This document discusses rectal cancer staging using MRI and the DISTANCE mnemonic for reporting findings. It provides an overview of MRI sequences for rectal cancer staging and describes the key elements to include in MRI reports. Examples of primary rectal cancer staging cases are presented along with conclusions. Post-chemoradiation therapy staging is also discussed, including tumor response grading. Several post-CRT cases demonstrate this assessment and show how MRI can predict treatment response.
1. Locally advanced rectal cancers are defined as T4 or node-positive lesions that cannot be completely resected without a high risk of residual disease. Management involves pre-operative chemotherapy with or without radiation therapy followed by surgery and adjuvant chemotherapy.
2. For resectable stage II/III cancers, pre-operative chemoradiation or radiation followed by surgery and adjuvant chemotherapy improves local control and survival compared to surgery alone.
3. For unresectable T4 cancers, induction chemotherapy and long-course chemoradiation may enable resection. Adjuvant chemotherapy is recommended in all cases.
1) Adjuvant chemoradiation improves local control for locally advanced rectal cancer compared to surgery alone based on multiple trials from the 1980s and 1990s.
2) Recent European trials have found no clear benefit of adjuvant chemotherapy after neoadjuvant chemoradiation and surgery for rectal cancer, with the exception of the QUASAR trial.
3) Adjuvant chemotherapy may be recommended after preoperative chemoradiation for mid-low rectal cancers with lymph node involvement (ypT3N+) or high rectal cancers with stage ypT2-3 based on trial results and expert guidelines.
Rectal carcinoma is primarily treated with surgery involving a total mesorectal excision to achieve negative margins. Neoadjuvant chemoradiation is used to reduce local recurrence risk for transmural or node-positive cancers. Response to neoadjuvant therapy determines prognosis and need for adjuvant treatment, with better response associated with improved outcomes. Adjuvant chemotherapy may improve disease-free survival for stage II-III cancers receiving neoadjuvant chemoradiation and surgery. Surgical options include low anterior resection or abdominoperineal resection. Metastatic disease has a poor prognosis and is evaluated for resectability and treatment with chemotherapy.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bi...Dr. Muhammad Bin Zulfiqar
Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bin Zulfiqar
here we will discuss the the resectability of the pancreatic tumors preoperatively using 16 slice MDCT
1) The document discusses management of carcinoma of the hypopharynx, including pre-treatment evaluation, staging, treatment options of surgery, radiotherapy, chemotherapy, and biological therapy.
2) Key tests for pre-treatment evaluation are described, including endoscopy, CT/MRI scans, PET scans, and blood tests. Staging follows the AJCC 7th edition system.
3) Treatment recommendations are based on stage, with options including single modality therapy for early stages, and multi-modality therapy including chemoradiotherapy or induction chemotherapy followed by radiotherapy for advanced stages.
Post mastectomy Radiotherapy with trailsAnban Bala
The document discusses indications and evidence for post-mastectomy radiation therapy (PMRT), noting that randomized trials have shown PMRT reduces recurrence and breast cancer mortality in patients with 1-3 positive lymph nodes. It also reviews recommendations for treating regional lymph nodes based on additional trials showing benefit from regional nodal irradiation (RNI). Indications for PMRT and extent of treatment fields are described based on lymph node status and other risk factors.
1. Locally advanced rectal cancers are defined as T4 or node-positive lesions that cannot be completely resected without a high risk of residual disease. Management involves pre-operative chemotherapy with or without radiation therapy followed by surgery and adjuvant chemotherapy.
2. For resectable stage II/III cancers, pre-operative chemoradiation or radiation followed by surgery and adjuvant chemotherapy improves local control and survival compared to surgery alone.
3. For unresectable T4 cancers, induction chemotherapy and long-course chemoradiation may enable resection. Adjuvant chemotherapy is recommended in all cases.
1) Adjuvant chemoradiation improves local control for locally advanced rectal cancer compared to surgery alone based on multiple trials from the 1980s and 1990s.
2) Recent European trials have found no clear benefit of adjuvant chemotherapy after neoadjuvant chemoradiation and surgery for rectal cancer, with the exception of the QUASAR trial.
3) Adjuvant chemotherapy may be recommended after preoperative chemoradiation for mid-low rectal cancers with lymph node involvement (ypT3N+) or high rectal cancers with stage ypT2-3 based on trial results and expert guidelines.
Rectal carcinoma is primarily treated with surgery involving a total mesorectal excision to achieve negative margins. Neoadjuvant chemoradiation is used to reduce local recurrence risk for transmural or node-positive cancers. Response to neoadjuvant therapy determines prognosis and need for adjuvant treatment, with better response associated with improved outcomes. Adjuvant chemotherapy may improve disease-free survival for stage II-III cancers receiving neoadjuvant chemoradiation and surgery. Surgical options include low anterior resection or abdominoperineal resection. Metastatic disease has a poor prognosis and is evaluated for resectability and treatment with chemotherapy.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bi...Dr. Muhammad Bin Zulfiqar
Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bin Zulfiqar
here we will discuss the the resectability of the pancreatic tumors preoperatively using 16 slice MDCT
1) The document discusses management of carcinoma of the hypopharynx, including pre-treatment evaluation, staging, treatment options of surgery, radiotherapy, chemotherapy, and biological therapy.
2) Key tests for pre-treatment evaluation are described, including endoscopy, CT/MRI scans, PET scans, and blood tests. Staging follows the AJCC 7th edition system.
