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1
Q

Koos grading scale for vestibular schwannoma

A

Grade 1: intracanalicular, Grade II: tumor extending into posterior fossa with or without intracanalicular component without touching brainstem, Grade III: Tumor extending into posterior fossa compressing brainstem without midline shift, Grade IV: Tumor extending into posterior fossa compressing brainstem with midline shift

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2
Q

Management of vestibular schwannoma

A

Usually observation if asymptomatic, q6 mo MRI.

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3
Q

Indications for treatment of vestibular schwannoma

A

> 2.5mm growth per year, new or worsening symptoms (hearing loss)

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4
Q

If treating Schwannoma, how do you treat it

A

surgery if young and anatomically favorable, RT if elderly or refusing surgery or STR or recurrence

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5
Q

RT technique for Schwannom

A

SRS 13 Gy, 25/5, 50.4/28(preferred for tumor>3-4 cm with significant brainstem abutment

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6
Q

What are imaging characteristics of GBM on MRI

A

T1 hypointense, heterogeneously enhancing/central necrosis, T@ edema hyperintense

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7
Q

What are imaging characteristics of LGG on MRI

A

Increased T2/FLAIR signal, no enhancement, calcs suggest 1p19q codeletion

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8
Q

What is true of MGMT methylated tumors

A

they are sensitiev to DNA damage from alkylating agents (good prognostic factor)

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9
Q

What things make a Grade II-III astrocytoma pretty much into a GBM

A

EGFR amplification, gain of chrom 7 and loss of chrom 10, TERT promoter, IDH wt

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10
Q

What makes a LGG patient high risk

A

Age>=40 and STR

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11
Q

Management of GBM

A

MSR then CCRT 60/2Gy + TMZ 75 mg/m2 qd (or adj TMZ 150 mg/m2 then TTF)

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12
Q

Management of GBM for frail or elderly

A

MSR then CCRT 60 vs 4005 vs adj TMZ alone vs RT alone (if MGMT unmethylated)

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13
Q

Management for anaplastic glioma

A

MSR then if 1p10q non co deleted: CCRT 5940, if codeleted: RT 5940 then PCV x 6

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14
Q

Management of LGG

A

MSR then if Low risk: NFT, if high risk: RT 54 Gy then PCV x 6

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15
Q

PTV 60 for GBM

A

Tumor Cavity + T! enhancing disease + 2cm to CTV + 0.5 cm to PTV

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16
Q

PTV 46 for GBM

A

T2 flair + cavity+ T!, 2 cm CTV, .5 cm PTV

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17
Q

Hypofrac GTV, CTV, PTV

A

GTV: cavity + T1, 1.5 cm CTV, 0.5 cm PTV

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18
Q

LGG define GTV and PTV

A

GTV: cavity + T2/FLAIR, Block edge: GTV+2cm

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19
Q

Brainstem max

A

55 Gy

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20
Q

optics max

A

55Gy

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21
Q

Cochlea mean

A

<45 Gy

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22
Q

Retina max

A

<45 Gy

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23
Q

Lacrimal gland

A

Max <40Gy

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24
Q

Lens max

A

<7 Gy

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25
Spinal cord max
<50Gy
26
What makes a meningioma WHO Grade II
>=4 mitoses/10 HPF, Brain invasion,
27
What makes a meningioma WHO Grade III
>=20 mitoses/10 HPF
28
What are the Grade II meningioma subtypes
chordoid, clear cell, atypical
29
What are the Grade III subtypes of meningioma
anaplastic, papillary, rhabdoid
30
Management WHO GRADE I meningioma
Observe 1/2 mm expected annual growth OR surgical resection for large or symptomatic tumors, adj RT only if STR (54 in 30)
31
Management of WHO G2 Meningioma
Surgical resection, GTR: obs vs 5940, STR: 5940 Gy
32
Management of WHO G3 Meningioma
Surgical resection + 60 Gy
33
What is CTV for Meningioma
Postop cavity + residual nodular enhancement + 5 mm margin. (1 cm margin for WHO G3 60 Gy, 2 cm to 54 Gy in WHO G3)
34
1 fx SRS brainstem, spinal cord, optics, brain constraints
max 15 Gy, max 14 Gy, max 8 Gy(10Gy), V12<10 cc
35
3 fx SRS brainstem, spinal cord, optics
max 23 Gy, max 20 Gy, Max 17.4 Gy
36
5 fx SRS brainstem, spinal cord, optics
max 31 Gy, max 25 Gy, Max 25 Gy
37
HA WBRT constraints
Max < 16 Gy, D100<9 Gy
38
When does pseudoprogression occur?
1-3 months
39
When does radiation necrosis occur?
3 months to several years after RT
40
How to treat GBM recurrence?
35 in 10 with avastin, GTV+5mm
41
What postop things push you toward RT for LGG?
SATAN, size>6cm, Age>40, Tumor crossing midline, astrocytic components, neuro sx's
42
CTV for LGG?
Cavity + flair --> 1 cm CTV
43
SRS dose postop?
18 Gy
44
SRS dose to intact lesion?
0-2 cm: 24 Gy, 2-3 cm: 18 Gy, 3-4 cm: 15 Gy
45
What study can be done to differentiate between necrosis and recurrence in the brain?
MRS (magnetic resonance spectroscopy)
46
Workup after finding CNS lymphoma?
testicular exam, optho exam, LP, BM biopsy, PET, routine labs
47
What chemo is used for PCNSL?
R-MVP (Ritux, HD MTX, VCR, Procarbazine)
48
Treatment for PCNSL?
R-MVP x 5 q 2 weeks, if CR-->RT if
49
If CR after R-MVP in PCNSL, what RT dose do you use?
23.4 Gy
50
If PR after R-MVP in PCNSL, what RT dose do you use?
23.4 Gy with boost to 45 Gy
51
What dose of RT for PCNSL if no chemo was given?
36 Gy boost to 45 Gy
52
PCNSL 63 year old patient with CR to HD-MTX?
observe because WBRT is toxic
53
DDX of lesions with dural tails?
Chloroma, Lymphoma, Sarcoid, Meningioma, CLSM (Cats like spilled milk)
54
Treatment of AVM?
surgery but if no surg feasible, SRS to 16-20 Gy, 16 Gy for >3cm
55
SRS dose for Acoustic neuroma?
12-13 Gy
56
Suprasellar mass DDX?
COP GEMM (cranio, optic glioma, pituitary adenoma, germ cell tumor, ependymoma, meningioma, mets)
57
Surgical approach for pituitary tumor?
transsphenoidal, transcranial for large tumors
58
Lab workup for pituitary mass?
prolactin, TSH, ACTH, GH, LH, Testosterone
59
Imaging for pit tumor?
MRI brain
60
Management of nonfunctioning pituitary adenoma?
Surgery with RT for STR or recurrence
61
Management of prolactinoma?
bromocriptine, surgery if pharmaco refractory, RT if fails surgery, hold dopamine agonist 2mo prior to RT
62
Management of TSHoma?
surg + RT 54/1.8
63
Dose for nonfunc pit mass?
45-50.4
64
Dose for func pit mass?
50.4-54
65
SRS dose for nonfunc?
14-16 Gy
66
SRS dose for func pit tumor?
18-20 Gy
67
Craniopharyngioma management?
GTR, if STR do 54 Gy or 12 Gy SRS.

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