Efeitos agudos do tratamento de radioterapia em doentes com carcinoma de cabeça e pescoço: IMRT vs RapidArc

A Radioterapia é parte integrante, standart, da abordagem multidisciplinar do tratamento de Carcinomas de Cabeça e Pescoço (CPP). A perceção e descrição dos efeitos provocados pelo tratamento ao nível dos tecidos normais é importante para avaliação clínica do doente, já que com o aparecimento de efeitos agudos severos/graves ao tratamento, este é interrompido, o que afetando diretamente a sobrevida do doente. Este estudo incidiu na avaliação de 6 semanas de tratamento de 46 doentes, contemplando a avaliação dos efeitos agudos do tratamento em cinco áreas anatómicas distintas: Pele, Mucosa, Glândulas Salivares, Faringe/Esófago e Laringe. Fundamentada nos critérios de classificação do Acute Radiation Morbidity Scoring Criteria da Radiation Therapy Oncology Group (RTOG). Após a avaliação e análise dos dados, verificou-se que os efeitos agudos obtidos com a técnica de RapidArcTM surgiram mais precocemente, quando comparados com técnica de IMRT. Por outro lado, com a técnica de IMRT registaram-se efeitos mais exacerbados, de alto Grau.

Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA)

As the mean age of the global population increases, breast cancer in older individuals will be increasingly encountered in clinical practice. Management decisions should not be based on age alone. Establishing recommendations for management of older individuals with breast cancer is challenging because of very limited level 1 evidence in this heterogeneous population. In 2007, the International Society of Geriatric Oncology (SIOG) created a task force to provide evidence-based recommendations for the management of breast cancer in elderly individuals. In 2010, a multidisciplinary SIOG and European Society of Breast Cancer Specialists (EUSOMA) task force gathered to expand and update the 2007 recommendations. The recommendations were expanded to include geriatric assessment, competing causes of mortality, ductal carcinoma in situ, drug safety and compliance, patient preferences, barriers to treatment, and male breast cancer. Recommendations were updated for screening, primary endocrine therapy, surgery, radiotherapy, neoadjuvant and adjuvant systemic therapy, and metastatic breast cancer.

Menopausal status: A possible predictive factor for recurrence in women with cancer of the uterine cervix without pelvic lymph node metastasis

Objectives: To evaluate risk factors for recurrence of carcinoma of the uterine cervix among women who had undergone radical hysterectomy without pelvic lymph node metastasis, while taking into consideration not only the classical histopathological factors but also sociodemographic, clinical and treatment-related factors. Study design: This was an exploratory analysis on 233 women with carcinoma of the uterine cervix (stages IB and IIA) who were treated by means of radical hysterectomy and pelvic lymphadenectomy, with free surgical margins and without lymph node metastases on conventional histopathological examination. Women with histologically normal lymph nodes but with micrometastases in the immunohistochemical analysis (AE1/AE3) were excluded. Disease-free survival for sociodemographic, clinical and histopathological variables was calculated using the Kaplan-Meier method. The Cox proportional hazards model was used to identify the independent risk factors for recurrence. Results: Twenty-seven recurrences were recorded (11.6%), of which 18 were pelvic, four were distant, four were pelvic + distant and one was of unknown location. The five-year disease-free survival rate among the study population was 88.4%. The independent risk factors for recurrence in the multivariate analysis were: postmenopausal status (HR 14.1; 95% CI: 3.7-53.6; P < 0.001), absence of or slight inflammatory reaction (HR 7.9; 95% CI: 1.7-36.5; P = 0.008) and invasion of the deepest third of the cervix (FIR 6.1; 95% CI: 1.3-29.1; P = 0.021). Postoperative radiotherapy was identified as a protective factor against recurrence (HR 0.02; 95% CI: 0.001-0.25; P = 0.003). Conclusion: Postmenopausal status is a possible independent risk factor for recurrence even when adjusted for classical prognostic factors (such as tumour size, depth of turnout invasion, capillary embolisation) and treatment-related factors (period of treatment and postoperative radiotherapy status). (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Comparison of biological behavior between early-stage adenocarcinoma and squamous cell carcinoma of the uterine cervix

