BNCT research activities at the Granada group and the project NeMeSis: Neutrons for medicine and sciences, towards an accelerator-based facility for new BNCT therapies, medical isotope production and other scientific neutron applications.

The Granada group in BNCT research is currently performing studies on: nuclear and radiobiological data for BNCT, new boron compounds and a new design for a neutron source for BNCT and other applications, including the production of medical radioisotopes. All these activities are described in this report.

Spanish Society of Radiation Oncology clinical guidelines for stereotactic body radiation therapy in lymph node oligometastases

Data in the literature support the existence of a state of limited metastases or oligometastases. Favorable outcomes have been observed in selected patients with such oligometastases that are treated with local ablative therapies, which include surgical extirpation, stereotactic body radiation therapy (SBRT), and radiofrequency ablation. The role of SBRT in the setting of lymph node oligometastases is still emerging but the early results for local control are promising. However, the biggest challenge is to identify patients who will benefit from treatment of their oligometastatic disease with local aggressive therapy. Patients are initially categorized based upon examination of the initial biopsy, location, stage, and previous treatments received. Appropriate patient management with SBRT requires an understanding of several clinicopathological features that help to identify several subsets of patients with more responsive tumors and a good tolerance to SBRT. In an effort to incorporate the most recent evidence, here the Spanish Society of Radiation Oncology presents guidelines for using SBRT in lymph node oligometastases (AU)

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Spanish Society of Radiation Oncology clinical guidelines for stereotactic body radiation therapy in lymph node oligometastases.

Data in the literature support the existence of a state of limited metastases or oligometastases. Favorable outcomes have been observed in selected patients with such oligometastases that are treated with local ablative therapies, which include surgical extirpation, stereotactic body radiation therapy (SBRT), and radiofrequency ablation. The role of SBRT in the setting of lymph node oligometastases is still emerging but the early results for local control are promising. However, the biggest challenge is to identify patients who will benefit from treatment of their oligometastatic disease with local aggressive therapy. Patients are initially categorized based upon examination of the initial biopsy, location, stage, and previous treatments received. Appropriate patient management with SBRT requires an understanding of several clinicopathological features that help to identify several subsets of patients with more responsive tumors and a good tolerance to SBRT. In an effort to incorporate the most recent evidence, here the Spanish Society of Radiation Oncology presents guidelines for using SBRT in lymph node oligometastases.

Análisis descriptivo del tratamiento quirúrgico del cáncer de pulmón en los centros del sistema sanitario público de Andalucía. Proyecto vara II / Descriptive analysis of the surgical treatment of lung cancer at Public Health Hospitals in Andalusia: VARA Project II

Introducción: El cáncer de pulmón es el responsable de unas 3000 muertes cada año en Andalucía y, aunque la cirugía es el tratamiento de elección en estadios iniciales, menos del 20-25% son intervenidos. La Dirección del Plan Integral de Oncología de Andalucía (PIOA) realizó un estudio (Proyecto VARA I) sobre variabilidad y accesibilidad al tratamiento de radioterapia en 2003, observando una infrautilización manifiesta de este recurso en cáncer de pulmón. Esto motivó la puesta en marcha de un 2º estudio (VARA II) para evaluar el tratamiento locorregional, radioterapia y cirugía, del cáncer de pulmón en esta Comunidad. Material y métodos: Se evaluaron retrospectivamente las historias clínicas de los pacientes intervenidos en 2007 por cáncer de pulmón en los Hospitales Públicos de Andalucía. Se realizaron análisis descriptivos y de variabilidad entre los distintos equipos quirúrgicos. Resultados: Se evaluaron 418 pacientes, de los que 303 ofrecieron datos suficientes para el análisis. La edad media fue de 64 años (94% varones) con la siguiente distribución por estadios: I (60%), II (13%), III (21%), IV (6%). Se practicó tomografía de emisión de positrones (PET) en el 75% y mediastinoscopia en el 5%. La tasa de cirugía fue del 17% del total de casos esperados de cáncer de pulmón no células pequeñas. En el 97% de los casos se practicó linfadenectomía, la mayoría de ellas (72%) con un número de (..) (AU)

Introduction: Lung cancer is responsible of 3000 deaths every year in Andalusia. Although surgery is the elective treatment in early stages, less than 20-25% are operated on. The Direction of the Comprehensive Cancer Plan of Andalusia (PIOA) performed a study (VARA I Project) about variability and accessibility to radiation therapy in Andalusia in 2003, finding a clear infra utilisation in lung cancer. This motivated a second study (VARA II) to evaluate the locoregional treatment, both radiotherapy and surgery, of lung cancer in this region. Material and methods: Medical Records of patients operated in 2007 for lung cancer in Andalusian Public Hospitals were retrospectively evaluated. Descriptive analysis and studies of variability between surgical teams were performed. Results: Medical records of 418 patients were evaluated, 303 of them showing sufficient data for the analysis. Mean age was 64 (94% males), with the following stage distribution: I (60%), II (13%), III (21%), IV (6%). A PET was realized in 75% and mediastinoscopy in 5%. Surgery rate was 17% of the total expected cases of non small cell lung cancer. A lymphadenectomy was performed in 97%, the majority of them (72%) with less than 10 nodes resected. A good clinical and pathological concordance was demonstrated and low values of perioperative mortality (6%). Inter-hospitals variability study showed significant differences on histology, PET use, number of mediastinal nodes resected and reintervention rate. Discussion: The estimated surgical rate is similar to the published by other authors, although with a larger percentage of advanced stages III-IV. An important variability in patterns of care is demonstrated. Last, a low use of diagnostic mediastinoscopy is highlighted, while the use of PET for preoperative mediastinal evaluation is increasing, especially when the hospital owns the technique (AU)

