НОВЫЕ ИСТОЧНИКИ МАЛЫХ ДОЗ РАДИАЦИИ: РЕЗУЛЬТАТЫ РАЗВИТИЯ ДИАГНОСТИЧЕСКОЙ И ТЕРАПЕВТИЧЕСКОЙ РАДИОЛОГИИ

The ambiguity of opinions about the effects of "small" doses of radiation is one of the key problems of modern radiobiology. Improvement of medical devices, new methods of diagnosis and treatment is accompanied by increased radiation burden on patients and staff. In this article we present the radiation-hygienic analysis of modern methods of radiation diagnostic procedures and radiation therapy, their dosimetric characteristics and the possible effects of low doses of ionizing radiation due to medical procedures.Неоднозначность мнений об эффектах «малых» доз радиации является одной из ключевых проблем современной радиобиологии. Совершенствование медицинского оборудования, появление новых методов диагностики и лечения сопровождается ростом лучевых нагрузок на пациента и персонал. В настоящей статье приведен радиационно-гигиенический анализ современных методов лучевой диагностики и лучевой терапии, их дозиметрических характеристик и возможных последствий воздействия малых доз ионизирующего излучения, обусловленных медицинскими процедурами

Stereotactic body radiation therapy for inoperable localized kidney cancer

Purpose of the study: to evaluate the overall survival and local control in patients with inoperable kidney cancer treated with stereotactic body radiotherapy (SBRT).Material and Methods. From 2011 to 2021, 42 patients with histologically verified kidney cancer underwent SBRT to a total dose ranging from 30 to 45 Gr in 3 fractions using the CyberKnife robotic radiosurgical system. SBRT was performed for inoperable patients, taking into account various factors (age, severity of concomitant pathology, ASA IV physical status level), patients’ refusal of surgical treatment, and tumor size of ≤5.0 cm in diameter. SBRT was not performed for patients with tumor size of ≥5.0 cm in diameter, impaired renal function, generalization of cancer and decompensation of concomitant pathology. The median age of the patients was 67.9 years. 93 % of patients had stage I kidney cancer. The primary tumor was diagnosed in 37 cases, recurrence after previous surgical treatment in 6, including 1 patient with recurrence of cancer of both kidneys. The average tumor volume was 28.1 cm3.Results. The median overall survival (OS) was not reached due to the fact that the majority of patients (n=36) were alive at the time of the study. The 1-, 3- and 5-year OS rates were 94.1 %, 88.7 %, and 72.6 %, respectively. The 1-year local control rate was 93 %. At 3-6 months, 26.2 % of patients showed partial response, 66.8 % had stable disease and 7 % had disease progression (according to the RECIST 1.1 criteria). Renal toxicity occurred in 23.8 % of patients 3 months after radiation therapy; however, kidney function was restored in these patients within a year.Conclusion. SBRT has demonstrated high efficacy with minimal toxicity in the treatment of inoperable patients with kidney cancer

Immunohistochemical Markers in the Assessment of Tumor Response

The examination of the possibility of using immunohistochemical and molecular (NCRT) and prognostic factors of the disease state. The study included 21 patients with locally advanced gastric cancer. All patients underwent the NCRT followed by gastrectomy D2. We analyzed the expression of HER2 / neu marker, Ki-67, p53, Cyklin D1, E-cadherin in biopsy (before therapy) and the operating material (after chemoradiotherapy and the treatment gap). We have found statistically significant decrease in the expression of Ki-67 markers and Cyklin D1, a trend towards to a decrease of p53 expression after the NCRT. The dynamics of expression of immunohistochemical markers examination is a promising approach in search for predictors of NCRT effectiveness for patients with locally advanced gastric cancer. Keywords: neoadjuvant chemoradiotherapy, immunohistochemical markers, molecular genetic markers, therapeutic pathomorphism, gastric cancer

