This document provides information on colorectal cancer epidemiology, anatomy, staging, diagnosis and treatment. It discusses:
- Colorectal cancer is the 3rd most common cancer in the US, with over 100,000 new cases annually and a lifetime risk of 1 in 10 for men and 1 in 14 for women.
- The rectum is located in the pelvis and is divided into lower, mid, and upper portions. It has various blood, nerve and lymphatic supplies.
- Staging involves determining the depth of invasion (T stage), lymph node involvement (N stage), and presence of metastases (M stage). Treatment involves surgery with the aim of local control and survival while preserving function
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
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
IORT uses a high single-fraction radiation dose (10-30 Gy) is delivered during surgery to a surgically-exposed tumour bed, immediately after a chunk of the tumour has been surgically excised. This slide includes topics like APBI, IOERT, IOHDR.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
IORT uses a high single-fraction radiation dose (10-30 Gy) is delivered during surgery to a surgically-exposed tumour bed, immediately after a chunk of the tumour has been surgically excised. This slide includes topics like APBI, IOERT, IOHDR.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
GB cancer is the 5th most common GIT malignancy(worldwide).200 years later it is still considered to be a highly malignant disease with a poor survival rate
.Here is a brief description regarding
The stomach J-shaped. It has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
Stomach cancer begins when cancer cells form in the inner lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
It could be:
malignant or benign
primary or secondary
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- 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
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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.
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.
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Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Epidemiology
Colorectal caner is the third most frequently diagnosed
cancer in the US men and women.
108,070 new cases of colon cancer and 40,740 new cases
of rectal cancer in the US in 2008. Combined mortality for
colorectal cancer 49,960 in 2008.
Worldwide approx. 1 million new cases p.a. are
diagnosed, with 529,000 deaths.
Incidence rate in India is quite low about 2 to 8 per
100,000
Median age- 7th decade but can occur any time in
adulthood
Lifetime risk
1 in 10 for men
1 in 14 for women
4. Clinical Anatomy
12-15 cm from anal
verge.
Diameter
4 cm (upper part)
Dilated (lower part)
Posterior part of the
lesser pelvis and in
front of lower three
pieces of sacrum and
the coccyx
Begins at the
rectosigmoid junction,
at level of third sacral
vertebra
5. Clinical Anatomy
.
Ends at the anorectal
junction, 2-3 cm in front of
and a little below the coccyx
Taenia of the sigmoid colon
form a continuous outer
longitudinal layer of smooth
muscle
Fatty omental appendices are
discontinued
6. Rectum is divided into 3
portions
3 distinct intraluminal
curves ( Valves of
Houston)
Lower rectum : 3 – 6 cm from
the anal verge
Mid rectum: 6 cm to 8 -10cm
from anal verge
Upper rectum: 8 cm to
12 -15cm from anal verge
7. Peritoneal Relations
Superior 1/3rd of the rectum
Covered by peritoneum on
the anterior
surfaces
and
lateral
Middle 1/3rd of the rectum
Covered by peritoneum on
the anterior surface
Inferior 1/3rd of the rectum
Devoid of peritoneum
Close proximity to adjacent
structure including boney
pelvis.
8. Arterial Supply
Superior rectal A – from
IMA; supplies upper
and middle rectum
Middle rectal A- from
Internal iliac A.
(supplies lower rectum)
Inferior rectal A- from
Internal pudendal A.
11. Lymphatic drainage
Upper and middle rectum
Pararectal
lymph
nodes,
located directly on the muscle
layer of the rectum
Inferior mesenteric lymph
nodes, via the nodes along the
superior rectal vessels
Lower rectum
Sacral group of lymph nodes
or Internal iliac lymph nodes
NODAL GROUPS
Perirectal
Common iliac
Internal iliac
Paraortic
17. Signs
Pallor
Abdominal mass
PR mass
Jaundice
Nodular liver
Ascites
Rectal metastasis travel along portal drainage to liver via
superior rectal vein as well as systemic drainage to lung
via middle inferior rectal veins.
