This document provides information on carcinoma of the anal canal, including its anatomy, risk factors, clinical features, staging, treatment options and outcomes. Some key points:
- The anal canal is 3-4 cm in length and lies between the rectum and perianal skin. Lymphatic drainage is to the inguinal, internal iliac and inferior mesenteric lymph nodes.
- Risk factors include HPV infection, immunosuppression, smoking and certain sexual practices. Symptoms are often non-specific but may include bleeding, pain, masses or discharge.
- Staging involves physical exam, biopsy, MRI and PET-CT. Treatment typically involves chemoradiation with 5-FU and
The document provides guidelines for contouring the clinical target volume (CTV) and organs at risk for carcinoma of the cervix treated with 3D conformal radiation therapy or intensity-modulated radiation therapy. The CTV includes the involved lymph nodes (GTV N) and relevant draining nodal groups. The CTV for the primary tumor (CTV-P) includes the gross tumor, uterus, cervix, parametrium, vagina, and ovaries. Detailed guidelines are provided for contouring the lymph node regions, uterus, vagina, and parametrium. A planning target volume (PTV) is created by adding a 10 mm margin to the total CTV. Additional margins are used to create an
Principles of radiotherapy in gastric carcinomaAnil Gupta
This document discusses principles of radiotherapy for gastric carcinoma. It summarizes that post-operative radiotherapy can reduce local recurrence rates after surgery for gastric cancer, although no survival benefit has been proven. Newer radiation techniques like IMRT and VMAT may further reduce doses to organs-at-risk compared to 3D conformal radiotherapy. Pre-operative radiotherapy can also improve resectability in some inoperable cases.
Contouring in breast cancer current practice and future directions Anil Gupta
Contouring guidelines for breast cancer radiation therapy aim to define target volumes to adequately treat while minimizing toxicity. The RTOG and ESTRO guidelines provide consensus on contouring clinical target volumes (CTVs) for the breast/chest wall, lymph nodes, and organs at risk. However, some recurrences occur outside these guidelines. A study mapping 243 nodal recurrences found most were within RTOG or ESTRO CTVs, but out-of-field recurrences were often in the lateral and posterior supraclavicular region, particularly for young, triple-negative patients. While contouring guidelines provide standardization, individualized risk assessment may be needed to optimize local control versus toxicity.
The document discusses adjuvant radiotherapy for locally advanced stomach cancers. It provides background on stomach cancer incidence and need for adjuvant therapy after surgery. Guidelines recommend adjuvant chemoradiation with 45Gy after surgery for advanced or node-positive disease. Target volumes include the stomach bed and regional lymph nodes. Organs at risk include kidneys, liver, lungs and spinal cord. Intensity modulated radiotherapy planning aims to meet dose constraints for targets and organs at risk.
1) The document discusses various techniques for radiation therapy treatment planning and delivery for breast cancer, including tangential field planning, supraclavicular field matching, electron boosts, and accelerated partial breast irradiation.
2) Techniques for accelerated partial breast irradiation discussed include multi-catheter interstitial brachytherapy, balloon-based brachytherapy using devices like Mammosite, and external beam radiation therapy.
3) Factors that determine suitability for accelerated partial breast irradiation include patient age, tumor size and characteristics, and nodal involvement. Dosage schedules and advantages and disadvantages of different techniques are also reviewed.
This slide explains the radiotherapy contouring guidelines for carcinoma esophagus. It has detailed explanations in a quite simple way, so that you need not go anywhere else for esophageal contouring guidelines.
Dr. Ashutosh Mukherji's document discusses contouring for rectal cancers. It provides guidelines for clinical target volume (CTV) delineation based on international consensus. The CTV should encompass the tumor, mesorectum, presacrum, and lymph node regions depending on tumor stage and location. Proper contouring is important for administering precise radiotherapy doses to treat rectal cancer while avoiding unnecessary radiation to healthy tissues.
This document discusses the use of intensity-modulated radiation therapy (IMRT) for cervical cancer. It addresses the challenges of IMRT including uterine and vault motion. IMRT is well-suited for post-operative cases, extended field radiation to cover para-aortic lymph nodes, dose escalation to lymph nodes through simultaneous integrated boost plans, and bone marrow sparing to reduce chemotherapy toxicity. The document reviews several studies demonstrating the dosimetric benefits of IMRT for reducing doses to organs at risk like the bowel, bladder, and rectum.
The document provides guidelines for contouring the clinical target volume (CTV) and organs at risk for carcinoma of the cervix treated with 3D conformal radiation therapy or intensity-modulated radiation therapy. The CTV includes the involved lymph nodes (GTV N) and relevant draining nodal groups. The CTV for the primary tumor (CTV-P) includes the gross tumor, uterus, cervix, parametrium, vagina, and ovaries. Detailed guidelines are provided for contouring the lymph node regions, uterus, vagina, and parametrium. A planning target volume (PTV) is created by adding a 10 mm margin to the total CTV. Additional margins are used to create an
Principles of radiotherapy in gastric carcinomaAnil Gupta
This document discusses principles of radiotherapy for gastric carcinoma. It summarizes that post-operative radiotherapy can reduce local recurrence rates after surgery for gastric cancer, although no survival benefit has been proven. Newer radiation techniques like IMRT and VMAT may further reduce doses to organs-at-risk compared to 3D conformal radiotherapy. Pre-operative radiotherapy can also improve resectability in some inoperable cases.
Contouring in breast cancer current practice and future directions Anil Gupta
Contouring guidelines for breast cancer radiation therapy aim to define target volumes to adequately treat while minimizing toxicity. The RTOG and ESTRO guidelines provide consensus on contouring clinical target volumes (CTVs) for the breast/chest wall, lymph nodes, and organs at risk. However, some recurrences occur outside these guidelines. A study mapping 243 nodal recurrences found most were within RTOG or ESTRO CTVs, but out-of-field recurrences were often in the lateral and posterior supraclavicular region, particularly for young, triple-negative patients. While contouring guidelines provide standardization, individualized risk assessment may be needed to optimize local control versus toxicity.
The document discusses adjuvant radiotherapy for locally advanced stomach cancers. It provides background on stomach cancer incidence and need for adjuvant therapy after surgery. Guidelines recommend adjuvant chemoradiation with 45Gy after surgery for advanced or node-positive disease. Target volumes include the stomach bed and regional lymph nodes. Organs at risk include kidneys, liver, lungs and spinal cord. Intensity modulated radiotherapy planning aims to meet dose constraints for targets and organs at risk.
