RAD ONC - Q BANK GENERAL

What immumotherapy drugs are the only PD-L1

PD-L1: Atezolizumab Durvalimumab Avelumab PD1 Nivolimumab Pembrolizumab Cemiplimab

Based on the ICRU-83, the Treated Volume (TV) is defined as what?

V98% (volume of the tumor receiving 98% of the prescribed dose - a "therapeutic dose" of radiation)

Median age of presentation of ________ in the pediatric population? ependymoma ATRTs Medulloblastoma

ependymoma: 5-6 yrs old ATRTs: <3 yrs Medulloblastoma: 5-9 years

What % of clincially node negative breast patients will have positive SLNB?

~30%

Dose Constraint Overview Card Conventional Fractionation (60 Gy/30 fxn + chemo) - Lung - Spinal cord - Brachial plexus - Heart - Esophagus - Kidney Main constraints to know for 45 Gy in 30 bid fractions - spinal cord - lung - heart SBRT Constraint -- SPINAL CORD - 60/8 = __ Gy - 50/5 = __ Gy - 54/3 = __ Gy Brachial plexus = ? - 54/3 - 50/5 Chestwall = ? (two constraints - 1 easier to hit) (5 fraction) Lungs = ? (5 and 8 fraction) Heart = ? (5 fraction) Esophagus = ? (5 fraction) Great Vessels = ? (5 fraction)

- Lung: V20 <30% (as high as 35-40 depending on protocol, institutional preference aim <20%) -- MLD <20 Gy (~8% RP vs >20% RP) - Spinal cord: <45 Gy - Brachial plexus: <66 Gy to 0.1 cc - Heart: V30 < 50%, mean dose <20 Gy or V50 < 25% (for breast think mean dose <4 Gy) - Esophagus: Mean dose <34 Gy; Max point dose <66 Gy, 10 cc < 60 Gy (last two MKF says are kind of made up but he uses) -- NCCN guideline MKF likes (V60 <17%) - Kidney V20 <32% Main constraints to know for 45 Gy in 30 bid fractions - spinal cord = <36 Gy (Turissi - but old, big fields because of ENI, etc), <41 Gy (Convert), <42 (CALGB) - lung = V20 <35% (Convert); V20 <40% (CALGB) - heart = Total dose to <30% of heart OR >50% of heart getting <50% of total dose (Convert) General rule = 6 Gy/fxn (ie. 5 fractions, 30 Gy point dose max) - 60/8 = 32 Gy - 50/5 = 30 Gy - 54/3 = 18 Gy Brachial plexus = <6 Gy / fxn to <0.5 cc - 54/3 = <24 - 50/5 = <32 Chest wall - V30 < 30 cc OR - V30 < 70 cc Lungs = B/L Lung minus GTV = <10% for SBRT (some say 12-15%, but <10 is safest) Heart = SBRT (5 fraction): D0.5 cc <29 Gy Esophagus = D0.1 cc < 27-30 Gy (can also say <105% of RX) Great Vessels = D0.5 cc < 53 Gy (3 fx, <40 Gy)

CNS Constraints - - 1.8 Gy/fxnDose tolerance per fraction --> Total --> Risk - Spinal Cord - Brainstem core - Brainstem surfance - Optic chiasm - Optic nerve - Retina - Lens - Cochlea - Lacrimal gland - Pituitary gland

- Spinal Cord = Dmax 50 Gy or less - Brainstem = 1.8-2 Gy --> Dmax < 55 Gy, 55-60 Gy "Acceptable" - Brainstem surface = ventral 3 mm of brainstem from 9 O clock to 3 O Clock - Dmax <55 Gy, 55-64 Gy "acceptable" - Optic chiasm = 55 Gy, 55-60 acceptable - Optic nerve = 55 Gy, 55-60 acceptable - Retina = Dmax = 45 Gy, 45-50 acceptable - Lens = Dmax <7 Gy, 7-10 acceptable - Cochlea = Ideally one side mean <45 Gy - Lacrimal gland - Dmax = <40 G - Pituitary gland - Dmax = <50 Gy Risk of SN hearing loss if mean dose to cochlea is 45 Gy is ~30%.

In Indelicato et al., Acta Oncologica (2014), what was the rate of symptomatic brainstem toxicity among pediatric brain tumor patients treated with proton therapy who received a maximum brainstem dose > 56.5 Gy? a. 2% b. 5% c. 10% d. 25%

10% Although the overall incidence of symptomatic brainstem injury was 3% among the patients treated with proton therapy, subset analysis showed the rate of symptomatic brainstem injury among patients who had tumors of the posterior fossa, had a maximum point dose of D50%>52.3 Gy, or maximum point dose >56.5 Gy was approximately 10%.

What % of patients with cutaneous T-cell lymphoma present with Sezary syndrome (generalized erythroderma, generalized lymphadenopathy, and Sezary cells in the peripheral blood)? Bonus: - What is the other name for CTCL of the skin? - what are Sezary cells? - what actually defines Sezary syndrome?

5% Bonus: - mycosis fungoides - Sezary cells = enlarged atypical lymphocytes with convoluted nuclei found in the skin, nodes, and blood - Sezary syndrome = Sezary cells >1000/uL found in the peripheral blood (usually in the setting of diffuse erythroderma)

What is FOLFOX?

5-FU Folinic acid Oxaliplatin

Arms in Wheelan 2010 canadian hypofract study? Bonus: - exclusion criteria? - 10 yr LR rates? - cosmetic outcomes reported? - what was the only group was found to have any inferior outcome? - was boost done?

50 Gy / 25 fraction VS 42.56 Gy / 16 fractions Bonus: - exclusion criteria = T3 (>5 cm), positive margins, or >25 cm breast separation (measured from medial border of the breast to lateral edge where your tangent lies) - actually kind of important because this is the reason that KW occasionally gives to not hypofrac whole breast for large breasted women - 10 yr LR rates = 6.7% vs 6.2% NS (CF vs HF) - cosmetic outcomes reported = good to excellent = 71.3 vs 69.8% NS (CF vs HF) - what was the only group found to have any inferior outcome = HIGH GRADE TUMORS (LR was rate was 4.7% vs 15.6%, p = 0.01)* *however, subsequent central path review manuscript (Bane 2014) - molecular subtype (luminal A/B/her2 enriched) was predictive of LR but grade was not) - boost was NOT done on canadian hypofrac

In the intergroup study (Loehrer 1997), unresectable thymoma or thymic carcinoma with induction chemo then XRT 54 Gy to the mediastinum followed by consolidation chemotherapy What was the 5 yr freedom from failure?

54% P2 trial, 2-4 cycles of PAC chemo (cis, doxo, cyclophosphamide) Primary and regional nodes 54 Gy

In the ACOSOG Z6041, patients with cT2N0 rectal adenocarcinoma were treated with preoperative chemoradiation followed by local excision. What was the approximate 3-year DFS?

90%

What was considered "per protocol" coverage of the PTV2 (high dose volume) for RTOG 08-25 (radiation + temodar +/- bevacizumab) for GBM?

95% of the PTV2 covered by 60 Gy (100%), 99% of the PTV2 covered by 54 Gy

What is a borderline resectable lesion?

