This document summarizes key points about the management of intrahepatic cholangiocarcinoma. It finds that surgical resection provides the best chance for long-term survival, with 5-year survival rates of 20-30% for resectable disease. For unresectable tumors, options include liver transplantation in select patients and local therapies like radiofrequency ablation, transarterial chemoembolization, and yttrium-90 microsphere treatment, which have shown some promise for improving survival. Systemic chemotherapy with gemcitabine and cisplatin is the standard first-line treatment based on improved survival seen in a phase III trial, while various targeted agents in combination with chemotherapy are under investigation in clinical trials
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
A brief description on Cholangiocarcinoma, its classification and management. Contains management of Intrahepatic cholangiocarcinoma, Perihilar cholangiocarcinoma, Distal cholangiocarcinoma.
Cholangiocarcinomas (bile duct cancers) arise from the epithelial cells of the intrahepatic and extrahepatic bile ducts.
Please do not edit or rename.
Note it is only for academic purposes.
Management of renal cell carcinoma - presented at Asian Oncology Summit 2013Siewhong Ho
Dr Ho lectured at the Asian Oncology Summit 2013 in Bangkok on the surgical opinion on management of renal cell carcinoma. He presented to a varied audience of medical oncologist, radiation oncologist, urologists, researchers, para clinical staff and nurses. The most interesting aspect of the lecture was on the role of urologists in management of Stage 4 kidney cancer in the era of 'targeted therapy'. The role of cytoreductive nephrectomy was reviewed potential future developments in this area was discussed
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
A brief description on Cholangiocarcinoma, its classification and management. Contains management of Intrahepatic cholangiocarcinoma, Perihilar cholangiocarcinoma, Distal cholangiocarcinoma.
Cholangiocarcinomas (bile duct cancers) arise from the epithelial cells of the intrahepatic and extrahepatic bile ducts.
Please do not edit or rename.
Note it is only for academic purposes.
Management of renal cell carcinoma - presented at Asian Oncology Summit 2013Siewhong Ho
Dr Ho lectured at the Asian Oncology Summit 2013 in Bangkok on the surgical opinion on management of renal cell carcinoma. He presented to a varied audience of medical oncologist, radiation oncologist, urologists, researchers, para clinical staff and nurses. The most interesting aspect of the lecture was on the role of urologists in management of Stage 4 kidney cancer in the era of 'targeted therapy'. The role of cytoreductive nephrectomy was reviewed potential future developments in this area was discussed
GB cancer is the 5th most common GIT malignancy(worldwide).200 years later it is still considered to be a highly malignant disease with a poor survival rate
.Here is a brief description regarding
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
CyberKnife is an option in inoperable or medically not suitable for surgery
& in patient with progression / not tolerating systemic therapy
- Initial results are impressive with low toxicity, good response rate
Pts with small tumour, no prior treatment with good performance
treated with high dose have significantly better survival
Dose >45 Gy; 15Gy/# and small vol tumour (<50cc) have better prognosis
There is minimal toxicity with CyberKnife in liver tumours
Addition of chemotherapy along with CyberKnife will be the future
Epatocarcinoma: nulla di nuovo sotto il sole - Gastrolearning®Gastrolearning
Gastrolearning II modulo/13a lezione
Epatocarcinoma: nulla di nuovo sotto il sole
Relatore: Prof. Massimo Colombo (Milano)
Discussants: Prof. F. Farinati (Padova), Prof.ssa E. Villa (Modena), Prof. A. Grieco (Roma).
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
Advances in cholangiocarcinoma
1. AUBHO 2014
Rachna T. Shroff, MD, MS
Assistant Professor,
Dept of GI Medical Oncology
M.D. Anderson Cancer Center
rshroff@mdanderson.org
2. None with the subject matter to be
presented
Research Funding:
Celgene
Clovis Oncology
3. >7,0000 cases annually in 2009
5-year survival is <15%
Most patients present with locally advanced or metastatic
disease
Treatment commonly administered in the community,
at low-volume centers.
