Cancer epidemiology in Central, South and Eastern European countries

AIM

To collect cancer epidemiology data in South Eastern European countries as a basis for potential comparison of their performance in cancer care.

METHODS

The South Eastern European Research Oncology Group (SEEROG) collected and analyzed epidemiological data on incidence and mortality that reflect cancer management in 8 countries - Croatia, Czech Republic, Hungary, Romania, Poland, Slovakia, and Serbia and Montenegro in the last 20-40 years.

RESULTS

The most common cancer type in men in all countries was lung cancer, followed by colorectal and prostate cancer, with the exception of the Czech Republic, where prostate cancer and colorectal cancer were more common. The most frequent cancer in women was breast cancer followed by colorectal cancer, with the exceptions of Romania and Central Serbia where cervical cancer was the second most common. Cancer mortality data from the last 20-40 years revealed two different patterns in men. In Romania and in Serbia and Montenegro, there was a trend toward an increase, while in the other countries mortality was declining, after increasing for a number of years. In women, a steady decline was observed over many years in the Czech Republic, Hungary, and Slovakia, while in the other countries it remained unchanged.

CONCLUSIONS

There are striking variations in the risk of different cancers by geographic area. Most of the international variation is due to exposure to known or suspected risk factors which provides a clear challenge to prevention. There are some differences in incidence and mortality that cannot be explained by exposure to known risk factors or treatment availabilities.

[Combined hormono-radiotherapy in treatment of locally advanced prostate cancer]

Numerous questions regarding combined hormono-radiotherapy in the treatment of locally advanced prostate cancer still remain open. We present results of combined treatment in 133 our patients with locally advanced prostate cancer. All patients recieved hormonotherapy as neoadjuvant, concomitant with radiotherapy (tumor dose range 65-72 Gy), and adjuvant. In six months follow-up time, complete regression (CR) was noted in 120 patients (90%), partial regression (PR) in 6 (4.5%), stabile disease (SD) in 2 (1.5%) and progression of disease (PD) in 5 patients (4%). In mean follow up time of 17 months (6-77), 13 patients relapsed. Five-year time to progression was 70%. Five-year disease-free interval for CR patients was 70%. At the date of last control CR was noted in 116 patients (87%), PR in 2 patients (2%), SD in 7 patients (5%), and 8 patients (6%) had progressive disease. Second malignancy was noted in 4 patients. Multidisciplinary studies directed towards the optimisation of combined treatment are ongoing. There are no definitive conclusions.

[Postoperative radiotherapy of cervival carcinoma: treatment results and analysis of prognostic factors]

The purpose of the study was to evaluate the efficacy of postoperative radiotherapy (RT) and to investigate prognostic factors for early-stage cervical cancer patients. We reviewed the medical records of 162 cervical cancer patients treated by RT during 2003 year. RT included 30-45 Gy of external photons to pelvis in 12-25 fractions. Brachytherapy with 192Ir was delivered in 3-5 fractions to a dose of 27-32 Gy. The mean age was 49 years (range 27-71). Majority of patients 130 had Stage Ib. Radical hysterectomy with lymphadenectomy was performed in 122 pts. and simple hysterectomy in 40 pts. The 5-year actuarial overall survival (OS) for all patients was 92.6% and disease-free survival (DFS) was 90.9%.There was statistically significant differences in OS and DFS in pat. with positive vs. negative pelvic lymph nodes; tumor 4 cm vs. tumor < or = 4 cm; positive vs. negative surgical margin/residual tumor (p < 0.05). Late GIT complications were determined in 35.8% and UT in 12.3%. In conclusion, postoperative radiotherapy has achieved high-satisfactory survival with acceptable complications. The survival benefit was less evident among patients with positive lymph nodes, tumor > 4 cm and positive surgical margin/residual tumor.

