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Volum 19 Numarul 1, 2013

3 Establishing the Romanian Federation of Cancer Societies

Viorica Nagy, Rodica Anghel

5 Guidelines for the Planning and Delivery of High-Precision Conformal Radiotherapy for Lung Cancer

Petronela Rusu, Victor Bogdan

Institute of Oncology Prof. Dr. Ion Chiricuta Cluj-Napoca

The aim was to define guidelines for each recommendation categories for routine practice and clinical trials to implement high precision conformal radiotherapy for lung cancer. With this objective in mind, a search of the literature was undertaken to identify the available evidence. Recommendations were categorized under the following headings: Therapeutic categories and patient selection; Data acquisition; Generating Target Volumes; Dose prescription and reporting; Beam energies; beam arrangements; Treatment plan evaluation; Treatment verification and delivery; Evaluating response and toxicity. Some issues and techniques that are considered investigational at present are also presented.

Key words: guidelines, conformal radiotherapy, lung cancer

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11 Dose-Dense Chemotherapy in Advanced Ovarian Cancer: Old Idea, New Perspectives

Vlad Manolescu1,2, Viorica Nagy1,2

1) Institute of Oncology Prof. Dr. I. Chiricuta Cluj Napoca; 2) The “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj Napoca

The current standard of care in advanced ovarian cancer consists of maximum cytoreductive surgical effort followed by chemotherapy – 6 cycles of Paclitaxel 175mg/m2 (iv, 3 hours) plus carboplatin AUC 5-7 every 21 days, leading to excellent response rates but also to frequent relapses. Several methods of improving outcomes were intensively studied: addition of a third agent to chemotherapy, addition of anti-angiogenesis drugs – Bevacizumab, intraperitoneal chemotherapy, dose dense chemotherapy. Dose dense chemotherapy regimens rationale is the Norton-Simons model of growth according to which the increasing of dose density of chemotherapy will increase efficacy by minimizing the opportunity for regrowth of tumor cells between cycles of chemotherapy. Several clinical studies using DD regimens were first developed for breast cancer treatment in the neoadjuvant, adjuvant and metastatic disease setting. Taking into account the promising findings of breast cancer clinical trials, the DDC principles were applied in advanced ovarian cancer chemotherapy in the first and second line treatment setting clinical studies. Several regimens including weekly paclitaxel + cisplatin or weekly paclitaxel + carboplatin were investigated with results that proved that dose-dense weekly platinum is an effective therapy in platinum-sensitive as well as in platinum resistant patients. The Japanese Gynecology Oncology Group (JGOG) was the first to demonstrate the survival advantage of dose dense weekly administration of paclitaxel in 2009. Patients were randomly assigned to receive six cycles of either paclitaxel (180mg/m2; 3 hours intravenous infusion) plus carboplatin (area under the curve [AUC] 6 mg/ml per min) given on day 1 of a 21 day cycle – conventional regimen arm with 320 patients) or dose dense (DD) paclitaxel (80mg/m2; 1 hour infusion) given on days 1, 8 and 15 plus carboplatin given on day 1 of a 21-day cycle (dose dense regimen arm with 317 patients). Statistical analysis showed that median progression-free survival was longer in the DDC group (28 months, 95% CI 22.3-35.4) than in the conventional treatment group (17.2 months, 15.7-21.1; hazard ratio [HR] 0.71; 95% CI 0.58-0.88; p=0.0015). Moreover, the 3 years overall survival was higher in the dose-dense regimen group (72.1%) than in the conventional treatment group (65.1%; HR 0.75,0.57-0.98; p=0.03). Hematologic toxicities – neutropenia and severe anemia were higher in the dose dense group but peripheral neuropathy was similar in the two study arms. The ongoing trials for treatment of advanced ovarian cancer include dose-dense chemotherapy arms. Although new biological therapies (bevacizumab) showed its efficacy in ovarian cancer, it is still used in combination with chemotherapeutic agents such as paclitaxel. Such approaches as dose dense administrations are intensively investigated in ongoing trials and the right dosing, frequency is to be established after publication of new emerging data.

