1. The document summarizes the key discussion points from the second St. Gallen EORTC Gastrointestinal Cancer Conference regarding primary treatment of rectal cancer.
2. The optimal treatment strategy depends on tumor staging using MRI and/or EUS, and ranges from local excision for early tumors to neoadjuvant radiochemotherapy plus surgery for advanced cases.
3. There was no clear consensus on the ideal approach for intermediate stages, with debate around preoperative vs postoperative treatment and the sequence of multimodal therapies.
The document discusses recommendations from the St Gallen EORTCTreatment Conference for primary rectal cancer.
Key points include:
- MRI is the preferred method for pre-therapeutic staging of rectal cancer to assess T and N categories.
- Risk stratification separates patients into low, intermediate, and high risk based on MRI and clinical findings.
- For intermediate risk T3N0 mid-rectal cancers, preoperative short-course radiotherapy or chemotherapy alone may be sufficient.
- Preoperative long-course chemoradiation is generally recommended for locally advanced or node-positive cancers to downstage the tumor.
- Adjuvant chemotherapy is not routinely recommended after preoperative chem
The document summarizes evidence and guidelines for managing locally advanced rectal cancer. It discusses that neoadjuvant chemoradiation is preferred over postoperative chemoradiation based on trials showing lower local recurrence rates and less toxicity. Long-course neoadjuvant chemoradiation followed by surgery 6-8 weeks later is the standard approach. Post-treatment assessment of tumor response helps predict outcomes, with complete response indicating a good prognosis. Adjuvant chemotherapy after surgery may further improve survival based on meta-analyses of trials. Guidelines recommend a multidisciplinary, tailored approach incorporating staging, treatment response, and patient factors.
1. Locally advanced rectal cancers are defined as T4 or node-positive lesions that cannot be completely resected without a high risk of residual disease. Management involves pre-operative chemotherapy with or without radiation therapy followed by surgery and adjuvant chemotherapy.
2. For resectable stage II/III cancers, pre-operative chemoradiation or radiation followed by surgery and adjuvant chemotherapy improves local control and survival compared to surgery alone.
3. For unresectable T4 cancers, induction chemotherapy and long-course chemoradiation may enable resection. Adjuvant chemotherapy is recommended in all cases.
1) Preoperative chemoradiotherapy improves local control rates and tumor downstaging for rectal cancer compared to postoperative chemoradiotherapy or radiotherapy alone.
2) The addition of chemotherapy to radiotherapy, whether in the preoperative or postoperative setting, improves local control and disease-free survival compared to radiotherapy alone.
3) For patients who achieve a clinical complete response after preoperative chemoradiotherapy, observation without surgery may be feasible, with local recurrence rates of approximately 30% that can often be successfully salvaged.
Dr. Ashutosh Mukherji's document discusses contouring for rectal cancers. It provides guidelines for clinical target volume (CTV) delineation based on international consensus. The CTV should encompass the tumor, mesorectum, presacrum, and lymph node regions depending on tumor stage and location. Proper contouring is important for administering precise radiotherapy doses to treat rectal cancer while avoiding unnecessary radiation to healthy tissues.
Role of radiation in carcinoma rectum and colon Bharti Devnani
1. Radiation therapy has been shown to decrease rates of local recurrence in rectal cancer when used preoperatively or postoperatively.
2. Studies have demonstrated benefits of preoperative chemoradiation over postoperative chemoradiation, including lower rates of local recurrence, reduced toxicity, and increased rates of sphincter preservation.
3. Techniques such as prone positioning, abdominal compression, and bladder filling can help displace small bowel out of the radiation field and decrease toxicity.
This document discusses changes in the management of rectal cancer over time. It proposes separating treatment into early, TME, and beyond TME tumors. Total mesorectal excision (TME) surgery, which removes the rectum and surrounding tissue, reduced local recurrence rates from 30% to under 10%. Neoadjuvant therapies combined with TME further improved outcomes. Advancements like improved imaging and minimally invasive techniques have led to a paradigm shift. Rectal cancer is now conceptualized and treated according to tumor location and stage.
The best way to treat locally advanced rectal cancerMohamed Abdulla
This document discusses treatment approaches for locally advanced rectal cancer. It begins with basic facts about colorectal cancer incidence and risk factors. It then outlines the principles of surgery as the cornerstone treatment but notes the high rates of local recurrence without adjuvant radiation therapy. The document reviews evidence demonstrating the benefits of total mesorectal excision surgery and chemoradiation in reducing recurrence rates. It examines neoadjuvant and adjuvant chemotherapy approaches, noting some trials found no benefit to adjuvant therapy especially for those who received preoperative chemoradiation. The document discusses moving towards a total neoadjuvant paradigm with upfront chemotherapy and chemoradiation to achieve pathologic complete responses when possible.
The document discusses recommendations from the St Gallen EORTCTreatment Conference for primary rectal cancer.
Key points include:
- MRI is the preferred method for pre-therapeutic staging of rectal cancer to assess T and N categories.
- Risk stratification separates patients into low, intermediate, and high risk based on MRI and clinical findings.
- For intermediate risk T3N0 mid-rectal cancers, preoperative short-course radiotherapy or chemotherapy alone may be sufficient.
- Preoperative long-course chemoradiation is generally recommended for locally advanced or node-positive cancers to downstage the tumor.
- Adjuvant chemotherapy is not routinely recommended after preoperative chem
The document summarizes evidence and guidelines for managing locally advanced rectal cancer. It discusses that neoadjuvant chemoradiation is preferred over postoperative chemoradiation based on trials showing lower local recurrence rates and less toxicity. Long-course neoadjuvant chemoradiation followed by surgery 6-8 weeks later is the standard approach. Post-treatment assessment of tumor response helps predict outcomes, with complete response indicating a good prognosis. Adjuvant chemotherapy after surgery may further improve survival based on meta-analyses of trials. Guidelines recommend a multidisciplinary, tailored approach incorporating staging, treatment response, and patient factors.
1. Locally advanced rectal cancers are defined as T4 or node-positive lesions that cannot be completely resected without a high risk of residual disease. Management involves pre-operative chemotherapy with or without radiation therapy followed by surgery and adjuvant chemotherapy.
2. For resectable stage II/III cancers, pre-operative chemoradiation or radiation followed by surgery and adjuvant chemotherapy improves local control and survival compared to surgery alone.
3. For unresectable T4 cancers, induction chemotherapy and long-course chemoradiation may enable resection. Adjuvant chemotherapy is recommended in all cases.
1) Preoperative chemoradiotherapy improves local control rates and tumor downstaging for rectal cancer compared to postoperative chemoradiotherapy or radiotherapy alone.
2) The addition of chemotherapy to radiotherapy, whether in the preoperative or postoperative setting, improves local control and disease-free survival compared to radiotherapy alone.
3) For patients who achieve a clinical complete response after preoperative chemoradiotherapy, observation without surgery may be feasible, with local recurrence rates of approximately 30% that can often be successfully salvaged.
Dr. Ashutosh Mukherji's document discusses contouring for rectal cancers. It provides guidelines for clinical target volume (CTV) delineation based on international consensus. The CTV should encompass the tumor, mesorectum, presacrum, and lymph node regions depending on tumor stage and location. Proper contouring is important for administering precise radiotherapy doses to treat rectal cancer while avoiding unnecessary radiation to healthy tissues.
Role of radiation in carcinoma rectum and colon Bharti Devnani
1. Radiation therapy has been shown to decrease rates of local recurrence in rectal cancer when used preoperatively or postoperatively.
2. Studies have demonstrated benefits of preoperative chemoradiation over postoperative chemoradiation, including lower rates of local recurrence, reduced toxicity, and increased rates of sphincter preservation.
3. Techniques such as prone positioning, abdominal compression, and bladder filling can help displace small bowel out of the radiation field and decrease toxicity.
This document discusses changes in the management of rectal cancer over time. It proposes separating treatment into early, TME, and beyond TME tumors. Total mesorectal excision (TME) surgery, which removes the rectum and surrounding tissue, reduced local recurrence rates from 30% to under 10%. Neoadjuvant therapies combined with TME further improved outcomes. Advancements like improved imaging and minimally invasive techniques have led to a paradigm shift. Rectal cancer is now conceptualized and treated according to tumor location and stage.
The best way to treat locally advanced rectal cancerMohamed Abdulla
This document discusses treatment approaches for locally advanced rectal cancer. It begins with basic facts about colorectal cancer incidence and risk factors. It then outlines the principles of surgery as the cornerstone treatment but notes the high rates of local recurrence without adjuvant radiation therapy. The document reviews evidence demonstrating the benefits of total mesorectal excision surgery and chemoradiation in reducing recurrence rates. It examines neoadjuvant and adjuvant chemotherapy approaches, noting some trials found no benefit to adjuvant therapy especially for those who received preoperative chemoradiation. The document discusses moving towards a total neoadjuvant paradigm with upfront chemotherapy and chemoradiation to achieve pathologic complete responses when possible.
Early stage colorectal cancer is treated with surgery, while more advanced stages receive surgery plus chemotherapy or radiation and chemotherapy. Metastatic or recurrent disease is treated with chemotherapy, targeted therapy, and sometimes radiation or surgery. Radiation is commonly used to treat rectal cancer before or after surgery to reduce the risk of local recurrence. It can safely expand the surgical resection area and increase the chance of sphincter preservation. Radiation techniques use imaging like CT and PET scans to precisely target the radiation dose to areas at risk while minimizing side effects. Radiation can also effectively palliate symptoms from recurrent or metastatic colorectal cancer.
Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...ensteve
1) The document discusses complete response rates for patients with advanced rectal cancer receiving pre-operative chemoradiotherapy. It reports a complete pathological response rate of 17.5% in its study.
2) Patients who had a complete pathological response were found to have excellent long-term survival and no recurrence of cancer, with a median follow-up time of over 5 years.
3) A complete clinical response seen before surgery does not guarantee there is no remaining cancer, as viable tumor cells may still be present. The nature of the surgery should not be determined based on clinical response alone.
The anal canal is approximately 4 cm in length extending from the anorectal junction to the anal verge. Anal cancers are rare and mostly squamous cell carcinomas arising from the anal transitional zone. Risk factors include HPV infection and immunosuppression. Combined chemoradiotherapy is the standard first-line treatment and results in high response rates and organ preservation compared to radiation alone. Salvage surgery may be considered for select cases after failed nonsurgical treatment or as primary treatment for those who cannot tolerate chemoradiotherapy. Prognosis depends on tumor stage, with 5-year survival rates ranging from 45-86% depending on depth of invasion and nodal involvement.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
This document discusses treatment approaches for rectal cancer. It notes that rectal cancer is best treated through a multidisciplinary team approach. Surgery remains the primary treatment but neoadjuvant chemoradiation is preferred to postoperative chemoradiation for stages II and III disease due to improved outcomes and toxicity profiles. Fluoropyrimidine chemotherapy forms the backbone of treatment regimens and can be given orally. Long course radiation therapy is the standard approach. Achieving a pathologic complete response through neoadjuvant therapy leads to significantly better outcomes. Further research is still needed.
