Predictors of urinary and rectal toxicity after external conformed radiation therapy in prostate cancer: Correlation between clinical, tumour and dosimetric parameters and radical and postoperative radiation therapy. / Factores predictivos de toxicidad urinaria y rectal tras radioterapia externa conformada en el cáncer de próstata: correlación de parámetros clínicos, tumorales y dosimétricos con radioterapia radical y postoperatoria.

OBJECTIVE: To determine rectal and urinary toxicity after external beam radiation therapy (EBRT), assessing the results of patients who undergo radical or postoperative therapy for prostate cancer (pancreatic cancer) and their correlation with potential risk factors. METHOD: A total of 333 patients were treated with EBRT. Of these, 285 underwent radical therapy and 48 underwent postoperative therapy (39 cases of rescue and 9 of adjuvant therapy). We collected clinical, tumour and dosimetric variable to correlate with toxicity parameters. We developed decision trees based on the degree of statistical significance. RESULTS: The rate of severe acute toxicity, both urinary and rectal, was 5.4% and 1.5%, respectively. The rate of chronic toxicity was 4.5% and 2.7%, respectively. Twenty-seven patients presented haematuria, and 9 presented haemorrhagic rectitis. Twenty-five patients (7.5%) presented permanent limiting sequela. The patients with lower urinary tract symptoms prior to the radiation therapy presented poorer tolerance, with greater acute bladder toxicity (P=0.041). In terms of acute rectal toxicity, 63% of the patients with mean rectal doses >45Gy and anticoagulant/antiplatelet therapy developed mild toxicity compared with 37% of the patients with mean rectal doses <45 Gy and without anticoagulant therapy. We were unable to establish predictors of chronic toxicity in the multivariate analysis. The long-term sequelae were greater in the patients who underwent urological operations prior to the radiation therapy and who were undergoing anticoagulant therapy. CONCLUSIONS: The tolerance to EBRT was good, and severe toxicity was uncommon. Baseline urinary symptoms constitute the predictor that most influenced the acute urinary toxicity. Rectal toxicity is related to the mean rectal dose and with anticoagulant/antiplatelet therapy. There were no significant differences in severe toxicity between radical versus postoperative radiation therapy.

Relaciones de la facultad de medicina con el hospital universitario. La enseñanza de la medicina clínica / Relationships between the medical school and the university hospital. The teaching of clinical medicine

Las nuevas necesidades en la formación de los futuros médicos, particularmente aquellas relacionadas con la definición, adquisición y evaluación de competencias, necesitan una potente estructura hospitalaria que soporte la docencia práctica en habilidades clínicas. El trascendente papel reservado a los hospitales universitarios significa que la institución sanitaria debe adaptarse para facilitar la implantación de una enseñanza de calidad, en aspectos estructurales y en el proceso de definición de objetivos y de evaluación de resultados a través de pruebas objetivas. Ellos implica cambios en la estructura, en la organización y en la gestión (AU)

The training of future doctors entails a series of new needs, especially in relation to the definition, acquisition and evaluation of abilities, and this requires the backing of a powerful hospital structure that ist capable of offering the practical teaching and learning of clinical skills. The fundamental role played by university hospitals means that the health care institution must adapt itself to facilitate the implementation of high quality teaching, both as regards structural aspects and in the process of defining aims and evaluationg results by means of objective testing. This involves changes in the structure, the organisation and management (AU)

Phase II trial: concurrent radio-chemotherapy with weekly docetaxel for advanced squamous cell carcinoma of head and neck.

