RT dose/volume and Evidence Every Site Flashcards

Question

Radiation dose and rationale for primary CNS lymphoma.

Answer 1

Evidence supports a PFS but not OS advantage to WBRT. The critical treatment is Autologous Stem Cell transplant (if pt can get to that): Fit young Pt: High-dose methotrexate, Ritux and alk agent - Progression = salvage 36/20. Partial 23.4/13 (These are the same as the CSI doses for medulloblastoma). complete may omit WBRT. Elderly/not ASCT candidate: Chemo as above -> Partial/complete = 23.4/13, or watch and wait or maintenance e.g tmz Progression = Individualised care, including WBRT up to salvage 36/20. Unfit: Curative intent WBRT40/22 Palliative: E.g. 30/10

Answer 2

Nodal, splenic, MALT (90%, GI 60%, 85% gastric): Orbital (12% due to chlamydia psittaci - gross) 24/12 (same dose as??, Deb uses 4Gy/2 55% contol), CTV = whole bony orbit Late tox: epiphora, cataracts, Gastric MALT: If failure of triple therapy (Claire's Amplified esophagus) of t(18,11): 30/10 entire stomach (GIJ to duodenal bulb) Fast 4hrs (commonly overnight).

Answer 3

Surveillance can be considered but indolent progression highly likely (with a larger lesion the to be treated). * Surgery: Excisional biopsy is an option for single symptomatic lesion. Can provide sustained local control * Radiotherapy: Wide variation of dose (20Gy/10- 30Gy/15#) – higher dose has improved and more durable response * Topical therapy – limited experience with imiquimod * Cryotherapy – mainly cosmetic, no documentation of LC rate * Intra-lesion therapy – painful, not generally recommended Like other sarcomas can take 4 months to regress XRT - 80-90% LCR but significant risk of progression outside of field.

Answer 4

I will offer this patient palliative radiotherapy to the right lower leg lesion to a total dose of 20Gy in 10 fractions, 2Gy/X, VMAT technique for local control * An alternative technique is with water-bath technique, this is cumbersome, with less accurate dosimetry calculation, and on the assumption that the entire ‘water-bath’ (including the leg) is of homogenous density Sim * Position: supine, arms on chest, leg towards gantry, left hip/ knee flex to move left leg out of treatment field * Immobilisation: cradle under right leg * Clinical mark-up the symptomatic lesion, or wire the most superior/ inferior/ lateral edge of lesion * Bolus: 5mm bolus inside cradle, and 1cm bolus on skin anterior to the cradle * Planning CT: 3mm slice from mid-thigh all the way down to cover the entire foot Target volume * CTV20 will be 1cm thickness from skin surface circumferentially from superior to inferior marker, clipped at bone/ muscle fascia, and spare at least one strip of soft tissue * PTV20 = CTV20 + 5mm expansion Technique: partial arc VMAT with 6MV photon Plan review: * Ensure PTV well-covered by 95% isodose line * Minimise hotspot outside of PTV * Minimal OAR at risk of concern; important to ensure contralateral leg is not receiving any dose Treatment verification: daily kV imaging, with 5mm tolerance

Answer 5

Burmeister study: Improve LC (lymph nodes) from 60-80% CTVprimary - 2cm margin around scar CTVnodal - 3cm prox-distal (like esophagus) and 0.5cm axial. EVIQ CTVs: Pre-operative disease + surgical bed (including scar) ± margin as appropriate for potential sub-clinical disease. Consider non-surgically perturbed at risk nodal basin Dose 48/20 UNLESS H&N, Groin lymphoedema - 50/25 Burm's criteria at least 1 RF: 1 or more parotids, 2 or more neck (pr>3cm), 3 or more groin (or >4cm), ENE

Answer 6

Avg = age>3, GTR w<1.5cm, not mets I will offer this patient cranio-spinal irradiation to a dose of 23.4Gy in 13 fraction followed by tumour bed boost to total dose of 54Gy/30#) (1.8Gy/#, 5#/ week). VMAT technique with 6MV photon- 3 isocentres (cranial, upper spinal, lower spinal), junction at 4cm depth, no feathering. Pre-SIM * Ensure recovery from surgery (but within 4 weeks!!) SIM * Positioning: supine, arms on side, head towards gantry * Immobilisation: on vac bag/ body cradle, thermoplastic mask * CT simulation: 3mm slice planning CT from vertex to mid-thigh * Fusion: with pre-op MRI, post-op MRI Target volume: * Phase 1: CSI 23.4Gy/13# (entire intracranial/ spinal subarachnoid volume) o CTVcranial = Entire brain, covering cribriform plate, and optic nerve o CTVspine = Thecal sac expand laterally to intervertebral foramina; inferior level must be determined on MRI (usually ~ S1-2) o PTVcranial = CTVcranial + 3mm o PTVspine = CTVspine + 5mm lat + 10mm AP + 10mm SI * Phase 2: Tumour bed boost 30.6Gy/17# o GTV: surgical cavity + post-op residual disease o CTV30.6: GTV + 5mm o PTV30.6: CTV30.6 + 3mm

Answer 7

SEER database suggests likely OS benefit to PORT. T2 = 2-5cm (consider PET even in T1 - 25% T1 and T2 get upstaged). Definitive EBRT alone 54Gy in 27 fractions, 2Gy per fractions to the right deltoid primary and axillary node + supraclavicular fossa to improve local and distant control, and overall survival. Pre-SIM: - MDM discussion Simulation: - Position: supine, arms akimbo, head towards gantry - Immobilisation: vac bag, knee fix, ankle support - Addition: wire scar, bolus 3-5 cm around scar/ primary lesion - Planning CT: 3mm slice planning CT from upper cervical to below diaphragm (cover the entire lung for DVH) Fusion: pre-op MRI/ PET Target volume: - CTV54 = (pre-op GTV and scar) + 4cm radial margin, and 1.5cm DEEP to skin down to fascia, clipped at anatomical boundaries - CTV51.2 (50Gy EQD2) = CTV54 + at risk nodal group (level 1-3 axilla and supraclavicular fossa) - PTV = CTV + 1cm margin for setup uncertainties Technique: 5-7 field IMRT technique with 6MV photons Plan review - Target coverage, PTV D98>95% - Minimise hotspot PTV D2<107%, ensure no hotspot outside of PTV or in OAR - Ensure low dose (10%, 50%) reasonably distributed around PTV - Try to spare a strip of skin/ subcutaneous tissue - Review OAR DVH o Brachial plexus Dmax< 54Gy o Ipsilateral lung: V20Gy<30%, V30Gy<20% Treatment verification: daily CBCT, matched to bone, soft tissue review

Answer 8

DOSE PRESCRIPTION * 12Gy in 6 fractions, 2 Gy per fraction, 2 fractions per day, over 3 days * Prescribed to a single point at midline of the patient (usually umbilicus) * (Other dose options: 2Gy/1#, 13.2Gy/11#, 4Gy/2#) Pre-SIM * MDM discussion * Fertility preservation referral SIMULATION * Position: supine, upper arms on side resting on 4cm polystyrene (maximise lung shielding from lateral beam), and hand resting on abdomen * Planning CT: 3mm slice covering the entire body length (from vertex to mid-thigh) TARGET VOLUME * Entire body contour TECHNIQUE * 4-field equally weighted MV photons AP/PA and opposing lateral, with extended SSD (4m) and largest practical field size * 6/10/18 MV (avoid 18MV if possible) Alternate APPA and oppose lateral for each fraction (e.g. APPA for fraction 1, 3, 5, lateral for fraction 2, 4, 6) Lateral field Position: * patient lie supine, small sponge under head, knee fix, * Upper arm resting on 4cm polystyrene (to reduce lung dose) * Hand resting on abdomen * Trolley turn around for the opposing lateral field treatment Compensator/ bolus (‘beam spoiler’) – (because of skin-sparing effect of photon) * Super-flab – on lateral and anterior surface of neck + chest (to reduce dose to lung) * Perspex – as head frame compensator, and from mid-thigh inferiorly (thicker from mid knee inferiorly)

Answer 9

SRS (non-functional) 14-16 Gy/ 1# SRS (functional) 20 Gy/1# Functional needs higher dose Fractionated SRT 25 Gy/ 5# (5 Gy/#) (BED~ 11-13Gy / 1#) (FSRT if: lesion >3cm size, or <3mm from optic IMRT/ VMAT 40Gy/ 15# (1.8Gy/#) 50.4 Gy/ 28# (1.8Gy/#) PRE-SIM * Baseline ophthalmology, neurology, and endocrinology review

Answer 10

24Gy/2# Rationale - Compared to multi# EBRT, multiple RCTs demonstrate higher complete response rates at 3 months, BUT higher vert body collapse 17% vs 10%. In oligomet setting - COMET SABR shows OS benefit, Contras: Previous radiation at site!! (No evidence to support this), SIN Score > 11. >3 spinal mets (i.e. much higher risk of collapse) Technique: sim CT + MRI fusion 8-Field co-planar, non-opposed 6Mv photons Prescribe to covering isodose Volumes: GTV on fusion CTV = GTV + CTV defined by International Spin Radiation Consortium (ISRC) guidelines. E.g Well lateralised Vert body then CTV = whole vert body + ipsi pedicle. e.g 2. Diffuse vert body, CTV whole v.body bilateral peds. PTV = CTV +2mm, EXCEPT trimmed off spinal cord!!! Verification daily 3D CBCT to bone.

Answer 11

Key studies: O'sullivan = RCT of pre vs PORT STRASS = retroperitoneal dont do RT unless relapse (if you have to to 50.4/28) SEER database Rationale: For higher-grade STS SEER multistudy reterospective analysis supports a benefit to RT in conjunction with surgical resection. Both pre and post have equivalent OS but differ in their toxicities - E.g higher wound complications (reversible) in pre vs higher fibrosis rates in PORT (not reversible). RCT supports Brachytherapy as approx equivalent LCR. For reteroperitoneal tumours surgery alone (STRASS). PORT not recommended, consider if recurrence. For extremities: Pre-Op: 50.4/28 (Myxoid liposarcoma 36/12) Some data demonstrating equivalent outcomes with 30/5!! GTV as delineated on all imaging (MRI T1+C) CTV = GTV + 1.5cm radial, 4cm (or 3cm) sup-inf PTV= CTV +1cm PORT: CTV60= pre-op GTV/tumour bed +1.5cm radial (as above) + !2cm! sup inf CTV50= CTV60+2cm sup-inf PTV = CTV50+1cm Definitive: At least 70Gy required for local control

Answer 12

(except for popcorn cell nodular lymph prodominant HL) Relevant studies in order of disease severity: HD10/EORTC, HD11, RAPID, HD15 (Stag III/IV). Risk = AMEEN = Age>50, Mediastinum>1/3rd, ESR elevated, Extra Nodal, Nodes>3. (1 or more = HR stg I/II). ISRT: GTVp = residual, GTVpre = prechemo. CTV=GTVp+5mm axial, and cranio-caudal expansion to cover GTVpre. If no GTV pre then 1.5cm. Stg I/II and low risk (H10): 1) x2ABDV then ISRT 20Gy (10yr PFS 10%) is standard 2) PET direct RAPID (fav or Unfav) x3ABVD no need for RT if PET-ve post c3. IFF +ve then x1ABVD the 30Gy ISRT Stg I/II and HR (AMEEN>0) H11 (10yr PFS 85% same as fav): 1) x4ABVD the 30Gy ISRT (i.e 10Gy more) 2) PET direct RAPID (fav or Unfav) x3ABVD no need for RT if PET-ve post c3. IFF +ve then x1ABVD the 30Gy ISRT Stg III/IV (HD15): BEACOPPx6 (dose escalation to x8 kills more ppl than it helps). IFF PET +ve or residual >2.5cm then 30Gy. Exception: urgent debulking of initially bulky - 30/15. ABVD = Adriamycin, Bleomycin, vinBLASTine, Dacarbazine - 1 month cycles, 2 infusions/mth BEACOPP= Bleo, etoposide, Cyclophosphamise, Oncoven (vincristine), procarbazine, pred.

Answer 13

HL = RS cells (CD 15 and 30) or Popcorn cells (CD 19,20 like NHL, and neg CD 15/30) Classical has 4 types (2 are assoc w/EBV): 1) Nodular sclerosing (70%) often mediastinum M=F broad band of bifingent sclerosing collagen 2) Mixed Cellularity (20%) EBV associated, often abdo/Spleen, M>F, Diffuse effacement of node with mix of lympocytes/plasma/eosin and RS Cells. No sclerosis 3) Lymphocyte Rich (5%): best prognosis 4) Lymphocyte Depleted EBV associated. Nodular Lymphocyte Predominant HL (5%) CD 19 and 20 (Ritux target). Frequently transform into DLBCL Stage I/II get upfront ISRT 30Gy then R-CHOP if PET +ve III/IV get R-CHOP +/I ISRT

Answer 14

Bladder preservation approach offers chance of preservation (66% at 8 years) with comparable OS to neoAdj chemo + surgery (both in order of 75%). Combined analysis of 2 trials favours hypofractionated approach for better LCR ~60%. Concurrent chemo is supported by multiple phase II trials that demonstrate LC benefit, one trial had a trend for OS benefit EBRT, Vmat technique 55Gy/20#, 5#s/week, to bladder and tumour volume (no clear evidence for ENI), 6MV photons, prescribed to D50. Concurrent with weekly cisplatin 35mg/m.sqr.

Answer 15

EBRT, Vmat technique 55Gy/20#, 5#s/week, to bladder and tumour volume (no clear evidence for ENI), 6MV photons, prescribed to D50. Conc w/Day 1 MMC 12mg/msq, and D1 and D15 5-FU 2.5g/msq (DFS BENEFIT, trend to OS). Pre sim: EMPTY BLADDER and Rectum. Maximal TURBT. Sim: supine head, towards gantry, vac bag immobilisation, w/knee/ankle fix. 2mm Slice CT+contrast mid-abdomen to upper 1/3rd femur. Fuse w/pelvic MRI. GTV: Gross tumour volume on imaging/cystoscopy, or is complete TURBT than pre TURBT volume. CTV = GTV+5mm on gross extravesicular extension, whole bladder, IF: bladder neck/trigone, CIS, multi tumour do prostate, or females 2cm urethra. IF posterior tumours ant vag wall.

Answer 16

(never Bx) Orchidectomy with high spermatic cord ligation The Mx based on seminoma vs NSGCT: NSGCT: Any residual then resect. Lmited role for RT, LVI is critical (relapse 50 vs 15%), LVI = BEPx1, LVI neg = Surveillance. Seminoma Mx based on Stg (Stg 1 = TanyN0, IIa=N<2cm = N1): Stg 1 = Surveillance (15% Recurrence, but no OS risk) vs 1-2 cycles of carboplatin (unclear data for 1vs2) vs Para-aortic 20/10. The TE19 study suggests Chemo is as effective as RT (relapse rate 5%), but less toxic. Factors that may make surveillance bad = tumour>4cm, involves scrotum, raised markers post surg, poor compliance with follow up Stg II - IIa (single node<2cm) consider dog-leg RT 20/10 (30/10 to dose). Otherwise BEPx3 (or EPx4 if cant do B): BEP = Bleomycin (pulmfibrosis risk) Etoposide

Answer 17

<3cm do surveillance, >3cm do PET at 6 weeks. If neg surveillance, if+ resection (preferred) or RT

Answer 18

Rationale: Decrease relapse rate from 15% to 5% 1) EBRT VMAT technique treating para-ortic nodes to 20G/10#s, 6MV photons, prescribed to D50. CTV20= IVC and aorta, from 2cm below renal apex to aortic bifurcation, expanded by 2cm and trimmed to anatomical boundaries. PTV = 0.5cm 2) Dogleg: As above but include common, internal, external and iliac vein to UPPER-BORDER of acetabulum

Answer 19

Inoperable panc cancer has 5yr OS of 5%, operable has 25% One key role therefore is in borderline inoperable - where metananlysis suggests neoAdj ChemoRT may make 1/3rd operable. BUT the specific role of RT is unclear (PREOPANC 2), with 36/15+ gemcitabine -> surg ->x4cycle gem = x6FOLFIRINOX (both approaches are highly toxic w/50% Pt having "serious adverse events"). Operable: Resecection - if +ve margin metanalysis supports a LC benefit to 45/25. Inoperable: Very limited evidence of OS benefit to the addition of RT to Chemo - 50.4/28 MASTERPLAN trial is looking at 4 cycles mFOLFIRINOX SABR with chemo: 40/5

Answer 20

Fusion: MRI and FDG PET Target volume: - GTV = visible disease based on planning CT, and fused MRI/ FDG PET (T1 and T2 sequence + contrast) - CTV = GTV + 1.5cm radial expansion + 4cm sup-inf expansion (include all oedema on T2 sequence) - PTV = CTV + 1cm expansion

Answer 21

Free knowledge: Histological Dx - characterised by osteoid production, and classified by site (central = within = conventional = 90% high grade, Juxta cortical most low grade, Extraskeletal is rare). RT only if: 1) Cannot be resected - neoAdj Chemo->70Gy->Adj Chemo (3 agents including methotrexate) 2) Further resection not possible:

Answer 22

Main role Palliative 20Gy/5# low dose equivalent to HD Other: 1) Neoadjuvant - investigational 2) Adjuvant: NOT if Extra pleural pneumonectomy (EPP)! Consider but don’t for pneumonectomy and decortication. RO 50/25 R1 50/25 and boost to 56/28. Phase 2 (MARS) says no benefit and may cause harm after EPP May be tolerated, await IMPRINT trial to see if any benefit. * SABR for oligo-mets No role Prophylactic RT to procedural tract

Answer 23

At least 7RCTs have shown non-inferiority to WBRT IMPORT LOW: Unifocal. Age>50, IDC grd1 to 3, <=3cm, <3nodes (N1) 40/15, 5#/week, 3Dplanned tangents with FIF, Prescribed to ICRU83, 100% PTV>95%. Sim: breath hold - all that shit Volumes: Tumour bed on imaging (clips, wired scar) CTV=TB + 15mm, trimmed 5mm off skin and lung interface. PTV=CTV+10mm.

