Biomedical subjects

I Barillot

Publications and source records attributed to I Barillot.

At least 19 recordsLinked to original sources

PubMed2006

[High precision radiotherapy with ultrasonic imaging guidance].

Conformal radiation therapy with or without intensity modulation is the standard treatment of localized prostate cancer and facilitates dose escalation. The implementation of three-dimensional conformal radiotherapy necessitates focusing on target volume delineation, dosimetry, reproducibility of treatment and quality control. Recently, ultrasound systems that allow direct daily visualization of the prostate have become available. This non-invasive technique can be used to correct both prostate organ motion and set-up error and leads to increase treatment accuracy.

Humans↗

PubMed2006

The use of MRI in planning radiotherapy for gynaecological tumours.

Parameters that significantly influence results in radiation treatment of gynaecological malignancies are mainly related to the tumour characteristics and the radiotherapy technique used. High-dose radiotherapy requires accurate localisation of the tumour volume and its relationship to surrounding normal tissues. For many years the standard technique used for irradiation of the pelvic area was the four-field box technique which offered the potential benefit of the lateral fields to shield the rectum and small bowel. However, this conventional technique was designed according to bony landmarks and offered limited information regarding the topography of the tumour and the flexion of the uterus which are influenced by the tumour burden and bladder and rectal filling. CT and MRI enable the visualisation of the cervix, uterus, vagina, iliac vessels and organs at risk, but MRI allows tumour depiction in all planes. In the early 1990s, several studies reported on the value of pelvic MRI in designing the lateral fields of the box technique. They demonstrated that conventional lateral portals would have resulted in a marginal tumour miss and incomplete coverage of the uterine fundus in more than 50% of cases, thus leading to the conclusion that if a box technique is used its design should be based on sagittal MRI. CT-based 3D planning systems are now routinely used in the vast majority of radiotherapy departments. Target volumes and organs at risk are delineated by the physician on each CT slice in order to conform the radiotherapy fields to the tumour volume. For several reasons, such as distortion and lack of electron density which is essential for dose calculation, the implementation of MRI into radiation treatment planning has its limitations. However, MRI can still be used if planning systems integrate tools for CT/MR image registration. There is little experience in the literature for gynaecological malignancies demonstrating that image fusion allows an improvement of the definition of the target and the organ at risk compared to CT alone. Only a few papers in the literature report on the use of CT/MR image registration in planning the external irradiation of gynaecological tumours. Most demonstrate feasibility, but they fail to quantify the improvement for volume definition compared to the use of CT alone. Finally, recent possibilities offered by MRI technology are promising in the area of brachytherapy planning as the full potential of individually defining and evaluating GTV and CTV based on tumour extent and anatomical structures is exploited.

Female↗

PubMed2004

[To boost the tumor bed: the age of reason].

It is well known that the conservative reference treatment of infiltrative carcinoma of the breast, after en bloc complete excision, should be completed by irradiation of the whole breast delivering 50 Gy in 25 fractions. The discussion related to the validity and the procedures of delivery of the boost of the tumor bed has to be adjusted with our knowledge of specific prognostic factors of local recurrence. Through the two phase III randomized trials published in the literature, the young age of the patient, palpable tumor and negative receptor to progesterone may be recognized as statistically linked to a higher risk of local recurrence. Tumor size and palpable tumor remain unquestionable factors of bad prognosis. The true level of significativeness of age remains controversial as well as peri-tumoral characteristics such as ductal carcinoma in situ. Treatment technique should be rigorous either in terms of prescription of external radiation therapy or for the boost. They have a major impact on the cosmetic result and the fibrosis rate. Improvement of the results is expected through careful analysis of genic and molecularly prognostic factors of the tumor in order to select patients amenable to this type of technique.

Adult↗

PubMed2004

[Ductal in situ carcinoma: is it ethical to consider the breast conserving therapy as a standard?].

The increasing incidence of DCIS during the past 20 years needs a continuous evaluation of the treatment strategies and a multidisciplinary decision process. The management of the DCIS remains a challenging issue in 2003. Mastectomy should still be considered as the reference treatment which is able to guarantee cure in almost all cases, whereas breast conserving surgery followed by radiation therapy is associated with 7-10% of local recurrence. However, the increasing knowledge of the predictive factors of the local recurrence allows to propose a conservative treatment strategy to a large amount of patients, without negative impact on their prognosis. This review presents the arguments that permit to justify the reasoned choice of the different therapeutic options according to the clinico-pathological situations.

