This document discusses indications, evidence, and radiation therapy techniques for oral cavity and oropharyngeal cancers. It covers:
- Anatomy of the oral cavity and oropharynx.
- Staging principles and indications for surgery vs systemic therapy.
- Principles of surgery including adequate resection margins and neck management.
- Use of adjuvant radiation therapy or chemoradiation to improve local control, especially for high-risk features like positive margins or extracapsular extension.
- Radiation techniques for oral cavity cancers including field design, dose recommendations, and advantages of IMRT for sparing parotid glands.
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.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
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AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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
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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
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.
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
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Radiotherapy techniques, indications and evidences in oral cavity and oropharynx
1. INDICATIONS , EVIDENCES & R.T. TECHNIQUES IN
ORAL CAVITY & OROPHARYNX
Dr. Amrita Rakesh
D.N.B. resident
BHAGWAN MAHAVEER CANCER HOSPITAL AND RESEARCH CENTRE,
JAIPUR
2. ANATOMY OF ORAL CAVITY
• Oral cavity consists of the lips, oral tongue, floor of the mouth,
retromolar trigone, alveolar ridge, buccal mucosa, and hard palate.
3.
4. ANATOMY OF OROPHARYNX
• Boundaries:
• Anteriorly: Oral cavity
• Post.inferiorly: larynx & hypopharynx
• Superiorly: Nasopharynx
• Oropharynx consists of :
- Base of the tongue (lingual tonsil)
- Tonsillar region (anterior & posterior
tonsillar pillar, palatine tonsil),
- Soft palate
- Lateral & posterior oropharyngeal walls
8. PRINCIPLES OF SURGERY
• En block resection should be attempted wherever feasible
• In continuity neck dissection is necessary when there is direct
extension of the primary tumor into the neck.
• Perineural invasion should be suspected when tumors are adjacent
to motor or sensory nerves.
• Partial or segmental mandibular resection for adequate tumor free
margins.
9. • Adequate resection is defined as clear resection margins with at least
enough clearance from the gross tumor to obtain clear frozen section
and permanent margins (often 1.5 to 2.0 cm of visible and palpable
normal mucosa).
• For glottis cancers – 1 to 2 mm margin is considered adequate.
• Clear margin – distance from the invasive tumor front 5mm
• Close margin – <5mm
• Positive margin – ca in situ or invasive ca at the margin of resection.
10. NECK MANAGEMENT
• N0 - selective neck dissection
* oral cavity at least levels I-III
* oropharynx at least levels II-IV
* hypopharynx levels II-IV & VI when appropriate
• N1 – N2a-c – selective or comprehensive neck dissection
• N3 – comprehensive neck dissection
11. INDICATIONS FOR SYSTEMIC THERAPY
• Unresectable disease or residual disease
• DOI - >/= 4 mm
• LVI +
• PNI +
• T 3 / 4
• Node > 3cm
13. • NCCN recommend only single modality treatment for T1 / T2 lesions ;
primary surgical approach preferred.
• Advanced lesions – adjuvant radiation or chemoradiation
• Adjuvant RT can be delivered pre or post operatively.
14. ADJUVANT RADIATION
• Enhancing the likelihood of locoregional tumor control.
• Robertson et al. – phase III study .
• N = 350 pt.
• T 2 – 4 , N 0 – 2 oral cavity or oropharyngeal cancers.
• Comparing surgery and post op radiation versus radiation alone.
• Study closed early due to difference in survival but better results were
seen in surgery + post op RT ARM.
15. A phase III study at M.D. Anderson Cancer Centre – established relative
prognostic significance of cluster of two or more clinicopathological
features :
1. Close or positive margins
2. Nerve involvement
3. Two or more positive lymph nodes
4. Largest node > 3 cm
5. Treatment delay > 6 weeks
6. Zubord performance status >/= 2.
7. ECE – independent predictive factor of LRR.
Escalation of dose beyond 63 Gy to sites of increased risk does not
improve LRC.
16. Ang et al. – multi-institutional prospective study
• Total treatment time from completion of surgery to the completion of
radiation may affect the likelihood of ultimate disease control.
• Impact of overall treatment time on 5 year LRC.
