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Volum 14 Numarul 1, 2008

5 EDITORIAL

G. Kacsó

6 What is the Optimal Management of the Clinically Negative Neck for Patients with Head and Neck Squamous Cell Carcinomas?

Voichiţa Bar Ad, M.D.

Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA

Head and neck oncologists continue to debate the appropriate treatment approach of the clinically negative neck among patients with head and neck squamous cell carcinoma (HNSCC). The clinically negative neck of the patients with HNSCC may be managed with observation only, elective neck dissection or elective radiation therapy. There are no large prospective randomized trials comparing between these treatment options. The principal aim of treating electively the clinically negative neck in patients with HNSCC, by ei­ther surgery or radiation therapy is to maximize the rate of control of the disease in the neck. It remains to be proven if the elective neck treatment contributes to improved overall survival for the patients with HNSCC and clinically negative neck.

Key words: Head and Neck Cancer, Clinically Negative Neck, Selective Neck Dissection.

10 The Role of Inguinal Node Dissection in the Management of Vulvar Carcinoma

Ovidiu Coza1,2, Viorica Nagy1,2, Claudia Ordeanu1, Sorin Gavriş1, Alin Rancea1,2, Alexandru Trăilă1, Adriana Tudosescu1, Rareş Buiga1, Nicolae Todor1

1Ion Chiricuta Cancer Center Cluj-Napoca;

2I. Hatieganu University of Medicine and Pharmacy Cluj-Napoca

Vulvar cancer is a highly curable tumor if it is diagnosed in an early stage. Survival is strictly correlated with the pathologic status of inguinal lymphnodes which, together with primary tumor dimension, represents the most important prognostic factors. Primary sur­gery remains the main curative treatment method and consists of modified radical vulvectomy with the bilateral inguinofemoral node dissection, with a minimum number of 10 excised lymphnodes. New data are available regarding the sentinel lymph node concept in vulvar carcinoma, and, also surgical techniques in order to diminish acute and late morbidity.

Key words: Vulvar Cancer, Inguinofemoral Lymphadenectomy.

13 Prostate Intensity Modulated Radiation Therapy (IMRT) in the 4D era

Ştefan Both1, Voichiţa Bar1

1Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA

The aim of prostate intensity modulated radiation therapy (IMRT) is to maximize control in prostate cancer delivering a high enough dose for tumour eradication while minimizing the dose for the organs of risk. The increased dose conformality achieved through IMRT made the accuracy and precision of patient/target positioning one of the most critical components in the radiation therapy process. We analyze the prostate IMRT process from the prostate motion management and setup uncertainty perspective. The use of image guided daily setup or radiofrequency markers for continued tracking and quantitative characterization of uncertainty margin will help to realize the full potential of IMRT for the prostate.

Key words: Intensity Modulated Radiotherapy, Prostate Cancer.

18 Adenopathies with Unknown Primary: Therapeutic Implications

Călin Căinap1,2, Tudor E. Ciuleanu1,2

1Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca;

2Ion Chiricuta Cancer Center, Cluj-Napoca

Although over the past decades the incidence of unknown adenopathies has decreased these categories of patients represents considerable difficulties, due to many diagnostic and therapeutic problems for the oncologist. On the one hand the overall results of these treatments are very disappointing with only a survival rate of 15-20% at 1 year, with a median survival of 3-5 months. On the other hand in order to opti­mise resources, we must be careful to do the minimal number of diagnostic examinations necessarily for the diagnosis from the point of view of prognosis or types f treatment such as: breast cancer, prostate, lymphoma, neuroendocrine tumors, thyroid cancer, germinal tumors. The authors have tried to suggest a guide for physicians interested in the diagnosis and treatment of this category of patient.

Key words: Adenopathies, Therapy.

21 Prognostic Value of Lymph Node Involvement in the Radio-Surgical Treatment in Laryngeal Carcinoma

Elisabeta Ciuleanu1, Valentin Cernea1,2, Daniela Martin1, Iolanda Sicoe1 , Emöke Palyi Kiss1, Nicolae Todor1, Dănuţ Gheorghiu1, Octavian Chiş1 , Constantin Iencica1, Marcel Cosgarea2,3, Magdalena Chirilă1, Liliana Resiga1

1Ion Chiricuta Cancer Center Cluj-Napoca; 2Iuliu Hatieganu University of Medicine and Pharmacie, Cluj-Napoca; 3Head and Neck Clinics, Cluj-Napoca

