Esta investigación fue apoyada por la sentencia de Centro Integral del Cáncer (P30 CA43703).

1. Estereotáctica radiocirugía CyberKnife Consulta <ol><li> Describe tratamiento CyberKnife radiocirugía. Cyberknife radiocirugía implica el uso de un acelerador lineal montado en un brazo robótico industrial similar a las máquinas utilizadas para hacer los automóviles. El brazo robótico se mueve el acelerador lineal en el espacio tridimensional en torno a un paciente a medida que avanza a través de &#39;las paradas de los múltiples tratamientos para la entrega de la viga. Cruz plano rayos X se obtienen durante el tratamiento para verificar el paciente está en una posición de tratamiento correcto. Dado que la aplicación del tratamiento del haz no se limita a un plano de dos dimensiones, este sistema mejora aún más la capacidad de entregar dosis concentradas de radiación para el cáncer objetivos y reducir al mínimo la dosis de radiación a la piel crítica y estructuras viscerales de órganos. </li><li> Discuta los riesgos radiocirugía CyberKnife. Radiocirugía CyberKnife puede resultar en una posible curtido y enrojecimiento de la piel, fatiga, náusea, poco frecuente o diarrhea, lesión poco frecuente órganos viscerales, el nervio del músculo, y la lesión ósea y el riesgo muy pequeño de segundo tipo de cáncer. </li></ol> 2. Estereotáctica radiocirugía CyberKnife colocación Fiducial <ol><li> Describa la colocación fiducial. Las mujeres que recibían tratamiento para los cánceres ginecológicos persistentes o recurrentes someterse a operación o guiada por tomografía computarizada colocación de al menos tres individuales de 1,6 x 3 mm fiduciales de oro de tejidos blandos (aproximadamente del tamaño de un grano de arroz) en o cerca de la meta de cáncer. Clips quirúrgicos colocados en el momento de la cirugía previa no son de densidad suficiente para ser utilizado como fiduciales radioquirúrgicos. Clips quirúrgicos no interfieran con radioquirúrgica orientación debido a la discrepancia densidad. </li><li> Indique la posición fiduciaria en relación con objetivo de radiocirugía. Fiduciales se colocan a diferentes profundidades del tejido alrededor de la meta con radiocirugía y deben estar separados por dos centímetros o más. Fiduciales están posicionados dentro de 4 a 6 centímetros de la tArget. </li></ol> 3. Estereotáctica radiocirugía CyberKnife planificación del tratamiento <ol><li> Sobre el plan de radiocirugía tratamiento. Por lo menos una semana después de la colocación de fiduciario (es decir, de manera que haya ocurrido la curación y el movimiento fiduciario se reduce al mínimo), los pacientes se someten guiada por tomografía computarizada simulación del tratamiento SBRT. En nuestro programa, de dos pines localizado evacuado al vacío bolsa de inmovilización pélvica se utiliza. </li><li> Indique la posición del paciente en la mesa de tratamiento. Las mujeres son tratadas en una posición de tratamiento en posición supina sobre la mesa radiocirugía CyberKnife plana. </li><li> Hable de destino y la inmovilización del paciente. El paciente puede someterse a evacuados al vacío bolsa de inmovilización para reducir el movimiento intrafraction durante la entrega de dosis de radiación. Una vez inmovilizado, las mujeres se someten no contrastada contigua TC axial de alta resolución de imagen (1 a 1 de tono, de 1,0 mm de espesor de loncha, la tensión de 120 kVp, 450 mAs). </li><li> Discuta el uso de tecnologías avanzadasimágenes para la localización de destino. Después de la TC, las mujeres se someten preferentemente convencional 18 F-FDG PET / CT en la posición SBRT mismo tratamiento. Por otra parte, las mujeres pueden someterse a contraste de imagen convencional de la resonancia magnética nuclear. </li><li> Describir la imagen del co-registro para la planificación del tratamiento con radiocirugía. Las imágenes de TC de alta resolución y 18 F-FDG PET / CT se importan para la planificación inversa tratamiento de radiación en el MultiPlan 3.5.2 Sistema de planificación de tratamiento (Accuray). </li><li> Describir enfoque de equipo para la planificación del tratamiento con radiocirugía. Para la planificación del tratamiento, tanto de un radio-oncólogo y ginecólogo oncólogo del contorno volúmenes de destino clínicos sobre el cáncer de destino (CTV). Otra enfermedad en situación de riesgo los tejidos se contornea y se incluye en el CTV. Cerca de las estructuras de los tejidos normales, tales como el intestino delgado, recto, vejiga, hígado, riñones, pulmones, fémures proximales bilaterales, la vagina, y las raíces nerviosas sacras están contorneados porel oncólogo de radiación. </li><li> Describir la prescripción de dosis de radiación. Una