Radiotherapy of Breast Cancer-Professional Guideline 1st Central-Eastern European Professional Consensus Statement on Breast Cancer.

The international radiotherapy (RT) expert panel has revised and updated the RT guidelines that were accepted in 2020 at the 4th Hungarian Breast Cancer Consensus Conference, based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (stage 0), as RT decreases the risk of local recurrence (LR) by 50-60%. In early stage (stage I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor-positive tumour, hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives to conventional WBI administered for 5 weeks. Following mastectomy, RT significantly decreases the risk of LR and improves overall survival of patients who have 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant systemic treatment (NST) followed by BCS, WBI is mandatory, while after NST followed by mastectomy, locoregional RT should be given in cases of initial stage III-IV and ypN1 axillary status.

[4th Hungarian Breast Cancer Consensus Conference - Radiotherapy guidelines]. / IV. Emlorák Konszenzus Konferencia ­ Sugárterápiás irányelvek.

The radiotherapy (RT) expert panel revised and updated the RT guidelines accepted in 2016 at the 3rd Hungarian Breast Cancer Consensus Conference based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (St. 0), as RT decreases the risk of local recurrence (LR) by 50-60%. In early stage (St. I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor positive tumour hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives of conventional WBI. Following mastectomy RT significantly decreases the risk of LR and improves overall survival of patients having 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant chemotherapy (NAC) followed by BCS WBI is mandatory, while after NAC followed by mastectomy locoregional RT should be given in cases of initial stage III-IV and ypN1 axillary status.

[3rd Hungarian Breast Cancer Consensus Conference - Radiotherapy Guidelines]. / III. Emlõrák Konszenzus Konferencia - Sugárterápiás irányelvek.

The radiotherapy expert panel revised and updated the radiotherapy (RT) guidelines accepted in 2009 at the 2nd Hungarian Breast Cancer Consensus Conference based on new scientific evidence. Radiotherapy of the conserved breast is indicated in ductal carcinoma in situ (St. 0), as RT decreases the risk of local recurrence by 60%. In early stage (St. I-II) invasive breast cancer RT remains a standard treatment following breast conserving surgery. However, in elderly (≥70 years) patients with stage I, hormone receptor positive tumour hormonal therapy without RT can be considered. Hypofractionated (15×2.67 Gy) whole breast irradiation and for selected cases accelerated partial breast irradiation are validated treatment alternatives of conventional (25×2 Gy) whole breast irradiation. Following mastectomy RT significantly decreases the risk of locoregional recurrence and improves overall survival of patients having 1 to 3 (pN1a) or ≥4 (pN2a, pN3a) positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be omitted and substituted with axillary RT. After neoadjuvant chemotherapy (NAC) followed by breast conserving surgery whole breast irradiation is mandatory, while after NAC followed by mastectomy locoregional RT should be given in cases of initial stage III-IV and ypN1 axillary status.

[Changes in radiotherapy indication for early-stage operated endometrial cancer. Revised staging, predictive factors. Conclusions from our own results]. / Változások a korai stádiumú operált méhtestcarcinoma sugárkezelésének indikációjában. Újabb stádiumbeosztás, prediktív tényezok. Tanulságok saját eredményeink alapján.

Optimal postoperative radiotherapy indications for early-stage operated endometrial cancers have drastically changed with the new imaging generation (magnetic resonance imaging, positron emission tomography/computed tomography) and more detailed pathomorphology. The depth and growth of tumor invasion, presence or absence of the lymph node metastases, grading and lymphovascular invasion are the most important factors to predict the progression and to influence the prognosis. In 2016, on the basis of these, the European Gynecologist Oncology and Radiotherapy Society published a report in which they proposed unanimously indications for postoperative radio- and/or radiochemotherapy. The basis of their work was prospective multilevel randomized investigations which could avoid over- or undertreatment hazards. The results obtained by the authors of this article from 164 operated patients in early-stage endometrium carcinoma seem to be acceptable, in spite of the fact that their earlier radiotherapy indication was different and in the pathological description lymphovascular invasion was not included and the grading was not always applied.

[The need for a paradigm shift in radiotherapy]. / Paradigmaváltás szükségessége a sugárterápiában.

The status and indications of radiotherapy have significantly changed in the past decade because novel techniques, radiobiological research and major advances in informatics have made better local control possible. Using supplemented marking of the target volume with computer tomography based other image-making methods adapted made it possible to define the tumor and intact surrounding tissues more precisely. With novel radiotherapy techniques the dosage of the homogenity and the covering in the target volume can be raised optimally, especially with intensity modulated arc radiotherapy (volumetric modulated arc therapy) without causing radiation injury or damage to intact surrounding tissues. Furthermore, with novel techniques and target volume marking, new indications have appeared in clinical practice and besides stereotactic radiotherapy for intracranial metastases, the extracranial so-called oligometastic conditions can be maintained close to a curative state (or in remission) for many years. Among these, perhaps the most striking is the stereotactic radiotherapy treatment of liver, lung and spinal cord metastases in one or more fractions, for which the indispensable condition is the image or respiratory guided technique.

