• Original Papers Session •

Strangers on the shore: PIK3CA and TP53 gene mutations in 104 patients with metastatic colorectal cancer

Vlad-Adrian Afrăsânie1, Mihai Vasile Marinca1,2, Andrei Lefter2, Marius Păduraru1, Iuliu Ivanov1, Dana Clement2, Teodora Alexa-Stratulat1,2, Bogdan Gafton1,2, Lucian Miron1,2, Cristina Rusu1 

1. “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
2. Medical Oncology Department, Regional Institute of Oncology, Iaşi, Romania

Introduction. In metastatic colorectal cancer (mCRC), PIK3CA and TP53 genes are biomarkers that are not currently used in daily practice. In the literature, there are little data that evaluated the correlations of these gene mutations with the clinical, pathological and mo­le­cu­lar features of tumors. Methodology. We performed a retrospective analysis on the data of patients diag­nosed with mCRC who were tested with NGS for RAS, BRAF, PIK3CA and TP53 mutations in the Regional In­sti­tu­te of Oncology Iaşi, from January 2018 to October 2019. Results. We identified 104 patients in which the mu­ta­tio­nal status of RAS, BRAF, PIK3CA and TP53 was determined. PIK3CA mutations were detected in 7 patients (6.7%) and TP53 mutations in 76 patients (73.1%). PIK3CA mutations were associated with N0 (p=0.006). Mutant TP53 tumors compared with wild-type tumors were associated with: the absence of per­so­nal history of cancer (4.8% versus 93.3%; p=0.007), ul­ce­rated histopathological type (62.5% versus 18.3%; p=0.04), moderate degree of differentiation (63.5% versus 19.2%; p=0.01) and exon 2 KRAS mutations (34.6% ver­sus 4.8%; p=0.006). Conclusions. Comparing the re­sults in our study group with data from literature, PIK3CA and TP53 mutations had a similar prevalence. This study completes the few data that exist on metasta­tic colorectal cancer regarding the clinical, pathological and molecular features of PIK3CA and TP53 mutations with a North-East Romanian cohort of subjects. 


 

3D laparoscopic enucleoresection of a PADUA 10 kidney tumor in a horseshoe kidney (video presentation)

M. Apetrei, I. Perciuleac, P. Medan, I. Andraş, D.V. Stanca, I. Coman, N. Crişan 

Department of Urology, Cluj-Napoca Municipal Clinical Hospital, Romania

Introduction and objectives. Horseshoe kidney is a renal fusion anomaly found in about 0.2% of the population. Renal tumors associated with horseshoe kidney have been described in fewer than 200 cases. The surgical management of such tumors can be challenging due to anatomic particularities, especially highly variable vascularization. Materials and method. We report the case of a 62-year-old male with cT1bN0M0/54-mm tumor located in the right unit of a horseshoe kidney. The partial nephrectomy was performed by transperitoneal approach with the patient in left lateral decubitus. Five abdominal trocars were used. Following the opening of Gerota fascia, two arteries were identified, cranially of the renal isthmus area, supplying the right renal unit. Bulldog clamps were applied on both arteries and the enucleoresection of the renal mass was done. The renorraphy was performed in two layers, using the sliding-clip technique. The tumor was extracted in an endobag and a drain was left in place. Results. The operative time was 180 minutes, with warm ischemia time of 24 minutes. The estimated blood loss was 200 mL. The drain was removed on postoperative day 4 and the patient was discharged on day 6, with no high-grade perioperative complications. Conclusions. The anatomic variability of vascularization, the kidney position and the presence of the isthmus in horseshoe kidneys pose a technical surgical difficulty in treating a cT1b (PADUA 10) renal tumor. The detailed preoperative imaging evaluation of these particularities and careful surgical planning are needed. Laparoscopic nephron-sparing surgery is feasible and should be considered in these cases.


3D laparoscopic cystoprostatectomy with intracorporeal ileal conduit (video presentation)

A. Berindean1, M. Moga1, E. Popovici1, V. Ona2, I. Andraş1,2, D.V. Stanca1,2, I. Coman1, N. Crişan1,2 

1. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. County Emergency Clinical Hospital of Cluj-Napoca, Romania

Introduction and objectives. Radical cystectomy is the standard treatment for localized muscle-invasive bladder cancer (T2-T4aN0M0). Choosing and performing a certain type of urinary diversion are the main challenge of this intervention, due to the complexity of the technique and the high complications rate. Minimally invasive techniques have replaced the open approach for radical cystectomy in high-volume centers, ensuring lower intraoperative blood loss, faster recovery and shorter length of hospital stay. Also, intracorporeal urinary diversions have been proven to decrease the morbidity of this procedure, especially in highly comorbid patients. Thus, most large centers worldwide are reporting an increasing number of intracoporeal ileal conduit and orthotopic neobladder. Materials and method. We hereby present our technique for 3D laparoscopic cystoprostatectomy with pelvic lymphadenectomy and ileal conduit. The surgery was performed using five abdominal trocars and transperitoneal approach. The ileal conduit was performed in an intracoporeal manner, by isolation of a 15 cm ileal segment, located 20 cm proximal to the ileo-caecal valve. Uretero-ileal anastomosis was performed and two double-J stents were placed. Results. The operative time was 5 hours: 2 hours for radical cystectomy, 1 hour for lymphadenectomy and 2 hours for the ileal conduit. The blood loss was minimal (100 ml). No high-grade perioperative complications were encountered. The length of hospital stay was 8 days. Ureteral catheters were removed six weeks after surgery. The histopathological report confirmed the presence of pT3N0/33MxL0V0R0 urothelial carcinoma. Conclusions. 3D laparoscopic radical cystectomy with intracoporeal ileal conduit is a feasible minimally invasive treatment option, in centers with experience in laparoscopic surgery, with good oncologic outcomes and improved postoperative recovery.


Algorithm for the prediction of response to immunotherapy with nivolumab in non-small cell lung cancer and malignant melanoma

Ioana-Carmen Brie1, Maria Perde-Schrepler1, Piroska Virag1, Eva Fischer-Fodor1, Olga Soriţău1, Nicolae Todor1, Tudor Eliade Ciuleanu1,2

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Immunotherapy (IT) is likely to become a key part in the management of non-small cell lung cancers (NSCLC) and malignant melanoma (MM). But IT doesn’t help everyone, and only a subset of patients benefits of it. Most likely, a battery of molecules is required to predict the therapy outcome in these patients. The aim of our study was to identify the patients with NSCLC and MM who are likely to benefit from IT with nivolumab, based on multiple molecules involved in the cancer immunity cycle. We performed a translational prospective study with two arms. In the experimental arm, immune molecules at different levels were evaluated through immunofenotyping and ELISA, before, during and at the end of therapy. In the clinical arm, the patients with NSCLC and MM were tested for the same markers and their treatment response and outcome were assessed. PD-1 and PD-L1 tumor expression correlated with the response to the therapy. In the peripheric blood, the number and dynamics of CD8/CD95/PD1 lymphocytes were markers of positive prognostic when the values were closed to those of healthy subjects and when those values increased in the first three months after therapy. The initial levels and the dynamics of the cytokines TNFα, IL-2 and IL-10 were also correlated with the response to therapy. Taking into account all the significant clinical and experimental results, an integrated algorithm for the prediction of response to IT with nivolumab in NSCLC and MM was established.


3D laparoscopic radical cystectomy with bilateral nerve sparing and intracorporeal orthotopic neobladder (video presentation)

D. Bujor, A. Berindean, S. Druta, P. Medan, I. Andraş, D.V. Stanca, I. Coman, N. Crişan

Department of Urology, Cluj-Napoca Municipal Clinical Hospital, Romania

Introduction and objectives. The standard treatment for localized muscle-invasive bladder cancer (T2-T4aN0M0) is radical cystectomy. The oncological outcome of the procedure is vital, but the quality of life for patients undergoing radical cystectomy is also very important. Preserving the neurovascular bundles and intracorporeal urinary diversions can decrease the morbidity of the procedure and improve the postoperative quality of life for these patients. Materials and method. The video presents the technique of laparoscopic radical cystoprostatectomy with bilateral nerve-sparing, pelvic lymph node dissection and totally intracorporeal neobladder. The surgery was performed using five abdominal trocars by transperitoneal approach. For the neobladder, a 40-cm ileal segment was used, 20 cm proximal to the ileo-caecal valve. The bowel anastomoses were performed with Endo-GiA stapler device. Wallace-B anastomosis was performed between the ureters and the neobladder and two mono-J stents were placed. Prior to the surgery, the patient received neoadjuvant chemoterapy (gemcitabine and cisplatin). Results. The operative time was 7 hours: 2 hours for radical cystectomy, 1 hour for lymphadenectomy, and 4 hours for the neobladder. Blood loss was approximately 150 mL. The neobladder catheter was removed three weeks after the surgery. The mono-J stents were removed six weeks after the surgery. The histopathological report described (G3) pT1bN0/13MxL0V0R0 urothelial carcinoma. The patient is continent during the day and uses one pad/night and has resumed the sexual activity using PDE5 inhibitors. Conclusions. 3D laparoscopic radical cystectomy with orthotopic neobladder and bilateral nerve-sparing is an optimal treatment method for sexually active male patients with localized bladder tumors.


Hereditary polyposis colon cancer versus hereditary non-polyposis colon cancer: diagnosis, prognostic and targeted molecular therapy

Andreea Cătană1,2,3, Gabriela Bolba Morar1, Daniela Martin1, Mariela Militaru2,3, Patriciu Cadariu-Achimaş1,2

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. Genetic Center, Romania

Background. Colorectal cancer (CRC) is an important cause of morbidity and mortality, this pathology being currently the second leading cause of cancer-related mortality in Romania, after lung cancer. Approximately 10-15% of colon cancers have a hereditary genetic component and several molecular features with varying phenotypic implications compared to sporadic types of colon cancer. Study summary. We present the results of a retrospective study conducted within the Molecular Investigations Department of the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, which included 76 patients diagnosed with hereditary colon cancer (Lynch syndrome, familial adenomatous polyposis, MUTYH-associated syndromes). All subjects were tested using state-of-the-art gene sequencing panels extended for germline mutations associated with hereditary colon neoplasms. We identified constitutional mutations in APC, MMR/MSI group and MUTYH genes. The genetic testing allowed the particular molecular diagnosis, specific associations of the malignant genotype-phenotype, prognosis assessment, molecular targeted therapy, as well as proper familial genetic counseling. Conclusions. Hereditary colon cancer is a particular neoplastic entity that requires adequate molecular genetic testing in order to establish the appropriate diagnosis, therapy and the familial screening. 


Image-guided intensity-modulated external beam radiochemotherapy and CT-based adaptive brachytherapy in locally advanced cervical cancer: initial single-center experience

Beatrice Dragomir-Anghel, Ilie-Sorin Bogdan 

Sanador Oncology Center, Bucharest, Romania 1. Fundeni Clinical Institute, Bucharest, Romania

Background. Image-guided brachytherapy (IGBT) is a vital component of the curative treatment of locally advanced cervical cancer (LACC). Purpose. The aim of this study was to investigate the current use of IGBT technique and its limitations, applicator type on target dose, isodose surface volumes and organs at risk (OAR) dose. Methodology. The retrospective analysis included 15 patients with FIGO IIB-IVA cervical cancer (7/15 patients with more than stage T3) treated with definitive EBRT ± concurrent chemotherapy (CT) followed by IGBT between July and December 2019. The endpoints were overall treatment time (OTT), and dose-volume parameters (D90 HR-CTV, Point A, IR-CTV, D2cc OARs) determined and converted into biologically equivalent doses in 2 Gy fractions (EQD2). Results. All patients received EBRT with more than 45 Gy to pelvis (8 patients had 55 Gy) and 11/15 patients received concomitant cisplatin. Each patient underwent three insertions (one patient had two procedures only) with CT-compatible tandem and ovoid applicator. Nine patients (60%) received their treatment below 50 days. Mean D90 HR-CTV was 81.58 EQD2 for HR-CTV volumes of mean 49.35 cc at the time of first BT (range: 24.9-115.3 cc). Intermediate risk CTV has received above 60 Gy in 13/15 patients. Only one patient has not received above 65 Gy to point A due to non-attendance to third insertion. Mean 2 cc was: rectum 74.37±14.93, small bowel 57.95±19.15, sigmoid 66.58 ±15.72 and bladder 83.73±16.97. Conclusions. IGBT combined with EBRT and CT leads to good local control, but for LACC it is important to adjust our practice implementing interstitial IGBT for better tumor volume coverage and, therefore, for improved clinical parameters.


