• 27-29 August 2020 •

Detection of protein glycation using spectroscopic methods

Jasim Hafedh Mohammed Al-Saedi1, Oana Grigore2, Maria Mernea1, Cristina Doina Niţu1,3, Miruna Silvia Stan1, Gheoghe Stoian1, Dan Florin Mihăilescu1

1. Faculty of Biology, University of Bucharest, Romania
2. Laboratory of Solid-State Quantum Electronics, National Institute for Laser, Plasma and Radiation Physics, Măgurele, Ilfov County, Romania
3. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Introduction. Glycated hemoglobin (Hb) is a sig­ni­ficant marker in the investigation of diabetes. The gly­ca­­tion process involves two stages. In the first stage, the amino-free groups of hemoglobin chain suffer a nucleophilic attack of the carbonyl group of reducing sugars. A reversible Schiff base product results, that can undergo a spontaneous rearrangement. In the second stage, a complex series of reactions occur, leading to the formation of many different highly reactive compounds. Objective. The objective of the present study was to monitor the glycation of Hb using different spectroscopic techniques. In addition, we compared the glycation effects of different reducing sugars like glucose, fructose and galactose. Method. Hb was in­cu­bated with sugars for zero, two, four and six days, un­der heat treatment at 50°C. The resulting mixtures were dialyzed against ammonium bicarbonate buffer in or­der to remove unreacted compounds. The glycation of samples and Hb conformation in the samples were cha­rac­te­rized by native electrophoresis (native-PAGE), Fourier-transformed infrared spectroscopy (FTIR), and terahertz (THz) spectroscopy. Results. Native-PAGE revealed that non-glycated and glycated Hb present different properties that allow their separation in an electric field. FTIR results show that attached sugars present an absorption band around 2000-900 cm-1. The intensity of this band changes with incubation time, supporting the continuous attachment of sugars to Hb. The secondary structure of Hb had a significant ten­dency to convert into a disordered secondary structure, decreasing the structural stability of Hb. These changes alter the low-frequency collective vi­bra­tional modes of hemoglobin, as observed by THz spec­troscopy. When comparing the effect of different su­gars, galactose appears to be the most reactive. Conclusions. All the results indicate a progression of Hb glycation with incubation time, which changes the structure of Hb.


Medical physicists’ contribution to the radiotherapy practice

Ancuţa Elena Baciu1, Emil Puşcaşu1, Cristina Sîrbu1, Maria Mihai1,2

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology , Bucharest, Romania
2. County Emergency Hospital of Craiova, Romania

Purpose. The aim of this paper is the pre­sen­ta­tion of the complex activity realized by the me­dical physicists involved in the radiotherapy prac­tice, starting from the preparation of the technical documentation necessary for the medical equipments authorization, until the physical and clinical dosimetry measurements, quality assurance (QA), and also the realization/evaluation/approval of the treatment plan. Materials and method. Medical linear accelerators (LINAC), equipments for dosimetry measurements, and specific softwares were used. Results. After the preparation of authorization documentation and obtaining the specific licenses for the medical equipments, there were performed the physical dosimetry measurements according to the international guidelines for three linear accelerators, photons’ beams (with energy of 6 MV, and 15 MV), and electrons’ beams (with energy of 4 MeV, 6 MeV, 9 MeV, 12 MeV and 15 MeV). Further, there were realized some tests, proposed in the IAEA-TECDOC-1583(1) report of the International Atomic Energy Agency (IAEA), using the CIRS THORAX phan­tom, a special device for clinical dosimetry, ha­ving 8 localizations associated with 8 different den­si­ty structures; those structures are situated at different depths and distances from the central axis. The pre­scribed dose taken into consideration was 200 cGy/frac­tion; dose values calculated using the specific soft­wares based on the numerical models were compared with the values measured using ionization chamber and the further results were evaluated according to the ac­cep­tance protocols (variation/deviation threshold is bet­ween ±2% and ±4%). Also, for all the three linear ac­ce­le­ra­tors the IAEA external periodic audit “Dose Qua­li­ty” was performed. The follow-up and the cli­ni­cal dosimetry measurements were realized for all ra­dio­lo­gical equipments, taking into consideration different tu­mor localizations, in accordance with the medical pres­cription: dose (D) per fraction (Fr.), Dmax for PTV (plan­ning target volume) and the specific dose for or­gan at risk (OAR). Conclusions. Medical physicists’ ac­ti­vi­ties are very complex, the specialists having the pro­fes­sional mission to assure constantly that radio­the­rapy equip­ments are properly used according to the ra­dio­lo­gical norms. Also, they perform physical and clinical do­si­me­try for quality assurance in ra­dio­therapy practice. In­de­pen­dent of its source, the ra­dia­tion can produce radio­logical incidents or accidents, therefore the entire professional activity of the medical physicist must be efficient and ef­fi­ca­cious developed. The measurements results are si­tua­ted in the acceptance standards of 2-4%. Dose rate verification is a very important step because a pos­sible dose rate variation of the equipments may in­duce monitor units variation calculated with TPR. With the aim to obtain valid results, it is important to use ionization chambers calibrated at time intervals spe­ci­fied in their calibration certificates. Treatment plans calculated with numerical algorithms may also be verified through manual calculation, taking into con­sideration the medium’s density in the reference point.
1 Commissioning of radiotherapy treatment planning systems: Testing for typical external beam treatment techniques, IAEA, VIENNA, 2008, IAEA-TECDOC-1583, ISBN 978–92–0–100508–3, ISSN 1011–4289.

Expression of soluble proteins S100B and MIA in different stages of malignant melanoma progression

Lucica Mădălina Bolovan1, Silviu Voinea2, Angela Şandru2, Adina Stanciu2, Antonela Buşcă2, Marieta Panait2, Corina Mihalcea2, Daniela Murăraşu2, Sabin Cinca2, Lorelei Irina Braşoveanu1

1. “Ştefan S. Nicolau” Institute of Virology, Bucharest, Romania
2. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Malignant cutaneous melanoma (MMC) is a neoplasm with an unpredictable evolution, given the heterogeneity and its multigenic etiology. The current methods of detection, the prognostic and the monitoring are orientated to the clinical and morphological aspects of the tumor cells; however, after tumor dissemination, the mortality rate increases worryingly. S100B and MIA proteins are soluble biomolecules with important potential as serological tumor markers. Their quantifiable expression helps to refine and individualize the diagnosis, prognosis, treatment and monitoring for patients with melanoma. This study evaluates the serological expression of S100B and MIA proteins, for a group of 135 patients diagnosed with MMC, and emphasizes the correlation of these two biomolecules concentration with different stages of melanoma progression. Serum and plasma samples were analyzed by ELISA method (enzyme-linked immuno sorbent assay). The results showed that in stages I and II, the concentrations values for both proteins are uniformly expressed around the cut-off (MIA proteins: cut-off = 9.5 ng/ml; S100B: cut-off = 90 ng/L). In stage III, 42% of patients had positive values for S100B and 40% of patients had positive values for MIA proteins. In stage IV, 64% of the patients registered an overexpression for S100B, and 59% for MIA proteins. Furthermore, 16.21% of the patients in stage III and 40.90% in stage IV had both markers positive. At least one of these markers was positive in 66.21% of stage III and 81.80% of stage IV patients. In conclusion, both S100B and MIA proteins are involved in tumor progression. Their use in clinical practice, independently or in combination, could lead to a better strategy in patients’ selection and treatment decision.

