This document provides an overview of management for meningioma, pituitary gland tumors, and spinal cord tumors. It discusses:
1. Meningiomas are the most common primary intracranial tumors, mostly benign but some malignant. Treatment options include surgery, radiation therapy, and chemotherapy depending on tumor grade and extent of resection.
2. Pituitary tumors account for 10-15% of primary brain tumors and most are endocrinologically active. The pituitary gland anatomy and tumor epidemiology are outlined.
3. Spinal meningiomas are typically treated with surgical resection if possible, or with stereotactic radiosurgery or hypofractionated radiation if not. Management depends on tumor
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
Carcinoma rectum the complete aproach to how to investigate and treat a case ...nikhilameerchetty
this is a complete guide to the understanding of the anatomy clinical features and the latest investigation to the most modern methods of treating the case of carcinoma rectum , all the latest journal published and the ongoing trials hav been searched and incorporated
This seminar is presented as a part of weekly journal club and seminar regularly conducted at Apollo hospital,Kolkata Department of Radiation oncology.
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
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this is a complete guide to the understanding of the anatomy clinical features and the latest investigation to the most modern methods of treating the case of carcinoma rectum , all the latest journal published and the ongoing trials hav been searched and incorporated
This seminar is presented as a part of weekly journal club and seminar regularly conducted at Apollo hospital,Kolkata Department of Radiation oncology.
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Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Similar to Satyajeet meningioma pituitary adenoma spinal cord tumours (20)
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
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
3. Meningioma
Meningiomas: MC primary intracranial tumours.
majority are benign, with about 1%-3% classified as malignant
98% are intracranial but may arise anywhere in central nervous system
Classified into grades : WHO grade I,II and III : On the basis of local invasiveness
and cellular features of atypia.
Histological verification is not mandatory in all cases
Originates from arachnoid cap cells
Incidence increases with age, More common in females
40% and 80% of meningiomas contain an abnormal chromosome 22 (22q12.2)
NF type 2 :Multiple meningiomas
Express ER (40%)/PR(70%) +ve , may grow faster in pregnancy
5. MRI
• MRI is preferred , as it is superior in demonstrating dural origin, as well as
vascularity, edema, sinus and bone invasion.
• Present as solitary round tumours, with close contact to the duramater and strong
enhancement with contrast.
• Thickening of the duramater at the perimeter of the tumour (so-called dural tail) is
displayed by T1 with gadolinium.
• Isointense or hypointense to gray
matter on T1.
• Isointense or hyperintense on T2
weighted images.
• Areas of necrosis and calcification
do not enhance
6. Meningioma of the
right convexity
with typical
radiological signs
(A) Bone window of
the cerebral CT scan
in coronal view
showing hyperostosis
facing the tumour
(arrow). (B) Cerebral
MRI (fluid-attenuated
inversion recovery)
showing the tumour
slightly hyperintense.
The oedema of the
parenchyma adjacent
to the tumour is shown
by the arrow. (C) T2
sequences in coronal
view showing
cerebrospinal fluid
(arrows) interposed
between tumour and
parenchyma, showing
the extra-axial nature
of the tumour. (D) T1-
weighted MRI after
gadolinium injection
depicting intense
enhancement of the
tumour. The arrow
shows the large
contact of the tumour
with the dura mater
and the thickening of
the adjacent dura
mater
7.
8. Treatment Options
• MC intracranial tumours BUT the level of evidence to provide
recommendations for the diagnosis and t/t is low compared with other tumours
such as HGG
• Surgery
– Objective: total removal of the meningioma, dural attachment and bone involved
with the tumor
– Priority: preserve and improve neurological function
• Radiotherapy
– Indications:
• Residual tumor left at operation
• Recurrence
• Tumors could not be treated surgically
• Malignant histology
The available treatment
modalities are-
Observation Surgery Radiotherapy Chemotherapy
11. Observation
• Asymptomatic patients with little or no edema in the adjacent brain
areas
• Patients with mild or minimal symptoms
• Patients in whom treatment carries a significant risk
12. Meningioma Grade 1 – Role of Sx
• Asymptomatic: Observation (6 monthly to annually: Clinical examination
and MRI )
• Imaging strongly S/O Meningioma => Histological verification is not
mandatory.
