oral board questions

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Hello all and my empathy goes out to all those similarly crunching away for boards.

I had a few questions that I was hoping others more experienced might be able to enlighten me with a good response for the upcoming orals. Thanks in advance.

1) Stage IE diffuse large B-cell lymphoma of vert body: how many cycles R-CHOP? RT dose? target involved part of bone + margin or entire bone?

2) Extramedullary plasmacytoma of H&N: 50 Gy to involved field though include regional draining lymphatics (ipsilateral or B neck) if not clinically involved?

3) Stage I bulky DLBCL of abdomen not eligible for chemo. IFRT to what dose? (by NCCN saw if PR to initial R-CHOP 40-50 though unsure for non chemo candidate)

Finally, anyone considering INRT for oral boards or just stick to IFRT as Yahalom's guidelines?

Originally Posted by radonc80

1) Stage IE diffuse large B-cell lymphoma of vert body: how many cycles R-CHOP? RT dose? target involved part of bone + margin or entire bone?

In my notes I have R-CHOP x3-4 c followed by 45 Gy to lesion + 2-3 cm margin.

2) Extramedullary plasmacytoma of H&N: 50 Gy to involved field though include regional draining lymphatics (ipsilateral or B neck) if not clinically involved?

It's a bit controversial. I think you are fine either way so for simplicity I would suggest against treating lymph nodes electively.

3) Stage I bulky DLBCL of abdomen not eligible for chemo. IFRT to what dose? (by NCCN saw if PR to initial R-CHOP 40-50 though unsure for non chemo candidate)

I pray that I don't get a question like this.

Finally, anyone considering INRT for oral boards or just stick to IFRT as Yahalom's guidelines?

IFRT. They may give you a hard time about it, but there are exactly ZERO published trials comparing IFRT to INRT. If you happen to work in a high-volume lymphoma center then more power to you, stick with INRT. For the rest of us, IFRT all the way.

Here's a tag along question.

any body got some references for field design parameters for bulky DLBCL extranodal disease in a patient w/advanced stage disease s/p chemo w/PR. Residual sites of disease include a focus of dz in the liver, spleen and pancreatic lesion....

Originally Posted by radonc80

3) Stage I bulky DLBCL of abdomen not eligible for chemo. IFRT to what dose? (by NCCN saw if PR to initial R-CHOP 40-50 though unsure for non chemo candidate)

Originally Posted by Gfunk6

I pray that I don't get a question like this.
.

I haven't heard of that case very often. In any case, it's pretty straightforward. Probably around 45-50 Gy IFRT and prayer because your patient is probably missing out on the most important component of their treatment.

Originally Posted by johnthomas75

Here's a tag along question.

any body got some references for field design parameters for bulky DLBCL extranodal disease in a patient w/advanced stage disease s/p chemo w/PR. Residual sites of disease include a focus of dz in the liver, spleen and pancreatic lesion....

This is highly unlikely to be tested. If you get to a residual lymphoma in the pancreas, you are doing very, very well on your exam. I would say "I'll make sure to include all residual with a generous margin (2 cm?) , respecting normal tissue tolerance in the abdomen (kidneys V15 < 40%, no hotspot in small bowel).

Regarding the total dose for lymphoma, the teaching seems to be not to go over 40 Gy based on retrospective data from PMH (graph in Perez).

Originally Posted by medgator

I haven't heard of that case very often. In any case, it's pretty straightforward. Probably around 45-50 Gy IFRT and prayer because your patient is probably missing out on the most important component of their treatment.

This isnt necessarily a boards question as it is a Im seeing this consult soon question and no Yaholam fields are published for extranodal sites.

Originally Posted by seper

Regarding the total dose for lymphoma, the teaching seems to be not to go over 40 Gy based on retrospective data from PMH (graph in Perez).

I'll have to check that out. The SWOG in DLBCL study went to 45 Gy.

1) Stage IE diffuse large B-cell lymphoma of vert body: how many cycles R-CHOP? RT dose? target involved part of bone + margin or entire bone?

I would personally do 4 cycles R-CHOP followed by 36 Gy to pre-chemo volume +1-1.5 cm margin. If PR to chemo 40-45 Gy (can boost just the residual PET-avid disease to 41.4-45/1.8 after taking the pre-chemo volume to 36 Gy)

2) Extramedullary plasmacytoma of H&N: 50 Gy to involved field though include regional draining lymphatics (ipsilateral or B neck) if not clinically involved?