Prostate biopsy – arbitrary impediment in the treatment of prostate cancer

Sorin Bulgariu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

The protocols adopted by the multidisciplinary commissions for cancer (tumor boards) require that the clinical discovery of prostate cancer be followed by biological diagnostic (PSA) and imaging support. The diagnostic certainty is ensured by the prostate biopsy, the only procedure legally succeeded by other decided procedures, such as surgical, oncological, radiotherapeutic etc. The urology outpatient cabinet of the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, unfortunately faced unforeseen and uncomfortable situations, apparently unsolvable, for the following reasons: in the territorial hospital units of the remote area, clinical and biological detections are made, but for various reasons, not prostatic biopsy as well, a manoeuvre that involves costs and even hospitalization sometimes. The motivations invoked by the patients’ senders directly to the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology vary from the lack of specialized technique to the lack of hospital beds. Although these motivations reveal quite often the clear lack of interest, the need to escape of an unrewarded or unproductive effort, as well as the desire to transfer responsibilities elsewhere, the possibilities to counteract these tricks are minimal. It is known that, in the absence of biopsy, oncologists and radiotherapists cannot take any measures dedicated to the cure of the disease. Under the given conditions, a hiatus is created between establishing the probability diagnosis and the certainty diagnosis, without which it is impossible to provide effective help to the patient. The purpose of this presentation is not to verify the sincerity and probity of the senders in the territory, but to find a solution for the continuity of investigations and, hence, to apply the treatment without undue delay.

“Remodeling” in radiotherapy

I.C. Chiricuţă

Amethyst Radiotherapy Center, Otopeni, Ilfov County, Romania

The processes of “remodeling” are known since time immemorial. In many medical fields, we need to un­der­stand them and make remodeling possible. Any scar at any level is not a reshaping, but just a failure. The appearance of therapeutic guidelines aims at per­for­­ming an individualized treatment according to the stage of the disease, offering maximum therapeutic suc­cess. Guidelines – no matter how they are called: NCCN, ASTRO, ESTRO, ESMO etc. – do not offer a gua­ran­tee regarding healing. Medicine and its im­ple­men­ta­tion, regardless of the existing guidelines, also re­quire something extra defined as “professional ex­pe­rience”, that you don’t really find in the guides. In the Google era, it is not enough to consult online the guide and the conduct established there, but it also requires a correct interpretation, adapted to each pa­tient, defined too simply as “individualization”. It should be mentioned here that 30-40% of patients are not treated according to the guidelines (unfortunately); the causes are multiple. The application of the guide must be learned, interpreted and practiced during the intern­ship. Google does not replace a teacher or an ex­cep­tio­nal clinic. I wonder how many young people be­­come “specialists” without ever having performed a single treatment! Maybe in radiotherapy it is more com­mon than in other specialties. It would be good if my opinion was totally wrong. Specialists must also have the capacity for personal remodeling, so necessary for progress. In my presentation, there will be shown the results of radiotherapy applied to various cases in which remodeling is of highest importance. Remodeling is the basis of quality of life. A healing without a good qua­­­li­ty of life is not desired by the patient. The quality of life is today a parameter of utmost importance for the patient and the attending physician. The ra­dio­the­­rapy of the future will be a local cure without the side effects, which today limit the healing itself. The pro­­gress through the FLASH radiotherapy method is a fast one, and the healing is expected in 1-3 sessions, with­­out side effects. Reirradiation is possible in case of failure due to other methods, but even as a requirement fol­lowing radiotherapy failure.

Complete pulmonary parenchyma sparing resection for bronchus intermedius carcinoid tumor

Adrian Ciuche, Camelia Găvan, Claudiu-Eduard Nistor

“Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania

Objectives. We present the case of a patient who underwent a segmental resection of the bronchial tree without resection of lung parenchyma, called “triple sleeve bronchial resection”, for a typical carcinoid tumor of the bronchus intermedius. Method. We made a triple bronchial resection of the main axis of the right bronchial tree (right main bronchus, right upper lobe bronchus and bronchus intermedius) with edge-to-edge triple bronchial anastomosis. Results. The evolution was favourable, with the complete expansion of the pulmonary parenchyma without air leaks or atelectasis. An emergency appendicectomy was made in the third postoperative day for an acute appendicitis. This intervention was made under general anaesthesia with endotracheal intubation, without any complications, even at the bronchial anastomosis level, with fast recovery of the patient. Conclusions. This is an effective and safe technique for selected patients with benign or low-grade malignant bronchial tumors when performed carefully by an experienced surgeon. Although it may have an increased risk of complications compared to a standard sleeve resection, the main advantage is preserving the entirely healthy lung parenchyma, avoiding bilobectomy or even pneumonectomy. 

Metastatic colorectal cancer – from conventional to individualized treatments

Adina Croitoru1,2, Ioana Dinu1, Monica Miron1, Ioana Luca1, Iulia Gramaticu1, Florina Buica1,2, Mihai Vlad Croitoru3, Irina Cazacu4, Diana Bogdan3, Cătălin Guiu1

1. Fundeni Clinical Institute, Bucharest, Romania
2. Faculty of Medicine, “Titu Maiorescu” University, Bucharest, Romania
3. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
4. Filantropia Municipal Clinical Hospital of Craiova, Romania

Colorectal cancer (CRC) is one of the most lethal and frequent malignancies worldwide, being responsible for 881,000 deaths in 2018. Surgery and chemotherapy are the first therapies of choice especially in metastatic CRC (mCRC), but with an unsatisfactory response. Individualized therapy represents a new approach that succesfully prolonged the overall survival of the CRC patients. As a result of the benefits obtained with anti-EGFR treatments (cetuximab, panitumumab) and with anti-VEGF therapies (bevacizumab, aflibercept), new agents that block other carcinogenesis pathways, such as immune control points, appear in an unprecedent rhythm. The actual chemotherapy includes fluoro­py­ri­mi­dine, oxaliplatin and irinotecan. Although studies have claimed that the first-line therapy with a single agent is not inferiour to combined regimens such as FOLFOX, FOLFIRI, CAPOX and CAPIRI regarding the overall survival, the latter one remains the main the­ra­py approach in the first line. Chemotherapy is as­so­ciated with systemic toxicity, with unsatisfactory res­ponse rates, with inborn and acquired resistance, and with low tumor selectivity. The first targeted drug for the treatment of mCRC, approved by FDA, was cetuximab, in 2004, followed by bevacizumab in the same year. Other agents target different stages of carcinogenesis: the initiation, promotion and pro­gres­­sion on different pathways, such as Wnt/β-catenin path­way, Notch pathway, Hedgehog and TGF-β/SMAD path­way, along with the pathway that activates the sig­na­ling cascade, such as phosphatidylinositol 3-kinase (PI3K)/AKT or RAS/RAF. Both anti-EGFR and anti­an­gio­genic therapies demonstrated decent benefits in mCRC; however, what is to be preferred in the first line was an issue of intense debate. The CRC subtypes clas­si­fication according to the molecular consensus that takes into account both the histopathology and the gene expression involved in the immune or inflamatory response divides colorectal cancer into four groups: CMS1 – immune; CMS2 – canonical; CMS3 – metabolic; CMS4 – mesenchymal. This classification could have a prognostic role and could help guiding the development of new therapies.