Iodine-125 brachytherapy and robotic stereotactic radiotherapy — treatment options for patients with localized prostate cancer

Introduction. Modern radiological treatment options for patients with localized prostate cancer (PCa) have several advantages and allow achieving high rates of biochemical control.Purpose of the study. To compare immediate, proximate, and long-term results of low-dose Iodine-125 brachytherapy (I-125 BT) and robotic stereotactic radiotherapy (SBRT) in patients with localized low- and intermediate-risk PCa.Materials and methods. The study included 296 patients with localized low- and intermediate-risk PCa. I-125 BT and SBRT were performed in 208 and 88 patients, respectively. All patients with an intermediate-risk PCa were prescribed neoadjuvant androgen-deprivation therapy (NADT) with luteinizing hormone-releasing hormone analogues (LHRH) for 4-6 months. Only radiation treatment was used for low-risk PCa. As a result, two groups and four subgroups of patients were formed depending on the treatment method. The immediate, proximate, and long-term results of radiation treatment methods were studied in groups and subgroups.Results. No complications were recorded during brachytherapy I-125. Radiation cystitis grade 1 and radiation rectitis grade 1 were diagnosed after SBRT in 16.6% and 4.0% of cases, respectively. In the only I-125 BT subgroup, the PSA level during the year decreased from 8.3 to 1.1 ng/ml, in the SBRT subgroup — from 7.5 to 0.8 ng/ml. In the case of combined treatment, PSA decreased from 1.2 to 0.93 ng/ml and from 4.5 to 0.5 ng/ml, respectively. Changes in prostate volume, residual volume, and urinary quality (I-PSS) were comparable in all subgroups. Five-year cancer-specific survival and overall survival in the group of patients after SBRT was 100%, after I-125 BT — more than 90%.Conclusion. Radiation treatment options for patients with localized PCa are safe. Conducting NADT does not significantly reduce the prostate volume and does not affect the indicators of urodynamics. High rates of cancer-specific five-year survival rate testify to the effectiveness of the evaluated treatment options

ФАКТОРЫ, ВЛИЯЮЩИЕ НА ЧАСТОТУ ЛУЧЕВЫХ РЕАКЦИЙ У ОНКОЛОГИЧЕСКИХ БОЛЬНЫХ ИЗ КОГОРТЫ РЕКИ ТЕЧА И ВУРС

For revealing the main factors determining the frequency of radiation reactions and radiation complications in cancer patients previously exposed to chronic accidental exposure associated with the activity of the plant «Mayak», the data from medical records of 89 patients, treated with external beam radiotherapy from 1995 to 2011, and had reference to chronic radiation exposure history are analyzed. The assessment of peripheral blood, the nature and severity of radiation reactions and complications was performed. Statistical processing of the data revealed that the factors determining the frequency and severity of radiation reactions did not differ in features in cancer patients with chronic radiation exposure history. The value of absorbed dose has no significant effect on the frequency of radiation reactions.Для выявления основных факторов, определяющих частоту лучевых реакций и лучевых осложнений у онкологических больных, ранее подвергшихся хроническому аварийному облучению, связанному с деятельностью комбината «Маяк», проанализированы данные из историй болезни и технологических карт лучевой терапии 89 больных раком различных локализаций, получавших дистанционную лучевую терапию с 1995 по 2011 г. и имевших указание на хроническое радиационное воздействие в анамнезе. Проведена оценка показателей периферической крови, характера и тяжести лучевых реакций и осложнений. При статистической обработке данных установлено, что факторы, определяющие частоту и выраженность лучевых реакций, не отличаются особенностями у онкологических больных с хроническим радиационным воздействием в анамнезе. Величина поглощенной дозы не оказывает существенного влияния на частоту лучевых реакций

Recurrent squamous cell carcinoma of head and neck: results of treatment in the Chelyabinsk Regional Clinical Center of Oncology and Nuclear Medicine in 2012–2016

