1. Perineural invasion (PNI) and perineural spread (PNS) in head and neck cancers can involve invasion of tumor cells along cranial nerves from the primary site.
2. PNI is classified based on extent from microscopic to gross involvement visible on imaging. Macroscopic PNI involving large nerves is considered a poor prognostic factor.
3. Magnetic resonance imaging is the preferred method to evaluate PNI and PNS with features including nerve enhancement, enlargement, and loss of perineural fat.
4. The trigeminal, facial, and vestibulocochlear nerves are most commonly involved. Treatment volumes in radiation therapy aim to cover the primary site, involved nerve,
Dose to the Dysphagia/Aspiration-Related Structures (DARS) is critical to ensure proper swallowing functions to the patients after IMRT to the head and neck region
Radiotherapy is used as primary treatment for early-stage Hodgkin lymphoma or as part of combined modality treatment with chemotherapy. Historically, large mantle fields covering lymph node regions from the skull to the pelvis were used. More modern approaches use smaller involved field radiotherapy targeting only initially involved lymph node regions after chemotherapy based on imaging. Proper delineation of clinical target volumes requires pre-chemotherapy imaging ideally with PET/CT to define original disease extent.
This document provides an overview of management options for carcinoma of the nasal cavity and paranasal sinuses. It discusses the lymphatic drainage, histologic subtypes, treatment options including surgery, radiotherapy, and chemotherapy. Surgical procedures and approaches are described depending on the involved sinus. Post-operative radiotherapy techniques and dose recommendations are provided for different tumor locations and stages. Complications of treatment are also summarized.
This document discusses various particle beams used in radiation therapy, including their properties and effectiveness. It states that proton beams have superior dose distribution compared to photon beams but lower LET. Neutron beams have high LET properties but poor dose distribution. Heavy charged particle beams like carbon ions have both superior distribution and high LET. BNCT uses boron compounds and neutrons to specifically target tumor cells but is limited by availability and cost. Overall, the document provides an overview of different particle therapies and their advantages over conventional photon radiation.
Nasopharyngeal carcinoma is typically treated with radiation therapy. Concurrent chemotherapy and radiation is the standard for locally advanced disease and improves survival compared to radiation alone. Intensity-modulated radiation therapy provides better tumor coverage and reduces side effects. Surgery has a limited role except for biopsy or salvaging recurrent tumors. Temporal lobe necrosis is a serious potential complication, so fractional doses above 2Gy should be avoided. Close follow-up is needed due to risk of recurrence or late effects.
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.
Dose to the Dysphagia/Aspiration-Related Structures (DARS) is critical to ensure proper swallowing functions to the patients after IMRT to the head and neck region
Radiotherapy is used as primary treatment for early-stage Hodgkin lymphoma or as part of combined modality treatment with chemotherapy. Historically, large mantle fields covering lymph node regions from the skull to the pelvis were used. More modern approaches use smaller involved field radiotherapy targeting only initially involved lymph node regions after chemotherapy based on imaging. Proper delineation of clinical target volumes requires pre-chemotherapy imaging ideally with PET/CT to define original disease extent.
This document provides an overview of management options for carcinoma of the nasal cavity and paranasal sinuses. It discusses the lymphatic drainage, histologic subtypes, treatment options including surgery, radiotherapy, and chemotherapy. Surgical procedures and approaches are described depending on the involved sinus. Post-operative radiotherapy techniques and dose recommendations are provided for different tumor locations and stages. Complications of treatment are also summarized.
This document discusses various particle beams used in radiation therapy, including their properties and effectiveness. It states that proton beams have superior dose distribution compared to photon beams but lower LET. Neutron beams have high LET properties but poor dose distribution. Heavy charged particle beams like carbon ions have both superior distribution and high LET. BNCT uses boron compounds and neutrons to specifically target tumor cells but is limited by availability and cost. Overall, the document provides an overview of different particle therapies and their advantages over conventional photon radiation.
Nasopharyngeal carcinoma is typically treated with radiation therapy. Concurrent chemotherapy and radiation is the standard for locally advanced disease and improves survival compared to radiation alone. Intensity-modulated radiation therapy provides better tumor coverage and reduces side effects. Surgery has a limited role except for biopsy or salvaging recurrent tumors. Temporal lobe necrosis is a serious potential complication, so fractional doses above 2Gy should be avoided. Close follow-up is needed due to risk of recurrence or late effects.
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.
Prophylactic cranial irradiation (PCI) is used to prevent brain metastases in cancers with a high risk of spreading to the brain. It is indicated for small cell lung cancer and certain leukemias. PCI significantly reduces the rate of brain metastases in small cell lung cancer, especially when administered early at higher doses. For extensive stage small cell lung cancer, MRI surveillance may be an alternative to PCI. While PCI reduces brain metastases in leukemia, the risk of brain involvement is low for some types such as AML. The standard dose for PCI is 1200-1800 cGy in fractions, with timing and volumes depending on the cancer type. Potential toxicities include neurocognitive effects, endocrine disorders, and secondary cancers.
Hippocampal sparing whole brain radiation therapy- Making a case!VIMOJ JANARDANAN NAIR
- A 58-year-old female nurse presented with headache, nausea, and mental status changes. Imaging showed 3 brain metastases with no known primary site.
