Onkologija
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Stereotaktična radioterapija telesa pri bolnikih s pljučnim rakom
Get PDFStereotactic body radiation therapy (SBRT) is used for treatment of early stage lung cancer for patients without lymph node involvement. The standard treatment option for early disease is surgical resection; however, this type of treatment might be too risky due to age, co-morbidities and an impaired lung function. Traditionally, the three-dimensional conformal radiotherapy (3D CRT), radiofrequency ablation or symptomatic palliative treatment have been used for these patients in the past, but significantly worse local control of disease and survival rates were achieved compared to surgery. The SBRT technique offers patients with lung cancer treatment results comparable to surgery and a lower risk of impaired lung function compared to the standard 3D CRT. Due to a lower number of fractions, the whole treatment is shorter and more convenient for the patient. This enables patients a better treatment outcome and an increased quality of life; and therefore it has become part of the global guidelines for treatment of inoperable lung cancer in the early stages of the disease and for those who refuse surgery.Stereotaktična radioterapija telesa (SBRT) bolnikov s pljučnim rakom je metoda zdravljenja bolnikov v zgodnjem stadiju bolezni, ki nimajo prizadetih regionalnih bezgavk. Standardno so ti bolniki zdravljeni z operacijo, ki pa je lahko preveč tvegana zaradi starosti, spremljajočih bolezni ali slabe pljučne funkcije. V teh primerih smo bolnikom nudili druge načine zdravljenja, kot so tridimenzionalno konformno obsevanje, radiofrekvenčna ablacija ali pa le podporna terapija. S temi pristopi je bila kontrola rakave bolezni in preživetje bolnikov občutno slabše kot z operacijo. Obsevanje s tehniko SBRT pa bolnikom ponuja primerljive rezultate zdravljenja kot operacija ob manjšem tveganju za poslabšanje pljučne funkcije kot standardno obsevanje. Zaradi manjšega števila obsevanj je zdravljenje krajše in bolnikom bolj prijazno. Vse to bolnikom omogoča boljši izid zdravljenja in boljšo kakovost življenja ter je zato že postalo del svetovnih smernic za zdravljenje neoperabilnega raka pljuč v zgodnjem stadiju bolezni in tistih, ki operacijo odklonijo
Imunoterapija prvič tudi za zdravljenje lokalno napredovalega nedrobnoceličnega pljučnega raka
Get PDFDuring the last fifteen years, we have witnessed rapid development in the field of the lung cancer treatment, which remains cancer with the highest morbidity and mortality worldwide. Most patients with metastatic disease are treated with chemotherapy, targeted treatment is appropriate for less than 20% of patients with non-small cell lung cancer (NSCLC). In 2010, we were impressed by the results of research from the field of immunotherapy. Tumor cells must be recognized as foreign in order to be removed by the immune system. However, tumor cells have developed various mechanisms to escape immune control, one of which is the release of immune inhibitory molecules such as the ligand programmed cell death (PD-L1), which is the principal mediator of immunosuppressive action. Medicinal products which are currently used to treat metastatic NSCLC are monoclonal antibodies against PD-L1 or PD-1. By binding to PD-L1 or its PD-1 receptor on immune cells, they prevent the immunosuppressive effect and enable the activated T lymphocytes to function successfully. In Slovenia, two medicinal products with the described mode of action are registered, nivolumab and pembrolizumab. At the ESMO 2017 Congress, the results of PACIFIC study showing benefit with immunotherapy treatment also in locally advanced patients with NSCLC were presented. Patients had received durvalumab or placebo after standard treatment with chemoradiotherapy. In the group treated with durvalumab, the progression-free survival was significantly longer. The synergistic effect of irradiation, a widely recognized method of local treatment, in combination with immunotherapy, blurs the boundaries between the systemic and local treatment of cancer, as has been shown by numerous pre-clinical studies. Future research will provide answers which method of combining immunotherapy and irradiation is most appropriate.V zadnjih petnajstih letih smo priča hitremu razvoju na področju zdravljenja pljučnega raka, ki ostaja v svetovnem merilu še vedno rak z najvišjo obolevnostjo in umrljivostjo. Večina bolnikov z metastatsko boleznijo se zdravi s kemoterapijo (KT), tarčno zdravljenje je primerno za manj kot 20% bolnikov z nedrobnoceličnim pljučnim rakom (NDPR). V letu 2010 so nas navdušili rezultati raziskav na področju imunoterapije. Tumorske celice morajo biti prepoznane kot tuje telesu, da jih imunski sistem lahko odstrani. Vendar so tumorske celice razvile različne mehanizme za izmikanje imunskemu nadzoru, eden od teh je tudi sproščanje imunskih zaviralnih molekul kot je ligand programirane celične smrti (PD-L1), ki je glavni mediator imunosupresivnega