This document discusses stereotactic body radiation therapy (SBRT) versus surgery for early stage non-small cell lung cancer (NSCLC). SBRT delivers a high dose of precision radiation to the tumor target in 1-5 fractions. Several studies have shown comparable survival and recurrence rates between lobectomy and sublobar resection for stage I lung cancer. SBRT has comparable or better local tumor control and survival rates than conventional radiation therapy for early stage NSCLC, with fewer side effects. While surgery may remain the standard of care, SBRT has emerged as a viable alternative to surgery for medically inoperable early stage NSCLC patients, with some studies investigating its use in operable patients as well.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Lung cancer stage 3 symptoms and treatment methodologiesDaniel Henny
lung cancer stage 3 contains various types of symptoms and treatment methodologies which help to cure cancer. This slide contains information about lung cancer stage 3 symptoms and treatments.
Lung cancer stage 3 symptoms and treatment methodologiesDaniel Henny
lung cancer stage 3 contains various types of symptoms and treatment methodologies which help to cure cancer. This slide contains information about lung cancer stage 3 symptoms and treatments.
Robert Sinha, M.D., Radiation Oncologist .Western Radiation Oncology - Dorothy Schneider Cancer Center - 2013 Mills-Peninsula Health Services Cancer Symposium
How to defeat lung cancer at earlier stageDaniel Henny
The lung cancer causes a various problem which can be defeat at earlier stage if it is identified at starting time. To know more details about lung cancer and its stages visit the above slide.
the role of brachytherapy in oral cavity carcinoma.
physics of brachytherapy
radiobiology of brachytherapy
clinical application in tongue, buccal mucosa cancer
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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.
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
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
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
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!
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.
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.
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
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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
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
SBRT versus Surgery in Early lung cancer : Debate
1. Stereotactic Body Radiation Vs Surgery Therapy
for Early stage NSCLC
DR RUCHIR BHANDARI
Dept of Radiation Oncology
B.R.A.I.R.C.H, AIIMS
MODERATOR
Dr KP Haresh
2. SBRT definition
Stereotactic body radiation therapy (SBRT) is a novel
treatment modality in radiation oncology that delivers a very
high dose of radiation to the tumor target with high
precision using single or a small number of fractions
(typically 5 or less)
Critical Reviews in Oncology/ Hematology (2012)
Regardless of the treatment delivery unit used, one feature
in common is the image-guided therapy capability that
enables verification of the location of the tumor or
target volume before treatment delivery
3. Stereotactic Body Radiotherapy
• High ablative dose
– SRS= single Fx SBRT= 2-5 Fx
– BED important? (>100)
• Short time (1-5 treatments)
• Tight targets and rapid dose fall-off
– Damages everything in high dose area
– Overwhelms repair/repopulation mechanisms
– It is Critical to limit toxicity
– Need target tracking or gating system
20Gy x 3 = 180Gy
12Gy x 5 = 132Gy
12Gy x 4 = 106Gy
16Gy x 3 = 125Gy
18Gy x 3 = 151Gy
XRT BED
60 Gy/30 fr = 72 Gy
70 Gy/35 fr = 84 Gy
4. The Radiobiology of SBRT
The 4 R’s of Radiobiology do not apply to SRS & SBRT.