INTRODUCTION: Standard fractionation radiation therapy (RT) combined with concomitant chemotherapy (CT) based on cisplatin schemes is actually the standard treatment for locally advanced non-resectable squamous cell carcinoma of head and neck (SCCHN). The appearance of taxoids has introduced a new kind of treatment with high antitumoral power. The aim of this study is to add more information about the role of this new approach. MATERIALS AND METHODS: Twenty-six patients with locally advanced non-resectable SCCHN were recruited at six institutions in Spain, between January 2001 and January 2003. Docetaxel was administered weekly, for 6 weeks, concurrently with RT. RESULTS: The mean total delivered dose of RT was 70'2 Gy (range 64-74 Gy). The median and mean duration of time were 63 days and 61 days (range 49-103 days) respectively. After a median time control of 19 months (range 3.3-42.2 months), the response rate was 83.4%. The median time to local progression was 16.4 months (95% confidence interval [CI]=4.4-28.4 months). The median survival time was 26.9 months, with one- and two-year overall survival of 66.9% (95% CI=48.1-85.7%) and 57.5% (95% CI=37.3-77.7%) respectively. The median duration time response was 15.1 months (95% CI=3.7-26.5 months). The median time until treatment failure was 9.4 months (95% CI=4.7-14.1). Incidence of grade III-IV mucositis was 88%, neutropenia 72% and skin toxicity 92% (24% grade III-IV). The incidence of severe late toxicity (grade III and IV) due to RT/CT was 31.4%. CONCLUSIONS: Although therapeutics results are equivalent to cisplatin schemes of concurrent CT-RT, mucositis and cutaneous toxicity registered in this trial must be considered as limiting factors to application of this new approach.

[Impact of FDG-PET in therapeutic management of patients with suspected recurrence of head and neck cancer]. / Impacto de la PET-FDG sobre el manejo terapéutico de pacientes con sospecha de recurrencia tumoral por cánceres de cabeza y cuello.

OBJECTIVE: This study aims to evaluate the impact of Positron Emission Tomography on therapeutic decisions in patients with suspicion of recurrence of head and neck cancers. MATERIAL AND METHODS: The diagnostic and therapeutic impact of FDG-PET was evaluated in 59 of 60 studies performed in a sample of 54 patients. The impact was graded on five levels (high, moderate, low, no impact and negative impact) following the Hicks et al. classification modified by us. RESULTS: The FDG-PET impact was high in 28 studies (47.46 %), moderate in 7 (11.86 %), low in 20 (33.90 %), no impact in 3 (5.09 %) and finally negative impact in 1 study (1.69 %). CONCLUSIONS: FDG-PET is useful in the management of patients in 59.32 % of the studies with indeterminate physical examination and conventional imaging tests. This paper supplies new data since we did not find any studies showing statistical results on therapeutic impact of FDG-PET in head and neck cancers in a systematic review of the literature made by our group.

Comparación entre la PET 18F-FDG y las técnicas de imagen convencionales (TACy RMN) en el diagnóstico de sospecha de recurrencia de tumores de cabeza y cuello / Comparison between 18F-FDG PET and conventional imaging techniques (CT SCAN and MRI) in the diagnosis of head and neck tumor suspicion of recurrence

Objetivo: El propósito de este estudio fue evaluar los resultados obtenidos con la Tomografía por Emisión de Positrones (PET) y con los métodos de imagen anatómicos convencionales (TAC y RMN), en el diagnóstico de sospecha de recurrencia tumoral en cánceres de cabeza y cuello. Pacientes y métodos: Se revisaron retrospectivamente 30 pacientes con sospecha de recidiva tumoral por cánceres de cabeza y cuello, a los que les fueron realizados 34 estudios PET. Las imágenes fueron obtenidas en el Instituto PET de Madrid. Se interpretaron mediante análisis visual y semicuantitativo. La confirmación de los resultados se hizo por seguimiento clínico, respuesta a tratamiento o estudio histológico. Resultados: La sensibilidad y especificidad de la PET fueron 95,6% y 81,8% respectivamente, mientras que para la TAC/RMN fueron de 65% y 80%. Conclusiones: Podemos concluir que la PET aporta mejores resultados que las técnicas de imagen convencionales en la detección de recurrencia tumoral

Background: This study aimed to assess the results obtained with the positron emission tomography (PET) and conventional anatomic imaging methods (CT scan and MRI) in the diagnosis of suspicion of tumor recurrence in head and neck cancers. Methods: Thirty patients with suspicion of tumor recurrence due to head and neck cancers were reviewed retrospectively. Consequently, 34 PET studies were performed. The images were obtained in the PET Institute of Madrid. They were interpreted by visual and semiquantitative analysis. The results were confirmed with clinical followup, response to treatment or with histological studies in some cases. Results: Sensitivity and specificity of the PET were 95.6% and 81.8% respectively, while it was 65% and 80% for the CT scan/MRI. Conclusions: We can conclude that PET provides better results than conventional imaging techniques in the detection of head and neck cancer recurrence