prescripción de dosis de radiación de 3 x 800 = 2400 cGy cGy (comúnmente a la línea de isodosis 70%) ha sido seleccionado. En un 200 cGy biológica cálculo de la dosis equivalente, cerca de 6.170 cGy se entregan con esta receta suponiendo un &quot;α / β&quot; relación de 10 para el tumor. La radiación emitida por un acelerador lineal SBRT es colimada ya sea mediante el uso de uno de los 12 colimadores de tungsteno circulares fijas (5 a 60 mm) o mediante el uso de una aleación de tungsteno-cobre segmentado hexágono colimador IRIS. 14 órganos normales tienen una tolerancia de radiación y el uso de dosis-volumen parámetros del histograma para la restricción del tejido normal durante la radiocirugía estereotáctica ablativa se enumeran en la Tabla 1. </li></ol> 4. Estereotáctica radiocirugía CyberKnife la administración del tratamiento <ol><li> Realizar la verificación cruzada de plano de la imagen. Durante CyberKnife SBRT, los tejidos blandos fiduciales(O en algunos casos rígidos puntos de referencia anatómicos tales como el cráneo de lesiones intracraneales y la columna vertebral de lesiones de la columna) se realiza un seguimiento por imágenes crossplane radiográfico y se confirmó que en el lugar de destino previsto por el sistema de destino localización (TLS) del subsistema. </li><li> Verificar la posición de destino. Fiduciales se realiza un seguimiento de tres y hasta seis grados de libertad (es decir, x, y, z, cabeceo, balanceo y guiñada). Imágenes generadas por los TLS se registran automáticamente y se comparan con radiografías reconstruidas digitalmente (DRR) generados por el tratamiento inicial de la planificación de la TC. </li><li> Verificar la posición de destino. Si los resultados de la inscripción automática fiduciales indican que se han desplazado más allá de las tolerancias predefinidas en cualquiera de los seis grados de libertad (x, y, z, cabeceo, balanceo y guiñada), el tratamiento se detiene automáticamente. Reposicionamiento del paciente se produce entonces. </li><li> Considere la posibilidad de movimiento del objetivo. Los objetivos que se mueven con el movimiento respiratorio son treated utilizando el subsistema de seguimiento respiratorio Synchrony, (sincronía). Con el uso de una cámara montada en la sala de tratamiento, el sistema de seguimiento continuo patrón de respiración del paciente (es decir, obtener datos externos de posición) con el uso de diodos emisores de luz (LED) fijados a un chaleco alrededor del tórax del paciente. 10 Juntos con la información de ubicación fiduciales (datos internos de posición) obtenido a partir transversal plano de rayos X, el sistema Sincronía construye un modelo de correlación con los datos externos y los datos internos. Este modelo de correlación permite que el brazo robótico de seguir cualquier movimiento respiratorio inducido por el objetivo, mientras que durante la entrega de cualquier y todos los haces de tratamiento. </li><li> El tratamiento puede implicar 100-150 posiciones de tratamiento entregables del brazo robótico. Los tratamientos pueden durar de 30 a 90 minutos. </li></ol> 5. Los resultados representativos Cuerpo de la radioterapia estereotáctica (SBRT) puede implicar muchos haces de radiación individuales (<html> vectores azules) y todos convergen en uno o varios objetivos estrechamente asociados radiación clínicos, como se muestra en la Figura 1A. Un representante del buen resultado la planificación de un tratamiento de radiocirugía da SBRT entrega con altas dosis de radiación de la cobertura del volumen blanco y el cáncer de destino conformalidad cáncer. Figuras 1B-D muestran 131 vigas se utiliza para tratar una recaída de la pelvis de un objetivo de cáncer de ovario quimiorrefractaria más de 42 minutos. SBRT prescrito a la línea de isodosis del 80% representa 100% de cobertura clínica volumen de destino con un índice de 1,94 conformalidad para una dosis total de 2400 cGy en tres fracciones diarias de 800 cGy. Los histogramas dosis-volumen para el objetivo clínico (rojo) y de las estructuras críticas de recto (marrón), vejiga (amarillo), intestino delgado (luz azul) sacros nervios (TAN) y las caderas (naranja) se muestra en la Figura 2. <img alt="Figura 1" src="/files/ftp_upload/3793/3793fig1.jpg" /> Figura 1.tp :/ / www.jove.com/files/ftp_upload/3793/3793fig1large.jpg &quot;target =&quot; _blank &quot;&gt; Haga clic aquí para ver más grande figura. <img alt="Figura 2" src="/files/ftp_upload/3793/3793fig2.jpg" /> Figura 2. Volumen de la dosis-histogramas para el objetivo clínico (rojo) y de las estructuras críticas de recto (marrón), vejiga (amarillo), intestino delgado (luz azul) sacros nervios (TAN) y las caderas (naranja).