3D laparoscopic radical right nephrectomy by transperitoneal and retroperitoneal approach (video presentation)

S. Druta, A. Berindean, D. Bujor, P. Medan, I. Andraş, D.V. Stanca, I. Coman, N. Crişan 

Department of Urology, Cluj-Napoca Municipal Clinical Hospital, Romania

Introduction and objectives. The laparoscopic approach has become the standard for radical nephrectomy. With increased experience, the indications for minimally invasive approach have been extended also to locally advanced disease. The combination of retroperitoneal and transperitoneal approach allows a primary ligation of the renal artery, retroperitoneal lymphadenectomy and lumbar veins ligation, followed by the possibility of complete vena cava isolation and thrombectomy in cases of renal cell carcinoma and venous thrombus. Materials and method. We report the case of a 71-year-old male who was incidentally diagnosed with a right renal mass of 82/83/74 mm, with invasion in the perirenal fat and renal sinus. The tumor extended by a tumoral thrombus into the renal vein and the inferior vena cava on a distance of 14 mm. The CT scan also identified multiple retroperitoneal and interaortocaval lymphadenopathies, the largest measuring 40/35 mm. After presenting the case in the multidisciplinary meeting, radical surgical treatment was advised. 3D laparoscopic right nephrectomy with locoregional lymph node dissection and inferior vena cava thrombectomy was performed using retroperitoneal and transperitoneal approach. Results. The operative time was 9 hours: 3 hours for radical nephrectomy, 2 hours for retrocaval lymphadenectomy, 2 hours for interaortocaval lymphadenectomy, and 2 hours for the complete isolation of the inferior vena cava, cavotomy, thrombectomy and cavorraphy. The blood loss was 500 ml, with no need for perioperative transfusions. The patient was mobilized in the first postoperative day and resumed bowel movements on the second day. The drainage was removed in the second postoperative day. The patient was discharged six days after surgery. The histopathological report revealed a pT3aN1(9+/9)MxL1V2R0 clear cell renal carcinoma grade 4 ISUP, Fuhrman 4. Conclusions. The combination of retroperitoneal and transperitoneal laparoscopic approach is an option for the surgical treatment of locally advanced renal masses. The increased experience in laparoscopic surgery allows to perform highly complex procedures in a minimally invasive manner, with similar oncological results, but with decreased morbidity compared to open surgery. 


ARCHES: Efficacy of androgen deprivation therapy (ADT) with enzalutamide (ENZA) or placebo (PBO) in metastatic hormone-sensitive prostate cancer (mHSPC) by prior local and systemic treatment

Laurenţia Galeş1, Arnulf Stenzl2, Russell Z. Szmulewitz3, Daniel Petrylak4, Jeffrey Holzbeierlein5, Arnauld Villers6, Arun Azad7*, Antonio Alcaraz8, Boris Alekseev9, Taro Iguchi10, Neal D. Shore11, Francisco Gomez-Veiga12, Brad Rosbrook13, Benoit Baron14†, Gabriel P. Haas15, Andrew J. Armstrong16

1. Department of Oncology, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology,“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Department of Urology, University Hospital, Eberhard Karls University, Tübingen, Germany
3. Department of Medicine, University of Chicago, Chicago, IL, USA
4. Department of Medical Oncology, Yale Cancer Center, New Haven, CT, USA
5. Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
6. Department of Urology, University Hospital Centre, Lille University, Lille, France
7. Department of Oncology, Monash Health, Melbourne, Victoria, Australia
8. Hospital Clinic de Barcelona, Barcelona, Spain
9. Department of Oncology, Hertzen Moscow Cancer Research Institute, Moscow, Russia
10. Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
11. Carolina Urologic Research Center, Myrtle Beach, SC, USA
12. Department of Urology, University Hospital, GITUR-IBSAL, University of Salamanca, Salamanca, Spain
13. Department of Clinical Statistics, Pfizer Inc., San Diego, CA, USA
14. Department of Biostatistics, Astellas Pharma Inc., Leiden, The Netherlands
15. Global Medical Affairs, Astellas Pharma Inc., Northbrook, IL, USA
16. School of Medicine, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
*Arun Azad was affiliated with Monash Health during the conduct of the study. Current affiliation: Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; †Benoit Baron was affiliated with Astellas Pharma Inc. during the conduct of the study. Current affiliation: B-value, Leiden, the Netherlands

Introduction and objectives. ENZA, a potent androgen receptor inhibitor, has demonstrated benefit in men with castration-resistant prostate cancer. A clinical benefit of ENZA+ADT versus PBO+ADT for men with mHSPC has been shown in the ARCHES trial regardless of prior treatment, including prior docetaxel exposure, radical prostatectomy, and/or radiation therapy. The objective of this post hoc analysis was to evaluate the efficacy of ENZA+ADT in key clinical secondary endpoints in patients enrolled in the ARCHES trial by prior local and systemic treatment. Materials and method. In ARCHES, a global, double-blind, PBO-controlled, phase 3 study (NCT02677896), patients with mHSPC were randomized 1:1 to ENZA (160 mg/day) + ADT or PBO+ADT, stratified by disease volume and prior docetaxel therapy. Ethical Committee approval was obtained. The primary endpoint was radiographic progression-free survival (rPFS; scans assessed centrally). Secondary endpoints included prostate-specific antigen progression and radiographic responses. The analyses of clinical endpoints were completed by prior local and systemic treatment (including docetaxel exposure, radical prostatectomy and/or radiation therapy) to further assess the efficacy of ENZA. The treatment continued until disease progression or unacceptable toxicity. Results. A total of 1150 men were randomized (ENZA+ADT: 574; PBO+ADT: 576). The baseline characteristics were balanced between groups. Median follow-up was 14.4 months. ENZA+ADT significantly improved rPFS (p<0.0001), with similar improvements reported in all subgroups (Table 1). Significant treatment benefits were observed with ENZA+ADT in several secondary clinical endpoints in the overall population and in prior local and systemic treatment subgroups (Table 1). Conclusions. This post hoc analysis demonstrates clinical benefit of ENZA+ADT versus PBO+ADT based on rPFS and secondary clinical endpoints in patients with mHSPC, which is maintained in most evaluated subgroups, irrespective of the prior local and systemic treatments received.
 

Table 1 Treatment effects for primary and secondary endpoints according to prior treatment
Table 1 Treatment effects for primary and secondary endpoints according to prior treatment

Transperitoneal 3D laparoscopic left radical nephrectomy with periaortic lymph node dissection for oligometastatic left renal tumor

I.M. Hlodec1, M. Moga1, P. Medan1, I. Perciuleac1, M. Apetrei1, F. Dobrotă2, I. Andraş1,2, D.V. Stanca1,2, I. Coman1, N. Crişan1,2

1. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Cluj-Napoca Municipal Clinical Hospital, Romania

Background and method. Nephrectomy for large renal mass with periaortic lymphadenectomy (LND) is deemed a demanding laparoscopic procedure. We report the case of a 44-year-old woman who presented with left flank pain and hematuria. CT scan showed a 114-mm left kidney mass, periaortic, enlarged lymph nodes and one lung metastasis. After discussing the case in the MDT panel, the decision was to perform radical surgery, followed by adjuvant treatment. Through a transperitoneal 3D LP approach, the reflection of the left colon was performed. The left ureter was identified and the dissection continued cranially. The renal pedicle was isolated, clipped and sectioned. The periaortic LND and the mobilization of the left kidney were done. The specimen was extracted through an incision in the left iliac fossae. Results. The total operating time was 195 minutes. The blood loss was minimal. The patient was mobilized on the first postoperative day. No high-grade perioperative complications were encountered. The length of postoperative hospital stay was 5 days. The pathological examination yielded a pT3aN0/16MxL1V0Pn0R0 clear cell and eosinophilic renal cell carcinoma, ISUP 4. Conclusions. The oncologic rules of an en bloc resection for locally advanced renal cell carcinoma can equally be followed using a laparoscopic approach, ensuring a fast postoperative recovery and a low morbidity.


The clinical features of ovarian cancer patients with BRCA mutations

Paul Kubelac1,3, Cătălin Vlad2,3, Ioana Berindan-Neagoe4,5,6, Alexandru Irimie2,3, Patriciu Achimaş-Cadariu2,3

1. Department of Medical Oncology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Department of Surgery, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
3. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
4. Research Centre for Functional Genomics, Biomedicine and Translational Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
5. MedFUTURE Research Center for Advanced Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
6. Department of Functional Genomics and Experimental Pathology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. Ovarian cancer is frequently diagnosed in advanced stages, where complete cytoreduction and platinum-based chemotherapy are the standard of care. BRCA mutations are considered hallmarks of platinum sensitivity. Our study evaluated the responses to platinum-based therapy across a Romanian retrospective cohort. Methodology. Institutional data were extracted for all patients tested for the presence of BRCA germline or somatic mutation across a 3-year period. Results. Eighty-eight patients were included in the present analysis. FIGO stage IIIC+ was common at diagnosis, with approximatively 60% of patients undergoing primary debulking surgery. The patients positive for BRCA mutations had a significantly higher frequency for complete pathologic response, first and second platinum sensitive relapse, and a significantly longer overall survival. Conclusions. Upfront knowledge of BRCA status is mandatory, given the recent maintenance treatments available for selected patients and for the decision regarding the optimal sequence of platinum-based therapy.


3D laparoscopic transperitoneal right radical nephrectomy for late recurrence after initial open right partial nephrectomy (video presentation)

P.A. Medan1, I. Perciuleac1, M. Apetrei1, M. Hlodec1, N. Crişan1,2, I. Coman1,2, D.V. Stanca1,2

1. Department of Urology, Cluj-Napoca Municipal Clinical Hospital, Romania
2. Department of Urology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Introduction and objectives. The majority of kidney tumors are diagnosed incidental, at an early stage. Nephron-sparing surgery (NSS) is a reasonable oncological option for cT1. After NSS for pT1 disease, recurrences within the remaining kidney occur in 1.8-2.2% of patients. Most of the recurrences occur within 1-2 years postoperatively. Materials and method. We present the case of a 46-year-old male diagnosed at the age of 36 with an incidental 29-mm right renal tumor for which open right partial nephrectomy had been performed through a lumbar approach. The pathology at the time was clear cell renal carcinoma Fuhrman grade 2 pT1aNxMxL0V0R0. At the 10-year follow-up, tumor recurrence is identified by CT, which revealed a 30-mm mostly endophytic tumor located at the middle of the kidney. Considering the complexity of the tumor location, laparoscopic right radical nephrectomy was performed through a transperitoneal approach using four trocars. Results. The operative time was 180 minutes. The blood loss was insignificant. The patient was discharged at day 4, with no perioperative complications. The pathology report described a ccRCC ISUP grade 2 pT1aNxMxL0V0R0. The postoperative serum creatinine was 1.67 mg/dl, from a baseline of 1.25 mg/dl. Conclusions. The long-term follow-up is important for patients undergoing NSS, even in cases with negative surgical margins or with no negative prognostic factors, because late recurrence is possible. As in this case, laparoscopic transperitoneal radical or even partial nephrectomy (in selected cases) is feasible for tumor recurrence even after the initial open NSS, with all the benefits of minimally invasive surgery.


