Why Is Surgery Still Done after Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer in Romania?

The incidence and mortality of cervical cancer are high in Romania compared to other European countries, particularly for locally advanced cervical cancer cases, which are predominant at the time of diagnosis. Widely accepted therapeutic guidelines indicate that the treatment for locally advanced cervical cancer consists of concurrent chemoradiotherapy (total dose 85-90 Gy at point A), with surgery not being necessary as it does not lead to improved survival and results in significant additional morbidity. In Romania, the treatment for locally advanced cervical cancer differs, involving lower-dose chemoradiotherapy (total dose 60-65 Gy at point A), followed by surgery, which, under these circumstances, ensures better local control. In this regard, we attempted to evaluate the role and necessity of surgery in Romania, considering that in our study, residual lesions were found in 55.84% of cases on resected specimens, especially in cases with unfavorable histology (adenocarcinoma and adenosquamous carcinoma). This type of surgery was associated with significant morbidity (28.22%) in our study. The recurrence rate was 24.21% for operated-on patients compared to 62% for non-operated-on patients receiving suboptimal concurrent chemotherapy alone. In conclusion, in Romania, surgery will continue to play a predominant role until radiotherapy achieves the desired effectiveness for local control.

Challenges in the Surgical Management of Patients with Diabetic Neuropathy

Background: Diabetes Mellitus represents a major socio-economic issue both by influencing the patient's quality of life and also considering the impact on the healthcare system. Diabetic neuropathy is one of the main complications associated, in most cases being present from the moment of diagnosis. Considering the high incidence of diabetes among patients with biliodigestive surgical conditions, a thorough analysis of the evolution and management of these patients is necessary. Materials and Methods: The association between the evolution of diabetic patients with biliodigestive conditions and diabetic neuropathy as well as risk criteria and associated complications were analyzed in a descriptive, correlational study (314 patients) conducted in the Dr. I. Cantacuzino Clinical Hospital during 2020-2022. In the study, the patients were distributed into two groups, one consisting in patients without diabetes mellitus (control group) and the second further subdivided into two groups of study, first (2a) containing patients with type II with diabetic neuropathy and high and medium risk rate, and a second one (2b) including patients with diabetes mellitus type II with confirmed neuropathy and low risk rate. Clinical and laboratory evaluations were performed and management protocols applied. Results: Statistically significant correlations were highlighted between diabetic neuropathy and the variables tested which were subsequently combined to achieve a risk score and a management protocol. Conclusions: Diabetes mellitus associated with diabetic neuropathy represents a negative prognostic factor for the postoperative outcome being associated with high risk of morbidity and mortality. The risk score and the management protocol described as results of this study represent feasible solutions and a subservient instrument in preventing the occurrence of complications in patients with bilio-digestive surgical pathologies in order to improve the prognosis and survival of the patients.

Tips and Tricks for a Successful Literature Review as Part of Medical Career Development

The literature review is a direct consequence of the increased volume of scientific information, becoming a necessity not only for the medical field. Such material, properly done, is of great use to any professional who wishes to keep abreast of the latest knowledge and concepts. The proposed goal is to help and guide resident doctors, doctoral students, and young researchers in understanding the concepts that are the basis of conducting a literature review and acquiring the generally accepted methodology for conducting it. The selection of information sources, accessing databases, the concept of peer-review, indexing and the impact factor are clearly presented as elements that cannot be neglected in the valorisation of scientific information sources. The structure of a literature review must consider the generally accepted format for such an article, with each chapter having its own importance. Depending on the quality and heterogeneity of the results obtained after analysing the collected data, the review can be structured narratively or systematically, the homogeneity of the results allowing the application of statistical study methods (meta-analysis). Although it seems difficult, conducting a literature review is easier and faster than developing an original study based on experimental or clinical scientific research. The literature review can be carried out in comfortable conditions, online, regardless of location and is a welcome support in the development of the professional and scientific career.

HER2 Positive Breast Cancer Therapy - A Challenging and Continuously Moving Pathway – A Narrative Literature Review

Background: Alteration of the expression of human epidermal growth factor receptor-2 gene as an oncogenic pathway in breast cancer was first explored in the 1980'. Since then, tremendous progress has been made in treating HER2-positive breast cancer. Methods: We performed a narrative type review of the existing literature using as a starting point the PubMed database, investigated by keywords, later the search being refined and the articles that we considered relevant were selected. The approach to the topic under discussion being variable in the various studies identified convinced us of the inappropriateness of a meta-analysis. As a secondary method of analysis, we evaluated the bibliography of each of the selected studies and from this we identified other publications of interest. Results: At present, there are three major classes of FDA-approved anti-HER2 agents: monoclonal antibodies (Trastuzumab, Pertuzumab and Margetuximab), TKIs (Lapatinib, Neratinib and Tucatinib) and antibody-drug conjugates (T-DM1 and T-DXd). The treatment of HER2+ breast cancer suffered some changes in the last few years. If in 2018, after progression under first-line treatment with taxane-trastuzumab/pertuzumab and second line with T-DM1 was a big challenge, being up to the oncologist to choose from lapatinib-capecitabine, trastuzumab-lapatinib or different chemotherapeutic agents, depending on toxicities and therapies available in the country, nowadays we have a new third- and fourth-line FDA approved standard, which consists of tucatinib-trastuzumab-capecitabine and trastuzumab-deruxtecan.  Conclusion: Times are very exciting for HER2-positive disease. What differentiates novel therapies and if we do it better is both the question that we tried to give an answer to in this review of literature, but it remains at the same time a topic of discussion and a directive for analysis in the future, because we are only getting closer to an optimal version of treatment for HER2+ breast cancer, hoping that the introduction of new drugs and the establishment of new indications for old drugs will allow us to standardize the treatment of these patients.

