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.
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.
Techniques for Inguinal/Groin IrradiationAjeet Gandhi
Inguinal radiotherapy delivery is many a times a complex dosimetric uncertainty and we need to judiciously choose the technique for best patient outcome
Techniques for Inguinal/Groin IrradiationAjeet Gandhi
Inguinal radiotherapy delivery is many a times a complex dosimetric uncertainty and we need to judiciously choose the technique for best patient outcome
Treatment of Brain Metastases Using the Current Predictive Models: Is the Pro...CrimsonpublishersCancer
Brain metastases from solid tumours are the most common intracranial tumours [1] and it occur in 40% of patients with cancer [2]. The most common primary tumours that metastasize to the brain are lung(40%),breast (25%) and melanoma (20%) [3]. The incidence is expected to be on the increase, due to improved survival, with use of modern cytotoxic drugs, targeted therapy, immunotherapy and modern radiotherapy techniques, in addition to greater use of magnetic resonance imaging of the brain. Brain metastases are common in the elderly, defined as above 60 years [4], and the interval between diagnosis of the primary and the development of brain metastases is variable, however some reported an average of 19 months [5] and adenocarcinoma is the commonest histology that metastasizes to the brain [6].
Stereotactic Radiosurgery and Radiotherapy of Brain Metastases Clinical White...Brainlab
Learn more: https://www.brainlab.com/iplan-rt
Brain metastases are a common manifestation of systemic cancer constituting as much as 30% of all intracranial malignant tumors. Each year, 15 to 30% of cancer patients develop brain metastases, yielding an incidence of over 100,000 patients in the US. Development of brain metastases leads directly to the patient’s death in the majority of cases.
Stereotactic Radiotherapy for the Treatment of Acoustic Neuromas Clinical Whi...Brainlab
Learn more: https://www.brainlab.com/radiosurgery-products/
Acoustic neuromas (AN) have an annual incidence of approximately one per 100,000 people and may account for up to 8% of all new tumors presenting to a neurosurgical referral practice. Acoustic neuromas are benign tumors arising from Schwann cells from the vestibular branch of the eighth cranial nerve. Nevertheless, they can pursue a potentially aggressive course, with uncontrolled local growth resulting in compression of the brainstem and fourth ventricle, cranial nerve and other neurological deficits.
Austin Oncology is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Oncology.
The journal aims to promote research communications and provide a forum for doctors, researchers, physicians and healthcare professionals to find most recent advances in all the areas of Oncology. Austin Oncology accepts original research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of oncology.
Austin Oncology strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Austin Oncology is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Oncology.
The journal aims to promote research communications and provide a forum for doctors, researchers, physicians and healthcare professionals to find most recent advances in all the areas of Oncology. Austin Oncology accepts original research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of oncology.
Austin Oncology strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Robotic Radiosurgery Treatment for Eye Tumours duttaradio
Robotic radiosurgery treatment is an excellent treatment option for eye tumours. This presentation explains in detail the application of CyberKinfe as a treatment option.
Stereostatic Radiosurgery in Pancreas Cancerduttaradio
SBRT has potential role in HCC, liver mets, cholangiocarcinoma, pancreas, Klaskin tumour, GIST. The initial results are impressive with low toxicity, high response rate Short course, high dose radiation therapy will improve local control and may improve survival function. The data presented in this presented is emerging data.
Small AVMs need treatment with either surgery or radiosurgery
Deep seated & eloquent area AVMs need radiosurgery treatment
Radiosurgery is single fraction, usually dose more than 18 Gy to the nidus
Obliteration rate (cure rate) is 70-80% at 2-year evaluation
Gammaknife / Linac based systems: need invasive frame
Cyberknife: No need for invasive frame
Out-patient procedure, excellent compliance
Obliteration rate is similar to frame based systems
Less then 1 cm tumour / no hearing impairment
- Observation
- Yearly MallRI scan & audiometry
Early sm tumor: (size <2.5>3.5 cm) / brainstem compression
- Facial Nr preservation not possible: Surgery
- Facial Nr Preservation possible: Surgery only with complication
Safe Surgery + radiosurgery
- Surgery not possible: Fractionated radiotherapy
CyberKnife is an option in inoperable or medically not suitable for surgery
& in patient with progression / not tolerating systemic therapy
- Initial results are impressive with low toxicity, good response rate
Pts with small tumour, no prior treatment with good performance
treated with high dose have significantly better survival
Dose >45 Gy; 15Gy/# and small vol tumour (<50cc) have better prognosis
There is minimal toxicity with CyberKnife in liver tumours
Addition of chemotherapy along with CyberKnife will be the future
Meningiona/ Craniopharyngioma/ High Grade Gliomaduttaradio
Small recurrent / residual meningioma need to be treated with radiosurgery. There is regression of tumour after high dose radiosurgery. Usual dose for radiosurgery is 12-15 Gy in single fraction.