Objectives: (1) To compare the anatomopathological variables and recurrence rates in patients with early-stage adenocarcinoma (AC) and squamous cell carcinoma (SCC) of the uterine cervix; (2) to identify the independent risk factors for recurrence. Study design: This historical cohort study assessed 238 patients with carcinoma of the uterine cervix (113 and IIA), who underwent radical hysterectomy with pelvic lymph node dissection between 1980 and 1999. Comparison of category variables between the two histological types was carried out using the Pearson`s X-2 test or Fisher exact test. Disease-free survival rates for AC and SCC were calculated using the Kaplan-Meier method and the curves were compared using the log-rank test. The Cox proportional hazards model was used to identify the independent risk factors for recurrence. Results: There were 35 cases of AC (14.7%) and 203 of SCC (85.3%). AC presented lower histological grade than did SCC (grade 1: 68.6% versus 9.4%; p < 0.001), lower rate of lymphovascular space involvement (25.7% versus 53.7%; p = 0.002), lower rate of invasion into the middle or deep thirds of the uterine cervix (40.0% versus 80.8%; p < 0.001) and lower rate of lymph node metastasis (2.9% versus 16.3%; p = 0.036). Although the recurrence rate was lower for AC than for SCC (11.4% versus 15.8%), this difference was not statistically significant (p = 0.509). Multivariate analysis identified three independent risk factors for recurrence: presence of metastases in the pelvic lymph nodes, invasion of the deep third of the uterine cervix and absence of or slight inflammatory reaction in the cervix. When these variables were adjusted for the histological type and radiotherapy status, they remained in the model as independent risk factors. Conclusion: The AC group showed less aggressive histological behavior than did the SCC group, but no difference in the disease-free survival rates was noted. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

Development of an adenoviral vector with robust expression driven by p53

Here we introduce a new adenoviral vector where transgene expression is driven by p53. We first developed a synthetic promoter, referred to as PGTx beta containing a p53-responsive element, a minimal promoter and the first intron of the rabbit P-globin gene. Initial assays using plasmid-based vectors indicated that expression was tightly controlled by p53 and was 5-fold stronger than the constitutive CMV immediate early promoter/enhancer. The adenoviral vector, AdPG, was also shown to offer p53-responsive expression in prostate carcinoma cells LNCaP (wt p53), DU-145 (temperature sensitive mutant of p53) and PC3 (p53-null, but engineered to express temperature-sensitive p53 mutants). AdPG served as a sensor of p53 activity in LNCaP cells treated with chemotherapeutic agents. Since p53 can be induced by radiotherapy and chemotherapy, this new vector could be further developed for use in combination with conventional therapies to bring about cooperation between the genetic and pharmacologic treatment modalities. (c) 2007 Elsevier Inc. All rights reserved.

Gamma-linolenic Acid Alters Ku80, E2F1, and Bax Expression and Induces Micronucleus Formation in C6 Glioma Cells In Vitro

Gamma-linolenic acid (GLA) is an inhibitor of tumor cell proliferation in both in vitro and in vivo conditions. The aim of this study was to investigate the effects of 150 mu M GLA on the expression of E2F1, cyclin D1, bax, bcl2, Ku70, and Ku80 in C6 rat glioma cells. The Ku proteins were chosen as previous studies have shown that loss or reduction in their expression causes increased DNA damage and micronucleus formation in the presence of radiation. The fact that GLA exposure is known to enhance the efficacy of radiation treatment raised the question whether the Ku proteins could be involved in this effect as seen for other molecules such as roscovitine and flavopiridol. GLA altered the mRNA expression of E2F1, cyclin D1, and bax, but no changes were found for bcl2, Ku70, and Ku80. Alterations in protein expression were observed for bax, Ku80, and E2F1. The 45% decrease in E2F1 expression was proportional to decreased cell proliferation (44%). Morphological analysis found a 25% decrease in mitotic activity in the GLA-treated cells, which was accompanied by a 49% decrease in S-phase by FACS analysis. A 39% increase in the number of micronuclei detected by Hoechst fluorescence points to GLA`s effects on cell division even at concentrations that do not produce significant increases in apoptosis. Most important was the finding that Ku80 expression, a critical protein involved in DNA repair as a heterodimer with Ku70, was decreased by 71%. It is probable that reduced Ku80 is responsible for the increase in micronucleus formation in GLA-treated cells in a similar manner to that found in Ku80 null cells exposed to radiation. The decreased expression of Ku80 and E2F1 could make cells more susceptible to radiotherapy and chemotherapy. (C) 2009 IUBMB

