Brief Review of Surgical management of Early laryngeal cancer e.g glottic and supraglottic cancer.
This presentation describes latest literature evidence of conservative laryngeal surgery as well as radiotherapy in early glottic cancer
Management of supraglottic and glottic larynx cancer has been revised lately. This presentation gives an overview of guidelines for management of laryngeal cancer. includes latest NCCN guidelines.
Brief Review of Surgical management of Early laryngeal cancer e.g glottic and supraglottic cancer.
This presentation describes latest literature evidence of conservative laryngeal surgery as well as radiotherapy in early glottic cancer
Management of supraglottic and glottic larynx cancer has been revised lately. This presentation gives an overview of guidelines for management of laryngeal cancer. includes latest NCCN guidelines.
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
laryngeal malignancies, laryngeal cancer
Presentation prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal, for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students
Ca cervix epidemiology,screening and preventionDrAnkitaPatel
CA CERVIX IS PREVENTABLE AND CURABLE IF DETECTED AT EARLY STAGE .VACCINATION, PAP SMEAR AND HPV VACCINATION ARE KEY COMPONENTS FOR PREVENTION AND EARLY DETECTION.
CA CERVIX, DR ANKITA PATEL , APEX HOSPITAL ,SYMPTOMS, DIAGNOSIS,STAGING, NCCN GUIDELINES FOR THE MANAGEMENT, SURVIVAL , MULTIMODALITY APPROACH , CHEMOTHERAPY , RADIOTHERAPY , SURGERY
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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.
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
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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.
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Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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.
1. Laryngeal
CancerDr ANKITA SINGH PATEL
MBBS,MD(KGMU)
CONSULTANT
Apex Hospital Cancer Institute
TRAINING AND FELLOWSHIP
Fortis Research Institute ,New Delhi
Tata Memorial Hospital,MUMBAI
Mob. 8765845035,9305421547
Email: dr.ankitapatel.onco@gmail.com
WEBSITE: www.apexhospitalvaranasi.com
2.
3. Anatomy – subdivision
SITE SUBSITE
Supraglottis Suprahyoid epiglottis
Infrahyoid epiglottis
Aryepiglottic fold(Laryngeal aspect)
Arytenoids
Ventricular bands (false cord)
Glottis True vocal cords , including ant & Posterior
commissure
Subglottis Subglottis
APEX HOSPITAL CANCER INSTITUTE
5. Patient-related
factors
• Age and gender: MC after age 55.
M:F 4:1
• Lifestyle: cigarette, cigar, and pipe smoking (2–
25× increase) and heavy alcohol consumption (2–
6× increase)
• Past medical history
• Weakened immunity
Environmental
factors
Industrial chemicals: sulfuric acid mist, nickel
or wood dust, or asbestos
RISK FACTORS
APEX HOSPITAL CANCER INSTITUTE
6. INCIDENCE OF CANCER BY SUBSITE
Larynx
Supraglottic 35%
Glottic 65%
Subglottic <1%
Hypopharynx
Pyriform sinus 65%
Pharyngeal wall 20%
Postcricoid 15%
7. Routes of spread for laryngeal
and hypopharyngeal cancer
Stage
Local
Extension
1. Most common manner of spread
2. Spread to cartilages initially causes sclerosis f/b erosion
3. Additional growth results in destruction and penetration of the
cartilages (and precludes laryngeal-preservation strategies)
Regional
lymph node
Metastasis
1. Lymphatic drainage depends on the Extent of primary tumor
origin of the primary disease
2. Hypopharyngeal tumors can spread to the retropharyngeal
nodal chain
Distant
Metastasis
Bones , lungs
APEX HOSPITAL CANCER INSTITUTE
8. Lymph node groups commonly involved
in laryngeal and hypopharyngeal cancer
Site Ipsilateral nodes (%) Contralateral nodes (%)
I II III IV V I I I III IV V
Supraglottic
larynx
1% 39% 26% 8% 0% 5% 12% 5% 3% 3%
Hypopharynx 1% 58% 42% 16% 11% 0% 7% 3% 1% 1%
Hypopharyngeal tumors also spread to the retropharyngeal lymph nodes
Source: Lindberg RD (1972) Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory
and digestive tracts. Cancer 29:1446–1449
APEX HOSPITAL CANCER INSTITUTE
9. Commonly Observed Signs and Symptoms in
Laryngeal and/or Hypopharyngeal Cancer
STAGE DESCRIPTION
Early laryngeal •Hoarseness
•Change in voice quality
Early hypopharyngeal oDifficulty swallowing
oCervical adenopathy
Advanced laryngeal
and/or hypopharyngeal
Hoarseness
