Diseño de un programa de base de datos para el seguimiento de pacientes, aplicando el Real Decreto 1566/1998 sobre control de calidad en radioterapia

Introduction

In July of 1999, following the Royal (State) Decree # 1566/1998 and the ISO 9002 guidelines, a computer program was designed to analyze, annually, the parameters of toxicity, control of disease and survival.

Material and methods

A total of 2.192 patients were studied in Radiation Oncology until may 2005. Of the patients, 51,8% had initial stage disease and the 46.4% had advanced stages. The initial-advanced tumor index was of 1.1. Treatment intent was palliative in 23.8% and curative in 60.3% of cases.

Results

The 3-year disease free survival (DFS) in curative-intent cases was 78.5% in the initial-stage and 55.2% in the advanced-stage patients (p<0.00001). Follow-up was 95.8% of the patients. Loco-regional failure rate was 9.7% and tumor persistence following radiotherapy was 9.4%. The overall rate of late-onset complications was 4.2% (RTOG scoring).

Conclusions

The initial-to-advanced tumor index, the rates of loco-regional filure, of survival and of complications provide an evaluation of the quality of treatment in an Oncology-Radiotherapy departiment.     

Variabilidad en la utilización del tratamiento conservador del cancer de marna localizado en un área geográfica

Objetivos

Conocer el porcentaje de tratamiento conservador del cancer de marna en estadios I y II en un área geográfica, la variabilidad de indicación entre diferentes centros y los posibles factores relacionados.

Métodos

En un estudio de corte transversal retrospectivo se recogieron un total de 225 casos de cáncer de marna en estadios iniciales y se determinó el tipo de cirugía (conservadora o mastectomía) y su relación con posibles predictores de la misma.

Resultados

La frecuencia de conservación mamaria fue del 27% para el conjunto de casos (IC del 95%, 22–34%). En el estadio I se realizó en el 49% de casos y en el estadio II en el 21%. La probabilidad de ser tratada con tratamiento conservador no pudo establecerse ni con la edad de la paciente ni con el área de residencia rural o urbana, pero si de forma significativa con el centro de tratamiento y el estadio.

Conclusiones

La menor frecuencia de conservación en estadio II no se ajusta en nuestro medio a los estándares aceptados. Factores propios de cada centro o del cirujano que atiende a la paciente pueden explicar la variabilidad en la frecuencia de indicación de conservación mamaria entre ellos.     

Sobreimpresión en fracción única con braquiterapia intersticial de alta tasa en el tratamiento conservador del carcinoma de mama

Introduction

We evaluated the effectiveness of interstitial high dose rate brachytherapy as a single fraction boost to the surgical bed in patients with breast cancer undergoing conservative treatment. The comparison was with the alternative of electron boost.

Materials and methods

Between April 1999 and December 2000, we conducted a prospective study of 84 patients with infiltrative breast carcinoma treated with conservative surgery, with free margins. This was followed by external radiotherapy to the breast of up to 46 Gy and one application of brachytherapy with needles inserted into the surgical bed, and administering 7 Gy to 90% with high dose rate (HDR)/

Results

With a mean follow-up of 43 months, only one patient had therapeutic failure in the implant area, and local control was 98.5%. Another patient had a 2^nd tumour in a different quadrant and 3 developed metastasis. Survival at 5 years was 98.7%. Acute toxicity was minimal, with excellent or good cosmetic appearance in 95%.

Conclusions

Brachytherapy with high dose rate as single fraction boost in conservative treatment of breast carcinoma is simple, fast, well tolerated, with excellent local control, good cosmetic appearance, and with minimal late-onset toxicity.     

Hepatitis fulminante tras suspensión del tratamiento inmunosupresor en un paciente con hepatitis crónica por virus de la hepatitis B y C

We report a patient with chronic virus B and C hepatitis, who developed a fatal hepatic failure after chemotherapy suppression. A 56 years old man diagnosed of glioblastoma in treatment with cisplatin, procarbacin and UFT whose treatment was stopped because a raise in serum transaminases. Five days later, he developed an acute hepatic failure and died. Fulminant hepatitis is a known complication of immunosuppresive therapy withdrawal in patients with chronic virus B and virus C infection. It is accepted to be caused by the reactivation of viral replication during inmunosupressive therapy followed by hepatic necrosis with the restablishment of normal immunity. Management should include corticosteroid therapy and probably lamivudine, however the best way to face it is to prevent it measuring the viral DNA in patients with chronic hepatitis receiving chemotherapy.     