Gamma Knife(A (R)) 3-D Dose Distribution Mapping by Magnetic Resonance Imaging

In medical processes where ionizing radiation is used, dose planning and dose delivery are the key elements to patient safety and treatment success, particularly, when the delivered dose in a single session of treatment can be an order of magnitude higher than the regular doses of radiotherapy. Therefore, the radiation dose should be well defined and precisely delivered to the target while minimizing radiation exposure to surrounding normal tissues [1]. Several methods have been proposed to obtain three-dimensional (3-D) dose distribution [2, 3]. In this paper, we propose an alternative method, which can be easily implemented in any stereotactic radiosurgery center with a magnetic resonance imaging (MRI) facility. A phantom with or without scattering centers filled with Fricke gel solution is irradiated with Gamma Knife(A (R)) system at a chosen spot. The phantom can be a replica of a human organ such as head, breast or any other organ. It can even be constructed from a real 3-D MR image of an organ of a patient using a computer-aided construction and irradiated at a specific region corresponding to the tumor position determined by MRI. The spin-lattice relaxation time T (1) of different parts of the irradiated phantom is determined by localized spectroscopy. The T (1)-weighted phantom images are used to correlate the image pixels intensity to the absorbed dose and consequently a 3-D dose distribution with a high resolution is obtained.

Determination of Very Slow Diffusion of Paramagnetic Ions by NMR Spectroscopy

In this paper, we propose a new method of measuring the very slow paramagnetic ion diffusion coefficient using a commercial high-resolution spectrometer. If there are distinct paramagnetic ions influencing the hydrogen nuclear magnetic relaxation time differently, their diffusion coefficients can be measured separately. A cylindrical phantom filled with Fricke xylenol gel solution and irradiated with gamma rays was used to validate the method. The Fricke xylenol gel solution was prepared with 270 Bloom porcine gelatin, the phantom was irradiated with gamma rays originated from a (60)Co source and a high-resolution 200 MHz nuclear magnetic resonance (NMR) spectrometer was used to obtain the phantom (1)H profile in the presence of a linear magnetic field gradient. By observing the temporal evolution of the phantom NMR profile, an apparent ferric ion diffusion coefficient of 0.50 mu m(2)/ms due to ferric ions diffusion was obtained. In any medical process where the ionizing radiation is used, the dose planning and the dose delivery are the key elements for the patient safety and success of treatment. These points become even more important in modern conformal radio therapy techniques, such as stereotactic radiosurgery, where the delivered dose in a single session of treatment can be an order of magnitude higher than the regular doses of radiotherapy. Several methods have been proposed to obtain the three-dimensional (3-D) dose distribution. Recently, we proposed an alternative method for the 3-D radiation dose mapping, where the ionizing radiation modifies the local relative concentration of Fe(2+)/Fe(3+) in a phantom containing Fricke gel and this variation is associated to the MR image intensity. The smearing of the intensity gradient is proportional to the diffusion coefficient of the Fe(3+) and Fe(2+) in the phantom. There are several methods for measurement of the ionic diffusion using NMR, however, they are applicable when the diffusion is not very slow.

MRI study of radiation effect on Fricke gel solutions

The quality control optimization of medical processes that use ionizing radiation in the treatment of diseases like cancer is a key element for patient safety and success of treatment. The major medical application of radiation is radiotherapy, i.e. the delivery of dose levels to well-defined target tissues of a patient with the purpose of eliminating a disease. The need of an accurate tumour-edge definition with the purpose of preserving healthy surrounding tissue demands rigorous radiation treatment planning. Dosimetric methods are used for dose distribution mapping region of interest to assure that the prescribed dose and the irradiated region are correct. The Fricke gel (FXG) is the main dosimeter that supplies visualization of the three-dimensional (3D) dose distribution. In this work the dosimetric characteristics of the modified Fricke dosimeter produced at the Radiation Metrology Centre of the Institute of Energetic and Nuclear Research (IPEN) such as gel concentration dose response dependence, xylenol orange addition influence, dose response between 5 and 50Gy and signal stability were evaluated by magnetic resonance imaging (MRI). Using the same gel solution, breast simulators (phantoms) were shaped and absorbed dose distributions were imaged by MRI at the Nuclear Resonance Laboratory of the Physics Institute of Sao Paulo University. (C) 2007 Elsevier Ltd. All rights reserved.

