A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Please find the power point on Carcinoma of rectum. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Please find the power point on Carcinoma of rectum. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Highlights in the treatment of Rectal cancer.pptxMona Quenawy
rectal cancer treatment updates in simple way and the advances in the molecular techniques .the role of the neo adjuvant chemoradiotherapy and the state of the art in the management by each stage.radiotherapy role and technique by using the RTOG guidance in target definition
Hodgkin Lymphoma - Diagnosis to ManagementSubhash Thakur
Presentation is about Hodgkin lymphoma, its incidence and epidemiology, diagnosis, molecular and immunophenotype, work up, staging, treatment and follow up
This presentation is about chronic lymphocytic leukemia (CLL), its epidemiology and incidence, staging, molecular characteristics, clinical features and management.
This presentation is about anemia of chronic disease, nowadays also called as anemia of Inflammation. I have dealt with anemia in CKD and malignancy in detail.
Treating Metastatic NSCLC with Immunotherapy - Update 2019Subhash Thakur
This presentation discusses about important trials like keynote 042 and Checkmate 227, emerging role of immunotherapy in metastatic non small cell lung cancer.
Patient Positioning and Immobilization Devices In Radiotherapy PlanningSubhash Thakur
This is a overview of the devices used in the radiotherapy planning. These are specifically designed for patient proper positioning, reproducibility and immobilization of patient during radiotherapy treatment.
2D, 3D, VMAT and electron planning done for IMN field
considering all aspects, including PTV coverage, dose homogeneity, OAR doses, Electron for IMN was the best
TBI is the radiotherapy technique to irradiate whole body before doing stem cell transplant. The main purpose of doing TBIB is to condition the immune system of body so that there will be maximum chance of transplant acceptance.
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.
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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.
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
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
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!
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
2. Introduction
How are rectal cancer different from colon cancer?
Upper Third : anteriorly and
laterally : peritoneal lining But
Posteriorly it is retroperitoneal
without serosal covering
At Rectovesical Pouch rectum
becomes completely
retroperitoneal.
Lack of peritoneal covering for
most of the rectum is a major
cause for higher risk of local
failure after primary surgical
management than for colon
cancer
6. Investigations for staging
•Local Information
•Tumor location
•Depth of invasion
•LN positivity
•Proximity to neighbouring structures
•Integrity of mesorectal envelope
•Lateral margin
•Local peritoneal involvement by tumor and
•Venous invasion
•Metastatic Work up :
7. clinical staging, 80-95% accurate in
tumor staging, 70-75% accurate in
mesorectal lymph node staging
Very good at
Demonstrating layers of rectal
wall
Determining extension of
disease into anal canal : clinical
importance for planning
sphincter preserving surgery
Limitations :
Useful only for lesions < 14 cm
from anus
Not applicable for upper rectum
Figure. Endorectal
ultrasound of a T3 tumor of
the rectum,
through the
extension
muscularis
propria, and into perirectal
fat.
Transrectal Ultrasound
8. CT scan
Part of routine workup of patients
Useful in identifying enlarged pelvic lymph-nodes and
metastasis outside the pelvis than the extent or stage
of primary tumor
Limited utility in small primary cancer
Sensitivity 50-80%
Specificity 30-80%
Ability to detect pelvic and para-aortic lymph
nodes is higher than peri-rectal lymph nodes.
9. Figure: Mucinous adenocarcinoma of the
rectum. CT scan shows a large
heterogeneous mass (M) with areas of
cystic components. Note marked luminal
narrowing of the rectum (arrow).
Rectal cancer with uterineFigure:
invasion. CT
heterogeneous
scan shows a
rectal mass (M)
large
with
compression and direct invasion into the
posterior wall of the uterus (U).
10. Magnetic Resonance Imaging (MRI)
Greater accuracy in
defining extent of rectal
cancer
Also helpful in lateral
extension of disease,
critical in predicting
circumferential margin for
surgical excision.
11. Staging
Why ???