3) Treatment recommendations are based on stage, with options including single modality therapy for early stages, and multi-modality therapy including chemoradiotherapy or induction chemotherapy followed by radiotherapy for advanced stages.
Post mastectomy Radiotherapy with trailsAnban Bala
The document discusses indications and evidence for post-mastectomy radiation therapy (PMRT), noting that randomized trials have shown PMRT reduces recurrence and breast cancer mortality in patients with 1-3 positive lymph nodes. It also reviews recommendations for treating regional lymph nodes based on additional trials showing benefit from regional nodal irradiation (RNI). Indications for PMRT and extent of treatment fields are described based on lymph node status and other risk factors.
This document summarizes a lecture on the multidisciplinary treatment of locally advanced rectal cancer. It defines locally advanced rectal cancer and discusses the goals of neoadjuvant treatment. It also addresses frequently asked questions about staging, the importance of lymph nodes, optimal radiation doses and chemotherapy regimens, the timing of surgery after chemoradiation, the type of surgery needed, and treatment of synchronous metastases.
Neoadjuvant therapy in colorectal carcinomaAnkita Singh
- Several studies have shown that neoadjuvant therapy decreases local recurrence rates in colorectal cancer when compared to surgery alone. One study showed a statistically significant decrease in local recurrence with the addition of chemotherapy to preoperative radiotherapy.
- Evidence indicates that long-course chemoradiotherapy, induction chemotherapy followed by long-course chemoradiotherapy, and short-course radiotherapy are the three accepted neoadjuvant approaches, with long-course chemoradiotherapy being the most commonly used currently. Short-course radiotherapy has also shown non-inferior oncologic outcomes compared to long-course chemoradiotherapy in some studies.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
approach for rectal carcinoma and managementrajendra meena
This document discusses the multidisciplinary approach to managing rectal carcinoma. It defines rectal carcinoma and provides details on incidence, risk factors, staging, diagnostic workup including various imaging modalities, and the roles of different specialists involved. It describes the prognostic factors and presents the tumor, node, metastasis (TNM) staging system. Surgical approaches like transanal local excision and total mesorectal excision are outlined. The roles of neoadjuvant therapy and advantages of pre-operative radiation are summarized. Clinical trials comparing outcomes of pre-operative versus post-operative chemoradiation are also reviewed.
This document discusses contact radiotherapy (Papillon) as an alternative to surgery for early stage rectal cancer. It notes that surgery is overtreatment for some early cancers and presents morbidity risks, especially in elderly patients. Contact radiotherapy delivers a high dose of localized radiation directly to the tumor and has shown good response rates with few side effects. It may allow some patients to avoid surgery and its risks. The document advocates for considering contact radiotherapy as a non-surgical option for select early stage rectal cancers based on a patient's risk factors and preferences.
This document discusses updates in radiation therapy for colorectal cancers. It covers clinical features and prognostic markers for different locations of colorectal cancer. It discusses the goals and need for a multidisciplinary approach in treating rectal cancers. It compares pre-operative vs postoperative chemoradiation and short course vs long course radiation. It also discusses omitting adjuvant chemotherapy for some patients and contouring guidelines for radiotherapy planning.
This document discusses radiation therapy for non-small cell lung cancer. It begins with an overview of staging for lung cancer using the TNM system. For stage I/II disease, surgery is generally recommended when possible, along with radiation therapy or chemotherapy to reduce the risk of recurrence. For stage III disease, concurrent chemoradiation is often recommended. Stereotactic body radiation therapy is discussed as a technique for delivering high ablative doses of radiation to small tumors in a few fractions. The document concludes with details on the author's experience using SBRT to treat early stage lung cancers and metastases at their institution.
Management of malignant spinal cord compressionShreya Singh
This document summarizes the management of malignant spinal cord compression. It defines MSCC as cancer growth in or near the spine that presses on the spinal cord. Symptoms include back pain, motor deficits, and sensory deficits. Treatment involves corticosteroids, surgery, and radiotherapy. Surgery plus radiotherapy provides better outcomes than radiotherapy alone for patients with good performance status and at least 3 months life expectancy. Standard radiotherapy is 30 Gy in 10 fractions. Shorter courses are used when survival is poor. Surgery may be indicated for instability, intractable pain, or radioresistant cancers.
The document discusses recommendations from the St Gallen EORTCTreatment Conference for primary rectal cancer.
Key points include:
- MRI is the preferred method for pre-therapeutic staging of rectal cancer to assess T and N categories.
- Risk stratification separates patients into low, intermediate, and high risk based on MRI and clinical findings.
- For intermediate risk T3N0 mid-rectal cancers, preoperative short-course radiotherapy or chemotherapy alone may be sufficient.
- Preoperative long-course chemoradiation is generally recommended for locally advanced or node-positive cancers to downstage the tumor.
- Adjuvant chemotherapy is not routinely recommended after preoperative chem
1) Pre-operative chemoradiotherapy remains the standard of care for stage 2-3 rectal cancer as it reduces local recurrence rates and allows for sphincter preservation.
2) For selected low-risk patients, de-intensified treatment with less surgery or radiation can be considered as local recurrence rates have reached low levels with current regimens.
3) High-risk patients still require trimodality treatment with chemotherapy, radiation, and surgery.