Effects of Low-Level Laser Therapy on Collagen Expression and Neutrophil Infiltrate in 5-Fluorouracil-Induced Oral Mucositis in Hamsters

Background and Objectives: Several studies have suggested that low-level laser therapy (LLLT) can ameliorate oral mucositis, however, the mechanisms involved are not well understood. The aim of this study was to investigate the mechanisms of action of LLLT on chemotherapy-induced oral mucositis, as related to effects on collagen expression and inflammation Materials and Methods: A hamster cheek pouch model of oral mucositis was used with all animals receiving intraperitoneal 5-fluorouracil, followed by surface irritation. Animals were randomly allocated into three groups, and treated with an InGaAIP diode laser at a wavelength of 660 nm and output power of 35 or 100 mW laser, or no laser Clinical severity of mucositis was assessed at four time-points by a blinded examiner Buccal pouch tissue was harvested from a subgroup of animals in each group at four time-points. Collagen was qualitatively and quantitatively evaluated after picrosinus staining. The density of the neutrophil infiltrate was also scored Results: Peak clinical severity of mucositis was reduced in the 35 mW laser group as compared to the 100 mW and control groups The reduced peak clinical severity of mucositis in the 35 mW laser group was accompanied by a decrease in the number of neutrophils and an increase in the proportion of mature collagen as compared to the other two groups. The total quantity of collagen was significantly higher in the control (no laser) group at the day 11 time-point, as compared to the 35 mW laser group, consistent with a more prolonged inflammatory response in the control group. Conclusion: This study supports two mechanisms of action for LLLT in reducing mucositis severity. The increase in collagen organization in response to the 35 mW laser indicates that LLLT promotes wound healing In addition, LLLT also appears to have an anti-inflammatory effect, as evidenced by the reduction in neutrophil infiltrate Lasers Surg Med 42 546-552, 2010. (C) 2010 Wiley-Liss, Inc.

Thermoluminescent and optical absorption properties of neodymium doped yttrium aluminoborate and yttrium calcium borate glasses

Neodymium doped yttrium aluminoborate and yttrium calcium borate glasses were prepared by the conventional melting-quenching technique with neodymium concentration varying from 0.10 to 1.0 mol%. The obtained glasses present a wide transparency in the UV-visible region (till 240 nm). The thermoluminescent (TL) emission of beta-irradiated samples was measured, showing a broad peak at similar to 240 degrees C with intensities related to the Nd(3+) content, for both glasses. Calcium borate glass samples are about one order of magnitude less luminescent than the aluminoborate glasses. Probably the presence of Ca(2+), instead of Al(3+) and Y(3+) in the matrix, inhibits the production of the intrinsic hole centers. connected to boron and oxygen, known in the literature to act as luminescent centers in TL emission of borate glasses. We suggest that Nd(3+) ions act as electron trapping centers in both glass matrices, as they modify the temperature of emission and the light intensity. Also, the Nd:YAIB glass can be used as a dosimeter in various applications, including radiotherapy. but the sensitivity of this material to neutron should be checked. (C) 2008 Elsevier B.V. All rights reserved.

Estudo clínico de fase II e farmacocinético para o uso de Talidomida em pacientes com câncer colorretal metastático