<ol>
	<li>Sherouse, G., Bourland, J., Reynolds, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual+simulation+in+the+clinical+setting:+some+practical+considerations.">Virtual simulation in the clinical setting: some practical considerations.</a> Int. J. Radiat. Oncol. Biol. Phys. 19, 1059-1065 (1990).</li><li>Dickesn, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Personalized+fixation+using+a+vacuum+consolidation+technique.">Personalized fixation using a vacuum consolidation technique.</a> Br. J. Radiol. 54, 257-258 (1981).</li><li>Wunderink, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduction+of+respiratory+liver+tumor+motion+by+abdominal+compression+in+stereotactic+body+frame,+analyzed+by+tracking+fiducial+markers+implanted+in+liver.">Reduction of respiratory liver tumor motion by abdominal compression in stereotactic body frame, analyzed by tracking fiducial markers implanted in liver.</a> Int. J. Radiat. Oncol. Biol. Phys. 71, 907-915 (2008).</li><li>Mageras, G., Yorke, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Deep+inspiration+breath+hold+and+respiratory+gating+strategies+for+reducing+organ+motion+in+radiation+treatments.">Deep inspiration breath hold and respiratory gating strategies for reducing organ motion in radiation treatments.</a> Semin. Radiat. Oncol. 14, 65-75 (2004).</li><li>Wong, J., Sharpe, M., Jaffray, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+active+breathing+control+(ABC)+to+reduce+margin+for+breathing+motion.">The use of active breathing control (ABC) to reduce margin for breathing motion.</a> Int. J. Radiat. Oncol. Biol. Phys. 44, 911-919 (1999).</li><li>Ford, E., Mageras, G., Yorke, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Respiration-correlated+spiral+CT:+a+method+of+measuring+respiratory-induced+anatomic+motion+for+radiation+treatment+planning.">Respiration-correlated spiral CT: a method of measuring respiratory-induced anatomic motion for radiation treatment planning.</a> Med. Phys. 30, 88-97 (2003).</li><li>Kunos, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cyberknife+radiosurgery+for+squamous+cell+carcinoma+of+the+vulva+after+prior+pelvic+radiation+therapy.">Cyberknife radiosurgery for squamous cell carcinoma of the vulva after prior pelvic radiation therapy.</a> Technol. Cancer Res. Treat. 7, 375-380 (2008).</li><li>Kunos, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereotactic+body+radiosurgery+for+pelvic+relapse+of+gynecologic+malignancies.">Stereotactic body radiosurgery for pelvic relapse of gynecologic malignancies.</a> Technol. Cancer Res. Treat. 8, 393-400 (2009).</li><li>Kilby, W., Dooley, J., Kuduvalli, G., Sayeh, S., Maurer, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Cyberknife+robotic+radiosurgery+system+in+2010.">The Cyberknife robotic radiosurgery system in 2010.</a> Technol. Cancer Res. Treat. 9, 431-438 (2010).</li><li>Ozhasoglu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Synchrony+&#x2013;+Cyberknife+Respiratory+Compensation+Technology.">Synchrony &#x2013; Cyberknife Respiratory Compensation Technology.</a> Med. Dosimetry. 33, 117-123 (2008).</li><li>Hoogeman, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+Accuracy+of+the+Respiratory+Tumor+Tracking+System+of+the+Cyberknife:+Assessment+By+Analysis+of+Log+Files.">Clinical Accuracy of the Respiratory Tumor Tracking System of the Cyberknife: Assessment By Analysis of Log Files.</a> Int. J. Radiat. Oncol. Biol. Phys. 74, 297-303 (2009).</li><li>Antypas, C., Pantelis, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Performance+evaluation+of+a+CyberKnife+G4+image-guided+robotic+stereotactic+radiosurgery+system.">Performance evaluation of a CyberKnife G4 image-guided robotic stereotactic radiosurgery system.</a> Phys. Med. Biol. 53, 4697-4718 (2008).</li><li>Wilcox, E., Daskalov, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+GAFCHROMIC+EBT+film+for+Cyberknife+dosimetry.">Evaluation of GAFCHROMIC EBT film for Cyberknife dosimetry.</a> Med. Phys. 34, 1967-1974 (2007).</li><li>Echner, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+design,+physical+properties+and+clinical+utility+of+an+iris+collimator+for+robotic+radiosurgery.">The design, physical properties and clinical utility of an iris collimator for robotic radiosurgery.</a> Phys. Med. Biol. 54, 5359-5380 (2009).</li><li>Choi, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Image-guided+stereotactic+body+radiation+therapy+in+patients+with+isolated+para-aortic+lymph+node+metastases+from+uterine+cervical+and+corpus+cancer.">Image-guided stereotactic body radiation therapy in patients with isolated para-aortic lymph node metastases from uterine cervical and corpus cancer.</a> Int. J. Radiat. Oncol. Biol. Phys. 74, 147-153 (2009).</li></ol>