The experience of a Romanian oncology department with bevacizumab (Bev) in the treatment of metastatic colorectal cancer

Ioana Dinu1, Iulia Gramaticu1, Ioana Luca1, Florina Buica1, Monica Miron1, Vlad Croitoru2, Irina Cazacu3, Diana Bogdan2, Sorin Alexandrescu1, Doina Hrehoreţ1, Mirela Boroş1, Ioana Lupescu1, Simona Dima1, Irinel Popescu1, Liana Gheorghe1, Mircea Diculescu1, Vlad Herlea1, Gabriel Becheanu1, Mona Dumbravă1, Adina Croitoru1

1. Fundeni Clinical Institute, Bucharest, Romania
2. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
3. Filantropia Municipal Clinical Hospital of Craiova, Romania

Background. Bevacizumab (Bev) is approved in Europe and USA in combination with chemotherapy (CTH) based on fluoropirimidine (FP) in the treatment of adult patients with metastatic colorectal cancer (mCRC) in the first line of therapy, as maintenance treatment, postprogression, and in the second line of therapy. It was performed a retrospective analysis on mCRC patients treated with CTH + Bev in succesive lines in the Medical Oncology Department of the Fundeni Clinical Institute, Bucharest. Method. We collected demografic and clinical data: the disease stage at diagnosis, histopathology data, duration and CTH line, grade 3/4 adverse events, response rate (RR), progression-free survival (PFS), and overall survival (OS). Between August 2007 and December 2018 there had been treated with Bev 516 patients. At 3-6 months from the diagnosis, 384 patients (67.4%) presented synchronous metastases and 168 patients (32.6%) presented metachronous metastases. Results. A total of 358 patients (69.2%) received Bev in the first line of the treatment, of which 260 patients (72.6%) received FP + oxaliplatin (OX): FOLFOX/CAPOX, and 86 patients (24%) received FP + irinotecan(IRI): FOLFIRI/CAPIRI. Four patients received FOLFOXIRI in the first line, and eight patients received only FP. As maintenance therapy, it was administered Bev/Bev+FP in 88 patients (79.3%) in the OX group and in 20 patients (18%) in the IRI group. A total of 128 patients (35.8%) received Bev beyond progression, of which 99 patients (79.8%) in the OX group and 22 patients (17.7%) in the IRI group; 137 patients (38.3%) received subsequent therapy lines after Bev failure. The medium chemotherapy duration for patients who received OX was 9.9 months (95% CI; 8.67-11.18), and 9.2 months (95% CI; 6.72-11.62) for those who received IRI. A total of 219 patients presented a therapy response, with a RR of 75.34% on OX, and a RR of 24.65% on IRI. The median PFS was 8.12 months (95% CI; 6.89-9.35) for OX and 8.35 months (95% CI; 6.6-10.1) for IRI, with p=0.034. The median OS was 17.03 months (95% CI; 14.66-19.40) for OX and 18.87 months (95% CI; 15.28-22.46) for IRI, with p=0.900. Conclusions. In our experience, Bev-OX had a similar efficacy as Bev-IRI regarding both PFS and OS, but with a higher response rate for those treated with OX.

Clinical bioinformatics. Part I: Biological databases

Iolanda Dumitrescu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

With the advent of technological advances, such as high-throughput technologies developed for each molecular type present in the cell, data size and flow are rapidly increasing in cancer research. The requests on data processing are huge in terms of computational power, data storage and data flow. Bioinformatics is seen as an interface between the biomedical research and genomics, proteomics, transcriptomics and other related omics approaches. Computers and software are involved in storage, retrieval, manipulation and distribution of information related to biological macromolecules. The development of computational tools and databases help in the application of these tools and databases in generating biological knowledge. The goal of a biological database is represented by in­for­mation retrieval and knowledge discovery. Based on their contents, the biological databases are divided into primary, secondary and specialized data­bases, warehousing raw data without or with com­pu­ta­tio­nally processed and/or manually curated information. Starting from metadatabases, we came on nucleic acid databases (DNA, RNA, gene expression), amino acid/protein databases (structure, sequence, expression), metabolic pathway and protein function databases. Data in biological databases are prone to errors: sequence errors, annotation errors, redundancy pro­blems, but an international effort focuses on cor­rect some of them. The informatics requirements of multi-institutional translational research projects are characterized by the need to securely share and ac­cess data and analytical resources hosted at different sites. Thus, the Electronic Authentication Guideline has defined four levels of authentication in terms of the consequences of the authentication errors and misuse of credentials. Biological data mining requests com­pli­cated technical and computational tools. An incursion in this area may ease to understand their optimal use in modern-day biomedical research.

Clinical bioinformatics. Part II: A software-aided approach

Iolanda Dumitrescu 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Biocomputing tool development is at the basis of all bioinformatics analysis. It means writing software for sequence, structural, functional analysis, the con­struc­tion and management of biological databases. Sequence comparison is becoming of great importance to get functional and evolutionary inference of a new sequence with sequences already existing in biological data­bases. Pairwise sequence alignment is to find the optimum pairing of two sequences, so that there should be the best correspondence among residues. The existing alignment algorithms, based either on a glo­bal or a local strategy, differ only in the optimization stra­te­gy used in aligning similar residues. In retrieving bio­lo­gical sequences in databases based on similarity, ex­hau­stive algorithms lead to a best or exact solution by exa­mining all mathematical combinations, but they are computationally very intensive. Heuristic al­go­rithms are rather a computational strategy to find an em­pi­rical or near optimal solution in a realistic time frame. In multiple sequence alignment, sequences are aligned so that a maximum number of residues from each sequence are matched up according to a par­ti­cu­lar scoring function. Exhaustive approaches in­volve exa­mi­ning all possible aligned positions si­mul­tan­e­ously, but at the expense of computational time and memory space required. To alleviate that, heu­ris­tic approaches have been developed: progressive align­ment, iterative align­ment, block-based alignment. Using bioinformatics soft­ware it is necessary to make a compromise between ac­curacy and computational fea­si­bility. Accurate results can be obtained if one draws a consensus by comparing the output from dif­ferent programs implementing al­go­rithms that sa­tis­fy the computational conditions. The ap­plication of bio­in­formatics in cancer research is still in an early stage; it has already become an obligatory tech­nology to assist and improve the development of cancer therapy in the post-genomic era. 

News and perspectives in optimizing CTC isolation methods – challenges versus reality in laboratory

Daniela Frăţilă 

CSIII, “Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Circulating tumor cells (CTCs) derive from the primary tumor and appears early in the process of hematogenous metastasis, being a predictive marker in the early detection of recurrences, with an essential role in initiating and monitoring the therapeutic response. Recent experimental investigations have shown that, although deformed in the capillary system, over 80% of CTCs retain their membrane integrity, survive and manage to extravasate, but only a minor subset of CTCs form micrometastases, an even smaller percentage form macroscopic tumors, and about 30% of the injected cells remain as hibernating solitary cells (“dormant cells”). The role of immune system (IS) in controlling tumor growth is proven by experimental research which has shown that immune response (IR) is mediated primarily by cytotoxic CD8 T lymphocytes that induce cytolysis of tumor cells, with the exception of CTCs that are kept in clinical hibernation by IS, thus preventing the expansion of proliferating tumor cells. The marked heterogeneity of CTCs is also the motivation for therapeutic resistance to standard chemo- and radiotherapy treatment.