- She had a KPS of 90, age <60, controlled primary (pending further workup), and no extracranial mets, placing her in RPA class I and GPA group with a predicted median survival of 7.1-11.3 months.
- Treatment options included WBRT alone or WBRT with boost to reduce risk of neurocognitive toxicity based on the RTOG 0933 trial, which showed reduced memory decline with hippocampal avoidance. Patient selection focused on tumor types likely to benefit and survival duration to gain
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses hemi body irradiation (HBI) technique used to treat metastatic cancer. HBI involves irradiating only the upper or lower half of the body using parallel opposed radiation fields. It has advantages over total body irradiation like smaller field size and less side effects. HBI is used to palliate widely metastatic disease and as adjuvant therapy for certain cancers. Potential complications include nausea, diarrhea, pneumonitis and hematological effects. The document also provides an overview of cancer registries in India, which systematically collect cancer data to help understand cancer patterns and guide control programs. Population-based and hospital-based registries use active and passive methods to collect data on cancer incidence, stages and survival.
Reirradiation can provide local tumor control for recurrent head and neck cancer when surgery is not possible. Modern radiation techniques like IMRT allow higher radiation doses to be safely delivered to the tumor while minimizing risks of severe toxicity. Outcomes from reirradiation include a median survival of 10-12 months and 2-year local control rates of 40-64%. Patient selection is important to balance potential benefits of local tumor control against risks of treatment-related side effects.
Altered fractionation schedules in radiation oncologyAbhishek Soni
Altered fractionation schedules aim to optimize tumor control and normal tissue sparing by manipulating total dose, dose per fraction, time interval between fractions, dose rate, and overall treatment time based on tumor and tissue radiosensitivity and repair characteristics. Hyperfractionation uses a higher total dose with smaller, more frequent fractions to exploit tumor reoxygenation and cell cycle effects while hypofractionation uses fewer, larger fractions which is more effective for tumors with low α/β ratios. Accelerated fractionation decreases treatment time to limit tumor repopulation at the cost of increased acute toxicity. Phase III trials show hyperfractionation and accelerated fractionation improve local control for head and neck cancers with acceptable toxicity.
Proton beam therapy uses protons to treat cancer. It can reduce the dose to healthy tissues compared to photon therapy by depositing most of the energy at a specific depth. Proton therapy has potential applications in tumors near critical structures where dose escalation may improve outcomes. However, more evidence from controlled trials is still needed to demonstrate comparative effectiveness versus other radiation therapies.
Carcinoma nasopharynx anatomy to managementDrAyush Garg
The document provides information on carcinoma of the nasopharynx, including its anatomy, epidemiology, etiology, clinical features, patterns of spread, diagnostic evaluation, and metastatic workup. The key points are:
1) Nasopharyngeal carcinoma is most common in Southern Chinese populations and has a bimodal age distribution. Viral, genetic, and environmental factors like Epstein-Barr virus and salted fish contribute to its etiology.
2) The tumor can spread superiorly into the skull base, anteriorly into the nasal cavity/sinuses, and posteriorly into neck muscles and brain. Distant metastases most often involve bones and lungs.
3) Diagnostic evaluation includes endoscopic
This document provides an overview of interstitial brachytherapy principles and concepts. It discusses the history and evolution of brachytherapy sources from radium to modern radioactive sources like iridium-192. Key concepts covered include dose rate calculations, implant systems like the Paris system, and factors that influence dose distribution from a radioactive source like distance, absorption and scattering. The document also describes temporary and permanent brachytherapy sources and different methods of source application including preloading, afterloading and remote afterloading.
This seminar is presented as a part of weekly journal club and seminar presented in Apollo Hospital,Kolkata Department of Radiation Oncology.This seminar is moderated by Dr Tanweer Shahid.
This document discusses the history and techniques of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). It begins by outlining the early development of SRS by Lars Leksell in the 1950s. It then defines key terms like SRS, SBRT, and fractionated stereotactic radiosurgery. The document goes on to discuss the rationale and advantages of SRS/SBRT, including its ability to deliver high radiation doses with steep dose gradients using multiple beams and image guidance. It also covers topics like tumor oxygenation, cell kill mechanisms, and recent technological advances in the field like VMAT, flattening filter free beams, and 4D
Radiotherapy for Seminoma
- Seminoma accounts for over 60% of testicular germ cell tumors with an incidence of 0.95 per 100,000.
- For stage I seminoma, prophylactic radiation to the para-aortic lymph nodes is the standard of care to reduce the risk of recurrence.
- For stage IIA/IIB seminoma, radiotherapy to the para-aortic, iliac, and inguinal lymph nodes is recommended, with 30Gy to the whole field and a 10Gy boost for stage IIA and 36Gy total for stage IIB.
- Intensity modulated radiation therapy (IMRT) allows for improved sparing of
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
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
Proton beam therapy is a form of external beam radiotherapy that uses proton beams rather than x-rays to treat cancer. Protons deposit most of their radiation in the target tumor due to the physics of the Bragg peak. This allows higher doses to be delivered to tumors while minimizing exit dose and reducing radiation exposure to surrounding healthy tissues compared to traditional x-ray radiotherapy. Proton therapy has the potential to improve patient outcomes by better controlling tumors and reducing treatment toxicity.
