Quality assurance in stereotactic radiosurgery/radiotherapy according to DIN 6875-1.

The new DIN ('Deutsche Industrie-Norm') 6875-1, which is currently being finalised, deals with quality assurance (QA) criteria and tests methods for linear accelerator and Gamma Knife stereotactic radiosurgery/radiotherapy including treatment planning, stereotactic frame and stereotactic imaging and a system test to check the whole chain of uncertainties. Our existing QA program, based on dedicated phantoms and test procedures, has been refined to fulfill the demands of this new DIN. The radiological and mechanical isocentre corresponded within 0.2 mm and the measured 50% isodose lines were in agreement with the calculated ones within less than 0.5 mm. The measured absorbed dose was within 3%. The resultant output factors measured for the 14-, 8- and 4-mm collimator helmet were 0.9870 +/- 0.0086, 0.9578 +/- 0.0057 and 0.8741 +/- 0.0202, respectively. For 170 consecutive tests, the mean geometrical accuracy was 0.48 +/- 0.23 mm. Besides QA phantoms and analysis software developed in-house, the use of commercially available tools facilitated the QA according to the DIN 6875-1 with which our results complied.

Pertreatment radiation induced oedema causing acute hydrocephalus after radiosurgery for multiple cerebellar metastases.

BACKGROUND: Most complications of radiosurgery occur after 6-12 months and some long term complications up to after 5-10 years. Although severe, immediate side effects are rare, we report a patient who shows that this possibility should be taken into account when large volumes are treated especially in the posterior fossa. CASE REPORT: A patient was treated with radiosurgery for multiple brain metastases, of which 5 were located in the posterior fossa. Deterioration occurred, radiosurgery was halted abortion and CT showed acute hydrocephalus caused by a significant edema in the posterior fossa, not present in an MR examination performed some 6 hours earlier. After intubation and external ventricular CSF drainage, a permanent shunt was inserted, the edema resolved, and the patient recovered to her pretreatment condition within 10 days. The remaining metastases were treated during the first session and MR images showed the hydrocephalus resolved when all the radiated tumors had significantly decreased in size. INTERPRETATION: Care should be taken when treating with radiosurgery patients posterior fossa metastases and signs of compressed CSF pathways. Exceptionally, an acute radiation induced edema could result in a block of the CSF pathways, necessitating a surgical intervention. Prophylactic shunt insertion or hospitalization the night following the treatment should be considered.

[Pain in patients with breast-conserving cancer treatment and radiotherapy]. / Schmerz bei brusterhaltend operierten und bestrahlten Brustkrebspatientinnen--Status und Verlauf.

In patients with breast-conserving surgery of carcinoma and radiotherapy pain rarely is an issue between patient and physician because the operation is considered to be well tolerable and radiotherapy to have few side- effects. There are very few data about frequency and management of pain in these patients. Therefore we evaluated a group of 180 patients after breast-conserving surgery during radiotherapy using a new Likert-scaled questionnaire. Data on the following items were collected: number of patients experiencing pain, pain attribution, frequency and intensity of pain, subjective evaluation and restriction in daily routine. Furthermore, we evaluated the side effects of radiation in an RTOG scale. 85% of patients had pain during radiation which by most was attributed to cancer treatment (surgery and radiation). More than 50% reported light to moderate pain during the entire six-week treatment. Thus pain is a more common symptom in breast cancer patients during radiation therapy than normally assumed and therefore should receive more attention by gynecologists and radiotherapists.

[18F-Deoxyglucose PET for the staging of oesophageal cancer: influence of histopathological subtype and tumour grading]. / 18F-Desoxyglukose-PET zum Staging des Osophaguskarzinoms: Einfluss des histopathologischen Subtyps und des Gradings.