4) Biomarkers or functional imaging may help further select appropriate patients for de-intensified treatment. Distant metastases remain problematic and more effective systemic therapies are still needed.
This document discusses staging and treatment of locally advanced cervical cancer (LACC). It summarizes a study evaluating survival outcomes of LACC patients who underwent laparoscopic para-aortic lymph node staging after having no para-aortic uptake on PET-CT imaging. The study found that half of patients with false-negative PET-CT results had lymph node metastases under 5mm. Patients with small (<5mm) solitary para-aortic metastases who received extended chemoradiation had similar survival to those without metastases, but survival remained poor for those with larger metastases despite extended treatment.
This document discusses the management of colorectal liver metastases, which is an area of uncertainty or "grey zone" in treatment. It provides background on the burden of metastatic colorectal cancer and outlines an algorithm for evaluating whether a patient with liver metastases is fit for surgery. This includes assessing the patient's fitness, tumor staging, extrahepatic disease, future liver remnant volume, and tumor response to neoadjuvant chemotherapy. For fit patients, treatment may involve surgery with or without neoadjuvant therapy, followed by adjuvant chemotherapy. Other local therapies and surgical techniques like two-stage hepatectomy are also discussed.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
Croatia vs Italy Modric's Last Dance Croatia's UEFA Euro 2024 Journey and Ita...Eticketing.co
UEFA Euro 2024 fans worldwide can book Croatia vs Italy Tickets from our online platform www.eticketing.co. Fans can book Euro Cup Germany Tickets on our website at discounted prices.
Georgia vs Portugal Georgia UEFA Euro 2024 Squad Khvicha Kvaratskhelia Leads ...Eticketing.co
UEFA Euro 2024 fans worldwide can book Georgia vs Portugal Tickets from our online platform www.eticketing.co. Fans can book Euro Cup Germany Tickets on our website at discounted prices.
This document summarizes a lecture on the multidisciplinary treatment of locally advanced rectal cancer. It defines locally advanced rectal cancer and discusses the goals of neoadjuvant treatment. It also addresses frequently asked questions about staging, the importance of lymph nodes, optimal radiation doses and chemotherapy regimens, the timing of surgery after chemoradiation, the type of surgery needed, and treatment of synchronous metastases.
Neoadjuvant therapy in colorectal carcinomaAnkita Singh
- Several studies have shown that neoadjuvant therapy decreases local recurrence rates in colorectal cancer when compared to surgery alone. One study showed a statistically significant decrease in local recurrence with the addition of chemotherapy to preoperative radiotherapy.
- Evidence indicates that long-course chemoradiotherapy, induction chemotherapy followed by long-course chemoradiotherapy, and short-course radiotherapy are the three accepted neoadjuvant approaches, with long-course chemoradiotherapy being the most commonly used currently. Short-course radiotherapy has also shown non-inferior oncologic outcomes compared to long-course chemoradiotherapy in some studies.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
approach for rectal carcinoma and managementrajendra meena
This document discusses the multidisciplinary approach to managing rectal carcinoma. It defines rectal carcinoma and provides details on incidence, risk factors, staging, diagnostic workup including various imaging modalities, and the roles of different specialists involved. It describes the prognostic factors and presents the tumor, node, metastasis (TNM) staging system. Surgical approaches like transanal local excision and total mesorectal excision are outlined. The roles of neoadjuvant therapy and advantages of pre-operative radiation are summarized. Clinical trials comparing outcomes of pre-operative versus post-operative chemoradiation are also reviewed.
This document discusses contact radiotherapy (Papillon) as an alternative to surgery for early stage rectal cancer. It notes that surgery is overtreatment for some early cancers and presents morbidity risks, especially in elderly patients. Contact radiotherapy delivers a high dose of localized radiation directly to the tumor and has shown good response rates with few side effects. It may allow some patients to avoid surgery and its risks. The document advocates for considering contact radiotherapy as a non-surgical option for select early stage rectal cancers based on a patient's risk factors and preferences.
This document discusses updates in radiation therapy for colorectal cancers. It covers clinical features and prognostic markers for different locations of colorectal cancer. It discusses the goals and need for a multidisciplinary approach in treating rectal cancers. It compares pre-operative vs postoperative chemoradiation and short course vs long course radiation. It also discusses omitting adjuvant chemotherapy for some patients and contouring guidelines for radiotherapy planning.
This document discusses radiation therapy for non-small cell lung cancer. It begins with an overview of staging for lung cancer using the TNM system. For stage I/II disease, surgery is generally recommended when possible, along with radiation therapy or chemotherapy to reduce the risk of recurrence. For stage III disease, concurrent chemoradiation is often recommended. Stereotactic body radiation therapy is discussed as a technique for delivering high ablative doses of radiation to small tumors in a few fractions. The document concludes with details on the author's experience using SBRT to treat early stage lung cancers and metastases at their institution.
Management of malignant spinal cord compressionShreya Singh
This document summarizes the management of malignant spinal cord compression. It defines MSCC as cancer growth in or near the spine that presses on the spinal cord. Symptoms include back pain, motor deficits, and sensory deficits. Treatment involves corticosteroids, surgery, and radiotherapy. Surgery plus radiotherapy provides better outcomes than radiotherapy alone for patients with good performance status and at least 3 months life expectancy. Standard radiotherapy is 30 Gy in 10 fractions. Shorter courses are used when survival is poor. Surgery may be indicated for instability, intractable pain, or radioresistant cancers.
