This document discusses reirradiation in recurrent head and neck cancer. It notes that radiation therapy plays a central role in head and neck cancer treatment but recurrence still occurs in 20-35% of patients. Reirradiation presents challenges due to prior radiation exposure and damage to normal tissues. The document discusses treatment options, appropriate patient selection, techniques like IMRT to minimize dose to organs at risk, optimal timing and dosing of reirradiation, and management of toxicities.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
Controversies in the management of rectal cancersAjeet Gandhi
Management of rectal cancers have undergone a huge paradigm shift over the last decade. One the one hand, it has opened up new avenues; it also has thrown up new challenges and controversies
General management
Management of low grade gliomas: overview
Pilocytic astrocytoma
non pilocytic/diffuse infiltrating gliomas
Management of high grade gliomas: overview
Anaplastic gliomas
Glioblastoma multiformae
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
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
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
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.
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
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.
Evaluation of antidepressant activity of clitoris ternatea in animals
Head and neck reirradiation
1. ABC OF REIRRADIATION IN RECURRENT
HEAD AND NECK CANCER
Dr Kanhu Charan Patro
RADIATIATION ONCOLOGIST
2/25/2018 1
2. Background
• Radiation therapy plays a central role in the
treatment of head and neck cancer (HNC) patients.
• Both organ-preserving definitive chemo-
radiotherapy (CRT) and selective postoperative CRT
improve loco-regional recurrence (LRR) and prolong
overall survival .
• Nevertheless, despite improvements, LRR after CRT
continues to be a vexing problem for 20–35% of
patients.
2/25/2018 2
3. Background-contd.
• As radiation is delivered more precisely with smaller
margins, the potential for recurrences related to
'marginal misses' has increased.
• Over protective for OARs also give marginal misses.
• Longer survival leads to second primary and ongoing
exposure to carcinogens, such as cigarette smoke,
leads to a 3–5% yearly risk of a second malignancy.
• Improved cancer treatment..
• Longer survival due to less chance of distant
metastasis in head and neck cancer.
• Commercialization of radiotherapy treatment.
2/25/2018 3
6. Definition
Irradiation in a previously irradiated field due
to Recurrent lesion or second primary after a
definitive cure .
2/25/2018 6
7. Treatment options
• Salvage surgery f/b Re-irradiation +chemotherapy
• Re-irradiation + chemotherapy
• Chemotherapy alone
– NACT
– Definitive
– Metronomic
• Best supportive care
2/25/2018 7
8. Approach
• The care of these patients should be coordinated by an
interdisciplinary team, consisting of representatives from
– Radiology,
– Pathology,
– Otolaryngology,
– Medical Oncology,
– Radiation Oncology,
– Dentistry,
– Speech Pathology
– Nutrition.
• Chances of cure/at least towards cure
• Expected survival-how long?
2/25/2018 8
9. Postoperative Re-RT
• The therapeutic ratio is lower than in re-RT of non-resectable
disease
– While risk of recurrence may be high, the tumor may not recur
even if we do not re-irradiate
– In high risk patients, tumor may recur in sites which are not the
highest-risk sites
– Not having a GTV, radiation volumes may be larger compared to
treating gross recurrent disease
– The risk of complications is nearly as high as treating recurrent
non-resectable tumor.
2/25/2018 9
10. Postoperative Re-RT
• Randomized study of post-op chemo-re-RT
– 130 pts, previously irradiated, with recurrent
tumors who underwent surgery with complete
macroscopic tumor resection.
– Randomized to:
• Post-op RT: 60 Gy concurrent with 5-FU and HU; RT to
tumor bed +first echelon nodes
• Observation only
–Janot F et al, JCO 2008
2/25/2018 10
11. Postoperative Re-RT
• Randomized study of post-op chemo-re-RT
• Late toxicities: RT arm: 39%. Observation: 10%
• Late toxicities (RTOG>3) in the RT arm:
– Subcutaneous-22%
– Osteonecrosis-17%
– Trismus-28%
– Laryngeal damage-6%
– Feeding tube dependency- 25% (compared with 10% in the
observation arm)
2/25/2018 11
12. Randomized study of post-op re-RT
– Disease-free survival (DFS) was significantly improved
in the RT arm, with a hazard ratio of 1.68
– overall survival (OS) was not statistically different.