3D laparoscopic anterior pelvectomy with totally intracorporeal ileal conduit (video presentation)

I. Perciuleac1, M. Apetrei1, M. Hlodec1, I. Andraş1,2, D.V. Stanca1,2, I. Coman1, N. Crişan1,2

1. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2, Urology Department, Cluj-Napoca Municipal Clinical Hospital, Romania

Introduction and objectives. Currently, anterior pelvectomy is the standard treatment for women with invasive bladder cancer without evidence of distant metastases (T2-T4aN0M0). This involves the removal of bladder, ovaries, uterus, uterine tubes, anterior wall of the vagina and of the pelvic lymph nodes. Choosing and performing a certain type of urinary diversion are the main challenges of this intervention. We present the experience of our department for the performance of laparoscopic anterior pelvectomy with pelvic lymph­adenectomy and totally intracorporeal ileal conduit. Materials and method. We report the case of a 62-year-old female diagnosed with high-grade infiltrative urothelial carcinoma. CT scan revealed a 34-mm thickening of the left bladder wall, without distant metastases or lymphadenopathies. 3D laparoscopic anterior pelvectomy with standard lymphadenectomy and total intracorporeal ileal conduit was performed using five abdominal trocars, by the isolation of a portion of 15 cm ileal segment, 20 cm away from the ileocecal valve, using Endo GIA staplers. The small intestine continuity was restored by side-to-side ileo-ileal anastomosis, using staplers. The proximal part of the ileal conduit was opened, the ureters were spatulated and a Wallace 2 uretero-ileal anastomosis was performed. The anastomosis was protected by two ureteral mono-J stents. Results. The operative time was 300 minutes: anterior pelvectomy time – 120 minutes, lymphadenectomy – 60 minutes, and ileal conduit – 120 minutes. The intraoperative blood loss was 120 ml. Clavien grade 1 complications were reported in the postoperative period. The drainage tube was removed on postoperative day 2 and the intestinal transit was recovered on postoperative day 5. The patient was discharged with a serum creatinine of 0.97 mg/dl. The final pathology exam described a pT3bG3N0MxL1V0Pn1R0 urothelial carcinoma. A total of 17 lymph nodes were retrieved. Conclusions. Our team’s experience in 3D laparoscopic anterior pelvectomy with totally intracorporeal ileal conduit demonstrated that it is a feasible minimally invasive treatment option, in centers with experience in laparoscopic surgery. In comparison with the open procedure, it provides more perioperative benefits, such as reduced morbidity and hospital stay, early recovery and an increased quality of life, without compromising the oncological outcomes.


Partial nephrectomy techniques: 3D laparoscopy versus da Vinci Xi robot

B. Petruţ1,2, Cristina E. Bujoreanu2, C.V. Maris2, V.V. Hardo2 

1. Departament of Urology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Departament of Urology, “Prof. Dr. I. Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. Minimal invasive approaches for partial nephrectomy (PN) require a specific skillset for optimal oncologic and functional results and, even more, each renal tumor requires a personalized technical approach depending on its characteristics. Materials and method. We report our experience regarding PN performed with 3D laparoscopy and with the da Vinci Xi robot. The surgical technique adaptations depending on tumor characteristics and anatomy are explained. Results. Out of 283 PN performed minimally invasive, 97 cases were endophytic tumors (PADUA score ≥10), with a challenging technical complexity. Seventeen cases were tumors on a solitary kidney and two cases on a horseshoe kidney. Five surgeries were performed with the da Vinci Xi robot. Indocyanine green (ICG) guidance was used for selective clamping. Mean warm ischemia time was 16 minutes (19 minutes for highly complex cases) and the complications were grade 1 Clavien-Dindo for both approaches. Conclusions. Both minimal invasive techniques are safe and feasible to perform PN, with each tumor challenging the surgeon to adapt the operatory technique. Regardless the learning curve or the surgical approach, the oncologic outcome and minimal warm ischemia time for optimal postoperative renal function are mandatory. The da Vinci robot brings a higher dexterity with precise tissue manipulation and the ergonomics of the FireFly system makes it faster to use than ICG in conventional laparoscopy.


Robot-assisted versus 3D laparoscopic totally intracorporeal pure Studer ileal neobladder: our experience and technical advice

B. Petruţ1,2, Cristina E. Bujoreanu2, C.V. Maris2, V.V. Hardo2 

1. Departament of Urology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Departament of Urology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. Creating a new urinary reservoir from ileum for patients undergoing radical cystectomy for muscle infiltrative bladder cancer brings technical challenges for the minimal invasive approach, being one of the most complex urologic surgeries, especially when performed totally intracorporeal. Materials and method. We report our experience of performing 43 totally intracorporeal ileal neobladder (33 laparo­scopic cases and 10 robot-assisted cases). Both Y-shaped and Studer neobladder types were performed, under indocyanine green guidance on two female and 41 male patients. Our experience is exemplified presenting the 3D laparoscopic approach versus the robot-assisted one, with key technical advice and peri-/postoperative management. Results. The mean operatory time is longer for the robot-assisted technique, but there is no difference between the two approaches regarding mean blood loss and Clavien-Dindo complications. The follow-up data of long-term oncologic and functional results are noted. Conclusions. Totally intracorporeal ileal neobladder is feasible using both 3D laparoscopic and robot-assisted approach within oncologic safety, offering optimal functional results and a good life quality. ICG fluorescence offers a potential in reducing the risk of complications such as strictures of fistulas. The da Vinci Xi robot allows a gentle tissue manipulation as the wrist articulation helps the surgeon to optimize the surgical movements.


The potential of indocyanine green fluorescence in urology

B. Petruţ1,2, Cristina E. Bujoreanu2, C.V. Maris2, V.V. Hardo2 

1. Departament of Urology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Departament of Urology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. Indocyanine green (ICG) has recently started to be used in minimal invasive urologic surgery. It is a dye that can highlight anatomy through vascularization trajects and limphography, guiding excision and reconstruction under near infrared fluorescence/FireFly fluorescence mode on da Vinci Xi robot. Materials and method. We describe our experience of using ICG both in 3D laparoscopic and robotic surgery for benign and malignant urologic pathologies: vesico-vaginal fistula repair, pyeloplasty, radical prostatectomy and pelvic lymphadenectomy, totally intracorporeal ileal orthotopic neobladder and partial nephrectomy. The technique is explained, along with the peri- and postoperative implications of ICG usage. Results. There were no side effects of ICG administration. The reconstructive surgery was performed on optimally vascularized tissues, the selective arterial clamping during partial nephrectomy reduced the warm ischemia effect and a lymph node in the standard dissection template was identified only because of the ICG administration during radical prostatectomy with pelvic lymphadenectomy. Conclusions. ICG facilitates the identification of ischemic tissues and highlightes the vascularization and lymphatic trajects with a potential in optimizing the postoperative functional and oncologic outcomes in a broad range of urologic pathologies.

   


3D laparoscopic nephroureterectomy with anterior pelvectomy and pelvic and retroperitoneal lymph node dissection (video presentation)

V. Schiţcu, I. Cojocaru, B. Borz, N. Marica, D.S. Popescu, V.C. Munteanu

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. The upper urothelial tract tumors are rare entities, but even rarer is their presence in the ureter and bladder. This type of cancer is aggressive, and radical treatment is required. Surgery represents the best option, being of high amplitude, involving the exclusion of the kidney, ureter bladder and the lymph nodes that drain these organs. The recovery after such a surgery can be quite complicated, which determined surgeons to go for the minimally invasive technique (laparoscopy). Recent advancements in this area have allowed the surgeon to approach complicated surgeries. Objectives. To assess the feasibility of the 3D laparoscopic approach in the nephroureterectomy, cystectomy, pelvic and retro­­peritoneal lymph node dissection. Materials and method. We present our technique performed on a 62-year-old female patient diagnosed with high-grade infiltrative urothelial carcinoma after TUR-B surgery for a 1.5-cm left wall bladder tumor. The patient had previously accused hematuria. The CT-urography scan described a left mid-ureteral contrast-enhancing tumor with left III/IV hydronephrosis, while the bladder had no alterations. We performed 3D laparoscopic en bloc nephroureterectomy with anterior pelvectomy, para-aortic and pelvic lymphadenectomy. The surgery was divided into two surgical times: in the first surgical time, 3D laparoscopic left nephroureterectomy with para-aortic lymph node dissection was performed using a 3-trocar approach, with the patient in lateral decubitus. Secondly, we performed 3D laparoscopic anterior pelvectomy consisting of cystectomy, hysterectomy and bilateral adnexectomy with pelvic lymph node dissection, using the standard 5-trocar approach, with the patient in lithotomy position. Results. The operative time was 300 minutes, divided into 90 minutes for the nephroureterectomy with para-aortic lymph node dissection and 180 minutes for the anterior pelvectomy with pelvic lymph node dissection. There were 30 additional minutes used for changing the patient’s position and for redraping. The blood loss was 300 ml. The removal of the specimen was performed through a minimal subumbilical midline incision. Two drain tubes were placed. We minimized the number of trocar incisions to six, by using the same positions for two of them, in the left iliac fossa. Conclusions. The minimal invasive approach represents a real option for this pathology, with an excellent recovery and with excellent oncological and functional results. Due to the high amplitude of the surgery and the wide excisions needed, this type of surgery should only be performed by experts in the field.


3D laparoscopic ureterolysis and ureteric reimplantation (video presentation)

V. Schiţcu, I. Cojocaru, B. Borz, N. Marica, D.S. Popescu, V.C. Munteanu

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. Secondary retroperitoneal fibrosis for gynecological tumors, after radiotherapy and chemotherapy, is rare and difficult to treat. The patients are usually young, and due to this secondary treatment complication, their life becomes dominated by pain and renal insufficiency, with a low quality of life. The ureterolysis with or without ureteric reimplantation approach is very difficult due to the fact that the whole pelvis is frozen. Laparoscopy in these cases is technically challenging, but the results are superior to the classic open approach – the cosmetic results, less pain and less painkillers, and early social reintegration. Objectives. To assess the feasibility of ureterolysis and of ureteric reimplantation via 3D laparoscopic approach in the secondary retroperitoneal fibrosis. Materials and method. We retrospectively reviewed six patients. We performed a 3D laparoscopic approach for all patients, using four to five trocars, three of 10 mm and one or two of 5, depending on the case. Ligasure, cold scissors and forceps were used for adhesiolysis and fibrosis dissection. The ureteric reimplantation was performed on JJ stent, and the anastomosis was done using mono- or multifilament absorbable threads, interrupted suture. Results. The mean operating time was 240 minutes, with a mean blood loss of 300 ml. We placed two tube drains which we suppressed in days 8 and 9, and the patients were discharged on day 10. One patient presented ure­terohydronephrosis each time we tried to extract the JJ stent, therefore the patient had to wear a stent for life. Conclusions. 3D laparoscopic ureterolysis and ureteric reimplantation done by expert surgeons can be a safe and viable option for patients with secondary retroperitoneal fibrosis. 


3D laparoscopic retroperitoneal lymph node dissection for testicular tumor residual masses after chemotherapy (video presentation)

V. Schiţcu, I. Cojocaru, B. Borz, N. Marica, D.S. Popescu, V.C. Munteanu 

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. Retroperitoneal lymph node dissection is one of the most challenging interventions for the urologist. Usually, patients undergo adjuvant chemotherapy treatment, which triggers a desmoplastic reaction that causes tissue fibrosis in the retroperitoneum and around the great vessels. These aspects make a basic open surgery challenging, but a 3D laparoscopic approach becomes even more difficult. Objectives. To determine and assess the feasibility of 3D laparoscopic retroperitoneal lymph node dissection. Materials and method. We analyzed 18 patients (three with right testicular tumor and three with left testicular tumor). The tumor’s dimensions ranged from 3.5 to 9 cm (mean: 5.6 cm). We performed a 3D laparoscopic approach for all six patients, using four to five trocars, three of 10 mm and one or two of 5, depending on the case. For the lymph vessels we used titan clips and Hem-o-Lok clips. Results. The mean operating time was 158 minutes, with a mean blood loss of 150 ml. We placed one tube drain which we suppressed in day 3, and the patients were dis­charged in day 4. One patient presented lymphoreea. In the 10th day he reported less than 100 ml col­lected for 24 hours, therefore we suppressed his tube. Conclusions. The 3D laparoscopy approach in re­tro­pe­ri­to­neal lymph node dissection represents a modern and safe option, but only for selected patients and in experienced centers. 


