LINAC radiosurgery in skull base meningiomas.

LINAC radiosurgery has provided increasing access and changed treatment strategies in patients with benign skull base meningiomas in recent years. From January 1996 to January 2003, 37 patients with skull base meningiomas were treated with LINAC radiosurgery. A combination of the University of Florida system and the X Knife System, developed by Radionics, was used in all patients. Eight patients were treated by microsurgical resection before radiosurgery, in two patients tumor recurrence was treated and in 29 patients LINAC radiosurgery was the initial treatment procedure. The median treatment volume was 5.9 mL (0.7 to 22 mL) and the median given dose was 14.6 Gy (12.8 to 18 Gy) prescribed to the 80 percent isodose line. The follow-up period is between 12 and 96 months, median 66 months. 12 patients (32.4 %) showed a significant reduction in tumor size, in 11 patients (29.7 %) there was significantly less contrast enhancement and in 13 patients (35.1 %) the skull base meningioma was without any change. In one patient (2.8 %) there was tumor growth 48 months after radiosurgery, so the tumor control rate was 97.2 %. Two patients (5.6 %) showed neurological worsening after radiosurgery, whereas the symptoms were transient in one patient. LINAC radiosurgery offers us an effective treatment modality and changes treatment strategies in skull base meningiomas towards a less aggressive surgical approach. By combining microsurgery and radiosurgery we can achieve high tumor control rates with an acceptable low morbidity and a high level of quality of life.

Adjuvant vs. neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94.

AIM: The standard treatment for patients with clinically resectable rectal cancer is surgery. Postoperative radiochemotherapy (RCT) is recommended for advanced disease (pT3/4 or pN+). In recent years, encouraging results of pre-operative radiotherapy have been reported. This prospective randomized phase-III-trial (CAO/ARO/AIO-94) compares the efficacy of neoadjuvant RCT to standard postoperative RCT. We report on the design of the study and first results with regard to toxicity of RCT and postoperative morbidity. PATIENTS AND METHODS: Patients with locally advanced operable rectal cancer (uT3/4 or uN+, Mason CS III/IV) were randomly assigned to pre or postoperative RCT: A total dose of 50.4 Gy (single dose 1.8 Gy) was applied to the tumour and the pelvic lymph nodes. 5-FU (1000 mg/m2/d) was administered concomitantly in the 1th and 5th week of radiation as 120 h-continuous infusion. Four additional cycles of 5-FU-chemotherapy (500 mg/m2/d, i.v.-bolus) were applied. RCT was identical in both arms except for a small-volume boost of 5.4 Gy postoperatively. The time interval between RCT and surgery was 4-6 weeks in both arms. Techniques of surgery were standardized and included total mesorectal excision. Primary endpoints of the study are 5-year survival and local and distant control. Secondary endpoints include the rate of curative (R0) resection and sphincter saving procedures, toxicity of RCT, surgical complications and quality of life. RESULTS: As of July 2002, 805 patients were randomized from 26 participating institutions. Acute toxicity (WHO) of RCT was low, with less than 15% of patients experiencing grade 3 or higher toxicity: The principal toxicity was diarrhea, with 12% in the postoperative RCT-arm and 11% in the pre-operative RCT-arm having grade 3-, and 1% in either arm having grade 4-diarrhea. Erythema, nausea and leukopenia were the next common toxicities, with less than 3% of patients in either arm suffering grade 3 or greater leukopenia or nausea. Postoperative complication rates were similar in both arms, with 12% (postop. RCT) and 12% (pre-op. RCT) of patients, respectively, suffering from anastomotic leakage, 3% (postop. RCT) and 3% (pre-op. RCT) from postoperative bleeding, and 6% (postop. RCT) and 4% (pre-op. RCT) from delayed wound healing. CONCLUSION: The patient accrual to the trial is satisfactory. Neoadjuvant RCT is well tolerated and bears no higher risk for postoperative morbidity.

Adjuvant versus neoadjuvant radiochemotherapy for locally advanced rectal cancer. A progress report of a phase-III randomized trial (protocol CAO/ARO/AIO-94).

