This document discusses mediastinal staging for non-small cell lung cancer (NSCLC). Chest CT has reasonable sensitivity (55%) and specificity (81%) for mediastinal staging but multi-station CT using lymph node size and location criteria can improve sensitivity to 94-100% and specificity to 98.5%. PET-CT further improves staging with a meta-analysis showing sensitivity of 80% and specificity of 88% but may miss metastases in small lymph nodes. Artificial neural networks analyzing PET-CT scans can predict mediastinal nodal stage with 99% accuracy. Tissue confirmation is still recommended when PET-CT indicates mediastinal involvement.
How the role of radiotherapy has evaluated in pancreatic cancer. Now it has become indispensable for treatment in pancreatic cancer. Radiotherapy can be used in the form of EBRT/SBRT/IORT.
LOCAL ABLATIVE RADIOTHERAPY/LIVER METASTASIS SBRTKanhu Charan
This document discusses and compares local ablative therapy options for treating liver metastases, including surgery (metastatectomy), thermal ablation techniques (radiofrequency ablation (RFA), cryoablation), chemotherapy (transarterial chemoembolization (TACE), transarterial radioembolization (TARE)), and radiotherapy (stereotactic body radiation therapy (SBRT), brachytherapy). It provides details on techniques such as RFA and SBRT and reviews studies comparing the effectiveness and safety of RFA versus SBRT. Overall, the document analyzes the benefits and limitations of different local treatment approaches for liver cancer metastases.
The CROSS trial found that neoadjuvant chemoradiotherapy followed by surgery significantly improved long-term overall and progression-free survival compared to surgery alone for patients with resectable esophageal or esophagogastric junction cancer. At a minimum follow-up of 5 years, median overall survival was 48.6 months for chemoradiotherapy plus surgery versus 24 months for surgery alone. Both squamous cell carcinoma and adenocarcinoma subtypes benefited. Neoadjuvant chemoradiotherapy using carboplatin and paclitaxel is now considered the standard of care for these patients.
This document discusses several landmark trials comparing different treatment approaches for esophageal cancer. The CALGB 9781 trial compared trimodality therapy (chemotherapy, radiation therapy, and surgery) to surgery alone and found improved overall survival and progression-free survival with trimodality therapy. Median overall survival was 4.48 years with trimodality therapy versus 1.79 years with surgery alone. The trial was closed early due to poor accrual, resulting in a small sample size.
This document discusses staging and treatment for limited stage small cell lung cancer (SCLC). The standard of care is combined concurrent chemoradiotherapy. Chemotherapy typically includes a platinum agent (cisplatin or carboplatin) and etoposide. Concurrent chemoradiotherapy improves survival compared to chemotherapy alone. Optimal sequencing and timing of radiotherapy is being investigated, with some evidence that earlier radiotherapy initiation may improve outcomes. Standard radiotherapy fractionation is 45 Gy in 1.8 Gy fractions or 61-70 Gy total dose in 2 Gy fractions, though hypofractionated regimens are also used. Ongoing trials are further optimizing radiotherapy dose and scheduling.
This document discusses the treatment of lung cancer with radiation. Stage I-II lung cancers are typically treated with surgery and sometimes post-operative chemotherapy or radiation. Stage III cancers usually receive chemotherapy and radiation, sometimes followed by surgery. Stage IV cancers are treated with chemotherapy or radiation. Advanced techniques like CT-guided planning, adaptive radiotherapy using daily CT images, and stereotactic body radiation therapy can help target radiation doses precisely to tumors while minimizing exposure to healthy lung tissue. Radiation is generally well-tolerated but can cause short-term effects like cough and long-term effects like fibrosis. Careful treatment planning aims to limit radiation doses to normal lungs.
Role of Chemotherapy, Targeted therapy and Immunotherapy in NSCLC Part IMohammed Fathy
1) Chemotherapy provides a modest survival benefit for early stage NSCLC based on multiple randomized trials. The absolute improvement in 5-year survival is approximately 5%.
2) The IALT trial showed a 4% improvement in 5-year survival with cisplatin-based chemotherapy compared to observation alone for stage I-III NSCLC.
3) The JBR.10 trial demonstrated an 11% absolute improvement in 5-year survival with vinorelbine and cisplatin compared to observation for stage IB-II NSCLC. However, the benefit was largely seen in stage II patients.
How the role of radiotherapy has evaluated in pancreatic cancer. Now it has become indispensable for treatment in pancreatic cancer. Radiotherapy can be used in the form of EBRT/SBRT/IORT.
LOCAL ABLATIVE RADIOTHERAPY/LIVER METASTASIS SBRTKanhu Charan
This document discusses and compares local ablative therapy options for treating liver metastases, including surgery (metastatectomy), thermal ablation techniques (radiofrequency ablation (RFA), cryoablation), chemotherapy (transarterial chemoembolization (TACE), transarterial radioembolization (TARE)), and radiotherapy (stereotactic body radiation therapy (SBRT), brachytherapy). It provides details on techniques such as RFA and SBRT and reviews studies comparing the effectiveness and safety of RFA versus SBRT. Overall, the document analyzes the benefits and limitations of different local treatment approaches for liver cancer metastases.
The CROSS trial found that neoadjuvant chemoradiotherapy followed by surgery significantly improved long-term overall and progression-free survival compared to surgery alone for patients with resectable esophageal or esophagogastric junction cancer. At a minimum follow-up of 5 years, median overall survival was 48.6 months for chemoradiotherapy plus surgery versus 24 months for surgery alone. Both squamous cell carcinoma and adenocarcinoma subtypes benefited. Neoadjuvant chemoradiotherapy using carboplatin and paclitaxel is now considered the standard of care for these patients.
This document discusses several landmark trials comparing different treatment approaches for esophageal cancer. The CALGB 9781 trial compared trimodality therapy (chemotherapy, radiation therapy, and surgery) to surgery alone and found improved overall survival and progression-free survival with trimodality therapy. Median overall survival was 4.48 years with trimodality therapy versus 1.79 years with surgery alone. The trial was closed early due to poor accrual, resulting in a small sample size.
This document discusses staging and treatment for limited stage small cell lung cancer (SCLC). The standard of care is combined concurrent chemoradiotherapy. Chemotherapy typically includes a platinum agent (cisplatin or carboplatin) and etoposide. Concurrent chemoradiotherapy improves survival compared to chemotherapy alone. Optimal sequencing and timing of radiotherapy is being investigated, with some evidence that earlier radiotherapy initiation may improve outcomes. Standard radiotherapy fractionation is 45 Gy in 1.8 Gy fractions or 61-70 Gy total dose in 2 Gy fractions, though hypofractionated regimens are also used. Ongoing trials are further optimizing radiotherapy dose and scheduling.
This document discusses the treatment of lung cancer with radiation. Stage I-II lung cancers are typically treated with surgery and sometimes post-operative chemotherapy or radiation. Stage III cancers usually receive chemotherapy and radiation, sometimes followed by surgery. Stage IV cancers are treated with chemotherapy or radiation. Advanced techniques like CT-guided planning, adaptive radiotherapy using daily CT images, and stereotactic body radiation therapy can help target radiation doses precisely to tumors while minimizing exposure to healthy lung tissue. Radiation is generally well-tolerated but can cause short-term effects like cough and long-term effects like fibrosis. Careful treatment planning aims to limit radiation doses to normal lungs.
Role of Chemotherapy, Targeted therapy and Immunotherapy in NSCLC Part IMohammed Fathy
1) Chemotherapy provides a modest survival benefit for early stage NSCLC based on multiple randomized trials. The absolute improvement in 5-year survival is approximately 5%.
