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Y3S1 TREATMENT
| Question | Answer |
|---|---|
| Chamfer | Automatic bony match |
| MMI | Automatic soft tissue match |
| Basic steps in prostate CBCT image matching (e.g. prostate) | Verify CBCT - image qual, offsets/ext scans Turn on PTVs, fem heads, blad and rect (+- GTV/CTV), 95% IDL Auto bony match - suitable clip box size Balance bone match with soft tissue (rect/blad and junction) Is disease vol in PTV in today's image? |
| In what order do we match/view CBCT | Sagittal, coronal, transverse (sag sup/inf, ant/post, PITCH) (cor l/r, sup/inf. YAW) (trans, sup/inf, l/r, ROLL) |
| rationale for tattooing patients | Reproducibility + localisation + future reference for further RT Provides identifiable external reference marks with reference to internal anatomy |
| What are the three essential components of tattooing | 1. Correct location - determined at CT with lasers and marked with pen 2. Documentations - measurements made from common landmarks and photos taken 3. Visibility - be aware of breast fall/skin rolls, hair and moles |
| safety precautions for tattooing as students | always supervised as a student, universal precautions, never recap, be familiar with departmental procedure and stick injury protocol, be way of patients moving abruptly, explain to patient |
| Universal Needle Safety Precautions (PRRDHSI) | 1. Use PPE 2. Never re-use needles 3. Avoid needle recapping 4. Dispose properly 5. Handle appropriately (keep track of location, point away, do not pass) 6. Clean spills 8. Report and manage needle stick injuries |
| Steps of tattooing | Line patient up, identify proposed location and mark area, check equipment, clean area, inform patient, wash hands and glove, place drop of ink, hold skin taut and pierce skin, dispose of needle, wipe of residual ink, remove gloves and wash hands |
| Why may patients refuse tattoos? | -Fear of needles -Cosmetic effect – breast tattoos can be quite visible -Seen as a reminder of their cancer journey -Not wanting people to know that they have had cancer / have had RT |
| What information is provided to patients about tattoos to obtain informed consent | How many tattoos will be done, location of tattoos, what the tattoos will look like Provide the patient with the opportunity to ask any questions. ensure questions are answered and any patient concerns addressed |
| Tattoo alternatives | Point guards and SGRT (camera to facilitate 3D surface tracking) |
| Bony match structures for brain | bony skull, sinuses (frontal, sphenoid, maxillary), mandible, maxilla, sutures, occipital eminence, surgical clips and surgical bone deformities |
| Soft tissue match structures for brain | lateral ventricles, parietal and frontal lobes, falx cerebri. tumour 'mass' is not as accurate as surrounding anatomy in CBCT |
| what are the three primary descriptors in image-matching | ANATOMY, DIRECTION, MAGNITUDE |
| Considerations of brain matching | Turn on structures close to PTV (e.g. orbits, brainstem, lenses) Appropriate clip box size Sinuses etc - may fill up with fluid, this can affect dosimetry and must be monitored |
| General considerations of head and neck matching | Clip box - follow volumes inf, not far ant - jaw pos variable (espec if metal artefact - effects system) Turn on PTVs, BS, eyes, inner ears, lens, SC, parotid Nodal vols affected by shoulder pos/clav - mobile Be aware of swelling + lymphodoema |
| Sagittal rotation | Pitch |
| Coronal rotation | Yaw |
| Transverse rotation | Roll |
| Expected info in first day chat | Step by step of routine, gown, 15 mins/day, set up same as sim, lie still, breathe normally, no help, measurements, call out no, treatment wont hurt, come close not touch, watching at all times, wave, side effects / nursing chat |
| cues for successful communication with your patient | display genuine empathy and concern, maintain appropriate interpersonal proximity, actively listen, demonstrate appropriate non-verbal communication with the patient (body lang, facial expressions, gestures) |
| five key elements of active listening | pay attention, show that you are listening, provide feedback, respond appropriately, defer judgement |
| when should an alert notification be created for rectum image matching | sep change >3cm, pelvic tilt consistently not reproducible within 5mm, change in gtv/ctv, bladder + bowel not achieveable and affecting PTV significantly |
| Tattooing equipment | Needle/s, gloves, marker pen, ink, alcohol wipe, sharps bin |