Adult↗

PubMed2004

[Critical organs and external irradiation in gynaecological cancers: can water be used as contrast agent to make easier the delineation of the small intestine?].

PURPOSE: To validate the use of water as contrast agent for the delineation of the small intestine on the planning CT of external beam in patients treated with conformal radiotherapy for gynaecological tumours. PATIENTS AND METHODS: From March to September 2003, 20 patients received an external irradiation for a gynaecological carcinoma (13 with cervix carcinoma, seven with endometrial carcinoma) in the radiotherapy department of the Centre G.F. Leclerc of Dijon. The protocol of opacification of the small intestine consisted in administration of a "negative" contrast agent: water. The protocol commonly used for the bladder filling, i.e. absorption of 500 cm(3) of water from 60 to 30 min before the CT-scan, was applied for the evaluation of the visualisation of the small intestine in the 12 first patients (group I). For the last eight patients (group II), the absorption of the same amount of water was fractionated, every 10 min within half an hour before the start of the examination. RESULTS: The small bowel identification was possible in 100% of cases without any need of administration of a "positive" contrast agent. In overall, the identification of the small intestine was considered as easy in 14 patients (70%) and as difficult in two patients (10%). In group I, the delineation was considered as easy in 50% of cases, moderately easy in 33% of cases and none easy in 17% of cases. Conversely, no difficulty was encountered for the definition of the small bowel in all patients of group II. CONCLUSIONS: Water is an efficient "negative" contrast agent for the differentiation of the small bowel from the colon on the planning abdomino-pelvic CT. Nevertheless, the delineation was really made easier only when the fractionated protocol of water absorption within half an hour before CT was used.

Adult↗

PubMed2004

[Constraints to organs at risk for treatment of head and neck cancers by intensity modulated radiation therapy].

Constraint definitions in intensity modulated radiation therapy is a key point factor during the treatment planning process. In literature some data are available about dose constraints and volumes according to the tissue architectures. Following ICRU recommendations, organs at risk organized in a parallel structure could receive an acceptably small proportion of high dose component. Mean dose and dose volume histogram is a most convenient tool for incorporating such constraints. Organs described as a serial structure are supposed to receive less than the given maximum dose, directly linked to the occurrence of complications. Dmax is the best way to describe such events. These constraints are new tools in radiation therapy, available for optimizing the dose distribution in target volume, sparing the organs at risk to protect the organ function or at least decreasing the late functional damages like xerostomia. It is necessary to define with accuracy gross target volumes and clinical target volume with available radio-anatomical guidelines before introducing current constraints on each volume in the inverse dosimetry. The management of these constraints remains under the responsibility of the clinicians. A permanent compromise has to be chosen between homogeneity of the dose distribution in the target volume and the probability of preserving functions of organs at risk.

Brain Stem↗

PubMed2004

Conservative treatment of early glottic carcinomas with exclusive radiotherapy.

BACKGROUND: Early glottic carcinomas can be treated with radiotherapy or surgery with similar local control rates but with better functional results with radiotherapy. The aim of this study was to analyze the results of our experience of exclusive radiotherapy. PATIENTS AND METHODS: From 1975 to 2001, 155 patients with Tis, T1 and T2 glottic carcinomas were treated with exclusive radiotherapy. Prognostic factors of survival, local control and larynx-preservation rates were analyzed in uni and multivariate analyses. RESULTS: Median prescribed dose was 65 Gy in 44 days. Overall survival was 75% for the whole group, 75% for Tis, 85% for T1a, 72% for T1b, 59% for T2. Specific survival was 88% for the whole group, 75% for Tis, 94% for T1a, 90% for T1b, 69% for T2. Disease-free survival was 68% for the whole group, 75% for Tis, 77% for T1a, 51% for T1b, 58% for T2. Laryngeal preservation rate was 85% (133/155). Twenty-nine (29/155, 18%) patients developed a local relapse within 31 months. Out of the 10/86 (12%) T1a-Tis relapses, 7/10 patients underwent total laryngectomy and 79/86 larynx were preserved (92%). Out of the 8/22 (36%) T1b relapses, 4/8 patients underwent total laryngectomy. Out of the 11/47 (23%) T2 relapses, 8/11 patients underwent total laryngectomy. Increased overall treatment time, tumor stage, sub-glottis extension were associated with poorer local control. Second malignancies remain a major problem in the outcome of this population. CONCLUSION: Radiotherapy remains an efficient option in the treatment of early glottic carcinomas providing a high local control rate with excellent functional results in laryngectomy-free patients. This strategy should be discussed according to the tumor stage, feasibility of conservative surgery and patient's preferences.