AIM: Evaluation of the influence of histopathologic sub-types and grading of primaries of oesophageal cancer, relative to their size and location, on the uptake of (18)F-deoxyglucose (FDG) as measured by positron emission tomography (PET). METHODS: 50 consecutive patients were evaluated. There were four drop-outs due to previous surgical and/or chemotherapeutical treatments and thus in 46 patients (28 squamous cell carcinomas and 18 adenocarcinomas) a pretherapeutic PET evaluation of the primary including a standard uptake value (SUV) was obtained. In 42 cases data on tumour grading were available also. RESULTS: Squamous cell carcinomas (SCC) were in 7/13/8 cases located in the proximal, medial and distal part of the oesophagus, respectively the grading was Gx in 3, G 2 in 12, G2-3 in 7, and G3 in 6 cases. The SUV(max) showed a mean of 6.5+/-2.8 (range 1.7-13.5). Adenocarcinomas (ACA) were located in the medial oesophagus in two cases and otherwise in its distal parts. Grading was Gx in one, G2 in 4, G2-3 in 3, G3 in 3, G3-4 in 3, and G4 in one case. The mean SUV(max) was 5.2+/-3.2 (range 1-13.6) and this was not significantly different from the SCC. Concerning the tumour grading there was a slight, statistically not relevant trend towards higher SUV(max) in more dedifferentiated cancer. DISCUSSION: SCC and ACA of the oesophagus show no relevant differences in the FDG-uptake. While there was a significant variability of tumour uptake in the overall study group, a correlation of SUV and tumour grading was not found.

Influence of irradiation on therapy-associated psychological distress in breast carcinoma patients.

PURPOSE: To confirm our assumptions regarding factors that apparently cause psychological distress related to adjuvant radiotherapy in breast cancer patients and to evaluate variables that can predict therapy-associated distress. METHODS AND MATERIALS: Between January 1997 and April 1998, 111 women (33-84 years) with early-stage breast cancer were irradiated (56 Gy) after breast-conserving surgery. Patients were given self-assessment questionnaires on the first and last day of radiotherapy. Statistical analysis was performed using the structural equation model LISREL, variance analysis, and regression analysis. RESULTS: The internal subject-related factors (coping, radiation-related anxiety, physical distress, psychological distress) reciprocally influenced each other, whereas external radiotherapy-specific factors (environmental influence, confidence in the medical staff) were causally related to coping, anxiety, and distress. Fifty-three percent of the women felt distressed because cancer affected the breast; 48% were initially afraid of radiotherapy. For 36%, anxiety was not reduced during treatment. Highly distressed women were identified by the following parameters: < or =58 years; initial anxiety; they were affected by having breast cancer, were negatively affected by environmental factors, and did not find distraction helpful. CONCLUSION: Despite considerable individual variability in breast cancer patients, it seems possible to identify women who run a high risk of therapy-associated distress. In these patients, psychosocial support is necessary to reduce treatment-related anxiety and to stabilize confidence in the medical staff.

Influence of CT contrast agents on dose calculations in a 3D treatment planning system.

In treatment planning for conformal radiotherapy, it is possible to attain high accuracy in contouring the outline of the target volume and organs at risk by giving contrast agents (CAs) during the CT scan. In order to calculate the dose from the CT scans, Hounsfield units (HUs) are converted into the parameters of a standard set of tissues with given atomic composition and density. Due to the high atomic number of contrast media, high HU values are obtained during CT scanning. The Helax treatment planning system, for instance, erroneously takes them for high density tissue. This misinterpretation results in high absorption of high-energy photon beams and thus affects the dose calculation significantly. A typical bolus diameter of 3 cm and HU values of 1,400 cause an overdose of up to 7.4% and 5.4% for 6 MV and 25 MV photon beams, respectively. However, since the CA concentration and its expansion are rather low the effect on dose calculation in treatment planning is negligible.

[Palliative radiochemotherapy with Bendamustin for advanced recurrent head and neck tumors]. / Palliative Radiochemotherapie mit Bendamustin bei fortgeschrittenen Tumorrezidiven im HNO-Bereich.