18. Signs
Signs of primary cancer
Abdominal tenderness and distension – large bowel obstruction
Intra-abdominal mass
Digital rectal examination – most are in the lowest 12cm &
reached by examining finger
Rigid sigmoidoscope
Signs of metastasis and complications
Signs of anaemia
Hepatomegaly (mets)
Monophonic wheeze
Bone pain
19. WHO Classification of
Rectal Carcinoma
Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma
20. Dukes classification
Dukes A: Invasion into but not through the
bowel wall
Dukes B: Invasion through the bowel wall but
not involving lymph nodes
Dukes C: Involvement of lymph nodes
Dukes D: Widespread metastases
21. Modified astler coller
classification Stage A : Limited to mucosa
Stage B1 : Extending into muscularis propria
penetrating through it; nodes not involved
but not
Stage B2 : Penetrating through muscularis propria;
nodes not involved
Stage C1 : Extending into muscularis propria but not
penetrating through it. Nodes involved
Stage C2 : Penetrating through muscularis propria.
Nodes involved
Stage D: Distant metastatic spread
22. TX
T0
Tis
T1
T2
TNM Classification
Primary tumor cannot be assessed
No evidence of primary tumor
Carcinoma in situ: intraepithelial or invasion of lamina propria
Tumor invades submucosa
Tumor invades muscularis propria
T3
Tumor invades through the muscularis propria into pericolorectal tissues
T4a
Tumor penetrates to the surface of the visceral peritoneum
T4b
Tumor directly invades or is adherent to other organs or structures
Tis
T1
T2 T3
T4
Mucosa
Muscularis mucosae
Submucosa
Muscularis propria
Subserosa
Serosa
Extension to an adjacent organ
25. Stage 0 Rectal Cancer
Known as ―cancer in
situ,‖ meaning cancer
is located in the
mucosa.
26. Stage I Rectal Cancer
The cancer has grown
through the mucosa
and invaded the
muscularis (muscular
coat)
27. Stage II Rectal Cancer
The cancer has grown
beyond the muscularis
of the colon or rectum
but has not spread to
lymph nodes
28. Stage III Rectal Cancer
Cancer has spread to
the regional lymph
nodes (lymph nodes
near the colon and
rectum)
29. Stage IV Rectal Cancer
Cancer has spread
outside of colon or
rectum to other areas of
the body
30. Prognostic factors
Good prognostic
factors
Old age
Gender(F>M)
Asymptomatic pts
Polypoidal lesions
Diploid
Poor prognostic
factors
Obstruction
Perforation
Ulcerative lesion
Adjacent structures
involvement
Positive margins
LVSI
Signet cell carcinoma
High CEA
Tethered and fixed
cancer
31. Stage and Prognosis
Stage
5-year Survival (%)
0,1
Tis,T1;No;Mo
> 90
I
II
T2;No;Mo
T3-4;No;Mo
80-85
70-75
III
T2;N1-3;Mo
70-75
III
T3;N1-3;Mo
50-65
III
IV
T4;N1-2;Mo
M1
25-45
<3
33. Diagnostic Workup
History—including family history of colorectal cancer
or polyps
Physical examinations including DRE and complete
pelvic examination in women:
size, location, ulceration, mobile vs. tethered vs.
fixed, distance from anal verge and sphincter functions.
Proctoscopy—including assessment of
mobility, minimum diameter of the lumen, and distance
from the anal verge
Biopsy of the primary tumor
34. Diagnostic Evaluation
General
Clinical features.
Lab. Studies
Complete blood cell count
Blood chemistry profile
CEA
Evaluation
Determination of Occult Blood
Digital Rectal Examination
Proctosigmoidoscopy
Flexible Fibreoptic Sigmoidoscopy & Colonoscopy.
Barium Enema
• Urologic Evaluation
• Other Imaging studies
• CT, USG, MRI, Chest X-ray, FDG- PET scan, Endorectal U/S.
35. Colonoscopy or barium
enema
To evaluate remainder of large bowel to rule out
synchronous tumor or presence of polyp syndrome.
Figure: Carcinoma of the rectum. Doublecontrast barium enema shows a long
segment of concentric luminal narrowing
(arrows) along the rectum with minimal
irregularity of the mucosal surface.
36. Transrectal Ultrasound
Used for clinical staging.
