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Radiation Oncology/Vulva

Epidemiology

 * Rare tumor, estimated 3500 patients per year in the US. Incidence ~1/100,000 accounting for 3-4% of GYN malignancies
 * Higher incidence in age >70
 * Clinical presentation is usually due to symptoms: pruritus, spotting or bleeding, pain, and discharge
 * ~70% arise in labia majora/minora
 * ~20% are locally advanced
 * Follow predictable lymphatic drainage: superficial inguinofemoral, deep inguinofemoral, external illiac
 * Likelihood of LN+ depends on size and depth of primary, it ranges from 5%-60%
 * In GOG experience, 24% of patients who had clinically negative LNs were pathologically positive. If the lymph nodes were clinically suspicious, 76% were pathologically positive
 * Hematogenous dissemination occurs late
 * 15% of patients have a second primary tumor in the cervix, vagina, or anus

Staging
AJCC 7th Edition (2009)
 * Is based on revised FIGO staging (2009)
 * FIGO 2009 PMID 19329116 -- "Revised FIGO staging for carcinoma of the vulva."
 * see also: Revised FIGO Staging (2009)(PDF) (clarifies some errors in AJCC Manual)

Primary Tumor:
 * Tis - in situ
 * T1
 * T1a (FIGO IA) - ≤ 2 cm in size and <= 1mm depth of stromal invasion
 * T1b (FIGO IB) - > 2 cm in size, or any size with >1mm depth of stromal invasion
 * T2 (FIGO II) - extension to adjacent perineal structures (lower/distal 1/3 urethra, lower/distal 1/3 vagina, or anal involvement)
 * T3 (FIGO IVA) - extension to any of the following: upper/proximal 2/3 of urethra, upper/proximal 2/3 of vagina, bladder mucosa, rectal mucosa, or fixed to pelvic bone

Regional Lymph Nodes:
 * Regional nodes: include femoral and inguinal nodes. Involvement of iliac nodes is Stage IVB.

 * N0 - none
 * N1 (FIGO IIIA)
 * N1a - 1-2 LN mets, each < 5 mm
 * N1b - 1 LN met ≥ 5 mm
 * N2
 * N2a (FIGO IIIB) - 3 or more LN, each < 5 mm each
 * N2b (FIGO IIIB) - 2 or more LN ≥ 5 mm
 * N2c (FIGO IIIC) - LN with extracapsular spread
 * N3 (FIGO IVA) - fixed or ulcerated LN

Distant Metastases:
 * M0 - none
 * M1 (FIGO IVB) - yes (includes pelvic LN met)

Stage Grouping:
 * IA - T1a N0 (FIGO IA)
 * IB - T1b N0 (FIGO IB)
 * II - T2 N0 (FIGO II)
 * IIIA - T1-2 N1 (FIGO IIIA)
 * IIIB - T1-2 N2a-b (FIGO IIIB)
 * IIIC - T1-2 N2c (FIGO IIIC)
 * IVA - T3 or N3 (FIGO IVA)
 * IVB - M1 (FIGO IVB)

Changes from 5th edition:
 * Now includes number and size of lymph nodes and presence of extracapsular spread
 * Stage III is subdivided into IIIA/B/C

Older staging systems
AJCC 5th Edition (2002) FIGO stage: (AJCC difference in parentheses) Surgical staging implemented in 1989.
 * I
 * IA - 2 cm or less in size, and <= 1mm depth of stromal invasion
 * IB - 2 cm or less in size, >1mm depth of stromal invasion

 * II - > 2cm in size
 * III(T3) - spread to lower urethra, vagina, or anus
 * III(N1) - unilateral lymph node metastasis
 * IVA(T4) - invades upper urethra, bladder mucosa, rectal mucosa, or fixed to pubic bone
 * IVA(N2) - bilateral lymph node metastases
 * IVB - distant mets (including pelvic nodes)

Older staging systems: An older version included N2 (same as now) and N3 nodes (pelvic LN mets).

Functional Staging:
 * Early stage - can treat with primary surgery (WLE, modified radical vulvectomy, radical vulvectomy)
 * Locally advanced stage - unable to resect without ultra-radical (exenterative) surgery

Pathology

 * 85% are squamous cell
 * The others are: melanoma, basaloid (cloacogenic), adenocarcinoma, etc.
 * Tumors may arise in or near areas of premalignant conditions such as lichen sclerosus, erythroplasia of Queyrat, Paget's disease, or Bowen's disease.

Survival
Stage I - 90% at 5 yrs Stage II - 70-75% Stage III - 40-50% Stage IV - 20%

'''Vulvarcancer! nomogram'''
 * Korean KGOG-1010; 2008 PMID 19471576 -- "Validation of a nomogram for predicting outcome of vulvar cancer patients, primarily treated by surgery, in Korean population: multicenter retrospective study through Korean Gynecologic Oncology Group (KGOG-1010)." (Kim MK, J Gynecol Oncol. 2008 Sep;19(3):191-4. Epub 2008 Sep 30.)
 * Validation. 90 cases from 11 institutions. Mean F/U 4 years
 * Outcome: RFS 2-year observed 81% vs calculated 79% (R2 = 0.35), 5-year observed 68% vs calculated 72% (R2 = 0.8). Concordance index 0.79, improved to 0.82 with squamous cell
 * Conclusion: The nomogram provides predictive capacity in Korean patients

 * Creteil, France; 2006 (1978-2001) PMID 16507940 -- "Development and validation of a nomogram for predicting outcome of patients with vulvar cancer." (Rouzier R, Obstet Gynecol. 2006 Mar;107(3):672-7.)
 * Nomogram. 244 patients from Creteil used as a training set; 129 patients from Torino as a validation set
 * Outcome: Covariaes for RFS included age, T-stage, number of LN+, bilateral LN involvement, omission of LND, SM status, LVI status, depth of invasion. Concordance 0.83 in validation set, which was better than FIGO stage (concordance 0.78, SS)
 * Conclusion: Nomogram developed for predicting 2 and 5 year RFS

Surgery

 * Typically the primary treatment option for resectable disease (appropriate for the ~80% of localized disease)
 * Historically, radical vulvectomy was performed. Even after radical vulvectomy (GOG 37), local failure rate was still 9%. With less radical surgery (modified radical vulvectomy, WLE), importance of margin becomes critical
 * Surgical margin is the most important predictor of recurrence, with >1cm margin satisfactory and <8mm margin ~50% recurrence rate based on UCLA data
 * Other factors: size > 4 cm, lymphatic-vascular space invasion
 * Either factor - 20% recurrence. No factors - 9%
 * However, local vulva recurrences are salvageable (unlike LN failures) and do not strongly correlate with overall survival
 * To some, this suggests that adjuvant RT for vulva may not be as critical as for inguinal lymph nodes
 * Please see below for unresectable disease; a GOG Phase II trial of concurrent chemo-RT followed by surgical resection and LND is ongoing
 * ASTRO 2008 refresher: Adjuvant RT to vulva if SM+ or <8mm, or 2+ "Heaps" factors, or if treat LN already then 1+ "Heaps factor"

 * UCLA; 1990 (1957-1985) PMID 2227541 -- "Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva." (Heaps JM, Gynecol Oncol. 1990 Sep;38(3):309-14.)
 * Retrospective. 135 patients, Stage I-IV.
 * Outcome: Recurrence rate SM >=8mm 0% vs. SM <8mm 48% (SS).
 * Predictors for recurrence: depth of invasion (9 mm), tumor thickness (1cm), infiltrative growth, LVI+, increasing keratin, >10 mitoses
 * Conclusion: Surgical margin most powerful predictor of local recurrence

Adjuvant RT

 * Harvard; 2013 (1988-2009) PMID 23747330 -- "Relationship of margin status and radiation dose to recurrence in post-operative vulvar carcinoma." (Viswanathan AN, Gynecol Oncol. 2013 Sep;130(3):545-9. doi: 10.1016/j.ygyno.2013.05.036. Epub 2013 Jun 5.)
 * Retrospective. 205 patients, Stage I-IVA. Slides reviewed, margin scored as negative (≥ 1 cm) in 34%, close (<1 cm) 56%, or positive 10%. Median F/U 4.1 years
 * Outcome: 4-year vulvar recurrence negative SM 18%, close SM 37% (HR 3.0), positive 77% (HR 7.0). Highest risk of recurrence with margins ≤ 5 mm. Adjuvant radiation dose ≥ 56 Gy better
 * Conclusion: Close or positive margins significantly increase vulvar recurrence risk. Radiation dose ≥ 56 Gy may decrease the risk of recurrence

 * U. Pittsburgh, 1997 (1980-94)
 * PMID 9226327, 1997 — "Adjuvant radiation for vulvar carcinoma: improved local control." Faul CM et al. Int J Radiat Oncol Biol Phys. 1997 May 1;38(2):381-9.
 * Retrospective. 62 pts with close (<8mm) or positive margins, 31 were observed and 31 received RT. RT fields covered the vulva, bilateral groins, and lower pelvis. Mean dose 56 Gy.
 * Mean f/u 3.16 yrs. For pts with positive margins, LRR in 69% (obs) vs 33% (RT). Close margins, 31% vs 5%.

