The mobile app “Leul Curajos”, an innovative tool for the psychosocial assessment of hospitalized children with cancer

Katie Rizvi, Laura Răducan

Little People Association Romania
Introduction. Numerous studies support the positive impact of applications and video games in therapeutic intervention on children and adolescents affected by cancer, because this type of interaction provides relevant information in a dynamic manner, and also creates a virtual context in which patients can play different roles and become active in the management of the disease. At the same time, by using these mobile applications, an improvement has been observed on problem solving skills, perception and memory, but also on the ability to communicate with medical staff or to use more effective strategies for coping with the disease(1). Methods. In February 2016, The Little People Association of Romania officially launched the first mobile application specially designed for children aged 6 to 15 who are in active treatment for cancer or registered with a specialist for such a diagnosis. Built on assessment methods that were previously applied and used by psychologists and trained Little People stuff in eight clinic hospitals for seven years, the digital questionnaire from the mobile app evaluates issues like compliance with the treatment, fear of medical procedures, the emotional spectrum, coping mechanisms for difficult situations, hope and positive thinking, identifying perception of one’s own person, detecting the negative thoughts experienced by patients through  hospitalization, knowledge of the human body and plans for the future. In addition to the questionnaire, the mobile app also contains some therapeutic games, as well as the pain scale and mood indicator. Both are helpful for the patient - physician or patient - parent communication and facilitate self-knowledge and self-expression. After completing the evaluation on the existing devices in each of the 9 units where the project is deployed, each patient can download the app on his own device, such as a tablet or phone, with a dedicated username and password provided by our staff. The frequency by which the oncological patients, hospitalized or at home, are using the mobile application, as registered in the back office, is an indicator of the effectiveness of using mobile technology as a therapeutic intervention method. Results. 415 patients, from 9 treatment centres from all over the country, users of the mobile app, were evaluated during the first year from the introduction of the mobile app “Leul Curajos”, some important aspects of the challenges they each pertained to oncology treatment being identified. A significant number of patients believe that invasive medical procedures are the main factors of psycho-emotional discomfort during hospitalization, also pointing the feeling of fear. A significant number of patients identify non-specific steps such as “courage”, “belief”, “treatment” as facilitating the healing process, rather than specific aspects such as chemotherapy, radio­therapy, surgery or other medical interventions reflecting the understanding of the treatment. The frequency of using the mobile app proves the interest of oncological patients for understanding the disease and the need for treatment. By analysing the number of users and the frequency of use of specific therapeutic games within the application, we can see which aspects are addressed by children with the greatest need, the patients being classified according to gender, age, diagnosis and type of therapy received. Games have a therapeutic effect on pain management, body image and self-image,­ emotional changes, and changes in cognitive biases. Conclusions. Qualitative information, gathered directly from oncological paediatric patients and their relatives, outlines a complete picture of the socio-emotional spectrum of children and adolescents affected by cancer, users of the mobile app. The data only available for visualization in back office for the association’s specialists, provided  to medical professionals, lead to a multidisciplinary approach to the oncological paediatric patient, both in terms of treatment and psychosocial aspects. Discussions. The use of mobile technology in therapeutic interaction with oncological paediatric patients is certainly an element of innovation in the support services offered in Romania to this category of beneficiaries. The mobile app “Leul Curajos” gives us the opportunity to easily measure nationwide the needs of children and adolescents affected by cancer and to build the relevant support programs to meet these needs. We want this mobile app and the processed data to be well received and used by onco-paediatric specialists. Data processing will help us see in real time how specific and patient-centred interventions that followed the initial assessment helped changing the behaviour of the children with cancer and lead to better results. 

Statement: Project financed by the Vodafone Romania Foundation through the Mobile for Good Program. 

1. Beale, I.L.,Kato, P.M., Marín-Bowling, V.M., Guthrie, N., Cole, S.W. (2007). Improvement in cancer-related knowledge following use of a psychoeducational video game for adolescents and young adults with cancer. Journal of Adolescent Health, 41, 263-270.

Brachytherapy indications in various cancers

Veronel Ivașc, Raluca Vasile, Florian Iancu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Brachytherapy (or “internal radiotherapy”) is another form of radio­therapy and represents an advanced treatment for oncological diseases, which involves the placement of seeds or radioactive sources in­side or near the tumour, sources that administer a high dose of radia­tion in tumour’s volume and at the same time reduce radiation exposure of healthy tissues. Brachytherapy can be used in several types of cancer, such as: gynaecological cancers, prostate cancer, breast cancer, lung cancer, esophageal cancer, anal tumours, rectal cancer, sarcomas, ENT cancers. LDR brachytherapy (low radiation dose) is usually used for oral cancers, oropharynx and prostate cancer. Permanent brachy­the­rapy involves the placement of small LDR seeds (about the size of a grain of rice) inside the tumour or in the treatment area, leaving them permanently there to slowly decompose. MDR brachytherapy (moderate radiation dose) is characterized by an average rate of delivery, ranging from 2 to 12 Gy, for lungs or breasts. HDR brachytherapy (high radiation dose) is the latest innovation and allows administration of high doses during 2-4 treatment sessions. Possible side effects of brachytherapy: The acute side effects associated with brachytherapy include local ecchymosis, swelling, bleeding, fatigue or discomfort within the implanted region. These usually resolve within a few days of treatment. The safety of the brachytherapy treatment: However, as a precaution, some of the people receiving permanent brachytherapy may be advised that, for a short period of time after treatment, they should not stay close to young children or pregnant women.

