EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
Contouring Guidelines for Gynecological MalignancyJyotirup Goswami
A brief overview of gynecological malignancy contouring guidelines (teletherapy & brachytherapy), including a discussion of problems and inadequacies of the present guidelines
Conformal Radiotherapy in Head and neck cancers is essential in terms of improving quality of life and local control in this era. This presentation aimed at giving an overview of conformal radiotherapy and its role in HNC to a 'general audience'.
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
Contouring Guidelines for Gynecological MalignancyJyotirup Goswami
A brief overview of gynecological malignancy contouring guidelines (teletherapy & brachytherapy), including a discussion of problems and inadequacies of the present guidelines
Conformal Radiotherapy in Head and neck cancers is essential in terms of improving quality of life and local control in this era. This presentation aimed at giving an overview of conformal radiotherapy and its role in HNC to a 'general audience'.
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.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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
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- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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2. Location & Pattern of Involvement.
Why is it needed ??
• Cancer treatment does not mean only cure but also to
provide good quality of life.
• Therapeutic gain can be accomplished either by
increasing the control rate or by decreasing the side
effect of treatment.
• That is what modern radiotherapy like IMRT has done so
far.
• Not all the neck nodes are involved in all sites.
• Gone are the days when with 2-D radiation every thing
between the radiation portal are treated irrespective of
need.
3. Location & Pattern of Involvement.
Why is it needed ??
• Depending upon the primary site and stage of the
disease, Surgeons practice selective neck
dissection.
• If location and pattern of spread are known, then
Radiation Oncologist can also plan selective neck
irradiation thus avoiding many normal structures
like parotid and swallowing muscles leading to
better quality of life.
• With high precision radiotherapy, the goal of
providing better quality of life is further achieved.
4. Classification of neck nodes - levels
• Robbins Classification:- Surgeons usually
follow this system.
• For Radiation Oncologists 2 systems of classifications are
commonly used
- Brussels system
-Rotterdam system
• Due to discrepancies in different systems , a consensus
guidelines was derived (RTOG Consensus guidelines).
5. Changes in Robbins classification
• Based on surgical boundaries like muscles, nerves
and vessels.
• But these structures may not be identifiable on
CT.
• Cranial limit for level II was defined by surgeons
at insertion of post belley of digastric muscle at
mastoid.
• But this point may not be identifiable on CT.
• So cranial limit was modified to bony land mark
like cervical vertibrae.
6. Changes in Robbins classification
• Similarly, Robbins defined the caudal limit of
level III as the point at which the omohyoid
muscle crossed the internal jugular vein (IJV);
again not clearly identifiable on CT.
• Again easily identifiable landmark is choosen
like lower border of cricoid cartilage.
7. Changes in Robbins classification
• Robbins used the spinal accessory nerve (SAN)
to sub-divide level II into IIa (anterior to a
vertical plane defined by the nerve) and IIb
(posterior to that plane).
• SAN cannot be identified on CT scans,
• So, posterior edge of the IJV for the
subdivision between levels IIa and IIb
15. Lymph Node Regions
• Level I
Submental Nodes (Ia)
Submental triangle:
–Bounded by two anterior belly of digastric
16. Primary for Ia
• Floor of the mouth.
• Anterior oral tongue.
• Anterior mandibular alveolar ridge.
• lower lip.
17. Lateral-> Medial edge
of ant belly of two
digastric muscles
Anterior-> Platysma
muscle and the symphysis
menti,
Level Ia
Posterior ->
body of the hyoid
bone,
22. Lymph Node Regions
• Level Ib:
Submandibular Triangle
–Formed by the anterior and posterior belly
of the digastric muscle and the body of the
mandible
23. Primary for Ib
• cancers of the oral cavity,
• anterior nasal cavity,
• soft tissue structures of the mid-face and
• the submandibular gland.
31. Most of the jugular nodes(lev. II-IV) present ant., post., and lateral
to the IJV.
So medial boundary is medial edge of the vessel bundle.
Jugular nodes
32. Level II
• Cranial limit for level II was defined by
surgeons at insertion of post belly of digastric
muscle at mastoid.