The document discusses recommendations from the St Gallen EORTCTreatment Conference for primary rectal cancer.
Key points include:
- MRI is the preferred method for pre-therapeutic staging of rectal cancer to assess T and N categories.
- Risk stratification separates patients into low, intermediate, and high risk based on MRI and clinical findings.
- For intermediate risk T3N0 mid-rectal cancers, preoperative short-course radiotherapy or chemotherapy alone may be sufficient.
- Preoperative long-course chemoradiation is generally recommended for locally advanced or node-positive cancers to downstage the tumor.
- Adjuvant chemotherapy is not routinely recommended after preoperative chem
1) Pre-operative chemoradiotherapy remains the standard of care for stage 2-3 rectal cancer as it reduces local recurrence rates and allows for sphincter preservation.
2) For selected low-risk patients, de-intensified treatment with less surgery or radiation can be considered as local recurrence rates have reached low levels with current regimens.
3) High-risk patients still require trimodality treatment with chemotherapy, radiation, and surgery.
4) Biomarkers or functional imaging may help further select appropriate patients for de-intensified treatment. Distant metastases remain problematic and more effective systemic therapies are still needed.
This document discusses staging and treatment of locally advanced cervical cancer (LACC). It summarizes a study evaluating survival outcomes of LACC patients who underwent laparoscopic para-aortic lymph node staging after having no para-aortic uptake on PET-CT imaging. The study found that half of patients with false-negative PET-CT results had lymph node metastases under 5mm. Patients with small (<5mm) solitary para-aortic metastases who received extended chemoradiation had similar survival to those without metastases, but survival remained poor for those with larger metastases despite extended treatment.
This document discusses the management of colorectal liver metastases, which is an area of uncertainty or "grey zone" in treatment. It provides background on the burden of metastatic colorectal cancer and outlines an algorithm for evaluating whether a patient with liver metastases is fit for surgery. This includes assessing the patient's fitness, tumor staging, extrahepatic disease, future liver remnant volume, and tumor response to neoadjuvant chemotherapy. For fit patients, treatment may involve surgery with or without neoadjuvant therapy, followed by adjuvant chemotherapy. Other local therapies and surgical techniques like two-stage hepatectomy are also discussed.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
Croatia vs Italy Modric's Last Dance Croatia's UEFA Euro 2024 Journey and Ita...Eticketing.co
UEFA Euro 2024 fans worldwide can book Croatia vs Italy Tickets from our online platform www.eticketing.co. Fans can book Euro Cup Germany Tickets on our website at discounted prices.
Georgia vs Portugal Georgia UEFA Euro 2024 Squad Khvicha Kvaratskhelia Leads ...Eticketing.co
UEFA Euro 2024 fans worldwide can book Georgia vs Portugal Tickets from our online platform www.eticketing.co. Fans can book Euro Cup Germany Tickets on our website at discounted prices.
Match By Match Detailed Schedule Of The ICC Men's T20 World Cup 2024.pdfmouthhunt5
20 Teams, One Trophy: What to Expect from the ICC Men's T20 World Cup 2024
The ICC Men's T20 World Cup 2024 is set to be an exciting event, co-hosted by the West Indies and the USA from June 1 to June 29, 2024. This edition of the tournament will feature a record 20 teams divided into four groups, competing across 55 matches for the prestigious title.
Belgium vs Romania Injuries and Patience in Belgium’s Euro Cup Germany Squad....Eticketing.co
Belgium coach Domenico Tedesco will wait for several key players to recover from injury. Even if it means they miss the opening Euro Cup Germany stages of the European Championship in Germany this month. Veteran defender Jan Vertonghen, midfielder Youri Tielemans and defender Arthur. Theate are being given time to play in the tournament because they are considered vital to Belgium’s cause, Tedesco said on Tuesday.
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"Of course, you prefer to take players who are fully fit, but that's okay. We want to wait and be patient for some players even if they cannot play in those first matches," he told a press conference. The 37-year-old Vertonghen, Belgium’s Euro Cup 2024 most-capped international with 154 appearances, is struggling to shake off a groin injury.
"He will be there normally. This also applies to Youri Tielemans and Arthur Theate. The latter's position is very sensitive. We don't have many choices at left back. "It will only change if it turns out that they will only be available when, say, the final of the Euro 2024 Championship comes around. That's too long to wait. "However, I am confident that the injured boys are on track for the Euros.
Belgium vs Romania: Radu Dragusin Prepares for Crucial Role in Euro Cup Germany
Some of them have taken not one but two steps forward in their rehabilitation," he said. None of the injured players will feature in this week’s warm-up friendlies against Montenegro and Luxembourg. Romania centre-back Radu Dragusin found chances limited at Tottenham Hotspur in the second half of the 2023-24 season.
But is crucial to his country's cause at UEFA Euro 2024 where his aerial ability, physicality and hard graft make him a standout player. The 22-year-old moved to North London from Italian side Genoa in January but was kept on the sidelines by the form of another new arrival for the season, Mickey van de Ven, something Romania coach Edward Iordanescu admitted was a concern.
It will mean limited game-time going into the finals, but Dragusin, who cites Netherlands defender Virgil van Dijk as a role model, started every Euro Cup Germany qualifier as Romania went through the campaign unbeaten in their 10 games. He will be among their most important players in their first game in Germany against Ukraine in Munich on June 17, taking the right centre-back role in what is likely to be a back four.