Difficulty swallowing
Cervical adenopathy
Weight loss
Throat pain/referred pain in ear/s
Airway obstruction
10. AJCC TNM classification of carcinoma of
SUPRAGLOTTIS
Stage Description
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Supraglottis
T1 Tumor limited to 1 subsite of supraglottis, with normal vocal cord mobility
T2 Tumor invades mucosa of more than 1 adjacent subsite of supraglottis or
glottis or region outside the supraglottis, without fixation of the larynx
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the
following: postcricoid area, preepiglottic space, paraglottic space, and/or
inner cortex of thyroid cartilage
T4a Moderately advanced local disease: Tumor invades through the thyroid
cartilage and/or invades tissues beyond the larynx
T4b Very advanced local disease: Tumor invades prevertebral space, encases
carotid artery, or invades mediastinal structures
11. GLOTTIS
T1a Tumor limited to 1 vocal cord with normal mobility
T1b Tumor involves both vocal cords with normal mobility
T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired
vocal cord mobility
T3 Tumor limited to the larynx with vocal cord fi xation and/or invasion of
paraglottic space, an/or inner cortex of the thyroid cartilage
T4a Moderately advanced local disease: Tumor penetrates the outer cortex
of the thyroid cartilage and/or invades tissues beyond the larynx
T4b Very advanced local disease: Tumor invades prevertebral space, encases
carotid artery, or involves mediastinal structures
12. SUBGLOTTIS
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fixation
T4a Moderately advanced local disease: Tumor invades cricoid or
thyroid cartilage and/or invades tissues beyond the larynx
T4b Very advanced local disease: Tumor invades prevertebral space,
encases carotid artery, or involves mediastinal structures
13. HYPOPHARYNX
T1 Tumor limited to 1 subsite of hypopharynx and/or ≤2 cm in greatest
dimension
T2 Tumor invades more than 1 subsite of hypopharynx or an adjacent site,
or measures >2 cm but ≤4 cm in greatest dimension
T3 Tumor >4 cm in greatest dimension or with fi xation of hemilarynx or
extension to esophagus
T4a Moderately advanced local disease: Tumor invades thyroid/cricoid
cartilage, hyoid bone, thyroid gland, or central compartment soft tissue
includes prelaryngeal strap muscles and subcutaneous fat
T4b Very advanced local disease: Tumor invades prevertebral fascia, encases
carotid artery, or involves mediastinal structures
14.
15. STAGE GROUPING
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III
T3 N0 M0
T1-3 N1 M0
Stage IVA
T4a N0-1 M0
T1-4a N2 M0
Stage IVB
T4b any N M0
any T N3 M0
Stage IVC any T any N M1
Early
stage
Advanced
stage
16. Picture of glottic squamous cell carcinoma of the
larynx. The tumor involves the anterior half of
the left vocal cord.
APEX HOSPITAL CANCER INSTITUTE
19. MULTIDISCIPLINARY TEAM
• The management of patients with head and neck cancers is complex.
• All patients need access to the full range of support and specialists with the expertise in the management of
patients with head and neck cancer for optimal treatment and follow up.
Head and neck surgery Speeech and swallowing therapy
Radiation oncology Clinical social work
Medical oncology Nutrition support
Plastic and reconstructive
surgery
Pathology(Cyto and Histo)
Specialised nursing care Diagnostic radiology
Dentistry /Prosthodontics Physical Medicine and
rehabilitation
APEX HOSPITAL CANCER INSTITUTE
20. LARYNX /HYPOPHARYNX CANCER SUSPECTED
COMPLETE HISTORY AND PHYSICAL EXAMINATION
ENDOSCOPY AND BIOPSY
IMAGING LAB STUDIES INTERVENTION
• CT or MRI or PET-CT
With contrast and
thin cuts of primary
and neck
• CECT Thorax
• CBC
• Serum Chemistry
•Dental Prophylaxis if
upper neck nodes
require irradiation
•Speech and Swallowing
evaluation if needed
APEX HOSPITAL CANCER INSTITUTE
21. ADVERSE FEATURES warrenting
adjuvant treatment
• Extracapsular nodal spread
• +ve margin
• pT3,4
• N2,N3 nodal disease
• Perineural invasion
• Vascular embolism(lymphovascular invasion)
APEX HOSPITAL CANCER INSTITUTE
23. CLINICAL
STAGING
TREATMENT OF
PRIMARY AND
NECK
ADJUVANT TREATMENT
Carcinoma in
situ
Endoscopic
resection(preferred)
Or
RT
Amenable to
Larynx
preserving(c
onservation)
surgery (T1-
T2 or select
T3)
RT
Partial laryngectomy /
endoscopic or open
resection as indicated
or neck desection as
indicated.
