Maxillary sinus carcinoma arises from the maxillary sinus and can spread locally and to lymph nodes. Diagnosis involves physical exam, CT/MRI imaging, and biopsy. Staging evaluates tumor size, lymph node involvement, and distant spread. Treatment depends on stage but may include surgery such as maxillectomy, radiation therapy such as IMRT, and chemotherapy such as cisplatin for locally advanced cases. The goal of treatment is a complete resection with negative margins or effective control with radiation with or without chemotherapy while minimizing side effects to nearby structures like the optic nerves and chiasm. Outcomes depend on stage, with earlier stages having higher survival rates treated with surgery or surgery plus radiation.
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
This is a Central presentation, presented at National Institute of Cancer Research & Hospital(NICRH), Mohakhali, Dhaka, Bangladesh on Metastatic neck node of unknown primary.
This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
This is a Central presentation, presented at National Institute of Cancer Research & Hospital(NICRH), Mohakhali, Dhaka, Bangladesh on Metastatic neck node of unknown primary.
This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
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
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
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.
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.
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.
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
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
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.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
3. Maxillary sinus
“Maxillary sinus is the pneumatic space that is lodged
inside the body of maxilla and that communicates
with the environment by way of the middle meatus
and nasal vestibule.”
Anatomy of the maxillary sinus was 1st described by
Highmore in 1651.
4. Ohngren’s Line
A line that is drawn
from the angle of
mandible to the medial
canthus.
Ohngren indicated that
tumors that presented
above this line
(suprastructure); both
superiorly and
posteriorly, tended to
have a worse
prognosis
5. Lymphatic Drainage
The lymphatic drains in to submandibular lymph
nodes.
The lymphatic drainage reaches the specialised
cells in the maxillary sinus via infra orbital foramen
or through the anterosuperior wall and then to the
submandibular lymph nodes.
11. History & Physical examination
•The sinonasal, ocular, and neurologic systems
should be studied in detail
•Ant & post rhinoscopy
•Nasal endoscopy
12. Radiological Examination
Radiographic studies are essential as the full extent
of a sinonasal neoplasm cannot be established even
with modern fibreoptic technology.
Both CT & MRI are the effective ways to know the
extent of tumor extracranially and intracranially.
13. Computed Tomography
Bone erosion
Key areas include the bony orbital walls,
cribriform plate, fovea ethmoidalis,
posterior wall of the maxillary sinus,
pterygopalatine fossa, the
sphenoid sinus, and the posterior table
of the frontal sinus.
85% accuracy
Difficult
Periorbital involvement
Difficult to differentiate between: Tumor vs. inflammation
vs. secretions
14. MRI
• 94% accuracy
• Inflammatory tissue & secretions:
intense T2
• Tumor: Intermediate T1 & T2,
Enhancement with Gadolinium
• MRI is excellent for determining
perineural spread, involvement of
the dura, or involvement
intracranially.
15. Biopsy
Transnasal
Medial wall of maxilla is the preferred route
Needle biopsy is sufficient
Biopsy via Caldwell-Luc approach (canine fossa
puncture) is not recommended because of the
potential to seed the gingivobuccal sulcus and
cheek skin with tumor.
19. Prognostic Factors
• Patient-specific
• Age and performance status.
• Disease-specific
• Location,
• Histology,
• Locoregional extent (reflected in TNM stage),
• Perineural invasion.
• Extensive local disease involving the nasopharynx, base of skull, or
cavernous sinuses markedly increases surgical morbidity as well as
the risk of subtotal surgical excision.
• Tumor extension into the orbit may require enucleation, but minimal
invasion of the floor or medial wall may be dealt with through
resection and reconstruction, sparing the globe.
23. •Stage IV B: (T4b/ M1 disease)
•Multidisciplinary input is required even for
very advanced cases
•Palliation may involves limited surgery,
radiation therapy, chemotherapy,
investigational studies, best supportive care.
•Control of pain and discomfort a first priority.
•Chemotherapy can be given as single-agent
therapy in investigational settings.
25. Weber fergussen approach tumors
involving the maxilla extending
superiorly to the infraorbital nerve and into the orbit.
wide access to all areas of the maxilla
and orbital floor.
