vol.44 no.3 september 2010 pemetreksed Pravi Izbor Pravi Bolnik Pravi Cas Edina histološko usmerjena citostaticna terapija ALIMTA/cisplatin: Zdravljenje prvega reda pri bolnikih z nedrobnocelicnim pljucnim karcinomom, ki nimajo pretežno luskaste histologije Edina kombinirana terapija s signifikantno izboljšanim preživetjem: 12,6 meseca pri bolnikih z adenokarcinomom pljuc1 SKRAJŠAN POVZETEK GLAVNIH ZNACILNOSTI ZDRAVILA Ime zdravila ALIMTA 100 mg prašek za koncentrat za raztopino za infundiranje in ALIMTA 500 mg prašek za koncentrat za raztopino za infundiranje Kakovostna in kolicinska sestava ALIMTA 100 mg: vsaka viala vsebuje 100 mg pemetrekseda (v obliki dinatrijevega pemetrekseda). Po pripravi vsebuje vsaka viala 25 mg/ml pemetrekseda. Pomožne snovi: Vsaka viala vsebuje približno 11 mg natrija. Manitol, klorovodikova kislina, natrijev hidroksid. ALIMTA 500 mg: vsaka viala vsebuje 500 mg pemetrekseda (v obliki dinatrijevega pemetrekseda). Po pripravi vsebuje vsaka viala 25 mg/ml pemetrekseda. Pomožne snovi: Vsaka viala vsebuje približno 54 mg natrija. Manitol, klorovodikova kislina, natrijev hidroksid. Terapevtske indikacije: ALIMTA je v kombinaciji s cisplatinom indicirana za zdravljenje bolnikov z neresektabilnim malignim plevralnim mezoteliomom, ki jih še nismo zdravili s kemoterapijo. ALIMTA je v kombinaciji s cisplatinom indicirana kot zdravljenje prvega izbora za bolnike z lokalno napredovalim ali metastatskim nedrobnocelicnim pljucnim karcinomom, ki nima pretežno luskaste celicne histologije. ALIMTA je indicirana kot monoterapija za zdravljenje lokalno napredovalega ali metastatskega nedrobnocelicnega pljucnega karcinoma, ki nima pretežno luskaste celicne histologije pri bolnikih, pri katerih bolezen ni napredovala neposredno po ke­moterapiji na osnovi platine. Zdravljenje prvega izbora naj bo platinasta dubleta z gemcitabinom, paklitakselom ali docetakselom. ALIMTA je indicirana kot monoterapija za zdravljenje drugega izbora bolnikov z lokalno napredovalim ali metastatskim nedrobnocelicnim pljucnim karcinomom, ki nima pretežno luskaste celicne histologije. Odmerjanje in nacin uporabe: ALIMTO smemo dajati le pod nadzorom zdravnika, usposobljenega za uporabo kemoterapije za zdravljenje raka. ALIMTA v kombinaciji s cisplatinom Priporoceni odmerek ALIMTE je 500 mg/m2 telesne površine (TP), dan kot intravenska infuzija v 10 minutah prvi dan vsakega 21-dnevnega ciklusa. Priporoceni odmerek cisplatina je 75 mg/m2 TP, infundiran v dveh urah približno 30 minut po zakljucku infuzije pemetrekseda prvi dan vsakega 21 dnevnega ciklusa. Priporoceni odmerek cisplatina je 75 mg/m2 TP, infundiran v dveh urah približno 30 minut po zakljucku infuzije pemetrekseda prvi dan vsakega 21 dnevnega ciklusa. Bolniki morajo prejeti zadostno antiemeticno zdravljenje, pred in/ali po prejemanju cisplatina jih moramo tudi ustrezno hidrirati. ALIMTA kot samostojno zdravilo Priporoceni odmerek ALIMTE je 500 mg/m2 TP, dan kot intravenska infuzija v 10 minutah prvi dan vsakega 21 dnevnega ciklusa. Režim premedikacije Da zmanjšamo incidenco in resnost kožnih reakcij, dajemo kortikosteroid dan pred dajan­jem pemetrekseda, na dan dajanja pemetrekseda in naslednji dan. Kortikosteroid naj ustreza 4 mg deksametazona, danega peroralno dvakrat dnevno. Za zmanjšanje toksicnosti morajo bolniki dnevno jemati tudi peroralno folno kislino ali multivitaminski pripravek, ki jo vsebuje (350 do 1000 mikrogramov). V sedmih dneh pred prvim odmerkom pemetrek­seda morajo vzeti vsaj pet odmerkov folne kisline, odmerjanje pa morajo nadaljevati ves cas zdravljenja in še 21 dni po zadnjem odmerku pemetrekseda. Bolniki morajo prejeti tudi intramuskularno injekcijo vitamina B12 (1000 mikrogramov) v tednu pred prvim odmerkom pemetrekseda in enkrat vsake tri cikluse zatem. Kasnejše injekcije vitamina B12 lahko dajemo isti dan kot pemetreksed. Kontraindikacije: Preobcutljivost za zdravilno ucinkovino ali katerokoli pomožno snov. Dojenje. Socasno cepljenje proti rumeni mrzlici. Posebna opozorila in previdnostni ukrepi: Pemetreksed lahko zavre delovanje kostnega mozga, kar se kaže kot nevtropenija, trombocitopenija in anemija (ali pancitopenija). Pri bolnikih, ki pred zdravljenjem niso prejemali kortikosteroidov, so porocali o kožnih reakcijah. Uporabe pemetrekseda pri bolnikih z ocistkom kreatinina < 45 ml/min ne priporocamo. Bolniki z blagim do zmernim popušcanjem delovanja ledvic naj se izogibajo jemanju nesteroidnih protivnetnih zdravil (NSAID), denimo, ibuprofena in acetilsalicilne kisline 2 dni pred dajanjem pemetrekseda, na dan dajanja in še 2 dni po dajanju pemetrekseda. Vsi bolniki, ki jih lahko zdravimo s pemetreksedom, naj se izogibajo jemanju NSAID-ov z dolgimi razpolovnimi casi izlocanja vsaj 5 dni pred dajanjem pemetrekseda, na dan dajanja in še vsaj 2 dni po dajanju pemetrekseda. Porocali so o resnih ledvicnih primerih, vkljucno z akutno ledvicno odpovedjo, s pemetreksedom samim ali v povezavi z drugimi kemoterapevtiki. Pri bolnikih s klinicno pomembno tekocino tretjega prostora moramo razmisliti o drenaži izliva pred dajanjem pemetrekseda. Kot posledico toksicnosti pemetrekseda v kombinaciji s cisplatinom za prebavila so opažali hudo dehidracijo, zato moramo bolnike pred prejemanjem terapije in/ali po njej ustrezno hidrirati, prejeti morajo zadostno antiemeticno zdravljenje. Obcasno so v klinicnih študijah pemetrekseda, obicajno ob socasnem dajanju z drugo citotoksicno ucinkovino, porocali o resnih srcnožilnih dogodkih, vkljucno z miokardnim infarktom in možganskožilnimi dogodki. Odsvetujemo uporabo živih oslabljenih cepiv. Spolno zrelim moškim odsvetujemo zaploditev otroka v casu zdravljenja in še 6 mesecev zatem. Priporocamo ukrepe prosti zanositvi ali vzdržnost. Zaradi možnosti, da zdravljenje s pemetreksedom povzroci trajno neplodnost, naj se moški pred zacetkom zdravljenja posvetujejo o shranjevanju semena. Ženske v rodni dobi morajo v casu zdravljenja s pemetreksedom uporabljati ucinkovito kontracepcijo. Porocali so o primerih radiacijske pljucnice pri bolnikih, ki so jih zdravili z radiacijo pred, med ali po zdravljenju s pemetreksedom. Porocali so o radiacijskem izpušcaju pri bolnikih, ki so se zdravili z radioterapijo pred tedni ali leti. Zdravilo Alimta 500 mg vsebuje približno 54 mg natrija na vi-alo. Pomembno za bolnike, ki so na dieti z nadzorovanim vnosom natrija. Medsebojno delovanje z drugimi zdravili in druge oblike interakcij: Socasno dajanje nefrotoksicnih zdravil (denimo, aminoglikozidov, diuretikov zanke, spojin platine, ciklosporina) lahko potencialno povzroci zakasnjeni ocistek pemetrekseda. Socasno dajanje snovi, ki se tudi izlocajo s tubulno sekrecijo (denimo, probenecid, penicilin), lahko potencialno povzroci zakasnjeni ocistek pemetrekseda. Pri bolnikih z normalnim delovanjem ledvic lahko visoki odmerki nesteroidnih protivnetnih zdravil (NSAID-i, denimo, ibuprofen) in acetilsalicilna kislina v visokih odmerkih zmanjšajo eliminacijo pemetrekseda in tako lahko povecajo pojavnost neželenih ucinkov pemetrekseda. Pri bolnikih z blagim do zmernim popušcanjem delovanja ledvic se moramo izogibati socasnemu dajanju pemetrekseda z NSAID-i (denimo, ibuprofenom) ali acetilsalicilne kisline v visokih odmerkih 2 dni pred dajanjem pemetrekseda, na dan dajanja in še 2 dni po dajanju pemetrekseda. Socasnemu dajanju NSAID-ov z daljšimi razpolovnimi casi s pemetreksedom se moramo izogibati vsaj 5 dni pred dajanjem pemetrekseda, na dan dajanja in še vsaj 2 dni po dajanju pemetrekseda.Velika razlicnost med posamezniki v koagulacijskem statusu v casu bolezni ter možnost medsebojnega delovanja med peroralnimi antikoagulacijskimi ucinkovinami ter kemoter­apijo proti raku zahtevata povecano pogostnost spremljanja INR. Kontraindicirana socasna uporaba: Cepivo proti rumeni mrzlici: tveganje za smrtno generalizirano bolezen po cepljenju. Odsvetovana socasna uporaba: Živa oslabljena cepiva (razen proti rumeni mrzlici): tveganje za sistemsko, potencialno smrtno bolezen. Neželeni ucinki Klinicne študije malignega plevralnega mezotelioma Zelo pogosto: znižani nevtrofilci/granulociti, znižani levkociti, znižan hemoglobin, znižani trombociti, nevropatija-senzoricna, diareja, bruhanje, stomatitis/faringitis, slabost, anoreksija, zaprtje, izpušcaj, alopecija, povišan kreatinin, znižan ocistek kreatinina, utrujenost. Pogosti: dehidracija, motnje okusa, konjuktivitis, dispepsija. Klinicne študije nedrobnocelicnega pljucnega karcinoma - ALIMTA monoterapija, zdravljenje 2. izbora: Zelo pogosti: znižan nevtrofilci/granulociti, znižani levkocitit, znižan hemoglobin, diareja, bruhanje, stomatitis/faringitis, slabost, anoreksija, izpušcaj/lušcenje, utrujenost. Pogosti: znižani trombociti, zaprtje, povišanje SGPT (ALT), povišanje SGOT (AST), srbenje, alopecija, povišana telesna temperatura. Klinicne študije nedrobnocelicnega pljucnega karcinoma - ALIMTA v kombinaciji s cisplatinom, zdravljenje 1. izbora: Zelo pogosti: znižan hemoglobin, znižani nevtrofilci/granulociti, znižani levkocitit, znižani trombociti, slabost, bruhanje, anoreksija, zaprtje, stomatitis/faringitis, diareja brez kolostomije, alopecija, izpušcaj/lušcenje, povišan kreatinin. Pogosti: nevropatija-senzoricna, motnje okusa, dispepsija/zgaga. Klinicne študije nedrobnocelicnega pljucnega karcinoma - ALIMTA monoterapija, vzdrževalno zdravljenje: Zelo pogosti: znižan hemoglobin, slabost, anoreksija, utrujenost, izpušcaj/lušcenje, utrujenost. Pogosti: infekcija, znižani levkociti, znižani nevtrofilci, nevropatija-senzoricna, bruhanje, mukozitis/stomatitis, diareja, povišanje ALT (SGPT), povišanje AST (SGOT). Obcasno so v klinicnih študijah pemetrekseda porocali o primerih resnih srcnožilnih in možganskožilnih dogodkov, vkljucno z miokardnim infarktom, angino pektoris, cerebrovaskularnim insultom in prehodnimi ishemicnimi atakami; primerih kolitisa ter o primerih intersticijske pljucnice z respiratorno insuficience, primerih edema in o ezofagitisu/radiacijskem ezofagitisu. Redkeje pa o primerih potencialno resnega hepatitisa in pancitopenije. Po uvedbi zdravila na trg so porocali o primerih akutne odpovedi ledvic s pemetreksedom samim ali v povezavi z drugimi kemoterapevtiki, primerih radiacijske pljucnice pri bolnikih, ki so jih zdravili z radiacijo pred, med ali po njihovem zdravljenju s pemetreksedom, primerih radiacijskega izpušcaja pri bolnikih, ki so se v preteklosti zdravili z radioterapijo in o primerih periferne ishemije, ki je vcasih vodila v nekrozo okoncin. Imetnik dovoljenja za promet Eli Lilly Nederland B.V., Grootslag 1 5, NL 3991 RA, Houten, Nizozemska. Datum zadnje revizije besedila 21.09.2009. Nacin izdaje zdravila: H Podrobnejše informacije o zdravilu Alimta, so na voljo na lokalnem predstavništvu SIALM00005 Eli Lilly Farmacevtska družba, d.o.o. Brnciceva 41G, 1231 Ljubljana - Crnuce, Slovenija Telefon: +386 (0)1 5800 010 Faks: +386 (0)1 5691 705 Publisher Association of Radiology and Oncology Affiliated with Slovenian Medical Association – Slovenian Association of Radiology, Nuclear Medicine Society,Slovenian Society for Radiotherapy and Oncology, and Slovenian Cancer Society Croatian Medical Association – Croatian Society of RadiologySocietas Radiologorum HungarorumFriuli-Venezia Giulia regional groups of S.I.R.M. Italian Society of Medical Radiology Aims and scope Radiology and Oncology is a journal devoted to publication of original contributions in diagnostic and interventionalradiology, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical andexperimental oncology, radiobiology, radiophysics and radiation protection. Editor-in-Chief Gregor SeršaLjubljana, Slovenia Executive Editor Viljem KovacLjubljana, Slovenia Deputy Editors Andrej Cör Izola, Slovenia Igor KocijancicLjubljana, Slovenia Editorial Board Advisory Committee Karl H. Bohuslavizki Hamburg, Germany Damir Miletic Rijeka, Croatia Marija Auersperg Ljubljana, Slovenia Maja Cemažar Ljubljana, Slovenia Maja Osmak Zagreb, Croatia Tomaž Benulic Ljubljana, Slovenia Christian Dittrich Vienna, Austria Branko Palcic Vancouver, Canada Jure Fettich Ljubljana, Slovenia Metka Filipic Ljubljana, Slovenia Dušan Pavcnik Portland, USA Valentin Fidler Ljubljana, Slovenia Tullio Giraldi Trieste, Italy Geoffrey J. Pilkington Portsmouth, UK Berta Jereb Ljubljana, Slovenia Maria Godény Budapest, Hungary Ervin B. Podgoršak Montreal, Canada Vladimir Jevtic Ljubljana, Slovenia Vassil Hadjidekov Sofia, Bulgaria Uroš Smrdel Ljubljana, Slovenia Stojan Plesnicar Ljubljana, Slovenia Marko Hocevar Ljubljana, Slovenia Maksimilijan Kadivec Ljubljana, Slovenia Miklós Kásler Budapest, Hungary Primož Strojan Ljubljana, SloveniaBorut Štabuc Ljubljana, SloveniaRanka Štern-Padovan Zagreb, Croatia Mirjana Rajer Ljubljana, SloveniaŽiva Zupancic Ljubljana, Slovenia Michael Kirschfink Heidelberg, Germany Justin Teissié Toulouse, France Janko Kos Ljubljana, Slovenia Sándor Tóth Orosháza, Hungary Tamara Lah Turnšek Ljubljana, Slovenia Gillian M. Tozer Sheffield, UK Damijan Miklavcic Ljubljana, Slovenia Andrea Veronesi Aviano, Italy Luka Milas Houston, USA Branko Zakotnik Ljubljana, Slovenia Radiol Oncol 2010; 44(3): A. Editorial office Radiology and Oncology Institute of Oncology Zaloška 2 SI-1000 Ljubljana Slovenia Phone: +386 1 5879 369 Phone/Fax: +386 1 5879 434 E-mail: gsersa@onko-i.si Copyright © Radiology and Oncology. All rights reserved. Reader for English Vida Kološa Secretary Mira KlemencicZvezdana Vukmirovic Design Monika Fink-Serša, Samo Rovan, Ivana Ljubanovic Layout Matjaž Lužar Printed byTiskarna Ozimek,Slovenia Published quarterly in 600 copies Beneficiary name: DRUŠTVO RADIOLOGIJE IN ONKOLOGIJEZaloška cesta 2, 1000 Ljubljana Slovenia Beneficiary bank account number: SI56 02010-0090006751 IBAN: SI56 0201 0009 0006 751 Our bank name: Nova Ljubljanska banka, d.d., Ljubljana, Trg republike 2, 1520 Ljubljana; SloveniaSWIFT: LJBASI2X Subscription fee for institutions EUR 100, individuals EUR 50 The publication of this journal is subsidized by the Slovenian Book Agency. Indexed and abstracted by: Science Citation Index Expanded (SciSearch®)Journal Citation Reports/Science EditionScopusEMBASE/Excerpta MedicaOpen J-gateChemical AbstractsBiomedicina Slovenica This journal is printed on acid- free paper On the web: ISSN 1581-3207 http://versita.com/science/medicine/ro/http://www.onko-i.si/radioloncol/ Radiol Oncol 2010; 44(3): B. contents contents review 135 Post-treatment surveillance in colorectal cancer Vaneja Velenik 142 Fluorescence imaging agents in cancerology Aurélie Paganin-Gioanni, Elisabeth Bellard, Laurent Paquereau, Vincent Ecochard, Muriel Golzio and Justin Teissié experimental radiology 149 Infrahepatic caudal/inferior vena cava interruption with azygos/hemiazygos continuation. Vascular anomaly in swine Miran Jeromel and Dusan Pavcnik radiology 153 Direct coronary stenting in reducing radiation and radiocontrast consumption Jasmin Caluk, Enes Osmanovic, Fahir Barakovic, Zumreta Kusljugic, Ibrahim Terzic, Selma Caluk, Amela Sofic 158 Diagnostic imaging of traumatic pseudoaneurysm of the thoracic aorta Serif Beslic, Nermina Beslic, Selma Beslic, Amela Sofic, Muris Ibralic, Jasmina Karovic 164 Radiological considerations in von Hippel-Lindeau disease: imaging findings and the review of the literature Melda Apaydin, Makbule Varer, Ozgur Oztekin experimental oncology 168 Loss of heterozygosity of CDKN2A (p16INK4a) and RB1 tumor suppressor genes in testicular germ cell tumors Tomislav Vladusic, Reno Hrascan, Nives Pecina-Slaus, Ivana Vrhovac, Marija Gamulin, Jasna Franekic, Bozo Kruslin 174 Study of radiation induced changes of phosphorus metabolism in mice by 31P NMR spectroscopy Igor Sersa, Simona Kranjc, Gregor Sersa, Alenka Nemec-Svete, Bojan Lozar, Ana Sepe, Jernej Vidmar, Marjeta Sentjurc Radiol Oncol 2010; 44(3): C. contents oncology 180 Prophylactic cranial irradiation in patients with small-cell lung cancer: the experience at the Institute of Oncology Ljubljana Karmen Stanic, Viljem Kovac 187 Gonadal function in patients treated for Hodgkin´s disease in childhood Lorna Zadravec Zaletel, Nevenka Bratanic, Berta Jereb 194 Intensity modulated radiotherapy (IMRT) in bilateral retinoblastoma Banu Atalar, Enis Ozyar, Kaan Gunduz, Gorkem Gungor radiophisic 199 Linear array measurements of enhanced dynamic wedge and treatment planning system (TPS) calculation photon beam and comparison with electronic portal imaging device (EPID) measurements Borislava Petrovic, Aleksandra Grzadziel, Laza Rutonjski, Krzysztof Slosarek Radiology and oncology is covered in Science Citation Index Expanded (SciSearch®),Journal Citation Reports/Science Edition, Scopus, EMBASE/Excerpta Medica, Open J-gate, Chemical Abstracts, Biomedicina Slovenica Radiol Oncol 2010; 44(3): D. review Post-treatment surveillance in colorectal cancer Vaneja Velenik Institute of Oncology Ljubljana, Ljubljana, Slovenia Received 2 January 2010 Accepted 18 January 2010 Correspondence to: Assist. Prof. Vaneja Velenik, MD, PhD, Department of Radiotherapy, Institute of Oncology Ljubljana, Zaloška c. 2, 1000 Ljubljana, Slovenia. Phone: +386 1 5879 661; Fax: +386 1 5879 304; E-mail: vvelenik@onko-i.si Disclosure: No potential conflicts of interest were disclosed. Background. Though the post treatment surveillance of patients with colorectal cancer (CRC) treated with curative intent is common practice, its value is controversial. In the absence of conclusive clinical data, various modalities for the routine follow-up of patients with CRC have been proposed. In practice, the guidelines across countries and regions differ and are influenced by different health care policies, resource availability and doubts about effective­ness of follow-up. Conclusions. The results of metaanalyses of available clinical trials demonstrated a survival benefit of intensified monitoring, but the questions regarding the optimal frequency of visits and the examinations to be performed re­main unanswered. Furthermore, intensive monitoring of CRC survivors may be difficult to be administrated, causes discomfort and morbidity to the patient and can have serious cost-implications to the healthcare system. However, as it seems from available data, a comprehensive surveillance program does not affect the quality of patients’ life. Ongoing large prospective multi-institutional randomised trials might elucidate some of the crucial questions and exist­ing dilemmas to establish adequate surveillance strategy for CRC patients. Key words: surveillance; colorectal cancer Introduction Colorectal cancer (CRC) is a significant public health problem. In Slovenia, CRC is the second most frequently diagnosed cancer in both men and women and the second leading cause of can­cer death, with estimated 1,284 new cases and 682 related deaths in 2006.1Five year relative survival in 2005 was 57.7% for colon cancer and 45.4% for rectal cancer, increasing by 16.2% and 11.4%, re­spectively, from 1991.2Over the last two decades, CRC research has lead to better understanding of disease behaviour, resulting in more efficient treat­ments and higher prevalence of cancer survivors. In spite of radical treatment, approximately 30-50% of patients will develop recurrent disease of whom only 5–30% would be considered eligible for fur­ther surgery; of those only 3-5% will be actually cured.3,4In addition, the reported rates of second primary tumours in CRC patients are ranging from 5% to 10%.5-10Furthermore, long-term analyses of Scandinavian trials have shown an increased risk of second cancers in the patients treated with pr­eoperative radiotherapy for rectal cancer in organs within or adjacent to the irradiated volume.11 The main aim of post-treatment surveillance af­ter potentially curative treatment of CRC is to im­prove survival through early detection of polyps and new primaries or recurrent tumours when effi­cient treatment is possible.12-15Secondary goals are to assess the efficacy of initial treatment, manage­ment of long-term post-treatment complications, to offer comprehensive psychologic support and sup­port in disease prevention.16 Studies of CRC follow-up strategies To define the value of varying levels of follow-up intensity in surveillance programs among CRC survivors, six randomized controlled trials were conducted (Table 1).17-22Two of them have showed a survival benefit from more intensive follow­up.21,22There was a great variability between the 136 Velenik V / Post-treatment surveillance in colorectal cancer TABLE 1. Studies comparing intensive with less intensive follow-up Makela17 1995 106 Yes Yes 59 (54) 0.26 Ohlsson18 1995 107 Yes No 75 (67) 0.50 Kjeldsen19 1997 597 No No 68 (70) 0.48 Schoemaler20 1998 325 No Yes 76 (70) 0.20 Pietra21 1998 207 Yes Yes 73 (58) 0.02 Secco22 2002 358 Yes Yes 62 (43) <0.05 Abbreviations: No = number of patients; OS = overall survival; IFU = intensive follow-up studies in defining the follow-up. For example, the kind of follow-up that was considered as “inten­sive” in the study by Makela et al.17, was assessed by Shoemaker et al.20as “less intensive”. In some of the studies, the sample size was not sufficient to detect survival differences with different surveil­lance strategies, and some of the studies included patients with stage I disease. Therefore, somemeta-analysis were performed as a systematic approach to identification and ab­straction of critical information from different ran-domised, controlled trials.23Two meta-analyses of five randomised trials identified a survival advan­tage for the patients followed more intensely as significantly higher incidence of asymptomatic lo­cal or systemic recurrence was recognized among the patients monitored closely and, consequential­ly, reoperation for cure was more frequent in this group.24,25These results were confirmed by anoth­er, recently published meta-analysis including six randomised trials on this topic with a significant improvement in survival favouring more intense follow-up (Relative Risk Ratio 0.80; 95%CI, 0.70 to 0.91; p = 0.0008). A significant improvement in sur­vival was observed only those trials which includ­ed CEA testing and/or liver imaging.26Another two meta-analyses (on randomised and nonran­domised trials) concluded that intensive follow-up programmes can improve survival27,28, and should be »individualised« according to a person’s char­acteristics.27 In an attempt to rationalize CRC follow-up, three prospective multi-institutional randomised trials comparing more intensive with less intensive monitoring are being carried out at the moment: the FACS trial in United Kingdom, the FFCD trial in France and the GILDA trial in Italy.29The GILDA follow-up schemes are presented in Table2. The re­sults of these trials are pending. Potential limitations of follow-up Few considerations have to be taken into account when promoting surveillance and there are some limitations to this approach. First, there is a small risk of adverse events asso­ciated with colonoscopy itself or with polipectomy during the follow-up. Only one of the prospective randomised follow-up studies reported these data: two perforations and two gastrointestinal haemor­rhages from a total of 731 colonoscopies.20 Secondly,frequentvisitstophysicianmightbe inconvenienttothepatientsandevenharmfuldue tounnecessaryexpositiontoradiation.30Fearofre­currenceorunnecessarystressresultingfromfalse positivesresultsmayalsohaveanegativeimpact onthequalityoftheirlives.Falsepositiveresults areonaverage16times(0.2-200)morecommon thantruepositiveresults.31Ontheotherhand,re­assuringeffectofnormaltestresultsandpsycho­logicalsupportfromphysicianmightbebeneficial. Thedataabouttheeffectoffollow-uponpatients’ health-relatedqualityoflife(HRQL)arelimitedand conflicting.WhileStiggelboutetal.andWattchowet al.indicatedthatHRQLwasnotimprovedthrough follow-upvisits,Kjeldsenetal.demonstrateda smallbutsignificantincreaseinHRQLwithamore intensivefollowup.32-34However,Stiggelboutetal. emphasizedthatmostpatientswouldpreferregu­larcontactseveniftheyshowednobenefitinterms ofearlierdetectionofrecurrence.32 The third factor to be taken into consideration when promoting surveillance is high cost of such program. A wide variety of follow-up schemes are associated with large differences in costs. Few studies focusedon this issue. Virgo et al. reported a 28-fold difference in costs between minimal and Radiol Oncol 2010; 44(3): 135-141. TABLE 2. GILDA trial for rectal cancer follow-up Less intensive Office visit + + + + + + + + + + + CEA + + + + + + + + + + + Proctoscopy + Colonoscopy + + Chest X-ray + Liver ultrasound + + More intensive Office visit + + + + + + + + + + + Blood tests + + + + + + + + + + + Proctoscopy + + Colonoscopy + + + + + Chest X-ray + + + + + Liver ultrasound + + + + + + + + Abdominal-pelvic CT + + + + Abbreviations: blood tests include complete blood count, liver tests, tumour markers CEA and Ca 19-9. most extensive 5-year follow-up in USA, ranging from US$ 910 to US$ 26.717.35Audisio et al. calcu­lated the 5-year follow-up costs in Italy as follows: US$ 3.800 per patient; US$ 13.580 for each recur­rence; US$ 59.841 for every recurrence treated for cure and US$ 13.6779 for each cured patient; the difference in costs between minimal and aggressive 5-year follow-up protocol was US$ 4.800 per pa­tient. Authors recommended that the programmes should be tailored to the stage and site of primary cancer in order to reduce costs36and that control­led economic studies are required.37The cost-effec­tiveness analysis of five randomized trials showed that the cost for the intensive follow-up resulted in a net extra cost of US$ 4.214–4.299 per patient com­pared with the less intensive follow-up arm. Each life year saved through the intensive follow-up was calculated to cost between US$ 5.230–5.783.24 When resectability of recurrences was consid­ered, a cost minimization analysis performed by Rodrigues et al. demonstrated that the cost per re-sectable tumour recurrence was lower in the inten­sively followed group.38This is a logical conclusion despite the fact that the overall cost of intensive fol­low up was higher in the intensive strategy group than in less intensive one. Other authors pointed to the high cost of follow­up suggesting that it should be transferred to the primary care setting. The arguments were that the specialist care is more intense and that specialists tend to propose more expensive follow-up strate­gies.39 The question remains, who should carry out the follow-up visits. With increasing numbers of CRC survivors, primary care physicians (PCPs) are more and more engaged in CRC follow-up programs.40-42The data from the literature regarding the utility of general versus specialist care in CRC survivors are sparse. In a study by Nissen et al., PCPs reported dissatisfaction with this transfer of care for survi­vors; they also felt uncertain about the appropriate frequency and duration of surveillance testing for cancer recurrence.43Moreover, in a recently pub­lished study by Snyder et al., the authors reported a decreased intensity of cancer-related screening program as oncologists were becoming less in­volved in survivor care. The survivors followed up by both a PCP and an oncologist were most likely to receive both noncancer-related recommended care and cancer surveillance.42The authors concluded that a shared model of survivorship care should be developed with a clear and detailed description of roles of both sides, PCP’s and oncologist’s, to gain maximal coordination and efficacy.44On the other hand, some data suggest that the survivors fol­lowed up by PCP only did not perceive lower qua- Radiol Oncol 2010; 44(3): 135-141. 138 Velenik V / Post-treatment surveillance in colorectal cancer TABLE 3. Follow-up guidelines of main professional societies History, physical exam Every 3-6 m for 3 y, then every 6 m up to 5 y Every 3-6 m for 2 y, then every 6 m up to 5 y every 3-6 m for 3 y, then every 6-12 m for 2 y (colon) every 6 m for 2 y (rectal cancer) Colonoscopy at 3y, every 5y thereafter At 1y, then at 3y, every 5y thereafter After 1y, then every 3y (colon) every 5y (rectal cancer) Flexible proctoscopy (rectal cancer) every 6m for 5y (for not irradiated patients) every 6m for 5y (for patients with LAR) every 6 m for 2 years Blood tests not recommended not recommended not recommended CEA every 3-6m for 3y (stage II and III) every 3-6m for 2y, then every 6m up to 5y (staged as T2 or greater) if initially elevated: every 3-6m for 3y, then every 6-12m for 2y (colon) not recommended (rectal cancer) Chest x-rays not recommended not covered not recommended US abdomen not covered not covered not recommended CT thorax and CT abdomen annually for 3y for pts with high risk of recurrence annually for 3-5y for stage II and III Every 6m for 3y for pts with high risk of recurrence (colon) Not recommended (rectal cancer) Pelvic CT (rectal cancer) negative prognostic features, especially for not irradiated pts (no frequency) Not covered not recommended Abbreviations: m=months; y=years; ASCO=American Society Clinical Oncology; NCCN=National Comprehensive Cancer Network; ESMO=European Society Medical Oncology lity of care40, which was also confirmed by others mentioning that no difference was recorded in the rate of recurrence and death as well as time to de­tection of recurrence in comparison to the patients followed by a surgeon or PCP.45 Finally, with respect to cost and time consump­tion of follow-up, it seems reasonable that the sur­veillance of patients for whom additional therapeu­tic options when recurrence occurs are available4,46, should be more intense. Furthermore, particular attention was paid to determine the subgroups of CRC patients which might benefit the most from follow-up with regard to tumour site or stage. The results of a prospective randomized trial on 259 CRC survivors conducted by Rodrigues-Moranta et al. indicated that the patients with stage II tu­mours or lesions in the rectum had higher over­all survival when followed more intensively than those on less intensive follow-up program. No dif­ference was found between the patients with stage III lesions or lesions located in colon.38 Current recommendations and adherence to them by physicians Several guidelines have been published on the surveillance of CRC survivors. Follow-up pro­gram is recommended by all leading professional societies, e.g. the American Society of Clinical Oncology (ASCO)47, National Comprehensive Cancer Network (NCCN)48,49and European Society Medical Oncology (ESMO).50,51Surveillance proto­cols include regular outpatient’s visits followed by physical examination, CEA monitoring, radio­logical and endoscopic examinations. It must be stressed that none of diagnostic procedures by it­self is sensitive or specific enough to detect the re­currence at early, treatable stage; so, the guidelines recommend different packages of tests. Although there are differences in frequency, intensity and combinations of investigations as proposed by various programs, some parts of rec­ommendations are similar (Table 3). Monitoring is more intense during the first two to three years after radical treatment, as most of the recurrences Radiol Oncol 2010; 44(3): 135-141. occur within this period of time. There is a debate when to stop performing individual tests or moni­toring the patients as they are an increased lifetime risk of developing recurrent disease or new pri­mary CRC. The guidelines recommend continued, albeit less frequent visits during 3-5 years after therapy. Although local recurrences after adjuvant therapy are less common, irradiated rectal cancer patients may experience late relaps.52,53Many ex­perts believe that follow-up beyond five years is necessary for such patients.54 While recommendations concerning colonos­copy in high risk patients are consistent, there is a great variability in the standards of other tests. In ESMO guidelines the routine clinical, laboratory and radiological examinations are not indicated in rectal cancer patients at all. Furthermore, pelvic CT scanning for rectal cancer is recommended only in ASCO guidelines (Table 3). Due to aggressive therapy, CRC survivors can exhibit late sequelof treatment54-59, most common being impaired bowel, voiding, sexual malfunc­tioning and quality of life impairment, bone frac­tures after pelvic radiation, oxaliplatin-induced neuropathy and psychosocial distress. Among the three guidelines mentioned only the NCCN ones describe potential late effects of treatment; unfortu­nately, they include only little information on how to manage the symptoms. The consequence of lacking uniform guidelines is that the heterogeneity among physicians regard­ing the use of follow-up tests is serious. For exam­ple, a postal survey of all the active members of the American Society of Colon and Rectal Surgeons (ASCRS) undertaken in 1994 found that only 50% of surgeons who returned the questionnaire ad­here to official recommendations.60Twelve years later, Giordano et al. reported that only 30% of sur­geonsfollowed any guidelines. Of these, only 20% stuck to the national guidelines and 80% followed local recommendations.61 Disparities in follow-up care are also observed when patient’s race and age are taken into account. The report from Rolnick et al. highlighted that one of the reasons for poorer survival of black CRC patients in comparison with white patients might be that they have less follow-up surveillances.62A study conducted by Cooper et al. in 9.426 patients aged over 65 revealed that less than half of older CRC patients in the US during post-therapy period receive recommended screening for recurrence, in­dicating that the physician’s preferences may influ­ence the choice of testing.63 Conclusions Follow-up of CRC survivors is a common prac­tice. Intensive surveillance enhances the probabil­ity of diagnosing precancerous lesions, recurrences or new primaries at early stage when the existing treatment options could be used with curative intent. Consequentially, comprehensive surveil­lance program improves the survival and at the same time – as it seems from available data, does not affect the quality of patients’ life. On the other hand, the increased costs and time consumption of intensive surveillance limit its utility. Due to limited, and to some extent conflicting data, there are no uniform guidelines for the CRC survivors regarding the frequency of visits and tests to be performed at each visit. Ongoing large prospec­tive multi-institutional randomised trials might elucidate some of the crucial questions and exist­ing dilemmas to establish an adequate surveillance strategy for CRC patients. Acknowledgement The article resumes the lecture given by the au­thor during the second edition of the international course “Oncology for surgeons” in Iasi, Romania on April 14-18, 2009. References 1. Cancer incidence in Slovenia 2006. Report no. 48. 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Quality of life in colorectal cancer: stoma vs.nonstoma patients. Dis Colon Rectum 1995; 38: 361-9. 58. Kalso E, Tasmuth T, Neuvanen PJ. Amitriptyline effectivelly relieves neuro­patic pain following treatment of breast cancer. Pain 1996; 64: 293-302. 59. Baxter NN, Habermann EB, Tepper JE, Durham SB, Virnig BA. Risk of pelvic fractures in older women following pelvic irradiation. JAMA 2005; 294: 2587-93. 60. Vernava AM 3rd, Longo WE, Virgo KS, Coplin MA, Wade TP, Johnson FE. Current follow-up strategies after resection of colon cancer. Results of a survey of members of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1994; 37: 573-83. 61. Giordano P, Efron J, Vernava AM III, Weiss EG, Nogueras JJ, Wexner SD. Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons. Tech Coloproctol 2006; 10: 199-207. 62. Rolnick S, Hensley Alfors S, Kucera GP, Fortman K, Ulcickas Yood M, Jankowski M, et al. Racial and age differences in colon examination surveil­lance following a diagnosis of colorectal cancer. J Natl Caner Inst Monogr 2005; 96-101. 63. Cooper GS, Kou DT, Reynolds HL Jr. Receipt of guideline-recommended follow-up in older colorectal cancer survivors: a population-based analysis. Cancer 2008; 113: 2029-37. Radiol Oncol 2010; 44(3): 135-141. 