Nosotros (CAK, JMB, RD) no tienen nada que revelar.

Alentar a los resultados SBRT primeros han alimentado la investigación clínica de la radiocirugía para el tratamiento de cánceres ginecológicos persistentes o recurrentes. 7, 8, 15 datos cuestionan los efectos radiobiológicos y modo de muerte celular que resulta de SBRT. Pequeños estudios clínicos han demostrado que las dosis de radiación de ablación proporcionados por SBRT producen dirigidas las tasas de control de la enfermedad superior al 90%. A diferencia de la radiación convencional, ha sido un reto para combinar con quimioterapias SBRT radiosensitizing y citotóxicos / citostáticos. Mejor cáncer de orientación a través de mayores expansiones de volumen de planificación del tratamiento y la inclusión de 18 F-FDG PET / CT imágenes ha mejorado los resultados clínicos. Si bien es imprescindible para estudiar otros métodos de entrega de la dosis de radiación con una escalada de alta precisión, lo que queda por decidir si SBRT puede proporcionar eficacia terapéutica equivalente a un precio tan bajo y la alta tasa de dosis de braquiterapia. De hecho, la braquiterapia es el más común y validaciónfecha técnica para lograr la escalada de dosis de radiación en los objetivos del cáncer ginecológico. En este sentido, tanto el entusiasmo y la prudencia son apropiados en la lectura de los datos disponibles SBRT para el tratamiento de los cánceres ginecológicos.

<table border="1"><tbody><tr><td> Nombre del dispositivo </td><td> Empresa </td><td> Número de catálogo </td><td> Comentarios </td></tr><tr><td> Sistema CyberKnife </td><td> Accuray (Sunnyvale, CA) </td><td></td><td></td></tr></tbody></table>

stereotactic radiosurgery for gynecologic cancer

La radioterapia estereotáctica corporal (SBRT) se distingue por necesitando más inmovilización rígida del paciente, lo que representa el movimiento respiratorio, la planificación del tratamiento complejo, las imágenes de a bordo, y la reducción del número de dosis de radiación de ablación de objetivos de cáncer suele ser refractaria a la quimioterapia y la radioterapia convencional. Campos de dosis de radiación Steep SBRT drop-off permisos estrecha &#39;haz de lápiz &quot;de tratamiento que se utiliza para el tratamiento de radiación ablativa condensado en 1 a 3 tratamientos. El tratamiento de los médicos deben comprender que SBRT llega en un mayor peligro de lesión del tejido normal y la posibilidad de fallo del tumor geográfica. Ambos deben ser abordados por la inmovilización de los objetivos de cáncer y por la prestación del tratamiento de alta precisión. Inmovilización del Cáncer objetivo se ha logrado mediante el uso de moldes personalizados indexados de espuma de poliestireno, evacuados bolsas de frijol, o moldes fijos con el cuerpo del paciente independiente de la compresión abdominal. Movimiento Intrafraction 1-3 de targe el cáncerdebido a la respiración ct ahora puede ser reducido por el paciente que responden a las técnicas de apnea, 4 de coordinación boquilla paciente respirar activo, 5-respiración correlacionada tomografía computarizada, 6 o guiada por imagen de seguimiento de fiduciales implantados dentro y alrededor de un tumor en movimiento. 7-9 El Cyberknife sistema (Accuray [Sunnyvale, CA]) utiliza un acelerador de radiación lineal montado en un brazo robótico industrial que sigue con precisión el movimiento respiratorio del paciente por una cámara-seguimiento conjunto de diodos emisores de luz (LED) impregnados en un chaleco provisto de un paciente. 10 reducciones sustanciales en los márgenes de la radioterapia se puede lograr mediante el seguimiento de movimiento, en última instancia, la prestación de unos volúmenes más pequeños de planificación de destino que son irradiados con una precisión submilimétrica. 11-13 Objetivos de cáncer que son tratados por SBRT se irradian por la convergencia, vigas bien colimado. Dosis de radiación resultante de histogramas de cáncer de volumen de destino tiene un pronombre másla radiación CED &quot;hombro&quot;, indicando una alta cobertura de destino y un pequeño porcentaje de altas dosis de radiación &quot;cola&quot;. Así, el aumento conformalidad objetivo se logra a costa de uniformidad de la dosis se redujo en el objetivo cáncer SBRT. Esto puede tener implicaciones tanto para el control posterior del tumor en el objetivo SBRT y la tolerancia del tejido normal de los órganos en riesgo. Debido a la caída de dosis fuerte SBRT, la posibilidad de escapar de la enfermedad oculta la dosis de radiación de ablación se produce cuando los objetivos del cáncer no están plenamente reconocidos y la insuficiencia de los márgenes de dosis SBRT aplican. Volumen clínico objetivo (CTV) expansión por 0,5 cm, lo que resulta en un volumen de planificación blanco más grande (PTV), se asocia con mayor control de destino sin lesión indebida tejido normal. 7,8 Una mayor reducción de la probabilidad de geográfica señorita puede lograrse mediante la incorporación de 2 - [18F] fluoro-2-desoxi-D-glucosa (18 F-FDG) tomografía por emisión de positrones (PET) 8 Uso de los 18 F-FDG PET / CT en SBRT trat.planificación nt es sólo el comienzo de los intentos de descubrir nuevas firmas de destino de imagen molecular para los cánceres ginecológicos.