Pathologic complete remission after preoperative high-dose-rate brachytherapy in patients with operable cervical cancer: preliminary results of a prospective randomized multicenter study.

The role of preoperative intrauterine brachytherapy (BT) in the multidisciplinary treatment of early stage cervical carcinoma (ESCC) is controversial. In 2005, a prospective randomized multicenter study was initiated in Hungary in order to explore the potential advantages of preoperative high-dose-rate (HDR) BT. In this article we evaluate the efficiency of preoperative HDR BT by the rate of pathologic complete remission (pCR) in the first 185 patients enrolled in the study at the National Institute of Oncology and at the Uzsoki Municipal Cancer Center in collaboration with the 1st Department of Gynaecology and Obstetrics of Semmelweis University, Budapest, Hungary. In arm A, patients received 2x8Gy preoperative intracavitary HDR BT, while in arm B no preoperative treatment was given. In both arms patients underwent radical Wertheim (Piver III) hysterectomy. The pCR rate was 25.7% after preoperative HDR BT, while it was only 11.2% with surgery alone (p=0.03), in these cases the tumor was eliminated during the diagnostic excision or conisation. The rate of positive surgical margins was 1.5% after preoperative BT, while it was as high as 11.4% without preoperative RT (p=0.02). There was no significant difference in the local tumor control (LTC), distant metastases free survival (DMFS) and overall survival (OS) between the two arms. According to our preliminary results preoperative intracavitary HDR BT significantly increases the rate of pCR and decreases the rate of positive surgical margins in patients with ESCC. Longer follow-up is required to establish the possible impact of pCR on the ultimate LTC and OS.

[Novel irradiation techniques in the treatment of solid tumours. Radiotherapy for metastases]. / Új besugárzási technikák a szolid tumorok kezelésében. Metasztázisok sugárterápiája.

Novel developments in percutaneous radiotherapy, such as positron emission tomography/computed tomography, adaptive radiation planning, intensity modulation radiotherapy and intensity modulated arc therapy (RapidArc), as well as the newer generation of image control (cone-beam computed tomography) and image guided radiotherapy ensure increased dosages of planning target volume and clinical target volume of solid tumours without damaging surrounding tissues and providing maximal protection. By raising the dosages of planned target volume and clinical target volume, these novel technical developments have created new indications in the treatment of solid tumours. With the aid of the cone-beam computed tomography and image guided radiotherapy the organ metastasis (lung, liver, spinal cord) and the primary tumour can be treated safety and effectively. Hypofractionation, dose escalation and the use of stereotactic devices can probably decrease radiation damage. The authors review the most common forms of evidence-based fractionation schemes used in irradiation therapy.

[Current methods of chemoradiotherapy for locally advanced cervical cancer. Options for reduction of side-effects]. / A lokálisan elorehaladott méhnyakrák radiokemoterápiája napjainkban. Lehetoségek a mellékhatások csökkentésére.

The advantages of cisplatin based radiochemotherapy have been proven for over one and a half decades, particularly in the treatment of advanced solid tumours. In head and neck, and cervical tumours results of prospective studies are available. Those showed that both in the early and advanced stages, local control and overall survival rates are better than radiotherapy alone. The effect of cisplatin can be probably intensified with novel, more effective molecules, such as m-TOR inhibitors and tirapazamine. The authors review cisplatin and non-cisplatin based radiochemotherapy protocols, which improve previous treatment results. It should be considered, however, radiotherapy for cervical cancer can cause hematological, urogenital and intestinal toxicity, similarly to other combined treatments. The authors briefly outline international recommendations and their own experience for the prevention of these side-effects.

[Symptoms, diagnosis and treatment of radiation-induced enteritis]. / Sugárkezelés mellett fellépo bélgyulladások tünettana, diagnosztikája, terápiás lehetoségei.

The number of radiotherapy in the treatment of malignant diseases is increasing worldwide. During the radiotherapy of tumors in the minor pelvis and abdomen intestinal inflammation of different degree may occur even if special attention is paid. Irradiation to the minor pelvis causes in half of the cases radiation induced acute enteritis, whereas in 25% chronic enteritis and colitis will develop. Chronic enteritis following radiotherapy raises a number of diagnostic and therapeutic problems that can be solved only with cooperation of different specialties. Authors present a short review regarding therapeutical options of radiation induced enteritis.

