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Mini Humans Flashcards

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1
Q

Peds brain tumors which ones do we not resect

A

Germinoma, NGGCT, Optic and brainstem Glioma

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2
Q

Only Peds CNS to biopsy

A

Germinoma

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3
Q

Only CNS peds tumor that doesnt go to 54 Gy

A

Germinoma

Carbo/etop x 4

M0: whole WVRT 21 Gy + boost to 30 Gy (36 PR)

M1: CSI 24 Gy -> boost to 45 Gy

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4
Q

Posterior Fossa Syndrome

A

PF syndrome (24-48 hrs after surgery):
-15% after craniotomy
SAME
- Swallowing dysfxn
- Ataxia (truncal)
- Mutism (cerebellar)
- Emotional lability

  • can also have respiratory failure
  • do NOT delay RT – improves over 1-6 months
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5
Q

Medulloblastoma imaging timing

A

Imaging:
MRI brain pre-op and 24-72 hr post-op
MRI total spine; then 10-14 days post (false positive if too early)

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6
Q

Medulloblastoma treatment algorithm

A

Imaging -> do not get CSF or biopsy -> straight to MSR-> CRT within 31 days post-op -> adj chemo (GTR achieved 90% of time)

Don’t forget post-op MRI within 48 hrs and spine MRI at day 10 followed by CSF

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7
Q

Medulloblastoma prognosis subtype

A

: WNT > group 4 > SHH > Group 3 bad

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8
Q

Medullo standard risk adjuvant treatment

A

Standard risk:
CSI 23.4 Gy + tumor bed boost (IF) to 54 Gy with concurrent vincristine (1.5 mg/m2 q week)
Adjuvant chemo

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9
Q

Medullo High risk adjuvant treatment

A

High risk: M+, STR, anaplasia
CSI 36 Gy + IF boost to 54 Gy with concurrent vincristine
Adjuvant chemo
Boosts:
Focal at/above cord: 45
Focal below cord: 50.4
Diffuse: CSI to 39.6

Adjuvant chemo: platinum, CCNU, vincristine x 8 cycles – NOT PCV (procarbazine)

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10
Q

Medullo High risk criteria

A

M+, STR, anaplasia

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11
Q

Medullo < 3 yo

A

Infant:
If <3 yo: max safe resection  chemo alone (Head Start)
- Reserve RT for salvage or progression
- If you have to treat with RT, use IFRT 54 Gy (1 cm margin supratentorral, 1.5 cm margin infratentorial)

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12
Q

CSI script Medullo

A

1) CT based simulation - will fuse pre-op and post-op MRI
2) Prone immobilization with Aquaplast mask – also make mold in supine position – head extended to avoid divergence into the mandible, shoulders down – BBs on mask, shoulders, lumbosacral spine
-anesthesia if <11 years
3) Scan vertex to mid femur (2.5 mm slices thru brain, 5 mm elsewhere)
4) Contour globes, lenses, brain (including cribriform plate), cauda
5) Set spine field first
Sup: C7 (as low as possible without going through shoulders)
Inf: thecal sac (S2/S3)
Lat: 1 cm lat to vertebral body;
spade at sacrum to include SI joints
- use a single field if length < 40 cm
- if > 36 cm, can either:
a. Treat at 120 cm SSD
b. Use two fields
6) If using two fields, match anterior to cord (post edge of vertebral body) with skin gap equation
7) Next set-up the brain field. Parallel opposed laterals (or RAO/LAO to minimize divergence into C/L eye). Iso at mid plane (in same coronal plane as spine field).
8) Rotate collimator to match the divergence of the spine field
9) Kick the couch toward the gantry to match divergence of brain field
Note: theoretical underdose of cribiform
Brain – use RAO/LAO to avoid divergence of brain field into contralateral retina
10) Feather all junctions by increasing middle field and decreasing brain and inf spinal fields by 0.5 cm after every 9 Gy (1 week)
11) Image WBRT field daily, apply z shifts with table indexing for lower field isocenters
12) Image all fields weekly
13) Boost

