[Initial experience with image-guided and intensity-modulated postoperative radiotherapy of gynecological cancer]. / Nõgyógyászati tumorok képvezérelt, intenzitásmodulált adjuváns sugárkezelésével szerzett kezdeti tapasztalataink.

Our goal was to determine the extent of the CTV-PTV margin. Accuracy of patient setup was checked with daily CBCT. Two radiation oncologists performed the image matching independently. The CTV-PTV margin was calculated with the van Herk formula. The treatment plans were created with the Varian Eclipse v11 planning system, and the treatments were carried out with a Varian TrueBeam accelerator by using RapidArc technique with two full arcs. Dose constraints on the target volume and organs at risk recommended by international bodies were applied. Conformity number (CN) for PTV, V45 and V50 for organs at risk were used to assess and compare the treatment plans of RapidArc and 3D-KRT (conformal radiotherapy) techniques. The average CTV-PTV margins with or without IGRT were 0.67 cm vs. 1.53 cm, 0.66 cm vs. 1.25 cm and 0.34 cm vs. 0.98 cm in vertical, longitudinal and lateral directions, respectively. In case of daily on-line CBCT verification 0.5 cm margin can be used.

Genital angiokeratomas of Fordyce 595-nm variable-pulse pulsed dye laser treatment.

BACKGROUND: Angiokeratoma of Fordyce (AF) represents dark red or blue-black papules with a scaly surface located on scrotum, labia majora, and penis. Though usually asymptomatic, bleeding after mechanical trauma and sexual intercourse may occur. AF should be differentiated from malignant melanoma, angiosarcoma, and other pigmented lesions. The treatment, usually asked from patients as the result of anxiety and social embarrassment, should be performed in a non-aggressive manner. OBJECTIVES: To determine the safety and effectiveness of 595-nm variable-pulse pulsed dye laser (VPPDL) with a Dynamic Cooling Device (DCD) in the treatment of AF. METHODS: Twenty-four patients (22 men and two women) aged 40.88 ± 12.48 years with AF were included in the retrospective study. Lesions located on scrotum, labia majora, and penis were treated with 595-nm VPPDL in the intervals of one to three months. Variable spot, fluence, and pulse-width parameters were used with and/or without DCD skin cooling. RESULTS: AF were successfully removed in all patients in one to seven (mean ± SD = 3.38 ± 2.16) treatment sessions with no permanent side effects or complications such as dyspigmentations or scarring. Recidives were observed in four patients after 0.5-1 year intervals. CONCLUSIONS: 595-nm VPPDL with DCD represents an efficient and safe method for the removal of multiple lesions of AF in genital localization.

The different dose-volume effects of normal tissue complication probability using LASSO for acute small-bowel toxicity during radiotherapy in gynecological patients with or without prior abdominal surgery.

PURPOSE: To develop normal tissue complication probability (NTCP) model with least absolute shrinkage and selection operator (LASSO) to analyze dose-volume effects that influence the incidence of acute diarrhea among gynecological patients with/without prior abdominal surgery. METHODS AND MATERIALS: Ninety-five patients receiving gynecologic radiotherapy (RT) were enrolled. The endpoint was defined as the grade 2(+) acute diarrhea toxicity during treatment. We obtained the range of small-bowel volume in V4 Gy to V40 Gy of dose. RESULTS: The number of patients experiencing grade 2(+) acute diarrhea toxicity was 23/61 (38%) in the group without abdominal surgery (group 0) and 17/34 (50%) patients with abdominal surgery (group 1). The most significant predictor was found for the logistic NTCP model with V16 Gy as the cutoff dose for group 0 and V40 Gy for group 1. Logistic regression NTCP model parameters were TV10 ≈ 290 cc for V16 Gy and TV10 ≈ 75 cc for V40 Gy, respectively. CONCLUSION: To keep the incidence of grade 2(+) acute small-bowel toxicity below 10%, we suggest that small-bowel volume above the prescription dose (V16 Gy) should be held to <290 cc for patients without abdominal surgery, and the prescription dose (V40 Gy) should be maintained <75 cc for patients with abdominal surgery.