1) The document discusses various radiation techniques for treating cancer of the esophagus including 2D, 3D conformal radiation therapy, IMRT, and IGRT.
2) It covers topics like target volume delineation, field design considerations for different esophageal subsites, and evolution from 2D to 3D treatment planning.
3) While there is no consensus, most contemporary trials use margins of 3-5cm cranially and caudally on the gross tumor with approximately a 2cm radial margin.
Brachytherapy is an excellent treatment for prostate cancer that provides long term tumor control comparable to radical prostatectomy and external beam radiation therapy. It involves placing radioactive sources directly in the prostate gland temporarily or permanently. Common radioactive sources include iodine-125 and palladium-103 seeds. Brachytherapy can be used as monotherapy for low risk prostate cancer or as a radiation boost combined with external beam radiation for higher risk disease. It allows a highly conformal dose to be delivered to the prostate while sparing surrounding tissues from radiation exposure. Brachytherapy is generally a low risk treatment with most side effects being temporary increased urinary symptoms. It provides patients an alternative to surgery or external beam radiation for localized prostate cancer
Role of radiation in benign conditionsPurvi Rathod
This document discusses the role of radiation therapy in treating various benign conditions. It provides indications for RT in benign tumors of the brain and head and neck such as meningiomas, pituitary adenomas, and craniopharyngiomas. It also discusses using RT to treat other benign conditions such as trigeminal neuralgia, hemangiomas, arteriovenous malformations, and Langerhans cell histiocytosis. Radiation therapy aims to control symptoms, provide pain relief, and achieve good local control of benign lesions with minimal side effects when used judiciously for the right indications.
The document discusses intensity-modulated radiation therapy (IMRT) for head and neck cancers. It describes how IMRT improves target coverage and sparing of organs-at-risk like the parotid glands compared to conventional radiation therapy. Studies show IMRT reduces the risk of xerostomia and improves quality of life outcomes for patients.
This document discusses the management of oropharyngeal cancer. It begins by stating the goals of treatment are functional organ preservation and minimizing treatment-induced morbidity while maintaining cure rates. For early stage disease, single modality radiotherapy or surgery is usually sufficient. For advanced stages, surgery plus radiation or chemoradiation are recommended based on risk factors. It then discusses treatment options and outcomes for different subsites within the oropharynx and the benefits of adjuvant therapy or altered fractionation schedules for radiotherapy.
This document discusses carcinoma of the nasopharynx, including its detection in early stages using MRI imaging, patterns of local and lymphatic spread, association with EBV, clinical features, staging according to AJCC guidelines, pathological classification, and treatment using radiotherapy techniques like three-dimensional conformal radiation therapy and intensity-modulated radiotherapy. Key points covered are detection of early lesions via MRI, common sites of local extension like the parapharyngeal space and skull base, routes of lymphatic spread to cervical lymph nodes, and role of plasma EBV DNA levels in diagnosis and prognosis.
Prophylactic cranial irradiation (PCI) is used to prevent brain metastases in cancers with a high risk of spreading to the brain. It is indicated for small cell lung cancer and certain leukemias. PCI significantly reduces the rate of brain metastases in small cell lung cancer, especially when administered early at higher doses. For extensive stage small cell lung cancer, MRI surveillance may be an alternative to PCI. While PCI reduces brain metastases in leukemia, the risk of brain involvement is low for some types such as AML. The standard dose for PCI is 1200-1800 cGy in fractions, with timing and volumes depending on the cancer type. Potential toxicities include neurocognitive effects, endocrine disorders, and secondary cancers.
Hippocampal sparing whole brain radiation therapy- Making a case!VIMOJ JANARDANAN NAIR
- A 58-year-old female nurse presented with headache, nausea, and mental status changes. Imaging showed 3 brain metastases with no known primary site.
- She had a KPS of 90, age <60, controlled primary (pending further workup), and no extracranial mets, placing her in RPA class I and GPA group with a predicted median survival of 7.1-11.3 months.
- Treatment options included WBRT alone or WBRT with boost to reduce risk of neurocognitive toxicity based on the RTOG 0933 trial, which showed reduced memory decline with hippocampal avoidance. Patient selection focused on tumor types likely to benefit and survival duration to gain
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses hemi body irradiation (HBI) technique used to treat metastatic cancer. HBI involves irradiating only the upper or lower half of the body using parallel opposed radiation fields. It has advantages over total body irradiation like smaller field size and less side effects. HBI is used to palliate widely metastatic disease and as adjuvant therapy for certain cancers. Potential complications include nausea, diarrhea, pneumonitis and hematological effects. The document also provides an overview of cancer registries in India, which systematically collect cancer data to help understand cancer patterns and guide control programs. Population-based and hospital-based registries use active and passive methods to collect data on cancer incidence, stages and survival.
Reirradiation can provide local tumor control for recurrent head and neck cancer when surgery is not possible. Modern radiation techniques like IMRT allow higher radiation doses to be safely delivered to the tumor while minimizing risks of severe toxicity. Outcomes from reirradiation include a median survival of 10-12 months and 2-year local control rates of 40-64%. Patient selection is important to balance potential benefits of local tumor control against risks of treatment-related side effects.