Interphase death , caused by vascular damage,
Negligible repopulation
tumours with low a/b greatest benefit
SBRT could be eliminating stem cells (in the perivascular
niche) Superior local control
5. Several recent studies have
demonstrated comparable recurrence
and survival rates for lobectomy and
sublobar resection, even in good-risk
patients with stage I lung cancer
1. Christopher Cao et al.Meta-analysis of intentional sublobar resections
versus lobectomy for early stage non-small cell lung cancer : CORE group
STUDY, Ann cardiothoracic surgery, 2014
2. Amgad El-Sherif,Outcomes of Sublobar Resection Versus Lobectomy
for Stage I Non–Small Cell Lung Cancer: A 13-Year
Analysis, Ann Thorac Surg 2006; 82:408 –16
3.Okada M et al. Radical sublobar resection for small-sized NSCLC: a
multicenter study. J Thorac Cardiovasc Surg 2006;132:769-75
4. Watanabe A et al. Feasibility of VATS segmentectomy for selected
peripheral lung carcinomas. Eur J Cardiothorac Surg 2009;35:775-80
6. SBRT can accomplish more than conventional
XRT…
Historical control
SBRT 54 Gy in 3 #, 98% (local), (RTOG 0236)
EBRT 60-66 Gy / 30-33 #, ~50% (Qiao, Lung Cancer 2003)
Beaumont experience (Lanni, Am J Clin Oncol 2011)
3y LC, 88% vs. 66% (p=0.10) in favor of SBRT
Meta-analysis (Grutters, Radiother Oncol 2010)
SBRT (n=895) vs. EBRT (n=1326)
– 2-year OS, 70% vs. 53% (p=<0.001)
– 2-year DFS, 83.4% vs. 67.4% (p=0.006)
The poor outcome achievable with Conventional Radiotherapy is
reflected in the SEER study, showing a poor global CSS @ 5-yr --> 15%.
7. Conventional Radiation vs. SBRT
Conventional Radiotherapy SBRT
Entire course of Rx in 1-2 wks; 20-60 min/treatment, 1-5 Rxs; no sedation
or anesthesia, outpatient Rx; immediate return to activities
9. Medically inoperable – PFT ( FEV1 or DLCO < 40%),
DM/CAD, cerebral disease, Pul. HTN
Patient choice to avoid surgery
PS 0-2
Stage T1-2, N0 following PET-CT
Max tumour size < 5cm
Not adjacent to major vessels, heart, esophagus etc
Able to lie flat for at least one hour
Patient selection criteria for SBRT in early stage
NSCLC
10. The work flow
SBRT selected as a preferred treatment by a
multidisciplinary team
Lung SBRT protocol at PMH, JTO, 2008
Pre-SBRT work up
Simulation (+/- 4DCT )
Tumor & OAR contouring
Plan analysis & acceptance
Trial setup & off line CBCT
Treatment delivery & review
Follow up & data collection
13. Challenge #2: Target Motion
Solution: Respiratory Gating
- 4DCT ; MIP
- Multislice CT & dynamic scans
- Abdominal compression
- evaluation of the target
position during maximum
inspiration and expiration.
4DCT with
bellows
14. OR ROUTINE CT WITH
ACTIVE BREATHING CONTROL (ABC)
• Temporarily immobilizes patient’s breathing
• The inspiration and expiration paths of airflow are closed at a
predetermined flow direction
15. • MIP images for Target
volume contouring
• GTV= CTV=ITV (MIP)
• Contouring on lung
windows
• Image fusion to
confidently identify
target margin
• PTV= ITV+ 3-5 mm
• GTV= Gross tumor volume, CTV= Clinical
target volume, PTV= planning target
volume
Contouring
16. Stephans et al. l SBRT for Central Lung Tumors l 10/4/11 l 16
Beam placements
17. Compact intermediate dose
This accounts for toxicity.
All of this dose is in normal tissues
Very large low dose volume
A little dose to a lot of normal tissue is
better than a lot of dose to a little normal
tissue
18. Stereotactic Radiation for Stage I NSCLC
• Lung SBRT is gaining a track record of efficacy, now
reaching the intermediate term, in more robust
patients.
– Long term Japanese, IU and VUmc data
– Multi-institutional RTOG 0236 , JCOG 0406
– Many single institutional series
– Japanese, VUmc data for operable patients
– Need larger, cooperative databases
- started at the Swedish Karolinska University hospital in 1991 with tumors in the liver
and lungs . Simultaneously in Japan and clinically introduced in 1994 for lung tumors.
- During the last 5 years of the 1990s, SBRT started in Europe and the US
19. 14 Institutions ; Japan , 1993 - 2003
3yr OS 69% when BED > 100 Gy
3yr OS 81% when BED > 100 Gy ( for
operable pts.)