A borderline resectable lesion is defined as one in which there is a higher likelihood of an incomplete surgical resection. As such, these patients are not good candidates for upfront resection in comparison to patients with resectable lesions. Can consider neoadjuvant treatmen to make resectable

Based on last card: What trials do we reference for pN1 after SLNB for early stage bresat cancer (T1-2) to support NOT doing completion ALND for 1-2 positive lymph nodes on SLNB? Briefly cover what each compared and outcome

ACOSOG Z11, EORTC AMAROS, EORTC 22922 ACOSOG Z11 - T1-2 cN0 --> pN1 after SLNB -- randomized to completion ALND or observation (all got whole breast in supine position covering low axilla) - ALND increased lymphedema with NO benefit. EORTC AMAROS - same group as above, randomized to completion ALND or Breast/RNI (w/ SCV) - outcomes the same with better lymphedema in RT arm MA20 - same group (pN1 = 1-3 ax nodes) or high risk node negative (T3/T4) randomized to WBI or WBI+RNI - Addition of RNI did NOT improve OS, but did improve PFS (3%), DFS (5%), and DMFS (~4%) EORTC 22922 - addition of RNI reduced breast cancer specific mortality and reduced breast cancer recurrence - regional nodal irradiation in the setting of node-positive breast cancer improved disease-free survival and reduces breast cancer death and should therefore be strongly considered.

An electron scattering foil is used in a LINAC to scatter the beam across the treatment field. What is the approximate relative dose in the beam due to x-ray "contamination" from the foil? Bonus: What is this called? Bonus: What are the following values for a given electron beam energy: - Rmax? (100% IDL depth) = D100? - R90% - R80% = "useful dose" -What is the range of dose (not due to X-ray contamination) -- depth (Rp = Practical range)? - what is the dose at the surface? Extra bonus, why does surface dose go up for electron beams but NOT for photon beams?

Approximately 5% of the dose is 2/2 X-ray (bremsstrahlung) or radiative dose (5% holds up to energies of <20 MeV - Rmax? (100% IDL depth) = R100 = E/5 or Ex2 (in mm) - R90% = E/4 - R80% = "useful dose" = E/3 -What is the range of dose (not due to X-ray contamination) -- depth (Rp = Practical range) = E/2 - what is the dose at the surface = 74 + E = % Dose goes up at the surface for increasing energies of electron beams because of lateral scatter that happens as electrons deposit their energy superficially - photons don't do that

Generally what is acceptable coverage of your PTV?

At least 95% of the PTV to prescription dose (100% of prescription dose)

In the 8th edition of the AJCC Staging system, oral cavity T-category will now include which of the following? a. Perineural invasion b. Depth of invasion c. Lymphovascular invasion d. Margin status

B - DOI Rationale: The AJCC 8th edition incorporates depth of invasion (DOI) in assigning a T-category for oral cavity cancer. This recognizes the prognostic importance of a deeply invasive tumor, even if it is a small tumor. Previous staging did not include depth of invasion.

How did the addition of WBRT affect outcomes in the NCCTG N0574 randomized trial of SRS alone vs. SRS + WBRT for treatment of brain metastases? a. Improved OS, worse cognitive function b. Similar OS, worse cognitive function c. Improved OS, similar cognitive function d. Similar OS, similar cognitive function

B - similar OS, worse cognition Thought process -- we typically don't say that whole brain improves survival -- unless you are talking about PCI for LS/ES-SCLC (conflicting data but may reduce incidence of brain mets and increase OS). And we generally say that it worsens cognition. Rationale: Patients treated with SRS alone had less cognitive deterioration at 3 months compared to patients treated with SRS + WBRT. The median OS of patients treated with SRS + WBRT was 7.4 months vs. 10.4 months for SRS alone (HR, 1.02; 95% CI, 0.75-1.38; p = .92).

What are the subtypes of sarcoma more likely than others to spread lymphatogenously?

CARE Clear cell sarcoma Angiosarcoma Rhabdomyosarcoma Epitheliod sarcoma/Ewing Sarcoma Synovial sarcoma NO LONGER included

General principle of cervix management -- who should get CRT vs surgery?

ChemoRT OR surgery from 1A1 to 1B1 (as long as <4 cm primary) If bulky/>4 cm, they should get def CRT. If they go to surgery and they had things like close margins, LVSI, larger than they expected (>4 cm) -- you lean toward offering PORT. If 3 P's need CRT

In addition to abdominal ultrasound, what imaging studies are routinely required for staging a newly diagnosed Stage III Wilms tumor with favorable histology? What additional imaging is required if histology is clear cell sarcoma, malignant rhabdoid, or renal cell carcinoma?

Chest CT only Abdominal ultrasound is preferred at diagnosis for its ability to provide vascular invasion and flow information about the renal vessels as well as delineate the primary tumor extent with non-irradiative means. Chest CT is preferred at diagnosis to delineate any findings concerning for metastatic disease. Given the radiation exposure related to use of CT, many providers will switch to chest x-rays following the initial evaluation. An - MRI of the brain is only required for clear cell sarcoma of the kidney, malignant rhabdoid tumors and renal cell carcinoma - bone scans are typically only required for clear cell sarcoma and renal cell carcinoma.

What is the 1 fraction cochlea constraint

Cochlea 4.2 Gy

For low LET irradiation with a high oxygen enhancement ratio (OER) in regions of the tumor, tumor cell killing is: a. lowest when the tumor cells are well-aerated b. greatest in hypoxic conditions c. greatly reduced at 5% oxygen versus 20% oxygen d. greatly reduced at 0.5% versus 20% oxygen

D Tumor cell killing best in well oxygenated setting Radiation with a high OER, such as X-rays, exhibit enhanced cell kill under aerated conditions and reduced within hypoxic regions. The radiation sensitivity of cells is reduced as the partial pressure of oxygen drops below ~30mm Hg (~5% oxygen). The OER is greatest below this point. Partial pressure of oxygen at ~ 3mm Hg approximates the radiosensitivity halfway between a hypoxic and aerated condition. Thus, cell kill is dependent on oxygen concentration, and will be decreased at partial pressures below 30 mm Hg, certainly at 3 mm Hg. Little increase in radiation sensitivity is seen at partial pressures greater than 30 mm Hg.

Based on the updated results of Intergroup 0116 trial, which subset of patients with resected gastric cancer is unlikely to benefit from adjuvant chemoRT? a. Male b. Node-positive c. Intestinal histology d. Diffuse histology

D Rationale: Updated analysis of the INT 0116 trial (Smalley S, J Clin Oncol 2012) showed a benefit to adjuvant chemoradiation for most subsets, with the notable exception of patients with diffuse histology.

Which dose quantity is used to assess the radiation exposure to radiation workers? a. Absorbed dose b. Collective effective dose c. Dose equivalent d. Effective dose equivalent

D Rationale: Radiation workers are limited to an annual effective dose equivalent of 50mSv. The effective dose equivalent is used since it takes into account differences in radiation type, tissue sensitivity, and internal/external exposure.