| How to set up h/n patients to achieve accurate image match | - Align ITN/ATN on board in AP direction - replicate head pos - Assess swelling (chemo, medication) - remove or add shims - Arm and torso position effect set-up and image match -straighten using SSN and relax shoulders into mask |
| Bony match points for H/N matching | Transverse: focus on spinous processes of vertebrae and mandible to establish roll Sag: C6 vertebrae, C2, anterior cranial fossa and frontal sinus, establish rotation Cor: vertebral bodies and clavicles - yaw |
| Soft tissue match points for H/N | Focuses on PTV mass/area (primary) in relation to thecal sac/brainstem (secondary) -> brachial plexus in shoulder region |
| What is a correction reference point in H/N image matching? | Best match occurs at CRP - by spreading out from CRP, algorithm decreases in accuracy Bilateral - CRP at ant surface of C1 vert - ensures TS/BS has accurate match along midline Unilateral - likely on iso to achieve best match at PTV secondary to TS/BS |
| 4 types of leukemia | ▪ Acute Lymphoblastic Leukemia (ALL) ▪ Acute Myeloid Leukemia (AML) ▪ Chronic Lymphocytic Leukemia (CLL) ▪ Chronic Myeloid Leukemia (CML) |
| Define leukemia | Leukemia refers to a cancer of the blood thatis characterised by the growth of abnormal blood cells (WBCs) in the bone marrow |
| Define lymphocytic cancer cells | Develop from lymphoid cells (type of WBC) which normally develop into WBC |
| Define myeloid cancer cells | Develop from myeloid cells (type of WBC) which normally develop into RBC, WBC, platelets |
| How does leukemia originate / grow | DNA of single cell in bone marrow mutates (most commonly immature WBC). These cells start as haematopoietic stem cells, which -> myeloid/lymphoid cells. Begins to rapidly multiply, and takes over the space in the bone marrow |
| Define acute leukemia | Rapid division and quick disease progression. Requires immediate treatment due to sudden onset of txt. COMMON IN CHILDREN. Immature cells |
| Define chronic leukemia | May behave as immature and mature blood cells. Slow progression with minimal symptoms, often only picked up by blood test. More common in adults. |
| Diagnosis of leukemia | Physical exam - enlarged LNs Blood test - may show inc/dec WBCs/RBCs/platelets BMBx - needle aspiration of BM from hipbone Lumbar puncture - conducted if CNS disease is suspected Imaging - for disease progression (particularly testes and brain) |
| What is the blood testes barrier | The blood-testis barrier prevents high concentrations of chemotherapy from reaching the testes, protecting hidden leukemia cells. |
| Most common pop for acute lymphoblastic leukemia | most common type of leukemia in children, teens and young adults up to the age of 39 – good chance of cure (70% survival rate) can affect adults at any age but less common and reduced chance of cure |
| Aetiology of ALL | Environmental factors e.g. exposure to benzene, genetic disorders (downs, blooms, fanconi's anaemia), exposure to high levels of radiation |
| signs/symptoms of ALL | bleeding gums, bone pain, fever, frequent infections, frequent/severe nosebleeds, lumps caused by swollen LNs (neck, armpits, abdo, groin), splenomegaly, pale skin, SOB, weakness/fatigue, general energy decrease |
| adverse prognostic factors of childhood ALL | - Adverse cytogenetic markers - CNS disease at presentation - Early marrow relapse - Testicular relapse - T-cell phenotype - Philadelphia chromosome present |
| Outline treatment of ALL in children | Chemo 3-phase approach: induction, consolidation, maintenance. 2-3 years |
| Induction chemo for childhood ALL | Goal to achieve remission. Also administered intrathecal chemo. Most patients enter remission after 1 month |
| Consolidation chemo for childhood ALL | intense, commences once the patient is in remission. several months. combination of chemotherapeutic agents given to prevent remaining cells from developing resistance. those in high-risk groups may be given a stem cell transplant after this phase |
| maintenance chemo for childhood ALL | Commences if the leukemia is still in remission after the induction and consolidation phases have finished. Combination of oral and IV drugs. |
| Outline treatment of ALL in adults | More intensive treatments are used with older adults. Often CNS spread is found on diagnosis. 3 phase approach Length of treatment = 2 years (maintenance phase takes up most of this time) |
| Induction chemo for adult ALL | goal to achieve remission. patients with the Philadelphia chromosome will receive a targeted drug. 1 month. CNS treatment involves intrathecal chemotherapy (methotrexate) and RT to the brain & SC |
