Botulinum toxin-A injections vs radiotherapy for drooling in ALS.

OBJECTIVES: Botulinum neurotoxin (BoNT) injections in the salivary glands and radiotherapy (RT) on these glands are commonly used to alleviate severe drooling in patients with amyotrophic lateral sclerosis (ALS). This study compares BoNT type A with RT based on patient-rated evaluations. MATERIALS & METHODS: A prospective randomized controlled pilot study to compare RT (n = 10; on the parotid and the posterior part of the submandibular glands) with BoNT-A treatment (n = 10; in the parotid glands only, because of the risk of increasing oropharyngeal weakness) in patients with ALS. The primary outcome was the drooling status (burden of drooling), and our secondary interests were the degree of salivation, global change of drooling after treatment, and level of satisfaction with the treatment and negative experiences. RESULTS: There were no statistically significant between-treatment differences for the drooling status after treatment. Only at twelve weeks more saliva reduction was achieved by RT (P = 0.02). Patients treated with RT also described more transient negative experiences (like pain in mandible) directly after treatment. Subgroup analysis showed that patients with very severe dysphagia (no oral intake) were less satisfied and experienced a lower global change of drooling after treatment. CONCLUSIONS: This pilot study showed no significant difference in the burden of drooling between the treatments. However, with RT more saliva reduction was achieved, including negative experiences directly after treatment, but without the risk of decreasing oropharyngeal function. In addition, patients with very severe dysphagia do not seem to benefit from either treatment.

FDG-PET/CT in radiation treatment planning of head and neck squamous cell carcinoma.

Advances in the field of radiation oncology in the last decade resulted in an increasing number of opportunities to optimize therapy. Increased accuracy to deliver the dose to tumors while sparing normal tissues demands more precise delineation of the tumors. When considering to deliver a boost to more aggressive parts of tumors, intratumoral heterogeneity needs to be assessed accurately. Adaptive radiotherapy demands evaluation of response during the course of radiotherapy, in terms of both volumetric and functional changes. Molecular imaging with fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has found its way into clinical practice for various indications in head and neck cancer and new applications are under investigation. In this review, an overview is provided of the current status and developments of the use of FDG-PET/CT in radiation oncology, describing the current status in radiation treatment planning, adaptation of therapy and the position compared to other imaging techniques.

Systematic review of the effect of external beam radiation therapy to the breast on axillary recurrence after negative sentinel lymph node biopsy.

BACKGROUND: Axillary recurrence after negative sentinel lymph node biopsy (SLNB) in patients with invasive breast carcinoma remains a concern. Previous investigations to identify prognostic factors for axillary recurrence identified that a disproportionate number of patients with an axillary recurrence after negative SLNB were not treated with external beam radiation therapy (EBRT) of the breast as part of initial treatment. This finding prompted a systematic review to test the hypothesis that EBRT to the breast reduces the risk of axillary recurrence after negative SLNB. METHODS: A literature search was performed in PubMed, the Cochrane Library and the Spanish-language database LILACS to identify articles publishing data regarding follow-up of sentinel lymph node (SLN)-negative patients. Reports and articles lacking information on the initial treatment were excluded. RESULTS: Forty-five articles were accepted for review. A total of 23,357 SLN-negative patients were identified with median follow-up ranging from 15 to 102 months. Some 18,878 patients were treated with EBRT to the breast as part of their initial treatment. One hundred and twenty-seven patients with an axillary recurrence were identified, of whom 73 had EBRT as part of their initial treatment. Meta-analysis showed that EBRT was associated with a lower rate of axillary recurrence (P < 0·001), but this finding was subject to heterogeneity. CONCLUSION: This review and meta-analysis showed that EBRT is associated with a significantly lower axillary recurrence rate after negative SLNB.

Validated image fusion of dedicated PET and CT for external beam radiation and therapy in the head and neck area.