Radiotherapy in low grade gliomas benefit with local control advantage
Patients with high risk factors need immediate radiation after surgery
RT dose of 50-54 Gy in 2 Gy/Fr
Fractionated radiosurgery in optic nerve glioma and small volume disease
Large patient cohort prospective study with more than 500 patients and more than 5
years follow up have shown that CyberKnife is equally effective as long coures RT
SBRT/ CyberKnife is now standard of care treatment for localized prostate cancer
Outcome of CyberKnife treatment is similar to long course RT
Side-effect after Cyberknife is less than 1% in prostate cancer
CyberKnife is safe, out patient, short course
CyberKnife: Radiosurgery System Introductionduttaradio
Radiation source is mounted on a precisely controlled industrial robot.
- Image guidance system(continuous tracking system)
- Eliminates the need of gating techniques and restrictive head frames
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
1. Debnarayan Dutta, MD
Head, Radiation Oncology
Amrita Institute of Medical Science, Kochi
duttadeb07@gmail.com
Radiosurgery in Brain Metastases
2. Is WBRT effective ?
Is SRS alone good enough ?
Is SRS only an option after surgery ?
Is WBRT an history now?
Brain metastasis
3. Solitary brain metastasis Multiple brain metastasisLimited brain metastasis
Brain metastasis
Surgery SRS WBRT
?
Surgery/ SRS
WBRT
• Ph III study
• Solitary mets with no
Extra cranial site disease
• 2 mo survival benefit
• Standard of Care
• Large series
• WBRT-30Gy/10#
• MS 6-9 mo
• Standard of Care
• Till recently NO
Standard of Care
4. Brain metastasis: Conventional Treatment
• WBRT (30Gy/10#) IS STANDARD OF CARE
• Outcome of treatment: Survival 6-12 months
• German helmet Field
• 30Gy/10# = 40Gy/16# = 20Gy/5#
• Prognosis based on RPA (Gasper 1997)
• RPA is based on KPS, age, Extra-cranial site
disease, Controlled primary
RPA
Class
Age
(Yr)
KPS Systemic disease Survival
(Mo)
I <65 >70
Controlled primary
No other disease
7.1
II NS >70 NS 4.2
III NS <70 NS 2.3
Gasper et al, IJROBP 1997
5. Surgery
Whole Brain RT vs Observation
WBRT
OBS
OAS: 46 wks (WBRT) vs 43 wks (OBS)
WBRT
OBS
Death due to
neurological cause
(p<0.03)
WBRT better than Observation
Patchell A. JAMA 1998
6. Brain metastasis: Solitary mets: WBRT+SRS/Surgery
- Single brain metastasis: WBRT + SRS/Sur boost have 2 months survival benefit
Andrew D, Lancet 2004
7. Tallet et al, Radiat Oncol 2012
Issues with WBRT: Cognitive function impairment
Decline in domain scores after WBRT
10. w w w .t h e l a n c e t .c o m / o n c o l o g y V o l 1 0 N o v e m b e r 2 0 0 9 1037
Neurocognition in patients with brain metastases treated
with radiosurgery or radiosurgery plus whole-brain
irradiation: a randomised controlled trial
EricLChang,JeffreySWefel,KennethRHess,PamelaKAllen, FrederickFLang,DavidGKornguth,RebeccaBArbuckle,JMichael Swint,
AlmonSShiu,MosheHMaor, ChristinaAMeyers
Summary
Background It is unclear whether the benefit of adding whole-brain radiation therapy (WBRT) to stereotactic
radiosurgery (SRS) for the control of brain-tumours outweighs the potential neurocognitive risks. We proposed that
the learning and memory functions of patients who undergo SRS plus WBRT are worse than those of patients who
undergo SRS alone. We did a randomised controlled trial to test our prediction.
