viernes, 25 de octubre de 2013

Oncología Radioterápica Huelva: ONCOURG® Guía Práctica de Actuación en Urgencias Oncológicas para Especialistas Internos Residentes y Médicos de Atención Primaria

Oncología Radioterápica Huelva: ONCOURG® Guía Práctica de Actuación en Urgencias Oncológicas para Especialistas Internos Residentes y Médicos de Atención Primaria

ONCOURG® Guía Práctica de Actuación en Urgencias Oncológicas para Especialistas Internos Residentes y Médicos de Atención Primaria

Editor Dr. David M Muñoz Carmona

Nueva guía clínica para la actuación en urgencias con enfermos oncológicos.
Muy Interesante tal y como está la Sanidad

La atención del paciente oncológico en urgencias no representa un alto porcentaje de todos los pacientes que acuden a urgencias, pero su atención por médicos no especialistas en oncología hace que a menudo sea bastante compleja.
Algunas series nos hablan que entorno al 5-10% de los pacientes que acuden a urgencias son enfermos oncológicos. Entre los tumores más frecuentes que hacen que el paciente acuda con urgencia podemos encontrar el cáncer de pulmón, el cáncer de mama y el cáncer de colon entre otros.
Además es muy frecuente que el paciente oncológico sea un gran demandante de atención urgente, estando sus consultas relacionadas tanto por la enfermedad como por cualquier otra patología no relacionada con su proceso oncológico.
Al existir un gran desconocimiento de la patología oncológica en urgencias hace que el índice de ingresos aumente de manera significativa en el hospital.
En primer lugar podríamos llegar a definir el concepto de urgencia oncológica como toda aquella situación que supone un riesgo para la vida del paciente con cáncer o un deterioro de su estado de salud relacionada tanto con su enfermedad como con los tratamientos derivados de su proceso oncológico.
Hoy por hoy cada día más se aumenta tanto la supervivencia como la calidad de vida de los pacientes oncológicos, esto hace que cualquier proceso intercurrente en nuestros pacientes pueda deteriorar la supervivencia de los mismos, por lo que es fundamental el conocimiento de las urgencias oncológicas por los médicos que los van a atender de manera urgente.
La evolución que se ha producido en el campo del tratamiento del paciente oncológico se debe tanto a la importancia que en el sistema de salud supone la patología oncológica, como a que hoy el cáncer es la primera causa de mortalidad nuestro país, por encima de las causas por enfermedades cardíacas o vasculares. En el año 2000 en España fallecieron 91.000 pacientes, lo que representa el 25% de todas las muertes. Por otro lado la supervivencia del paciente diagnosticado de cáncer en España a los cinco años ronda el 57% para los hombres y en el 44% para la mujeres. Todo esto no hace más que resaltar la importancia de la actualización de los conocimientos en la patología urgente oncológica en el entorno de atención primaria y la medicina de urgencias.
No debemos olvidar que los pacientes oncológicos tienen relación directa con su oncólogo médico o su oncólogo radioterápico de manera que cuando son atendidos por los médicos de urgencia demandan la atención de su oncólogo de referencia, lo cual hace incluso más difícil la atención al paciente y a su familia, sin mencionar el probable desconocimiento del proceso de la enfermedad, pronóstico y tratamiento seguidos por el paciente durante su evolución.  Todo esto hace que la toma de decisiones por parte del médico que lo atiende de urgencias sea realmente complicada a la vez que importante.
Nos gustaría resaltar que debido a las circunstancias especiales de la atención en urgencias, y que el paciente que estamos tratando es un enfermo oncológico, hace que la actitud médica de urgencia deba desarrollarse en el entorno de la empatización tanto con el enfermo como con su familia.
Tendremos que ir adquiriendo cada vez más habilidades en el campo de la comunicación con el enfermo oncológico, las técnicas de entrevista clínica, el manejo del control de síntomas, la atención y apoyo a la familia que sin lugar a dudas redundarán en una mejora de la atención del paciente oncológico en urgencias.
Si el paciente llega a urgencias sin diagnóstico o sin filiación de su neoplasia tendremos que estar alerta del síntoma que nos refiera tanto él como su familia realizando una anamnesis y exploración física completa. Tras haber alcanzado una sospecha diagnóstica podremos solicitar estudios complementarios, adquirir una presunción diagnóstica y realizar una derivación al especialista en Oncología de manera adecuada.
Si el paciente llega a urgencias con un diagnóstico y/o tratamiento oncológico establecido, tendremos que orientar nuestra historia clínica hacia el motivo principal de la consulta (efectos secundarios de la quimio-radioterapia, síntomas derivados de la progresión  tumoral, patología intercurrente, etc.)
Para solucionar todas estas situaciones urgentes que entrañan un riesgo vital para el enfermo oncológico o que empeoran su calidad de vida confeccionamos esta GUÍA PRÁCTICA DE ACTUACIÓN EN URGENCIAS ONCOLÓGICAS para médicos especialistas internos residentes y  médicos de atención primaria, al igual que intentamos establecer una pauta de actuación para todos los profesionales sanitarios que atiendan enfermos oncológicos, con todo ello, hemos pretendido que esta guía sea de fácil manejo y útil en la toma de decisiones clínicas urgentes. Pretendemos que sirva para realizar una evaluación integral del paciente oncológico y de su familia, que permita reconocer los problemas tanto físicos, sociales y psicológicos del paciente y por ende que los profesionales que los atienden se sientan capaces de poner en marcha todas sus habilidades y conocimientos a disposición de nuestros pacientes oncológicos.