[Implementation of 3D- CT based brachytherapy in the postoperative radiotherapy of cervical cancer: treatment technique and dose-volume parameters]

Intracavitary brachytherapy has an important roll in developing complications in postoperative radiotherapy of cervical cancer. 3D- CT based brachytherapy gives precisely estimating doses to organ at risk. In this study, we show our preliminary results in implementation of 3D-imaging based postoperative brachytherapy of cervical cancer: treatment technique and dose-volume parameters. During 2009 year, in 6 patients with early stage I-II of cervical cancer, brachytherapy treatment planning was based on the radiographs and CT imaging brachytherapy technique. Mean values of ICRU reference points of rectum was R max 4,2 Gy and bladder B max 4,5 Gy, while estimated volume-dose parameters D0.1 cm3 D1.0 cm D2.0 cm3 were presented with higher dose.Volume of organ at risk reflected the need for better bladder preparation. Our initial experience in performing CT-based brachytherapy, enabled us to introduce the characteristics of the parameters, assessment of their significance from the aspect of mutual relations applicators and organs at risk. Further analysis are needed, for monitoring the effects of 3D planning on complications.

[Diagnosis of breast cancer in women age 40 and younger: mammography and breast ultrasound]

Breast cancer is the leading cause of mortality among women aged 25 to 44 years in Serbia. The purpose of this study was to determine basic clinical and radiological features of breast cancer in young women. 93 women aged 31.0 +/- 3.5 years with breast cancer were identified. The analysis included clinical characteristics (TNM classification) and radiological features (mammography and breast ultrasound). 53.8% of the patients had locoregional disease. The mean diameter of breast cancer was 2.6 +/- 6 cm. Carcinoma in situ was found in 2.2%. Mammography was performed in 25.8% of the patients and breast ultrasound in 68.8%. The results of our study indicate that the diagnosis of breast cancer in young women is late, in the stage with palpable breast tumor and lymph node metastases. Mammography or breast ultrasound are not routinely used. The implementation of algorithms for breast cancer detection and diagnosis in young women helps in earlier detection of breast cancer and consequently improves outcomes.

[Mammography in detection clinically occult breast carcinoma]

AIM

The significance of mammography in detection of nonpalpable breast cancer

MATERIAL AND METHODS

This prospective study was conducted at the Institute for oncology and radiology of Serbia in Belgrade. It involved 198 asymptomatic women with performed screening mammography, 154 specimen mammography, out of wich 38 had stereotaxic mark, "ex tempore" biopsy, while 44 women had "ex tempore" biopsy and adequate surgery.

RESULTS

Screening mammography revealed suspect microcalcifications in 148 cases, impaired structural tissue in 59 and focal condensation in 55 cases. Histologic examination verified breast carcinoma in 80 patients with very statistical significance of ductal type, especially comedo subvariant (p < 0.001). Pleomorphic microcalcifications smaller than 0.5 mm of grouped or segmented form are statistically very significant for malignity (p < 0.001) as well as associated microcalcifications with altered architectony and focal tissue condensation (p < 0.001).

CONCLUSION

Mammography has great significance in detection of occult breast carcinoma which are not only preinvasive, but olso microinvasive and invasive. This fact leads to the neccesity of introduction of legal obligation for mammography screening, especially for women aged between 50 and 70 years.

Effects of X-ray irradiation on the overexpression of HER-2/Erb-B2 on breast cancer cell lines

Irradiation is the conventional treatment modality for cancer patients. However, besides its cytotoxic effects on malignant cells it might also affect the biology of surviving cells. Since overexpression of HER-2 receptors on malignant cells is a prerequisite for the therapeutic efficacy of Herceptin, it seems important to know whether previous irradiation changes their overexpression. The experiments performed in this work were aimed to determine whether X-ray irradiation of MDA-MB-361 and MDA-MB-453 breast carcinoma cell lines, besides its cytotoxic action, affects the overexpression of HER-2 protein. Determination of the cytotoxic effect of X-ray irradiation was done using trypan blue test. The breast carcinoma cell responsiveness to herceptin treatment in the presence of 10% fresh human serum (from healthy volunteer's) in the presence or absence of 25 microg/ml of herceptin, in vitro before and after cell-irradiation, was evaluated by MTT test. The degree of HER-2 overexpression was determined by immunocytochemistry, using DAKO HercepTest. Preliminary results obtained in this work showed that X-ray irradiation, besides its cytotoxic effect on malignant cells, could lead to overexpression of HER-2 receptors on (initially by immunocytochemistry, HER-2 negative) tumor cells, indicating change in biology of treated tumor cells. Further investigation in this direction will probably be helpful to elucidate this task in order to improve the selection of irradiated patients for Herceptin therapy.