Neoadjuvant treatment in triple-negative breast cancer

Laurenţia Galeş, Xenia Bacinschi, Oana Trifănescu, Luiza Şerbănescu, Rodica Anghel 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Triple-negative breast cancer (TNBC) is a form of breast cancer which is ER negative, PgR negative and HER2 negative. TNBC accounts for 10% to 20% of all breast carcinomas and is more commonly diagnosed in women younger than 40 years of age, being significantly more aggressive and having a poorer prognosis than other molecular subtype tumors. TNBC is still a very heterogeneous population of tumors and it was classified in at least six subtypes: basal-like type 1, basal-like type 2, immunomodulatory type, mesenchymal-like, mesenchymal stem-like and luminal/apocrine (androgen receptor positive) type. Compared with other breast cancer forms, TNBC has a shorter disease-free interval and a higher incidence of visceral and central nervous system (CNS) metastases. Historically, given the absence of targeted therapy, the mainstay of treatment has been chemotherapy. The largest worldwide meta-analysis of patients treated in prospective randomized trials with neoadjuvant chemotherapy (NACT), published by P. Cortazar et al. in Lancet in 2014, demonstrated an excellent correlation of pathologic complete respone (pCR) with disease-free survival (DFS) and overall survival (OS), especially in patients who had triple-negative or HER2-positive tumors. The St. Gallen Consensus Meeting panelists opted in the year 2017, and in 2019 again, with a large majority for NACT in patients with triple-negative tumors. The clinical re­search is focused on two main axes in the neoadjuvant set­ting: how to increase pCR and how to improve out­comes in patients with residual disease. The rate of pCR after anthracycline- and taxane-based neoadjuvant che­mo­therapy is higher in TNBC (±30%) than in luminal breast cancer. In addition, patients presenting pCR after neoadjuvant chemotherapy generally have a bet­ter prognosis compared to patients who do not pre­sent pCR at the time of surgery. Unfortunately, pa­tients suffering from TNBC who present residual di­sease after neoadjuvant chemotherapy have very poor out­comes. New therapies should be evaluated in pa­tients who present residual disease after neoadjuvant chemotherapy. The retrospective research has suggested improved outcomes in terms of pCR when cisplatin was added to the neoadjuvant treatment. INFORM study was designed to determine if the pCR rate with cisplatin would be higher than with AC as neoadjuvant therapy in newly diagnosed HER2-negative breast cancer patients with gBRCA mutations. The rates of pCR and RCB 0/1 were not higher with cisplatin versus AC in patients with early-stage breast cancer and germline BRCA mutations in both TNBC and ER+/HER2- disease. BRCA mutation in breast cancer may be a biomarker for sensitivity to DNA-damaging chemotherapy rather than specifically pla­tinum agents. In the latest years, TNBC has become a candidate for immunotherapy, because it has a higher ex­pression of PD-L1 than in HR+ breast cancers, a higher level of TILs is reported in TNBCs, and TNBC is characterized by genomic instability and high rates of genetic mutations, which implicate the production of more neoantigens and increased immunogenicity. KEYNOTE 522 study showed that, in patients with early-stage TNBC, neoadjuvant pembrolizumab + che­mo­the­rapy was associated with a larger pCR benefit versus chemotherapy alone, particularly for patients with stage III or node-positive disease. The benefit was also seen in patients who received less than the planned full chemotherapy. A similar benefit was observed regardless of PD-L1 expression level. On the other hand, in NEOTRIPAPDL1 study, no significant increase in pCR rate was observed with the addition of atezolizumab to carboplatin/nab-paclitaxel in women with TNBC. In a multivariate analysis, PD-L1 expression significantly influenced the pCR rate (OR 2.08; p<0.0001). EFS data are waiting for both molecules in neoadjuvant setting. New targeted treatments and immunotherapeutic drugs are under development. The challenge is to drive studies on more selected patient populations due to the importance of heterogeneity in TNBC. The most promising new approaches include immunotherapy with checkpoint inhibitors, PARP inhibitors and AR inhibitors. 

Soluble biomarkers associated with the processes of cell proliferation and angiogenesis in the breast cancer cell line MCF-7

Daniela Glăvan¹, Maria Iuliana Gruia¹, Camelia Mia Hotnog², Mirela Mihăilă², Lorelei Irina Braşoveanu² 

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. Center of Immunology, “Ştefan S. Nicolau” Institute of Virology, Bucharest, Romania

The aim of our study was to develop an in vitro, hu­man experimental model, used in modulation ex­pe­ri­­ments with treatments in which cytostatics and/or bio­logically active compounds were used, following the expression of soluble biomarkers associated with tumor proliferation processes and angiogenesis. As an experimental model, we used the MCF-7 breast can­­cer cell line, on which we applied treatments with cy­­clo­­phos­­pha­mi­de, epirubicin, avastin and some fla­vo­no­ids like resveratrol, quercetin and curcumin. We evaluated the expression of soluble biomarkers (VEGF, MMP-2, TIMP-1, cathepsin D, sialic acid) as­so­­cia­ted with the processes of cell proliferation and an­­gio­­genesis in breast cancer, which could be used in the cancer clinic to improve diagnostic procedures and prognosis, highlighting the risk of metastasis, and monitoring treatment. Cytotoxicity tests by the MTS or RTCA method indicated that epirubicin and cy­clo­phosphamide treatments caused an increase in cell lysis percentages and thus a decrease in cell via­bi­li­ty. The analysis of the data obtained in case of mo­du­la­ting the release of VEGF in the supernatants of the MCF-7 line treated with cytostatics and bio­com­­po­­sites showed that the combined treatment of cyto­statics (epirubicin + cyclophosphamide), prolonged up to 48-72 hours, determined the decrease of VEGF levels. The present study showed that quercetin, ad­mi­nis­tered before or after cytostatics, has the effect of decreasing the concentration of VEGF, with the pro­lon­gation of treatments at 72 hours, thus decreasing the angiogenesis. In case of resveratrol, the accentuated decrease in VEGF level occurs when the biocomposite is administered 24 hours before cytostatics. The analysis of the data obtained in case of modulating the release of MMP-2 in the supernatants of the MCF-7 line treated with cytostatics and biocomposites showed that the 24-hour treatment with all three biocompounds studied decreased the levels of this proteinase, the same effect being noticed in cytostatics at 48 hours and 72 hours. The analysis of the data obtained in case of modulating the release of TIMP-1 in MCF-7 supernatants treated with cytostatics and biocomposites showed that the 48-72-hour treatments with resveratrol and curcumin caused the decreased levels of this molecule, the same effect being generally observed in combined treatments with cytostatics and biocomposites, especially for 72 hours. In case of quercetin, it seems that the maximum effect is obtained at the combined treatment in which the biocompound is added after cytostatics, except for the time of 72 hours. The combined treatments cause a decrease in both cathepsin D and sialic acid in the supernatants of the treated cells for a longer period, of 48-72 hours. As in case of cathepsin D, the sequential treatments with epirubicin + cyclophosphamide (24 hours) and avastin (24 or 48 hours) determine the decrease of sialic acid levels compared to avastin (48 hours) or epirubicin + cyclophosphamide (48 hours). The combinations of cytostatics and biocompounds are more effective with increasing treatment time, the best effect being obtained at 72 hours. There is a significant direct correlation between cathepsin D and sialic acid levels (p<0.001). The sequential treatment, with cytostatics and biocompounds, generally causes a decrease in the level of proliferation and angiogenesis biomarkers, especially for the 48- and 72-hour periods, compared to single treatments, but it depends on the biocompound and the time of administration (before or after cytostatics). 