80-95% accurate in tumor
staging
70-75%
accurate
in
mesorectal lymph node
staging
Very good at demonstrating
layers of rectal wall
Use is limited to lesion < 14
cm
from
anus,
not
applicable for upper rectum,
for stenosing tumor
Very useful in determining
extension of disease into
anal canal (imp to plan
sphincter
preserving
surgery)
Figure.Endorectal ultrasound
of a T3 tumor of the
rectum, extension through the
muscularis propria, and into
perirectal fat.
37. EUS : Accuracy
EUS CT
Depth of infiltration T staging
91% 71%
N staging
87% 76%
38. CT Scan
Part of routine workup of patients
Useful in identifying enlarged pelvic lymph-nodes and
metastasis outside the pelvis than the extent or stage of
primary tumor
Limited utility in small primary cancer
Sensitivity 50-80%
Specificity 30-80%
39. CT Scan
Ability to detect pelvic and para-aortic lymph nodes
is higher than peri-rectal lymph nodes(75% to 87%
vs. 45%)
Accuracy
T stage
60-80%
Accuracy
N stage
60-75%
Liver met.
70-79%
40. Figure:
Rectal cancer with uterine
invasion. CT scan shows a large
heterogeneous rectal mass (M) with
compression and direct invasion into the
posterior wall of the uterus (U).
Figure: Mucinous adenocarcinoma of the
rectum. CT scan shows a large
heterogeneous mass (M) with areas of
cystic components. Note marked luminal
narrowing of the rectum (arrow).
41. Magnetic Resonance
Imaging (MRI)
Greater accuracy in defining extent of rectal cancer
extension and also location & stage of tumor
Helpful in lateral extension of disease, critical in
predicting circumferential margin for surgical excision.
Different approaches (body coils, endorectal MRI &
phased array technique)
42. Figure: Normal rectal and perirectal
anatomy on high-resolution T2-weighted
MRI. Rectal mucosa (M), submucosa
(SM), and muscularis propria (PM) are
well discriminated. Mesorectal fascia
appears as a thin, low-signal-intensity
structure (arrowheads) and fuses with the
remnant of urogenital septum making
Denonvilliers fascia (arrows).
Figure: Mucinous adenocarcinoma of the
rectum. T2-weighted MRI shows high
signal intensity (arrowheads) of the cancer
lesion in right anterolateral side of the
rectal wall.
43. PET with FDG
Shows promise as the most sensitive
study for the detection of metastatic
disease in the liver and elsewhere.
Sensitivity of 97% and specificity of
76% in evaluating for recurrent
colorectal cancer.
cancer
rectum
prostate
Small bowel
bladder
pubic bone
44. Aims of treatment
Local control
Long-term survival
Restoration of bowel continuity and Preservation
of anal sphincter.
Bladder and sexual function and maintenance or
improvement in QOL.
Careful preoperative screening is crucial in
determination of the location of lesion and its
depth of invasion
46. Treatment Overview
Sx mainstay of treatment.
After curative resection the 5 year survival drops
from 80% in stage I to about 40% in stage III
disease.
Local recurrence remains a major site of failure
ranging from 5% in few selected series to about
40% in most reports.
LF associated with devastating symptoms that
severely affects the QOL & difficult to salvage
47. Principles of surgical
management
Removal of primary tumor with adequate margin.
T/t of draining LN.
Restoration of function
―En bloc‖ resection if necessary
48. PELVIC SUBSITES
Five subsites :predominant areas at risk for local
recurrence:
Mesorectal subsite (MS),
Posterior pelvic subsite (PPS)
Lateral pelvic subsite (LPS)
Inferior pelvic subsite (IPS)
Anterior pelvic subsite (APS)
49. PATERN OF NODAL
RECURRENCE
MS less common as it gets totally removed in
TME
PPS most common site of nodal recurrence 22
to 49% in various series.
LPS around 21%
IPS around 3 to 11%
APS around 5 to17%
50.
51. Surgical procedures for
Rectal ca
APR ( abdomino-perineal resection).
LAR ( Low ant. Resection)
Radical
Proctectomy & colo-anal anastomosis
Local excision
Transanal excision
Post. Proctotomy
Non-Radical
Trans-anal endoscopic microsurgery(TEM).
