Techniques for Inguinal/Groin IrradiationAjeet Gandhi
Inguinal radiotherapy delivery is many a times a complex dosimetric uncertainty and we need to judiciously choose the technique for best patient outcome
Techniques for Inguinal/Groin IrradiationAjeet Gandhi
Inguinal radiotherapy delivery is many a times a complex dosimetric uncertainty and we need to judiciously choose the technique for best patient outcome
This slide explains the radiotherapy contouring guidelines for carcinoma esophagus. It has detailed explanations in a quite simple way, so that you need not go anywhere else for esophageal contouring guidelines.
IORT uses a high single-fraction radiation dose (10-30 Gy) is delivered during surgery to a surgically-exposed tumour bed, immediately after a chunk of the tumour has been surgically excised. This slide includes topics like APBI, IOERT, IOHDR.
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarFight Colorectal Cancer
Michael Bassetti, MD, Ph.D. from the University of Wisconsin Carbone Cancer Center discusses all you need to know about radiation. Dr. Bassetti will talk about what radiation treatment is, how it’s used for rectal and colon cancer patients, how to prepare for treatment, how to manage side effects and more.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
This slide explains the radiotherapy contouring guidelines for carcinoma esophagus. It has detailed explanations in a quite simple way, so that you need not go anywhere else for esophageal contouring guidelines.
IORT uses a high single-fraction radiation dose (10-30 Gy) is delivered during surgery to a surgically-exposed tumour bed, immediately after a chunk of the tumour has been surgically excised. This slide includes topics like APBI, IOERT, IOHDR.
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarFight Colorectal Cancer
Michael Bassetti, MD, Ph.D. from the University of Wisconsin Carbone Cancer Center discusses all you need to know about radiation. Dr. Bassetti will talk about what radiation treatment is, how it’s used for rectal and colon cancer patients, how to prepare for treatment, how to manage side effects and more.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
This is a Central presentation, presented at National Institute of Cancer Research & Hospital(NICRH), Mohakhali, Dhaka, Bangladesh on Metastatic neck node of unknown primary.
Similar to Management of anal canal tumors with emphasis on treatment(1) (20)
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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
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.
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
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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
Management of anal canal tumors with emphasis on treatment(1)
1. MANAGEMENT OF ANAL CANAL
TUMORS WITH EMPHASIS ON RT
PLANNING.
DR . SUMERA SABA
Moderator: DR. ARSHAD MANZOOR
2. INTRODUCTION
Cancers of the anal region accounts Anal canal cancer most commonly
for 1% to 2% of all large bowel cancers develops in patients 50 to 60
and 4% of all anorectal carcinomas. Years of age.
I ) squamous cell carcinomas:75%-80% The corresponding 5-year relative
survival rates were:-
II) Adenocarcinomas :- 15%
I) 80.1% for localized disease,
There is slight female predominance II) 60.7% for regional lymph nodes
with 1.7 cases per 100,000 women 29.4% for distant metastasis.
compared with 1.4 per 100,000 men
per year III) 55.4% for unstaged disease.
3. INTRODUCTION
ANATOMY
Anal canal extends from the
anorectal ring to
the anal verge (3-4cm).
REGIONS:-
Intraanal lesions:- cannot be
Visualized or only slightly visualized
With gentle traction on the buttocks.
Perianal lesions:-completely visible
------within a 5cm radius of anal
opening with gentle traction
Skin lesion:-
---- outside of 5cm radius
6. Development:-
upper 15mm develops from primitive ano rectal canal (distal part of
hindgut).
lower part below the pectinate line (lower 15+8cm) ectodermal
invagination i-e proctodeum.
ARTERIAL SUPPLY :-
above pectinate line superior rectal artery
below pectinate line inferior rectal artery.