| Consolidation chemo for adult ALL | a short course phase (approx. 2 months long) and commences once the patient is in remission. CNS prophylaxis is continued during this phase Drugs used are the same as in the induction phase |
| maintenance chemo for adult ALL | commences if leukemia still in remission after the induction and consolidation phase. This phase lasts for 2 years CNS prophylaxis is continued during this phase |
| Most common pop for AML | This is the most common type of leukemia in adults. Can be diagnosed at any age, but is less common before the age of 45 |
| Aetiology of AML | age (50+), smoking, high radiation exposure, benzene, autoimmune conditions (RA, anaemia, ulcerative colitis), past chemo (e.g. hodgkin's, breast cancer) |
| signs and symptoms of AML | bleeding with no other cause (nose/gums), pain in bones/back/stomach, fever, frequent infection, bruising easily, paleness or change in skin colour, SOB, extreme tiredness |
| Outline treatment of AML | More intensive treatments are used for young/healthy pts with 2 phase approach: Remission Induction + Consolidation Treatment asap due to quick disease progression. Some pts may also have leukostasis |
| Treatment for younger AML patients (under 60) | remission: goal to achieve remission. intensity of txt dependent on age/health. 7+3 regime repeat bmx 1-2 weeks after first round - should go into remission consolidation: several cycles of chemotherapy + stem cell transplant |
| Treatment for AML patients older/poor health | Intensive treatment is not given, as this has been shown to potentially shorten life expectancy Treatment is not divided into phases, and is given for as long as it is helpful Low intensity chemo + a targeted drug |
| Explain chronic lymphocytic leukemia | Slow growing, affects B-lymphocytes. Most common type of leukemia in adults (67-72). Asymptomatic, picked up on routine blood tests |
| Symptoms of CLL | enlarged lymph nodes, fatigue, fever, pain caused by an enlarged spleen, night sweats, weight loss and frequent infections |
| Risk factors of CLL | age (older adults), ethnicity - caucasians, family history of blood and bone marrow cancers, exposure to chemicals (agent orange), monoclonal B-cell lymphocytosis. |
| Treatment of CLL | not required for asymptomatic pts. active monitoring - txt if disease progresses. treatment includes - chemo - targeted drug therapy - immunotherapy - stem cell transplant |
| Describe CML | Can occur at any age, common >40. Men. Slow disease progression. Asymptomatic (picked uo on routine blood tests) |
| Symptoms of CML | anaemia, increased or unexplained bleeding or bruising, frequent or repeated infections and slow healing, excessive sweating, unexplained weight loss, pain or discomfort under the ribs on the left side |
| Risk factors of CMl | Ph chromosome - produced tyrosine kinase. prolonged benzene exposure, exposure to specific types of chemo, previous RT, high dose radiation exposure |
| Three phases of CML progression | chronic, accelerated, blast |
| Chronic phase of CML | more than 90% diagnosed in this phase. blood counts stable, <5% of blast cells in bone marrow/blood, asymptomatic. 70% good response. treated with TKI |
| accelerated phase of CML | 5% of pts experience inc blast cells. if untreated -> blast phase. if no TKI, begin. Otherwise increase dose or switch TKI. Allogenic stem cell transplant may be offered |
| Blast phase of CML | less than 5% risk of patient developing blast phase. 30% inc in blast cells. more severe symptoms resembling AML or ALL. TKI with stem cell transplant reccomenndd |
| Role of RT in leukemia | used as secondary/prophylactic txt for: • spread to CNS • spread to testicles • treat symptoms caused by swollen internal organs, e.g. the spleen presses on other organs • alleviate bone pain from mets • eradicate remaining cells before SCT -> TBI |
| Describe RT for CNS relapse | Used with caution, only when absolutely necessary for pts who have CNS disease at diagnosis or relapse Intrathecal chemotherapy used first High risk of secondary cancer + long term effects on brain in younger children, including cognitive effects |
| Field and prescription for CNS RT | whole brain -> C1/2 23.4Gy/13 fx 2 lateral beams or VMAT |
| Describe RT for testicular relapse | caution, only when necessary primary agents = chemo which penetrate testis/blood barrier |
| Positioning and px for testicular RT | ▪ 24-26Gy given in 12-13 fractions ▪ Patient is supine, lying in a frog leg position with the soles of the feet touching ▪ Treatment field should include the scrotum and lower spermatic cord ▪ Penis should be shielded so that it is not in the field. |