How were the target volumes defined on the RTOG 0630 trial of pre-operative radiation and daily image guidance for extremity soft tissue sarcoma? a. CTV = GTV with 2 cm radial and 5 cm cranial caudal expansions b. CTV excluded edema seen on T2 MRI c. CTV expanded into bone and soft tissue d. GTV was defined by use of T1 weighted gadolinium enhanced MRI

D Rationale: On RTOG 0630 trial of pre-operative radiation for soft tissue sarcoma of the extremity with daily image guidance, target volumes were defined as follows: GTV was defined by MRI T1 plus contrast images. Co-registration of pretreatment MRI and planning CT in the same position was recommended to delineate the GTV for RT planning. For intermediate to high-grade tumors >= 8 cm, CTV=GTV +3 cm margins in the longitudinal (proximal and distal) directions. The radial margin was 1.5 cm beyond the GTV. For low-grade tumors or < 8 cm, the longitudinal margin was 2 cm beyond the GTV and, the radial margin was 1 cm. The CTV was expanded to cover the suspicious edema if it extended beyond the CTV margin and was constrained by anatomic barriers, including fascia, bone, or compartment. PTV included CTV plus 5 mm for all patients.

further ROC explanation

Essentially this is saying that in this test, you are more likely to identify the TPs than FPs and as long as curve is to the left, you are better than random chance alone (red) line - which is where TP rate equals the FP rate Below the curve, your test more often would identify false positives than true positives

In ASCENDE-RT randomized trial comparing 3DCRT boost vs. LDR I-125 boost after 46 Gy whole pelvic EBRT, brachytherapy boost was associated with: a. improved biochemical PFS. b. worse rectal toxicity. c. improved urinary toxicity. d. no difference in biochemical PFS, rectal and urinary toxicity.

In ASCENDE-RT trial, brachytherapy boost was associated improved biochemical PFS but worse urinary toxicity.

In a patient, electrons lose energy predominantly through: a. inelastic collisions with atomic electrons. b. inelastic collisions with nuclei. c. elastic collisions with atomic electrons. d. elastic collisions with nuclei.

In water or tissues, electrons lose energy predominately through inelastic collisions (ionization and excitation) with atomic electrons

For treatment of liver metastases with SBRT, what is the liver dose constraint for a 3-5 fraction regimen? a. 700 cc of liver should receive < 21 Gy b. 700 cc of liver should receive < 28 Gy c. 500 cc of liver should receive < 21 Gy d. 500 cc of liver should receive < 28 Gy Bonus what is whole liver constraint for conventional frac? Toxicity associated with radiation liver damage? - time course? - symptoms? - two major classifications? - pathophys?

Key: A Rationale: Eligible patients had one to five hepatic metastases, ability to spare a critical hepatic volume (volume receiving <21 Gy) of 700 ml, adequate baseline hepatic function, no concurrent antineoplastic therapy, and a Karnofsky performance score of ≥60. There was no grade 4 or 5 toxicity or treatment-related grade 3 toxicity. Whole liver <30 Gy; RILD = Radiation induced liver disease - Time course: 3-4 months - Symptoms: Anicteric hepatomegaly, ascites, fever, RUQ pain - Classic (normal AST/ALT, elevated Alk-P) and Nonclassic - Path: Veno-occlusive disease due to progressive fibrin deposition within the blood vessels, macrophage infiltration and consumption of fibrin products → further occlusion of blood vessels

A recent pooled analysis of two Phase-III studies (STARS and ROSEL) examining SABR/SBRT versus surgery for early stage NSCLC demonstrated: a. a statistically superior OS in favor of the radiation arm. b. a statistically reduced distant metastases in favor of the radiation arm. c. a statistically superior LRC in favor of the surgery arm. d. similar rates of grade 3-4 toxicity events in the two arms.

Key: A Rationale: Estimated overall survival at 3 years was 95% in the SABR group compared with 79% in the surgery group (p=0·037). Recurrence-free survival at 3 years was 86% in the SABR group and 80% in the surgery group (p=0·54). Grade 3-4 toxicity rates were 44% in the surgery arm versus 10% in the SABR arm. References: Chang JY. Lancet Oncology, 2015 Jun, 16(6):630-7.

What were the preliminary 1 year toxicity results of RTOG 1014 trial of partial breast re-irradiation following second breast conserving surgery for recurrent breast cancer after previous breast conservation? a. <5% rate of grade 3 fibrosis b. 5% rate of grade 3 breast edema c. 15% rate of grade 2 chest wall pain d. 15% rate of grade 2 breast pain

Key: A Rationale: RTOG trial 1014 evaluated partial breast re-irraditation after second lumpectomy in patients previously treated with breast conservation. A protracted hyperfractionated course of treatment was used (45 Gy in 30 fractions given bid). Treatment-related skin, fibrosis, and/or breast pain AEs were recorded as grade 1 in 64% and grade 2 in 7%, with only 1 (<2%) grade >= 3 and identified as grade 3 fibrosis of deep connective tissue.

What was the outcome of the POET randomized trial of preoperative chemoRT vs. preoperative chemotherapy alone for gastroesophageal junction adenocarcinoma? a. There was a trend towards improved survival with preoperative chemoRT b. There was a trend towards improved survival with preoperative chemotherapy alone c. There was a statistically significant survival advantage with preoperative chemoRT d. There was a statistically significant increase in postoperative mortality with preoperative chemoRT

Key: A Rationale: The POET randomized trial (Stahl M et al, J Clin Oncol 2009) did not meet its target accrual. Nevertheless, there was a trend towards improved survival in the preoperative CRT group (p=0.07). There was no statistically significant different in postoperative mortality.

What is a major safety risk of information technology systems in radiation oncology? a. Loss of data b. Failover protection c. DICOM transfers d. Auto File archiving

Key: A Rationale: Failover protection and file archiving are used to mitigate impact if a system fails. DICOM transfers are standard actions and do not pose major safety risks.

In an epidemiologic study, 500 workers with respiratory disease and 200 workers without respiratory disease were studied. Of those with disease, 250 reported exposure while only 50 without disease reported being exposed. This study is best described as a: a. case-control study. b. cohort study. c. cross-sectional study. d. randomized clinical trial.

Key: A -- case-control study. Rationale: A case-control study looks backward in time to detect a cause to a particular outcome. A cohort study occurs over extended time to study a characteristic suspected of being a precursor to the effect and tries to answer what will happen. A cross-sectional study is a snapshot of what is happening at the moment. A randomized clinical trial looks at the result relative to the intervention.

For patients with limited stage SCLC who receive first cycle of chemotherapy prior to the start of radiation, the nodal target volume should cover: a. initially involved nodal region but post-induction volume. b. initially involved nodal region + a nodal echelon above and below. c. current residual nodal disease + a nodal echelon above and below. d. current residual nodal disease excluding nodal level with a complete response.

Key: A Rationale: While historical nodal irradiation volumes for patients with limited stage- SCLC have extended to beyond involved nodal regions, modern series and clinical trials omit elective nodal irradiation (ENI). Further, a small randomized study reported by Hu et al., observed that irradiation of post-chemotherapy tumor extent without ENI did not have a negative impact on loco-regional control. Hence, for patients who start systemic therapy prior to the radiation therapy, the

What mean dose to the pharyngeal constrictors results in a 20% risk of dysphagia and aspiration? a. 40 Gy b. 50 Gy c. 60 Gy d. 70 Gy

Key: B Rationale: 50 Gy mean dose to the constrictors results in a 20% risk of dysphagia and aspiration. References: Marks et al., Supplement, 2010, Int. J. Radiation Oncology Biol. Phys., Vol. 76, No. 3, S10-19.