TARGET DELINEATION OF CANCER ESOPHAGUSKanhu Charan
1. The document discusses guidelines for delineating target volumes for radiation treatment planning in esophageal cancer.
2. It describes expanding the gross tumor volume (GTV) to create the clinical target volume (CTV) with margins of 4cm above and below the tumor and 1-1.5cm radially, plus inclusion of involved lymph nodes.
3. The planning target volume (PTV) is created by expanding the CTV by 0.5-1cm to account for setup variability and organ motion.
Indications and rt techniques in liver,gb & pancreasDr.Amrita Rakesh
1. The document discusses the anatomy, staging, and treatment options for pancreatic cancer, liver cancer, and gallbladder cancer including surgery, chemotherapy, radiation therapy, and newer techniques like stereotactic body radiation therapy.
2. Key points include that surgical resection offers the only chance for cure in pancreatic cancer but is only possible in 20% of cases, and adjuvant or neoadjuvant chemoradiation can improve outcomes. For liver cancer, options include resection, transplantation, ablation, embolization, and stereotactic body radiation has shown promise in early studies.
3. Guidelines for contouring targets and organs at risk in radiation therapy for the pancreas and liver are also reviewed.
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarFight Colorectal Cancer
Michael Bassetti, MD, Ph.D. from the University of Wisconsin Carbone Cancer Center discusses all you need to know about radiation. Dr. Bassetti will talk about what radiation treatment is, how it’s used for rectal and colon cancer patients, how to prepare for treatment, how to manage side effects and more.
The document discusses several topics related to colorectal cancer including hereditary forms, staging, treatment with surgery and targeted therapies. It presents two case studies, one with a family history of colon cancer who was found to have a genetic mutation, and another with a locally advanced rectal tumor treated with preoperative chemoradiation followed by surgery.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
This document discusses carcinoma of unknown primary (CUP). It notes that CUP has a poor prognosis, with a median survival of 8-12 months. The most common histological types are adenocarcinoma and poorly differentiated carcinoma. Immunohistochemistry can help determine the primary site through markers for epithelial, melanoma, germ cell, neuroendocrine, lymphoma, thyroid, prostate, and sarcoma origins. Certain subsets have a more favorable prognosis, such as women with isolated axillary adenopathy or peritoneal papillary serous carcinoma, and should receive site-directed therapy. Treatment options are discussed for various clinical presentations like axillary lymph nodes, cervical lymph nodes, bone or prostate involvement, or single resectable metastases
Preoperative chemoradiotherapy is commonly used to treat rectal cancer. It can reduce the tumor size and increase the likelihood of sphincter-sparing surgery. Studies have shown that preoperative chemoradiotherapy results in lower local recurrence rates compared to postoperative chemoradiotherapy or radiotherapy alone, without increasing distant metastases or mortality. Short-course radiotherapy followed by surgery within a week is also effective at reducing local recurrence compared to surgery alone, especially when combined with total mesorectal excision.
This document discusses surgical treatment options for rectal cancer, including radical resection and local excision procedures. It emphasizes that total mesorectal excision during radical resection is optimal for most rectal cancers as it facilitates nerve preservation and complete resection, improving local control rates to less than 10%. Local excision may be adequate for early stage cancers, with local failure rates of around 20% when strict selection criteria are followed. Adjuvant chemotherapy and radiation are recommended to improve outcomes after conventional surgery for advanced cancers.
The document announces the 8th European Multidisciplinary Colorectal Cancer Congress (EMCCC) to be held on December 11-13, 2016 in Amsterdam. It provides information on registration deadlines, the scientific program including workshops on various topics related to colorectal cancer, and keynote speakers. The congress aims to facilitate multidisciplinary interaction and discussion among researchers and clinicians from different areas involved in colorectal cancer.
- Neoadjuvant chemoradiation is now considered mandatory for locally advanced rectal cancer based on improved outcomes seen in clinical trials. Complete pathological response following neoadjuvant therapy occurs in 15-30% of patients and is associated with improved survival and possibility of avoiding surgery. However, accurately identifying patients who achieve complete response remains challenging and radical surgery remains the standard of care. Ongoing research aims to optimize neoadjuvant regimens and develop methods to safely select patients for non-operative management when complete response is achieved.
The document discusses recent advances in the management of rectal cancer. It covers:
1. Molecular biology advances like DNA chip technology that help determine prognosis and need for prophylactic surgery based on genes like APC, mismatch repair genes, and markers like p21 and p53.
2. Improved staging using endorectal ultrasound, CT, MRI and PET scans to accurately determine tumor depth and node involvement to guide treatment decisions.
3. Advances in surgery including total mesorectal excision, laparoscopic and robotic techniques, and the use of neoadjuvant chemoradiation to improve outcomes.
Early stage colorectal cancer is treated with surgery, while more advanced stages receive surgery plus chemotherapy or radiation and chemotherapy. Metastatic or recurrent disease is treated with chemotherapy, targeted therapy, and sometimes radiation or surgery. Radiation is commonly used to treat rectal cancer before or after surgery to reduce the risk of local recurrence. It can safely expand the surgical resection area and increase the chance of sphincter preservation. Radiation techniques use imaging like CT and PET scans to precisely target the radiation dose to areas at risk while minimizing side effects. Radiation can also effectively palliate symptoms from recurrent or metastatic colorectal cancer.
Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...ensteve
1) The document discusses complete response rates for patients with advanced rectal cancer receiving pre-operative chemoradiotherapy. It reports a complete pathological response rate of 17.5% in its study.
2) Patients who had a complete pathological response were found to have excellent long-term survival and no recurrence of cancer, with a median follow-up time of over 5 years.
3) A complete clinical response seen before surgery does not guarantee there is no remaining cancer, as viable tumor cells may still be present. The nature of the surgery should not be determined based on clinical response alone.
The anal canal is approximately 4 cm in length extending from the anorectal junction to the anal verge. Anal cancers are rare and mostly squamous cell carcinomas arising from the anal transitional zone. Risk factors include HPV infection and immunosuppression. Combined chemoradiotherapy is the standard first-line treatment and results in high response rates and organ preservation compared to radiation alone. Salvage surgery may be considered for select cases after failed nonsurgical treatment or as primary treatment for those who cannot tolerate chemoradiotherapy. Prognosis depends on tumor stage, with 5-year survival rates ranging from 45-86% depending on depth of invasion and nodal involvement.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
This document discusses treatment approaches for rectal cancer. It notes that rectal cancer is best treated through a multidisciplinary team approach. Surgery remains the primary treatment but neoadjuvant chemoradiation is preferred to postoperative chemoradiation for stages II and III disease due to improved outcomes and toxicity profiles. Fluoropyrimidine chemotherapy forms the backbone of treatment regimens and can be given orally. Long course radiation therapy is the standard approach. Achieving a pathologic complete response through neoadjuvant therapy leads to significantly better outcomes. Further research is still needed.
TARGET DELINEATION OF CANCER ESOPHAGUSKanhu Charan
1. The document discusses guidelines for delineating target volumes for radiation treatment planning in esophageal cancer.
2. It describes expanding the gross tumor volume (GTV) to create the clinical target volume (CTV) with margins of 4cm above and below the tumor and 1-1.5cm radially, plus inclusion of involved lymph nodes.
3. The planning target volume (PTV) is created by expanding the CTV by 0.5-1cm to account for setup variability and organ motion.
Indications and rt techniques in liver,gb & pancreasDr.Amrita Rakesh
1. The document discusses the anatomy, staging, and treatment options for pancreatic cancer, liver cancer, and gallbladder cancer including surgery, chemotherapy, radiation therapy, and newer techniques like stereotactic body radiation therapy.
2. Key points include that surgical resection offers the only chance for cure in pancreatic cancer but is only possible in 20% of cases, and adjuvant or neoadjuvant chemoradiation can improve outcomes. For liver cancer, options include resection, transplantation, ablation, embolization, and stereotactic body radiation has shown promise in early studies.
3. Guidelines for contouring targets and organs at risk in radiation therapy for the pancreas and liver are also reviewed.
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarFight Colorectal Cancer
Michael Bassetti, MD, Ph.D. from the University of Wisconsin Carbone Cancer Center discusses all you need to know about radiation. Dr. Bassetti will talk about what radiation treatment is, how it’s used for rectal and colon cancer patients, how to prepare for treatment, how to manage side effects and more.
The document discusses several topics related to colorectal cancer including hereditary forms, staging, treatment with surgery and targeted therapies. It presents two case studies, one with a family history of colon cancer who was found to have a genetic mutation, and another with a locally advanced rectal tumor treated with preoperative chemoradiation followed by surgery.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
This document discusses carcinoma of unknown primary (CUP). It notes that CUP has a poor prognosis, with a median survival of 8-12 months. The most common histological types are adenocarcinoma and poorly differentiated carcinoma. Immunohistochemistry can help determine the primary site through markers for epithelial, melanoma, germ cell, neuroendocrine, lymphoma, thyroid, prostate, and sarcoma origins. Certain subsets have a more favorable prognosis, such as women with isolated axillary adenopathy or peritoneal papillary serous carcinoma, and should receive site-directed therapy. Treatment options are discussed for various clinical presentations like axillary lymph nodes, cervical lymph nodes, bone or prostate involvement, or single resectable metastases
Preoperative chemoradiotherapy is commonly used to treat rectal cancer. It can reduce the tumor size and increase the likelihood of sphincter-sparing surgery. Studies have shown that preoperative chemoradiotherapy results in lower local recurrence rates compared to postoperative chemoradiotherapy or radiotherapy alone, without increasing distant metastases or mortality. Short-course radiotherapy followed by surgery within a week is also effective at reducing local recurrence compared to surgery alone, especially when combined with total mesorectal excision.
This document discusses surgical treatment options for rectal cancer, including radical resection and local excision procedures. It emphasizes that total mesorectal excision during radical resection is optimal for most rectal cancers as it facilitates nerve preservation and complete resection, improving local control rates to less than 10%. Local excision may be adequate for early stage cancers, with local failure rates of around 20% when strict selection criteria are followed. Adjuvant chemotherapy and radiation are recommended to improve outcomes after conventional surgery for advanced cancers.
The document announces the 8th European Multidisciplinary Colorectal Cancer Congress (EMCCC) to be held on December 11-13, 2016 in Amsterdam. It provides information on registration deadlines, the scientific program including workshops on various topics related to colorectal cancer, and keynote speakers. The congress aims to facilitate multidisciplinary interaction and discussion among researchers and clinicians from different areas involved in colorectal cancer.
