Radiation therapy for benign diseases: patterns of care study in Germany.

BACKGROUND: Radiotherapy of benign diseases is controversial and rarely applied in Anglo-American countries, whereas in other parts of the world it is commonly practiced for several benign disorders. Similar to a European survey, a patterns of care study was conducted in Germany. METHOD: Using a mailed questionnaire, radiation equipment, treatment indication, number of patients, and treatment concepts were assessed in 1994, 1995, and 1996 in 134 of 152 German institutions (88%): 22 in East and 112 in West Germany; 30 in university hospitals and 104 in community hospitals. Average numbers of each institution and of all institutions were analyzed for frequencies and ratios between regions and among institutions. Radiation treatment concepts were analyzed. RESULTS: A mean of 2 (range 1-7) megavoltage and 1.4 (range 0-4) orthovoltage units were available per institution; 32 institutions (24%) had no orthovoltage equipment. A mean of 20,082 patients were treated annually: 456 (2%) for inflammatory diseases (221 hidradenitis, 78 local infection, 23 parotitis; 134 not specified) 12,600 (63%) for degenerative diseases (2711 peritendinitis humeroscapularis, 1555 epicondylitis humeri; 1382 plantar/dorsal heel spur; 2434 degenerative osteoarthritis; 4518 not specified); 927 (5%) for hyperproliferative diseases (146 Dupuytren's contracture, 382 keloids; 155 Peyronie's disease; 244 not specified); 1210 (6%) for functional disorders (853 Graves' orbitopathy; 357 not specified); and 4889 (24%) for other disorders (e.g., 3680 heterotopic ossification prophylaxis). In univariate analysis, there were geographic (West vs. East Germany) differences in using radiation therapy (RT) for inflammatory and degenerative disorders, and institutional differences (university versus community hospitals) in using RT for hyperproliferative and functional disorders (p < 0.05). The prescribed dose concepts were mostly in the low dose range, <10 Gy but varied widely and inconsistently within geographic regions and institutions. CONCLUSION: Radiation therapy is a well-accepted and frequently practiced treatment for several benign diseases in Germany; however, there are significant geographic and institutional differences. As the number of orthovoltage units decreases, an increasing patient load will demand more megavoltage units, which may compromise the cost-effectiveness of this treatment. Only 4% of all clinical institutions have been involved in controlled clinical trials. To maintain a high level of RT service to other disciplines, RT treatment guidelines, quality control, and continuing medical education are required.

[Radiotherapy of benign diseases: a pattern of care study in Germany]. / Strahlentherapie von gutartigen Erkrankungen: eine Bestandsaufnahme für Deutschland.

BACKGROUND: Radiation therapy of benign diseases is controversially discussed and rarely applied in Anglo-American countries, while in other parts of the world, especially Central and East Europe, it is commonly practised for several benign disorders. Similar to the European Society of Therapeutic Radiology and Oncology survey, a patterns of care study was performed in Germany. METHOD: A questionnaire was mailed in 3 years (1994, 1995, 1996) to all radiation facilities in Germany, which assessed equipment, indications, number of patients and treatment concepts. A total of 134 (88%) institutions returned all requested data: 22 in East and 112 in West Germany; 30 in university and 104 in community/private hospitals. The average data of each institution and of all institutions were analyzed for frequencies and ratios between different regions and institutions. RESULTS: A mean of 2 (range 1 to 7) megavoltage (Linac/Cobalt 60) and 1.4 (range 0 to 4) orthovoltage units were available per institution; 32 (24%) institutions had no orthovoltage equipment. A mean of 20,082 patients were treated per year: 456 (2%) for inflammatory diseases (221 hidradenitis, 78 nail bed infection, 23 parotitis, 134 not specified), 12,600 (63%) for degenerative diseases (2,711 peritendinitis humeroscapularis, 1,555 epicondylitis humeri, 1,382 heel spur, 2,434 degenerative osteoarthritis, 4,518 not specified), 927 (5%) for hypertrophic diseases (146 Dupuytren's contracture, 382 keloids, 155 Peyronie's disease, 244 not specified), 1,210 (6%) for functional disorders (853 Graves' orbitopathy, 357 not specified), and 4,889 (24%) for other disorders (e.g. 3,680 heterotopic ossification prophylaxis). In univariate analysis, there were significant geographical (West vs East Germany) differences in the use of radiotherapy for inflammatory and degenerative disorders and institutional differences (university vs community/private hospitals) in the use of radiotherapy for hypertrophic and functional disorders (p < 0.05). The prescribed dose concepts were mostly in the low dose range (< 10 Gy), but varied widely and inconsistently within geographic regions and institution types. CONCLUSION: Radiotherapy is a well accepted and frequently practised treatment for several benign diseases in Germany, however, there are significant geographical and institutional differences. As the number of orthovoltage units decreases, an increasing patient load is in demand of more megavoltage units, which may compromise the cost-effectiveness of this treatment. Only 4% of all clinical institutions are involved in controlled clinical trials. To maintain a high level of radiotherapy service to other disciplines, radiotherapy treatment guidelines, quality control and continuing medical education are required.

