Breast cancer: primary treatment with external-beam radiation therapy and high-dose-rate iridium implantation.

PURPOSE: To evaluate a treatment for breast cancer and to demonstrate the safe use of iridium-192 high-dose-rate (HDR) implantations. MATERIALS AND METHODS: In December 1984, the authors began to use HDR Ir-192 brachytherapy to deliver an interstitial boost to the primary site in conservative breast cancer treatment. By December 1989, 212 patients with 216 tumors were treated with external-beam irradiation of 45-50 Gy to the whole breast, which was followed by an interstitial 10-Gy boost. Median follow-up was 62 months (range, 36-101 months). RESULTS: Ten patients (10 of 216 breasts, 4.6%) developed local tumor recurrences, and 36 (17.0%) had distant metastases. At 5 years, overall survival was 88%, local tumor control was 96%, and disease-free survival was 81%. There were no serious complications. CONCLUSION: The use of an HDR source as a boost to the primary tumor site after external-beam radiation therapy with a dose of 10 Gy in one fraction is a safe procedure and does not negatively affect cosmetic appearance.

Case report: salvage fractionated high dose rate after-loading brachytherapy in the treatment of a recurrent tumour in the middle ear.

Re-irradiation of previously irradiated head and neck sites is associated with a high complication rate. In an attempt to reduce this complication risk, multiple fractions of high dose rate (HDR) intracavitary irradiation were used in a young patient who had developed recurrent transitional cell carcinoma in the tympanic cavity one year after radical radiotherapy. After gross surgical removal of the tumour, an afterloading probe was placed into the middle ear by a surgical approach. In 11 treatments of 3 Gy each over 4 days, a total dose of 33 Gy was delivered to a spherical volume, 1.7 cm in diameter. The patient was 24 months free of disease at the start of 1993. Audiometry shows no severe deterioration of hearing. We concluded that fractionated HDR brachytherapy can be used to achieve local control in small volume recurrences at previously irradiated sites, without the inevitability of complications.

[External irradiation and interstitial HDR brachytherapy in the treatment of breast cancer]. / Externe Bestrahlung und interstitielle HDR-Brachytherapie in der Behandlung des Mammakarzinoms.

PURPOSE: In the breast conserving management of mammary cancer a high-dose-rate (HDR)-Iridium-192 source is used for interstitial boosting of the primary tumor site after external radiotherapy. We want to show the clinical results and side effects and to demonstrate the safe use of a HDR source. PATIENTS AND METHOD: From December 1984 until November 1988, 154 patients with breast cancer stage T1-2, N0-1 were treated by conservative surgery and radiation. A dose of 45 to 50 Gy was given to the whole breast by external radiotherapy, and the previous tumor area was boosted by an interstitial implant with Iridium-192 HDR. We applied 10 Gy in one or two fractions. RESULTS: The mean follow-up period of survivors is 76 months (range 57 to 107 months). In 36 patients failures occurred: eight patients (5%) developed local recurrences, 31 patients (20%) had distant metastases, and 19 (12%) died with cancer. The Kaplan-Meier estimation for five year overall survival is 86.9%, for disease-specific survival 89.3%, for local control 95.8%, and for disease free survival 80.1%. The most frequent late effects were telangiectasia (11%), fibrotic masses in the previous tumor area (6.5%), and lymphedema of the arm (6.5%). No serious complications could be observed. CONCLUSION: With the HDR-Boost of 10 Gy in addition to external beam radiotherapy in the treatment of breast cancer we obtained good clinical results without serious side effects.

[Quality assurance of interstitial irradiation in the breast-conserving therapy of breast cancer]. / Qualitätssicherung der interstitiellen Bestrahlung in der brusterhaltenden Therapie des Mammakarzinoms.

PURPOSE: The purpose of this communication is to describe the procedure of interstitial implant planning in definitive irradiation of early breast cancer. There are some reports about localization techniques of the boost volume for external irradiation. Less has been reported about the target volume localization of HDR implants of the breast. METHODS: Conservative surgery and following radiation therapy have become a standard treatment in the management of early breast cancer. The use of a boost irradiation in the area of the primary tumour seems to be promising in decreasing local recurrence rates. Most of our patients received a boost dose by interstitial HDR iridium-192 therapy. Therefore we have improved the method of interstitial implantation by CT under general anesthesia. The implant is planned in the simulator room by localizing the radiopaque clips of the tumor bed, the entrance and exit points of the needles are determined by marking the skin. Then the implantation is done in the operating and afterloading room. A device for patient transportation between brachytherapy unit and CT has been constructed. So patients can be shifted under general anesthesia between the different devices without any problems. The implanted needles and the clips are visualized by the means of CT. The target volume can be defined and the source dwell positions determined. CONCLUSION: This method improves the accuracy of target localization. Therefore the treated volume can be adapted and minimized, resulting in less side effects and may contribute to maximize local control.

Combined external and high dose rate intracavitary radiotherapy in the primary treatment of cancer of the uterine cervix.