Introduction. There is no treatment for recurrence of head and neck squamous cell carcinoma, which significantly increases the overall survival (OS) of patients.The study objective is to analyze the results of treatment of patients with recurrences of squamous cell carcinoma of the head and neck and to assess the impact of risk factors for relapse, as well as different treatment options for relapse on OS. Materials and methods. In the period from 2012 to 2016, 182 patients with relapses of squamous cell carcinoma of the larynx, oral cavity and tongue received treatment in the Chelyabinsk regional clinical center of Oncology and nuclear medicine. The group 1 included 66 patients with resectable relapse who were operated. The group 2 consisted of 25 patients who received a course of radiation therapy. The group 3 consisted of 46 patients who underwent chemotherapeutic treatment of relapse. The group 4 was represented by combined treatment (surgery + radiation therapy), this group included 9 people. The group 5 consisted of those of patients who were not specifically treated for relapse because of the low Karnofsky index in patients (<70 %). Results. OS among patients who received special treatment was significantly higher compared with the group of symptomatic therapy. The median OS in the special treatment group was 40 months, and without it – 18 months. Comparing all types for treating relapse, the highest rates of OS were in the surgical treatment group. OS rates in combined therapy group and radiotherapy group were comparable rate in the radiotherapy. The lowest OS rate was after chemotherapy (only 21 months).Conclusion. Surgery is the optimal method for treating recurrent squamous cell carcinoma of head and neck, if it is resectable. If surgical treatment is not possible, no other method significantly increases the OS. If the overall status of the patient is normal, re-radiation or polychemotherapy may be performed. A limited category of patients can be subjected to combined treatment for relapse

Применение стереотаксической лучевой терапии в лечении неоперабельных пациентов с локализованным раком почки

Purpose of the study: to evaluate the overall survival and local control in patients with inoperable kidney cancer treated with stereotactic body radiotherapy (SBRT).Material and Methods. From 2011 to 2021, 42 patients with histologically verified kidney cancer underwent SBRT to a total dose ranging from 30 to 45 Gr in 3 fractions using the CyberKnife robotic radiosurgical system. SBRT was performed for inoperable patients, taking into account various factors (age, severity of concomitant pathology, ASA IV physical status level), patients’ refusal of surgical treatment, and tumor size of ≤5.0 cm in diameter. SBRT was not performed for patients with tumor size of ≥5.0 cm in diameter, impaired renal function, generalization of cancer and decompensation of concomitant pathology. The median age of the patients was 67.9 years. 93 % of patients had stage I kidney cancer. The primary tumor was diagnosed in 37 cases, recurrence after previous surgical treatment in 6, including 1 patient with recurrence of cancer of both kidneys. The average tumor volume was 28.1 cm3.Results. The median overall survival (OS) was not reached due to the fact that the majority of patients (n=36) were alive at the time of the study. The 1-, 3- and 5-year OS rates were 94.1 %, 88.7 %, and 72.6 %, respectively. The 1-year local control rate was 93 %. At 3-6 months, 26.2 % of patients showed partial response, 66.8 % had stable disease and 7 % had disease progression (according to the RECIST 1.1 criteria). Renal toxicity occurred in 23.8 % of patients 3 months after radiation therapy; however, kidney function was restored in these patients within a year.Conclusion. SBRT has demonstrated high efficacy with minimal toxicity in the treatment of inoperable patients with kidney cancer. Цель исследования ‒ оценить результаты применения стереотаксической лучевой терапии (СТЛТ) в лечении неоперабельных пациентов с локализованным раком почки с учетом показателей общей выживаемости и локального контроля.Материал и методы. С 2011 по 2021 г. на базе Челябинского областного клинического центра онкологии и ядерной медицины (ЧОКЦО и ЯМ) 42 пациентам с морфологически верифицированным диагнозом рака почки проводилась СТЛТ до СОД от 30 до 45 Гр за 3 фракции на аппарате CyberKnife. СТЛТ проводилась в случае неоперабельности пациента с учетом различных факторов (возраст, тяжесть сопутствующей патологии, степень анестезиологического риска ASA IV), отказа пациентов от хирургического лечения, в случае размеров опухоли до 5,0 см в диаметре. Не проводилась СТЛТ при размерах опухоли более 5,0 см в диаметре, при значимом нарушении функции почек (хроническая болезнь почек С5), генерализации процесса, при декомпенсации сопутствующей патологии. Средний возраст больных составил 67,9 года. У 93 % пациентов была I стадия рака почки. Первичная опухоль была диагностирована в 37 случаях, в 6 – рецидив после предшествующего оперативного лечения, в том числе у 1 пациента – рецидив рака обеих почек. Средний объем опухоли составил 28,1 см3.Результаты. Медиана общей выживаемости (ОВ) не была достигнута в связи с тем, что большинство пациентов (n=36) на момент анализа результатов исследования были живы. Показатели 1-, 3- и 5-летней ОВ составили 94,1; 88,7 и 72,6 % соответственно. Зафиксирован уровень 1-летнего локального контроля в 93 %. Частичный ответ по критериям RECIST 1.1 спустя 3–6 мес после СТЛТ отмечен в 26,2 % случаев, в 66,8 % – стабилизация процесса, в 7 % (n=3) – прогрессирование процесса. Ренальная токсичность возникла у 23,8 % пациентов спустя 3 мес после проведенной лучевой терапии, но в течение года функция почек у этих пациентов была восстановлена.Заключение. СТЛТ рака почки демонстрирует высокую эффективность при минимальной токсичности, что позволяет применять данный метод в лечении рака почки у неоперабельных пациентов