The Management of Axillary Lymph Nodes in Breast Cancer - A Retrospective Single-Centre Study

Introduction: We are presenting the experience of our centre with the surgical treatment of breast cancer, by comparing the use of axillary node dissection with sentinel lymph node biopsy (SNLB). Methods: We have made a retrospective analysis of breast cancer cases in the Surgical Oncology Clinic no. 1, "Alexandru Trestioreanu" Oncology Institute, Bucharest, in the period between December 2019 and December 2020. We are presenting the situations in which axillary node dissection can be replaced with SNLB and the limitations of this method. Results: Although the use of SNLB has advantages compared to axillary node dissection, it is limited by the early detection of breast cancer and by the necessity of adding axillary dissection to surgical treatment in the case of positive SNLB. Conclusions: The replacement of axillary node dissection with SNLB is a desideratum for the following decades in view of an optimal treatment of early-stage breast cancer, with fewer postoperative complications and a better life quality.

THE ROLE OF CECOSTOMY IN THE SURGICAL PATHOLOGY OF THE COLON

In spite of a correct surgical technique, colon interventions can lead to complications of the fistula, sometimes real abdominal dramas, worsening the prognosis of these patients and hardening the surgical technique. We present the evolution of a patient initially treated endoscopically for a sigmoid polyp. The histopathological examination of the biopsy confirmed its malignant character, with invasion of the pedicle, for which reason the endoscopic polypectomy is considered insufficient from an oncological point of view and a colonic resection is advisable. In the postoperative evolution of the patient there appear complications through the occurrence of an anastomotic fistula and peritonitis, whose presence leads to the necessity of performing a terminal colostomy which permits the cessation of the inflammatory syndrome. The further reinstatement of transit is done by means of an “a minima” cecostomy, thus reducing the clinical impact in case of other complications of the fistula. The following elements were analyzed: the patient’s history, associated diseases, fistula-related risk factors, biochemical, imaging and clinical samples, elements related to the surgical technique and the entire postoperative evolution of the patient. This paper stands as an argument in supporting the advantages of “a minima” cesostomy in case of colon surgery, proving how a technical artifice which is minimally invasive for the patient and easy to achieve may become very useful in solving or even preventing some severe complications arising on the background of a simple pathology.

Pancreaticojejunostomy - Risk Anastomosis after Cephalic Pancreaticoduodenectomy

INTRODUCTION

The authors bring to attention pancreaticojejunalanastomosis (PJA) performed after cephalic pancreaticoduodenectomy(CPD). This type of anastomosis is renowned forits high risk of complications. Among these complications, pancreatic fistula (PF) is distinguishable due to a significant frequency, averaging 10%. It is perhaps the most unsafe type of anastomosis in digestive surgery, due to its pancreatic partnership. Performing a sealed APJ can be considered a great achievement: a digestive lumen is set in contact with a brittleparenchymal structure, centred by a delicate excretory channel, difficult to anastomose in itself.

MATERIAL AND METHODS

We studied two distinct groups of patients undergoing CPD. A first group - 58 cases operated on between 1967 and 1983, and the second one - 70 cases operated on between 1984 - 2013. In all cases we performed PJA; by in-continuity loop technique in the first group, and with separate loop in the second group. In the second group we used a variant own technique that does not allow anastomotic loss of pancreatic fluid. Thus, a decline in the incidence of PF from 20% to 8% was obtained, the final percentage corresponding to group two. Of the 8% of patients with PF losses were recorded strictly at pancreatic level, with no bile or food contamination. Stenting was recorded for biliary- and pancreaticojejunal anastomoses in group two.

DISCUSSIONS

The percentage of PF after CPD did not show anynotable revival when comparing the 1980s period to the present. Also, mortality due to FP is approaching 40%, adaunting figure. The multitude of technical options for restoring bowel movement after CPD, over 80 procedures, further confirms the lack of safety and trust in relation to PJA.The authors bring forward several surgical gestures addressing PJA, gestures capable of providing an 8% frequency of PF,percentage which we consider to be reasonable.

CONCLUSIONS

The authors consider PJA stenting mandatory.Placing an isolated PJA on the short branch of the "Y", separate from the biliary and food flow, prevents the formation of a complex fistula. The proposed technique does not require a"duct - to - mucosa" type or "telescoping" type pancreaticojejunalanastomosis.