142 review Fluorescence imaging agents in cancerology Aurélie Paganin-Gioanni1,2, Elisabeth Bellard1,2, Laurent Paquereau1,2, Vincent Ecochard1,2, Muriel Golzio1,2 and Justin Teissié1,2 1 CNRS; IPBS (Institut de Pharmacologie et de Biologie Structurale); Toulouse, France 2 Université de Toulouse; UPS; IPBS; Toulouse, France Received 13 January 2010 Accepted 4 May 2010 Correspondence to: Muriel Golzio and Justin Teissié, CNRS; Institut de Pharmacologie et de Biologie Structurale, 205 route de Narbonne, F-31077 Toulouse, France. E-mail: muriel.golzio@ipbs.fr; justin.teissie@ipbs.fr Disclosure: No potential conflicts of interest were disclosed. Background. One of the major challenges in cancer therapy is to improve early detection and prevention using novel targeted cancer diagnostics. Detection requests specific recognition. Tumor markers have to be ideally present on the surface of cancer cells. Their targeting with ligands coupled to imaging agents make them visible/detectable. Conclusions. Fluorescence imaging is a newly emerging technology which is becoming a complementary medi­cal method for cancer diagnosis. It allows detection with a high spatio-temporal resolution of tumor markers in small animals and in clinical studies. In this review, we focus on the recent outcome of basic studies in the design of new approaches (probes and devices) used to detect tumor cells by fluorescence imaging. Keywords: Photonic imaging; fluorescence; cancerology; apramers; smart probes State of the art Specific visualization of carcinogenesis or estab­lished tumor cells offers opportunities to guide surgery and monitor the response to therapy. In the clinic, radio-imaging uses contrast agents Indium-111 and Technetium-99 coupled to anti­bodies to target prostate1,2, colorectal3, ovarian4or small-cell lung cancers.5These radioelement-based technologies are powerful tools for the detection and therapy of cancers but they cannot be used during surgery. Fluorescence imaging is more user-friendly and provides on-line information. Therefore, fluorescence imaging agents which al­low fast detection with a high spatio-temporal resolution can increase detection of the edge of the primary tumor, the presence of metastasis and therefore help tissue resection by the surgeon. Fluorescence imaging Why the NIR (near infra red) light? In tissue fluorescence imaging, it is necessary to take into account five important parameters: reflec­tion, absorption, refraction, background autofluo­rescence and distribution of photons emitted by the fluorochrome targeted to tissues. Skin is an obstacle because the emitted light is reflected by this barrier and this reflection brings a loss in the penetration of the excitation light. In tissue, different chromophores in biomol­ecules strongly absorb the incident (or emitted) light. This is a major limit for the near UV and vis­ible part of the spectrum. Light absorption by he­moglobin is a problem in the visible range (from 400 to 670 nm). Indeed, the absorption coefficient (cm-1) decreases when the wavelength increases. Absorption due to the chromophores in biomole­cules is very strong below 460 nm and remains im­portant up to 580 nm. Thus, only a weak penetra­tion in the tissue can be obtained. The same prob­lem is of course present if emission is in the same wavelength range as absorption. A deeper penetra­tion is obtained when working in the near infrared (NIR) part of the spectrum between 600 and 1000 nm (Figure 1).6The upper limit in the wavelength (around 1200 nm) is due to water which is a strong light filter in IR spectroscopy. Light scatteringdue to turbid media is also re­duced in this high wavelength window as predict­ed by the Rayleigh law. Nevertheless, scattering in tissues remains high, due to refractive index mis­matches between the different cellular components and fluids. This is a limit in the spatial definition. Finally, light absorption by endogenous tissue fluorochromes can result in light emission, the so called autofluorescence of the tissue. This phe­nomenon is due to the oxidized forms of ribofla­vin, the co-enzymes flavin and NADH reduced inside cells.7,8 Other molecules like lipofuscin and ceroides or other components of the skin, such as collagen and melanin, also contribute to this effect. Autofluorescence is also a consequence of food that contains chlorophyll.9,10Tissueautofluorescence is mainly present in the UV and visible range of the spectrum. Compared to fluorescence imaging in the vis­ible light range, fluorescence imaging in the NIR bandwidth offers less photon absorption by blood hemoglobin, lipid and water, and a limited light scattering, enabling photon transmission deeper into the body. Thus, substantially reduced tissue autofluorescence, enabling higher sensitivity de­tection of target NIR molecular imaging agents due to a low background, can be achieved. For a greater discussion of the physics underly­ing efficient NIR photon delivery through tissues, fluorescence chemistry synthesis approaches and fluorescence hardware systems, the interested reader can consult several reviews.11,12 As a conclusion, an accurate quantitative and spatially resolved detection in vivoby an optical method faces intrinsic limitations due to the optical properties of intact biological tissues. Taking into account these optical properties of living tissues, optimized conditions by choosing the relevant bio­logical reporter fluorophores could be obtained. Which fluorophore? Two kinds of commercial organic fluorochromes emitting in the NIR wavelength domain are availa­ble: cyanine13and Alexa Fluor.14They can be graft­ed on any kind of molecules of interest such as nu­cleic acids, proteins or antibodies. They have sev­eral advantages such as weak toxicity, a small mo­lecular weight, a functional group allowing their grafting and weak photo-degradation. Their limit is a weak fluorescent quantum yield.13Therefore, multigrafting of these molecules on “rafts”15or on dendrimers16is performed to overcome this prob­lem by increasing the local number of emitters on the target. Company brand fluorophores are now on the market (DyLight Fluor family by Dyomics in collaboration with ThermoFisher Scientific, KODAK X-SIGHT Large Stokes Shift Dyes and nanospheres, XenoLight CF by Caliper). Commercially available quantum dots are promising competitors of organic probes for fluo­rescent imaging (Qdot®nanocrystals by Molecular probes,Quantum Dot Corporation Qtracker). Indeed, they have a strong fluorescent quantum yield13, a weak sensibility to photobleaching and a strong stability. However, they have significant toxicity in vivodue to their chemical core (nanoto-xicology).17In vivo, they are used with success in biphoton microscopy and some reports are cited in small animal imaging studies.18 144 Paganin-Gioanni A et al. / Fluorescence imaging agents Probe design Targeting tumor cells by fluorescence imaging can be achieved by coupling a fluororescent agent with biological probes (antibodies, aptamers, peptides or enzymatic ligands or metabolites) that recognize specific tumor markers only expressed or over-ex­pressed by tumor cells. The labeling of the biologi­cal probes can be done by fluorescent markers or complex molecular assemblies (Figure 2). Tumor markers Tumor cells differ from healthy cells by tumor markers which are expressed and located on their plasma membrane. These tumor markers are pro­teins or glycoconjugates over-expressed on the membrane surface of tumor cells such as protein receptors that interact with a panel of probes (or ligands) described in the following paragraph. Several membrane antigens are recognized by monoclonalantibodies and used for imaging of tumors: prostate specific membrane antigen (PSMA) 16,19,20, the carcino embryo antigen (CEA) 21, the VEGF receptor (Vascular Endothelial Growth Factor) or the Human Epidermal Growth Factor Receptor-2 (HER-2).22,23 These antigens are mem­brane proteins over-expressed by tumor cells and involved in life processes such as exogenous or en­dogenous transduction of signals or the cell cycle. In addition, they can be used in imaging to detect various tumors. PSMAisamembraneandcytoplasmicgluta­matecarboxypeptidasewhichisinvolvedinthe cellcycleandincarcinogenesisassociatedwith prostatecancer.CEAisinvolvedincelladhesion andisfoundinvariouscancerssuchascolorectal, gastric,pancreatic,lungandbreastcancers.The VEGFreceptorisover-expressedinmosttumor andendothelialcellsinvolvedinangiogenesis. HER-2isatyrosinekinasemembranereceptor involvedinsignaltransductionpathwaysinduc­inggrowthandcellulardifferentiation.Itisover-expressedinbreastandovariancancersandother carcinomas. There are other proteins over-expressed on the surface of several types of tumor cells such as met­alloproteinase-2 (MMP-2) 24, integrins aVb3 25,26and lectins.27These molecules are less specific for tumor cells than the antigens described above be­cause they are also expressed by healthy cells but in much smaller quantities. Their natural ligands are used as probes. Biological probes Antibodies. Antigenic tumor markers used in molecular imaging are generally derived from anatomopathological tissues studies. A large li­brary of antibodies specific for tumor cells has been gathered. They have been adapted for human administration (humanized and recombinant an­tibodies). Monoclonal antibodies are widely used in fluorescence imaging due to their strong affinity for their target. On the other hand, one should keep in mind their disadvantage of triggering immune reactions. It is difficult to find a good compromise between modifications (humanization, chimeriza­tion) of antibodies to make them more biocompat­ible and their loss of affinity for their target. Several monoclonal antibodies are available for in vivofluorescence imaging applications: the anti-PSMA antibody that targets prostate tumor cells20,28, the anti-CEA antibody that targets tumor cells of pros­tate, pancreas and colorectal cancer29,21, the anti-VEGF receptor antibody that targets tumor cells and those associated with the angiogenic process30or the anti-HER-2 targeting tumor cells in breast, ovary, and other carcinomas (Table 1).23,31 Peptides and proteins. Peptides or proteins can also be used to target tumor cells but they are still at an experimental stage. This approach consists of using the binding properties of the peptide (or protein) with glycoconjugates or membrane pro­teins over-expressed in tumor cells (Table 1). For example, Chlorotoxin is used to detect various tu­mor cells (glioma, medulloblastoma, prostate can­cer, bowel cancer and sarcomas).24This peptide, derived from scorpion venom, is composed of 36 amino acids with 4 disulfide bonds and interacts with MMP-2. Due to its anti-cancer properties, it can be used to target tumor cells. In vivodetection of cells over-expressing MMP-2 was obtained by non-invasive fluorescence imaging.24Cyanine 5.5 was coupled to primary amines of Chlorotoxin (3 amino functions). Another example is the RGD peptide, which is a cyclo-peptide that mimics an-giotensin. It is used to detect tumor cells because it specifically interacts with aVß3integrins over-expressed on the surface of many different tumor cells.25,26 Metabolites. Another approach is to use metabol­ic properties of tumor cells that differ from normal cells. Indeed, they absorb more nutrients because they over-express proteins involved in cell growth. Thus, administration of metabolites is used to target receptors over-expressed in tumor cells (Table1). For example, albumin that interacts with TaBle 1. Examples of tumors markers and probes used in fluorescence imaging PAMAM + PSMA Antibody (x6) rhodamine or (x6) FITC Prostate 20, 28 PSMA Aptamer Rhodamine, QDots LNCap 19, 39 CEA Antibody AlexaFluor 488; Cyanine (DY-676) Colorectal, gastric, pancreatic, lung, breast 21, 29 HER-2 Antibody PAMAM + (x5) AlexaFluor 488 Breast, ovarian carcinoma 23, 31 VEGF Receptor Antibody NIR-800 Licor Brain 30 Integrin aVb3 RGD Peptide (c(RGDyK); RGD-4C (doubly cyclised RGD); c(RGDfK)) Q-Dot 705; PAMAM +(x3) Alexa Fluor 488; PAMAM +(x4) FITC; RAFT +(x2) Cy5 U87MG, brain, HUVEC, HEK293 26, 49, 52 b-D-galactose receptor (lectin) BSA / GSA Rhodamine G Ovarian and adenocarcinoma 27 MMP-2 Chlorotoxin Cyanine 5.5 Glioma, neuroectoderma 24 Folate receptor Folate Q-Dots Brain 32, 33 Mucine MUC1 Aptamer Rhodamine MCF7 34 the b-D-galactose receptor 27or folic acid (vitamin B9) that interacts with the folate receptor (or folate-binding protein (FBP) 32,33,are both effective for lo­cating various tumor cells (ovary, kidney, uterus, brain, colon, lung adenocarcinoma). This approach is less specific for tumor cells than approaches tar­geting tumor antigenic markers but it is widely used in imaging modalities such as MRI and PET for the specific detection of tumor cells and also for drug-targeted delivery to tumors. Aptamers. Aptamers can be used for targeting live cells. Aptamers are highly structured oligo­nucleotides selected by Systematic Evolution of Ligands by Exponential Enrichment (SELEX) to bind tightly (nanomalor range) and specifically to a target molecule. Recently, specific aptamers have been selected against tumor markers like PSMA or MUC1 (Table 1).19,34 Nucleotidic aptamers present all characteristics, which make them suitable as imaging probes: they are smaller (10-15 kDa) than antibodies (150 kDa), hence they exhibit higher tissue penetration and faster blood clearance. In addition, compared with antibodies, aptamers present a low immunogenic­ity, are not toxic and they can be chemically modi­fied.35 The first aptamer used in imaging was designed against human neutrophil elastase.36This work demonstrated for the first time the potential feasi­bility of using an aptamer labeled with technetium­99m (99mTc) as reagents for diagnostic imaging. The aptamer had a signal-to-noise ratio higher and more rapid than the antibody. More recently, an aptamer labeled with 99mTc directed against human tenascin-C was also used for in vivoimaging.37These authors showed a rapid uptake of aptamers by tumor and a rapid clearance from blood and other non-target tissues, which enabled clear tumor imaging. Another report used 99mTc -labeled-aptamer di­rected against MUC1 and was tested in MCF-7 tu­mor-bearing mice.38Their first results showed the necessity to optimize the radiolabeled aptamer in terms of pharmacokinetics prior to use in imaging. Actually, fluorescently-labeled aptamers that bound the tumor cell surface were either used for in vitroimaging on culture cells that expressed, for example, PSMA39and MUC134, or by injections of a fluorescent aptamer against tenascin-C into tumor-bearing mice followed by fluorescence microscopy on tissues sections.37However, they are still not of­ten used in fluorescence imaging of small animals. 146 Paganin-Gioanni A et al. / Fluorescence imaging agents Smart probes. “Smart probes” or “smart sensors” are probes activated by an intracellular proteolytic reaction of targeted tumor cells that become fluo­rescent. These probes give an excellent signal-to-noise ratio because they are activated only when internalized in target cells. Basically, they are ac­tivated by proteases or intracellular reductases (metalloproteinases MMP-2, cathepsins B and D, cysteine proteases, thioreductases) over-expressed in tumor cells which cut Lys-Lys or disulfide bonds of the complex and release the fluorophore.35,40 ProSense probes developed by Weissleder (VisEn Medical, Inc., Woburn, MA) are polylysines labeled by non-fluorescent cyanines. When the probe is internalized into cells by endocytosis, the peptide link (between lysines) separating the cy­anines is broken by the action of intracellular pro­teases such as cathepsins (B or D) or metalloprotei­nases (MMP-2) and fluorophores are released into the cells which become fluorescent.24,41 Razkin et al.have shown that the molecule RAFT­RGD-Cy5-SS-Q penetrates effectively and specifi­cally in tumor cells and is activated once inside. The complex consists of 4 RGD peptides specifi­cally targeting the aVß3 receptors over-expressed on the surface of cancer cells, and of a quencher (Q) connected to a cyanine 5 via a disulfide bond. This bond is reduced by thioredoxin in the cytoplasm and endosomes after internalization into cells. Once internalized, the quencher is spatially sepa­rated from the cyanine and the complex becomes fluorescent. The phenomenon of quenching can be achieved by combining two identical fluorophores but the rate of cleavage of the disulfide bond is weaker and the contrast obtained in vivois much smaller.40 Engelman et al.demonstrated that the pH low insertion peptide (pHLIP) is able to insert into the lipid bilayer of the plasma membrane by forming an a helix when the acidity increases in the extra­cellular matrix.42Indeed, the extracellular matrix surrounding tumors and areas of inflammation or infection are relatively acidic environments compared to healthy tissues. The insertion of the peptide in the cell membrane occurs at a pH below 6.5. The C terminal end of the complex is trans-located into the cytoplasm. Two applications are then possible — the targeted delivery of drugs in tumor cells and the fluorescence imaging of these cells. Engelman et al.first grafted a disulfide bond to the C terminal end of the peptide, linking it to a fluorescent molecule or a drug that can be released into the cells by cleavage of the disulfide bond by thioredoxin. They also showed that this peptide is effective in vivofor detection of tumor cells by non­invasive fluorescence imaging. It is shown that this peptide localizes specifically in tumor cells within 20 hours.43 Molecular assemblies. Functionalization of fluo­rescent agents by coupling with enzymatic lig­ands44, antibodies45or peptides46, enable their tar­geting to tumor cells. Classically, tumor probes are bound to an organic fluorophore45,21or quantum dot28,31 to visualize tumor cells by fluorescence imaging. The commercial fluorophores have reac­tive groups such as amine, carboxylic acid or thiol of the amino acid of the protein probe. However, the number of reactive groups per probe is low. According to protein size and the number of reac­tive groups, 4 to 10 fluorophores can be grafted per protein. In order to increase the fluorescence signal of tumor probes and/or increase their specificity for target cells, molecules called “platforms” were used as a covalent support to several fluorophores and/or several probes (Table 1). The quantum dots can be used as “platforms” because they allow several connections with bio­logical probes. Cai et al.have shown this with the RGD peptide by grafting multiple RGD peptides onto a quantum dot.26This greatly increases the specificity of quantum dots for tumor cells. The work of Coll et al.on the regioselectively addressable functionalized template RGD peptide (RAFT RGD) showed the specific labeling of tumor cells over-expressing integrin aVß3 receptor. This molecule is a deca-peptide accepting 4 cyclo-RGD peptides and one fluorochrome of the cyanine 5 type. They showed that it was necessary to have at least 4 RGD peptides per platform to specifically detect tumor cells in vivo.44 Dendrimers are now experiencing their first ma­jor applications as diagnostic agents when grafted with contrast agents47,48or fluorochromes23,20,49and targeting agents. PAMAM dendrimers are used in imaging because they are water-soluble, biocompatible and biodegradable.50,51They allow an increase in the sensitivity of detection because several imaging agents are bound per dendrimer. Furthermore, by increasing the number of biologi­cal probes by complex, it is possible in some cases to increase the specificity of the detection signal. The work of Hill and that of Thomas show the de­tection efficiency in fluorescence imaging of tumor cells in vivoby a complex composed of a PAMAM dendrimer with multiple RGD peptides52,53and several fluorochromes.52,49This approach can in­crease both the fluorescence signal of tumor probes and their specificity for tumor cells. Several studies using dendrimers as imaging agents are reported in Table 1. Dendrimers are real molecular platforms that may also be grafted to drugs. These systems allow us to specifically target cells and provide local de­livery of drugs in patients.54 Conclusion In small animals, optical imaging is a low-cost tech­nology by which tumor cells are detected over sev­eral weeks depending on the mouse strain. Whole-body imaging gives access to relative quantitative detection with a “crude” topological definition over a long period. The technology is rather sim­ple and is now available on the market (Berthold, www.bertholdtech.com; Hamamatsu, www.ha-ma-comp.com; Caliper Xenogen, www.caliperls.com; Fuji, www.fuji-sciences.com; Carestream, www.carestreamhealth.com; Cambridge Research Instrumentation, www.cri-inc.com; Biospace, www.biospacelab.com). This was recently re­viewed as a technological feature in “Nature”.Detection is associated with a light signal. The ma­jor limit is sensitivity and topological definition which remains associated with the turbidity of tis­sues. It could be improved by selecting the probes, light source and detector suitable for red fluores­cence detection to avoid tissue absorption. More ac­curate data is obtained by other methods (intravital microscopy) but over a more limited period of time due to the associated surgery (Cellvizio, www.visualsonics.com; macrofluo, www.leica-microsys-tems.com; macroscope, www.nikoninstruments.eu). Real-time imaging of tumors by an IV injected probe sensitive to angiogenesis (AngioStamp®, Angiosense), can be obtained by a user-friendly intra-operative imager (Fluobeam®) that will dras­tically improve cancer surgery. Preclinical de­vices are available. The new (“smart”) fluorescent probes associated with fluorescence endoscopy should help surgeons with tumor resection in the near future (Fluoptics, www.fluoptics.com; Visen, www.visenmedical.com). A preclinical study just showed a better survival over a 6-month period when tumors in the animal were resected by using a Cy5-labeled cell-penetrating peptide conjugated to a dendrimer to guide surgery.56 Therefore, following and quantifying tumor progression in vivoby optical imaging is a fantastic tool to monitor the expression of therapeutic genes in target tissues, in disease models and/or to assess the effectiveness of cancer therapies (surgery, ra­diotherapy, gene therapy). Added to the routinely used imaging techniques57,58, it can be used for di­agnostic evaluation and surgical management. acknowledgments: Support from the Slovenian French Proteus pro­gram, from the ITAV program, from the Region Midi Pyrénées, from the ARC (Grand Sud) and from Biodendridots ANR project should be ac­knowledged. References 1. Sodee DB, Conant R, Chalfant M, Miron S, Klein E, Bahnson R, et al. Preliminary imaging results using In-111 labeled CYT-356 (Prostascint) in the detection of recurrent prostate cancer. Clin Nucl Med 1996; 21: 759-67. 2. Nanus DM, Milowsky MI, Kostakoglu L, Smith-Jones PM, Vallabahajosula S, Goldsmith SJ, et al. Clinical use of monoclonal antibody HuJ591 therapy: targeting prostate specific membrane antigen. J Urol 2003; 170(6 Pt 2): S84-8; discussion S88-9. 3. Abdel-NabiH,DoerrRJ,ChanHW,BaluD,SchmelterRF,MaguireRT.In-111­labeled monoclonal antibody immunoscintigraphy in colorectal carcinoma: safety, sensitivity, and preliminary clinical results. 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Radiol Oncol 2009; 43: 180-6. case report Infrahepatic caudal/inferior vena cava interruption with azygos/hemiazygos continuation. Vascular anomaly in swine Miran Jeromel1,2 and Dusan Pavcnik1 1 Dotter Interventional Institute, Oregon Health Sciences University, Portland, OR, USA 2 Institute of Radiology, University Clinical Center, Ljubljana, Slovenia Received 22 March 2010 Accepted 22 April 2010 Correspondence to: Prof. Dušan Pavcnik, M.D., Ph.D., Dotter Interventional Institute, Oregon Health Sciences University 3181 SW Sam Jackson Park Road, L-342, Portland, OR 97239-3098, U.S.A. E-mail: pavcnikd@ohsu.edu Disclosure: No potential conflicts of interest were disclosed. Background. Swine are commonly used as a model to study congenital cardiovascular defects that occur in hu­mans and these models have been both spontaneous and experimentally induced. Ventricular septal defect, patent ductus arteriosus, and atrial septal defect (ASD) are examples of experimentally induced models. Absence of caudal/ inferior vena cava (CVC/IVC) with azygos/hemiazygos continuation is an uncommon vascular anomaly. Case report. The vascular anomaly presented in this case report was an incidental finding on a pig that was evalu­ated for experimental percutaneous atrial septal defect creation and its closure using a percutaneous femoral vein approach. Absence of CVC/IVC was confirmed by venography and necropsy. Conclusions. To the best of the investigators knowledge, this is the first report of absence of CVC/IVC with azygos/ hemiazygos continuation in the swine. Key words: experimental animal model; congenital vascular anomaly; azygos vein; hemiazygos vein; inferior vena cava Introduction Swine and ovine are frequent used for the experi­mental studies of interventional radiology proce­dures.1,2However, swine are commonly used as a model to study congenital cardiovascular defects that occur in humans and these models have been both spontaneous and experimentally induced. Ventricular septal defect, patent ductus arteriosus, and atrial septal defect (ASD) are examples of ex­perimentally induced models. In necropsy surveys of commercial breeds of farm pigs, ASD was detect­ed in 31/1906 pigs for an incidence of 1.6%.1Swine have been used as a model to produce a functional ASD by using a transeptal stationary angioplasty balloon technique.1 Caudal vena cava (CVC) in animals is the equiv­alent of inferior vena cava (IVC) in humans and normally, CVC/IVC provides the main channel of drainage for the hind limbs, abdominal muscles, and abdominal organs through the portal and he­patic veins. The main tributaries of the CVC/IVC are common iliac, lumbar, deep circumflex iliac, right testicular or right ovarian, renal phrenicoab­dominal, hepatic, and phrenic veins.3,4,5 The vascular anomaly presented in this case re­port was an incidental finding on a pig that was evaluated for experimental percutaneous atrial septal defect creation and its closure using a percu­taneous femoral vein approach. To the best of the investigators knowledge, this is the first report of absence of CVC/IVC with azygos/hemiazygos con­tinuation in the swine. Case report The study protocol was approved by the Oregon Health & Science University’s (OHSU) Animal Care and Use Committee (IACUC). The animal fa­cilities are accredited by the American Association for the Accreditation of Laboratory Animal Care 150 Jeromel M and Paucnik D / Vascular anomaly in swine international (AAALAC international) and meet all federal (AWA and PHS) guidelines for animal care. The animal room was maintained at an average tem­perature of 68ş F and a relative humidity of 30-70%. A female domestic swine (Sus scrofa domestica), 38 kg of body weight and approximately 4 months of age, was evaluated for experimental transcatheter implantation of a closure device for foramen ovale, using the percutaneous femoral vein approach. The swine was acclimated for at least 48 h before the ter­minal procedure. Preanesthesiatreatmentincluded0.01mg/kgof atropinesulfate(AmericanRegentLaboratories, Shirley,NY,USA)and1gdoseofCephasolin(Ancef; AbbotLaboratories,Chicago,IL,USA)intramuscu­larly.AnesthesiawasinducedwithTelazol(tilet-amineHCIandzolazepamHCI;FortDodgeAnimal Health,FortDodge,IA)3-6mg/kg,IM,andanen-dotrachealtubewasplaced.Maintenanceofanesthe­siawasdonewith2-3%isoflurane(Isothesia,Burns VeterinarySupply,RockvilleCenter,NY,USA). Duringanesthesia,oxygen,carbondioxide,EKG, respirationandheartrateweremonitored,andaGE/OEC9800cardiacmobilesystemwithdigitalimag­ing(GEMedicalSystems,OEC,SaltLakeCity,UT) wasusedforimaging. Asize7Frenchvascularsheath(CookInc., Bloomington,IN,USA)waspercutaneouslyintro­ducedintorightfemoralvein,andthenaguidewire andasize5Frenchcatheter(CookInc.,Bloomington, IN,USA)wereinsertedintorightfemoralveinand advancedcranially.Afterfluoroscopyshowedthe catheterlocatedontheleftsideofthespine,contrast medium(Hypaque-76,Amersham,Piscataway,NJ, USA)wasinjectedtoperformavenogramforeval­uationofvenousanatomy.Inaddition,twosize7 Frenchvascularsheathswerepercutaneouslyin­troduced,oneintotherightfemoralarteryandthe otherintotherightjugularveinforperformance ofbilateralrenalarteryangiogramsandajugular venogram,respectively.Therighthepaticveinwas thencatheterizedandvisualizedfromtheright jugularapproachusingasize5FrenchH1catheter (CookInc.,Bloomington,IN,USA)passedthrough therightatrium.Attheendoftheprocedurethe animalwaseuthanizedwhileunderanesthesiawith anoverdoseofsodiumpentobarbital(Euthasol: DelmarvaLab,Midlothian,VA,USA). Diagnostic findings The ventrodorsal subtraction venogram after simul­taneous injection via the right femoral vein and the right jugular vein is shown in Figure 1. Normal su­perior or cranial vena cava was seen on the right side, but CVC/IVC was not observed. A dilated hemiazygos vein was seen on the left side of the lumbar vertebra, emptying into the coronary si­nus, which communicated directly with the right atrium. The lateral venogram after simultaneous injection of the right femoral and right jugular vein shown in Figure 2 demonstrated anomalous drain­age of blood from the hemiazygos vein that abnor­mally emptied into the coronary sinus and then into the right atrium. Thelateralsubtractionvenogramaftersimulta­neousinjectionofcontrastviarightfemoralvein andrighthepaticveinidentifiedthehepaticvein astheonlydrainageintothesuprahepaticCVC/IVC.TheinfrahepaticCVC/IVCwasnotseenor identifiedduringthevenogram.Thehemiazygos veindrainageintothecoronarysinuswasthemajor channelfromtheabdomen.Bothrenalveinsseen onlateimagesofrenalarterigramsdrainedintothe azygosandhemiazygoschains.Theabnormality wasdiagnosedasinfrahepaticCVC/IVCinterrup­tionwithazygos/hemiazygoscontinuation.This findingofinfrahepaticCVC/IVCinterruptionwith azygos/hemiazygoscontinuationwasconfirmedat necropsy(Figure3).Becauseofthefoundanomaly, theplanedpercutaneouscreationofASDusinga femoralapproachcouldnotbeperformed. Discussion Anomalies of the CVC/IVC are often associated with congenital heart disease. Its prevalence is 0.6­2.0% in patients with congenital heart disease and less than 0.3% among otherwise normal patients.6During embryogenesis, the IVC/CVC is made up of the hepatic, prerenal, renal, post renal segments, which by segmental fusion, regression, and mid-line anastomosis form the CVC/IVC.7Failure of fusion between the hepatic and prerenal segments results in infrahepatic CVC/IVC interruption that is the most common developmental anomaly of CVC/IVC.8The infrahepatic CVC/IVC may con-either side of the lumbar vertebrae there may be tinue as the azygos vein7,9,10, or it may continue as one or two ascending lumbar veins. The right as-the hemiazygos vein to the persistent left superior cending lumbar vein becomes the azygos vein as vena cava10, intrathoracic veins11,or anomalous in-it enters the thorax, and the left ascending lumbar trahepatic veins.12Infrahepatic CVC/IVC interrup-vein is continuous with hemiazygos chain.13If the tion with azygos and hemiazygos continuation is inferior caudal vein (CVC/IVC) is occluded, blood associated with congenital cardiac or visceral mal-from the lower extremities may reach the heart formation in the human.5,8through the paravertebral and azygos systems. If Segmental lumbar veins are joined by a longitu-the inferior vena cava is congenitally absent, the dinal vessel called the ascending lumbar vein. On same avenues is utilized.13Normally in species 152 Jeromel M and Paucnik D / Vascular anomaly in swine such as the dog the azygos vein empties into the cranial vena cava and then into the right atrium.4The presence of the hemiazygos vein is variable, and when present it is located left to the aorta, communicating the azygos vein with the CVC.4In the present case, the enlarge hemiazygos vein was the major drainage channel from the abdomen, and it emptied into the coronary sinus that opens into the right atrium, and similar findings have been re­ported in the human literature.13 Larger azygos/hemiazygos vein can be misinter­preted as an aortic dissection or mediastinal mass.5Moreover, the enlarged azygos/hemiazygos arch may be mistaken for a right paratracheal adenopa-thy on the chest radiography.14The authors were able to make the correct diagnosis by means of CT scan, which has been accepted as a valuable modal­ity for demonstrating IVC anomalies.15Although most of IVC interruption with azygos/hemiazy-gos continuation is usually an asymptomatic mal­formation, a dozen cases of deep vein thrombosis have been causally linked to IVC anomaly in the English literature.5,9,15,16Theoretically, this anomaly may predispose to venous thrombosis because an inadequate blood return through the collaterals may increase the venous pressure in the veins of the leg, thereby favoring venous stasis.15,16,17 The absence of CVC/IVC may lead to procedural difficulties during femoral vein catheter advance­ment9, IVC filter placement18, temporary pacing through the transfemoral route1, electrophysiology studies19,20, and cardiopulmonary bypass surgery.21Awareness of the existence of these anomalies be­fore femoral vein catheter advancement or other procedure through femoral vein would avoid unnecessary injury or undue delay. The recogni­tion of this congenital venous anomaly (CVC/IVC interruption with azygos/hemiazygos continua­tion) is important for interventional radiologist and cardiologist, especially for conditions such as venous thromboembolism, IVC filter placement, transcatheter closure of the ASD, ventricular septal defect (VSD) patent foramen ovale (PFO) shunt22, or pacing and electrophysiology, cardiopulmonary bypass surgery, and palliative systemic venous-pulmonary artery shunt surgery. Acknowlegments We thank Sheri Imai-Swiggart for her excellent as­sistance. References 1. Swindle MM, Thompson RP, Carabello BA, Smith AC, Green CT, Gillette PC. Congenital cardiovascular disease. In: Swindle MM, editor. Swine as models in biomedical research. Ames: Iowa State University Press, Inc; 1992. p. 176-84. 2. Wei Lu, Pavcnik D, Uchida B, Park WK, Liu L, Timmermans HA, et al. The ovine jugular vein as a model for interventional radiology procedures. Radiol Oncol 2008; 42: 59-65. 3. Dondelinger RF, Ghysels MP, Brisbois D, Donkers E, Snaps FR, Saunders J, et al. Relevant radiological anatomy of the pig as trining model in interven­tional radiology. Eur Radiol 1998; 8: 1254-73. 4. Miller ME. Veins. In: Evans HE, Christensen GC, editors. Miller’s anatomy of the dog. 2th edition. Philadelphia: Saunders; 1979. p. 757-801. 5. Kutlu R. Obliterative hepatocavopathy – ultrasound and cavography find­ings. Radiol Oncol 2008; 42: 181-6. 6. Timmers GJ, Falke TH, Rauwerda JA, Huijgens PC. Deep vein thrombosis as a presenting symptom of congenital interruption of the inferior vena cava. Int J Clin Pract 1999; 53: 75-6. 7. Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferior vena cava. Review of embryogenesis and presentation of a simplified classifica­tion. Br J Radiol 1974; 47: 206-13. 8. Anderson RC, Adams P, Burke B. Anomalous inferior vena cava with azygos continuation (infrahepatic interruption of the inferior vena cava). J Pediatr 1961; 59: 370-83. 9. Gayer G, Zissin R, Strauss S, Hertz M. IVC anomalies and right renal aplasia detected on CT: a possible link? Abdom Imaging 2003; 28: 395-9. 10. Roguin N, Lam M, Frenkel A, Front D. Radionuclide angiography of azygos continuation of inferior vena cava in left atrial isomerism (polysplenia syn­drome). Clin Nucl Med 1987; 12: 708-10. 11. Arakawa A, Nagata Y, Miyagi S, Takahashi M. Interruption of inferior vena cava with anomalous continuations. J Comput Tomogr 1987; 11: 341-5. 12. Balkanci F, Ozmen MN. Case report: interruption of inferior vena cava with anomalous intrahepatic continuation. Br J Radiol 1993; 66: 457-9. 13. Abrams HL, Meyerovitz MF. The vertebral and azygos veins. In: In Baum S. Abram’s angiography. 4th edition. Boston: Little, Brown and Company; 1997. p. 891-914. 14. Paramanathan A, Bapahla AS, Padmanabhan K, Dhar SR. An unusual cause of a right paratracheal mass. Chest 1994; 106: 1626-8. 15. Barack BM. Persistence of the cardinal veins and thrombosis: CT demon­stration. J Comput Assist Tomogr 1986; 10: 327-8. 16. Hamoud S, Nitecky S, Engel A, Goldsher D, Hayek T. Hypoplasia of the in­ferior vena cava with azygos continuation presenting as recurrent leg deep vein thrombosis. Am J Med Sci 2000; 319: 414-46. 17. Obernosterer A, Aschauer M, Schnedl W, Lipp RW. Anomalies of the inferior vena cava in patients with iliac venous thrombosis. Ann Intern Med 2002; 136: 37-41 18. Sardi A, Minken SL. The placement of intracaval filters in an anomalous (left-sided) vena cava. J Vasc Surg 1987; 6: 84-6. 19. Kler TS, Bhatia A, Saxena A, Sardana R, Arora V. Catheter ablation of left free wall accessory pathway in a patient with inferior vena cava interruption. Indian Heart J 2002; 54: 705–7. 20. Vijayvergiya R, Bhat MN, Kumar RM, Vivekanand SG, Grover A. Azygos continuation of interrupted inferior vena cava in association with sick sinus syndrome. Heart 2005; 91: 26. 21. Wolfhard U, Splittgerber FH, Gocke P, Peidemeister JC. Bilateral inferior vena cava with azygos continuation but without congenital heart disease complicates routine venous cannulation for cardiopulmonary bypass in an adult. Thorac Cardiovasc Surg 1997; 45: 40-2. 22. Pavcnik D, Tekulve K, Uchida BT, Pavcnik Arnol M, VanAlstine W, Keller FS, et al. Biodisk: A new device for closure of patent foramen ovale. A feasibility study in swine. Catheter Cardiovasc Interv 2010; 75: 861-7. research article Direct coronary stenting in reducing radiation and radiocontrast consumption Jasmin Caluk1, Enes Osmanovic1, Fahir Barakovic2, Zumreta Kusljugic2, Ibrahim Terzic1, Selma Caluk2, Amela Sofic3 1 BH Heart Center Tuzla, Department of Interventional Cardiology, Tuzla, Bosnia-Herzegovina 2 University Clinical Center Tuzla, Department of Internal Medicine, Tuzla, Bosnia-Herzegovina 3 Clinical Center of Sarajevo University, Department of Radiology, Sarajevo, Bosnia-Herzegovina Received 24 November 2009 Accepted 11 February 2010 Correspondence to: Jasmin Caluk M.D., Ph.D., BH Heart Center Tuzla, Department of Interventional Cardiology, Ul. Izeta Sarajlica bb, 75000 Tuzla, Bosnia-Herzegovina. E-mail: j.caluk@gmail.com Disclosure: No potential conflicts of interest were disclosed. Introduction. Coronary stenting is the primary means of coronary revascularization. There are two basic techniques of stent implantation: stenting with balloon predilatation of stenosis and stenting without predilatation (direct stenting). Limiting the time that a fluoroscope is activated and by appropriately managing the intensity of the applied radia­tion, the operator limits radiation in the environment, and this saves the exposure to the patient and all personnel in the room. Nephrotoxicity is one of the most important properties of radiocontrast. The smaller amount of radiocon­trast used also provides multiple positive effects, primarily regarding the periprocedural risk for the patients with the reduced renal function. The goal of the study was to compare fluoroscopy time, the amount of radiocontrast, and expenses of material used in direct stenting and in stenting with predilatation. Patients and methods. In a prospective study, 70 patients with coronary disease were randomized to direct stent-ing, or stenting with predilatation. Results. Fluoroscopy time and radiocontrast use were significantly reduced in the directly stented patients in com­parison to the patients stented with balloon-predilatation. The study showed a significant reduction of expenses when using a direct stenting method in comparison to stenting with predilatation. Conslusions. If the operator predicts that the procedure can be performed using direct stenting, he is encouraged to do so. Direct stenting is recommended for all percutaneous coronary interventions when appropriate conditions have been met. If direct stenting has been unsuccessful, the procedure can be converted to predilatation. Key words: coronary stenting; balloon predilatation; percutaneous transluminal coronary angioplasty; expenses Introduction Heart is supplied with blood through coronary arteries. Disbalance in myocardial oxygen sup­ply and demand may cause myocardial ischemia with contractile dysfunction, arrhythmias, infarc­tion, and possibly death.1Interventional cardiol­ogy deals with catheter-based interventions in the treatment of the structural heart disease. Coronary stent implantation is the primary means of coro­nary revascularization.2Stenting of arterial steno-sis in other organs is also the method of choice as the minimally invasive interventional procedure.3There are two basic techniques of the coronary stent implantation. The first one consists of PTCA (percutaneous transluminal coronary angioplasty)­balloon predilatation of stenosis before stenting, a sort of ‘preparing the ground’ for stenting itself. This technique is the usual, or the conventional one, evolved from bail-out stenting used to treat complications, such as coronary dissection, in the era of PTCA. The second technique is somewhat newer. It implies stent implantation without pre-dilatation, and is called ‘direct stenting’. Fluoroscopic radiation is a carcinogen that can also cause a severe injury (radiation burns) to pa­tients and practitioners.4When fluoroscopy is well managed, the likelihood that these severe effects 154 Caluk J et al. / Direct coronary stenting could occur is extremely low. Medical practition­ers who have accumulated considerable radiation doses have been shown to have developed radia­tion-induced cancers, cataracts, or skin injury.5-7Attention to rigorous radiation abatement meas­ures is therefore warranted and required.8Time, intensity, distance, and shielding (TIDS) describes the management of the radiation exposure by min­imizing the time to which one is exposed to radia­tion, by minimizing the intensity of the radiation that is deployed, by maximizing the distance from the source, and by shielding the personnel from the radiation. The operator can limit the radiation in the cathlab by limiting the time that the fluoro­scope is activated and by appropriately managing the intensity of the applied radiation, thus reduc­ing the exposure to the patient and all personnel in the room. Cardioangiographic equipment is one of the most sophisticated and complex equipment used in medicine.4The goal in cardioangiographic imaging is to produce an X-ray beam that results in an excellent compromise between the appropri­ate image quality and the radiation dose. Limiting the beam-on time limits the exposure time for the patient, but also for the personnel. Blood vessel walls and myocardium have simi­lar X-ray absorbance to that of blood, making their imaging by conventional radiographic techniques virtually impossible without the use of the intra-vascular contrast agent. Therefore, the use of radio-contrast is absolutely necessary in order to obtain images of coronary arteries. Those images are ob­tained by directly injecting the radiocontrast into the coronaries and recording an X-ray image, or sequence. Adverse reactions to radiocontrast are most importantly anaphylactoid, but also toxic effects, such as nausea or vomiting, but the inci­dence of adverse reactions has been significantly reduced with the use of nonionic contrast media.9Nephrotoxicity is one of the most important prop­erties of radiocontrast. The smaller amount of ra­diocontrast used also provides multiple positive effects, primarily regarding the periprocedural risk for the patients with the reduced renal function. Contrast induced nephropathy (CIN) causes renal failure, increased morbidity, prolonged hospital stay, higher hospitalization costs, and increased mortality.10Although its pathogenesis remains unclear, CIN is probably due to a combination of decreased renal medullary perfusion (possibly be­cause of alterations in renin-angiotensin system, nitric oxide synthesis, adenosine metabolism, pros-tacyclin production, and endothelin synthesis)11-13, resulting in critical medullary ischemia and direct tubular toxicity.14Patients with diabetic nephropa-thy are at especially great risk from CIN. Although it is logical to assume that the risk is reduced when using smaller amounts of contrast per procedure, there is no consensus regarding a ‘safety dose’. Additional benefits from the reduced radiocontrast use are primarily economical, for these agents are relatively expensive. The goals of the study were: To compare fluoroscopy time as a measure of radiation exposure during direct coronary stenting and stenting with predilatation. To compare the amount of radiocontrast used during direct coronary stenting and stenting with predilatation. To compare expenses of material used in direct stenting and in stenting with predilatation. Patients and methods In a prospective study, 70 patients that have under­gone coronary stent implantation as the treatment of coronary disease were analyzed. The patients were randomized into two groups of 35 patients each. The patients in one group were treated by stenting with PTCA-balloon predilatation, and the patients in the other group – by direct stenting. Groups were similar by the criteria of age, gender, affected coronary arteries, types of stents used for the treatment, and severity of coronary stenoses. Exclusion criteria were: acute myocardial infarc­tion, two or more stenoses treated per patient per