Thyroid+Gland

Oncocytic carcinomas (also known as //Hürthle cell carcinomas//) behave as a slightly more aggressive form of follicular cancer, but both present similarly. Medullary thyroid carcinomas tend to present in the earlier years of life for familiar disease and later for sporadic disease. Anaplastic or undifferentiated thyroid carcinoma, which is rare, afflicts those in the later decades of life. 7 || -Lesions in the thyroid gland should arouse suspicion if they exhibit extreme hardness, appear to be fixed to deep structures or skin, and are associated with recurrent laryngeal nerve paralysis (hoarseness). -Anaplastic carcinomas are usually large, hard, and fixed; grow rapidly; and occur in older patients. Patients can appear with symptoms related to compression and/or invasion of the esophagus, airway, or recurrent laryngeal nerves. Symptoms include pain, dysphagia, dyspnea, stridor and hoarseness. - Most patients with medullary carcinoma initally have an asymptomatic painless mass. They may appear with systemic symptoms of diarrhea related to vasoactive substances (calcitonin) produced by the tumor. This usually represents an advanced stage of the disease. 1 || -Thyroglobulin levels cannot distinguish between a benign tumor and differentiated thyroid cancer. Postoperatively, however, elevated levels indicate residual, recurrent, or metastatic differentiated thyroid cancer and can be correlated with iodine-131 (I-131) imaging for detection of thyroid cancer. -Calcitonin levels that are elevated preoperatively indicate C-cell hyperplasia and/or medullary thyroid cancer. Postoperatively elevated levels indicate residual, recurrent, or metastatic medullary thyroid carcinoma. - Radionuclide thyroid imaging is commonly used to evaluate the function and anatomic location of a palpable thyroid nodule through the localization of a hot or cold spot in the gland. By this means the detection of occult cancers in high-risk patients can be accomplished. This imaging technique can detect a primary lesion in patients with suspected regional and distant thyroid cancer metastases. In addition, radionuclide imaging can detect local-regional or distant metastases in patients with known thyroid cancer. -Sonography can determine whether a nodule is solid or cystic. This technique is used as a complementary test to radionuclide imaging. A nodule found to be solid through sonography has a 30% probability of being a cancer. -A CT scan cannot differentiate between a benign or malignant lesion. However, it can show the local and regional extent of advanced or recurrent cancer. Ct can also help a radiation oncologist in treatment planning if the use of external beam radiation is anticipated. -MRI can be useful in depicting lesion margins, lesion extent, tissue heterogenicity, cystic or hemorrhagic regions, cervical lymphadenopathy, invasion of adjacent structures and additional nonpalpable thyroid nodules. -A needle **biopsy** in some circumstances can obviate surgery by differentiating malignant from nonmalignant lesions. Two types of needle biopsies are needle aspiration cytology ( performed with a small-gauge needle) and a core needle biopsy ( performed with a large-cutting biopsy needle of the silverman type). - Both biopsies have a false-negative rate of up to 10%. 1 || 1) **Papillary**- and mixed papillary are the most comon types of thyroid cancer, representing 33% to 73% of all malignant thyroid lesions. Papillary carcinoma is the type most frequently seen in irradiated individuals. These tumors are slow growing, are nonaggressive, and have an excellent prognosis. In children younger than 15 years, papillary carcinoma accounts for 80% of thyroid cancers. 2) **Follicular-** accounts for 14% to 33% of all thyroid cancers. These tumors have the greatest propensity to concentrate I-131. 3) **Medullary**- represent 5% to 10% of all thyroid cancers. About 80% of medullary thyroid cancers appear spontaneously. 4) **Anaplastic**- carries the worst overall prognosis. It is more aggressive than the previously mentioned types, and a patient's life expectancy is usually short after the diagnosis is established. 1 ||
 * Epidemiology: || In papillary and follicular carcinomas of the thyroid, three main trends seem to emerge. The incidence in women is greater that in me by a factor of 2.5. Whites and Asians seem to be overrepresented in most case studies. And the median age at diagnosis is earlier for papillary carcinoma than follicular.
 * Etiology: || External-beam irriadiation to the head and neck region, particularly during childhood, appears to be associated with a markedly increased risk of papillary carcinoma of the thyroid. Other factors found in studies over the past years include dietary iodine deficiency. This may increase the incidence of follicular carcinoma. Ingestion of seafood, shellfish, and diets high in iodine appear to be associated with papillary carcinomas, particularly where active volcanoes are close to fishing grounds, like Hawaii or Iceland. Chronic elevations of TSH levels may increase the incidence of differentiated thyroid carcinoma. ACS p.637 7 ||
 * Signs & Symptoms: || -Most people with thyroid cancer have a palpable neck mass, which is often detected during a routine physical examination. Almost 25% of young people with differentiated thyroid carcinoma present because of a palpable cervical lymph node metastasis as a result of occult primary thyroid cancer. These occult, differentiated thyroid cancers can go undetected for years because of their indolent nature.
 * Diagnostic Procedures: || -**__Laboratory testing__** includes an analysis of thyroglobulin and calcitonin levels.
 * __-Imaging studies__** include radionuclide imaging, sonography, computed tomography (CT), and magnetic resonance imaging (MRI).
 * Histology: || Malignant Thyriod neoplasms are divided into four categories:
 * Lymph Node Drainage: || Lymphatic capillaries are arranged throughout the gland and drain to many nodal sites. These sites include the internal jugular chain, Delphian node (anterior cervical node), pretracheal nodes, and the paratracheal nodes in the lower neck. Superior mediastinal lymphatics can be considered the lowest part of the cervical lymphatic system. If it is involved, this represents significant regional spread of disease. 8,6