Adult↗

PubMed2003

[Quality control during radiation therapy].

The aim of quality control procedures during radiation therapy is to check the consistency between actual and prescribed treatments. Given the technical complexity of modern radiotherapy, stricter policies are necessary to meet increasing requirements for quality and safety. Among the various tools available, electronic imaging systems play an increasing role in patient-beam position checking and in vivo dose measurements. Written procedures will have to be established in order to describe the control modalities and frequency, as well as the rules for error corrections according to the treatment intent. Non medical staff will be devoted to new tasks, under the radiation oncologist's responsibility. A special attention should be directed at electronic archives, since the present technology is unlikely to meet the legal requirement to keep medical records accessible for at least 30 years.

Diagnostic Imaging↗

PubMed2003

Intramural neovascularization and haemorrhages are major long-term effects of intravascular gamma-radiation after stenting.

Structural changes that might influence the structural integrity of the vessel in response to intravascular brachytherapy (IVB) and stenting were examined, focus being on the importance of neovascularization in rabbit stented arteries. Stents were implanted in the infrarenal aortas of rabbits, immediately followed by gamma IVB or a sham radiation procedure, and the arteries harvested at 6 months. Labelling for von Willebrand factor showed an increase in adventitial and medial neovascularization in irradiated versus control arteries group (5.04+/-0.89 versus 1.51+/-0.23 mm(-2), respectively; p=0.004). Moreover, intramedial haemorrhages (free hemosiderin deposition) and inflammation (macrophages) were only observed in irradiated arteries. No significant change in expression of matrix metalloproteinase 1, 2 or 3 was observed between the irradiated and control group while collagen content decreased in the irradiated versus the control group (10.05%+/-1.48% versus 31.92%+/-3.12%, respectively; p<0.001). The study supports the hypothesis that IVB associated with stenting induces late deleterious effects on the medial layer, characterized by formation of intramural neovessels, haemorrhages and a decrease in collagen content.

Animals↗

PubMed2003

[Endometrial carcinoma: which radiotherapy for which patient?].

The endometrial carcinoma is the third most common cancer in women. The endometrioid adenocarcinomas represent 75% to 80% of the pathologic sub-types, and 90% of the lesions are stages I or II at diagnosis. The treatment strategies are based upon surgery and radiotherapy, but the respective place of external irradiation and vaginal cuff brachytherapy is not strictly established. The role of the pelvic lymphadenectomy and the role of chemotherapy for aggressive histologies or locally advanced diseases remain also controversial issues. The question "which radiotherapy for which patient?" is still a current question, however, the answers we will bring do not permit yet to remove all uncertainties.

Age Factors↗

PubMed2001

Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation.

BACKGROUND: Radiotherapy prevents local recurrence of breast cancer after breast-conserving surgery. We evaluated the effect of a supplementary dose of radiation to the tumor bed on the rates of local recurrence among patients who received radiotherapy after breast-conserving surgery for early breast cancer. METHODS: After lumpectomy and axillary dissection, patients with stage I or II breast cancer received 50 Gy of radiation to the whole breast in 2-Gy fractions over a five-week period. Patients with a microscopically complete excision were randomly assigned to receive either no further local treatment (2657 patients) or an additional localized dose of 16 Gy, usually given in eight fractions by means of an external electron beam (2661 patients). RESULTS: During a median follow-up period of 5.1 years, local recurrences were observed in 182 of the 2657 patients in the standard-treatment group and 109 of the 2661 patients in the additional-radiation group. The five-year actuarial rates of local recurrence were 7.3 percent (95 percent confidence interval, 6.8 to 7.6 percent) and 4.3 percent (95 percent confidence interval, 3.8 to 4.7 percent), respectively (P<0.001), yielding a hazard ratio for local recurrence of 0.59 (99 percent confidence interval, 0.43 to 0.81) associated with an additional dose. Patients 40 years old or younger benefited most; at five years, their rate of local recurrence was 19.5 percent with standard treatment and 10.2 percent with additional radiation (hazard ratio, 0.46 [99 percent confidence interval, 0.23 to 0.89]; P=0.002). At five years in the age group 41 to 50 years old, no differences were found in rates of metastasis or overall survival (which were 87 and 91 percent, respectively). CONCLUSIONS: In patients with early breast cancer who undergo breast-conserving surgery and receive 50 Gy of radiation to the whole breast, an additional dose of 16 Gy of radiation to the tumor bed reduces the risk of local recurrence, especially in patients younger than 50 years of age.

