Dr. Upasna Saxena presented on brachytherapy. Brachytherapy involves placing radioactive sources close to or inside the tumor. It has advantages like high localized dose and sparing of surrounding tissues. Intracavitary brachytherapy is commonly used to treat cervical cancer using applicators like tandems and ovoids. Key planning points include Point A which is 2cm lateral and 2cm superior to the cervical os. Dose to organs at risk like bladder and rectum are also important. Proper placement and geometry of applicators is important for adequate dose coverage and sparing of organs at risk.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
A summary of recent innovations in radiation oncology focussing on the priniciples of different techniques and their application. An overview of clinical results has also been given
The vmat vs other recent radiotherapy techniquesM'dee Phechudi
VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams.
This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotations
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
A summary of recent innovations in radiation oncology focussing on the priniciples of different techniques and their application. An overview of clinical results has also been given
The vmat vs other recent radiotherapy techniquesM'dee Phechudi
VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams.
This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotations
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
A review of advances in Brachytherapy treatment planning and delivery in last decade or so, with main focus on brachytherapy for Prostate cancer, Breast cancer and Cervical cancer
Current controversies in cervical cancer management (2014)Jyotirup Goswami
Overview of the current controversies in the management of cervical cancer, including screening, prevention, staging, chemoradiation,teletherapy techniques, brachytherapy techniques
Background: Several sonographically guided injection methods have been described to treat carpal tunnel syndrome.
In most cases, the medication diffuses through the carpal tunnel to the site of maximum compression of the nerve after
being injected proximally. In this article, we describe a novel method of sonographically guided carpal tunnel injection that
utilizes a distal-to-proximal, in-plane, and transligamentous approach. This novel method may provide ergonomic as well
as safety advantages to both clinicians and patients, and should be considered by those performing carpal tunnel injections.
Similar to Carcinoma cervix brachytherapy- dr upasna (20)
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
3. ‘Brachy’ Greek word for ‘short distance‘
The term brachytherapy proposed first time by
Forsell in 1931
Form of radiation treatment in which radiation is
delivered by small sealed radioactive sources
arranged in a geometric fashion in & around
tumor.
4. Radioactivity was described by Becquerel in 1896
Marie curie extracted radium from pitchblende ore
in 1898
Danlos and Bloc performed first radium implant
(1901)
First “schools” of brachytherapy were at
Stockholm , Memorial Salon Kettering and the
Holt Radium Institute (Paris).
Ra & Rn –two radioactive sources used extensively
in the early years
5. From 1940 – 1970s , Co⁶⁰, Cs¹³⁷, Ir¹⁹² first used in
brachytherapy
Cs¹³⁷ began to replace Ra²²⁶
Wickham-The father of radium treatment of
uterine cancer treated 1000 cases from 1906-1910
1953-Afterloading technique- Henschke. He was
also first to use Ir192
LDR brachytherapy became the gold standard.
6. Rules for implantation were
made
1970 -Emergence of remote after
loading system ( selectron
machine – LDR machine)
HDR became widely accepted
after a long struggle particularly
for Ca Cervix
PDR has now been developed
Now with more sophisticated
imaging, hardware and software
: image assisted and image
guided brachytherapy coming
up
Intracavitary
Brachytherapy:
Stockholm system
(1914)
Paris System (1926)
Manchester System
(1938)
Interstitial
Brachytherapy:
Manchester system
Quimby System
Paris system
7. 7
Advantages of brachytherapy
• A high localized radiation dose to a small volume
--higher local control
•Spares surrounding normal organs and tissues
•Ultimate form of conformal radiotherapy
•Shorter treatment time- convenient, prevents tumour
proliferation
•Non-homogenour dose distribution to tumour targeting the
hypoxic central core
8. Invasive
Needs expertise and experience and equipment
Time consuming
Difficult to maintain uniformity across various
centres
9. According to method of source loading :
Preloading
Afterloading
Manual afterloading
Remote afterloading
According to type of application :
Intracavitary
Interstitial
Intraluminal – cylinders/ moulds
10. 10
•According to dose rate
•Ultra-low dose rate (ULDR): 0.01-0.3 Gy/hour
•LDR- 0.4-2 Gy/hr Cs-137
•MDR- 2-12 Gy/hr
•HDR- > 12Gy/hr Ir-192
•PDR- dose rate as HDR, But delivered in pulses ,
say for 10-15 minutes every hour
12. Between the period 1910-1950 three preloading
systems were devloped for CA cervix
Paris System
Stockholm System
Manchester System
Subsequently remote after loading technique was
developed which overcame the hazards of
preloaded sources.
