Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
This presentation is intended to refer while doing planning of SBRT Prostate for all practical aspects from Simulation - contouring - planning - treatment. I am sure it will be very useful presentation for any radiation oncologist who are willing to start workflow of SBRT Prostate in the department of radiation oncology
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
This presentation is intended to refer while doing planning of SBRT Prostate for all practical aspects from Simulation - contouring - planning - treatment. I am sure it will be very useful presentation for any radiation oncologist who are willing to start workflow of SBRT Prostate in the department of radiation oncology
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
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
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
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
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
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
The most common type of cancer arising in the kidney: Renal cell carcinoma(RCC)(also known as Hypernephroma or Grawitz tumor).
Renal cell carcinoma accounts for over 3% of all adult malignancies and has several histological subtypes.
Approximately 85% of kidney tumors are renal cell carcinoma, and approximately 70% of these have a Clear cell histology. Its diagnostic work-up, staging and management.
Lecture on haematuria & urinary tract malignancy for medical students. Encompasses basic sciences, classification,staging and principles of management. Specifically on renal and bladder carcinoma.
A basic approach towards carcinoma of prostate , symptoms, investigations , diagnosis, staging, treatment and follow up along with recent advances in surgeries, vaccines and immunotherapy.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- 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
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.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Radiation Therapy in Prostate
Cancer
Lokesh Viswanath M.D.
Professor, Radiation Oncology,
Kidwai Memorial Institute of Oncology 2014
2. Prostate Cancer
• World wide :
– Second most common cause of cancer
– New Cases ~ 1.1 million (15%)
– Developed countries ~ 70%
– 307,000 deaths
• Prostate cancer incidence
– Lowest:
• Asian populations 10.5 per 100,000
• Eastern and South-Central Asia 4.5 per 100,000
– Highest :
• 111.6 Australia/New Zealand and
• 97.2 per 100,000 Northern America
3.
4. In India
• Previously – thought - prevalence of prostate cancer in
India is far lower compared to western countries
• but …
– increased migration rural to urban areas
– changing life styles
– increased awareness
– easy access to medical facility
…..
– more cases of prostate cancer are being picked up
– we are not very far behind the rate from western countries.
– Current incidence rate of prostate cancer in India is ~ 10.66
per 100000 population
5. Current India Data:
• Prostate cancer:
– 2nd leading site of - Delhi, Kolkatta, Pune and Thi'puram
– 3rd leading site of Bangalore and Mumbai
Projected cases of prostate cancer for selected time periods (2013, 2014, 2015 and 2020).
ICD-10 Site name 2013 2014 2015 2020
C61 Prostate 35,029 37,055 39,200 51,979
6. Prostate : Anatomy
• Prostate
– Accessory gland
– Inverted Cone encompasses the p. urethra
– Dense fibromuscular stroma
– Surrounded by a capsule
– 4 x 3 x 2cms
– 8g
• Prozimity to Rectum & U Bladder
– Denonvilliers fascia
• Blood supply
– Inferior vesical
– Mid rectal
– Internal pudendal
• Lymphatics
– Internal iliac nodes
– Sacral
– Partly external iliac nodes
Nervous supply
– Neurovascular bundle
• Lies on either side of the prostate on the rectum
– Derived from the pelvic plexus - Important for erectile function.
7. Epidemiology
• Risk factors
– Increasing age
– Family history
– African-American
– Dietary factors.
• Race
– Incidence doubled in African Americans compared to white Americans.
• Genetics
– Common among relatives with early-onset prostate cancer
– Susceptibility locus
• Chromosome 1, band Q24
• Found in < 10% of prostate cancer patients
• Nutritional factors - protective effect against prostate cancer
– Reduced fat intake
– Soy protein
– Lycopene
– Vitamin E
– Selenium
8. Clinical Manifestations : Symptoms
• Early state (organ confined)
– Asymptomatic
• Locally advanced
– Obstructive voiding symptoms
• Hesitancy
• Intermittent urinary stream
• Decreased force of stream
– May have growth into the urethra or bladder neck
– Hematuria
– Hematospermia
• Advanced (spread to the regional pelvic lymph nodes)
– Edema of the lower extremities
– Pelvic and perineal discomfort
9. Clinical Manifestations : 2
• of Metastasis :
– Most commonly to bone (frequently asymptomatic)
• Can cause severe and unremitting pain
– Bone metastasis
• Can result in pathologic fractures or
• Spinal cord compression
– Visceral metastases (rare)
– Can develop pulmonary, hepatic, pleural, peritoneal, and
central nervous system metastases late in the natural
history or after hormonal therapies fail.