Adult↗

PubMed2001

[Gross tumor volume and clinical target volume in radiotherapy: tumors of the corpus uteri].

Surgery is the major treatment of the tumours of the corpus uteri. The imaging workup is essentially used to detect locally advanced lesions which are not suitable for surgery, because the preoperative knowledge of prognostic factors seldom influences treatment strategy in the early stages. The 3D planning of external irradiation for corpus uteri tumours is not very widespread, despite its real impact in preoperative irradiation strategy or irradiation alone. In postoperative strategy its importance is less evident; however, CT planning leads to a better knowledge of the dose distribution to the critical organs, which will probably contribute to a better control of late complications.

Female↗

PubMed2001

[Radiotherapy for tumors of the uterine cervix. Gross tumor volume and clinical target volume].

Treatment of carcinoma of the uterine cervix needs a multidisciplinary approach. External irradiation and brachytherapy are highly curative because of the tumor radiosensitivity. The main prognostic factors are tumoral volume and nodal involvement. Tumoral extent is evaluated by diagnostic MR imaging, and gynecological exam. Nodal involvement can be assessed, accurately by coelioscopic pelvic node sampling and by imaging modalities such as CT scan. The knowledge of these two factors helps to choose the treatment strategy. The use of imaging (MRI and CT) added to clinical findings allows to design external irradiation fields. 3D treatment planning in external irradiation and brachytherapy is based upon the use of imaging (CT and MRI). It leads to a better knowledge of dose distribution to the target and critical organs and allows more individualized and conformal treatment.

Brachytherapy↗

PubMed2001

Long-term prognostic value of 201Tl single-photon emission computed tomographic myocardial perfusion imaging after coronary stenting.

BACKGROUND: The prognostic value of (201)Tl myocardial imaging has been demonstrated in several studies concerning patients with a known significant coronary artery disease. However, the evolution of a coronary stenosis after stenting is difficult to predict. This study was designed to assess the prognostic value of (201)Tl single-photon emission computed tomography (thallium SPECT) perfusion imaging in patients after intracoronary stenting. METHODS: One hundred fifty-two patients were studied. They were followed up during 40 +/- 13 (mean +/- SD) months after thallium SPECT. Stent-related events were studied after thallium stress testing and included cardiovascular death, myocardial infarction, and revascularization. Stress thallium imaging was performed 5 +/- 2 months after stenting, and ischemia was considered to be present if at least 2 contiguous segments were showing reversible defects. RESULTS: Only 3 (3%) among the 105 nonischemic patients had major cardiac events during the follow-up versus 13 (28%) of the 47 ischemic patients (P < .001) after thallium SPECT. The relative risk of major cardiac events for patients with significant ischemia was 10.5 compared with nonischemic patients (P < .001). Fourteen (30%) of the ischemic patients and 8 (8%) among the nonischemic patients underwent iterative revascularization (P < .001). Therefore, only 11 (10%) of the nonischemic patients had major cardiac events or revascularization compared with 24 (51%) of the ischemic patients (P < .001). CONCLUSIONS: Absence of ischemia on thallium SPECT imaging at 5 months after coronary stenting indicates a low risk for cardiovascular events or interventional procedure. These results may have important clinical implications in patient treatment.

Angioplasty, Balloon, Coronary↗

PubMed2001

[Secondary effects of brachytherapy in the treatment of coronary restenosis].