 * U. Minnesota, 1994 (1971-92)
 * PMID 8083101, 1994 — "Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block." Dusenbery KE et al. Int J Radiat Oncol Biol Phys. 1994 Jul 30;29(5):989-98.
 * Retrospective. 27 pts with positive nodes treated with post-op RT. RT was to bilateral groin and pelvic nodes, unilateral groin and pelvis, or unilateral groin only. Midline was blocked in all but 1 pt. Median dose 45 Gy.
 * Recurrences in 63% at a median of 9 months from surgery. Recurrences were under the midline block in 76%.

Unresectable disease

 * GOG 101 (1989-94)
 * Phase II. 96 pts. Two groups: 1) T3 or T4 not resectable by std surgery, and 2) unresectable N2/N3 nodes (see below). Split-course cisplatin/5-FU + RT followed by resection of residual tumor and bilateral inguinal LN dissection. RT dose 4760 cGy (170 cGy/d qd, 170 cGy/fx BID on days 1-4 of each course), given as two courses of 2380 cGy. RT fields were to tumor only if N0-1, or to include groin and lower pelvis (to SI joint) if N2-3.
 * Pts with unresectable primary:
 * PMID 9747823, 1998 — "Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group." Moore DH et al. Int J Radiat Oncol Biol Phys. 1998 Aug 1;42(1):79-85.
 * 73 pts with unresectable primary (of whom 50 were N0-N1 and 23 were unresectable N2-N3). 48% cCR. 70% of those had pCR. 84% of those with residual disease had negative margins. Of 50 pts who were initially felt to require pelvic exenteration, only 1 had exent. and 2 had colostomy. Only 2 pts had residual unresectable disease.
 * Median f/u 50 months for pts alive. 32.9% had recurrence. 54.9% alive without disease.
 * Pts with unresectable nodes:
 * PMID 11072157, 2000 — "Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study." Montana GS et al. Int J Radiat Oncol Biol Phys. 2000 Nov 1;48(4):1007-13.
 * 46 pts with unresectable N2/N3 nodes. Became resectable in 38/42 pts. pN0 in 15/37. Primary tumor had pCR in 20/38 pts. 4 pts had CR of primary and had biopsy only.
 * 12 pts alive without disease (median f/u 78 mo). Control of LN disease in 36/37 and control of primary and nodes in 27/38.
 * Conclusion: preoperative treatment is effective. High rate of pCR for the nodes (~40%) and primary (~31%).

 * GOG 185 - ? cisplatin + RT - closed due to poor accrual?

 * GOG 205 (2003-?) -- Phase II
 * 58 pts. Unresectable T3 or T4, any N. RT (1.8 x 32 = 57.6 Gy) with weekly cisplatin, followed by resection of residual disease.
 * 2012 PMID 22079361 -- "A phase II trial of radiation therapy and weekly cisplatin chemotherapy for the treatment of locally-advanced squamous cell carcinoma of the vulva: a gynecologic oncology group study." (Moore DH, Gynecol Oncol. 2012 Mar;124(3):529-33.)
 * 40 of 58 pts (69%) completed study treatment. cCR in 64% (37/58); of those having CR, 29 had pCR (29/37; 78% of those in cCR. 29/58; 50% of total)
 * Conclusion: "This combination of radiation therapy plus weekly cisplatin successfully yielded high complete clinical and pathologic response rates with acceptable toxicity."
 * Comment: the 64% cCR rate is an increase from the ~48% seen in GOG 101. pCR of 50% is an increase from the 31% in GOG 101.

Management of the lymph nodes

 * Metachronous (after primary treatment) groin node metastases are primary predictor of treatment failure and death
 * Therefore, management of lymph nodes is critically important in vulvar cancer
 * Initial surgery should include histologic assessment of inguinal nodes if the primary has >1mm stromal invasion
 * For lateralized T1a lesions (<1 mm stromal invasion), likelihood of LN involvement is <5%
 * If depth of invasion 2mm - 8% risk, 3 mm - 17% risk, overall 24% risk
 * Clinical tumor size correlates with occult metastases in patients with clinically negative lymph node involvement as follows: 0 to 1 cm = 7.7%; 1.1 to 2 cm = 23.9%; 2.1 to 3 cm = 31%; 3.1 to 5 cm = 36.4%. (from Gonzalez Bosquet, PMID 12957253)
 * At least 10-12 lymph nodes should be removed from bilateral inguinal-femoral dissection for optimal assessment
 * Predictors of lymph node metastasis: tumor thickness, grade, capillary space invasion, depth of invasion, location of tumor, tumor size
 * Approximately 70-75% of patients with clinically negative inguinal groins will have pathologically negative inguinal lymph nodes
 * In the clinically negative patients, GOG 88 showed that bilateral groin LND is superior to poorly done prophylactic RT (0% failures vs 20% failures), as that RT was prescribed to 3 cm and was not CT planned
 * The Dutch have shown that SLND is feasible, and failure rate after SLN- is ~2-3%
 * Number of involved groin lymph nodes strongly correlates with survival; and there is a benefit to adjuvant inguinal/pelvic RT. GOG 37 showed benefit for all patients with LN+, though on subset analysis the benefit was not significant for patients with a single positive LN. Retrospective SEER data suggests that these patients benefit as well, especially if they have inadequate inguinal/femoral LND (<12 lymph nodes removed)
 * Based on GOG data, ~25% of patients with pathologic ipsilateral groin disease will also have contralateral disease
 * PET thus far appears to have <70% sensitivity for assessing contralateral groin LN
 * Therefore, contralateral groin requires assessment/management in ipsilateral groin LN+ patients
 * Based on GOG data, ~28% of patients with groin LN + disease will also have pelvic LN+ disease
 * There is no Phase III data for use of chemotherapy. In GOG 37, the 2-year OS for inguinal LN+ was 68%, but the 2-year OS for pelvic LN+ was only 23%. Extrapolated data from other organs might argue for concurrent chemo-RT
 * ASTRO 2008 refresher: Adjuvant RT if 2+ LN involved, single grossly involved LN with ECE (old N2/N3 disease), or 1 LN+ but inadequate dissection (<5 on that side). Consider adjuvant chemo-RT if 3+ LN involved or ECE. Prophylactic groin RT reasonable with appropriate treatment techniques

Anatomic considerations

 * Torino, Italy; 2002 PMID 12210022 -- "Rationale and definition of the lateral extension of the inguinal lymphadenectomy for vulvar cancer derived from an embryological and anatomical study." (Micheletti L, J Surg Oncol. 2002 Sep;81(1):19-24.)
 * Embryological and anatomic study to determine lateral extension of groin lymphadenectomy in vulvar cancer. 3 human fetuses, 1 patient dissected
 * Outcome: Most lateral superficial inguinal lymph node does not rise above medial margin of the sartorius muscle, nor far lateral to where superficial circumflex iliac vessels cross the inguinal ligament
 * Conclusion: Lateral surgical landmark established

