[Radiotherapy of follicle center lymphoma. Results of a German multicenter and prospective study. Members of the Study Group "NHL-early stages"]. / Strahlenbehandlung von follikulären Keimzentrumslymphomen. Ergebnisse einer deutschen multizentrischen und prospektiven Studie. Mitglieder der Studiengruppe "NHL--frühe Stadien".

PURPOSE: Follicle centre lymphoma grade I, II (REAL) or centroblastic-centrocytic lymphoma (Kiel classification) present a well defined clinical entity from a clinical point of view. These lymphomas are not curable by chemotherapy in early or advanced stages. They are treated by radiation therapy in early stages, but up to now the curative potency of radiotherapy has not been confirmed by prospective clinical trials. PATIENTS AND METHODS: Between January 1986 and August 1993 117 adults with follicle centre lymphoma were recruited from 24 institutions to enter the multicentric prospective, not randomised clinical trial. Patients with histologically proven nodal follicle centre lymphoma of stages I, II and limited III were included. They were treated by a standardised radiotherapy regimen, in stage I by extended field and in stages II and III by total nodal irradiation. Dose per fraction was 1.8 to 2.0 Gy, in the abdominal bath 1.5 Gy up to a total dose of 26 Gy in adjuvant situation and 36 Gy to enlarged lymphoma. RESULTS: All patients developed a complete remission at the end of radiotherapy. Median follow-up is 68 months. Overall survival of all patients in 86 +/- 3% at 5 and 8 years. Stage adjusted survival at 5 and 8 years was 89% for stage I, 86% for stage II and 81% for III. Patients in stages I and II < 60 years had survival rates of 94% at 5 and 8 years, patients > 60 years 63% (p < 0.0001). Recurrence free survival of all patients is 70% at 5 and 60 +/- 5% at 8 years. The number of recurrences is high with 29% at 5 and 41% at 8 years. All recurrences were seen within 7 years. The probability of localised nodal in-field recurrences is 11% and 22% at 5 and 8 years, respectively. Adverse prognostic factors were identified by multivariate analysis: age > 60 years, treatment breaks > or = 7 days and dose deviations > 20% from prescribed doses. Acute side effects of extended field irradiation were moderate. CONCLUSIONS: On the basis of these results radiotherapy is a potentially curative therapeutic approach in stages I, II and limited III of follicle centre lymphoma. The optimal technique is total lymphoid irradiation with doses of 30 Gy in the adjuvant situation and 40 to 44 Gy in enlarged lymphomas. The number of local recurrences leads to the assumption, that the extension of radiotherapy to the total lymphoid system might reduce their frequency.

[Adjuvant whole-brain irradiation in small-cell bronchial carcinoma]. / Zur Frage der adjuvanten Ganzhirnbestrahlung beim kleinzelligen Bronchialkarzinom.

PURPOSE: To analyse if prophylactic cranial irradiation in small cell lung cancer for improved survival is indicated; if adjuvant irradiation could cure the microscopic disease; if and how late effects could be minimized. PATIENTS AND METHODS: Data from randomized trials and retrospective studies are critically analysed related to the incidence of central nervous system (CNS) metastases in limited disease patients in complete remission with or without prophylactic cranial irradiation. The mechanisms of late effects on CNS of prophylactic cranial irradiation and combined treatment are presented. RESULTS: Prophylactic cranial irradiation could decrease the incidence of CNS metastases but could not improve survival. A subgroup of patients (9 to 14%) most likely to benefit from prophylactic cranial irradiation includes patients who are likely to have an isolated CNS failure. The actual used total dose in the range 30 to 40 Gy could only conditionally decrease the CNS failure. Higher total and/or daily doses and combined treatment are related with potentially devastating neurologic and intellectual disabilities. CONCLUSIONS: No prospective randomized trial has demonstrated a significant survival advantage for patients treated with prophylactic cranial irradiation. Prophylactic cranial irradiation is capable of reducing the incidence of cerebral metastases and delays CNS failure. A subgroup of patients most likely to benefit from prophylactic cranial irradiation (9 to 14%) includes patients who are likely to have an isolated CNS failure, but this had yet to be demonstrated. The toxicity of treatment is difficult to be influenced. Prophylactic cranial irradiation should not be given concurrently with chemotherapy, a larger interval after chemotherapy is indicated. The total dose should be in the range 30 to 36 Gy and the daily fraction size not larger than 2 Gy.

