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French For Football/Notes/Introductory Material

Material for New Lessons
This is NOT a lesson page - it contains NOTES for lesson material for the Introductory Modules. It is being produced by adapting the text from the Introductory and Level One sections of the French Wikibook. As the new material is generated, the corresponding old material is deleted.

Grammar: The French alphabet
In addition, French uses several accents which are worth understanding. These are: à, è, ù, (grave accents) and é (acute accent) which only applies to e. A circumflex applies to all vowels as well: â, ê, î, ô, û. And also a tréma (French for diaerasis) for vowels: ä, ë, ï, ö, ü, ÿ and combined letters:  æ and œ

Vocabulary: Cardinal numbers
Things of note about numbers:

 * For 70-79, it builds upon "soixante" but past that it builds upon a combination of terms for 80-99
 * Only the first (21,31,41,51,61 and 71, but not 81 nor 91) have "et un" without a hyphen; but past this it is simply both words consecutively (vingt-six, trente-trois, etc) with a hyphen in between.
 * For 100-199, it looks much like this list already save that "cent" is added before the rest of the number; this continues up to 1000 and onward.
 * Many speakers of French outside of France refer to the numbers 70 to 99 in the same pattern as the other numbers. For instance, in Switzerland and Belgium, seventy is "septante," 71 is "septante et un," 72 "septante deux," and so on.    Ninety is "nonante". In Switzerland, Eighty is "huitante" or "octante".

Vocabulary: The days of the week.
Notes:
 * What day is it today? is equivalent to Quel jour sommes nous aujourd'hui?, Quel jour est on aujourd'hui? or On est quel jour aujourd'hui? (last one is less formal but more common)
 * Quel jour sommes nous aujourd'hui? can be answered with Aujourd'hui c'est..., C'est... or Nous sommes ... / On est...
 * Nous sommes... is not used with hier, aujourd’hui, or demain. C'était (past) or C'est (present/future) must be used accordingly.
 * The days of the week are not capitalized in French.

Vocabulary: The months of the year

 * The months of the year are not capitalized in French.
 * For phrases relating to the months of the year, see the phrasebook

Vocabulary: Time
In French, “il est” is used to express the time; though it would literally translate as “he is”, it is actually, in this case, equivalent to “it is” (impersonal "il"). Unlike in English, it is always important to use “heures” (“hours”) when referring to the time. In English, it is OK to say, “It’s nine,” but this wouldn’t make sense in French.

G: The verb avoir
"Avoir" can be translated as "to have".

Expressing Age
Avoir is used to express age.
 * Tu as quel âge? - How old are you? [lit: You have what age?]
 * J'ai trente ans. - I'm thirty (years old). [lit: I have thirty years]

There is/are - Il y a
The expression il y a means there is or there are.
 * Il y a un livre. - There is a book.
 * Il y a des livres. - There are books.

Grammar: Direct Object Pronouns le, la, and les
le, la, and les are called direct object pronouns, because they are pronouns that are, you guessed it, used as direct objects. A direct object is a noun that is acted upon by a verb. In the above sentence la balle is the direct object.
 * Il lance la balle. - He throws the ball.

You have learned earlier that names and regular nouns can be replaced by the subject pronouns (je, tu...). Similary, direct objects, such as "la balle", can be replaced by pronouns.
 * le - replaces a masculine singular direct object
 * la - replaces a feminine singular direct object
 * l' - replaces le and la if they come before a vowel
 * les - replaces plural direct objects, both masculine and feminine

The direct object pronouns come before the verb they are linked to.
 * Il la lance. - He throws it.
 * Il les lance. - He throws them.

Le, la, and les can replace either people or inanimate objects.

Grammar: Subject pronouns
French has six different types of pronouns: the 1st, 2nd, and 3rd person singular and the 1st, 2nd, and 3rd person plural.

When referring to more than one person in the 2nd person, “vous” must be used. When referring to a single person, “vous” or “tu” may be used depending on the situation; see notes in the introductory lessons.

The pronoun it does not exist in French. Il replaces all masculine nouns, even those that are not human. The same is true with elle and feminine nouns.

In addition to the nuances between vous and tu, as discussed earlier, French pronouns carry meanings that do not exist in English pronouns. The French third person "on" has several meanings, but most closely matches the now archaic English "one". While in English, "One must be very careful in French grammar" sounds old-fashioned, the French equivalent "On doit faire très attention à la grammaire française" is quite acceptable. Also, while the third person plural "they" has no gender in English, the French equivalents "ils" and "elles" do. However, when pronounced, they normally sound the same as "il" and "elle", so distinguishing the difference requires understanding of the various conjugations of the verbs following the pronoun. Also, if a group of people consists of both males and females, the male form is used, even with a majority of females — however, this sensibly yields to overwhelming majority: given a group of only one male to thousands of females, the female form would be used.

In everyday language, “on” is used, instead of “nous”, to express “we”; the verb is always used in the 3rd person singular. For example, to say "We (are) meeting at 7 o'clock", you could say either “On se rencontre au cinéma à sept heures.” (colloquial) or “Nous rencontrons au cinéma à sept heures.” (formal). For more, see the Wikipedia entry.

G: Introduction to Verbs
A verb is a word that describes an action or mental or physical state.

Tenses and Moods
French verbs can be formed in four moods, each of which express a unique feeling. Each mood has a varying number of tenses, which indicate the time when an action takes place. In the next section, we will look at the conjugations in the present tense of the indicative mood, more commonly called the present indicative. There is one conjugation for each of the six subject pronouns.

Infinitives
The infinitive form is the basic form of a verb. It does not refer to a particular tense, person or subject. In this book, the infinitive form of the verb is used to identify it. In English, the infinitive form is to ___. In French, the infinitive is one word. For example, parler translates to to speak, finir translates to to finish, and aller translates to to go.

Conjugation
French verbs conjugate, which means they take different shapes depending on the subject. English verbs only have one conjugation; that is the third person singular (I see, you see, he/she sees, we see, they see). The only exception is the verb "to be" (I am; (thou art); you are; he/she is; we are; they are;). Most French verbs will conjugate into many different forms. Most verbs are regular, which means that they conjugate in the same way. The most common verbs, however, are irregular.

G: Être - To Be
Être translates as to be in English. It is an irregular verb, and is not conjugated like any other verb.

Examples
Try to learn all these conjugations. They will become very useful in forming tenses.

Idioms

 * Ça y est! - I've done it! Finished!
 * J'y suis! - I get it!
 * Vous y êtes? - Are you ready?

Expressing Agreement
Tu es d’accord ou pas?, Tu es d’accord? (lit: You are of agreement?), or simply D'accord? is used informally to ask whether someone agrees with you.

To respond positively, you say Oui, je suis d'accord. or simply D'accord. D'accord corresponds to the English okay.

Grammar: Cities and Nationalities
To say what city you are from, you use the preposition de. When stating your nationality or job, it is not necessary to include the article. This is an exception to the normal rule. There is both a masculine and feminine form of saying your nationality - for males and females respectively. In the next lesson, you will learn how to say the nationality of more than one person.
 * Il est de Paris.
 * Je suis Australien(ne). - I am [an] Australian.
 * Il est Australien. - He is [an] Australian.
 * Elle est Australienne. - She is [an] Australian.

Grammar: Adjectives - Les adjectifs
Just like articles, French adjectives also have to match the nouns that they modify in gender and plurality.

Regular Formation
Most adjective changes occur in the following manner:
 * Feminine: add an -e to the masculine form
 * un garçon intéressant --> une fille intéressante
 * un ami amusant --> une amie amusante
 * un camion lent --> une voiture lente
 * Plural: add an -s to the singular form
 * un garçon intéressant --> des garçons intéressants
 * une fille intéressante --> des filles intéressantes

Pronunciation
Generally, the final consonant is pronounced only when it comes before an -e. Most adjectives, such as those above, are affected by this rule. With plural adjectives, the -s ending is not pronounced, so the adjective will sound exactly the same as the singular form.
 * Masculine Pronunciation: intéressan, amusan, len
 * Feminine Pronunciation: intéressant, amusant, lent

Exceptions and Irregularities
Adjectives that end in e in the masculine form do not change in gender. When an adjective, such as gros, ends in -s, it does not change in the masculine plural form. Sometimes the final consonant is doubled in the feminine form. See French/Grammar/Adjectives for more.

Grammar: Adverbs Expressing Degree

 * assez - rather, enough
 * Il est assez intelligent. - He is rather intelligent.
 * très - very
 * Il est trèszintelligent. - He is very intelligent.
 * vraiment - truly, really
 * Il est vraiment intelligent. - He is really intelligent.

Often when a vowel sound comes after a consonant, the usually unpronounced s and z change to a sharp z sound and link to the next syllable. This process is called liaison. In this book, will will show that the sound is connected using z. Trèszin is pronounced trayzahn.

Formation
Most French verbs fall into the category of -er verbs. To conjugate, drop the -er to find the "stem" or "root". Add endings to the root based on the subject and tense.

Elision and Liaison
In all conjugations, je changes to j ' when followed by a vowel. Example: J'attends. Also, as a rule of thumb: h is considered a vowel; as in J'habite.... If a phrase is negative, ne changes to n'.

In all plural forms, the s at the end of each subject pronoun, normally unpronounced, becomes a z sound and the n of on becomes pronounced when followed by a vowel.

S'amuser
The verb s'amuser means to have fun in English. It is a type of pronominal verb (a verb that includes a pronoun as part of it) called a reflexive verb, which means that the action of the verb is reflected back onto the subject. Literally translated, the verb means To amuse oneself.

Conjugated Verb + Infinitive
Like in English, some verbs can be followed by infinitives. The most common -er verbs used in this manner are aimer and détester. When negating a sentence, remember that the negative goes around the conjugated verb.
 * J'aime parler. - I like to speak.
 * Nous détestons travailler. - We hate working.
 * Je n'aime pas parler. - I don't like to speak.

D: Recreation
Here is a short dialog about people planning/doing leisure activities. Besides the new vocabulary you should also have a look at how the verbs are conjugated depending on the subject of the sentence.

 * Jean-Paul : Qu'est-ce que vous faites ?
 * Marc et Paul : Nous jouons au tennis.
 * Marie : Je finis mes devoirs.
 * Michel : J'attends mon ami.
 * Pierre : Je vais au parc.
 * Christophe : Je viens du stade.

V: Recreation
Finir and attendre are not -er verbs. You will learn their conjugation in a later lesson.

Tu rigoles! means You’re joking! or You don’t mean it!

Mon is often substituted for ma when the following word begins with a vowel. Thus, mon amie is used instead of ma amie, while ma bonne amie would be okay.

G: Indirect Object Pronouns lui and leur
Indirect objects are prepositional phrases with the object of the preposition, a direct object is a noun that receives the action of a verb.
 * Il jette la balle à Jacques. - He throws the ball to Jack.
 * Il jette la balle à Marie. - He throws the ball to Mary.
 * Il jette la balle à Jacques et Marie. - He throws the ball to Jack and Mary.

Lui and leur are indirect object pronouns. They replace nouns referring to people and mean to him/her and to them respectively.

 * lui - replaces a singular masculine or feminine indirect object referring to a human
 * leur - replaces a plural masculine or feminine indirect object referring to a human

An example follows:

 * Il lui jette la balle. - He throws the ball to him.
 * Il lui jette la balle. - He throws the ball to her.
 * Il leur jette la balle. - He throws the ball to them.

Whether lui means to him or to her is given by context.

In English, "He throws him the ball" is also said, and means the same thing.

When used with the direct object pronouns le, la, and les, lui and leur come after those pronouns.

 * Il la lui jette. - He throws it to him.

Note that while le, la, and les are used to replace people or inanimate objects, lui and leur are not used to replace innanimate objects and things.

Also note that unlike le and la, which are shortened to l' when followed by a vowel, lui is never shortened

V: Jouer
The verb jouer is a regular -er verb meaning to play. It can be used to refer to both sports and instruments.

When referring to sports, use jouer à, but when referring to instruments, use jouer de...

As always, jouer must be conjugated rather than left in the infinitive.