2/25/2018 12
13. Post-op RE-RT: Recommendations
• Discuss with patients: high complication risk,
better LR control, no survival benefit.
Alternative: wait for LR recurrence and re-RT at the time of
recurrence.
• Offer re-RT only to the highest risk patients
(ECE, +margins, diffuse tumor infiltration)
• Target only the high risk volumes
– the neck level with ECE
2/25/2018 13
14. Radiotherapy Indication
• Radical-Reirradiation is the only potentially curative
treatment when surgery is not an option.
• Post operative-after salvage surgery
• Palliative condition
– Comp/Haemmorage/Obstruction/Pain
2/25/2018 14
23. Hiccoughs
• Optimal Gap
• Optimal Dose
• Optimal Imaging
• Target Volume Delineation
• What Technique
• Addressing OARs.
– Spinal Cord Dose
– Mandible-ORN
– Skin- Fistula, Fibrosis etc.
– CAR
2/25/2018 23
Re-RT is more challenging than initial
treatment because of the side effects of prior
therapy and concerns about the risks of high
cumulative radiation doses to normal
structures.
25. Optimal gap
• There is no clear cut guideline.
• Most of the studies are gap of more than two
years of prior radiation.
• Relative contraindications:
– Less than one year since previous RT
• Lower chance of cure
• Higher risk of severe complications
2/25/2018 25
26. Imaging-staging
• Biopsy is mandatory.
• The sensitivity and specificity of PET-computed tomography (CT)
for detecting distant metastasis is reported to be 86–91 and 84–
93%, respectively.
• [Gourin CG et.al, Perlow A et.al]
• Re-staging is of paramount importance as up to 25% of patients
will have metastatic disease.
– [Gourin CG et.al, Perlow A et.al]
• MRI demonstrated a trend towards improved sensitivity (96.4 vs
82%) for detecting local recurrence of nasopharyngeal
carcinoma when compared with PET-CT
– [Comoretto M,et al]
2/25/2018 26
27. What should be the target?
• Treatment volumes for ReRT are in general
more limited than for initial courses of
radiotherapy
• To minimize toxicity to nearby critical OARs,
the smallest possible target volume is used
• Elective nodal irradiation is generally not
recommended, as the risk of failure in these
sites is low (0–6%).
2/25/2018 27
28. What should be the targets?
From Popovtzer A, et al, IJROBP 20092/25/2018 28
30. Which technique?
• IMRT is a potentially useful tool for a second
course of radiation as a means of reducing the
volume of high radiotherapy doses as well as
minimizing doses to critical normal structures.
• SBRT
• Brachytherapy
• Electron
• IMPT
2/25/2018 30
34. Optimal dose?
• Prescribed as cumulative BED.
• The maximal cumulative prescribed dose is expected
to be 140-160 Gy.
• No clear cut guideline.
• Doses near 60 Gy was planned in studies.
• (Salama jk IJROBP 2006)
• Schaefer u et al, radiology 2000,
• Datta NR int j clin oncol 2003
2/25/2018 34
35.
36. Fractionation schedule?
• Conventional fractionation@2Gy/# is standard of care
• Hyper fractionation
• Accelerated fractionation
• Hypo-fractionation-SBRT
• Recent data (GORTEC, RTOG) suggests no benefit of
altered fractionation with conc. chemo vs. standard
fractionation with conc. chemo, regarding tumor
control/survival.
2/25/2018 36
37. Hyperfractionation
• Potential for reduced late effects
• 70 Gy at 1.25 BID/6 weeks, conc with cisplatin-5FU
• 66 patients
• 23% 3-year DFS.
• 29% late complications grade III, notably dysphagia.