Symptoms of colon cancer 

Gina Untescu, Mihaela Rica 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Chemotherapy is obviously a good treatment for oncological conditions, but first of all you need to know the type of cancer that affected your body. If you could recognize early signs and symptoms of colon cancer, you could treat the disease in its early stages. Early symptoms of cancer are not obvious in one-third of colon cancer patients. Signs of this condition are easy to understand and discover if you are informed about some details of the symptoms associated with colon cancer. Colon cancer affects the digestive system. Bleeding is the most common symptom in both men and women. Local signs of colon cancer include: problems with constipation, diarrhea, abnormal stools, dark or light red coloured blood present in the stools, painful bloating. Systemic signs of colon cancer are: involuntary weight loss, low appetite, signs of unexplained fatigue or exhaustion, nausea or vomiting, anaemia, yellow colouring of skin and mucous membranes. Treatment of colon cancer: the treatment for colon cancer usually involves surgery, followed in some cases by chemotherapy. Treatment options for colon cancer: surgery is the first option for most cases of colon cancer. Colostomy can be performed when the distal intestine has been surgically removed or when it is impossible for stools to pass through the colon. Colostomy may be temporary as in case of an inflammation or permanent if a major portion of the large intestine has been removed. Radiation therapy is not an option in colon cancer. Local radiation therapy is indicated in the initial stages of colorectal cancer to prevent relapse. Radiation therapy does not increase the patient’s chances of survival if colon cancer is in an advanced stage. Chemotherapy can be used if the cancer is advanced or metastatic, or is detected in lymph nodes. The most common location of metastasis is in the liver.

Anal cancer

Georgeta Marinache, Luminița Crăciun, Raluca Orzata

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Anal cancer is a disease in which malignant cells develop in the tissues from the anal region. Anus is the terminal part of the large intestine, after the rectum, where faeces are removed from the body. The risk factors for cancer are: age over 50 years, human papillomavirus infection, multiple sexual partners, practicing anal sex, frequent anal erythema, inflammation and pruritus, anal fistulae, smoking. Possible signs of anal cancer are bleeding from the anus or rectum or the presence of a swelling near the anus. Tests that examine the rectum and anus are used to find and diagnose anal cancer. The following procedures can be used: objective examination and patient history, the digital rectal examination, anoscopy, proctoscopy, ultrasound, biopsy. Once anal cancer has been diagnosed, tests are carried out to determine whether the cancer cells have spread beyond the anus or to other parts of the body. This process is called staging. Staging can be done using the following methods: computerized tomography, chest radiography, endoanal ultrasound. Treatment. Patients with anal cancer have several treatment options. Some are standard treatments and others are just in the trial stage in clinical studies. Before starting the treatment, the patient can think if he wants to be part of such a trial. The treatment used in the clinical trials is actually a study aimed at improving current treatments or obtaining information for new treatments. Radiotherapy. Radiation therapy is a way to treat cancer using high energy X-rays or other types of rays to kill cancer cells. Chemotherapy. Chemotherapy is a way to treat cancer using drugs that stop the growth of cancer cells either by killing the cells, or by stopping cells division. Surgery. There are several types of interventions: a) the local resection; b) the abdominal pelvic resection. Other treatments. The infection with the human papillomavirus can influence the treatment of anal cancer. The condition of patients infected with human immunodeficiency virus that already have a deficient immune system is even more aggravated by the treatments used in cancer, so HIV patients who also have anal cancer are treated with lower chemotherapy and radiotherapy doses than patients without HIV.

Stress relief - a combatant against diseases

Mihaela Buflea, Ioana Catrinoiu, Costinela Bogdan

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
What happens in the human body when we are subjected to stressful factors? Severe stress induces the release of stress hormones, cortisol and catecholamine, resulting in diseases such as diabetes, hypercholesterolemia, cardiovascular disease, hypertension and depres­sion. Following the release of these hormonal cascades, changes in the human body occur, expressed through anxiety and hypervigilance. What are the stressors?  Stressors are: physical or mental illness; emotional, physical or sexual abuse; work problems or family problems; conflicts with friends or lack of friends; natural disasters; lack of self-confidence. The reasons for stress are: the desire to achieve, to get, to have, and the fear to fail or to lose. If we were to look deeper, we would realize that unsatisfied wishes and fear of helplessness lead to disappointment. 
How do we fight stress?
  •  Self-observation: Am I relaxed right now? What is happening in my mind at this moment? What do I feel?
  •  Pay attention to these questions, especially in tense moments, but do not compare them to other situations and do not catalogue them!
  •  Do not criticize yourself, just analyse the situation and see how you responded to a crisis situation!
  •  In conflict situations you either shut up, or say what you need to say, but without raising the tone!
  •  Pay attention to what you do, no matter what it is, while clearing your mind from any thought!
  •  Be organized and do things one at a time!

Conflict of interests in the hospital environment

Irina Daniela Dumitru, Adelina Florentina Bortoloti, Georgeta Mirela Albișoru

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
The hospital environment, by itself, is a universe governed by mundane laws. The contributors to the hospital environment appear to be reduced to: patients and their relatives, physicians and associate staff. They all declare the support for the patients’ health interests. The remaining shareholders have a satellite role in their attempt to influence the hospital environment: researchers, sponsors, state health policy, media etc. That being said, shareholders, taken in categories, run the risk of overcoming the actual number of patients and have a well defined role in the whole health process.

Neoplasm of the right parotid, operated and recurrent

Ana Nae, Raluca Poenaru

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Introduction. Otorhinolaryngology neoplasms rank fifth in Romania. In recent years, they have increased by 12.88% compared to previous years. In the past, the risk factors were excessive smoking and alcohol, but over the last two decades there has been an increase in neoplasms due to HPV infection. Case presentation. We present the case of an 81-year-old patient who denies smoking and alcohol consumption and denies APP. The patient is hospitalized in our clinic in March 13th 2017, according to the ENT recommendation for the establishment of specialized treatment - adjuvant radiotherapy. A rigorous wound care and wound cure plan is put in place, with the supply of the water and nutritional intake needed for this case. The patient is undergoing specialized treatment: radiotherapy. Conclusions. The specificity of the case is represented by the aggressiveness of the tumour., with an infiltrative process at the retro-mandibular level, and adenopathy at cervical inferior and overclavicular level.