10. Clinical Signs
• Routine
Clinical history and clinical examination
Rectal examination
• Signs: PR examination - Abnormal
• ( +ve for Malignancy 25-50%)
• Hard nodule / extremely firm
• Evaluate for disease extension in
– Lateral sulcus
– superior
11. Presentation
• Peripheral zone (PZ)
– 70% of cancers
• Transitional zone (TZ)
– 20%
– Some
• TZ prostate cancers are relatively nonaggressive
• PZ cancers are more aggressive
– Tend to invade the periprostatic tissues.
12. Investigations
Routine: Laboratory
Complete blood cell count,
blood chemistry
Serum PSA (total, free, complex PSA:: ratio of Free : Total
PSA < 0.2 - likely Prostate Ca. )
(Normal Age-Specific Limits for PSA -
Plasma acid phosphatases (prostatic/total)
Testosterone
Other Experimental:
RT PCR for mRNA of PSA & PSMA
+ve - Extraprostatic – 72%
-ve - Organ confined - 88%
13. Staging Tests
1. Magnetic resonance imaging (MRI) –
defn Apex, NV bundle, ano rectal wall, intra prostatic dises location, capsular extension,
seminal vesicle involvement
1. T2 axial / coronal : neurovascular bundle , penile bulb
2. PZ - T2 Normal – high signal , Tumor – Low signal , T1 – Hemorrhage – Low
signal intensity
3. Extracapsular extension : focal, irregular capsular bulge, invasion of NV bundle,
obliteration of rectoprostatic angle
4. endorectal MRSI – MR spectroscopy : metabolic activity and extra capsular
extension, seminal vesicle invasion : Increase coline
2. Transrectal ultrasound (TRUS) :
» Ca – variable echo, hyper – 69%, margin - poorly defined ,
3. Transrectal or transperineal biopsy :
– 16 guage , 10 -18 core (base, apex, both lateral, mid, lat peripheral zone)
– Core length
4. Chest radiograph (high risk for metastatic disease)
5. Computed tomography (CT) scans – pelvis node assesment
6. Radionuclide bone scans : Indicated: PSA>20, Gleason score ≥8, Bone pain
Other:
1. PET/CT with 11C- Acetate - detecting microscopic +LN
14. Others : essential base line evaluation
• Erectile function
• Bowel : SI/LI/Rectum/Anal Sphincters
• Bladder : Flow/rate
18. Evaluation of the histologic grade ('G')
GX: cannot assess grade
G1: the tumor closely resembles normal tissue (Gleason 2–4)
G2: the tumor somewhat resembles normal tissue (Gleason 5–6)
G3–4: the tumor resembles normal tissue barely or not at all
(Gleason 7–10)
19. Gleason score
• histological patterns, emphasizing degree of
glandular differentiation and relation to stroma
• Histologic patterns 1 through 5
• nine discrete scores (range, 2 to 10)
• one of the strongest predictors of
– biologic behavior in prostate cancer
– invasiveness
– metastatic potential
– < 6
21. Treatment options for prostate cancer
• Observation alone
• Radical prostatectomy
• Radiation therapy
• Hormonal treatment
22. Overview Treatment Options by Stage for Prostate Cancer
Stage ( AJCC TNM Staging Criteria) Standard Treatment Options
Stage I •Watchful waiting or active surveillance
•Radical prostatectomy
•External-beam radiation therapy (EBRT)
•Interstitial implantation of radioisotopes
Stage II •Watchful waiting or active surveillance
•Radical prostatectomy
•External-beam radiation therapy (EBRT) with or without hormonal therapy
•Interstitial implantation of radioisotopes
Stage III •External-beam radiation therapy (EBRT) with or without hormonal therapy
•Hormonal manipulations (orchiectomy or luteinizing hormone-releasing hormone [LH-RH] agonist)
•Radical prostatectomy with or without EBRT
•Watchful waiting or active surveillance
Stage IV •Hormonal manipulations
•Bisphosphonates
•External-beam radiation therapy (EBRT) with or without hormonal therapy
•Palliative radiation therapy
•Palliative surgery with transurethral resection of the prostate (TURP)
•Watchful waiting or active surveillance
Recurrent •Chemotherapy for hormonal management of prostate cancer
•Immunotherapy
23. Indications for RT
T N0 N1 M1 PSA GS
SURVELLI
ANCE SURGERY Radical RT
Radical
Brachytherapy HT
T1a + <10 <6 YES RP+ PLND RT BRACY
T1b + <10 <6 YES
RP+ PLND
(<2% +ve nodes) RT BRACY
T1c + <10 <6 YES
RP+ PLND
(>2% +ve nodes) RT BRACY
T2a + RT + ADT
T2b + RT + ADT
T2c +
10
to
20 7 YES RP+ PLND
RT + ADT
+ BRACHY BOOST BRACY Y
T3a + >20
8 to
10 RP+ PLND RT + ADT BRACHY BOOST Y
T3b + RT + ADT BRACHY BOOST Y
T4 + RT + ADT BRACHY BOOST ADT
Any T + RT + ADT Y
Any T / N + RT ADT
26. • Radiation therapy is the art of using ionising
radiation to destroy malignant tumours while
being able to minimise damage to normal
tissue.