Watch this Scientific Journal Video about Stereotactic Radiosurgery for Gynecologic Cancer at JoVE.com

Stereotactic Radiosurgery for Gynecologic Cancer

La radioterapia estereotáctica corporal (SBRT) implica guiada por imagen, radioterapia ablativa entregado a objetivos de cáncer resistente a la quimioterapia o la radioterapia convencional. La robótica CyberKnife sistema de armado SBRT, con la localización de destino sofisticado, ofrece una dosis de radiación capaces de hipofraccionados esterilización de los objetivos del cáncer. En este artículo se tendrá en cuenta las nuevas funciones terapéuticas de SBRT para los cánceres ginecológicos.

La radiocirugía estereotáctica para el cáncer ginecológico

Stereotactic body radiotherapy (SBRT) distinguishes itself by necessitating more rigid patient immobilization, accounting for respiratory motion, ...

stereotactic-radiosurgery-for-gynecologic-cancer

Research

JoVE Journal

Medicine

17.5K vistas.  University Hospitals Case Medical Center and Case Western Reserve University School of Medicine. La radioterapia estereotáctica corporal (SBRT) implica guiada por imagen, radioterapia ablativa entregado a objetivos de cáncer resistente a la quimioterapia o la radioterapia convencional. La robótica CyberKnife sistema de armado SBRT, con la localización de destino sofisticado, ofrece una dosis de radiación capaces de hipofraccionados esterilización de los objetivos del cáncer. En este artículo se tendrá en cuenta las nuevas funciones terapéuticas de SBRT para...

Video: Stereotactic Radiosurgery for Gynecologic Cancer

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema.4,5 As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor.6 In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix.7 The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid.
Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion.8 It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used.9.
The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

Multiespectrales en tiempo real imágenes de fluorescencia para la detección intraoperatoria del ganglio centinela en Oncología Ginecológica

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

Investigación

Medicina

Stereotactic Intracranial Implantation and In vivo Bioluminescent Imaging of Tumor Xenografts in a Mouse Model System of Glioblastoma Multiforme

Glioblastoma multiforme (GBM) is a high-grade primary brain cancer with a median survival of only 14.6 months in humans despite standard tri-modality treatment consisting of surgical resection, post-operative radiation therapy and temozolomide chemotherapy 1. New therapeutic approaches are clearly needed to improve patient survival and quality of life. The development of more effective treatment strategies would be aided by animal models of GBM that recapitulate human disease yet allow serial imaging to monitor tumor growth and treatment response. In this paper, we describe our technique for the precise stereotactic implantation of bio-imageable GBM cancer cells into the brains of nude mice resulting in tumor xenografts that recapitulate key clinical features of GBM 2. This method yields tumors that are reproducible and are located in precise anatomic locations while allowing in vivo bioluminescent imaging to serially monitor intracranial xenograft growth and response to treatments 3-5. This method is also well-tolerated by the animals with low perioperative morbidity and mortality.

Stereotactic Intracranial Implantation and In vivo Bioluminescent Imaging of Tumor Xenografts in a Mouse Model System of Glioblastoma Multiforme

We describe an integrated method for the precise, stereotactic implantation of human glioblastoma multiforme cells into the brains of nude mice and subsequent serial in vivo imaging to monitor growth and response to treatment of the resultant xenografts.

La implantación estereotáctica intracraneal y<em&gt; En vivo</em&gt; Radiología bioluminiscente de xenoinjertos de tumores en un sistema modelo de ratón de glioblastoma multiforme

Glioblastoma multiforme (GBM) is a high-grade primary brain cancer with a median survival of only 14.6 months in humans despite standard tri-modality ...

Cerenkov Luminescence Imaging (CLI) for Cancer Therapy Monitoring

In molecular imaging, positron emission tomography (PET) and optical imaging (OI) are two of the most important and thus most widely used modalities1-3. PET is characterized by its excellent sensitivity and quantification ability while OI is notable for non-radiation, relative low cost, short scanning time, high throughput, and wide availability to basic researchers. However, both modalities have their shortcomings as well. PET suffers from poor spatial resolution and high cost, while OI is mostly limited to preclinical applications because of its limited tissue penetration along with prominent scattering optical signals through the thickness of living tissues.
 Recently a bridge between PET and OI has emerged with the discovery of Cerenkov Luminescence Imaging (CLI)4-6. CLI is a new imaging modality that harnesses Cerenkov Radiation (CR) to image radionuclides with OI instruments. Russian Nobel laureate Alekseyevich Cerenkov and his colleagues originally discovered CR in 1934. It is a form of electromagnetic radiation emitted when a charged particle travels at a superluminal speed in a dielectric medium7,8. The charged particle, whether positron or electron, perturbs the electromagnetic field of the medium by displacing the electrons in its atoms. After passing of the disruption photons are emitted as the displaced electrons return to the ground state. For instance, one 18F decay was estimated to produce an average of 3 photons in water5. 
 Since its emergence, CLI has been investigated for its use in a variety of preclinical applications including in vivo tumor imaging, reporter gene imaging, radiotracer development, multimodality imaging, among others4,5,9,10,11. The most important reason why CLI has enjoyed much success so far is that this new technology takes advantage of the low cost and wide availability of OI to image radionuclides, which used to be imaged only by more expensive and less available nuclear imaging modalities such as PET.
 Here, we present the method of using CLI to monitor cancer drug therapy. Our group has recently investigated this new application and validated its feasibility by a proof-of-concept study12. We demonstrated that CLI and PET exhibited excellent correlations across different tumor xenografts and imaging probes. This is consistent with the overarching principle of CR that CLI essentially visualizes the same radionuclides as PET. We selected Bevacizumab (Avastin; Genentech/Roche) as our therapeutic agent because it is a well-known angiogenesis inhibitor13,14. Maturation of this technology in the near future can be envisioned to have a significant impact on preclinical drug development, screening, as well as therapy monitoring of patients receiving treatments.

