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By: K. Konrad, M.B. B.A.O., M.B.B.Ch., Ph.D.
Assistant Professor, University of Nebraska College of Medicine
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The 121 accuracy and availability of a physical examination or of different imaging modalities to identify true complete responses adds controversy to this issue. This consensus statement will address some of the controversies surrounding the role of neck dissection following chemoradiotherapy for squamous-cell carcinomas of the head and neck, with particular reference to patients in Asia. Conclusion: the management of patients with a radiocurablepharyngolaryngeal primary with large nodes by this approach is a feasible option with adequate control and survival. The commonest pathologies are carcinomas (adenocarcinomas, squamous cell carcinomas, olfactory neuroblastomas etc) and the commonest site of involvement is the maxillary sinus (60%), whereas approximately 20% arise in the nasal cavity, 5% in the ethmoid sinuses, and 3% in the sphenoid and frontal sinuses. T2 Tumor causing bone erosion or destruction includ ing extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates T3 Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses T4a Moderately advanced local disease. Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus Nasal Cavity and Ethmoid Sinus T1 Tumour restricted to one subsite of nasal cavity or ethmoid sinus, with or without bony invasion T2 Tumour involves two subsites in a single site or extends to involve an adjacent site within the nasoethmoidal complex, with or without bony invasion. T3 Tumour extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate T4a Moderately advanced local disease. Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses T4b Very advanced local disease. Radical Radiotherapy preferred if surgical resection morbid/patients unfit or unwilling for surgery. Resection in very select group with favourable histology with low biologically aggressive tumours for eg. Pterygoplatine fissure involvement Involvement of dura and intra-cerebral extension of squamous carcinoma. Bilateral orbital involvement Absolute contraindications for Endoscopic resection: Skin involvement Anterior wall of maxilla 130 Gross brain invasion Involvement of floor of nasal cavity Involvement of lateral or posterior nasopharyngeal walls Involvement of lateral wall of maxilla Involvement of posterior wall of frontal sinus PostMaxillectomy Reconstruction: If palatal defect less than one third obturator preferred. Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. Methods: Three hundred thirty-four patients from 17 institutions were analyzed for outcome. Statistical analyses for outcomes were performed in relation to patient characteristics, tumor characteristics, including histologic findings and extent of disease, surgical resection margins, prior radiation, and prior chemotherapy to determine predictive factors. Methods: Two hundred twenty patients who were treated between 1975 and 1994 with a minimum follow-up of 4 years were reviewed retrospectively. A systematic review of published articles on patients with malignancies of the nasal and paranasal sinuses during the preceding 40 years was performed. Local extension factors that were associated with a worse prognosis included extension to the pterygomaxillary fossa, extension to the frontal and sphenoid sinuses, the erosion of the cribriform plate, and invasion of the dura.
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The surviving cells in the radioresistant late S phase move to and accumulate in the radiosensitive 102 G2/M phase. Therefore, if the next irradiation is performed during the period of G2 arrest, then the effectiveness of cell killing by radiation is increased. Reoxygenation the response of tumours to large single doses of radiation is dominated by the presence of hypoxic cells within them, even if only a very small fraction of the tumour stem cells are hypoxic [6. Immediately after a dose of radiation, the proportion of the surviving cells that is hypoxic will be elevated. However, with time, some of the surviving hypoxic cells may gain access to oxygen and hence become reoxygenated and more sensitive to a subsequent radiation exposure. Reoxygenation can result in a substantial increase in the sensitivity of tumours during fractionated treatment. Reoxygenation has been shown to occur in almost all rodent tumours studied, but both the extent and the timing of this reoxygenation are variable. Reoxygenation may result from increased or redistributed blood flow, reduced oxygen utilization by radiation damaged cells, or rapid removal of radiation damaged cells so that the hypoxic cells become closer to functional blood vessels. Measurements of the pO2 in human tumours (using Eppendorf oxygen electrodes) during fractionated radiotherapy have demonstrated improved oxygen status in some tumours. Although there is no direct evidence for reoxygenation of surviving hypoxic cells in human tumours, it is probable that it is a major reason why fractionating treatment leads to an improvement in therapeutic ratio (compared with single large doses) in clinical radiotherapy [6. Repopulation In rapidly growing cells, an increase in the number of surviving cells resulting from cell division, or repopulation, might occur during fractionated radiotherapy because of proliferation and/or reduction of cell loss. Therefore, an extension of the overall treatment time leads to a decrease in the local control rate [6. Recently, the involvement of cancer stem cells has been suggested in repopulation after radiation. Molecular targets are often differentially expressed in tumours and normal tissues, offering a potential therapeutic gain. Their results showed that adding cetuximab to primary radiotherapy increased overall survival in patients with locoregionally advanced squamous cell carcinoma of the head and neck with acceptable side effects. Studies using temozolamide and radiotherapy for glioblastoma also showed a positive effect [6.
