This document provides information on evaluating and staging esophageal cancer. It discusses various diagnostic tests and their abilities to determine the extent of disease. Complete history and physical exam provide baseline information. Imaging tests like barium swallow, CT scan, PET scan, EUS and EBUS are used to characterize the primary tumor and detect metastatic spread. Endoscopy with biopsy is needed for tissue diagnosis and can provide details on tumor size, location and involvement. Together these tests are used to determine the clinical stage of disease, which guides prognosis and treatment planning.
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
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
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
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
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
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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.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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!
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
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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.
2. Complete history, physical examination – cornerstone of diagnostic evaluation.
Laboratory profile - anemia, hypoalbuminemia, elevated PT/INR (vitamin K
deficiency, possibly elevated liver function tests if metastatic disease).
Serological markers of cancer – No high Sn/Sp in esophageal SCC.
Evaluation - dependent on tissue diagnosis through biopsy f/b staging for
prognosis & therapeutic planning.
3. BARIUM SWALLOW
- Was used traditionally when UGIscopy was not commonly available.
- Identifies polypoid tumors, Apple core constrictions, strictures with mucosal
integrity
- DCBS is more useful & informative in the absence of UGIscopy availability –
PPV – 42%.
- CURRENT INDICATIONS –
- Dysphagia & weight loss – endoscopy not readily available.
- Stricture precludes complete endoscopic evaluation – barium studies -
demarcate distal extent
of the tumor.
5. Standard initial diagnostic modality if Ca esophagus is a D/D
Scopy should include - tumor morphology, distance from incisors, length of
lesion, % of circumferential involvement, position wrt GEJ (length of extension
into cardia if present).
Skip lesions; Presence, location, and length of Barrett esophagus
Several Biopsies - increase the diagnostic accuracy.
To increase diagnostic yield –
- >= 6 biopsies
- Don’t biopsy necrotic/ fibrotic area
Brush Cytology – tight malignant strictures – Obtain Brushings Before Biopsy
7. First radiologic test in staging evaluation endoscopically diagnosed esophageal
cancer.
Esophageal wall thickness > 5 mm on CT scan – abnormal.
Main utility - CT – detect distant systemic disease (hepatic, adrenal, lung
mets).
In AdenoCa of GEJ and gastric cardia, peritoneal mets - more likely than with
SCC. – CT inferior to D-lap in peritoneal mets detection.
Can exclude T4 d/s – Sn – 25, Sp-94%
8. Obliteration of fat plane between esophagus & Aorta, TB, Pericardium -
suggestive of invasion.
Thickening/ indentation of membranous trachea & L main bronchus -suggestive
of invasion
Ao-Eso contact angle extends beyond 90 degrees of the circumference - 80%
accuracy infiltration.
CT scan cannot reliably distinguish the various T stages
T1 & T2 lesions - esophageal wall thickness -5 -15 mm, and T3 lesions > 15 mm
thickness
MS, Abd Lymphadenopathy - suboptimal with CT (CT diagnostic criteria - Size
alone)
Intrathoracic, abd nodes > 1 cm; SCLN short axis > 0.5 cm; retrocrural nodes >
0.6 cm – Pathologic
LN in CT - Sn – 50%, Sp - 83%
9. Staging:
Figure Esophageal cancer with tracheal invasion. CT scan shows
circumferential wall thickening of the proximal esophagus (arrowheads),
which shows irregular interface with the posterior wall of the trachea
(arrows), indicating direct extension into the lumen
Figure Esophageal cancer with aortic invasion. An arc (bent arrow) of
the contact between the esophageal cancer (arrows) and the aorta
(arrowheads) is more than 90 degrees, indicating aortic invasion.
10.
11. Now routinely used in the staging of esophageal cancer.
Detect primary tumors – Sn – 78 – 95%(less for T1/T2) -
Functional assessment of metabolically active LN/ mets
Distinguish between inflammatory and malignant LN involvement
SCC > EAC in FDG avidity
Parameter Sn Sp Accuracy
Primary Tumor 78-95 %
LN 38 – 82%(lower in
mid & lower MS)
76 – 95%
Distant Mets 69% 93% 84%
Management
strategies
changed due to
PET
3 – 20%
12. Routinely performed when - standard staging methods (CT and EUS) show
regional invasive cancer with no distant metastatic disease
Is an independent predictor of OS in patients with non-metastatic
esophageal cancer.
Poor spatial resolution – insufficient to separate the primary Tr & juxtatumoral
lymph LN nodes secondary to the interference from the primary tumor.
13. Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT PET demonstrates para-aortic lymph node
metastases showing increased FDG uptake (arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in
diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan
14. Assess depth of invasion of cancer.
Dedicated
EUS operating at frequencies of 7.5 and 12 MHz
The deeper the tumor the higher the sensitivity of EUS.