From August 1980 to December 1985, 153 patients with stage I, II and III carcinomas of the uterine cervix were treated with external beam irradiation and high dose rate (HDR) Cs-137 and Ir-192 Curietherapy at the Barmherzige Schwestern Hospital in Linz, Austria. Complete remission was achieved in 146 patients (95.4%). The 5-year overall survival probabilities (Kaplan-Meier) in stages I, II and III were 79.3%, 62.6% and 40.8%, respectively. The 5-year recurrence-free survival rates were 91.5%, 59.6% and 52.9%. These results are equivalent to those achieved by treatments incorporating low dose rate (LDR) Ra-226 applications in regard to the limitations of historical comparisons. Use of the high dose rate afterloading methods lead to similar rates of local failures and complications.

[MCA and CA 15-3 in the follow-up of patients with breast cancer]. / MCA und CA 15-3 in der Verlaufskontrolle bei Patientinnen mit Mammakarzinom.

After surgery and radiotherapy circulating serum levels of the tumour markers MCA and Ca 15-3 were evaluated in 226 clinically disease-free breast cancer patients. 15 of them presented with local recurrences and/or distant metastases after a follow-up period of twelve months. Six patients belonged to the group of 180 with both markers negative, two belonged to the 32 patients with only one marker positive, and seven to the group of 14 with both markers positive. After twelve months the probability of disease-free survival (calculated by the method of Kaplan-Meier) is 96% in patients with negative tumour markers and only 51.4% in patients with both markers positive (p less than 0.001). After 16 months these values are 96% versus 25.7% with the same statistical significance. The value of tumour marker examinations in the regular follow-up of patients with breast cancer lies in the early detection of tumour activity and therefore in a better chance of response to subsequent treatment. The diagnostic sensitivity of MCA was 75.5%, and for Ca 15-3 70.24%.

[Combined external and interstitial radiotherapy of vocal cord carcinoma]. / Kombinierte externe und interstitielle Radiotherapie des Stimmbandkarzinoms.

Since 1984 an Ir-192 source with a high dose rate has been used for interstitial implants, and since 1986 in the treatment of the tumor-bearing vocal cord in the organ-preserving management of larynx carcinoma. The combined percutaneous and interstitial treatment has been administered either as the primary treatment or after incomplete removal of the tumour. So fat 16 patients have been treated, two of them presented with tumours on both cords. All patients refused radical surgical interventions, four of them refused cord stripping too. The treatment method included external radiotherapy with a dose of 4600 to 5000 cGy to the larynx. One to two weeks after external XRT an interstitial implant into the vocal cord followed. Using two needles per cord, a boost dose of 1000 cGy was given to the tumour area. The median follow-up time is 21.3 months (range five to 49, calculated October 1990). So far no local or regional failures occurred. None of the patients had intra- or postoperative complications. All patients have preserved their voice. No severe late effects could be observed. The number of patients is very low, but the preservation of voice is high psychosocial value.

[Percutaneous and intracavitary radiotherapy of non-operated cervix carcinoma]. / Perkutane und intrakavitäre Radiotherapie des nichtoperierten Zervixkarzinoms.

At the Krankenhaus der Barmherzigen Schwestern in Linz 153 patients with cancer of the uterine cervix in the stages I to III have been treated from August 1980 to December 1985. In 146 patients (95.4%) complete remission could be achieved. The 5-years overall survival probability (Kaplan-Mayer) in the stages I to III is 79.3%, 62.6% and 40.8% respectively. The 5-years recurrence free survival rate is 91.5%, 59.6% and 52.9% respectively. These results are equivalent to the data achieved by treatments with Radium application. Using the high-dose-rate afterloading method the complication rate is lower.

The community health movement started from a simple program.

PIP: Multiple personal accounts are used to describe how the Integrated Planning Nutrition and Parasite Control Project (IP) in Ahintia, Ghana directly affected individual's lives and created the impetus for further health development. Vera Quayers is a community-based contraceptive distribution agent (IBD), a volunteer for the IP project who teaches mothers how to space their babies. One 22-year old mothers decides to space her desired 3 more children 4 years apart to insure healthy babies as a result of Vera's effort. The rate of acceptance of family planning increased in June 1990 to 30.92% from 12.8% in November 1987. Villages built a community toilet and people do not relieve themselves around houses. Women clean their surroundings on Wednesdays and men do the same every Friday morning. Rubbish does not litter the ground anymore, as reported by one farmer. Immunization covers 70% of the population. The village population has focused attention on mothers and children. A preschool nursery center has been opened to educate and provide nutritious food, which is cooked by the mothers' club. This farming community is money poor, where 80% in 1987 earned less than 30,000 cedi (US185 at the rate of exchange of 162.37 cedi per US1.00); however, the food resources are high with crops of cassava, yam, pepper, and tomatoes.^ieng

One or two children--Thai career women value home discipline for the child.