No adverse
features
OBSERVE
Adverse
features
CRT/RT
APEX HOSPITAL CANCER INSTITUTE
24. CLINICAL
STAGING TREATMENT OF PRIMARY AND NECK
T3
requiring(
amenable
to total
laryngecto
my)
(N0,N1)
RT/CRT
PRIMARY SITE:
CR (N0)
PRIMARY SITE: CR
(N+)
Residual in
neck
Neck dissection
CR Post
treatment
evaluation
-ve Observ
e
Neck
dissecti
on
+v
Primary site: residual
tumor
Salvage
surgery and
neck
dissection
SURGERY
N0 : Laryngectomy
with I/L
thyroidectomy
No adverse
features
N1: Laryngectomy
with I/L
thyroidectomy as
indicated, I/L neck
dissection , or B/L
neck dissection
adverse
features
CRT
Induction
chemother
apy APEX HOSPITAL CANCER INSTITUTE
25. CLINICAL
STAGING TREATMENT OF PRIMARY AND NECK
T3
requiring(am
enable to total
laryngectomy
) (N2,N3)
CRT/RT
PRIMARY SITE:
Complete clinical
response
Residual in
neck
Neck
dissection
Complete
clinical
response of
neck
Post
treatment
evaluation
-ve Observe
Neck
dissection
+v
Primary site:
residual tumor
Salvage
surgery and
neck
dissection
Surgery
Laryngectomy with
I/L thyroidectomy
as indicated, I/L
neck dissection , or
B/L neck dissection
No adverse
features
adverse
features
CRT/RT
Induction
chemother
apy
APEX HOSPITAL CANCER INSTITUTE
26. RESPONSE ASSESSMENT
Response
after
induction
chemother
apy
Primary
site: CR Definitive
RT
Residual
in neck
Neck dissection
CR of neck Post treatment
evaluation
-ve Observe
+ve Neck
dissection
Primary site
: PR
RT / CRT CR Observe
Residual Salvage
surgery
Primary site
<PR Surgery
No
adverse
features
RT
Adverse
features
ECE +/ +ve margin CRT
Other risk factor CRT
27. CLINICA
L
STAGING
TREATMENT OF PRIMARY AND NECK
T4a,any N Surgery
N0 Total laryngectomy +
thyroidectomy as indicated +- U/L
or B/L neck dissection
RT
Or
CRT
Observe for highly selective
cases
N1 Total laryngectomy +
thyroidectomy as indicated + I/L +-
C/L neck dissection
N2-3 Total laryngectomy +
thyroidectomy as indicated +- I/L
or B/L neck dissection
Selected
T4a
patients
who
decline
surgery
CRT Primary
Site:Complet
e clinical
response
Residual in neck Neck
dissection
CR of neck Post treatment
evaluation
-ve Observatio
n
+ve Neck
dissection
Primary Site:
Residual
tumor
Salvage surgery
and neck
dissection
Induction
chemo APEX HOSPITAL CANCER INSTITUTE
31. CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Amenable to
larynx-
preserving
(conservatio
n)
surgery(T1-2
,N+ and
selected
T3,N1)
CRT/RT Primary
site:CR
Residual in neck Neck
dissection
(ND)
CR of neck Post
treatment
evaluation
-ve obs
+ve ND
RT Primary
site:
residual
tumor
Salvage surgery +neck dissection as
indicated
Partial
Supraglottic
laryngectomy
and neck
dissection
No adverse
feature
Observe / RT
Adverse
feature
CRT/RT
Induction
chemotherap
y
APEX HOSPITAL CANCER INSTITUTE
32. CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Requiring
(amenable
to) total
laryngectom
y(Most
T3,N2-N3)
CRT/RT Primary
site:CR
Residual in neck Neck
dissectio
n
(ND)
CR of neck Post
treatment
evaluation
-ve obs
+ve ND
Primary
site:
residual
tumor
Salvage surgery +neck dissection as
indicated
Laryngectom
y,I/L
thyroidectom
y with neck
dissection
No adverse
feature
RT
Adverse
feature
CRT/RT
Induction
chemotherap
y APEX HOSPITAL CANCER INSTITUTE
