Klinicka Onkologie最新文献

Background: Lung cancer is one of the leading causes of death worldwide, with incidence and mortality significantly affected by population ageing and changes in the prevalence of risk factors. Lung nodules, which are often detected incidentally on imaging studies, pose a significant diagnostic challenge as they may indicate both benign and malignant processes. Correct diagnosis and management of these nodules is therefore essential to optimize clinical outcomes.

Purpose: This article provides a comprehensive review of diagnostic and therapeutic approaches to pulmonary nodules, focusing on the assessment of malignant potential based on nodule morphology, size and growth potential. Risk factors influencing the decision-making process such as smoking, age and exposure to carcinogens are also discussed. In addition, key recommendations from the Fleischner Society and the British Thoracic Society are discussed in detail. The article analyses the benefits of modern imaging techniques, including the use of artificial intelligence (AI) in the diagnosis of lung nodules. AI technologies, particularly deep learning techniques, have shown high accuracy in detecting and assessing malignancy risk, and their use is increasingly complementary to expert clinical judgement. Finally, the article highlights the importance of a multidisciplinary approach to the diagnosis and management of lung nodules, and also mentions the implementation of a pilot lung cancer screening programme in the Czech Republic aimed at early detection of the disease. This programme has the potential to significantly reduce lung cancer mortality and improve patient prognosis.

Background: Immunotherapy is one of the fundamental treatment modalities, especially in the treatment of metastatic non-small cell lung carcinoma, but it is also applied in neoadjuvant, or adjuvant therapy. A certain limitation continues to be immune-mediated toxicity and the broad clinical spectrum of its manifestations, which can present considerable differential diagnostic challenges.

Case: We present a case of a female patient who has been treated at our institute since February 2023 for metastatic squamous cell carcinoma of the right lung with first-line systemic therapy of pembrolizumab in initial combination with carboplatin and paclitaxel. Reassessment after four cycles of treatment showed a significant regression of the oncological finding, but also partial fibrotic changes in both lungs. The patient was completely asymptomatic and after consultation with her, it was decided to continue the treatment, now with pembrolizumab monotherapy. Several days after administration, the patient developed resting dyspnea, cough, and fevers. She consulted this deterioration of her condition only at the next scheduled appointment. Persistent dyspnea raised suspicion of immune-mediated pneumonitis. CT of the chest showed significant involvement of all lung lobes and treatment with corticosteroids and antibiotics was initiated. Through bronchoalveolar lavage, positivity for rhinovirus and enterovirus was detected. Viral pneumonia was assessed as the most likely cause of the clinical finding. The established corticosteroid treatment was gradually reduced and after discussion with the patient, we continued the administration of pembrolizumab. A follow-up CT of the lungs showed both further significant regression of the tumor and significant regression of inflammatory changes. Currently, the patient is after a total of 14 cycles of chemo/immunotherapy (of which 9 cycles of pembrolizumab after re-initiation), clinically in excellent condition, while a significant therapeutic response continues.

Conclusion: Our case report emphasizes the need for a broader differential diagnosis in the event of pulmonary complications during the administration of immunotherapy. Correct diagnosis of these complications can, among other things, fundamentally affect oncological treatment.

Backround: The development of highly effective anti-cancer therapies over the past several decades has dramatically changed the situation of patients with malignant tumor disease, who currently achieve a high rate of cure in the early stages of the disease. Despite tremendous progress, chemotherapy remains the primary treatment modality for early breast cancer. However, chemotherapy-related complications have a major impact on cardiovascular morbidity and mortality in this group of patients. Almost 80% of women diagnosed with breast cancer are over 50 years of age and already have risk factors for cardiovascular disease, such as age, family history, hypertension, elevated cholesterol, smoking, diabetes, and elevated body mass index. Most breast cancer patients do not die and, in line with the general population, cardiovascular disease remains the most common cause of death. Clinical research, extensive retrospective analyzes and prospective works describe the dyslipidemic effect of cytostatics, which may predispose to the development of atherosclerotic cardiovascular diseases. The administration of neoadjuvant or adjuvant chemotherapy based on anthracyclines and taxanes can lead to an increase in total cholesterol, triacylglycerides, LDL cholesterol and a decrease in HDL cholesterol. Abnormally high concentrations of lipids in the blood represent one of the main risk factors for the development and progression of cardiovascular diseases. The works also indicate a correlation between serum lipid levels and the rate of achieving pathological complete remission after the administration of neoadjuvant chemotherapy. Dyslipidemia is associated with a worse prognosis in breast cancer patients treated with neoadjuvant chemotherapy.