IF boost
CTV = pre-op tumor + tumor bed + 1.5 cm (cropped at tentorium and bone)
Anatomically confined to the posterior fossa, trim inside tent/bones
PTV = CTV + 0.3-0.5 cm

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13
Q

Medullo what to check before treatment

A

Before RT, check that ANC > 1000 and plt > 100K.
If not, start with boost then do CSI after

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14
Q

Germ cell tumor
AFP or high B-HCG (>50)

A

indicates NGGCT
Embryonal – bHCG (> 50) + AFP (>10)
Yolk sac – AFP
Chorio - >> bHCG

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15
Q

Germ cell when to biopsy

A

Pure germinoma if markers elevated do not have to

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16
Q

Germinoma treatment M0

A

Chemo -> (biopsy if incomplete response) -> whole ventricle 21 Gy boost IF 30 (36 PR)

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17
Q

Germinoma treatment M1

A

M1:
Chemo -> 21 Gy CSI boost to 36 if CR

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18
Q

NGGCT treatment

A

Chemo x 6 -> restage
-chemo: alternating cis/etoposide and ifos/etop

If CR: RT
If < CR: max safe resection -> post-op RT

-RT: CSI 36 Gy + boost 54 Gy

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19
Q

Pineoblastoma

A

treat like high risk medullo:

CSI 36 Gy + IF boost to 54 Gy with concurrent vincristine
Adjuvant chemo
Boosts:
Focal at/above cord: 45
Focal below cord: 50.4
Diffuse: CSI to 39.6

Adjuvant chemo: cisplatinum, lomustine, vincristine x 8 cycles

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20
Q

Ependymoma workup

A

MRI brain/spine
-pre-op and 10-14 days post-op
LP 10-14 days post-op and after MRI spine
-contraindicated pre-op for posterior fossa mass for risk of herniation

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21
Q

Ependymoma
MRI spine/LP negative: treatment

A

MRI spine/LP negative:
Max safe resection (be aggressive!) -> post-op IFRT to 54)
-goal is GTR –chemo then re-resecting if needed to achieve GTR

Historically no role for chemo unless < 3 yrs s/p GTR to delay RT

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22
Q

Ependymoma
MRI spine/LP positive: treatment

A

MRI spine/LP positive:
Max safe resection -> post-op CSI to 36 Gy
-boost spine dz to 45, 50.4-59.4 if below cord
-boost intracranial primary to 59.4

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23
Q

Ependymoma start within

A

56 days

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24
Q

Ependymoma volumes and dose

Study These Flashcards
A

GTV=tumor bed + residual + tissues originally involved w tumor
CTV=GTV + 5 mm
PTV=CTV + 5 mm