miércoles, 23 de octubre de 2013

Blood Test Detects Lung Cancer



News | October 22, 2013 | Lung Cancer

A blood test that detects a combination of proteins can distinguish between early lung cancer and noncancerous lung nodules, according to a study published in Science Translational Medicine. The two types of nodules are currently difficult to distinguish using imaging. The test showed a 90% negative predictive value in a study of 104 patient samples from three clinical sites. Further validation on 37 samples from a single site showed a 94% negative predictive value.
This molecular test may complement the current tools used by clinicians to diagnose early-stage lung cancer.
The early lung cancer detection test is being developed by Seattle-based molecular diagnostic company Integrated Diagnostics (Indi). The test detects the levels of 13 proteins in a patient’s blood sample and could prevent unnecessary biopsies of lung nodules detected by CT scans.
“These studies suggest that Indi’s technology is capable of detecting the molecular signature of lung cancer by measuring the presence of multiple proteins in a patient’s blood,” said senior author Paul Kearney, PhD, president and chief science officer of Integrated Diagnostics, in a released statement.
The researchers used a systems biology approach, screening 371 blood-based proteins on 143 patient samples with either benign or stage 1A lung cancer that were matched for nodule size, age, gender, and clinical site.
Multiple reaction monitoring (MRM) mass spectrometry is used to analyze the relative concentrations on biomarkers. The technology allows simultaneous analysis of many protein levels.
Further analysis to understand the role of these biomarker proteins showed that all 13 are likely regulated by four transcription factors that bind to the regulatory elements of the 13 genes that encode the proteins. All four transcription factors have been associated with lung inflammation and lung cancer, as well as oxidative stress pathways.
The validation using 104 patient samples showed a test sensitivity of 71% and specificity of 44%. The study researchers assumed that the rate of cancer prevalence was 15%. At the same cancer prevalence rate, the sensitivity was 82% and the specificity was 66% in the discovery cohort of 143 samples.
The protein levels were found to be independent of known risk factors for pulmonary nodules: the size of the nodule detected, history of smoking, and age.
According to Kearney and fellow study authors, one-fifth of patients with detectable lung nodules who undergo biopsy or surgery actually have a malignant nodule. Therefore, a reliable test that can discriminate between a benign lung mass and a cancerous lung mass is needed to prevent unnecessary invasive procedures and surgery.
Still, the study cohorts used here are retrospective, and a prospective validation trial is needed to understand the full clinical potential of the blood test. Additionally, the authors note that the test results are not integrated with clinical risk factors, although they also note that “pulmonologists vary broadly in the use of clinical risk factors, and so, it is actually preferable to have a molecular diagnostic test that produces a score independent of clinical risk factors.”
Even if validated, it is likely that such a blood test will be part of the other information used by clinicians to make the best-informed decision for each individual patient.
Stephen Malkoski, MD, PhD, who specializes in pulmonary medicine at the University of Colorado Cancer Center in Aurora and who was not involved in the research, says interpreting the test results would likely depend on the calculated risk clinicians currently use to assess whether a nodule could be cancerous. Factors that go into the risk calculation include size of the nodule, its location, smoking history, age, emphysema, and family lung cancer history. “In a low-risk patient with a 1% to 2% risk of lung cancer, the patient would still likely need a follow-up CT scan since the blood test could not definitely exclude malignancy.”
Malkoski sees the test as potentially being the most helpful in intermediate-risk patients with a calculated risk of malignancy between 10% and 20%. “In this group, a negative test might obviate the need for additional workup, such as a PET scan or biopsy,” he notes. “This may make a clinician more comfortable opting for radiographic follow-up rather than an invasive procedure.”