Ablative procedures
Endoscopic surgery
Fulguration
52. Local excision
For superficially invasive (T1) tumors with low
likelihood of LN metastases
Total biopsy, with further T/t based on pathology
Tumors within 8 to 10 cm of anal verge,
Encompass less than 40% of circumference of bowel wall,
well or moderately well differentiated histology,
No pathological evidence of venous or lymphatic vessel
invasion on biopsy
With unfavorable pathology patient should undergo
total mesorectal excision with or without sphincterpreservation:
Positive margin (or <2 mm), lymphovascular invasion,
Poorly differentiated tumors, T2 lesion
53. Local Excision Techniques
Transanal Excision.
Post proctotomy.
TEM
Fulguration
Endoscopic laser
Staging of such lesions should be performed using EUS
to minimize likelihood of doing a local excision for T3
tumors.
54. LAR
For tumors in upper/mid rectum allows
preservation of anal sphincter
Join colon to low rectum
Permanent colostomy if tumor too low
w
Reduced ability to define distant
disease
Difficulty localizing lesion
OR time and costs
55. Abdomino-perineal
resection
For tumors of distal rectum(lower 1/3rd) with distal edge
up to 6 cm from anal verge
Associated with permanent colostomy and high
incidence of sexual and genitourinary dysfunction
56. Procedure
Through combined abdominal and perineal
incisions, the anus, rectum, and sigmoid colon
are removed en bloc.
Also called Miles Resection
The proximal end of the bowel is exteriorized
through a separate stab wound as a
colostomy.
The distal end is pushed into the hollow of the
sacrum and removed via perineum
Performed to treat cancer of the lower
rectum—and diseases are too low for use of
stapling devices
60. Total mesorectal excision
Local failures are most often due to inadequate surgical
clearance of radial margins.
Conventional resection violates the mesorectal circumference
during blunt dissection, leaving residual mesorectum.
Excision of fascia enveloping the fat pad around the rectum
TME involves precise dissection and removal of the entire
rectal mesentery as an intact unit.
Local recurrence with conventional surgery averages approx.
25-30% vs. TME 4-7% by several groups (although several
series have higher recurrence)
63. Pelvic Exenteration
The surgeon removes the rectum as well as nearby organs such as the
bladder, prostate, or uterus if the cancer has spread to these organs.
A colostomy is needed after this operation. If the bladder is
removed, a urostomy (opening to collect urine) is needed.
High Anterior Resection
15 cm
Low Anterior Resection
Ultra-low Anterior Resection
Abdominoperineal Resection (APR)
65. SUMMARY OF BOWEL FUNCTION IN THE 2 GROUPS
Non-Radiation
(59 Patients)
No. of bowel movements/day
Medican (range)
4
Clustering
5
Awoken at night for movement
Incontinence
None
Occasional
Frequent
Wear a pad
Perianal skin irritation
Regularly use Lomotil ± Imodium
Unable to differentiate stool from gas
Liquid consistency (sometimes or always)
Unable to defer defecation >15 min
Need to defecate again within 30 min
Bowel function different to preoperative
2 (1-7)
83%
3%
14%
14%
–
93%
7%
0%
10%
12%
5%
15%
5%
19%
37%
61%
Chemoradiotherapy
(41 Patients)
7 (1-20)
22%
42%
37%
46%
–
44%
39%
17%
41%
41%
58%
39%
29%
78%
88%
93%
p Value
<0.001
–
–
–
<0.001
<0.001
–
–
–
<0.001
<0.001
<0.001
0.009
0.001
<0.001
<0.001
0.001
JH012804
67. Purpose of
Radio(chemo)therapy
To lower local failure rates and improve
survival in resectable cancers
To allow surgery in primarly inoperable cancers
To facilitate a sphincter-preserving procedure
To cure patients without surgery: very small
cancer or very high surgical risk
69. PREOPERATIVE CHEMORADIATION
NSABP R-03 : improved DFS & OS
German trial : improved locoregional control.
REGIMENS :
5- FU : 225 mg/ m2 – daily continous infusion
Capecitabine : 825 mg/ m2 BD on days of radiation
5- FU : 400 mg / m2 IV bolus + leucovorin 20 mg /m2
IV bolus for 4 days : wk 1 & wk 5.
