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.
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
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 presentation is part of MIU CE Pharmacy Program and is designed primarily for pharmacists with the following learning objectives:
1- Explain the mechanisms of action behind immune response to cancer and the application of immunotherapy in cancer treatment
2- Distinguish new and emerging immunotherapy classes and individual agents efficacy, safety to therapy in cancer treatment
3-Strategies to counsel and assist patients to overcome barriers to therapy, including Treatment side effects to improve adherence to therapy
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
24° CORSO RESIDENZIALE DI AGGIORNAMENTO
con il patrocinio dell’Associazione Italiana di Radioterapia Oncologica (AIRO)
Moderna Radioterapia, Nuove Tecnologie e Ipofrazionamento della Dose
21 marzo 2014: Trattamenti stereo-RT e radiochirurgici come opzioni standard di trattamento: stato dell’arte in base a linee guida internazionali
Controversies in the management of rectal cancersAjeet Gandhi
Management of rectal cancers have undergone a huge paradigm shift over the last decade. One the one hand, it has opened up new avenues; it also has thrown up new challenges and controversies
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
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.
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.
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
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- 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
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.
Follow us on: Pinterest
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
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
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
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
11. Radical RT Stage I – II: Selected Studies -Results 20-30% worse compared to surgery -Stage IA: 5y OS 60% (almost comparable to surgery)
12.
13. SBRT – Example -T2 N0 -CR after radical radiation -COPD with emphysema
14. Other Techniques improving Outcome Hyperfractionation (Jeremic 1997, 1999) Stage I Stage II Median survival 33mts. 27mts. 5y-OS 30% 25% Protons (Bush 2004) 3y local control 74% Disease-specific survival 72% Pneumonitis, esophageal or late cardiac toxicity 0%
15.
16.
17. Summary: Management of Stage I+II NSCLC -Pathologic stage I+II represents a minority of cases (staging !) -In contrast to advanced stages curable with aggressive therapy and have good prognosis -Surgery is the standard treatment of choice (Lobectomy) -Adjuvant ChT (Cisplatin) for stage II and selected IB -Definitive RT as an alternative for medical inoperable patients and for those who refuse surgery -No adjuvant RT after R0-Resection -Adjuvant RT after R1-/ R2-Resection -Further trials are needed to establish the role of RT in a post- operative setting and its optimal dose/fractionation/technique in a radical setting
18.
19. Radiotherapy for Stage III NSCLC Definitive radiotherapy alone -for patients who are not fit for combined treatment -isolated thoracic recurrence after surgery -palliative for patients with poor performance status or stage IV Early randomized trial: RT vs. Placebo (Roswit 1968) modest but significant survival benefit (18 vs. 14% at 1 year) RT alone: MS 10mts. 5y-OS 5% Factors associated with improved prognosis: (Basaki 2006, RTOG 93-11 2008) -small primary tumor -small total tumor volume
20. Radiotherapy for Stage III NSCLC Definitive radiotherapy alone Should it be given immediately or deferred ? Randomized trial: immediate RT vs. RT reserved for symptoms (Falk 2002) -median survival ns -rate of symptom control similar Palliative symptomatic care is a valuable option for patients with locoregionally advanced NSCLC who are not candidates for combined modality treatment.
21. Radiotherapy for Stage III NSCLC Dose and local control RTOG phase III trial: (Perez 1986) -60Gy / 30 fractions: standard today -phase II data show better local control with higher doses -limiting factor: normal tissue tolerance Improved therapeutic index -altered fractionation schedules -Amifostine -IMRT, IGRT, Tomotherapy, Protons..
22. Radiotherapy for Stage III NSCLC Altered Fractionation Schedules CHART (Saunders 1997,1999): 2y-survival 29% vs. 20% Severe dysphagia 19% vs. 3% ECOG 2597 (Belani 2005): No statistical significance reached Central Cancer Treatment Group (Schild 2002): No statistical significance in terms of TTP, OS, Toxicities
23.
24.
25.
26.