BACKGROUND: In case of recurrent carcinoma of the head and neck region therapeutic options are often limited due to intensive prior therapy and/or reduced physical condition of the patient. Nevertheless there is a need for palliative treatment to control symptoms like pain, obstruction of the airways, dysphagia and for hygienic and cosmetic reasons. Side effects, treatment time and achievable results have to be adjusted to the needs of this patient subgroup. PATIENTS AND METHOD: 14 patients (13 male, one female) with recurrent squamous cell carcinoma of the head and neck region were studied. Average age was 56.1 years (range 42-76 years) (Table 1). Prior therapy: radiotherapy n = 14 (42-71.3 Gy), surgery: n = 10, chemotherapy: n = 13 (Table 2). Our patients received 100-150 mg/m2 Bendamustin i.v. (day 1 and 2) and involved field irradiation 15 Gy (daily dose 3 Gy, day 1-5) (Figure 1). Remission status, time to progression, side effects and survival were documented. RESULTS: Ten patients showed partial remissions, four patients had complete remissions of the treated lesion (Figure 2), amelioration of 70% of tumor symptoms was documented (Figure 3). Time to progression was 2-104 weeks. Side effects: 71% of patients had no significant side effects, CTC Grade 3 to 4 toxicity was seen in two patients (14%). CONCLUSION: The reported therapy regimen allows successful palliative treatment of intensively pretreated patients with progressive recurrent tumors of the head and neck. Side effects are tolerable even in patients with reduced physical condition.

Three-dimensional BANG gel dosimetry in conformal carbon ion radiotherapy.

In this study we applied BANG polymer-gel dosimetry using magnetic resonance imaging (MRI) to densely ionizing radiation such as carbon ion beams. BANG polymer gels were irradiated with a quadratic field of monoenergetic 12C ions at different beam energies in the range of 135 MeV u(-1) to 410 MeV u(-1). They were irradiated at the radiotherapy facility of the GSI, Darmstadt, Germany. Our object was to examine the saturation effect for densely ionizing radiation that occurs at high values of linear energy transfer (LET). The examination yielded the first effectiveness values that will be discussed in the following sections. A solid sphere and a hollow sphere were both irradiated with a horizontal pencil beam from the raster scanning facility at energies of 268 MeV u(-1) (solid sphere) and 304 MeV u(-1) (hollow sphere) respectively. MR dosimetry measurements were compared with data from a planning system. As far as quality is concerned, there is good agreement between the measured dose distributions of both samples and the dose maps from the planning software. The measured MR signals cannot be converted into absolute dose, since the relative efficiency is still unknown for mixed radiation fields of primary carbon ions and it is known only to a limited extent for nuclear fragments with different energies from highly energetic photon radiation. Model calculations are in progress in order to facilitate conversions of measured MR signals into dose.

Radiation enhancement of gemcitabine in two human squamous cell carcinoma cell lines.

BACKGROUND: Gemcitabine (dFdC) is a new nucleoside analogue with promising activity in different solid tumors. We investigated whether dFdC enhances the effect of irradiation in human squamous carcinoma cells of the oropharynx (#4197) and of the uterine cervix (HeLa) with special regard to the time-dose-relationship concerning dFdC and the dependence upon the timing of irradiation. MATERIALS AND METHODS: Under standardized conditions monolayers of cells were exposed to various dFdC concentrations (0.003-10 mumol/l) for different times (4-24 h). Irradiation (0-6 Gy) followed immediately or 12 h after dFdC exposure (0.003-0.03 mumol/l; 4-24 h). RESULTS: The cytotoxic effect of dFdC depends on its concentration and the exposure duration. Exposed to non and/or slightly cytotoxic concentrations (> or = 0.003-0.03 mumol/l) for 4, 8, 16 and 24 h and followed by immediate irradiation the radiation enhancement ratio (RER) is 1.03-1.67 in #4197 cells and 1.04-2.47 in HeLa cells, respectively. Irradiated 12 h after 24 h exposure (dFdC 0.01-0.03 mumol/l) the RER is reduced to 1.10-1.17 (#4197) and 1.18-1.72 (HeLa). CONCLUSIONS: Depending on the drug concentration, exposure duration, and timing of irradiation, dFdC enhances the irradiation effect on human squamous cell carcinoma cell lines (#4197, HeLa).