martes, 15 de octubre de 2013

Phase II clinical trial of whole-brain irradiation plus three-dimensional conformal boost with concurrent topotecan for brain metastases from lung cancer

Xiao-hui GeQiang LinXiao-cang RenYue-e LiuXue-ji ChenDong-ying WangYong-qiang WangBin CaoZhi-gang Li and Miao-ling Liu
Radiation Oncology 2013, 8:238 
Published: 14 October 2013

Abstract 

Background

Patients with brain metastases from lung cancer have poor prognoses and short survival time, and they are often excluded from clinical trials. Whole-cranial irradiation is considered to be the standard treatment, but its efficacy is not satisfactory. The purpose of this phase II clinical trial was to evaluate the preliminary efficacy and safety of the treatment of whole-brain irradiation plus three-dimensional conformal boost combined with concurrent topotecan for the patients with brain metastases from lung cancer.

Methods

Patients with brain metastasis from lung cancer received concurrent chemotherapy and radiotherapy: conventional fractionated whole-brain irradiation, 2 fields/time, 1 fraction/day, 2 Gy/fraction, 5 times/week, and DT 40 Gy/20 fractions; for the patients with <= 3 lesions with diameter >= 2 cm, a three-dimensional (3-D) conformal localised boost was given to increase the dosage to 56--60 Gy; and during radiotherapy, concurrent chemotherapy with topotecan was given (the chemoradiotherapy group, CRT). The patients with brain metastasis from lung cancer during the same period who received radiotherapy only were selected as the controls (the radiotherapy-alone group, RT).

Results

From March 2009 to March 2012, both 38 patients were enrolled into two groups. The median progression-free survival(PFS) time , the 1- and 2-year PFS rates of CRT group and RT group were 6 months, 42.8%, 21.6% and 3 months, 11.6%, 8.7% (chi2 = 6.02, p = 0.014), respectively. The 1- and 2-year intracranial lesion control rates of CRT and RT were 75.9% , 65.2% and 41.6% , 31.2% (chi2 = 3.892, p = 0.049), respectively. The 1- and 2-year overall survival rates (OS) of CRT and RT were 50.8% , 37.9% and 40.4% , 16.5% (chi2 = 1.811, p = 0.178), respectively. The major side effects were myelosuppression and digestive toxicities, but no differences were observed between the two groups.

Conclusion


Compared with radiotherapy alone, whole-brain irradiation plus 3-D conformal boost irradiation and concurrent topotecan chemotherapy significantly improved the PFS rate and the intracranial lesion control rate of patients with brain metastases from lung cancer, and no significant increases in side effects were observed. Based on these results, this treatment method is recommended for phase III clinical trial.

domingo, 13 de octubre de 2013

NUEVO ARTICULO: QT-RT EN ESTADIO IV DE CA PULMON???. Overall survival and toxicities regarding thoracic three-dimensional radiotherapy with concurrent chemotherapy for stage IV non-small cell lung cancer: results of a prospective single-center study