2) The IALT trial showed a 4% improvement in 5-year survival with cisplatin-based chemotherapy compared to observation alone for stage I-III NSCLC.
3) The JBR.10 trial demonstrated an 11% absolute improvement in 5-year survival with vinorelbine and cisplatin compared to observation for stage IB-II NSCLC. However, the benefit was largely seen in stage II patients.
This document summarizes a panel discussion on oligometastatic disease. It defines oligometastatic disease as having a solitary or few detectable metastatic lesions confined to a single organ or more than one organ. There is ongoing debate around how many lesions constitute oligometastatic disease. The document discusses various theories on metastasis patterns and improving treatments like stereotactic radiosurgery that have led to reclassification of some metastatic tumors as oligometastatic. Ongoing trials are exploring more aggressive local treatment of oligometastatic lesions combined with systemic therapies to improve long-term survival.
This document discusses treatment options for larynx cancer, including radiotherapy, transoral laser surgery (TLS), and open partial laryngectomy for early glottic cancers. For locally advanced cancers, concurrent chemoradiotherapy is now the standard of care. Organ preservation approaches have improved larynx preservation rates to 85-95% for early cancers and 87.9% for advanced cancers treated with chemoradiotherapy plus cetuximab. Salvage total laryngectomy following organ preservation has acceptable morbidity and survival is not influenced by initial treatment approach.
This document discusses the management of luminal breast cancers. It covers several topics:
1) The different breast cancer subtypes, including luminal A and B cancers, which make up 50-60% and 15-20% of cases respectively. Luminal A has a better prognosis while luminal B is more aggressive.
2) The need for molecular signatures to better classify cancers and predict outcomes. Trials have shown certain gene expression profiles can determine if chemotherapy is needed.
3) Guidelines for adjuvant systemic therapies for luminal cancers, including chemotherapy, endocrine therapy, radiation, and duration of treatment. Trials support extended endocrine therapy to lower recurrence risk.
4) Neoadjuvant endocrine therapy
Gastric cancer discussion slides final version.pptnew.pptzoezettemarc
1) Peri-operative chemotherapy with ECX before and after surgery improves overall survival compared to surgery alone in resectable gastric cancer based on the MAGIC trial.
2) The ACTS-GT trial showed adjuvant S-1 chemotherapy improves 3-year survival compared to observation alone after D2 gastrectomy for stage II-III gastric cancer.
3) Combination chemotherapy improves survival over best supportive care alone in advanced gastric cancer, with regimens including anthracyclines and cisplatin or oxaliplatin showing better efficacy.
The document discusses the role of chemotherapy in carcinoma of the stomach. It outlines several key trials investigating neoadjuvant, adjuvant and perioperative chemotherapy approaches. The MAGIC trial showed significantly improved 5-year survival with perioperative chemotherapy compared to surgery alone. The French FNCLCC trial also demonstrated improved disease-free and overall survival with perioperative chemotherapy. Adjuvant chemoradiation was shown in the INT0116/SWOG 9008 trial to improve 5-year overall and disease-free survival compared to surgery alone. The Japanese S-1 trial found significant benefit in 5-year disease-free and overall survival with adjuvant S-1 chemotherapy compared to observation after surgery.
1. Lung metastasis is the second most common site of metastasis after the liver for many cancers. Complete resection of pulmonary metastases can improve survival for certain primary cancers like sarcoma, colon cancer, and breast cancer when the metastases are limited in number and size.
2. Pulmonary metastases can present radiographically in different patterns including cannonball lesions, miliary nodules, cavitating lesions, and endobronchial lesions. Diagnosis is typically made through CT scan, and biopsy may be needed to differentiate from a primary lung cancer.
3. Surgical resection is recommended for isolated, resectable metastases to potentially improve survival, with criteria including controlled primary cancer, no other distant metastases, and ability
The document discusses several trials evaluating preoperative chemoradiotherapy versus postoperative chemoradiotherapy or radiotherapy alone for rectal cancer. Some key trials found that preoperative therapy improved local recurrence rates and survival compared to postoperative or no adjuvant therapy. Longer intervals between preoperative radiotherapy and surgery were associated with higher rates of tumor downstaging. Adding oxaliplatin or chemotherapy without radiation improved survival outcomes in some trials. Ongoing studies are exploring chemotherapy alone and targeted agents in rectal cancer.
Lymphoma arises from mutations in cells of the lymphatic system. It is the 7th and 6th most common cancer in men and women respectively. The median age of diagnosis is 66 for non-Hodgkin lymphoma and 38 for Hodgkin lymphoma. Treatment depends on the lymphoma type and stage but may include chemotherapy, targeted therapies like rituximab, and radiation therapy. Radiation is commonly used at low doses to treat localized non-Hodgkin lymphoma and is also used in combination with chemotherapy for early stage or high risk Hodgkin lymphoma to improve outcomes. Long term risks of radiation include damage to nearby tissues and potential new cancers later in life.
This document discusses evidence-based management of rectal malignancy. It provides an overview of preoperative staging for rectal cancer, TNM staging criteria, the importance of total mesorectal excision surgery, and the role of adjuvant radiation therapy and chemotherapy based on randomized controlled trials. For locally advanced rectal cancer, it reviews evidence that preoperative radiation therapy with chemotherapy provides benefits of downstaging and reduced local recurrence compared to postoperative treatment.
The document discusses the role of radiation therapy in treating oligometastatic prostate cancer, noting that radiation can potentially achieve durable responses or even cure in some cases when metastases are limited. It reviews definitions of oligometastatic prostate cancer, the rationale for local and metastasis-directed radiation therapy, clinical evidence from studies on the use of external beam radiation therapy and stereotactic body radiation therapy to treat the primary tumor and metastases, and outcomes from these studies including local control rates, progression-free survival, and overall survival. The document concludes that radiation therapy plays an important role in the treatment of oligometastatic prostate cancer.
This document provides information on carcinoma of the esophagus, including:
- Esophageal cancer is the 8th most common cancer worldwide, with high incidence rates in parts of Africa and Asia. Squamous cell carcinoma and adenocarcinoma account for most cases.
- The esophagus has three layers - mucosa, submucosa, and muscularis propria. It lacks a serosa, allowing early extraesophageal spread.
- Staging uses AJCC TNM and other systems to assess tumor size, lymph node involvement, and metastasis.
- Risk factors include smoking, alcohol, hot foods/liquids, micronutrient deficiencies, GERD, and Barrett's
This document summarizes the current standards and evidence for managing the axilla in breast cancer. It discusses how to evaluate the axilla clinically and with sentinel lymph node biopsy (SLNB). Studies such as NSABP B-32 and ACOSOG Z0011 showed that SLNB alone is sufficient for node-negative patients, reducing morbidity compared to axillary lymph node dissection (ALND). For node-positive patients, completion ALND is still standard, though trials are investigating axillary radiation instead. SLNB accuracy improves with dual tracer use and removing ≥3 nodes. SLNB is now widely used after neoadjuvant chemotherapy in clinically node-negative patients, though false negatives remain higher in clinically node-positive patients
Total neoadjuvant therapy for rectal cancer 2016Mohamed Abdulla
1) Total neoadjuvant therapy, consisting of chemotherapy followed by chemoradiation and surgery, may improve outcomes for rectal cancer over the traditional approach.
2) Ongoing clinical trials are investigating selective use of radiation and whether radiation can be omitted from some neoadjuvant regimens based on risk factors and response.
3) Near total neoadjuvant therapy with upfront chemotherapy alone may achieve pathologic complete responses in a third of patients and warrants further exploration as an alternative to traditional chemoradiation.