1) The document discusses various techniques for radiation therapy treatment planning and delivery for breast cancer, including tangential field planning, supraclavicular field matching, electron boosts, and accelerated partial breast irradiation.
2) Techniques for accelerated partial breast irradiation discussed include multi-catheter interstitial brachytherapy, balloon-based brachytherapy using devices like Mammosite, and external beam radiation therapy.
3) Factors that determine suitability for accelerated partial breast irradiation include patient age, tumor size and characteristics, and nodal involvement. Dosage schedules and advantages and disadvantages of different techniques are also reviewed.
This slide explains the radiotherapy contouring guidelines for carcinoma esophagus. It has detailed explanations in a quite simple way, so that you need not go anywhere else for esophageal contouring guidelines.
Dr. Ashutosh Mukherji's document discusses contouring for rectal cancers. It provides guidelines for clinical target volume (CTV) delineation based on international consensus. The CTV should encompass the tumor, mesorectum, presacrum, and lymph node regions depending on tumor stage and location. Proper contouring is important for administering precise radiotherapy doses to treat rectal cancer while avoiding unnecessary radiation to healthy tissues.
This document discusses the use of intensity-modulated radiation therapy (IMRT) for cervical cancer. It addresses the challenges of IMRT including uterine and vault motion. IMRT is well-suited for post-operative cases, extended field radiation to cover para-aortic lymph nodes, dose escalation to lymph nodes through simultaneous integrated boost plans, and bone marrow sparing to reduce chemotherapy toxicity. The document reviews several studies demonstrating the dosimetric benefits of IMRT for reducing doses to organs at risk like the bowel, bladder, and rectum.
Radiotherapy is an important treatment option for penile carcinoma. It can be used as curative treatment for early stage tumors, as adjuvant treatment after surgery to reduce the risk of recurrence, and for palliation of advanced tumors. The main radiotherapy techniques are external beam radiotherapy and brachytherapy. Brachytherapy involves placing radioactive sources inside or next to the tumor and is often used for small early stage tumors, providing good tumor control rates and organ preservation. External beam radiotherapy uses external radiation beams and can treat larger tumors or be used as adjuvant therapy. Proper patient positioning and immobilization is important for both techniques to precisely target the tumor while sparing surrounding organs. Radiotherapy is generally well-tol
The CROSS trial found that neoadjuvant chemoradiotherapy followed by surgery significantly improved long-term overall and progression-free survival compared to surgery alone for patients with resectable esophageal or esophagogastric junction cancer. At a minimum follow-up of 5 years, median overall survival was 48.6 months for chemoradiotherapy plus surgery versus 24 months for surgery alone. Both squamous cell carcinoma and adenocarcinoma subtypes benefited. Neoadjuvant chemoradiotherapy using carboplatin and paclitaxel is now considered the standard of care for these patients.
1. Radiation techniques for treating esophageal cancer include EBRT using 3D-CRT, IMRT, or brachytherapy. IMRT allows for better sparing of organs at risk like the spinal cord, heart, and lungs compared to 3D-CRT.
2. For treatment planning, the gross tumor volume (GTV) and clinical target volume (CTV) must be accurately delineated using imaging like CT, PET, and endoscopy. The CTV includes margins around the GTV to account for microscopic disease.
3. Radiation fields typically cover 3-5cm above and below the tumor with a 2cm radial margin. Enlarged fields covering the whole esophagus
1. Radiation therapy plays an important role in the treatment of Wilms tumor, especially for advanced or high-risk cases.
2. It is used preoperatively, postoperatively, and for metastatic disease to reduce the risk of recurrence.
3. The indications and techniques for radiation therapy depend on factors like tumor stage, histology, response to chemotherapy, and whether metastases are present. Precise radiation treatment planning is required to effectively target tumors while sparing healthy tissues.
This document discusses the use of intensity-modulated radiation therapy (IMRT) for treating cervix cancer. It notes that IMRT is rarely used currently but could help reduce dose to normal tissues and potentially replace brachytherapy. The document outlines the need for accurate target volume definition using imaging like MRI and CT. It also describes the inverse planning process for IMRT and challenges like organ motion. While IMRT may help spare organs at risk, issues like increased leakage, integral dose and treatment time must be considered.
1) Radiation therapy has a questionable role in treating primary renal cell carcinoma (RCC) but is commonly used to palliatively treat brain and other metastatic lesions.
2) Stereotactic body radiation therapy (SBRT) enables high doses of radiation to tumors while sparing normal tissues and has shown promise for treating primary or metastatic RCC, with local control rates of 90-98% in studies.
3) While some studies found adjuvant radiation after surgery reduced local recurrence in advanced RCC, prospective randomized trials found no survival benefit and increased toxicity, so radiation is not routinely recommended after surgery.
Contouring Guidelines for Gynecological MalignancyJyotirup Goswami
A brief overview of gynecological malignancy contouring guidelines (teletherapy & brachytherapy), including a discussion of problems and inadequacies of the present guidelines
This document discusses external beam radiation therapy (EBRT) techniques for cervical cancer. It begins by introducing cervical cancer staging and the principles of EBRT management based on tumor stage. It then covers indications for pre-operative, post-operative and palliative EBRT. The document discusses various EBRT techniques including conventional, 3D-CRT, IMRT and IGRT. It provides details on treatment planning including patient positioning, simulation, field design and dose fractionation. Finally, it covers 3D-CRT planning and discusses the rationale and caveats of IMRT for cervical cancer treatment.
The panel discussion focused on target delineation in glioma. For low grade gliomas, the GTV includes the surgical cavity while the CTV expands 1 cm from the T2/FLAIR hyperintense area. For high grade gliomas, the GTV is the cavity plus enhancing tumor and the CTV expands 2 cm from the GTV while also including any FLAIR abnormalities. Proper trimming of the CTV is discussed to respect anatomical barriers like the ventricles, falx, optic apparatus, brainstem, and interthalamic area. OAR sparing is also emphasized to reduce treatment toxicity.
