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Volum 05 Numarul 4, 1999

272 Editorial

The forth issue of our journal for this end of century signifies certain reference moments for our members and we hope to be a good omen for what we should do in the future. The published papers could be grouped in three areas of interest: the 70th jubilee of I. Chiricuţă Cancer Institute, the annual SRRO Conference and aspects from our oncological life with a special mention for the activity of the journal.

The foundation of the Cancer Institute Cluj 70 years ago was celebrated just before the beginning of the process of the reform of our obsolete health system, which implies many changes, and especially of mentalities. The physician should more and more involved in administration and the management of resources, which inevitably are and will be scarce. The optimization of the cancer care is a topic of great actuality for all the countries over the world and no matter who will be the sponsor – individual or society as a whole, the expenses are high and should be justified by the quality of medical procedures. In this context, the theme of the jubilee symposium, The Management of the Cancer Patient, was of real importance and in the journal are published some of the lectures presented. N. Ghilezan presents the activities organized in the Cancer Institute Cluj to foster a managerial and educational system, to train the professionals for solving the problems, which the Institute will be facing in the future. We are not alone in our efforts and the article signed by professor M. Monconduit, director of Anticancer Center H. Becquerel (Rouen) discloses us the same worries and the French experience which could be taken as a model. Ajoint venture between Lehigh University, Bethlehem PA (USA) and Cancer Institute Cluj-Napoca familiarize us with the American way of evaluation and reimbursement procedures, system that will be tested in our activities.

A useful material for a good functioning of any cancer unit, signed by Viorica Nagy and N. Ghilezan comments on the Professional Objectives of Cancer Committees. The practice of modem oncology cannot be understood outside a multiprofessional environment that has to assure the quality of therapeutic decision but also the treatment itself in permanent confrontation with clinical results. In the paper From Radiotherapy I / Mastology Department to a Breast Tumor Center, Cristina Vitoc describes the conditions that led to the organization of a specialized service for the diagnosis and treatment of breast tumors. The great number of patients, the complexity of diagnostic investigations and work up but especially the therapeutic problems, justify the existence of such a specialized structure in each cancer center. The Breast Tumor Center is an example of the flexibility that should characterize the cancer services, to be always adapted to the needs of the population. In the same trend is also the paper Quality of Life: a New Dimension and Challenge for the Cancer Patients and the Care Team (Dana Cernea) which close the section The Management of the Cancer Patient by underlining the quality of life concept, a more discussed topic but much more neglected.

The annual conference of Romanian Society for Radiation Oncology that was held in October in Arad, with the generous support of the V Goldis University, is largely presented in the journal. The conference was attended by a great number of members and covered all the aspects of head & neck cancers: epidemiology, risk factors, surgery, radiobiol- ogy, radiotherapy and chemotherapy. It is worth to mention the results presented by the staff of the Cancer Institute Cluj for hyperfractionation in larynx cancer (V. Cernea), radiochemotherapy for nasopharynx cancer (Elena Ciuleanu) as well the review on the clinical trials in progress (E. Banu) as an invitation for an active participation in ftudies organized by SRRO.

The last section is an overview of the Oncological Life in Romania informing on the General assembly of SRRO 1999, the activity of the National Commission on Cancer in the forth trimester and the project for the National Plan for Oncology for 2000. Two other events of the Romanian oncological community are presented: the 1 st Congress of Surgical Oncology from 23-25 September and the National Conference of Oncology from 14-16 October.

A special mention deserves the support group „Common Destinies”, that was born and lives through the commitment of Mrs. Stela Hanusz The encounter with these ladies who, close together, are looking for answers to their existential questions, is impressive and we express all our respect for the dignity they have, to adapt to their destiny. A wonderful experience that should be shared in so many places across the country as possible!