Fotemustine given simultaneously with total brain irradiation in multiple brain metastases of malignant melanoma: report on a pilot study.

Melanoma patients with multiple brain metastases not amenable to surgery or stereotactic radiotherapy were treated with total brain irradiation in fractions of 2.5 Gy four times weekly, up to 40 Gy. At days 1, 8, and 25100 mg/m2 fotemustine was infused 4 h before irradiation. Of 12 evaluable patients, four showed partial remission and three stabilization in the brain. The median survival in these two groups of patients was 6 months; the survival of the other patients was 2 months. Severe haematological side effects were observed in 6/13 patients. In conclusion, the combination of fotemustine and total brain irradiation seems to be more effective than either treatment alone, but bears the risk of additional bone-marrow toxicity.

Omission of the pelvic irradiation in stage I testicular seminoma: a study of postorchiectomy paraaortic radiotherapy.

PURPOSE: To review the survival, cure rate, and pattern of relapse or progression of patients with histologically confirmed Stage I testicular seminoma who underwent orchiectomy and radiation therapy to paraaortic lymphatics only. The pelvic ipsilateral lymph nodes were not irradiated. METHODS AND MATERIALS: Between 1978 and 1992, 150 patients with Stages I or II testicular seminoma received treatment at the Department of Radiation Oncology of the University of Wuerzburg. The distribution by stage was Stage I, 117 patients of which 93 were pT1 N0 M0 and 24 were pT2 N0 M0. Four patients were staged as Stage II (pT3 N0 M0), and in 29 patients the T Stage was not specified. Eighty-six patients from the 117 Stage I (pT1-pT2, N0 M0 according to the TNM classification) seminoma received postorchiectomy irradiation, and are analyzed for outcome in this article. The distribution of the Stage I patients by pT Stage was 71 pT1 and 15 pT2 patients. All these 86 patients had their paraaortic nodes (the biological target volume extending from top of L1 to the bottom of L5) irradiated with four field technique. Tumor dose was specified at normalization point along the central axis. The median tumor dose was 30 Gy given in 1.8-2.0 Gy fractions. Elective irradiation to the ipsilateral hemipelvis (iliac nodes) was totally abandoned. RESULTS: The 10-year disease-free survival and overall survival were 95.3 and 100%. No recurrence in the irradiated field was noted. Four patients (4.7%) experienced relapse of disease outside the treated volume. The most common site of solitary failure was the ipsilateral hemipelvis (one iliacal and one inguinal). One patient developed metastatic disease to the lung. One patient developed a mediastinal recurrence with superior vena cava syndrome and was successfully salvaged by mediastinal irradiation and chemotherapy. CONCLUSIONS: Recommendation for the future management of Stage I seminoma include: reduced biological target volume to the paraaortal lymph nodes (from lumbar vertebra L1 to L5). Complete elimination of irradiation to the pelvic nodes is warranted. Radiation dose should not exceed 30 Gy.

[Usefulness of prophylactic whole brain irradiation in small-cell bronchial carcinoma]. / Der Nutzen der prophylaktischen Ganzhirnbestrahlung (PCI) beim kleinzelligen Bronchialkarzinom.