VENOUS SUPPLY :- veins of anal canal connects with both the systemic and
portal venous system .
veins from inf. Part of venous plexus communicate with systemic system via the
internal pudendal & internal iliac veins.
veins from the superior canal flows predominantly to inferior mesentric vein
then to portal system.
7. Nerve supply :-
above pectinate line - supplied by autonomic nervous system.
(sympathetic by inf, hypogastric plexus L1, L2)
(parasympathetic by pelvic splanchic S2.S3.S4)
below pectinate line supplied by somatic nerves .
( inf. rectal .S2,S3.S4)
SPHINCTERS:- internal sphincter contracts symphathetic nerves
relaxed parasymphathetic nerves
external sphincter :- supplied by inf. Rectal nerve & Perineal
branch of 4th sacral nerve.
10. RISK FACTORS
Most significant risk factors so far identified are:-
sexually transmitted virus
immuno supression
tobacco smoking.
11. PATHOLOGY
WHO classification of carcinoma of anus.
ANAL CANAL ANAL MARGIN
Squamous cell Malignant epithelial tumors:
Large cell keratinizing squamous cell carcinoma
Large cell non keratinizing ( transitional) gaint condyloma
Basaloid basal cell carcinoma
others.
Adenocarcinoma Bowen’ s disease
Rectal type Paget’ s disease
Anal gland type
Small cell carcinoma
Undiffrentaited
melenomas
12. PATHOLOGY
¶ primary anal melanoma is a rare
tumor that accounts for only 1%
0f all anal cancers. Anal melanoma
is similar to melanoma of skin and
is characterized by the distant
spread of disease
¶ Outcome is poor after WLE or APR
with just a 10% survival is most
series at 5-year follow up.
13. PATHWAYS OF TUMOR SPREAD
Anal cancer tumor spread by
direct extension to surrounding tissue
Lymphatic dissemination to pelvic
and inguinal lymph nodes, or
Hematogenous spread to distant
viscera .
14. PATHWAY OF TUMOR SPREAD
LOCAL EXTENSION:- LYMPHATIC SPREAD
i. Sphincter muscle May occur early.
ii. Perianal connective tissue Overall lymph node spread is seen
iii. Rectum in 25% of cases at diagnosis.
iv. Perineum
v. pelvic wall Delayed inguinal lymph node
vi. Prostate metastasis is seen in approximately
vii. Vaginal septum 10% -25% of patient.
Anal-vaginal fistula is seen in <5% of cases.
15. Distant metastasis is relatively rare , and extra
pelvic metastasis is seen in <10% of patients before
treatment.
Common sites of metastasis includes:-
liver
lung
extrapelvic lymph nodes
16. PROGNOSTIC FACTOR
:Tumor related prognostic Factors for poorer OS included
node-positive Cancer,
large(>5cm) tumor diameter,
Tumor >5cm in diameter Regardless of nodal status , had a
higher colostomy rate and inferior DFS.
Patient related poor prognostic factors:-
age >65yrs
Poor Performance score
Male gender
Base line HB < 10g/l
Presence of HIV infection/ AIDS
patient who continues to smoke tobacco are at greater risk of
local relapse .
17. CLINICAL PRESENTATION
Bleeding Per Rectum. (45%)
Perianal Pain (30%)
Pruritus.
A Palpable anal Mass
anal discharge
Change In Bowel Habits
18. WORKUP FOR ANAL CANAL CANCER
PET imaging is useful in further evaluating
the extent of the primary tumor
and the presence of regional lymph nodal
metastasis and distant metastasis, as well
as in evaluating the response to therapy.
For patients with HIV risk factors,
a determination of HIV status should
be made before the initiation of
therapy.
Female patients should be subjected to a
gynecological examination to exclude
other HPV –associated cancers.
Counseling for loss of fertility for men
and women.
Under no circumstances should a formal lymph node dissection be carried out for initial evaluation
of suspicious nodes
21. MANAGEMENT OF ANAL CANAL CARCINOMA
For a long time APR remained the standard of care for anal
cancer.
