Spinal growth after irradiation for Wilm's tumour.

Between 1960 and 1983, 82 children were treated for Wilm's tumour at our hospital. The secondary effects and changes in the skeleton have been assessed. Radiotherapy was found to cause growth disturbances and osteochondrosis of variable degree, but not osteonecrosis. Since irradiation produces late damage, it should be applied symmetrically to the spine and the dose limited as far as is possible. A long follow up is necessary since skeletal damage can only be assessed after the end of growth.

[Vertebral changes after irradiation for Wilms' tumor in early childhood. A retrospective interdisciplinary long-term study of 82 children]. / Wirbelsäulenveränderungen nach Bestrahlung wegen Wilmstumor im Kleinkindesalter. Retrospektive interdisziplinäre Langzeitstudie an 82 Kindern.

82 children with nephroblastomas, who had therapy between 1960 and 1983, underwent continuous follow-up examinations until 1988. 79 children who survived had been treated with nephrectomy followed by radiation therapy (n = 72) and chemotherapy (n = 72). 64 of these patients had a combination of both post-surgical treatments. Radiotherapy was performed with cobalt-60 until 1977, followed by high-energy photon and electron beam therapy since 1978. In the beginning the dose applied in each patient within five to seven weeks was 46.5 Gy. Since 1972 it was reduced to 42.8 Gy and after 1978 to 32.3 Gy. The overall survival rate between 1960 and 1988 was 65% and rising to 91% since 1980. 47 children had spinal X-ray examinations at regular intervals for more than two years and 28 of these patients could be followed up to 20 years after radiotherapy. 39 children who had been irradiated before the age of 2 1/2 years developed a more pronounced degree of scoliosis and lumbar kyphosis with a higher incidence. 1500 spinal radiograms were evaluated. Measurements of the second lumbar vertebra, which was constantly situated within the target volume, were compared with those of the eight thoracic vertebral body outside the radiation field, and the curvature of the spine was analysed. Late radiation injuries of the spine could be reduced by involving the whole vertebral diameter into the radiation beam, by the use of high-energy radiation techniques and by excluding children under the age of one year from radiotherapy. However, disturbances of spinal growth cannot always be prevented.

[Results of local radiotherapy and modified total-brain irradiation in astrocytoma]. / Ergebnisse der lokalen Strahlentherapie und modifizierten Ganzhirnbestrahlung von Astrozytomen.

A retrospective evaluation was made on the results of primary or postoperative radiotherapy in 162 patients with grade I to IV astrocytomas. The greatest part of the overall group was built by 113 patients suffering from glioblastoma multiforme. For the survival analysis, the prognostic importance of the following factors was investigated: sex, age, surgery, radicality of surgery, grading according to Kernohan, tumorous lesions in central structures, and target volume of radiotherapy. The prognosis is first of all dependent on the operability, the grading, and the age of the patient. The survival of patients with malignant gliomas is not influenced by the radicality of the operation and the extension of the target volume to the whole brain (total-brain irradiation and boost). Thus in the treatment of malignant astrocytomas, the less extensive surgical and radiotherapeutical intervention seems an adequate method to manage this disease.

[Radiotherapy of locally recurring colorectal tumors. Prognostic factors, follow-up diagnosis and results]. / Strahlentherapie bei Lokalrezidiven kolorektaler Tumoren. Prognostische Faktoren, Verlaufsdiagnostik und Ergebnisse.

From 1979 through April, 1985, 74 patients were treated by percutaneous irradiation for local recurrences of colorectal carcinomas. The treatment consisted of a contralateral irradiation up to a dose of 40 Gy and a small-volume boost up to 60 to 66 Gy. In case of progressive remote metastases, the treatment was finished at 50 Gy. 53 patients received a dose of 50 Gy or more and were followed for at least six months. The decisive prognostic parameter was the presence of remote metastases when the recurrence appeared (n = 32). The median survival was six months, in patients without remote metastases at this moment it was 15 months. A complete or considerable relief of pain was obtained in 78%; it continued for a median period of 8.5 months, although most of the patients showed a new local tumor progression after an interval of three to 26 months. Computed tomography showed only small regressions or, in most cases, unchanged volumes of the tumors.

[Electron therapy of malignant parotid tumors]. / Elektronentherapie bei malignen Parotistumoren.

Between 1968 and 1984, 61 patients with malignant parotid tumors were irradiated with fast electrons. The irradiation was performed after surgery in 58 patients, 37 out of them had tumor reresidues at the beginning of radiotherapy. The local recurrence rate was 16%, and there were no differences between patients operated in sano and patients operated non in sano. The survival at five years, however, was only 43%. This is explained by the preponderance of tumor histologies with unfavorable prognoses. Distant metastases were observed in 38% of patients. 8/10 patients with local recurrences developed distant metastases. It is noticeable that polymorphous adenomas were found in the anamneses of ten patients and histologically different secondary carcinomas in 9/61 cases.