Key words: ovarian cancer, dose dense chemotherapy, paclitaxel, carboplatin

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17 Neo-adjuvant Chemotherapy Associated to Concurrent Radio-chemotherapy in Locally Advanced Cervical Cancer: a Feasibility Study of the Institute of Oncology “Prof. Dr. Ion Chiricuta”

Andreea Marita1, Daniela Sturzu1, Claudia Ordeanu1, Alin Rancea1,2, Adriana Tudosescu1, Nicolae Todor1 , Viorica Nagy1,2

1) Institute of Oncology Prof. Dr. I. Chiricuta Cluj Napoca, 2) The “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj Napoca

Objective: The assessment of therapeutic response of neo-adjuvant chemotherapy associated to concurrent radio-chemotherapy in locally advanced cervical cancer, in a non randomized, feasibility study conducted at the Oncologic Institute Prof. Dr. I. Chiricuta Cluj Napoca (OICN). Material and methods: The study included patients with cervical cancer stage IIB-III treated in OICN during November 2010 and February 2012. Therapeutic protocol provided 2 or 3 cycles of neo-adjuvant chemotherapy (NACT) with 2 regimens (Paciltaxel and Carboplatin or Topotecan and Cisplatin) followed by concurrent radio-chemotherapy (RCT) with Cisplatin 20 mg / m² 5 days. The total dose (TD) of external beam radiotherapy (EBRT) was 60 Gy for patients with exclusive RCT and 46 Gy preoperatively, associated with brachytherapy(TD 10 to 20 Gy). At TD of 46Gy patients were surgical evaluated and those with favorable parametrial response were optionaly operated. Response assessment was done at the end NACT, at the end of the RCT and pathological outcome for operated patients. In the study were included 58 patients with cervical cancer: st. IIB -14 patients, IIIA – 27 patients, IIIB – 17 patients; age > 50 years – 28 patients, ≤ 50 years respectively 30 patients. 50 (86%) patients had squamous cell carcinoma, and 14% adenocarcinoma. Results: 43 (74%) of patients performed NACT Paclitaxel and Carboplatin schedule and 15 (26%) had Topotecan and Cispatin. Evaluation after NACT showed a complete response (CR) in 3 (5%) of the patients, partial response (PR) in 35 (60%) and stationary disease (SD) in 20 (35%) of patients. Objective response (OR= CR + PR) to CTNA was correlated with stage: for st. IIB was (10/14)71.5% of patients, st. IIIA in (18/27)67% of patients, and for st. IIIB in (10/17)59% of patients. Therapeutic response was correlated with the type of chemotherapy: 72% OR for patients with Paclitaxel and Carboplatin vs. 47% for Topotecan and Cisplatin regimen. Therapeutic evaluation at the end of RCT showed CR in (28/58) 48% of cases. This response was correlated with tumor stage and volume as follows: CR in st. IIB – 64%, st. IIIA – 44.5%, respectively st. IIIB – 41; 54% CR for tumor diameter ≤ 4 cm vs. 39% for diameter > 4cm. CR was revealed in 65% of patients with Paclitaxel and Carboplatin vs. 0% patients with Topotecan and Cisplatin (p <0.01). Pathological evaluation revealed negative surgical specimen (complet remission) in 21/26 (81%) of the operated patients. Pathological outcome was correlated with chemotherapy regimens: 90.5% complete remission in pts. with Paclitaxel and Carboplatin vs. 40% in pts. with Topotecan and Cisplatin. Conclusions: Neo-adjuvant chemotherapy associated to concurrent RCT provides a good therapeutic response, that probably will be reflected in survival. For confirmation requires a long-term evaluation and a larger number of patients.