Methods Patients with one to three newly diagnosed brain metastases were randomly assigned using a standard
permutated block algorithm with random block sizes to SRS plus WBRT or SRS alone from Jan 2, 2001, to Sept 14,
2007. Patients were stratified by recursive partitioning analysis class, number of brain metastases, and radioresistant
histology. The randomisation sequence was masked until assignation, at which point both clinicians and patients were
made aware of the treatment allocation. The primary endpoint was neurocognitive function: objectively measured as a
significant deterioration (5-point drop compared with baseline) in Hopkins Verbal Learning Test–Revised (H VLT-R)
total recall at 4 months. An independent data monitoring committee monitored the trial using Bayesian statistical
methods. Analysis was by intention-to-treat. This trial is registered at www .ClinicalTrials.gov, number NCT00548756.
Findings After 58 patients were recruited (n=30 in the SRS alone group, n=28 in the SRS plus WBRT group), the trial
was stopped by the data monitoring committee according to early stopping rules on the basis that there was a high
probability (96%) that patients randomly assigned to receive SRS plus WBRT were significantly more likely to show a
decline in learning and memory function (mean posterior probability of decline 52%) at 4 months than patients
assigned to receive SRS alone (mean posterior probability of decline 24%). At 4 months there were four deaths (13%)
in the group that received SRS alone, and eight deaths (29%) in the group that received SRS plus WBRT. 73% of
patients in the SRS plus WBRT group were free from CNS recurrence at 1 year, compared with 27% of patients who
received SRS alone (p=0· 0003). In the SRS plus WBRT group, one case of grade 3 toxicity (seizures, motor neuropathy,
depressed level of consciousness) was attributed to radiation treatment. In the group that received SRS, one case of
grade 3 toxicity (aphasia) was attributed to radiation treatment. Two cases of grade 4 toxicity in the group that received
SRS alone were diagnosed as radiation necrosis.
Interpretation Patients treated with SRS plus WBRT were at a greater risk of a significant decline in learning and
memory function by 4 months compared with the group that received SRS alone. Initial treatment with a combination
of SRS and close clinical monitoring is recommended as the preferred treatment strategy to better preserve learning
and memory in patients with newly diagnosed brain metastases.
Funding No external funding was received.
Introduction
About 170000 new brain metastases are diagnosed in the
USA each year.1
For over 50 years, wholebrain radiotherapy
(WBRT) has served as the standard palliative treatment
for brain metastases. More recently, randomised trials
have established the added survival benefi t of either
surgery or stereotactic radiosurgery (SRS) combined with
WBRT over WBRT alone for patients with single brain
metastases,2–4
raising questions about the role of WBRT
and its possible effect on neurocognitive function.
A strategy to preserve neurocognition in patients with
one to three newly diagnosed brain metastases is to use
SRS alone with clinical monitoring to defer or completely
avoid WBRT.5
However, SRS plus WBRT is frequently
given to maximise disease control, since the omission of
WBRT increases the risk of recurrent brain metastases.6–10
We did a randomised controlled trial to help clarify
whether elective WBRT should be given with SRS, or