Answer 24

Peripheral: >2cm from proximal bronchial tree = 54Gy/3#s UNLESS <2cm from chestwall - then 48Gy/4#s Central: <=2cm around proximal bronchial tree, but not ultra central. 50Gy/5# Ultracentral: PTV overlaps: proximal bronchial tree, pulmonary artery/vein, or esophagus. Controversial whether to treat with SABR - some reports of fatal pulmonary haemorrhage. SUNSET Trial 2024. Prospective phase 1 - 30Pts good LCR and no haemorrhage with 60Gy/8#s.

Answer 25

Superior sulcus tumour: 2 phase II trials show pre-operative chemoRT has superior DFS and OS compared to historical controls. Approx 50% 5yrOS. But other phase II data suggests chemo alone may be sufficient... DO ONLY if resectable (

Answer 26

Curative intent SABR 50Gy/5#s (using central tumour), 1#/day, prescribed to 100% isodose, 6MV photons, DCAT technique. Aim Dmax within PTV 125-140% of prescribed dose, CI-100; 1.2-1.3, CI-50<5. PTV D98>100%PD. CI-100 = Ratio of Volume getting 100% of prescribed dose to volume of PTV. Should be 1.2-1.3 CI-50 = Ratio of Volume getting 50% of prescribed dose to volume of PTV. Should be <5.

Answer 27

Technique options - Fixed beam >7 beam – fixed beam angle, converging on one isocentre, with open field, mixed coplanar/ non- coplanar - DCAT technique – modulated; open field; doesn’t allow MLC covering PTV at any stage; preferred for moving target - VMAT technique – static target DCAT (dynamic conformal arc therapy) - MLC only modulate field edge, and doesn’t cover the PTV at all time (compared to VMAT where MLC can cover PTV at some) - Avoid Interplay effect i.e. shielding of PTV with MLC during VMAT, leading to underdosage of PTV due to tumour motion - VMAT is ok on apex

Answer 28

EBRT (VMAT partial arc 6MV photons) **alone**: CTV_70Gy/35# = GTV+5mm CTV_63/35 (EQD2 60Gy) = Entire nasopharynx + Sup: Skull base w/ovale and rotundum, inf sphenoid sinus **if >=T3** - whole sphenoid and cavernous sinus Inf: Soft palate Ant: posterior 1/3 of max and nasal sinus Post: Bilateral retropharynx nodes, ant 1/3 of clivus (**whole clivus if involved - i.e. T3**) Lateral: Pterygoids and parapharyngeal space. CTV 56 (EQD2 50): CTV 63+ Levels II-V. **If node +ve include 1B.**

Answer 29

Divide into, young, elderly, and fit and unfit. Then response based (Autologous stem cell or WBRT or more chemo). Evidence: post chemo WBT improves PFS but unclear OS benefit. Unfit (for chemo): 40/20 WBRT or less All fit (young n old) should get HDmethotrex + ritux + Alkylating agent (eg TMZ). +/- further chemo then: If response: ASCT (preferred in young) or WBRT 23.4/13 No response/prog: Isofosphamide vs 23.4/13 then boost residual to 45/25 Fit elderly - 3 options: WBRT Maintenance TMZ or Wait and Watch

Answer 30

Brain stem/ optic chiasm = Dmax <54Gy Optic nerve Spinal cord = Dmax <45Gy Temporal lobe/Brain = Dmax< 60Gy, V40Gy<5cc Brachial plexus= Dmax< 66Gy Retina/ eye = Dmax< 50Gy Lens = Dmax < 8Gy Lacrima = Dmax < 30Gy Manidble = Dmax < 70Gy Carotid = Dmax <100Gy Parodid is a mean dose = Dmean 26Gy

Answer 31

Most recurrence is locoregional, so the role of CT CAP is unclear. "Ass"ess at 8-12 weeks * Clinical review at 6-8 weeks to ensure clinic complete response. If incomplete continue as normal but at 26weeks residual/progression should be Bx and plan for APR. * Clinical follow-up (DRE, and endoscopy surveillance) 3 monthly 1 st year, 6 monthly 2nd year, annually until 5 years * 3-month MRI and PET * Consider annual CT C/A/P if T3-4 or N+

Answer 32

>T1, then chemo= MMC + (5-FU or Capecitabine) (MMC essential, substitute for cisplatin as last resort) for improved LC and CSS SIB technique: CTV50or54: primary + 2cm+ whole canal/sphincters CTVnodes: inguinal, mesorectal, ischiorectal, pre-sacral, internal (inc obturator and external ilacs - do not do common. Non bulky (<4cm = <=T2): 50.4Gy/28 and 42Gy/28 - COVID Dose 45/15 Bulky (T3): 54/30 and 45/30.

Answer 33

1st year: 3monthly: Physical exam/Hx 6monthly: - CEA for 2 yrs then annually for 2 yrs - DRE and sigmoidoscopy CT CAP at 1 year. 2nd Year: 24month - Hx/Ex, DRE/Sigmoidoscopy 3rd-5th years: Annual Hx/Ex Coloscopy every 3-5year

Answer 34

Nigro (1974) Retrospective study 30/15 + CTx (MMC+5FU) ACT1: Chemo improves LC and CSS compared w/RT alone. Other trial says cant omit MMC. No benefit to induction chemo. ACT2: MMC+5FU = MMC+cis isoeffective/isotoxic PLATO recruiting=ACT3 (T1 surg +/- adj), ACT4 (<4cm de-escalation 41.4Gy/ 23 = butt hole CROSS), ACT 5 (N+ and/or T>=3, boost to 61Gy). OTT should be minimised (Not>6wks) Treatment breaks are shit for tumour control avoided - BD or treat on weekend if any missed #.

Answer 35

5FU/ MMC (MMC IV D1 12mg/m2 + 5FU infusion 1000mg/m2/day D1-4 week 1 and 5

Answer 36

The goal is organ preservation. Benefit of concurrent chemo is extrapolated from vulva/anal. For adj Pelvis RT retrospective data is mixed. Some suggests DSS and OS benefit, especially where multiple nodes. Therefore, adjuvant RT is recommended following a PLND with +ve nodes.

Answer 37

Use 2gy/# cisplatin 40mg. 1) Definitive local: - Primary <4cm and does not involve cavernosum local +/- cisplatin - 60Gy/30#s CTV = GTV+2cm (alternative is brachy 60/5). Surgery seems about equivalent for local - 5yr OS 75%, 80% LCR. 2) Definitive advanced (surg is the standard approach): >4cm, or >=T3 (meaning cavernosus invasion or worse): 50/25 whole penis and inguinal/pelvis, boost primary (+ve nodes, or ece and dissection) to 66/33Gy. This supported by UK RCR. (PORT is the same but adds 60/30 to micro) >4cm or >T2 should always get concurrent chemo: E.g. cisplatin or cisplain + MMC 3)PORT: 66/33 to residual, 60/30 to R1and ECE, then 50/25 to everything else. Chemo is R1, ECE or very advanced. Benefit extrapolated from anal/cervix. RT added to CT may increase PFS to 30% from 15% (multi-institutional anaylsis). 4) NeoAdj is investigational InPACT (45/25).

Answer 38

Approximately 20–30% of patients with positive inguinal nodes have positive pelvic nodes. Lymph node status is a major prognostic factor for penile cancer. Surgery is the mainstay of locoregional treatment. There is a lack of high-level evidence to guide management. ECE or >2 nodes

Answer 39

A multi-institutional retrospective analysis was carried out to review the benefit of adj RT to Adj Ctx after inguinal surgery for penile cancer. Found longer cancer-specific survival with ChemoRT (29%) compared with adj chemoalone (16%)

Answer 40

NeoAdj: 1) Bulky: resectable disease rarely cured with a single modality; therefore, consider NACTx prior to Iliac LND. 2) >2 nodes or bilateral nodes - Phase 2 support OS benefit to TIP (paclitaxel, ifosfamide, and cisplatin) or "TIP PIC". Adj: No diff bet adjuvant versus neoadjuvant chemotherapy or adjuvant versus no intervention, OS was higher with neoadjuvant chemotherapy compared to no intervention and PFS was higher with adjuvant compared to neoadjuvant chemotherapy.

Answer 41

Vaginal cylinder (often segmented) - best for symmetric brachy Multichannel cylinder - For asymmetric dose (also e.g. to avoid bowel loop 80Gy) Tandem and ovoid or ring applicator (or tandem or ring): Cervix cancer Combined interstitial intracavity devices. Rotte applicator (a 2 channel tandem thing where both channels can go into the uterine cavity) - in rare case of intact uterus.

Answer 42

Free knowledge: contraindicated prostate >60cc. Planning: - Based on TRUS volume - Contouring o CTV = prostate; PTV = CTV + 3mm (except 0mm posterior) o Urethra and rectum - Placement of seed ~ 100 through the prostates - Review DVH o PTV: V100>98%, V150% ~50%, V200%~ 13-18% , D100%>95Gy o Urethra: D10<210Gy, no 150% isodose line encircling/ in urethra o Rectum: V100<1cc, 70% isodose line away from anterior rectal wall - Seed ordered from overseas

Answer 43

- GA, lithotomy position - Prep and drape - IDC and injection of ~120mL mixed normal saline/ contrast - TRUS probe per-rectum, ensure image closely resembles volume study - Interstitial needle inserted using template and under ultrasound guidance, and position checked - Stylet (with radioactive seed) deployed - Interstitial needles removed, leaving stylet (with radioactive seed) in situ - TRUS probe removed - Cystoscopy – to check bladder and urethra of any seed, trauma, obstruction

Answer 44

PORT dose = definitive (post chemo) dose. Post operative volumes based on degree of necrosis (<90% necrosis = bigger volume = pre chemo GTV). Indications for PORT: * Positive (R1/R2) or close margin <1cm * poor response to chemotherapy (<90% necrosis) * tumour spill * For tumour spill, boost pre-chemo volume 45Gy/25# to pre-chemo volume then boost to 54/30 as below (I.e the only thing that changes is bigger volume if worse/less necrosis): IF post CTx NECROSIS >90%, then boost 9Gy/5# (1.8Gy/#) to post-chemo GTV (smaller volume) IF NECROSIS <90%, then boost 9Gy/5# (1.8Gy/#) to pre-chemo GTV (bigger volume) = forget post-chemo GTV and simply treat 54/30 based on pre chemo GTV.

Answer 45

* Do not treat across a joint/ encompass an extremity circumferentially (i.e. need to spare a strip), unless absolutely necessary for tumour coverage * Reduce margins if there is no extension beyond joint space, but adjacent epiphysis is in volume * For diaphyseal lesion, exclude one epiphysis of the affected bone, if possible * If CR to chemo, boost post-chemo volume * If incomplete response then boost pre-chemo volume

Answer 46

VDCA-IE – VDCA+IE better than VDCA alone in CCG-7881 trial (5yr OS 72% vs 61%) Induction chemotherapy 6 cycles Q2W (=12 weeks) o Chemotherapy break for surgery (week 13) o Adjuvant chemotherapy (restarted as soon as possible) to 48 weeks (i.e. total of 24 cycles) o If definitive/ adjuvant RT, start with cycle continue chemotherapy (withhold doxorubicin during RT)

Answer 47

1) CEA: Colorectal Ca, colangiocarcinoma, medullary thyroid 2) CA15.3: Breast 3) CA 125: Ovarian 4) CA19.9: Pancreatic Ca 5) AFP: NSGCTs = yolk sac and embryonal, Liver HCC 6)Beta or just hCG: choriocarcinoma, some mixed NSGCTs, and approx 10%seminomas that express it. 7) LDH: Melanoma, Myeloma, Folicular lymphoma, DLBCL 8) Calcitonin: Medullary thyroid ca 9) NSE: can be a marker of SCLC 10) S100: melanoma - not routine at Dx/or ever

Answer 48

Males: - Infertility if >6Gy - Reduced sperm count (and North Queensland quality sperm) 0.15-0.5Gy - Azoospermia 0.5-6Gy - Leydig dysfunction 10-15Gy Ladies: - Permanent: >12Gy prepubertal, >2Gy near menopause - Hormone insufficiency 10-15Gy (same as Leydig)

Answer 49

All get TAH+BSO+lymph node sampling + washings (peritoneal sampling if serous carcinoma). Stages: 1A = Observation (includes 1AmPOLEmut) 1B = VBT 28/4 (GOG99) consider ommitting 1C= Pelvic RT alone (45/25, SIB 55 to nodes) GOG249. VBT may be reasonable (PORTEC2) 2-IVa = ChemoRT (cisplatin 5mg D1 and D20) 45/25 pelvis and bed + VBT 10Gy/2#s (PORTEC 3) Definitive: EBRT 45/25 pelvis,SIB nodes 55Gy, VBT 21/3.+ Chemo. Or for IA definitive brachy: 27/3 Salvage (if no previous Rad): 45/25 (55 to nodes), 21/3 VBT - Observational data only. + Chemo. Whole abdo RT for IIIC/V 30/20 is shit compared to chemo alone.

Answer 50

Stgs based on: Invasion, extensive LVI, fav (grd I-III) vs aggressive (III, serous, clear cell), local (stg III) regional (III) systemic. POLEmut, p53abn.

Answer 51

Definitive: For IA in-operable: 27/3 PORTEC 2 - VBT adj alone. Stage IB 21Gy/ 3, 7Gy/ , 1-2 #/ week * Prescribed to 5mm from surface of cylinder * Dose to 5mm cranial from vaginal vault along the axis of cylinder should not vary more than 10% of prescribed dose PORTEC 3 - ChemoPelvis and VBT if stroma involved. * 10Gy/ 2, 5Gy/#, 1-2 #/ week * Prescribed to 5mm from surface of cylinder

Answer 52

Stromal involvement: Vaginal vault brachytherapy * Position: supine, use largest vaginal cylinder that will fit comfortably to minimise air pocket * Target volume: upper half of vagina * Dose/fractionation: 10Gy/ 2#, 5Gy/#, 2#/ week * Technique: HDR brachytherapy with Iridium-192 radioactive source, prescribed to 5mm from surface.

Answer 53

If GTR then >90% dont come back = observation. STR = 70% recurrence = Adj RT = 54/30.