Journal club: Durvalumab as Consolidation therapy in Advanced NSCLCAnimesh Agrawal
This study evaluated the addition of durvalumab consolidation therapy following chemoradiotherapy in patients with unresectable stage III non-small cell lung cancer. The study found that durvalumab improved progression-free survival compared to placebo, with median progression-free survival of 16.8 months versus 5.6 months respectively. Overall survival was also improved with durvalumab, though final analysis is still pending. Safety profiles were similar to other PD-L1 inhibitors, with immune-related adverse events in approximately 25% of durvalumab patients. This study provides evidence that durvalumab consolidation improves outcomes for stage III NSCLC following chemoradiotherapy.
This document discusses several clinical trials comparing different treatment approaches for esophageal cancer, including:
- Preoperative chemotherapy improved survival compared to surgery alone in some trials but not in others. High toxicity reduced benefits in some studies.
- Perioperative chemotherapy with fluorouracil and cisplatin significantly improved resection rates, survival, and disease-free survival compared to surgery alone.
- Chemoradiotherapy resulted in improved survival over radiotherapy alone or surgery alone in some trials for resectable esophageal cancer.
- Existing evidence did not clearly show preoperative radiotherapy alone improved survival over surgery alone for resectable esophageal cancer. Larger trials were needed.
LUNG CANCER remains the leading cause of cancer-related mortality in men and women in the United States, accounting for over 157,000 deaths annually.Despite advances in imaging, lung cancer is often detected when the disease has spread from the primary tumour to regional lymph nodes or distant sites. Appropriate therapy is dependent on accurate staging to identify those patients who are surgical candidates and those patients for whom chemotherapy and radiation therapy is indicated.
In this review, the current staging system for lung cancer is discussed, along with practical imaging approaches.
Radiotherapy For Non Small Cell Lung Cancerfondas vakalis
- The document discusses treatment options for non-small cell lung cancer (NSCLC), including surgery, radiotherapy, chemotherapy, and combinations.
- For early stage NSCLC (stages I-II), surgery is the standard treatment but radiotherapy is an alternative for medically inoperable patients. Adjuvant chemotherapy may improve outcomes for stage II.
- For locally advanced NSCLC (stage III), combined modality treatment is usually recommended, with concurrent chemoradiotherapy being superior to sequential treatment for stage IIIB.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
- Non-small cell lung cancer is the most common malignancy worldwide and a leading cause of cancer death. It accounts for the majority (70-80%) of lung cancers.
- Imaging techniques like CT scans are important for accurately assessing the primary tumor and detecting metastasis. Positron emission tomography (PET) CT is more sensitive than size-based criteria alone for detecting lymph node involvement.
- Staging involves classifying the size and extent of the primary tumor and determining if the cancer has spread to lymph nodes or distant organs. Higher stages indicate larger primary tumors or spread beyond the lungs.
LOCALLY ADVANCED LUNG CANCER MANAGEMENTFaraz Badar
This document discusses the management of locally advanced lung cancer. It provides information on the epidemiology, risk factors, anatomy, patterns of spread, diagnostic workup, staging, and management approaches for resectable stage III disease. Management involves induction chemotherapy or chemoradiation followed by surgery with postoperative radiotherapy or chemotherapy, depending on pathological findings. The evidence from clinical trials supports the use of multimodality therapy with chemotherapy and radiation for improved outcomes in resectable locally advanced non-small cell lung cancer.
Lung cancer is the leading cause of cancer death worldwide, responsible for close to 2 million deaths per year. The main risk factor is tobacco, explaining about 90% of lung cancer cases. The two main types are small cell lung cancer (15% of cases) and non-small cell lung cancer (85% of cases). Diagnosis involves pathology to determine the histologic subtype and molecular testing to guide targeted therapy options. Staging uses the TNM system to classify tumors based on size, lymph node involvement, and metastasis. Treatment depends on the stage but may include surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy.
This document summarizes a panel discussion on oligometastatic disease. It defines oligometastatic disease as having a solitary or few detectable metastatic lesions confined to a single organ or more than one organ. There is ongoing debate around how many lesions constitute oligometastatic disease. The document discusses various theories on metastasis patterns and improving treatments like stereotactic radiosurgery that have led to reclassification of some metastatic tumors as oligometastatic. Ongoing trials are exploring more aggressive local treatment of oligometastatic lesions combined with systemic therapies to improve long-term survival.
This document discusses treatment options for larynx cancer, including radiotherapy, transoral laser surgery (TLS), and open partial laryngectomy for early glottic cancers. For locally advanced cancers, concurrent chemoradiotherapy is now the standard of care. Organ preservation approaches have improved larynx preservation rates to 85-95% for early cancers and 87.9% for advanced cancers treated with chemoradiotherapy plus cetuximab. Salvage total laryngectomy following organ preservation has acceptable morbidity and survival is not influenced by initial treatment approach.
This document discusses the management of luminal breast cancers. It covers several topics:
1) The different breast cancer subtypes, including luminal A and B cancers, which make up 50-60% and 15-20% of cases respectively. Luminal A has a better prognosis while luminal B is more aggressive.
2) The need for molecular signatures to better classify cancers and predict outcomes. Trials have shown certain gene expression profiles can determine if chemotherapy is needed.
3) Guidelines for adjuvant systemic therapies for luminal cancers, including chemotherapy, endocrine therapy, radiation, and duration of treatment. Trials support extended endocrine therapy to lower recurrence risk.
4) Neoadjuvant endocrine therapy
Gastric cancer discussion slides final version.pptnew.pptzoezettemarc
1) Peri-operative chemotherapy with ECX before and after surgery improves overall survival compared to surgery alone in resectable gastric cancer based on the MAGIC trial.
2) The ACTS-GT trial showed adjuvant S-1 chemotherapy improves 3-year survival compared to observation alone after D2 gastrectomy for stage II-III gastric cancer.
3) Combination chemotherapy improves survival over best supportive care alone in advanced gastric cancer, with regimens including anthracyclines and cisplatin or oxaliplatin showing better efficacy.
The document discusses the role of chemotherapy in carcinoma of the stomach. It outlines several key trials investigating neoadjuvant, adjuvant and perioperative chemotherapy approaches. The MAGIC trial showed significantly improved 5-year survival with perioperative chemotherapy compared to surgery alone. The French FNCLCC trial also demonstrated improved disease-free and overall survival with perioperative chemotherapy. Adjuvant chemoradiation was shown in the INT0116/SWOG 9008 trial to improve 5-year overall and disease-free survival compared to surgery alone. The Japanese S-1 trial found significant benefit in 5-year disease-free and overall survival with adjuvant S-1 chemotherapy compared to observation after surgery.
1. Lung metastasis is the second most common site of metastasis after the liver for many cancers. Complete resection of pulmonary metastases can improve survival for certain primary cancers like sarcoma, colon cancer, and breast cancer when the metastases are limited in number and size.
2. Pulmonary metastases can present radiographically in different patterns including cannonball lesions, miliary nodules, cavitating lesions, and endobronchial lesions. Diagnosis is typically made through CT scan, and biopsy may be needed to differentiate from a primary lung cancer.
3. Surgical resection is recommended for isolated, resectable metastases to potentially improve survival, with criteria including controlled primary cancer, no other distant metastases, and ability
The document discusses several trials evaluating preoperative chemoradiotherapy versus postoperative chemoradiotherapy or radiotherapy alone for rectal cancer. Some key trials found that preoperative therapy improved local recurrence rates and survival compared to postoperative or no adjuvant therapy. Longer intervals between preoperative radiotherapy and surgery were associated with higher rates of tumor downstaging. Adding oxaliplatin or chemotherapy without radiation improved survival outcomes in some trials. Ongoing studies are exploring chemotherapy alone and targeted agents in rectal cancer.
