ADIOLOGY AND NCOLOGY March 2007 Vol. 41 No. 1 Ljubljana ISSN 1318-2099 ADIOLOGY AND NCOLOGY Editorial office RadiologtJ and OncologtJ Institute o f OncologiJ Zaloška 2 SI-1000 Ljubljana Slovenia Phone: +386 1 5879 369 Phone/Fax: +386 1 5879 434 E-mail: gsersa@onko-i.si Aims and scope March 2007 Vol. 41 No. 1 Pages 1-56 ISSN 1318-2099 UDC 616-006 CODEN: RONCEM Radiologij and OncologiJ is a journal devoted to publication oj original contributions in diagnostic and interventional radiology, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncologtJ, radiobiologiJ, radiophysics and radiation protection. Editor-in-Chief Gregor Serša Ljubljana, Slovenia Executive Editor Viljem Kovac Ljubljana, Slovenia Editorial Board Karl H. Boh11slavizki Hamburg, Germany Maja Cemažar Ljubljana, Slovenia Christian Dittrich Vienna, Austria Metka Filipic Ljubljana, Slovenia 1l1llio Giraldi Trieste, Italy Maria Godeny Budapest, Hungary Vassil Hadjidekov Sofia, Bulgaria Marko Hocevar Ljubljana, Slovenia Maksimilijan Kadivec Ljubljana, Slovenia Advisory Committee Deputy Editors Andrej Car Ljubljana, Slovenia Igor Kocijancic Ljubljana, Slovenia Mikl6s Kasler Budapest, Hungary Michael Kirsc1ifink Heidelberg, Germany Janko Kos Ljubljana, Slovenia Tamara Lah T11rnšek Ljubljana, Slovenia Damijan Miklavcic Ljubljana, Slovenia L11kaMilas Houston, USA Damir Miletic Rijeka, Croatia MajaOsmak Zagreb, Croatia Branko Palcic Vancouer, Canada D11šan Pavcnik Portland, USA Geoffrey J Pilkington Portsmouth, UK Ervin B. Podgoršak Montreal, Canada Uroš Smrdel Ljubljana, Slovenia Primož Strojan Ljubljana, Slovenia Bor11t Štab11c Ljubljana, Slovenia Ranka Štern-Padovan Zagreb, Croatia J11stin Teissie Tolouse, France SandorT6th Oroshaza, Hungary Gillian Tozer Sheffield, UK Andrea Veronesi Aviano, Italy Branko Zakotnik Ljubljana, Slovenia Marija Auersperg Ljubljana, Slovenia; Tomaž Be1wlic Ljubljana, Slovenia; J11re Fettich Ljubljana; Valentin Fidler Ljubljana, Slovenia; Berta Jereb Ljubljana, Slovenia; Vladimir Jevtic Ljubljana, Slovenia; Stojan Plesnicar Ljubljana, Slovenia; Živa Z11pancicLjubljana, Slovenia Publisher Association of Radiology and Oncology Affiliated with Slovenian Medica/ Association -Slovenian Association of Radiology, Nuclear Medicine Society, Slovenian Society far Radiotherapy and OncologiJ, and Slovenian Cancer Society Croatian Medica/ Association -Croatian Society of Radiology Societas Radiologorum Hungarorwn Friuli-Venezia Giulia regional groups of S.I.R.M. (ltalian Society of Medica! Radiology) Copyright © Radiology and Oncology. Ali rights reserved. Reader for English Vida Kološa Keywords Eva Klemencic Secretary Mira Klemencic Design Monika Fink-Serša Printed by Imprint d.o.o., Ljubljana, Slovenia Published quarterly in 500 copies Beneficiary name: DRUŠTVO RADIOLOGIJE IN ONKOLOGIJE Zaloška cesta 2, 1000 Ljubljana Slovenia Beneficiary bank account number: SI56 02010-0090006751 IBAN: SI56020100090006751 Our bank name: Nova Ljubljanska banka, d.d., Ljubljana, Trg republike 2, 1520 Ljubljana; Slovenia SWIFT: LJBASI2X Subscription fee for instih1tio11s EUR 100, individuals EUR 50 The publication of this journal is subsidized by the Slovenian Research Agency. Indexed and abstracted by: BIOMEDICINA SLOVENICA CHEMICAL ABSTRACTS EMBASE / Excerpta Medica Sci Base Scopus This journal is printed on acid-free paper Radiologij and OncologiJ is available on the internet at: http://www.onko-i.si/radioloncol and http:j/www.versita.com ISSN 1581-3207 Editoral RADI0LOGY ANO ONC0LOGY celebrates its esteemed 40 years of existence. The journal has evolved from Radiologia Iugoslavica, a regional journal of the former Yugoslavia into an inter­national journal that is published quarterly in English language. Its international involvement is reflected in the esteemed membership of Editorial Board and many published papers by the authors from Central European countries. We greatly acknowledge the work of the former editorial board and we would like to thank them for their contribution in the development of the journal. In order to bring new momentum into the journal, we have asked some of the new members to actively participate in the develop­ment of the journal in the future. We also welcome new Editors of the journal. With joined efforts we would like to make the journal more recognizable in the scientific community of radiologists and oncologists. With this goal in mind we have also decided to make some technical changes in the jour­nal RADI0LOGY ANO ONC0L0GY. We decided to publish Web based journal on Meta Press technology that will enable us to be indexed in international data bases. This will enable an open access of the journal to ali the readers. We believe that this is the way how to make the journal more visible and more attractive. Everybody is welcome to publish in RADI0LOGY ANO ONC0LOGY. We believe that with mutual efforts we will in a few years reach broader international recognition and become an esteemed journal. We thank also our supporters, especially Research Agency of Slovenia that has financially supported regular publishing of RADI0LOGY ANO ONCOLOGY. Gregor Serša Editor-in-Chief of Radiology and Oncology Radio/ Onco/ 2007; 41(1): C. Ljubljana, Slovenia ISSN 1318-2099 March 2007 UDC 616-006 Vol. 41 No. 1 CODEN: RONCEM CONTENTS RADIOLOGY Computed tomography and magnetic resonance colonography Vegar-Zubovic S, Sefic-Pašic I, Lincender L, Vreže D, Klancevic M, Delic U IMAGES IN CLINICAL MEDICINE Recurrence of carcinoma of the lower lip treated by interferon and irradiation Jancar B 13 ONCOLOGY Subchronic exposure of rats to sublethal dose of microcystin-YR induces DNA damage in multiple organs Filipic M, Žegura B, Sedmak B, Horvat-Žnidaršic I, Milutinovic A, Šuput D 15 Testing of mechanisms of action of rituximab and clinical results in high-risk patients with aggressive CD20+ lymphoma Jezeršek Novakovic B, Kotnik V, Južnic Šetina T, Vovk M, Novakovic S 23 Radiofrequency ablation of lung tumours -new perspective in treatment of lung neoplasms Kocijancic K, Kocijancic I 33 Paratesticular adenocarcinoma: unusual presentation of metastasis of pancreatic cancer Ocvirk J, Šeruga B RADIOPHYSICS Analytical investigation of properties of the iso-NTCP envelope Stavrev P, Schinkel C, Stavreva N, Markov K, Fallone BG Implementing of the offline setup correction protocol in pelvic radiotherapy: safety margins and number of images Kasabašic M, Faj D, Belaj N, Faj Z, Tomaš I REPORT Basic Clinical Radiobiology Course, Ljubljana (Slovenia), 21.-25. May 2006. View from a local participant Rajer M 56 SLOVENIAN ABSTRACTS I NOTICES VIII Radiology and Oncology is covered in Bio medicina Slovenica, Chemical Abstracts, EMBASE / Excerpta Medica, Sci Base and Scopus review Computed tomography and magnetic resonance colonography Sandra Vegar-Zubovic, Irmina Sefic-Pašic, Lidija Lincender, Dunja Vrcic, Melika Klancevic, Una Delic Institute of Radiology, Clinical Center University of Sarajevo, Bosnia and Herzegovina Background. Colon cancer is the second leading cause of cancer death in the western world. Adenomatous colorectal polyps, which are found in 30-50% of Americans more than 50 years old, are recognized as impor­tant precursors of malignancy. Probably most of the invasive colon carcinomas arise from polyps. For this reason an early detection of these polyps and their complete removal is a recognized strategy for the preven­tion of colon cancer. So far no single method for an early diagnosis of colon polyps or colon cancer offers high sensitivity and specificity along with low cost and good patient acceptance. Endoscopic colonoscopy allows the accurate detection of very small lesions and has since almost completely replaced fluoroscopy. Cross-sectional imaging techniques, including magnetic resonance imaging (MRI) and computed tomogra­phy (CT), are increasingly being considered imaging modalities for the detection of colorectal polyps. Conclusions. CT and MR colonography are new techniques for imaging of the colon. In symptomatic patients, these new techniques show promising results for the detection of polyps equal to or larger than 1 cm in diameter. Key words: colonic neoplasms-diagnosis, tomography, X-ray computed; magnetic resonance imaging Introduction Colon cancer is the second leading cause of cancer death in the western world.1 Several risk factors predispose a person to develop colon cancer.2 Adenomatous colorectal polyps, which are found in 30­ Received 14 December 2006 Accepted 12 January 2007 Correspondence to: Sandra Vegar-Zubovic M.D., M.Sc., Institute of Radiology, Clinical Center of Sarajevo University, Bolnicka 25, 71000 Sarajevo, Bosnia and Herzegovina; Phone /Fax: + 387 33 444 553; E-mail: sandra.vegar@gmail.com 50% of Americans more than 50 years old, are recognized as important precursors of malignancy. Probably most of the invasive colon carcinomas arise from polyps. An early polyp removal has been shown to reduce mortality from colon cancer by 25­50%. For this reason the early detection of these polyps and their complete removal is a recognized strategy for the prevention of colon cancer.3,4 So far no single method for an early diagnosis of colon polyps or colon cancer including faecal occult blood test­ing (FOBT), proctosigmoidoscopy, double contrast barium enema (fluoroscopy) or conventional endoscopy offers high sensi­tivity and specificity along with low cost and good patient acceptance. Endoscopic colonoscopy allows the accurate detection of very small lesions and has almost com­pletely replaced fluoroscopy. Furthermore, biopsies are easily harvested and polypec­tomy is also feasible. Although providing means for an early diagnosis of colon polyps and therapeutic intervention, endo­scopic colonoscopy is a costly procedure which depends on the skill of the examiner and carries a low but not negligible risk of bowel perforation. Therefore, the indication to perform colonoscopy should be restrict­ed to symptomatic patients or persons with an increased risk of cancer development. Furthermore, colonoscopy fails to reach the caecum in 5-10% of average risk-patients and in even higher percentages of patients with obstructing cancer.5 Cross-sectional imaging techniques, in­cluding magnetic resonance imaging (MRI) and computed tomography (CT), are in­creasingly being considered imaging mo­dalities for the detection of colorectal po­lyps.6,7 Using thin section axial images and assigned software both techniques allow the generation of three-dimensional views of the colon, simulating those obtained with conventional colonoscopy. Since CT-colonography is relatively safe and minimal­ly invasive, it has the potential to become an attractive alternative to existing tests for an early diagnosis of colorectal cancer.8 Major advantages over endoscopy are its shorter examination time, non-invasive­ness, and relative independence from the examiner. Thus, patient acceptance for this new method may be improved. Inherent ad­vantages of CT-colonography, compared to endoscopy, include the visualization of the colon proximal and distal to constricting le­sions, the ability to quantify local morpho-metric characteristics of the colon such as wall thickness and tumour extension in the extraluminal space, and the accurate locali­zation of other abnormalities. It has to be stressed, however, that CT-colonography re­quires bowel cleansing and bowel distension by air insufflation similar to barium enema or conventional colonoscopy. Therefore, the patient’s discomfort still remains a problem. Currently MRI CT-colonography is restricted by limited availability of scan­ners and high procedural costs. MRI as well as single-slice CT suffers from restrictions in spatial resolution and from motion arte-facts, which explain insufficient detection rates for masses smaller than 10 mm.6,7 Single-slice CT requires several breath holds or a slice thickness exceeding 4 mm in order to scan the entire colon. A recent study comparing single-slice CT-colonog­raphy and conventional colonoscopy sug­gests a similar efficacy for the detection of polyps 6 mm or more in diameter (82­91%). However, restrictions in spatial reso­lution resulted in a low sensitivity for pol­yps smaller 6 mm (55%) and frequent false positive findings.6 Recently introduced multi-slice CT (MSCT) scanners represent a significant improvement in CT technol­ogy, combining high-resolution thin slice imaging with high-speed volume coverage,9 resulting in multiple advantages over sin­gle-slice-CT which has been documented for CT-angiography or lesion detection in the liver.10,11 MSCT has already been shown to enhance the quality of CT-colonography due to the improved colonic distension and reduction of respiratory motion artefacts compared to single slice CT.12 Methods of colon investigation Currently, there are four methods for the investigation of the entire colon. These are double-contrast barium enema (DCBE), colonoscopy, CT colonography, and MR colonography. Fischer described the DCBE technique in 1923.13 It was refined in the Radiol Oncol 2007; 41(1): 1-12. late 1960s and became the radiologic tech­nique of choice for colon imaging in the mid-1970s.14,15 Recently, the DCBE tech­nique was reviewed.16 It was concluded that performing a high-quality DCBE study requires tailoring of the examination to the clinical history, patient, and fluoroscopic findings. Each colonic segment should be viewed in detail with spot radiographs or magnified digital images. The order in which these are obtained is flexible, as long as each loop of colon has adequate barium coating and distention and is demonstrat­ed en face. Overhead views such as left and right side–down decubitus views and a prone-angled view of the rectosigmoid junction are helpful in piecing together the spot images.16 Colonoscopy was first described in 1965 by three independent Japanese groups in the same journal.17-19 Since then, technical developments made scopes smaller, easier to manipulate around angles, and improved the quality of the visualization methods. Compared to DCBE studies and colon­oscopy, CT and MR colonography (MRC) have a short history and are still being de­veloped. CT colonography was described in 1994 by Vining et al.20 and MR colonog­raphy in 1997 by Luboldt et al.21 Both are cross-sectional methods that generate nu­merous images in the axial plane (CT) or any desired plane (MR imaging), preferably during one breath-hold. To efficiently read these images, postprocessing on a worksta­tion is necessary. Such workstations should be able to handle the data quickly and, therefore, should have adequate hardware and software to allow fast interaction with the data set. These data sets can consist of up to 700 images with relatively high spatial resolution. Reading the source images is the first step. These images need to be viewed care­fully for filling defects and, if applicable, enhancing lesions. Postprocessing is an im­portant feature of image interpretation. The most simple and important postprocessing technique for CT and MR colonography is multiplanar reformatting (MPR).22,23 Furthermore, volume rendering techniques, such as tissue transition projection or endo­scopic three-dimensional (3D) viewing (vir­tual endoscopy), can be performed. These require a great deal of computer power; endoscopic 3D viewing is especially time-consuming. Other 3D rendering techniques such as maximum-intensity projection (MIP) and shaded surface display (SSD) are easy to perform but only a small part of the entire data set is used in these techniques. Thus, much important information is lost and this makes these techniques unsuitable for the polyp detection.Postprocessing tech­niques will be discussed in detail. The pur­pose of this article is to describe scanning techniques in CT and MR colonography, discuss the currently available postprocess­ing methods, and discuss the accuracy of these techniques for the polyp detection compared with colonoscopy and DCBE. CT colonography Computed tomography (CT) colonography (virtual colonoscopy) is a promising new method for detecting colorectal polyps and cancers. Although multiple articles on this issue have been published since the mid­1990s, it remains an important discussion topic in current radiology and gastroenter­ology societies. Regarding its clinical role, there is no doubt that this imaging tech­nique is best suited and highly recommend­ed for those patients who are unable or unwilling to undergo conventional colonos­copy. Its role as a general screening tool for colon cancer is obvious for many, equivocal for some, and doubtful for others. CT colonography uses multidetector-row CT to generate data, which is then Radiol Oncol 2007; 41(1): 1-12. converted by computer software into 2­dimensional (2D) and 3-dimensional (3D) displays of the colon. CT colonography has several advantages over conventional colonoscopy: No sedation is needed, it is only minimally invasive, and the examina­tion is less time-consuming than conven­tional colonoscopy. However, there is still a need for bowel cleansing and insufflation of gas to expand the colon. Moreover, ex­posure to radiation is inherent to CT, and there is no possibility of biopsy, polypec­tomy, or treatment during the examination (Figures 1, 2). MSCT has the potential to significantly improve the detection rate for colorectal polyps due to its better z-axis resolution, improved 3D-image quality and faster data acquisition. The detection and the subse­quent removal of colorectal polyps remain the most important approaches for the re­duction of colon cancer related mortality (Figures 3, 4, 5). Studies A meta-analysis of data from 14 studies with a total of 1324 patients reported the sensitivity and specificity of CT colonog­raphy for the detection of polyps, using conventional colonoscopy as the reference standard. The pooled per-patient sensitiv­ity for polyps 10 mm or larger was 88% (95% confidence interval [CI], 84–93%), for polyps 6–9 mm it was 84% (95% CI, 80–89%), and for polyps 5 mm or smaller it was 65% (95% CI, 57–73%). The pooled per-polyp sensitivity for polyps 10 mm or larger was 81% (95% CI, 76–85%), for polyps 6–9 mm it was 62% (95% CI, 58–67%), and for polyps 5 mm or smaller it was 43% (95% CI, 39–47%). The overall specificity for the detection of polyps 10 mm or larger was 95% (95% CI, 94–97%). A study involving 1233 asymptomatic adults reported that the per-patient sensi­tivity for polyps 10 mm or larger was 94% (95% CI, 83–99%) for CT colonography and 88% (95% CI, 75–95%) for conventional colonoscopy. The per-patient sensitivity for polyps 6 mm or larger was 89% (95% CI, 83– 93%) for CT colonography and 92% (95% CI, 87–96%) for conventional colonoscopy. A study of 615 patients reported per-pa­tient sensitivities of 55% (95% CI, 40–70%) for polyps 10 mm or larger and 39% (95% CI, 30–48%) for polyps 6 mm or larger. Another study of 614 patients reported that CT colonography was significantly more sensitive than barium enema but less sensi­tive than colonoscopy. Radiol Oncol 2007; 41(1): 1-12. Figure 2. Multislice CT colonography. Colon tumour in 67-year old patient. Figure 3. Shaded surface display of inflammatory Figure 4. Virtual colonoscopic view of polypoid stenosis. lesion. Radiol Oncol 2007; 41(1): 1-12. Figure 5. Virtual colonoscopy. (A) Retrograde and (B) antegrade views of polyp. A study of 203 patients that used faecal tagging reported an overall per-patient sen­sitivity of 90% (95% CI, 86–94%).24 MR colonography Currently two techniques are being evalu­ated for MR colonography . Based on the signal within the colonic lumen, they can be differentiated as “bright lumen” and “dark lumen” MRC (Figure 6). Bright lumen MRC Similar to contrast enhanced 3D MR angi­ography, MRC is based on the principles of ultra fast, T1 weighted 3D GRE acquisitions collected within the confines of a single breath hold.25 This requires the use of an MR scanner equipped with high perform­ance gradients. To permit the homogenous signal transmission and the reception over the entire colon with high CNR values, a combination of phased array surface coils should be used. The size of the coil must permit a coverage of the entire colon. As colonic lesions can often not be differenti­ated from stool, the patient has to undergo bowel cleansing in a manner similar to that required for conventional colonoscopy. Before the examination the patient should be screened for contraindications to MRI such as severe claustrophobia, presence of metallic implants in critical regions such as the eyes, spinal chord or brain, or cardiac pacemakers. The presence of hip prosthe­ses, which normally is not regarded a con­traindication to MRI, impedes a complete analysis of the rectum and sigmoid co­lon. Therefore, patients with hip prosthesis should also not be examined by MRC. After the placement of a rectal enema tube, the colon is filled with the patient in the prone position using 1000 to 2000 ml of a water based enema, spiked with para­magnetic contrast (1:100). The enema is ad­ministered using 100 cm–150 cm of hydro­static pressure. To reduce bowel motion and alleviate colonic spasm, the use of intrave­nously administered spasmolytic agents (for example, scopolamine or glucagon) be­fore and during the bowel filling is helpful. In contrast with conventional colonoscopy sedative or analgesic agents do not have to Radiol Oncol 2007; 41(1): 1-12. be applied. To ensure safe and optimal bo­wel filling and distension, the filling proc­ess is monitored with a non-slice select 2D acquisition, collecting one image every three seconds. Once the enema has reached the caecum, a 3D dataset of the abdomen en­compassing the entire colon is collected. To compensate for the presence of residual air exhibiting “filling defects” similar to polyps within the colonic lumen, 3D datasets are collected in both the prone and supine pa­tient positions. Here-after the enema bag is placed on the floor for facilitated empty­ing of the colon and the patient is removed from the scanner. The acquired 3D MR datasets consist of coronal sections, ranging in thickness be­tween 1.5 mm and 2 mm. The sequence is based on the use of short repetition (TR 1.6 ms–3.8 ms) and echo times (0.6 ms – 1.6 ms). The achievable minimum TR should be shorter than 5 ms; otherwise, the acquisition of a 3D dataset cannot be collected within the confines of a single breathhold. In con­junction with a field of view of 400 x 400 mm and an imaging matrix of 460 x 512, the spa­tial resolution includes an interpolated voxel size of about 1 mm x 1 mm x 1.6 mm. On the 3D GRE datasets only the co-lonic lumen containing the enema is bright, whereas all other tissues remain low in sig­nalintensity. The resulting contrast between the colonic lumen and surrounding struc­tures is the basis for the subsequent virtual colonographic viewing. The MRC protocol can be further amplified by the acquisition of 2D gradient echo datasets after the in­travenous application of a gadolinium con­taining contrast compound. This permits a more comprehensive assessment of paren­chymal abdominal organs and increases the ability to detect hepatic metastases. Bright lumen MRC can be completed within 20 minutes, including the time for patient positioning, image planning, and data acquisition. The 3D datasets are sub­sequently processed using commercially available software and hardware. A com­plete analysis of an MRC examination still requires 15 minutes of interactive image viewing on a high performance work sta­tion. In the first step MRC images should be interpreted in the multiplanar reformation mode scrolling through the prone 3D data­set in all three orthogonal planes. In regions containing larger pockets of residual air, the assessment needs to be supplemented by views of the supine dataset. In the sec­ond step the data should be assessed based on virtual endoscopic renderings displaying the inside of the colonic lumen. A virtual endoscopic fly through allows the observer to concentrate on the colon facilitating the depiction of small structures protruding into the colonic lumen. Furthermore, the three dimensional depth perception per­mits the assessment of haustral fold mor­phology, thereby increasing the observer’s ability to distinguish polyps from haustra. To assure the complete visualisation of both sides of haustral folds, the virtual fly through should be performed in an ante-grade as well as retrograde direction. Dark lumen MRC The detection of colorectal lesions with “bright lumen” MRC relies on the visualisa­tion of filling defects. Differential considera­tions for such a filling defect beyond polyps include air bubbles as well as residual faecal material. To permit differentiation datasets are collected in both the prone and su­pine patient position: air and faecal material move, while polyps remain stationary. While effective in most instances, the technique can introduce errors. Thus, polyps with a long stalk may move sufficiently to impress as a moving air bubble or more probably residual stool, while stool adherent to the colonic wall may not move at all and, thus, Radiol Oncol 2007; 41(1): 1-12. falsely impress as a polyp. In addition to obviating the need for the second, time con­suming 3D data acquisition “dark lumen” MRC facilitates the identification of polyps. “Dark lumen” MRC focuses on the co-lonic wall. It is based on the contrast gener­ated between a brightly enhancing colonic wall and a homogeneously dark colonic lu­men.26 The technique differs from “bright lumen” MRC in the following manner: 1. Instead of gadolinium containing en­ema only tap water is rectally applied rendering low signal on heavily T1 weighted 3D GRE acquisitions. 2. The colonic filling process is monitored with a fluoroscopic T2w sequence, rather than a T1w sequence. 3. To obtain a bright colonic wall paramag­netic contrast is applied intravenously. 3D datasets are collected before the ap­plication and after a 75 second delay. 