Answer 54

If recurrent. <24hrs pre-op, <72hrs post. Dose fractionation - 7Gy/1# , AP/PA dose to midline, spare a strip of soft tissue. Reduces risk of recurrence to 10%. Alternative - Surgery followed by NSAID (indomethacin 75-100mg/day) for 7-14 days post-op

Answer 55

Germinoma - do CSI if Mets NGGCT - do CSI IF Mets OR No response to induction chemo. After induction carbo-etop (4-6 cycles): Germinoma (always 1.5Gy#s): Mets = CSI (1.5Gy/#) 18/12 + GTV boost to total 45Gy/30#. NGGCT (always 1.8Gy#s): Mets or No response to induction CSI (1.8Gy/#) 36Gy/20# (1.8Gy/#) + 18Gy/10# boost to GTV (total dose of 54Gy/30#)

Answer 56

Always aim GTR. Pineal parancymal tumours if GTR then obs, if STR consider RT. Germ cell: InductionCT (carbo etop) x4 if germinoma, x6 NGGCT: Radiation based on class, and induction response (CT/PR/none) and mets. 1) Germinoma (always 1.5Gy/#, total 30 or 36Gy): CR: 30Gy total. WVRT 18Gy/12# + GTV boost 12Gy/8# PR: 36Gy total. WVRT 24Gy/16# + GTV boost 12Gy/8# Mets: 45Gy. CSI 24Gy/16# + GTV boost to 45Gy/30# 2)NGGCT (always 1.8Gy, total 54Gy) CR/PR: WVRT 30.6Gy/17# + GTV boost 23.4Gy/13# = 54Gy No-response or mets: 36Gy/20# (1.8Gy/#) CSI + 18Gy/10# boost to GTV (total dose of 54Gy/30#) + 9Gy/5# to bulky spinal met (total dose of 45Gy/25#)

Answer 57

1/2000 people. 2-4% chance of bleed/year, At each bleed - 30%chance of morbidity, 10%chance of death. Biggest risk for bleed is a previous bleed. Present from birth, average age become clinically apparent is in 30s. Graded (Spetzler-Martin) score 1-5: based on Size (<3cm, 3-6,>6cm), location (eloquent/non-eloquent), Presence of deep venous drainage. Size >4cm attempt emobilisation to facilitate surgery/SRS Surgery Tx of choice where possible. Improves seizures indicated in S-M score 1-2 (may not be possible in eloquent brain or deep venous drainage). SRS - tumours <3cm Observation: may be only option, if previous, aneurysm or deep location should be avoided if possible.

Answer 58

SRS for tumours <3cm. with dose 16-20Gy/1# (GTV on angiogram). Outcome 80-90% at 3years (requires endothelial proliferation to cause obliteration), in latent period risk of bleeding is unchanged.

Answer 59

8% Brain tumours, 96% of NF2 get them (often bilateral), 5%NF1 (also oft bilateral). M=F. Merlin is a Schwan cell tumour suppressor protein (gene on chromo 22), dsPyfunction ->proliferation. Preferred Mx = surgery, especially in younger Pt - allows debulking and reduction of BS compression (but signif risk hearing loss if tumour >2cm) Observation=6-12month MR, if growth>2.5mm/year or hearing loss/worsening Sx need Tx. SRS: 12.5Gy/1# for tumours <3cm and PTV not on BS. Otherwise..... SRT: 25/5 Outcomes growth arrest (=LC) 85%@3yrs. It’s possible some crazy big tumours need VMAT 50/25.

Answer 60

Gamma Knife based brain SRS, 50% is usually chosen as the prescription (marginal) dose. We (Hamilton) prescribe to 100%, other places prescribe to 60-80%, it’s apparently not an arbitrary choice. Lower dose point leads to faster dose fall off, remember radiation necrosis is partly a function of volume irradiated.

Answer 61

You could do WBRT (e.g 30/10) isoefective control - but more neurotoxicity and time toxicity (2 phase 3 trials). Neither SRS or WBRT is better than observation in terms of OS. SRS 12-20Gy ALIANCE Trial SRT if <30cc 27Gy/3# If > 30cc 25Gy/5#s Adj SRT to the surgical cavity, VMAT technique, 6mV photons, Prescribed to 100% isodose line. Sim: patient supine, head towards gantry, arms by side, knee rests, comfort measures. Imo: thermoplastic mask. Contrast CT 1mm fine slice - vertex to C4. Planning MRI T1+C. HighRiskTumourVolume=HRTV=Surgical cavity CTV = HRCTV + any GTV + 2mm (may include tract and/or dural margin). PTV: =GTV +3mm OARS: in 2Gy/# (I would convert for SRT): Brain stem <45Gy, Brain Dmax<60Gy, V40Gy<5cc. Verification: daily CBCT matched to bone

Answer 62

GTV if any (though if residual present is technically post operative SRS) High Risk Tumour Volume=HRTV=Surgical cavity CTV = HRCTV + any GTV + 2mm (may include tract and/or dural margin). PTV: = CTV +2mm (1-3mm) DOSE: 30/5 (if >3cm). OR 27/3 IF<2cm Caution >5cm, Change to WBRT at about 5.5cm. Osimertinib only if Exon 19/21 EGFR mutations.

Answer 63

No RT or TACE if Childs C (caution in B) 1) Surgery: -Solitary tumour<2cm do Partial/hemihepatectomy -2-3 lesions or a single lesion <5cm (Milan criteria) aim liver transplant with bridging therapies while waiting (see below). 5yr OS70% (best chance survival) 2) Ablation: - Thermal = RFA if <3cm 90%CR, 2-5cm 50-70%, Microwave improved CR for tumours up to 5cm. - Non Thermal = Irreversible Electroporation: preserves structural integrity of. bile ducts and vessels (used more in pancreas). 3) Trans Arterial Embolisation - +Chemo (TACE) Yttium-90 microsphere (TARE). Local response 50% (TARE up to 70%) - For lesions too large for TACE (>5cm) - 85% post-embolisation syndrome 3-4days, 15% irrevesible liver injury. 4) XRT - preferred in patients w/vascular invasion, portal vein thrombosis: SABR 30 or 50 in 5# (LC up to 90%). Conventional 66/33 (French), Palliative whole liver 10/2 for 60%response rate 5) Systemic - no chemo, but Sorafenib increases OS 2-3 months 6) Sorafinib + SABR for disease unsuited to other treatments.

Answer 64

54/3. 3# doses range from 42/3 to 54. Large (i.e 5-6cm) consider 5# 40/5 up to 60/5. 36-96hrs apart Ideally 1-3 Maximum diameter 6 cm, or combined ≤10 cm, larger Solitary oligometastatic or oligoprogressive disease. No evidence of nodal or distant mets Unresectable mets or patient unfit/declines resection. If cirrhosis; Child Pugh score A/B maximum 7 points. Adequate liver function If close to kideny do split renal function.

Answer 65

Can be used in bridging prior to transplant. In combination with other therapies (e.g. TACE+RT reduces recurrence in tumours>3cm). Preferred in patients w/vascular invasion, portal vein thrombosis. Some retrospective data suggests better LC with SABR compared to RFA, SABR 30 or 50 in 5# (LC up to 90%). Conventional 66/33 (French), Palliative whole liver 10/2 for 60%response rate In patients unsuitable or refractory to TACE Sorafinib OS + SABR for disease unsuited to other treatments. SABR adds 3-5 Months OS = 16months.

Answer 66

Rationale: Equivalent local control to historic RFA (90%<3cm, with better control than RFA for tumours >3cm). SABR: 30/5 to 50/5 1#/day 5#s week, prescribed to 100% isodose. 4DCT Contrast CT 1mm slice (HCC enhances on arterial phase only). + MRI Volumes contoured on MIP and checked across all phases of respiratory cycle. iGTV= All parenchymal (iGTVp) + vascular (iGTVv) on imaging. CTV=GTV PTV=CTV+5mm Motion management system. Mean liver dose <28Gy

Answer 67

Phase 2 SWOG trial for T2-T4 node positive resected Ro or R1: Adjuvant RT increases OS compared to historic data (Median OS=3yrs). 45/25 nodes 54/30 to bed 59/33 to R1.

Answer 68

NeoAdj chemo -> Mastectomy +ALND -> Adj RT + Receptor targeted therapy You need pre-treatment clinical photos. There will never be an RCT, but large retrospective studies demonstrate control benefit of escalation>60Gy. MDACC (largest study): 66/44, 1.5Gy/#BD, CTV 3cm beyond scar + Bolus until skin rxn too significant. Do this for age<45 or residual post chemo, otherwise can de-escalate - e.g. 60Gy. 5yr OS =40% If no residual post

Answer 69

MDACC suports dose escalation in this patient (up to 66Gy). I would treat chestwall and undissected nodes including IMC to 50Gy/25, then boost chest wall to 16Gy. VMAT, DIBH. Bolus as long as tolerated. CTV50= GTV+1cm (trimmed to boundaries) + whole chest wall and nodes (level III, SCF, IMC) PTV=CTV+5mm CTVboost= GTV+1cm (trimmed to boundaries) + whole chest wall

Answer 70

The SOFT-Text trial: Ovarian suppression (for 5 years, GnRH agonist=goserelin) added to either AI or tamoxifen improves DFS and OS. In particular women <35, T>2cm, or grd III, where an AI is preferred to Tamox due to improved DFS and decreased distant failure. Begin Ovarian suppression at start of chemo

Answer 71

5yr OS = 30% Curative intent EBRT 45Gy/30#s, 2#s/day, at least 6 hours apart, 10#s per week. VMAT technique, 6MV photons, prescribed to D50. Concurrent with chemotherapy = Carboplatin + Etopside. iCTV=iGTVp + 7mm, iGTVn+5mm PTV+7mm

Answer 72

LUNG: Mean lung dose <20Gy, V20gy<30% Heart: MHD<20Gy, Spinal cord DMax < 50Gy Esophagus Mean< 25Gy, Dmx<66Gy Brachial plexus DMax<66Gy

Answer 73

Quick numbers. Malignancy 6% increase in absolute risk/Gy. IQ 25 points/Gy threshold hold dose for effects is 0.1Gy: During the organogenesis phase of foetal development the foetus is at most risk from radiation. Studies of atomic bomb survivors, and other disaster exposures, combined with animal studies demonstrate: A threshold dose of 0.1Gy W/general features of Interuterine growth restriction, Cognitive impairment, and future malignancy (6% increase absolute risk/Gy) risk being proportional to dose and also the phase of development at which exposure occurred: Exposure during (Germinal) pre-implantation phase (day 0-10) - often fatal/failed implantation. Organogenesis (Embryonic) phase (up to 6 weeks): Highest risk of congenital abnormalities, especially CNS (microencephaly). Severe intrauterine growth restriction (due to cellular depletion). Foetal period 6 weeks to 9 months: 1) Mental retardation - 25 IQ points per Gy, threshold 0.1Gy, due to failure of neurons to migrate peripherally. 2) Microcephaly 3) Eye, skeletal, genital abnormalities 4) Intrauterine growth restriction

Answer 74

Benign (e.g. pleomorphic adenoma): Controversial - doses up to 60Gy Malignant: Low grade (e.g. Maligant mucoepithelial carcinoma): Surgery and observation. High grade PORT: 63/30 to R1, 60/30 to R0. 54Gy to nodes (1B II and III). All adenoid cystic carcinomas. Close margins (<2mm) PNI T3-T4 Node +ve/ENE ENI: All HG - But dont bother with ACC N0 = cover IB-III N+ = cover 1B, II-V PNI: Treat to BOS if: cPNI, rPNI, named nerve, extensive PNI, or adenoid cystic

Answer 75

63/30 to R1, 60/30 to R0. 54Gy to nodes (1B II and III, Unless node + then do 1B to V). Exception ACC don’t do nodes unless involved nodes (very rare).

Answer 76

Generally age>45. ENI: II-VII MTC: If extensive nodes, residual or extension beyond the thyroid. PTC/FTC: Poor I-131 (e.g. Hurtle cell), I-131 failure, >T3b (Extra thyroid/capsular extension), Gross residual post op. Anaplastic: Always do PORT, or start 70Gy ASAP if inoperable. Median OS 3months, 5yr OS 10%. 70Gy (or 66/30 to gross residual) 66/30 - to residual/gross 60

Answer 77

With RT - LC 75%, 5yr OS 50% (remember often elderly, immunesupressed). Definitive: 66/33 PORT: T1 (<2cm) dont need nodes (but do need LNBx). 50/25+3cm margin. >=T2: R0 then 50/25 to BOTH bed +3cm and nodes. R1 then 60/30 to Bed and 54/30 to nodes. R2 66/30, and 56/30 to nodes Avelumab is investigation Stg I-III Chemo: Consider in stg >I, But no clear role, carboplatin as radiosensitiser.

Answer 78

Definitive Naso: 3 dose clouds SIB in 35#s: 70GTV+5mm, 63Gy HR, 56Gy nodes II-V (include IB if node+ve). I.e clouds drop by 7Gy. Definitive: 70/35 GTV+5mm 63/35 = HR = equivocal nodes, Oral = entire BOT if tongue involved. Oropharynx = also entire BOT if tongue involved. Larynx = entire larynx. Hypo pharynx = entire hypopharynx. Glottic T1 (limited to vocal cords): RCT supports 55/20 for T1, with concurrent chemo improving preservation. 80% 10yrs. >T1, as above. PORT: in 30#s, 63Gy (if +ve margin/ECE, historic data from the Peters Trial for ECE), 60Gy to bed and +ve nodes, 57Gy to dissected neck, 54Gy to undissected neck.

Answer 79

Pooled analysis of 2 RCT demonstrates OS benefit IFF ENE or +ve margin. Interestingly no clear benefit for +Nodes even >5+,

Answer 80

Curative intent stage 1A: Brachytherapy alone (not favoured approach) for inoperative/declined operative intervention. 27Gy/3# As part (adjuvant post surgery) curative intent treatment. 1) Stage 1B (>50% myometrial invasion, no LVSI, limited to uterus), without pelvic EBRT. E.g. 21Gy/3. (PORTEC2) 2) Stage II (extension beyond uterus where stromal invasion has occurred) in addition (brachy boost) to pelvic EBRT. 10Gy/2# 3) Stage III and IVa. In addition (brachy boost) to pelvic EBRT. e.g. 10Gy/2# (PORTEC3).

Answer 81

RCT Data (PORTEC3) demonstrates at 5years concurrent chemo (weekly cisplatin) followed by adjuvant x4 cycles (Carboplatin Paclitaxel) can provide LC, FFS and OS benefit when concurrent with radiotherapy. It may be considered from grd 3 stg1. Sub-analysis of PORTEC3 shows the benefit of chemo is primarily in any of the following: Stage III (serosa or nodes involved), Papillary Serous or p53abn.

Answer 82

Assume stage 1B: Adjuvant vaginal vault Brachytherapy (Ir-192 source, remote after loader technique), 21Gy/3# to the upper 1/2 of vaginal vault prescribed to 5mm from cylinder surface. Pre sim: Full discussion of procedure for consent. Analgesia, comfort measures as appropriate. Dilator education with educator (to begin 4 weeks post). Sim: Patient in lithotomy position. Manual examination and selection of appropriate vaginal cylinder/cylinder segments. Aim largest size that is comfortable to minimise air gaps. Plan selected from Plan library for applicator selected. Planning system to provide dwell times for after loader. OARS: Rectum, Bladder. Verification: External measurement from labia. Dose Delivery (in specialised bunker with video/audio monitoring, interlocks) via remote after loader.

Answer 83

Anti-androgen medications - Typically non steroidal anti-androgens (e.g. Bicalutamide): In hormone naive pts: part of initial therapy + GnRH agonist +/- abiraterone (e.g.STAMPEDE) increases progression free survival, and OS. Alternatively can be used for 3-4 weeks as part of commencement of GnRH agonist - to prevent testosterone spike from initial LH surge. Can also be used when progression despite GnRH agonist (“total androgen blockade) to prolong PFS. ADT+ Apalutamide superior DMFS (SPARTAN). Used life-long or until significant progression. GnRH agonist (e.g Goserelin), provides an PFS, OS and Sx benefit in patients with newly Dx metastatic prostate cancer, and is part of multimodal therapy as above. Duration life-long, or until progression, or in the setting of stable disease intermittent (restart when >10ng/ml). Androgen synthesis inhibitor - Abiraterone: Improves OS and PFS (STOPCAT RCT)- used in the following contexts - as initial therapy for newly Dx metastatic disease (in combination with ADT but not ADT+Enzalutimide), or when progression on ADT. Chemo - Taxane chemotherapy - Docetaxel, improves PFS and OS (CHAARTED phase III RCT OS increase from 48 to 58months) when part of initial Mx of metastatic disease. Also increases OS for N+ and locally advanced (STAMPEDE). 75mg/m.sqr (65mg for Asians) until response (up to 10 cycles).

Answer 84

Traditionally, LC-CRT was preferred over SCRT in patients with locally advanced tumours whereby ‘downstaging’ is required to minimise the chance of a positive circumferential resection margin or maximise sphincter preservation. The lesser ‘downstaging’ effect of SCRT may be overcome with a longer delay to surgery or addition of pre-operative chemotherapy (i.eTNT approach).

