas

A
  • If R0 with B2/B3- 45 Gy
  • If R1 - 50.4 Gy
  • If R2 - 60 Gy
  • If unresectable - 60 Gy
184
Q

Dose of PORT for stage III or IV thymoma

A
  • If close margins 50.4 Gy
  • If R2 or unresectable: 60 Gy
185
Q

Does of RT for thymic carcinoma

A
  • If R0 negative margin - no role
  • If stage II+ or R1: 60 Gy
186
Q

What to do if thymic tumor is borderline resectable

A
  • Start with chemo (adriamycin based)
  • Then surgery
  • Then RT with dose depending on margin status
  • Then more chemo
187
Q

5 year OS for Stage I thymomas

A

>90%

188
Q

5 year OS for Stage II thymomas

A

80%

189
Q

5 year OS for Stage III thymomas

A

70%

190
Q

5 year OS for Stage IV thymomas

A

50-60%

191
Q

Treatment option for unresectable thymic tumor

A

CRT to 60-70 Gy

Concurrent cyclophosphamide, adriamycin, cisplatin

192
Q

Contouring for thymic tumors

A
  • CTV = tumor bed + gross residual + 1.5 cm margin
  • PTV = CTV + 5mm
  • No elective nodes (maybe for carcinoma)
193
Q

Special constraints for thymoma

A

Consider mean heart dose of 30 Gy since younger pts

194
Q

What is the most prognostic feature for mesothelioma

A

Subtype NOT stage

195
Q

What are the mesothelioma subtypes

A

Epithelioid (60%)

Sarcomatoid (worst prognosis)

Biphasic/mixed

196
Q

T1 mesothelioma

A

Ipsi parietal pleura with extension to visceral, mediadtinal or diaphragm

197
Q

T2 mesothelioma

A

Involving pleural surfaces with diaphragm muscle or pulm parenchymal involvement

198
Q

T3 mesothelioma

A

Potentially resectable, involved local fascial, mediastinal fat, chest wall, pericardial fat

199
Q

T4 mesothelioma

A

Technically unresectable

200
Q

Imaging workup of meso

A
  • CT CAP
  • PET
  • MRI C/A (to determine invasion of chest wall and diaphragm)
201
Q

Tissue diagnosis of mesothelioma

A

Thoracentesis is diagnostic 25% of times

BUT STILL NEED tissue to do IHC

VATS biopsy is preferred over CNB

202
Q

Surgical options for mesothelioma

A
  • EPP - extrapleural pneumonectomy (en bloc removal of full pleural and lung, pericrdium and hemi diaphragm
  • P/D - pleurectomy and decortication - parietal and visceral pleruectomy: leaves residual tumor but less morbid
203
Q

Treatment strategy for resectable meso

A
  • Induction chemo (cis/pem) –> restage
  • Surgery
  • Adjuvant RT
204
Q

Strategy for adjuvant RT after P/D

A
  • Use IMRT
  • Dose of 54 Gy in 27 Fx
  • 1.5 cm above the lung apex
  • Include CW, latral portion of the vertebral body and sternum
  • Include ipsi pericardium
  • Include diaphragm insertion T12-L1
  • Ensure 8 mm on gross disease
205
Q

Constraints for adjuvant RT after P/D

A
  • Lung V20 < 20%
  • MLD < 10 Gy
206
Q

Suitable location for 18 x 3 SBRT

A
  • Peripheral tumors
  • >1 cm from the chest wall
207
Q

Suitable location for 12 Gy x 4 SBRT lung

A

Central or peripheral tumors <5 cm

Especially <1 cm from chest wall

208
Q

Suitable location for 10 Gy x 5 SBRT

A

Central tumors (PTV in NFZ)

Location less than 1 cm from chest wall

209
Q

Spinal cord constraint for 3-5 fx SBRT

A
  • Remember ~6 Gy per fraction
  • 3 fx: 18 Gy
  • 4 fx: 26 Gy (6.5/fraction)
  • 5 fx: 30 Gy
210
Q

Esophagus constraint for 3-5 fx SBRT

A
  • 3 fx: 27 Gy
  • 4 fx: 30 Gy
  • 5 fx: 105% of RX
211
Q

Chest wall constraint for 3-5 fx SBRT

A
  • Try for V30 < 30 cc (2 cm rind of the chest wall)
  • If impossible, accept V30 < 50 cc
212
Q

Brachial plexus constraint for 3-5 fx SBRT

A
  • 3 fx: 27 Gy (9/fraction)
  • 4 fx: 32 Gy (8/fraction)
  • 5 fx: 35 Gy (7/fraction)
213
Q

Small bowel MPD for 5 fx SBRT

A

30 Gy

214
Q

Heart constraint for 3-5 fx SBRT

A
  • 3 fx - 30 Gy MPD
  • 4 fx - 34 Gy MPD
  • 5 fx - 105% RX MPD
215
Q

Lung constraint for 3-5 fx SBRT

A

Ipsi lung V20 < 25%

V20 of Lungs minus GTV < 12%

216
Q

How is SBRT contoured?

A

GTV= gross disease, fuse PET to help

ITV= GTV with motion

PTV = ITV + 5 mm

217
Q

How is SBRT plan normalized

A

100% corresponds to PTV at isocenter

218
Q

What is the goal coverage for SBRT

A

95% of PTV receives 100% of dose

219
Q

If not doing 45 Gy BID for SCLC, what is other options

A

66 Gy / 33 fx

220
Q

Contouring for locally advanced NSCLC

A

GTV = gross disease, tumor and involved nodes

Use 4DCT to create ITV

CTV = ITV + 7 mm

PTV = CTV + 5 mm

221
Q

What is a 4DCT

A

During 4DCT acquisition, images are acquired in all phases of the respiratory cycle while simultaneously recording respiration, followed by a retrospective sorting process that correlates CT images with the phase of respiration.

The respiratory cycle is derived using chest height as a surrogate, which is determined using an RPM marker on the patient’s upper abdomen. An infrared camera notes the height of the box

222
Q

What is benefit of PCI for LS-SCLC

A

5% benefit in 3 year OS

223
Q

How does PCI change risk of BM for SCLC

A

roughly half

60% to 30%

224
Q

How to approach borderline resectable thymomas?

A

Try neoadjuvant chemo

Adriamycin-based chemo (Adria/ cyclophos/ cis) then surgery or RT

Then more chemo

225
Q

What is the GTV to CTV margin for thymoma

A

0.5 cm

226
Q

What is the contouring strategy for thymoma

A

CTV = GTV + 0.5

Form ITV

PTV = ITV + 0.5 cm

227
Q

Regimen for ES-SCLC

A

carbo, etoposide, atezo

228
Q

Contouring approach for SBRT

A

GTV –> ITV

PTV of 5 mm

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