PURPOSE: An analysis of the incidence of brain metastases in small cell lung cancer, time of occurring during the course of disease, and the prognosis of these patients depending on the use of prophylactic cranial irradiation for three well defined patient groups. MATERIAL AND METHODS: A retrospective study included 133 unselected patients with histologically proven SCLC who were treated from 1985-1990 in our department. From these, 118 patients without CNS metastases at primary diagnosis were divided into three well defined patient groups: group I consisted of 23 patients who achieved a complete remission after primary therapy and who were subsequently treated with PCI, group II consisted of 23 patients in complete remission without PCI. Group III consisted of 72 patients without CNS metastases at the primary diagnosis and without PCI treatment since they did not achieve a complete response after primary therapy. The primary therapy consisted of combined radiochemotherapy or only chemotherapy. Sixteen patients were treated only by irradiation. RESULTS: The overall incidence of CNS metastases for all 133 patients was 33.1%. The incidence of new CNS metastases in group I was 21.7% in group II 26.1%, and in group III 22.2%. The average time to development of CNS metastases after primary diagnosis was different for the three groups: in group I 15.4 months, in group II 9.5 months and in group III 8.4 months. No statistical significance was noted. Median survival time for group I was 16.1 months, for group II 13.8 months and 8.4 months for the group III. No statistical significance was achieved between group I and II (P > 0.05). CONCLUSIONS: These data suggest that treatment with PCI appears to be ineffective in reducing the incidence of subsequently CNS metastases or to improve survival of SCLC patients. We recommend the use of PCI only in well defined clinical studies.

[CNS metastases in malignant melanomas]. / ZNS-Metastasen beim malignen Melanom.

PURPOSE: To show treatment results and to define prognostic subgroups in patients undergoing radiotherapy for brain metastases from malignant melanoma. PATIENTS AND METHODS: Between 1985 and 1993 30 patients underwent radiation therapy for brain metastases from malignant melanoma. In 9 patients they had been surgically resected. All except 1 patient received whole brain irradiation with a total dose of 20 to 46 Gy/2 to 5 weeks using daily fractions of 2.0 to 4.0 Gy. In 5 patients a local boost of 20 to 25 Gy/2 weeks was administered. Survival rates were compared using the Cox-method. Univariate and multivariate analyses were performed to define prognostic subgroups. RESULTS: In 6/30 patients (20%) brain metastases were diagnosed at the time of primary manifestation of melanoma. In 83% of patients brain metastases developed during the first 5 years following primary diagnosis. Late manifestation was observed (18 years). Overall survival rate of the whole group was 39% at 6 months and 23% at 1 year. Univariate analysis revealed that age at diagnosis of brain metastases, time to manifestation, number of intracranial metastases and existence of extracerebral distant metastases had significant influence on survival. Sex was not found to influence survival rate. Multivariate analysis identified the existence of extracerebral distant metastases at the time of diagnosis of brain metastases as the most important prognostic factor for survival, followed by age and surgical resection. The role of fractionation was studied separately in a subgroup of patients receiving whole brain irradiation to a total dose of 39 to 42 Gy. Survival rates deteriorated when overall treatment time exceeded 3 weeks. CONCLUSION: Prognosis following brain metastases from malignant melanoma is very unfavourable. The described prognostic factors can be helpful to choose the adequate therapeutic modality for the patient, especially for selection of patients for radiosurgery. Whole brain irradiation with 13 x 3 Gy/3 weeks seems a safe and well tolerated treatment schedule either in palliative care or following surgical resection or preceding radiosurgical treatment.

The clinical relevance of metastatic pattern in breast-cancer - the heterogeneity of metastatic disease.

Patients with metastatic breast cancer are considered as a homogeneous group because of the relative rarity of data relating to specific organ metastases. In this study, the clinical course of metastatic breast cancer was documented for 278 female patients registered from 1978 through 1988 at the Clinic for Radiotherapy of the University of Wurzburg. We analysed these 278 patients with metastatic disease to work out the clinical significance of specific organ metastases (SOM). A comparison of the six most frequent specific organ metastatases (SOM), i.e., bone, lung, CNS, liver, lymph node and skin metastases, is presented. Our findings indicate, that the group of patients with metastatic disease is heterogenous relating to age at time of metastatic disease, to metastatic-free intervall and to the influence of specific organ metastases on survival. The heterogeneity in the group of patients with distant metastatic disease has to be taken in consideration, when the results of chemotherapy are reported.