Implementation of a comprehensive cancer plan. A health planning experience

Here we describe the working method used to implement an Integrated Cancer Health Plan in Andalusia (Spain) and to set out some of the lines of work for improving quality of care and health network planning. Four main initial considerations were made: (1) work must be centred on patients and respect for their autonomy; (2) cancer requires action at every healthcare level; (3) integration of expert professionals is to be encouraged; and (4) relevant information and data should be systematically used for planning. Two operative approaches were also established: structured participation and evidence-based healthcare. This methodology was used in various planning programmes, largely in relation to healthcare resources. In this article, as examples, we describe the development of two types of programmes: one for radiotherapy equipment and another for the management of lymphoedema in breast cancer patients. Analysis of results obtained against cancer is always controversial. It is necessary to review the healthcare structure used in terms of effectiveness and excellence. Comprehensive or integrated health plans are a useful model for a wide-ranging and multi-level approach to cancer. The structured and real participation of experts and an evidence- based healthcare strategy proved very useful in this public health planning experience (AU)

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Evidence-based estimation and radiotherapy utilisation rate in Andalusia.

INTRODUCTION: The objective of this study was to estimate the theoretical needs -based on evidence- of radiotherapy treatments (RDT) in Andalusia, compare these needs with actual use of RDT in 2006 and analyse their evolution from 2003. MATERIALS AND METHODS: Correlation between quantitative variables was analysed with Pearson's correlation coefficient. This dealt with differences between administered/estimated treatments and treatments carried out in years with the Student's t-distribution, and the Xi2 test among qualitative variables. RESULTS: In Andalusia, the evidence-based rate of cancer irradiation is 55%. Eighty-five percent of theoretical treatments were administered in 2006. From this group, 107% were in gynaecological tumours, 100% in breast cancer cases, 71% in head and neck cancer and 48% in lung cancers; differences in the last two conditions were significant (p<0.01). As for regional distribution, differences were reported with reference to irradiation rates (p<0.0002) and resource distribution. In the last three years, an increment of 17% was observed in treatments conducted in public hospitals. The rate increased from 61% (with regard to optimal values) to 85% in 2006; in a parallel way, an increment was seen in therapy units (from 22 to 26) and radiation oncologists (from 57 to 69). CONCLUSIONS: Despite the increment of irradiation rates seen in the last years, there is still a serious underutilisation of RDT for some cancer types (lung, head and neck cancer), as well as a great variability in the use of RDT between hospitals.

Evidence-based estimation and radiotherapy utilisation rate in Andalusia

INTRODUCTION: The objective of this study was to estimate the theoretical needs -based on evidence- of radiotherapy treatments (RDT) in Andalusia, compare these needs with actual use of RDT in 2006 and analyse their evolution from 2003. MATERIALS AND METHODS: Correlation between quantitative variables was analysed with Pearson's correlation coefficient. This dealt with differences between administered/estimated treatments and treatments carried out in years with the Student's t-distribution, and the Xi2 test among qualitative variables. RESULTS: In Andalusia, the evidence-based rate of cancer irradiation is 55%. Eighty-five percent of theoretical treatments were administered in 2006. From this group, 107% were in gynaecological tumours, 100% in breast cancer cases, 71% in head and neck cancer and 48% in lung cancers; differences in the last two conditions were significant (p<0.01). As for regional distribution, differences were reported with reference to irradiation rates (p<0.0002) and resource distribution. In the last three years, an increment of 17% was observed in treatments conducted in public hospitals. The rate increased from 61% (with regard to optimal values) to 85% in 2006; in a parallel way, an increment was seen in therapy units (from 22 to 26) and radiation oncologists (from 57 to 69). CONCLUSIONS: Despite the increment of irradiation rates seen in the last years, there is still a serious underutilisation of RDT for some cancer types (lung, head and neck cancer), as well as a great variability in the use of RDT between hospitals (AU)

Para qué sirve y quién debe hacer el seguimiento después del tratamiento del paciente con cáncer / What is the usefulness and who has to do the follow-up after the treatment of cancer patients