Papillon et al
In the early 1960’s
Introduced the concept --- long-term local control with
definitive radiation therapy.
22. Chemo radiotherapy:-
Nigro et al. In 1974
First demonstrated complete pathologic responses to
concurrent .
5-fluorouracil, Mitomycin C, and Radiation therapy
Nigro ND , Vaitkevicius VK, Considine B Jr. Combined therapy for
cancer of the anal canal : a preliminary report . Dis colon rectum
1974 ; 17 : 354-356
23. SURGERY
Surgery is the principal treatment for Anal intraepithelial neoplasia but
retains only a limited place in the initial management of primary
invasive anal cancer.
Local excision;- Preserving ano rectal function is possible in
well differentiated squamous cell ca.
<2cm (T1).
not invading sphincter .
located distal to dentate line .
APR is still useful for local recurrence after conservation therapy &
for management of complication of conservation therapy.
.
24. RADIATION THERAPY
Use of RT alone either as brachytherapy or EBRT has been
greatly reduced since the confirmation of improved outcome
with Concurrent chemo radiation.
RT alone is given in patient who are unable to under go CCRT
( because of old age or any Contraindication for chemotherapy)
26. Other Drug Radiation Combination:-
UKNCRIAS phase II trail
RT (50.4Gy /28#-- 5.5week) + single MMC (12mg/m2 on D1) + oral
capcitabine ( 825mg/m2 BD with RT )
This schedule was well tolerated with acceptable compliance .
Results :- TRR after treatment was 90%.
EORTC phase II trail:-
RT ( 36Gy + 2week gap + 23Gy) + MMC/ 5FU or MMC/ CDDP
Results :- after 8week
ORR were 92% in MMC/CDDP vs 80% in MMC/5FU
Although greater compliance to full regimen was seen with
RT,MMC,and 5FU.
27. ROLE OF INDUCTION CHEMOTHERAPY
NCCN :-
“ Induction chemotherapy preceding chemoradiation
may be beneficial in subset of patients with T4 cancer. 5-year
colostomy free survival rate was significantly better in T4 patient
who received induction 5-FU/ Cisplatin compared to those who
did not .(100% vs 38+/_16.4%. p=.ooo6) ˝
28. RADIATION THERAPY TECHNIQUES AND DOSES
Anal region can be irradiated with various techniques due to complex
anatomy of this region & inguinal lymphatic.
AIM :- to reduce the dose supplied to the genital organs, bladder, small
intestines and femur head , and to increase dose to primary tumor and
deep inguinal lymphatics .
we can use:
AP/PA portal
Wide anterior field – narrow posterior field
4 field box technique.
3DCRT
IMRT
Brachytherapy
29. RADIATION THERAPY
Localization. Immobilization and Simulation.
Immobilization and patient position.
• Supine with arm across the chest or prone in a belly board in an alpha-cradle or other
immobilization device , arms extended . If using the prone setup for primary field,
may consider supine positioning for the boost (which is typically away from small
bowel) so that desquamated patient may be positioned more comfortably.
Contrast agent and markers
I. Oral contrast to delineate the small bowel.
II. Barium enema to delineate the tumor.
III. IV contrast to delineate the tumor and LN.
IV. Anal marker to delineate the anus.
V. Wire to involved inguinal LN.
VI. Bladder should be moderately filled.
30. Target volume definitions :
GTV : primary tumor ,clinically positive LN seen on planning CT
(>1cm short axis diameter).
I. PET or MRI fusion typically aides in GTV delineation.
II. Colonoscopy / anoscopy reports may help determine tumor
location.
CTV : LN at risk include common iliac, external iliac, internal
iliac, presacral, mesorectal , perianal, and inguinal.
I. CTV = 2.5cm expansion on primary tumor and 1cm expansion
on involved nodes.
