Short-time splenic irradiation for splenomegaly.

BACKGROUND: Splenic irradiation is routinely used in the supportive treatment of lymphoepithelial and hemopoietic diseases associated with splenomegaly. A new short-time irradiation schedule with conventional dosage (Group A: 2 Gy/fract.) was compared retrospectively with low-dose prolonged treatment schedules (Group B: < or = 1 Gy/fract.) to establish its tolerance and its efficacy in terms of relieving splenomegaly-associated symptoms. PATIENTS AND METHOD: Between 12/1996 and 3/2002 49 patients (6 with CLL, 14 with CML, 6 with NHL, 16 with MPD, 6 with OMF and 1 with AML) underwent 85 treatment courses (13 courses low-dose prolonged treatment and 72 courses short-time treatment).The spleens had been exposed to pretreatment doses of 3-70 Gy (mean 20.75 Gy). Splenic size was 12-35 cm (mean 22.76 cm). One treatment was done with 60Co. 9-20 MeV electron beams were used in 23 treatments and 6 MV photons in 61 treatments. Blood counts were monitored daily. Clinical improvement (pain relief, improvement of splenomegaly-associated symptoms), spleen volume reduction and effects on blood counts were evaluated and documented at the end of the treatment. RESULTS: Of the 85 treated patients, 55 (Group A: 47/72, Group B: 8/13) showed a > 10% reduction of spleen volume and 62 (Group A: 57/72, Group B: 5/13) clinical improvement. 15 of 49 patients underwent multiple irradiation (2-8 courses) without clinical or hematologic complications. The intervals between the courses were 2-19 months. Rapid response in terms of reduction in splenic size in 23 patients permitted field reduction during treatment. Significant hematologic abnormalities were absent throughout. CONCLUSION: The short-time treatment schedule ensured a rapid response with relief of pain and improvement of gastrointestinal and pulmonary symptoms at an overall treatment time shorter than that of low-dose prolonged treatment schedules. No differences in terms of hematologic abnormalities were found between single doses of 2 Gy and < or = 1 Gy.

[Determination of therapy management in rectal carcinoma by staging with 18-FDG-PET]. / Bestimmung des Therapiemanagements beim Rectumcarcinom durch Staging mittels 18-FDG-PET.

The curative treatment of carcinoma of the rectum in the early stage of the disease is radical local surgery. If there is a solitary liver metastasis, resection is also a curative treatment. This report describes a female patient with rectal carcinoma, in whom a solitary liver metastasis in the left lobe was diagnosed only by FDG-PET and verified at surgery. This case report demonstrates the potential role of FDG-PET even for primary staging in detecting occult hepatic and extrahepatic metastases, thus significantly influencing the therapeutic management and prognosis of these patients.

Improvement of skin care during radiotherapy.

BACKGROUND: State-of-the-art radiotherapy, new insights into pharmacology and novel operating techniques require patient-oriented adaptation of care. PATIENTS AND METHOD: At the Radio-oncology Department of the Kaiser Franz Josef Spital, Vienna, a new skin care concept for patients undergoing radiotherapy was introduced in March 1999. This concept has subsequently been applied in all cases regardless of the diagnosis prompting referral (79 ENT, 305 breast, 134 prostate, 89 colorectal cancer and 751 other patients). Radiotherapy consisted of photon and/or electron radiation on the linear accelerator. The energy ranges were between 6 and 15 MV for photon therapy and between 6 and 12 MeV for electron radiation. Patients received an average total radiation dose of 50-66 Gy at single fractional doses of 1.8-2 Gy 5 times a week. Powdering of the skin was replaced by a moist skin care program. Patients were allowed to take cool whole-body showers without soap, including the irradiated skin areas, 3 times a week. RESULTS: With the new skin care program dryness of the skin and resultant allergic skin reactions became less common. Broken skin an epitheliolysis were clearly reduced and superinfections were prevented. CONCLUSION: Moist care of irradiated skin areas during radiotherapy thus improved radiation tolerance and patient acceptance.

Three years experience in the development of a dynamic quality management concept in a digitized radiotherapy department.