Su S, Hu Y, Ouyang W, Lu B, Ma Z, Li Q, Li H, Geng Y
BMC Cancer 2013, 13 :474 (12 October 2013)

Background
The role of chemotherapy given concurrently with thoracic three-dimensional radiotherapy for stage IV non-small cell lung cancer (NSCLC) is not well defined. We performed this study to investigate overall survival and toxicity in patients with stage IV NSCLC treated with this modality.
Methods
From 2003 to 2010, 201 patients were enrolled in this study. All patients received chemotherapy with concurrent thoracic three-dimensional radiotherapy. The study endpoints were the assessment of overall survival (OS) and acute toxicity.
Results
For all patients, the median survival time (MST) was 10.0 months, and the 1-, 2- and 3-year OS rates were 40.2%, 16.4%, and 9.6%, respectively. The MST was 14.0 months for patients who received a total radiation dose 63 Gy to the primary tumor, whereas it was 8.0 months for patients who received a total dose <63 gy="" span="">P = 0.000). On multivariate analysis, a total dose 63 Gy, a single site of metastatic disease, and undergoing 4 cycles of chemotherapy were independent prognostic factors for better OS (P = 0.007, P = 0.014, and P = 0.038, respectively); radiotherapy involving metastatic sites was a marginally significant prognostic factor (P = 0.063). When the whole group was subdivided into patients with metastasis at a single site and multiple sites, a higher radiation dose to the primary tumor remained a significant prognostic factor for improved OS. For patients who received 4 cycles of chemotherapy, high radiation dose remained of benefit for OS (P = 0.001). 
Moreover, for the subgroup that received < 4 chemotherapy cycles the radiation dose was of marginal statistical significance regarding OS (P=0.063). Treatment-related toxicity was found to be acceptable. 
Conclusions
Radiation dose to primary tumor, the number of metastatic sites, and the number of chemotherapy cycles were independent prognostic factors for OS in stage IV NSCLC patients treated with concurrent chemoradiotherapy. In addition to systemic chemotherapy, aggressive thoracic radiotherapy was shown to play an important role in improving OS. 

miércoles, 9 de octubre de 2013

Spare the Hippocampus, Preserve the Memory in Whole Brain Irradiation

News October 01, 2013
ATLANTA (IMNG) – Sparing the hippocampus during whole brain irradiation can pay off in memory preservation for months to come, according to Dr. Vinai Gondi.
Adults with brain metastases who underwent whole brain radiation therapy (WBRT) with a conformal technique designed to minimize radiation dose to the hippocampus had a significantly smaller mean decline in verbal memory 4 months after treatment than did historical controls, reported Dr. Gondi, codirector of the Cadence Health Brain Tumor Center in Chicago and a coprincipal investigator in the Radiation Therapy Oncology Group Trial 0933.
“These phase II results are promising, and highlight the importance of the hippocampus as a radiosensitive structure central to memory toxicity,” Dr. Gondi said in a briefing prior to his presentation in a plenary session of the American Society for Radiation Oncology.
The hippocampus has been shown to play host to neural stem cells that are constantly differentiating into new neurons throughout adult life, a process important for maintaining memory function, he noted.
Previous studies have shown that cranial irradiation with WBRT is associated with a 4- to 6-month decline in memory function, as measured by the Hopkins Verbal Learning Test (HVLT) total recall and delayed recall items.
By using intensity modulated radiation therapy (IMRT) to shape the beam and largely spare the pocket of neural stem cells in the dentate gyrus portion of the hippocampus, the investigators hoped to avoid the decrements in memory function seen with earlier, less discriminating WBRT techniques, he said.
They enrolled 113 adults with brain metastases from various primary malignancies and assigned them to receive hippocampal-avoiding WBRT of 30 Gy delivered in 10 fractions. Radiation oncologists participating in the trial were trained in the technique, which involves careful identification of hippocampal landmarks and titration of the dose to minimize exposure of the hippocampus in general, and the dentate gyrus in particular. 
Under the protocol, the total radiation dose to the entire volume of the hippocampus can be no more than 10 Gy, and no single point in the hippocampus can receive more than 17 Gy.
Controls were patients in an earlier phase III clinical trial who underwent WBRT without hippocampal avoidance.
At 4 months, 100 patients treated with the hippocampal-sparing technique who were available for analysis had a 7% decline in the primary endpoint – delayed recall scores from baseline – compared with 30% for historical controls (P = .0003).
Among the 29 patients for whom 6-month data were available, the mean relative decline from baseline in delayed recall was 2% and in immediate recall was 0.7%. In contrast, there was a 3% increase in total recall scores.
The risk of metastasis to the hippocampus was 4.5% during follow-up, Dr. Gondi said.
The Radiation Oncology Therapy Group is currently developing a phase III trial of prophylactic cranial radiation with or without hippocampal avoidance for patients with small cell lung cancer.
The study demonstrates the value of improving and incorporating into practice newer radiation delivery technologies such as IMRT, said Dr. Bruce G. Haffty, a radiation oncologist at the Cancer Institute of New Jersey in New Brunswick, and ASTRO president-elect.
“It’s nice to have that technology available, and it’s now nice to see that we can use that technology to [reduce] memory loss and improve quality of life for our patients undergoing whole brain radiation therapy,” he said.
Dr. Haffty moderated the briefing, but was not involved in the study.
RTOG 0993 was supported by the National Cancer Institute. Dr. Gondi and Dr. Haffty reported having no relevant financial conflicts. 