Which circular electron beam field will result in the lowest relative surface dose? a. 6 MeV, 4 cm diameter b. 6 MeV, 8 cm diameter c. 18 MeV, 4 cm diameter d. 18 MeV, 8 cm diameter

Key: B Rationale: For electron beams, relative dose at the surface increases with beam energy. This occurs because lateral scatter reduces with increases in energy. With reduced scatter, electron fluence becomes increasingly similar between shallow regions and the depth of maximum dose (or, said differently, the relative depth-dose ratio approaches unity as incident beam energy is increased). Additionally, loss of lateral charged particle equilibrium results in increased surface dose and decreased depth of maximum dose. A rule-of-thumb for central axis equilibrium is that the field radius Req in [cm] should satisfy Req ≥ 0.88*√(E). For 6 MeV this is 2.2

In patients with thymoma, the preferred choice of chemotherapy regimen for patients with unresectable disease is: a. carboplatin and paclitaxel b. cisplatin, doxorubicin and cyclophosphamide c. carboplatin and gemcitabine d. Bevacizumab, carboplatin and paclitaxel

Key: B Rationale: For locally advanced thymomas, induction chemotherapy with cisplatin, doxorubicin and cyclophosphamide (CAP) or CAP + prednisone is recommended with an overall response rate of 70% or more (Kim et al, Lung Cancer 2004). The alternate approach is induction chemoRT with CAP chemotherapy plus thoracic radiation therapy with a reported overall response rate of nearly 70% (Loehrer PJ Sr et al. JCO 1997).The preferred chemotherapy regimen for thymic carcinoma is carboplatin and paclitaxel. Other regimens are not recommended as first line therapy.

What factor is included in the Gail model for predicting risk of developing breast cancer? a. Family history of ovarian cancer b. Number of prior breast biopsies c. Breast cancer in first and second degree relatives d. Age of onset of breast cancer

Key: B Rationale: The Gail model was one of the initial tools that attempted to estimate a woman's risk of developing breast cancer over the next 5 years. It considers: - age - race - age of first menstrual period - number of first degree relatives with a history of breast cancer - number of prior biopsies. It is thought to underestimate the need for testing as it does not take into consideration a family history of ovarian cancer, age of onset of breast cancer, occurrence of bilateral breast cancers, history of second degree relatives with breast cancers, or the biology of the breast cancer; all important in assessing risk.

What minimum radiation dose to the whole volume of both kidneys will likely result in nephropathy with hypertension and anemia? a. 20 Gy in 2 Gy/Fx b. 30 Gy in 2 Gy/Fx c. 40 Gy in 2 Gy/Fx d. 50 Gy in 2 Gy/Fx

Key: B Rationale: The kidneys are radiosensitive late responding tissues. Radiation damage develops slowly, reflective of the slow turnover of the tissue. Radiation nephropathy usually manifests as proteinuria and hypertension, with anemia. The fractionation sensitivity of the kidney is high (i.e. the α/β ratio is low). The dose tolerated by the kidney does not increase with increasing time after radiotherapy, but declines because of a continuous progression of damage, after doses well below the threshold for induction of functional deficit, which usually precludes re-irradiation. The pathogenesis of radiation nephropathy is complex. Most studies suggest glomerular endothelial injury as the start of a cascade leading to glomerular sclerosis and later tubulo-interstitial fibrosis. Several experimental studies have shown the importance of the renin-angiotensin system in the induction of glomerular sclerosis via upregulation of plasminogen activator inhibitor 1 (PAI-1) and enhanced fibrin deposition. Owing to loss of tubular epithelial cells, fibrin may then leak into the interstitium causing the onset of tubulointerstitial fibrosis. One or partial kidney irradiation can receive higher doses before damage is evident, but the whole bilateral volume is irradiated a dose of 30 Gy is sufficient to produce damage.

The tumor PD-L1 expression enrollment requirement in the KEYNOTE-010 phase 2/3 randomized study for previously treated advanced NSCLC (pembrolizumab vs docetaxel) was: a. No requirement. b. 1%. c. 5%. d. 50%.

Key: B Rationale: To be eligible for the Keynote-010 study, patients with previously treated advanced NSCLC were required to have at least 1% tumor cells with PD-L1 expression. In the total patient population, median OS in the two pembrolizumab dose arms was significantly longer than docetaxel. In a planned subset analysis of patients with expression of PD-L1 on 50% of the tumor cells, median OS and PFS in the two pembrolizumab dose arms was significantly longer than docetaxel.

A recent multi-institutional analysis of brain metastases from EGFR-mutant NSCLC which examined sequencing of SRS, WBRT, and EGFR-TKI therapy, demonstrated: a. upfront EGFR-TKI preserves neurocognition without a detriment in OS. b. SRS followed by EGFR-TKI resulted in the longest OS. c. upfront WBRT was inferior to upfront EGFR-TKI. d. upfront WBRT was superior to upfront SRS.

Key: B Rationale: The median OS for the SRS, WBRT, and EGFR-TKI cohorts was 46, 30, and 25 months, respectively. Upfront SRS had the best survival outcomes with improved survival in both favorable and unfavorable patient groups, when stratified by ds-GPA. Despite having more patients with less favorable prognosis, even on multivariate analysis upfront WBRT had improved survival over upfront EGFR-TKI (30 vs 25 months, median OS, p < 0.039). Deferring RT was associated with inferior OS.

According to the International Consensus Contouring Guidelines for Adjuvant Radiation for Bladder Cancer, the superior anatomic border of the cystectomy bed CTV should extend 2 cm superior to the: a. initial pre-operative bladder tumor. b. superior aspect of the pubic symphysis. c. most superior placed surgical clips. d. inferior aspect of the sacro-iliac joint.

Key: B Rationale: The superior anatomic border of the contour will extend 2 cm superior to the superior aspect of the pubic symphysis. `

Per PORTEC-2 (Postoperative Radiation Therapy in Endometrial Carcinoma), what is the same for EBRT and vaginal brachytherapy? a. Long-term QoL b. Pelvic recurrence c. Vaginal cuff recurrence d. Acute grade 1-2 GI toxicity

Key: C Rationale: PORTEC-2 was a randomized study that compared adjuvant external beam radiotherapy to vaginal cuff brachytherapy for patients with intermediate-risk endometrioid adenocarcinomas. While pelvic relapses were more frequent in the brachytherapy arm, vaginal recurrence rates were comparably low in both arms. The toxicity measures strongly favored brachytherapy.

What is the limitation of the linear-quadratic (α/β) cell survival model at high levels of cell kill? a. Under predicts survival at low doses b. Over predicts survival at low doses c. Under predicts survival at high doses d. Over predicts survival at the high doses

Key: C ationale: At low doses, the linear-quadratic α/β model does a good job at predicting cell survival. At higher doses while the model will predict a continuous bending of the survival curve, in reality, the curve "straightens" out; i.e. it becomes essentially exponential. This makes the model very useful for predicting outcomes for fractionated treatment regimens where a relatively large number of low dose fractions are used. When one or a small number of high dose fractions are delivered, the α/β model would tend to under predict survival under conditions similar to SBRT (at high levels of cell kill). Whether this under prediction is sufficiently large to affect treatment outcomes is under debate.