4. As residual air exhibits no signal in the colonic lumen, the examination needs to be performed only in the prone pa­tient position. Compared with “bright lumen” MRC that has been extensively evaluated in the past, “dark lumen” MRC harbours consid­erable advantages including the reduced examination and post-processing times, as only one 3D dataset needs to be collected. Furthermore, the “dark lumen” technique copes with the problem of residual stool in a simple manner: if the lesion enhances, it is a polyp; if it does not enhance, it repre­sents stool. Suspicious appearing lesions are analysed by comparing signal intensi­ties on the pre-contrast and post-contrast images. If analyses were limited to the post-contrast dataset, bright stool could be mis­interpreted as a polyp. A comparison with the pre-contrast images records the lack of contrast enhancement, which assures the correct diagnosis. The enhancement of colorectal masses following the intravenous administration of contrast has been reported in conjunction with MRC22 and CT colonography.23 The use of intravenously administered contrast material significantly improves the reader confidence in the assessment of bowel wall conspicuity and the ability to depict medi­um sized polyps in suboptimally prepared colons. The enhancement observed within polyps exceeds the increase determined within the colonic wall. This may aid in dif­ferentiating even very small polyps from thickened haustral folds. A further advantage of “dark lumen” MRC relates to the fact that it permits a di­rect analysis of the bowel wall. This might facilitate the evaluation of inflammatory changes in patients with inflammatory bowel disease. Increased contrast uptake and bowel wall thickening, as recorded on contrast enhanced T1 weighted images, have already been shown to correlate well with the degree of inflammation in the small bowel.27 Hence, the “dark lumen” ap­proach may indeed amplify the list of indi­cations for MRC in the future to encompass also inflammatory bowel disease. Finally, the intravenous application of paramagnetic contrast permits a more com­prehensive assessment of parenchymal abdominal organs contained within the field of view. By combining pre-contrast and post-contrast T1 weighted imaging, the liver can be accurately evaluated regard­ing the presence and type of concomitant disease. Dark lumen MRC also offers new perspectives regarding the optimisation of bowel distension. Although the administra­tion of water as a rectal enema does not ad­versely affect patient comfort in most cases, a modified strategy could be based on the application of gases like carbon dioxide.28 The gas is signalless and would thus easily permit delineation of the contrast enhanced colonic wall and masses. The diagnostic performance of bright lumen MRC was assessed in several stu- Radiol Oncol 2007; 41(1): 1-12. Table 1. Sensitivity and specificity of bright lumen MR colonography (MRC)29 All lesions Sensitivity 27/58 = 47% Specificity 48/59 = 81% PPV 27/38 = 71% NPV 48/79 = 61% Lesions >10 mm Sensitivity 13/14 = 93% Specificity 102/103 = 99% PPV 13/14 = 93% NPV 102/103 = 99% PPV = Positive predictive value NPV = Negative predictive value dies using conventional colonoscopy as the standard of reference. While most mass lesions smaller than 5 mm in size were missed, almost all lesions exceeding 10 mm were correctly identified (Table 1).29 In a study by Pappalardo et al. MRC even detected a higher total number of polyps exceeding 10 mm in size than conventional colonoscopy. MRC identified additional polyps in regions of the colon not reached by colonoscopy (Figure 6). Figure 6. MR colonography. A, Bright lumen technique: 3D GRE sequence with water-gadolinium enema. B, Virtual colonoscopy of normal ascending colon. C, D, Combined bright and black lumen technique: C, contrast-enhanced 3D spoiled T1-weighted GRE image and, D, nonenhanced 3D spoiled and balanced GRE image. Radiol Oncol 2007; 41(1): 1-12. Faecal tagging MRC still requires bowel cleansing in a manner similar to conventional colonos­copy. As 75% of patients undergoing bow­el preparation complain about symptoms ranging from “feeling unwell” to “inability to sleep”, patient acceptance is affected negatively. To assure high patient accept­ance of MRC, bowel cleansing needs to be eliminated. This can be accomplished with faecal tagging—a concept based on modulating the signal intensity of faecal material by adding contrast compounds to regular meals. Fitting the two approaches to MRC (bright lumen and dark lumen); there are also two theoretical approaches to faecal tagging. Its principle was demonstrated on the basis of a bright rectal enema distend­ing the colonic lumen containing brightly tagged stool in conjunction with bright lu­men MRC. By adding a T1 shortening Gd based MR contrast agent to regular meals before the MR examination, harmonisation of signal properties between faecal material and the Gd based enema was achieved. The oral administration of a paramagnetic MR contrast agent (Gd-DOTA) has been shown to be safe. The combination of faecal tag­ging with a paramagnetic contrast agent and colonic filling results in a homogenous signal distribution throughout the colon. In these examinations virtual MRC permits an unobstructed view through the colon because the tagged stool is virtually indis­tinguishable from the administered enema. Although encouraging results concerning acceptance and image interpretation were obtained, the clinical implementation of bright lumen faecal tagging was hindered by the high cost of the Gd based paramag­netic contrast agent. A second strategy for faecal tagging is based on rendering the colonic lumen dark. For faecal tagging, a highly concentrated, barium sulphate containing contrast agent (Micropaque; Guerbet, Sulzbach, Germany; 1 g barium sulphate/ml) is administered in a volume of 200 ml with each of four main meals beginning 36 hours before MRC. Patients are instructed to avoid the intake of all fibre rich foodstuff and nourishments with high concentration of manganese such as chocolate or fruits during this period, as manganese leads to increased signal in­tensity in T1w sequences. “Barium based” faecal tagging is combined with dark lumen MRC: the colon is distended with a rectally applied water enema and paramagnetic contrast is administered intravenously to render the colonic wall and adherent color-ectal mass lesions bright. Barium sulphate is a well known diag­nostic contrast agent, still in common use as an oral agent for oesophageal, gastric, and small bowel radiography. Compared with Gd based contrast compounds, it is far less costly and characterised by an even better safety profile. Anaphylactoid reactions or other adverse side effects are virtually un­known. The agent is not absorbed and mix­es well with stool. Thus, barium includes all characteristics as an ideal oral tagging agent for MRC. The barium based approach to faecal tagging has been successfully assessed. The signal reducing effects upon stool has been documented in volunteer studies. By in­gesting barium before the MR examination, stool is rendered virtually indistinguish­able from the administered water enema on heavily T1w 3D GRE image. The MR examination without the prior ingestion of barium reveals signal rich stool that cannot readily be differentiated from the brightly enhancing colonic wall. Recently, the barium based faecal tag­ging concept has been successfully evalu­ated in a pilot patient study. Faecal tagged MRC detected all polyps larger than 8 mm in a population of 24 patients with known Radiol Oncol 2007; 41(1): 1-12. or suspected colorectal tumours. The over­all sensitivity of MRC amounted to 89.3% for the detection of colorectal masses, and specificity was 100%. Colorectal cancers and polyps were readily identified as such. Although further work is required to confirm these excellent results, it seems that barium tagged MRC has vast poten­tial to emerge as the examination strategy of choice for the early detection of polyps in asymtomatic subjects. The technique seems to combine the excellent diagnostic accuracy with the high patient acceptance based on a painless examination and no need for colonic cleansing. Conclusions In conclusion, CT and MR colonography are new techniques for imaging of the co­lon. In symptomatic patients, these new techniques show promising results for the detection of polyps equal to or larger than 1 cm in diameter. It must be remembered that in all research protocols, colonoscopy was considered to be the standard of ref­erence, which implies that other imaging modalities with which colonoscopy is com­pared will always perform worse. In most studies, patients preferred CT colonogra­phy to conventional colonoscopy. The bowel-cleansing regimen is consid­ered to be cumbersome, so from the patient acceptance point of view, faecal tagging techniques are promising. Their value in polyp detection still needs to be deter­mined in large studies. In medicine, there is a trend toward performing non-invasive or less invasive imaging techniques rather than older and more validated invasive techniques. (MR angiography or CT angi­ography vs digital subtraction angiography, MR cholangiopancreatography vs endo­scopic retrograde cholangiopancreatogra­phy). The invasive techniques are used for problem solving and interventions. CT and MR colonography fit in this trend perfectly. Both techniques have shown promising ini­tial results in symptomatic patients and are still in evolution. Before these techniques can be implemented in daily practice, they must show the same accuracy as colonos­copy and should be cost-effective in both high-risk and screening patients. The radiation-dose issue in CT colonog­raphy must be discussed, and a consen­sus on the maximum acceptable dose for a screening patient must be reached. MR colonography has the advantage of being a zero-dose examination, but at this point, CT colonography is faster and provides images with higher resolution. References 1. Potter JD, Stattery ML, Bostick RM, Gapstur SM. Colon cancer: a review of epidemiology. Epidemiologic Rev 1993; 15: 499-545. 2. Visser O, Coebergh JWW, Schouten LJ, et al. Incidence of cancer in the Netherlands 1996. Utrecht: Vereniging van integrale kankercentra; 2000. 3. Seidman H, Mushinski MH, Gelb SK, Silverberg E. Probability of eventually developing and dying of cancer: United States, 1985. CA Cancer J Clin 1985; 35: 36-56. 4. Muto T, Bussey HJR, Morson BC. The evolution of cancer of the colon and rectum. Cancer 1975; 36: 2251-70. 5. Vogelstein B, Fearon ER, Hamilton SR, Kern SE, Preisinger AC, Leppert M, et al. Genetic altera­tions during colorectal-tumor development. N Engl J Med 1988; 319: 525-32. 6. Morson BC. The evolution of colorectal carcinoma. Clin Radiol 1984; 35: 425-31. 7. Toribara NW, Sleisinger MH. Screening for color-ectal cancer. N Engl J Med 1995; 332: 861-7. 8. Geenen RW, Hussain SM, Cademartiri F, Poley JW, Siersema PD, Krestin GP. CT and MR colonog­raphy: scanning techniques, postprocessing, and emphasis on polyp detection. Radiographics 2004; 24(1): e18. Epub 2003 Oct 3 Radiol Oncol 2007; 41(1): 1-12. 9. Macari M, Lavell M, Pedrosa I. Effect of different preparations on residual fluid at CT colonography. Radiology 2001; 218: 274-7. 10. Yee J, Hung RK, Akerkar GA, Wall SD. The useful­ness of glucagon hydrochloride for colonic disten­tion in CT colonography. AJR Am J Roentgenol 1999; 173: 169-72. 11. Luboldt W, Fletcher JG, Vogl TJ. Colonography: current status, research directions and challenges: update 2002. Eur Radiol 2002; 12: 502-24. 12. Fletcher JG, Luboldt W. CT colonography and MR colonography: current status, research directions and comparison. Eur Radiol 2000; 10: 786-801. 13. van Gelder RE, Venema HW, Serlie IW, Nio CY, Determann RM, Tipker CA, et al. CT colonogra­phy at different radiation dose levels: feasibility of dose reduction. Radiology 2002; 224: 25-33. 14. Lauenstein T, Goyen M. Dark-lumen MR colo­nography. Highlights in MRI. Essen: Department of Diagnostic and Interventional Radiology University Hospital Essen; 2004. 15. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. CA Cancer J Clin 1998; 48: 6-29. 16. O’Brien MJ, Winawer SJ, Zauber AG, Gottlieb LS, Sternberg SS, Diaz B, et al. The National Polyp Study. Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterology 1990; 98: 371-9. 17. Luboldt W, Debatin JF. Virtual endoscopic colonog­raphy based on 3D MRI. Abdom Imaging 1998; 23: 568-72. 18. Lauenstein TC, Herborn CU, Vogt FM, Gohde SC, Debatin JF, Ruehm SG. Dark lumen MR-colonog­raphy: initial experience. Rofo 2001; 173: 785-9. 19. Schoenenberger AW, Bauerfeind P, Krestin GP, Debatin JF. Virtual colonoscopy with magnetic resonance imaging: in vitro evaluation of a new concept. Gastroenterology 1997; 112: 1863-70. 20. Vining DJ, Shifrin RY, Grishaw EK, Liu K, Gelfand DW. Virtual colonoscopy. [Abstract]. Radiology 1994; 193: 446. 21. Luboldt W, Bauerfeind P, Steiner P, Fried M, Krestin GP, Debatin JF. Preliminary assessment of three-dimensional magnetic resonance imag­ing for various colonic disorders. Lancet 1997; 349:1288-91. 22. Ajai W, Lauenstein TC, Pelster G, Goehde SC, Ruehm SG, Debatin JF. MR colonography: How do es air compare to water for colonic distention. J Magn Reson Imaging 2004; 19: 216-21. 23. Fischbach R, Wessling J. CT-colonography using multi-slice computed tomography. Electromedica 2001; 69(2): 116-9. 24. Interventional procedure guidance 129. London: National Institute for Health and Clinical Excellence; 2005; ISBN 1-84629-042-2. 25. Ajaj W, Pelster G, Treichel U, Vogt FM, Debatin JF, Ruehm SG, et al. Dark lumen magnetic reso­nance colonography: comparison with conven­tional colonoscopy for the detection of colorectal pathology. Gut 2003; 52: 1738-43. 26. Lauenstein TC, Goehde SC, Ruehm SG, Holtmann G, Debatin JF. MR colonography with barium-based fecal tagging: initial clinical experience. Radiology 2002; 223: 248-54. 27. Vandaele P, Oliva MR, Barish MA, Mortelé KJ. CT colonography: the essentials. Applied Radiology 2006; 35(1): 246-9. 28. Debatin JF, Lauenstein TC. Virtual magnetic reso­nance colonography. Gut 2003; 52(Suppl 4): iv17­22. 29. Luboldt W, Bauerfeind P, Wildermuth S, Marincek B, Fried M, Debatin JF. Colonic masses: detec­tion with MR colonography. Radiology 2000; 216: 383–8. Radiol Oncol 2007; 41(1): 1-12. images in clinical medicine Recurrence of carcinoma of the lower lip treated by interferon and irradiation Boris Jancar Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia A seventy-year-old patient was referred to our hospital for a tumour on the lower lip, which had been growing for the last two years. On the first clinical examination, the tumour, measuring 3.5 cm in diameter, was visible to the naked eye. Histological ex­amination of the biopsy sample confirmed verrucous carcinoma. The patient had been treated for miocar­diopathy and emphysema for several years. Though at rest, the patient was breathing heavily and suffered from oedemas and small ulcers on both shanks. It was thus evident that the patient was not eligible for surgery under general anaesthesia, but rather for irradiation therapy. The irradiation was performed by an or-thovolt machine (PANTAC) with a total dose of 40 Gy (10 x 4 Gy). The tumour regressed completely. Six months after the complet­ed therapy, a minor lesion, which would not heal up, developed on the tumour site. Several subsequent fine-needle aspiration biopsy (FNAB) examinations did not detect any malignant cells in the lesion. The pa­tient complained that the lesion was pain­ful. Two years after the completed radio- Received 5 February 2007 Accepted 15 February 2007 Correspondence to: Prim. Boris Jancar, MD, MSc, Department of Radiation Oncology, Institute of Oncology, Zaloška 2, Ljubljana, Slovenia; Phone; + 386 1 5879 295; Fax: + 386 1 5879 295; E-mail: bojancar@onko-i.si therapy, a tumour with a diameter of 1 cm appeared on the lower lip on the same site as the primary which completely regressed after the therapy, but obviously recurred two years later. The patient, believing that the tumour would fade away by itself, re­fused surgical treatment under local anaes­thesia. In the following two years, the tumour was growing further and four years after the completed radiotherapy measured 3 x 2 cm (Figure 1). FNAB examination con­firmed the recurrence of the squamous cell carcinoma. Due to poor physical condition of the patient, surgical treatment was most unlikely. The patient was therefore treated with the interferon injected directly into tu­mour. The tumour partially regressed after 5 injections and the therapy with interferon was then combined with irradiation. The patient was receiving 3 Mil IE per applica­tion and was submitted to hyperfractiona­ted radiotherapy (38 fractions, 2 x /day, 1.5 Gy/fraction). In two months’ time, the tu­mour regressed. Nine months later the cos­metic effect was quite good (Figure 2). At the last follow-up control three years after the second therapy, the lower lip was NED. As the patient’s poor physical condition did not improve and the transfer from home to the hospital and back were getting more and more physically exhausting for him, he was not invited to follow-up controls any more. He died of myocardial infarction 4.5 years after the last therapy for the tumour, with NED on the lower lip. Radiol Oncol 2007; 41(1): 13-4. Subchronic exposure of rats to sublethal dose of microcystin-YR induces DNA damage in multiple organs Metka Filipic1, Bojana Žegura1, Bojan Sedmak1, Irena Horvat-Žnidaršic2, Aleksandra Milutinovic2, Dušan Šuput2 1National Institute of Biology, Department for Genetic Toxicology and Cancer Biology, Ljubljana, Slovenia; 2Medical Faculty, Institute of Pathophysiology, University of Ljubljana, Ljubljana, Slovenia Background. Microcystins (MCs) are cyclic heptapeptides that are considered to be liver specific toxins. They are potent tumour promoters and recent studies indicate that they are also genotoxic. In this study we measured DNA damage in lymphocytes, liver, kidney (cortex and medulla), lung, spleen and brain cells of male Fisher F344 rats that were exposed to sublethal dose (every second day 10 ”g/kg b.w.; i.p) of micro-cystin-YR (MCYR) for one month. Methods. At the end of exposure the animals were sacrificed, the lymphocytes were isolated from blood taken from jugular vein, liver cells were obtained by perfusion with collagenase A and the cells from other organs were isolated by incubating small tissue pieces with collagenase A. The DNA damage in isolated cells was measured with the single cells gel electrophoresis (SCGE) also called the comet assay. Results. A significant increase of the % tail DNA in MCYR-exposed animals compared to the nonexposed control ones was observed in brain (2.5 fold), liver (2.1 fold), kidney medulla (1.9 fold), kidney cortex (1.8 fold) and lung (1.7 fold) cells, while the DNA from lymphocytes and spleen cells was not affected. Conclusion. This study demonstrated that subchronic exposure to sublethal doses of MCs can induce sys­temic genotoxicity in mammals, and it affects not only the liver but also other vital organs. Key words: DNA damage; comet assay; cyanobacteria; bacterial toxins; rats, inbred F344 Introduction Microcystins (MCs) comprise a family of more than 60 structurally related hepato- Received 21 March 2007 Accepted 29 March 2007 Correspondence to: Assist. Prof. Metka Filipic, Ph.D., National Institute of Biology, Vecna pot 111, 1000 Ljubljana, Slovenia. Phone: +386 1 42 33 388; Fax: +386 1 25 73 847; E-mail: metka.filipic@nib.si toxins produced by cyanobacterial species.1 Among them microcystin-LR (MC-LR) is the most toxic. The variable amino acids of the most common microcystin variants, MC-LR, RR and YR are leucine (L), arginine (R) and tyrosine (Y) (Figure 1). Toxic cyanobacteria found in eutrophic, freshwater, municipal and residential water supplies represent an increasing environmental hazard in many parts of the world.2,3 Cyanobacterial blooms in surface water have been associated with poisoning and death of wildlife and domes­tic animals.2 In humans MCs intoxication caused symptoms such as nausea/vomiting, weakness, skin irritation, and illnesses rang­ing from gastroenteritis and pneumonia to hepatoenteritis.4 The most severe human in­toxication happened in 1996 in Brazil, where 60 of 126 dialysis patients died of liver fail­ure due to cyanobacterial contamination of the water used for dialysis.5 Epidemiological studies have suggested that MCs are one of the risk factors for the high incidence of pri­mary liver cancer in certain areas of China, where people have consumed pond-ditch water contaminated with cyanobacteria.6 Although MCs accumulate predomi­nantly in the liver, they have also been de­tected in other organs.7,8 Liver is the main target organ for MCs toxicity, because they are entering the cells through the multi-specific transport system for bile acids9,10 and the predilection for hepatic damage by MCs thus probably depends on the high concentration of these transporters in the hepatocyte membrane. However, several in vitro studies showed that MCs exert toxic effects in different non-hepatic cell lines. Microcystin-LR induced toxic effects in epi­dermoid carcinoma cells (KB)11 and apopto-sis in human endothelial and epithelial cells and in rat fibroblasts and promyelocytes.12 MCs are potent inhibitors of protein phosphatase 1 and 2A, leading to the in­creased protein phosphorylation, which is directly related to their cytotoxic and tumor-promoting activity.13,14 Apart from the inhibition of protein phosphatases, the oxidative stress also plays a significant role in the pathogenesis of microcystin toxic­ity. MCs can induce intracellular reactive oxygen species (ROS) formation, cell injury and lipid peroxidation.15-18 There is increa­sing evidence that MCs are also genotoxic. It has been reported that MCs induce DNA strand breaks in liver cells in vivo19,20 and in vitro.21,22 Several in vitro studies showed, that MCs induced DNA strand breaks also in different types of non-hepatic cells in­cluding baby hamster kidney cells, mouse embryo primary fibroblasts23 and human peripheral lyphocytes.24 In addition, they induced micronuclei formation and loss of heterozygosity in human lymphoblastoid TK6 cells,25 and base substitution mutations at K-ras codon 12 in human RSa cells.26 The aim of our study was to explore if a subchronic exposure of rats to a sublethal dose of microcystine-YR (MCYR) induces DNA strand breaks in different organs. The DNA damage was measured by single cell gel electrophoresis (SCGE), also called the comet assay, which is a very sensitive method for detecting DNA double- and sin-gle-strand breaks, alkali labile sites, DNA­DNA and DNA-protein cross links, and single-strand breaks associated with the incomplete excision repair.27 The in vivo comet assay is being increasingly used in genotoxicity testing because of its applica­bility to various tissues and its sensitivity to low levels of DNA damage. Materials and methods Animals Male Fischer F 344 rats weighing 200 to 250 g were housed in standard plastic Radiol Oncol 2007; 41(1): 15-22. cages with sawdust cover on the floor. They were maintained on a 12 h light-dark cycle (light on: 07.00–19.00 h) in a colony room controlled at 22–24°C, with free access to rodent pellets and tap water. The animals were maintained following the guidelines in the Slovenian Law for Animal Health Protection and Instructions for Granting Permission for Animal Experimentation for Scientific Purposes. Toxin and experimental design MCYR was isolated from cyanobacterial bloom (Microcystis aeruginosa) from an arti­ficial recreational pond (Koseze, Ljubljana, Slovenia) according to the method of 28 Harada et al., as described previously.3 The toxin was dissolved at a final concen­tration of 2.7 ”g/ml in the vehicle solution of ethanol (0.8%) and methanol (0.2%) in physiological saline (0.9%). The experimental rats (7 animals) were applied i.p. with 10 ”g/kg b.w. MCYR in a volume of 3.7 ml/kg, every second day du­ring the period of 30 days. The control group (4 animals) received 3.7 ml/kg i.p. vehicle (the mixture of ethanol and methanol dis­solved in physiological saline). At the end of the experiment the animals were sacri­ficed using CO2 anaesthesia. At sacrifice, blood, liver, kidneys (cortex and medulla were separated), lung, spleen and brain tis­sues were collected in order to proceed the comet assay as detailed below. Cell isolation and preparation of single cell suspension Blood was collected from jugular vein on heparin from anesthetized animals just be­fore they were sacrificed. The lymphocytes were then isolated using Ficoll-PaqueTM plus (Amersham Pharmacia Biotech AB, Sweden) and suspended in RPMI 1640 me­dium. The single cell suspensions of liver cells was prepared by liver perfusion with collagenase A as described.29 The single cell suspensions from kidney (cortex and medulla were separated), lung (inferior lobe), spleen and brain (distal part) were prepared with a non-perfusion procedure using collagenase A. Briefly, partial tissue was cut from each isolated organ, washed twice with chilled PBS solution, gently cut in small pieces and incubated in the solu­tion of 0,5 mg/ml collagenase A (Sigma) for 20 minutes. The cell suspension was then gently aspirated several times with the pipette and transferred into centrifuge tube with 2 ml Eagle’s essential minimal medi­um (Sigma) containing 10% fetal bovine se­rum (FBS) to inactivate collagenase A. The cell suspension was then centrifuged for 10 minutes at 1000 rpm. The collagenase su­pernatant was removed and the precipitate was re-suspended in Eagle’s essential mini­mal medium (Sigma) supplemented with 10% FBS. The viability of cells was assessed using trypan blue exclusion assay.30 Comet assay The assay was performed as described by Singh et al.31 30 ”l of single cell suspen­sion (˜ 400,000 cells/ml) was mixed with 70 ”l of 1% low melting point agarose and added to fully frosted slides that had been covered with a layer of 1% normal melting point agarose. The cells were then lysed (2.5 M NaOH, pH 10, 0.1 M EDTA, 0.01 M Tris and 1% Triton X-100 for 1 hr at 4°C), rinsed with distilled water, placed in the electrophoresis solution (300 mM NaOH, 1mM EDTA, pH 13) for 20 minutes to allow DNA unwinding, and electrophoresed for 20 minutes at 25 V and 300 mA. Finally, the slides were neutralized with 0.4 M Tris buffer (pH 7.5), and the DNA stained with ethidium bromide (5 ”g/ml). Two slides were prepared per tissue per animal and 50 randomly selected nuclei per slide were Radiol Oncol 2007; 41(1): 15-22. captured under the fluorescence micro­scope (Olympus) and the images analyzed with image analysis software (VisCOMET, TillPhotonics, Germany). The % tail DNA was used to measure DNA damage. Statistical Analysis One-way analysis of variance (ANOVA, Kruskal-Wallis) was used to analyze the dif­ferences between treated and control ani­mals. A Dunnet test was used to compare mean values of % tail DNA; p<0.05 was considered as statistically significant. Results In this study we recorded DNA damage in liver, kidney medulla and cortex, lung, brain and spleen cells and in lymphocytes of rats that were treated with sublethal dose of MCYR (10 ”g/kg b.w.; i.p) every second day during the period of 30 days. The control rats received the vehicle (mixture of 0.8% etanol and 0.2% methanol dissolved in 0.9% physiological saline). The control animals appeared healthy and free from pathologi­cal signs, while animals that have received MCYR appeared less active and the fur was less shiny, suggesting a systemic toxic effect. After sacrifice and autopsy, no mac­roscopic evidence of degenerative processes was observed in any of the experimental animals. The cell viability after the isolation from organs was found to be more than 80% in all animals (data not shown). A significant increase of DNA damage in MCYR treated animals compared to the control was detected in liver, kidney medul­la and cortex, lung and brain, while no DNA damage was detected in spleen and lym­phocytes (Figure 1 and Table 1). From the ra­tio between mean value of the % tail DNA of the cells from the treated animals and that of the control animals it can be seen that the highest level of DNA damage was induced in brain, followed by liver > kidney medulla > kidney cortex > lung (Table 1). The data of the % tail DNA were further analyzed in terms of the distribution of sin­gle cells according to the extent of DNA damage in the whole population of ana­lyzed cells from each organ (Figure 1). The cells isolated from vehicle treated control animals had relatively uniform low DNA damage; however, the mean values of the percent comet tail DNA were different for different organs. The cells isolated from liv­er, kidney medulla, kidney cortex, lung and brain of the treated animals showed a het­erogeneous distribution ranging from cells with low to cells with high DNA damage. The majority of the cells had higher % tail DNA compared to the distribution of % tail DNA in cells isolated from the correspond­ing organ of the control animals. Discussion Acute hepatotoxic effects of MCs are well explored, while their effects on other or­gans have been neglected for a long time because the acute hepatotoxic effects caused by lethal intoxication are dominant and sufficient to cause the death of the animals before effects on other organs can be observed. However, at sublethal chronic intoxication it seems reasonable to expect that MCs could cause effects also in other organs. Recently Milutinovic et al.32 report­ed that