deferred. We proposed that patients treated with SRS plus
WBRT would have inferior neurocognitive function based
on the Hopkins Verbal Learning Test–Revised (H VLT–R)
compared with patients treated with SRS alone.
Methods
Patients
Eligible patients who presented at the Departments of
Radiation Oncology, and Neurosurgery, and at the Brain
and Spine Center, MD Anderson Cancer Center, Houston,
L a n c e t O n c o l 2 0 0 9 ; 1 0 : 1 0 3 7 – 4 4
P u b l i s h e d O n li n e
O c t o b e r 5 , 2 0 0 9
D O I:1 0 .1 0 1 6 / S 1 4 7 0 -
2 0 4 5 ( 0 9 ) 7 0 2 6 3 - 3
S e e R e fl e c t i o n a n d R e a c t i o n
p a g e 1 0 2 4
D e p a r t m e n t o f R a d i a t i o n
O n c o l o g y ( E L C h a n g M D ,
P K A l l e n P h D , D G K o r n g u t h M D ,
P r o f M H M a o r M D ) ,
N e u r o p s y c h o l o g y S e c t i o n ,
D e p a r t m e n t o f
N e u r o - O n c o l o g y ( J S W e f e l P h D ,
P r o f C A M e y e r s P h D ) ,
D e p a r t m e n t o f N e u r o s u r g e r y
( P r o f F F L a n g M D ) , D e p a r t m e n t
o f B i o s t a t is t i c s
( P r o f K R H e s s P h D ) ,
D e p a r t m e n t o f
P h a r m a c o e c o n o m i c s
( R B A r b u c k l e M S ) , a n d t h e
D e p a r t m e n t o f R a d i a t i o n
P h y s i c s ( P r o f A S S h i u P h D ) ,
T h e U n i v e r s i t y o f T e x a s ,
M D A n d e r s o n C a n c e r C e n t e r ,
H o u s t o n , T X , U S A ; a n d
U n i v e r s i t y o f T e x a s S c h o o l o f
P u b li c H e a l t h a n d T h e C e n t e r
f o r C l in i c a l R e s e a r c h a n d
E v i d e n c e - B a s e d M e d i c i n e ,
U n i v e r s i t y o f T e x a s – H o u s t o n
M e d i c a l S c h o o l, H o u s t o n , T X ,
U S A ( P r o f J M S w i n t P h D )
C o r r e s p o n d e n c e t o :
D r E r i c L C h a n g , D e p a r t m e n t o f
R a d i a t i o n O n c o l o g y , U T M D
A n d e r s o n C a n c e r C e n t e r ,
1 5 1 5 H o l c o m b e B o u le v a r d ,
U n i t 9 7 , H o u s t o n , T X 7 7 0 3 0 , U S A
e c h a n g @ m d a n d e r s o n . o r g
Chang E et al, Lancet 2009
- No difference in OS
- Impaired recall with WBRT
- No difference in cumulative distant
brain recurrence
11. Analysis 1.1. Comparison 1 Whole-Brain Radiotherapy versus Observation, Outcome 1 Overall Survival.
Review: Surgery or radiosurgery plus whole brain radiotherapy versus surgery or radiosurgery alone for brain metastases
Comparison: 1 Whole-Brain Radiotherapy versus Observation
Outcome: 1 Overall Survival
Study or subgroup
Whole-Brain
Radiotherapy Observation log [Hazard Ratio] Hazard Ratio Weight Hazard Ratio
N N (SE) IV,Random,95% CI IV,Random,95% CI
Patchell 1998 49 46 -0.09 (0.22) 21.5 % 0.91 [ 0.59, 1.41 ]
Aoyama 2006 65 67 0 (0.19) 24.6 % 1.00 [ 0.69, 1.45 ]
Roos 2006 10 9 0.01 (0.52) 6.6 % 1.01 [ 0.36, 2.80 ]
Chang 2009 28 30 0.9 (0.31) 14.5 % 2.46 [ 1.34, 4.52 ]
Kocher 2011 180 179 -0.02 (0.12) 32.7 % 0.98 [ 0.77, 1.24 ]
Total (95% CI) 332 331 100.0 % 1.11 [ 0.83, 1.48 ]
Heterogeneity: Tau2 = 0.05; Chi2 = 8.34, df = 4 (P = 0.08); I2 =52%
Test for overall effect: Z = 0.72 (P = 0.47)
Test for subgroup differences: Not applicable
0.5 0.7 1 1.5 2
Favours WBRT Favours Observation
Soon et al, Cochrene metaanalysis, 2014
Brain metastasis: Cochrane meta-analysis 2014
Surgery/SRS+ WBRT Vs SRS/Surgery alone: Over all Survival
No difference in over all survival
p-value=0.47
12. Analysis 1.2. Comparison 1 Whole-Brain Radiotherapy versus Observation, Outcome 2 Progression Free
Survival.