Key words: neo-adjuvant chemotherapy, cervical cancer, radiochemotherapy

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23 Peculiarities of Palliative Care Team Occupational Stress

Gabriela Rahnea Nita, Anda-Natalia Ciuhu, Loredana Antuanela Tuinea

“Sf. Luca” Chronic Disease Hospital of Bucharest

Introduction. Burnout stands as an experience of physical, emotional and mental exhaustion, resulting from long-term involvement in emotionally demanding situations (1). By studying and understanding better occupational stress, one may get both personal and professional benefits. Objectives.1. Evaluation of palliative care team burnout. 2. Identification of particular risk factors that cause occupational stress. 3. Identification of strategies to reduce occupational stress. 4. Evaluation of palliative care team job satisfaction. Materials and methods. The palliative care team of the Department of Oncology – Palliative Care for Chronic Patients within “Sf. Luca” Chronic Disease Hospital of Bucharest filled in the hospital’s survey on job satisfaction and Maslach Burnout Inventory (2) for burnout evaluation. The team formulated, freely, the answers to two categories of questions, i.e. listing of the three major factors that cause occupational stress and listing of the three main strategies to reduce occupational stress. Results and discussions. Out of the 16 members of the palliative care team (3 physicians and 13 nurses) 62.5% of participants experienced symptoms that indicated an average level of burnout, while 37.5% of participants experienced symptoms that indicated a low level of burnout. No participant had a high level of burnout. Conclusions. This survey highlights the degree of job satisfaction, the level of occupational stress of the palliative care team, identifies the particular risk factors and the strategies to reduce occupational stress.

Key words: job satisfaction, burnout, palliative care team

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28 Anthracycline-Induced Cardiotoxicity: a Case Presentation and Literature Review

Doina P. Pruteanu

Institute of Oncology „Prof.Dr. Ion Chiricuta”; Cluj Napoca, Romania

We present the case of a 48-year old female patient diagnosed with primary breast cancer, treated with standard adjuvant chemotherapy that developed into congestive heart failure one year after treatment completion. The main aspects of cardiotoxicity are presented in a short literature review: incidence, classification, mechanism of anthracycline induced cardiotoxicity, detection methods, prevention and treatment.

Key words: anthracycline, cadiotoxicity, cardiomyopathy, detection, treatment

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32 Complete Pain-Control with Methadone and Ketamine in Intractable Neuropathic Severe Pain. A case report and review of literature

Ariana Roşiu1, Răzvan-Ovidiu Curcă2

1) Emergency County Hospital Alba Iulia, Palliative Care Unit – Medical Oncology Department; 2) Emergency County Hospital Alba Iulia, Medical Oncology Department

Pain remains one of the main symptoms of oncological patients, being a complaint in 75% of them, and severe pain is noticed in more than a half of the cancer patients reporting pain. Neuropathic pain is known as implying a potentially difficult management. We report a case of a 50-yr old patient with advanced cervical cancer, with severe pain, uncontrolled with morphine and co analgesics, but with complete control with methadone first, then with ketamine and oxycodone.

Key words: cervical cancer, neuropathic, intractable pain, methadone, ketamine

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35 Resection of Solitary Metastases in Breast Cancer Patients: a Case Report

Ramona Matei, Gergely Holló

1) Institute of Oncology Prof. Dr. I. Chiricuta Cluj Napoca, Romania

Although metastatic breast cancer is widely believed to carry a grim prognosis, treatment developments over the past 25 years have greatly improved survival outcomes in the patients. Bone is one of the earliest and most common sites of breast cancer metastasis and it is generally associated with better outcomes than visceral involvement. Standard treatment for breast cancer bone metastasis is systemic hormonal therapy or chemotherapy. We report the case of a 52-year old breast cancer patient with a history of serial resections for solitary bone and lung metastases, treated with curative intent.

Key words: breast cancer, solitary metastasis, curative treatment, surgery

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39 Guidance for Authors