Lymphoma arises from mutations in cells of the lymphatic system. It is the 7th and 6th most common cancer in men and women respectively. The median age of diagnosis is 66 for non-Hodgkin lymphoma and 38 for Hodgkin lymphoma. Treatment depends on the lymphoma type and stage but may include chemotherapy, targeted therapies like rituximab, and radiation therapy. Radiation is commonly used at low doses to treat localized non-Hodgkin lymphoma and is also used in combination with chemotherapy for early stage or high risk Hodgkin lymphoma to improve outcomes. Long term risks of radiation include damage to nearby tissues and potential new cancers later in life.
This document discusses evidence-based management of rectal malignancy. It provides an overview of preoperative staging for rectal cancer, TNM staging criteria, the importance of total mesorectal excision surgery, and the role of adjuvant radiation therapy and chemotherapy based on randomized controlled trials. For locally advanced rectal cancer, it reviews evidence that preoperative radiation therapy with chemotherapy provides benefits of downstaging and reduced local recurrence compared to postoperative treatment.
The document discusses the role of radiation therapy in treating oligometastatic prostate cancer, noting that radiation can potentially achieve durable responses or even cure in some cases when metastases are limited. It reviews definitions of oligometastatic prostate cancer, the rationale for local and metastasis-directed radiation therapy, clinical evidence from studies on the use of external beam radiation therapy and stereotactic body radiation therapy to treat the primary tumor and metastases, and outcomes from these studies including local control rates, progression-free survival, and overall survival. The document concludes that radiation therapy plays an important role in the treatment of oligometastatic prostate cancer.
This document provides information on carcinoma of the esophagus, including:
- Esophageal cancer is the 8th most common cancer worldwide, with high incidence rates in parts of Africa and Asia. Squamous cell carcinoma and adenocarcinoma account for most cases.
- The esophagus has three layers - mucosa, submucosa, and muscularis propria. It lacks a serosa, allowing early extraesophageal spread.
- Staging uses AJCC TNM and other systems to assess tumor size, lymph node involvement, and metastasis.
- Risk factors include smoking, alcohol, hot foods/liquids, micronutrient deficiencies, GERD, and Barrett's
This document summarizes the current standards and evidence for managing the axilla in breast cancer. It discusses how to evaluate the axilla clinically and with sentinel lymph node biopsy (SLNB). Studies such as NSABP B-32 and ACOSOG Z0011 showed that SLNB alone is sufficient for node-negative patients, reducing morbidity compared to axillary lymph node dissection (ALND). For node-positive patients, completion ALND is still standard, though trials are investigating axillary radiation instead. SLNB accuracy improves with dual tracer use and removing ≥3 nodes. SLNB is now widely used after neoadjuvant chemotherapy in clinically node-negative patients, though false negatives remain higher in clinically node-positive patients
Total neoadjuvant therapy for rectal cancer 2016Mohamed Abdulla
1) Total neoadjuvant therapy, consisting of chemotherapy followed by chemoradiation and surgery, may improve outcomes for rectal cancer over the traditional approach.
2) Ongoing clinical trials are investigating selective use of radiation and whether radiation can be omitted from some neoadjuvant regimens based on risk factors and response.
3) Near total neoadjuvant therapy with upfront chemotherapy alone may achieve pathologic complete responses in a third of patients and warrants further exploration as an alternative to traditional chemoradiation.
Journal club: Durvalumab as Consolidation therapy in Advanced NSCLCAnimesh Agrawal
This study evaluated the addition of durvalumab consolidation therapy following chemoradiotherapy in patients with unresectable stage III non-small cell lung cancer. The study found that durvalumab improved progression-free survival compared to placebo, with median progression-free survival of 16.8 months versus 5.6 months respectively. Overall survival was also improved with durvalumab, though final analysis is still pending. Safety profiles were similar to other PD-L1 inhibitors, with immune-related adverse events in approximately 25% of durvalumab patients. This study provides evidence that durvalumab consolidation improves outcomes for stage III NSCLC following chemoradiotherapy.
This document discusses several clinical trials comparing different treatment approaches for esophageal cancer, including:
- Preoperative chemotherapy improved survival compared to surgery alone in some trials but not in others. High toxicity reduced benefits in some studies.
- Perioperative chemotherapy with fluorouracil and cisplatin significantly improved resection rates, survival, and disease-free survival compared to surgery alone.
- Chemoradiotherapy resulted in improved survival over radiotherapy alone or surgery alone in some trials for resectable esophageal cancer.
- Existing evidence did not clearly show preoperative radiotherapy alone improved survival over surgery alone for resectable esophageal cancer. Larger trials were needed.
LUNG CANCER remains the leading cause of cancer-related mortality in men and women in the United States, accounting for over 157,000 deaths annually.Despite advances in imaging, lung cancer is often detected when the disease has spread from the primary tumour to regional lymph nodes or distant sites. Appropriate therapy is dependent on accurate staging to identify those patients who are surgical candidates and those patients for whom chemotherapy and radiation therapy is indicated.
In this review, the current staging system for lung cancer is discussed, along with practical imaging approaches.
Radiotherapy For Non Small Cell Lung Cancerfondas vakalis
- The document discusses treatment options for non-small cell lung cancer (NSCLC), including surgery, radiotherapy, chemotherapy, and combinations.
- For early stage NSCLC (stages I-II), surgery is the standard treatment but radiotherapy is an alternative for medically inoperable patients. Adjuvant chemotherapy may improve outcomes for stage II.
- For locally advanced NSCLC (stage III), combined modality treatment is usually recommended, with concurrent chemoradiotherapy being superior to sequential treatment for stage IIIB.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
- Non-small cell lung cancer is the most common malignancy worldwide and a leading cause of cancer death. It accounts for the majority (70-80%) of lung cancers.
- Imaging techniques like CT scans are important for accurately assessing the primary tumor and detecting metastasis. Positron emission tomography (PET) CT is more sensitive than size-based criteria alone for detecting lymph node involvement.
- Staging involves classifying the size and extent of the primary tumor and determining if the cancer has spread to lymph nodes or distant organs. Higher stages indicate larger primary tumors or spread beyond the lungs.
LOCALLY ADVANCED LUNG CANCER MANAGEMENTFaraz Badar
This document discusses the management of locally advanced lung cancer. It provides information on the epidemiology, risk factors, anatomy, patterns of spread, diagnostic workup, staging, and management approaches for resectable stage III disease. Management involves induction chemotherapy or chemoradiation followed by surgery with postoperative radiotherapy or chemotherapy, depending on pathological findings. The evidence from clinical trials supports the use of multimodality therapy with chemotherapy and radiation for improved outcomes in resectable locally advanced non-small cell lung cancer.
Lung cancer is the leading cause of cancer death worldwide, responsible for close to 2 million deaths per year. The main risk factor is tobacco, explaining about 90% of lung cancer cases. The two main types are small cell lung cancer (15% of cases) and non-small cell lung cancer (85% of cases). Diagnosis involves pathology to determine the histologic subtype and molecular testing to guide targeted therapy options. Staging uses the TNM system to classify tumors based on size, lymph node involvement, and metastasis. Treatment depends on the stage but may include surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy.