14. ICRU specified dose specification system that relates dose
distribution to target volume, instead of dose to specific point.
Also includes information on various treatment parameters.
DOSIMETRIC INFORMATION FOR REPORTING
Complete description
Technique
Time-dose pattern
Treatment prescription
Total Reference Air Kerma
Dose description
Prescription points/surface
Reference dose in central plane
Mean central /peripheral dose
Volumes: Treated/ point A/ reference volume
Dose to Organs at Risk : bladder, rectum
15. the dose should be prescribed & assessed at a
representative point.
Point A, lies in the paracervical triangle.
Chosen initially because
Believed to be a good index of normal tissue tolerance which is the dose
limiting factor
“High dose in the paracervical tissues, where the uterine vessels are crossed by the
ureter, produces dangerous extrinsic reactions”
And comparable from case to case, not too variable with application
(textbook by Paterson)
ABS recommends this point as it falls within the portion of the
isodose distribution with little cephalocaudal gradient.
16. Definition
Original – 2cm lateral to the central canal of the
uterus, and 2cm up from the mucous membrane of
the lateral fornix in the axis of the uterus.
17. Although point A was defined
in terms of important
anatomical structures, these can
not be revealed on a
radiograph.
So point A definition was
modified in 1953.
“2 cm superior from lower end
of central radium tube and 2 cm
lateral from uterine canal in
radiograph of radium insertion.
Variant – beginning at the
flange abutting the cervical os.
Manchester cont
18. Tandem and ovoid - Draw a
line connecting middle of
sources in vaginal ovoids on
A-P radiograph and move 2
cm plus the radius of ovoid
superiorly along the tandem
from intersection of this line
with intrauterine source line
and then 2 cm lateral on
either side of the tandem.
19. Vaginal ring applicator – use line connecting lateral
most source dwell points on the ring and then
extend 2 cm superiorly (along the tandem from
where the line intersects the tandem) and then 2 cm
laterally on either side
Tandem and cylinders – extend 2 cm along tandem
from the flange, and then 2 cm laterally from it on
each side
20.
21. Is at same level as point A, but 5
cm from the midline.
Depicts dose delivered to
obturator nodes.
Indicates rate of fall-off of
dosage laterally.
Dose to point B is ~ 20-25% of
dose at point A.
Depends upon total amount of
radium used
22. is used by
Mallinckrodt
Institute of
Radiology System
to specify minimum
dose to pelvic
lymph nodes.
It is 6 cm to Rt and
Lt of patient
midline in same
plane as of classical
point A.
23. Description of reference volume i.e the tissue volume
encompassed by a reference isodose surface is
proposed for specification in reporting
An absorbed dose level of 60 Gy was widely accepted
as reference level
Reference volume described is pear shaped co-incident
with intra-uterine sources
24. This Reference volume is defined by 3 dimension:
1) Height(dh): Maximum dimension along the intrauterine
source, measured in oblique frontal plane.
2) Width (dw): Maximum dimension perpendicular to the
intra-uterine source, measured in oblique frontal plane.
3) Thickness (dt): Maximum dimension perpendicular to the
intrauterine source and is measured in saggital plane.
26. 47
BLADDER REFERENCE
POINT: Foley balloon
with 7 cc contrast pulled down .