–Popovtzeretal,IJROBP2009
2/25/2018 37
38. Hypofractionation
• Unger et al, IJROBP 2009 (Georgetown U)
– 38 patients
– 21-35 Gy (median 30)/2-5 fractions
– Higher total doses and nasopharyngeal sites:
improved OS
– Severe toxicity: 11%
2/25/2018 38
39. Hypofractionation
• Heron et al, IJROBP 2009: Phase I study of
escalating hypofractionation doses
– 25, 32, 36, 40, 44 Gy, all in 5 fractions over two
weeks
2/25/2018 39
40. Hypofractionation-summary
• Tumor-related outcome seems to be similar
to series of standard fractionated RT, however,
SRS series have much shorter f/u and late
toxicity rates are not yet known.
2/25/2018 40
46. Addressing OARs.
• Vital
– Cord
– Optic apparatus
– Brain[temporal lobe, Brain stem]
• Less vital
– Cochlea
– Carotid
– Parotid
– mandible
2/25/2018 46
keep in mind ,The α/β of
prior irradiated tissue is not
the same as
Non-irradiated tissue
47. Complication-acute toxicity
• MUCOSITIS
– The rate of grade 3–4 mucositis was lower for previously
irradiated patients. More contemporary trials have
demonstrated similar results.
– Primary CRT is associated with higher rates of grade 3–4
mucositis (71–77%) when compared with CRRT (14–26%). This is
probably due to the smaller RT target volumes that are
commonly used for a course of salvage Re-RT
• [Brizel DM et al, Calais G et al]
• HEMATOLOGIC TOXICITY
– Hematologic toxicity appears to correlate with the intensity of
the systemic therapy regimen and is also not influenced by prior
therapy
• DEATH DURING TREATMENT
– This may be related to the fact that functional reserve is
compromised in heavily pretreated patients[Glisson BS et al]
2/25/2018 47
48. Complication-Late toxicity-ORN
• It is possible that the rates of ORN are less in patients
treated with more modern radiotherapy techniques for
CRRT. Increasing photon energies, 3DCRT and IMRT
ameliorate this phenomenon.
• One series, cases of ORN only occurred in patients
receiving a cumulative RT dose of greater than 120 Gy
– [De Crevoisier R et al, Sulman EP et al]
• In a cohort of 105 patients treated between 1996 and
2005, 70% of whom received IMRT, only one case of grade
2 osteitis was reported.
– [Lee N et al]
• In another cohort of 74 patients all treated with IMRT
between 1999 and 2004, only 5% developed ORN
– [Sulman EP et al]
2/25/2018 48
50. SPINAL CORD RECOVERY
• On the basis of literature data (and with due
caution), the risk of myelopathy appears small
after ≤135.5 Gy2
– Carsten Nieder, M.D. IJROBP 2004
• From the sparse clinical and primate data, it
appears that at least 50% recovery of 45 Gy
would be obtained 2 years after treatment.
– Supe et al. Radiobiological considerations .Rep. Pract.
Oncol. Radiother. 7 (2) 2002
2/25/2018 50
58. CENTRAL AND PERIPHERAL AND CNS TOXICITY
• Radiation Myelopathy
• Brachial Plexopathy
• Temporal lobe necrosis
• Brain necrosis
We would recommend limiting the dose to
this level, whenever technically feasible
2/25/2018 58
60. Carotid artery rupture (CAR)
• Devastating condition due to
– Tumor recurrence,
– Chronic infection,
– Surgery (pharyngocutaneous fistula and neck dissection),
– Poor nutrition
– Chronic inflammation
– (long-term tracheostomy and nasogastric tubes)
A meta-analysis of CRRT trials reporting CAR showed a
crude incidence rate of 2.6% at a median of 7.5 months
following CRRT
[McDonald MW et al]
2/25/2018 60
64. Complication-Late toxicity-contd.
• In the GETTEC–GORTEC randomized trial, the
actuarial rate of grade 3–4 toxicity at 2 years
was 39%.
• The crude rates of grade 4 or higher toxicity in
RTOG 96-10 and RTOG 99-11 were 3 and
31.8%, respectively
2/25/2018 64
65. Role of radio protector
• Amifostine
– Concentrates actively in salivary glands, but not in
most other tissues
– Randomized studies assessing acute
mucositis/late swallowing with or without
amifostine are inconclusive
2/25/2018 65
68. Role of radio-sensitizer
• Radiobiological tenant that tumor hypoxia
confers radioresistance has been confirmed
clinically in HNC
• Prior radiotherapy, surgery and/or systemic
therapy may worsen tumor hypoxia in recurrent
HNC.
