ADIOLOGY l1111J NCOLOGY March 2004 Vol. 38 No. 1 Ljubljana ISSN 1318-2099 SIEMENS SiemensMedical.com/oncology SEEK-FIND-ACT-FOLLOW -the Continuum of Oncology Care™ Siemens oncology portfoho compnses · comprehensIve maxIm1zed ut1hzat,on potent1al, and patient-friendly des1gn workflow soluttons Integrating the tuli spectrum of care and features. from screening/early detectton and d1agnos1s through therapy and follow-up. Ali from one prov,der -w,th over Every day in the Un,ted States alone. 29,000 cancer 100 years h1story of innovauon ,n medica! technology. pat,ents rece,ve rad,at,on therapy dehvered by Siemens hnear accelerators. As clin,cal protocols transItIon to Siemens praven chn,cal methods can help you to ach,eve ,nclude IMRT and JGRT. Siemens seamlessly ,ntegrates more successful outcomes. How? Through 1ndustry­the d1agnos1,c and treatment modaltttes. That's what we leading technology, ,ncreased producuv,ty measures far call Best Practice Oncology Care. Siemens medica! Solutions that help Editorial office Radiology and Oncology March 2004 Institute of Oncology Vol. 38 No. 1 Zaloška 2 Pages 1-71 SI-1000 Ljubljana ISSN 1318-2099 Slovenia UDC 616-006 Phone: +386 1 5879 369 CODEN: RONCEM Phone/Fax: +386 1 5879 434 E-mail: gsersa@onko-i.si Aims and scope Radiologi; and Oncology is a journal devoted to publication of original contributions in diagnostic and interventional radiologi;, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncologi;, radiobiology, radiophysics and radia/ion protection. Editor-in-Chief Editor-in-Chief Emeritus Gregor Serša Tomaž Benulic Ljubljana, Slovenia Ljubljana, Slovenia Executive Editor Editor Viljem Kovac Uroš Smrdel Ljubljana, Slovenia Ljubljana, Slovenia Editorial board Marija Auersperg Valentin Fidler Maja Osmak Ljubljana, Slovenia Ljubljana, Slovenia Zagreb, Croatia Nada Bešenski Be1a Fornet Branko Palcic Zagreb, Croatia Budapest, Hungary Vancouver, Canada Karl H. Bohuslavizki Tullio Giraldi Jurica Papa Hamburg, Germany Trieste, Italy Zagreb, Croatia Haris Boka Andrija Hebrang Dušan Pavcnik Zagreb, Croatia Zagreb, Croatia Portland, USA Nataša V. Budihna Laszl6 Horvtith Stojan Plesnicar Ljubljana, Slovenia Pecs, Hungary Ljubljana, Slovenia Marjan Budihna Berta Jereb Ervin B. Podgoršak Ljubljana, Slovenia Ljubljana, Slovenia Montreal, Canada Malte Clausen Vladimir Jevtic Jan C. Roos Hamburg, Germany Ljubljana, Slovenia Amsterdam, Netherlands Christoph Clemm H. Dieter Kogelnik Slavko Šimunic Miinchen, Germany Salzburg, Austria Zagreb, Croatia Mario Corsi Jurij Lindtner Lojze Šmid Udine, Italy Ljubljana, Slovenia Ljubljan_.a,Slovenia Ljubomir Diankov Ivan Lovasic Borut Stabuc Sofia, Bulgaria Rijeka, Croatia Ljubljana, Slovenia Christian Dittrich Marijan Lovrencic Andrea Veronesi Vienna, Austria Zagreb, Croatia Aviano, Italy Ivan Drinkovic LukaMilas Živa Zupancic Zagreb, Croatia Houston, USA Ljubljana, Slovenia Gillian Duchesne Metka Milcinski Melbourne, Australia Ljubljana, Slovenia Publisher Association oj Radiology and Oncology Affilia ted wi th Slovenian Medica/ Association -Slovenian Association oj Radiologi;, Nuclear Medicine Society, S/ovenian Society far Radiotherapy and Oncologi;, and S/ovenian Cancer Society Croatian Medica/ Association -Croatian Society oj Radiology Societas Radiologorum Hungarorum Friuli-Venezia Giulia regional groups of S.I.R.M. (Italian Society oj Medica/ Radiology) Copyright © Radiology and Oncologi;. A/l rights reserved. Reader for English Mojca Cakš Keywords Eva Klemencic Secretaries Milica Harisch Mira Klemencic Design Monika Fink-Serša Printed by Imprint d.o.o., Ljubljana, S/ovenia Published quarterly in 700 copies Bank account number 02010-0090006751 Foreign cun-ency account number 010-7100-900067 /4 NLB d.d., Podružnica Ljubljana Center, Ljubljana S. W.I.F. T. Code L]BASI2X Subscription fee far instih1tions EUR 100 (16000 SIT), individuals EUR 50 (5000 SIT) The publication oj this journal is subsidized by the Ministn; of Education, Science and Spori oj the Republic oj S/ovenia. Indexed and abstracted by: BIOMEDICINA SLOVENICA CHEMICAL ABSTRACTS EMBASE / Excerpta Medica Sci Base This journal is printed on acid-free paper Radiologi; and Oncologi; is avai/able on the internet at: http://www.onko-i.si/radiolog/rno.html ISSN 1581-3207 Psychosocial coping strategies in cancer patients COLOGY Ljubljana, Slovenia March 2004 Vol. 38 No. 1 ISSN 1318-2099 UDC 616-006 CODEN: RONCEM CONTENTS RADIOLOGY Boerhaave' s syndrome: a case with an atypical right-sided oesophageal perforation Sjekavica I, Pavliša G, Šeronja-Kuhar M, Moscatello I, Štern-Padovan R 1 MR imaging of aortic coarctation Bešlic Š 5 CLINICAL ONCOLOGY Rituximab affects the prognosis of patients with nonHodgkin(s lymphomas Jezeršek Novakovic B, Vovk M, Borštnar S, Tomšic R Neuron specific enolase -selective marker for small-cell lung cancer Ilievska Poposka B, Spirovski M, Trajkov D, Stefanovski T, Atanasova S, Metodieva M 21 Breast cancer and breast health awareness as an evolving health promotion concept Plesnicar A, Kovac v; Kralj B 27 EXPERIMENTAL ONCOLOGY Comet assay in the assessment of the human genome damage induced by y-radiation in vitro Garaj-Vrhovac v; Davor Zeljezic D A web-application that extends functionality of medical device for tumor treatment by means of electrochemotherapy Pavlovic I, Kramar P, Corovic S, Cukjati D, Miklavcic D RADIATION PHYSICS Evaluation of water equivalency of Plastic W ater™ for high-energy electron beams using IAEA TRS-398 Code of Practice Casar B, Zdešar U, Robar V 55 SLOVENIAN ABSTRACTS 61 NOTICES Radio/ Oncol 2004; 38(1): 1-4. Boerhaave' s syndrome: a case with an atypical right-sided oesophageal perforation Ivica Sjekavicat, Goran Pavlisa1, :ty~arina Seronja-Kuhar1, Ines Moscatello2, Ranka Stern-Padovan1 1Clinical institute for diagnostic and interoentional radiology, Zagreb School of Medicine, University Hospital Center Zagreb -Rebro, Zagreb, Croatia 2Department of radiology, General hospital Pula, Pula, Croatia Background. Boerhaave's syndrome is a complete transmural perforation of the thoracic oesophagus, with the oesophageal tear occurring on the left posterolateral side in 90 % of the patients. Case report. We present a case of Boerhaave's syndrome with an atypical feature of right-sided oe­sophageal rupture. Chest CT has the advantage of imaging all thoracic structures and complications and ex­cluding differentially diagnostic conditions in the case of a high clinical suspicion of oesophageal rupture. Conclusions. CT is especially important in patients whose severe clinical condition does not permit eso­phagography. Key words: esophageal diseases, rupture, spontaneous; tomography, X-ray computed Introduction Boerhaave's syndrome is a spontaneous com­plete transmural perforation of the thoracic oesophagus secondary to food bolus im­paction. Perforation in most cases results from violent retching or vomiting after exces­sive food and alcohol intake. The syndrome Received 1 March 2004 Accepted 15 March 2004 Correspondence to: Goran Pavlisa, M.D., Clinical Institute for Diagnostic and Interventional Radiology, University Hospital Center Zagreb -Rebro, Kispaticeva 12, 10000 Zagreb, Croatia; Phone: +385 1 2388455; Fax: +385 1 2388250; E-mail: goran.pavlisa@ zg.htnet.hr owes its' name to famous Dutch 171h century physician Hermann Boerhaave who de­scribed a case of Great Admiral of Dutch fleet who overate and after vomiting acquired this condition. The syndrome is life threatening, with overall mortality of about 35%.1-3 It is a con­sequence of neuromuscular incoordination, with a barogenic injury caused by a sudden increase in intraluminal pressure against a constricted cricopharyngeus muscle which fails to relax. Since the perforation is caused by vomiting and oesophageal barotrauma, it is, literally spoken, not spontaneous, but this term distinguishes it from much more often iatrogenic rupture. The oesophageal tear is usually linear, 1-5 cm in length, vertically ori­ented. It occurs in a majority of cases (90%) on the left posterolateral side, 2-3 cm above the gastroesophageal junction.u Gastric con­tent extraluminates into mediastinum and pleural space, ensuing mediastinitis, sepsis and shock. No haematemesis occurs because blood escapes outside the oesophageal lumen after rupture. Haematemesis is a feature of more common Mallory-Weiss tear, which is a gastric (rarely oesophageal) mucosal and sub­mucosal tear. The clinical features of Boerhaave's syn­drome are often misleading. The so-called Mackler triad is virtually pathognomonic, consisting of forceful vomiting, sudden onset of pain (substernal, neck, abdominal-epigas­tric, or radiating to the shoulder) and subcu­taneous emphysema. Complete triad is sel­dom present. Other symptoms include dysp­nea, tachypnea, abdominal rigidity and signs of haemodinamic shock. The mainstay of therapy is prompt surgical intervention with closure of the tear, intravenous volume resus­citation and mediastinal drainage, except for some cases of small-contained iatrogenic in­juries and cervical perforations. Boerhaave's syndrome occurs 2-5 times more often in males than in females, typically in middle­aged men.1•3 We present a case of Boerhaave's syn­drome with extensive bilateral intrathoracic pathology and an atypical feature of right­sided oesophageal rupture, reported in a mi­nority of cases.4•5 Case report A 57-year old male patient was admitted to a county hospital after suffering a vomiting se­ries. He presented with epigastric pain, force­ful vomiting and signs of gastro-intestinal bleeding, without subcutaneous emphysema. His cardiac condition was stable. Plain ab­dominal film was normal. After insertion of nasogastric tube, about 700 ml of haematinic content was removed. Endoscopy revealed extensive blood coagula in the oesophageal and stomach lumen. Thirty-six hours after the presentation the patient was transferred to Clinical Hospital Center in haemodynamically stable condi­tion, with intermitent vomiting. Initial oe­sophagography and endoscopy both failed due to dyspnea and psychomotoric excitation of the patient. During ultrasound examina­tion he developed cardiorespiratory arrest, and was transferred to the intensive care unit after cardio-pulmonary resuscitation. Ultrasound examination showed signs of in­testinal paresis and extensive pleural effu­sion. Thoracocentesis acquired gastric-like content. Since the patient was not able to un­dergo oesophagography, urgent endoscopy was performed and demonstrated 1 cm long oesophagus tear, on the right lateral side, just above the gastro-oesophageal junction with irregular margins, covered with fibrin. The adjacent mucosa was normal and without varices. There were no signs of bleeding ar­tery or fresh blood flow, while stomach was filled with blood clots. Figure 1. Chest er scout view. Non-homogenous in­filtration of the left lung, widened upper and middle mediastinum and signs of paralytic ileus. CT was performed to demonstrate the ex­tent of the disease. A scout view displayed a non-homogenous infiltration of the left lung, widened upper and middle mediastinum and signs of paralytic ileus (Figure 1). Pleural effusions were bilateral, with right­sided major pneumothorax, infiltration of the left lung with atelectatic component and mi­nor pneumothorax (Figure 2). Pneumomediastinum was observed with tiny lucencies especially around distal oe­sophagus and air-fluid levels within medi­astinum (Figures 3,4). Subcutaneous emphy­sema was also noted. Shortly after CT examination the patient died. Pathology report confirmed right-sided oesophageal laceration and CT findings. Figure 2. Axial cr. Bilateral pleural effusions, with right-sided major pneumothorax, non-homogenous infiltration of the left lung with atelectatic component and minor pneumothorax. Figure 3. Axial Cr. Pneumomediastinum with tiny lu­cencies especially around distal oesophagus. Figure 4. Axial CT. Air-fluid levels within medi­astinum. Extensive pleural effusions. Discussion Boerhaave's syndrome is a rare, but diagnos­tically demanding entity. Fast and accurate diagnostics is invaluable. Upright chest radi­ograph is initially abnormal in 90% of patients with pneumomediastinum as the most impor­tant finding.3 The chest radiographs may be normal, because the findings may take an hour after the perforation to appear. The common feature is usually left-sided pleural effusion due to the site of perforation which mostly occurs in the left posterior aspect of the oesophagus; however if perforation oc­curs into right pleural cavity, it is usually in very young patients. Hydropneumothorax (in 51% of cases), subcutaneous emphysema or mediastinal widening may be present.6 A spe­cific, but insensitive radiographic sign is the >>V-sign of Naclerio«-an air lucency between lower thoracic aorta, oesophagus and di­aphragm in the shape of the letter V, present­ing localized mediastinal emphysema. All described signs were present in this case, seen at CT, with an atypical site of oe­sophageal tear on the right lateral side and major right-sided pneumothorax. Computer­ized tomography has the advantage of dis­playing all thoracic structures and excluding differentially diagnostic conditions, like such as: aortic dissection, myocardial infarction, acute pancreatitis, pneumothorax, oesophagi­tis, peptic ulcer disease, spontaneous intra-mural haematoma of the oesophagus (SIHO, oesophageal apoplexy) and Mallory -W eiss tear.7 CT scout view may replace chest radi­ograph in an urgent case. It is required espe­cially in patients whose condition does notal­low oesophagography,8•9 demonstrating the extralumination of contrast material into me­diastinum and displaying the presence, loca­tion and the length of the tear. Presented case emphasises the severity of this syndrome and the importance of aware­ness of clinical manifestations. Survival rate is 70-75% if surgical repair of the rupture is performed in early injury, within 24 hours of the incident.3 Significant number of patients are late in presentation for medical care_lO,ll With late intervention, the mortality rate (even with surgical intervention) rises to higher than 50% and to over 80% after 48 hours.2•3•12 The delay in raising suspicion of oesophageal perforation results in postpon­ing of appropriate and simple diagnostic method-oesophagography. References 1. Janjua KJ. Boerhaave's syndrome. Postgrad Med] 1997; 73: 265-70. 2. Hafer G, Haunhorst WH, Stallkamp B. A traumatic rupture of the esophagus (Boerhaave syndrome). Zentralbl Chir 1990; 115: 729-35. 3. Murphy M, Kalapatapu V. Boerhaave syndrome. eMedicine [serial on line] 2003 Aug [cited 2003 Dec 01]; 5(21): [1 screen]: Available from URL: http:// www.emedicine.com 4. Levy F, Mysko WK, Kelen GD. Spontaneous esophageal perforation presenting with right­sided pleural effusion. ] Emerg Med 1995; 13: 321­5. 5. Jagminas L, Silverman RA. Boerhaave's syndrome presenting with abdominal pain and right hydrop­neumothorax. Am] Emerg Med 1996; 14: 53-6. 6. Hegenbarth R, Birkenfeld P, Beyer R. [Roentgen findings in spontaneous esophageal perforation (Boerhaave syndrome)] [German] Aktuelle Radio/ 1994; 4: 337-8. 7. Clark W, Cook TJ. Spontaneous intramural haematoma of the oesophagus: radiologic recogni­tion. Australas Radio/1996; 40: 269-72. 8. Klaue HJ, Baron Y, Bauer E. [Value of computer­ized tomography in diagnosis of Boerhaave syn­drome] [German]. Zetztralbl Chir 1998; 123: 272-5. 9. Di Maggio EM, Preda L, la Fianza A, Dore R, Pallavicini 0, Di Maggio G, et al. [Spontaneous rupture of the esophagus (Boerhaave syndrome): computerized tomography diagnosis in atypical clinical presentation] [Italian]. Radio/ Med (Torino) 1997; 94: 52-7. 10. Sabanathan S, Eng J, Richardson J. Surgical man­agement of intrathoracic oesophageal rupture. Br] Surg 1994; 81: 863-5. 11. Lawrence OR, Ohri SK, Moxon RE, Townsend ER, Fountain SW. Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg 1999; 67: 818-20. 12. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Amz Thorac Surg 1986; 42: 235-9. Radiol Oncol 2004; 38(1): 5-13. MR imaging of aortic coarctation Šerif Bešlic Institute of Radiology, Clinical Center University, Sarajevo, Bosnia and Hercgovina Purpose. The purpose of this paper is to analyse the contribution of MRI as diagnostic procedure in the pre­operative diagnosis of aortic coarctation (CoA), in patients with clinical and echocardiographic suspicion for this disease. Patients and methods. During the period of three years, eight patients were examined, 5 (62.5%) male and 3 (37.5%) female patients with clinical echocardiographic suspicion of CoA. The ratio between male and fe­male patients was 1.7 : 1. The youngest patient was 3 and the oldest 46 years (median age was 15 years). Without administration of contrast media and using body coil the examinations were performed with MR machine Magnetom 1.0 Tesla (»Siemens«), with the slice thickness of 6 mm, Fast spin-echo (FSE) T1W se­quences, Cine gradient echo (GRE) sequence with slab 7 mm and time of flight (TOF) sequence with MIP reconstructions were applied. During the examinations the patients underwent also ECG gating. Examinations were done in axial, coronal and oblique sagittal projections with measuring of the dimensions of cardiovascular structures. Results. CoA was found in 8 (100%) patients. In 7 (87.5%) cases, coarctation developed at isthmus and in one case, coarctation was detected at the horizontal part of aortic arch, between the truncus arteriosus of the left carotid communis artery. Aortal insufficiency was found in 7 (87.5%) patients; in four of them (50%), bicuspidia was confirmed (bicuspid aortic valve), 7 (87.5%) patients had slightly expressed hypertrophy of the left ventricle. Two (25%) patients had dilatation of the ascendant aorta, six (75%) wider outgoing ves­sels of the aortic arch, four (50%) had well developed arterial collaterals and 2 (25%) patients rib notching. In 2 (25%) patients as side finding thymus persistent was found. Average diameter of coarctation was 10 mm. In one patient, CoA was accompanied with stenosis of pulmonary artery, in one with ventricular sep­tal defect, and one with tricuspid insufficiency. The results of MRI 100% were in correlation with clinical and echocardiographic findings. Conclusions. MRI is a non-invasive method of investigation of the heart and large blood vessels and it is more and more an alternative to the invasive angiographic investigations, especially in paediatrics, because there is no radiation at all. It is complementary to the echocardiographic, intra-arterial digital subtraction an­giography (IA DSA) and helical CT (SCT). Key words: aortic coarctation-diagnosis; magnetic resonance imaging Correspondence to. Assist. Prof. Šerif Bešlic, M.D., Ph.D., Institute of Radiology, Clinical Centre University Sarajevo, Bolnicka 25, Bosnia and Hercegovina; Phone: +387 33 444-553; E-mail: sbeslic@bih.net.ba Received 5 January 2004 Accepted 7 March 2004 Introduction Coarctation of aorta (CoA) is acongenital anomaly of the aortic arch as anomaly of the caliber.1 It occurs as the obstruction of aortic isthmus, very frequently localized distally to the left subclavian artery, opposite to inser­tion of the ductus arteriosus.2-4 The level of the collateral blood circulation through the subclavial and intercostal arteries depends on the level of narrowing of the aortic coarcta­tion.3 A stenosed lumen can be narrowed in­to the size of the knitting needle, but it can be very rarely completely occluded.5 Pathohisto­logicaly this is an obstruction membrane in location of aortic isthmus.6 Based on the statistics of M. Abbott, we meet this anomaly in 8% of overall congenital heart malformations; it is three times more frequently in males than in females patients.5 This is the third most frequent anomaly of cardiovascular system.3 There are two types of CoA: juvenile - the diffuse type (preductal tubular hypoplasia) and the adult type - stenosis of short segment (postductal and periductal).2-5 This anomaly can be accompanied with the so-called coarctation syndrome, which is a coartctation triad of previous ductus arte­riosus and ventricular septal defect. It can al­so be accompanied with hypoplasia of aortal arch (small arch) bicuspodia of the aortal valve (25-50%), aneurysm of sinus valsavle, aneurysm at the place of coartctation, aneurysms of subclavia artery, ductus arterio­sus or circulus Willis, anomalies of aortal arch as in many other congenital heart dis­eases (until 70%).2,3,6,7 We meet it also in Turner’s syndrome. Coarctation of abdominal aorta is seen in 2% of cases.2 Radiologically similar to coarctation is so called pseudocoarctation. It is unusual asymptomatic variant of coarctation, in which the descendent end of aortal arch re­tracted sharply in front, at the place of inser­tion of the arteriosum ligament. The aortal arch above the bended part is abnormally high and convex and it can look similar to the tumour of back upper part of the medi­astinum. Stenosis, deficit of pulse and rib notches do not exist in pseudocoarctation.2,6,8 The idea of some authors is to declare all mediastinal masses as vascular etiology, until it is not proved the otherwise.6 Two changes are regarded as repercussion to coarctation: development of arterial collat­erals and hypertrophy of left ventricle.2 Coarctation of the aorta is a disease which very frequently escapes on the early detection and treatment, too. This may causes cardio­vascular accidents and early death as the con­sequence of the coartctation increase with de­laying the treatment.9 It was diagnosed in about 20% of our pa­tients at adolescence for the first time. In a big series of patients with coarctation of aor­ta the mean age at diagnosis was 10 years. In younger patients most frequent sign (mean age 6 years) was a murmur, and in older pa­tients (mean age 18 years), was systemic hy­pertension.9 Average survival of patients with the adult type of this malformation is 33 year; only 25% survive 40 years.5 Death occurs because of the rupture of aorta (around 25%), infective endocarditis or aortitis (around 20%), heart insufficiency (around 20%), intracranial haemorrhage (around 10%), and rupture of the heart (1%).5 Beside murmurs and hypertension, other accompanying signs are the delay of pulse be­tween radial and femoral artery, difference in pressure between upper and lower extremi­ties or rib notches in the lower margins of ribs on the thoracic plain film.9 Rib notches were anatomically found by Meckel in 1827 and radiologically by Resler in year 1928. They are almost always present in adults, especially we meet them between the 3th and 6th rib, some authors found them between the 4th and 8th rib, bilaterally, but not symmetrically. Although, usually they do not occur in chil­dren younger then 7-8 years of age, they can be met even at child nine months old. According to Pugh they are not present in 1/3 of cases.2,5 Beside rib notches, thoracic plain film shows hypertrophy of the left ventricle, aorta ascendant very frequently forms the right edge of the heart, and rarely aortal button is missing. The examination of the esophageous with barium contrast showed the number three sign. Lung vascularisation is normal.2,5 Most frequent clinical feature is hyperten­sion of upper extremities, while femoral pulse is usually not palpable.6 The treatment of coarctation is surgery with resection of coarctation and end-to-end anastomosis, patch isthmio-plastics with syn­thetic material or subclavian patch, balloon angioplasty, for stenosis of short segment.2,6 Beside the above mentioned clinical find­ings and the thoracic plain film, in the diag­nostics of the coarctation, the conventional angiography, intra arterial digital subtraction angiography (IA DSA), helical CT (SCT), trans-oesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are used.4,6,9 The last three methods are non-in­vasive and more and more used in the diag­nostics of the conditions of the heart and vas­cular anomalies. MRI is especially interesting in establishing the diagnosis of coarctation of aorta and planning the treatment in the early phase because of its multiplanarity, no radia­tion and information which it can give about the present haemodinamic disturbances. The purpose of our study is to analyse the MRI contribution in diagnostics of CoA. Patients and methods In the period of three years eight patients are examined and all of them were suspect clini­cally and echo-cardiographycally for CoA. Among those patients 5 (62.5%) were male and 3 (37.5%) female. The rate between male (5) and female (3) patients was 1.7 : 1. The youngest patient was three years old and the oldest 46 (average age was 15 years). Examinations were performed with MR ma­chine Magnetom 1.0 Tesla (»Siemens«). We did not use the contrast media because of missing the proper connector required by the size of gantry. During the examination, fast spin-echo (FSE) T1W (black blood) sequences were used, especially in the oblique saggittal plane because of determining the location and level of the stenosis, the spread of the coarctation and presence of collateral vessels in regard to the morphology of vascular struc­tures and accurate orientation Cine-gradient echo (GRE) sequence. From GRE (bright blood) sequence, Cine sequence is used aim­ing to evaluate the disturbance of signal void in the part of coarctation and valve apparatus (place of stenosis). In other words the evalua­tion of the functional state of the aortal coarc­tation and time of the flight (TOF) sequence was performed, with the use of maximum in­tensity projection (MIP) reconstructions, to show the place of coarctation, outgoing ves­sels of the aortic arch, collaterals and collat­eral flow. During the examination, ECG gat­ing was also used. Examinations were performed in axial, coronal and oblique positions, in the direc­tion and extend of aortic arch, with the slice