- Objetivos: estudiar las características de una consulta de seguimiento de un servicio de radioterapia de un hospital que ofrece tratamiento completo del cáncer y valorar su utilidad en términos de diagnóstico de recaídas, molestias al paciente y carga de trabajo.- Material y métodos: hemos medido durante 52 semanas consecutivas el número de pacientes citados/atendidos por día en una consulta semanal; la localización del tumor, el tiempo tras el tratamiento, el número de servicios que le hacen seguimiento y el número de sospechas clínicas de recidiva.- Resultados: se recogen 715 visitas de 524 pacientes distintos (el 40 por ciento una visita, 40 por ciento dos visitas y 20 por ciento más de dos). La media de citas es de 18 por día (mediana 19, moda 24) de los que asisten 16 en promedio. Dos pacientes no acuden a la visita programada y uno lo hace fuera de cita. Predominan las pacientes de mama, cabeza y cuello, endometrio, cérvix y pulmón. El 74 por ciento es seguido en dos servicios y el 10 por ciento en más de 2, con media tras la radioterapia de 2,5 años (21 por ciento a más de cinco años). Se detectan 28 sospechas de recaída (5,4 por ciento de pacientes) y se confirman 6 (21 por ciento de sospecha, 1,2 por ciento de pacientes): 4 locales y dos a distancia.- Comentario: el seguimiento clínico tras el tratamiento persigue objetivos tales como controlar los efectos secundarios, detectar precozmente las posible recaídas y ofrecer al enfermo una relación más continua en el tiempo. Sin embargo, por las características del manejo de estos enfermos (multidisciplinaria), el seguimiento puede hacerse de forma engorrosa, redundante e ineficaz (AU)

Evaluación de un modelo de dirección médica de hospital elegida por los profesionales / Assessment of a model of Health Manager elected by professional

Desde 1996 los directores médicos (DM) de los hospitales públicos de Andalucía se eligen mediante un proceso participativo. Objetivos: Conocer el perfil de los DM y evaluar este cambio organizativo a través de la opinión de los profesionales implicados. Material y métodos: El estudio se realizó entre abril de 1997 y enero de 2001, e incluyó todos los hospitales públicos. Para su realización se utilizó un cuestionario de 20 ítems (13 cerrados y 7 abiertos) para conocer el perfil de los DM y un estudio Delphi (dos rondas), que se aplicó a un grupo de 97 expertos (10 directivos, 24 gerentes, 23 DM y 40 médicos) seleccionados con arreglo a criterios explícitos (tiempo mínimo de permanencia y relación con la DM). Los datos se presentan como descripción de las variables, del grado de acuerdo/desacuerdo y de las diferencias en las respuestas entre categorías profesionales (ANOVA).Resultados: Perfil de DM: tasa de respuesta 69,5 por ciento (16/23). El DM es un varón de 45 años (media), especialista vía MIR, adjunto clínico y sin experiencia en gestión; refiere haber cubierto sus expectativas en estos años y que sus mayores dificultades se debieron a los propios médicos. Estudio Delphi: participación del 67,5 por ciento (directivos sólo 20 por ciento). No se identifican áreas de retroceso y la DM se valora en un plano positivo para accesibilidad y relación gestores/médicos; pero la confianza en el modelo es limitada y la DM tiene un papel poco definido y ambiguo. Las diferencias más significativas en la respuesta se establecen entre gerentes y DM. Comentario: El modelo parece suponer un cambio interesante más teórico que real en la manera de entender la relación entre médicos y gestores, ya que produce recelo entre ambos y escaso entusiasmo (AU)

[Physiopathologic knowledge and clinical practice. A case of high dose chemotherapy in breast cancer]. / Conocimiento fisiopatológico y práctica clínica: quimioterapia a altas dosis en el cáncer de mama.

Breast cancer is the major cause of death from cancer in women. This causes a great activity in oncological investigation in this field. During the 80s preclinical data and retrospective analysis suggested a dose-response relationship both for adjuvant treatment and metastatic disease. Technical advances in collection and administration of peripheral stem cells and the development of hematological growth factors permitted the use, in this and other diseases, of high dose chemotherapy, usually with hematological support. All these things produced the widespread use of this technique with the only scientific support of phase II studies usually performed in only one center and with highly selected patients. Most of the randomized trials performed afterwards did not show a clinically important relationship between dose and response. This makes us think that this technique should not be used as routinary treatment. From a methodological point of view it would be interesting to investigate the evolution of this modality of treatment and why, its use has been so generalized without good quality scientifically support. This could be due to predetermined ideas in relation to what is the evolution and treatment of this disease, the neglect in the use of scientific methodology and the pressures coming from different directions trying to adopt new (and presumably better, treatments). It is evident that if most of the patients who have received high dose treatment for breast cancer had participated in randomized trials the question would probably have already been answered.

[The clinical usefulness of the serological study of IgG antibodies and IgA against the antigens associated with the Epstein-Barr virus in patients with nasopharyngeal carcinoma]. / Utilidad clínica del estudio serológico de anticuerpos IgG e IgA antiantígenos asociados al virus de Epstein-Barr en pacientes con carcinoma de nasofaringe.

The relationship between nasopharyngeal carcinoma (NPC) and Epstein-Barr virus (EBV) has been already well established. Titulation of the antibodies IgG and IgA against EBV-related antigens has been proved reliable but always suitable having tested and age-matched control population. We present here the preliminary results from the 14 patients bearing NPC and 12 patients with other carcinoma of the head and neck and healthy donors.