33. RESPONSE ASSESSMENT AFTER NACT
Response
after
induction
chemothera
py
Primary
site: CR Definitive
RT
Residual in
neck
Neck dissection
CR of neck Post treatment
evaluation
-ve Observe
+ve Neck
dissection
Primary
site : PR
RT
Or
CRT
CR Observe
Residual Salvage
surgery
Primary
site <PR Surgery
No adverse
features
RT
Adverse
features
RT/CRT
APEX HOSPITAL CANCER INSTITUTE
34. CLINICAL
STAGING
T4a,N0-
N3
Laryngectomy ,
thyroidectomy
as indicated with
I/L or B/L neck
dissection
Risk factor + RT/CRT
T4a,N0-
N3
patients
who
decline
surgery
RT/CRT
Primary
Site: CR
Residual neck Neck dissection
CR
Neck
Post
treatment
evaluation
-ve Observe
+ve Neck
dissection
Primary
Site:
Residual
disease
Salvage surgery + neck dissection
Induction
chemotherapy APEX HOSPITAL CANCER INSTITUTE
36. CLINICAL
STAGING
TREATMENT OF
PRIMARY AND
NECK
PATHOLOGY
STAGE
ADJUVANT
TREATMENT
Most T1N0 ,
Selected T2NO ,N0
Amenable to larynx
preserving
(conservation)
surgery
Definitive RT
Pimary
Site:Complete
clinical response
Pimary Site:
residual tumor
Salvage surgery +
neck dissection as
indicated
Surgery: Partial
laryngopharyngect
omy (open or
endoscopic ) + I/L
or B/L neck
dissection.
No adverse feature
Adverse feature RT/CRT
APEX HOSPITAL CANCER INSTITUTE
37. CLINICAL
STAGING
TREATMENT
T2-3 , any N
if requiring
(amenable to
)
pharyngecto
my with total
laryngectom
y);
T1,N+
Induction
Chemotherapy
CR RT/CRT
PR Surgery or RT/CRT
Laryngophary
ngectomy +
neck
dissection
Including level
VI
No adverse features
Adverse
features
CRT/RT
CRT/RT Primary
site:compl
ete clinical
response
Residual in neck Neck dissection
Complete
clinical
response
of neck
Post
treatment
evaluation
-ve Observe
+ve Neck
dissectio
n
Primary
site :
residual
tumor
Salvage surgery + neck dissection as
indicated
APEX HOSPITAL CANCER INSTITUTE
38. CLINICAL
STAGING
T4a,any N Surgery and Neck dissection Adverse features RT/CRT
Induction
chemother
apy
CR/PR CRT/RT
<PR or
progression
Salvage surgery + neck
dissection
No adverse features
Adverse
features
RT/CRT
CRT/RT Primary site:
complete
clinical
response
Residual in neck Neck dissection
Complete
clinical
response of
neck
Post
treatment
evaluation
Negative Observe
Positive Neck
dissection
Primary site :
residual
tumor
Salvage surgery + neck dissection as indicated
APEX HOSPITAL CANCER INSTITUTE
39. SUMMARY OF GUIDELINE
STAGE TREATMENT
Tis Endoscopic removal (stripping/laser) or
definitive RT
T1-2N0
glottic
Definitive RT. Advantage of RT is that failures
can be salvaged with partial laryngectomy
and still have third chance with salvage total
laryngectomy.
Alternative, cordectomy or
partial laryngectomy ± selective neck dissection.
Post-op RT for close/+ margin, PNI, LVSIv
APEX HOSPITAL CANCER INSTITUTE
41. Resectable
T1-2N+,
T3N0/+
requiring
total
laryngectomy
Concurrent chemo-RT as in RTOG 91–
11(preferred).
If < CR , salvage surgery and neck dissection may be
performed.
If residual neck mass or initial N2-3, post-RT neck
dissection
Considered
Alternative is total laryngectomy, and I/L or B/l (N0-1)
or bilateral comprehensive neck dissection (N2-3).
Post-op chemo-RT high risk disease.
Induction chemo × 3c may be considered.
If CR or PR, proceed with concurrent chemo-RT
as above.