IORT uses a high single dose of radiation delivered during surgery to treat cancer remnants after tumor removal. It has two objectives: increase local tumor control and increase the ratio of tumor control to damage of nearby healthy tissues. IORT can be delivered via two methods - IOERT uses electron beams from a LINAC and IOHDR uses radioactive sources. Treatment planning requires a multidisciplinary team to determine applicator positioning and appropriate dose to maximize tumor coverage while minimizing radiation to other organs. IORT provides local tumor control comparable to conventional fractionated radiotherapy but with faster treatment time and less damage to surrounding tissues.
This document discusses the use of stereotactic body radiation therapy (SBRT) for liver tumors. It provides details on common liver tumors including hepatocellular carcinoma and metastases. It describes SBRT as a treatment option for inoperable early stage tumors, as a bridge to transplant, and for intermediate or locally advanced stages. Key factors for patient selection and treatment planning such as tumor size, number and location, as well as liver function are summarized. The document also briefly discusses proton beam therapy and current clinical trials investigating SBRT for liver cancer.
Axillary radiotherapy provides comparable regional control to axillary lymph node dissection for breast cancer patients with positive sentinel nodes, with fewer side effects. The AMAROS trial found similar 5-year axillary recurrence, disease-free survival, and overall survival between the radiotherapy and dissection groups. However, radiotherapy resulted in significantly less lymphedema. While control was excellent with both treatments, the trial was underpowered to definitively show non-inferiority due to lower-than-expected axillary recurrences.
1) The document discusses various radiation techniques for treating cancer of the esophagus including 2D, 3D conformal radiation therapy, IMRT, and IGRT.
2) It covers topics like target volume delineation, field design considerations for different esophageal subsites, and evolution from 2D to 3D treatment planning.
3) While there is no consensus, most contemporary trials use margins of 3-5cm cranially and caudally on the gross tumor with approximately a 2cm radial margin.
This document provides contouring guidelines for radiation treatment planning of carcinoma of the cervix. It outlines the key anatomical targets and organs at risk that must be delineated, including the gross tumor volume, clinical target volume for the primary tumor and lymph nodes, planning target volume, and organs like the bladder and bone marrow. It also discusses important aspects like bladder filling protocol, dose prescription for the tumor and nodes, use of intensity-modulated radiation therapy to spare organs at risk, and set up verification during treatment.
This document discusses various methods used to evaluate radiotherapy treatment plans, including physical and biological parameters. Physically, plans are evaluated using isodose curves, dose distribution statistics, differential and cumulative dose-volume histograms (DVHs). Target coverage should be within 95-100% of the prescribed dose. Biologically, tumor control probability (TCP) and normal tissue complication probability (NTCP) models are used. The therapeutic ratio and index compare the dose required for tumor control versus normal tissue complications. NTCP models include Lyman-Kutcher-Burman and critical element/volume models. Plan evaluation ensures target doses are adequate while respecting organ tolerance doses.
This document discusses radiotherapy planning and techniques for breast cancer treatment. It describes the iterative process of developing a treatment plan, which involves initial beam arrangement based on clinical experience, reviewing dose distributions, and modifying the plan based on parameters like isodose lines and dose-volume histograms. It also covers challenges like respiratory motion and setup uncertainties, and techniques to address these like deep inspiratory breath hold and respiratory gating. The goal is to deliver the prescribed radiation dose to the target while sparing surrounding healthy tissues as much as possible.
Radiotherapy is used as primary treatment for early-stage Hodgkin lymphoma or as part of combined modality treatment with chemotherapy. Historically, large mantle fields covering lymph node regions from the skull to the pelvis were used. More modern approaches use smaller involved field radiotherapy targeting only initially involved lymph node regions after chemotherapy based on imaging. Proper delineation of clinical target volumes requires pre-chemotherapy imaging ideally with PET/CT to define original disease extent.
This document outlines the key aspects of radiotherapy treatment planning for rectal cancer, including:
1) The epidemiology of rectal cancer, stages of disease, and patient positioning and immobilization techniques.
2) How to define the target volumes including the gross tumor, clinical target volume, and planning target volume based on disease stage and risk of lymph node involvement.
3) Typical three-field beam arrangements and doses of 45-50.4 Gy given in 1.8 Gy fractions for preoperative or postoperative radiotherapy, with additional boost doses sometimes used.
4) The acute and chronic complications of radiotherapy and dose constraints for organs at risk like the small bowel and bladder.
1) Carcinoma of the anal canal most commonly presents as squamous cell carcinoma. Risk factors include HPV infection, HIV/AIDS, immunosuppression, and a history of other anogenital cancers.
2) The standard of care is chemoradiotherapy with concurrent 5-FU and mitomycin C, based on trials showing improved local control over radiation alone. Surgery has a limited role and is reserved for salvage after failed chemoradiotherapy.
3) Bowen's disease, or anal intraepithelial neoplasia, is a precursor lesion caused by HPV that may progress to invasive squamous cell carcinoma in some cases. It is typically treated with local excision or ablative
This document discusses mesothelioma, a rare and aggressive cancer associated with asbestos exposure. It provides details on etiology, pathogenesis, clinical presentation, diagnosis, staging, and treatment options. Mesothelioma most commonly affects the pleura and has a median survival of 1 year without treatment. The standard of care is trimodality therapy with induction chemotherapy, followed by extensive pleurectomy/decortication surgery or pleurectomy/decortication, and then hemithorax radiation. Trimodality therapy results in a 5-year survival rate of 27.7 months, though patient selection is important. Ongoing research is evaluating novel targeted therapies and immunotherapy approaches to improve outcomes for this difficult to treat cancer
Radiotherapy is an important treatment option for penile carcinoma. It can be used as curative treatment for early stage tumors, as adjuvant treatment after surgery to reduce the risk of recurrence, and for palliation of advanced tumors. The main radiotherapy techniques are external beam radiotherapy and brachytherapy. Brachytherapy involves placing radioactive sources inside or next to the tumor and is often used for small early stage tumors, providing good tumor control rates and organ preservation. External beam radiotherapy uses external radiation beams and can treat larger tumors or be used as adjuvant therapy. Proper patient positioning and immobilization is important for both techniques to precisely target the tumor while sparing surrounding organs. Radiotherapy is generally well-tol
The CROSS trial found that neoadjuvant chemoradiotherapy followed by surgery significantly improved long-term overall and progression-free survival compared to surgery alone for patients with resectable esophageal or esophagogastric junction cancer. At a minimum follow-up of 5 years, median overall survival was 48.6 months for chemoradiotherapy plus surgery versus 24 months for surgery alone. Both squamous cell carcinoma and adenocarcinoma subtypes benefited. Neoadjuvant chemoradiotherapy using carboplatin and paclitaxel is now considered the standard of care for these patients.