OVERALL TREATMENT TIME LRC
< 11 WEEKS 76 %
11-13 WEEKS 62 %
> 13 WEEKS 38 %
17. ADJUVANT CHEMORADIOTHERAPY FOR
OROPHARYNGEAL CANCER
• Cisplatin based chemotherapy + PORT versus PORT alone in medically
fit H & N cancer patients of any site – several randomized studies.
• Statistically significant trend to better LRC with chemo + PORT.
18. • The landmark studies of the Radiation Therapy Oncology Group
(RTOG) 9501 and the European Organisation for Research and
Treatment of Cancer (EORTC) 22931, followed by the comparative
analysis of Bernier and colleagues, demonstrated that all patients
with resected head and neck cancer receiving standard fractionated
postoperative radiation who are found to have positive margins or
extranodal extension should be assigned to a combined
chemoradiation approach using concurrent cisplatin (100 mg/m2 on
days 1, 22, and 43).
19. • More recently, the German Cancer Society 95-06 trialdemonstrated
that even with hyperfractionated accelerated treatment regimens,
patients that received concurrent 5-FU and mitomycin experienced an
improvement in locoregional control and overall survival
• A study by Garden and colleagues examined patients with stage III and
IV disease who received a concomitant boost treatment regimen and
cisplatin on days 1 and 22, and found that 4-year locoregional
progression-free survival was 74% and that 4-year overall survival was
54%—results which are quite promising.
20. RTOG 0234
• High risk post operative patients
• Cetuximab – 400 mg/m2 loading followed by
250 mg/m2 weekly
• Docetaxel – 15 mg/m2
• Cisplatin – 30 mg/m2
• Results were found better with cisplatin
PORT +CETUXIMAB +
WEEKLY DOCETAXEL
PORT + CETUXIMAB +
WEEKLY CISPLATIN
High risk features :
Positive margin
ENE
>/= 2 pathologically involved lymph nodes
21. ADJUVANT RADIOTHERAPY DOSE
• 60 to 66 Gy in 2 Gy daily fractions to high risk areas.
• 50 to 54 Gy in 2 Gy per fraction to areas at risk of microscopic
involvement.
POSTOPERATIVE RADIOTHERAPY TREATMENT VOLUME
• Primary tumor site + bilateral neck
22. DEFINITIVE RADIOTHERAPY
• Early stage oropharyngeal cancers – radiotherapy as single modality
associated with good outcome and better functional preservation.
HYPERFRACTIONATED RADIOTHERAPY
EORTC 22791
• T2-3
• N0-1
• Non-base of tongue oropharyngeal cancers
23. Randomized to
associated with statistically significant improvement in LRC (5 YR –
59% vs 40 % ).
CONVENTIONALLY
FRACTIONATED – 70 Gy @ 2
Gy per day
HYPERFRACTIONATED - 80.5 Gy
@ 1.15 Gy twice daily
24. RTOG 90-03
• 4 arms
Conventional fractionation – 70
Gy @ 2Gy daily fractions
Hyperfractionation – 81.6 Gy @
1.2 Gy twice daily fractions
Acclerated fraction with split
course – 67.2 Gy @ 1.6 Gy twice
daily with 2 week rest after 38.4
Gy
Accelerated fraction with
concomitant boost – 72 Gy @ 1.8
Gy fractions for 14 fractions
followed by 1.8 Gy morning and
1.5 Gy afternoon boost to gross
disease.
IMPROVED LRC
AND DFS
25. SIMULTANEOUS INTEGRATED BOOST
RADIOTHERAPY
RTOG 00-22
• T 1-2
• N 0-2
• Oropharyngeal cancer patients
• Treated with bilateral neck radiotherapy
• Doses –
• 2 yr OS & DFS – 95% and 82 % respectively
Gross tumor - 2.2 Gy Intermediate risk – 2 Gy Low risk PTVs – 1.8 Gy
26. NEOADJUVANT THERAPY
Licitra et al. – phase III study
• N = 195
• T 2 – 4 ( >3cm)
• N 0 – 2
• Sq CC of oral cavity
• Surgery alone versus three cycles of CDDP & 5 – FU.