"Difficult" Colorectal Polyps - Therapeutic Approach

INTRODUCTION

Endoscopic polypectomy is the gold standard in the treatment of colorectal polyps. The importance of polypectomy rests primarily on the fact that polyp-type lesions present a high risk of malignant degeneration, colorectal polyps being able, if left unattended therapeutically, to generate a colorectal cancer (CRC) - a lesion with a far more negative prognosis. Although preferable, endoscopic polypectomy of colorectal polyps is not always possible, multiple factors generating difficulties in performing this therapeutic measure.

MATERIAL AND METHOD

We performed a retrospective study in the First Surgical Clinic of the "Prof. Dr. Alexandu Trestioreanu" Bucharest Oncology Institute, spanning a period of 3 years (2008-2011), in which time 224 patients were diagnosed by colonoscopy with colorectal polyps, of whom 222 patients benefited from endoscopic polypectomy. The aim of the study was to identify "difficult" polyps and to identify the criteria for endoscopic surgery versus classic surgery as a therapeutic indication.

RESULTS

Presence of "difficult" polyps was observed in 37.56% of the patients diagnosed with colorectal polyps. In over 88% of cases endoscopic polypectomy was possible, and for the remaining patients classic surgery was the therapeutic solution opted for.

CONCLUSIONS

Presence of "difficult" polyps generates inconveniences in performing endoscopic polypectomy, increasing the risk of postoperative complication occurrence, as well as the duration of the operation. If the criteria for characterizing polyps as "difficult" are relatively well-established, the choice between endoscopic and classic surgery as a therapeutic measure is left at the free will of the operating surgeon, with the exception of situations in which classic surgery is resorted to for oncological reasons.

Morbidity after Ultra Low Anterior Resection of the Rectum

Anterior resections of the rectum, used as an alternative to amputation of the rectum, are performed more and more frequently, being presently indicated for neoplasms located ata distance of 7 to 4 cm from the anus. Complications of low and ultra low anterior resections are not at all negligible, and local neoplastic recurrence rate is significantly higher than after amputation of the rectum. However, literature data recommends low and ultra low anterior rectal resections, even if sometimes the method indications are pushed to the limit or the interventions are performed at the patient's request, in order to avoid permanent colostomy. The authors of this article aim to outline a true picture of the changes caused by anterior resections of the rectum, low and ultra low, so that, without denying the merits of these resections, the entire postoperative pathology that occurs in these patients is depicted and understood. Ultra low rectal resections, up to 3-4 cm from the anus, bring important morphological and functional changes to the act of defecation and to anal continence. These changes in colo-anal bowel movement have a much higher incidence than postoperative genitourinary disorders. Another important aspect emerging from the present study is related to the increased incidence of anastomotic disunity, stenosis and various degrees of incontinence, complications that often can only be solved by completion of rectum amputation and permanent colostomy. In addition, the functional outcomes of these ultra low resections are not always at the level expected by the patient. Also, in terms of surgical performance, the higher share of specific complications of the procedure raises questions with regard to the technique. For all these reasons the authors consider it necessary to review the lower limit to which an anterior rectal resection can descend.

Surgical treatment in stenosing rectal cancer

INTRODUCTION

Rectal cancer represents an important health issue, which involves multidisciplinary treatment, posing a major surgical challenge, both in terms of diagnosis and treatment.

MATERIAL AND METHOD

Between 2009-2013, we analysed 83 patients with stenosing rectal cancer operated on at the Clinic of General Surgery II of Colentina Clinical Hospital and at the Clinic of General Surgery I of "Prof. Dr. Al. Trestioreanu"€ Oncology Institute, in Bucharest. Gender distribution was: 51 males and 32 females. Average age was 65 years old. The most frequently encountered symptoms were colicky abdominal pain and rectorrhagia. 25 patients presented intestinal occlusion phenomena at admission, the other 58 cases being in subocclusive stage.

RESULTS

In occlusive stages: 17 patients presented with resectable tumour, while 8 patients had locally advanced neoplastic forms (€œfrozen pelvis€), left iliac colostomy with tumour biopsy being the chosen approach. In subocclusive stages: 5 cases had unresectable tumours for which left iliac anus with tumour biopsy was performed; 53 cases presented with resectable tumour, for which the Hartmann procedure (12 patients) and left iliac colostomy with tumour biopsy (41 patients) were performed. Depending on the histopathological result, patients were submitted to radio- and chemotherapy.Tumour resection was possible in 70 cases (84.33%), only 34 of these (40.96%) being with radical intent.

CONCLUSIONS

Treatment for stenosing rectal cancer is multimodal,represented by surgical approach, radio- and chemotherapy. The rationality behind surgery as a first therapeutic gesture in the given study group was represented by the need to treat occlusive type complications, patients benefitting subsequently from radio- and chemotherapy. The opportunity of a second surgical intervention, with the objective to remove the tumour, was established based on the therapeutic response to radio- and chemotherapy.