procedure, and chronic total coronary occlusions on coronary angiography finding. All patients have undergone prior selective cor­onary angiography. Thereafter, the patients rand­omized to conventional stenting had their coronary stents implanted after PTCA-balloon predilatation, and those randomized to direct stenting had their stents implanted directly into coronary lesions, without the prior PTCA-balloon predilatation. Fluoroscopy time measured in seconds and ra­diocontrast dye use measured in milliliters were recorded for all patients. Selective coronary an­giography and percutaneous coronary interven­tions (PCIs) were performed on cardioangiograph Siemens Axiom. Results There were no significant differences in age (p=0.17) or gender (p=0.51) between the groups. TABLE 1. Intensity of coronary stenoses, observed by coronary arteries in investigated groups n % stenosis n % stenosis -RCA 9 86.11 ± 6.50 7 86.42 ± 5.56 0.91 Artery -LAD 21 84.28 ± 6.18 17 87.64 ± 5.62 0.09 -CX 5 83.00 ± 6.70 11 87.72 ± 5.64 0.16 Legend: RCA – right coronary artery, LAD – left anterior descending coronary artery, CX – circumflex coronary artery, DS – direct stenting; SWP – stenting with predilatation. Values are displayed as mean, standard deviation, and in absolute numbers. TABLE 2. Amount of radiocontrast used and fluoroscopy time in investigated groups Fluoroscopy time s 204.1 ± 98.46 392.8 ± 207.7 ‡*0.0001 Radiocontrast ml 280 (100 – 350) 350 (200 – 400) .0.0001 Legend: s-second, ml-millilitre; DS – direct stenting; SWP – stenting with predilatation ; ‡*Student T-test (df 68, test statistic 4.85, p < 0.0001); .Mann-Whitney test (Large sample test statistic Z -4.58; p < 0.0001). The average age in directly stented group was 57.40±10.03, and that in the conventionally stented group 54.31±8.70. The most often affected coronary artery was left anterior descending coronary artery in both groups (p=0.23). There was no significant difference in stenosis intensity between the groups (Table 1). During the study, no ECG showed signs of new­ly onset myocardial necrosis (new Q-wave), nor new bundle-branch blocks, which would speak in favor of significant myocardial necrosis. Fluoroscopy time and radiocontrast use were significantly reduced in patients that were stented directly, in comparison to patients stented with prior balloon-predilatation (Table 2). In both groups, using quantitative coronary angiography (QCA), we found a complete elimi­nation of previous stenosis to 0% in all patients, without residual stenoses. We found no major ad­verse cardiac events (MACE), defined as urgent coronary revascularization, myocardial infarction, lethal outcome in either of the groups. A financial analysis of the expenses of materials used during direct stenting, and stenting with pre-dilatation showed an average reduction of costs of 27.86±2.81 % (p<0.05) when using the direct stent-ing method in comparison to stenting with predila­tation. The basic role in this cost reduction plays the elimination of the use of PTCA balloon for pre-dilatation and lower amount of radiocontrast used in direct stenting. Discussion During 1993 two important trials compared the im­plantation of Palmaz-Schatz coronary stents to con­ventional PTCA, and established coronary stent-ing as the standard treatment. The BENESTENT trial involved 520, and the STRESS trial 410 pa­tients, independently demonstrating that coronary stents reduce restenoses (>50% of new stenosis of the earlier treated artery at the site of treatment – PTCA or stenting).15,16 As early as 1999, stenting took 84.2% of all PCIs.17Direct stenting is defined as positioning and implantation of stent without balloon-predilatation of coronary stenosis.18It is a new strategy of the coronary disease treatment enabled by the development of the advanced stent and the implantation system design with the low cross-section area, high safety standards, and high rated burst pressures.19Initial registers show a high success rate in combination with low complication rates.20The procedure is safe in selected cases, and can help reducing the expense of coronary inter­ventions through the reduction in total procedural and fluoroscopy time, the amount of radiocontrast and the number of angiographic catheters used.21,22 156 Caluk J et al. / Direct coronary stenting Wilson et al.showed that direct stenting has posi­tive effects on total procedural time, radiation exposure, and the use of radiocontrast.23In our research, direct stenting has significant positive effects regarding these criteria too, in comparison to stenting with predilatation. The procedural out­come seems to be superior without predilatation, because of the reduced incidence of coronary dis­sections at stent edges.24In our study, the proce­dural outcome was the same in both groups: the reduction of coronary stenoses, measured by quan­titative coronary angiography, was complete to 0% in all patients, without residual stenoses. We have found no edge-dissections as a periprocedural complication. In the group of patients treated by stenting with predilatation, 2 out of 35 patients had localized small, non-obstructive coronary dissec­tions after balloon-predilatation, which were rou­tinely covered by stent implantation immediately afterwards. In the directly stented group, out of 35 patients, there were no coronary dissections after stenting. In the DISCO trial, conducted in 10 cent­ers in Spain, 416 patients with 446 coronary lesions were randomized to conventional or direct stent­ing.25The main goal of this trial was to evaluate safety, feasibility, and the effect on angiographical restenosis of direct stenting in comparison to the conventional method of stenting with predilata­tion. The direct stenting strategy was effectively accomplished in 97% of lesions, and the patients converted to the predilatation strategy were all treated successfully. In our research (on a much smaller sample), the direct stenting strategy was successfully accomplished in all patients of that group, and there was no conversion to the pre-dilatation strategy. Of course, it is only realistic to assume that a randomized sample that would in­clude a larger number of patients would result in a certain small number of patients to be converted to predilatation, which we observe sometimes in our daily practice, especially in patients with criti­cal sub-occlusions or highly calcified lesions. In our study, we found no MACEin either group. We have also found no major peri- or postprocedural complications. There were no electrocardiographi-cal signs of myocardial necrosis, periprocedurally, or during the one-month follow-up. The reduction of fluoroscopy time is very impor­tant both for the patient and for the staff. Ionizing radiation is one of the leading causes of malignan­cies26, and the staff, especially the operator who is close to the radiation source and the source of scattered radiation during the entire intervention, is under a significant health risk.27According to our study, the fluoroscopy time was significantly reduced during direct stenting (p=0.0001) in com­parison to conventional stenting, regardless of the artery treated. While we found fluoroscopy time to be 392.8±207.7 s during stenting with predilata­tion, we observed that this value in direct stenting was 204.1±98.46s. In the study of Martinez-Elbal et al., the most important differences between the patients treated by direct or conventional stenting were significant fluoroscopy time reduction in di­rect stenting when compared to stenting with pre-dilatation (6.4 min: 9.2min, respectively, p<0.0005) and significant reduction of total procedural time (21.2 min: 27.8 min, respectively, p<0.0005).25The interventional radiation environment creates the conditions for accumulation of high doses in the staff. That is why it is essential to pay attention to rigorous measures of decreasing radiation expo­sure.8 The smaller amount of radiocontrast used also provides multiple positive effects, primarily re­garding the peri-procedural risk for the patients with reduced renal function. The main adverse effects from radiocontrast use are anaphylactic re­actions and contrast-induced nephropathy (CIN). The use of radiocontrast, measured in milliliters, in our research was significantly lower in direct stent-ing, than in stenting with predilatation (280 (100­350) : 350 (200-400), respectively, p=0.0001). We found no CIN in either of the groups. Additional benefits from the reduced radiocontrast use are primarily economical, for these agents are relative­ly expensive. With the elimination of expenses by saving PTCA-balloons and their dilatation catheters, the reduction in radiocontrast use also significantly reduces the overall cost of the intervention. In our study, a 27.86±4.81 % (p<0.05) cost reduction was recorded when using direct stenting in comparison to stenting with predilatation. The expenses related to the material used were taken into account. This sort of cost saving is similar to the reports of other authors, who describe cost savings in the range 20%-40% with the use of direct stenting.18 Conclusions Direct stenting is defined as positioning and im­plantation of coronary stents without prior balloon dilatation of coronary stenosis. It can be used to ac­celerate the procedure and reduce intimal trauma. Complex lesions in small arteries and severe cal­cifications limit the use of this technique. Direct stenting reduces health risks connected to radia­tion by significantly reducing fluoroscopy time. It also decreases the risk of contrast induced neph­ropathy by using significantly less radiocontrast when compared to stenting with predilatation. Direct stenting is not connected to an increased risk of major adverse cardiac events (acute myocardial infarction, urgent coronary revascularization, le­thal outcome) in comparison to stenting with pre-dilatation. New low-profile stents with high rated burst pressure values have enabled the routine use of this PCI technique. If direct stenting has been unsuccessful, the procedure can be converted to predilatation. If the operator predicts that the pro­cedure can be performed using direct stenting, he is encouraged to do so. Direct stenting is recom­mended for all percutaneous coronary interven­tions when appropriate conditions have been met. References 1. Braunwald E. Myocardial oxygen consumption: The quest for its deter­minants and some clinical fallout. J Am Coll Cardiol 2000: 35: 45B-8B. 2. Gilard M, Cornily JC, Pennec PY, Le Gal G, Nonent M, Mansourati J, et al. Assessment of coronary artery stents by 16 slice computed tomography. Heart 2006: 92: 58-61. 3. Gjikolli B, Hadzihasanovic B, Jaganjac S, Herceglija E, Niksic M, Hadzimehmedagic A, et al. Treatment of complicated case with subclavia steal syndrome and stenosis of common iliac artery. Radiol Oncol 2008; 42: 1-12. 4. Wagner LK. 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Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175: 621-8. 10. McCullough PA, Wolyn R, Rocher LL, Levin RN, O’Neill WW. Acute renal failure after coronary intervention: incidence, risk factors, and relation­ship to mortality. Am J Med 1997; 103: 368-75. 11. Deray G. Festschrift for Professor Claude Jacobs. Nephrotoxicity of con­trast media. Nephrol Dial Transplant 1999; 14: 2602-6. 12. Pflueger A, Larson TS, Nath KA, King BF, Gross JM, Knox FG. Role of adenosine in contrast media-induced acute renal failure in diabetes mel­litus. Mayo Clin Proc 2000; 75: 1275-83. 13. Margulies KB, Hildebrand FL, Heublein DM, Burnett JC Jr. Radiocontrast increases plasma and urinary endothelin. J Am Soc Nephrol 1991; 2: 1041-5. 14. Barrett BJ. Contrast nephrotoxicity. J Am Soc Nephrol 1994; 5: 125-37. 15. Serruys PW, de Jaegere P, Kiemeneij F, Macaya C, Rutsch W, Heyndrickx G, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994; 331: 489-95. 16. Fischman DL, Leon MB, Baim DS, Schatz RA, Savage MP, Penn I, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994: 331: 496-501. 17. Holmes DR Jr, Savage M, LaBlanche JM, Grip L, Serruys PW, Fitzgerald P, et al. Results of Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial. Circulation 2002: 106: 1243-50. 18. Barbato E, Marco J, Wijns W. Direct stenting. Eur Heart J 2003: 24: 394­403. 19. Ijsselmuiden AJJ, Serruys PW, Scholte A, Kiemeneij F, Slagboom T, et al. Direct coronary stent implantation does not reduce the incidence of in-stent restenosis or major adverse cardiac events. Eur Heart J 2003: 24: 421-9. 20. Herzum M, Cosmeleata R, Maisch B. Managing a complication after direct stenting: removal of a maldeployed stent with rotational atherec­tomy. Heart 2005; 91: e46. 21. Miketic S, Carlsson J, Tebbe U. Clinical and angiographic outcome after conventional angioplasty with optional stent implantation compared with direct stenting without predilatation. Heart 2002; 88: 622-6. 22. Briguori C, Sheiban I, De Gregorio J, Anzuini A, Montorfano M, Pagnotta P, et al. Direct coronary stenting without predilation. J Am Coll Cardiol 1999; 34: 1910-5. 23. Wilson SH, Berger PB, Mathew V, Bell MR, Garratt KN, Rihal CS, et al. Immediate and late outcomes after direct stent implantation without balloon predilatation. J Am Coll Cardiol 2000; 35: 937-43. 24. Ballarino MA, Moreyra E Jr, Damonte A, Sampaolesi A, Woodfield S, Pacheco G, et al. Multicenter randomized comparison of direct vs con­ventional stenting: the DIRECTO trial. Catheter Cardio Interv 2003; 58: 434-40. 25. Martinez-Elbal L, Ruiz-Nodar JM, Zueco J, López-Minguez JR, Moreu J, Calvo I, et al. Direct coronary stenting versus stenting with balloon pre-dilation: immediate and follow-up results of a multicentre, prospective, randomized study. The DISCO trial. Eur Heart J 2002; 23: 633-40. 26. Botros M, Quevedo JF, Miller RC. Angiosarcoma of the liver after mul­timodality therapy for gallbladder carcinoma. Radiol Oncol 2009; 43: 126-31. 27. Miklos M, Gajski G, Garaj-Vrhovac V. Usage of the standard and modified comet assay in assessment of DNA damage in human lymphocytes after exposure to ionizing radiation. Radiol Oncol 2009; 43: 97-107. 158 research article Diagnostic imaging of traumatic pseudoaneurysm of the thoracic aorta Serif Beslic, Nermina Beslic, Selma Beslic, Amela Sofic, Muris Ibralic, Jasmina Karovic Institute of Radiology, Sarajevo, Bosnia and Herzegovina Received 24 January 2010 Accepted 2 April 2010 Correspondence to: Prof. Šerif Bešlic, MD, PhD, Clinical Centre University Sarajevo, Radiology Clinic, Bolnicka 25, 71000 Sarajevo. Phone: +387 3344 4553; Fax: +387 3344 4553; E-mail: sbeslic@bih.net.ba Disclosure: No potential conflicts of interest were disclosed. Background. The purpose of the study was the presentation of findings and diagnostic imaging in patients with trau­matic pseudoaneurysms of the thoracic aorta, as a rare consequence of road traffic accidents. Patients and methods. In 22 years we have found 8 traumatic pseudoaneurysms of the thoracic aorta, out of which 7 (87.5%) in male and 1 (12.5%) in female patients. At the time of accidents the youngest patient was 21 and the oldest was 55 (mean age 33.8 years), and at the moment of diagnosing a pseudoaneurysm they were 26 and 55 years old, respectively (mean age 38.7 years). In all patients chest radiography was performed as well as CT scan, in 6 (75%) patients intra-venous digital subtraction angiography was performed (i.v. DSA) and in 1 (12.5%) MRI. CT was performed with the application of 120 ml, and i.v. DSA with 60 ml of contrast medium, respectively. Results. In 8 (100%) patients, who suffered a road traffic accident, and whose chest radiograph showed the enlarge­ment of the aortic knob and widening of the mediastinum, CT, i.v. DSA and MRI revealed a traumatic pseudoaneu­rysm of the thoracic aorta. Periods of time between the accidents and the initial diagnosis of the pseudoaneurysm varied from 7 days to 18 years (median 2.0 years). The diameter of the pseudoaneurysm was from 4.5 to 9.2 cm (me­dian 5.5 cm). In 7 (87.5%) isthmus was involved, and in 1 (12.5%) descending thoracic aorta, respectively. The chest radiograph revealed marginal calcifications in 4 (50%), and on the CT in 5 (62.5%) patients. Intraluminal thrombosis was found by CT in 2(25%) traumatized patients. Conclusions. Traumatic pseudoaneurysm should be taken into consideration in blunt chest trauma, where a chest radiograph shows suspicious regions. A multislice CT is a diagnostic method of choice. Key words: traumatic pseudoaneurysm; chest radiography; CT; i.v. DSA; MRI Introduction Backin1557,Vesaliusdescribedapostmortem findingofanaorticrupture,whichhesuspected hadbeencausedbyatrauma.DuringtheFirst WorldWar,theaorticrupturewasfrequentlyno­ticedinvictimsofplanecrashes.Immediatelyafter theSecondWorldWar,in1947,Strassmanpub­lished72casesofaortictraumaswithfrequency of1%.1Thedevelopmentoftrafficandmotorvehi­clesgeneratedmoreinterestintraumaticchanges, whichbecamemoreandmorefrequent.InIreland, theannualmortalitycausedbydamagetothoracic bloodvesselsduringmotorvehicleaccidentswas approximately3%fortheperiod1995–1998.In 1966,Greendykereportedaboutanumberofvic­timsofaccidentaldeathswhosebodieshadbeen examinedinanautopsy,where10%ofwhomhad sufferedfromaorticrupture,mostlyinmotortraffic accidents.Hestatedthatinoneoutofsixfatalacci­dents,thevictimsufferedfromtheaorticrupture.2,3 Injuriestotheaortamaybecausedbyadirect penetrationoftheaortabyaknife,bulletorafor­eignbody,ortheycanbearesultofablunttrauma.4Theycanappearasincompleteaorticrupture,andas traumaticaorticdissection.5Survivorsmaydevelop chronictraumaticaneurysmorpseudoaneurysm.6 Chronic post-traumatic thoracic aneurysm of aorta is a secondary dilatation in the rupture of the isthmus of aorta, which may be unnoticed in the moment of trauma.7Most casesof aneurysm are lo­cated in the inner side of the aortic arch with a ven­tral extension.8In contrast to atherosclerotic aneu­rysm, post-traumatic aneurysm occurs in younger people, where 90% patients are younger than 45. In almost 50% of cases, they were detected acciden­tally during a systematic radiographic examina­tion. A detailed medical history can assist in asso­ciating this aneurysmatic formation with a trauma which had previously occurred many years ago.7 The traumatic aortic rupture may be difficult to be diagnosed, and if missed, it almost always leads to a fatal result. Thoracic radiography is considered to be a very useful screening method. Patients and methods Duringtheperiodof22yearswehavefound8post-traumaticpseudoaneurysmsofthoracicaorta,in7 (87.5%)maleand1(12.5%)femalepatient.Atthe momentoftheiraccidenttheyoungestpatientwas 21andtheoldestwas55(meanage33.8),andat themomentofdiagnosingapseudoaneurysmthey were27and55yearsold(meanage38.7).Overthe periodof22yearsdifferentdiagnosticmethods wereused,dependingontechnologicalachieve­mentsanddiagnostictoolsthatwehavehadondis­posalatdifferenttimes.All8(100%)patientshada chestradiographandCTscanperformed(7exami­nationswereperformedonsequentialSomatom DR,and1onthefour-rowVolumeZoomSiemens), 6(75%)patientshadi.v.DSAand1(12.5%)patient hadaMRIscan.CTexaminationswereperformed withthei.v.applicationof120ml,andi.v.DSAwith 60mlofcontrastmedium.MRIscanexamination wasperformedonMagnet1TSiemensunit,with the“timeofflight”(TOF)sequence.Considering that7examinationswereperformedonsequential CTunit,andonlyoneonthemultislicemachine, the“roadmaps“reviewwasacquiredwithi.v.DSA in6casesandoncewithMRI,beforemakingadeci­sionconcerningthesurgicaltreatment. Results In 8 (100%) patients who suffered road traffic ac­cidents, who had signs of mediastinal widening and enlargement of the aortic knob (Figure 1A, B), some had lamellar calcifications as well, the trau­matic pseudoaneurysm was proved by CT (Figure 2A, B), i.v. DSA and MRI (Figure 3). In 7 (87.5%) patients it was a chronic posttraumatic pseudoan­eurysm, and in only one case it was an acute post-traumatic pseudoaneurysm. The period from the accident to the diagnosis of the pseudoaneurysm was 7 days in the last patient, and in the others it was between 2 months and 18 years (median 2.0 years). The diameter of the pseudoaneurysm was 4.5 to 9.2 cm (median 5.5 cm). In 7 (87.5%) injured patients the isthmus was involved, and in 1 (12.5%) case it was the descending thoracic aorta. In all 8 FIGURE 1A, B. Chest x – ray of aortic knob enlargement. 160 Beslic S et al. / Traumatic pseudoaneurysm (100%) patients the chest radiograph has shown the enlargement of the aortic knob and widening of the mediastinum. The chest radiographs have shown marginal calcifications in 4 (50%), and CT in 5 (62.5%) patients. Intraluminal thrombosis was discovered by CT examinations in 2 (25%) trauma­tized patients. All three methods have shown the presence of the posttraumatic pseudoaneurysm of the thoracic aorta. The chest radiograph was the initial method indicating pathology (Figure 1A, B). The largest diameter of the posttraumatic pseu­doaneurysm was 9.2 cm, and it was detected in the pregnant patient 8 years after the accident, while the aneurysm detected 18 years after the accident in a male patient had a diameter of 7 cm. The char­acteristics and localization of the posttraumatic pseudoaneurysms are presented in Table 1. CT scanning had a 100% specificity and sensitiv­ity, and also provided the additional information on the wall calcification and thrombotic masses, as well as some other findings in the thorax. Six(75%)patientsweretreatedwiththesurgical placementofaDacrongraft,andthelastcasedi­agnosedwithmultisliceCT7daysaftertheinjury, wastreatedwiththeplacementofastentgraft.One patientdidnotagreetoundergoasurgicalopera­tion,andhasbeenoccasionallycheckedupfora longerperiod. Discussion The traumatic rupture of the thoracic aorta is a rare condition in critically injured victims of a blunt trauma. The cause for the trauma are falls from heights >3 m, and motor vehicle crashes, so that some authors believe that all victims of significant decelerating traumas should be referred to an angi­ographic examination of the aorta. A blunt trauma can damage the thoracic aorta with several mechanisms, by the fracture dislocat­ing thoracic vertebrae, or by the penetration of the first rib and clavicula. A very high pressure may occur in the aorta due to various forces occurring in the thorax caused by acceleration, either in hori­zontal or vertical plane in the moment of impact (the effect of a water hammer) and the rupture is caused by an explosive burst. During a motor traffic accident, the descending aorta remains fixed to the back thoracic wall by means of interosseous arteries, whilst the heart and ascending aorta contort toward the front and the split occurs within the isthmus, which is the most common rupture site.1 According to the referential data, about 90% of injuries include the region of the aortic isthmus, immediately distal from ligamentum arteriosum, and the left subclavical artery with ripping of ves­sels of the arch. Splits of ascending aorta, of distal descending aorta, or of abdominal aorta are much less common.7,9In this analysis we had 7 (87.5%) TABLE 1. Characteristics and localization of the posttraumatic pseudoaneurysms 1 M 7 days 4.8 cm --Isthmus Stent 2 M 2 years 5.2 cm + -Isthmus Dacron graft 3 M 60 days 4.5 cm --Isthmus Dacron graft 4 M 18 years 7.0 cm + + Isthmus Dacron graft 5 M 2 years 5.5 cm + + Descending aorta Dacron graft 6 M 9 years 6.0 cm + -Isthmus Refused treatment 7 M 180 days 5.5 cm --Isthmus Dacron graft 8 F 8 years 9.2 cm + -Isthmus Dacron graft isthmic lesions and one lesion of the descending thoracic aorta. According to the literature, most victims die im­mediately (85%), whilst those who manage to get to hospital, if they are properly diagnosed, may have a surgical or another reparation procedure done. The aortic injury may be limited to a partial cir­cumferential split in the intima and/or media of the aortic wall.5 About 15-20% of them survive an acute episode long enough to manage to get to hospital, with a periaortic haematoma and false aneurysm since adventitia has not been ruptured yet.3,4,10 The traumatic rupture of the thoracic aorta may occur at any time, sometimes during the exami­nation procedure, whilst some patients appear to be in a more stable condition. Many patients can be referred to treatments of other life threatening conditions before the reparation of the traumatic rupture of the thoracic aorta, although a postponed therapy is not routinely recommended.11 According to some data, about 2% to 5% of pa­tients are discharged from hospital without being diagnosed with the traumatic pseudoaneurysm of the thoracic aorta, so that a chronic post-traumatic aneurysm develops later on.4,7,8 In most cases, they suffer a secondary rupture, which results in death later on. However, there are rare reports in medical literature about a prolonged period of surviving.3 It has been suggested in medical literature that the enlargement and the risk of the rupture pro­gressively increase the longer the aneurysm is present.8In this analysis, posttraumatic pseudoan­eurysm of the aorta was found in 8 patients, out of which in 7 (87.5%) cases at the isthmus, which is in accordance with the literature. The median time period from the accident un­til the detection of pseudoaneurysm was 2,0 years, while in one patient it was as long as 18 years. This demonstrates the potentially long survival period in some patients. The primary damage of the aortic wall prob­ably influences the development and the size of the aneurysm. With time, lamellar calcifications will develop around the pseudoaneurysm, which were found in 62.5% of cases, mainly in patients with the pseudoaneurysms over 2 years old. Calcifications can be seen in a chest radiograph, and especially on multislice CT. It is possible that they have a certain role in the length of the survival in such patients. Intramural thrombosis in these patients was rare, in only 2 (25%) patients. All described post-traumatic pseudoaneurysms were chronic, except in one patient where it was detected 7 days after the accident. The traumatic rupture of the thoracic aorta is a highly lethal condition and is often combined with multiple injuries, all of which may require an im­mediate evaluation and treatment.11 Clinicians keep perplexed how such a cata­strophic lesion presents with so few real symptoms and signs. It is crucial that the emergency health practitioner recognizes it in making an initial diag­nosis. Quite often those subtle changes remain un­noticed in the initial stage and remain undetected until the complete rupture and death occur.3 Symptoms of the traumatic rupture of the tho­racic aorta include: chest pain, dyspnoea, back­ache, harsh voice, dysphasia and cough, as well as contusion of the front wall of the chest, with the impression of the wheel on the front part of the chest, and the acute coarctation syndrome.3,9The unstable condition of a bleeding patient should also raise suspicion. Thoracicradiographyisaninitialanalysismost frequentlyusedforverifyingthetraumaticrupture ofthethoracicaorta.Itisindicativeinalmosthalf 162 Beslic S et al. / Traumatic pseudoaneurysm ofallcases.Theinterpretationofthoracicradiogra­phyinthepatientinlyingpositionisdifficult.The extensionandchangesintheshapeofthemediasti­numonradiographyarethemostimportantsigns oftheaorticruptureandtraumaticpseudoaneu­rysmoftheaorta(Figure1A,B).Themostfrequent­lyradiographicsignsreportedare:abnormalshape oftheaorta,shadingofaortic-pulmonarywindow, leftmajorbronchusshiftdownwards,deviationof tracheatotherightfromthemedialline,shiftofthe nasogastrictubus,apicalcapandbordercalcifica­tionsontheouterpartofthemass,etc.Haematomas mostcommonlycomefromsmallarteriesandveins inthemediastinum.Some7.3%ofpatientshavea normalmediastinumpresentedontheinitialra­diography,unlessthetraumaticpseudoaneurysm hasbeenfollowedbyamediastinalhaemorrhage, orhaematoma,orthepseudoaneurysmhasbeen verysmall,orithasbeenlocatedinsuchmanneras tokeepthemediastinalshapeunchanged.3,8 In this study, the chest radiography in 8 patients (100%) with post-traumatic pseudoaneurysm of the thoracic aorta, showed an enlargement in the mediastinum, as well as an enlargement of the aor­tal knob. In 4 patients (50%), lamellar border cal­cifications were also noticed. History of the road traffic accident directed the diagnostic method. Untilrecently,aortographywasthemostaccept­edstandardamongstmethodsofscreeningsforthe signsofthetraumaticruptureofthethoracicaorta. Theproblemwithaortographyisthatitisaninva­sivemethodwhichusesiodineasacontrastmedi­um,anditalsogivesaninadequatepictureofintra-luminalthrombosis.Althoughaortographywasthe mostacceptedstandard,itwasnotfreefromfalse-positiveandfalse-negativeresults.Theproblemis alsothetransportationofapotentiallyunstablepa­tienttotheareaforthevascularexamination. In this analysis, the posttraumatic pseudoan­eurysm was in 7 (87.5%) casesconfirmed with se­quential CT scan and in 6 (75%) cases it was sup­plemented with i.v. DSA. In 1 (12.5%) case the posttraumatic pseudoaneurysm was confirmed with MRI, and the last one with the multislice CT (Figure 2A, B). In 1976, transoesophageal echocardiography ap­peared, as a method to complement and possibly substitute aortography of the arch in the evalua­tion of unstable multiple traumatized patients with a potential rupture of the aorta. The examination is less invasive, it does not require a contrast me­dium, it can be performed with the patient lying in bed, and lasts for 15 minutes. However, it depends highly on the professional who performs it, it is not always available, and there is also a problem due to securing airways and cervical spine. With the emergence of a spiral CT (SCT), it has confirmed to be efficient for screening of critically injured patients with the traumatic rupture of the thoracic aorta. In 1998, Wicky et al.reported that with the blunt trauma to the chest and injury to the aorta, CT has 100% of sensitivity, and 99.8% of specificity, with 89% positive and 100% negative predictive values, and the total diagnostic accuracy of 99.7%.12CT examination results typically consist of a sack-shape bulge which has been demarked from the aortal lumen with a collar. According to this author, an operation based on CT is safe and expeditious. A positive SCT leads to thoracotomy, whereas a negative one excludes it. According to this author, an angiogram is unnecessary and it only delays a definite therapy, whilst a positive CT is the only diagnostic method which needs to be done prior to referring a patient to the theatre.10 Contrary to the conventional angiography, a multilayered CT angiography not only shows blood vessels, but it also allows an evaluation of nearby structures, or determining of optimal stent-graft values.13The endovascular stent graft, is a very useful method in managing the aneurism as a minimally invasive procedure.14 A more liberal use of CT in evaluation of patients with a blunt trauma has resulted in making more diagnoses of aortal splits, which could certainly be treated without surgery.13 The diagnosis of post-traumatic pseudoaneurysm in this study has been confirmed by using CT in 8 (100% cases), i.v.DSA in 6 cases (75%), and MRI in 1 case (12.5%). CT has confirmed to be an excellent method in depicting the aneurismal sack, calcifications and thrombus within the pseudoaneurysm (Figure 2A, B). A cardiovascular MRI is a non-invasive exami­nation, without irradiation, for the evaluation of the real and false aneurysm of aorta. 3D gadolin­ium-enriched magnet resonance angiography col­lects information and thus enables a detailed ex­amination of aneurysm and its relationship with other structures.6The weakness of this procedure is in its slowness, also its frequent inability to con­nect to monitoring devices needed in urgent situa­tions, and a poor visibility of calcified deposits and changes in pulmonary parenchyma (Figure 3). Until recently the treatment of patients with the traumatic injury of the thoracic aorta has been surgical with an operative death rate between 3.5­4.6%, or the risk of a post-operative paraplegia.8,9,15However, the latest studies emphasise that pa­tients treated with the endovascular stent graft stay shorter in hospital compared to those who have been referred to the open surgery.15 In this study, 6 patients were treated with the open surgery and the placement of a Dacron graft, 1 patient was treated with the placement of an en-dovascular stent graft, while one patient has re­jected an open surgery and has been periodically checked up. Conclusions It is significant to point out the hidden nature of the traumatic rupture of the thoracic aorta, which may be undiagnosed and many years later accidentally revealed as a chronic posttraumatic pseudo aneu­rysm of the thoracic aorta, unless it ruptures in the meantime and threatens the patient’s life. Pseudoaneurysm should be considered in pa­tients with a blunt chest trauma, and with suspi­cious chest radiographic findings. Multislice SCT angiography is a fast, safe and non-invasive imag­ing technique which can prevent the occurrence of late pseudoaneurysm formation of the thoracic aorta, with an excellent depiction of the aneurys­matic sack, marginal calcifications and thrombotic masses within the pseudoaneurysm, as well as of associated thoracic lesions. All departments that receive trauma patients should have a multislice CT. In most trauma centres CT screening is an inte­gral part of the diagnosis and care of patients with serious blunt injuries. References 1. Strassman G. Traumatic rupture of the aorta. Am Heart J 1947; 33: 508-15. 2. GreendykeRM.Traumaticruptureofaorta;specialreferencetoautomobile accidents. JAMA 1966; 195: 527-30. 3. O’Conor CE. Diagnosing traumatic rupture of the thoracic aorta in the emergency department. Emerg Med J 2004; 21: 414-9. 4. Sutton D, Gregson RHS. Arteriography and interventional angiography. In: Sutton D, editor. Radiology. Churchill Livingston: Elsevier; 2003. p. 425-6. 5. Alkadhi H, Wildermuth S, Desbiolles L, Schertler T, Crook D, Marincek B, et al. Vascular emergencies of the thorax after blunt and iatrogenic trauma: multi-detector row CT and three-dimensional imaging. Radiographics 2004; 24: 1239-55. 6. Chai P, Mohiaddin R. Traumatic pseudoaneurysm of the descending tho­racic aorta. Circulation 2005; 112: e260-1. 7. Roques X. Chronic post-traumatic aneurysms of the thoracic aorta. [French]. Rev Prat 1991; 41: 1789-92. 8. Heystraten FM, Rosenbusch G, Kingma LM, Lacquet LK. Chronic posttrau­matic aneurysm of the thoracic aorta: surgically correctable occult threat. AJR Am J Roentgenol 1986; 146: 303-8. 9. Rogers FB. Traumatic laceration of the aorta. N Engl J Med 2004, 351: 1239. 10. Fraser RS, Colman N, Muller NL, Pare PD. Synopsis of diseases of the chest. Third edition. Philadelphia: Elselvier-Saunders; 2005. p. 796-9. 11. Downing SW, Sperling JS, Mirvis SE, Cardarelli MG, Gilbert TB, Scalea TM, et al. Experience with spiral computed tomography as the sole diagnostic method for traumatic aortic rupture. Ann Thorac Surg 2001; 72: 495-501. 12. Wicky S, Capasso P, Meuli R, Fischer A, von Segesser L, Schnyder P. Spiral CT aortography: an efficient technique for the diagnosis of traumatic aortic injury. Eur Radiol 1998; 8: 828-33 13. Gjikolli B, Hadzihasanovic B, Jaganjac S, Herceglija E, Niksic M, Hadzimehmedagic A, et al. Treatment of complicated case with subclavia steal syndrome and stenosis of common iliac artery. Radiol Oncol 2008; 42: 1-12. 14. Pavlisa G, Ozretic D, Rados M, Pavlisa G. Migration of Enterprise stent in treatment of intracranial aneurysms: a report of two cases. Radiol Oncol 2009; 43: 233-9. 15. Lebl DR, Dicker RA, Spain DA, Brundage SI. Dramatic shift in the primary management of traumatic thoracic aortic rupture. Arch Surg 2006; 141: 177-80. 164 case report Radiological considerations in von Hippel-Lindeau disease: imaging findings and the review of the literature Melda Apaydin1, Makbule Varer1, Ozgur Oztekin2 1 Department of Radiology, Izmir Atatürk Education and Research Hospital, Izmir, Turkey 2 Department of Radiology, Izmir Education and Research Hospital, Izmir, Turkey Received 20 October 2009 Accepted 25 January 2010 Correspondence to: Melda Apaydin, MD, 236 Sokak 72/8, 35360 Hatay, Izmir, Turkey. Phone: +90 232 244 7290; Fax: +90 232 339 0002; E-mail: meldapaydin@gmail.com Disclosure: No potential conflicts of interest were disclosed. Background. Von Hippel Lindau disease is an autosomal dominant multisystem/multitumoral cancer disease diag­nosed by clinical, radiologic and genetic findings. Its prevalence has been estimated to be of 1/36000 inhabitants. The tumours can be benign or malignant. Case report. We represent MR findings of a family with ten children. Mother and five siblings had von Hippel-Lindau disease. Conclusions. Radiologic imaging is very important for the early diagnosis and treatment of asymptomatic patients. Diagnosing it early is important because the tumours in von Hippel Lindau disease are treatable. Also, an early detec­tion allows the patient’s survival and quality of life. A multidisciplinary team approach is important in screening. Key words: von Hippel-Lindau; magnetic resonance imaging; brain; spine; tumours Introduction von Hippel Lindau (VHL) disease was described in von Hippel’s literature in1911 and Lindau’s lit­erature in 1926.1Symptoms caused by VHL disease depend on the organ which was involved. Patients with the involvement of the central nervous system (CNS) at presentation are usually aged 25-35 years. CNS haemangioblastoma is the most commonly recognized manifestation of VHL disease and oc­curs in 40% of patients.2,3CNS lesions include hae­mangioblastomas and endolymphatic sac tumours. Visceral manifestations include renal/pancreatic carcinomas and cysts, neuroendocrine tumours and epidydimal cysts. The most important causes of mortality are renal cell carcinoma and cerebellar haemangioblastomas. We represent a family with von Hippel-Lindau disease and discuss imaging findings with regard to the literature. Case report Patients’ medical history and family history The MR findings of an intermarriaged family with VHL disease were presented. The family had ten children. Two female siblings died from central nervous system haemangioblastomas as like their mother (Figure 1). A 22 year-old male sibling had intraventricular choroid plexus papillomas (Figure 2) with cerebellar and spinal haemangioblasto-mas (Figure 3). A 33 year-old female patient had headache, tinnitus and abdominal pain. She had a history of endolymphatic sac tumour (Figure 4) treated by surgery. She was found to have cerebel­lar/spinal haemangioblastomas, pancreas and kid­ney cystic masses (Figure 5). The younger (21 year-old) asymptomatic female sibling was referred to the radiology department for magnetic resonance (MR) imaging. She was investigated for possible tumours. She was found to have ELST and cere-bellar/spinal haemangioblastomas (Figure 6) and underwent radiosurgical ablation (gamma-knife) therapy twice. She has been stabile for three years. The father and the other five siblings were found to be free of the disease. Discussion VHL disease is an autosomal dominant progressivedisorder that is associated with various tumours and cysts in the CNS and other visceral organs.1-5The VHL gene was identifiedin 1993 by Latif et al.by positional cloning.2The responsible gene is locatedon the chromosome 3p25-26. The gene has high penentrance but delayed or variable expres­sion and may cause widely different clinical mani­festations. VHL disease causes tumours in multiple organs.4Some studies showedthat the VHL gene is also inactivated in sporadic renal cell carcinoma, haemangioblastoma andpheochromocytoma.1 The clinical manifestation of the disease is re­ported in 14 different organs with 40 different lesions. These include retinal and CNS haeman­gioblastomas, endolymphatic sac tumours, renal cell carcinomasand cysts, pancreatic tumours and cysts, pheochromocytomas, and epididymal cys­tadenomas.4,5The most common CNS tumour is haemangioblastoma and occurs in 40% of patients.3Symptoms often begin in the second to third dec­ades of life. Patients may present with neurologic symptoms such as headache, ataxia, and blindness. The exact neurologic deficit depends on the site of the primary lesion.6,7The median life expectancy is 49 years.4Usually morbidity and mortality are associated with frequent surgeries to the tumour recurrence. Renal cell carcinomas are the cause of death in 30-50% of the patients.1 Molecular genetic testing allows the identifica­tion of a deletion or significant mutation that con­firms the diagnosis of VHL disease.4But there is also a clinical diagnosis in VHL disease. The diagnostic criteria for VHL disease are: • More than 1 haemangioblastoma in the CNS, • 1 CNS haemangioblastoma and visceral man­ifestations of VHL, or • 1 manifestation and a known family history of VHL.6 VHL disease was clinically classified into two types. Pheocromocytoma predicts the type. Those which accompanied with this tumour are VHL type 2.1 Imaging plays a key role in the identification of abnormalities and in the subsequent follow-up of lesions. It is also important in screening of individ­uals who are not yet symptomatic.2 Recent VHL disease-associatedCNS molecular base studies enable new knowledge into their ori­gin and development.6Also the timely diagnosis of this syndrome is important for manifestations.7The high-risk gene carriers must be screened regularly 166 Apaydin M et al. / Von Hippel-Lindeau disease by clinically and radiologically examinations.4One asymptomatic female sibling was found to have endolymphatic sac tumour. She received the thera­py before she became symptomatic. VHL disease can be detected easily by a simple blood test. Accuracy is approaching 100% but the test is not widely available.5A multidisciplinary approach is necessary. Geneticists, neurologists, urologists, gastroenterologists, ophthalmolo­gists, and radiologists are needed to constitute this team.6Screening protocols will vary between centres, but the protocol of National Institute of Health, USA is being widely accepted.8Computed tomography (CT) has the risk of ionizing radia­tion, which is a problem when screening asymp­tomatic patients or at-risk relatives.6MRI should be considered instead of CT5, because of avoiding ionizing radiation.9CNS manifestations can be de­tected with great accuracy by MRI.4,6,7MRI is also effective in the differential diagnosis of the ab­dominal involvement.10-13It is very important not to use gadolinium base MR contrast agents in pa­tients with the renal involvement whose estimated glomerular filtration rate of less than 30 mL/min. There is a risk of nephrogenic systemic fibrosis.14,15However, nephrogenic systemic fibrosisincidence in at-risk patients receiving contrast-enhanced MRI can be reduced after changing contrast administra­tion protocols that include changing the type and dose of the contrast agent.16VHL patients usually have multiple operations for haemangioblastoma. Recently, it is believed thatpostoperative morbidi­ties are major causes of the physical disabilityin VHL disease.6The important point is to decide the perfect time for the operation. Mother of the fam­ily had died due to haemangioblastoma and hy­drocephalus after having multiple operations. Her tumour was located in medulla oblongata. Three siblings had multiple CNS haemangioblastomas. One underwent operation, the other two received stereotactic radiosurgical ablation (gamma knife therapy). This therapy was found to be useful in patients with multiple small haemangioblastomas in VHL disease. Renal cell carcinomas of less than 3 cm in diameter have to be followed by 6 to 12 months period.4One of our patients has multiple cysts in kidney. She has been under MRI follow up in every year with laboratory testing. There have been important improvements in the management of VHL in the last two decade. The morbidity and mortality of patients with VHL disease has been reduced.5The resection of the tumour, cyst aspiration, stereotactic radiosurgical ablation, photocoagulation, and cryotherapy of any retinal lesions are the choices of the treatment.4VHL is a lifetime disease. Patients need to be con­stantly checkedfor the tumours and cysts that de­velop at various sites in theCNS and visceral or­gans throughout his/her lifetime. Some patientseven receive up to 20 surgical operations in their lifetime to remove tumours.1,17 The conservative approach to the treatment of VHL lesions is now more widely accepted, a radio­logic follow-up with non-invasive imaging espe­cially with MRI is important. References 1. Shuin T, Yamasaki I, Tamura K, Okuda H, Furihata M, Ashida S. Von Hippel-Lindau disease: molecular pathological basis, clinicalcriteria, genetic testing, clinical features of tumors and treatment. Jpn J Clin Oncol 2006; 6: 337-43. 