The document discusses the management of oropharynx carcinoma. The goals of management are to maximize survival while minimizing morbidity given the site's involvement in speech, swallowing and airway. Management includes radiotherapy, chemotherapy and surgery. Radiotherapy techniques discussed include IMRT, hyperfractionation and concurrent chemoradiotherapy. Chemotherapy regimens used concurrently with radiotherapy include cisplatin or carboplatin with infusional 5-FU. Brachytherapy is also discussed as a boost technique for oropharynx carcinoma.
Nasopharyngeal carcinoma is typically treated with radiation therapy. Concurrent chemotherapy and radiation is the standard for locally advanced disease and improves survival compared to radiation alone. Intensity-modulated radiation therapy provides better tumor coverage and reduces side effects. Surgery has a limited role except for biopsy or salvaging recurrent tumors. Temporal lobe necrosis is a serious potential complication, so fractional doses above 2Gy should be avoided. Close follow-up is needed due to risk of recurrence or late effects.
This document discusses reirradiation in recurrent head and neck cancer. It notes that radiation therapy plays a central role in head and neck cancer treatment but recurrence still occurs in 20-35% of patients. Reirradiation presents challenges due to prior radiation exposure and damage to normal tissues. The document discusses treatment options, appropriate patient selection, techniques like IMRT to minimize dose to organs at risk, optimal timing and dosing of reirradiation, and management of toxicities.
NEWER ADVANCES IN MANAGEMENT OF RECURRENT HNC FINAL.pptxagarwalpankaj
This document discusses newer advances in managing recurrent head and neck cancer (HNC). It notes that locoregional recurrence rates after initial treatment are 40-50% and distant metastasis rates are 20-30%. Salvage surgery, re-radiation, and systemic therapy are used to treat recurrence. Studies show 5-year survival of 35% for patients with a single metastasis and 4% for multiple metastases treated with metastasis-directed therapy. Immunotherapy has improved outcomes for recurrent/metastatic HNC, with nivolumab and pembrolizumab approved based on clinical trials. Combining immunotherapy with radiation shows potential synergistic effects.
Nasopharyngeal carcinoma has unique features including association with Epstein-Barr virus and a high risk of distant metastases. Definitive radiotherapy is the primary treatment, with intensity-modulated radiotherapy improving outcomes. Concurrent chemoradiotherapy provides significantly improved progression-free and overall survival compared to radiotherapy alone for locally advanced disease based on a landmark randomized trial. Brachytherapy may be used as a boost for early-stage tumors following external beam radiotherapy.
Three clinical trials comparing different treatments for oropharynx and larynx cancer were summarized:
1. RTOG 9003 found that hyperfractionated RT showed significantly improved OS and LRC compared to standard fractionation for advanced cancers. Acute toxicities were similar between arms.
2. GORTEC 9902 and the study by Brizel et al. found CCRT with altered fractionation like hyperfractionation or accelerated fractionation improved outcomes over RT alone.
3. RTOG 9501 and EORTC 22931 showed that for cancers with high-risk features, adjuvant chemoRT with cisplatin improved locoregional control and DFS compared to RT alone, with
This document discusses the management of oropharyngeal cancer. It begins by stating the goals of treatment are functional organ preservation and minimizing treatment-induced morbidity while maintaining cure rates. For early stage disease, single modality radiotherapy or surgery is usually sufficient. For advanced stages, surgery plus radiation or chemoradiation are recommended based on risk factors. It then discusses treatment options and outcomes for different subsites within the oropharynx and the benefits of adjuvant therapy or altered fractionation schedules for radiotherapy.
Nasopharyngeal carcinoma is typically treated with radiation therapy. Concurrent chemotherapy and radiation is the standard for locally advanced disease and improves survival compared to radiation alone. Intensity-modulated radiation therapy provides better tumor coverage and reduces side effects. Surgery has a limited role except for biopsy or salvaging recurrent tumors. Temporal lobe necrosis is a serious potential complication, so fractional doses above 2Gy should be avoided. Close follow-up is needed due to risk of recurrence or late effects.
This document discusses reirradiation in recurrent head and neck cancer. It notes that radiation therapy plays a central role in head and neck cancer treatment but recurrence still occurs in 20-35% of patients. Reirradiation presents challenges due to prior radiation exposure and damage to normal tissues. The document discusses treatment options, appropriate patient selection, techniques like IMRT to minimize dose to organs at risk, optimal timing and dosing of reirradiation, and management of toxicities.
NEWER ADVANCES IN MANAGEMENT OF RECURRENT HNC FINAL.pptxagarwalpankaj
This document discusses newer advances in managing recurrent head and neck cancer (HNC). It notes that locoregional recurrence rates after initial treatment are 40-50% and distant metastasis rates are 20-30%. Salvage surgery, re-radiation, and systemic therapy are used to treat recurrence. Studies show 5-year survival of 35% for patients with a single metastasis and 4% for multiple metastases treated with metastasis-directed therapy. Immunotherapy has improved outcomes for recurrent/metastatic HNC, with nivolumab and pembrolizumab approved based on clinical trials. Combining immunotherapy with radiation shows potential synergistic effects.
Nasopharyngeal carcinoma has unique features including association with Epstein-Barr virus and a high risk of distant metastases. Definitive radiotherapy is the primary treatment, with intensity-modulated radiotherapy improving outcomes. Concurrent chemoradiotherapy provides significantly improved progression-free and overall survival compared to radiotherapy alone for locally advanced disease based on a landmark randomized trial. Brachytherapy may be used as a boost for early-stage tumors following external beam radiotherapy.
Three clinical trials comparing different treatments for oropharynx and larynx cancer were summarized:
1. RTOG 9003 found that hyperfractionated RT showed significantly improved OS and LRC compared to standard fractionation for advanced cancers. Acute toxicities were similar between arms.
2. GORTEC 9902 and the study by Brizel et al. found CCRT with altered fractionation like hyperfractionation or accelerated fractionation improved outcomes over RT alone.