Lymph node management
Sentinel lymph node mapping:
 * GROINSS-V II; 2021 (2005 - 2016) PMID 34432481 -- "Radiotherapy Versus Inguinofemoral Lymphadenectomy as Treatment for Vulvar Cancer Patients With Micrometastases in the Sentinel Node: Results of GROINSS-V II" (Oonk MHM, J Clin Oncol. 2021 Aug 25;JCO2100006. doi: 10.1200/JCO.21.00006)
 * Prospective multicenter Phase II, single arm trial. 1535 patients. Early stage vulvar cancer (<4 cm), negative lymph nodes by imaging, sentinel node assessment. If SNB+, adjuvant RT 50/25
 * Outcome: SN metastasis in 21%. Stopping rule activated, since groin recurrence above threshold. 90% of recurrences wwere in SN mets >2 mm and/or ECE+. Protocol amended if SN macromets (>2 mm), completion IFL dissection, if SN micromets, continued adjuvant RT.
 * Outcome: If SN micromet, 2 year isolated groin recurrence 1.6%. If SN macromet, 2 year isolated groin recurrence 22% if RT only, and 7% if IFL (SS)
 * Toxicity: Less frequent after RT compared with IFL
 * Conclusion: Inguinofemoral RT safe alternative with SN micromets; not sufficient with SN macromets
 * GROINSS-V (2000-2006)
 * Primary Outcome; 2008 PMID 18281661 -- "Sentinel node dissection is safe in the treatment of early-stage vulvar cancer." (Van der Zee AG, J Clin Oncol. 2008 Feb 20;26(6):884-9.)
 * Prospective. 623 groins in 403 patients. T1-2, <4cm, SCC of vulva, clinically negative inguino-femoral LNs. SLN performed. If SLN- by ultrastaging, LND omitted. Median F/U 3 years
 * Outcome: SLN- in 68% patients. If SLN-, 2.3% groin failure rate and 3-year OS 97%
 * Toxicity: lymphedema 2% vs. 25%, recurrent erysipelas 0.4% vs. 16%
 * Conclusion: In early-stage vulvar CA, groin recurrences are low in patients with negative SLN
 * SLN Positivity; 2010 PMID 20537946 -- "Size of sentinel-node metastasis and chances of non-sentinel-node involvement and survival in early stage vulvar cancer: results from GROINSS-V, a multicentre observational study" (Oonk MH, Lancet Oncol. 2010 Jul;11(7):646-52. doi: 10.1016/S1470-2045(10)70104-2. Epub 2010 May 25.)
 * Sentinel node positive in 33% patients; completion inguinofemoral lymphadenectomy in 85%, 10% received RT or 5% no further treatment
 * Outcome: Further non-sentine metastases in 4% with ITC, 10% with micromets (<2 mm), 13% with macromets (2-5 mm), and 48% with macromets (>5 mm). DSS if <2mm 94% vs >2 mm 69% (SS)
 * Conclusion: Risk of non-sentinel node metastases increases with size of sentinel node metastasis

 * GOG 173 (1999-2009) - Phase III trial.
 * 459 eligible pts. Eligible if depth ≥ 1mm, tumor limited to vulva, primary tumor ≥ 2 cm and ≤ 6 cm, and inguinal lymph nodes negative by examination; i.e. T1b and N0 (but <=6cm).
 * Performed SLNB followed by completion lymphadenectomy. If tumor within 2 of midline, bilateral SLNB and lymphadenectomies were performed; otherwise, unilateral.
 * 2012 PMID 22753905 -- "Lymphatic Mapping and Sentinel Lymph Node Biopsy in Women With Squamous Cell Carcinoma of the Vulva: A Gynecologic Oncology Group Study." (Levenback CF, J Clin Oncol. 2012 Nov 1;30(31):3786-3791.)
 * 452 pts underwent lymphatic mapping. 772 groin dissections performed (320 bilateral, 132 unilateral). SLN identified in 418 of 452 pts.
 * LN metastases found in 132 of 418 pts (31.6%). SLN positive in 121 of 418 pts; 11 pts with negative SLN but positive LN identified on dissection. Sensitivity of SLNB 91.7%. In pts with tumors < 4 cm, false negative rate is 2%.
 * Conclusion: "Sentinel lymph node biopsy is a reasonable alternative to inguinal femoral lymphadenectomy in selected women with squamous cell carcinoma of the vulva." Women with tumors < 4 cm can be counseled that they have a less than a 3% risk of a groin relapse due to a false-negative SLN.

Lymph node dissection:
 * Ottawa; 2007 (1980-2004) PMID 17473950 -- "The definition of optimal inguinal femoral nodal dissection in the management of vulva squamous cell carcinoma." (Le T, Ann Surg Oncol. 2007 Jul;14(7):2128-32. Epub 2007 May 2.)
 * Retrospective. 58 patients with vulvar cancer, radical vulvectomy, and bilateral inguinal/femoral LND. 20th percentile for total LN removed = 10. RT 31%
 * Outcome: Only predictor for time-to-progression was <10 lymph nodes removed
 * Conclusion: Total number of LNs removed is independent prognostic factor, and at least 10 removed from bilateral dissection should be used for optimal evaluation

 * Mayo; 2003 (1955-90) - PMID 12957253 -- "Risk of occult inguinofemoral lymph node metastasis from squamous carcinoma of the vulva." (Gonzalez Bosquet J, Int J Radiat Oncol Biol Phys. 2003 Oct 1;57(2):419-24.)
 * Retrospective. 226 pts, clinically N0.
 * Lymph node metastases by clinical tumor size: 0 to 1 cm = 7.7%; 1.1 to 2 cm = 23.9%; 2.1 to 3 cm = 31%; 3.1 to 5 cm = 36.4%

 * GOG 74 (1983-89) - superficial inguinal lymphadenectomy
 * 121 evaluable pts. Tumor thickness ≤ 5 mm; no vascular invasion, clinically negative LNs.
 * 1992 PMID 1553164 -- "Early stage I carcinoma of the vulva treated with ipsilateral superficial inguinal lymphadenectomy and modified radical hemivulvectomy: a prospective study of the Gynecologic Oncology Group." (Stehman FB, Obstet Gynecol. 1992 Apr;79(4):490-7.)
 * 19 recurrences. Vulvar recurrence: 8 of 10 pts salvaged. Groin recurrence: 5 of 7 deaths from cancer occurred in pts with first recurrence in the groin.
 * Conclusion: "The number of patients who experienced recurrence in the operated groin is of concern and may be attributable to the decision to leave the femoral nodes intact."

 * GOG 36 (1977-84) - Surgery-pathologic study after lymph node dissection.
 * 588 evaluable pts
 * Superficial tumors (<= 5mm); 1987 - PMID 3578430 — "Positive groin lymph nodes in superficial squamous cell vulvar cancer. A Gynecologic Oncology Group Study." (Sedlis A, Am J Obstet Gynecol. 1987 May;156(5):1159-64.)
 * Subset of 272 of 588 pts (48.7%) had superficial tumors, defined as <= 5mm thick (N.B.: this is different that the cutoff of 1 mm used for Stage IA vs IB. This study measured the total tumor thickness, not the depth of stromal invasion.)
 * Significant predictors of groin LN metastasis: tumor thickness, grade, capillary-like space involvement, clitoral or perineal location, and clinically suspicious nodes.
 * Conclusion: "The risk of lymph node metastases is best determined by simultaneous evaluation of all risk factors rather than a single factor such as tumor thickness."
 * All patients; 1993 - PMID 8314530 — "Prognostic factors for groin node metastasis in squamous cell carcinoma of the vulva (a Gynecologic Oncology Group study)." (Homesley HD, Gynecol Oncol. 1993 Jun;49(3):279-83.)
 * All 588 pts. Predictors of groin LN metastasis (ranked in order of importance): higher grade, suspicious or fixed/ulcerated LNs, presence of capillary-lymphatic involvement, older age, greater tumor thickness. Tumor size and location were not predictive.
 * Toxicity: Chronic lymphedema 27%, wound breakdown 49%

Adjuvant RT

 * Radiation indicated for: >1 LN+, LN with ECE, margin < 8-10 mm, lymphadenectomy not performed due to comorbid disease, LVSI
 * Patients with fixed or ulcerated nodes should be treated with chemo/RT as per unresectable disease

 * GROINSS-V II (ongoing, opened 2005) - Non-randomized, observational study. In patients with SLN+, adjuvant RT (or chemo-RT, at physician discretion). For pts with SLN-, observation.