Neoplastic complications after colon cancer surgery

Antoaneta-Sorina Ilie1, Teodor-Gabriel Magdici1, Laurenţiu Simion1,2 

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

A major public health issue, colon cancer can only be­ne­fit from surgery as a form of curative treatment, and this only if diagnosed relatively early. Even in those hap­py cases where the patient undergoes surgery at the right time, there are no guarantees for a good outcome from an oncological point of view, both on medium and long term. This paper is looking to evaluate especially those neoplastic complications that may arise in these pa­tients. This retrospective, single-centre study included 138 patients with colon cancer who have undergone sur­ge­ry in the First Surgical Department of the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, over the course of two years, between Ja­nua­ry 2015 and December 2016. This study included only those patients confirmed with colon cancer through a histopathological exam, with an initial localization of the tumor strictly in the colon and where curative sur­gi­cal treatment was possible. Those patients in which tu­mors were localized in the rectum as well, along with those not having undergone surgery or where data were in­com­plete had been excluded from our study. Out of the 138 patients included in this study, 45 presented neo­plas­tic complications after an interval of time, varia­ble in length, since the initial surgery. For all those pa­tients included in the study, the following criteria were eva­lua­ted: sex, age, symptoms at the onset of the di­sease, localization of the tumor, complications at the on­set, type of surgical intervention, adjuvant therapy, type of neoplastic complications, their diagnosis and ma­nage­ment. This study’s findings are consistent with the available data regarding colon cancer, its evolution and the evolution of complications. In the majority of cases, the surgical interventions had a curative goal from an oncological point of view, as later confirmed through histopathological examinations of the resected spe­ci­mens. The incidence rate after colon cancer surgery was 46.9%, including both local recurrences, locoregional recur­rences, adenopathic blocks or metastases, as well as meta­chro­nous cancer or a second, extracolonic, cancer. The management of neoplastic complications has, at most times, consisted of adapted surgical resections (77.77%) and adjuvant therapy. Our study confirms the rather high incidence rate of neoplastic complications after radical colon cancer surgery and underlines the importance of postoperative follow-ups of patients through colonoscopy, medical imaging techniques and monitoring of tumor markers. As previously shown in other studies, we consider that this monitoring pro­gramme is mandatory especially in the first two years after surgery, the time interval when most neoplastic com­pli­ca­tions may arise. We consider that the future studies should focus on discovering certain specific markers that could allow identifying a subset of patients who could benefit from more intense postoperative follow-ups, as well as finding certain biological markers that could allow the early identification of recurrences, in potentially curable stages.

Management of intestinal occlusion in ovarian cancer

Alina-Florina Jianu1, Teodor-Gabriel Magdici1, Laurenţiu Simion1,2

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

As well as being known as one of the deadliest gynae­co­logical diseases, ovarian cancer is frequently dis­co­vered in advanced stages, the patients already pre­sen­ting peritoneal metastases when diagnosed. In­tes­tinal occlusion may occur at any moment during the evolution of the disease, but is being met more frequen­tly in the advanced stages of the disease, when it can lead to patient’s death. This study aims to review the treat­ment options of intestinal occlusion in ovarian can­cer patients. This retrospective, single-centre study in­clu­ded 240 patients diagnosed with ovarian cancer, trea­ted in the First Surgical Department of the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, between January 2015 and December 2017. A series of parameters were analyzed, such as age, pathological type, grade of differentiation, tumor di­men­sions, localization of metastases, number of epi­sodes of intestinal occlusions during the evolution of the disease, therapeutic modalities etc. Out of the 240 patients included in the study, 32 presented with in­tes­tinal occlusion during the evolution of the disease, out of which only two patients were under the age of 40 years old. One third of the pa­tients presented with in­tes­tinal involvement at the mo­ment of diagnosis. Re­gar­ding the number of episodes of in­tes­tinal occlusion du­ring the evolution, 24 out of the 32 patients had a single episode. The optimal therapeutic ap­proach is the surgical treatment, but this was possible only in 73% of cases. Nevertheless, surgical interventions were not seeking a curative goal and were accompanied by com­plex measures of palliative care. In the 32 patients in­­clu­ded in the study, we have found a total of 41 epi­sodes of intestinal occlusion, identified and treated at the “Prof. Dr. Alexandru Trestioreanu” Institute of On­co­­lo­gy, out of which 30 episodes benefited from sur­gi­cal treat­ment. While still being, unfortunately, dis­co­vered late, ovarian cancer is mostly diagnosed du­ring the stage of complications, intestinal occlusion being fairly frequent and life-threatening. The available the­ra­peu­tic approaches are centred on the management of symp­toms and on ensuring a quality of life as high as pos­sible for the time left, the surgical interventions, even pal­liative, being the only option that might prolong sur­vi­val when feasible. 

Cancer stem cells: the real culprits in cancer? Clinical and therapeutic relevance

Isabela Anda Komporaly1, Dana Lucia Stănculeanu1,2 

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

Carcinogenesis is a complex phenomenon which involves a portfolio of genetic, epigenetic, biochemical and histological changes, ultimately leading to the development of pathological manifestations. Despite all the significant advancement in the field of cancer research, the obscurity to understand the real mechanism of cancer development is still there. Tu­mors of various tissues initiate and harbor from a re­la­tively small population of cells known as cancer stem cells (CSCs), which are the main oncogenic dri­ving cells due to their self-renewal ability and po­ten­tial to redevelop entire tumor heterogenicities and, hence, are an important target for the treatment of hu­man malignancies. CSCs are the main cause for can­cer development, metastasis and drug resistance. A number of dysregulated signaling mechanisms, in­clu­ding Notch, Wnt/B-Catenin, JAK/STAT, PI3K/AKT-mTOR etc., responsible for carcinogenesis and poor cli­ni­cal outcomes, have been detected in CSCs. Al­though known, all these mechanisms must be further in­ves­ti­ga­ted, for the moment the outcomes not being sa­tis­fac­tory. Recent developments in cancer research proved the connections between miRNAs and the signalling path­­ways that drive the oncogenic potential of the CSC. Dys­regulated expression and functioning of miRNAs have been considered an important mechanism for CSCs in cancer, as a single miRNA can control the ex­pres­­sion of multiple genes. In this presentation, we are discussing whether the CSCs are the real culprits in carcinogenesis, which are the roles of the signalling path­­ways and of miRNAs in regulating CSCs, and as­so­ciated challenges in the understanding of cancer de­velop­­ment and therapeutics. 


Reconstructive surgery – oral and maxillofacial prosthetic rehabilitation with titanium implants and implantable silicone

Elena Lăţcan

ENT primary physician, PhD, Reconstructive Surgery, Oral and Maxillofacial Prosthetic Rehabilitation, PRAIN Medical Center, Bucharest, Romania

In this paper, the author presents her experience in reconstructive surgery – oral and maxillofacial prosthetic rehabilitation, using silicone and titanium im­plant as fixation method, over a 20-year period (2000-2020), in a study on 701 patients. The elastomer silicone im­plan­table beyond 29 days was invented in 1960 and, to­gether with titanium implants, are the synthetic ma­te­rials very well accepted by the organism. Silicone is used in manufacturing external prostheses (epitheses) and implantable prostheses (endoprostheses), being even used as a heart valve, as it was proven to be a good oxygen transporter. The prosthetic reconstructive sur­ge­ry with titanium implants and implantable silicone is used for replacing different parts of the human body, with high substance loss, which cannot be fixed using con­ven­tional surgical techniques. The titanium implant was invented in 1950 by Prof. Dr. Branemark (Sweden), ha­ving a very high purity (approximately 99.75%), being ini­tially used in orthopedics and stomatology untill 1977, and ever since it was used in the craniofacial pros­thetic reconstructive surgery and of the body, for pros­thesis fixation using Brånemark osseointegration method. The titanium implant is very well tolerated by the human body (even for the entire life), without being toxic or allergic. The osseointegration process is an oxidoreduction process that leads to bone growth ar­round the implant area, after a surgical fixation period of ap­proximately 3-6 months. The silicone implant beyond 29 days (endoprosthesis) is also very well tolerated by the human body, becoming an integral part of the area where it was introduced, rendering an almost normal as­pect, for the rest of the patient’s life, and improving his life quality.