3. RTOG 9501 and EORTC 22931 showed that for cancers with high-risk features, adjuvant chemoRT with cisplatin improved locoregional control and DFS compared to RT alone, with
This document discusses the management of oropharyngeal cancer. It begins by stating the goals of treatment are functional organ preservation and minimizing treatment-induced morbidity while maintaining cure rates. For early stage disease, single modality radiotherapy or surgery is usually sufficient. For advanced stages, surgery plus radiation or chemoradiation are recommended based on risk factors. It then discusses treatment options and outcomes for different subsites within the oropharynx and the benefits of adjuvant therapy or altered fractionation schedules for radiotherapy.
This document discusses total neoadjuvant therapy (TNT) for rectal cancer. It summarizes evidence from trials showing that TNT with chemotherapy prior to chemoradiation and surgery improves pathologic complete response rates and reduces distant metastases compared to adjuvant chemotherapy. The document also reviews the experience with TNT at the author's institution, including a clinical complete response rate of 36% and a pathologic complete response rate of 15.6% among surgery patients. Non-operative management strategies with a watch-and-wait approach are also discussed.
This document discusses the management of Wilms tumor and the role of radiotherapy. It covers the epidemiology, molecular biology, clinical presentation, diagnostic workup, staging, pathology, treatment options according to NWTS and SIOP protocols, and long-term treatment outcomes from NWTS trials. Radiotherapy techniques for flank irradiation, whole abdominal irradiation, whole lung irradiation, and conformal planning are also described.
Role of radiotherapy and chemotherapy in oral cavity cancerDr.Rashmi Yadav
Radiotherapy and chemotherapy play important roles in the treatment of oral cavity cancer alongside surgery. Radiotherapy is often used as the primary treatment for early stage cancers or as an adjuvant treatment with surgery for more advanced cancers. Chemotherapy is commonly used neoadjuvantly or concurrently with radiotherapy to improve treatment outcomes, especially for advanced cancers. Brachytherapy can also be used as a radiation boost for early stage oral cavity cancers. The goals of treatment are maximizing local tumor control while preserving function and minimizing side effects through a multidisciplinary approach.
The document discusses organ preservation using radiation therapy techniques like brachytherapy. It provides examples of various cancers where brachytherapy can be used to preserve organs like penis, breast, bone, soft tissue sarcomas, anal canal, tongue and others. Brachytherapy provides conformal dose distribution allowing dose escalation to tumor and sparing of adjacent normal tissues, thus helping organ preservation and improved quality of life for patients. Expertise is required for brachytherapy planning and procedures to achieve optimal outcomes of local tumor control and organ preservation.
1) The document discusses optimal practice in radiation treatment for head and neck cancer in the 21st century, focusing on balancing treatment targets and sparing normal tissues using available technology and expertise.
2) It reviews treatment options and approaches for different stages of head and neck cancer, highlighting evidence that altered fractionation and chemoradiation can improve outcomes over standard radiation alone.
3) Challenges of implementing intensity-modulated radiation therapy (IMRT) for head and neck cancer are discussed, as well as examples of how IMRT can improve target coverage and tissue sparing compared to conventional techniques.
This document discusses hypofractionation in the treatment of head and neck cancers. It begins by outlining outcomes for different stages of disease, then discusses how fraction size, total dose, and treatment time impact treatment. Hypofractionation can counter tumor repopulation and improve local control. Studies show hypofractionation is effective for early disease, palliative cases, and can be safely delivered using simultaneous integrated boost with IMRT. Severe toxicity is low while disease control remains high. Extreme hypofractionation with SBRT also provides good local control with acceptable toxicity.
Radiation Therapy in the Management of Lung Cancerflasco_org
This document discusses modern radiation therapy techniques for lung cancer, focusing on non-small cell lung cancer (NSCLC). It summarizes that stereotactic ablative radiotherapy (SABR) is now the standard of care for inoperable stage I NSCLC, providing local control and survival rates comparable or superior to surgery with less toxicity. For stage III NSCLC, concurrent chemotherapy and radiation improves survival compared to sequential treatment, though local control remains challenging and toxicities can be significant. Ongoing studies are exploring dose escalation using intensity-modulated radiation therapy (IMRT) and proton therapy to improve outcomes while reducing normal tissue damage.
This document summarizes the use of radiotherapy in early breast cancer treatment. It discusses how breast-conserving therapy with radiotherapy is as effective as mastectomy, and how radiotherapy reduces local recurrence when used as part of breast-conserving surgery for ductal carcinoma in situ. It also describes different radiotherapy techniques for early invasive breast cancer including whole breast irradiation, tumor bed boosts, and accelerated partial breast irradiation.
This document discusses the management of carcinoma of the esophagus. It begins by outlining treatment approaches for localized versus metastatic disease, including definitive and palliative therapies. It then reviews the evolution of esophageal cancer treatment, including non-surgical approaches using radiation therapy alone or combined modality therapy, as well as surgical treatments. Several studies evaluating different treatment regimens are summarized, including the benefits of concurrent chemoradiation therapy over radiation alone. The role of preoperative chemoradiation is discussed. Techniques for radiation therapy delivery are also outlined. The document concludes by discussing palliative care approaches for esophageal cancer patients.
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses clinical issues related to IMRT planning for head and neck cancer. It summarizes guidelines for delineating the gross tumor volume (GTV) using PET, CT, and MRI imaging as well as clinical examination. It also provides recommendations for outlining nodal GTVs and clinical target volumes (CTVs). Additionally, it addresses dose escalation strategies and techniques for sparing organs at risk like the larynx when treating the low neck region.
This document discusses penile conservation for squamous cell carcinoma of the penis. It provides evidence that radiotherapy can successfully preserve the penis in over 50% of cases, with 5-year survival rates comparable to surgery. Brachytherapy is highlighted as an effective non-surgical approach, allowing for homogenous dose distribution and sparing of surrounding tissue. Complications are mostly mild to moderate, with urethral stenosis occurring in under 15% of cases. With close follow-up, radiotherapy can offer local control and penile preservation similar to surgery while maintaining patient quality of life and sexuality.