In vivo dose evaluation during gynaecological radiotherapy using L-alanine/ESR dosimetry.

The dose delivered by in vivo 3-D external beam radiation therapy (EBRT) was verified with L-alanine/electron spin resonance (ESR) dosimetry for patients diagnosed with gynaecological cancer. Measurements were performed with an X-band ESR spectrometer. Dosemeters were positioned inside the vaginal cavity with the assistance of an apparatus specially designed for this study. Previous phantom studies were performed using the same conditions as in the in vivo treatment. Four patients participated in this study during 20-irradiation sessions, giving 220 dosemeters to be analysed. The doses were determined with the treatment planning system, providing dose confirmation. The phantom study resulted in a deviation between -2.5 and 2.1 %, and for the in vivo study a deviation between -9.2 and 14.2 % was observed. In all cases, the use of alanine with ESR was effective for dose assessment, yielding results consistent with the values set forth in the International Commission on Radiation Units and Measurements (ICRU) reports.

[Development of a quality assurance phantom for brachytherapy: the feasibility of daily check with the phantom].

PURPOSE: We developed a quality assurance (QA) phantom to enable easy confirmation of radiation source output measurements of a high dose rate (192)Ir intracavitary brachytherapy unit in gynecology. The purpose of this study was to evaluate the feasibility of daily checks using the QA phantom. METHODS AND MATERIALS: The QA phantom was designed with tough water phantoms to hold a Farmer-type ionization chamber, with semiconductor detectors used as in vivo dosimeters to measure rectal dose, and three transfer tubes for gynecology. To test the reliability of our QA phantom for the detection of abnormalities in source output or semiconductor detectors, we applied different doses. RESULTS: Variations due to different settings of the QA phantom were within 2%. The temporal variations were less than 2% and 5% in the Farmer-type ionization chamber and semiconductor detectors, respectively. Interobserver variations were below 3%. CONCLUSIONS: With tolerance levels of 2% and 5% for a Farmer-type ionization chamber and semiconductor detectors, respectively, a QA phantom is potentially useful for easily detecting abnormalities by applying daily checks of the brachytherapy unit.

[New possibilities for elimination of human papillomavirus from the organism].

The variety of mechanisms of human papillomavirus (HPV) infection suggests that the success of treatment depends on the choice of a universal method, which combines the actions of etiotropic, pathogenetic and symptomatic approaches, without causing unwanted side effect. All these requirements are met by a drug based on the products of plant origin - Indinol. The observed patients with resistant forms of genital warts were divided into 3 groups: first group received the treatment according to the standard, conventional scheme; patients of the second group in addition to the standard scheme 2 times a day (for 90 days) received 2 capsules of Indinol (200 mg) and the patients of third group simultaneously with Indinol undergo infrared irradiation. The results of the observation have shown that the addition of Indinol to the standard treatment had a significant positive effect on the healing process of patients with resistant forms of genital warts. The effects of the Indinol in combination with infrared therapy revealed a statistically significant reduction (3 times) the frequency of relapses in cases of clinically sever forms of disease. Thus, during combined treatment of patients with recurrent, clinically severe forms of genital HPV, it is advisable to use the Indinol, which evidently has the well pronounced virus-eliminative and anti-recurrent actions.

Impacto da radioterapia e da quimioterapia sobre o aparelho genital feminino: procedimentos terapêuticos / Radiotherapy and chemotherapy impact on female genital apparatus: therapeutic procedures

No presente estudo apresentamos os diversos procedimentos terapêuticos existentes com o intuito de obter-se proteção e melhoria dos danos induzidos por radioterapia e quimioterapia no aparelho genital feminino.

The aim of this study is obtain a convenient analysis of different therapeutic methods to improve better conditions before and after radiotherapy and chemotherapy in the female genital apparatus.

O impacto da radioterapia e da quimioterapia no aparelho genital feminino / Radiotherapy and chemotherapy impact on female genital apparatus

O tratamento de diversos tipos de câncer poderá muitas vezes condicionar as pacientes a redução no seu potencial reprodutivo. As pacientes com diferentes neoplasias deverão ser informadas das opções terapêuticas e também das medidas necessárias para preservar sua fertilidade, dos possíveis danos no aparelho reprodutor feminino e das possibilidades futuras quanto à reprodução, antes de receberem qualquer orientação terapêutica. Esse foi o propósito deste estudo.