• However, exclusion of rare differential diagnoses such as metastasis is
recommended
• Radiologically growth / clinical symptoms: Surgery is the First Choice
• Extent of resection should be confirmed by a postoperative MRI (within 48 h
after surgery / after 3 months to avoid artefacts)
13. Meningioma Grade 1 – Role of Radiotherapy
• Indications:
Elderly patients (older than 65 years)
Not safely accessible by surgery.
Incomplete surgical resection
SRS-for small tumours
Evidence**: 35 retrospective studies showed a 5-year progression-free survival of 86−100% after primary
stereotactic radiosurgery.
Fractionated EBRT: 50−55 Gy given in doses of 1·8−2·0 Gy per fraction can be applied
(Evidence level III, Recommendation level B).
• **Rogers L, Barani I, Chamberlain M, et al. Meningiomas: knowledge base, treatment outcomes, and uncertainties.
• A RANO; review. J Neurosurg 2015; 122: 4–23.
• Radiotherapy with subtotal resection: is associated with disease control and
survival rates similar to those reported for gross total resection
• IMRT/ fSRT: to spare critical neurovascular structures surrounding the tumour and
to reduce the risk of long-term cognitive deterioration => similar disease control to
conventional radiotherapy.
14. Surgery is the first choice of treatment.
Should aim to achieve Simpson Grade I resection
• Role of adjuvant radiotherapy after partial resection??
Adjuvant radiotherapy (54–60 Gy given in 1·8−2·0 Gy per fraction) should
be considered (evidence level III, recommendation level C)
Fractionated RT is preferred over SRS techniques
although SRS offers similar results for small tumours/ tumour residual
Meningioma Grade 2 – Role of Sx
15. • Role of adjuvant radiotherapy after gross complete resection?????
– ROAM/EORTC 1308 trial (ISRCTN71502099) : whether radiotherapy reduces the risk of or delays
tumour recurrence.
Newly diagnosed Atypical Meningioma (WHO grade II)
Gross total resection (Simpson grade I–III)
early adjuvant radiotherapy (60 Gy in 30 fractions) vs. observation
• Role of adjuvant radiotherapy after partial resection??
Adjuvant radiotherapy (54–60 Gy given in 1·8−2·0 Gy per fraction) should be
considered (evidence level III, recommendation level C)
Fractionated RT is preferred over SRS techniques
although SRS offers similar results for small tumours/ tumour residual
Meningioma Grade 2 – Role of Radiotherapy
16. Meningioma Grade 2 – Role of Chemotherapy
and targeted therapy
Retrospective studies and small prospective studies: (WHO grade II and III meningiomas)
o Hydroxycarbamide
o Cyclophosphamide/Doxorubicin/Vincristine chemotherapy,
o interferon-alfa,
o Megestrol acetate, Medroxyprogesterone acetate, Octreotide, Pasireotide (long-acting
release),
o Imatinib, Erlotinib, Gefitinib, Vatalanib, Sunitinib,
o Bevacizumab.
Most promising results for Bevacizumab, Vatalanib, and Sunitinib
EORTC phase 2 trial (NCT02234050): efficacy of TRABECTEDIN shown promising activity in
recurrent WHO grade II and grade III meningiomas.
17. Meningioma Grade 3
• Surgical resection:
– should be as radical as possible
• Adjuvant Radiotherapy: Fractionated
– Dose: at least 54 Gy 1·8−2·0 Gy fractions
– Dose:
– Complete resection: 54 Gy
– Incomplete resection: 6o Gy
18. Ongoing trials
RTOG 0539 trial (NCT00895622):
• WHO Grade II: RT with 54 Gy in 30 fractions after gross total resection
• High-risk meningioma (ie, WHO Grade II recurrent disease, WHO Grade II after
subtotal resection, and all WHO grade III) are receiving up to 60 Gy.