[Radiotherapy in malignant tumors of the thyroid gland]

The primary treatment of thyroid gland malignoma is surgery. Success of radiotherapy depends of extent of the previous surgery treatment. The types of radiotherapy are: curative (prophylactic and postoperative) and palliative. Tumor dose and radiotherapy tehnique depend on histologica type, extent of the previous surgery treatment, curative or paliative intent and general condition of patient, and they are from 40 Gy to 65 Gy by conventional fractionation. The basis of radiotherapy treatment planning and choice of radiotherapy treatment technique in survey of the region of interest by imaging procedure. On the basis of those data we determine therapeutic volume and structure of risk (spinal cord, lung) and protection of the risky structures is planned.

Medularni karcinom stitaste zlezde-uticaj postoperativne transkutane zracne terapije u lokalnoj kontroli i rezultatima lecenja

In the period of Octo. 01, 1987. up to Dec. 31, 1998. retrospective-prospective, non-randomized study was conducted at IORS, which included 36 patients diagnosed with thyroid gland medullar cancer. Our study had the following aims: evaluation of treatment results following probability of total survival, survival without signs of disease and disease-free interval until local reccurrence of the disease and influence of parameters of transcutaneous radiotherapy (intensity of total tumor dose and length of disease-free interval from date of performed operation to beginning of radiotherapy). After finished treatment, median of the patient follow-up was 37,75 months (3,5 up to 141 monts); probability of total five-year survival was 62,61% and of 10 year survival was 23,48%. Probability of 5-year survival, without signs of disease was 37,13%, and of 10-year survival 18,56%. As to radiotherapy parameters, intensity of total therapy dose was statisticaly insignificant, while time interval to beginning of transcutaneuos radiotherapy, shorter than 2 months, was statistically significant in relation to prognosis of disease outcome.

[Role of postoperative radiotherapy in the treatment of early breast carcinoma]

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Combined chemoradiotherapy in the treatment of locally advanced non-small cell lung cancer

PURPOSE

To evaluate prospectively the combination of radiotherapy with low doses of carboplatin given as radiosensitizer in patients with locally advanced non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients enrolled in this trial were randomly allocated in two groups. The study group consisted of 67 patients with stage IIIA/B NSCLC who were treated initially with a tumor dose (TD) of 30 Gy in 10 fractions, 5 fractions per weeks, in 2 weeks. Carboplatin was administered simultaneously as radiosensitizer at a dose of 20 mg/m(2) i.v. bolus just prior to each radiotherapy fraction. After a 2-week rest an additional 25 Gy were given in 10 fractions, with carboplatin as previously described. The total tumor dose (TTD) was 55 Gy (30+25 Gy) in 20 fractions in 6 weeks and the total dose of carboplatin was 600 mg. The study group was compared with a control group of 70 NSCLC patients who were treated with radical conventional radiotherapy (60 Gy in 30 fractions, 2 Gy per fraction, 5 fractions per week).

RESULTS

Haematological toxicity and oesophagitis were statistically more often seen in the study group. There was no statistically significant difference in the response rate between the 2 groups (53.7% versus 62.8%). The 2-year survival was 27% in the study group and 33% in the control group (p >0.05).

CONCLUSION

The results showed no response and survival benefit of concomitant chemoradiotherapy compared with conventional radiotherapy. We believe that further prospective, multicenter trials are required to evaluate the concurrent combination of new cytotoxic agents used as radiosensitizers with conventional radiotherapy or radiotherapy with different fractionation schedules and high-technology equipment which enables the application of higher tumor doses.

[Radiotherapy of locally advanced breast carcinoma in elderly female patients]

INTRODUCTION

Breast cancer is the most frequent cancer in elderly patients (over 65 years). The recent data indicate that in women aged over 72 years the incidence of breast cancer is twice greater than in women aged 45 years. As more and more women are getting older, the total incidence of breast cancer can be expected to increase. The treatment of these patients is complicated by many other diseases including cardiovascular and pulmonary disorders associated with aging, and because chemotherapy and radical surgery are often contraindicated.

