Thoracic/Sarcoma Flashcards
What criteria make someone’s lung cancer medically inoperable?
FEV1 <1.2, <0.8L post-op predicted
FEV1 <40-50%
DLCO <40-50%
FEV1/FVC <50%
PCO2 >50
02 Sat <88% resting
Thoracic dose constraints for chemoRT?
Who should get NGS testing and adjuvant therapy or neoadjuvant chemo/IO?
> =4cm or N+.
Ways to decrease lung dose?
DIBH
More AP-PA beam weighting
Tigher margins
Re-sim half-way through treatment
Give neoadjuvant chemo
66-70Gy to 60Gy
Treat palliatively
If cant meet, move forward with RT but stop at constraint and if you can’t re-sim and decrease dose then just palliative.
How do you manage cardiac device?
Is the patient dependent on device? If not, don’t need to move it.
Keep <2Gy
How do you treat extensive stage SCLC?
4 cycles of Atezo/Etop/Carbo then re-eval (brain MRI and CT TAP), if no new sites of disease consider consolidative 3DRT 30Gy in 10 fractions. Hold the Atezo until complete, then resume Atezo for maintenance.
Unresectable NSCLC with EGFR mutation tx?
CRT followed by 3 years of Osimertinib.
Who should get an EBUS?
LN >10mm, primary tumor >2cm, or central tumors.
Who is eligble for chemo/IO?
Stage IIA-IIIA
Chemo/nivo x q3wks for 3 cycles then surgery then consider another 12 cycles of nivo
Who should get adjuvant chemo and or IO?
Patients who did not get neoadjuvant therapy and stage IIA<= then give chemo then either immunotherapy or targeted therapy.
What is the 5yr OS benefit on Pacific Trial?
5yr OS **42.9%. **
How to follow nodules?
If <8mm then CT Chest in 6 months if >8mm then PET or biopsy.
Markers for Adeno, SCC, and SCLC
TTF-1 Napsin1; p40, CK 5/6 (keratin pearl); chromogranin, enolase, synaptofysin.
Dose constraints for 50/5 and 60/8?
5fx:
Lung: V20<10, mean <6
Heart: max 38, V32<15cc
Esophagus: max 38, V27.5<5cc
CW: V30<30Gy up to 70Gy if overlap
PBT: 52.5Gy
Brachial Plexus: 32Gy
8fx:
Lung: mean<10
Heart: max 44Gy, V38<15cc
Esophagus: max 40Gy, V32<5cc
CW: same
PBT: 63Gy max, 60<10cc
Brachial plexus: 39Gy
How long do you give consolidative durva after chemoRT for SCLC?
2 years of durvalumab
F/U for SCLC?
Brain MRI and CT chest q3 mos for 2yrs then q6 mos.
Limited stage SCLC median survival and 5yr OS survival?
30 mos and 5yr OS 30%.
NSCLC chemoRT PACIFIC trial median survival and 5yr OS?
Median survival 48 months (4yrs)
5 yr OS 43%
How do you know likely a Thymoma and no need to biopsy?
Well-defined anterior mediastinal mass in the thymic bed, tumor markers negative, absence of other adenopathy, and absence of continuity with the thyroid.
*biopsy if doubt or locally advanced/metastatic. Avoid transpleural approach.
After resection of thymoma who gets RT? When do you add chemo?
II-IV consider
R1/R2
50Gy if R0, 54Gy if R1, and 60Gy R2.
Add chemo if R2 or unresectable; carbo/taxol (thymic carcinoma) and cis/etop (thymoma).
How do you approach potentially resectable Thymoma?
Induction CAP: cis/adriamycin/cyclophos q3 weeks for 4 cycles.
What chemo for sarcoma?
AIM: Doxorubicin, ifosfamide, mesna
Preop RT decreases what tox in sarcoma?
Fibrosis, edema, and joint stiffness. Worse complications 35% vs 17%.
Sarcoma constraints?
Joint V50 < 50%
Bone V50 < 50%
Skin strip V20 < 50%
Anus/vulva V30 < 50%
Testis V3 < 50%
Bone dose:
Max <59Gy
Mean <37
V40<64%