Brachytherapy is proposed for the treatment or prevention of coronary restenosis with encouraging results, especially in intra-stent restenosis. The results of the first clinical studies show benefit, for example those of the American SCRIPPS trial with a 3 year follow-up. However, recent reports in the literature have described secondary effects associated with this technique: 1) stenoses occurring at the limits of the irradiated segments which are attributed to a proliferative effect of low doses on damaged tissue; 2) late occlusions at the irradiated site: their incidence is estimated at 9% at 6 months. The mechanisms of these thromboses are not understood but delayed re-endothelialisation probably plays a rôle; 3) finally, irradiation is associated with uncovered dissection probably related to delayed healing. Other long-term trials are necessary to provide a more complete assessment of the secondary effects of brachytherapy, especially with regards to their mechanisms, prevention and treatment.

Angioplasty↗

PubMed2000

Impact on treatment outcome and late effects of customized treatment planning in cervix carcinomas: baseline results to compare new strategies.

PURPOSE: The aim of the study was to determine the predictive factors of complications, to evaluate the impact of customized treatment planning on late normal tissue effects per stage, and to report disease-free survival (DFS) and local control (LC) rates. METHODS AND MATERIALS: From 1970 to 1994, 642 patients were treated with radiotherapy alone for carcinoma of the intact uterine cervix. According to the International Federation of Gynecology and Obstetrics (FIGO) substaging, 34% were Stage I, 39% Stage II, and 27% Stage III. The analysis was divided into three periods: 1970-1978 (use of standard prescriptions),1979-1984 (implementation of individual adjustments), 1985-1994 (systematic individual adjustments). Five-year DFS, LC, and complications rates were calculated using the Kaplan-Meier method. Predictive factors of complications were determined by univariate analysis using frequency tables and nonparametric t-tests. Multivariate analysis consisted of a polychotomous stepwise regression. RESULTS: The comparison of the three time periods showed a significant reduction of the external radiation dose (dose above 40 Gy in 47% of patients before 1979 vs. 36% after 1984), of the use of parametrial boost (55% vs. 39%), of the use of vaginal cylinder (28% vs. 11.5%), and of the HWT volume (combined intracavitary and external irradiation) (842 cc vs. 503 cc on average). The total sequelae/complications rate, all toxicity grades, all stages, all organs was 51%. Five-year actuarial rate per toxicity grade was: G1, 42%; G2, 23.5%; G3, 10%; G4, 3%. The three main predictive factors for rectal and bladder sequelae/complications (all toxicity grades) taking into account time period were: the increase of external radiation dose, the high dose rate at reference points, and the whole vagina brachytherapy. No G4 occurred in the third period. The rate of G3 complications dropped from 16% to 6% over time: from 5% during the first period to 0% during the third period in Stage I, from 8% to 6% in Stage II, and from 23% to 12% in Stage III. G3 currently describes a variety of clinical situations with a different impact on quality of life which justifies further refinements of definitions of late effects. In our experience the severity of G3 markedly decreased: less than one-third of G3 had a real impact on quality of life in the last period compared to more than two-thirds in the first period. Meanwhile, 5-year LC rates remained stable in Stages I and II, 91% and 85% respectively. Conversely they fell from 75% to 55% in Stage III, thus raising the problem of underdosage and/or more accurate staging with time. CONCLUSIONS: Customized treatment planning eradicated lethal complications and provided a significant decrease of G3 in all stages while maintaining high cure rates in early stages. Dose reduction should be considered with caution in Stage III.

Actuarial Analysis↗

PubMed2000

High dose rate brachytherapy for superficial cancer of the esophagus.