Cerenkov Luminescence Imaging CLI for Cancer Therapy Monitoring

Use of Cerenkov Luminescence Imaging (CLI) for monitoring preclinical cancer treatment is described here. This method takes advantage of Cerenkov Radiation (CR) and optical imaging (OI) to visualize radiolabeled probes and thus provides an alternative to PET in preclinical therapeutic monitoring and drug screening.

Cerenkov Luminiscencia Imaging (CLI) para la Vigilancia del Cáncer Terapia

In  molecular imaging, positron emission tomography (PET) and optical imaging (OI)  are two of the most important and thus most widely used modalities1-3. ...

Bioluminescent Orthotopic Model of Pancreatic Cancer Progression

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%. New therapeutic options are critically needed and depend on improved understanding of pancreatic cancer biology. To better understand the interaction of cancer cells with the pancreatic microenvironment, we demonstrate an orthotopic model of pancreatic cancer that permits non-invasive monitoring of cancer progression. Luciferase-tagged pancreatic cancer cells are resuspended in Matrigel and delivered into the pancreatic tail during laparotomy. Matrigel solidifies at body temperature to prevent leakage of cancer cells during injection. Primary tumor growth and metastasis to distant organs are monitored following injection of the luciferase substrate luciferin, using in vivo imaging of bioluminescence emission from the cancer cells. In vivo imaging also may be used to track primary tumor recurrence after resection. This orthotopic model is suited to both syngeneic and xenograft models and may be used in pre-clinical trials to investigate the impact of novel anti-cancer therapeutics on the growth of the primary pancreatic tumor and metastasis.

Improved understanding of pancreatic cancer biology is critically needed to enable the development of better therapeutic options to treat pancreatic cancer. To address this need, we demonstrate an orthotopic model of pancreatic cancer that permits non-invasive monitoring of cancer progression using in vivo bioluminescence imaging.

Modelo ortotópico bioluminiscente de la progresión del cáncer de páncreas

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%.  New therapeutic options are critically needed and depend on improved ...

Profiling of Estrogen-regulated MicroRNAs in Breast Cancer Cells

Estrogen plays vital roles in mammary gland development and breast cancer progression. It mediates its function by binding to and activating the estrogen receptors (ERs), ER&#945;, and ER&#946;. ER&#945; is frequently upregulated in breast cancer and drives the proliferation of breast cancer cells. The ERs function as transcription factors and regulate gene expression. Whereas ER&#945;&#39;s regulation of protein-coding genes is well established, its regulation of noncoding microRNA (miRNA) is less explored. miRNAs play a major role in the post-transcriptional regulation of genes, inhibiting their translation or degrading their mRNA. miRNAs can function as oncogenes or tumor suppressors&#160;and are also promising biomarkers. Among the miRNA assays available, microarray and quantitative real-time polymerase chain reaction (qPCR) have been extensively used to detect and quantify miRNA levels. To identify miRNAs regulated by estrogen signaling in breast cancer, their expression in ER&#945;-positive breast cancer cell lines were compared before and after estrogen-activation using both the &#181;Paraflo-microfluidic microarrays and Dual Labeled Probes-low density arrays. Results were validated using specific qPCR assays, applying both Cyanine dye-based and Dual Labeled Probes-based chemistry. Furthermore, a time-point assay was used to identify regulations over time. Advantages of the miRNA assay approach used in this study is that it enables a fast screening of mature miRNA regulations in numerous samples, even with limited sample amounts. The layout, including the specific conditions for cell culture and estrogen treatment, biological and technical replicates, and large-scale screening followed by in-depth confirmations using separate techniques, ensures a robust detection of miRNA regulations,&#160;and eliminates false positives and other artifacts. However, mutated or unknown miRNAs, or regulations at the primary and precursor transcript level, will not be detected. The method presented here represents a thorough investigation of estrogen-mediated miRNA regulation.