26. Midfacial Degloving
Nasal cavity tumors with
bilateral involvement
Most suited for inferiorly
located tumors.
Subperichondrial plane of
nasal septum
28. Surgical procedures
The goal of surgery for nasal cavity and paranasal sinus tumors
is to achieve en bloc resection of all involved bone and soft
tissue with clear margins while maximizing the cosmetic and
functional outcome.
Limited nasal cavity lesions may be resected with medial
maxillectomy.
Ethmoid lesions usually require medial maxillectomy and en
bloc ethmoidectomy.
combined craniofacial procedure for lesions involving the
inferior surface of the cribriform plate ,the roof of the ethmoid
& frontal sinus.
Multidisciplinary skull base approach has improved the
outcome
34. Immobilisation:
1. Patients should be immobilised supine in a
thermoplastic cast.
2. If the low neck nodes are to be treated (level III–
V) the neck should be extended to allow
treatment of most of the neck nodes
3. A mouth bite is used to depress the tongue and
oral cavity away from the treated volume and
reduce acute morbidity.
4. Patients should be asked to look straight ahead
to avoid rotating the lens or retina, particularly if
the orbital cavity is included in the treated
volume.
35. Imaging:
1. CT scan is performed with 3 mm slices from 2
cm superior to the superior orbital ridge to the
hyoid bone.
2. Fused CT-MRI images can be useful in the
definition of the optic pathways and skull base.
3. MRI also allows retained secretions to be
differentiated from tumour where resection has
been incomplete.
36. 2D CONVENTIONAL: A three-field technique is
used: 1 anterior and 2 lateral fields.
Patient lies in a supine cast with the head in neutral
position.
Tongue bite is used to depress tongue & lower
alveolus away from the target volume.
37. Anterior field:
Superior border: Above the crista galli to encompass the
ethmoids.
Inferior border: 1 cm below the floor of the sinus.
Medial border: 1 to 2 cm (or more if necessary) across the
midline. Cover contralateral ethmoidal
extension.
Lateral border: 1 cm beyond the apex of the sinus or falling
off the skin.
38. Lateral fields:
Superior border: follows the
floor of anterior cranial fossa.
Anterior border: behind the
lateral canthus parallel to the
slope of face.
Posterior border: covers the
pterygoid plates.
39. Anterior field:
When there is no gross involvement of the orbit, the
cornea, lens & lacrimal gland are shielded from the
anterior field.
If there is disease in the orbit, cornea is spared by
cutting out the cast and treating with the eyes open.
Lateral field:
It is angled 5-10 degree posteriorly so that the exit
beam avoids the opposite eye.
Optic chiasma & hypothalamus are shielded from the
lateral field.
41. 3D CRT Radiotherapy Planning
• Delineation of target volumes is based on:
• Physical examination
• Pre-treatment imaging
• Intra-operative findings (tumor extension relative
to critical structures such as orbital wall,
cribriform plate, cranial nerve foramina, and ease
of resection)
• Pathologic findings (such as positive margin or
perineural invasion).
42. Target volume definition
• GTV (Gross Tumor Volume):
• Where resection is not possible or has been
incomplete, the GTV is outlined.
• CTV (Clinical Target Volume):
• Defining the CTV is the most important step for
most patients.
• These tumors need a meticulous CTV definition
due to proximity of these tumours to critical
structures such as the optic nerves and chiasm,
brainstem, and lacrimal glands.
43. The CTV should encompass
• All initial sites of disease(presurgery GTV),
• The mucosa of adjacent compartments of the
sinonasal complex
• A 10 mm margin at least from initial sites of
GTV where no good bony barrier to invasion
exists (E.G. Masticator space, cribriform plate
and infraorbital fissure)
• Bony orbit if involved
For most tumours, the CTV will include the
ipsilateral maxillary sinus and bilateral nasal
cavity and the ethmoid sinuses.
44. Organs at Risk (OAR)
Include the
1. Lenses
2. Lacrimal glands (in the superolateral orbit and
upper eyelid)
3. Optic nerves and chiasm
4. Spinal cord
5. Brainstem
6. Pituitary gland
45. OAR & possible complications of RT
• Lens <10 Gy (cataracts)
• Lacrimal gland <30–40 Gy (dry eye syndrome)
• Retina <45 Gy (blindness)
• Optic chiasm and nerves <54 Gy at standard fractionation.