MATERIAL AND METHODS

In an one year period in the Institute of Oncology and Radiology of Serbia a group of 53 elderly (65 years and more) patients with locally advanced breast cancer were treated. Twenty four patients (group A) were treated with hypofractionated (concentrated) radiotherapy. The irradiation was delivered to the breast with TD24-26 Gy with two tangentional portals and 19 Gy to regional lymphatics with anterior fields owner 8 fractions, breast and lymphatics alternatively. The same treatment plan was repeated after 28 days (split course). Co60 was used. Twenty nine patients (group B) were treated with conventional fractionated radiotherapy. Irradiation was delivered to the breast with 51 Gy tumour dose in 16 fractions and to the lymphatics with 45 Gy in 15 fractions. Breast and lymphatics were irradiated alternatively, during 31 working days. After 51 Gy the whole breast was boosted with 20 Gy tumour dose and axilla with TD 12 Gy. The concentrated radiotherapy is, in fact, an alternative for radical--conventional or protracted radiotherapy according to the so-called hypofractionated split course technique. Both techniques have very similar TDF factors. The aim of such a plan is the achievement of adequate tumour dose adapted to the age of patients (the patients should be treated in a smaller number of fractions). All patients were aged 65 years or were older. The median age in group A was 72 years and in group B 68 years. Also in all patients breast cancer was locally advanced (stadium III). In group A median follow-up was 29.79 months and in group B 23.62 months.

RESULTS

All patients had acute skin reactions. In group A (irradiated with concentrated technique) 91.7% of patients had erythema, 8.3% dry desquamation, but moist desquamation was not observed. In group B (irradiated with conventional technique) 27.6% of patients had erythema, 55.2% dry desquamation and 17.2% moist desquamation. Delayed radiation changes manifested as fibrosis of the breast and region of axilla were noted in 29.24% of patients in group A and 13.8% in group B. The relapse in group A was 41.7% with median relapse free interval of 13.9 months and in group B 48.2% with relapse free interval of 15.6 months. There was no significant statistical difference between the two groups according to standard statistical methods (chi 2 = 0.96; DF = 3; p > 0.05). After approximately 30 months of follow-up, 50% of patients in group A are alive without signs of disease; 16.7% are alive with disease, and 16.7% are dead due to primary disease. In group B 24.1% of patients are alive without signs of disease; 24.1% are alive with disease; and 20.7% are dead due to primary disease. There was no significant statistical difference between the two groups (chi 2 = 4.09; DF = 4; p > 0.05). The overall survival rate in group A was 67% after 4 years and 53% in group B. Relapse free survival was 53% in group A after 4 years and 36% in group B. In conclusion, according to our study there was no statistically significant difference in local control between conventional and hypofractionated radiotherapy in the treatment in elderly patients. The main advantage of concentrated schedule is shortening of duration of irradiation, but the main disadvantage is a high incidence of fibrosis which makes difficult the evaluation of local control. Consensus about treatment of breast cancer in elderly women has not yet been clearly established. Our data suggest that hypofractionated schedule is an effective, suitable and comfortable therapeutic approach in the management of breast cancer in elderly women.

Expression of epidermal growth factor receptor in breast cancer, from early stages to advanced disease

Epidermal growth factor receptor was determined in 106 newly diagnosed breast cancer patients, using the biochemical method. The group consisted of 58 patients in stage I-II, and 48 patients in stage III-IV. Although a significant inverse correlation was found between EGF-R status, and ER or PR status, quantitative content of EGF-R did not correlate either with quantitative ER, or PR levels. The ER/PR content was similar in all clinical stages, suggesting their stability during the clinical course of the disease. EGF-R content was significantly higher in stage IV, compared to stage I, while intermediate clinical stages and all substages did not differ according to the EGF-R content. EGF-R was confirmed as a weak prognostic factor within clinical stages. However, in a whole group, the overall survival was significantly better in patients whose tumors EGF-R content was lower than 26 fmol/mg, compared to those with higher ERF-R content. EGF-R content was highly predictive for the response to systemic endocrine treatment, in metastatic breast cancer patients. In locally advanced breast cancer a trend towards higher levels of EGF-R was found in inflammatory breast cancers, compared to non-inflammatory ones. Slightly higher levels were found in responders to local non-endocrine primary treatments (radiotherapy with or without chemotherapy), compared to non-responders, suggesting the possible predictive role of EGF-R for the response to such treatments. Our results emphasized the usefulness of quantitative receptor determination suggesting the relative stability of EGF-R content during the clinical course of breast cancer, its independence from ER, its significant predictive and weak prognostic values, and a possible correlation with the aggressiveness of the disease, and response to non-endocrine treatments.