the chronic intoxication of rats with sublethal doses of microcystins MCLR and MCYR induced kidney injury. In the present study we investigated the in vivo genotoxicity of MCYR in some organs and tissues of rats by measuring the DNA damage with the comet assay. The organs examined were liver, which is the target organ and kidney, lung, brain, spleen and lymphocytes which are considered as non- Radiol Oncol 2007; 41(1): 15-22. Table 1. The DNA damage in rat organs after 30 day exposure to The acute exposure of sublethal dose (10 ”g/kg b.w. i.p. every second day) of MCYR rats to MCLR resulted in a decrease of the en- Number of Treatment Organ animals % tail DNA IFa dogenous antioxidant defence system together Control Liver 4 7.0 ± 1.44 with an increase of lipid MCYR Liver 7 14.8 ± 0.80* 2.1 peroxidation in liver and in kidney.33 This supports Control Kidney cortex 4 13.5 ± 1.86 the assumption that the MCYR Kidney cortex 7 24.4 ± 5.61* 1.8 DNA damage of liver and kidney cells we observed Control Kidney medulla 4 10.6 ± 1.36 in our study was medi-MCYR Kidney medulla 7 20.6 ± 5.44* 1.9 ated by oxidative stress. The extent of DNA dam-Control Lung 4 14.4 + 2.06 age in liver cells was high- MCYR Lung 7 24.7 ± 5.77* 1.7 er than in kidney cells, which is in line with the Control Brain 4 10.0 ± 1.46 above mentioned study MCYR Brain 7 24.5 ± 6.30* 2.5 of Moreno et al.,33 who showed that antioxidant Control Spleen 3 9.9 ± 0.49 enzymes were signifi- MCYR Spleen 7 10.7 ± 3.67 1.1 cantly decreased in liver, while minor decrease Control Lymphocytes 4 18.2 ± 2.34 MCYR Lymphocytes 7 20.8 ± 6.81 1.1 was found in kidney, in­dicating different organ a induction factor: the ratio between the mean values of the % tail susceptibility to adverse DNA of treated and control animals effects of MCs. * statistically significant differences between control and treted ani- An interesting find- mals (p<0.05) ing of this study was the highest level of DNA target organs. The results clearly showed damage in brain cells. The result corrobo-that prolonged exposure of rats to suble-rates recent results of Maidana et al.34 who thal dose of MCYR induced DNA damage showed that intrahippocampal infusion of not only in liver, but also in brain, kidney microcystin raw extract induced oxidative and lung cells. The observed DNA dam-stress and DNA damage in cells isolated age was most likely due to MCLY induced from hippocampus. The question is how oxidative stress in affected organs. This as-MCs are transported through the body and sumption is based on: i) demonstration that absorbed by non hepatic tissue. Fisher et the oxidative stress plays a significant role al.35 reported that members of organic an-in the pathogenesis of chronic exposure to ion transporting polypeptide super family MCLR;17 ii) reactive oxygen species (ROS) involved in MCs uptake (including the hu-are known to induce DNA strand breaks, man OATP1A2 transporter) are expressed which can be readily detected with the in liver and in endothelial cells of the blood-comet assay and iii) MCLR induced DNA brain barrier. This explains brain as the tar-strand breaks in human hepatoma HepG2 get of MCs toxicity. The low antioxidant cells were ROS mediated.18 and DNA repair capacity of the brain could Radiol Oncol 2007; 41(1): 15-22. Figure 2. Distribution of the level of DNA damage in rat liver, kidney medulla, kidney cortex, lung, brain, spleen and lymphocytes after sub-chronic exposure to MCLY. The experimental group of rats (n = 7) received, every second day during the period of 30 days, 10 ”g/kg i.p. MCYR, the control group (n = 4) received vehicle. The extent of DNA damage in isolated cells was measured with the comet assay. The level of DNA strand breaks is expressed as % tail DNA. One hundred cells were analyzed per organ per animal. The polled data are presented as quantile box plots. The edges of the box represent the 25th and 75th percentiles, the median is a solid line through the box, mean values are represented as square ( ), and the error bars represent the 95% confidence intervals. * denotes a significant difference between MCLY-treated groups and control (Kruskal–Wallis test, P < 0.05). Radiol Oncol 2007; 41(1): 15-22. be the explanation for the highest level of DNA damage in the brain.36 MCYR induced DNA damage also in lung, however, little is known about the ef­fects of MCs on lung. The only report we are aware of is by Gupta et al.37 who found that in mice after the acute exposure to MCLR, MCRR and MCYR induced pulmo­nary inflammation, congestion and haem­orrhage. Interestingly no DNA damage was observed in the haematopoietic system; spleen and lymphocytes. An in vitro study has shown that MCs induce DNA damage in human lymphocytes,24 however, no in vivo study of the effects of MCs on lym­phocytes is available. In conclusion, the subchronic adminis­tration of sublethal dose of MCYR induced DNA strand breaks that were observed in brain liver, kidney, and lung confirming the genotoxic potential of this toxin. However, the correlation of these findings with carci­nogenicity of MCs needs to be further in­vestigated. Acknowledgments This study was supported by the Slovenian Research Agency, program #P1-245 and project # J1-6712. We thank Professor Tamara T. Lah for valuable suggestions and discussion and Prof. Roger Pain for critical reading of the manuscript. References: 1. McElhiney J, Lawton LA. Detection of the cyano-bacterial hepatotoxins microcystins. Toxicol Appl Pharmacol 2005; 203: 219–30. 2. Dawson RM. Toxicology of microcystins. 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Ito E, Kondo F, Harada KI. First report on the dis­tribution of orally administered microcystin-LR in mouse tissue using an immunostaining method. Toxicon 2000; 38: 37-48. 9. Eriksson JE, Gronberg L, Nygćrd S, Slotte JP, Meriluoto JA. Hepatocellular uptake of 3H-dihy­dromicrocystin-LR, a cyclic peptide toxin. Biochim Biophy Acta 1990; 1025: 60–6. 10. Carmichael WW, Falconer IR. Diseases related to freshwater blue-green algal toxins and control measures. In: Falconer IR, editor. Algal toxins in sea­food and drinking water. London: Academic Press; 1993. p. 187-209. 11. Chong MW, Gu KD, Lam PK, Yang M, Fong WF. Study on the cytotoxicity of microcystin-LR on cultured cells. Chemosphere 2000; 41: 143-7. 12. McDermott CM, Nho CW, Howard W, Holton B. The cyanobacterial toxin, microcysin-LR can induce apoptosis in a variety of cell types. Toxicon 1998; 36: 1981-6. 13. Carmichael WW, Azevedo SM, An JS, Molica RJ, Jochimsen EM, Lau S, Rinehart KL, Shaw GR, Eaglesham GK. Human fatalities from cyanobac­teria: chemical and biological evidence for cyano-toxins. Environ Health Perspect 2001; 109: 663–8. 14. Yoshizawa S, Matsushima R, Watanabe MF, Harada K-I, Ichihara A, Carmichael WW, Fujiki H. Inhibition of protein phosphatases by microcys-tins and nodularin associated with hepatotoxicity. J Cancer Res Clin Oncol 1990; 116: 609–14. 15. Ding W-X, Shen H-M, Ong C-N. Critical role of reactive oxygen species and mitochondrial perme­ability transition in microcystin-induced rapid apoptosis in rat hepatocytes. Hepatology 2000; 32: 547–55. Radiol Oncol 2007; 41(1): 15-22. 16. Bouaïcha N, Maatouk I. Microcystin-LR and nodu­larin induce intracellular glutathione alteration, reactive oxygen species production and lipid per-oxidation in primary cultured rat hepatocytes. Toxicol Lett 2004; 148: 53–63. 17. Guzman ER, Solter PF. Hepatic oxidative stress following prolonged sublethal microcystin-LR ex­posure. Toxicol Pathol 1999; 27: 582–8. 18. Žegura B, Lah TT, Filipic M. The role of reactive oxygen species in microcystin-LR-induced DNA damage. Toxicology 2004; 200: 59-68. 19. Rao PV, Bhattacharaya R. The cyanobacteria toxin microcystin-LR induced DNA damage in mouse liver in vivo. Toxicology 1996; 114: 29-36. 20. Maatouk I, Bouaïcha N, Plessis MJ, Perin F. Detection by 32P-postlabelling of 8-oxo-7,8-di­hydro-2'-deoxyguanosine in DNA as biomarker of microcystin-LR- and nodularin-induced DNA damage in vitro in primary cultured rat hepato­cytes and in vivo in rat liver. Mutat Res 2004; 564: 9-20. 21. Ding W-X, Shen H-M, Zhu H-G, Lee B-L. Genotoxicity of microcystic cyanobacteria extract of a water source in China. Mutat Res 1999; 442: 69-77. 22. Rao PV, Bhattacharaya R, Parida M M, Jana A M, Bhaskar A S. Freshwater cyanobacteri-um Microcystis aeruginasa (UTEX 2385) induced DNA damage in vivo and in vitro. Environ Toxicol Pharmacol 1998; 5: 1-6. 23. Žegura B, Sedmak B, Filipic M. Microcystin-LR in­duces oxidative DNA damage in human hepatoma cell line HepG2. Toxicon 2003; 41: 41-8. 24. Lankoff A, Krzowski L, Glab J, Banasik A, Lisowska H, Kuszewski T, et al. DNA damage and repair in human peripheral blood lymphocytes following treatment with microcystin-LR. Mutat Res 2004; 559: 131–42. 25. Zhan L, Sakamoto H, Sakuraba M, Wu D-S, Zhang L-S, Suzuki T, et al. Genotoxicity of microcystin-LR in human lymphoblastoid TK6 cells. Mutat Res 2004; 557: 1-6. 26. Suzuki H, Watanabe MF, Wu Y, Sugita T, Kita K, Sato T, et al. Mutagenicity of microcystin-LR in human RSa cells. Int J Mol Med 1998; 2: 109–12. 27. Tice RR, Agurel, E, Anderson D, Burlinson B., Hartmann A, Kobayashi H, et al. Single cell gel/ comet assay: Guidelines for in vitro and in vivo genetic toxicology testing. Environ Mol Mutagen 2000; 35: 206-21. 28. Harada KI, Matusura K, Suzuki M, Oka H, Watanabe MF, Oishi S, et al. Analysis and puri­fication of toxic peptides from cyanobacteria by reversed-phase high-performance liquid chroma­tography. J Chromatogr 1988; 448: 275–84. 29. de Sousa G, Delescluse C, Pralavorio M, Perichaud M, Avon M, Lafaurie M, Rahmani R. Toxic effects of several types of antifouling paints in human and rat hepatic or epidermal cells. Toxicol Lett 1998; 96-97: 41-6. 30. Pool-Zobel BL, Guigas C, Klein RG, Neudecker CH, Renner HW, Schnezer, P. Assessment of genotoxic effect by lindane. Food Chem Toxicol 1993; 31: 271–83. 31. Singh NP, McCoy MT, Tice RR, Schneider EL. A simple technique for quantitation of low levels of DNA damage in individual cells. Exp Cell Res 1988; 175: 184–91. 32. Milutinovic A, Živin M, Zorc-Pleskovic R, Sedmak B, Šuput D. Nephrotoxic effects of chronic ad­ministration of microcystins -LR and -YR. Toxicon 2003; 42: 281-8. 33. Moreno I, Pichardo S, Jos A, Gomez-Amores L, Mate A, Vazquez CM, Camean AM. Antioxidant enzyme activity and lipid peroxidation in liver and kidney of rats exposed to microcystin-LR adminis­tered intraperitoneally. Toxicon 2005; 45: 395-402. 34. Maidana M, Carlis V, Galhardi FG, Yunes JS, Geracitano LA, Monserrat JM, Barros DM. Effects of microcystins over short- and long-term memory and oxidative stress generation in hippocampus of rats. Chem Biol Interact 2006; 159: 223-34. 35. Fischer WJ, Altheimer S, Cattori V, Meier PJ, Dietrich DR, Hagenbuch B. Organic anion trans­porting polypeptides expressed in liver and brain mediate uptake of microcystin, Toxicol Appl Pharmacol 2005; 203: 257–63. 36. Walker AP, Bacherald HS. Studies on DNA dam­age and repair in mammalian brain, J Neurochem 1988; 51: 1394–9. 37. Gupta N, Pant SC, Vijayaraghavan R, Lakshmana Rao PV. Comparative toxicity evaluation of cyano-bacterial cyclic peptide toxin microcystin variants (LR, RR, YR) in mice. Toxicology 2003; 188: 285­96. Radiol Oncol 2007; 41(1): 15-22. Testing of mechanisms of action of rituximab and clinical results in high-risk patients with aggressive CD20+ lymphoma Barbara Jezeršek Novakovic1, Vladimir Kotnik2, Tanja Južnic Šetina1, Marjeta Vovk1, Srdjan Novakovic3 1Department of Medical Oncology, Institute of Oncology Ljubljana; 2Institute of Microbiology and Immunology, Medical Faculty Ljubljana;3Department of Molecular Diagnostics, Institute of Oncology Ljubljana, Ljubljana, Slovenia Background. Rituximab has been applied successfully in the treatment of indolent and aggressive CD20 positive B cell lymphomas, yet the exact in vivo mechanisms of its action have not been unambiguously ex­plained. This study was therefore aimed to confirm the presumed major mechanisms of action of rituximab and concomitantly to assess the effectiveness of first-line chemoimmunotherapy in high-risk patients with aggressive CD20 lymphomas. Patients, materials and methods. The activity of rituximab was tested in vitro on Raji and SU-DHL-4 cells using the cell proliferation assay and flow cytometry. In the clinical part of the study, 20 high-risk patients with aggressive CD 20 lymphomas were treated with R-CHOP. Results. Only complement-mediated cytotoxicity was observed under the in vitro applied experimental conditions. Neither the direct apoptotic effect nor the antibody-dependent cell-mediated cytotoxicity was detected probably due to a too low concentration of rituximab and a too low ratio of cytotoxic lymphocytes to tumor cells. The treatment outcome in patients was excellent since complete remissions were achieved in 90% of poor-risk patients at the end of primary treatment and 80% of patients were disease-free at 18.5 months median observation period. Conclusions. According to our results, the complement-dependent cytotoxicity is an important mechanism of rituximab action in vitro. To achieve direct apoptosis, higher concentrations than 20 ”g/ml of rituximab should be used, while for an effective antibody-dependent cell-mediated cytotoxicity, the ratio of cytotoxic lymphocytes to tumor cells should be higher than 1:1. In the high- risk patients with aggressive CD20 lym­phomas, the addition of rituximab to CHOP substantially improves the therapeutic results. Key words: lymphoma, B-cell – therapy; antigens, CD 20; antibodies, monoclonal Received 5 February 2007 Accepted 9 March 2007 Correspondence to: Dr. Srdjan Novakovic, D.Sc. Institute of Oncology Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia. Tel.: +386 1 5879 432; Fax: +386 1 5879 434; E-mail: snovakovic@onko-i.si Introduction The CD20 antigen, a 35 kDa phospho-protein, is restricted to the B cell lineage and is expressed by mature B cells and most malignant B cell lymphomas. While the exact functions of CD20 are presently unknown, it is considered to be involved in many cellular signaling events, includ­ing proliferation, activation, differentiation, and apoptosis upon crosslinking. Its at­tributes, as its tetraspan binding in the cell membrane and the lack of internalization or downregulation upon antibody binding, make CD20 a suitable target for an effective antibody.1, 2 Rituximab, a chimeric (human-mouse) IgG . monoclonal antibody that recognizes the CD20 antigen3, is the most widely rec­ognized and used monoclonal antibody in the B cell lymphoid malignancies. It has been applied successfully in the treatment of indolent CD20 positive B cell lymphomas and, more recently, also in the treatment of aggressive lymphomas in combination with standard chemotherapy. The indications for its use are now expanding to autoimmune diseases.4 The mechanisms of anti-tumor action of rituximab are diverse. The human IgG component of the antibody is able to bind human complement (CDC) and also inter­act with effector cells to kill cells by anti-body-dependent cell-mediated cytotoxic-ity (ADCC). Some investigators have also shown direct effects of the antibody on human tumor cell lines expressing CD20. These effects include inhibition of prolifera­tion, induction of apoptosis and increased sensitivity to chemotherapeutic agents, al­though the extent to which each of these mechanisms may contribute to the anti-tu­mor action of rituximab remains to be de­termined. Rituximab thus acts by addition­al mechanisms compared to conventional chemotherapeutic agents. The chimeric nature of the antibody results in minimal immunogenicity and allows repeated use. The antibody may be combined with con­ventional chemotherapy, with potential for increased efficacy and minimal added tox­icity.5 Due to still unambiguously explained mechanisms of action, we aimed our study at additional in vitro testing of rituximab activities. There were predominately three questions we wanted to resolve – firstly, to confirm the in vitro anti-tumor activity of the antibody against established CD20 positive lymphoma cell lines, secondly, to evaluate the importance of the three major mecha­nisms of action (i.e. complement mediated cytotoxicity, antibody mediated cellular cy­totoxicity and apoptosis) in in vitro condi­tions, and thirdly, to determine some of the pharmacokinetic data (the time needed for rituximab binding as well as the duration of rituximab-CD20 binding). Furthermore, a smaller clinical research was performed in order to determine the effectiveness of first-line chemoimmunotherapy with rituxi­mab and CHOP (R-CHOP) in the high-risk patients with aggressive CD20 positive NonHodgkin's lymphoma (NHL). Patients, materials and methods Cell cultures The CD20+ human B-cell lines - Raji (American Type Culture Collection - ATCC, Rockville, MD, USA) and SU-DHL-4 (Deutsche Sammlung von Mikroorganismen und Zellkulturen - DSMZ, Braunschweig, D) were grown in RPMI 1640, 25 mM HEPES (Gibco, Invitrogen, Grand Island, NY) supple­mented with 10% of inactivated fetal calf serum - iFCS (Sigma, St. Louis, MO), penicillin (100 units/ml, Pliva, Zagreb, CRO), and gentamycin (50 ”g/ml, Krka, Novo mesto, SLO). Isolation of human monocytes from peripheral blood (hPBMC) Human PBMC were isolated on Ficoll-Paque (Amersham Pharmacia Biotech AB, Uppsala, S). Radiol Oncol 2007; 41(1): 23-32. Determination of mechanisms of action of rituximab - design of in vitro experiments In the experiments, CD20+ human B-cell lines Raji and SU-DHL-4 were used. When the cells in the tissue culture reached the optimal density (70-80% of confluence), the growth medium was removed and replaced with the growth medium (RPMI) contain­ing the following tested components: • 2% of inactivated fetal calf serum - FCS, • 2% of inactivated human serum - iHS, • 20% intact human serum - HS, • 2% FCS + fresh hPBMC (ratio of target cells and lymphocytes - 1:1), • 2% FCS + 20 ”g/ml of rituximab, • 2% iHS + 20 ”g/ml of rituximab, • 20% HS + 20 ”g/ml of rituximab, • 2% FCS + fresh hPBMC (ratio of target cells and lymphocytes - 1:1) + 20 ”g/ml of rituximab. The samples were taken from the culture 4 hours, 24 hours and 48 hours after the be­ginning of treatment. The saturation of the CD20 epitopes on lymphocytes with rituximab was deter­mined at each point of the experiment. Cell proliferation assay Biological test used for the detection of cell proliferation was the CellTiter 96ź Aqueous Non-Radioactive Cell Proliferation Assay (Promega, Madison, WI, USA). This is a colorimetric method for determining the number of viable cells in chemosensitivity assays. The method is based on the detection of MTS (tetrazolium compound) bioreduction into a formazan product that is soluble in tis­sue culture medium. The absorbance of the formazan was measured at 490 nm. In the ex­periments, 2x104 CD20+ human B-cells/well were cultured in the growth medium supple­mented with 10% of serum (either FCS or iHS or HS) with or without rituximab. Survival in the control group (cell growth medium and FCS) was taken as 100%. Flow cytometry Staining for the presence of CD20 antigen. The CD20+ human B-cells (1x106) were spun down at 1000 rpm/min. The sediment was carefully resuspended in the residual fluid and 100 ”l of culture medium was added (MeM with 2% inactivated FCS). The cells were stained with 10 ”l of CD20 mono­clonal antibodies conjugated with PE-Cy5 (BD Biosciences Pharmingen, San Diego, CA, USA) for 30 minutes at room tempera­ture in the dark and then washed 3 times using MeM and resuspended in Facsflow solution (BD Biosciences, San Diego, CA, USA). Apoptosis – Annexin test. For the detection of apoptosis, Annexin V test was used (BD Pharmingen, San Diego, CA, USA). The CD20+ human B-cells were resuspended in 100 ”l of binding buffer and stained with 5 ”l Annexin V-FITC reagent and 10 ”l of pro-pidium iodide (Molecular probes, Eugene, Oregon, USA) for 15 minutes at room tem­perature in the dark. After incubation, 400 ”l of binding buffer was added to each tube. Measurements were performed within one hour. Adjustment of the flow cytometer. Flow cytometer (FACSort, Becton Dickinson, San Jose, CA, USA) was adjusted for the optimal acquisition of lymphocytes. In the dot plot screen {FSC = (X) toward the SSC = (Y)}, the lymphocyte-like population was gated. In the histogram screen, PE-Cy peak was selected and transferred into the dot plot screen. The percentage of live, apop­totic and dead CD20+ human B-cells was calculated using the quadrant statistic tool. Statistical analysis The in vitro experiments were set up in triplicates and the results were expressed as means ± SD. The results were analyzed for statistical significance of difference be­tween the groups using the unpaired two Radiol Oncol 2007; 41(1): 23-32. tail Student’s t test. The p level <0.05 was considered as statistically significant. Patients In the clinical part of the research, 20 patients with aggressive CD20 positive NHL were treated with R-CHOP at the Department of Medical Oncology of the Institute of Oncology Ljubljana, Slovenia, from October 2003 to February 2005. The research included 6 male patients with the median age of 66.5 years (range 44 to 74) and 14 female patients with the median age of 63.5 years (range 37 to 78). Seventeen patients were diagnosed with diffuse large B-cell lymphoma and 3 patients had fol­licular lymphoma grade 3. The R-CHOP treatment was first-line treatment for newly diagnosed lymphomas and all patients in­cluded in the study had advanced lympho­mas (stages III and IV according to Ann Arbor staging). Rituximab (kindly donated by Roche) was applied at standard doses (375 mg/m2) intravenously on day 1, followed by CHOP chemotherapy (cyclophosphamide 750 mg/ m2, doxorubicyn 50 mg/m2 and vincris-tine 2 mg, unless adjusted to the patient's performance status or previous toxicity). Premedication with methylprednisolone, paracetamole and clemastine was given prior to every rituximab application. The cycles of chemo-immunotherapy were re­peated every three weeks. The majority of patients received 8 cycles of such treat­ment, one patient died of complications after the first cycle, and in one patient, the treatment was terminated due to disease progression after the sixth cycle. Eleven patients received intrathecal chemother­apy in order to prevent the spreading of lymphoma into CNS, and in two patients, middle doses of methotrexate were added to R-CHOP due to concomitant CNS locali­zation of lymphoma. Treatment response was evaluated after the 4th and after the 8th cycle of treatment according to Cheson's criteria.6 Results Cell growth inhibition by rituximab In order to determine the in vitro effect of rituximab on CD20+ B lymphocytes, Raji and SU-DHL-4 cell lines were grown in the growth medium supplemented with rituxi­mab and either 10% of inactivated FCS (FCS) or 10% of inactivated human serum (iHS) or 10% of intact human serum (HS). The viability of cells after 24h, 48h and 72h was determined using the cell proliferation assay. The growth of both Raji and SU-DHL-4 cells was inhibited by rituximab in the pres­ence of HS. In Raji cells, the inhibition was observed at all time points – at 24h, 48h and 72h. The difference was statistically signifi­cant at all time points when compared to the cell growth of cells cultured only with iHS or HS (p values were in the range of 0,045 to 0,003) (Figure 1A). When comparing with the growth of the cells cultured with rituxi­mab and FCS or iHS, a statistically signifi­cant growth reduction of the cells cultured with rituximab in the presence of HS was obtained only after 72h. The p values were 0.026 (R+iHS/R+HS) and 0.003 (R+FCS/ R+HS), respectively (Figure 1A). In SU-DHL-4 cells, a statistically signifi­cant growth reduction was obtained for the cells cultivated with rituximab in the pres­ence of HS compared to all other groups at 48h and 72h. The p values were in the range of 0.012 to 0.001. After 24h, the only statis­tically significant growth reduction was ob­served when we compared the growth of the cells cultured with rituximab in the presence of HS with the growth of the cells cultured only with iHS (p = 0.013) (Figure 1B). Radiol Oncol 2007; 41(1): 23-32. Determination of mechanisms of rituximab action In order to confirm the mechanisms by which rituximab induces killing of CD20+ B lymphocytes, Raji cells were incubated with rituximab for 4h, 24h, and 48h in the pres­ence of HS (20%) or hPBMC (ratio 1:1) and the proportions of alive, apoptotic, or dead cells were determined by flow cytometry. There was no difference in the propor­tions of alive, dead or apoptotic cells be­tween the cells that were grown in the me­dium supplemented with FCS or iHS and the cells grown in the same medium, but with added rituximab (data not shown). However, the ratio of apoptotic cells was substantially increased in those cells that had been co-incubated with rituximab in the presence of 20% HS. Comparing these cells to the cells cultured only with HS, a significantly increased proportion of apop­totic cells was obtained after 24h and after 48h. The relating p values were 0.001 after 24h and 0.003 after 48h. Similar results were obtained when the ratios of apoptotic cells among the cells incubated with rituxi­mab in the presence of 20% HS and among the cells cultured only with FCS were com­pared. The relating p values were 0.017 after 24h and 0.009 after 48h (Figure 2). In our study, hPBMC (isolated from the same blood sample as human serum) did not affect significantly the number of apop­totic cells either when used alone or in com­bination with rituximab. There was also no statistically significant difference in the number of apoptotic cells when CD20+ B lymphocytes were co-incubated with rituxi­mab and hPBMC in the presence of FCS or when co-incubated only with hPBMC in the presence of FCS. Significant difference was not observed even when the results obtained with rituximab and hPBMC were compared to other groups. Figure 1. Growth of lymphoma CD20+ Raji (panel A.) and SU-DHL-4 cells (panel B.) in the presence of 20 ”g/ml of rituximab. The plots represent the AM±SD of three independent experiments. The proportion of viable cells in experimental groups was calculated as % of the control (cells grown in medium supplemented with FCS). iHS – cells grown in 10% of inactivated human serum, HS – cells grown in 10% of intact human serum, R+FCS - cells grown with rituximab in 10% of inactivated fetal calf serum, R+iHS - cells grown with rituximab in 10% of inactivated human serum, R+HS - cells grown with rituximab in 10% of intact human serum. Radiol Oncol 2007; 41(1): 23-32. Figure 3. Saturation of CD20 receptors on Raji cells by rituximab after different periods of time. Raji cells (1x106) were co-incubated with 20 ”g/ml of rituximab in the presence of FCS. As the control, the same number of Raji cells without rituximab was used. The plots represent the AM±SD of three independent experiments. patients had lymphomatous infiltration of the stomach/intestine, 4 had skeletal in­volvement, 2 CNS involvement, 4 patients lung and 2 patients pleural infiltration, 2 patients pancreatic and 1 renal infiltration, in 4 patients, there was soft tissue involve­ment (skin or muscles), and in 4 patients, infiltrates were detected in the ORL region (tonsils, maxillary sinus, salivary glands). The international prognostic index was low intermediate (2) in 5 patients, high in­termediate (3) in 8 patients, and high (4 or 5) in 7 patients. The serum LDH concentra­tions were also elevated in 15 patients, with the highest concentration reaching 29 ”kat/l (i.e. approximately seven-times the upper normal limit). During the treatment, some grade 3 or 4 toxicities developed in 15 patients and only the remaining 5 had practically no or only minor side effects. Among the most com­mon side effects were neutropenia with or without fever (in 14 patients) and serious infection/septicemia (in 6 patients), all of which resulted in the necessity for drug dosage reductions in 7 patients. cells incubated with rituximab for 4h, 24h, and 48h in the presence of HS (20%) or hPBMC (ratio 1:1) determined by flow cytometry. The plots represent the AM±SD of three independent experiments. FCS - cells grown in 2% of inactivated fetal calf serum, HS – cells grown in 20% of intact human serum, R+HS - cells grown with rituximab in 20% of intact human serum, hPBMC+FCS – cells grown in 2% of FCS with fresh hPBMC, R+hPBMC+FCS – cells grown with rituximab in 2% of FCS and in the presence of fresh hPBMC. Saturation of CD20 receptors by rituximab Binding of rituximab to cell receptors was followed by flow cytometric determination of free CD20 receptors after 4h, 24h and 48h when 1x106 Raji cells were co-incubated with 20 ”g/ml of rituximab in the presence of FCS. As the control, the same number of Raji cells without rituximab was used. Four hours following the addition of rituximab, only 30.7% of CD20 receptors remained free. However, after 24h and 48h the proportion of free CD20 receptors increased to 75.6% and 66.0%, respectively (Figure 3). Clinical results According to Ann Arbor staging system, 3 patients had stage III.A disease, 3 patients III.A.E, 1 patient III.B, 1 patient IV.A, 5 patients IV.A.E, and 7 patients IV.B.E dis­ease. Extranodal localizations of lymphoma were found in as much as 15 patients (and in some patients they were multiple). Five Radiol Oncol 2007; 41(1): 23-32. Table 1. Treatment response to R-CHOP in patients with aggressive CD20 Non-Hodgkin's lymphomas. 