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Question

Adjuvant radiotherapy for oral cavity cancer + nodes

Answer 1

Indicated for most except if all of: T1-T2N0, No PNI or LVSI, no microscopic muscle invasion Adjuvant radiotherapy 60Gy/30#/6 weeks. If ECS or positive margins: Adjuvant radiotherapy 66Gy/33#/6.5 weeks with concurrent cisplatin 100mg/m2 week 1 and week 4 (If PS 0-1 and <70). LNs I/L I-V, C/L I-IVa Oral tongue cancer Don't treat C/L N0 neck unless: T3/4, primary /=N2) or ENE. Consider if 1LN (No ENE) in I/L neck.

Answer 2

T1-T3 Surg or Rad RT (surgery if poor function). Radical radiotherapy 70Gy/35#/7 weeks If T3 or N+, with concurrent cisplatin 100mg/m2 week 1 and week 4 (If PS 0-1 and <70). Ps>2, consider pall RT 45Gy/15#/3 weeks. Alt: 30/10, 20/5, 8/1. LNs (roughly OP + IV): N0 II-IVa bilat. +/-IV I/L for apex (most inferior bit near oesoph inlet) of piriform sinus, postcricoïd l/L+C/L for oesophageal extension +/- VIIa if post phar wall tumour N1-2b OP all (1b-V, VIIa/b) +/- VI. C/L as N0. N3 Ib, II, III, IVa, Va,b, +VIIa+ VIIb, +VI (i.e. OP all + VI). C/L as N0.

Answer 3

T4a pharyngolaryngectomy. T4b pall SACT or pall RT Palliative radiotherapy 45Gy/15#/3 weeks. Alt: 30/10, 20/5, 8/1. T4: moderately advanced and very advanced local disease T4a: moderately advanced local disease in which tumour invades one or more of the following: thyroid cartilage cricoid cartilage hyoid bone thyroid gland oesophageal muscle central compartment soft tissue (prelaryngeal strap muscles and subcutaneous fat) T4b: very advanced local disease in which tumour encases carotid artery or invades one or more of the following: mediastinal structures prevertebral fascia

Answer 4

Palliative radiotherapy 45Gy/15#/3 weeks. Alt: 30/10, 20/5, 8/1.

Answer 5

Glottic T1a - transoral laser surgery T1b-T2 surg or RT (better for voice preservation) Radical radiotherapy 55Gy/20#/4 weeks without nodes. Supraglottic and subglottic Surgery (laryngectomy not laser) or RT + b/l neck without chemo LNs II-IVa +/-VI if subglottic or transglottic extension

Answer 6

Surg or Rad RT (no chemo) + B/L neck RT. Radical radiotherapy 70Gy/35#/7 weeks. LNs: bilat II-IV +/- VI for transglottic or subglottic extension

Answer 7

Surg +adj RT or Rad RT (no chemo) + B/L neck RT. LNs: bilat II-IV +/- IV for transglottic or subglottic extension

Answer 8

Surgery (if poor function) or CRT. Radical chemo-radiotherapy 70Gy/35#/7 weeks with concurrent cisplatin 100mg/m2 week 1 and week 4 (If PS 0-1 and <70). LNs: N0 II-IVa bilat. +/-VI for transglottic or subglottic extension N2a-N2b above + Va/b. C/L as N0. N3 above + 1b + VIIb. C/L as N0.

Answer 9

T1N0 Radical radiotherapy 70Gy/35#/7 All else - consider induction TPF chemo x 3 every 21 days. D1 Docetaxel 75mg/m2 IV infusion, D1 Cisplatin 75mg/m2 IV infusion D1-4 Fluorouracil 750mg/m2/day Continuous IV infusion. Followed by radical chemo-radiotherapy 70Gy/35#/7 weeks with concurrent cisplatin 100mg/m2 week 1 and week 4 (If PS 0-1 and <70). LNs: N0-N2 II-V, VIIa/b bilat. N3 add 1b, IVb, Vc

Answer 10

In the post-operative setting ,radiotherapy should always be considered in cases where: There are close (<5mm) or positive resection margins There is evidence of extra-capsular spread/extra nodal extension in lymph node metastases Salivary gland malignancies which are high grade +/- T3/4 stage Salivary gland malignancies which are low grade but with close or positive margins Adenoid cystic carcinoma irrespective of stage or histological factors Post-operative radiotherapy (PORT) should be considered in cases pT3/4 tumours presence of perineural invasion +/- lymphovascular invasion poorly differentiated HPV negative SCC SCC of the oral cavity multiple positive lymph nodes within a single level multiple lymph node levels involved large single lymph node metastasis >3cm i.e. >N2a disease In select cases where there is surgical or histological uncertainty which may result in a higher chance of recurrence

Answer 11

Surgery +/- adjuvant radiotherapy 60-66Gy/30-33#.

Answer 12

Radical chemo-radiotherapy 70Gy/35#/7 weeks with concurrent cisplatin 100mg/m2 week 1 and week 4 (If T3 or N+ and PS 0-1, <70). 70Gy = p + involved nodes, If using 5+5, 63Gy = intermediate dose = GTVp+10mm, elective dose = 56Gy. LNs: Node positive neck should usually have levels 1B to V and retropharyngeal included Node negative neck should have levels II to IV included. If a level II LN is involved, the retrostyloid nodes should be included If the posterior pharyngeal wall or soft palate is involved, BL retropharyngeal nodes are included. Offer unilateral curative radiotherapy for lateralised* T1-2 SCC tonsil in an N0 neck or with one involved ipsilateral neck node. Consider unilateral RT as above + N2b but without significant nodal burden (3+, >3cm or levels other than II and III) after discussing benefits and risks. *Lateralised = a tumour confined to the palatine tonsil/tonsillar fossa/lateral pharyngeal wall with greater than 10 mm clearance from midline, not involving base of tongue or posterior pharyngeal wall and extending onto the adjacent soft palate by less than 10 mm

Answer 13

Only if >12m, no significant late effects. Small margins (CTV =GTV +5mm max) Max irradiated vol <50cm3 OAR doses as low as poss Phsyics input Discuss/consent/document thoroughly

Answer 14

Surgery +/- adjuvant RT. 60-66Gy/33#/6-6.5 weeks. LNs (N+ = OP but bilat, N0 = minus IV and V) N0 Ib-III, VIIa bilat + IX for ant 1/3 nasal cavity I'l only N1-3 Ib-V, VIIa +/- VIIb + IX for ant 1/3 nasal cavity I'l only

Answer 15

Surgical. RT if positive margins, R1/R2 or multifocal recurrence to increase local control. Radical/Adjuvant radiotherapy 50Gy/25#/5 weeks.

Answer 16

Volume <20cc Ps 0-1 Prognosis > 6 months Other disease controlled or controllable (Post neuro-surgery - can consider for residual or recurrent disease.) Single fraction * <20 mm – 21–24 Gy single dose (Grade B) * 21–30 mm – 18 Gy single dose (Grade B) Hypofractionated SRS: * 24–27 Gy in 3 daily fractions (Grade B) * 30 Gy in 5 daily fractions (Grade B) Fractionated/Staged SRS if: larger than 2–3 cm in diameter, close proximity to a critical OAR or if V12 Gy >10 cm3.

Answer 17

New lesions - can consider if >3m since last treatment. Treated lesions, could consider if >6m post initial treatment.