Answer 85

Capecitabine 825mg/M.sqr BD, or continuous 5-FU daily (better than bolus), dont 5-FU dMMR/MSI patients. Studies from the 1980 and 90s suggested a LC and OS benefit to chemo in post op setting, more significant in the concurrent setting. In the the neoadjuvant setting concurrent improves LC compared to LCRT alone. Recent trials have demonstrated that total neoadjuvant therapy may avoid TME (OPRA - 54Gy+cap -> FOLFOX/CAPOX, or FOLFOX/Capox->54Gy, radiation before better trend) can achieve 50% 5yr preservation rates, w/no change in 5yr DFS = 75% = historical control. Recently PROSPECT RCT trial demonstrated that neoAdj RT could be avoided (if >20% response on MRI to FOLFOXx6 AND followed by TME and more FOLFOX).

Answer 86

Neoadj long-course chemoRT, EBRT to a maximum of 50Gy/25#, 2Gy/#, 5#s/week. VMAT SIB technique, >=6MV photons, prescribed to D50. Concurrent with oral capecitabine 825mg/m.sqr BD. Pre-sim: consider if defunctioning indicated, fertility counseling, analgesia, anti-emetics. Comfortably full bladder, bowels empty (enema) prior to sim and each treatment.

Answer 87

Volumes: GTVp= GTV on imaging and endoscopy GTVn= Positive nodes on imaging. CTVp50= GTV+1cm craniocaudally, + mesorectum and pre-sacral space at these axial levels. CTVn50 (if outside above volume) = GTVn +5mm. CTV45=CTV50 p and n, Entire mesorectum (+1cm anterior internal margin for bladder filling) and presacral space, external iliacs (as prostate involved), obturators, and internal iliacs to bifurcation. Entire prostate. PTV=CTV45+1cm OARS: Bladder V40Gy<40%, DMax <50Gy (ideally) Small bowel DMax<50Gy Large bowel V45Gy<195cc Femoral heads V40Gy<40%

Answer 88

1. CTV50 = GTV+1cm craniocaudal, entire mesorectum and presacral space at those axial levels. CTV45= CTV50 + entire mesorectum, presacral space and internal iliacs. 1cm anterior expansion to account for variable bladder filing. 2) CTV50 = GTV+1cm craniocaudal + entire anal canal including sphincters and mesorectum and presacral space at those levels. CTV45=CTV50 NOW include inguinal and external iliacs. (same with lower 1/3 vag). 3) As above. CTV45 = as above, BUT include prostate/vag. External iliacs and obturators. If bladder, may reasonable to do entire bladder (in which case sim empty).

Answer 89

Curative intent EBRT to a total of 50Gy/25#, 2Gy/#. 5#s/week (see boost below). VMAT Technique, photons >= 6MV, prescribed to D50. Concurrent with weekly cisplatin 40mg/Msqr. Combined with brachytherapy (described below) in final week(s) of treatment. Pre-sim: Preg test, offer fertility counselling/service referral, analgesia, anti-emetics as required. Comfortably full bladder (also prior to each fraction). Sim: Supine, arms on chest, head towards gantry. Immobilization with vac bag, knee and ankle supports as needed. Bowel empty (enema at sim and prior to daily RT). 2mm slice CT+contrast, L4-mid femur. Fused with MRI and diagnostic PET.

Answer 90

Volumes: For non-nodal volume contour on full and empty bladder and merge CTVs for ITV. GTV = Primary tumour on imaging and examination. iCTVp= GTV+5mm, Entire vaginal canal, and Cervix PTVp = iCTVp+7mm CTVn = Inguinal, external and internal iliacs (to bifurcation), obturator and presacral nodes (Pre sacral nodes if cervix involved). PTVn = CTVn+7mm. OARS: Bladder V40Gy<40% Rectum V40Gy<60% Hips V40Gy<40%

Answer 91

Patient - Sphincter preservation is considered important Tumour - cT4 tumour - N2 - Low rectal tumour (e.g. <5cm from anal verge) - Presence of EMVI (on MRI) - Threatened/ close/ positive CRM - Recurrent rectal cancer (even in patients without prior RT) Treatment - As adjuvant treatment - Re-irradiation in patient with previous RT - When non-operative approach is considered

Answer 92

OPRA: T3aN0 (invades subserosa)- to T4N2 (Stg II to III). No hx prior pelvis RT/recurrence/mets. Better organ pres seen in ChemoRT->FOLFOX/CAPOX, than FOLFOX/CAPOX->ChemoRT. 5yr 55% organ pres. 5Yr 80% OS 90% LC, with 90% recurrences within 2 yrs. BUT: grd III or IV tox in 20% Recent metaanalyis suggests for TNT any LR is associated with poorer outcomes (compared to TME <10% viable cells).

Answer 93

For: improved chemo compliance by front‐loading this treatment resulting in improved disease‐free survival, Increased primary tumour complete response rates, Less time with a covering stoma. Chance (55% @ 5yrs) organ preservation and sub subsequent lower rates of permanent stoma. Equivalent AGainst: How to interpret near complete Response on mrTRG (.e. grade 2 outcomnes same as 1?). Lack of definitive histo - while inter-operator mrTRG is good, less than TRG. Possible worse outcomes if LR (metanal compared to <10% TRG post TME). Still quite toxic - >20% GrdIII or IV toxicity. Direct (phase III) comparison of TNT v.s std approach is lacking. Promising toxicity and ocologic outcomes with s/cRT + NeoAdj + Adj chemo (STELLAR Trial). Less established.

Answer 94

1) MRI Tumour Response Grade (mrTRG): Graded 1 to 5 (1 complete response_, based on

Answer 95

Retrospective and prospective data suggest safe and associated with better outcomes. 45/25 concurrent with capecitabine or 5-FU (no if dMMR).

Answer 96

Surgery: 1) For stage III (T3 where thyroid cart not fully penetrated) - Larynx sparing surgery w/followed by PORT (no chemo). Advantage: Avoids chemo, equivalent to definitive ChemoRT (i.e VA study). Histology on resection provides more fine grained prognostic information/risk qualification and decisions on adjuvant therapies (e.g. the addition of chemo). Disadvantages: Worse reported QOL outcomes than definitive chemoRT, operative risks including failed organ preservation and dyspnonia/nerve injury. Does not avoid radiation. 2) For stage IV: Total laryngectomy and adjuvant PORT +/- Chemo. Advantage: Definitive operation, with en bloc resection and detailed pathological information, preferred option for advanced disease. Disadvantages: Offers no chance of organ preservation, highly morbid surgery with poor QOL, intraoperative and post operative risks and complications, despite intensity of intervention may not be curative. ChemoRT (note the role of induction chemo, e.g. VCF is controversial in terms of benefit vs toxicity, may consider for bulky disease where definitive chemoRT is treatment of choice). 1) Definitive For Stage III - 70Gy/35# with cisplatin (eg. 100mg/msqr) 2) as for 1, potential proceeded by induction chemo. Palliative: 1) Palliative radiation for local control and symptom MX (e.g. 20/5 or 30/10): Not curative (main disadvantage), can offer good durable local control and symptom relief. 2) In severe case IV - Best supportive care, with medical Mx of Sx, and social emotional and family support.

Answer 97

Small bowel loop V30Gy<200c, Dmax<50Gy Large Bowel loops = same as small bowel. Rectum V40Gy <60%(e.g. cervix) Bladder: V40Gy< 30% (or 35%), V50Gy<5% External genitalia: V40Gy< 5% Femoral head/neck: V30Gy< 50% Kidneys: Mean dose <15Gy

Answer 98

Adjuvant treatment (nodal) – TROG 0201 * ≥1 parotid node, ≥ 2 cervical or axillary nodes, ≥3 inguinal nodes * Largest node ≥3cm (cervical nodes), or ≥4cm (axillary/ inguinal nodes) * ENE

Answer 99

STAMPEDE - FFS benefit 85% vs 55% (compared to no irradiation). This is consistent witrh a number of prospective trials suggestive of significant benefit - including OS. Dose: 74/37 to prostate and SV + positive nodes. 55/37 to prostate.

Answer 100

Gonadotropin Releasing Hormone ANTAGONIST (as oppsed to the typical GnRH agonsist goserelin/leuporelin). Phase III open label data demonstrated superior PSA response, and mixed difference in toxicity. Degarelix has more injection site reactions. Monthly S/c Dose: Dose 1 =240mg. Dose 2-infinity = 80mg.

Answer 101

OARS (in EQD2): Rectum V50Gy<50% Bladder V50<50% (may compromise to V65<50), Femoral heads V50Gy<5% Small bowel V45<195cc, Large bowel - avoid hotspots.

Answer 102

Curative intent EBRT with ADT (2-3 years) to maximum 60Gy/20#, 3Gy/#, 5#s/week. VMAT SIB technique, >=6MV photons, prescribed to D50. Aim PTV D95>98% prescribed dose, avoid plan hotspots over OARS (especially bowel), Dmax<107%. Pre sim: LUTSxt assessment and Mx as appropriate/if needed. Pre sim and each # - bowels empty (enema) and comfortably full bladder. Sim: Supine, hands on chest, knee/ankle supports, immob w/vac bag. 22mm slice CT+ con(L3 - upper 1/3rd femur), consider fusion with dx MRI/PSMA PET if +ve nodes small/reduced with ADT. STAMPEDE - Improves failure free survival. Volumes: CTV60p = Entire prostate + 1st 1cm of SVs GTVn = + nodes CTV60n= GTVn+3mm (depending on prox to bowel may reduce to 55/20). CTV44= CTV60 + remaining SVs, pre-sacral (always forget to write that) external iliacs+obturator nodes, internal and common iliac nodes to bifurcation or 2cm above highest positive node (whichever is higher).!!!!!!!!!!!1 PTV= CTV44+7mm. OARS (in EQD2): Rectum V40Gy<40% (ideal) may accept up to V50Gy<50% Bladder V40Gy<30%, Small bowel V45<195cc, femoral heads V40Gy<40%. Large bowel - avoid hotspots

Answer 103

No phase III data (i.e comparing SABR to RFA). Multiple retrospective and 2 phase II prospective trials. A HyTEC analysis of 13 studies found 1year LCR to be 90%. Outcomes were significantly better for lesions treated with BEDs exceeding 100 Gy (3-year local control 93%). Rule et. al "Rule" for dose response: LC rate at 2yrs - 100% at 60Gy years, 89% for the 50 Gy cohort, and 56% for 30 Gy. 54/3#, SABR with motion Mx, iGTV to 5mm PTV expansion (if GTV unclear consider 3mm CTV expansion). Contour on CT+contrast - late arterial phase if technically feasible with 4DCT

Answer 104

i. indications - Clinical exophthalmus due to thyroid eye disease - Failed trial of steroids - Not suited to or declined other approaches (surgical decompression) ii. contraindications - Responsive to steroids/other Mx. - Connective tissue diseases (cautionary) - Eye diseases: e.g. glaucoma iii. target volumes CTV= preorbital tissues, PTV 3mm. E.g. with 5 × 5 cm lateral fields using 6 MV photons and 5° poste- rior tilt or half-beam block iv. radiation dose fractionation schedules and v. expected response rates to therapy? 20Gy/10#, recent evidence suggests that this dose may be reduced (Don’t ever hypofractionate benign). Local control in approximately 2/3rds.

Answer 105

Local recurrence after surgery alone =50%. (25% post RT) 21 Gy/3 fx for most locations and 18 Gy/3 fx for earlobe 24–72 hrs after surgical excision. 37.5 Gy/5 fx if RT is used definitively. LC 75%. Other options include steroid injection, cryotherapy, pulsed-dye laser, interferon, or topical agents.

Answer 106

Absolute indications = T4, +ve margin where further resection not available. PNI in large nerve. Recurrence where no previous RT given. Relative (if 2 or more then do): T21, 2 or T31. ≥6 mm depth of invasion. Close margins < 2 mm. Poorly differentiated. Pathological microscopic perineural invasion (PNI). Lymphovascular invasion. Immunosuppression. Higher risk sites, e.g. non-hair bearing lip, chin, ear, preauricular, periorbital, temple.

Answer 107

Adjuvant RT to reduce risk of recurrence. SXR technique, 40Gy/15#, 5#s/week, 100% prescribed dose at skin surface, energy/filter/SSD selected for D90 cover at target depth (e.g. 3mm). Pre: Explain vision changes associated with topical anaesthetic (may need to arrange transport etc). Sim: Mark-up scar, make or select lead cutout and applicator appropriate to markup + 10mm margin (for CTV + setup error and penumbra). Make setup template from above + setup photos. Eyeshield fitted. Using departmental tables, select Energy/Filter/SSD e.g 20cmSSD 2mmAl, 100Kv for D90 ~3mm (consider contribution of scatter from eye shield to dose). Clinical setup photos. Volume: as above, Dmax at skin surface aim D90 based on path report. OARS (in EQD2, note SXR higher BED): Eye: lens DMax<8Gy, Eye <45Gy, lacrimal duct Dmax<30Gy. Verification via template match and setup photographs.

Answer 108

COGS/ IRS (US/ Australia) Surgery → chemotherapy → RT SIOP Surgery → chemotherapy → no adjuvant RT * 50% will relapse – intensive therapy for relapse including exenteration + RT (reserve RT for salvage) Variables (that define risk): Site, Histo. Surgical/Post-op. Doses: Embryonal R0 - No Rt R0 Alveolar and all R1 - 36/20 N+ 41.4/23 Gross disease 50.4/28

Answer 109

Definitive EBRT 50.4Gy/28#, 1.8Gy/#, 5#s/week to the right orbital mass with concurrent chemotherapy (vincristine and cyclophosphamide; and omitting actinomycin-D during RT) Pre-SIM: * Repeat MRI post chemotherapy * Consider GA if patient not able to remain still on RT SIM * Position: supine, arms down, head towards gantry, under GA * Immobilisation: thermoplastic mask, vac bag, neck support, * Marker: no specific * Planning CT: 2mm slice CT from vertex to lower cervical spine Fusion: pre-chemo and post-chemo MRI Targe volume: * GTV = pre-chemo gross disease * CTV = GTV + 1cm clipped at anatomical (i.e. bone) boundaries (no need to cover entire orbit) * PTV=CTV+5mm Technique: partial arc unilateral VMAT technique with 6MV photon Plan evaluation: * Tumour coverage PTV D98>95% * Minimise hotspot PTV D2<107%, ensure no hotspot outside of PTV/ over critical OAR * Ensure low dose (10% and 50%) reasonably distributed around PTV, with contralateral sparing * Review OAR DVH o Pituitary and temporal lobe ALARA o Lacrimal gland Dmax< 41.4Gy o Optic nerve/ chiasm/ brain stem: Dmax< 50.4Gy o Lens Dmax< 14Gy Verification: Daily kV, matched to bone, with 3mm tolerance

Answer 110

If no BRAF than target T-Cell mediated cell death evasion: CTLA4 - Ipilumimab. Normal role is to downregulate T-Cell activation. Upregulated in cancer leading to immuncheckpoint evasion. Ipilumimab binds CTLA4 and inactivates it. By itself adds 3 months PFS. PD-1 - E.g. Nivolumab. Binds PD1 receptor on T-Cell preventing PDL-1 from binding and inactivating T-Cell, By itself adds 6Months Ipi + Nivo = 12months PFS 5Yr OS for metastatic BRAF negative is 45% 5Yr OS for +v is higher at 55%

Answer 111

Best results combine BRAF and Mek targeted therapies: TKI signal transduction pathway RAS RAF MEK ERK Braf: Dabrafinib MEKtargeted by molecular inhibition = Trametinib. Get on the 'ol Dab Tram for 1yr OS 70% next stop death.