 * SEER data; 2006 (1988-2001) PMID 16889821 -- "The benefit of adjuvant radiation therapy in single-node-positive squamous cell vulvar carcinoma." (Parthasarathy A, Gynecol Oncol. 2006 Dec;103(3):1095-9. Epub 2006 Aug 4.)
 * Retrospective SEER data. 208 patients with single positive inguinal LN. 92% underwent radical vulvectomy with uni/bilateral LND. Median number LN resected 13. ~50% adjuvant RT.
 * Outcome: 5-year DSS adjuvant RT 77% vs. no RT 61% (SS). 5-year DSS improved if <12 LN removed RT 77% vs. no RT 55% (SS), if >12 LN removed RT 77% vs. no RT 67% (NS)
 * Conclusion: Adjuvant RT may improve DSS in patients with single LN+ who underwent less extensive LND

 * GOG 88 (1986-1990) -- GN-: RT vs bilateral groin dissection
 * Randomized. Stopped prematurely after failures seen only in RT arm. 52/300 patients, radical vulvectomy. T1-T3 (T1 eligible if LVI+ or depth >5mm). Nonsuspicious (clinical N0-N1) inguinal nodes. Arm 1) Bilateral inguinal/femoral LND vs Arm 2) bilateral groin irradiation. RT dose 50 Gy prescribed to 3 cm depth, CT planning not mandated.
 * 1992 PMID 1526880 — "Groin dissection versus groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study." (Stehman FB, Int J Radiat Oncol Biol Phys. 1992;24(2):389-96.)
 * Outcome: Groin recurrence RT 18% vs surgery 0% (SS), though 20% found to have positive disease and received ipsilateral inguinal/pelvic RT. OS RT 63% vs. surgery 88%. All recurrences were in-field
 * Conclusion: Radiation of intact groins is inferior to surgical dissection
 * Criticism: Dose to groin was prescribed at 3cm which greatly underdosed the nodes. ~50% patients had BMI >28. (See article by Koh below.) Koh showed that of the 5 pts who failed, all received tumor doses <47 Gy and 3 were underdosed by 30%. Failure rate of 18% is comparable to surgical LN+ rate of 20%, which is comparable to historical GOG data 24%

 * GOG 37 (1977-84) -- GN+: Inguinal/pelvic RT vs pelvic LND
 * Randomized. Closed prematurely for better outcome in RT arm. 114 patients with invasive SCC of vulva, who underwent radical vulvectomy and bilateral inguinal LND, and were found to have positive inguinal lymph nodes (unilateral or bilateral). Arm 1) Ipsilateral pelvic LN dissection vs Arm 2) Bilateral inguinal/pelvic RT. RT AP/PA 45-50 Gy (midplane) to bilateral pelvic nodes and bilateral groins. Superior border L5/S1. No radiation to primary. FIGO clinical staging used (but pathologic confirmation of + LN required for study entry).
 * 1986 PMID 3785783 — "Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes." (Homesley HD et al. Obstet Gynecol. 1986 Dec;68(6):733-40.)
 * Outcome: 2-yr OS RT 68% vs LND 54% (SS). Local groin failures RT 5% vs surgery 24% (SS). Failure rate in vulva 9% (23% of recurrences). Most recurrences within 2 years
 * Subset analysis: Survival advantage to RT if clinically suspicious/matted nodes or 2+ LN positive. 2-year OS clinically normal nodes (N0-N1) 78% vs. suspicious nodes (N2) 52% vs. matted nodes (N3) 33%. One LN+ 80% vs. 2-3 LN+ 66% vs. 4+ LN+ 27% (SS). If 2+ LN, RT 63% vs. surgery 37% (SS); no difference in only single LN+.
 * Toxicity: No significant difference
 * Conclusion: Adjuvant RT to groin and pelvic lymph nodes after WLE/B inguinal LND is superior to pelvic LN dissection
 * Comment: Benefit of RT was from control of the previously dissected groins (24% -> 5% failure rate)
 * 2009 PMID 19701032 -- "Radiation therapy compared with pelvic node resection for node-positive vulvar cancer: a randomized controlled trial." (Kunos C, Obstet Gynecol. 2009 Sep;114(3):537-46.) Median survivor F/U 6.1 years
 * Outcome: 6-year vulva recurrence RT 9% vs PLND 7% (recall no vulva RT given), groin LN recurrence 5% vs 24%, pelvic LN recurrence 5% vs 2%, DM only 12% vs 11%. 6-year RFS RT 59% vs PLND 48% (HR 0.4, SS). CSS 71% vs 49% (HR 0.5, SS). OS 51% vs 41% (HR 0.6, NS). RT still significantly improved OS for cN2-N3 disease and 2+ groin LN
 * LN disease burden: Significant benefit for RT (HR 3.9) if ≥ 20% ipsilateral LN+. If ≥ 20% LN+, significantly more likely to have contralateral LN+, relapse, and cancer-specific death. 6-year OS for these patients RT 36% vs PLND 13%. Single LN+ in 35% of patients, so inadequate power to estimate benefit
 * Toxicity: chronic lymphedema RT 16% vs PLND 22% (NS)
 * Conclusion: RT significantly reduces local relapses and cancer-related deaths; new indication for adjuvant RT is ≥ 20% ipsilateral LN+

Primary site

 * Pittsburgh; 2008 PMID 18455637 -- "Preoperative intensity-modulated radiotherapy and chemotherapy for locally advanced vulvar carcinoma." (Beriwal S, Gynecol Oncol. 2008 May;109(2):291-5.)
 * Retrospective. 18 patients, locally advanced Stage II-IVA cancer. Concurrent 5-FU/cisplatin and IMRT 45 Gy. Surgery 6-8 weeks post-treatment. Median F/U 1.8 years
 * Outcome: cCR 72%, pCR 64%
 * Toxicity: No Grade 3+ acute or late toxicity
 * Conclusion: Well tolerated, with good clinical response

 * Minnesota; 1994 (1971-92) - PMID 8083101 — "Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block." Dusenbery KE et al. Int J Radiat Oncol Biol Phys. 1994 Jul 30;29(5):989-98.
 * Retrospective. 26 pts. 76% of recurrences were under the central block. Recommend tailoring the block to the individual pt.

Inguinal lymph nodes

 * University of Florida; 2004 PMID 15528067 — "Irradiating the groin nodes without breaking a leg: a comparison of techniques for groin node irradiation." Gilroy JS et al. Med Dosim. 2004 Winter;29(4):258-64.
 * Advocate the use of the "photon through-and-through" (similar fields for AP/PA but using 15 MV PA and 6MV AP) or the "photon thunderbird" (uses smaller field for the PA that spares the femoral head; electron patch over the inguinals to make up for the dose)

 * Taiwan; 1996 PMID 8641909, 1996 — "Topographic distribution of inguinal lymph nodes metastasis: significance in determination of treatment margin for elective inguinal lymph nodes irradiation of low pelvic tumors." Wang CJ et al. Int J Radiat Oncol Biol Phys. 1996 Apr 1;35(1):133-6.
 * Mapped inguinal mets on a sim film. The gross nodes lie within: 1) Lateral - lateral border of the femoral head, 2) Medial - 3 cm from body's midline, 3) Superior - 1 cm below upper border of femoral head, 4) Inferior - 2.5 cm below the bottom of the ischial tuberosity. 1-2 cm should be added to this region in designing a radiation portal to give adequate margin on the nodes.

 * University of Washington; 1993 PMID 8244831 — "Femoral vessel depth and the implications for groin node radiation." Koh WJ et al. Int J Radiat Oncol Biol Phys. 1993 Nov 15;27(4):969-74.
 * Measured depth of femoral vessel beneath the skin in 50 pts using CT. Range was 2-18 cm. Mean was 6.1 cm.
 * Importance: had implications for results of GOG study of prophylactic groin irradiation.

Official Guidelines
Link to guidelines page

Reviews

 * PMID 8431907, 1993 — "Gynecologic Oncology Group randomized trials of combined technique therapy for vulvar cancer." Keys H et al. Cancer. 1993 Feb 15;71(4 Suppl):1691-6.

title: Radiation Oncology/Vulva


text:
Bartending/Alcohol/Beer

Ale
Ale is a top-fermented beer that originated in England, as early as the 7th century. The top fermenting yeast, Saccharomyces cerevisiae, performs fermentation at a higher temperature of between 55 °F and 70 °F (13-21 °C) than the yeast used to produce lager, and their byproducts are more evident in the final taste and aroma of the ale.

Ale is properly supplied to the point of sale as a "living" beer in which the yeast fermentation continues to occur. Managing the final stages of this process in the cellar or special cool-room is a skilled task, but this is the role of the cellarman rather than the barman or barmaid and is not considered further here.

Ale can be served in two ways - from a beer engine or by gravity. The latter is the simpler technique, in which the glass is filled directly from the cask which is usually placed on a counter behind the bar. The tap in the end of the cask may be an ordinary threaded beer-line tap with a twisting action, or it may be a pouring tap with a lever-style handle. The glass is simply placed close under the tap and filled. Gravity service is usually found in ale-centric establishments with many beers on at once, and at beer festivals.

In most British pubs, the beer engine is used instead. This is the proper name for the tall, manually operated hand pump on the top of the bar, which is connected via the beer-line to the cask in the cellar. Most pumps dispense around a half-pint per pull, although they are frequently worn and require several pulls to obtain a complete pint. Quarter-pint engines also exist. The handle should be operated in a smooth manner across the whole of its arc, rather than jerked rapidly to and fro which tends to agitate the beer, creating a large head into which much of the bitterness migrates.

Head size is also regulated by the sparkler which may be fitted to the outlet of the pump. This forces the beer through small holes, deliberately agitating it and producing a large head. Some beers are brewed with this in mind, and others are not - a good barman will use a sparkler only on those beers meant to be served through one. In the UK, CAMRA's Good Beer Guide indicates whether this is the case; most brewers will also tell their customers, and may even affix labels with these kind of instructions to the casks.

