This document discusses the forward intensity-modulated radiation therapy (IMRT) technique known as field-in-field (FIF) for whole breast radiotherapy. It begins by explaining how FIF uses multiple subfields in addition to the main tangential fields to improve dose homogeneity throughout the breast. Studies show improved homogeneity decreases skin toxicities. The document then evaluates three FIF techniques - single pair of subfields, multiple pairs of subfields, and alternate subfields. It finds the alternate subfields technique provides the best dose distribution and target coverage while being less time-consuming than other techniques. Finally, the document discusses how FIF with lung blocks further reduces lung dose compared to physical wedges.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
Accelerated partial breast irradiation is an alternative to whole breast irradiation in carcinoma breast patients Post breast conserving surgery with equivalent outcome, less duration & less burden on the patient.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
Accelerated partial breast irradiation is an alternative to whole breast irradiation in carcinoma breast patients Post breast conserving surgery with equivalent outcome, less duration & less burden on the patient.
Immobilization and setup for Prone Breast Radiotherapy- A Therapist approachTeekendra Singh Faujdar
Immobilization and daily treatment setup for Prone Breast Radiotherapy is always challenging for radiation therapist team. This presentation will highlights the possibilities of the different immobilization and setup approaches in therapist perspective.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
Journal Club: Dose-escalated simultaneous integrated boost radiotherapy in early breast cancer (IMPORT HIGH): a multicentre, phase 3, non-inferiority, open-label, randomised controlled trial
“Alopecia-less” Whole Brain Radiotherapy: Preliminary Experience and OutcomesTodd Scarbrough
Whole brain radiotherapy (WBRT) is indicated for many patients with brain metastases. Most of these patients develop alopecia with standard WBRT technique (opposed lateral fields). A multi-field, very conformal beam arrangement might limit scalp dose thereby resulting in less or eliminated alopecia toxicity. We present our initial clinical experience with a new technique of WBRT, as well as limited comparative analyses of dosimetric data.
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
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
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.
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.
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.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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
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
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.
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.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. Introduction
• Prime objective for the planning : to deliver uniform dose
throughout the target volume, with adequate tumour coverage
and minimise dose to normal tissue.
• Evolution of treatment planning : conventional to 3D conformal
to IMRT.
• Most patients with early breast cancer undergo breast-
conserving treatment consisting of wide excision and post-
operative whole-breast radiotherapy. This form of
postoperative radiotherapy reduces the risk of local recurrence
and results in long-term survival similar to that obtained
with mastectomy.
• Thus, postoperative breast therapy is a standard treatment
3. • In recent years, the field-in-field (FIF) technique (i.e.,
Forward IMRT) has become a widely performed
method of administering tangential whole-breast
radiotherapy.
• The use of the FIF technique permits reductions in
the size of the high-dose region and better
homogeneity index.
4. Why homogeneity Matters?
Whole breast irradiation often leads to both acute and
long term toxicities such as :
• moist desquamation
• pain
• breast discomfort
• breast hardness
Many studies shown that toxicities were associated with
dose inhomogeneity (hot spots).
5. • Pignol et al
358 patients were randomized in a multicenter
double-blind clinical trial to either 2-dimentional
treatment planning or IMRT planning with improved
dose homogeneity.
The incidence of moist desquamation in the IMRT
group was 31.2% vs 47.8%, p=0.002
Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to
reduce acute radiation dermatitis. J Clin Oncol. 2008 May 1;26(13):2085-92.
6. • Donovan et al
306 patients were randomized to 2D or 3D IMRT.
After 5 years 240 patients data was available for
analysis.
The 2D arm patients were 1.7 times more likely to
have changes in breast appearance than IMRT
group
Donovan E, Bleakley N, Denholm E, et al. Randomised trial of standard 2D radiotherapy (RT) versus
intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol. 2007 Mar;82(3):254-
64.
7. Breast V105%
and V110%
were significantly associated
with increase in acute skin toxicity
• V110%
< 200cc: 31% grade >2 skin toxicity
• V110%
> 200cc: 61% grade >2 skin toxicity
Vicini et.al. Int.J. Radiat Oncol Biol Phys 54: 1336-1344; 2002.
8. • The use of IMRT in the treatment of the whole
breast results in a significant decrease in acute
dermatitis, edema, and hyperpigmentation and a
reduction in the development of chronic breast
edema compared with conventional wedge-based
WBRT.