70. POSTOPERATIVE CHEMORT :
EORTC 22921 trial : improved DFS & OS.
MOSAIC trial : Addition of oxaliplatin + 5- FU + leucovorin
.
REGIMENS :
5-FU : bolus weekly regimen ( leucovorin 20 mg/m2 over 2
hrs : 5- FU 500 mg/ m2 bolus
if no neoadjuvant chemoRT :
Weekly Roswell Park regimen : 5-FU + leucovorin
( leucovorin 500 mg /m2 given over 2 hrs followed by 5-FU
bolus ) : weekly over 6 wks then 2 wks rest .
mFOLFOX 6
Capecitabine 1000 – 1250 mg/ m2 from day 1-14 ( 21 day
cycle )
71. Role of Radiotherapy
Neo-adjuvant/Adjuvant RT in resectable Ca Rectum
pre-op
post-op
RT in locally advanced rectal cancer
pre-op for down staging
IORT
Definitive RT
unfit for surgery
Palliative RT – Pain, bleeding etc.
72. ADVANTAGES OF PRE
OP CT+RT
•
Down staging, hence increased resectability
•
Decreased risk of dissemination during surgery.
•
Radiation more effective with tumour cells
highly vascular.
•
Less serious bowel toxicity due to easy
exclusion.
•
Possibility of increasing sphincter preservation
in borderline cases.
73. TARGET VOLUME
Site of local involvement
spread to other organ - sacrum, vagina or
prostate
Whole of the sacrum
Posterior margin should be beyond the sacrum
Anterior border 2-3 cm anterior to the promontry
of sacrum to include common iliac LN
74. Positioning
Prone position with belly
board
Purpose is to displace
bowel superior and
anteriorly & bladder
anteriorly
Bladder distension
Blocks are used to spare
the posterior muscle and
soft tissues behind the
sacrum and small bowel.
75. Treatment energy
PA portal with 6MV to decrease bladder dose
Lateral portal requires 10/15 MV to increase depth
dose and decrease dose to hip joints
30 degree wedges improves distribution
Portals
4 fields (AP, PA, two lateral fields)
3 fields (PA, two lateral fields)
2 fields(AP,PA-rarely used)
76. PA Borders – Pre Op
Case In most cases upper border
lies at L5-S1 junction to
cover Sacral promontary.
Inferior margin should be 34 cm below inferior tumour
extent on sigmoidoscopy.
For upper rectal Ca, inferior
border upto dentate line(
cover all mesorectum)
Lateral border -1.5 cm
beyond the bony pelvic wall
77. Lateral portal
Upper Border- L5-S1
Lower Border 3-5 Cm below
inferior Tx extension
Posterior border should be
atleast 1 cm behind sacral
convexity
Anterior border at pubic
symphysis*(T3-T4)
78. Issues in Postoperative RT
of Rectum
Increased risk of bowel toxicity
Adhesions
Bowel sags in pelvic cavity
Large portals
1.
2.
Anastomotic site in ANTERIOR RESECTION
Perineal scar in APR
79. PA Borders – Post Op
Case
In case of APR, inferior border
should cover perineal scar
8-30% scar recurrence if scar
not included in field
While only 2% reoccur if scar
included in portal
80. Lateral Borders – Post Op
Case
In case of APR, inferior border
should cover perineal scar
86. Portals- Two Fields : APPA
Parallel opposing not commonly used
High dose to bladder and bowel
Used in palliative cases & when bladder or
anterior wall involved
90. Pre-Op radiotherapy
Short course
25 Gy in 5 daily fractions of 5 Gy given in 1
week.
Long course
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy(2 lat. Fields)
91. Post-Op Radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 week
Phase 2 (optional)
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy(2 lat. fields)
92. Palliative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–14.4 Gy in 3–8 daily fractions of 1.8 Gy(2 lat fields)
A hypofractionated regimen can be used
30–36 Gy in 5–6 fractions of 6 Gy once weekly given in 5–
6 weeks.