Many pumps are fitted with a "swan neck" designed to reach to the bottom of the glass. If a sparkler is fitted it is important to use this in order not to create an excessive head which must either be allowed to drop in its own time or spilled out of the glass and wasted. The glass should be raised around the swan-neck so that the outlet is at the bottom. It should be left there until the glass is almost full.

Stout
Stout is an ale and a dark, sometimes black beer made with roasted grain. Like other beers, Stout is usually served cool, but some drinkers prefer having Stout at room temperature. Traditionally, the matching food for Stout is the oyster.

Stout was originally known as "Stout Porter" to emphasize its fuller body. Stouts are typically distinguished by use of roasted barley, which gives the drink its characteristic sharp roasty flavor. Porters typically achieve their color with chocolate malt, so named for its color and slight chocolate taste.

The most famous variety of stout is Guinness, originally from Ireland but now brewed around the world. Guinness has a light body with a distinct astringency, and is known for its creamy head of Nitrogen foam. Scottish stout is less bitter than Guinness and more fruity. Oat is sometimes added during the brewing process to make an oatmeal variety.

Lager
A lager is a type of beer made with specific strains of yeast which ferment at a significantly lower temperature than ale yeast, resulting in a usually crisper taste. A popular type of lager is a pilsner which is widely consumed in North America, Budweiser and Miller both being of this general style. Like Ales, Lagers also have a number of different styles of brewing.

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

title: Bartending/Alcohol/Beer


text:
AQA Information and Communication Technology/ICT5

ICT5 is assessed by a 2 hour written paper consisting of a series of short, structured questions and a longer essay question, making up 15% of the total A-Level marks. The UMS for this paper is 90 marks.

ICT5 aims to cover the subject of "Information: Policy, Strategy and Systems" and has 10 topics.

 * 14.1 /Policy and Strategy Issues/
 * 14.2 /Software/
 * 14.3 /Database Management Concepts/
 * 14.4 /Communication and IS/
 * 14.5 /Networks/
 * 14.6 /Human-Computer Interaction/
 * 14.7 /Human-Computer Interfaces/
 * 14.8 /Software Development/
 * 14.9 /Software Reliability/
 * 14.10 /Portability of Data/


text:
User talk:Laser~enwikibooks

Hello and welcome to Wikibooks!

Here are some tips to help you get started:

 * Remember to conduct any editing experiments in the sandbox.
 * Check out our help page if you need additional help.
 * Eventually, you might want to read the Manual of Style and Policies and Guidelines.
 * Remember to maintain a Neutral point of view.
 * Explore, be bold in editing pages, and have fun!

Good luck!

(Donovan|Geocachernemesis|Interact) 12:36, 22 Jun 2005 (UTC)

Your account will be renamed
Hello,

The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

Unfortunately, your account clashes with another account also called Laser. To make sure that both of you can use all Wikimedia projects in future, we have reserved the name Laser~enwikibooks that only you will have. If you like it, you don't have to do anything. If you do not like it, you can pick out a different name.

Your account will still work as before, and you will be credited for all your edits made so far, but you will have to use the new account name when you log in.

Sorry for the inconvenience.

Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:21, 17 March 2015 (UTC)

Renamed
 This account has been renamed as part of single-user login finalisation. If you own this account you can |log in using your previous username and password for more information. If you do not like this account's new name, you can choose your own using this form after logging in: . -- Keegan (WMF) (talk) 05:11, 19 April 2015 (UTC)

title: User talk:Laser~enwikibooks


text:
User talk:86.126.132.74

Hello and welcome to Wikibooks!

Here are some tips to help you get started:

 * Remember to conduct any editing experiments in the sandbox.
 * Check out our help page if you need additional help.
 * Eventually, you might want to read the Manual of Style and Policies and Guidelines.
 * Remember to maintain a Neutral point of view.
 * Explore, be bold in editing pages, and have fun!

Good luck!

(Donovan|Geocachernemesis|Interact) 12:43, 22 Jun 2005 (UTC)

title: User talk:86.126.132.74


text:
User talk:210.213.127.112

Hello and welcome to Wikibooks!

Here are some tips to help you get started:

 * Remember to conduct any editing experiments in the sandbox.
 * Check out our help page if you need additional help.
 * Eventually, you might want to read the Manual of Style and Policies and Guidelines.
 * Remember to maintain a Neutral point of view.
 * Explore, be bold in editing pages, and have fun!

Good luck!

(Donovan|Geocachernemesis|Interact) 12:49, 22 Jun 2005 (UTC)

title: User talk:210.213.127.112


text:
AQA Information and Communication Technology/ICT5/Policy and Strategy Issues

The use of ICT has exploded, it is no longer used by just experts, so an IT policy is required to manage IT resources in an effective and efficient way and to avoid fragmentation between departments of IT systems.

A single IT policy allows for an overall view and control of an organisation's IT setup. It is important to ensure that the policy reinforces the overall strategy of the organisation.

If each section is allowed to develop individually, without an overall IT policy, it would make it difficult to introduce systems such as Management Information Systems

It is important to acknowledge the different needs of users when creating an overall IT policy, however.

 * The graphics department may need a higher spec of machine to deal with image/video manipulation
 * The publishing department may prefer using Macs.
 * Operational users may need to interact with the system in a different way to the tactical/strategic users.

A good IT policy will deal with issues such as:

 * Access to information - who needs it?
 * How will internal communication work
 * How will data be captured?

In order to be successful in the long-term, the IT policy will need to be flexible to deal with new technology, new requirements, and changes to the organisational structure.

Centralised approach
A centralised system is one where the whole IT system in an organisation is ran by a specific area of the company, sometimes called Information Systems.

It has various advantages, such as:

 * Increased hardware and software compatibility
 * The ability to take advantage of economies of scale
 * Ease of transfer of data
 * Simpler maintenance
 * Easier training/reuse of skills due to consistent interface

Decentralised approach
In this approach, each department has its own strategy and allows for them to plan their IT system exactly to their needs. This has several disadvantages, such as a lack of coherence among the whole organisation, and the lack of expertise.

Upgrading systems
There are various reasons you may wish to upgrade a system. For example, you may have a legacy system that is no longer supported by the vendor and is difficult to maintain and is inefficient. However, even current software may need upgrading. It may not be meeting the needs of the organisation, or the organisation may wish to take advantage of features that may exist in newer versions of the software, or may just want to improve performance with faster hardware. Changes in the organisational structure, objectives, or just a "cutting-edge" business culture may result in upgrades.

Don't upgrade

 * This is not always the cheapest option, although involves the least initial capital.
 * Is upgrading really necessary?
 * Is our current system sufficient to our needs?
 * There's no training costs or change management required, and little risk
 * The only costs are maintenance costs

Upgrade the entire system

 * This involves a lot of capital expenditure
 * Has large technical and support implications
 * This may involve a totally new infrastructure set up
 * High risk

Partial upgrade

 * Only upgrade who needs it
 * Cheaper than all at once
 * May cause incompatibilities in the IT systems
 * Medium risk

Future proofing
Future proofing is impossible, and it is impossible to know with certainty what the future will hold. It is only possible to prepare for what could happen.

This generally involves purchasing software with a clear upgrade path, or developing software making it easy to expand in the future. Alternatively, this could be purchasing systems with a higher specification than the organisation actually needs in order to allow for future growth.

A method of future-proofing is leasing, where an organisation leases it's IT systems, and does not actually own it. Therefore, upgrading occurs as part of the lease.

Emulation
Emulation is where software is used to run software which is not designed to run on a particular system. For example, software written to run on a specific hardware platform can be emulated to run on another using emulation software. Of course, it is impossible for this to be anywhere near as efficient as running it on the original hardware, but does reduce the hardware costs of having to buy many bits of different hardware. Additionally, an emulator may not fully emulate all the areas of the hardware it is emulating, so the program may not work as intended.

Hardware emulation also exists, where a piece of hardware emulates another piece to provide compatibility with systems designed to use that hardware.

Backup Strategies
This should be part of the corporate IS security policy, as backups are often a weakpoint in security of IS.

A backup strategy should ask these 3 basic questions:

 * How often? (the frequency)
 * What? (areas to backup)
 * Where? (storage of backup)

When deciding on an appropriate backup strategy, we must consider:

 * Value of data
 * Quantity of data
 * Frequency of data change
 * Resources available

Backup media
A range of backup media is available, from the old fashioned, but still popular, magnetic tape, Zip drives, or more recently, recordable DVDs and USB flash drives.