20. Vrije university, Amsterdam
676 Patients, (stage 1 & 2 ) single
institution , all pet staged
• DOSE= 60GY/ 3 – 8 # ( risk adapted )
• Median f/u = 33 months
• 124 ( 18% ) RECURRENCES
82 (66%) -distant
42(34%) – locoregional
• LR( 10%), LRR( 12.7%) DR (20%)
• Median survival: 41 months
5 year CSS > 60%
5yrs LC – 90%
21. Multicenter Phase II Trials Medically Inoperable
• Dutch Investigators
- 206 patients with Stage I
- Risk adapted approach well tolerated
- Primary tumor recurrence 3%, regional failure 9%, 2 year OS 64%
• JCOG 0403
- Peripheral T1a, N0, M0, inoperable
- 100 patients ,15 centres
- 3yr OS (60%), 3yr LRFS(53%)
- S/E = Gr4(1%), Gr3 (9% Dyspnoea)
• Nordic Study Group
- peripheral T1-T2, N0, M0
- completed accrual of 57 patients in 2005
- Primary tumor recurrence 7%, 2 year OS 65%
27. • SBRT has become a standard of care for medically inoperable
patients
No randomized trial deemed necessary
Up to 10,000 patients treated per year in US
• Successful clinical model using hypofractionated radiotherapy:
Rigorously conducted, highly scrutinized
Multicenter QA
Rapid and widespread acceptance
A recent survey in the USA reported that 64% of RO are currently practicing
SBRT lung (89.3%), liver (54.5%) ,spine (67.5%).
Pan H, Simpson DR et al. A survey of stereotactic body radiotherapy use in the United States. Cancer 2011;117(19):4566e4572.
28. CAUTION
• 6 possibly treatment related deaths
- 4 bacterial pneumonia
- 1 pericardial effusion
- 1 hemoptysis*
(ascribed to carinal recurrence)
Using risk-adapted treatment schedules
(60 Gy / 7.5 Gy #), excellent control rates also
in central tumours with comparable toxicity
profiles. *
* Haasbeek CJ et al J Thorac Oncol 2011;6:2036–43.21.
* Milano MT et al Radiother Oncol 2009;91:301–6.
29. 1. GTV < 13 cc
2. Stage 1A
* Radiation pneumonitis-
1. total lung V5 of >37% and c/L lung V5 > 26%
2. higher V40 -- > faster RP
3. MLD
** Chest wall toxicity-
1. Chest wall dosimetry : V30 < 30 mm3
V60 < 3 mm3
2. Tumors > 1 - 2 cm from the chest wall
and 5 cm from the posterior skin -- > low risk
PREDICTORS FOR TOXICITY
GOOD PROGNOSTIC FACTORS
- Umberto Ricardi et al , LUNG CANCER 2014
*Dutch study
*Michael strauder, Green journal 2012
** Kevin I Stephans, Red Journal 2012
30. Cancer, 2010
Median age = 79 years
80% medically inoperable, and 20% refused surgery.
Severe COPD in 25% of patients.
Risk-adapted SRT schemes were used.
The actuarial LC @ 3 years 89%.
Acute toxicity was uncommon, and late Gr 3 toxicity seen in <10% of
patients.
20 Gy x 3 # ( T1 tumors )
12 Gy x 5 # ( T1 tumors with broad
contact with chest wall ; T2 tumors)
7.5 Gy x 8 # ( tumors adjacent to heart,
large vessels, hilus, brachial plx,
mediastinum).