Treatment of several types of cancer, in many cases, lead to a reduction of the patients' reproductive potential. Such patients must be informed of different therapeutic options and possible resulting damage to the female reproductive tract, as well as all measures necessary for preserving their fertility and future possibilities to reproduce, prior to receiving any therapeutic orientation geared toward this goal. This was the basic purpose of this study.

Cancer risk from low-level ionizing radiation: the role of age at exposure.

This article examines methodological issues related to epidemiologic investigations of the influence of age at exposure on radiation risk estimates; the epidemiologic literature on the role of age at exposure in radiation-cancer associations; and biological mechanisms that may account for associations observed in these studies. There is substantial evidence that young children, and especially the fetus, are highly vulnerable to ionizing radiation. Investigations also suggest that sensitivity may increase at the oldest ages of exposure. Further attention to modifying factors in radiation-cancer associations, such as age at exposure, may help to protect workers and the public by improving our understanding of sensitivity variation within populations.

[Fertility preservation by ovarian tissue cryopreservation]. / Préservation de la fertilité par congélation de tissu ovarien.

Female fertility may be compromised after radio or chemotherapy for malignant as well as non-malignant diseases. It could be saved by cryopreservation of ovarian tissue, since it is now well established that primordial follicles can survive freezing. Many births have been obtained in rodents with thawed ovarian fragments, after grafting or in vitro folliculogenesis. Both techniques are more difficult in large animal species, and need further development to enter clinical practice. However, storing ovarian samples is already indicated, especially in younger patients who will require restoration of their fertility in a far future.

Pelvic radiotherapy, sex hormones, and breast cancer.

Radiotherapy for malignant and benign gynecologic disease in middle age has been found to be associated inversely with the risk of breast cancer in several published studies. The ovaries received substantial doses of radiation from such treatments, in the tens of Gray (Gy) from radiotherapy for cervical cancer and one to 10 Gy from radiotherapy for benign gynecologic disease (BGD). The relative risk of breast cancer incidence or mortality decreased with increasing radiation dose to the ovaries between zero to six Gy but varied little with further increases in dose. Evidence of a protective effect even among women irradiated past the age of 50 suggests a mechanism other than that associated with induction of an early menopause. An inverse association with radiotherapy among women over age 50 was seen only for women with ovarian doses exceeding about four to five Gy, namely, those treated for cervical cancer or with external beam X-rays for BGD. Ovarian doses of two to three Gy from intrauterine radium (226Ra) treatments for BGD were not associated with an appreciably reduced risk of breast cancer, even though the treatments had the intended effect of inducing menopause in women in their mid-40s. The relevant target cells in the ovaries for radiologic menopause likely are those involved in estrogen production. Although the postmenopausal ovary has largely stopped producing estrogens, it continues to secrete androgens. Serum hormone measurements on a small sample of cervical cancer patients indicate that high-dose pelvic radiotherapy eliminates or greatly reduces this residual androgen-producing activity in ovaries of postmenopausal women.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative study of different laser systems.

OBJECTIVE: To review lasers, laser physics, laser-tissue interaction, delivery systems, and their clinical applications relevant to gynecology. SETTINGS: Gynecological Service at Massachusetts General Hospital (MGH) and MGH Laser Center. INTERVENTIONS: None. DESIGN: Laser literature review and personal experiences of the authors were used to prepare this manuscript. CONCLUSIONS: Lasers have been used in gynecologic practice for cutting and coagulating purposes. Photodynamic therapy has been used clinically for malignant conditions and is being investigated for dysplastic lesions of the lower genital tract and for endometrial ablation. Laser welding has potential, but further work is required in this field before it finds a clinical application. The main lasers used in gynecology are CO2, neodymium-yttrium aluminum garnet (Nd:YAG), and potassium tatanyl-phosphate-doubled Nd:YAG. Pulsed Ho:YAG laser looks promising, as does diode lasers. Holmium-yttrium aluminum garnet and diode lasers will be soon available commercially. Improvements in delivery systems have increased user friendliness, and more developments in this area are anticipated, for example, a fiber-optic delivery system for CO2 lasers. We believe that enhanced understanding of laser technology will provide unique applications for development in gynecology.