Treatment of Advanced stage of Carcinoma Cervix & Ca cervix in Pregnancy.pptxMuthuRamanK3
1. Treatment of advanced stage of carcinoma cervix: Radiotherapy (including brachytherapy, teletherapy and adjuvant radiotherapy), Chemotherapy and Chemoradiotherapy;
2. Ca Cervix in Pregnancy: Includes flowchart for screening and management
This document summarizes recent advances in the management of high grade gliomas. It discusses current guidelines for radiotherapy treatment planning including target volume delineation. It describes the use of concurrent and adjuvant temozolomide with radiation. Response assessment is based on RANO criteria. Advances discussed include the prognostic value of methylation status and results of trials investigating dose-dense chemotherapy schedules and radiosurgery. MRS is shown to help delineate tumor volumes beyond what is seen on standard MRI alone.
1) There are multiple options for adjuvant and perioperative treatment of resectable gastric cancer according to different guidelines.
2) Adjuvant chemotherapy is supported by evidence from trials like INT-0116 and CALGB 80101, while adjuvant chemoradiotherapy has evidence from the Macdonald trial for less than D2 surgery.
3) Perioperative chemotherapy has level 1 evidence from trials like MAGIC, FNCLCC, and FLOT4 showing improved survival compared to surgery alone. Regimens include ECF/ECX, PF, and FLOT.
ROLE OF RADIOTHERAPY AND CHEMOTHERAPY IN CARCINOMA LARYNX1 (1).pptxBrijesh Maheshwari
This document discusses the role of radiotherapy and chemotherapy in treating carcinoma of the larynx. It covers staging of the disease, workup, treatment algorithms, dose prescriptions and management for different stages. Early glottic carcinoma is typically treated with radiotherapy to preserve the voice. Advanced stages may require total laryngectomy with adjuvant chemoradiation. Intensity modulated radiotherapy can help spare nearby organs at risk. Concurrent chemoradiation with cisplatin improves outcomes for advanced stages. Close follow up is needed after treatment to monitor for recurrence.
This document discusses various clinical trials related to stomach cancer treatment. It summarizes that:
1) The D2 dissection surgery showed better local control and reduced gastric cancer deaths compared to D1 dissection.
2) Perioperative chemotherapy was found to be better than surgery alone in reducing tumor size and death rates based on the MAGIC trial.
3) The FLOT regimen showed improved survival over ECF/ECX as perioperative chemotherapy in locally advanced gastric cancer.
4) Postoperative chemotherapy provides a survival benefit compared to surgery alone based on meta-analysis results. The CLASSIC trial also showed improved outcomes with adjuvant capecitabine and oxaliplatin.
The document discusses the anatomy and histology of the endometrium, the lining of the uterus. It then covers endometrial cancer, including risk factors, common presentations, workup involving endometrial biopsy and imaging, and staging. Treatment is discussed for each stage, with surgery being primary treatment and adjuvant therapy depending on grade, myometrial invasion, and other pathological factors. Sentinel lymph node biopsy and recent advances are also mentioned.
This document discusses total neoadjuvant therapy (TNT) for rectal cancer. It summarizes evidence from trials showing that TNT with chemotherapy prior to chemoradiation and surgery improves pathologic complete response rates and reduces distant metastases compared to adjuvant chemotherapy. The document also reviews the experience with TNT at the author's institution, including a clinical complete response rate of 36% and a pathologic complete response rate of 15.6% among surgery patients. Non-operative management strategies with a watch-and-wait approach are also discussed.
This document discusses the management of Wilms tumor and the role of radiotherapy. It covers the epidemiology, molecular biology, clinical presentation, diagnostic workup, staging, pathology, treatment options according to NWTS and SIOP protocols, and long-term treatment outcomes from NWTS trials. Radiotherapy techniques for flank irradiation, whole abdominal irradiation, whole lung irradiation, and conformal planning are also described.
Role of radiotherapy and chemotherapy in oral cavity cancerDr.Rashmi Yadav
Radiotherapy and chemotherapy play important roles in the treatment of oral cavity cancer alongside surgery. Radiotherapy is often used as the primary treatment for early stage cancers or as an adjuvant treatment with surgery for more advanced cancers. Chemotherapy is commonly used neoadjuvantly or concurrently with radiotherapy to improve treatment outcomes, especially for advanced cancers. Brachytherapy can also be used as a radiation boost for early stage oral cavity cancers. The goals of treatment are maximizing local tumor control while preserving function and minimizing side effects through a multidisciplinary approach.
The document discusses organ preservation using radiation therapy techniques like brachytherapy. It provides examples of various cancers where brachytherapy can be used to preserve organs like penis, breast, bone, soft tissue sarcomas, anal canal, tongue and others. Brachytherapy provides conformal dose distribution allowing dose escalation to tumor and sparing of adjacent normal tissues, thus helping organ preservation and improved quality of life for patients. Expertise is required for brachytherapy planning and procedures to achieve optimal outcomes of local tumor control and organ preservation.
1) The document discusses optimal practice in radiation treatment for head and neck cancer in the 21st century, focusing on balancing treatment targets and sparing normal tissues using available technology and expertise.
2) It reviews treatment options and approaches for different stages of head and neck cancer, highlighting evidence that altered fractionation and chemoradiation can improve outcomes over standard radiation alone.
3) Challenges of implementing intensity-modulated radiation therapy (IMRT) for head and neck cancer are discussed, as well as examples of how IMRT can improve target coverage and tissue sparing compared to conventional techniques.
This document discusses hypofractionation in the treatment of head and neck cancers. It begins by outlining outcomes for different stages of disease, then discusses how fraction size, total dose, and treatment time impact treatment. Hypofractionation can counter tumor repopulation and improve local control. Studies show hypofractionation is effective for early disease, palliative cases, and can be safely delivered using simultaneous integrated boost with IMRT. Severe toxicity is low while disease control remains high. Extreme hypofractionation with SBRT also provides good local control with acceptable toxicity.
Radiation Therapy in the Management of Lung Cancerflasco_org
This document discusses modern radiation therapy techniques for lung cancer, focusing on non-small cell lung cancer (NSCLC). It summarizes that stereotactic ablative radiotherapy (SABR) is now the standard of care for inoperable stage I NSCLC, providing local control and survival rates comparable or superior to surgery with less toxicity. For stage III NSCLC, concurrent chemotherapy and radiation improves survival compared to sequential treatment, though local control remains challenging and toxicities can be significant. Ongoing studies are exploring dose escalation using intensity-modulated radiation therapy (IMRT) and proton therapy to improve outcomes while reducing normal tissue damage.