Altered fractionation schedules in radiation oncologyAbhishek Soni
Altered fractionation schedules aim to optimize tumor control and normal tissue sparing by manipulating total dose, dose per fraction, time interval between fractions, dose rate, and overall treatment time based on tumor and tissue radiosensitivity and repair characteristics. Hyperfractionation uses a higher total dose with smaller, more frequent fractions to exploit tumor reoxygenation and cell cycle effects while hypofractionation uses fewer, larger fractions which is more effective for tumors with low α/β ratios. Accelerated fractionation decreases treatment time to limit tumor repopulation at the cost of increased acute toxicity. Phase III trials show hyperfractionation and accelerated fractionation improve local control for head and neck cancers with acceptable toxicity.
Proton beam therapy uses protons to treat cancer. It can reduce the dose to healthy tissues compared to photon therapy by depositing most of the energy at a specific depth. Proton therapy has potential applications in tumors near critical structures where dose escalation may improve outcomes. However, more evidence from controlled trials is still needed to demonstrate comparative effectiveness versus other radiation therapies.
Carcinoma nasopharynx anatomy to managementDrAyush Garg
The document provides information on carcinoma of the nasopharynx, including its anatomy, epidemiology, etiology, clinical features, patterns of spread, diagnostic evaluation, and metastatic workup. The key points are:
1) Nasopharyngeal carcinoma is most common in Southern Chinese populations and has a bimodal age distribution. Viral, genetic, and environmental factors like Epstein-Barr virus and salted fish contribute to its etiology.
2) The tumor can spread superiorly into the skull base, anteriorly into the nasal cavity/sinuses, and posteriorly into neck muscles and brain. Distant metastases most often involve bones and lungs.
3) Diagnostic evaluation includes endoscopic
This document provides an overview of interstitial brachytherapy principles and concepts. It discusses the history and evolution of brachytherapy sources from radium to modern radioactive sources like iridium-192. Key concepts covered include dose rate calculations, implant systems like the Paris system, and factors that influence dose distribution from a radioactive source like distance, absorption and scattering. The document also describes temporary and permanent brachytherapy sources and different methods of source application including preloading, afterloading and remote afterloading.
This seminar is presented as a part of weekly journal club and seminar presented in Apollo Hospital,Kolkata Department of Radiation Oncology.This seminar is moderated by Dr Tanweer Shahid.
This document discusses the history and techniques of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). It begins by outlining the early development of SRS by Lars Leksell in the 1950s. It then defines key terms like SRS, SBRT, and fractionated stereotactic radiosurgery. The document goes on to discuss the rationale and advantages of SRS/SBRT, including its ability to deliver high radiation doses with steep dose gradients using multiple beams and image guidance. It also covers topics like tumor oxygenation, cell kill mechanisms, and recent technological advances in the field like VMAT, flattening filter free beams, and 4D
Radiotherapy for Seminoma
- Seminoma accounts for over 60% of testicular germ cell tumors with an incidence of 0.95 per 100,000.
- For stage I seminoma, prophylactic radiation to the para-aortic lymph nodes is the standard of care to reduce the risk of recurrence.
- For stage IIA/IIB seminoma, radiotherapy to the para-aortic, iliac, and inguinal lymph nodes is recommended, with 30Gy to the whole field and a 10Gy boost for stage IIA and 36Gy total for stage IIB.
- Intensity modulated radiation therapy (IMRT) allows for improved sparing of
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
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
Proton beam therapy is a form of external beam radiotherapy that uses proton beams rather than x-rays to treat cancer. Protons deposit most of their radiation in the target tumor due to the physics of the Bragg peak. This allows higher doses to be delivered to tumors while minimizing exit dose and reducing radiation exposure to surrounding healthy tissues compared to traditional x-ray radiotherapy. Proton therapy has the potential to improve patient outcomes by better controlling tumors and reducing treatment toxicity.
1) The document discusses various radiation techniques for treating cancer of the esophagus including 2D, 3D conformal radiation therapy, IMRT, and IGRT.
2) It covers topics like target volume delineation, field design considerations for different esophageal subsites, and evolution from 2D to 3D treatment planning.
3) While there is no consensus, most contemporary trials use margins of 3-5cm cranially and caudally on the gross tumor with approximately a 2cm radial margin.
Brachytherapy is an excellent treatment for prostate cancer that provides long term tumor control comparable to radical prostatectomy and external beam radiation therapy. It involves placing radioactive sources directly in the prostate gland temporarily or permanently. Common radioactive sources include iodine-125 and palladium-103 seeds. Brachytherapy can be used as monotherapy for low risk prostate cancer or as a radiation boost combined with external beam radiation for higher risk disease. It allows a highly conformal dose to be delivered to the prostate while sparing surrounding tissues from radiation exposure. Brachytherapy is generally a low risk treatment with most side effects being temporary increased urinary symptoms. It provides patients an alternative to surgery or external beam radiation for localized prostate cancer
Role of radiation in benign conditionsPurvi Rathod
This document discusses the role of radiation therapy in treating various benign conditions. It provides indications for RT in benign tumors of the brain and head and neck such as meningiomas, pituitary adenomas, and craniopharyngiomas. It also discusses using RT to treat other benign conditions such as trigeminal neuralgia, hemangiomas, arteriovenous malformations, and Langerhans cell histiocytosis. Radiation therapy aims to control symptoms, provide pain relief, and achieve good local control of benign lesions with minimal side effects when used judiciously for the right indications.