- Neoadjuvant chemoradiation is now considered mandatory for locally advanced rectal cancer based on improved outcomes seen in clinical trials. Complete pathological response following neoadjuvant therapy occurs in 15-30% of patients and is associated with improved survival and possibility of avoiding surgery. However, accurately identifying patients who achieve complete response remains challenging and radical surgery remains the standard of care. Ongoing research aims to optimize neoadjuvant regimens and develop methods to safely select patients for non-operative management when complete response is achieved.
The document discusses recent advances in the management of rectal cancer. It covers:
1. Molecular biology advances like DNA chip technology that help determine prognosis and need for prophylactic surgery based on genes like APC, mismatch repair genes, and markers like p21 and p53.
2. Improved staging using endorectal ultrasound, CT, MRI and PET scans to accurately determine tumor depth and node involvement to guide treatment decisions.
3. Advances in surgery including total mesorectal excision, laparoscopic and robotic techniques, and the use of neoadjuvant chemoradiation to improve outcomes.
Présentation "Dictionnaire humoristique de la condition humaine Selon la psyc...Editions du Pantheon
Présentation de l'ouvrage de Michelle Bergheimer ayant pour titre : "Dictionnaire humoristique de la condition humaine Selon la psychanalyste du 126". Editions du Panthéon, mai 2013.
El documento resume las acciones realizadas por una organización en julio y agosto de 2011, incluyendo actos de cierre de programas en varias ciudades de España, envío de notas de prensa, entrevistas a participantes ganadores, y un viaje a Silicon Valley. También incluye estadísticas del número total de impactos generados cada mes desde diciembre hasta agosto por la inserción de información en varios medios de comunicación a nivel nacional y regional.
Reisen. Staunen. Genießen.
Die Mariazellerbahn ist immer eine Reise wert! Die der hügeligen bis gebirgigen Landschaft optimal angepasste Linienführung mit ihren schonend eingefügten Kunstbauten bildet die Basis für die Strecken, die nie den Eindruck störender Gigantomanie vermittelt. Trotz der Leistung, die die Bahn aufbringen muss, um sich zum Scheitelpunkt hochzuarbeiten, vermittelt sie eine spielerische Leichtigkeit, einen Hauch von Märchenwelt und Entschleunigung.
Ob mit der hochmodernen Himmelstreppe, im komfortablen Panoramawagen, oder mit den Nostalgiezügen mit Lok 1099 und MH6 - eine Fahrt mit der Mariazellerbahn ist immer ein ganz besonderes Erlebnis!
La autora reflexiona sobre lo que realmente considera importante en la vida a raíz de las enfermedades de amigos cercanos. Señala que el éxito, poder y dinero no son tan importantes más allá de lo necesario para vivir con dignidad. Ahora en esta etapa de su vida, lo único que desea es la compañía de su amor y amigos, recuerdos gratos, belleza natural, libertad intelectual y serenidad para afrontar la vida.
Este documento presenta una lista de integrantes y luego proporciona información sobre las características de la epopeya. Define la epopeya como un amplio poema que narra una acción heroica, popular o nacional. Explica que tiene una estructura básica con un narrador, acción y personajes. La acción se compone de exposición, nudo y desenlace. Las epopeyas suelen incluir fuerzas sobrenaturales y tratan sobre valores nacionales. Se transmitían oralmente y por escrito en verso.
El documento presenta a los principales protagonistas y antagonistas de la serie de libros Harry Potter. Harry Potter, Ron Weasley y Hermione Granger son los tres protagonistas principales que asisten a Hogwarts y se enfrentan repetidamente a Lord Voldemort, el antagonista que busca dominar el mundo mágico. Otros personajes importantes son Albus Dumbledore, el director de Hogwarts, y Severus Snape, un profesor con una lealtad ambigua.
Iniciación en oriente ( prosa poética) (1)tomasvila
El documento narra la historia de una joven que conoce a un hombre mayor que la inicia en temas sexuales a través de ejercicios y fantasías. El hombre la lleva a experimentar placer con él y otras personas de forma gradual. La joven parece disfrutar de las experiencias aunque también muestra dudas y vergüenza en algunos momentos. El relato sugiere que la joven luego busca encuentros lésbicos de forma independiente.
Este documento anuncia un curso intermedio de análisis estructural asistido por computadora (SAP 2000 Parte II) que se llevará a cabo durante abril de 2009 en el Colegio de Ingenieros Civiles de Aguascalientes. El curso cubrirá el análisis de estructuras continuas como muros, losas y bóvedas mediante el método de elementos finitos, así como análisis dinámico modal espectral. El curso tendrá una duración de 30 horas a lo largo de 2 sesiones seman
Carrefour Property es la primera inmobiliaria comercial de Europa, con más de 1.000 centros y 4 millones de metros cuadrados. En España tiene 109 centros y 1,9 millones de metros cuadrados. Se centra en el desarrollo de proyectos, la gestión de activos, el incremento del atractivo de los centros y la mejora de la experiencia de los clientes a través de eventos y promociones.
The document discusses various querying methods in Grails including dynamic finders, where queries, detached criteria, HQL queries, and performance optimizations. It provides examples of how to use findBy, findWhere, get, count, list and other dynamic finder methods. It also covers where queries, operators, aggregate functions, collections, subqueries, bulk updates/deletes, criteria queries, and HQL queries. It discusses returning different result types and filtering query results. Lastly, it mentions caching and performance techniques.
Este documento ofrece consejos para vivir una vida plena y feliz, como apreciar los pequeños momentos y las cosas simples de la vida, tener pensamientos y actitudes positivas, respetar a los demás, perdonar, ser espontáneo, creativo y sincero, y aprovechar cada oportunidad para crecer personal y espiritualmente.
The document discusses the differences between publishing data versus curating data. While making data openly available through publishing is a simple concept, it has some downsides for data like not meeting the needs of developers and machines or ensuring the data is up to date. Curation is presented as a better approach that involves taking responsibility for the data through planning, modeling and keeping collections updated over time to help audiences use the data. However, challenges still remain around keeping data updated, organizing it effectively and meeting the formatting needs of developers. The document is promoting the company Kasabi as providing data curation services to address these issues.
Reporte Visita Cerrejón. Por Kumar Cabrerakumarcabrera
Colombia es el segundo exportador mundial de carbón térmico. La mina de carbón El Cerrejón en La Guajira es la operación de explotación a cielo abierto más grande del mundo. El documento describe el proceso de extracción de carbón en El Cerrejón, que incluye la remoción de la vegetación y suelo, perforación, voladura, cargue y transporte del carbón hasta el puerto de embarque en Puerto Bolívar, desde donde se exporta principalmente a Europa y Asia. También describe las instalaciones y equipos de la mina, así
Colorectal carcinoma anatomy to managementDrAyush Garg
This document provides an overview of colorectal carcinoma, including its anatomy, epidemiology, risk factors, clinical features, screening, pathology, staging, and diagnostic workup. It begins with a description of the embryological development of the colon and rectum. It then discusses the risk factors for colorectal cancer, pre-invasive lesions, clinical presentation, screening guidelines, the adenoma-carcinoma sequence of tumor progression, staging system, and tests used to diagnose and stage colorectal cancer. The goal is to comprehensively cover colorectal carcinoma from anatomy to management.
This document summarizes the key points from Joël Shapiro's thesis on prognostication and new treatment strategies for esophageal and junctional cancer.
Part I of the thesis focuses on prognostication, evaluating the impact of neoadjuvant chemoradiotherapy (nCRT) on established prognostic factors. Part II focuses on new treatment strategies, analyzing long-term results from the CROSS trial comparing nCRT plus surgery to surgery alone. The thesis also evaluates methods to identify patients with a pathologic complete response after nCRT who may not require surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
Colorectal cancer (CRC) has potential to spread within the peritoneal cavity, and this transcoelomic
dissemination is termed “peritoneal metastases” (PM).The aim of this article was to summarise the current
evidence regarding CRC patients at high risk of PM. Colorectal cancer is the second most common cause of cancer
death in the UK. Prompt investigation of suspicious symptoms is important, but there is increasing evidence that
screening for the disease can produce significant reductions in mortality.High quality surgery is of paramount
importance in achieving good outcomes, particularly in rectal cancer, but adjuvant radiotherapy and chemotherapy
have important parts to play. The treatment of advanced disease is still essentially palliative, although surgery for
limited hepatic metastases may be curative in a small proportion of patients.
Digital version thesis Salvage for radiorecurrent prostate cancer, Max PetersMax Peters
This document discusses salvage therapy for prostate cancer recurrences after primary radiotherapy. It notes that patients undergoing radiotherapy are at risk of recurrent disease, which is often confined to the prostate and eligible for salvage treatment. Traditionally, salvage modalities targeted the entire prostate due to difficulties assessing localized recurrences, but this resulted in significant toxicity rates. Recent advances in MRI and biopsy techniques allow for focal salvage treatments targeting only the recurrent tumor area, maintaining cancer control while decreasing toxicity. Focal salvage Iodine-125 brachytherapy appears able to provide durable disease control with minimized toxicity. However, dose constraints are needed for organs at risk to prevent complications, and constraints developed for primary radiotherapy may not apply
This document summarizes cancer surgery. It discusses how surgery is often used to diagnose, treat, and potentially prevent cancer. The basic principles of oncologic surgery include excising the tumor, removing regional lymph nodes, and managing local and regional recurrence. Responsibilities of surgical oncologists include following treatment protocols, participating in research, and educating other surgeons. Cancer surgery traditionally involves removing the tumor and surrounding healthy tissue through an incision. Pathologists examine the removed tissue to ensure all detectable cancer cells were eliminated. Risks of cancer surgery include complications from anesthesia, infections, and immunosuppression.
The document discusses the current roles of radiotherapy and chemotherapy in treating oral cavity cancer. It outlines how radiotherapy and chemotherapy are used as primary treatments, adjuvantly after surgery, and for salvage treatment, depending on factors like disease stage and patient suitability for surgery. Postoperative radiotherapy or chemoradiotherapy can improve outcomes for patients with high-risk features like positive margins, lymph node involvement, or advanced T-stage disease.
1) The document reviews the current role of radiotherapy and chemotherapy in treating oral cavity cancer.
2) Treatment options include surgery, radiotherapy (external beam and/or brachytherapy), and chemotherapy, either alone or in combination.
3) The main factors considered in selecting treatment are disease control probability, anticipated functional outcomes, tumor resectability, and patient condition. Postoperative radiotherapy or chemoradiotherapy can improve outcomes for patients with high-risk features.
1) The document reviews the current role of radiotherapy and chemotherapy in treating oral cavity cancer.
2) Treatment options include surgery, radiotherapy (external beam and/or brachytherapy), and chemotherapy, either alone or in combination.
3) The main factors considered in selecting treatment are disease control probability, anticipated functional outcomes, tumor resectability, and patient condition. Postoperative radiotherapy or chemoradiotherapy can improve outcomes for patients with high-risk features.
A dramatic increase in the incidence of the diffuse form of gastric adenocarcinomas and particularly signet ring cell carcinomas has been observed in Western countries. Evidence is accruing that signet ring cell carcinomas may have inherent chemo resistance leaving many clinicians unsure of the benefits of delaying surgery to pursue a neoadjuvant approach.