PTV :
PTV= CTV + 1cm
31. Radiation therapy can be divided into three phases
Entire pelvic field
Cone down pelvic field
Tumor bed only
33. RADIATION THERAPY
GUIDELINES:-
Whole pelvic field
Posterior-anterior:-
Superior border: L5/S1 junction
Lateral borders:- 1.5 cm lateral to the widest bony margin of the
true pelvic side walls. The lateral border extended to include the
lateral inguinal nodes. These nodes should be outlined with wire
in order to help identify them.
inferior border:- minimum 2.5 cm below the anal verge or the
inferior extent of the primary tumor---- which ever is most
inferior.
34. GUIDELINES
laterals:-
Superior border:- same as posterior-anterior field.
Inferior border:- same as posterior-anterior field.
Posterior border:- 1-1.5cm behind the anterior
body sacral margin.
Anterior border:- posterior margin of the symphysis
pubis ( to treat only internal iliac nodes).
Blocking:-
Blocks are used to spare the posterior muscle and soft tissue behind
the sacrum, to reduce the amount of dose inferior to symphysis
pubis , and to decrease the amount of small bowel treated both
superiorly and anteriorly .
36. InguinaL lymph nodes are potential site for metastatic
dissemination.
Inguinal involvement is demonstrated to be a poor prognostic
factor.
Benefit of prophylactic inguinal irradiation (PII) remains
questionable because of the potential serious long term wound
and lower extremity complications.
37.
38. CONE DOWN FIELD BORDERS
Lower superior border to the bottom of S1 joint .
Inferior and lateral borders remain the same.
39. BOOST ( additional 9-14 Gy)
Indicated for T2, T3,/ T4, N1,
Use 2cm margin on GTV via AP/PA , 3 field ( opposed laterals and PA-
lowest anterior skin dose), or 4-field (AP/PA/laterals) approach.
40. Inguinal nodes boost field:-
Nodes are situated 3-4cm below ant skin
surface.
Use CT scan image for verification of depth.
patient -- supine position
energy – electrons
portal - single anterior
sup. Border:- 2cm above ing ligament
inf. Borger :- 5cm below inguinal ligament
lateral border :- upto ASIS
Medial boder :- pubic tubercle
42. VOLUMETRIC PLANNING GOALS
95% of the PTV should receive at least 95% of the prescription dose.
No portion of PTV should receive less then 85% of the prescription dose.
99% of the CTV should receive at least 95% of the prescribed dose.
0.1cc of the tissue is limited to 115% of the prescription dose.
1.0cc of tissue ( or 5% of the PTV) is limited to 110% of the prescription dose.
5cc of tissue ( 10% of the PTV ) is ideally limited to 105% of the prescription
dose.
For external genitalia, attempt to limit
50% to less than 20GY
95% to less than 40Gy.
For iliac crest, may attempt to limit
5o% to less than 30Gy
95% to less than 50Gy
43. DOSE / FRACTIONAION ( NCCN)
CTV to 45Gy / 1.8 Gy/fx.
Field reduction to cone down after 30.4 Gy.
T2,T3,T4, or N1 should receive an additional 9 to 14.4 Gy to the GTV via
boost field.
T2 dose goal, 45 to 50.4 Gy.
T3 dose goal , 54 Gy.
T4 dose goal, 54- 59.4 Gy.
Clinically negative inguinal LN should receive a minimum of 36 Gy,
measuring prescription depth on CT classically, 3cm has been used . (
this may under dose thicker patients.)
44. DOSE / FRACTIONAION ( NCCN)
Clinically positive inguinal lymph node Should receive a minimum 45
Gy.
Boost additional 5.4 to 9 Gy depending On size of LN and clinical
response.
Clinically positive pelvic LN may be Boosted along with primary boost
field for an additional 5.4 TO 9 Gy above 45Gy CTV Dose depending
on LN size and clinical Response.
45.
46.