27. Introduction
• Basics of Radiation Therapy
– Ionizing Radiation – X / γ Rays
– Interaction of Radiation with matter
Transmission Attenuation
Scatter Absorption
Rad / Gray / cGy
28. Cancer Cell & Ionizing Radiation
• Cancer cell multiply faster than normal cell
• DNA is primary target
• Double Strand breaks
>>> Reproductive Cell Death
48. Indications for RT in Ca Prostate
• Radical RT
– T1, T2, T3, T4a
• Un-resectable (Altered Fractionation HF/CB or RT + HT )
• elderly, frail, comorbid conditions
• refusal for surgery
• prohibitive morbidity due to surgery
• Post OP RT : after Radical Prostatectomy
– pT3/4
– Close & +ve margin
– Extra Capsular extension
– Invasion to
• Seminal vesicle
• Extraprostatic extensions
– Multiple nodes
– R 1 resection
• Pre OP PSA > 10ng/ml
• Pre OP PSA velocity > 2ng/ml/year
– Post RP – Recurrent disease
– Post RP - early PSA failures
49. RADIOTHERAPY DOSE
1. External :
a. IMRT / IGRT / Rapid Arc / Protons :
– > 7400 cGy to 7600 cGy / 6-8 wks
– 180-200cGy / fr, 5fr/wk
b. CK / SBRT / FFF : 5 – 20 Gy / fr, 3-5 fr
c. Post-op.: 60-66 Gy / 6-7 wks
d. Palliative RT: 30Gy/10f, 20Gy/5 or 4f, 7-8Gy/1f
2. Brachytherapy :
a. Alone : 6000 - 7000 cGy in 6 to 7 days.
b. External + Brachytherapy
Ext : 46-50 Gy in 4 1/2 - 5 1/2 wks. +
Brachy : 2000-3000 cGy in 2-3 days
HDR : 9.5Gy x 2f, as mono therapy 9.5Gy bid x 4f x 2dys
I -125 : 0.2-0.9mCi, T1/2-17dy, 21Kev
86. Target Motion ITV Management
• Daily localization IGRT techniques to account
for interfraction motion:
– intraprostatic fiducial markers with daily imaging
– transabdominal US
– daily in-room CT imaging
– endorectal balloon immobilization
• All of these methods employ daily imaging of
the prostate in the treatment room.
87. Target Tracking
• During RT
– Celing mounted Cross fired X-Ray / Fluro eg.CK, X Tack
–
• Before RT
– Orthogonal KV / MV Portal imaging – best with fidutial
– CBCT / Onrail CT – suitable for patients without
fidutials
89. Motion Management
reference (simulation film) online (port film) co-registered
(right)
In this technique, the isocenter is shifted until the bony contours (setup error) or the implanted markers
are in agreement (total error).
90. Motion Management
Cone beam computerized
tomography (CBCT) allows volumetric
visualization of the prostate and
adjacent organs.
– Daily online correction allows for
PTV margins:
• 4 mm in all directions and 3
mm posterior (Pawlowski, Red
Journal 2010)
• 5 mm all around and 3 mm
posterior (Hammoud, Red
Journal 2008)
2 stages of image registration: Top: pelvic bone region of interest
Bottom: prostate/sv represented by masked area.
91. Motion Management
• Intrafraction Motion
– Changes in position while the treatment beam is on
(“second by second”)
– Mostly from peristalsis/gas, pelvic floor movement,
respiration coughing, etc.
– Techniques to account for intrafraction motion:
• RGRT (radiofrequency-guided RT techniques)
• Rectal balloon
• Bowel prep (anti-gas tablets and daily bm)
• Consistent Bladder filling
92.
93.
94.
95.
96.
97.
98.
99.
100.
101. Motion management
Endorectal balloon
– Used for prostate
immobilization/fixation
– Ensures reproducibility of
rectal filling and spares
posterior rectum
Teh, Red Journal 2001
78 Gy IMRT plans without (left) and with
balloon (right)
Contours: rectal wall (green), anal wall
(purple) and PTV (blue).
106. most commonly used hormone
therapies
• Orchiectomy
Medical Castration - reversible
• luteinizing hormone-releasing hormone (LHRH) agonists –
synthetic proteins - similar to LHRH and bind to the
LHRH receptor in the pitutary gland- causes the pituitary gland
to stop producing luteinizing hormone, which prevents
testosterone from being produced- leuprolide, goserelin,
and buserelin
• LHRH antagonists - act by preventing LHRH from binding to
its receptors in the pitutary gland