BACKGROUND: This article addresses general procedures for dynamic quality management and offers some practical suggestions to control an electronic radiotherapy system. The review of data takes place additionally to and completely independent of visual opportunities such as the approval of port images. MATERIAL AND METHODS: The radiotherapy procedure was split up into individual processes, all steps were analyzed with respect to their potential of being influenced by human mistakes or system malfunction. RESULTS: Relating the mistakes to the absolute number of treated fields, we can show that the percentage of fields that is related to an error was 0.22% in 1997 and could be decreased to 0.18% in 1999. For an average number of about 90-100 patients per day the time to verify the electronic data were: 6-8 h for the routine weekly control, 4 h/week to check the first treatments and manually calculated treatment fields, 6 h/week for physicists to check the 3D plans and 12 h/week for senior oncologists to check the 3D plans and data approval in the verification system. CONCLUSIONS: Meticulous monitoring and the currently available level of automation ensure that even clinically irrelevant errors and mistakes can be detected so that patients can be offered patient-oriented efficient radiotherapy in a routine hospital setting.

[The foramen sternale: a minor anomaly--great relevance]. / Foramen sternale: kleine Anomalie--grosse Relevanz.

PURPOSE: Evaluation of the incidence of a midline sternal foramen, as a developmental anomaly, in order to avoid fatal complications following sternal puncture of sternal acupuncture treatment. MATERIAL AND METHODS: 100 chest computed tomograms were evaluated in reference to the incidence of this anomaly and its various features. RESULTS: The variety of CT aspects ranged from very incomplete types with only sandglass-like retraction of sternal cortex, to a complete foraminal defect. The incidence of midline sternal foramen in a feature bearing a risk of complication, is approximately 6%. CONCLUSION: We conclude that--if sternal acupuncture is planned in the region of corpus--previous radiographs should be done to rule out this anomaly. Furthermore, we strongly recommend the acupuncture technique of the "Wiener Schule", which prescribes a safe superficial-oblique approach to the sternum.

Effective radiochemotherapy with cisplatin and etoposide for the management of patients with locally inoperable and metastatic esophageal carcinoma.

BACKGROUND: The limited therapeutic value of available chemotherapeutic drug combinations in patients with advanced esophageal carcinoma, the documented synergistic activity of etoposide and cisplatin, which might be further enhanced by simultaneous radiotherapy, and promising though only preliminary therapeutic results with this combination regimen have stimulated the present Phase II trial. The specific aim of the study was to determine the efficacy and tolerance of this combined treatment approach in previously untreated patients with either local regional unresectable or metastatic esophageal carcinoma. METHODS: Thirty patients with Stage IIIB or IV squamous cell or adenocarcinoma of the esophagus were entered in this study between October 1992 and November 1994. Chemotherapy was comprised of cisplatin, 30 mg/m2, combined with etoposide, 120 mg/m2, both given intravenously on 4 consecutive days. Treatment courses were repeated every 4 weeks. Radiation therapy (total dose, 5000 centigray) was administered concurrently during the 2nd and 3rd chemotherapy course, during which both drugs were given with a 25% dose reduction. RESULTS: After a median of 4 chemotherapeutic treatment courses (range, 1 to 6 courses), 3 patients had a complete response for 5, 8, and 11.5 months, and 9 patients had a partial response lasting for a median duration of 5.3 months (range, 2.5 to 7.5 months), yielding an overall response rate of 40% (95% confidence interval, 23-59%). The response rates tended to be higher for squamous cell carcinomas (11 of 23; 48%) than for adenocarcinomas (1 of 7), as well as for locoregional disease (7 of 13; 54%) than for patients with disseminated disease (5 of 17; 29%). For the entire study population, median time to progression was 5.4 months (range, 1.5 to 13.5 months), and median survival was 9.2 months (range, 1.5 to 28 months), with 4 patients still alive at the time of this report. Clinically, the most important toxic effect was myelosuppression. Grade 3-4 granulocytopenia occurred in 16 patients (53%), severe thrombocytopenia in 11 (37%), and Grade 3 anemia in 5 (17%). There were four hospitalizations among three patients for the management of fever during neutropenia. Other nonhematologic side effects were generally mild or modest, and most commonly included nausea/emesis (40%), mucositis and/or esophagitis during simultaneous radiotherapy (40%), and alopecia (43%). CONCLUSIONS: Combined radiochemotherapy with cisplatin and etoposide is active against advanced esophageal carcinoma, but can be associated with significant hematotoxicity. Although the therapeutic potential of this regimen appears to be comparable to other, conventional fluorouracil/cisplatin-based chemotherapy, less toxic and more effective regimens need to be identified.