PIP: Career women with more education are among the foremost acceptors of family planning (FP) in Thailand. They know the advantages of having a small family and about birth spacing. The mean preferred number of children for ever-married women of "higher" education was 2.4; the average was 2.8 according to the Thailand Demographic and Health Survey in 1987. Career women and their husbands hold home discipline in high regard. They want to give their child the best of practices, attitudes, and values. There is an unfavorable employment situation for women. They generally are paid less than men. Girls should be given better educational opportunities, 3 career women interviewed said. They all married husbands of their own choosing. They all went to the US after having graduated from Thai Universities to get a Master's Degree. They manage work and family life well, perhaps because they have domestic help. FP has become a way of life today in Thailand. 88% of contraceptive methods are used by Thai women (pill, 28.18%; IUD, 8.78%; female sterilization, 35.97%; and injection, 15.43%). Only 8% are used by men (male sterilization, 5.38%; and condom, 2.69%). 4% are used by both. The 3 career women think men should share contraceptive usage.^ieng

Measurements of retinal microcirculation in retinal vessel occlusion before and after treatment.

Blood flow, arterial velocity, and vascular diameter were measured in patients with retinal vessel occlusion before and after treatment, especially after light coagulation. The mean values in the patient group showed significantly reduced blood flow and velocity compared to the normal group. The mean group difference before and after therapy revealed that while there is an increase in blood flow after treatment, the normal value is not reached. Individual patient values indicated both increased and decreased blood flow and velocity after treatment as compared with the values before therapy. There are various stages in microcirculatory disease and the microcirculation also behaves differently after treatment, which could be observed by measurement in vivo of the physiological flow parameters.

[Clinical interpretation of retinal circulatory measurements. IV. Photocoagulation in diabetic retinopathy and venous occlusive diseases]. / Klinische Interpretation retinaler Durchblutungsmessungen. IV. Fotokoagulation bei diabetischer Retinopathie und venösen Verschlusserkrankungen.

Based on the pathomechanism of diabetic retinopathy, the effect of photocoagulation on retinal microcirculation as assessed by measurements of retinal microcirculation magnitudes is discussed. The clinico-experimental results support the opinion that an essential effect of photocoagulation is due to an improvement in the flow conditions of the noncoagulated central retinal area with regard to metabolic exchange and stasis situation by the coagulation-induced occlusion of peripheral capillary areas. Further clinico-experimental measurements of retinal microcirculation magnitudes for the assessment of the behavior of microcirculation after photocoagulation in venous occlusive diseases of the retina are presented. It is shown that retinal microcirculation immediately after photocoagulation reacts by transitory instationary flow conditions; in this period it is quite possible that an additional blood flow reduction over several days will occur. In particular, the effect of photocoagulation in venous occlusive diseases with narrow arterial vessels is discussed. It is emphasized that with regard to the therapeutic effect of photocoagulation as well as to the discussion of pathomechanisms, apart from blood flow, the differentiated behavior of single retinal vascular areas, such as arteries, arterioles, capillaries, venules and veins, requires more attention. Particularly with this in mind, substantial improvements in differential diagnosis and treatment of retinal circulatory disturbances may be expected from measurements of retinal circulation magnitudes.

[Clinical interpretation of retinal circulatory measurements. II. Blood flow]. / Klinische Interpretation retinaler Durchblutungsmessungen. II. Blutfluss.

Beginning as early as the mid-4th decade of life, an age-dependent reduction in retinal blood flow has to be considered an essential risk factor for disorders of retinal microcirculation. Blood flow measurements are a valuable, but not the sole criterion of microcirculatory disorders. While in retinal occlusive diseases blood flow is a valuable indicator of the severity of microcirculatory disorders, the latter can also occur in the presence of normal and elevated blood flow values. Shifts of the metabolic activity of the retina and changes in the metabolic activity of the retina and changes in the metabolic conditions have to be taken into account when a clinical interpretation is given.

[Clinical interpretation of retinal circulatory measurements. III. Blood flow velocity and vessel diameter in normal persons and in patients with venous occlusive diseases]. / Klinische Interpretation retinaler Durchblutungsmessungen. III. Blutgeschwindigkeit und Gefässdurchmesser bei Normalpersonen und bei Patienten mit venösen Verschlusskrankheiten.

Based on results from measurements of arterial blood velocity, arterial and venous diameters of major segmental retinal vessels in normal persons and in patients with venous occlusive diseases and in continuation of the two preceding parts of this series of articles, further possibilities for the differential diagnosis of measurements of retinal microcirculation magnitudes are discussed. Whereas the measurement of blood velocity is an important criterion for the assessment of the stasis conditions and the arterial involvement in an occlusive disease, the diameters of the vessels offer essential suggestions to local regulative processes. In this connection, a dependence on pH of the contraction state of the smooth vascular musculature detected in porcine coronary arteries is presented. By its transmission to the arterial retinal vessels, it is possible to unequivocally clarify the local regulative and pathological behavior of arterial retinal vessels in terms of flow physiology.