[Scintigraphic localization of the liver and kidneys for abdominal radiotherapy: methods, accuracy and comparison with the ultrasonic procedure]. / Szintigraphische Leber- und Nierenlokalisation für die Strahlenbehandlung des Abdomens: Methodik, Genauigkeit, Vergleich mit Ultraschallverfahren.

The exposure of liver and kidney has to be avoided when irradiation fields for radiotherapy of the abdomen are planned and adjusted, unless these organs themselves are the target of therapeutic procedure. A scintigraphic method is presented which allows to transfer the site and borderlines of the organs to the body surface taking exactly into account the irradiation position. A precise transfer of site, size, and shape of the organs facilitates the adjustment of irradiation fields or the positioning of satellite field stops. Scintigraphic organ localization is performed by means of static liver or kidney scintigraphy with suitable radiocolloids for the liver and 99mTc DMSA for the kidneys. The scintigraphic procedure meets all practical requirements regarding the precision of organ localization and shows evident advantages compared to X-ray and ultrasonographic methods. It can be performed at every department of nuclear medicine without preparing the patient and is not influenced by intestinal air artefacts, skeletal parts, obesity, or dystopic organ sites. The results of scintigraphic and ultrasonographic kidney localisation are compared in 15 patients. The scintigraphic procedure has shown to be superior, even with regard to precision and possibility of variable projections to the body surface.

Three-dimensional dose distributions for radiotherapy of sinus maxillary tumours.

Three-dimensional dose distributions for the radiation therapy of sinus maxillary tumours have been calculated. Irradiation techniques with 8 MV X-rays and 15 MV X-rays from a linear accelerator (Siemens Mevatron 74 and Siemens Mevatron 77) and 60Co gamma-irradiation (Siemens Gammatron S80) are compared to each other. Using an anterior and a lateral field, the three-dimensional dose distribution of high energy photons shows that the radiation burden of the lens and the skin is significantly lower than with the use of 60Co irradiation. Sufficient dose coverage and sparing of the lens and the skin can be reached using the irradiation technique with 8 MV X-rays.

Perspectives of radiotherapy.

The 5 years' survival rate of all cancer patients is 35-45%. In that survival rate radiotherapy takes part in 15%. By further development of radiological methods and techniques radiotherapy gains significance in the recent time. Optimizing radiation planning and tactics, all modern imaging techniques are applied consequently. The radiotherapist must be able to asses their immanent specifity which should remain object of the radiological training, even if separated into therapy and diagnostics. Dose distribution is calculated by computer; three-dimensional planning is done in tumors of the mediastinum, oesophagus carcinoma and paraaortic lymphomas. Critical description of radiation techniques, results, problems and prognoses are given by results in tumors of the epipharynx and gastric cancer. After-loading, done until now only in gynaecological tumors, is performed in recurrences of pharyngeal tumors by individually shaped applicators. Reducing the number of therapy failures as well as possible, the application of higher tumor doses, new kinds of rays as neutrons and combinations with physical and chemical methods is outlined. Modifications of radiation volumes are discussed, especially the irradiation of the complete abdomen in ovarian cancer, the irradiation of the complete body surface by electrons in mycosis fungoides, and the total body irradiation prior to autologue bone marrow transplantation. Modifications of fractionation are shown in short-time radiation of bone metastases and single-time radiation of brain lesions. Low penetrating electron therapy facilitates intraoperative single-time irradiation. Because of higher biological efficiency neutrons and heavy ions allow to irradiate low sensible tumors or recurrences embedded in fibrotic tissue respectively. The combination with hyperthermia yields good results in tumors of the head and neck with better local response and total remissions of 59%. There are potentials in synchronising with chemotherapeutics. Remissions of different duration were achieved in 190 patients. Because of neutrotoxicity there are still problems in applicating radiosensitizers. New methods are applied treating endocrine active tumors by labelled hormone precursers.

[Therapy of elderly cancer patients from the viewpoint of the radiologist]. / Therapie krebskranker alter Menschen aus der Sicht des Radiologen.

For elderly cancer patients radiology is of importance in diagnosis and predominantly in therapy. Non invasive diagnostic procedures, the basis for an optimal organ-saving plan of radiotherapy, are well tolerated by these patients. Prognosis, especially indication of curative or palliative radiotherapy, depend more on the general condition of health than the patient's age. Physiological alterations caused by age and concomitant diseases produce a certain risk of radiological side-effects, for which examples of the skin, lung and brain are given. Even though radiotherapy of elderly cancer patients can hardly be expressed by statistics, it often prolongs survival time and improves quality of life.

[Radiotherapy of malignant lymphomas]. / Strahlentherapie maligner Lymphome.