The surgical oncologic patient: needs and informational practices

Octavia-Luciana Madge, Sînziana Ionescu, Claudiu Daha

First Clinic of General and Oncological Surgery, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Introduction. The evolution and general condition of the oncology patients, along with their treatment compliance are strongly influenced by the information provided by doctors or found in different sources. The information regarding the disease itself, the stage, prognosis, the treatment and side effects are taking their toll on the psychological state of the patients. At its turn, an adequate physician-patient communication can help the latter overcome his fear, depression and other feelings which oncology patients experience, from the moment of their diagnosis, but also in the course of their treatment and even thereafter, in the recovery phase. Objective. The goal of this research was to analyze the informational behaviour of the surgical oncology patients and the resources they resort to. Method. This qualitative study was based on semi-structured interviews performed in April-June 2020. The participants were selected from the female patients diagnosed and operated for breast cancer in the First Clinic of General and Oncological Surgery of the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest. Results. The patients, with ages between 36 and 78 years old, have underlined the importance of the information provided by doctors or found in different sources especially in accepting their disease and the treatment to follow, and considered the information from the surgeon who operated them as enough. The participants also looked for information on their own, regarding breast cancer, its treatment, and the diet to follow. The main information resources they accessed were represented by the internet, other doctors, books and other patients. As information source, their attending physician ranked first regarding trust level. The informational needs concerned especially the new treatments, the steps to follow, the prognosis and the diet. Conclusions. Knowing the informational needs and practices of the oncology patients is important for the medical team, and the data provided by this study can contribute to the improvement of the surgeon-patient interaction. 

Multidisciplinary management of pulmonary nodules

Veronica Manolache1,2, Natalia Motaş1,2, Mihnea Davidescu1,2, Vasile Cristian1, Ovidiu Rus1, Corina Bluoss1, Elena Jianu1,2, Vlad Alexe1, Mădălina Iliescu1, Teodor Horvat1,2 

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

Objectives. Discovered usually as an incidental finding or as part of the screening of the neoplastic patient, the pulmonary nodule seems to remain a frequent cause for debate. Is biopsy always suited, or the follow-up and the later resection are the better option? The authors present the diagnostic and treatment procedures regarding pulmonary nodules involving a multidisciplinary team, and they establish what method is best suited for each case. Method. The ideal path in diagnosing and treating a pulmonary nodule is through a method as less invasive as possible, with maximal results. More often, lately, minimally invasive surgery has become the preferred technique by surgeons and patients alike. Given that most nodules are small in size and sometimes difficult to locate during VATS surgery, we are faced with challenges that we overcome by a multidisciplinary approach. We evaluated specific cases of pulmonary nodules and how they were managed from diagnostic to treatment. Aside from the oncologist and pathologist, there is a key role in the thoracic surgery team for the interventional radiologist. Once the decision for resection is made, marking the pulmonary nodule prior to surgery is an excellent method for faster and precise localization during minimally invasive surgery. Results. When pulmonary nodules were followed-up, diagnosed and treated in a multidisciplinary team, the precision of histologic diagnostic was achieved faster and the surgical treatment was successful. Conclusions. Pulmonary nodules are best addressed in a multidisciplinary team, starting early in the diagnostic procedures, and the treatment and management should be individualized, since “one size does not fit all”. 

Therapeutic sequencing in the treatment of BRAF-mutated malignant melanoma: targeted therapy versus immunotherapy – case presentation

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

Metastatic melanoma is the most aggressive and obstinate type of skin cancer, with poor prognosis. The recent developments in BRAF-targeted therapy and checkpoint inhibitor immunotherapies for metastatic melanoma patients have led to better tolerability, higher objective response rates, and longer survival. Treatment planning has become complex in patients with metastatic BRAF-mutant melanoma: clinicians must weigh various patient factors, including the extent of disease and central nervous system involvement, as well as factors related to the therapeutic agent, such as the rate of clinical response, the durability of response, and the impact on median- and long-term survival. Although targeted therapies generated remarkable and rapid clinical responses in the majority of patients, acquired resistance was developed promptly within months, leading to tumor relapse. By contrast, immunotherapies elicited long-term tumor regression, but the overall response rate was limited. However, pending the results of clinical trials, not only is it currently unclear whether immune checkpoint-inhibitors or targeted therapy should be started up front, but the optimal time for changing treatment, specifically to prevent resistance whilst maintaining disease control, is unknown. In view of the above, we discuss a clinical case of BRAF-mutated melanoma and how can we navigate the treatment decisions for this type of patients. 

Interdisciplinarity and excellence – lung resections by video-assisted thoracic surgery (VATS)

Natalia Motaş1, Veronica Manolache1, Mădălina Iliescu1, Vlad Alexe1, Sorela Rădoi2, Dayana Nechita2, Costina Diaconu2, Cristian Vasile3, Ariana Neicu4, Cristina Guti4, Teodor Horvat1

1. Department of Thoracic Surgery, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. Department of Anesthesiology and Intensive Care Unit, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
3. Department of Radiology, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
4. Department of Pathology, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Objectives. Thoracic oncology patients are being offered minimally invasive thoracic surgery in our institute. Method. More than two years of video-assisted thoracic surgery (VATS) lung resections are presented and exemplified. Results. Every patient operated by VATS represented a challenge and required a teamwork, together with our colleagues from anes­thesiology and intensive care unit, radiology, path­o­logy, medical oncology, radiotherapy, and so on. Conclusions. Pulmonary resections by video-assisted thoracic surgery are a good example of an excellent in­ter­disciplinary teamwork.

Primitive malignant tumor with rare localization – breef review and case presentation

Claudiu-Eduard Nistor, Camelia Găvan, Adrian Ciuche

“Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania

Introduction. Primary cardiac tumors are rare ca­ses, and most of them are benign. Cardiac sarcomas are, however, clinically aggressive, clinically high-grade neo­plasms with an unfavorable prognosis, and they re­pre­sent 10-20% of all cardiac neoplasms. Depending on the location of the heart, they may present with a va­rie­ty of cardiopulmonary symptoms, such as left or right heart failure, respiratory failure, embolism phe­no­me­na or cardiac disorders. The most frequently used ima­ging investigations in diagnosing these tumors are: CT, MRI, cardiac ultrasound, transesophageal ul­tra­sound, and other methods. The diagnosis of cer­tain­ty is established by histopathological and im­mu­no­his­to­che­mical examination from biological samples obtained by biopsy. The therapeutic attitude is determined ac­cording to the location, tumor size and the degree of locoregional tumor invasion. Tumor resection can some­times be curative, when tumors are detected in an early stage of evolution. Other treatment options are chemotherapy, immunotherapy and radiotherapy. Case summary. A 65-year-old patient, sent from another hos­pi­tal service, presented with the suspicion of a left lung tumor with pulmonary metastases, respiratory fai­lure, heart failure, post-radiochemistry status for bi­la­te­ral breast cancer operated. The thoracic computed to­mo­graphy performed at admission identified bilateral pul­mo­nary disseminated nodular lesions, and the heart with suspicion of intraventricular tumor. Cardiac MRI sug­gested the diagnosis of right ventricular tumor for­ma­tion, left ventricular and apical. In order to establish the diagnosis of certainty, tumor biopsy was performed by transthoracic cardiac puncture, guided by ul­tra­sound in the operating block of cardiac surgery. His­to­pa­tho­logical examination – cardiac sarcoma. Im­mu­no­histochemical examination – intimate cardiac sar­co­ma with MDM2 positive, ki-67 80%. The patient died three weeks after discharge, after the personalized diag­no­sis, without the benefit of oncological treatment. Dis­cussion. Cardiac tumors are often identified du­ring investigations for other conditions, since the symp­to­ma­tology is nonspecific, requiring a high degree of sus­pi­cion for diagnosis. Custom treatment includes sur­gical treatment, chemotherapy, radiotherapy and im­munotherapy. 

