This presentation is intended to refer while doing planning of SBRT Prostate for all practical aspects from Simulation - contouring - planning - treatment. I am sure it will be very useful presentation for any radiation oncologist who are willing to start workflow of SBRT Prostate in the department of radiation oncology
This presentation is intended to refer while doing planning of SBRT Prostate for all practical aspects from Simulation - contouring - planning - treatment. I am sure it will be very useful presentation for any radiation oncologist who are willing to start workflow of SBRT Prostate in the department of radiation oncology
Robert Sinha, M.D., Radiation Oncologist .Western Radiation Oncology - Dorothy Schneider Cancer Center - 2013 Mills-Peninsula Health Services Cancer Symposium
24° CORSO RESIDENZIALE DI AGGIORNAMENTO
con il patrocinio dell’Associazione Italiana di Radioterapia Oncologica (AIRO)
Moderna Radioterapia, Nuove Tecnologie e Ipofrazionamento della Dose
21 marzo 2014: Trattamenti stereo-RT e radiochirurgici come opzioni standard di trattamento: stato dell’arte in base a linee guida internazionali
Robert Sinha, M.D., Radiation Oncologist .Western Radiation Oncology - Dorothy Schneider Cancer Center - 2013 Mills-Peninsula Health Services Cancer Symposium
24° CORSO RESIDENZIALE DI AGGIORNAMENTO
con il patrocinio dell’Associazione Italiana di Radioterapia Oncologica (AIRO)
Moderna Radioterapia, Nuove Tecnologie e Ipofrazionamento della Dose
21 marzo 2014: Trattamenti stereo-RT e radiochirurgici come opzioni standard di trattamento: stato dell’arte in base a linee guida internazionali
Treatment of Advanced stage of Carcinoma Cervix & Ca cervix in Pregnancy.pptxMuthuRamanK3
1. Treatment of advanced stage of carcinoma cervix: Radiotherapy (including brachytherapy, teletherapy and adjuvant radiotherapy), Chemotherapy and Chemoradiotherapy;
2. Ca Cervix in Pregnancy: Includes flowchart for screening and management
retroperitoneal tumors esp. retroperitoneal sarcoma is most challenging condition to treat in retroperitoneal region inspite of using all treatment modalities.here is brief description of its management acc. to nccn , and other text book ref.
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
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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.
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.
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.
1. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Stereotactic Body Radiotherapy (SBRT) for
the Inoperable Early Stage Lung Cancer Patient
Lucien A. Nedzi, M.D.Lucien A. Nedzi, M.D.
Department of Radiation OncologyDepartment of Radiation Oncology
Univ. of Texas Southwestern Medical CenterUniv. of Texas Southwestern Medical Center
2. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Early Stage Lung Cancer Risk Groups
3 broad groups:3 broad groups:
Average RiskAverage Risk
Generally can tolerate removal of anGenerally can tolerate removal of an
entire lobeentire lobe
High RiskHigh Risk
Can tolerate partial removal of a lobeCan tolerate partial removal of a lobe
MedicallyMedically InoperableInoperable
Cannot tolerate surgery for lung cancerCannot tolerate surgery for lung cancer
3. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Circa 1995: A new treatment called
“Extracranial Stereotactic
Radioablation” (later SBRT)
• GammaKnife-like treatments in the bodyGammaKnife-like treatments in the body
• Swedish pioneers Ingmar Lax and HenricSwedish pioneers Ingmar Lax and Henric
BlomgrenBlomgren
• Japanese pioneer Minoru UematsuJapanese pioneer Minoru Uematsu
• Facilitated by technology (immobilization, motionFacilitated by technology (immobilization, motion
control, 3-D dosimetry, image-guidance)control, 3-D dosimetry, image-guidance)
4. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
What Characterizes Stereotactic
Body Radiation Therapy
(SBRT)?
5. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Spread out the entry radiation
damage
6. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Punishing Radiation Target Dose
This dose defines tumor control (place it well)This dose defines tumor control (place it well)
7. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Steep Radiation Gradients to Normal Tissue
This intermediate doseThis intermediate dose
Can kill microscopic tumor tentaclesCan kill microscopic tumor tentacles
BUT, accounts for toxicity.BUT, accounts for toxicity.
8. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Very large low dose radiation volume
- SBRT (and radiosurgery) Assumption: A little dose to a lot of- SBRT (and radiosurgery) Assumption: A little dose to a lot of
normal tissue is better than a lot of dose to a little normal tissuenormal tissue is better than a lot of dose to a little normal tissue
9. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
SBRT Treatment Logistics
OutpatientOutpatient
No Sedation orNo Sedation or
AnesthesiaAnesthesia
(painless)(painless)
1-5 Treatments1-5 Treatments
qd or qodqd or qod
20-60 Minutes20-60 Minutes
Per TreatmentPer Treatment
Immediate ReturnImmediate Return
To ActivitiesTo Activities
Entire course ofEntire course of
Rx in 1-2 weeksRx in 1-2 weeks
10. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Tissue Effects After SBRT
• Dramatic tumor responses even in solid organsDramatic tumor responses even in solid organs
• Solid organ–sloughing unlikely contributing to responseSolid organ–sloughing unlikely contributing to response
• Implies SBRT preserves competence of immune systemImplies SBRT preserves competence of immune system
to carry out phagocytosisto carry out phagocytosis
Pre-treatmentPre-treatment 6 weeks6 weeks
post-treatmentpost-treatment
3 years3 years
post-treatmentpost-treatment
11. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Tissue Effects After SBRT
• Normal tissue collateral damage does occurNormal tissue collateral damage does occur
Dose and location dependantDose and location dependant
Adjacent tissue doesn’t function (ablated)Adjacent tissue doesn’t function (ablated)
12. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Summary of SBRT
• Very convenient and non-invasiveVery convenient and non-invasive
• Technology intensive and dependantTechnology intensive and dependant
• In contrast to CFRT, local immune function appears mostlyIn contrast to CFRT, local immune function appears mostly
preservedpreserved
Dramatic tumor responsesDramatic tumor responses
Avoidance of necrosisAvoidance of necrosis
• Immediately surrounding normal tissue is damaged to theImmediately surrounding normal tissue is damaged to the
point of dysfunctionpoint of dysfunction
Decreased organ reserve (?symptomatic)Decreased organ reserve (?symptomatic)
13. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
3-5 Year Outcome in
Early Stage Lung Cancer
Rx ModalityRx Modality % alive% alive
• Stage IStage I SurgerySurgery 60-80%60-80%
Stage I*Stage I* Conventional XRTConventional XRT 15-45%15-45%
*clinically staged and mostly medically inoperable (some*clinically staged and mostly medically inoperable (some
refused surgery)refused surgery)
Conventional RT generally 60-66 Gy delivered in 6-7 weeksConventional RT generally 60-66 Gy delivered in 6-7 weeks
14. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Early Investigations of SBRT
• Mostly ad hoc, retrospectiveMostly ad hoc, retrospective
• Treated typical drug discovery phase I populationTreated typical drug discovery phase I population
Incurable patientsIncurable patients
Metastatic cancerMetastatic cancer
Near end of lifeNear end of life
• Difficult to draw conclusionsDifficult to draw conclusions
15. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
SBRT in Early Stage NSCLC
• First prospective trials were in medicallyFirst prospective trials were in medically
inoperable patients with stage I NSCLCinoperable patients with stage I NSCLC
Those refusing surgery (confounders) not allowedThose refusing surgery (confounders) not allowed
• Intent, originally, was to improve tumor controlIntent, originally, was to improve tumor control
probably at the expense of increased toxicityprobably at the expense of increased toxicity
• Experience has been that tumor control isExperience has been that tumor control is
improved and treatment is surprisingly wellimproved and treatment is surprisingly well
toleratedtolerated
16. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
• Classic phase I designClassic phase I design
• Low starting dose 8 Gy X 3 = 24 GyLow starting dose 8 Gy X 3 = 24 Gy
• Dose escalation to very high doses 20-Dose escalation to very high doses 20-
24 Gy X 3 = 60-72 Gy24 Gy X 3 = 60-72 Gy
17. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Tumor Control Definitions
• Follow-up policy and control definitions:Follow-up policy and control definitions:
CT scan q3 monthsCT scan q3 months
Progressive CT consolidation within or adjacent toProgressive CT consolidation within or adjacent to
tumor prompt PETtumor prompt PET