delovanja. Zdravila, ki se trenutno uporabljajo za zdravljenje metastatskega NDPR, so monoklonska protitelesa proti PD-L1 ali PD-1. Z vezavo na PD-L1 ali njegov receptor PD-1 na imunskih celicah preprečijo imunosupresiven učinek in omogočijo uspešno delovanje aktiviranih T limfocitov. V Sloveniji sta registrirani dve zdravili z opisanim načinom delovanja, nivolumab in pembrolizumab. Na kongresu ESMO 2017 pa so bili predstavljeni rezultati raziskave PACIFIK, ki opisujejo dobrobit zdravljenja z imunoterapijo tudi pri lokalno napredovalih bolnikih z NDPR. Bolniki so po standardnem zdravljenju s kemoradioterapijo prejemali durvalumab ali placebo. V skupini, zdravljeni z durvalumabom, je bil čas brez napredovanja bolezni značilno daljši. Sinergistično delovanje obsevanja, ki je splošno priznan način lokalnega zdravljenja, v kombinaciji z imunoterapijo briše meje med sistemskim in lokalnim načinom zdravljenja raka, kar so pokazale tudi številne predklinične raziskave. Bodoče raziskave bodo podale odgovore, kateri način kombiniranja imunoterapije in obsevanja je najbolj primeren
Radioterapija sekundarnih tumorjev jeter
Get PDFLiver is commonly involved in a metastatic setting of gastrointestinal, lung and breast cancers. Symptoms of liver metastases are rarely mitigated by systemic (palliative) treatments only. Whole or partial liver radiotherapy is a cost-effective treatment option with minimal treatment toxicity to offer the mitigation of symptoms to patients with diffuse liver metastatic involvement. This treatment approach is different (and sometimes with curative intent) for selected patients with a lower tumour burden and an oligo-metastatic disease. Local ablative treatments of limited number and size of liver metastases show improvements in local control of the tumour, disease-free survival and overall survival. This article describes radiation induced liver disease and different radiation therapy approaches that can be chosen while taking into account the burden of the disease, size and number of liver metastases, symptoms, laboratory tests, possibilities of other local treatments and the clinical performance status of the patient.Sekundarni tumorji jeter, med njimi zasevki tumorjev gastrointestinalnega trakta, raka dojk in pljuč pogosto povzročajo simptome, ki niso obvladljivi s sistemskim zdravljenjem. V primeru difuznih jetrnih zasevkov lahko z obsevanjem celotnih jeter hitro, učinkovito in z majhnimi stroški dosežemo dobro paliacijo simptomov z blagimi neželenimi učinki. Ko je zasevkov manj in je tudi obseg bolezni v telesu manjši, lahko pri izbranih bolnikih z dodatnim lokalnim (ablativnim) zdravljenjem jetrnih zasevkov dosežemo izboljšanje časa do progresa bolezni in celokupnega preživetja. V nadaljevanju prispevka sta opisana radiacijska poškodba jeter in obsevanje jeter z različnimi radioterapevtskimi tehnikami, med katerimi izberemo najustreznejšo glede na obseg bolezni, velikost jetrnih zasevkov, simptome, laboratorijske izvide in stanje zmogljivosti bolnika
Radioterapija v Sloveniji
Get PDFTreatment with irradiation or radiotherapy is one of the three basic cancer treatment methods. In Slovenia, radiotherapy is carried out at the Institute of Oncology in Ljubljana and since November 2016 in a lesser extent also at the Department of Radiotherapy in the University Medical Centre in Maribor. In recent years in Slovenia, we performed on average over 6,000 teletherapy procedures in approximately 5,000 patients, and also around 400 brachytherapy procedures annually. This paper shows the current situation in the field of radiotherapy in Slovenia and also, based on the results of several international studies, where our current hardware and personnel capacities in this area put us in the European scale.Zdravljenje z obsevanjem ali radioterapija je eden od treh temeljnih načinov zdravljenja raka. V Sloveniji zdravljenje z obsevanjem izvajamo na Onkološkem inštitutu v Ljubljani in v manjšem obsegu od novembra 2016 tudi na Oddelku za radioterapijo v Univerzitetnem kliničnem centru v Mariboru. V Sloveniji smo v zadnjih letih v povprečju vsako leto opravili preko 6.000 teleradioterapevtskih obsevanj pri skoraj 5.000 bolnikih, ob tem pa letno opravimo tudi približno 400 brahiterapevtskih posegov. V članku je prikazano trenutno stanje na področju radioterapije v Sloveniji, na osnovi rezultatov nekaterih mednarodnih raziskav pa tudi, kam nas trenutne strojne in kadrovske zmogljivosti na tem področju uvrščajo v evropskem merilu
Povzetek smernic diagnostike in zdravljenja diferenciranega raka ščitnice
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Anti PD-1 protitelesa: uporaba, delovanje, neželeni učinki
Get PDFProgrammed cell death protein 1 (PD-1) is a transmembrane protein expressed in T, B, NK cells, monocytes, and dendritic cells. The binding of PD-1 to its ligands inhibits tumor cell apoptosis, stimulates T-cell depletion, and prevents active antitumor response, which consequently enables an uninhibited growth and development of tumor cells.