In the recent OnCoRe registry study of non-operative management for rectal cancer, what was the approximate rate of local tumor regrowth? a. 15% b. 25% c. 35% d. 45%

Key: C -- 35% Rationale: In this recent multicenter-registry study from the UK, the authors reported no difference in non-regrowth DFS or OS between surgical resection versus non-operative approach. However, 34% of patients in the non-operative group experienced local regrowth. Of these, 88% were surgically salvaged, emphasizing the need for close post-treatment surveillance with this approach.

What molecular marker provides prognostic information for grade II astrocytomas? a. INI-1 b. WNT c. IDH d. Her2

Key: C -- IDH Rationale: Gliomas are classified by molecular status in view of data identifying molecular markers such as isocitrate dehydrogenase (IDH), to be predictive of clinical outcome. IDH mutation is associated with more favorable outcomes.

As per the ABS guidelines, the equivalent dose (EQD2) in patients who have not responded well with a residual tumor greater than 4 cm at the time of brachytherapy is? a. <80 Gy b. 80 to 84 Gy c. 85 to 90 Gy d. >90 Gy

Key: C -- think gross residual disease 85-90 ationale: The EQD2 is 85-90 Gy in order to maximize local control in tumors greater than 4 cm at the time of implant. The toxicity associated with doses greater than 90 Gy would simply be too high. Doses lower than 80 greater would be inadequate. EQD2 between 80 to 84 are more appropriate for tumors that are less than 4 cm. References: Viswanathan,

Regarding the IELSG (International Extranodal Lymphoma Study Group) 10 Phase II trial for DLBCL of the testes, what was the dose to the contralateral testes DLBCL? a. 20 Gy b. 25 Gy c. 30 Gy d. 40 Gy

Key: C Rationale: The IELSG-10 phase II included 53 patients from age 22- with stage I or stage 2 Primary DLBCL of the testes. They were treated with 6 cycles of R-CHOP every 21 days with 4 doses of IT MTX and RT to contralateral testes (30 Gy) and to regional LNs (30-36) for stage II disease. 5 yr PFS was 74% and OS was 85%; There were no deaths as result of toxicity. Testicular RT was associated with good outcome and avoided contralateral testis relapse.

What describes beta-minus nuclear decay? a. A proton becomes a neutron, creating an electron and neutrino b. A proton becomes a neutron, creating an electron and antineutrino c. A neutron becomes a proton, creating an electron and neutrino d. A neutron becomes a proton, creating an electron and antineutrino

Key: D Rationale: Beta-minus or negatron decay occurs when there is an excess of neutrons in the atomic nucleus. To achieve greater stability, a neutron transforms into a proton, thereby bringing the neutron/proton ratio closer to the line of stability. To conserve charge, a negatron (electron) is created. To conserve spin/angular momentum, an antineutrino is created. The decay energy is imparted as kinetic energy split between the negatron and antineutrino.

According to GEC ESTRO recommendations for 3D image-based treatment planning for cervical cancer brachytherapy, which volume is used to assess high dose regions? a. V90 b. V100 c. V120 d. V150

Key: D Rationale: Cumulative DVH are recommended for evaluation of complex dose heterogeneity. DVH parameters for GTV, HR CTV and IR CTV are the minimum dose delivered to the 90% and 100% of the respective volume: D90 and D100. The volume, which is enclosed by the 150% and 200% of the prescribed dose (V150 and V200) is recommended for overall assessment of high dose volumes.

What percentage of oropharyngeal cancers in the United States are currently caused by HPV? a. <5% b. 5-10% c. 30-40% d. >60%

Key: D Rationale: Human papillomavirus (HPV) causes an epidemiologically and clinically distinct form of oropharyngeal squamous cell carcinoma (OPSCC). HPV-positive OPSCCs have risk factors related to sexual behavior whereas HPV-negative cancers are strongly associated with tobacco and alcohol use. HPV is now the major cause of oropharyngeal cancer in the United States. The incidence has increased significantly over the last 20 years.

Which is accurate regarding different definitive treatment modalities for Stage I seminoma? a. There is a significant difference in RFS between treatment with chemotherapy and radiation therapy b. 3-year RFS after radiation is approximately 90% c. At least two cycles of chemotherapy are necessary to achieve the same disease control as 20-30 Gy of radiation d. Chemotherapy results in a greater proportion of para-aortic nodal failures compared with radiation

Key: D Rationale: In stage I seminoma, whether randomized to one cycle of carboplatin chemotherapy or radiation, 5 year recurrence free survival was very good (95% vs 96%). Patients receiving chemotherapy experienced a higher rate of para-aortic nodal failures (74% vs 9%) while patients receiving radiation had a higher rate of pelvic failures (28% vs 0%).

For cT1N0M0 breast cancer treated with breast-conserving surgery and sentinel lymph node biopsy with 1 of 2 sentinel lymph nodes positive without ECE {pT1cN1a(sn)}, which subsequent locoregional treatment option is best supported by level 1 evidence? a. Completion axillary dissection followed by whole breast radiation b. Completion axillary dissection followed by radiation of the breast and dissected axilla c. No further axillary surgery and whole breast radiation in the prone position d. No further axillary surgery and whole breast radiation +/- draining lymphatics Bonus: What was the effect of axillary dissection?

Key: D Rationale: The ACOSOG Z-11 trial enrolled women with T1-T2 clinically node negative breast cancer who underwent breast conserving surgery and SLNBx with 1 or 2 positive nodes. - They were randomly assigned to axillary dissection or no further surgery. All patients subsequently received whole breast RT in the supine position, likely encompassing the low axilla in the tangent fields. - Axillary dissection increased morbidity (notably lymphedema risk) without improving any oncologic endpoint. The EORTC AMAROS trial enrolled a similar population and randomized them to axillary dissection vs. radiotherapy to the axilla and SCV nodes. The two treatments yielded equivalent rates of regional recurrence and disease-free survival, but the RT arm was superior with regard to lymphedema rates. CONCLUSION: Therefore, axillary dissection should be omitted for women receiving RT. Also, results from the MA-20 and EORTC 22922 suggest that the addition of regional nodal irradiation in the setting of node-positive breast cancer improved disease-free survival and reduces breast cancer death and should therefore be strongly considered.

Compared to patients who received temozolomide alone, what was the cognitive function and health-related QoL at 3 years for patients who received radiation alone on EORTC 22033-26033 for high risk, low grade glioma? a. Worse cognitive function, worse QoL b. Better cognitive function, worse QoL c. Better cognitive function, better QoL d. Similar cognitive function, similar QoL

Key: D Rationale: The EORTC 22033-26033 study for high risk low grade gliomas randomized patients to either 50.4Gy versus temozolomide for up to 12 cycles. In their report of health-related quality of life and mini-mental status exam (MMSE), the analysis showed no significant differences between the groups for change in MMSE scores during 3 years of follow up for patients receiving radiation versus 1 year of temozolomide.

Vaginal tumors are BEST visualized using MRI: a. T1 images. b. T2 images. c. T1 images with vaginal gel. d. T2 images with vaginal gel.

Key: D Rationale: Vaginal tumors generally are best seen on MRI using T2 images with vaginal gel inserted into the canal which distends the vaginal walls and aids in assessing the tumor's thickness.