• But this point may not be identifiable on CT.
• Surgeons were asked to put the clips at the
upper level of dissection for level II nodes in
node negative neck.
33. How consensus was made for cranial border for level II Nodes?
• Clips cluster
around caudal
border of
transverse
process of
vertebra C1.
• So cranial
border of level
II is taken at
caudal edge of
transverse
process of C1.
Parotid projection
so if cranial limit is
taken at base of
skull then more
parotid will be
irradiated.
34. Usually the cranial
limit of level II is
caudal border of
transverse process of
C1 vertebrae.
But few nodes also
present superior to
this up to base of
skull.
This region cranial
to cranial limit of
Level II is called Retro
Styloid region.
Level II
Retrostyloid Region
35. When to treat Retro Styloid Region
• Ca Nasopharynx.
Bilateral
• In +ve level II node
Ipsilateral
37. • anteriorly by the
– the anterior edge
of the carotid
artery
– posterior edge of
the submandibular
gland,
– the posterior belly
of the digastric
muscle,
Level II
Anterior Relation
Cranial
Caudal
45. Primary for II
• Nasal cavity.
• Oral cavity.
• Oropharynx.
• Hypopharynx.
• Larynx.
• Major salivary glands.
• Nasopharynx,
46. IIa IIb
• Level II is further
subdivided into two
compartments.
– IIa
– IIb
• Surgeons demarcate
between the two by
spinal accessory
nerve (SAN).
• From a radiological
point of view, the
posterior edge of the
IJV is taken as the
boundary between
levels IIa and IIb.
Sub division of Level II
48. Level III
• contains the middle jugular lymph nodes located
around the middle third of the IJV.
• It is the caudal extension of level II
• Primary.
Oral cavity.
Oropharynx.
Hypopharynx.
Larynx.
Nasopharynx,
56. includes the lower
jugular lymph nodes
located around the
inferior third of the IJV.
According to Robbins, it
extends from the caudal
limit of level III to the
clavicle.
But since surgeons
never dissect upto clavicle
so consensus is that the
caudal limit is 2cm cranial
to the cranial edge of
sterno-clavicular joint.
2 cm
Level IV
64. The uppermost part of
level V contains superficial
occipital lymph node(s),
which are not involved in
head and neck ca except skin
cancer.
So cranial limit is a
horizontal plane crossing the
cranial edge of the body of
the hyoid bone
Level V
65. Cranial -> Horizontal plane crossing the cranial edge of
the body of the hyoid bone Level V
66. • For the caudal limit of level V, it appears from
critical examination of neck dissection
procedure, that surgeons never dissect up to
clavicle but go only up to to the transverse
cervical vessels.
• Hence, caudal limit of level V is kept at CT
slices encompassing the cervical transverse
vessels
Level V
Caudal
67. Caudal -> CT slices at the level of transverse Cervical vessels
Level V
71. Posterior -> Antero-lateral border of the trapezius muscles
.Practically, a virtual line joining the antero-lateral border of both trapezius muscles can be use
to set the posterior limit of level V
Level V
73. Primary for Level V
• Nasopharynx.
• Oropharynx.
• Subglottic larynx.
• Apex of the pyriform sinus.
• Cervical esophagus.
• Thyroid gland.
74. Va
Vb
Level V is
divided into Va
and Vb by
omohyoid muscle
where it crosses
the internal
jugular vein.
But this
crossing point
can not be
appreciated on
CT film.
Level V
75. Hyoid
Thyroid
Cricoid
For practical
purpose, use of the
plane between levels
III and IV extended
posteriorly is
recommended,
which means lower
border of cricoid can
be taken as dividing
line between Va and
Vb
Level V
Level III
Level IV
Level Va
Level Vb
76. Located in anterior
neck compartment
They are pre- and
para tracheal nodes
including the pre-
cricoid (Delphian)
node and lymph nodes
along the recurrent
laryngeal nerves.
Level VI
77. Cranial -> Caudal edge of the body of the thyroid cartilage,
Level VI
83. Primary for Level VI
• cancers of the thyroid gland,
• the Trans glottic and subglottic larynx,
• the apex of the piriform sinus and
• the cervical esophagus.
