Malpractice stress syndrome in radiologists and radiotherapists: perceived causes and consequences.

PURPOSE: Radiology is among the specialties with an increasing risk of litigation. Regardless of the outcome of legal proceedings, physicians who are sued usually perceive the claim as an assault on their integrity and may suffer psychological or physical effects known as "malpractice stress syndrome". MATERIALS AND METHODS: Two hundred and six radiologists and 108 radiotherapists responded to a questionnaire containing specific items concerning their perception of malpractice stress and their opinions about the causes of clinical errors, as well as an assessment of work satisfaction and general health. RESULTS: One third of physicians had been sued for malpractice. Age was significantly related to the occurrence of malpractice litigation. Radiological errors were purportedly related to occupational discomfort, and the latter variable was significantly associated with work dissatisfaction and a low level of psychological and physical well-being. CONCLUSIONS: Radiologists are well acquainted with medical malpractice and its causes; however, they have limited familiarity with clinical risk management practices and often ignore procedures of informed consent. A targeted educational effort is required to overcome these shortcomings.

Dislocation of small bowel volume within box pelvic treatment fields, using new "up down table" device.

PURPOSE: To present the impact of a novel minimization device, the up down table (UDT), on the volume of small bowel included within a 4-field pelvic irradiation plan. METHODS: A polystyrene bowel displacement standard mold was created and added to a customized vacuum cushion (Vac Lok) formed around the abdomen and legs of each patient in the prone position. Two hundred seventy-seven consecutive patients with pelvic malignancies treated with the UDT device were compared with 1 historic series (68 cases) treated at our division. Small bowel contrast dyes at the time of simulation were used in all patients. RESULTS: The average volume of small bowel within the planning target volume (high-dose volume, calculated with Gallagher method) was 100 cm(3) (median 49 +/- 114) in the series treated with standard box technique and 23 cm(3) (median 0 +/- 64) in the series treated with the UDT (p < 0.001). The average volume of small bowel included in any isodose (any-dose volume) was 505 cm(3) (median 447 +/- 338) and 158 cm(3) (median 69 +/- 207), respectively (p < 0.001). The incidence of G1, G2, and G3 acute enteric toxicity (Radiation Therapy Oncology Group criteria) in the UDT series was 16%, 15%, and 1.5%; in the standard box technique, it was 28%, 25%, and 3%, respectively (p < 0.05). The incidence of acute enteric toxicity directly correlated with the irradiated small bowel volume. In the UDT series, the 5-year actuarial incidence of G3 chronic enteric toxicity was 1.8%. The setup procedures, analyzed in 18 cases, revealed no systematic errors and a standard deviation equal to +/-5 mm for random errors. CONCLUSIONS: The UDT technique is comfortable, inexpensive, highly reproducible, and permits an almost full bowel displacement from standard radiotherapy fields.

The role of a conventional simulator in multileaf-plan simulation: a proposal.

Modern computer networks provide satisfying levels of data recording and verification between the treatment planning system (TPS) and the accelerators, while the main weakness of the preparation chain remains the simulation. When a conventional simulator is employed, it may adversely affect the three-dimensional treatment planning system (3DPS) process because of the difficulty to document the leaf positions on the simulator location films and on the patient's skin. With a conventional simulator, hard copies of the DRRs of each field and CT scans at isocenter level are needed. In an attempt to transfer more information displayed from a BEV perspective from the 3DPS to simulator radiographs, this study aimed to reduce the quality loss by using a 2D conventional simulator in a 3DPS process. We realized an acetate photocopy of TPS data for each field, from a BEV perspective, containing: DRR, wire frames of the PTV, organs at risk and MLC aperture. The photocopies, with an appropriate magnification factor to obtain a correct projective value (ratio 1:1) at isocenter level, are carefully placed on the radiographic images on the same hard copy which allows us to better understand possible setup errors and obliges us to correct these. The method provides reliable documentation, facilitates treatment verification, and fulfils the criteria for MLC simulation. It is accurate, simple, and very inexpensive.

Immobilization devices between routine and quality assurance.

AIMS AND BACKGROUND: To evaluate the impact of immobilization devices in reducing treatment errors and delivering high doses to limited target volumes. The clear advantages are matched with quality control necessity. METHODS: The Authors examine two fundamental aspects of the topic: 1) the immobilization of head and neck and the relative implications in reducing the skin-sparing at the build-up region; 2) the rationale and management of quality assurance procedures in the immobilization devices utilization, with a particular reference to pelvic radiation treatment. CONCLUSIONS: The immobilization devices utilization certainly leads to an optimization in the execution of radiation treatments. Nevertheless, in the choice for their routine use, the Authors suggest to follow some "conceptual rules" with the aim of successfully matching each of the discussed aspects connected with their utilization.

