Image guided adaptive brachytherapy of cervical cancer - practical recommendations.

Brachytherapy (BT) is an integral part of radical radiotherapy (RT) or radiochemotherapy (RCT) in patients who are not suitable candidates for surgery. These are usually patients with locally advanced cervical cancer. The goal of all BT planning eff orts has been, still is, and certainly will continue to be, to defi ne the anatomical boundaries of the tumor and the relationship of the tumor to organs at risk (OARs) as best as possible, using available modern imaging techniques. Image guided adaptive brachytherapy (IGABT) is currently the most advanced method of uterovaginal BT. Adaptive planning allows dose escalation from BT to newly defi ned target volumes, according to the risk of recurrence, which is mainly determined by the level of tumor burden. This dose adaptation based on the response to external RCT is a major change in practice compared to conventional BT planning based on dose prescription to point A. The main advantage of the IGABT concept is that it allows the assessment of individual dose distributions in target volumes and OARs, which in turn leads to improved dose coverage of target volumes while decreasing the volume irradiated by the prescribed dose compared to conventional 2D planning. Purpose: In this review article, I provide a comprehensive up-to-date perspective on this issue, particularly in terms of practical recommendations regarding the defi nition of target volumes, the use of diff erent types of uterovaginal applicators, intraoperative complications, and potential manifestations of late gastrointestinal, genitourinary, and vaginal toxicity.

[A Development and Overview of the Use of Chemotherapy and the Role of Radiotherapy and Surgery in Patients with Newly Diagnosed Pancreatic Tumor and Cancer in the Current 5-year Center Practice]. / Vývoj a prehled vyuzití chemoterapie a role radioterapie a chirurgie u pacientu s nove diagnostikovaným tumorem a karcinomem pankreatu v bezné 5leté praxi centra.

BACKGROUND: Chemotherapy (CHT), surgery and radiotherapy (RT) are essential modalities in the treatment of pancreatic malignancies. Their use in practice may be influenced by a number of factors. PATIENTS AND METHODS: Retrospective analysis of CHT, surgery and RT indications and CHT results in patients reported with pancreatic tumor in Pilsen in 2012-2016. RESULTS: A total of 348 patients with median age 68 (19-89) years with newly diagnosed pancreatic tumor, resp., with histology/cytology verified carcinoma in 74.5% cases, with v. s. carcinoma without verification in 21% and with other malignancy not further analyzed here in 4.5% (mostly neuroendocrine tumor). In patients with generalized malignancy (n = 195), exploratory laparotomy was performed in 23% to get tissue samples or verify staging - palliative anastomoses were done in 25% of operated patients, CHT was performed in 29% of the generalized tumors, palliative RT of tumor was performed in 1 patient, and RT of metastases in 3 patients. In patients with local or regional nodal affection (n = 137) laparotomy was done in 59%, R0 resection in 34 (42%) of 81 operated, R1 in 6%, palliative anastomoses were done in 17% and irreversible electroporation in one patients, CHT or radiochemotherapy after R0 and R1 resections was provided in 61% operated patients. The most commonly used CHT was monotherapy with gemcitabine or FOLFIRINOX. The indication of CHT in cytology/histology verified generalized cancers and with excluding patients refusing CHT was proposed in 2012 to 16%, in 2014 to 49% and in 2016 to 84% of patients. In the case of a local or regional nodal involvement the CHT was proposed to 40, 55 and 86% of patients. Median overall survival in generalized tumor patients receiving CHT (n = 137) vs. not-receiving CHT (n = 56) was 2 vs. 8 months (p = 0.0001), and in the local or regional nodal involvement patients receiving CHT (n = 74) vs. not-receiving CHT (n = 62) was 5 vs. 16 months (p = 0.0001). CONCLUSION: CHT and surgery are the dominant treatment modalities. There has been a marked increase in the CHT and histology/cytology verifications indications, with a major factor being a clinician evaluation of a patient to be fit for CHT and its benefit or to complete pancreatic tumor verification. With still very limited results in pancreatic cancer treatment, a careful assessment of each patients indication, respecting patients desire, is always required, knowing that even in the case of advanced disease, CHT can bring benefit, albeit limited.Key words: pancreas - carcinoma - chemotherapy The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. This study was supported by the grant of Ministry of Health of the Czech Republic - Conceptual Development of Research Organization (Faculty Hospital in Pilsen - FNPl, 00669806).Submitted: 13. 3. 2018Accepted: 18. 4. 2018.

[Radiotherapy Indications in Patients with Hematological Malignancies During the Five Years Course of Modernized Center of Oncology and Radiotherapy Clinic in Pilsen]. / Indikace radioterapie u pacientu s hematologickými malignitami v prubehu peti let provozu modernizovaného centra Onkologické a radioterapeutické kliniky v Plzni.

Submitted: 27. 2. 2016.

[MRI based 3D brachytherapy planning of the cervical cancer -  our experiences with the use of the uterovaginal Vienna Ring MR CT applicator]. / Na MRI zalozené 3D plánování brachyradioterapie karcinomu delozního hrdla -  nase zkusenosti s pouzitím uterovaginálního aplikátoru Vienna Ring MR CT.