27. Management of Stage IIIB NSCLC -Long Term OS < 5% ! (Hagen 1997) -Most patients die from metastasis -Median survival prolonged 8-10 months with RT-ChT for younger patients with good performance status (Sause 1997) -Other patients: good palliation by RT -Combined ChT-RT better survival than RT alone (Pignon 1994) -Concomitant ChT-RT better than sequential, but more toxicities (Furuse 1999, RTOG 9410) -Role of surgery uncertain (SAKK 16/01: preoperative ChT-RT)
28. Management of Stage IIIB NSCLC Definitive Chemoradiotherapy Objective: treat locoregional and micrometastasic disease -initially sequential therapy to avoid overlapping toxicities -initial trials established benefit of combined approach -subsequent studies compared sequential vs. concurrent chemo- radiotherapy
30. Management of Stage IIIB NSCLC Concurrent Chemoradiotherapy Objective: early treatment of micrometastases radio-sensitization (better local control) -randomized trials established this approach as the preferred treatment -toxicity is increased but manageable
32. Management of Stage IIIB NSCLC Superiority of Concurrent Chemoradiotherapy over Sequential Two large multicenter trials 1. Furuse, JCO 1999 Randomized -conc. ChT (CMV) + 56Gy (split course RT) -same regime sequential Concurrent Sequential Response Rate 84% 86% Median Survival 17mts. 13mts. 2y-survival 35% 17% 5y-survival 16% 9%
33. Management of Stage IIIB NSCLC Superiority of Concurrent Chemoradiotherapy over Sequential Two large multicenter trials 2. RTOG 9410 Randomized -conc. ChT (CV) + 60Gy -same regime sequential Concurrent Sequential Median Survival 17mts. 14.6mts. 4y-survival 21% 127% Toxicity Increased, but nut increased treatment related death
34. Management of Stage IIIB NSCLC Concurrent low dose Chemoradiotherapy Objective: improved locoregional control minimize toxicity -only one randomized trial demonstrate benefit over RT alone (Schaake-Koning, 1992) -several other studies failed to demonstrate survival benefit -no trials comparing low dose vs. standard dose ChT -option for elderly patients
35. Management of Stage IIIB NSCLC Recommendations: -Concomitant ChT-RT as first choice -Concomitant daily low-dose Cisplatin + RT 60Gy elderly patients (Schake-Koning, 1992) -Sequential ChT-RT: Cisplatin + 60Gy (Dillman, 1990) for large tumors -RT only (30 x 2Gy – 13-15 x 3Gy) poor performance status, palliation -Surgery only within study protocol or selected patients (e.g. T4 N0-1 after induction therapy)
36. Summary: Management of Stage IIIB NSCLC -Heterogeneous group, therapy to be discussed at tumor board -Radical multimodality treatment vs. good palliation -Combined Radio-Chemotherapy is standard treatment -Concomitant better than sequential (survival benefit) but more toxicities -Sequential Chemo- Radiotherapy or RT alone for unfit patients -Induction Chemotherapy for extensive tumor-volume which can not be encompassed in reasonable RT portals -Role of Surgery uncertain, only selected patients -Optimal regime not clear, therapy within clinical trials as possible: Induction-therapy – OP Accelerated RT schemes New drugs + concomitant RT … ..
37. Management of RT Toxicity - Pneumonitis Pneumonitis: 4-6 wks. after RT (Fibrosis after 12-24 mts.) Symptoms: fever, cough, illness Risk factors: -Lung function (FEV 1 ) -Treated volume: V 20 =25% (8% pneumonitis) V 20 =37% (39% pneumonitis) V 10 , V 5 , …. V 30-40 (fibrosis) -D mean : <10Gy - very small risk 20Gy - 15% risk 30Gy - 50% risk Treatment: Antibiotics (e.g. Roxithromycin) for 10d Steroids (e.g. Prednisone) beginning with high dose for 6wks. (reducing doses)
38. Management of RT Toxicity - Pneumonitis Radiation portal (left) with subsequent radiation pneumonitis Sequential transverse images through lung showing radiation pneumonitis in right lung Radiographic finding: diffuse interstitial infiltrate
39. Management of RT Toxicity - Fibrosis Rosen, I. I. et al. Radiology 2001;221:614-622
40. RT-Planning – Definition of Target Volumes ICRU 50 + 62 Gross Tumour Volume Clinical Target Volume Planning Target Volume = critical step = weakest link in radiotherapy chain
41. RT-Planning – Defining the GTV CT: standard imaging modality Complementary information by MRI and PET scanning Limiting factors of CT imaging for lung cancer: -planning-CT without intravenous contrast so as not to disturb the electron density information interpretation always in conjunction with diagnostic CT -not routinely possible to distinguish T3 – T4 (MRI some advantages) -MRI used for imaging apical primary tumours (Pancoast) -Sensitivity / specificity only 60 / 77% for LN knowledge of normal anatomy (LN levels, hilar anatomy) ! knowledge of patterns of lymphatic drainage
42. RT-Planning – Defining the GTV Knowledge of anatomy LN levels (American College of Surgeons)
43. RT-Planning Defining the GTV Knowledge of anatomy LN levels - Cross Sectional Anatomy Murray JG, Eur J Radiol, 1993,17:61-68.