Answer 18

Operable = stage I, II and selected 3a. Upto T3N2a or T4(size criteria only)N2a max. All PS 0-1. eGFR and alk negative. If operable stage II - IIIB, >4cm or N+ Neo-adjuvant chemotherapy-IO 3 cycles of Nivolumab 350mg, carbo AUC 5, paclitaxel 175mg/m2, all IV D1, 3 weekly cycles. No adjuvant chemo. Alternative, no NACT-IO but >4cm or N+ 4 cycles of Adjuvant cisplatin 80mg/m2 IV D1, vinorelbine 80mg/m2 PO D1 and D8, 3 weekly cycles. If there's no progression, followed by adjuvant pembrolizumab IV 400mg every 6 weeks for 1 year (no pdl1 requirement). Alternative = Atezo if pdl1 >50%. eGFR positive -exon 19 deletions or exon 21 (L858R) substitution mutations. Stage 1b (>3cm) to IIIA, after complete resection. Adjuvant osimertinib 80mg OD oral for upto 3 years. Given with or without adjuvant chemo. alk positive Complete resection, stage IB (>/=4cm) to IIIA. Adjuvant alectinib upto 2 years 600mg BD PO. No adjuvant chemo. +/- PORT Indicated for R1, R2 resection (not indicated for nodal disease alone) Adjuvant radiotherapy 50Gy/20#/4weeks.

Answer 19

Metachronous metastasis (>6m post primary tx) PS 0-2 Life expectancy >6m Histological diagnosis 1-3 mets in 1-2 organs. Max 5cm any single met (QART (except lung) say upto 6cm ok) Bone, spine, adrenal, LN, liver, Lung Bone (non-spine) incl. sacrum 30Gy/3# on alternate days. Liver Small oligomet (e.g. ≤ 4cm) & away from chest wall/visceral OAR. 45Gy/3#/alternate days. Larger oligomet (> 4cm, ≤6cm) &/or PTV is within 1cm of small bowel/visceral OAR/bile duct or adjacent to chest wall/rib. 55Gy/5#/alternate days Adrenal 30Gy/3# on alternate days 45Gy/5#/alternate days Spine - I would follow the SABR consortium guidelines for delineation. 27Gy/3#/alternate days (EQD2 approx. 74Gy) Pelvic LNs 30Gy/3#/alternate days.

Answer 20

I would offer 63Gy/30#/6 weeks with concurrent chemotherapy cisplatin D1 80mg/m2 IV, vinorelbine oral D1, D8 60mg/m2, 3 weekly cycle. Followed by 2 more 3 weekly cycles of cisplatin/vinorelbine. Alternative: e.g. high tumour, near to brachial plexus. I would offer 55Gy/20#/4 weeks with concurrent chemotherapy cisplatin D1 80mg/m2 IV, vinorelbine oral D1, D8 60mg/m2, 3 weekly cycle. (In practice, I believe Vin is given D1, D8, D19, D26 = #1,#6,#15,#20). Followed by 2 more, 3 weekly cycles of cisplatin/vinorelbine. If there is no progression post-CRT, pdl1>/= 1%, and no CI, proceed with durvalumab 1500mg q28 IV, start within 42 days. lung function - FEV 1 ≥ 1.0, DLCO ≥ 40% Alternative chemo is cisP CI: weekly carbo AUC2/paclitaxel 40mg/m2. | WHO PS 0-1, selected PS2

Answer 21

55Gy/20#/4weeks. CHART 54Gy/36#/2.5 weeks, 3 #/day. RCR, not QART - 66Gy/33#/6.5 weeks QART not RCR hypofractionated 50, 52, 58 or 60/15#.

Answer 22

Non-SCC 4 cycles of carbo AUC5 and Pemetrexed 500mg/m2 IV D1, 21 day cycle. SCC 4 cycles of carbo AUC5 IV D1 with gemcitabine 1250mg/m2 IV D1, D8, 21 day cycle. Followed by radical radiotherapy: 55Gy/20#/4weeks. CHART 54Gy/36#/2.5 weeks, 3 #/day. RCR, not QART - 66Gy/33#/6.5 weeks QART not RCR hypofractionated 50, 52, 58 or 60/15#.

Answer 23

Good PS 0-2 36Gy/12#/2.5 weeks. Poor PS 17Gy/2#/8days, 10Gy/1#. Usuals 30/10, 20/5, 8/1.

Answer 24

Limited stage, PS 0-1, not for surgery (T1-T2 N0 -after extensive staging- for surgery). 4 cycles 3 weekly cisplatin, eptoposide. Cisplatin 80mg/m2, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3. Commence radiotherapy C2D1 45Gy/30#/3 weeks BD. This would be followed by durvalumab 1500mg IV D1 every 4 weeks for upto 2 years. I would consider PCI if good response to treatment (limited especially, also extensive stage). Caution if >70 or PS 2. 25Gy/10#/2weeks, delivered with a lateral POP. Alternative OP regime 66Gy/33#/6.5weeks.

Answer 25

4 cycles 3 weekly Carbo (or cis), etoposide. Carbo AUC5, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3. Radical radiotherapy 40Gy/15#/3weeks 50Gy/20#/4 weeks. This would be followed by durvalumab 1500mg IV D1 every 4 weeks for upto 2 years.

Answer 26

Consider if persistent disease or was bulky at presentation (not if CR). 30Gy/10#/2weeks.

Answer 27

Consider if good response to treatment (limited especially, also extensive stage). Caution if >70 or PS 2. 25Gy/10#/2weeks, delivered with a lateral POP.

Answer 28

Pancoast tumours (T3–4 N0–1): If resectable: I would offer tri-modality therapy, 45Gy/25#/5 weeks with concurrent cisplatin (carbo if less fit) and etoposide. Cisplatin 80mg/m2, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3. Followed by surgery (if no PD) and 2 more cycles of cisplatin/etoposide. If unresectable post CRT, straight to 2 more cis/etop. If unresectable at outset, treat as standard NSCLCa.

Answer 29

Resectable - upfront surgery. Potentially resectable - 2-4 x CAP (cyclophos adriamycin, cisplatin) or cis/etop, then surgery +/- Adj RT. If upfront or post chemo, unresectable, for rad CRT. Chemo-radiotherapy 54Gy/30#/6 weeks with concurrent cisplatin etoposide, to complete 4 cycles. Cisplatin 80mg/m2, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3. Adjuvant radiotherapy 54Gy/30#/6 weeks. Indications: All stage III, R1/R2 resection or thymic carcinoma (C).

Answer 30

Indicated for R1, R2 resection (not indicated for nodal disease alone) Adjuvant radiotherapy 50Gy/20#/4weeks.

