This document provides an overview and practical tips for spine stereotactic body radiation therapy (SBRT). It discusses patient selection criteria including good performance status and life expectancy. Required imaging includes MRI and CT to aid targeting of the gross tumor volume (GTV) and clinical target volume (CTV). Treatment planning considerations include dose selection of 24-35Gy in 3-5 fractions and organ at risk constraints. Delivery involves cone beam CT guidance to ensure accurate positioning. Case studies demonstrate targeting of spinal metastases from different primary cancers. The document emphasizes the importance of immobilization, image guidance and multidisciplinary care for safe and effective spine SBRT.
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.
El QUANTEC nos ayuda a los oncólogos radioterápicos a la hora de aprobar un tratamiento con sus tablas con "constraints" de los órganos de riesgo (los límites de dosis que pueden recibir los órganos sanos situados entorno al tumor que queremos tratar).
PD: Las tablas se encuentran en las páginas 15-17
Accelerated partial breast irradiation is an alternative to whole breast irradiation in carcinoma breast patients Post breast conserving surgery with equivalent outcome, less duration & less burden on the patient.
El QUANTEC nos ayuda a los oncólogos radioterápicos a la hora de aprobar un tratamiento con sus tablas con "constraints" de los órganos de riesgo (los límites de dosis que pueden recibir los órganos sanos situados entorno al tumor que queremos tratar).
PD: Las tablas se encuentran en las páginas 15-17
Accelerated partial breast irradiation is an alternative to whole breast irradiation in carcinoma breast patients Post breast conserving surgery with equivalent outcome, less duration & less burden on the patient.
ASI Technologies was founded in the year 2012, as a prominent manufacturer, supplier and trader of a comprehensive range of Automation, Integration Systems & Solution. With the objective of providing our customers optimal solutions, we have brought forward Control and Power Panels, PLC Systems and VIPA PLCs. These systems are manufactured using qualitative components, as per the industry laid parameters. As we regulate and conduct our fabrication procedure stringently in order to maintain & achieve flawless configuration of these products, we ensure our customers flawless usage of these panels & systems. In addition, we render automation and after sales services, using advanced methodology with the help of trained technocrats.
Carcinoma Larynx; Evidence based management
Staging - Surgery - Adjuvant therapy - Organ Preservation - Altered fractionation, chemotherapy - Radiotherapy (RT) techniques, Role of IMRT
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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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.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
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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.
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SPINE SBRT for beginners
1. Education
Clinical Care
Research
Spine SBRT 101 : practical tips
3rd International SBRT symposium
2016
Dr. Bala Vellayappan
Assoc. Consultant
MBBS (Singapore), GDFM,
FRANZCR
2. Outline
• Background and rationale
• Determining eligibility (Patient selection)
• Required imaging
• Simulation
• Targeting
• Planning, dose selection
• OAR tolerances
• Plan evaluation
• Delivery and IGRT
• Case studies
3. Background
• Exponential rise in the use of SBRT
• Patients are living longer due to more effective
systemic therapy, and therefore durable control
becomes important
• There is a dose-response curve in palliation. Higher
doses more durable pain relief
• SBRT affords high doses in short schedules (win-
win)
4. Rationale
• Advances in techniques, equipment and positional
verification high doses in tight spaces
• 35Gy/ 5# = BED 60Gy
• 24Gy/2# = BED 53Gy
• Large dose fractions = immune-mediated cell-killing
and endothelial apoptosis 1,2
1. Radiobiological mechanisms of stereotactic body radiation therapy and stereotactic radiation surgery.
Kim et al Radiat Oncol J. 2015 Dec; 33,265
2. Radiation-Induced Vascular Damage in Tumors: Implications of Vascular Damage in Ablative
Hypofractionated Radiotherapy. Park et al. Radiation Research: March 2012, (177),311
5. Patient Selection
• Patient factors
• KPS >50 (preferably 70)
• Life expectancy > 6m
• Able to lie still for treatment
• Not radiosensitive histology
like MM or lymphoma
• Patients with previous EBRT
<45Gy (3 months apart)
• Tumour factors
• <=3 contiguous segments
• Not in cord/cauda
compression (ideal >2mm
gap)
• Spine not unstable (SINS
score)
6. Revised Tokuhashi Score SINS score
Category Options
General Condition
(Performance status)
Poor
Moderate
Good
Number of extraspinal
bone met
>=3
1-2
0
Number of mets in
vertebral body
>=3
2
1
Mets to major internal
organs
Unremovable
Removable
No mets
Primary cancer site
Palsy Complete (Frankel
A,B)
Incomplete (Frankel
C,D)
None (Frankel E)
0-8 : 6m
9-11 : 6 – 12m
12-15 >1 y
Ref : Tokuhashi Y, et al. Spine 2005 2186-91
Component Options
Location Junctional
Mobile Spine
Semi-rigid
Rigid
Pain Yes
Occasional pain but not mechanical
Pain-free lesion
Bone Lesion Lytic
Mixed
Blastic
Radiographic spinal
alignment
Subluxation/translation present
De novo deformity
Normal
Vertebral body
collapse
>50%
<50%
No collapse with >50% body
involved
None
Posterolateral
involvement of spinal
elements
Bilateral
Unilateral
None
0-6 : stable
7 – 12: potentially unstable
13 – 18 : unstable
Ref: Fisher et al Spine 2010 1221
7. Denis’ three column concept
• One column injury is stable
• Two column injury is unstable
• Three column injury is
invariably unstable
Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res. 1984
Oct;(189):65-76.
