[Reducing the risk of radiation-induced cardiotoxicity in patients with left breast tumor]. / A sugárkezelés okozta cardiotoxicitas kockázatának csökkentése bal oldali emlotumoros betegek kezelése során.

INTRODUCTION: Breast cancer is one of the most common malignancies affecting women. Treatment with drugs and radiotherapy increases the incidence of late cardiovascular disease. It is therefore particularly important to protect the heart from radiation exposure. METHOD: We prepared an irradiation plan for 45 patients with left breast cancer using deep breathing and normal breathing techniques. The plans were compared and analyzed. The irradiation plans were created in the Philips Pinnacle v. 16 planning system. RESULTS: At the same target volume coverage, the use of the deep breathing technique leads to a reduction of the dose burden to the heart and to the left descending coronary branch, thus reducing the incidence of late cardiovascular complications. DISCUSSION: The results obtained show that the use of the deep breathing technique during adjuvant radiotherapy of left-sided breast cancer patients has a beneficial effect on the radiation exposure of the heart. Our results are in good agreement with similar data from national centres. We were not only able to maintain planning target volume coverage, but also to achieve an improvement of 1%. There is a significant difference in dose to the heart and coronary artery. By using the deep breathing technique, we were able to reduce the average cardiac dose by almost half (deep breathing: 2.87 Gy, normal breathing: 5.4 Gy). The coronary exposure was reduced from 19.5 Gy to 10.98 Gy. CONCLUSION: The accuracy of treatment can be further improved by using a respiratory gating system with a surface-guided radiotherapy system. The successful use of deep breathing technique requires professionalism of the treatment staff and good patient cooperation. It is less equipment intensive than a respiration-guided system. The deep breathing technique is no longer considered state-of-the-art in the era of breath-holding, but the experience gained in our department is worth describing because of its relevance to oncocardiology. Orv Hetil. 2023; 164(11): 420-425.

Familial clustering of nasopharyngeal carcinoma in a non-endemic geographical region. Report of two Hungarian cases and a review of the literature.

The aim of this study was to investigate the familial clustering of nasopharyngeal carcinoma (NPC) in a non-endemic geographical region on the basis of two case reports and a review of the literature. Following an upper respiratory infection, NPC (WHO type III) was detected in a 57-year-old female (Case 1) who presented with nasal symptoms and a year later in her 36-year-old son (Case 2) who presented with enlarged lymph nodes. After a full diagnostic work-up, cT2a cN0 cM0 (stage IIA; Case 1) and cT2a cN2 cM0 (stage III; Case 2) disease were identified, and telecobalt irradiation was administered to both patients. The mother achieved complete remission and has been disease-free during a 14-year follow-up period. After initial complete remission, the son experienced regional (cervical) and base of the skull relapses within 2 years, which were treated unsuccessfully by means of radical neck dissection, a second course of radiotherapy and chemotherapy. Epstein-Barr virus (EBV) was detected in pathology sections from both patients. The authors review 20 additional well-documented cases of familial clustering of NPC in non-endemic geographical regions from the English language literature. This clinical entity typically has WHO type III histology; it may occur following an upper respiratory tract infection, and EBV-related serological titers were elevated in all 20 investigated cases. No consequent promoting factors were identified. The present two cases and the review of the literature strongly suggest that familial clustering of NPC in non-endemic geographical areas may be related to EBV infections. The difference in outcome of our two cases may be explained by the fact that the disease in Case 2 was diagnosed 1 year later than that in Case 1 and hence at a more advanced stage.

Increased metabolic activity in the spinal cord of patients with long-standing Lhermitte's sign.

PURPOSE: To investigate the pathophysiology of the radiation-induced, chronic Lhermitte's sign (LS) on the basis of long-standing case histories with partial functional recovery. PATIENTS AND METHODS: As radiotherapy in two nasopharyngeal cancer patients, a biologically effective dose (BED) of 103.8 Gy(2) (case 1) and 94.8 Gy(2) (case 2) was delivered to the cervical spinal cord. Neurologic signs relating to the irradiated spinal cord segments developed after 2 months (case 1) and 5 years (case 2), with radiation-induced damage equivalent to grade 3 (case 1) and grade 2 (case 2) toxicity (Common Toxicity Criteria, Version 2.0). The clinical status improved to grade 2 (case 1) and grade 1 (case 2). Positron emission tomography (PET) and fibroblast clonogen assay were applied 25 and 7 years postirradiation, respectively, to characterize this rare clinical picture. RESULTS: PET demonstrated increased [(18)F]fluorodeoxyglucose (FDG) accumulation and [(15)O]butanol perfusion, but negligible [(11)C]methionine uptake in the irradiated spinal cord segments in both patients. In clonogenic assays, fibroblasts from case 1 displayed much higher radiation sensitivity than in healthy controls, while in case 2 the fibroblasts sensitivity was normal. CONCLUSIONS: These data suggests a close direct relationship between regional perfusion and metabolism of the spinal cord, similarly as in the brain. The postirradiation recovery may be related to energy-demanding conduction, explaining the increased metabolism and perfusion. The increased radiosensitivity and higher spinal cord BED may have contributed to the more severe sequelae in case 1.

