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Volum 07 Numarul 3, 2001

232 Editorial

We are glad to present in this issue of our journal, an important therapeutic progress in oncology, as a result of a joint venture between the 3rd Surgical and Medical Clinics of University I. Hţieganu and the departments Day Hospital and Radiotherapy II from the Cancer Institute I. Chiricuţă Cluj, for liver metastases. Stimulated and convinced by the enthusiastic professor Liviu Vlad, trained in the demanding field of liver surgery in the well known hospital Saint-Antoine from Paris, through a common effort we have succeed to implement this modem approach in premiere in Cluj, offering new hopes for a large group of patients. We let the pleasure to professor Vlad as Special Guest to present the results of this fine professional event but not before to mention what important role has the organ specialist in creating a multidisciplinary cancer team.

Our SRRO is continuing the publication of the guidelines for 3 more new malignancies: nasopharynx, endometrium and Hodgkin lymphoma, edited by well known specialists from Cancer Institute Cluj (Elisabeta Ciuleanu, Viorica Nagy, Alin Rancea, Cristina Cebotaru). Their publication is also an invitation for our readers to a critical lecture and we are waiting for your comments to prepare the final form.

Under the heading Clinical Case, a group from The 5th Medical Clinic Cluj, lead by D. Rădulescu, communicates a rare case of a cardiac angiosarcoma, and they outline the role of transesophageal echography in diagnosis and follow up as well the recent therapeutic progress.

Actualities in Oncology bring us information from some international important meetings that were attended by members of our Society: palliative care in the attention of Council of Europe (Marinela Murg – Oradea), highlights from ASCO 2001 (T.E. Ciuleanu) and from an advanced training course for young oncologists in KIakow (Anca Mihailov, Larisa Ciule – Cluj).

The Oncological life in Romania, is publishing the conclusions of some national meetings in which our Society was an active partner as The 4C or Community against Cervix Cancer (Satu-Mare, May 4-5), Lung Cancer (Iaşi, May 31 Mai-June 1), the 2nd Bristol-Myers Squibb Colloquium (Bucharest, June 15) and the training course on the Informatics for the cancer county units (Craiova, July 5-7). A very active Romanian oncological life and we are wishing many other successes to follow and more and stronger presence in our medical world.

  1. Ghilezan

Rond Table Unresectable Liver Tumours (Diagnostic and Therapeutic Strategies), UMPh „I. Haţieganu”, Cluj-Napoca, December 5-6, 2000

233 Editorial (liver metastases)

The liver is a common site for metastases, especially of neoplasms whose primary sites are intraabdominal. Two structural features favour metastases in the liver: the double hepatic circulation (75% of the portal vein and 25% of the hepatic artery) and the filtrating histological character of the liver tissue. Metastases formation is very frequent for digestive cancers in the drainage territory of the portal vein, but mechanisms of cellular interaction also seem to exist, favouring the lodging of the neoplastic cells in the liver. Once they are grafted on the liver, these tumours have a biological activity consisting of the secretion of proteolytic enzymes and factors that stimulate angiogenesis. An autonomous irrigation of these tumours is thus created which favours their further growth. Ischemic and intraarterial therapies are based on the predominantly arterial vascularization of these tumours.

The most frequent liver metastases are found in relation to colorecta1, breast, or lung neoplasms, as well as melanoma, pancreatic neoplasms and digestive adenocarcinoma.

Metastatic liver tumours are much more numerous than the primary ones and represent the most common malignant liver tumours. The ratio between primary and metastatic tumours is estimated to be 1 :20. The most frequent secondary liver involvement is due to colorectal cancer, 25% of the cases already have liver metastases at the time of presentation, and 50% of the metastases develop in a metachronous way [1, 2, 3].

Liver metastases of colorecta1 cancer are more widely studied because they are more frequent and imply a secondary location usually limited to the liver. They are usually asymptomatic and are discovered by examinations such as ultrasound. The detection and evaluation of colorectal cancer metastases does not require a specific test, none of the ones used having an accuracy over 65%. The CEA antigen, generally considered a relatively reliable test, does not present significant values even in the presence of extensive malignancy. Imaging techniques seem to have a higher performance, such as ultrasonography, CT and angiography. Intraoperative ultrasonography seems to be the best, with a sensitivity of 98-100%. It evidences the relation of the tumour with the vascular structures and indicates the resection approach. Intraoperative ultrasound changed the therapeutic strategy in 15-49% of the cases [4, 5]. The sensitivity of imaging examinations for the detection of liver metastases seems to be: 56-75% for CT, 65-95% for arterio-porta1 dynamic CT; 56-78% for MRI; 96% for spiral CT with arterioportography, and 80-100% for intraoperative ultrasound [6].