Endoscopic ultrasonography versus computed tomography in the differential diagnosis of perianorectal complications in Crohn's disease.

In this prospective study the performance of transrectal or transvaginal endoscopic ultrasonography (EUS) was compared with that of computed tomography (CT) in the diagnosis of perirectal fistulae, abscesses and diffuse inflammatory changes in the lower pelvis in 25 patients with Crohn's disease. Results were verified by surgery in eight patients and by correlation with findings on endoscopy, barium radiography and fistulography, and the clinical course in all other patients. EUS was superior to CT in diagnosing fistulae (14 vs 4 correct diagnoses) and inflammatory infiltration of the lower pelvic muscles (11 vs 2 correct diagnoses). The methods were equivalent in diagnosing perianorectal abscesses. CT was superior in the detection of inflammatory changes in the pararectal fasciae and fatty tissue which could not be detected by EUS. It is concluded that EUS should be used as the primary method for diagnosing perianorectal changes in patients with Crohn's disease especially in the case of fistulae and abscesses, having the added advantage of lack of radiation for the patient.

[Native radiologic staging of osteoporosis--CT densitometry of lumbar vertebral spongiosa. A correlation study]. / Nativradiologisches Osteoporosestaging--CT-Densitometrie der Wirbelkörperspongiosa. Eine Korrelationsstudie.

Lumbar spine radiographs in 47 patients with manifest or clinically suspected osteoporosis were evaluated, using a staging system, and correlated to quantitative computed tomography (QCT) of lumbar vertebrae. The accuracy of osteoporosis assessment, obtained with plain film analysis, was 60%, the sensitivity 67%, the specificity 56%. Statistical correlation showed high standard deviation of each of the QCT-mean values according to the respective stage groups, and altogether poor linear correlation between increasing morphological stages of osteoporosis and decreasing QCT-values. As our results show plain film differentiation of normal from reduced trabecular bone mineral content is unreliable, even by use of a staging system. The diagnostic value of spine radiographs therefore remains limited to demonstration of advanced osteoporotic changes.

Endosonographic features of the lower pelvic region in Crohn's disease.

Anorectal complications in long-term Crohn's disease are frequent and evaluation of inflammatory changes in the lower pelvic region is difficult. Abnormalities are fistulas and abscesses which can be demonstrated rapidly and easily by endosonographic measures. Further topographical localization of the abnormalities is possible. Over a period of 2 yr, 55 patients with anorectal complications were examined. Using endosonography, 46 fistulas were found in 36 patients. Forty patients presented inflammatory changes. Abscesses were demonstrated in four cases. Our findings were verified by surgery, fistulography, and correlation with clinical course of illness. Limiting factor of the examination procedure proved to be painful and strictures in male patients, whereas in female patients the alternative of performing the examination via vagina was given. Our results demonstrate that endosonography is an excellent screening method for detecting and evaluating fistulas and abscesses in Crohn patients. Omitting radiation exposure is a further advantage of endosonography.

High-resolution computed tomography of the lungs in irradiated breast cancer patients.

Fifty-five breast cancer patients underwent high-resolution computed tomography (HRCT) of the lungs before, 8-12 weeks, 6, 9 and 12 months after adjuvant radiotherapy. During the follow-up time, 17 of them (30%) were found to develop minimal parenchymal alterations in the irradiated lung volume by HRCT evidence. The parenchymal alterations were classified by five scores. Scores 1-4 described chronic radiologic changes, score 5 acute radiologic changes. Three patients presented with acute radiologic changes (alveolar filling) within the first 3 months after radiotherapy. Two did not show any abnormalities at later follow-ups. Chronic radiologic fibrosis (15 patients) was not seen before the sixth month post irradiation except in 2 cases. There was no correlation between acute changes and chronic fibrosis. None of these changes were seen at a lung dose of less than 40 Gy. The appearance of interstitial pulmonary lesions secondary to breast irradiation was comparable to that of other interstitial diseases of the lungs. Chest radiographs were normal in all patients. None of the 55 patients presented with clinical symptoms.