Not in the last, we mention the opinions on our journal, from our members but also from outsiders and we content to stress that this is the first year in which all the issues have been in time due to the special contribution of the editorial staff, Mrs. Maria Retegan Turdeanu, Chief Editor and Mrs. Maria Bugnariu, Technical Editor. The answers to a question- naire for our readers are analyzed by Mrs. Turdeanu: there are many favorable opinions which we let you to appreciate yourself but also unfullfilments among which the most sorrowful is the passivity of a great majority of our members, a topic to pond over. Eventually we enjoy the quotation granted to our journal by the Library of the University 1. Hatieganu Cluj, throu the very authorized opinion of Mrs. Joana Robu, a stimulus for further performances in the quality of publications and number of collaborators.

We hope that you also will appreciate this issue and we wish to all SRRO members and our readers, to step trustfully in the next century and let it to give us the satisfaction for professional fulfillment and the joys of eve,ry day.

  1. Ghilezan

274 Problems & Progress in the Management of Cancer Patient in the Cancer Institute „I. Chiricuţă” Cluj-Napoca/România

  1. Ghilezan

Cancer Institute „Prof Ion Chiricuţă” Cluj-Napoca

U.M. Ph. „I. Haţieganu” Cluj-Napoca

The analysis of the 1997-1998 period points out to the need for a long-tenn policy to meet the future expectations of the patients and the financial constraints of the health refonn. To further improve the professional & scientific development of the Institute, several Education & Organizational Changes have been design and implemented. Continuing Monitoring & Evaluation actions are mandatory to be carried out in order to assure the fulfillment of European quality standard criteria and to strengthen the leading role of the Institute in the years to tome.

Key words: health reform, education, organization, evaluation.

Radioterapie & Oncologie Medicală, 1999, 4:274-279

280 Organisation of Cancer Control in France. The Role of the Cancer Centres

  1. Monconduit

284 The Evaluation of Inpatient Medical Services and Procedures at the ,,I. Chiricuţă” Cancer Institute

  1. Spottheim, G.R. Wilson

288 The Role of Cancer Committees for the Progress in the Management of Cancer Patients

Viorica Nagy, N. Ghilezan .

292 From Radiotherapy/ Mastology Department to a Breast Tumor Center

Cristina Vitoc

Cancer Institute „Prof I. Chiricuţă” Cluj-Napoca

The main topic of this article is to review the most important periods of the breast cancer care within our Institute. It is chronologically structured as it refers to the evolution of the natural history conceptions, to the therapeutical behaviors and to the available facilities, but also to the remarkable personalities involved in this medical field. The academic and educational activity, the organization of the breast cancer Biennial Oncology Symposium Oradea Felix Spa, the support of the professional Romanian Society of Oncological Radiotherapy and its journal ,. Radiotherapy & Medical Oncology”, are more than the acquirements of the last few years, they are the premises for the future goals of our Institute. As a concluding remark the article presents why there is the need to transform the Radiotherapy II Senology Department into the Breast Tumor Center.

Key words: Radiotherapy Department, Breast Tumor Center, history, present, future of breast cancer management. Radioterapie & Oncologie Medicală, 1999, 4:292-297

298 Quality of Life, a New Dimension and Challenge for the Cancer Patients and the Care Team

Dana Cernea

Cancer Institute „Prof I. Chiricuţă”, Cluj-Napoca

Quality of life is a multidimensional item which illuminates the psycho social problems that face all cancer patients before, during and after therapy. There are specific management objectives and outcomes for patients with different solid tumours, and also specific criteria to provide a measurable index of patient’s self- esteem, perception of health, and satisfaction with life.

Key words: quality of life, evaluation, gynaecologic cancer, prostate cancer, colorectal cancer