Impacto de la PET-FDG sobre el manejo terapéutico de pacientes con sospecha de recurrencia tumoral por cánceres de cabeza y cuello / Impact of FDG-PET in therapeutic management of patients with suspected recurrence of head and neck cancer

Objetivo. El propósito de este estudio es evaluar el impacto de la tomografía por emisión de positrones (PET) sobre las decisiones terapéuticas en pacientes con sospecha de recidiva tumoral de cánceres de cabeza y cuello. Material y métodos. El impacto diagnóstico y terapéutico de la PET-FDG fue evaluado en 59 de los 60 estudios llevados a cabo en una muestra de 54 pacientes. La gradación del impacto se hizo en 4 niveles (alto, moderado, bajo, no impacto e impacto negativo), siguiendo la clasificación de Hicks et al modificada por nosotros. Resultados. El impacto de la PET con 18F-fluorodeoxiglucosa (PET-FDG) fue alto en 28 estudios (47,46 %), moderado en 7 (11,86 %), bajo en 20 (33,90 %), no impacto en 3 (5,09 %) y finalmente impacto negativo en un estudio (1,69 %). Conclusiones. La PET-FDG es útil en el manejo de pacientes en el 59,32 % de los estudios con exploración física y pruebas de imagen convencionales indeterminadas. Este trabajo aporta datos novedosos, ya que en una revisión sistemática de la literatura realizada por nuestro equipo, no encontramos estudios que mostraran resultados estadísticos sobre el impacto de la PET-FDG en cánceres de cabeza y cuello

Objective. This study aims to evaluate the impact of Positron Emission Tomography on therapeutic decisions in patients with suspicion of recurrence of head and neck cancers. Material and methods. The diagnostic and therapeutic impact of FDG-PET was evaluated in 59 of 60 studies performed in a sample of 54 patients. The impact was graded on five levels (high, moderate, low, no impact and negative impact) following the Hicks et al. classification modified by us. Results. The FDG-PET impact was high in 28 studies (47.46 %), moderate in 7 (11.86 %), low in 20 (33.90 %), no impact in 3 (5.09 %) and finally negative impact in 1 study (1.69 %). Conclusions. FDG-PET is useful in the management of patients in 59.32 % of the studies with indeterminate physical examination and conventional imaging tests. This paper supplies new data since we did not find any studies showing statistical results on therapeutic impact of FDG-PET in head and neck cancers in a systematic review of the literature made by our group

[Comparison between 18F-FDG PET and conventional imaging techniques (CT SCAN and MRI) in the diagnosis of head and neck tumor suspicion of recurrence]. / Comparación entre la PET 18F-FDG y las técnicas de imagen convencionales (TAC y RMN) en el diagnóstico de sospecha de recurrencia de tumores de cabeza y cuello.

BACKGROUND: This study aimed to assess the results obtained with the positron emission tomography (PET) and conventional anatomic imaging methods (CT scan and MRI) in the diagnosis of suspicion of tumor recurrence in head and neck cancers. METHODS: Thirty patients with suspicion of tumor recurrence due to head and neck cancers were reviewed retrospectively. Consequently, 34 PET studies were performed. The images were obtained in the PET Institute of Madrid. They were interpreted by visual and semiquantitative analysis. The results were confirmed with clinical follow-up, response to treatment or with histological studies in some cases. RESULTS: Sensitivity and specificity of the PET were 95.6% and 81.8% respectively, while it was 65% and 80% for the CT scan/MRI. CONCLUSIONS: We can conclude that PET provides better results than conventional imaging techniques in the detection of head and neck cancer recurrence.

Oncología Radioterápica en el Hospital. Un modelo viable para la integración en gestión, asistencia, docencia e investigación / Radiotherapeutic Oncology in the Hospital. A viable model for integration in management, care, teaching and investigation

La gestión clínica en Oncología Radioterápica (OR) debe organizar la práctica asistencial, la docencia y la investigación desde un compromiso de innovación permanente. Su ámbito de actuación, estrictamente hospitalario, unido a una práctica sujeta a una exigente normativa legal, hacen de la OR una especialidad exigente en su compromiso asistencial. En el presente capítulo, se analizan las características diferenciadoras de la OR, así como la integración en la gestión de la asistencia, la docencia y la investigación, sin olvidar sus limitaciones y la necesaria relación con otras especialidades (AU)

This work analyses the differentiating characteristic of Radiotherapeutic Oncology, as well as its integration in the management of care, teaching and investigation, without forgetting its limitations and the necessary relation with other specialties (AU)

[Preservation of the bladder in rectal cancer with prostatic invasion]. / Preservación de la vejiga en el cáncer de recto con invasión de la próstata.