PD-1 receptor inhibitors pembrolizumab and nivolumab are already used in the treatment of various types of advanced cancer, such as melanoma, non-small cell lung cancer, Hodgkin’s lymphoma, and renal carcinoma. Depending on the indication and line of treatment, a different number of patients responds to the treatment successfully, ranging from 18 % to 80 % of patients. The particularities of treatment with immunotherapy include very long-lasting remissions and, in individual patients, we might even dare talk about cure.
The most common side effects are fatigue, pruritus, rash, diarrhea, and nausea. Among the most serious side effects are immune-related adverse reactions – including colitis, thyroiditis, pneumonitis, hepatitis, and nephritis – and severe infusion-related reactions.Protein programirane celične smrti 1:PD-1 (Programmed cell death protein 1) je transmembranski protein, ki je izražen na celicah T, B, NK ter monocitih in dendritičnih celicah. Vezava med PD-1 in njegovimi ligandi zavira tumorsko celično apoptozo, spodbuja izčrpanost T-celic in preprečuje aktiven antitumorski odziv, kar posledično omogoča nemoteno rast in razvoj tumorskih celic.
Zaviralca receptorja PD-1, pembrolizumab in nivolumab, že uporabljamo v zdravljenju različnih vrst napredovalega raka, kot so: melanom, nedrobnocelični karcinom pljuč, Hodgkinov limfom in karcinom ledvic. Na zdravljenje odgovori zelo različno število bolnikov, kar je odvisno od indikacije in linije zdravljenja, to je od pri 18 do 80 odstotkih bolnikov. Posebnosti zdravljenja z imunoterapijo so zelo dolgotrajne remisije, pri posameznih bolnikih pa bomo morebiti upali govoriti celo o ozdravitvi.
Najpogostejši neželeni učinki so utrujenost, srbečica, izpuščaji, driska in slabost. Najresnejši neželeni učinki so imunsko pogojeni neželeni učinki in hude z infuzijo povezane reakcije. Imunsko pogojeni neželeni učinki so kolitis, tiroiditis, pneumonitis, hepatitis in nefritis
Magnetnoresonančni simulator za potrebe načrtovanja obsevanja
Get PDFThe use of magnetic resonance imaging (MRI) in process of radiotherapy (RT) planning and treatment is expanding. MRI is very increasingly being used in RT process, cause represent superior soft-tissue contrast compared with computer tomography (CT). Purpose of review is mainly introduce the features of MRI process in RT process and describe differences between diagnostic and therapeutic MR machine. Main goal of MRI examination it is scanning the patient in dedicated special RT position with unique RF coils which is used for imaging in RT process. Most common process is to perform both MRI and CT examination in the treatment position and finally fuse both datasets imaging. These MR images are primarily used to outline the tumour volumes (TV) and organs at risk (OAR).Uporaba magnetnoresonančnega (MR) slikanja v radioterapiji (RT) predstavlja številne uporabne prednosti v procesu izdelave obsevalnega načrta. Pri MR slikanju se predvsem izkorišča boljša kontrastnost in prostorska ločljivost mehkih tkiv v primerjavi s slikanjem z računalniško tomografijo (CT). V prispevku je opisan postopek MR slikanja v procesu RT in predstavljene so razlike med diagnostičnim in radioterapevtskim MR aparatom ter opisane kontraindikacije samih MR preiskav. Namen MR slikanja je pridobitev in zlitje s serijo CT slik, natančno določenega anatomsklega področja v specifičnem radioterapevtskim položaju s pomočjo ustreznih fiksacijskih pripomočkov in tuljav, ki se uporabljajo v procesu RT. Tako zlitje MR in CT slik omogoča natančnejšo vrisovanje tumorja in/ali drugih tarčnih struktur ter sosednjih rizičnih organov
Delno obsevanje dojke
Get PDFThroughout the last decade, partial breast irradiation has grown increasingly interesting and been the subject of numerous studies. Compared to standard irradiation which can take anywhere from 5 to 7 weeks, it bears the advantage of shorter treatment that lasts only from 1 to 3 weeks. As the term itself suggests, only a small part of the breast is irradiated following the surgical procedure, namely the area of the tumor bed and the surgical margin. For now, this method is only used in treating patients within the frameworks of controlled clinical research, while outside these frameworks it is only available to a carefully selected group of individuals as an optional supplementary irradiation treatment.Za delno obsevanje dojke se v zadnjem desetletju povečuje zanimanje in je predmet številnih raziskav. V primerjavi s standardnim obsevanjem, ki lahko traja 5–7 tednov, je njegova prednost predvsem v krajšem zdravljenju, ki traja le 1–3 tedne. Kot že ime pove, se po operaciji obseva le manjši del dojke in sicer področje ležišča tumorja z varnostnim robom. Zaenkrat se na takšen način zdravi bolnice le znotraj nadzorovanih kliničnih raziskav, izven tega pa le kot možnost dopolnilnega obsevalnega zdravljenja za skrbno izbrano skupino bolnic