Answer 31

High risk = micronodular, infiltrative, PN spread, recurrent, morphoeic, positive/close margins. Radical radiotherapy 55Gy/20#/4 weeks. Margins: CTV 0.5cm - low-risk (nodular or superficial) and well defined. CTV 1cm - poorly defined or high risk (micronodular, infiltrative) PTV +0.5cm for electrons. Alternative: Frail and field size <3cm 18-20Gy/1# Field size < 3.5cm - 35Gy/5#/1week, 45Gy/10#/2weeks (RCR any size) Field size <5cm diameter 50Gy/15# (RCR any size) Poor tolerance/big 60Gy/30#

Answer 32

Indications: positive margins, recurrence Relative indications (not in QART): Challenging sites, T3/4 disease, close margin at high risk site e.g. ear canal. Adjuvant radiotherapy 55Gy/20#/4 weeks. Margins: CTV 0.5cm - low-risk (nodular or superficial) and well defined. CTV 1cm - poorly defined or high risk (micronodular, infiltrative) PTV +0.5cm for electrons. Alternative: Frail and field size <3cm 18-20Gy/1# Field size < 3.5cm - 35Gy/5#/1week (RCR lesions <4cm), 45Gy/10#/2weeks (RCR any size) Field size <5cm diameter 50Gy/15# (RCR any size) Poor tolerance/big 60Gy/30#

Answer 33

QART Adjuvant treatment for: o Incomplete excision o Locally Recurrent disease o Margin < 1mm and one other risk factor or immunocompromised o Perineural invasion o In a completely excised T3 tumour, consider RT if more than one of: size > 40mm, depth > 6mm, PNI of defined nerve or N ≥ 0.1mm or immunosuppression I would offer radical/adjuvant radiotherapy 55Gy/20#/4weeks. 50Gy/15# - shorter fractionations may be used for frail patients with smaller field sizes (RCR say any size). Poor tolerance/big 60Gy/30# CTV 1cm PTV +0.5cm for electrons. T3: any of the following: tumour >4 cm minor bone erosion perineural invasion, defined as either of the following: clinical or radiographic involvement of named nerves without skull base invasion or transgression, or tumour infiltration of the sheath of a nerve deeper than the dermis or measuring ≥0.1 mm in calibre deep invasion, defined as either of the following: invasion beyond the subcutaneous fat, or invasion >6 mm from granular layer of adjacent epidermis to base of tumour

Answer 34

60Gy/30#/6 weeks (QART recommended dose) For large fields/elective regions consider 50Gy/25#/5weeks (RCR also recommends).

Answer 35

E.g. ECS 66Gy/33#/6.5weeks

Answer 36

If surgery not possible and M0 can consider primary RT. 60-66 Gy in 30-33 fractions in 6-6.5 weeks 55Gy in 20 in 4 weeks Single or 2 dose levels used

Answer 37

· Consider prophylactic radiotherapy to draining lymph node region in all patients who have had Merkel cell carcinoma excised and if no SLNB performed. · Adjuvant after nodal dissection for stage III disease and extracapsular spread or multiple nodes 60-66 Gy in 30-33 fractions in 6-6.5 weeks 55Gy in 20 in 4 weeks Single or 2 dose levels used

Answer 38

Definitive RT if unresectable 60Gy/30#/6 weeks (QART) RCR says 50Gy/15#/3weeks. Mucosal melanoma (nasal cavity) - always for adjuvant RT post surgery. Adjuvant - involved or close margins and re-excision not possible. -post -lymphadenectomy - ECS and/or multiple nodes. Dose/# for all = 60Gy/30#/6weeks. QART Can lower dose to 50Gy/30# where PTV extends into pelvis. QART can escalate to 66Gy/33# for nasal cavity mucosal melanoma.

Answer 39

8Gy/1# painful skin lesion poor PS (2 in exam example) 20Gy/5# Lots of other options (RCR): 20Gy/2#/1 week apart Melanoma: Limited evidence suggests 30Gy/10#/2weeks gives better palliation (RCR document). "Reirradiation of the skin can be considered in the radical, adjuvant (following salvage surgery) or palliative settings in instances where the benefits of exposure to further radiotherapy have been discussed within the multidisciplinary team." RCR document - no data about how to do it.

Answer 40

(RCR only - Solitary tumour <5cm, CPA, meets dose constraints for 3#. 45Gy/3#/alternate days.) Eligibility: Histology or radiol (If cirrhotic and >1cm) diagnosis, unsuitable for resection, transplant, TACE or PD post RFA or TACE, max 6cm (10cm in QART), max 5 lesions (3 lesions in QART - 5 difficult in practice). PS 0-2, CPA. 30-50Gy/5#/alternate days according to the mean liver dose that can be achieved (16 with 30Gy/5# = not suitable for SABR). | Radical retreat with SABR not permitted outside of a trial.

Answer 41

For resected gallbladder and extrahepatic CCA (not IHC). As per phase II trial: T2-T4 N+ or positive margins. 50-60Gy (1.8-2Gy#) to tumour bed and 45Gy (in 1.8Gy/# i.e. 25#) to nodes with concurrent Fpd. E.g. 50Gy/25#/5 weeks to tumour bed with 45Gy to nodes with concurrent capecitabine.

Answer 42

Unresectable biliary tract Ca except gallbladder. 50.4Gy/28#/5.5 weeks

Answer 43

Locally advanced pancreatic cancer (unresectable or medically unfit for surgery). At least stable disease post induction chemo (folfirinox or Gem if less fit). PS0-1, lesion 5-6cm (max 7cm QART), no duodenal involvement. Improves local control not OS. 50.4Gy/28#/5.5 weeks with concurrent capecitabine 830mg/m2 BD on days of RT. Adjuvant CRT, as above - occasionally considered (MDT decision) if very high risk features.

Answer 44

>/= T3N0/N+ SCC Concurrent chemo-radiotherapy 50Gy/25#/5 weeks with concurrent cisplatin and capecitabine. Before radiotherapy, the patient would complete 2 cycles of cisplatin 60mg/m2 IV D1 and capecitabine 625mg/m2 BD, every 21 days. Radiotherapy would start with the 3rd cycle, 4 cycles in total. OR If v. fit and young and in operable distribution: Neo-adjuvant chemo-radiotherapy as per cross trial with 41.4Gy/23#/4.5 weeks with concurrent weekly IV carbo AUC2 with paclitaxel 50mg/m2. Either CRT then followed by surgery +/- adjuvant nivolumab if residual disease at surgery post CRT. Definitive CRT alone considered for: Cervical oesophageal lesion (operation very morbid) or if not fit for surgery.

Answer 45

ACa - if not suitable for peri-operative FLOT. SCC - If very fit and young w SCC in operable distribution. Neo-adjuvant chemo-radiotherapy as per cross trial with 41.4Gy/23#/4.5 weeks with concurrent weekly IV carbo AUC2 with paclitaxel 50mg/m2. Followed by surgery +/- adjuvant nivolumab if residual disease at surgery post CRT.

Answer 46

Consider in R1 resection without heavy nodal burden or mets. Consider if less likely to benefit from chemo e.g. mandard (tumour regression grade) score of 5 = high. 45Gy/25#/5weeks with 5Fu or cape (RCR Aca chemo). With chemo if fit enough (QART).

Answer 47

"A small cohort of patients may be considered unfit to receive chemoradiotherapy but fit enough to receive radical radiotherapy. Radiotherapy is given here for maximum local control as the chance of cure is extremely small." QART If tumour < 5cm 50Gy/16#/Daily If tumour 5- 10cm 55Gy/20#/ 4 weeks Immobilisation · Cervical and upper 1/3 oesophageal tumours Supine with arms by sides with knee support and immobilisation using an orfit shell. · Middle and lower 1/3 tumours Supine with arms above head with knee support.

Answer 48

Good PS, for longer term local control: 30Gy/10#/2weeks 40Gy/15#/3weeks (occassionally) Standard dose = 20Gy/5#/1week Poor Ps or bleeding 8Gy/1#

Answer 49

Can be used for bleeding 20Gy/5# or 8Gy/1#. 8Gy may be preferred for less toxicity and option of re-treatment.

Answer 50

QART. Consider for palliative retreatment following good response to initial RT and >6mth symptomatic improvement. 20Gy/10#/2weeks. Alternative 15Gy/5#/1week.