Chair & Moderator, Prof. Solange Peters, MD, PhD, Mark M. Awad, MD, PhD, and Jonathan D. Spicer, MD, PhD, FRCSC, prepared useful Practice Aids pertaining to Cancer Immunotherapy for this CME/MOC/CC activity titled “Parsing the Practicalities of Pathologic Response Assessment After Neoadjuvant Immunotherapy to Facilitate Progress in Early-Stage Cancers.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/CC information, and to apply for credit, please visit us at https://bit.ly/3uRHyjk. CME/MOC/CC credit will be available until May 9, 2023.
Co-Chairs, Nasser Altorki, MD, and Jonathan D. Spicer, MD, PhD, FRCSC, prepared useful Practice Aids pertaining to NSCLC for this CME/MOC activity titled “How to Integrate Perioperative Immunotherapy Into Multimodal Treatment Plans to Improve Outcomes in Resectable NSCLC.” For the full presentation, downloadable Practice Aids, and complete CME/MOC information, and to apply for credit, please visit us at https://bit.ly/3xb6WS1. CME/MOC credit will be available until June 14, 2023.
This study retrospectively analyzed 69 patients who underwent total thyroidectomy with lymph node dissection for papillary thyroid cancer with clinical nodal metastases. The rate of locoregional recurrence with positive cervical lymph nodes after an average 8-year follow-up was 34.7%, which was higher than the 4.2% recurrence rate reported in patients without nodal metastases. Nodal metastases were found to be a predictor of local recurrence. Male gender and age under 50 were associated with higher risk of nodal recurrence. The study concludes that nodal metastases increase the likelihood of local recurrence after surgery for papillary thyroid cancer.
Short-course radiotherapy followed by neo-adjuvant chemotherapy in locally ad...Enrique Moreno Gonzalez
Current standard for most of the locally advanced rectal cancers is preoperative chemoradiotherapy, and, variably per institution, postoperative adjuvant chemotherapy. Short-course preoperative radiation with delayed surgery has been shown to induce tumour down-staging in both randomized and observational studies. The concept of neo-adjuvant chemotherapy has been proven successful in gastric cancer, hepatic metastases from colorectal cancer and is currently tested in primary colon cancer.
This document summarizes the results of updated meta-analyses on the use of altered fractionated radiotherapy in head and neck squamous cell carcinoma (HNSCC) patients. The March 2006 meta-analysis found improved overall and progression-free survival with altered fractionation compared to conventional radiotherapy, with hyperfractionation showing the greatest benefit. The updated 2017 meta-analysis confirmed these findings based on 34 trials and over 11,000 patients, with longer follow-up. It found hyperfractionated radiotherapy continued to have a significant survival benefit over moderately or very accelerated regimens.
1) Hormonal therapy targets estrogen receptor positive breast cancers, which comprise around 70% of cases. It works by blocking the effects of estrogen through various mechanisms.
2) Available hormonal therapies include selective estrogen receptor modulators (SERMs) like tamoxifen, aromatase inhibitors, LHRH analogues, and ovarian ablation through surgery or radiation.
3) In the adjuvant setting, 5 years of tamoxifen reduces recurrence and mortality rates in both pre- and postmenopausal women. Longer durations up to 10 years provide further benefits in high risk patients. Aromatase inhibitors are now preferred over tamoxifen for initial therapy in postmenopausal women.
1) Brachytherapy is an effective penile-conserving treatment for T1-T2 penile cancers, delivering a high radiation dose over 4-5 days directly to the tumor while sparing surrounding tissue.
2) The document describes the patient selection criteria, dosimetry techniques, needle placement procedures, and acute and late side effects of brachytherapy based on a study of 75 penile cancer patients treated between 1989-2009.
3) Results showed 5-year local tumor control rates of 70-86% and penile preservation rates of 72-88%, with generally good cosmetic outcomes and erectile function preservation. Brachytherapy is concluded to be a simple and highly effective
Fractionated radiation and dose rate effectParag Roy
Fractionated radiation and the dose-rate effect can impact cell survival through mechanisms like sublethal damage (SLD) repair and cell cycle redistribution. SLD repair occurs as double-strand breaks are rejoined after radiation exposure. At lower dose rates, more SLD can be repaired between fractions, improving cell survival. However, very low dose rates may instead reduce survival if cells become frozen in radiosensitive phases of the cell cycle. The dose-rate effect varies between cell types and depends on factors like oxygenation and ability to progress through the cell cycle after radiation.
This document discusses the concept of relative biological effectiveness (RBE), which compares the biological effects of different types of ionizing radiation. It defines RBE as the ratio of doses of radiation (such as x-rays versus neutrons) required to produce the same biological effect. Higher RBE values indicate radiation that causes greater biological damage. The document explains that RBE depends on factors like radiation dose, number of fractions, and biological endpoint. It also discusses how RBE varies with linear energy transfer (LET), being highest around 100 keV/μm, and how RBE and oxygen enhancement ratio are inversely related and peak around the same LET value.
Ewings sarcoma management Chemotherapy trialsParag Roy
This document provides information on the management of Ewing's Sarcoma, including:
- Ewing's Sarcoma is identified by the translocation t(11;22) in 90-95% of cases.
- Metastases most commonly spread to the lungs, bones, and bone marrow. Nearly all patients have micrometastases at diagnosis.
- Treatment involves induction chemotherapy followed by local control with surgery or radiotherapy and maintenance chemotherapy.
- Several clinical trials have evaluated chemotherapy regimens and dosing schedules, with INT-0099 establishing VDC/IE as the standard of care and AEWS-0031 showing improved outcomes with interval-compressed chemotherapy.
Carcinoma vagina surgery radiotherapy managementParag Roy
This document summarizes the management of carcinoma vagina including surgery, radiation therapy, and chemoradiation. It discusses prognostic factors, patterns of failure, survival rates, and management approaches for different stages of disease. For early stage disease, radiation therapy is preferred while surgery may be considered for superficial lesions. Later stages are best managed with external beam radiation and brachytherapy, with chemoradiation potentially playing a role but requiring further study. Outcomes depend strongly on stage, with stage I disease having 5-year survival rates of 60-85% with radiation alone.
Clinical response to normal tissue with radiationParag Roy
The document discusses the clinical response of normal tissues to radiation. It makes three key points:
1) The response of normal tissues to radiation is determined by the inherent radiosensitivity of individual cells, the kinetics of the tissue as a whole, and how cells are organized structurally within the tissue.
2) Radiation effects are divided into early (acute) effects, which occur within days or weeks and result from cell death, and late effects, which appear months or years later and occur in slowly proliferating tissues.
3) Tissues can be classified based on their functional subunits (FSUs). Tissues with well-defined FSUs like the kidney have a low radiation tolerance, while tissues
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
This document discusses endovascular brachytherapy for treating vascular stenosis. It provides background on vascular anatomy and the pathology of arteriosclerotic vessels and restenosis. Radiotherapy helps prevent restenosis by reducing neointimal proliferation through damaging DNA and inhibiting cell proliferation in the vessel wall. The target volume for treatment includes cells in the adventitia and possibly media layers, rather than just the intima. Indications for brachytherapy include in-stent restenosis and some de novo lesions at high risk of restenosis. Contraindications include prior radiation to the chest and restenosis after previous brachytherapy.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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.
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
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
NVBDCP.pptx Nation vector borne disease control program
St gallen primary treatment of rectal ca
1. Review
Second St. Gallen European Organisation for Research
and Treatment of Cancer Gastrointestinal Cancer
Conference: consensus recommendations on controversial
issues in the primary treatment of rectal cancer
Manfred P. Lutz a,
*, John R. Zalcberg b
, Rob Glynne-Jones c
,
Theo Ruers d
, Michel Ducreux e
, Dirk Arnold f
, Daniela Aust g
,
Gina Brown h
, Krzysztof Bujko i
, Christopher Cunningham j
,
Serge Evrard k
, Gunnar Folprecht g
, Jean-Pierre Gerard l
,
Angelita Habr-Gama m
, Karin Haustermans n
, Torbjo¨rn Holm o
,
Koert F. Kuhlmann d
, Florian Lordick p
, Gilles Mentha q,y
,
Markus Moehler r
, Iris D. Nagtegaal s
, Alessio Pigazzi t
,
Salvatore Puciarelli u
, Arnaud Roth q
, Harm Rutten v
,
Hans-Joachim Schmoll w
, Halfdan Sorbye x,y
, Eric Van Cutsem z
,
Ju¨rgen Weitz g
, Florian Otto aa
a
CaritasKlinikum St. Theresia, Saarbru¨cken, Germany
b
Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, The Alfred Centre,
Melbourne, Australia
c
Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
d
The Netherlands Cancer Institute, Amsterdam, The Netherlands
e
Gustave Roussy, Universite´ Paris-Saclay, De´partement de Me´decine, Villejuif, France
f
CUF Hospitals, Oncology Center, Lisbon, Portugal
g
Universita¨tsklinikum Carl Gustav Carus, Dresden, Germany
h
Department of Diagnostic Imaging, The Royal Marsden NHS Foundation Trust, London, UK
i
The Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
j
Oxford University Hospitals NHS Trust, Oxford, UK
k
Institut Bergonie´, Universite´ de Bordeaux, Bordeaux, France
l
Centre A Lacassagne, Nice, France
m
Angelita and Joaquim Gama Institute, Sa˜o Paulo, Brazil
n
Department of Radiation Oncology, University Hospitals Leuven, Belgium
o
Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
p
University Cancer Center Leipzig (UCCL), University Medicine Leipzig, Germany
q
Visceral Surgery, HUG, Geneva, Switzerland
* Corresponding author: Caritasklinikum Saarbru¨cken, St. Theresia, Medizinische Klinik, Rheinstrasse 2, 66113 Saarbru¨cken, Germany.
Tel.: þ49 681 406 1001; fax: þ49 681 406 1003.
E-mail addresses: m.lutz@caritasklinikum.de (M.P. Lutz).
y
Professor Mentha passed away in May 2014.
http://dx.doi.org/10.1016/j.ejca.2016.04.010
0959-8049/ª 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.ejcancer.com
European Journal of Cancer 63 (2016) 11e24
2. r
I. Med. Klinik und Poliklinik, Johannes Gutenberg Universita¨t Mainz, Mainz, Germany
s
Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
t
Department of Surgery, University of California, Irvine, CA, USA
u
Clinica Chirurgica I, University of Padova, Padua, Italy
v
Catharina Hospital Eindhoven, Eindhoven and GROW: School of Oncology and Developmental Biology, University
Maastricht, Maastricht, The Netherlands
w
Department of Oncology/Haematology, Martin-Luther-University Halle, Halle (Saale), Germany
x
Department of Oncology, Haukeland University Hospital, University of Bergen, Norway
y
Department of Clinical Science, Haukeland University Hospital, University of Bergen, Norway
z
Digestive Oncology, University Hospitals Gasthuisberg/Leuven, Leuven, Belgium
aa
Tumor- und Brustzentrum ZeTuP, St. Gallen, Switzerland
Received 20 January 2016; received in revised form 10 April 2016; accepted 17 April 2016
KEYWORDS
Rectal cancer;
Staging;
Imaging;
Radiochemotherapy;
Radiotherapy;
Surgery
Abstract Primary treatment of rectal cancer was the focus of the second St. Gallen European
Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Con-
ference. In the context of the conference, a multidisciplinary international expert panel dis-
cussed and voted on controversial issues which could not be easily answered using
published evidence. Main topics included optimal pretherapeutic imaging, indication and type
of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report
the key recommendations and summarise the related evidence. The treatment strategy for lo-
calised rectal cancer varies from local excision in early tumours to neoadjuvant radioche-
motherapy (RCT) in combination with extended surgery in locally advanced disease.
Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended
magnetic resonance imaging (MRI) or MRI þ endoscopic ultrasonography (EUS) as manda-
tory staging modalities, except for early T1 cancers with an option for local excision, where
EUS in addition to MRI was considered to be most important because of its superior near-
field resolution. Primary surgery with total mesorectal excision was recommended by most pa-
nellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear
mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were
considered for multimodal treatment. The consensus panel recommended long-course RCT
over short-course radiotherapy for most clinical situations where neoadjuvant treatment is
indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even
no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable
tumours and synchronous liver metastases, most panel members did not see an indication to
start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course
radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection
approach in resectable metastases, which both allow optimal systemic therapy for the metasta-
tic disease. In general, proper patient selection and discussion in an experienced multidisci-
plinary team was considered as crucial component of care.
ª 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
The second St. Gallen European Organisation for
Research and Treatment of Cancer (EORTC) Gastro-
intestinal Cancer Conference 2014 focussed on the pri-
mary treatment of rectal cancer. A representative faculty
of expert surgeons, radiation oncologists and medical
oncologists, pathologists and gastroenterologists
reviewed the current knowledge and discussed treatment
recommendations in a panel session based on a
moderated consensus process. The main interests were
controversial issues which could not be easily answered
through study of published evidence and guidelines
[1e4]. As in the St. Gallen Breast Cancer Conferences,
the panel was asked to assess the available evidence and
vote on recommendations using a precirculated set of
questions. A detailed review of the presentations has
been published elsewhere [5]. Here, we summarise the
key discussion points of the panel members.
The treatment strategy for localised rectal cancer is
based on clinical examination together with endoscopy
and imaging using either magnetic resonance imaging
(MRI) and/or endoscopic ultrasonography (EUS) and is
currently guided mainly by the risk of local recurrence,
e.g. European Society for Medical Oncology (ESMO) [1]
or the National Comprehensive Cancer Network
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e2412
3. (NCCN) guidelines [4]. The most important aim is the
prevention of recurrent disease with as little treatment-
related morbidity as possible and with maintained
bowel, sexual and genitourinary function. Treatment
options vary from organ-preserving local excision in
very early tumours to a combination of radio-
chemotherapy (RCT) with extended surgery in locally
advanced disease. If the risk of recurrence or lymphatic
invasion is low (i.e. in cT1 sm1 tumours without nodal
involvement and without unfavorable prognostic factors
like poor differentiation or venous invasion), local
excision may be sufficient. Primary extended surgery
with total mesorectal excision (TME) is discussed for
early tumours with limited risk of recurrence (i.e. mrT1-
2 or mrT3a spread <5 mm, mrEMVI negative with clear
TME plane), whereas all other substages are commonly
considered for multimodal treatment. In any case,
optimal pretherapeutic staging is essential for any
treatment decision.
There is an ongoing debate on the ideal modality and
sequence of combination treatment for intermediate
stages. Influencing factors are depth of extramural
spread, the distance from the anal verge, the circum-
ferential location, the distance of the tumours from the
mesorectal fascia, and the involvement of extramural
vessels (extramural vascular invasion [EMVI]) or nerves.
This uncertainty may be exemplified in T3b or less
tumours in the upper or middle rectum, which have a
low risk of local failure, if the tumour is >1 mm from
the mesorectal fascia (MRF). For these stages, the
ESMO guidelines consider primary surgery followed by
adjuvant treatment if judged necessary after patholog-
ical evaluation [1], whereas the NCCN guidelines favour
preoperative chemotherapy or preoperative combined
RCT and recommend adjuvant treatment for all pa-
tients [4].
The choice and sequence of multimodal treatment
combinations was another topic. In general, preopera-
tive treatment is preferred because it is less toxic and
more effective in local control than adjuvant treatment.
Accepted standards for the preoperative approach are
either the use of a short course of radiotherapy (SCRT)
over 5 d followed by immediate surgery or the combi-
nation of fluoropyrimidine-based chemotherapy with a
long course of conventionally fractioned RCT followed
by surgery after 6e8 weeks. Compliance and immediate
toxicity are in favour of SCRT, whereas RCT has the
potential of downsizing and downstaging of tumours. In
contrast, the standards for postoperative treatment are
less well defined. Adjuvant chemotherapy (ACT) is
performed in many patients who had already received
preoperative RCT, even though the evidence is limited.
Postoperative RCT is recommended for all pT3/T4 and/
or pNþ tumours which had not been treated preoper-
atively, a recommendation which may not hold in
limited disease (i.e. T3 tumours) or in tumours of the
upper rectum.
2. Methods
In preparation for the panel session, which was held on
8th March 2014 with 27 experts, existing guidelines were
used to identify areas of uncertainty in order to define
the topics for debate. Over 100 questions were circulated
between panel members, of which 42 were retained for
the joint discussion. During the session, the panel
members were asked to assess and comment on the
existing data and to recommend treatment strategies as
expert opinion. Panel members were given the oppor-
tunity to comment on the questions, before and after an
electronic vote. Here, we summarise the extent of
agreement or disagreement of the panel members.
Even though care was taken to invite a representative
spectrum of panellists from relevant disciplines, the gen-
eral applicability of their conclusions may be limited by
an unequal distribution of disciplines and/or
underrepresentation of some regions of the world. In
addition, generalised treatment recommendations
depend also on patient selection. The statements to follow
are usually meant for reasonably fit patients with no
relevant comorbidities. Many patients in clinical practice
will not match the hypothetical model and treatment
decisions will need to be made on an individual basis.
3. Pretherapeutic local staging
Accurate pretherapeutic imaging of the tumour and
lymph nodes is the key component of any treatment
decision, in addition to clinical examination, endoscopy
and screening for distant metastases. The vast majority
of the expert panel members considered the inclusion of
MRI (91% of the panellists) or even MRI þ EUS (33%)
as mandatory for ‘local imaging of the tumour’ with no
role for EUS or computed tomography (CT) scans
alone. Sole exceptions are T1 tumours where organ-
sparing surgery or endoscopic en-bloc resection is
considered as a potential treatment option. There, EUS
was recommended by 88% of the panellists because of its
excellent resolution and its superior definition of the
infiltration depth, with 38% opting for additional MRI.
To detect ‘lymph node involvement’, MRI was also
considered to be the best imaging tool (92% for MRI
alone, 8% together with EUS). The validated parameters
using MRI are irregularity of the border and mixed
signal intensity [6,7]. Using ultrasound, the roundness,
echogenicity, and imaging pattern (architecture) have
been described.
Several meta-analyses or systematic reviews exam-
ined the quality of T and N staging with various imaging
techniques. Summary results of the largest series are
listed in Table 1. However, the meta-analyses incorpo-
rating such a wide range of imaging standards must be
interpreted with caution as many of the older and larger
studies included used low-resolution techniques and
undefined diagnostic assessment criteria.
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e24 13
4. Overall, an acceptable accuracy was demonstrated
for all three imaging modalities. In a meta-analysis
reviewing nonehigh-resolution techniques and older
MRI studies, EUS performed significantly better for the
definition of ‘invasion into the muscularis propria’, i.e.
for the distinction of T1 and T2 tumours, where its
specificity reached 86% (95% confidence interval [CI]:
80e90%) compared with 69% (95% CI: 52e82%) for
MRI [8]. The sensitivity was high in both groups (94%),
indicating a greater potential for overstaging with MRI
when using older low-resolution techniques and impre-
cise definitions of assessment of tumour spread [8].
However, the modern high-resolution techniques have
proven MRI to assess depth of spread accurately to
within 1 mm of histopathology assessments [9]. The use
of MRI in selecting patients for local excision rather
than TME surgery now hinges on the assessment for the
degree of preservation of the muscularis and submucosal
layers which enable a judgement of the safety of the
excision planes [5]. CT imaging was not compared
because of the insufficient resolution of the layers of the
rectal wall.
Results for lymph node involvement were compara-
ble for all three modalities with low-sensitivity rates
(55e69%). However, EUS can technically only be used
to evaluate the perirectal lymph nodes, whereas MRI
using high-resolution techniques identifies disease within
the entire mesorectum and pelvic sidewall compartment.
Based on the morphologic criteria of mixed signal in-
tensity and irregularity of the nodal border rather than
size criteria, the prevalence of pelvic sidewall metastatic
disease is 11%, and MRI detection of patients with
pelvic sidewall nodal disease is associated with poorer
overall disease-free survival (DFS) unless RCT is given
[9]. CT is used to examine the regional lymph nodes in
the pelvis and retroperitoneum. The accuracy is related
to T-stage and increases with lymph node size [10]. In a
series of EUS-staged rectal cancer, lymph node metas-
tases of increasing size were observed in the resection
specimen in 29% of pT1 tumours (median size of
3.3 mm), in 30% of pT2 tumours (median size of
6.2 mm), and in 46% of pT3 tumours (median size of
8.0 mm) with resulting accuracies of preoperative im-
aging of 48% in pT1, 67% in pT2, and 84% in pT3.
Measuring only the size of lymph nodes leads to sub-
stantial overstaging because benign reactive nodes are
seen in many patients and can enlarge to any size [11].
Nodal heterogeneity or penetration of the outer rim
which results in border irregularity in high-resolution
images are well-known features of malignancy [6,12,13]
which may be used as additional parameters if there is
sufficient imaging resolution in larger nodes.
MRI will depict lymph nodes with high sensitivity
and the majority of benign reactive nodes will be
positioned close to the mesorectal fascia posteriorly.
However, audit of specimens has shown that lymph
nodes are an extremely rare cause of circumferential
resection margin (CRM) involvement occurring in
<1.3% of patients and, therefore, caution should be
exerted when recommending neoadjuvant therapy solely
because an encapsulated lymph node is visualised close
to the mesorectal fascia [12]. Both EUS and CT are
unable to identify the mesorectal fascia [8]. Optimised
MRI performed according to standardised protocols by
trained investigators is able to predict the extent of
tumour outside the muscularis propria within a toler-
ance of 0.5 mm and correctly predicted a clear CRM in
94% in the MERCURY trial [14], with 1 mm as best
cut-off distance for predicting CRM involvement [15].
