Peds Cases

[BraggPeak]

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For Ewings:

If you have an unresectable, non-chest wall primary and metastatic pulmonary nodules, do you do:

1) Whole Lung (12 Gy for <6, 15>6)
2) Surgery for any remaining pulmonary nodules, or 27 Gy boost
3) AND 55.8 Gy to the primary site)

Also, what order would that be in?

 

[BraggPeak]

....or am i way off?

 

[deleted4401]

Is there any rationale for having oral exams for pediatrics when the correct damn answer is "I will send the cute little guy to a pediatric specialist".

I've had to treat one kid in almost 3 years. ALL with PCI. Too far for him to drive to Baltimore every day. I called the peds guy there, asked him exactly what to do, and sent him DRRs of the fields for review. That is how you do it....

S

 

[BraggPeak]

Thanks for your help.

Just to clarify, you do the WLI RT + RT to the primary at the same time (week 12)?

Also, in a recently closed COG protocol, it says "surgical management of residual pulmonary tumors after induction chemotherapy in encouraged."

 

[Gfunk6]

Is there any rationale for having oral exams for pediatrics when the correct damn answer is "I will send the cute little guy to a pediatric specialist".

I've spoken to a couple of board-certified ROs who gave this answer on oral boards in response to being given a Peds case. Both said they got away with it without having to cite specific management.

Obviously I don't recommend doing this but if you're desperate . . .

 

[medgator]

when the correct damn answer is "I will send the cute little guy to a pediatric specialist".

First thing that popped into my head too reading this thread. 😛

I've had to treat one kid in almost 3 years. ALL with PCI. Too far for him to drive to Baltimore every day. I called the peds guy there, asked him exactly what to do, and sent him DRRs of the fields for review. That is how you do it....

I've heard of that exact scenario occurring at my current practice as well. I guess it happens in the community more than we realize, and probably why it won't be leaving our oral boards anytime soon. I am just dying to know how much of it ends up on recerts.....

 

[medgator]

I've spoken to a couple of board-certified ROs who gave this answer on oral boards in response to being given a Peds case. Both said they got away with it without having to cite specific management.

Obviously I don't recommend doing this but if you're desperate . . .

Wow. I've heard a similar ace in the hole, but yours takes the cake... "I think it's X, but I would consult the current COG protocol to confirm this before treating as things can change frequently...."

 

[lazers]

For Ewings:

If you have an unresectable, non-chest wall primary and metastatic pulmonary nodules, do you do:

1) Whole Lung (12 Gy for <6, 15>6)
2) Surgery for any remaining pulmonary nodules, or 27 Gy boost
3) AND 55.8 Gy to the primary site)

Also, what order would that be in?

Wouldn't it depend on primary? ie wouldn't it be different for Wilms vs Rhabdo?

 

[BraggPeak]

Ewing's, not Rhabdo.

For Rhabdo, you don't do WLI (i thought)

 

[lazers]

I see. Yeah I missed the part where you said for Ewings 😛

 

[Palex80]

We treat all our Ewing patients in the Euro-Ewing-protocol or according to it. That would mean:

Chemo + early RT to the primary site (55.8 Gy is a good figure, if you can push it higher, do it) followed whole lung RT 12 or 15 Gy (according to age) after all chemo has been completed.


I treated a 16 year old girl with an unresectable primary in the sacrum and bilateral pulmonary nodules 5 years ago just like that. She's still in remission.
🙂


The Euro-Ewing protocol also gives you the option to perform hyperfractionated-accelerated treatment in marginally resectable / unresectable tumors with 2 x 1.6 Gy/d. If you don't have concerns about toxicity, do it. Some data seem to show higher local control for this approach. I've treated a 17 year old with an arm soft-tissue-Ewing surrounding nerval structures (marginally limb sparing resectable) and achieved a pCR (+ he got to keep his arm, still functioning 2 years later 🙂 )


I would not advise to perform pulmonary resections before WLI. Keep lung surgery as a backup option, if everything else fails (in which case, the prognosis is really bad anyway). Pulmonary resections together with WLI have been linked to higher lung toxicity. http://www.ncbi.nlm.nih.gov/pubmed/18398583

 

[BraggPeak]

Did you boost the pulmonary nodules after WLI?

 

[Palex80]

Nope!