This document summarizes the use of radiotherapy in early breast cancer treatment. It discusses how breast-conserving therapy with radiotherapy is as effective as mastectomy, and how radiotherapy reduces local recurrence when used as part of breast-conserving surgery for ductal carcinoma in situ. It also describes different radiotherapy techniques for early invasive breast cancer including whole breast irradiation, tumor bed boosts, and accelerated partial breast irradiation.
This document discusses the management of carcinoma of the esophagus. It begins by outlining treatment approaches for localized versus metastatic disease, including definitive and palliative therapies. It then reviews the evolution of esophageal cancer treatment, including non-surgical approaches using radiation therapy alone or combined modality therapy, as well as surgical treatments. Several studies evaluating different treatment regimens are summarized, including the benefits of concurrent chemoradiation therapy over radiation alone. The role of preoperative chemoradiation is discussed. Techniques for radiation therapy delivery are also outlined. The document concludes by discussing palliative care approaches for esophageal cancer patients.
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses clinical issues related to IMRT planning for head and neck cancer. It summarizes guidelines for delineating the gross tumor volume (GTV) using PET, CT, and MRI imaging as well as clinical examination. It also provides recommendations for outlining nodal GTVs and clinical target volumes (CTVs). Additionally, it addresses dose escalation strategies and techniques for sparing organs at risk like the larynx when treating the low neck region.
This document discusses penile conservation for squamous cell carcinoma of the penis. It provides evidence that radiotherapy can successfully preserve the penis in over 50% of cases, with 5-year survival rates comparable to surgery. Brachytherapy is highlighted as an effective non-surgical approach, allowing for homogenous dose distribution and sparing of surrounding tissue. Complications are mostly mild to moderate, with urethral stenosis occurring in under 15% of cases. With close follow-up, radiotherapy can offer local control and penile preservation similar to surgery while maintaining patient quality of life and sexuality.
Treatment of Advanced stage of Carcinoma Cervix & Ca cervix in Pregnancy.pptxMuthuRamanK3
1. Treatment of advanced stage of carcinoma cervix: Radiotherapy (including brachytherapy, teletherapy and adjuvant radiotherapy), Chemotherapy and Chemoradiotherapy;
2. Ca Cervix in Pregnancy: Includes flowchart for screening and management
This document summarizes recent advances in the management of high grade gliomas. It discusses current guidelines for radiotherapy treatment planning including target volume delineation. It describes the use of concurrent and adjuvant temozolomide with radiation. Response assessment is based on RANO criteria. Advances discussed include the prognostic value of methylation status and results of trials investigating dose-dense chemotherapy schedules and radiosurgery. MRS is shown to help delineate tumor volumes beyond what is seen on standard MRI alone.
1) There are multiple options for adjuvant and perioperative treatment of resectable gastric cancer according to different guidelines.
2) Adjuvant chemotherapy is supported by evidence from trials like INT-0116 and CALGB 80101, while adjuvant chemoradiotherapy has evidence from the Macdonald trial for less than D2 surgery.
3) Perioperative chemotherapy has level 1 evidence from trials like MAGIC, FNCLCC, and FLOT4 showing improved survival compared to surgery alone. Regimens include ECF/ECX, PF, and FLOT.
ROLE OF RADIOTHERAPY AND CHEMOTHERAPY IN CARCINOMA LARYNX1 (1).pptxBrijesh Maheshwari
This document discusses the role of radiotherapy and chemotherapy in treating carcinoma of the larynx. It covers staging of the disease, workup, treatment algorithms, dose prescriptions and management for different stages. Early glottic carcinoma is typically treated with radiotherapy to preserve the voice. Advanced stages may require total laryngectomy with adjuvant chemoradiation. Intensity modulated radiotherapy can help spare nearby organs at risk. Concurrent chemoradiation with cisplatin improves outcomes for advanced stages. Close follow up is needed after treatment to monitor for recurrence.
This document discusses various clinical trials related to stomach cancer treatment. It summarizes that:
1) The D2 dissection surgery showed better local control and reduced gastric cancer deaths compared to D1 dissection.
2) Perioperative chemotherapy was found to be better than surgery alone in reducing tumor size and death rates based on the MAGIC trial.
3) The FLOT regimen showed improved survival over ECF/ECX as perioperative chemotherapy in locally advanced gastric cancer.
4) Postoperative chemotherapy provides a survival benefit compared to surgery alone based on meta-analysis results. The CLASSIC trial also showed improved outcomes with adjuvant capecitabine and oxaliplatin.
The document discusses the anatomy and histology of the endometrium, the lining of the uterus. It then covers endometrial cancer, including risk factors, common presentations, workup involving endometrial biopsy and imaging, and staging. Treatment is discussed for each stage, with surgery being primary treatment and adjuvant therapy depending on grade, myometrial invasion, and other pathological factors. Sentinel lymph node biopsy and recent advances are also mentioned.
1) A cell survival curve shows the relationship between the proportion of cells surviving and the radiation dose or dose of a cell-killing agent. It is used to assess the biological effectiveness of radiation.
2) Radiation can kill cells through direct damage, free radical injury, apoptosis, mitotic death, bystander effects, autophagy, and senescence. The mechanism of cell death influences whether the survival curve is linear or has a shoulder.
3) Factors that influence the cell survival curve include linear energy transfer (LET), cell cycle stage, intrinsic radiosensitivity, genetic factors, and fractionation of radiation doses. Higher LET radiation and apoptosis result in a more linear curve, while lower LET
Hyperthermia involves heating tumor tissue above normal body temperature to damage and kill cancer cells. It has been used experimentally for thousands of years to treat tumors. Effects are due to protein damage within cells. Hyperthermia can enhance the effects of radiation therapy by making tumor cells more sensitive. Temperature and exposure time determine cell death in a predictable way. Factors like pH, oxygen levels, and cell cycle stage influence response. Temperature is monitored and thermal dose is calculated to determine treatment effectiveness. Hyperthermia shows promise for improving cancer treatments when combined with other therapies.
The document discusses the anatomy, histology, staging, and workup of esophageal cancer. It describes the esophagus as a hollow muscular tube connecting the pharynx to the stomach. Esophageal cancer most often presents with dysphagia and can spread through lymphatic channels or directly invade nearby structures. Staging involves endoscopy, endoscopic ultrasound, CT, and PET scans to determine the depth of invasion and presence of metastases.