The tumor PD-L1 expression enrollment requirement in the KEYNOTE-024 Phase-III randomized study for untreated advanced NSCLC (pembrolizumab vs chemotherapy) was: a. No requirement b. 1%. c. 5%. d. 50%.

Key: D - 50% Rationale: To be eligible for the Keynote-010 study, patients with previously treated advanced NSCLC were required to have at least 1% tumor cells with PD-L1 expression. In 024, for UNTREATED, PD-L1 had to be 50% In the total patient population, median OS in the two pembrolizumab dose arms was significantly longer than docetaxel. In a planned subset analysis of patients with expression of PD-L1 on 50% of the tumor cells, median OS and PFS in the two pembrolizumab dose arms was significantly longer than docetaxel.

Which soft tissue sarcoma subtype has a better DSS than other subtypes, but a higher local relapse rate? a. Angiosarcoma b. Leiomyosarcoma c. Malignant Peripheral Nerve Sheath Tumor d. Myxofibrosarcoma

Key: D - Myxofibrosarcoma Rationale: In multiple institutional series, myxofibrosarcoma has demonstrated a better disease-specific survival than other sarcoma subtypes, but also a higher local relapse rate. Propensity for local recurrence is predicted by positive or close margins at resection. Aggressive surgery combined with radiotherapy may contribute to more effective local control.

Which of the following isotopes is used for single photon emission computed tomography (SPECT)? a. 18F b. 60Co c. 82Rb d. 99mTc

Key: D -- 99mTc Rationale: 99mTc is used in ~85% of nuclear medicine procedures. It satisfies many requirements for an injectable imaging radioisotope (emits a well-defined and highly detectable 140.5 keV gamma, has short physical and biological half-lives, can be produced with high specific activity, it is easy to use and store, etc.). 18F emits primarily positrons rather than photons, making is useful for positron emission tomography. 82Rb is also a positron emitter, albeit less common than 18F. 60Co is useful for teletherapy as it emits high energy gamma photons with a very long half-life, but as such is not suitable for injection or SPECT applications.

Which systemic therapy in combination with doxorubicin has been shown to improve PFS and OS in patients with advanced or metastatic soft tissue sarcoma? a. Dasatinib b. Eribulin c. Pazopanib d. Olaratumab

Key: D Rationale: In a study of olaratumab and doxorubicin versus doxorubicin for soft tissue sarcoma, the combination showed improvement in overall survival (26.5 vs 14.7 mos) and progressive-free survival (6.6 vs 4.1 mos) compared to doxorubicin alone.

In patients with T1-T2 invasive breast cancer with 1 to 3 positive axillary nodes, what are the effects of postmastectomy radiation? a. No change in LRF, no change in breast cancer mortality b. No change in LRF, decreases breast cancer mortality c. Decreases LRF, no change in breast cancer mortality d. Decreases LRF, decreases breast cancer mortality

Key: D Rationale: PMRT decreases the risk of locoregional failure, any recurrence, and also decreases breast cancer mortality. The benefit of PMRT has to be weighed against potential toxicities associated with radiation therapy.

In treating vulvar cancer with an involved pelvic lymph node, the superior field border can be raised what distance above the most cephalad-positive node? a. 2 cm b. 3 cm c. 4 cm d. 5 cm

Key: D Rationale: The superior border should be no lower than the bottom of the sacroiliac joints or higher than L4/L5 junction unless the pelvic LNs are involved. If the pelvic LNs are involved the upper border can be raised to 5cm above the most cephalad-positive node. References: NCCN Vulvar Cancer; 1.2017

Small round blue cell tumors

LEARN NMR Lymphoma Ewing sarcoma ALL Rhabdomyosarcoma Neuroblastoma Neuroepithelioma Medulloblastoma Retinoblastoma

Poor prognostic factors for Ewings sarcoma

MASSive LDH Response Male gender Age >15 years Site: pelvis, axilla, spine Stage (localized v. metastatic) Elevated LDH Poor Response to chemotherapy = <90% necrosis on pathology Size: volume >200 cc or >8 cm

Is separation distance still included as a limiting factor for hypofractionation?

No -- it is not included on the ASTRO consensus statement as it wasn't excluded from START A/B as it was on Wheelan. It was a surrogate for minimizing the hotspot. Canadian hypofractionation generally we used to say keep hotspot <107%; now based on ASTRO guidelines we just "minimize the 105"

Ovoid positioning was evaluated for the cervical cancer trials RTOG 0116 and 0128. What is the impact on LR and DFS if the ovoids are displaced away from the OS? a. Increase, decrease b. Increase, unchanged c. Decrease, increase d. Unchanged, decrease

Patients with displacement of ovoids in relation to the cervical os have a significantly increased risk of local recurrence with decreased DFS as evaluated in RTOG 0116 and 0128.

Classic histologic features of Ependymoma?

Perivascular pseudorosettes, ependymal rosettes situated radially around a central lumen

Regarding EORTC 22845, which randomized patients with low grade glioma to 54 Gy vs. observation, what outcome was improved by the use of early radiation therapy? a. Cognitive function b. Quality of life c. Progression free survival d. Overall survival

Progression free survival Rationale: The EORTC 22845 trial randomized patients to 54 Gy vs observation. The median progression free survival was statistically different, 5.3years vs 3.4years and the 5 year PFS was 55% vs 35%. However the median overall survival was not statistically different at 7.4 years vs 7.2 years.

What are expendable bones? (5)

Proximal fibula ribs distal ⅘ clavicle body scapula (inferior portion) iliac wings "Expendable" or "dispensable" bones—such as the fibula, clavicle, ribs, or some bones of hand/feet—are very likely to be treated with surgery because the long-term morbidity of resection of these bones considered reasonable. Pelvic and sacral lesions, particularly those involving sacral nerve roots, are much more difficult surgeries and the surgeries can be very morbid. References: Marcus KJ, Yock T, Tarbell NJ. In Halperin, et al. Pediatric Radiation Oncology. Lippincott

Which cranial nerve is damaged if the tongue deviates to the RIGHT when they protrude their tongue? Bonus point: Where in the base of skull does this nerve traverse?

RIGHT CN XII (hypoglossal) - goes to the side of the defect Hypoglossal nerve goes through the hypoglossal canal at the level of the foramen magnum Ex: Base of skull tumor at the foramen magnum could damage the nerve as it exits the hypoglossal canal.

Effect of neoadjuvant ADT on post-treatment biopsy results (rate of positive biospy)?

Reduces rate of positive post treatment biopsy (42% vs 16%) MSK biopsy study (Zelefsky et all J Urol 2008)

Sickle cell trait is a risk factor for what type of cancer?

Renal medullary cancer (highly aggressive malignancy often found in young, black patients with sickle cell trait)

In a meta-analysis of randomized trials (Auperin et al., JCO 2010), the use of concurrent chemoRT (versus sequential chemoRT) in patients with locally advanced NSCLC demonstrated: a. increased acute grade 3-4 esophagitis. b. improved LC, but not DM or OS. c. improved LC and DM, but not OS d. improved LC and OS, but not DM.

Sort of A and D Concurrent chemoRT increased OS by 4.5% at 5 years (p=0.004), and decreased locoregional progression (HR 0.77 (p= 0.01). No effect (HR of 1.04) was noted on distant progression. Grade 3-4 esophagitis increased from 4% to 18% with a HR of 4.9.