НЕЙТРОННАЯ ЛУЧЕВАЯ ТЕРАПИЯ В ЛЕЧЕНИИ РЕЦИДИВОВ ВЫСОКОЗЛОКАЧЕСТВЕННЫХ ГЛИОМ ГОЛОВНОГО МОЗГА

 The main objective of this study was to determine the place and role of neutron radiation therapy in the treatment of patients with recurrent high-grade glioma. Material and Methods. Treatment outcomes were analyzed in 40 patients who were treated at Oncology Center (Chelyabinsk) and Center for Neutron Therapy (Snezhinsk) from 2005 to 2015. The median age of patients was 45 years. The male to female ratio was 1:1. Recurrent glioblastoma was diagnosed in 19 patients, and anaplastic astrocytoma was revealed in 21 patients. Twenty patients underwent neutron therapy alone,and 20 patients underwent combined neutronphoton radiation therapy. The median overall survival time for all patients with recurrent high-grade glioma was 50 months. The 1-year, 2-year and 3-year survival rates were 94.1 %, 77.8 % and 66.7 % respectively.Results. The median survival time after treatment for relapse was 27 months. The main prognostic factors affecting the treatment outcomes were the age of the patients, histological verification and time to relapse. The method-specific overall survival rate was significantly higher in patients who underwent combined neutron-photon radiation therapy than in patients who underwent neutron therapy alone (48 months versus 20 months, p=0.05).  Целью исследования явилось определение места и роли нейтронной лучевой терапии в лечениипациентов с рецидивами высокозлокачественных глиом головного мозга. Материал и методы. Были проанализированы результаты лечения 40 больных, получивших лечение с 2005 по 2015 г. на базе ГБУЗ «Челябинский областной клинический центр онкологии и ядерной медицины» и Центра нейтронной  терапии (г. Снежинск). Средний возраст пациентов – 45 лет.  Соотношение мужчин и женщин – 1:1. У 19 пациентов был рецидив глиобластомы, у 21 – анапластической астроцитомы. В 20 случаях проведена нейтронная терапия в самостоятельном варианте, 20 больным проведен курс сочетанной нейтронно-фотонной лучевой терапии. Результаты. Медиана общей выживаемости для всех пациентов с рецидивами высокозлокачественных глиом головного мозга после проведенного лечения составила 50 мес, показатели 1-летней общей выживаемости – 94,1 %; 2-летней – 77,8 %; 3-летней – 66,7 %. Медиана выживаемости после лечения рецидива – 27 мес. Основными  прогностическими факторами, влияющими на результаты лечения, стали возраст пациентов, гистологическое  заключение, а также время до возникновения рецидива. Метод-специфическая выживаемость была достоверно выше у пациентов с проведением сочетанной нейтронно-фотонной терапии: 48 мес против 20 мес при проведении нейтронной терапии в самостоятельном варианте (р=0,05).

