Onkologija
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Sarkomi: klinična pot
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First treatment is crucial in the management of sarcoma patients, therefore it is essential to refer these patients to sarcoma centre. Diagnostic procedures and treatment have to proceed in sarcoma centre. First resection of the tumor has to be performed by a sarcoma surgeon. Institute of Oncology Ljubljana is the only referral centre for soft tissue sarcoma patients and Department of Orthopaedic surgery of the Ljubljana University Medical Centre is the only referral centre for bone sarcoma patients in Slovenia. In the absence of a diagnosis of malignant disease, rapidly growing and/or painfull tumors, all tumors deep to fascia and superficial tumors larger than 5 cm are suspicious for soft tissue sarcoma of the trunk and limbs; in retroperitoneum, tumors containing fat are suspicious for sarcoma. Patients with the tumor suspicious for soft tissue sarcoma or proven sarcoma schould be referred to the Institute of Oncology Ljubljana. Patients with the radiologic bone laesion suspicious for bone sarcoma schould be referred to the Department of Orthopaedic surgery of the Ljubljana University Medical Centre.Izvleček
Za uspeh zdravljenja bolnikov s sarkomi je odločilnega pomena prvo zdravljenje, zato naj tumor ostane nedotaknjen. Ključna je napotitev bolnikov v referenčni center za sarkome, kjer naj potekata tako diagnostika kot zdravljenje. Prvo operacijo naj opravi sarkomski kirurg v referenčnem centru. Onkološki inštitut Ljubljana edini izpolnjuje pogoje za referenčni center za sarkome mehkih tkiv v Sloveniji. Ortopedska klinika Ljubljana je ob sodelovanju z Onkološkim inštitutom Ljubljana referenčni center za zdravljenje bolnikov s sarkomi kosti. Ob odsotni diagnozi rakave bolezni so za sarkom mehkih tkiv na trupu in udih sumljivi tumorji, ki hitro rastejo in/ali bolijo, vsi tumorji pod fascijo, ne glede na velikost in povrhnji tumorji, večji od 5 cm, v retroperitoneju pa tumorji, ki vsebujejo maščobo. Bolniki s tumorjem sumljivim za sarkom mehkih tkiv oziroma potrjenim sarkomom bodo imeli najboljše možnosti, če bodo napoteni na Onkološki inštitut v Ljubljano. V primeru radiološko ugotovljene lezije sumljive za primaren maligen tumor kosti pa, če bodo napoteni na Ortopedsko kliniko v Ljubljano
Pojavnost klavstrofobije pri bolnikih v radioterapiji, pri katerih se uporablja fiksacijska maska
Get PDFIntroduction: Radiotherapy is one of the more efficient methods of treating cancer. During preparation for radiation therapy, certain patients are fitted with an immobilization mask. This can cause feelings of anxiety or claustrophobia.Purpose: The aim of the study was to evaluate the portion of radiographers that had met with claustrophobia in patients due to the use of an immobilization mask, as well as to investigate measures for reducing said claustrophobia. Methods: In a cross-sectional survey, a questionnaire as a metric instrument was used. The participants were radiographers who worked with patients with immobilization masks, either during preparation for radiation therapy or during radiation therapy on a linear accelerator. Results and discussion: Results show that 98.4 % of radiographers had met with claustrophobia in patients with an immobilization mask. In 87 %, they had previously been warned about the problems. Having identified signs of anxiety, the most effective measures for their mitigation were: friendly attitude towards patients, understandable explanation of the procedure, mask with larger eye holes and music during the irradiation. Conclusion: Considering that a panic attack in claustrophobic patients can significantly limit their involvement in radiation therapy, it is important to recognize signs of anxiety and use strategies to control it. In clinical practice, it would be useful to introduce various relaxation techniques, also.Uvod: Radioterapija je eden izmed učinkovitejših načinov zdravljenja raka. Postopek zdravljenja pa lahko povzroči občutek tesnobe oziroma klavstrofobijo, kar je posebej izrazito pri bolnikih, pri katerih se uporablja fiksacijska maska. Namen: Ovrednotiti delež radioloških inženirjev, ki so se pri svojem delu v radioterapiji srečali s pojavom klavstrofobije zaradi uporabe fiksacijske maske pri bolnikih, in raziskati uporabljene ukrepe za njeno zmanjšanje. Metode: V presečni raziskavi je bil uporabljen anketni vprašalnik. V raziskavi so sodelovali radiološki inženirji, ki pripravljajo bolnike s fiksacijskimi maskami na obsevanje ali jih obsevajo na obsevalnem aparatu. Rezultati