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Volum 13 Numarul 2, 2007

103 Romanta Lusa – In memoriam

105 Congresul XVII al SRRO

114 EDITORIAL

116 Diagnostic and Treatment Guidelines for Febrile Neutropenia in Patients with Solid Tumors

129 Image Guided Whole Body Gamma Knife (IGWBGK) – Gamma Star from the Physical Principle to the Clinical Application. The Results of a Workshop in Xian (China)

I.C. Kiricuta1, U. Götz1, Mei Shing2, Shipeng Song3

1ISRO Limburg, Germany, 24-th Military Hospital, Kian, China, 3Song Sjipeng Co. Ltd. Shanghai, China

Background: A new whole body gamma knife with a special focalized Co 60 sourse make a triple focalized whole body stereotactic radiotherapy available. Introduction: The 5-th generation of the chinese gamma knifes (GK) developed by Song Shipeng and based on the principle of the gamma knife of Leskel make an image guided stereotactic radiotherapy (IGWBSRT) possible (Fig. 1). The last three of them are whole body gamma knifes (WBGK). Principles: To intensify the focalization effect and to produce a depth dose distribution (Fig. 2) similar with the “Bragg peak” of the proton irradiation, in the 5-th generation of chinese GK the radiation is produced by a triple focalized irradiation thechnique. The first focalization is produced by the construction of the C0 60 sourse itself. The secound focalization is produced by a spinning movement of the source in the irradiation head around an axis focalized on the rotation center of the whole irradiation head around an isocenter localized in the clinical target volume. The third focalisation is made possible by a 360 degree movement of the whole irradiation head around the machine´s isocenter (Fig. 3). Four collimators with different diameters make “Bragg peaks” with different “high dose volumes” possible (Fig. 4). During an 1 degree rotation of the irradiation head around the machine isocenter a 27 degree spinning rotation of the cobalt sourse of the irradiation head is performed. Dependent of the depht of the irradiation isocenter in the body a full or only well defined arc or rotations should be used. To calculate dose distributions and dose volume histograms a special designed own therapy planning system (TPS) for this gamma knife was developed. The Xian Workshop on IGWBSGK: Last year between the 8-th and 12-th december an international workshop at the 4-th Military Hospital in Xian (China) was held. Physical tests and the first clinical results were presented and discussed. Irradiation Techniques: With the WBGK different irradiation techniques as: with one isocenter or with multiple isocenters are possible. To cover larger target volumes additionally the so called “marble” conformal technique (Fig. 5) and a “scanning” technique is under investigation. Clinical Studies: Special devices for the immobilisation of the patients during the CT scanning and irradiations of the head and neck, chest, abdomen and pelvis were developed. Six of the discussed clinical cases are here presented. Two of them (case 1 and 2) are peripheral situated lung metastases irradiated by a single or double isocenter irradiation technique. Other three cases (case 3-5) are primary lung cancers with mediastinal lymph node metastases treated by a two isocenter irradiation technique. The last case (case 6) is a liver metastases irradiated with an one isocenter irradiation technique. Conclusions: It seams that the 40 years old principle of the initial “Leskel GK” used only for brain pathology under the Song Shipeng´s developments of the new IGWBSRT machine called GAMMA STAR represents a break through in the field of radiotherapy. The stereotactic radiotherapy of target volumes outside the head are now treatable by the new WBGK called Gamma Star.

Key words: Image guided radiotherapy (IGRT)

Radioterapie & Oncologie Medicală, 2007, 2:129-136

137 Oncological Pain – Ignorance or Helplessness?

  1. Kacsό, Claudia Burz

„Iuliu Haţieganu” University of Medicine Pharmacy Cluj-Napoca;

„Prof. Ion Kiricuţă” Cancer Institute, Cluj-Napoca

The lack of knowledge regarding the efficacy and tolerance of opioids as pain medication is widespread among patients, their families and unfortunately even in the medical community, partially due to the paucity of national literature in this field. We present the principles of pain treatment in oncology, emphasizing the practical aspects of opioid medication in nociceptive or neuropatic cancer pain.

Key words: Cancer pain, Analgesic treatments.