• No difference in overall survival
• Possibility of neoadjuvant chemo for improving resectibility and
reducing need of adjuvant RT
27. Mohr et al.
• N = 268 pt
• T 2-4 / N 0-3
• Oral cavity and oropharyngeal carcinoma
• Preoperative chemoradiation with cisplatin or surgery alone
• Results – improvement in OS & LC with the use of preoperative
therapy.
28. RADIATION TECHNIQUES-
ORAL CAVITY
• Carcinoma of oral cavity traditionally treated with lateral opposed
fields, using either 2-D or 3-D (CT-based) techniques.
• Immobilisation with thermoplastic mask.
• Supine position
• Bite block – for tongue and floor of mouth cases, to depress the
tongue away from the hard palate.
• Short neck – shoulders are depressed by having the pt pull on a
tensioning device looped beneath the feet.
29. FIELD DESIGN
• Upper border- 1.5 to 2.0 cm from the tumor bed and regional lymphatics.
• Inferior border – thyroid notch,just above the true vocal cords.
• Posterior border – midvertebral body,if level V coverage not required.
For coverage of level V – behind C1 vertebral body.
• Lower neck – single half beam blocked AP field is matched to the inferior
border of the opposed lateral fields at the level of thyroid notch.
• Anterior larynx block is used.
30.
31.
32. • Megavoltage beams with energy 4 to 6 MV most suitable
• Cobalt-60 comparable to 4 MV beam.
• Bolus required for higher energy beams or large nodal volume disease or
extracapsular extension.
• Tissue compensators with lateral opposed fields if variation of separation > 3
cm.
• All fields should be treated daily with at least 5 treatments per week.
33.
34. IDEAL CANDIDATE FOR IMRT-
• T1-4 primary lesion with less than or equal to N2b neck disease.
• IMRT not required in T1-2/N0 patients as bulk of parotid can be
excluded from opposed lateral portals.
• Patients with ipsilateral positive neck nodes, IMRT allows dose
limitation to the contralateral parotid gland without compromising
treatment results.
• In patients with bilateral neck disease(N2c), difficult to spare parotids
if level II is also involved.
35. BROAD PRINCIPLES OF PLANNING
• Most of the cases are treated post-operatively.
• CTV1 – high risk clinical target volume should include primary tumor
bed (based on preoperative imaging) + regions of grossly involved
adenopathy.
• CTV2 – intermediate risk clinical target volume should include the
pathologically positive hemineck
• CTV3 – low risk clinical target volume includes the prophylactically
treated neck- uninvolved low or contralateral neck.
36.
37. • Neck dissection disrupts the anatomic landmarks, so entire surgical bed
should be encompassed within CTV1.
• For cases of lateralized disease , it is recommended that contralateral neck
be included when ipsilateral neck involvement is greater than N1.
• IMRT results in more conformal dose distributions but also more sensitive to
intertreatment setup variations than conventional radiotherapy.
• With the use of cone-beam CT , PTV expansions on the CTV may be limited to
2 to 5 mm.
38. DOSE RECOMMENDATIONS:
• High risk PTV (PTV1) – 60 to 66 Gy @ 2Gy/#.
If microscopically positive margin or extracapsular spread is present- 64 to
66 Gy @ 2Gy/#.
• Intermediate risk regions (without ECE or microscopically positive margins)
may receive 60 Gy.
• PTV 2 & PTV 3 should receive 60 Gy & 50 to 54 Gy , respectively.
• Most common dose fractionation – 1.8 to 2.0 Gy per fraction.
39. • For close or positive microscopic margins or extracapsular nodal extension, a
4- to 6-Gy localized boost should be considered.
• For gross residual disease – focal boosting upto 70 Gy is adviced.
• Regions of lesser risk (clinically or pathologically uninvolved neck) – 50 to 54
Gy.
40.
41. BRACHYTHERAPY
• Used to boost the ptimary site in the oral cavity before or followed by
EBRT or as a sole modality small early stage lesions.
• For tumors < 1cm size – single-plane implants are adequate. Also
surface mold radiation can also be considered.