Other methods of backup could be online, including RAID (a redundant array of independent disks) which makes backups of data constantly.

Backup strategies

 * Full backups
 * All data is backed up
 * For large amounts of data, this takes a long time and requires a lot of space
 * Partial backups
 * Only part of the data is backed up at a time. For example, one night might backup the Payroll database, and on the next night, the e-mails are backed up
 * Makes large data sources more manageable
 * Incremental backups
 * Full backups are made occasionally
 * Incremental backups only back up what's different from the last full backup
 * Batch process
 * Similar to incremental backups, but used for databases
 * Grandfather-Father-Son Backup
 * Most popular method of backing up
 * A copy of the masterfile and transaction is made at the grandfather level
 * At the father level, a copy of the transaction file and the masterfile as a result of the grandfather master file and transaction file is made.
 * At the son level, a copy of the transaction file and the masterfile as a result of the father master file and transaction file is made.


text:
Cookbook:Potato and Cauliflower Curry (Aloo Gobi)

| India | Vegetarian

Aloo gobi (or gobhi) is a South Asian dish popular in both India and Pakistan. Aloo means potato and Gobi means cauliflower. This dish has a prominent role in the movie Bend It Like Beckham, and it can be prepared in a variety of ways. Also, sometimes aloo gobi is made without the tomato.

Ingredients

 * 800 g (6.5 ea.) medium tomatoes, diced or puréed
 * 2 big cauliflower cut into chunks
 * 4–5 potatoes, peeled and cut into cubes
 * 1 lemon
 * 3–5 tablespoons of ghee or vegetable oil
 * 1 teaspoon cumin seeds (jeera)
 * 5 tablespoons salt
 * 1 tablespoon ground curcuma (turmeric)
 * 2 tablespoons ground coriander
 * 1–2 tablespoons ground chilli
 * 2–4 tablespoons garam masala
 * 5 sprigs of mint

Procedure

 * 1) Heat the ghee/oil in frying pan, wok, or karahi (an Indian utensil specially used for frying purposes)
 * 2) Add cumin seeds and wait until they turn a light brown color.
 * 3) Add the spices (except for garam masala) and the tomatoes.
 * 4) When the mixture turns oily, add the vegetables.
 * 5) Roast the cauliflower and the potatoes until they turn soft. Stir occasionally.
 * 6) Add the garam masala, mint, and lemon juice.


text:
Electronics/Adders

Intro
When adding one number A with another number B the operation will produce a Sum S and a Carry C.The Operation of an adder is Shown below.

Half adder
If there are two binary number A and B. The operation of adding two numbers can be shown below
 * A + B = S C

 * 0 + 0 = Sum 0 Carry 0
 * 0 + 1 = Sum 1 Carry 0
 * 1 + 0 = Sum 1 Carry 0
 * 1 + 1 = Sum 0 Carry 1

The operation of Half Adder can be summarized in the Truth Table below
 * {| class="wikitable" style="text-align:center"

! $$A$$ !! $$B$$ !! $$C$$ !! $$S$$
 * 0 || 0 || 0 || 0
 * 0 || 1 || 0 || 1
 * 1 || 0 || 0 || 1
 * 1 || 1 || 1 || 0
 * }
 * 1 || 0 || 0 || 1
 * 1 || 1 || 1 || 0
 * }
 * }

From above, In term of logic gate XOR will produce a sum of two input. logic gate AND produce carry
 * $$S = A \oplus B$$
 * $$C = A \cdot B$$

Half Adder can constructed from AND gate and XOR gate as shown below
 * Half Adder.svg

___________     A --|           | |  Half    |- $$S = A \oplus B$$ |  Adder   | |          |- $$C = A \cdot B$$ B --|___________|

Full adder
A full adder is a logical circuit that performs an addition operation on three one-bit binary numbers. The full adder produces a sum of the two inputs and carry value. It can be combined with other full adders (see below) or work on its own.

 * {| class="wikitable" style="text-align:center"

!colspan="3"| Input !!colspan="2"| Output ! $$A$$ !! $$B$$ !! $$C_i$$ !! $$C_o$$ !! $$S$$
 * 0 || 0 || 0 || 0 || 0
 * 0 || 1 || 0 || 0 || 1
 * 1 || 0 || 0 || 0 || 1
 * 1 || 1 || 0 || 1 || 0
 * 0 || 0 || 1 || 0 || 1
 * 0 || 1 || 1 || 1 || 0
 * 1 || 0 || 1 || 1 || 0
 * 1 || 1 || 1 || 1 || 1
 * }
 * 0 || 0 || 1 || 0 || 1
 * 0 || 1 || 1 || 1 || 0
 * 1 || 0 || 1 || 1 || 0
 * 1 || 1 || 1 || 1 || 1
 * }
 * 1 || 1 || 1 || 1 || 1
 * }
 * }

 * $$S = (A \oplus B) \oplus C_{in}$$
 * $$C_{out} = (A \cdot B) + (C_{in} \cdot (A \oplus B)) $$
 * [[Image: Full-adder logic diagram.svg|Full adder circuit diagram Inputs: {A, B, CarryIn} → Outputs: {Sum, CarryOut}]]
 * [[Image:1-bit full-adder.svg|200px|Schematic symbol for a 1-bit full adder]]

Note that the final OR gate before the carry-out output may be replaced by an XOR gate without altering the resulting logic. This is because the only difference between OR and XOR gates occurs when both inputs are 1; for the adder shown here, this is never possible. Using only two types of gates is convenient if one desires to implement the adder directly using common IC chips.

A full adder can be constructed from two half adders by connecting A and B to the input of one half adder, connecting the sum from that to an input to the second adder, connecting Ci to the other input and OR the two carry outputs. Equivalently, S could be made the three-bit XOR of A, B, and Ci, and Co could be made the three-bit majority function of A, B, and Ci.

Ripple carry adder
It is possible to create a logical circuit using multiple full adders to add N-bit numbers. Each full adder inputs a Cin, which is the Cout of the previous adder. This kind of adder is a ripple carry adder, since each carry bit "ripples" to the next full adder. Note that the first (and only the first) full adder may be replaced by a half adder.

The layout of ripple carry adder is simple, which allows for fast design time; however, the ripple carry adder is relatively slow, since each full adder must wait for the carry bit to be calculated from the previous full adder. The gate delay can easily be calculated by inspection of the full adder circuit. Each full adder requires three levels of logic. In a 32-bit [ripple carry] adder, there 32 full adders,so the critical path (worst case) delay is $$32*3=96$$ gate delays.

Carry look-ahead adders
To reduce the computation time, engineers devised faster ways to add two binary numbers by using carry lookahead adders. They work by creating two signals (P and G) for each bit position, based on whether a carry is propagated through from a less significant bit position (at least one input is a '1'), a carry is generated in that bit position (both inputs are '1'), or if a carry is killed in that bit position (both inputs are '0'). In most cases, P is simply the sum output of a half-adder and G is the carry output of the same adder. After P and G are generated the carries for every bit position are created. Some advanced carry look ahead architectures are the Manchester carry chain, Brent-Kung adder, and the Kogge-Stone adder.
 * [[Image:4-bit carry lookahead adder.svg|none|framed|4-bit adder with Carry Look Ahead]]

Some other multi-bit adder architectures break the adder into blocks. It is possible to vary the length of these blocks based on the propagation delay of the circuits to optimize computation time. These block based adders include the carry bypass adder which will determine P and G values for each block rather than each bit, and the carry select adder which pre-generates sum and carry values for either possible carry input to the block.

Other adder designs include the conditional sum adder, carry skip adder, and carry complete adder.

Lookahead Carry Unit
By combining multiple carry look-ahead adders even larger adders can be created. This can be used at multiple levels to make even larger adders. For example, the following adder is a 64-bit adder that uses four 16-bit CLAs with two levels of LCUs.

 * [[Image:64-bit lookahead carry unit.svg|none|framed|A 64-bit adder]]

Reference

 * 1) Digital Adder on Wikipedia

title: Electronics/Adders


text:
User:RobinH

Books:

=The Best Books=

General
Guitar

Technical
Control Systems

Engineering Acoustics

Latex

Basic Physics of Nuclear Medicine

Science
Human Physiology

Biological Machines

Observing the Sky from 40°N

Special relativity

Communication Theory

Cognitive Psychology and Cognitive Neuroscience

Consciousness studies

=Great Books that Could be Better=

Just a tweak of presentation would make the following books much better

Contemporary Educational Psychology - What about a PDF?