[Palliative irradiation in the treatment of breast carcinoma]

It is considered that in 30% of female patients with breast cancer a certain form of evolutive disease occurs within 5 years from documented diagnosis. In these female patients, 58% develop distal metastases. Thus, a great number of these female patients enter the phase when hope for recovery is small. Then supportive therapy is used. It's main task is to alleviate the life of these patients. Palliative radiotherapy is one of the main elements of this therapy. It is directed to decrease the pain, and bleeding, to prevent fractures and decompression of the spinal cord, as well as many other evolution consequences of local or distal disease. The correct and timely definition of indications for radiotherapy, the optimal planning and conduction of the therapy should take into account the patient's characteristics as well as the main postulates on which radiotherapy is based. In this way the satisfying effects on patients with disseminated breast cancer, may be expected.

[Local recurrence after preoperative irradiation and radical surgery in patients with locally advanced breast carcinoma (clinical stage A)]

The rationale preoperative irradiation is expressed by the sound: eradication of sensitive tumour cells at the periphery of a lesion making complete resection more likely and dissemination of tumour cells by operative manipulation less likely. The dose of irradiation required is approximately 80 to 85% of the dose needed to permanently control the palpable disease, a dose which does not interfere with subsequent mastectomy, if 3 to 4 weeks elapse between the termination of irradiation and mastectomy. One hundred fifteen consecutively examined patients with stage IIIa breast cancer were treated over the period from January 1985 to December 1987 at the Institute of Oncology and Radiology, Belgrade, Serbia. We were interested in the local control of preoperatively irradiated and radically operated patients with the median follow-up of 82 months. Fifteen patients had local recidives, the local control was made in 87%, in the interval between 6 and 66 months (median 18 months). We analyzed the correlation between the local control and the grade of malignancy (GM) of the axillary lymph node and the T status of the tumour. GM was more important than T. Based on our results and on those of other authors, we believe that this multimodal regimen, which includes preoperative irradiation, radical mastectomy and adjuvant cheme-hormonotherapy, is satisfactory for patients with stage IIIa primary breast cancer.

[Results of combination therapy of inflammatory carcinoma of the breast]

Mastitis carcinomatosa or inflammatory breast cancer (IBC) is a very rare form of breast cancer with aggressive progression, as well as rapid dissemination. Though this disease has been for a long time in focus of interest of clinicians, the problem of its treatment is still unsolved. In the Belgrade Institute of Oncology and Radiology IBC has been already treated with combination of chemotherapy and radiotherapy, and results of such treatment are evaluated and presented in this paper. Taking into account results of the above mentioned treatment as well as that reported in literature, we decided to make its modification. Irradiation was carried out by hyperfractionation, preceded and followed by chemotherapy. Hyper-fractionated regime was assessed using LQ model for determination of radiobiological efficiency. The obtained results showed only a percentual, but not statistically significant improvement. The presented treatment was only an attempt after which it could be concluded that the oncologist today, no matter whatsoever he was trying in the treatment of IBC, could not expect extraordinary results, but must be satisfied with the fact that he has given his best help. Nevertheless, we find our attempt valuable since it gives new opportunities for non-conventional radiotherapeutic treatment, as well as new perspectives in the treatment of IBC, but always in combination with systemic therapy.

[Current diagnosis of classic mastitis carcinomatosa]

Mastitis carcinomatosa (inflammatory carcinoma) is a very rare form of breast cancer, with a rapid progress, generalisation and dissemination into the vital organs, and lethal issue. Inflammatory carcinoma of the breast (ICB) accounts for 1 to 4 per cent of all breast carcinomas. Only 3 to 6 per cent of patients survive for 5 years, and a great number of patients die within 1 to 2 years, with disseminated metastases. Undefined diagnostical criteria of the desease are responsible of undefined therapeutical procedures. There are still contra-many diction which are well documented in the literature. In this paper we tried to give our contribution to the solution of some of these problems. Today it is clear that tumour embolism in dermal lymphatics of the involved breast skin is a pathohistologic basis of this fatal desease. Accordingly consequences are visible in all clinical signs, which have a very poor prognosis. There is a very large group of local advanced breast carcinomas that are similar to the ICB, but that are not really ICB. In fact, although all these malignant deseases are very similar, their differentiation is very important esspecialy because of their evaluation. A great number of other benignant deseases have very similar signs. Therefore ICB is a interdisciplinary problem.