Radioterapie & Oncologie Medicală, 2007, 2:137-144

145 Primary (neoadjuvant) chemotherapy as treatment for locally advanced breast cancer patients: clinical response does not correlate with pathologic response

Al. Eniu1, Mihaela Galatâr2, R. Buiga2, Cristina Vitoc2, N. Todor3, N. Ghilezan3

„Prof. I. Kiricuta“ Cancer Institute Cluj-Napoca:

1Dept. of Tumors mamare; 2Dept. of Anatomcal Pathology; 3Dept. Radiotherapy II

Background: Primary (neoadjuvant) chemotherapy with anthracycline- based combinations represents the standard treatment for locally advanced breast cancer patients, yet only a minority of patients derives the maximum benefit defined as a pathologic complete response (pCR). Purpose: The aim of this study was to identify clinical and histological predictive and prognostic factors to allow evidence-based selection of breast cancer patients candidate for primary chemotherapy, in order to maximize the benefits and spare toxicity for non-responsive patients. Patients and Methods: Between April 1999-December 2003 , 132 pts with biopsy-confirmed locally advanced breast cancer were treated with a minimum of 4 cycles of anthracycline-based chemotherapy (either EC: epidoxorubicin 100mg/mp i.v. d1 and cyclophosphamide 600mg/mp i.v. d 1, q21days, or AC: doxorubicin 60mg/mp i.v. d1 and cyclophosphamide 600mg/mp i.v. d 1, q21days), followed by surgery, additional chemotherapy and radiotherapy if indicated, and tamoxifen for hormone receptor positive patients. Both the pretreatment biopsy and the resection specimen were evaluated for histopatological parameters, including estrogen, progesterone and Her2 receptors, and E cyclin. Clinical and pathologic tumor responses to preoperative therapy were assessed and correlated with clinical and histological varaibles. Results: Primary chemotherapy was well tolerated, with 4 % incidence of febrile neutropenia and no toxic death. We observed 19 clinical complete responses (cCR, 14,4%) and 86 partial responses (cPR, 65%), for an overall response rate of 79,5%. Twenty seven patients (20,5%) had stable disease (cBS). A pathologic complete response (pCR) was obtained in 11 patients (8,9%), with an additional 8 patients having a pCR but with positive axillary lymph nodes. There is a poor concordance between clinical and pathological response: only 1 of the 11 pCR was recruited from the cCR group, while 8 came from the cPR and 2 patients from the cBS group. In addition, 95% of the patients being classified as cCR didn’t obtain a pCR. With a median follow up of 61 months (range 23,3 -89,4), the disease free survival was 67 % (IC 95% 59-75%). Overall survival, at a median follow-up of 65,2 months (range 42- 92) was 79 % (IC: 71%­85%). Conclusions: Clinical response is a poor predictor for identifying patients that derive maximum benefit from primary chemotherapy and achieve a pathologic complete response. We present a group of patients homogenously treated and followed over 5 years, that were individually re-tested for estrogen, progesterone and Her2 receptors and E cyclin, both on the pretreatment biopsy and on the resection specimen. This article that only presents the main characteristics of the study sets the stage for our future presentation of univariate and multivariate analysis correlating clinical and histological parameters with pathologic response and disease free survival.

Key words: Locally advanced breast cancer, Primary chemotherapy, Predictive factors.

Radioterapie & Oncologie Medicală, 2007, 2:145-159

160 The Benefit of High Dose Methotrexate Therapy as Protector of the Pharmacological Sanctuaries in the Childhood Haematological Malignancies

Rodica Cosnarovici1 , Ştefania Neamţu1, Dana Cernea2, N. Todor2

„Prof. I. Kiricuta“ Cancer Institute Cluj-Napoca:

1Dept. of Pediatrics Oncology; 2Dept. of 2nd Radiotherapy

Aim: High dose Methotrexate (HDMTX) therapy is a recent approach, since 1999. We evaluated the benefit of the treatment with HDMTX, for childhood haematological malignancies, concerning the response rates the protection of the pharmacological sanctuaries. We studied the toxicity of HDMTX. Patients: We have analyzed 89 patients with acute lymphoblastic leukaemia and 64 patients with nonHodgkin lymphomas. We compared the results obtained with the classical and aggressive regimens (BFM 95, containing HDMTX) and we considered the toxicity and risk of HDMTX therapy. Results: The therapeutic response was significantly in the advantage of HDMTX containing regimens. In haematological malignancies the HDMTX proved his efficiency in the protection of the central nervous system, and also the testicle for the patients with acute lymphoblastic leukaemia. We delivered 249 cycles of HDMTX. Major side effects were bone marrow suppression, mucositis, infections, gastrointestinal symptoms and higher liver enzymes, very rare renal impairment. The toxicity was important, related to the delayed elimination of the drug and usually reversible. Conclusion: The HDMTX therapy is effective and seif.