Exploring the prognostic biomarker value of NLR, PLR and MLR in colorectal cancer: a protocol for systematic review and meta-analysis

Daniel Sur1,2, Andrei Havasi1, Alecsandra Gorzo1, Claudia Burz1,3 

1. Department of Medical Oncology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Department of Medical Oncology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. Department of Immunology and Allergology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Colorectal cancer (CRC) is one of the most frequent tumors worldwide and one of the leading causes of death by cancer. Finding proper biomarkers may help to improve CRC patient’s prognostic profile. The neutrophile-lymphocyte ratio (NLR), the platelet-lymphocyte ratio (PLR) and the monocyte-lymphocyte ratio (MLR) come as an affordable, effective option for developing new biomarkers for CRC. Even though these markers were explored in different cancers, this issue was not explored systematically in CRC. For designing this meta-analysis protocol to evaluate prognostic biomarkers, we used the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines. We strictly followed the steps suggested by the Cochrane Handbook of Systematic Reviews. The initial search in different databases will be carried out by two independent reviewers that will evaluate each title and abstract. The retrieved articles will be selected for qualitative and quantitative analysis based on the inclusion and exclusion criteria. All the relevant data collected, such as study characteristics, clinical data and statistical measures, will be grouped in an Excel sheet. The meta-analysis will be conducted using the random effects model by analyzing the hazard ratios (HRs) and 95% confidence interval (CI) measurements. The results will be presented using a forest plot diagram. The risk of bias will be assessed by funnel plots and Egger test. The proposed protocol can assure that researchers follow the right steps in conducting a meta-analysis for the prognostic evaluation of biomarkers.


• Research Papers Session •


Exploring the signaling landscape underlying breast cancer stem cells migration in microfluidic 3D environments

Oana Baldaşici1,2, Valentina Pilecki1, Daniel Cruceriu1, Loredana Bălăcescu1, Ovidiu Bălăcescu1,3, Oana Tudoran1 

1. Functional Genomics and Experimental Pathology Department, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Pharmaceutical Technology and Biopharmacy Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. Medical Oncology Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Cancer stem cells have been proposed as the main actors responsible for tumor progression and metastasis. The complex, multi-step process that leads to tumor dissemination requires cells that are able to actively migrate through the tumor stroma, towards the blood vessels which they intravasate in order to reach distant sites. While the ability of differentiated tumor cells to detach from the primary tumor mass and invade the extracellular matrix has been extensively investigated, far less is known about the migratory abilities of cancer stem cells, the seeds of tumor metastasis. Therefore, we aim to evaluate the migration capabilities of breast cancer stem cells in confined 3D environments and to explore the underlying signaling landscape. Mammosphere assays were used for cancer stem cells enrichment in 7 breast cancer cell lines, while 3D microfluidic devices were employed for assessing the cells migration in confined environments. The transcriptomic landscape of mammosphere-derived cells was explored by microarray analysis and computational mapping of signaling networks. Our data revealed significantly different gene expression levels in mammosphere-derived cells, of which MYC, PLAUR and CXCL10 were associated with cancer stem cells migration speed in microfluidic devices. 


Tumor-agnostic treatment using three-dimensional models

Ancuţa Jurj1, Laura Pop1, Lucian Barbu2, Alexandru Irimie3,4, Ioana Berindan-Neagoe1,5

1. Research Center for Functional Genomics, Biomedicine and Translational Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. National Research and Development Institute for Isotopic and Molecular Technologies, Cluj-Napoca, Romania
3. Department of Surgery, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
4. Department of Surgical Oncology and Gynecological Oncology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania 5. Department of Functional Genomics and Experimental Pathology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Agnostic therapy presented an important increase in interest from the scientific community in the last years. Thus, agnostic therapies target specific genomic anomalies or molecular features regardless of tumor site of origin. In this regard, of tremendous importance is the correct selection of the target. A compound that has potential in this direction is represented by trastuzumab, which is an anti-HER2 antibody. This therapy is generally used for HER2-positive breast cancer, but there are other carcinomas that also express this receptor. In this study, we used several different carcinoma cell lines on which we first assessed the expression level of HER2. Then, on 2D cultures treated with increasing concentrations of trastuzumab, we performed an MTT assay to assess the viability of these cells and we compared the differences between the viability curves of different cell lines with the HER2 expression level. Additionally, to offer a better overview on tumor architecture, we made 3D cultures of the selected cell lines, which we treated with trastuzumab and we assessed through fluorescence microscopy the difference occurring between the 3D cultures. More specifically, we observed differences regarding annexin expression and alterations in cellular morphology and cell-to-cell contact. Thus, in the current study we observed that trastuzumab can function in other malignancies from an in vitro perspective, with a potential impact for being used in the arsenal of other carcinomas which present increased HER2 levels. 


Genetic profile and hippo signaling expression in serous ovarian adenocarcinoma

Laura Ancuţa Pop1, Paul Kubelac2,3, Paul Chiroi1, Lajos Raduly1, Braicu Cornelia1, Patriciu Achimaş-Cadariu2,3, Ioana Berindan-Neagoe1,3

1. Research Center for Functional Genomics, Biomedicine and Translational Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Department of Oncology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Background. Ovarian cancer is one of the most common cancers worldwide. Truthfully, the clinicopathological and molecular features of these neoplasms are so miscellaneous that over 70% of the cases do not get diagnosed until late III or IV stages, where the five-year survival rate has a dismal 25%. Methodology. In this study, we evaluated the genetic profile of ovarian serous carcinoma samples using next-generation sequencing technology. In addition, the expression level of hippo signaling genes was evaluated. Results. We identified four patients with pathogenic BRCA1/BRCA2 and 13 genes mutated in our cohort of patients. The most frequently mutated genes were TP53, ERBB4, STK11 and PIK3CA, which are well-known cancer driver genes. We also observed a statistically significant increased level for TP53 and reduced expression level for LATS1, LATS2, MST1, TAZ and TEF. Conclusions. This study was able to demonstrate that ovarian cancer patients also present BRCA1/2 pathogenic mutations and mutations in specific cancer driver genes. The expression levels of TP53, LAST1, LAST2 TAZ and MST1 was correlated with the stage of ovarian patients and with the presence of mutations. These data could be used as a starting point for new biomarkers of early diagnosis of ovarian cancer. 


Case-control study on the impact of chronic exposure to low doses of ionizing radiations on human health

P. Virag1, M. Perde-Schrepler1, I.C. Brie1, E. Fischer-Fodor1, T. Dicu2 

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Babeş-Bolyai” University, Cluj-Napoca, Romania

Background and objectives. Chronic exposure to low-dose ionizing radiations (IR) can affect the genetic material of the individuals, and if the DNA repair rate is low, cancer risk increases. In Romania, the measurements indicate a mean of 126 Bq/m3 of natural radioactive background, placing it in the top of European countries. Băiţa-Ştei region, the location of a former uranium mine, has even higher radon concentrations. Therefore, this area offers the possibility to study the biological effects induced by chronic exposure to natural low doses of IR. Materials and method. Forty women form the Băiţa-Ştei region were included in the case group, and a control group was selected from a region loca­ted at 25 km away from this area. Peripheral blood samples were obtained by venipuncture, and peripheral blood mononucleated cells (PBMCs) were isolated by density gradient separation. The annual effective dose was assessed by placing RaThoGamma kits in the bedroom of the subjects. DNA damage and repair were assessed by comet assay (CA) and micronuclei formation by micronucleus test (MN) from the subjects PBMCs. 8-hydroxi-2’deoxyguanosine (8-OHdG) and poly(ADP-ribose)polymerase (PARP) inductions were evaluated by ELISA from the serum of the subjects. Results. The level of indoor radon concentration is three times higher in the case group (531 Bq/m3) as compared to the control group (173 Bq/m3). The basal DNA damage is 1.3 times higher in the case group as compared to the control group (p=0.001). The ability to repair radio-induced DNA lesions was significantly better for the control group as compared to the case group, both after 2 hours and 24 hours from the additional irradiation of the PBMCs (p=0.04). Higher frequency of MN (p=0.01) and induction of PARP (p=0.01) were observed in the case group, however no significant differences was observed in terms of 8-OHdG means. Conclusions. Chronic exposure to low doses of IR causes important DNA lesions and chromosomal aberrations in the PBMCs of the exposed people. Base excision repair is also affected, however no detectable oxidative stress changes occurred in the subject’s serum.


• Poster Session •


Cellular and molecular alterations of adipocytes and mammary epithelium by conditional reprogramming cell culturing

Cornelia Braicu1, Olga Soriţău2, Ancuţa Jurj1, Maximilian Munteanu3,4, Oana Zănoagă1, Raduly Lajos1, Patriciu Achimaş-Cadariu3,4, Ioana Berindan-Neagoe1,5

1. Research Center for Functional Genomics, Biomedicine and Translational Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Department of Cell Culture, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
3. Department of Surgery, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania.
4. Department of Surgical Oncology and Gynecological Oncology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Introduction. Preclinical in vitro models developed by conditional reprogramming is an essential tool to investigate cancer cell biology, as well as to facilitate the regenerative medicine research, by studying normal mammary cells and adipocytes differentiation, two important components of the tumor microenvironment. Materials and method. Normal mammary cells and adipocytes were specifically differentiated from mesenchymal stem cells (MSCs) isolated from the peritumoral areas of breast cancer, using specific cell culture medium, followed by microscopical and transcriptomic alteration evaluation. Results. There were highlighted important cellular and morphological alterations, confirming the differentiation process. The microarray data revealed at passage three the activation of significant MSCs markers, along with key immune response modulators in both types of cells. In case of adipocytes, the transcriptional level analysis revealed gene expression patterns of adipogenesis and immune response related transcripts, meanwhile for mammary cells there were observed an activation of chemokine activity and alteration of key epithelial markers, particularly those related to transforming growth factor beta signalling pathway. Conclusions. We emphasize important alteration of cell morphology and also alteration of signalling processes dictating the reciprocal regulation MSC differentiation and the ultimate control of the adipogenesis balance. This study demonstrates that it is important to have a better understanding of the molecular mechanisms altered on an in vitro model, like the one presented here, for developing better therapeutic strategies in regenerative medicine.


The COVID-19 effect on urology residency program

Cristina E. Bujoreanu2, C.V. Maris2, A. Grivei2, S. Turturică2, S. Crivat2, T. Pop2, Roxana A. Coman2, B. Petruţ1,2 

1. Department of Urology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Department of Urology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Introduction. The effects of COVID- 19 pandemic are difficult to quantify and even to identify, as it is still modifying many aspects of our daily life. This paper studies COVID-19 effects on the medical training of 10 urology residents from a tertiary healthcare center. Materials and method. The training activity of seven urology residents has been analyzed during the same period (March-September), in 2020 versus 2019, comparing also the activity of the same-year residents. The following aspects were analyzed: time spent in the operating room, number of assisted surgeries and type of surgeries, frequency of accessing the operating room, participating at scientific activities, including oral/video and poster presentations, research projects, hands-on trainings, publishing and teaching activity. Results. The COVID-19 pandemic influenced the training activity of our residents, with online learning gaining popularity. Conclusions. The adaptability and optimal resource management are crucial traits for a surgeon. As COVID-19 effects are still ongoing, residents must find online resources and alternative training methods to develop and cover the learning curve. This could be challenging, expecially in the surgical field.


Metastatic cervical cancer treatment options – case presentation

Mădălina Coşer1, Diana Iordache1, Iulia Monica Groza2 

1. Oncology resident, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Oncology medical doctor, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania 

Cervical cancer is the third most frequent type of can­cer which affects women under 45 years old, with a survival rate at five years of 17% in the metastatic set­ting. We present the case of a 44-year-old woman, diag­nosed with papillary squamous cell carcinoma of the cervix, stage IVB (lung, mediastinal, hepatic meta­sta­sis), ECOG 2, with altered hepatic function (5x VN) and grade 3 anemia, which caused difficulties in initiating the treatment. Initially, the patient received hemosta­tic radiotherapy and weekly chemotherapy regimen (car­bo­pla­tin+paclitaxel; x6), resulting in clinical and biological im­provement. In this setting, we could administer the che­mo­therapy regimen of cisplatin+paclitaxel every 3 weeks, with the association of bevacizumab. Obtaining che­mo­therapy-induced cytoreduction, with clinical and bio­lo­gical benefit, the possibility of administering the stan­dard of care treatment option which led to partial tu­mor response, with manageable toxicities (grade 2 hyper­tension), represented the particularities of this case. Currently, the patient has reached a progression-free survival (PFS) of 12 months from the moment of diag­nosis (the adition of bevacizumab to chemotherapy in the GOG-0240 trial resulted in a 8.3-month PFS).