[The indications for the curative radiotherapy of non-small-cell bronchial carcinoma. Reflections from a clinical viewpoint]. / Indikationen zur kurativen Strahlenbehandlung des nichtkleinzelligen Bronchialkarzinoms. Uberlegungen aus klinischer Sicht.

PURPOSE: To find out the indications for treatment and selection criteria of patients who will profit from curative radiotherapy. PATIENTS AND METHODS: A literature review and own data concerning the lymphogenous metastatic pathways and incidence of involvement of loco-regional lymph nodes are used to define the biological treatment volume of a curative irradiation. A retrospective analysis of 266 patients with non-small-cell lung cancer (NSCLC) was performed. The metastatic pathway of the lymphogenous spread was analysed based on pretherapy CT scan as well as clinical examination. RESULTS: Only carefully selected patients under similar selection criteria as for curative surgery are suitable to undergo a curative radiotherapy. The biological treatment volume for curative irradiation has to include the primary with a margin, the ipsilateral hilar nodes as well as the whole mediastinum including the subcarinal lymph nodes, but not the contralateral hilar and supraclavicular lymph nodes. The survival rate of patients with N3 nodal stage are 0%. A 3-step concept for curative radiotherapy until 70 Gy is proposed. CONCLUSIONS: A limited number of patients with NSCLC, carefully selected as for surgery, are suitable to undergo a curative radiotherapy with 70 Gy. This will enable to demonstrate a curative value of radiotherapy.

[A retrospective analysis of the treatment results in Hodgkin's disease in a radiotherapy clinic]. / Retrospektive Analyse der Behandlungsergebnisse bei Morbus Hodgkin in einer strahlentherapeutischen Klinik.

PURPOSE: Treatment results were reviewed in a retrospective analysis and compared with literature data. Prognostic factors for freedom from relapse and overall survival were identified. PATIENTS AND METHODS: We analyzed the history of 183 patients treated for Hodgkin's disease between 1977 and 1989 at the Department of Radiation Therapy at the University of Würzburg. There were 100 males and 83 females between 16 and 86 years of age. 70.5% of patients presented with early stage Hodgkin's disease (23.5% stage I and 47.0% stage II) and 29.5% had advanced stages (25.1% stage III and 4.4% stage IV). All patients were treated initially with radiotherapy, 114 had radiotherapy alone and 69 patients received combined modality treatment. RESULTS: Hundred and sixty-one patients (88.0%) reached a complete remission. Freedom from relapse was 73.7% at 5 years and 70.3% at 10 years for these patients, overall survival was 74.3% and 62.8% at 5 and 10 years for all patients. Prognostic factors for freedom from relapse were stage IV, B symptoms, age greater than 35 years and more than 3 involved lymph node regions. These factors also were relevant for overall survival, in addition mixed cellularity or lymphocyte depleted subtype, high erythrocyte sedimentation rate, failure to achieve a complete remission following initial treatment and relapse of Hodgkin's disease were identified as negative prognostic factors. Laparotomy staged patients who received radiotherapy only for stage I and II Hodgkin's disease had better outcome than clinically staged patients. Our data suggest that adequate therapy is able to reduce the impact of unfavourable prognostic factors. The outcome for patients with bulky mediastinal disease was similar to that in patients without a mediastinal mass. CONCLUSIONS: The optimal choice of treatment for patients with early stage Hodgkin's disease--combined modality treatment/radiotherapy alone/chemotherapy alone?--and for patients with advanced stages--consolidation radiotherapy?--remains an unresolved issue and needs further testing in large randomized trials considering acute and late complications. Staging laparotomy may be used only for a small group of patients who would receive radiotherapy alone as definitive treatment. Modifications of therapy clearly reduce the impact of negative prognostic factors.