[Role of radiotherapy in the treatment of multiple myeloma]. / Wertigkeit der Radiotherapie in der Behandlung des multiplen Myeloms.

BACKGROUND: Chemotherapy is the treatment of choice in multiple myeloma; but there are no curative options. Therefore, the treatment rationale is characterized by reduction of symptoms and inhibition of complications. Regarding reduction of pain, treatment of (impending) fractures, and spinal cord compression radiation is an important part of palliative treatment. In our retrospective study we report the effect of radiotherapy on reduction of pain, recalcification and the reduction of neurological symptoms and evaluate factors which have an impact on therapeutic outcome. PATIENTS AND METHODS: From 1, Jan 1988 to 31, Dec 1998, 42 patients (19 women, 23 men; range of ages 46 to 85 years, median age 64.9 years) with 71 target volumes were irradiated (median dose 36 Gy, 2 to 3 Gy 5 times/week) because of symptomatic disease (67/71: osseous pain, 45/71: fractures/impending fractures, 13/71: spinal cord compression) (Tables 1 and 2). The median time from diagnosis to the first course of radiotherapy was 11.9 months (0.3 to 90 months). At the time of first irradiation, 5 and 37 patients were in tumor Stage II and III (Salmon/Durie), respectively. The median value of the Karnofsky performance was 70% (40 to 90%). RESULTS: During follow-up (at least 6 months) in 85% of target volumes complete and partial pain relief (measured by patients' perception and the use of analgetic medication) was achieved; recurrences were seen in 8.8%. In 26/56 (46.4%) lesions evaluable a recalcification was seen whereas 17.9% showed progressive disease (comparison of radiographs before and after radiation). In 22.3% of all lesions initially with impending fracture (4/18) radiotherapy failed because of fracture after treatment (Tables 3 and 4). Simultaneous chemotherapy and a Karnofsky performance > or = 70 had a significant impact on a positive response to treatment, respectively. Spinal cord compression symptoms were reduced in 7/13 (53.8%) of patients (scaled due to the classification by Findlay 1987). The median survival from diagnosis for the entire group was 34.9 months (7.5 to 119.3 months), after irradiation 13.1 months (0.2 to 105.3 months) (Figure 1). CONCLUSION: When adequately indicated radiotherapy has shown to be an effective palliative treatment. Taking under consideration that the results are retrospective we suppose that in multiple myeloma the local response to radiation is supported by a favorable performance status and simultaneous chemotherapy. Irradiation treatment does not change prognosis regarding overall survival.

[Metastatic breast carcinoma with neuroendocrine differentiation--its combined therapy with tamoxifen and the somatostatin analog octreotide]. / Metastasiertes Mamma-Karzinom neuroendokriner Differenzierung--kombinierte Therapie mit Tamoxifen und dem Somatostatin-Analogon Octreotid.

HISTORY AND ADMISSION FINDINGS: A 75-year-old woman with histologically confirmed liver metastases from an undiagnosed primary tumor was admitted for further diagnosis and treatment. She had no symptoms and was in a very good general condition. The physical examination was unremarkable. INVESTIGATIONS: The liver enzymes GOT and GPT were slightly elevated. The carcinoembryonic antigen (CEA) and the erythrocyte sedimentation rate (ESR) were markedly raised. Repeat analysis of the liver biopsies revealed a carcinoma with neuroendocrine differentiation (carcinoid). TREATMENT AND COURSE: Chemoembolization of the advanced liver metastases was undertaken. Subsequently the breast tumor was resected. Histological analysis revealed a mammary carcinoma with neuroendocrine differentiation. Postoperative radiotherapy to the breast was instituted and she was started on tamoxifen (30 mg daily). But despite repeat chemoembolization the liver metastases continued to grow. Administration of octreotide, a somatostatin analogue, was begun (200 micrograms twice daily). There were no side effects; the tumor markers showed definite reduction and scintigraphy demonstrated almost complete regression. Computed tomography indicated a dissociated response of the liver metastases to the treatment (some got smaller, one had grown and several new ones had appeared). CONCLUSION: Combined tamoxifen and octreotide treatment of a metastasizing carcinoma of the breast with neuroendocrine differentiation may give effective palliation.