•On lateral x-ray-
•Anteroposterior line drawn
through the centre of balloon
.A point on this line on the
posterior surface of the
balloon
•AP x-ray
•at the centre of the balloon
•There are some articles that suggest
that dose at bladder base and bladder
neck should be recorded
27. RECTAL REFERENCE POINT:
• Lateral x-ray-an anteroposterior line drawn from the lower
end of intra uterine source (or middle of intra vaginal
sources). Point located on this line 5 mm behind the post
vaginal wall
• AP x-ray-this at the lower end of intrauterine source or at the
middle of intravaginal sources
• Some articles show that rectal dose along several points over the length of
the implant
28. On lateral radiograph
A line is drawn from junction of S1-S2 to the
top of symphysis pubis
Then a line is drawn from the middle of that
line to the middle of anterior aspect of L4
29. A point 6 cm lateral to the midline at the inferior end is
used to estimate dose rate to mid-external illiac nodes
At the top of trapezoid points 2 cm lateral to midline at
L4 level gives an estimate to dose of Para-aortic nodes
Midpoint of line connecting to these to points is used to
estimate the dose to common illiac node
31. This point represent the absorbed dose to distal part of
parametrium and obturator nodes
On frontal radiograph, the pelvic wall reference point
is intersected by 2 line, a horizontal line tangential to
the highest point of acetabulum and a vertical line to
the inner aspect of acetabulum
On lateral radiograph highest point of Rt & Lt
acetabulum is joined and pelvic reference point is at
the mid-distance of these 2 points
34. Lack of information about correlation between
Applicator and tumour
Applicator and OAR
Tumour and OAR
OAR anatomic boundaries not very clear, estimated based
on contrast
Dose to target and OARs is not reliable
All doses reported are a point dose which do not depict the
actual dose delivered to entire structure
Points do not correlate with local control or toxicity
35. It relates to position of sources and not
to specific anatomic structure.
It is very sensitive to position of ovoid
sources relative to tandem sources
which should not be determining factor
in deciding on implant duration.
Depending on size of cervix point A
may be inside or outside of tumor.
Manchester cont
36. A & B are not anatomic sites
A &B varies with applicator type
A is not in paracervical triangle
A is not a reliable indicator of minimum tumor
dose
B does not always represent obturator node
37.
38. 59
Loose Tandem & Ovoids
Stockholm
Paris or London colpostat
Manchester system
Fixed applicators
Fletcher-suit-Delclos
Manchester
Vienna ring
INTRACAVITARY
APPLICATORS
39. Loose system.
Intrauterine applicator
Rubber tubing, with flange at end.
Varying length, can take – 1,2,3 radium tubes in line.
Ovoids
Rubber or nylon
Shape follows the distribution in 3-D space of the
isodose curves around the contained radium tube,
ensuring homogenous dose on its surface.
43. 64
MANCHESTER SYSTEM
Point A : 2 cm lateral to the central canal of the uterus and 2 cm up from the
mucous membrane of the lateral fornix in the axis of the uterus.( In practice,2 cm
up from the flange and 2cm lateral from the central axis)
Point B : Being in the transverse axis through points A , 5 cm from midline
46. Tandems of angles 0, 15, 30 and 45 degress
Length is adjustable with a flange placed
according to length of the uterus to prevent
perforation and mark the external os on
radiograph
47. Ovoids
3 sizes
Small –shortest dia – 2cm
Medium – dia – 2.5cm
Large – dia – 3cm.
Pairs of ovoids held apart by a “SPACER” .
Fixes at a distance of 1 cm.
“WASHER” – holds the ovoids in position in narrow
vagina.
Range of ovoid pair – 4-7cm.
48. Select the longest possible intra-uterine applicator and
the largest possible size of ovoids, which can be placed
snugly.
Carries the ovoid closer to point B
Gives better proportional depth dose.
Pushes the isodose of lethal damage as laterally as
possible.
Longer tandem – more contribution to pt B
Bigger ovoid – vaginal surface dose falls by 35%
49. Intact uterus should always have a tandem
placed
Supracervical hysterectomy- short tandem
Intact uterus with extensive disease – tandem
with interstitial needles
50. INTERSTITIAL – large lesions, lower vaginal
disease, applicators not fitting
TANDEM + CYLINDER – upper vaginal
stenosis/narrowing, superficial disease (5mm thick) in
lower vagina
TANDEM + RING – shallow fornices
51. TANDEM + OVOIDS – barrel shaped cervix,
using largest ovoid. To cover cervix, uterus, medial
parametrium and upper 1-2 cm of vagina
TANDEM + RING/OVOIDS +
INTERSTITIAL NEEDLES – large bulky
tumours (for tumour coverage and OAR sparing),
vaginal extension of disease, fistulae, pelvic side
wall invasion
OVOIDS OR CYLINDERS ALONE – for post op
cases
52.