• For tumors > 2.5 cm – it is difficult to avoid cold spots in the implant
volume,so it recommended that a part of treatment should be given
with EBRT.
50 Gy over 5 weeks with EBRT followed by 30 Gy with brachytherapy
implant.
42. • Decroix and Ghossein – reported outcomes in 602 patients with cancer of
oral tongue, treated with radium implantation or implantation + EBRT.
Recurrence at the primary site or the primary site and the neck was 14% and
22% for T1 & T2 lesions respectively.
• The Royal Marsden Hospital reported local control rates of 90% at 5 years for
T1 & T2 tumors treated with interstitial radiation with or without EBRT.
• Pernot et al. reported local control rates of 96% for T1 , 85% for T2 and 64%
for T3 lesions of the oral cavity treated with brachytherapy and neck
dissection. The locoregional control rates were 83% , 70% and 44%
respectively.
43.
44.
45. INTRAORAL CONE
• Another delivery tool to enable boosting of radiation dose to sites
within the oral cavity while avoiding direct dose to mandible.
• Generally best suited for anterior oral cavity lesions in edentulous
patients.
• Palatal arch sites can also be targeted with the intraoral cone.
• 100- to 250-kilovolt (peak) kvp x-rays or electron beams in the 6- to
12- MeV range.
46. • Lesions upto 3 cm are amenable to treatment.
• Requires careful daily positioning and verification by physician.
• Device is equipped with periscope to visualize the lesion.
• The cone abuts the mucosa and is centered directly over the lesion.
• Intraoral cone treatment should take place prior to EBRT so that the lesion is
adequately visible.
• Major advantage – highly focal to tumor bed but noninvasive.
49. LIP
• Early lesions may be cured equally well with
surgery or RT.
• Surgical treatment for early lesions (0.5-1 . 5
em) uses a V- or W-shaped excision.
• Lip cancer may be successfully treated by EBRT,
interstitial brachytherapy, or a combination of
both.
• EBRT techniques use orthovoltage ( 5 5 . 8 Gy at
1 . 8 Gy per fraction) or electrons ( 60-66 Gy at 2
Gy per fraction) with lead shields behind the lip
to limit exit EBRT.
• For early-stage lesions, orthovoltage photons
(100 to 200 keV) or electrons may be used. The
electron energy should be chosen based on the
thickness of the lesion (commonly 6 to 9 MeV).
• “Moustache field” for elective irradiation of the
perifacial lymphatics (approximately 50 Gy) for
more advanced upper lip lesions
51. FLOOR OF MOUTH AND ORAL TONGUE
• Surgical resection is generally preferred
Depending:
on the size
depth of invasion
grade of the primary tumor
nodal status
• Postoperative radiotherapy is recommended in
the following situations
large primary tumor (e.g., T3 or T4)
close or positive surgical margins
presence of perineural spread
vascular invasion
presence of multiple positive nodes
• Primary radiotherapy is generally reserved for
patients who refuse surgery or those who are
borderline operable.
52. • Intraoral stent is used to exclude the following
organs from the radiation
a large area of the buccal mucosa,
lower lip
oral commissure
• Parallel opposed-lateral photon fields are used
to treat the primary tumor bed and upper neck
nodes.
• Field borders are,
Anterior border: just in front of the mandible
for anterior tumors or 2 cm in front of the scar
for posterior oral cavity lesions.
Superior border: 1 to 1.5 cm superior to the
dorsum of the tongue or the scar if part of the
oral tongue can be spared.
Posterior border: usually is dictated by the
surgical scar. The level II nodes are usually
irradiated,so the posterior border is behind the
spinous processes
Inferior border: just superior to the arytenoids.
• An anterior appositional field is used to treat
the mid- and lower neck nodes
• To deliver the boost dose to the primary tumor
and upper neck nodes, the size of lateral fields is
reduced to encompass the known disease
locations. To boost the upper neck without the
primary site, a lateral appositional electron field
is used. To deliver the boost to the mid- or
lower neck, a lateral appositional electron field
or glancing photon fields are used.