O objetivo deste estudo foi avaliar a eficácia, a segurança e a farmacocinética da talidomida nos pacientes com câncer colorretal metastático. Dezessete pacientes com adenocarcinoma colorretal metastático, previamente tratados com pelo menos um regime de quimioterapia, foram incluídos no estudo. Os pacientes eram inicialmente tratados com talidomida 200 mg/dia, com um aumento de dose de 200mg a cada duas semanas, até atingir a dose máxima de 800 mg/dia. Os pacientes eram reavaliados a cada duas semanas para toxicidade e a cada 8 semanas para taxa de resposta através de exames de imagem. A farmacocinética foi caracterizada em quatro pacientes no nível de dose de 200 mg/dia.Todos os dezessete pacientes incluídos foram avaliados no perfil de toxicidade e quatorze pacientes nos critérios de taxa de resposta. A talidomida foi bem tolerada, sendo os principais efeitos colaterais a sonolência, a tontura, a xerostomia e a constipação. Não houve nenhuma resposta objetiva ou doença estável após oito semanas de tratamento. A sobrevida global mediana foi de 3,6 meses. A talidomida é bem tolerada como agente único de tratamento, mas não demonstrou nenhuma atividade antitumoral em pacientes com câncer colorretal metastático, já tratados previamente com outro regime de quimioterapia. Apesar disto, futuros estudos com este agente em estágios iniciais desta neoplasia devem ser considerados, quando as propriedades antiangiogênicas desta droga poderão ser mais relevantes para a progressão da doença.

Estudo da farmacocinética da talidomida em pacientes com tumores sólidos refratários

O objetivo deste estudo foi avaliar os parâmetros farmacocinéticos da talidomida em pacientes com tumores sólidos refratários incluídos em estudo de fase II em nossa Instituição. Foram incluídos 14 pacientes, sendo 5 com diagnóstico de adenocarcinoma de reto, 4 com adenocarcinoma de cólon, 4 com melanoma e 1 com adenocarcinoma de pâncreas. Todos os pacientes foram previamente tratados, 14 com cirurgia, 11 com quimioterapia, 5 com radioterapia e 1 com imunoterapia. Os pacientes foram inicialmente tratados com talidomida 200 mg/dia, com um aumento de dose de 200mg a cada duas semanas, até atingir a dose máxima de 800 mg/dia. Treze pacientes atingiram o nível de 400mg/dia, 9 pacientes os níveis de 600mg/dia e apenas 5 pacientes atingiram 800mg/dia. A farmacocinética foi caracterizada em oito pacientes no nível de dose de 200 mg/dia. Todos os 14 pacientes incluídos foram avaliados quanto ao perfil de toxicidade e resposta antitumoral. A talidomida foi bem tolerada, sendo os principais efeitos colaterais a sonolência, a tontura, a xerostomia e a constipação. Não foram observadas respostas tumorais objetivas. Para avaliar os parâmetros farmacocinéticos da talidomida foram coletadas amostras de sangue imediatamente antes da administração da droga, 1h, 2h, 2,5h, 3h, 3,5h, 4h, 5h, 7h e 24h após a administração da primeira dose de talidomida de 200mg. A determinação das concentrações e parâmetros farmacocinéticos da talidomida nestas amostras foi realizada por cromatografia líquida de alta performance. A curva de decaimento das concentrações plasmáticas obedeceu a um modelo farmacocinético monocompartimental. A média dos principais parâmetros farmacocinéticos estudados foi: Cmax 1,48 ± 0,56μg/ml, Tmax 4,4± 0,5h, ASC 17,7±8,4μg x h/mL e t½ 6,5±3,0 hs. O autor pode concluir que os parâmetros farmacocinéticos da talidomida estudados nestes pacientes foram semelhantes àqueles descritos anteriormente em voluntários sadios, pacientes com HIV, hanseníase ou adenocarcinoma de próstata.

Avaliação da saúde bucal e anomalias dentárias em pacientes tratados com leucemia na infância e adolescência