Answer 51

BCS 26Gy/5#/1week to the whole breast or chest wall. alternative: NICE says can consider 40Gy/15 if more acceptable e.g. for reconstruction, raised BMI. Can OMIT if >/=70, /= 50, 60 only boost if positive margins and further surg not possible. FRAIL/CO-MORBID - can consider 28.5Gy/5#/5weeks.

Answer 52

Definite indications = N2, involved margins, inflammatory breast cancer. Relative indications: >/=T3, post-NACT sub-optimal response, N1+ high risk (G3, triple neg). Can avoid if int. risk + N1 (Supremo) T1-T2N1, T3N0, T2N0 +/-LVSI or G3). 26Gy/5#/1 week unless needs 40/15 for nodal irradiation.

Answer 53

Consider for all. 26Gy/5#/1week. May OMIT for lowest risk: >60, T1 (2mm (more likely to be multifocal), LG or int. grade, no necrosis or calcifications.

Answer 54

40Gy/15#/3weeks N2 and/or stage III having NACT - for SCF and IMN Extras: SCF - If level III positive, ypN+ post NACT, N1 (1-3LNs) and high risk (G3, T3, LVI +/- T2) IMN - T4, N1 (1-3LNs) and central/medial disease. Axilla - 1-2 macromets - offer adj RT but not mandatory (RCR cons) if all of: Post-menopausal, T1, G1-G2, Her2 neg, ER +. Axillary dissection if: >/=3 macromets, or macromet post NACT. No RT if: post clearance (actually go to their clips - rarely clear L2/interpectoral nodes), negative SLNBx, ITCs or micromets on SLNBx.

Answer 55

In patients with incurable disease but possible long prognosis, radical planned treatment may be appropriate for local control: 40Gy/15#/3weeks. Alternatives include: 30Gy/10 #/2weeks 20Gy/5#/1week 36Gy/6#/6 weeks

Answer 56

QART - For local recurrence on the chest wall in patients who have previously undergone radical chest wall radiotherapy, further treatment with a direct electron field may be appropriate. Single Direct Electron Field 20-30Gy/10#/2weeks The field is marked up clinically and electron energy chosen according to thickness of lesions. Bolus is applied.

Answer 57

Stage I seminoma (any T, N0, Any S) Offer if >4cm or rete testis invasion. 1 x carboplatin AUC 7. If unsuitable for carbo for para-aortic strip RT 20Gy/10#/2weeks. Stage 1 NSGCT. If vascular invasion, offer 1 x BEP chemo.

Answer 58

IIA = Any T, N1, S0-1. N1 = 5LNs, >2cm 5cm. Stage IIA seminoma 30Gy/15#/3 weeks "dog-leg" radiotherapy to para-aortic strip and I/L iliac nodes. Alternatives: = 1 x carbo + PA strip 30Gy/15# or 1 x carbo + involved node RT only. IIB - consider if small volume nodes

Answer 59

Indications: Little evidence = Offer if N3 (fixed or ECS) or >/= 2LNs. Inguinal - 54Gy/25#/5weeks with a boost to sites of residual of 57Gy. Pelvic - 45Gy/25#/5 weeks with boost to residual of 54Gy to residual. NB can give unilateral nodal RT to I/L side where +ve nodes were.

Answer 60

T2-T4aN0 (Note N+ treated similarly without good evidence). If T4a, CIS, multifocal, incomplete TURBT or hydronephrosis: Rad cystectomy +/- NACT +/- adjuvant nivolumab if high risk features (T3/T4, ypT2 or N+), M0, R0 and pdl1 >/=1% Otherwise for trimodality therapy - PS 0-1: TURBT. Radical CRT +/- NACT. Early salvage cystectomy if needed. Rad CRT + NACT: I would recommend neo-adjuvant chemotherapy cisplatin 70mg/m2 IV D1 with gemcitabine 1000mg/m2 IV D1, D8, every 21 days, 3-4 cycles with CT post C3. Note eGFR >60, as above, eGFR 50-60, for split dose cisP D1 and D8. If eGFR <50 for carboplatin. Radical chemo-radiotherapy 55Gy/20#/4 weeks (46Gy to nodes) with mitomycin C IV D1 12 mg/m2 (max 20mg) and 5FU 500mg/m²/day IV infusor for 5 days with radiotherapy # 1-5 and #16-20. Alternative - for NACT, then assess which approach is better. Nodes (as per piv. boost-note dose to nodes is 46 for bladder, not 47): Includes int/ext iliac, pre-sacral and obturator. Contour the vessels (includes external iliac, internal iliac and obturator vessels) from lower border L5 to top of femoral heads. - Expand by 7mm - 18mm rollerball to connect internal & external iliac volumes. - Obturator nodes continue inside pelvis to 10mm above pubic symphysis - 12mm rollerball anterior sacrum down to S3 (bottom of L5 to bottom of S3). - Edit CTVn_46 out of muscle, bone, bladder & bowel+3mm. ## Footnote NB PA nodes are classed as metastatic.

Answer 61

Radiotherapy alone 55Gy/20#/4weeks. Or Radical chemo-radiotherapy with 55Gy/20#/4 weeks with concurrent carbogen/nicotinomide. Carbogen for 5 minutres prior and during RT, nicotinamide 60mg/kg PO 1.5-2 hours pre RT. Avoid if have lung disease. ## Footnote NB PA nodes are classed as metastatic.

Answer 62

If poor PS or co-morbidity can give high dose palliative 36Gy/6#/6weeks. 21Gy/3#/alternate days in 1 week. Usuals: 20/5, 8/1. ## Footnote NB PA nodes are classed as metastatic.

Answer 63

CPG 1 Grade Group 1 ( Gleason 6) and PSA level < 10 and T1-2 Active surveillance = Year 1: PSA every 3-4m, DRE @12m, MRI @12-18m. Year 2: PSA every 6m, DRE 12m, no repeat MRI as standard. LDR seed brachytherapy with Iodine-125 145Gy prescribed to the CTV. Alternatives: Watchful waiting = PSA alone UNFIT only. NICE also say Rad RT or prostatectomy if AS not acceptable.

Answer 64

CPG 2 = Grade Group 2 (Gleason 3 + 4 = 7) OR a PSA 10 and 20 ng/ml and a T 1-2. CPG 3 = Grade Group 2 (Gleason 3 + 4 = 7) AND PSA 10 and 20 ng/ml and T1-2. Or Grade Group 3 (Gleason 4 + 3 = 7) and T1-2. Prostatectomy, especially if young and fit. Radical radiotherapy 60Gy/20#/4weeks. Prostate +SV - HDR Brachy boost 15Gy/1# (Leeds) followed 2 weeks later by EBRT 37.5Gy/15#/3weeks. Prostate + nodes - HDR Brachy boost 15Gy/1# (Leeds) followed 2 weeks later by EBRT (QART) 47Gy/20#/4weeks to nodes and 42Gy to prostate/SV. Alternative = 115Gy LDR brachy boost instead of HDR. CPG2 only SBRT 36.25Gy/5#/alternate days. Also N0, M0 Ps0-2, IPSS