Receiver Operating Characteristic (ROC) curve is a plot of the true positive rate against the false positive rate for the different possible cut points of a diagnostic test. What shape of a ROC curve demonstrates the best test accuracy?

The area under the ROC is a measure of test accuracy. The closer the curve follows the left-hand border and then the top border of the ROC space, the more accurate the test. The closer the curve comes to the 45-degree diagonal of the ROC space, the less accurate the test.

In patients with Mycosis Fungoides who receive total skin electron beam therapy (TSEBT), a boost is required to which areas? a. Elbows b. Hands c. Scalp d. Neck Bonus list the three areas that require boost.

The scalp, perineum, and soles of the feet require a boost because they involve body surfaces that are tangential to the TSEBT beam axis and therefore otherwise do not receive sufficient dose.

In which part of the radiation damage response does DNA-dependent protein kinase (DNA-PKcs) primarily function? a. Non-homologous end joining repair b. Homologous recombination repair c. Inhibition of Rad50 activation d. Inhibition of p53 activation

There are two major types of DSB repair pathways in mammalian cells - homologous recombination repair (HRR) and non-homologous end-joining (NHEJ). A third type, single-strand annealing (SSA), shares components with both NHEJ and HRR. NHEJ uses little to no sequence homology in a process that may or may not be error-free. NHEJ requires fewer proteins than HRR, The NEHL proteins are Ku70/80, DNA-PKcs, DNA ligase IV, and XRCC4. HRR is dependent on DNA homology and is error-free. The requirement for sequence homology is the fundamental difference between HRR and NHEJ. It is generally believed that NHEJ plays a more important role than HRR in mitotically replicating cells while HRR may play a more prominent role when sister chromatids are available during late S and G2 stages of the cell cycle. NHEJ is more important during G1 and early S phase, while HRR operates in S and G2 due to the requirement for sequence homology.

Cervical cancer - Int 0107 (GOG 109/SWOG 8797/RTOG 9112) - Peters JCO 2000 (role of adjuvant chemoradiation in high risk cervical cancer) - What are the 3 P's of cervical cancer? - Who was included in the trial? - What were the Arms? - EBRT dose? Dose to PA contingent on what? - Chemo? - Was brachy included? Results - 4 yrs OS and PFS? - toxicity? Final NCCN recommendations? - chemoRT needed for who? - when might brachytherapy be appropriate?

This study looked at risk factors AFTER radical hysterectomy, pelvic lymphadenectomy - 3 P's: High risk features after surgery 1. Positive margins 2. Positive lymph nodes 3. Parametrial involvement - Inclusion: ~250 pts stage IA2, IB, and IIA (1A2-2A) - Arms: Adjuvant XRT alone or CRT - EBRT: whole pelvis 49.3 Gy @ 1.7 Gy/fraction w/ 45 Gy to PA nodes if common illiac nodes were involved - chemo was Cisplatin + 5 FU (70 mg/m2 and 1000 mg/m2 resp) q 3 weeks for 4 cycles (2 of the cycles concurrent with radiation and 2 cycles adjuvant) - brachytherapy NOT included 4 year - Chemoradiation had OS benefit and PFS benefit - OS: 71% vs 81% (RT vs CRT, p = 0.007) - PFS: 63% vs 80% (RT vs CRT, p = 0.003) - not surprisingly WORSE hematologic toxicity (pancytopenias) in CRT arm NCCN - CRT for positive margins, positive nodes, parametrial involvement -- brachytherapy is appropriate for positive mucosal margins

Which factor is linked with radiation induced pneumonitis? a. Transforming growth factor-β1 (TGF-β1) b. Tumor necrosis factor-α (TNF-α) c. NF-kappaB (NF-kB) d. Interleukin-6 (IL-6)

Transforming growth factor beta 1 (TGF-β1) gene controls proliferation and cellular differentiation. TGF-β1 is an important modulator of the inflammatory response and in the development of tissue fibrosis in irradiated lungs. Animal and human studies have demonstrated that TGF-β1 is a major regulator of radiation-induced lung injury. Administration of anti-TGF-β1 antibodies can decrease the inflammatory response and reduce TGF-β1 activation several weeks after radiotherapy.

For a patient with histologic findings of neoplastic thymic epithelial cells with spindle shape, with great vessel invasion, what is the WHO Histologic Classification and Modified Masaoka stage?

Type A, Stage IIIB WHO Histologic Classification "A is abnormal" Type A: has neoplastic thymic epithelial cells with spindle/oval shape. Type AB has features of type A admixed with foci rich in lymphocytes. "B is Boring" Type B1 resembles normal functional thymus Type B2 has scattered plump cells with vesicular nuclei among a heavy population of lymphocytes Type B3 is predominantly composed of round or polygonal shape with minimal atypia "C is Carcinoma" Type C is a thymic carcinoma with atypia with cytoarchitectural features no longer specific to the thymus. Modified Masaoka staging: Stage I: Grossly and microscopically encapsulated. Also called a noninvasive thymoma. That is, it has not spread beyond the thymus. Stage II: The thymoma invades beyond the capsule (outer boundary of the thymus) and into the nearby fatty tissue or to the pleura (outer covering of the lung). Sometimes divided into: -Stage IIa: Microscopic transcapsular invasion -Stage IIb: Macroscopic capsular invasion Stage IIIA involves macroscopic invasion of neighboring organs such as pericardium, and lung without invasion of great vessels Stage IIIB has invasion of great vessels. Stage IVA: Pleural or pericardial dissemination. The thymoma has spread widely throughout the pleura and/or pericardium. Stage IVB: Hematogenous or lymphatic dissemination. The thymoma has spread to distant organs.

Protein responsible for degradation of HIF1a?

VHL

START A -- ARMS: 50 Gy/25 fractions vs 41.6/13 daily vs 39/13 over 5 weeks (3 fxn per week) -- 13 fraction arms were inferior. START B -- ARMS: 50 Gy/25 fractions vs 40 Gy/15 fractions - arms were equiv for local control and cosmesis was technically better for hypofrac. - db says short followup (although was 9.9 yrs) and were provider reported outcomes, not patient. Cosmetic pt reported outcomes were excellent to good in Wheelan w/ longer follow up. - Take home: Cosmetic outcomes better in 40 Gy/15 compared to 15 with equiv LRC outcomes. UK start A and B (Lancet 2013) were RCT comparing stardard frac w/ hypofrac - inclusion: T1-3N0-1 - surgery = lumpectomy + SLNB (85%) or mastectomy (15%) - boost allowed (10 in 5), not required - Not for great reasons for why we do 16, LRR was similar between 40/15 (~4.3% HF vs 5.5% CF) and 42.56/16 (6.2% HF vs 6.7 CF) but patient reported outcomes thought to be better for Canadian than start B and generally db says Canadian was longer fu and better quality data - INTERESTING POINT: 40 Gy/15 had a statistically significant DECREASED distant metastasis and overall mortality rate (Distant recurrence 10.3% vs 16% HF vs CF, p = 0.014; overall mortality was 19.2% vs 15.9% HF vs CF, p = 0.042.) HF = Hypofrac CF = Conventional Hypofrac Blurb about nodes: Generally speaking there is always the question of XRT for 1-3 nodes (N1) but there is no question about benefit for 4 or more nodes (N2). So the N1 people on these hypofract studies (Start A/B/B39) -- accrued very small numbers and treating nodes were optional, so N1's didn't necessarily get nodal XRT. Thus we still don't have enough data regarding the role of hypofrac in regional nodal.