Paget’s disease of the breast - a form of hardly detectable cancer 

Nicoleta Eleonora Marinca,  Mariana Radu, Bogdan Paul Ioan 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Throughout their lives, women may experience various breast symptoms. Paget’s breast disease is a rare tumour of the nipple and is one of the most serious complications a woman may face. The manifestations of Paget’s disease do not make the woman think of breast cancer. Signs of onset may be attributed to a skin problem, as the disease is manifested by itching of the nipple, burning or stinging sensation. Very rarely a white-yellowish or reddish discharge may appear. The patient can cause injuries to herself. This disease is not common, but it is more dangerous than others, being often confused with a dermatological condition (psoriasis or eczema) and treated as such, which is a very serious error. This is why Paget’s disease of the breast is difficult to diagnose, often too late, in advanced stages of the cancer.

Colon - a vital organ always forgotten

Gabriela Ioan, Cristina Sharifi, Elena Croitoru 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
We are generally concerned about the state of organs or parts of the body that we consider to be more important (heart, liver, stomach, skin or hair condition), but never or very rarely about the state of our colon. Why not admit this is the last one in our list of concerns about our health? The list of colon diseases is a long one: colon cancer, polyps, diverticulum, diverticulitis, inflammatory diseases - Crohn, ulcerative haemorrhagic recto colitis, infectious and non-infectious colitis, irritable colon, intestinal parasitosis, adhesions, haemorrhoids, anal fissure, anal fistula, anal prolapse, anal abscess, condylomas, anal incontinence, rectocele, anal pruritus, constipation, carcinoid, intestinal floral imbalance, Candida infection. In most colon pathologies, a prolonged asymptomatic period is noted.

Psychological support for the oncological patient 

Rodica Maria Dinca, George Daniel Ioniță

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Cancer, “public enemy no. 1”, is perhaps the best example of a disease whose origin is often attributed to external factors that get rid of our control, but which in most cases is a consequence of our lifestyle. The cancer diagnosis, regardless of its nature and regardless of the age or psychic structure of the person receiving the news, has an emotional and devastating impact. An extremely important element in this approach is the family and close persons. These are the ones who have access to the patient’s privacy, providing emotional and motivational support in his struggle with the disease. Psychotherapy has a crucial contribution to emotionally rebalancing.

Relationship between the level of parental distress and the emotional and behavioural problems of the child with cancer

Teodora Goloiu, Stelian Bălan, Fotinica Gliga

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Objectives. The level of parental psychological distress can influence the well-being of the child with cancer during the oncological treatment. The objective of this study was to investigate the relationship between the affective disorder (AD) of the parent and the emotional and behavioural problems (EBP) of the child with cancer. The environmental objective was to improve and adapt the therapeutic intervention for patients and their families. It has been hypothesized that the existence of siblings, the gender differences, the type of treatment and the time since the diagnosis may influence the correlation between AD and EBP. Measurements. The transversal correlational study used PDA as tools (Opriş and Macavei, 2005) to measure AD and CBCL (Achenbach and Rescorla, 2001) for EBP measurement of the child with cancer. Participants. Seventy-two participants were selected from the Institute of Oncology Bucharest and the Fundeni Clinical Institute. Subjects were children (N=36) with cancer/leukaemia in active chemotherapy (Cht) or Radiotherapy (Rdt) (M=13.4, SD=3.7). The sample consisted of 17 girls and 19 boys, of which 61.1% had combined treatment and 47.2% had been diagnosed for more than six months. Thirty-six mothers (M=40.4, SD=7.2) were involved in the study. Results. The Spearman correlation coefficient revealed significant correlations between AD and the symptoms of depression, social problems, and the attention problems among boys who have siblings, problems increasing during hospitalization and in combined treatment. Conclusions. The results indicate that psychological intervention should be centred on the specific relationship between mother and child, involving the extended family, adapted to the gender differences, the type of treatment and the duration of hospitalization of the child/young person with oncological diagnosis.

Three-dimensional conformal radiation therapy in the treatment of rectal neoplasm

Valentin Grosu, Elena Marcela Albu, Angela Grosu 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Rectal cancer is the fourth most commonly diagnosed cancer and the second cause of mortality. Risk factors for rectal cancer are: environmental factors, diet, excessive consumption of meat and alcohol, low folate consumption, family history of rectal cancer. The rectal cancer’s clinical signs are minimal or non-specific symptoms: alteration of intestinal transit alternating diarrhea with constipation, rectal haemorrhage, rectal tenesmus, abdominal pain. The goal of three-dimensional conformal radiation therapy are: the geometric matching of the irradiated volumes with the treated tumour tissue; modelling the prescribed dose distribution in the target volume; minimizing the dose that gets to healthy tissue. The indication is established within a multidisciplinary committee: oncologist, radiotherapist, and surgeon. The radiotherapist should consider the following: tumour location, distance to the anal sphincter, type of surgery, and tumour position relative to OAR. Steps in the three-dimensional conformal radiation therapy: image acquisition by CT investigation; images are transferred to the conturing console; validation of the treatment plan by the physician; transmition of treatment plan to Varian Linear Accelerator; performing portal imaging and starting irradiation. Conclusions. RT-3D CRT is a modern irradiation technique that offers: a suitable dose distribution for the therapeutic intention, geometric matching of volumes irradiated with the tumour tissue, and reduced side effects by getting a minimum dose in healthy tissue.