ОСОБЕННОСТИ ЛУЧЕВОЙ ТОКСИЧНОСТИ ПРИ ПРОВЕДЕНИИ ЛУЧЕВОЙ ТЕРАПИИ С ТРАСТУЗУМАБОМ

The aim of the study was to determine and analyze the most significant risk factors for developing cardiac, pulmonary and skin toxicities among patients who received concurrent radiation therapy and chemotherapy with trastuzumab.Material and methods. The study included 66 patients with histologically verified invasive intermediate or low-grade breast carcinoma, who received radiation therapy and chemotherapy with trastuzumab from 2018 to 2019. The average age of the patients was 53.1 ± 4.2 years. Locally advanced stage iii a and iii b breast cancer was the most common (52 %) followed by stage ii a and ii b cancer (36 %). The lvef of all patients was ≥50 %. All patients received neoadjuvant chemotherapy with anthracyclines and/or taxanes. Radiation-induced side effects were assessed using the rtog/eortc scoring criteria. Dose-volume histogram (dvh) of radiotherapy planning was matched to the quantec criteria.Results. Radiation-induced pulmonitis was observed in 2 patients within 2 to 6 months after the completion of radiation therapy. A 10 % reduction in lvef was observed in 3 patients, while a 20 % decrease in ef was not found. Long qt syndrome was observed in 3 patients, and it was accompanied by clinical manifestations in 2 patients. When evaluating the echo-cg protocols after treatment, normal lv diastolic function was recorded in 39 patients, moderate diastolic dysfunction (lv dd) in 27, and 1 patient had severe lv dd. When assessing the dose received by the lv myocardium, the excess of the average dose to the myocardium was present both on the left and on the right. Only in 16 % of cases, left myocardial irradiation met criterion v 25. Clinically, arrhythmias, unstable angina pectoris, and other manifestations of coronary artery disease were mostly observed among patients with left-sided breast cancer. Significant factors for the development of cardiotoxicity were left-sided breast cancer, previous chemotherapy with anthracyclines and/or taxanes, as well as myocardial doses. The occurrence of radiation pulmonitis did not show an obvious relationship with any factor, while the body mass index (bmi) of >30 was a significant factor for the occurrence of radiation-induced skin damage.Conclusion. The combination of radiation therapy and trastuzumab was associated with an acceptable risk of cardiotoxicity. Monitoring of the cardiovascular system parameters during treatment and detection of early signs of cardiotoxicity were shown to be of great importance.Целью исследования являлись определение и анализ наиболее значимых факторов, влияющих на развитие явлений кардио-, пульмо- и кожной токсичности среди пациенток, получавших лучевую терапию одновременно с введением трастузумаба.Материал и методы. В исследование вошли 66 пациенток с гистологически верифицированной инвазивной карциномой молочной железы умеренной и низкой степени дифференцировки, которые с 2018 по 2019 г. в ГБУЗ ЧОКЦО и ЯМ получали лучевую терапию с одновременной таргетной терапией трастузумабом. Средний возраст составил 53,1 ± 4,2 года. У 52 % пациенток диагностирован местнораспространенный рак молочной железы (iiia и iiiB стадии), у 36 % пациенток – iia и iiB стадий. Фракция выброса левого желудочка (ФВ ЛЖ) у всех пациенток составила ≥50 %. Все пациентки получили неоадъювантную химиотерапию с включением антрациклинов и/или таксанов. Явления токсичности оценивались по шкале Rtog/eoRtc для ранней лучевой токсичности. Гистограмма объема дозы (dVH) планов лучевой терапии соотносилась с критериями QuaNtec.Результаты. Лучевой пульмонит был зарегистрирован у 2 пациенток в сроки от 2 до 6 мес после окончания лучевой терапии. У 3 пациенток отмечалось снижение ФВ ЛЖ на 10 % от исходного значения, снижение ФВ на 20 % от исходного уровня не зарегистрировано. Удлинение интервала Qt зафиксировано у 3 пациенток, что у 2 больных сопровождалось клиническими проявлениями. При оценке протоколов ЭХО-КГ после проведения лечения у 39 пациенток отсутствовали нарушения функции ЛЖ, умеренная диастолическая дисфункция (ДД ЛЖ) зарегистрирована у 27, выраженная ДД ЛЖ – у 1 пациентки. Превышение средней дозы на миокард присутствовало и слева, и справа. Клинически значимые аритмии, нестабильная стенокардия и другие проявления ишемической болезни сердца в большинстве случаев наблюдались у пациенток с левосторонней локализацией рака молочной железы. Значимыми факторами кардиотоксичности стали левосторонняя локализация процесса, предшествующая полихимиотерапии антрациклинами и/или таксанами, а также доза, полученная миокардом. Возникновение лучевого пульмонита оказалось не связанным с какими-либо факторами, для возникновения лучевого дерматита значимым фактором оказался индекс массы тела пациенток >30 кг/м2.Заключение. Сочетание лучевой терапии и трастузумаба ассоциировано с приемлемым риском кардиотоксичности, при этом большое значение имеют мониторинг показателей сердечнососудистой системы в процессе лечения и диагностика ранних признаков кардиотоксичности