[The effect of adjuvant radiotherapy on the mental health of female patients with a breast-conserving operated breast carcinoma]. / Einfluss der adjuvanten Radiotherapie auf das psychische Befinden von Patientinnen mit einem brusterhaltend operierten Mammakarzinom.

BACKGROUND: In literature there are only few informations about the influence of postoperative irradiation on the psychological health of breast cancer patients treated by breast-conserving surgery. However, psychological distress and anxiety related to irradiation are often observed. Purpose of our study was the evaluation of the influence of radiotherapy-induced distress in these patients. PATIENTS AND METHODS: Between October 1995 and June 1996 in 48 breast cancer patients (31 to 76 years old) treated by breast-conserving surgery adjuvant irradiation with or without systemic therapy was applied. On the first and the last day of radiotherapy they were given a questionnaire (Table 1) which was designed together with psychologists. Covering different situations related to radiotherapy the construction of items are determined by factors with possible influence on psychological distress and perception with regard to irradiation. RESULTS: Most of the women (92%) stated to be well informed about the irradiation and tried to obtain further information about this treatment (83%). 56% tried not to think about radiotherapy and/or to distract themselves (81%). 40% were anxious about the fact to undergo irradiation. In the end of treatment 77% reported to have been anxious only initially or never; only 19% were anxious almost or most of the time. 35% were worried about the expected cosmetic alterations of their breast; only 30% observed acute cosmetic changes. With regard to situation-related distress all patients (100%) stated that the communication with the medical staff made it easier to stand the irradiation treatment. CONCLUSIONS: In spite of theoretical considerations our results are explorative in character. However, following statements seem to be important: 1. A large requirement exists to get information about radiotherapy. 2. The patients experience irradiation treatment more positive than initially expected by themselves. 3. With regard to radiotherapy anxiety is reduced during the course of treatment. Here the psychosocial care of the medical staff is an important support for reduction of anxiety.

[The intensification of the radiotherapeutic effect on HeLa cells by gemcitabine]. / Verstärkung der radiotherapeutischen Wirkung auf HeLa-Zellen durch Gemcitabine.

BACKGROUND: Gemcitabine (2'.2'-difluorodeoxycytidine; dFdC) is a new nucleoside analog with promising activity in different solid tumors in vivo and in vitro. As published up to now, combined with irradiation dFdC demonstrates a radiosensitizing effect on pancreas and colon carcinoma cell lines. We investigated the influence of dFdC on the radiosensitization of human squamous carcinoma cells of the cervix (HeLa-cells, ATCC CCL-2). MATERIAL AND METHODS: Under standardized conditions monolayer cultures of HeLa-cells were incubated in medium with dFdC for different times (4 to 24 hours) and exposed to different concentrations (0.003, 0.01 and 0.03 mumol/l). Irradiation (2 to 6 Gy, electron beam) followed immediately or 12 hours after dFdC-exposure. Cell survival was determined by colony forming assay. Using the linear-quadratic model cell survival curves were fit after correction for drug-induced cytotoxicity and the mean inactivation dose (MID) was calculated. Radiation enhancement was defined as the ratio MIDRT(= Control)/MIDRT + dFdC > 1. RESULTS: Exposed to gemcitabine for 4 and 8 hours and followed by immediate irradiation the radiation enhancement ratio (Table 1) is 1.07 to 1.14 and 1.04 to 1.22, respectively, if dFdC concentration is > or = 0.01 to 0.03 mumol/l. Further increase of the irradiation effect is demonstrated in cells exposed to > or = 0.003 to 0.03 mumol/l dFdC for 16 and 24 hours (radiation enhancement ratio 1.08 to 2.0 and 1.08 to 2.48, respectively) (Figure 3). If irradiation is applied 12 hours after 24-hour-exposure (0.01 and 0.03 mumol/l) the enhancement ratio was 1.18 and 1.7, respectively (Figure 4). CONCLUSIONS: In cell cultures the assays combining irradiation with dFdC demonstrate that dFdC is a potent radiation sensitizer of HeLa-cells. The effect of irradiation on cells pre-treated with non- and hardly cytotoxic concentrations of dFdC is increased in dependence of dose and time of exposure.