EORTC 22042-26042 trial (NCT00626730):
WHO Grade II and III after Gross Total resection: 60 Gy in 30 fractions
After subtotal resection: 60 Gy in 30 fractions followed by Boost 10 Gy in 5 fractions to
residual
- Results awaited
19. Spinal Meningioma
• Surgical resection: 1st Choice
• To remove the tumour and decompress the spinal cord is the therapy of choice
• If surgical resection not possible: SRS or hypofractionated RT
(recommendation level: good practice point)
• Adjuvant therapy is done according to WHO grade and resection.
20. Follow-up
WHO grade I:
First 5 years: Annually
After 5 years: every 2 years.
WHO grade II :
First 5 years: Every 6 months
After annually after 5 years
WHO grade III :
Every 3–6 months indefinitely
22. SRS
Kondziolka et al. (1999):
– 99 patients from U. Pittsburgh
– 43% SRS alone, 57% surgery + SRS
– median tumor margin dose 16 Gy, max dose 32 Gy, median tumor volume 4.7
cc.
• LC 93-95% ,PFS 90- 93% in both arms at 5–10-year.
Stafford et al. (2001):
– 190 patients from Mayo Clinic,
– 59% had prior surgery, 12% with atypical or malignant histology.
• Median tumor margin dose was 16 Gy. Median prescription isodose
volume was 8.2 cm3.
• Five-year LC for patients with benign, atypical, and malignant tumors
were 93, 68, and 0%, respectively.
• Five-year CSS for patients with benign, atypical, and malignant tumors
were 100, 76, and 0%, respectively.
23. • 628 patients (130 men and 498 women) - gamma knife radiosurgery for intracranial
meningioma,
• with single lesion meningioma, followed up after 6 months with imaging, and then
at 24 months with a clinical examination.
• The median patient's age was 56.8 years. Maximal dosage was 27.8 Gy and
marginal dosage was 13.9 Gy.
Results
• The overall tumor control rate was 95%.
• Twenty-eight patients (4.4%) showed evidence of tumor recurrence.
• Ninety-eight patients (15%) developed peritumoral edema (PTE) after gamma-knife
surgery; two of them (2%) underwent surgical resections due to PTE.
• Nine patients had craniotomy and tumor removal after gamma knife surgery.
Conclusion
• Gamma knife surgery for intracranial meningioma has proven to be a safe and
effective treatment tool with successful long-term outcomes.
25. Anatomy
• It is called the Master of endocrine
orchestra
• 15 mm in ant-post and 12 mm in
supero inferior axis
• It weighs about 0.5 gm.
• The pituitary gland occupies a
cavity of the sphenoid bone called
sella turcica
• Roof is formed by diaphragm sellae
• Floor – hypophyseal fossa
• On each side :The cavernous sinus
with its content
• The stalk of pituitary is attached
above to the floor of third ventricle
26. • Anterior and intermediate lobe
– Rathke’s pouch
• The posterior lobe or
neurohypophysis
– Downward pocketing of third ventricle.