Dose: 59.4/1.8

25
Optic Glioma workup
Fundoscopic and CN exam Visual field testing No biopsy!!
26
Optic Glioma treatment
\< 10 yo: Observation w close surveillance -Carbo/vincristine at radiographic or sx progression -RT if progresses post-chemo \>10 yo: RT to 54/1.8 Gy (confirm not 50.4)
27
craniopharyngioma presentation and workup
Arise from remnants of Rathke’s pouch H&P – present w DI, growth failure, behavior issues, visual field defects Labs – pituitary panel Imaging – MRI brain – solid calcified nodule with cyst filled w crankcase oil Biopsy – not necessary Other: Audiometry Ophtho exam
28
Cranio treatment
Max safe resection If GTR -\> observe (20% recurrence) if STR (70% recurrence) -\> adjuvant RT to 54/1.8 Gy Decompress cyst prior to RT MRI q 1-2 wks to assess cyst growth requiring replanning. Daily CBCT can guide too. EBRT GTV (just post-op GTV) = tumor + cyst wall (can use 0.5 cm CTV) PTV = GTV + 0.5 cm Dose: 54 Gy
29
DIPG
DIPG Steroids and RT to 54 Gy GTV=FLAIR + 1.5 cm CTV=entire brainstem (midbrain to C1) PTV=CTV+0.5 cm
30
LGG
GTR – obs NF-1 indolent \<10 yo vincristine carbo to delay RT RT-54Gy
31
HGG
High Grade Glioma: MGMT bad, H3.3 K27M bad, IDH better Surgery, RT 54-60Gy
32
Rhabdo Favorable sites
• Favorable sites: BONG Biliary Orbit Non parameningeal HN GU (non bladder/prostate)
33
Rhabdo Unfavorable sites
Unfavorable sites: • Parameningeal (MMNNOOPP): Middle ear, Mastoid region, Nasal Cavity, Nasopharynx, Pterygopalatine fOssa, Infratemporal fOssa, Paranasal Sinus, Parapharyngeal region • Bladder/prostate • Extremities • Other: Trunk/retroperitoneum
34
RMS Staging
Simple RMS Staging Stage=Site 1 Favorable (any size/N) 2 Unfavorable, small and N0 3 Unfavorable, large or N+ (or both) 4 Distant Mets
35
RMS Grouping
Simple RMS Grouping Group = Surgical Group Based on surgical status prior to chemo start. I GTR, margins – II GTR, + microscopic disease III Gross residual IV Mets
36
Rhabdo Risk group
Low – (all others): based on histology FH, fav site, group 1-3 (no met) FH, unfav site, group 1-2 Int – unfav site & group 3(gross disease) or UH High – mets
37
RMS overall treatment paradigm
Surgery\* -\> chemo -\> RT -\> chemo
38
RMS low risk paradigm
Low-risk: Surgery then - VAC (vincristine/actinomycin D/cyclophos) wk 1-12 - RT at week 12 w chemo - VA wk 13-24
39
RMS Int-risk paradigm
Int-risk (UH) - VAC wk 1-42 -RT at week 12 \*\* no actinomycin during RT \*\*
40
RMS high risk
High-risk - VAC + IE (ifos/etop) wk 1-20 - RT at week 20 to primary and mets - VAC + IE wk 20-52 Gy If compression etc can start with chemo
41
RT Doses by Group and Histology RMS
RT Doses by Group and Histology Group. FH. UH. 1(neg marg) 0 36 +margin 36 36 node+ 41.4 41.4 3(gross) 50.4\* 50.4\* (\*45 Gy if orbit; \*\*36 Gy if delayed primary excision) FH: Embryonal UH: Alveolar Basically: UH or + margin: 36 Gy Node + 41.4 Gross: 50.4
42
RMS volumes
Pre-chemo, pre-surgical GTV based on the gross disease on MR. ``` CTV = GTV + 1 cm PTV = CTV + 5 mm ``` Lung mets: 15/1.5 Gy Boost if gross disease to 50.4 Gy
43
RMS constraints
Optic nerve & chiasm \< 46.8 Gy (per RMS protocol) Contralat whole kidney \< 14.4 Whole Liver \< 23.4
44
Ewing's Workup
H&P: w neuro and MSK exam Labs: CBC, CMP, LDH, ESR Imaging: - MRI primary (T1 enhancing) - PET with diagnostic CT - CT chest - Bone scan Biopsy: - Bx primary site – longitudinal incisional bx - BM biopsy (25% have BM+!!!)
45
Ewing's treatment