Colorectal cancer in the 2nd commonest cancer in Europe. In 5-10% of cases there is infiltration of urological organs. When infiltration affects the bladder or the prostate, anterior pelvic exenteration is the treatment that achieves the largest percentage of tumor free margins and the best 5-year survival. In very select cases of prostatic infiltration, the bladder can be preserved and prostatectomy and abdominoperineal block resection are carried out fulfilling oncological surgical requirements and producing an important improvement in the patient's quality of life. Owing to the very scarce published literature (two articles with three cases) we contribute our experience of 2 patients who received cytoreducing preoperative radiochemotherapy, prostatectomy and block abdominoperineal amputation and intraoperative radiotherapy. We describe the surgical technique used, which is substantially different from standard prostatectomy and requires good coordination between surgeons and urologists.

Preservación de la vejiga en el cáncer de recto con invasión de la próstata / Preservation of the bladder in rectal cancer with prostatic invasion

El cáncer colo-rectal es el 2º tumor en frecuencia en Europa. En el 5-10% de los casos existe infiltración de órganos urológicos. Cuando la infiltración afecta a la vejiga o a la próstata, la exenteración pelviana anterior es el tratamiento con el que se consiguen mayor porcentaje de márgenes quirúrgicos libres de tumor y mayores probabilidades de supervivencia a los 5 años. En casos muy seleccionados de infiltración prostática es posible preservar la vejiga, realizando una prostatectomía y amputación abdominoperineal en bloque cumpliendo con los requisitos quirúrgicos oncológicos y mejorando de forma importante la calidad de vida del paciente. Debido a la escasa bibliografía existente (dos artículos con 3 casos) presentamos nuestra experiencia en 2 pacientes a los que se les realizó radioquimioterapia preoperatoria citoreductora, prostatectomía y amputación abdominoperineal en bloque y radioterapia intraoperatoria. Describimos la técnica quirúrgica utilizada, que presenta diferencias sustanciales con la prostatectomía estándar y precisa de una buena coordinación entre el equipo de cirujanos y el de urólogos

Colorectal cancer in the 2nd commonest cancer in Europe. In 5-10% of cases there is infiltrationof urological organs. When infiltration affects the bladder or the prostate, anterior pelvic exenterationis the treatment that achieves the largest percentage of tumor free margins and the best 5-yearsurvival. In very select cases of prostatic infiltration, the bladder can be preserved and prostatectomyand abdominoperineal block resection are carried out fulfilling oncological surgical requirementsand producing an important improvement in the patient’s quality of life.Owing to the very scarse published literature (two articles with three cases) we contribute ourexperience of 2 patients who received cytoreducing preoperative radiochemotherapy, prostatectomyand block abdominoperineal amputation and intraoperative radiotherapy. We describe the surgicaltechnique used, which is substantially different from standard prostatectomy and requires goodcoordination between surgeons and urologists

Neuropsychological evaluation of children with intracranial tumors: impact of treatment modalities.

Antineoplastic treatment has a deleterious effect on intellectual functions, which is mainly attributable to radiotherapy. With the object of determining the neuropsychological disturbances associated with brain irradiation in the child, and to try to differentiate them from the effects caused by the other types of treatment (surgical and chemotherapy) as well as from the effects of the tumor itself, a cross-sectional study was carried out in 25 survivors of medial edge intracranial tumors. In order to monitor the effect of systemic chemotherapy on the cognitive functions, and the effect of prolonged absence from school, two control groups were formed, one made up of subjects treated with chemotherapy for extracranial tumors, and the other of patients with non-malignant chronic disease. Neuropsychological functions were measured using the Spanish version of the Wechsler scale, as well as the following tests: Spreen-Benton, ITPA and TALE scales, Yuste Memory Test, Thurstone Attention Test, and the Rey Complex Figure. In addition to a progressive decline found in the full scale intelligence quotient in children irradiated for intracranial tumors, variance analysis showed that these patients deteriorate mainly in visual attention and memory, but also significantly in verbal fluency and in the Performance Intelligence Quotient and all its subtests, when compared to the control groups. Visual attention and the Wechsler Picture Arrangement and Block Designs, were the tests whose decline correlated with the total radiation administered. The article relates this specific neuropsychological injury with the total brain irradiation dose but also with the structures located in the cone-down fields of irradiation to boost regions in the middle edge intracranial content.