53. RETROMOLAR TRIGONE AND ANTERIOR FAUCIAL PILLAR
• Primary radiotherapy is for relatively early
tumors (T1-T2 and selected cases of T3)
• Larger tumors are treated with either
combination of radiation and chemotherapy or
surgery and postoperative radiotherapy
Target Volume
• A well-lateralized tumor without
lymphadenopathy: primary lesion (at least 2-cm
margins) and ipsilateral level IB (submandibular)
and level II (subdigastric) nodes.
• A well-lateralized tumor with a single small
ipsilateral node (N1): primary lesion and the
entire ipsilateral neck (including supraclavicular
nodes).
• Other cases (larger tumors and/or more
advanced N-stage): primary lesion and bilateral
neck.
• Anterior border: at least 2 cm anterior to the
tumor.
• Superior border: includes the pterygoid plates
when the tonsillar fossa is involved (this border
is at least 1 to 1.5 cm rostral to the hard palate).
• Posterior border: just behind the mastoid
process (N0) or behind the spinous processes
(N+).
• Inferior border: just above the arytenoids
54.
55. BUCCAL MUCOSA
• The buccal mucosa includes the mucosal surfaces of the cheek and
lips from the line of contact of the opposing lips to the
pterygomandibular raphe posteriorly.
• This extends to the line of attachment of the mucosa of the upper
and lower alveolar ridge superiorly and inferiorly.
56. • T1 to T2 lesions: surgery or primary radiotherapy
• T3 to T4 lesions, surgery followed by postoperative radiotherapy is generally
recommended.
Target Volume
• T1 -T2 N0: primary tumor and ipsilateral level IB (submandibular) and level II
(subdigastric) nodes.
• T1 -T2 N1: primary tumor and entire ipsilateral neck.
• N2 to N3: bilateral irradiation.
• Boost volume encompasses the primary tumor and, when present, involves lymph
nodes.
57. • Anterior and superior borders: at least 2-cm
margins from the visible-palpable tumor
borders.
• Posterior border: just behind the mastoid
process (N0) or behind the spinous processes
(N+).
• Inferior border: just above the arytenoids
58. • Target Volume
• the entire surgical bed, including primary site and ipsilateral
submandibular and subdigastric nodes, and the ipsilateral mid- and
lower neck
• boost volume encompasses areas of known disease locations.
• The anterior and superior field borders are determined by the spread
pattern of the primary tumor and by the extent of surgery
• The initial target volume receives 50 Gy in 25 fractions.
• For external beam technique, 16 Gy in eight fractions for T1 and 20 Gy
in ten fractions for T2 lesions are administered.
• For brachytherapy, 25 to 30 Gy is administered.
59. • IMRT in the postoperative setting, treatment is given in 30 fractions.
• Generally, the tumor bed target volume receives 60 Gy, the operative
bed 57 Gy, and undissected regions 54 Gy.
60. HARD PALATE AND UPPER ALVEOLAR RIDGE
• Primary radiotherapy is indicated for small, superficial squamous cell
carcinomas (SCC).
Target Volume
• The entire surgical bed
• the location of the primary lesion, the extent of surgery
• treatment with opposed-lateral fields
• Ipsilateral irradiation is used in well-lateralized lesions of the alveolar
ridge.
61. • Anterior and superior borders: at least 2 cm beyond the surgical bed.
If disease extended into the maxillary sinus, the entire sinus is
included up to the floor of the orbit.
• Posterior border: at midvertebral bodies for non-SCC and N0; behind
the mastoid process for SCC and N0; behind the spinous processes for
N+ (or more posteriorly to cover large surgical bed).
62. • Inferior border: just above the arytenoids for squamous cell
carcinoma with no nodal involvement, or 2 cm below the surgical
margin for low-grade minor salivary gland tumors.
• presence of positive nodes, an anterior photon field is used for
irradiation of the mid- and low cervical nodes.
63.
64. • For boost volume:-
• fields are reduced to encompass the tumor volume with at least 1-cm
margins
• involved upper neck nodes are included in the lateral fields or in a
separate appositional electron field
• involved mid- and lower neck nodes are irradiated with an
appositional electron field
• For ipsilateral irradiation, the patient is immobilized in a supine
position. Anterior and ipsilateral wedge-pair photon fields are used to
treat the primary tumor bed .