The document discusses intensity-modulated radiation therapy (IMRT) for head and neck cancers. It describes how IMRT improves target coverage and sparing of organs-at-risk like the parotid glands compared to conventional radiation therapy. Studies show IMRT reduces the risk of xerostomia and improves quality of life outcomes for patients.
This document discusses the management of oropharyngeal cancer. It begins by stating the goals of treatment are functional organ preservation and minimizing treatment-induced morbidity while maintaining cure rates. For early stage disease, single modality radiotherapy or surgery is usually sufficient. For advanced stages, surgery plus radiation or chemoradiation are recommended based on risk factors. It then discusses treatment options and outcomes for different subsites within the oropharynx and the benefits of adjuvant therapy or altered fractionation schedules for radiotherapy.
This document discusses carcinoma of the nasopharynx, including its detection in early stages using MRI imaging, patterns of local and lymphatic spread, association with EBV, clinical features, staging according to AJCC guidelines, pathological classification, and treatment using radiotherapy techniques like three-dimensional conformal radiation therapy and intensity-modulated radiotherapy. Key points covered are detection of early lesions via MRI, common sites of local extension like the parapharyngeal space and skull base, routes of lymphatic spread to cervical lymph nodes, and role of plasma EBV DNA levels in diagnosis and prognosis.
METASTATIC NECK DISEASE FOR ENT & HNS.pptxSatishray9
1) Metastatic neck disease is an important prognostic factor in head and neck cancer and is classified by lymph node levels.
2) Imaging techniques like ultrasound, CT, MRI and PET scans are used to assess cervical lymphadenopathy and detect metastatic neck disease.
3) Treatment of metastatic neck disease depends on factors like number of involved nodes, size of nodes, bilateral involvement and previous treatment and may involve surgery, radiation or chemoradiation.
This document discusses the management of neck metastasis. Some key points:
1. Neck metastasis, also called neck nodes, refers to cancer spreading from a primary site to lymph nodes in the neck. The presence, level, size and number of metastatic nodes are important prognostic factors.
2. Cancer cells can spread passively through lymph vessels from a primary tumor to regional lymph nodes. They then proliferate, remain dormant, or enter blood vessels to metastasize further.
3. Assessment of neck nodes involves medical history, physical exam, imaging like ultrasound, CT, MRI, and biopsy of suspicious nodes. Nodes are grouped by anatomical levels that correlate with primary drainage patterns.
4. Treatment depends
- Metastatic neck disease is an important prognostic factor in head and neck cancer.
- Management of neck disease involves choices of treatment modality, timing, and combination of treatments which are controversial.
- Assessment of cervical lymphadenopathy involves clinical examination, fine needle aspiration cytology, imaging like ultrasound, CT, MRI, and PET.
- Treatment depends on neck stage - elective neck treatment for N0, neck dissection for N1, neck dissection with postoperative radiation for N2, and debate over treatment for massive N3 nodes.
Cerebellopontine Angle Tumor can arise from various structures in the CPA. Vestibular schwannoma, also known as acoustic neuroma, is the most common type and arises from the vestibulocochlear nerve. Patients present with hearing loss, tinnitus, and imbalance. MRI is the preferred imaging method and shows a well-defined enhancing mass. Treatment options include observation, surgery to remove the tumor, and stereotactic radiosurgery.
Nasopharyngeal carcinoma (NPC) arises from the epithelial lining of the nasopharynx. It is most common in Chinese and North African populations. Radiotherapy is the primary treatment, with chemotherapy added for advanced stages. Follow up care involves regular endoscopy and imaging to monitor response and detect recurrence, which most often occurs in the first three years. Salvage treatments include additional radiotherapy, brachytherapy, surgery, or chemotherapy depending on the location and extent of recurrence. Prognosis depends on stage, with 5-year survival rates ranging from over 80% for early stages to less than 50% for late stages.
Oropharynx cancer practical target delineation 2013 aprYong Chan Ahn
This document provides an overview of the anatomy, patterns of spread, and treatment considerations for oropharyngeal cancer. It describes the boundaries and common spread patterns for primary tumors originating in different sites within the oropharynx, including the tonsillar fossa, soft palate, and base of tongue. It also discusses the incidence of subclinical lymph node metastases and the order of lymphatic spread. Important considerations for target delineation and elective neck irradiation are presented. Practical points for contouring and treatment planning with newer imaging technologies are provided.
Nasopharyngeal carcinoma (NPC) arises from the epithelial lining of the nasopharynx. It is most common in Chinese and North African populations. Radiotherapy is the primary treatment, with chemotherapy added for advanced cases. Follow up care involves regular endoscopy and imaging to monitor response and detect recurrence. Salvage treatments include additional radiotherapy, brachytherapy, surgery, or chemotherapy depending on the location and extent of recurrence. Prognosis depends on stage, with 5-year survival rates ranging from over 70% for early stage to less than 50% for late stage disease.