Concomitant radiochemotherapy of cervical cancer: is it justified to reduce the dosage of cisplatin?

PURPOSE: To review the experiences regarding the therapeutic response and side effects of concomitant radiochemotherapy of cervical cancer carried out with different cisplatin doses. PATIENTS AND METHODS: At the Municipal Center for Oncoradiology, Budapest, Hungary, 92 patients with cervical cancer were treated with concomitant radiochemotherapy in the period between July 2002 and March 2007. The total dose of high-energy external radiation (megavoltage) treatment was 50.4 Gy with a fraction dose of 1.8 Gy on the small pelvis. Before irradiation, cisplatin 40 mg/m(2), 30 mg/m(2), or 20 mg/m(2) was administered once a week. RESULTS: In 17 cases, the cisplatin dose was 30 mg/m(2); during radiochemotherapy the number of cisplatin treatments was equal to or more than four in 14 patients (82%). After administering 40 mg/m(2) cisplatin to 64 patients, chemotherapy in four or more treatments could only be applied in 37 cases (58%). Eleven patients received cisplatin at the dose of 20 mg/m(2); in ten (91%) of them, the number of treatments was four or more. By comparing the side effects, it can be stated that hematologic side effects (mostly leukopenia) grade 3 occurred in 12% of the patients receiving cisplatin 30 mg/m(2), and grade G3-4 in 16% of the 40-mg/m(2) cisplatin group. For cisplatin 30 mg/m(2), 82% of hematologic side effects were in the G1 range. There was no significant difference between the 20- and 30-mg/m(2) regimens. As for the gastrointestinal toxicity, similar side effects grade 1 were detected, which occurred in 58% and 38% of the patients receiving 30 mg/m(2) and 40 mg/m(2), respectively. CONCLUSION: On the basis of a detailed analysis, the correlation between the number of treatments, the therapeutic and the side effects could be verified. In the course of dose reduction, there was no significant difference when comparing the results of therapy, however, the quality of life was better if cisplatin 30 mg/m(2) was administered instead of 40 mg/m(2). If cisplatin 20 mg/m(2) was given, the results were significantly worse. On the basis of the own results, it can be stated that the optimal weekly dose of cisplatin is 30 mg/m(2).

[PET/CT based radiotherapy treatment planning in head and neck cancers]. / PET/CT alapú besugárzástervezéssel szerzett tapasztalatok fej-nyaki tumorokban.

The purpose of this study was to evaluate the experiences of PET/CT based radiation planning in patients suffering from head and neck cancer. PET/CT based 3D-conformal irradiation was used in eleven patients between March 2008 and February 2009. In six of the eleven cases the therapeutic plan was modified after PET/CT examination, as the previously determined lymph node negative state proved to be lymph node positive. For that reason, the treatment needed to be completed by chemotherapy and in some cases clinical target volume and planning target volume have been also modified. PET/CT examination has a decisive influence on therapeutic planning and on the planning process in patients with head and neck cancer.

Quality Control of Portal Imaging with PTW EPID QC PHANTOM.

PURPOSE: Quality assurance (QA) and quality control (QC) of different electronic portal imaging devices (EPID) and portal images with the PTW EPID QC PHANTOM. MATERIAL AND METHODS: Characteristic properties of images of different file formats were measured on Siemens OptiVue500aSi, Siemens BeamView Plus, Elekta iView, and Varian PortalVision and analyzed with the epidSoft 2.0 program in four radiation therapy centers. The portal images were taken with Kodak X-OMAT V and the Kodak Portal Localisation ReadyPack films and evaluated with the same program. RESULTS: The optimal exposition both for EPIDs and portal films of different kind was determined. For double exposition, the 2+1 MU values can be recommended in the case of Siemens OptiVue500aSi Elekta iView and Kodak Portal Localisation ReadyPack films, while for Siemens BeamView Plus, Varian PortalVision and Kodak X-OMAT V film 7+7 MU is recommended. CONCLUSION: The PTW EPID QC PHANTOM can be used not only for amorphous silicon EPIDs but also for images taken with a video-based system or by using an ionization chamber matrix or for portal film. For analysis of QC tests, a standardized format (used at the acceptance test) should be applied, as the results are dependent on the file format used.

[Chemo- and radiotherapy of germ cell testicular cancer in the literature]. / Csírasejtes heredaganatok kemo- és sugárterápiája az irodalom tükrében.

The study reviews the incidence, histologic types and prognostic factors of testicular cancer. The measurement of tumor-marker levels before castration determine the further activity regarding the data of imagings. The authors explain the treatment of seminoma and non-seminoma by stages. Carboplatin monotherapy is equivalent to the irradiation in early seminoma cases. Nowadays applied second and third line chemotherapies are reviewed. It is necessary to take into consideration not only the remission rate but also the late toxicity during the complex treatment of testicular germ cell cancer.