Probably wouldn't personally include the lymphatics, but I believe it's controversial. I think no lymphatics is a safe boards answer

3) Stage I bulky DLBCL of abdomen not eligible for chemo. IFRT to what dose? (by NCCN saw if PR to initial R-CHOP 40-50 though unsure for non chemo candidate)

I agree, I would do ~45 Gy/1.8 Gy fractions. If fact, I'm currently treating something like this (old guy, non-chemo candidate). RT alone can be curative for early stage DLBCL, though cure rates are certainly quite a bit lower than with combined modality (older data from Princess Margaret and others).

Finally, anyone considering INRT for oral boards or just stick to IFRT as Yahalom's guidelines?

I plan use use IFRT for Hodgkins on the boards, but would omit the axillae and upper necks unless involved. For NHL, INRT is included in the NCCN guidelines and I plan to just use generous margins on the pre-chemo volume.

any body got some references for field design parameters for bulky DLBCL extranodal disease in a patient w/advanced stage disease s/p chemo w/PR. Residual sites of disease include a focus of dz in the liver, spleen and pancreatic lesion....

If you can stay within bowel/liver tolerance, residual disease +1 cm margin to 40-45 Gy.

just my thoughts......

As far as the dose for DLBCL the NCCN does say 30-40Gy for CR and 40-50 Gy for PR. The UK did come out with a randomized trial last year looking at radiation dose for low and high grade lymphomas with over 1000 patients (PMID:21664710). This showed that for DLBCL 30 Gy was equivalent to 40-45Gy.

- In the case of CR, to chemo for DLBCL, I would give 30 Gy. I would still favor 40 Gy for PR and/or bulky diease as the trial didn't really break down chemo response in the high grade group. However, 12% of the patients in the high grade grade arms did not receive any chemo and radiotherapy was currative intent. Some are using this trial to argue that doses higher than 30 Gy are not necessary. I would stick to the low end of the NCCN guidelines for now.

"This isnt necessarily a boards question as it is a Im seeing this consult soon question and no Yaholam fields are published for extranodal sites."

- I would give 2 cm margin around the extranodal sites, but could shrink this if you do an ITV or something to manage motion. If you have very large fields above and below the diaphragm then you could treat sequentiallu above and then below the diaphragm (or vice versa) if you are worried about toxicity. If you are having a difficult time meeting dose constraints due to field size then you could decrease the dose to 30 Gy (using above trial) to try to help.

I think it's been mentioned, but some of the examiners will hassle you if you draw out the Yaholom fields, saying sure, that's an acceptable standard, but it's way too much tissue. Just keep in mind.
S

Wow, thanks to everyone for their input! Gfunk you are hilarious - I too am praying for straight forward examiners.

Couple more areas but just thought I'd check for any concensus as well.
1) Plasmacytoma bone target radiographic tumor + 2 cm margin and not whole bone

2) Rare case hodgkins not chemo candidate: subtotal nodal irradiation with 30 to spleen/PA and 36 to mantle?

Finally, anyone considering INRT for oral boards or just stick to IFRT as Yahalom's guidelines?

I plan use use IFRT for Hodgkins on the boards, but would omit the axillae and upper necks unless involved. For NHL, INRT is included in the NCCN guidelines and I plan to just use generous margins on the pre-chemo volume.

How would you define the "upper" or "high" neck? I assumed that this was above the level of the hyoid (i.e. approx the level of the bottom of mandible on an AP DRR), though a colleague thinks its above C5/C6.

Originally Posted by alphacentauri

Finally, anyone considering INRT for oral boards or just stick to IFRT as Yahalom's guidelines?

I plan use use IFRT for Hodgkins on the boards, but would omit the axillae and upper necks unless involved. For NHL, INRT is included in the NCCN guidelines and I plan to just use generous margins on the pre-chemo volume.

Though INRT is an option as per NHL as per NCCN, I'm heavily leaning towards using IFRT (w/ sparing both uninvolved high neck and axillae) for both HD and NHL for the oral boards. That being said, for INRT, what kinda margins on the pre-chemo volume are recommended?

Originally Posted by FractionJackson

Though INRT is an option as per NHL as per NCCN, I'm heavily leaning towards using IFRT (w/ sparing both uninvolved high neck and axillae) for both HD and NHL for the oral boards. That being said, for INRT, what kinda margins on the pre-chemo volume are recommended?

+ 2 cm seems reasonable (1.5 cm CTV, 0.5 cm PTV). For mediastinum/abdomen/pelvis, NCCN recommends using post-chemo volumes in the transverse dimension.

Originally Posted by FractionJackson

How would you define the "upper" or "high" neck? I assumed that this was above the level of the hyoid (i.e. approx the level of the bottom of mandible on an AP DRR), though a colleague thinks its above C5/C6.