thickness of 6 mm. In cases of improper cross-section because of the thickness of the slices in the region of the coarctation e.g. in case of small children, stratified slices were made to acquire the best scan. During the in­vestigation, measurements of the heart wall and heart cavity were performed, especially of the left ventricle, ascendant aorta, aortic arch, descendent aorta and the zone of coarc­tation. Examinations were done preoperative-ly in order to evaluate the severity of the dis­ease and decide about the preoperative plan. Body coils are not used because they were not available. Results Among the examined patients, coarctation of the aorta was found in 8 patients. In 7 (87.5%) cases, the coarctation developed at the isth­mus, and in one case at the horizontal part of the aortic arch. Aortal insufficiency was con­firmed in 7 (87.5%) patients, in 4 (50%) of them bicuspidia was observed, while in 7 (87.5%) patients hypertrophy of the left ven­tricle was slightly expressed. Wider outgoing vessels from the aortic arch were found in 6 (75%) patients. In 2 (25%) patients dilatation of the ascending aorta was observed. In 4 pa­tients (50%), collateral flow was well devel­oped, and in 2 (25%) patients, rib notching in the plain thoracic radiographs was revealed. In one patient coarctation was accompa­nied by stenosis of pulmonary artery, in one by ventricular septal defect and in other one with tricuspid insufficiency. Those findings were in correlation with echo cardio graphic findings. The oldest patient (46 years) had in medical history the heart infarction and dilat­ed cardiomyopathy. Patient was with coarcta­tion in the horizontal part of the aortic arch between truncus brachyocephalicus and the left carotid communis artery, and with knocking of the same in its back part (variant of pseudocoarctation). As accompanying finding, in 2 (25%) younger patients, thymus persistent was found. In all cases spin-echo (SE) sequence gave an excellent morphologic presentation of the location of coarctation of the ascendant aorta, aortic arch, with outgoing vessels from the arch, descendent thoracic aorta, discontinuity of the collateral flow and mammary artery. An average diameter of the coarctation place was 10 mm; in one young female patient 13 aged, the diameter was 5 mm. Cine sequence in the slab of 7 mm, though providing satisfactory morphologic presentation in real time, appears to be ex­traordinary sensitive to the velocity, thus clearly showing the signal void in the region of the valve apparatus and at the site of coarc­tation. The image of aortal coarctation was com­plete after using the time of flight (TOF) se­quence that contributed enormously to mor­phology, in addition to providing an image of the collateral flow and the mammary artery. Using this set of sequences - about the morphology of the coarctation and circulato­ry disorders - important information was ob­tained in a non-invasive way, and without us­ing the contrast media. MR results were in 100% of cases in corre­lation with the ones gained by echocardiogra­phy when it was about the heart’s morpholo­gy and the valve apparatus. Discussion As it was presented in the introductory part, CoA is the most frequent anomaly of the car­diovascular system. Its diagnostics is relative­ly easy and for a long time it has been made only clinically, based on the discovery of heart murmur, hypertension, differences in pressure between upper and lower limbs and rib notches in the thoracic plain films. In this investigation the most frequent clinical sign in young patients was heart mur­mur and the difference in pressure between the upper and lower limbs, and in older pa­tients hypertension. Rib notches were found in a 1/4 of patients, whereas in literature there were found in 1/3. Here we have to bear in mind that half of our patients were younger then 8 years. In this series the oldest child was 13 year old, and the 2 grown patients were 30 and 46 years old, respectively. In the larger series the mean age of patients at diagnosis was 10 years, and in our series it was 15 years. The ratio between male and female patients was 1.7 : 1 in our study, while in literature it was 3 : 1.5 In adults over 40 years CoA is observed in only 20 % of cases, and in our small series 1 (25%) patient was over 40 years. Aortal insuf­ficiency was found in 7 patients; in 50% of them bicuspidia was discovered, which is in line with the percentage reported in litera­ture, where it ranges between 25-50%.2 Correlation with other congenital anomalies in CoA is high and reaches 70 %; in our series, it was 37.5%. The obtained results were in line with the one gained from echocardiogra­phy. MR proved to be very sensitive to flow disturbances. CoA falls in the group of curable congeni­tal anomalies of the vascular system. The treatment of choice is surgery; therefore, it is necessary to establish a precise diagnose and to identify all accompanying anomalies. Today, several excellent methods for analysis of the big blood vessels and Coal, like SCT, MR and TEE, are used.3 Conventional angiography has been, until recently, the golden standard. It allows meas­uring the pressure, but it is invasive, risky be­cause of radiation, haemorrhage, vascular le­sions, thrombosis and allergic reactions to the contrast media. Echocardiography is non-invasive alterna­tive which is widely used today. However, at times, it is very hard to acquire good visuali­zation of the site of coarctation because of small acoustic window, long distance be­tween transducer and the isthmus region, and because of non-cooperation of patient. In recent years the use of MR imaging have become more intensive and proved to be ex­cellent tool for non-invasive investigation of cardiovascular system in older and younger patients.10 In our series clinical and echocardiograph­ic suspicions on CoA were confirmed in 100% of cases by MRI with the use of fast spin echo (FSE), Cine and TOF (time of flight) se­quences, that allow an extraordinary morpho­logic presentation of the heart and big vascu­lar structures, as zones of disturbed flow (Figures 1,2,3,4). Drawbacks of this technique are its inca­pacity to measure the pressure in the zone of coarctation and the impossibility of applying of contrast media in the way as it is applied in contrast enhanced magnetic resonance an­giography (CE MRA). Reasons for this were of technical nature. The shortage of the tho­racic coil was, to a certain degree, substituted by proper sedation and preparation of patient before scanning. According to literature MR, imaging is a powerful tool in the evaluation of full range of congenital and acquired diseases of the tho­racic aorta. It is safe, accurate and can be re­peated several times, giving extremely useful anatomic information and clearly detecting collateral vessels. It also provides information about the extraluminar relationship of aorta with the surrounding organs, no matter in which projections they are seen.11 In our investigation, this advantage was observed with the discovery of thymus in 2 younger patients with coarctation of aorta. Today, in the diagnostics of aortal coarcta­tion, FSE and angiographic gradient echo (Cine - GRE, TOF, PC and recently also CE 3D MR) sequence are used worldwide. MRI SE sequences provide very useful anatomic details, while Cine MRI sequence can detect a turbulent jet of blood and the place of coarctation. MR angiography (MRA) does not provide adequate information about the wall of the vessel; the intimal flap and parietal thrombus can be dizzy and hardly seen even with the help of MIP (maximum intensity projection) algorithm. SE and GRE technique are complementa­ry; the first takes a lot of time, especially when ECG triggering is used. MRI is non-invasive and doesn’t depend much on the experience of operator. In children, sedation is needed, possibly general anaesthesia; echo navigator tech­niques have been developed to prevent image degradation.12 MRI can be used preoperatively to evalu­ate the severity of the disease and to decide about the operative plan. Beside the analyses of morphologic abnor­malities, it also allows to measure the size of vascular structures with the speed of the flow at the place of stenosis, in order to assess functional disturbances.13 It has also some limitations, as artefacts because of respiratory movements, saturation problems and long time of diagnostic oroce­dure.14 Basic (without contrast) MRA-GRE tech­nique is time of flight (TOF) and phase-con­trast (PC) sequences.15 Beside those the so-called contrast enhanced (CE) three-dimen­sional (3D) MRA sequence is also used today. CE 3D MRA and TSE sequence are used in the set for analyzing the morphology of aortal arch, vascular diameter, location and scope of the abnormality of coarctation, its relation­ship to the outgoing vessels from aortic arch.16 Measuring the dimensions of the aor­ta proved to be very useful before the surgical correction or balloon dilatation of the coarc­tation. A good correlation was observed be­tween the measurement performed with MIP reconstruction and catheter angiography.17 3D reconstruction using the maximum in­tensity projection (MIP) technique is a reli­able non-invasive technique which can re­place the diagnostic catheter angiography, es­pecially during postoperative controls of the coarctation. It provides the clinician with valuable information concerning further ap­plication of invasive procedures. In regard to decreasing the effect of altered flow dynam­ics, CE 3D MR angiography of thoracic aorta has several advantages over to spin-echo SE (black blood) and TOF (bright blood) MRI se­quences. It is independent from ECG trigger­ing, which is of special importance in patients with arrhythmias. This technique is proved to be reliable in the diagnosis of aortic coarcta­tion.15 ECG triggered breath-hold contrast material-enhanced magnetic resonance an­giography sequence has been developed for imaging the thoracic aorta, aiming to de­crease the respiratory motion artefacts and pulsation artefacts. 3D MRA is independent from that if the flow is laminar, turbulent or stagnating. Different congenital and acquired abnormalities are clearly identified with this technique.18 Breath hold contrast enhanced 3D MR an­giography is faster and more accurate method in diagnostics of the diseases of thoracic aor­ta, but has limitations in the estimation of the aortal lumen. This is why black blood and bright blood MR sequences are necessary in the analysis of aortal wall, aortal valve and periaortic tissue.19 CE MRI is especially useful in small chil­dren who cannot keep their breath, which is required in 3D reconstructions.10 Moreover; gadolinium has smaller nephrotoxicity and less allergic reactions as iodine based contrast medias.12 Aortal diameter, stenosis, aneurism, inti­mal calves or atherosclerotic plaques can be analyzed with 3D reconstruction using MIP technique.17 The role of MRI is also of special value for following the patient’s with repaired cardio­vascular anomalies and is also widely used for presenting the morphology of large blood vessels. MR flow mapping can be used for an­alyzing the flow in large vessels.20 3D CE MRA with 0.2 mmol/kg Gd. in IV bolus, more exactly 20 ml Gd was followed with 20 ml saline most frequently at a flow of 3ml/s with ECG gating and preceding bolus test may be necessary. With such proceeding it is obtains optimal quality of the image, made in the oblique saggittal plain with stan­dard MIP/MPR reconstructions. It is impor­tant in case of artefacts from surgical clips which can disturb considerably the quality of the image.21-23 3D MRA (FISP) is used to measure the flow and elasticity of the vascular wall. With these techniques it is possible to have an adequate follow up of coarctation, meaning that, usual­ly, IA DSA is not needed in defining the con­dition and size of the proximal and distal anastomosis and the morphology of the tho­racic aorta.23,24 The so-called fluoroscopic triggering of centrically encoded 3D MR angiographic ac­quisitions have also been developed and have been reported as highly accurate methods of acquiring 3D MR angiograms with high spa­tial resolution.25 Because of the reasons mentioned earlier, the described 3D CE MRA sequences were not applied in this study. Conclusions MRI is a non-invasive method of examina­tion; it is becoming more and more an alter-native to the invasive angiography, especially in paediatric patients, because it is radiation-free. It is complementary to the other meth­ods, like US, DSA and SCT. MRI is an excel­lent technique for evaluating the morpholog­ic anomalies of aortic isthmus before and af­ter the operation or percutaneus treatment. It may be concluded that, by this method the coarctation of aorta can be followed up non-invasively. References 1. Beigelman-Aubry C, Badachi Y, Akakpo JP, Lenoir S, Gamsu G, Grenier PA. Practical morphologic approach to the classification of anomalies of the aortic arch. Eur Radiol 2002; 12 Suppl 1: 391. 2. Weissleder R,Wittenberg J.Giagnostic maging. St.Louis: Mosby; 1994. p. 94-6. 3. Maeshal G, Bogaert J. Non-invasive imaging of the great vessels of the chest. Eur Radiol 1998; 8: 1099­105. 4. Bogaert J, Kuzo R, Dymarkowski S, Janssen L, Elis I, Budts W, et al. Follow-up of patients with previ­ous treatment for coarctation of the thoracic aorta: comparison between contrast-enhanced MR an­giography and fast spin-echo MR imaging. Eur Radiol 2000; 10: 1847-54. 5. Schintz HR, Baensch WE, Friedl E, Wehlinger E, Holzmann M. Traite de radiodiagnostic. Le thorax. Vol. 3. Neuchatel: Delachaux-Niestle SA; 1957. p. 2950-3. 6. Gurney JW, Winer-Muram HT. Aortic anomalies. In: Pocket Radiologist. Chest. Salt Lake City: Amirsys Inc; 2003. p. 284-6. 7. Bertaccini P, Fattori R, Napoli G, Piva T, Lovato L, Russo V, et al. Incremental value of MRI angiogra­phy in postoperative assessment of aorticcoarcta­tion repair. Eur Radiol 2002; 12(10): G 11. 8. Grainger RG. The mediastinum. In: Teplick JG, Haskin ME, editors. Surgical radiology. Philadelphia: Saunders Company; 1981. p. 1432-3. 9. Julsrud PR, Breen JF, Felmlee JP, Warnes CA, Connolly HM, Schaff HV. Coarctation of the aor­ta: Collateral flow assessment with phase-contrast MR angiography. AJR 1979; 169: 1735-42. 10. Kramer U, Dammann F, Breuer J, Sieverding L, Claussen CD. Cardiac imaging in infants with aor­tic isthmus stenosis: A comparison of contrast en­hanced MRA and a high-resolution 3D double slabtechnique. Eur Radiol 2002; 12: 295-6. 11. Bonomo B. Spiral CT vs MR in aortic diseases. (Abstract(. ECR 2000. Eur Radiol 2000; 10 Suppl 1: 28. 12. Godart F, Labrot G, Devos P, McFadden E, Rey C, Beregi JP. Coarctation of the aorta: comparison of aortic dimensions between conventional MR im­aging, 3D MR angiography, and conventional an­giography. Eur Radiol 2002; 12: 2034-9. 13. Mastorakou I, Kelekis NL, Kaklamanis I, Apostolopoulou SC, Katsilouli S, Karapanagiotou O, et al. Coarctation of the aorta: A pictorial re­view. Eur Radiol 2003; 13 Suppl 1: 565. 14. Leung DA, Debatin JF. Three-dimensional con-trast-enhanced magnetic resonance angiography of the thoracic vasculature. Eur Radiol 1997; 7: 981­9. 15. Joarder R, Gedroic WM. Magnetic resonance an­giography: the state of the art. Eur Radiol 2001; 11: 446-53. 16. Bogaert J, Dymarkowski S, Janssen L, Celis I, Budts W, Gewilling M. Contrast enhanced MR an­giography in patients with previous surgery for coarctation of the thoracic aorta. [Abstract]. ECR, European congress of radiology Vienna, Austria. Eur Radiol 2000; 10(Suppl 1): 302. 17. Schaffler GJ, Sorantin E, Groell R, Gamillscheng A, Maier E, Schoellnast H, et al. Value of CT an­giography with reconstruction in the postopera­tive care of aortic coarctation. (Abstract(. ECR., European congress of radiology, Vienna, Austria. Eur Radiol 2001; 11(Suppl 1): 305. 18. Arpasi PJ, Bis KG, Shetty AN, White RD, Simonetti OP. MR angiography of the thoracic aor­ta with an electrocardiographically triggered breath-hold contrast-enhanced sequences. Radiographics 2000; 20: 107-20. 19. Soler R, Rodriguez E, Bello M, Diaz A, Remuinan C. Magnetic resonance of thoracic aortic diseases. A pictorial essay. ECR, The 14th European Congress of Radiology, Vienna,Austria. Eur Radiol 2002; 12(Suppl 1): 488. 20. De Roos A. MR of congenital cardiac diseases. Euro Radiol 2000; 10(Suppl 1): 28. 21. De Santis M, Banci M, Manganaro F, Passariello. »Bright blood« technikues versus 3D contrast-en­hanced MR angiography in thoracic aortic vascu­lopathy. Eur Radiol 2000; 10(Suppl 1): 194. 22. Kreitner KF, Kunz PR, Kalden P, Kauczor HU, Oelert H, Thelen M. Contrast-enhanced 3D MR angiography (ca-MRA) of the thoracic aorta: Experiences after 117 examinations with a single-dose contrast administration. Eur Radiol 2000; 10(Suppl 1): 193 23. Poll LW, Koch JA, Peters A, Korbmacher, Gams E, Modder U. Breath-hold, contrast-enhanced, sub­tracted 3D-angiography after long-term repair of aortic coarctation. Eur Radiol 2000; 10(Suppl 1): 434. 24. Rodenwaldt J, Vosshenrich R, Kopka L, Castillo E, Fischer U, Grabbe E. Morphological and function­al follow-up after aortic coarctationsurgery: as­sessment With MR. Eur Radiol 2000; 10(Suppl 1): 193. 25. Riederer SJ, Bernstein MA, Bree JF, Bussen RF, Ehman RL, Fain SB et al. Three-dimensional con-trast-enhanced MR angiography with real-time fluoroscopic triggering: Design specifications and tehnical reliability in 330 patient studies. Radiology 2000; 215: 584-93. Radio/ Oncol 2004; 38(1): 15-9. Rituximab affects the prognosis of patients with nonHodgkin' s lymphomas Barbara Jezer5ek Novakovic"l, Marjeta Vovk1, Simona Borstnar1, Radka Tomsic2 1Department of Medical Oncology, 2Department of Radiotherapy, Institute of Oncology Ljubljana, Slovenia Background. Rituximab -the most widely used monoclonal antibody in the B cell lymphoid malignancies ­has been applied successfully in the treatment of relapsed and refractory indolent CD20 positive B cell lym­phomas and more recently, also in the treatment of aggressive lymphomas in combination with standard chemotherapy. Albeit the chemo-immunotherapy has a wide range of potential applications, there are still several issues that have to be resolved: (1) the optimal scheduling of antibody-chemotherapy combinations, (2) the most active of these combinations, as well as (3) the predictors of response to rituximab. Patients and methods. To facilitate addressing the first two questions, we performed an analysis in 25 pa­tients with different histological types of CD20 positive nonHodgkin's lymphomas (10 aggressive and 15 indolent). Seventeen patients were treated with chemo-immunotherapy for a relapse, and just in 8 patients rituximab was added to first line chemotherapy. Most of the responders received the CHOP regimen, but al­so other regimens (FC, BVCPP) were effective in combination with rituximab. Results. The overall response rate was 76%, with 68% complete remissions. The median response duration has not been reached yet. The response was markedly better in the group of previously untreated patients, where the overall response rate reached 100%, with 7 patients in complete and 1 patient in partial remis­sion. Most of the treatment failures occurred in heavily pretreated patients with aggressive lymphomas. No serious adverse effects were observed. Conclusion The chemo-immunotherapy improves the treatment outcomes in patients with untreated and relapsed CD20 positive nonHodgkin's lymphomas in comparison to chemotherapy alone. The combined treatment is the most effective when used as soon as possible (preferably as the first line treatment). To op­timize the use of rituximab, not only the most active antibody-chemotherapy combination will have to be determined, but also the predictors of success of such treatment will have to be identified. Key words: lymphoma, nonHodgkin's; rituximab Received 27 January 2004 Accepted 03 February 2004 Correspondence to: Barbara Jezersek Novakovic, M.D., Ph.D., Institute of Oncology, Zaloska 2, 1000 Ljubljana, Slovenia, Tel. +386 1 587 9561, Fax. +386 1 587 9454, E-mail: bjezersek@onko-i.si Introduction The CD20 antigen, a 35 kDa phosphoprotein, is restricted to the B cell lineage and is ex­pressed by mature B cells and most malignant B cell lymphomas. While the exact functions of CD20 are unknown, it may play an integral role in the activation of cell cycle progression in B lymphocytes, possibly via calcium regu­lation. Its attributes, as its tetraspan binding in the cell membrane and the lack of inter­nalization or downregulation upon antibody binding, make the CD20 suitable as a target for an effective antibody.1 Rituximab, a chimeric IgG K monoclonal antibody that recognizes the CD20 antigen2, is the most widely recognized and used mon­oclonal antibody in the B cell lymphoid ma­lignancies. It has been applied successfully in the treatment of relapsed and refractory in­dolent CD20 positive B cell lymphomas and more recently, also in the treatment of ag­gressive lymphomas in combination with standard chemotherapy. The indications for its use are now expanding also to Hodgkin's disease and autoimmune diseases.3 Even though the results with rituximab as monotherapy as well as in combinations with chemotherapy have been encouraging, many questions still remain to be answered about optimizing its use in patients with malignant lymphomas. Actually, the optimal scheduling of antibody-chemotherapy combinations and the identification of the most active of these combinations have to be resolved, as have the details about its mechanisms of action and the predictors of response to this agent. With the aim of seeking the optimal sched­uling of antibody-chemotherapy combination and identifying an active combination, we performed a retrospective analysis of the re­sults obtained from 25 patients with predom­inately relapsed CD20 positive nonHodgkin's lymphomas. Patients and methods In the year 2001, 25 patients with CD20 posi­tive nonHodgkin's lymphomas were treated with the combination of rituximab and chemotherapy at the Institute of Oncology in Ljubljana, Slovenia. The group consisted of 10 male and 15 female patients. According to the histological type, there were 1 patient with Burkitt's lymphoma, 5 patients with dif­fuse large B cell lymphoma, 2 patients with unclassified CD20 positive aggressive lym­phoma, 13 patients with follicular lymphoma (5 patients grade I, 3 patients grade II, 2 pa­tients grade II/III, 3 patients grade Ill, and 1 patient unspecified grade), 2 patients with mantle cell lymphoma, and 2 patients with small lymphocytic lymphoma/ CLL. Most of the patients were treated for a relapse -in 12 patients the combined treatment with ritux­imab and chemotherapy was third (or more) line treatment, in 5 patients second line treat­ment, and just in 8 patients rituximab was added to inadequately successful first line chemotherapy. The patients received at least 2 and not more than 6 cycles of chemo-immunothera­py. Rituximab was applied in standard doses (375 mg!m2) on day 1 of the chemotherapy cycle, and was combined predominately with CHOP regimen (20 patients), but also with other chemotherapy schedules (1 patient COP, 2 patients FC, 1 patient VACPE, 1 pa­tient BVCPP) according to their previous treatments. All patients received methylpred­nisolone, paracetamole and clemastine prior to the application of rituximab. Treatment response was evaluated accord­ing to Cheson's criteria.4 Results In total, complete response was achieved in 17 patients, which represents 68%. The longest observed duration of complete re-sponse until now is 19 months, and 11 pa­tients are still in complete remission. The partial response was observed in 2 pa­tients (8%), with the median duration of 8 months. In 1 patient there was stable disease after rituximab and FC treatment, and the pa­tient continued his treatment with a different chemotherapy regimen. Five patients progressed during chemo-im­munotherapy-they all received less than 6 cyc­les of therapy (at least 2 and at the most 4 cyc­les), and eventually died of lymphoma. In 3 of these patients, the chemo-immunotherapy was fifth line treatment, in 1 patient second line treatment, and in 1 patient third line treatment. Four of the 5 patients with progressive disease had aggressive histological types of lym­phomas, and only 1 patient had indolent follic­ular lymphoma, but was heavily pretreated. Surprisingly good results were observed in the small group of patients in whom ritux­imab wad added to the first line chemothera­py treatment. The overall response rate in this group was as high as 100% with 88% complete responders (7 out of 8 patients), and 1 partial responder. The patient with par­tial remission relapsed after 14 months, while 6 of 7 complete responders are still in remis­sion. The treatment outcomes according to his­tological subtypes are given in Table 1. The chemo-immunotherapy was very well tolerated and no serious infusion related ad­verse effects were observed in more than 100 applications. The addition of rituximab to chemotherapy also had no significant influ­ence on the hematological toxicity, and no WHO grade IV infections were observed. Table 1. The treatment outcomes according to histological subtypes Histological No. of Chemotherapy Line of Response Duration of subtype patients regimen treatment complete or partial response (months) Burkitt's lymphoma 1 CHOP (1 pt.) Second (1 pt.) Progressive disease (1 pt.) Diffuse large B cell lymphoma 5 CHOP (2 pts.) VACPE (1 pt.) FC (1 pt.) BVCPP (1 pt.) First (1 pt.) Second (1 pt.) Third (3 pts.) Complete response (4 pts.) Progressive disease (1 pt.) 12+ Unclassified aggressive lymphoma 2 CHOP (1 pt.) COP (1 pt.) Third or more (2 pts.) Progressive disease (2 pts.) Follicular lymphoma 13 CHOP (13 pts.) First (5 pts.) Complete response (11 pts.) Second (3 pts.) Partial response (1 pt.) Third or more (5 pts.) Progressive disease (1 pt.) 8,8+ 14 Mantle cell lymphoma 2 CHOP (2 pts.) First (2 pts.) Complete response (2 pts.) 4+ Smalllymphocytic lymphoma/CLL 2 CHOP (1 pt.) FC (1 pt.) Third or more (2 pts.) Partial response (1 pt.) Stable disease (1 pt.) 2 Discussion Although various standard chemotherapeutic regimes are active in the treatment of pati­ents with nonHodgkin's lymphomas, the results of such treatments are far from opti­mal. The addition of rituximab to chemother­apy seems to offer an advantage to these pa­tients both in terms of the percentage of re­sponse as well as in terms of the response du­ration. As to the chemotherapy regimen choice it has been namely confirmed by in vit­ro observations that monoclonal antibody ex­posure may sensitize tumor cells to chemotherapy, and specifically to fludara­bine, cisplatin, vinblastine, and doxoru­bicin.5·6 Most of the applied regimens in our study included one of the above mentioned cytotoxic drugs, while for the others it has been expected that rituximab will enhance their effect through its interference with the apoptotic processes.7 Our outcomes are in accordance with the clinical results of various authors stating that the addition of rituximab to different chemotherapy regimens improves the treat­ment results.8•12 However, more and more da­ta confirm the fact that rituximab should be used as soon as possible (preferably in the first line treatment) in the treatment of lym­phoma patients in order to achieve maximal efficacy.13•14 Among our patients, in only 8 patients rituximab was added to inadequate­ly successful first line chemotherapy, while all others received immunotherapy for relaps­es of nonHodgkin's lymphomas. All 8 pa­tients actually achieved a remission after the addition of the rituximab to the chemothera­py regimen that they had been receiving be­fore (in 7 patients a complete remission, and in 1 patient a partial remission). The results with relapsed lymphomas were convincingly worse. Out of 17 patients, 10 achieved a com­plete remission (59%), 1 a partial remission (6%), 1 a stable disease (6%), and 5 patients progressed (29%). Certainly, the significance of these results is inestimable due to a small number of patients. However, the results speak in favor of using rituximab as a first line treatment. Since it is becoming obvious from the nu­merous clinical studies that rituximab im­proves the treatment outcomes when it is combined with various chemotherapy regi­mens, the next step in the research will have to be the identification of predictors for suc­cess with chemo-immunotherapy. Not only the IPI, but also new molecular, biologic, and immunologic factors will have to be recog­nized, before the use of rituximab can be stat­ed as rational. Currently, the overexpression of certain genes involved in cellular immuni­ty has already been confirmed in nonrespon­ders to rituximab15, as well as the meaning of pretreatment Mcl-1/Bax ratio.16 Also the cyto­genetic abnormality as del (17p13.1) was identified as the predictor of poor response to rituximabY Another predictor, the bcl-2 overexpression, that according to Mournier et al.18 foretells a better outcome of first line rit­uximab plus CHOP treatment (compared to bcl-2 negative patients) has not been con­firmed in patients with relapsed diffuse large B cell lymphoma.19 Thus to determine more accurately the patients that will benefit at most from the chemo-immunotherapy, fur­ther studies will have to be done on a larger number of patients. References 1. Lucas BJ, Homing SJ. Monoclonal antibodies have finally arrived. In: Cavalli F, Armitage JO, Longo DL, eds. Amwal of Lymphoid Malignancies. London: Martin Dunitz Ltd; 2001. p. 153-67. 