V: The House
To express to live on ____ street, you say habiter rue ____
 * J'habite Rue Lecourbe. - I live on Lecourbe Street.
 * Il habite Rue de Rennes. - He lives on Rennes Street.

Quitter must be followed by a direct object, usually a room or building.. Partir is used in other phrases. You will learn how to conjugate these verbs in a future lesson.

G: Faire
The verb faire is translated to to do or to make. It is irregularly conjugated (it does not count as a regular -re verb).

Uses For Faire

 * sports (in French you do sports rather than play them)
 * weather
 * tasks
 * le faire causatif
 * faire (conjugated) + infinitive - to have something done for oneself
 * Je fais réparer le fourneau. - I make/have the stove repaired.

Related Words

 * défaire - to demolish
 * malfaire - to do badly
 * refaire - to remake

Expressions with Faire

 * faire attention - to pay attention
 * faire connaissance - to get acquainted
 * faire la morale - to scold
 * faire la queue - to wait in line
 * s'en faire - to worry

G: me, te, nous, and vous

 * Direct and Indirect Object Pronouns

Meanings

 * me - me, to me
 * te - you, to you (singular, informal)
 * nous - us, to us
 * vous - you, to you (plural, formal)

Place in sentences

 * These pronouns are placed before the verb that they modify
 * Je te vois. - I see you.
 * Je veux te voir. - I want to see you.
 * If a perfect tense is used, these pronouns go before the auxillary verb.
 * Je t'ai vu. - I saw you.

Direct Object Replacement

 * Il me voit. - He sees me.
 * Il te voit. - He sees you.
 * Il nous voit. - He sees us.
 * Il vous voit. - He sees you.

Indirect Object Replacement

 * Il m'appelle. - He calls to me.
 * Il te le jette. - He throws it to you.
 * Il nous le jette. - He throws it to us.
 * Il vous le jette. - He throws it to you.

G: Standard Negation
In order to say that one did not do something, the ne ... pas construction must be used. The ne is placed before the verb, while the pas is placed after.

Formation and Rules

 * Simple negation is done by wrapping ne...pas around the verb.
 * Je ne vole pas. - I do not steal.
 * In a perfect tense, ne...pas wraps around the auxillary verb, not the participle.
 * Je n'ai pas volé. - I have not stolen.
 * When an infinitive and conjugated verb are together, ne...pas usually wraps around the conjugated verb.
 * Je ne veux pas voler. - I do not want to steal.
 * ne pas can also go directly in front of the infinitive for a different meaning.
 * Je veux ne pas voler. - I want to not steal.
 * ne goes before any pronoun relating to the verb it affects.
 * Je ne le vole pas. - I am not stealing it.

Negation of Indefinite Articles
The indefinite articles un, une, and des change to de (or d’) when negating a sentence.
 * J'ai un livre. - I have a book.
 * Je n'ai pas de livre. - I don't have any book.
 * J'ai des livres. - I have some books.
 * Je n'ai pas de livres. - I don't have any books.

V: Weather - Le temps
Le temps means both the weather and the time.

G: Aller
The verb aller is translated to to go. It is irregularly conjugated (it does not count as a regular -er verb).

Formation
In the present indicative, aller is conjugated as follows:

Usage
There is no present progressive tense in French, so aller in the present indicative is used to express both I go and I am going.

Aller must be used with a place and cannot stand alone.

The preposition à, meaning in, at, or to, is used, followed by the place. Remember that à le contracts to au and à les contracts to aux. Instead of a preposition and place, you can use the pronoun y, meaning there. Y comes before the verb. Remember that aller must be used with a place (there or a name) when indicating that you are going somewhere, even if a place wouldn't normally be given in English.
 * Tu vas a l'école? - You're going to school.
 * Je vais au stade. - I'm going to the stage.
 * J'y vais. - I'm going there.
 * Tu y vas. - You're going there.
 * Nous y allons. - We're going there.

Futur Proche
The structure aller + infinitive is used to say that something is going to happen in the near future. Remember that the negative goes around the conjugated verb.
 * Il va pleuvoir demain. - It's going to rain tomorrow.
 * Il va faire froid. - It's going to be cold.
 * Il ne va pas pleuvoir demain. - It's not going to rain tomorrow.

Idioms

 * Allons-y - ahlonzee - Let's go! (impératif)
 * Ça va? - How are you? (lit: It goes?)
 * On y va! - Let's get going!
 * On y va? - Should we go?

Liaison
Usually, whenever a vowel sound comes after ...ons or ...ez, the usually unpronounced s and z change to a sharp z sound and link to the next syllable. (This process is called liaison.) However, since allons and allez begins with vowels, nous allons is pronounced nyoozahloh and vous allez is pronounced voozahlay. In order to have a pleasing and clean sound, two liaisons should not go connsecultively. There is therefore no liaison in allons à when it comes right after nous and allez à when it comes after vous.
 * In the phrase Vous allez à l'école?, vous allez à is pronounced vouzahlay ah.
 * In the phrase vous et Marie allez à l'école?, allez à is pronounced ahlayzah.

G: Regular -ir Verbs
The second category of regular French verbs is -ir verbs. To conjugate, drop the -ir to find the "stem" or "root". Add endings to the root based on the subject and tense.

Usage
As you can probably tell from their name, possessive adjective are used to express possession of an object. In English the possessive adjective agrees with the subject (his sister, her brother). But in French, possessive adjectives act like all other adjectives: they must agree with the noun they modify. Whether the third person singular possessive adjectives son, sa and ses are his or her is indicated by context.
 * C'est mon livre. - It's my book.
 * Elle lit son livre. - She reads her book.

Liaison and Adjective Changes
Liaison occurs when mon, ton, and son are followed by a vowel. Liaison also occurs with all plural forms, since they all end in s. Mon, ton, and son are used before a feminine singular noun. Elision (to m', t', or s') does not occur.
 * Il est monnami. - He is my friend.
 * Il est tonnami. - He is your friend.
 * Il est sonnami. - He is his/her friend.
 * Ils sont meszamis. - They are my friends.
 * Ils sont noszamis. - They are our friends.
 * Elle est monnamie. - She is my friend.

G: Regular -re Verbs
The third category of regular verbs is made up of -re' verbs. To conjugate, drop the -re to find the "stem" or "root". Add endings to the root based on the subject and tense, as demonstrated below for the present tense.

Vendre
The verb vendre is a regular -re verb:

Common -re Verbs
Compared to -er verbs, -re verbs are not very common. You will however see the following verbs fairly often.

Sentences Placement
As you have already learned, most adjectives come after the noun they modify in French. However, some common French adjectives, including beau, nouveau, and vieux come before the noun. Des is replaced with de when an adjective comes before the noun. Note that in informal speech, des in very often used in place of de.
 * un homme intelligent - an intelligent man
 * des hommes intelligents - intelligent men
 * une jolie voiture - a pretty car
 * de jolies voitures - pretty cars

G: Prendre
Prendre is not a regular -re verb, and is conjugated differently.

Related Words

 * prendre - to take
 * apprendre - to learn
 * comprendre - to comprehend/understand
 * se méprendre - to be mistaken
 * surprendre - to surprise

Idioms and Related Expressions

 * prendre - to take, to have something to eat
 * prendre conscience (de) - to become aware (of)
 * prendre la correspondance - to change trains
 * prendre une décision - to make a decision
 * prendre des kilos - to gain weight
 * prendre part (à) - to take part (in)
 * prendre la parole - to start talking
 * prendre le pas sur - to surpass
 * prendre le petit déjeuner - to eat breakfast
 * prendre rendez-vous - to make an appointment


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Talk:French For Football/FAQ

Untitled
This is all provisional really, as the book has only just started.

I have to admit using Google translated text which I have tried to correct, so I expect there is still plenty of room for improvement by a native French speaker. All help will be most appreciated! Recent Runes 20:52, 19 November 2007 (UTC)

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Talk:French For Football/FAQ


text:
Talk:French For Football/Notes/Analysis Of Vocabulary

Untitled
Thanks for visiting this page.

Please note, the use of X-Sampa instead of IPA in these notes is only for convenience in identifying words which have similarities in pronunciation. There is no intention to include X-Sampa notation in the final Wikibook. Recent Runes 20:58, 19 November 2007 (UTC)


text:
Talk:XQuery/Page scraping and Yahoo Weather

text to go in an introduction

Much of the web's data lies tied up in HTML pages. Few of these conform to XHTML and are thus not parseable as XML. HTML pages have to be tidied to well-formed XML to be parsed in XQuery. This example uses a web service from Fons Sonnemans at Reflection IT to carry out the conversion from HTML to XML on any URL. The documentation also describes the tidying necessary to clean up HTML pages. In the next release eXist-db will be able to perform this operation natively.

Scrapping is failing at present


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User talk:Wahsu

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally.– Mike.lifeguard  | talk 00:33, 20 November 2007 (UTC)

title: User talk:Wahsu


text:
Biology, Answering the Big Questions of Life/reproduction1

How are babies made?
For human reproduction there are two sexes: Male and Female. Babies are made when special cells called sperm (produced by male sex organs) combine with cells called eggs (produced by female sex organs) in a process called Fertilization. Not every cell can combine to make a new organism. Sperm and Egg cells are produced by a process called meiosis which makes cells containing half the information found in the parent's cells. When the cells combine, they form a new cell, called a zygote which has all of the information needed to make a new person. The zygote will grow to become a baby with a unique combination of their parent's traits.

Where do babies come from?

The simplest answer is that they come from inside of the mother. In order for fertilization to occur, the father must enter his sperm into the mother's body by a process called copulation or sexual intercourse. The man inserts his penis into the female's vagina and the sperm cells swim into the mother's body.

They travel through the vagina and through the womb to the oviduct where conception usually takes place. The newly made zygote will divide rapidly to make a ball of cells called a blastocyst that will lodge in the womb and grow into a baby.

About 266 days after fertilization, a new baby will come out of the mothers vagina in a process called childbirth.

What is Puberty?
Puberty is the time in a person's life when they first have the ability to create babies. For boys this is when they first produce sperm. For girls, this is after their first menstruation. Menstruation, sometimes called a period, happens when the lining of the womb sheds and a red blood like material flows out of the girl's vagina. Menstruation usually occurs once a month for women. Menstruation signals that a woman is releasing eggs that can be fertilized. The lining of the womb grows to prepare for the growth of a baby. If the egg is not fertilized that month, the womb will shed its lining and begin growing anew.

The time of puberty varies greatly and can be anywhere from age eight to about fifteen years. Typically puberty in girls happens at a younger age than in boys. After puberty a person's body changes from that of a child to that of an adult. In boys, they will grow hair in their groin, under their arms, on their chest and on their face. Their voice will drop in tone, and they will grow larger. For girls, their breasts will grow and their hips will widen, they will also grow hair in their groin and under their arms. It takes years before a person grows to their full adult size. This period of changing from a child to adult is called adolescence.


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First Aid/Appendix E: First Aid Kits

First Aid Kits
Everyone should have a well-stocked first aid kit for in the car, at home, and other events. For first aid kits in the workplace, there will be legislation which specifies what must be present; this will depend on the size and type of the workplace and may vary depending on local, regional, or national regulations. Know where first aid kits are located, whether at home, at work, or at play. First aid kits should be clearly marked; in the workplace, there should be sufficient indication of the kit's location for those who are unfamiliar with its location to identify it.

First aid kits must be kept well-stocked; supplies do expire, and must be replaced periodically. Consider creating a schedule for checking that the kit is stocked, and replacing any expired items as required. Quantities below are guidelines; determine what is required based on the kit's expected use.

If possible use a bright-colored, watertight plastic container. Tool boxes are popular, or it may be worthwhile to purchase a kit made specifically for this purpose.

title: First Aid/Appendix E: First Aid Kits


text:
User talk:Ladiesman217xxx

You may want to start off by reading What is Wikibooks?, which outlines what the project is for. In short, Wikibooks is for textbooks; the page you created was not a textbook, and was therefore deleted, per policy.