53.
54.
55.
56.
57. 78
ICRT STEPS
Anesthesia / sedation
Positioning - Lithotomy
Cleaning & draping
Bladder catheterization—7 cc radio opaque
contrast in balloon. If US guided procedure
planned, 100-120 cc saline infused into the
bladder
EUA
Dilatation of os
Uterine sounding to assess length
Insertion of tandem and ovoids
Posterior and anterior vaginal packing
61. After the application – patient is shifted for
imaging
AP and orthogonal x-rays for 2-D planning.
Planning CT scan for 3-D planning
MRI based planning – 1.5-T MR sequence maybe
used that allows the needle tip to appear as a
balloon on saggital image and cross on axial image
64. Potish et al used linear least-square regression
to show that although there was good
correlation between the milligram-hours and
colpostats and the dose to point A, it was
markedly affected by the position of the
tandem and colpostats
MD Anderson quatified the acceptable implant
geometry
65. Tandem should be
4 cm from sacrum
1/3 distance between pubis and sacrum
Midway betweem sacrum and bladder
Tandem should bisect the ovoids in AP & lat films
Distance between vaginal ovoids and cervical marker
seeds was 7mm
66. Superior tip should be below promontry (in the pelvis)
The bladder and rectum should be packed away from
the implant with no packing above the ovoids
Packing was within a line 5mm behind the line along
posterior surface of ovoids, running parallel to the
tandem
67.
68. Ovoids should fill the
vaginal fornices – largest
ovoid size to be used.
- should be separated by
0.5 –1.0 cm, admitting the
flange on the tandem with
no inferior displacement
-should be against the
cervix (marker seeds)
The axis of the tandem
should be central between
the ovoids
Should be bisected by the
tandem
69. RTOG 0116 and 0128 studied 103 patients (both LDR
and HDR).
They concluded that unacceptable geometry had
higher LR (HR=2.67, 95%CI=1.11 to 6.45; p=0.03)
Displacement of ovoids in relation to the cervix and
inappropriate packing also resulted in a lower DFS
70.
71. Check proper application
Proper delineation of OARs
More reliable dose distribution
Kim et al found that dose to point A is significantly lower
than D90 of HRCTV. Though dose to point A should be
reported
Himmelman et al described individualized computer
treatment optimization of source position and dwell time
74. Advantages
Acceptability due to wide use
Checks applicator geometry or perforation
Easy delineation of applicator
OARs position
Disadvantage
Artifacts due to metal applicator
Overestimate the tumour contours as compared to MRI
Can not distinguish sigmoid well as there is no contrast
Can not distinguh cervix from uterus – hence both are
contoured in CT based guidelines
75. Advantages
Better for tumour and parametrial visualization
Can distinguish sigmoid colon and also cervix from
uterus
Disadvantage
Needs specific titanium & zirconium applicators
Poor bony anatomy distinction
Necessary to fuse CT scan with MRI for planning
Inconvenient & Expensive
77. Cervix and GTV can not be differentiated, so uterus
along whole tandem should be included in CTV
The top dwell position is optimized off the sigmoid
Uterosacral ligaments, if detected, should be included
in the CTV contours
78. First guidelines published in 2004 by ABS (Nag et al)
Guidelines of GEC-ESTRO (Groupe European
Curietherapy-European Society for Therapeutic
Radiation Oncology) issued guidelines for MRI based
brachytherapy in 2005 (Haier-meder et al, Poetter et al)
In july 2005, ABS and GEC-ESTRO agreed to follow
GEC-ESTRO guidelines
79. GEC-ESTRO guidelines are followed-
GTV – include all T2 bright area of enhancement
HRCTV(high risk CTV) – entire cervix, any regions
of high to intermediate signal intensity in the
parametria, uterus and vagina and any residual
disease clinically
IRCTV (intermediate risk CTV) – subtracts the OAR
from the GTV at the time of diagnosis and a 1cm
margin to the HRCTV
90. It is early to draw definitive conclusions