This document discusses the lymph node levels of the neck and management of unknown primary cancers of the neck. It begins with an overview of neck anatomy and the different lymph node groups. It then covers evaluation, staging, and treatment of unknown primary cancers presenting as metastatic neck nodes. Key points include: physical exam and imaging are used to identify the neck level involved; treatment is usually neck dissection and radiation, tailored to the specific neck level and node characteristics; and radiation fields aim to cover potential primary sites while minimizing toxicity.
This document discusses the lymph node levels of the neck and management of unknown primary cancers of the neck. It begins with an overview of neck anatomy and the different lymph node groups. It then covers the classification of lymph node levels, evaluation and diagnosis of unknown primary neck cancers, and treatment approaches based on nodal staging. Physical exam, biopsy, imaging, and endoscopy are used to diagnose while treatment involves neck dissection and/or radiation depending on nodal stage and characteristics.
This document provides information on vestibular schwannoma (VS), including:
- VS arises from schwann cells surrounding the vestibular nerve in the internal acoustic meatus.
- It is a benign, slow-growing tumor that initially causes hearing loss and tinnitus. As it expands, it can compress cranial nerves and cause symptoms like facial numbness.
- Diagnosis involves hearing tests showing asymmetric hearing loss and imaging like MRI showing a globular mass.
- Treatment depends on tumor size and hearing status. Surgery options include translabyrinthine, middle fossa, and retrosigmoid approaches.
Carcinoma Buccal Mucosa- Anatomy to ManagementDrAyush Garg
This document provides information on carcinoma of the buccal mucosa, including its anatomy, epidemiology, risk factors, clinical features, diagnosis, staging, treatment, and prognosis. Carcinoma of the buccal mucosa is most common in India, Malaysia, and Taiwan, where it affects men more than women. Risk factors include tobacco and betel nut chewing. Treatment depends on the stage, with surgery or radiation typically used for early stages and chemoradiation for advanced stages. Prognosis depends on factors like tumor size and nodal involvement.
Recent guidelines in management of oral and oropharyngeal carcinoma barun kumar
This document provides guidelines for the management of oral and oropharyngeal cancer. It discusses the multi-disciplinary approach, TNM staging, diagnostic workup, treatment options based on stage, principles of surgery including resection, reconstruction and management of neck nodes, as well as follow up care. The guidelines emphasize a team-based approach and tailored treatment strategies based on specific tumor characteristics and stage.
This document discusses the anatomy, staging, treatment and techniques for carcinoma of the nasopharynx. It describes the parapharyngeal space and lymphatic drainage of the nasopharynx. It discusses the AJCC staging system and Ho's staging system. It covers treatment techniques including two-field and three-field approaches, doses used, treatment volumes, nodal volumes, planning and field matching considerations.
This document provides an overview of common pediatric brain tumors located in the posterior fossa (infratentorial region). It discusses the most frequently used MRI sequences for evaluating these tumors and provides clinical and imaging features of the most common tumor types, including medulloblastoma, ependymoma, pilocytic astrocytoma, and brainstem glioma. Differential diagnoses are also reviewed. Key sequences discussed are T1WI, T2WI, FLAIR, DWI, and post-contrast T1WI. Common features and imaging findings are highlighted for each tumor type in 1-3 sentences.
This document discusses the management of neck nodes in head and neck cancers. It covers topics such as:
- The lymphatic drainage patterns in the head and neck region
- Imaging techniques used to evaluate neck nodes such as CT, MRI, PET-CT and ultrasound
- Criteria used to determine if a lymph node is suspicious for metastasis
- Staging of neck node metastasis
- Risk classification of clinically node negative necks
- Selection of radiation therapy or neck dissection for node negative cases
- Guidelines for target volume delineation in radiation therapy for neck nodes from institutions like RTOG, DAHANCA and MD Anderson.
1) Radiation therapy remains the main treatment for nasopharyngeal cancer and has improved with advances in precision delivery techniques like IMRT.
2) Important prognostic factors include tumor stage, nodal involvement, and histology, with lower nodal disease and non-keratinizing tumors having better outcomes.
3) Treatment planning involves delineating target volumes in the nasopharynx, neck nodes, and potentially intracranial areas, and balancing high radiation doses to targets versus respecting organ at risk constraints.