In malignant lymphomas, radiotherapy is an important factor within the treatment schedule. This applies in particular to Hodgkin's disease, whereas chemotherapy is more important in other types of lymphomas. In all cases, treatment is carried out in strict accordance with the stage of the disease, taking into consideration the occult paths of spread; in the lymphomas not associated with Hodgkin's disease, their histological type was also taken into account (Kiel classification). The technique of irradiation--especially preparation and execution of mantle field radiation--is described in detail, taking into consideration the organs of risk, the possibility of complications, and how these complications can be prevented. The treatment results obtained at present clearly show that the rates of survival and cure have been significantly improved--a development in which radiotherapy has been playing an important part.

[Radiotherapy of bone metastases]. / Die Strahlentherapie von Knochenmetastasen.

Bone metastases represent an advanced stage of tumour disease. The incidence rate and the affiction of the individual segments of the skeleton is different for the individual organ tumours; likewise, the metastases may be of an osteolytic, osteoblastic or mixed nature. In most of the cases, multiple metastasising has occurred. Radiotherapy occupies a position of central importance. It is the aim of the treatment to prevent or (by remineralisation) relieve fracture-conditioned immobilisation; the first consideration, however, is the alleviation of pain caused by the metastases. Attention is drawn to the possibilities of surgical orthopaedic measures and of hormonal and chemotherapy.

[Afterloading method for simulating the intrauterine packing method in case of carcinoma of the body of the uterus (author's transl)]. / Afterloading-Methode zur Simulation der intrauterinen Packmethode beim Korpuskarzinom.

A method of simulating the conventional radium packing method by the afterloading system is presented which consists in introducing three or four probes into the cavity of the uterus which can be spread in a defined manner by a balloon lying in a central position. The probe combination can be adapted to the individual forms and sizes of the uterus by varying the number, length and charge of the probes and by different manners of spreading and different location times of the individual probes. The method is applied for long term therapy as well as for short term irradiation.

[Methodical and critical analysis of the determination of target volumes in case of hypopharyngeal and epiglottic tumors and the adaptation of the dose distribution to their dimensions.--Part 1 (author's transl)]. / Methodische und kritische Analyse zur Bestimmung der Zielvolum,ina bei Hypopharynx-und Epiglottisfumoren und die Anpassung der Strahlendosisverteilung an ihre Ausbreitung. Teil 1.

After having discussed the problem of optimization with regard to the dose distribution in space, the authors enter into the particulars of the classification of hypopharyngeal and epiglottic tumors according to the TNM system. Taking into consideration the communications of literature and the cases of the Radiologic Hospital of the University of Heidelberg, the authors describe the clinical manifestations of these tumors, their histology, their distribution to age and sex, their symptomatology and time of anamnesis as well as the therapeutic results.

[Methodical and critical analysis of the determination of target volumes in case of hypopharyngeal and epiglottic tumors and the adaption of the dose distribution to their dimensions - Part 2 (author's transl)]. / Methodische und kritische Analyse zur Bestimmung der Zielvolumina bei Hypopharynz- und Epiglottistumoren und die Anpassung der Strahlendosisverteilung an ihre Ausbreitung. Teil 2.

Seventy-five patients with a hypopharynx or epiglottis carcinoma were treated between 1954 and 1974 at the Radiologic Hospital of the University of Heidelberg. The clinical study of these cases provides a survey of the extension and formation of metastases of these tumors. This allows to establish empirically justified target volumes for hypopharyngeal and epiglottic tumors.

[Mammary carcinoma: radiotherapy (author's transl)]. / Mammacarcinom: Strahlentherapie.

Radiotherapy for mammary carcinoma has special indications, depending upon the TNM stage and the localization. The use of megavoltage irradiation, a well-defined technique, and consideration of radiobiologic factors are necessary. Radiotherapy is the only therapeutic possibility in cases of recurrences.

[CT in the diagnosis, treatment planning and follow-up in craniopharyngeoma (author's transl)]. / Computertomographische Diagnostik, Therapieplanung und Verlaufskontrolle beim Kraniopharyngeom.

The axial computed tomography of the skull has become an important part of the neuroradiologic diagnostics. The intracranial CT diagnosis is completed by the coronal sections which is used in particular in case of processes in the posterior cranial fossa and its differentiation of the supra- and infratentorial dimensions and in order to localize tumors in the sella region. The accurate determination of the tumor volume and the para-, supra-, and retrosellar dimensions makes possible an exact operation and irradiation planning. Solid, cystic and calcified tissues of the craniopharyngioma can be delimited. The quantitative evaluation by means of a computed tomogram of a tumor reduction obtained by surgery and irradiation with ultrahard X-rays (42 MV) with a target volume dose of about 5000 rd is illustrated by two examples. Under the above mentioned radiotherapeutic conditions, one partially resected craniopharyngioma with cystic, calcified and solid tissues showed a diminuation of the tumor volume of 60%, whereas the volume of a craniopharyngioma consisting of solid and calcified parts which had not been operated upon was reduced by about 40% two weeks after the end of the radiotherapy.