93. Dose limitations
Small bowel- 45–50 Gy
Femoral head and neck- 42 Gy
Bladder -65 Gy
Rectum- 60 Gy
96. TARGET VOLUMES
CTVA: Defined to be the regions that would always be
treated for rectal cancer
Internal iliac
Pre-sacral
Peri-rectal
CTVB:
External iliac nodal region
CTVC:
Inguinal nodal region
97. GUIDELINES
Lower Pelvis:
The caudal extent minimum of 2 cm caudal to
gross disease, including coverage of the entire mesorectum
to the pelvic floor
Extension of CTVA does not need to go more than a few
millimeters beyond the levator muscles unless there is
radiographic evidence of extension into the ischiorectal
fossa
For very advanced anal or rectal cancers, extending
through the mesorectum or the levators, add ~1-2 cm
margin up to bone wherever the cancer extends beyond the
usual compartments
An MRI and/or PET/CT scan is strongly recommended in
such cases.
98. Mid pelvis
The posterior and lateral margins of CTVA should
extend to lateral pelvic sidewall musculature or, where
absent, the bone.
Anteriorly extend CTVA to ~1 cm into the posterior
bladder, to account for day-to-day variation in
bladder position.
Include the posterior portion of the internal
obturator vessels (which lie between the external and
internal iliacs in the mid pelvis) with CTVA.
99. Upper pelvis:
Superior extent - the rectosigmoid junction or 2 cm
proximal to the superior extent of macroscopic disease
in the rectum/peri-rectal nodes.
This defines how much of the distal large bowel
within CTVA.
Properly cover the internal iliac and pre-sacral
regions.
The most cephalad aspect of CTVA - the common
iliac vessels bifurcate into external/internal iliacs
(landmark: sacral promontory).
100. Indications for elective
irradiation (CTVB+CTVC)
Elective coverage of the inguinal and external iliac regions
should be routine for anal carcinoma.
For rectal carcinomas extending into gynecologic or
genitourinary structures, the external iliac region should be
added (i.e. elective nodal coverage = CTVA + CTVB for
these cases).
Include the external iliacs for rectal cancers that extend
into the anal canal.
Electively irradiate the inguinal nodal region for rectal
adenocarcinomas that extend to the anal verge or peri-anal
101. OAR
The femoral head and neck should be avoidance
structures.
The small and large bowel are important structures to
consider when planning treatment.
The entire abdominal contents need to be contoured up to
~ 1 cm above the PTV.
Absolute volume of bowel (in cc) is more important than
relative volume (in %).
102. IORT radiation therapy (IORT) delivers a
Intra-operative
concentrated dose of radiation therapy to a tumor
bed during surgery
Dose range from 1250-2000cGy.
Patient must be a surgical candidate in order to be
eligible for IORT
Reserved for pts. with early-stage disease.
103. Maximum effect, while minimizing recurrence
Delivered immediately after tumor is removed,
helping to destroy the microscopic tumor cells
that may be left behind
The tumor site is typically at high risk for
recurrence & traditional RT requires a recovery
period after surgery, which leaves microscopic
disease in the body for longer
Spares healthy tissues and organs
Shortened treatment times
IORT T/t itself takes about 4 to 5 min.
104. A "boost" for traditional radiation pts.
Patients who must receive additional radiation
therapy following surgery can receive a boost of
radiation during IORT
After they have recovered from the surgical
procedure, they can continue with their RT with
fewer complications.
105.
106. Endocavitary Radiation
Propagated initially by Papillon and Sischy
High doses low energy radiation delivered using
50 KVp unit
Initially utilised applicator cones of 2.4 – 2.9 cm
dia
Later intra-luminal catheters were used after
development of after-loading techniques.
Dose at 1 cm depth = 1/3 rd of surface dose
Since, very small volume very high doses can be
tolerated
Multiple treatment done till CR achieved
107. Treatment Recommendations
Stage
Rectal cancer
~5-year LF/OS
I
• TME with APR or LAR.
• If pT1-2N0, no adj. treatment.
• Local excision for favorable tumors (<3 cm
size, <30% circumference, within 8 cm of anal
verge, well-moderately differentiated; margin
>3 mm, no LVSI/PNI).
favorable T1 lesions- observation.