The therapeutic options vary and depend mainly on whether metastases formation is limited to the liver. In patients with isolated liver metastases, regional treatment seems to be the most reasonable and is preferred to the systemic one. The most frequently used therapeutic procedures for the liver metastases of the co1orecta1 cancer include: surgical tumour resection, local ablation by cryotherapy, radiofrequency, tumour alcoholization, chemoembo1ization and hepatic intra- arterial chemotherapy [7, 8, 9]. The latter are removal techniques in situ and aim at metastases that are not surgical resectable. As only about 20% of the tumours are resectable when detected, this issue contains a number of articles dealing with the diagnosis and treatment ofunresectab1e liver tumours. These problems have been discussed at the round table of 5 December 2000 and represent a start in establishing a common strategy for the multidisciplinary group for the study of the liver, which has proposed to have periodical meetings and improve the treatment of patients with primary and secondary liver tumours. The articles in this issue are concerned with the investigative and therapeutic aspect and the early experience in improving the treatment of malignant liver tumours.


  1. American Cancer Society: Cancer Facts and Figures 1995. American Cancer Society Inc., Atlanta, GA, 1995.
  2. Greenlee, RT, Murray, T, Bolden, S, Wingo, PA.: Cancer Statistics, 2000. CA Cancer J Clin 2000; 50:7.
  3. Fuhrman G, Curley S, Hohn D, et al: Improved Survival after Resection of Colorectal Liver Metastases. Ann Surg OncoI1995,2(6):537-541.
  4. Soyer P, Levesque M, Elias D, et al: Preoperative Assessment of Resectability of Hepatic Metastases from Colonic Carcinoma: CT Portography vs. Sonography and Dynamic CT AmJRoentgenol 1992, 159: 741-744.
  5. Fortunato L, Clair M, Hoffman J, et al: Is CT Portography (CTAP) Really Useful in Patients with Liver Tumors who Undergo Intraoperative Ultrasonography (IOUS)? Am Surg 1~5, 61 :560-564.
  6. Hagspiel KP, Neidl KF, Eichenberger AC, et al: Detection of Liver Metastases.. Comparison of Superparamagnetic Iron Oxide-Enhanced and Unenhanced MR Imaging at I.5 Twith Dynamic C1; Intraoperative US, and Percuta- neous US. Radiology 1995, 196(2): 471-478.
  7. Yoon, SS, Tanabe, KK.: Multidisciplinary Management of Metastatic Colorectal Cancel: Surg Onco11998; 7: 197.
  8. Bartlett, DL.: Treatment of Patients with H~patic Meta- stases. Cancer J 2000; 6 Suppl2: S169.
  9. Kemeny, N, Daly, J, Reichman, B, et al.: Intrahepatic or Systemic Injilsion of Fluorodeoxyuridine in Patients with Liver Metastasesfrom Colorectal Carcinoma. A Rando- mized Trial. Ann Intern Med 1987; 107:459.


Special guest editor,

3rd Surgical Clinic, „IuliuHatieganu” University of Medicine and Pharmacy, Cluj-Napoca

235 U nresectable Liver Thmours

(Diagnositic an.d Therapeutic Strategies)

  1. Vlad

3rd Surgicai Clinic, Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca

Are presented the general features of unresectable hepatic tumours: the anatomic and surgical criteria that limit and contraindicate the resection. Because of the high rate of unresectability are discussed the main alternatives of the palliative procedures such as: systemic chemotherapy, external radiation therapy, radio immune therapy, intra-arterial chemotherapy, cytoreduction and sequential resection, chemoembolization. Further therapeutic strategies including: crycoagulation, radiofrequency, tumour alcoholization and laser photocoagulation are presented as palliative surgical procedures.

Key words: liver tumours, surgery of unresectable liver turnours, and palliative surgical procedures.

Radioterapie & Oncologie Medicală, 2001, 3:235-238

239 Ultrasonographic Criteria for Nonresectability of Liver Tumours

Adriana Petrică

3rd Medical Clinic, Cluj-Napoca

Malignant liver tumours are rarely resectable surgically in the symptomatic stage. For this reason an early diagnosis of the tumor in a pre symptomatic stage is required and this can be achieved by periodical ultrasonographic monitoring of the high risk patients.

The paper highlights the role of the new ultrasound-based techniques in the diagnosis of liver tumours and defines the main ultrasonographic criteria for the nonresectability of these malignancies.

Key words: liver turnours, nonresectability, ultrasonography, Doppler ultrasonography, contrast ultrasonography.