65. • A lateral appositional electron field is used for elective treatment of
the submandibular and subdigastric nodes when ipsilateral treatment
is adopted for SCCs.
• Superior border: matches the inferior border of the photon fields (a
small triangle over the cheek may be spared).
• Anterior border: just short of fall-off.
• Posterior border: behind the mastoid process.
• Inferior border: at the thyroid notch.
67. RADIATION TECHNIQUES IN OROPHARYNX
• T1-2 N0-1 : Definitive RT.
Alternative, surgery with post-op RT as indicated
68. • PORT Indication:
• Large primary-T3 or T4
• Close (<5mm) or positive margins of excision
• Deep infiltrative tumor
• Lymphovascular invasion
• Perineural invasion
• Bulky nodal disease N2 /N3
• Extra capsular extension
• Multiple level involvement (level IV , V)
Post-op chemo-RT indications :
• Extracapsular nodal spread,
• Postive margin
69. • Simulate patient supine with head
hyperextended.
• The shoulders should be positioned as caudally
as possible to allow adequate exposure of the
neck.
• Tongue immobilization can be useful for
oropharyngeal cancer patients with oral
tongue involvement.
• Bite blocks are also useful because they often
elevate the hard palate with its minor salivary
glands.
• Mark involved LN with lead wire
70. Borders of the lateral fields :
Superior border: (1.5 to 2 cm above the superior extent)
• This should cover the retropharyngeal and jugulodigastric lymph nodes and
approach the jugular fossa in patients with advanced nodal disease.
• The ipsilateral medial pterygoid insertion for early-stage tumors and the pterygoid
plates for more advanced stage tumors .
Anterior border:
• The most anterior extent of the primary site with margin ,may be extended more
anteriorly if level IB lymph node coverage is warranted.
• Tonsillar carcinoma fields have traditionally covered the ipsilateral retromolar
trigone.
• Anterior coverage of BOT tumors ext. 2 cm considering infiltrative nature of
primary tumor.
71. Posterior border:
• Approx. 2 cm behind the mastoid process and just posterior to the
cervical vertebral spinous processes, with additional posterior
extension if warranted by level V nodal metastases.
• Adequate dosimetric margins must be ensured with posterior
pharyngeal wall tumors,
• Offcord boost (Phase II) is typically placed at the posterior third of
the vertebral body.
• The posterior margin may be moved 1 to 2 cm anteriorly for early-
stage, node-negative tonsillar and soft palate tumors.
72. Inferior border:
• Extends to the thyroid notch.
• This is placed just cranial to the arytenoids to limit post-treatment
supraglottic edema.
• However, this border may be lowered to account for extension of the
primary tumor into the larynx or hypopharynx.
73.
74. AP supraclavicular field :
• Extends from the inferior lateral photon border to the bottom of the
sternoclavicular joints and covers the middle and lower neck nodes.
• Laterally, the supraclavicular field extends to the mid-clavicle and
typically measures 18 to 20 cm in width, again tailored to known
nodal disease.
• Beam-split above larynx at
thyroid notch, if possible,
to allow laryngeal sparing
75. • Broad opposed lateral fields covering the primary tumor bed and upper neck
extending to the thyroid notch are initially treated to 42 to 44 Gy in 2-Gy fractions.
(4 - 6-MV photons)
• The isocenter is typically placed at approximately the C1 to C2 level just anterior
to the intervertebral space.
• An off-cord boost (Phase II) is then created by shifting the posterior field border
anteriorly to split the vertebral bodies vertically.
• The final field reduction boost carries the tumor GTV plus a margin to 66 to 70 Gy.
(Phase III)
76. • POSTERIOR ELECTRON BOOST
• Electron fields (commonly, 6 to 9 MeV; occasionally, 12 MeV for bulky nodal
disease) are matched on the skin to abut the posterior aspect of the off-cord
photon field and thereby treat the posterior neck to 50 to 54 Gy, with higher
doses if positive posterior nodes are present
• Involved nodes at the match line warrant 2 to 3 mm of photon-electron field
overlap to limit underdosing at depth.
