[History of German radiation oncology]. / Geschichte der deutschen Radioonkologie.

An overview of the development of radiotherapy especially in Germany, from its beginning until today, is given, including the difficulties during and after the two world wars. Technical progress is described as well as the organization and structure of radiology and especially radiotherapy.

Radiation oncology: historical development in Germany.

In the first period after the discovery of x-rays by Roentgen until World War II, German radiotherapy made major contributions to the development of the specialty. During the Nazi regime and World War II, German doctors were separated from international developments, and after the war the technical standard was poor. It took German radiotherapy a relatively long time to return to international standards again. Because of the difficulties caused by the war, mistakes were made in placing too much emphasis on technical, physical, and biological questions in the publications of the 1960s and 1970s, while in other countries clinical research was promoted. An exception is the work of K. Musshoff (47, 48) from Freiburg. His treatment results in Hodgkin's disease were known and acknowledged internationally. Because of a variety of reasons, it was and is difficult to perform prospective randomized trials in Germany even today. In addition, the turn to the English language in medicine made it difficult for publications written in German to be popular outside of Germany. Therefore, today German journals publish abstracts in English, too. In the meantime, the clinical and technical standard as well as scientific work in German radiotherapy are comparable again to the international level, especially relative to the United States, Great Britain, France, and the Scandinavian countries.

Small cell lung cancer with and without superior vena cava syndrome: a multivariate analysis of prognostic factors in 408 cases.

PURPOSE: Patients with small cell lung cancer (SCLC) and superior vena cava syndrome (SVCS) are widely believed to have a grave prognosis. The purpose of this study was to determine the prognosis of patients with SCLC and SVCS as compared to SCLC without SVCS. METHODS AND MATERIALS: A retrospective analysis of 408 cases of SCLC +/- SVCS was performed. Three- hundred and sixty showed no clinical signs of SVCS and 43 (11%) had SVCS; in 5 patients no adequate information was available about clinical signs of SVCS. All patients were classified as limited disease cases. About 98% received chemotherapy usually as the first treatment followed by radiotherapy. A median total dose of 46 Gy (range 30 to 70 Gy) was given at 2.0 Gy per fraction five times weekly. A prophylactic cranial irradiation was applied if a complete remission was achieved after chemotherapy or after 30 Gy of irradiation. Kaplan-Meier survival curves are shown and comparisons were made by the log-rank and the Gehan/Wilcoxon test. To adjust for prognostic factors, a proportional hazards analysis was done. RESULTS: Patients without SVCS had 5-year survival rates ( +/- SE) and a median survival time (MST; 95% confidence intervals) of 11% +/- 2% and 13.7 months (12.7-14.5) in UICC Stage I to III; in Stage III the figures were 9% +/- 2% and 12.6 months (11.2-13.7). In comparison, SCLC with SVCS had 5-year survival rates of 15% +/- 7% and MST of 16.1 months (13.8-20.5). The difference was significant in univariate analysis (Stage II disease: p = 0.008 by the log-rank test). In a multivariate analysis of all patients, Stage (Stage I + II > III; p = 0.0003), SVCS (yes > no; p = 0.005), and Karnofsky performance status ( < or = 70 < 80-100%; p = 0.008) were of significant importance. CONCLUSIONS: SVCS is a favorable prognostic sign in SCLC. The treatment should be curatively intended.

Is the time interval between surgery and radiotherapy important in operable nonsmall cell lung cancer? A retrospective analysis of 340 cases.

PURPOSE: To evaluate the influence of prognostic factors in postoperative radiotherapy of NSCLC with special emphasis on the time interval between surgery and start of radiotherapy. METHODS AND MATERIALS: Between January 1976 and December 1993, 340 cases were treated and retrospectively analyzed meeting the following criteria: complete follow-up; complete staging information including pathological confirmation of resection status; maximum interval between surgery (SX) and radiotherapy (RT) of 12 weeks (median 36 days, range 18 to 84 days); minimum dose of 50 Gy (R0), and maximum dose of 70 Gy (R2). Two hundred thirty patients (68%) had N2 disease; 228 patients were completely resected (R0). One hundred six (31%) had adenocarcinoma, 172 (51%) squamous cell carcinoma. RESULTS: In univariate analysis, Karnofsky performance status (90+ >60-80%; p = 0.019 log rank), resection status stratified for nodal disease (R+

Inoperable non-small cell lung cancer: a retrospective analysis of 427 patients treated with high-dose radiotherapy.