2. Maloney DG, Liles TM, Czerwinski OK, Waldichuk C, Rosenberg J, Grillo-Lopez A, et al. Phase I clinical trial using escalating single-dose infusion of chimeric anti-CD20 monoclonal anti­body (IDEC-C2B8) in patients with recurrent B-cell lymphoma. Blood 1994; 84: 2457-66. 3. Boye J, Elter T, Engert A. An overview of the cur- rent clinical use of the anti-CD20 monoclonal anti­body rituximab. Ann of Oncol 2003; 14: 520-35. 4. Cheson BD, Homing Sj, Coiffier B, Shipp MA, Fisher RI, Connors JM, et al. Report of an interna­tional workshop to standardize response criteria for Non-Hodgkin's lymphomas.] C/in Oncol1999; 17: 1244-53. 5. Demidem A, Lam T, Alas S, Hariharan K, Hanna N, Bonavida B. Chimeric anti-CD 20 antibody sen­itizes a B-cell lymphoma cell line to cell killing by cytotoxic drugs. Cancer Biother Radiophamz 1997; 12: 177-86. 6. Alas S, Bonavida B. Rituximab inactivates signal transducer and activation of transcription 3 (STAT3) activity in B-non-Hodgkin's lymphoma through inhibition of the interleukin 10 au­tocrine/paracrine loop and results in down-regula­tion of bcl-2 and sensitization to cytotoxic drugs. Cancer Res 2001; 61: 5137-44. 7. Ghetie M, Bright H, Vitetta ES. Homodimers but not monomers of rituximab (chimeric anti-CD20) induce apoptosis in human B-lymphoma cells and synergize with a chemotherapeutic agent and an immunotoxin. Blood 2001; 97: 1392-8. 8. Czuczman MS, Grillo-Lopez AJ, White CA, Saleh M, Cordon L, LoBuglio AF, et al. Treatment of pa­tients with low-grade B-cell lymphoma with the combination of chimeric anti-CD20 monoclonal antibody and CHOP chemotherapy. ] C/in Oncol 1999; 17: 268-76. 9. Coiffier B, Lepage E, Briere PD, Herbrecht R, Tilly H, Bouabdallah R, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large B-cell lymphoma. N Engl] Med 2002; 346: 235-42. 10. Howard OM, Gribben JG, Neuberg DS, Grossbard M, Poor C, Janicek MJ, et al. Rituximab and CHOP induction therapy for newly diagnosed mantle-cell lymphoma: molecular complete responses are not predictive of progression-free survival.] Clin Oncol 2002; 20: 1288-94. 11. Rambaldi A, Lazzari M, Manzoni C, Carlotti E, Arcaini L, Baccarani M, et al. Monitoring of mini­mal residual disease after CHOP and rituximab in previously untreated follicular lymphoma pa­tients. Blood 2002; 99: 856-62. 12. Vose JM, Link BK, Grossbard ML, Czuczman M, Grillo-Lopez A, Gilman P, et al. Phase 11 study of rituximab in combination with CHOP chemother­apy in patients with previously untreated, aggres­sive non-Hodgkin's lymphoma.] Clin Oncol 2001; 19: 389-97. 13. McLaughlin P, Grillo-Lopez AJ, Link BK, Levy R, Czuczman MS, Williams ME, et al. Rituximab chimeric anti CD-20 monoclonal antibody therapy for relapsed indolent lymphoma; half of patients respond to a four-dose treatment program. J Clin Oncol1998; 16: 2825-33. 14. Colombat P, Salles G, Brousse N, Eftekhari P, Soubeyran P, Delwail V, et al. Rituximab (anti­CD20 monoclonal antibody) as single first-line therapy for patients for patients with follicular lymphoma with a low tumor burden: clinical and molecular evaluation. Blood 2001; 97: 101-6. 15. Bohen SP, Troyanskaya 0, Alter 0, Warnke R, Botstein D, Brown PO, et al. Predicting rituximab response of follicular lymphoma using cDNA mi­croarray analysis. Oncology 2003; 17 (Suppl1): 31­2 (Abstr 1222). 16. Kitada S, Young D, Pearson M, Flinn IW, Shinn CA, Reed JC, et al. Mci-1/ Bax ratio is a predictor for outcome of rituximab therapy in patients with chronic lymphocytic leukemia. Oncology 2003; 17 (Suppll): 33 (Abstr 1466). 17. Smith LL, Heerema N, Hackbarth ML, Flinn IW, Young D, Proffitt JH, et al. Interphase cytogenetics are predictive of chronic lymphocytic leukemia re­sponse to thrice-weekly rituximab therapy. Oncology 2003; 17 (Suppll): 33-4 (Abstr 2147). 18. Moumier N, Briere J, Gisselbrecht C, Gaulard P, Lederlin P, Sebban C, et al. Rituximab plus CHOP in the treatment of elderly patients with diffuse large B-celllymphoma overcomes bcl-2-associated chemotherapy resistance. Oncology 2003; 17 (Suppl1): 25 (Abstr 603). 19. Jezersek Novakovic B. Can rituximab overcome the bcl-2 associated chemotherapy resistance? ] Tumor Marker Oncol 2003; 18: 169 (Abstr A9). Radiol Oncol 2004; 38(1): 21-6. Neuron specific enolase - selective marker for small-cell lung cancer Biljana Ilievska Poposka1, Mirko Spirovski2, Dean Trajkov2, Tome Stefanovski3, Sonja Atanasova1, Marija Metodieva1 1Institute for Lung Diseases and Tuberculosis, Clinical Center, Skopje 2Institute for Immunology, Clinical Center, Skopje 3Pulmology and Allergology Clinic, Clinical Center Skopje, Macedonia Background. Neuron specific enolase (NSE) is an isomer of the glycolytic enzyme enolase, which was first found in extracts of brain tissue, and was later shown to be present in neuroendocrine cells and neuroen­docrine tumours. The aim of the study was to confirm the importance of serum NSE as a tumour marker in patients with small-cell lung cancer. Patients and methods. Serum levels of NSE were measured by the radioimmunoassay in 71 patients with lung cancer (LC), in 24 patients with non malignant lung diseases and in 28 healthy adults. Results. According to the serum values in the group of healthy adults, 16.6 ng/ml was determined as a cut of level of NSE. By the specificity of 88.13 % in the group of non malignant lung diseases, the sensitivity of 47.82 % was obtained in patients with LC, which increased to 72.72 % in the patients with SCLC. In pa­tients with non-small-cell lung cancer (NSCLC) the sensitivity of NSE test was 38.89 %. The patients with SCLC-extensive disease had a significantly higher mean NSE level (290.48 ng/ml) than patients with the limited stage disease (46.94 ng/ml). Serial measurements in 16 patients receiving combined chemotherapy and/or radiotherapy showed an excellent correlation between serum NSE level and clinical response. Conclusions. These results indicate that serum NSE may be a useful marker for diagnosis, staging and for monitoring response to the therapy in patients with SCLC. Key words: lung neoplasms; carcinoma small cell; tumor markers; biological; neuron specific enolase Received 25 February 2004 Accepted 10 March 2004 Correspondence to. Biljana Ilievska Poposka, MD, Institute for Lung Diseases and Tuberculosis; Vodnjanska 17, 1000 Skopje, Macedonia; Phone: +389 02 3147 616; Fax: +389 02 3229166; E-mail : biljana_ili@hotmail.com Introduction Enolase is a glycolytic cytoplasmic enzyme, present in all human cells, catalysing the con­version of 2-phosphoglycerate to 2-phospho­enolpyruvate.1 The enzyme consists of thrree dimeric isoenzymes, called as a, ß and .. Neuron specific enolase (NSE) is .-. dimer and presents the neuronal form of the eno­lase.2 Originally extracted from the bovine brain tissue, it was first considered that the gene coding for NSE was restricted to neu­rons, and that it was only present in the cen­tral nervous system. In 1978 Schmechel et al. have shown that NSE is also present in all pe­ripheral and central neuroendocrine cells, named APUD (amine precursor uptake and decarboxylation) cells.3 Tapia et al. have ex­tended this work with immunohistochemical and extraction techniques and showed that NSE is present in a wide variety of APUD neoplasms or APUDomas including: islet tu­mours of the pancreas, gastrinomas, VIPomas, medullary carcinoma of the thy­roid, pheochromocytoma, and small-cell car­cinoma of the lung (SCLC) among others.4 In contrast, they could not find NSE presence in any non-neuroendocrine tumours.4,5 High pre-treatment levels of NSE have been detec­ted by the radioimmunoassay in the sera of the patients with neuroendocrine tumours, including SCLC.6-8 Therefore, this study was designed to re­evaluate the role of serum NSE in the diag­nosis and differential diagnosis of the pa­tients with lung carcinoma; to re-evaluate whether serum NSE levels are in the correla­tion with the extent of tumour dissemination or stages of the disease, and to re-evaluate the role of NSE as a marker for monitoring a therapeutic response in the patients with lung carcinoma. Patients and methods Patients In this study 123 persons divided in three groups were included: first group - 71 newly diagnosed untreated patients with a different type of lung carcinoma; second group - 24 pa­tients with non malignant lung diseases and third group - 28 healthy adults. According to the histological types of lung carcinoma, the patients from the first group were further divided in two groups: 33 pa­tients with SCLC and 38 patients with no­small-cell lung cancer (NSCLC). Methods Clinical assessment The routine pre-treatment staging procedures consisted of physical examination; biochem­istry; chest X ray; lung functional tests; fiberoptic bronchoscopy (with bronchial biopsy and cytological examination of brush-ings and washings); ultrasound procedures; radionuclide scan of bone. Biopsy or fine nee­dle aspiration specimens of enlarged lymph-nodes, subcutaneus nodules and pleural effu­sions were taken when clinically indicated. According to these findings, the patients with SCLC were staged as having limited disease (tumour confined to one hemithorax, includ­ing the ipsilateral lymph nodes) or extensive disease (outside these limits). The patients with NSCLC were divided in five stages of TNM classification. Only 16 patients were followed up and a response to chemotherapy and/or radiotherapy was evaluated. The re­sponse was judged to be: complete (CR) when both clinical and pathological evidence of tumour totally disappeared; partial (PR) when there was a reduction of 50% or more in the sum of all measurable and evaluable tu­mour masses. Lesser degrees of tumour re­duction were judged as no response. The diagnosis of all patients was con­firmed at the Institute for Lung Diseases and Tuberculosis; the patients were treated at the Institute for Radiology and Oncology, Medical Faculty in Skopje. Immunoassay Blood specimens were collected from each of the 71 patients with lung carcinoma at diag­nosis, as well as from the patients with non malignant lung diseases and healthy adults. Serial samples were obtained from 16 of 71 patients with lung carcinoma, usually at 6­week intervals, after each course of chemotherapy or after the end of radiothera­py. The serum was separated immediately af­ter the collection and was stored at - 20 °C be­fore the assay. NSE levels were determined by a double-antibody solid phase radioim­munoassay technique (Pharmacia NSE-RIA test) at the Institute for Immunology, Medical Faculty, Skopje. Student's t test, Newman- Keuls test and x2 test were used to determine the statistical significance between the mean values and be­tween raised frequencies separately. Results Twenty eight healthy adults had NSE serum level ranging from 2.58 to 17.41 ng/ml (mean level 8.01 +/- 4.40 ng /ml). The upper limit of the normal interval for serum NSE 16.6 ng/ml is defined as the mean value for healthy con­trols plus 1.96 standard deviations. Only two patients from this group (7.14%) had a raised serum level above the normal value. In the group of patients with non-malig­nant lung diseases NSE serum level was ranged from 2.61ng/ml to 41.87ng/ml, with the mean level of 11.79 +/- 9.53 ng/ml. Among them, five were serum NSE positive (20.83%). On the basis of these findings 88.13% was determined as a specificity of NSE test. The mean level of NSE in the group of 71 patients with LC was 127.96 +/- 442.53 ng/ml. Thirty-four of them were found to have raised serum NSE concentrations that determined the sensitivity of NSE in LC of 47.82%. A statistical analysis between the positive NSE findings in the three groups showed a significant difference (x2 = 18.19 p< 0.001). With Newman-Keuls test we obtained a statistical significant difference between the mean values in the three groups (F=1.84, p<0.05). When the upper normal limit for serum NSE was taken to be 16.6 ng/ml, 73% of pa­tients with SCLC were found to have raised NSE concentrations compared with 38% of patients with NSCLC (x2 = 12.78, p<0.001). Eighteen of 33 patients with SCLC had a limited stage disease and 56 had an extensive disease. NSE was raised in 10 of 18 (55.55%) limited-stage patients and in all 15 (100%) pa­tients with an extensive-stage disease (x2 = 8.8. p<0.005). The mean pre-treatment NSE in the limited-stage disease was 46.94 +/- 56.92 ng /ml, versus 290.48 +/- 325.24 ng/ml for the extensive-stage disease (Student's t test = 2.69, p<0.001; Table 1). There was not a significant statistical dif­ference between the number of patients with NSCLC in different TNM stages who had the raised serum NSE level above 16.6 ng/ml. The results are shown in the Table 2 (x2 = 7.27, p non significant). Serum NSE was measured again in 16 pa- Table 1. Mean value and sensitivity of NSE in the patients with SCLC Group Mean value Frequency of raised value >16,6ng/ml Sensitivity SCLC limited diseases 46.94 +/- 56.92 10/18 55.5 % SCLC extensive diseases 290.48 +/- 325.24 15/15 100 % Table 2. Sensitivity of NSE in patients with NSCLC in different TNM stages Group Number Freqensy of raised value> 16,6ng/ml Sensitivity (%) Stage I 13 4 / 13 30.7 Stage II 12 1 / 8 12.5 Stage IIIa 10 2 / 6 33.3 Stage IIIb 9 2 / 5 40.0 Stage IV 11 5 / 6 83.3 tients after the end of each course of chemotherapy or at the end of radiotherapy when staging procedures were repeated. Eleven of these 16 patients were with SCLC, and 5 with NSCLC. In Figure 1a, there are the changes of serum NSE level in 13 patients who responded to therapy (responders); 9 were with SCLC and 2 with NSCLC. Eight pa­tients had the elevated serum NSE level above 16.6 ng/ml and had a predominantly extensive disease. According to the clinical signs, when a complete or a partial response was obtained, the serum NSE level in 6 patients decreases to a normal range; in one patient the serum NSE level decreased, but between 16 and 20 ng / ml, and in one patient the level remained stable. In other five patients who had the serum NSE level in a normal range at diagno­sis, at the moment when CR or PR was clini­cally achieved, the serum NSE level de­creased in 2 patients, versus slightly elevation in three patients, even in the normal range. However, when they had a relapse, the serum NSE rose again: in 11 patients above a normal range and in 2 patients to a normal value. Figure 1b shows the changes in the serum level of NSE in three patients who did not re­sponse to chemotherapy. In one patient the pre-treatment level was in a normal range; in the other two patients NSE level was above 16.6 ng/ml. In all three patients there is a clear elevation in NSE during the chemother­apy that predicted the clinical recognition of relapse. Discussion and conclusions A raised serum NSE was observed in 47.8% of the patients with LC; the sensibility of NSE was 72.72% in patients with SCLC versus 38.89% in NSCLC. Our results correspond to the findings of other authors: Carney et al.6 ­ NSE sensibility of 69% in SCLC with the cut of level of 12 ng/ml, Cooper et al.8 - NSE sen­ sibility of 77% in SCLC with the cut of level of 13 ng/ml, Esscher et al.1 - NSE sensibility of 85% in SCLC and 25% in NSCLC with the cut of level of 12 ng/ml, Lorenz et al.9 - NSE sen­ sibility of 98% in SCLC and 4% in NSCLC with the cut of level of 15 ng/ml. NSE is a marker specific for the neuroen­ docrine system and for tumours that arise from it, the so-called ADUP neoplasms. The characteristics of these tumours are defined ab Figure 1. Serum NSE level changes (ng/ml) in patients with SCLC and NSCLC during treatment. in vivo and in vitro studies: many neurosecre­tory granules, the ability for the production of different hormones and polypeptides, the high level of L-Dopa decarboxylasa and NSE.10 When the characteristic features of SCLC were first described, this tumour was considered to be an anaplastic malignancy with which a variety of paraneoplastic syn­dromes were associated.11 In the 1960, how­ever, the presence of neurosecretory granules within the cells was described, which led to the inclusion of SCLC within the APUD sys­tem. It was thus presumed that the anaplastic cells were derived, in the normal bronchial mucosa, from the Kulchitsky cells which posses APUD properties. It is interesting why serum NSE is elevated in some of patients with NSCLC. The mechanisms by which NSCLC cells are capable of producing APUD-derived enzymes and hormones are not known. According to the findings of Gazard, there is a possibility of in vitro "conversion" of small-cell lung cacinoma to large cell cancer morphology. Although "transformed" cells had lost most or all of their "amine precusor uptake and decarboxylation characteristics" certain neuroendocrine features such as NSE were retained. Thus, it is possible that the large cell lung cancers were originally small cell tumours that "changed" histology, but "re­tained" NSE activity or were mixed tumours with the small cell component. The appear­ance of heterogeneous cell populations in the carcinomas is the reason why different parts of the tumour tissue show a different im­munohistochemical expression for the same marker and why the tumour metastasises do not release some tumour marker which is re­leased by the primary tumour.12 The results regarding the extension of the disease in patients with SCLC are compara­ble with the results reported by other authors (mean value of limited disease versus mean value of extensive disease): Fischbah and Berthold13 - 8.4 +/- 0.8 / 47.7 +/- 8.8 ng/ml; Carney et al.6 - 13.8 / 59.0 ng/ml; Johnson et al.7 - 33.4 +/- 4.7 / 94.5 +/- 13.8 ng/ml; Cooper et al.8 - 14 / 42 ng/ml; Splinter et al.14 - 25 / 51 ng/ml. According to Carney et al.6, Johnson et al7 and others, the serum level of NSE, is more in correlation with the tumour burden and the number of metastatic site than with the individual ability of tumour to produce NSE. Our follow-up studies in 16 patients showed the correlation between the tumour burden, the clinical response and serum NSE concentrations: the elevated, pre-treatment NSE levels decline to normal or nearly nor­mal when CR or PR was achieved, while 1 re­sponding patient maintained the essentially stable NSE level. When the relapse or pro­gression in the disease occurred, the NSE lev­el rose again; what is more important, raising was obtained before the clinical recognition of the relapse; a rising NSE level may predict relapse weeks to months in advance of other clinical evidence and signal the need to change a therapy sooner. A progressive rise in NSE levels during the treatment indicates the tumour resistance or relapse and also need to change the therapy. With serial NSE measurements we can follow up the disease course of the patients with SCLC, and give a different therapy at a time when it is likely to be most beneficial, i.e., when the tumour bur­den is low.7,8,15 NSE is a useful tumour mark­er for the diagnosis and the differential diag­nosis in patients with SCLC. This means that NSE measurements in patients with SCLC are at least a useful addition to standard in-vestigational methods. Serial NSE measure­ments are useful for monitoring the course of the disease and therapeutical response; they provide information relevant to patient man­agement which could not be obtained by the physical examination or routine staging pro­cedures. References 1. Essher T, Steinoltz L, Berg J, Nou E, Nilsson K, Pahlman S. Neuron specific enolase: a useful di­agnostic serum marker for small cell carcinoma of the lung. Thorax 1985; 40: 85-90. 2. Marangos PJ, Zomzoly-Neurath C, Goodwin FK. Structural and immunological properties of neu­ron specific protein (NSP) from rat, cat and hu­man brain: comparison to bovine 14-3-2. J Neurochem 1977; 28: 1097-107. 3. Schmechell DE, Marangos PJ, Zis AP, Brightman M. Brain enolase and specific markers of neuronal and glial cells. Science 1978; 199: 313-5. 4. Tapia FJ, Barbosa AJA, Marangos PJ, Polak JM, Bloom SR, Dermody C, et al. Neuron-specific eno-lase is produced by neuroendocrine tumors. Lancet 1981; 11: 808-11. 5. Prinz RA, Marngos PJ. Use of neuron-specific eno-lase as a serum marker for neuroendocrine neo-plasma. Surgery 1982; 92: 887-9. 6. Carney DN, Marangos PJ, Ihde DC, Bunn PA Jr, Cohen MH, Minna JD, et al. Serum neuron- spe­cific enolase: a marker for disease extent and re­sponse to therapy of small cell lung cancer. Lancet 1982; 1: 583-5. 7. Johnson DH, Marangos PJ, Forbes JT, Hainsworth JD, Van Welch R, Hande KR, et al. Potential utili­ty of serum neuron specific enolase levels insmall cell carcinoma of the lung. Cancer Res 1984; 44: 5409-19. 8. Cooper EH, Splinter TAW, Brown DA, Muers MF, Peake MD, Pearson SL. Evaluation of radioim­munoassay for neuron specific enolase in small cell lung cancer. Br J Cancer 1985; 51: 645-52. 9. Lorenz J, Mai GA, Schulz V. Neuronenspezifische enolase - ein selektiver marker des kleinzelligen bronchialkarzinoma. Prax Klin Pneumol 1986; 40: 100-2. 10. Marangos PJ, Gazdar AF, Carney DN. Neuron spe­cific enolase in human small cell carcinoma cul­tures. Cancer Lett 1982; 15: 67-71. 11. Cole GA, Polak JM, Wharton J, Marangos PJ, Pearse AGE. Neuron specific enolase as a useful histochemical marker for the neuroendocrine sis-tem of the lung. J Pathol 1980; 132: 351-2. 12. Bombardieri E, Jotti GS, Cocciolo MG, Mori M, Rusconi A, Rusca M, et al. Tissue polypeptide anti­gen and carcinoembruonic antigen in colon tu­ mors: serum levels and immunohistochemical lo­calization. Cancer Detect Prev 1985; 8: 219-26. 13. Fischbach W, Berthold J. Neuron-specific enolase in the diagnosis and therapy monitoring of lung cancer: a comparison with CEA, TPA, ferritin and calcitonin. Int J Biol Markers 1986; 1: 129-36. 14. Splinter TAW, Cooper EH, Kho GS. Neuron spe­cific enolase as a guide to the treatment of small cell lung cancer. Cancer Clin Oncol 1986; 23: 171-6. 