Functional recovery in osteosarcoma in infant

Vladimir Mita, Daniela Mitu, Elena Dobre

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Osteosarcoma, or osteogenic sarcoma, is a type of bone cancer, the most common malignant bone tumour that occurs when osteoblasts turn into cancerous cells. These cancer cells continue to divide and multiply, forming a tumour. Tumours usually develop in younger, growing cells, in the bone section that grows during childhood. During bone remodelling, osteoblastic cells disfavour or resorb bone tissue. Osteosarcoma usually affects patients up to 20 years of age, especially among adolescent men. Most often the knee region is affected - 70% of cases (both in the femur and the tibia). Humerus is the third bone, with a frequency of 15%, especially at the upper extremity. Osteosarcoma is the most common of primitive bone tumours. The diagnosis is based on the front and profile radiography and the histological examination of the tumour after biopsy. The treatment of osteosarcoma usually involves chemotherapy and surgical ablation of the tumour. Treatment can only be done after setting up a plan to which contributes the surgeon, the oncologist and the anatomo-pathologist specialized in bone tumours. One of the most important parameters of treating this condition is medical recovery. The patient has to undergo complex physio-kinetotherapy programs under the guidance of an over-specialized medical team. Objectives and means are created on certain personalized principles for each patient who will achieve the progress of functional recovery.

Mother’s emotional needs in paediatric oncology

Gianina Rotariu, Daniela Ștefan, Irina Loredana Olar

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Human needs are innate and general-human motivational experiences that influence behaviour. The more a need is frustrated, the more it manifests itself in a person’s behaviour. We can understand, support, or influence a mother’s behaviour only by discovering needs that are not contented at the time. The mother of the child with oncological diagnosis can experience frustration of her biological or psycho-emotional needs. The psycho-emotional needs are: the need for protection and emotional safety, the need to be loved and to love, the need for stability and emotional self-control, the need to be appreciated and the need for self-esteem. In this piece of work we will explain how frustration of emotional needs of the mother of a child with oncological diagnosis can influence her behaviour. Understanding this dynamics is necessary for the nurse to be able to support or influence the mother’s behaviour. It is well-known that at any child’s age, especially in acute or chronic illness, the mother and the mother’s emotional balance have an important role in achieving therapeutic compliance and clearly influence the emotional balance of the child.

Palliative therapy - rehabilitation of oncological patients’ lives 

Iuliana Chivu, Mariana Moraru, Florența Chelu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Cancer is one of the most painful conditions, and pain control is a priority for patients diagnosed in advanced stages. Palliative care is the only way to ensure a minimum comfort and a better quality of life. Palliative treatment means active care for patients with a continually progressive disease that no longer responds to curative treatment, pain and other symptoms being targeted. Palliative therapy has three components, interlaced and with common elements: 1. Supportive therapy; 2. Hospice care; 3. Palliative care. The primary goal of palliative therapy is to ensure the quality of life of the cancer patient. Quality of life, or “well-being”, is composed of two elements: physical activity capacity, and patient’s satisfaction. Hospice care refers to the care of patients in terminal stages of the disease. According to World Health Organization, palliative care is “a way of approach that improves the quality of life of patients facing life-threatening diseases and of their families, by preventing and removing pain and other physical, psychosocial and spiritual problems”. Palliative care starts at the identification of an incurable disease and continues until the end of patient’s suffering. In these situations, palliative care follows methods that do not prolong the patient’s life, but allow the individual to “cohabit with his illness”.

Preoperative assessment of pulmonary residual capacity in patients with bronchopulmonary carcinoma, obtained by pulmonary perfusion scintigraphy

Constanța Niță, Mihaela Vasile

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Pulmonary perfusion scintigraphy is a non-invasive, non-irradiating tech­nique that provides functional information particularly useful both in diagnosis and in establishing the optimal therapeutic response for serious conditions such as bronchopulmonary carcinoma. In patients with bronchopulmonary cancer, pulmonary perfusion scintigraphy is used for the assessment of postoperative pulmonary function and of the maximum expiratory volume per second. The visualization of pulmonary perfusion is achieved by intravenous injection of radioactively labelled particles which are retained in the terminal pulmonary circulation, imitating the mechanism of the embolic accident; because of their dimensions, marked­ particles are blocked at terminal pulmonary circulation with­out causing local haemodynamic changes. By computerized analysis of the number of impulses collected on images from anterior and posterior incidence, pulmonary function is determined, for each lung and in each and every pulmonary region. This quantitative analysis is useful in selecting patients for pneumonectomy and exclu­sion of those at high risk of postoperative respiratory failure. An estimated maximum expiratory volume per second less than 0.8 l or less than 40% is associated with an increased risk of morbidity and pulmonary post-intervention mortality and therefore excludes surgery.

Scintigraphic detection of bone metastases and radionuclide therapy for palliative purpose with Sr-89

Iuliana Anton, Romaniţa Zaporoscenco 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Many patients with advanced malignancy develop evolutive bone metastases. Although bone metastases may be clinically silent, the patients suffer from intense bone pain that lowers the quality of life. Therefore, it is necessary for these metastases to be discovered as early as possible, whole-body bone scintigraphy having an important role in achieving this goal. Before bone metastases cause pain, it is very important that radionuclide therapy be started as soon as possible. Radionuclide the­rapy is the alternative, sometimes complementary, in an attempt to reduce intense and unbearable pain caused by bone metastases. Currently, a radionuclide such as Strontium-89 is recommended for palliative use, especially in patients with multiple wide-spread bone metastases. This radionuclide is mainly bound by phosphonates that, due to their affinity for the metabolic very active bone tissue, reach directly and target bone metastases. The main setting are osteoblastic lesions, but part of the amount of radiopharmaceutical also reaches osteolytic lesions. Radionuclide systemic therapy is effective in reducing pain, increases quality of life and reduces the need for analgesics. This effect lasts on average for several months, and the treatment can be repeated if necessary.