Obesity paradox in cancer: to be or not to be obese?

Radu-Dumitru Dragomir 

“Victor Babeş” University of Medicine and Pharmacy, Timişoara; OncoHelp Oncology Center, Timişoara, Romania 

Non-communicable diseases have become responsible for the majority of deaths worldwide, with cancer being the second leading cause. Furthermore, the incidence and mortality of cancer continue to grow, and statistical estimations reveal that cancer will be the first cause of death, globally, overcoming cardiovascular diseases. Obesity is a metabolic disorder defined by an uncontrolled weight gain, widely known as an important factor in increasing morbidity and decreasing survival, mainly due to cardiovascular diseases, type 2 diabetes mellitus and to related cancers. Obesity is considered to be the second highest risk factor for malignant diseases (after tobacco smoking), and one of its contributions to cancer development is the induction of a low-grade chronic inflammation, which further impacts the immune system in a way that favors immune evasion of malignant cells. In recent years, immunotherapy has emerged as a new way of treating cancer, stimulating the immune system to specifically target tumor cells, resulting in a much longer duration of response to treatment and the avoidance of side effects that are typically associated with other strategies, such as chemotherapy. Not all patients benefit the same, but more recent studies highlight the fact that obesity seems to have a positive impact on patients survival, following the therapy with immune checkpoint inhibitors.


Potential biomarkers and targeted therapy in advanced prostate cancer

Anita Cristina Ionescu1,2, Mariana Aşchie3,4,5, Georgeta Camelia Cozaru4,5 

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. “C.C. Iliescu” Emergency Institute for Cardiac Diseases, Bucharest, Romania
3. Faculty of Medicine, “Ovidius” University of Constanţa, Romania
4. “Sf. Apostol Andrei” County Emergency Clinical Hospital, Constanţa, Romania
5. CEDMOG Center, “Ovidius” University of Constanţa, Romania

Despite considerable advances in recent years, prostate can­cer represents a major public health issue worldwide due to its high prevalence, mortality and morbidity. Recent tech­no­­logi­cal upsurge has enabled the examination of potential bio­mar­kers that can be used in the early diagnosis and help us choose the optimal treatment for each patient. In this paper, we describe the increased need and use of prostate cancer tis­sue specimens and genetic testing. Most of the genomic chan­ges described in prostate cancer do not yet have a clear ap­pli­ca­bi­li­ty. Issues related to the cell signaling pathway in­vol­ving androgen receptor are reviewed and discussed. We also examine the role of its aberrant variants in the evolution of advanced prostate cancer and the probability of using them as early, viable biomarkers. Finally, we examine studies that con­si­der the use of bromodomain and extra-terminal (BET) fa­mi­ly as the target of new therapies in prostate cancer. 


Multiple primary tumors in a patient with colon, pancreatic cancer and melanoma – bad luck or bad genes?

Mihaela Mărioara Stana, Sandra Deac, Andrei Dan Havasi, Ovidiu Vasile Bochiş 

Oncology Department, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

A coaggregation of malignant tumors at the same patient raises a question about the genetic field of the person. Usually, we are thinking of multiple genetic syndromes to find an explanation of this pathologic event. Syndromes like Li-Fraumeni, hereditary non-polyposis colon cancer or a mutation in the BRCA1 or BRCA2 gene were often associated in special cases with multiple primary tumors. We present the case of a 59-year-old female patient with three primary tumors, simultaneously. She was diagnosed with in situ melanoma and colon cancer stage II in September 2019, for which she underwent a segmental resection of the transverse colon. Intraoperatively, multiple liver metastases have been discovered and biopsied, which seemed to belong to a pancreatic origin. In October 2019, after a biopsy through echo-endoscopy, a diagnosis of pancreatic cancer stage IV was established. She received multiple systemic treatment regimens in order to cover both digestive tumors: 8 cycles of FOLFOX4 with locoregional and pulmonary progression disease, followed by 6 cycles of FOLFIRI, and now she is under treatment with gemcitabine. Unfortunately, the disease’s evolution, with symptoms of acute angiocholitis, deep vein thrombosis and septic condition, expressed the predictable evolution of pancreatic cancer. The NGS test is in progress, in order to clarify the genetic mutational status of the patient.


The value of early palliative care interventions in advanced cancer patients regarding symptoms and quality of life – review

Monica Şerbulescu

First-year Medical Oncology Resident, OncoHelp Oncology Center, Timişoara, Romania

Palliative care for terminally ill patients is based on a holistic approach of symptom management. A misunderstanding is that palliative care is exclusively for the end of life, when in truth it should be provided alongside active disease treatment such as chemotherapy, radiotherapy or surgery. Unpleasant symptoms (pain, dyspnea, nausea, depression, anxiety, tiredness, drowsiness etc.) are common in patients diagnosed with cancer. Up to 60% of patients experience more than one unpleasant symptom, and up to 30% experience more than five unpleasant symptoms. Fear of pain and other symptoms can limit what patients do in terms of their global functional status. Palliative care has shown significant benefits to quality of life and symptom control when integrated earlier into the management of patients diagnosed with metastatic or advanced cancer. Furthermore, patients are better informed about their goals of care, which alleviates their distress as death approaches. Both the European Society of Medical Oncology and the American Society of Clinical Oncology recommend that patients with metastatic cancer should receive committed palliative care services next to routine cancer care, early in their disease trajectory.


• "Resident Morning" Session •


The impact of COVID-19 on cancer patients from the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca

Alexandra-Cristina Boţ1,2, Nicolae Todor1, Ovidiu Bălăcescu1, Patriciu-Achimaş Cadariu1,2, Cătălin Vlad1,2, Mihaela Lupşe2,3, Violeta Tincuţa Briciu2,3, Tudor-Eliade Ciuleanu1,2

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. Clinical Hospital of Infectious Diseases, Cluj-Napoca, Romania

The gravity of the association between COVID-19 and cancer remains a controversial topic. From April to June 2020, at the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, 44 patients tested positive for SARS-CoV-2 RNA via RT-PCR test. During infection, 31.8% remained asymptomatic, 15.9% developed a mild form, 31.8% had a moderate form, and 11.4% had a severe form of COVID-19 that led to death. The only negative prognostic factors in the univariate analysis were male sex and advanced active cancer. The specific treatment included hydroxychloroquine (in 57.5% of patients), anticoagulants (21 patients; 52.5%), paracetamol (19; 47.5%), lopinavir/ritonavir (18; 45%), and azithromycin (42.5%). In our series, the incidence of SARS-CoV-2 infection was similar in cancer patients compared to the general population, and the difference regarding death rate was not statistically significant (11.4% versus 4.9%; p=0.11). By active testing, our objective is to keep the institute as a coronavirus-free sanctuary. 


Iatrogenic thyroid diseases in children treated for brain tumors – a single-center experience

Maria Margareta Cosnarovici1, Simona Sorana Căinap2, Rodica Voichiţa Cosnarovici3, Diana Olteanu3, Paula Pruteanu3, Doina Piciu1,4

1. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2. Department of Mother and Child, 2nd Pediatric Clinic, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. Department of Pediatric Oncology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
4. Department of Nuclear Medicine, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Aim. We present a relevant number of iatrogenic thyroid diseases in children treated for brain tumors at the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania. Methodology. We studied a number of 178 children treated for brain tumors at the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, from 2001 to 2011. Among these patients, we recorded a 5-year survival rate of 65.20%. From this group, 6.17% of the children developed thyroid disorders. Almost one-third of the patients had thyroid hormone insufficiency from the onset of the oncological condition. Two-thirds of the children developed long-term thyroid diseases following the oncological treatment. There were no cases of thyroid malignancy in this group. Conclusions. We recorded a significant number of thyroid diseases in children with brain tumors. All children developed this condition at long time intervals from the end of the oncological treatment. This study shows the importance of the screening in all children with long-term survivals after brain tumors, for thyroid malfunctions. 


Corrected QT prolongation among chemotherapy-treated patients: a study of a Romanian center

Cristina Crişan1, Tiberiu Moldovan1, Eduard Radu1, Călin Căinap1,3, Simona Căinap2,3, Ovidiu Bochiş1, Gabriela Morar-Bolba1

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Second Pediatric Clinic, Emergency Clinical Hospital for Children Cluj-Napoca, Romania
3. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania 

Background. Chemotherapy cardiotoxicity occurs sometimes as QTc prolongation, which may lead to ventricular arrythmia. We assessed the incidence of QTc prolongation among chemotherapy-treated patients. Methodology. We enrolled 396 consecutive patients receiving chemotherapy in the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania. A total of 870 ECGs were performed at baseline and every two months, for five assessments, during 2016. Results. Most patients were diagnosed with gastrointestinal tumors and received regimens containing more than one drug. Maximum QTc was recorded after four months, when we also found the maximum incidence of increased QTc (>470 msec), of 3.73%, and of increased ΔQTc (>60 msec), of 4%. Female gender was associated with a higher baseline QTc=421 msec, ±26.9 (p=0.02). No particular chemotherapy regimen was proved to significantly increase QTc. Age was associated with higher QTc and was also an independent variable predicting QTc prolongation (for QTc >480 msec; p=0.02), as well as increase of ΔQTc (p<0.001). The number of prior chemotherapy lines correlates with baseline QTc (p<0.0001), with QTc prolongation after two months (p=0.01) and predicts higher ΔQTc after two months (p=0.01), although within normal range. There was no additive effect during all the five assessments. Conclusions. Our results confirm QTc prolongation with chemotherapy and a special attention should be paid to previously treated patients and to elderly patients.


Clinical and pathological prognostic factors in melanoma

Andrada Larisa Deac1,2, Remus Sereş1, Dragoş Goadă1, Iulia Vlaicu1, Vlad Gâta1, Rareş Buiga1,2, Claudia Burz1,2

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Melanoma is an aggressive form of skin cancer which affects approximately 300,000 people each year worldwide. The incidence of melanoma is rising faster than any of other type of cancer. The American Joint Committee on Cancer (AJCC) staging system is the main prognostic factor in melanoma and is dependent on primary tumor thickness, ulceration and nodal status. Additional markers were sought to identify patients at increased risk of local and distant recurrence and more recently to identify patients responsive to immunotherapy and targeted therapy. Melanoma is an immunogenic tumor and the main advantage of immunotherapy is its ability to provide a durable res­ponse. Alterations in the tumor microenvironment, host-related factors, and the influence of extrinsic factors can contribute to the variability of response to immunotherapy. We present a series of four cases of melanoma with the presence of in-transit nodules and satellites as the common feature at diagnosis. Two patients received treatment with BRAF-MEK inhibitors, and two received treatment with immunotherapy. Those with immunotherapy had a fulminant clinical evolution after only three cycles. In this small study, we try to identify the clinical and pathological prognostic factors that will help us to choose the patients who will respond and benefit from immunotherapy.