100 After the 4th cycle of treatment, partial response (PR) was observed in 8 patients, complete response (CR) in 10 patients, and stable disease (SD) in 1 patient. One pa­tient died 2 days after the first cycle in sep­tic shock most probably due to necrotizing pancreatitis. This patient had a lymphoma-tous infiltration of the pancreas confirmed prior to the introduction of treatment. At the end of systemic treatment, 4 of 8 patients with prior partial remission achieved complete remission, while in the other 4, the final outcome was partial re­mission. These 4 patients continued their treatment with irradiation of the residual lymphoma masses and eventually achieved complete remission. The patient with stable disease following the 4th cycle progressed (PD) after another two cycles of treatment and was further on treated with another chemotherapy schedule. This patient died of progressive lymphoma 4 months after the last R-CHOP cycle (Table 1). The complete response still lasts in 16 patients (80%) with the median observa­tion period of 18.5 months (range 12 to 15.5 months) and the median response duration has not been reached yet (Figure 4). On the other hand, two patients progressed (both IPI 3), one 5.5 and the other 9.5 months af­ter the end of treatment. These two patients were subsequently treated with different 50 percent survival 0 0 10 20 30 time (months) Figure 4. Disease free survival in 20 high-risk patients with aggressive CD 20 lymphoma after treatment with R-CHOP. chemotherapy schedules and are still alive – one of them in the second remission and the other one still under treatment. Discussion Clinical application of rituximab in com­bination with chemotherapy has signifi­cantly improved the treatment outcome in the patients with indolent and aggressive non-Hodgkin’s lymphoma (NHL).4 Still, the exact in vivo mechanisms of action of rituximab are not fully understood, al­though antibody-dependent cell-mediated cytotoxicity (ADCC), complement-depend­ent cytotoxicity (CDC), and apoptosis have been suggested.7 This study, was aimed to confirm the presumed major mechanisms of action of rituximab and concomitantly to assess the effectiveness of first-line chem-oimmunotherapy with R-CHOP in the high-risk patients with aggressive CD20 NHL. The results of in vitro experiments on Raji and SU-DHL-4 cells provided evidence for a significant effect of rituximab on the cell growth starting more than 24 h after the exposure to the drug, but only when the cells were grown in the presence of intact HS. Culturing of these cells with rituximab and inactivated FCS or HS did not result in Radiol Oncol 2007; 41(1): 23-32. a significant growth reduction alluding to the possibility that, in in vitro conditions, rituximab by itself was not sufficient to af­fect critically the tested cells. The observa­tion was unexpected since certain previous studies validated this very mechanism of action of rituximab.7-10 A gene expression analysis revealed that the binding of rituxi­mab to CD20 receptors induces in vitro ac­tivation of genes known to be involved in the cell growth control and apoptosis. In the study of Jazirehi et al., evidence was provided that rituximab treatment of B-cell lines Ramos and Daudi inhibits the con­stitutive NF-.B signaling pathway thereby down-regulating the Bcl-xL expression. In this way, the antibody directly affects cells through CD20 receptors diminishing their proliferative activity and, even more, rituxi­mab also sensitizes tumor cells to the cyto­toxic activity of certain drugs.10 Due to the observed discrepancy between the stated results and our results, we expanded the in vitro experimentation to flow cytometry. The effects of rituximab were thus followed by the determination of proportions of ap­optotic, dead and alive cells among the dif­ferently treated cells. Surprisingly, also the results obtained from the flow cytometric analysis confirmed our previous observa­tions. There was a statistically significant reduction in the number of live cells (for the groups HS/R+HS after 24h and 48h the p values were 0.005 and 0.044, respectively) and a statistically significant increase of ap­optotic cells, but only among the cells treat­ed with rituximab in the presence of intact HS (for the groups HS/R+HS after 24h and 48h the p values were 0,001 and 0,003, re­spectively). The anticipated increase in the number of apoptotic cells among cells treat­ed with rituximab in the presence of iHS or FCS was not observed. Since the degree of apoptosis and growth conditions in the studies evaluating this mechanism varied from study to study7, it is quite possible that the model used in our study was not sensi­tive enough to detect the changes as direct consequences of the monoclonal binding to CD20 receptors. Therefore, the next step in our investigation was the determination of the extent of rituximab binding and satura­tion of CD20 receptors on the target cells. Using 20 ”g of rituximab per one ml of cell growth medium, the saturation of CD20 re­ceptors was the highest 4 h after the begin­ning of treatment (almost 70%). In the next hours, the saturation rapidly decreased indicating that the initial concentration of rituximab was probably too low - which may actually be one of the reasons why direct apoptosis due to cross-linking of CD20 has not been observed. Additionally, in some studies of normal and malignant human B cells in vitro, B-cell depletion was observed predominately with rituximab in the pres­ence of mononuclear cells, but not in the presence of a complement, suggesting the importance of cell-mediated mechanisms (ADCC).11 In other studies, however, both the activation of ADCC and complement-mediated lysis have been demonstrated in vitro and in vivo after the treatment with rituximab.12-14 Our in vitro testing failed to demonstrate any significant difference in the number of alive, apoptotic or dead cells between the cells co-incubated only with hPBMC or with hPBMC in combina­tion with rituximab. Most probably, the rea­son for this is an inadequate ratio between hPBMC and CD20+ B-cells. This ratio was 1:1 in our study, meaning that the ratio of the cells capable of mediating the cytotoxic response, i.e. NK cells and monocytes, was at the best 1:1 or lower, making it unlikely that cytotoxicity had any significant impact on the proportion of dead cells. When commenting the clinical data, the treatment results in the poor-risk patients with aggressive NHL were disappointing in the pre-rituximab era as reported by Shipp et al in 1993.15 For example, complete remis- Radiol Oncol 2007; 41(1): 23-32. sion was achieved in only 44% of patients with high IPI and in 55% of patients with high intermediate IPI as compared to 87% of patients with low IPI. In our research, pre­dominately the patients with high interme­diate (8 patients) and high IPI (7 patients) were included and not one single patient had low IPI. Therefore, the fact that as much as 90% of these patients finally achieved complete remission (14 patients after chem-oimmunotherapy and 4 patients after ad­ditional radiotherapy) definitely speaks for superior activity of R-CHOP compared to chemotherapy alone in the high-risk pa­tients (in spite of the small number of the patients included in our study). Also the rate of disease free survival was much higher in our study (80% of the pa­tients) compared to the data of Shipp et al.15 who reported 58% and 59% 2-year relapse-free survival for high and high intermediate IPI groups, respectively, even though our median observation period was only 18.5 months. Obviously the addition of rituximab to the treatment protocol for the poor-risk pa­tients with aggressive NHL improved the previous treatment results achieved only with chemotherapy (± radiation treatment). This improvement could be the reflection of an increased sensitivity to chemotherapeu­tic agents induced by rituximab which is in accordance with the in vitro results of the two lately published studies.10,11 Conclusions The results of our study indicate that the complement-dependent cytotoxicity (CDC) is an important mechanism of rituximab action in vitro since it seems to be triggered easily even if the absolute saturation of CD20 receptors is not reached. To achieve direct apoptosis, higher concentration of rituximab (>20 ”g/ml) should be used while for an effective ADCC, the ratio of cytotoxic lym­phocytes to tumor cells should be increased (to more than >1:1). From the clinician’s point of view, the addition of rituximab to CHOP in the high-risk patients with aggres­sive CD20 NHL is obligatory if the goal of the treatment is to cure the patient. Accordingly, it is no exaggeration to state that rituximab changes the prognosis of poor-risk patients with aggressive CD20 NHL. Acknowledgements This research was supported by Roche (donation of rituximab for the in vitro and clinical part of the study) and Slovenian Ministry of Science (grant J3-6363). References 1. Lucas BJ, Horning SJ. Monoclonal antibodies have finally arrived. In: Cavalli F, Armitage JO, Longo DL, editors. Annual of Lymphoid Malignancies. London: Martin Dunitz Ltd; 2001. p. 153-67. 2. Jazirehi AR, Bonavida B. Cellular and molecular signal transduction pathways modulated by ritux­imab (rituxan, anti-CD20 mAb) in non-Hodgkin’s lymphoma: implications in chemosensitization and therapeutic intervention. Oncogene 2005; 24: 2121-43. 3. Maloney DG, Liles TM, Czerwinski DK, Waldichuk C, Rosenberg J, Grillo-Lopez A, et al. Phase I clini­cal trial using escalating single-dose infusion of chimeric anti-CD20 monoclonal antibody (IDEC­C2B8) in patients with recurrent B-cell lymphoma. Blood 1994; 84: 2457-66. 4. Boye J, Elter T, Engert A. An overview of the cur­rent clinical use of the anti-CD20 monoclonal an­tibody rituximab. Ann of Oncol 2003; 14: 520-35. 5. Maloney DG. Mechanisms of action of rituximab. Anticancer Drugs 2001; 12 Suppl 2: S1-S4. 6. Cheson BD, Horning SJ, Coiffier B, Shipp MA, Fisher RI, Connors JM, et al. Report of an interna­tional workshop to standardize response criteria for Non-Hodgkin's lymphomas. J Clin Oncol 1999; 17: 1244-53. Radiol Oncol 2007; 41(1): 23-32. 7. Smith MR. Rituximab (monoclonal anti-CD20 antibody): mechanisms of action and resistance. Oncogene 2003; 22: 7359–68. 8. Cittera E, Onofri C, D’Apolito M, Cartron G, Cazzaniga G, Zelante L, et al. Rituximab induces different but overlapping sets of genes in human B-lymphoma cell lines. Cancer Immunol Immunother 2005; 54: 273-86. 9. Smith MR, Joshi I, Jin F, Obasaju C. Enhanced efficacy of gemcitabine in combination with anti­CD20 monoclonal antibody against CD20+ non­Hodgkin’s lymphoma cell lines in vitro and in scid mice. BMC Cancer 2005; 5: 103. 10. Jazirehi AR, Huerta-Yepez S, Cheng G, Bonavida B. Rituximab (chimeric anti-CD20 monoclonal an­tibody) inhibits the constitutive nuclear factor-.B signaling pathway in non-Hodgkin’s lymphoma B-cell lines: role in sensitization to chemothera­peutic drug-induced apoptosis. Cancer Res 2005; 65: 264-76. 11. Clynes RA, Towers TL, Presta LG, Ravetch JV. Inhibitory Fc receptors modulate in vivo cytoxicity against tumor targets. Nat Med 2000; 6: 443-6. 12. Reff ME, Carner K, Chambers KS, Chinn PC, Leonard JE, Raab R, et al. Depletion of B cells in vivo by a chimeric mouse human monoclonal antibody to CD20. Blood 1994; 83: 435-45. 13. Golay J, Zaffaroni L, Vaccari T, Lazzari M, Borleri GM, Bernasconi S, et al. Biologic response of B lymphoma cells to anti-CD20 monoclonal anti­body rituximab in vitro: CD55 and CD59 regulate complement mediated lysis. Blood 2000; 95: 3900­8. 14. Winkler U, Jensen M, Manzke O, Schulz H, Diehl V, Engert A. Cytokine-release syndrome in pa­tients with B-cell chronic lymphocytic leukemia and high lymphocyte counts after treatment with an anti-CD20 monoclonal antibody (rituximab, IDEC-C2B8). Blood 1999; 94: 2217-24. 15. Shipp MA, Harrington DP, Anderson JR, Armitage JO, Bonadonna G, Brittinger G, et al. A predictive model for aggressive non-Hodgkin's lymphoma. N Engl J Med 1993; 329: 987-94. Radiol Oncol 2007; 41(1): 23-32. Radiofrequency ablation of lung tumours – new perspective in treatment of lung neoplasms Ksenija Kocijancic and Igor Kocijancic Institute of Radiology, Clinical Center Ljubljana, Ljubljana, Slovenia Background. Percutaneous radiofrequency ablation (RFA) is a minimally invasive technique used to treat solid tumours. Because of its ability to produce large volume of coagulation necrosis in controlled fashion this technique has been progressively tested as a possible treatment of lung malignancies. Recent clinical studies have shown that RFA enables successful treatment of relatively small lung malignancies with high rate of complete response and acceptable morbidity and have suggested that the technique could represent a viable alternate or complementary method for patients with non-small cell lung cancer or lung metastases of favourable histotypes who are not candidates for surgical resection. Conclusions. Initial intenational studies as well as the clinical experience of Institute of Radiology in Clinical Center Ljubljana, although limited, indicated that RFA is mostly well tolerated by patients and also, that it can result in complete necrosis of targeted lesion. Pneumothorax is most common procedure related complication, occurring in up to 40% of cases, with approx. half of them requiring drainage. Key words: lung neoplasms – surgery; catheter ablation Introduction Image-guided percutaneous radiofrequency ablation (RFA) is a minimally invasive tech­nique for the treatment of solid tumours that has only been introduced recently into every day clinical practice. Now it is considered to be a feasible treatment op­tion for patients with primary hepatocel­lular carcinoma or limited metastatic liver Received 22 January 2007 Accepted 2 February 2007 Correspondence to: Assist. Ksenija Kocijancic, MD, MSc, Institute of Radiology, Clinical Center Ljubljana, Zaloška 2, SI - 1000 Ljubljana, Slovenia; Phone: + 386 1 520 46 42; Fax: + 386 1 520 24 97; E-mail: ksenija.kocijancic@kclj.si disease.1,2 With the improvement of the technology RFA is now being evaluated for in other types of tumours, including lung neoplasms. As being well known, the lung is the most common site of primary cancer world­wide and is also a common site for meta­static disease. Many of these patients and also the patients with otherwise resectable tumours are not operable due to associated conditions such as age, poor cardiovascular and/or respiratory function and/or other serious coexisting health conditions or be­cause of the size and location of the tumour itself. For all these patients (e.g. patients with limited lung tumours not eligible for surgical resection) radiofrequency ablation seems to be a good treatment option.3-8 RFA In principle RFA is caused by high-fre­quency current from radiofrequency gen­erator passed between the needle electrode placed in the tumour and a large elec­trode on patient’s skin. Electrodes create an alternating electric field which induces marked agitation of iones resulting in fric­tional heating of the surrounding tissue, which results in irreversible damage.3,5,6,9,10 Experimental studies in animals showed a well defined area of coagulation 72 hours after RFA, surrounded by a zone of hyper-aemia that gradually resolves. The technique found to be especially suitable for lung tumours since the air in surrounding alveoli acts as insulation, help­ing to concentrate the energy in the lesion. The disadvantage of the method is, how­ever, that the technique is suitable only for patients with solitary or small number of lung lesions since each tumour or metasta­sis need to be treated individually.3 Detailed diagnostic workup, includ­ing chest CT, is essential to determine the exact number, site and position of target tumour(s). The treatment procedure is CT guided. During the procedure the needle electrode is positioned in the tumour, using the workflow of stereotactic biopsy of lung lesions.3 It is important to select the entry site on the skin that allows the shortest and most vertical path for the needle, avoiding blood vessels, interlobar fissures and bullae. Image reconstructions and multiple planes help us to ensure the correct placement of the electrode needle within the tumour, which is a crucial point of the procedure. The ablation device has 9 flexible hooks, de­ployed from the trocar tip, some use cooled tip electrodes. The power output of the ra­diofrequency generator and duration of the ablation are programmed according to tu­mour volume and continuously monitored by a computer. At the end of procedure the track ablation is carried out to reduce the risk of seeding tumour cells.3 The important limitation for the pro­cedure is the size of the tumour. Since we need to ablate all viable tumour tissue and an adequate tumour-free margin which is 1 cm, it is clear, that largest, a 5 cm ablation device can be used to treat tumours up to 3 cm in diameter and not more.11 One cm margin is necessary to assure that all pos­sible microscopic invasions around the pe­riphery of a tumour have been eradicated. Lung RFA is painful and requires ad­equate pain relief with conscious seda­tion or general anaesthesia, although the latter seems to be connected with greater risk of pneumothorax in the ventilated pa­ tient.3,5,7,8,12 International clinical experience Initial studies as well as the clinical experi­ence of Institute of Radiology in Clinical Center Ljubljana, although limited, indi­cated that RFA is mostly well tolerated by patients and also, that it can result in complete necrosis of targeted lesion. Pneumothorax is most common procedure related complication, occurring in up to 40% of cases, with approx. half of them requiring drainage.3,5,6,9,10 Recently, one of the largest trials of RFA for lung tumours was completed.12 Patients were followed up to 27 months. Patients with primary lung cancer or lung metastas­es 3.5 cm or less in diameter, who were not candidates for surgery, were included into this multicenter, prospective study. One hundred and six patients with 186 malig­nant masses were enrolled. There were 33 patients with non-small cell lung cancer, 53 with colorectal lung metastases and 20 with other primary malignancy metastasis, none of them eligible for surgery. Patients underwent CT guided RFA treatment un- Radiol Oncol 2007; 41(1): 33-8. der conscious sedation. There were no procedure-related deaths, but 27 cases of pneumothorax, requiring treatment and also 4 pleural effusions, 2 pneumonias and 1 atelectasis. At CT evaluation after 3 months post procedure, complete ablation of the tumour was observed in 173 of 186 tumours, which set the primary effectiveness rate to 93%. Overall survival rate of the primary lung cancer patients was 69% at year 1 and 49% at year 2. However, many deaths were not cancer related and when excluded, the can­cer specific survival rates were 91% at year 1 and 2. In patients with colorectal metas­tases the survival rates were 88% at year 1 and 72% at year 2, after exclusion of non-cancer related deaths.12 Clinical experience of Institute of Radiology in Clinical Center Ljubljana We have treated 5 patients up-to date. In all cases the procedure was performed with intent to cure. All patients have had cito/histologically proven non-small cell lung cancer without metastatic disease. The disease was resectable in all cases but patients were inoperable due to cardiac and pulmonary disease (3 patients), extreme obesity (1 patient) and consent withdrawal (1 patient). During pre-ablation work-up patients underwent a chest CT to determine target tumour(s) location and size and percutane­ous or CT-guided fine needle biopsy to con­firm the nature of the lesion. Abominal US or CT were used to search for distant metas­tases. All patients had solitary primary lung neoplasms without distant metastatic dis­ease. In all cases the disease was unilateral and as such treated during single session. One patient had larger (3 x 5 cm) tumour with central necrosis while the rest were smaller, up to 3 cm in diameter, and solid. In case of patients with history of diffuse lung disease or lung surgery lung spirom­etry is needed, since it is known that the tolerance is good in patients with a FEV1 of more that 1 litre but transitory respira­tory insufficiency developed in about one third of patients with a FEV1 less than 1 litre. We used general anaesthesia in 4 cases and conscious sedation in one. The first provides higher feasibility while with latter Figure 2. Radiofrequency ablation procedure in pa­tient with NSLC of the left lung. The flexible part of expandable needle is outside the patient while the rigid part is already placed in patient’s lung. On the handle of the electrode there are clearly seen the markings (arrow), which indicate the amount of elec­trode array deployment from the trocar. Radiol Oncol 2007; 41(1): 33-8. patient suffered from periprocedural pain and the treatment needed to be interrupted twice due to pain. Duration of the proce­dure was 1-3 hours, mean duration was 1.5 hour. We used a 150 W generator (Figure 1) and 15-gauge ablation needles. The abla­tion procedure was CT-guided (Figure 2) Figure 4a. Lung tumour treated with radiofrequency ablation. Pre-treatment CT shows the focal mass of about 2 cm in diameter in right upper lobe (white arrow). In the parenchyma there are numerous larger and smaller emphysematic bullae – this patient was not a surgical candidate due to severe emphysema, COPD and cardiac condition – note artefacts after sternotomy for CABG (black arrow) and a cardiac pacemaker. and handled with 9-hook expandable elec­trode needle (StarBurst XL, RITA Medical Systems) which was flexible and stiff (Figure 3). They enabled direct temperature measurement throughout the tissue to pre­vent any electrode in multi-tined configura­tion from exceeding 1100 C. The radiofrequency generator had multi­ple temperature displays as well as imped­ance and power monitoring. The generator was programmed on the “average tempera­ture” mode and the target temperature was set at 900. Ablation protocols, appropriate for lungs, were used, since lung parenchy-ma is different from e.g. liver in terms of energy deposition, electrical conductivity, heat diffusion and heat convection. The ab­lation procedure was terminated by coagu­lating the needle track to prevent tumour cell dissemination along the needle path. After completion of the procedure a sin­gle expiratory scan is obtained throughout the thorax to detect pneumothorax and other possible complications (parenchy­mal changes, haemorrhage, pleural effu­sion). We put the patient into the needle Radiol Oncol 2007; 41(1): 33-8. Figure 4c. Lung tumour treated with radiofrequen­cy ablation. CT after completed ablation procedure shows ground glass density area (between black ar­rows) encompassing the native tumour as well as a safety margin of surrounding lung parenchyma. In addition, a small asyptomatic pneumothorax (white arrow) was detected at the end of procedure. site dependent position which helps reduce air leak and post-procedural pneumotho­rax and possibly prevents transbronchial spread of induced alveolar haemorrhage. There were no major procedure-relat­ed complication in our patients, in gen­eral the procedure was well tolerated. Pneumothorax requiring catheter drainage occurred in only one case. Productive cough with brown sputum lasting about one week was observed in one patient (Figures 4a, 4b, 4c). All patients received antibioprophylaxis with broad spectrum antibiotic adminis­tered intravenously immediately before ab­lation. Antibiotics were given orally after 24 hors and prolonged over 7 days. Follow up examinations are usually per­formed at month 1, 3 and 6 after the proce­dure and at 3-month or 6-month intervals thereafter. However the compliance of the patients was low. One of our patient had 6 month disease free interval while in second we observed tumour recurrence at month 9 follow up. The rest were lost to follow up. Conclusions RFA is a new, minimally invasive procedure that shows promise for the treatment of pri­mary and secondary lung cancer. Results of recent clinical studies have shown that it can provide effective and reproducible tumour destruction with acceptable mor­bidity but no survival benefit associated with the use of RFA of lung malignancies has been demonstrated so far. Owing to small number of treated cases and short follow-up period, no definite con­clusion concerning the potential clinical role can currently be drawn. For this reason ad­ditional clinical trials are required to further evaluate the place of the method in the man­agement of primary tumours and metastas­es in lung, either alone or with respect to ad­ditional chemotherapy or radiotherapy. Nevertheless, with continued improve­ment in technology and increasing clinical experience RFA could represent a viable al­ternate or complementary treatment for pa­tients with NSCLC or lung metastases who are not candidates for surgical resection. References 1. Lencioni R, Cioni D, Crocetti L, Franchini C, Pina CD, Lera J, et al. Early-stage hepatocellular carci­noma in patients with cirrhosis: Long-term results of percutaneous image-guided radiofrequency ab­lation. Radiology 2005; 234: 961-67. 2. Berber E, Pelley R, Siperstein AE. Predictors of survival after radiofrequency thermal ablation of colorectal metastases to the liver: a prospective study. J Clin Oncol 2005; 23: 1358-54. 3. Lencioni R, Crocetti L, Cioni R, Mussi A, Fontanini G, Ambrogi M, et al. Radiofrequency of lung malignancies: where do we stand? Cardiovasc Intervent Radiol 2004; 27: 581-90. Radiol Oncol 2007; 41(1): 33-8. 4. Fernando HC, De Hoyos A, Landreneau RJ, Gilbert S, Gooding WE, Buenaventura PO, et al. Radiofrequency ablation for the treatment of non-small cell lung cancer in marginal surgical candi­dates. J Thorac Cardiovasc Surg 2005; 129: 639-44. 5. Herrera LJ, Fernando HC, Perry Y, Gooding WE, Buenaventura PO, Christie NA, et al. Radiofrequency ablation of pulmonary malig­nant tumors in nonsurgical candidates. J Thorac Cardiovasc Surg 2003; 125: 787-8. 