Neuropsychological outcome of children after radiotherapy for intracranial tumours.

With the aim of determining the neuropsychological disturbances associated with cranial radiotherapy in the child, a cross-sectional study was carried out on 25 survivors of medial-edge intracranial tumours. Children irradiated for intracranial tumours experienced deterioration mainly in visual attention and memory, but also in verbal fluency, full-scale IQ, and performance IQ and all its subtests, compared with control groups. This deterioration progressed with time, finally involving at least abstract thought and verbal skills. The pattern of damage by irradiation varied according to the degree of brain maturity, therefore the younger the child at irradiation, the greater the decline in IQ and visual-constructive abilities, and the earlier the deterioration of visual memory and verbal skills.

[Intraoperative radiotherapy in the multidisciplinary treatment of malignant tumors in children. Preliminary results]. / Radioterapia intraoperatoria en el tratamiento multidisciplinario de tumores malignos infantiles. Resultados preliminares.

From September 1984 to March 1989, 57 children received intraoperative radiotherapy as part of a multidisciplinary tumor treatment. Their age ranged from 2 to 18 years. Tumor types: osteosarcoma, 21; Ewing's sarcoma, 19; soft tissue sarcomas, 6; neuroblastoma, 5; Wilm's tumor, 3; Hodgkin, 1; glioma, 1, and malignant pheochromocytoma, 1. In 44 patients the disease was localized while 13 had distant metastases. Intraoperative radiotherapy was used in 48 previously untreated patients as part of a radical treatment program and in 9 cases as an effort to rescue local failures (5 in previously irradiated areas). The intraoperative radiation field included the surgically exposed tumor or tumor bed, and the single doses ranged from 10 to 20 Gy, with 6-20 MeV electrons. With a median follow up time of 25 months (4 to 51 + months) 44 out of 57 patients are alive without local recurrence and 13 have died from tumor (6 with local progression). Intraoperative radiotherapy seems to be a feasible treatment which might promote local control in pediatric tumors.

[Hodgkin's disease and pregnancy]. / Enfermedad de Hodgkin y embarazo.

This is a short communication in which 2 cases of familiar Hodgkin's disease are reported. The first case is a 27 years old woman with the diagnosis of Hodgkin's disease, nodular sclerosis, stage III-B (with mediastinal, para-aortic and right supraclavicular involvement), treated initially with radical radiotherapy. She was pregnant at the time of diagnosis. The second case is a 15 years old woman with similar diagnosis of Hodgkin's disease stage II-A (with mediastinal and right supraclavicular involvement) and identical histology. She was the daughter of case 1. The observation of familiar Hodgkin's disease and its possible biological implications are discussed.

[The spectrum of lupus nephropathy]. / El espectro de la nefropatía lúpica.

Clinical manifestations and immunological characteristics in a series of 15 patients with systemic lupus erythematosus and renal involvement are presented. These findings have been correlated to different pathologic lesions and compared to another series of patients without renal involvement. The overall rate of renal involvement was 25 percent, with ages ranging from 14 to 47 years. A female predominance was noticed. Histopathologic findings were as follows: focal glomerulonephritis (five cases), and minimal changes (one case). Under a histological glomerulonephritis (two cases); membranous glomerulonephritis (one case), and minimal change (one case). Under a histological standpoint the earliest lesions had the worse prognosis. Patients with diffuse glomerulonephritis showed a high degree of renal function impairment. Urinary infection was present in half of the cases. A significant hyperlipidemia was found in patients with nephrosis. Proteinuria and abnormal urinary sediment were common findings in all histologic types. Antinuclear antibodies, were positive in 14 cases, with statistical significant high titres in diffuse glomerulonephritis. Serum immunoglobulins IgG and IgA were elevated. Decrease of serum complement levels (C3, C4, C3PA and C5) were found in patients with renal involvement.