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Hesan Soufi's Legacy: Inspiring the Next GenerationHesan Soufi
Hesan Soufi's impact on the game extends far beyond his on-field exploits. With his humility, sportsmanship, and unwavering commitment to excellence, Soufi has become a role model for aspiring footballers worldwide. His legacy lies not only in his achievements but also in the inspiration he provides to the next generation of talented players.
Italy vs Albania Soul and sacrifice' are the keys to success for Albania at E...Eticketing.co
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Luciano Spalletti Leads Italy's Transition at UEFA Euro 2024.docxEuro Cup 2024 Tickets
Italy are the defending European champs, but after Luciano Spalletti swapped Roberto Mancini last September, they are still taking the cautious first steps of a new era
According to the report, the consumption of video content related to IPL 2024 has seen significant growth, nearly 3 times more than the previous season, reflecting an increasing interest of fans.
Paris 2024 History-making Matildas team selected for Olympic Games.pdfEticketing.co
Paris 2024 fans worldwide can book Olympic Football Tickets from our online platforms e-ticketing. co. Fans can book Olympic Tickets on our website at discounted prices. Experience the thrill of the Games in Paris and support your favourite athletes as they compete for glory.
Psaroudakis: Family and Football – The Psaroudakis Success StoryPsaroudakis
Psaroudakis, a name that resonates with football fans around the globe, is a testament to the powerful synergy between familial support and individual passion. Born on March 10, 1992, in the historic city of Heraklion, Crete, Psaroudakis’ journey to international football stardom is a compelling narrative of dedication, perseverance, and unwavering family support. His story not only highlights his athletic prowess but also underscores the crucial role his family played in shaping his career and character.
Psaroudakis’ early life in Heraklion was deeply influenced by a supportive and nurturing family environment. His father, a former semi-professional footballer, recognized Psaroudakis’ potential from an early age. Acting as his first coach, his father’s guidance was instrumental in igniting Psaroudakis’ passion for football. This paternal influence instilled in him a strong work ethic and fundamental skills that would become the foundation of his future success. His mother, a dedicated homemaker, provided a stable and nurturing environment, ensuring that Psaroudakis could pursue his dreams without any hindrances.
From a young age, Psaroudakis showed an innate talent for football. Growing up in Heraklion, he spent countless hours playing football in local parks and streets with friends and family. His natural ability was evident even in these informal settings, and his enthusiasm for the game was infectious. By the age of five, Psaroudakis had joined a local youth football club, where his skills began to flourish. His father’s role as his first coach during these formative years was crucial, as he emphasized not only technical skills but also the importance of discipline and teamwork.
The transition from playing in local parks to joining a structured football environment marked a significant step in Psaroudakis’ journey. At the age of ten, he joined the youth academy of OFI Crete, one of Greece’s most esteemed football clubs. This move marked the beginning of a more rigorous and professional approach to his training. The academy environment was demanding, focusing on honing technical abilities and instilling values of sportsmanship and dedication. Psaroudakis’ dedication to his craft was evident as he quickly rose through the ranks, becoming a standout player in the youth teams.
The support of Psaroudakis’ family was unwavering during this critical period. His father continued to be a source of guidance and mentorship, while his mother ensured that he had everything he needed to succeed. Their collective efforts created a balanced environment where Psaroudakis could focus entirely on his development as a footballer. This familial support was not just about providing the basics; it was about creating an environment where Psaroudakis felt encouraged and motivated to pursue his dreams relentlessly.
As Psaroudakis transitioned from the youth academy to professional football, the challenges became more significant.
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Netherlands vs Austria Netherlands Face Familiar Foes in Euro Cup Germany Gro...Eticketing.co
The Netherlands are in Group D in Euro Cup Germany - and, unpaid to this, they will be coming up against familiar foes. Remarkably, they have played France, who have fashioned some of the greatest players of all time, 30 times throughout history. Despite France being more effective in major competitions, including captivating the World Cup in 2018, Holland have the greater head-to-head record.
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However, in 2023, they played one another twice, with France endearing both matches 4-0 and 2-1 individually. Against Poland and Austria, the Netherlands also have a stout record, winning just under half the matches. They faced Austria at Euro 2020, engaging 2-0, and they haven't lost to Poland since 1979.
The lettering is on the wall for Holland to qualify for the knockouts, but nothing is failsafe. The Netherlands kickstart their Euros campaign against Poland on Sunday, June 16th. In Hamburg, they will have to go up against one of the best strikers in the world, Robert Lewandowski.
Netherlands vs Austria: Tough Challenges Await the Netherlands in Euro Cup Germany
Five days later, they travel south to face France in Leipzig, a side led by Kylian Mbappe - one of the finest players in the world currently and one of the most impressive players in his nation's history. To conclude, they face Austria in Berlin, knowing it could be the end of the road if they don't perform.
Ronald Koeman is widely considered one of the more successful Dutch managers in Premier League history, considering the nation has a reputation for struggling to replicate their talents in England. The former Everton manager went against that script and shone — and now he is back managing his nation.
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Netherlands vs Austria: Ronald Koeman's Tactical Approach For UEFA Euro 2024
As well as being the highest-scoring defender in history, Koeman is a man with immense tactical knowledge. He returned to manage Holland at the start of 2023 after it was announced Louis van Gaal would retire. His life back in the dugout with the team wasn't easy, as he lost his first match 4-0 to France after going 3-0 down within 21 minutes.