– Cisplatin
– TPZ
– Carboplatin
2/25/2018 68
69. TPZ STUDY
• 25 patients received cisplatin (50 mg/m2) and TPZ (260
mg/m2) on weeks 1, 3 and 5 during daily RRT to a total
dose of 72 Gy.
• Additional TPZ (160 mg/m2) was given on days 1, 3 and
5 of week 2, and possibly week 4, based on
randomization.
• Locoregional control was 56% overall and the 1- and 2-
year rates of OS were 56 and 27%, respectively.
• Treatment-related toxicity was comparable with other
CRRT trials
– Dische S. Chemical sensitizers for hypoxic cells: a decade
of experience in clinical radiotherapy. Radiother.
Oncol.3(2), 97–115 (1985)]
2/25/2018 69
70. Role of chemotherapy
• Still to be established.
• NACT
– for high volume disease
– Prolonging the period for Re-RT
• CONC.
• Mostly as radio-sensitizer
• Common drugs
– HFX REGIMEN-[HU+5FU+RT]
– Cisplatin
– Carboplatin
– Taxanes
– Gemcitabine
– Cetuximab/Biomab
2/25/2018 70
71. RTOG study of chemo-re-RT
• 79 patients
• Treatment: 1.5 Gy BIDx5 weekly x4 weeks,
alternating weeks, total 60 Gy over 8 weeks
• Concurrent 5-FU and HU
• 76%- recurrent tu, 23%- new primary tumors
• Most common sites: oral & oropharyngeal
– Spencer S et al, Head Neck 2008
2/25/2018 71
72. RTOG study of chemo-re-RT
• Toxicities
– Acute:
• 2 fatal hemorrhages due to tumor lysis
– Late:
• Feeding tube at last follow-up: 70%
• Other: subcutaneous fibrosis (5%), laryngeal damage
(2%), neurologic toxicity (2%), pain (2%), “other” (2%)
2/25/2018 72
73. RTOG study of chemo-re-RT
• Tumor control and survival
– At 2 years: 15% survival.
• 75% of deaths due to persistent/recurrent cancer,
8% due to treatment complications
• Slightly better (but statistically sig) survival if
interval between treatments >1 year
2/25/2018 73
78. Summary
• Currently no single optimal treatment schema for Re-RT of patients
with HNSCC due to widely ranging differences in the location and
extent of recurrent tumor,
• Initial radiation parameters, amount of time since prior treatment,
degree of existing normal tissue toxicity, and limitations of available
data on normal tissue recovery from prior treatment and tolerance
to Re-RT.
• Most Re-RT experiences have targeted the recurrent gross disease
with limited margin, without elective nodal Re-RT.
• The chance of local control is higher in patients receiving an
additional dose of at least 60 Gy.
• Advanced radiation techniques (eg, intensity modulated radiation,
stereotactic body radiosurgery, or proton therapy) should be used
to protect nearby critical normal structures. :
2/25/2018 78
79. Summary contd.
• The prognosis for recurrent HNSCC treated with chemotherapy
is poor.
• With the average survival time being about 1 year.
• The overall 2-year survival rate is just 26%.
• These data demonstrate superiority to those seen in separate
trials of patients treated with palliative chemotherapy alone.
• Retrospective data in patients undergoing Re-RT suggests that
overall survival can improve if local control is obtained.
• While toxicities may be reduced with newer targeted radiation
modalities, 28% to 40% of patients Re-RT with conventional
radiation techniques experienced significant
2/25/2018 79
80. Summary contd.
• Heterogeneous patient population, very limited level I
evidence is available to inform decision making of
physicians and patients.
• When planning for radiation for first time don’t be so
over-protective for less vital OARs ,otherwise it may give
geographical miss, which may need Re-RT.
• When planning for re-irradiation try for conformal
avoidance of even less vital OARs.
• Re-RT should be offered to patients with detailed
discussion of the expected results
• A multidisciplinary approach.
2/25/2018 80