15. Akoun GM, Scarna HM, Milleron BJ, Benichou MP, Herman DP. Serum neuron specific enolase: marker for disease extent and response to therapy for small cell cancer. Chest 1985; 87: 39-43. Radiol Oncol 2004; 38(1): 27-34. Breast cancer and breast health awareness as an evolving health promotion concept Andrej Plesnicar1, Viljem Kovac2, Božo Kralj1 1University of Ljubljana, University College of Health Studies, Ljubljana, Slovenia 2Institute of Oncology, Ljubljana, Slovenia Background. Breast cancer is the most frequent malignant disease in the majority of developed countries. In the last few years the introduction of mammography screening programmes has resulted in an improved survival of breast cancer patients. However, the incidence of the disease in these countries is still on the in­crease. Present focus on secondary breast cancer prevention activities, consisting of early detection and treatment, cannot ensure a decrease of breast cancer incidence. Improved breast health awareness could therefore represent a part of specific health promotion activities aimed at decreasing the incidence of breast cancer. Conclusions. In developed countries breast cancer is a significant health care issue. Secondary breast can­cer prevention activities should therefore be complemented by specific health promotion activities in order to reduce its incidence in the future. Primary breast cancer prevention would include health promotion ac­tivities aimed at enhancement of the individual as well as collective breast health awareness. Properly en­lightened members of the influential population groups could attain appropriate changes in the fields of leg­islation, taxation, customs and commercial regulations that would enable women to control their own breast health. Key words: breast neoplasms - prevention and control; health promotion Received 15 January 2004 Accepted 2 February 2004 Correspondence to: Andrej Plesnicar, MD, MSc, University of Ljubljana, University College of Health Studies, Poljanska cesta 26a, SI 1000 Ljubljana, Slovenia; Phone: +386 1 300 11 67; Fax: +386 1 300 11 19; E-mail: andrej.plesnicar@vsz.uni-lj.si Introduction Breast cancer is the most prevalent cancerous disease in women in the majority of devel­oped countries. The incidence of breast can­cer in most of these countries is still on the in­crease. However, the current increase of new­ly discovered cases is partly attributable to the introduction of efficient mammography screening tests. This also brought about an improvement in survival of the patients, measured with the length of survival after the discovery of breast cancer, and with an in­crease in the five-year survival rate.1,2 Also in Slovenia breast cancer is major cancerous dis­ease in women. According to the Cancer Registry of Slovenia the incidence of the dis­ease is still on the increase; in the year 2000 there were 932 newly discovered cases in a two million population.3 Present health care activities with mam­mography screening tests are primarily fo­cused on early breast cancer detection and treatment. These tests enable the discovery of the disease in the early stages of its clinical development, hence improving the chances for longer survival of breast cancer patients.4 The truth is that the disease is usually rela­tively advanced when it is detected as a per­ceivable change in a mammography image or as a clinically ascertained, locally advanced or metastatically expanded tumorous forma­tion.2,4 In Slovenia, as in most developed countries, the greatest emphasis is put on the already mentioned secondary breast cancer prevention activities. The methods of primary prevention are rarely or hardly ever mentioned, especially via health promotion activities. These activi­ties could no doubt include initiatives for en­actment of legislation that would create cir­cumstances where choices for avoiding the risk factors leading to breast cancer were of­fered and made easily available to women. At least at the beginning we would try to get some of the influential population groups in the Republic of Slovenia better acquainted with breast cancer characteristics and with the role that the members of those groups could play in stopping the increase of the dis­ease and later, hopefully, in its decrease. Present focus on secondary breast cancer prevention activities For the last few years experts from different fields have been quite active in spreading in­formation on breast changes that women should be attentive to. Above all, the impor­tance of early detection and treatment of al­ready existent breast cancer has been empha­sised.2,4 In doing this, professionals en­counter women’s fear of breast cancer, vari­ous myths and anxieties. They learn about different levels of their knowledge and un­derstanding of cancerous alterations of the breast, as well as about their different opin­ions of benefits of being included in mam­mography screening test programmes.2,4 In most women of all ages, breast cancer brings about fear, confusion and concern. When they visit a specialist those feelings are inten­sified by possible breast pain, asymmetry of the breasts, discharge, lumps or thickenings in the breasts, as well as positive family his­tory.1,5 Indirectly, breast health concern in women is quite well expressed, however, a deeper knowledge of healthy breast charac­teristics or breast health awareness can most often not be found. As a rule it is limited on­ly to the absence of tumorous changes in the breasts. In some countries certain measures have been adopted more than ten years ago in or­der to reduce the number of deaths caused by breast cancer. With methods of early detec­tion the breast cancer mortality rate was sup­posed to drop to less than 25% by the year 2000. Therefore, numerous activities were aimed at increasing the number of women in­cluded in the mammography screening test programmes. In certain age groups with high risk for developing breast cancer the inclu­sion rate was expected to increase at least to 70%. In some places and regions of certain countries this inclusion rate was actually achieved, above all by dissemination of spe­cific information about mammography screening tests.2, 5-8 In this context information about the ben­efits of being included in mammography screening tests was an integral part of specif­ic health promotion activities. Traditional in­formation methods aimed at an increase of the inclusion rates comprised of information brochures and posters, newspaper, radio and sometimes television advertising, meetings with experts in local communities and peri­odical visits to the local centres for early breast cancer detection with the introduction of a mammography apparatus. Also, specific information and education programmes on this subject have been introduced for primary health care professionals. Women with first­hand breast cancer experience very often par­ticipated in those activities by writing news­paper articles and giving interviews in the media, and sometimes even their partners joined in with their support.1,5,8 However, these activities are chiefly aimed at the in­crease of inclusion rates to mammography screening test programmes and as such their main aspect is emphasis on the secondary prevention that is focused on detecting and treating the already existing disease. Mostly they anticipate a change of attitude of a cer­tain part of the health care system and also changes of women’s attitude.1,2,5-8 Despite an increase of the inclusion rate in mammogra­phy screening test programmes, the role of women in this process remains limited and passive. New initiatives and activities would not be limited only to women in certain age groups, but would include women of all ages as well as everybody else. They would be aimed at overreaching the existing cultural and social differences among women.5 Such initiatives and activities would encompass a wider, more holistic and, maybe some time in the fu­ture, more successful approach to the breast cancer problem. Apart from disseminating and adapting information on breast cancer in healthy women, we would like to put special emphasis on breast health awareness.2,5,9-12 Lower average clinical stages in patients with subsequently citologically confirmed breast cancer and longer survival can be achieved with high inclusion rates into the mammog­raphy programmes.1,2 However, the inci­dence of breast cancer itself can not be re­duced solely in this way. Health promotion, individual and collective breast health awareness and breast cancer incidence reduction Long-term changes in the community in re­sponse to the decreased incidence of breast cancer (as well as some other cancers) could possibly be achieved by applying intersec­tional and multidisciplinary approaches.4,5,13 Primary prevention activities, first of all health promotion activities with quite specif­ic aims (e.g. the already mentioned breast cancer incidence reduction) would have to be implemented on the individual as well as on the community or collective level with the participation of the interested public and the adequately educated experts. The sole in­volvement of doctors and other health care professionals would most probably not suf­fice.4,5 On the individual level, breast health awareness means accepting health responsi­bilities to greater extent by being able to rec­ognize normal appearance and structure of breasts during different cycle periods and with regard to age, and by being able to rec­ognize undue changes and inform the physi­cian immediately.14 It could therefore proba­bly also be enhanced by learning how to choose healthy nutrition, a healthy lifestyle and by realisation of biological potentials, as well as by getting to know the structure and composition of healthy breasts with regular self-examination. On the community level (local, regional and state institutions), breast health awareness could also be explained as arising from the underlying collective breast health awareness; initiatives would have to be instigated that would stimulate groups of influential individuals to actively participate in the implementation of adequate changes of legislation, taxation, customs and commercial regulations, enabling every woman to have at least partial control over her own health.13 Breast health awareness would therefore not be limited only to individual women but would become a collective and community prospect, thus gaining a wider social dimen­sion. Planning of the integral initiatives in the field of health promotion, including the achievement of greater collective breast health awareness, can be taken up only on the basis of reliable data. Although data on women’s views and perceptions of breast health are not available in Slovenia, regular yearly reports of the Cancer Registry of Slovenia render possible a notion the influ­ence of life-style changes have on the inci­dence of breast cancer and other cancers in the second half of the 20th century in Slovenia.3-5 The overall strategy for achieving the goal (breast cancer incidence reduction) could therefore include smaller, and tem­porarily, only hypothetical projects with a common basic outline (Figure 1). In the case of breast cancer, a decreased exposure to 1. Project design 2. Project development and goal specification 3. Acquiring funds and active project participants 4. Identification of individual and group goals (e.g. within the National Assembly) 5. Evaluation 6. Data presentation (symposium, workshop,...) 7. Evaluation 8. Project evaluation 9. Presentation of project results Figure 1. Outline of a hypothetical health promotion project (possible reduction of exposure to breast can­cer risk factors). some of the risk factors connected to the de­velopment of this cancerous disease, would be attained with time (Table 1).1,2 Some of these factors could be influenced only indi­rectly with the hope that after a longer period of time breast cancer incidence would finally decrease. A more direct influence could be exerted by banning cancerous agents in food, at the work place and in the living environ­ment. The specific importance of adequate health education could also be defined. In the beginning, planning of integral ini­tiatives aimed at achieving greater collective breast health awareness would be focused on different influential and other population groups: perhaps even the members of the National Assembly of the Republic of Slovenia. Specific health promotion activities would include projects that would introduce breast cancer risk factors, breast cancer epi­demiology in Slovenia and basic information on carcinogenesis at least to some members of these groups. The beginning of any such hypothetical projects for improvement of col­lective breast health awareness with the help of influential population groups would defi­nitely be marked by endeavours to identify the interested individuals in those groups. Later they could be joined by the other mem­bers of these groups. However, in the begin­ning, they could represent important parts of alliances or coalitions for achieving the strate­gic goals. Different professionals from differ­ent educational areas, members of govern­ment, as well as non-government organisa­tions and volunteers could work together.5 Execution of a hypothetical project for improvement of collective breast health awareness within an influential group The elected members of the legislative bodies are definitely one of the most powerful groups in society. They should serve as an ex­ample for illustrating the form and anticipat-ed development of health promotion projects, with a long-term goal of reducing the inci­dence of breast cancer. In the Republic of Slovenia there are 90 members of the National Assembly; many of them are also members of various committees, councils and other bodies.15 The powers of the National Assembly enable their members to pass laws and executive regulations that could help women to make healthy choices towards an active breast cancer prevention role. Assistance for the realisation of such projects should be sought from women members of the Assembly, deputies that are doctors and other medical professionals, and probably amongst those members of the Assembly with women relatives who have developed breast cancer. These people alone could rep­resent a particularly influential group within the National Assembly and the project could be carried through. In favourable conditions it could be later repeated with the participa­tion of all the members of the National Assembly (or of any other influential group). Interested groups and individuals could prob­ably also be found among volunteers and oth­er participants of such a pilot project, and participation of women who recovered from breast cancer would also be invaluable. In the initial part of health promotion strategic activities, focused on decreasing the exposure to breast cancer risk factors, a smaller multiphase project would be used to gather information about the views of specif­ic groups (or all members) of the National Assembly of the Republic of Slovenia (Figure 1). According to the results, we would later try to introduce significant characteristics of this type of cancer and to discuss with Assembly members to what extent they would be willing to participate in specific health promotion activities with the final goal of decreasing the breast cancer incidence. Already in the conceptional phase of the project pertinent references to the subject of »breast cancer and health promotion« would be found in professional publications. Alliance and/or coalition of the interested participants would be identified (Table 2), and at the end of this phase, the leadership of the project would be determined. During the designing phase of the project, attainable and Table 1. Breast cancer risk factors Early menarche, late menopause Nulliparity, age at first birth, number of born children Excessive body weight Treatment with estrogens Excessive alcohol consumption and high energy nutrients intake Benign epithelial proliferative lesions Family history of breast cancer Genetic mutations (BRCA1, BRCA2, TP53) Table 2. The expected participants of a hypothetical health promotion project for the reduction of exposure to breast cancer risk factors Interested members of influential groups (e.g. members of the National Assembly, ...) Ministries Epidemiology, carcinogenesis and breast cancer experts Clinical specialists (doctors, nurses, ...) Non-government organisations (Cancer Society of Slovenia, »Europa Donna« Society, ...) Volunteers realistic goals would be set and suitable spon­sors found. The contents, the structure and the methodology of the project would be dis­cussed with the project participants, and, if possible, the interested individuals and specifically interested groups among the National Assembly members would be iden­tified. Qualitative and quantitative data on how well the National Assembly members are acquainted with this particular health promotion project and how willing they are to participate in it would be gathered via spe­cially prepared questionnaires. The relevant information about this topic would be pre­sented in a form of a symposium, a workshop (brainstorming) or in another manner of con­veying information, and it would be followed by handing out evaluation questionnaires. Processing of the gathered information and the following discussion would reveal whether the continuation of the project is vi­able. This discussion would also cover the participants’ perception of breast health and an exchange of possible experiences with breast cancer within their families. Experts would help clarify any dilemmas that might occur, and concrete health promotion activi­ties with the goal of reducing the incidence of breast cancer in the future would also be dis­cussed. Reports on the evaluation of the proj­ect results would be presented to the partici­pants, sponsors and to the National Assembly members, and in various other forms possibly also to the professional and lay public. One can only guess at the expected results of the project. Nevertheless, it could be put to good use as a means of spreading information about breast cancer among the members of the group that crucially influences the life of the population. Data on the attitude of this group towards an important health issue and at least some reflections about the chosen method of presenting information on breast cancer would also be gathered. Discussion In developed countries worldwide and also in Slovenia, breast cancer represents an impor­tant public health problem together with oth- diseases.2,4,5,16-18 er cancerous In the last decades, introduction of and constant per­fecting of different treatment methods with surgical procedures, radiotherapy, chemo­therapy and supportive treatment have markedly improved survival rate and quality of life of breast cancer patients in these coun­tries.2,19,20 However, in the majority of devel­oped countries, including Slovenia, the inci­dence of breast cancer is still on the in­ crease.2,3,13,18,21,22 Improved breast health awareness for the individual and for the col­lective level could therefore represent a part of specific health promotion activities with the goal of decreasing the incidence of this disease. Health promotion activities aimed at greater individual and collective breast health awareness can only be a supplement and by no means a substitute for the secondary breast cancer prevention activities. Early de­tection and timely treatment have con­tributed to longer survival of breast cancer patients.2,23-32 The use of these secondary pre­vention methods instigated deliberations about breast health and breast health aware­ ness.5,10,13 Certain activities, that could be conditionally viewed as health promotion ac­tivities, are aimed at increasing the inclusion of women from specifically defined groups (certain age groups with some specific excep­tions at younger age) into mammography screening test programmes.2,5,23-32 One should bear in mind that the carcinogenesis of breast cancer is a phasic and continuous process at all ages, that it takes several years for breast cancer to develop, and that it takes quite some time for a tumorous formation in­side the breast to become clinically observ­able.2,33,34 New attitude towards breast health that would focus not only on the absence of tumorous formations in the breasts could in time probably result in the decreased expo­sure to breast cancer risk factors that directly or indirectly intensify the processes of car-cinogenesis in the breast tissue. It would be an attempt at introducing subtle and hardly measurable changes in women’s and the gen­eral population’s way of daily living that could in longer time frame bring about the de­crease of breast cancer incidence. Individual and collective breast health awareness levels are co-dependent up to a point, and improvement of one could proba­bly trigger a positive change in the other. Goal oriented activities of influential groups of population could probably represent also an incentive for the improvement of breast health awareness on the collective level. The most influential of all groups in every demo­cratic country is undoubtedly the highest leg­islative body. In the Republic of Slovenia this is the National Assembly with its 90 mem­bers. On different levels health promotion ac­tivities usually include also politics, therefore the idea of a project that would inform the members of the influential groups (the most influential group being the National Assembly) about the meaning and the burden of breast cancer in Slovenia and also about breast health awareness, should not come as a surprise.13,35 Since in Slovenia breast cancer is an im­portant public health issue, the inclusion of influential population groups into health pro­motion activities would be reasonable and ac­ceptable. Just like the whole community and its every individual, the members of these groups should be adequately educated and informed about this problem. Specific health promotion activities in connection with breast cancer within the framework of well considered public health policy would thus come near to the sphere of activities, recom­mended in the Ottawa Charter.4,13,35 The re­duction of breast cancer incidence as a possi­ble outcome of these activities would signifi­cantly influence the health of a large part of women in the community and consequently the health of the entire community. References 1. Hossfeld DK, Sherman CD, Love RR, Bosch FX, editors. International Union Against Cancer: Manual of clinical oncology. 5th edition. Berlin: Springer-Verlag; 1990. 2. Bishop JF, editor. Cancer facts: a concise oncology text. Amsterdam: Harwood Academic Publishers; 1999. 3. Register raka za Slovenijo. Incidenca raka v Sloveniji: 2000. Porocilo RR št. 42. Ljubljana: Onkološki Inštitut; 2003. 4. Jekel JF, Elmore JG, Katz DL. Epidemiology, Biostatistics and Preventive Medicine. Philadelphia: W. B. Saunders Company; 1996. 5. Mitchell A. Breast health awareness. In: Perkins ER, Simnett I, Wright L, editors. Evidence-based 4th Health Promotion. edition. Chichester: John Wiley & Sons; 2002. p. 266-74. 6. Harris TJ, Cook DG, Shah S, Victor CR, De Wilde S, Beighton C, et al. Mammography predictors in older women. Fam Pract 2002; 19: 661-4. 7. Hamilton EL, Wallis MG, Barlow J, Cullen L, Wright C. Women’s view of a breast screening service. Health Care Women Int 2003; 24: 40-8. 8. Edwards A, Unigwe S, Elwyn G, Hood K. Effects of communicating individual risks in screening programmes: Cochrane systematic review. Br Med J 2003; 327: 703-9. 9. Anderson BO, Braun S, Lim S, Smith RA, Taplin S, Thomas DB. Global Summit Early Detection Panel. Early detection of breast cancer in countries with limited resources. Breast J 2003; 9(Suppl 2): S51-9. 10. Braun S. The history of breast cancer advocacy. Breast J 2003; 9(Suppl 2): S98-100. 11. Moore MA, Kunimoto T, Tsuda H. Cancer screen­ing literature in the period 2000-2002: pointers to future research avenues. Asian Pac J Cancer Prev 2003; 4: 57-60. 12. Zorbas HM. Breast cancer screening. Med J Aust 2003; 178: 651-2. 13. Tulchinsky TH, Varavikova EA. The New Public Health. An Introduction for the 21st Century. San Diego: Academic Press; 2000. 14. Austoker J. Breast self examination. Br Med J 2003; 326: 1-2. 15. http://www.dz-rs.si 16. Oluwole SF, Ali AO, Adu A, Blane BP, Barlow B, Oropeza R. Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community. J Am Coll Surg 2003; 196: 180-8. 17. Yazidi-Belkoura IE, Adriaenssens E, Vercoutter-Edouart AS, Lemoine J, Nurcombe V, Handermarck H. Proteomics of breast cancer: out­comes and prospects. Technol Cancer Res Treat 2002; 1: 287-96. 18. Weir HK, Thun MJ, Hankey BF, Ries LA, Howe HL, Wingo PA, et al. Annual report to the nation on the status of cancer, 1975-2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 2003; 95: 1276-99. 19. Dignam JJ, Wieand K, Johnson KA, Fisher B, Xu L Mamounas EP. Obesity, tamoxifen use, and out­comes in women with estrogen receptor-positive early-stage breast cancer. J Natl Cancer Inst 2003; 95: 1467-76. 20. Buchholtz TA, Hunt KK, Whitman GJ, Sahin AA, Hortobagyi GN. Neoadjuvant chemotherapy for breast carcinoma: multidisciplinary considera­tions of benefits and risks. Cancer 2003; 98: 1150­60. 21. Quinn MJ. Cancer trends in the United States - a view from Europe. J Natl Cancer Inst 2003; 95: 1258-61. 22. Botha JL, Bray F, Sankila R, Parkin DM. Breast cancer incidence and mortality in 16 European countries. Eur J Cancer 2003; 39: 1718-29. 23. Dean PB. The rationale and current controveries of mammographic screening for breast cancer. Scand J Surg 2002; 91: 288-92. 24. de Kooning HJ. Mammographic screening: evi­dence from randomised controlled trials. Ann Oncol 2003; 14: 1185-9. 25. Walter SD. Mammographic screening: case-con­trol studies. Ann Oncol 2003; 14: 1190-2. 26. Hackshaw A. EUSOMA review of mammography screening. Ann Oncol 2003; 14: 1193-5. 27. Duffy SW, Tabar L, Vitak B, Yen MF, Warwick J, Smith RA, Chen HH. The Swedish Two-County Trial of mammographic screening: cluster ran-domisation and end point evaluation. Ann Oncol 2003; 14: 1196-8. 