47. RTOG Ano rectal Target Volumes
Consensus Guidelines------- 2008 (RTOG 0529 protocol)
For Anal canal : Primary tumor
GTV = All gross tumor + involved nodes ( clinical &
radiological )
CTVA = 2cm proximal and caudad to gross disease. It should
include 2-2.5cm normal perianal skin around the anal verge.
it should include mesorectum, presacral and peri anorectal
tissue 2cm cephalad and caudad to gross disease.
1cm of posterior bladder/prostate/uterus.
PTVA = 1cm expansion from CTVA in all directions ( trimmed
t0 3 -5mm to spare non target skin surface).
Dose to PTVA = 54-59.4 Gy
50. CTVa ( internal iliac , presacral nodal regions)
Covers entire mesorectum, sup. From sacral promontary to
pelvic floor made by levator ani inferiorly .
Anterior surface of rectum posteriorly ( presacral),
iliopsoas /perirectal area laterally .
Mesorectum;- cylindrical , with cone shaped
tips in cranial and caudal direction . Starts at
level of sacral promontory at origin of
superior rectal artery & ending at the level
where leveter ani muscle inserts into the
rectal wall.
51. CTVb ( for external iliac nodal regions )
cephalad;- upper end at SI joint ( division of common iliac
artery)
caudad- upper end of pubic rami ( bottom of internal iliac
artery )
52. CTVc ( Inguinal nodal region)
cephalad-: upper end of pubic
ramus, or at the inferior extent of
Internal obturator artery.
Caudad : 2cm cuaded to
saphenous/Femoral junction
(SF junc. Lies at 4cm down & 4cm
lateral to pubic tubercle ,
LN is med. to vessel).
55. RTOG 0529: A phase 2 evaluation of dose- painted intensity
modulated radiation therapy in combination with 5FU and MMC
for the reduction of acute morbidity in carcinoma of anal canal.
Anal Cancer
Nodes
High risk node
DP-IMRT was associated with significant sparing of acute
grade 2+ hematogical and grade 3+ dermatologic and GIT
toxicity.
56. RTOG 0529 ( IMRT WITH 5FU and MMC)
VS . RTOG 98-11.
77% of patients experienced grade 2 or
higher gastrointestinal/ genitourinary
(GVGU) acute adverse event (AEs) that
were equal to that noted in the MMC
arm of RTOG 98-11(76%).
There were statistically significant
reduction in grade 3 or higher GVGU Aes
with IMRT , 21% vs 36% RTOG 98-11, and
grade 3 or higher dermatologic Aes, 21%
Vs 47% RTOG 98-11( p<.ooo1).
The use of IMRT with 5FU and MMC
resulted in significant reduction in grade 3+
dermatological and GU acute toxicity.
57. NORMAL TISSUE CONTOURING
No specific DVH recommendation for normal tissue by
RTOG, still investigation but
Femoral head, iliac crest
Small bowel up to 1cm beyond PTVA
Large bowel including recto sigmoid
Bladder
External genitalia
59. BRACHYTHERAPY
Interstitial Brachytherapy is an ideal method by which to deliver conformal
radiation for anal cancer while sparing the surrounding normal structures
such as small intestine and bladder.
INDICATIONS:- as boost to EBRT / CCRT
If Tumor volume does not exceed ½ circumference,
5mm thick,
5cm long i.e T1, T2, or small T3 lesion
Presence of lymph nodes in the rectal wall may not CI as long as they are located
in distal 8cm and responded well to CCRT.
Note;-
Brachytherapy alone is effective in controlling small lesions, but causes painful
reaction in half the patients and late necrosis in 10-15% , and therefore has to
be individualised.
60. Target volume:-
It is the palpable & visible tumor with a safety margin of apparently normal
mucosa and skin of at least 5mm
To exactly localize target area – carefully DRE ( preferable EUA).
Timing of brachytherapy :-
2-8 week after External beam radiotherapy.