Application of nanomedicine in lung cancer

Claudiu-Eduard Nistor, Adrian Ciuche, Camelia Găvan

“Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania

Introduction. Lung cancer is a major issue in on­co­lo­gy pathology worldwide, being the leading cause of death worldwide, according to the World Health Or­ga­ni­za­tion. In this context, the research has focused on using nanotechnology for personalized fast diagnosis and treatment with nanoparticles. Nanosensors for mo­le­cular diagnosis and nanoparticles for treatment and ima­ging sightings continue to have a progressive impact on how tumors are diagnosed and treated. The unique phy­si­co­chemical properties of nanoscale materials allow access to a set of diverse molecular tools that can be manipulated for use in respiratory oncology pathology. Method. Nanotechnology for the rapid detection of tumor markers of lung cancer is achieved by using nanobiosensors – electrochemical, optical, stochastic and piezoelectric, which analyze biological fluids. Targeted imaging diagnosis based on nanoparticles is being used more and more frequently. The personalized diagnosis obtained by detection on nanosensors is verified by immunohistochemical exa­mi­na­tion. Nanotechnology for the treatment is represented by nanoparticles with the administration system that in­cludes liposomal nanoparticles, polymer nanoparticles, me­tal nanoparticles and bio-nanoparticles. Based on per­so­nalized diagnosis, custom nanotreatment schemes are being created. Conclusions. Custom nanodiagnosis and personalized treatment of lung cancer are based on evi­dence, an individualized prescription that guarantees the right treatment at the right time. Therapeutic nano­particles are used for the delivery of targeted therapeutic agents and targeted imaging assessments using a nanotechnology-based delivery platform.

Evaluation of new 68Ga derivatives as potential radiopharmaceutical agents for PET investigation of malignant tumors

Marieta Elena Panait1, Antonela Buşcă1, Ana Maria Coman1, Daniela Frăţilă1, Radu Fumărel1, Gina Manda2, Maria-Iuliana Gruia1, Dana Niculae3

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. “Victor Babeş” National Institute of Research Development in the Pathology Domain and Biomedical Sciences, Bucharest, Romania
3. “Horia Hulubei” National Institute for Research and Development in Physics and Nuclear Engineering, Măgurele, Ilfov County, Romania

The purpose of the present study was to evaluate in vitro and in vivo the potential biological effects of various 68Ga labeled peptide derivatives, in order to use them as radiopharmaceutical agents in positron emission tomography (PET) imaging of malignant tumors. For the in vitro experiments there were used the following human cancer cell lines: glioblastoma (U87MG) and colon carcinoma (HT-29), and murine cancer cell lines – malignant melanoma (B16F10) and pancreatic carcinoma (AR42J). C57BL/10 mice with B16F10 melanoma were used for in vivo experiments. Peptides with known specificity for the aforementioned malignant cellular receptors were selected, namely: Arg-Gly-Asp (RGD) peptide [integrin alpha (v) beta (3) receptors], somatostatin synthesis analogues [octreotide and octreotate (SST2)] and the glycopeptide Exendin-4 (GLP-1). These were labeled using 68Ga from a commercially obtained 68Ge/68Ga radionuclide generator (925 MBq, ITG, Germany) using different chelators (DOTA, NOTA, NODAGA), the resulting compounds (radiochemical purity >98%; HPLC) being inoculated with cell lines (approximately 37 kBq/ml or 1 μCi/ml), or injected i.v. in tumor-bearing animals (10 MBq; 10 μg). There were investigated the effects of the radiolabeled peptides on cell cycle phases and apoptosis, in correlation with the level of oxidative stress in cell lysates exposed to the radiolabeled com­pounds. The results demonstrate the ability of some 68Ga-labeled peptides to exert significant in­hi­bi­tory effects on human and murine cancer cell lines, con­sis­ting in the induction of apoptosis and cell cycle block­age in correlation with oxidative stress ge­ne­ra­tion. We con­sider that the results will lead to a better un­der­stan­ding of the radiation biology, revealing some of the cellular changes associated with medical imaging pro­ce­dures. This work is also a promising prerequisite for further in vitro and in vivo evaluation of peptide recep­tor radionuclide therapy. 

Analysis of somatic mutations in colorectal cancer using next-generation sequencing

Liliana Puiu, Daniela Murăraşu, Corina Elena Mihalcea

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Colorectal carcinoma (CRC) is one of the most frequen­tly diagnosed cancers worldwide and remains a significant contributor to cancer mortality and mor­bi­dity. Despite the scarcity of molecular biomarkers used in the routine oncological practice, CRC is cha­rac­terized by a plethora of activating mutations that may be of benefit in implementing personalized can­cer care. Next-generation sequencing (NGS) is an im­por­tant step forward in personalized medicine by providing individual’s genetic profile that guides cli­ni­cal decisions. In this study, we performed a mul­ti­gene sequencing screen in order to explore somatic alterations in colorectal patients using the Ion Torrent PGM sequencing platform and the Ion AmpliSeq Cancer Hotspot Panel v2. The NGS data for KRAS, BRAF and TP53 genes were validated by Sanger sequencing. Somatic mutation distribution was estimated according to MSI status. In total, 43 tumor samples and 22 tumor matched normal tissues were analyzed. Around 112 somatic mutations, grouped in 79 genetic variants, were identified. Of these, 63 variant types were reported in public databases, while 17 were new. Somatic mutations were detected in 88.4% (38/43) of CRC patients, affecting 22 genes, most of them associated with CRC. TP53 was the most common mutated gene (62.8%), followed by APC (55.8%), KRAS (44.2%), PIK3CA (18.6%), BRAF (14%), SMAD4 (9.3%), and FBXW7 (7%). The success rate in our validation analysis was 92.3% (48/52). Conflicting va­li­da­ting results were recorded in samples showing less then 10% mutation frequency. Microsatellite stable (MSS) tumors tended to have less mutations com­pared with high microsatellite instability (MSI-H) tu­mors. In conclusion, using the NGS approach we have identified novel and known somatic mutations in colorectal patients. The increased mutation number in MSI-H tumors contributes to the genetic diversity and complexity of CRC. 

The interrelation of biomarkers with a predictive role in the evaluation of breast cancer

Alina Oana Rusu-Moldovan1, Daniela Luminiţa Zob1, Camelia Manuela Mîrza2, Dan Mihu3

1. Third Department of Surgery, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. Discipline of Pathophysiology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3. Second Clinic of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Breast cancer clinically represents a heterogeneous di­sease. Over decades, the integration of prognostic and predictive markers in the treatment decisions has led to a more individualized and optimized therapy. The prognosis describes the risk of disease recurrence and disease-related death after diagnosis without the in­flu­ence of therapy, and the prediction illustrates the probability of efficacy or response of a specific thera­peu­tic measure. The present study evaluated the clinical sig­ni­ficance of Ki-67 index, ER, PGR, cerb-2 and Her2 recep­tors as prognostic markers and predictors of re­cur­rence in different molecular subtypes of breast can­cer. We analyzed the relationship of these receptors with different clinicopathological factors. We have pro­ces­sed samples from 130 patients hospitalized in the Third Surgery Department of the “Prof. Dr. Al. Tres­tio­reanu” Institute of Oncology, Bucharest. The bio­lo­gi­cal samples were taken by breast biopsy punctures or by excision of the tumors, and we analyzed them his­to­pa­tho­logically and immunohistochemically. The im­proved understanding of breast cancer biology and ge­netics together with the utilization of the classical bio­markers and the identification of new markers or profiles are increasingly defining the clinical decisions that are to be made in order to minimize overtreatment, undertreatment and incorrect treatment. 