Choleperitoneum due to intrahepatic bile duct rupture - case report

Non-traumatic perforations of the bile ducts are unfrequently encountered entities, all the more when they affect the intrahepatic bile ducts, exteriorizing their biliary content in the great peritoneal cavity. Reporting such a case has determined the authors to perform a careful overview of the cases present in the literature. An observation that can be made based on these is that the obstruction of the main bile duct due to lithiasis determines, by pressure increase, the dilation of the bile system branches, all on the background of an unknown malformation of the intrahepatic bile ducts.

Intestinal obstruction management in patients with advanced abdominal neoplasia

BACKGROUND

The present study describes the difficulties encountered in the diagnostic process and treatment of intestinal obstruction developed by patients with advanced abdominal neoplasia.

METHODS

This unicentric and retrospective study evaluates patients suffering from intestinal occlusion operated on at the First Surgical Clinic of the Oncology Institute in Bucharest, over a period of 4 years (2010 - 2013). Of these, 61 cases in which the occlusion occurred on the background of an advanced abdominal neoplasia were selected. We considered as advanced those cases of abdominal cancer where curative oncologic treatment is no longer possible due to the evolution stage.

RESULTS

The random selection of the study period, the introduction of all the patients identified with this type of pathology, as well as the concentration of advanced abdominal neoplasia at the Oncology Institute in Bucharest are the elements that allow us to state that the results of this study are representative. Particularities related to the clinical aspects of the intestinal occlusion in these patients, as well as difficulties in establishing the correct diagnosis were encountered.Surgical cure of the occlusion, with palliative aim of course,was possible in only 47 cases (representing 77.05%).

CONCLUSIONS

A standard treatment course cannot be devised for this type of patients. Palliative care, indispensable in cases of advanced neoplastic disease, remains the sole therapeutic method available for patients with no surgical cure for the obstruction. The main objective, for the entire study lot, was to ensure an as high as possible quality of life,a factor we must bear in mind as often as possible when choosing a surgical solution. Of course, when surgical treatment can be applied, overcoming the occlusive episode prolongs these patients' life and can even allow for other courses of complementary treatment to be undertaken.

Multiple polyps and colorectal cancer

INTRODUCTION

Malignant degeneration as a possible course of evolution of colorectal polyps renders their diagnosis and therapeutic management a prophylactic act in the prevention of colorectal cancer (CRC).

MATERIAL AND METHOD

The study was conducted over a period of 3 years (2008-2011), during which 1,368 colonoscopies were performed in our service. The aim of the study was to identify patients presenting multiple colorectal polyps and to determine their risk factors for developing CRC, as well as to establish the appropriate therapeutic conduct.

RESULTS

Presence of multiple polyps was recorded in over 40% of the patients identified with colorectal polyps of any kind. Dysplastic modifications observed during the histopathology exam presented a high incidence in the case of patients with multiple polyps, ranging from low-grade dysplasia to incipient CRC.

CONCLUSIONS

Dysplastic modifications and carcinomatous foci were identified mostly among patients with multiple polyps.Only benign lesions or in situ carcinomas benefited from endoscopic treatment, poorly differentiated carcinomas or those invading the submucosa being treated by conventional surgery. Patients diagnosed with colorectal polyps require a rigorous post-therapy follow-up protocol, able to identify any eventual polyposis recurrence.

Double suturless hepaticojejunostomy

In iatrogenic lesions of the main bile duct, especially when the injury is above the level of the hepatic bifurcation, the surgeon ought to use two short and thin biliary stumps. It is necessary to perform separate anastomoses, using a "Y loop" and creating a double hepaticojejunostomy. Technical difficulties increase when the biliary ducts are thinner, tighter and separated from one another for a distance more than 2 cm. In such case we have attempted to develop a double sutureless hepaticojejunostomy by simply keeping the bilioenteric partners in apposition with continuous traction exerted via the biliary stents.

Juxtapapillary duodenal diverticula early and late clinical and therapeutical implications

The aim of this paper is to identify the early and late implications of JPDD for biliary pathology, as well as for endoscopic therapy and classical surgery dealing mainly with lithiasis. This paper is based on a retrospective study comprising a number of 675 ERCP performed on 601 patients between 1997-2007, out of which 399 cases were followed by therapeutic measures. A total of 79 procedures were performed on 65 cases with JPDD. The main criteria were: gender, age, indications regarding the performance of ERCP+/-ES, complications that occurred while carrying out these procedures. In all the cases examined (601) the percentage of JPDD reported was of 10.81%. The rate of complications in the sphincterotomized patients without JPDD was 5.75% and the rate in the sphincterotomized patients with JPDD was 14.89%. In conclusion, the paper discusses the clinical and therapeutic implications of JPDD in biliary pathology. It has been found that JPDD is an important etiological cause for the late diseases occurring after cholelithiasis surgery. JPDD also leads to immediate therapeutic implications such as: difficult cannulation and high incidence of ERCP+/-ES complications.