What I saw in training and what I do in practice currently - we generally would only add about 1 cm margin superiorly above low cervical disease, and generally did not treat above the hyoid if just SCV involvement, or even lower (we would contour in the larynx, place a block, and then not treat the necks above the top of the larynx block). I think for boards if there is true cervical involvement it's probably safe to treat the neck on that side, and if only SCV involvment only bring the field up to the level of the hyoid. I'm studying for boards right now, and this is what I was planning on. I honestly don't think there is clear-cut data on this, and perhaps I'm being overly optimistic, but I would hope that one explained the rationale for avoiding upper cervical irradiation when uninvolved and suggested a reasonable superior border most examiners would be OK with it? Most of the boards horror stories I've heard haven't involved the lymphoma section

Originally Posted by alphacentauri

Most of the boards horror stories I've heard haven't involved the lymphoma section

You haven't heard all of the stories, obviously...

Some of the recent examiners may try to force you into INRT, and will rip you if you aren't doing 20 Gy and 2 cycles of ABVD for your early-favorable hodgkin's patients.

I don't envy you guys with the lymphoma section this year. We recently hosted Yahalom as a visiting prof and he was totally bashing the use of his own "standard" fields, saying that is way outdated and that the Louiville answer should be INRT. The same shpeel was repeated at the ASTRO Spring Refresher with the presenter saying we are moving toward involved "site," but the guidelines for that have not been released!

That being said, while I am not taking the OB until next year, I would think the safest thing is still to use the Yahalom fields. It may annoy the examiner, but I don't think they can possibly fail you for using those fields as opposed to guessing on INRT or ISRT if you aren't familiar with that technique.

If you were at the Spring Refresher, you probably also heard Dr. Dabaja say that if you got a neck Hodgkin's case on oral boards and you say IFRT then you should fail. In her view, there is absolutely no value in irradiating the whole neck after ABVD. I think the comment was a bit tongue in cheek but I know it freaked out a lot of the audience.

True 'nuff Gfunk. However, NCCN is still on your side and states IFRT. The only real guideline in NCCN for RT fields is that "when possible" you should spare the high neck and bilateral axillae in women.

here is one:

current indications for prophylactic cranial RT in pediatric ALL? Assuming treating off-protocol.

Originally Posted by seper

here is one:

current indications for prophylactic cranial RT in pediatric ALL? Assuming treating off-protocol.

High risk pts with blasts in CSF, WBC >50k, >10 yrs, T-cell, Ph+
18 Gy for children >2 yrs, 12 Gy for age 1-2

These are from UCSF slides, and I'm afraid are not correct. I was going to use these:

"administer cranial radiation only to those patients considered to be at highest risk for subsequent CNS relapse, such as those with documented CNS leukemia at diagnosis (>5 WBC/μL with blasts; CNS3) and/or T-cell phenotype with high presenting WBC count".


http://www.cancer.gov/cancertopics/treatment/childhoodcancers

From the Radonc wiki:

"CNS involvement at time of diagnosis
High risk disease
<1 yo, >10 yo
WBC > 100,000
T-cell ALL with WBC > 50,000
bcr-abl translocation (Philadelphia chromosome)
lymphomatous presentation"

Do they ask about leukemia on the boards???

Originally Posted by SimulD

Do they ask about leukemia on the boards???

I didn't see it on mine, and definitely didn't see any references to it on old recalls. I guess this week is time for some people to figure out the zebras that might show up next week.

agreed. ALL is not worth the time thinking about.

I agree leukemia should be rare for oral boards but recent studies show risk CNS failure with adequate high dose systemic/IT proph low 3-5% and can avoid RT except for cases overt CNS leukemia involvement. One question I can't seem to find a clear answer is for diffuse large b cell lymphoma involving Waldeyer's ring (tonsil, nasopharynx, BOT), does involved field include bilateral necks (matched low anterior neck field) along with waldeyer's ring? or just waldeyer's ring + upper neck nodes?

If you have a IIIC2 endometrial (obviously receiving chemo), will you give her PA nodal RT in addition to whole pelvic + brachy. I think the current GOG leaves it up to rad onc. Also, would you boost the area? Do 1 IMRT plan or just do IMRT for the para aortics?

I was going to use "comprehensive head and neck field" for NP/OP lymphoma (doubt anybody will get a case though).
For IIIC2 endometrium, I will answer single field pelvic/PA IMRT to 45 Gy + boost to the resected node site/higher boost to unresected nodes if any.

Good luck to everyone taking the oral boards over the next few days!

Congrats to everyone who is now feeling an enormous void of having passed the board exam.

Amen! It's like the lyrics to "Suddenly" by Billy Ocean.

Suddenly . . . life has new meaning to me
There is beauty up above and things we never take notice of [family and friends you ignored while studying]
Wake up suddenly and you're in love [with not studying]