[Radiation pneumonitis and pulmonary fibrosis after the CT-planned radiotherapy of bronchial carcinoma]. / Strahlenpneumonitis und Lungenfibrose nach CT-geplanter Radiotherapie des Bronchialkarzinoms.

PURPOSE: Examination of the influence of total tumor dose, additional therapy and age on the development of radiation pneumonitis and lung fibrosis. PATIENTS AND METHODS: Two hundred and sixteen patients with squamous cell carcinoma of the lung were examined retrospectively. Hundred and eighty-three of them received a percutaneous radiation therapy of the primary tumor and the mediastinal and ipsilateral hilar lymph nodes. The majority of 130 patients was given radiotherapy as only treatment, 27 were irradiated after resection and 26 received chemo- and radiotherapy. Treatment volume was determined by three-dimensional planning using chest CT-scan. The irradiation was administered in a first series of 56 Gy and a following boost to the primary and involved lymph nodes to a total dose of 70 Gy. There was one daily irradiation with 2 Gy 5 days a week. Post-resectional radiation encompassed the bronchus stump and the mediastinum with a total dose of about 60 Gy. RESULTS: Sixty-eight of the 183 irradiated patients developed a pneumonitis (37.2%) and 60 a lung fibrosis (32.8%). The most important factor was the administered total irradiation dose (p < 0.001). There was no pneumonitis documented below 36 Gy and no fibrosis below 40 Gy. An additional chemotherapy did not increase the incidence (pneumonitis after radiotherapy 35.4%, after radio- and chemotherapy 34.6%; fibrosis after radiotherapy 33.9%, after radio- and chemotherapy 38.5%). Particularly high was the incidence of pneumonitis when radiotherapy followed resection (48.2%) while the rate of fibrosis in this group of patients was relatively low (22.2%). Age of patients did not affect the frequency of pneumonitis while fibrosis significantly occurred more often with increasing age (p = 0.037). CONCLUSION: The total dose affecting the normal lung tissue is the most important factor for the development of radiation pneumonitis and lung fibrosis. It is recommended to keep the treatment volume appropriate to the individual extend of tumor. Good results are achieved with a computer supported CT-planning which helps to gain minimal burdening of normal tissue.

The lymphatic pathways of non-small cell lung cancer and their implication in curative irradiation treatment.

Using the pre-therapy CT scans of 266 node positive non-small cell lung cancer patients, we analysed the lymphatic pathways and the incidence of lymph node metastases in regional lymph nodes (as described by CT criteria corresponding to the modified mapping scheme of the American Thoracic Society), in order to develop the target volume for curative irradiation treatment. Among the 105 patients with node positive left sided primaries, the incidence of involvement of the ipsilateral supraclavicular lymph nodes was 9.5%, and the incidence of involvement of the contralateral lymph nodes was 3.8%. The incidence of involvement of the contralateral hilar lymph nodes was 4.8%. Among the 161 patients with nodal positive right sided primaries, the incidence of involvement of the ipsilateral supraclavicular lymph nodes was 8.7% and the incidence of involvement of the contralateral lymph nodes was 1.8%. For this group of patients, the incidence of involvement of the contralateral hilar lymph nodes was 3.7%. All patients with involvement of the contralateral hilar lymph nodes died within 2.5 years of diagnosis. In the cases where there was involvement of the supraclavicular lymph nodes, the patients died within 1.6 years. Involvement of the ipsilateral and/or contralateral supraclavicular lymph nodes, and/or the contralateral hilar lymph nodes, is defined as N3 disease, and is included in Stage IIIb. No curative surgery is indicated for these patients. Why therefore should this group of patients be treated with curative intent by irradiation of the primary, ipsilateral and contralateral hilar lymph nodes, as well as mediastinal, ipsilateral and contralateral supraclavicular lymph nodes? The curative radiation treatment volume for lung cancer has to include the primary tumor and the ipsilateral hilar, and the low and high mediastinal lymph nodes, as is indicated for Stage I, II and IIIa disease.