Molecular signaling through both estrogen and microRNAs are critical in breast cancer development and growth. Estrogen activates the estrogen receptors, which are transcription factors. Many transcription factors can regulate the expression of microRNAs, and estrogen-regulated microRNAs can be profiled using different large-scale techniques.

Perfiles de microARN regulados por estrógeno en las células del cáncer de mama

Estrogen plays vital roles in mammary gland development and breast cancer progression. It mediates its function by binding to and activating the estrogen ...

Utilizing Murine Inducible Telomerase Alleles in the Studies of Tissue Degeneration/Regeneration and Cancer

Telomere dysfunction-induced loss of genome integrity and its associated DNA damage signaling and checkpoint responses are well-established drivers that cause tissue degeneration during ageing. Cancer, with incidence rates greatly increasing with age, is characterized by short telomere lengths and high telomerase activity. To study the roles of telomere dysfunction and telomerase reactivation in ageing and cancer, the protocol shows how to generate two murine inducible telomerase knock-in alleles 4-Hydroxytamoxifen (4-OHT)-inducible TERT-Estrogen Receptor (mTERT-ER) and Lox-Stopper-LoxTERT (LSL-mTERT). The protocol describes the procedures to induce telomere dysfunction and reactivate telomerase activity in mTERT-ER and LSL-mTERT mice in vivo. The representative data show that reactivation of telomerase activity can ameliorate the tissue degenerative phenotypes induced by telomere dysfunction. In order to determine the impact of telomerase reactivation on tumorigenesis, we generated prostate tumor model G4 PB-Cre4 PtenL/L p53L/L LSL-mTERTL/L and thymic T-cell lymphoma model G4 Atm-/- mTERTER/ER. The representative data show that telomerase reactivation in the backdrop of genomic instability induced by telomere dysfunction can greatly enhance tumorigenesis. The protocol also describes the procedures used to isolate neural stem cells (NSCs) from mTERT-ER and LSL-mTERT mice and reactivate telomerase activity in NSCs in vitro. The representative data show that reactivation of telomerase can enhance the self-renewal capability and neurogenesis in vitro. Finally, the protocol describes the procedures for performing telomere FISH (Fluorescence In Situ Hybridization) on both mouse FFPE (Formalin Fixed and Paraffin Embedded) brain tissues and metaphase chromosomes of cultured cells.

Telomere and telomerase play essential roles in ageing and tumorigenesis. The goal of this protocol is to show how to generate two murine inducible telomerase knock-in alleles and how to utilize them in the studies of tissue degeneration/regeneration and cancer.

Utilizando murino Inducible telomerasa alelos en los Estudios de la degeneración del tejido / Regeneración y Cáncer

Telomere dysfunction-induced loss of genome integrity and its associated DNA damage signaling and checkpoint responses are well-established drivers that ...

Studying Pancreatic Cancer Stem Cell Characteristics for Developing New Treatment Strategies

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor initiation, metastasis and resistance to radio- and chemotherapy. Here we describe a specific methodology for culturing primary human pancreatic CSCs as tumor spheres in anchorage-independent conditions. Cells are grown in serum-free, non-adherent conditions in order to enrich for CSCs while their more differentiated progenies do not survive and proliferate during the initial phase following seeding of single cells. This assay can be used to estimate the percentage of CSCs present in a population of tumor cells. Both size (which can range from 35 to 250 micrometers) and number of tumor spheres formed represents CSC activity harbored in either bulk populations of cultured cancer cells or freshly harvested and digested tumors 1,2. Using this assay, we recently found that metformin selectively ablates pancreatic CSCs; a finding that was subsequently further corroborated by demonstrating diminished expression of pluripotency-associated genes/surface markers and reduced in vivo tumorigenicity of metformin-treated cells. As the final step for preclinical development we treated mice bearing established tumors with metformin and found significantly prolonged survival. Clinical studies testing the use of metformin in patients with PDAC are currently underway (e.g., NCT01210911, NCT01167738, and NCT01488552). Mechanistically, we found that metformin induces a fatal energy crisis in CSCs by enhancing reactive oxygen species (ROS) production and reducing mitochondrial transmembrane potential. In contrast, non-CSCs were not eliminated by metformin treatment, but rather underwent reversible cell cycle arrest. Therefore, our study serves as a successful example for the potential of in vitro sphere formation as a screening tool to identify compounds that potentially target CSCs, but this technique will require further in vitro and in vivo validation to eliminate false discoveries.

Pancreatic cancer stem cells (CSCs) can be expanded in vitro using the anchorage-independent sphere culture technique, which represents a powerful tool to study CSC biology and can serve as the first step to develop novel CSC-targeting therapies. Here the methodology for expanding, analyzing and targeting of pancreatic CSCs is provided.

El estudio de cáncer de páncreas Tallo Características de las células para el desarrollo de nuevas estrategias de tratamiento

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor ...

