[Image-guided radiotherapy for muscle invasive bladder cancer with intravesical lipiodol injection. A new option for bladder sparing treatment]. / Izominvazív hólyagrák képvezérelt sugárkezelése intravesicalisan befecskendezett lipiodolos jelöléssel. A hólyagmegtartó kezelés új lehetosége.

INTRODUCTION AND AIM: To implement lipiodol as a fiducial marker of the tumor bed for image-guided radiotherapy with simultaneous integrated boost technique as part of radiochemotherapy for muscle invasive bladder tumors. METHOD: Since April 2016, radiochemotherapy was performed in 3 male patients with muscle invasive, transitional cell bladder carcinoma. Prior to radiochemotherapy, tumor bed resection was performed for each patient, at the same time 10 ml of lipiodol solution was injected submucosally into the resection site, thus marking the tumor bed for escalated dose irradiation. During radiochemotherapy 51 Gy (1.7 Gy/die) to the pelvis, 57 Gy (1.9 Gy/die) to the whole bladder, and 63 Gy (2.1 Gy/die) to the lipiodol-labeled tumor bed was delivered with simultaneous integrated boost technique. The accuracy of the irradiation was controlled by daily kilovoltage CT. Early radiogenic urogenital and gastrointestinal side effects were recorded according to Radiation Therapy Oncology Group side-effects grading recommendation. RESULTS: Substantial perioperative side effect or toxicity were not observed during and after the injection of lipiodol. The prescribed dose was successfully delivered in all patients. Radiotherapy duration was 6 weeks. The lipiodol-labeled tumor bed was clearly visible on daily kilovoltage cone beam CT. In one patient grade II cystitis and proctitis was observed, another patient experienced only grade I cystitis. These complaints improved with symptomatic medication. In the third patient no significant side effect occurred. CONCLUSIONS: The injection of lipiodol into the bladder wall is a safe technique, without any perioperative toxicity or complication. The tumor bed demarcated by lipiodol was visible both on treatment planning and kilovoltage CTs. The total treatment time was shortened by 4 days. The treatment was well tolerated, early side effects were moderate, or slight. Orv Hetil. 2017; 158(51): 2041-2047.

[Radiotherapy of soft tissue sarcomas of the extremities and superficial trunk]. / A végtag és a törzsfelszín lágyrészszarkómáinak sugárkezelése.

Soft tissue sarcomas represent a histopathologically and clinically heterogeneous group of tumors that make up around 1% of malignancies, in which soft tissue sarcomas of the extremities and superficial trunk (STSET) are treated with more or less the same strategy. Over the past 30 years, there has been a migration away from amputation and radical ablative surgical procedures for localized STSET toward more conservative, function-preserving surgery combined with radiotherapy +/- chemotherapy. The latter complex treatment ensures equal local control to radical surgery. This multidisciplinary management includes organ sparing surgery as the main procedure but also radiotherapy of different types applied before, during or after the surgery, chemotherapy depending of the stadium of the tumor and plastic, reconstructive surgery, and last but not least rehabilitation of the patient after treatment. In this publication we overview the practical guidelines for the treatment of STSET based on the available literature from the last decades. Indication and timing of radiotherapy of STSET as well as available external beam and brachytherapy techniques are summarized. The prescribed radiation dose, the role of alternative fractionations, the combination of radiotherapy and systemic chemotherapy, hyperthermia or limb perfusion regards to STSET are also discussed. Practical considerations of radiotherapy, the target volumes and the role of newer radiotherapy technology in STSET treatment are overviewed.

[Use of gold radionuclide markers implanted into the prostate for image-guided radiotherapy in prostate cancer: side effects caused by the marker implantation]. / A prosztatába ültetett aranymarkerek alkalmazásának bevezetése prosztatarákos betegek képvezérelt sugárkezeléséhez. A beültetés okozta mellékhatások ismertetése.