If < PR or progression, proceed to
surgery and neck dissection as indicated
42. Resectable
T4N0/+
Total laryngectomy and I/L or B/L neck dissection
followed by post-op chemo-RT
Alternative for selected patients is definitive
concurrent chemo-RT as in RTOG 91–11.
Induction chemotherapy may be considered
Unresectable
T3-4 or N+
Concurrent chemo-RT.
If unable to tolerate chemo, definitive RT with
concomitant boost
(CB) and consider concurrent cetuximab
APEX HOSPITAL CANCER INSTITUTE
43. HYPOPHARYNX
Early T1-2 not
requiring total
laryngectomy (T1N0-1,
small T2N0, T1N2)
Definitive RT.
If < complete response, salvage
surgery and neck dissection as
indicated.
If complete response, neck dissection
considered
for N2-3
Alternatively,
partial laryngopharyngectomy and I/L
or B/L selective neck dissection (N0) or
comprehensive neck dissection (N+).
Post-op chemo-RT for high risk factors.
APEX HOSPITAL CANCER INSTITUTE
44. T2-4N0/+
requiring
total
laryngectomy
Concurrent chemo-RT as extrapolated from RTOG 91–11.
Or, induction chemo ×2c (with a third cycle if PR).
If CR at primary site, proceed with definitive RT (³70 Gy).
If primary site has only PR, proceed with concurrent chemo-
RT.
Nonresponders to induction chemo should undergo surgery
→ post-op RT or chemo-RT as indicated.
If residual neck mass after definitive RT or initial N2-3, post-
RT neck dissection considered
Or, laryngopharyngectomy and selective (N0) or
comprehensive neck dissection (N+ or T4).
Post-op chemo-RT forhigh risk factors.
Unresectable
T3-4
or N+
Concurrent chemo-RT. If unable to tolerate
chemo, definitive RT with CB
APEX HOSPITAL CANCER INSTITUTE
45. FOLLOW-UP SCHEDULE AND EXAMINATIONS
SCHEDULE FREQUENCY
First follow-up 2 weeks after radiation therapy
Years 0–1 Every month
Years 1–2 Every 2 months
Years 2–3 Every 3 months
Years 3+ Every 6 months
APEX HOSPITAL CANCER INSTITUTE
46. 1. Posttreatment baseline imaging recommended, and thereafter, as
clinically indicated.
2. CXR annually.
3. TSH every 6–12 month if neck irradiated.
4. Speech, swallow, dental, and hearing evaluations and
rehabilitation as indicated.
5. Smoking cessation counseling
If recurrence is suspected but biopsy is negative,
follow closely (at least monthly) until it resolves.
APEX HOSPITAL CANCER INSTITUTE
47. STAGE 2/5 YEAR OS SURVIVAL
LARYNX HYPOPHARYNX
2 year 5 year 2 year 5 year
I 95 % 88% 65% 35%
II 80% 60% 60% 30%
III 70% 50% 50% 30%
IV 60% 35% 35% 15%
Used with permission from the American Joint Committee on
Cancer (AJCC), Chicago, IL. APEX HOSPITAL CANCER INSTITUTE
58. TECHNICAL ESSENTIALS OF
EXTERNAL BEAM RADIATION
Co60 machine Linear Accelerator
APEX HOSPITAL CANCER INSTITUTE.
Thankyou Cobalt for the service to mankind…Time to bid
goodbye…
58
59. Why to sacrifice if we have better
option !!
59
APEX HOSPITAL CANCER INSTITUTE.APEX HOSPITAL CANCER INSTITUTE
60. WHAT ARE THE MODERN
MODALITIES?
ARE THEY BETTER THAN
CONVENTIONAL TREATMENT?
60
APEX HOSPITAL CANCER INSTITUTE.APEX HOSPITAL CANCER INSTITUTE
72. TPS (Teletherapy Planning system)
(Xio , Monte Carlo Based Planning System as approved by US FDA and AERB)
09-04-2016
E
72
APEX HOSPITAL CANCER INSTITUTE
73. For small cancers in the vocal cords it is
possible to keep the radiation far away from
other normal structures
73
APEX HOSPITAL CANCER INSTITUTE.APEX HOSPITAL CANCER INSTITUTE
76. Patient comes at fixed time,gets treated in 5 min and goes back.
No admission
No iv infusion
Can do household work.
Daily Treatment76
APEX HOSPITAL CANCER INSTITUTE