AIM: Integration of positron emission tomography (PET) information into computer tomography (CT)- based intensity modulated external beam radiation therapy (IMRT) allows adaptation of the target volume to functional parameters, but only when the image registration procedure is reliable. The aim of this study was to select the optimal method for software fusion of dedicated PET and CT, and to validate the procedure for IMRT head-neck area. METHOD: Fifteen patients with head and neck squamous cell carcinoma underwent separate CT and F-18-fluorodeoxyglucose positron emission tomography(FDG-PET), both in a custom-moulded rigid mask fitted with 4 multimodality fiducial markers. Five image registration methods were applied . PET emission and CT were registered manually (ME) and using the landmarks (LM). PET transmission and CT were registered manually (MT) using a mutual information-based method (MI) and an iterative closest point method (ICP). The error in image registration of each method was determined by evaluating the markers. RESULTS: LM showed an average registration error of 1.4 mm at the location of the markers, and 0.3mm in the planning area. However, this method proved to be laborious. Apart from LM, the best method was ICP, with registration errors of 3 and 2mm, respectively. The respective errors were 4.7 and 3.5 mm with ME, 3.6 and 2.7 mm with MT, and 5.3 and 4.1mm with MI. CONCLUSION: Image fusion of dedicated PET and CT of the head-neck area can be performed reliably using the operator-independent ICP method with no need for laborious markers. The achieved accuracy permits implementation of dedicated PET images in external beam radiation therapy.

From anatomical to biological target volumes: the role of PET in radiation treatment planning.

Progress in radiation oncology requires a re-evaluation of the methods of target volume delineation beyond anatomical localization. New molecular imaging techniques for tumour visualisation such as positron emission tomography (PET) provide insight into tumour characteristics and can be complementary to the anatomical data of computed tomography or magnetic resonance imaging. In this review, three issues are discussed: First, can PET identify a tumour more accurately? Second, can biological tumour characteristics be visualised? Third, can intratumoural heterogeneity of these characteristics be identified?

East-west differences in the organization of botulinum toxin use in nine Central European countries.

Availability and quality of expensive treatment modalities such as botulinum toxin (BTX) largely depend on organizational aspects such as costs, reimbursement by insurance companies, expertise and facilities for expert training, and the propagation of research. To investigate which determinants influence the organization of BTX' use throughout nine Central European countries (Austria, Croatia, Czech Republic, Germany, Hungary, Italy, Slovakia, Slovenia and Switzerland) we sent out questionnaires to leading BTX experts and consulted data banks of manufacturers and bulletins of international organizations. In Western European countries, there is a tendency for users to organize themselves in formal groups and to concentrate on research whereas the way how BTX is provided is diverse regarding qualifications of specialists and institutions. In the post-communist Eastern European countries, we found a tendency towards a centralized system of reimbursement and BTX treatment seems to be more in the hands of neurologists than any other specialists. Strong correlations were observed between the number of BTX centres, degree of organization of user groups and number of scientific publications, on the one hand, and parameters of healthcare performance and socioeconomic determinants, on the other. Our study suggests that in the nine countries surveyed, organizational aspects of BTX use vary considerably, whilst similarities are based mainly on socioeconomic rather than socio-demographic determinants.

[The importance of a complete diagnostic workup in patients with nontraumatic (partial) paraplegia]. / Het belang van afgeronde diagnostiek bij een patiënt met een niet-traumatische (partiële) dwarslaesie.

In two women, aged 86 and 56 years, respectively, who suffered from back pain and loss of strength, and in a 55-year-old man who lost sensation and strength in his left leg, spinal-cord compression in connection with vertebral destruction was seen on radiological examination. When spinal-cord compression is the result of a local malignant tumour, the therapy often entails emergency radiotherapy. In the first two patients, histological examination revealed a solitary plasmocytoma and curative high-dose radiotherapy was applied. The third patient also had a lung tumour and received low-dose palliative radiotherapy to the vertebrae, as a metastasis was suspected. Later, however, histopathologic examination of the vertebral lesion revealed osteomyelitis due to Listeria monocytogenes and the lung tumour was diagnosed as a pT2N0M0 broncho-alveolar carcinoma which was surgically removed. When a patient is referred with a nontraumatic spinal-cord injury, it is important to complete the radiological and histological examinations before starting emergency radiotherapy in order to prevent an inadequate or even incorrect treatment.