Similar to Perineural invasion head neck cancers radiation therapy volumes and doses (20)
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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
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.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- 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
Tests for analysis of different pharmaceutical.pptx
Perineural invasion head neck cancers radiation therapy volumes and doses
1. PNI and PNS in Head Neck Cancers Zonal Classification
2. • Perineural Spread of HNC described in literature for decades-understanding
is still evolving and has many grey areas
• Neurotropism- spread of tm along loose connective tissue of perineurium
• Carter et all-pathological studies found that cancer cells invade the
perineural space and use it as conduit for spread
• PNI is tumour cell invasion in, around and through nerves
PNI= Histologic- Microscopic entity
PNS= Gross PNI-Clinical, radiological or histological entity
3. • Overall frequency of PNI in HNC – 2.5-5%-- PNS much lower
• Common tms with PNI
1. Cutaneous malignancies- BCC, Melanoma
2. Adenoid Cystic Ca
3. Mucosal SCC- Nasopharynx, Sino nasal, Palate, Oral Cavity and
Tonsils
4. Salivary Gland Malignancies- High grade muco epidermoid ca,
Salivary duct ca
• Only 30-40% with PNI are symptomatic at presentation
4. Delay/Miss in diagnosis of PNI– Vigilant MDT
• C/F- paresthesia, pain, numbness and/or sensory motor deficits
• Symptoms attributed to multiple cranial Ns- suggest more central
involvement such as cavernous sinus, spread from one cranial N to
another
• Must pay attention for these s/s especially in tumours more commonly
a/w PNI
6. Growth pattern and pathophysiology
• Contiguous retrograde – from primary tumour towards –intra
cranially
• Antegrade spread -- towards skin is also a known pattern
• Rarely Skip lesions are also known
• PNS in HNC MC involves Trigeminal and Facial N– MC sensory motor
nerves of face
7. Classification System of PNI
• No well accepted classification systems– specially there is no system
which is combining all radiological and pathological information
• MRI Classification-
• Minimal- Abnormal enhancement without gross enlargement
• Moderate- Nerve enlargement- 2-3 times greater then normal mean
diameter, with or without abnormal enhancement
• Gross- Nerve enlargement >3 times the normal with or without
abnormal enhancement
William SL RSNA meeting 1998
8. Pathological Classification
• Small N <1 mm (WPOI Grade 1)
• Large N >1 mm (WPOI Grade 3)
• Focal (1 focus)
• Moderate (2-5 foci)
• Extensive (>5 foci)
• Location of PNI –
• Intratumoral
• Extratumoral
Ref
Brandwein Gensler ;Oral SCC HRAS- Am J
Pathology 2005 Feb 29 (2): 167-78
Miller ME; Novel classification system of PNI –
Am J Otolaryngol 2012 Mar Apr 33 (2); 212-5
Aivazian K et all ; PNI in Oral SCC – J Surg
Oncology 2015 Mar ; 111 (3) ; 352-8
Tarsitano et all Oral Surg Med Oral Pathology
Oral Radiol 2015 Feb 119(2)
9. Practical Approach to PNI in HNC
1. PNI present or absent
2 If PNI is present – is it overall “”bad” or “ugly” category
• Focal/ Small N/Microscopic/ Intratumoral- “Bad”
• Extensive/Large N/Gross/Radiological/Clinical – “Ugly”
3.”Bad” PNI in isolation—Alone not a well accepted indication for PORT
• ”Ugly”PNI– Red flag alert- Detailed clinical examination, discussion with
pathologist, review of imaging, intraop findings, MDT
• Named Nerve
• Un named N
11. • Majority MRI finding are subtle and require targeted imaging
• MRI has high rate of detection of PNS with sensitivity of 95- 100%
• Recommended imaging technique- High resolution, small FoV, thin
collimation; preferably 3 T
• T1 Axial and Coronal plain and fat suppressed PC- Most Important
• T2 Coronal fat suppressed- Denervation changes, CSF cleft around
ganglions
• ?CISS/Hypercube
• Multi planar reformations important in evaluation of base skull
foramina
• Foramen ovale and Meckels cave are best seen in coronal images
12. Imaging Features
• T1 weighted MRI- Fat is usually present around nerves & is
hyperintense
• Obliteration of fat pads is the key sign for PNI
• Enlargement and enhancement along course of N
• Asymmetrical thickening of a nerve/ganglion
• Convexity of cavernous sinus wall and soft tissue enhancement within
Meckel cave –s/o macroscopic PNI
• CT scan is good for bony anatomy-routinely check and compare all
important foramina
13. Zonal Classification of PNS
• Zone 1- Peripheral
• Zone 2 Central/Skull base
• Zone 3- Cisternal
Medenhall WM IJROBP Vol 49,No 49;1061-69, 2001.
14.
15.
16. Asymmetrical enhancement of a nerve/ganglion
Secondary denervation changes in muscles
T1 PC coronal- Enhancement and
thickening of V3 along foramen ovale
Zone 2 disease of V3- Mandibular N
Denervation changes in pterygoid ms
17. Loss of perineural fat pad within a foramina
containing cranial N branch
Normal fat on the right side
Loss of normal fat around N
on left side
Zone 1
Disease of V3(inferior
alveolar Nerve)
18. Enlargement of the foramina
Enlargement or enhancement of cavernous sinus or Meckel’s cave
Zone 3 disease of Trigeminal N
Axial fat suppressed T1 PC
Enhancement and enlargement of
Gasserian ganglion extending into
nerve root entry zone in pre
pontine cistern
19. CISS Sequence
b and c- Sensory and motor nucleus of V N in Brain
Stem
D- Root Zone entry
F- Cisternal segment of V N
E- Porus trigeminalis
G- Meckel’s Cave
Meckel’s cave lies just lateral to cavernous
sinus and is continuous with pre pontine
cistern
CSF containing pouch lined with dura
20.
21. Important Landmarks
• PPF- Pyramidal shaped space-
located b/w posterior wall of
maxillary sinus and pterygoid
process
• Important “crossroads” for PNS
as it connects Masticator space
with orbit and NPX
• Contents- Maxillary N V2, PP
ganglion, Internal maxillary A
HUB OF PNI
22. PPF
• On reaching PPF, tumours may extend to Meckel’s cave and cavernous
sinus via F rotundum
• Normally it’s a fat filled space
• Replacement of fat
• Enhancement
• Abnormal widening are imp features
23.