Purpose: The aim of the thesis is to point out the dyslipidemic effects of cytostatics and the risks of atherosclerotic cardiovascular diseases in breast cancer patients who have undergone adjuvant or neoadjuvant chemotherapy for early breast cancer. The identification of cardiovascular risk factors at the beginning of oncological treatment, the monitoring of the lipid spectrum during the treatment and the timely intervention of dyslipidemia treatment escape attention at present.

Background: Currently, there is no standard option that can be routinely recommended for the treatment of advanced melanoma after failure of modern immunotherapy and/or targeted therapy. Chemotherapy is an option, but its role is considered to be questionable. These doubts are based on historical experiences with chemotherapy, however, there is a lack of evidence of chemotherapy effectiveness after previous treatment with modern systemic therapy.

Patients and methods: At our institution, we managed to collect a set of 23 patients with advanced cutaneous melanoma who failed modern systemic treatment based on anti-PD-1 antibody immunotherapy or after failure of BRAFi (+MEKi) targeted treatments in the years 2017-2023. Dacarbazine monochemotherapy was indicated as further line systemic treatment for all these patients. The treatment effect was evaluated according to the RECIST/iRECIST criteria, and we also earned survival data for all patients.

Results: In our group, we observed substantial treatment response rate (complete remission 3times, partial remission 6times, response rate 39 %, stable disease twice), as well as long duration of those responses. Overall survival from the start of the therapy on second- or third-line dacarbazine in this group was 14.7 months and progression free survival was 9.3 months. In cases where a clinical benefit was achieved (complete remission, partial remission, or stable disease - 11times, 48%), the progression-free survival and overall survival values are 16.4 and 23.3 months respectively.

Conclusion: These excellent results show that the role of chemotherapy in this indication should not be doubted. Obviously, this raises questions about the reasons why these unexpectedly good results were achieved. We should seriously consider the possibility that previous immunotherapy does have a sensitizing and potentiating effect for subsequent chemotherapy.

Background: Lung cancer (LC) represents the leading cause of cancer-related deaths in the Czech Republic. Over the past decade, there have been notable advancements in LC treatment based on findings from controlled clinical trials (CTs). However, patients enrolled in CTs may not fully represent the diversity of real-world patient populations from routine clinical practice. To address this gap, we designed an observational retrospective study to describe the real-world evidence of LC treatment from a single-center registry.

Patients and methods: We present data from an observational, retrospective study based on electronic medical records of adults with LC registered at Masaryk Memorial Cancer Institute between 2018 and 2022. The primary objective was to set up a registry including patient attributes, clinical characteristics, pathological data, treatments, survival outcomes, and adverse events. The patients were identified based on ICD-10 code C34. The study population was further limited to those with verified histological subtypes - non-small cell LC (NSCLC) and small cell LC (SCLC). The primary treatment cohort included patients diagnosed or initiated on primary treatment during the study period. The non-curative systemic therapy cohort consisted of patients who received any systemic anti-cancer therapy with non-curative intent even if being diagnosed before 2018.

Results: A total of 1,382 patients were identified with the ICD-10 code C34. The eligible cohort included 1,172 LC patients, of whom 877 (75%) were diagnosed during the study period. Out of 827 LC patients included in the primary treatment cohort, 723 (87%) were diagnosed with NSCLC. At LC diagnosis, 56% of patients had stage IV disease. The median follow-up of the primary treatment cohort was 40.4 months, and the five-year overall survival rate was 20% for NSCLC patients and 8.2% for SCLC patients. A total of 495 NSCLC and 79 SCLC patients received systemic anti-cancer therapy at any line of treatment. In NSCLC patients, 61 (12%) received next generation sequencing mutation testing, 106 (30%) were identified with PD-L1 ≥ 50%, and 170 patients had evidence of particular driver oncogene mutation. Based on the testing, a total of 154 NSCLC patients received target therapy, and 86 NSCLC patients received immunotherapy as monotherapy or in combination with chemotherapy in the first line.