11. Hilar Cholangio
Biliary Obstruction
common
Cholangitis life
threatening
Local-directed
therapies (TACE, Y90,
RFA) increased risk of
abscess/
complications
Intrahepatic
Cholangio
Course can be
relatively indolent
Local therapies for
advanced disease
feasible, particularly
radiation
12. Surgical resection is the standard of care
Post operative radiation/ chemoradiation therapy
improves recurrence-free survival in R1 disease
Role of adjuvant therapy in R0 resection is debatable
Role of liver transplantation in unresectable hilar
cholangiocarcinoma.
NCCN Guidelines
13. Surgical resection results in 20-30% long term survival
> 5 years
Klatskin tumors-junction of the hepatic ducts are
complicated by extensive perineural and lymphatic
invasion, bilateral liver involvement, and vascular
encasement
Intrahepatic cholangiocarcinoma is a contraindication
for liver transplant at most centers.
14. Unresectable CCA or resectable Cholangio with PSC
Tumor size < 3 cm
Tumor above cystic duct
No intra- or extrahepatic metastases
No intrahepatic CCA or GB involvement
Vascular encasement of the hilar vessels is not a
contraindication
CA 19-9 > 100 with mass; Biliary ploidy by FISH with bile
duct stricture
15. Neoadjuvant EBRT: 4000 to 4500 cGy + 5-FU
2000 to 3000 cGy transcatheter iridium
Capecitabine until transplantation
5-year survival with neoadjuvant therapy = 55%
5-year survival after transplantation = 71%.
Rosen HPB (Oxford). 2008
16. American Association for the Study of Liver Diseases
Heimbach J, et al: Liver Transplantation 10; 65-68, 2004
17. Disease-related factors
• Uncommon malignancies
• Unwell, elderly population, infection/obstruction
• Histological / cytological confirmation difficult
Lack of evidence
• Disease often not measurable
• Primarily small phase II and one phase III study of
gemcitabine-based combinations
18. Eligible patients (n=400*)
Arm A
Gem 1000 mg/m2 D1,8,15 q 28d
24 weeks (6 cycles)
Arm B
Cisplatin 25 mg/m2
+ Gem 1000 mg/m2
24 weeks (8 cycles)
Randomized 1:1
(stratified by centre, primary site, PS, prior
therapy and locally advanced vs. metastatic)
Upon disease progression, management will be on clinician’s
discretion (mostly best supportive care)
D1,8 q 21d
* Including 86 patients in ABC-01
+ QoL
19. Main inclusion criteria:
Histologically / cytologically verified disease
Adequate biliary drainage, no uncontrolled infection
ECOG PS 0-2
LFTs: bilirubin 1.5 x ULN, ALT/ AST/ alk phos 3 x ULN
( 5 if liver metastases)
Measureable disease was not mandated
20. Primary
endpoint:
OVERALL SURVIVAL
Secondary
endpoints:
Progression-free survival
Toxicity
Quality of life (EORTC QLQ C-
30)
Sample
size:
Powered to detect increase in
MS from 8 to 11 months
Log-rank test with 80% power
and two-sided a 5% level
23. Result
Gem
n (%)
Gem + Cis
n (%)
Not assessed * 74 (36%) 56 (27%)
Assessed * 132 (64%) 148 (73%)
Complete Response 1 (0.8%) 1 (0.7%)
Partial Response 20 (15.2%) 37 (25.0%)
Stable Disease 73 (55.3%) 79 (53.4%)
Progressive Disease 33 (25.0%) 28 (18.9%)
CR + PR + SD 94 (71.2%) 117 (79.1%)
p-value 0.256
* Patients not required to have measurable disease at study entry,
some patients still in follow-up
24. Treatment arm Gem Gem + Cis
Number of patients n=206 n=204
PFS events n(%) 155 (75.2) 135 (66.2)
Median PFS (mo) 6.5 8.4
Log rank p value 0.003
Hazard ratio (95% CI) 0.72 (0.57, 0.90)
25. ABC-02 - Results:
Overall Survival (ITT)
Treatment arm Gem Gem + Cis
Number of patients n=206 n=204
Deaths n(%) 141 (68.5) 122 (59.8)
Median survival (mo) 8.3 11.7
Log rank p value 0.002
Hazard ratio (95% CI) 0.70 (0.54, 0.89)
26.