If PET has uptake similar to initial staging (EORTCIf PET has uptake similar to initial staging (EORTC
criteria), then score as tumor recurrencecriteria), then score as tumor recurrence
Otherwise continue to follow (NED)Otherwise continue to follow (NED)
18. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
72 yo female with T1N0M0 NSCLC s/p
SBRT 54Gy/3 fractions to 73% dose line,
dose at iso=73.97Gy, 10 beams
Example
20. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Follow-up
• 3 month scan with good response3 month scan with good response
• 6 months post SBRT develops cough, fever,6 months post SBRT develops cough, fever,
SOB, and chest wall painSOB, and chest wall pain
• Original PET SUV 9-10, repeat PET SUV 3-5Original PET SUV 9-10, repeat PET SUV 3-5
21. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Follow-up
• Treated with incentive spirometry, prednisoneTreated with incentive spirometry, prednisone
taper, albuterol nebulizers for pneumonitistaper, albuterol nebulizers for pneumonitis
• Symptoms improve graduallySymptoms improve gradually
Pre SBRTPre SBRT 2 years post SBRT2 years post SBRT
22. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Dose_Levels
2400 to 3600
4200 to 5400
6000 to 7200
Local Control
0 12 24 36 48 60 72 84 96
100
90
80
70
60
50
40
30
20
10
0
Months from Therapy
LocalRecurrenceFreeSurvival(%)
P = 0.01 (log rank)
23. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Dose Response
0
20
40
60
80
100
0 10 20 30 40 50 60 70
Total Dose in 3 Fractions
4-yearLocalControl
24. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
• IU 70 patient phase II studyIU 70 patient phase II study
• 20 Gy X 3 for T120 Gy X 3 for T1
22 Gy X 3 for T222 Gy X 3 for T2
• NO restriction on tumorNO restriction on tumor
locationlocation
25. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Zone of the Proximal Bronchial Tree
26. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
RTOG 0236
• Non-small cell lung cancer - biopsy provenNon-small cell lung cancer - biopsy proven
• T1, T2 (T1, T2 (≤≤ 5 cm)5 cm)
• Medical problems preclude surgeryMedical problems preclude surgery
(e.g. emphysema, heart disease, diabetes)(e.g. emphysema, heart disease, diabetes)
• No other planned therapyNo other planned therapy
Staging was non-invasive (PET/CT)Staging was non-invasive (PET/CT)
Only invasive step
28. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Local Control
• Local recurrence is primary tumor failure and/orLocal recurrence is primary tumor failure and/or
failure within the involved lobe of the lungfailure within the involved lobe of the lung
• 1 patient had primary tumor failure1 patient had primary tumor failure
++
3 patients had failure within the involved lobe3 patients had failure within the involved lobe
• 3-year Kaplan Meier local control = 90.7%3-year Kaplan Meier local control = 90.7%
29. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Regional Recurrence
• 2 patients have reported a regional failure, both2 patients have reported a regional failure, both
after 2 years (2.8 and 3.0 years)after 2 years (2.8 and 3.0 years)
• Patients avoiding both local and regionalPatients avoiding both local and regional
recurrence (loco-regional control) is 87.2%recurrence (loco-regional control) is 87.2%
30. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Disseminated Recurrence
• Eleven patients (20%) have experiencedEleven patients (20%) have experienced
disseminated failuredisseminated failure
8 of these patients had failure prior to 2 years8 of these patients had failure prior to 2 years
32. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Severe Toxicity
• No grade 5 toxicities (treatment deaths)No grade 5 toxicities (treatment deaths)
• Two (4%) grade 4 protocol specifiedTwo (4%) grade 4 protocol specified
toxicity (decline in PFTs to <25%toxicity (decline in PFTs to <25%
predicted & hypocalcemia)predicted & hypocalcemia)
• Seven (13%) grade 3 protocol specifiedSeven (13%) grade 3 protocol specified
toxicitiestoxicities
33. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Protocol Specified Grade 3 Toxicities
• 1 patient: low oxygen in blood (O1 patient: low oxygen in blood (O22
required)required)
• 2 patient: radiation inflammation of lung2 patient: radiation inflammation of lung
(O(O22 required)required)
• 3 patients: decline in pulmonary3 patients: decline in pulmonary
function, (25-50% of predicted value)function, (25-50% of predicted value)
• 1 patient: decline in pulmonary function1 patient: decline in pulmonary function
and coughand cough