10. Post-operative cases
• For patients in cord compression, or with unstable spines – upfront
surgical stabilization is preferred
• Challenges with post-operative SBRT
– Uncertainties in targeting due to streak artefacts
– Beam attenuation by rods (uncertainties in dose calculation, beam
modelling)
• Potential solutions
– Speak to your radiologist!
– Artefact reduction protocols are available
– CT myelogram delineates cord well, but may still have streak artefacts
19. Patient preparation
• During consult –
discuss goals and
challenges of the
procedure with the
patient
• Assess pain score,
anxiety and
claustrophobia
• MRI whole spine with
contrast
– T1/T2 sag and axial
– Short tau inversion
recovery (STIR)
• Re-staging CT
• Targeted MRI (limited
sequences for RT
planning)
• +- CT myelogram
Required imaging
20. CT-Simulation
• Near-rigid immobilization
• Thick thermoplastic shell for lesions above T4 (5 point)
• BODYFix for other sites (not simple Vaclock)
• IV contrast optional (good to have)
• We don’t use 4DCT or fiducials
• <3mm cuts through region of interest
• Patient must be relaxed and pain-free *
• Recent MRI for fusion
• Good practice point : reposition patient before simulation
22. Targeting
• GTV (tumour alone) – use diagnostic MRI(T1c,T2) and PET to help
• Involve the surgeon for post—op cases
• CTV = extend GTV to cover adjacent normal looking marrow. (refer to
consensus guidelines)
• Organs at risk (at least 5cm above and below PTV)
Cord or cauda (Defined on T2-MRI) , well above and below target
If cord not visible, can delineate thecal sac
Nerve root/plexus
Esophagus PRV
Bowel
Kidney
Skin (5mm)
27. Treatment planning
• Core group
• Dose selection
– 3 to 5 fraction SBRT is more forgiving, and still gives good results
– 24 – 27Gy in 3 fractions, 30 to 35Gy in 4 to 5 fractions
• Dose constraints
– TG 101
– RTOG 0631
– Follow what the experts do
• VMAT 2 arc
– Quicker than 9-13 field IMRT
– Non-coplanar usually doesn’t add much, and runs the risk of couch
collision
• Plan evaluation
– Know where to compromise
– Cord takes priority there will be dose spillage outside target
28. Treatment delivery
• Equipment
– Commissioning and QA is very important
– Daily machine and indv. patient QA
• Manage the situation
– Setup, imaging, verification and delivery done swiftly
• Setup with lasers and DRO shift initially
• 3D Cone-beam CT
– Estimated to be 2-5minutes
• Tolerances should align with PTV/PRV margins (Desired 1mm/2degree)
• What to match?
• Treatment time
• Mid-CBCT ? Post CBCT?
• Pre-meds
– Dexamethasone 4mg prior to each fraction and few days after
– Adequate analgesia
– Anxiolytics as needed
29. Case study 1 (Patient 001)
• 70 Male, ECOG 0
• Metastatic Cholangioca since 2006
• Progressive C2 lesion causing neck pain
1) Review the images
2) Target the lesion
30.
31.
32.
33. Case study 2 (Patient 003)
• 37 F, ECOG 0
• Met cervical Ca
• On PDL1 clinical trial
• Symptomatic L1 met s/p stabilisation
• For post-op SBRT
1) Review the images
2) Target the lesion
*Post-op targeting is more subjective. Post-op consensus guidelines likely to
be out in Red Journal soon
34.
35.
36.
37.
38. Case study 3 (Patient 009)
• 44, Female, ECOG 1
• RCC diagnosed 2007. Metastatic recurrence in 2012
• Prior RT to prevascular LN 50Gy/20# (2012)
• Started on Pazopanib, then everolimus
• Recent MRI spine shows met involving T3 and L1 vertebral body, with
involvement of superior endplate (L1)
1) Review the images
2) Target the lesion
Conventional RT results in poor control rates at 1 year (50%) for mass-type lesions
Improved imaging and localisation of tumours (and critical structures)
We are delivering 2-3x the doses compared to palliative EBRT – potential for improved local control
No progressive neurologic deficits
Be weary of skin dose in thin patients and where lesions are in the spinous process
Sag T1, Sag T1c
Ax T2
Ax T1C
Sag STIR
Pre-treatment PET showing very avid disease in anterior vert body
T1c and T2
Post-instrumentation diagnostic CT
Post RT PET at 7m
The treatment effect is likely a combination of PDL1 and SBRT