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3. Overview
• MR imaging sequences
• The report for MR rectal cancer staging and
“DISTANCE”
• Primary rectal cancer staging cases
• Post CRT staging and cases
4. We have come such a long way…
CT tomogram from the 1980’s
Courtesy Dr. Stephen Esler
5. • The radiologist plays a central role in the
multidisciplinary approach to rectal cancer
• MRI can accurately stage rectal cancer
• Pre-operative staging with MRI important to select
the appropriate therapy
• Rectal cancer staging with MRI remains a challenge
for many radiologists
6. Technique and sequences
• No need for bowel preparation, filling of rectum with
contrast/air
• Antispasmodic agents can be helpful but are not
mandatory
• Only sequence that is required is a T2 –weighted fast spin
echo sequence (high resolution)
• IV contrast is not recommended as it does not improve
diagnostic quality
8. Austin protocol:
• Three Plane Localiser
• Coronal T2 3D SPACE Whole Pelvis
• Axial T1 Whole Pelvis
• Axial T2 FS Whole Pelvis
• Axial DWI
Modifications Reformat 3D in 3 planes
• Coronal Oblique - Angled parallel to the long axis of the
rectum
• Sagittal
• Axial Oblique – Angled perpendicular to the long axis of
the rectum
9. Overview
• MR imaging sequences
• The report for MR rectal cancer staging and
“DISTANCE”
• Primary rectal cancer staging cases
• Post CRT staging and cases
10. 4 critical questions need to be answered
1. Location of the tumor (high, middle, low)
(you can use a specific staging for low rectal tumours describing the
involvement of the sphincters)
2. The T-stage of the tumour
3. Free resection margin for TME (CRM)
4. N-stage
11. Other things that need to go in the report:
• Tumor length, tumor description/morphology
(polypoid, ulcerative etc.)
• Distance of tumour to anal verge (+/- anorectal
junction)
• Circumferential?
• Involvement of pelvic side wall nodes
• Extramural vascular invasion (EMVI)
• Metastasis
12. • Pedersen et al. reported in 2011 that the report
quality overall could be significantly improved
• There is a need for standardisation of reports and
Taylor et al from Brown’s group created a form based
reporting tool in 2008
• Brown’s group also created the mnemonic
“DISTANCE”
13. Taylor FG et al. A sytematic approach to the interpretation pre-operative staging MRI
for rectal cancer. Am J Roentgenol. 2008 Dec;191(6):1827-35
14. DIS – distance from inferior part of tumor to
transitional skin
T – T-staging
A - Anal complex, sphincters and puborectalis
muscles
N - Nodal staging
C - CRM
E - Extramural vascular invasion
Nougaret S et al. The use of MR imaging in treatment planning for patients with rectal carcinoma: Have you
checked the “DISTANCE”. Radiology. 2013 Aug;268(2):330-44
15. Overview
• MR imaging sequences
• The report for MR rectal cancer staging and
“DISTANCE”
• Primary rectal cancer staging cases
• Post CRT staging
29. Report conclusion:
Low rectal tumour with a length of 5.5 cm with
extension to and involvement of the left levator
muscle. It reaches 2.7 cm above the anal verge
and there are 5 abnormal lymph nodes. An
enlarged left pelvic side wall node is present.
Staging in keeping with T4 N2 M1
33. Overview
• MR imaging sequences
• The report of MR rectal cancer staging and
“DISTANCE”
• Primary rectal cancer staging cases
• Post CRT staging
34. • Main indications for CRT:
– Locally advanced rectal tumor T3 with > 5mm of
extramural spread
– EMVI
– Tumor within 1mm of mesorectal fascia (node,
tumor, EMVI)
– Threatened or involved anal sphincter
– Nodal involvement
Post chemoradiation therapy (CRT) staging
35. • Locally advanced rectal cancer has a poor
prognosis
• Benefits of downstaging and downsizing
with neoadjuvant CRT:
1. improves resectability
2. sphincter preservation
3. reduced local recurrence
4. improved overall survival
36. • MRI is developing a central role in identifying
good and poor responders
• Can provide a basis to further fine tune
treatment
• In the future MRI may be used to select
patients that will just receive CRT (wait and
see approach)
37. • Tumour volume reduction of at least 70% predicts disease free survival and
good histologic regression.
Nougaret et al MR volumetric measurement of low rectal cancer helps predict tumour response and outcome after combined
chemotherapy and radiation therapy. Radiology May 2012.
• Post CRT MRI assessment of tumour regression grade correlated
with disease free survival.
Patel et al MRI-detected tumour response for locally advanced rectal cancer predicts survival outcomes JCO 2011
• A pathological complete response following neoadjuvant CRT is associated
with excellent long-term survival, with low rates of local recurrence and
distant failure.
Martin et al. Br J Surg 2012 Systematic review and meta analysis of outcomes following pathological
complete response to neoadjuvant chemoradiotherapy for rectal cancer.
• Tumour volume regression grade of less than 45% is predictive of a poor
tumour outcome.
Yeo et al, Tumour volume reduction rate after preoperative chemoradiotherapy as a prognostic factor in locally advanced rectal
cancer, Int J Radioation Oncolo Biol Phys 2012.