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally.– Mike.lifeguard  | talk 01:36, 20 November 2007 (UTC)

title: User talk:Ladiesman217xxx


text:
Radiation Oncology/CNS/Trigeminal neuralgia/Overview

Trigeminal Neuralgia

Epidemiology

 * 15,000 new cases in US per year; incidence 4/100,000 - 5/100,000
 * Majority of idiopathic TN after age 50

Definition

 * International Headache Society
 * Classical TN (also called Idiopathic, or tic douloureux)
 * A) Paroxysmal attack lasting from fraction of a second to 2 minutes, affecting one or more of the trigeminal nerve divisions
 * B) One of the two following: 1) intense, sharp, superficial, stabbing or 2) precipitated from trigger areas or by a trigger factor
 * C) Stereotyped in the individual patient
 * D) No other neurological deficits
 * E) Not attributed to another disorder
 * Symptomatic TN (also called Secondary)
 * Symptoms indistinguishable from Classical TN but caused by a demonstrable structural lesion (e.g. neuroma, vascular compression)

Signs and symptoms

 * Idiopathic has five classical features:
 * Paroxysmal
 * Provokable
 * Unilateral
 * Confined to the trigeminal nerve distribution
 * Unassociated with gross trigeminal motor or sensory loss.
 * Atypical TN is any pain that lacks the 5 classical features.
 * Multiple sclerosis-associated TN similar pain as idiopathic, but in the setting of MS

 * Typically does not wake patient up at night
 * Unilateral in most cases, if bilateral then not simultaneously
 * Trigger zones in distribution of CN V, include light touch, chewing, talking, brushing teeth, cold air, smiling/grimacing

Pain Scales
Barrow Neurological Institute (BNI)

Marseille scale

Etiology

 * Idiopathic TN
 * Compression of trigeminal nerve by aberrant artery or vein suspected in 80-90% of cases
 * Resulting demyelination somehow triggers TN (possibly via ephaptic cross-talk between fibers mediating light touch and pain)
 * Also evidence for central pain mechanisms (refractory period after episode, trans of pain after single stimulus, latency from stimulus to onset)
 * Secondary TN
 * Caused by other structural compressions (e.g. vestibular schwannoma, meningioma, epidermoid cyst, aneurysm, AVM)

 * Oregon, 2004 PMID 15540931 -- "Pathophysiology of trigeminal neuralgia: new evidence from a trigeminal ganglion intraoperative microneurographic recording. Case report. (Burchiel KJ, J Neurosurg. 2004 Nov;101(5):872-3.)
 * Intraop recordings suggest TN pain generated by an abnormal discharge within peripheral NS, both in trigeminal ganglion neurons and/or the nerve itself

Anatomy

 * Trigeminal nerve (CN V) supplies sensory to the face, and sensory and motor to muscles of mastication
 * V1 - Ophthalmic
 * V2 - Maxillary
 * V3 - Mandibular

 * Nerve exits at midlateral surface of the pons
 * Meckel's cave - gasserian ganglion (sensory ganglion), located 2 cm anterior to trigeminal root entry zone.

Imaging

 * Thin slice (1mm) MRI/MRA to rule out structural lesions. Sensitivity and specificity for identifying vascular compression 89% and 50%

 * Tufts
 * 2006 PMID 16436823 -- "Nerve atrophy in severe trigeminal neuralgia: noninvasive confirmation at MR imaging--initial experience." (Erbay SH, Radiology. 2006 Feb;238(2):689-92.)
 * 31 patient MRIs reviewed. Mean diameter on symptomatic side 2.11 mm vs. 2.62 mm (SS). Mean cross-sectional area 4.50 mm2 vs. 6.28 mm2 (SS)
 * 2005 PMID 15662790 -- "Targeting the cranial nerve: microradiosurgery for trigeminal neuralgia with CISS and 3D-flash MR imaging sequences." (Zerris VA, J Neurosurg. 2005 Jan;102 Suppl:107-10.)
 * Multiple imaging sequences evaluated. CISS/3D-Flash preferred method

 * MC Wisconsin PMID 16029818 -- "Effect of image uncertainty on the dosimetry of trigeminal neuralgia irradiation." (Jursinic PA, Int J Radiat Oncol Biol Phys. 2005 Aug 1;62(5):1559-67.)
 * Conclusion: uncertainty of target by MRI >2x than by CT. 4&8 mm collimator higher isodose line than 4mm collimator

 * UCLA PMID 15730595 -- "Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia." (Chavez GD, Neurosurgery. 2005 Mar;56(3):E628; discussion E628.)
 * Evaluation of 3-D-FIESTA sequence in 15 patients. 3-D-FIESTA sequence successfully demonstrated the trigeminal complex (root entry zone, trigeminal ganglion, rootlets, and vasculature) in 14 patients (93.33%). The 3-D-FIESTA sequence also allowed visualization of the branches of the trigeminal nerve inside Meckel's cavity.
 * Conclusion: SRS targeting of specific trigeminal branches may be feasible

 * Rosewell Park PMID 11733329 -- "Focal enhancement of cranial nerve V after radiosurgery with the Leksell gamma knife: experience in 15 patients with medically refractory trigeminal neuralgia." (Alberico RA, AJNR Am J Neuroradiol. 2001 Nov-Dec;22(10):1944-8.)
 * Retrospective. 15 patient MRIs. RT dose 35-45 Gy at 50% isodose line. Mean time to follow-up imaging 61 days
 * Target enhancement in 10/15; remaining 5 had RT dose 35 Gy

Treatment

 * Please see the treatment and retreatment pages

Cost-Effectiveness

 * Mayo
 * 1999-2001 PMID 15951649 -- "A prospective cost-effectiveness study of trigeminal neuralgia surgery." (Pollock BE, Clin J Pain. 2005 Jul-Aug;21(4):317-22.)
 * Prospective, nonrandomized. 126 patients (MVD 33, GR 51, SRS 69)
 * Outcomes (6 months, 24 months): MVD (85%, 78%) vs. GR (61%, 55%) vs. SRS (60%, 52%). MVD > GR = SRS
 * Cost per quality adjusted pain-free year: MVD $8174 vs. GR $6342 vs. SRS $8269
 * PMID 14677455 -- "CSNS Resident Award: the economics of trigeminal neuralgia surgery." (Ecker RD, Clin Neurosurg. 2003;50:387-95.)
 * No abstract


text:
Radiation Oncology/CNS/Trigeminal neuralgia/Treatment

Trigeminal Neuralgia Treatment

Treatment Overview

 * Medical (carbamazepine, phenytoin, gabapentin, baclofen) first, until failure
 * Surgical
 * Destructive: radiofrequency rhizotomy, glycerol rhizotomy, balloon compression, peripheral neurectomy
 * Non-destructive: microvascular decompression
 * Radiosurgery
 * Gamma Knife
 * Linac-based

Medical treatment

 * Meta-analysis (1960-2005) PMID 17174762 -- "Drug treatment of trigeminal neuralgia: a systematic review of the literature." (Chole R, J Oral Maxillofac Surg. 2007 Jan;65(1):40-5.)
 * 21 publications with high level of evidence (6 randomized, 15 controlled clinical trials), 348 patients
 * Conclusion: Anticonvulsants effective, but difficult to compare/combine data in a scientifically meaningful manner

Surgery

 * Pittsburgh
 * 1972-1991 -- "The Long-term Outcome of Microvascular Decompression for Trigeminal Neuralgia." (Barker et al. NEJM. 1996, 334:17, 1077-1083)
 * Retrospective study of 1185 patients who underwent microvascular decompression.
 * Immediate pain relief in 82%, partial 16%, and none in 2%. 75% had complete relief at 1 year, 9 % partial. 64% had complete relief at 10 years, 4 had partial (first surgery).
 * 11% had re-operation for recurrent or refractory symptoms-total 80% had complete relief at 1 year and 8% partial, 70% had complete relief at 10 years, 4 had partial.

Decision Analysis
 * Queen Mary; 2007 PMID 17451880 -- "Decision analysis of medical and surgical treatments for trigeminal neuralgia: how patient evaluations of benefits and risks affect the utility of treatment decisions." (Spatz AL, Pain. 2007 Oct;131(3):302-10. Epub 2007 Apr 23.)
 * 156 patients evaluated with time-trade-off utility measurement questionnaire
 * Outcome: MVD highest maximum expected utility (16.08), followed by balloon compression (15.97), glycerol rhizolysis (15.61), and RFA (14.93). Meds alone worst at 14.61. Difference between highest and lowest treatments 7%, and sensitive to utility values
 * Conclusion: Patients should consider surgery over meds, but treatment utility differences minimal

SRS vs. Surgery

 * Columbia; 2007 PMID 17167238 -- "Microvascular decompression vs. gamma knife radiosurgery for typical trigeminal neuralgia: preliminary findings." (Brisman R, Stereotact Funct Neurosurg. 2007;85(2-3):94-8.)
 * Prospective protocol. 85 patients (GKS 61, MVD 24). GKS 75 Gy max.
 * Outcome: CR (no pain, no meds): 1 year GKS 58% vs. MVD 68%; 2 years 24% vs. 68% (p=0.09)
 * Toxicity: no permanent complications
 * Conclusion: MVD more likely than GKS to result in complete pain relief

 * UCSF
 * 2005 PMID 16419978 -- "Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis." (Cheng JS, Neurosurg Focus. 2005 May 15;18(5):e13.)
 * Retrospective. 11 patients with TN-MS. Mean f/u 40 months
 * Conclusion: Complete pain relief in TN-MS significantly more difficult than other TN, including highly refractory TN. SRS effective procedure, resulting in fewer retreatments, longer pain-free intervals compared with MVD or RF ablation
 * 2005 PMID 16419977 1997-2004 -- "Recurrent or refractory trigeminal neuralgia after microvascular decompression, radiofrequency ablation, or radiosurgery." (Sanchez-Mejia RO, Neurosurg Focus. 2005 May 15;18(5):e12.)
 * Retrospective. 32/209 patients treated with SRS, MVD or RFA required retreatment.
 * Outcome: 19/93 MVD retreated (20%). 5/12 RFA retreated (42%), 8/108 (7.7%) SRS retreated, 2 with SRS.
 * Conclusion: lowest re-treatment rates with SRS. SRS also more likely to be final treatment for recurrence, regardless of initial treatment

 * Cooper University; 2005 1994-2002 PMID 16111575 -- "Glycerol rhizotomy versus gamma knife radiosurgery for the treatment of trigeminal neuralgia: an analysis of patients treated at one institution." (Henson CF, Int J Radiat Oncol Biol Phys. 2005 Sep 1;63(1):82-90.)
 * Retrospective. 36/79 patients (GR) and 63/109 (GK) evaluated. RT 70-90 Gy to 100% isodose.
 * Initial success: (Barrow I-III) 86% GR vs. 92% GK. Median time to relief <24hr GR vs. 3 weeks GK.
 * Failure or pain recurrence: 53% GR vs. 42% GK (NS). Median time to failure 5mo GR vs. 8 mo GK (NS). End of treatment 39% GR vs. 24% GK failed
 * Side effects: facial numbness 54% GR vs. 30% GK, bothersome 33% GR vs. 11% GK. GK lower pain score (OR 4.3)
 * Conclusion: GR for acute pain relief, GK otherwise

 * Mayo
 * 2005 PMID 15951649 1999-2001 -- "A prospective cost-effectiveness study of trigeminal neuralgia surgery." (Pollock BE, Clin J Pain. 2005 Jul-Aug;21(4):317-22.)
 * Prospective, nonrandomized. 126 patients (MVD 33, GR 51, SRS 69)
 * Outcomes (6 months, 24 months): MVD (85%, 78%) vs. GR (61%, 55%) vs. SRS (60%, 52%). MVD > GR = SRS
 * Cost per quality adjusted pain-free year: MVD $8174 vs. GR $6342 vs. SRS $8269
 * 2005 PMID 15913282 1999-2004 -- "Comparison of posterior fossa exploration and stereotactic radiosurgery in patients with previously nonsurgically treated idiopathic trigeminal neuralgia." (Pollock BE, Neurosurg Focus. 2005 May 15;18(5):E6.)
 * Retrospective. 55 patients PFE (MVD 89%, partial nerve section 11%), 28 patients SRS as initial treatment. RT mean dose 89.1 Gy. Mean f/u 25.5 months
 * Outcome: Pain free at 1 year: 75% vs. 59% (SS). Additional surgery in 18% after PFE vs. 29% after SRS (NS)
 * Side effects: facial numbness/dysesthesias: PFE 15% vs. SRS 43%
 * Conclusion: PFE more effective as primary therapy