Co-relation of multidetector CT scan based preoperative staging with intra-op...Apollo Hospitals
The document describes a study that aimed to assess the accuracy and correlation of multidetector CT scans in preoperatively staging colorectal carcinoma. Twenty-six patients undergoing surgery for colorectal cancer underwent preoperative MDCT scans and were evaluated. Intraoperative findings during surgery and postoperative histological findings were recorded. The MDCT findings correlated significantly with intraoperative staging and findings regarding site of lesion, serosa involvement, circumference involved, pericolic fat involvement, and lymph node assessment. MDCT also correlated with histopathological findings for site, circumference, serosa involvement, and size of lesion, but not as strongly for pericolic fat or lymph nodes. The study concludes that MDCT can be useful for preoperative
Conversatorio con cirugía de tórax sobre NSCLC - 1/3Mauricio Lema
This document summarizes several conferences and presentations on topics related to non-small cell lung cancer (NSCLC). It outlines three conference sessions that will discuss early and locally-advanced NSCLC as well as metastatic disease. Targeted therapies and immunotherapy for metastatic NSCLC are mentioned. Breaking news is also noted about interdisciplinary meetings on systemic therapy for NSCLC. Details are provided on TNM classification changes for lung cancer staging in the 8th edition.
Conversatorio con cirugía de tórax sobre NSCLC - 1/3 - Versión 2Mauricio Lema
This document outlines three conferences on topics related to non-small cell lung cancer (NSCLC). The first conference will discuss early-stage NSCLC and angiogenesis in metastatic NSCLC. The second will focus on locally-advanced NSCLC and targeted therapy for metastatic disease. The third conference controversies in oligometastatic NSCLC and immunotherapy for NSCLC. It also announces the beginning of interdisciplinary meetings on systemic therapy for NSCLC.
This document provides information on the management of small cell lung cancer (SCLC). It begins with defining SCLC and describing its typical clinical presentation and features. It then discusses the epidemiology and etiology of SCLC, noting that it is caused primarily by tobacco smoking. The document outlines the recommended workup, staging, and prognostic factors for SCLC. It provides details on the evidence-based management of limited-stage and extensive-stage SCLC, including the use of chemotherapy, radiotherapy, surgery, and protocols for concurrent and sequential chemo-radiotherapy treatment.
1. PET/CT is useful for diagnosing and staging gynecologic cancers like cervical and ovarian cancer by identifying lymph node and distant metastases that may be missed by conventional methods.
2. A study of 120 cervical cancer patients found that PET/CT identified more extensive disease in 20% of patients compared to conventional staging, including para-aortic lymph node metastases.
3. PET/CT improves radiotherapy planning for cervical cancer by precisely locating tumor tissue and organs at risk, allowing dose escalation with techniques like IMRT while reducing dose to surrounding healthy tissues.
Organ Preservation Surgery For Laryngeal Cancerfondas vakalis
The document discusses organ preservation surgery options for laryngeal cancer following failed radiation therapy. It presents a case study of a 71-year-old man with recurrent laryngeal cancer and evaluates his diagnosis and treatment options, which include transoral laser surgery, vertical partial laryngectomy, and supracricoid partial laryngectomy. It provides details on the procedures, selection criteria, outcomes, and complications based on literature reviews.
LUNG CANCER MANAGEMENT IN LOW RESOURCE SETTINGSKanhu Charan
The document provides information on lung cancer management in low resource settings. It discusses limited resources for setup, equipment, manpower, money and management. It also discusses potential sources of support including government, NGOs, donations and volunteers. Statistics on lung cancer prevalence and mortality are presented. The epidemiology, risk factors, diagnosis, staging and treatment of lung cancer are summarized.
This document discusses the importance of CT lung cancer screening programs and provides guidance on developing a successful screening program. Key points include: CT screening significantly reduces lung cancer mortality compared to chest x-rays based on results from the National Lung Screening Trial; nurse navigators play a central role in implementing screening programs and guiding patients; multidisciplinary conferences help manage abnormal screening results; and guidelines for starting a screening program include assembling a team, determining costs and guidelines, collecting data, and marketing to providers and patients.
Low Dose CT Screening for Early Diagnosis of Lung CancerKue Lee
This document summarizes the evidence and guidelines for low-dose CT screening for lung cancer. It discusses the National Lung Screening Trial which found a 20% reduction in lung cancer mortality with low-dose CT screening in high-risk individuals. However, screening also led to many false positives in 96.4% of cases. Guidelines from the USPSTF recommend annual screening for ages 55-80 who have at least a 30 pack-year smoking history if they currently smoke or quit within the past 15 years. Primary care providers have an important role in facilitating shared decision making about the benefits and harms of screening.
Lung cancer is a leading cause of cancer death. It is often caused by smoking and affects the lungs and other organs. The main types are small cell lung cancer and non-small cell lung cancer (which includes adenocarcinoma, squamous cell carcinoma, and large cell carcinoma). Symptoms include cough, chest pain, and weight loss. Screening is recommended for older adults with a significant smoking history. Treatment involves surgery, chemotherapy, radiation therapy, and targeted drug therapies depending on cancer type and stage. The goal is early detection and treatment to improve outcomes.
Mediastinoscopy & mediastinotomy indications & techniquesAbdulsalam Taha
The mediastinum is the central compartment of the chest. Its boundaries and compartments are well known.Although, it contains the most vital organs of the body; it is often a forgotten compartment. Involvement of mediastinal nodes has a dramatic prognostic and therapeutic impact in patients with non-small cell lung cancer. Cervical mediastinoscopy remains the most important technique for staging of the mediastinum.
The technique of extended mediastinoscopy and redo mediastinoscopy are described as well. Indications, technique and complications are discussed.
This document summarizes information about lung cancer types, risk factors, staging, and the role of radiotherapy in treatment. It notes that non-small cell lung cancer (NSCLC) accounts for 80% of cases, with the most common subtypes being adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Smoking is the primary risk factor. Radiotherapy can play definitive, adjuvant, or palliative roles. For early-stage NSCLC, stereotactic body radiotherapy is recommended. For locally advanced NSCLC, concurrent chemoradiotherapy is standard. Post-operative radiotherapy may improve outcomes for patients with pathological N2 disease but not for N0-1 disease.
Management of carcinoma nasopharynx presents many challenges:
1) Detection is difficult due to its deep, silent location and treatment is challenging due to proximity to critical structures.
2) Radiotherapy alone was historically used but results in 5-year OS of only 35-50%.
3) The current standard of care is chemoradiotherapy which provides excellent tumor control and improves outcomes over radiotherapy alone, with 5-year OS of 70-80% for early stages and 50% for advanced stages.
Austin Journal of Nuclear Medicine and Radiotherapy is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of Nuclear Medicine and Radiation. AJNMR supports in using radioactive substances in the diagnosis and treatment of disease by addressing the technologies that are revolutionizing the clinical examination and treatment by providing multi modality approach to the clinical problems.
The aim of the journal is to provide a forum for researcher scholars, physicians, and other health professionals for the exchange of scientific information in the areas of Nuclear Medicine and Radiotherapy.
Austin Journal of Nuclear Medicine and Radiotherapy accepts original research articles, review articles, case reports, commentaries, clinical images and rapid communication on all the aspects of Nuclear Medicine and Radio Therapy.
This document summarizes key points from a presentation on the treatment of non-small cell lung cancer (NSCLC). It discusses staging of NSCLC and stage-dependent survival rates. For early stage disease, lobectomy with lymph node dissection is standard. For more advanced N2 disease, neoadjuvant chemoradiotherapy followed by surgery may be considered. Minimally invasive lobectomy is becoming more common. Adjuvant chemotherapy is recommended for higher stage disease. Complete surgical resection after induction therapy improves survival outcomes for NSCLC.
This document provides information on diagnosing and staging lung cancer through symptoms, signs, diagnostic procedures, imaging, and surgery. It discusses common symptoms of primary lung tumors and intrathoracic metastases. Diagnostic procedures include noninvasive imaging like CT scans and invasive techniques like bronchoscopy. Imaging helps characterize tumors and guide biopsies. The TNM system is used for staging, and surgery is the main treatment for early stage I/II NSCLC when possible through procedures like lobectomy or segmentectomy. Pneumonectomy may be needed for larger central tumors. Accurate staging guides treatment decisions between surgery, chemotherapy, or radiation.