2. Latif F, Tory K, Gnarra J, Yao M, Duh FM, Orcutt ML, et al. Identification of the von Hippel-Lindau disease tumor suppressor gene. Science 1993; 260: 1317-20. 3. Melmon KL, Rosen SW. Lindau’s disease: review of the literature and study of a large kindred. Am J Med 1964; 36: 595-617. 4. Leung RS, Biswas SV, Duncan M, Rankin S. Imaging features of von Hippel-Lindau disease. Radiographics 2008; 28: 65-79. 5. Meister M, Choyke P, Anderson C, Patel U. Radiological evaluation, manage­ment, and surveillance of renal masses in Von Hippel-Lindau disease. Clin Radiol 2009; 6: 589-600. 6. Bonneville F, Sarrazin JL, Marsot-Dupuch K, Iffenecker C, Cordoliani YS, Doyon D, et al. Unusual lesions of the cerebellopontine angle: a segmental approach. Radiographics 2001; 2: 419-38. 7. Butman JA, Linehan WM, Lonser RR. Neurologic manifestations of von Hippel-Lindau disease. JAMA 2008; 11: 1334-42. 8. Maher ER, Yates JR, Harries R, Benjamin C, Harris R, Moore AT, et al. Clinical features and natural history of von Hippel–Lindau disease, Q J Med 1990; 77: 1151-63. 9. Franko A, Antulov R, Dunatov S, Antoncic I, Miletic D. Spinal subdural hae­matoma in von Willebrand disease. Radiol Oncol 2009; 43: 84-7. 10. Blansfield JA, Choyke L, Morita SY, Choyke PL, Pingpank JF, Alexander HR. Clinical, genetic and radiographic analysis of 108 patients with von Hippel-Lindau disease manifested by pancreatic neuroendocrine neoplasms (PNETs). Surgery 2007; 6: 814-18. 11. Tattersall DJ, Moore NR. von Hippel–Lindau disease: MRI of abdominal manifestations. Clin Radiol 2002; 57: 85-92. 12. Elsayes KM, Narra VR, Leyendecker JR, Francis IR, Lewis JS Jr, Brown JJ. MRI of adrenal and extraadrenal pheochromocytoma. AJR Am J Roentgenol 2005; 3: 860-67. 13. Yildirim M, Engin O, Oztekin O, Akdamar F, Adibelli ZH. Diagnostic evaluation and surgical management of recurrent hydatid cysts in an endemic region. Radiol Oncol 2009; 43: 162-9. 14. Lauenstein TC, Salman K, Morreira R, Tata S, Tudorascu D, Baramidze G, et al. Nephrogenic systemic fibrosis: center case review. J Magn Reson Imaging 2007; 26: 1198-203. 15. Morris MF, Zhang Y, Zhang H, Prowda JC, Silvers DN, Rashid A, et al. Features of nephrogenic systemic fibrosis on radiology examinations. Am J Roentgenol 2009; 193: 61-9. 16. Martin DR, Krishnamoorthy SK, Kalb B, Salman KN, Sharma P, Carew JD, et al. Decreased incidence of NSF in patients on dialysis after changing gadolinium contrast-enhanced MRI protocols. J Magn Reson Imaging 2010; 31: 440-6. 17. Pavesi G, Feletti A, Berlucchi S, Opocher G, Martella M, Murgia A, et al. Neurosurgical treatment of von Hippel-Lindau-associated hemangioblasto-mas: benefits, risks and outcome. J Neurosurg Sci 2008; 2: 29-36. 168 research article Loss of heterozygosity of CDKN2A (p16INK4a) and RB1 tumor suppressor genes in testicular germ cell tumors Tomislav Vladusic1*, Reno Hrascan1*, Nives Pecina-Slaus2, Ivana Vrhovac1, Marija Gamulin3, Jasna Franekic1, Bozo Kruslin4 1 Department of Biochemical Engineering, Faculty of Food Technology and Biotechnology, University of Zagreb, Zagreb, Croatia 2 Laboratory of Neurooncology, Croatian Institute for Brain Research, Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia 3 Department of Oncology, Rebro University Hospital Center, Zagreb, Croatia 4 Ljudevit Jurak Department of Pathology, Sisters of Mercy University Hospital, Zagreb, Croatia Received: 17 March 2010 Accepted: 25 May 2010 * These two authors contributed to this work equally. Disclosure: No potential conflicts of interest were disclosed. Correspondence to: Tomislav Vladušic, Faculty of Food Technology and Biotechnology, University of Zagreb, Pierottijeva 6, 10000 Zagreb, Croatia. E-mail: tvladusic@pbf.hr Background. Testicular germ cell tumors (TGCTs) are the most frequent malignances in young adult men. The two main histological forms, seminomas and nonseminomas, differ biologically and clinically. pRB protein and its immedi­ate upstream regulator p16INK4a are involved in the RB pathway which is deregulated in most TGCTs. The objective of this study was to evaluate the occurrence of loss of heterozygosity (LOH) of the CDKN2A (p16INK4a) and RB1 tumor suppressor genes in TGCTs. Materials and methods. Forty TGCTs (18 seminomas and 22 nonseminomas) were analyzed by polymerase chain reaction using the restriction fragment length polymorphism or the nucleotide repeat polymorphism method. Results. LOH of the CDKN2A was found in two (6%) out of 34 (85%) informative cases of our total TGCT sample. The observed changes were assigned to two (11%) nonseminomas out of 18 (82%) informative samples. Furthermore, LOH of the RB1 was detected in two (6%) out of 34 (85%) informative cases of our total TGCT sample. Once again, the observed changes were assigned to two (10.5%) nonseminomas out of 19 (86%) informative samples. Both LOHs of the CDKN2A were found in nonseminomas with a yolk sac tumor component, and both LOHs of the RB1 were found in nonseminomas with an embryonal carcinoma component. Conclusions. The higher incidence of observed LOH in nonseminomas may provide a clue to their invasive behavior. Key words: loss of heterozygosity; CDKN2A; RB1; seminomas; nonseminomas Introduction Testicular germ cell tumor (TGCT) is diagnosed mainly after puberty and is the most frequent ma­lignancy in young adult men1, however, it is also not rare in childhood.2The two main histological forms, seminomas and nonseminomas, differ bio­logically and clinically. About 50% of TGCTs are pure seminomas and 40% pure or mixed nonsemi­nomas. The remaining 10% containing both semi-noma and nonseminoma components are classi­fied as being nonseminoma according to the World Health Organization (WHO) classification system.3The genetic alterations underlying the develop­ment of these neoplasms have not been understood fully, although much has been done to elucidate them.4,5 The cell cycle regulatory pathway deregulated in almost all human tumors appears to be the G1phase-controlling mechanism centered around the pRB protein. Different cancers seem to have altered different key components of that mecha­nism, which may be connected with gene activity patterns in different target cells.6The mechanism involves pRB and its immediate upstream regu­lators, the cyclin dependent kinases (CDK4 and CDK6), their catalytic partners (cyclin D1, cyclin D2 and cyclin D3), and the members of the INK4 family of CDK inhibitors (p16INK4a, p15INK4b, p18INK4c and p19INK4d). This mechanism seems to be a common point for various signaling path­ways, serving as a growth factor dependent cell cy­cle switch. Deregulation of the RB pathway may be an obligatory step in oncogenesis, making tumor cells less dependent on growth stimuli.6,7 The pRB is essential in cell cycle regulation and its function is regulated by phosphorylation. In G0and the early G1phase, hypophosphorylated pRB is complexed with the transcription factor E2F.8In late G1, a significant hyperphosphorylation of the pRB by CDK4 and CDK6 in complex with D cyclins (D1, D2, D3) occurs.9 The CDKN2 locus at chromosomal region 9p21 encodes p16INK4a tumor suppressor protein in­volved in the RB cell cycle control pathway.10p16INK4a functions as a regulator of G1/S phase transition by inhibiting the activity of CDK4 and CDK6. Thus, by inhibiting pRB phosphorylation, p16INK4a can promote the formation of a pRB-E2F repressive transcriptional complex, which blocks cell cycle progression past G1/S restriction point.11 In diverse types of cancer the RB pathway be­comes deregulated through alterations in one or more of its components. The most common defects of the RB pathway are mutations or deletions of RB1and inactivating mutations or promoter meth-ylation of the CDKN2A(p16INK4a) tumor suppres­sor gene, as well as the overexpression of the cyclin D2/CDK4 complex.6,12,13 The objective of this study was to evaluate the occurrence of the loss of heterozygosity (LOH) of the CDKN2Aand RB1tumor suppressor genes in TGCTs. Materials and methods Patients and tumor material Fourty TGCT samples (18 seminomas and 22 non-seminomas) were collected from Sisters of Mercy University Hospital and University Hospital Center, Zagreb, Croatia. The samples were for-malin-fixed and paraffin-embedded. Clinical and pathological data for 40 TGCTs according to the WHO 2004 classification are shown in Table 1. DNA extraction For each specimen, 20 µm paraffin-embedded section was prepared for DNA extraction. In ad­dition, 4 µm section was stained with hematoxy-lin-eosin to identify the tumor and normal tissue areas which were removed separately from the microscopic slide, transferred to microtubes and extracted using QIAamp DNA Mini Kit (Qiagen, Hilden, Germany). LOH analysis of CDKN2A gene A previously described polymorphic microsatellite marker hMp16a-I1 consisting of a mononucleotide tract of (A)23located close to intron 1 of the CDKN2Agene was analyzed in this study.14Primers used for polymerase chain reaction (PCR) amplifications were 5’-CAATTACCACATTCTGCGCTT-3’ and 5’-CAGGCAGAGAGCACTGTGAG-3’, which pro­duced 190-210 bp fragments. PCR amplifications were performed in 25 µl reaction volume with a final concentration 0.2 mM of each dNTP, 3 mM MgCl2, 0.2 µM of each primer (Sigma-Aldrich, St. Louis, MI, USA), 1x Flexi buffer (Promega, Madison, WI, USA) and 0.5 U of GoTaq®Hot Start Polymerase (Promega, Madison, WI, USA). One hundred nanograms of DNA were used in each PCR reaction. PCR amplifications were carried out in a Eppendorf Mastercycler Personal (Hamburg, Germany), with cycling times of 96şC for 5 min (one cycle), then 45 cycles of 96şC for 30 s, 57şC for 45 s, and 72şC for 30 + 1 s. The final step was incu­bation at 72ş C for 10 min. Amplified DNA frag­ments were analyzed on silver-stained 15% poly­acrylamide gels. LOH of CDKN2Awas considered to had occuredif one out of two alleles (hetero­zygous samples) of a gene marker was missing or significantly reduced in comparison to alleles from adjacent normal tissue. LOH analysis of RB1 gene LOH of RB1was detected using polymerase chain reaction-restriction fragment length polymor­phism method (PCR-RFLP). Amplification with RB1primers 5’- TCCCACCTCAGCCTCCTTAG-3’ and 5’-GTAGGCCAAGAGTGGCAGCT-3’ used in our study produced a 190 bp segment of intron 17.15PCR amplifications were performed under conditions mentioned above. To generate the RFLP pattern for LOH analysis, 10 µl of PCR product were digested with 5 U of XbaI restriction enzyme (Fermentas, Vilnius, Lithuania) in a total volume of 170 Vladusic T et al. / Tumor suppressor genes in testicular germ cell tumors TABLE 1. Clinical and pathological data for 40 testicular germ cell tumor cases 1 26 pT1NXMX ITGCN, S 2 26 pT1NXMX ITGCN, S 3 37 pT1NXMX S 4 33 pT1NXMX ITGCN, S 5 31 pT1NXMX ITGCN, S 6 29 pT1NXMX ITGCN, S 7 39 pT1NXMX ITGCN, S 8 27 pT3NXMX S 9 41 pT1NXMX ITGCN, S 10 48 pT1NXMX S 11 48 pT2NXMX S 12 34 pT1NXMX ITGCN, S 13 60 pT1NXMX ITGCN, S 14 29 pT1NXMX ITGCN, S 15 60 pT1NXMX S 16 29 pT1NXMX ITGCN, S 17 28 pT1NXMX ITGCN, S 18 32 pT1NXMX ITGCN, S 19 37 pT1NXMX EC 20 18 pT2NXMX EC, IT, MT, S 21 24 pT1NXMX EC, ITGCN, S 22 22 pT2NXMX EC, YST 23 37 pT1NXMX EC, ITGCN, S 24 28 pT2NXMX C, EC, IT, MT 25 17 pT2NXMX EC, MT 26 34 pT2NXMX EC 27 19 pT1NXMX EC, ITGCN, MT, YST 28 39 pT1NXMX MT, YST 29 21 pT2NXMX EC, MT, YST 30 23 pT2NXMX EC, IT, MT 31 22 pT1NXMX MT, YST 32 25 pT3NXMX EC 33 45 pT2NXMX EC, ITGCN, S, YST 34 NK pT2NXMX C, EC, ITGCN, S, YST 35 23 pT2NXMX EC, IT, ITGCN, MT, YST 36 39 pT1NXMX EC, ITGCN, S, YST 37 24 pT2NXMX EC, ITGCN, YST 38 30 pT1NXMX EC, ITGCN, YST 39 36 pT1NXMX EC, ITGCN, MT, YST 40 58 pT2NXMX EC, ITGCN, YST *seminomas, patients no. 1-18; nonseminomas, pateints no. 19-40 C = choriocarcinoma; EC = embryonal carcinoma; IT = immature teratoma; ITGCN = intratubular germ cell neoplasia; MT = mature teratoma; S = seminoma; YST = yolk sac tumor; NK = not known 25 µl for 12 h. The restriction digestion resulted in fragments of 75 and 115 bp. DNA fragments were analyzed on silver-stained 15% polyacrylamide gels. LOH was recognized as a partial or complete loss of either the uncleaved (190 bp) or the cleaved (75 + 115 bp) allele. Results In this study 40 TGCTs, 18 seminomas and 22 non-seminomas, were analyzed. First, we searched for LOH of the intragenic polymorphic microsatellite marker hMp16a-I1 in the CDKN2Agene. From 40 TGCTs, 34 (85%) tumors were informative for this polymorphism, 16 (89%) seminomas and 18 (82%) nonseminomas. Our analysis revealed that two (6%) samples showed LOH of hMp16a-I1 marker. The observed changes were assigned to two non-seminomas (11%, patients no. 31 and 34, Table 2). In both tumor cases, one out of two allels of gene marker was missing in comparison to alleles from the adjacent normal tissue (Figure 1). In addition, both LOHs of the CDKN2Awere found in nonsem­inomas with a yolk sac tumor component. LOH of the CDKN2Agene was not observed among semi-nomas. The analysis of intragenic polymorphic restric­tion marker of the RB1gene showed that 34 (85%) of total TGCTs were heterozygous for this poly­morphism; 15 (83%) seminomas and 19 (86%) non-seminomas. LOH was observed in two (6%) sam­ples when looking at the total TGCTs analyzed. Once again the observed allelic losses were as­signed to nonseminomas: two samples (10.5%, pa­tients no. 20 and 25, Table 2) had one of the alleles missing in comparison to bands from the adjacent normal testis tissue. These nonseminoma samples showed loss of the cleaved allele (75- and 115-bp fragments), as the single uncleaved allele (190-bp fragment) appeared on the silver stained 15% poly­acrylamide gel (Figure 2). Furthermore, both LOHs of the RB1were found in nonseminomaswith an embryonal carcinoma component. None of the seminomas demonstrated LOH of the RB1 gene. No statistically relevant correlation between the occurrence of LOH, form of TGCT, histological type of contained components and tumor stage ac­cording to TNM classification could be determined by Fisher’s exact test. Discussion TGCT is associated with characteristic abnormali­ties in the RB pathway including upregulation of cyclin D2, and downregulation of pRB and the CDK inhibitors such as p16INK4a.7 The inactivation of the CDKN2Agene, which encodes an inhibitor of CDK4 and CDK6, is one of the most common molecular events in human neoplasms. The major mechanisms contributing to CDKN2Asilencing are promoter methylation, gene mutations and hemizygous or homozygous deletions. When one CDKN2Aallele is mutated or methylated, the second allele is often deleted.16 The analysis of the expression of INK4 family has pointed to a down-regulation of CDKN2Ain tes­ticular neoplasms.7,12Honorio et al.17demonstrated that promoter hypermethylation of that gene is not involved in the decrease of p16INK4a protein ex­pression. In contrast, some studies have found pro­moter mutation, a half of analyzed TGCTs had de novo promoter methylation and approximately half of TGCTs showed hypermethylation of CDKN2Aexon 1a. All that correlated with a decreased lev­el of CDKN2AmRNA expression.1,18However, Chaubertet al.18have not detected any CDKN2Amutations and observed LOH of the CDKN2A 172 Vladusic T et al. / Tumor suppressor genes in testicular germ cell tumors TABLE 2. A) Observed loss of heterozygosity (LOH) and B) distribution of observed LOH of CDKN2A and RB1 genes in testicular germ cell tumors 20 LOH 25 LOH 31 LOH NI 34 LOH I Seminoma, S 18 0% (0/16) 0% (0/15) Nonseminoma, S 22 11% (2/18) 10.5% (2/19) I = informative (heterozygous); NI = not informative (homozygous) Numbers in parentheses: the number of tumors demonstrating LOH over the number of informative tumors. gene in only one of 29 TGCTs with a yolk sac tumor component, using seven different markers. These observations indicate that CDKN2Agene inactiva­tion might be an important mechanism leading to cell deregulation in TGCTs. Despite of promoter methylation and muta­tions being the most common ways of inactivat­ing CDKN2Ain TGCTs, various studies detected LOH at the position of the CDKN2Agene, varying from as low as 5.5% to as high as 42%. The LOHs of CDKN2Awere reported mostly in nonsemi­nomas.5,19 Genomic region containing CDKN2A(9p21) is reported to be the most commonly dele­ted region early in the development of nonsemino-mas, which may be implicated in their ability to di­fferentiate into various types, for various markers located within this region.20 In our study only nonseminomas demonstrated LOH (Table 2). Both LOHs of the CDKN2Awere found in nonseminomas with a yolk sac tumor component, one sample also having an embryonal carcinoma component. Furthermore, one nonsemi­noma with the LOH of CDKN2Ademonstrated LOH of TP53gene, and the other showed LOH of the CDH1 gene.21 The RB1gene is often deleted or mutated to an inactive form in a variety of human tumors. Cells of embryonal testes and intratubular germ cell neoplasia (ITGCN) show no expression of pRB, whereas it is expressed in healthy testes during spermatogenesis. The lack of pRB in most TGCTs may, therefore, reflect its deregulation by normal mechanisms in testicular germ cells. However, the lack of pRB may facilitate the transition of those cells to tumor cells of ITGCN and thus contribute to molecular pathogenesis of TGCTs.7,12Lowered levels of pRB mRNA compared with normal tes­tis did not reflect a grossly altered structure of the DNA coding regions, but instead relates to a potentially reversible transcriptional modulation through the promoter methylation. The pRB ap­pears to be differentially expressed according to the differentiation status of the tumor, more dif­ferentiated cells of teratocarcinoma show positive immunohistochemical staining, less differentiated forms of TGCT such as embryonal carcinoma are stained negatively.12,22,23 In contrast, deletions of RB1gene are, along with its mutations, also reported as one of the most com­mon alterations of the RB pathway. Various studies revealed deletions of the RB1gene region in tes­ticular cancer.5For example, Peng et al.24used short variable number of tandem repeats in RB1introns 16 and 20, and found LOH in 5% of seminomas and 28% of nonseminomas analyzed within 93% of informative TGCT cases. The location of the RB1gene is reported to be one of the most common­ly involved in allelic imbalance within TGCTs.4The exact alterations of the RB1in various forms of TGCTs needs to be further elucidated in more detail. Studies also revealed a different pattern of LOH in different histological types of nonsemino-mas for markers located within the genomic region containing the RB1gene (13q14), varying from 0% in yolk sac tumor component to 50% in choriocar­cinoma.25 In our study, LOH of the RB1gene was found in nonseminomas with an embryonal carcinoma component, and both nonseminomas with LOH of RB1also demonstrated LOH of the TP53gene.21Interestingly, the amount of embryonal carcinoma component in TGCT, along with vascular invasion, has been proved so far to be the only clinically val­id prognostic factor for the development of stage II metastatic testicular cancer.26 LOH of CDKN2A, RB1, TP53and CDH1in TGCTs may increase their tumorigenic potential by the increased proliferation capacity due to RB1loss and decreased rate of apoptosis due to TP53altera­tion.19,21,27It has been shown that TP53 is abundant but inactive in cells of TGCTs. In healthy testes such reversibly inactivated TP53 may play a role in switching between proliferation and apoptosis in cells undergone meiosis.27It was reported that, in cells that sustained lesion in the RB pathway, there was a strong selection for the loss or inactivation of wild type TP53. Alterations of RB1are often seen together with alterations of TP53in variety of dif­ferent cancers.6,10,15It is possible that the inactiva­tion of both RB1and TP53genes in a cell produces a synergistic effect, which imposes a stronger selec­tive pressure for the cellular transformation. This may also help to explain the high proliferation rate and/or invasiveness of TGCTs with embryonal car­cinoma and yolk sac tumor component. A higher incidence of LOH in nonseminomas may provide a clue to their invasive behavior, because for some of the nonseminoma types there seem to be a re­gion of preferential loss (3q27–3q28 in embryonal carcinoma), and all of the TGCTs show gain of 12p11–12p12 sequences.20Knowing the exact na­ture of genetic alterations associated with these tumors may provide novel treatment strategies.28 However, the low frequency of observed LOHs in this study could be a consequence of genomic instability in above mentioned nonseminomas, rather than the main cause of CDKN2Aand RB1inactivation.24 Acknowledgments This work was supported by Grant 058-0582261­2246 from Ministry of Science and Technology, Republic of Croatia. References 1. Fombonne J, Devouassoux-Shisheboran M, Bouvier R, Droz J-P, Benahmed M, Krantic S. Analysis of p16INK4A genepromoterin male germ-cell tumors: identification of a new point mutation. Cancer Detect Prev 2005; 29: 1-7. 2. 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Frequent epigenetic inactivation of the RASSF1A tumour suppressor gene in testicular tumours and distinct methylation profiles of seminoma and nonseminoma testicular germ cell tumours. Oncogene 2003; 22: 461-66. 18. Chaubert P, Guillou L, Kurt A-M, Bertholet M-M, Metthez G, Leisinger H-J. Frequent p16INK4 (MTS1) gene inactivation in testicular germ cell tumors. Am J Pathol 1997; 151: 859-65. 19. Heidenreich A, Gaddipati JP, Moul JW, Srivastava S. Molecular analysis of P16Ink4/CDKN2 and P15Ink4B/MTS2 genes in primary human testicular germ cell tumors. J Urol 1998; 159: 1725-30. 20. Faulkner SW, Leigh DA, Oosterhuis JW, Roelofs H, Looijenga LHJ, Friedlander ML. Allelic losses in carcinoma in situ and testicular germ cell tumours of adolescents and adults: evidence suggestive of the linear progression model. Br J Cancer 2000; 83: 729-36. 21. Vladušic T, Hrašcan R, Vrhovac I, Krušlin B, Gamulin M, Grgic M, et al. Loss of heterozygosity of selected tumor suppressor genes in human testicular germ cell tumors. Pathol Res Pract 2010; 206: 163-7. 22. Jones RH, Vasey PA. New directions in testicular cancer; molecular determi­nants of oncogenesis and treatment success. Eur J Cancer 2003; 39: 147-56. 23. Strohmeyer T, Reissmann P, Cordon-Cardo C, Hartmann M, Ackermann R, Slamon D. Correlation between retinoblastoma gene expression and differ­entiation in human testicular tumors. Proc Natl Acad Sci 1991; 88: 6662-6. 24. Peng H-Q, Bailey D, Bronson D, Goss PE, Hogg D. Loss of heterozygosity of tumor suppressor genes in testis cancer. Cancer Res 1995; 55: 2871-75. 25. Rothe M, Albers P, Wernert N. Loss of heterozygosity, differentiation, and clonality in microdissected male germ cell tumours. J Pathol 1999; 188: 389-94. 26. Heidenreich A, Sesterhenn IA, Mostof FK, Moul JW. Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis. Cancer 1998; 83: 1002-11. 27. Bartkova J, Falck J, Rajpert-De Meyts E, Skakkebćk NE, Lukas J, Bartek J. Chk2 tumor suppressor protein in human spermatogenesis and testicular germ-cell tumours. Oncogene 2001; 20: 5897-902. 28. Kamensek U, Sersa G. Targeted gene therapy in radiotherapy. Radiol Oncol 2008; 42: 115-35. 174 research article Study of radiation induced changes of phosphorus metabolism in mice by 31P NMR spectroscopy Igor Sersa1, Simona Kranjc2, Gregor Sersa2, Alenka Nemec-Svete3, Bojan Lozar1, Ana Sepe1, Jernej Vidmar1, Marjeta Sentjurc1 1 Jozef Stefan Institute, Ljubljana, Slovenia 2 Department of Experimental Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia 3 Veterinary Faculty, Ljubljana, Slovenia Received 23 April 2010 Accepted 14 May 2010 Disclosure: No potential conflicts of interest were disclosed. Correspondence to: Igor Serša, PhD, Jožef Stefan Institute, Jamova 39, SI-1000 Ljubljana, Slovenia. Phone: +386 1 477 3696; Fax: +386 1 477 3191; E-mail: igor.sersa@ijs.si Background. The aim of this study was to examine whether 31P NMR can efficiently detect X-ray radiation induced changes of energy metabolism in mice. Exposure to ionizing radiation causes changes in energy supply that are as­sociated with the tissue damage because of oxidative stress and uncoupled oxidative phosphorylation. This has as a consequence decreased phosphocreatine to adenosine triphosphate ratio (Pcr/ATP) as well as increased creatine kinase (CK) and liver enzymes (transaminases AST and ALT) levels in serum. Materials and methods. In this study, experimental mice that received 7 Gy of X-ray radiation and a control group were studied by 31P NMR spectroscopy and biochemically by measuring CK and liver enzyme levels in plasma. Mice (irradiated and control) were measured at regular time intervals for the next three weeks after the exposure to radia­tion. Results. A significant change in the Pcr/ATP ratio, determined from corresponding peaks of 31P NMR spectra, was observed in the 7 Gy group 2 days or more after the irradiation, while no significant change in the Pcr/ATP ratio, was observed in the control group. This result was supported by parallel measurements of CK levels that were highly in­creased immediately after the irradiation which correlates with the observed decrease of the Pcr/ATP ratio and with it associated drop of muscle energy supply. Conclusions. The 31P NMR measurements of the Pcr/ATP ratio can in principle serve as an instantaneous and non­invasive index for assessment of the received dose of irradiation. Key words: X-ray irradiation; 31P NMR spectroscopy; creatine kinase; biological effects of radiation; radiation dosimetry Introduction Biochemical changes in macromolecules and with that associated tissue damage appears several ms after acute exposure to radiation. However, multi­ple consequences manifest in hours, years or even decades after the irradiation. Since stochastic bio­logical effects of radiation could be detected only through carefully planned epidemiological stud­ies, several attempts have been made to develop a successful method for detecting deterministic ef­fects of radiation, where the rate of tissue damage is proportional to a received radiation dose.1,2Such methods may help determining received doses of radiation for all subjects that were at the time of exposure not equipped with radiation detection devices. This may have important applications in military use as well as in civil use: hospitals, nu­clear power plants and in some industry branches. The most promising are the methods based on the measurements of the long lived radiation in­duced stable radicals in the hydroxyapatite com­ponent of teeth and bones which can be measured by electron paramagnetic resonance (EPR).3With the recent development of low-frequency EPR (1 GHz) the measurements in vivoon teeth seems to become plausible.4 The other challenge is to find the method by which it would be possible to measure direct bio­logical effect that is proportional to the dose of ra­diation. According to Bergonié-Tribondeu’s law5, where the radiosensitivity of cells is proportional to their reproductive activity and inversely propor­tional to their differentiation level, only spermato­gonia and erythroblasts are highly radiosensitive to radiation. Therefore, assessment of the radiation damage through methods, which detect the DNA damage6, i.e., gene aberration detection methods7or the FISH method8,9, is found to be rather com­plicated and time consuming due to a need of gathering specific samples. Effects of radiation are associated also with a skeletal damage, which can be detected by MR microscopy.10Radiation has significant effect also on metabolism of living sys­tems that is linked with changing concentrations of phosphocreatine (Pcr) and adenosine triphosphate (ATP) molecules. Pcr, also known as creatine phos­phate, is an important molecule for energy storage in skeletal muscles. Pcr is used to generate ATP by transferring phosphate group to the adenosine diphosphate molecule (ADP) forming creatine for the 2 to 7 seconds following an intense anaerobic effort. ADP conversion to ATP occurs in a catalytic reaction catalyzed by creatine kinase (CK). The presence of CK in plasma is indicative of the tis­sue damage that may occur in powerful ischemic stress action to muscles, as for example in myo­cardial infarction.11ADP to ATP conversion is a re­versible reaction and Pcr therefore acts as a spatial and temporal buffer of ATP. Pcr is first synthesized in the liver, then transported via the bloodstream and finally stored in muscle cells and the brain. Therefore, Pcr plays a particularly important role in tissues that have high, fluctuating energy de­mands.12Since irradiation impairs function of mul­tiple organs13(i.e. liver function) it is also possible to detect radiation effects by measuring liver en­zyme levels aspartate aminotransferase (AST) and alanine aminotransferase (ALT).14AST and ALT are parenchymal intracellular enzymes released into systemic circulation when there is hepatocel­lular injury and necrosis. The metabolic changes of tissues and organs can be efficiently monitored by NMR spectros­copy methods15-17, in particular by phosphorous 31P and carbon 13C NMR spectroscopy methods. Phosphocreatine to adenosine triphosphate ra­tio (Pcr/ATP) as determined from corresponding spectral line peaks of 31P spectra is an appropriate index to follow energy metabolism.18,19Until now few attempts have been made to detect effects of radiation by NMR spectroscopy. Ng et al.studied effects of gamma-irradiation on tumour cells by 31P NMR spectroscopy.20They detected a dramatic decline in high-energy phosphates beginning one day after irradiation. Box et al.studied effects of ra­diation on degradation of glycine, a protein build­ing block molecule, by 13C NMR spectroscopy.21In addition to NMR spectroscopy methods, magnetic resonance (MR) imaging can be efficient in detect­ing effects of radiation as well. For example 19F MR imaging was employed to detect accumulation of perfluorooctylbromide in spleen.22The accumula­tion was a consequence of macrophage dysfunc­tion induced by irradiation. The aim of this study was to examine relation between a received dose of ionizing irradiation and changes in metabolism that can be detected by31P NMR spectroscopy of mice for potential determi­nation of the received dose of radiation. The study is based on assumption that exposure of whole-body to high-dose radiation for only a short time period results in development of cell death, which presumably occurs due to uncoupling of oxida­tive phosphorylation and increased ion flux. This results in increased CK levels in serum and con­sequently decreased Pcr/ATP ratio due to homeo­static mechanisms responsible for energy supply. Assuming that the radiation affects multiple tis­sues, including liver, muscles and central nervous system, where is the major production and stor­age of Pcr, we expect the decrease of Pcr in irra­diated mice and no significant change in the non-irradiated control group. If the assumption is right, the Pcr/ATP ratio could be used as a biosensor for the received dose of radiation provided that other mechanisms effecting Pcr/ATP ratio are excluded. Materials and methods Experimental animals and irradiation In the experiments, C57Bl/6 mice raised at the Institute of Pathology (MedicalFaculty, University of Ljubljana, Slovenia) were used. Mice were main­tained at 21°C with natural day/night light cycle in a conventional animal colony. At the beginning of the experiments, mice, that were 16-20 weeks old, were subjected to an adaptation period of 7–10 days before experiments. Mice were divided equal­ly between a control group (6 mice) that was not 176 Sersa I et al. / Irradiated mice spectroscopy irradiated and a group that received 7 Gy of X-ray radiation (6 mice). For X-ray irradiation a Darpac 2000 unit (Gulmay Medical Ltd, Shepperton, UK), operated at 220 kV, 10 mA, and with 0.55 mm Cu and 1.8 mm Al fil­tration was used. In experiments whole-body of mice was irradiated at a dose rate 2.2 Gy/min with single doses of 7 Gy. During whole body irradia­tion mice were anaesthetised with intraperitoneal injection of acepromazine (Promace, Fort Dodge Animal Health, Iowa, USA; 0.05 mg/mouse), keta-mine hydrochloride (Bioketan, Vetoquinol, Paris, France; 2.5 mg/mouse) and xylazine hydrochloride (Rompun 2%, Bayer AG, Leverkusen, Germany; 0.25 mg/mouse). Animal studies were carried out according to the guidelines of the Ministry of Agriculture, Forestry and Food of the Republic of Slovenia (permission No 34401-60/2007/8), and in compliance with the Guide for the Care and Use of Laboratory Animals (National Institutes of Health, Bethesda, MD). Protocol was approved by Veterinary administra­tion of the Republic of Slovenia (34401-60/2007/8). 31P NMR Spectroscopy Metabolic changes in both mice groups were meas­ured using 31P NMR spectroscopy of the whole ani­mal at the specific time of day for several days after the prime dose of radiation. The first measurement on irradiated mice was done immediately after the irradiation and then every other day for the next 14 days; no mice died within that period. The rest of the measurements on the control group were performed in five day intervals until three weeks after the experiment onset. NMR experiments were performed on a 2.35 T (100 MHz proton frequency) horizontal bore Oxford superconducting mag­net (Oxford Instruments Ltd., UK) connected to a Tecmag Apollo spectrometer (TecMag, Huston TX, USA). 31P NMR signal was detected by a Bruker 4 cm double-tuned surface coil (Bruker, Ettlingen, Germany). For MRI, mice were fist anaesthetised using the same procedure as for X-ray irradiation. After that they were placed in the MRI magnet in the centre of the surface coil to focus signal acquisi­tion on muscles and internal organs. A special care was taken in reproducibility of the animal place­ment (in the standard ventral position) relative to the surface coil. The coil was then tuned to proton signal for the purpose of magnet shimming which was done using the proton NMR signal. After the shimming was completed the coil was tuned to 31P and the 31P NMR signal acquisition started. The signal was acquired by the standard 1D acquisi­tion sequence consisting of one 90° excitation pulse followed by the signal acquisition. The acquisi­tion parameters were: acquisition size 4096 points, spectral width 10 kHz, acquisition time 200 ms, repetition time 2.2 s. The signal was averaged 1200 times so the total experiment time was 44 min. The spectra were reconstructed using 10 Hz exponen­tial line broadening to decrease the signal noise. During the experiment the animals were coated with a layer of a cotton wool to prevent them dying from hypothermia. Measurement of creatine kinase and transaminases The activities of creatine kinase (CK) and transami­nases (AST and ALT) were measured in plasma of the irradiated mice with an automated biochemis­try analyser RX Daytona (Randox, Crumlin, UK). Blood samples (200 µl) were collected from the orbital sinus by heparinised glass capillary before and after irradiation at different time points (10 min and 2, 4, 7, 9, 11 days). To prevent degrada­tion of creatine kinase blood samples were centri­fuged (3000 rpm, 10 min) in 10 min after dispos­session. 