28. Lee SJ, Zelen M. Modelling the early detection of breast cancer. Ann Oncol 2003; 14: 1199-202. 29. Verbeek AL, Broeders MJ; National Evaluation Team for Breast Cancer Screening; National Expert and Training Centre for Breast Cancer Screening. Evaluation of the Netherlands breast cancer screening programme. Ann Oncol 2003; 14: 1203-5. 30. Giles GG, Amos A. Evaluation of the organised mammographic breast screening programme in Australia. Ann Oncol 2003; 14: 1209-11. 31. Goldhirsch A, Colleoni M, Domenighetti G, Gelber RD. Systemic treatments for women with breast cancer: outcome with relation to screening for the disease. Ann Oncol 2003; 14: 1212-4. 32. Sasieni P. Evaluation of the UK breast screening programmes. Ann Oncol 2003; 14: 1206-8. 33. Fidler IJ. Molecular biology of cancer: invasion and metastasis. In: De Vitta VT, Hellman S, Rosenberg SA, editors. Principles and practice of oncology. 5th edition. Philadelphia: Lippincott-Raven Pub­lishers; 1997. p. 135-52. 34. King RJB. Cancer biology. Harlow, England: Addison Wesley Longman Limited; 1996. 35. Vetter N, Matthews I. Epidemiology and Public Health Medicine. Edinburgh: Churchill Livingstone; 1999. Radiol Oncol 2004; 38(1): 35-42. review Psychosocial coping strategies in cancer patients Lilijana Šprah and Mojca Šoštaric Institute of Medical Sciences, Slovenian Academy of Science and Arts, Ljubljana, Slovenia Background. The aim of this review is to present common psychosocial problems in cancer patients and their possible coping strategies. Cancer patients are occupied with many psychosocial problems, which are only partially related to their health state and medical treatments. They are faced with a high social pres­sure, based on prejudices and stereotypes of this illness. The review presents the process of confrontation with the cancer diagnosis and of managing the psychological consequences of cancer. The effects of specif­ic coping styles, psychosocial interventions and a social support on initiation, progression and recurrence of cancer are also described. Conclusions. Although some recent meta-analysis could not provide scientific evidence for the association between coping strategies and the cancer initiation, the progression or the recurrence (neither have studies rejected the thesis of association), the therapeutic window for the psychosocial intervention is still wide and shows an important effect on the quality of lives of many cancer patients. Key words: neoplasms-psychology; social support; cancer patients, coping strategies psychosocial prob­lems, psychosocial support Introduction Coping is a complex mental process by which a person deals with stress, solves problems, and makes decisions. It is an emotional, cog­nitive and behavioural response of a patient to an illness. Coping process involves at least two stages: confronting (»Is this something to bother about?«) and managing (»What can I do about it?«) with different aspects of illness or Received 11 October 2003 Accepted 3 November 2003 Correspondence to: Lilijana Šprah, PhD., Institute of Medical Sciences, Slovenian Academy of Science and Arts, Novi trg 2, 1000 Ljubljana, Slovenija; Phone: +386 1 470 6439; Fax: + 386 1 426 1493; E-mail: lili­jana.sprah@guest.arnes.si disability. Since every patient is a unique per­son, an emotional, cognitive and behavioural response can vary a lot and can occasionally be quite unpredictable in the same patient. Despite striking differences in the progress of different cancers and the increas­ing effectiveness of medical treatments, can­cer continues to be the most widely feared group of diseases. Undoubtedly, cancer caus­es considerable psychological distress in patents, families, and often those health pro­fessionals who care for them. Some socially determined problems often augment distress in patients as well. Besides unpleasant symp­toms such as pain, nausea, fatigue and the distress, financial problems and problems concerning employment, housing, childcare, family worries and existential doubts also oc­cur. Only a well-planned care that fully in­volves patients and their families can mini­mize these problems. How do patients adapt to cancer? The number of studies aimed at answering this question has grown rapidly over the past twenty years. Consequently, much more is known today about the patient’s psychologi­cal functioning during the course of cancer and about the strategies they use in order to deal with this disease.1 It is commonly believed that a person’s mental attitude in response to the cancer di­agnosis affects his or her chances of the sur­vival. Although different coping strategies in cancer patients are predominantly designed in order to diminish the distress and to im­prove their quality of life, all studies did not prove convincing evidence that some psycho­logical coping styles like acceptance, fatalism, denial, helplessness, hopelessness can play a clinically important part in the survival or re­currence of cancer.2,3 At the same time, many studies lay great stress on psychological and social factors that could be involved in the ae­tiology and response to cancer and its treat­ment.4-6 Confrontation with cancer diagnosis The topic of cancer is associated with many social and clinical taboos. In popular lan­guage and in medical settings, euphemisms such as »growth«, »tumour«, »lump«, »shad­ow« are used to avoid the word »cancer«.7 Communications and reticence from commu­nicating about cancer reflect numerous nega­tive attitudes widespread among patients, their families, health professionals (including doctors and nurses), other hospital personnel and the wider lay community as well.8,9 These kinds of communications may arise from the fears and misconceptions surrounding cancer and using them and may give rise to their rootedness. Doctors may refrain from using the word »cancer«, because they believe pa­tients prefer not to be given a potentially ter­minal diagnosis. However, research studies show that members of the general public were more likely to say that they wish to be informed of a terminal diagnosis than doctors estimated they would be, nevertheless they may not take these opportunities when of­fered.10,11 Some researchers pointed out that every patient searches for the information about the identity, consequences and causes of an illness, time line and the cure. These compo­nents of common sense representations tend to be reasonably stable over time and across different illness episodes.12 Illness cognitions also tend to affect changes in health-locus-of­control-belief, different propensities to visit a doctor, changing attributions of getting sick and taking personal responsibilities over the treatment. Since the effectiveness of therapy not always depends on the medical treatment but also on patient’s representations of the ill­ness, the medical staffs have to recognize them and re-establish an effective communi­cation.13 Cancer specialists are beginning to acknowledge the value of improving commu­nication skills via training models, residential workshops and educational programs and thus reducing the risk of patient’s maladapta­tions to an improperly delivered diagnosis.14 Although most of the patients have al­ready constructed their own representations of their illnesses while waiting for the diag­nosis, the final diagnosis is mainly a stressful event. Patients have varied ways of copings with a cancer diagnosis. The response to a poor prognosis is ranging from shock and de­nial through anger, depression and finally ac­ceptance.15 While there is considerable doubt about the actual sequence of stages, this range of responses is commonly observed in patients with cancer. Researchers tempt to reveal whether the application of some of the coping strategies may result in a better ad­justment prognosis. In general, coping strate-gies that focus on emotional aspects of the re­sponse are associated with a poorer emotion­al adjustment. By contrast, patients whose strategies also focus on thinking about the is­sue in a different way, e.g. by acceptance of the condition, or on seeking solutions to problems, show a better subsequent adjust­ment.16,17 Some coping strategies may also in­fluence the prognosis. Patients that predomi­nantly show »denial«, »fighting spirit« or »stoic acceptance« were found to have better survival chances than patients whose coping responses reflected »helplessness / hopeless­ness«.18-20 Managing the psychological consequences of cancer The acknowledged psychological model of coping processes with the illness in general, is derived from the presumption that manag­ing with the illness is usually a long graduate process, accompanied with many ego-de-fence patterns (e.g. denial, repression, projec­tion, compensation, fatalism, dissimulation, etc.) and consecutively with a cognitive, emo­tional and behavioural consilidation.21,22 Heim21 described the coping process in a four step integrative model with alternating cop­ing phases. The start point of the patient’s perception phase is the moment, when the patient identifies some changes in his/her physiological condition and well-being and begins to analyze them. During the cognitive phase the patient is preoccupied with the dis­ease and tries to find the right definitions and estimations about his/her illness. Adjusted by numerous defence mechanisms (repres­sion, withdrawal, escapism, focusing, projec­tion, dissimulation, aggravation, isolation, ra­tionalization, reactive formation, regression, sublimation, symbolization), the patient’s coping process finally ends with a cognitive, emotional and behavioural consolidation. It should be pointed out that coping is a very delicate process, primary orientated on pa­tient’s needs and therefore often aggravating for the medical staff, patient’s family and oth­er patients as well. Conformed patients are socially more accepted than aggravating ones but in many occasions this condition can be a disadvantage that obstructs the coping process. After facing with the cancer diagnosis and the first abrupt reaction of a shock, which is a normal response to a stressful event, pa­tients often show signs of negation, disbelief and despair. This first step of the personal cri­sis usually lasts about a week. During the fol­lowing step patients slowly recognize the re­ality and become anxious, frightened, panic, depressed, having problems with cognitive functioning, sexual life, appetite, and sleep­ing and with managing daily routine.22-24 Some of the mentioned psychological adjust­ment problems may occur only in a smaller number of patients, while a range of psycho­logical responses (denial, anxiety and depres­sion) that accompany the cancer diagnosis, have been seen in the majority of cancer pa­tients.25 Denial is a mechanism of denying the presence of illness and medical diagnosis. It is normally activated after the first stages of a shock, and usually disappears after a short time.26,27 The denial may have a favourable effect when it appears in the first phase of coping, after the diagnosis has been estab­lished because it reduces anxiety. However, some negative effects of the denial have been observed, for example: it may interfere with the getting treatment (e.g., a delay in going to the doctor, not showing up for follow-ups, non-compliance) or it may disrupt the process of assimilating the stressful event. Furthermore, it may, adversely, affect inter­personal relations and constitute a cumula­tive stress depression - even immunocompe­tence.26 Some researches revealed that a ten­dency toward denial could be one of the im­portant risk factors for cancer.28 Anxiety is the response to a perceived threat. It is manifested as apprehension, un­controllable worry, restlessness, panic at­tacks, and avoidance of people and of re­minders of cancer, together with the signs of the autonomic arousal.29 In certain circum­stances anxious patients may overestimate the risks associated with the treatment and the likelihood of a poor outcome. The anxiety may also exacerbate perceptions of physical symptoms (such as breathlessness in lung cancer), and post-traumatic stress symptoms (with intrusive thoughts and the avoidance of reminders of cancer). Certain cancers and treatments are associated with specific fears. Thus, patients with head and neck cancers may worry about being able to breathe and swallow. Some patients may also develop phobias and conditioned vomiting in relation to unpleasant treatments such as chemother- apy.30,31 Insecurity, the outer locus of control over the situation, learned helplessness and per­ceived loss often result in depression. In con­trast to anxiety, which arises immediately af­ter the offspring of the disease and accompa­nies the clinical screenings, the depression is progressing more slowly. A diagnosis of can­cer and the awareness of associated losses may precipitate feelings similar to the be­reavement. The loss may be linked with lost parts of the body (such as a breast or hair), the role in family or society, or the impending loss of life. A severe and persistent depres­sive disorder is up to four times more com­mon in cancer patients than in the general population, occurring in 10-20 % during the disease.31 There is evidence that the depres­sion predicts the cancer progression and the mortality, although disentangling the delete­rious effects of disease progression on the mood complicates this research, as does the fact that some symptoms of cancer and its treatment mimic the depression. Obviously clinical signs of depression are often difficult to distinguish from the signs, which develop due to the chronic illness and side-effects of chemotherapeutic and radiological treatment (e.g. vomiting, weight loss, insomnia, tired­ness, etc).32,33 The depression in chronic pa­tients frequently leads to the high morbidity and suicide, especially in old patients, pa­tients with the psychiatric diagnosis and pa­tients without partners.34,35 Managing the psychosocial problems of cancer Cancer patients are occupied with many psy­chosocial problems, which are only partially related to their state of health and medical treatments. They are faced with a high social pressure, based on prejudices and stereo­types of this illness (e.g. suffering, dying, loneliness, dependence, no cure, loss of hair, mastectomy, etc).22 Only a few diseases are associated with as many negative connota­tions as cancer. Nonverbal signs, absence of spontaneous speech and reactions, embar­rassment, avoidance of interpersonal con­tacts or eye-contacts, poor communication and deficient concealing information are only a few signs of the prejudiced behaviour of medical staff, family members, friends and colleagues towards the cancer patient. Without doubt, these are representative be-havioural patterns that reflect social percep­tions of patients with cancer.36 Although psy­cho-oncology literature concerned with cop­ing strategies indicates that the coping style »thinking positive« is correlated with the can­cer patient’s overall level of mental health and mortality rates, the mentioned coping style could also represent a stress factor for cancer patients. In this case, »thinking posi­tive« does not represent an accurate report of internal cognitive state, but rather a conver­sational idiom, summarizing a socially nor­mative moral requirement.37 A social environment has an important im­pact on the patient’s crises; together with the disease it can affect different aspects of the patient’s life quality and discomfort. In such a manner some patients can transform from dominant to passive persons during hospital-isations, suffer from the social isolation and existential fears, concern about family rela­tionships and childcare and are anxious about their working career and financial situ­ation and have lower self-esteem and poor in­terpersonal relationships.38 Since the social support was found to be a preventive factor against stress and diseases and a curative factor by chronic diseases, it might serve as a significant cue in cancer pa­tients. The social support involves a social net, an important system of social relation­ships within the family, relatives, friends and colleagues. In most cases it is found to be use­ful but on some occasions it might have a dis­tressed effect. For instance, when the patient prefers to be alone because he/she feels that other people feel pity for him/her or in case when someone has taken control over the pa­tient and has broken the balance between support and control. It was also found that a continuous verbal communication about problems often leads to the depression in cancer patients.39,40 An effective social support increases self-esteem and decreases depression, but not all forms of support are necessary appropriate for cancer patients. For example, a marriage was found to have mixed effects. It was dis­covered that some spouses who had been very concerned about the partner’s health provoked depression and suffering in them.41 Psychosocial coping styles and their rele­vance to survival / recurrence of cancer Until recently there has been a common be­lief that psychosocial factors have a great in­fluence on the initiation and the survival from cancer. An association between psy­chosocial factors and the initiation or the sur­vival from cancer are biologically plausible through some immunological and neuroen­docrine mechanisms.42-45 Surprisingly, some meta-analysis studies discovered a little evi­dence that psychological coping styles and psychosocial interventions are important in the survival or the recurrence of cancer. In ad­dition, there is no evident association be­tween stressful life events, amount of social support, personality, locus of control, coping styles, negative emotional states / psychiatric symptoms, psychiatric diagnoses on repres­sion, initiation and progression of cancer.2,3,6 Although some studies indicated specific coping styles and psychosocial adjustments that influence the survival and the recurrence of cancer, the evidence of these discoveries is inconsistent, probably due to publication bias and methodological flaws (small samples, un­controlled and confounding variables, lack of studies of interactive effects). Some authors emphasized that people with cancer should not feel pressured into adopting particular coping styles (e.g. »fighting spirit«, problem focused coping, emotion focused coping, etc.) to improve the survival or reduce the risk of the recurrence because there is no good proof that a particular psychological coping style prolongs the survival or is more effective than some other.2 These findings suggest that psychological interventions should not be focused only on enhancing a certain coping style in regard to prolong survival. Therapists should be rather orientated to widening of a therapeutic win­dow and to helping cancer patients to achieve a better quality of life.46,47 A group therapy should be used first of all for the psychologi­cal benefit of cancer patients, not in order to prolong their life. Establishing a new social support network, expressing emotions, con­fronting existential issues, improving rela­tionships, enhancing communication, learn­ing coping skills, reducing of distress and pain, confronting with the possibility of dy­ing and destigmatising of cancer and cancer patients are many of benefits that the psy­chotherapy offers to their users. A well-trained and supervised staff should be en­couraged to achieve a notable and positive ef­fect on the quality of life in cancer pa­tients.14,47 Conclusions In spite of the lack of convincing evidence that psychological coping styles and psy­chosocial interventions are important in the survival or the recurrence of cancer, there is no doubt that during the confrontation and managing with cancer some psychosocial in­tervention should be employed in cancer pa­tients in order to diminish their distress. Some subgroups of cancer patients are espe­cially vulnerable and need to be recognized in order to prevent serious psychological com­ plications.6,34,46,48,49 Particularly attention is advised in groups of patients with the history of chronic depression, patients undergoing chemotherapy and radiotherapy, patients with breast and genitalia cancer, patients ex­periencing uncontrollable pain, patients with terminal illness, patients who practice un­healthy behaviours, patients without social support, children patients and elderly pa­tients. These patients are found to drive par­ticular benefit from psychosocial interven­tions. Their quality of life was improved by reducing psychological symptoms and dis­tress, by enhancing psychological and func­tional adjustment and by improving rehabili­tation. Furthermore subtle benefits are pre­dicted to correlate with psychosocial pro­grams. People with cancer benefit from care if psychological and medical cares are coordi­nated. Apart from the obvious benefits to quality of life, there is some evidence that en­couraging an active approach to living with cancer can improve the survival. As for all chronic illnesses, a multidisciplinary ap­proach and management protocols that in­clude psychological as well as medical assess­ment and intervention are required also for cancer. These protocols need not be specific for cancer as the issues are common to many medical conditions. The danger is that psy­chological care can be neglected by the med­ical focus on the cancer treatment. A case manager, whether nurse or doctor, who can coordinate the often diverse agencies in­volved in cancer patient’s care can ensure that the treatment is delivered efficiently.31 References 1. Lin HR, Bauer-Wu SM. Psycho-spiritual well-be­ing in patients with advanced cancer: an integra­tive review of the literature. J Adv Nurs 2003; 44: 69-80. 2. Petticrew M, Bell R, Hunter D. Influence of psy­chological coping on survival and recurrence in people with cancer: systematic review. BMJ 2002; 325: 1066-76. 3. Ross L, Boesen EH, Dalton SO, Johansen C. Mind and cancer: does psychosocial intervention im­prove survival and psychological well-being? Eur J Cancer 2002; 38: 1447-57. 4. van der Pompe G, Antoni M, Visser A, Garssen B. Adjustment to breast cancer: The psychobiological effects of psychosocial interventions. Patient Educ Couns 1996; 28: 209-2. 5. Heim E. Coping-based intervention strategies. Patient Educ Couns 1995; 26: 145-51. 6. Garssen B. Psycho-oncology and cancer: linking psychosocial factors with cancer development. Ann Oncol 2002; 13: 171-5. 7. Baile WF, Lenzi R, Parker PA, Buckman R, Cohen L. Oncologists’ attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol 2002; 20: 2189-96. 8. Mystakidou K, Parpa E, Tsilika E, Katsouda E, Vlahos L. Cancer information disclosure in differ­ent cultural contexts. Support Care Cancer 2003; 11: in press. 9. Amir M. Considerations guiding physicians when informing cancer patients. Soc Sci Med 1987; 24: 741-8. 10. Yun YH, Lee CG, Kim SY, Lee SW, Heo DS, Kim JS, et al. The attitudes of cancer patients and their families toward the disclosure of terminal illness. J Clin Oncol 2004; 22: 307-14. 11. Grassi L, Giraldi T, Messina E G, Magnani K, Valle E, Cartei G. Physicians’ attitudes to and problems with truth-telling to cancer patients. Support Care Cancer 2000; 8: 40-5. 12. Lau RR, Bernard TM, Hartman KA. Further explo­rations of common-sense representations of com­mon illnesses. Health Psychology 1989; 8: 195-219. 13. Shaw C. A framework for the study of coping, ill­ness behaviour and outcomes. J Adv Nurs 1999; 29: 1246-55. 14. Schapira L. Communication skills training in clin­ical oncology: the ASCO position reviewed and optimistic personal perspective. Crit Rev Oncol Hematol 2003; 46: 25-31. 15. Maxwell M. Elisabeth Kubler-Ross revisited: a per­sonal account of a »life and transitions« workshop. Oncol Nurs Forum 1979; 6: 26-7. 16. Foster LW, McLellan L. Cognition and the cancer experience. Clinical implications. Cancer Pract 2000; 8: 25-31. 17. Epping-Jordan JE, Compas BE, Howell DC. Predictors of cancer progression in young adult men and women: avoidance, intrusive thoughts, and psychological symptoms. Health Psychol 1994; 13: 539-47. 18. Greer S, Morris T, Pettingale KW. Psychological response to breast cancer: effect on outcome. Lancet 1979; 2: 785-7. 19. Watson M, Greer S, Rowden L, Gorman C, Robertson B, Bliss JM, et al. Relationships between emotional control, adjustment to cancer and de­pression and anxiety in breast cancer patients. Psychol Med 1991; 21: 51-7. 20. Kreitler S. Denial in cancer patients. Cancer Invest 1999; 17: 514-34. 21. Heim E, Moser A, Adler R. Defense mechanisms and coping behavior in terminal illness. An overview. Psychother Psychosom 1978; 30: 1-17. 22. Rakovec Felser Z. Zdravstvena psihologija. Maribor: Univerza v Mariboru, Visoka zdravstvena šola; 2002. p. 88-98. 23. David HP. Coping with cancer. A personal odyssey. Patient Educ Couns 1999; 37: 293-7. 24. Rakovec Felser Z. Zdravstvena psihologija. Maribor: Univerza v Mariboru, Visoka zdravstvena šola; 2002. p. 83-7. 25. Burgess C, Morris T, Pettingale KW. Psychological response to cancer diagnosis II. Evidence for cop­ing styles (coping styles and cancer diagnosis). J Psychosom Res 1988; 32: 263-72. 26. Kreitler S. Denial in cancer patients. Cancer Invest 1999; 17: 514-34. 27. Greer S. The management of denial in cancer pa­tients. Oncology (Huntingt) 1992; 6: 33-6; Discussi­on 39-40. 28. Morley C. The use of denial by patients with can­cer. Prof Nurse 1997; 2: 380-1. 29. Stark DP, House A. Anxiety in cancer patients. Br J Cancer 2000; 83: 1261-7. 30. House A, Stark D. Anxiety in medical patients. In: Mayou R, Sharpe M, Carson A, editors. ABC of psychological medicine. London: BMJ Books; 2003. p. 14-6. 31. White CA, Macleod U. Cancer. In: Mayou R, Sharpe M, Carson A, editors. ABC of psychological medicine. London: BMJ Books; 2003. p. 25-8. 