Serological levels of apoptotic bodies, sFAS and TNF in lupus erythematosus

In our study we have investigated the presence of apoptotic bodies, soluble FAS receptor and TNF (tumor necrosis factor) in three clinical forms of lupus erythematosus. Determinations were performed in attack period of: systemic lupus erythematosus (SLE) for 20 patients, 20 patients with subacute cutaneous lupus erythematosus (SCLE), 20 patients with chronic discoid lupus erythematosus (DLE). Determinations were performed by ELISA (for apoptotic bodies, kit Boehringer, normal values 400-800 mU), (for sFAS, kit R&D Systems, normal values 4500-17000 pg/ml) (for TNF, ELISA kit R&D Systems, normal values 0.4-3.6 pg/ml). Results in SLE: apoptotic bodies were increased in 16 cases (980-1030); sFAS in 18 cases (17000-24000 pg/ml) TNF was increased in all 20 cases (40-140 pg/ml). In SCLE with multiple cutaneous lesions and without internal organs disturbance the apoptotic bodies were increased in 10 cases (960-1030 pg/ml), sFAS in 9 cases (17000-22000 pg/ml), and TNF alpha in 9 cases. In DLE, apoptotic bodies were increased in 2 patients (980-1010 pg/ml), sFAS in 3 patients (17000-20000 pg/ml) and TNF in 2 patients (20-40 pg/mil). Investigated values were slightly correlated with immune parameters (anti dsDNA antibodies), but they were correlated with the presence of renal disturbances or extension of cutaneous lesions. We consider that the presence of increased apoptotic bodies as a result of peripheral mononuclear cells apoptosis appear as a nauto-limiting mechanism in a pathological immune response. The increase of sFAS in lupus patients serum might be interpreted as an alteration of apoptosis respectively a deficit in apoptosis which has as a first consequence the persistence of B and T lymphocytes, activated, in the pathogen immune response.

High levels of sFas and PBMC apoptosis before and after excision of malignant melanoma--case report

In our study we investigated the level of apoptosis in PBMCs and the serological level of sFas (CD95/APO-1) in 22 patients with malignant melanoma (12 patients with unique cutaneous primary tumour and 10 patients with unique brain metastasis). The first determination was performed before tumour excision and the second at 6-7 months after excision. Results in patients with primary tumour in the first determination: 6 patients with over normal values in PBMCs apoptosis and 5 patients with increased values of sFas. In the second determination: apoptosis was increased in 5 patients and sFas level was increased in 4 cases. In patients with metastases in the first determination apoptosis of PBMC was increased in 7 cases and sFas in 5 cases. In the second determination apoptosis was increased in 4 cases and sFas was increased in 4 cases. Our results show that half of the investigated patients presented elevated values of PBMCs apoptosis and Fas receptor both before and 6-7 months after tumour excision. Apoptosis values for PBMCs and sFas values were with 1/4 higher than normals. There was no difference in clinical evolution of the patients with normal or increased values for studied parameters. Clinical evolution was performed for 1 year. The presence of increased values for PBMCs and sFas after tumour excision, primary or metastasis is surprising and hard to explain. It is possible that tumoral evolution induces a disregulation at PBMCs level or other cells level that persists unexpectedly, after tumour excision or apoptotic processes, in a certain level to be independent and anterior to tumour development.

In-vivo rectal dose measurements with diodes to avoid misadministrations during intracavitary high dose rate brachytherapy for carcinoma of the cervix

Our purpose in this paper is to present an in vivo dosimetry program designed both for measuring the rectal dose and for avoiding misadministrations in gynecological intracavitary implants. A device containing an energy compensated diode was specially designed for these measurements. Our calibration procedure as well as the clinical protocol is described. Measurements have been performed for 50 treatments delivered with a Fletcher Suit Delclos applicator. The calculated and in vivo measured values for the "20% reading," i.e., the dose delivered to the diode by the initial 20% of the total dwell time, agreed to within 15%.

ICAM-1, ELAM-1, TNF-alpha and IL-6 in serum and blister liquid of pemphigus vulgaris patients

The levels of ICAM-1, ELAM-1, TNF-alpha and IL-6 were determined in 12 patients with pemphigus vulgaris (PV) both in serum and the blister liquid. As a control, the same parameters were determined in 7 patients with herpes zoster (HZ). The patients with PV presented significantly higher values of ICAM-1 in the blister liquid, as compared to the serum values. The values of TNF-alpha and IL-6 were increased both in serum and the blister liquid. The ELAM-1 values did not show significant differences between serum and the blister liquid. In HZ patients, the blister liquid values did not significantly exceed the serum values both for ICAM-1 and ELAM-1. TNF-alpha and IL-6 presented high values both in serum and the blister liquid. We consider that the high values of ICAM-1 in the blister liquid from PV patients suggest the involvement of this adhesion molecule in the PV pathogenic features. The implication of ICAM-1 could be nonspecific and limited, and could possibly represent a reaction to the destruction of the desmosomal bonds within keratinocytes.