100 µl of plasma samples were drawn in 1 ml tube and stored at -80°C until the analysis was performed. Statistical analysis Measured Pcr/ATP ratios of the irradiated and the control mice group were analyzed for statistically significant difference by the two-tailed Student t-test (MS Excel 2007). Results Typical31P NMR spectra of irradiated mice imme­diately after the irradiation, after 4 days and after 10 days are depicted in Figure 1 bottom row. For comparison, spectra of the control group acquired at identical time points are shown as well (Figure 1, top row). As expected, changes were significant only in spectra of irradiated mice, while in the con­trol group, in which mice were not exposed to radi­ation, all spectra are alike and were changing with time significantly less. In Figure 1 it can clearly be seen that metabolic changes due to the irradiation ppm ppm ppm 7 Gy group 15 10 5 0 -5 -10 -15-20 -25 15 10 5 0 -5 -10 -15-20 -25 15 10 5 0 -5 -10 -15-20 -25 ppm ppm ppm 1st day 4th day 10th day FIGURE 1. Typical 31P NMR spectra of X-ray irradiated mice at different times after the irradiation: immediately, after 4 days and after 10 days for the mice group that received 7 Gy of X-ray radiation (bottom row) and the control group that was not irradiated (top row). are associated mainly with the reduced Pcr peak, while no significant difference was observed in heights of the average ATP peak and the inorganic phosphate peak (Pi). Therefore, the ratio between heights of the Pcr and the average ATP peak is a convenient measure for metabolic activity and can be used for following effects of radiation on energy metabolism. In Figure 2 dependence of the Pcr/ATP ratio as a function of time after the exposure to radia­tion for the mice group that received 7 Gy of X-ray radiation and the control mice group is depicted. In the control group, the Pcr/ATP ratio was prac­tically constant all times, while the Pcr/ATP ratio in the irradiated group was initially identical to the Pcr/ATP ratio of the control group and then started decreasing until the animal death or par­tial recovery. The decrease was most significant within the first 7 days after the irradiation. After that time approximately half of the irradiated mice died and the other half never recovered complete­ly, which can be seen by somewhat reduced Pcr/ATP ratio (reduction was approximately 20%) of the irradiated group compared to the same ratio of the control group for 7 or more days after the ir­radiation. Statistical analysis of the Pcr/ATP ratio by the paired t-test showed significant difference between the irradiated and the control mice group (P = 0.023). Measurements of CK, AST and ALT levels in plasma of the irradiated mice as a function of time after radiation are shown in Figure 3. These meas­urements clearly indicate elevated CK levels im­mediately after the irradiation with almost tenfold increase of the CK level 10 min after the irradia­tion. The CK level then relatively fast returned to the normal level which was reached two days after the irradiation. Levels of both transaminases (ALT and AST) were elevated as well, however the in­crease was lower; the increase was approximately threefold for AST and 1.5-fold for ALT. Discussion Results of this study clearly indicate an existing re­lation between changes of energy metabolism and effects of radiation. These were detected instantly by in vivo31P NMR spectroscopy as well as with laboratory biochemical analysis of CK, AST and ALT levels in plasma, which was more time con­suming. As expected, both methods were able to reveal metabolic changes associated with radia­tion effects. In 31P NMR the change was observed in the reduced Pcr/ATP ratio, while biochemical analysis of plasma revealed increased CK and less pronounced increase of AST and ALT levels. The spectra reveal the level of Pcr and ATP through the whole body (muscle and internal organs). The decrease in the Pcr/ATP ratio supports our as­sumption, that metabolism of Pcr in post-radiation time is elevated due to a higher Pcr level in serum, which represents a substrate of CK. Uncoupling oxidative phosphorylation after the irradiation 178 Sersa I et al. / Irradiated mice spectroscopy tabolism of Pcr would be affected even more if the radiation dose would be higher. In the irradiated mice group, in the first few days after the irradia­ tion the ATP level was replenished by short-term mechanisms of the phosphate group transfer from Pcr to ADP. After that time, the ATP replenishment became due to severe radiation damage, which causes uncoupling of oxidative phosphorylation25 (i.e. liver damage) no longer possible thus resulting in the animal death with approximately 50% prob­ability in 10 days after the irradiation. The results of 31P NMR spectroscopy were con­ -20 2 4 6 810121416 firmed biochemically by measuring CK levels in time [days] plasma. Parallel measurements of Pcr/ATP ratios FIGURE 2. Pcr/ATP ratio as function of time after the irradia­tion for the mice group that received 7 Gy of X-ray radiation (squares) and the control mice group (circles). In the 7 Gy group the decrease of Pcr/ATP ratio is significant due to exten­sive radiation induced energy metabolism changes. 13 12 11 and CK levels in plasma showed correlation be­tween the 31P NMR spectroscopy and biochemical methods of assessment of effects of radiation; i.e., both methods showed initially increased CK ratios and decreased Pcr/ATP levels that returned to nor­mal values during the recovery. Elevation of CK is an indication of acute muscle damage (i.e trauma, rhabdomyolysis, myocardial infarction, myositis 1 Factor of plasma concentracion increase [a.u.] etc.), which was in our study induce by X-ray ra­ 9 diation.26In addition, increased levels of transami­ 8 7 6 nases (AST and ALT) indicate a liver damage which supports our assumption that irradiation 5 affected metabolism of multiple organs. While CK 4 3 2 1 2 4 6 81 Days after irradiation levels and levels of both transaminases returned to normal within two days after the irradiation, Pcr/ATP ratios remained decreased significantly longer (10 or more days). As long as CK levels in plasma are elevated ATP synthesis de novois extremely slow which explains different time dynamics of the return for CK and Pcr levels to normal. Limitations of our study are associated with the credibility of CK and Pcr/ATP peaks. For 31P NMR measurements surface coils were used. These have a sensitive region above the coil within a range ap­proximately identical to the coil’s radius. Therefore a proper positioning of a mouse relative to the coil is important for acquisition of the NMR signal from always identical body parts. A failure to do so may result in significantly different spectra and consequently inaccurate determination of the Pcr/ATP ratio. In addition CK levels were measured non-selectively for all different CK isoenzymes. However, it is expected that most of CK originated mainly from skeletal muscles since the muscles represent the major storage for CK. Due to the limited access to the X-ray radiation source the study was performed using only one dose of radiation (7 Gy, plus the control group that did not receive any radiation). Unfortunately this is not enough to determine a possible relation FIGURE 3. Relative creatine kinase (CK), aspartate aminotrans­ferase (AST) and alanine aminotransferase (ALT) levels in plasma of mice that received 7 Gy of X-ray radiation as a function of time after the radiation exposure. Immediately after the exposure the CK level increase is almost tenfold while the increase of both transaminases (AST and ALT) was not as big, however, still significant. due to cell death (or ascites cell mitochondria), creates a stressful environment with a lack of ATP.23Therefore, its rapid replenishment could be achieved by resynthesis from Pcr and ADP, cata­lyzed by CK. Cell death results also in a decreased Pcr synthesis in liver and in a decreased Pcr storage in muscles due to rhabdomylosis-like effect of ra­diation, which can be seen in lover Pcr/ATP in irra­diated group compared to the control group 20 or more days after the irradiation (Figure 2). The Pcr/ATP ratio decreased due to reduced intracellular creatine levels and therefore lower Pcr synthesis.24It is expected that the decrease in the Pcr/ATP ra­tio is radiation-dose dependant, meaning that me­between the received dose and the Pcr/ATP ratio change. For that, similar experiments should be repeated for other intermediate doses (between 0 Gy and 7 Gy), which is our plan for future experi­ments. Although the chosen dose of 7 Gy is relative­ly high (50% mortality rate of mice), determination of such radiation exposure is important. At such high dose of radiation dose-dependent radiation-induced multi-organ involvement (RIMOI) and radiation-induced multi-organ failure (RIMOF) occur. Both RIMOI and RIMOF contribute to the clinical outcome and prognosis of radiation acci­dent victims.27,28 Conclusions The NMR method for detection of radiation in­duced metabolic changes in living organisms was verified biochemically by analysing CK levels in plasma. The accuracy of the NMR method is infe­rior to standard dosimetry methods. However, its advantage is that the method is instantaneous and the radiation dose can still be determined even if the subject was not carrying a radiation detection device at the time of exposure. To determine pos­sible relation between the Pcr/ATP ratio and the received dose of radiation prospective studies are still needed. Acknowledgement This research was supported by the Slovenian Research Agency. References 1. Andreassen CN, Alsner J, Overgaard M, Overgaard J. Prediction of normal tissue radiosensitivity from polymorphisms in candidate genes. Radiother Oncol 2003; 69: 127-35. 2. Simon SL, Bailiff I, Bouville A, Fattibene P, Kleinerman RA, Lloyd DC, et al. BiodosEPR-2006 consensus committee report on biodosimetric meth­ods to evaluate radiation doses at long times after exposure. Radiation Measurements 2007; 42: 948-71. 3. Swartz HM, Iwasaki A, Walczak T, Demidenko E, Salikhov I, Khan N, et al. In vivo EPR dosimetry to quantify exposures to clinically significant doses of ionising radiation. Radiat Prot Dosimetry 2006; 120: 163-70. 4. Swartz HM, Iwasaki A, Walczak T, Demidenko E, Salikov D, Lesniewski P, et al. Measurements of clinically significant doses of ionizing radiation using non-invasive in vivo EPR spectroscopy of teeth in situ. Appl Radiat Isotopes 2005; 62: 293-9. 5. Haber AH, Rothstein BE. Radiosensitivity and rate of cell division: “law of Bergonie and Tribondeau”. Science 1969; 163: 1338-9. 6. Miklos M, Gajski G, Garaj-Vrhovac V. Usage of the standard and modified comet assay in assessment of DNA damage in human lymphocytes after exposure to ionizing radiation. Radiol Oncol 2009; 43: 97-107. 7. Wilding CS, Relton CL, Rees GS, Tarone RE, Whitehouse CA, Tawn EJ. DNA repair gene polymorphisms in relation to chromosome aberration frequen­cies in retired radiation workers. Mutat Res 2005; 570: 137-45. 8. Trask B, Pinkel D. Fluorescence in situ hybridization with DNA probes. Methods Cell Biol 1990; 33: 383-400. 9. Edwards AA, Lindholm C, Darroudi F, Stephan G, Romm H, Barquinero J, et al. Review of translocations detected by FISH for retrospective biological dosimetry applications. Radiat Prot Dosimetry 2005; 113: 396-402. 10. Patton PW, Jokisch DW, Rajon DA, Shah AP, Myers SL, Inglis BA, et al. Skeletal dosimetry via NMR microscopy: investigations of sample reproducibility and signal source. Health Phys 2002; 82: 316-26. 11. Hossein-Nia M, Kallis P, Brown PA, Chester MR, Kaski JC, Murday AJ, et al. Creatine kinase MB isoforms: sensitive markers of ischemic myocardial damage. Clin Chem 1994; 40: 1265-71. 12. Wallimann T, Wyss M, Brdiczka D, Nicolay K, Eppenberger HM. Intracellular compartmentation, structure and function of creatine kinase isoenzymes in tissues with high and fluctuating energy demands: the ‘phosphocreatine circuit’ for cellular energy homeostasis. Biochem J 1992; 281(Pt 1): 21-40. 13. Dovsak T, Ihan A, Didanovic V, Kansky A, Ihan Hren N. Influence of surgical treatment and radiotherapy of the advanced intraoral cancers on complete blood count, body mass index, liver enzymes and leukocyte CD64 expres­sion. Radiol Oncol 2009; 43: 282-92. 14. Almonte TJ, Barnes JH, Bautista SC, Delacruz B, Lansangan L, Pineda PA. Serum Transaminase in Mice after Whole-Body X-Irradiation and the Effect of a Chemical Protector. Int J Radiat Biol Relat Stud Phys Chem Med 1965; 9: 37-42. 15. Gupta RK. NMR spectroscopy of cells and organisms. Boca Raton, Fla.: CRC Press; 1987. 16. Evelhoch JL, Ewy CS, Siegfried BA, Ackerman JJ, Rice DW, Briggs RW. 31P spin-lattice relaxation times and resonance linewidths of rat tissue in vivo: dependence upon the static magnetic field strength. Magn Reson Med 1985; 2: 410-7. 17. Murata O, Sakurai H, Mitsuhashi N, Hasegawa M, Yamakawa M, Kurosaki H, et al. 31P NMR spectroscopy can predict the optimum interval between fractionated irradiation doses. Anticancer Res 1998; 18: 4297-301. 18. Weiss RG, Chatham JC, Charron MJ, Georgakopolous D, Wallimann T, Kay L, et al. An increase in the myocardial PCr/ATP ratio in GLUT4 null mice. Faseb J 2002; 16: 613-5. 19. Merchant TE, Alfieri AA, Glonek T, Koutcher JA. Comparison of relative changes in phosphatic metabolites and phospholipids after irradiation. Radiat Res 1995; 142: 29-38. 20. Ng CE, McGovern KA, Wehrle JP, Glickson JD. 31P NMR spectroscopic study of the effects of gamma-irradiation on RIF-1 tumor cells perfused in vitro. Magn Reson Med 1992; 27: 296-309. 21. Box HC, Lilga KT, Potienko G. 13C nuclear magnetic resonance studies of radiation damage: radiation-induced degradation of glycine. Proc Natl Acad Sci U S A 1977; 74: 2394-6. 22. Ratner AV, Muller HH, Bradley-Simpson B, Hirst D, Pitts W, Young SW. Detection of acute radiation damage to the spleen in mice by using fluo­rine-19 MR imaging. AJR Am J Roentgenol 1988; 151: 477-80. 23. Scaife JF, Hill B. The uncoupling of oxidative phosphorylation by ionizing radiation. Can J Biochem Physiol 1962; 40: 1025-42. 24. Conway MA, Allis J, Ouwerkerk R, Niioka T, Rajagopalan B, Radda GK. Detection of low phosphocreatine to ATP ratio in failing hypertrophied hu­man myocardium by 31P magnetic resonance spectroscopy. Lancet 1991; 338: 973-6. 25. Yost MT, Robson HH, Yost HT. Uncoupling of oxidative phosphorylation in rat liver and spleen mitochondria by exposure to total-body irradiation. Radiat Res 1967; 32: 187-99. 26. Jurdana M. Radiation effects on skeletal muscle. Radiol Oncol 2008; 42: 15-22. 27. Reitan JB, Brinch L, Beiske K. Multi-organ failure aspects of a fatal radiation accident in Norway in 1982. BJR Suppl 2005; 27: 36-40. 28. Meineke V, Fliedner TM. Radiation-induced multi-organ involvement and failure: challenges for radiation accident medical management and future research. BJR Suppl 2005;27: 196-200. 180 research article Prophylactic cranial irradiation in patients with small-cell lung cancer: the experience at the Institute of Oncology Ljubljana Karmen Stanic, Viljem Kovac Institute of Oncology, Department of Radiation Oncology, Ljubljana, Slovenia Received 4 June 2010 Accepted 14 June 2010 Disclosure: No potential conflicts of interest were disclosed. Correspondence to: Karmen Stanic, MD, MSc, Department of Radiation Oncology, Institute of Oncology Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia. Phone: +386 1 587 9502; E-mail: kstanic@onko-i.si Background. Prophylactic cranial irradiation (PCI) has been used in patients with small-cell lung cancer (SCLC) to reduce the incidence of brain metastases (BM) and thus increase overall survival. The aim of this retrospective study was to analyze the characteristics of patients with SCLC referred to the Institute of Oncology Ljubljana, their eligibility for PCI, patterns of dissemination, and survival. Patients and methods. Medical charts of 357 patients with SCLC, referred to the Institute of Oncology Ljubljana between January 2004 and December 2006, were reviewed to determine characteristics of patients chosen for PCI. The following data were collected: age, gender, performance status (PS), extent of the disease, smoking status, type of primary treatment with outcome, haematological and biochemical parameters, PCI use, and finally brain metas­tases (BM) status at diagnoses and after treatment. Results. PCI was performed in 24 (6.7%) of all patients. Six (25%) patients developed brain metastases after they were treated with PCI. Brain was the only site of metastases in 4 patients, two progressed to multiple organs. Median overall survival of patients with PCI was 21.9 months, without PCI 12.13 months (p = 0.004). From the collected data there were good prognostic factors: age under 65 years, limited disease (LD), performance status, normal levels of lactate dehydrogenase (LDH) and normal levels of C-reactive protein levels (CRP). Other prognostic factors did not show statistical significant values. Conclusions. Survival of patients with LD, who have had PCI, was significantly better than those who had not. We decided to perform PCI in patients with LD, in those with complete or near complete response, and those with good performance status (= 80). We did not use PCI in extended disease (ED). The reason for that shall be addressed in the future. Doses for PCI were not uniform, therefore more standard approach should be considered. Key words; small-cell lung cancer, brain metastases, prophylactic cranial irradiation Introduction Small-cell lung cancer (SCLC) expresses aggres­sive behaviour. Combined treatment with chemo­therapy and radiotherapy provides response rates between 50-85% in limited disease (LD). Local recurrence rate decreases with combined treat­ment; however, brain metastases (BM) become the most common site of relapse. Brain metastases are present in about 20% of patients at the time of diag­nosis, but in autopsy findings the rate reached over 50%.1,2As in other cancers, in clinical practice BM are diagnosed with computer tomography (CT), less common with magnetic resonance imaging (MRI)3,4; and all are treated with radiotherapy.5 In the early 1970s, prophylactic cranial irradia­tion (PCI) has been proposed to improve overall survival, because it is well known that central nerv­ous system is relatively refractory to chemotherapy due to the blood-brain barrier. In the 1980s and 1990s there were many prospective studies con­ducted to investigate the use of PCI; however, only after the publication of two meta-analysis report­ing improvement, both, in overall survival and dis­ease free survival, PCI became a part of the stand­ard treatment in SCLC. The first meta-analysis by Auperin et al. in 1999 reported the 5.4% increase in the rate of survival at three years as well as the in­creased rate of disease-free survival.6Meert et al.in meta-analysis in 2001 composed 12 randomized trials and reported a hazard ratio of 0.48 for the in­cidence of brain metastases after PCI.7 Recent studies suggest that patients in extensive disease setting could also benefit from PCI.8,9 The aim of this analysis was to review the use of PCI, to analyze the characteristics of patients with SCLC, referred to the Institute of Oncology Ljubljana, eligibility for PCI, patterns of dissemina­tion, and survival. Patients and methods Cancer Registry of Republic of Slovenia reported 574 newly diagnosed patients with SCLC in the pe­riod between 2004 and 2006.10-12Three hundred fifty seven patients (62.19%), reviewed in this analysis, were referred for further treatment to the Institute of Oncology Ljubljana, mainly from University Clinic of Respiratory and Allergic Diseases Golnik and University Clinical Centre Maribor. One pa­tient refused all types of further diagnostic proce­dures and treatments and was excluded from fur­ther evaluation. The following data were collected: gender, age, extent of disease, performance status, smoking sta­tus, presence of other malignancies, starting serum levels of haemoglobin (Hb), lactate dehydrogenase (LDH) and C-reactive protein (CRP), type of treat­ment, response to treatment, PCI information, pat­tern of dissemination, BM status at diagnoses and after the treatment. LDincludedpatientswithlesionsconfinedtoip­silateralhemitorax,andregionalandsupra-clavic­ularlymphnodes.Extendeddisease(ED)waschar­acterizedbyanevidentand/orprovenmetastases. Irradiation was performed at the Institute of Oncology Ljubljana; however, chemotherapy was delivered either at Institute of Oncology Ljubljana (189 patients), University Clinic of Respiratory and Allergic Diseases Golnik (123 patients) or at University Clinical Centre Maribor (29 patients). Twenty one referred patients received no treatment due to poor performance status at presentation at the Institute or due to deterioration of disease dur­ing the waiting time for therapy. Treatment responses were evaluated according to the data available in medical charts as judged TABLE 1. Characteristics of patients Gender Male Female Age (years) Clinical stage Limited disease Extended disease No data available Performance status (Karnofsky) >80 60-80 <60 No data available Lactate dehydrogenase (LDH) Normal (= 4.23 mkat/L) Elevated (> 4.23 mkat/L) No data available C-reactive protein levels (CRP) Normal (= 15 mg/L) Elevated (> 15 mg/L) No data available Haemoglobin (Hb) < 120 (g/L) = 120 (g/L) No data available Smoking status Non smokers Smokers Ex smokers No data available Other malignancies synchronic metachronic Brain metastases (BM) as the only site BM at diagnoses BM after primary treatment 270 75.84 86 24.15 61.86 (40-83) 167 46.10 188 52.80 1 0.2 71 19.9 196 55.05 29 8.14 60 16.85 158 44.38 102 28.65 96 26.96 122 34.26 132 37.07 102 28.65 86 24.15 186 52.24 84 23.59 8 2.24 163 45.78 84 23.59 101 28.37 36 10.11 6 1.6 30 8.4 66 18.53 37 10.39 29 8.14 182 Stanic K and Kovac V / Prophylactic cranial irradiation The overall survival time was defined as the time from diagnosis to death or until the end of follow up period on April 1st2010. The number of surviving patients was confirmed at this date. Time to progression to brain was defined as time from diagnosis to confirmation of brain metastases by image diagnostics. For patients with PCI time to development of brain metastases was calculated also for period after completion of PCI to confirma­tion of brain metastases by image diagnostic. Survival was calculated according to Kaplan­Meier’s method and differences were confirmed by the log-rank test. Independent variables that ap­peared statistically significant on univariate anal­ysis were tested by multivariate Cox regression analysis model. Results Between January 2004 and December 2006 institu- FIGURE 1. Survival of patients with prophylactic cranial irradiation (PCI) and without tions referred 357 patients with SCLC for further PCI (p = 0.004). treatment to the Institute of Oncology; 356 were evaluable. Characteristics of patients are detailed by radiation oncologist, based either on X-ray or in Table 1. CT examination during the follow-up. Some of Median age at diagnosis was 61.86 years (40-83); the complete responses (CR) were also confirmed majority were male (76%). bronchoscopically.LD was present in 46% of patients, ED in 53%. PCI patients were irradiated on Cobalt unit with Performance status, expressed in numbers of the 1.25 MV or on linear accelerator with 5 or 6 MV Karnofsky scale, could be collected for majority of photon beams for 5 days per week, once daily. The patients; however, for 17% patients only descrip-irradiated field involved whole brain using two tions of status could be found in medical records. opposed lateral fields.Majority of patients were smokers (46%). For ex- As established the biologic effectivenessof ra-smokers (24%) qualified patients who stopped diation schedules depends on total dose and dose smoking at least one year prior to diagnosis. Only per fraction.The Equivalent Dose in 2-Gy fraction 8 (2%) patients were non-smokers; for 28% of pa­(EQD2) was calculated withthe equation as de-tients data could not be retrieved from the medical rived from the linear-quadratic modelrecords. Thirty six (10%) patients have had second EQD2 = D x [(d + a/ß )/2 Gy + a/ß )],malignancy, 6 synchronously and 30 before SCLC. where D = total dose,d = dose per fraction, a = Majority have had head and neck tumours (13), linear (first-order dose-dependent)component of non-SCLC (6), skin tumours including melanoma cell killing, ß = quadratic (second-orderdose de-(6), breast tumours (3), lymphoma (2), prostate car-pendent) component of cell killing, a/ß -ratio= the cinoma (2) and other types (3). Two hundred twen-dose where both components are equal. In analysis ty six (63.48 %) patients have had CT or MR im-a/ß-ratio of 10 Gy was used to calculate the biologi-aging during their diagnostic work up procedure cal effectivenessof radiation for tumor-cells and -there were 15 (4.2%) without it; for 113 (31.74%) a/ß -ratio of 3 Gy was used for normal tissue.13patients, data were not available. The type of treatment and outcome are present­ed in Table 2. Majority of patients were treated with Statistics chemotherapy and irradiation. Chemotherapy as the only treatment was delivered mainly to pa-Statistical analysis was performed using personal tients with ED and 13 patients were irradiated only. computer and software statistical package SPSS, Four patients underwent surgery and completed version 13 (SPSS Inc., USA).chemotherapy. Treatment resulted in 9 complete TABLE 2. Treatment characteristics and outcome Chemotherapy 1 22 33 22 67 145 Chemotherapy and radiotherapy 6 64 37 13 53 173 Radiotherapy 0 3 1 0 9 13 Surgery and chemotherapy 2 1 0 0 1 4 No therapy 21 CR = complete response, PR = partial response; SD = stable disease; PD = progressive disease responses (CR), 90 partial responses (PR), 71 sta­ble diseases (SD) and 35 progressive diseases (PD). For 150 patients evaluation was not appropriately recorded. Metastases to brain as the only site of dissemi­nation was present in 37 patients (10.39%) at the time of diagnoses. Twenty-nine patients (8.14%) progressed after primary treatment. RadiotherapyoncologistsproposedPCIto30pa­tients,whomtheyconsideredeligible,but6havere­fusedit.24patients(6%)receivedPCI(20maleand 4female),meanageofpatientswithPCIwas53.54 years.CharacteristicsofpatientswhoreceivedPCI arepresentedinTable3.AllpatientswithPCIhad LD,statisticalsignificantbetterperformancestatus, wereyoungerandsmokersorexsmokers,onlyone patienthadpreviousothermalignancy. Dose schedules of PCI were not uniform and are presented in Table 4. No trends in difference of BM frequency with increased biological equivalent dose (calculated as EQD2) received at PCI could be detected. After PCI 6 (25%) patients developed brain me­tastases, in 4 patients brain was the only site of metastases, in 2 patients the disease progressed to multiple organs. In 4 out of 6 patients additional cranial irradiation was performed; in 2 patients the disease progressed while waiting for radiotherapy. Brain was the first site of metastases in 29 pa­tients with LD SCLC; among them 4 patients have had PCI and 25 patients were without PCI, includ­ing also 3 patients that have refused PCI. BM were present in 37 patients at the time of diagnosis (ED), 48 patients developed BM later. Overall incidence of BM in our population was therefore 32%. The mean time to development of BM as a single site of progression for patients with PCI was 32.7 months (14.59-58.62). Mean time to development of BM as single site of progression for 25 other patients with LD who did not have PCI was 10.75 months (0.72-30.1). The difference was statistically significant (p<0.001). The median overall survival (OS) for all 356 patients with SCLC included in analyses was 9.4 months (95% CI; 8.37 – 10.44) The median OS of 167 patients presented with LD SCLC was 13.34 months (95% CI; 12.17-14.51). Median OS of patients with PCI was 21.9 months (95% CI; 6.31-37.48), for those without PCI was 12.13 months (95%CI; 10.69-14.51). The difference was statistically significant (log rank, p=0.004) (Figure 1). On our cut-off date on April 1st2010 there were 28 patients still alive, 7 of them have re­ceived PCI. Univariate analysis including all patients with SCLC showed statistically significant better surviv­al in patients with age < 65 years, PS > 80, normal LDH and CRP levels, those with PCI and LD and, surprisingly, smokers. In multivariate analysis only LD (p<0.0001, HR = 0.49, 95 % CI 0.332-0.722) and PS (p = 0.03, HR = 0.63, 95 % CI 0.419-0.973) were identified as independent prognostic factors. Since PCI was only performed in patients with LD, separate analysis was performed for this popu­lation. In univariate analysis age < 65 years, PS > 80 and PCI showed statistically significant better survival. Multivariate analysis identified only age (p=0.001) and PS (p=0.008) as independent prog­nostic variables. Discussion PCI has been used in patients with LD SCLC to reduce the incidence of BM and increase overall survival, however reports suggest it should be used also in patients with ED SCLC. In our institu­tion only patients with LD received PCI (14.37%).Retrospective reports in the literature mention about 8%.14 Standard treatment consists of combination of chemotherapy and thoracic irradiation of the site of primary tumour.15Combined treatment was de­livered to 129 (77.24%) patients with LD SCLC, al­ 184 Stanic K and Kovac V / Prophylactic cranial irradiation TABLE 3. Characteristics of patients with prophylactic cranial irradiation so the majority of PCI patients in our review were given this treatment; one patient received only chemotherapy and was referred from another in- Gender Male Female Age (years) Performance status (Karnofsky) = 90 Data not available Smoking status Non smokers Smokers Ex smokers No data available Other malignancies synchronic metachronic Lactate dehydrogenase (LDH) Normal (< 4.23 mkat/L) Elevated (> 4.24 mkat/L) Data not available C-reactive protein levels (CRP) Normal (< 15 gr/L) Elevated (> 15 gr/L) Data not available Haemoglobin (Hb) < 120 (g/L) > 120 (g/L) Data not available Response to primary treatment CR PR Data not available Brain metastases As only site of progress In multiple organ progress 20 4 53.54 (43-73) 6 16 2 0 16 4 4 1 0 1 14 2 8 10 8 6 14 3 6 5 17 2 6 4 2 and chemotherapy prior to PCI. 83.33 PCI is eligible in patients who achieve complete or near complete response after treatment of prima­ 16.66 ry tumour. In our review only 69 (41.3%) patients in LD group met this criteria; however, data for 60 patients from the same group of LD were not avail­able -the majority of them completed treatment in other institutions and were evaluated there. In 25 group of patients with PCI 5 CR and 17 PR (near CR) were observed, for 2 patients appropriate data 66.66 were not available in medical records. 8.3 None of our patients with ED SCLC received PCI, although 30 had PR responses, however, there were no CR. There are reports that suggest consid­ 0 ering PCI also in patients who respond to first line 66.66 chemotherapy.16 16.66 Patients who received PCI were younger than 16.66 SCLC population studied. Radiation oncologists have chosen for PCI patients with the Karnofsky 4.1 performance status (PS) of 80 or higher. This is 0 in accordance with performance status patient’s 4.1 selection in prospective studies.17The majority of patients were heavy smokers as was expected in population of patients with SCLC.18Heavy smok­ 58.33 ers have comorbidities and therefore usually lower 8.3 performance status, making them less likely can­ 33.33 didates for radical treatment and also for PCI.19Bremnes et al.reported gender, extent of disease, PS, Hb levels and LDH to be independent prognos­ 41.66 tic factors.20In our analyses only age < 65 years and 33.33 PS were independent factors of survival in multi­25 variate analysis. Doses of PCI in our review were not uniform. Meta analysis suggested trend towards increased 58.33 reduction of BM rate with increased dose, how­ 12.5 ever, prospective study exploring high versus low dose in PCI found no reduction in total incidence of 25 BM, but there was increased mortality with higher doses.6Therefore a dose of 25 Gy was suggested to be the standard care in LD SCLC.16,21All our pa­ 20.83 tients received biological equivalent doses higher 70.83 than 25 Gy, but no increased mortality nor differ­ 8.33 ence in frequency of BM according to the biological 25 equivalent dose could be detected. The number of analysed PCI patients was small; therefore no con­ 16.66 clusions could have been made. 8.3 According to our review 4 patients refused PCI. CR = complete response, PR = partial response Details of this refusal were not described in our medical records. We could assume that the fear of possible side effects might have been one of the TABLE 4. Irradiation doses that were applied as prophylactic cranial irradiation 1 14 x 2.0 Gy = 28.0 Gy 28.0 28.0 3 0 2 15 x 2.0 Gy = 30.0 Gy 30.0 30.0 2 2 3 17 x 2.0 Gy = 35.0 Gy 35.0 35.0 1 0 4 12 x 2.2 Gy = 26.4 Gy 26.84 27.45 3 1 5 13 x 2.2 Gy = 28.6 Gy 29.07 29.74 1 1 6 14 x 2.2 Gy = 30.8 Gy 31.31 32.03 1 1 7 12 x 2.5 Gy = 30.0 Gy 31.25 33.0 4 2 8 14 x 2.5 Gy = 35.0 Gy 36.45 38.5 5 1 9 10 x 3.0 Gy = 30.0 Gy 32.5 36.0 4 0 EDQ2 = Equivalent Dose in 2-Gy fraction reasons. Several studies reported neurological im­pairment or abnormalities potentially related was PCI.9,22-26Acute toxicity consisted mostly of alo­pecia, headache, fatigue, nausea and vomiting and was usually manageable on outpatient basis. Long term toxicities such as memory loss, intellectual impairment, demenca, ataxia or seizures could be of great concern. The incidence of BM as the first site of relapse at 5 years have been reported to be 37% in a group of patients not receiving PCI and 20% in PCI group.17However, patients in the study reported had only CR and included also a proportion of ED SCLC. Recent retrospective report indicated 25% inci­dence of development of BM after PCI, however, number of patients was again small.27The same proportion of patients developed BM also in our series. There are still doubts among radiation oncolo­gists about using PCI, although even cost effective­ness and quality of life studies beside studies con­firming improvement in BM control, OS and DFS have been published.28There are decision making tools and practice guidelines available, but judg­ment of radiation oncologist should prevail spe­cially in cases of near CR.29-31 Conclusions Our analysis confirmed increased median survival time and decreased incidence for BM in patients with PCI. Our policy of treatment was to perform PCI in patients with LD and good performance status, the two variables that independently showed better survival. Adding PCI in these patients setting fur­ther increased survival. Possibilities of using PCI also in ED SCLC in our institution should be fur­ther explored in the future. Doses for PCI were not uniform therefore more standard approach should be considered. References 1. Hirsch FR, Paulson OB, Hansen HH, Larsen SO. Intracranial metastases in small cell carcinoma of the lung. Prognostic aspects. Cancer 1983; 51: 529-33. 2. Hirsch FR, Paulson OB, Hansen HH, Vraa-Jensen J. Intracranial metastases in small cell carcinoma of the lung: correlation of clinical and autopsy findings. Cancer 1982; 50: 2433-7. 3. Oztekin O, Savas R, Ozan E, Apaydin M, Yasar O, Adibelli ZH, et al. Pineal gland metastasis of auricular squamous cell carcinoma: an unusual case and literature review. Radiol Oncol 2009; 43: 175-9. 4. 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J Clin Oncol 2006; 24: 3597-603. research article Gonadal function in patients treated for Hodgkin´s disease in childhood Lorna Zadravec Zaletel1, Nevenka Bratanic2, Berta Jereb1 1 Institute of Oncology, Department of Radiation Oncology, Ljubljana, Slovenia 2 University Children Hospital Medical Center, Ljubljana, Slovenia Received 12 April 2010 Accepted 19 May 2010 Correspondence to: Lorna Zadravec Zaletel, MD, PhD, Department of Radiation Oncology, Institute of Oncology Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia. Phone: +386 1 587 9246; E-mail: lzaletel@onko-i.si Disclosure: No potential conflict of interest were disclosed Background. The long-term survival of patients treated for Hodgkin`s disease (HD) in childhood is high and the chief concern is now being directed toward the late effects of the treatment, including the endocrine dysfunction. Patients and methods. Testicular and ovarian functions were assessed in 64 long term survivors (24 females, 40 males) treated for HD in childhood in Slovenia between 1972 and 1994. At diagnosis they were 3-16 years old and had gonadal evaluation 4-27 years later at the age of 13-34. Fifty-four (84%) patients received chemotherapy (ChT), 49 in combination with radiation therapy (RT), 10 received RT alone. Gonadal function was assessed by the clinical examination and measurement of serum concentrations of estradiol and testosterone. Serum levels of LH and FSH were determined in the basal state and after the stimulation. Results. Primary hypogonadism (PH) was found in 30 (47%) patients. Twenty-four of 40 (60%) males had PH with evidence of damage of germinal epithelium, 4 of them had evidence of damage of Leydig cells (LC) and 10 had evidence of dysfunction of LC as well. PH was found in 6 of 24 (25%) females. Conclusions. After therapy for HD PH was more frequent in males than in females. Not only RT but also alkylating agents and procarbazine alone caused damage of LC. Age of patient at the time of treatment was not an important risk factor for gonadal toxicity. Pelvic RT in combination with ChT is the most important risk factor of the development PH both, in males and females. Key words: gonadal function; late effects; childhood cancer; Hodgkin’s disease Introduction The long-term survival of patients after the treat­ment of childhood cancer, especially Hodgkin`s diesease (HD), has greatly improved in the last few decades due to the effective treatment, especially multiagent chemotherapy (ChT).1The chief con­cern is now being directed toward the late effects of the treatment2, which influence on patient’s qual­ity of life and become more and more important in cancer treatment.3,4Endocrine glands, gonads in particular, are very susceptible to damaging ef­fects of anticancer therapy.5The damaging effect of both ChT and radiotherapy (RT) on gonads is well known.6In a study of 2283 long-term survivors of childhood cancer Byrne and colleagues found that RT below the diaphragm depressed fertility in both sexes for about 25%, ChT with alkylating agents with or without RT below the diaphragm depressed fertility by 60% in men, but in women alkylating agents therapy administered alone had no apparent effect on fertility.7 The aim of this study was to define the influ­ence of cancer treatment on the gonadal status of 64 young adults treated for HD during childhood and adolescence in Slovenia. Material and methods Patients Between 1972 and 1994, 104 patients were treated for HD during childhood (0-16 years of age) in Slovenia. Twenty-four patients had died, 4 were lost to follow-up. Seventy-six ptatients are regular­ly followed at the outpatient Clinic for Late Effects at the Institute of Oncology, Ljubljana. Twelve pa­ 188 Zadravec-Zaletel L et al. / Gonadal function after Hodgkin’s disease TABLE 1. Chemotherapy in 54 patients treated for Hodgkin’s disease MOPP 11 2 10 . 1 24 LOPP 14 1 1 16 MOPP/ABV hybrid 8 8 COPP(A) 3 3 OPPA 1 2 . 3 Total No of patients 37 2 11 4 54 . 4 patients received also LOPP, 1 patient COPPA . 1 female, missdiagnosed as having non-Hodkin’s lymphoma, received chemotherapy following protocol BFM 90 as first treatment LOPP = chlorambucil, vincristine, procarbazine, prednison; ABV(D) = doxorubicin, bleomycin, vinblastine, (dacarbazine); COPP(A) = cyclophosphamide, vincristine, procarbazine, prednisone, (doxorubicin); MOPP = mechlorethamine, vincristine, procarbazine, prednisone; OPPA = vincristine, procarbazine, prednison, doxorubicin TABLE 2. Gonadal function according the type of treatment in 40 males Pelvic RT + ChT Pelvic RT alone 8 2 1. 0 9 2 = 6 c (AAP) ChT with nonpelvic RT 13 1 4 18 = 6 c (AAP) ChT, no RT 1 1 2 = 5 c (AAP) ChT with nonpelvic RT Nonpelvic RT alone Total No of patients 1. 