The document summarizes staging methods for rectal cancer. It discusses various imaging modalities including endorectal ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) and their ability to assess key staging criteria such as tumor depth, lymph node involvement, and distant metastases. New developments including multi-detector CT, MRI with contrast agents, and PET/CT fusion show promise to more accurately stage rectal cancer.
Similar to Mediastinal staging in early-stage NSCLC (20)
Carga tumoral de cáncer renal - ConsultorSaludMauricio Lema
El documento clasifica los tipos histológicos principales de neoplasias renales humanas y sus mutaciones asociadas. El cáncer renal claro celular representa el 75% de los casos y está asociado con mutaciones en el gen VHL. El tipo papilar 1 representa el 5% de los casos y está asociado con mutaciones en c-Met, mientras que el tipo papilar 2 representa el 10% de los casos y está asociado con mutaciones en el gen FH. El cáncer renal cromofóbico representa el 5% de los casos y está asociado con mutaciones en
This document discusses a case of a 55-year-old non-smoking woman presenting with left hip and shoulder pain for 9 months. Imaging showed metastatic lesions and biopsy revealed adenocarcinoma positive for TTF1 and Napsin A. Genotyping found an EGFR L858R mutation but no ALK mutation. She began treatment with afatinib and experienced disease control for 8 months before progressing. Osimertinib was then initiated but also resulted in progression after 9 months, at which time crizotinib was added for a MET amplification, maintaining disease control for over 20 months. The document also reviews data on outcomes from trials of first-line afatinib versus chemotherapy in EGFR
Secuencia en cáncer gástrico metastásico (Versión 2)Mauricio Lema
The document summarizes key clinical trials in metastatic gastric cancer treatment. It discusses trials comparing different chemotherapy drugs and combinations, as well as trials investigating biologics and immunotherapy. The document notes that capecitabine is non-inferior to 5-fluorouracil, oxaliplatin is non-inferior and less toxic than cisplatin, and trastuzumab improves outcomes in HER2-positive cancer. Recent trials found nivolumab improves progression-free and overall survival, especially in patients with PD-L1 expression over 5%. Median overall survival across trials is approximately 10 months.
Secuencia en cáncer gástrico metastásicoMauricio Lema
Key trials in metastatic gastric cancer (1st-Line)
- Platinum + fluoropyrimidine (e.g. cisplatin or oxaliplatin + 5-FU or capecitabine) form the backbone of 1st-line treatment.
- Trastuzumab is added for HER2-positive cancers.
- Consider adding an anthracycline or taxane for younger fit patients.
- Immuno-oncology such as nivolumab shows promise when available, improving PFS and OS in some patients.
- Consider monotherapy with a fluoropyrimidine for those who cannot tolerate polychemotherapy.
The document discusses small-cell lung cancer (SCLC). Key points:
- SCLC accounts for 15% of lung cancers and is an aggressive neuroendocrine tumor that often spreads widely before diagnosis.
- Treatment options include chemotherapy with platinum agents and etoposide, sometimes combined with radiation therapy. Prophylactic cranial irradiation after treatment may help prevent cancer from spreading to the brain.
- The IMpower133 clinical trial showed that adding the immunotherapy drug atezolizumab to standard chemotherapy of carboplatin and etoposide improved outcomes for patients with extensive-stage SCLC, increasing median overall survival by 2 months.
The document summarizes key findings from the CASPIAN phase 3 clinical trial comparing durvalumab plus tremelimumab plus etoposide-platinum chemotherapy (D+T+EP) versus etoposide-platinum chemotherapy (EP) alone as first-line treatment for extensive-stage small cell lung cancer (SCLC). The trial found that D+T+EP improved overall survival compared to EP alone, with a median OS of 10.4 months versus 10.5 months and a hazard ratio of 0.82. Subgroup analyses showed consistent OS benefit across patient subgroups for D+T+EP. The combination of D+T+EP represents a new standard of care for extensive-stage S
This document summarizes information about immunotherapy for non-small cell lung cancer (NSCLC). It provides data on key clinical trials that evaluated immunotherapy drugs like nivolumab and pembrolizumab in previously treated NSCLC. It shows the efficacy results including overall survival benefits from these trials compared to chemotherapy. Long-term survival outcomes are also presented from pooled analyses of nivolumab trials with over 3 years of follow-up data.
CES202101 - Clase 15 parte 1 - Cáncer de cérvix Mauricio Lema
The document outlines the FIGO staging systems for ovarian cancer, endometrial cancer, and cervical cancer. It describes the stages from I to IV, defining the extent of primary tumor and metastasis involvement for each type of cancer. It then focuses on cervical cancer, discussing the TNM classification system and how it can guide therapy depending on whether the cancer is non-bulky or bulky. Treatment options including surgery, radiation, chemotherapy, and chemoradiation are covered.
CES202101 - Clase 15 parte 2 - Cáncer de endometrioMauricio Lema
El documento presenta información sobre la incidencia y mortalidad del cáncer de endometrio a nivel mundial, en Estados Unidos y Colombia. Se describen los diferentes tipos histopatológicos de cáncer de endometrio, factores de riesgo, síntomas, diagnóstico, estadificación, tratamiento y factores moleculares asociados.
CES202101 - Clase 14 - Cáncer de ovarioMauricio Lema
El documento trata sobre el cáncer de ovario. Resume los tipos principales de cáncer de ovario, incluyendo el carcinoma epitelial de ovario (EOC), los tumores de células germinales (GCT) y los tumores de cordón sexual y estromales (SCST). El EOC de alto grado seroso (HGSC) es el tipo más común, y describe sus características histológicas e inmunohistoquímicas. También resume los factores de riesgo, mecanismos de reparación del ADN y letalidad sinté
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The document discusses lung cancer treatment and biomarkers. It begins by covering small sample handling and immunohistochemistry markers like p63 and TTF1 that can help classify lung cancer subtypes. It then discusses genomic testing for drivers like EGFR, ALK, ROS1, and BRAF and associated targeted therapies. The TNM staging system and its impact on treatment options like surgery, chemotherapy, and immunotherapy are reviewed. About 35% of advanced non-small cell lung cancer patients have a targetable driver mutation that can be treated with approved targeted therapies to achieve longer survival compared to conventional chemotherapy.
CES202101 - Clase 11 - Cáncer de mama (2/2) (José Julián Acevedo)Mauricio Lema
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2. OncotypeDx ayuda a omitir quimioterapia en el 80% de pacientes con cáncer luminal temprano de bajo riesgo.
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Este documento presenta información sobre la emergencia oncológica y la neutropenia febril. Incluye estadísticas sobre la etiología, factores de riesgo y manejo de la neutropenia febril en pacientes oncológicos. También cubre temas como diagnóstico, tratamiento antimicrobiano, prevención y pronóstico de infecciones en este grupo de pacientes.
CES202101 - Clase 7 - Tamización para el cáncer (2/2)Mauricio Lema
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CES202101 - Clase 6 - Tamización contra el cáncer (parte 1/2)Mauricio Lema
The document discusses cancer screening and its goals, challenges, and effectiveness. It provides recommendations for cancer screening in Colombia based on age and cancer type. While screening aims to find cancers early and lower cancer mortality, its effectiveness varies by cancer. For example, mammography increases early breast cancer detection but has not reduced breast cancer mortality. Prostate cancer screening detects more early cancers but has not reduced mortality. Overall screening's benefits depend on the cancer, and it can lead to overdiagnosis and unnecessary treatment.