Answer 65

CPG 4 = 1 of: Grade Group 4 (Gleason 8), PSA level >20 ng/ml, T3 CPG 5 = 2 or more of: Grade Group 4 (Gleason 8), PSA level >20 ng/ml, T3. Or Grade Group 5 (Gleason 9 or10) Or T4. Prostatectomy if 30%, >/=T3b, expected long-term survival. Alternatives: - Prostate +SV - HDR Brachy boost 15Gy/1# (Leeds) followed 2 weeks later by EBRT 37.5Gy/15#/3weeks. - Prostate + nodes - HDR Brachy boost 15Gy/1# (Leeds) followed 2 weeks later by EBRT (QART) 47Gy/20#/4weeks to nodes and 42Gy to prostate/SV. Alternative = 115Gy LDR brachy boost instead of HDR. - Watchful waiting (PSA alone) if unfit - ADT alone e.g. if life-expectancy <5 years. ADT CPG1 and CPG 2 - give if significant LUTS for 6m starting with RT. CPG3 and above Start 3-6m pre RT for 2 years (18-36m). Nodes: Includes int/ext iliac, pre-sacral and obturator. Contour the vessels (includes external iliac, internal iliac and obturator vessels) from lower border L5 to top of femoral heads. - Expand by 7mm - 12mm rollerball anterior sacrum down to S3 (bottom of L5 to bottom of S3). - 18mm rollerball to connect internal & external iliac volumes. - Obturator nodes continue inside pelvis to 10mm above pubic symphysis - Edit CTVn_47 out of muscle, bone, bladder & bowel+3mm. ## Footnote NB common iliac (above bifurcation of common iliacs) and PA nodes are classed as metastatic. Some controversy re: how to treat pelvic side-wall nodes but can be treated radically.

Answer 66

Hormone sensitive, newly diagnosed, low metastatic burden. High burden = visceral disease and/or >/= 4 bone mets with at least 1 outside the spine/pelvis. 36Gy/6#/6weeks. Symptom control: Usuals 20/5, 30/10, 8/1 ant-post POP. ## Footnote NB common iliac (above bifurcation of common iliacs) and PA nodes are classed as metastatic. Some controversy re: how to treat pelvic side-wall nodes but can be treated radically.

Answer 67

Consider at: HB states >0.2. PSA > 0.1ng/ml or 3 consecutive rises (radicals) or 0.2ng/ml with high risk features (+ve margins, Gl >/=7, T3-T4) RT at <0.5 leads to better outcomes. Prostate bed only - 52.5Gy/20#/4weeks. Add nodes if: N+ on imaging, inadequate dissection (e.g. <10-15 nodes) or not done, high-risk of N+ i.e. Gl8, >/=T3a, short PSA doubling time. 66Gy/33#/6.5 weeks (52Gy to pelvic nodes). Can consider

Answer 68

Castrate-resistant. Sequenced after ARTA (enza or abi) and Doce (must be after Doce) +/- olaparib if BRCA +. Alternative is cabazitax. PS 0-2, no visceral mets, >/=2 bone mets, symptomatic, no LN >3cm, no i/MSCC. 55KBq/kg IV q28 x 6 cycles.

Answer 69

If < 6m bicalu, can offer tamox (20mg weekly) if get symptoms. If >6m bicalu, can offer breast bud RT 8Gy/1# e.g. orthovoltage 120kv or could use electrons.

Answer 70

BLADDER PA nodes are classed as metastatic. ANAL (+ PROSTATE) CI or PA nodes = M1 PROSTATE Common iliac (above bifurcation of common iliacs) and PA nodes are classed as metastatic. Some controversy re: how to treat pelvic side-wall nodes but can be treated radically. RECTAL CI and external iliac considered metastatic. Inguinal considered metastatic unless tumour is below the dentate line. CERVIX + ENDOMETRIAL Beyond PA nodes = distant incl. inguinal or intra-abdominal nodes. VULVAL Anything beyond inguinal and femoral = distant.

Answer 71

GTV = whole conjunctiva CTV = GTV +5mm Treat with electrons (e.g. 6MeV direct electron field) or superficial with corneal shielding. Peri-ocular indolent lymphoma: Use 4Gy/2# as per FORT trial where 50% response to this dose. This dose is considered to minimise toxicity to eye. If 4Gy/2# does not produce a clinical response then the remaining 20Gy/10# of standard dose or 20G/5# may be given after reassessment at 6-8 weeks.

Answer 72

CTV = Globe of the eye and optic nerves to the level of the optic chiasm. Intra-ocular lymphoma 36Gy/20#. Indolent: Use 4Gy/2# as per FORT trial where 50% response to this dose. This dose is considered to minimise toxicity to eye. If 4Gy/2# does not produce a clinical response then the remaining 20Gy/10# of standard dose or 20G/5# may be given after reassessment at 6-8 weeks. CNS and contra lateral disease needs to be excluded as very high risk of spread. If both eyes involved use lateral parallel opposed pair with non-divergent post border for later matching brain field if relapse. If one eye, can use superior and inferior wedges pair of photons

Answer 73

CTV The whole conus to orbital bony borders, expanded to include any areas of invasion.

Answer 74

GHSG stage IA or IIA without RF. GHSG MEEE3 A - Mediastinal bulk (>1/3 horizontal chest diameter) B - Extranodal disease C - ESR >50 (>30 if B symptoms) D - >/=3 LN areas 2 x ABVD, then interim PET Deauv 1-3 = For 20Gy/10#/2weeks involved site radiotherapy Deauv 4-5 = For escalated BEACOPDAC x 2 and 30Gy/15#/3week ISRT. Alternative = RAPID if want to avoid RT e.g. women <25, want to avoid RT to breast tissue. 3 x ABVD and omit RT if CMR on PET. Avoiding combined modality therapy will be associated with a reduction of PFS of 6.8% but if the patient is a candidate for salvage and the toxicity of radiotherapy is of significant concern then this approach can be considered. ## Footnote ABVD can be given from second trimester. Breast feeding not compatible with breast feeding.

Answer 75

GHSG stage IA or IIA without RF. GHSG MEEE3 A - Mediastinal bulk (>1/3 horizontal chest diameter) B - Extranodal disease C - ESR >50 (>30 if B symptoms) D - >/=3 LN areas Early unfav = I or IIA + >/=1RF (B sx also class as RF) or IIB with C/D (not A/B = treated as advanced) 4 x ABVD + 30Gy/15#/3weeks ISRT. Alternative (avoiding RT e.g. young female). Esc Beacopp x 2 (? BEACOPDac instead) + 2 x ABVD If CMR - FUp If Deauv 4/5 - 30Gy/15#/3weeks ISRT. Alternative (avoiding RT + Bleo e.g. older, male smoker) = RATHL 2 x ABVD If CMR - for 4 x AVD If Deauv 4/5 - for EscBEACOPDac x 2 and 30Gy/15#/3weeks ISRT. Stage I = 1 node, 1 group of nodes or 1 EN site w/o nodes. Stage II = >/=2 nodal groups all same side of diaphragm +/- limited contiguous EN involvement. ## Footnote ABVD can be given from second trimester. Breast feeding not compatible with breast feeding.

Answer 76

RATHL = 2 x ABVD +iPET If CMR - for 4 x AVD If Deauv 4/5 - for EscBEACOPDac x 4 +/- consolidation RT 30 - 36Gy/15-18#/3weeks ISRT. Alternative (often pick if young, fit, want shorter tx time) Esc BEACOPP x 2 + iPET If CMR, for 2 more EscBEACOPP or 4 x A(B)VD taken from RATHL approach) If Deauv 4/5 - for EscBEACOPDac x 4 +/- consolidation RT 30 - 36Gy/15-18#/3weeks ISRT. Alternative suboptimal (v.low chance of cure) chemo if can't have anthras e.g. CCF = CHlVPP (chlorambucil, vinblastine, procarbazine, pred).