PURPOSE: The influence of patient and treatment characteristics on survival as well as normal tissue toxicity were retrospectively analyzed. METHODS AND MATERIALS: Four hundred twenty seven patients with unresectable non-small cell lung cancer received at least 60 Gy and two-thirds were treated with 70 Gy. RESULTS: Five-year survival rates and median survival time (95% confidence interval) were 2 +/- 2% (mean +/- s.e.) and 11.1 months (9.1-14.5) after 60-66 Gy (median 60 Gy); 8 +/- 2% and 14.9 months (13.3-16.5) after > or = 70 Gy (p = 0.0013). Stage I-II patients had significantly higher survival rates as compared to Stage III patients (p = 0.0015). Within the subgroup of Stage III patients those with Stage IIIA had significantly higher survival rates than Stage IIIB (p = 0.0167). Female patients achieved 5-year survival rates after 70 Gy of 15 +/- 7% as compared to only 7 +/- 2% of their male counterparts. Chemotherapy, histology, Karnofsky status, and age had no influence on survival after univariate and multivariate analysis. Nine percent and 11% of the patients suffered from moderate to severe pneumonitis and esophagitis. CONCLUSION: High-dose radiotherapy of unresectable non-small cell lung cancer with total doses > 60 Gy conventionally fractionated is feasible. With doses of > or = 70 Gy significantly higher survival rates were achieved as compared to 60-66 Gy. Normal tissue toxicity was acceptable. For Stage IIIB patients, however, treatment results are disappointingly low even after 70 Gy with no 5-year survivor.

Management of carcinoma of the bladder.

Carcinoma of the bladder (CaB) is a common tumor of the genitourinary tract. In the United States in 1997, CaB was second in frequency of occurrence and third in mortality among genitourinary tumors. This tumor has a well-documented history of environmental and industrial causative factors. The strongest etiologic risk factors include the use of tobacco, which is thought to be responsible for half of the CaB diagnosed in men in the United States, and some arylamines. In the past 30 years, there has been major improvement in the survival of patients with this disease. Multiple factors were responsible for this accomplishment and they include: 1) better understanding of the natural history of CaB, 2) development of immunohistochemical analysis helpful in defining prognostic factors, 3) improved imaging and nonimaging diagnostic modalities helpful in making earlier diagnosis and better defining the true anatomical extent of the tumor, 4) development of more effective therapy for carcinoma in situ, 5) major improvement in surgical techniques resulting in better treatment outcomes, and 6) the wide use of adjuvant chemotherapy. Major stress has been placed on the quality of life of patients treated for CaB. Quality of life was improved by optimizing surgical, radiation, and medical treatment techniques. The two most important factors producing this quality-of-life improvement include: 1) the use of organ-preserving therapy in properly selected patients that involves the use of a multimodality therapeutic approach with transurethral resection, radiation therapy, and chemotherapy; and 2) the ability to treat selected men and women with radical cystectomy followed by orthotopic reconstruction that allows patients nearly physiologic voiding. Current research efforts are directed toward better patient selection for appropriate therapy which is expected to increase patient survival and improve quality of life. Of particular importance in the selection of this optimal therapy in patients with CaB is a wide application in the clinical practice of important recent advances in molecular genetics.

[Data processing in radiology: summary and prospects]. / Datenverarbeitung in der Radiologie: Resümee und Ausblick.

The technical aspects of radiology are particularly suitable for electronic data processing. In addition to automation of radiological apparatus and tumour registration, there are three areas in radiology particularly suitable for electronic data processing: treatment planning, dose calculations and supervision of radiotherapy techniques in radio-oncology. It can be used for word processing in the office and for documentation, both in diagnostic and therapeutic radiology, and digital techniques can be employed for image transmission, storage and manipulation. Computers for treatment planning and dose calculation are standard techniques and suitable computers allow one to spot occasional and systematic errors during radiation treatment and to eliminate these. They also provide for the automatic generation of the required protocols. Word processors have proved particularly valuable in private practice. They are valuable for composing reports from their basic elements, but less valuable for texts that are stereotypes. The most important developments are in digital imaging, image storage and image transmission. The storage of images on video discs, transmission through fibre-optic cables and computer manipulation of images are described and the consequences and problems, which may affect the radiologist, are discussed.