Answer 112

If optic nerve or being gentle - 50.4/28 Grd 1 R0 -observation Simpson 1-3 - Observation versus 54/30 STR/primary Mx - 54/30 SRS 14/1 SRT - 25/5 Grd II/III For grd II Observation is investigational (ROAM) Simpson I-III 54 to 60/30 or 59.4/33 (if big or young!!!) STR/residual - 60/30 or 59.4 SRS/SRT - 14G or 25/5 Note: 59.4Gy/33, 1.8 Gy# where large volume or young patient 1.8Gy/# - a common Exam trick question. Grd I-III Recurrence: Re-resection where possible Then doses as per relevant grade

Answer 113

GTV = gross disease (T1 + contrast) [if no resection] GTV(post-op) = residual disease (post-op MRI) (T1 + contrast) Grade 1 - CTV = GTV + 0.5cm for WHO Grade, 5mm into brain, clipped at anatomical boundaries Grade 2 - CTV = GTV + 1 - 1.5cm along the dural for WHO Grade 2/3, 5mm into brain, clipped at boundaries PTV=CTV+5mm

Answer 114

Fuse pre-op and post-op MRI GTVpost-op = GTR based on fusion of PO MRI CTV = GTV + surgical cavity + 1.5cm along dural + 5mm into brain, clipped at anatomical boundaries PTV = CTV + 5mm expansion I will offer her adjuvant RT to a total dose of 59.4Gy/33, 1.8Gy#, 5#/ week - Large volume hence use more fractionated + young patient 1.8Gy/# (lower late effects than 2Gy/#)

Answer 115

Historically trial data has been unclear or not supportive (e.g. GETUG, RTOG). More recently the POP RT trial, which studied a population of higher-risk of nodal involvement (>=20% by Roach) demonstrated a 5yr met free, disease free benefit but with higher late GU toxicity. WPRT = 90% 5yr disease free survival vs 75%. This study used a modern prostate dose (68/25), and 80% of pts had a PET. A new RTOG study 0924 is recruiting with an aim for higher-power than previous.

Answer 116

Int risk Unfav - ADT 6mths = DFS, biochemical failure reduced from 20 to 10% at 5yrs. PrSpec survival and potential OS benefit: NCCN recommendation is for ADT beginning at intermediate unfavourable prostate cancer. Its is based on 2 phase 3 RTOG trials and meta-analysis. The 1st RTOG trial 9408 found 4 months ADT provided a DFS benefit to IR-U but not IR-F (on subanalys). A 2nd RTOG phase III trial found int risk PrCa in general benefit from 6 months ADT in terms of DMS and prostate specific survival. Meta-anlysis suggests a small OS benefit at around 9 years in int prostate cancer. Notably ADT effect is independent of radiation dose.

Answer 117

OS benefit has been demonstrated with long-term ADT (28–36 months) compared to short-term regimens (4–6 months), even in the dose-escalated era (DART trial). EORTC trial 3yrs ADT improved 10yr OS from 40%-58% One trial (PCS IV) found similar oncologic outcomes between 18 months and 36 months. The RADAR trial found that 18 months of ADT was superior to 6 months prCa spec OS 13vs10%

Answer 118

In men with a detectable Prostate Specific Antigen (PSA) after prostatectomy for prostate cancer, salvage prostate bed radiotherapy (PBRT) results in about a 70% freedom from progression (FFP) at 5 years

Answer 119

Remember by treating the bed alone you achieve 70% freedom from progression benefit at 5yrs. The SPPORT trial (3-ARM) shows that with treatment of: Traditional arm = Bed RT = 71% Bed +6 months ADT benefit increases to 81% (a 10% gain) Bed+WPRT+ADT = 87% (16% gain!) Keep in mind OS at 5yrs is great regardless - 95% so no difference.

Answer 120

Age>65, ER or PR +, node -ve, margin >1mm, THEN can have either LVI or grd 3 BUT not both. RT + tamoxifen = Tamoxifen alone for OS, and DM. ONLY benefit is a reduction in IBTR from 4% to 1%

Answer 121

3 key proRCT studies: RAVES (failed to meet criteria), GETUG-AFU17, RADICAL suggest Salvage is non-inferior to Adjuvant radiotherapy in terms of event free survival - but is associated with less late GU toxicity, and some men may be spared radiation entirely. Salvage being defined as when PSA crosses a defined point (usually 0.2ng/ml).

Answer 122

RAVES uses 64/32 to bed, SPORT (bed+nodes+ 6 months ADT) uses up to 70Gy to bed, 45Gy to nodes. As we are only treating microscopic disease - I would use 55/20 (2.75Gy/#) to the bed and 44Gy to the nodes. EQD2 68Gy (for prostata alpha/beta 1.1), but only 60Gy in terms of bowel tox, and 58Gy in EQD2 for bladder tox. NCCN supports.

Answer 123

Low - Risk - 4S - Observation. Spontaneously resolve 5yrOS 95% (4S = age<1, ipsilateral node negative, Age <1y/o with <10%bone marrows, even mets to skin or liver) Low risk: Surg alone for non-4S = GTR: No benefits for adj RT * If STR, or recurrence after GTR: consider chemo Int risk: Induction chemo then surg, RT only if progression. HR: Always need multimodality treatment Sequence: Induction chemotherapy → surgery → consolidative chemotherapy → autologous stem cell transplant → RT (primary + metastatic site + boost residual disease) → differentiation therapy and immunotherapy. Consolidative RT = 21.6Gy/ 12# (1.8Gy/#) to tumour bed, For unresectable bulky sites, metastatic site = Boost residual disease to total of 36Gy/20# OS 15% at 5yrs!

Answer 124

ARR = I Experimental event rate - Control event rate I NNT = 1/ARR RR = Experimental Event rate/Control Event Rate RRR = ARR/Control event rate = 1-RR

Answer 125

i. What is the rationale for the use of bolus? (1) - to reduce dose to underlying lung - Increase skin and subcutaneous dose (most common site of recurrence post mastectomy) and - Smooth some post mastectomy tissue irregularities. Ii. Which patients require bolus? (2) - Pts with close/involved superficial/skin margin - Pts with highly irregular surface contour - Pts with shallow skin to lung interface depth,

Answer 126

Curative intent (local control 90%, 2yr OS 75%, 50%5yr vs 50%3yr EBRT): SABR 50Gy/5#s (using central tumour), 1#/day, prescribed to PTV D95>100% prescribed dose, 6MV photons, DCAT technique. Aim Dmax within PTV 125-14% of prescribed dose, CI-100; 1.1-1.3, CI-50<5. Presim: Baseline lung function Sim: Supine arms above head, head towards gantry, knee/ankle rests, head support Immobilise with vac bag. Patient breathing freely. 4DCT + contrast, fusion with PET if available. Volumes: iGTV = tumour volume contoured on MIP and checked against all phases of breathing cycle and referenced against PET, iCTV=GTV, PTV=iCTV+3mm OARS (in 2Gy#s, would convert or use published data - e.g. from CHISEL): Spinal cord Dmax<45Gy, brachial plexus Dmean<60Gy, Lung V20Gy<10%, oesophagus, heart MHD<2Gy.

Answer 127

Curative intent re-irradiation, hyperfractionated approach 60Gy/40, 2#s/day, 10#s/week, VMAT technique, 6MV photons, prescribed to D50. Aim PTV D98>100% prescribed dose. Avoid Dmax>107%. Pre-sim: Consent to include discussion of significant risk of potential severe toxities and death Sim: Supine, head towards gantry, arms by side, knee board, ankle supports. Immobilise with thermoplastic mask. 2mm fine slice CT+contrast, above vertex to T4, and fused with PET and planning MRI (T1+C). Volumes: GTV: defined on imaging and endoscopy. CTV: GTV+5mm trimmed to boundaries, PTV = CTV+5mm I would not include elective nodal regions. Verification: Daily CBCT matched to bone.

Answer 128

SCC - 8mm Adeno - 6mm Chem0 = Carbo Etop = both 50mg/msq SCLC = Carbo Etop = 5AUC!!! + 100mg/msq

Answer 129

Node status is by far and away the most important - 1 inguinal node 50% 5yr OS, 1 pelvic 11%, node - 90% The Heaps study was one of the 1st to identify RFs. Critical are: Margin <8mm Depth >5mm LVSI/VSI Size>4cm Stage III = Node +ve (GOG37!! OS benefit when clinical node +ve, more than 1 node, ECE or ulcerated). Others from Heaps (but not critical to the answer): Keratin production, mitotic rate.

Answer 130

GOG 205 - Phase II unresectable (T3-T4, N+): Pathological complete response in 50% with this dose escalated regimen: 45/25 to primary + nodes: Nodes and primary boosted to 59.4/33#s. Essential CTVprimary = GTV+1cm, Subcutaneous Mons bridge and whole vulva. - Add ons: Node volumes: If +ve treat bilateral level, treat the eschalon above bilaterally. Involvement of distal vagina, include: bilateral inguinofemoral, bilateral obturator, and internal and external iliac nodes. If proximal posterior vaginal involvement, include pre-sacral nodes (S1 to the bottom of S2/top of S3). If involvement of anal canal, include as per distal vagina and include perirectal, mesorectum and presacral nodes.

Answer 131

+ve margin - advocate re-excision. Divide into >2cm solitary node negative (i.e Ib-II) : R1- 54/27, R0 - 50/25. “Indications” : Margin <8mm (or 5mm…), DOI >5mm, LVSI, lesion>4cm, “Spray” (diffuse) histology, Node +ve: Micromet <2mm on Bx can have nodal irradiation instead of dissection Post inguinal dissection – if >1 node +ve Or “less extensive” dissection (<12 nodes). 50Gy/25 +/- 10Gy boost to positive nodes ?Adjuvant ChemoRT – no prospective data. Some retro analysis suggests possible OS benefit. Extrapolate from Cx Ca and consider when bulky nodes, +ve margin

Answer 132

?Adjuvant ChemoRT – no prospective data. Some retro analysis suggests possible OS benefit. Extrapolate from Cx Ca and consider when bulky nodes, +ve margin

Answer 133

CTV54p=positive margins and ECE (CTV54n)= Entire surgical bed +2cm CTV50nodes: 1) Treat echelon above highest involved node bilaterally. 2) If inguinofemoral node involved, treat contralateral inguinofemoral region and external iliac nodes. 3.1) Involvement of distal vagina, include: - bilateral inguinofemoral, - bilateral obturator- - internal and external iliac nodes. 3.2) If proximal posterior vaginal involvement, include pre-sacral nodes (S1 to the bottom of S2/top of S3). 4) Anal canal (same volumes as anal primary), include as per distal vagina: - bilateral inguinofemoral, - bilateral obturator- - internal and external iliac nodes & perirectal, mesorectum and presacral nodes.

Answer 134

PENTOCLO protocol: Pentoxifylline 400 mg, BD Tocopherol 500 mg, BD Clodronate BD 5 Days a week Continue til "acceptable clinical response"

Answer 135

1) Decide if unilateral or bilateral: - Unilateral only if single ipsilateral node & tumour well lateralised - at least 1cm from midline, BOT or tip of tongue. - Bilateral if >=2 ipsi nodes, close to midline. 2) Which nodes? IB, II and III always Any tumour close to midline or into oropharynx then include level IV. Obviously also if III involved. If bucal mucosae then level IX (buccal nodes) ipsilateral nodes.

Answer 136

Trick - p16+ may also be the same - unlear. 1) Decide if unilateral or bilateral (similar to oral cav): Unilateral if NO-N2a (single ipsilateral node <6cm). Tonsil fossa tumor NOT infiltrating the soft palate OR the BOT 2) Which nodes? If ipsilateral then: II, III, IVa', + 1B if oral cavity extension (e.g. into retromolar trigone) +VIla = retro pharyngeal nodes for posterior pharyngeal wall tumor If bilateral: Ib, II, III, IVa, Va,b, +VIla, +VIIb* only do bilateral retropharygeal nodes if posterior paryngeal wall tumour.

Answer 137

T1 = vocal cords (a = uni, b=bi) T2= extension in supra/sub glottis. 60/25old school - T1 now 63/28 CTV= Entire larynx at level of GTV and 0.5-1.0 cm superiorly and inferiorly.

Answer 138

CTV70 = GTV + 5-10mm both sites. CTV63 = CTV70+ intermediate risk nodes +: If Larynx SCC: consider entire larynx If Hypopharynx: entire hypopharynx CTV56=Bilateral nodal levels II, III and IV. Consider levels Ib and/or V included on side(s) of lymphadenopathy. Consider VIIb and level V for extensive level II lymph node involvement. IF Larynx: VI if subglottis Hypopharynx: VI for apex of piriform sinus, post cricoid and/or oesophageal extension

Answer 139

Positive/involved margin: <1mm Close margin: 1-5mm Clear margin: >5mm Large-calibre and small-calibre nerves: Large >0.1mm, small <0.1

Answer 140

No phase III data, but pooled and meta-analysis suggests LCR>95% at 5yrs (potentially better than historic ablative controls). Phase II data SABR + pembro offeres excellent local control rates. Indication is inoperable and not suited to ablative techniques. (dont give concurrently with molecular therapy!!) Dose of SABR: 26/1 (smaller lesion <2.5cm), 40/5 (up to 5cm)

Answer 141

There is no large randomised trial evidence (GETUG-01, RTOG 9413) supporting that PNRT improves oncological outcomes. A recent smaller phase III trial (POP- RT) showed improved biochemical control with PNRT 50Gy/25.

Answer 142

All the below doses are within UK-RCR Prostate-only RT: * 60 Gy/20 over 4 weeks CHIiP Trial (Grade A) EBRT+Brachy * 46 Gy in 23 fractions (prostate and pelvic nodes) over 4.5 weeks followed by 15 Gy HDR or 115 Gy LDR brachytherapy boost (Grade A) SBRT: * 36.25Gy/5(Grade A) - 2 trials: Hypo RT (42/7), PACE-B 36.25/5 (USE). Same outcomes as conventional, but possibly higher late grd II GU. Pelvic nodal RT node -ve: * 50Gy/25 over 5 weeks or equivalent (Grade A) - POP-RT current only trial for node-ve to show benefit - therfore this is current standard. *44-47/20 are in common use. 46/20 (2.3Gy/#) = 50Gy BED (Grade D) Node +: STAMPEDE - PFS benefit. 60/20 to Pr, 44/20 nodes, 55-60Gy to +ve nodes (OARS permitting). Postoperative RT: * I favour early salvage and treat nodes (SPORT Trial 64.8/36, 45/25 nodes), but dose I prefer 55/20 (60/20 is PSMA residual) and 44/20 to the nodes

Answer 143

Barigel - 9 to 10mls. Results from 2 RCTs were varied; however, the use of rectal spacers showed improvement in rectal toxicity and quality of life at up to 36 months. More severe toxic effects were less common.

Answer 144

TBI delivered to a total of 12Gy/6#, 2#s/day treat over 3 days, opposed lateral photons (SSD 4m), aim energies below 6Mv, prescribed to midpoint (typically umbilicus). Alternating between lateral beams at each fraction. Aim for 7 days prior to transplant. Pre sim: Anti-nausea medication, other meds to consider are dexamethasone and anti-anxiety meds (e.g. Lorazepam). Fertility preservation (though they’re pretty fucked if not done by this point). Sim: Supine, small under head, knee fix, Upper arm resting on 4cm polystyrene (to reduce lung dose), Hand resting on abdomen. Compensator/ bolus (‘beam spoiler’) – (because of skin-sparing effect of photon): Bolus (E.g. flab) – on lateral and anterior surface of neck + chest (to reduce dose to lung) Perspex – as head frame compensator, and from mid-thigh inferiorly (thicker from mid knee inferiorly)Linac field typically at most open position/largest practical field size. Volume: Whole Body – Covered by light field. Aim homogenous dose +/-5% of PD. OAR: Lungs – Aim <12.6Gy, consider Lung shields. Verification: Patient position confirmed with laser matching. Whole body within light field, in vivo dosimetry (e.g. TLDs on skin surface) not routine.

Answer 145

Assess for relative contraindications: Tumour>5cm, multifocal/in-situ, incomplete TURBT, irreversible hydronephrosis.

Answer 146

Recent (2023) Pooled analysis of phase II data suggests 5rOS for treated bladder Ca is 60-70% (slightly higher than surgery despite being a more com-morbid cohort). 66% chance of bladder preservation. Difficulties when comparing survival outcomes between cystectomy and bladder preservation: - No direct, randomised trial exists to demonstrate superiority/ (non) inferiority. - Populations may not be directly comparable - Bladder preservation candidates may have more co-morbidities/tumour complications than those selected for radical surgery. Comparisons with historic data in terms of patient outcomes may be out of date due to new surgical (increased options for conduit) and radiation (VMAT vs planned) techniques. Planned technique may have treated nodes!!