Vitamin D - the sun’s vitamin

Aurelia Berdila, Nicoleta Angheluș, Adriana Sandu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Vitamin D is not a vitamin in the proper sense of the word, for two reasons. First of all, our body can produce it after the sun exposure. Secondly, in its active form, it is considered a hormone. Specifically, it has effects as a hormone in mineral absorption, bone mineralization and some secretions. Due to the role of vitamin D in the minerals absorption and in the process of bone mineralization, it is extremely important in maintaining bone density. Studies show that supplements with calcium and vitamin D can prevent bone problems and improve bone density in the elderly. These two types of supplements together have shown a reduction in the hip fracture rate - a particularly good thing which hormone replacement therapy has not proven to achieve. There is real evidence that vitamin D can be a reliable help in preventing and treating many cancers, such as colon, breast or prostate cancer. But high levels of vitamin D may increase the risk of pancreatic cancer if one does not have a balanced diet, does not maintain normal weight and fall prey to sedentarism. The richest natural sources are salmon, mackerel, tuna, sardines, egg yolk, beef liver, cereals, nuts, apples, dairy etc. If these are not enough, you can also use vitamin D dietary supplements that are found in two forms: D2 - ergocalciferol (the same type found in food) or D3 - cholecalciferol (the form obtained from sun exposure).

ESR - one of the inflammation indicators in the organism

Gheorghe Alexe, Georgeta Stoian, Florentina Donici

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Blood tests are a priority because they are a health barometer. ESR is a blood test which determines the rate of sedimentation of the red blood cells. It is considered a non-specific, inexpensive and simple method, used for a long time to help diagnose diseases associated with chronic or acute inflammation, including infections, cancer and autoimmune diseases. It gives indications that something is wrong in the body and leads the doctor to recommendations for extensive tests that can provide a precise diagnosis. The test is also indicated to check if a condition (inflammatory disease, cancer etc.) responds to a particular treatment.

Psychosocial assistance in paediatric oncology

Alina Maria Mitroi, Carmen Voiculescu, Liliana Pavel

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Improving the quality of life of the oncology patient and of his/her family can be ensured by individualized planning of social, psychological and educational care, thoroughgoing study of information on illness, treatment and impact on the family, adapting the information to the level of understanding of the child, support and reassurance of the child by all members of the multidisciplinary team, for him/her to stay active and have a life as normal as their special circumstances are allowing. Once the treatment is completed, the multidisciplinary team ensures that the patient is able to reintegrate into school and society. The objectives of psychosocial care in the field of oncological paedia­trics are related to the activation of the psycho-emotional resources in increasing the compliance with the treatment and the social reintegration chances after the completion of the treatment, increasing the level of information on paediatric oncology (treatment options, diet, medical institutions inside the country and/or abroad etc.), increasing the financial power of the family in order for the patient to positively respond to the treatment and to enrich the social support network that meets the needs of the patient.

Caring for patients with vulvar neoplasm 

Stela Gais, Vera Zamfir, Daniela Parnica

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Vulvar cancer is a part of the gynaecological category of cancers, generally affecting older women. Most vulvar cancers develop due to squamous cell carcinomas. They originate from the epidermis of the vulvar tissue. In situ carcinoma is a precursor of squamous cell cancer, before invading the basal membrane. The main symptom of vulvar cancer is vulvar pruritus. It is usually accompanied by a small ulceration and red injuries. Analysis of the extracted vulvar tissue (obtained through biopsy) can help establish the diagnosis. Specialized treatment for vulvar cancer is indicated by an oncologist. The extent of the surgery is due to surgical staging. Surgery is a standard therapy and involves radical vulvectomy with elimination of lymph nodes in the inguinal and femoral areas. These interventions can lead to wound infection, sexual dysfunction, edema and thrombosis. Radiotherapy is given as postoperative adjuvant therapy. The 5-year survival rate of patients with stage I invasive epidermoid cancer is 80-90%. Survival rates decrease with the progress of the disease. However, a survival rate of 40% can be achieved even in patients with lymphatic metastases.

Caring for patients with breast reconstruction after mastectomy 

Mihaela Joian, Ana Maria Dumitrache, Angela Drăgoescu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Breast reconstruction is a physically and emotionally rewarding procedure for a woman who lost one or both breasts to cancer. Creating a new breast can dramatically improve the self-image and self-confidence. Although surgery may result in a relatively natural breast, a reconstructed breast will not look and feel exactly the same as the removed breast. The final results of breast reconstruction after mastectomy can alleviate the physical and emotional impact of mastectomy. There are side effects, but most women feel that these are small compared to the substantial increase in the quality of life and of the feeling of being and showing whole again. Surgical solutions are: reconstruction with mammary implants, tissue expansion, reconstruction with own tissues (flaps).

Processing of biological material from cancer patients and animals carrying experimental tumours for biochemical and immunological determinations

Sorina Aldea, Angelica Cordaș, Cornelia Dode, Marilena Jilavu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
The work aims to present the methods of processing the biological material (of human and animal origin) used in our laboratory in the Department of Biochemistry and Radiobiology of Cancer Disease within the Institute of Oncology Bucharest, for carrying out several biochemical and immunochemical determinations: sialic acid, oxidative stress parameters (products of lipid peroxidation, total thiols, celuloplasin oxidizing activity), immuno-phenotyping, assessment of cell cycle and apoptosis. The biological material provided to our laboratory comes from patients from our clinic, with various types of cancer (blood, urine) and experimental animals: mice, experimental tumour-bearing rats (blood, organs, tumour ascites, and solid tumours). Since the way of processing and preserving biological products has a decisive influence on the results of subsequent determinations, we hope that this work will prove useful and attract the interest of many practitioners in the field.