38. Post CRT MRI interpretation
• Predicting the stage prior to CRT ~ 85%, after CRT ~ 50%
(fibrosis vs tumour?)
• Need primary rectal cancer staging MRI
• “DISTANCE” comes into play first again (ymr added to the
abbreviations e.g. ymrT)
• Followed by MR Tumour Response Grading (mrTRG)
• Research has shown that ymrT and mrTRG predict the
corresponding histopathological parameters and can identify good
and poor responders to CRT
39. Post CRT T-staging and Tumour Response
Grading
• Difficult to differentiate between tumour and post-
therapeutic changes on T2 images
• DWI can be useful
• Some tumours have a “colloid” response > mucin
production bright on T2
40. Morphologic descriptions used in T-staging and Tumour
Response Grading
• Fibrosis within tumour and rectal wall: low signal.
• Desmoplastic reaction: low intensity spicules.
• Residual tumour: Intermediate signal and nodular margin.
• Mucinous change: mucinous response in non-mucinous
tumours suggests treatment response
1. Uniform mucinous change in tumours exhibiting baseline
mucinous heterogeneity suggests treatment response
2. Persistent heterogeneous mucinous signal unchanged post
treatment no response.
41. Nougaret S et al. The use of MR imaging in treatment planning for patients with rectal
carcinoma: Have you checked the “DISTANCE”. Radiology. 2013 Aug;268(2):330-44
Post CRT changes
42. TRG 1: Complete radiologic response:
no evidence of abnormalities
TRG 2: Good response: dense fibrosis
(>75%) no obvious residual tumour
or minimal residual tumour
TRG 3: Moderate response >50% fibrosis or
mucin and visible tumour
TRG 4: Slight response: small areas of
fibrosis or mucin, but mostly
tumour
TRG 5: No response, same appearance as
original tumour
47. • Rectal cancers may exhibit restricted or increased diffusion
dependant on tumour cellularity, intra-tumoral oedema, and
presence of cystic/necrotic areas.
• Low ADC value is predictive of good treatment response.
Dzik_Jurasz et al DWI-MRI for prediction of response of rectal carcinoma to chemoradiation.Lancet 2002
• An early increase in the ADC after commencing treatment is
predictive of better treatment outcome. Hein et al DWI-MRI for monitoring diffusion
changes in rectal carcinoma during combined chemoradiation. EJR 2003
55. mrTRG 2-3
Moderate - good response with > 50% fibrosis
and minimal remaining visible tumour.
T4 stage
56. Summary
• Imaging techniques
• DISTANCE easy mnemonic to help us remember
what to report on
• Some example cases and reports of primary
staging
• Brief discussion of post CRT staging and some
cases
58. References
• Nougaret S, Reinhold C, Mikhael W H et al. The use of MR imaging in treatment planning for
patients with rectal carcinoma: Have you checked the “DISTANCE”. Radiology. 2013
Aug;268(2):330-44
• Taylor FG, Swift RI, Blomqvis L et al. A sytematic approach to the interpretation pre-operative
staging MRI for rectal cancer. Am J Roentgenol. 2008 Dec;191(6):1827-35
• Pedersen BG, Blomqvist L, Brown G et al. Postgraduate multidisciplinary development
program: impact on the interpretation of pelvic MRI in patients with rectal cancer – a clinical
audit in West Denmark. Dis Colon Rectum 2011:54(3):328-334
• Barbaro B, Vitale R, Leccisotti L et al. Restaging locally advanced rectal Cancer with MR
Imaging after chemoradiation therapy. Radiographics 2010;30:699-721
• Patel UB, Taylor F, Blomqvist L et al. Magnetic resonance imaging-detected tumor repsonse
for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin
Oncol 2011; 29 (28):3753-3760
• Dzik_Jurasz et al DWI-MRI for prediction of response of rectal carcinoma to chemoradiation.
Lancet 2002
• Hein et al DWI-MRI for monitoring diffusion changes in rectal carcinoma during combined
chemoradiation. EJR 2003
Editor's Notes
The use of rectal contrast is not advised because stretching of the bowel wall may lead to an overestimation of an involved CRM and the mesorectal nodes in the distal mesorectum are not well appreciated
High resolution: muscularis propria invasion, lymph node morphology
There are some studies now suggesting that certain contrast agents may be useful for identifying diseased lymph nodes (USPIO or gadofosveset)
DWI does not have sufficient resolution to assess depth of extra-mural spread or to improve nodal staging.
Helpful:
EMVI
Localisation of Lymph nodes
Identify patients who might respond well to CRT (will get into that later)
Response assessment after CRT
3D:
Reformat in any plane
Not relying on technicians
Quicker
Large FOV > additional findings such as bone mets
A lot of stuff to remember Important to have a systematic approach when reporting a rectal MRI
Show Taylor reporting tool
The mnemonic was created to make it easier to remember what to report
This reporting form contains both primary staging parameters, including low rectal cancer staging, as well as post CRT tumour grading
Low rectal cancers are associated with higher rates of positive resection margins, higher local recurrence rates, poorer survival > good description important
NODES: shape, border, signal intensity, size in itself is not reliable
CRM: positive by lymph nodes, tumour extension, tumour deposit or EMVI. CRM quite often negative in the high rectal tumours > peritoneal reflection comes into play
Rectal tumours have a high to intermediate signal when comapred to the bowel wall and makes them easier to recognize
High signal as in this case is Mucinous adenocarcinoma LENGTH 8.7cm 7.8cm TO ANAL VERGE
4-1 o’clock, Important to note the distance of growth though the muscularis propria as tumours more than 5mm distance growth are associated with a significant drop in 5-year survival from 85% >54%
REPORT CONCLUSION: T3 N2 mid rectal tumour with a length of approximately 8.6 cm, which reaches 7.8 cm above the anal verge and has a positive CRM
REPORT CONCLUSION: T2 N0 low rectal tumour with a length of 5.1 cm m and reaches approximately 4.1 cm above the anal verge.