• Posterior lobe
– Oxytocin and Vasopressin which are
synthesised in the supraoptic and
paraventricular nuclei in
hypothalamus
• Anterior lobe
– ACTH,TSH,GH,FSH,LH,Prolactin
27. Epidemiology
• Pituitary neoplasm account for 10% to 15% of diagnosed primary intracranial neoplasm
• 10% of healthy population has pituitary abnormality detected by MRI
• Approximately 70% are endocrinologically active
• 70% of adenomas present between the ages 30 -50 yrs
• Women have high incidence of pituitary adenomas(15-44 yrs)
• Incidence of macroadenomas is similar between males and females
• Annual incidence ranges from 0.5 to 0.7/100,000
• A genetic predisposition to develop adenomas has been described in
– MEN I syndrome
– Carney complex
– Isolated familial somatotropinomas(IFS)
28. Natural History
• Usually has a long natural history with an insidious onset of symptoms
• Symptoms are usually present for years prior to diagnosis
• When small pituitary tumour tends to be smooth round tumours
• Macroadenomas are known for their local invasive properties
• Malignant behaviour with distant metastases is rare
29. Hyperpituitarism
• HYPERPROLACTINEMIA
Most common cause of pituitary hormone hypersecretion
Amennorhoea
Galactorrhoea
Infertility
• INCREASED GH
Acromegaly in adults
Frontal bossing
Increased hand foot size
Mandibular enlargement,Prognathism
Large fleshy nose
Proximal muscle wasting,carpal tunnel syndrome,macroglossia
Gigantism in children
• INCREASED ACTH
Causes cushing syndrome
Central obesity
Plethoric moon facies
Purple striae,increased bruisability
Glucose intolerence
Acne,hirsuitism
Proximal muscle weakness
Hypertension
Amennorhoea,infertility
31. FEATURES OF SELLAR MASS LESION
• PITUITARY
Hypopituitarism
• OPTIC CHIASMA
Bitemporal Hemianopia
Superior temporal defect
• CAVERNOUS SINUS
Ophthalmoplegia
Ptosis
Diplopia
• OTHERS
Head ache
Hydrocephalus
Dementia
32. Diagnostic Work-up
Detailed History and complete physical examination
Confirmation of diagnosis
• Radiological Examination
MRI-preferred modality better visualisation of soft tissue and
vascular structure than CT Scan
• Biopsy –In a case of non secreting lesion
33. HORMONALANALYSIS
• Serum Prolactin level
• Growth hormone:basal growth hormone level
IGF-I
Glucose suppression,insulin tolerence
• ACTH Hypersecretion:
Serum ACTH,Dexamethasone supression test
24 hrs urine for 17-hydroxy corticosteroids
and free cortisol
• Gonadal function: FSH, LH, Esradiol,Testosterone
• Thyroid function test
• Adrenal function: basal plasma,urinary steroids
cortisol response to insulin induced hypoglycaemia
35. Classification(Cont…)
• ACCORDING TO CLINICAL SYMPTOMS
Functional
Non functionaL
• ACCORDING TO EXTENT OF EXPANSION OR EROSION OF SELLA
Grade 0: Intrapituitary microadenoma with normal sellar appearance
Grade I: Normal-sized sella with asymmetric floor
Grade II: Enlarged sella with an intact floor
Grade III: Localized erosion of sellar floor
Grade IV: Diffuse destruction of floor
• ACCORDING TO SUPRASELLAR EXTENSION
Type A: Tumor bulges into the chiasmatic cistern
Type B: Tumor reaches the floor of the 3rd ventricle
Type C: Tumor is more voluminous with extension into the 3rd ventricle up to the foramen
of Monro
Type D: Tumor extends into temporal or frontal fossa
36. Pathological classification
Ant Pituitary has 5 specific cell types
• Somatotrophs:
– produces growth hormone,acidophilic
• Lactotrophs:
– produces prolactin,acidophilic
• Corticotrophs:
– produces ACTH,MSH,basophilic
• Thyrotrophs:
– produces TSH,basophilic
• Gonadotrophs:
– FSH,LH,basophilic
• Post pituitary: pituicytes and non