Quimioterapia de inducción seguida de radioquimioterapia como alternativa a la laringuectomía en el tratamiento del cáncer de cabeza y cuello localmente avanzado

Objective

To evaluate survival in patients with loco-regional advanced head and neck cancer treated with induction chemotherapy and to assess possible larynx preservation in good responders.

Materials and methods

Between December 1997 and June 2000, patients (n=46) diagnosed as having advanced head and neck carcinoma were treated with induction chemotherapy (CT). This was followed by radiotherapy (RT) + CT if there had been complete response (CR) or partial response (RP) >80%; or followed by total laryngectomy and adjuvant RT if CR or PR was <80%.

Results

Of the 46 patients studied, 57 (80%) had CR, 10% had PR and 10% had no response or disease progression (DP). Median survival was 33%, followup was of 50 months during which the overall survival was 36%, disease-free survival (DFS) was 60% and loco-regional control was 51%.

Conclusion

RT-CT resulted in high rates of disease resolution and speech preservation in patients who, traditionally, had poor clinical and functional outcomes.     

Radioterapia experimental. Parámetros de respuesta tumoral a la radiación

El conocimiento de los parámetros que definen la respuesta a la radiación de los tumores malignos, en particular el coeficiente de regeneración de los clonógenos tumorales supervivientes y la velocidad del proceso de proliferación tumoral subyacente, puede inferirse hoy día a partir de observaciones clínicas precisas, combinando los elementos básicos de la irradiación (dosis-tiempo-fraccionamiento) con los resultados del tratamiento (probabilidad de control observada) y ciertos supuestos relativos al efecto biológico radioinducido sobre los tumores tratados (relaciones dosis-supervivencia, dosis-tiempo y dosis-control tumoral). Ello explica la profunda transformación experimentada por la radioterapia durante los Últimos años. Del empirismo inicial se ha pasado a la aparición de un cuerpo doctrinal sólido, construido sobre bases racionales que permite formular hipótesis, predecir resultados, profundizar en el conocimiento de la biología de los tumores malignos y adoptar decisiones clínicas, impensables hace sólo una o dos décadas, en la terapéutica del cáncer. La radioterapia oncológica se ha configurado así como una disciplina con claros fundamentos científicos e importante proyección clínica, muy alejada de su carácter intuitivo inicial.     

Experiencia en la utilización del fentanilo transdérmico en un servicio de Oncología radioterápica

Introduction

This observational study, conducted in an Oncology Radiotherapy Service, was performed to evaluate efficacy and toxicity of TTS-fentanyl, and patient satisfaction with the treatment.

Material and methods

Patients (n=225) with non-controlled pain, intolerance to oral opioids or with dysphagia were recruited. Evaluations were at baseline (commencement of TTS-fentanyl treatment) and after 72 hours, 30 days and 60 days of follow-up at which times pain intensity, TTS-fentanyl doses, secondary effects and patient satisfaction were assessed.

Results

Of the patients, 68% commenced TTS-fentanyl treatment following failure of weaker opioids. After 60 days, the mean decrease in pain intensity was 4.06 points on the visual analogue scale (p<0.05). Sideeffects were low or moderate. Satisfaction was evaluated as high by 58%, moderate by 32% and unsatisfactory by 10% of patients.

Conclusion

We conclude that TTS-fentanyl, because of its ease of preparation, efficacy and good toxicity profile, is a useful analgesic in an Oncology Radiotherapy Service.     

Estudio de la expresión de ciclina D1, p16, MIB-1 y p53 en lesiones precancerosas orales

|Aims

To know the proteic expression of the genetic alterations that take place in the precocious stages of the field cancerization of oral cavity in our means. To study the MIB-1, cyclin D1, p16 and p53 expression levels to value if the alterations in the expression levels of these markers happen in a sequential pathway through the different stages in the field cancerization of oral cavity.

|Material and methods

We have studied by means of technical of immunohistochemistry on 53 patients with oral leucoplakia. They are included in the study 11 specimens of normal squamous epithelium, 15 mild and moderate dysplasias, 15in situ carcinomas and 12 microinvasive carcinomas.

|Results

Overexpression of MIB-1, cyclin D1 and p53 and loss of p16 expression was found as we increased in the grade of histopathological severity of the lesions. The most precocious alterations are overexpresion of MIB-1 and loss of p16 expression in mild and moderate dysplasic lesions. There are significant differences in the expression of cyclin D1 between light and moderate dysplasias andin situ carcinomas.

|Conclusions

The oral leucoplakia is a precancerous condition that constitutes a possible malignant transformation in oral carcinoma due to the genetic alterations that partipate in the evolution of the lesion. The immunohistochemistry and molecular study of the lesions is a routine means to make it possible to know the proteic expression of the genetic alterations that can help in the precocious diagnosis and treatment of this pathology, having special relevance the study of p16 expression in initial stages and p53 in more advanced lesions.     