Follow-up data indicate that MRI-based pretherapeutic
definition of an involved CRM is an independent
prognostic factor for 5-year overall survival (62.2% in
Table 1
Pooled estimates of sensitivities and specificities of the routinely used imaging modalities for local staging of rectal cancer.
T Staging N Staging
MRI [74]
Systematic review
and meta-analysis,
22 studies
T category CRM involvement N
Sensitivity Specificity Sensitivity Specificity Specificity Sensitivity
87 (81e92) 75 (68e80) 77 (57e90) 94 (88e97) 71 (58e81) 77 (69
EUS [75]
Systematic Review,
42 studies, N Z 5,039
T2 T3 T4
Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity
81 (78e83) 96 (95e96) 96 (95e97) 91 (90e92) 95 (92e98) 98 (98e99)
EUS versus MRI versus
1CT [8] Meta-analysis,
90 studies
T2
‘muscularis propria
invasion’
T3
‘perirectal tissue invasion’
T4
‘adjacent organ
involvement’
N
Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity
EUS 94 (90e97) 86 (80e90) 90 (88e92) 75 (69e81) 67 (70e73) 78 (71e84) 67 (60e73) 78 (71e84)
MR 94( 89e97) 69 (52e82) 82 (74e87) 76 (65e84) 66 (54e76) 76 (59e87) 66 (54e76) 76 (59e87)
CT e e 79 (74e84) 78 (73e83) 55 (43e67) 74 (67e80) 55 (43e67) 74 (67e80)
Values are expressed in % with 95% confidence interval in brackets.
CRM, circumferential resection margin; CT, computed tomography; EUS, endoscopic ultrasonography; MRI, magnetic resonance imaging.
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e2414
5. MRI-CRM clear as compared to 42.2% in CRM
involved), for DFS (67.2% versus 47.3%) and for local
recurrence with a hazard ratio of 3.5 (95% CI of
1.53e8.0, p < 0.05). MRI-defined EMVI is an addi-
tional independent poor prognostic factor for both local
recurrence and for DFS in stage II/III rectal cancer [16].
Examples for a minimum technical requirements and
reporting are given in Table 2.
4. Do T3 rectal cancers always need RCT or
radiotherapy?
Preoperative chemoradiation (RCT) or short-course
preoperative radiotherapy (SCRT) are considered stan-
dard of care for patients with clinical stage II and III
rectal cancer because of the risk of local recurrence with
surgery alone and because of the postulated potential
for sphincter preservation. Many multidisciplinary
teams advocate SCRT or RCT for all patients with
rectal cancer staged as cT3 regardless of nodal status,
tumour location, and proximity to other structures or
extent. However, omitting RCT or SCRT would offer
the benefit of improved wound healing, less frequent
anastomotic leaks, avoidance of long-term radiation
toxicity, and a smaller risk of secondary malignancies
[17e21].
The ‘site of the primary tumour location and the
presence of lymph node metastases’ appear crucial to
decision making. The consensus panel was asked to
choose the optimal preoperative treatment (SCRT,
RCT, or primary surgery with no additional multimodal
therapy) for three different clinical situations. For units
where quality-controlled TME is done, and for easily
resectable cancers of the mid-rectum with no detectable
lymph node metastases (cT3 cN0), 71% of panellists did
not feel combination treatment was required for all
patients, but 25% did, albeit there was some debate as to
the definition of ‘easily resectable’, which may be defined
as tumours with less than 5 mm infiltration depth into
the mesorectal fat and at least 1 mm distance from the
mesorectal fascia (see also Table 3). In contrast, for cT3
cN0 low rectal cancer, 66% voted that SCRT or RCT
were necessary. The majority of the panellists also
considered RCT the best option for treating easily
resectable rectal cancer of the mid-rectum with lymph
node metastases (cT3 cNþ). Only 20% voted that neo-
adjuvant treatment was not required, and 75% of the
panellists considered SCRT to be an appropriate alter-
native option in this situation. In the interval, data have
emerged from the multicentre MERCURY 2 trial which
has shown that almost half of patients with tumours
arising <6 cm from the anal verge when staged by MRI
Table 2
Minimum technical requirements for MRI and its interpretation and reporting in pretherapeutic staging of rectal cancer [76].
MRI staging of rectal cancer
Technical requirement
- 1.5 or 3 Tesla system with phase array coil
- Standard T2 fast-spin echo for initial localisation/planning
- High-resolution T2-weighed images: minimal voxel density of 1.1 mm3
, e.g. 3-mm sections with in-plane resolution of 0.5e0.8 mm
Scanning protocol
- Sagittal T2-weighted fast-spin echo to identify the tumour
- Large field-view axial sections of the whole pelvis
- High-resolution axial images of the tumour and adjacent tissues (perpendicular to the rectum long axis at the tumour level)
- Lymph node assessment: high-resolution axial imaging of the upper tumour border up to L5/S1
- Low tumours: high-resolution coronal imaging of levator muscles, sphincter complex and their relation to the rectal wall
- Sessile lesions/polyps: high-resolution sagittal series
Interpretation and reporting
- Technique, resolution, quality
- Height of the tumour (from the anal verge)
- Tumour description
Size
Circumferential location
T-stage
Infiltration depth beyond muscularis propria (mm)
- Nodal spread
Location (perirectal, pelvic)
Number
Description (size, signal intensity, irregular border)
Distance from tumour and MRF
- Extramural vascular invasion
- CRM status (distance to MRF 1 mm?)
CRM, circumferential resection margin; MRI, magnetic resonance imaging.
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e24 15
6. are not invading the distal TME/intersphincteric plane.
Rectal cancers localised in the upper third of the rectum
were exempt from the discussion as they are usually
treated by analogy with colon cancer.
A large majority of panellists believe RCT to be
required if clinical staging suggests the status is ‘cNþ’.
Also, when MRI shows a ‘threatened/breached CRM’
(10e15% of cases), or in cancers which require surgical
resection beyond the conventional TME and in clinically
unresectable cancers, downstaging is required and RCT
was considered the modality of choice [22]. As a
consequence, 66% of the panellists considered it neces-
sary to distinguish between patients with MRI criteria
which predict a high risk of local recurrence versus those
with a high risk of metastases (i.e. EMVI) and tailor
treatment appropriately.
The results from the Dutch TME trial [23] show a
marginal benefit for SCRT in stage II (N0) patients
(local recurrence [LR], 5.3% versus 7.2%), arguing
against any preoperative therapy, but the MRC CR07
trial [24] demonstrated a reduction of LR from 6.4% to
1.9%, again with SCRT. However, none of these trials
nor any of the chemoradiation trials published in the
last decade have shown any difference in overall survival
[25e28]. None of these trials used modern MRI staging
techniques to assess CRM, mrEMVI status or depth of
tumour spread beyond the muscularis propria. Norwe-
gian population data suggested low rates of local
recurrence for patients with pathological findings of a
clear CRM 3 mm and pN0 [29]. Several groups, which
are known to perform high-quality surgery, have
recently explored omitting radiotherapy when MRI
suggests the tumour is easily resectable and the meso-
rectal fascia is not threatened regardless of nodal stage.
This omission is associated with the local recurrence
rates of 5% [30e33].
The ‘quality of surgery’ is crucial. The majority of
local recurrences historically reflected inadequate mes-
orectal resection [34], which is a common finding on
postoperative MRI after partial mesorectal excision [35].
Careful dissection particularly in the posterior aspect of
a TME specimen with its higher prevalence of lymph
nodes is important [36]. Currently, optimal quality-
controlled surgery in terms of TME in the trial setting
can be associated with local recurrence rates of less than
10% whether patients receive radiotherapy or not [37].
Table 3
Proposed mid-rectal cancer risk categorisation based on MRI and clinical risk factors.
Risk stratification for cancer of the mid rectum
Low risk Intermediate risk High risk
Low-risk local recurrence/
low-risk metastases
Low-risk local recurrence/
moderate-risk metastases
Moderate-risk of local
recurrence/high-risk
metastases
High risk of local
recurrence/higher risk
metastases
High-risk local recurrence/
high-risk metastases
MRI cT2/T3a/T3b, 4 mm
extension into muscularis
propria, CRM not
threatened (predicted
2 mm), cN0, CT M0
MRI cT3b, 4 mm
extension into muscularis
propria, CRM not
threatened (predicted
2 mm), cN1, CT M0
MRI cT3b, 4 mm
cT3c, cN2, EMVI,
CRM not threatened
(predicted 2 mm), CT
M0
MRI cT3d, T4a
(resectable), CRM not
threatened (predicted
2 mm), CT M0
MRI cTany, extension into
muscularis propria, T4b, CRM
breached or threatened
(predicted 1 mm), CT M0
Possibly Mucinous
Potential MRI-directed recommendations
No requirement for preop
radiotherapy
Immediate surgery
If surgeon convinced able to
perform R0 resection and
good quality in mesorectal
plane could omit RT
SCRT depending on
whether shrinkage of
tumour required or
neoadjuvant
chemotherapy alone
SCRT or RCT depending
on whether shrinkage of
tumour required or
neoadjuvant
chemotherapy alone
Requires RCT
Clinical risk factors
- Obesity
- Male/with anterior tumours
- Narrow pelvis
- Previous pelvic surgery
- Large bulky tumour
- Sepsis/fistula/perforation
UK NICE Guidelines and Recommendations
Low risk þ (but does not
include T3b 4 mm)
Any cT3b or greater, in which the potential surgical margin is not
threatened or
Any suspicious lymph node not threatening the surgical resection
margin or
The presence of extramural vascular invasion
Threatened (1 mm) or breached
resection margin or low tumours
encroaching onto inter-
sphincteric plane or levator
involvement
Do not give RT SCRT or RCT RCT recommended
CRM, circumferential resection margin; CT, computed tomography; EUS, endoscopic ultrasonography; MRI, magnetic resonance imaging; RCT,
radiochemotherapy; SCRT, short course of radiotherapy; NICE, National Institute for Health and Care Excellence; RT, radiotherapy.
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e2416
7. There are also significant ‘late effects from pelvic
radiotherapy’ on anorectal, urinary and sexual func-
tion [17,38,39], unexplained late cardiac effects [17],
insufficiency fractures in the pelvis [40], and an
increased risk of secondary malignancies after 10 years
[20,21]dall of which need to be balanced against the
risk of local recurrence.
Some have, therefore, questioned the routine use of
both these approaches (RCT and SCRT).
Fluoropyrimidine-based RCT does not employ full
systemically active doses of chemotherapy and delays
the integration of ACT. Many current investigative ap-
proaches in rectal cancer take the view that better results
might be obtained by adding and/or extending more
intensive chemotherapy into the neoadjuvant setting.
The question is, whether radiotherapy is needed at all?