AIM: The standard treatment for patients with clinically resectable rectal cancer is surgery. Postoperative radiochemotherapy is recommended for patients with advanced disease (pT3/4 or pN+). In recent years, encouraging results of preoperative radiotherapy have been reported. This prospective randomized phase-III trial (CAO/ARO/AIO-94) compares the efficacy of neoadjuvant radiochemotherapy to standard postoperative radiochemotherapy. We report on the design of the study and first results with regard to toxicity of radiochemotherapy and postoperative morbidity. PATIENTS AND METHODS: Patients with locally advanced operable rectal cancer (uT3/4 or uN+, Mason CS III/IV) were randomly assigned to pre- or postoperative radiochemotherapy: A total dose of 50.4 Gy (single dose 1.8 Gy) was applied to the tumor and the pelvic lymph nodes. 5-FU (1,000 mg/m2/d) was administered concomitantly in the first and fifth week of radiation as 120-h continuous infusion. Four additional cycles of 5-FU chemotherapy (500 mg/m2/d, i.v. bolus) were applied. Radiochemotherapy was identical in both arms except for a small-volume boost of 5.4 Gy in the postoperative setting. Time interval between radiochemotherapy and surgery was 4-6 weeks in both arms. Techniques of surgery were standardized and included total mesorectal excision. In addition, stratification according to surgeons involved has been provided for. Primary endpoints of the study are 5-year overall-survival, local and distant control, secondary endpoints include rate of curative (R0) resections and sphincter saving procedures, toxicity of radiochemotherapy, surgical complications and quality of life. RESULTS: As of 15th November 2000, 628 patients were randomized from 26 participating institutions: 310 patients were randomized to postoperative radiochemotherapy, 318 patients to preoperative radiochemotherapy. Acute toxicity (WHO) of radiochemotherapy was low, with less than 15% of patients experiencing Grade 3 or higher toxicity: The principal toxicity was diarrhea, with 12% in the postoperative radiochemotherapy arm and 10% in the preoperative radiochemotherapy arm having Grade-3, and 1% in either arm having Grade-4 diarrhea. Erythema, nausea and leukopenia were the next common toxicities, with less than 3% of patients in either arm suffering Grade 3 or greater leukopenia or nausea. Postoperative complication rates were similar in both arms, with 12% (postoperative radiochemotherapy) and 13% (preoperative radiochemotherapy) of patients, respectively, suffering from anastomotic leakage, 4% (postoperative radiochemotherapy) and 3% (preoperative radiochemotherapy) from postoperative bleeding, and 6% (postoperative radiochemotherapy) and 5% (preoperative radiochemotherapy) from delayed wound healing. CONCLUSION: The patient accrual of our trial is satisfactory, neoadjuvant radiochemotherapy is well tolerated and bears no higher risk for postoperative morbidity.

Hyaluronidase as additive to induction chemotherapy in advanced squamous cell carcinoma of the head and neck.

Forty-eight patients with advanced head and neck tumours were treated with irradiation and concomitant chemotherapy with cisplatin, vindesine and hyaluronidase. The disease-free survival rate at 5 years was 47%. The toxic effects were mucositis (48 patients), nausea (25 patients, vomiting in six patients), bone marrow depression (15 patients) and peripheral neuropathy (14 patients). The results warrant a randomized trial.

Combined application of cisplatin, vindesine, hyaluronidase and radiation for treatment of advanced squamous cell carcinoma of the head and neck.

In a prospective pilot study, 32 patients with advanced inoperable squamous cell carcinoma of the head and neck were treated with polychemotherapy and hyaluronidase combined with radiation therapy. Polychemotherapy consisted of 5 mg vindesine on day 1 and 80 mg/m2 cisplatin on day 2. The patients were given 200,000 IU hyaluronidase intravenously 20 minutes prior to vindesine and cisplatin. Radiation in fractions of 2 Gy per day was administered on the following days (days 3-5, 8-12, 15-18), that is, 12 times. This regimen was repeated twice starting with day 22 and 43. Side effects were mainly of local character: moderate to severe mucositis in 10 patients and mild mucositis in 22 patients. No severe systemic toxicity was observed. Complete remission was achieved in 27 of 32 patients. At present, 16 patients are alive and without relapse. The average time of follow-up is 47 months (range: 26-75 months). These preliminary results suggest that combined therapy with vindesine, cisplatin, hyaluronidase, and radiation are well tolerated by most patients and highly effective against advanced squamous cell cancer of the head and the neck.

[Experiences with intraoperative radiotherapy in inoperable pancreatic carcinoma]. / Erfahrungen mit der intraoperativen Radiotherapie beim inoperablen Pankreaskarzinom.

From January 1983 to April 1985 six patients suffering from unresectable pancreatic cancer underwent intraoperative irradiation therapy (IORT) followed by external radiotherapy. All tumors showed T4-stages except one tumor staged as T2N2. From the onset of symptoms to IORT the median time of hospitalization was 26.5 days. After surgery, treatment (external irradiation included) required a median hospitalization period of 43.5 days. Follow up, complications and the terminal hospital stay of the patients who died lead to another median hospitalization period of 30 days. Altogether hospitalization required an average of 90 days which represented 38.5% of the mean life-expectancy of 234 (SE = 57.4) days. 47.3% of the survival time did not show discomfort, in 31.6% there were reversible and in 21.1% irreversible complaints. Therefore, patients suffering from unresectable pancreatic cancer had to pay a heavy price for prolonging life expectancy by IORT and following percutaneous irradiation.

[Collaborative report on "Therapy of bronchial carcinoma from the radiotherapist's viewpoint"]. / Co-Referat zu "Therapie des Bronchialkarzinoms aus der Sicht des Strahlentherapeuten".