Critical information concerning the extent of the disease
Used to
•determine prognosis
•To guide management and
•To assess response to therapy
12. Evolution of Rectal Cancer Staging
Long Evolution
1926 : Lockhart – Mummery
1932 : Dukes
1949 : Kirklin, Dockerty and Waugh proposed modification
of Dukes classification
1954 : Astler and coller : Modified Astler Coller
classification (MAC)
1963 : Turnbell modification
1987 : AJCC and IUCC : TNM staging updated in 2002 and
2009 and 2018
13. 1926, Lockhart – Mummery
•Depth of invasion and
•LN positivity in
specimens removed at
surgery
1932, Dukes
•Rectal cancer begins as
epithelial proliferation
raising from the surface
•carcinoma develops
from a previous adenoma
•Cancer metastasize
through the bowel wall to
lymphatics
14. 1949, Kirklin, Dockerty and Waugh modification of
Dukes staging
Preserved A, B and C frameworks and added
subscript 1 & 2 to B
B1 : lesions that have extended into but not
through the muscularis propria
B2 : tumors that have penetrated the muscularis
propria
23. Surgery remains the
mainstay of curative
treatment for carcinoma
of the rectum
Surgical management
depends on the stage and
location of a tumor within
the rectum.
24. GOAL
The general principles of a surgical approach
remain the removal of all gross and microscopic
disease with negative proximal, distal, and
circumferential margins
reserve intestinal continuity and the sphincter
mechanism whenever possible while still
maximizing tumor control
25. For Early cancers : limited surgeries like
Polypectomy
Transanal excision
Transanal endoscopic microsurgery (TEM)
For Advanced Cancers :
Low anterior resection (LAR) or
abdominoperineal resection (APR).
Different Surgical Options
26. Transanal Excision
When it can be done ?
selected T1, N0 early-stage cancers.
Small (<3 cm)
well to moderately differentiated tumors
within 8 cm of the anal verge
limited to less than 30% of the rectal
circumference
no evidence of nodal involvement
27. Structures Removed
Full thickness excision of involved rectum
perpendicularly through the bowel wall into
the perirectal fat.
Advantages
Minimal morbidity
Sphincter sparing
Rapid post operative recovery
Limitations
Absence of pathologic staging of nodal
involvement
28. Abdominoperineal Resection (APR)
The gold standard for surgical resection of distal rectal
cancer located within 6cm of the anal verge.
This procedure requires a tranabdominal as well as a
transperineal approach with removal of the entire rectum
and sphincter complex.
A permanent end colostomy is created and the
perineal wound either closed primarily or left to
granulate in after closure of the musculature
29. Limitations
slightly higher morbidity and mortality than LAR
Permanent Colostomy bag : worst quality of life
Higher risk of positive margins with APR as the
mesorectum is very thin in the distal segment of the
rectum
30. Low Anterior Resection
Now being performed not just for cancers of the upper
third of the rectum but also for middle and lower third
cancers
Preserving adequate anorectal function becomes a
bigger problem the more distal the level of anorectal
anastomosis
31. Patient Selection For LAR
Good anal sphincter continence prior to
considering sphincter-preserving options
A 2-cm distal margin of preserved normal
In carefully selected patients a functional coloanal
anastomosis can be achieved with significantly
reduced margins for more distal cancers especially
after neoadjuvant therapy.
32.
33. Total Mesorectal Resection
Mesorectum : the structure that contains the blood
supply and lymphatics for the upper, middle, and
lower rectum.
Most involved lymph nodes for rectal cancers are
found within the mesorectum
T Stage % of Positive LN
T1 5-7 %
T2 20%
T3 65%
T4 78%
34. Bill Heald from
Basingstoke,
England, 1982, first
began to write about
his technique of TME
He recognized that
most local recurrences
seen after rectal cancer
resection were a result
of inadequate
resections performed
using imprecise, blunt
dissection.