84. Typically, retropharyngeal
nodes are divided into
Medial Group
Lateral Group.
The medial group is an
inconsistent group which
consist of one to two
lymph nodes
The lateral group lies
medial to the carotid
artery.
The most superior lymph
node of this group is also
called the lymph node of
Rouvie`re.
lymph node of Rouvie`re.
RP Nodes
94. Node positive Neck
• With N+ve, one adjacent extra nodal level is
also at high risk of occult metastasis, for eg.
the level IV for oral cavity tumors and the level
I and V for oropharyngeal, hypopharyngeal,
and to a lesser extent laryngeal tumors.
95. Retrostyloid
Region
S/C fossa Till
Sternum
Point No 1
In level II node positive include retro styloid region and in level IV and
Vb nodes enlargement include s/c fossa up to sternum on the side of
the positive node.
98. Point No 2
In fact, this recommendation will only apply to patients with
a single involved lymph node (pN1) for whom post-operative
radiotherapy is considered (e.g. because of a capsular
rupture) and for whom selective treatment may be
advocated.
99. When an involved lymph node abuts a muscle (e.g. sterno-cleido-
mastoid or para-spinal) it is recommended to include this muscle at
the vicinity of the node in the CTV for the entire invaded level and at
least with a 1 cm margins in cranio-caudal direction.
Point No 3
1 cm
1 cm
100. Extra Capsular Extension(ECE)
Incidence of ECE is 20 to 40% in metastatic node <1cm size while
goes up to 75% if size is >3 cm.
The incidence of local recurrence increases, and the survival rate
decreases by greater than 50% when metastatic nodal disease
expands beyond the capsule i. e. if ECE present.
101. Magnitude of ECE
The majority of the ECE extend
<5mm from the capsule of node.
None extend >10mm
102. Margins of 1 cm from
the nodal GTV to the CTV
would be sufficient to
fully cover any subclinical
nodal extension for lymph
nodes smaller than 3 cm
in head-and-neck cancer
patients receiving IMRT.
For larger nodes or
matted nodes more
generous margins should
be given.
Point No 4
109. • Typically, nasopharyngeal and hypopharyngeal
tumors have the highest propensity of nodal
involvement which occurs in 80 and 70%,
respectively.
• Interestingly, the node distribution follows the
same pattern in the contralateral neck as in
the ipsilateral neck.
• Contra lateral level V is usually not involeved
110. Incidence and distribution of regional metastasis for
Levels I–V for clinically N0 neck
• Tumor site Levels involved (%)
I II III IV V
• Oral cavity 20 17 9 3 0.5
• Oropharynx 2 25 19 8 2
• Hypopharynx 0 13 13 0 0
• Larynx 5 19 20 9 2.5
• In non-nasopharyngeal cancers of head and neck,
level V is not included in N0 neck as incidence of
involvement is <5%.
• Similarly, in oro-pharynx, hypo-pharynx and
larynx, level I is not included as again incidence of
occult metastasis is <5%.
111. Non Nasopharyngeal N0 Neck
• Oral Cavity Ca
• Oro pharynx
• Hypo pharynx
• larynx
Level I, II, III and in
ca tongue level IV
Level II, II, IV
112. Incidence and distribution of regional metastasis for
Levels I–V for clinically N+ve neck
• Tumor site Levels involved (%)
• I II III IV V
• Oral cavity 48 39 31 15 4
• Oropharynx 15 71 42 27 9
• Hypopharynx 10 75 72 45 11
• Larynx 6 61 54 30 6
• Nasopharynx* 13 95 60 21 44
• In non-nasopharyngeal cancers of head and neck, level V is
included in N+ve neck except in ca oral cavity where
incidence is <5%.
• Similarly level I should be included in neck positive disease
except in larynx.
113. Primary site for RP Nodes inclusion
N0 Neck Nasopharynx and Pharyngeal Wall
N+ Neck All sites except larynx
In non nasopharyngeal cancers usually lateral
RP nodes are involved