La asociación entre metaplasia intestinal de la unión esofagogástrica y enfermedad for reflujo gastroesofágico en el Instituto Nacional de Cancerología

Introduction

Intestinal metaplasia in the oesophagus-gastric junction can originate in the distal oesophagus causing oesophagus-gastric reflux, or in the proximal portion of the stomach. This pre-malignant lesion can progress to cancer.

Objective

To determine the frequency of intestinal metaplasia of the oesophagus-gastric junction in patients with clinical gastric-oesophageal reflux and to evaluate the relationship with the chronic gastritis andHelicobacter pylori infection.

Material and Methods

Between March 2000 and June 2001, all patients who were referred to the Service of Endoscopy, without a diagnosis of cancer of the digestive tract and who, according to the Carlsson-Dent questionnaire, were classified as having oesophageal-gastric reflux were included in the study. Conventional endoscopy was performed and biopsies were obtained from the oesophagus-gastric junction. The pathologist who evaluated the samples was blinded with respect to the clinical details of the patients.

Results

The patients (n=51) included 20 men and 31 women, with a mean age of 53,7 years. The junction type was squamous-columnar in 30 patients and heterotopic “Z” type in 21. There were 17 patients with hiatus hernia and 12 with acute oesophagitis. Endoscopy indicated 6 patients with acute gastritis, 19 with chronic gastritis and 5 cases of Barrett's oesophagus. Histology indicated 3 patients with Barrett's oesophagus, 48 with chronic gastritis, 12 with cardial metaplasia and 34 withHelicobacter pylori infection.

Conclusions

Twelve (23.5%) patients presented intestinal metaplasia. In 66.6% there wasH. pylori infection and 48 patients (94.1%) had chronic gastritis. Endoscopically, the more frequent squamous-columnar junction was the heterotopic type in 58.8% with the type “Z” in 41.2% of patients.     

Síndrome de supresión del antiandrógeno: estrategia terapéutica en el cáncer de próstata andrógeno-independiente

|Introduction

The anti-androgen withdrawal syndrome is a well-established phenomenon in prostate cancer. It is widely accepted that a subset of patients will benefit from the withdrawal of anti-androgen or steroid hormone from hormonal therapy; the result being a decrease in prostate-specific antigen (PSA) values and clinical improvement. In our study, we review our experience in patients with prostate cancer in progression stage (androgen-independent prostate cancer) and the effect of anti-androgen withdrawal (evaluation of response; duration of response) as well as assessing the possible predictive factors.

|Material and methods

We studied 70 patients with prostate cancer in biochemical progression receiving hormonal therapy. We evaluated the response three months after anti-androgen withdrawal. Considered as response was the reduction of PSA levels of >50%. The Chi-squared test and the Fisher exact test were the statistical analyses used to identify possible predictive factors.

|Results

We observed a PSA reduction of >50% in 22 patients (31.4%), a stabilisation of PSA levels in 9 of the patients, and biochemical progression in 39 patients (68,6%). The mean duration of response was 5 months. We observed a greater percentage of response to the withdrawal of bicalutamide than to flutamida, but the differences were not statistically significant. Only the duration of prior hormonal therapy appeared to predict the response to antiandrogen withdrawal. Currently, it is not possible to identify the subset of patients whose tumors will respond to anti-androgen or steroid withdrawal. Tumors that respond may be classified as androgen-independent and hormone-sensitive tumors as opposed to androgen-independent and hormone-insensitive tumors, which do not respond. Patients who respond to anti-androgen withdrawal experience an improved quality of life for approximately 6 months. However, it is not known whether this translates into prolonged survival.

|Conclusions

Since about 30% of patients will respond to anti-androgen or steroid withdrawal in hormone-refractory prostate cancer, this needs to be taken into account in clinical trials of new cytotoxic agents. Cessation of flutamide for at least 4 weeks and, perhaps even 8 weeks in the case of bicalutamide, is mandatory before anti-androgen withdrawal syndrome can be excluded as the cause of a decrease in PSA values.     