Survival of very young children with medulloblastoma (primitive neuroectodermal tumor of the posterior fossa) treated with craniospinal irradiation.

PURPOSE: Very young children with medulloblastoma are considered to have a worse prognosis than older children. As radiotherapy remains an important part of the treatment, the adverse prognosis could be due to inadequate radiation treatment rather than biological factors. We analyzed the published literature to examine the impact of radiotherapy on survival in this group. METHODS AND MATERIALS: A Medline search was performed and we reviewed studies of treatment of medulloblastoma where radiotherapy was delivered using megavoltage equipment and the minimum follow-up allowed the calculation of 5-year survival rates. RESULTS: Thirty-nine studies were published between 1979 and 1996 with a treatment including craniospinal irradiation and boost to the posterior fossa. Eleven studies comprising 1366 patients analyzed survival by age at diagnosis. Eight of 11 studies showed a worse 5-year survival for the younger patient group which reached statistical significance in two. There is also a suggestion of a higher proportion of children with metastatic disease at presentation in the very young age group. The usual policy in younger children was to give a lower dose of radiotherapy to the craniospinal axis (CSA) and posterior fossa (PF) with reduction of dose in the range of 15 to 25% compared to standard treatment. As dose reduction to the posterior fossa is associated with worse survival and local recurrence is the predominant site of failure, the major determinant of worse survival in very young children with medulloblastoma may be suboptimal radiotherapy. Protocols including postoperative chemotherapy with delayed, omitted, or only local tumor irradiation do not reach survival rates of protocols with standard radiotherapy, also suggesting a continued importance for irradiation. CONCLUSION: Very young children with medulloblastoma have a worse prognosis than older children. Inadequate radiation dose and technique to the primary tumor region may be a major contributing factor. Current chemotherapeutic regimes alone are not sufficient to compensate for reduced radiation doses and volumes.

Brachytherapy with iridium-192 HDR to prevent from restenosis in peripheral arteries. An update.

The use of stents does not appreciably improve restenosis (usually resulting from intimal hyperplasia) as compared to percutaneous transluminal angioplasty (PTA) alone. The development of small-caliber probes for afterloading therapy in the biliary tract allowed us to use these for therapy in the vascular system. Using a special 9 F catheter, exact measurement of the length of the stented vascular segment and of the insertion length of the afterloading probe could be reproducibly performed. We used a Nucletron (Micro) Selectron HDR planning system version 10.10 for exact calculation, monitoring, and control of the afterloading procedure. Our source was iridium 192 (10 Ci) with a diameter of 1.1 mm. The program controls and monitors the insertion and removal of the iridium probe from the source into the special catheter through to the tip, and monitors the irradiation duration. The exposure time was around 200 seconds for a surface dose of 12 Gy. To date, a total of 40 patients have been treated with endovascular afterloading. All patients suffered from clinically relevant reocclusions or restenoses in stented vascular segments of the superficial femoral artery following successful PTA or laser treatment, within 6 to 8 months after the last therapy. In all patients it was possible to perform re-PTA treatment without remaining residual stenoses in the stented region. The additional time required as compared to PTA alone was approximately 45 minutes with most of this time spending for transportation between the cath lab and afterloading room. The follow-up period of the 40 patients ranged from 4 months to 71/2 years. In 33 patients, there was no deterioration of the clinical stage and no restenosis. One patient suffered from an acute thrombosis approximately 3 months after stent implantation, another patient had a stenosis 3 cm above the stented vascular segment 12 months after irradiation treatment. Follow-up examinations have revealed no evidence of nerve lesions following irradiation therapy. The tissue surrounding the artery showed no change following irradiation therapy, either in the CT, color-coded Doppler, endovascular ultrasonic scan or MRI. No complaints of discomfort were reported during or after irradiation. With the exceptions mentioned above, there was no evidence of any complications.