24 1 3 1 1 2 4 12 4 5 40 . pt received 3 cycles (c) of LOPP . RT to the iliacal region only PH = primary hypogonadism; SIG = subclinical impairment of gonadal function; SH = secondary hypogonadism; RT = radiotherapy; ChT = chemotherapy; AAP = ChT, containing alkylating agents and procarbazine (P) (MOPP, MOPP-ABV hybrid, MOPP/ABVD, LOPP, COPP(A) and OPPA) tients refused endocrinological evaluation, so 64 patients (24 females, 40 males) were included in our analysis. They were treated for HD at the age of 3-16 (median 13) years and had endocrinological evaluation 4-27 (median 10) years after the end of the treatment at the age of 13-34 (median 21) years. All patients were pubertal or postpubertal when studied (only two patients were younger than 16 years). Atdiagnosis,13patientswereinstageI(12above thediaphragm),23instageII(21abovethedia­phragm),25instageIIIand3instageIV(2involve­mentofthelung,oneoftheliver).Sevenpatients(5 boys,2girls)sufferedfromrelapse.Forty-ninepa-tientsweretreatedwithChTandRT,10withRTand 5withChTastheonlytreatmentmodality.Fifty-fourpatientshadcombinationChTwithMOPP [mechlorethamine,vincristine,procarbazine,pred­nisone],MOPP-ABV[mechlorethamine,vincris-tine,procarbazine,prednisone-doxorubicin,bleo­mycin,vinblastine]hybrid,MOPP/ABVD[mechlo­rethamine,vincristine,procarbazine,prednisone/ doxorubicin,bleomycin,vinblastine,dacarbazine], LOPP[chlorambucil,vincristine,procarbazine, prednisone],COPP(A)[cyclophosphamide,vinc­ristine,procarbazine,prednisone,(doxorubicin)] andOPPA[vincristine,procarbazine,prednisone, doxorubicin]8-11(Table1).Ofthe59patientstreated withRT,27(19boys,8girls)hadRTabovethedia­phragmwith20-40(median30)Gy,17(8boysand9 girls)RTtotheupperabdomenwith24-49(median 30)Gyand15(11boys,4girls)RTtothepelviswith 22-45(median30)Gy. Twenty-eight (12 girls and 16 boys) patients had also staging laparotomy with splenectomy. Assessment of gonadal function The patient’s data, regarding both, the diagnosis and the treatment, were collected from medical files, information concerning quality of life includ­ing attained educational level, marital status, em­ployment and social life, past and present menstru­al histories, the course of puberty and fertility his­tories were ascertained by the interview. The gen­eral physical examination was performed, height, weight and clinical abnormalities as well as Tanner stages of pubic hair and genital development were recorded. Each patient’s blood samples were ana­lysed for basal concentrations of total testosterone (RIA, IMUNOTECH), estradiol (DELFIA-LKB) and prolactin (DELFIA-LKB). Concentrations of lutein­izing hormone (LH) (DELFIA-LKB) and follicle stimulating hormone (FSH) (DELFIA-LKB) were determined before and 10, 20, 30, 60 minutes after i.v. administration of gonadotropin releasing hor­mone (50 mcg/m2) (LH-RH). Semen analyses were performed in 6 men. Primary hypogonadism (PH) was defined as basal serum FSH and/or LH level above the nor­mal upper limit and exaggerated response after the stimulation with LH-RH. In men, elevated basal serum FSH levels indicated germinal epithelium damage (GE-DA), while elevated LH levels (with/without reduced total testosterone levels) indi­cated Leydig cells (LC) damage (LC-DA). Normal basal values of LH and/or FSH and the exagger­ated response after LH-RH stimulation were con­sidered as a subclinical impairment of the gonadal function (SIG). The exaggerated response of FSH after LH-RH was considered as a dysfunction of germinal epithelium (GE-dys), while the exagger­ated response of LH after LH-RH were considered as a dysfunction of LC (LC-dys). Low serum basal FSH and LH levels with the poor response after i.v. bolus of LH-RH was considered as secondary hy­pogonadism (SH). Results Males We found PH in 24 of 40 males (60%); in 20 of 35 males (57%) who had primary treatment and in 4 of 5 males (80%) treated for the relapse (Table 2). All 24 males had the evidence of GE-DA, four of them had the evidence of LC-DA (low level of to­tal testosterone in one) and ten had the evidence of LC-dys as well. Twenty-two of 24 males with PH had received combination ChT (all but one = 6 cy­cles of AA and procarbazine (P) containing ChT) and RT (to the pelvis in 8), 2 had had pelvic RT only (Table 2). Patients with LC-DA or LC-dys had received somewhat higher cumulative doses of P (med. 7.4 g/m2) than those who had a normal LC function (med. 6.5 g/m2), while cumulative doses of alkylating agents, proportion of patients having received pelvic RT and ages at diagnosis did not differ among the two groups. Semen analyses were performed in 6 of 24 (25%) males with PH and all were azoospermic. Five males of the 24 with PH have children. Three patients had SIG: one had isolated GE-dys, the second LC-dys and the third GE-dys in combination with LC-dys, all after the treatment with combined ChT (MOPP/ABVD x 6, MOPP x 4 and LOPP x 6) without pelvic RT. One of them has children. One patient had evidence of SH. He had been treated with RT to the neck and mediastinum (40 Gy) (Table 2). Of 11 males who had had pelvic RT (9 to the iliacoinguinal region, 2 to the iliacal region), 9 in combination with ChT, 10 had PH. ChT alone was less gonadotoxic, causing PH in 14 of 29 (48%) males than ChT in combination with pelvic RT (PH in 8 of 9 (89%) males). Only one of these patients, who had received RT to the iliacal region only in combination with two cycles of MOPP, had normal gonadal function (Tables 2, 3). The endocrinological evaluation was normal in 12 males. Seven of them had received ChT and RT, four RT only and one ChT only (Table 3). Among 7 males having received 6 cycles of MOPP without pelvic RT only one had normal en­docrine tests. He had received 6 cycles of ABVD as well. Among 10 males having received 6 cycles of LOPP without pelvic RT 4 had normal gonadal function. Three patients had received 1 or 2 cycles of MOPP or OPPA and had normal testicular func­tion (Table 2). Age at diagnosis, follow-up time and age at en­docrine evaluation were similar in the group of pa­tients with PH and in the group of patients without endocrinological deficiences. The only difference between the groups was the treatment modality (Tables 2, 3). Females We found PH in 6 of 24 (25%) females (Table 4), 3 of them had low levels of estrogen as well. All 6 had been treated with ChT and RT. Two of them had been treated with ChT (COPPA×6 and LOPP×6) and unilateral pelvic RT (24 and 30 Gy), one has primary amenorrhea, the other has irregular men­strual periods and one child. Four females with PH had received ChT (two 6 cycles of MOPP, one 6 cycles of LOPP, one ChT following protocol BFM 90 and 3 cycles of (C)OPP(A)) and nonpelvic RT, 3 upper abdominal. Two of these 4 patients have regular menstrual periods and children, one has ir­regular menses and one is in early menopause after having given birth to 2 children. We found SIG in one female treated with 4 cy­cles of MOPP and neck RT. She has irregular men­strual periods and gave birth to one child (Table 4). Seventeen females had normal gonadal function with regular menstrual periods; 14 of them had had ChT, 13 in combination with RT (2 pelvic), 3 had had nonpelvic RT only (Table 4, 5). Among 6 females having received 6 or more cy­cles of MOPP ChT without pelvic RT, 4 had normal gonadal function (one even after 8 cycles of MOPP, 3 after ChT containing 6 cycles of ABVD as well). One female had normal gonadal function after 3 cycles of MOPP plus 3 cycles of LOPP. Of 2 females having received 6 cycles of LOPP without pelvic RT one had normal gonadal function (Table 5). All of 5 females having received 6 cycles of MOPP/ABV hybrid regimen (in combination with unilateral pelvic RT in 2) had normal gonadal func­tion (Table 5). The group of females with PH and the group with a normal gonadal function did not differ re­garding age at diagnosis, follow-up time or age at 190 Zadravec-Zaletel L et al. / Gonadal function after Hodgkin’s disease TABLE 3. Therapy for Hodgkin’s disease in twelve males with normal endocrine tests MOPP/ABVD ×6 none/nonpelvic 1 7 . . LOPP × 6 nonpelvic 4 10 . MOPP × 2 iliacal region (30 Gy) 1 1 MOPP × 1 nonpelvic 1 1 NONE nonpelvic 4 5 . OPPA × 2 nonpelvic 1 1 TOTAL 12 25 . also patients receiving 6 cycles of MOPP only . 1 patient had subclinical impairment of gonadal function . 1 patient had secondary hypogonadism ChT = chemotherapy; RT = radiotherapy; MOPP = mechlorethamine, vincristine, procarbazine, prednisone; ABVD = doxorubicin, bleomycin, vinblastine, dacarbazine; LOPP = chlorambucil, vincristine, procarbazine, prednison; OPPA = vincristine, procarbazine, prednisone, doxorubicin TABLE 4. Gonadal function according the type of treatment in 24 females Pelvic RT + = 4 c (AA) ChT 2 2 4 = 6 c (AA) ChT with nonpelvic RT 4 0 7 11 = 6 c (AA) ChT, no RT 0 0 3 3 = 5 c (AA) ChT with nonpelvic RT 0 1 2 3 Nonpelvic RT alone 3 3 Total No of patients 6 1 17 24 PH = primary hypogonadism; SIG = subclinical impairment of gonadal function; RT = radiotherapy; ChT = chemotherapy; AA = ChT, containing alkylating agents (MOPP, MOPP-ABV hybrid, MOPP/ABVD, LOPP, COPP(A) and OPPA) endocrine evaluation; they differ only by the mode of the treatment. Females with PH had received slightly larger cumulative doses of P (med. 7 g/m2) than those with a normal gonadal function (med. 5.5 g/m2). Females with PH had had abdominal RT in higher proportion (5 of 6 (83%) (pelvic RT in 2 of 6 (40%)) than females with normal gonadal function (abdominal RT in 8 of 17 (47%) (pelvic in 2 of 17 (12%)). ChT in combination with pelvic RT was more gonadotoxic, causing PH in 2 of 4 (50%) females, than ChT alone (PH in 4 of 20 (20%) fe­males). None of female patients had evidence of SH. Discussion Our study is a population based study. As to our knowledge there is no international population based study of gonadal dysfunction after the treat­ment of HD in childhood. The study populations of most studies, dealing with this topic, are selected according to the type of treatment, age, gender or institution. Several studies showed that in men basal FSH levels and FSH response to LH-RH correlated well with the sperm production.12-16An increased FSH response to LH-RH can be the first manifestation of testicular damage15, although normal FSH levels do not rule out the possibility of azoospermia.14,17,18In our study semen analyses in 6 patients with a high basal FSH level showed azoospermia. Our findings are in concordance with da­ta from other studies establishing that MOPP or MOPP-like combinations, such as MVPP (mechlorethamine,vinblastine, procarbazine and prednisone) and COPP induce azoospermia in 90­100% of patients with a 10-20% chance of recovery even 10 years after treatment.17,19-24In our study 1 of 7 males had a normal gonadal function after receiving 6 cycles of MOPP. The recovery of sper­matogenesis following MOPP therapy appears to TABLE 5. Therapy in 17 females with normal endocrine tests MOPP × 8 nonpelvic 1 3 . MOPP/ABV hybrid × 6 nonpelvic 3 3 MOPP/ABV hybrid × 6 pelvic-unil.(24Gy) 1 1 MOPP/ABVD ×6 none 2 2 MOPP/ABV×6+ABVD×6+LOPP×6 pelvic-unil.(22Gy) 1 1 MOPP/ABVD × 6 + LOPP × 3 none 1 1 MOPP × 3 + LOPP × 3 nonpelvic 1 1 LOPP × 3 +ABV × 2 nonpelvic 1 1 COPPA × 6 nonpelvic 1 1 LOPP × 6 nonpelvic 1 2 COPP × 2 + OPPA × 2 nonpelvic 1 1 None nonpelvic 3 3 Total 17 20 . 2 patients with primary hypogonadism received 6 cycles of MOPP ChT = chemotherapy; RT = radiotherapy; MOPP = mechlorethamine, vincristine, procarbazine, prednisone; ABVD = doxorubicin, bleomycin, vinblastine, dacarbazine; LOPP = chlorambucil, vincristine, procarbazine, prednison; COPP = cyclophosphamide, vincristine, procarbazine, prednisone; OPPA = vincristine, procarbazine, prednisone, doxorubicin; be dose-related with 3 courses of MOPP represent­ing a limiting gonadal exposure for the recovery, suggesting only a partial killing of germinal stem cells.25Indeed, in our study we found a normal go­nadal function in two males after having received 1 and 2 cycles of MOPP ChT. We found ChT ac­cording to the protocol LOPP less damaging for testicular function than MOPP, causing GE-DA in 5 of 10 males having received 6 cycles, a finding not published elsewhere to our knowledge. Four males had evidence of LC-DA, 12 had LC-dys. All but two of them had evidence of GE-DA as well. Only 1 of 4 males with LC-DA and 4 of 12 males with LC-dys had had pelvic RT, the oth­ers had received ChT with nonpelvic RT, indicat­ing the adverse effect of chemotherapeutic agents on Leydig cells. This is supportive to the observa­tions of Romerius and colleagues26and Mustieles and colleagues.12The possible explanation for a high incidence of the dysfunction of LC in males with damage of germinal epithelium (in 10 of 20) is coexistence of compensated LC failure with the germ cell depletion observed in males not treated for malignancies.27 Besides AA and P, pelvic RT turned out to be very gonadotoxic. Ten of eleven males, who had had pelvic RT, had PH. Two of those had had RT only, inverted Y, with doses of 40 Gy respectively, without special shielding of testes. It is well known that a cumulative dose of 200 cGy in multiple frac­tions may cause azoospermia and that is the dose of scattered radiation that the testes could receive from an inverted Y field.28 Five of 24 males with GE-DA fathered children indicating that they are not azoospermic but possi­bly oligospermic and fertile. Hoorweg-Nijman and colleagues found elevated levels of FSH compat­ible with normospermia.16FSH levels may provide an estimate of possible impaired spermatogenesis, however only the semen analysis is confirmatory assessment of the male gonadal function. We have no explanation for SH in male treated with RT above the diaphragm (not including hy­pophysis). We found PH in 6 of 24 (25%) females. Only one of them is amenorrhoic (after 6 cycles of COPPA). There are data of adverse effects of ChT that is in use for HD, on ovarian function in adult females, but very little on ovarian function in girls. In the study of Ortin and colleagues 2 of 18 girls were amenorrhoic after having received 6 or more cycles of MOPP.29In our study none of 6 girls is amenor­rhoic after 6 or more cycles of MOPP, but 2 have evidence of the ovarian damage while retaining fertility. Ionizing radiation is toxic to the ovaries. The dose of 20Gy is necessary for inducing ovarian failure in girls, but only one third of this dose will produce the same effect in women over 40 years.30After the abdominal irradiation in childhood with doses of 20-30 Gy, the ovarian failure was found in 17 of 18 females.31Four females in our series 192 Zadravec-Zaletel L et al. / Gonadal function after Hodgkin’s disease had had unilaterally pelvic RT. Half of them had evidence of PH, but all had received ChT with AA and P as well. After RT of paraaortic lymph nodes the estimated ovarian dose is about 6 % of the pre­scribed dose (in the range of 100 cGy) and this dose of radiation can cause transient disturbances of menstrual cycle. Haie-Mader and colleagues ana­lyzed the ovarian function in 134 females who had ovarian transposition during the treatment for HD or gynecological cancer and showed that the age over 25 years, MOPP ChT and total dose to the ova­ries higher than 5 Gy are important risk factors for the ovarian castration.32 Four females in our study had elevated basal and peak FSH levels while retaining menstru­al periods. Four of 6 with PH even gave birth to children. Sherman and Korenman stated that in­creased FSH concentration with regular menstrual cycles might be consistent with the deficient pro­duction of inhibin or an inhibin-like hormone by the partially damaged ovary.33It might announce the risk of premature menopause in these females, which occurredin one of our patients. Byrne and colleagues found out that the treatment for cancer during adolescence carries a substantial risk of ear­ly menopause.34In a study of Sklar and colleagues risk factors for nonsurgical premature menopause in survivors of childhood cancer were attained age, exposure to increasing doses of radiation to the ovaries, increasing alkylating agents score and a diagnosis of HD.35 It seems that in males with HD therapy is not the only cause of hypogonadism. Vigersky and colleagues found a low sperm count or sperm mo­tility in about one-third of male patients with HD before starting ChT.36Rueffer and colleagues found in their study semen abnormalities in 70% of pa­tients before the onset of the treatment for HD.37Unlike in males it seems that there is no adverse effect of Hodgkin’s disease on the female gonadal function. In a study of Chapman and colleagues, namely, histories and pretreatment ovarian biopsy specimens indicated the normal fertility before the therapy for HD.21 Conclusions After the therapy for HD hypogonadism is more frequent in males than in females. Six or more cycles of MOPP causes PH in more than half patients. This kind of treatment is more toxic for males than for females. Six cycles of LOPP seems less gonadotoxic than 6 cycles of MOPP. MOPP/ABV hybrid regimen is not gonadotoxic for females. Not only RT but also alkylating agents and pro-carbazine alone cause damage of Leydig cells. Elevated levels of FSH are compatible with the normal fertility in males and females. The age of patient at the time of the treatment doesn’t emerge as an important risk factor for go­nadal toxicity, caused by therapy. Pelvic RT in combination with ChT is the most important damaging factor causing the gonadal dysfunction both, in males and females. References 1. Donaldson SS. A discourse: the 2002 Wataru W. Sutow lecture. Hodgkin disease in children – perspectives and progress. Med Pediatr Oncol 2003; 40: 73-81. 2. von der Weid NX. Adult life after surviving lymphoma in childhood. Support Care Cancer 2008 ; 16: 339-45. 3. Velenik V, Oblak I, Anderluh F. Quality of life in patients after combined modality treatment of rectal cancer: Report of a prospective phase II study. Radiol Oncol 2008; 42: 207-14. 4. Ljuca D, Marosevic G. Quality of life in patients with cervical cancer FIGO IIb stage after concomitant chemoradiotherapy. Radiol Oncol 2009; 43: 293-8. 5. Kovac V. Causes of fertile disturbances in oncological male patients. Radiol Oncol 1996; 30(1): 46-54. 6. Zaletel LZ, Bratanic N, Jereb B. Gonadal function in patients treated for leukemia in childhood. Leuk Lymphoma 2004; 45: 1797-802. 7. Byrne J, Mulvihill JJ, Myers MH, Connelly RR, Naughton MD, Krauss MR, et al. Effects of treatment on fertility in long-term survivors of childhood or adolescent cancer. N Engl J Med 1987; 317: 1315-21. 8. Canellos GP, Anderson JR, Propert KJ, Nissen N, Cooper MR, Henderson ES, et al. Chemotherapy of advanced Hodgkin´s disease with MOPP, ABVD or MOPP alternating with ABVD. N Engl J Med 1993; 327: 1478-84. 9. Klimo P, Connors JM. MOPP/ABV hybrid program: combination chemo­therapy based on early induction of seven effective drugs for advanced Hodgkin´s disease. J Clin Oncol 1985; 3: 1174-82. 10. Hancock BW, Vaughan Hudson G, Vaughan Hudson B, Haybittle JL, Bennett MH, MacLennan KA, et al. British National Lymphoma Investigation randomised study of MOPP against LOPP in advanced Hodgkin´s disease-long term results. Br J Cancer 1991; 63: 579-82. 11. Schellong G, Pötter R, Brämswig J, Wagner W, Prott FJ, Dörffel W, et al. High cure rates and reduced long-term toxicity in pediatric Hodgkin’s disease:The German-Austrian multicenter trial DAL-HD-90. J Clin Oncol 1999; 17: 3736-44. 12. Mustieles C, Munoz A, Alonso M, Ros P, Yturriaga R, Maldonado S,et al. Male gonadal function after chemotherapy in survivors of childhood malignancy. Med Pediatr Oncol 1995, 24: 347-51. 13. Siimes MA, Rautonen J. Small testicles with impaired production of sperm in adult male survivors of childhood malignancies. Cancer 1990; 65: 1303-6. 14. Aubier F, Flamant F, Brauner R Caillaud JM, Chaussain JM, Lemerle J, et al. Male gonadal function after chemotherapy for solid tumors in childhood. J Clin Oncol 1989; 7: 304-9. 15. Kinsella T, Trivette G, Rowland J, Sorace R, Miller R, Fraass B,et al. Long. term follow-up of testicular function following radiation therapy for early-stage Hodgkin’s disease. J Clin Oncol 1989; 7: 718-24. 16. Hoorweg-Nijman JJG, Delemarre-van de Wall HA, de Wall FC, Behrendt H. Cyclophosphamide-induced disturbance of gonadotropin secretion manifesting testicular damage. Acta Endocrinol 1992; 126: 143-8. 17. Chapman RM, Sutcliffe SB, Rees LH, Edwards CR, Malpas JS. Cyclical combination chemotherapy and gonadal function. Retrospective study in males. Lancet 1979; 1(8111): 285-9. 18. Kjessler B, Wide L. Follicle Stimulating hormone (FSH) and interstitial cell stimulating hormone (ICSH) in relation to gametic output in 643 males. Acta Endocrinol 1973; 72: 243-56. 19. Viviani S, Santoro A, Ragni G, Bonfante V, Bestetti O, Bonadonna G, et al. Gonadal toxicity after combination chemotherapy for Hodgkin’s disease. Comparative results of MOPP vs ABVD. Eur J Cancer Clin Oncol 1985; 21: 601-5. 20. Sherins RJ, DeVita VT. Effects of drug treatment of lymphoma on male reproductive capacity. Studies in men in remission after therapy. Annals Int Med 1973; 79: 216-20. 21. Chapman RM, Sutcliffe SB, Malpas JS. Cytotoxic-induced ovarian failure in women with Hodgkin’s disease. JAMA 1979, 242: 1877-81. 22. Whitehead E, Shalet SM, Blackledge G, Todd I, Crowther D, Beardwell CG, et al. The effects of Hodgkin’s disease and combination chemotherapy on gonadal function in the adult male. Cancer 1982, 49: 418-22. 23. Waxman JHX, Terry YA, Wrigley PFM, Malpas JS, Rees LH, Besser GM, et al. Gonadal function in Hodgkin’s disease: long-term follow-up of chemo­therapy. Br Med J 1982, 285: 1612-13. 24. Diamond FB, Bercu BB. Endocrine sequelae of cancer therapy in child­hood. J Endocrinol Invest 2001; 24: 648-58. 25. da Cunha MF, Meistrich ML, Fuller LM, Cundiff JH, Hagemeister FB, Velasquez WS, et al. Recovery of spermatogenesis after treatment for Hodgkin’s disease: limiting dose of MOPP chemotherapy. J Clin Oncol 1984; 2: 571-7. 26. Romerius P, Stĺhl O, Moëll C, Relander T, Cavallin-Stĺhl E, Wiebe T, et al. Hypogonadism risk in men treated for childhood cancer. J Clin Endocrinol Metab 2009; 94: 4180-6. 27. Mecklenburg RS, Sherins RJ. Gonadotropin response to luteinizing hor­mone-releasing hormone in men with germinal aplasia. J Clin Endocrinol Metab 1974; 38: 1005-8. 28. Speiser B, Rubin P, Casarett G. Aspermia following lower truncal irradia­tion in Hodgkin’s disease. Cancer 1973, 32: 692-8. 29. Ortin TTS, Shostak CA, Donaldson SS. Gonadal status and reproductive function following tratment for Hodgkin’s disease in childhood:the Stanford experience. Int J Radiat Oncol Biol Phys 1990; 19: 873-80. 30. Lushbaugh CC, Casarett GW. The effects of gonadal irradiation in clinical radiation therapy: a review. Cancer 1976; 37: 1111-20. 31. Shalet SM, Beardwell CG, Morris Jones PH, Pearson D, Orrell DH. Ovarian failure following abdominal irradiation in childhood. Br J Cancer 1976, 33: 655-8. 32. Haie-MederC,Mlika-CabanneN,MichelG,Briot E, Gerbaulet A,Lhomme C,et al. Radiotherapy after ovarian transposition: ovarian function and fertility preservation. Int J Radiat Oncol Biol Phys 1993, 25: 419-24. 33. Sherman BM, Korenman SG. Hormonal characteristics of the human menstrual cycle throughout reproductive life. J Clin Invest 1975; 55: 699-706. 34. Byrne J, Fears TR, Gail MH, Pee D, Connelly RR, Austin DF,et al. Early menopause in long-term survivors of cancer during adolescence. Am J Obstet Gynecol 1992; 166: 788-93. 35. Sklar CA, Mertens AC, Mitby P, Whitton J, Stovall M, Kasper C, et al. Premature menopause in survivors of childhood cancer : a report from the childhood cancer survivor study. J Natl Cancer Ins. 2006; 98: 890-6. 36. Vigersky RA, Chapman RM, Berenberg J, Glass AR. Testicular dysfunction in untreated Hodgkin’s disease. Am J Med 1982; 73: 482-6. 37. Rueffer U, Breuer K, Josting A, Lathan B, Sieber M, Manzke O, et al. Male gonadal dysfunction in patients with Hodgkin´s disease prior to treat­ment. Ann Oncol 2001; 12: 1307-11. 194 case report Intensity modulated radiotherapy (IMRT) in bilateral retinoblastoma Banu Atalar1, Enis Ozyar1, Kaan Gunduz2, Gorkem Gungor3 1 Department of Radiation Oncology, Acibadem University Istanbul, Turkey 2 Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey 3 Department of Radiation Oncology, Acibadem Maslak Hospital, Istanbul, Turkey Received 25 November 2009 Accepted 4 December 2009 Correspondence to: Banu Atalar, MD, Department of Radiation Oncology, Acibadem University, Istanbul, Turkey. E-mail: banu.atalar@asg.com.tr Disclosure: No potential conflicts of interest were disclosed. Background. External beam radiotherapy (EBRT) for retinoblastoma has traditionally been done with conventional radiotherapy techniques which resulted high doses to the surrounding normal tissues. Case report. A 20 month-old girl with group D bilateral retinoblastoma underwent intensity modulated radiotherapy (IMRT) to both eyes after failing chemoreduction and focal therapies including cryotherapy and transpupillary ther­motherapy. In this report, we discuss the use of IMRT as a method for reducing doses to adjacent normal tissues while delivering therapeutic doses to the tumour tissues compared with 3-dimensional conformal radiotherapy (3DCRT). At one year follow-up, the patient remained free of any obvious radiation complications. Conclusions. Image guided IMRT provides better dose distribution than 3DCRT in retinoblastoma eyes, delivering the therapeutic dose to the tumours and minimizing adjacent tissue damage. Key words: retinoblastoma; radiotherapy; intensity modulated radiotherapy Introduction Retinoblastoma is the most common intraocular malignant tumour encountered in children. In most patients, retinoblastoma remains confined to the eye. However, in advanced cases, retinoblas­toma can secondarily invade the orbit and metasta­size to the central nervous system and other distant organs. Untreated retinoblastoma is nearly always fatal. Therefore, the early diagnosis and treatment is critical in saving lives of retinoblastoma patients and preserving a visual function of the affected eyes. Retinoblastoma occurs with an estimated frequency of 1/14000-1/34000 live births.1In the United States, approximately 200 to 300 new cases are diagnosed each year. About 2/3 of the patients have unilateral and 1/3 have bilateral disease. More than 90% of the patients are diagnosed before the age of 5 years.2Bilateral patients are generally dis­covered in the first year of life and unilateral ones are diagnosed later in the second year.1,3 Chemoreduction has changed the approach to the management of retinoblastoma. The dogma of enucleating the worse eye and irradiating the least affected eye in bilateral disease has largely been re­placed by chemoreduction as a first step for both eyes. For the unilateral retinoblastoma chemore­duction is appropriate for those with Group A to C disease, but much less successful for those children with Group D or E retinoblastoma, which is usu­ally treated by enucleation. External beam radiation therapy (EBRT) is used less often today. It is used for moderately advanced tumours, multiple tumours, especially those with vitreous or subretinal seeds that fail chemoreduc­tion. The external beam radiation dose is 35-45 Gy delivered over 4-5 weeks. An anterior lens-sparing, relative lens-sparing or modified lateral beam technique can be used. The anterior lens-sparing technique compared to the modified lateral beam technique leads to a higher tumour recurrence rate because the anterior retina is undertreated. On the Table 1. Comparison of doses for 3DCRT and IMRT plan of our patient R. Lens L. Lens R. Cornea L. Cornea R. Optic nerve L. Optic nerve R. Lac. Gland L. Lac. Gland Orbital Bones 3304 2657 3228 2874 3807 3741 2204 3676 3299 3830 3841 V26.5<78% V26.5<67% V34<99% V34<100% V20<56.8% 2763 2639 2609 2909 2527 2456 1965 3134 3270 V26.5<70.6% V26.5<50.6% 4147 4063 V34<5% V34<0% V20<49.7% V20 (volume received above 20 Gy), V34 (volume received above 34 Gy), V26.5 (volume received above 26.5 Gy) other hand, the relative lens-sparing and modi­fied lateral beam techniques yield similar eye con­servation rates with subsequent salvage therapy. Much higher doses (from 50 Gy to 100 Gy) have been used in the past decades and it is quite possi­ble that some second cancers have been due to the high radiation dose. The external beam radiation therapy can lead to significant complications such as facial hypoplasia from orbital bone atrophy, ra­diation cataract, and retinopathy. The aim of this study was to compare the dose distribution of intensity modulated radiotherapy (IMRT) with the conventional external beam radio­therapy in terms of target and normal tissue doses in a recurrent bilateral retinoblastoma patient. Case report An 8 month-old girl was referred to the Department of Ophthalmology, Ankara University Faculty of Medicine with the complaint of strabismus in the left eye. The examination under anaesthesia re­vealed bilateral group D retinoblastoma in both eyes. There was an exudative retinal detachment in both eyes with extensive subretinal seeds. There was no evidence of systemic involvement on bone marrow biopsy, spinal tap, and cranial MRI. The patient was initially treated with 6 cycles of in­travenous carboplatin, etoposide and vincristine chemotherapy. Initially, the tumours in both eyes responded well to chemotherapy with resolution of SRF. The patient received several cryotherapy and transpupillary thermotherapy applications to recurrent and new tumours in both eyes over a period of approximately 12 months. However, the massive recurrence developed both eyes at 12 month follow-up and it was felt that either EBRT or enucleation was necessary at this point. The family opted for EBRT. The patient was seen in the Department of Radiation Oncology, Acibadem University, Istanbul for IMRT. A thermoplastic mask was prepared for the immobilization un­der anaesthesia and thereafter she underwent Computerized Tomography (CT) imaging with 1-mm slices for treatment planning purposes. Target tumour volumes and organs at risk (OAR) such as orbital bone, cornea, lens, lacrimal gland and optic nerve were delineated. Grosstumourvolume(GTV)4dosewasnotspec­ifiedinthiscase,onlytherecurrenttumoursinboth eyesweredelineatedastumourinordertonotto lowerthedoseinthoseareas;clinicaltumourvol­ume(CTV)wasdefinedasbothrightandleftretina andplanningtargetvolume(PTV)wasgenerated fromCTVplus1mmmargin.DosetoOARwasde­finedaccordingtopreviouslyreporteddata.5-9 Comparison of 3DCRT and IMRT In order to provide dose constraints for OAR we performed 4 different IMRT plans and a confor­mal plan. Of these IMRT plans the best isodose distribution and the dose volume histogram were provided with a noncoplanar 4-field technique (Figure 1); when compared to a conformal plan there was no significant difference for cornea, lens and optic nerve doses. The patient was treated with 4-field noncoplanar IMRT plan to a total dose of 40 Gy, 2 Gy per fraction under general anaesthesia. According to our department’s image guided ra­ 196 Atalar B et al. / Retinoblastoma and intensity modulated radiotherapy FIguRe 1. Four-field noncoplanar IMRT plan diotherapy (IGRT) protocol, daily kilovoltage im­ages were taken from anteroposterior and lateral fields before each treatment and corrections were done by matching pretreatment images with digit­ally reconstructed radiographs. Radiation doses to the orbital bones and lac-rimal glands were apparently lower while the tu­mour dose was higher in the IMRT plan. As a result of using multiple non coplanar beams; there were low dose areas in brain, brainstem and hypophysis with IMRT plan whereas no dose with 3DCRT, but these doses were below 5 Gy which was a safe dose for the affected areas. The comparison of doses between conformal and IMRTplan is detailed in Table 1. At one year follow-up, the patient remained free of any obvious radiation complications. Discussion Retinoblastoma is a radiosensitive tumour. There is a wide spectrum of techniques used for retino­blastoma ranging from single fields to complex fields such as anterior lens sparing technique, later­al oblique fields, multiple non coplanar arcs, single anterior electron fields, stereotactic radiotherapy, conformal and intensity modulated radiotherapy plans. Even protons were used to perform homo­geneous dose coverage of retina while sparing the lens and bony anatomy.5,10-13IMRT for retinoblasto-ma was first reported by Krasin et al.5Subsequently, Reisner et al.published a comparative analysis of external radiotherapy techniques with IMRT in a case report of unilateral retinoblastoma.8Previous reports on IMRT planning for retinoblastoma re­vealed greater sparing of the surrounding bony orbit and lacrimal gland as in our study. High doses affecting bony orbital structures may cause growth arrest of orbital fossa and facial asymmetry.7IMRT leads to lower doses in orbit­al bones, while not reducing retinal doses. In our bilateral IMRT plan, doses in both orbital bones were higher when compared to unilateral cases of Reisner et al.8These relatively high doses can be explained by the location of recurrent tumours; which were in the posterior poles of both eyes. Plans were done in order to have an optimal dose in these regions. In cases where the tumour is lo­cated medially or anteriorly, a lower dose may be delivered to the orbital bones using IMRT. Dry-eye syndrome, because of lacrimal gland exposure to radiation, is also another important and irreversible complication for this patient group threatening life quality. One of the main ad­vantages of IMRT is to reduce lacrimal gland dose without lowering retinal doses. Our patient’s mean lacrimal gland doses were less than 30Gy. Dry eye is quite unlikely to develop with these radiation doses as reported by Parson et al.6 The optic nerve is also affected in the radiother­apy of retinoblastoma. Doses exceeding 54 Gy may lead to the development of radiation optic neu­ropathy leading to irreversible visual impairment. Reisner et al. reported maximum doses as high as 48 Gy for the optic nerve dose with several tech­niques including their IMRT planning.8In our set­ting the optic nerve received a maximum dose of 40-41 Gy which is a safe dose for optic neuropathy. The reduction in the optic nerve dose may prevent visual problems in the future life of the patient. Corneal injury after EBRT has also been report­ed previously. The critical dosage was considered 50 Gy as the 50% risk at 5 years for cornea.14Reisner et al.considered V26.5 for the evaluation of corneal injury probability based on the study of Jiang et al.9,10Our plan delivered less than 50 Gy to the cor­nea region (mean dose for right and left cornea was 32 Gy and 28.7 Gy respectively) but the V26.5 dose was relatively higher especially on the right side, where a tumour was located more anteriorly. Thelensisthemostradiosensitivetissueinthe eye.15Lenspreservationwasalwaysbeenanim­portanttargetinradiotherapyplanningforthe treatmentoftumoursaroundtheeyeregion.Doses exceeding12Gyusuallyresultscataract.Lensspar­ingtechniqueswithEBRTalsocausedcataractin 28%ofpatients.16However,agoodoutcomeafter thecataractsurgerywithphacoemulsificationwas reportedeveninyoungages.17Therefore,wepre­ferredtoachievetherapeuticdosesintheentire toavoidtherecurrenceofthetumourratherthan deliveringsubtherapeuticdosestotheretinainan efforttopreservethelensfromthecataractdevel­opment. Technologic developments improved outcomes enormously in the last 10 years for EBRT. The ca­pability of protecting normal tissue around tumour became available. IMRT with image guidance, so called IGRT-IMRT, is the superior technique that allows us to do the best and safe treatment. Outcomes of IMRT were successful with the more common cancers including prostate, head and neck, breast cancers in terms of the increased lo­cal control and normal tissue protection. Even with lung cancer, where a significant organ and tumour movement may be a problem in radiotherapy, IMRT proved to be successful. The outcomes of IMRT in rarer tumours such as retinoblastoma are not widely known because of the paucity of publi­cations in this area. It has been concluded that any genotoxic thera­py can induce second neoplasms after long latent times and the risk is slightly higher with radio­therapy but the side effects of radiotherapy have less impact on the patients’ quality of life when compared with other therapies.18In the pediatric setting the risk could be significant due to a higher inherent susceptibility of tissues. However, as the risk of secondary cancers as sarcomas, related with IMRT estimated to be 2% compared with 1% for 3DCRT, the use of protons became actual to reduce risk of radiation-induced carcinogenesis.19The effi­cacy of IMRT in reducing the acute and late toxicity in children with nasopharyngeal carcinoma (NPC) was reported by two centres recently.20,21Louis et al.found no difference with IMRT in terms of late toxicity such as hypothyroidism, xerostomia, hear­ing loss, and dental disease.20On the other hand Laskar et al.concluded that IMRT significantly reduces and delays the onset of the acute toxicity compared to EBRT, resulting in the improved tol­erance and treatment compliance for children with NPC.21However, the number of studies with IMRT in pediatric tumours was very limited and other centre experience should be awaited. In conclusion; image guided IMRT provides bet­ter dose distribution than 3DCRT in retinoblasto-ma eyes, delivering the therapeutic dose to the tu­mours and minimizing adjacent tissue damage. In terms of avoiding radiation complications includ­ing dry eye syndrome, facial deformity, cataract, radiation retinopathy and radiation papillopathy, IMRT planning should always be taken into con­sideration for patients that are referred for radio­therapy. References 1. Halperin EG, Kirkpatrick JP. Retinoblastoma. In: Halperin EG, Constine LS, Tarbell NJ, Kun LE, editors. Pediatric Radiation Oncology. 4th edition. Philadelphia: Lippincott Williams & Wilkins; 2004: 135-78. 2. KachanovDY,DobrenkovKV,ShamanskayaTV,AbdullaevRT,InushkinaEV, VarfolomeevaSR, et al. Solid tumors in young children in Moscow Region of Russian Federation. Radiol Oncol 2008; 42: 39-44. 198 Atalar B et al. / Retinoblastoma and intensity modulated radiotherapy 3. McDaidC,HartleyS,BagnallAM,RitchieG,LightK,RiemsmaR.Systematic review of effectiveness of different treatments for childhood retinoblas­toma. Health Technol Assess 2005; 48: 1-145. 4. Stavrev P, Schinkel C, Stavreva N, Fallone BG. How well are clinical gross tumor volume DVHs approximated by an analytical function? Radiol Oncol 2009; 43: 132-5. 5. Krasin MJ, Crawford BT, Zhu Y, Evans ES, Sontag MR, Kun LE, et al. Intensity-modulated radiation therapy for children with intraocular retinoblastoma: Potential sparing of the bone orbit. Clin Oncol 2004; 16: 215-22. 6. Parsons JT, Bova FJ, Fitzgerald CR, Mendenhall WM, Million RR. Severe dry-eye syndrome following external beam irradiation. Int J Radiat Oncol Biol Phys 1994; 30: 775-80. 7. Eifel PJ, Donaldson SS, Thomas PRM. Response of growing bone to irradia­tion: A proposed late effects scoring system. Int J Radiat Oncol Biol Phys 1995; 31: 1301-7. 8. Reisner ML, Viégas CM, Grazziotin RZ, Santos Batista DV, Carneiro TM, Mendonça de Araújo CM, et al. Retinoblastoma-comparative analysis of external radiotherapy techniques, including an IMRT technique. Int J Radiat Oncol Biol Phys 2007; 67: 933-41. 9. Jiang GL, Tucker SL, Guttenberger R, Peters LJ, Morrison WH, Garden AS, et al. Radiation induced injury to the visual pathway. Radiother Oncol 1994; 30: 17-25. 10. Blach LE, McCormick B, Abramson DH. External beam radiation therapy and retinoblastoma: long term results in the comparison of two tech­niques. Int J Radiat Oncol Biol Phys 1996; 35: 45-51. 11. CormackRA,KooyHM,BelleriveMR,LoefflerJS,PetersenRA,TarbellNJ.A stereotactic radiation therapy device for retinoblastoma using a noncircu­lar collimator and intensity filter. Med Phys 1998; 25: 1438-42. 12. McCormick B, Ellsworth R, Abramson D, LoSasso T, Grabowski E. Results of external beam radiation for children with retinoblastoma: A comparison of two techniques. J Pediatr Ophthalmol Strabismus 1989; 26: 239-43. 13. Schipper J. An accurate and simple method for megavoltage irradiation therapy of retinoblastoma. Radiother Oncol 1983; 1: 31-41. 14. Constine LS, Williams JP, Morris M, Rubin P, Okunie FF. Late effects of cancer treatment. In: Chao CKS, Perez CA, Brady LW, editors. Radiation Oncology Management Decisions. 2nd edition. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 103-10. 15. Constine LS, Williams JP, Morris M, Rubin P, Okunieff P. Late effects of cancer treatment on normal tissues. In: Perez CA, Brady LW, Halperin CE, Schmidt-Ullrich RK, editors. Principles and practice of radiation oncology, 4th edition. Philedelphia: Lippincott Williams&Wilkins; 2004. p. 357-90. 16. Foote RL, Garretson BR, Schomberg PJ, Buskirk SJ, Robertson DM, Earle JD. External beam irradiation for retinoblastoma: patterns of failure and dose-response analysis. Int J Radiat Oncol Biol Phys 1989; 16: 823-30. 17. Honavar SG, Shields CL, Shields JA, Demirci H, Naduvilath TJ. Intraocular surgery after treatment of retinoblastoma. Arch Ophthalmol 2001; 119: 1613-21. 18. Dörr W, Herrmann T. Second tumors after oncologic treatment. Strahlenther Onkol 2008; 184: 67-72. 19. Greco C, Wolden S. Current status of radiotherapy with proton and light ion beams. Cancer 2007; 109: 1227-38. 20. Louis CU, Paulino AC, Gottschalk S, Bertuch AA, Chintagumpala M, Heslop HE, et al. A single institution experience with pediatric nasopharyngeal carcinoma: high incidence of toxicity associated with platinum-based chemotherapy plus IMRT. J Pediatr Hematol Oncol 2007; 29: 500-5. 