Objective: to study the prognostic role of lymph node involvement in operated laryngeal carcinoma. Primary endpoints were disease-free survival and disease specific survival. Patients and methods: Between January 2003 – December 2005, 54 patients with laryngeal cancer, who had radical resection followed by postoperative radiotherapy at the Cancer Center Ion Chiricuta Cluj Napoca, were included. Results: The most frequent laryngeal anatomic site was the glottis – 29 patients (54%), followed by supraglottis – 24 patients (44%) and subglottis – 1 patient (2%). The most frequent histology was keratinizing squamous cell carcinoma in 50 patients (93%). The microscopic margins of the resected specimen were negative in 32 patients (59%), positive in 11 patients (20%), and not specified in 11 patients (20%). Thirty patients (56%) were lymph node positive, of which 19 patients (35%) had 1-3 nodes, 11 patients (20%) were with more than 4 lymph nodes. Eleven (37%) of the patients with positive lymph nodes had extracapsular extension. The pT category was: pT4a in 42 patients (78%), pT3 in 9 pa­tients (17%) and pT2 in 3 patients (6%). There was a statistically significant difference for disease specific survival (86% vs 82% vs 67%, p=0,01) and disease free survival (86% vs 81% vs 27% p <0,01), according to the number of the involved lymph nodes (0 vs 1-3 vs >= 4 nodes). The extracapsular extension significantly influenced disease-free survival (extracapsular extension vs no extracapsular extension: 79% vs 45%, p=0,05), but it did not influence disease specific survival. Conclusions: In radically resected laryngeal carcinoma patients, massive lymph node involvement (>=4 positive lymph nodes) significantly influenced disease specific survival and disease free survival. The extracapsular extension influenced disease free survival.

Key words: Laryngeal Cancer, Lymph Node Involvement, Postoperative Radiotherapy.

28 The Prognostic Value of Lymph Node Status in Patie nts with Advanced Cervical Cancer Operated After Radio-Chemotherapy

Viorica Nagy1,2, Alexandru Trăilă1, Alin Rancea1,2, Ovidiu Coza1,2,
Claudia Ordeanu1, Nicolae Todor1, Nicolae Ghilezan1,2

1Ion Chiricuta Cancer Center, Cluj-Napoca, Romania;
2Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania

Objectives: The main objective of the study was to analyse the lymph node (LN) status value in patients with advanced cervical can­cer, operated after radiotherapy (RT) with or without chemotherapy (CT) (RT±CT), according to survival rate and recurrences. The secondary objective was to correlate LN metastasis with other prognostic factors. Patients and methods: The study included 272 pa­tients with advanced cervical carcinoma treated in the Oncology Institute, Cluj-Napoca between March 1999 and August 2002, with RT±CT, followed by surgery (radical abdominal hysterectomy with bilateral pelvic lymphadenectomy -Wertheim operation-(WO). 189 patients (70%) were in stage IIB and 83 (30%) in stage IIIA-IIIB. The pathologic evaluation of the surgical specimen specified the number of the dissected LN, the residual tumour cells in the cervix and the endometrium, in parametrial tissues, in the vaginal margins and in the pelvic LN. Results: The mean number of dissected LN per patients during WO was 14: in 77 patients (28%) ≤10 LN and in 195 patients (72%) >11 LN. The rate of LN metastases (N+) was higher (59%) in patients with preoperative RT, compared to those with RT±CT. The 5 year survival was 78% in cases of ≤ 10 examined LN, compared to 89% in cases of patients with >10 LN (p=0.02). The 5- year survival rate was significantly reduced (61%) in patients with N(+) compared to negative nodes N(-) pa­tients (90%) with p<0.01. Conclusions: The LN status is an important prognostic factor in cervical cancer, regarding the number of dissected lymph nodes and the presence of metastases.

Key words: Cervix Cancer, Lymph Node, Prognostic Factors.

33 Three-dimensional Conformal Radiotherapy for Treatment of Localized Prostate Adenocarcinoma: the Ion Chiricuta Cancer Center Experience

Ciprian Chira1, Ovidiu Vereşezan2, Ovidiu Bran3, Victor Bogdan1, Andra Fizeşan1 ,
Dan Dordai1, Gabriel Kacsó1,3

1Department of Radiation Oncology, Ion Chiricuta Cancer Center, Cluj-Napoca; 2Sf. Spiridon Hospital, Department of Radiotherapy, Iaşi; 3IuliuHatieganu University of Medicine and Pharmacy Cluj-Napoca