in razprava: Pri uporabi fiksacijske maske se je s klavstrofobijo pri bolnikih srečalo že 98,4 % radioloških inženirjev. V 87 % so bili radiološki inženirji na težave bolnikov vnaprej opozorjeni. Ob ugotovljenih znakih anksioznosti so bili najbolj učinkoviti ukrepi za ublažitev prijazen odnos do bolnikov, razumljiva razlaga postopka, razširjena odprtina za oči v maski in predvajanje glasbe med obsevanjem.Zaključek: Glede na to, da panični napad pri klavstrofobičnih bolnikih lahko pomembno omeji njihovo sodelovanje pri zdravljenju z obsevanjem, sta pomembna prepoznavanje znakov anksioznosti ter uporaba primernih strategij za njihovo obvladovanje. V klinično prakso bi bilo smiselno vpeljati tudi različne tehnike sproščanja
Možnosti deintenzifikacije zdravljenja HPV pozitivnih ploščatoceličnih karcinomov orofarinksa
Get PDFUntil recently, the major risk factors for development of oropharyngeal squamous cell carcinoma were smoking and alcohol consumption. Prognosis of these patients is poor, thus intensive and often multimodal approach to treatment is warranted if cure is to be hoped for. However, side effects of such treatment are serious. In recent years, there is a steep increase of oropharyngeal cancer, most notably of base of tongue and tonsils, in younger patients who are not heavy smokers or drinkers. In these patients the culprit is infection with high-risk human papillomavirus (HPV). Albeit the response to non-surgical treatment and prognosis are much better in these patients compared to those with non-HPV mediated oropharyngeal cancer, these patients are treated aggressively earlier in their life and will have to live with side effects of such treatment for considerably longer. The legitimate question arises whether we are treating these patients too aggressively. Several strategies to treatment deintensification were proposed and the first results are already available. These confirm that substituting platinum based concomitant chemotherapy in the setting of radical chemoradiotherapy with concomitant cetuximab is equally toxic yet less effective. More promising are the early results of clinical studies utilizing transoral surgical approaches and de-escalation of radiotherapy dose with or without induction chemotherapy used for selection of patients suitable for treatment deintensification. We are still awaiting results of several such studies that could influence the treatment paradigm of these patients. Until then, the treatment of patients with oropharyngeal cancer remains the same regardless of HPV status.Do nedavnega sta bila poglavitna dejavnika tveganja za nastanek ploščatoceličnega karcinoma orofarinksa kajenje in prekomerno uživanje alkohola. Prognoza teh bolnikov je praviloma slaba, zaradi česar je zdravljenje intenzivno in multimodalno, kar edino nudi možnost ozdravitve, a hkrati povzroča resne neželene učinke. V zadnjih letih pa opažamo naraščanje incidence karcinoma orofarinksa, natančneje nebnic in jezične tonzile, pri bolnikih, ki so mlajši od tipičnih bolnikov s tem rakom in niso podvrženi škodljivim razvadam. Pri njih je povzročitelj karcinoma visokorizični podtip človeškega virusa papiloma (HPV). Ti bolniki v primerjavi s prvimi bolje odgovorijo na nekirurško zdravljenje in imajo pomembno daljše preživetje. Obenem to pomeni, da so ti bolniki agresivnega zdravljenja deležni v zgodnejšem življenjskem obdobju in morajo s posledicami tega živeti bistveno dlje. Zato se upravičeno poraja vprašanje, ali morda teh bolnikov s HPV povezanim rakom orofarinksa ne zdravimo pretirano agresivno. Predlaganih je bilo več načinov za zmanjšanje intenzivnosti zdravljenja, znani pa so tudi že prvi rezultati raziskav. Ti potrjujejo, da je način deintenzifikacije zdravljenja s kombinacijo sočasnega obsevanja in cetuximaba, ki je nadomestil cisplatin oz. karboplatin, neuspešen. Bolj obetavni so zgodnji rezultati kliničnih raziskav, ki vključujejo bodisi manj invazivno kirurgijo ali zmanjšanje odmerka radioterapije, z ali brez predhodne izbire bolnikov, primernih za deintenzifikacijo, z uvodno kemoterapijo. Mnoge raziskave so še v teku in morda bodo izsledki že kmalu spremenili paradigmo zdravljenja v tej skupini bolnikov. Do takrat pa ostaja zdravljenje karcinomov orofarinksa enako za vse bolnike, ne glede na etiologijo njihove bolezni
Karcinoza možganskih ovojnic in rak dojk: 11-letni rezultati zdravljenja z obsevanjem
Get PDFIntroduction: Leptomeningeal carcinomatosis (LMC) develops with infiltration of leptomeninges by malignant cells and means poor prognosis. Radiotherapy presents one of the treatment options for neurological symptom relief.