Harsolia et.al. Int.J. Radiat Oncol Biol Phys 68: 1375-1380; 2007
9. • Inverse Planning:
The user specifies the
goals, the computer then
adjusts the beam
parameters to achieve the
desired outcome.
• Forward Planning:
The beam geometry i.e
beam angle, shape,
modifier, weights etc. is
first defined, followed by
calculation of the 3D dose
distribution.
10. IMRT for Breast
Radiotherapy
Many beams with different angles may help with
dose conformality, but will lead to higher doses in
lung, heart and contralateral breast
Tangential beams provide best lung, heart and
contralateral breast sparing.
11.
12. FIELD-IN-FIELD
TECHNIQUE
• Comprises of two tangential open fields and multiple
subfields to achieve desired homogeneity.
• An open beam configuration is first calculated
and evaluated.
• 4+ subfields per gantry angle are used to produce an
optimal breast plan.
• No wedges.
FORWARD PLANNING
13. Subfields
• Generally have 1 lung block and 3 additional subfields per
gantry angle.
• Lung block is formed by fitting the MLC’s to the shape of
the lung. Aids in lateral hot spots.
• Additional subfields are generated by manually fitting
MLC’s to “hot” areas. Ex. 115%, 110%, etc…
15. Weighting of Subfields
• Generally, the open beam portion receives ~ 80%
of the dose while the subfields contribute ~20%.
• This makes FP IMRT similar to conventional
treatment .
• Minimizes effects of patient movement on target
coverage.
• Conventional breast plans are generally normalized
to 97% .
• Normalization for IMRT plans are based on
coverage.
16. Determination of the optimal method for the field-in-field
technique in breast tangential radiotherapy
Hidekazu Tanaka, Shinya Hayashi, and Hiroaki Hoshi
J Radiat Res. 2014 Jul; 55(4): 769–773.
• Several studies have reported the usefulness of the
field-in-field (FIF) technique in breast radiotherapy.
However, the methods for the FIF technique used in
these studies vary.
• There were no reports of comparisons among FIF
techniques.
17. • This study, classified the methods used for the FIF technique
into three categories :
• The single pair of subfields method -
• In the SSM, each main field was copied as a pair of subfields.
• The MLCs were manipulated to shield the areas of the breast
receiving any dose (mainly at 105–107% of the prescription
dose).
• The dose to shield the MLCs was determined such that the
isodose cloud disappears.
• This method was composed of four fields, including the main
fields.
18. • The multiple pairs of subfields method -
• Three pairs of subfields were generated.
• The MLCs were set to block the dose level at 1–
2% lower than the maximum dose (Dmax), and
this was followed by a 3–5% dose reduction
(mainly at 102–105% of the prescription dose).
• This method comprised eight fields, including the
main fields.
19. • The alternate subfields method -
• First, the medial main field was copied as the first
subfield.
• The MLCs were set to block the dose level at 1–2%
lower than the Dmax.
• Dose calculation was performed. The beam weight
of this subfield was added until the dose cloud
disappeared.
20. • Second, the lateral main field was copied as the
second subfield.
• The MLCs were set to block the dose level at 2–
3% lower than the dose blocked at the first
subfield.
• Dose calculation was performed again, and the
beam weight of this subfield was added until the
dose cloud disappeared.
21. • Finally, the medial main field was copied again as the
third subfield.
• The MLCs were set to block the dose level at 2–3%
lower than the dose blocked at the second subfield.
• After recalculation, the beam weight of this subfield
was added until the dose cloud disappeared.
• This method was comprised of five fields, including
the main fields.
22.
23. Beam's eye view for typical
subfield. The subfield was
manipulated to shield the
areas of the breast receiving
any dose cloud.
24. • The Dmax to the PTV and the volumes of the PTV
receiving 100% and 95% of the prescription dose
(V100% and V95%, respectively) were calculated.
• The homogeneity index (HI) was calculated.
25. • RESULTS:
• This planning study included 51 patients with early
stage breast cancer: 20 with right-sided breast
cancer and 31 with left-sided breast cancer.
• The median age of the patients was 53 years
(range, 26–76 years).