[Transrectal sonographic (TRUS) prostatic volumetry in assessing tumor response to radiation]. / Transrektal sonographische (TRUS-) Prostatavolumetrie zur Beurteilung des Tumoransprechens auf Radiatio.

The aim of this study was to document the grading-related response of carcinoma of the prostate to radiotherapy, especially in views of the fact that the PSA values of hormonal therapy are not evaluable if hormonal therapy is done prior to radiotherapy or in patients with high likelihood of metastatic spread. Controls were done on 55 patients before, during and after primary external radiotherapy of carcinoma of the prostate with volumetric analysis of transrectal ultrasound (TRUS) of the prostate. There were significant differences between G1 and G2 tumors on the one hand and G3 tumors on the other hand. The latter had a much larger volume to start with and their volume reduced more rapidly after therapy.

[The prevention of mucosal lesions during oropharyngeal irradiation with a dental-filling shield]. / Prävention lokaler Schleimhautläsionen während Oropharynx-Bestrahlung durch einen Plombenschutz.

In patients with metallic dental fillings radiation therapy to the oral cavity can cause mucous membrane lesions, which are more severe than expected. They appear as circumscribed erosions, opposite to metallic fillings and are caused by an increase in radiation dose through secondary radiation due to the higher density and atomic number of the filling material. This dose increase can be directly measured with 0.1 mm thin sheets of graphite-loaded TLD's (LiF, Vinten). For Co-60 gamma rays a commercial amalgam filling caused a dose increase by a factor of 1.7. The half value layer for this additional radiation was measured to be approximately 0.4 mm tissue. In order to avoid painful mucous membrane ulcerations which are even more a problem if hyperfractionated treatment schedules are used, we constructed individual dental shields for each patient. As shielding material we used a dental impression material (Optosil P+1 Bayer). This method was tested in 35 patients, in all of them circumscribed mucous membrane ulcerations could be avoided. The method proved to be fast and simple and was very well tolerated by all patients.

[The value of transrectal sonography in assessing radiogenic rectal changes]. / Wertigkeit der Transrektalsonographie in der Erfassung radiogener Rektumveränderungen.

The clinical value of TRS in diagnosis and staging of radiogenic rectal disorders is discussed. TRS was performed on 120 patients with tumours of lower pelvis who were treated by radiotherapy. They were divided in this trial into 2 groups. Group I (n = 113, with a mean interval to radiotherapy of 2 years) including patients who were under a routine control. Group II (n = 7, with a mean interval to radiotherapy of 13 years) including patients with strong local pain of the radiotherapy zone. The sonographic changes were divided into 4 grades (0-III) and verified histologically in group II patients by means of biopsy. A control group (n = 35) was also examined by TRS. The patients of this group were not treated radiotherapeutically. We concluded in our study that TRS in radiogenic rectal disorders, give us a very precise grading of the tumours which in turn, is of great importance in the further therapeutic procedure and in the evaluation of tumour recidives and second malignomas of the rectal wall.

[Incidence of osteoradionecrosis after combined radiotherapy-chemotherapy of head and neck tumors]. / Inzidenz der Osteoradionekrose nach kombinierter Radio-Chemotherapie von Kopf- und Halstumoren.

Combined modality therapy, consisting of radiation, chemotherapy and surgery are used to treat primary tumours aiming to preserve function and increase tumour control. In the present prospective trial 112 patients underwent combined preoperative radio-chemotherapy, 35 patients were treated with combined radio-chemotherapy as only treatment. At a median follow-up of 26 months eight patients (2.8%) have developed an osteo-radionecrosis, which is comparable with data from the literature. When known risk factors are avoided the incidence of osteo-radionecrosis is not increased following combined therapy. The most important factors for development of osteo-radionecrosis following radio-chemotherapy are large tumours and tumour infiltration in the mandible.