myelinated fibres
38. Observation
• In asymptomatic non secreting microadenomas
• Small asymptomatic prolactinomas
2-4 mm no testing required
5-9 mm MRI can be done once yearly
• Indications for intervention
Tumour growth on imaging
symptoms of hypersecretion
development of visual field defects
39. Surgery
INDICATIONS
• It is the first line treatment for
most symptomatic pituitary
tumours
• Useful when medical therapy
fails
• When prompt relief from mass
effect and hormone secretion is
required
• Pituitary apoplexy
Transfrontal
Trans-sphenoidal
40. Types
MICROSCOPIC TRANSSEPTAL TRANSSPHENOIDAL
• Current standard surgical procedure
• Safe procedure with mortality rate 0.5%
• Contraindications are sphenoid sinusitis,
ectatic midline carotid arteries
lateral surpasellar extent
ENDOSCOPIC TRANSNASAL TRANSSPHENOIDAL
• Allows better visualisation of pituitary gland, hyophyseal stalk,
cavernous sinuses,optic nerve and suprasallar areas
TRANSCRANIAL
• Requires craniotomy and retraction of frontal lobes
• Used for large invasive tumours with significant suprasellar
extension
• When transsphenoidal approach is contraindicated
41. COMPLICATIONS OF SURGERY
• CSF rhinorrhoea
• Meningitis
• Haemorrhage
• Stroke
• Damage to pituitary
• Visual loss
49. MANUAL AND 2D PLANNING
Positioning
Supine with neck flexed and head at
45 degrees
Pituitary board can be used to achieve
this
Immobilisation done with
thermoplastic mask
VOLUME
The entire pituitary gland with
extensions and a margin of 1-1.5
cm
50. PORTALS
Two parallel and opposite lateral fields and one anterior or vertex beam that
enters above the eyes
The centre of the pituitary is located at a point 2-2.5 anteriorly to tragus and
2-2.5 cm superiorly to that point
Taking this point as centre a field of( 4*4)cm-(6*6) cm is marked
ENERGY
4-10 Mev or Co 60
DOSE
Nonfunctioning tumours 45-50.4 Gy@1.8 Gy/#
Functional tumours 50.4-54 Gy
51. 3D PLANNING
• Image based treatment planning using a 3D
technique is the standard of care
• Defining the tumour volume
MRI,CT as well as clinical and surgical
findings should be used to define the tumour
volume
CT simulation assists in defining treatment
volume
GTV is the pituitary adenomas including any
extention into adjacent anatomic regions
CTV :GTV+5 mm in a clear defined tumour or
entire sella and cavernous sinus with invasive
tumours
PTV:CTV+5mm
52. FRACTIONATED STEREOTACTIC RADIOTHERAPY(FSRT)
FSRT is characterised by improved patient localisation,tighter volume
definition more conformal isodose distributions
It has better safety profile and efficacy
• IMMOBILISATION
Aim is to achieve a patient positioning error of less than 3mm by
various means like
Invasive halo ring
Radiocamera bite block
Non invasive Head frames
53. Stereotactic(cont…)
• TARGET VOLUME DELINEATION
• GTV is designed with help of MRI and extent of cavernous sinus invasion
should be included
• No additional margins is required for CTV
• PTV:CTV +2-3 mm margin
• TREATMENT PLANNING
• Depends on the delivery systems available
• Options include
Multiple spherical shots
Dynamic conformal arches
Nonisocentric robotic delivery
• DOSE 50.4 Gy in 28#@1.8Gy/#
54. STEREOTACTIC
RADIOSURGERY
Accepted treatment for smaller,radiologically well defined tumours located at a
distance (3-5 mm) from optic apparatus
Contraindicated if optic chiasma is closer than (3 -5)mmto the tumour
Delivery systems include linear accelerator and gamma knife
Head is fixed with an appropriate stereotactic head frame and a high resolution
imaging study is obtained
Gamma knife uses smallest collimators and maximum number of isocentres .