35. en bloc removal of the mesorectum, including
associated vascular and lymphatic structures
Structures Removed
36. Laparoscopic Resection
Advantages
less blood loss
shorter hospital stays
quicker return of bowel function
Limitations
larger operation times
No difference in completeness of resection, percentage
of patients with positive CRM
38. Pattern of local failure for tumors without lymph node
metastasis = 17 % but increased to 54 % in tumors that
were adherent to or invading adjacent organ and
structures
Five year survival for
Duke A : 77 %
Duke B : 44 %
Duke C : 23 %
40. Radiotherapy Alone
•Several trials have shown local benefit with RT alone with
acceptable toxicity
•NSABP R01 trial
randomized 555 patients with Duke B and C to 3 arms
1. observation
2. chemo (MOF)
3. RT : 46 to 47 Gy in 26 to 27 #
•Results
•RT arm : reduction in local failure from 25% to 16% but no
difference in overall survival (OS) and Disease free survival
(DFS)
•Chemo arm showed no improvement in local failure but
significant improvement in DFS and OS
41. MRC Trial
469 Post-curative surgery patients with Duke St B & C
Randomized into two arms :
Observation Vs RT @ 40 Gy/20#/4 weeks
Results
Local failure : 34 % 21 %
5 year survival : 41% 39%
42. NSABP and MRC trials
RT improved local control without improvement in overall
survival (OS)
??? Addition of Chemotherapy ??
RT + Chemotherapy ????
43. Gastrointestinal Tumor Study
Group (GITSG ) 7175 trial :
227 post-op patients with Duke stage B and C
Randomized into 4 arms
Observation
RT (40-48 Gy in 4/5 weeks)
Chemo ( 5 FU/Semustine)
RT + Chemo
Results
•combination treatment significantly reduced recurrence
rate and also prolonged time to recurrence
•Significant improvement in DFS (70% Vs 46%) and OS
(58% Vs 45%) in combination arm as compared to
surgery alone arm.
44. Mayo Clinic Trial
204 post-op patients stage T3, T4 or N1/N2
Randomized into two Arms
1. RT @ 45 to 50 Gy/5 weeks
2. RT + Chemo
Results
F/U of 7 years, overall recurrence reduced by 34% with
RT + Chemo and local recurrence reduced by 46 %
Distant metastasis reduced by 37 % and 29% reduction
in deaths
Toxicities : diarrhoea and dermatitis
45. Now, Proven clinical success of adj
Chemoradiation
Aim : improving the post-op
chemotherapy to further impact
overall survival
46. NCCTG Trial
Infusional 5 FU Vs Bolus 5 FU, further randomized into
bolus 5 FU + Semustine
Results :
F/U 46 months, 4 year OS significantly improved with
continuous infusion of 5 FU (70% Vs 60%)
Continuous infusion of 5 FU with conc. RT also reduced
the risk of distant metastasis (40% to 31%)
Addition of semustine to 5 FU had no beneficial efffect
on patient outcome
47. Neoadjuvant Vs Adjuvant Treatment
Timing of conc. Chemotherapy and RT in management
of rectal cancer -------- Controversial
Rationale for adjuvant treatment :
Accurate depth of tumor and LN status can be assessed
accurately Stage I tumors can be spared from adj. Rx
48. Rationale for using neoadjuvant
treatment :
Major benefit : increased rate of sphincter
preservation
Reduction in toxicity as after LAR or APR small bowel
falls into pelvis and hence they come into radiation
portals
By neoadjuvant Rx, irradiating bowels are later
removed during surgery and hence no risk of long term
toxicity eg. Perforation
From radiobiological perspective, tumor is well
oxygenated during neoadjuvant setting while blood flow
to tumor bed is compromised post surgery, hence low
sensitivity to RT
49. Trial : Neoadjuvant Vs Adjuvant
Sauer et al, 2004
823 patients, T3, T4 or N+
Two arms
1. Pre-op CRT
2. Post-Op CRT
Neoadj. Arm : 50.4 Gy, 1.8 Gy/# +
continuous infusion of 5 FU over
120 hrs during 1st and 5th week of
RT
6 weeks
surgery
1 month
4 five day cycle of 5 FU
@500mg/m2/day
Adj Arm : same with additional
boost of 540 cGy to tumor bed
50. Results
Neoadjuvant Adjuvant
OS at 5 yrs 76% 74%
5 yr local rec. 6% 13%
Rate of sphincter
preserving Sx 39% 20%
Toxicity Lower higher
Although no survival benefit has been seen ability to
improve local control and increase the ability to spare the
sphincter shifted the management side to neoadjuvant
51. SHORT COURSE VS LONG
COURSE RT
Two phase III trials
Polish trial : to determine whether long term
course increase chance of sphincter
preservation
TROG trial : compare local recurrence rates
between two approach
Schedule followed : 25 Gy/5# VS 50.4 Gy using
1.8 to 2 Gy fractions with concomitant bolus 5-
FU and leucovorin given during weeks 1 and 5
Results : No significant difference in local control,
overall survival, sphincter preservation with slight higher
incidence of acute toxicity in long CRT arm
54. TARGET VOLUME
The presacral space
The primary tumor site, and the perineum (for
post- APR cases)
The mesorectal and lateral lymph nodes and internal
illiac are included in all patients
The external iliac nodes should be covered for T4
lesions.