This document summarizes the anatomy, pathology, and epidemiology of breast cancer. It discusses the embryology, gross anatomy, histology, and molecular classification of the breast. It also describes the epidemiology of breast cancer, noting key risk factors like family history, age, reproductive history, hormone exposure, radiation exposure, BMI, physical activity, and diet. Screening and management of breast cancer is available at various levels of healthcare centers in India.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
2. SYNOPSIS
1. MANAGEMENT GOAL
2. OUTLINE
3. RADIOTHERAPY
4. CHEMOTHERAPY
5. SURGERY
6. COMPLICATIONS
24/08/2022 2
PRAGATHEESWARI G K , MMC
3. Management Goal
• Oropharynx is a site involved in speech, swallowing,
airway conduit
• Maximize survival while minimizing morbidity
24/08/2022 3
PRAGATHEESWARI G K , MMC
4. OROPHARYNX
• In recent years occurs most frequently in young
patients, non smokers, non alcoholic
• Due to HPV infection,
• The crypts in tonsil favours the infection, proliferation of
HPV
• The incidence of HPV associated OP ca increased by
about 220%.
• There is variation in incidence, pattern of disease,
staging, prognosis in hpv,
• As of now no major difference in management
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PRAGATHEESWARI G K , MMC
8. Definitive RT
• Early stage- single modality
• locally advanced – CCRT
Adjuvant RT
• Early stage – if margin +ve, ENE +ve
• Locally advanced stage - all cases
Palliative RT
24/08/2022 8
PRAGATHEESWARI G K , MMC
9. RT
• EBRT
• 2D
• conformal
• IMRT - parotid sparing (preferred)
• BRACHYTHERAPY (as a boost)
24/08/2022 9
PRAGATHEESWARI G K , MMC
10. DEFINITVE RT
• RT alone
• Is indicated only in
1. early T1 T2, NO , N1
2. in case of HPV N1(N1 -,3cm single node in HPV +)
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11. • Now advanced procedures
like trans oral techniques
available , but why RT ?
• The OS is equal in robotic
surgery and RT ,
• Complicaton were less in RT
• perment PEG feeding
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12. PRESCRIPTION
1. MODALITY - 2D/ 3D
/IMRT
• IMRT - reduces
incidence of acute and
late xerostomia
significantly
• NO survival benefit
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13. TIME DOSE AND FRACTIONATION
• Conventional - 66-70 Gy given as 2Gy /# - 5days /week
• Altered fractionation have been tried in OPC
• what are they ?
1. Hyper fractionation
2. Accelerated fractionation
3. Accelerated hyper fractionation
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14. Hyper fractionated RT
• HFX - twice daily fractions of small dose per fraction
given,
• EORTC 22791
• Here the total dose is more than the conventional dose
• 80.5 Gy HFX at 1.15Gy twice daily
• Result - 5yr LRC improved (59vs 40)
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15. ACCELERATED RT
• Acceleration - given for 6 days in a week
• DAHANCA 6&7 Trail
• here total dose not reduced
• 66-70 Gy in 2Gy/fraction 6 days a week
RESULT
• Loco regional control improved (42 vs30 %)
• LC for both p16+ & p16-
• late toxicities were similar in both arm
• acute toxicities high in accelerated arm
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17. Comparing all
• All altered fractionation
showed benefits than
conventional ,which is
better?
• Rtog 9003 , LAHNC
• Hyper fractionation
improved os
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18. Volume - definitive RT
• Radical RT alone is given for early lesions
• Here , the target volume is primary with clearance
• Along with unilateral neck is irradiated. Level II - IV
• perez - level II to IV
• Nancy lee - level II to IV , RP node
• B/L -
• in case of tonsil tumors when base of tongue, floor of mouth
involved.
• Other tumors near/ involving midline
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19. RT - LAHNC
• In LA cases, Concurrent chemo radiation is given
• but when chemo deferred when RT alone is given
for LA caseS
• RT - 66gy - 70 Gy 2G/# for 5 days in week
• IMRT is preferred
• Hyper fractionation without reducing total dose
shows benefit than conventional RT alone in LAHNC,
with added toxicity - meta analysis - bourhis et al
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20. RT IN CCRT
• in locally advanced cancer - is RT alone not sufficient ?
• why to give CCRT ?
• GORTEC - 94 -01
• CCRT Improved LRC / OS than RT alone.
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21. • Conventional fraction
with 3w chemo is better
than split course RT
• CCRT - conventional RT is
better
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22. RT in CCRT
• Volume - tumor + clearance
• Neck - B/L level II - IV,RP node
• Level IB - when node is + or large II node , that cannot
rule out involvement of level IB , tumor extension into
oral cavity
• Level V - positive node , large matted Level IV
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26. RT - BOOST TECHIQUES
IMRT with SIB
● Conventional 2gy or 1.8 Gy /# to whole field
● Boost to gross disease - added gy/# ,dose painting
● Derived in a single fraction
● RTOG 00-22
● T1,2 N0,1
● PFS, 2yr OS benefits, particularly in patients with HPV + disease
Concomitant boost -
● Boost to gross disease - 1.5 gy/# ,
● Derived in a second daily fraction
Sequential boost
● conventional RT 60 gy to whole field f/b 6 gy to gross disease in second phase.
26
28. 1. Hfx RT vs CCRT (chemo - 5fu +CDDP) - BRIZEL et al
2. HFX RT vs CCRT ( low dose CDDP) - Brainslev et al
3. HFX vs Chemo HFX - RTOG 95-06
4. ccrt vs accelerated CCRT vs Accelerated RT alone (GORTEC
99-02)
28
29. ● Acceleration / hyperfractionation of RT cannot
compensate for absence of chemotherapy
29
30. RT - ADJUVANT RT
• INDICATIONS
1.early stage - presence of adverse features
• adverse features -
• margin positive </= 1mm , (re resection if possible )
• close margin 2 to 5 mm
• PNI +
• LVSI+
• Nodes in level IV &V
• ENE +
2.advanced stage - T3,T4a, N2,N3
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31. VOLUME
• Bilateral neck and primary tumor site
• Completely resected margin neg, N+ --- can
also direct therapy only to neck
• margin positive, RND - N0 ----- direct
treatment for primary resection bed only is
tried
• Well lateralised tumors---- PORT to ipsilateral
neck only ,may be appropriate.