32. Spiegel D, Giese-Davis J. Depression and cancer: mechanisms and disease progression. Biol Psychiatry 2003; 54: 269-82. 33. Spiegel D. Cancer and depression. Br J Psychiatry 1996; 30(Suppl): 109-16. 34. Roth AJ, Modi R. Psychiatric issues in older cancer patients. Crit Rev Oncol Hematol 2003; 48: 185-97. 35. Chochinov HM. Depression in cancer patients. Lancet Oncol 2001; 2: 499-505. 36. Flanagan J, Holmes S. Social perceptions of cancer and their impacts: implications for nursing prac­tice arising from the literature. J Adv Nurs 2000; 32: 740-9. 37. Wilkinson S, Kitzinger C. Thinking differently about thinking positive: a discursive approach to cancer patients’ talk. Soc Sci Med 2000; 50: 797­811. 38. Rakovec Felser Z. Zdravstvena psihologija. Maribor: Univerza v Mariboru, Visoka zdravstvena šola; 2002. p. 98-115. 39. Ross CE, Mirowsky J. Explaining the social pat­terns of depression: control and problem solving ­or support and talking? J Health Soc Behav 1989; 30: 206-19. 40. Cheng WC, Schuckers PL, Hauser G, Burch J, Emmet JG, Walker B, et al. Psychosocial needs of family caregivers of terminally ill patients. Psychological Reports 1994; 75: 1243-50. 41. Manne S, Glassman M. Perceived control, coping efficacy, and avoidance coping as mediators be­tween spouses’ unsupportive behaviors and can­cer patients’ psychological distress. Health Psychol 2000; 19: 155-64. 42. Kiecolt-Glaser JK, Glaser R. Psychoneuro-immunology and cancer: fact or fiction? Eur J Cancer 1999; 35: 1603-7. 43. Irwin M, Daniels M, Bloom ET, Smith TL. Life events, depressive symptoms, and immune func­tion. Am J Psychiatry 1987; 144: 437-41. 44. Levy SM, Herberman RB, Whiteside T, Sanzo K. Perceived social support and tumor estrogen/progesterone receptor status as predic­tors of natural killer cell activity in breast cancer patients. Psychosom Med 1990; 52: 73-85. 45. Garssen B, Goodkin K. On the role of immunolog­ical factors as mediators between psychosocial factors and cancer progression. Psychiatry Research 1999; 85: 51-61. 46. Keller M, Weis J, Schumacher A, Griessmeier B. Psycho-Oncology in a united Europe - changes and challenges. Crit Rev Oncol Hematol 2003; 45: 109­17. 47. Spiegel D. Mind matters - group therapy and sur­vival in breast cancer. N Engl J Med 2001; 345, 24: 1767-8. 48. Turk DC, Flor H. Pain greater than pain behaviors: the utility and limitations of the pain behavior construct. Pain 1987; 31: 277-95. 49. Leopold KA, Ahles TA, Walch S, Amdur RJ, Mott LA, Wiegand-Packard L, et al. Prevalence of mood disorders and utility of the PRIME-MD in patients undergoing radiation therapy. Int J Radiat Oncol Biol Phys 1998; 42: 1105-12. Radiol Oncol 2004; 38(1): 43-7. Comet assay in the assessment of the human genome damage induced by . -radiation in vitro Vera Garaj-Vrhovac, Davor Zeljezic1 Institute for Medical Research and Occupational Health, Division of Mutagenesis, Zagreb, Croatia Background. The aim of the present study was to estimate a possible application of comet assay in the eval­uation of DNA damage caused by different gamma radiation doses in peripheral human lymphocytes in vit­ro. Materials and methods. Whole blood samples of young healthy, non-smoking donors were taken. The samples were divided in 4 specimens. The first specimen was used as the control. Other three specimens were irradiated using constant gamma irradiation source (60Co) giving the dose rate of 0.907 cGy/s. Different specimens were irradiated for 51 s, 437 s and 1099 s, giving the doses of 0.5 Gy, 4 Gy and 10 Gy. In order to estimate dose-response curve on the control and all 3 irradiated whole blood samples, the comet assay under alkali conditions was performed. Results and conclusions. The comet assay endpoints showed statistically significantly higher values for all irradiated blood samples compared to the control. For both, tail length and tail moment, dose-effect rela­tionship was found to be linear in a dose range of 0.5Gy and 10 Gy. By this work we also pointed out pos­sible usage of the comet assay in the detection of DNA lesions caused by extremely high radiation dose, which is not possible by using standard cytogenetic methods. Key words: lymphocytes-radiation effects; DNA damage; comet assay Introduction In radiobiology there is always a need for the development of new rapid and more sensitive methods for DNA damage evaluation. So far, Received 30 January 2004 Accepted 20 February 2004 Correspondence to: Davor Zeljezic, Institute for Medical Research and Occupational Health, Division of Mutagenesis, Ksaverska cesta 2, 10 000 Zagreb, Croatia; Tel.: +385 1 4673 188, Fax: +385 1 4673 303, E­mail: dzeljezi@imi.hr an analysis of structural chromosomal aberra­tions and micronucleus test have had great value in radiation biomonitoring.1,2 Recently, the comet assay, also called the single-cell gel electrophoresis (SCGE) assay appeared as new method of choice because it is a rapid and sensitive method for the detection of var­ious DNA damages (strand breaks and alkali-labile sites) in individual cells, induced by a variety of genotoxic agents. Since radiation may cause SSB, DSB, DNA-DNA as well as DNA-protein crosslinkings and damage to bases, all detectable by comet assay, this method could provide information on the to­tal DNA damage caused by ionizing radia­tion. This is not the case for standard cytoge­netic methods that, due to heterogeneity in genome damage caused by ionizing radiation, provide only average DNA damage informa­tion.3 Comet assay was first introduced by Östling and Johanson4, and later modified in­dependently by Singh et al.5 and Olive et al.6. The assay is based on the embedding of cells in agarose, their lysis in alkaline buffer and fi­nally subjection to an electric current. The electric current pulls the charged DNA from the nucleus so that relaxed and broken DNA fragments migrate further from the nucleus than intact DNA. The resulting images, named for their appearance as comets, are measured to determine the extent of DNA le­sion. Image analysis provides three important parameters for each comet: tail length, tail fluorescence intensity (percent of DNA in tail) and tail moment (roughly, the product of tail length and tail intensity).3 Although there were many papers consid­ering dose-DNA damage relations for struc­tural chromosome aberration analysis, until recently only few authors investigated those effects applying the comet assay2,6-9, which is essential for better understanding and inter­pretation of the results in the field of radia­tion biomonitoring obtained by this method. In the present paper, possible application of comet assay in the evaluation of DNA dam­age caused by different gamma radiation dos­es in peripheral human lymphocytes in vitro was studied. We also wanted to point out possible usage of the comet assay in the de­tection of DNA lesions caused by extremely high radiation dose, which is not possible by using standard cytogenetic methods. On the basis of these results using polynomial re­gression dose, a response curve for tail length and tail moment as comet assay endpoints was plotted. Materials and methods In vitro whole blood sample irradiation Two whole blood samples of young healthy, non-smoking donors from the cubital vein by using heparinized syringes were taken. Twelve months before blood sampling donors were not exposed to any physical or chemical agent that might interfere with the results ob­tained by radiation. Immediately after the sampling, the blood from each donor was di­vided in 4 specimens. The first specimen was used as the control. Other three specimens were irradiated using Gammacel irradiator, Model 220, with constant gamma irradiation source (60Co) giving the dose of 0.907 cGy/s.10 Different specimens were irradiated for 51 s, 437 s and 1099 s, giving the doses of 0.5 Gy, 4 Gy and 10 Gy. Description of gamma irradiation source The 60Co source consists of 48 linear source elements equidistantly spaced in a stainless steel rack to form a cylindrical shell or annu­lus, with a diameter of 20,9 cm, measured be­tween the centers of opposing elements. Each linear element consists of a welded stainless steel pencil filled with 60Co in the form of metallic cobalt. Internal dimensions of each pencil are 1 cm in diameter and 20.3 cm in length.10 The drawer is centrally located in the radi­ation shield and is power driven vertically through the center of the source. The materi­al to be irradiated is placed in the sample chamber, then lowered to the irradiation po­sition, i.e. the sample chamber is then in the center of the source.10 Comet assay After the irradiation the blood was put in ice and transferred to the laboratory. In order to estimate dose-response curve on the control and all 3 irradiated whole blood samples, the comet assay was immediately performed. The comet assay was conducted under alkali con-ditions according to Singh et al.5 All chemi­cals used to perform the comet assay were ob­tained by Sigma. Two µl of whole blood were suspended in 0.5% low melting agarose and sandwiched between a layer of 0.6% normal melting agarose and a top layer of 0.5% low melting agarose on fully frosted slides. During the polymerization of each gel-layer, the slides were kept on ice. After the solidifi­cation of 0.6% agarose layer, the slides were immersed in lysis solution (1% sodium sar­cosinate, 2.5 M NaCl, 100 mM Na2EDTA, 10 mM Tris-HCl, 1% Triton X-100 and DMSO 10%) at 4°C. After 1 hour, the slides were placed in electrophoresis buffer (0.3 M NaOH, 1 mM Na2EDTA, pH 10) for 20 min­utes at room temperature to allow for DNA unwinding. Electrophoresis was conducted in a horizontal electrophoresis platform in fresh, chilled electrophoresis buffer for 20 minutes at 300 mA and 19 V. The slides were neutralized with Tris-HCl buffer (pH 7.5) three times for 5 minutes and stained with 10% ethidium-bromide for 10 minutes. Each slide was analyzed by using Leitz Orthoplan epifluorescence microscope equipped with an excitation filter of 515 - 560 nm. For each irradiation dose, 100 cells were analyzed by automatic digital analysis system Comet as­say II (Perceptive Instruments Ltd., Suffolk, Halstead, UK), determining tail length and tail moment (tail length x tail % DNA/100). Statistical analysis Possible comet assay endpoints between con­trol and exposed group were evaluated by us­ing the Mann-Whitney U-test. The dose-re­sponse curve was obtained using the method of linear regression.11 Results As shown in Figure 1, tail length values for the control blood specimen varied between 10.37 µm and 17.50 µm (mean value 14.19 ± 1.49 Figure 1. Distribution of the comets regarding their tail length. Figure 2. Distribution of the comets regarding their tail moment. µm). After the irradiation of the whole blood with the dose of 0.5, Gy the tail length ranged from 12.97 µm to 27.88 µm (mean value 17.81 ±2.40 µm). At the dose of 4 Gy, it ranged from 14.26 µm to 44.73 µm (mean value 21.12 ± 5.06 µm) and at 10 Gy, from 21.39 µm to 55.75 µm (mean value 33.80 ± 7.80 µm). Tail mo­ment values (Figure 2) ranged for the control from 6.43 µm to 14.62 µm (mean value 11.04 ±1.92 µm), at 0.5 Gy, from 10.54 µm to 23.84 µm (mean value 14.81 ± 2.20 µm), at 4 Gy, from 9.33 µm to 34.10 µm (mean value 16.91 ± 4.52 µm), and at 10 Gy, from 15.04 µm to 81.96 µm (mean value 28.64 ±8.74 µm). For both, tail length and tail moment, dose-effect relationship was found to be lin­ear in a dose range of 0.5Gy and 10 Gy (Figures 3,4). Figure 3. Tail length dose-response curve Figure 4. Tail moment dose-response curve. Discussion Our goal was to determine the extent of DNA breakage measured with the comet assay in­duced by ionizing gamma radiation as DNA damaging agent. Under the alkaline condi­tions used here, the comet assay detects dou­ble- and single strand breaks and alkali-labile sites that could occur as the result of physio­chemical interaction of ionizing radiation with cellular DNA.12 The comet values that increased with the applied irradiation dose indicate a dependence of the extent of radia­tion-induced primary DNA damage on the dose value. Similar results, but only for the low-dose radiation, were obtained by Kormos et al.7, Olive et al.6, Vijayalaxmi et al.13, Plappert et al.8, Singh et. al.5, He et al.2. He et al. found the dose-response curve for tail length to be lin­ear between doses of 1 Gy and 2 Gy.2 They also assumed that the curve could remain lin­ear at the higher radiation doses. Also for the low dose irradiation, some other authors showed a good relationship between comet assay endpoints and results obtained by mi-cronucleus assay.2,9 But due to the mitotic ac­tivity requirements by standard cytogenetic methods (micronucleus assay, chromosomal aberration assay) which is significantly re­duced after the high dose irradiation, it is im­possible to apply these techniques at dose levels higher than 5 Gy.8,14 As shown in the present paper, the comet assay does note re­quire prior cell cultivation; it could therefore be used in the evaluation of the DNA damage even at the dose as high as 10 Gy which is es­sential in case of accidents involving ionizing radiation. As shown in the Figures 1 and 2, the appli­cation of higher irradiation dose caused a shift of tail length and tail moment toward higher values. Regardless to the dose in all ir­radiated blood samples lymphocytes with comet endpoint, values were significantly higher than the sample mean value. According to Plappert et al. these cells were considered to express a deficiency in DNA re­pair efficiency.8 Beside the already mentioned absence of need for cell cultivation, there are many oth­er advantages of the comet assay application in the ionizing radiation induced DNA dam­age risk assessment. The method is simple, rapid and it detects primary DNA lesions, whereas the other cytogenetic techniques are based on the detection of lesions left unre-paired and/or structural aberrations that could possibly occur as the result of the repair mechanisms.14 Comet assay also provides information on intercellular differences in the irradiation susceptibility. Because it does not involve cell cultivation, there is no need for the cell treat­ment with the chemicals as colchicine and cy­tochalasine B that are found to be mutagenic themselves and could possibly lead to false positive results.15 Therefore the comet assay could be widely applied in radiation biology and ionizing radiation risk assessment, espe-cially in the studies of high dose effects on the DNA level. Acknowledgments This work was supported by the Ministry of Science and Technology of the Republic of Croatia as a part of the scientific project No. 0022020. References 1. Lloyd DC, Edwards AA, Prosser JS. Chromosome aberrations induced in human lymphocytes by in vitro acute x and gamma radiation. Radiat Prot Dos 1986; 15(2): 83-6. 2. He JL, Chen WL, Jin LF, Jin HY. Comparative eval­uation of the in vitro micronucleus test and the comet assay for the detection of genotoxic effects of x-ray radiation. Mutat Res 2000; 469: 223-31. 3. Fairbairn DW, Olive PL, O’Neill KL. The comet as­say: a comprehensive review. Mutat Res 1995; 339: 37-59. 4. Ostling O, Johanson KJ. Microelectrophoretic study of radiation-induced DNA damages in indi­vidual cells. Biochem Biophys Res 1984; 123: 291-8. 5. Singh NP, Mc Coy MT, Tice RR. A simple tech­nique for quantitation of low levels of DNA dam­age in individual cells. Exp Cell Res 1988; 175: 184­91. 6. Olive PL, Banath JP, Durand RE. Heterogenity in radiation-induced DNA damage and repair in tu­mor and normal cells using the comet assay. Radiat Res 1990; 22: 86-94. 7. Kormos C, Koteles GJ. Micronuclei in x-irradiated human lymphocytes. Mutat Res 1988; 199: 31-5. 8. Plappert U, Raddatz K, Roth S, Fliedner TM. DNA-Damage detection in man after radiation expo­sure-The comet assay-Its possible application for human biomonitoring. Stem Cells 1995; 13: 215-22. 9. Maluf SW, Passoss DF, Bacelar A, Speit G, Erdtmann B. Assessment of DNA damage in lym­phocytes of workers exposed to x-radiation using the micronucelus test and the comet assay. Environ Mol Mutagen 2001; 38: 311-5. 10. Atomic Energy of Canada Limited. Gammacell 220 Research Irradiator. Specifications Number JS300. Ottawa, Canada; 1981. 11. Edwards AA, Denis JA. Polyfit - a computer program for fitting a specified degree of polynomial to data points. National Radiological Protection Board, Harwell, Didcot, Berks, NRPB-M11; 1973. 12. Tice RR. The single cell gel/comet assay: a micro-gel electrophoretic technique for the detection of DNA damage and repair in individual cells. In: Environmental Mutagenesis. Oxford: Bios Scientific Publishers; 1994. p. 67-96. 13. Vijayalaxmi GHS, Tice RR, Strauss GG. Assessment of radiation-induced DNA damage in human blood lymphocytes using single-cell gel electrophoresis technique. Mutat Res 1992; 271: 243-52. 14. Koteles GJ. Biological dosimetry. International Congress on Radiation Protection, Vienna, Austria; 1996. 15. IAEA. Biological dosimetry - chromosomal aberration analysis for dose assessment. Technical Report Series, vol 260; 1986. Radiol Oncol 2004; 38(1): 49-54. A web-application that extends functionality of medical device for tumor treatment by means of electrochemotherapy Ivan Pavlovic, Peter Kramar, Selma Corovic, David Cukjati, Damijan Miklavcic Faculty of Electrical Engineering, University of Ljubljana, Slovenia Electrochemotherapy (ECT) is a novel method for efficient tumor treatment in clinical environment. It com­bines local drug delivery and application of short high voltage pulses, which permeabilize the plasma mem­brane by electroporation. Drug can enter only the cells with permeabilzed membrane. Recently, medical de­vice Cliniporator™ for controlled electroporation was developed. Here, we present a web-application that extends the functionality of this medical device. The aim of the application is to collect, store and to allow the analysis of every ECT application using this medical device. The application helps transferring data col­lected by device during the electroporation process to the central database, and enables filling of medical records through the web-forms. The application is based on technologies ASP, HTML, Flash, JavaScript, XML and others. The application main advantages are easy and rapid data access, scalability and inde­pendence of client computer operating system as well as easy application debugging and upgrading. Key words: neoplasms-drug therapy; drug delivery systems; electroporation-instrumentation; internet Introduction In the cooperation with the European part­ners, the medical device called Cliniporator™ (IGEA s.r.l., Carpi, Italy) was developed, in the frame of the Cliniporator project (2000-03) funded by European Community. This device was designed for controlled in vivo cell per-meabilization by electroporation. Electro-poration is used to provide access to mole­cules distributed freely in the vascular and Received 10 December 2003 Accepted 19 January 2004 Correspondence to: Damijan Miklavcic, Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, 1000 Ljubljana, Slovenia; Tel: + 386 1 4768 456; Fax: +386 1 4264 658; E mail: damijan@ svarun.fe.uni-lj.si extracellular compartments that normally do not enter the intracellular compartments.1,2,3 This technique is already used clinically to de­liver cytotoxic molecules like bleomycin and cisplatin to solid tumors by electrochemo-therapy (ECT).4,5 For a successful cell electroporation a volt­age applied for a given electrode tissue geom­etry, pulse duration and number of pulses should always be in the range between re­versible and irreversible threshold value. If the voltage applied exceeds the irreversible threshold value, a change in a cell membrane becomes permanent and destroys the cell. The most commonly very short (100 µs) high-voltage pulse or a sequence of such pulses are delivered. Pulses are generated in the high-voltage generator of Cliniporator™ and deliv­ered through the needle or plate electrodes to the tissue. By measuring both current and voltage simultaneously the device is monitor­ing electrical property changes of tissue in re­al time. Cliniporator™ is also the first medical de­vice designed for in vivo DNA electrotransfer in clinical applications. The two key steps of DNA electrotransfer are the electroporation of the target cells and the electrophoresis of the DNA within the tissue. Therefore, the de­vice delivers to the target cells a combination of short high-voltage pulse(s) that permeabi­lize the cells without substantial DNA trans-fer/transport, and a long low-voltage pulse(s) that do not cause permeabilization but facili­tate DNA transfer into the cells. This non vi­ral gene therapy method is called electro-genetherapy (EGT) and has many advantages with respect to viral methods.6 Indeed, the medical device Cliniporator™ is already used in clinical trials. They are per­formed in four approved medical centers in Europe, funded by European Community in a frame of ESOPE project (2003-2004). The aim of the project is to define Standard Operating Procedures (SOP) for electrochemotherapy and electrogenetherapy. Definition of the SOP can only be based on the wide study of ECT and EGT efficiency. Therefore, it is nec­essary to carefully follow and collect out­comes of ECT and EGT clinical trials. For collection of data acquired in ECT clin­ical trials a standard paper forms (Clinical Report Forms - CRF) were prepared. The CRF consists of a number of subforms, of which extent depends on the number of treated tu­mors and number of sessions required to treat the tumor. The CRF include patient’s general data, his/her medical history, tumor treatment data and response data. A tumor treatment can be repeated if necessary. The melanoma nodules can efficiently be treated by ECT, therefore patients with this type of tumors were included in the study. For every patient, medical personnel has to fill in 40 pages of forms on average. Since all forms are predefined and same for all patients, we de­cided to set up a unified database (central data­base) for collection of data from all four med­ical centers involved in the study. For sub­mission of relatively high number of data in­to the central database we developed a web-application, which enables access to the cen­tral database and filling of forms from any computer connected to the World Wide Web. Cliniporator™ Cliniporator™ is a medical device for elec­trochemotherapy and electrogenetherapy. It consists of two parts: a console (industrial PC compatible computer) for local collection of treatment data and user friendly interface; and an electroporator. Electroporator consists of a control unit, high voltage amplifier and low voltage amplifier. Control unit consists of a processor board, a measurement card for current and voltage measurement, a control card for driving voltage amplifiers and a con-trol-relay card for switching between the elec­trodes. A user controls the electroporator through graphical display and a keyboard of the con­sole unit. He/she can enter relevant patient data, choose appropriate electrodes, and de­fine pulse parameters such as number (e.g. 8 pulses), amplitude (up to 1000 V), duration (e.g. 100 µs), and repetition frequency (e.g. 1 Hz) of pulses. All users’ presets are stored in a local database, which is integrated into the console. By pressing a foot switch, the user triggers pulse generation. Square-shaped pulses are delivered. During the pulse deliv­ery, the control unit measures voltage and current through the load (a cell suspension or a tissue). After the pulse application voltage and current measurements are stored into the local database. User can use the local data­base for later analysis of performed treat­ments. Based on collected data we intend to develop an algorithm, which will allow device to adjust pulse voltage according to the cur­rent and voltage measurements in the real time and thus prevent irreversible changes in the cell membranes. Central database The central database (Microsoft SQL Server) stores following data collected from all the medical centers involved in study: -patient data (demography, medical histo­ ry, physical examination,...etc.), -treatment data (sessions, evaluation visits, follow-ups,...etc.), -data submitted from local databases of Cliniporator™ medical devices, -images of tumor nodules in a different phases of treatment. A backup copy of central database is auto­matically generated once per week. Each medical center has limited data ac­cess. Users from one medical center cannot read or modify data entered by other centers. Entered data are protected by username and password. Every medical center can have more authorized users, who all have access to the same data. Users can lock selected data, so they cannot be accidentally modified (it is like signing medical forms). Web-application Since medical centers that share data in the central database are spread all over Europe, we had to develop an application for user in­teraction with the database, which is easy to install, debug and upgrade. It also had to be very intuitive for using, so the users (a med­ical personnel) should not require any com­puter knowledge background or excessive training. It had to involve functionalities like: filling the clinical report forms (CRF), interac­tive human map for marking location of nod­ules, uploading images to the central data­base, image gallery, uploading local databas­es to the central database, and review of al­ready submitted data. In order to follow the progress of individual centers the application also involves statistical representation of the submitted data. An important prerequisite, common in research studies, was that the sys­tem has to be upgradeable. A client-server application would be costly to maintain and upgrade, therefore such solu­tion was not acceptable. Therefore, we devel­oped a web-application (called Cliniporator