Gamma Knife

 * There is only one prospective trial published, from Marseille. At 1 year, 83% were pain free, with 58% off medications as well
 * There are a number of retrospective, single institution studies published
 * Target: ipsilateral trigeminal nerve adjacent to the pons with single shot 4mm collimator
 * Dose: Typically 70-90 Gy

Prospective

 * Marseille, 2006 (France) PMID 16776335 -- "Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia." (Regis J, J Neurosurg. 2006 Jun;104(6):913-24.)
 * Phase I. 100 patients, 42 prior surgical treatment. RT: median dose 85 Gy (70 - 90 Gy). Minimum F/U 12 months, median ?
 * Pain relief: 83/100 patients pain free at 12 months, 58/100 patients pain free and off meds. 17 patients underwent additional procedures
 * Probability of worse outcome (SS and trend): <60 year old, isocenter-nerve emergence distance >8mm, large cistern surface, lower minimal nerve dose, prior procedure
 * Side effects: Mild facial paresthesia 6%, hypesthesia 4%

Retrospective
Please see the Literature Review

GKS Technique

 * Brussels (Belgium)
 * 2007 PMID 17689881 -- "Clinical Evaluation of Targeting Accuracy of Gamma Knife Radiosurgery in Trigeminal Neuralgia." (Massager N, Int J Radiat Oncol Biol Phys. 2007 Aug 7; [Epub ahead of print])
 * Retrospective. 78 patients treated with 90 Gy. 68 (83%) had follow-up MRI with focal nerve enhancement. F/U MRI fused with treatment MRI and correlated
 * Outcome: Median deviation between pre and post MRI 0.91 mm. RT dose within contrast enhancement on post MRI median 77 Gy, range 49-85 Gy
 * Conclusion: Median deviation low
 * 2007 PMID 17415205 -- "Influence of nerve radiation dose in the incidence of trigeminal dysfunction after trigeminal neuralgia radiosurgery" (Massager N, Neurosurgery. 2007 Apr;60(4):681-7; discussion 687-8.)
 * Comparative. 358 patients (109 Brussels, 259 Marseilles). Three dosimetry groups: Group I <90 Gy no blocking, Group II 90 Gy no blocking, Group III 90 Gy blocking
 * Toxicity: mild Group I 15% vs. Group II 21% vs. Group III 49%; bothersome 1.4% vs. 2.4% vs. 10%
 * Pain control: excellent 66% vs. 77% vs. 84%; good 81% vs. 85% vs. 90%
 * Conclusion: Incidence of TN dysfunction and pain relief vary according to energy deposited to retrogasserian nerve root. Effect may be related to energy to nerve root rather than maximal dose delivered
 * 2006 PMID 16682146 -- "Effect of beam channel plugging on the outcome of gamma knife radiosurgery for trigeminal neuralgia." (Massager N, Int J Radiat Oncol Biol Phys. 2006 Jul 15;65(4):1200-5.)
 * Retrospective. 109 patients, 49 had channel blocking to brainstem. RT 90 Gy
 * Blocking increased length of trigeminal nerve exposure, and thus mean dose.
 * Outcome: better pain outcome (84% vs. 62% nonblocked), but worse trigeminal dysfunction (47% vs. 32%)
 * 2004 PMID 15070111 -- "Gamma knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation." (Massager N, J Neurosurg. 2004 Apr;100(4):597-605.)
 * Retrospective. 47 patients. Mean f/u 16 months
 * Pain relief: 68% excellent, 89% fair (>50%). Prognostic factors: higher dose, shorter distance to brainstem, development of facial sensory disturbance
 * Side effects: Mild facial numbness 38%, bothersome 4%
 * Conclusion: target nerve 5-8 mm from brainstem

 * Wake Forest; 2006 PMID 17121135 -- "Does dose rate affect efficacy? The outcomes of 256 gamma knife surgery procedures for trigeminal neuralgia and other types of facial pain as they relate to the half-life of cobalt." (Balamucki CJ, J Neurosurg. 2006 Nov;105(5):730-5.)
 * Retrospective. 239/326 patients. 80% experienced >50% pain relief, 56% complete relief
 * Neither dose rate nor treatment time were significantly associated with control rate or degree of pain relief
 * Conclusion: Consistent treatment any time during first half-life of Co source

 * Columbia
 * 2005 PMID 15850900 -- "Where to locate the isocenter? The treatment strategy for repeat trigeminal neuralgia radiosurgery." (Zhang P, Int J Radiat Oncol Biol Phys. 2005 May 1;62(1):38-43.)
 * Retrospective. 40 patients with repeat GK. RT max 75 Gy initially, 40 Gy retreatment. Median f/u 28 months
 * Pain relief: complete 27%, nearly complete 18%, partial 20%, minimal/none 35%
 * Isocenter distance: mean 2.86 mm (complete/nearly complete relief) vs. 1.93 (partial/none relief). Farther distance with trend to better pain relief
 * Side effects: 7% moderate dysesthesia (4/10), 3% severe dysesthesia (7/10) after retreatment. Not related to isocenter distance
 * 2002 PMID 12015844 -- "Trigeminal Nerve-Blood Vessel Relationship as Revealed by High-resolution Magnetic Resonance Imaging and Its Effect on Pain Relief after Gamma Knife Radiosurgery for Trigeminal Neuralgia." (Brisman R, Neurosurgery. 2002 Jun;50(6):1261-6, discussion 1266-7.)
 * Blood vessel - CNV contact evaluated. Group I (none) 24%, Group II (close) 17%, Group III (contact) 59%. Contact more often in men (SS), more often with unilateral TN.
 * If no prior surgery, BV-CNV contact may be prognostic factor
 * 2000 PMID 11143235 -- "Gamma knife radiosurgery for trigeminal neuralgia: dose-volume histograms of the brainstem and trigeminal nerve." (Brisman R, J Neurosurg. 2000 Dec;93 Suppl 3:155-8.)
 * Volume of brainstem that receives >20% of Dmax (VB20), and volume of trigeminal nerve that receives >50% of Dmax (VT50) assessed
 * VB20 excellent pain control: 6 months <20mm3 32% vs. >20mm3 56% (SS), 12 months <20mm3 27% vs. >20mm3 50% (SS)
 * VB20 is lower in TN-MS. VB20 is inversely related to VT50
 * Conclusion: isocenter proximity to brainstem (reflected by higher VB20) is better

 * Upstate 2005 1998-2003 PMID 15662807 -- "Gamma knife surgery for trigeminal neuralgia: improved initial response with two isocenters and increasing dose." (Alpert TE, J Neurosurg. 2005 Jan;102 Suppl:185-8.)
 * Retrospective. 63 patients, 1 shot in 27 vs 2 shots in 36 patients. Dose 20 patients <=80 Gy, 21 patients 85 Gy, 22 patients >=90 Gy. Pain evaluated using BNI scale
 * Pain relief: Initial 90%, overall 27%. Facial numbness 8%
 * Number of shots: "2" 2.83 BNI improvement vs. "1" 1.72 BNI improvement (SS)
 * Dose: SS improvement with each higher dose group

 * Maryland
 * 2005 ASTRO Abstract 2336 -- "Evaluating the Influence of Dose-Rate on Outcome with Gamma-Knife Stereotactic Radiosurgery in the Treatment of Trigeminal Neuralgia" (Patel S)
 * Retrospective. 61 patients. 31 prior to source change, 30 after source change. RT dose 75 Gy (70-80 Gy). Median f/u 30 months
 * Dose rate: 161.6 cGy/min (151-179) vs. 342.9 cGy/min (321-366)
 * Pain control: 61% vs. 83% (SS). Recommend dose escalation below dose rate 179.4 cGy/min
 * Side effects: 16% vs. 10% (NS)
 * 2004 PMID 15380590 1996-2001 -- "Gamma knife surgery for trigeminal neuralgia: outcome, imaging, and brainstem correlates." (Cheuk AV, Int J Radiat Oncol Biol Phys. 2004 Oct 1;60(2):537-41.)
 * Retrospective. 96/112 patients. RT 75 Gy (60-80Gy)
 * Imaging: 58% good, 31% fair, 10% poor. No correlation to outcome
 * Dose to brain stem: 44% received 10% of Dmax, 56% received 20% of Dmax. No correlation to outcome
 * Nerve compression: 11% by MRI. No correlation to outcome
 * 2004 PMID 15379025 -- "Selective source blocking for Gamma Knife radiosurgery of trigeminal neuralgia based on analytical dose modelling." (Li K, Phys Med Biol. 2004 Aug 7;49(15):3455-63.)
 * Algorithm to selectively block sources to minimize dose to brainstem.
 * Moderate number of plugs (30-50) significantly lowers (40%) dose to brainstem. No mention of dose to trigeminal nerve in abstract
 * 2003 PMID 12870587 -- "A technique to sharpen the beam penumbra for Gamma Knife radiosurgery." (Guerrero M, Phys Med Biol. 2003 Jun 21;48(12):1843-53.)
 * Physical penumbra (defined as distance 90% to 50% isodose) typically 1-2 mm. Technique to insert a conic filter into individual plug collimator to flatten beam profile
 * Able to reduce single penumbra width by 30-60%, at cost of reduced beam intensity by 20-50%

 * 2005 Northwest Hospital (Seattle) ASTRO Abstract -- "Dose-Response and Dose-Complication Relationships in Stereotactic Radiosurgery for Trigeminal Neuralgia" (Meier R, Abstract 2353)
 * Retrospective. 252 patients, typical or atypical TN. RT to 76 Gy (58 patients), 87 Gy (101 patients), or 98 Gy (93 patients) using 0.87 output factor. Mean f/u 3.9 years, 2.0 years, 1.7 years
 * Pain control: favorable 74%, 75%, 76% (NS)
 * Side effects: sensory deficit 9%, 22%, 39% (SS)
 * Conclusion: dose escalation doesn't improve pain control, but has more complications

 * Cleveland Clinic 2004 PMID 15007220 -- "Gamma knife radiosurgery for trigeminal neuralgia: comparing the use of a 4-mm versus concentric 4- and 8-mm collimators." (Kanner AA, Stereotact Funct Neurosurg. 2004;82(1):49-57.)
 * 101 patient evaluated, 54 treated with 4-mm helmet, and 47 with 4/8-mm helmet. RT 75 Gy to 100% isodose line
 * No difference in outcome

 * Royal Hallamshire 2002 (UK) PMID 12507100 -- "The clinical application of plugging patterns for the Leksell gamma knife." (Vaughan P, J Neurosurg. 2002 Dec;97(5 Suppl):579-81.)
 * Plugging significantly improved conformity and reduced brain stem exposure, without altering length of TN treated

 * Mayo 2001 PMID 11440460 1997-1999 -- "High-dose trigeminal neuralgia radiosurgery associated with increased risk of trigeminal nerve dysfunction." (Pollock BE, Neurosurgery. 2001 Jul;49(1):58-62; discussion 62-4.)
 * Retrospective. 68 patients. 40% 70 Gy, 60% 90 Gy. Mean f/u 14.4 months
 * Pain control: 70 Gy 41% pain free vs. 90 Gy 61% (NS)
 * Side effects: 70 Gy 15% TN dysfunction vs. 90 Gy 54% (SS). Bothersome in 4% vs. 32%. Corneal numbness in 3/41 (8%). Pain control better in those with TN dysfunction
 * Conclusion: recommend dose <90 Gy
 * Comment in PMID 12051192 "High-dose trigeminal neuralgia radiosurgery associated with increased risk of trigeminal nerve dysfunction." (Regis J, Neurosurgery. 2002 Jun;50(6):1401-2; author reply 1402-3.)