Methods: We retrospectively analyzed 423 patients with breast cancer (BC) and brain metastasis (BM) or LMC, who received radiotherapy of the brain between the years 2005–2015 at the Institute of Oncology Ljubljana. We analyzed patients with LMC in more detail and performed a validation of prognostic survival indexes, namely Breast Graded Prognostic Assessment (Breast-GPA) and Simple Survival Score for Brain Metastases (SS-BM).
Results: Seventy patients with LMC were treated with whole-brain radiotherapy in observed time. Median time from BC diagnosis to LMC appearance was 4,3 years and was shortest in triple-negative and longest in luminal A BC subtype. Median overall survival for patients with BM and LMC was 7,5 (95 % confidence interval, CI; 6,3–8,8) and 2,3 months (95 % CI; 1,5–3,2), respectively (p < 0,005), and it varied depending on molecular BC subtype. Survival was not affected by a higher total dose of radiation received (≤ 20 Gy vs. > 20 Gy) or by the immediate start of radiotherapy within two weeks from LMC diagnosis. Breast-GPA (p < 0,005) and SS-BM (p = 0,044) indexes predicted survival with statistical significance.
Conclusions: Performance status, BC molecular subtype, time from LMC diagnosis till the start of radiotherapy and prognostic indexes were all factors which influenced expected survival in our group of analyzed LMC patients.Uvod: Karcinoza mening (LMK) nastane z zasevanjem tumorskih celic na možganske ovojnice in pomeni slabo prognozo. Obsevanje je ena izmed možnosti zdravljenja za ublažitev nevroloških simptomov.
Metode: V retrospektivno analizo smo vključili 423 bolnic z rakom dojk (RD) in možganskimi zasevki (MZ) ali LMK, ki so se v obdobju med 2005 in 2015 z obsevanjem glave zdravile na Onkološkem inštitutu Ljubljana. Podrobneje smo analizirali skupino bolnic z LMK, za katere smo tudi preverili uporabnost prognostičnih indeksov preživetja Breast Graded Prognostic Assessment (Breast-GPA) in Simple Survival Score for Brain Metastases (SS-BM).
Rezultati: Z obsevanjem glave smo v analiziranem obdobju zdravili 70 bolnic z LMK. Srednji čas od diagnoze RD do pojava LMK je znašal 4,3 leta, vendar je bil ta čas najkrajši pri trojno negativnem in najdaljši pri luminal A podtipu RD. Srednje celokupno preživetje je za bolnice z MZ in LMK znašalo 7,5 (95 % interval zaupanja, IZ; 6,3–8,8) ter 2,3 meseca (95 % IZ; 1,5–3,2) (p < 0,005), in se je razlikovalo tudi glede na molekularni podtip RD. Na daljše preživetje ni vplivala višja prejeta doza obsevanja (≤ 20Gy vs. > 20Gy), kakor tudi ne hiter pričetek obsevanja znotraj prvih dveh tednov po postavitvi diagnoze LMK. Indeksa Breast-GPA (p < 0,005) in SS-BM (p = 0,044) sta statistično značilno napovedala razlike v preživetju.