Answer 77

CD20+, CD15/30 negative. Stage IA - IIA for 30Gy/15#/3weeks ISRT. Surgery = alternative mx, if R0, can occasionally not give further tx e.g. in teenager. Advanced = W+W or chemo e.g. R-CVP, occasionally R-CHOP

Answer 78

Consider RT for consolidation after CR 30Gy/15#/3weeks. Or for persistent disease 36-40Gy/19-20#/3.5-4weeks. Palliative: usuals 30Gy/10#, 20Gy/5#, 8Gy/1#.

Answer 79

Typically in young females. R-chop 14 (i.e. "dose-dense") x 6. PET/CT - if CMR, can omit RT If Deauv 4 - for ISRT or can consider dose-intensification of chemo to try to avoid RT. Butterfly VMAT for mediatsinal lymphoma = 8 partial arcs. 6 axial and 2 cranio-caudal with 90 degree couch rotation.

Answer 80

Limited = fits within RT field. Don't treat as limited if has bulky disease (>/=7.5cm in DLBCL). 3 x R-CHOP + ISRT 30Gy/15#/3weeks. Alternative: R-CHOP x 6 (or Pola-R-CHP if ipi >/=2) +/- RT for site of bulk Avoiding RT: If IPI = 0, non-bulky, no concerning EN site can consider PET adapted approach: 2 x R-CHOP, iPET If CMR - 2 more x R-CHOP If Deauv 4 - bespoke, including RT. The 5 IPI Factors. Each factor scores 1 point: AL2234 Age > 60 years Elevated LDH (lactate dehydrogenase) Performance status ≥ 2 (based on ECOG scale) Extranodal involvement > 1 site Stage III or IV disease (advanced stage) SM-IPI Factors (Early-Stage DLBCL). Each factor = 1 point: AL22 Age > 60 years Elevated LDH Performance status ≥ 2 (ECOG) Stage II

Answer 81

Consider if high-risk of CNS spread, i.e: High risk sites- breast, uterus, kidney, adrenal, testicle. CNS IPI 4-6. >/= 3 EN sites. Mx: High dose IV methotrexate. With testicular lymphoma - add intrathecal methotrexate and RT to contralateral testicle (plus whole scrotum to the inguinal ring) The 5 IPI Factors PLUS kidney/adrenal involvement. Each factor scores 1 point: AL2234 + kid/adrenal Age > 60 years Elevated LDH (lactate dehydrogenase) Performance status ≥ 2 (based on ECOG scale) Extranodal involvement > 1 site Stage III or IV disease (advanced stage) Kidney and/or adrenal involvement

Answer 82

R-CHOP x 6 (or Pola-R-CHP if ipi >/=2) + RT for sites of bulk Site of initial bulk can give: 30Gy/15#/3weeks. Residual PET positive/refractory disease: 36Gy/18#/3.5 weeks - 40Gy/20#/4weeks. The 5 IPI Factors. Each factor scores 1 point: AL2234 Age > 60 years Elevated LDH (lactate dehydrogenase) Performance status ≥ 2 (based on ECOG scale) Extranodal involvement > 1 site Stage III or IV disease (advanced stage) Relapse: If fit and <12m post tx - for CAR-T. If fit and >12m post tx - for auto.

Answer 83

Remission induction phase with high dose chemo e.g. MATRIX regime (MTX based). Consolidation phase with autograft (if fit enough). If can't have auto or not responding to chemo can have WBRT. Caution in >60s. WBRT: CTV = Whole brain + cribiform plate down to C3-C4 junction, includes the posterior third of the orbits. After chemotherapy consolidation low dose radiation may be used. CR: Give WBRT of 23.4Gy (1.8Gy/#) PR: Consider 36Gy in 1.8Gy/#. RCR guidelines: not fit for ASCT or not responding to chemo consider WBRT 23.4Gyin 13# or 36Gy in 20# (all 1.8Gy/#).

Answer 84

Indolent = follicular, marginal zone (Including EN marginal zone lymphoma, MALT), small lymphocytic lymphoma, lymphoplasmacytic lymphoma + others. Stage 1 indolent or durable palliation for advance stage. FL - Stage IA or IIA 24Gy/12#/2.5 weeks Palliation or special sites e.g. orbit 4Gy/2#/2days. Extranodal marginal zone - also known as MALT lymphoma. Stage 1 - treat as above, treat whole organ e.g. stomach, parotid. Advanced disease: W+W or 4 x R weekly - asymptomatic, no endo organ damage or cytopaenias. SACT - symptomatic. R-Benda (best if younger, fitter) R-CVP - less fit or older. Both followed by maintenance R. 2 monthly. O = alternative if FLIPI >/=2.Grade 3b = transformation = for R-CHOP. Stage I = 1 node, 1 group of nodes or 1 EN site w/o nodes. Stage II = >/=2 nodal groups all same side of diaphragm +/- limited contiguous EN involvement. Indolent: CTV = GTV +10mm.

Answer 85

As per indolent lymphomas. Stage 1 indolent or durable palliation for advance stage. FL - Stage IA or IIA 24Gy/12#/2.5 weeks Palliation or special sites e.g. orbit 4Gy/2#/2days. Extranodal marginal zone - also known as MALT lymphoma. Stage 1 - treat as above, treat whole organ e.g. stomach, parotid. Advanced disease: W+W or 4 x R weekly - asymptomatic, no endo organ damage or cytopaenias. SACT - symptomatic. R-Benda (best if younger, fitter) R-CVP - less fit or older. Both followed by maintenance R. 2 monthly. O = alternative if FLIPI >/=2.Grade 3b = transformation = for R-CHOP. Stage I = 1 node, 1 group of nodes or 1 EN site w/o nodes. Stage II = >/=2 nodal groups all same side of diaphragm +/- limited contiguous EN involvement.

Answer 86

Features of high and low grade disease, >90% disseminated at presentation. Mx - treat young patients intensively. Options: If localised - RT (RCR say 4-30Gy). W&W. If young and fit for TP, for SACT (e.g. RChop + high dose ara-C)/intsensive tx followed by auto. 2L SACT = ibrutinib.

Answer 87

Need absence of myeloma defining events = SLiM CRAB (Calcium, Renal, Anaemia, Bone) S: ≥ 60% clonal plasma cells in marrow Li: Light chain ratio ≥100 M: ≥1 focal lesion on MRI C — HyperCalcaemia, > 2.75 mmol/L Or >0.25 mmol/L above upper limit of normal. Symptoms: confusion, constipation, polyuria R — Renal impairment. Creatinine > 177 µmol/L Or eGFR significantly reduced (Often due to light chain cast nephropathy) A — Anaemia, Hb < 100 g/L Or >20 g/L below normal. Due to marrow infiltration B — Bone disease. Lytic lesions on imaging (X-ray, CT, PET-CT). Radical radiotherapy 45Gy/25#/5 weeks ("pelvic dose") CTV = GTV +20mm PTV = CTV +5-15mm depending on site For spine can do one vertebra above and below. Solitary extra-medullary plasmacytoma e.g. maxillary sinus, Mx = as above. ## Footnote Myeloma txindications = >1 lesion >5mm on MRI, plasma cells >60%, serum free LC ratio >100. Mx if young and fit = bortezomid based regime followed by autograft. E.g. VCD (bortezomib (velcade), cyclophos dex) or VTD (bortez, thalidomide, Dex).

