1. The document discusses optimal target volumes for primary and nodal stations in hepato pancreato biliary tumors. It covers delineation of organs at risk, gross tumor volumes, clinical target volumes, and planning target volumes.
2. Imaging protocols for various tumor sites are described, including use of triple phase CT and respiratory management techniques to reduce margins. Delineation guidelines are provided for different tumor types.
3. Target volumes are defined for liver, pancreas, biliary tract, and post-operative cases. The roles of imaging modalities like PET/CT and factors like vessel involvement are covered. Guidelines aim to balance target coverage with dose to organs at risk.
Evolution of Hypofractionated Radiotherapy in Breast Cancerkoustavmajumder1986
Hypofractionated radiotherapy in breast cancer is one of the major evolution. It started few decades back. We have to know its history and radiobiological perspective. In this presentation I have tried to cover as much as possible. It would be helpful for all Radiation Oncologist specially the trainees.
1.Aim of Radiotherapy
The goal of radiotherapy is to deliver a prescribed dose of radiation to the Target while sparing surrounding Healthy tissues to the largest extent possible
2.Organ Motion
Intra-fraction motion
during the fraction
Heartbeat
Swallowing
Coughing
Eye movement
Inter-fraction motion
- in between the fractions
Tumour change
Weight gain/loss
Positioning deviation
Breathing
Bowel and rectal filling
Bladder filling
Muscle relaxation/tension
3. Respiratory motion affects:
Respiratory motion affects all tumour sites in the thorax, abdomen and Pelvis. Tumours in the Lung, Liver, Pancreas, Oesophagus, Breast, Kidneys, prostate
Tumour displacement varies depending on the site and organ Location
Lung tumours can move several cm in any direction during irradiation
It is most prevalent and prominent in Lung cancers
4. Problems associated with respiratory motion during RT
Image acquisition limitations
Treatment planning limitations
Radiation delivery limitations
5. Methods to Account for Respiratory Motion
1. Motion encompassing methods
2. Respiratory gating methods
3. Breath hold methods
4. Forced shallow breathing with abdominal compression
5. Real-time tumor tracking methods
Summary:
The management of respiratory motion in radiation oncology is an evolving field
IGRT provides a solution for combating organ motion in radiotherapy
Delivering higher dose to tumor and less dose to normal tissue.
Limited clinical studies, needs to be studied further
IGRT – the future of radiotherapy
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Evolution of Hypofractionated Radiotherapy in Breast Cancerkoustavmajumder1986
Hypofractionated radiotherapy in breast cancer is one of the major evolution. It started few decades back. We have to know its history and radiobiological perspective. In this presentation I have tried to cover as much as possible. It would be helpful for all Radiation Oncologist specially the trainees.
1.Aim of Radiotherapy
The goal of radiotherapy is to deliver a prescribed dose of radiation to the Target while sparing surrounding Healthy tissues to the largest extent possible
2.Organ Motion
Intra-fraction motion
during the fraction
Heartbeat
Swallowing
Coughing
Eye movement
Inter-fraction motion
- in between the fractions
Tumour change
Weight gain/loss
Positioning deviation
Breathing
Bowel and rectal filling
Bladder filling
Muscle relaxation/tension
3. Respiratory motion affects:
Respiratory motion affects all tumour sites in the thorax, abdomen and Pelvis. Tumours in the Lung, Liver, Pancreas, Oesophagus, Breast, Kidneys, prostate
Tumour displacement varies depending on the site and organ Location
Lung tumours can move several cm in any direction during irradiation
It is most prevalent and prominent in Lung cancers
4. Problems associated with respiratory motion during RT
Image acquisition limitations
Treatment planning limitations
Radiation delivery limitations
5. Methods to Account for Respiratory Motion
1. Motion encompassing methods
2. Respiratory gating methods
3. Breath hold methods
4. Forced shallow breathing with abdominal compression
5. Real-time tumor tracking methods
Summary:
The management of respiratory motion in radiation oncology is an evolving field
IGRT provides a solution for combating organ motion in radiotherapy
Delivering higher dose to tumor and less dose to normal tissue.