26. Table
Average of dose parameters of PTV for each method
SSM (± SD) MSM (± SD) ASM (± SD)
Dmax 52.5 (± 0.7)52.2 (± 0.6)52.2 (± 0.7)
V100% 52.6 (± 16.7) 48.7 (± 14.9) 60.3 (± 14.2)
V95% 93.7 (± 4.2)93.2 (± 4.1)94.1 (± 3.5)
• The average V100% with ASM was
significantly higher than that with SSM and
MSM
27. • The ASM outperformed the SSM and MSM for two
possible reasons:
• First is that the number of subfields used is more
suitable for the population under study. When the
number of subfields is large, the dose to the PTV decreases, but
when the number of subfields is small, the full range of
advantages of the FIF cannot be fully obtained.
• The biggest advantage of the ASM is its ability to
perform dose calculation each time a subfield is
added.
28. Key note :
• Radiotherapy planning with SSM required a relatively short
time, because only a few subfields need to be generated.
• Because SSM is the simplest of the three methods, it
should be the method of choice for patients with small
breasts.
• The method most commonly reported is the one in which
multiple pairs of subfields are used. This method was
classified as MSM. The planning time is longer for this
method because of the high number of subfields.
29. • MD Anderson Cancer Centre group introduced in terms
of number of subfields, fewer subfields than MSM but
more than SSM. This method was classified as ASM.
• The most significant feature of this method is the
recalculation each time when creating subfields, and the
addition of subfields alternately.
• Of note, patients in the thin breast group derived similar
benefit with ASM and SSM.
• ASM resulted in better dose distribution regardless of
the breast size.
30. Nagoya J. Med. Sci. 77. 339 ~ 345, 2015
Evaluation of the field-in-field technique with lung blocks
for breast tangential radiotherapy
Hidekazu Tanaka et al.
• This study evaluated the FIF technique with lung
blocks for breast tangential radiotherapy.
• Compared to irradiation with physical wedges
(PWs), the use of the FIF technique permits
reductions in the size of the high-dose region.
• The impact of respiratory motion is smaller with the
use of the FIF technique than with the use of PWs.
31. • Several authors reported the advantages of lung-
blocked subfields, which help to reduce the dose
received by the lungs.
• However, the use of multileaf collimators (MLCs) to
block the lungs also results in blockade of some
parts of the planning target volume (PTV). This
could decrease the doses delivered to the PTV.
• In this study,16 patients with early-stage breast
cancer, including 9 patients with right-sided cancer
and 7 patients with left-sided breast cancer.
32. • Two opposed tangential fields were created without
PWs.
• The open field was copied as the subfields & on the
beam’s eye view, the MLCs were set to block the
hotspots.
• Then, dose calculation was performed. The beam
weight of this subfield was increased until the dose
cloud disappeared.
33.
34.
35. • The volumes of the ipsilateral lung receiving 20, 30,
and 40 Gy (V20Gy, V30Gy, and V40Gy,
respectively) were calculated.
• The volumes of the PTV receiving 100 and 95% of
the prescription dose (V100% and V95%,
respectively) and the mean dose (Dmean) to the
PTV were also calculated.
• The amounts of change in the FIF plan and PWs
were evaluated.
36. • In this study, lung blocks were useful for reducing
the dose delivered to the lungs, but a simultaneous
decrease in the PTV was observed.
• FIF plan was advantageous over the use of physical
wedges.
40. (a) Main field without multileaf collimator (MLC) blocking.
(b)drawing MLCs to block 112 % isodose cloud
(c) drawing MLCs to block out 106 % (d) drawing MLCs to block out 102%
42. The “skin flash” problem in
Inverse Planning
• Conventional : margin added
to field edge to allow for
uncertainties.
• IMRT : intensity remains
“zero” outside PTV. No skin
flash
43. • So, previously tissue equivalent material where
added during planning over the breast, and then
plan were made. So, in actual setup, when MLCs
opened up, actual PTV used to be in air.
44. • But now, after forward planning, MLCs are opened
to desired width in air, to allow “skin flash”.
45.
46. • To sum up:
• Conformality adaptions are limited
• Tangential beams are used for main field , as increasing number
of beams will increase lung dose.
• As main field is copied and subfields created to adjust beam
parameters,and then we do dose calculation- so, it is forward
planning.
• Dose homogeneity is improved.
• Less time taking.
• Simple planning.