Preoperative radiochemotherapy and radical surgery in comparison with radical surgery alone. A prospective, multicentric, randomized DOSAK study of advanced squamous cell carcinoma of the oral cavity and the oropharynx (a 3-year follow-up).

A multicentric, randomized study of squamous cell carcinoma (SCC) of the oral cavity and the oropharynx has been undertaken by DOSAK. The results after radical surgery alone have been compared with the results of combined preoperative radiochemotherapy followed by radical surgery. Patients with primary (biopsy proven) SCC of the oral cavity or the oropharynx with tumor nodes metastasis (TNM) stages T2-4, N0-3, M0 were included in the study. A total of 141 patients were treated by radical surgery alone, whereas 127 patients were treated by radical surgery preceded by preoperative radiochemotherapy. The preoperative treatment consisted of conventionally fractioned irradiation on the primary and the regional lymph nodes with a total dose of 36 Gy (5 x 2 Gy per week) and low-dose cisplatin chemotherapy with 5 x 12.5 mg cisplatin per m2 of body surface during the first week of treatment. Radical surgery according to the DOSAK definitions (DOSAK, 1982) was performed after a delay of 10-14 days. During the follow-up period, 28.2% of all patients suffered from locoregional recurrence, and 27.2% of the patients died. The percentages were higher after radical surgery alone for locoregional recurrence (31% and 15.6%) and for death (28% and 18.6%). The life-table analysis showed improved survival rates of 4.5% after 1 year and 8.3% after 2 years in the group of patients treated with combined therapy. The demonstrated improvement appeared to be significant with the Gehan-Wilcoxon test as well as with the log rank test below a P value of 5%.

The prognostic significance of the supraclavicular lymph node metastases in breast cancer patients.

PURPOSE: To define the patterns of failure and outcome of patients presenting supraclavicular lymph node involvement and the prognostic significance of supraclavicular lymph node involvement. METHODS AND MATERIALS: We reviewed the history of 795 breast cancer patients treated at the Department of Radiation Therapy, University of Würzburg between 1978 and 1988. The clinical and pathologic features of 21 patients who had ipsilateral supraclavicular lymph node metastases at primary diagnosis and 38 patients who presented supraclavicular lymph node recurrence during the course of disease were reviewed. These were compared with the features of 20 patients who initially had M1 status at primary diagnosis and 278 patients who had developed distant metastases in the follow-up period. Survival rates were calculated starting from the time of diagnosis of supraclavicular involvement respective of distant metastases. RESULTS: Survival from appearance of supraclavicular lymph node metastases at primary diagnosis or as a recurrence is not different from survival of patients presenting with a primary M1 stage or presenting distant metastases during the course of disease. Two and 5-year survival rates of patients with supraclavicular lymph node involvement at primary diagnosis were 52% and 34% compared to 50% and 16% 2- and 5-year survival rate of patients with supraclavicular lymph node involvement as a recurrence. Patients who presented a primary M1-status had 2- and 5-year survival rates of 56% and 24%. Survival of patients with distant metastases calculated from the onset of metastatic disease was similar to that of the other three groups with a 46% and 16% survival rate at 2 and 5 years. There was no difference in survival rates between the four groups. CONCLUSION: The prognostic significance of supraclavicular lymph node involvement at primary diagnosis or as a relapse is similar, both have the same significance as the first distant relapse and are characterized by a poor prognosis.

Supraclavicular lymph-node recurrence of breast-cancer.