46. RT-Planning – Defining the GTV Knowledge of lymphatic drainage according to localisation of PT (Hata 1990)
47. RT-Planning – Defining the GTV Integrating PET Value of PET for PT: Atelectasis – reduction of irradiated volume Value of PET for LN staging: Sensitivity 79% Specificity 91% Negative predictive value 95% Positive predictive value 80% (hot spots still require verification) Value of PET for Metastases: metastases detected in10-15% of surgical candidates
48. RT-Planning – Defining the GTV Impact of PET on RT planning PTV increased in 64% (detected nodes) decreased in 36% (exclusion of atelectasis) (Erdi 2002) Average reduction of PTV by 29% Average reduction of V 20 by 27% (Vanuytsel 2000) Interobserver variability reduced: mean ratio of GTV without PET: 2.31 mean ratio of GTV with PET: 1.56 (Caldwell 2001)
53. RT-Planning – Defining the GTV Limiting factors of PET -Resolution 4-8mm (depending on scanner and institution) -Registration errors (esp. with software based fusion) -Threshold value (SUV) individually to be determined Summary: PET is a promising complementary tool in RT planning of NSCLC. Its value for staging has been established and preliminary reports suggest that it may lead to more consistent definition of GTV in RT planning. However, it is still not clear, whether this will translate into better survival.
54. RT-Planning – Defining the CTV 1. Margin around primary tumour (microscopic spread) Histopathologic quantification of subclinical cancer around the grossly visible primary (Giraud 2000): This data could also be used for IMRT planning: -define constraint for GTV (dose escalation to primary) -define constraint for subclinical disease (less dose) -increase therapeutic index
55. RT-Planning – Defining the CTV 2. Subclinical lymph nodes (ENI) -high risk of nodal spread in lung cancer -but value of ENI is not proven Reasons against ENI: -less than 20% locally controlled 1y after RT with conventional dose (Arriagada 1991) -need for more intense treatment to gross tumour -large volumes prevent dose escalation (normal tissue tolerance) -small primary tumor and small total tumor volume predictive (Basaki 2006, RTOG 93-11 2008) -modern chemotherapy regimens may lead to better control of microscopic disease
57. RT-Planning – Defining the CTV 2. Subclinical lymph nodes (ENI) From large .... “ Old“ Standard … (Perez 1997)
58. RT-Planning – Defining the CTV 2. Subclinical lymph nodes (ENI) .... to small ! …“ New“ Trend (IMRT 2007)
59. RT-Planning – Defining the PTV ICRU recommendations CTV ... + Internal Margin (Internal Target Volume) variations in position, size and shape of CTV (internal reference system attached to the patient) + Set-up Margin variations in relation patient - beam (external reference system attached to machine)
60. RT-Planning – Defining the PTV Reducing set-up uncertainty: -Tattoos (instead of skin markers) -Custom immobilisation devices
61. RT-Planning – Defining the PTV Reducing set-up uncertainty: -Daily EPID: -matching DRR - EPI -distinguish between systematic (needs correction) and random error (no correction needed)
63. RT-Planning – Defining the PTV Reducing respiration induced errors: Size of movement dependent on: - tumour location in the lung - fixation to adjacent structures - lung capacity and oxygenation - patient fixation and anxiety Average movement in normal breathing: - Upper lobe 0 - 0.5 cm - Lower lobe 1.5 - 4.0 cm - Middle lobe 0.5 - 2.5 cm - Hilum 1.0 - 1.5 cm Steppenwoolde 2004
64. RT-Planning – Defining the PTV Reducing respiration induced errors: Gated CT normally reduces the margin PTV - CTV (compared to using published data):
65. RT-Planning – Defining the PTV Drawing PTV in gated planning CT: -Define GTV/CTV for inspiration and expiration phase -Give a margin of 0.5 - 1cm in all directions (setup uncertainty) Closing Words: DON’T use dose escalation and highly conformal techniques such as IMRT for lung cancer until tumour motion can be taken into account ! In the meantime ... -Outline GTV as best as possible -Construct CTV based on the literature -Construct PTV based on measured tumour motion and known setup uncertainty.