[The first Hungarian radiotherapy department was founded at Uzsoki Street Hospital 75 years ago]. / 75 éves az önálló sugárterápia az Uzsoki utcai Kórházban.

The first Hungarian radiotherapy department treating cancer patients by using 226Ra brachytherapy was founded in the Uzsoki Hospital 75 years ago. This institution represented the European level of the 1930s. The authors are presenting a brief summary of the main activities and the technical development of the Municipal Oncoradiological Centre as well as scientific investigations at the beginning of the 21st century.

[Experience with only preoperative radiotherapy of non-metastatic rectal tumours]. / Nem metastaticus rectumtumorok egyedüli preoperatív besugárzásával szerzett tapasztalataink.

INTRODUCTION: It is an accepted fact that the local recurrence rate can be decreased up to 50% for the metastatic rectum tumours irradiated only preoperatively. MATERIALS AND METHODS: 181 patients having rectum tumour were irradiated preoperatively with 36 or 40 Gy between 1990 and 2001. The classification was made according to the modified Astler-Coller pathological staging system. The radiation treatment was carried out with telecobalt unit or high energy photon of linear accelerator after computerized radiation treatment planning. RESULTS: The most important characterizing factor for the efficiency of the preoperative irradiation is the local recurrence rate that was found to be 21.56% in our investigation. The survival rate was significantly influenced by the age of the patient and the applied dose. CONCLUSION: Our statistical analysis was applied to investigate the efficiency of the only preoperatively irradiated patients. The results are in agreement with the reported contributions.

Digitalization and networking of analog simulators and portal images.

BACKGROUND: Many departments have analog simulators and irradiation facilities (especially cobalt units) without electronic portal imaging. Import of the images into the R&V (Record & Verify) system is required. MATERIAL AND METHODS: Simulator images are grabbed while portal films scanned by using a laser scanner and both converted into DICOM RT (Digital Imaging and Communications in Medicine Radiotherapy) images. RESULTS: Image intensifier output of a simulator and portal films are converted to DICOM RT images and used in clinical practice. The simulator software was developed in cooperation at the authors' hospital. CONCLUSION: The digitalization of analog simulators is a valuable updating in clinical use replacing screen-film technique. Film scanning and digitalization permit the electronic archiving of films. Conversion into DICOM RT images is a precondition of importing to the R&V system.

[Simultaneous radiochemotherapy and endoluminal HDR brachytherapy in esophageal cancer]. / Simultane Radiochemotherapie mit intraluminaler HDR-Brachytherapie des Osophaguskarzinoms.

PURPOSE: To study efficacy and toxicity of radiochemotherapy in esophageal cancer including initial endoluminal high-dose-rate brachytherapy (HDR-BT). PATIENTS AND METHODS: Between 01/1995 and 06/2005, 61 patients with esophageal cancer were treated preoperatively with definitive and palliative intent. Treatment started with intraluminal HDR-BT for recanalization of the esophagus (single fraction size of 8 Gy in 0.5 cm depth, three times, q7d) followed by external-beam radiation therapy (50 Gy total dose, 5 x 2 Gy/week, 25 fractions in 5 weeks). Chemotherapy was started simultaneously with external irradiation (three courses of cisplatin and 5-fluorouracil, q21d). RESULTS: Swallowing function improved in 55/61 patients (dysphagia classification according to the RTOG), and worsened in 6/61 patients, respectively. Median duration of symptomatic improvement was 11 months, median follow-up 12 months (range 3-68 months). Following simultaneous radiochemotherapy, tumor resectability was achieved in 7/25 patients of the neoadjuvant group, and the histological specimen showed complete remission in 6/7 patients. CONCLUSION: These results indicate a favorable effect of simultaneous radiochemotherapy starting with endoluminal HDR-afterloading-( AL-)BT in esophageal cancer.

[Radiotherapy of pituitary tumours]. / A hypophysisdaganatok radioteráipiáija.

In this article, the role of conventional radiotherapy and radiosurgery in the management of pituitary tumors is discussed. After a brief review about the mechanism of action and different techniques of irradiation therapy, the therapeutic effectiveness and side effects are analysed in the various types of pituitary tumors. Conventional fractionated radiotherapy has long been used to control growth and/or hormonal secretion of residual or recurrent pituitary tumors. Nevertheless, there is still a controversy concerning patient selection for radiotherapy, because several potentially significant side effects including hypopituitarism may develop. Stereotactic radiosurgical methods may have several advantages over conventional radiotherapy; they can be applied, for example, in patients with residual or recurrent pituitary tumors who had previously received conventional radiotherapy. However, long-term follow-up data with these relatively new techniques are still limited.