A potent steroid cream is superior to emollients in reducing acute radiation dermatitis in breast cancer patients treated with adjuvant radiotherapy. A randomised study of betamethasone versus two moisturizing creams

published online 08 July 2013.

Background and purpose

The aim was to investigate whether treatment with potent local steroids can reduce signs and symptoms of acute radiation dermatitis in breast cancer patients undergoing adjuvant radiotherapy (RT) compared to emollient creams.

Material and methods

The study was randomised and double-blinded. Patients with breast cancer who had undergone mastectomy or breast-conserving surgery were included when they started adjuvant 3-D planned RT.
In all, 104 patients were randomised 2:1:1 to three treatment groups, i.e. betamethasone+Essex® cream, Essex® cream or Canoderm® cream. The patients themselves treated the irradiated area during the radiation period (5weeks) and two weeks after cessation of RT. Signs of RT dermatitis were measured qualitatively with RTOG clinical scoring and quantitatively by colorimeter. In addition, the patients’ symptoms were recorded as well as the Fitzpatrick skin type.
There was a statistically significant difference (p=0.05) in skin reactions when assessed with RTOG in favour of the group treated with the potent steroid. Patient-related symptoms did not differ between the treatment groups.
The effect of the steroid was prominent in three subgroups, i.e. (i) patients treated with ablation of the breast, (ii) patients receiving RT to the armpit and the supraclavicular fossa, and (iii) patients with Fitzpatrick skin type 1.

Conclusions

Treatment with betamethasone cream is more efficient than moisturizers for the control of acute RT dermatitis in patients treated with adjuvant RT for breast cancer.

martes, 8 de octubre de 2013

Modern post-operative radiotherapy for stage III non-small cell lung

Charlotte Billiet a,, Herbert Decaluwé b, Stephanie Peeters a, Johan Vansteenkiste c, Christophe Dooms c,
Karin Haustermans a, Paul De Leyn b, Dirk De Ruysscher a
a Radiation Oncology; b Thoracic Surgery and Leuven Lung Cancer Group; and c Respiratory Oncology (Pneumology) and Leuven Lung Cancer Group, University Hospitals Leuven/KU Leuven, Belgium