Traditional and MLC based dose compensator design for patients with hip prostheses undergoing pelvic radiation therapy

Perturbations in the dose distribution caused by a hip prosthesis when treating pelvic malignancies can result in unacceptable dose inhomogeneities within the target volume. Our results, obtained by in vivo exit dose measurements with diodes, showed a 55% reduction in the dose at the exit dmax of a lateral 15 MV photon beam after passing through a bilateral cobalt-chrome alloy hip prosthesis. Such an inhomogeneous dose distribution may decrease the curability. Solutions such as treatment techniques to avoid the prosthesis are often not the best choice as the dose to the rectum may be unacceptably high. In this work an alternative method of dose compensator is presented. Two types of dose compensators were designed based on a 3-D treatment planning system and CT images of a pelvic phantom containing a hip prosthesis: one was fabricated from a polyethylene-lead slab in the representation of step fringes and placed on a tray in the path of the beam while the other was produced by the use of several fields shaped with a multileaf collimator. The calculation procedures developed by the authors for generating the compensators are described. Results of film measurements performed in a phantom with and without the compensators in place are discussed.

Photodynamic treatment of basal cell carcinoma and squamous cell carcinoma with hypericin

Hypericin displays antiproliferative and cytotoxic effects on tumor cells. This effect depends on photodynamic activation with visible light and oxygen. Hence, we explored its potential use in treating skin cancer. Eight patients with squamous cell carcinoma (SCC) and eleven patients with basal cell carcinoma (BCC) were treated topically with hypericin. After intralesional injection, the hypericin was irradiated with visible light. Patients with SCC were given 40-100 micrograms hypericin intralesionally, 3-5 times per week for 2-4 weeks; patients with BCC 40-200 micrograms hypericin 3-5 times per week for 2-6 weeks. Hypericin displayed selective tumor-targeting: penetration in the surrounding tissues did not induce necrosis or cell loss and even the generation of a new epithelium at the surface of the malignancy was noticed. The effectiveness of the therapy depends on the concentration and total dose of hypericin, the frequency and duration of the therapy; clinical remissions can be expected after 6-8 weeks.

The interleukin-1, interleukin-2, interleukin-6 and tumour necrosis factor alpha serological levels in localised and systemic sclerosis

Serological level of interleukin-1 (IL-1), Interleukin-2 (IL-2), Interleukin-6 (IL-6) and tumour necrosis factor (TNF) alpha was investigated in 26 patients with scleroderma, divided into three lots, by the extension and the progress of the disease. Determinations were performed by ELISA in attack and in remission (after treatment with prednison). Normal values: IL-1 (0-5 pg/ml), IL-2 (0-5 pg/ml), IL-6 (5-15 pg/ml), TNF (0-16 pg/ml). Lot A. Results obtained at the first determination showed that IL-1 is elevated in 4 cases (10-15 pg/ml), IL-2 in 5 cases (10-32 pg/ml), IL-6 in 5 cases (15-42 pg/ml) and TNF in 4 cases (18-34 pg/ml). In the second determination IL-1 was increased in 1 case (8 pg/ml), IL-2 in 1 case (9 pg/ml), IL-6 in 2 cases (12 pg/ml) and TNF was normal. Lot B. In the first determination IL-1 was elevated in 5 cases (8-12 pg/ml), IL-2 in 5 cases (10-15 pg/ml), IL-6 in 7 cases (16-20 pg/ml) and TNF was raised in 3 cases (18-25 pg/ml). At the second determination IL-1 showed normal values in all the cases, IL-2 was raised in 2 cases (10 pg/ml), IL-6 in 2 cases (12.15 pg/ml), TNF in 1 case (20 pg/ml). Lot C. In the first determination there were raised values in 4 cases for IL-1 (6-8 pg/ml), 3 cases for IL-2 (10-18 pg/ml), 5 cases for IL-6 (18-20 pg/ml), 2 cases for TNF (20 pg/ml). At the second determination IL-2 was elevated in 1 case (10 pg/ml), IL-6 in 1 case (15 pg/ml). We consider that in scleroderma there is a disturbance of the investigated cytokines due to the activation and involvement of the secretory cells into the pathogenesis of the disease. The increase of the serological levels of IL-1, IL-2, IL-6 and TNF depends on the extension of the lesions and the clinical and biological activity periods of the disease. The absence of the increase of the serological levels does not exclude their activity at the lesional site.

A method to improve the effectiveness of diode in vivo dosimetry

A routine diode in vivo dosimetry program based on a combination of entrance and exit dose measurements was clinically implemented in the radiation oncology department of Grace Hospital, Detroit, in January 1995. The delivered dose has been monitored by taking weekly measurements. The calibration of the diodes and the in vivo dosimetry protocol for this new, more effective type of dose verification is presented. The problems encountered within the program are discussed along with our solutions.

Dose perturbations due to in vivo dosimetry with diodes

In vivo dosimetry performed with semiconductor detectors is a reliable method for patient dose control. The purpose of this study is to evaluate the perturbations introduced in the patient's absorbed dose distribution by three types of commercially available diodes (Isorad, Sun Nuclear Corp.; model 114200, 114300 and 114400) from the same company and to present possible solutions for minimizing this side-effect.