Modern techniques of external radiotherapy

Steluța Ene, Lili Alexe, Carmen Reisler

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Improving irradiation techniques has been achieved by improving the equipment(s). Currently, these are: using beams of different types (photons, electrons, protons etc.); equipped with multilamellar collimators for adapting the shape of the beam to the shape of the treated tumour volume; association of imaging equipment for the treatment and verification plan - CT (computed tomography), MRI (magnetic resonance imaging) or PET/CT (positron emission tomography) are used (this way, the vicinity of the tumour with the healthy organs can be visualized); improving hardware and software reduced the time ne­eded for treatment planning and determined the use of increasingly sophisticated and accurate computational algorithms; the appearance and refinement of devices using other types of beam, excluding those of photons. Radiation techniques. The main modern radiotherapy solutions are modern techniques of external radiotherapy: 2D radiotherapy, 3D radiotherapy, modulated intensity radiotherapy, imagistic guided radiotherapy, arc therapy, tomotherapy, proton therapy, modern techniques of intraoperative radiotherapy, radiosurgery and stereotaxic radiotherapy, gama knife, cyberknife.

Suspicious skin tumours

Ionelia Batrinu, Ruxandra Ramona Pop

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Melanoma is a form of skin cancer that originates in pigment-producing cells called melanocytes. These cells become abnormal, grow uncontrollably and invade the surrounding tissues aggressively. Although less common than other types of skin cancer, melanoma is the most serious of them. Fortunately, melanoma can be cured if it is detected and treated in the early stages, when is located only in the skin. In more advanced stages, haematogenous (blood) or lymphatic way metastases may spread to other organs or bones, in which case healing is less likely. Causes. The most common causes of melanoma are: exposure to ultraviolet (UV) radiation between 10 AM and 3 PM and sun exposure at high altitudes; destruction of melanocytes DNA as a result of sun and UV exposure (short wavelength radiation is the most important factor causing melanoma); the tanning lamp is also exposing the skin to UV radiation, increasing the risk of melanoma; depletion of the ozone layer can significantly affect the incidence of melanoma (it is estimated a 1% increase in melanoma incidence with each ozone layer thinning percentage), family aggregation of melanoma (more cases of melanoma in the same family), atypical moles, deficient immune system, especially in organ transplant patients, patients with leukaemia or lymphoma.  Early symptoms. The most important alarm signal for melanoma is the change in size, shape or colour of a mole or another skin tumour, such as a birth sign. The changes that occur should be monitored after a period of one month to 1-2 years. The ABCD guidelines of the American Skin Cancer Society should be used to assess skin changes, and the family doctor must be consulted should one of the following changes occur: A is for asymmetry. Half of the mole or cutaneous tumour does not overlap with the other half. B is for irregular borders. The edges are frayed, dentate or spotted. C is for colour. Pigmentation is uneven. Shades of brown, brown and black are present. Red, white, and blue lines are added to the appearance of colour spots. Changing colour distribution, especially spreading the colour from the mole’s border to the surrounding skin, is also an early sign of melanoma. D is for diameter. The mole or cutaneous tumour is larger than 6 mm or the size of a pencil eraser. Any enlargement of a mole should be a signal of concern. Signs of melanoma in case of a mole include: changes in height - such as depth invasion or elevation of the previously flat mole; changes in surface - like redness, swelling or the appearance of new small spots of colour around the larger lesion (satellite pigmentation); itchy, tingling or burning sensation at the lesion level; friable, soft consistency with small pieces that break very easily. Melanoma can develop on an existing mole or other sign on skin, but it often develops on normal skin, free of any sign. Although melanoma can develop anywhere on the skin, it occurs more frequently in the chest area, both in men and women, and on the lower limbs in women. Less commonly, it can develop on the soles, palms, the nail bed or the mucous membranes that latch the body cavities such as the mouth, rectum and vagina. Many other conditions (like seborrheic keratosis, warts, and basal cell carcinoma) have melanoma-like features. Late symptoms of melanoma in­clude: a ulcerative skin lesion or bleeding from a mole or other coloured skin lesions, pain from a mole or skin lesion. Symptoms of metastatic melanoma may be vague and include: lymphadenitis (inflammation of the lymph nodes), especially in the lining of the axilla or abdomen, a more discoloured or dense portion under the skin, unexplained weight loss, grey skin (melanosis).

Suspicious breast tumours

Ruxandra Ramona Pop, Ionelia Batrinu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Breast tumours are most commonly classified as benign and malignant tumours. Benign tumours are fibro-adenoma, hamartoma, intraductal papilloma and simple mammary cysts.  Malignant tumours (breast cancer) have various clinical and histological forms. Another classification of mammary tumours is in solid tumours and tumours containing fluid (mammary cysts). Most breast cancers are solid tumours. Mammary cysts are very rarely malignant. The patient cannot differentiate a benign from a malignant tumour. Therefore, a woman who discovers a breast nodule should contact a surgeon or oncologist for consulta­tion and to be guided to the necessary paraclinical investigations. The examination of a specialist and imaging examinations may be highly suggestive of a benign or malignant tumour or may in some cases be inconclusive. However, the only way to differentiate benign tumours from cancer tumours is to microscopically examine some fragments of the tumour. These fragments can be obtained through an imagistic guided puncture or through surgery. It has not been proven a cause for the appearance of breast fibroadenoma (inherited hormonal causes are incriminated). Breast tumours cannot be prevented, according to current knowledge. Except for the feminine sex and age, all the risk factors incriminated are insignificant. Women should be encouraged and supported to breastfeed for as long as possible. Patients with clinical diagnosis of breast fibroadenoma were until recently undergoing surgery - tumour­ectomy, mammary sectorectomy. Surgical excision involves, of course, direct (general anaesthesia, operated room, sometimes hospitalization) and indirect (convalescence, postoperative recovery, subsequent visits for evacuation puncture of the postsectorectomy cavity) costs. Unimportant in superficial nodule tumourectomies, the damage of the ductal system is to be considered in the case of any sectorectomy or tumourectomy targeting deeper formations. Let’s not forget that fibroadenoma generally affects young women during the reproductive period. Aesthetic changes depend on the size of the tumour and of the breast, the nodule’s position, the surgeon’s experience, and last but not least, the quality of the patient’s tissue. Surgical excision provides definitive lesion treatment and allows the histological confirmation.