The dose to optic chiasma is limited to <8-9 Gy
DOSE
• Non functioning (12-20Gy)
• Functioning (15-30 Gy)
55. RT Dosing Guidelines
EBRT
(1.8Gy/fx)
Radio-surgery
(optic chiasm
dose < 9 Gy)
Local
Tumor
Control
Biochemical
Control
Nonfunctioning
tumors
45-50.4
Gy
12-24 Gy to
margin
95% NA
Functioning
tumors
45-54 Gy 25-30 Gy to
margin
90-95% 33-95%
56. Results
MODALITY SURGERY
VS
SURG+POSTOP RT
SURG+POST OP
RT
VS
RT ALONE
GAMMA KNIEF
RADIOSURGERY
RESULTS Park et.al
10 yrs recurrence rate
2.3%with rt,50.5%only
surgery
Grigsby et al
Proggression free
survival at 5 yrs 96%
and 20 yrs 88%
Maschiro.et al
Tumour control at 5 yrs is
93.6% and
endocrinological
improvement is 80.3%
CONCLUSION Post op RT should be
preferred
Surg+rt had a greater
control of local disease
Results are similar to
#EBRT but gamma knief
seems to be safer in terms
of complications
57.
58. • In acromegaly, the rate of reduction of GH after conventional therapy is a
50% drop in 27 (± 5) months (Biermasz et al., 2000).
• It has also been expressed as halving of mean GH level in a population of
acromegalic patients in about 2 years (Ciccarelli et al., 1989).
• The rate of reduction of IGF-I is slower with normalization in 60% of
patients 5–10 years after treatment (Biermasz et al., 2000).
• In Cushing's disease, the normalization of plasma and urinary cortisol has
been reported in 50–100% of patients. A detailed prospective study of 30
adults demonstrated remission in all patients 60 months after radiotherapy,
with the majority normalizing in the first 2 years after treatment
(Estrada et al., 1997).
59. COMPLICATIONS OF RADIOTHERAPY
• ACUTE REACTIONS
Fatigue, Focal alopecia, Otitis
• CHRONIC REACTIONS
1. Hypopituitarism
primarily due to hypothalamic injury. In patients with normal pituitary function around the time of radiotherapy, hormone
replacement therapy is required in 20–40% of patients at 10 years
2. Damage to optic apparatus
1·5% risk of radiation optic neuropathy (Brada et al., 1993; Tsang et al., 1994)
3. Secondary brain tumours
The reported frequency is in the region of 2% at 10–20 years (Brada et al., 1992; Tsang et al.,
1993; Erfurth et al., 2001).
4. Brain necrosis
0·2% risk of necrosis of normal brain structures (Becker et al., 2002).
5. Although radiation is blamed for potential cognitive impairment, there is no clear evidence
that small-volume fractionated irradiation affects cognitive function beyond the deleterious
effect of surgery and the pituitary adenoma (Grattan-Smith et al., 1992; Peace et al., 1997).
61. Introduction
• Rare heterogeneous group of tumors.
• 15% of all primary cns neoplasms arise in the sc.
• Incidence higher in males than females
• Age – 10 to 40 yrs
• Extramedullary tumors comprises around 2/3 & intramedullary ~ 10%.
• Cervical spine involvement is seen in 15-20%, thoracic in 50-55%, lumbar
in 25-30% cases.
62.
63. BIOLOGIC CHARACTERISTICS & MOLECULLAR BIOLOGY
1. Diversity of spinal axis tumors due to large spectrum of
phenotypically distinct cells in the axis.
2. Most are benign.
3. Significant morbidity due to direct compression of important neural
structures.
4. Histology is an important prognostic factor
– Ependymoma better prognosis than > astrocytoma
– Low grade & pilocytic astrocytoma better prognosis.
64.
65.
66.
67.
68. Radiotherapy
• Controversial since SC tumors are indolent (SC toxicity)
• Not indicated in
– Completely excised intra medullary
– Ependymoma and astrocytoma low grade
• Incomplete / piece meal excision :- adjuvant radation
• Follow up after surgery and second surgery/adjuvant RT if recurrence
particularly in children
• RT induced spinal deformity due to damage of epiphyseal plate, soft tissue
fibrosis and contracture.
• In high grade astrocytomas & ependymomas adjuvant RT is recomended
irrespecive of extent of resection ( Mayo data –IJROBP:27-- 1986,2000)
69.