Limited clinical studies, needs to be studied further
IGRT – the future of radiotherapy
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Radiological investigation of billiary tact 01Kajal Jha
The name biliary tract is used to refer to all of the ducts, structures and organs involved in the production, storage and secretion of bile.
Bile canaliculi >> Canals of Hering >> intrahepatic bile ductule (in portal tracts / triads) >> interlobular bile ducts >> left and right hepatic ducts >>
These merge to form the common hepatic duct
This exits the liver and joins with the cystic duct from gall bladder
Together these form the common bile duct which joins the pancreatic duct
These pass through the ampulla of Vater and enter the duodenum
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
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neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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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
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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NVBDCP.pptx Nation vector borne disease control program
TARGET DELINEATION IN HEPATOPANCREATICOBILIARY TUMORS
1. Optimal target volumes of
primary and nodal stations in
Hepato Pancreato Biliary Tumors
DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FICRO,FAROI,PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam, India
drkcpatro@gmail.com /M+91-9160470564
1
10. Which is better?
• Which motion management system is better?
• Which phase is better?
• Empty stomach/filled stomach is better?
• DIBH/DEBH is better?
• Which immobilization is better?
• Contrast/water is better?
10
11. 11
1. Analyze the tumor in all phases of triple
phase CT
2. See the greatest resolution
3. Try to synchronization with breath hold
42. Common Bile Duct
• CBD contour should start at the first bifurcation or at its entry
to the portal triad inferiorly to the first portion of duodenum
• It passes posterior and medial to the duodenum and joins with
the pancreatic duct
• Irradiation of caudate lobe liver tumors may lead to high
radiation doses being received by the CBD
43
64. How it looks?
• Usually, the mass enhances vividly during late arterial (~35 seconds)
• Then washes out rapidly, becoming indistinct or hypoattenuating in the portal
venous phase, compared to the rest of the liver
• Portal vein tumour thrombus can be distinguished from bland thrombus by
thrombus by demonstrating enhancement.
65
85. 1. Size of the tumor
2. Involvement of critical vascular structures as defined by the NCCN or DPCG
criteria
3. Invasion of nearby structures like transverse mesocolon, root of the
mesentery and perineural invasion
4. Lymph node involvement locoregional or extraregional
86
107. HANDLING STOMACH FILLING
1. Variations in gastric filling may lead to significant intrafraction
differences dose to normal stomach.
2. To mitigate this most panelists recommended keeping patients
NPO for 2-3 hours before simulation and each treatment.
3. However, treating patients at a consistent interval after meals
also appears to result in reproducible gastric positioning, and
may be more comfortable for some patients
108
111. 1. Use water rather than contrast
2. Pancreatic phase instead of the arterial phase.
Pancreatic phase refers to the late arterial
phase (typically 40-45 sec after contrast
injection) during IV contrast.
Pancreatic Protocol
112
113. A CT REQUSITION
• High-resolution dual-phase (arterial and portal)
contrast material–enhanced CT is the established
technique for evaluating pancreatic adenocarcinoma.
• LATE Arterial phase imaging (per-formed 20–40
seconds after contrast agent injection) allows optimal
visualization of the tumor and peripancreatic arteries.
• Portal phase imaging (performed 50–70 seconds after
injection) is optimal for detecting metastatic disease to
the liver and for assessing the peripancreatic veins
114
132. Target delineation
133
1. Delineate ROI’s:
1. Portal vein (PV: starts at confluence of SMV and splenic vein)
2. Pancreaticojejunostomy (PJ)
3. Celiac artery (proximal 1-1.5cm)
4. SMA (proximal 2.5-3cm)
5. Aorta (superiorly to most cephalad of CA, PV, or PJ contours; inferiorly to bottom
L2, or as low as L3 to cover pre-op GTV)