Another mucinous tumour
Staging and measurements are not always straightforward as in this case with intussusception
Initial thought was this was a T2 tumour. But with reformatting using the high resolution volume showed this lesion was actually a T3 tumor with breach of the muscularis propria
There were also 2 positive lymph nodes not depicted here
Actually T3
Report conclusion: T3 N1 mid rectal tumour with a length of 6.7 cm (inferior edge of tumour even though intussuscepted) with a distance of 10 cm from the anal verge.
T4 TUMOUR EXTENSION TO LEVATOR
IN this case go on to further describe the anal sphinter and the involvement of the anal sphincter by tumour
5 abnormal lymph nodes only 2 seen here
5.5 cm length, 2.7 cm above anal verge
Positive pelvic side wall nodes
Again would need to describe the involvement of the anal sphinter, which wasn’t the case in this patient.
Extra-mural vascular invasion EMVI associated with T3 tumour. Presence of tumour signal intensity within a vascular structure, expanded vessels and tumoral expansion through and beyond the vessel wall
Obvious T4 tumour extension through sciatic foramen
Restricted diffusion
Tend to radiate even below 5 mm in Australia
- Primary and post CRT staging both have a role in this
-
A lot of literature out there describing the importance identifying the good and poor responders to CRT with MRI, which has a bearing on prognosis and disease free survival outcomes.
Post CRT staging with MRI remains hard and fairly inaccurate
Very important of course to have the preCRT MRI available to asses for change, but sometimes the tumour is not even visible anymore so you need to know where to look with the original scan by your side
DISTANCE just like the pre-CRT MRI
TRG has fairly recently be developed to try and attempt to grade the responses of tumours to CRT on MRI
DISTANCE plus TRG becomes important to further select those patients that might need further neoadjuvant CRT (e.g. those with persistent T4/CRM involvement or those that can go to surgery)
DWI can be useful to identify residual tumour in surrounding tissue and fibrosis
Residual Tumour may be bright on DWI in surrounding tissue and fibrosis and may be useful to identify residual tumour
Some tumours have a “colloid” response > mucin production bright on T2 (bright on DWI and ADC =“ T2-shine through”)
Can be very hard to detect remaining viable tumour amongst tumour with a strong collloid response
A: mainly nodular pattern
B: thick scarring to mesorectal fascia > difficult to exclude tumour
C: thin linear scar > fibrosis
D: multiple thin linear scars if low signal > fibrosis
An MRI tumor regression grade has recently been proposed in addition to T-downstaging and seems to be a strong prognostic indicator for tumor recurrence and survival outcomes.
The response grading is based on the assumption that fibrosis results in very low signal intensity compared with tumour, and that mucin has high signal intensity compared to tumor
(Some centers also use volume measurement of the tumours in combination with the morphological changes and has been shown to correlate well with patholgical tumour repsonse in terms of downstaging and tumor regression grade > this is done by summing all the cross sectional volumes and using a specific soft ware package)
Go through the grades
A 4cm mid-low rectal tumour 5 cm from the anal verge. Extends to the meso-rectal fascia in keeping with a T3d tumour and a positive CRM. There are 4 abnormal lymph nodes and there is EMVI. No abnormal pelvic side wall nodes are seen. Some restrcited diffusion.
The features of the tumour are compatible with T3N2 with a postive CRM and EMVI.
TRG2 good response(>75% FIBROSIS) with tumour replaced by dense fibrosis with no obvious tumour left. No remaining DWI restriction/low ADC left overall the features are compatible with a TRG 2.
Diffusion weighted MRI can be effective for the pre-treatment prediction of treatment outcome, with those tumours presenting with a lower ADC value on presentation responding better to treatment.
A recent study has shown that an increased apparent diffusion co-efficient in patients during and after CRT could be used to predict an early pathological response to CRT.
(Increased ADC values post CRT suggest reduced cell burden)
Early response in ADC more sensitive than change in tumour size.
Increased ADC values may be seen as early as 3-7 days post CRT in responders
TRG1 : As was suggested by the pre-radiation low ADC the tumour responded extremely well to radiation prior to tumour in keeping with a complete response TRG1 > no evidence of any tumour left
POOR RESPONDER, THERE WAS NO RESTRICTED DIFFUSION ON THE DWI
TRG4 slight response with some fibrosis but mostly tumour remains
Stage 4 post CRT good response in terms of volume reduction, still tumour present
Good response, when considering the size reduction, however some nodular thickening remains as well as some fibrosis and remaining tumour can not be excluded especially extending into the left seminal vesicle
TRG 3: Moderate response >50% fibrosis or mucin and visible tumour
END
EVEN THOUGH THE SIZE REDUCTION IS IMPRESSIVE STILL SOME TUMOUR PRESENT AND STILL A T4 TUMOUR