[The cobalt-60 irradiation of skeletal metastases--conventional fractionation versus accelerated hyperfractionation]. / Kobalt-60-Bestrahlung von Skelettmetastasen--konventionelle Fraktionierung versus akzelerierte Hyperfraktionierung.

Purpose of this study was to compare the results of two different modalities of palliative radiation i.e. conventional fractionated (group I: 35 patients) vs. hyperfractionated radiation (group II: 20 patients). Group I received 1.8 to 2.3 Gy one time a day (total dose 30 to 40 Gy), with an average treatment duration of 20 days. Group II received 1.8 to 2 Gy two times a day (total dose 25 to 35 Gy), with an average treatment duration of ten days. Regression of complaints occurred in 80% of group I, with an average of twelve days, and in 95% of group II, with an average onset of four days after beginning of treatment. Neither acute nor long term complications did occur in any group. The advantages of the hyperfractionated radiation modality therefore are on one hand a higher regression-rate of subjective complaints, with equal good recovery of clinical and radiological findings and lack of side-effects especially those of the myelon, and on the other hand are resulting in a shortening of hospitalisation.

[Value of transrectal sonography in irradiation planning and oncological follow-up in prostatic cancer]. / Die Wertigkeit der transrektalen Sonographie für die Bestrahlungsplanung und onkologische Nachsorge des Prostatakarzinoms.

Transrectal ultrasonic scanning of the prostate is a simple, cheap, easily employed examination method which requires no preparation. In radiation therapy of prostatic carcinoma it allows in staging and follow-up during and after therapy, an exact imaging of shape, size, capsule infiltration and structure of the prostate, thus permitting a more exact evaluation of the treatment response than with usual methods of examination. The analysis of the acoustic characterisation allows an early recognition of recurrences.

[First clinical experiences with the radiosensitizer MTDQ in advanced primary and recurrent tumors]. / Erste klinische Erfahrungen mit dem Radiosensitizer MTDQ bei fortgeschrittenen Erst- und Rezidivtumoren.

Between April 1981 and February 1983 55 patients with advanced tumours or recurrences in preirradiated fields with different localizations and histology underwent radiotherapy in a pilot I study with MTDQ, a radiosensitizer developed in Hungary, at the University Clinic for Radiotherapy and Radiobiology of Vienna. The prognostically unfavourable group with recurrences following complete irradiation of the target volume shows the same response rate and frequency of complete remissions as the prognostically favourable group without pretreatment (73% versus 61% and 27% versus 29%). The best results are noted in epithelial and mesenchymal tumours of head and neck and in gynaecological malignancies. Furthermore, the side-effects of the drug MTDQ, which are clinically acceptable, are comprehensively described and discussed. The authors have come to the conclusion that MTDQ accomplishes the clinical prerequisites of a radiosensitizer, and propose a prospective randomized study for head and neck tumours.

[Hormones and tumor therapy: current clinical status and future developments in endocrine therapy of breast cancer]. / Hormone und Tumortherapie: Klinischer Stand und Entwicklung der endokrinen Therapie beim Mammakarzinom.

Postoperative adjuvant hormone therapy and hormone therapy in disseminated breast cancer will be discussed systematically. The classical ablative and additive endocrine therapeutic measures--with the exception of ovarectomy and gestagen therapy--are increasingly being replaced by antagonists. Individual chapters discuss recent experience with combined hormone-radiotherapy or hormone-chemotherapy. In addition, a successful therapy scheme for the treatment of disseminated breast cancer will be presented.

[Hormones and tumor therapy: the rational basis of endocrine therapy in breast cancer]. / Hormone und Tumortherapie: die rationalen Grundlagen der endokrinen Therapie beim Mammakarzinom.

Since endocrine therapy has gained great importance in curative and palliative radiotherapy, the hormone-therapy of breast cancer owing to the relevance of the receptor contents in the tumour, has had to be reconsidered over the past decade. Accordingly, this paper deals with endocrine pathophysiology both in relation to the central and cellular mechanisms of hormone action; in addition it presents recent findings on biosynthesis of the different hormones. Furthermore, important treatment criteria with regard to patient selection will be listed. The discussion of these criteria is based both on clinical findings ("empirical criteria") and on the receptor status ("objective criteria") with a view to a better assessment of risk and prognosis at the time of surgery.