Radiotherapy in the elderly with lung carcinoma: the experience of the Italian "Geriatric Radiation Oncology Group".

One hundred ninety-six patients aged > or = 70 years, with non small-cell lung carcinoma and no evidence of metastasis on staging, observed over a 6-month period in 20 Italian Radiotherapy Centers, were analyzed in order to assess indications for treatment, tolerance of radiotherapy (assessed in terms of completion of planned doses and toxicity), and quality of life using the Performance Status and a concise activity of life test. Of the 196 patients studied in 20 Italian Centers, 182 (98%) underwent radiotherapy, 109(60%) of whom with radical intent and 73 (40%) with palliative intent. Of 179 assessable patients undergoing radiation treatment, 163 (91%) completed the treatment as originally planned. Of the 64 assessable patients who completed palliative radiotherapy, relief of symptoms was observed in a percentage ranging from 78% to 86%. Analysis of parameters assessing the quality of life, showed no significant differences in general and functional conditions, as assessed before and upon completion of radiotherapy.

Radiation therapy of bone metastases in the elderly: a multicentric survey of the Italian "Geriatric Radiation Oncology Group".

External radiation therapy (ERT) has been reported to be the elective treatment of symptomatic bone metastases. A nationwide survey on the use of ERT in elderly patients with bone metastases has been conducted by the Italian "Geriatric Radiation Oncology Group" with a three-fold aim: define the state of the art of ERT, evaluate the analgesic efficacy and identify the optimal dosage and schedule, if any. 347 patients aged 70 or over, treated in 29 different institutions for a period of six months were analyzed. Conclusive results were: a significant pain relief achieved shortly after ERT completion; an improvement in the quality of life; a decrease in the dose of analgesics and consequently, a reduction in treatment-related costs. Unfortunately the optimal treatment schedule remains unidentified; ERT was neither aggressive nor toxic in this series of elderly patients.

[Quality control in radiotherapy. Computerized management of the "total" oncologic follow-up]. / Il controllo di qualità nella radioterapia. La gestione informatizzata del follow-up oncologico "totale".

Since 1992, in the Rovigo Radiotherapy Department, we have computerized the management of oncologic follow-up to minimize all "non-medical" times during the different phases. System efficiency was analyzed and the results follow: 1) the absolute number of follow-up visits, compared with the standard reference year (1991), shows that we were able to double our "performance" within the time unit, with the same "resources"; 2) the average number of follow-up visits per malignancy within 6 months of the diagnosis and then every seventh month, approximated to the number of scheduled visits; 3) the number of cancer relapses in the patients who could not be submitted to a specific antiblastic treatment (a reversed efficacy indicators) progressively reduced from 13.7% to 12.6% and 10.4% respectively, in 1992, 1993 and 1994; 4) secondary lesion diagnosis, an indirect efficacy parameter, was found to be accurate; 5) the cost of follow-up per malignancy reduced, in 6 months' periods, especially in the cancers with easier clinical diagnosis (-32% for breast cancer, -50% for head and neck cancer), by as much as 43,639,000 Italian liras in 1994 (relative to 1993); 6) the scheduled visits began only 12 minutes late, as studied on 2,346 visits. To conclude, the computed management of medical records improves our Department's efficiency, with no additional cost for the patients.

[Case histories of extranodal non-Hodgkin's lymphomas with primary gastrointestinal appearance]. / Contributo casistico sui linfomi non-Hodgkin extranodali a primitivo esordio gastrointestinale.

Authors refer results obtained in 24 cases of primary NHL of gastrointestinal tract. These cases were observed in the period 1981-1990. All cases can be included as primary extranodal lymphomas satisfying criteria of the literature. Sixty-six per cent (16/24) had a gastric localization half cases were centrocytic-centroblastic lymphomas followed by immunoblastic, centroblastic, follicular centrocytic-centroblastic and lymphocytic-well-differentiated. In intestinal localisation (34% of cases), the most represented was lymphocytic poor-differentiated, followed by mixed centrocytic lymphoma. Therapeutic strategy was: surgery in all patients followed by chemotherapy (CHOP 14/24) or by radiotherapy plus chemotherapy (8/24). Surgery alone was adopted in 2 out 24 patients. Patients who received radiotherapy plus chemotherapy had a sandwich treatment (CVP = 4/8, CHOP = 4/8) consisting of splint course of 3 cycles followed by radiotherapy and completed with other 3 drugs cycles. Sixteen out 24 patients were valuable (4 patients were lost during the follow-up due to problems other than the disease; 4 patients are still under treatment). In the 16 valuable patients we had a complete remission (CR) with a median free-disease survival of 82 months (range: 12-116 months) by means of the primary treatment. Four out 16 patients relapsed. In these patients the free-disease survival was range 8-108 months. All patients reached a second CR by means of chemotherapy (CCNU + VIP16) or radiotherapy. No cases of second tumor insorgence was observed.