6. Lee JM, Jin GY, Goldberg SN, Lee YC, Chung GH, Han YM, et al. Percutaneous radiofrequency abla­tion for inoperable non-small cell lung cancer and metastases: preliminary report. Radiology 2004; 230: 125-34. 7. King J, Glenn D, Clark W, Zhao J, Steinke K, Clingan P, et al. Percutaneous radiofrequency ablation of pulmonary metastases in patients with colorectal cancer. Br J Surg 2004: 91: 217-23. 8. Steinke K, Glenn D, King J, Clark W, Zhao J, Clingan P, et al. Percutaneous imaging-guided radiofrequency ablation in patients with colorectal pulmonary metastases: 1-year follow-up. Ann Surg Oncol 2004; 11: 207-12. 9. Schaefer O, Lohrmann C, Langer M. CT-guided radiofrequncy ablation of a bronchogenic carci­noma. Br J Radiol 2003; 76: 268-70 10. Steinke K, Habicht JM, Thomsen S, Soler M, Jacob AL. CT-guided radiofrequency ablation of a pul­monary metastasis followed by surgical resection. Cardiovasc Intervent Radiol 2002; 25: 543-6. 11. Steinke K, Glenn D, King J, Morris DL. Percutaneous pulmonary radiofrequency ablation: difficulty achieving complete ablations in big lung lesions. Br J Radiol 2003; 76: 742-5. 12. Lencioni R. Radiofrequency ablation of lung tu­mours. Controversies and consensus in imaging and intervention 2006; 3: 16-7. Radiol Oncol 2007; 41(1): 33-8. Paratesticular adenocarcinoma: unusual presentation of metastasis of pancreatic cancer Janja Ocvirk and Boštjan Šeruga Department of Medical Oncology, Institute of Oncology, Ljubljana, Slovenia Background. Metastatic paratesticular adenocarcinoma from the pancreatic cancer is very rare. To our knowledge, there are less than 20 cases published in the literature. Case report. We experienced a case of paratesticular adenocarcinoma from the primary pancreatic cancer. A 42-year-old man was presented with locoregionally advanced carcinoma of the tail of the pancreas with intraoperatively found liver metastases and with a tumour in the right hemi-scrotum. Ultrasound of the scrotum revealed a paratesticular tumour. A fine needle aspiration biopsy (FNAB) confirmed a poorly differentiated adenocarcinoma and it was in concordance with the diagnosis of the primary tumour. The patient started treatment with chemotherapy with gemcitabine. Unfortunately, he progressed one month later and the treatment was discontinued. Conclusions. Outcome in the adenocarcinoma of the pancreas is dismal. The only possible treatment op­tion for metastatic disease is systemic therapy but the results are disappointing, as in the present case. Key words: pancreatic neoplasms; neoplasms metastasis; testicular neoplasms - secondary Introduction Pancreatic cancer can be silent for a long time before it manifests with features related to local and distant spread. Paratesticular metastases of pancreatic cancer are unusual tumours. Generally, paratesticular tumours are rare. Primary malignant tumours and metastatic tumours account for 32.9% of all tumours and 6-8% of malignant tumours of paratesticular tissue, respectively. In 47.6% of the cases, Received 19 March 2007 Accepted 26 March 2007 Correspondence: Boštjan Šeruga, M.D., Institute of Oncology Ljubljana, Dept. of Medical Oncology, Zaloska c. 2, 1000 Ljubljana, Slovenia; Phone +386 1 5879 103; Fax: +386 1 5879 400: E-mail: bseruga@onko-i.si the metastases and the primary tumours are found simultaneously. Uncommonly, in 9.5% they are the first sign of occult cancer. The most common primary sites of metastasis of the paratesticular tissue are prostate, kidney, gastrointestinal tract, lung and breast can­cer.1,2. We report a case of simultaneous meta­static paratesticular adenocarcinoma originat­ing in the tail of the pancreas. Case presentation and management A 42-year-old man was presented to abdomi­nal surgeon with recurrent vague upper ab­dominal discomfort lasting for few months and without significant weight loss. His past history was not remarkable. Abdominal and endoscopic ultrasound examinations revealed a suspicious cystic and nonhomo­geneous lesion in the tail of the pancreas. Chest X-ray was negative for metastasis. The abdominal CT scan confirmed a 2 cm cystic lesion in the tail of the pancreas. The serum tumour marker antigens Ca 19-9 and CEA were elevated, 78 U/ml and 2.6 ng/ml, re­spectively. Explorative laparatomy was done and locoregionally inoperable tumour of the pancreas with multiple liver metasteases was found. Histologically, moderately differenti­ated adenocarcinoma from the pancreas and the liver was confirmed. Afterwards, the patient was presented to the medical oncologist and he complained of palpable tumour mass in the right hemi-scro­tum. On examination a painless, hard and ir­regular 2x2 cm large swelling was identified. Ultrasound revealed a paratesticular tumour. A fine needle aspiration biopsy (FNAB) confirmed a poorly differentiated adenocarcinoma. Tumour marker antigens Ca 19-9 and CEA were further elevated, 296 U/ml and 15.4 ng/ml, respectively. Based on these find­ings, the patient was diagnosed as having a metastatic paratesticular adenocarcinoma originating from pancreatic carcinoma with liver metasteses. He started treatment with chemothera­py with gemcitabine. Unfortunately, he pro­gressed one month later and the treatment was discontinued. Discussion Metastatic paratesticular adenocarcinoma from the pancreatic cancer is very rare. To our knowledge, there are less than 20 cases published in the literature. In most cases the primary tumour was located in the body or the tail of the pancreas what is in concord­ance with the present case.3-6 Results from the 154 consecutive autop­sies of the patients with pancreatic adenocar­cinoma revealed that carcinomas of the body Radiol Oncol 2007; 41(1): 39-40. and/or tail of the pancreas were more fre­quent characterized by transperitoneal and hematogenous dissemination than carcino­mas of the head of the pancreas.7 Kamisawa et al have sugested a mechanisem of unusual pattern of spread due to hepatofugal porto-systemic shunting induced by splenic vein ob­struction, retrograde lymphatic infiltration or even aggressive tumour characteristics.8 In the present case, we postulate a hematogenous route of dissemination to the paratesticular tissue because of the presence of liver metas­tases without any metastatic lymph nodes. Outcome in the adenocarcinoma of the pancreas is dismal with a five-year survival rate of 4%.9 The only possible treatment op­tion for metastatic disease is systemic ther­apy but the results are disappointing, as in the present case. References 1. Algaba F, Santaularia JM, Villavicencio H. Metastatic tumor of the epididymis and spermatic cord. Eur Urol 1983; 9: 56-9. 2. Beccia DJ, Krane RJ, Olsson CA. Clinical manage­ment of non-testicular intrascrotal tumors. J Urol 1976; 116: 476-9. 3. Tanaka H, Yasui T, Watase H. Metastatic tumor of the epididymis from pancreatic carcinoma: a case report. [Japanese]. Acta Urol Jpn 1999; 45: 649-52. 4. Sawa TE, Duun S, Andersen JT. Paratesticular tu­mor: a metastasis from primary pancreas cancer. Scand J Urol Nephrol 2000; 34: 70-1. 5. Seo IY, Kim SG, Han WC, Rim JS. Paratesticular mucinous cystadenocarcinoma: metastasis from pancreatic cancer. Int J Urol 2004; 11: 1147-9. 6. Dookeran KA, Lotze MT, Sikora SS, Rao UN. Pancreatic and ampullary carcinomas with intras­crotal metastases. Br J Surg 1997; 84: 198-9. 7. Mao C, Domenico DR, Kim K, Hanson DJ, Howard JM. Observations on the developmental patterns and the consequences of pancreatic exocrine ad-enocarcinoma. Findings of 154 autopsies. Arch Surg 1995; 130: 125-34. 8. Kamisawa T, Isawa T, Koike M, Tsuruta K, Okamoto A. Hematogenous metastases of pancreatic ductal carcinoma. Pancreas 1995; 11: 345-9. 9. Brenner H. Long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. Lancet 2002; 360: 1131-5. Analytical investigation of properties of the iso-NTCP envelope Pavel Stavrev2, Colleen Schinkel1,2, Nadia Stavreva2, Krassimir Markov2, B. Gino Fallone1-3 1Department of Physics, University of Alberta, Edmonton, Alberta, Canada; 2Department of Medical Physics, Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, T6G 1Z2, Canada; 3Department of Oncology, University of Alberta, Edmonton, Alberta, Canada Background. A property of the integral dose-volume histogram (DVH) space is analytically investigated in this work. A curve called an a-iso-NTCP (normal tissue complication probability) envelope is constructed by connecting points belonging to step-like integral DVHs, each corresponding to homogeneous partial organ irradiation of a relative volume vk to dose Dk such that the resulting NTCP has, in all cases, a particular value a. The two subspaces into which the envelope divides the DVH space are analytically explored in terms of the equivalent uniform doses (EUDs) corresponding to the different DVHs. It is theoretically proven that any DVH, other than the step-like DVH, passing through a point (Dk, vk) from the a-iso-NTCP envelope, will result in an NTCP > a. Conclusions. Thus, it is proven that any DVH that at least partially lies above the envelope results in an NTCP > a. For some of the DVHs lying under the envelope, e.g. those that are tangential to the envelope, it is also true that the resulting NTCP > a. However, it was numerically demonstrated elsewhere that there exist DVHs lying entirely in the lower subspace that result in an NTCP < a. Therefore, one can conclude that since there is a chance that a DVH lying under the a-iso-NTCP envelope will result in NTCP < a, it would be preferable in the treatment optimization process to seek solutions for DVHs lying entirely under an iso-NTCP envelope and avoid solutions that have DVHs above an iso-NTCP envelope. Key words: dose – response relationship, radiation; NTCP, iso-effect, DVH Introduction Recently we proposed that the DVH av­eraged from those resulting in a certain Received 28 February 2007 Accepted 7 March 2007 Correspondence to: B. Gino Fallone, Ph.D., Department of Medical Physics, Cross Cancer Institute, 11560 University Ave., Edmonton, Alberta, T6G 1Z2, Canada; Phone: +1 780 432-8750; Fax: +1 780 432-8615; E-mail: gfallone@phys.ualberta.ca normal tissue complication probability (NTCP) can be used as a source of dose-volume constraints for inverse planning.1,2 Constraint points were estimated for a number of organs using two NTCP models – the Lyman model3 with the parameters 4 of Burman et al. and the critical volume population model5 with the parameters of Stavrev et al.6 We also reported an observed property of the integral dose-volume histo­gram (DVH) space.1,2 In those reports we constructed a curve, which we called an a-iso-NTCP envelope, by connecting points belonging to step-like integral DVHs. Each of these DVHs corresponded to homogene­ous partial organ irradiation of a relative volume vk to dose Dk such that, for each DVH, the resulting NTCP had a particular value a. We numerically demonstrated that any DVH passing through a point (Dk, vk) from the a-iso-NTCP envelope, i.e., any DVH that tangents or crosses the envelope, will result in an NTCP =a. It should be em­phasized that the equality is valid only for the step-like DVH that corresponds to the homogeneous partial organ irradiation of vk to Dk. In our present report, we prove, ana­lytically, this property of the a-iso-NTCP envelope for the three most commonly used NTCP models – the Lyman model, the indi­vidual critical volume model and the popu­lation critical volume model. Proof for the Lyman model For our purposes, a normalized integral DVH is defined as a monotonically decreas­ing function characterized by the set of points Di, vi: i = 1, …, N such that v = 1 , 1 = 0 , vv , D < D . . vN + 1 i + 1 < ii i + 1 We begin this proof for the Lyman3 NTCP model: x EUD - D 50 . - t 2 1 1 x . . ; F () x = . . . . . dt = . [1] NTCP = F erf + . 1 .. .. . exp . . , . . mD 50 2 p . 2 . 2 . 2 . -8 . . . . . . where m and D50 are model parameters, and EUD is the equivalent uniform dose, which will be defined later. It is clear from Eq. [1] that NTCP is a monotonically increasing function of EUD. Thus, for two arbitrary EUDs, if EUD1 > EUD2, then it follows that NTCP(EUD1) > NTCP(EUD2). Consider an arbitrary integral DVH, with points (Di, vi : i = 1,…,N), that passes through the point (Dk, vk) on the a-iso-NTCP envelope (see Figure 1). The EUD of this arbitrary DVH will be referred to as EUD. Now consider a step-like DVH that also passes through the same point. This step-like DVH has an NTCP of a. If we call the EUD of this DVH EUDa, then we may write that NTCP(EUDa) = a. According to our observation,2 the NTCP of the arbitrary DVH that passes through a point on the a-iso-NTCP envelope will be greater than a: [2a] NTCP ( EUD )>NTCP ( EUD a)=a . Because of the monotonic nature of NTCP as a function of EUD, this statement is true, if and only if, [2b] EUD >EUDa . Therefore, if we can show that EUD > EUDa , then Eq. [2a] is also true. To calculate EUD, the integral DVHs must be converted into differential DVHs. In the case of homogeneous partial organ irradiation of volume vk to a dose Dk, the integral and the dif­ferential DVHs are determined solely by the pair (vk, Dk). For any other type of irradiation, the corresponding differential DVH is given by the following set of points: (vi – vi+1, Di). One of the commonly accepted forms of EUD is the one given by the generalized mean dose (GMD):7-9 Radiol Oncol 2007; 41(1): 41-7. n . . [3] EUD = GMD = . . ( vi - vi + 1) Di n . , . i . where n is a volume parameter. For the case of partial organ irradiation of the volume vk to dose Dk, Eq. [3] simplifies to: qp n nn [4] EUD =( vD )= vD . a kk kk For the arbitrary DVH passing through point (Dk, vk), the EUD may be written as: n N . . n EUD = . ( v - v ) D . . ii + 1 i . i = 1 . [5] . n k - 1 N . . n n n = . . ( vi - vi + 1 ) Di +( vk - vk + 1 ) Dk + . ( vi - vi + 1 ) Di . . i = 1 i = k + 1 . To prove Eq. [2b], we have to prove, from Eqs. [4] and [5], that the following inequality is valid: EUD a< EUD [6] k - 1 N n . n . . n n n n . ( vD )< . ( v - v ) D +( v - v ) D +( v - v ) D . kk . ii + 1 i kk + 1 k . ii + 1 i . i = 1 i = k + 1 . Taking each side of Eq. [6] to the power of 1/n, we obtain: k - 1 N 1 n n n n [7] vk Dk < . ( vi - vi + 1 ) Di +( vk - vk + 1 ) Dk + . ( vi - vi + 1 ) Di , i = 1 i = k + 1 which can then be written as: k - 1 N n n n [8] vk + 1 Dk < . ( vi - vi + 1 ) Di + . ( vi - vi + 1 ) Di . i = 1 i = k + 1 We now proceed by proving that Eq. [8] is true. n First, consider the term vk +1 Dk in Eq. [8]. It may be re-written as: n 1 n n n v k + 1 Dk =( vk + 1 - vk + 2 ) Dk +( vk + 2 - vk + 3 ) Dk + ... +( vN - vN + 1 ) Dk [9] N , n =( v - v ) D . ii + 1 k i = k + 1 where, by definition, vN + 1 = 0 . We can expand the second sum in Eq. [8]: N n n n n [10] ( v - v ) D =( v - v ) D +( v - v ) D + ... +( v - v ) D . . ii + 1 ik + 1 k + 2 k + 1 k + 2 k + 3 k + 2 NN + 1 N i = k + 1 According to our definition of the integral DVH, Di < Di +1 for all i = 1... N . Therefore, each term of the sum in Eq. [9] is less than the corresponding term in Eq. [10], and we can write: Radiol Oncol 2007; 41(1): 41-7. N 1 n 1 n v [11] k + 1 Dk < . ( vi - vi + 1 ) Di . i = k + 1 Because of our definition of an integral DVH, vi >vi + 1 for all i = 1... N , the first sum in Eq. [8] is greater than zero: k - 1 1 n [12] . ( vi - vi + 1 ) Di > 0 . i = 1 From Eqs. [11] and [12], the following is true: k - 1 N 1 n 1 n 1 n [13] vD <( v - v ) D +( v - v ) D , k + 1 k . ii + 1 i . ii + 1 i i = 1 i = k + 1 which is identical to Eq. [8]. Thus, we have proven Eq. [8], which is equivalent to Eq. [6], and thus, Eq. [2b]. Therefore, Eq. [2a] is also true, and we have thus mathematically proven the property of the envelope for the Lyman model. Proof for the critical volume model The basic property of the a-iso-NTCP envelope will also be proven for the critical volume (CV) NTCP model. The CV model exists in two forms – individual and population models. The individual CV model is given by: . N (” d -” cr ) . [14] NTCPind =F . . , s . ” . . d . where N is the total number of functional subunits (FSUs) comprising the organ, ” is the d mean relative damaged volume, s” is the variance in ”, and ” is the relative critical d dcr volume of the organ.5,10,11 The population CV model, under the assumption that only the relative critical volume dis­plays inter-patient variability, is given by: . - ln (- ln ” d ) ( + ln - ln ” cr ) . [15] NTCP =F . . pop -s ” ” ln ” , cr cr . .. cr . 5 where ”cr is the population mean relative critical volume and s is the variance in ”cr ” . cr As can be seen in Eqs. [14] and [15], both the individual and the population CV models are monotonically increasing functions of the mean relative damaged volume ”. This quantity d is given by the following sum: vi ) () Pi [16] ” d = . ( i - v + FSU D , 1 i where FSU ()i is the probability that a functional subunit is damaged beyond repair. It, PD in turn, is given by:g y [17] P ()= [- N exp (- a D )] , D exp FSUi c ci Radiol Oncol 2007; 41(1): 41-7. where Nc is the number of cells in an FSU and ac is the cell radiosensitivity. The quan­tity exp (-a D) is the probability that a cell survives an irradiation to dose D. Since c ac is a positive quantity, then exp (-a D) is a decreasing function of dose. The term c N exp (- a D) is the mean number of cells that survive dose D and also decreases as cc D increases. Equation [17] is the probability that a functional subunit is damaged beyond repair, which is equivalent to the probability that all cells in the subunit are destroyed. Therefore, -a exp (- Ne cD ) , which is the probability of zero cell survivals, increases with decreasing c mean number of cell survivals, N exp (- a D) , or increasing dose D. cc We now compare the mean relative damaged volume caused by an arbitrary DVH that is tangential to or is crossing the a-iso-NTCP envelope at point (Dk, vk) with the mean rela­tive damaged volume caused by a step-like DVH given by (Dk, vk). From Eq. [16], the mean relative damaged volume for the arbitrary DVH passing through the point (Dk, vk) on the a-iso-NTCP envelope is: N ”= ( v - v ) () PD d . ii + 1 FSU i i = 1 [18] . k - 1 N = (- v ) ()( - v ) () PD + (- v v PD + vv ) () PD . ii + 1 FSUi kk + 1 FSU k . ii + 1 FSU i i = 1 i = k + 1 The mean relative damaged volume caused by partial organ homogeneous irradiation of relative volume vk to dose Dk will be denoted as ”d ,a and is given by: [19] ”= vP ()D . d , a k FSU k N We now compare ”= ( v - v ) () PD (Eq. [18]), containing point (Dk, vk), with d . ii + 1 FSU i i = 1 ”= vP ()D PFSU() is an increasing function of dose, Eqs. [18] (Eq. [19]). Since D d , a k FSU k and [19] are similar to the EUD form of Eq. [3] from the Lyman model. By applying the same process as to the proof of Eq. [6] it can be shown that the following inequality is valid: N [20] ” d = . ( v - v + PD >” a= vP () i 1 ) () i , k Dk i FSU d FSU . i = 1 Given that NTCP is an increasing function of the mean relative damaged volume, it follows that NTCP ()” d > NTCP (” d , a )=a for DVHs having a common point with the a-iso-NTCP envelope. Radiol Oncol 2007; 41(1): 41-7. Figure 1. Illustration of an a-iso-NTCP envelope and two arbitrary DVH curves – one that crosses the envelope at the point (Dk, vk) and one that is tangential to the envelope at the same point. Also shown is a step-like DVH passing through (Dk, vk) that corresponds to homogeneous partial organ irradiation. The NTCP of the step-like DVH should be equal to a, while the NTCP for both arbitrary DVHs should be greater than a. Discussion and conclusions Because we have proven that the discussed property of the a-iso-NTCP envelope ap­plies to three of the most commonly used NTCP models – the Lyman model, the critical volume individual model, and the critical volume population model – there is reason to believe that this property may be model-independent. The a-iso-NTCP envelope divides the dose-volume space in two sub-spaces. For the sub-space above the envelope, we have analytically proven that all DVH curves with at least one point in this region result in an NTCP > a. For the sub-space under the a-iso-NTCP envelope, it was numeri­cally demonstrated elsewhere2 that there exist DVH curves that result in an NTCP < a. However, as it is shown above, there do exist other curves, e.g., those that are tan­gential to the envelope from below, which result in an NTCP > a. Nevertheless, since there is a chance that a DVH lying under the a-iso-NTCP envelope will result in an NTCP less than a, one can conclude that it would be preferable in the treatment opti­mization process to seek solutions for DVHs lying entirely under an iso-NTCP envelope and avoid those that lie even partially above the envelope. The physical dose-volume constraint points that we calculated in a previous work2 were found to be dependent on the NTCP model as well as the parameters used for their determination. The iso-NTCP en­velope could be used to estimate the impact of a change of NTCP model and/or param­eters on the calculated constraint points for a given organ, since the envelope curve is dependent on both of these quantities. Dawson et al.12 observed that the iso-NTCP curve corresponding to their liver parame­ters for the Lyman3 model was shifted con­siderably to the right in DVH space com­pared to the iso-NTCP curve corresponding to the Burman et al.4 parameters for the same organ. To estimate how the source of dose-volume constraints (the average of DVHs with a certain NTCP) would change Radiol Oncol 2007; 41(1): 41-7. with a change of NTCP parameter values, one could calculate the iso-NTCP envelope corresponding to these new parameters. The distance in DVH space between the old and new iso-NTCP curves is approximately the same as the distance between the old and new averaged DVHs. The position of the new dose-volume constraints could then be estimated by shifting them in DVH space by an amount equal to the distance between the two iso-NTCP curves. In this way, one can avoid having to perform an extensive recalculation of the dose-volume constraints. Acknowledgements This research was supported by student­ships from the Alberta Foundation for Medical Research, the Alberta Cancer Board and the Translational Research Training in Cancer program (Canadian Institutes for Health Research), as well as the Alberta Cancer Board Research Initiative Program Grant RI-218/20624. References 1. Schinkel-Ranger C, Stavrev P, Stavreva N, Weldon M, Scrimger R, Fallone BG. On the dose-vol­ume constraints based on radiobiological consid­erations. Presented at the AAPM 47th Annual Meeting, Seattle, WA; 2005. 2. Schinkel C, Stavrev P, Stavreva N, Fallone BG. A theoretical approach to the problem of dose-vol­ume constraint estimation and their impact on the dose-volume histogram selection. Med Phys 2006; 33: 3444-59. 3. Lyman JT. Complication probability as assessed from dose-volume histograms. Radiat Res Suppl 1985; 8: S13-19. 4. Burman C, Kutcher GJ, Emami B, Goitein M. Fitting of normal tissue tolerance data to an ana­lytic function. Int J Radiat Oncol Biol Phys 1991; 21: 123-35. 5. Stavrev P, Stavreva N, Niemierko A, Goitein M. Generalization of a model of tissue response to radiation based on the idea of functional subunits and binomial statistics. Phys Med Biol 2001; 46: 1501-18. 6. Stavrev P, Stavreva N, Niemierko A, Goitein M. The application of biological models to clinical data. Phys Medica 2001; XVII: 71-82. 7. Niemierko A. Reporting and analyzing dose dis­tributions: a concept of equivalent uniform dose. Med Phys 1997; 24: 103-10. 8. Niemierko A. A generalized concept of equiva­lent uniform dose. Presented at the 41th AAPM Annual Meeting, Nashville; 1999. 9. Stavrev P, Hristov D, Sham E. IMRT inverse treat­ment planning optimization based on physical constraints and biological objectives. Presented at the 47nd Annual General Meeting of the Canadian Organization of Medical Physicists (COMP), Kelowna, BC, Canada; 2001. 10. Jackson A, Kutcher GJ, Yorke ED. Probability of radiation-induced complications for normal tissues with parallel architecture subject to non­uniform irradiation. Med Phys 1993; 20: 613-25. 11. Niemierko A, Goitein M. Modeling of normal tissue response to radiation: the critical volume model. Int J Radiat Oncol Biol Phys 1993; 25: 135-45. 