Dynamic Lung Tumor Tracking for Stereotactic Ablative Body Radiation Therapy

Physicians considering stereotactic ablative body radiation therapy (SBRT) for the treatment of extracranial cancer targets must be aware of the sizeable risks for normal tissue injury and the hazards of physical tumor miss. A first-of-its-kind SBRT platform achieves high-precision ablative radiation treatment through a combination of versatile real-time imaging solutions and sophisticated tumor tracking capabilities. It uses dual-diagnostic kV x-ray units for stereoscopic open-loop feedback of cancer target intrafraction movement occurring as a consequence of respiratory motions and heartbeat. Image-guided feedback drives a gimbaled radiation accelerator (maximum 15 x 15 cm field size) capable of real-time &#177;4 cm pan-and-tilt action. Robot-driven &#177;60&#176; pivots of an integrated &#177;185&#176; rotational gantry allow for coplanar and non-coplanar accelerator beam set-up angles, ultimately permitting unique treatment degrees of freedom. State-of-the-art software aids real-time six dimensional positioning, ensuring irradiation of cancer targets with sub-millimeter accuracy (0.4 mm at isocenter). Use of these features enables treating physicians to steer radiation dose to cancer tumor targets while simultaneously reducing radiation dose to normal tissues. By adding respiration correlated computed tomography (CT) and 2-[18F] fluoro-2-deoxy-&#7429;-glucose (18F-FDG) positron emission tomography (PET) images into the planning system for enhanced tumor target contouring, the likelihood of physical tumor miss becomes substantially less1. In this article, we describe new radiation plans for the treatment of moving lung tumors.

Stereotactic ablative body radiation therapy (SBRT) involves the precise delivery of high-dose radiation to cancer tumor targets. A novel SBRT platform offers a first-of-its-kind gimbaled radiation accelerator mounted within a pivoting O-ring gantry capable of dynamic image-guided tumor tracking. Here, we describe dynamic tumor tracking for lung targets.

Dinámica de seguimiento del tumor de pulmón para estereotáctica ablativa Radioterapia Corporal

Physicians considering stereotactic ablative body radiation therapy (SBRT) for the treatment of extracranial cancer targets must be aware of the sizeable ...

Working with Human Tissues for Translational Cancer Research

Medical research for human benefit is greatly impeded by the necessity for human tissues and subjects. However, upon obtaining consent for human specimens, precious samples must be handled with the greatest care in order to ensure integrity of organs, tissues, and cells to the highest degree. Unfortunately, tissue processing by definition requires extraction of tissues from the host, a change which can cause great cellular stress and have major repercussions on subsequent analyses. These stresses could result in the specimen being no longer representative of the site from which it was retrieved. Therefore, a strict protocol must be adhered to while processing these specimens to ensure representativeness. The desired assay(s) must also be taken into consideration in order to ensure that an optimal technique is used for sample processing. Outlined here is a protocol for tissue retrieval, processing and various analyses which may be performed on processed tissue in order to maximize downstream production from limited tissue samples.

Translational cancer research is dependent on extraction of human tissues. Much work has gone into optimizing extraction methods for ex vivo analysis. Here, we describe tissue processing methods allowing for maximal data output from limited samples.

Trabajar con Tejidos Humanos para la Investigación del Cáncer Traslacional

Medical research for human benefit is greatly impeded by the necessity for human tissues and subjects. However, upon obtaining consent for human ...

Modeling the Early Steps of Ovarian Cancer Dissemination in an Organotypic Culture of the Human Peritoneal Cavity

The pattern of ovarian cancer metastasis is markedly different from that of most other epithelial tumors, because it rarely spreads hematogenously. Instead, ovarian cancer cells exfoliated from the primary tumor are carried by peritoneal fluid to metastatic sites within the peritoneal cavity. These sites, most notably the abdominal peritoneum and omentum, are organs covered by a mesothelium-lined surface. To investigate the processes of ovarian cancer dissemination, we assembled a complex three-dimensional culture system that reconstructs the lining of the peritoneal cavity in vitro. Primary human fibroblasts and mesothelial cells were isolated from human omentum. The fibroblasts were then mixed with extracellular matrix and covered with a layer of the primary human mesothelial cells to mimic the peritoneal and omental surfaces encountered by metastasizing ovarian cancer cells. The resulting organotypic model is, as shown, used to examine the early steps of ovarian cancer dissemination, including cancer cell adhesion, invasion, and proliferation. This model has been used in a number of studies to investigate the role of the microenvironment (cellular and acellular) in early ovarian cancer dissemination. It has also been successfully adapted to high throughput screening and used to identify and test inhibitors of ovarian cancer metastasis.

Here, we present a protocol to construct a three-dimensional in vitro model of the lining of the peritoneal cavity, composed of primary human mesothelial cells and fibroblasts layered with extracellular matrix, as a tool to investigate ovarian cancer cell adhesion, invasion, and proliferation.

Modelado de los primeros pasos de cáncer de ovario Difusión en una cultura organotípicos del Peritoneal Cavity Humano

The pattern of ovarian cancer metastasis is markedly different from that of most other epithelial tumors, because it rarely spreads hematogenously. ...