Este documento resume información sobre el cáncer renal. El cáncer renal se origina en las células del riñón y representa entre el 2-3% de los diagnósticos de cáncer. Los factores de riesgo incluyen la edad, el sexo masculino, la obesidad e hipertensión. El tratamiento depende del estadio y puede incluir cirugía, ablación o terapia sistémica.
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This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
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Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
Mediastinal staging in early-stage NSCLC
1. Mediastinal Staging in Clinical Stage I and II NSCLC
Mauricio Lema Medina MD
Clínica de Oncología Astorga / Clínica SOMA, Medellín, Colombia
Medellín, 21.05.2018
6. Mediastinal LN status MUST be as
accurate as posible BEFORE undergoing
surgery with curative intent
7. Importance of N status in M0 NSCLC
cT1-3 cN0/N1 cT1-3 cN3cT1-3 cN2
Surgery
Pre-Op/Definitive
Chemo-RT
Definitive Chemo-RT
8.
9. CT-scan
Contrast-enhanced
Thorax, liver & adrenal
Silvestri GA, et al. Chest, 2013
Radiographic group A: mediastinal infiltration that encircles
the vessels and airways, so that discrete lymph nodes can
no longer be discerned or measured
Radiographic group B: mediastinal infiltration in whom the
size of discrete nodes can be measured
Radiographic group C: central tumor (within proximal 1/3
of the thorax) or suspected N1 disease (Level 10 ≥1 cm)
(N2/N3 risk in the 20-25% range).
Radiographic group D: peripheral clinical stage I
10. CT-scan
“For patients with extensive mediastinal
infiltration of tumor and no distant metastases,
it is suggested that radiographic (CT)
assessment of the mediastinal stage is usually
sufficient without invasive confirmation”
Silvestri GA, et al. Chest, 2013
RUL cancer
Radiographic groups A and B
11. CT-scan
“…the most widely used
criterion is a short-axis lymph
node diameter of 1 cm on a
transverse CT scan.”
Silvestri GA, et al. Chest, 2013
12. CT-scan
“…the most widely used
criterion is a short-axis lymph
node diameter of 1 cm on a
transverse CT scan.”
Prenzel KL, Chest, 2003
2891 resected hilar and mediastinal nodes
101/139 (77%) patients with pN0 had at least 1
node > 1 cm
256 patients
14/117 (12%) patients with pN2/pN3 had no
nodes greater than > 1 cm
13. CT-scan
“…the most widely used
criterion is a short-axis lymph
node diameter of 1 cm on a
transverse CT scan.”
Silvestri GA, et al. Chest, 2013
14. CT-scan
“…the most widely used
criterion is a short-axis lymph
node diameter of 1 cm on a
transverse CT scan.”
Silvestri GA, et al. Chest, 2013
Sens Spec PPV NPV
15. 15
Mediastinal Staging with Chest CT
Sensitivity
PPV
Specificity
NPV
Prevalence of mediastinal metastasis
55%
58%
81%
83%
30%
17. 17
Mediastinal Staging with Chest CT
Sensitivity
PPV
Specificity
NPV
Prevalence of mediastinal metastasis
55%
58%
81%
83%
30%
18. 18
Mediastinal Staging with Chest CT
Clinical stage I
5-15% mediastinal LN involvement
CT-Chest: N0
The American Thoracic Society and The European Respiratory Society. Pretreatment evaluation of non-small-cell
lung cancer. Am J Respir Crit Care Med . 1997 ; 156 ( 1 ): 320 - 332
19. 19
Mediastinal Staging with Chest CT
Clinical stage I
5-15% mediastinal LN involvement
CT-Chest: N0
The American Thoracic Society and The European Respiratory Society. Pretreatment evaluation of non-small-cell
lung cancer. Am J Respir Crit Care Med . 1997 ; 156 ( 1 ): 320 - 332
20. "but it remains the best overall anatomic study available for the thorax.
CT scanning usually guides the choice of nodes for selective node biopsy
by invasive techniques, and thus continues to be an important
diagnostic tool in lung cancer.
The choice of individual nodes for sampling, as well as the choice of the
most appropriate invasive technique (including transbronchial,
transthoracic, or transesophageal NA; mediastinoscopy; or more
extensive surgery), are typically directed by the findings of the CT scan"
Mediastinal Staging with Chest CT
Silvestri GA, et al. Chest, 2013
28. High-risk LN station for primary
tumor location?
Short-axis size > than normal?
Central LN lipomatosis or
calcification
Non-pathologic LN
Pathologic LN
Non-pathologic
LN
Yes
YesNo
NoYes
Volterrani L. Eur J Radiol. 2011 Sep;79(3):459-66.
29. MSCT multi-criteria: a novel approach in assessment of mediastinal
lymph node metastases in non-small cell lung cancer.
Volterrani L. Eur J Radiol. 2011 Sep;79(3):459-66.
86 consecutive patients with histopathologically proven NSCLC. All patients underwent surgical lymph node resection
within 30 days from the CT examination. In all cases pathological and CT results were reviewed and correlated.
33. 33
Mediastinal Staging with MSCT-multicriteria
Sensitivity
PPV
Specificity
NPV
94-100%
94%
98.5%
98.5-100%
If confirmed
34. PET-CT
With FDG
Patients with known NSCLC and no suspicious extra thoracic abnormalities on chest
CT, additional imaging for metastases is recommended (ie, PET-CT)
Silvestri GA, et al. Chest, 2013
37. PET-CT
With FDG
Patients with known NSCLC and no suspicious extra thoracic abnormalities on chest
CT, additional imaging for metastases is recommended (ie, PET-CT)
Silvestri GA, et al. Chest, 2013
A reduction, from approximately 40% to 20%, in the
number of non curative resections performed
(defined as the presence of benign disease,
unsuspected N2 involvement, unresectable disease,
or death from any cause within 1-yr).
38. PET-CT
Meta-analysis of PET + CT in
mediastinal staging of NSCLC
n= 4105 patients
Silvestri GA, et al. Chest, 2013
39. PET-CT
Meta-analysis of PET + CT in
mediastinal staging of NSCLC
n= 4105 patients
Silvestri GA, et al. Chest, 2013
40. PET-CT
Meta-analysis of PET + CT in
mediastinal staging of NSCLC
n= 4105 patients
Silvestri GA, et al. Chest, 2013
Sens Spec PPV NPV
41. PET-CT
Meta-analysis of PET + CT in mediastinal
staging of NSCLC
Years 2004-2011
n= 2,014 patients
Silvestri GA, et al. Chest, 2013
42. 42
Mediastinal Staging with PET-CT
Sensitivity
PPV
Specificity
NPV
Prevalence of mediastinal metastasis
80%
75%
88%
91%
28%
43. “In nodes less than 1 cm, the sensitivity of FDG-PET-CT to detect nodal
metastasis is not optimal and has been reported as sensitivity or 32.4%
versus 85.3% in nodes greater than or equal to 1 cm.”
Billé A, et al. Eur J Cardiothoracic Surg, 2009
44. 44
Mediastinal Staging with PET-CT
Clinical peripheral stage I
4% mediastinal LN involvement
PET-CT: N0
Kozower BD , Meyers BF , Reed CE , Jones DR , Decker PA , Putnam JB Jr . Does positron emission tomography
prevent nontherapeutic pulmonary resections for clinical stage IA lung cancer? Ann Thorac Surg . 2008 ; 85 ( 4 ):
1166 - 1169.