 * Pittsburgh 2001 PMID 11567820 -- "Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study." (Flickinger JC, Int J Radiat Oncol Biol Phys. 2001 Oct 1;51(2):449-54.)
 * Randomized. 87 patients. RT 75 Gy to 1 or 2 isocenters. Median f/u 26 months
 * Pain relief: excellent 52%, good (low dose meds) 14%, partial 17%, failed 17%. Identical for 1 or 2 isocenters. Relapse in 42% of responding patients
 * Side effects: 14% of 2 isocenters vs. 7% of 1 isocenter (NS). Complications correlated (SS) to nerve length irradiated

Linac Outcomes

 * Wisconsin 2005 PMID 16331167 -- "Linear accelerator radiosurgery for trigeminal neuralgia." (Richards GM, Neurosurgery. 2005 Dec;57(6):1193-200; discussion 1193-200.)
 * Retrospective. 28 patients. RT 80 Gy with 4-mm collimator and 7-arc technique. Median f/u 12 months
 * Outcome: 57% complete pain relief, 75% 3 point pain reduction (10 point scale). Median time to pain relief 1 month. Mean time to pain recurrence 14 months. Women longer mean time to pain recurrence (16 vs. 7 months)
 * Side effects: 3 patients mild facial numbness; 1 neurotrophic keratopathy

 * Stanford
 * 2005 PMID 15913285 2002-2004 -- "CyberKnife radiosurgery for idiopathic trigeminal neuralgia." (Lim M, Neurosurg Focus. 2005 May 15;18(5):E9.)
 * Retrospective. 41 patients with typical TN. Mean follow-up 11 months
 * Pain control: Initial 93% at median 7 days. Pain control 88% excellent, 5% moderate, 7% no change. Recurrence 16%, median time to recurrence 6 months. Long term response (@ 11 months) 78%
 * Higher prescribed doses not associated with pain relief or recurrence rate. Hypesthsia rate related to length of trigeminal nerve treated
 * 2003 PMID 14742972 -- "Cyberknife radiosurgery for trigeminal neuralgia." (Romanelli P, Stereotact Funct Neurosurg. 2003;81(1-4):105-9.)
 * Preliminary report. CT cisternography for localization. 10 patients, 7 achieved pain relief.

 * Minnesota 2004 PMID 15637446 -- "Long-term follow-up of trigeminal neuralgia treatment using a linear accelerator." (Kubicek GJ, Stereotact Funct Neurosurg. 2004;82(5-6):244-9.)
 * Retrospective. 20 patients. RT 82.3 - 100 Gy. Median f/u 56.5 months
 * Pain control: 35% complete, 78% >50% improvement. Recurrence 63%, mean interval 21.5 months

 * Kaiser Permanente 2004 2002-2003 PMID 15537188 -- "Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results." (Chen JC, J Neurosurg. 2004 Nov;101 Suppl 3:346-50.)
 * Retrospective. Novalis. 32 patients treated. RT 85-90 Gy in 5- or 7- noncoplanar arcs with 4-mm collimator. For GKS retreatment, 60 Gy dose
 * Pain relief: BNI I-III in 78% patients, median time to relief 6 weeks.

 * UCLA
 * 2004 PMID 14981193 -- "Noninvasive linear accelerator radiosurgery as the primary treatment for trigeminal neuralgia." (Frighetto L, Neurology. 2004 Feb 24;62(4):660-2.)
 * Retrospective. 22 patients treated on dedicated Linac
 * Pain control: 95.5% significant pain relief
 * 2003 PMID 14519214 1999-2001 -- "Linear accelerator radiosurgery using 90 gray for essential trigeminal neuralgia: results and dose volume histogram analysis." (Goss BW, Neurosurgery. 2003 Oct;53(4):823-8; discussion 828-30.)
 * Retrospective. 25 patients. RT 90 Gy with 5-mm collimator. Median f/u 18 months
 * Pain relief: 76% excellent, 100% >50% relief
 * Side effects: 32% facial numbness, none painful. No correlation with brainstem volume
 * 2003 PMID 12959439 1995-2001 -- "Dedicated linear accelerator radiosurgery for the treatment of trigeminal neuralgia." (Smith ZA, J Neurosurg. 2003 Sep;99(3):511-6.)
 * Retrospective. 60 patients, 68% essential TN, 20% secondary, 11% atypical. RT mean 83 Gy (70-90 Gy). 5-mm collimator in 75% patients, 7.5-mm collimator in 25% patients. Mean f/u 23 months
 * Pain relief: essential TN 56% excellent, 88% good+excellent; secondary pain 58% significant; atypical pain "worse results". Relief experienced at mean 2.7 months
 * Side effects: 25% new numbness
 * 2002 ASTRO Abstract 1995-2001 -- "Linear Accelerator Radiosurgery Comparing 90Gy and Less Than 90 Gy for Essential Trigeminal Neuralgia" (Goss B, Abstract 247, 2002)
 * Retrospective. 41 patients treated. RT dose 70-85 Gy (16 patients), 90 Gy (25 patients). Median f/u 13 months
 * Pain control: 70-85Gy - 37% excellent, 31% good. Relapse 50%. 90Gy - 76% excellent, 24% good. Relapse 32%. Length of pain relief, good&excellent response better in 90Gy
 * Side effects: 70-85Gy - 31% numbness, none bothersome. 90Gy - 32% numbness, none bothersome

Linac technique

 * Maryland PMID 16264249 -- "Comparative analyses of linac and Gamma Knife radiosurgery for trigeminal neuralgia treatments." (Ma L, Phys Med Biol. 2005 Nov 21;50(22):5217-27.)
 * Dose fall-off and set-up error tolerance of linac vs. Gamma Knife
 * Equivalent dose fall-off with high number of arcs. However, increased treatment time and icocenter accuracies a concern

 * Minnesota PMID 15753942 -- "Linac-based stereotactic radiosurgery for treatment of trigeminal neuralgia." (Gerbi BJ, J Appl Clin Med Phys. 2004 Summer;5(3):80-92.)
 * Accuracy comparable to Gamma Knife, dose distributions equivalent. Disadvantage time involved.

Outcome Evaluation

 * ESI-55 PMID 1556879 -- "A health-related quality of life instrument for patients evaluated for epilepsy surgery." (Vickerey BG, Med Care. 1992 Apr;30(4):299-319.)
 * 55 item scale to measure health-related quality of life in epilepsy patients
 * Reliable, valid, sensitive to differences in seizure status
 * Used by Marseille group in the prospective TN trial to evaluate QOL

Serious SRS side effects

 * Semmelweist; 2007 (Hungary) PMID 17317993 -- "Pathological findings following trigeminal neuralgia radiosurgery." (Szeifert GT, Prog Neurol Surg. 2007;20:244-8.)
 * Case report. Retreatment, initial dose 90 Gy distally, followed by 70 Gy proximally. Hemorrhagic stroke 26 days after 2nd treatment
 * Autopsy: neurovascular conflict close to 2nd shot, with acute and chronic radiation-induced lesions in trigeminal nerve

 * Amakusa; 2005 (Japan) PMID 16167795 -- "[A case of delayed facial palsy following gamma knife radiosurgery for intractable trigeminal neuralgia]" [Article in Japanese] (Itai K, Masui. 2005 Sep;54(9):1018-20.)
 * Case report. 77 y/o F. SRS RT 77 Gy.
 * After 20 months developed left facial palsy with hydropsia, left xerophthalmia, left facial hypesthesia. Resolved over several months on oral prednisolone

 * Mayo
 * 2004 PMID 15317722 -- "Vision loss as a complication of gamma knife radiosurgery for trigeminal neuralgia." (Naseri A, Br J Ophthalmol. 2004 Sep;88(9):1225-6.)
 * Case report. RT 40 Gy to the 50% isodose line. Presented 15 months later
 * Initial exam showed vision 20/25, fine punctate epitheliopathy, no corneal sensation. 10 weeks later vision 20/200, severe epithelial keratopathy. Punctal plug placed, artificial tears, vision returned to 20/60 over 6 weeks
 * 2000 PMID 11077103 -- "Radiation induced vascular injury after stereotactic radiosurgery for trigeminal neuralgia: case report." (Maher CO, Surg Neurol. 2000 Aug;54(2):189-93.)
 * Case report. SRS failed, patient underwent MVD. At operation, two adjacent veins and the superior cerebellar artery noted to have focal changes consistent with atheromatous disease.

 * Chiba; 2002 (Japan) PMID 12507089 -- "Gamma knife radiosurgery for trigeminal neuralgia: the dry-eye complication." (Matsuda S, J Neurosurg. 2002 Dec;97(5 Suppl):525-8.)
 * Retrospective. 33/41 patients treated with GKS to 80 Gy, 4-mm collimator, single isocenter. Mean f/u 13 months
 * 3 patients reported "dry eye", with diminution/absence of corneal reflex. No other abnormalities. Hypesthesia of V1 developed prior to "dry eye". Brain stem irradiated volume significantly correlated with complication

 * UCLA; 1997 PMID 9018707 -- "Leksell Gamma Knife treatment of tic douloureux." (Rand RW, Neurosurg Clin N Am. 1997 Jan;8(1):75-8.)
 * Retrospective. 12 patients. F/u 3-4 years. Pain control: 8/12 improvement or complete relief.
 * Side effects: 1 radionecrosis in medial temporal lobe

Radiobiology

 * Maryland PMID 11674826 -- "An investigation of eye lens dose for gamma knife treatments of trigeminal neuralgia." (Ma L, J Appl Clin Med Phys. 2000 Autumn;1(4):116-9.)
 * Phantom studies and in vivo dosimetry for 6 patients. Average dose to ipsilateral lens 7.7 cGy (+/- 0.6 cGy). Calculated cataract probability 0.1%

 * Pittsburgh PMID 10764273 -- "Histological effects of trigeminal nerve radiosurgery in a primate model: implications for trigeminal neuralgia radiosurgery." (Kondziolka D, Neurosurgery. 2000 Apr;46(4):971-6; discussion 976-7.)
 * 2 adult baboons SRS to 80 and 100 Gy (4 nerves total). Target proximal trigeminal nerve just anterior to pons. Nonirradiated baboon brains as controls. 6 months after MRI and pathology
 * MRI: 4 mm area of contrast enhancement
 * Pathology: axonal degeneration, mild edema, with remnants of myelinated axons. Large and small myelinated and unmyelinated fibers affected. No inflammation. Nerve necrosis at 100 Gy treatment. Trigeminal ganglion normal.

 * NCI PMID 7607923 -- "Clinical toxicity of peripheral nerve to intraoperative radiotherapy in a canine model." (Johnstone PA, Int J Radiat Oncol Biol Phys. 1995 Jul 15;32(4):1031-4.)
 * 40 animals, laparotomy with IORT 0-75 Gy to lumbosacral plexus. Then periodically sacrificed to monitor peripheral nerve. F/u 5 years
 * Dose >= 25 Gy resulted in ipsilateral neuropathy. Inverse relationship between dose and time-to-neuropathy, ED50 for paralysis 17.2 Gy. One animal treated with 15 Gy IORT developed paralysis after much longer latency. Consider 15 Gy threshold for paralysis.