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32. Dose
• PORT -60 to 66Gy in 2Gy daily fractions to high risk
areas( primary tumor bed with positive margin or nodal
region with extra capsular spread) RTOG 95-01
• Microscopic involvement- 50 to 54 Gy/2Gy fractions
• IMRT is preferred
• RTOG 73-03, krammer et al
• PORT Vs preop rt
• LRC improved in PORT 70 vs 58 %
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33. REIRRADIATION OF LOCOREGIONALLY CONFINED
RECURRENT OR SECOND PRIMARY DISEASE
Indications
locoregionally confined recurrent disease
second primary disease
Locoregionally confined recurrent disease
Surgery recommended
• Following sx high risk pathology/ not surgical
candidates- second course full dose RT with CT- long
term survival 20 % pts
• High risk of normal tissue toxicity
20 % carotid rupture
15 % fatal toxicity
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34. • Prior RT should be more than 6 months
• Rare circumstances- reirradiation with IORT or brachy
considered
• ECOG- 0 to 1
• Incidence of myelopathy thought to increase after
cumulative BED of 120gy, but risk is increased with
large fraction size>/=2.5 gy/#
• Radiation volume should include only known
disease
• Prophylactic treatment of subclinical disease not
routinely recommended
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35. • Best outcomes- small tumors with no skin involvement
• Reirradiation dose
• Conventional fractionation
• Postop- 56 to 60 gy at 1.8- 2gy/#
• Definitive- 66 to 70 gy at 1.8-2 gy/#
• Accelerated fractionation
• 60-70gy at 1.2- 1.5 gy/# twice daily
• Careful pt selection needed if SBRT used for
reirradiation
• SBRT- 35 to 44gy using 5 #
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36. RT -PALLIATIVE RT
INDICATIONS
• advanced cancer with no curative intent
• widely metastatic disease
Use
• relief of symptoms
RT regimen
• 50 gy in 20 #
• 37.5 gy in 15#( if well tolerated , upto 50 gy)
• 30 gy in 10#
• 30gy in 5 # - 2 # per week with >/= 3 days between #s
• 44.4gy in 12 #, in 3 cycles( for each cycle, give 2 # 6 hrs
apart for 2 days in a row, and treatments must exclude the
spinal cord after 2nd cycle)
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37. WORK FLOW
Diagnosis & staging
Policy - tumor board concurrence
Simulation - send via LAN
Image registration - importing , fusion of diagnostic /
pre op images
Image segmentation - contouring
Planning
Plan verification
Execution
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47. 1. Done at 3-4 weeks interval from chemoRT completion
2. Tracheostomy placed to prevent from edema or
bleeding
3. Techniques
- loop technique
- gold button single strand technique
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48. 4. Loop technique- similar to oral tongue
5.Initial extent of tumor prior to chemo+ residual at the
time of implant taken into account+ margin of approx.
1cm added
6.Not to implant catheter within 5mm of epiglottis, lateral
pharyngeal wall, or mandible
7.Loop technique not generally used for HDR because the
remote afterloading source may have difficulty in
navigating the loop
8.The gold button single stranded technique- used in
LDR/HDR
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51. CHEMO IN CCRT
• CCRT > RT
• Drug - cisplatin
• Dose - high - 100mg /m2
• Time- 3 weekly . days 1,22,43
• category 1 - NCCN
• Adelstein et al, intergroup trial , -
• improved overal survival,DFS
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52. • CDDP - cis -diammine dichloro platinum
• pre requisite - cc >60ml/min
• it is available as a powder form
• mixed using distilled water
• pre medication - anti emesis
• pre hydration
• cddp in 500ml NS over 2- 4 hours
• after hydration
• When only one drug is used, theMACH-NC indicates that the impact is
largest with a platin, - cisplatin .
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53. ALT. REGIMEN
• Drug - carboplatin, infusional 5FU
• 3cycles , 3 weekly
• category 1 - Gortec 94-01
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54. WEEKLY CISPLATIN
• Category 2A
• 40mg/m2
• phase 2 study - tried along with concomittant boost RT,
• radiosensitisizing effect
• Ja medina et al
• beckman et al
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55. combination regimen ?? - CCRT
• Platin + 5FU offered no clear advantage over cisplatin
alone
• MACHC , E1392 study
• 3weekly high dose single agent cisplatin regimen is
widely accepted and standard
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56. INDUCTION CHEMOTHERAPY
• induction chemo f/b RT is inferior than CCRT :MACH -
NC
• induction chemo f/b CCRT , doesn’t show any survival
advantage - PARADIGM trial
• if at all given TPF is the preferred regimen -
• TAXANE , PLATINUM, FU - DECIDE trial, tax 323
• as of now no role of induction chemotherapy in
oropharynx cancer
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57. MACH - NC
• CCRT >> RT , how much ?
• ans -- 6.5% at 5yrs.
• drug - single agent , high dose cisplatin.
• CCRT >> IC f/b RT, RT f/b adj CT
• inverse relation between age and
impact of CT, no benefit after 70 years
of age
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58. chemo - adjuvant ,
• Adjuvant CHEMO RT > Adj.RT alone
• Indications
• ENE +/- margin positivity
• drug -weekly cisplatin 40 mg / m2 (bachaud et al)
• cisplatin in eligible - docetaxel + cetuximab (cooper et l)
• trials - intergroup 0034, RTOG 9501,EORTC 22931
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59. Chemotherapy - RECURRENT/
REFRACTORY /METASTATIC
• IN combination with RT - carboplatin
• with no surgery or RT as option
• Targeted agents + chemotherapy
• meteronomic chemotherapy
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60. Meteronomic chemotherapy
• daily / frequent administration / with no interval
• 1/10 th to 1/3 rd of maximum tolerated dose of drug
• based mainly on anti - angiogenic property of the drug
• most often used are
• Methotrexate,capecitabine,cetuximab,gefinitinib,
• cyclophosphamide, etoposide
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61. Targeted Agents - Definitive treatment
• cetuximab - EGFR inhibitor
• RT alone vs RT +cetuximab
• showed imprved LRC
• Trial - bonner et al ,
• category 2B in definitive / post op setting
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62. Adding cetuximab to CCRT - RTOG 0522
arm A
• cetuximab + cisplatin RT
• toxicity more
• 3 yr OS - 72.9%
• here HPV positive has
better PFS than neg
• 72.8% vs 49.2%
arm B
• cisplatin RT
• 3yr os - 75 .8%
Adding CETUXIMAB to RT CDDP did not improve outcome - should not be prescribed
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63. • considering the fact that HPV positive
cancers has better response to Cetuximab
and
• cetuximab + RT > RT
• whether we can use cetuximab + RT
rather than Cisplatin + RT is studied, there
by we can reduce the toxicity associated
with cisplatin - De ESCAL aTE trial
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64. De - ESCALaTE trial
• low risk ( non smokers, <10 PY) HPV positive oropharynx
ca patients
• RT 70 Gy + CDDP vs RT + cetuximab
• primary outcome - toxicity
• no difference in acute and late toxicity.