Reirradiation of locally recurrent nasopharyngeal carcinoma.

PURPOSE: To study the efficacy of reirradiation as salvage treatment in patients with locally recurrent nasopharyngeal carcinoma. PATIENTS AND METHODS: Between 1993 and 2000, 20 consecutive patients (twelve males and eight females) with nasopharyngeal cancer, previously irradiated in different Hungarian institutions, were reirradiated for biopsy-proven locally recurrent tumor. Histologically, 85% of the patients had WHO type III, 5% type II, and 10% type I disease. Stages I-IV (AJCC 1997 staging system) were assigned to five (25%), seven (35%), five (25%), and three (15%) patients, respectively; none of them had distant metastases, and only eight (40%) displayed regional dissemination. The median time period between termination of primary treatment and local recurrence was 30 (range, 10-204) months. Brachytherapy was the method most frequently used: in ten cases alone (especially for rT1 tumors), and in eight cases in combination with external beam therapy. Two patients with locally advanced disease underwent external beam therapy only. The median dose in the event of brachytherapy alone was 20 Gy (4 x 5 Gy or 5 x 4 Gy, range, 16-36 Gy), and the dose range for exclusive external irradiation was 30-40 Gy. In cases of combined irradiation, a median 20-Gy brachytherapy (range, 16-40 Gy) was associated with 30-40 Gy of external irradiation. Radiotherapy was supplemented by neck dissection (six patients), nasopharyngectomy (one patient), or chemotherapy (eleven patients). RESULTS: 16 patients were reirradiated once, three twice, and one patient three times, with a median equivalent dose for tumor effect of 36 Gy (mean, 44 Gy; range, 19-117 Gy; the estimated alpha/beta-ratio was 10 Gy). The median equivalent dose of reirradiation for late effect on normal tissue (with an estimated 70% delivery of the tumor dose) amounted to 30 Gy (mean, 37 Gy; range, 13-101 Gy, estimated alpha/beta-ratio 3 Gy). After a median follow-up of 37 (range, 12-72) months, the overall survival was 60% (12/20). Seven of the twelve surviving patients are currently tumor-free. After primary irradiation, xerostomy occurred in all patients as an unavoidable side effect of treatment. Following reirradiation, a severe (grade 3 or higher) late toxicity (CTC criteria, version 2) has been observed in two tumor-free patients (10%) so far (necrosis of soft palate and paresis of glossopharyngeal nerve). CONCLUSION: Retreatment of nasopharyngeal carcinoma with radiotherapy (preferably a combined modality), can result in longterm local control and survival in a substantial proportion of patients, at the price of an acceptable morbidity.

[Repeated radiotherapy in locally recurrent nasopharyngeal cancer]. / Az epipharynxrák lokális kiújulásának ismételt sugárkezelése.

PATIENTS AND METHODS: In the period between 1993 and 2000, 20 patients with nasopharyngael cancer were re-irradiated for locally recurrent carcinomas. The median duration between primary treatment and recurrence was 30 months. Brachytherapy was the method most frequently used in 10 cases alone, and in 8 cases in combination with external beam therapy. 2 patients underwent only external beam therapy. The external irradiation was performed with CT/MRI-based treatment planning. Brachytherapy involved a high dose rate afterloading method. The cumulative dose of re-irradiation was 20-60 Gy. RESULTS: After a median follow-up of 37 months the overall survival and the local control were 60% (12/20) and 58% (7/12), respectively. 7 of the 12 surviving patients are currently tumour-free. After primary irradiation xerostomy occurred in all patients as an unavoidable side-effect of the treatment. A severe (grade 3 or higher according to the Common Toxicity Criteria version 2.0) late-side effect has so far been observed in 2 cases (10%). Authors' results lie in the medial range of the data in the international literature, though the rate of radiogen side-effects in the patient group is low. Both results are assumed to be a consequence of the re-irradiation dose being lower than the value considered optimum in the recent literature. CONCLUSIONS: Re-irradiation of locally recurrent nasopharyngeal cancers is an efficient treatment modality, which should be used as a combination of external beam therapy and brachytherapy. The optimum cumulative dose is about 50-60 Gy. This dose results in a 5 years survival rate of about 40% with an acceptable (30%) risk. The results of re-irradiation may be improved, if PET is used to determine the extent of the surviving tumour tissue. This can help in the choice of the proper treatment modality.

[PET scan in patients with epipharyngeal tumors]. / Epipharynx-daganatok PET-vizsgálata.

Whole-body FDG PET examinations in 10 cases of epipharyngeal tumour (8 males, 2 females, mean age: 48 years) have been performed since January 1999. The PET examinations were aimed at the accurate staging, follow-up of the patients after the treatment, identification of recurrencies and localization of the unknown primary tumor. Functional imaging resulted in "upstaging" in 3 patients as compared to staging by the conventional diagnostic tools. Four additional patients with hyperplastic epipharyngeal tissue were investigated for occult primary cancer after negative results of multiple excisions, resulting in one case of primary epipharyngeal cancer. Correct staging, early detection of recurrencies, localization of occult primary tumor and the better post-therapeutic assessment of epipharyngeal masses all facilitate a more reasonable therapeutic approach, which may improve survival results.