| TBI rationale | ▪ Destroy all cancer cells in bone marrow/CNS ▪ Reduce the amount of bone marrow to make space for the transplant ▪ Safely suppress a patient’s immune system to increase chance of success of stem cell transplant |
| TBI regime | 12Gy/6fx. Bidaily for 3 days. 1-1.5 hours with 20-30 min txt time. TLDS placed to measure dose - adjustments made before next fx Day -5 and -4: chemo Day -3 and -2: TBI Day -1: TBI and chemo Day 0: stem cells Following: methotrexate |
| Side effects of TBI | Acute: nausea, vomiting, diarrhoea, fatigue, skin erythema, mucositis, alopecia, parotitis Chronic: infertility, early onset menopause, hormone changes, fatigue, cataracts, dry eyes, radiation pneumonitis, radiation induced malignancy |
| acute side effects - brain | alopecia, headache, naus/vomiting, cognitive changes, hearing loss, seizure, oedema, insomnia, blurred vision |
| general recs for patient comms about side effects | establish baseline vs escelation. query and identify timeline of side effect onset. frequency, when is symptom worst/how is it relieved. all the time or just after txt. current protocols/medication. chemo vs RT side effects |
| side effect segue examples | mouthpiece - looking sore skin - this looks red, how does it feel mask - weight loss - looking like lost some weight what did you have for dinner? |
| acute side effects - head and neck | dysphagia, mucositis, xerostomia, loss/changed taste, weight loss, dental caries/toothache, hoarseness / loss of shell |
| mgmt of brain acute side effects | anti emetics, pain relief, skin care |
| mgmt of head and neck acute side effects | speech therapist/dietician => supplements and dietary modifications inc hydration avoid alcohol and hot drinks |
| acute side effects - breast | skin reaction, breast swelling, discomfort, oedema, itching, potential SOB (lung dose) |
| acute side effects - chest/thorax | oesophagitis, cough, SOB, haemoptysis, naus/vom (if stomach dose) |
| acute side effects - abdomen | weight loss, naus/vomiting, anorexia, diaorrhoea |
| acute side effects - pelvis | proctitis, cystitis, nocturia, vaginal stenosis, diaorrhoea, bowel/bladder urgency or incontenence. painful urination, cysititis, nocturia |
| which type of leukemia is most common in children | ALL |
| general characteristics of electrons | finite range, rapid dose falloff, high surface dose with a wide penumbra that increases at depth |
| min and max electron sizes and max depth | approx. 6cm depth, 4x4 minimum size, 20x20 maximum size |
| where do we prescribe electrons to | - Dose usually prescribed to 90% IDL (100% is small area, unreliable) Depth in cms at 90% is approx one third of electron energy |
| describe electron PDD curve (+a,b,c) | high surface dose , almost constant dose to depth just beyond dmax, sharp fall off a. build up region b. dose fall-off region c depth-dose tail |
| describe differences in PDD of high and low electron energy | Higher energy = wider peak and less rapid dose fall-off At lower energies there is less high isodose line constriction, with lateral spread At higher energies isodose lines constrict laterally, fall farther apart with forward and lateral expansion |
| Electron vs photon PDD | • Electrons deposit dose as soon as the skin surface is reached • Surface dose for electron beams increases with increasing energy • This is opposite to photon beams where the surface dose decreases with energy |
| Effect of extended electron SSD | The lower % lines get wider The higher % lines (80-100%) get narrower and lose depth |
| what is junctioning | Matching of electron/electron or electron/photon fields Risk of hotspots created at junction due to penumbra of electron field -> be weary of where this hotspot is and increase gap between fields (-> coldspots) difficult reproducibility of gap |
| Effect of small/irregular field cut outs on electron isodose lines | Smaller/irregular field cut outs lead to more of a 'point-dose' of the 90-100% IDL and a ballooning penumbra Beam flatness is a problem at small field sizes |
| Role of bolus in electrons | - To increase surface dose - Flatten out irregular surfaces - Reduce beam penetration - Packing air cavities |
| Advantages of electrons | Sharp dose fall off below surface Less absorption in bone and cartilage compared to SXRT Good cosmetic results |
| Disadvantages of electrons | Expensive linac, field size limitation, dose inhomogeneity on curved surfaces, affected by heterogeneities, hard to model / look-up tables do not predict dose for oblique incidence, penumbra |