[Neutropenic enterocolitis]. / Neutropene Enterokolitis.

A 58-year old patient with metastasizing squamous cell carcinoma of the left lung developed fever, diffuse abdominal pain and profuse diarrhea while treated with paclitaxel and radiation therapy. A sigmoidoscopy was performed to exclude pseudomembranous colitis but showed multiple mucosal petechiae. Histologic examination disclosed neutropenic colitis. Conservative treatment was successful.

Radiotherapy vs. radiotherapy and razoxane in the treatment of soft tissue sarcomas: final results of a randomized study.

PURPOSE: The effect of the sensitizer razoxane on soft tissue sarcomas (STS) was prospectively evaluated in a randomized, controlled trial. The main purpose of the study was to determine the response rates and local control under the combined treatment compared to irradiation alone. METHODS AND MATERIALS: Between 1978 and 1988, 144 patients entered the study; 130 were evaluable for response, toxicity, or survival. The patients were randomized to receive radiotherapy alone or radiotherapy with razoxane. They were divided into postoperative cases and patients with gross disease (unresectable primaries, recurrent disease, or metastatic disease). The median radiation dose was 60 Gy postoperatively, and 56-58 Gy in patients with gross disease. The dose difference has palliative reasons. Razoxane was given orally at a daily dose of 150 mg/m2 during the time of the radiotherapy, starting 5 days before the first irradiation. In general, the groups were comparable as to their prognostic factors. There was some imbalance, however, in favor of the postoperative group reveiving radiotherapy alone. RESULTS: Between the patient groups treated postoperatively in an adjuvant form, there were no substantial differences in local control and survival. Among 82 patients with gross disease, the treatment with radiotherapy and razoxane led to an increased response rate compared to photon irradiation alone (74 vs. 49%). The local control rate was likewise improved (64 vs. 30%;p < 0.05). The acute toxicity was somewhat higher in the sensitizer arm, but there was no difference in the occurrence of late complications. CONCLUSIONS: Radiotherapy combined with razoxane seems to improve the local control in inoperable, residual, or recurrent STS compared to radiotherapy alone. The combined treatment is a fairly well tolerated procedure at low costs. It can be recommended for inoperable primary STS or gross disease after incomplete resection, conditions which are still associated with limited local control and a grave prognosis.

[Radiation treatment of benign diseases--indications, results and technic]. / Die Strahlenbehandlung gutartiger Erkrankungen--Indikationen, Ergebnisse und Technik.

Radiotherapy is an effective means to treat several benign diseases; in fact, the therapeutic effects set in quickly and are of a long-term nature. Relapses are rare. Side effects or other undesirable reactions are negligible. The gonads are under risk that should not be underestimated, but this is usually acceptable within reasonable limits. The age of the woman patient and localisation of the disease are decisive factors. Definite dosage reductions can be achieved by suitable radioprotective measures. Nevertheless, indications for any kind of radiotherapy with ionising radiation should be strict as a matter of principle.