BUT
First results show that systematic MRI based
treatment planning enables prospective control and
maybe reduction of morbidity
DIRECT COMPARISON
G3-G4 gastrointestinal and urinary late morbidity
(Pötter et al R&O 2007)
10% in 1998–2000 and 2% in 2001–2003
G3 gastrointestinal and urinary late morbidity
(Haie-Meder et al R&O 2009,2010, Chargari et al Int J Radiat Oncol Biol Phys 2009 )
5% in 2000–2004 and 2% in 2004–2006
Outcome of 3D-Image Based Gynaecological
Brachytherapy
Morbidity: Rectum, Sigmoid, Bladder, Vagina
91. 112
Eliminates RT exposure hazard for caregivers, visitors; eliminates source
prepration and transportation
Allows shorter treatment time
Less patient discomfort
Possible to trt patients who can’t tolerate long periods of isolation
Less risk of applicator movement during therapy
Due to OPD procedure results in cost shifting
Allows greater displacement of nearby normal tissues by packing
Possible to treat large number of patients
Allows use of smaller diameter sources than are used in LDR
Reduces the need of dilatation
Reduces the need of GA
High risk who don’t tolerate GA
Physically easier to insert applicator into the cervix
Makes dose distribution optimization possible
Allows integration of EBRT & HDR, which can lead to a shorter overall Rx
duration & better tumor control
HDR vs. LDR IN CA CERVIX -ADVANTAGES
92. Limited experience
Requires infrastructure
Maintenance is costly
Potential for more late effects in non-
fractionated HDR
93. Similar outcomes in LDR vs HDR
Recommended to use 3D imaging for HDR
For larger tumours (>4cm)using HDR early on during
treatment, results in poor outcome
Displacing the bladder and rectum away while short HDR
treatment may overcome the disadvantage of toxicity
associated with fewer no of HDR fractions
Newman et all treated 115 patients , 87 LDR, 30 HDr. No
significant differences were found in the local control and
toxicity
94. 115
HDR (%) LDR (%)
5 yr Dis Sp. Sur ST II 69 87
ST III 55 60
5 yr Pelvic RFS ST II 89 100
ST III 69 70
Distant Metastases 25 24
Pelvic R/E 18 13
Para aortic Recurrence 10 11
Overall 5yr compli 10 13
ST II 5 12
ST III 7 13
Rectum 3.5 8.7
Small Bowel 2.4 1.6
Bladder 4 7.5
P= ns
P= ns
Hareyama et al. Cancer 2002.
95. HIGHER TOXICITY grade>2 seen for higher
values of D2cc (Koom et al)
For interstitial, EQD2 of <62 Gy is recommended
and it is further reduced as the length of vagina
treated increases
98. Used in post op cases of carcinoma cervix (>=4weeks
postop)
Less than radical hysterectomy
Close/positive margins
Large or deeply invasive tumours
Parametrial/vaginal involvement
Extensive LVI
Intact uterus with narrow vagina, in combination with
a tandem
Ovoids alone can also be used, but cylinders are more
effective to treat the ‘dog ears’ of the vault and whole
length of vagina
100. 3-5 cm proximal vagina is treated
Whole length treated only if -
Papillary serous/clear cell
Grade 3 disease
Extensive LVI
Prescription at 0.5 cm from vaginal surface as 95%
lymphatics are located within 3mm of the mucosa
(Choo J et al)
101. ABS suggests
If only upper length of vagina is to be treated, cylinder
should not extend to introitus
If whole vagina is to be treated, cylinder should extend
beyond introitus
Condoms should be placed on the cylinders to facilitate
cleaning and for applicator longevity
Single channel or multiple channel applicators are
used
Single channel – low dose to mucosa with larger size
cylinders
Multiple channel – risk of higher dose to the mucosa has
to be guarded
118. Form of brachytherapy where sealed radioactive
sources are directly implanted into the tumour in a
geometric fashion
First suggested in USA by Alexander Graham Bell
(1903)
At same time independently being used in France
& Germany
First case treated for an inoperable Parotid
Sarcoma
119. 140
Indications of interstitial implantation in ca
cervix
• Extensive residual disease(not likely to be taken care of by
intracavitary application)