Diagnostic performance of a multi-biomarker panel for the noninvasive detection of bladder cancer

Adina Elena Stanciu1, Anca Elena Hurduc1, Mădălina Bolovan1, Marcel Stanciu2, Mihaela Mihai3, Robert Stoica3, Ioanel Sinescu3

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

As the incidence of bladder cancer has alarmingly in­creased in the last decade, its early diagnosis is a prio­ri­ty. Non-muscle-invasive bladder cancer (NMIBC) has a 5-year survival rate of over 96%. The survival rate de­­crea­ses to 70% in the case of muscle layer damage and to 35% when the disseminated disease is present. Al­though the number of biomarkers for NMIBC as­ses­sment is high, their actual diagnostic performance is not well known. This study aimed to compare the diag­nos­tic accuracy of voided urine cytology with that of bio­mar­kers with unique characteristics in the detection of NMIBC [bladder tumor-associated antigen (BTA), uri­nary bladder cancer antigen (UBC), tissue polypeptide spe­ci­fic antigen (TPS)] and to report the diagnostic uti­li­ty of their various multivariate combinations. A case-controlled validation study was performed, in which voided urines and venous blood samples from 124 patients were analyzed. The urinary concentrations of BTA, UBC, and the serum concentrations of TPS were assessed by enzyme-linked immunosorbent assay (ELISA). The diagnostic performance of each biomarker and multivariate models were compared using receiver ope­ra­ting characteristic (ROC) curves. Our results in­di­ca­ted that the overall clinical sensitivity of BTA was the high­est of all assays (76.92%), whereas that of voi­ded urine cytology was the smallest one (12.50%). In terms of clinical specificity, BTA and voided urine cyto­logy had the highest specificities (89.79% versus 96.87%), with no sig­ni­ficant differences between them. Our results show that a multi-biomarker panel in­cluding BTA, UBC and TPS with an overall clinical specificity of 100% better as­sesses the primary NMIBC as compared to approaches en­tai­ling just one or two of these biomarkers or routine voi­ded urine cytology, and can markedly improve the ac­curacy of the noninvasive detection of bladder cancer.

Valuable proliferation markers as prognostic and treatment predictive factors

Maria Monica Vasilescu1, Marieta Elena Panait1, Mirela Dumitru1, Maria Iuliana Gruia1, Angelica Cordas1, Mirela Mihăilă2, Marinela Bostan2, Camelia Hotnog2, Lorelei Irina Braşoveanu2

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. Center of Immunology, “Ştefan S. Nicolau” Institute of Virology, Bucharest, Romania 

Establishing the prognosis and the optimal treat­ment of cancer is of great importance in clinical prac­tice. The choice of treatment should ideally be based on predictors of response to treatment, but many of the potential indicators still require clinical va­li­dation. Since cell proliferation plays an important role in determining tumor behavior, markers of cell pro­liferation may be useful for the prediction of prog­nosis and chemotherapy response. Therefore, the present study aims to determine and evaluate, in association with some clinical and histopathological prognostic factors, the nuclear protein Ki-67, widely used for the evaluation of tumor cell proliferation, and topoisomerase II alpha (Topo IIa), also a nuclear protein with similar expression pattern to Ki-67, considered more for its predictive potential value in response to chemotherapy, especially after association with Her2, in order to establish additional biomarkers that might be useful in order to improve treatment decisions and prognosis. However, there are currently no standardised staining techniques and clinically validated cut-off points for Ki-67, as well as for Topo IIa, so by using flow cytometry or immunohistochemistry analysis we determined higher levels of these parameters in poorly differentiated tumors; no association was observed with lymph node status and with patients’ age. Tumors with high Ki-67 index were also associated with an increased expression of Topo IIa. No obvious positive association was observed between Her2/neu protein expression and Topo IIa or Ki-67, but approximately half of Her2-positive tumors overexpress Topo IIa and Ki-67. The determination of chemosensitivity in association with Topo IIα expression showed in tumor cell lines a correlation between the response to doxorubicin (IC50) and the level of protein expression of Topo IIα. Along with Ki-67, Topo IIα may be useful in assessing tumor aggressiveness, being important risk stratification tools, arguing the early application of a more aggressive treatment to the group of patients apparently at low risk. In addition, the increased expressions of these biological markers could be important predictive factors for chemosensitivity.

Sentinel lymph node biopsy in cutaneous malignant melanoma – our experience from 2009-2019

Silviu Voinea1,2, Angela Şandru1, Cristian Bordea1,2, Lăcrămioara Borangic1, Alexandru Blidaru1,2

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

Nowadays, the identification and biopsy of the sentinel lymph node (SLN) have become a standard in the treatment of cutaneous malignant melanoma (CMM). Method. At the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, from 2009 to 2019, at the Second Department of Surgycal Oncology, SLN was performed in 300 cases, including 171 women (57%) and 129 men (43%). The localizations of CMM were: head and neck (16; 5.3%); trunk (148; 49.3%); upper limb (66; 22%), and lower limb (70; 23.3%). Results. The SLN was positive in 56 cases (19%) and the rate of false negative results was 10.94%, with a negative predictive value of 92.19%, and an accuracy of 93.65%. Conclusions. In our experience, SLN is a reliable and reproducible technique for establishing the status of regional lymph nodes in CMM, and today represents the standard of care.

The value of paraaortic lymph nodes sampling in gynecological cancers

Silviu Voinea1,2, Cristian Bordea1,2, Raluca Nicolaescu1, Angela Şandru1, Elena Ichim1, Lăcrămioara Borangic1, Alexandru Blidaru1,2

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

The invasion of paraaortic lymph nodes (PAN) re­pre­sents an important adverse prognostic factor for gynecological malignancies, and for this reason it is important to establish the correct staging of the disease, being also a cause of therapeutic failure. But the role of PAN sampling or lymphadenectomy is still controversial in terms of less beneficial therapeutic options. In patients with cervical cancer, PAN in­vol­vement, alongside pelvic nodes, tumor volume and clinical stage are the most important factors for sur­vival. For endometrial cancer, PAN involvement re­pre­sents stage IIIC TNM clasification, meaning no distant me­ta­stasis, like in other gynecological cancers, and is corelated with the depth of myometrial invasion, the cervical involvement, and the involvement of pelvic nodes. For ovarian and tubal cancers, PAN involvement seems to be underestimated and also represents a less important prognostic factor. In vaginal and vulvar cancers, PAN invasion is very rare and is associated with the concomitant presence of other distant metastases, and sampling is not the routine recomandation. The sentinel lymph node technique appears as the strategy of choice to verify the absence of lymph node involvement and today is part of the treatment strategy for cervical, endometrial and vulvar cancers.

Multiple intestinal metastases of malignant melanoma with severe anemia as a first sign of recurrence

Roxana Zaharia¹, Alina Oana Moldovan¹, Florin Radu¹, Mihaela Vîlcu², Eduard Catrina²

1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. “Dr. I. Cantacuzino” Clinical Hospital, Bucharest, Romania

Malignant melanoma that involves the gastrointestinal tract may be either primary or metastatic. Metastases may be present both at the time of the primary diagnosis or later as the first sign of recurrence. The dissemination in multiple organs is not uncommon. The symptoms often mimic those of other gastrointestinal neoplasms, such as abdominal pain, dysphagia, constipation, small bowel obstruction, perforation with peritonitis, hematemesis, melena or anemia, depending on tumor site. We present a case report on a 62-year-old female patient with a rapid onset of abdominal pain and the appearance of intestinal occlusion, while she was considered for further investigations for severe anemia. The patient was known with left deltoid ulcerated malignant melanoma (Clark III, Breslow 6 mm) excised 14 months before the current presentation. Further on, the patient underwent for identification a biopsy of the sentinel node on left axillary and lateral cervical lymph nodes, continuing with chemotherapy. The actual investigations consist of superior and inferior endoscopy, which revealed a voluminous large bowel tumor with invagination on hepatic angle, confirmed by computed tomography examination. The intraoperative exploration revealed the site of occlusion and the proper inspection detected other small intestinal and mesenteric similar tumors, which led to right extended ileocolectomy and segmental small intestinal resection, with favorable postoperative outcome.