55. The inguinal lymph nodes may be included
if tumour invades the lower third of the vagina
if there is major tumour extension into the
internal and external anal sphincter
59. Conventional Field borders
Superior Border : L5-S1 junction
Inferior Border : 3 cm below the primary tumor or at the
inferior aspect of the obturator foramen whichever is most
inferior
Lateral Border : 1.5 cm lateral to widest bony margin of true
pelvic side walls
Anterior Border :
T3 disease : posterior margin of symphysis pubis : to
treat only the internal iliac nodes
T4 disease : anterior margin of symphysis pubis : to
include external iliac nodes
Posterior Borders : 1 to 1.5 cm behind the anterior bony
sacral margin
60. Boost field:
A : Treat the primary
tumor bed plus a 3-cm
margin (not the nodes).
61. Fig B: For a T4N1M0 rectal
cancer 8 cm from the anal
verge. Since the tumor was a
T4, the anterior field is at the
anterior margin of the
symphysis pubis (to include
the external iliac nodes).
Fig A: Treatment fields after a low anterior
resection for a T3N1M0 rectal cancer 8 cm
from the anal verge. The distal border is at
the bottom of the obturator foramen and the
perineum is blocked. Since the tumor was a
T3, the anterior field is at the posterior
margin of the symphysis pubis (to treat only
the internal iliac nodes).
Fig C: Treatment fields following an
abdominoperineal resection for a T4N1M0
rectal cancer 2 cm from the anal verge,
because the tumor was a T4, the anterior
field is at the anterior margin of the
symphysis pubis (to include the external
iliac nodes). Since the distal border is
being extended only to include the scar
and external iliac nodes, the remaining
normal tissues can be blocked
65. CT based Planning
To ensure adequate coverage of the tumor and
regional nodes
Improved dose homogeneity
Planning CT :
Prone Position using Belly board
Mid abdomen L1 to mid thigh
IV, rectal and bowel contrast given
Fusion of planning CT with MRI/PET may be
done for better target delineation
3D CONFORMAL RT
66. Prone Position
Advantages :
Allows access for DRE and allows verification of lower and
middle rectal lesion location in relation to anal verge, while
maintaining the treatment position
Anal verge can be marked with a radiopaque maarker and rectal
contrast to assist radiographic identification of primary lesion
Belly board
Advantages : significant reduction of small bowel in treatment portal
Perineal Scar after APR
Patients who have undergone APR must have the perineal scar
marked and included in the initial pelvic fielsds
Perineal recurrence : 8-30% of patients in absence of adjuvant RT
but as low as 2% when scar is adequately treated.
67. The GTV includes all gross tumour seen on the
planning CT scan with reference to information
from diagnostic endoscopy, MRI and DRE
Any involved lymph nodes, extrarectal extension, or
extranodal deposits seen on MRI should be included
CTV should include peri-rectal, pre-sacral,
internal iliac regions
68. RTOG GUIDELINES
The caudad extent of this elective target volume
should be a minimum of 2 cm caudad to gross
disease, including coverage of the entire
mesorectum to the pelvic floor
The posterior and lateral margins of CTV should
extend to lateral pelvic sidewall musculature or,
where absent, the bone
Anteriorly, the group recommended extending 1 cm
into the posterior bladder, to account for day to day
variation in bladder position.