Web-Recorder), which is in our opinion an op­timal solution. Such solution does not need any installations on a client computer. Clients can access the central database through the web-application from any computer connect­ed to the World Wide Web and installed in-ternet browser (Internet Explorer, Netscape, Mozzila,...). The web-application is executing on a web-server. The application speed de­pends only on the web-server capabilities and the internet communication bandwidth while the client computer does not affect the appli­cation speed. By submitting username and password users can access all the application functionalities according to their level of au­thorization. Cliniporator Web-Recorder maintenance and upgrade is performed exclusively on the web-server. This is the quickest and the most effective and inexpensive way for debugging and upgrading the system. During the appli­cation development users have a possibility to participate in testing, which is very impor­tant for timely detection of irregularities in the system. Cliniporator Web-Recorder functionalities are: -web-forms (digital clinical report file (CRF)); -interactive human map for marking loca­ tion of tumor nodules; -image upload; -local database upload; -basic statistics (statistical processing of the submitted data). Web-forms (digital CRF) are form-like web pages (Figure 1). Through digital CRF users submit patient and treatment data to the cen­tral database. Digital CRF have the same form as the paper-based CRF. They are organized in the following sections: pre-study visit, ses­sions, adverse events, concomitant medica­tions, follow-up and end of study. The partic­ular section is divided into several pages. Pre-study visit consists of few pages where users enter patient’s demography data, medical his­tory (history of cancer, previous treatments and history of chronic non malignant dis­eases), vital signs, physical examinations, tu­mor lesions, laboratory results, inclusion cri­teria and exclusion criteria. Users can add any number of sessions (most usually two ses­sions). For every session users have to mark treated nodules and fill several pages with the following data: the time of the begin and the end of the session, vital signs, physical exam­ination, post procedure data (memory from the procedure and pain assessment), and, lat­er, day 15 and day 30 evaluation visit data (re­sponse to the treatment and memory from the procedure). Users can create one or more fol­low-up sections and enter data like date of the visit and lesion measurements. In the end of study section users should enter the reason for study termination. According to the already submitted data, some form-like web pages are dynamically generated, (e.g. if a patient has more tumor nodules, each nodule requires few form-like web pages for its description). Figure 1. A digital CRF page. An important advantage of the digital CRF is an automatic data checking. The web-ap­plication warns a user if he/she mistypes or enters erroneous data. The other advantage is a simple navigation through numbered forms. At the end of every section users have an opportunity to »digitally sign« the completed section. By signing a section the correspon­ding forms are »locked« and all further modi­fications are disabled. The purpose of the interactive human map is a visual representation of the tumor loca­tions. According to the patient’s sex, appro­priate body map is displayed. Users can switch between four views: front, rear, left and right. By simply clicking on the map, user can »add« a tumor, and then submit some principal data about the tumor (location, measurement lesion, date and method of ex­amination) and corresponding images. During the sessions, users can select on the map which of the pre-registered tumors are treated. The interactive human map is shown on the Figure 2. Image upload enables storing of tumor im­ages into the central database. Images, cap­tured by a digital camera, can be uploaded in the original size. A smaller image, suitable for displaying, as well as a thumbnail of the im­age, are dynamically generated and also stored in the database. Users can add a cap­tion and a description to every image. Images can be added in every phase of the treatment (pre-study, sessions, follow-up,...). In the im­age gallery (Figure 3) users can review all the uploaded images of one patient, or only the pictures of a particular phase of the treat­ment. This is very useful for the visual obser­vation of tumor changes. Local database upload is also performed trough the internet browser. The user simply selects the local database file and fills in com­ments. The rest of the process is automatic: application saves uploaded file on the server, records some upload information (date and time, user id, name of the file,...), and then copy data from the uploaded file to the cen­tral database. Application takes care of a du­plicate data and their overwriting - the newer data will overwrite the older ones. At the end of the upload process user is informed about the upload success. In the list of the uploaded data user can check all the data uploaded from his/her center. Basic statistics, which allow the follow-up of the project progress, are dynamically gen­erated from the data in the central database. Therefore, it offers information about the number of treated patients per center as well as number of ended therapies, number of tu­mor sessions and uploaded corresponding lo­cal databases, distributions of applications of different electrode types and different drugs. Every center has access to these statistics and can compare its activities with others. Some statistics (usually local statistics) can be dedi­cated to a particular center and therefore hid­den from other users. Conclusion We have developed a web-application, Cliniporator Web-Recorder, for user interaction with the database of medical records collect­ed during the testing period of medical device Cliniporator™. It also supports central collec­tion of data stored in local databases of Cliniporator™ medical devices. This is im­portant for fast detecting of possible device malfunctions and for following the single-use electrode stocks. The amount of data collect­ed in the central database gives us an oppor­tunity to perform a wide analysis of clinical trial results. The results of analysis will con­tribute to establish standard operating proce­dures (SOP) for electrochemotherapy and lat­er for electrogenetherapy. These results will also help us in improving the Cliniporator™ medical device and determining algorithms for intelligent pulse delivery. A large collec­tion of medical records can also be helpful to clinicians in choosing optimal treatment pro­tocol for a particular tumor lesion. Our aim is to build a decision making system that will be able to suggest an optimal therapy for a par­ticular tumor. The advantage of the Cliniporator Web-Recorder is that the system can easily be up­graded without any users’ disturbance. Due to the web-application and database central­ization all system modifications are imple­mented locally on the server, while users are just informed about the improvements. Acknowledgement The instrumentation and software were de­veloped within the Cliniporator (QLK-1999­00484) and ESOPE (QLK3-02002-2003) proj­ects. References 1. Macek Lebar A, Serša G, Cemažar M, Miklavcic D. Electroporation. Med Razgl 1998; 37: 339-54. 2. Neumann E, Kakorin S, Toensing K. Fundamentals of electroporative delivery of drugs and genes. Bioelectrochem Bioenerg 1999; 48: 3-16. 3. Satkauskas S, Bureau MF, Puc M, Mahfoudi A, Scherman D, Miklavcic D, et al. Mechanisms of in vivo DNA electrotransfer: respective contribu­tions of cell electropermeabilization and DNA electrophoresis. Mol Ther 2002; 5: 133-40. 4. Serša G, Cemažar M, Rudolf Z. Electrochemotherapy: advantages and drawbacks in treatment of cancer patients. Cancer Therapy 2003; 1: 133-42. 5. Mir LM, Orlowski S. Mechanisms of elec­trochemotherapy. Adv Drug Deliv Rev 1999; 35: 107-18. 6. Ferber D. Gene Therapy. Safer and virus-free? Science 2001; 294: 1638-42. Radiol Oncol 2004; 38(1): 55-60. Evaluation of water equivalency of Plastic Water™ for high-energy electron beams using IAEA TRS-398 Code of Practice Božidar Casar1, Urban Zdešar2 and Vlado Robar1 1Institute of Oncology, Ljubljana, Slovenia 2Institute of Occupational Safety, Ljubljana, Slovenia Introduction. In the International Code of Practice for dosimetry TRS-398 published by International Atomic Energy Agency (IAEA), water is recommended as the reference medium for the determination of ab­sorbed dose for high-energy electron beams. Plastic phantoms may be used under certain circumstances for electron beam dosimetry for beam qualities R50 < 4g/cm2 (E0 below 10 MeV). In our study, water equiva­lency of Plastic Water™ was evaluated in order to determine fluence scaling factors hpl for Plastic Water. Extended set of measurements in water and in Plastic Water were performed. Material and methods. The absorbed dose was determined according to IAEA TRS-398 dosimetry proto­col following recommendations for all relevant parameters involved. Water equivalency of Plastic Water was evaluated for five electron beams with nominal energies from 6 MeV to 18 MeV generated by linear ac­celerator Varian Clinac 2100 C/D. Adequate dosimetry equipment was used throughout the measurements and reference conditions, set by IAEA TRS-398, were followed carefully. Results. The results are presented as ratios Dpl /Dof absorbed dose in Plastic Water and water. Upon the w selection of electron energy, the ratios vary from 0.9990 - 1.0058 with combined uncertainties (1SD) of 0.46% - 0.68%. From the measured data, the fluence scaling factors hpl were determined and found to be in the range from 0.9942 to 1.0010. Measurements were taken over a period of 18 months, within the frame of a Coordinated Research Project of the International Atomic Energy Agency. Conclusions. Our results are compatible with previously published data. Key words: dosimetry; electron bcams; Plastic Water; IAEA TRS-398 Received 20 January 2004 Accepted 2 February 2004 Correspondence to: Božidar Casar, Head of Radiophysics Department, Institute of Oncology, Zaloška 2, 1000 Ljubljana; Phone +386 1 522 3946; Fax: +386 1 4319108; E-mail: bcasar@onko-i.si Introduction In the International Code of Practice for dosimetry TRS-398 published in the year 2000 by International Atomic Energy Agency (IAEA),1 water is recommended as the refer­ence medium for the determination of ab­sorbed dose for high energy photon and elec­tron beams. Plastic phantoms should not be used for reference dosimetry in photon beams, however, they can be used for routine quality assurance measurements (daily or weekly output checks), provided a transfer factor between plastic and water has been es­tablished. According to IAEA TRS-398 dosimetry protocol, plastic phantoms in the form of slabs may be used under certain cir­cumstances for electron beam dosimetry for the beam qualities R50 < 4 g/cm2 (E0 below 10 MeV); their use is permitted when no water­proof chamber is available or when accurate positioning in water is not possible. Presently, many different plastic materials are used for dosimetry purposes in radiother­apy and radiophysics departments: white and clear polystyrene, PMMA, Solid water WT1, Solid water RMI-457, Virtual water, Plastic water and possibly a few others. Several arti­cles comparing the equivalency of various plastics as phantom material to water for electron beam dosimetry have been pub­lished.2-8 Ideally, the phantom material should be water equivalent; that is, it should have the same absorption and scatter proper­ties as water for selected range of photon or electron energies used clinically. In our study we evaluated the water equiv­alency of Plastic Water™ developed by Computerized Imaging Reference Systems Inc. Norfolk, VA, USA, also marketed by Nuclear Associates, Inc. Carle Place, NY, USA. We limited our evaluation only to five electron beams within a range of energies from 6 MeV to 18 MeV. The aim of the study was to determine the energy fluence scaling factor hpl for Plastic Water at the selected five electron energies and to compare this factor to the recommended one in the IAEA TRS­398 dosimetry protocol. Material and methods A. Theoretical background According to IAEA TRS-398 Code of Practice, the calculation of absorbed dose by water ) for high-energy electron beams at Dw,Q(zref,wthe reference depth zref,w in water, for the ref­erence beam quality Q, and in the absence of the chamber, is given by the equation [1] where MQ is electrometer reading M1 correct­ed for temperature and pressure kT,p, as well as for other influencing quantities - polarity kpol s. is and recombination effects k ND,W,Qo the calibration factor of the selected ionisa­tion chamber in terms of absorbed dose by water in 60Co beam (reference quality Qo), and kQ,Qo is chamber specific factor correcting for the difference between the beam of refer­ence quality Qand user quality Q. In TRS- o 398, electron beam quality is characterized in terms of half-value depth in water R50, which is a depth in water where the absorbed dose in water is 50 % of the maximum absorbed dose. The reference depth zref,w is also speci­fied by R50 and is given by the equation [2] To determine the absorbed dose in water at using a plastic phantom, the reference zref,w point of the chamber must be positioned at a scaled reference depth in plastic. For zref,pl particular beam quality, the measurement depth in plastic expressed in g/cm2 is ob­tained from the equation [3] where cpl is a depth-scaling factor. The cpl is the ratio of the average depth of electron pen­etration in water zand in plastic av,w zav,pl, where these depths are expressed in g/cm2 [4] Additonally to depth scaling, the electrom­eter reading MQ,pl at the reference depth in plastic zref,pl must be converted to the equiva­lent reading MQ,w at the reference depth in water zref,w using the relation [5] where hpl is the fluence scaling factor and is generally energy dependant. The uncertainty associated with this scaling factor is the main reason for avoiding the use of plastic phan­toms. B. Experimental conditions and setup Experimental equipment In the study, well guarded waterproof plane parallel ionisation chamber PPC 40 was used together with DOSE 1 electrometer (both pro­duced by IBA Scanditronix - Wellhöfer). The ionisation chamber was calibrated at the IAEA Standard Dosimetry Laboratory in Seibersdorf. The comparison was done for five high-energy electron beams with the en­ergies of 6 MeV, 9 MeV, 12 MeV, 15 MeV and 18 MeV generated by linear accelerator Varian Clinac 2100 C/D. The temperature was monitored with a digital thermometer of the resolution of 0.1°C and the pressure with a digital barometer of resolution of 0.1 mbar. 1D water phantom (produced by MED- Table 1. Chemical composition in terms of fractional weight, nominal density .[g/cm3], mean atomic num- — ber . and depth scaling factor cpl for Plastic Water. Liquid water data are included for comparison Liquid water Plastic Water H 0.1119 0.0925 C 0.6282 N 0.0100 O 0.8881 0.1794 Cl 0.0096 Ca 0.0795 Br 0.0003 .[g/cm3] 1.000 1.013 — Z 6.6 6.62 cpl 1.000 0.982 TEC) with PMMA walls was used for the measurements in water. The phantom was equipped with a fine mechanical depth ad­justment mechanism with the resolution of 0.1 mm. Distilled water was used throughout the measurements. For the measurements in plastic phantom, Plastic Water (cream coloured) in the form of slabs of the size of 30 x 30 cm2 was used. The thickness of the slabs varied from 1 mm up to 60 mm. Chemical composition (fraction by weight), nominal density, mean atomic num­ber and depth scaling factor for Plastic Water are given in Table 1. For comparison, the da­ta for liquid water are included. Reference conditions and set-up Measurements were done in four sessions on four different days. In each session five meas­urements were done in water as well as in plastic for five high-energy electron beams. Chamber, water and plastic were left in a bunker for several hours before measure­ments in order to reach as thermal equilibri­um. Before we started with measurements in water, the chamber was dipped into water for at least 15 minutes. Reference conditions were always the same: SSD = 100 cm, 10 x 10 cm2 electron applicator was used and the ir­radiation time was 200 MU at a constant dose-rate of 300 MU/min. Gantry and colli­mator were set to 0° and all the measure­ments were made along the central axis of the beam. Polarising voltage of the chamber was +300 V - the same as during the chamber cal­ibration. The reference depths were set according to the expressions [2] and [3] for water and plas­tic, respectively. R50 was determined in sepa­rate relative dosimetry measurements using a computer controlled water phantom (Blue Phantom made by IBA Scanditronix -Wellhöfer), where the data were collected in 0.4 mm increments. As the thinnest available slab was 1 mm thick, the actual depth of the chamber reference point in plastic was at the depth that was nearest to the calculated one and not exactly at the calculated one. However, the differences were small. As de­fined in TRS-398 dosimetry protocol, the ref­erence point of the chamber (effective point of measurement) is at the inner surface of the entrance window. Reference depths and some other chamber parameters for selected set of energies are presented in Table 2. When dipping the chamber into water we were careful not to trap any air bubble at the chamber bottom because it could lower the absorbed dose. For setting up the chamber in plastic, a special cylindrical disc made of white polystyrene was fitted in the chamber hole at its bottom. This was to ensure that no scattered radiation would be lacking due to the absence of scattered material at the cham­bers bottom. One of the blocks was machined to fit exactly to ionisation chamber PPC40 so that the entrance window of the chamber was at the level of one surface of the block. Under the point of measurement, 6 cm of Plastic Water was always kept to provide an ade­quate backscatter conditions. Results and discussion The results are presented in Table 3 and Figure 1, as the dose ratios Plastic Water/wa­ter as a function of nominal beam energy [6] Depending upon the beam energy, the ra­tios varied from 0.9990 to 1.0058. From the calculated ratios, the fluence scaling factors can be determined. hpl The measured doses in Plastic Water are within 1% of those measured in water for all electron beam energies, and all the ratios are higher than 1.0 (apart from the ratios for 18 MeV electron beam, where ratios are lower than 1.0). Combined measurement uncertain­ties (1SD) of type A and type B (detailed ex­planation about uncertainties is given in ref­erence1), joining the uncertainties from re- Table 3. Ratios Dpl /Dof absorbed doses measured in w Plastic Water and in water for five high energy elec­tron beams produced by Varian Clinac 2100 C/D lin­ear accelerator. Combined measurement uncertainties (1SD) of type A and type B (detailed explanation about uncertainties is given in reference1), joining the un­certainties from repeated measurements from four sessions and estimated uncertainties due to setup and other influencing quantities (pressure, temperature.) Corresponding fluence scaling factors hpl for each electron energy are presented without standard devia­tions. Dpl /Dw hpl 6 MeV 1.0020 ±0.0068 0.9980 9 MeV 1.0035 ±0.0050 0.9965 12 MeV 1.0058 ±0.0046 0.9942 15 MeV 1.0022 ±0.0061 0.9978 18 MeV 0.9990 ±0.0053 1.0010 Table 2. Various beam and ionisation chamber (PPC40) parameters used for calculation and measurements of the absorbed dose in water for high energy electron beams generated by linear accelerator Varian Clinac 2100 C/D 6 MeV 9 MeV 12 MeV 15 MeV 18 MeV R50 [cm] 2.31 3.54 4.97 6.28 7.58 Rp [cm] 2.91 4.37 6.02 7.54 9.18 zref,w a [cm] 1.29 2.02 2.88 3.67 4.45 zref,pl b [cm] 1.31 2.06 2.93 3.74 4.53 zref,pl c [cm] 1.30 2.10 2.90 3.70 3.50 a Reference depth in water of the effective measurement point of the chamber according to TRS-398 b Reference depth in Plastic Water of the effective measurement point of the chamber according to TRS-398obtained from formula expression [3] c Actual depth in PW of the effective measurement point of the chamber due to limitation of minimal slab thickness of 1 mm Radiol Oncol 2004; 38(1): 55-60. Figure 1. Ratios Dpl/Dof absorbed doses determined w with measurements in Plastic Water and in water for five high-energy electron beams - electron beam qual­ities. Measurements were performed with plane paral­lel ionisation chamber PPC40. Beam data are in Table 2. peated measurements from four sessions and the estimated uncertainties due to setup and other influencing quantities (pressure, tem­perature) are presented in Table 3 and are in the range from 0.46% to 0.68%. In our study, the average value for hpl for energies below 10 MeV is 0.9973, which is in line with the value published in TRS-398, where hpl is 0.998. Average value of hpl for all electron energies in our study is 0.9975. A slight disagreement with results obtained by Tello et al.5 was observed, but well within the reported uncertainties. We can conclude that our results confirm previously published data for hpl for Plastic Water. However, we must emphasize, that the temperature of the air in the chamber cavity was probably not the same as the tempera­ture of water when the measurements in wa­ter phantom were performed. Due to specific temperature conditions in the accelerators bunker, we could assume that the tempera­ture of the air in the chamber cavity was al­ways at least a little bit higher than the meas­ured water temperature; this, sometimes large difference (up to 3°C) between the tem­perature measured in water and the room temperature was due to a slow but permanent rising of room temperature (air condition did-n't work optimally). The measured and re­ported ratios Dpl /Dcould thus be too high w by up to 0.3%, which corresponds to the tem­perature difference of 1°C. As it was not pos­sible to measure actual temperature of the air in the chamber cavity, we included 0.3% of possible temperature variation in the uncer­tainties of our measurements, rather that in the systematic errors. We can conclude, that when no water phantom is available in the clinic, or when the use of plastic phantom would be less time consuming or, from any other reason, more appropriate for physicists, the Plastic Water phantom can be used for routine constancy checks of high energy electron beams within the energy range checked in this study and also taking into account the fluence scaling factors as suggested in this study. Even if we take an average fluence scaling factor for all beams in the energy range from 6 MeV - 18 MeV, which is in our case 0.9975, the esti­mated difference of the absorbed dose deter­mination in Plastic Water should be below 1% comparing to the absorbed dose in water. However, before Plastic Water is to be used as water substitute for reference dosimetry, a careful comparison with measurement in wa­ter should be performed. Acknowledgements Present study was done in the framework of Co-ordinated Research Project (CRP E2.40.09) of the International Atomic Energy Agency. The main goal of the extended proj­ect was testing of the procedures recom­mended in TRS-398 dosimetry protocol for different types of radiation beams and ionisa­tion chambers as well as comparison of the results obtained with the existing protocols. Authors would like to thank colleagues in the project group: Mariella Affonseca, Ivaldo Ferreira, Günther Hartmann, Saiful Huq, Govinda Rajan and specially to Scientific Officer of the project Stanislav Vatnitsky. References 1. IAEA International Atomic Energy Agency. Absorbed dose determination in external beam ra­diotherapy: An international Code of Practice for Dosimetry Based Standards of Absorbed Dose to Water. IAEA Technical Reports Series No. 398. Vienna: IAEA; 2000. 2. Thwaites DI. Measurements of ionisation in water, polystyrene and 'solid water' phantom material for electron beams. Phys Med Biol 1985; 30: 41-53. 3. Bruinvis IAD, Heukelom S, Mijnheer BJ. Comparison of ionisation measurements in water and polystyrene for electron beam dosimetry. Phys Med Biol 1985; 30: 1043-53. 4. Thomadsen B, Constantinou C, Ho A. Evaluation of water-equivalent plastics as phantom material for electron-beam dosimetry. Med Phys 1995; 22: 291-6. 5. Tello VM, Tailor RC, Hanson WF. How water equivalent are water-equivalent solid materials for output calibration of photon and electron beams? Med Phys 1995; 22: 1177-89. 6. Nilsson B, Montelius A, Andreo P, Johansson J. Correction factors for parallel-plate chambers used in plastic phantoms in electron dosimetry. Phys Med Biol 1997; 42: 2101-18. 7. Björeland A, Svensson H. Testing of the Code of Practice at different electron energies and phantom ma­terial. IAEA-TECDOC-1173: Review of data and meth­ods recommended in the international code of practice for dosimetry IAEA Technical Reports Series No. 381, The use of plane parallel Ionization chambers in high energy electron and photon beams. Vienna: IAEA; 2000. p. 97-103. 