Zaključki: Pričakovano preživetje se je v naši skupini analiziranih bolnic z LMK razlikovalo glede na stanje zmogljivosti, molekularni podtip RD, čas od diagnoze LMK do pričetka z obsevanjem ter točke prognostičnih lestvic
Učinkovitost kanabinoidov pri zdravljenju raka – mit ali resnica?
Get PDFThe use of cannabis derivatives (cannabinoids) in oncology is sometimes indicated in the symptomatic treatment of nausea and vomiting, in pain management and in some neuropsychiatric disorders. In the recent years, there has been a growing interest in determining the anticancer effects of cannabinoids. Based on our clinical experience, we know that many patients use cannabinoids, among them also those with the aim of curing their disease. But despite the extensive and convincing data on the anticancer properties of cannabinoids from in vitro studies on cell cultures and studies on animal models, these properties have not (yet) been confirmed in a clinical trial. This paper summarises the currently available data on the potential of cannabinoid use in the clinical practice of oncology.Uporaba derivatov konoplje (kanabinoidov) je v onkologiji občasno indicirana pri simptomatski terapiji slabosti in bruhanja, bolečini ter nevropsiholoških motnjah. V zadnjih letih je opaziti tudi čedalje pogostejše zastavljanje vprašanj v povezavi z morebitnimi zdravilnimi učinki konoplje pri zdravljenju malignih neoplazem. Po naših izkušnjah mnogo bolnikov uživa eno izmed oblik kanabinoidov, tudi z namenom protitumorskega delovanja. Kljub številnim prepričljivim podatkom o protitumorskem učinku kanabinoidov v laboratorijskih poskusih na celičnih kulturah in živalskih modelih pa ta v kliničnih študijah doslej (še) ni bil potrjen. V tem prispevku povzemamo glavna dejstva, ki so trenutno na voljo, glede upravičenosti uporabe kanabinoidov z namenom onkološkega delovanja
Uporabnost slikovno preiskovalnih metod pri določanju HPV statusa karcinomov glave in vratu
Get PDFHead and neck cancer presents a serious health issue and is the sixth most common cancer in the world. With an estimated annual burden of 650,000 incident cases worldwide and approximately 440 incident cases in Slovenia, squamous cell carcinoma accounts for about 90 % of head and neck cancer (2015).In the last few decades, the number of oropharyngeal carcinoma cases has notably increased. The reason lies in the human papillomavirus (HPV) epidemic, with high-risk HPV type 16 being isolated from 40–60 % cases of oropharyngeal squamous cell carcinoma. Patients with HPV-positive HNSCC have a notably higher survival rate as well as better treatment response opposed to their HPV-negative counterparts. Therefore, the evaluation of HPV status in these patients has become the main factor in treatment planning and outcome prediction. The current golden standard for determining the viral aetiology of carcinoma is amplifying viral RNA with PCR. While recent studies indicate that radiographic imaging techniques are useful in determining HPV status, there is not enough evidence for them to be used as the sole method for HPV status determination. However, certain radiographic parameters were proven to be specific for HPV-related carcinomas and can be, when combined with other methods, used for determining HPV status. Primary HPV-positive carcinomas are generally smaller, less metabolically active, cause less necrosis and ulcerations, and have well-defined borders. They are usually found in the tonsillar region and at the base of the tongue. HPV-positive HNSCC presents with more frequent and earlier nodal metastases than HPV-negative HNSCC. HPV-positive HNSCC nodal metastases typically have a cystic appearance.Karcinomi glave in vratu predstavljajo pomemben zdravstveni problem in so šesti najpogostejši karcinom na svetu. Okoli 90 % karcinomov glave in vratu je ploščatoceličnih karcinomov, ki predstavljajo globalno letno incidenco okoli 650.000, v Sloveniji pa okoli 440 primerov (2015). V zadnjih desetletjih strmo raste incidenca karcinomov orofarinksa. Vzrok je epidemija okužb s humanim papiloma virusom (HPV), visokorizični tip 16 izoliramo kar iz 40–60 % ploščatoceličnih karcinomov orofarinksa. Bolniki s HPV-pozitivnimi PCKGV imajo