Click on discussion for more.

title: User:RobinH


text:
AQA Information and Communication Technology/ICT5/Software

In ICT5, we cover evaluation of software.

It is performed as part of the Analysis stage of the IS lifecycle.

Software should be evaluated against evaluation criteria to see if it meets the requirements it is needed for.

 * Functionality - does the software do what is required, and what we want it to do? (i.e., does it meet the specification)
 * Performance - does it do it efficiently and quickly?
 * Usability - can the software be used effectively by the intended end-user?
 * Compatibility - can it co-exist and work alongside our existing software/can it import data from the software we're replacing?
 * Robustness - is the software stable?
 * User support - do we have people to turn to if it goes wrong?
 * Resource requirements - does it run on our existing hardware? Can our staff be training to use it?
 * Upgradability - can we continue to use it in the future?
 * Cost - is it cheaper than the alternatives? Can we afford it?
 * Vendor quality - what kind of reputation does the vendor have?
 * Flexibility - can we alter it to do exactly what we want? (especially relevant for generic as opposed to bespoke software)

Benchmarking is a good way of discovering whether the software is suitable or not. You give each criterion a weight, and then each product being evaluated a score. You multiply the weight by the score and add up all the criteria for that product and the one with the highest total score wins.

Evaluation report
This is what should be written once evaluation is complete to be relayed back to the board of directors.

It should consist of the following sections:

 * Introduction, who and why is the report being done?
 * Methodology, how was the best software decided upon?
 * Evaluation, an actual breakdown of each software package showing the results
 * Recommendations, which product do the report writers think we should be investing in?
 * Justification for this recommendation


text:
AQA Information and Communication Technology/ICT5/Database Management Concepts

Early databases were flat-file, meaning they were small, had lots of duplicated data and could not relate data to each other. As a result of data duplication, data can be inconsistent in separate parts of the database. Flat-files also tended to be unique to a particular program, making data portability difficult.

A database management system (DBMS) was conceived to help alleviate these shortcomings. This model gives three properties:

 * Entities - An area of interest about which the data may be held
 * Attributes - Properties of entities
 * Relationships - A link between entities There are different types of relationships:
 * One-to-one - where an entity has a single link to another entity
 * One-to-many - where an entity may link to many other entities
 * Many-to-many - lots of one-to-ones

By using relationships, you can link data and have queries that will update linked data at the same time, saving time and increasing the accuracy of data. The Wikipedia has more information about DBMS's.

The role of a database administrator (DBA) is to manage and maintain the DBMS for most efficient usage. The DBA maintains access rights, relationships and updates the database of the design if need be.

Data normalisation is the process of increasing database efficiency by reducing duplication of records and producing the best possible database design. A normalised database is consistent and flexible.

Data consistency is ensuring that the data is consistent across all occurrences of it (this is made simple using relationships).

Data integrity is the quality of the data held in the database.

Data redundancy is where data is unnecessarily duplicated.

Data independence is where data should be independent of any other changes in the database.


text:
AQA Information and Communication Technology/ICT5/Communication and IS

Originally, most large organisations had a mainframe with dumb terminals (simply front-ends to the mainframe; they did no work themselves) to use an IT system. Such systems are rare, although old-style ATM's are such an example.

Nowadays, people use distributed processing, where each terminal has its own processing power and does operations itself, rather than relying on a mainframe. Early computers tended to be stand-alone, with no communication.

Standalone computers require their own individual facilities (such as printers), and files on one can not be easily transferred to another system. However, they are more protected from external virii. Networked systems can take advantage of shared resources and easier communication and also tend to be easier to administer.

We covered networking comprehensively in ICT2. You need to know which kind of network to use for a specific application in ICT5.

When considering the Internet, you basically think of it as a series of LAN's which are connected together. Routers sit on the border of each LAN where the links are and announce to the world which IP addresses are on that LAN, and listen for other routers so it knows where to send data to.

Distributed databases
When an organisation is spread out all over the world, it can be expensive to provide network access to a single central database, so databases are distributed.

With a distributed database, only the part of the database that is required for that area of the business is held. However, ensuring data integrity becomes important.

Client/server databases
In the client/server model, a dedicated database machine runs the database server (typically the DBMS). The client machine connects to the server to perform queries and generate reports.


text:
Wikijunior:Solar System/Mars/Phobos

Phobos Facts:
 * Phobos orbits Mars closer than any other moon in our Solar System.
 * Over the next 50 million years it is expected the Martian gravity will shred Phobos into smaller pieces, possibly creating some spectacular impacts on Mars
 * It takes less time for Phobos to orbit Mars than for Mars to turn round on its axis.
 * Several craters on Phobos are named after characters in Gulliver's Travels.

How big is Phobos?
Phobos is actually quite tiny compared to most other moons in the Solar System. It is not a round sphere-like object, but irregularly shaped, more like a lumpy potato. At the largest extreme, it is 26 km across, and the smallest is about 18 km across. Basically about the size of a large city here on the Earth.

What is its surface like?
From the basic appearance, it is very much as it would look on the Earth's Moon, except that the surface features are exaggerated. Just like the Earth's Moon, Phobos has no atmosphere. Also like the Earth's moon to the Earth, Phobos has one face that constantly points the same direction toward Mars, and is called tidally locked.

One big difference you would notice is that there is almost no gravity at all on Phobos. Just by jumping with your own legs, you would be able to put yourself into "orbit" and "fly" around Phobos. The gravity is only 1/1000th as strong as it is on the Earth. This also affects "mountains" on Phobos, as there would appear to be huge cliffs and other features where on even the Earth's Moon they would have collapsed due to gravity pulling them down.

One of the most prominent features on Phobos is a giant crater named Stickney. The impact from this crater has a significant effect on the structure of the entire moon, and there are lines or "grooves" along the surface of Phobos that were formed as a result of this impact.

If you were standing on Phobos, Mars would be a significant feature in the sky, taking up almost 1/4 of the sky.

How long is a day on Phobos?
A day on Phobos is about 7 hours 40 minutes.

How long is its orbit around Mars?
Phobos is tidally locked to Mars. This means that a day on Phobos is precisely the same as the time it takes to orbit Mars. So, the same side of Phobos always faces Mars.

Phobos is very close to the surface of Mars. In fact, no other moon that has been discovered so far in the Solar System is closer to the surface of the planet that it orbits. This produces a very interesting experience to somebody on Mars, where Phobos rises from the west and sets in the east, as it travels faster than the Sun on a Martian day.

Does Phobos cause a solar eclipse on Mars?
Just as on the Earth by the Earth's Moon, Phobos does eclipse the Sun on Mars. This is also called a transit, and produces many of the same effects that you see from a solar eclipse. If you were to see such an eclipse on Mars, it would significantly darken the Sun, but it would not go into totality as the Earth's Moon does on the Earth. This is because Phobos is too small to cover the Sun completely. Also, because the orbit of Phobos is so fast, the eclipse would happen very quickly, in just a few seconds instead of the several minutes you see an eclipse on the Earth.

Because Phobos orbits Mars so closely, an eclipse near the Martian equator will be much more noticeable than an eclipse further north or south, because Phobos is usually quite a bit closer to an observer at the equator.

Is there a future for people on Phobos?
Because Phobos is so close to Mars, and because of the very low gravity, Phobos may be a place where people and supplies are transferred before going to the surface of Mars and then going to the Earth, almost like a space station in orbit around the Earth. It is very likely that if people go to Mars as astronauts, they will be visiting Phobos as well. Phobos also has frozen water that could be useful to astronauts on Mars as drinking water and for extracting oxygen to breathe.

However, Phobos is a doomed world. In about 50 million years, it will not exist. Every year, it gets about two meters closer to the surface of Mars, and will eventually crash or be ripped apart, forming a ring around Mars which will eventually fall to the ground.

Who is it named after?
Phobos (Ancient Greek Φόβος) was named after the son of Mars, who in mythology was the god of "fear" or "fright", and one of the servants of Mars.

How was it discovered?
Asaph Hall was an astronomer with the United States Naval Observatory, where he studied many of the planets and objects in the Solar System. In 1877 he discovered both Phobos and Deimos, and identified them as moons of Mars. The name for Phobos was suggested by Henry Madan, based on the book Iliad, a classical Greek book about mythology. His wife's maiden name, Stickney, gave the name of the giant crater.

How much will Phobos' gravity pull on me?
Phobos, because it is so small, has hardly any gravity at all. It has so little gravity that a 100-pound person on Phobos would only weigh 1/20 of a pound. This also means that you would be able to lift massive amounts of mass. A person who could carry 10 kg on Earth would be able to carry three elephants on Phobos.