8. Saitoh H, Tomaru T, Fujisaki T, Abe S, Myojoyama A, Fukuda K. A study on properties of water sub­stitute solid phantom using EGS code. Proceedings of the Tenth EGS4 Users Meeting in Japan, KEK Proceedings 2002; 18: 55-64. Radio/ Oncol 2004; 38(1): 1-4. Boerhaavejev sindrom: primer neznacilnega predrtja požiralnikove desne stene Sjekavica I, Pavliša G, Šeronja-Kuhar M, Moscatello I, Štern-Padovan R Izhodišca. Boerhaavejev sindrom imenujemo popolno predrtje požiralnikove stene v predelu prsnega koša. V 90 % se pojavi raztrganina na levi posterolateralni strani požiravnika. Prikaz primera. Prikazujemo primer Boerhaavejevega sindroma z neznacilno raztrganino desne­ga dela požiravnikove stene. Zakljucki. CT prsnega koša je prednostna preiskava, saj ob prikazu struktur v prsnem košu lahko vidimo tudi morebitne komplikacije obolenja in CT pomaga pri diferencialni diagnozi, kadar sumimo, da ima bolnik predrt požiralnik. Posebno pomembna pa je CT preiskava, kadar je bolnikovo stanje tako resno, da ne dovoljuje esofagografije. Radio/ Oncol 2004; 38(1): 61-8. Radio/ Oncol 2004; 38(1): 5-13. Ugotavljanje zožitve aorte z magnetno resonanco Bešlic Š Izhodišca. Namen pricujocega clanka je analizirati pomen magnetne resonance pri ugotavljanju zožitve aorte pri bolnikih, ki so imeli klinicno in ultrazvocno sumljive znake bolezni. Bolniki in metode. V treh letih smo pregledali 8 bolnikov, 5 (62,5%) moških in 3 (37,5%) ženske, pri katerih smo sumili, da imajo zožitev aorte. Razmerje med moškimi in ženskami je bilo 1,7: 1. Najmlajši bolnik je bil star 3 leta, najstarejši pa 46 (srednja starost 15 let). Preiskave smo naredili z napravo Magnetom 1.0 Tesla, Siemensove proizvodnje, s 6 mm rezi, brez kontrasta in ob uporabi telesne tuljave. Uporabili smo T1 obtežene frekvence s hitrim spinskim odmevom (fast spin-echo Tl W) in z rezi debeline 6 mm brez uporabe kontrastnega sredstva ter gradient echo sekvence z rezi debeline 7mm. Naredili smo magnetno resonancno angiografijo vrste time oj flight (TOF) z rekonstrukcijami projekcije najvecje intenzitete (MIP). Med preiskavami smo uporabljali EKG usklajevalnik, preiskave pa naredili v transverzalnih, koronarnih in poševnih sagitalnih ravninah in ob tem merili obsežnost srcno žilnih struktur. Rezultati. Zožitev aorte smo odkrili pri vseh osmih bolnikih (100%). Pri sedmih bolnikih (87,5%) je bila aorta zožena na mestu isthmus aorte in pri enem primeru bolniku na mestu horizontal­nega dela loka aore, med truncus arteriosus in levo carotidno arterijo. Aortno insuficienco smo našli pri sedmih bolnikih (87,5%), od katerih so štirje (50%) imeli bicuspidijo (bicuspidija aortne zaklopke), sedem bolnikov (87,5%) pa je imelo rahlo izraženo hipertrofijo levega prekata. Pri dveh bolnikih (25%) smo odkrili dilatacijo ascendentnega dela aorte, pri šestih (75%) pa razširitev iztocnih žil aortnega loka. Štirje bolniki (50%) so imeli dobro razvite kolateralne arter­ije, ki so pri dveh bolnikih povzrocile spremembe na rebrih. Pri dveh bolnikih (25%) smo nakljucno odkrili, da imata ohranjen thymus. Povprecen premer aortne zožitve je bil 10 mm. Pri enem bolniku je zožitev aorte spremljala stenoza pulmonarne arterije, pri enem ventricularni septalni defekt in pri enem trikuspidalna insuficienca. Izsledki, ki smo jih dobili z magnetno resonanco, so bili v celoti (100 %) enaki izsledkom klinicnih in ultrazvocnih preiskav. Zakljucki. Magnetna resonance je neinvazivna preiskovalna metoda srca in velikih žil in lahko v vedno vecji meri predstavlja nadomestilo invazivnim angiograskim preiskavam, zlasti v pedi­atriji, ker se na ta nacin izognemo sevanju. Uporabljamo jo kot komplementarno preiskavo ul­trazvocni priskavi, intraarterialni digitalni subtrakcijski angiografiji (IA DSA) in špiralnemu CT­ju (SCT). Radio/ Oncol 2004; 38(1):15-9. Rituximab spreminja prognozo bolnikov z neHodgkinovimi limfomi Jezeršek Novakovic B, Vovk M, Borštnar S, Tomšic R Izhodišca. Rituximab -najpogosteje uporabljeno monoklonalno protitelo s podrocja B celicnih limfoproliferativnih obolenj -se je izkazal kot uspešno zdravilo pri zdravljenju ponovitev ali re­ fraktarnih oblik indolentnih CD20 pozitivnih B celicnih limfomov, v novejšem casu pa tudi pri zdravljenju agresivnih limfomov v kombinaciji s standardno citostatsko terapijo. Ceprav ima takšna kemo-imunoterapija širok razpon indikacij, ostajajo v zvezi z njo številna vprašanja, ki jih je potrebno razjasniti: (1) kakšno je optimalno casovno zaporedje aplikacij protiteles in cito­statikov in kateri odmerki omenjenih substanc so najbolj ucinkoviti, (2) kateri citostatiki so naj­bolj ucinkoviti v kombinaciji z rituximabom, ter nenazadnje, (3) kateri so napovedni dejavniki, ki napovedujejo ugoden odziv na rituximab. Bolniki in metode. Z namenom delno razjasniti prvi dve vprašanji, smo opravili analizo rezulta­tov zdravljenja s kemo-imunoterapijo pri 25 bolnikih z razlicnimi histološkimi podtipi CD20 pozitivnih B celicnih limfomov (10 agresivnih in 15 indolentnih). Sedemnajst bolnikov je preje­malo kemo-imunoterapijo za zdravljenje ponovitev limfoma in le pri 8 bolnikih smo rituximab dodali k citostatski terapiji prvega reda. Vecina bolnikov, ki se je ugodno odzvala na zdravljen­je, je v kombinaciji z rituximabom prejemala shemo CHOP, kot uspešne pa so se izkazale tudi druge kombinacije citostatikov (FC, BVCPP). Rezultati. V celoti smo odgovor na kemo-imunoterapijo dosegli pri 76% bolnikov, pri 68% smo ugotovili popolni odgovor. Srednjega trajanja odgovora še nismo dosegli. Odgovor na terapijo je bil precej boljši v skupini bolnikov, ki pred tem še ni bila zdravljena, saj smo v tej skupini odgov­or na terapijo dosegli pri vseh (100%) bolnikih in sicer popolni odgovor pri 7 in delni odgovor pri 1 bolniku. Kemo-imunoterapija pa je bila neuspešna prvenstveno pri bolnikih z agresivnimi lim­fami, ki so bili pred tem že veckrat zdravljeni. V teku raziskave nismo opazili resnejših stran­skih ucinkov. Zakljucki. Kemo-imunoterapija izboljša rezultate zdravljenja v primerjavi s samim citostatskim zdravljenjem tako pri prej nezdravljenih bolnikih kot tudi pri bolnikih, ki so bili že prej zdravl­jeni. Kombinirano zdravljenje je najbolj uspešno, kadar ga uporabimo cimbolj zgodaj v poteku bolezni (najbolje kot terapijo prvega reda). Da pa bi optimizirali (oz. racionalizirali) uporabo rit­uximaba, bo potrebno dolociti najbolj ucinkovite kombinacije citostatikov s protitelesi, pred­vsem pa tudi ugotoviti napovedne dejavnike za uspeh terapije z rituximabom. Radio/ Oncol 2004; 38(1): 61-8. Radio/ Oncol 2004; 38(1): 21-6. Neuronsko specificna enolaza -selektivni tumorski oznacevalec za drobnocelicni pljucni rak Ilievska Poposka B, Spirovski M, Trajkov D, Stefanovski T, Atanasova S, Metodieva M Izhodišca. Nevronsko specificna enolaza (NSE) je izomer glicoliticnega encima enolaza, ki je bil prvic odkrit v ekstraktu možganskega tkiva, kasneje pa so dokazali njegovo prisotnost v nor­malnih neuroendokrinih celicah in neuroendokrinih tumorjih. Namen raziskave je bil potrditi pomen serumske NSE kot tumorskega oznacevalca pri bolnikih z drobnocelicnim pljucnim rakom. Bolniki in metode. Serumski nivo NSE smo merili z radioimunološko metodo pri 71 bolnikih s pljucnim rakom, pri 24 bolnikih z nemaligno pljucno boleznijo in pri 28 zdravih odraslih osebah. Rezultati. Glede na serumsko vrednost NSE pri skupini zdravih odraslih osebah smo dolocili zgornjo mejo normalne vrednosti NSE v srumu, ki je bila 16,6 ng/ml. Glede na vrednosti serumske NSE pri bolnikih z nemaligno pljucno boleznijo pa smo dolocili specificnost preiskave, ki je bila 88,13 %. Pri bolnikih s pljucnim rakom je bila senzitivnost preiskave 47,82%, pri bolnikih z drobnocelišnim pljucnim rakom je narastla na 72,72%, pri bolnikih z nedrobno­celicnim pljucnim rakom pa je bila le 38,89%. Bolniki z razširjeno obliko drobnocelicnega pljucnega raka so imeli statisticno znacilno višjo srednjo vrednost serumske NSE (290,48 ng/ml), kot bolniki z omejeno obliko bolezni (46,94 ng/ml). Vrednosti serumske NSE smo spremljali tudi pri 16 bolnikih, ki so dobivali kombinirano kemoterapijo in/ali bili obsevani in ugotovili zelo visoko soodvisnost s klinicnim odgovorom na zdravljenje. Zakljucki. Tudi pricujoci rezultati potrjujejo, da je lahko serumska NSE koristen tumorski oz­nacevalec pri bolnikih z drobnocelicnim pljucnim rakom. Koristi nam lahko pri diagnosticiran­ju, ugotavljanju razširjenosti bolezni, predvsem pa pri ugotavljanju odgovora na zdravljenja in ponovitve bolezni. Radio/ Oncol 2004; 38(1): 27-34. Rak dojke in ozavešcenost o zdravju dojk kot razvijajoci nacrt promocije zdravja Plesnicar A, Kovac V, Kralj B Izhodišca. Rak dojke je najpogostejša maligna bolezen žensk v vecini razvitih držav. V zadnjih nekaj letih se je po uvedbi presejalnih programov z mamografijo preživetje bolnic z rakom do­jke izboljšalo, vendar incidenca te bolezni v omenjenih državah še vedno narašca. Ob osredo­tocenosti na sekundarno prevencijo raka dojk z zgodnjo detekcijo in zgodnjim zdravljenjem zmanjšanja incidence raka dojk ni mogoce doseci. Pomembna je primarna prevencija, ki lahko zmanjša incidence raka dojk .. Tako lahko ozavešcenost o zdravju dojk predstavlja del speci­ficnih aktivnosti promocije zdravja. Zakljucki. Rak dojke je v razvitih državah velik problem javnega zdravja. Aktivnosti na podrocju sekundarne prevencije raka dojke bi zato morali dopolniti s specificnimi aktivnostmi promocije zdravja in v prihodnosti zmanjšati njegovo incidenco. Promocija zdravja bi kot del primarne pre­vencije raka dojke vkljucevala aktivnosti pri izboljšanju individualne in skupne ozavešcenosti o zdravju dojk. Clani vplivnih skupin prebivalstva bi s primerno kolektivno ozavešcenostjo lahko dosegli ustrezne spremembe zakonodaje, davcnih ukrepov, carinskih in trgovinskih predpisov, ki bi ženskam omogocale nadzor nad lastnim zdravjem dojk. Z zmanjšanjem incidence raka do­jke bi lahko pomembno vplivali na zdravje celotne skupnosti. Radio/ Oncol 2004; 38(1): 35-42. Soocanje, spoprijemanje in obvladovanje psihosocialne obremenjenosti pri bolnikih z rakom Šprah L, Šoštaric M Izhodišca. Namen preglednega clanka je predstaviti najpogostejše psihosocialne obremenitve pri bolnikih z rakom in njihove psihosocialne strategije spoprijemanja s to boleznijo. Bolniki z rakom se srecujejo s številnimi psihosocialnimi težavami, ki niso samo posledica razvoja bolezni in njenega zdravljenja. Soocajo se tudi s socialnim pritiskom, ki izhaja iz predsodkov in stereotipov do te bolezni. V clanku so predstavljeni nekateri procesi soocanja z diagnozo in spoprijemanja s psihološkimi posledicami raka. Prav tako so opisani vplivi ucinkovitosti posameznih nacinov spoprijemanja z rakom in vplivi psihosocialnih intervencij ter socialne pod­pore na razvoj, potek in ponavljanje bolezni. Zakljucki. V zadnjem casu je bilo opravljenih nekaj metaanaliz, ki niso povsem potrdile povezanosti med psihosocialnimi strategijami spoprijemanja z rakom in razvojem, potekom bolezni ter ozdravitvijo. Terapevtsko okno v primerih psihosocialnih intervencij je široko in lahko v precejšnji meri izboljša kvaliteto življenja mnogih bolnikov z rakom. Radio/ Oncol 2004; 38(1): 61-8. Radio/ Oncol 2004; 38(1):43-7. Test komet in vitro pri ocenjevanju poškodbe cloveškega genoma po obsevanju z žarki y Garaj Vrhovac V, Zeljezic D Namen. Z raziskavo smo želeli preveriti možnost uporabe testa komet pri ocenjevanju poškodb DNK, ki jih povzrocijo razlicne doze žarkov x na perifernih cloveških limfocitih in vitro. Materiali in metode. Ciste krvne vzorce smo odvzeli mladim, zdravim prostovoljcem -nekadil­cem. Vzorce smo razdelili v 4 skupine. Prvo smo uporabili kot kontrolo, ostale tri pa smo obse­vali z napravo s konstantnim obsevalnim virom žarkov y (6°Co) s hitrostjo doze 0,907 cGy/s. Skupine krvnih vzorcev smo obsevali 51 sekund, 437 sekund in 1099 sekund z ustretajocimi dozami 0,5 Gy, 4 Gy in 10 Gy. Za oceno krivulj, ki so ponazarjale odgovor kontrolne skupine vzorcev in treh obsevanih skupin vzorcev na obsevanje, smo opravili kometni test v alkalnih pogojih. Rezultati in zakljucki. Izid kometnega testa je pokazal statisticno pomembno višje vrednosti pri obsevanih skupinah vzorcev v primerjavi s kontrolno skupino. Ucinek doze v razponu od 0,5 Gy do 10 Gy je bil premosorazmeren tako z dolžino kometovega repa kot z momentom. Z raziska­vo smo tudi potrdili, da je kometni test mogoce uporabiti za odkrivanje poškodb DNK, ki jih povzrocijo visoke obsevalne doze. Takšnih poškodb s citogenetskimi metodami ni mogoce od­kriti. Radio/ Oncol 2004; 38(1):49-54. Spletna aplikacija kot nadgradnja funkcionalnosti medicinske naprave za zdravljenje tumorjev s pomocjo elektrokemoterapije Pavlovic I, Kramar P, Corovic S, Cukjati D, Miklavcic D Elektrokemoterapija (ECT) je sodobna metoda za ucinkovito zdravljenje tumorjev v klinicnem okolju. Metoda temelji na elektroporaciji, s katero omogocimo lokalno vbrizganemu kemoter­apevtiku vstop v celice tumorja. Kemoterapevtik lahko vstopi le v celice, katerih membrano smo predhodno uspešno permeabilizirali z elektroporacijo, kar dosežemo z uporabo kratkih vi­sokonapetostnih pulzov. V ta namen je bila nedavno razvita medicinska naprava imenovana Cliniporator™ . Tako vam predstavljamo spletno aplikacijo, ki smo jo razvili z namenom povecanja njene funkcionalnosti. Osnovni namen aplikacije je zbiranje, shranjevanje in analiza elektrokemoterapij izvedenih s pomocjo te medicinske naprave. Že med samim potekom elek­troporacije naprava zbira in lokalno shranjuje vse podatke povezane s tem procesom, razvita spletna aplikacija pa omogoca enostavno zbiranje teh podatkov na enem mestu, t.j. v centralni bazi podatkov. Prav tako pa preko spletnih obrazcev omogoca izpolnjevanje medicinskih obrazcev, ki opisujejo zdravstveno stanje bolnika, tumorje in potek zdravljenja, ter izdelavo porocil statisticnih obdelav. Spletna aplikacija temelji na sodobnih tehnologijah kot so ASP, HTML, Flash, JavaScript in XML. Glavne prednosti takšne rešitve centraliziranega zbiranja in obdelave podatkov so lahek in hiter dostop do podatkov, neodvisnost od operacijskega sistema in spletnega brskalnika, ki ga uporablja uporabnik, ter enostavno odpravljanje napak in nad­gradljivost sistema. Radio/ Oncol 2004; 38(1): 61-8. Radio/ Oncol 2004; 38(1): 55-60. Ocenitev ekvivalentnosti plasticnega materiala (Plastic W ater™) in vode za visokoenergijske elektronske žarke ob upoštevanju dozimetricnega protokola IAEA TRS-398 Casar B, Zdešar U, Robar V Izhodišca. V mednarodnem protokolu za dozimetrijo TRS-398, ki ga je izdala Mednarodna agen­cija za atomsko energijo (IAEA), je za dolocitev absorbirane doze za visokoenergijske elek­tronske žarke kot referencni medij priporocena voda. Plasticne fantome lahko uporabljamo le pod dolocenimi pogoji za kvalitete žarkov R50 < 4 g/cm2 (E0 pod 10 MeV). V naši študiji smo ocenjevali ekvivalentnost plasticnega materiala Plastic Water™ in vode, z namenom da bi za to plastiko dolocili faktor hpl. Opravili smo obsežne meritve v vodi in v plasticnem fantomu. Material in metode. Absorbirano dozo smo dolocili v skladu z dozimetricnim protokolom IAEA TRS-398 ter upoštevali priporocila za vse pomembne parametre. Ekvivalentnost izbranega plas­ticnega materiala smo ocenili za 5 elektronskih žarkov z energijami od 6 MeV do 18 MeV. Pri meritvah smo uporabili primerno dozimetricno opremo ter natancno sledili referencnim pogo­jem iz TRS-398. Rezultati. Rezultate smo predstavili kot razmerje D/D10 med absorbirano dozo v plastiki in ab­ p sorbirano dozo v vodi. Dobljena razmerja so bila od 0.9990 -1.0058, odvisno od izbrane energi­je z negotovostjo rezultatov (lSD) od 0,46% -0,68 %. Zakljucki. Naši rezultati so primerljivi z do sedaj objavljenimi izsledki drugih raziskav. Notices Natices submitted far publicatian shauld cantain a mailing address, phane and/ ar Jax number and/ ar e-mail af a Contact persan ar department. Radiation oncology May 2-6, 2004 The ESTRO course »Radiation Oncology: a Molecular Approach« will take place in Giardini Naxos, Italy. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail infa@estro.be; or see http://www.estro.be Radiotherapy May 2-6, 2004 The ESTRO course »Dose Determination in Radiotherapy: Beam Characterisation, Dose Calculation and Dose Verification« will take place in Nice, France. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call + 32 775 93 40; or fax +32 2 779 54 94; or e-mail infa@estro.be; or see http://www.estro.be Brachytherapy May 13-15, 2004 The Annual Brachytherapy Meeting GEC-ESTRO will take place in Barcelona, Spain. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail infa@estro.be; or see http://www.estro.be Radiology June 6-8, 2004 The UK Radiological Congress will be held in Manchester, U.K. Contact Ms. Rebecca Gladdish, UKRC 2003 Secretariat, PO Box 2895, London WlA SRS, U.K., or call +44(0) 20 7307 1410/20, or fax +44(0) 20 7307 1414; or e-mail conference@ukrc.org.uk / exhibition@ukrc.org.uk; or see www.ukrc.org.uk Radiation oncology June 13-18, 2004 The ESTRO course »Evidence-Bases Radiation Oncology: Methodological Basis and Clinical Application« will take place in Moscow, Russia. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail infa@estro.be; or see http://www.estro.be Radiotherapy June 20-24, 2004 The ESTRO course »IMRT and Other Confarmal Techniques in Practice« will take place in Amsterdam, The Netherlands. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail infa@estro.be; or see http://www.estro.be Prostate cancer June 2 7-29, 2004 The ESTRO course »Brachytherapy far Prostate Cancer« will take place in Leeds, U.K.. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail infa@estro.be; or see http://www.estro.be Oncology July 3-6, 2004 The 18th EACR (European Association far Cancer Research) Congress will be held in Innsbruck, Austria. See http://www.fecs.be/conferences/eacr18 70 Notices Gynaecological cancer August 26-28, 2004 The ESTRO advanced teaching course on »Brachyherapy for Gynaecological Cancer« will take place in Vienna, Austria. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Medica! physics August 29 -September 2, 2004 The ESTRO course »Physics for Clinical Radiotherapy« will take place in Leuven, Belgium. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Paediatric oncology September, 2004 The International Society of Paediatric Oncology ­SIOP Annual Meeting will be held in Oslo, Norway. See http://www.siop.nl Radiobiology September 19-23, 2004 The ESTRO course »Basic Clinical Radiobiology« will take place in Lausanne, Switzerland. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Lung cancer September 23-25, 2004 The »9th Central European Lung Cancer Conference« will be offered in Gdansk, Poland. Contact Conference Secretariat, »9th Central European Lung Cancer Conference«, Via Medica, ul. Swietokrzyska 73, 80 180, Gdansk, Poland; or call/fax +48 58 349 2270; or e-mail celcc@amg.gda.pl; or see www.lungcancer.pl Radiation therapy October 3-7, 2004 ASTRO Annual meeting will be held in Atlanta, USA. Contact American Society for Therapeutic Radiology and Oncology Office, 1891 Preston White Drive, Reston, VA 20191, USA; or see http:// www.as­tro.org Therapeutic radiology and oncology October 24-28, 2004 The 23rd ESTRO Meeting will be held in Amsterdam, the Netherlands. Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgium; or call +32 7759340; or fax +32 2 7795494; or e-mail info@estro.be; or see http://www.estro.be Medica! oncology October 29-November 2, 2004 The 28th ESMO Congress will be held in Vienna, Austria. See http://www.esmo.org Radiation oncology November 7-12, 2004 The ESTRO course »Evidence-Based Radiation Oncology: Methodological Basis and Clinical Application« will take place in Cyprus. Contact ESTRO office, Avenue E. Mounier, 83/12, B-1200 Brussels, Belgium; or call +32 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiation oncology November 25-28, 2004 The ISRO international teaching course on »Practical Radiation and Molecular Biology with Mayor Emphasis on Clinical Application« will take place in Chiangmai Thailand. See http://www.isro.be Notices 71 Radiation oncology March, 2005 The ISRO international teaching course on »Palliative Care in Cancer Treatment« will take place in Dar es Salaam, Tanzania. See http://www.isro.be Lung cancer July 3-6, 2005 The » 11 th W orld Conference on Lung Cancer« will be offered in Barcelona, Spain. Contact Heather Drew, Imedex, Inc., 70 Technology Drive, Alpharetta, GA 30005 USA; or call +1 770 751 7332, or fax +1 770 751 7334; or e-mail h.drew@ imedex.com, or see www.imedex.com/calenders/on­cology/htm Radiation oncology September -October, 2005 The ISRO international teaching course on »Rational Developments from developing to devel­oped Countries« will take place in Lombok, Indonesia. See http://www.isro.be Oncology October 30 -November 3, 2005 The ESTRO 24 / ECCO 13 Conference will take place in Paris, France. Contact FECS office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgium; or call +32 7759340; or fax +32 2 7795494; or e-mail info@estro.be; or see http://www. fecs.be As a service to our readers, notices oj meetings ar courses will be inserted free oj charge. Please send injonnation to the Editorial ojfice, Radiology and Oncology, Zaloška 2, SI-1000 Ljubljana, Slovenia. Radio/ Oncol 2004; 38(1): 69-71. Sanolabor FONDACIJA "DOCENT DR. J. CHOLEWA" JE NEPROFITNO, NEINSTITUCIONALNO IN NESTRANKARSKO ZDRUŽENJE POSAMEZNIKOV, USTANOV IN ORGANIZACIJ, KI ŽELIJO MATERIALNO SPODBUJATI IN POGLABLJATI RAZISKOVALNO DEJAVNOST V ONKOLOGIJI. MESESNELOVA 9 1000 LJUBLJANA TEL 0 1 51 9 1 2 77 FAKS 01 251 81 13 ŽR: 50100-620-133-05-10331 15-214779 Activity of »Dr. J. Cholewa« Foundation for Cancer Research and Education -A Report for the First Quarter Of 2004 In the start of the year 2004 the Administrative and Supervising Boards of the Dr. J. Cholewa Foundation for Cancer Research and Education Foundation and the Health experts Commission of the Foundation reflected upon some aspects of the previous year. Although several new members joined the Foundation and the acquirement of the generous and important donation to the Foundation by Dr Ana Hinterlechner Ravnik, it remains the fact that various public and privately owned enterprises find it more and more difficult to contribute financially to help running day to day operations of the Foundation and its many scopes of activity. Other topics were also discussed and were presented at the last meeting of the Administrative and Supervising Boards of the Dr. J. Cholewa Foundation for Cancer Research and Education Foundation at their last joint meeting in the year 2003. Despite aforementioned financial constraints the detailed review of the Foundation's activity for the year 2003 shows that it achieved all the anticipated and stated goals for that year. In short, the main goal still remains to support and sustain research in cancer in Slovenia, and various pathways are to be undertaken to achieve this goal. The Foundation will continue to support the regular publication of »Radiology and Oncology« international scientific journal, which is edited, published and printed in Ljubljana, Slovenia. The Dr. J. Cholewa Foundation for Cancer Research and Education also remains optimistic about the prospects in the year 2004. Republic of Slovenia will join the European Union in 2004, and this important fact may help the Foundation to gain more information, to expand its existing framework of activities and to find and deal with new challenges in the new economic and political sur­roundings. This may help the Foundation to find the ways to collaborate with similar institutions all over Europe and elsewhere, and the Foundation may in this way fur­ther expand its scope and goals. Borut Štabuc, MD, PhD Andrej Plesnicar, MD Tomae Benulic, MD kapsule raztopina za intravensko infundiranje Kontraindikacije: Preobcutljivost za flukonazol, pomožne sestavine zdravila in za druge azole. Socasno jemanje flukonazola s terfenadinom ali cisapridom. Stranski ucinki: Lahko se pojavijo slabost. napenjanje, bruhanje, bolecine v trebuhu, driska. Možni so glavobol, krti in alopecija. Zelo redke so preobcutljivostne reakcije. Pri bolnikih s hudimi glivicnimi obolenji lahko pride do levkopenije, trombocitopenije, povecane aktivnosti jetrnih encimov ter hujše motnje v delovanju jeter. Oprema in nacin izdajanja: 7 kapsul po 50 mg, 28 kapsul po 100 mg, 1 kapsula po 150 mg -samo na zdravniški recept. 1 viala s 100 ml raztopine za intravensko infundiranje (200 mg/100 ml) -uporaba samo v bolnišnicah. Datum priprave besedila: marec 2003 • sistemske kandidoze • mukozne kandidoze • vaginalna kandidoza • kriptokokoze • dermatomikoze • preprecevanje kandidoze Ucinkovit antimikotik, ki ga bolniki dobro prenašajo. specialna laboratorijska plastika testi za aplikacijo v imunohistokemiji, za aplikacijo v imunologiji, mikro­biologiji-virologiji, ipd. aparati za pripravo histoloških preparatov mikro-inkriotomi, zalivalci, tkivni procesorji, barvalci, pokrivalci laminar flow tehnika, inkubatorji, sušilniki, suhi sterilizatorji in oprema za laboratorijsko vzrejo živali -kletke INTEGRA laboratorijska oprema za mikro­biologijo celic, molekularno biologijo in biotehnologijo diagnosticni kiti, reagenti za uporabo v mikrobiologiji, imunologiji, citogenetiki, molekularni biologiji patologiji, mikrobiologiji, virologiji, mono-in poliklonalna protitelesa •.• .. k ••• ottermann 0 SyHs::mL1h7 laboratorijsko pohištvo, varnostne omare, ventilacijska tehnika in digestorji hladilna tehnika in aparati za laboratorije, transfuzijo, patologijo in sodno medicino i hitri testi za diagnostiko, EIA /RIA testi Fisher Bio&lodc Sdenllftc kompletna oprema in pripomocki za delo v laboratoriju AstraZeneca :-::,. Vaš partner pri zdravljenju raka dojke in prostate Casodex Zoladex®LA 10.8mg goserelin AstraZeneca . @m'1@)11@.}!].}c\ AstraZeneca UK Limited, Podružnica v Sloveniji, Einspielerjeva 6, Ljubljana www.astrazeneca.com PE: Stritarjeva 5, 4000 Kranj, Slovenija tel.: (0)4/ 2015 050, fax: (0)4/ 2015 055 e-mail: kemomed@siol.net, KEMOMED www.kemomed.si o 11gmm11m11 Promega A" y ff. IZDELKI ZA MOLEKULARNO BIOLOGIJO DOKUMENTACIJA PLASTIKA ZA CELICNE KULTURE IN ANALIZA GELOV ti lnvitrogeff SNNWO lite technologles CISTA VODA ZA LABORATORIJ SKRINJE CELICNE KULTURE, GELI IN HLADILNIKI IN MOLEKULARNA BIOLOGIJA m1ne1Ya--. ..&II. BIOHfT biolab, .. Biosciences ELEKTRONSKE IN MEHANSKE AVTOMATSKE PIPETE DIAGNOSTIKA SEKVENATORJI MIKOPLAZEM IN LEGIONEL CAELVX' doksorubicinijev klorid v pegiliranih liposomih upan1e z zaupan1em • metastatsl