70. Radiation Technique
Conventional technique
– Cervical:-parallel opposed portal
– Thoracic:-direct posterior or posterior wedge
– Lumbar & cauda equina:-opposed AP/PA fields
– In female :-lateral techniques are used to avoid the dose to ovary
• Depth of spinal cord:-determined from CT/MRI
Beam energy:-
– Cervical:-4 to 6 mv
– Thoracic & lumbar:-combination of low energy (4-6 mv) & high energy(8 to 25 mv)
• Dose:-
– Low grade astrocytoma and ependymoma gtr/50.4 Gy after str
– High grade astrocytoma:-54 Gy
– High grade ependymoma csi = 36Gy + boost 50.4 Gy – 54 Gy
– Meningiomas : 50.4 GY or 16 GY/fx 80% IDL by SBRT
• Margins:-
– 3-5cms suproinferior, thecal sac at S 2-3 needs to be covered in caudal
ependymomas
– 0.5-1 cm margin for low grade astrocytoma
• Imrt
• SRT & Proton beam therapy
71.
72. Radiation toxicity
• Reversible myelopathy (2-6 mths) – Lhermitte’s sign is seen
characterized by shock like sensation in hands and feet when
neck is flexed.
– Lasts for weeks .
– Requires no treatment.
• Progressive myelopathy (13-29 mths) - characterized
parasthesia,progressive motor weakness pain/temp
lossbowel/bladder dysfunction
• Spinal cord tolerance– Quantec guidelines show for
conventional RT a dose of 50Gy, 60Gy& 69Gy is associated
with 0.2%, 6% & 50% rates of myelopathy.
73. Chemotherapy
• Limited role
• Used after all modalities are exhausted or in <3 yr age group to borrow
time for RT
• Platinums & etoposides are most active agents for ependymoma
• Temozolamide may be used in spinal glioma. Used as concurrent with
RT and then maintainance therapy
• In <3year age groups– intensive treatment with carboplatin,
procarbazine, vincristine, cyclophosphamide, etoposide, cisplatin
agents
74. Astrocytoma
• Age– paediatric and adolescent
• Site – mostly cervical & thoracic
• Mostly focal but whole cord involvement may occur.
• Majority are low grade (who gr I & II )
• Accompanying syrinx in 40 % cases.
• Complete surgical resection is often impossible.
• Juvenile pilocytic astrocytoma (who gr I) due to its non infiltrative nature can be
treated with radical resection
• Fibrillary(gr II), Anaplastic (gr III), GBM(gr IV)– due to local infiltration resection
enblock not possible onlybiopsy/subtotal resection done
• Adjuvant radiotherapy indicated
75. Nerve sheath tumours
• Arise from schwann cells
• Types – schwannoma, neurofibroma,ganglioneuroma
• Majority are intradural arising from dorsal sensory nerve root
• When it has both intra and extra dural component it is called dumbbell lesion.
Schwannoma –
– Most frequently seen in cervical and lumbar region
– Present with radicular sensory change with weakness being a less common sign
– Mostly solitary but when associated with nf2 & schwannomatosis these are
multiple
– Pathological types – conventional (mc),cellular,melanotic ,plexiform(do not
undergo malignant change)
– Grow eccentricaly without nerve infiltration
• Treatment – radical surgical resection(hemilaminectomy)
• Recurrence is rare and they usually donot undergo malignant
transformation.
76. Neurofibroma
• Commonly seen in NF-1
• Cervical spine most commonly affected
• Often multiple, benign
• Encases the nerve root hence excision without sacrificing the
nerve is difficult
Ganglioneuroma
• Mostly benign and paraspinal
• Arises from sympathetic nervous system
• Pathological types
– a. Ganglioneuroma (Extradural, Dumbell)
– b. Gangliocytoma
– c. Ganglioganglioma (Intradural, Intramedullary)
77. Hemangioblastoma
• Highly vascular tumors
• May be associated with Von- Whippel - Lindau
• Usually dorsal
• Sometimes multiple
• Renal cell carcinoma must be searched for
• Treatment – surgical resection