1. Radiation techniques for treating esophageal cancer include EBRT using 3D-CRT, IMRT, or brachytherapy. IMRT allows for better sparing of organs at risk like the spinal cord, heart, and lungs compared to 3D-CRT.
2. For treatment planning, the gross tumor volume (GTV) and clinical target volume (CTV) must be accurately delineated using imaging like CT, PET, and endoscopy. The CTV includes margins around the GTV to account for microscopic disease.
3. Radiation fields typically cover 3-5cm above and below the tumor with a 2cm radial margin. Enlarged fields covering the whole esophagus
1. Radiation therapy plays an important role in the treatment of Wilms tumor, especially for advanced or high-risk cases.
2. It is used preoperatively, postoperatively, and for metastatic disease to reduce the risk of recurrence.
3. The indications and techniques for radiation therapy depend on factors like tumor stage, histology, response to chemotherapy, and whether metastases are present. Precise radiation treatment planning is required to effectively target tumors while sparing healthy tissues.
This document discusses the use of intensity-modulated radiation therapy (IMRT) for treating cervix cancer. It notes that IMRT is rarely used currently but could help reduce dose to normal tissues and potentially replace brachytherapy. The document outlines the need for accurate target volume definition using imaging like MRI and CT. It also describes the inverse planning process for IMRT and challenges like organ motion. While IMRT may help spare organs at risk, issues like increased leakage, integral dose and treatment time must be considered.
1) Radiation therapy has a questionable role in treating primary renal cell carcinoma (RCC) but is commonly used to palliatively treat brain and other metastatic lesions.
2) Stereotactic body radiation therapy (SBRT) enables high doses of radiation to tumors while sparing normal tissues and has shown promise for treating primary or metastatic RCC, with local control rates of 90-98% in studies.
3) While some studies found adjuvant radiation after surgery reduced local recurrence in advanced RCC, prospective randomized trials found no survival benefit and increased toxicity, so radiation is not routinely recommended after surgery.
Contouring Guidelines for Gynecological MalignancyJyotirup Goswami
A brief overview of gynecological malignancy contouring guidelines (teletherapy & brachytherapy), including a discussion of problems and inadequacies of the present guidelines
This document discusses external beam radiation therapy (EBRT) techniques for cervical cancer. It begins by introducing cervical cancer staging and the principles of EBRT management based on tumor stage. It then covers indications for pre-operative, post-operative and palliative EBRT. The document discusses various EBRT techniques including conventional, 3D-CRT, IMRT and IGRT. It provides details on treatment planning including patient positioning, simulation, field design and dose fractionation. Finally, it covers 3D-CRT planning and discusses the rationale and caveats of IMRT for cervical cancer treatment.
The panel discussion focused on target delineation in glioma. For low grade gliomas, the GTV includes the surgical cavity while the CTV expands 1 cm from the T2/FLAIR hyperintense area. For high grade gliomas, the GTV is the cavity plus enhancing tumor and the CTV expands 2 cm from the GTV while also including any FLAIR abnormalities. Proper trimming of the CTV is discussed to respect anatomical barriers like the ventricles, falx, optic apparatus, brainstem, and interthalamic area. OAR sparing is also emphasized to reduce treatment toxicity.
IORT uses a high single dose of radiation delivered during surgery to treat cancer remnants after tumor removal. It has two objectives: increase local tumor control and increase the ratio of tumor control to damage of nearby healthy tissues. IORT can be delivered via two methods - IOERT uses electron beams from a LINAC and IOHDR uses radioactive sources. Treatment planning requires a multidisciplinary team to determine applicator positioning and appropriate dose to maximize tumor coverage while minimizing radiation to other organs. IORT provides local tumor control comparable to conventional fractionated radiotherapy but with faster treatment time and less damage to surrounding tissues.
This document discusses the use of stereotactic body radiation therapy (SBRT) for liver tumors. It provides details on common liver tumors including hepatocellular carcinoma and metastases. It describes SBRT as a treatment option for inoperable early stage tumors, as a bridge to transplant, and for intermediate or locally advanced stages. Key factors for patient selection and treatment planning such as tumor size, number and location, as well as liver function are summarized. The document also briefly discusses proton beam therapy and current clinical trials investigating SBRT for liver cancer.
Axillary radiotherapy provides comparable regional control to axillary lymph node dissection for breast cancer patients with positive sentinel nodes, with fewer side effects. The AMAROS trial found similar 5-year axillary recurrence, disease-free survival, and overall survival between the radiotherapy and dissection groups. However, radiotherapy resulted in significantly less lymphedema. While control was excellent with both treatments, the trial was underpowered to definitively show non-inferiority due to lower-than-expected axillary recurrences.
1) The document discusses various radiation techniques for treating cancer of the esophagus including 2D, 3D conformal radiation therapy, IMRT, and IGRT.
2) It covers topics like target volume delineation, field design considerations for different esophageal subsites, and evolution from 2D to 3D treatment planning.
3) While there is no consensus, most contemporary trials use margins of 3-5cm cranially and caudally on the gross tumor with approximately a 2cm radial margin.
This document provides contouring guidelines for radiation treatment planning of carcinoma of the cervix. It outlines the key anatomical targets and organs at risk that must be delineated, including the gross tumor volume, clinical target volume for the primary tumor and lymph nodes, planning target volume, and organs like the bladder and bone marrow. It also discusses important aspects like bladder filling protocol, dose prescription for the tumor and nodes, use of intensity-modulated radiation therapy to spare organs at risk, and set up verification during treatment.
This document discusses various methods used to evaluate radiotherapy treatment plans, including physical and biological parameters. Physically, plans are evaluated using isodose curves, dose distribution statistics, differential and cumulative dose-volume histograms (DVHs). Target coverage should be within 95-100% of the prescribed dose. Biologically, tumor control probability (TCP) and normal tissue complication probability (NTCP) models are used. The therapeutic ratio and index compare the dose required for tumor control versus normal tissue complications. NTCP models include Lyman-Kutcher-Burman and critical element/volume models. Plan evaluation ensures target doses are adequate while respecting organ tolerance doses.