• The posterior electron field border can be extended by 5 mm to help compensate
for electron dose constriction at depth.
77. • Ipsilateral Radiation for Tonsillar Cancer :
• Conventional irradiation to the ipsilateral neck for
early stage tonsillar cancers typically consists of a two-
field, wedge-pair beam arrangement (anterior &
posterior obliques) covering the primary tumour and
ipsilateral level II lymph nodes.
• The level III and IV LN ipsilaterally are covered by
an anterior supraclavicular field directed to the
hemineck
78.
79. • Upper Nodal Border :
• Some cases of marginal failure in the
retrostyloid space have been reported after
IMRT. (Eisbruch et al )
• In case of involvement of upper level II (IIa or
IIb) with one or more lymph nodes, it is
recommended to extend the upper border of
level II to include the retrostyloid space up to
the base of skull.
80. • Lower Nodal Border :
• Similarly, in case of involvement of level IV or Vb with one or more lymph nodes, it is
recommended to extend the lower border to include the SC fossa in the CTV.
81. • Post-op CTV :
• Entire operative bed should be covered, especially in ECE.
• If level II (IIa or IIb) pN+, include retrostyloid space up to base of skull.
• If level V pN+, include the SCF.
• When a pathological lymph node abuts or invades a muscle – include the muscle
at least in the entire invaded level.
• In selected LN dissection with one or few (pN1) marginal nodes affected – include
adjacent level.
• In pharyngeal tumors with pN+, include lateral retropharyngeal nodes.
82. SIMULATANEOUS INTEGRATED BOOST RT (IMRT)
• The RTOG completed a study (00-22) in early-stage (T1-2, N0-2) oropharyngeal
cancer patients treated with bilateral neck radiotherapy using doses of 2.2 Gy, 2
Gy, and 1.8 Gy to gross tumor, intermediate-risk, and low-risk planning target
volumes (PTVs), respectively.
• Two-year overall survival was 95%, and disease-free survival was 82%.
83. • Lymph node coverage:
N0 include levels II–IV and retropharyngeal node(RPN)
N1 include levels IB–IV and RPN
N2-3 include IB–V and lateral RPN
84. FRACTIONATION
Standard Fractionation 70 Gy in 35 fractions of 2 Gy per day, 5 days
/week
Accelerated fractionation 66 -70 Gy , 2 Gy /fraction , 6 days /week
Hyperfraction 81.6 Gy in 68 fractions,
1.2 Gy twice daily (interval of 6 hrs)
Accelerated split-course
fractionation
67.2 Gy in 42 fractions, 1.6 Gy twice daily with
a 2-week rest after 38.4 Gy
Accelerated fractionation
with a concomitant boost
72 Gy in 42 fractions over 6 weeks; 54 Gy in 30
fractions of 1.8 Gy to initial fields plus 18 Gy in
1.5-Gy fractions
to a cone-down boost field as a second daily
dose during the final 12 treatments
85. •Improved LRC were seen with both the hyperfractionation and accelerated
fractionation with concomitant boost in this large, randomized study of 1113
patients, of whom 60% had oropharyngeal primary tumors.
•These schedules also trended toward improved DFS, although DFS and OS
were not significantly different.
•Significantly greater acute side effects were present with all three altered
fractionation groups
86. BRACHYTHERAPY -- Guidelines
• Care should be taken to delineate the pretreatment tumor extent because regression is
not always uniform
• The CTV used is recommended by ESTRO to be 5 mm at minimum and more commonly 1
to 1.5 cm for base of tongue tumors.
• The PTV is usually equal to the CTV as the implanted catheters move with the tumor.
• Catheters are typically positioned parallel and equidistant at 1 to 1.5 cm apart.
87.
88. BRACHYTHERAPY -- DOSE
GEC-ESTRO - guidelines for HDR Brachytherapy
• 45 to 50 Gy external-beam radiotherapy followed by
- 25 to 30 Gy boost for tonsillar tumors,
- 30 to 35 Gy boost to BOT tumors.
• Total brachytherapy boost dose is fraction-size dependent :
- 21 to 30 Gy in 3-Gy fractions & 16 to 24 Gy in 4-Gy fractions.