Historical Note

 * PMID 9309292 -- First use of RT for trigeminal neuralgia in 1897
 * PMID 15397004 -- "Roentgenotherapy in trigeminal neuralgia." (Trostler IS, Miss Valley Med J. 1949 Nov;71(6):204.)


text:
Radiation Oncology/CNS/Trigeminal neuralgia/Retreatment

Trigeminal Neuralgia Retreatment

Gamma Knife Retreatment

 * San Diego Gamma Knife Center 2006 NSA Abstract -- "Dose response of Gamma Knife surgery for trigeminal neuralgia and high-dose salvage of failed Gamma Knife surgery" (Ott K, Neurosurgical Society of America Abstract, 2006)
 * Retrospective. 263 patients treated, 26 retreated. RT dose range 26-140 Gy. Average f/u 32 months
 * Pain control: Typical TN 85% excellent/good, Atypical TN 46% excellent/good. Dose response present, now use 97 Gy for both treatment and retreatment.
 * Side effects: >50% facial numbness, usually transient. Better pain control results
 * Retreatment: Same benefit. Comparable facial numbness, better response. Some with fair/poor/no response initially had excellent response on retreatment

 * Columbia
 * 2005 PMID 15850900 -- "Where to locate the isocenter? The treatment strategy for repeat trigeminal neuralgia radiosurgery." (Zhang P, Int J Radiat Oncol Biol Phys. 2005 May 1;62(1):38-43.)
 * Retrospective. 40 patients with repeat GK. RT max 75 Gy initially, 40 Gy retreatment. Median f/u 28 months
 * Pain relief: complete 27%, nearly complete 18%, partial 20%, minimal/none 35%
 * Isocenter distance: mean 2.86 mm (complete/nearly complete relief) vs. 1.93 (partial/none relief). Farther distance with trend to better pain relief
 * Side effects: 7% moderate dysesthesia (4+/10), 3% severe dysesthesia (7+/10) after retreatment. Not related to isocenter distance
 * 2003 PMID 14742963 1998-2003 -- "Repeat gamma knife radiosurgery for trigeminal neuralgia." (Brisman R, Stereotact Funct Neurosurg. 2003;81(1-4):43-9.)
 * Retrospective. 335 patients treated to 75 Gy, 45 patients retreated with 40 Gy. Mean 15 months f/u
 * Final pain relief: >50% in 62%. If no prior neurosurgical procedure, more likely to have better pain relief
 * Side effects: significant dysesthesias (>5/10) in 2 patients (4%)

 * Prague (Czech)
 * 2005 PMID 15662776 -- "Treatment of essential trigeminal neuralgia with gamma knife surgery." (Urgosik D, J Neurosurg. 2005 Jan;102 Suppl:29-33.)
 * Retrospective. 107 patients, retreat in 19 patients, same dose. RT 70-80 Gy.
 * Pain relief: Initial 96% (complete 80%). Median time to improvement 3 months (1 day, 13 months). Recurrence 25%, median interval 36 months (6, 94).
 * Retreatment: 19 patients (17%), initial pain relief 89% (complete 58%). Relapse 1 patient thus far
 * Side effects: Hypesthesia 20% after first GK, 32% after second GK. Median interval 35 months (3, 94) after first GK, 21 months (1, 72) after second

 * Mayo
 * 2005 PMID 15629611 1997-2002 -- "Repeat radiosurgery for idiopathic trigeminal neuralgia." (Pollock BE, Int J Radiat Oncol Biol Phys. 2005 Jan 1;61(1):192-5.)
 * Retrospective. 19 patients retreated. Median interval 16 months. Median dose 76.1 Gy (median additive dose 163.1 Gy). Median f/u 24 months
 * Pain relief: 74% excellent, 95% >50% pain reduction. 61% excellent outcome at 2 years. 2 patients recurred at 7, 22 months.
 * Side effects: 58% facial parathesia, numbness or dysesthesia, 16% bothersome. 2 patients (11%) corneal numbness. Recommend reducing dose
 * 2000 PMID 11143237 1997-1999 -- "Results of repeated gamma knife radiosurgery for medically unresponsive trigeminal neuralgia." (Pollock BE, J Neurosurg. 2000 Dec;93 Suppl 3:162-4.)
 * Retrospective. 10 patients retreated. Median interval 13 months. All initially significant reduction, none with facial numbness
 * Pain relief: 80% excellent outcome at 1 year. All developed minor dysfunction

 * Maryland
 * 2005 ASTRO Abstract 1996-2004 -- "Comparison of Repeat GK-SRS for Refractory or Recurrent Trigeminal Neuralgia: Does Dose Matter" (Dutta PR, Abstract 2118)
 * Retrospective. 63/69 patients (Maryland 28, Kentucky 35).
 * Maryland:
 * First GKS RT median 75 Gy (70-80 Gy), second GKS 70 Gy (45-75 Gy). Median retreatment in 13 months. Median f/u 14 months
 * Pain control: Initially 43% excellent, 43% good. Retreatment 39% excellent, 43% good. All 3 with initially poor response did not respond to retreatment
 * Side effects: 25% new after 2nd GKS, total 43% numbness; 14% bothersome but had complete relief
 * Kentucky
 * First GKS median 90 Gy (80-90 Gy), second GKS 90 Gy (70-90 Gy). Median f/u 19 months
 * Pain control: initially 33% excellent, 22% good. Retreatment 64% excellent, 20% good. Of 8 with poor response, 50% excellent result after retreatment
 * Side effects: 25% new after 2nd GKS, total 33% numbness or dysesthesia. 3% bothersome
 * Conclusion: Cumulative dose 150 Gy vs. 180 Gy. Similar pain control, but 180 Gy more likely to have excellent outcome. Minimal bothersome effects.
 * 2004 1996-2001 PMID 15093906 -- "Repeat gamma knife radiosurgery for refractory or recurrent trigeminal neuralgia: treatment outcomes and quality-of-life assessment." (Herman JM, Int J Radiat Oncol Biol Phys. 2004 May 1;59(1):112-6.)
 * Retrospective. 112 treated, 18 underwent repeat GKS. Median 8 months (3-42 months). Median RT 75 Gy first GKS, 70 Gy second GKS. Median f/u 37 months after first GKS, 24 months after second GKS
 * Pain control: Excellent 50%, good 28%, fair 6%, poor 16%. None of initial failures responded to repeat GKS
 * Side effects: 2 patients (11%) facial numbness, 1 bothersome
 * 2003 ASTRO Abstract -- "Repeat Gamma Knife Radiosurgery for Refractory or Recurrent Trigeminal Neuralgia" (Petit H, Abstract 22, 2003). Full paper Herman 2004 above

 * Barrow Neurological Institute; 2002 1997-2002 PMID 12507092 -- "Gamma knife radiosurgery for recurrent trigeminal neuralgia." (Shetter AG, J Neurosurg. 2002 Dec;97(5 Suppl):536-8.)
 * Retrospective. 19/29 patients. Questionnaires. Initial RT dose mean 78.2 Gy (70-90). RT retreatment mean dose 46.6 Gy (35-80). Mean f/u 13.5 months
 * Pain control: 53% excellent, 21% pain free but on reduced meds
 * Side effects: Facial numbness 42%, none bothersome. Those with facial numbness greater likelihood of being pain free

 * Pittsburgh 2002 PMID 11841716 -- "Repeat radiosurgery for refractory trigeminal neuralgia." (Hasegawa T, Neurosurgery. 2002 Mar;50(3):494-500; discussion 500-2.)
 * Retrospective. 27/31 patients assessed. Median dose 75.6 Gy (60-80 Gy), retreatment 64 Gy (50-80 Gy). Median f/u 43 months after 1st GKS, 20 months after 2nd GKS.
 * Pain control: 18% excellent, 30% good, 37% fair, 15% poor. Overall 48% complete pain relief (with or without meds)
 * Dose-response: low dose (120-135 Gy) vs. high dose (140-160 Gy): NS, although slightly fewer excellent and slightly more good outcomes with low dose. Now deliver 50-60 Gy)
 * Side effects: 13% dysfunction

 * Tianjin 2001 (China) 1996-1999 PMID 12007276 -- "Stereotactic radiosurgery for primary trigeminal neuralgia using the Leksell Gamma unit." (Zheng LG, Stereotact Funct Neurosurg. 2001;76(1):29-35.)
 * Retrospective. 80 patients. RT dose mean 75.6 Gy (70-90 Gy). Follow-up 24 months
 * Pain control: excellent 52%, good 31%, fair 10%, fail 6%. Mean time to improvement 22 days (1-120 days). Recurrence 10% in 5-26 months later
 * Retreatment: 12 patients (7 recurrent, 5 failures). RT dose mean 74.2 Gy (70-80 Gy). Mean f/u 18 months, 9/12 excellent result, 2/12 good result, 1 failed. Mean time to improvement 15 days (1-120)
 * Side effects: 11% facial numbness

 * Norhtwest Hospital 2000 Abstract 1991-1999 -- "Gamma Knife radiosurgery for treatment of trigeminal neuralgia: long term results" (Young RF, 3rd TN Conference, 2000)
 * Retrospective. 435 patients. RT 76-98 Gy. Median f/u 51 months. 51 patients retreated. Joint with Good Samaritan data??
 * Pain control: 6 months - 60% excellent, 30% good (some meds). Last f/u - 78% excellent/good. Including retreatment, 65% excellent, 20% good
 * Retreatment: success 80%
 * Side effect: 16% facial numbness


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User talk:Ridehonda43

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally.– Mike.lifeguard  | talk 02:34, 20 November 2007 (UTC)

title: User talk:Ridehonda43


text:
User talk:Racehonda43

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally.– Mike.lifeguard  | talk 02:34, 20 November 2007 (UTC)

title: User talk:Racehonda43


text:
Muggles' Guide to Harry Potter/Places/Headmaster's Office, Hogwarts

General Overview
The Headmaster's Office at Hogwarts is the office in which the current headmaster or headmistress of Hogwarts works. Although this is never mentioned, it is very likely that his residence is adjacent. It is reached by means of a circular, moving stone staircase, which in turn is concealed by a gargoyle on the third floor. The gargoyle will step aside in response to a password. At the top of the staircase is a wooden double door; the Headmaster's office is directly behind these doors.

First Six Books
As the series progresses, we gradually see more and more of the Headmaster's office, and understand its function better.

We first see it in Harry Potter and the Chamber of Secrets. Harry has just rather literally tripped over the Petrified body of Justin Finch-Fletchley. Professor McGonagall, the first on the scene, says nothing in response to Harry's pleas of innocence, except to say that it is out of her hands. She proceeds to a gargoyle in the halls, and says the password ("Sherbert Lemon"), whereupon the gargoyle leaps aside, revealing a slowly ascending circular staircase. Reaching the top of this, they find an oaken double door. They pass through this, then Professor McGonagall leaves Harry in the Headmaster's office. Harry sees that the room contains a vast number of portraits of past headmasters, all evidently asleep; many spindly tables with intricate silvery devices upon them; and the Sorting Hat resting on a shelf. After exchanging some words with the Sorting Hat, Harry notices a very ill-looking bird on a perch behind the door; as he watches, aghast, the bird catches fire. Professor Dumbledore, then entering, tells Harry that the bird, Fawkes, is a Phoenix, and that is his method of immortality; he will shortly be reborn from his own ashes. Harry and Dumbledore, though briefly interrupted by Hagrid, discuss the petrification of students that is then occurring. Dumbledore asks Harry if he has any ideas about what is going on; Harry, mindful of Ron's earlier comment that "hearing voices" was not something normal for wizards any more than for Muggles, chooses to say he knows nothing about it.

In that same book, in a memory of Tom Riddle's, Harry sees the Headmaster's office as it had been in the time of Professor Dippet, the headmaster preceding Dumbledore. At this point, Tom Riddle is seeking permission to stay at the school over the summer; Dippet refuses him, on the grounds that with the Monster from the Chamber loose, nobody's safety is assured within the school. While Harry notes that the many intricate devices and Fawkes are not present, he does not mention any of Dippet's possessions.

In Harry Potter and the Goblet of Fire, Harry again visits the headmaster's office, this time of his own volition, guessing at the password. Once within, he is interviewed briefly by Dumbledore, Professor Moody, and Cornelius Fudge, and then is left alone while the three adults visit the site where Mr. Crouch had last been seen. While alone in the office, Harry finds another artifact of Dumbledore's: a Pensieve. Dumbledore, returning, surprises him still using the Pensieve, and enlightens him as to its use, before asking why Harry had come to visit him. Harry relates the dream from which he has just awoken, in which he had perceived a discussion between Voldemort and Peter Pettigrew. Dumbledore asks for other occasions when Harry's scar had pained him, informing him that he is in contact with Sirius Black; Dumbledore also mentions that Neville's parents had been driven insane by the people Harry had seen in the Pensieve, and were now permanently in hospital.

In the same book, after the unmasking of Barty Crouch, Dumbledore takes Harry to his office again. There, with support from Sirius and Fawkes, Harry is required to recount the events of the evening, including the duel with Voldemort in the cemetery. Dumbledore seems momentarily pleased that Voldemort had used Harry's blood in his re-animation, but does not explain why. With the story told, Dumbledore escorts Harry and Sirius to the Hospital Wing.