Radioterapie & OncologieMedicaăa, 2001, 3:239-241

242 Evaluation of Liver Thmours Resectability by Ultrasound Examination

Ligia Cadariu Achimaş

3rd Surgical Clinic, Ultrasound Division, Cluj-Napoca

The usefulness of the ultrasound technique in the examination of liver tumours is based on the significant diagnostic accuracy in the case of primary and metastatic turnoUTS. Liver ultrasound may establish the localization, size and number of lesions. The evaluation of the ultrasonographic structure of the tumours is important, as it often happens that malignant and benign tumours coexist. Another important element in the surgery of hepatic lesions is the presence or absence of the capsule. Surgical decision is also influenced by the assessment of portal or hepatic veins invasion, the aspect of the liver parenchyma, presence of cirrhosis, periportal, parapancreatic and coeliac trunk lymph nodes. For an optimal surgical treatment of liver tumours, intraoperative ultrasound assessment is necessary. Ultrasonographic evaluation of the resectability of liver tumours is based on the existence of metastases, extrahepatic dissemination and vascular involvement.

Key words: liver tumour, resecability, ultrasound examination.

Radioterapie & Oncologie Medicală, 2001, 3:242-245

246 Radiotherapy for Liver Metastases

  1. Ghilezan

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

Liver metastases have an ominous prognosis with few real therapeutic options. Radiation therapy has a limited role for unresectable lesions due to localization or volume, which associate with pain and/or obstructive symptoms, in the presence of a good performance index and a reasonable life expectancy. The standard technique delivers initially 20 Gy for the whole liver followed by boost up to 30-35 Gy for limited volumes that do not address to more than 30% from the total healthy hepatic tissue. A positive response concerning pain and quality of life is observed for 40 to 50% of the patients but it is nonsignificant regarding survival. The combination of classical external radiotherapy or 3D conformal irradiation with intra arterial hepatic chemotherapy is a promising area of research, limited to centers with the necessary equipment, as randomized clinical trials.

Key words: liver metastases, irradiation.

Radioterapie & Oncologie Medicală, 2001, 3:246-249

250 Role of Chemotherapy in the Management of Liver Metastases

  1. E. Ciuleanu

U.M.Ph. ,,Iuliu Haţieganu”, Cancer Institute „Prof I.Chiricuţă”, Cluj-Napoca

Palliative chemotherapy is the standard treatment in patients with unresectable liver metastases and good performance status, improving survival as compared with best supportive care. In metastatic colorectal carcinomas, the use of CPT 11 in combination with 5FU/ Leucovorin resulted in an improved survival as compared with FU/ Leucovorin alone. Intraarterial FUDR is superior to systemic 5FU in terms of response rate, progression free survival and overall survival, but no direct comparison is available between IAH -FUDR and 3rd generation systemic combination chemotherapy regimens. Adjuvant combined IAH + systemic chemotherapy after complete resection of the liver metastases improves survival as compared to systemic chemotherapy or best supportive care alone. The preliminary experience with IAH chemotherapy in Cluj is presented.

Key words: intraarterial hepatic Chemotheray, liver metatases.

Radloteraple & OncologleMedicală, 2001, 3:250-258

259 Regional Chemotherapy of Liver Tumours. Early Results and Perspectives of the Liver Group

L.Vladl, N.Ghilezan2, T.E.Ciuleanu2, Ligia Achimaşl, G.Osian1, F.Graur1, D.Miclăuşl, C.Zdrehuş3

13rd Surgical Clinic „Iuliu Halieganu” U.M.Ph., Cluj-Napoca;

2Cancer Institute „Prof I. Chiricula”, Cluj-Napoca;

3Dept. of Anaesthesia and Intensive Care, „Iuliu Halieganu” U.M.Ph., Cluj-Napoca

The paper presents the results of the first cases of metastatic liver cancers treated by hepatic intraarterial chemotherapy associated or not with systemic chemotherapy. The technique of hepatic intra-arterial infusion, the intraoperative investigative strategy, the associated excision or metastasectomy and the evolution of the lesions at various therapeutic stages are reported for a total number of 14 cases.

Key words: Liver tumours, Liver metastases, Colorectal cancer, Hepatic resection, Hepatic intraarterial chemotherapy; IACh – Intraarterial chemotherapy.

Radioterapie & Oncologie Medicală, 2001, 3:259-266

267 Therapeutical Guide: Nasopharyngeal Carcinomas

Elisabeta Ciuleanu, N. Ghilezan

273 Therapeutical Guide: Endometrical Cancer

Viorica Nagy, A. Rancea, N. Ghilezan

279 Therapeutical Guide: Hodgkin’s Disease

Cristina Cebotaru

287 Right Atrium Angiosarcoma

D.Radulescu1, C.Duncea1, Ioana L.Rădulescu2, T.E.Ciuleanu2, V.Haş1

15th Medical Clinic, UMPh „I. Haţieganu„;

2Cancer Institute „Prof I. Chiricuţă”, Cluj-Napoca

In the present paper we present two cases of cardiac angiosarcomas, documented at transesophageal echocardiography. We also discuss the benefice of modem chemotherapy in treating such cases.

Key words: cardiac angiosarcomas, transesophageal echocardiography.

Radioterapie & Oncologie Medicală, 2001, 3:287-289