T2 lesions - adjuvant 5-FU/RT
<5% LF
90% OS
II and III
(locally
resectabl
e)
• Pre-op 5-FU/RT LAR/APR adjuvant 5FU-based therapy × 3 cycles (preferred)
• If surgery initially then adjuvant 5-FU × 2
cycles concurrent chemoRT 5-FU ×2
cycles
T3N0 and T1-2N1:
5–10% LF
80% OS
T4N0 and T3N1:
10–15% LF
60% OS
T4N1 and T3/4N2:
15–20% LF
40% OS
108. Stage
III
(T4/ Locally
unresectable
)
Rectal cancer
If obstructed, diverting colostomy or stent
placed definitive treatment. 5-FU/RT
resection if possible. Consider
IORT for microscopic disease (after 50 Gy
EBRT, give IORT 12.5–15 Gy) or
brachytherapy for macroscopic disease
adjuvant 5-FU-based therapy*
IV
Individualized options, including combination
5-FU-based chemo alone, or chemo ± resection
± RT
Recurrent
Individualized options.
If no prior RT, then chemoRT surgery ±
IORT or brachytherapy.
If prior RT, then chemo surgery ± IORT or
brachytherapy as appropriate.
~5-year LF/OS
110. Pre-op RT vs. surgery alone
Swedish Rectal Cancer Trial(NEJM 1997;336:980 ): 1168 patients
randomised to 25 Gy (5x5) PRT or no RT.
Surgery alone
Preop. RT
Rate of local recurrence 27%
11%
p<0.001
5-year overall survival 48%
58%
p=0.004
Dutch Colorectal Cancer Group (Kapiteijn E. NEJM
2001;345:638): 1861 patients randomised TME vs
PRT+TME
TME
PRT+TME
Recurrence rate 2.4%
8.2%
OS
ns
ns
111. Pre-op vs. post-op Chemo RT
Randomized trial of the German Rectal Cancer study Group (Sauer
R et al. N Engl J Med 2004;351:1731-40):
cT3 or cT4 or node-positive rectal cancer
50.4 Gy (1.8 Gy per day)
5-FU: 1000 mg/m2 per day (d1-5) during 1. and 5. week
Preop CRT
Patients
5 y. OS
5 y. local relapse
G3,4 toxic effects
Postop CRT
N=415
76%
6%
27%
N=384
74% p=0.8
13% p=0.006
40% p=0.001
• Increase in sphincter-preserving surgery with preop Th.
112. • MRC CR07/NCIC-CTG C016 (Sebag-Montefiore et al.
2009): 1350 pt. with resectable rectal cancer randomized.
▫ 25 Gy/5# + Surgery (TME)
▫ Surgery (TME) + (45 Gy & 5 FU)
CRT
5 y. OS
5 y. local relapse
DFS
Preop RT
80.8%
4.4%
79.5%
Postop
78.7%
10.6%
74.5%
113. Polish Trial
• Polish Study (Br J Surg. 2006): 316 pts with resectable T3-
4 rectal cancer, no sphincter involvement, tumor palpable
on DRE (1999-2002).
– RT short-course RT with 5 Gy/d x 5 days + Surgery
(TME)
– CRT 50.4 Gy (1.8 Gy /# over 5.5 weeks) + bolus 5-FU
325 mg/m²/d + LV x 5 days 1st and 5th wks of RT +
Surgery (TME)
Preop SCRT Preop LCRT
5 y. OS
5 y. local relapse
DFS
67.2%
9.0%
58.4%
66.2%
14.2%
55.6%
114. Post-op chemo, RT, and/or ChemoRT
GITSG 7175 (Thomas and Lindblad, 1988): 227 patients with stage B2-C
rectal CA randomized postoperatively to:
no adjuvant therapy vs.
chemo alone vs.
RT alone vs.
concurrent chemoRT.
Result: Chemo-RT arm improved 5-year OS (54%) and LR(10%) over
observational arm OS (27%) & LR (25%).
Mayo NCCTG 79-47-51 (NEJM 1991): 204 patients with T3/4 or
LN+(B2-C) randomized to
post-op RT (45–50.4 Gy) vs.
chemoRT (bolus 5-FU concurrent).
Result: Chemo-RT improved LF (25 14%), DFS, and OS (48 58%)
vs. RT alone.