Background: We hypothesized that modern postoperative radiotherapy (PORT) could decrease local recurrence (LR) and improve overall survival (OS) in patients with stage IIIA-N2 non-small-cell lung cancer(NSCLC).
Methods: To investigate the effect of modern PORT on LR and OS, we identified published phase III trials for PORT and stratified them according to use or non-use of linear accelerators. Non-individual patient data were used to model the potential benefit of modern PORT in stage IIIA-N2 NSCLC treated with induction chemotherapy and resection.
Results: Of the PORT phase III studies, eleven trials (2387 patients) were included for OS analysis and eight (1677 patients) for LR. PORT decreased LR, whether given with cobalt, cobalt and linear accelerators, or with linear accelerators only. An increase in OS was only seen when PORT was given with linear accelerators, along with the most significant effect on LR (relative risk for LR and OS 0.31 (p = 0.01) and 0.76 (p = 0.02) for PORT vs. controls, respectively).
Four trials (357 patients) were suitable to assess LR rates in stage III NSCLC treated with surgery, in most cases after induction chemotherapy. LR as first relapse was 30% (105/357) after 5 years. In the modelling part, PORT with linear accelerators was estimated to reduce LR rates to 10% as first relapse and to increase the absolute 5-year OS by 13%.
Conclusions: This modeling study generates the hypothesis that modern PORT may increase both LR and OS in stage IIIA-N2 NSCLC even in patients being treated with induction chemotherapy and surgery.

domingo, 6 de octubre de 2013

Phase I study of hypofractionated intensity modulated radiation therapy with concurrent and adjuvant temozolomide in patients with glioblastoma multiforme.

Radiat Oncol. 2013 Feb 20;8:38. doi: 10.1186/1748-717X-8-38.
Source
Division of Radiation Oncology, Cross Cancer Institute and University of Alberta, 11560, University Avenue, Edmonton, AB, T6G 1Z2, Canada.
Abstract
PURPOSE:
To determine the safety and efficacy of hypofractionated intensity modulated radiation therapy (Hypo-IMRT) using helical tomotherapy (HT) with concurrent low dose temozolomide (TMZ) followed by adjuvant TMZ in patients with glioblastoma multiforme (GBM).
METHODS AND MATERIALS:
Adult patients with GBM and KPS > 70 were prospectively enrolled between 2005 and 2007 in this phase I study. The Fibonacci dose escalation protocol was implemented to establish a safe radiation fractionation regimen. The protocol defined radiation therapy (RT) dose level I as 54.4 Gy in 20 fractions over 4 weeks and dose level II as 60 Gy in 22 fractions over 4.5 weeks. Concurrent TMZ followed by adjuvant TMZ was given according to the Stupp regimen. The primary endpoints were feasibility and safety of Hypo-IMRT with concurrent TMZ. Secondary endpoints included progression free survival (PFS), pattern of failure, overall survival (OS) and incidence of pseudoprogression. The latter was defined as clinical or radiological suggestion of tumour progression within three months of radiation completion followed by spontaneous recovery of the patient.
RESULTS:
A total of 25 patients were prospectively enrolled with a median follow-up of 12.4 months. The median age at diagnosis was 53 years. Based on recursive partitioning analysis (RPA) criteria, 16%, 52% and 32% of the patients were RPA class III, class IV and class V, respectively. All patients completed concurrent RT and TMZ, and 19 patients (76.0%) received adjuvant TMZ. The median OS was 15.67 months (95% CI 11.56 - 20.04) and the median PFS was 6.7 months (95% CI 4.0 - 14.0). The median time between surgery and start of RT was 44 days (range of 28 to 77 days). Delaying radiation therapy by more than 6 weeks after surgery was an independent prognostic factor associated with a worse OS (4.0 vs. 16.1 months, P = 0.027). All recurrences occurred within 2 cm of the original gross tumour volume (GTV). No cases of pseudoprogression were identified in our cohort of patients. Three patients tolerated dose level I with no dose limiting toxicity and hence the remainder of the patients were treated with dose level II according to the dose escalation protocol. Grade 3-4 hematological toxicity was limited to two patients and one patient developed Grade 4 Pneumocystis jiroveci pneumonia.
CONCLUSION:
Hypo-IMRT using HT given with concurrent TMZ is feasible and safe. The median OS and PFS are comparable to those observed with conventional fractionation. Hypofractionated radiation therapy offers the advantage of a shorter treatment period which is imperative in this group of patients with limited life expectancy.


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