| describe how curved suraces affect electron distribution | different parts of the beam hit at different angles SSD changes across the surface oblique incidence increases scatter dose becomes less uniform at the edges |
| describe how air and bone affect electron distribution | air: dose becomes uneven around the cavity edge, IDL pulled inward / pinched bone: Electrons lose energy faster in bone, range becomes shorter, more scattering occurs. |
| describe LMPA | Custom field shaping blocks used for electron txts; • complicate and slow down txt procedure • low cost • manual labour and handling toxic materials. • transferring outline from TPS to cutting tools introduces field shape and placement uncertainties |
| How to set up electrons with bolus | set 100cm to bolus, NOT SKIN |
| Safety cons of electron | Heavy applicator, possible collision |
| why would we use an extended SSD electron | access issues or trying to increase field size |
| examples of best contact vs set angles | best contact - extremeties, keloids, breast boost set angles - head and neck, junction techniques |
| What are the two types of Primitive neuroectodermal tumours (PNET) | Pinealoblastoma and medulloblastoma Highly invasive and spread rapidly through CSF. -20% have spread to SC before diagnosis |
| Which is the most common childhood brain tumour | Medulloblastoma 2 males: 1 females |
| S+S of medulloblastoma | Headaches/nausea/vom (worse in morn due to raised ICP), irritability, motor function problems, tiredness, tilting of head to one side, walking troubles, back pain, incontinence - can make it difficult to identify in young children |
| S+S of glioblastoma | Headaches, seizures, vomiting, trouble speaking, blurred vision |
| Overview of clinical management for medulloblastoma | Dependent on risk/staging categories 1. Age (above or below 3yo) 2. Post-op residual disease 3. Metastatic spread Modalities: surgery, CSI, adjuvant chemo (usually a mixture of 3, with surgery being paramount) CSI - 2-3 weeks after surgery |
| Describe supine VMAT treatment to entire CSI (overview) | Skull: 2 arcs that encompass C spine Spine: 2 x 2 posterior quarter arcs (to avoid arms), C-spine to sacral foramina (to include sacral nerve roots). 3 isos - 2 arcs per iso. anterior arc may be required to improve conformity if patient is large. |
| How is the overlap of skull and spine arcs managed in VMAT CSI | SKULL ARCS OVERLAP AND SPINE ARCS OVERLAP - THIS REGION IS MODULATED BY THE PLANNING SYSTEM |
| Describe VMAT treatment to brain/skull only | VMAT techniques, 1-2 arcs, an extra NCP arc to achieve OAR tolerances may be used Most important OAR: optic chiasm, nerves and globes. Cochlea, brainstem, hypothalamus and pituitary dose |
| Historical 3DCRT CSI technique | 2 lats to brain (iso near face - shielding) PRONE set up -> 2 piece shell. Chin tilt important Zero junction with two zero jaws to minimise overlap Spine fields: moving junction with gaps on pt surface to account for divergence/overlap |
| Cons of chin tilt in 3dcrt CSI | Swelling -> increased skin folds and bolus effect |
| Describe moving junction in CSI | Spine fields: moving junction with gaps on patient surface to account for divergence and feather out overlap effect. Rotate 3-5mm daily |
| How does age/patient height affect 3DCRT CSI set-up | Age of the patient/patient height can complicate field set-up, extended SSDs introduce txt error and plan complexity |
| How does age/patient height affect VMAT CSI set-up | How does age/patient height affect 3DCRT CSI set-up |
| Advantages of prone CSI set up | Prone is favourable due to access to spine, palpation for set-up and field placement, skin marks for junctions, general accuracy -> reduction of margins |
| Advantages of supine CSI set up | Supine is current SOP (especially for VMAT) due to comfort, reproducibility, feeling of security (paediatrics), access to anaesthesia |
| Prone positioning (actual equipment) CSI | Torso and legs elevated, head with prone pillow and two piece shell, arms by side, shoulders supported and drawn inf. ensure no skin folds on back of neck, elevate chin (whilst avoiding skin folds) as post field should not diverge into mouth |
| Supine positioning (actual equipment) CSI | ideally in vacbag, mask, arms by sides with shoulders supported and drawn inf/ant, C-spine as horizontal as possible - try to maintain neck level, legs raised to flatten back, chin raised to avoid exit from post spine field (without curving c-spine) |