• Os not negotiable
• Fistulae
• Adjacent organ invasion
• Extensive parametrial +/- sidewall invasion
• Vaginal extension
• Recurrent disease (post RT/post surgery)
• Narrow vagina
• Prior supracervical hysterectomy
120. 141
Intracavitary
brachytherapy
Interstitial brachytherapy
More accumulated
experience
Relatively new technique
Easy to perform Requires expertise
Less invasive More invasive
Dose to cervix and
adjacent paracervical
areas
Dose to cervix, paracervical and
parametrial tissues
Lesser possibilities of
optimisation of dose
Owing to many number of needles,
more possibilities of dose
optimisation
Used in most cases Used with special indications
122. The Paris System lead to a Stepping Source Dosimetry System
(SSDS) for HDR
Dose points are placed midway between the catheters, not only in
the central plane but along all catheters
Dwell times are optimized such that the same dose is delivered to
all dose points; dwell times in the outer ends of the catheters are
increased substantially
123. 147
• History
• Clinical examination
• CT / MRI
• PAC clearance of the patient
• Admit the patient 48 hours prior to the implant
PATIENT EVALUATION
124. 148
One day prior to the implant
Clear liquid diet from 24 hours prior to the implant
Shave and clean perineum
Start antibiotic
Peglec 1 sachet diluted in I litre of water to drink till evening
Proctoclysis enema / soap water enema at 10 PM
Carry out anesthetic pre op orders
Nil orally after 10 PM
On day of implant
Proctoclysis enema/ soap water enema early morning
Slow iv fluids started in the morning
PRE OP PREPARATION
132. •Visible target and OAR
•Easy reconstruction of the
needles
•Optimization program
133.
134. D90, D100, V100 for HRCTV
V150, V200 may be reported
OAR reporting – same as in image based ICRT
135. 159
POST OP
•Carefully observe for any bleeding per rectum/hematuria
•Maintain frog leg position
•Maintain continuous infusion of epidural anaesthesia
IMPLANT REMOVAL
•Each needle to be removed separately
•Apply tincture benzoin at the bleeding points
•Advise perineal sitz baths and vaginal douches 2-3 times 3
hours apart after implant removal
136.
137. 161
TEMPLATE RESULTS
Syed , Puthawala et al- IJROBP Sep 2002
• N=185
• EBRT-5040 cGy-----Template LDR 40-50 Gy in 2 applications
• 5YDFS- IB-65%, II-67%, III-49%, IV-17 %
• Grade 3,4 late complications- 10%
Demanes et al- IJROBP Aug 1999, CEC ,1991-96
• N=62 ,locally advanced , early with abn anatomy
• EBRT-50Gy ----Template 5.5 - 6 Gy X 6 #
• 5YDFS - I-81%, II-47% III-39%, IV-0%
• LC rate- I-100% (12/12), II- 93% (25/27) III- 95% (18/19) IV- 75% (3/4)
• Grade 3-4 late complications -6.5 %
138. Image guided insertion resulted in lesser risk of
inadvertent insertion into surrounding organs and
accurate placement of catheters
In face of inadvertent insertion into a normal organ,
need not remove it, just do not load the needle
Optimization by PDR or HDR improves target
coverage and OAR avoidance
Mikami et al reported displacement of 1-2mm cranio-
caudal, replanning for >3mm displacemnt (daily CT
scans)
139. Damatao et al reported <1cm displacement occurred
over the course of treatment
Shukla et al reported these shifts for alternate fraction
CT imaging
Cranial – 2.5mm
Caudal – 17.4mm
Anterior- 1.7mm
Posterior – 2.1mm
Right – 1.7 mm
Left - 0.6mm
140.
141. Essential part of treatment (along with EBRT)
of carcinoma cervix stage IB2-IV A
Maybe used alone for stage IA-IB1
142. Staging evaluation before starting EBRT and before
commencing brachytherapy
Imaging – CT scan +/- MRI
Whole treatment (EBRT + brachy) within 8 weeks.
Delay decreases LC and survival 1% per day
Patients at risk of DVT should receive heparin +/-
compression stockings or calf compression devices
143. Trimethoprim-sulphamethoxazole should be used for
coverage
Fiducial seeds to mark cervical os and extent of disease,
possible
Smitt sleeve may be used
Rectal separator reduced the rectal dose substantially.