• 2yr OS better with CDDP 97.5 % vs 89.4%
• so - when they are eligible for CDDP , CDDP + RT is
preffered in Low risk HPV + oropharyngeal patients.
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65. Targeted agents - recurrent and
metastatic disease
• not amenable for surgery and RT
• category 1 recommendation :
• first line - Pembrolizumab /CDDP or Carboplatin / 5FU
• second line - nivilomumab / pembrolizumab (if disease
progress on or after platinum , not used previously )
• Pembrolizumab - for tumor that express PDL - 1
(keynote - 012)
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67. SURGERY
• When it is operable- operate
• En bloc removal –primary with adequate margin
• Drainage is also addressed
• I/L ND --Well lateralised tonsillar tumors , not involving base
of tongue, floor of mouth and N0
• Tumors in the base of tongue , pharyngeal wall, soft palate
require consideration of B/L ND
• Midline tumors , N2c , N3b B/L ND,
• Vital function loss is the limitation – larynx, soft palate
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68. TONSIL
PROCEDURE:
●
Small lesions less than 1cm confined to anterior pillar - WIDE LOCAL
EXCISION
• Tumors involving the palatine tonsil - RADICAL TONSILLECTOMY
• Tonsil, tonsil at fossa, pillars, portion of soft palate , tongue and mandible -
COMPOSITE RESECTION
APPROACH:
• Trans oral approach
• Mandibulectomy - midline or partial
COMPLICATION:
• Impaired swallowing, fistula, flap failure, poor wound healing, and aspiration
occasionally leading to laryngectomy
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71. BASE OF TONGUE
PROCEDURE DONE :
● Large midline tumors – total glossectomy
● Well lateralised/ polypoidal lesions- PARTIAL GLOSSECTOMY
● Close to laryngeal apparatus which arise from the vallecula - SUPRAGLOTTIC
OR TOTAL LARYNGECTOMY
APPROACH :
• Midline mandibulotomy by spilting the lip , mandible and oral tongue
• Lateral mandibulotomy - division of mandible near angle
• Floor drop -elevating inner periosteum of mandible from angle to angle
COMPLICATION :
• Infection, fistula, bleeding, tongue sensory deficits, dysphagia, exposed
hardware, poor wound healing, and cranial nerve injuries.
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72. SOFT PALATE
• Definitive RT is preferred even in early lesions
PROCEDURE:
• WIDE LOCAL EXCISION for tumors confined to the soft
palate
• COMPOSITE RESECTION
• Reconstructed with flaps or protheses to preserve
velopharyngeal competence
APPROACH:
• Transoral approach
• Mandibulectomy - midline or partial
COMPLICATION:
• Nasal speech and regurgitation of food into the
nasopharynx are sequelae of full-thickness soft
palate resection.
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73. TRANS ORAL SURGICAL APPROACH
• Alternative to open surgical procedures
• Quick recovery time
• Less morbidity
TRANS ORAL LASER SURGERY
• Stage 1 to 2 cancers - transoral laser
microsurgery ± neck dissection +adjuvant RT
/CRT
• ↑ locoregional contol-87 to 100 %
• local recurrence in stage 2 to 4 - 20 to 30 %
COMPLICATIONS
• Post op haemorrhage
• Temporary tracheostomy
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74. TRANS ORAL ROBOTIC SURGERY
Da Vinci surgical system
3 surgical instruments and binocular endopscope
controlled by robotic arms and inserted under direct or
endoscopic guidance by surgeon from patient side apparatus
• surgeon controls from a console
• operative environment-virtual 3D
• surgeon movement translated as micromovements of
instruments.
ADVANTAGES
• motion scaling
• increase precision
• reduce hand tremors and fatigue
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76. • Here are no prospective randomized studies supporting
the use of
• Robotic surgery (TORS) for oropharyngeal tumor
resection over conventional surgery.
• Until mature prospective multi-institutional series and
randomized data are available, the true utility of trans
oral laser microsurgery and TORS remains unknown.
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77. NECK DISSECTION
• U/L – Well lateralised tonsil lesions, with NO infiltration
into floor of mouth, base of tongue.
• B/L – midline lesions,N2c, N3b.
1. NO- SND Level 1B- IV
2. N1,N2 - SND , Comprehensive if level IV, V nodes
positive.
3. N3- Comprehensive ND
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78. Types
• Radical/comprehensive :
• The superficial and deep cervical fascia with its
• enclosed lymph nodes (levels I to V) were removed
in continuity with the sternocleidomastoid muscle,
the omohyoid muscle, the internal and external jugular
veins, cranial nerve XI, and the submandibular gland.
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79. MRND/SND
• SNDs are more limited and include removal of lymph
node levels that are at greatest risk for nodal metastatic
spread.
• The type of SND is denoted by the lymph node levels
removed (e.g., SND II to IV).
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80. Complications
• The more extensive the neck dissection, the higher the
risk of complications. Complications after neck dissection
include
• Hematoma; seroma; lymphedema; wound infections and
dehiscence; damage to the 7th, 10th, 11th, and 12th cranial
nerves; phrenic nerve injury; brachial plexus injury; chyle
leak; and vascular injury.