This document discusses radiotherapy planning and techniques for breast cancer treatment. It describes the iterative process of developing a treatment plan, which involves initial beam arrangement based on clinical experience, reviewing dose distributions, and modifying the plan based on parameters like isodose lines and dose-volume histograms. It also covers challenges like respiratory motion and setup uncertainties, and techniques to address these like deep inspiratory breath hold and respiratory gating. The goal is to deliver the prescribed radiation dose to the target while sparing surrounding healthy tissues as much as possible.
Radiotherapy is used as primary treatment for early-stage Hodgkin lymphoma or as part of combined modality treatment with chemotherapy. Historically, large mantle fields covering lymph node regions from the skull to the pelvis were used. More modern approaches use smaller involved field radiotherapy targeting only initially involved lymph node regions after chemotherapy based on imaging. Proper delineation of clinical target volumes requires pre-chemotherapy imaging ideally with PET/CT to define original disease extent.
This document outlines the key aspects of radiotherapy treatment planning for rectal cancer, including:
1) The epidemiology of rectal cancer, stages of disease, and patient positioning and immobilization techniques.
2) How to define the target volumes including the gross tumor, clinical target volume, and planning target volume based on disease stage and risk of lymph node involvement.
3) Typical three-field beam arrangements and doses of 45-50.4 Gy given in 1.8 Gy fractions for preoperative or postoperative radiotherapy, with additional boost doses sometimes used.
4) The acute and chronic complications of radiotherapy and dose constraints for organs at risk like the small bowel and bladder.
1) Carcinoma of the anal canal most commonly presents as squamous cell carcinoma. Risk factors include HPV infection, HIV/AIDS, immunosuppression, and a history of other anogenital cancers.
2) The standard of care is chemoradiotherapy with concurrent 5-FU and mitomycin C, based on trials showing improved local control over radiation alone. Surgery has a limited role and is reserved for salvage after failed chemoradiotherapy.
3) Bowen's disease, or anal intraepithelial neoplasia, is a precursor lesion caused by HPV that may progress to invasive squamous cell carcinoma in some cases. It is typically treated with local excision or ablative
This document discusses mesothelioma, a rare and aggressive cancer associated with asbestos exposure. It provides details on etiology, pathogenesis, clinical presentation, diagnosis, staging, and treatment options. Mesothelioma most commonly affects the pleura and has a median survival of 1 year without treatment. The standard of care is trimodality therapy with induction chemotherapy, followed by extensive pleurectomy/decortication surgery or pleurectomy/decortication, and then hemithorax radiation. Trimodality therapy results in a 5-year survival rate of 27.7 months, though patient selection is important. Ongoing research is evaluating novel targeted therapies and immunotherapy approaches to improve outcomes for this difficult to treat cancer
This document discusses mesothelioma, including its etiology, pathogenesis, clinical presentation, diagnosis, staging, treatment, and prognosis. Some key points:
- Asbestos exposure is the main risk factor and there is a long latency period of 20-40 years between exposure and tumor development.
- Symptoms include chest pain, dyspnea, and chest wall masses in about 25% of patients. Median survival is only 1 year without treatment.
- Tissue biopsy is needed for diagnosis and immunohistochemistry can help distinguish mesothelioma from other tumors.
- Surgery such as extrapleural pneumonectomy or pleurectomy/decortication may provide a survival benefit when combined with
1. Management of carcinoma of the anal canal involves multimodality treatment with chemoradiation rather than surgery as the primary treatment. Surgery is reserved for patients who do not respond to chemoradiation or have recurrence.
2. Staging of anal canal cancer uses the TNM system and is based on tumor size rather than depth of invasion.
3. Chemoradiation involves concurrent radiation therapy and chemotherapy such as 5-FU and mitomycin-C over several weeks to treat both the primary tumor and regional lymph nodes.
1. The document discusses treatment approaches for head and neck cancers, focusing on oral cavity and oropharynx cancers.
2. For oral cavity cancers, treatment typically involves surgery with postoperative radiation for high-risk features. Trials are exploring adding chemotherapy or targeted agents to postoperative radiation.
3. For oropharynx cancers, the 8th edition AJCC staging system separates HPV-positive and HPV-negative cancers based on differences in prognosis. HPV-positive oropharynx cancers have a better prognosis and revised staging aims to better predict outcomes.
1. Benign neck diseases are commonly seen in both children and adults. Common etiologies include congenital lesions like lymphangiomas, dermoid cysts, and thyroglossal duct cysts as well as acquired lesions like branchial cysts.
2. Lymphangiomas are benign vascular lesions composed of dilated lymphatic channels or cysts. They can be simple, cavernous, or cystic hygromas. OK-432 is an effective sclerosing agent for treatment.
3. Dermoid cysts contain skin elements and arise from ectodermal differentiation along fusion lines. Complete surgical excision is the treatment of choice.
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.
Vulvar cancer is a rare malignancy that represents less than 1% of cancers in women. Risk factors include older age, precancerous skin changes, HPV infection, smoking, and immune disorders. There are two main types characterized by different precursor lesions and histologies. Treatment involves radical surgery with groin lymph node dissection, with postoperative radiation used for high-risk features. Advanced cases may receive neoadjuvant chemoradiation to downsize tumors prior to surgery or definitive chemoradiation without surgery. Radiotherapy planning requires delineation of primary tumors and nodal volumes, with techniques including 3DCRT and IMRT to optimize dose distribution and spare organs-at-risk.
The document discusses the management of salivary gland tumours, including an overview of the different salivary glands and tumours that can occur in each, the workup, staging, treatment options of surgery, radiation therapy and chemotherapy, with a focus on the evidence for use of adjuvant radiation therapy to improve local control based on several studies. Adjuvant radiation therapy significantly increases local control for high-risk features like advanced T and N stage, close or positive margins, nerve involvement and perineural invasion. Elective nodal radiation is also recommended for high-grade tumours but not for adenoid cystic or ac
The document summarizes radiation techniques used in treating nasopharyngeal carcinoma. It discusses 2D planning techniques including field borders and portals. It also discusses 3D conformal radiation therapy and intensity-modulated radiation therapy (IMRT), noting that IMRT allows a high dose to the tumor while limiting dose to surrounding tissues. The document reviews studies showing improved local control and reduced toxicity with 3D and IMRT techniques compared to 2D planning. It also discusses dose escalation techniques including brachytherapy and stereotactic radiosurgery boosts as well as altered fractionation schedules.