The following diagram is of the lymphatic drainage of the thyroid gland. 3

||
 * Metastatic Spread: || Papillary and mixed papillary-follicular carcinomas metastasize to regional lymph nodes through lymphatic channels. Follicular cancers have a tendency to invade vascular channels and metastasize hematogenously to distant sites, including the bone, lung, liver, and brain. Lymph node metastases are uncommon. Medullary carcinoma spreads regionally before displaying distant metastases. Metastases occur hematogenously and through lymphatic routes involving mainly the cervical nodes, lung, liver, and bone. Anaplastic carcinoma displays local invasion of structures such as the trachea. Skin invasion is also seen, giving rise to dermal lymphatic metastases on the chest and abdominal walls. Regional neck nodes are often involved, although sometimes the primary tumor is so extensive that the regional node status is difficult to assess. 6   ||
 * Grading: || **__Histopathologic grade (G)__**

GX - Grade not assessable G1- Well Differentiated G2 - Moderately differentiated G3 - Poorly differentiated G4 - Undifferentiated 6 || __**Primary Tumor (T)**__  __**Regional Lymph Nodes (N**__) Regional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lymph nodes.   __**Stage Grouping** Papillary or Follicular (under 45 years of age__) Stage I  Stage II __<span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">Papillary of Follicular (over 45 years of age __ <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 87.12%;">) <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 114.79%;">Stage I <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 114.79%;">Stage II <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 114.79%;">Stage III <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 96.63%;">Stage IVa <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 146.41%;"> * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 100.43%;">T1 N1b M0 <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">Stage IVb <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">Stage IVc <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 133.1%;"> __ Medullary Carcinoma __ <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Stage I <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Stage II <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Stage III <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Stage IVa <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Stage IVb <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Stage IVc <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 121%;"> __<span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">Anaplastic Carcinomas __ <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive;">All anaplastic carcinomas are considered stage IV Stage IVa T4a Any N M0 Stage IVb T4b Any N M0 Stage IVc Any T Any N M1 <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 99%; vertical-align: super;">2 || __Early complications__
 * Staging: || <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">The system used for thyroid staging is the TNM system by the AJCC.
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">TX Primary tumor cannot be assessed
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">T0 No evidence of primary tumor
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">T1 The tumor is less than 2 cm in greatest dimension limited to the thyroid
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">T2 The tumor is more than 2 cm but less than 4cm in greatest dimension limited to the thyroid
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">T3 The tumor is greater than 4 cm in greatest dimension limited to the thyroid or any tumor with minimal extrathyroid or any tumor with minimal extrathyroid extension (example: extension to sternothyroid muscle or perithyroid soft tissues)
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">T4a Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">T4b Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">NX Regional lymph nodes cannot be assessed
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">N0 No regional lymph node metastasis
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">N1 Regional lymph node metastasis
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">N1a Metastasis to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">N1b Metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes
 * __Distant Metastasis (M)__**
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">MX Presence of distant metastasis cannot be assessed
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">M0 No distant metastasis
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">M1 Distant Metastasis
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Any T Any N M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 117.12%;">Any T Any N M1