Resultados a largo plazo de radioterapia y quimioterapia concomitante en cáncer microcítico de pulmón, enfermedad limitada al tórax, fuera de ensayos clínicos

Introduction

Chemotherapy combined with radiotherapy can improve local control and survival in patients with small cell lung cancer (SCLC).

Material and methods

We used cisplatin and etoposide (PE) with concurrent thoracic radiation therapy (TRT) followed by prophylactic cranial irradiation (PCI) in patients achieving a complete response. The objective was to evaluate the efficacy and toxicity of this regime in patients with localised SCLC. Patients (n=89) diagnosed with localised SCLC were treated with PE (4 to 6 cycles) together with TRT (50–60 Gy).

Results

The response rate was 92% (62%CR, 30%PR). The 20 patients with CR had PCI administered. Grade III–IV toxicities were 68% neutropenia, 23% thrombocytopenia, 23% anaemia and 24% severe dysphagia. Median overall survival rate was 17 months (probable survival rate of 35% at 2 years).

Conclusions

The treatment is feasible and provides acceptable survival rates despite the accompanying toxicity. It is recommended that PCI be provided for all patients achieving complete response.     

Fiebre y neutropenia en niños con cáncer: evaluación de un protocolo terapéutico con monoterapia

Background

Traditionally, fever and neutropenia in cancer patients has been managed with an association of two or more antibiotics. In recent years, monotherapy has emerged as an adequate option. We began a new empirical antibiotic protocol in 2001, including monotherapy as initial treatment for a selected group of patients.

Results

Forty seven patients had 98 fever and neutropenia episodes and 97 were included in the protocol. Leukemia and lymphomas were the most common underlying diagnosis. In most cases, no infection focus was found. In comparison with our previous series, we found an increment in gramnegative sepsis incidence and the disappearance ofStaphylococcus epidermidis as an etiological agent. Initial treatment according to protocol was not modified in 69/97 (71,2%) and 48/67 (71,6%) were treated with monotherapy. Only 5/97 patients were readmitted and finished treatment in the hospital without any further complications.

Conclusion

In conclusion we managed to treat our patients effectively and safely, with early discharge from the hospital.     

Quimioterapia intensiva con soporte de progenitores hematopoyéticos en neoplasias sólidas no hematológicas de la edad pediátrica: indicaciones y estado actual del tema

High-dose chemotherapy with autologous bone marrow or peripheral stem cell support is frequently used for the treatment of high-risk pediatric solid tumors. The gained experience with these treatments runs parallel with a considerable decrease on the procedure-related complications. These strategies have demonstrated its efectivity in the treatment of high-risk neuroblastoma as well as in refractory or relapsed germ cell tumors. There are also evidences showing that its use in high-risk Ewing’s sarcoma, and in chemosensitive relapsed or metastatatic brain tumors, contributes to ameliorate the dismal prognosis of these patients.     

Linfoma angiocéntrico centrofacial. Características clínicas, de tratamiento y seguimiento de 40 pacientes (experiencia en el Instituto Nacional de Cancerología, México)

Fourthy patients with diagnosis of angiocentric centrofacial lymphoma were seen in the Instituto Nacional of Cancerology, México, among 1982 to 1999. The following features were considered: age, sex, primary tumor site, main symptoms, treatment, outcome and histopathologic findings. There was a ratio male to female of 1.5:1 with mean age of 44 years (range, 18 to 98 years). The most frequent initial manifestation was in nasal cavity (50%), continued by palate (15%). The main symptoms included fever, nasal obstruction and rhinorrea. The treatment was grouped in four categories thus, eight patients received chemotherapy, thirteen patients chemotherapy followed by radiotherapy, 14 patients treated with radiotherapy followed by chemotherapy, and five patients received only radiotherapy. The patients whom besides development tuberculosis, and AIDS, had an aggressive course. The average of follow up in these 40 patients was 32 months. The patients treated with radiotherapy followed by chemotherapy showed better response and survival. The angiocentric centrofacial lymphoma, is an aggressive, quickly progressive disease, with T/NK cells type, associated with EBV and more aggressive in immunocompromised patients, mainly in patients with AIDS and tuberculosis. The treatment scheme with better results was that of patients receiving radiotherapy followed by chemotherapy.