This document discusses the management of carcinoma of the stomach. It outlines the various treatment options including surgery, radiation, chemotherapy, and chemoradiation. For localized resectable disease, surgery with D2 lymph node dissection is the primary treatment. Adjuvant chemotherapy or chemoradiation is recommended to improve outcomes. For locally advanced or metastatic disease, combination chemotherapy is used. Trials have shown perioperative and adjuvant chemotherapy with fluoropyrimidine-based regimens provide a survival benefit.
This document discusses esophageal cancer, including:
- It remains the 6th most common malignancy and rates vary globally. Squamous cell carcinoma is most common.
- Risk factors include smoking, alcohol, hot liquids and micronutrient deficiencies. Barrett's esophagus increases adenocarcinoma risk.
- Symptoms depend on location and stage but include dysphagia, weight loss, pain and cough.
- Diagnostic tools include endoscopy, CT, PET, MRI and EUS to determine stage.
- Treatment involves chemotherapy, radiation, and surgery depending on location and stage. Surgical techniques include transhiatal, Ivor Lewis and minimally invasive approaches.
This document provides an overview of anal cancer management. It discusses the epidemiology, risk factors, pathology, spread, clinical presentation, staging, treatment including role of surgery and radiotherapy, toxicities, indications for postoperative radiotherapy, palliative care, relapse, and special circumstances like HIV patients. Radiotherapy techniques including delineation of target volumes and organs at risk are described in detail. The document is a comprehensive reference for clinicians on anal cancer management.
This document provides treatment recommendations for Hodgkin's lymphoma based on stage. For early stage disease, recommended treatment is chemotherapy (ABVD) followed by involved field radiation therapy (IFRT). For advanced stages III and IV, the recommended treatment is ABVD chemotherapy followed by IFRT to bulky or residual sites. Relapse is treated with chemotherapy followed by IFRT to previously untreated sites. The document also discusses definitions of radiation therapy fields and doses for different involved sites.
This document summarizes the management of salivary gland tumors. It discusses the different types of salivary glands and their lymphatic drainage. It then covers the epidemiology, risk factors, workup including imaging and biopsy, staging, histopathological classification, prognostic factors, and treatment options for salivary gland tumors including surgery, neck dissection, adjuvant radiotherapy with different dose schedules, chemotherapy, and follow-up guidelines.
This document discusses laryngeal transplantation, including:
1. Pioneering attempts at laryngeal transplantation in the 1960s-1980s faced technical limitations and ethical concerns.
2. Advances in microsurgery, immunosuppression, and organ preservation have made laryngeal transplantation a possibility once deemed too risky.
3. The first reported successful human laryngeal transplantation was in 1998, where the patient regained voice function and swallowing abilities over time despite facing some complications.
This document discusses carcinoma of the hypopharynx. It begins with the anatomy of the hypopharynx and then discusses the epidemiology, etiology, prognostic factors, pathology, patterns of spread, clinical presentation, evaluation and staging, and management. For management, it describes both surgical and radiation therapy approaches. Radiation therapy techniques including simulation, conventional planning, and fractionation are covered in detail.
Radiotherapy planning in carcinoma urinary bladder Dr.Rashmi Yadav
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- Video recording of this lecture in English language: https://youtu.be/RvdYsTzgQq8
- Video recording of this lecture in Arabic language: https://youtu.be/ECILGWtgZko
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Carcinoma anal canal
1. CARCINOMA ANAL CANAL
DR MEGHA PREM
JUNIOR RESIDENT
DEPARTMENT OF RADIATION
ONCOLOGY GMC CALICUT
2. ANATOMY
• Length =3-4 cm
• Posterior wall >anterior wall
• BEGINS : Rectum enters puborectalis sling at
apex of anal sphincter complex
• ENDS: Squamous mucosa blending with the
perianal skin palpable intersphincteric
groove / outermost boundary of the internal
sphincter muscle
3. • ANAL SPHINCTER COMPLEX :
Palpable as anorectal ring on DRE & approx 1-2
cm proximal to dentate line
4.
5.
6. The lumen has folds of mucous membrane(anal
columns) produced by arterial cavernous
bodies (anal cushions) in the submucosa.
The columns are connected to each other at
their distal end by valves by transverse folds
anal valves
7. • Perianal skin :hair bearing skin elsewhere
• Anal verge: skin blends with a pale colored
zone
8.
9.
10. Lymphatic drainage
The major lymphatic pathways flow to three
lymph node systems.
The perianal skin, the anal verge, and the canal
distal to the dentate line drain predominantly to
the superficial inguinal nodes, with some
communications to the femoral nodes and to the
external iliac systems.
10
11. Lymphatics from around and above the dentate
line flow with those from the distal rectum to
the internal pudendal, hypogastric, and
obturator nodes of the internal iliac systems.
The proximal canal drains to the perirectal and
superior hemorrhoidal nodes of the inferior
mesenteric system.
Intramural system
11
12.
13.
14. • Sexually transmitted viruses
• Immunosupression
• Tobacco
• Sexual pratices
• Multiple sexual partners in
homo/heterosexual relationships
• Unprotected anal intercourse
15. • Compromise of CMI reduces bodys ability to
prevent/eliminate infection by viruses such
as HPV
• INFECTION WITH IATROGENIC
HIV SUPRESSION IN
ORGAN TRANSPLANT PTS
31. • BIOPSY
• PROCTOSCOPY
• FNAC / excision biopsy of enlarged LN
clinicaly/ radiologicaly
• CERVICAL CANCER SCREENING- association of
anal cancer & HPV
33. •
• MRI MOST ACCURATE METHOD FOR
ASSESSING PRIMARY TUMOR & PELVIC
NODES
34. • Thoracic , abdominal & pelvic CT & pelvic MRI
• To identify lung/liver mets / enlarged LN
• SKELETAL STUDIES NOT INDICATED IN THE
ABSENCE OF FOCAL SYMPTOMS
35. • PET CT & INGUINAL SLNB to identify inguinal
ln mets & refine RT plans
36. •
PET CT CANNOT REPLACE DIAGNOSTIC CT
• RECTAL ULTRASOUND TO DETERMINE DEPTH
OF TUMOR INVASION IS NOT USED IN
STAGING
37.