občutno boljše preživetje in odzivnost na zdravljenje v primerjavi s HPV-negativnimi, zaradi česar je postalo določanje HPV statusa karcinoma ključno pri načrtovanju zdravljenja in napovedi preživetja. Trenutni zlati standard za dokaz HPV predstavlja pomnoževanje virusne RNA z verižno reakcijo s polimerazo, čedalje večjo veljavo pa dobivajo tudi radiološke slikovno preiskovalne metode. Zaenkrat izključno s pomočjo tovrstnih metod ne moremo rutinsko razlikovati med HPV-pozitivnimi in HPV-negativnimi karcinomi. Kljub temu pa raziskave kažejo na specifične, tudi radiološke lastnosti HPV-pozitivnih karcinomov, ki jih poleg rezultatov ostalih preiskav lahko uporabimo pri določanju HPV statusa. Vrednotimo tako primarni karcinom kot zasevke v bezgavkah. Primarni HPV-pozitivni karcinomi so v primerjavi s HPV-negativnimi običajno manjši, bolje zamejeni, metabolno manj aktivni in z manj nekrozami ter ulceracijami. Značilno se pojavljajo v tonzilarni regiji in na bazi jezika. Zasevki v bezgavkah so pri HPV-pozitivnih karcinomih zgodnejši in pogostejši kot pri HPV-negativnih, poleg tega imajo pogosteje cističen videz
Radioterapija s protonskimi žarki
Get PDFTogether with surgery and systemic treatment, radiotherapy constitutes one of the three pillars of cancer treatment. Tremendous technological development of particle accelerators has led to the implementation of proton beam therapy as the treatment of choice for a specific group of patients with cancer, especially children. Competition among several manufacturers has contributed to the lowering of prices of proton accelerator, which have lately also become accessible to less wealthy countries. The complexity of proton therapy, size of accelerators, and lingering high prices are the three main reasons for a relatively low number of proton therapy centres around the world, and the fact that there are no such centres in Slovenia as of yet. While proton therapy is a valid treatment of choice for the particular patient group, it is still difficult to determine unambiguously which patients would benefit from it most. From a strictly physical point of view, the dosimetric properties of proton beams differ significantly from those of photons, and are advantageous compared to photons. Protons traverse the tissue and deposit only a small part of their energy until they reach a certain depth where nearly all of their energy is deposited, while photons deposit their energy almost entirely in the first few centimetres of the tissue exposed to the beams. Like many other countries, Slovenia is at a crossing where it has to decide on the time and mode of photon therapy implementation, which will have to be carried out in a prompt and transparent manner.Ob kirurškem in sistemskem zdravljenju je radioterapija eden od treh stebrov zdravljenja raka. Izjemen tehnološki razvoj na področju pospeševalnikov nabitih delcev je pripeljal do uveljavitve protonske radioterapije kot terapije izbora pri določenih skupinah bolnikov obolelih za rakom, v prvi vrsti otrok. Velika konkurenčnost med proizvajalci je botrovala postopnemu znižanju cen protonskih pospeševalnikov, ki so v zadnjih letih postali dostopni tudi državam, ki ne sodijo med najbogatejše. Kompleksnost radioterapije s protoni, velikost naprav in še vedno sorazmerno visoka cena so glavne ovire, da protonskih centrov že v tem trenutku ni več in da takšnega centra še vedno ni niti v Sloveniji niti ne drugod v jugovzhodni Evropi. Izbor bolnikov, ki bi imeli pomembno klinično korist od protonske radioterapije, je zahteven in tudi v svetu še ne docela dorečen. Prednost protonske pred konvencionalno fotonsko radioterapijo je v večji biološki učinkovitosti protonskih žarkov. Tudi fizikalno gledano so dozimetrične lastnosti protonskih žarkov bistveno ugodnejše glede sevalne obremenitve zdravih tkiv in rizičnih organov: večina njihove energije se sprosti na mestu, kjer je tumor, za razliko od fotonskih žarkov, kjer se večina energije sprosti v prvih nekaj centimetrih pod površino kože, kjer žarki vstopajo v telo. Podobno kot mnoge druge države je tudi Slovenija pred odločitvijo, kdaj in kako ustvariti pogoje za protonsko terapijo, ki pa jo bo treba sprejeti hitro in transparentno