12. Dawson LA, Normolle D, Balter JM, McGinn CJ, Lawrence TS, Ten Haken RK, Analysis of radia­tion-induced liver disease using the Lyman NTCP model. Int J Radiat Oncol Biol Phys 2002; 53: 810-21. Radiol Oncol 2007; 41(1): 41-7. Implementing of the offline setup correction protocol in pelvic radiotherapy: safety margins and number of images Mladen Kasabašic1, Dario Faj1, Nenad Belaj1, Zlatan Faj2, Ilijan Tomaš1 1Department of Oncology and Radiotherapy, University Hospital Osijek, Croatia 2Croatian Electric Power Industry, Osijek, Croatia Background. Patient positioning errors in pelvic radiotherapy at Department of Oncology and Radiotherapy in Osijek are explored in order to establish the offline setup correction protocol and determine the safety margins. Material and methods. Film portal imaging is used during the whole treatment in order to find patient positioning errors. Eleven patients are included in the study and 420 images are analyzed. Setup errors are found by measuring distances between the center of the field and bony landmarks. Systematic and random errors are analyzed. Results. Safety margins that should be employed at our department are 11 mm, 13 mm and 14 mm in medi­olateral, craniocaudal and anteroposterior direction, respectively. Time trend is found only in an aged, obese patient with a hip problem. No action level offline setup protocol was employed by taking and averaging first four images in mediolateral and craniocaudal and 5 images in anteroposterior direction. Conclusions. Since time trend is found only in a patient who was hard to position because of his age, obesity and the hip problem, we decided that such patients are to be positioned without a bellyboard and in supine position. Time trends are not found in all of the other patients so we employed the offline setup error protocol by averaging setup errors from the first few consecutive images. Safety margins that will ensure 90 % probability of depositing at least 95 % of the prescribed dose in the target are calculated. Safety margins and number of images that should be taken showed that the most inaccurate positioning was in the anteroposterior direction. Key words: pelvic neoplasms – radiotherapy; radiotherapy dosage - methods Received 19 January 2007 Accepted 14 February 2007 Correspondence to: Mladen Kasabašic, Department of Oncology, University Hospital Osijek, J. Huttlera 4, 31000 Osijek, Croatia; Phone: +385 31 511 478; Fax: +385 31 512 219; E-mail: kasabasic.mladen@kbo.hr Introduction The pelvic radiotherapy is often indicat­ed for patients with cervical, uterine and rectum carcinomas. One of the problems during the radiotherapy is that total doses of 40-50 Gy to the whole pelvis can give rise to early or late complications of the small bowel.1-3 This is important especially because a long term survival is very often expected among those patients. The use­ful methods to reduce the irradiated small bowel volume are: three-field box tech­nique, individualized normal tissue blocks, physically moved healthy tissues from the treatment field, bladder distention and prone position of the patient.1,3,4 The use of open tabletop devices or the bellyboard, where patients are in the prone position, has been described previously.2­6 Positioning of patients with gynecologic tumours for radiotherapy has proven to be relatively inaccurate.7 Misspositioning of the patient can give rise to complications or influence the results of the treatment.8 With now commonly available electronic portal imaging devices (EPID) it is possi­ble to correct systematic and random field placement errors on a daily basis.7,9 The systematic error (SE) is defined as the mean displacement of the treatment isocenter from the planning isocenter,10 and the ran­dom error (RE) as a deviation of the each individual position from the mean position of the patient. The systematic error is the main factor when considering the margin size to account for setup uncertainties.10-12 When correcting the patient position, only the systematic component of the setup er­ror must be corrected.8,11,12 The purpose of this study was to investi­gate the accuracy of daily patient positioning in our department in the bellyboard pelvis radiotherapy. Since our department is not equipped with EPID, we chose to imple­ment strategy called no action level (NAL) protocol for reducing patient setup errors.13 It means that position of the patient will be measured during the first N treatment frac­tions, and an unconditional correction of the setup position will be done once at the (N + 1)th fraction. In this paper we investigated how many images (N) are needed to be per­formed, before deciding that the error is sys­tematic and that repositioning of the patient should be done. Too low number of images taken means that random errors (a mistake in positioning of the patient, a wrong field size, a wrong distance between the film and the patient, wrong readings of parameters on the film, wrong calculation of deviations, moving the patient during the treatment or some other reason) can cause an action and too high number of images would prolong the treatment time unnecessarily. Materials and methods Six patients with cancer of corporis uteri, four patients with cancer of cervicis uteri and one patient with rectal carcinoma were included in this study. The median age of the 11 patients was 64 years (47-76 years). All patients were treated using the three-field box technique at the linear accelera­tor Siemens Mevatron MD2. Patients are simulated at the conventional simulator SIMVIEW 3000. Shielding was done with conformal Cerrobend blocks made indi­vidually for each patient. Seven patients received the total dose of 50 Gy in 25 daily fractions, two patients received 40 Gy in 20 daily fractions followed by brachytherapy, and the patient with rectal carcinoma re­ceived the total dose of 45 Gy in 25 daily fractions of 1.8 Gy + boost 3 x 1.8 Gy. One patient was predicted to receive 50 Gy in 25 daily fractions, but she died after the 21st fraction. All patients were simulated in the prone position using our custom-made bellyboard. We constructed two identical bellyboards (one for the simulator, and the other for the linear accelerator) with a thickness of 8 cm, overall size 56 cm x 104 cm and opening 28.5 cm x 30.5 cm. Bellyboards do not have small caudal aperture for the pubic bone and they are used in the combination with the leg support. Radiol Oncol 2007; 41(1): 48-55. To reduce the volume of the small bowel within the treatment fields, patients were set in the way that the caudal border of the bellyboard opening is at the lower end of the sacroiliac joints. It means that the symphysis is out of the bellyboard open­ing for at least 5 cm. The isocentar posi­tion was visualized using laser equipment and marked on patients’ skin by markers. To enable the reproducible position of the patient, the opening of the bellyboard was marked by two lines on the skin. During the simulation procedure two sets of simulation films were obtained. One film was taken for the anteroposterior field and the other for one of the lateral fields. During the treatment session, for the verification of positioning of the patient, we were using the Kodak EC-L film sys­tem. The setup errors in patient position­ing are defined by the deviations from the measured distance between the centre of the field and visible bony anatomical land­marks8,10 along the craniocaudal (CC), an-teroposterior (AP), and lateral (ML) axis. Displacements of the ML and CC direction were measured from the anteroposterior field, and AP direction from the lateral field. The ML displacement was defined as a distance from the isocentar to the pelvic rim; the CC as a distance to the obturator point and the AP as a distance to the sym­physis (Figure 1). We tried to measure the CC setup error also from the lateral field, but the results showed big uncertainty so we decided to omit those measurements. All deviations in the caudal direction, to the left and dorsum were marked as posi­tive, and the deviations in the cranial direc­tion, to the right and anterior were marked as negative. The image acquisition was completed in 80.4 %. In total, 420 images were acquired for the analysis. At the beginning of the analysis the safe­ty margins for the setup inaccuracy were 15 mm in all directions. At first, we examined the presence of time trends in any direction. The time trend is defined as drift of the field displacement in a one, systematic way during the treat­ment. If the time trend exists, the correc­tion of the systematic error may not be accurate.11 Time trends were investigated using a linear regression approach and the existence of time trends was considered if the slope was greater than 4 mm during the treatment. This limit was used to avoid Figure 1. Determination of ML, CC and AP displacements, according to the pelvic anatomic structures, on anteroposterior and lateral projections. Radiol Oncol 2007; 41(1): 48-55. 2 4 deviation (cm) 1 0 Figure 2. Presence of the time trend in the AP direction in one patient. Those data were excluded from the study. too many patients to be excluded from the study. The systematic error (SE) is defined as the mean displacement of the treatment isocentar from the planning isocentar, and the random error (RE) as a deviation of each individual measurement from the mean value. The systematic error is the main factor when considering the margin size for setup uncertainties.10-12 The systematic error for the entire group (SEeg) was defined as the arithmetic mean of all patients’ systematic errors. The random deviation of the pa­tients’ SE from SEeg was estimated by 1 SD (SDse). The random deviation of all in­dividual RE around the mean patients’ RE was also estimated by 1 SD (SDre). Thus, systematic and random setup errors were calculated for the entire group of patients and the safety margin size was formed ac­cording to the sizes of those deviations. The margin size is the one that ensures the 90% probability of depositing at least 95% dose in the target.12,14 These values are a sensible compromise between the risk of underdosing the target volume and of ex­cessive overdosing the surrounding healthy tissue14. The calculation of the safety mar­gins, H, is done by using the following ex­pression.12 set-up inaccuracy (cm) 1 0 -1 -2 Figure 3. Mean translations and their SD for each patient in the craniocaudal direction. H = 2.5 SDse + 0.7 SDre. Because these margins do not include ro­tational errors, they should be used as the lower limit for safe radiotherapy.12 We chose to implement strategy called no action level (NAL) protocol13 for reduc­ing patient setup errors. It means that the position of the patient will be measured during the first N treatment fractions, and an unconditional correction of the setup position will be done once at the (N + 1)th fraction. We investigated when to do the correction of systematic positioning error by evaluating setup errors during the whole treatment session. Results At the beginning, we checked for the pres­ence of time trends for all patients and directions. Data were fitted as linear, and the slope of the curve is tested to be less than 4 mm during the whole treatment. For the ML and CC directions there was no evi­dence of time trends. In the AP direction, a time trend existed in an aged, obese patient with a hip problem (Figure 2). Since that patient was very difficult to position, we excluded his AP data from our analysis. Figures 3, 4 and 5 show the mean trans­lations and their SDs for each patient in all three directions. Radiol Oncol 2007; 41(1): 48-55. 2 2 1 set-up inaccuracy (cm) 0 -1 patient number Figure 4. Mean translations and their SD for each patient in the anteroposterior direction. The ranges of errors along the lateral, craniocaudal and anteroposterior are shown in the Table 1 together with ranges of the systematic and random compo­nents of the errors. The systematic and random errors represented by 1 SD are also shown in the Table 1 together with the safety margins (SMs) calculated as ex­plained before. The calculated SMs are the lower lim­its for the treatment planning and we will use rounded values in upper directions. Besides, we neglected the existence of the time trends less than 4 mm in all directions, so this value was added to the SM sizes. Finally SMs are 11 mm, 13 mm and 14 mm in ML, CC and AP directions respectively. To avoid random errors to cause reposi­tioning of the patient, we investigated how many images (fractions) should be averaged 0 12 3 45 6 78 910 11 12 patient number Figure 5. Mean translations and their SD for each patient in the lateral direction. to determine whether the error is random or systematic. In a direction, the sum of all patients’ REs around SE is zero. We deter­mined the fraction number (N) where the random error averaged over 1th, 2nd...Nth fraction is a good approximation of the zero value. For the jth patient the array ni,j was formed by averaging all deviations of pre­ceded fractions for a fraction i. Since REs are equally dispersed around the zero val­ue, all patients’ arrays will fast converge to the zero value. A characteristic curve for a patient is shown in Figure 6. At a fraction i = N, the array value can be approximated as it reached the zero value. It means that one can decide how many frac­tions (N) should be averaged for a good ap­proximation of the zero value. In this way, for the jth patient, we approximated the systematic error at the end of the treatment Table 1. The range of the setup errors, and systematic and random components of the setup errors, standard deviations of systematic errors (SDse), standard deviations of random errors (SDre) and calculated safety margins (SM) of 11 patients included in the study Radiol Oncol 2007; 41(1): 48-55. n i, j 0,2 0 -0,2 -0,4 -0,6 -0,8 -1 0 5 number of fraction, i 10 15 20 0 1 2 3 4 5 6 7 8 910 11 12 13 14 15 16 number of fraction, i Figure 7. Averaged random deviations in CC, AP Figure 6. Array of averaged REs around SE in AP and ML directions for all of the patients during the direction for a patient. After all the REs are averaged, treatment. It can be seen that random deviations are the array ends at zero value. close to zero after a certain number of fractions in all of the directions and after that the slope of the curve is very mild. (SEj), with systematic and random error at the chosen fraction. In order to be able to make this decision for a number of patients (M), all absolute values of ni,j are averaged for all of the patients. Thus, we formed the M k = n i i , j new array M 1. of average absolute REs j at a fraction i for all fractions. Again, the ar­ray converges to the zero value and one can decide how many fractions should be aver­aged for a good approximation of the zero value. In this way a number of fractions, i = N, for a group of patients is found, which can be averaged to represent a good approx­imation of the systematic error at the end of the treatment. The calculation is done in all of the directions. Arrays of ki values are shown in Figure 7. According to the Figure 7, numbers of images that must be taken for a patient were 3 in the ML, 4 in the CC and 5 in the AP direction. Since deviations in ML and CC directions are measured from the same image we decided to average four images in the ML direction as well. Discussion Accuracy data of daily patient positioning at our department are shown in Figures 3, 4 and 5. The setup errors of individual meas­urements ranged up to 18 mm, 30.3 mm, 30.5 mm in ML, CC and AP directions, respectively. Out of systematic and random setup errors the safety margins were cal­culated. They were 11 mm in the ML, 13 mm in the CC and 14 mm in the AP direc­tion. To find out how many images must be taken to decide that the setup error is systematic, the average REs of all patients during the treatment were compared. It is possible to decide when this error is close enough to zero for a group of the patients, so at that fraction, the error can be con­sidered systematic (Figure 7). Numbers of images that must be taken are 4 in ML and CC directions and 5 in the AP direction. The group of the patients included in the study is assumed to be representative for treatments done at our department. Only one patient showed time trend in one direction to be greater than 4 mm through the treatment (Figure 2) and those data were excluded from the study. That pa­tient was elderly, obese and had a hip prob­lem. We decided that the patients difficult to position by bellyboard would be planed in the supine position. The problem that occurred during this study is non-existence of “pubic aperture” Radiol Oncol 2007; 41(1): 48-55. in our bellyboard device. This makes the position of the patient uncomfortable and they tend to move. Our measurements showed that there are no preferable direc­tions. For future treatments the “pubic ap­erture” is improvised in our bellyboard. Systematic and random errors reported are comparable to the results published in the referenced studies of gynecological patients.3,15 The safety margins extracted from this study are smaller than the mar­gins employed before and they are on the upper side of the range of other reported results.14,15 It is important to note that the most of the published results are from ad­vanced institutions and may not indicate variations applicable to an average, busy department.14 Although at the beginning all of the SM sizes were equally sized, the study showed that patients are moving mostly in the AP direction, so in that direction the calculated SM was the largest. This can be explained by the specific prone position of a patient and use of a bellyboard device as it was reported before.14, 15 In order to apply the NAL protocol, a number of fractions for reposition value determination was found. Again, more images must be taken in AP than in CC and ML direction in order to find SE. The use of the NAL protocol means that every patient will be repositioned once during the treatment and we will explore future setup errors in order to compare them to the results of this study. References 1. Park W, Huh SJ, Lee JE, Han Y, Shin E, Chan Y, et al. Variation of small bowel sparing with small bowel displacement system according to the physi­ological status of the bladder during radiotherapy for cervical cancer. Gynecol Oncol 2005; 99: 645­51. 2. Ghosh K, Padilla LA, Murray KP, Downs LS, Carson LF, Dusenbery KE. Using a belly bord de­vice to reduce the small bowel volume within pel­vic radiation fields in woman with postoperatively treated cervical carcinoma. Gynecol Oncol 2001; 83: 271-75. 3. Olofsen-van Acht M, van den Berg H, Quint S, de Boer H, Seven M, van Somsen de Koste J, et al. Reduction of irradiated small bowel volume and accurate patient positioning by use of a bellyboard device in pelvic radiotherapy of gynecological can­cer patients. Radiother Oncol 2001; 59: 87-93. 4. Hollenhorst H, Schaffer M, Romano M, Reiner M, Siefert A, Schaffer P, et al. Optimized radiation of pelvic volumes in the clinical settings by using a novel bellyboard with integrated gonadal shield­ing. Med Dosim 2004; 29: 173-8. 5. Huh SJ, Park W, Ju SG, Lee JE, Han Y. Small-bowel displacement system for the sparing of small bow­el in three-dimensional conformal radiotherapy for cervical cancer. Clin Oncol 2004; 16: 467-73. 6. Weiss E, Richter S, Hess CF. Radiation therapy of the pelvic and paraaortic lymph nodes in cervical carcinoma: a prospective three-dimensional analy­sis of patient positioning and treatment technique. Radiother Oncol 2003; 68: 41-9. 7. Stroom JC, Olofsen-van Acht MJJ, Quint S, Seven M, De Hoog M, Creutzberg CL, De Boer HCJ, et al. On-line set-up corrections during radiotherapy of patients with gynecologic tumors. Int J Radiat Oncol Biol Phys 2000; 46: 499-506. 8. Cazzaniga LF, Frigerio M. Errors in positioning the patient during transcutaneous radiotherapy of the pelvis. Radiol Med 1997; 94: 664-70. 9. Quint S, de Boer HCJ, van Sörnsen de Koste JR, Heijmen BJM, Olofsen van Acht MJJ. Set-up verifi­cation of cervix cancer patients treated with long treatment fields; implications of a non-rigid bony anatomy. Radiother Oncol 2001; 60: 25-9. 10. Kragelj B. Setup error and its effect on safety margin in conformal radiotherapy of the prostate. Radiol Oncol 2005; 39: 211-7. Radiol Oncol 2007; 41(1): 48-55. 11. Ludbrook JS, Greer PB, Blood P, D’Yachkova Y, Coldman A, Beckham WA, et al. Correction of sys­tematic setup errors in prostate radiation therapy: how many images to perform? Med Dosim 2005; 30: 76-84. 12. van Herk M, Remeijer P, Rasch C, Lebesque JV. The probability of correct target dosage: Dose population histograms for deriving treatment mar­gins in radiotherapy. Int J Radiat Oncol Biol Phys 2000; 43: 1121-35. 13. Bortfeld T, Van Herk M, Jiang SB. When should systematic patient positioning errors in radiothera­py be corrected? Phys Med Biol 2000; 47: 297-302. 14. Booth JT. Modelling the impact of treatment un­certainties in radiotherapy. PhD thesis. Adelaide: University of Adelaide, Australia; 2002. 15. Haslam JJ, Lujan AE, Mundt AJ, Bonta DV, Roeske JC. Setup errors in patients treated with inten­sity-modulated whole pelvic radiation therapy for gynecological malignancies. Med Dosim 2005; 30: 36-42. Radiol Oncol 2007; 41(1): 48-55. report Basic Clinical Radiobiology Course Ljubljana (Slovenia), 21.-25. May 2006 View from a local participant As the course took place in Slovenia, I should first of all tell a couple of words about my country and its capital Ljubljana. Slovenia is a small country with only two million people, but it has all that one needs to enjoy life: the sea, mountains, some beautiful lakes and Karst landscapes with a lot of natural caves. Add to this some very good wines and food delights – but you should really find out first hand. Ljubljana is a city of cultural and rich historical heritage. It is similar to other Central European cities. Some compare it to Vienna or Prague, but its particular charm lies in the smallness of this town, with the total population of only around 300.000 people. The course started on Sunday, the 21st of May with the introduction to radiobiology. In the afternoon, after the coffee break, the participants could attend the tutorials of “basic” or “ad­vanced knowledge” of radiobiology. I suppose people who work in radiotherapy must be modest, since most participants chose the “basic knowledge” group. Even if the group was supposed to be “basic”, the discussions were not. During the first day, as well as during the following days, we discussed some very interesting topics like re-radiation, modifiers of late complications, a/ß ratio in prostate cancer and whether or not to give the same treatment for the whole course of radio­therapy. We also touched upon the eventual connection between IMRT and secondary tumors. The second day started with a lecture about radiobiology of normal tissues and continued with an explanation of the role of checkpoints in the cells. The next lecture emphasized the importance of proper documenting. The day continued with a presentation of the linear quadratic model, followed by a lecture about hyperfractionation. During the third day, the issues of oxygenation in radiotherapy, of mathematical models and of combination of radiotherapy with chemotherapy were discussed. The following day when the participants were confronted with the problems of using such models in practice, all the enthusiasm about models faded away. It became obvious that, unfortunately, models do not always work well in practice. The next topic on the agenda was biological image-guided radiotherapy, and in the afternoon, the combination of new biological therapies with radiotherapy was presented. Tuesday was the so called “social day”. The participants first took a trip to the beautiful lake of Bled, and in the evening, they were invited to dinner. The atmosphere was excellent, just right to meet other people and make new acquaintances. The participants had a great time – but how could it have been otherwise with such great lecturers and participants. They came from all around the world, from exactly eighteen countries. During the evening two new members of the “radiobiology” team were presented to us, the new lecturer Dr. Susan Short and the new orga­nizer Mrs. Viviane Van Egten. One of the standard features of such events is the poor quality of the coffee served during the breaks. Surprisingly, during this course, the coffee was really good and one of the lecturers even said that this was the best coffee he had ever had at any course. However, this course will not be remembered because of the coffee, but rather for excellent lectures and teachers. Thanks to them, the course was really good. The participants had the chance to learn a lot and were challenged to use this knowledge in everyday practice. Special thanks go to the course director Professor Van der Kogel for the excellent scientific program. And to all of you, hope to see you next time in Ljubljana. Mirjana Rajer, MD Institute of Oncology Ljubljana Ljubljana, Slovenia report Basic Clinical Radiobiology Course Ljubljana (Slovenia), 21.-25. May 2006 View from a local participant As the course took place in Slovenia, I should first of all tel1 a couple of words about my country and its capital Ljubljana. Slovenia is a small country with only two million people, but it has all that one needs to enjoy life: the sea, mountains, some beautiful lakes and Karst landscapes with a lot of natural caves. Add to this some very good wines and food delights -but you should really find out first hand. Ljubljana is a city of cultural and rich historical heritage. It is similar to other Central European cities. Some compare it to Vienna or Prague, but its particular charm lies in the smallness of this town, with the total population of only around 300.000 people. The course started on Sunday, the 2l5t of May with the introduction to radiobiology. In the afternoon, after the coffee break, the participants could attend the tutorials of "basic" or "ad­vanced knowledge" of radiobiology. I suppose people who work in radiotherapy must be modest, since most participants chose the "basic knowledge" group. Even if the group was supposed to be "basic", the discussions were not. During the first day, as well as during the following days, we discussed some very interesting topics like re-radiation, modifiers of late complications, a/. ratio in prostate cancer and whether or not to give the same treatment for the whole course of radio­therapy. We also touched upon the eventual connection between IMRT and secondary tumors. The second day started with a lecture about radiobiology of normal tissues and continued with an explanation of the role of checkpoints in the cells. The next lecture emphasized the importance of proper documenting. The day continued with a presentation of the linear quadratic model, followed by a lecture about hyperfractionation. During the third day, the issues of oxygenation in radiotherapy, of mathematical models and of combination of radiotherapy with chemotherapy were discussed. The following day when the participants were confronted with the problems of using such models in practice, all the enthusiasm about models faded away. It became obvious that, unfortunately, models do not always work well in practice. The next topic on the agenda was biological image-guided radiotherapy, and in the afternoon, the combination of new biological therapies with radiotherapy was presented. Tuesday was the so called "social day". The participants first took a trip to the beautiful lake of Bled, and in the evening, they were invited to dinner. The atmosphere was excellent, just right to meet other people and make new acquaintances. The participants had a great tirne -but how could it have been otherwise with such great lecturers and participants. They came from all around the world, from exactly eighteen countries. During the evening two new members of the "radiobiology" team were presented to us, the new lecturer Dr. Susan Short and the new orga­nizer Mrs. Viviane Van Egten. One of the standard features of such events is the poor quality of the coffee served during the breaks. Surprisingly, during this course, the coffee was really good and one of the lecturers even said that this was the best coffee he had ever had at any course. However, this course will not be remembered because of the coffee, but rather for excellent lectures and teachers. Thanks to them, the course was really good. The participants had the chance to learn a lot and were challenged to use this knowledge in everyday practice. Special thanks go to the course director Professor Van der Kogel for the excellent scientific program. And to all of you, hope to see you next tirne in Ljubljana. Mirjana Rajer,MD .. Institute of Oncology Ljubljana Ljubljana, Slovenia Radio/ Oncol 2007; 41(1): 1-12. Racunalniško tomografska in magnetno resonancna kolonografija Vegar-Zubovic S, Sefic-Pašic I, Lincender L, Vrcic D, Klancevic M, Delic U Izhodišca. V razviten svetu je rak debelega crevesa drugi najpogostejši vzrok smrti pri onkoloških bolnikih. Pogosto se razvije iz žleznih kolorektalnih polipov, ki jih najdemo pri 30-50% Americanov, starejših od 50 let. Zato je zgodnje odkrivanje crevesnih polipov in nji­hova odstranitev ucinkovita prevencija crevesnega raka. Do sedaj pa nismo poznali metode odkrivanja crevesnih polipov, ki bi imela visoko senzitivnost in specificnost, ki bi bila hkrati poceni ter ne bi obremenjevala bolnika. Endoskopska kolonoskopija omogoca natancno ugotavljanje zelo majhnih sprememb in je skoraj popolnoma nadomestila fluoroskopijo. V novejšem casu za ugotavljanje kolorektalnih polipov vedno v vecji meri uporabljamo slikov­ne preiskave z magnetno resonanco (MRI) in racunalniško tomografijo (CT. Zakljucki. CT in MR kolonografija sta novi slikovni tehniki pri preiskavi crevesa. Zaradi obetavnih rezultatov pri ugotavljanju polipov, ki so enaki ali vecji kot 1 cm, jih v vedno vecji meri uporabljamo pri simptomatskih bolnikih. Radio/ Oncol 2007; 41(1): I-VII. Radio/ Onco/ 2007; 41 (1): 15-22. Podaljšana izpostavljenost podgan neletalnim odmerkom mikrocistina-LR povzroci poškodbe DNA v razlicnih organih Filipic M, Žegura B, Sedmak B, Horvat-Žnidaršic I, Milutinovic A, Šuput D Izhodišca. Mikrocistini (MC) so obrocasti hepatapeptidi, za katere velja, da so specificni jetrni strupi. So ucinkoviti promoterji tumorjev, novejše raziskave pa kažejo, da so tudi genotoksicni. V tej raziskavi smo merili poškodovanost DNA limfocitov, jetrnih, ledvicnih (skorje in sredice), pljucnih, vranicnih in možganskih celic samcev podgan Fisher F344, ki so bili en mesec izpostavljene neletalnim odmerkom mikrocistina-YR (MCYR) (vsak drugi dan 10 ”g/kg t.m.; i.p). Metode. Po koncani izpostavljenosti smo živali žrtvovali. Limfocite smo izolirali iz krvi, odvzete iz podjezicne vene, jetrne celice smo izolirali s perfuzijo s kolagenazo A, celice ostalih organov pa smo izolirali z inkubiranjem drobnih košckov tkiv s kolagenaso A. Poškodovanost DNA izoliranih celic smo merili z elektroforezo posamezne celice, ki jo imenujemo tudi test komet. Rezultati. Pri živalih, ki so bile izpostavljene MCYR, smo ob