27. Cisplatin and gemcitabine significantly improves overall
survival compared with gemcitabine monotherapy (11.7
vs. 8.3 months)
Benefit gained with no clinically significant added toxicity
CisGem is recommended as a worldwide standard of
care and the backbone for further studies
Caution required in patients with PS > 2
31. Agents Target Patients RR PFS Author
Combination Regimens First line therapy
GEMOX-cetuximab
EGFR 51 - 61% (4 mths) Malka
GEMOX-bevacizumab
VEGF 35 40
7 months
(median)
Zhu
Single Agent Regimens First or Second line
AZD6244
MEK1/2 22 14
5.4 months
(median)
Bekaii-Saab
Erlotinib
EGFR 43 7
2.6 months
(median)
Philip et al
Lapatinib
EGFR/HER2 17 0
1.8 months
(median)
Ramanathan
Sorafenib
BRAF/VEGFR 36 6
2 months
(median)
El-Khoueiry
Sorafenib
BRAF/VEGFR 46 2
2.3 months
(median)
Bengala
Zhu et al, JCO, 2009
32. Bile Acids Induce EGFR in CCA cells via TGF-α and COX-2
Hepatol. 2004;41(5):808-14
33. Wide range reported k-ras mutation in biliary
cancer (10-45%)
More likely in anomalous pancreato-biliary ducts
Less likely in the setting of pre-existing adenoma
In Wt k-ras, EGFR-directed TKIs or Monoclonal
antibodies are a consideration
37. 268 pts randomized: GEMOX +
Erlotinib
PR higher in erlotinib group (40 vs.
21, p=0.005)
Higher PFS with erlotinib (5·9
months vs 3·0 months) (p=0·049)
Median overall survival was the
same in both groups
Lancet Oncol. 2012;13(2):181-8.
38. Phase 2: GEMOX+ Bevacizumab (10 mg/kg bi-weekly)
35 pts enrolled
Median PFS 7 months (6 months was 63%)
Toxicities: neutropenia, hypertension, AST
elevation, neuropathy
Partial responses or SD associated with
significant improvement in SUV
Lancet Oncol Nov 2009 (Epub)
39. Sorafenib: 400 mg twice a day
46 patients were treated; 26 (56%) had received
chemotherapy earlier
Progression-free survival (PFS) was 2.3 months (range:
0-12 months)
Median overall survival was 4.4 months (range: 0-22
months).
El Khoureiy, ASCO 2007
44. 33 patients with intrahepatic cholangioca
Median tumor size - 8.8 cm
88% previously chemotherapy
Dose: 50.4 Gy (range, 35–70 Gy), most with xeloda
1-year PFS: 47%, and 1-year OS: 62%
1-year OS rate was 100% with RT dose ≥ 60 Gy
Gastrointest Cancer Res. 2010 Nov-Dec; (Suppl 1): S34
45. Intrahepatic Cholangio: 67.5 Gy in
15 fractions. No concurrent
chemotherapy
N=57
1 and 2-year OS is 69% and 58%
PFS is 41% and 28%
respectively.
46. Locoregional Therapy: Y90
48 90Y treatments were
administered to hepatic
segments or lobes.
Fatigue, abdominal pain common
Rare: grade 3 bilirubin toxicity,
gastroduodenal ulcer.
PR 6 pts (27%), SD 15 patients
(68%), and PD in 1 patient (5%).
Median OS was 14.9 months.
OS for pts without and with prior
chemo was 31.8 months and 4.4
months, respectively (P = .02).
Cancer. 2008;113(8):2119-28.
47. Vascularity is lower than HCC, thus limiting
the value of TACE
Retrospective Study 60 cases
DEB-TACE: PFS of 3.9 mos, OS 11.7 mos,
cTACE: PFS of 1.8 mos OS of 5.7 mos
Chemo (GEMOX): PFS of 6.2 mos and OS
of 11.0 mos
Eur J Gastroenterol Hepatol. 2012 (4):437-43.
49. Approach to management of intrahepatic cholangiocarcinoma
Patel, T. (2011) Cholangiocarcinoma—controversies and challenges
Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2011.20
50. Localized
Induction Chemo
followed by
ChemoRT
Disseminated
Systemic
Chemotherapy
NGS
Add targeted
agents based on
molecular
phenotype
Clinical trials:
MEK + Pazopanib
FGFR Inhibitor
Proton Therapy
Select cases
with SD/PR> 6
mos on chemo,
consider OLT
(investigational)