Acc to Lee et al, it applied only when target received
>70% of prescribed dose
144. Van Dyk et al and Mahantshetty et al compared US
and MRI guided target and OAR delineation and
found them comparable
A study showed that local recurrence when dose to
HRCTV of >87 Gy vs <87Gy was 4% vs 20%
LC of >95% for HRCTV D90 >87Gy
(Dimopoulous JC
et al)
145.
146.
147. STAGE IA
LDR - 60Gy in one # or 75-80 Gy in 2#
HDR – 5GY X 10#
STAGE IB to IVA (35-45Gy following 45Gy EBRT)
Small tumour (non bulky stage I/II ,< 4 cm diameter) –
80-85Gy to point A
Pelvic side wall dose-50-55 Gy
Large tumour ( > 4 cm diameter or stage IIIB)
good response, point A – 85-90Gy
poor response, point A - >90Gy
Pelvic side wall dose-55-60 Gy
148. 172
• ABS recommends that OAR dose should be <80% of
prescription dose
•Keep the bladder dose below the LDR equivalent of 80 Gy
•Keep the rectal dose below the LDR equivalent of 75 Gy
(use LQ model with late tissue effect parameters-a/b -3)
149. 2 sessions
First within 4-6
weeks of starting
EBRT
Second 1-2 weeks
after 1st application
(to allow tumour
volume reduction)
PDR
•Same dose in pulses
•No established
guidelines about
dose per pulse and
pulse intervals
SCHEDULING
150. HDR dose LDR equivalent
6 Gy X 4 32 Gy
6Gy X 5 40Gy
151. Optimal time-dose-fractionation scheme for HDR
brachytherapy of cervix is yet to be established
LDR to HDR reduction factor (Orton et al)
0.54-0.6 for 3-5 #
0.75 for 6-8 #
EQD2 (equivalent dose in 2Gy) obtained by
ABS worksheet
Isoeffect tables by Liu et al (Concluded that 2-4 # LDR is equivalent to 4-7 # of
HDR)
Viswanathan et al found significant variations
internationally
152. Complete/partial response with tumour <4cm - EQD2
>= 80Gy
Non responders/residual tumour >4cm – EQD2 85-
90Gy
153.
154. Different schedules
Deliver max EBRT to reduce tumour volume and
treat nodes 5days/wk brachy
Starting 2nd week, weekly #. No EBRT or chemo on
brachy day. Boost to nodes on non brachy day
EBRT 5# given twice/week
155.
156.
157. BRACHY ALONE
LDR dose equivalent of 60Gy
HDR –
PORTEC 2 – 7Gy X 3
MD Anderson – 6Gy X 5
Dana Farber/Bringham – 4Gy X 6
158. BRACHY AS A BOOST TO EBRT
No disease
LDR equivalent of 70Gy
HDR
RTOG 0921 – 6Gy X 3
RTOG 0418 – 6Gy X 2
Margin positive/ recurrence
70-80Gy LDR equivalent
159.
160. Treated with interstitial +/- EBRT
PREVIOUSLY IRRADIATED - 40-45Gy by interstitial
alone/EBRT boost alone
PREVIOUSLY SURGERY ALONE – EBRT 45-50Gy
20-35Gy interstitial for total dose of 80Gy
162. Retrospective. 7662 intracavitary procedures in 4043 patients for
FIGO I-III cervical CA (Jhingran A et al)
Complications
2.8% uterine perforation rate
14% have fever >101 C during at least 1 admission
0.1% fatal thromboembolism rate
Perforation did not affect DSS in stage I, II, but did lead to worse
prognosis in stage III.
Vaginal lacerations
– mild – no intervention
- Large – bleeding may require postponing session and control of
bleeding by pressure or suturing of mucosa
163. Eifel PJ et al.
Retrospective. 1784 pts, FIGO stage IB.
Grade 3 or higher complications occurred in 7.7% at
3 yrs and 9.3% at 10 yrs. After 10 yrs, 0.34% per year,
so at 20 yrs, 14.4% risk.
Risk of rectal complications was the greatest, more
than urinary complications.
164. Age did not affect the usefulness of
brachytherapy
Always recommended whenever possible even
in elderly
165. EBRT reports significantly inferior results than
brachytherapy
60Gy volume is much larger and high central
tumour dose is much less in EBRT than in
brachytherapy
Recommended only for
Medical reasons
Unusual anatomic configurations of the pelvis or
tumour