primerjavi s kontrolnimi živalmi ugotovili znacilno povecanje % DNA v repih kometov celic možganov (2,5 krat), jeter (2,1 krat), sredice ledvic (1,9 krat), ledvicne skorje (1,8 krat) in pljuc (1,7 krat). DNA limfocitov in celic vranice ni bila poškodovana. Zakljucki. Raziskava je pokazala, da podaljšana izpostavljenost neletalnim odmerkom mikrocistinov pri sesalcih lahko povzroci sistemski genotoksicni odziv, ki prizadene ne le jetra, ampak tudi druge organe. Radio/ Onco/ 2007; 41(1): I-VII. Radio/ Oncol 2007; 41(1): 23-32. Ugotavljanje mehanizmov delovanja rituksimaba in klinicni rezultati pri visoko rizicnih bolnikih z agresivnimi CD20+ limfomi Jezeršek Novakovic B, Kotnik V, Južnic Šetina T, Vovk M, Novakovic S Izhodišca. Rituksimab se je izkazal kot ucinkovito zdravilo pri zdravljenju bolnikov z indo­lentnimi in agresivnimi CD20 pozitivnimi B celicnimi limfomi, vendar natancnih mehaniz­mov njegovega delovanja in vivo še ne poznamo v celoti. To raziskavo smo zato usmerili v potrjevanje domnevnih glavnih mehanizmov delovanja rituksimaba in hkrati želeli oceniti ucinkovitost prvega zdravljenja visoko rizicnih bolnikov z agresivnimi CD20 limfomi s ke­moimunoterapijo. Bolniki, materiali in metode. Delovanje rituksimaba smo preucevali in vitro na Raji in SU­DHL-4 celicah s testom pomnoževanja celic in s pretocno citometrijo. V klinicnem delu raziskave smo 20 visoko rizicnih bolnikov z agresivnimi CD20 limfomi zdravili s kemoimu­noterapijo R-CHOP. Rezultati. V in vitro pogojih smo ugotavljali le s komplementom posredovano citotoksicno delovanje rituksimaba. Pri tem pa nismo dokazali niti direktnega apoptoticnega delovanja niti s protitelesi posredovane celicne citotoksicnosti verjetno zaradi prenizke koncentracije rituksimaba oziroma neustreznega razmerja med citotoksicnimi limfociti in tumorskimi celicami. Klinicni rezultati zdravljenja z R-CHOP so bili odlicni, saj smo popolno remisijo ob koncu primarnega zdravljenja dosegli pri 90% visoko rizicnih bolnikov. Poleg tega se pri 80% bolnikov bolezen v medianem casu opazovanja 18,5 mesecev ni ponovila. Zakljucki. Glede na naša opažanja je s komplementom posredovana citotoksicnost pomem­ben mehanizem delovanja rituksimaba in vitro. Za direktno sprožitev apoptoze so potrebne višje koncentracije rituksimaba od 20 .tglml, medtem ko je za ucinkovito od protiteles odvisno celicno citotoksicnost potrebno razmerje med citotoksicnimi limfociti in tumor­skimi celicami, ki je vecje od 1:1. Pri bolnikih z visoko rizicnimi agresivnimi CD20 limfomi dodatek rituksimaba k CHOP kemoterapiji pomembno izboljša ucinek zdravljenja. Radio/ Oncol 2007; 41(1): I-VII. Radio/ Oncol 2007; 41 (1): 33-8. Radiofrekvencna ablacija pljucnih tumorjev ­nova oblika zdravljenja pljucnih novotvorb Kocijancic K, Kocijancic I Izhodišca. Perkutana radiofrekvencna ablacija (RFA) je minimalno invazivna tehnika zdravljenja solidnih tumorjev. Preizkušati so jo zaceli tudi kot možen postopek zdravljenja pljucnega raka in zasevkov, ker lahko z njo v kontroliranih pogojih dosežemo obsežnejša podrocja koagulacijske nekroze. Na ta nacin lahko uspešno zdravimo sorazmerno majhne zloceste spremembe v pljucih. RFA je sprejemljiva zamenjava ali dodatna metoda zdrav­ljenja za bolnike z nedrobnocelicnim pljucnim rakom ali s pljucnimi zasevki drugih rakov, ki jih iz razlicnih vzrokov ne moremo operirati. Zakljucki. Dosedanje mednarodne klinicne raziskave pa tudi zacetne izkušnje Inštituta za radiologijo v Klinicnem centru Ljubljana so pokazale, da zdravljenje z RFA bolniki soraz­merno dobro prenašajo in da lahko s to metodo zdravljenja dosežemo popolno nekrozo tkiva v tarcnem volumnu. Najpogostejši zaplet je pneumotoraks (do 40%), pri polovici bol­nikov s tem zapletom pa je potrebna torakalna drenaža. Radio/ Oncol 2007; 41(1): I-VII. Radio/ Onco/ 2007; 41(1): 39-40. Paratestikularni žlezni rak ­neobicajna oblika zasevka raka trebušne slinavke Ocvirk J, Šeruga B Izhodišca. Metastatski paratestikularni žlezni rak trebušne slinavke je zelo redka ob­lika bolezni. Po nam dostopnih podatkih je v literaturi do sedaj opisanih manj kot 20 primerov. Prikaz bolnika. Predstavljamo bolnika z zasevkom primarnega raka repa trebušne slinavke v paratestikularnem tkivu. Pri 42-letnem bolniku z lokalno napredovalim rakom v repu trebušne slinavke smo intraoperativno odkrili jetrne zasevke, socasno pa tudi tumor v desni polovici mošnje, ki je ultrazvocno pripadal paratestikularnemu tkivu. S tankoigelno as­piracijsko biopsijo (TAB) je bila potrjena citološka diagnoza slabo diferenciiranega žleznega raka, ki je bila skladna z diagnozo primarnega raka v repu trebušne slinavke. Bolnika smo priceli zdraviti s kemoterapijo z gemcitabinom. Kljub temu smo že po enem mesecu ugo­tovili napredovanje bolezni in smo sistemsko zdravljenje prekinili. Zakljucki. Pricakovani potek bolezni pri bolnikih z žleznim rakom trebušne slinavke je zelo neugoden. Edino možno zdravljenje pri razširjeni obliki bolezni je sistemska terapija, vendar rezultati zdravljenja niso ohrabrujoci, kot kaže tudi opisani primer bolnika. Radio/ Oncol 2007; 41(1): I-VII. Radio/ Oncol 2007; 41(1): 41-l Analiticna raziskava lastnosti izo-NTCP ovojnice Stavrev P, Schinkel C, Stavreva N, Markov K, Fallone BG Izhodišca. V clanku smo raziskali lastnost prostora integralnega dozno-volumskega histo­grama (DVH). Krivuljo enake verjetnosti poškodbe zdravega tkiva [a-izo-NTCP (normal tis­sue complication probability)] smo oblikovali s povezovanjem tock, ki pripadajo intervalom vk stopnicastega integralnega DVH s pripadajoco dozo Dk in posledicnim NTCP z vrednostjo a. Podprostora, na katera krivulja razdeli DVH prostor, smo raziskali v smislu ekvivalentnih uniformnih doz (EUD), ki pripadajo razlicnim DVH-jem. Zakljucki. Teoreticno je dokazano, da ima vsak DVH, ki je razlicen od stopnicastega DVH in ki gre skozi tocko (Dk , vk) a-izo-NTCP ovojnice, NTCP > a. Iz cesar sledi, da vsakemu DVH, ki vsaj delno leži nad ovojnico, pripada NTCP > a. Nekaterim DVH, ki ležijo pod ovojnico, npr. se je dotikajo, prav tako pripada NTCP > a. Vendar je bilo numericno dokazano, da ima DVH, ki v celoti leži v spodnjem podprostoru, NTCP < a. Glede na slednje bi bilo v postopku optimizacije zdravljenja zaželeno iskati rešitve z DVH povsem pod izo-NTCP ovo­jnico in se izogibati tistim, ki ležijo nad njo. Radio/ Oncol 2007; 41(1): I-VII. Radio/ Oncol 2007; 41(1): 48-55. Uvedba protokola za izvedbo ofline popravkov pri nastavitvah: varnostne meje in število slik Kasabašic M, Faj D, Belaj N, Faj Z, Tomaš I Izhodišca. Na Oddelku za onkologijo in radioterapijo Univerzitetne bolnice v Osjeku smo proucili, kakšne so napake pri nastavitvi pacientov ob radioterapiji v obmocju medenice. Izsledke smo uporabili za izdelavo protokola korekcij nastavitev in za dolocitev varnostnih robov. Bolniki in metode. Natancnosti nastavitve smo preverjali z gamagrafijo. V študijo smo vkljucili 11 bolnikov, obdelali pa smo 420 slik. Napake pri nastavitvi smo dolocali z mer­itvijo razdalj med centrom polja in znacilnimi kostnimi tockami. Analizirali smo sistemske in nakljucne napake. Rezultati. Varnostni robovi, ki bi jih na našem oddelku morali upoštevati, so 11 mm v me­diolateralni smeri, 13 mm v kraniokaudalni in 14 mm v anterioposteriorni smeri. V offline korekcijskem protokolu smo upoštevali povprecje prvih štirih gamagrafij za popravke v medio-lateralni in kranio-kavdalni smeri ter povprecje petih slik za popravke v anterio-pos­teriorni smeri. Zakljucki. Natancnost nastavitve se med frakcijami ni bistveno spreminjala, razen pri enem bolniku. Tega bolnika je bilo posebno težko nastavljati zaradi njegovih let, debelosti in težav s kolkom. Odlocili smo se, da bomo takšne paciente odslej nastavljali brez podlag za trebuh (bellyboardov), na hrbet. Pri vseh ostalih bolnikih se natancnost nastavitve med frakcijami ni bistveno spreminjala. Za te smo uvedli offline nastavitveni protokol, pri katerem smo upoštevali povprecne napake pri prvih nekaj nastavitvah. Izracunali smo varnostne meje, za katere velja, da tarcni volumen z 90 % gotovostjo obsega vsaj 95 % predpisane doze. Varnostni robovi in variacije nastavitev kažejo, da je najnenatancnejše nastavljanje v ante­rioposteriorni smeri. Radio/ Oncol 2007; 41(1): I-VII. Notices Notices submitted for publication should contain a mailing address, phone and/ or fax number and/ or e-mail oj a Contact person or department. Oncology April 29 -May 3, 2007 The ESTRO teaching course "Molecular Oncology for the Radiation Oncologist" will take place in Estoril, Portugal. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiotherapy April 29 -May 3, 2007 The ESTRO teaching course "Dose Calculation and Verification for External Beam" will take place in Budapest, Hungary. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Brachytherapy May 10-12, 2007 The GEC-ESTRO brachytherapy meeting will take place in Montpellier, France. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Oncology May 12-14, 2007 The "lOth International Wolfsberg Meeting on Molecular Biology/Oncology" (in association with ESTRO) will take place in Wolfsberg, Germany. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Rectal cancer May 21-23, 2007 The ESTRO teaching course "Evidence and Research in Rectal Cancer" will take place in Rome, Italy. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiotherapy May 27-31, 2007 The ESTRO teaching course "Imaging for Target Volume Determination in Radiotherapy" will take place in Izmir, Turkey. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radio/ Oncol 2007; 41 (1): VII-XI. Radiobiology Oncology Jzme 3-7, 2007 The ESTRO teaching course "Basic Clinical Radiobiology (extra edition)" will take place in Beijing, China. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Oncology June 12-15, 2007 The EORTC annual course "Clinical Trials Statistics for Non Statisticians" will take place in Brussels, Belgium. Contact Mr. Danielle Zimmermann; EORTC Education Office, Avenue E. Mounier, 83, bte 11, B-1200 Brussels, Belgium; or call +32 2 774 16 02; or fax +32 2 772 61 33; or e-mail Danielle.zimmermann@eortc.be; or see http://www.eortc.be Oncology June 20-30, 2007 The 5th Central European Oncology Congress will take place in Opatia, Croatia. Contact Dr. Mirko Šamija; Central European Oncology Congress Secretariat, University Hospital for Tumors; !lica 197, 10000 Zagreb, Croatia; or call +385 1 3783 520; or fax +385 1 3775 536; or e-mail mirko.samija@kzt.hr; or see http://www.penta-zagreb.hr/CEOFC2007 Brachyradiotherapy June 24-26, 2007 The ESTRO teaching course "Brachyradiotherapy for Prostate Cancer" will take place in Prague, Czech Republic. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be July 5-8, 2007 The "ESMO Conference Lugano" will take place in Lugano, Switzerland. Contact ESMO Head Office, Congress Department, Via La Santa 7, CH-6962 Viganello-Lugano, Switzerland; or +41 (0)91 973 19 19; or fax +41 (0)91 973 19 18; or e-mail congress@esmo.org; or see http://www.esmo. org/activities/ecluconference/ Radiotherapy July 1-5, 2007 The ESTRO teaching course "IMRT and Other Conformal Techniques in Practice" will take place in Vienna, Austria. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiation oncology July 1-6, 2007 The ESTRO teaching course "Evidence Based Radiation Oncology: Methodological Basis & Clinical Application (extra edition)" will take place in Krakow, Polanci. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Toxicology July 15-19, 2007 The "11 th International Congress of Toxicology" will be offered in Montreal, Canada. Contact Congress Secretariat, e-mail: ict2007@nrc­cnrc.gc.ca; or see http://www.ict2007.org Radiotherapy August 22-25, 2007 The ESTRO teaching course "3D Planning and Imaging (special edition)" will take place in St Petersburg, Russia. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radio/ On col 2007; 41 (1): VII-XI. Gynaecology August 30 -September 1, 2007 The ESTRO teaching course "3D Image-based Brachytherapy in Gynaecological Malignancies" will take place in Copenhagen, Denmark. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Lungcancer September 2-6, 2007 The "12th World Conference on Lung Cancer" will be offered in Seoul, Korea. Contact Conference Secretariat; e-mail WCLC2007@ ncc.re.kr; or see http://www.iaslc.org1umages/ 12worldconfannounce.pdf Oncology September 7, 2007 The EORTC annual course "One-Day Introduction to EORTC Trials" will take place in Brussels, Belgium. Contact Mr. Danielle Zimmermann; EORTC Education Office, Avenue E. Mounier, 83, bte 11, B-1200 Brussels, Belgium; or call +32 2 774 16 02; or fax +32 2 772 61 33; or e-mail Danielle.zimmermann@eortc.be; or see http://www.eortc.be Radiotherapy September 8-13, 2007 The "9th Biennial ESTRO Meeting on physics and Radiation Technology for Clinical Radiotherapy will take place in Barcelona, Spain. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Oncology September 23-27, 2007 The "141h European Cancer Conference ECCO 15/ ESTRO 26" will take place in Barcelona, Spain. Contact Conference Secretariat, ECCO 14, The European Cancer Conference, European Cancer Societies (FECS), Avenue E. Mounier, 83, B--1200 Brussels, Belgium; or call +32 2 775 02 01; or fax +32 2 775 02 00; or e-mail ECC014@fecs.be; or see http://www.fecs.be Radio/ Oncol 2007; 41 (1): VII-XI. Radiotherapy September 30 -October 4, 2007 The ESTRO teaching course "Radiotherapy with Protons and Ions" will take place in Heidelberg, Germany. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiobiology October 14-18, 2007 The ESTRO teaching course "Basic Clinical radiobiol­ogy" will take place in Giardini Naxos, Italy. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiotherapy October21-25, 2007 The ESTRO teaching course "Physics for Clinical ra­diotherapy" will take place in Limassol, Cyprus. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiation oncology November 11-16, 2007 The ESTRO teaching course "Evidence Based Radiation Oncology: Methodological Basis & Clinical Application" will take place in Athens, Greece. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Prostate cancer November 15-17, 2007 The ESTRO multidisciplinary prostate cancer meeting will be offered. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiotherapy December 9-13, 2007 The ESTRO teaching course "Image-Guided Radiotherapy in Clinical Practice" will take place in Brussels, Belgium. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://wvvw.estro.be Lungcancer June 12-14, 2008 The "11 th Central European Lung Cancer Conference" will be offered in Ljubljana, Slovenia. Contact Conference secretariat, Ms. Ksenia Potocnik, Department of Thoracic Surgery, Medica! Centre Ljubljana, Slovenia; or call +386 1 522 2485; or fax +386 1 522 3968; or e-mail ksenia.potocnik @kclj.si; or see http://en.ce-lung2008.org/ Lung cancer August 21-24, 2009 The "13th World Conference on Lung Cancer" will be offered in San Francisco, USA. Contact Conference Secretariat; e-mail WCLC2007@ ncc.re.kr; or see http://www.iaslc.org!umages/ 12worldconfannounce.pdf Oncology September 4-8, 2009 The "34th ESMO Congress" will take place in Vienna, Austria. Contact ESMO Head Office, Congress Department, Via La Santa 7, CH-6962 Viganello-Lugano, Switzerland; or +41 (0)91 973 19 19; or fax +41 (0)91 973 19 18; or e­mail congress@esmo.org; or see http://www.esmo.org As a service to our readers, notices of meetings ar courses will be inserted free o f charge. Please send information to the Editorial office, Radiologi; and OncologtJ, Zaloška 2, SI-1000 Ljubljana, Slovenia. Radio/ Oncol 2007; 41(1): VII-XI. FUNDACIJA "DOCENT DR. J. CHOLEWA" JE NEPROFITNO, NEINSTITUCIONALNO IN NESTRANKARSKO ZDRUŽENJE POSAMEZNIKOV, USTANOV IN ORGANIZACIJ, KI ŽELIJO MATERIALNO SPODBUJATI IN POGLABLJATI RAZISKOVALNO DEJAVNOST V ONKOLOGIJI. DUNAJSKA 106 1000 LJUBLJANA ŽR: 02033-001 7879431 Activity of "Dr. J. Cholewa" Foundation for Cancer Research and Education -a report for the first quarter of 2007 The Dr. J. Cholewa Foundation for Cancer Research and Education plans to stay active in promoting all the forms of cancer education in general population, among medical and nursing students and among all the others in 2007. It will particularly focus its activities and attention to cancer research and education in Slovenia. The requests and proposals for research grants and scholarships will thus be dealt with great at­tention and responsibility, with the Foundation members with clinical and research experience in cancer and by members with important experience in finance being instrumental in this activity. As noted previously, the support for cancer research and education in various forms, financial and otherwise, remains the top priority of the Dr. J. Cholewa Foundation. A number research and study grants have been bestowed and allocated by the Foundation in 2006 and this will remain its core activity in 2007. The Foundation is continuing to pay special attention to the support of the publication of the results from cancer research in Slovenia in respectable international scientific journal worldwide. The Dr. J. Cholewa Foundation for Cancer Research and Education continues to support the regular publication of "Radiology and Oncology" international medical scientific journal in 2007. This journal is edited, published and printed in Ljubljana, Slovenia. This support is in line with the philosophy of the Foundation, emphasizing the spread of information and knowledge among many professionals in clinical and laboratory cancer research in Slovenia, but it also gives special attention to many in­terested individuals in lay public and others in Slovenia and elsewhere. The Dr. J. Cholewa Foundation for Cancer Research and Education once again respect­fully acknowledges the contribution of its members with clinical and research experi­ence in cancer and its members with important experience in finance. Without their efforts the Foundation would lack many of its qualities. Tomaž Benulic, MD Andrej Plesnicar, MD Borut Štabuc, MD, PhD SIEMENS S1emensMed1cal.com 'oncology SEEK-FIND-ACT-FOLLOW -the Continuum of Oncology Care™ Siemens oncology portfoho compr1ses comprehens1ve max1m1zed ut1hzat1on potent1al. and pauent-friendly des1gn workflow solut1ons 1ntegrat1ng the full spectrum of care and features from screening/early detect1on and d1agnos1s through therapy and follow-up AII from one prov1der -wllh over Every day 1n the Un1ted States alone. 29.000 cancer 100 years h1story of 1nnovat1on 111 medica! technology pat1ents rece1ve rad1at1on therapy dehvered by Siemens hnear accelerators As chn1cal protocols trans,t,on to Siemens proven chn1cal methods can help you to ach1eve include IMRT and IGRT. Siemens seamlessly 1nte91ates more successful outcomes How) Through 1ndustry­the d1agnost1c and treatment modaht1es That's what we lead1ng technology, increased product1v1ty measures tor call Best Practice Oncology Care Siemens medica 1 Solutions that help Sanolabor •.•:• k ii tt er man n • 1 Kottermann (Nemcija): laboratorijsko pohištvo, varnostne omare za kisline, luge, topila, pline in strupe, ventilacijska tehnika in digestorji Angelantoni scientifica (Italija): hladilna tehnika in aparati za laboratorije, transfuzijo, patologijo in sodno medicino CORNING Corning (Amerika): specialna laboratorijska plastika za aplikacijo v imunologiji, mikrobiologiji, virologiji, ipd., mehanske eno-in veckanalne pipete in nastavki Micronic (Nizozemska): sistemi za shranjevanje vzorcev, pipete, nastavki za pipete Tnwlanwch· Tben:'s No Reason to Operate with .yonc Elsc Implantech (Amerika): obrazni in glutealni vsadki Biomerica (Amerika): hitri testi za diagnostiko, EIA /RIA testi LABORMED d.o.o. Beži,grajski dvor P,eri,ceva 29, Ljubljana Tel.: (0)143649 01 Fax: (0)1 436 49 OS Ehret (Nemcija): Laminar flow tehnika, inkubatorji, sušilniki, suhi sterilizatorji in oprema za laboratorijsko vzrejo živali -kletke Dako (Danska): testi za aplikacijo v imunohistokemiji, patologiji, mikrobiologiji, virologiji, mono-in poliklonalna protitelesa FB Sakura finetek (Evropa): aparati za pripravo histoloških preparatov: mikro­inkriotomi, zalivalci, tkivni procesorji, barvalci, pokrivalci IBS/,%1ffin Integra Biosciens (Švica): laboratorijska oprema za mikrobiologijo, biologijo celic, molekularno biologijo in biotehnologijo SpectrumDesigns MEDICAL (Amerika): moški pektoralni vsadki Byron {Amerika): liposuktorji in kanile za liposukcijo ln fo@11 ob orm ed. s 11 w w w abormed,s Erbitux 2 mg/ml raztopina za infundiranje (skrajšana navodila za uporabo) Cetuksimab je monoklonsko lgGl protitelo, usmerjeno proti receptorju za epidermalni rastni faktor (EGFR). Terapevtske indikacije: Zdravilo Erbitux je v kombinirani terapiji z irinotekanom indicirano za zdravljenje bolnikov z metastatskim rakom debelega crevesa in danke, in sicer po neuspešni citotoksicni terapiji, ki je vkljucevala tudi irinotekan. Zdravilo Erbitux je v kombinaciji z radioterapijo indici rano za zdravljenje bolnikov z lokalno napredovalim rakom skvamoznih celic glave in vratu. Odmerjanje in nacin uporabe: Zdravilo Erbitux 2 mg/ml se daje z intravensko infuzijo prek linijskega filtra. Zdravilo Erbitux pri vseh indikacijah infundirajte enkrat na teden. Zacetni odmerek je 400 mg cetuksimaba/m' telesne površine, vsi naslednji tedenski odmerki so vsak po 250 mg/m'. Pred prvo infuzijo mora bolnik prejeti premedikacijo z antihistaminikom. Ta premedikacija je priporocljiva tudi pred vsemi naslednjimi infuzijami. Kontraindikacije: Zdravilo Erbitux je kontraindicirano pri bolnikih z znano hudo preobcutljivostno reakcijo (3. ali 4. stopnje) na cetuksimab. Pred zacetkom kombiniranega zdravljenja morate upoštevati kontraindikacije za irinotekan ali radioterapijo. Posebna opozorila in previdnostni ukrepi: ce pri bolniku nastopi blaga ali zmerna reakcija, povezana z infundiranjem, lahko zmanjšate hitrost infundiranja. Priporocljivo je, da ostane hitrost infundiranja na nižji vrednosti tudi pri vseh naslednjih infuzijah. Ce se pri bolniku pojavi huda kožna reakcija (:,_ 3. stopnje po kriterijih NCI CTC), morate prekiniti terapijo s cetuksimabom. Z zdravljenjem smete nadaljevati le, ce se je reakcija pomirila do 2. stopnje. Posebna previdnost je potrebna pri oslabljenih bolnikih in pri tistih z obstojeco srcno pljurno boleznijo. Neželeni ucinki: Zelo pogosti (:,_ 1/10): dispneja, blago do zmerno povecanje ravni jetrnih encimov, kožne reakcije, blage ali zmerne reakcije, povezane z infundiranjem, blag do zmeren mukozitis. Pogosti(:,_ 1/100, < 1/10): konjunktivitis, hude reakcije, povezane z infundiranjem. Pogostost ni znana: hipomagneziemija. Pakiranje: 1 viala po 50 ml. Imetnik dovoljenja za promet: Merek KGaA, 64271 Darmstadt, Nemcija. Podrobne informacije o zdravilu so objavljene na spletni strani Evropske agencije za zdravila (EMEA) http://www.emea.eu.int/ Dodatne informacije so vam na voljo pri: Merek, d.o.o., Dunajska cesta 119, 1000 Ljubljana, tel.: 01 560 3810, faks: 01 560 3831, el. pošta: info@merck.si 1 plošcatocelicni rak glave in vratu 1 2 v primerjavi z radioterapijo II 3 Bonner et al. Radiotherapy plus Cetuximab for Squamous Celi Carcinoma of the Head and Neck. N Engl J Med 2006; 354(6): 567 78 ',MERCK II www.oncology.merck.de 1 Temodal 20 mg; 100 mg, 250 mg. Sestava zdravila Vsaka kapsula zdravila Temodal vsebuje 20 mg, 100 mg ali 250 mg temozolamida.Terapevtske indikacije Temodal kapsule so indicirane za zdravljenje bolnikov z: -za zdravljenje novo diagnosticiranega glioblastoma multiforme, socasno z radioterapijo in kasneje kot monoterapija, -malignim gliomom, na primer multiformnim glioblastomom ali anaplasticnim astrocitomom, ki se po standardnem zdravljenju ponovi ali napreduje. Odmerjanje in nacir uporabe Temodal smejo predpisati le zdravniki, ki imajo izkušnje z zdravljenjem možganskih tumorjev. Odrasli bolniki z novo diagnosticiranim glioblastomom multi· forme Temodal se uporablja v kombinaciji z žarišcno radioterapijo (faza socasne terapije), temu pa sledi do 6 ciklov monoterapije z temozolomidom.Faza socasne tera­pije Zdravilo Temodal naj bolnik jemlje peroralno v odmerku 75 mg/m' na dan 42 dni, socasno z žarišcno radioterapijo (60 Gy, danih v 30 delnih odmerkih). Odmerk, ne boste zmanjševali, vendar se boste vsak teden odlocili o morebitni odložitvi jemanja temozolomida ali njegovi ukinitvi na podlagi kriterijev hematološke ir. nehematološke toksicnosti. Zdravilo Temodal lahko bolnik jemlje ves cas 42-dnevnega obdobja socasne terapije do 49 dni, ce so izpolnjeni vsi od naslednjih pogojev. absolutno število nevtrofilcev ? 1,5 x 109/1, število trombocitov ? 100 x 109/1, skupni kriteriji toksicnosti (SKT) za nehematološko toksicn_ost :5 1. stopnje (z izjeme alopecije, slabosti in bruhanja). Med zdravljenjem morate pri bolniku enkrat na teden pregledati celotno krvno sliko. Faza monoterapije Stiri tedne po zakljucku faze socasnega zdravljenja z zdravilom Temodal in radioterapijo naj bolnik jemlje zdravilo Temodal do 6 ciklov monoterapije. V 1. ciklu (monoterapija) je odmerek zdravila 150 mg/m' enkrat na dan 5 dni, temu pa naj sledi 23 dni brez terapije. Na zacetku 2. cikla odmerek poveca.e na 200 mg/m', ce je SKT za nehematološko toksicnost za 1. cikel stopnje :5 2 (z izjemo alopecije, slabosti in bruhanja), absolutno število nevtrofilcev (AŠN) ? 1,5 x 109/1 in število trombocitov? 100 x 109/1. ce odmerka niste pov­ecali v 2. ciklusu, ga v naslednjih ciklusih ne smete povecevati. Ko pa odmerek enkrat povecate, naj ostane na ravni 200 mg/m' na dan v prvih 5 dneh vsakega nasled­njega ciklusa, razen ce nastopi toksicnost. Med zdravljenjem morate pregledati celotno krvno sliko na 22. dan (21 dni po prvem odmerku zdravila Temodal). Ponavljajoci se ali napredujoci maligni gliom: Odrasli bolniki Posamezen ciklus zdravljenja traja 28 dni. Bolniki, ki še niso bili zdravljeni s kemoterapijo, naj jemljejo Temodal pero­ralno v odmerku 200 mg/m' enkrat na dan prvih 5 dni, temu pa naj sledi 23-dnevni premor (skupaj 28 dni). Pri bolnikih, ki so že bili zdravljeni s kemoterapijo, je zacetni odmerek 150 mg/m2 enkrat na dan, v drugem ciklusu pa se poveca na 200 mg/m' enkrat na dan 5 dni, ce ni bilo hematoloških toksicnih ucinkov. Pediatricni bolniki Pri bolnikih, starih 3 leta ali starejših, posamezen ciklus zdravljenja traja 28 dni. Temodal naj jemljejo peroralno v odmerku 200 mg/m2 enkrat na dan prvih 5 dni, potem pa naj sledi 23-dnevni premor (skupaj 28 dni). Otroci, ki so že bili zdravljeni s kemoterapijo, naj prejmejo zacetni odmerek 150 mg/m' enkrat na dan 5 dni, s povecanjem na 200 mg/m' enkrat na dan 5 dni v naslednjem ciklusu, ce ni bilo hematoloških toksicnih ucinkov. Bolniki z motnjami v delovanju jeter ali ledvic Pri bolnikih z blagimi ali zmernimi motnjami v delovanju jeter je farmakokinetika temozolomida podobna kot pri tistih z normalnim delovanjem jeter. Podatki o uporabi zdravila Temodal pri bolnikih s hudimi motnjami v delovanju jeter (razred III po Child-u) ali motnjami v delovanju ledvic niso na voljo. Na podlagi farmakokineticnih last­nosti temozolomida obstaja majhna verjetnost, da bo pri bolnikih s hudimi motnjami v delovanju jeter ali ledvic potrebno zmanjšanje odmerka zdravila. Kljub temu je potrebna previdnost pri uporabi zdravila Temodal pri teh bolnikih. Starejši bolniki Analiza farmakokinetike je pokazala, da starost ne vpliva na ocistek temozolomida. Kljub temu je potrebna posebna previdnost pri uporabi zdravila Temodal pri starejših bolnikih. Nacin uporabe Temodal mora bolnik jemati na tešce. Temodal kapsule mora bolnik pogoltniti cele s kozarcem vode in jih ne sme odpirati ali žveciti. Predpisani odmerek mora vzeti v obliki najmanjšega možnega števila kapsul. Pred jemanjem zdravila Temodal ali po njem lahko bolnik vzame antiemetik. ce po zaužitju odmerka bruha, ne sme še isti dan vzeti drugega odmerka. Kontraindikacije Temodal je kontraindiciran pri bolnikih, ki imajo v anamnezi preobcutljivostne reakcije na sestavine zdravila ali na dakarbazin (DTIC). Temodal je kontraindiciran tudi pri bolnikih s hudo mielosupresijo. Temodal je kontraindiciran pri ženskah, ki so nosece ali dojijo. Posebna opozorila in previdnostni ukrepi Pilotno preskušanje podaljšane 42-dnevne sheme zdravljenja je pokazalo, da imajo bolniki, ki so socasno prejemali zdravilo Temodal in radioterapijo, še posebej veliko tveganje za nastanek pljucnice zaradi okužbe s Pneumocystis carinii (PCP). Profilaksa proti tovrstni pljucnici je torej potrebna pri vseh bolnikih, ki socasno prejemajo zdravilo Temodal in radioterapijo v okviru 42-dnevne sheme zdravljenja (do najvec 49 dni), ne glede na število limfocitov. ce nastopi limfopenija, mora bolnik nadaljevati s profilakso, dokler se limfopenija ne povrne n, stopnjo < 1. Antiemeticna terapija: Z jemanjem zdravila Temodal sta zelo pogosto povezana slabost in bruhanje. Laboratorijske vrednosti Pred jemanjem zdravil, 11orata liTti izpolnjena naslednja pogoja za laboratorijske izvide: ANC mora biti ? 