Ovarian cancer associated with paraneoplastic cerebellar degeneration in the presence of anti-Yo antibodies

Sandra Deac1, Mihaela Mărioara Stana1, Andrei Dan Havasi1, Ana Maria Bordeianu2, Raluca Popiţa1, Ovidiu Vasile Bochis1

1. Department of Oncology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. RoNEURO Institute, Cluj-Napoca, Romania

Paraneoplastic neurologic syndromes (PNS) are a group of disorders that appear as a consequence of the pro­duction of chemical signaling molecules (hormones or cytokines) by tumor cells or by an altered immune sys­tem response against a neoplasm. PNS affect 1-3% of all cancer patients. Paraneoplastic cerebellar degeneration (PCD) is a rare neurological syndrome that occurs in less than 1% of all cancer patients due to tumor-induced auto­im­munity against cerebellar antigens and is charac­te­rized by acute or subacute onset cerebellar ataxia. Most commonly, PCD is associated with gynecologic and breast cancer, small-cell lung cancer and Hodgkin lym­ph­oma. Multiple antibodies (Ab) are highly specific for PCD, the most common being Anti-Yo antibodies. Anti-Yo-mediated PCD tends to occur predominantly in wo­men around 60 years of age and is mostly associated with gynecologic malignancy (ovary, uterus and breast). The early diagnosis and treatment of PCD include neurolo­gi­cal treatment, immunotherapy and oncological treatment of associated malignancy, which may improve the ove­rall prognosis. We present the case of a 59-year-old wo­man with ovarian cancer whose first manifestation was acute PCD. The laboratory investigations showed the presence of anti-Yo antibodies in the serum. The brain MRI revealed specific modifications suggestive for PCD. The immunological and imagistic results led to the diagnosis of PCD. The patient received neurological treat­ment associated with intravenous immunoglobulin therapy and chemotherapy. Even though the oncological response was satisfactory, the neurological disease pro­gressed, causing the patient’s death. 


Long-term nivolumab as second-line therapy for recurrent/metastatic squamous-cell lung carcinoma

C. Deak, M. Bandi, A. Boţ, D. Iancu, C. Mocan, T.E. Ciuleanu

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania 

Background. Patients with advanced squamous non-small-cell lung cancer (SQ NSCLC) who have disease progression during or after first-line chemotherapy have limited treatment options. Nivolumab, a fully human antibody inhibiting PD-1 immune checkpoint, is the standard of care for previously treated NSCLC, demonstrating a long-term survival benefit, with a favourable efficacy and a safety profile (CheckMate 017). Methodology. Patients from our centre, treated in the CheckMate 171 trial, who received long-term nivolumab for more than 100 cycles, were included in our analysis for demographic characteristic and overall survival (OS). Results. Six out of 33 patients (18%) received long-term immunotherapy; five were men, with a median age of 64.5 years old, with ECOG PS status of 1 in all patients; four patients (66.6%) were current/former smokers; five patients (83.3%) received nivolumab in the second line, and one (16.6%) in the third line. The median time from completion of systemic chemotherapy to disease progression was 3.3 months (0-4.8). The median number of nivolumab doses was 109.5 (102-113), with a median duration of 51.7 months (49.2-53). The most frequent TRAEs were fatigue, asthenia, decreased appetite, maculopapular rash, none of them leading to the discontinuation of the treatment. The median OS was 52.1 months (50.1-53.1+). Conclusions. Nivolumab is well tolerated, and 18% of the patients benefited from over 100 cycles, with a median overall survival of 52.1 months. 


Real world data of oncogene-driven NSCLC: the Romanian experience

Daniel-Vasile Dulf, Dana Iancu, Alexandra Boţ, Anca Ballok, Tudor-Eliade Ciuleanu

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania 

Introduction. Targeted therapies against specific genomic aberrations have been shown to be effective for the treatment of non-small-cell lung cancer (NSCLC) for almost two decades. However, there is still a lack of data from routine clinical practice. This study aims to determine the treatment and outcomes in patients with EGFR mutation positive and ALK translocation positive NSCLC treated in a real world setting. Data were collected from patients admitted to the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca. Furthermore, ano­ny­mous data were collected from the major genetic la­bo­ra­tories that are operating in our country in order to better profile our population testing and the positi­vity rates. Materials and method. This retrospective, ob­ser­va­tional and transversal study was performed using data from patients admitted to the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca. The cli­ni­cal characteristics, the information about NSCLC treat­ment regimens, progression-free survival (PFS), sur­vi­val outcomes and the toxicity data were obtained retro­spec­tively from our cancer center. In addition to PFS and overall survival (OS), subgroup analyses were conducted based on first- and second-line treatments and combinations. Results. Of the 364 patients with advanced or metastatic NSCLC in the database, 187 met the inclusion criteria. The median age was 69.1 years old, and the majority were males (57%), with stage IV, non-squamous cell carcinoma (93.4%). EGFR tyrosine kinase inhibitors (TKI) were the most widely prescribed first-line therapy (83%) for EGFRm, and ALK TKIs (87%) for ALK translocation positive NSCLC. The patients treated with an EGFR tyrosine kinase inhibitor or ALK tyrosine kinase inhibitor had significantly longer time to the next treatment than those given other first-line systemic therapies. Most patients progressed on their primary tumor site rather than any other metastatic site. TKIs were generally well tolerated. Discussion and conclusions. We conducted a real-world survival analysis of EGFR mutation positive and ALK translocation positive NSCLC patients. This study provides long-term follow-up data on a large patient group. We showed that patients managed in a real-world setting can also have a long PFS and OS benefit from targeted therapies. Both EGFR-TKIs and ALK-TKIs, together with chemotherapy and, in recent years, immunotherapy, have roles to play in the clinical management of these patients.


Malignant phyllodes tumor – case presentation

Maria Enea1, Monica Groza2

1. Resident Doctor, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. MD, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania 

We chose to present the case of a patient diagnosed with malignant phyllodes tumor, because it represented a challenge both in establishing the diagnosis and especially in choosing and administering the treatment. A 46-year-old woman was evaluated at the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, in October 2019, for a mass she had identified in her left breast. Given the extremely rapid and mutilating local evolution, a re­pea­ted biopsy was necessary to confirm the suspicion of sarcomatous component of phyllodes tumor (his­to­path­ological differential diagnosis between phyllodes tumor, primary breast sarcoma or sarcomatous com­ponent of metaplastic carcinoma). The impressive size of the tumor (13/14 cm) and the invasion of the chest wall structures made the surgery impossible at the time of diagnosis (although there were no distant metastases identified), which is why we opted for neoadjuvant chemotherapy. The patient underwent epirubicin + ifosfamide chemotherapy, associated with bisphosphonates (hypercalcaemia interpreted as paraneoplastic syndrome), with an extremely good clinical and biological response, which permitted the surgical intervention (left mastectomy). Post-mastectomy, the persistence of hypercalcaemia raised the suspicion of a concomitant endocrinological condition, the biological and histopathological (parathyroidectomy) results confirming the diagnosis of right inferior parathyroid adenoma. Currently, the patient follows the sequence of radiotherapy. 


Lifestyle assessment and awareness of cancer risk factors among oncological patients from Romania – a cross-sectional study

Adelina Silvana Gheorghe1,2, Isabela Anda Komporaly1,2, Elena Adriana Mateianu1, Dana Lucia Stănculeanu1,2

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

The quality of life of oncological patients is strongly related to their behavior regarding nutrition and exercise. Living a healthy lifestyle plays an important role in cancer prevention and also in a better control of the causes of related mortality and morbidity. We applied a quantitative, cross-sectional interview study in 153 oncology patients, based on a validated structured questionnaire, in order to assess the lifestyle changes made after diagnosis, the present dietary patterns and the key features of the doctor-patient relationship. Most of the participants from our study experienced an involuntary weight loss. Over half of the respondents admitted to have made dietary/lifestyle changes after cancer diagnosis. The majority of respondents agreed that smoking cigarettes and excessive alcohol drinking are risks factors for cancer. The scores resulted from the assessment of physical and mental health, weight control and nutrition were positively associated with a higher educational level, with younger age and higher income. Almost all patients stated that they would appreciate to receive a personalized nutritional counseling from a specialized healthcare professional. There is a constant need for a substantially reinforced action in raising public awareness about the risk factors for cancer. Moreover, the study shows that patients should be better counseled to adopt one of the available nutritional therapeutic options, in order to enhance the outcome of the oncological treatment. 


Rare epicardial metastasis in breast cancer – case presentation and analysis of literature data

Ana Maria Ilie1, Ana Maria Pâslaru2, Laura Rebegea1,3

1. Radiotherapy Department, “Sf. Ap. Andrei” Emergency Clinical Hospital, Galaţi, Romania
2. Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galaţi, Romania
3. Faculty of Medicine and Pharmacy, Medical Clinical Department, “Dunărea de Jos” University, Galaţi, Romania

Introduction. Heart metastases are more frequent than primary cardiac tumors. They are discovered at autop­sies with an incidence between 1.5% and 20%. The pri­mary tumors that generate their occurrence are ma­lig­nant melanomas, lymphoma, lung, breast, eso­phagus and, very rarely, gynecological tumors. The most affec­ted site is the pericardium. Regarding the cli­ni­cal point of view, they are generally silent (more exac­tly, 90% of the ca­ses). In case of breast cancer, the differential diagnosis with post-radiotherapy fi­bro­sis is necessary. The treatment is palliative and must be individualized according to the location of the primary tumor and the performance status of the pa­tient. Materials and method. We present the case of a 73-year-old woman, diagnosed with left breast neo­plasm in 2006 for which she performed multimodal oncological treatment. Results. After a period of 9 years, the patient presented sternal bone metastasis, radiotreated, for which she performed hor­mo­nal the­ra­py. In 2018, lung metastases were detec­ted. At the mo­ment of stage review, performed in 2020, se­con­da­ry epi­car­dial metastases were evidenced. We are pre­sen­ting the case, the therapeutic conduct, and the data from literature. Conclusions. Epicardial metastases are rare, being frequently silent. The incidence is on the rise due to the progress realized in the diagnosis and the treatment of neoplastic diseases. Stereotactic body ra­dia­tion therapy (SBRT) may be a therapeutic op­tion in ca­ses with a good performance and with oligo­metastatic disease.


The impact of the medical oncology internship on students’ perception of cancer

Cristina Lungulescu1, Cristian Virgil Lungulescu2

1. University of Medicine and Pharmacy of Craiova, Romania
2. Oncology Department, University of Medicine and Pharmacy of Craiova, Romania

As our understanding of oncological diseases develops and the treatment protocols change, determining the ideal method of educating students in medical oncology becomes increasingly difficult, requiring longer periods of study to effectively incorporate all knowledge. Therefore, obtaining answers from students can guide the educational process towards obtaining more valuable results. The purpose of this research paper is to evaluate how students of the Faculty of Medicine and the Faculty of Midwives and Nursing of the University of Medicine and Pharmacy of Craiova perceive certain aspects related to cancer and the specialty of medical oncology. Thus, valuable answers can be obtained from students that will lead to improvements in their education in this field. We included in this study two groups of students: one from the 5th year of the Faculty of Medicine, and another consisting of students in the 4th year of the Faculty of Midwives and Nursing. We made a comparison between the questionnaires filled in by the students from the Faculty of Medicine and by the students from the Faculty of Midwives and Nursing at the beginning and at the end of the medical oncology internship. Completing the questionnaires involved checking the answer considered appropriate by the student. The questions of the questionnaire were identical for the students from both faculties. Also, the same questions remained identical at the beginning and at the end of the semester, respectively. Student participation was voluntary. Four areas of interest were established: the role of the clinician, the psychosocial factors associated with cancer, the treatment, and prognosis of neoplasms. The questionnaires were distributed to students at the first and last oncology internship of the academic year. In total, 40 students participated in the study: 15 students from the Faculty of Medicine and 25 from the Faculty of Midwives and Nursing.
Faculty of Medicine
The most striking differences were observed in the students’ confidence in diagnosing cancer (p=0.012), question 27 (“I feel confident diagnosing cancer”), and in the implication of the side effects of treatment in patients who can no longer be cured (p=0.04), question 7 (“I think a doctor should not consider the side effects if the treatment will prolong the life of a patient who can no longer be cured”). The students began to recognize cancer as a chronic condition, and psychosocial issues were more adequately considered after their clinical placement. The strongest areas of agreement were that patients should be well informed about their prognosis and diagnosis, that the involvement of the multidisciplinary team is beneficial for individual patient care, and that palliative care can have a positive impact on the patient and his family. The students did not agree with the association of cancer with a short lifespan. Prior to placement in the clinical trial, five students at the Faculty of Medicine stated that they would consider a career in oncology, two students stated that they would not do so, and eight were not determined in this regard. After placement, eight students said they would consider a career in oncology, one said he would not, and six students remained undecided.
Faculty of Midwives and Nursing
The most important different results were found in terms of the toxicity that patients receive from oncological treatments in relation to the benefits they obtain (p=0.007) and their increased confidence in diagnosing cancer (p=0.001). Like students in the Faculty of Medicine, students in the Faculty of Midwives and Nursing strongly believe that cancer patients should be well informed about the prognosis and diagnosis of the disease, that cancer treatments should improve the quality of life, and that the involvement of a multidisciplinary team is advantageous for the individual care of the patient. Unlike students at the Faculty of Medicine, students at the Faculty of Midwives and Nursing did not agree to consider side effects if the treatment can prolong the life of a patient who can no longer be cured. Prior to placement in the clinical trial, one student stated that he would consider a career in oncology, nine students stated that they would not do so, and 15 students were undecided in this regard. After placement, eight students said they would consider a career in oncology, five said they would not, and 12 students were undecided. The evaluations of the students participating in our study showed that both those from the Faculty of Medicine and from the Faculty of Midwives and Nursing strongly believe that patients should be informed about the diagnosis and prognosis of the disease. Students began to recognize cancer as a chronic condition, and psychosocial issues were more adequately considered after their clinical placement. The strongest areas of agreement were that patients should be well informed about their prognosis and diagnosis, that the involvement of the multidisciplinary team is beneficial for individual patient care, and that palliative care can have a positive impact on the patient and his family. The results of our questionnaires show an increase in empathy for cancer patients and an increase in the likelihood that students will consider oncology as a specialty in the future. 