Serological level of ICAM and ELAM adhesion molecules in allergic vascularitis

A 24-patient lot with hypersensitivity vasculitis was investigated for serological determinations of ICAM and ELAM adhesion molecules. Determinations were made in attack and in remission. Over two thirds of the cases presented elevated serological levels of ICAM and ELAM in attack, with twofold higher values than normal. In remission, in the absence of clinical signs, ICAM and ELAM values were normal in 19 cases (ICAM) and 22 cases (ELAM). Serological level of ICAM and ELAM was concordant with serological level of IL-2, IL-6, circulating immune complexes and clinical status. The increased values of ICAM and ELAM are due to the expression of these molecules both on the surface of endothelial cells and on immune cells. The adherence of leukocytes on the endothelial cells, by adhesion molecules involvement, followed by their extravasation represents an important event in the vascular lesion pathogeny of the hypersensitivity vasculitis.

Tumoral infiltrate after local treatment with interferon in squamous cell carcinoma

Using monoclonal antibodies UCHL-1 (T lymphocytes), MT-1 (pan T) and L-26 (B lymphocytes) in the study of the tumoral infiltrate after local treatment with alpha interferon (Roferon) in patients with squamous cell carcinoma of the lower lip, it was observed that: the proportion of UCHL-1 positive cells was between 30% and 80%, the proportion of MT-1 positive cells was of 85% and that of the L-26 positive cells was of 30% of all the cells in the infiltrate. In the area in which after treatment with interferon the tumoral structures had disappeared, the proportion of T lymphocytes was smaller than in the areas in which the tumoral structures were still present. The therapeutic effect of interferon is due both to the direct effects on the tumoral cell and also to the indirect effects, namely the activation of the cytotoxic T lymphocytes and of other cells in the tumoral infiltrate.

Highly active effect of alpha interferon in blocking the cutaneous delayed hypersensitivity

A group of 13 patients with contact dermatitis to various chemical compounds such as potassium dichromate, nickel sulphate, formaldehyde and balsam of Peru, was investigated by patch test and by the agreement between the history of disease and the patch test, the specific allergen involved in each special case could be demonstrated. Two-three days after the first patch test three normal skin areas were chosen. The first area was intradermally infiltrated with alpha-2a Interferon (IFN) (100,000 I.U. in 1 ml), the second area was infiltrated with saline and the third area, considered as control, did not receive any treatment. Once more the corresponding allergen was applied into the skin in a second patch-test. After 48 hours in the IFN infiltrated area, only the delayed contact hypersensitivity become negative thus proving that alpha-2a IFN behaves as an efficient inhibitor of these immune effector reactions. Since the lymphocytes involved in the delayed type hypersensitivity reactions (in our case contact dermatitis) belong to the T helper line, i.e., are CD-4 positive cells we conclude that alpha-2a IFN in vivo is an efficient inhibitor of the activation of these cells. This effect achieved by any CD-4(+) DTH clones does not depend on their antigenic specificity. Some clinical trials are now in progress in our laboratory to turn to account this important biological effect in the clinical practice as an efficient inhibitor in skin contact dermatitis.

Therapeutic effect of intralesional interferon (Roferon) in squamous cell carcinoma

Recombinant alpha-2 interferon (IFN)--Roferon--100,000 IU/ml was intralesionally administered in 8 cases of squamous cell carcinoma (SCC) three times a week during 4-6 weeks in inoculations of 1 ml each. The therapeutic effect was scored as major--more than 60% reduction of the tumor size, moderate--30-60% reduction of the tumor mass and, nonreactive--less than 30% reduction of the tumor size. Three cases showed a major reduction, three showed a moderate reduction and two patients showed no reduction of the tumor volume. Histopathological examination of the surgically removed tumors after completion of the Roferon administration confirmed the clinical diagnosis of squamous cell carcinoma and revealed that an intense leukocyte, mainly lymphocytes, infiltration can be observed along with necrotic centers, progressively surrounding and reducing in size the tumor islets, thus proving an intense activation of the immune effector reactions against tumor cells.

Intralesional human leukocyte interferon treatment alone or associated with IL-2 in non-AIDS related Kaposi's sarcoma

Patients with classical European Kaposi's sarcoma were treated by intra- and peritumoral injections of human alpha leukocyte interferon (IFN) (12 cases) or, alternatively, with IFN and naturally synthesized IL-2 (8 cases). All the patients were HIV negative with tumors which had been present for at least six months. In each patient, one tumor received 1 ml (50,000 IU) IFN alone or alternatively associated with 1 ml IL-2 twice a week for 4-6 weeks; another nodule situated 10-12 cm away was considered as a control and remained uninjected. The clinical follow-up revealed that, in the same patient in the same anatomical area, the treated nodule was cured in all the investigated cases; the untreated one was not. These data strongly suggest that IFN is the factor responsible for the involution and final cure of these Kaposi tumors treated by perilesional inoculations. Association with IL-2 (and certainly also other interleukins) increases the beneficial clinical activation of the tumor involution. Histological examination showed that important histopathological changes occur in the treated nodules: complete disappearance of the Kaposi's aspect, fibrosclerous modifications progressively replacing the fibroblasts characteristic of Kaposi's sarcoma, abundant infiltrations of leukocytes, especially lymphocytes and necrotic patches, often with hemorrhagic centers. IL-2 association seems to especially induce this last type of histological phenomenon.