31. 16 % absolute increased use of SABR in aged >75years from 26% (1999–
2001) to 42% (2005–2007) resulting in significant increase in OS rate ( 16
m 21 m )
36. 2013
45 reports ( 2006 - 2012) containing 3771 patients, stage 1 NSCLC
SABR 2yr LC 91% , OS 70% ( 95% CI : 67-72)
Surgery 68% (95% CI: 66–70)
No survival or local PFS difference with different radiotherapy technologies used for
SABR.
patients with early stage NSCLC treated with SBRT had similar DFS, CSS, LC and
DC as patients treated with surgery but worse 3-year OS ( ?? Better patient profile)
Phase 3 randomised direct comparison highly recommended
37. Frank J. Lagerwaard, Neil K. Aaronson, Chad M. Gundy, Cornelis J.A. Haasbeek, Ben J. Slotman and Suresh
Senan
SABR is a highly effective treatment for stage I NSCLC, with limited toxicity.
In contrast to surgery, SABR does not lead to significant worsening of QOL in the
first year after treatment
2012
Quality of life was maintained, and emotional functioning improved significantly
after SBRT for stage I NSCLC, while
survival was acceptable, local tumor control was high, and toxicity was low.
2010Noelle C Van der Voort et al.
38. 2014
“ In conclusion, probably surgery has a potential rival in early
stage NSCLC, and in the future SABR might be more usedin one
patients’ subgroup “
At the same time, quality assurance procedures and
standardisation of stereotactic treatments ( dose prescription,
delivery techniques ) are warranted.
39. Cost-Effectiveness of SBRT vs. Surgery
Mean cost (USA) Mean cost (INDIA)
SBRT (MO) $42,094 2 – 2.5 lacs
SBRT (CO) $40,107 2 – 2.5 lacs
Wedge resection $51,487 3 – 3.5 Lacs
Lobectomy $49,093 3 – 3.5 Lacs
Shah, Cancer 2013: 119: 3123-32
Clearly operable SBRT is most effective
Lobectomy is more cost effective than wedge resection
40. Future Directions
Randomized comparison of Surgery vs SABR for
operable patients ( stage 1)
ROSEL STUDY (Vumc & Dutch study group)
- lobectomy Vs SBRT
ACOSOG Z4099/RTOG 1021
- Wedge vs SABR
*STARS Trial Lobectomy vs SABR
*MAYO Trial sublobar Sx Vs SABR
*ACCURAY Trial
41. Relapse Patterns from all RT series
Study Local Nodal Distant
CALGB 39904 8% 5% 18% (T2: 30%)
Grills 8% -- 26%
VU 4% 9% 23% @ 2 yrs
Japan 3% 8% 20%
RTOG 0236 3% 5% 22% @ 3 yrs (T2: 47%)
Can adjuvant systemic therapy improve outcomes for
early stage inoperable patients?
CALGB/RTOG – SABR +/- chemo for 2-5cm T1 tumors
43. - Palma; JCO November 2010
Time Trend Analysis: Use of SBRT vs. Observation
vs. Surgery
• 875 pts , Stage I NSCLC: SBRT introduction was associated with 16% increase
in the use of RT and increase in OS (16 Vs 21 mo, HR= 0.70 ).
44. Conclusions
• Multidisciplinary management the Gold-standard Rx approach
• Stage I: Extent of surgery and surgical expertise matters
– Good pulmonary function: Lobectomy is standard of care
• SBRT is a competitive and less morbid option than limited resection for an
Elderly, Borderline operable who can only tolerate limited lung resection
(particularly wedge) or in medically inoperable cases
• At present SBRT not a rival to Surgery….it gives chance of cure for more
localized lung cancers who were otherwise ignored
• But BEWARE about FUTURE…
• SBRT going to be a challenge to Surgery in fit operable patients
• Randomized trails are needed…But will the Surgeons allow us to do
this????
47. A Matched Pair Analysis of Stage I Non-Small Cell Lung Cancer
Treated With Lobectomy, Stereotactic Radiation Therapy
(SBRT), or Wedge Resection
• 286 pts: L (89), W (69), or SBRT (128): 39 pts in each of 3 well-matched groups. 90
day mortality “0” in all groups
ASTRO 2013, Int J of Rad Onc Bio Phy Vol. 87 (2), S10