1) The document discusses different radiotherapy techniques for head and neck tumors including conformal radiotherapy and IMRT.
2) It describes target volumes according to ICRU guidelines and the delineation of lymph node levels in the neck.
3) Examples are provided of different conformal radiotherapy plans including an "antique" 7-field plan, a "middle age" 9-field plan, and an "art nouveau" 10-field plan with comparisons of dose distributions and organ at risk sparing.
4) Inverse planning IMRT is also discussed with an example cumulative segment dose distribution.
Basic information about Elekta and its familiar with xvi and Iviewgt protocols and there import and defining the Target area clip box registration along with HEXAPOD 6Dof couch & Apex Dmlc setup
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
Organs at risk delineation is as critical as delineation of the target volumes. This atlas presentation is made from a reference material which is quoted in the second slide.
Basic information about Elekta and its familiar with xvi and Iviewgt protocols and there import and defining the Target area clip box registration along with HEXAPOD 6Dof couch & Apex Dmlc setup
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
Organs at risk delineation is as critical as delineation of the target volumes. This atlas presentation is made from a reference material which is quoted in the second slide.
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
Conventional radiotherapy treatments are delivered with radiation beams that are of uniform intensity across the field (within the flatness specification limits). Wedges or compensators are used to modify the intensity profile to offset contour in irregularities and produce more uniform composite dose distributions such as in techniques using wedges. This process of changing beam intensity profile to meet the goals of a composite plan is called intensity modulation
IMRT refers to a radiation therapy technique in which nonuniform fluence is delivered to the patient from any given position of the treatment beam to optimize the composite dose distribution. The optimal fluence profiles for a given set of beam directions are determined through inverse planning. The fluence files thus generated are electronically transmitted to the linear accelerator, which is computer controlled, to deliver intensity modulated beams (IMBs) as calculated.
Why we don’t know how many colors there areJan Morovic
There have been many attempts to answer the question of how many distinct colors there are, with widely varying answers. Here we present an analysis of what it would take to arrive at a reliable answer and show how currently available models fail to make predictions under the wide range of conditions that needs to be considered. Gamut volumes are reported for a number of light sources and viewing modes and the conclusion is drawn that the only reliable data we have comes from psychophysical work. The color gamut of the LUTCHI data in CIECAM02 is therefore shown as an alternative to the gamut of all possible colors.
SPICE MODEL of DF2B6.8FS , PSpice Model in SPICE PARKTsuyoshi Horigome
SPICE MODEL of DF2B6.8FS , PSpice Model in SPICE PARK. English Version is http://www.spicepark.net. Japanese Version is http://www.spicepark.com by Bee Technologies.
SPICE MODEL of 1SS193 (Standard Model) in SPICE PARKTsuyoshi Horigome
SPICE MODEL of 1SS193 (Standard Model) in SPICE PARK. English Version is http://www.spicepark.net.Japanese Version is http://www.spicepark.com by Bee Technologies.
SPICE MODEL of 1SS193 (Standard Model) in SPICE PARKTsuyoshi Horigome
SPICE MODEL of 1SS193 (Standard Model) in SPICE PARK. English Version is http://www.spicepark.net.Japanese Version is http://www.spicepark.com by Bee Technologies.
SPICE MODEL of MTM23223 (Standard+BDS Model) in SPICE PARKTsuyoshi Horigome
SPICE MODEL of MTM23223 (Standard+BDS) in SPICE PARK. English Version is http://www.spicepark.net. Japanese Version is http://www.spicepark.com by Bee Technologies.
The presentation I gave in the plenary session at the ICCS (Presentation A3). It has been slightly modified for publishing. Please contact me if you have any questions!
SPICE MODEL of FMLG14S (Professional Model) in SPICE PARKTsuyoshi Horigome
SPICE MODEL of FMLG14S (Professional Model) in SPICE PARK. English Version is http://www.spicepark.net. Japanese Version is http://www.spicepark.com by Bee Technologies.
This new release is features-rich, as we added several new functionality: trend analysis (for linear, polynomial, logarithmic, and exponential trends), histograms, spectral analysis (discrete Fourier transform), and more. We also revised the existing correlation function (XCF) to extend support for new methods (e.g. Kendall, Spearman, etc.), and added a statistical test for examining its significance. Finally, NumXL now includes a new unit-root and stationarity test: the Augmented Dickey-Fuller (ADF) test.
http://www.spiderfinancial.com/products/numxl
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
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.
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.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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
New Drug Discovery and Development .....NEHA GUPTA
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.
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
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
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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
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.