Sources and dose rate:-
Ir 192, HDR
Pre op instructions.
laxative 4-6 hrly , light low fiber diet, overnight fasting
61. Technique:-
Lithotomy position.
Under GA / Spinal/ Epidural anesthesia.
Foleys catheter.
Use of template :-
Papillon’s template
Syed neblett template
Modified syed template
Modified anal template with an obturator.
62. Implantation blindly by palpating the canal , done with stainless
steel needles 15cm long , 1.7-1.9mm diameter.
The template is firmly sewn against the perineum .
Needles are them implanted through the hole while a finger is
placed inside the lumen to verify that the needle do not penetrate
the lumen.
Usually the needles are implanted 5mm beneath the anorectal
mucosa.
Sometime it is difficult to insert needles in the recto vaginal
septum-- in that case it is easier to implant first in the RVS before
sewing the template to the perineum.
Needles are inserted taking margin of 2-3 cm .
63. A typical implant contain 5 needles spaced at 1cm, 5-7cm long
for a T1-T2 tumor and 6-7 needles , 7-8cm long for a small T3
tumor.
In some cases if tumor is thicker than 1cm , 2 single plane
implant can be done.
All needles are positioned at same depth and verification
made that needles do not retract when the patient’s legs are
retracted.
Elastic tap dressing to fix the anal applicator – Y shaped
64. Post implant ---- treatment planning
CT film / orthogonal X rays.
Catheter reconstruction.
Target contouring.
Prescription – 0.5 -1 cm from any chosen catheter.
Check target coverage and dose to mucosa.
Dose -15-20 Gy @ 3 Gy / # twice daily at least 6 hrs apart.
65. Results
However problem with brachytherapy
22-27% -- sphincter necrosis
incontinence , stenosis , needing colostomy -10%
Hence newer approach---
Image guided brachy – TRUS guided brachy
to position the needles under image control
and assessing tumor extent
following by 3D planning and optimization.
no brachy brachy
Local control 61% 79%-83%
5 yr DFS 76% 82%
67. SIDE EFFECTS OF PELVIC RADIATION
RADIATION FIELD
Radiation may hit the bladder
and rectum causing urinary
burning or frequency and
ano-rectal irritation and skin
burning.
High dose area.
In pre-menopausal women, radiation is likely to effect ovarian function and
should not be used if women is pregnant.
68. SIDE EFFECT OF TREATMENT
Early complication Late complication
Diarrhea Small bowel obustraction
Increased bowel frequency Persistent diarrhea
Dysuria Urinary incontinence
Dyspareunia
Acute proctitis Stricture
Malabsorption of fat, carbohydrate,
protien and bile salt.
Scrotol / perineal tenderness
impotence
Perineal dermatitis PIF
69.
70. SALVAGE THERAPY FOR LOCAL RECURRENCE
Most patient undergo an APR and a permanent colostomy is
established with creation of large pelvic floor defect.
Tumors that invade local structure such as the vagina or prostate
should be resected with negative margins and often involves
multivisceral resection.
The OS at 5 year following resection is in the range of 30% to
64%, with DFS rates in the range of 30% to 40%.
The most important prognostic factor of survival after resection is
the status of the margin, and patients with negative margins (R0)
have up to 75% 5 year OS.
71. Predictors of a poor OS outcome following surgery are
inguinal lymph node status, tumor size greater than 5cm,
adjacent organ involvement , male gender, and more
numerous co morbidities.
72. MANAGEMENT OF METASTATIC DISEASE
Systemic chemotherapy for metastatic squamous cell
carcinoma of anus is generally similar to other metastatic
squamous histology , such as lung or head n neck cancer.
Cisplatin & 5FU have been reported to achieve an 11%
complete response and 61% partial response rate.
Hainsworth et al:- treated 60 patient with the combination of
carboplatin , paclitaxel & 5FU in a phase 2 study with an
overall response rate 90%.