Answer 147

ASTRO (2018) Guidelines: 50 years or younger with any grade tumor, or in patients aged 51 to 70 years with high-grade tumors or positive margins. ***Consistent w/subgroup analysis of Bartelink (now 20yrs) - suggests greatest benefit age<50. Also those w/adjacent DCIS (at long term follow up) and grdIII

Answer 148

PMRT improves both locoregional control and OS in both pre and post-menopausal women w/locally advanced BrCa. A large EBCTG pooled analysis (which is pre Her-2 era, pre modern LND/Bx and RT techniques) but is the most comprehensive to date: 1) T1-T2 with 1-3 nodes (i.e N1, stage II) - LRR and BrCaS benefit 2) 4 or more nodes (Stage III) - LRR and BrCaS benefit. SUPREMO is ongoing looking in the modern era at the extent to which this benefit extends to: T2 grdIII, T2 LVSI, T1-2N1. RCR UK supports 26/5 (Fastforward had 90pts, only recurrence was in 40/15grp) as Grade A.

Answer 149

1) Observation (i.e. no further axillary treatment) Z0011 study, patients with 1-2 SLN + - Randomised to ALND vs. observation - no differences in nodal recurrence/ OS with between arms - higher risk of lymphoedema in patients who had ALND (13% vs. 2%) Also, given that she has endocrine therapy and targeted therapy options 2) Axillary RT AMAROS study – patients with SLN+ - randomised to level 1-3 ALND vs. axillary RT 50Gy/25# - no differences in axillary recurrence (primary endpoint) or OS between arms - less lymphoedema with axillary RT (23% vs. 11%) 3) ALND In AMAROS, ALND arm - 33% had further LN+, and 8% had 4 LN+ 4) MA20 also did IMC - demonstrated a DFS benefit and included high risk N0. 5)Clinical trial POST-NOC (1-2 SLN+, macro mets >2mm) - randomised to observation vs. axillary treatment (surgery or RT) 6) EBCTG meta-analysis 2023: 8 modern studies up to 20years out suggest BCS and OS extending down to node negative. Hopefully POSNOC clarifies.

Answer 150

MA.20 (median follow-up was 9.5 years): Patient cohort: node+Ve or high-risk node-Ve breast treated w/BCS and adjSystemics: WBI+ plus RNI (including internal mammary, SCF, and axillary) (nodal-irradiation group) VS Whole-breast irradiation alone Notably, IM nodes were included. Found: RNI + WBRT did not improve OS but reduced the rate recurrence = 5% improvement in DFS at 10yrs (they talk up the "40% relative risk reduction")(But in general most pts did well so this number is small - pts w/>3 nodes tended to be excluded as they all had radiation- taking away the strength of the signal). Higher rates of grdII pneumonitis

Answer 151

I would treat IMN if N2 (Thorsten prospective), or N1 and medial tumour (KROG). Major RNI studies (MA.20) have included IMN and demonstrated minimal added toxicity. The Thorsten prospective trial suggests an OS benefit to IMN (that studied included up to 9nodes+ve) for N+ Krog - DFS benefit in medial N+ tumours

Answer 152

This pt with N2 disease following ALND would benefit from RNI to levels 3, SCF and IMN. I would boost the surgical bed for improved local control given age <50 (Barlelink 20yr data, Astro guidelines). As per MA.20 and EBCTG meta-analysis this is likely to improve DFS (in the order of 5% or more). MA.20 included IMN, and specific benefit is noted in prospective data (Thorsten) when N2 disease.

Answer 153

Adj EBRT for improved IBTR, and DFS to the left breast and level III, SCF and IMC nodes, 40.05Gy/15#, +10Gy boost to the tumour bed, 5#s/week. VMAT 6MV photons, breathhold technique, prescribed to D50. Pre sim: well-healed, assess for baseline lympoedema, Beta-HCG. Sim: the usual, DIBH. wire scar. no bolus. 2mm slice CT+contrast. CTV=all breast tissue on imaging, trimmed 5mm off skin, deep border fascia of pec major. Level III, SCF, and IMN intercostal space 1-3 (5mm expansion on internal mammary vessels trimmed to boundaries). PTV=CTV+5mm CTV boost= scar tissue on imaging, encompassing surgical clips PTVboost = CTVboost+5mm

Answer 154

Stg III is largely based on surgery events or non-events: Bx (i.e. causes seeding) Seeding LN +Ve Unresctable Ruptue Piecemeal rescetion B_SLURPP Unfav Histo (UH) = Diffuse anaplasia = 19.8Gy/11. Stage V is bilateral kidney disease at Dx - Stage each lesion separately!

Answer 155

Residual disease gets a boost - 10.8Gy/6# (i.e double the R0 port dose). Siop Dose is higher Stg III get at minimum 10.8/6 (i.e. +/- boost) UH get 19.8/11 NWTS: Upfront Nephrectomy -> RT if indicated - VACD-IE Siop: Upfront CTx (VA) - Delayed nephrectomy - Chemo Whole Abdo RT (10.5/7) if Spill, Peritoneal Seed, Ascites Cyto+, Rupture (SPAR). Whole Lung RT 12Gy/8: if lung mets (NWTS), incomplete path response to CTx (SIOP)

Answer 156

Whole Abdo RT (10.5/7) if Spill, Peritoneal Seed, Ascites Cyto+, Rupture (SPAR). Whole Lung RT 12Gy/8: if lung mets (NWTS), incomplete path response to CTx (SIOP) Stg III 10.8/6 to bed. UH 19.8/11 Boost 10.8/6

Answer 157

"the big 3" trial is utter bullshit - they changed the definition of risk due to failure to recruit, they dont say, but the NNT is 24 (they sell the benefit as 40% risk reduction! But the control event rate IBTR was 7% the experimental rate 3%). 16Gy extra to the boob for that. Total nonsense. Age <50 or Grd II or higher, multifocal, margin<10mm, size >1.4cm, palpable or necrosis (so basically everyone. total BS). I would boost age <40, grd III, +margin (less than 2mm) or necrosis.

Answer 158

Broadly: LRR 10-15% WLE+RT, 2%Mastectomy

Answer 159

Indications for adjRt: - Stage II-IVA disease (Masaoaka Stage) - Residual disease (R1-R2) - Thymic cancer (i.e. WHO Grade C) b. Definitive - 60Gy (minimal evidence, but if higher-grade consider concurrent chemo carbo-pac) R0 - 45/25 (e.g. thymic carcinoma) R1 - 54/27. R2 - 60/30 iCTV = iGTV (if any)+5mm, entire thymic space.

Answer 160

PORT: CTV60= pre-op GTV/tumour bed +1.5cm radial (as above) + !2cm! sup inf CTV50= CTV60+2cm sup-inf PTV = CTV50+1cm

Answer 161

The goal of therapy is to reduce ipsilateral breast tumour recurrence (approximately 50% of recurrences are invasive disease). Broadly (depending on prognostic factors) recurrence at 10 years ranges between 10-30% (very significantly less if hormone therapy part of treatment), 50% or recurrences are with invasive disease. With adjuvant RT reducing by more than half (~60%) this risk.

Answer 162

Surgery - offers highest chance of cure: - Partial/hemihepatectomy: Indications solitary tumour <2cm. Generally well tolerated, offer highest chance of cure >70%5yr OS, but most disease does not present when indicated. Contraindications= multiple tumours, size>2cm, invasion into vessels. Pt must be fit for surgery. - Liver transplant: Offers excellent survival (Os 70% 5 years), however has long wait times for suitable donor, and often requires bridging therapy, pt must also be fit enough for intensive surgery. Indications (UCSF): Solitary <6.5cm (or 5cm Milan), or up to 3 small lesions with cumulative size <8cm.

Answer 163

2 types: Cardiac output dependent pacing or not dependent. At booking initiate pacemeker pathway )physic team, planners aware, device contoured). In general avoid >10Mv if possible, total dose <2Gy. - Dependent: Vitals monitoring during each #, Device function assessment during treatment and at end. - Independent: If above constraints not met then vitals during. If met then just device assessment at end of Tx.

Answer 164

1) Non-believers: Early adjuvant - better PFS but not OS 2) Believers: 45Gy=59.4Gy, No OS benefit. SATAN criteria: Size>6cm, Age>40, Tumour crosses midline, Astrocytoma, Neurology. 3-5 factors = high risk. 3) Shaw - adjuvant PCV (after 54Gy) significantly increases OS. Median OS 13years. On sub analysis benefit only in IDH mut (both deleted and co-deleted) - Greatest gain = codeleted. 4) Fisher - low grade IDHmut AND 3 SATAN risk factors, 54Gy w/TMZconcurrent + adj appears better than controls. 5) Catnon - no-codeleted gliomas (anaplastic astrocytoma) has been assessed in the CATNON trial - final results pending, but so far OS benefit to 59.4/33 and adjuvant (but not current tmz). 6) Indigo trial - Grd II - Vorasidinib - IDH mut inhibitor - buys 2 years progression free. Therefore: For lower risk (SATAN <2) oligo it may be reasonable to delay adjuvant treatment, potentially give chemo 1st (Non-belivers,Baumert Trial). Grd II - consider delaying RT with Vorasidinib (Indigo) Grd III - Oligo (co-deleted): 54/30 followed by PCV (Shaw trial) - Astro: 59.4/33 with adjuvant Tmz. (CATNON) (Grd 4 Astro - Stupp, as these used to be GBMs)

Answer 165

SATAN criteria: Size>6cm, Age>40, Tumour crosses midline, astrocytoma, Neurology. 3-5 Factors considered high risk. For lower risk (SATAN <2) oligo it may be reasonable to delay adjuvant treatment, potentially give chemo 1st (Non-belivers, Baumert Trial). Grd II - consider delaying RT with Vorasidinib (Indigo) Grd III - Oligo (co-deleted): 54/30 followed by PCV (Shaw trial) - Astro: 59.4/33 with adjuvant Tmz. (CATNON (Grd 4 Astro - Stupp, as these used to be GBMs) Brainstem/gentle dose - 50.4/28 PORT: CTV= residual GTV + operative cavity based on post-operative imaging. Inoperable: GTV on fused T1!!!

Answer 166

50.4/28.!!!! GTV = fused T1 MRI CTV=GTV+1.5cm (trimmed to boundaries) PTV=CTV+3mm

Answer 167

Glioma: Inoperable: GTV on fused T1. CTV= GTV+1.5cm. PORT: Residual GTV + operative cavity based on post-operative imaging. Use contrast to better deliniate tumour bed (obviously tumour wont enhance). GBM: GTV Bx only: the entire tumour on T1+C. GTV post resection: T1+C residual GTV (including the MASS/tumour component on T2/FLAIR)+ tumour bed CTV=GTV + 1.5cm trimmed to boundaries. Checked against T2 FLAIR abnormality which may be included beyond this expansion.

Answer 168

CT: 1) Califications: Astro (20%), Oligo (80-90%!), GBM (rare) 2) GBM: hypodense centre if large due to necrosis, thickened (dense) irregular edges due to hypercellularity, oedema, marked mass effect. MRI: T1 - most tumours are hypointense. BUT astros may be iso. GBM hypo to iso. Contrast enhancing. T2 (high water content): Oligo HYPER Astro HYPER GBM HYPER Contrast enhancing: Extra-axial tumours, GBM and PILOCYTIC ASTRO!! Give 60gy SIB to the contrast enhancing bit of an Astro.

Answer 169

Consolidative radiotherapy to a total dose of 36Gy/20: pre-op GTV 21.6Gy/12#, boost surgical bed to total overall treatment dose of 36Gy/#, 1.8Gy/#, 5/#s/wk to reduce LRR Remember 1.5cm on pre-op and post op CTVs. Pre-SIM - Consider GA Position: supine, arms up, head towards gantry- Immobilisation: vac bag - Planning CT: 2mm slice CT from thoracic inlet to femoral head (overing entire lung, kidney for OAR DVH) Fusion: pre-op and post-op MRI Target volume - GTV(pre-op) = post-chemo and pre-op right adrenal tumour - GTV(boost) = post-op gross residual disease - CTV21.6 = GTV(pre-op) + 1.5cm, clipped at anatomical boundaries - CTV14.4 = GTV(boost) + 1.5cm, clipped at anatomical boundaries - PTV=CTV+5mm 5yr OS 5-10%!!!

Answer 170

Adjuvant RT to flank (to reduce risk of local recurrence): Stage 3 (includes all the surgical stuff, Eg biopsy only, rupture, partial resection) Unfavourable histo. R1.

Answer 171

Key RCT trials for older people w/GBM Roa = phase III RCT - 40/15 = 60/30 NOA & NORDIC = TMZ = RT if methylated Roa = Phase III - 25/5 = 40/15 IF - age >64 Or - age >50 and poor performance status (KPS 50-70)

Answer 172

GBM 35Gy/10#: Particularly in pts who have relapsed after a reasonable interval of local control (e.g>12mnths). 1 RCT phase II RTOG trial randomised pts to bevacizumab with or without reirradiation giving 35/10. No OS benefit but significant PFS benefit. UK RCR Grade A - 35/10 Sub analysis suggests OS benefit in methylated patients and ECOG0. LG: 45/25. UK RCR

Answer 173

2 or more node mets Parotid node (unless parotidectomy and full nodal dissection) Size: any lymph node >3 cm. ENE +Ve nodal margin or spillage Close margins <2 mm to facial nerve. Recurrent nodal disease.

Answer 174

This is very high risk disease with extensive PNI with multiple nerves >0.1mm involved, deep invasion (>=6mm), positive deep margin (0.3mm, unexcised <2mm treat as +ve). PNI spread beyond foramina is incurable. Therefore in 30#s: R1(surgical bed) should get 63Gy CTV63=bed + 1cm trimmed to boundaries. CTV60 = HR PNI disease = CTV63+1cm (i.e 2cm expansion for PNI) CTV56 (intermediate risk) = CTV60 + skin and subcutaneous tissues extending from inferior border of CTV60 to the supraorbital notch (course of V1 branches), and to the superior edge of preauricular nodes. CTV54n (nodes and extended to stylomastoid foramen): Preauricular nodes with inferior portion extended to stylomastoid foramen. CTV54elective - Discuss with patient: covering supraorbital course of nerve to potentially to fissure.

Answer 175

BCC 3-4mm SCC and at least 4 mm for a low-risk SCC. There are no published guidelines for a high-risk SCC. 6-10mm is accepted range.

Answer 176

There is overall a lack of trial data (no RCT) regarding radiation for thymoma. For at least stg >=II (Mazaoka stage) prospective database review suggests adjuvant radiotherapy is associated with improved OS. This extends to patients who have had an R0 resection - opening the question of whether adj RT is reasonable for most patients. Lower grade (less than B2) have excellent 20year OS >=90%, and the role of radiotherapy in this setting is controversial given the outcomes without it, and the toxicities of RT especially late (cardiac, and second malignancy) given 20yr survival data.

Answer 177

- Inoperable - as local control or palliative. - Neoadj - to downstage tumour prior to resection. - Adjuvant: R1 and R2 resection, consider in R0. Thymic carcinoma. - Palliative: radioresponsive, decrease mass effect. NeoAdj = 45/25 R0 thymic carcinoma = 45/25 to thymic space R1= 54/27 - bed and thymic space R2 = 54/27 thymic space and bed + 60Gy boost (to GTV + 5mm)

Answer 178

- Anti-androgen medications - Typically non steroidal anti-androgens (e.g. Bicalutamide): In hormone naive pts: part of initial therapy + GnRH agonist +/- abiraterone (STAMPEDE ADT+enzalutamide + abiraterone no benefit). Alternatively can be used for 3-4 weeks as part of commencement of GnRH agonist - to prevent testosterone spike from initial LH surge. Can also be used when progression despite GnRH agonist (“total androgen blockade) to prolong PFS. ADT+ Apalutamide superior DMFS (SPARTAN). Used life-long or until significant progression. - GnRH agonist (e.g Goserelin 10.8mg s/c q3monthly), provides a PFS, OS and symptomatic benefit in patients with newly Dx metastatic prostate cancer, and is part of multimodal therapy as above. Duration life-long, or until progression, or in the setting of stable disease intermittent (restart when >10ng/ml). -Androgen synthesis inhibitor - Abiraterone: Improves OS and PFS (STOPCAT meta-analysis)- used in the following contexts - as initial therapy for newly Dx metastatic disease (in combination with ADT but not ADT+Enzalutimide STAMPEDE), or when progression on ADT/disease progression. -Chemo - Typically Taxane chemotherapy - Docetaxel, improves PFS and OS (CHAARTED phase III RCT OS increase from 48 to 58months) when part of initial Mx of metastatic disease. Also increases OS for N+ and locally advanced (STAMPEDE). 75mg/m.sqr (65mg for Asians) until response (up to 10 cycles).