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 114.79%;">T1 N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 114.79%;">T2 N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 114.79%;">T3 N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 100.44%;">T1 N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 95.66%;">T2 N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 96.63%;">T3 N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 96.63%;">T4a N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 96.63%;">T4a N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">T2 N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">T3 N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">T4a N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">T4b Any N M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 102.48%;">Any T Any N M1
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T1 N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T2 N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T3 N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T1 N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T2 N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T3 N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T4a N0 M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T4a N1a M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T1 N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T2 N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T3 N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T4a N1b M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">T4b Any N M0
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 103%;">Any T Any N M1
 * Radiation Side Effects:<span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">​ ​ || <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">__**Radioactive Iodine**__
 * Occur withing 3 months of treatment
 * Acute illness consisting of fatigue, headache, nausea, and/or vomiting can occur within 12 hours of administration of 131-I but it occurs in less than 1% of patients.
 * Swelling and pain in the salivary glands (sialadenitis) occurs shortly after administration in about 5% to 10% of patients and can last for a few days.
 * After 131-I ablation, neck edema has been reported.
 * Transient hyperthyroidism may occur after large amounts of thyroid tissue destruction and subsequent release of large amounts of thyroid hormone into circulation.
 * Bone marrow suppression may be observed in almost all patients receiving 131-I therapy. Transient anemia, thrombocytopenia, and leukopenia have been reported. "Permanent or severe marrow suppression has been reported with blood radiation doses greater than 2Gy."
 * After 131-I ablation of residual thyroid gland after a near-total thyroidectomy, transient vocal paralysis has been reported.
 * "Sudden hemorrhage into functioning cerebral metastases and severe fatal cerebral edema in a patient with functioning cerebral metastases have been reported. Pretreatment with corticosteroids may avert serious complications of therapy, especially with brain metastases."

__Long term complications__
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Occur 3 months or longer after treatment
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Radiation pneumonitis and pulmonary fibrosis are associated with 131-I treatment, especially with diffuse functioning lung metastases.
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Permanent bone marrow suppression is rare but when it does occur it is primarily in patients who received large cumulative doses of 131-I for bone metastases.
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Leukemia is a rare complication--less than 2%. Those who receive the largest amounts in the shortest amount of time appear to be the most susceptible to leukemia, especially if they are older than 50 years of age. Acute myelogenous leukemia is the most common type.
 * <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Ovarian failure and azoospermia have been reported after treatment with 131-I. <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 99%; vertical-align: super;">2 ||
 * Prognosis: || [[image:thyroid_prognnew.jpg width="400" height="202"]] ||
 * Treatments: || <span style="color: #0000ff; font-family: Georgia,serif;">A subtotal or total thyroidectomy is the treatment of choice for all thyroid cancers. Mandatory thyroid hormone therapy is required following thyroidectomy to provide patient with normal thyroid function and suppress TSH to eliminate potential growth of residual tissue. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">3 <span style="color: #0000ff; font-family: Georgia,serif;"> The thyroid hormone therapy is withheld for 6 weeks if postoperative radioiodine studies are planned. Anaplastic carcinomas are commonly unresectable . Radiation therapy is required for inoperable, residual, recurrent or metastatic disease. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">4 <span style="color: #0000ff; font-family: Georgia,serif;"> Patients with grossly involved nodes will undergo a radical neck dissection. Precautions must be taken during the radical neck dissection to preserve the recurrent laryngeal, vagus, spinal accessory, and phrenic nerves and the parathyroid glands. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">1 <span style="color: #0000ff; font-family: Georgia,serif;">

- If this type is confined to the thyroid it can often be fully controlled with surgery alone.
 * Follicular carcinoma: (encapsulated)**

- Treatment includes surgery followed by Iodine 131 (150mCi)
 * Medullary Thyroid Cancer :**