Human leukocyte interferon treatment associated with IL-2 in the non-AIDS related Kaposi's sarcoma

Patients with classical European Kaposi's sarcoma have been treated by intra- and peritumoral injections of human alpha-leukocyte interferon (IFN) (12 cases) or alternatively with IFN and naturally synthetized IL-2 (8 cases). All the patients were HIV negative their tumour appearing at least six months before. In each patient one tumour received 1 ml (50,000 IU) IFM alone or associated, alternatively with 1 ml IL-2, twice a week during 4-6 weeks, whereas another nodule situated 8-10 cm apart was considered as control and remained uninjected. The clinical follow-up revealed that in the same patient in the same anatomical area the treated nodule was cured in all the investigated cases while the untreated nodule was not. These data undoubtedly prove that IFN is the responsible factor for the involution and final cure of the Kaposi tumours treated by perilesional inoculations. Association with IL-2 (and certainly also other interleukins) increases the beneficial clinical effect activating the tumour involution. The histological examination showed that important histopathological changes occur in the treated nodules, i.e., complete disappearance of the Kaposi's aspect; fibrosclerous modifications progressively replacing the abundant fibroblastic cells characteristic of Kaposi's tumour; abundant infiltrations of leukocytes especially lymphocytes; necrotic patches often appearing along with hemorrhagic centers. IL-2 association seems to frequently induce especially this last type of histological phenomena.

Intralesional human leukocyte interferon treatment in the non-AIDS related Kaposi's sarcoma

Twelve patients with classical European Kaposi's sarcoma have been treated by intra- and peritumoral injections of human alpha leukocyte interferon (IFN)--Ginterferon ("V. Babeş Institute", Bucharest). All the patients were HIV negative their tumour appearing at least six months before. In each patient one tumour received 1 ml (50,000 IU) IFN twice a week during 6-7 weeks whereas another nodule considered as control remained uninjected. After treatment biopsies of both the IFN-treated and the untreated nodules were performed in 8 patients and histological examinations were carried out. The clinical follow-up revealed: The skin colour progressively changed from purple red to dark reddish or even brown in all the IFN-treated tumours and only in 3 of the untreated ones (p less than 0.001). The consistency of the nodules decreased in all the treated tumours and only in 2 of the untreated ones (p less than 0.001). The tumour thickness decreased in 9 of the treated tumours and in none of the untreated ones (p less than 0.001). The surface of the lesions decreased in 4 of the treated nodules but not in the untreated ones (p less than 0.05). The IFN-inoculated tumours were gradually cured even in the four cases in which during the treatment some other tumour progressed or even new lesions appeared. The histological examination showed that: all the IFN-treated tumours were either predominantly sarcomatous or predominantly angiomatous. The typical Kaposi aspect disappeared totally in 2 of the cases examined, and in 3 a fibrosclerotic massive change was obvious.(ABSTRACT TRUNCATED AT 250 WORDS)

Interferon efficiency in the treatment of herpetic dermatites. II. Comparison between human leukocyte interferon (Ginterferon) and a recombinant interferon (Roferon)

The comparative efficiency of a recombinant interferon-Roferon (R-IFN) and a human, naturally synthetized interferon-Ginterferon (G-IFN), applied as ointments in the treatment of herpetic dermatites, was studied in a blind trial. It was found that R-IFN in doses of 20,000 IU/g has practically similar results as G-IFN in doses of 10,000 IU/g therefore half the dose of the former product. Thus both preparations reduced significantly the mean duration of a herpetic dermatitis attack and both proved more efficient on smaller lesions (less than 2 sq.cm) than on larger ones (over 2 sq.cm). Likewise with both preparations the reduction of the healing period was more marked when administered in the first 2-3 days after onset. It was also found that the arrest of new vesicle appearance after two days of treatment is a reliable clinical criterion for the estimation of IFN capacity to block effectively viral multiplication in the host's epithelial cells. Finally the efficacy of both R-IFN and G-IFN proved similar whatever the localization of disease (oral or genital) or in their capacity to prevent relapses or the appearance of bacterial complications.

Interferon efficiency in the treatment of herpetic dermatites. I. A double-blind placebo controlled study

The effect of an alpha human leukocyte interferon (IFN) locally applied as an ointment in herpetic dermatitis was investigated in a double blind trial. It was observed that IFN reduced significantly by 25-42% the mean healing period of attacks. This reduction was more important if the period till disappearance of vesicles was considered than if the period till complete epithelialization was taken into consideration. Likewise IFN was proved more effective if administered within the first 2-3 days after onset of attacks than 5 days after. As compared with the group which received placebo the effect of IFN was more marked when the size of the lesions was smaller than 2 sq. cm. IFN did not reduce significantly the number of cases with bacterial superinfections nor the rate of relapses in the first three months after treatment. These results suggest that alpha IFN administered as an ointment is an efficient agent in blocking viral multiplication and therefore useful in the treatment of herpetic dermatitides whatever their localization.