Answer 88

High risk features: Size >5cm Grade 2 or 3 (Trojani) Location 2 things: deep fascia involvement or location where resection would be difficult. Margins 2 things: positive or close (Leeds = <1mm)/marginal resection (QART < 2-10mm where re-excision not possible e.g. abuts bone or nerve). 60Gy/30#/6weeks. 66Gy/33#/6.5 weeks if positive margins. Trjoani score = Grading. Tumor differentiation, Mitotoses/HPF >/=20 = highest, Tumor necrosis >50% = highest. Scored 1-3. Retroperitoneal STS - don't usually offer RT. Pelvic sarcoma - occassionally offer. Volumes: GTV - reconstructed with clips and pre-op imaging. CTV = GTV + 2 radially + 5cm sup/inf. PTV = +5-10 depending on immobilisation. ## Footnote Reduces local relapse by 1/3 to 1/2.

Answer 89

For resectable disease as part of multi-modality treatment. More wound complications but reduced fibrosis and reduced field and dose. Myxoid liposarcoma - v. radiosensitive, more likely to use NAdjRT. 50Gy/25#/5 weeks CTV = GTV + 2 radially + 3cm sup/inf. PTV = +5-10 depending on immobilisation.

Answer 90

If inoperable. 66Gy/33#/6.5 weeks

Answer 91

Can offer higher dose palliative schedules due to relative "radioresistance". 36Gy/6#/6weeks. 36Gy/12#/2.5 weeks 45Gy/15#/3 weeks i.e. bladder, lung and H+N doses. 1L SACT Doxo or ifos - occassionally together if young, fit, extensive disease Alternative cylophos and pred - good in elderly. 2L = alternative of doxo or ifos. Gem and docetaxel,dacarbazine, trabectidin. ## Footnote Don't forget SABR for upto 3 lung mets.

Answer 92

All except low grade osteo or unresectable osteo. For induction chemo. Definitive treatment - surgery +/- RT Then adjuvant chemo. RMS/Ewing's +/- extra RT to lung/abdo. Osteo +/- metastaectomy (lung).

Answer 93

Definitive RT in unresectable disease. Chordoma - often unresectable 75.6Gy/42#/8.5 weeks delivered with protons.

Answer 94

Adjuvant RT chordoma - if high risk of local relapse and limited option for further surgery. 70.2Gy/39-75.6Gy/42#/8.5 weeks delivered with protons. Chondro/OsteosarcomaAdjuvant RT Limb: 60-66Gy/30-33#/6-6.5weeks depending on margins. Pelvis/spine: 68.4/38#-75.6Gy/42#/8.5 weeks

Answer 95

Chemoreduction, Definitive treatment = surgery +/- NeoAdj RT if marginal resection expected +/- Adjuvant RT. Or definitive RT. Then adjuvant chemo. +/-adjuvant lung RT. Neo-adj 50.4Gy/28#/5.5weeks Adj or definitive 54Gy/30#/6weeks. Whole lung RT: If CR or near CR. <14 years of age: 15 Gy in 10 fractions over 2 weeks >/=14 years of age:18 Gy in 12 fractions over 2.5 weeks Volumes: CTV = +2cm isotropically

Answer 96

Chemoreduction, Definitive treatment = surgery +/- NeoAdj RT if marginal resection expected +/- Adjuvant RT. Or definitive RT. Then adjuvant chemo. +/-adjuvant lung RT +/- whole abdo RT. Neo-adj 41.4Gy/23#/4.5 weeks Adj/definitive 50.4Gy/28#/5.5weeks- note for definitive RT to all mets in adults in favourable (PAX-FOX01 negative) only. Whole abdo RT if ascites or diffuse periotoneal disease 24Gy/16#/daily Whole lung RT - kids only, 15Gy/10#/2weeks

Answer 97

Both indicated if have lots of abdo disease. Wilm's: If have disseminated abdominal disease or gross per- or peri-operative rupture. Intermediate risk 15Gy/10#/12 weeks. High risk 25.2Gy/14#/3weeks RMS: If ascites or diffuse periotoneal disease. 24Gy/16#/daily

Answer 98

Wilm's - If don't achieve CR. int risk: 12Gy/8#/1.5 weeks. High risk 15Gy/10#/12weeks. <1yr for lower dose/#. RMS - kids only (? adults also if favourable as "definitive RT to all mets") 15Gy/10#/2 weeks. Ewing's - Whole lung RT If CR or near CR. <14 years of age: 15 Gy in 10 fractions over 2 weeks >/=14 years of age:18 Gy in 12 fractions over 2.5 weeks

Answer 99

Complete surgical resection. Adjuvant craniospinal radiotherapy. Adjuvant Chemo. CSRT: Medulloblastoma, CNS embryonal tumours and pineoblastoma: Standard-risk craniospinal: * 23.4 Gy /13#/2.5 weeks followed by boost of 30.6 Gy in 17 fractions of 1.8 Gy daily in 3.5 weeks to tumour bed or whole posterior fossa to a total dose of 54 Gy/30#/6weeks (Level B) High-risk craniospinal: * 36.0 Gy in 20 fractions of 1.8 Gy daily over 4 weeks (Level B) * 39.6 Gy in 22 fractions of 1.8 Gy daily over 4.5 weeks (St Jude’s regimen for M2–3) (Level B) * Followed by boost to primary site to a total of 54.0–55.8 Gy in fractions of 1.8 Gy daily i.e. 54Gy/30#/6weeks. (Level B) * Boost to sites of metastases to a total of 45–50.4 Gy (spinal) and 54–55.8 Gy (intracranial) fractions of 1.8 Gy daily (Level B) Adjuvant chemo = 6-8 cycles of packer chemotherapy. Medulloblastoma is an embryonal tumour of the CNS, which arises in the cerebellum. It is notable for its propensity for metastatic spread via the craniospinal fluid (CSF) and its radiosensitivity. Embryonal tumours can arise elsewhere in the CNS and are now referred to as CNS embryonal tumours, with those arising in the pineal area defined as pineoblastoma. ## Footnote Treatment technique 6 MV photons are used for all treatments. Detailed planning instructions are given in TP/182. Phase 1: The cranium is treated by two parallel opposed lateral fields, appropriately shielded by MLC’s. These cover the whole skull and upper neck to include C2 or C3 although the lower edge should be altered where possible to prevent the exit beam of the spinal field passing through the teeth or lower jaw. The spine is treated by posteriorly applied direct field/s. Where possible, a single fixed-SSD field should be used. Depending on the length to be treated, a second field may be required. One or more boost fields may be required to compensate for any spine curvature that may be present. The inferior edges of the lateral cranial fields are matched to the superior edge of the direct posterior spinal field. In order to follow beam divergence of the spinal field, the collimator is twisted approximately 10 degrees for the cranial fields. (The angle collimator is 7-8 degrees if the length of spine necessitates use of the two spinal fields). Phase 2: Typically this involves a boost within the cranium, delivered via RapidArc utilising 2 full arcs with avoidance sectors anteriorly (to reduce the low dose splash to facial tissues), although this does depend on the site that is being boosted. Sometimes a spinal boost is required; this is generally achieved via a direct posterior field.