Review: Surgery or radiosurgery plus whole brain radiotherapy versus surgery or radiosurgery alone for brain metastases
Comparison: 1 Whole-Brain Radiotherapy versus Observation
Outcome: 2 Progression Free Survival
Study or subgroup
Whole-Brain
Radiotherapy Observation log [Hazard Ratio] Hazard Ratio Weight Hazard Ratio
N N (SE) IV,Random,95% CI IV,Random,95% CI
Kocher 2011 180 179 -0.34 (0.11) 88.4 % 0.71 [ 0.57, 0.88 ]
Roos 2006 10 9 0.24 (0.52) 11.6 % 1.27 [ 0.46, 3.52 ]
Total (95% CI) 190 188 100.0 % 0.76 [ 0.53, 1.10 ]
Heterogeneity: Tau2 = 0.03; Chi2 = 1.19, df = 1 (P = 0.28); I2 =16%
Test for overall effect: Z = 1.47 (P = 0.14)
Test for subgroup differences: Not applicable
0.5 0.7 1 1.5 2
Favours WBRT Favours Observation
Soon et al, Cochrene metaanalysis, 2014
Brain metastasis: Cochrane meta-analysis 2014
Surgery/SRS+ WBRT Vs SRS/Surgery alone: Progression free Survival
WBRT: Definite reduction in local failure
p-value=0..14
13. QUARTZ trial
N=536
WBRT vs optimal supportive care (OSC)
Lung cancer
OAS: 9.2 weeks for WBRT+ OSC & 8.5 Weeks for OSC
Patients with poor prognosis
WBRT does not add any benefit over OSC for QOL and OAS
Mulvenna P. Lancet 2016
15. Brain
Mets
S
t
r
a
t
i
f
y
Age:18-59 vs>60
Extracranial disease controlled
< 3 months vs > 3 months
Number of Brain mets
1 vs 2 vs 3
Institution
SRS
SRS+WBRT
Primary objective:
Determine if cognitive progression 3 months
post RT SRS is less with SRS alone as
compared to SRS combined with WBRT
Arm A
Lesion < 2 cm-24Gy
Lesion 2-2.9 cm-20Gy
Arm B
Lesion < 2 cm- 20Gy
Lesion 2-2.9 cm-18Gy
WBRT: 30Gy/12 fractions
SRS Alone vs SRS+WBRT in Patients With 1 to 3 Brain Metastases
A Randomized Clinical Trial
Paul D. Brown et al. JAMA. 2016
16.
17. Results
SRS Alone SRS +WBRT P value
Cognitive deterioration 63.5% 91.7% p<0.001
QOL –Mean change From baseline -0.1 -12.0 0.001
Functional well-being 2.5 -22.3 0.006
Barthel ADL Index scores -1.5 -4.2 0.26
Salvage therapy 32.4% 7.8% 0.001
20. Conclusion: Brown et al study
• In pts with 1-3 mets, SRS alone compared to SRS+WBRT
resulted in less decline in the cognitive function
• Overall survival-comparable
• 1-3 metastases-SRS preferred strategy
32. New brain lesion free
survival (%)
Group Score 6 mo 12 mo P-value
Gr I 16-17 36 27
<0.001Gr II 18-20 65 44
Gr III 21-22 80 71
Prognostication
“New brain lesion free survival” after SRS only (n= 214)
Huttenlocher S et al Radiat Oncol 2015
36. Some patients: (10-15%)
- Oligo brain metastasis
- Good PS
- SRS
Few patients: (5%)
- Solitary brain metastasis
- Good PS
- Either Surgery or SRS
- If surgery-Post-OP SRS
Brain metastases: Decision making
37. Evolving standard of care in brain metastasis
Till 1990s:
• Whole brain RT is standard of care
• Studies were focused on dosage schedule
• 30Gy/10# equivalent to 40Gy/16#
• Median survival 6-12 months
Since 1990s:
• Limited brain mets- WBRT+ SRS is standard of care (Level 1 evidence, Rec A)
• Randomized studies showed 2 mo survival benefit on addition of SRS
• 30Gy/10# + 12 Gy Boost
• Median survival 2 months benefit
38. Evolving standard of care in brain metastasis
• 1-3 lesions: SRS is the standard of care (Level 1A evidence, Rec A)
• Post-OP: Cavity boost with SRS is standard of care (Level 1A, Rec A)
Since 2012:
• Limited brain metastasis- SRS alone (Level 1A evidence, Rec A)
• Randomized studies showed no OS benefit with WBRT
• Meta-analysis confirmed: No OS benefit with WBRT, only LC benefit
• Randomized studies confirmed Cognitive function decline with WBRT
• WBRT only on recurrence / leptomeningial disease
• SRS boost after surgery: reduce local recurrence (Level II, Rec B)
• Preservation of cognitive function
• Hippocampal sparing RT is new & exciting (Level II, Rec B)
• Need randomized study for confirmation of it’s effectiveness
Since 2016:
39. Is it feasible to do SRS in Indian scenario
Machine availability:
- Tomo/ RapidArc/ Truebeam/ CyberKnife/VMAT/ BrainLAB
- LA available in all major cities in India
Expertize:
-Trained radiation oncologists & Physicists available
-Focused radiosurgery specialists available
Requirement/ Actual expenses:
- ONLY thermoplastic mask & electricity
Planning time:
- Usually 1-2 hrs
Treatment duration:
-1-3 days
-10-30 min daily
ONE LA machine can treat:
30-40 patients / month
3-5 SRS/day: 150 SRS/month
Possible even in Indian scenario