The paper refers to the radiotherapy treatment of patients with operated or non-operable bronchial carcinoma. The operated group includes patients with pneumonectomy and lobectomy with histological positive lymphnodes in hilum and/or mediastinum. These patients all had a curative radiotherapy with a 50 Gy radiation dose on mediastinum, hilum and the supraclavicular area. According to literature these patients show a 25-50% 5 year survival rate, depending on extent of the tumor infiltration. The inoperable cases, especially those with atelectasis dyspnoe etc. were treated with palliation radiotherapy as to improve the quality of life. The oatcell-carcinoma was treated corresponding to the method referred by Seeber as a combined radio-chemotherapy.

[Combined surgical and radiological therapy of pancreatic cancer--case report--future aspects]. / Chirurgisch-radiologisch kombiniertes Therapieverfahren beim Pankreaskarzinom--Falldemonstration--Zukunftsaspekte.

On the basis of the literature [1, 3-5], combined surgical management and intraoperative radiotherapy of carcinoma of the pancreas is demonstrated and illustrated by a case report and further aspects are discussed.

[Combination therapy of local tumour recurrence in patients with breast cancer (author's transl)]. / Kombinationstherapie von Lokarlrezidiven beim Mammakarzinom.

Treatment of 54 patients with extensive loco-regional recurrence of breast cancer is reported. Combined radio-chemotherapy was given to all patients with the aim of reducing the irradiation dosage and also decreasing the side effects of chemotherapy by reduced drug dosage. In this way a significant improvement in the quality of life could be achieved. The remission rate in patients with their first recurrence was 87.5%, while for subsequent recurrences the rate decreased to 50%. The median time of remission in both groups of patients was 7 months. There was complete loco-regional tumour control in 51% of all patients (with and without distant metastases). A significant prolongation of the survival time was not accomplished by this treatment.

[Endoscopy and radiological investigations of the stomach and duodenum. Alternative or complementary procedures? (author's transl)]. / Röntgendiagnostik und Endoskopie von Magen und Duodenum. Alternative oder komplementäre Verfahren?

The results of radiological and endoscopic examination in 1,030 patients were compared. In one third of cases there was some discrepancy relating to a significant diagnostic finding (malignant process, peptic ulcer, polyp, stenosis or deformity, abnormal folds, diverticula or normal findings). In analysing false negative and false positive radiological diagnoses, the patients were divided into two groups (with or without a double contrast technique). Conventional radiography proved ten to 38% less reliable than the double contrast technique for a variety of reasons. In view of the high diagnostic accuracy of modern radiological investigations of the stomach and duodenum, endoscopy and biopsy are recommended as complementary procedures. In addition to the high degree of accuracy of radiological methods for various pathological processes, endoscopy places considerable demands during investigation of the upper intestinal tract. At present radiology is used 19 times as frequently as endoscopy, suggesting that there might have to be a tenfold increase in the capacity of pathological departments if endoscopy is used more frequently.

[Radiation therapy in myasthenia gravis (author's transl)]. / Die Strahlentherapie bei Myasthenia gravis.

The etiology, pathogenesis, diagnosis and treatment of myasthenia gravis are discussed. We treated 16 patients, 13 of them with conventional X-rays and three by megavoltage irradiation. Our results show that radiotherapy has a definite role in the management of patients with myasthenia gravis and should be considered more frequently in future.

[Ideal application of computer tomography in the field of radiotherapeutic planning (author's transl)]. / Die Bestrahlungsplanung als ideales Anwendungsgebiet der Computertomographie.

The value of computerized radiotherapeutic planning is illustrated by the case report of a patient with an extensive pelvic wall metastasis of a carcinoma of the uterine cervix diagnosed by conventional methods. The exact topography is delineated by computer tomography and enables optimum dosimetric radiotherapeutic planning.

[Pulmonary perfusion, ventilation, and gas exchange during modified cobalt-60 teletherapy of operated on breast carcinomas]. / Lungenperfusion,-ventilation and Gaswechsel unter einer modifizierten Kobalt-60-Teletherapie operierter Mammakarzinome

Post ablationem mammae, 22 patients were exposed to a modified telecobalt-irradiation because of mammary carcinoma. (Tangential pendulum irradiation of the thoracic wall with deflection of the central beam off the pendulum axis, parasternal irradiation with pendulum fields, irradiation of the supraclavicular and axillar area with deflection of the central beam to lateral and cranial directions.) During radiation therapy and up to six months after its termination, periodical pulmonary function tests were accomplished, consisting in a radiogram of the thorax, in spirometric check-up and blood gas analysis, and in an examination of pulmonary perfusion and ventilation using radionuclide techniques. In one patient with metastases to the ribs, the spirographic and nulear-medical ventilatory results changed for the worse in the course of time, whereas the other 21 patients did not show any significantly abnormal alterations at follow-up examinations.