69. The recommended superior extent of the peri-
rectal component
the rectosigmoid junction or 2 cm proximal to the
superior extent of macroscopic disease in the
rectum/peri-rectal nodes.
To include illiac vessels it should be kept at L5-S1
junction
70. Margin around blood vessels: The group
recommended a 7 mm margin in soft tissue
around the external iliac vessels
but one should consider a larger 10+ mm
margin anterolaterally if nodes are identified
in this area
71. BOOST VOLUME
The group recommend that any boost clinical
target volumes extend to entire mesorectum and
presacral region at involved levels
including ~2 cm cephalad and caudad in the
mesorectum and ~2 cm on gross tumor within the
anorectum.
PTV margin should be ~0.7 to 1.0 cm, except at
skin
72.
73.
74.
75.
76. Techniques to Decrease Radiation
Toxicity in Small Bowel
High-energy (>6 MV) linear accelerators.
Treatment 5 days per week and all fields each
day.
Pelvic field: multiple-field technique (posterior-
anterior plus laterals or posterior-anterior-anterior-
posterior plus laterals) is recommended.
77. Boost field: opposed laterals.
Computerized dosimetry optimizing between
minimizing the lateral hot spots and small bowel
dose and increasing the homogeneity within the
target volume
In thin patients, a combination of 6 MV for the
posterior fields and higher-energy photons for the
lateral fields may result in more homogeneous
dosimetry.
Shaped blocks and, if needed, wedges on the
lateral fields.
78. Intensity-Modulated Radiation
Therapy
Potential to reduce toxicity
No set standards regarding its use
Different IMRT volume–based dose constraints
have been proposed for bowel and bladder, but
there is no set consensus.
IMRT-based sparing of the iliac crests may also
reduce bone marrow toxicity
79. Currently, IMRT is not recommended for routine
use.
IMRT can be used in re irradiation for recurrence
80. Endocavitary radiation therapy.
Indications
T1 or T2 tumors less than 3 cm
not poorly differentiated
with no evidence of nodal involvement.
Patients are treated with a low energy x- ray machine (50 kV)
that is attached to a rigid endoscopic-type device that can
be placed in the rectum directly over the tumor.
As the opening of the applicator is 3 cm, it isdifficult to
treat tumors larger than this.
81. Patients typically receive four treatments of 2,500 to 3,000 cGy each
with 2 to 3 weeks between treatments to allow for tumor regression.
Although the total dose is extremely high, the minimal penetration
of the radiation beam protects the underlying normal tissue.
Local control results with this approach have been very
good in properly selected patients
but specialized equipment is required (which is not generally
available)
less pathological information is obtained than after a local excision.
This approach is rarely used at the present time
82. Dose
Preoperative radiotherapy
Short course: 25 Gy in 5 daily fractions of 5 Gy given in 1
week.
Long course
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2
5.4 in 3 daily fractions of 1.8 Gy
Postoperative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy.
83. Adverse effects
Acute complications
diarrhea and increased bowel frequency (small
bowel)
acute proctitis (large bowel)
thrombocytopenia, leukopenia, and dysuria are
common during treatment.
These conditions are usually transient and
resolve within a few weeks following the
completion of radiation.
84. In the small bowel, loss of the mucosal cells results
in malabsorption of various substances, including fat,
carbohydrate, protein, and bile salts.
The bowel mucosa usually recovers completely in1 to
3 months following radiation.
Management usually involves the use of
antispasmodic and anticholinergic medications.
85. Delayed complications
occur less frequently, but are more serious.
The initial symptoms commonly occur 6 to 18 months
following completion of radiation.
persistent diarrhea and increased bowel frequency
proctitis, small bowel obstruction (SBO) not requiring
surgery,
perineal and scrotal tenderness