[Medical and physical aspects of quality assurance in radio-oncology]. / Medizinische und physikalische Aspekte der Qualitätssicherung in der Radioonkologie.

A more extensive interpretation of quality control in radio-oncology is opposed to the conception mostly restricted to technical inspections. A review is given of the most important medical and physical aspects of an optimized radiotherapy. Some examples are chosen from the great number of national and international recommendations agreed upon in order to standardize the measures of quality control. Finally some simple radiobiologic models are presented and the corresponding precision requirements are compared with the uncertainties of the dose determination resulting in clinical practice.

[Development of a clinical tumor registry using the DATACORD program package]. / Aufbau eines klinischen Tumorregisters mit Hilfe des Programmpaketes DATACORD.

During the establishment of a new radiooncologic department in a general hospital, a clinical tumor register has been developed for internal patient documentation. The authors describe the general requirements which had to be fulfilled by this tumor register as well as the reasons leading to the purchase of a commercial program package adapted to an irradiation planning system. The structure of the programs and the specification of characteristics are defined. Finally some aspects of organisation regarding the use of the register are mentioned.

[Indication and treatment with surgical therapy in primary non-epithelial cancers of the stomach]. / Indikation und Behandlung der chirurgischen Therapie bei nichtepithelialen, primären Malignomen des Magens.

The importance of surgical treatment in non-epithelial, primary malignant tumors of the stomach was investigated retrospectively in 27 cases. 85.2% of these tumors were non-Hodgkin lymphomas, 14.8% were leiomyosarcomas and Hodgkin's disease. There were no typical symptoms; those present resembled the symptoms of carcinomas and peptic ulcers. Most patients showed symptoms on average 6 months prior to diagnosis. Histocytological studies of endoscopic biopsies enabled a correct diagnosis to be made preoperatively in up to 75% of cases. The postoperative mortality was 14.8%; the 5-year survival rate was 56.2%. Thus the prognosis is significantly better than that of advanced cancer of the stomach.

[Results of retrobulbar irradiation in case of benign endocrinous ophthalmopathy (author's transl)]. / Ergebnisse der Retrobulbärbestrahlung bei benigner endokriner Ophthalmopathie.

83 patients with a benign endocrinous ophthalmopathy were submitted to radio-iodine and thyreostatic therapy and to high voltage therapy of the retrobulbar region. The ophthalmologic controls showed that 30% of the treated patients had improved data and 70% had unchanged data. These results were independent from the individual radiation qualities used and the field sizes.

Measurements on the radiation protection of patients irradiated with an 18-MeV electron linear accelerator.

In order to quantify the influence of some physical and geometrical treatment parameters on the stray radiation dose absorbed by patients undergoing radiotherapy on an 18-MeV linear accelerator, dose distributions were measured in a polystyrene phantom by means of LiF-dosimeters. For 10-MV X-rays, 6-MeV and 18-MeV electron radiation dose profiles, depth dose and isodose curves were obtained at various field sizes and treatment couch positions. By covering the phantom with 1 or 2 mm thick lead sheets a remarkable dose reduction was found. A two-exponential expression was derived to estimate stray radiation dosage in routine radiotherapy. The validity of the calculation method was demonstrated by comparing the gonadal load measured in an Alderson phantom with the calculated data.

[Influence of radiotherapy upon tumor accumulation and organ distribution of 57Co-bleomycin in mice with chemically induced squamous cell carcinoma (author's transl)]. / Einfluss der Strahlentherapie auf Speicherung von 57Co-Bleomycin im Tumor und Verteilung in den Organen bei Máusen mit chemisch induziertem Plattenepithelkarzinom.