Management of radiation injuries of vulva and vagina.

BACKGROUND: Acute and late injuries of vulva and vagina are frequent and potentially serious complications in radiotherapy of gynecologic tumors. They still are reported poorly in literature. METHODS: Based on a literature search a survey will be given of the modalities, which are used or recommended for prophylaxis or treatment of these radiation injuries. The principles of the different measures will be discussed with available study results. RESULTS: Hygiene measures and the topical application of antimicrobial or granulation stimulating substances, which is mostly based on long standing clinical experience, are the principles of the treatment of acute reactions of vulva and vagina. The topical use of estrogen, which promotes proliferation of epithelium, is generally described in connection with treatment and prophylaxis of late radiation injuries. As a prophylaxis for the late reaction of vaginal stenosis, vaginal dilatation is recommended in literature. CONCLUSIONS: With the exception of a few reports on estrogen, there are no data about the effectiveness of the currently used medical substances. The local application of estrogen as prophylaxis of the acute reactions will therefore be examined in a prospective study.

Influence of radiotherapy on psychological health in breast cancer patients after breast conserving surgery.

BACKGROUND: The purpose of this study was the evaluation of the radiotherapy-induced psychological distress of patients and changes in psychological health during radiotherapy (RT). PATIENTS AND METHODS: 53 breast cancer patients undergoing irradiation after breast conserving surgery participated in this study. In the beginning and at the end of radiotherapy they answered a questionnaire asking for coping strategies, psychological distress with regard to irradiation and influence of surroundings. RESULTS: 92% stated to be well informed about radiotherapy. Coping strategies in order of importance: Talking to physician (94%) or partner (84%), 81% try to distract themselves, 56% repress thoughts about radiotherapy. 40% were anxious about RT and expected side effects (54%). At the end of therapy anxiety was reduced: 77% were anxious only initially or never. CONCLUSIONS: Patients are very interested in information about RT. Their experience of radiotherapy was more positive than initially expected. The relation to medical staff plays an important part in the reduction of irradiation-related psychological distress.

[Value of 18F fluorodeoxyglucose positron emission tomography in radiotherapy planning of head-neck tumors]. / Stellenwert der 18F-Fluordeoxyglucose-Positronenemissionstomographie in der Radiotherapieplanung von Kopf-Hals-Tumoren.

PURPOSE: An individualized radiation treatment planning in patients with head and neck tumors requires an exact definition of tumorspread. Despite of high reliability of methods like computed tomography, sonography or magnetic resonance imaging used in daily routine, the correct diagnosis of lymphonodal tumor infiltration is often not possible. In a prospective trial, we examined whether an additional FDG-PET gives a relevant gain of information for radiation treatment planning. PATIENTS AND METHODS: We studied data of 34 patients with histologically confirmed squamous cell carcinoma of the head and neck who received a FDG-PET prior to treatment planning additionally to conventional staging procedures. The extent of changes of treatment strategy or target volume due to additional FDG-PET findings were analyzed. RESULTS: In 9/22 of patients with primary tumors and in 7/12 of patients with recurrent disease, FDG-PET detected additional tumor manifestations. In all cases, changes of treatment strategy or target volume were necessary. Regarding patients with primary tumors, the percentage of treatment modifications was highest in patients with large tumors (T3 and T4) and patients with advanced lymph node involvement (N2 and N3). CONCLUSIONS: Especially in patients with recurrent disease and patients with advanced tumor stages, FDG-PET is able to give clinically relevant information compared to conventional staging procedures. Therefore, in these group of patients a FDG-PET study prior to radiotherapy planning should be considered.