45. 45
Mediastinal Staging with PET-CT
Clinical peripheral stage I
4% mediastinal LN involvement
PET-CT: N0
Kozower BD , Meyers BF , Reed CE , Jones DR , Decker PA , Putnam JB Jr . Does positron emission tomography
prevent nontherapeutic pulmonary resections for clinical stage IA lung cancer? Ann Thorac Surg . 2008 ; 85 ( 4 ):
1166 - 1169.
46. "One should not preclude a potential curative surgery based on a
positive PET scan alone without tissue confirmation."
Mediastinal Staging with PET CT
Silvestri GA, et al. Chest, 2013
47. "However, PET scanning is the most accurate noninvasive imaging
modality available to evaluate the mediastinum in patients with lung
cancer.
PET scanning is also a whole-body study (excluding the brain), offers
additional information relating to extrathoracic sites of possible disease
involvement, and can reduce noncurative resections.
PET scanning has now assumed a central role in the staging of lung
cancer.”
Mediastinal Staging with PET CT
Silvestri GA, et al. Chest, 2013
49. Neural Networks for Nodal Staging of Non–Small Cell Lung Cancer with
FDG PET and CT: Importance of Combining Uptake Values and Sizes of
Nodes and Primary Tumor
Toney LK, Radiology, 2014
“The authors developed a back-
propagation ANN with one hidden layer
and eight processing units”.
50. Neural Networks for Nodal Staging of Non–Small Cell Lung Cancer with
FDG PET and CT: Importance of Combining Uptake Values and Sizes of
Nodes and Primary Tumor
Toney LK, Radiology, 2014
51. Neural Networks for Nodal Staging of Non–Small Cell Lung Cancer with
FDG PET and CT: Importance of Combining Uptake Values and Sizes of
Nodes and Primary Tumor
Toney LK, Radiology, 2014
52. 52
Mediastinal Staging with ANN PET-CT
Correct prediction of N stage
Correct prediction of N0/1 vs N2/3
99%
99%
72%
92%
ANN Expert reader
ANN: Artificial Neural Network
Toney LK, Radiology, 2014
53. 53
Mediastinal Staging with ANN PET-CT
Correct prediction of N stage
Correct prediction of N0/1 vs N2/3
99%
99%
72%
92%
ANN Expert reader
ANN: Artificial Neural Network
Toney LK, Radiology, 2014
54. 54
Mediastinal Staging with ANN PET-CT
Correct prediction of N stage
Correct prediction of N0/1 vs N2/3
99%
99%
72%
92%
ANN Expert reader
ANN: Artificial Neural Network
Toney LK, Radiology, 2014
If confirmed
56. Pancoast syndrome is characterized by a
malignant neoplasm of the superior sulcus of the
lung with destructive lesions of the thoracic inlet
and involvement of the brachial plexus and
cervical sympathetic nerves (stellate ganglion, go
here).
This is accompanied by
(1) severe pain in the shoulder region
radiating toward the axilla and scapula along the
ulnar aspect of the muscles of the hand,
(2) atrophy of hand and arm muscles,
(3) Horner syndrome (ptosis, miosis,
hemianhidrosis, enophthalmos), and
(4) compression of the blood vessels with
edema.
Silvestri GA, et al. Chest, 2013
57. Chest MRI
MRI of the chest should not be performed
routinely for staging of the mediastinum.
MRI is useful in patients with NSCLC when
there is concern about involvement of the
superior sulcus or the brachial plexus.
Silvestri GA, et al. Chest, 2013
58. Mediastinoscopy
“…involves an incision just above the
suprasternal notch, insertion of a
mediastinoscope alongside the trachea,
and biopsy of mediastinal nodes.”
Silvestri GA, et al. Chest, 2013
Morbidity: 2%
Mortality: 0.08%
59. 2R
4R
7
2L
4L
1
3a
Mediastinoscopy
Node groups that cannot undergo a
biopsy with this technique include:
Posterior subcarinal (station 7)
Inferior mediastinal (stations 8, 9),
Aortopulmonary window (APW) (station 5)
Anterior mediastinal (station 6) nodes.
60. Mediastinoscopy
“…involves an incision just above the
suprasternal notch, insertion of a
mediastinoscope alongside the trachea,
and biopsy of mediastinal nodes.”
Silvestri GA, et al. Chest, 2013
61. Mediastinoscopy
“…involves an incision just above the
suprasternal notch, insertion of a
mediastinoscope alongside the trachea,
and biopsy of mediastinal nodes.”
Silvestri GA, et al. Chest, 2013
Sens Spec PPV NPV
62. Video Assisted Mediastinoscopy
“…A videomediastinoscope allows better visualization, more extensive
sampling (including posterior station 7)…”
Silvestri GA, et al. Chest, 2013
67. Video-Assisted Thoracic Surgery
“This is performed under general
anesthesia and, in general, is limited
to an assessment of only one side of
the mediastinum.
Access to the R-sided nodes is
straightforward, but access to the L
paratracheal nodes is more difficult”
Silvestri GA, et al. Chest, 2013
Morbidity: 2%
Mortality: 0%
90. 90
Minimally Invasive Endoscopic Staging of
Suspected Lung Cancer
TB-NA
PPV
EUS-NA
EUS-NA & EBUS-NA
EBUS-NA
Wallace MB, JAMA, 2008
36%
69%
69%
93%
78%
88%)
88%
97%
Sensitivity NPV
138 consecutive non(obviously) metastatic NSCLC underwent all three procedures
91. 91
Minimally Invasive Endoscopic Staging of
Suspected Lung Cancer
TB-NA
PPV
EUS-NA
EUS-NA & EBUS-NA
EBUS-NA
Wallace MB, JAMA, 2008
36%
69%
69%
93%
78%
88%)
88%
97%
Sensitivity NPV
138 consecutive non(obviously) metastatic NSCLC underwent all three procedures
92. 92
Endobronchial ultrasound versus mediastinoscopy for mediastinal
nodal staging of non-small-cell lung cancer
Sensitivity
PPV
Specificity
NPV
Accuracy
Um SW, JTO, 2015
88%
93%
100%
85%
81%
89%)
100%
78%
EBUS-TBNA Mediastinoscopy
138 consecutive NSCLC with cN1-cN3
*
*
*
* p < 0.005
93. 93
Endobronchial ultrasound versus mediastinoscopy for mediastinal
nodal staging of non-small-cell lung cancer
Sensitivity
PPV
Specificity
NPV
Accuracy
Um SW, JTO, 2015
88%
93%
100%
85%
81%
89%)
100%
78%
EBUS-TBNA Mediastinoscopy
138 consecutive NSCLC with cN1-cN3
*
*
*
* p < 0.005
94. 94
EBUS-centred versus EUS-centred mediastinal
staging in lung cancer: a randomized controlled
trial
Group A (EBUS-NA then EUS-NA)
PPV
EBUS after EUS improves accuracy and sensitivity. Therefore,
EBUS-FNA should be first
Kang HJ, Thorax, 2014
92%
86%
93%
97%
Accuracy post 1st test - Sensitivity Accuracy post 2nd test - Sensitivity
160 patients with histologically confirmed or strongly suspected potentially operable NSCLC
Group B (EUS-NA then EBUS-NA)
82%
60%
85%
92%
95. 95
P O S I T I O N S T A T E M E N T
My practice take…
96. 96
Known or suspected NSCLC
Contrast-Enhanced Chest CT (+liver & adrenal)
Negative / borderline positive Chest CT, clinical stage I/II
FDG PET-CT
VATS or EBUS/EUS-NA
Massive N2/N3 disease on
Chest CT
No further mediastinal
work-up
PET-CT(-) and
peripheral cI
No further mediastinal
work-up
PET-CT(+)
Tissue confirmation
required
PET-CT(-)
Context-based strategy