5. Neoadjuvant long-course RCT versus SCRT
The aims of neoadjuvant therapy in locally advanced
rectal cancer (LARC) are to decrease the risk of
locoregional relapse and to downsize/downstage tu-
mours that threaten the mesorectal fascia or to facilitate
sphincter preservation. Long-course RCT or SCRT is
currently used (Tables 4 and 5). In the latter, the original
protocol scheduled the operation for the week following
radiation therapy. More recently, protocols for delayed
surgery have been evaluated in clinical trials [41].
The consensus panel discussed the indications for
RCT and SCRT in various clinical situations. Rectal
cancers localised in the upper third of the rectum were
exempt from the discussion as they are usually treated
similarly to colon cancer.
For easily resectable rectal cancer of the mid-rectum
with no detectable lymph node metastases (cT3 cN0), an
equal number of panellists favoured either option, if a
combined therapy was indicated. In the trials directly
comparing SCRT and RCT [19,42], LR rates were
similar and 75% of the panellists considered SCRT to be
acceptable in this situation. As discussed above, the
indication for preoperative therapy in this group of
patients has been questioned since the introduction of
TME has significantly reduced the rate of LR.
However, more than half of the panellists considered
RCT the best option for cancer of the mid-rectum with
lymph node metastases (cT3 cNþ) even when it was
easily resectable, with only very few voting against any
neoadjuvant treatment. Both the Dutch and the MRC
trials [23,24] show a significant decrease of LR in node-
positive tumours in the TME era. However, analysis of
the surgical specimen quality in the CR07 trial has also
shown that pelvic recurrence rates were 20% for poor-
grade TME compared with only 6% for good-quality
CRM-negative TME node-positive patients which
compared favourably with 5% local recurrence rates in
node-negative patients in good-grade TME specimens
[37]. Approximately 18% of audited TME specimens in
the Dutch TME trial were poor grade and preoperative
CRM status had not been assessed in either CR07 or
Dutch TME trials. Therefore, a neoadjuvant approach
seems indicated in node-positive disease if the quality of
the TME surgery is in doubt and preoperative assess-
ment of the MRI-validated prognostic factors linked to
local recurrence, i.e. mrCRM, mrT substage and
mrEMVI, is not established.
For rectal cancer situated in the ‘low rectum’
(without lymph node metastases), three quarters of the
panellists favoured RCT and only one quarter consid-
ered SCRT the best option. The risk for LR for tumours
in the low rectum even in the TME era and after neo-
adjuvant therapy is relatively high (10.1% LR in the
German trial) [43]. Implementation of an MRI-based
low rectal cancer staging classification enables identifi-
cation of patients for primary surgery with a 98% clear
margin rate in just under half of the patients presenting
with low-risk rectal cancers at 6 cm from the anal
verge. Preoperative therapy of high-risk MR low rectal
cancer tumours followed by a good mrTRG and
regression of tumour from the intersphincteric plane
results in 0% pCRM rates. A poor response necessitates
the use of a beyond TME approach in order to achieve
clear margins either by extralevator APE or in some
cases exenterative surgery [44].
The role of SCRT was first established in the 1990s by
a series of randomised trials [45e47] in resectable and
early rectal cancers with the aim of reducing the risk of
Table 4
Comparison of treatment and performance characteristics of SCRT or RCT for rectal cancer.
SCRT Short-course radiotherapy RCT Long-course radiochemotherapy
Total radiation dose 25 Gy 45e50.4 Gy
Fraction size/number 5 Gy in five fractions 1.8e2 Gy in 23e28 fractions
Radiation duration 1 week 5e5.5 weeks
BED, acute effects 37.5 Gy 37.5e44.4 Gy
BED, late effects 66.7 72e84 Gy
Overall time to surgery 10 d 10e14 weeks
Concomitant chemotherapy No Yes
Acute toxicity Minimal if immediate surgery 10e24% G3
Late toxicity G3/G4 8e10% G3/G4 8e10%
Downsizing/downstaging No (unless surgery delayed) Yes
BED, biologically effective dose; RCT, radiochemotherapy; SCRT, short course of radiotherapy.
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e24 17
8. Table 5
Summary results of randomised radiotherapy trials in rectal cancer.
Treatment arms TME Stages Adjuvant
chemotherapy
LR (5 years) DR (5 years) OS (5 years) Remarks
Trials with RCT (long-course RCT)
EORTC 22921 [51], N Z 1011 25 Â 1.8 Gy
25 Â 1.8 Gy/preop 5FU
25 Â 1.8 Gy/postop 5FU
25 Â 1.8 Gy/preop
þ postop
n.a. IIeIII 4 Cycles 5FU/LV
(depending on
treatment arm)
21.9%
10.9%
13.7%
10.7%
36.9%
32.1%
33.5%
29.8%
No significant
difference at
10 years
Bolus 5FU/LV with
radiotherapy (depending
on treatment arm)
FFCD 92032 [27],
N Z 733
25 Â 1.8 Gy
25 Â 1.8 Gy/bolus 5FU
Rec. IIeIII 4 Cycles 5FU/LV 16.5%
8.1%
19.3%
24.3%
67.9%
67.4%
Bolus 5FU/LV with
radiotherapy
NSABP R-03 [28],
N Z 267
Preop 28 Â 1.8
Gy/5FU
Postop 28 Â 1.8
Gy/5FU
n.a. IIeIII 5 Cycles 5FU/LV 10.7%
10.7%
n.a. 74.5%
65.6%
Bolus 5FU/LV with
radiotherapy
CAO/ARO/AIO-94
Trial [43], N Z 823
Preop 28 Â 1.8
Gy/5FU
Postop 28 Â 1.8
Gy/5FU
Yes IIeIII 4 Cycles 5FU/LV 5.0%
9.7%
29.8% (10 years)
29.6%
59.6% (10 years)
59.9%
CIV 5FU with
radiotherapy
Trials with SCRT (short-course radiotherapy)
Swedish Rectal
Cancer Trial [45], N Z 1168
None
5 Â 5 Gy
No IeIII No 26% (13 years)
9%
34% (13 years)
34%
30% (13 years)
38%
Equal effects for
mid and low rectum
Dutch Colorectal
Cancer [46] Group
Trial 2, N Z 1861
None
5 Â 5 Gy
Yes IeIII
(eIV)
No 10.9%
5.6%
28.3%
25.8%
63.5%
64.2%
Little effect for high
and low rectum
MRC CR-07/NCIC-
CTG C016 [24]
N Z 1350
5 Â 5 Gy
(postop 25 Â 1.8
Gy, 5FU)
Rec. IeIII According to
local policy
4.7%
11.5%
19%
21%
70.3%
67.9%
Postop. RCT for
involved circumferential
margin only
Polish Rectal Cancer
Trial [19], N Z 312
5 Â 5 Gy
28 Â 1.8 Gy,
bolus 5FU
Yes T3/4 N0-2 Optional 9.0% (4 years)
14.2%
31.4% (4 years)
34.6%
67.2% (4 years)
66.2%
Trans-Tasman Trial
01.04 [42], N Z 326
5 Â 5 Gy
28 Â 1.8 Gy,
5FU CIV
Yes T3 N0-2 Mandated
FUFA 6/12
7.5% (3 years)
4.4%
27%
30%
74%
70%
Imbalance regarding
location of primary
Pach et al. [77],
N Z 154
5 Â 5 Gy surgery
7e10 d
5 Â 5 Gy surgery
4e5 weeks
n.a. IeIII Not stated 1.5% 7% 63%
73%
Delayed surgery may
require longer interval
EORTC, European Organisation for Research and Treatment of Cancer; n.a., not applicable; TME, percentage of patients treated with total mesorectal excision; LR, local recurrence; DR, distal
recurrence; OS, overall survival; preop, preoperative; postop, postoperative; RCT, radiochemotherapy; Rec., recommended; FFCD, Fe´de´ration Francophone de Cance´rologie Digestive; NSABP,
National Adjuvant Breast and Bowel Project; CAO/ARO/AIO, Chirurgische Arbeitsgemeinschaft Onkologie/Arbeitsgemeinschaft Radioonkologie/Arbeitsgemeinschaft Internistische Onkologie;
MRC, Medical Research Council; NCIC-CTG, National Cancer Institute of Canada Clinical Trials Group; LV, leucovorin; 5FU, 5-fluorouracil.
M.P.Lutzetal./EuropeanJournalofCancer63(2016)11e2418
9. local recurrence, which was 20e30% after surgery alone,
reflecting the suboptimal surgical practice at that time.
Two subsequent, more modern trials early in the
TME era, addressed the key question: did SCRT simply
compensate for poor surgical technique? These trials
tested whether SCRT still reduced local recurrence even
if TME was performed [24,46]. In the control group,
postoperative radiotherapy or RCT was intended to be
given in the event of a histopathological positive CRM
in the Dutch TME study and the CR07 trial, respec-
tively. Both trials demonstrated a reduction in local
recurrence, but overall survival was not improved, and
the risk of metastases predominated over local recur-
rence [21,24,37,46].
The second radiation option is combined RCT with
daily radiation fractions of 1.8 e 2.0 Gy up to a total
dose of 45 e 50 Gy. Concurrently, a fluoropyrimidine-
based chemotherapy is given, most often infusional 5-
fluorouracil (5FU) or capecitabine, which has been
extrapolated from the successful strategy of post-
operative 5FU-based RCT for patients with stage II or
III rectal cancer. Several groups performed randomised
trials of preoperative 5FU-based RCT and demon-
strated an improvement in locoregional control [25e27]
but this did not translate into an improvement in DFS
or OS. Only in more advanced unresectable or border-
line resectable cases did RCT result in improved
resectability and DFS [22].
With the increased accuracy of preoperative imaging
to define the potential for curative resection, RCT has
been taken up more widely, particularly when the CRM
is predicted to be compromised. In contrast, SCRT and
immediate surgery is primarily not intended to achieve
significant shrinkage or pathological downstaging. The
Dutch TME trial found no significant difference in
TNM stage distribution between SCRT and surgery-
alone groups [46], but T-stage downstaging was
observed if surgery was delayed for more than 10
d following the completion of SCRT [48]. Further
extension of the interval following SCRT to surgery of
at least 6 weeks does demonstrate more downstaging,
but the optimal interval has not been defined [41,49].
Whether the same degree of tumour shrinkage to that
seen with RCT can be achieved with SCRT and an
extended interval to surgery is currently unclear. Recent
preliminary data from a Polish trial comparing two
neoadjuvant treatment protocols (SCRT followed by
4 Â FOLFOX4 or RCT with bolus 5FU/leucovorin
(LV) and oxaliplatin) resulted in comparable local effi-
cacy and possibly improved overall survival with SCRT
(ASCO GI 2016, Abstract # 489).
Overall,theconsensuspanel recommendedlong-course
RCT over short-course radiotherapy for most clinical
situations in which neoadjuvant treatment is indicated,
with the exception of T3a/b N0 tumours with clear mes-
orectal fascia (1 mm) where short-course radiotherapy
or no therapy were regarded to be equivalent.