38.
39. “Direct invasion of the rectal wall, perirectal skin,
subcutaneous tissue, or the sphincter muscle(s) is
not classified as T4.”
39
40.
41.
42. PROPHYLATIC VACCINES
• Routine use of 4 valent/9 valent vaccine in
boys 11-12 yrs & females 13-18 yrs
• Also in men who have sex with men who have
not been previously vaccinated
43. Prognostic factors
• TUMOR FACTORS
• D/s confined to the pelvis : T STATUS most
useful predictor of local control, sphincter
preservation, and survival
• MOST ADVERSE FACTOR IS PRESENCE OF
EXTRAPELVIC METASTASIS
43
47. • PATIENT FACTORS
• NOT CONSISTENT
• Age, PS, baseline HB LEVEL & race
• Pts continuing to smoke
• HIV POSITIVE PTS : High viral load, low CD4
counts & AIDS prognostic of poor LC & OS
47
48. • EARLY RESPONSE & EXTENT OF RESPOMSE TO
CHEMORADIATION WERE CORRELATED WITH
SURVIVAL
49. Treatment
Historically Abdominoperineal resection
(APR) was the primary treatment modality
Local relapses were common
5 year overall survival 40 – 60 %
Now reserved as salvage for patients who fail
radiation or who had prior pelvic RT
49
50.
51.
52.
53. United Kingdom Coordinating Committee for Cancer Research
(UKCCCR) ACT I (1987-1994)
577 patients with SCCof the anal canal or anal
margin
40%- T3/T4, 20% LN+, 2% extrapelvic metastases
53
• 45 Gy / 20-25 #RT alone
• 45 Gy / 20-25 #
• 5FU 1000 mg/m²/day,
CI for 4 days, 1st & final
weeks of RT
• Mitomycin 12 mg/m²
IV bolus day1
ChemoRT
Reassessed clinically 6 weeks
after treatment.
Primary tumor not regressed by
at least 50% APR
Otherwise, the patients received
an additional 15 Gy in six
fractions by a perineal field or
25 Gy over 2 to 3 days by
iridium-192 implant
54. 3-Year Results
54
RT RTCT P value
Locoregional
control
39% 61% <.0001
Cause specific
survival
61% 72% o.o2
Overall survival 58% 65% o.25
There were six (2%) deaths due to treatment in the combined-modality arm and
two (0.7%) in the irradiation-alone arm. Acute toxicity, other than hematologic,
was considered comparable in each group
56. EORTC
103 patients with advanced cancers of the
anal canal
85% - T3 or T4 cancers and 51% -abnormal nodes
56
• RT 45 Gy/25#RT alone
• RT 45 Gy/25#
• Chemo 5-FU (750 mg/m2/day for 5 days) in
weeks 1 and 5 of RT
• mitomycin (15 mg/m2) by bolus IV injection
on day 1 of the first course of 5-FU only.
ChemoRT
After 6 weeks,
boost irradiation
of 15 Gy (if CR)
or 20 Gy (if PR)
was given by
external-beam
or interstitial
irradiation
57. RT RTCT P value
Local control 50 68 SS
Colostomy free
survival
40 72 SS
Overall survival 65 70 NS
57
J Clin Oncol 1997;15:2040-2049.
Chemo RT improves local control and colostomy
free survival , no impact on overall survival, with
comparable toxicity
58. SHRINKING FIELD
• Treatment using at least two phases, where
latter phases use smaller fields than the
former phases.
59. • Shrinking fields are used when different volumes
within the patient are thought to contain different
quantities of tumour stem cells, in an effort to reduce
the volume of normal tissue treated to high dose.
• The initial fields distribute dose to all areas of concern,
up to the dose required in the areas thought to be at
'least risk'.
• Smaller fields are then used to increase the dose to the
smaller volume believed to be at higher risk.
• It is possible to have several phases with shrinking
fields between each
60. • Anal cancer may be treated with a three phase
technique:
• Phase I uses large fields to treat all the nodal
regions at risk (internal iliac, presacral, and
inguinal nodes) as well as any involved nodes and
the primary tumour
• Phase II constricts the fields to treat the involved
nodes and anal canal
• Phase III delivers the final few treatments to the
anal canal only
61. SIMULATION
• Supine with arms across chest
• Prone in a alpha cradle / other immobilization
devices
• Wires for inguinal LN
• Marker near growth
• Vaginal dilators
• Bladder moderately filled
62. • All patients will be treated with a daily dose of
1.8 Gy, 5 days per week to a dose of 45 Gy in
25 Fx in 5 to 6.5 weeks (< 10-day break, as
indicated, for skin intolerance)
63. • Patients with T3, T4, or N+ lesions or T2
lesions with residual disease after 45 Gy
should receive additional 10-14 Gy (2 Gy per
Fx) to a reduced field
66. AP PA
Upper border – L5-S1 junction (includes the common iliac,
upper presacral, and rectosigmoid nodes )
This border moved down (after 30.6 Gy) to the
lower end of the sacroiliac joints (encompassing only the
perirectal, lower presacral, and internal iliac nodes and, if the volume is
sufficiently wide, the lower external iliac nodes) in order to lessen
the risk of radiation enteritis
Lower border
3 cm below the anal verge or the inferior extent
of the primary tumor whichever is most inferior
67.
68.