[RODOC--a system for the documentation of radiographic diagnoses with electronic data processing (author's transl)]. / RöDoc--ein System zur Dokumentation von Röntgendiagnosen mit elektronischer Datenverarbeitung

A system for the documentation of radiographic diagnoses is described, based on the "documentation method for radiographic diagnosis" (Formmhold et al 1972) and on the diagnostic information system of the medical faculty of the University of Tübingen. The diagnostic indeces are dictated in relation to the findings and the diagnosis and fed on punched cards into a computer (IBM 1800). Various programmes provide patient-orientated diagnoses for clinical routine, as well as diagnoses-orientated lists of patients for demonstrations, teaching or research.

[Bronchial cancer: radiation therapy]. / Bronchuskarzinom: Strahlentherapie.

Postoperative radiotherapy as a routine procedure has failed to show any benefit in prospective randomized studies. Local failure was diminished, but survival rates remained unchanged, probably because of radiation complications. By improvement of radiation techniques, however, reduction of single doses and total dose and focusing postoperative irradiation of lung cancer to high risk cases (N2, T4) survival rates with postoperative irradiation are about 20% after 5 years. The results of 191 treated patients are demonstrated.

[Kilovolt-megavolt irradiation techniques for malignant tumors. Characteristics, indication and limits (author's transl)]. / Kilovolt-Megavolt-Technik bei Bestrahlung maligner Tumoren. Charakteristika, Indikation und Grenzen

For curative effects of irradiation tumour doses of 5000 to 7000 rd are needed. They can be achieved in depth-therapy with conventional kilo-volt techniques only in carcinoma of the larynx and - via additional gamma rays - in radium-X-ray irradiation of the cervix. For all other indications mega-volt techniques are needed. If properly used, their side-effects are less. The kilo-volt technique for malignant tumors remains for palliative indications. Training will have to be undertaken in centres equipped for all types of therapy.

[Radiotherapy in northern Germany: data on radio-oncology from 6 Bundesländer]. / Strahlentherapie in Norddeutschland: Daten zur Radioonkologie aus sechs Bundesländern.

BACKGROUND: Facts and figures about German radio-oncologic centers are scarcely available. A first glance was made possible by the accumulation of data published by the German Röntgen Society ("Abteilungen und Praxen für Strahlentherapie in der Bundesrepublik Deutschland, 1994"[4]). Detailed and up-to-date information is difficult to collect from the whole Federal Republic. Therefore, a regional data-base limited to the 6 northern German states was created in order to get correct, detailed and current facts and figures from radio-oncologic departments of this region. PATIENTS AND METHOD: Traditionally there was a close cooperation between the Röntgen Society of Northern Germany and the Society of "Niedersachsen" and "Sachsen-Anhalt". Therefore, hospital departments and free standing office-type facilities in radio-oncology from 6 states have put together a regional North German data-base. Detailed questionnaires were sent out in order to get data on heads of departments, professional staff, technical equipment, workload, diagnoses and training facilities. The collected data were distributed to all participating centers for confidential individual analysis. This paper reports the data collected. RESULTS: The survey 1995/96 had an unexpected return. Thirty-six from 38 centers in a region with 17.36 million inhabitants in 6 states (21.3% of Germany) took part. There were 73 megavolt machines and 31 afterloading facilities. Two hundred and forty physicians, 110 physicists, and 350 radiographers were working in radio-oncology; and there were 852 hospital beds specifically assigned to radio-oncology for the care of in-patients. In 1995, 32,000 patients were treated with 37,000 series, 570,000 treatment visits and 1,600,000 radiation fields. The average patient got 1.2 series, 18 treatment visits and 50 fields. Equipment-wise, an average department runs a mean of 2 megavolt machines and 1 afterloading facility. The corresponding data for 1 megavolt machine were 3.5 physicians, 1.6 physicists, 5 radiographers and 13 hospital beds. There was 1 machine for 240,000 inhabitants. The average workload of a megavolt machine was 439 patients a year with 513 series, 7,813 treatment visits and 21,845 radiation fields. CONCLUSIONS: A regional data-base for radio-oncology is being described. It is demonstrated that it is possible to get detailed and current data by this method. It provides transparent data on equipment, personnel and workload in radio-oncology. It should set an example for other regions to collect their data in the same fashion, and then compile all such data for the whole country to identify and correct potential deficiencies for improvement of care.