Prophylaxis with povidone-iodine against induction of oral mucositis by radiochemotherapy.

Oral mucositis is a frequent complication of radiochemotherapy. The origin of radiation-induced mucosal lesions is iatrogenic in nature, although further development of mucositis is essentially influenced by infection. It can be assumed that disinfection measures should decrease the severity of mucositis induced by radiochemotherapy. Therefore, in a prospective randomised study the efficacy of prophylactic oral rinsing with a disinfection agent was investigated. A randomised, prospective comparative trial was conducted with 40 patients undergoing radiochemotherapy of the head and neck region because of malignant disease. The treatment scheme consisted of irradiation to the tumour region and adjacent lymph nodes, with a total dose of 71.3 Gy, and simultaneous chemotherapy with carboplatin (60 mg/m2) on days 1-5 and 29-34. In all patients mucositis prophylaxis with nystatin, rutosides, panthenol and immunoglobulin was undertaken. In addition, 20 patients rinsed the oral cavity 4 times daily with povidone-iodine solution, while the group for comparison rinsed with sterile water. Clinical examination of the oral mucosa was performed weekly. Onset, grading and duration of mucositis were used as the main variables. Clinically manifest oral mucositis was observed in 14 patients in the iodine group (mean grading: 1.0) and in all 20 patients in the control group (mean grading: 3.0). The total duration (mean) of clinically observed mucositis was 2.75 weeks in treatment patients and 9.25 weeks in control patients. Median AUC (area under curve for grade vs duration) was 2.5 in the iodine rinsing patients and 15.75 in control patients. All differences found between the two groups were statistically significant. Increased iodine incorporation was not observed. A pathologic rise in thyroid hormone levels was not found in the iodine group. The results obtained indicate that incidence, severity and duration of radiochemotherapy-induced mucositis can be significantly reduced by oral rinsing with povidone-iodine in addition to the standard prophylaxis scheme. It can be concluded that rinsing with povidone-iodine is an easy, cheap and safe prophylactic method and can be recommended as a supportive treatment during antineoplastic treatment of the head and neck region.

The use of a standardized positioning support cushion during daily routine of breast irradiation.

PURPOSE: The use of positioning and immobilization techniques during external beam irradiation of the female breast is time consuming and expensive. The currently available standardized positioning devices are insufficient. For this reason, we designed a new and generally useable hard foam positioning support cushion for the use during breast irradiation, and tested its clinical usefulness in a prospective study. METHODS AND MATERIALS: Fifty-five female breast cancer patients receiving adjuvant radiotherapy following breast-conservative surgery were irradiated either without immobilization (n = 27) or with the positioning support cushion (n = 28). The time necessary for patient setup, the lying subjective comfort and--comparing portal images with simulator images--the reproducibility of the set up were determined. RESULTS: Irradiation reproducibility was significantly improved (average deviation without positioning support cushion: 8.4 mm, with positioning support cushion: 6.1 mm, p < 0.001). The time required for the positioning of the patient with positioning support cushion was in average 73 s, without cushion it was 55 s. A significantly higher proportion of patients (72%) found the position with the positioning support cushion as pleasant, whereas only 46% of patients were pleased with the position without cushion. CONCLUSION: The positioning support cushion designed in our department makes a substantial contribution to quality assurance in breast irradiation. It significantly increases the patients' comfort in a supine position. In contrast to conventional positioning and fixation aids it may be quickly and easily applied at low costs. Therefore, its use can be recommended.