In Harry Potter and the Order of the Phoenix, Professor McGonagall again takes Harry and Ron to the Headmaster's office, this time immediately after Harry has seen the vision of Mr. Weasley being attacked. As they approach the office doors, Harry hears a large number of voices all talking at once, but when the doors open, there is nobody there except Dumbledore himself. Over the course of the next few minutes, it becomes apparent that Dumbledore has been speaking with, and apparently receiving information and advice from, the portraits, even though they appear to be sleeping. The evidence for this is that he addresses two of the portraits, who immediately awaken, and sends them off to gather information; and wakens a third who reluctantly carries a message to Sirius Black at Number 12, Grimmauld Place. Harry also notes that many of the portraits appear to be simply pretending to sleep. Dumbledore also makes use of one of the small devices on the spindly tables, to determine something about the snake which had attacked Mr. Weasley.

Later in that same year, Professor Umbridge, having been informed of the existence of Dumbledore's Army, and with the help of her Inquisitorial Squad, manages to capture Harry and parades him in front of Cornelius Fudge in Dumbledore's office. Based on the name of the group, Fudge leaps to the conclusion that Dumbledore is raising an army to attack the Ministry, and attempts to put Dumbledore under arrest. The attempt fails, but Dumbledore does leave his office. Professor Umbridge is appointed Headmistress by the Ministry, but the Headmaster's office remains sealed to her; evidently the school itself does not recognize her authority.

When the Ministry is forced to recognize that Voldemort has returned, at the end of that book, Dumbledore is re-instated as Headmaster. Harry, sent to the Headmaster's office by Portkey, notes that the damage that had occurred in Dumbledore's abortive arrest had somehow been repaired. Dumbledore himself arrives shortly by means of Floo powder. In the ensuing, rather heated, discussion, Harry destroys one of the spindly tables and the instrument sitting upon it; Dumbledore does not seem perturbed by this. In Harry Potter and the Half-Blood Prince, Harry is called to Dumbledore's office a number of times to share memories of Tom Riddle and learn of his past. Harry notes that, instead of an instrument, one of the tables contains, at various times, artifacts of Tom Riddle's early life. Apart from this, however, Harry notes very little about the office that has not already been mentioned. The occasional comment from a portrait is generally dismissed.

Deathly Hallows
At the end of Harry Potter and the Half-Blood Prince, after Dumbledore's death, a large portrait of him, asleep, appears in the Headmaster's office. The portrait is already present when Professor McGonagall summons the Heads of House to discuss the future of Hogwarts, mere hours after Dumbledore has died, and without anyone else (as far as we know) having been in the office.

While we do see the Headmaster's office several times in Harry Potter and the Deathly Hallows, we hear very little of how the new Headmaster has changed the decor. The desk is present, the Pensieve is present, and the portraits are all still present on the walls, but of Dumbledore's instruments, or what has replaced them, there is no mention. When Harry first enters the office, after collecting Snape's memories in the Shrieking Shack, he notes that all of the portraits are vacant, and guesses that they are all in other portraits scattered around the school, keeping track of the progress of the battle. After Voldemort's defeat, the portraits are all back in residence, and give Harry a loud ovation upon his arrival.

Analysis
As mentioned, it is likely that the headmaster's office is merely the public area of his residence. We don't, of course, know where Dumbledore lives while he's at school, but the theory that he lives in a suite of rooms fronted by the office is supported by his appearance in Harry Potter and the Chamber of Secrets. There, Harry is brought into the office through the double wooden doors by Professor McGonagall; Dumbledore enters afterwards, but does not enter through these doors, instead apparently appearing from the other side of the office. We can surmise that this is common for all of the teachers at the school, that they have an office available to the school staff and students, and private rooms behind. In support of this, we can offer the Slug Club Christmas party hosted by Professor Slughorn in Harry Potter and the Half-Blood Prince; entrance is through Professor Slughorn's office, but there seem to be several rooms involved in the party.

It is, perhaps, a little strange that a password is required to reach the Headmaster's office. Of course, all the teachers must know that password, and Harry happens to overhear it when Professor McGonagall takes him to Dumbledore's office in Harry Potter and the Chamber of Secrets, so the secret is not particularly well guarded. Still, one must wonder why any protection of that nature is needed. We can only surmise that this is a remnant of earlier Headmasters, who were perhaps not as popular as Dumbledore. It is noted in one of the books that Phineas Nigellus Black was the least popular Headmaster in recent history; one can suppose that he certainly felt the need for security of his office. The password does have the effect of preventing Dumbledore from being bothered by students passing through, as he does not appear to have a secretary or receptionist to prevent anyone who reaches the door of the office disturbing him.

It is most curious that Harry, when he was only a second-year student in Harry Potter and the Chamber of Secrets, should be left alone in the Headmaster's office. This actually is a signal of the respect that Dumbledore inspires in the students; he is willing to trust that the students will not pry into areas of his office that he does not wish them to see. Harry somewhat strains the limits of this respect, by trying on the Sorting Hat on his first visit, and by investigating Dumbledore's Pensieve on a later visit.

While we see the Headmaster's office under three Headmasters, it is more often defined by what is not there than what is there. With Dumbledore in residence, Harry remarks on the many small tables bearing intricate mechanical devices. When we see the office in Dippet's time, the only difference Harry notes is the absence of the small tables and devices. And Harry is centered on the portrait of Dumbledore and the Pensieve when he visits the office after Snape becomes Headmaster, and does not notice much else about what is present in the office.

It is quite possible that Snape does not feel comfortable putting his personal stamp on what must seem to him, still, to be Dumbledore's office. While we cannot be certain, it is likely that Dumbledore was already Headmaster when Snape entered the school, and for Snape's entire 20 year tenure, first as a student, then as Potions Master, that space would have been Dumbledore's alone. Even if Snape is able to see it as his own, rather than as Dumbledore's, he has been in that office less than a year, and it is possible that he simply hasn't yet had time to personalize the office to any great extent. It is possible that Snape still holds Dumbledore in sufficient reverence that he does not feel worthy to place his own stamp upon what he must feel to be Dumbledore's home turf; supporting this theory is the discovery that Dumbledore's name is the password.

Greater Picture
In Harry Potter and the Deathly Hallows, there is no mention of Snape's portrait being present in the Headmaster's office after his death; there is also no mention of a portrait of Umbridge appearing. In the case of Snape, it could be argued that he did not retire or die in office, but rather had run away at a time when the school needed all the help it could get; as no human agent seems to be available to create these portraits, it is possible that the school does it itself, and had refused to create a portrait for a headmaster who deserted his post. In the case of Umbridge, it is quite possible that the school, as mentioned, had never accepted her as headmistress in the first place. It is mentioned that Umbridge was frustrated that she could not gain access to the Headmasters office. In particular, we can see that with assistance from Fawkes, Dumbledore can enter and depart his office without recourse to the Floo network or Portkeys, both of which can be monitored. We can also see that his office has been repaired. It is almost certain that Dumbledore returned to his office, at least occasionally, in order to do the necessary repairs, and was present often enough that the school recognized him as remaining its headmaster. It is actually possible that Dumbledore, having ensured his office was empty, returned and sealed it against Umbridge, then remained there throughout the time he was supposedly absent. He would certainly have needed to get food, but likely he could have arranged something with his brother Aberforth at the Hog's Head.

It is perhaps interesting to note the nature of the passwords used to gain entrance to the headmaster's office. During Dumbledore's tenure, it changes from time to time, but it is always the name of a sweet, either a Muggle candy like Sherbert Lemon, a magical treat like Whizzing Fizzbees, or an "unusual tastes" candy like Cockroach Clusters. When Harry has a need to get into the Headmaster's office in the final book, he finds much to his surprise that Snape has made Dumbledore's name a password. One might wonder how he explains this to his Death Eater teachers, the Carrows, but the Carrows are portrayed as being so very dense that they are unlikely to question any explanation Snape makes, no matter how far-fetched. What would be more difficult is explaining his choice of passwords to every other teacher in the school, notably Professor McGonagall, and to Voldemort on those occasions when he visits. We suggest that Dumbledore's name might be one password, and that only Snape himself, and Harry, ever use it; there could easily be several passwords, one more aligned with Snape's visible allegiance for the use of Hogwarts teachers.

Something that might be harder to explain is the portrait of Dumbledore. In fact, Snape will have had little to do with its size or placement, as we have noted: it seems to have appeared in the Headmaster's office without human intervention. However, it may have caused some comment among the Death Eaters that it is located so close to Snape's desk; in Harry's visits to the office, we gain the impression that it is the largest portrait there, and apparently accorded pride of place. We know that it is fairly close to the floor as well, as Snape is able to reach the Sword of Gryffindor which is hidden behind it, without any mention of his having to fly. Snape is, of course, still required to appear loyal to Voldemort in order to do the portrait's bidding; we must assume that he dismisses the portrait's advice if it is offered when any teacher is present. This actually is a concern, as Snape must repeatedly have conferences with the portrait of Dumbledore. Can he be certain that none of the Headmasters are carrying information to Death Eaters? Granted that no other portrait of Phineas Nigellus Black exists, and his communications are limited to Grimmauld Place and the Headmaster's office, is it even likely that he is the only headmaster who ever believed in Blood purity? Exactly how much control does the Headmaster exert over the portraits?


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Radiation Oncology/Rectum/Randomized

Rectal Cancer Randomized Evidence In process of being cross-linked...

Surgical Technique

 * National Taiwan University (1997-1999) -- medial-to-lateral vs lateral-to-medial laparoscopic dissection
 * Randomized. 67 patients, rectosigmoid cancer, single surgeon performing laparoscopic dissection. Arm 1) medial-to-lateral dissection vs Arm 2) lateral-to-medial dissection
 * 2003 PMID 12616435 -- "Comparison of medial-to-lateral versus traditional lateral-to-medial laparoscopic dissection sequences for resection of rectosigmoid cancers: randomized controlled clinical trial." (Liang JT, World J Surg. 2003 Feb;27(2):190-6.)
 * Outcome: No difference in LN harvest, intraop complications, conversion rate, postop complications, or disability. Improved OR time, C-RP and ESR in medial group
 * Conclusion: Medial-to-lateral dissection may be most appropriate for laparoscopic rectection of rectosigmoid cancers

TME Surgery +/- Neoadjuvant RT

 * Dutch
 * Randomized. 1805 patients treated with 1) Preop RT 25/5 or 2) TME alone. If surgery-only patients had SM+ (<=1mm), mandatory post-op RT
 * 5-years; 2007 PMID 17968156 -- "The TME Trial After a Median Follow-up of 6 Years: Increased Local Control But No Survival Benefit in Irradiated Patients With Resectable Rectal Carcinoma." (Peeters KC, Ann Surg. 2007 Nov;246(5):693-701.). Median F/U 6.1 years
 * Outcome: 5-year LR TME 11% vs. RT + TME 6% (SS); OS 63% vs. 64% (NS)
 * Subgroup benefit: N+, tumors 5-10 cm from anal verge, negative radial margins
 * Conclusion: Preop short-term RT improves local control; no effect on survival

Preop Chemo-RT: Dose Intensification

 * ACCORD 12/0405-Prodige 2 (2005-2008) -- Cap 45 vs Capox 50
 * Randomized. 598 patients, resectable T3-T4 rectal adenoca, T2 tumors in anterior/lower rectum also included. Arm 1) RT 45/25 with concurrence capecitabine 800 mg/m2 BID (Cap 45) vs Arm 2) RT 50/25 with concurrence capecitabine 800 mg/m2 BID and oxaliplatin 50 mg/m2 QW (Capox 50). RT excluded external/common illiac, in Capox 50 group boost after 44 Gy. Primary endpoing ypCR to get quick answer, as follow up to FFCD 9203
 * 2010 PMID 20194850 -- "Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced rectal cancer: results of the phase III trial ACCORD 12/0405-Prodige 2." (Gerard JP, J Clin Oncol. 2010 Apr 1;28(10):1638-44. Epub 2010 Mar 1.)
 * Outcome: ypCR Cap45 14% vs Capox 50 19% (NS). SM+ (0-2mm) 19% vs 10% (SS)
 * Toxicity: Preop G3+ Cap 45 1% vs Capox 50 25% (SS). No difference in surgery (75%) or postop deaths (0.3%).
 * Conclusion: Benefit of oxaliplatin not demonstrated. Suggest Cap 50 as the next regimen to test