Conclusion: The presented descriptive study of a consecutive cohort of LC patients from one cancer center over a five-year period (2018-2022) indicates the potential of LC patient registry. The LC registry, with its prospective development including an entire-country extension, provides a tool for real-world evidence that complements data from the registration and post-registration CTs, offering invaluable insights derived from clinical practice.

Introduction: Multiple myeloma is a common plasma cell neoplasia usually accompanied by the formation of osteolytic foci, whereas osteosclerotic myeloma is a very rare form of plasma cell dyscrasia. When osteosclerotic myeloma is detected, osteosclerotic foci are usually part of the POEMS syndrome. Osteosclerotic myeloma without other manifestations of the POEMS syndrome is an unusual finding.

Case description: In a 46-year-old woman, osteosclerotic changes of the temporoparietal region caused soft tissue induration over this lesion, which initiated further investigation. Imaging studies subsequently showed multiple osteosclerotic foci in the skull. Examination of blood proteins revealed 8 g/L of IgG-lambda monoclonal immunoglobulin, subclass IgG1. In search of the cause of the osteosclerotic changes, FDG-PET/CT was performed, which revealed no FDG accumulation, i.e., no other tumor (breast or stomach cancer). Low-dose CT showed irregular bone structure, but not significant osteolytic or osteosclerotic foci. To map the extent of osteosclerotic changes, NaF-PET/CT imagination followed, which revealed multiple spots with high fluoride accumulation. A parietal bone biopsy showed osteosclerosis with minor clonal plasma cell infiltration. Trepanobioptic bone marrow sampling revealed an infiltration of bone marrow with atypical plasma cells in 8%. Flow-cytometric examination of bone marrow showed 0,37% of plasma cells, however predominantly (91%) clonal with lambda expression. MRI of the brain identified asymptomatic meningeal thickening. There was no evidence of POEMS syndrome in the patient; thus, we concluded the diagnosis as monoclonal gammopathy of clinical significance with osteosclerosis which was previously termed osteosclerotic multiple myeloma.

Conclusion: Monoclonal gammopathy of clinical significance (MGCS) with osteosclerotic skeletal changes, documented on CT and multiple foci with intensive osteoneogenesis, documented on NaF-PET/CT without evidence of POEMS syndrome, is an extremely rare form of plasma cell dyscrasia. This publication documents the unique clinical manifestations of IgG-lambda type plasma cell proliferation without signs of POEMS syndrome and the role of NaF-PET/CT imaging. Classification of this disease as MGSC with osteosclerotic manifestations is more consistent with the indolent nature of the disease with a significantly better prognosis, compared with multiple myeloma.

Background: The goal of treatment for anal squamous cell carcinoma (ASCC) is to preserve a functional anal sphincter and maintain the best quality of life. Surgical excision is reserved only for very early stages, and concomitant chemoradiotherapy (CHRT) is usually used in the treatment of ASCC. The aim of the study is a retrospective analysis of a group of patients with ASCC treated with CHRT using accelerated radiotherapy at the Institute of Radiation Oncology of Bulovka University Hospital in Prague (IRO BUH).

Patients and methods: Between 2014 and 2022, 73 patients with ASCC underwent definitive CHRT. Patients were treated with accelerated radiotherapy in 25 fractions - to the tumor and affected lymph nodes at 2.3 Gy to a dose of 57.5 Gy and to the area of the lymphatics at 1.8 Gy to a dose of 45 Gy. Concomitant chemotherapy mitomycin + 5-fluorouracil, later mitomycin + capecitabine was administered.

Results: A total of 64 (87.7%) patients underwent CHRT, in the remaining 9 (12.3%) cases only radiotherapy was applied. The 2- and 5-year overall survival rates were 85.8% and 76.3%, disease-free survival 88.0% and 86.3%, local control 91.9% and 91.9%, and colostomy-free interval 68.5% and 68.5%, respectively. The median of these parameters was not reached. Acute toxicity grade G3-4 was reported in 51 (69.8%) patients, late toxicity G3-4 was detected in 10 (13.7%) cases. No grade 5 toxicity occurred.

Conclusion: Accelerated radiotherapy in the treatment of ASCC resulted in favorable disease control but was burdened with significant toxicity.