Because Phobos' gravity is so small, it is easy to escape Phobos and float off into space. In fact, Phobos' gravity is so light that you could throw a tennis ball or a baseball and it would fly away from Phobos and become a new moon of Mars!

Wiki junior Sunčev sistem/Mars/Fobos Wikijunior Sonnensystem/ Mars/ Phobos

title: Wikijunior:Solar System/Mars/Phobos


text:
User talk:Calvin~enwikibooks

Hi, It's rather unorthodox to remove your comments from the talk page of the main Cookbook module. I think your desire to have a better search is a good one, and perhaps leaving the comments there would spur discussion. Kellen 18:03, 22 Jun 2005 (UTC)

Your account will be renamed
Hello,

The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

Unfortunately, your account clashes with another account also called Calvin. To make sure that both of you can use all Wikimedia projects in future, we have reserved the name Calvin~enwikibooks that only you will have. If you like it, you don't have to do anything. If you do not like it, you can pick out a different name.

Your account will still work as before, and you will be credited for all your edits made so far, but you will have to use the new account name when you log in.

Sorry for the inconvenience.

Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:01, 17 March 2015 (UTC)

Renamed
 This account has been renamed as part of single-user login finalisation. If you own this account you can |log in using your previous username and password for more information. If you do not like this account's new name, you can choose your own using this form after logging in: . -- Keegan (WMF) (talk) 04:45, 19 April 2015 (UTC)

title: User talk:Calvin~enwikibooks


text:
Cookbook talk:Barbecue Sauce (Kansas City-style)

User:Reubenbarton, why'd you nix all the sweeteners? Kellen 18:29, 22 Jun 2005 (UTC)


text:
User talk:83.43.216.165

Noe registered as djdoyle

title: User talk:83.43.216.165


text:
JavaScript/Debugging

Firebug

 * Firebug is a powerful extension for Firefox that has many development and debugging tools including JavaScript debugger and profiler.

Venkman JavaScript Debugger

 * Venkman JavaScript Debugger (for Mozilla based browsers such as Netscape 7.x, Firefox/Phoenix/Firebird and Mozilla Suite 1.x)
 * Introduction to Venkman
 * Using Breakpoints in Venkman

Internet Explorer debugging

 * Microsoft Script Debugger (for Internet Explorer) The script debugger is from the Windows 98 and NT era. It has been succeeded by the Developer Toolbar
 * Internet Explorer Developer Toolbar
 * Microsofts Visual Web Developer Express is Microsofts free version of the Visual Studio IDE. It comes with a JS debugger. For a quick summary of its capabilities see
 * Internet Explorer 8 has a firebug-like Web development tool by default (no add-on) which can be accessed by pressing F12. The Web development tool also provides the ability to switch between the IE8 and IE7 rendering engines.

Safari debugging
Safari includes a powerful set of tools that make it easy to debug, tweak, and optimize a website for peak performance and compatibility. To access them, turn on the Develop menu in Safari preferences. These include Web Inspector, Error Console, disabling functions, and other developer features. The Web Inspector gives you quick and easy access to the richest set of development tools ever included in a browser. From viewing the structure of a page to debugging JavaScript to optimizing performance, the Web Inspector presents its tools in a clean window designed to make developing web applications more efficient. To activate it, choose Show Web Inspector from the Develop menu. The Scripts pane features the powerful JavaScript Debugger in Safari. To use it, choose the Scripts pane in the Web Inspector and click Enable Debugging. The debugger cycles through your page’s JavaScript, stopping when it encounters exceptions or erroneous syntax. The Scripts pane also lets you pause the JavaScript, set breakpoints, and evaluate local variables.

JTF: JavaScript Unit Testing Farm

 * JTF is a collaborative website that enables you to create test cases that will be tested by all browsers. It's the best way to do TDD and to be sure that your code will work well on all browsers.

jsUnit

 * jsUnit

built-in debugging tools
Some people prefer to send debugging messages to a "debugging console" rather than use the alert function. Following is a brief list of popular browsers and how to access their respective consoles/debugging tools.

 * Firefox: Ctrl+Shift+K opens an error console.
 * Opera (9.5+): Tools >> Advanced >> Developer Tools opens Dragonfly.
 * Chrome: Ctrl+Shift+J opens chrome's "Developer Tools" window, focused on the "console" tab.
 * Internet Explorer: F12 opens a firebug-like Web development tool that has various features including the ability to switch between the IE8 and IE7 rendering engines.
 * Safari: Cmd+Alt+C opens the WebKit inspector for Safari.

Common Mistakes

 * Carefully read your code for typos.
 * Be sure that every "(" is closed by a ")" and every "{" is closed by a "}".
 * Trailing commas in Array and Object declarations will throw an error in Microsoft Internet Explorer but not in Gecko-based browsers such as Firefox.
 * Remember that JavaScript is case sensitive. Look for case related errors.
 * Don't use Reserved Words as variable names, function names or loop labels.
 * Escape quotes in strings with a "\" or the JavaScript interpreter will think a new string is being started, i.e:
 * alert('He's eating food'); should be
 * alert('He\' s eating food'); or
 * alert(" He's eating food" );</tt>

 * When converting strings to numbers using the parseInt function, remember that "08" and "09" (e.g. in datetimes) indicate an octal number, because of the prefix zero. Using parseInt using a radix of 10 prevents wrong conversion. <tt>var n = parseInt('09',10);</tt>
 * Remember that JavaScript is platform independent, but is not browser independent. Because there are no properly enforced standards, there are functions, properties and even objects that may be available in one browser, but not available in another, e.g. Mozilla / Gecko Arrays have an indexOf function; Microsoft Internet Explorer does not.

Debugging Methods
Debugging in JavaScript doesn't differ very much from debugging in most other programming languages. See the article at Computer Programming Principles/Maintaining/Debugging.

Following Variables as a Script is Running
The most basic way to inspect variables while running is a simple alert call. However some development environments allow you to step through your code, inspecting variables as you go. These kind of environments may allow you to change variables while the program is paused.

Browser Bugs
Sometimes the browser is buggy, not your script. This means you must find a workaround.

Browser bug reports

browser-dependent code
Some advanced features of JavaScript don't work in some browsers.

Too often our first reaction is: Detect which browser the user is using, then do something the cool way if the user's browser is one of the ones that support it. Otherwise skip it.

Instead of using a "browser detect", a much better approach is to write "object detection" JavaScript to detect if the user's browser supports the particular object (method, array or property) we want to use.

To find out if a method, property, or other object exists, and run code if it does, we write code like this:

title: JavaScript/Debugging


text:
Cookbook talk:Potato and Cauliflower Curry (Aloo Gobi)

Is there a reason this page's title is lowercased (rather than Aloo Gobi)? Kellen 19:02, 22 Jun 2005 (UTC)

This recipe contains ghee, aka clarified butter, which is certainly not vegan. Can the recipe be modified to use a substitute or should it be removed from the vegan cookbook entirely?

 * I previously provided a vegan variation in the "variations" section, which simply substitutes oil or melted margarine for the ghee. There's not much special about ghee. This variation was removed by Albert with the note that the substitution is obvious. I also think it's obvious, but I'm not quite sure if we should/how we should provide per-recipe variations for ingredients like ghee, or if we should expect vegans to figure it out. Kellen T 15:34, 23 November 2005 (UTC)

Personaly, I would prefer adding a link or note in the area about the possible substitutions. I am by no means a vegan, but I have a daughter with a mil allergy and I find browsing vegan cookbooks the safest place to find a good, new meal. THAT SAID I jumped onto the discussion page to make a note about ghee not being vegan only to find it was noticed. I was not aware of the substitution, although it does seem obvious. A simple link would be appropriate, I believe.

Waite 03 October, 2006


text:
Cookbook talk:Lancashire Hotpot

what's a suet crust? Kellen 20:17, 22 Jun 2005 (UTC)

 * I'll guess it is like a pie crust, using suet as the fat. The cuisine is known for keeping heart surgeons employed. AlbertCahalan 02:18, 24 September 2005 (UTC)

title: Cookbook talk:Lancashire Hotpot


text:
Cookbook talk:Garlic Lemon Chicken

"Sit all night" (instruction point 3) - can't I go to bed as usual? :) Redlentil 20:38, 22 Jun 2005 (UTC)
 * Well, at least it didn't say stand in a bucket of water all night.;) (Donovan|Geocachernemesis|Interact) 02:16, 23 Jun 2005 (UTC)

title: Cookbook talk:Garlic Lemon Chicken


text:
Radiation Oncology/Prostate/SWOG Prostate

SWOG Website

Prostate Trials Overview as of 1997