Answer 179

OPRA Phase 2.- Stg II-III up to T3bN1 (3 or less regional nodes), 4nodes=N2. They maxed out at 5cm T size. FOLFOX/CAPOX -> Chemo RT may not be as good as ChemoRT -> FOlfox Capox 3yr organ preservation 80%

Answer 180

i. A hip replacement - Avoid high energy beam (e.g. 18MV) - Avoid beam entry through hip prosthesis - Contour artefact from hip prosthesis on planning CT and adjust densities in RT planning dose calculation - Get physicist involved - Review proximity between tumour to prosthesis - Oblique kv imaging for treatment verification ii. Excess small bowel dose within the field in a patient requiring neoadjuvant radiation therapy. - Check persistent over more than 1 fraction. - Re-SIM with full bladder to push bowel further out of field - Most conformal technique (e.g. IMRT/VMAT) and prioritize dose constraints to bowel - Prone position - Trim superior PTV expansion, and consider compromise coverage more superiorly (if safe to do so) - Daily CBCT to monitor, re-plan if required - Monitor GI toxicity, pre-med ondansetron

Answer 181

"Good" prog on MRI pts with minimal extension into perirectal fat (<15) may be considered for surgery only. Short course Long course TNT.

Answer 182

WBRT 30Gy/10# with hippocampal sparing. Aim Hippocampus D100 <10Gy. This is the conventional dose, if no hippocampal sparing do 20/5 (no evidence this is less effective). If 4 or less tumours and size <4.5cm 1) Cavity: SRS 12-20Gy <30cc 27Gy/3 >30cc 25/5 (note this is only dose different from defitive where 30/5) HR CTV = residual, bed, tract. 2) Intact SRS 16Gy-20Gy <30cc 27/3 (single 27/1 is in use) >30cc to less than <4.5cm 30/5. Volumes CTV=GTV, PTV=CTV+2mm

Answer 183

Standford study 2/3 patients not need Tx at 7 years. 85% 10yr OS. Compare that with: Taking all grades <3 RT 24Gy in 12 fraction + CVP/ R-CVP - TROG 99.03 showed improved PFS with addition of CVP/ R-CVP From 50% 5yr RFS to 60%. I.e Stanford study shows RT alone gives you a 50% chance of relapse free survival.

Answer 184

HRCTV := Disease on Ex and MRI at time of brachy + entire Cervix. Aim D90> 85Gy EQD2 IR HTV= HRCTV + 1cm Aim D90>65Gy OARS: Bladder Dmx (2cc) <90Gy Rectum Dmx <75Gy, (D40Gy<60% ideal)

Answer 185

24gy/3#s, 3days apart, 2#s/week. Timed with final 2 weeks of RT (aim OTT <49 days), no chemo on brachy days. HRCTV D90 to receive 100% of prescribed dose. Pre-treatment - Anaesthetic review Applicator insertion - Under GA - Lithotomy position - Examination under anaesthesia (EUA): to assessment of tumour response (from external beam radiotherapy), cervix and fornix anatomy (for selection of appropriate applicator/ ovoid size) - Prep and drape - 18F 3-way IDC catheter inserted, 7-10ml balloon, bladder filled to 300-400mL normal saline - Uterus sounded to determine length of tandem applicator - Cervical os dilated - Insert applicator (tandem and 2x ovoid) under ultrasound guidance - Vaginal packing with gauze to hold applicator in situ - Position checked with ultrasound Planning Imaging: MRI pelvis performed with applicator in situ Target volume - GTV = macroscopic tumour (based on EUA at applicator insertion and MRI) - HR-CTV = GTV + whole cervix - IR-CTV = HR-CTV + 1cm expansion Plan review - Aim HR-CTV D90 of EQD2 85-90Gy with / of 10 (with assuming the entire volume received 45Gy in 25 fraction on EBRT) - Aim IR-CTV EQD2 65-70Gy - Review OAR dosimetry o Bladder D2cc<90Gy o Rectum/ sigmoid/ bowel D2cc<75Gy Treatment delivery - Treatment delivery in bunker, with patient in supine position - Treat with Iridium-192 radiation source - Applicator removed after each brachytherapy fraction

Answer 186

Unresectable Proper (note that the role of radiation is controversional, especially with modern chemo FOLFIRNOX nab-Paclitaxel): 50.4/28 (45/28 nodes)- LAP07 improves LC no OS benefit Consider MASTERPLAN Trial Borderline: Approximately 1/3 can be made resectable. 45/25 or 36/15.

Answer 187

Cranio-spinal irradiation to a dose of 23.4Gy in 13 fraction followed by tumour bed boost to a dose of 30.6Gy/17# (to total dose of 54Gy/30#) (1.8Gy/#, 5#/ week). (NB HR is 36/20 see then boot to a total of 54Gy - i.e 18gy). RT Technique: VMAT technique with 6MV photon * 3 isocentres (cranial, upper spinal, lower spinal), junction at 4cm depth, no feathering Plan evaluation: * Ensure CTV D98>98%, and PTV D98>95%, * Minimise hotspot: D2<105% of prescribed dose * Homogenous 16Gy covering entire vertebra body Additional * Weekly FBE monitoring (given entire vertebral marrow irradiation)

Answer 188

50mg/m.sq D1 of week 1 and 4 (i.e Not weekly!!!!!!!!) Adj is Carbo Pac. PORTEC 3: OS and PFS benefit - Especially stage III, serous and p53abn

Answer 189

Neo-Adj = inoperable after chemo. MDACC 66/44, 1.5Gy/# BD. Breast and nodes 50.1Gy, GTV+1cm to 66Gy. Adjuvant Residual/R1 resection: MDACC 66/44, 1.5Gy/# BD. Breast and nodes 50.1Gy, GTV+1cm (or area of +ve margin) to 66Gy. Full mastectomy and otherwise all good: 50/25 to everything. Use Bolus!!

Answer 190

The risk of cardiac event increases linearly 7.4% per Gy, with no threshold This will likely be higher with the use of anthracycline-based chemotherapy and Herceptin

Answer 191

1) Expiratory breathold: most reproducible, least movement. Cons: dificult, loose the benefit of reduced dose to oars. 2) DIBH: Often protects critical normal tissues. Minimal additional equipment. Con: limited by patient compliance/participation/lung function 3) DIBH + Active Breathing control: Highly regulated breathing if tolerated. Con: may be poorly tolerated extra set up time/training. Some evidence further reduces heart dose. 4) Abdominal drape/Compression: -less dependent on pt participation. can support smaller margins (lower ITV). Con - uncomfortable, may effect dosimetry for caudal tumours. 5) Vacuum drape: Less dependent on pt. Con: uncomfortable,long set up. 6) Real-time target tracking (e.g. MR linac): Great, super expensive. 7) Respiratory gating: Objective way to ensure reproducible position, increased treatment time, relies on tracking equipment.

Answer 192

More recent analysis in B-27 suggests 10-year risk of LRR is significant after neoAdjCTx (>10%) for the following patients: tumor size >5 cm, positive axillary lymph nodes, younger age, and incomplete response to NACT portend a higher risk of LRR.

Answer 193

Taxanes: Perif neuropathy - cardiomyopathy if used with Acanthracycline. Cisplatin: Neuropthy, ottotoxicity, nephropathy, N&V Carboplatin: Myleosuppression Oxaloplatin (e.g adj rectal ca) famous for peripheral neuropathy - 90% peaks at 6months. 5-FU: Mucocitis, hand foot and mouth - like rash, coronary artery spasm Capecitabine: Is converted to 5-FU Etoposide: Myleosuppression Ritux: Super COVID Cetuxumab: Skin rash - 95% of the time.

Answer 194

Myxoid liposarcoma. Only needs 36/20.

Answer 195

Concurrent: Daily 75mg/M.sq One month post: Monthly cycles (conventionally 6 but more can be considered): Cycle 1: Day 1-5 = 150mg/M.Sq/day Cycle 2 onwards: If tolerated increase to 200mg.

Answer 196

Whole brain RT 30Gy/10#s, 3Gy/# VMAT technique with hippocampal sparing. 6MV photons. Prescribed to D50. Would include down to C2 if post fossa mets. Pre sim: dex, analgesia, anti seizure as required. Sim: Supine, head towards gantry, knee and ankle supports. Immob with thermoplastic mask. 1mm Slice CT scalp vertex to C7. Planing MRI (T1) to help deliniate hippos. Volumes: CTV = whole brain. Hippocampal Avoidance Zone = bilateral hippos +5mm. PTV = CTV+5mm with the hippocampal avoidance zone subtracted from this volume. Goals: 1) Hippo: Aim max dose <16Gy Min dose <9Gy. Blah.

Answer 197

- Prego, or up the duff. - For small volume asymptomatic disease, consider central nervous system (CNS) penetrating systemic therapy, if available. - Previous radiation therapy to the same site. - Cardiac implantable electronic devices (CIEDs). - Concurrent cytotoxic therapy. - Non-rheumatoid collagen vascular disorders. - Degenerative neurological conditions e.g. MS - Possible hydrocephalus Patients with favourable prognosis (>4 months life expectancy). Consider Brain metastases palliative EBRT hippocampal avoidance whole brain to decrease the risk of neurocognitive decline.

Answer 198

35Gy/5#, 7Gy/#, 5#s/week. (EQD2 52Gy)

Answer 199

"Guidelines vary" 1cm radial (unless PD the 1.5cm), 0.5mm below estimated depth. If T3 or higher deep margin is 1cm. If PNI then 2cm expansion. This is trick question - The above margin should include sub clinical extension and margin for setup errors and penumbrum (which is 0.5mm for SXR)

Answer 200

Prescribed to surface. Select SSD 20cm, Beam energy 120KV, AL filter 5mm

Answer 201

"I would prescribe to the 90% isodose." "6MEV and with 1cm bolus, I would expect 90% Isodose at 1cm" "9MEV and with 1cm bolus, I would expect 90% Isodose at 2cm"

Answer 202

Patient: Immunosupression, Gorlin syndrome Tumour: >5cm (50% 5yr LCR), location in "H zone", Morphoiec, infiltrative, basosquaromus, recurrent, PNI. Treatment: R1 30% 2yr recurrence.

Answer 203

Phase III NSCLC: Best supportive care vs WBRT in patients unsuited to resction or SRT/SRS. No difference in OS, QOL, dex dose. Subanalysis suggestive of a survival benefit age <60.

Answer 204

WBRT alone (where not appropriate for SRS/T): Main goal is to palliate Sx of brain mets/oedema, and prevent deterioration of neurologic function. Despite much investigation/meta-analysis, little evidence for OS benefit. The QUARTZ trial (unresectable/not for SRS NSCLC): no better than best supportive care except Pts <60. Adj: Increased LC, No OS bene, worse cog and QOL. No benefit whatsoever for melanoma (Hong). SRS+WBRT -

Answer 205

(Note about +ve margins. NCCN: <1mm is positive, <5mm = close). Given lesion PD and node +ve I would consider 1mm +ve. Can consider concurrent Chemo. Therefore I would treat EBRT, VMAT SIB technique to a maximum dose of 63/30, 5#s/week. Prescribed to D50. Pre sim: Dental review and necessary work Consider PEG Analgesia/PRN/anxiolytics as needed. Dietician Smoking cessation and other allied health such as psychology as needed. Sim: Supine, head towards gantry, in neural position, arms by side shoulders lowered. Immobilisation with thermoplastic mask, knee and ankle supports. 2mm slice CT+contrast, vertex to upper thorax. Fused w/planning MRI and pre-operative imaging. Volumes: CTV63= Tumour bed based on imaging expanded by 5mm and trimed to boundaries. CTV60=CTV63+1cm trimmed to boundaries. CTV56=dissected nodal levels AND lingual nerve to the stylomastoid foramen - could consider path of V3 to foramen. CTV54 = CTV56 + undisected bilateral nodes: 1a, 1B, II, III and IV. I would treat level V on ipsilateral side and omit IIa on the contraleral side. PTV = CTV54+7mm Daily CBCT matched to bone with soft tissue review. OARS (in EQD2): Brain Dmax<60Gy, lens Dmax<6Gy, retina mean <45Gy, Lacrimal duct Dmean<30Gy, Parotid mean<26Gy, mandible avoid hotspots, cervical eso mean<30Gy,

Answer 206

Indications = symptomatic splenomegaly: - Malignant e.g. AML, NHL - Cirrhosis related - Extramedullary haematopoesis (e.g. due to myelodysplasia). - Many more. 0.5Gy/# every second day with bloods every 2nd fraction. Titrated to clinical effect, total dose 10Gy.

Answer 207

Indications: Node+ OR, T3 with R1, OR, T4. Int trial - OS benefit, but role of RT debatable (CRITICS trial, success of FLOT). 45Gy/25#, 1.8Gy/#, 5#s/week, concurrent with capecitabine and cisplatin. Consider R1 boost to 50.4/33. VMAT technique Volumes: CTVboost = Tumour bed +1cm CTV = CTVboost + Using table from TROG trial include CTV structures based on tumour location (gastroeso, proximal 1/3, body, distal 1/3). As per that guideline I would include pergastric and coeliac nodes and other nodal groups based on that table for each tumour location. PTV = CTV+1cm.

Answer 208

2.67Gy#: Lung V15%<15Gy Heart V20 Gy <5% Mean Heart Dose (MHD): <4 Gy 5.2Gy#: Lung V15%<8Gy Heart V7Gy<5%

Answer 209

GTV+1cm Whole vulva Sub cutaneous mons bridge.

Answer 210

Lung V16Gy<15% Contralateral lung V5Gy<10% Heart V20Gy<5% MHD<2Gy or 4Gy Contra boob mean dose <1.5Gy

Answer 211

Rectum V40Gy<40% Bladder V40Gy<50% Femur V40Gy<50% Small bowel Dmax<43Gy Large Dmax<44Gy

Answer 212

Lutetium-177–PSMA-617: - Beta-emitter with a half life of 6.7 days - Appropriate patients = castrate resistant, met prostate ca, with PSMA avid disease (duh) and have already had at least one line of anti-androgen therapy AND one line of taxane chemo. - Improves OS by ~4 months compared to “standard of care” - no phase 3 RCT vs things like carbazitaxel or Radium-223 so the NICE group wasn’t impressed enough to fund it in the UK. - Given by IV infusion, 200mCi once every 6 weeks for 4-6 cycles. Not necessary to do a post treatment uptake scan in most cases. - Pretty well tolerated. SEs include dry mouth, nausea, fatigue. - Risk of acute grade 3 myelosuppression modest (7-10%).

Answer 213

Disease localised to the cervix AND less than 2cm (Stage IA and IB1) OR IIA (upper 2/3rds of vag) NB: 1B2 (limited to the cervix but big = 2 to 4cm) = Chemo RT Peters (for post op chemo) = 3Ps = Parametrial Invasion, Pos Margin, Pos Node Sedlis (for adj RT) = SDLvi = based on size, depth of stromal invasion, LVI

Answer 214

Rhabdo (Surg->VAC-RT or not if SIOP): Site (H&N/GU = 50.8Gy), Histo (RO alveolar 36/20), N+ (41/.4), Resection (alveolar or Embryonal R1 both get 36/20, R = 50.4). Wilms (NWTS is upfront surg +/-RT +/-Chemo): Stg 3 = adjRT = surgical events - Bx (seeding), seeding, piecemeal resection, STR, Rupture. Fav Histo and Stg 3 = 10.8/6Gy Anaplasia = Unfav Histo = 19.8Gy/11#, R1/R2 = Boost 10.8/6 WART (10.5/7) if Spill, Peritoneal Seed, Ascites Cyto+, Rupture (SPAR). Whole Lung if Mets: 12/8 (do SIOP approach, if Cr no RT to lung) Ewings (VCDA-IE): Response to chemo (<90 or >90%) Surgical Events: R1/R2Spill rupture, Margin <1cm Unresctable - neoAdj 45/25 Poor (<90%) response to chemo = prechemo GTV to 54/30 Good = 45/25 to prechemo, boost postchemo to 54/30.

Answer 215

- Alternatives : 1. Tandem and ring (with smallest ring) + interstitial needle (shown in EMBRACE study to improve dose coverage and conformity as well) 2. Tandem and multichannel cylinder (but dosimetry may be suboptimal) 3. If not possible to insert brachytherapy applicator, consider external beam radiotherapy boost (e.g. 20Gy in 10 fractions), accepting inferior dosimetry compared to brachytherapy

Answer 216

Did not use (banned) spacer. Exclusions: 1) ISUP 3 or higher (i.e. no 4+3) Confusingly allows for "Intermediate and select high-risk prostate adenocarcinoma" 2) Node positive 3) Unable to have fiducials UNLESS using planning MRI (ideally MRI linac) 4) Previous pelvic RT Caution: large prostate (>80cc) Urinary function poor (IPSS>15, flow<15) IBD Bilateral hip replacement Previous TURP High-Five - SBRT 40/5 to prostate, 25/5 to pelvis (30-40Gy to +ve nodes).