Squamous cell carcinoma was induced in male 6 to 8-week old NMRI-mice by application of 9,10-dimethyl-1,2-benzanthracene on the skin. 15 weeks later macroscopically visible skin tumors are developed. Then organ distribution and tumor accumulation of 57Co-Bleomycin (spec. activity 1 mCi/3.3 mg) were studied 1 to 48 hours after injection. In squamous cell carcinoma a high uptake of this tumor-seeking agent can be demonstrated (n = 46). After radiotherapy (100 kV; 1.7 mm Al-filter; 18.8 Gy) (n = 26), however, a significantly reduced uptake of 57Co-Bleomycin in tumor tissue is observed. Possible consequences from these animal studies for tumor scintigraphy with this radiopharmaceutical in man are discussed.

[Radiation therapy of humeroscapular periarthritis (author's transl)]. / Die Strahlenbehandlung der Periarthritis humeroscapularis.

The effectiveness of radiation therapy in 233 cases with periarthritis humeroscapularis is reviewed in a prospective study from the Basel canton hospital. The patients are studied with regard to different parameters, such as duration of the anamnesis, importance of the dose, moment of evaluation of the results and influence of a 2-series technique. The total result, comprising 43.3% cases without complaints, 30.9% being better, and 25.8% whose troubles had not changed, is compared with the compiled statistical data of 4957 cases found in literature. The gonadal load is discussed on the basis of our own investigations.

[Measurement on a 42-meV betatron with regard to the radiological protection of patients (author's transl)]. / Messungen zum Patientenstrahlenschutz an einem 42 MeV Betatron.

In order to examine the side radiation field of X-rays from the 42-meV Siemens betatron, transverse and depth dose distributions were measured in the phantom with LiF dosemeters. The influence on the dose distribution exerted by the kind of radiation and its energy, the rotation angle of the patient's table, and the field dimensions was determined. The quality of the side radiation and the effect of additional lead shieldings were examined. The dose distributions can be calculated approximately by means of an exponent which can be used in order to estimate the surface dose for all desired irradiation conditions and to determine any distances from the field edges.

[Effect of SL 25 on radiogenic xerostomia in the radiotherapy of tumors in the region of neck and face (author's transl)]. / Die Wirkung von SL 25 auf die radiogene Xerostomie bei der Strahlentherapie von Tumoren im Hals- und Gesichtsbereich.

The radiogenic xerostomia often poses problems to the radiotherapeutist because this symptom can become so severe that treatment has to be interrupted or in some cases even stopped. The therapeutic success can become uncertain because of such deviations from the irradiation scheme. Because of promising observations reported in literature, we have examined the stimulating effect on the salivation produced by the test preparation SL 25 from Kali-Chemie Pharma GmbH in Hannover. A double blindfold test was made. Only three out of fourteen patients (22%) in the active substance group declared to feel a relief of the xerostomia, whereas in the control group five out of twenty patients (25%) felt this relief.

[Study on hematological toxicity in irradiation and ICRF 159 combination treatment during experimentation on animals with particular consideration of long-term effects (author's transl)]. / Zur hämatologischen Toxizität bei kombinierter Strahlen- und ICRF 159-Behandlung im Tierversuch unter besonderer Berücksichtigung der Langzeitwirkung.

Experiments on animals are utilized for the control of hematological toxicity in sound NMRI mice during and after fractionated ICRF 159 therapy, fractionated whole-body irradiation and a combination of both. In the course of the 32-day therapeutic phase, and also during the total follow-up period lasting 196 days, continual determination of leukocytes and thrombocytes was performed. Leukocyte and thrombocyte depression is related to radiation effects during the phase of therapy and subsequently. In the later period of follow-up, however, hematological toxicity developed by ICRF 159 is higher than that produced by irradiation. Early and late effects of the preparation must be distinguished therefore. The thrombocytopenic effect is altogether less pronounced than the leukocytopenic effect. Here, too, the thrombocytopenic action of ICRF 159 appears in the course of the late phase only, but then more distinctly. The present results are discussed and compared to hitherto existing observations from animal experimentation and from clinical findings described in literature.