Discrimination of invasion of mucosa & submucosa (i.e., the T1a versus T1b stages) –
controversy
Drawbacks – Overstaging(MC in T2; peritumoral edema); Understaging(Tr penetration
below resoln of EUS.
Parameter Sn Sp Accuracy
T staging
T1a
T1b
T4
85%
86%
87%
86%
84%
N (EUS FNA) > 85?% >85% >85%
15. Modified EUS criteria – for identifying Malignant LN
Standard criteria -
- hypoechoic
- smooth border
- round
-width >5 to 10 mm
Extra-criteria -
- EUS-identified celiac lymph nodes
- >5 lymph nodes
- EUS T3/4 tumor.
16. EUS:
assess the depth of penetration and LN involvement. Limited by the degree of obstruction.
Compared with EUS, CT is not a reliable tool for evaluation of the extent of tumor in the esophageal wall.
Fig. —55-year-old man with T2 esophageal tumor (m) shown on endoscopic
sonogram. Note alternating hyperechoic and hypoechoic layers (arrowheads) of
normal esophageal wall as seen on sonography. Innermost layer is hyperechoic
and corresponds to superficial mucosa. Second layer is hypoechoic and
corresponds to deep mucosa and muscularis mucosae. Third layer is again
hyperechoic and corresponds to submucosa and its interface with muscularis
propria. Fourth layer is hypoechoic and corresponds to muscularis propria, and
outer fifth layer is hyperechoic and corresponds to adventitia.
17.
18.
19. Accurate assessment of depth of infiltration, LVI, degree of differentiation
Estimates Local LN Mets
Used predominantly in therapeutics in superficial EAC.
20. INDICATIONS –
- obstructing esophageal tumor – inability to progress scope & do EUS.
- Mid- and upper esophahgeal Trs.
SIGNS OF TB INVOLVEMENT -
- widened carina
- external compression
- tumor infiltration and fistulization – contraindicate resection
If erythema, edema - Brush cytology/ Bronchial Biopsy
Recent studies – EBUS - greater accuracy in evaluating TB invasion by esophageal
neoplasia compared with conventional bronchoscopy, CT, and EUS.
EBUS combined with EUS – Libermann et al – in upper & middle eso Trs – easier sampling
of periTr LN- Less false positivity
21. Selectively done –
Excludes small volume intraperitoneal mets(Occult IP/IT distant mets)
Excludes Liver Cirrhosis
GEJ/ Distal esophagus Trs (mainly EAC) with extensive gastric involvement –
sampling regional LN
Liver/ peritoneal mets are suspected, confirmation required.
Limits unnecessary negative laparotomy
SOS Lap US of liver
With better PET-CT & EUS – staging lap – less indicated.
Effect on CT &
EUS nodal status
Upstaged in Downstaged in Changed
management in
Laparoscopy 0 – 21% 4 – 19% 20%
22. No serosal covering, direct invasion of contiguous structures occurs early.
Commonly spread by lymphatics (70%)
Lymph node involvement increases with T stage.
T1 – 14 to 21%
T2 – 38 to 60%
25% - 30% hematogenous metastases at time of presentation.
Most common site of metastases are
lung, liver, pleura, bone, kidney & adrenal gland
Median survival with distant metastases – 6 to 12 months
23.
24. a: Includes nodes previously labeled
as “M1a”
b : “M1a” designation is no longer
recognized in the 7th edn. of the
AJCC system
25.
26. Chauges.in 8th edition
Classification Staging was separated clinical, pathological
and pathological prognostic staging
L-category The definition of EGJ cancer was changed to
tumors centered within 2 cm of the IDG
T-category Subcategorized Tla and Tlb were used for
pathological and pathological prognostic
staging. T4a includes the peritoneum
G-categor G4 was eliminated and undifferentiated type
was categorized as G3
Notable changes between the 7th and 8th editions
EGJ: esophagogastric junction.
27.
28.
29. Group T N M Grade
0 Tis (HGD)
N0
M0
1, X
IA T1 1-2, X
IB T1 3
T2 1-2, X
IIA T2 3
IIB T3
Any
T1-2 N1
IIIA T1-2 N2
T3 N1
T4a N0
IIIB T3 N2
IIIC T4a N1-2
T4b Any
Any N3
IV Any Any M1
30. cStage group cT cN cM
Squamous cell carcinoma
0 Tis N0 M0
I T1 N0–1 M0
II T2 N0–1 M0
T3 N0 M0
III T3 N1 M0
T1–3 N2 M0
IVA T4 N0–2 M0
T1–4 N3 M0
IVB T1–4 N0–3 M1
Adenocarcinoma
0 Tis N0 M0
I T1 N0 M0
IIA T1 N1 M0
IIB T2 N0 M0
III T2 N1 M0
T3–4a N0–1 M0
IVA T1–4a N2 M0
T4b N0–2 M0
T1–4 N3 M0
IVB T1–4 N0–3 M1
Table 2
Clinical (cTNM) stage groups