Chemo -\> local therapy (surgery vs RT) -\> chemo 1) VDC-IE q 2 wks x 6 cycles (wk 1-12) 2) local therapy at wk 14: - surgery preferred for “expendable” bones - otherwise RT + chemo (minus adriamycin) 45 Gy to pre-chemo volume (bone and soft tissue) + 2 cm 55.8 Gy boost to post-chemo soft tissue + pre-chemo bone + 2 cm No elective nodes -if vertebral body, do 45 then 5.4 to 50.4 total
46
Ewing dont forget
CLAM SHELL IF MALE!!!!!!! OVARIAN transposition for women if RT to pelvis.
47
Osteosarcoma
Chemo -\> surgery -\> chemo -Chemo: MAP (MTX, adria, cisplatin) RT if: - inoperable (70 Gy) - R1/R2 resection (60 Gy)
48
Neuroblastoma workup
Labs: blood catecholamines Urine catecholamines (inc in 90%): VMA, HMV - Imaging: CT c/a/p - calcs MIBG scan Bone scan (if MIBG neg) -Biopsy Bilateral BM biopsy Biopsy primary and involved nodes: do NOT biopsy primary until wilms ruled out Homer-Wright pseudorosettes
49
Neuroblastoma risk cat
Low: Stage I: - -unilateral GTR or R1 - -Stage II: STR, R2, ipsi LN Int: all others High Risk: - -N-Myc - -Mets \>18mo - -Stage III UH \>18mo: cross midline, contralateral LN, unresectable
50
Neuroblastoma presentation
Young 2 and under, sick pushes kidney out of the way, urine catecholamines +, skeletal mets are common(MIBG scan) MS is mets in \<18months calcifications in mass Neural crest cells of the sympathetic ganglion
51
Neuroblastoma treatment
Low – surgery alone -chemo for persistence or recurrence Int Max safe resection -\> chemo High Make sure you have biopsy! 1) Induction CAPE x 5 months (cisplatin-based regimen) 2) Repeat MIBG 3) max safe resection 4) tandem transplant (ABMT x 2) 5) RT day 28 to primary and persistent MIBG+ sites 5) maintenance cis-retinoic acid x 6 months and immune tx x 5 months
52
Neuroblastoma dose
Primary site & mets: 21.6/1.8 Gy Post-induction, pre-op volume with 2 cm margin (1.5 cm CTV, 0.5 cm PTV) Cover entire vertebral body to prevent scoliosis. 4S liver palliation causing respiratory distress (Pepper syndrome) give 1.5 Gy x 3 fx Symptomatic cord compression: Try chemo first! RT if persistent \<3yo: 9/1.8 Gy \>3yo: 21.6/1.8
53
Neuroblastoma constraints
Liver V9 \< 50% ; V18\< 25% Ipsilateral kidney \< 14.4 Lung V15 \< 30%
54
Wilms histology
FH: (90%) – no anaplasia or sarcomatous features UH: (10%) anaplastic (focal or diffuse), clear cell, rhabdoid
55
Wilms workup
Labs – CBC, Chem7, LFTs, UA w catecholamines (to r/o NB) Imaging - Abd U/S CT/MRI of primary CT chest For clear cell: add bone scan, MRI brain, BM bx For rhabdoid: add MRI brain DO NOT BIOPSY (unless bilateral or unresectable)
56
Wilms stage
I: completely resected, confined to kidney II: completely resected, but beyond capsule, or vessel III: SLURPP-Bx Spillage LN+ Unresectable Residual tumor Positive margins Peritoneal implants Biopsy performed IV: mets or LN+ outside abd/pelvis V: bilateral (stage each side separately) \*pre-op chemo=Stage III\*
57
Wilms overall treatment
Surgery - \> Chemo - \> +/- RT
58
Flank field
Flank Field: pre-op tumor +1.5cm anatomically modified, include vertebral bodies
59
Pediatric Hodgkins treatment
_Low risk:_ AVPC x 3 c -\> **ISRT 21/1.5** Gy (AHOD 0431) -adria, vincristine, pred, cyclo _Int risk:_ AVPC-BE x 4-6 c -\> **ISRT to 21/1.5 Gy** -adria, bleo, vincristine, etop, pred, cyclophos _High risk_: ABPC-BE x 6-8 c -\> **ISRT 21/1.5** Ann Arbor staging Low risk: Favorable stage I-II (no B sx, non-bulky, no extranodal extension, 1-2 sites) Int risk: Unfav stage I-II Stage IIIA (no B sx) High risk: Stage IIIB or IV

Rad Onc Oral Boards (11 decks)

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