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
3. Immobilization of
Head & Neck patients
l 15 head & neck tumors
l 15 brain tumors
l 3 different masks (3, 4 & 5 FP)
l 3 fictitious isocenters
4. Immobilization of Head & Neck patients
l 915 portals images acquired.
l 98 % analysed.
l Total Displacement.
u SIM - EPIDi
l Systematic Displacement.
u M(SIM - EPIDi)
l Random Displacement.
u (SIM - EPIDi) - [ M(SIM -
EPIDi)]
l Intraobserver variation:
0.7 mm (1 Sd).
6. Characteristics of current
imaging modalities
CT MRI PET fMRI
Image characteristics
skin contour + ± ± -
soft-tissue contrast ± + - -
bone contrast + ± - -
air contrast + ± ± -
metallic artefacts + ± - ±
movement artefacts - + ± +
Machine characteristics
large “tunnel” size + - - -
distortion - + ± +
electron density + - ± -
multiplannar imaging - + ± +
7. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Image acquisition
• Dual detector spiral CT
• 2.7 mm collimation, pitch 0.7,
reconstruction of 2 - 2.5 mm
• Display matrix of 512 x 512
pixels
• Contrast enhancement
(interstitial and blood vessel
contrast)
12. The present … which CTV for the neck ?
Cervical lymph node groups
(MSKCC classification)
Adopted by the
Academy’s Committee for
Head & Neck Surgery and
Oncology
Robbins et al, 1991
13. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Definition of the extend of the CTV in the neck
State of the art
• Predictive pattern of lymph node involvement in
HNSCC
• Selective neck treatment (irradiation or dissection)
for selected N stage
14. The present …CT-based delineation of
lymph node levels in the neck
Ia
Ib VI
III
RP V
II
Grégoire et al., 2000
23. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Mr H. D. (77 years): T3-N0-M0 base of tongue (ICD0-10: C01)
24. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Mr H. D. (77 years): T3-N0-M0 base of tongue (ICD0-10: C01)
Target volumes
• T: CTV1: GTV + 1.5 cm margin
CTV2: GTV + 0.5 cm margin
PTV1&2 : CTV + 4 mm
• N:CTV: R & L LII - IV
PTV: CTV + 4 mm
Dose prescription
• T: PTV1: 50 Gy, 25x2 Gy
PTV2: 70 Gy, 35x2 Gy
• N:PTV: 50 Gy, 25x 2Gy
25. Conformal radiotherapy and IMRT
in Head and Neck Tumors
“Antique”
(7 fields)
Rx 6 MV Rx 6 MV
40 Gy 30 Gy
Elect 8 MeV Rx 6 MV
10 Gy 50 Gy
26. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Dose (Gy) at various organs at risk
Antique Middle-age Art nouveau
PTV 55 Gy
Dmean 63.2 60.1 59.2
Dmax 79,1 76.6 74.6
Dmin 10.0 39.1 44.4
SD 10.2 9.5 8.1
PTV 70 Gy
Dmean 72.4 71.7 70.6
Dmax 76.9 76.5 74.6
Dmin 67.4 65.2 67.0
SD 1.8 2.1 1.5
L parotid
Dmedian 68.7 52.1 50.7
Dmax 72.8 72.5 71.8
Dmin 46.4 8.4 5.4
SD 7.6 12.2 15.5
R parotid
Dmedian 69.6 65.7 40.6
Dmax 72.9 72.6 55.9
Dmin 62.1 4.4 3.6
SD 1.7 24.9 16.7
27. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Dose (Gy) at various organs at risk
Antique Middle-age Art nouveau
Spinal cord
Dmean 22.8 19.6 22.7
Dmax 43.0 41.9 47.6
Dmin 5.5 3.3 2,7
SD 16.0 16.1 18.0
Mandibula
Dmedian 71.5 68.9 60.5
Dmax 76.8 74.5 72.2
Dmin 51.1 4.8 3.7
SD 2.2 22.0 17.4
Internal contour
Dmedian 41.6 13.6 19.3
Dmax 79.2 76.6 74.6
Dmin 2.0 1.2 1.1
SD 21.5 23.4 22.2
28. Conformal radiotherapy and IMRT
in Head and Neck Tumors
“Middle Age”
(9 fields)
Rx 6 MV Rx 6 MV
40 Gy 10 Gy
Elect 8 MeV Rx 6 MV Rx 6 MV
10 Gy 20 Gy 50 Gy