BACKGROUND: Uterovaginal brachytherapy planning is conventionally based on the use of two orthogonal Xray projections. Currently, there is a large development of 3D brachytherapy planning based on the fusion of CT and MRI, which takes into account the extent of the tumor and the location of organs at risk. In this work, we evaluated the dosimetric data and first clinical results in patients with inoperable cervical cancer using MRI/ CT compatible applicator enabling 3D planning. PATIENTS AND METHODS: Between June 2012 and March 2013, we performed 52 uterovaginal applications in 13 patients with inoperable cervical cancer using Vienna Ring MR CT applicator. Planning was carried out by the fusion of MRI and CT. Target volumes and organs at risk delineation were carried out on the basis of GEC ESTRO and ABS recommendations as well as doses report-ing. RESULTS: Overall radiotherapy duration was 37- 52 days with median of 45 days. The median total dose delivered to the HR CTV was 88 Gy (70.7- 97.9) EQD2. The median single dose in brachytherapeutic applications was D90 = 6.45 Gy (3.2- 9.82). The median total doses delivered to the rectum, sigmoid colon and bladder were D2ccrectum = 64.2 Gy (54.3- 74.1), D2ccsigmoid = 68.6 Gy (57- 74.7) a D2ccbladder = 73.9 Gy (58.3- 92.6). In 11 patients (84.6%), complete locoregional remission was achieved, in the remaining two patients (15.4%), partial locoregional remission was achieved. Twelve patients (92.3%) had complete regression of the tumor in the cervix, one patient (7.7%) developed metastatic spread to the liver. Yet we did not observe manifestations of a higher degree of toxicity than the first grade, both GI and GU. Late GI toxicity was manifested in two patients (15.4%) and late GU toxicity was manifested in five patients (38.5%). CONCLUSION: 3D brachytherapy planning of inoperable cervical cancer using the fusion of MRI and CT conclusively raises the possibility of the dose escalation to the tumor and significantly spares the surrounding organs at risk. Subsequently, this way of planning leads to better local control of the disease and to lower radiation morbidity.

[Secondary angiosarcomas after conservation treatment for breast cancers]. / Sekundární angiosarkomy po konzervativn lécebe nádoru prsu.

BACKGROUNDS: The cancerogenic effect of ionizing radiation was documented just several years after it started to be used as a treatment option. Ionizing radiation produces a small but detectable risk of carcinoma as well as bone and soft tissue sarcomas. Over the past 20 years angiosarcomas arising from the area of the irradiated breast have been reported with increasing frequency as the number of women undergoing the breast conserving surgery with consecutive radiotherapy has increased also. Angiosarcomas can originate from either lymphatic or capillary endothelium, namely lymphangiosarcomas and haemangiosarcomas. The most of haemangiosarcomas arising from the breast skin developed in the irradiated area after breast conserving procedure--secondary angiosarcomas. Lymphangiosarcoma is typically associated with longstanding extremity lymphedema--Stewart-Treves syndrome. CASES: We report three cases of angiosarcomas which occured in this region after breast conserving treatment and we also review the literature. CONCLUSION: Paradoxically, the decrease in the use of radiotherapy to the post-mastectomy chest wall and the axillary area is expected to reduce the incidence of angiosarcomas, while the increase in the use of breast conserving procedure plus radiotherapy could lead to increased incidence of angiosarcomas in the residual breast tissue. Special attention should be paid to skin leasions and changes occuring after breast conserving treatment and especially to the ones with the skinthickening. The early detection and diagnosis has the crucial prognostic value.

[The use of PET/CT fusion in radiotherapy treatment planning of non-small-cell lung cancers]. / Vyuzití PET/CT vysetrení pri plánování radioterapie nemalobunecných plicních karcinomu.

BACKGROUNDS: Lung cancer is currently the most frequently diagnosed malignant disease worldwide and radiotherapy has a fundamental and irreplaceable role in the therapeutic algorithm of this disease. Conventionally, radiotherapy is planned using CT alone. However, this could be a source of many inaccuracies and errors in the process of contouring the target volumes, the likelihood of which could be decreased by using the data from PET imaging and, ideally, from a fusion of PET and CT (as has already been proven in the diagnosis of lung cancer). CASE: This review is devoted to all important aspects related to the use of PET/CT imaging in radiotherapy treatment planning of non-small-cell lung cancer and to the advantages resulting from its use. CONCLUSION: Investigation of PET/CT imaging is a useful tool leading to increased accuracy of contouring of the target volumes. The integration of both diagnostic modalities reduces the limitations of these modalities if used separately. The use of combined PET/CT imaging often leads to an identification of a change in tumor size (it also often uncovers distant metastases) resulting in a change of treatment intention. The change of the target volume size and thus the change of irradiated volume of critical structures could lead to an increase of the dose delivered to the tumor in situations when a reduction of these volumes was reached. Investigation of PET/CT imaging also has a positive impact on subjective approach to contouring by different radiation oncologists.