Leukemia, lymphoma, and multiple myeloma after pelvic radiotherapy for benign disease.

The relationship between exposure to sparsely ionizing radiation and mortality due to cancers of hematopoietic and lymphopoietic tissues was studied among 12,955 women treated for benign gynecological disorders at any of 17 hospitals in New England or New York State and followed for an average of 25 years; 9770 women were treated by radiation (intracavitary 226Ra, external-beam X rays), while 3185 were treated by other methods, including curettage, surgery, and hormones. The average age at treatment was 46.5 years, and the mean dose to active bone marrow among irradiated women was 119 cGy. Forty deaths due to acute, myelocytic, or monocytic leukemia were observed among irradiated women. This number was 70% higher than expected based on U.S. mortality rates [standardized mortality ratio (SMR) = 1.7; 90% confidence interval (CI) 1.3-2.3]. A deficit was recorded among nonirradiated women, based on three observed deaths (SMR = 0.5; 90% CI 0.1-1.2). A well-defined gradient in the SMR with dose among exposed women was not detected. The SMR was highest within 5 years after irradiation but remained elevated even after 30 years. The temporal pattern differed by subtype of leukemia: excess mortality due to chronic myelocytic leukemia occurred almost exclusively within the first 15 years, whereas the SMR for acute leukemia, though also elevated, varied little over time. Cancers of lymphoreticular tissue occurred more often than expected based on U.S. mortality rates, but not appreciably differently for irradiated and nonirradiated women. There was little or no evidence of effects attributable to radiotherapy for chronic lymphocytic leukemia [relative risk (RR) = 1.1; 90% CI 0.5-3.0], Hodgkin's disease (RR = 0.9; 90% CI 0.3-3.2), non-Hodgkin's lymphoma (RR = 0.9; 90% CI 0.6-1.6), or multiple myeloma (RR = 0.6; 90% CI 0.3-1.4). These results corroborate previous findings indicating that acute and myelocytic leukemias are the most prominent malignancies after exposure to sparsely ionizing radiation, occurring in excess shortly after irradiation, and that lymphomas are either not caused by radiation or are induced only rarely.

[Ureteral complications in the treatment of gynecologic diseases]. / Complicanze ureterali nel trattamento delle affezioni ginecologiche.

Ureteral injuries are an uncommon complication after gynecological procedures. The Authors consider separately direct lesions during surgery and those following radiotherapy. For both these situations preventive criteria, which permit a lower incidence in ureteral injuries, are considered. Early diagnosis and intraoperative repair are the most important tool for surgical lesions while the exact stage of neoplasm and N.E.D. status are fundamental for lesions resulting from radiation therapy. In our opinion, best treatment of stable lesions is surgery, while endourology is not usually a definitive treatment and has only a temporary and palliative role.

Pap smear examinations in women post-treated for genital organ diseases by operation and radiation.

A total of 846 Pap smears in women post-treated for genital organ diseases by operation and radiation (1.7% of all those made) at the Cytological Unit, Department of Obstetrics & Gynaecology, Faculty of Medicine, Siriraj Hospital between April 4, 1983 and July 4, 1984, were examined. The women were aged 21-75 years (mean age 43.1 +/- 9.7 years). Sixty-seven point two per cent of the women had Wertheim operations and 30.1 per cent total abdominal hysterectomies, due to invasive carcinoma (68.1% of cases) and carcinoma in situ of the uterine cervix (15.2%). Cytological findings revealed 72.8 per cent normal smears, 26.0 per cent infections (17.7% with mixed bacteria), one case of carcinoma in situ and one case of postirradiation dysplasia (both cases were post Wertheim operation). Hormonal conditions were 53.2 per cent in early menopause, 11.7 per cent in crowded menopause, 11.9 per cent in late menopause and 23.2 per cent had no hormonal evaluation. Pap smears of women post-treated for genital organ diseases by operation and radiation were examined for consideration of treatment of choice.