29. Conformal radiotherapy and IMRT
in Head and Neck Tumors
“Middle Age”
(9 fields)
Rx 6 MV Rx 6 MV
40 Gy 10 Gy
Elect 8 MeV Rx 6 MV Rx 6 MV
10 Gy 20 Gy 50 Gy
30. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Dose (Gy) at various organs at risk
Antique Middle-age Art nouveau
PTV 55 Gy
Dmean 63.2 60.1 59.2
Dmax 79,1 76.6 74.6
Dmin 10.0 39.1 44.4
SD 10.2 9.5 8.1
PTV 70 Gy
Dmean 72.4 71.7 70.6
Dmax 76.9 76.5 74.6
Dmin 67.4 65.2 67.0
SD 1.8 2.1 1.5
L parotid
Dmedian 68.7 52.1 50.7
Dmax 72.8 72.5 71.8
Dmin 46.4 8.4 5.4
SD 7.6 12.2 15.5
R parotid
Dmedian 69.6 65.7 40.6
Dmax 72.9 72.6 55.9
Dmin 62.1 4.4 3.6
SD 1.7 24.9 16.7
31. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Dose (Gy) at various organs at risk
Antique Middle-age Art nouveau
Spinal cord
Dmean 22.8 19.6 22.7
Dmax 43.0 41.9 47.6
Dmin 5.5 3.3 2,7
SD 16.0 16.1 18.0
Mandibula
Dmedian 71.5 68.9 60.5
Dmax 76.8 74.5 72.2
Dmin 51.1 4.8 3.7
SD 2.2 22.0 17.4
Internal contour
Dmedian 41.6 13.6 19.3
Dmax 79.2 76.6 74.6
Dmin 2.0 1.2 1.1
SD 21.5 23.4 22.2
32. Conformal radiotherapy and IMRT
in Head and Neck Tumors
“Art nouveau” (10 fields, 12 segments )
SRAO SLAO Post. Seg. 1 Post. Seg. 2
Rx 6 MV 50 Gy
RPO LPO Ant. …
33. Conformal radiotherapy and IMRT
in Head and Neck Tumors
“Art nouveau” (11 fields, 12 segments )
Ant. RAO LPO
Rx 6 MV 20 Gy
LAO1 LAO2
34. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Dose (Gy) at various organs at risk
Antique Middle-age Art nouveau
PTV 55 Gy
Dmean 63.2 60.1 59.2
Dmax 79,1 76.6 74.6
Dmin 10.0 39.1 44.4
SD 10.2 9.5 8.1
PTV 70 Gy
Dmean 72.4 71.7 70.6
Dmax 76.9 76.5 74.6
Dmin 67.4 65.2 67.0
SD 1.8 2.1 1.5
L parotid
Dmedian 68.7 52.1 50.7
Dmax 72.8 72.5 71.8
Dmin 46.4 8.4 5.4
SD 7.6 12.2 15.5
R parotid
Dmedian 69.6 65.7 40.6
Dmax 72.9 72.6 55.9
Dmin 62.1 4.4 3.6
SD 1.7 24.9 16.7
35. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Dose (Gy) at various organs at risk
Antique Middle-age Art nouveau
Spinal cord
Dmean 22.8 19.6 22.7
Dmax 43.0 41.9 47.6
Dmin 5.5 3.3 2,7
SD 16.0 16.1 18.0
Mandibula
Dmedian 71.5 68.9 60.5
Dmax 76.8 74.5 72.2
Dmin 51.1 4.8 3.7
SD 2.2 22.0 17.4
Internal contour
Dmedian 41.6 13.6 19.3
Dmax 79.2 76.6 74.6
Dmin 2.0 1.2 1.1
SD 21.5 23.4 22.2
36. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Forward planning IMRT
• « human optimization »
Inverse planning IMRT
• Dose-volume constraints & weights for PTV and OARs
• optimization algorithms
• Penalty function
37. Inverse planning IMRT for
Head and Neck Tumors
Cummulative % of MUs
l Spare cord Segment #
l Spare left parotid 1 6.
l 15 segments
l 10 levels
Courtesy of C. Field
38. Inverse planning IMRT for
Head and Neck Tumors
PTV
Spared parotid gland
Courtesy of C. Field
41. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Duration of treatment planning procedure
2D planning Forward planning Inverse planning
(St-Luc) (Edmonton Cancer center)
Volume delineation 0 - 0.25h 2 - 3h 1 - 1.5h
Planning 0.25h 2 - 8h 1 - 2h
Individualized QC 0h 0.25h 1h
Treatment (per session) 10 - 15 min 20 - 25 min 15 min
42. Conformal radiotherapy and IMRT
in Head and Neck Tumors
Definition of the extend of the CTV in the neck
State of the art
• Predictive pattern of lymph node involvement in
HNSCC
• Selective neck treatment (irradiation or dissection)
for selected N stage