Objetivo: o objetivo deste estudo foi avaliar as condições de saúde bucal e a ocorrência de anomalias dentárias em crianças tratadas para leucemia linfoblástica aguda (LLA) no Serviço de Oncologia Pediátrica (SOP) do Hospital de Clínicas de Porto Alegre (HCPA), comparadas com um grupo crianças saudáveis. Amostra: foram selecionadas 56 crianças com diagnóstico de LLA e analisadas as presenças de anomalias dentárias e os índices CPO-D (cariado, perdido, obturado-dente), IPV (índice de placa visível), ISG (índice de sangramento gengival) e fluxo salivar. As crianças tratadas apresentaram uma média de idade, na época do diagnóstico da LLA, de 5,3 ± 2,6, e 11,8 ± 4,2 na avaliação, sendo 32 masculinos e 24 femininos. Os pacientes tratados para LLA foram divididos em três grupos: crianças tratadas somente com quimioterapia, com quimio e radioterapia, e com quimio, radio e transplante de medula óssea. Resultados: os resultados revelaram 80,4% de anomalias dentárias nas crianças tratadas, ou seja, 45 destas apresentaram pelo menos uma alteração, e o grupo de pacientes tratados com quimio, radio e submetidos ao transplante de medula óssea foi o que revelou a maior média de anormalidades dentárias por indivíduo (15,37 ± 15,03), não ocorrendo diferença estatística entre os gêneros. As crianças tratadas para LLA obtiveram CPO-D de 1,9 ± 4,0, ISG de 26,5%, IPV de 72,0%, e índice de fluxo salivar médio de 0,19 mL/min criança. Já o grupo de crianças sadias apresentou CPO-D de 1,52 ± 3,5, ISG de 11,1%, IPV de 53,8% e índice de fluxo salivar médio de 0,27 mL/min. Conclusão: o tratamento para a cura da LLA provoca um aumento significativo no número de anomalias dentárias, sendo mais freqüente nos pacientes menores de cinco anos de idade, principalmente nos pacientes submetidos a quimio e radioterapia associadas ao transplante de medula óssea, o que requer, por parte do cirurgião-dentista, intervenções clínicas diferenciadas e cuidadosas nestes pacientes, tendo-se em vista também os índices aumentados de ISG e IPV. As alterações sofridas pelas glândulas salivares durante o tratamento não são permanentes sob o aspecto do fluxo salivar, que retorna à normalidade. A orientação e o acompanhamento adequados destes pacientes por parte da equipe de saúde bucal podem mantê-los com o índice de CPO-D dentro dos padrões preconizados pela Organização Mundial de Saúde.

Valor prognóstico de células TCD8+ E natural killer em carcinoma epidermóide oral e orofaringeano tratado com radioterapia e quimioterapia

The most common malignant neoplasm of the oral cavity and oropharynx are squamous cell carcinoma. Injuries to the same stage and subjected to the same treatment protocol have sometimes different evolutionary courses. The scope of this study was to investigate, through a retrospective cohort, associations between the number of CD8 + T cells and natural killer, identified immunohistochemically in the inflammatory infiltrate in a series of cases of oral squamous cell carcinoma and orofaringeano, and the level of tumor response to radiotherapy and chemotherapy, overall survival and relapse-free survival of patients. We identified 54 patients with unresectable disease were treated exclusively with radiotherapy and chemotherapy. The median follow-up was 22 months. The sample was characterized by the predominance of male subjects, median age 60 years, all were smokers. The most frequent site was the tongue and 81.5% were in stage IV. Patients with disease in the oral cavity had a worse response to treatment (p = 0.006), worse relapse-free survival (p = 0.007), worse overall survival (p = 0.007). The advanced T stage was shown a negative prognostic factor (p= 0.006) for the clinical treatment response made. Immunohistochemistry was performed to select CD8 + cells (anti-CD8) and NK cells (anti-CD57). Lymphocytes positive and negative markings were counted using the program ImageJ ®. Two groups were created for each marking evaluated: Group I patients with more than 50% cells positive, Group II: less than 50% of labeled cells. For CD8 + cells detected in 38 (70.3%) of Group I were CD8 + and 16 (29.7%) Group II CD8 +. For NK cells, 26 (48.15%) Group I NK and 28 (51.85%) Group II NK. Regarding the clinical response to treatment, we observed that 39% of patients achieved a complete response and 25.9% remained without recurrence at the end of follow-up. These results were better in Group I CD8 + (p = 0.2). Identified that 72.2% of patients progressed to death, this finding had no association with the immunohistochemical data. There was no statistically significant differences between the number of CD8 + and NK cells and the ability of tumor response to radiotherapy and chemotherapy, or with overall survival and relapse-free survival of patients. However, especially in relation to a learned response, we found that this group of patients with advanced disease have a low count of CD8 + T cells active. Believing in the role that the immune response plays in the local fight against neoplastic cells, however, our results do not support the use of quantitative analysis of CD8 + T cells and NK cells as a prognostic factors for oral squamous cell carcinoma and oropharynx