1,5 x 109/1 in število trombocitov ? 100 x 109/1. Na 22. dan (21 dni po prvem odmerku; ali v roku 48 ur od navedenega dne, morate pregledati celotno krvno sliko in jo nato spremljati vsak teden, dokler ni ANC nad 1,5 x 10'/1 in število trombocitov nad 1 OC < 109/1. ce med katerimkoli ciklusom ANC pade na < 1,0 x 109/1 ali število trombocitov na < 50 x 109/1, morate odmerek zdravila v naslednjem ciklusu zmanjšati za ene, Jdmerno stopnjo. Odmerne stopnje so 100 mg/m', 150 mg/m' in 200 mg/m2 • Najmanjši priporoceni odmerek je 100 mg/m2 • Moški bolniki Temozolomid lahko deluj, Jenotoksicno, zato morate moškim, ki se zdravijo z temozolomidom svetovati, da naj ne zaplodijo otroka še šest mesecev po zdravljenju. Interakcije Socasna uporaba 1dravila Temodal in ranitidina ni povzrocila spremembe obsega absorpcije temozolomida ali monometiltriazenoimidazol karboksamida (MTIC). Jemanje zdravila Temodal s hrano je povzrocilo 33 % zmanjšanje Cmax in 9 % zmanjšanje površino pod krivuljo (AUC). Ker ne moremo izkljuciti možnosti, da bi bila sprememba Cmax lahko ,linicno pomembna, naj bolniki jemljejo zdravilo Temodal brez hrane. Analiza populacijske farmakokinetike v preskušanjih druge faze je pokazala, da socasna uporaba jeksametazona, proklorperazina, fenitoina, karbamazepina, ondansetrona, antagonistov receptorjev H2 ali fenobarbitala ne spremeni ocistka temozolomida. Socasno emanje z valprojsko kislino je bilo povezano z majhnim, a statisticno znacilnim zmanjšanjem ocistka temozolomida. Uporaba zdravila Temodal v kombinaciji z drugimi 11ielosupresivnimi ucinkovinami lahko poveca verjetnost mielosupresije. Nosecnost študij na nosecih ženskah ni bilo. Predklinicne študije na podganah in kuncih z Jdmerkom 150 mg/m2 so pokazale teratogenost in/ali toksicnost za plod. Zato naj nosece ženske naceloma ne bi jemale zdravila Temodal. ce pa je uporaba v casu 1osecnosti nujna, morate bolnico opozoriti na možne nevarnosti zdravila za plod. ženskam v rodni dobi svetujte, naj med zdravljenjem z zdravilom Temodal preprecijo 1anositev. Dojenje Ni znano, ali se temozolomid izloca v materino mleko, zato ženske, ki dojijo, ne smejo jemati zdravila Temodal. Neželeni ucinki V klinicnih preskušanjih so bili najpogostnejši neželeni ucinki, povezani z zdravljenjem, prebavne motnje, natancneje slabost (43 %) in bruhanje (36 %). Oba ucinka sta bila ponavadi 1. ali 2. stopnje (od O do 5 epizod bruhanja v 24 urah) in sta prenehala sama ali pa ju je bilo mogoce hitro obvladati s standardnim antiemeticnim zdravljenjem. lncidenca hude sla­Josti in bruhanja je bila 4 %. Laboratorijski izvidi: Trombocitopenija in nevtropenija 3. in. 4. stopnje sta se pojavili pri 19 % in 17 % bolnikov, zdravljenih zaradi malignega Jlioma. Zaradi njiju je bila potrebna hospitalizacija in/ali prekinitev zdravljenja z zdravilom Temodal pri 8 % in. 4 % bolnikov. Mielosupresija je bila predvidljiva (ponavadi ,e je pojavila v prvih nekaj ciklusih in je bila najizrazitejša med 21. in 28. dnem), okrevanje pa je bilo hitro, ponavadi v 1 do 2 tednih. Opazili niso nobenih dokazov ,umulativne mielosupresije. Trombocitopenija lahko poveca tveganje za pojav krvavitev, nevtropenija ali levkopenija pa tveganje za okužbe.Imetnik dovoljenja za pro­met SP Europe 73, rue de Stalle B-1180, Bruselj, Belgija. Nacin in režim izdaje Zdravilo se izdaja samo na recept, uporablja pa se pod posebnim nadzorom zdravnika ,pecialista ali od njega pooblašcenega zdravnika. Oatum priprave informacije januar 2006 Podrobnejše informacije o zdravilu Temodal dobite na sedežu podjetja. bu.jsl ULN in/ali ALT in AST > 3,5-kratno ULN ter hkrati alkalno fosfatazo > 6-kratno ULN, ni mogoce priporociti zmanjšanja odmerka; pri teh bolnikih se docetaksela ne sme uporabljati, ce ni strogo indiciran. Otroci in mladostniki: Izkušnje pri otrocih in mladostnikih so omejene. Starostniki: Za uporabo pri starostnikih glede na analizo farmakokinetike na populaciji ni posebnih navodil. K2ntnllruti.ki!ci. Preobcutljivost za zdravilno ucinkovino ali katerokoli pomožno snov. Docetakse!a se ne sme uporabljati pri bolnikih z izhodišcnim številom nevtrofilcev < 1.500 ce!ic/mm3• Docetaksela ne smejo dobivati nosecnice in dojece ženske. Docetakse!a se ne sme uporabljati pri bolnikih s hudo okvaro jeter. Ce se v kombinaciji z docetakselom uporabljajo še druga nevtropenija. Vsem bolnikom, ki prejemajo docetakse!, je treba pogosto pregledovati celotno krvno sliko. Preobcutljlvostne reakcije: Bolnike je treba skrbno opazovati glede preobcutljivostnih reakcij, zlasti med prvim in drugim infundiranjem. Preobcut!jivostne reakcije se lahko pojavijo v nekaj minutah po zacetku infundiranja docetaksela. Kožne reakcije: Na udih {dlaneh in podplatih) so opažali lokalen kožni eritem z edemi in poznejšo deskvamacijo. Zastajanje tekocine: Bolnike s hudim zastajanjem tekocine, npr. s plevralnim izlivom, perikardlalnim izlivom ali ascitesom, je treba skrbno nadzorovati. tivcevfe: ce se pojavijo hudi periferni nevrotoksicni ucinki, je treba odmerek zmanjšati. Kardiotoksicnost: Pri bolnicah, ki so prejemale TAXOTERE v kombinaciji s trastuzumabom so opazovali srcno popušcanje, še posebno, ce je zdravljenje sledilo kemoterapij! z antraciklinom. Drugo: Med zdravljenjem in vsaj še tri mesece po njegovem koncu je treba uporabljati kontracepcijsko zašcito. Medsebojno d._ftlQvanje z drugimi zdravili in druge oblike intera_kgjj; študije in vitro so pokazale, da lahko presnovo docetakse!a spremeni socasna uporaba zdravil, ki inducirajo ali inhibirajo citokrom P450-3A ali se z njim presnavljajo {in ga tako lahko kompetitivno inhibirajo). Nosecnost in dojenje.;Ženskam v rodni dobi, ki dobivajo docetakse!, je treba odsvetovati nosecnost; ce zanosijo, morajo o tem takoj obvestiti Jececega zdravnika. Zaradi možnih neželenih ucinkov na dojencke je treba dojenje med zdravljenjem z docetakselom prekiniti. Neželeni ucinki:Napogosteje opisani neželeni ucinki na sam TAXOTEAE so: nevtropenija, anemija, a!opecija, navzea, bruhanje, stomatitis, driska in astenija. Zelo pogosti neželeni ucinki glede na razlicne režime dajanja so: TAXOTERE 100 mglrrlv monoterapiji: okužbe, nevtropenija, anemija, lebrilna nevtropenija, preobcutljivost, anoreksija, periferna senzoricna nevtropatija, periferna motoricna nevtropatija, dizgevzija, dispneja, stomatitis, driska, navzea, bruhanje, alopecija, kožna reakc ja, spremembe nohtov, miafg ja, zastajanje tekocine, astenija, bolecine. TAXOTERE 75 mg!m2monoterapiji: okužbe, nevtropenija, anemija, trombocitopenija, anoreksija, periferna senzoricna nevropatja, navzea, stomatitis, bruhanje, driska, atopecija, kožna reakcija, astenija, zastajanje tekocine, bolecine. TAXOTERE 75 mglrrlv kombinaciji z doksorubicinom: okužba, nevtropenija, anemija, febrilna nevtropenija, trombocitopenija, periferna senzoricna nevropatija, navzea, stomatitis, driska, bruhanje, zaprtje, alopecija, spremembe nohtov, kožna reakcija, astenija, zastajanje tekocine, bolecine. T AXOTERE 75 mglrrl v kombinaciji s cisplatinom: okužba, nevtropenija, anemija, trombocitopenija, preobcutljivost, anoreksija, periferna senzoricna nevropatija, periferna motoricna nevropatija, navzea, bruhanje, driska, stomatitis, alopecija, spremembe nohtov, kožna reakcija, mia!gija, astenija, zastajanje tekocine, zvišana telesna temperatura. TAXOTERE 100 mglrrl v kombinaciji s trastuzumabom: nevtropenija, febrilna nevtropenlja ali nevtropenicna sepsa, anoreksija, nespecnost, parestezije, glavobol, dizgevztja, hipestezija, mocnejše solzenje, konjunktivitis, limfedem, epistaksa, faringo-laringea!na bolecina, nazofaringitis, dispneja, kaše j, rinoreja, navzea, driska, bruhanje, zaprtje, stomatitis, dispepsija, bolecine v trebuhu, a!opecija, erilem, izpušcaj, spremembe nohtov, mialgja, iartralgija, bolecine v udih, bolecine v kosteh, bolecine v hrbtu, astenija, periferni edemi, pireksija, utrujenost, vnetje sluznice, bolecine, gripi podobna bolezen, bolecine v prsih, mrzlica, povecanje telesne mase. TAXOTERE 75 mg/rrlv kombinaciji s kapecitabinom: nevtropenija, anemija, roka/noga sindrom, alopecija, spremembe nohtov, stomatltis, driska, navzea, bruhanje, zaprtje, bolecine v trebuhu, dispepsija, dizgevzija, parestezije, anoreksija, zmanjšan apetit, mocnejše solzenje, mialgija, artralgija, faringo•laringealna bolecina, astenija, pireksija, utrujenost/šibkost, periferni edemi. TAXOTERE 75 mglrrl v kombinaciji s prednizonom ali prednizolonom: okužba, nevtropenija, anemija, anoreksija, periferna senzoricna nevropatija, dizgevzija, navzea, driska, stomatitis/faringitis, bruhanje, a!opecija, spremembe nohtov, utrujenost, zastajanje tekocine. TAXOTERE 75 mglrrl v kombinaciji z doksorubicinom in ciklofosfamidom: okužba, nevtropenicna okužba, anemija, nevtropenija, trombocitopenija, febrilna nevtropenija, preobcutljivost, anoreksija, dizgevzija, periferna senzoricna nevropatija, vazodi!atacija, navzea, stomatitis, bruhanje, driska, zaprtje, alopecija, toksicni ucinki na koži, spremembe 0 nohtov, mialgija, artra!gija, amenoreja, astenija, zvišana telesna temperatura, periferni edemi, povecanje ali zmanjšanje telesne mase. TAXOTERE 75 mglrrlv kombinaciji s cispfatinom in 5-fluorouracilom . za adenokarcinom želodca: nevtropenicna okužba, okužba, anem ja, nevtropenija, trombocitopenja, febrilna nevtropenija, preobcutljivost, anoreksija, periferna senzoricna nevropatija, driska, navzea, it3 stomatitis, bruhanje, a!opecija, letargija, zvišana telesna temperatura, zastajanje tekocine. TAXOTERE 75 mglrrl v kombinaciji s cispfatinom in 5-ffuorouracilom {za rak glave in vratu): infekcija, nevtropenicna g infekcija, nevtropenija, anemija, trombocitopenija, anoreksija, dizgevzja/parozmija, periferna senzoricna nevropatija, letargija, navzea, stomatitis, diareja, bruhanje, alopecija, pireksija, retenca tekocine, q edem. Za ostale neželene ucinke prosimo glejte celoten povzetek glavnih znacilnosti zdravila. Nacin izdajanja zdravila: Izdaja zdravila je le na recept. Ime in naslov imetnika dovoljenja za promet z u3 zdravilom:Aventis Pharma S. A., 20 avenue Raymond Aron, 92165 Antony Cedex, Francija. Zadnji pregled besedila:12.01.2007 (docetaksel) Pred predpisovanjem, prosimo, preberite celoten povzetek glavnih sanofi aventis znacilnosti zdravila, ki ga dobite pri naših strokovnih sodelavcih. Podrobnejše informaciJe so na voljo pri: sanofi-aventis d.o.o, zaupa!M v ŽiVlfenje Dunajska cesta 119, 1000 Ljubljana, tel.: 01 560 48 00, lax: 01 560 48 46 Ker je 1. 1) slab!e odzivajo na zdranlo in pn njih tudi pogosteje opalamo zaplete, kot so zvl!ana tele sna temperatura, okužbe in sepsa. Pomembno je, da se bolnikovo telesno stanje ob zaletku zdravljenja natanlno oceni i zagotovi, da se ne poslab!a na l. Z uporabo topotekana za zdravljenje bolnikov s hudimi motnjami delovanja ledvic (.e kreatinlna < 20 ml/min) ali s hudo okvaro jetrne funkcije, ki je .edlca ciroze (serumski bilirubin . 10 mg/dl), nima lzku!enj. Pri teh skupinah bolnikov zdravljenje I topotekanom ni priporolljivo. le manjle ltenlo bolnikov z jetrno okvar (vredn. serumskega bilirubina med 1,5 In 10 mg/dl) Je prejelo odmerek 1,5 mg/m'po5 dni na vsake tri tedne. Pri tem opazili manjll .ek topotekana. Vseeno za sedaj nimamo na voljo zadostne kollline podatkov, da bi pnporolill odmere za to skupino bolnikov. Medsebojno dtlovanj• z drugimi zdranll In druge oblik• Interakcij Topotekan ne zavi endmo, aovelkega dtokroma P410. V popu@d.ki !tudi ji niso za.edill, da bi solasno dajanje granisetrona, ondansetron morfina ali konikosteroldov pomembneje vplivalo na farmakokinetiko celokupnega topotekana (aktivne in neaktivne ob like). Pri socasni uporabi topotekana z drugimi kemoterape,tiki je zaradi bolj!ega prenalanja potrebno zmanj!ati odmere vsakega zdravila. Pri socasni uporabi s p.tlnoviml spojinami pride do izrazite Interakcije, ki je odvisna od zaporedja dajanj zdravil, in sicer od tega ali damo pripiavek s p.tlno na 1. ali l. dan dajanja topotekana. (e dajemo dsplatin ali karboplati na 1. dan dajanja topotekana, je potrebno zaradi bolj!ega prena!anja zmanj!ati odmerek teh zdravil v primerjavi z odmerki ki jih .hko dajemo, kadar damo p.tinove spojine na S. dan uporabe topotekana. HOHlnost In dojenje Topotekan j med nosecnostjo kontralndidran. Predkiinllne raziskave so pokazale, da uporaba topotekana povzrola smn In deformacij zarodka oziroma ploda. lenskam je potrebno svetovati, da med zdravljenjem s topotekanom ne smejo zanositi, v prime zanositve pa naj o tem takoj ob.ljo zdravnika. Topotekan je med dojenjem kontraindkiran. Hdtlenl uanki Zelo po g.i: nevtropenija s socasno povl!ano telesno temperaturo, nevtropenlja, trombocrtopenlja, anemija, levkopenija, anorek sija, mukozitis, navzea, bruhanje, d.reja. zapnje, abdominalna bolelina, alopedja, zvl!ana telesna temperatura, anenlja utrujenost .r. preoblutlj.na reakcija, vkljulno z lzpullajem, hlperblllrublnemlja, pruntus, obluteks@bostl. V ovojnine In vsebina HYCAMTIH 4 mg je na voljo v !lcatlah z 1 vial. Naan uporabe Topotekan se sme uporabljati le .novah, ki so specializirane za uporabo crtotoksllnih kernoterape,tikov. Uporaba zdravi. naj vedno poteka pod nad rom zdravnika z izku!njaml na podrolju kemoterapije. Datum priprave lnfonnadje: Februar 1007 Pred piedpisovanjem, prosimo, preberite celoten povzetek temeljnih znaalnosti zdra..­ llteratura: 1 long H J 3rd etaLJOlnOncol 200S; ll (11):4616-4633 Dodatne informacije so vam na voljo pri: GSK d.o.o., ljubljana, Knezov štradon 90, 1001 ljubljana ź rimidex anastrozol Kratka Informacija o zdravilu Ime zdravila Arimidex 1 mg filmsko obložene tablete Sestava Ena tableta vsebuje 1 mg anastrozola. Indikacije Adjuvantno zdravljenje žensk po menopavzi, ki imajo zgodnji invazivni rak dojke s pozitivnimi estrogenskimi receptorji. Zdravljenje napredo­valega raka dojke pri ženskah po menopavzi. Ucinkovitost pri bolnicah z negativnimi estrogenskimi receptorji ni bila dokazana razen pri tistih, ki so imele predhodno pozitiven klinicni odgovor na tamoksifen. Odmerjanje In nacin uporabe 1 tableta po 1 mg peroralno, enkrat na dan. Pri zgodnjem raku je priporocljivo trajanje zdravljenja 5 let. Kontraindikacije Arimidexje kontraindiciran pri: ženskah pred menopavzo, nosecnicah in dojecih materah, bolnicah s hujšo ledvicno odpovedjo (ocistek kreatinina manj kot 20 ml/min (oziroma 0,33 ml/s)), bolnicah z zmernim do hudim jetrnim obolenjem, bolnicah, ki imajo znano preobcutljivost za anastrozol ali za katerokoli drugo sestavino zdravila. Posebna opozorila In previdnostni ukrepi Menopavzo je potrebno biokemicno dolociti pri vseh bolnicah, kjer obstaja dvom o hormonskem statusu. Ni podatkov o varni uporabi Arimidexa pri bolnicah z zmerno ali hudo jetrno okvaro ali hujšo ledvicno odpovedjo (ocistek kreatinina manj kakor 20 ml/min (oziroma 0,33 ml/s)). Pri ženskah z osteoporozo ali pri ženskah s povecanim tveganjem za razvoj osteoporoze je treba dolociti njihovo mineralno gostoto kosti z denzitometrijo, na primer s slikanjem DEXA na zacetku zdravljenja, pozneje pa v rednih intervalih. Po potrebi je treba zaceti z zdravljenjem ali preprecevanjem osteoporoze in to skrbno nadzorovati. Povzetek glavnih neželenih ucinkov Zelo pogosti (;,; 10 %): navali vrocine, obicajno blagi do zmerni Pogosti (;,; 1 % in < 10 %): astenija, bolecine / okorelost v sklepih, suhost vagine, razredcenje las, izpušcaji, slabost, diareja, glavobol (vsi obicajno blagi do zmerni) Arimidex znižuje nivo estrogena v obtoku, zato lahko povzroci zmanjšanje mineralne kostne gostote, kar pomeni za nekatere bolnike zvecano tveganje za zlome. Medsebojno delovanje z drugimi zdravili Zdravila, ki vsebujejo estrogen, ne smete dajati socasno z Arimidexom, ker bi se njegovo farmakološko delovanje iznicilo. Tamoksifena se ne sme uporabljati skupaj z Arimidexom, ker lahko pride do zmanjšanja njegovega delovanja. Režim Izdajanja zdravila Rp/Spec Datum priprave informacije Februar 2007 Pred predpisovanjem, prosimo, preberite celoten povzetek glavnih znacilnosti zdravila. Dodatne informacije in literatura so na voljo pri: AstraZeneca UK Llmlted Podružnica v Sloveniji Verovškova 55, Ljubljana in na spletnih straneh: www.breastcancersource.com www.arlmldex.net AstraZeneca POVZETEK GLAVNIH ZNACILNOSTI ZDRAVILA transderma!ne obliže hranite nedosegjive otrokom. Obližev ne smete razdeliti, razrezati ali na kakršenkoli l Fentanil Lek 25, 50 in 100 mikrogramih transdermalni obliži SESTAVA: t transdermalnl obliž vsebuje na in poškodovati. Fentanil lahko povzroci znatno respiratorno depresijo. Fentanil Lek je treba previdno dajati: 2,5 mg, 5,0 mg ali 10,0 mg fentanila. TERAPEVTSKE INDIKACIJE: Kronicne bolecine, pri katerih je bolnikomskronicnopjucnoebo!eznijo,povišanimeintrakranialnimetlakom,možganskimetumorjem,eboleznim!srca, l potrebno zdravljenje z opioidnimi analgetiki. ODMERJANJE IN NACIN UPORABE: Odmerek zdravila jeter in ledvic, tistim z zvišano telesno temperaturo, pri starejših bolnikih, bolnikih z miastenijo gravis. Od11isnos1 prilagodite posameznim bolnikom in po vsaki uporabi ovrednotite njegov ucinek. /.zbira .zacetnega odmerka. od .zdravita: Aol posledica ponavljajoce se uporabe se lahko razvijeta toleranca za ucinkovino ter psiho!oška višina odmerka naj temelji na predhodni uporabi opioidov. Pri bolnikih, ki nimajo izkušenj z opioidi in ki ir\lali fizi na odvisnost od nje. Drug1'. lahko se pojavijo neepilepticne (mio)klonicne reakcije. MEDSEBOJNO opioidov predhodno niso jemali, zacetni odmerek ne sme presegali 25 ”g.,tl. Predhodnega zdravljenja z DELOVANJE Z DRUGIM ZDRAVILI IN DRUGE OBLIKE INTERAKCIJ:. Opioidi, sedativi, hipnotiki, splošni analgetiki ne smete prekiniti prej kot v t 2 urah po name sli Ivi prvega transdermalnega obliža. Dolocitev anestetiki, fenotiazini, anksiolitiki, sredstva za sprošcanje mišic, sedativni antihistaminiki in alkoholne pijace, velikosti odmerka in vzdrževalnega odmerka. Transdermalne obliže menjajte v 72-urnih presledkih. Odmerek titrirajte, dokler ne dosežete analgeticnega ucinka. ce je analgeticni ucinek ob koncu zacetnega obdobja uporabe neustrezen, lahko odmerek povecujete v tridnevnih presledkih do želenega ucinka. Prehod na drugo .zdravljenje alipn>nellanje .zdravljenja. ce želite preiti na zdravljenje z drugim opioidom, odstranite transdermalni obliž Fenlanil Lek in titrirajte odmerek novega analgetika glede na bolnikovo porocanje o bolecini, dokler ne dosežete ustreznega analgeticnega ucinka. Pri nekaterih bolnikih se lahko pojavijo odtegnitveni simptomi. Uporaba pri otrocih. Zaradi jakosli odmerkov tega zdravila se uporaba pri otrocih ne priporoca. Uporaba pri slare/ših. pri starejših bolnikih je treba biti pozoren na znake prevelikega odmerjanja in odmerek po potrebi zmanjšati. Uporaba pri bolnikih .z o,hgro ledvic alijeler. pri teh bolnikih je treba biti pozoren na znake prevelikega odmerjanja in odmerek po potrebi zmanjšati. Uporaba pri bolnikih s povišano telesno temperaturo. med epizodami povišane telesne temperature bo morda potrebno prilagajanje odmerka. KONTRAINDIKACIJE: Znana preobcutljivost za fentanil, katerokoli pomožno snov ali lepilo transdermalnega obliža. Hudo okvarjeno delovanje osrednjega živcevja. Socasna uporaba zaviralcev MAO ali uporaba v 14 dneh po prenehanju zdravljenja z zaviralci MAO. POSEBNA OPOZORILA IN PREVIDNOSTNI UKREPI: Zaradi razpolovnega casa fentanila morate bolnika po pojavu resnega neželenega ucinka nadzorovati še 24 ur po odstranitvi transdermalnega obliža. Uporabljene in neuporabljene ritonavir, ketokonazol, itrakonazol in nekateri makrolidni antibiotiki, petidin in zaviralci monoaminske oksidaze (npr. tranilcipromin), pentazocin, buprenortin. VPLIV NA SPOSOBNOST VOŽNJE IN UPRAVLJANJA S STROJI: Zdravilo ima mocan ucinek na sposobnost za vožnjo in upravljanje strojev. Bolniki naj se o tem, ali smejo voziti in upravljati stroje, posvetujejo z zdravnikom. NEŽELENI UCINKI: Najresnejši neželeni ucinek fenlanila je respiratorna depresija. Zelo pogosti (> 1/10): zaspanost, glavobol, navzeja, bruhanje, zaprtje, potenje, pruritus. Pogosti(> 1/100, < 1/10): sedacija, zmedenost, depresija, tesnoba, živcnost, halucinacije, zmanjšan apetit, kserostomija, dispepsija, kožne reakcije na mestu uporabe. Obcasni(> 1/1000, < 1/100): evforija, amneZlja, nespecnost, razdražljivost, tre mor, paresteZlja, motnje govora, bradikardija, tahikardija, hipotenzija, hipertenzija, dispneja, hipoventilacija, hemoptiza, pulmonalna kongestija in faringitis, driska, izpušcaji, eritem, zadrževanje urina. Preobcutjivoslne reakcy8. anafilakticne reakcije, laringospazem. Drog, neželeni ucinki: pri dolgotrajni uporabi se lahko razvijeta toleranca in psihicna ali fiziološka odvisnost. Pri nekaterih bolniklh, ki z drugega opioidnega analgetika preidejo na transdermalne obliže Fentanil Lek, se lahko pojavijo reakcije, znacilne za prekinitev zdravljenja z opioidi. NACIN IZDAJE ZDRAVILA: Na zdravniški recept. OPREMA: Škatlice s 5 transdermalnimi obliži po 25, 50 in 100 mikrogramov/h. IMETNIK DOVOLJENJA ZA PROMET Z ZDRAVILOM: Lek farmacevtska družba d.d., Verovškova 57, Ljubljana, Slovenija. INFORMACIJA PRIPRAVLJENA: oktober 2006 @lek r.l::in i:;kuninP. S::inrln7 IP.t r;::i?Vni;::i UKRC 2007 -Advances in Technology UKRC 2007 should prove to be one of the most stimulating congresses to date in terms of the scien­tific coverage of new and developing fields within medica! imaging. Key sessions will build on the !at­est technology being presented within the technical exhibition, providing a unique multi-disciplinary forum to exchange ideas about the !atest developments in technology which will impact on radiology and clinical applications. Monday sees a revisit to a very popular session from 2006 on image perception, featuring an inter­national cast from Europe and the USA, a key update on radiation protection and x-ray equipment per­formance issues, including Dr. Walter Huda from the USA presenting a new paradigm for CT dosim­etry. This first day also involves a look at new emerging imaging techniques such as PET/MR systems and what promises to be a very poignant debate, hosted by Prof. Mike Smith and Dr. Giles Maskell, on whether advances in technology will render the radiologists and radiographer redundant. Tuesday morning has a session on the !atest advances in cartilage imaging and two sessions on developments in MR imaging, incorporating presentations on blood pool agents by Dr. Giles Roditi, molecular MRI by Dr. Arne Hengerer from Erlangen and MR elasticity imaging by Dr. Ralph Sinkus from Paris. The afternoon covers quantitative imaging applications in medicine and a key session on CT with Prof. Mathias Prokop from Utrecht addressing the future role of multi slice CT, dual source CT described by Prof. Thomas Flohr from Erlangen, and 256 slice CT systems from Toshiba. The pace fails to slow down for the fina! day on Wednesday, so it' s best not to have too late a night at Tiger-Tiger on the Tuesday night! The scientific sessions involve a look at interactive imaging applica­tions for surgery, including interventional MR, stereotaxy in neurosurgery and surgical robotics along with a constantly topical look at the changing face of cardiac CT. The afternoon sees a CT teaching course for radiographers, clinicians, and scientists with everything you need to know about physics, technology, image quality and patient dose. The advances in technology sessions provide a unique opportunity to view and appreciate develop­ing areas of radiology from a truly multi-disciplinary standpoint. Where else could you meet colleagues of ali disciplines and enjoy stimulating presentations from clinicians, scientists and radiographers; not to mention surgeons and cardiologists? Be there in Manchester or be disappointed! Best wishes, Mr Andrew Jones Vice President, UKRC Advances in Technology UKRC 2007 Organisers PO Box 2895 London W1A 5RS Tei: +44(0) 20 7307 1410/20 Fax: +44(0) 20 7307 1414 Email: conference@ukrc.org.uk exhibition@ukrc.org.uk Proffer work by 15 J anuary 2007 and present your paper at the largest Radiological Congress in the UK. Take advantage of our 30% reduction in fees and register now! Catch our early deadline of 16 April 2007 and make a further saving up to .t:60! View the Advance Programme, proffer work and register now at www.ukrc.org.uk Radiology and Oncology Editorial policy Editorial policy of the journal Radžology and Oncology is to publish original scientific papers, professional papers, review arti­cles, case reports and varia (editorials, re­views, short communications, professional information, book reviews, letters, etc.) pertinent to diagnostic and intervention­ al radiology, computerized tomography, magnetic resonance, ultrasound, nuclear medicine, radiotherapy, clinical and experi­mental oncology, radiobiology, radiophys­ics and radiation protection. The Editorial Board requires that the paper has not been published or submitted for publica­tion elsewhere: the authors are responsible for all statements in their papers. Accepted articles become the property of the journal and therefore cannot be published else­where without written permission from the editorial board. Papers concerning the work on humans, must comply with the principles of the declaration of Helsinki (1964). The approval of the ethical commit­tee must then be stated on the manuscript. Papers with questionable justification will be rejected. Manuscript written in English should be submitted to the Editorial Office in tripli­cate (the original and two copies), including the illustrations: Radžology and Oncology, Institute of Oncology, Zaloska 2, SI-1000 Ljubljana, Slovenia; (Phone: +386 (0)1 5879 369, Tel./Fax: +386 (0)1 5879 434, E-mail: gsersa@onko-i.si). Authors are also asked to submit their manuscripts electronically, either by E-mail or on CD rom. The type of computer and word-processing package should be specified (Word for Windows is preferred). All articles are subjected to editorial re­view and review by independent referee selected by the editorial board. Manuscripts which do not comply with the technical re­quirements stated herein will be returned to the authors for correction before peer­review. Rejected manuscripts are generally returned to authors, however, the journal cannot be held responsible for their loss. The editorial board reserves the right to ask authors to make appropriate changes in the contents as well as grammatical and stylistic corrections when necessary. The expenses of additional editorial work and requests for reprints will be charged to the authors. General instructions• • Radiology and Oncology will consider manuscripts prepared according to the Vancouver Agreement (N Engl J Med 1991; 324: 424-8, BMJ 1991; 302: 6772; JAMA 1997; 277: 927­34.). Type the manuscript double spaced on one side with a 4 cm margin at the top and left hand side of the sheet. Write the paper in grammatically and stylistically correct language. Avoid abbreviations un­less previously explained. The technical