Purpose: To perform an evaluation of toxicity and to report preliminary results of three dimensional conformal radiotherapy (3D-CRT) for treatment of localized prostate adenocarcinoma in current practice in Romania. Patients and Methods: From January 2005 to June 2007, 52 patients stratified by D’Amico prognostic factors were included in this Phase II prospective trial. In 73% of cases, radiation treatment was as­sociated with androgen deprivation therapy; 4% received 3D-CRT plus a brachytherapy boost and the remainder of cases- 3DCRT as a sole curative intent treatment. Only 3 patients had RT as salvage therapy for isolated locally confirmed recurrence after radical prostatectomy. The first 46Gy were administered using a four conformal field arrangement to prostate, seminal vesicle or up to 54Gy to prostate and seminal vesicle in case of T3b while the boost was given by a six field technique to prostate only plus lower half of SV if T3b. Pelvic lymphnodes were irradiated only if their risk of involvement, based on Roach formula,was at least 15 %. The planned doses were 74-76Gy for high and medium risk patients, 70-72Gy for low-risk, 66-70 Gy for local recurrence following radical prostatectomy and 46Gy for those patients re­ceiving brachyterapy boost. In all cases standard fractionation (fr.) was applied (i.e 2Gy/fr, 5d/wk, 1 fr/day). Toxicity was scored using the CTC3.0 scale. Results: With a median follow-up of 18 months (6-33 months) there were 2 biochemical failures at the time of analysis, one due to distant recurrence. Severe acute toxicities were remarkably low with Grade 3 urinary morbidity in 7.7% of cases, digestive in 5.7%, while sexual toxicity was slightly higher (9.61%). Late severe urinary effects (grade 3) were seen in 3.8% of cases while sexual related toxic­ity was observed in 7.7% of patients. No late severe digestive toxicity was reported. There were no Grade 4 or 5 acute and/or late events. Conclusions: 3D-CRT reveals better tolerance, significantly less acute and chronic toxicity compared with conventional techniques and ap­parently yields higher biochemical disease-free intervals, although longer follow-up is needed to determine the impact on long-term outcome and late sequelae.

Key words: Conformal Radiation Therapy, Prostate Cancer, Toxicity.

40 Low-Dose Rate Brachytherapy in the Treatment of Low-Ri sk Prostate Cancer: the European Institute of Oncology Experience

  1. Fodor1, A. Vavassori1, F. Cattani2, C. Fodor1, L. Santoro3, V.D. Matei4 ,

B.A. Jereczek- Fossa1,5, O. De Cobelli4, R. Orecchia1, 5

1Division of Radiotherapy, European Institute of Oncology, Milan, Italy; 2Division of Physics, European Institute of Oncology; 3Division of Statistics, European Institute of Oncology; 4Division of Urology, European Institute of Oncology; 5University of Milan, Italy

Objectives: 301 patients have undergone prostate brachytherapy at the European Institute of Oncology, until July 2007. We present the out­come data of these patients. Methods: Data was analysed from a retrospective database of 301 consecutive patients, median age 70 years (range 39-85 years) treated with permanent prostate brachytherapy between October 1999 and July 2007. Patients were stratified into low (49.83%), intermediate (32.23%) and high (17.94%) risk as defined by the Memorial Sloan-Kettering Prognostic Index. Patients received 145 Gy brachytherapy (BT) as monotherapy (89.04%), 45 Gy external beam radiotherapy (EBRT) with 110 Gy BT (7.64%), or BT for fail­ure after EBRT/ surgery (3.32%). Biochemical relapse-free survival (bRFS) and prostate-specific antigen (PSA) nadirs were analysed for treatment received in each risk group according to both definitions in use: ASTRO 1997 and 2006. Results: Median follow-up was 46 months (range 1-90 months). Prostate cancer-specific mortality at 7 years was 2.3% and 22.9% of the patients (7%) experienced biochemical failure according to the 1997ASTRO definition (3 consecutive PSA rising) and 15.9% according to the 2006 ASTRO definition (nadir + 2ng/ml). Taking into account the PSA bounce, only 10.9% of patients have had a failure (4% in the low risk group). The 5 years overall sur­vival, 91%, was biased by the median age; 75% of the deaths were for other reasons. Conclusions: LDR prostate brachytherapy performs an excellent cause specific survival, a low toxicity and a good biochemical control in low risk tumors.

Key words: Prostate Cancer, Low Dose Rate Brachytherapy.

50 Significance of Disease Stabilization for Survival and Quality  of Life Benefits with Erlotinib in Relapsed Non-small-cell Lung Cancer

Tudor E. Ciuleanu

Ion Chiricuta Cancer Center Cluj-Napoca, Dept. of Medical Oncology

We describe the outcome of treatment with erlotinib in three patients with non-small-cell lung cancer who had relapsed during first-line chemotherapy. Each had either refused further cytotoxic agents and/or their poor performance status precluded this. One had a partial response; the disease stabilised in the others. There were marked reductions in non-target lesions, and improvements in dis­ease-related symptoms and quality of life.

Key words: Non-small-cell Lung Cancer, Erlotinib.

54 30th Charles A. Coltman San Antonio Breast Cancer Symposium (SABCS). December 13-16, 2007, SanAntonio, Texas, USA

Alexandru Eniu

62 Important International Cancer Conferences

63 Guidance for Authors on the Preparation and Submission of Manuscripts to the Journal of Radiotherapy and Medical Oncology