6. Hepaticojejunostomy (HJ)
7. Tumor bed (based on review of pre-op imaging, pathology report, surgical clips)
2. Expansion 1: 1.0cm on PV, PJ, CA, SMA
3. Expansion 2: all on Aorta --> 2.5-3cm on R, 1cm on L, 2-2.5cm anteriorly,
0.2cm posteriorly
4. CTV Boolean Expansions 1 + 2, confirm that tumor bed (including clips) and HJ (if
present) are encompassed
5. PTV = CTV + 0.5cm
142. Steps
pancreatic
SBRT
14
3
• Delineate vessels
– CA - Celiac artery
– CHA - Common hepatic artery
– LGA - Left gastric artery
– PV - Portal vein
– SMV - Superior mesenteric vein
– SV- Splenic vein
– AORTA
• Delineate GTV TOTAL
– GTV PRIMARY {GTVp}
– GTV VESSEL EXAPANSION- GTVp + 0.5 mm
• Delineate TVI
– The entire circumference of involved or
proximal vessels are contoured to form
tumor vessel interface
• CTV
– GTV + TVI
• PTV
– CTV + 0.5mm
143. What is GTV in pancreas?
• MRI
• PET
• ENDOSCOPY- Duodenal involvement
• CT
– The GTVp should include fibrotic areas near vessels based on experienced radiologist
review. This is identified as poorly defined or thickened vessel edges.
– It is now known that pancreatic stellate cells and the desmoplastic reaction around tumor
edges is a key contributor to pancreatic cell cancer biology, including regional progression
and distant metastasis.
– As such, this poorly defined area around the tumor should be included in the GTVp.
– If it is unclear whether a vessel is involved, it should be included in the GTVp
144
146. The TVI
• We define the TVI as the area where the GTVp is involving or within
5 mm of the major vessels in the upper abdomen, including celiac
artery, superior mesenteric artery, common hepatic artery, left gastric
artery, superior mesenteric vein, portal vein, splenic vein, or aorta.
• If GTVp is within 5 mm of these structures, then a TVI is defined as
above and incorporated into a clinical target volume of 40.
• In principle, any major vessel within 5 mm of the tumor should be
contoured from 5 mm proximal to 5 mm distal of the GTVp (Fig
2).
• This region should be defined in 3 dimensions (eg, using axial,
sagittal, and coronal planes Whole vessel circumference should be
included.
• In the case of aorta and portal vein, only the proximal half may
need to be contoured as part of the TVI as these vessels have a
much larger circumference
147
152. Handling the PTV
• In general, a 5-mm margin is
recommended.
• When a PTV of 40 crosses into or near a
hollow viscous PRV, compromises need to
be made to dose coverage in this area to
Preserve hollow viscous dose constraints
153
153. PRV
• We recommend the duodenal, stomach, small bowel,
and large bowel PRV be a minimum 3-mm expansion.
• However, if treating during free breathing or organ
movement is seen to be large on multiple end expiratory
breath hold scans or 4D-CT, a greater PRV margin is
required.
• Concessions to large bowel maximum dose (D0.5
cm3 and D5 cm3) may be considered to meet coverage
goals
154
154. The ITV CONCEPT
• ITV40 creation using motion information
from multiple end-expiratory breath hold
scans and/or 4D-CT
155
161. Imaging pictures
• The lesion has the following characteristics:
• The lesion is hypodense in the arterial and portal venous phase with
some peripheral enhancement.
• The lesion is hyperdense in the equilibrium phase indicating dens
fibrous tissue.
• The lesion causes retraction of the liver capsule
• The finding of an infiltrating mass with capsular retraction and
delayed persistent enhancement is very typical for a
cholangiocarcinoma.
163
162. Delayed phase enhancement
• Small cholangiocarcinoma not visible in portal
venous phase (left) but seen as relative hyperdense
lesion in the delayed phase (right).
164
183. CTV N0
• In this CTV-N delineation, a 10 mm margin of soft
tissue around vessels, ligament and ducts was
suggested, based on several literature data, without
overlap with radiosensitive structures (duodenum,
liver, small bowel, stomach).
• Only for para-cardials nodes and lesser gastric
curvature nodes, the suggested target was defined
without any further expansion to preserve the
surrounding OARs
189
184. See the continuity
See the contour
See the location
Follow the vessel
0.7 to 2.5 cm margin to vessel
190
215. For liver contouring
• Gallbladder should be excluded
• IVC should be excluded when it is discrete from the liver
• Portal vein (PV) should be included in the liver contour
when Segment (Seg) I (caudate lobe) is seen to the left
of PV
221