Nutrition in cervical cancer

Mariana Forcoș, Violeta Bota, Mihaela Morlova

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Nutrition has an important role in fighting cancer and keeping the immune system as strong as possible. Recommendations: personalized healthy diet, depending on each patient’s deficiency; supplementing the diet with appropriate vitamins, minerals and medicines; prevention of weight loss occurring in 50% of the cancer patients; anticipation of treatments side effects interfering with nutrition (taste and smell alteration, loss of appetite, nausea, vomiting, dysphagia, changes in intestinal transit); balanced diet, consumption of foods containing key nutrients (carbohydrates, fats, vitamins, minerals); minimum daily intake of eight glasses of water (insufficient water intake leads to severe dehydration with bad consequences for the body). Ideally, the cancer patient should have a balanced diet with food from all five basic food groups!

The development of primitive tumour and ganglionary invasion in mammary cancer

C. Morocoasa, C. Cizevschi, M. Ichim

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
The local development of the tumour is achieved by direct invasion of the breast parenchyma, gradually extending to the surface and catching the skin, followed by tegument retraction, cutaneous edema and ultimately ulceration. The in-depth evolution of the local extension will affect the large pectoral fascia, then the pectoral muscle, and finally the ribs and the intercostal muscles, even invading the thoracic organs. The local invasion is done both by canalicular path and via lymphatic vessels. These multiple mechanisms of intra-mammary dissemination largely explain the extension of the disease away from the macroscopic margins of the tumour, known as multifocality, which require differentiation from multicentricity (the presence of different outbreaks of disease in different quadrants without causation between them). Studies show that breast cancer is often multifocal and rarely multicentre. The presence of residual microscopic lesions after conservative surgical treatment is the cause of local relapse, occurring most often near the postoperative scar.

Breast cancer in men

A. Gheorghe, S. Meceanu, G. Bisea

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Breast cancer is the most frequent form of cancer in women, the risk of developing this disease being of 1 in 8. Unlike them, men have a lifetime risk of developing this disease of 1 in 1000, especially in men over 60 years of age. In puberty, the girls’ ovaries produce hormones (estrogens) which cause the growth of the channels and the development of the lobes at the ends of the canals, thus the amount of tissue increases, so that the mammary glands (breasts) not only have an aesthetic role, but also a  functional role. In boys, hormones secreted by the testes (testosterone) prevent the growth of non-functional breast tissue (which does not produce milk) concentrated in the area behind the nipple and the development of lobes. Therefore, the male breast is made up of predominantly low and undeveloped canals and a small amount of fat and connective tissue. In both cases, breast cancer is the uncontrolled growth with spreading potential of certain cells of the breast tissue. These cells become abnormal in terms of appearance and behaviour, and they are called cancerous.


Orieta Ilincescu, Georgiana Petre, Georgiana Martinescu

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
The tumour, or neoplasm, is an abnormal tissue mass resulting from excessive, uncontrolled and irreversible cell proliferation which continues even after the initiation stimulus has ceased. Epidemiology and incidence. Neoplasms, and among them the malignant ones, currently represent a major public health problem. It is believed that about 20% of human deaths are caused by cancers, but their incidence is undoubtedly much higher. It is believed that about a quarter of the human popula­tion will develop during their life a form of cancer. The incidence of this condition is uneven, depending on several factors: geographic factor, age, sex, race, inherited predisposition, acquiring preneoplastic lesions or conditions. Biomorphological characteristics of malignant tumours: evolutive characteristics (fast and unsteady evolution, they produce local invasion; they relapse post-intervention and give remote insemination); macroscopic characteristics - generally they have a low consistency, the tumour tissue is soft, brittle, most commonly coloured white-grey for carcinomas and reddish-haemorrhagic for sarcoma; microscopic characteristics. Criteria of assessing the prognosis of malignant tumours: degree of differentiation, tumour stage, diagnostic methods. Types of benign and malignant neoplasms: tumors of epithelial tissue (papilloma, adenoma, carcinoma, adenocarcinoma), tumors of common connective tissue (fibroma, myxoma, sarcoma), tumors of adipose tissue (lipomas, liposarcomas), tumors of cartilaginous tissue (condroma and chondrosarcoma), bone tissue tumours (osteoma, osteoclastic, osteosarcoma), tumors of muscle tissue (leiomyoma, rhabdomyoma, leiomyosarcoma and rhabdomyosarcoma), tumors of blood vessels (haemangioma and hemangiosarcoma), tumors of melanoma pigment tissue (pigmented nevi and malignant melanoma), tumors of lymphoreticular tissue (Hodgkin’s and non-Hodgkin’s lymphomas).