21. Laskar S, Bahl G, Muckaden M, Pai SK, Gupta T, Banavali S, et al. Nasopharyngeal carcinoma in children: comparison of conventional and intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 2008; 72: 728-36. research article Linear array measurements of enhanced dynamic wedge and treatment planning system (TPS) calculation photon beam and comparison with electronic portal imaging device (EPID) measurements Borislava Petrovic1, Aleksandra Grzadziel2, Laza Rutonjski1, Krzysztof Slosarek2 1 Department of Radiotherapy, Institute of Oncology Vojvodina, Sremska Kamenica, Serbia 2 Radiotherapy and Brachytherapy Planning Department, Comprehensive Cancer Centre, Maria Sklodowska Curie Memorial Institute, Gliwice, Poland Received 8 March 2010 Accepted 19 May 2010 Correspondence to: Borislava Petrovic MSc, Department of Radiotherapy, Institute of oncology Vojvodina, Institutski put 4, 21204 Sremska Kamenica. E-mail: nsbim@eunet.rs Disclosure: No potential conflicts of interest were disclosed. Introduction. Enhanced dynamic wedges (EDW) are known to increase drastically the radiation therapy treatment efficiency. This paper has the aim to compare linear array measurements of EDW with the calculations of treatment planning system (TPS) and the electronic portal imaging device (EPID) for 15 MV photon energy. Materials and methods. The range of different field sizes and wedge angles (for 15 MV photon beam) were measured by the linear chamber array CA 24 in Blue water phantom. The measurement conditions were applied to the calculations of the commercial treatment planning system XIO CMS v.4.2.0 using convolution algorithm. EPID measurements were done on EPID-focus distance of 100 cm, and beam parameters being the same as for CA24 measurements. Results. Both depth doses and profiles were measured. EDW linear array measurements of profiles to XIO CMS TPS calculation differ around 0.5%. Profiles in non-wedged direction and open field profiles practically do not differ. Percentage depth doses (PDDs) for all EDW measurements show the difference of not more than 0.2%, while the open field PDD is almost the same as EDW PDD. Wedge factors for 60 deg wedge angle were also examined, and the dif­ference is up to 4%. EPID to linear array differs up to 5%. Conclusions. The implementation of EDW in radiation therapy treatments provides clinicians with an effective tool for the conformal radiotherapy treatment planning. If modelling of EDW beam in TPS is done correctly, a very good agreement between measurements and calculation is obtained, but EPID cannot be used for reference measure­ments. Key words: enhanced dynamic wedge; linear array; EPID Introduction Mechanical wedge filters (hard wedges) are often used in the treatment planning as compensators of dose inhomogeneities in the photon therapy. Nowadays, they are often replaced by Enhanced Dynamic Wedge (EDW). EDW is a technical so­lution of Varian Medical Systems, but also other manufactureres have solutions which achieve the same result (Elekta- omni wedge, Siemens- vir­tual wedge). The EDW technique achieves wedge-shaped dose distributions by the computer-con­trolled movement of one of the collimator jaws un­der the simultaneous adjustment of dose rate and speed of the moving jaw. The relationship between the number of delivered monitor units and the po­sition of the moving jaw is governed by lookup ta­bles referred to as ”Segmented Treatment Tables” 200 Petrovic B et al. / Verification of EDW in three ways TABLE 1. EDW profile measurements CA 24 in build up versus EPID -50 1.03 3.01 -100 1.83 6.17 -120 3.86 10.00 -140 6.98 16.08 -45 1.87 3.53 -95 2.55 6.78 -115 4.33 10.87 -135 7.76 17.06 -40 1.9 3.97 -90 2.82 7.47 -110 5.13 11.87 -130 8.67 18.67 -35 2.84 4.49 -85 3.37 8.27 -105 5.66 13.18 -125 9.87 20.40 -30 4.78 5.32 -80 3.71 9.20 -100 6.31 14.49 -120 11.56 22.07 -25 12.02 7.37 -75 4.36 10.13 -95 7.37 15.71 -115 14.08 24.09 -20 50.2 47.84 -70 4.85 11.14 -90 9.49 17.28 -110 21.05 25.99 -15 93 99.39 -65 6.61 12.39 -85 14.53 19.16 -105 65.42 30.55 -10 100.19 100.74 -60 10.25 13.92 -80 39 22.52 -100 160.61 92.80 -5 100.12 100.44 -55 25.45 16.75 -75 107.34 59.80 -95 185.95 166.63 0 100 100.00 -50 79.05 52.91 -70 130.84 124.18 -90 186.12 166.80 5 99.59 99.65 -45 108.59 107.10 -65 133.61 125.23 -85 181.62 164.32 10 98.68 99.00 -40 111.69 108.19 -60 132.46 124.01 -80 176.63 160.58 15 94.37 96.90 -35 111.59 107.67 -55 130.4 122.30 -75 171.42 156.95 20 67.12 44.70 -30 110.35 106.74 -50 127.98 120.69 -70 166.64 152.97 25 19.13 7.28 -25 108.99 105.73 -45 125.24 118.90 -65 161.35 149.40 30 6.51 5.32 -20 107.33 104.52 -40 122.26 116.85 -60 156.44 145.25 35 2.93 4.58 -15 105.6 103.27 -35 119.87 114.80 -55 151.61 141.50 40 2.38 4.06 -10 103.94 102.38 -30 117.16 112.61 -50 146.82 137.41 45 1.87 3.58 -5 101.19 101.13 -25 113.98 110.34 -45 141.25 133.43 50 1.85 3.10 0 99.98 100.00 -20 111.23 108.03 -40 136.55 129.28 5 99.28 99.19 -15 108.43 106.11 -35 131.67 125.48 10 98.76 98.43 -10 105.69 104.02 -30 127.09 121.50 15 98.32 97.38 -5 102.07 101.92 -25 122.26 117.46 20 97.72 96.61 0 99.91 100.00 -20 117.6 113.55 25 96.96 95.88 5 98.5 98.43 -15 112.98 110.32 30 96.11 95.04 10 97.11 97.03 -10 108.93 106.80 35 94.97 93.95 15 95.96 95.37 -5 103.32 103.23 40 93.17 92.74 20 94.61 93.98 0 99.93 100.00 45 88.98 90.27 25 93.34 92.84 5 96.96 97.06 50 70.98 38.82 30 91.98 91.58 10 94.28 94.41 55 22.68 14.97 35 90.57 90.22 15 91.59 91.76 60 9.09 12.63 40 89.04 88.83 20 89.04 89.16 65 5.97 11.22 45 87.5 87.47 25 86.52 86.63 70 5 10.21 50 85.97 85.68 30 83.75 84.44 75 4.13 9.20 55 84.05 84.20 35 81.32 82.19 80 3.34 8.31 60 82.11 82.15 40 78.55 79.71 85 3.29 7.59 65 79.78 80.18 45 76.2 77.46 90 2.65 6.86 70 76.51 76.87 50 73.56 74.99 95 2.35 6.13 75 63.15 34.00 55 70.96 72.62 100 1.63 5.65 80 26.21 16.24 60 68.4 70.32 85 10.32 14.27 65 65.96 67.95 90 7.25 12.92 70 63.53 65.59 95 4.92 11.79 75 61.05 63.17 100 4.19 10.74 80 58.53 60.81 105 4.04 9.86 85 56.34 58.67 110 3.48 9.04 90 54.11 56.08 115 3.01 8.25 95 49.82 52.97 120 2.74 7.64 100 43.59 24.67 105 21.59 14.52 110 8.34 13.08 115 5.9 11.99 120 4.91 11.24 125 4.5 10.43 130 3.84 9.63 135 3.38 9.11 140 3.14 8.70 (STT). The EDW provides seven wedge angles (10°, 15°, 20°, 25°, 30°, 45°, and 60°) for both symmetric and asymmetric field sizes. The upper independ­ent jaws, assigned to as Y1 and Y2, can travel from a full open position to 10 cm across the central axis, thus allowing field sizes up to 30 cm along the wedged direction. Two wedge orientations are available: Y1-IN and Y2-OUT, indicating the mov­ing jaw. The EDW needs only one reference STT for each photon energy. This so called ”Golden” STT represents the full field width of 30 cm and a wedge angle of 60°. Intermediate wedge angles can be derived by means of weighted averaging of an ”open field STT” and the Golden STT (ratio of tan-gens method). The individualized treatment STT is then obtained by the truncation to the desired field size and normalization so that the final number of monitor units is the total number of monitor units needed to deliver a certain dose to the reference point. These individualized STTs are created au­tomatically by the linac computer, as the operator types in the energy, wedge angle, monitor units, etc. In order to deliver a dynamically wedged field, the length of the treatment field is divided into 20 segments, and the speed of the moving jaw and the dose rate within each segment are controlled based on a calculated segmented treatment table (STT) generated by the linear accelerator computer. The implementation of dynamic wedges in the various radiation therapy planning (RTP) systems has already been described.1,2As with any other commissioning activity, great care must be taken to ensure that enhanced dynamic wedges are cor­rectly modelled in the treatment planning system. To directly verify the computational accuracy of a treatment planning system, measurements need to be made with the accelerator setup to the same identical specifications as already planned.3 This work was aimed to verify EDW (described in details in literature)4in the treatment planning system (TPS) and use patient set up equipment to compare dosimetrical and calculation results with electronic portal imaging device (EPID) measure­ments. In addition, comparison with hard wedges was also presented. The electronic portal imaging device is very so­phisticated gadget, accessory at the stand of the ac­celerator, which has an amorphous silicon detector remaining resistant to irradiation after the applica­tion of very high doses, and has certain dosimetri-cal characteristics which were also investigated here but also well described in literature.5-10 202 Petrovic B et al. / Verification of EDW in three ways TABLE 2. Open field profiles in 3 cm build up vs EPID profiles in direction perpendicu- Materials and methods lar to the movement of Y jaw, 10x10 cm2 field Linear array CA24 measurements -110 1.3 2.8 2.8 2.9 2.9 The measurement of enhanced dynamic wedge -105 1.3 3.1 3.1 3.2 3.2 profiles using a linear chamber array requires the -100 1.5 3.2 3.2 3.2 3.3 integration of the dose during the entire exposure -95 1.7 3.8 3.8 3.8 3.9 at each point of measurement. It was done by the -90 2.0 4.3 4.3 4.3 4.4 CA 24 Scanditronix Welhofer, and two electrom- -85 2.2 5.1 5.1 5.1 5.2 eters, MD 240 and CU 500E, connected to the PC -80 -75 -70 -65 2.7 3.3 4.0 5.4 6.0 6.7 7.8 9.3 6.0 6.8 7.9 9.3 6.0 6.8 7.9 9.3 6.1 6.9 8.0 9.4 and OmniPro 6.2A software. The linear array CA 24 consists of 23 ionization chambers, the volume of each is 0.147 cm3, diameter 0.6 cm and active length 0.33 cm. The each two neighbouring cham­bers are placed on 2 cm distance, and their long ax­ -60 9.2 11.0 11.0 11.0 11.1 es are parallel to the central axis of the beam. They -55 26.1 13.9 14.0 14.0 14.0 are mounted to the holder of the Blue water phan- -50 71.2 51.0 51.5 51.6 49.7 tom. The main feature of this linear array is that the -45 96.5 97.1 97.3 97.1 97.0 profiles are measured directly in the water, under -40 100.9 99.2 99.3 99.2 99.1 the same conditions as measurements of the open -35 -30 -25 -20 102.2 102.3 101.9 101.8 100.1 100.5 100.6 100.5 100.2 100.6 100.6 100.6 100.1 100.5 100.6 100.6 100.0 100.4 100.5 100.5 field profiles or mechanical wedged field profiles.The beam data was collected according to the guidelines provided by Varian5,6. This consists of measurements of cross profiles and depth dose curves for the maximum (60°) and at least one in­ -15 101.1 100.7 100.7 100.6 100.6 termediate wedge angle, in addition to measure­ -10 100.5 100.5 100.6 100.6 100.5 ments of the output factors. -5 99.7 100.4 100.4 100.4 100.3 The calculated percentage depth dose curves 0 100.0 100.0 100.0 100.0 100.0 (PDDs) and profiles were compared with meas­ 5 100.6 100.2 100.4 100.3 100.3 ured data for 15 MV photons at a Varian Clinac 10 15 20 25 101.2 101.5 101.9 102.5 100.2 100.1 100.0 100.0 100.2 100.2 100.1 100.1 100.2 100.2 100.0 100.1 100.2 100.2 100.0 100.0 2100C. Square field sizes ranging from 4x4 cm2to 20x20 cm2were evaluated with measurements of PDDs and profile curves on few depths (build up, 5 cm, 10 cm, and 20 cm). 30 102.9 99.8 100.0 99.9 100.0 35 102.6 99.6 99.7 99.7 99.7 EPID measurements 40 100.5 98.8 98.8 98.8 98.9 45 96.2 96.6 96.7 96.6 96.8 The features of EPID are described well in the lit­ 50 74.1 48.4 46.2 48.3 50.1 erature.7-13Portal imager aS1000 was positioned on 55 60 65 22.5 8.3 5.1 13.4 10.8 9.2 13.4 10.9 9.2 13.5 11.0 9.3 13.6 11.0 9.4 a source to skin distance (source-EPID surface dis­tance- SSD) 100 cm (not on standard 140 cm). The standard calibration procedure was then applied under this condition. 70 4.1 7.8 7.9 8.0 8.0 The EDW fields of 4 cm x 4 cm, 10 cm x10 cm, 15 75 3.1 6.7 6.8 6.8 6.9 cm x 15 cm, and 20 cm x20 cm were imaged (with 80 2.6 5.8 5.8 5.8 6.0 the usage of EPID portal dosimetry mode) for the 85 2.3 5.1 5.1 5.2 5.3 wedge angles of 15 deg, 30 deg, 45 deg and 60 deg, 90 1.9 4.4 4.5 4.5 4.6 with the collimator orientation and movement as 95 1.6 3.9 3.9 4.0 4.1 for CA 24 measurements. The collimator orienta­ 100 105 110 1.6 1.4 1.2 3.4 3.1 2.9 3.5 3.1 2.9 3.5 3.2 2.9 3.5 3.2 3.0 tion for all measurements was 90 degrees and Y1­IN wedge orientation (Y1 being the dynamic jaw). Linearity of the pixel response with dose was checked, followed by field measurements. TABLE 3. WF measured for the angle of 60°, and field sizes 4x4 cm2, 10x10 cm2, 15x15 cm2, 20x20 cm2, 30x30 cm2 using the energy of 15M 4 2 2 0.892 0.882 0.431 10 5 5 0.713 0.689 0.437 15 7.5 7.5 0.596 0.575 0.444 20 10 10 0.499 0.483 n/a 30 20 10 0.343 0.345 n/a 120 The image acquired by EPID, which results from each EDW field irradiation, is 2D image, with the different pixel values and is closely related to the intensity map of the EDW field. The pixel values 100 carry information about the intensity of the signal within the pixel area. Pixels lying on lines crossing 15 MV 10x10 wedge 60 deg the central axis pixel are creating in plane and cross plane profiles. One profile is in the direction of the moving jaw, creating the wedged distribution, and 80 PDD (%) hard 60 another one is the perpendicular to the direction of the moving jaw. Other pixels are lying off axis, and can be used to create 3D image of a wedged field. In order to extract useful information about the 40 profiles, the central axis pixel value is assigned value 100. All other pixels got then a relative value, depending on the ratio of the original pixel value 20 on central axis, and elsewhere in plane and cross plane profiles. The series of relative pixel values on 0 both profiles creates profiles comparable to other methods of measurements. open CA24 XIO 0,4 10,1 19,7 30,2 40,2 49,8 60,4 70,1 79,8 90,3 100109,6120,2129,8140,3 150160,4170,1179,9190,4199,9210,4219,9229,7240,2250,1259,7270,1279,8290,2300,1 depth (mm) FIGURE 1. PDD of 10 cm x 10 cm field, 15 MV, wedge 60 deg. External beam treatment planning calculations 140 The treatment planning system used for this pur-120 pose was XIO CMS v. 4.2.0, convolution algorithm. Virtual phantom of the size of the big Blue phan­tom (used for measurements in water), was de-100 fined in the TPS, and the electron density of water assigned to the inner space of the phantom. The EDW beam was created with the collimator and 80 CA 24 gantry orientation as in water and EPID measure­ ments, and appropriate field size, wedge angle, weight point definition, normalization, etc, imi­tating the measurements under real conditions in water. The resulting calculated plan was analyzed taking into consideration the depth dose curve and profiles on determined depths (build up, 5 cm, 10 cm and 20 cm). Dose values were read from the Dose Profile in the menu of the treatment planning space of XIO, on 5 mm distance along the profile of the field. 60 portal 40 20 0 depth (mm) FIGURE 2. EPID profile vs CA24 profile, 10 cm x10 cm field, wedge 60 deg. 204 Petrovic B et al. / Verification of EDW in three ways PDD (%) 100 80 60 40 20 0 15 MV, 10x10 cm build up, pen ˙eld vs. pr ˙le in n n wedge directi n open .eld EDW 15 deg EDW 30 deg EDW 45 deg EDW 60 deg These calculated profiles, as well as the profiles obtained by CA 24, and EPID, were compared to the profiles of hard wedges obtained using Blue phantom and CC13 ionization chambers, collected upon commissioning and acceptance tests of this linear accelerator. Hard wedges measurements and open field measurements The measured data of open fields and for hard wedges, collected during commissioning and ac­ceptance tests of the Varian 2100C linac were used for this study. Only additional measurements for the field 4x4 cm2were collected during this survey for all wedge angles and depths, since Varian rec­ommendations for commissioning do not include this field size as mandatory. -109,9-100,2-89,8-80,1-70,3-59,9-50,1 -39,8-30 -20,4-9,9-0,110,319,829,64049,860,269,980,39099,7 depth (mm) Results FIGURE 3. Open field profiles overlap with the EDW profiles in non wedged direction (example is 10 cm x10 cm field). Percentage depth doses The percentage depth dose curves of the open fields (measured by CC13 chambers), hard wedged fields (measured also by CC13 chambers), EDW fields (measured by linear array CA 24- PDD val­ues extracted from profiles) and calculated by XIO, were compared. Generally speaking, the PDDs of open fields and EDW fields do not differ more than 0.5%. PDDs of open fields have a higher surface dose than the PDDs of hard wedged fields (dose extrapolated to the surface of water- 0 cm depth) (Figure1). This comes from the beam hardening under the mechanical wedge. The beam hardening effect is also clearly visible on the tail of the PDD curve of the mechanical wedge and gives the dif­ference of around 2%. PDDs generated from profiles measured by CA 24 and calculated by XIO are practically identical (result of modelling the EDW in TPS). The PDDs with EPID could not be obtained at this stage, since only measurements in build up were possible. depth (mm) FIGURE 4. CA 24 profiles in comparison with hard wedge profiles, 10 cm x10 cm field, 60 deg wedge. Profile measurements EPID profiles in build up compared to linear array measurements in build up Profiles were obtained in direction of the moving jaw, showing the wedged shaped distribution. EDW profiles obtained by EPID in comparison 160 with the same measured by the linear array dif­fer around 1%, max up to 2%, within the field 140 (Table1). At the edges of the fields, the EPID profiles were having a larger gradient (dose fall 120 down) than the profiles obtained by other meth­ods. This applies to all wedge angles. 100 A dose measured by EPID outside the field (pe­ 15 MV, 10x10 wedge 60 deg, depth 30 mm ripheral dose) was much larger than the one meas­ ured by CA 24 linear array. This is characteristic for all angles and for all field sizes. (Figure 2) PDD (%) CA 24 80 hard portal 60 XIO Profiles measured by EPID in comparison to open beam profiles measured by ionization chamber EDW profiles imaged by EPID in the perpen­dicular direction to the movement of the jaw, were also examined, and compared to the open field profiles, which were measured during com­missioning of the machine, by CC13 ionization chambers. A very good agreement was found (Table 2, Figure3). This is not the case with the profiles of hard wedged fields, measured also in the non-wedged direction, where the interaction of the beam with the material of the hard wedge (beam hardening effect), influences the shape of the profile (a hard wedged profile demonstrates a decrease in dose at the field edges in compari­son with the EDW and open field profile in non wedged direction). Profiles of EDW field measured by linear array in comparison of hard wedges profiles measured by ionization chambers EDWlineararrayprofilestohardwedgesdodif­fermoreinallcases,butthatwasexpecteddueto thephysicaldifferencesoftwotechniques(Figu­re4) Profiles of EDW field measured by linear array in comparison to the calculation of XIO CMS TPS In most cases, the dose values on profiles differ around 0.5%, within the field, while outside the field it seems that XIO underestimates the periph­eral doses by factor of 2. 40 20 0 depth (mm) FIGURE 5. 15 MV profiles for a 10 cm x10 cm field, 60 deg wedge, build up (four methods of measurements and calculations). EDW wedge factors EDW wedge factors are the strong functions of the field size. This is proved by the measurements of wedge factors of EDW fields, and by the calcula­tion of WF in the treatment planning system. This, of course, does not apply to the hard wedge whose dependence of the field size is almost negligible. This is due to the fact that mechanical wedges are always placed in the same position on the tray of the accelerator, and because the central beam al­ways passes through the same thickness of the wedge, it does not matter what the field size is ac­tually set (Table 3). Discussion For the quality assurance(QA) in radiotherapy we can use in vivoor in vitromethods with phantoms.14The second one can be used for for routine QA or for reference measurements. The basic conclu­sion of our study would be that EPID aS1000 can be used for the routine QA and for EDW verifica­tion, but not for commissioning, only for regular QA checks. The conclusion would also be that the implemented dose calculation algorithm well de­scribes the EDW treatment. 206 Petrovic B et al. / Verification of EDW in three ways TheperipheraldoseofEDWfieldishalfthedose ofthehardwedgedfield.Thereasonforthatlies inscatteroutsidethehardwedgedfield,duetothe interactionofthebeamwiththematerialoftheme­chanicalwedge.Clinically,thisisanadvantageof EDWwedgedfield.Thewedgeangleisbetterpre­servedforEDWthanforhardwedgesatalldepths. The profile dose measured by EPID outside the field (peripheral dose) was much larger than the one measured by the CA 24 linear array. This is characteristic of all angles and for all field sizes. The reason for that as explained in the literature, might be due to the difference in absorption of low energy photons which appears in the material of the high Z. Spectrum of the photons is changed with the distance from the central axis, and region outside the field has only a scatter radiation. That is why the difference in profiles outside the field can be assumedto come from the difference of low energy photons of other dosimetrical methods and sensitive material of EPID detectors. Practically, all measurement techniques of EDW give very satisfactory results in terms of the agree­ment within PDDs and profiles (Figure 5). Still, standard dosimetric measurements cannot be un­derestimated, and EPID implemented as verifica­tion tool in terms of implementation of a new tech­nique in the department. References 1. Klein E. Treatment planning for enhanced dynamic wedge with the CMS Focus/Modulex treatment planning system. Med Dosim 1997; 22: 213-14. 2. Miften M, Wiesmeyer M, Beavis A, Takahashi K, Broad S. Implementation of enhanced dynamic wedge in the Focus RTP system. Med Dosim 2000; 25: 81-6. 3. Gossman MS, Robertson MA, Lawson RC. Correlation between detector array measurements and a computer algorithm for enhanced dynamic wedge. Med Dosim 2007; 32: 211-15. 4. C series Clinac Enhanced Dynamic Wedge Implementation Guide. Palo Alto: Varian Medical Systems; 2002. 5. Brady LW, Heilmann HP, Molls M. New technologies in radiation oncology. Springer Verlag Berlin Heidelberg; 2006. 6. PortalVision Users Guide: Reference Manual for aS500 PortalVision. Palo Alto: Varian Medical Systems; 2003. 7. Berger L, Francois P, Gaboriaud G, Rosenvald JC. Performance optimization of the Varian aS500 EPID system. J Appl Clin Med Phys 2006; 7: 105-114. 8. Greer PB, Barnes MP. Investigation of an amorphous silicon EPID for meas­urement and quality assurance of enhanced dynamic wedge. Phys Med Biol 2007; 10: 1075-87. 9. Menon GV, Sloboda RS. Quality assurance measurements of a-si EPID per­formance. Med Dosim 2004; 29: 11-17. 10. Bailey DW, Kumaraswamy L, Podgorsak MB. A fully electronic intensity-modulated radiation therapy quality assurance (IMRT QA) process imple­mented in a network comprised of independent treatment planning, record and verify, and delivery systems Radiol Oncol 2010; 44: 124-30. 11. Curtin-Savard A; Podgorsak EB. An electronic portal imaging device as phys­ics tool. Med Dosim 1997; 22: 101-5. 12. Greer PB, Popescu CC. Dosimetric properties of an amorphous silicon elec­tronic portal imaging device for verification of dynamic intensity modulated radiation therapy. Med Phys 2003; 30:1618-27. 13. Winkler P, Hefner A, Georg D. Dose-response characteristics of amorphous silicon EPID. Med Phys 2005; 32: 95-105. 14. Heikal AA, Wachowicz K, Thomas SD, Fallone BG. A phantom to assess the accuracy of tumor delineation using MRSI. Radiol Oncol 2008; 42: 232-9. Slovenian abstracts Radiol Oncol 2010; 44(3): 135-141. doi:10.2478/v10019-010-0018-8 Sledenje bolnikov po zdravljenju raka debelega crevesa in danke Velenik V Izhodišca. Ceprav je sledenje bolnikov po radikalnem zdravljenju raka debelega crevesa in danke obicajno, so mnenja o njegovi vrednosti nasprotujoca. Zaradi pomanjkanja prepricljivih klinicnih podatkov so predlagani razlicni nacini sledenja. Smernice v državah in regijah se razlikujejo tudi zaradi razlicne zdravstvene politike, razpoložljivih de­narnih sredstev in dvoma o ucinkovitosti sledenja. Zakljucki. Rezultati metaanaliz klinicnih raziskav sicer dokazujejo izboljšanje preživetja bolnikov, ki smo jih intenzivno sledili, vprašanje optimalne pogostnosti klinicnih pregledov in preiskav pa ostaja neodgovorjeno. Intenzivni nadzor bolnikov je težak, za bolnika je lahko neprijeten in nevaren ter predstavlja resno financno obremenitev zdravstvenemu sistemu. Dosegljivi podatki pa kažejo, da sledenje bolnikov ne zmanjšuje kakovosti življenja bolnikov. Potekajoce velike prospektivne multicentricne raziskave bodo lahko odgovorile na nekatera vprašanja, ki nastajajo ob sledenju bolnikov z rakom debelega crevesa in danke. Radiol Oncol 2010; 44(3): 142-148. doi:10.2478/v10019-010-0031-y Uporaba fluorescentnih tarcnih molekul v slikovni diagnostiki raka Paganin-Gioanni A, Bellard E, Paquereau L, Ecochard V, Golzio M, Teissié J Izhodišca. Glavi izziv pri zdravljenju raka sta izboljšanje zgodnjega odkrivanja in presejanje z upo­rabo tarcnih molekul. Takšno zgodnje odkrivanje raka zahteva specificno vezavo na rakave celice, na tumorske oznacevalce, ki naj bi v idealnem primeru bili prisotni na površini tumorske celice. Tarcno oznacevanje tumorskih celic z molekulami, ki jih lahko slikovno zaznamo, omogoca odkri­vanje tumorskih celic. Zakljucki. Fluorescentna slikovna diagnostika je novejša tehnologija, ki se komplementarno uvršca med diagnosticne metode v onkologiji. Omogoca zaznavanje tumorskih oznacevalcev z visoko pro-storsko in casovno resolucijo pri malih živalih in v klinicnih študijah. V pregledu smo se osredotocili na novejše temeljne raziskave priprave testov in aparatur, ki jih uporabljamo za zgodnje odkrivanje raka s fluorescentnimi slikovnimi tehnikami. Radiol Oncol 2010; 44(3): I-VI. Slovenian abstracts Radiol Oncol 2010; 44(3): 149-152. doi:10.2478/v10019-010-0029-5 Odsotnost spodnje vene kave z nadaljevanjem poteka vene azygos/hemiazygos. Žilna nepravilnost pri prašicjem živalskem modelu. Jeromel M, Pavcnik D Izhodišca. Prašice pogosto uporabljamo kot živalski model za proucevanje prirojenih srcno-žilnih napak, ki se poja­vljajo pri cloveku. Napake na živalskem modelu lahko nastanejo spontano ali pa jih ustvarimo umetno. Defekt preka­tnega pretina, odprt Botallov vod in defekt preddvornega pretina so stanja, ki jih lahko na takem modelu ustvarimo umetno. Odsotnost spodnje vene kave z nadaljevanjem poteka vene azygos/hemiazygos je redka žilna nepravilnost. Prikaz primera. Odsotnost spodnje vene kave z nadaljevanjem poteka vene azygos/hemiazygos smo slucajno odkrili, ko smo na prašicjem živalskem modelu proucevali zapiranje defekta preddvornega pretina. Ob posegu smo uporabljali perkutani femoralni pristop. Odsotnost spodnje vene kave smo potrdili z venografijo in z obdukcijo. Zakljucki. Po pregledu literature je mnenje avtorjev, da je pricujoci prispevek prvi te vrste, ki opisuje odsotnost spo­dnje vene kave z nadaljevanjem poteka vene azygos/hemiazygos pri prašicu. Radiol Oncol 2010; 44(3): 153-157. doi:10.2478/v10019-010-0016-x Direktno vstavljanje koronarnih žilnih opornic zmanjša sevanje in kolicino kontrastnega sredstva Caluk J, Osmanovic E, Barakovic F, Kusljugic Z, Terzic I, Caluk S, Sofic A Izhodišca. Z vstavljanjem koronarnih žilnih opornic omogocimo revaskularizacijo. Uporabljamo dva nacina: pred vstavitvijo žilne opornice dilatiramo žilo z balonom ali pa direktno vstavimo žilno opornico. Ce zdravnik, ki opravlja poseg, lahko zmanjša cas uporabe fluoroskopa, lahko s tem tudi zmanjša izpostavljenost sevanju bolnika kot tudi me-dicinskega osebja. Prav tako lahko z zmanjšano kolicino kontrastnega sredstva zmanjša nevarnost nefrotoksicnosti, ki je najpomembnejši možni stranski ucinek njegove uporabe. Namen klinicne raziskave je bil primerjati cas fluoroskopije, kolicino uporabljenega kontrastnega sredstva in ceno pri obeh nacinih vstavljanja koronarnih žilnih opornic. Bolniki in metode. V prospektivni klinicni raziskavi smo 70 bolnikov s koronarno boleznijo randomizirano zdravili s koronarno balonsko dilatacijo in vstavljanjem žilne opornice ali pa z direktnim vstavljanjem žilne opornice. Rezultati. Cas fluoroskopije in kolicina kontrastnega sredstva sta bila pri direktnem vstavljanju žilnih opornic statistic­no znacilno zmanjšana. Prav tako je bila cena pri direktnem vstavljanju žilnih opornic statisticno znacilno manjša kot pri posegu z balonsko dilatacijo. Zakljucki. Svetujemo, da direktno vstavimo koronarne žilne opornice pri vseh perkutanih koronarnih posegih, ce ugotovimo primerne pogoje. Ce je direktna vstavitev koronarne žilne opornice neuspešna, moramo narediti predho­dno balonsko dilatacijo žile. Radiol Oncol 2010; 44(3): I-VI. Slovenian abstracts Radiol Oncol 2010; 44(3): 158-163 doi:10.2478/v10019-010-0026-8 Slikovne preiskave pri sumu na travmatsko psevdoanevrizmo torakalne aorte Bešlic Š, Bešlic N, Bešlic S, Sofic A, Ibralic M, Karovic J Izhodišca. Namen raziskave je bil predstaviti izsledke slikovnih preiskav pri bolnikih s sumom na travmatsko psevdoa­ nevrizmo torakalne aorte, ki je nastala po prometni nesreci. Bolniki in metode. V 22 letih smo odkrili 8 travmatskih psevdoanevrizem torakalne aorte pri 7 (87,5%) moških in 1 (12,5%) ženski. V casu prometne nesrece je bil najmlajši bolnik star 21 let in najstarejši 55 (srednja starost 33,8 let), v casu ugotovljene psevdoanevrizme pa je bila starost od 26 do 55 let (srednja starost 38,7 let). Pri vseh bolnikih smo rentgen­sko slikali prsne organe in naredili CT preiskavo, pri 6 (75%) bolnikih intravenozno digitalno subtrakcijsko angiografijo (i.v. DSA) in pri 1 (12,5%) MRI. Pri CT preiskavi smo intravenozno vbrizgali 120 ml kontrasta in pri DSA 60 ml. Rezultati. Pri 8 (100%) bolnikih, ki so imeli prometno nesreco in pri katerih je rentgensko slikanje prsnih organov po­kazalo povecan aortni gumb in mediastinum, smo s CT preiskavo, i.v. DSA in MRI odkrili travmatsko psevdoanevrizmo torakalne aorte. Cas od nesrece do ugotovitve psevdoanevrizme je bil od 7 dni do 18 let (srednja vrednost 2,0 leta). Premer ugotovljene psevdoanevrizme je bil od 4,5 do 9,2 cm (srenja vrednost 5,5 cm). Pri 7 (87,5%) bolnikih je bila psev­doanevrizma v predelu istmusa aorte in pri 1 (12,5%) v predelu descendentnega predela torakalne aorte. Z rentgen-skim slikanjem smo ugotovili robno kalcifikacijo aorte pri 4 (50%) bolnikih, s CT preiskavo pa pri 5 (62,5%). Intraluminalno trombozo smo našli s CT preiskavo pri 2 (25%) travmatiziranih bolnikih. Zakljucki. Pri topih poškodbah prsnega koša moramo pomisliti na možnost travmatske psevdoanevrizme aorte, še zlasti, ce rentgensko slikanje prsnih organov pokaže sumljive znake. Pri ugotavljanju psevdoanevrizme aorte je metoda izbora vecrezinska CT preiskava. Radiol Oncol 2010; 44(3): 164-167. doi: 10.2478/v10019-010-0014-z Radiološka ocena von Hippel-Lindeaujeve bolezni: slikovne znacilnosti in pregled literature Apaydin M, Varer M, Oztekin O Izhodišca. Von Hippel-Lindaujev a bolezen je dedna avtosomska dominantna onkološka bolezen, ki prizadene vec organskih sistemov. Ugotovimo jo s klinicnimi, radiološkimi in genetskimi preiskavami. Ocenjujemo, da je prevalenca bolezni 1 bolnik na 36000 prebivalcev. Tumorji pri tej bolezni so lahko benigni ali maligni. Prikaz primera. Opisujemo MR znacilnosti bolezni pri družini z 10 otroki. Von Hippel-Lindaujevo bolezen smo odkrili pri materi in 5 otrocih. Zakljucki. Radiološke preiskave so zelo pomembne za zgodnjo diagnozo in zdravljenje asimptomatskih bolnikov z von Hippel-Lindaujevo boleznijo. Zgodnja diagnoza je pomembna, ker omogoca zgodnje zdravljenje in na ta nacin lahko vplivamo na preživetje bolnikov ter na njihovo kakovost življenja. Pri presejalnih preiskavah bolnikov, ki so dedno obremenjeni, je važna multidisciplinarna obravnava. Radiol Oncol 2010; 44(3): I-VI. Slovenian abstracts Radiol Oncol 2009; 44(3): 168-173. doi:10.2478/v10019-010-0035-7 Izguba heterozigotnosti CDKN2A (p16INK4a) in tumor supresorskih genov RB1 pri germinalnih tumorjih testisov Vladušic T, Hrašcan R, Pecina-Šlaus N, Vrhovac I, Gamulin M, Franekic J, Krušlin B Izhodišca. Germinalni tumorji testisov so najpogostejši malignomi pri mladih odraslih moških. Biološko se razlikujeta dve najpogostejši histološki entiteti seminomski in neseminomski tumorji. Protein pRB in njegov regulatorni protein p16INK4a sta udeležena pri poti nastanka proteina RB, ki je pogosto okvarjena pri germinalnih tumorjih testisov. Namen študije je bil dolociti pogostnost izgube heterozigotnosti CDKN2A (p16INK4a) in RB1 tumor supresorkih genov RB1 pri germinalnih tumorjih testisov. Materiali in metode. 40 germinalnih tumorjev testisov (18 seminomov in 22 neseminomov) smo z verižno polimera­ zno reakcijo analizirali na polimorfizme genov. Rezultati. Izgubo heterozigotnosti CDKN2A smo dokazali pri dveh (6%) od 34 (85%) primerov germinalnih tumorjev testisov. Opisane spremembe smo našli pri dveh (11%) od 18 (82%) neseminomskih tumorjih. Izgubo heterozigotnosti RB1 pa smo dokazali pri dveh (6%) od 34 (85%) primerih vseh germinalnih tumorjev testisov. Te spremembe so bile opažene pri dveh (10.5%) od 19 (86%) neseminomskih tumorjih. Obe izgubi heterozigotnosti CDKN2A smo dokazali pri neseminomskih tumorjih s komponento jajcne vrecke, obe izgubi heterozigotnosti RB1 pa smo dokazali pri neseminom­skih tumorjih s komponento embrionalnega karcinoma. Zakljucki. Povišana incidence izgub heterozigotnosti CDKN2A (p16INK4a) in tumor supresorskih genov RB1 je lahko razlog za vecjo invazivnost germinalnih tumorjev testisov. Radiol Oncol 2010; 44(3): 174-179. doi:10.2478/v10019-010-0030-z Raziskava sprememb metabolizma fosforja z 31P jedersko magnetno resonanco pri poskusnih obsevanih z rentgenskimi žarki Serša I, Kranjc S, Serša G, Nemec-Svete A, Lozar B, Sepe A, Vidmar J, Šentjurc M Izhodišca. Cilj raziskave je bil prouciti, ali lahko z 31P jedrsko magnetno resonanco (JMR) ucinkovito odkrijemo spre­membe energetskega metabolizma povzrocene z rentgenskimi žarki pri poskusnih miših. Izpostavljenost ionizirajocemu sevanju povzroci spremembe v oskrbi z energijo. Spremembe so povezane s poškodbami tkiva zaradi oksidativnega stresa in oksidativne fosforilacije. Posledice obsevanja so vidne v zmanjšanju razmerja med fosfokreatinom in adenozin trifosfatom (Pcr/ATP), kot tudi v povecani koncentracji kreatin-kinaze (CK) in jetrnih encimov (transaminaz AST in ALT) v serumu. Material in metode. V raziskavi so bile poskusne miši razdeljene na skupino, ki je prejela 7 Gy rentgenskega sevanja in na kontrolno skupino. Metabolizem obeh skupin smo spremljali z 31P JMR spektroskopijo in biokemijsko z merjenjem ravni CK in jetrnih encimov v plazmi. Meritve obeh skupin miši so bile opravljene v rednih casovnih intervalih v nasle­dnjih treh tednih po obsevanju. Rezultati. V skupini obsevanih miši smo dva ali vec dni po obsevanju iz izmerjenih višin vrhov 31P JMR spektrov opazili bistveno spremembo razmerja Pcr/ATP, medtem ko v kontrolni skupini miši nismo opazili nobene pomembne spre­membe razmerja Pcr/ATP. Ta rezultat podpirajo tudi opravljene vzporedne meritve ravni CK. Raven CK je bila izrazito povecana takoj po obsevanju, kar se dobro ujema z opaženim zmanjšanjem razmerja Pcr/ATP in z njim povezanim upadom mišicne oskrbe z energijo. Zakljucki. 31P JMR meritve razmerja Pcr/ATP lahko služijo kot takojšen in neinvaziven pokazatelj prejete doze sevanja. Radiol Oncol 2010; 44(3): I-VI. Slovenian abstracts Radiol Oncol 2010; 44(3): 180-186. doi:10.2478/v10019-010-0038-4 Preventivno obsevanje glave pri bolnikih z drobnocelicnim rakom pljuc: izkušnje na Onkološkem Inštitutu Ljubljana Stanic K, Kovac V Izhodišca. Preventivno obsevanje glave (PCI) uporabljamo pri bolnikih z drobnocelicnim rakom pljuc za znižanje incidence možganskih metastaz in podaljšanje preživetja. Namen retrospektivne raziskave je bila analiza znacilnosti bolnikov z drobnocelicnim rakom pljuc, napotenih na Onkološki inštitut Ljubljana, njihova primernost za PCI, mesta širjenja bolezni in preživetje. Bolniki in metode. Pregledali smo dokumentacijo 357 bolnikov z drobnocelicnim rakom pljuc, ki so bili med janu­arjem 2004 in decembrom 2006 napoteni na Onkološki inštitut Ljubljana, da bi ugotovili, kakšni bolniki so bili izbrani za PCI. Beležili smo naslednje podatke: razširjenost bolezni, starost, spol, telesno zmogljivost, kadilski status, nacin in rezultat primarnega zdravljenja, nekaj hematoloških in biokemicnih parametrov, uporabo PCI ter status možganskih metastaz ob diagnozi in po zdravljenju. Rezultati. Preventivno obsevanje glave je imelo 24 (6,7%) izmed vseh bolnikov. Po PCI je pri 6 (25%) bolnikih prišlo do možganskih zasevkov, pri 4 bolnikih je bilo to edino mesto razsoja, pri dveh je bolezen napredovala v vec organov. Srednje preživetje bolnikov, ki so imeli PCI, je bilo 21,9 mesecev, tistih brez pa 12,13 mesecev (p=0,004). Dobri progno­sticni dejavniki so bili: starost pod 65 let, omejena oblika bolezni, telesna zmogljivost in normalne vrednosti laktatne dehidrogenaze ter C-reaktivnega proteina. Drugi prognosticni dejavniki niso bili statisticno znacilni. Zakljucki. Preživetje bolnikov z drobnocelicnim rakom pljuc, ki smo jim profilakticno obsevali glavo, je bilo statisticno znacilno boljše od tistih brez PCI. Za takšno obsevanje smo se odlocali pri bolnikih, ki so imeli omejeno bolezen, popoln ali skoraj popoln odgovor na zdravljenje in dobro telesno zmogljivost. PCI nismo uporabljali pri bolnikih z razširjeno boleznijo, to podrocje bi bilo potrebno še raziskati. Doze obsevanja niso bile enotne, potrebno bi bilo oblikovati bolj standarden pristop. Radiol Oncol 2009; 44(3): 187-193. doi:10.2478/v10019-010-0034-8 Okvara spolnih žlez po zdravljenju Hodgkinove bolezni v otroštvu Zadravec Zaletel L, Bratanic N, Jereb B Izhodišca. Preživetje bolnikov, zdravljenih v otroštvu zaradi Hodgkinove bolezni (HB), je visoko. Pricakovana življenjska doba mladih bolnikov je dolga, zato so raziskave poznih posledic zdravljenja raka v otroštvu, vkljucno okvar žlez z notranjim izlocanjem, v ospredju zanimanja. Preiskovanci in metode. Delovanje spolnih žlez smo ocenili pri 64 mladostnikih (24 ženskah in 40 moških), ki so se zdravili zaradi HB v otroštvu v Sloveniji med leti 1972 in 1994. Ob postavitvi diagnoze so bili stari 3-16 let, spolne žleze smo ocenili 4-27 let kasneje v starosti 13-34 let. 54 (84%) preiskovancev je prejemalo kemoterapijo (KT), 49 v kombi­naciji z obsevanjem (RT), 10 mladostnikov je imelo le RT. Delovanje spolnih žlez smo ocenili s klinicnim pregledom in merjenjem serumske koncentracije estradiola in testosterona ter serumske koncentracije LH in FSH v bazalnem stanju in po stimulaciji. Rezultati. Primarni hipogonadizem smo ugotovili pri 30 (47%) preiskovancih. 