An afterloading technique suitable for carcinomas of the oral cavity.

The authors describe an afterloading brachytherapy to treat oral cavity carcinomas. Catheters for arterial/venous catheterization are inserted percutaneously in the target volume. The internal needles are then removed and replaced with iridium wires inside tubes to form wire loops. This technique has proven to be simple, quick and safe.

[Influence of radiotherapy on lymphocyte subpopulations]. / Influenza della terapia radiante sulla popolazione linfocitaria.

The authors investigated the effects of radiation therapy on the immune system by studying lymphocyte subsets and other parameters in 32 patients undergoing radiation therapy for solid cancer. With monoclonal antibody techniques, we studied both T- and B-lymphocytes; cell suspensions were analyzed by means of a Facs Spectrum III Ortho (Ortho-Diagnostic) unit. The first control was performed right after the beginning of radiotherapy, when the dose to the patients was 50 Gy or higher. The second control was performed at 40 Gy because all patients received this dose. 30% of the patients exhibited lymphopenia from the beginning of the study; at 40 Gy the number of T-lymphocytes was low and helper/suppressor ratio was altered. A variable response of B-cells was observed, although all patients exhibited restoration of normal values at 6 months. Four patients only suffered from side-effects: a patient with tongue cancer presented oral mycosis, and a woman--treated for breast cancer--presented vaginal mycosis. Two cases of cystitis were also observed, after 18 Gy, in patients with uterine carcinoma undergoing pelvic irradiation. Disease progression was observed in 2 patients with head and neck cancer, while 3 patients died from lung cancer progression. Another one, with head and neck cancer, died because of heart failure.

[Role of accelerated electrons in the therapy of advanced-stage skin epithelioma advanced stage: analysis of 31 cases]. / Ruolo degli elettroni accelerati nella terapia degli epiteliomi cutanei in stadio avanzato: analisi di 31 casi.

Electron beam therapy is the superior modality of treatment for advanced skin cancer or in specific anatomical situations. The authors report the results for the electron beam therapy of 31 patients with advanced skin carcinoma. There were 15 squamous cell carcinomas, 11 basal cell carcinomas and 5 mixed, basosquamous cell carcinomas. All lesions were 3 cm or greater in maximum diameter. With follow-up ranging from 1 to 6 years, 28 patients have not evidence of disease, 1 is dead with disease, 1 is alive with suspicious residual disease and 1 is alive with recurrence. Acute and late complications are acceptable; bone, cartilage and soft tissue necrosis are not reported. The treatment results are similar to those in the literature and show the advantages of the electron beam irradiation for advanced skin carcinomas.

[The treatment of cancer of the anal area with radiotherapy. An analysis of the authors' personal experience]. / Trattamento del cancro della regione anale con radioterapia. Analisi dell'esperienza personale.

The treatment of anal canal carcinoma is very difficult and great care must be taken in planning therapy because this type of cancer is potentially curable. From 1982 through 1989 we treated 16 patients with carcinoma of the anal canal. All patients were evaluable for toxicity and 14/16 for response after treatment. Of the 12 patients who underwent irradiation alone and were N0 M0, 8 are alive with no evidence of the disease, 4 had a recurrence which was treated with radical surgery, and 2 underwent palliative treatment alone. Therapy toxicity was not relevant in most cases and our results are in agreement with those reported in the literature.

[Templates for curietherapy of the oral cavity and their dosimetric use]. / I templates nella curieterapia del cavo orale e loro implicazioni dosimetriche.

Flexible 192Ir wire implants are commonly used for the treatment of some types of cancer in the oral cavity. A modified technique of plastic tubes is here presented which aims at correctly positioning the active wires with thin plastic templates. Possible sources of error are examined and their consequences on the dose distribution around the implant are analyzed. In most cases control dosimetry matches the provisions satisfactorily. It may be thus concluded that the use of templates allows good and reproducible results to be obtained in the brachytherapy of the oral cavity.

A new technique for endocavitary irradiation of the esophagus.

Recently, high-dose rate intracavitary irradiation has been used as a boost therapy or a palliative therapy in the treatment of the esophageal carcinoma. The new intraesophageal device is based on a modified Sengstaken-Blackemore tube. On the surface of the esophageal balloon of the S-B tube Cyponil tubes are fixed as iridium containers. The device is placed at the level of the neoplastic lesion. Treatment tolerance is good.