69. Lateral borders
The position - depends on the desirability of treating a
continuous homogenous volume or the preference to
minimize irradiation of the femoral head and neck
Options include
1. Anterior and posterior fields of equal size encompassing
the inguinal nodes
69
70. . Anterior and posterior fields of equal size, but
restricted to include the medial borders of the pelvis
only (1.5 cm lateral to bony pelvis) and the inguinal
nodes being treated by anterior electron beams
matched to the photon fields
71. 4 FIELD
• The lateral border of the AP field shall include
the lateral inguinal nodes as determined by
bony landmarks
• The lateral border of the PA field shall extend
2 cm lateral to the greater sciatic notch
72. • If utilized, the target volume includes all areas
at risk (pelvis, anus plus margin, inguinal
nodes, external iliac nodes)
• AP and lateral fields should be shaped such
that the lateral inguinal nodes are included in
these fields. The inguinal nodes should not be
included in the PA field
73. Deliver 14.4 Gy/8 Fx for a total of 45 Gy at 1.8
Gy/day
After 30.6 Gy has been given to an initial pelvic
field
74. • the superior border shall be dropped to the
upper level of the greater sciatic notch
(inferior border of SI joints). The reduced
pelvic field shall be continued to 45 Gy at 1.8
Gy per day
75. • (For all T3, T4, and N+ patients or T2 patients
with residual disease after 45 Gy)
76. • After 45 Gy, boost fields shall be utilized to
encompass the original primary tumor volume
plus a 2.0 to 2.5 cm margin
77. • Treatment field options include reduced
multiple photon fields with the patient in
supine position (i.e., 4-field or PA and laterals
with wedges) or a direct photon or electron
perineal field with the patient in the lithotomy
position
78. • An additional 10-14 Gy (2 Gy per Fx) shall be
delivered (total 55-59 Gy). If pelvic nodes are
grossly involved, they should be included in
the final boost field if small bowel can be
avoided
79. Posterior Pelvis Techniques
• The anal canal and posterior pelvic nodes may be treated by multiple
beam techniques.
• The volume irradiated is reduced compared with that of whole-pelvis
techniques and dose to anterior perineum and external genitalia is less
• Commonly 3/4-field techniques, such as a direct posterior or AP-PA fields
and opposed lateral beams
79
81. • Inguinal nodes receive only exit dose ( 30-40%
0f prescribed dose)
• Inguinal nodes boosted concurrently with
electron to bring dose up to 100% of
prescribed dose
82. Boost fields
Target volume for boost field is the original primary tumor volume/node
plus a 2-2.5 cm margin
Options include
1. External-beam therapy with a perineal field, or by multifield
techniques
2. Interstitial therapy
82
83. Brachytherapy
Brachytherapy is used for boosting T1 - 2, and
small T3 tumors which have responded well to
chemoradiation.
Contraindications
Insufficient tumour response after primary chemoradiotherapy
Lesions involving more than the half the circumference of the anal canal,
because there is a higher risk of stenosis and necrosis,
Lesions of which the proximal limit is not palpable and thus cannot be
implanted.
T4 tumours (however, in T4 tumours extending into the anovaginal septum
and responding to external beam radiotherapy, brachytherapy is possible).
83
84. A small acrylic template is used to space a
semicircle of hollow needles in place and are
after loaded with Ir-192 to deliver 15-20 Gy at 1
Gy/h to a depth of 0.5 cm as a boost to the anal
canal primary site
A typical implant contains 5 radioactive lines
spaced at 1 cm, 5 - 7 cm long for a T1 - 2 tumor,
and 6-7 needles, 7 - 8 cm long for a small T3
tumor
84
85. CHEMOTHERAPY REGIMENS
• 5 FU +MITOMYCIN +RT
• Continuous infusion of 5FU 1000mg/m2/d IV
D1-4
• MITOMYCIN 10mg/m2 bolus d1 & d29
93. The primary tumor planning target volume
(PTV) receives 54 Gy (red colorwash), and the
elective nodes 45 Gy (blue colorwash). An
involved right-sided inguinal node was dose-
painted to 50.4 Gy (orange colorwash)
94. • GTV A = primary anal tumor(examination,
imaging & endoscopy)
• GTVN 50=metastatic nodal regions ≤3 cm
• GTVN 54 =metastatic nodal regions >3 cm
• CTV =2.5 -1 cm (manually edited to avoid
overlap into nontarget muscles or bone,
considered natural barriers to tumor
infiltration)
95. • Elective nodal CTVs (mesorectum, presacrum,
bilateral internal and external iliac, and
bilateral inguinal)
• PTV =CTV+1cm
• PTVs were not edited in any way except to
avoid overlap with the skin.
96. • Normal structures (small bowel, large bowel,
bladder, femoral heads, iliac bones, perianal
skin, genitalia) were also contoured, the bowel
as individual loops to 2 cm above the most
superior extent of the target CTVs
97.
98.
99.
100. • Acute 3+ hematologic toxicity rates appear
similar across RTOG 9811 (62%), RTOG 0529
(58%) which suggests that pelvic bone marrow
is similarly suppressed by chemoradiation,
regardless of radiation approach
106. RESULTS
• THE REPLACEMENT OF MITOMYCIN WITH
CDDP IN CHEMORT DOES NOT AFFECT THE
RATE OF COMPLETE RESPONSE NOR DOES
ADMINISTRATION OF MAINTENANCE
THERAPY DECREASE THE RATE OF D/S
RECURRENCE
107. ROLE OF INDUCTION THERAPY
• ACCORD 03 NO BENEFIT OF INDUCTION CT
• A RECENT RETROSPECTIVE ANALYSIS
INDUCTION CT IS BENEFICIAL FOR T4 D/S
108. Evaluation of planned treatment breaks during radiation therapy
for anal cancer: update of RTOG 92-08.
RTOG 92-08 began as a single arm, Phase II trial consisting of RT + 5-FU +
M with a mandatory 2-week break
High rate of colostomy trial re-opened in 1995 evaluated the same
treatment regimen without a mandatory treatment break
Each cohort of RTOG 92-08, the mandatory treatment break and
continuous radiation schedule, were compared to Mitomycin-C arm of
RTOG 87-04.
The study was not designed to compare the two RTOG 92-08 cohorts to
each other
108
Int J Radiat Oncol Biol Phys. 2008 Sep 1;72(1):114-8. Epub 2008 May 9.
110. Conclusion
Late toxicity was low in both cohorts.
5-year Disease Free Survival and Colostomy Free Survival in mandatory
treatment break arm - lower than reported on RTOG 87-04
DFS and CFS in the no mandatory treatment break cohort were
comparable to other reported series.
Treatment breaks in anal canal treatment should be kept to a minimum.
110
113. Role of surgery
• LOCAL EXCISION – 2 SITUATIONS
• SUPERFICIALLY INVASIVE ANAL CANCER : anal
cancer that has been completely excised with
≤3mm BM invasion & a max horizontal spread
of ≤7mm
• T1N0 WD perianal cancer MARGINS
RECOMMENDED 1CM
114. • CANCER IS AN ACCIDENT BUT NOT THE END
OF THE ROAD