Radioterapie & Oncologie Medicală, 1999, 4:298-300

301 Head & Neck Cancers: Challenges and Perspectives

  1. Ghilezan

UMPh „Iuliu Haţieganu” Cluj-Napoca

Cancer Institute „Prof I. Chiricuţă” Cluj-Napoca

The goals of therapeutic studies for Head & Neck Squamous Cell Carcinomas (HNSCC) in the last decade have been the improvement of local control and survival, larynx preservation and diminishing the risk for distant metastases and of second primary tumors (SPT). The main research areas are the combinations of chemotherapy with radiation, modified fractionation and chemoprevention. The modalities of association of chemotherapy with irradiation are very diverse concerning drugs, timing of administration or specific objective. Generally, the HNSCC respond favorably to chemotherapy but the benefit is not high and needs large groups of patients to be demonstrated or to use modern statistical methods for evaluation as metaanalysis. These studies have shown a statistical significant benefit, of 8% but only for concurrent radio-chemotherapy and not for all other combinations. The neoadjuvant chemotherapy permits the preservation of the larynx for a selected group of patients and remains a high priority for medical oncologists and radiotherapists as well. The nasopharynx cancer has the best response to chemotherapy, in neo- or adjuvant setting, but yet, there is no consensus about the best modality.

Hyperfractionation or accelerated fractionation, in various variants, produced substantial improvements of the local control and survival comparing with the standard regimens. The acute reactions, of lesser importance for hyperfractionation, are severe for accelerated fractionation and limit their practical use. An acceptable solution, especially for our conditions could be the concomitant boost.

In improving the survival of HNSCC patients a new trend becomes evident: the chemoprevention of SPT by using


The future perspectives for HNSCC are the further developing of radio-chemotherapy combinations by introducing new molecules and more flexible fractionation regimens, to keep under control the intensity of acute and late reactions, and also to integrate the chemoprevention in the overall management of these patients.

Key words: Head & Neck Cancers, radio-chemotherapy, larynx preservation, modified fractionations, chemoprevention.

Radioterapie & Oncologie Medicală, 1999, 4:301-306

307 Head and Neck Cancers. Epidemiology & Risk Factors

Cs. Szekely1, Anna Szekely2

1 West University „Vasile Goldiş” from Arad, Faculty of Medicine

2County Clinical Hospital Arad

The H&N Cancers, a heterogeneous group oftumours with starting point in the anatomic structures of the head and neck, represent a public health problem due to the permanently increasing incidence and mortality, especially concerning the smokers and alcohol consumers. They are more frecquent in the active years life, but associated with biological deficiencies, advanced stage at presentation compliance with treatment, low response and survival.

In comparison with the multitude of risk factors, the number ofH & N cancers is much more reduced, demonstrating the importance of the personal reactivity. The isolation of biological markers of „sensitiveness” (particularities of the DNA repair, the inadequate expression of proto oncogenes or suppressor genes, etc.) represent promissing perspectives for the identification of the groups at risk and prevention.

Key words: H&N cancers, alcohol+smoking potentiation, biological markers, individual sensitive.

Radiotherapy & Medical Oncology, 1999.4:307-311

312 Principles of Surgery in Head and Neck Cancers

  1. Tomescu, D. Manu

UMPh „I. Haţieganu”, Head & Neck Clinic, Cluj-Napoca

The surgery of tumors of the head and neck includes an ever~increasing spectrum of procedures requiring increasing knowledge, sophistication, and experience of their successful application,technical execution and ultimate success. However,surgery is increasingly only one component of the multidisciplinary management of neoplasia in this region.No longer is it sufficient for the surgeon to understand the indication for, the contraindication of, and the technical aspects of the complex surgery,but he must also be able to appropriately and adequately integrate that surgery into modem,complex,multidisciplinary management. The increasing emphasis upon conservation of fonn and function to enhance quality of survival is entirely appropriate and valid. Such conservation should not be at the sacrifice of the adequacy of tumor resection.

As a result of our knowledge and experience accumulated in the last years we want to present in this work our attitude concerning the surgical treatment of head and neck cancers.

Key words: Oncological Surgery; Head and Neck cancer.