Communication and its tools encountered day by day in medical practice

Liliana Viorica Alexe, Gheorghe Alexe, Loredana Ionela Borțea

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
The process of communication is seen as a simple process by which we receive and provide information, we express our thoughts, fe­elings, desires and intentions. It starts from birth and evolves according to the native dowry of each individual. It is a natural, simple thing that comes from itself and for which you do not need special training. But if we think of what communication is, we will be surprised of how complex in reality this process is. The communication process is considered an instrument that can be used with positive or negative intentions. Communication is perceived as a fundamental element of human existence.

The role of computed tomography in establishing the treatment plan for cervical cancer

Georgeta Burcea, Simona Zamfir, Teodor Pană

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Cervical cancer represents 15% of the total malignant tumours in Romania, first place in female genital cancers and the second cause of death in women. Radiotherapy is the only treatment used for early stage I cervical cancer and can be associated with chemotherapy in advanced stage II or early stage III and IV. Sometimes radiotherapy is also used after surgery, and in advanced stages, when a large dissemination occurs to other organs, it can be used as a palliative treatment to control bleeding and pain. Each radiotherapy patient will initially perform a planning tomography on which the proper treatment plan will be completed. The planning tomography differs from the diagnosis tomographic examination and takes place according to specific radiotherapy treatment procedures established by the radiotherapy physician and the directions of the medical physicist. Differences are both in data acquisition and at technical level, because during the examination the position of the patient’s body and a certain physiological state must be identical or as accurate as possible to those of the radiotherapy session.

Radiotherapeutic treatment of brain tumours

Andrei Coliță, Ileana Coraci, Cătălina Vasilica

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Radiotherapy represents the use of ionizing radiation to kill cancer cells and stop their growth and division. Brain tumours occur when cells begin to uncontrollably multiply and move or invade nearby tissues. Usually, for radiotherapy of the full brain or of larger areas, a number of external radio­therapy sessions will be prescribed for about 1 or 2 weeks. Hyperfractionation is a form of radiotherapy applied in doses much lower than usual, two or three times a day instead of once a day. The treatment is performed with an external irradiation device (linear accelerator, cobalt therapy). Once the treatment completed, the patient will have to periodically perform a series of tests for early tracing of a possible relapse of the disease.

Surgical treatment of lip cancer

Ecaterina Marinov, Alina Cristina Vătu, Camelia Iordache 

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Work’s goal. The study analyses different therapeutic protocols, establishing the optimal treatment both for healing the patient and for its social, functional and aesthetic integration as quickly as possible. Early detection of lip cancer is very important, conditioning surgical technique and postoperative prognosis. Previous incomplete treatments (such as simple excision, electro-cauterization) lead to scarring that hinders plastic reconstruction techniques. Surgical treatment involves extirpation of the tumour with oncological safety margins and plastic reconstruction of the defect.

Preparation for total body irradiation - compulsory condition for the success of the technique and of the bone marrow transplant

Mioara Nibi, Elena Negrescu, Gabriela Ianole

Amethyst Otopeni Clinic
The total body irradiation technique is part of the international protocol for the preparation of the patients with malignant hematological diseases, especially acute lymphoblastic leukemia, in order to receive the bone marrow transplant. The transplant represents a procedure through which the patient receives hematopoietic stem cells (cells ­which help differentiate all the other blood cells) from a compatible donor. During the period of the transplant, the defence functions of the body will be very prejudiced, a condition necessary for accepting the hematopoietic graft. In this sense, the patient will be taken over in an especially built centre for protection against infection, where he/she will remain throughout the period of preparing the transplant and then for 4-5 additional weeks after the transplant. Amethyst Radiotherapy Otopeni is the only radiation therapy centre in Romania which performs the Total Body Irradiation (TBI) procedure through the newest IMRT-VMAT technique. For TBI in the Amethyst Clinic, a special preparation is also performed for 6 days, while the therapy is administered. Preparation consists in daily general cleansing (performed during the night) followed by disinfection through nebulisation and the use of UV lamps, the disinfection of the waiting room, of the undressing cabin and of the rooms and contact surfaces (device table, retention elements, mask). At the same time, the equipment used by the patient and by the medical team applying the technique will be made up of scrubs, footwear, sterile bonnet, operating theatre and sterile beds, sterile surgical gloves. At the same time, the patient and the personnel should wear sterile gloves. Infection prophylaxis will positively and considerably influence the evolution of transplant.

Malignant melanoma - a form of aggressive cancer

Daniela Nela Stancu, Rodica  Akin, Mirela Sima

“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology Bucharest
Melanoma is a form of skin cancer that originates in pigment-producing cells called melanocytes. These cells become abnormal, grow uncontrollably and invade aggressively the surrounding tissues. It is characterized by a special aggression. It is the only cancer that most often appears on visible areas and despite the fact that it is observable, its incidence is rapidly increasing.

Total body irradiation through VMAT technique 

Gigi Ianole, Florentina Bertescu, Mihaela Iuliana Mihai

Amethyst Otopeni Clinic
Annually, approximately 80 patients are diagnosed with acute lympho­blastic leukemia at the Fundeni Clinical Institute and only 20% of them have as a therapeutic indication the total body irradiation followed by bone marrow transplant. Total Body Irradiation (TBI) is the most efficient treatment method used internationally in preparing patients for bone marrow transplant, having minimum side effects, the success rate being of 100%. At the Amethyst Radiotherapy Otopeni clinic, the first TBI protocols have been implemented with the latest IMRT-VMAT technique. The procedure is very complex and involves great atten­tion and responsibility from the entire team. Treatment is performed in approximately 6 sessions, on a daily basis, under strict sterilisa­tion conditions. The TBI procedure involves the scanning of the entire body every 2 mm and the reconstruction of each section, from bone to blood, resulting in a virtual reconstruction in volume of the patient. In the optimization stage, structures which are irradiated (bone struc­tures) are differentiated from the rest of the tissue.