Perceptions towards fertility preservation among cancer patients: level of information, knowledge and healthcare professional involvement – survey

Elena Adriana Mateianu1, Adelina Silvana Gheorghe1,2, Isabela Anda Komporaly1,2, Dana Lucia Stănculeanu1,2

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2.” Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 

Cancer treatment is the most frequent cause of reduced fertility in cancer patients. Successful survivorship for this group of patients includes maintaining a high quality of life after the oncological treatment; however, lifesaving treatments can impact survivors by impairing reproductive and endocrine health. Fertility preservation can lead to better coping with the diagnosis and to less psychological distress during treatment. This study aimed to assess the knowledge about the risk of infertility in cancer patients after treatment, and the awareness of fertility preservation. To assess and measure aspects of perception towards fertility preservation, we applied a cross-sectional interview study, based on a questionnaire survey, among cancer patients. The participants were mostly women, with a median age of 35 years old, and most of them had breast cancer. Few participants were aware that cancer treatment can lead to infertility or had ever heard about fertility preservation options. However, a higher educational level was significantly associated with more knowledge about the effects of cancer on fertility and about the options for fertility preservation. The majority of participants did not have knowledge about the impact of oncologic treatment on fertility and did not know that there are options to preserve fertility. The awareness of infertility risk factors is an essential first step to safeguard future fertility and, therefore, more educational initiatives are needed to spread knowledge about oncofertility. 


Neutrophil-to-lymphocyte ratio – a prognostic factor in stage III or IV pancreatic cancer. A unicenter retrospective case series study

Elena-Florida Mitroi

“Victor Babeş” University of Medicine and Pharmacy, Timişoara; Oncohelp Timişoara, Romania 

Introduction. Pancreatic cancer is the 7th most common cause of cancer-related death. Because the majority of patients are diagnosed in the late stages, the prognosis is dire, and thus it is important to use a various range of prognostic factors. Among the biomarkers studied, we have observed that the neutrophil-to-lymphocyte ratio can be more easily approached in the clinical setting. Materials and method. This retrospective study was conducted at the Oncohelp Hospital Timişoara, bet­ween January 2015 and December 2019. The value of neutrophils and lymphocytes were obtained at the start of the first cycle of chemotherapy. The period of time calculated was between the first day of chemotherapy and the last day of in-hospital stay. Results. We assessed 50 patients, 23 males and 27 females. The mean age at diagnosis was 64 years old, the mean value of NLR was 3.94, and the mean of survival days was 281. We noticed that for an NLR<3.94, the mean survival was 537.38 days, while for ≥3.94 the mean survival was 263.18. We assessed the Pearson correlation and the Kaplan-Maier curve. Discussion. The Pearson correlation is weak, but there were many limitations of the study.


Male breast cancer – a retrospective study at the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca

Narcis Polocoşer1, Ioan Adrian Buda1, Ana-Maria Heroiu1, Anita Kovendi1, Andra Meşter1,2

1. Department of Medical Oncology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Discipline of Medical Oncology, “Iuliu Haţieganu” Universitaty of Medicine and Pharmacy, Cluj-Napoca, Romania

Background. Male breast cancer is a rare disease, accounting for approximately 1% of all cancers in men and for approximately 1% of all breast cancers worldwide. In these conditions, the treatment recommendations are often extrapolated from clinical trials enroling female patinets with breast cancer. Materials and method. We made a retrospective descriptive study that analyzed the characteristics of male patients with breast cancer from a database from the “Prof. Dr. Ion Chiricuţă” Institute of Oncology (IOCN) between 2000 and 2019. The main characteristics studied were: hystological type and immunohistochemistry status, initial tumor size, lymph node status, the presence of metastases and the treatment administered depending on the characteristics listed above. Results. The study enrolled a total of 95 patients, with a median age of 63 years old. The predominant histological type was intraductal carcinoma (IDC). A rate of 95% of patients presented estrogen receptors and less than 10% were HER2-positive. The great majority of the patients had undergone surgery. The mastectomy was done in all but one situation, where the sectorectomy was the surgical intervention. Axillary lymph nodes dissection accompanied in most situations the mastectomy. Antracyclines represented the most frequent chemotherapeutic regimen administered in adjuvant setting, and tamoxifen was the most frequent hormonal adjuvant therapy. Approximately half of the patients received thoracic or axillary radiotherapy. Conclusions. The purpose of the study was to show the heterogeneity of the therapy applied because of the wide period of time that this retrospective study analyzed. Our study confirms that the data collected from the IOCN database are comparable with those from literature regarding male breast cancer. 


Correlation between serum levels and tissue expression of IL-6 in pancreatic cancer

Vlad-Vasile Pop1, Rareş Buiga1, Claudia Burz1,2

1. Department of Medical Oncology, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. Department of Immunology and Allergology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania 

Introduction. Pancreatic cancer (PC) is regarded as an intractable disease because of the poor prognosis despite the new diagnostic procedures and the knowledge regarding the prevention of risk factors. It is marked by a one-year survival rate of approximately 24%, and solely 9% of patients remain alive at 5 year after diagnosis. CA 19-9 is regarded as a serum prognosis biomarker, but is considered a nonspecific one, because it is expressed in hepatobiliary inflammations and in many other digestive malignancies. Therefore, other specific markers should be implemented in clinical practice. The pancre­atic tumor cells and the tumor microenvironment express many surface proteins, one of which is represented by interleukin-6 (IL-6), implicated in many cell processes, such as oncogenesis. A series of studies suggest that IL-6 overexpression correlates with a poor prognosis. Thus, it may be important to detect this marker on the pancreatic tissue. However, the tissue obtained through biopsy may be insufficient to perform immunohistochemistry on it. An easier method for the cytokine detection should be blood detection, but there are no data that serum IL-6 tumor expression correlates with the serum levels. This study investigates the association between the two detection methods. Materials and method. Twenty-one patients with diagnosed PC were included in the study. For each patient, serum and tissue IL-6 levels were determined by ELISA and immunohistochemistry. Study data were attained using GraphPad. Results and discussion. The detected serum levels IL-6 were in some cases too low to me measured, but in contrast to healthy control group, the levels were higher. Regarding the tumor expression of the cytokine, it was observed that IL-6 was detected in both macrophages, represented as a part of the tumor microenvironment, and in cancer cells. Pearson correlation revealed a very high correlation between serum IL-6, tumor and macrophage cytokine expression, meaning that high blood levels match the tumor IL overexpression. Conclusions. PC represents an aggressive tumor that, in spite of the new discoveries in diagnosis and knowledge regarding risk factors, is still marked by an increasing prevalence and a poor prognosis. In clinical practice, there isn’t any specific prognosis biomarker, which states the need of a more precise one. IL-6 could be one of them; however, more studies on a sizeable number of patients should be conducted to validate the response. 


The efficiency of immunotherapy in malignant melanoma – the quiet before the storm

Liliana-Cristina Popescu2, Raluca Ioana Mihăilă2, Daniela Zob2, Dana Lucia Stănculeanu1,2

1. Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Department of Medical Oncology I, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest,Romania

Malignant melanoma is the most aggressive skin tumor, with lethal evolution and a high potential for metastasis. Although it represents only about 1-3% of all malignant tumors and 7-8% of skin tumors, the mortality remains high in the context of an unfavorable evolution. In terms of therapeutic options, the checkpoint inhibitors are in the frontline, regardless of BRAF status, and the combination of nivolumab with ipilimumab has proven a real benefit on survival compared to monotherapy treatment. The presented clinical case depicts the oncological history of a 47-year-old patient, diagnosed in 2019 with right, operated hallux malignant melanoma, stage T4Nx M1LYM (right inguinal-femoral adenopathy of 4.7/3.3 cm) and suspicion of lung metastases, BRAF wild type, who had a favorable response to the dual blockade of nivolumab + ipilimumab, according to RECIST 1.1 criteria (regression of oncological disease at 43.5%), but who developed grade IV hepatic and pancreatic toxicity after the first cycle. Although the laboratory parameters recorded very high values of pancreatic enzymes and transaminases (over 10-20 times the normal value of reference), the patient’s symptoms were disproportionately mild (nausea and discomfort in the upper abdominal floor), remitted under appropriate treatment. The favorable response to immunotherapy has been maintained and is long-lasting, even though the treatment has been stopped after the first cycle due to severe toxicity aforementioned. The early addressability of the patient to the doctor, the prompt management and the dynamic monitoring of the evolution are important. The toxicities associated with the administration of dual immunotherapy may be severe even in the absence of preexisting pathologies or in the apparent “normality” of the clinical status, but when properly managed and remitted in time, they do not interfere with the real and proven long-term clinical benefit.


An unusual presentation of malignant melanoma with bladder and gluteal muscle metastases. Case report and literature review

Remus Mihai Sereş1, Andrada Deac1, Dragoş Goadă1, Claudia Burz1,2

1. Medical Oncology Department, “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

A 40-year-old man presented to the urology department for clinical complaints of dysuria and hematuria, with the onset approximately one month before. Prior to the discovery of the bladder involvement, the patient had a paravertebral ulcerative area that healed with difficulties and which left an amelanotic lesion. Thereafter, the patient had no evidence of the disease until the urological evaluation, and the pathology findings were consistent with the diagnosis of malignant melanoma. We review the literature regarding unusual metastasis to the bladder and gluteal muscle, along with the treatment strategies and the importance of targeted therapies whenever it is possible. 



• VARIA •


The challenges in colorectal cancer management during the COVID-19 pandemic (Digestive oncology sessions)

Călin Căinap1,2, Ovidiu Bochiş1, Cristina Crişan1, Tiberiu Moldovan1, Simona Căinap2

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania  

Colorectal cancer (CRC) represents one of the most challenging malignant localizations of the digestive system. The long-term survival rate in CRC is increasing, occupying the third place after breast and prostate cancers. Approximately 95% of the deaths induced by CRC occur during the first five years from the initial diagnosis, and 30-50% of the patients with CRC will suffer from a relapse of the disease – local-regional or distal. The COVID-19 pandemic dramatically changed the life of medical personnel and of our patients. The access to medical treatments or facilities is often restricted by epidemiologic or administrative measures. The patients as well as the healthcare workers are constantly under pressure and they risk becoming infected – in hospital (like other nosocomial infections) or by “domestic” ways, during transportation from or to hospitals. During this very difficult time, when national healthcare systems are under huge pressures, our strategy must change: the new cases need to be investigated and treated, the current treatments should be continued and the medical personnel needs to be protected from exhausting and risky daily exposure to inherent viral contact. The COVID-19 knowledge is a constant and developing process which could dramatically interfere with our daily practice. There are some guideline recommendations which will be presented, along with data from international cancer registries and national medical regulations which could be clarified in order to have a homogenous clinical practice. 