(Optic neuropathy)
• Brain <60 Gy (necrosis)
• Mandible <60 Gy (osteoradionecrosis)
• Parotid mean dose <26 Gy (xerostomia)
• Pituitary and hypothalamus mean dose <40 Gy.
46. Definition of CTV for a pT4a carcinoma of the maxilla
resected with clear margins. (a) Preoperative T1-
weighted contrast-enhanced MRI showing primary
tumour invading the cheek (C), masticator space (M)
and lateral pterygoid muscle (P). (b) Corresponding
planning CT slice showing CTV.
48. IMRT
• IMRT provides a more conformal dose distribution to the unusual
PTVs in Maxillary cancer.
• Five or seven field coplanar beams have been used but these
arrangements will increase dose to the orbital contents.
• A non-coplanar arrangement of three to five sagittal midline beams
with right and left lateral beams avoids entry or exit of beams
through the eyes and provides a uniform dose distribution
49.
50.
51. • IMRT is the preferred treatment method as it generally yields better dose
distribution in terms of both tumor coverage and sparing of normal
tissues
• IMRT is rapidly becoming the standard of care technique for external
beam therapy for sinonasal malignancies.
•
52. Adjuvant Radiotherapy
Addition of RT to surgery improve 5-years
survival (44%) when compared to RT alone
(23%) or surgery alone.
Postoperative Radiotherapy: Preferred
interval between resection and postoperative
RT is 6 weeks
•60–66 Gy (1.8–2.0 Gy/fraction); daily 5 days
a week in 6–6.5 weeks
55. Concurrent Chemotherapy
•Concurrent chemoradiation therapy can be
used for patients with medical conditions that
preclude surgery if those patients have good
performance status.
•Depending on the patient’s performance status
and renal function, single-agent cisplatin can be
used concurrently with external beam radiation
for locally advanced, unresectable squamous
cell carcinoma.
56. Neo-adjuvant Chemotherapy
• Neoadjuvant chemotherapy (i.e., chemotherapy given
before surgery) can reduce tumor volumes
• May allow a less extensive surgical resection than
would be possible otherwise.
• Can also reduce tumor volumes and facilitate
radiotherapy planning by increasing the distance
between tumor borders and critical organ structures
such as brain, chiasm, optic nerve, or spinal cord.
• Investigations are ongoing to determine whether the
response to neoadjuvant chemotherapy can help in the
choice of definitive treatment.
57. •Concurrent:
•Inj Cisplatin 100mg/m2, triweekly with
radiotherapy or 35mg/m2weekly with
radiotherapy.
•Neo-adjuvant/Induction:
•3-6 cycles induction chemotherapy with
•Inj. Docetaxel 75mg/m2 i.v. day 1
•Inj. Cisplatin 75mg/m2 i.v. day 1
•Inj 5F.U. 750 mg/m2 i.v.Day 1-day 4
•Others: Paclitaxel /cisplatin/ infusional 5-FU
•Following induction, agents to be used with
concurrentchemoradiation typically include
weekly carboplatin or cetuximab
58. Palliative chemotherapy
•Cisplatin or carboplatin + 5-FU + cetuximab
(category 1)
•Cisplatin or carboplatin + docetaxel or
paclitaxel
•Cisplatin/cetuximab (non-nasopharyngeal)
•Cisplatin/5-FU
60. T3-T4a N0, T1-T4a N+, T4b any N
T3-T4a N0
Surgical Resection
Adverse Features
-ve
Radiotherapy To
primary
Adverse Features
+ve
RT or Consider
systemic therapy/RT
to primary
T1-T4a N+
Surgical Resection+
Neck dissection
Adverse Features
-ve
Radiotherapy To
primary and Neck
Adverse Features
+ve
RT or Consider
systemic therapy/RT
to primary and neck
T4b any N
Clinical trial
Definitive R.T. with
systemic therapy
For example, if neoadjuvant chemotherapy produces a complete response, then primary radiation therapy, with or without chemotherapy, can be considered; a less-than-complete response would prompt surgical excision of the lesion followed by adjuvant radiation therapy.