PURPOSE: We analyzed our experience with external radiotherapy, combined modality treatment, or HDR brachytherapy alone to limited esophageal cancers. METHODS AND MATERIALS: From 1991 to 1996, 25 patients with limited superficial esophagus carcinomas were treated by high dose rate brachytherapy. The mean age was 63 years (43-86 years). Five patients showed superficial local recurrence after external radiotherapy. Eleven patients without invasion of the basal membrane were staged as Tis. Fourteen patients with tumors involving the submucosa without spreading to the muscle were staged as T1. Treatment consisted of HDR brachytherapy alone in 13 patients, external radiotherapy and brachytherapy in 8 cases, and concomitant chemo- and radiotherapy in 4 cases. External beam radiation was administered to a total dose of 50 Gy using 2 Gy daily fractions in 5 weeks. In cases of HDR brachytherapy alone (13 patients), 6 applications were performed once a week. RESULTS: The mean follow-up is 31 months (range 24-96 months). Twelve patients received 2 applications and 13 patients received 6 applications. Twelve patients experienced a failure (48%), 11/12 located in the esophagus, all of them in the treated volume. One patient presented an isolated distant metastasis. In the patients treated for superficial recurrence, 4/5 were locally controlled (80%) by brachytherapy alone. After brachytherapy alone, 8/13 patients were controlled (61%). The mean disease-free survival is 14 months (1-36 months). Overall survival is 76% at 1 year, 37% at 2 years, and 14% at 3 years. Overall survival for Tis patients is 24% vs. 20% for T1 (p = 0.83). Overall survival for patients treated by HDR brachytherapy alone is 43%. One patient presented with a fistula with local failure after external radiotherapy and brachytherapy. Four stenosis were registered, two were diagnosed on barium swallowing without symptoms, and two required dilatations. CONCLUSION: High dose rate brachytherapy permits the treating of patients with superficial esophageal cancer with good tolerance. Early tumors, located in the mucosa, might be treated by HDR brachytherapy alone or by a combined modality treatment in which HDR brachytherapy can take place like a boost. This approach may cure localized recurrences.

Adenocarcinoma↗

PubMed2000

Radiotherapy of advanced mycosis fungoides: indications and results of total skin electron beam and photon beam irradiation.

BACKGROUND: The goals of this retrospective study of advanced mycosis fungoides are (1) to describe the indications of a combination of total skin electron beam and photon beam irradiation and (2) to analyze the results of total body or segmental photon irradiation for patients with extension beyond the skin. METHODS: From January 1975 to December 1995, 45 patients with pathologically-confirmed mycosis fungoides or Sézary syndrome received a combination of TSEB and photon beam irradiation for advanced disease: 34 males and 11 females, mean age 61 years (range 27-87 years). The mean follow-up was 111 months (range 18-244 months, median 85 months). Whole-skin irradiation treatment to a depth of 3-5 mm with a 6-MeV electron beam was produced by a linear accelerator to a total dose of 24-30 Gy in 8-15 fractions, 3-4 times a week. In cases of thick plaques or tumors that were beyond the scope of low energy electron beams or for treating nodal areas (especially in the head and neck area or axilla involvement), regional irradiation (RRT) with Co-60 photon beams was followed by whole-skin electron beam irradiation (15 patients). In cases of diffuse erythrodermia, Sézary syndrome, nodal or visceral involvement, total body irradiation was delivered with a 25-MV photon beam using a split-course regimen to prevent hematological toxicity (22 patients). The first course consisted of 1.25 Gy delivered in ten fractions and 10 days. Subsequently, patients received TSEB. Four to 6 weeks after TSEB, they received a second course of 1.25 Gy. The cumulative TBI dose ranged from 2.5 to 3 Gy in about 3 months. Hemi-body irradiation (HB) with Co-60 (and a bolus) was given in cases of multiple regional tumors with large and thick infiltration of the skin to a dose of 9-12 Gy (using fractions of 1-1.5 Gy/day) which, once flattened, were boosted with whole-skin electron beam therapy (8 patients). RESULTS: At 3 months, the overall response rate was 75% with 23/45 (51%) patients in complete response and 24% in partial response; one patient had stable lesions and 1 patient presented progressive disease. The overall response rate was 81% for T3 patients, 61% for T4, 79% for N1 and 70% for N3. The complete response rate was 67% for T3 and 28% for T4. Sixty-four percent of N1 patients and 41% of N3 had a complete response. The 5-year actuarial overall survival was 37% for T3 and 44% for T4 (P = 0.84). Patients with clinically abnormal lymph nodes that were pathologically negative (N1) presented a 5-year survival of 63%. Patients with pathologically positive lymph nodes (N3) experienced a 5-year survival rate of 32% (P = 0.040). CONCLUSIONS: TSEB provides an excellent quality of life by reducing itching and discharge from the skin. Patients with more advanced disease may be treated and cured by the addition of photon beams in combination with TSEB. A selection of patients with advanced skin disease and regional extension may be cured by a combination of TSEB and photon beam irradiation. The regional treatment allows the use of electrons after the reduction of the plaques or thick tumors and a prophylactic irradiation of the adjacent nodal area.

Adult↗