24. Cavernous Sinus CN III, IV, VI , V1 and V2
Superior orbital fissure CN III, IV, V1 and VI
F Rotundum V2; Connects cavernous sinus and PPF
Vidian Canal Vidian N ( Formed by GSPN/V3 and Deep
petrosal N VIIN)
F Spinosum Middle meningeal A
F Ovale V3
PPF V2
Stylomastoid Foramina VII
Infra Orbital F V2
Greater Palatine F V2
Mandibular and Mental Foramen Inferior Alveolar N- Branch of V3
Hypoglossal Canal Hypoglossal N
32. COMMUNICATIONS BETWEEN NERVES
• BETWEEN BRANCHES OF TRIGEMINAL N
• 1. Communication b/w branches of V1 and V2 at orbital apex (where
they lie close to each other after passing through superior orbital
fissure)
• 2.Communication b/w branches of V1 and V2 in PPF via inferior
orbital fissure
• 3. Communication b/w branches of V2 and V3 in PPF via pterygo
palatine fissure
33. • BETWEEN BRANCHES OF V and VII N
• Communication b/w branches of V2 in PPF and VII N in the vidian N
canal
• Auricuotemporal branch of V3 crosses body of parotid at right angle
to VII N- and can have communication
• If macroscopic PNI involving V N is present , carefully examine VII N
clinically and radiologically and vice versa
34. Radiation Therapy Planning
• When designing target volumes in PNI – weigh the risk benefit
• Increasing volumes to cover CN central origin can increase toxicity
• Decision to include elective CN pathways in addition to primary
tumour region depends on extent of PNI, histology, margin status and
clinical presentation
35. • Microscopic PNI of named N-CTV is 0.5 cm AA nerve
• Nerves at max risk are chosen to be covered according to anatomic
location of tumour
• Gross PNI- Clinical/radiological/Intra operative- consider elective
coverage of CNS via inter nerve connections
• ACC- higher predilection for tracking proximally along nerve tissues
towards base skull– cover CNs till base skull and inter nerve
connections
36. Treatment Volumes for “Ugly” PNI
• HR CTV =GTV= Entire post contrast enhancing path of nerve +5 mm AA
• LR CTV = Additional margin of 30 mm along nerve path and potential
margin along skull base
• In case skull base is involved- LR CTV should be prolonged up to brain
stem
• Consider appropriate margins for antegrade PNI spread and cross
commuincation b/w CNs
• Follow Zonal Classification- Involved Zone HR CTV and Subsequent zone
LR CTV
Garden AS IJROBP 1995; 32:619-26
Zukauskaite R RO 2018; 126”48-55
37.
38. Doses
• Microscopic PNI with negative margins on Nerve- 54Gy along course
of nerve
• Gross PNI with negative margin on the nerve- 60Gy along course of N
• Gross PNI with positive margin on N 66Gy to tumour bed – while
remaining N gets 60Gy – while respecting OARs
39.
40. 48 years old gentleman
May 2018 presented with a ulcer on
right lateral border tongue
Biopsy- MD SCCC
Surgery- Partial glossectomy + MND
HPR- 3x 1.5 x1 cm tumour
MD SCC
DoI- 10 mm
LVI +
PNI + in large nerves
All Margins free
3/51 LN positive
Largest LN 2 Cm
Microscopic ECE+
Patient with ca tongue and large
N PNI
41. Post op MRI-
• Contralateral Level IV LN
• Enhancement along ipsilateral V3 N
extending along foramen ovale to
meckel’s cave
• V3 Zone II
42. Patient had numbness along V3 distribution
FNAC- LN positive for malignancy
Left ( Contralateral LND)
HPR- 2/32 LNs with ECE
One LN at level II and second at level IV
High Risk Ds- Large N PNI
Bilateral LNs with ECE
Contralateral Lower neck LN
44. Treatment Considerations
• MICROSCOPIC PNI
• SCC- Focal/intratumoral small N PNI- relative indication for PORT –
needs case by case discussion
• Salivary Duct Ca and Adenoid cystic Ca- have higher incidence of local
and base skull recurrences– need PORT
45. Treatment Considerations
• MACROSCOPIC PNI
• All pts with macroscopic PNI merit PORT + Concurrent Chemotherapy
• RT with IMRT
• Prerequisite-
• Good clinical examination to identify specific territory affected
• Detailed study of MRI and pathological and intraop findings
46. Recommended Reading
• Raut AA et al. Imaging of Skull base – Indian Journal of Radiology and
Imaging (Nov 2012) Vol 22. Issue 4
• Baskt RL et al. PNI and PNTS in HNC. PRO (2014);
• Baskt RL et al. Contouring guide for HNC with PNI. IJROBP (2019); Vol
103(5).
• Goraykai P et al. Post Op RT in for large nerve PNS in HNC. J Neuro Surg B
(2016); 77. 173-181.
• Gandhi M et al. Imaging of large nerve PNS. J Neuro Surg B (2016); 77. 113-
123.
• Bourhis J. Practical guidelines for contouring trigeminal nerve.
Radiotherapy and Oncology. (2018).