Key words: MTX, Pharmacological sanctuaries, Childhood cancers.

Radioterapie & Oncologie Medicală, 2007, 2:160-165

166 Merkel cell Carcinoma. Case Report and Review of the Literature

Ioana Lucia Muntean1, Liliana Resiga2, Doiniţa Crişan1,3, C.D. Olinici1,2,3

1 Emergency Clinical Hospital Cluj, Department of Pathology 2 „Prof. Dr. I. Kiricuta” Cancer Institute, Cluj Napoca, Department of Pathology 3 „Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj Napoca, Department of Pathology

The authors report the case of a 60-year old male who showed a Merkel cell carcinoma on the right radiocarpal region. The diagnosis was confirmed histopathologically and immunohistochemically (positivity for cytokeratins- AE1/AE3, CK20, chromogranin A, c-kit and synaptophysin). The etiology, pathogenesis and the principles of treatment of this rare entity are shortly discussed.

Key words: Merkel cell, Carcinoma, Pathology, Treatment.

Radioterapie & Oncologie Medicală, 2007, 2:166-169

170 Radiochemotherapy with Brachytherapy Boost as Curative Treatment for Locally Advanced Epidermoid Anal Carcinoma

Case Report and Review of the Literature

Zs. Fekete1, M. Mureşan2, G. Kacsó1,3

“I. Kiricuta” Cancer Institute, Cluj, 1Dept. of Brachytherapy, 2Dept. of Surgery; 3 “Iuliu Haţieganu” University of Medicine and Pharmacy

A case with stage cT4N2M0, IIIB anal canal squamous cell carcinoma is presented, which was successfully treated with radiochemotherapy followed by interstitial brachytherapy boost. The disease free survival is now 25 months and the late toxicity is only G1. We also present a short up to date review of the literature regarding this malignancy emphasizing on advanced stages and their treatment.

Key words: Epidermoid anal canal cancer, Locally advanced, Interstitial brachytherapy.

Radioterapie & Oncologie Medicală, 2007, 2:170-174

175 A Case of Pelvin Condroblastic Osteosarcoma. Prognostic Factors and Particular Respons to Treatment

Iolanda Sicoe, Dana Cernea, C. Mocanu

“Prof. I. Kiricuta” Cancer Institute Cluj-Napoca, Dept. of 2nd Radioterapy

The purpose of the article is to present the particular case of an 18 years old patient with lombo-sacrate condroblastic osteosarcoma. The treatment was surgery with palliative intent (decompression) follwed by local radiotherapy concomitant with Cisplatin chemotherapy. The simptomatology was improved and the treatment continued with adjuvant chemotherapy. We present the clinical outcome and the prognostic factors of this rare bone tumor.

Key words: Pelvin osteosarcoma, Radiotherapy, Chemotherapy.

Radioterapie & Oncologie Medicală, 2007, 2:175-180

181 Radiation-Induced Leiomyosarcoma of the Scapulo-Deltoid Region. A Case Report and Short Literature Review

  1. Chira1, Daniela Martin1, V. Cernea1,2

1„Prof. I. Kiricuta“ Cancer Institute, Department of Radiation Oncology, Cluj-Napoca

2„Iuliu Hatieganu“ University of Medicine and Pharmacy, Cluj-Napoca

In this paper we report a case of subcutaneous leiomyosarcoma that developed in a 66-year-old woman in her right scapulo-deltoid region 24 years after she had undergone surgery and orthovoltage radiotherapy for a breast carcinoma. The probable relation of second tumor to radiotherapy, diagnostic steps and treatment of sarcoma are discussed below as well as key facts regarding incidence of radiation-associated sarcomas, clinicopathological features of leiomyosarcomas, radiation carcinogenesis and behaviour/treatment of superficial leiomiosarcomas.

Key words: Leiomyosarcoma, Radiation-induced sarcoma, Breast carcinoma.

Radioterapie & Oncologie Medicală, 2007, 2:181-185

186 Present Trends in Systemic Treatment for Gastric Cancer

Viorica Magdalena Nagy

188 2007 SRRO’s Elections

N. Ghilezan

189 BOOK REVIEW

191 GUIDELINDES FOR AUTHORS