24 od 40 (60%) moških je imelo okvaro klicnega epitelija testisa, pri štirih od teh smo ugotovili tudi okvaro Leydigovih celic, pri desetih pa njihovo disfunkcijo. Primarni hipogonadizem smo ugotovili pri 6 od 24 (25%) žensk. Zakljucki. Po zdravljenju HB v otroštvu se je primarni hipogonadizem pogosteje pojavil pri moških kot pri ženskah. Okvare Leydigovih celic ni povzrocila le RT, temvec tudi alkilirajoci agensi in prokarbazin. V naši raziskavi starost bolni­kov v casu zdravljenja ni bil pomemben dejavnik tveganja za okvaro spolnih žlez. RT medenice v kombinaciji s KT je bil najpomembnejši dejavnik tveganja za razvoj primarnega hipogonadizma tako pri moških kot pri ženskih. Radiol Oncol 2010; 44(3): I-VI. Slovenian abstracts Radiol Oncol 2010; 44(3): 194-198. doi:10.2478/v10019-010-0013-0 Radioterapija z modulirano intenziteto žatkovnega snopa (IMRT) pri obojestranskem retinoblastomu Atalar B, Ozyar E, Gunduz K, Gungor G Izhodišca. Teleradioterapijo uporabljamo tudi za zdravljenje retinoblastomov. S konvencionalnimi tehnikami obseva­ nja se težko izognemo obsevanju zdravih okolnih tkiv. Prikaz primera. Pri 20 mesecni deklici, ki je imela obojestranski retinoblastom skupine D, smo uporabili radioterapijo z modulirano intenziteto žatkovnega snopa (IMRT). Za obsevanje obeh oces smo se odlocili ob ponovitvi bolezni. Deklica je bila že zdravljena s kemoterapijo pa tudi s krioterapijo in transpupilarno termoterapijo. Z izracuni smo primer-jali, kakšno sevalno dozo na okolana zdrava tkiva je deklica prejela z IMRT tehniko obsevanja in kakšno bi prejela, ce bi se odlocili za 3-dimenzionalno konformalno radioteraijo. Po letu dni nismo opazili nobenih izrazitejših sevalnih zapletov. Zakljucki. Slikovno vodena IMRT tehnika obsevanja retinoblastoma omogoca boljšo razporeditev doze kot 3-dimen­zionalna konformalna radioteraija. Pri obsevanju tumorja poškodujemo okolna zdrava tkiva v najmanjši možni meri. Radiol Oncol 2010; 44(3): 199-206. doi: 10.2478/v10019-010-0037-5 Merjenja dinamicnih klinov na linearnem pospeševalniku energije 15 MV z uporabo linearnega niza detektorjev in z napravo za elektronsko portalno slikanje ter primerjava z izracunom nacrtovalnega sistema za obsevanje Petrovic B, Grzadziel A, Rutonjski L, Slosarek K Izhodišca. Znano je, da dinamicni klini (EDW) znatno izboljšajo ucinkovitost zdravljenja z obsevanjem. Namen te raziskave je primerjati meritve EDW, opravljene z linearnim nizom detektorjev, z meritvami, opravljenimi z napravo za elektronsko portalno slikanje (EPID) ter primerjava obeh z izracunom nacrtovalnega sistema za obsevanje (TPS). Vse meritve EDW in izracuni so narejeni za žarkovni snop z energijo 15 MV. Materiali in metode. Z linearnim nizom ionizacijskih celic smo v fantomu »Blue water« izmerili žarkovne snope razlic­nih velikosti in z razlicnimi klinastimi filtri. Z nacrtovalnim sistemom za obsevanje XIO CMS v.4.2.0 smo omogocili pogoje pri meritvah in s konvolucijsko metodo izracunali dozo žarkovnih snopov. Rezultati. Izmerili smo krivulje globinskih doz (PDD) ter dozne profile žarkovnih snopov. Meritve žarkovnih snopov z EDW so se od izracunov s XIO CMS TPS razlikovale za približno 0,5%. Profili v smeri, ki je bila pravokotna na smer klina, se skorajda niso razlikovali od profilov odprtega polja. Krivulje PDD za vse meritve EDW se niso razlikovale za vec kot 0,2%, PDD odprtega polja pa je bila skoraj enaka krivuljam PDD polj z EDW. Preverili smo tudi faktorje prepustnosti klina za 60° dinamicni klin in odkrili razlike do 4%. EPID meritve se od meritev z linearnim nizom razlikovale do 5%. Zakljucki. Implementacija EDW v radioterapiji zagotovi ucinkovito orodje za nacrtovanje konformne radioterapije. S pravilnim modelom EDW lahko dobimo zelo dobro ujemanje med meritvami in izracuni. EPID pa ni primeren za referencne meritve. Radiol Oncol 2010; 44(3): I-VI. notices Notices Notices submitted for publication should contain a mailing address, phone and/or fax number and/or e-mail of a Contact person or department. Thoracic oncology October 7 – 9, 2010 The 2nd International Thoracic Congress Dresden will be held in Dresden, Germany. E-mail profmanegold@t-online.de Oncology October 8 – 12, 2010 The “35th ESMO Congress” will take place in Milan, Italy. Contact ESMO Head Office, Congress Department, Via La Santa 7, CH-6962 Viganello-Lugano, Switzerland; or call +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 Nuclear medicine October 9 – 13, 2010 The “EANM’10 Annual Congress of the European Association of Nuclear Medicine” will take place in Vienna, Austria. Contact EANM Executive Secretariat and call +43 1 212 80 30; or fax +43 1 212 80 309; or e-mail office@ eanm.org; or see http://www. eanm.org Therapeutic radiology and oncology October 31 – November 4, 2010 The “American Society for Therapeutic Radiology and Oncology Annual Meeting ASTRO” will take place in San Diego, California, USA. Contact ASTRO, 8280 Willow Oaks Corporate Dr., Suite 500, Fairfax, VA 22031; or call +1 703 502-1550; or see http://www.astro.org Radiation oncology November 13 – 19, 2010 The ESO/ESTRO masterclass in radiation oncology will be offered in Cascais, Portugal. Contact Chiara Gasparotto, European School of Radiotherapy, ESTRO Office, Av. E. Mounier 83, 1200 Brussels, Belgium; or phone +32 2 775 9337; or fax +32 2 779 5494; or e-mail cgasparotto@estro.org; or see www.eso. Net or www.estro.org Lung cancer December 2 – 4, 2010 The 4th Asia Pacific Lung Cancer Conference (APLCC 2010) will be held in Seoul, South Korea. E-mail hjk3425@skku.edu Lung cancer December 2 – 4, 2010 The 12th Central European Lung Cancer Conference (CELCC) will be held in Budapest, Hungary. E-mail ostorosgyula@freemail.hu Thoracic oncology December 9 – 11, 2010 The ASCO/ASTRO/IASLC/University of Chicago Multidisciplinary Symposium in Thoracic Oncology will be held in Chicago, IL, USA. E-mail evokes@medicine.bsd.uchicago.edu Clinical oncology June 3 – 7, 2011 The American Society of Clinical Oncology Conference (ASCO 2010) will be offered in Chicago, USA. E mail enews@asco.org; or see http://www/asco.org Lung cancer July 3 – 7, 2011 The “14th World Conference on Lung Cancer” will be offered in Amsterdam, The Netherlands. See http://www.iaslc.org Oncology September 23 – 27, 2011 The “16th ECCO and 36th ESMO Multidisciplinary Congress” will be offered in Stockholm, Sweden. See http://www.ecco-org.eu Nuclear medicine October 15 – 19, 2011 The “EANM’11 Annual Congress of the European Association of Nuclear Medicine” will take place in Birmingham, United Kingdom. Contact EANM Executive Secretariat and call +43 1 212 80 30; or fax +43 1 212 80 309; or e-mail office@ eanm.org; or see http://www. eanm.org As a service to our readers, notices of meetings or courses will be inserted free of charge. Please send information to the Editorial office, Radiology and Oncology, Zaloška 2, SI-1000 Ljubljana, Slovenia. Radiol Oncol 2010; 44(3): VII. Zadeli smo pravo tar;o Izredno u;inkovito zdravljenje prvega reda pri nedrobnoceli;nem plju;nem raku z mutacijo EGFR Iressa je prva in edina tar;na monoterapija, ki dokazano podaljša preživetje brez napredovanja bolezni v primerjavi z dvojno kemoterapijo kot zdravljenje prvega reda pri bolnikih z napredovalim nedrobnoceli;nim plju;nim rakom z mutacijo EGFR. 1 IRESSA® (GEFITINIB) 1. Povzetek glavih zna;ilnosti zdravila Iressa (gefitinib). Junij 2009. SKRAJŠAN POVZETEK GLAVNIH ZNA:ILNOSTI ZDRAVILA Sestava' Filmsko obložene tablete vsebujejo 250 mg gefitiniba. Indikacije' zdravljenje odraslih bolnikov z lokalno napredovalim ali metastatskim nedrobnoceli;nim plju;nim rakom z aktivacijskimi mutacijami EGFR-TK Odmerjanje in na;in uporabe' Zdravljenje z gefitinibom mora uvesti in nadzorovati zdravnik, ki ima izkušnje z uporabo zdravil proti raku. Priporo;eno odmerjanje zdravila IRESSA je ena 250-mg tableta enkrat na dan. Tableto je mogo;e vzeti s hrano ali brez nje, vsak dan ob približno istem ;asu. Kontraindikacije' preob;utljivost za zdravilno u;inkovino ali katerokoli pomožno snov, dojenje Opozorila in previdnostni ukrepi' Pri 1,3 % bolnikov, ki so dobivali gefitinib, so opažali intersticijsko bolezen plju; (IBP). Ta se lahko pojavi akutno in je bila v nekaterih primerih smrtna. :e se bolniku poslabšajo dihalni simptomi, npr. dispneja, kašelj in zvišana telesna temperatura, morate zdravljenje z zdravilom IRESSA prekiniti in bolnika takoj preiskati. ;e je potrjena IBP, morate terapijo z zdravilom IRESSA kon;ati in bolnika ustrezno zdraviti. ;eprav so bile nepravilnosti testov jetrnih funkcij pogoste, so jih redko zabeležili kot hepatitis. Zato so priporo;ljive redne kontrole delovanja jeter. V primeru blagih do zmernih sprememb v delovanju jeter je treba zdravilo IRESSA uporabljati previdno. :e so spremembe hude, pride v poštev prekinitev zdravljenja. Zdravilo IRESSA vsebuje laktozo. Bolniki z redko dedno intoleranco za galaktozo, laponsko obliko zmanjšane aktivnosti laktaze ali malabsorpcijo glukoze/galaktoze ne smejo jemati tega zdravila. Bolnikom naro;ite, da morajo takoj poiskati zdravniško pomo;, ;e se jim pojavijo kakršnikoli o;esni simptomi, huda ali dolgotrajna driska, navzea, bruhanje ali anoreksija, ker lahko vse te posredno povzro;ijo dehidracijo. Medsebojno delovanje zdravile' Induktorji CYP3A4 lahko pove;ajo presnovo gefitiniba in zmanjšajo njegovo koncentracijo v plazmi. Zato lahko so;asna uporaba induktorjev CYP3A4 (npr. fenitoina, karbamazepina, rifampicina, barbituratov ali zeliš;nih pripravkov, ki vsebujejo šentjanževko\Hypericum perforatum) zmanjša u;inkovitost zdravljenja in se ji je treba izogniti. Pri posameznih bolnikih, ki imajo genotip slabih metabolizatorjev s CYP2D6, lahko zdravljenje z mo;nim zaviralcem CYP3A4 pove;a koncentracijo gefitiniba v plazmi. Na za;etku zdravljenja z zaviralcem CYP3A4 je treba bolnike natan;no kontrolirati glede neželenih u;inkov gefitiniba. Pri nekaterih bolnikih, ki so jemali varfarin skupaj z gefitinibom, so se pojavili zvišanje internacionalnega normaliziranega razmerja (INR) in\ali krvavitve. Bolnike, ki so;asno jemljejo varfarin in gefitinib, morate redno kontrolirati glede sprememb protrombinskega ;asa (P:) ali INR. Zdravila, ki ob;utno in dolgotrajno zvišajo pH v želodcu npr. zaviralci protonske ;rpalke in antagonisti H2, lahko zmanjšajo biološko uporabnost gefitiniba in njegovo koncentracijo v plazmi in tako zmanjšajo u;inkovitost. Redno jemanje antacidov, uporabljenih blizu ;asa jemanja zdravila IRESSA, ima lahko podoben u;inek. Neželeni u;inki' V kumulativnem naboru podatkov klini;nih preskušanj III. faze so bili najpogosteje opisani neželeni u;inki, ki so se pojavili pri ve; kot 20 % bolnikov, driska in kožne reakcije (vklju;no z izpuš;ajem, aknami, suho kožo in srbenjem). Neželeni u;inki se ponavadi pojavijo prvi mesec zdravljenja in so praviloma reverzibilni. Ostali pogostejši neželeni u;inki so' anoreksija, konjunktivitis, blefaritis in suho oko, krvavitev, npr. epistaksa in hematurija, intersticijska bolezen plju; (1,3 %), navzea, bruhanje, stomatitis, dehidracija, suha usta, nepravilnosti testov jetrnih funkcij, bolezni nohtov, alopecija, asimptomati;no laboratorijsko zvišanje kreatinina v krvi, proteinurija, astenija, pireksija. Vrsta in vsebina ovojnine' škatla s 30 tabletami po 250 mg gefitiniba Na;in izdajanja zdravila' samo na recept Datum priprave besedila' junij 2009 Imetnik dovoljenja za promet' AstraZeneca AB, S-151 85, Sodertalje, Švedska Pred predpisovanjem, prosimo, preberite celoten povzetek glavnih zna;ilnosti zdravila. Dodatne informacije so na voljo pri' AstraZeneca UK Limited, Podružnica v Sloveniji, Verovškova 55, 1000 Ljubljana, telefon' 01\51 35 600. Erbitux 5 mg/ml raztopina za infundiranje (skrajšana navodila za uporabo) Cetuksimab je monoklonsko IgG1 protitelo, usmerjeno proti receptorju za epidermalni rastni faktor (EGFR). Terapevtske indikacije: Zdravilo Erbitux je indicirano za zdravljenje bolnikov z metastatskim kolorektalnim rakom in nemutiranim tipom KRAS; v kombinaciji s kemoterapijo in kot samostojno zdravilo pri bolnikih, pri katerih zdravljenje z oksaliplatinom in irinotekanom ni bilo uspešno. Zdravilo Erbitux je indicirano za zdravljenje bolnikov z rakom skvamoznih celic glave in vratu; v kombinaciji z radioterapijo za lokalno napredovalo bolezen in v kombinaciji s kemoterapijo na osnovi platine za ponavljajoco se in/ali metastatsko bolezen. Odmerjanje in nacin uporabe: Zdravilo Erbitux pri vseh indikacijah infundirajte enkrat na teden. Zacetni odmerek je 400 mg cetuksimaba na m2 telesne površine. Vsi naslednji tedenski odmerki so vsak po 250 mg/m2. Kontraindikacije: Zdravilo Erbitux je kontraindicirano pri bolnikih z znano hudo preobcutljivostno reakcijo (3. ali 4. stopnje) na cetuksimab. 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 US National Cancer Institute, Common Toxicity Criteria; NCI-CTC), morate prekiniti terapijo s cetuksimabom. Z zdravljenjem smete nadaljevati le, ce se je reakcija pomirila do 2. stopnje. Priporoca se dolocanje koncentracije elektrolitov v serumu pred zdravljenjem in periodicno med zdravljenjem s cetuksimabom. Po potrebi se priporoca nadomešcanje elektrolitov. Posebna previdnost je potrebna pri oslabljenih bolnikih in pri tistih z obstojeco srcno-pljucno boleznijo. Neželeni ucinki: Zelo pogosti (= 1/10): dispneja, blago do zmerno povecanje 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: Opazili so progresivno zniževanje nivoja magnezija v serumu, ki pri nekaterih bolnikih povzroca hudo hipomagneziemijo. Glede na resnost so opazili tudi druge elektrolitske motnje, vecinoma hipokalciemijo ali hipokaliemijo. Posebna navodila za shranjevanje: Shranjujte v hladilniku (2 °C - 8 °C). Ne zamrzujte. Vrsta ovojnine in vsebina: 1 viala po 20 ml ali 100 ml. Imetnik dovoljenja za promet: Merck KGaA, 64271 Darmstadt, Nemcija. Podrobne informacije o zdravilu so objavljene na spletni strani Evropske agencije za zdravila PM-ONC-02/09/10.04.2009 (EMEA) http://www.emea.europa.eu. Dodatne informacije so vam na voljo pri: Merck d.o.o., Dunajska cesta 119, 1000 Ljubljana, tel.: 01 560 3810, faks: 01 560 3831, el. pošta: info@merck.si www.oncology.merck.de Povzetek glavnih znacilnosti zdravila Ime zdravila: Temodal 20 mg, 100 mg, 140mg, 180 mg, 250 mg, Temodal 2,5 mg/ml prašek za raztopino za infundiranje Kakovostna in kolicinska sestava: Vsaka kapsula zdravila Temodal vsebuje 20 mg, 100 mg, 140 mg, 180 mg ali 250 mg temozolomida. Ena viala vsebuje 100 mg temozolomida Po rekonstituciji 1 ml raztopine za infundiranje vsebuje 2,5 mg temozolomida. Pomožna snov: Ena viala vsebuje 2,4 mmol natrija. Terapevtske indikacije: Zdravilo Temodal 2,5 mg/ml je indicirano za zdravljenje: odraslih bolnikov z novo diagnosticiranim multiformnim glioblastomom, socasno z radioterapijo (RT) in pozneje kot monoterapija in otrok, starih 3 leta in vec, mladostnikov in odraslih bolnikov z malignimi gliomi, npr. multiformnimi glioblastomi ali anaplasticnimi astrocitomi, ki se po standardnem zdravljenju ponovijo ali napredujejo. Odmerjanje in nacin uporabe: Zdravilo Temodal 2,5 mg/ml smejo predpisati le zdravniki, ki imajo izkušnje z zdravljenjem možganskih tumorjev. Odrasli bolniki z novo diagnosticiranim multiformnim glioblastomom Zdravilo Temodal 2,5 mg/ml se uporablja v kombinaciji z žarišcno radioterapijo (faza socasne terapije), temu pa sledi do 6 ciklov monoterapije (monoterapijska faza) z temozolomidom (TMZ). Faza socasne terapije TMZ naj bolnik jemlje v odmerku 75 mg/m2 na dan 42 dni, socasno z žarišcno radioterapijo (60 Gy, danih v 30 delnih odmerkih). Zmanjševanje odmerka ni priporoceno, vendar se boste vsak teden odlocili o morebitni odložitvi jemanja TMZ ali njegovi ukinitvi na podlagi kriterijev hematološke in nehematološke toksicnosti. TMZ lahko bolnik jemlje ves cas 42-dnevnega obdobja socasne terapije (do 49 dni), ce so izpolnjeni vsi od naslednjih pogojev: • absolutno število nevtrofilcev (ANC – Absolute Neutrophil Count) = 1,5 x 109/l; • število trombocitov = 100 x 109/l; • skupna merila toksicnosti (SMT) za nehematološko toksicnost = 1. stopnje (z izjemo alopecije, navzee in bruhanja). Med zdravljenjem morate pri bolniku enkrat na teden pregledati celotno krvno sliko. Faza monoterapije Štiri tedne po zakljucku faze socasnega zdravljenja s TMZ in RT naj bolnik jemlje TMZ do 6 ciklov monoterapije. V 1. ciklu (monoterapije) je odmerek zdravila 150 mg/m2 enkrat na dan 5 dni, temu pa naj sledi 23 dni brez terapije. Na zacetku 2. cikla odmerek povecajte na 200 mg/m2, ce je SMT za nehematološko toksicnost za 1. cikel stopnje = 2 (z izjemo alopecije, slabosti in bruhanja), absolutno število nevtrofilcev (ANC) = 1,5 x 109/l in število trombocitov = 100 x 109/l. Ce odmerka niste povecali v 2. ciklu, ga v naslednjih ciklih ne smete povecevati. Ko pa odmerek enkrat povecate, naj ostane na ravni 200 mg/m2 na dan v prvih 5 dneh vsakega naslednjega cikla, razen ce nastopi toksicnost. Zmanjšanje odmerka in ukinitev zdravila med fazo monoterapije opravite, kot je opisano v preglednicah 2 in 3. Med zdravljenjem morate 22. dan pregledati celotno krvno sliko (21 dni po prvem odmerku TMZ). Odrasli in pediatricni bolniki, stari 3 leta ali vec, s ponavljajocim se ali napredujocim malignim gliomom:Posamezen cikel zdravljenja traja 28 dni. Bolniki, ki še niso bili zdravljeni s kemoterapijo, naj jemljejo TMZ v odmerku 200 mg/m2 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 ciklu pa se poveca na 200 mg/m2 enkrat na dan 5 dni, ce ni bilo hematoloških toksicnih ucinkov. Kontraindikacije: Preobcutljivost za zdravilno ucinkovino ali katerokoli pomožno snov. Preobcutljivost za dakarbazin (DTIC). Posebna opozorila in previdnostni ukrepi: Pljucnica, ki jo povzroca Pneumocystis carinii Pilotno preskušanje podaljšane 42-dnevne sheme zdravljenja je pokazalo, da pri bolnikih, ki so socasno prejemali TMZ in RT, obstaja še posebej veliko tveganje za nastanek pljucnice zaradi okužbe s Pneumocystis carinii (PCP). Malignosti Zelo redko so porocali tudi o primerih mielodisplasticnega sindroma in sekundarnih malignostih, vkljucno z mieloidno levkemijo. Antiemeticno zdravljenje Navzea in bruhanje sta pogosto povezana z zdravljenjem s TMZ. Antiemeticno zdravljenje se lahko da pred uporabo TMZ ali po njej. Odrasli bolniki z novo diagnosticiranim multiformnim glioblastomom Antiemeticna profilaksa je priporocljiva pred zacetnim odmerkom socasne faze in je mocno priporocljiva med fazo monoterapije. Ponavljajoci se ali napredujoci maligni gliom Pri bolnikih, ki so mocno bruhali (stopnja 3 ali 4) v prejšnjih ciklih zdravljenja, je potrebno antiemeticno zdravljenje. Laboratorijske vrednosti Pred jemanjem zdravila morata biti izpolnjena naslednja pogoja za laboratorijske izvide: ANC = 1,5 x 109/l in število trombocitov = 100 x 109/l. 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 > 1,5 x 109/l in število trombocitov > 100 x 109/l. Ce med katerimkoli ciklom ANC pade na < 1,0 x 109/l ali število trombocitov na < 50 x 109/l, morate odmerek zdravila v naslednjem ciklu zmanjšati za eno stopnjo (glejte poglavje 4.2). Stopnje odmerka so 100 mg/m2, 150 mg/m2 in 200 mg/m2. Najmanjši priporoceni odmerek je 100 mg/m2. Pediatricna uporaba Klinicnih izkušenj z uporabo TMZ pri otrocih, mlajših od 3 let, ni. Izkušnje z uporabo tega zdravila pri starejših otrocih in mladostnikih so zelo omejene. Starejši bolniki (stari > 70 let) Videti je, da je pri starejših bolnikih tveganje za nevtropenijo ali trombocitopenijo vecje, kot pri mlajših. Zato je pri uporabi zdravila TMZ pri starejših bolnikih potrebna posebna previdnost. Moški bolniki Moškim, ki se zdravijo s TMZ je treba svetovati, naj ne zaplodijo otroka še šest mesecev po prejetem zadnjem odmerku in naj se pred zdravljenjem posvetujejo o možnostih za shranitev zmrznjene sperme. Natrij To zdravilo vsebuje 2,4 mmol natrija na vialo. To je treba upoštevati pri bolnikih na nadzorovani dieti z malo natrija. Medsebojno delovanje z drugimi zdravili in druge oblike interakcij: Študije medsebojnega delovanja so izvedli le pri odraslih. V loceni študiji 1. faze, socasna uporaba TMZ in ranitidina ni povzrocila spremembe obsega absorpcije temozolomida ali izpostavljenosti njegovem aktivnem presnovku monometiltriazenoimidazol karboksamidu (MTIK). Analiza populacijske farmakokinetike v preskušanjih 2. faze je pokazala, da socasna uporaba deksametazona, proklorperazina, fenitoina, karbamazepina, ondansetrona, antagonistov receptorjev H2 ali fenobarbitala ne spremeni ocistka TMZ. Socasno jemanje z valprojsko kislino je bilo povezano z majhnim, a statisticno pomembnim zmanjšanjem ocistka TMZ. Študij za dolocitev ucinka TMZ na presnovo ali izlocanje drugih zdravil niso izvedli. Ker pa se TMZ ne presnavlja v jetrih in se na beljakovine veže le v majhni meri, je malo verjetno, da bi vplival na farmakokinetiko drugih zdravil. Uporaba TMZ v kombinaciji z drugimi mielosupresivnimi ucinkovinami lahko poveca verjetnost mielosupresije. Neželeni ucinki: Pri bolnikih, ki se zdravijo s TMZ v kombinaciji z RT ali monoterapijo po RT zaradi novo diagnosticiranega multiformnega glioblastoma ali z monoterapijo pri bolnikih s ponavljajocim se ali napredujocim gliomom, so bili zelo pogosti neželeni ucinki podobni; slabost, bruhanje, zaprtje, neješcnost, glavobol in utrujenost. Pri bolnikih z novo diagnosticiranim glioblastomom multiforme na monoterapiji so zelo pogosto porocali o konvulzijah, medtem ko je bil izpušcaj opisan zelo pogosto pri bolnikih z novo diagnosticiranim multiformnim glioblastomom, ki so prejemali TMZ socasno z RT, ter pri tistih, ki so zdravilo prejemali v obliki monoterapije, pogosto pa pri tistih s ponavljajocim se gliomom. Pri obeh indikacijah so o vecini hematoloških neželenih reakcij porocali pogosto ali zelo pogosto. Imetnik dovoljenja za promet: Schering-Plough Europe, Rue de Stalle 73, Bruselj Belgija Nacin in režim izdaje zdravila: Zdravilo Temodal 20 mg, 100 mg, 140mg, 180 mg, 250 mg se izdaja na recept (Rp/Spec), Temodal 2,5 mg/ml prašek za raztopino za infundiranje pa je namenjeno uporabi samo v bolnišnicah (H). Datum priprave informacije: februar 2010 Literatura: 1 Povzetek temeljnih znacilnosti zdravila Temodal 2 Stupp R, et. al. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a 0233 Nova, intravenska oblika zdravila Temodal, za zdravljenje bolnikov z novo diagnosticiranim glioblastomom multiforme in bolnikov s ponavljajocim se ali napredujocim malignim gliomom.1 Resnicni napredek Pomembno izboljšanje preživetja potrjeno tudi ob daljšem spremljanju bolnikov.2 Dunajska 22, 1000 Ljubljana tel: 01 300 10 70 fax: 01 300 10 80 mehurjevalilu{~enjakože.Zeloredkosoporo~alioprimerihperforacijealiulceracijeroženice;opazilisotudidrugeo~esnebolezni.Zdravljenjez zdravilomTarcevajetrebaprekinitialiukiniti,~esepribolnikihpojavijoakutneo~esnebolezni,kotjebole~inavo~eh,alisele-teposlab{ajo.Tabletevsebujejolaktozoinjihnesmemodajatibolnikomzredkimidednimistanji:intolerancozagalaktozo,laponskooblikozmanj{aneaktivnostilaktazealimalabsorpcijoglukoze/galaktoze. Medsebojno delovanje z drugimi zdravili in druge oblike interakcij: Erlotinibsepriljudehpresnavljavjetrihzjetrnimicitokromi,primarnosCYP3A4invmanj{imerisCYP1A2.PresnovaerlotinibazunajjeterpotekasCYP3A4v~revesju,CYP1A1vplju~ihinCYP1B1vtumorskihtkivih.Zzdravilnimiu~inkovinami,kisepresnavljajostemiencimi,jihzavirajoalipasonjihoviinduktorji,lahkopridedointerakcij.Erlotinibjesrednjemo~anzaviralecCYP3A4inCYP2C8,kottudimo~anzaviralecglukuronidacijezUGT1A1in vitro.Prikombinacijiciprofloksacinaalimo~negazaviralca CYP1A2 (npr.fluvoksamina)zerlotinibomjepotrebnaprevidnost.Vprimerupojavaneželenihu~inkov,povezanihzerlotinibom,lahkoodmerekerlotinibazmanj{amo.Predhodnoaliso~asnozdravljenjezzdravilomTarcevanispremeniloo~istkaprototipovsubstratov CYP3A4, midazolamaineritromicina.Inhibicijaglukoronidacijelahkopovzro~iinterakcijezzdravili,kisosubstrati UGT1A1 inseizlo~ajosamopotejpoti.Mo~nizaviralci aktivnosti CYP3A4 zmanj{ajopresnovoerlotinibainzve~ajokoncentracijeerlotinibavplazmi.Priso~asnemjemanjuerlotinibainmo~nihzaviralcevCYP3A4jezatopotrebnaprevidnost.^ejetreba,odmerekerlotinibazmanj{amo,{eposebnopripojavutoksi~nosti.Mo~nispodbujevalci aktivnosti CYP3A4 zve~ajopresnovoerlotinibainpomembnozmanj{ajoplazemskekoncentracijeerlotiniba.So~asnemudajanjuzdravilaTarcevaininduktorjevCYP3A4sejetrebaizogibati.Pribolnikih,kipotrebujejoso~asnozdravljenjezzdravilomTarcevainmo~niminduktorjemCYP3A4,jetrebapremislitiopove~anjuodmerkado300mgobskrbnemspremljanjunjihovevarnosti.Zmanj{anaizpostavljenostselahkopojavitudizdrugimiinduktorji,kotsofenitoin,karbamazepin,barbituratiali{entjanževka.^etezdravilneu~inkovinekombiniramozerlotinibom,jepotrebnaprevidnost.Kadarjemogo~e,jetrebarazmislitiodrugihna~inihzdravljenja,kinevklju~ujejomo~negaspodbujanjaaktivnostiCYP3A4.Bolnikom,kijemljejokumarinske antikoagulante,jetrebarednokontroliratiprotrombinski~asaliINR.So~asnozdravljenjezzdravilomTarcevainstatinom lahkopove~atveganjezamiopatijo,povzro~enosstatini,vklju~nozrabdomiolizo;tosoopaziliredko.So~asnauporabazaviralcev P-glikoproteina,kotstaciklosporininverapamil,lahkovodivspremenjenoporazdelitevin/alispremenjenoizlo~anjeerlotiniba.Zaerlotinibjezna~ilnozmanj{anjetopnostipripHnad5.Zdravila, ki spremenijo pH v zgornjem delu prebavil,lahkospremenijotopnosterlotinibainposledi~nonjegovobiolo{kouporabnost.U~inkaantacidovnaabsorpcijoerlotinibanisoprou~evali,vendarjetalahkozmanj{ana,karvodivnižjeplazemskekoncentracije.Kombinacijierlotinibainzaviralcaprotonske~rpalkesejetrebaizogibati.^emenimo,dajeuporabaantacidovmedzdravljenjemzzdravilomTarcevapotrebna,jihjetrebajematinajmanj4urepredali2uripodnevnemodmerkuzdravilaTarceva.^erazmi{ljamoouporabiranitidina,moramozdravilijematilo~eno:zdraviloTarcevajetrebavzetinajmanj2uripredali10urpoodmerkuranitidina.V{tudijifazeIbnibilopomembnihu~inkovgemcitabina nafarmakokinetikoerlotiniba,pravtakonibilopomembnihu~inkoverlotinibanafarmakokinetikogemcitabina.Erlotinibpove~akoncentracijoplatine.Pomembnihu~inkovkarboplatina alipaklitakselanafarmakokinetikoerlotinibanibilo.Kapecitabin lahkopove~akoncentracijoerlotiniba.Pomembnihu~inkoverlotinibanafarmakokinetikokapecitabinanibilo.Neželeni u~inki: Zelo pogosti neželeni u~inki sokožniizpu{~ajindriska,kottudiutrujenost,anoreksija,dispneja,ka{elj,okužba,navzea,bruhanje,stomatitis,bole~inavtrebuhu,pruritus,suhakoža,suhikeratokonjunktivitis,konjunktivitis,zmanj{anjetelesnemase,depresija,glavobol,nevropatija,dispepsija,flatulenca,alopecija,okorelost,pireksija,nenormalnostitestovjetrnefunkcije.Pogosti neželeni u~inki sokrvavitvevprebavilih,epistaksa,keratitis,paronihija,fisurenakoži.Ob~asno soporo~alioperforacijahvprebavilih,hirzutizmu,spremembahobrvi,krhkihnohtih,odstopanjunohtovodkože,blagihreakcijahnakoži(npr.hiperpigmentacija),spremembahtrepalnic,hudiintersticijskibolezniplju~(vklju~nossmrtnimiprimeri).Redko pasoporo~aliojetrniodpovedi.Zelo redko soporo~alioStevens-Johnsonovemsindromu/toksi~niepidermalninekroliziteroulceracijahinperforacijahroženice.Režim izdaje zdravila: H/Rp.Imetnik dovoljenja za promet: RocheRegistrationLimited,6FalconWay,ShirePark,WelwynGardenCity,AL71TW,VelikaBritanija.Verzija: 2.0/10.Informacija pripravljena: avgust2010. DODATNE INFORMACIJE SO NA VOLJO PRI:Roche farmacevtska družba d.o.o.Vodovodna cesta 109, 1000 Ljubljana.Povzetek glavnih zna~ilnosti zdravilaje dosegljiv na www.roche.si. 053-10-TAR ^AS ZA ŽIVLJENJE. DOKAZANO PODALJŠA PREŽIVETJE PRI BOLNIKIH: zlokalno napredovalim ali metastatskim zmetastatskim rakom trebu{ne slinavke1 1 Povzetek glavnih znacilnosti zdravila TARCEVA, www.ema.europa.eu Lek farmacevtska družba d.d., Verovškova 57, 1526 Ljubljana, Slovenija, www.lek.si SKRAJŠAN POVZETEK GLAVNIH ZNACILNOSTI ZDRAVILA Epufen 12,5, 25, 50, 100 in 150 mikrogramov/uro transdermalni obliži SESTAVA: 1 transdermal­ni obliž vsebuje 2,89 mg, 5,78 mg 11,56 mg, 23,12 mg ali 34,65 mg fentanila. TERAPEVTSKE INDIKACIJE: Huda kronicna bolecina, ki se lahko ustrezno zdravi le z opioidnimi analgetiki. ODMERJANJE IN NACIN UPORABE: Odmerjanje je tre­ba individualno prilagoditi ter ga po vsaki uporabi redno oceniti. Izbira zacetnega odmerka: velikost odmerka fentanila je odvisna od predhodne uporabe opioidov, kjer se upošteva možnost pojava tolerance, socasnega zdravljenja, bolnikovega splošnega zdravstvenega stanja in stopnje resnosti obolenja. Pri bolnikih, ki pred tem niso dobivali mocnih opioidov, zacetni odmerek ne sme preseci 12,5-25 mi-krogramov na uro. Zamenjava opioidnega zdravljenja: pri zamenjavi peroralnih ali parenteralnih opioidov s fentanilom je treba zacetni odmerek izracunati na osnovi kolicine analgetika, ki je bila potrebna v zadnjih 24 urah, jo pretvoriti v odgovarjajoci odmerek morfina s pomocjo razpredelnice in nato preracunati ustrezen odmerek fentanila, spet s pomocjo razpredelnice (glejte SmPC). Prvih 12 ur po prehodu na transdermalni obliž Epufen bolnik še vedno dobiva predhodni analgetik v enakem odmerku kot prej; v naslednjih 12 urah se ta analgetik daje po potrebi. Titracija odmerka in vzdrževalno zdravljenje: obliž je treba zamenjati vsakih 72 ur. Odme­rek je treba titrirati individualno, dokler ni dosežen analgeticni ucinek. Odmerek 12,5 mikrogramov/uro je primeren za titriranje odmerka v manjšem odmernem ob-mocju. Ce analgezija na koncu zacetnega obdobja nošenja obliža ni zadostna, se lahko odmerek po 3 dneh zveca. Možno je, da bodo bolniki potrebovali obcasne dodatne odmerke kratko delujocih analgetikov (npr. morfina) za prekinitev bolecine. Sprememba ali prekinitev zdravljenja: vsaka zamenjava z drugim opioidom mora potekati postopoma, z majhnim zacetnim odmerkom in pocasnim zvecevanjem. Splošno veljavno pravilo je postopna ustavitev opioidne analgezije, da bi preprecili odtegnitvene simptome, kot so navzeja, bruhanje, diareja, anksioznost in mišicni tremor. Uporaba pri starejših bolnikih: starejše in oslabljene bolnike je treba skrb-no opazovati zaradi simptomov prevelikega odmerjanja ter odmerek po potrebi zmanjšati. Uporaba pri otrocih: transdermalni obliži Epufen se lahko uporabljajo le pri pediatricnih bolnikih (starih od 2 do 16 let), ki tolerirajo opioide in peroralno že dobivajo opioide v odmerku, enakovrednemu najmanj 30 mg morfina na dan. Bolnik mora prvih 12 ur po prehodu na Epufen še vedno dobivati predhodni anal-getik v enakem odmerku kot prej. V naslednjih 12 urah je treba ta analgetik dajati odvisno od klinicnih potreb. Titracija odmerka in vzdrževalno zdravljenje: ce je anal­geticni ucinek Epufena prešibak, je treba bolniku dodati morfin ali drugi opioid s kratkim delovanjem. Odvisno od dodatnih potreb po analgeziji in jakosti bolecine pri otroku se lahko uporabi vec obližev. Odmerek je treba prilagajati korakoma, po 12,5 mikrogramov/uro. Uporaba pri bolnikih z jetrno ali ledvicno okvaro: Zara-di možnosti pojava simptomov prevelikega odmerjanja je treba te bolnike skrbno spremljati in odmerek ustrezno zmanjšati. Uporaba pri bolnikih s povecano telesno temperaturo: Pri teh bolnikih bo morda treba prilagoditi odmerek. Nacin uporabe: transdermalni obliž Epufen je treba takoj po odprtju vrecke nalepiti na nerazdraženo, neobsevano kožo, na ravno površino prsnega koša, zgornjega dela hrbta ali nadlakti. Po odstranitvi zašcitne plasti je treba obliž trdno pritrditi na izbrano mesto in z dlanjo pritiskati približno 30 sekund, da se obliž popolnoma nalepi, še zlasti na robovih. Uporaba pri otrocih: pri mlajših otrocih je obliž priporocljivo nalepiti na zgornji del hrbta, ker je manjša verjetnost, da bi otrok odstranil obliž. Transdermalnega obliža se ne sme deliti, ker podatkov o tem ni na voljo. KONTRAINDIKACIJE: Preobcu­tljivost za zdravilno ucinkovino, hidrogenirano kolofonijo, sojo, arašide ali katerokoli pomožno snov. Akutna ali pooperativna bolecina, ko v kratkem casovnem obdobju ni možno titriranje odmerka in obstaja verjetnost za življenjsko ogrožajoco respirator-no depresijo. Huda okvara osrednjega živcnega sistema. POSEBNA OPOZORILA IN PREVIDNOSTNI UKREPI: Zaradi razpolovne dobe fentanila je treba bolnika v primeru pojava neželenega ucinka opazovati še 24 ur po odstranitvi obliža. Pri nekaterih bol­nikih, ki uporabljajo transdermalni obliž Epufen, se lahko pojavi respiratorna depre­sija. Epufen je treba previdno dajati: bolnikom s kronicno pljucno boleznijo, zvišanim intrakranialnim tlakom, možganskim tumorjem, boleznimi srca, jeter in ledvic, tistim z zvišano telesno temperaturo, pri starejših bolnikih in otrocih, bolnikih z miaste­nijo gravis. Odvisnost od zdravila: kot posledica ponavljajoce se uporabe se lahko razvijeta toleranca na ucinkovino ter psihicna in/ali fizicna odvisnost od nje. Ostali: lahko se pojavijo neepilepticne (mio)klonicne reakcije. MEDSEBOJNO DELOVANJE Z DRUGIMI ZDRAVILI IN DRUGE OBLIKE INTERAKCIJ: Derivati barbiturne kisline, opioidi, anksiolitiki in pomirjevala, hipnotiki, splošni anestetiki, fenotiazini, mišicni relaksanti, sedativni antihistaminiki in alkoholne pijace, zaviralci MAO, itrakonazol, ritonavir, ketokonazol, nekateri makrolidni antibiotiki, pentazocin, buprenorfin. VPLIV NA SPOSOBNOST VOŽNJE IN UPRAVLJANJA S STROJI: Zdravilo ima mocan vpliv na sposobnost vožnje in upravljanja s stroji. NEŽELENI UCINKI: Najbolj resen neželen ucinek fentanila je respiratorna depresija. Zelo pogosti (= 1/10): drema­vost, glavobol, navzeja, bruhanje, zaprtje, znojenje, srbenje, somnolenca. Pogosti (= 1/100 do < 1/10): kserostomija, dispepsija, reakcije na koži na mestu aplikacije, sedacija, zmedenost, depresija, tesnoba, živcna napetost, halucinacije, zmanjšan apetit. Obcasni (= 1/1000 do < 1/100): tahikardija, bradikardija, tremor, parestezija, motnje govora, dispneja, hipoventilacija, diareja, zastajanje urina, izpušcaj, rdecina, hipertenzija, hipotenzija, evforija, amnezija, nespecnost, vznemirljivost. Nekateri od naštetih neželenih ucinkov so lahko posledica osnovne bolezni ali drugih zdravljenj. Drugi neželeni ucinki: odpornost, fizicna in psihicna odvisnost se lahko razvijejo med dolgotrajno uporabo fentanila. Pri nekaterih bolnikih se lahko pojavijo odtegnitveni simptomi, ko zamenjajo prejšnje opiodne analgetike s transdermalnim obilžem s fentanilom ali po nenadni prekinitvi zdravljenja. NACIN IZDAJE: Samo na zdravni­ški recept. OPREMA: Škatle s 5 transdermalnimi obliži. IMETNIK DOVOLJENJA ZA PROMET: Lek farmacevtska družba, d.d., Verovškova 57, Ljubljana, Slovenija INFOR­MACIJA PRIPRAVLJENA: avgust 2009 ucinkovita in preizkušena možnost zdravljenja anoreksije-kaheksije ... še vedno EDINO ZDRAVILO, ki je v Sloveniji registrirano za zdravljenje anoreksije-kaheksije pri bolnikih z napredovalim rakom 1,2 - predpisovanje na zeleni recept v breme ZZZS 6 izboljša apetit 1,5 pomaga ohraniti in pridobiti telesno težo 3,4,5 izboljša splošno pocutje bolnikov 3,4 SKRAJŠAN POVZETEK GLAVNIH ZNACILNOSTI ZDRAVILA: MEGACE 40 mg/ml peroralna suspenzija Sestava: 1 ml peroralne suspenzije vsebuje 40 mg megestrolacetata. TERAPEVTSKE INDIKACIJE: Zdravljenje anoreksije-kaheksije ali nepojasnjene, pomembne izgube telesne mase pri bolnikih z AIDS-om. Zdravljenje anorekticno-kahekticnega sindroma pri napredovalem raku. ODMERJANJE IN NACIN UPORABE: Pri aidsu je priporoceni zacetni odmerek Megace za odrasle 800 mg (20 ml peroralne suspenzije) enkrat na dan eno uro pred jedjo ali dve uri po jedi in se lahko med zdravljenjem prilagodi glede na bolnikov odziv. V raziskavah bolnikov z aidsom so bili klinicno ucinkoviti dnevni odmerki od 400 do 800 mg/dan (10 do 20 ml), uporabljani štiri mesece. Pri anorekticno-kahekticnem sindromu zaradi napredovalega raka je priporocljiv zacetni odmerek 200 mg (5 ml) na dan; glede na bolnikov odziv ga je mogoce povecati do 800 mg na dan (20 ml). Obicajni odmerek je med 400 in 800 mg na dan (10–20 ml). V raziskavah bolnikov z napredovalim rakom so bili klinicno ucinkoviti dnevni odmerki od 200 do 800 mg/dan (5 do 20 ml), uporabljani najmanj osem tednov. Pred uporabo je potrebno plastenko s suspenzijo dobro pretresti. Uporaba pri otrocih: Varnosti in ucinkovitosti pri otrocih niso dokazali. Uporaba pri starostnikih: Zaradi pogostejših okvar jeter, ledvic in srcne funkcije, pogostejših socasnih obolenj ali socasnega zdravljenja z drugimi zdravili je odmerek za starejšega bolnika treba dolociti previdno in obicajno zaceti z najnižjim odmerkom znotraj odmernega intervala. KONTRAINDIKACIJE: Preobcutljivost za megestrolacetat ali katerokoli pomožno snov. POSEBNA OPOZORILA IN PREVIDNOSTNI UKREPI: Uporaba gestagenov med prvimi štirimi meseci nosecnosti ni priporocljiva. Pri bolnikih s tromboflebitisom v anamnezi je treba zdravilo Megace uporabljati previdno. Zdravljenje z zdravilom Megace se lahko zacne šele, ko so bili vzroki hujšanja, ki jih je mogoce zdraviti, ugotovljeni in obravnavani. Megestrolacetat ni namenjen za profilakticno uporabo za preprecitev hujšanja. Ucinki na razmnoževanje virusa HIV niso ugotovljeni. Med zdravljenjem z megestrolacetatom in po prekinitvi kronicnega zdravljenja je treba upoštevati možnost pojava zavore nadledvicne žleze. Morda bo potrebno nadomestno zdravljenje s stresnimi odmerki glukokortikoidov. Megestrolacetat se v veliki meri izloci prek ledvic. Ker je verjetnost zmanjšanega delovanja ledvic pri starostnikih vecja, je pri dolocitvi odmerka potrebna previdnost, prav tako je koristno spremljanje ledvicne funkcije. Peroralna suspenzija vsebuje saharozo. Bolniki z redko dedno intoleranco za fruktozo, malabsorpcijo glukoze/galaktoze ali pomanjkanjem saharoza-izomaltaze ne smejo jemati tega zdravila. Peroralna suspenzija vsebuje tudi majhne kolicine etanola (alkohola), in sicer manj kot 100 mg na odmerek. INTERAKCIJE: Aminoglutetimid: porocali so o zmanjšanju koncentracije progestogena v plazmi z možno izgubo terapevtskega delovanja zaradi inducirane presnove. Socasno jemanje megestrolacetata (v obliki peroralne suspenzije) in zidovudina ali rifabutina ne povzroca sprememb farmakokineticnih parametrov. NEŽELENI UCINKI: Pogosti (= 1/100, < 1/10): navzea, bruhanje, driska, flatulenca, izpušcaj, metroragija, impotenca, astenija, bolecina, edem. Neznana pogostnost (pogostnosti ni mogoce oceniti iz razpoložljivih podatkov): poslabšanje osnovne bolezni (širjenje tumorja), adrenalna insuficienca, kušingoidni izgled, Cushingov sindrom, diabetes mellitus, motena toleranca za glukozo, hiperglikemija, spremembe razpoloženja, sindrom karpalnega kanala, letargija, srcno popušcanje, tromboflebitis, pljucna embolija (v nekaterih primerih usodna), hipertenzija, navali vrocine, dispneja, zaprtje, alopecija, pogosto uriniranje. Vrsta ovojnine in vsebina: Plastenka z 240 ml suspenzije. Režim izdaje: Rp/Spec. Imetnik dovoljenja za promet: Bristol-Myers Squibb spol. s r.o., Olivova 4, Praga 1, Ceška; Odgovoren za trženje v Sloveniji: PharmaSwiss d.o.o., Ljubljana, tel: 01 236 4 700, faks: 01 236 4 705; MGS-120609. Pred predpisovanjem preberite celoten povzetek glavnih znacilnosti zdravila! Reference: 1. Povzetek glavnih znacilnosti zdravila Megace – 12. junij 2009; 2. Register zdravil Republike Slovenije XI – leto 2008; 3. Beller, E., 1997. Ann Oncol 8: 277-283; 4. Cufer, T, 2002. Onkologija 9(2): 73-75; 5. Yavuzsen, T., 2005. J Clin Oncol 23(33): 8500-8511; 6. Bilten Recept 7(1), 22.5.2009 MEG1109-07; november, 2009 Novartis Oncology prinaša spekter inovativnih zdravil, s katerimi poskuša spremeniti življenje bolnikov z rakavimi in hematološkimi obolenji. Ta vkljucuje zdravila kot so Glivec® (imatinib), Tasigna® (nilotinib), A. nitor® (everolimus), Zometa® (zoledronska kislina), Femara® (letrozol), Sandostatin® LAR® (oktreotid/i.m. injekcije) in Exjade® (deferasiroks). Novartis Oncology ima tudi obširen razvojni program, ki izkorišca najnovejša spoznanja molekularne genomike, razumskega nacrtovanja in tehnologij za odkrivnje novih ucinkovin. Novartis Pharma Services Inc. • Podružnica v Sloveniji • Tivolska cesta 30 • 1000 Ljubljana Samo za strokovno javnost. NV-JA-02/09-SI zdravnikom ali s farmacevtom. Instructions Instructions for authors The editorial policyof the journal Radiology and Oncologyis topublish original scientific papers, professional papers, review articles case reports and varia (editorials, short communications, professional information, book reviews, letters, etc.) perti­nent to diagnostic and interventional 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). 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If corrections are not received by the stated deadline, proof-reading will be carried out by the editors. Reprints: The electronic version of the published papers will be available on www.versita.com free of charge. Radiol Oncol 2010; 44(2) BISTVENE INFORMACIJE IZ POVZETKA GLAVNIH ZNACILNOSTI ZDRAVILA SUTENT 12,5 mg, 25 mg, 37,5 mg, 50 mg trde kapsule Sestava in oblika zdravila: Vsaka trda kapsula vsebuje 12,5 mg, 25 mg, 37,5 mg ali 50 mg sunitiniba v obliki sunitinibijevega malata. Indikacije: Zdravljenje neizrezljivega in/ali metastatskega malignega gastrointestinalnega stromalnega tumorja (GIST), ce zdravljenje z imatinibijevim mesilatom zaradi odpornosti ali neprenašanja ni bilo uspešno. Zdravljenje napredovalega in/ali metastatskega karcinoma ledvicnih celic (MRCC). Odmerjanje in nacin uporabe: Terapijo mora uvesti zdravnik, ki ima izkušnje z zdravljenjem MRCC ali GIST. Priporoceni odmerek je 50 mg enkrat dnevno, peroralno vsak dan 4 tedne zapored; temu sledi 2-tedenski premor (Shema 4/2), tako da celotni ciklus traja 6 tednov. Odmerek je mogoce prilagajati v povecanjih po 12,5 mg, upoštevaje individualno varnost in prenašanje. Dnevni odmerek ne sme preseci 75 mg in ne sme biti manjši od 25 mg. Pri socasni uporabi z mocnimi zaviralci ali induktorji CYP3A4 je potrebno odmerek ustrezno prilagoditi. Uporaba pri otrocih in mladostnikih (< 18 let): Sutenta ne smemo uporabljati, dokler ne bo na voljo dodatnih podatkov. Uporaba pri starejših bolnikih (= 65 let): med starejšimi in mlajšimi bolniki niso opazili pomembnih razlik v varnosti in ucinkovitosti. Insuficienca jeter: pri bolnikih z jetrno okvaro razreda A in B po Child-Pughu prilagoditev odmerka ni potrebna; pri bolniki z okvaro razreda C Sutent ni bil preizkušen. Insuficienca ledvic: klinicnih študij niso izvedli. Sutent se uporablja peroralno, bolnik ga lahko vzame z ali brez hrane. Ce pozabi vzeti odmerek, ne sme dobiti dodatnega, temvec naj vzame obicajni predpisani odmerek naslednji dan. Kontraindikacije: Preobcutljivost za zdravilno ucinkovino ali katerokoli pomožno snov. Posebna opozorila in previdnostni ukrepi:Koža in tkiva. Krvavitve v prebavila, dihala, secila, v možganih ter krvavitve tumorja. Ucinki na prebavila: poleg navzee in driske tudi resni zapleti. Hipertenzija. Hematološke bolezni. Bolezni srca in ožilja: zmanjšanje LVEF in srcno popušcanje. Podaljšanje intervala QT. Venski trombembolicni dogodki. Dogodki na dihalih: dispneja, plevralni izliv, pljucna embolija ali pljucni edem. Moteno delovanje šcitnice. Pankreatitis. Delovanje jeter. Delovanje ledvic. Fistula. Preobcutljivost/angioedem. Motnje okušanja. Konvulzije. Pri krvavitvah, ucinkih na prebavila, hematoloških boleznih, dogodkih na dihalih, venskih trombembolicnih dogodkih, pankreatitisu in ucinkih na jetra so opisani tudi smrtni izidi. Medsebojno delovanje z drugimi zdravili: Zdravila, ki lahko zvišajo koncentracijo sunitiniba v plazmi (ketokonazol, ritonavir, itrakonazol, eritromicin, klaritromicin ali sok grenivke). Zdravila, ki lahko znižajo koncentracijo sunitiniba v plazmi (deksametazon, fenitoin, karbamazepin, rifampin, fenobarbital, Hypericum perforatum oz. šentjanževka). Antikoagulanti. Nosecnost in dojenje: Sutenta se ne sme uporabljati med nosecnostjo in tudi ne pri ženskah, ki ne uporabljajo ustrezne kontracepcije, razen ce možna korist odtehta možno tveganje za plod. Ženske v rodni dobi naj med zdravljenjem s Sutentom ne zanosijo. Ženske, ki jemljejo Sutent, ne smejo dojiti. Vpliv na sposobnost vožnje in upravljanja s stroji: Sutent lahko povzroci omotico. Neželeni ucinki: Najpogostejši neželeni ucinki: pljucna embolija, trombocitopenija, krvavitev tumorja, febrilna nevtropenija, hipertenzija, utrujenost, diareja, navzea, stomatitis, dispepsija, bruhanje, obarvanje kože, disgevzija, anoreksija, zvišanje ravni lipaze. Zelo pogosti: anemija, nevtropenija, hipotiroidizem, zmanjšanje teka, motnje okušanja, glavobol, bolecina v trebuhu / napihnjenost, flatulenca, bolecine v ustih, sindrom palmarno plantarne eritrodizestezije, spremembe barve las, astenija, vnetje sluznice, edemi. Nacin in režim izdajanja: Izdaja zdravila je le na recept, uporablja pa se samo v bolnišnicah. Izjemoma se lahko uporablja pri nadaljevanju zdravljenja na domu ob odpustu iz bolnišnice in nadaljnjem zdravljenju. Imetnik dovoljenja za promet: Pfizer Limited, Ramsgate Road, Sandwich, Kent, CT13 9NJ, Velika Britanija. Datum zadnje revizije besedila: 28.10.2009 Pred predpisovanjem se seznanite s celotnim povzetkom glavnih znacilnosti zdravila. SUT-01-10 Pfizer Luxembourg SARL, Grand Duchy of Luxembourg, 51, Avenue J.F. Kennedy, L-1855, PFIZER, Podružnica za svetovanje s podrocja farmacevtske dejavnosti, Ljubljana, Letališka 3c, 1000 Ljubljana, SLOVENIJA