= 7= 7 patients (all pulmonary toxicity)patients (all pulmonary toxicity)
34. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
• SBRT has become a standard of care for medicallySBRT has become a standard of care for medically
inoperable patientsinoperable patients
No randomized trial deemed necessaryNo randomized trial deemed necessary
Up to 10,000 patients per year in USUp to 10,000 patients per year in US
• Successful clinical model using hypofractionatedSuccessful clinical model using hypofractionated
radiotherapy:radiotherapy:
• Rigorously conducted, highly scrutinizedRigorously conducted, highly scrutinized
• Multicenter QAMulticenter QA
• Rapid acceptanceRapid acceptance
35. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Multicenter Phase II Trials Medically Inoperable
• Dutch InvestigatorsDutch Investigators
206 patients with Stage I206 patients with Stage I
Risk adapted approach well toleratedRisk adapted approach well tolerated
Primary tumor recurrence 3%, regional failure 9%, 2 year OSPrimary tumor recurrence 3%, regional failure 9%, 2 year OS
64%64%
• JCOG 0403JCOG 0403
Peripheral T1a, N0, M0Peripheral T1a, N0, M0
100 patients – still enrolling100 patients – still enrolling
• Nordic Study GroupNordic Study Group
peripheral T1-T2, N0, M0peripheral T1-T2, N0, M0
completed accrual of 57 patients 9/2005completed accrual of 57 patients 9/2005
Primary tumor recurrence 7%, 2 year OS 65%Primary tumor recurrence 7%, 2 year OS 65%
36. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Future Directions
• Refine SBRT for medically inoperable patientsRefine SBRT for medically inoperable patients
Refine dose constraints with dosimetry databases andRefine dose constraints with dosimetry databases and
patient outcomespatient outcomes
Refine dose prescription comparing variousRefine dose prescription comparing various
fractionation regimens (RTOG 0915)fractionation regimens (RTOG 0915)
Refine dose prescription for centrally located tumorsRefine dose prescription for centrally located tumors
via phase I trial (RTOG 0813)via phase I trial (RTOG 0813)
Refine therapy in combination with systemic therapiesRefine therapy in combination with systemic therapies
• Explore use of SBRT in an operable patientExplore use of SBRT in an operable patient
subset (RTOG 0618)subset (RTOG 0618)
37. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
ACOSOG Z4099 / RTOG 1021
PIs: Hiran C. Fernando, MD (ACOSOG); Robert Timmerman, MD (RTOG)
Patients randomized to SBRT will receive 18Gy in three fractions, for a total dose of
54Gy.
Brachytherapy is allowed with SR.
All registered patients will be followed for study endpoints, regardless of the status of
their treatment. That includes patients receiving adjuvant therapy for any reason.
38. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Conclusions
• SBRT for lung cancer is effective and tolerableSBRT for lung cancer is effective and tolerable
Prospectively studiedProspectively studied
Encouraging and reproducible resultsEncouraging and reproducible results
Admittedly imperfect therapy with both failure and harmAdmittedly imperfect therapy with both failure and harm
• SBRT is an established standard therapy forSBRT is an established standard therapy for
medically inoperable patientsmedically inoperable patients
• SBRT should be compared to less invasive/lessSBRT should be compared to less invasive/less
radical surgery in high risk operable patientsradical surgery in high risk operable patients
Momentum extremely strong for SBRT, but ideallyMomentum extremely strong for SBRT, but ideally
studies will be donestudies will be done
39. DEPT OF RADIATION ONCOLOGYDEPT OF RADIATION ONCOLOGY
Acknowledgements
• UTSW Rad OncUTSW Rad Onc
Robert Timmerman, M.D.Robert Timmerman, M.D.
Hak Choy, M.D.Hak Choy, M.D.
Ramzi Abdulrahman, M.D.Ramzi Abdulrahman, M.D.
Lech Papiez, Ph.D.Lech Papiez, Ph.D.
Timothy Solberg, Ph.D.Timothy Solberg, Ph.D.
• UTSW CT SurgeryUTSW CT Surgery
Michael Wait, M.D.Michael Wait, M.D.
Michael Dimiao, M.D.Michael Dimiao, M.D.
• UTSW Med OncUTSW Med Onc
Joan Schiller, M.D.Joan Schiller, M.D.
David Gerber, M.D.David Gerber, M.D.
• RTOG HeadquartersRTOG Headquarters
Rebecca Paulus, Ph.D.Rebecca Paulus, Ph.D.
Linda Walters, M.S.Linda Walters, M.S.
• RTOG CollaboratorsRTOG Collaborators
Jeff Bradley, M.D.Jeff Bradley, M.D.
Harvey Pass, M.D.Harvey Pass, M.D.
• RPCRPC
Goeff Ibbott, Ph.D.Goeff Ibbott, Ph.D.
David Followill, Ph.D.David Followill, Ph.D.
• ATC/ITCATC/ITC
Jeff Michalski, M.D.Jeff Michalski, M.D.
Walter Bosch, Ph.D.Walter Bosch, Ph.D.
Bill Straube, Ph.D.Bill Straube, Ph.D.