Cardiotoxicity in oncology (Digestive oncology sessions)

Călin Căinap1,2, Ovidiu Bochiş1, Cristina Crişan1, Tiberiu Moldovan1, Simona Căinap2

1. “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania
2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Cancer represents one of the most important diseases and a public health challenge worldwide due to its increase in incidence. As a result of the new treatments which are implemented in actual strategies, the general prognosis is more and more favorable. It is estimated that chemotherapy and radiotherapy cure 20% of patients with cancer in addition to surgery. The efficacy of the chemotherapeutical treatments is associated with inherent side effects – one of the most important toxicity is represented by cardiotoxicity. The mechanisms incriminated to be involved in cardiotoxicity are very heterogenous. In this oral presentation, we will discuss the chemotherapeutical category of agents associated with cardiac toxicity and the actual guidelines recommendations. In order to prevent the severe sequelae after systemic treatment, a standard workup is indicated for an early diagnosis – cardiac ultrasound, MRI, which could show endocardial fibrosis, or serological biomarkers, such as troponin I and NT pro-BNP. All of them could contribute to a correct noninvasive evaluation of a patient treated with potential cardiotoxic agents.


Reconstruction of cervical substance loss after the oncological treatment of laryngeal cancer by free tissue transfer

Constantin Ciuce

“Regina Maria” Hospital, Cluj-Napoca, Romania 

Radiotherapy and laryngectomy can have as consequences the development of pharyngocutaneous fistula. The poor vascularization of irradiated tissues makes it difficult the closure of these fistulas by local flaps or, sometimes, by regional pediculated flaps. Often, the repetead failures deplete the local or regional resources and lead to giving up at the reconstructive efforts using classical surgery. The tissue defects can be partial, involving the anterior wall of the pharynx, circular when they harm the pharynx, leading to different degrees of stenosis, or complex when the anterior wall defect is associated with a visceral defect. For the reconstruction of these defects, one can resort to tissue autotransplantation using microsurgery techniques. The autor’s personal experience comprises 21 patients, of which 6 with simple defects, 11 with circular defects and 4 with complex defects. For the reconstruction of cervical region, we used the double-arched radial flap for simple defects, jejunal autotransplantation for circular defects, and double (jejunal and epiploon) autotransplantation for complex defects. For the revasculation of transplanted tissues, we used the carotid artery and jugular vein or vessels from the supraclavicular region. We had a minor complication (the partial reopening of the pharyngocutaneous fistula which was closed by debridement and suture) and a case of death due to great-vessel hemorrhage in a patient with complex defect. All patients could stop using the nasogastric feeding tube or the gastrostomy, and then resume oral feeding. 


The surgical treatment of retroperitoneal tumors with invasion of the great vessels

Constantin Ciuce

“Regina Maria” Hospital, Cluj-Napoca, Romania  

Retroperitoneal tumors of different etiologies may come in close contact with great vessels or can invade them. Adventitial contact or parietal invasion does not represent a contraindication for surgical excision, irrespective of the involvement on the veins or the major arteries from the retroperitoneum. It is very important that the surgery decision should be taken after a multidisciplinary evaluation, and the team which performs the surgery be trained in vascular surgery. The author’s personal experience comprises 12 patients with retro­peritoneal malignant tumors for which the excision implied resections and reconstructions of major vessels. From an etiologic point of view, the group comprises inferiour vena cava leiomyosarcoma (two cases), ganglionar metastases due to testicular cancer (six cases), metastases due to colorectal cancer with vascular invasion (three cases), and renal cancer with inferiour vena cava invasion (one case). For tumor removal, we performed venous resections and reconstructions: inferiour vena cava (2), iliac veins (4), and arterial resections/reconstructions – abdominal aorta (2), common iliac arteries (4). We registered a case of death due to peritonitis caused by dehiscence of biliodigestive anastomosis in a patient with mechanical cardiac valve, with clear-cell renal cancer with pancreatic and inferiour vena cava invasion, for which the resection and reconstruction of inferiour vena cava were associated with cephalic pancreaticoduodenectomy. 


Lung cancer from the perspective of the Multidisciplinary Committee of Therapeutic Indications

Mircea Dediu

Sanador Oncology Medical Center, Romania 

The management of the oncology patients is essentially multidisciplinary. The medical oncology societies recommend that every case should be evaluated by the Multidisciplinary Committee of Therapeutic Indications (Tumor Board). The evaluation is necessary both at the beginning of the treatment and when the clinical evolution requires it. For lung cancer patients, the multidisciplinary consultation is essential, taking into consideration that, for each of the disease stages, different combinations of various therapeutic methods can be discussed: surgery, systemic therapy, radiotherapy. This presentation will discuss the challenges for the medical oncologists regarding the decision that must be taken according to the clinical particularities and the TNM staging of the tumors.


Clinical evidence of the increased effectiveness of MRgRT

Martin Fuss

Clinical Cooperative Think Tank (C2T2) 

Recent advances in radiation oncology include the clinical adoption of the so-called MR-linacs, a combination of an MRI imaging system integrated with a radiation oncology linear accelerator. The advantages of using an MRI in the radiation therapy vault include: (1) superior soft tissue imaging for daily image-guidance, (2) the ability to better assess the potential changes in tumor size or a potential change in the relationship between a tumor and the nearby organs at risk for radiation damage, as well as (3) the ability to continuously monitor a target’s location while the radiation dose is being delivered. The two commercially available clinical systems (ViewRay MRIdian® and Elekta Unity®) will be presented and their similarities and differences will be discussed. The growing body of clinical outcome data in a variety of cancerous diseases will be presented and the projected impact of using an MR-linac on the field of radiation oncology will be summarized. 


Malignant melanoma – radioresistant tumors need more precise techniques

Claudiu Hopîrtean

Radiation Oncologist, Medisprof Cancer Center, Cluj-Napoca, Romania 

Melanoma has historically been considered a radioresistant tumor, with great potential for repairing sub­lethal damage. The role of radiotherapy (RT) in the treatment of melanoma is constantly evolving. Emerging data have challenged this viewpoint and radiation therapy (RT) is now considered an effective treatment option in some settings. The most common indication for radiotherapy in melanoma was adjuvant treatment after lymphadenectomy in patients with risk factors for nodal recurrence (large metastasis diameter, multiple nodes involved, extracapsular extension). Adjuvant radiotherapy after lymphadenectomy has been shown to almost double the local control of the disease, but it does not improve the patient’s survival and may also lead to a significant toxicity. More important, RT can provide effective palliation for up to 50% of the patients with unresectable locally recurrent or metastatic disease that produces bone pain, epidural spinal cord compression and central nervous system dysfunction. Stereotactic techniques, such as stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT), are becoming more widely used and can be effective in ablating limited metastasis (oligometastatic disease). RT could be a definitive treatment for a limited number of metastases or in cases of limited progression (oligoprogressive disease) on the systemic treatment. An increasing number of reports suggest a great benefit from the combination of RT with immunotherapy. Currently, there is no convincing evidence supporting the combination of RT with molecularly targeted treatment and, according to the emerging data on the toxicity of such a combination, it should be used with caution. 


Cancer – a multiple trauma. Burnout and secondary traumatic stress in medical personnel

Florina Pop

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca; “Babeş-Bolyai” University, Cluj-Napoca, Romania 

The experience of cancer generates a significant clinical distress for the patient, affecting also the carers’ life quality. The medical personnel, who are exposed daily to this trauma, pay an “emotional price”. The main stress factors are the communication of diagnosis, the sickness’ symptoms, the unforeseen changes, the frustrations related to the deterioration of the situation, the dramatic images, the periods with numerous deaths, the difficult patients and/or families, the patients without social support or those significantly affected psychologically, the high work load, the medical activity permanently under the state of emergency, and so forth. The prevalence of burnout, the depletion of compassion and the secondary traumatic stress in medical personnel are significant factors, imposing evaluation and intervention methods for the identification and attenuation of psychological symptoms. The psychological adaptation techniques imply the activation of cognitive behaviours regarding the perception upon the situation, its assessment and evaluation, its explanation and planning methodologies for cognitive and behavioural response and, to some extent, physiological response (relaxation exercises, mindfulness, medication where necessary).


Radiotherapy in lung cancer. Actualities and future perspectives

Laura Rebegea

Medical Clinical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galaţi; Radiotherapy Department, “Sf. Ap. Andrei” Emergency Clinical Hospital, Galaţi, Romania 

Lung cancer is continuing to register the highest incidence and mortality in Romania, according to GLOBOCAN 2019. External beam radiotherapy (EBRT) represents an important component of the therapeutic arsenal in the multimodal treatment of lung cancer, being the only treatment modality for which there are indications in all disease stages, based on performing status; approximately 80% of patients with lung neoplasms have indication for radiotherapy in one moment of the disease course. We present the therapeutic strategies in non-small-cell and small-cell lung cancer’s EBRT, discussing various fractionations schemas, conventional or hypofractionated, applied in many international trials. The goal of escalation dose in EBRT is the improvement of local control and survival. We are also mentioning the new concepts of isotoxic and isoeffective. The year 2020 came with a major challenge – COVID-19 pandemic. Lung cancer patients who can benefit of curative EBRT represent the patient’s category with the highest risk of severe complications and death due to COVID-19 infection, thus we considered appropriate to present the ASTRO and ESTRO professional societies and panel of experts recommendations, regarding radiotherapy indications in conventional and hypofractionated EBRT, in local and metastatic/oligometastatic disease. 


Immunotherapy in gynecological cancers

Dana Lucia Stănculeanu

“Carol Davila” University of Medicine and Pharmacy, Bucharest; “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania  

Immune-based therapies have revolutionized the therapeutic approach in oncology in the last decade and there are emerging data from trials that support its efficacy in gynecological cancers. This comprehensive review of the role of the immune system in the treatment of gynecologic cancers will highlight recent data regarding immunotherapy applications in ovarian, uterine and cervical cancers, drawing future directions for maximally exploiting the res­ponsiveness to different types of immunotherapies. There are several approaches to immunity-based cancer therapy, such as tumor-directed immune responses through vaccine-based approaches, stimulate antitumor responses using immune checkpoint inhibitors (ICI), expand T-cell populations using adoptive cellular therapy or targeting the tumor microenvironment to overcome the inhibitory pathways (tumor-associated macrophages). Although there have not been registered exceptional response rates in gynecological cancers treated with ICI, combinatorial immunotherapies have shown promise and also combining ICI with other therapeutic strategies, such as targeted therapy, chemotherapy or radiation therapy, led to improved responses. The large number of systemic factors which are influenced by the interplay between immune and cancer cells can contribute to the success or failure of immunotherapy, offering this approach an immense complexity and the opportunity for a paradigm shift towards a personalized treatment of gynecological cancers. 


The RTT’s role in radiotherapy

Noemi Vincze, Radu Diviricean, Eliza Voinea, Andrada Maroşan

“Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania 

The correct and efficient administration of radiotherapy treatment involves a strong collaboration of the team members: radiation oncologist, medical physicist, RTT (radiation therapy technologist) and nurse. During the treatment, the RTT is the one who gets most often in contact with the patient, having both technical and medical attributions, but also offering psychological support. He is involved in both the preparation of the treatment and its daily administration. An element of major significance for the correct administration of the treatment is the repeated and accurate patient’s positioning, starting with the CT scan for treatment planning, and throughout the treatment duration, until the end of the last session. The RTT is trained and qualified to identify the possible treatment’s side effects or the patient’s worsening general condition, informing the attending physician as soon as possible about it. The constant, empathic and constructive communication with the patients increases their compliance and mental comfort during the treatment. Identifying and reporting procedural errors or the technical failures are mandatory for ensuring and controlling the quality of the treatment. A strong cooperation with the members of the medical team and also with the technical department that is responsible for the good functioning of the radiotherapy equipment will ensure an optimal development of the entire process. During his training and throughout his entire professional activity, the RTT will have to acquire and afterwards improve his medical, technical and communication skills, for the benefit of the patients.