• The main long-term complication of neck dissection is
caused by injury to the spinal accessory nerve, which can
result in shoulder and neck pain, weakness, loss of
range of motion, and decreased shoulder-related quality
of life.
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82. LATE toxicities of CHEMO RT
• Dysphagia
• Trismus
• Xerostomia
• dental caries
• feeding tube dependence
• neuritis
• Fibrosis
• Osteoradionecrosis
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83. • the management goal - MAXIMIZE CURE , MINIMIZE
TOXICITY
• the more specific toxicities to treatment oropharynx
are
• TRISMUS, XEROSTOMIA, DYSPHAGIA
• trismus & dysphagia caused by disease , and treatment
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84. PREVENTION >> CURE
• Xerostomia- parotid sparing IMRT
• Trismus - mouth opening exercise from starting itself
• Dysphagia - PRV - pharyngeal constrictor muscles,
swallowing exercise from starting itself
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89. DYSPHAGIA
• Prevention - dose constraints to pharyngeal constrictors
in contouring
• Treatment
• Direct methods - swallowing exercises
• Supportive measures- RT feeds, PEG tube, FJ tube .
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90. PHARYNGEAL CONSTRICTORS
• Contouring - EORTC guidelines
• Thickness - 3mm
• From caudal tip of pterygoid plates to caudal edge of
arytenoids
• Anterior - superior: hamulus of pterygoid plate; mandibula;
base of tongue; pharyngeal lumen. Middle: base of tongue;
hyoid. Inferior: soft tissue of supraglottic/glottic larynx
• Posterior - prevertebral muscles
• Lateral - superior: medial pterygoid muscle. Middle: greater
horn of hyoid bone. Inferior: superior horn of thyroid cartilage
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92. SWALLOWING EXERCISE
• Complete the following swallowing exercises times a day.
• Effortful Swallow: Gather saliva in your mouth, then swallow as hard as you can.
squeezing your throat muscles. Repeat times.
• Tongue retraction hold: Pull your tongue back like to say the /k/ sound, hold it tight in
that position for 5 seconds. Repeat times.
• Masako: Stick your tongue out and hold it gently between your teeth or lips. Swallow
while holding your tongue out. Repeat times.
• Mendelsohn: Swallow your saliva, but halfway through the swallow, hold your Adam's
apple up using your neck muscles or you can use a finger. Hold it up for 1-3 seconds.
Repeat times.
• Chin Tuck Against Resistance (CTAR): Place a squishy ball or rolled-up towel under your
chin, pressing lightly against your throat. Push your chin down hard on the ball/towel
and hold for 60 seconds. Relax. Repeat x2. Then, press your chin down hard and hold
for 3 seconds, relax, repeat x30..
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93. • Shaker: Lay flat on your back, no pillow. Raise your head to
look at your toes, keep shoulders flat, hold for 60 seconds.
Relax for 60 seconds. Repeat x2, Then, raise your head for 3
seconds, relax. Repeat x30
• Yawn: Yawn and when you get into a big stretch, hold that
position for 5 seconds. Repeat times
• Supraglottic Maneuver: Gather saliva in your mouth. Take a
deep breath and hold your breath. Swallow while holding
your breath. Immediately after you swallow, cough. Practice
with saliva prior to food or liquid. Repeat times.
• Effortful Pitch Glide: Say "eee" in as low a pitch as possible
and then gradually raise the pitch of your voice until the
highest tone possible. Hold for 5 seconds in the highest
pitch. Repeat times.
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94. FOLLOW UP RECOMMENDATIONS- NCCN
• After post chemoRT or RT-clinical assessment in 4-8 weeks
• If there is response- assess disease extent by FDG-PET/CT at minimum
12 weeks or CT of primary and neck or MRI withg contrast at 8-12 wks
• FDG PET/CT
-Negative- observation
- equivocal- observation or repeat PET/CT at 3-6 months- follow up
- strongly positive- CT/ MRI with contrast- BX or resection of primary
if feasible and/or neck dissection if nodal disease present
• CT/ MRI
- positive- FDG PET/CT>/= 12 wks OR neck dissection
- negative- observation
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95. • No response- residual/ persistant/ progression
• Assess disease extent or distant mets- CT/ MRI with
contrast or FDG PET/CT
• Confirmed residual / persistant/ progression
-resectable- resection of primary/ neck – follow up
- unresectable- treat with second line
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96. • H&P exam-complete head and neck exam, and mirror
and fiberoptic examination
-year 1, every 1-3 months
-year 2, every 2-6 months
-year 3-5 every 4-8 months
->5yrs, every 12 months
• Imaging
• TSH every 6-12 months if neck irradiated
• Dental evaluation of sites exposed to RT
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97. POST TREATMENT MANAGEMENT AND
SURVEILLANCE- perez
• Radiographic complete response defined as non
enhancing, non necrotic nodal tissue <1.5cm- 100 %
long term disease control- no furthur treatment
needed
• Surveillance CT of primary does not add additional
information to physical/ fiberptic examination- not
routinely performed
• PET/CT more widely available and often used as sole
imaging modality following RT
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98. TAKE HOME MESSAGE
1. OROPHARYNYX CARCINOMA
2. upfront surgeries are difficult and morbid, TORS yet to develope in our
country
3. NO role for induction chemo/NACRT at present
4. SO the management - RT/ CCRT
5. RT - hyperfractionation can be tried, CONVENTIONAL PAROTID SPARING
IMRT ALONG WITH HIGH DOSE CDDP IS THE RECOMMENDED REGIMEN
NOW.
6. unless for well lateralised early tonsil ca, B/L neck is irradiated.
7. Though the epidemiology, staging, prognosis of HPV associated OPC are
different, the cause specific treatment is yet to come.
8. For Oropharynx cancer the toxicities which affects QOL patients - should be
kept in mind ,prevent and treated accordingly.
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99. REFERENCE
• PEREZ & BRADYS TEXTBOOK OF ONCOLOGY
• DEVITA TEXT BOOK OF ONCOLOGY
• NCCN GUIDELINES
• PUBMED
• LANCET
• the MED SLP 2022
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100. ACKNOWLEDGEMENT
• ASST PROF - Dr. DURGA PRASAD MD RT
• PROF - Dr. JEEVA MD RT
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