To describe prognosis and outcome of patients with a recurrence in the supraclavicular fossa (SCLNR) and to evaluate the role of different therapeutic options for recurrence on the outcome of these patients, clinical and pathological characteristics, treatment and time course of 55 patients with supraclavicular recurrence as their first relapse of disease were analysed. Thirty-nine patients had an isolated recurrence, i.e. no distant metastases were known at the time of supraclavicular recurrence. Median follow-up was 20.4 months from supraclavicular recurrence and 58.8 months from primary diagnosis. For evaluation of treatment only the 39 patients without distant disease before or simultaneous with supraclavicular recurrence were analysed. Mean age of the 55 patients at primary diagnosis and at diagnosis of recurrence was 56.7 and 61.2 years respectively. The majority of patients developing such a recurrence was younger than 60 years at the time of primary diagnosis, Evaluation of patient characteristics showed a high proportion of positive axillary status (65%) at the time of primary diagnosis with a mean number of 7.5 involved nodes. Tumor was located in the medial or central part of the breast in 53% of patients in whom primary tumor location was known. About 80% of patients developed their recurrence in the first 5 years from primary diagnosis of breast cancer. Global survival after SCLNR was poor. Survival rate from recurrence was 65% at 2 years and only 16% at 5 years. Among the 39 patients with an isolated SCLNR 88% developed distant metastases within 5 years from recurrence. The evaluation of different therapeutic options for a SCLNR (radiotherapy, surgery, systemic therapy) revealed no significant influences on survival rates. When local regional control was obtained, a trend towards improved survival was noted. Patients aged younger than 60 years at primary diagnosis, with high positive primary axillary status or tumor of the medial or central part of the breast seem to be at higher risk for developing SCLNR and internal mammary lymphatic route may be a more probable pathway to the supraclavicular nodes besides the common axillary route. SCLNR carries a grave prognosis. Most patients develop distant disease within short time, with only a small section surviving more than 5 years from the onset of recurrence. Survival rate of patients with SCLNR is clearly inferior to patients with local or regional axillary recurrence. From this we conclude that SCLNR should be considered as an indicator of systemic disease despite its lymphogenous genesis and not as regional recurrence. Local therapy of SCLNR is to be defined with palliative intent in most cases. Systemic therapy has to be applied additionally even if no other distant disease is known. Further prospective analyses will have to evaluate the role of systemic treatment for solitary supraclavicular recurrences.

[Interstitial HDR afterloading therapy with flexible catheters]. / Interstitielle HDR-Afterloading-Therapie mit flexiblen Kathetern.

At the department of radiation therapy of the university of Würzburg flexible catheters are in use since 1989 for interstitial brachytherapy in high dose rate mode as the sole treatment modality or in combination with external beam therapy. The afterloading technique is applied in carcinoma of the oropharynx, of the oral cave, of the pancreas and in brain tumors. As flexible catheters are well tolerated, high radiation doses are given in fractions over several days up to two weeks. Localisation radiographs and CT scans are needed, in order to calculate exactly the dose distribution of target volume and adjacent healthy tissue. Doses up to 30 Gy for the target volume in 10 to 15 fractions are well tolerated. The patients daily activities are not restricted during the whole treatment time. Excellent palliations are achieved with minimal side effects.

[Prognostic factors in breast cancer--classification in non-university hospitals]. / Prognosefaktoren beim Mammakarzinom--Klassifikation in nichtuniversitären Krankenhäusern.

Prognostic factors in breast cancer have been frequently discussed in the oncologic literature. We reviewed our data of 795 patients who were referred to the Department of Radiation Oncology of the University of Wuerzburg between 1978 and 1988 in order to find out, whether the well known and proven prognostic factors in breast cancer were sufficiently in use in clinical routine, even out of university oncologic centres. We found, that beside of determination of the histological tumor-type the assessment of tumor size (= pT-status) and axillary (= pN-)status is performed nowadays in all patients. In contrary, the determination of the hormonal receptor status (HRS) had a slow beginning. From 1980 the rate of determinated HRS arose from 5% to 80% nowadays. The demand of removal and examination of at least 12 axillary lymph nodes in axillary dissection in order to determine correctly the axillary status is not yet part of the oncological routine. In 1988 in only 40% of the referred patients axillary diagnosis was done in a manner corresponding to international rules.