The purpose of the study was to introduce the use of the gold radiopaque markers implanted into the prostate for image-guided radiotherapy of prostate cancer patients and to present the side effects caused by the marker implantation. Between November 2011 and November 2013, three radiopaque, gold-plated markers (Best Medical International, Springfield, VA, USA, 1.0 mm x 3.0 mm) were implanted transperineally into the prostate of 60 patients under transrectal ultrasound guidance. Local anaesthesia was performed in all patients. A week after the procedure the patients filled in a questionnaire regarding the pain, dysuria, urinary frequency, nycturia, rectal bleeding, haematuria, haematospermia or fever symptoms caused by the implantation. The pain caused by the intervention was scored on a 1-10 scale, where 1 was a very weak and 10 was an unbearable pain. Ten days after the implantation a treatment planning CT was performed and subsequently patients started intensity-modulated radiation therapy (IMRT) within one week. During the treatments markers were used for daily verification and correction of patient's setup. No patients experienced fever or infection. Based on the questionnaires nobody experienced dysuria or rectal bleeding after implantation. Among the 60 patients studied, five (8 %) had haematospermia, nine (15 %) haematuria, which lasted in average of 3.4 and 1.8 days, respectively. The average pain score on 1-10 scale was 4.2 (range: 0-9). After the marker implantation 18 patients (30%) reported less, 10 patients (17%) more, and 27 patients (45%) equal amount of pain compared to biopsy. Five patients, who had a biopsy performed under general anaesthesia, did not answer this question. None of the patients needed analgesics after implantation. The gold marker implantation implemented for image-guided radiotherapy was well tolerated under a local anaesthesia. The complications were limited, rate and frequency of perioperative pain was comparable to the pain caused by biopsy. After implantation, the patients did not require analgesics. The method can be performed safely in clinical practice.

[Patient positioning using in-room kV CT for image-guided radiotherapy (IGRT) of prostate cancer]. / Kilovoltos CT-vel végzett betegbeállítás vizsgálata prosztatarákos betegek képvezérelt külsõ besugárzásakor.

The purpose of the study was to evaluate accuracy of patients' set up verified by kV CT-on-rails system and compare automatic and manual image registration of planning and verification kVCT-s. Between January 2001 and March 2011, at ten patients with prostate cancer the clinical target volumes (CTVs) for prostate (CTV-PROS), and prostate plus caudal 1 cm of seminal vesicles (CTV-PVS) with or without pelvic lymph node region were contoured on the treatment planning CT, according to risk category of the patient. Planning target volumes (PTVs) were created with 1 cm margin extended around the CTVs in each direction. The isocentre was marked on the skin with three radiopaque markers. After the set up, treatment couch with the patient was turned by 180 degree and images were acquired of the region of the isocentre with a kV helical CT-on-rails system (treatment CT). An image registration software was used to co-register planning and treatment CT images. Automatic CT image co-registration was followed by manual co-registration taking into account the CTV-PROS contour and soft tissue informations. Deviations of the isocentres in lateral (LAT), longitudinal (LONG) and vertical (VERT) directions were recorded after each image co-registration. Corresponding data were compared using the t-probe. Systematic (S) and random (s) errors of the set up were calculated. Adequate PTV to CTV margins were calculated by van Herk's formula (2.5xS + 0,7xs). Overall 252 deviations were analysed on fourty-two CT series of 10 patients. The mean errors of the set up with automatic and manual image co-registrations were 0.19 cm and 0.07 cm (p=0.001) in LAT, 0.05 cm and 0.03 cm (p=0.07) in LONG and 0.16 cm and 0.22 cm (p=0.16) in VERT directions, respectively. The systematic errors of the set up for automatic and manual image registrations were 0.22 cm and 0.26 cm in LAT, 0.17 cm and 0.18 cm in LONG, 0.25 cm and 0.26 cm in VERT directions, respectively. The random errors of the set up for automatic and manual image registrations were 0.31 cm and 0.26 cm in LAT, 0.27 cm and 0.27 cm in LONG and 0.24 cm and 0.33 cm in VERT directions, respectively. In case of manual image co-registration, the required PTV to CTV margins to cover at least 95% of the CTVs with at least 95% percent of the prescribed dose were calculated to 0.93 cm in LAT, 0.65 cm in LONG, and 0.89 cm in VERT directions. Patients set up can be verified with manual image co-registration based on soft tissues around the prostate using a kV CT-on-rails system installed in the treatment room. The difference between automatic and manual image co-registration was significant in LAT direction. A PTV to CTV margin <1 cm seems to be appropriate to cover the CTVs in image-guided prostate radiotherapy. These findings support our recent clinical protocol.