РЕЗУЛЬТАТЫ СОЧЕТАННОЙ ЛУЧЕВОЙ ТЕРАПИИ РАКА ПИЩЕВОДА С ПРИМЕНЕНИЕМ БРАХИТЕРАПИИ ВЫСОКОЙ МОЩНОСТИ

Between 2008 and 2015, 82 patients with inoperable esophageal cancer were treated with radiation therapy. The patients were divided into 3 groups. Group I consisted of 30 patients, who received external beam radiation therapy (EBRT) in combination with brachytherapy. Group II and group III patients (30 and 22 patients, respectively) received EBRT alone. Patients of group II received EBRT at a total dose of 60–70 Gy and patients of group III received EBRT at a total dose of 40–50 Gy. Treatment outcomes were better in patients treated with combination of EBRT and brachytherapy than in patients treated with EBRT alone. There was no significant difference between groups 2 and 3 with regard to their survival rates. Two-year overall survival rates in group I, II and III were 36 %, 12 % and 12 % and the median overall survival time was 15.7; 9.7 and 6.6 months, respectively.Проведено сравнительное исследование с включением 82 пациентов, страдающих раком пищевода, получивших самостоятельный курс лучевой терапии. В первую группу вошли 30 пациентов, получивших сочетанную лучевую терапию с брахитерапией, во 2-ю группу – 30 пациентов, получивших дистанционную лучевую терапию (ДЛТ) до суммарной дозы 60–70 Гр, у 22 пациентов 3-й группы суммарная доза ДЛТ была ограничена 40–50 Гр. Результаты лечения оказались лучше в группе сочетанной лучевой терапии, в то время как значение суммарной дозы ДЛТ не повлияло на показатели выживаемости. Двухлетняя общая выживаемость в сравниваемых группах составила 36, 12 и 12 %, медиана общей выживаемости – 15,7; 9,7 и 6,6 мес соответственно.