Background: Intensity modulated radiotherapy (IMRT) has become a standard radiotherapy treatment delivery option owing to the advantages it offers in terms of target coverage and organ sparing. Furthermore, the ability to introduce different fractionation for different targets lets us deliver higher doses to the high-risk areas and lower doses to the elective volumes at the same sitting, referred to as simultaneous integrated boost (SIB). In the current study, we intended to retrospectively analyze the clinical outcomes and patterns of the failure of oropharyngeal cancers treated with SIB-IMRT and concurrent chemotherapy at our centre and analyze the factors contributing to poorer outcomes.

Material and methods: Data of oropharyngeal cancer patients treated with SIB-IMRT and concurrent chemotherapy were retrieved from the institutional database. Patient demographic details, histopathological features, staging, treatment details, failure patterns and outcomes were documented. All potential factors were evaluated for outcomes. Radiation was delivered by using the SIB-IMRT technique. High-risk planning target volume (PTV) received 66 Gy in 2.2 Gy/fraction, intermediate and low-risk PTV received 60 Gy and 54 Gy, respectively. Primary endpoint was to assess local control (LC), regional control (RC) and loco-regional control (LRC) rates and secondary end point was to evaluate the survival outcomes - overall survival (OS) and cancer-specific mortality. All survival analyzes were performed using the Kaplan-Meier method.

Results: A total of 169 cases were included in the final analysis. The median age was 55 years (range 20-78) with 95.3% males. The base of tongue was the most common primary site. Around 54% cases were node negative with 38% patients having stage IV disease. The local control rates for N0 vs. N+ cases were 74.1 vs. 62.3% (P = 0.046), respectively. Similarly, the 4-year RC rates for N0 vs. N+ cases were 94.4 vs. 83.5% (P = 0.024), respectively. On multivariate analysis, only 4-year RC rates showed significant difference between the two (P = 0.039). No differences were found between T stages in LRC and OS. The 4-year LRC rates for stages 1, 2 vs. 3, 4 were non-significant (69.2 vs. 66.3%; P = 0.178). The 4-year OS rate was 81.3%. The 4-year LC and LRC rates were 67.8 and 89.5%, respectively. There were 54 local and 17 regional failures. The median time to failure was 13 months (range 3.6-82.9).

Conclusion: SIB-IMRT provides comparable outcomes for oropharyngeal cancers. OS and loco-regional recurrences were significantly worse for nodal positive disease.

The guidelines for clinical practice for carriers of pathogenic variants in clinically relevant genes predisposing to Lynch syndrome and colorectal cancer define the steps of primary and secondary prevention that should be provided to the individuals at high risk of developing hereditary cancer in the Czech Republic. The drafting of the guidelines was organized by the Oncogenetics Working Group of the Society for Medical Genetics and Genomics of J. E. Purkyně Czech Medical Society, in cooperation with representatives of oncology, oncogynecology, and gastroenterology. The guidelines are based on the current recommendations of the National Comprehensive Cancer Network (NCCN), European Society of Medical Oncology (ESMO) and take into account the capacity of the Czech healthcare system.

Background: Positron emission tomography (PET) is a state-of-the-art diagnostic method of nuclear medicine, used for diagnostics of many pathological states in the organism, first and foremost in oncological issues. The first analysis of utilization and potential utilization of PET in the Czech Republic was published in 2013. In the following years, there was a sharp increase in a number of PET/CT and PET/MRI scanners in the country; in 2013-2021, it doubled. Simultaneously with the increase in scans performed, the range of available radiopharmaceuticals also broadened.

Material and methods: The study analyses the numbers and structure of PET, PET/CT and PET/MRI scans in the 2013-2021 period, using the pseudonymized data acquired from the General Health Insurance Company of the Czech Republic. The data was evaluated through a series of qualitative and quantitative indicators (number of scans performed, structure of diagnoses, use of different tracers, and availability of a scan for a patient).

Results: In the observed interval of time, the number of scans performed practically doubled, both thanks to more scanners installed and more radiopharmaceuticals available. The percentage of oncological and non-oncological scans remains more or less the same. Nevertheless, the regional differences in a number of scans performed persist, as does the availability of the scan for patients.

Conclusion: PET is still a dynamically developing molecular imaging method in the Czech Republic. The analysis of a number and structure of scans performed offers a priceless overview of the development of the method over the years, in regard to diagnoses, utilization of individual radiopharmaceuticals or geographic distribution of scans performed. The observed findings are a motivation for further analyses.