| Prone set-up steps | set equipment, position pt, set lateral field iso using mask marks, check field/SSDs, check + set daily junction, determine correct junction + ensure int edge passes through, treat, set upper spine field (palpate, SSD, junction), treat, lower spine repeat |
| side effects of CSI | erythema, dry/moist desquamation, oedema, hair loss (permanent >40Gy), drowsiness, lethargy, dec mental status, worsening of tumour symptoms, cognitive impairment, decreased visual spatial, motor, fine motor skills, decreased memory and arithmetic skills |
| patient care for CSI | Assess patient well-being esp. emotional stability Paediatrics may need more time/be patient, prepare a separate area to talk, patients can be aggressive, consider parents' needs, encourage patients to eat well and rest, weekly blood tests |
| diagnosis of medulloblastoma | - Symptom history and neurological examination - MRI with and without contrast - if MDB is suspected, MRI entire spine - Lumbar puncture - Surgery - biopsy or removal of tumour Pathology report |
| general considerations of paeds txt | different tumour types to adults, younger children at greater risk of late side effects, neurocognitive effects, muscle and bone development/growth, tissue tolerance differences, late carcinogenesis, compliance, pituitary function -> puberty |
| classification of childhood medullablastoma (high vs average risk) | High risk : 1. <3 years at diagnosis -> advanced disease with spread 2. Tumour following surgery >1.5cm2 3. M1-4 (spinal/brain spread or distant mets) otherwise AVERAGE risk child will be categorized as having “ average risk” disease |
| survival rates of childhood medulloblastoma | M0 - survival 70-80% If the disease has spread to the spinal cord, the survival is about 60% Children younger than age 3 often have lower survival rates because their disease tends to be more aggressive (and diagnosed later) |
| paed RT MDT | occupational therapy (play therapy), physiotherapists, MOs, paed nurses, GA team, dieticians, speech path, teachers, family liasion, pall care, paed RT |
| familial cons for paeds | social cons: siblings, separated parents (consent), children in foster care, families/patients requiring to travel or stay away from home, legal requirements e.g. DV orders |
| list paediatric interventions | - Play therapy - Environment - Distraction -> screens Rewards/incentives |
| describe play therapy | sessions prior to ct and treatment, usually 1-3 sessions. extent of therapy is pt dependent. can include: delivery of social story by OT, making mask/VB on toy or parents, playing w controls, watching parents on monitor, practice leaving child inside |
| benefits of play therapy | reduced cost + resource load compare to GA. Daily sedation carries respiratory risks, depression, aspiration, central line infections, learning disabilities, decreased attentiveness and cognitive functioning |
| indications vs contraindications for GA | generally children under 3 require GA exceptions = Behavioural issues + medical traumas/fear, compliance issues due to a condition eg. posterior fossa syndrome |
| describe posterior fossa syndrome | Constellation of symptoms noted following surgery for posterior fossa tumours Occurs in 8-24% cases Can include: • Absence or reduction in speech • Axial hypotonia and ataxia • Broad spectrum of severity -mild to completely disabling symptoms |
| challenges in paed sim | - Swelling from surgery and shunt location - GA: changing equipment used by anaesthetists changed jaw position and head tilt Solution mouthpiece at CT for worst case scenario |
| cons of bone irradiation in paed rt | bone growth is arrested if more than 18Gy is delivered - coverage must be adjusted to include entire vertebral bodies rather than only treating half -> can lead to differential growth and functional disabilities, pain, scoliosis |
| how many cbcts per iso paeds | 3 iso CSI may require 3x, 4x, 5x extended CBCTs also kV imaging before delivering spine fields, with post CBCT if requested |
| cons of imaging dose in paeds | exposure settings ALARA longer lifetime during which cancer, cataracts, marrow suppression can present children more sensitive to rads (developing tissue) + less efficient at repairing mutations caused by IR low body fat -> inc absorption |
| side effects of CSI txt paeds (beth) | growth hormone deficiency, hearing loss, heart damage, second cancers, cognitive deficits, abnormal bone or muscle growth, cognitive deficits, psychosocial issues, low thyroid hormone, reduced lung function, treatment related obesity, infertility |
Created by:
jrichardss