-** Treatment includes surgery, radiation therapy, and chemotherapy (doxorubicin)
 * Anaplastic Thyroid Cancer:

Post operative treatment usually includes radioiodine treatments of Iodine 131. If the tumor does not take up ¹³¹ I, external-beam irradiation is used. The following list are indications for use of external radiation. It can be used alone or in conjunction with I131 and surgery. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">1 <span style="color: #0000ff; font-family: Georgia,serif;"> - inoperable lesion - Patient physically unfit for surgery - Incomplete surgical removal of thyroid carcinoma - Superior vena cava syndrome - Skeletal metastases in which minimal accumulation of I 131 occured - Residual disease involving the trachea, larynx, or esophagus <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">1 <span style="color: #0000ff; font-family: Georgia,serif;">

The radiation therapy target volume should include the thyroid gland(or tumor bed if reseccted), bilateral cervical and superior mediastinal lymph nodes. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">4 <span style="color: #0000ff; font-family: Georgia,serif;"> One treatment technique consists on anterior and posterior opposed fields. The anterior is weighted more and the posterior field has a midline block to provide some skin sparing of the spinal cord. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">4 <span style="color: #0000ff; font-family: Georgia,serif;"> See insert 1.1 below. A boost field is usually delivered via oblique wedged fields or an anterior electron field. Precise planning is required for thyroid treatment because this malignancy requires a dose between 60-70Gy depending on tumor type. This dose is delivered in 7-8 weeks. Lymphoma of the thyroid is usually treated with a dose of 45Gy. See Simulation film below in insert 1.2. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">5 <span style="color: #0000ff; font-family: Georgia,serif;"> Chemotherapy is considered for patients with recurrent or metastatic maglignancy that is unrescetable, not responsive to radioiodine therapy, or external beam radiation therapy. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">3

<span style="color: #0000ff; font-family: Georgia,serif;">insert 1.1 || ||
 * || [[image:thyroid_ap_field_001.jpg width="476" height="254" align="left"]] ||
 * || <span style="color: #0000ff; font-family: Georgia,serif;">Insert 1.2
 * TD5/5: || <span style="color: #0000ff; font-family: Georgia,serif;">**__Organ__** **__-TD 5/5 (in cGy)__** <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">1 <span style="color: #0000ff; font-family: Georgia,serif;">

spinal cord - 6000 thyroid gland- 4500 parotid (1/3) - 3200 oral cavity- 6000 skin - 5500 larynx - 4500 || <span style="color: #2a8000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">2. Perez CA, Brady LW, Halperin EC, Schmidt-Ullrich RK. //Principle and Practice of Radiation Oncology.// 4th edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2004: 844, 855. <span style="color: #0000ff; font-family: Georgia,serif;">3. Murphy GP, Lawrence W, Lenhard RE, //American Cancer Society Textbook of Clinical Oncology//. second edition. Atlanta, GA: The American Cancer Society, Inc. 1995; 348-352. 4. Bentel GC. //Radiation Therapy Planning//. 2ond edition. New York, NY: McGraw-Hill Companies,Inc. <span style="color: #0000ff; font-family: Georgia,serif;">1996; 318-3 24. 5. Chao CK, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. second edition. Philadelphia, PA : Lippinco<span style="color: #0000ff; font-family: Georgia,serif;"> tt Williams & Wilkins. 2002; 300. 6. Washington,C.M & Leaver, D.(Eds.).(2004). //Principles and Practice of Radiation Therapy// (Second ed). St. Louis, Missouri; Mosby Inc: pg. 96,630-634. 7. Lenhard RE, Osteen RT, Gansler T. The American Cancer Society's Clinical Oncology. 1st edition. Atlanta, GA: The American Cancer Society, Inc. 2001: 633-634, 637, 642. 8. American Cancer Society. Lymphatic Mapping and Sentinel Node Analysis. Available at: []. Accessed January 17th, 2010. ||
 * References: || <span style="color: #0000ff; font-family: Georgia,serif;">1. Washington CM, Leaver DT. //Principles and Practice of Radiation Therapy Practical Applications//. St. Louis, Missouri: Mosby,Inc. 1997; 104-106.159.