Answer 100

Localised disease for both germinoma (non-secretory) and non-germinoma GCT (80% secrete AFP, BHCG) refers to unifocal or bifocal disease involving only the pineal and/or the pituitary/suprasellar region. Mx: Chemo (PIE x 4 - cisP, ifos, etoposide). Whole ventricular RT + boost to either residual disease (Germinoma) or primary (NGGCT). RCR guidance: Germinoma, post-chemotherapy, localised disease – whole-ventricular radiotherapy: *24 Gy in 15 fractions of 1.6 Gy daily over 3 weeks *Bifocal tumours, and those localised to suprasellar or pineal regions not achieving complete radiological response (CR) with induction chemotherapy, should receive a further boost to residual disease of 16 Gy in 10 fractions of 1.6 Gy daily over 2 weeks, delivering a total dose of 40 Gy (Level B) Non-germinomatous GCT, localised disease – whole-ventricular radiotherapy: *24 Gy in 15 fractions of 1.6 Gy daily over 3 weeks followed by a boost to primary tumour to a total dose of 54 Gy, in fractions not exceeding 1.8 Gy daily (Level B) - can also consider surgery to residual disease. *A simultaneous integrated boost approach can be used to treat the primary site(s) to 27 Gy in 15 fractions (1.8 Gy daily) concurrently with the whole ventricles receiving 24 Gy in 15 fractions (1.6 Gy daily). This is followed by a boost of 27 Gy in 15 fractions to the primary site(s) only, with a total dose to the primary site(s) of 54 Gy in 30 fractions of 1.8 Gy daily over 6 weeks.

Answer 101

Localised disease for both germinoma and non-germinoma GCT refers to unifocal or bifocal disease involving only the pineal and/or the pituitary/suprasellar region. Germinoma, localised with no chemotherapy or metastatic disease – craniospinal radiotherapy: *24 Gy in 15 fractions of 1.6 Gy daily over 3 weeks followed by boost to primary and metastatic sites of 16 Gy in 10 daily fractions of 1.6 Gy daily over 2 weeks (Level B) Non-germinomatous GCT, meningeal metastases – craniospinal radiotherapy: *30 Gy in 20 fractions of 1.5 Gy daily over 4 weeks (Level B). Boost to primary and metastatic sites of 24 Gy in 15 fractions (intracranial) or 20.8 Gy in 13 fractions (spinal) of 1.6 Gy daily over 2.5–3 weeks, delivering a total dose of 54 Gy intracranially and 50.8 Gy to involved spinal sites *If more than two-thirds of spine is involved with macroscopic disease, the total dose should be limited to 45 Gy (ie additional boost of 15 Gy in 10 fractions of 1.5 Gy daily over 2 weeks)

Answer 102

Arise within ventricular wall, metastasise within CSF. Mx = surgery - to primary + mets if feasible. Post-op RT for all G3 tumours or incomplete resection (SP says not G1) Consider Adj RT completely resected G2. Intracranial ependymoma: *59.4 Gy in 33 fractions of 1.8 Gy daily over 6.5 weeks (Level B) *54 Gy in 30 fractions of 1.8 Gy daily over 6 weeks in very young children <18 months, poor neurological status or multiple surgeries. Volumes as per HGG. Spinal ependymoma: *50.4–54 Gy in 28–30 fractions of 1.8 Gy daily over 5.5–6 weeks (Level B Do consider re-irradiation for relapse.

Answer 103

Initial management = active surveillance. Koos 1-3, if enlarging, for SRS 12-13Gy. Koos IV (compressing brainstem) = consider surgery. If unfit for surgery can consider hypofractionated or conventionally fractionated RT for Koos IV.

Answer 104

Primary tx = surgery. Consider RT if: not fit for surgery, recurrent or progressive following excision, residual disease and threat to vision, adverse oath e.g. ki67 >3%, secretory with peristent raised hormones despite max blockade. 45Gy/25#/5weeks. Lagre of marked invasion = 50.4Gy/28#/5.5 weeks - 54Gy/30##6 weeks. Volumes GTV (pre-op), no CTV, PTV =GTV +0.5cm.

Answer 105

Cystic hypothalamic tumour arising from rathke's pouch. RT if residual disease. 50.4Gy/28#/5.5 weeks (QART) - 54Gy/30##6 weeks (alternative option on RCR). Volumes GTV (pre-op), CTV = GTV +0.5cm, PTV =CTV +0.5cm.

Answer 106

Dural based, include the dural tail in the GTV. G1 if inoperable, incomplete resection or recurrance. QART says G2 +G3 and meningeal sarcomas = consider RT, balance of risks and benefits. RCR dose/# Grade 1: * VMAT 50–54 Gy in 25–30 fractions over 5–6 weeks (Grade C) * SRS 13–15 Gy in a single fraction (Grade C) = small volume (<7.5-10cc and >5mm from OARs) * SRS 25 Gy in 5 fractions (Grade D) (small <3cm, clsoder to OARs Grade 2 (atypical): * VMAT 54–60 Gy in 30 fractions over 6 weeks (Grade B) Grade 3 (anaplastic) (also meningeal sarcomas): * VMAT 60 Gy in 30 fractions over 6 weeks (Grade B)

Answer 107

Glioblastoma, IDH wildtype: Good performance status (KPS 80–100) and aged <70 with minimal residual tumour: * 60 Gy in 30 daily fractions over 6 weeks ± temozolomide 75mg/m2 OD during RT with PCP prophylaxis. (Grade A) Moderate performance status (KPS 60–70) PS 2, or aged over 70: * 40 Gy in 15 fractions over 3 weeks ± temozolomide if MGMT methylated (Grade A) Followed by 6 cycles of 4 weekly temozolamide 150 mg/m2 (cycle 1) then 200mg/m2 (cycle 2 onwards) OD PO D1-5. Poor performance (KPS 50–60) may be considered for shorter-course: 30 Gy in 6 fractions on alternate days/2 weeks (Grade C)) Diffuse Midline glioma (H3K27M mutant) V.poor prognosis - for upfront RT. 54Gy/30#/6weeks. 1L palliative SACT: TMZ (don't re-challenge if <6m since TMZ). PCV Lomustine alone Alternative: carboplatin

Answer 108

Diffuse midline Glioma of brainstem - consider 20Gy/10# if >6m post RT. Brioche inclusion criteria: First recurrence (incl. if had surg for recurrence + residual or new lesion), >/= 6m post primary RT, Small - max diameter

Answer 109

Adjuvant radiotherapy 59.4Gy/33#/6.5 weeks with adjuvant: 1p19q co-deleted oligo = PCV x 6 cycles. Procarbazine PO D1-10, Lomustine (CCNU) 100mg/m2 PO D1, Vincristine 1.5mg/m2 IV D1, 42 day cycle. 1p19q NON co-deleted = 12 x adjuvant temozolamide 4 weekly temozolamide 150 mg/m2 (cycle 1) then 200mg/m2 (cycle 2 onwards) OD PO D1-5.

Answer 110

RT if >40 or incomplete resection. Pignatti score for LGG = SLASH. 3 or more features = definitely needs treatment. Size >/=6cm, location = midline, age >40, nonSeizure = non-seizure pre-op neuro deficit, histology = astrocytic. Adjuvant radiotherapy 50.4Gy/28#/5.5 weeks followed by adjuvant PCV chemo.

Answer 111

Low or high grade (biopsy recommended) = same dose/# 54Gy/30#/6weeks. Same for paeds or can go lower to 50.4Gy/28#/5.5weeks.

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