Radioterapie & Oncologie Medicală. 1999, 4:312-318

319 Radiochemotherapy in Advanced Head and Neck Cancers – a New Therapeutic Standard?

  1. Kacso, V. Cernea

U.M.Ph. „I. Haţieganu„, Cluj-Napoca

Cancer Institute „Prof I. Chiricuţă”, Cluj-Napoca

The purpose of this paper is to define the place of chemotherapy in stages III-IV of head and neck cancers, on the basis of recent metaanalyses and randomized trials comparing a local treatment (surgery and/or radiotherapy) versus the association of the same treatment to chemotherapy. Neoadjuvant chemotherapy is indicated only for T3 carcinomas of the hypopharynx or larynx. In two thirds of the patients who are locally controlled after 2-3 cycles of 5-fluorouracil and cisplatin, mutilating surgery can be avoided without jeopardizing the 5 years’ survival. In advanced locoregional carcinomas of the nasopharynx the treatment of choice is concomitant radio-chemotherapy with cisplatin followed by three adjuvant cycles of 5-fluorouracil and cisplatin. In the same setting, neoadjuvant therapy with antracyclines, cisplatin associated or not to bleomycin, followed by radiotherapy does not change overall survival compared to radiotherapy alone. Concomitant radio-chemotherapy represents standard treatment in loco regionally advanced head and neck carcinomas, improving by 8% the 5 years’ survival compared to radiotherapy alone. Excepting the previously mentioned situations, adjuvant or neoadjuvant chemotherapy is up to now useless. New dI.ugs (taxanes, gemcitabine) may change things in future.

Key words: radiotherapy, chemotherapy, carcinomas, head and neck, stage III and IV.

Radioterapie & Oncologie Medicală, 1999,4:319-330

331 Clinical Radiobiology of Head and Neck Cancers. Fractionation, Results, Trends

  1. Cernea, N. Ghilezan

339 Treatment Results in Nasopharyngeal Carcinoma

Elisabeta Ciuleanu

Cancer Institute „Prof I. Chiricuţă”, Cluj-Napoca, Dept. Radiotherapy II

The aim of this study was to compare the outcome achieved with neoadjuvant chemotherapy followed by radiotherapy to that achieved with radiotherapy alone for patients with locoregionally advanced nasopharyngeal carcinoma and compare the two chemotherapy schedule BEC vs EC.

Methods: Between 1990-1995, 232 patients with locoregionally advanced NPC entered the study. T N categories were defined according UlCC (1987) and Ho’s staging system; 72 pts. received neoadjuvant chemotherapy followed by radiotherapy and 160 pts. received radiotherapy alone. Relapse free survival, overall survival were estimated using Kaplan – Meier method. The median follow up was 72 months for the whole cohort.

Results Analysis of 232 pts. showed no significant differences in releapse free survival(RFS) or overall survival (OS) between the 2 treatment arms, CT+RT vs RTalone (5- yearRFS rate: 52% vs 46%, p=0,91; 5 -year as rate: 62% vs46%, p=O,O6.). Also when we compared the 2 chemotherapy schedules BEC vs EC, in terms ofRFS and as, there were not significant differences between the 2 treatment arms. However when we compared CT(BEC)+RT vs CT(EC)+RT vs RT alone, we found out a significant difference for as, between CT(EC)+RT vs RT alone, 69% vs46%, p=0,03.

Conclusions. The role of chemotherapy in NPC is still uncertain. It’s true that we obtained a gain in term of overall survival for neoadjuvant chemotherapy with EC+RT vs RT alone, but I would like to mention that our study is a retrospective study and a nonrandomized one.

Keywords: nasopharyngeal carcinoma, neoadjuvant chemotherapy.

Radioterapie & Oncologie Medicală. 1999, 4:339-347

348 Clinical Trials in Head and Neck Cancers

National Group of Clinical Trials in Oncology, Romanian Society of Oncological Radiotherapy

After a brief review of the most important head and neck clinical trials in Cancer Institute „Ion Chiricuta” Cluj Napoca, we discuss some basic problems concerning each trial.

Is very clear that some of these have a common part, the association of the most important treatment methods; radiochemotherapy in a concurrent or sequential manner.

The multicentric and international type of these clinical trials, put the head and neck cancers in front of present and retrospective studies in our cancer center.

Keywords: clinical trials, radio chemotherapy combination, overall survival, objective response, toxicity.

Radioterapie & Oncologie Medicală, 1999, 4:348-351