Answer 217

Pre sim: urinary function, fertility/counseling. Comfortably full bladder, empty rectum. Sim: Feet towards, vac bag immob, ankle/knee and comfort supports. Planning: MRI in tx position ideally flat top couch, and CT non-con mid femur to L5 2mm. Fusion with PSMA PET CTV= prostate +/- proximal 1cm of SV if risk>15% of involvement (Partin table). PTV = CTV+3mm uniform expansion Dominant intraprostatic lesion (DIL) on MRI T2, Diffusion-weighted imaging (DWI) and Dynamic contrast enhanced (DCE), and PSMA PET GTV = DIL PTV_DIL = PTV40!!! = GTV+2mm, exclude urethral PRV. Urethral_PRV = Urethra + 0.2- cm radial expansion

Answer 218

Wong meta-anlysis suggest euivalent, with potentially higher retreatment rates at 1 year for 8Gy (but possible selection bias). Note RCT/phase 3 data shows superior pain control with SABR at 3 months. Outcomes: 3-4 weeks for full response (median 3 weeks) 25% CR 66% Some response 33% NO response 20% (to 30%) Acute pain flair (80% in 1st week). - Evidence for dex prophylaxis is mixed. Phase 3 data sugggests a small reduction.

Answer 219

1) T4 2) Positive margins (when further surgery is contraindicated e.g. associated with significant functional or cosmetic impairment). 3) Large nerve perineural spread. 4) Recurrent disease in an area previously not irradiated.

Answer 220

Relative indications (consider PORT when 2 or more present) T2 or T3 ≥6 mm DOI Close margins < 2 mm. Poorly differentiated. Pathological microscopic PNI LVI Immunosuppression. Higher risk sites, e.g. non-hair bearing lip, chin, ear, preauricular, periorbital, temple.

Answer 221

Low risk R0 = 0Gy Give 36/20 when either: LR R1 IR node neg (either R0 or R1) 41.4/23 only when: IR node +ve 50.4/28: Macroscopic disease - e.g orbital embryonal Bx only (they love that one).

Answer 222

Phase II - Outcomes for: 26/1 (<4cm) or 42/3 (>4cm) kidney SABR. 1yr LC 100% 3yr FFDF 97% 3yr OS 82%. GFR reduction at 1 year =10mL/min Dose constrain ipsilateral kidney outside of ITV v10Gy<1.5cc

Answer 223

Curative intent EBRT SABR technique w/motion Mx for 100%1yr LC. 26Gy/1# (if tumour<4cm), 42Gy/3# (2-3/# week, non consecutive day), prescribed to covering isodose, >=6MV photons.

Answer 224

Presim: - Pre-sim planning session to decide best motion Mx strategy. - Prg test/Hb/antimetics ect - Split renal function - Fast 3 hours prior (and prior to each#) Sim: Sup, feet towards, arms above head, knee, ankle supports. Immob with vac bag. Assume FB technique w/resp gating: 2mm slice CT mid Thorax to pelvis, 4DCT fused with Dx imaging. Volumes: iGTV=GTV contoured on all slices of MIP (checked against all phases of cycle) PTV=iGTV+5mm OARS (in EQD2) (as per FASTTRACK II): include constraints on ipslateral kidney, aim contralat kidey V10Gy<33%, SC Dmax<45Gy, Bowel DMax<50Gy. Skin, liver. Verification = intrafraction 4DCT, match to tumour volume. Aims: DMax = 125-143% of PD PTVD99>100% PD

Answer 225

Indications: Localised RCC not for resection ECOG <3 Life expectancy >3yrs Contraindications: Tumour extending into bowel Very Cautious: tumour>10cm3 GFR<30

Answer 226

Pace A/B did not include 4+3 (ISUP 3) At this point the roach score is probably high enough for POP RT-style RT to date and nodes

Answer 227

Imprint (ongoing phase 3) 50.4/28Gy after pneumonectomy and decortication + chemo (NA or Adj) Italian Phase III (included all histo): Lung sparring surgery the 50Gy to pleural and 60Gy SIB to residual. Very high grd III tox, bit high 2yr OS. No RT SAKK - Phase II RCT = no benefit to RT if Pt has chemo->EPP and

Answer 228

A number of studies vary in criteria. IMPORT Low: age >50 Unifocal IDC (any grade) Node negative <3cm.

Answer 229

Roach are 3 formulas bnased on PSA and gleason score to determine: 1) Risk SV involved 2) Risk node + 3) Risk extracapsular extension. The Roach formula for N+ (2/3PSA + 10(GI-6)) was used in POP-RT - if >20% do elective nodes (even when PSMA neg). Gleason score does no differentiate 3+4 from 4+3 - but note PACE A and B cut off for ultrahypo is 3+4. Partin table: Nomogram based on PSA, GI and clinical stage to predict whether the tumor will be confined to the prostate NB: both approaches do not use ISUP, and suffer from the pitfalls of using an overall Gleason score.

Answer 230

Contoured on empty, 15mins and 30mins post void for plan of the day library. GTV= lesion on imaging and examination findings (cystoscopy). CTV=GTV+5mm (gross extra-vesical extension) + bladder. Extra conditions: If VUJ invloved consider including 1-2 cm of the distal ureter. Male: - Involved bladder neck/trigone = proximal 1 cm of the prostatic urethra - Involved proximal prostatic urethra then whole prostatic urethra Ladies: With bladder neck involvement, multiple tumours or CIS, consider including the proximal 1.5-2.0 cm of the urethra. If the anterior vaginal wall is involved, include in the any remaining uninvolved anterior vaginal wall in the CTV. For posterior tumours, the anterior vaginal wall can be included in the CTVPrimary. If the vagina is included, consider including the proximal urethra.

Answer 231

Meta-analysis suggests OS benefit with tumours >=IB While the SUNSET trial suggests adj chemo after RT has no benefit (in contrast to NeoAdj carboTax INTERLACE), recent KEYNOTE trial demonstrates from stage IB2 onwards there is an OS benefit to concurrent then adjuvant pembro.

Answer 232

- Surveillance cystoscopy +/- TURBT + cytology, 3 monthly 2 years, then 6 monthly year 3-4, annually 5-10 years – high risk of recurrence - Staging CT C/A/P 6 monthly – for 1 year.

Answer 233

A well insured patient who isn’t chatty. Patient: - Unfit for surgery - Adequate bladder capacity/ function - Satisfactory renal function for concurrent chemo - Compliant with endoscopic surveillance - Patients who prefer organ preservation Tumour Relative C/I if: - Large tumour >5cm, multifocal tumour, hydronephrosis, widespread CiS And only after safe maximal TURBT

Answer 234

5yr OS 60% 5yr LC 60% - 75% LR are non invasive, 25% invasive 30% have distant mets, only 10%nodal. 5yr bladder preservation 60% Tox - Grd III GU - 10% (cyctitis) GI - 2% (proctitis) Other tox Sexual dysfunction Pelvic insufficiency fracture Lower limb lymphoedema 2nd malignancy Fistula

Answer 235

5yrs: (60% organ pres, 60%OS) 40% local recurrence: 75% are non-invasive 25% invasive (i.e only 10% of patients get an invasive recurrence) 30% get distant mets (10% nodal)

Answer 236

OPRA: 5yr = 55% (Long course chemoRT Consolidation FOLFOX) 5yr 76% DFS 75% OS, Toxicity: TNT is pretty toxic with 40% patient experiencing Grd III toxicity (Same rat as significant LAR syndrome post resection) 1.5% Grd V (death)

Answer 237

60/20 is slightly less late GU toxic than 40/5. GU late Tox >= grd 2 is 25% (27%Ultra) GI late Tox >= grd 2 is 10% For int favourable and unfav *w/GI 3+4 but not 4+3): 95% BPFS 1% DM

Answer 238

Data is limited to phase 2 or less. recent metaanalysis sugests HDR or SABR could achieve 60% freedom from progression at 5yr (the highest compared with resection, LDR, and cryo 50-54% FFP). HDR offered the lowest rates of severe GU 9% or GI tox 0% Therefore HDR offers good control, limiting re-irradiation to surrounding OARS and subsequent toxicity.

Answer 239

Parametrial involvement CTV= upper half vag and paravag tissues, parametrium. Contoured on full and empty blader and merged for iCTV. CTV nodes: obturator, internal iliac, external iliac, pre-sacral nodes, and common iliac + 3cm above the highest involved nodes. PTV=CTVnodes + iCTV+ 1cm. 2 cycles cisplatin 50mg/m2, week 1 and week 4 (as radiosensitizer) Adjuvant chemotherapy: 4 cycles carboplatin (AUC5) and paclitaxel (175mg/m2), every 3 weeks

Answer 240

PROSPECT RCT trial demonstrated that neoAdj RT could be avoided (if >20% response on MRI to FOLFOXx6 AND followed by TME and more FOLFOX). Long term toxicity may be worse in LC chemoRT->TME-> FOLFOX group (sex, fatigue, neuropathy). Roughly same cohort as OPRA. T3N0-T3N1.

Answer 241

1. No arterial tumour contact of coeliac axis, SMA, and common hepatic artery 2. No radiographic evidence of SMV, or portal vein contact, or <180deg contact without vein contour irregularity

Answer 242

Folfurinox superior (PRODIGE) ChemoRT equivalent to (older=gemcitabine) chemo alone but less toxic. RTOG: with improved resecability imaging criteria 50.4Gy+BD cap has good outcomes for N+ (same as PRODIGE = 5yr OS 45%).

Answer 243

Unresctable 5yr OS 5%, resectable 20% (in PREOPANC). Surgery in the borderline group followed by gemcitabine is 7%5yr OS Gemcitabine + 36/15 starting on c2 of gem increases OS to 21% (PREOPANC 1) Pre-operative FOLFIRNOX alone is not superior (8 cycles then surg), with Chemo RT less toxic (PREOPANC2)

Answer 244

Some controversy but one high-level bit of evidence: LAP-07 (Phase III): No OS benefit to 54Gy + BD cap vs gemcitabine. Possible improved LC. The greater effectiveness of FOLFURINOX may further undermine any benefit to RT. BUT: Pooled analysis suggest may be some benefit to the addition of SABR to systemic therapy. MASTERPLAN ongoing = FOLFIRNOX+ 30-40Gy in 5#

Answer 245

FOLFIRNOX - much better OS than gemcitabine. Growing evidence for SABR in oligo mets. EXTEND trial - phase II. 1-5 mets 50/4 to 70/10 given (40/5 typical dose to primary) 1 year PFS 40% vs 9% systemic therapy alone.

Answer 246

1) Preferred: Perioperative FLOT, superior to periop ECF (MAGIC). 4cycles pre, 4cycles post. 2) FLOT-ChemoRT -> Surg -> FLOT (NOt superior to FLOT alone or MAGIC), but may downstage, higher path complete response. TOPGEAR 3) NA chemo - Surg - ChemoRT. No better than MAGIC alone (which is inferior to FLOT), not superior to neoadj chemo. CRITICS 4) Surgery alone. Early work (pre D2 resection - MAcDonald) underlined OS benefit to additional modality (e.g. INT adj Chemo RT), ARTIST studies (1 and 5) show need for RT where less than D2 or R1 or higher resection.

Answer 247

If markers/IHC and Ix fail to identify: 1) Molecular cancer CLASSIFIER assay - can "predict" to some degree in in about 60% of cases. 2) Establish actionable mutations (Comprehesive Molecular Profile) and predictors of of response to immunotherapy - Tumour Mutational Burden (Mutations create neoantigens that the immune system may attack - e.g. T-cell directed Ipilumimab). Tx: If solitary met (much better prognosis) aim resection or ablative. If belongs to a clinicopathological subgroup (30-40%) e.g. Female with axillary mets (better prog), Female with peritoneal carcinomatosis, dude with bone mets and elevated PSA - then directed therapy has much better PFS. If target mut, or high TMB score, then directed therapy. If and only if none of the above "Empiric Chemo" doublet w/platinum: Classic combos Carbo Pac, Cis Gem.

Answer 248

Most common (90% epithelial origin Ca125 marker, most common of which is serrous = better prog than others). 1) Surgical staging. TAHBSO + pelvic + PA node dissection. + Cytoreductive surgery (e.g. bowel rescection/hemi-hepatectomy) if indicated. 2) Adjuvant chemo = platinum doublet - typically carbPac. For minimal post op residual consider intra peritoneal chemo. 3) BRAC associated - maintenance PARP inhibitor 4) Recurrence = "platinum resistance". If fit Paclitaxel is common second line - docetaxel may be 3rd line.

Answer 249

1) Biologic therapy alone until symptomatic or progression. Common approach. Spares RT tox. But recent evidence (e.g. SINDAC) points to OS benefit in setting of oligmetastatic disease (e.g. TKIs are oncostatic, RT is oncoreductive). 2) Surgery preferred if possible in large or symptomatic disease. Older data suggests OS benefit, quicker reduction in Sx, quicker reduction in oedema (less steroids - commence earlier immuno). Adj SRS or WBRT for improved LC (possible decreased neurologic death). SRS adj preferred due to better cognitive outcomes (MDACC) 3) Primary SRS (unless >6cm, or 12, or very small) due to improved neurocog (MDACC). 4) WBRT w/hippocampal sparing (ideally with memantine) phase III data shows superior neurocog outcomes to WBRT. 5) WBRT - 20/5 less time toxicities better neuro PFS than observation 6) Observation/best supportive care. May in patients >60, or poor performance status offer equivalent OS and QoL. QUARTZ: WBRT benefit OS on subanalysis in mets >=5 or age <60. Trend to benefit if no extracranial disease, higher GPA.

Answer 250

In EQD2: Rectum V50Gy<50% Bladder V50Gy<50% (may accept up to V65<50) Femoral heads V50Gy<5% Small bowel V45<195cc.

Answer 251

For high-urgency patients = Significant Sx, high risk from mass effect, rapid recurrence or growth: Surgery gold standard: >20% Recurrence despite clear margins RT 54/30 (or 59.4/33): Limited retrospective data suggests LC 80-90%. Benefit appears independent of size. May take many months to years for significant regression - therefore may not be an option where life-impacting Sx. Chemo in cases of high-urgency/treatment failure/cant have surg or RT = doxorubicin = 75% RR

Answer 252

1) Tamoxifen: 50-60% CR/PR response 2) SOrafinib: 80%PFS (interseting 20% response in placebo group) 3) NSAIDS: some limited data

Answer 253

Intrahepatic: Hepatic resection +/- node dissection (opinions differ) Extra hepatic: - Perihilar resection (60% of cholangioCa's are perihilar). - Distal Whipple = pancredudenectomy (do same for Ampullar Vater Carcinoma). _______________________________________ Surg->Capecitabine has OS and DFS benefit (BILCAP) IF Extrahepatic & either N+ or R1 SWOG Trial (for N+) OS benefit compared to historic controls: 54/30 to bed 45 to nodes (boost R1 to 59.4/33).

Answer 254

Chemo: Gemcitabine + Cisplatin. Some evidence for RT as consolidation (no progression): EBRT or SABR. If Metachronus: consider a COMET approach.

Answer 255

Courvoisier's sign (he described it in himself): Painless (i.e. not gallstones) palpable GB mass + Jaundice = probable tumour (e.g. HOP, GB Ca) RACE-GB: Cisplatin + Gemcitabine x4. IF stable or PR 45/25+ 9Gy boost concurrent with capecitabine improves OS from 4 months to 10.

Answer 256

Dx does not require Bx. Enroll in trial if possible given 10month OS. Dex is critical Sx Mx step in initial Sx Mx, Bevacizumab reduces vasogenic oedema and can help substitute for Dex when long-term side effects become concern. RT is the only standard disease imapctful intervention: Doses: 59.4/33 to 54/30 (larger) Mindful of time tox 36/13 and 45/15 may also be suitable (and equally toxic) - a trial randomised to 54, 45 or 36Gy. CHemo: Tmz has no benefit and adds toxicity. Investigational: H#K27M vaccine looks promising as does CAR T cell.. Retreatment: Small prospective trial suggests not too toxic, may have clinical, QoL and radiologic befefits

RT dose/volume and Evidence Every Site Flashcards

(282 cards)