6. Adjuvant chemotherapy
Most cancer-related deaths in patients with rectal cancer
are due to distant metastases. ACT in colon cancer re-
duces the incidence of distant relapse and improves
overall survival. In analogy, ACT was integrated into
postoperative and perioperative treatment strategies in
rectal cancer. However, although ACT after preopera-
tive RCT and surgery is currently recommended in most
guidelines [50], the contribution of the adjuvant part to
the benefit of the perioperative therapy had not been
formally tested in a randomised trial at the time of the
St. Gallen 2014 consensus meeting. The first indication
that ACT may not improve local or distant relapse rate
after preoperative RCT came from the EORTC 22921
trial [51] and was further questioned in other trials
[52e54] (see Table 6).
At the consensus session, most panellists (83%) rec-
ommended against ACT for cN0/ypN0 tumours.
However, for tumours that were initially lymph node
positive but became lymph node negative after RCT
(i.e. cNþ/ypN0), the panellists’ opinion on ACT was
divided (pro 41%, con 59%). In cases with histologically
confirmed positive lymph nodes after neoadjuvant RCT
Table 6
Adjuvant chemotherapy trials in rectal cancer and meta-analysis.
Treatment Arms Stages DFS OS Remarks
EORTC 22921 [51]
N Z 1011
Follow-up
5FU/LV
IIeIII 47%
43.7%
51.8%
48.4%
At 10 years
Chronicle [52]
N Z 113
Follow-up
Xelox
IeIII 71.3%
77.5%
87.8%
88.8%
At 3 years
I-CNR-RT [54]
N Z 655
Follow-up
5FU/LV
IIeIII 62.8%
65.3%
70%
69.1%
At 5 years
PROCTOR/SCRIPT [53]
N Z 823
Follow-up
5FU/LV or cape
IIeIII 55.4%
62.7%
79.2%
80.4%
At 5 years
Meta-analysis [55]
N Z 1196
Follow-up
Adjuvant chemotherapy
IIeIII HR 0.91
(0.77e1.07)
HR 0.97
(0.81e1.17)
10e15 cm from anal verge
HR for DFS 0.59 (0.40e0.85)
cape, capecitabine; DFS, disease-free survival; EORTC, European Organisation for Research and Treatment of Cancer; HR, hazard ratio; OS,
overall survival.
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e24 19
10. (ypNþ), the majority of panellists (77%) voted in favour
of ACT.
About half the panellists (47%) were in favour of
ACT that included oxaliplatin with 16% against this
option. When ACT is indicated, most panellists (68%)
agreed that a colostomy should be closed after
completion of chemotherapy to avoid an interruption
that might mitigate the effect of the ACT.
After the consensus meeting, results from a number of
clinical trials investigating the role of ACT in this situa-
tion were published (Table 6). Since these results have the
potential to change clinical practice, we compiled the ev-
idence in a table without additional panel voting. These
new data do not support the further use of ACT as a
standard in mid and low rectal cancer (less than 10 cm
from the anal verge) after neoadjuvant RCT and R0
resection, irrespective of T stage and nodal status [55].
However, for upper rectal cancer between 10 and 15 cm
from the anal verge, ACT can be considered as standard
for lymph nodeepositive tumours (either cNþ before
neoadjuvant therapy and/or ypNþ) [55]. This regimen
should usually include oxaliplatin (panel: 47% yes, 16%
no, 37% abstain), which is supported by data from colon
cancer and from a phase II trial in rectal cancer [56].
7. Clinical complete response after preoperative long-
course RCT
After RCT, some patients experience a complete clinical
response of their tumour. Managing these patients
without immediate surgery, but with frequent surveil-
lance presents an option that may obviate the need for a
surgical intervention for some of them [57]. To test the
limits of this strategy, the panellists were asked whether
this ‘watch and wait’ strategy was also justified in lymph
nodeepositive, low rectal cancer. In this situation, the
panel was equally divided for and against. Half of the
panellists were in favour of ‘adjuvant’ chemotherapy
after achieving a complete clinical response by RCT
provided careful follow up was feasible, thus avoiding a
primary operation. We did not ask if local excision with
organ preservation was also considered as an option.
8. Rectal cancer with synchronous liver metastases
The incidence of synchronous liver metastases in pa-
tients with primary rectal cancer is approximately 15%
[58]. The principle treatment goal is complete resection
of all primary and metastatic lesions with a curative
approach, but the choice and sequence of the available
treatment modalities depend on the clinical situation.
Patients can grossly be divided into two groups: those
with initially resectable and potentially resectable dis-
ease after conversion therapy and those patients in
whom complete resection of the primary tumour or the
metastases will not be achievable.
In patients with ‘unresectable metastatic rectal can-
cer’, the primary treatment goal is maintaining quality
of life, improving tumour-related symptoms and mini-
mising treatment-related side-effects. Accordingly, if the
primary tumour was not going to be removed, the panel
voted against pelvic radiotherapy in patients with an
asymptomatic rectal tumour and synchronous liver
metastases (79% no) and also against local ablative
treatment by surgery or radiologic intervention even if
the hepatic lesions were small and few (80% no).
Reported mortality after resection of the primary
tumour in patients with incurable stage IV colorectal
cancer ranges from 1.3% to 16%, which is significantly
higher than resection for colorectal cancer in general
[59,60]. For this reason, there is a tendency towards a
conservative approach, especially in asymptomatic pa-
tients. A deviating loop colostomy (preferably by lapa-
roscopy) is often an effective alternative. Palliative
pelvic radiotherapy was analysed in a systematic review
by Cameron et al. [62] and showed a pooled overall
symptom response rate of 75%, although toxicity results
were not available [61]. SCRT with chemotherapy has
even been shown to spare palliative surgery in 80% of
symptomatic patients in a phase II trial. A stent can be
placed to treat obstructing rectal cancer, but endoscopic
stenting options for low-lying rectal tumours are limited
and may cause significant side-effects. A randomised
study by Fiori et al. [63] analysed 22 patients with stage
IV unresectable rectosigmoid cancer with symptoms of
subacute obstruction. Patients were treated by either
endoscopic placement of an expandable stent or
diverting proximal colostomy and were followed until
death. There were no differences between treatment-
related morbidity or mortality, but hospital stay and
restoration of oral feeding and bowel function were
shorter after stenting.
In ‘potentially resectable disease’, treatment of the
primary rectal tumour per se consists of surgery after
SCRT or RCT. Most patients with synchronous liver
metastases present with advanced rectal disease and, thus,
formally have an indication for prior RCT [64]. However,
standard RCT based on a fluoropyrimidine-alone
chemotherapy backbone likely results in under-treatment
of the metastatic disease for a substantial time interval
which may be further prolonged by postoperative com-
plications if the rectal tumour is removed first. Therefore,
the panel did not see an indication to start with
fluoropyrimidine-based RCT in these patients (83% no).
As SCRT and delayed (4e8 weeks) rectal surgery in
resectable cancers can result in local tumour regression
in 74% of patients and has a low-toxicity profile [65], it
may offer both local control and, more importantly, the
opportunity to start systemic therapy almost instantly,
optimising the treatment of metastatic disease. The
feasibility of such an approach has been demonstrated
in a phase II trial, where SCRT was followed by cape-
citabine, oxaliplatin, and bevacizumab for up to six
M.P. Lutz et al. / European Journal of Cancer 63 (2016) 11e2420
11. cycles and surgery 6e8 weeks after the last cycle [66].
Radical R0 surgery of all tumour sites was possible in 36
of 50 (72%) patients. An interim analysis of a rando-
mised trial in patients with fixed cT3 or cT4 or locally
recurrent rectal cancer showed this strategy
(SCRT þ FOLFOX) achieved a microscopically radical
resection (primary end-point) in 73% [67].
‘Systemic therapy alone’ can also induce significant
response of the tumour. A case series of 22 patients with
rectal cancer demonstrated an objective pathological
response in 12 patients, including one patient with a
complete response [68]. Prior to the start of treatment,
symptomatic rectal tumours with clinical signs of
obstruction should be decompressed with a colostomy to
avoid treatment delays for emergency intervention.
However, in patients with an endoscopically obstructing
tumour only (with no clinical symptoms or signs of
obstruction), a diversion colostomy seems not needed.
Patel et al. [69] showed progression to complete obstruc-
tion needing surgery in only 2 of 85 patients during neo-
adjuvant systemic therapy in patients with endoscopically
obstructing rectal tumours. As to the panel, all members
elected combination regimens for initial treatment.
Traditionally, the strategy for surgical management
of colorectal carcinoma with resectable liver metastases
was resection of the primary tumour followed by treat-
ment of the liver metastases, with or without perioper-
ative systemic therapy. This approach has been
challenged by a ‘liver-first approach’ because the prog-
nosis is usually related to the liver metastases. Further-
more, the liver-first approach has a higher percentage of
patients completing the full treatment protocol and it
avoids delay due to complications of rectal surgery [70].
The St. Gallen panel saw a place for the primary
resection of a small resectable liver lesion before the
start of RCT for LARC (52% yes versus 43% no).
In a systematic review of patients with colorectal
tumours, the common treatment sequence in four
studies comprised neoadjuvant systemic chemotherapy,
liver resection, RCT for the rectal tumours, followed by
colorectal resection and ACT; 90 of the 121 (74%) pa-
tients in this review completed the full treatment pro-
tocol and disease progression occurred in 23 patients
(19%). In the study describing patients with rectal
cancer only, 73% (16 of 22) completed the full protocol
with a 5-year survival rate of 67% and a median pro-
gression-free survival of 19 months [71]. Another
argument to choose a liver-first strategy in patients with
synchronous rectal cancer is the chance of a complete
response of the primary tumour after chemoradiation
of 15e25% and, thus, the possibility of a wait-and-see
policy [72]. Synchronous resection has been proposed
as an alternative approach with less abdominal in-
terventions, but this approach has not been compared
to others in a randomised trial [73]. An important
factor seems to be patient selection by an experienced
multidisciplinary team.
In summary, optimised MRI with standardised pro-
tocols or MRI þ EUS were considered as corner stones
of pretherapeutic imaging. Early tumours with limited
risk of recurrence were considered as candidates for
primary surgery whereas all others should receive
multimodal treatment. In general, long-course RCT was
preferred over short-course radiotherapy, if neoadjuvant
treatment is indicated. In patients with resectable syn-
chronous liver metastases, a treatment strategy with
optimum systemic chemotherapy supported by short-
course radiotherapy of the primary tumour was the
favoured approach.
Conflict of interest statement
None declared.
Acknowledgements
This meeting was made possible through the financial
support of St. Gallen Oncology Conferences. We wish to
thank Hans-Jo¨rg Senn and Agnes Glaus for sharing
their expertise from the St. Gallen Breast Cancer Con-
ference as well as Judith Eberhardt for the excellent
operational management of the meeting.
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