TME Surgery with Lateral LND +/- Pelvic LN Sparing with IORT

 * Kyorin University; 2008 (2000-2007) PMID 18172677 -- "Intraoperative radiotherapy for oncological and function-preserving surgery in patients with advanced lower rectal cancer." (Masaki T, Langenbecks Arch Surg. 2008 Jan 3 [Epub ahead of print])
 * Randomized. 41 patients with advanced lower rectal CA. Arm 1) TME + bilateral lateral LND + limited PANP vs. Arm 2) TME + bilateral lateral LND + complete PANP + IORT to preserved pelvic nerve plexuses
 * Outcome: No difference in LR, DFS, OS. Improved time with indwelling catheter and voiding function
 * Conclusion: Complete pelvic autonomic nerve preservation with IORT may be useful

Preop vs Postop Therapy

 * MRC CR07 and NCIC C016 (1998-2005) -- preop RT 25/5 vs. selective postop chemo-RT 45/25
 * Randomized. 1350 patients, operable carcinoma of rectum, <15cm from anal verge, TME encouraged but not mandated (done in 92%). Arm 1) RT 25/5 vs. Arm 2) surgery + selective postop chemo-RT if SM+ (RT 45/25 + concurrent 5-FU and leucovorin). RT sacral promontory superiorly, 3–5 cm below the inferior tumor extent, 2–3 cm anterior to the sacral promontory, 1 cm posterior to the anterior sacrum, and 1 cm lateral to the most lateral aspect of the bony true pelvis. Primary outcome LR. In postop arm, SM+ was in 12% as trigger for postop chemo-RT vs 10% in preop group. Adjuvant chemo in 40% of preop arm and 45% of postop arm
 * 2009 PMID 19269519 -- "Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial." (Sebag-Montefiore D, Lancet. 2009 Mar 7;373(9666):811-20.) Median F/U 4 years
 * Outcome: LR preop RT 4% vs. postop RT 11% (SS), DFS 77% vs. 71% (SS), no difference in OS. By SM status: SM+ 14% vs. 21% (NS), SM- 4% vs. 9% (SS). Upper 1/3 tumors lower LRR than lower 1/3, preop RT 1% vs. 5%, postop chemo-RT 6% vs. 10%
 * Conclusion: Short-course RT more effective than selective postop chemo-RT
 * Editorial (PMID 19269501): Preop RT appears to benefit both good-prognosis and bad-prognosis tumors, so need a good way to select, and patient preference likely to play a role. Nevertheless, short preop RT is an excellent option

 * German Rectal Cancer Study CAO/ARO/AIO (1995-2002) -- preop chemo-RT vs. postop chemo-RT
 * Randomized. 823 patients, clinical stage T3-4 or N+, inferior margin within 16cm from anal verge. Arm 1) post-op regimen: surgery (TME) -> chemo/RT (55.8 Gy) -> 4 cycles bolus 5-FU, or 2) pre-op regimen: chemo/RT (50.4 Gy) -> surgery (TME) -> 4 cycles bolus 5-FU. In both arms, chemo was 5-FU C.I. 1000 mg/m2/d on days 1-5, weeks 1+5.
 * 2004 PMID 15496622 Full text "Preoperative versus postoperative chemoradiotherapy for rectal cancer." (Sauer R, N Engl J Med. 2004 Oct 21;351(17):1731-40.) Median F/U 3.8 years
 * Outcome: 5-year OS preop 76% vs postop 74% (NS); 5-year DFS 68% vs. 65% (NS); LR 6% vs. 13% (SS); DM 36% vs. 38% (NS). Preop downstaging: pCR 8%, 25% (vs 40%) were Stage III/LN+. TNM Stage I disease found in 18% of post-op group (vs. 25% in pre-op).
 * Toxicity: Fewer acute (27% vs 40%) and late toxicities (14% vs 24%) in preoperative-treatment group. Increased rate of sphincter-preserving surgery (39% vs 19%) in preoperative-treatment group.
 * Conclusion: Preop chemo-RT improved local control and improved toxicity, but did not impact overall survival
 * Critique (and clinical reality): only 54% of adjuvant patients vs. 92% of neoadjuvant patients received full RT dose

 * NSABP R-03 (1993-1999) -- Preop vs postop chemo-RT
 * Randomized. Trial closed prematurely due to poor accrual. 267/900 expected patients. Clinical T3-T4 or N+ rectal cancer. Arm 1) Preop chemo-RT 50.4/28 + 5-FU 500 mg/m2 and leucovorin 500 mg/m2 vs Arm 2) Postop chemo-RT (same as preop). Surgery APR, LAR, or local excision; TME not mandated. Both groups adjuvant 3 cycles of 5-FU/leucovorin
 * 2009 PMID 19770376 Full text — "Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03." (Roh M et al. J Clin Oncol. 2009 Nov 1;27(31):5124-30. Epub 2009 Sep 21.)
 * Outcome: 5-year DFS was improved for pre-op over post-op (64.7% v 53.4%, SS). Nonsignificant trend in 5-year OS (74.5% v 65.6%, p=0.065). No difference in locoregional recurrence, 11% in each group. pCR in 15%. Significant reduction in N+ (67% vs. 52%, SS)
 * Toxicity: Grade 4 diarrhea preop 24% vs. postop 13%; Grade 5 toxicity 5% vs 3%
 * Conclusion: Pre-op chemoradiotherapy, compared with post-op chemoradiotherapy, significantly improved DFS and showed a trend toward improved OS

Induction chemo vs adjuvant chemo, with neoadjuvant chemo-RT-surgery

 * Grupo Cancer De Recto 3, Spain (2006-2007) -- Induction chemo vs adjuvant chemo, with chemo-RT -> surgery
 * Randomized, Phase II. 108 patients, locally advanced rectal cancer, <12 cm from verge, LAR disease based on high-res MRI. Treated with chemo-RT followed by surgery. Randomized to Arm 1) Induction capecitabine 2000 mg/m2 and oxaliplatin 130 mg/m2 (CAPOX) x4 cycles vs Arm 2) Adjuvant CAPOX x4 cycles. Primary endpoint pCR
 * 2010 PMID 20065174 -- "Phase II, randomized study of concomitant chemoradiotherapy followed by surgery and adjuvant capecitabine plus oxaliplatin (CAPOX) compared with induction CAPOX followed by concomitant chemoradiotherapy and surgery in magnetic resonance imaging-defined, locally advanced rectal cancer: Grupo cancer de recto 3 study." (Fernandez-Martos C, J Clin Oncol. 2010 Feb 10;28(5):859-65. Epub 2010 Jan 11.)
 * Outcome: pCR induction 13% vs adjuvant 14% (NS), no difference in downstaging, tumor regression, R0 resection.
 * Toxicity: Higher during adjuvant arm. No difference during chemo-RT.
 * Conclusion: No difference in outcomes, but less toxicity with induction chemo compared with adjuvant chemo

Adjuvant RT vs Chemo-RT

 * NCCTG 79-47-51 (1980-1986) -- postop RT vs postop chemo-RT
 * Randomized. 204 patients, rectal CA T3-4 or N+, within 12 cm of anal verge. Arm 1) post-op RT vs. Arm 2) post-op chemo-RT. RT given 45/25 + 5.4/3 Gy boost to tumor bed and adjacent LN. Chemo bolus 5-FU bolus + semustine x1 month, then bolus 5-FU 500 mg/m2 concurrent with RT, then 2 months consolidative 5-FU/semustine. Major deviations 9%
 * 7-years; 1991 PMID 1997835 — "Effective surgical adjuvant therapy for high-risk rectal carcinoma." (Krook JE et al. N Engl J Med. 1991 Mar 14;324(11):709-15.). Median F/U 7 years
 * Outcome: 5-year recurrence RT 63% vs. chemo-RT 41% (decreased by 34%, SS). LR 25% vs. 13% (decreased by 47%, SS), DM 46% vs. 29% (SS). 5-year OS ~40% vs. ~55% (decreased by 29%, SS). Reduction in death rate highly significant for LAR (52%), not significant for APR (10%)
 * Toxicity: SBO 5%, median time-to-complication 10 months; overall severe late toxicity 7% (comparable between 45 and 50.4 Gy)
 * Conclusion: Adjuvant chemo-RT superior to RT alone; confirms prior GITSG 7175 results
 * Comment: CRT generally well tolerated, unlike GITSG GI-7175. Adjuvant chemo 1 month first, consolidation 2 months vs 1.5 years in GITSG. On the basis of this study and GITSG 7175, NIH consensus conference recommended chemo-RT as standard of care for T3-T4 or N+ patients

 * GITSG GI-7175 (1975-1980) -- surgery alone vs postop chemo vs postop RT vs postop chemo-RT
 * Randomized, 4 arms. Terminated early due to significant benefit of chemo-RT arm. 227/520 patients. Dukes B and C (T3-4 or N+), distal edge within 12 cm from anal verge. Only R0 resection allowed. Treated with 1) Surgery alone, 2) post-op Chemo (bolus IV 5-FU/M-CCNU), 3) post-op RT 40 or 48 Gy standard fraction, 4) post-op Chemo-RT 40 or 44 Gy standard fraction + 5-FU 500 mg/m2 followed by adjuvant 5-FU/M-CCNU as in chemo alone arm. RT given AP/PA, superior border L4/L5, inferior border included perineum; major deviations in 39%. Consolidative chemo given x1.5 years or until disease progression
 * 7-years, 1985 PMID 2859523, 1985 — "Prolongation of the disease-free interval in surgically treated rectal carcinoma. Gastrointestinal Tumor Study Group." [No authors]. N Engl J Med. 1985 Jun 6;312(23):1465-72. Median F/U 6.7 years.
 * Outcome: Recurrence surgery 55% vs. chemo 46% vs. RT 48% vs. chemo-RT 33% (SS). Benefit of chemo-RT (p=0.009) due to both RT (, better LRC p=0.06) and chemo (better DM p=0.06) components. Initial LRR overall 21%; by arm 24% vs. 27% vs. 20% vs. 11%; initial DM overall 25%. LR in perineum 21%, vagina/uterus 17%, anastomosis 12%, sacrum/coccyx 12%, bladder/prostate 12%. Actuarial OS 36% vs. 46% vs. 46% vs. 56% (p=0.07)
 * Toxicity: Severe nonhematological chemo 15% vs. RT 16% vs. chemo-RT 35%
 * Conclusion: Postoperative chemo-RT significantly better for disease-free survival, with trend to overall survival benefit
 * 8-years, 1986 PMID 3773947, 1986 (No abstract) — "Survival after postoperative combination treatment of rectal cancer." Douglass HO et al. N Engl J Med. 1986 Nov 13;315(20):1294-5. Median F/U 7.8 years
 * Outcome: No new recurrences. Now overall survival benefit for chemo-RT over surgery alone (SS)
 * Conclusion: Postoperative chemo-RT improves overall survival over surgery alone in T3-4 or N+ patients
 * GITSG overview, 1988 PMID 3064191, 1988 — "Adjuvant postoperative radiotherapy and chemotherapy in rectal carcinoma: a review of the Gastrointestinal Tumor Study Group experience." Thomas PR et al. Radiother Oncol. 1988 Dec;13(4):245-52.
 * Severe acute toxic side-effects, but late effects rare in arm 4. Three late deaths (2 enteritis in chemo-RT group, one acute leukemia in chemo group).
 * Conclusions: Compared to surgery alone, postop Chemo-RT improved OS (45% v 27% @ 10yrs), prolonged Time-To-Recurrence, decreased Recurrence Rate (33% v 55%), and decreased LF Rate (10% v 25%).
 * Critique: severely underpowered to show benefit, unequal randomization and not analyzed by intent to treat, semustine x1.5 years increases risk for leukemia

title: Radiation Oncology/Rectum/Randomized


text: File talk:First Aid for Canada.pdf

title: File talk:First Aid for Canada.pdf


text:
User talk:Rrs207

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally.– Mike.lifeguard  | talk 05:42, 20 November 2007 (UTC)

title: User talk:Rrs207


text: User talk:81.129.141.104

title: User talk:81.129.141.104