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Motor examiner as increased resistance to passive disturbances include slow initiation of movemovement across the joints. Examination may ment (akinesia), sluggishness of movement reveal cogwheel rigidity, i. Propulsion motor disturbances are often more pronounced and retropulsion arise in the early stages of on one side of the body, especially in the early Parkinson disease because of generalized imstages of disease. They affect the craniofacial pairment of the postural reflexes that maintain musculature to produce a masklike facies (hythe bipedal stance. Related phenomena include pomimia), defective mouth closure, reduced involuntary acceleration of the gait (festination), blinking, dysphagia, salivation (drooling), and difficulty in stopping walking, gait instability, speech that is diminished in volume (hypoand frequent falls. The patient Accompanying Manifestations mayfindithardtoinitiatespeech,ormayrepeat syllables; there may be an involuntary accelera-! Postural changes include stooped tions includes worry, anxiety, avoidance of soposture,amildlyflexedandadductedpostureof cial contact, general unhappiness, listlessness, the arms, and postural instability. Gait disturquerulousness, brooding, somatoform disturbances appear in the early stages of disease and bances, and (rarely) suicidal ideation. Tension, worry, mental agitation, lack fling, and limping, with reduced arm swing. Difof concentration, and dizziness are relatively ficulty initiating gait comes about in the later common complaints. It becomes difficult for the patient to stand up from a seated posi206 tion, or to turn over in bed. Sleep may also be difficult to distinguish from depressive manifeinterrupted by nocturnal akinesia, which makes stations. The side effects of pharmacotherapy it difficult for the patient to turn over in bed. Spontaneous complaints of is initiated for patients suffering from disoriendiminished libido or impotence are rare. Intation, confusion, suspiciousness, and other creased libido is a known side effect of levodopa emotional changes. Mainly occurs as generalized, irgresses, about 20% of patients develop regular, sudden episodes of sweating. Mainly on the forehead, nose, and severation, and increasing difficulty in planning scalp (greasy face, seborrheic dermatitis).
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Triglycerides signs or symptoms of infection which include a serve as the backbone of many types of lipids (fats). Treatment is usually with the drug metronidazole given by mouth the level of triglycerides in the blood. Having trichomoniasis once does levels are influenced by recent fat and alcohol not protect a person from getting it again. The normal level of triglycerides depends on impulse control disorder characterized by the the age and sex of the individual. Mild to moderate repeated urge to pull out scalp hair, eyelashes, eyetriglyceride increases occur in many conditions. Markedly high triglyceride levels (greater than 500 mg/dl) can trisomy 18 syndrome the presence of three cause inflammation of the pancreas (pancreatitis). Children with trisomy 18 syndrome have multiple malformations and mental retardation. They triiodothyronine A hormone that is made by the characteristically have low birth weight, small head thyroid gland. Triiodothyronine has three iodine (microcephaly), small jaw (micrognathia), malformolecules attached to its molecular structure. It is mations of the heart and kidneys, clenched fists with the most powerful thyroid hormone, and it affects abnormal finger positioning, and malformed feet. A secondtrochanter One of the bony prominences toward trimester fetus that is born prematurely may be the near end of the thighbone (the femur). In humans, triploid is equal to 69 trochanter is also called the minor chromosomes. The trochanters are points at which hip and thigh trismus pseudocamptodactyly syndrome See muscles attach. The most comtrochanter receives the insertion of several muscles mon trisomies in newborns are trisomy 13 (Patau (including the psoas major and iliacus muscles). Children with trisomy 13 syndrome are prothe eyeball upward and outward (and, therefore, in foundly mentally retarded and have multiple malfordouble vision). The trochlear nerve is the fourth mations, commonly including scalp defects, cranial nerve, and it is the only cranial nerve that hemangiomas (blood vessel malformations) of the arises from the back of the brain stem. It follows the face and nape of the neck, cleft lip and palate, mallongest course within the skull of any of the cranial formations of the heart and abdominal organs, and nerves. Gestational trophoblastic tumors considered permanent because reversal requires start inside the uterus, the hollow, muscular, pearmajor surgery. This type of tubes by various surgical techniques, usually under tumor occurs in women during the years when they general anesthesia. There are two types of gestational trophoblastic tumors: hydatidiform mole tubal pregnancy See pregnancy, tubal. For specific types of troponin test A sensitive and specific blood test tubes, see their alphabetical listing.
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