What were the arms of the START A trial? What were the arms of the START B trial? Bonus Qs: - what were inclusion criteria? - what was surgery? - was boost done? - why do we use Canadian at WF instead of fractionation per START B? - interesting point: Was there a different in distant recurrence rate or OS between the 40 Gy and 50 Gy arms?

When do you need to cover pre-sacral lymph nodes for uterine cancer?

When there is cervical stromal involvement Uterosacral ligament/ischiococcygeus is the border anatomically

For mycosis fungoides, the palm plus the digits on one hand represent what percent of body surface area? a. 1% b. 3% c. 5% d. 10%

a. 1% groin 1%

What dose needed for gross disease in upper urinary tract? a. 54-60 Gy b. 60-66 Gy c. 70 Gy d. 78 Gy

a. 54-60 Gy stupid question but the point is you are limited by bowel toxicity and need to keep bowel dose lower so you can't go to 70 When treating unresectable disease in the renal pelvis, the radiation field should include the primary tumor bed and the entire length of the ureter. The initial field should receive 45-50.4 - 1.8 gy fractions. Boosting to 54-60 is recommended if you cna mean normal issue tolerances.

Involvement of which blood vessel would render a pancreatic mass borderline resectable? a. 180 degree involvement of the splenic artery, with splenic vein thrombosis b. 90 degree involvement of the celiac axis c. Obliteration of the portosplenic confluence d. 270 degree involvement of the superior mesenteric artery

b is borderline who cares about spleen (A/C) 270 is >180 so D is unresectable (D)

Regarding role of extrapleural pneumonectomy (EPP) in patients with mesothelioma: a. localized sarcomatoid mesothelioma should best be managed with EPP, chemotherapy and adjuvant RT b. pleurectomy/decortication followed by pleural based IMRT to 45 Gy in 25 fractions has similar outcomes than EPP followed by adjuvant RT c. post-operative radiation dose after EPP with negative margins is 60 Gy d. positive cytology for malignant cells in the pleural fluid is a contraindication for EPP

b. pleurectomy/decortication followed by pleural based IMRT to 45 Gy in 25 fractions has similar outcomes than EPP followed by adjuvant RT Per single institutional experience from MSKCC and a multicentre phase II study that used pleural based IMRT following pleurectomy/decortication for localized mesothelioma is an appropriate and safe option for therapy. Results appear promising and may be safer and more effective than historical data with EPP followed by adjuvant radiation.

isomers = ? isobars = ? isotope = ?

isomer = When two nuclei have the same number of neutrons and protons but different energy states. isobars = When two nuclei have the same number of nucleons. isotope = When two nuclei have the same number of protons but a different number of neutrons they are referred to as isotopes.

General rules for resectable vs not?

- the spleen and its vasculature are resected in a distal pancreatectomy so consider it sacrificable and ignore these answers - Superior mesenteric and celiac axis are important so they are considered unresectable if they are contacted by >180 degrees. If they give a % contact <180 degrees for these, they are borderline resectable If they mention any involvement of IMA, this is outside of the regional vasculature of pancreas and would be considered a MET. Unresectable

Brainstem dose constraint of GKRS?

12.5 Gy max

What spinal cord dose results in a 50% risk of myelopathy? a. 45 Gy b. 55 Gy c. 61 Gy d. 69 Gy

69 Gy

Optic chiasm constraint for SRS?

<8 Gy

In INT-0091, what was the 5 year incidence of isolated local failure in pediatric patients with Ewing Sarcoma treated with radiation alone for local control? a. 2% b. 9% c. 16% d. 23%

B The 5-year incidences of isolated local failure with radiation alone, surgery alone, combination surgery and radiation were 9.2%, 5.1% and 2%, respectively. However, this was not statistically significant. Moreover, the local control decision was not specified by the protocol, so there is speculation that there was an adverse selection for the patients treated with radiation alone. Further, the selection of local therapy modality does not appear to affect event free survival as even patients with localized disease are most at risk of metastatic recurrences.

What was the conclusion from the secondary analysis of RTOG 0617 randomized clinical trial evaluating the radiation dose (60 Gy vs 74 Gy) for NSCLC? a. Two-year OS and PFS was superior with IMRT b. Lower grade ≥3 pneumonitis was seen with IMRT c. Lung V5 was associated with any grade ≥3 pneumonitis d. 3DCRT group had larger PTV: Volume of lung ratio

B - IMRT to reduce V20 Rationale: In the secondary analysis of RTOG 0617 data, the use of IMRT was associated with reduced rates of ≥ grade 3 pneumonitis (7.9% vs 3.5%, p = 0.039), reduced dose to heart without any differences in 2-year OS, PFS, local or distant failure despite having larger PTV: Volume of lung ratio. Lung V20 Gy and not V5 Gy was associated with increased ≥ grade 3 pneumonitis. Hart V40 Gy was associated with OS. Primary outcome of 0617 said not to dose escalate -- 74 Gy did WORSE in terms of LC and OS than 60 Gy (some thought that volumes were too conservative since pushing dose, some thing it was because of high heart dose -- but its hard to explain

Per the RTOG 3-arm randomized trial (91-11), which treatment yielded optimal locoregional control for advanced laryngeal cancer?

ChemoRT to 70 Gy in 35 fractions. Updated data showed LRC benefit, NOT OS benefit. 91-11 compared IC-RT, CRT, or RT alone

For the commissioning of a new LINAC, what is a 3D, scanning water tank system used to measure? e a. Beam profiles b. Output versus gantry angle c. In-air output factors d. Head leakage

Key: A - BEAM PROFILES Rationale: Option B is incorrect because the water tank would get in the way of measurements of output versus gantry angle. Option C is incorrect because in air measurements are taken without a water tank. Optio

What is the CNS classification for an asymptomatic child with ALL and 3 WBCs/μL in the CSF? a. CNS 1 b. CNS 2 c. CNS 3 d. CNS 4 Define the CNS classiciations?

Key: B Rationale: CNS involvement by ALL is described as: CNS 1: no blasts CNS 2: < 5 WBCs/uL with blasts CNS 3: >= 5 WBCs/uL with blasts, or the presence of a cranial nerve palsy

Which HPV strain is MOST commonly associated with oropharyngeal cancer? a. HPV 8 b. HPV 16 c. HPV 18 d. HPV 31

Key: B Rationale: In the oropharynx, HPV 16 accounts for more than 90% of all HPV-associated cancers.

A glioma has IDH mutation, p53 mutation, ATRX loss, 1p deletion, and 19q intact. How should this tumor be classified according to the 2016 WHO classification?

Key: B Rationale: In the 2016 WHO Classification of Brain Tumors, some of the molecular characteristics of an astrocytoma are: IDH mutation, p53 mutation, ATRX mutation leading to loss, and lack of co-deletion of 1p19q. A single deletion in 1p or 19q is not sufficient to make an oligodendroglioma diagnosis; they must be co-deleted. Furthermore, p53 mutation and ATRX loss together denote an astrocytoma and are largely mutually exclusive from 1p19q co-deletion.