Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs - a Danish population-based cohort study.

BACKGROUND: People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship. METHODS: We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0-7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization. RESULTS: For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03-1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03-1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09-1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01-1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes. CONCLUSIONS: We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

Antidiabetic Potential of Stem Bark Extract of Enantia chlorantha and Lack of Modulation of Its Therapeutic Efficacy in Diabetic Rats Co-Administered with Lisinopril.

This study validates the antidiabetic efficacy of Enantia chlorantha stem bark and the possible therapeutic implications of the co-administration of lisinopril and E. chlorantha in type 2 diabetic rats. E. chlorantha stem bark was extracted by cold maceration. The inhibitory effect of the plant on carbohydrate metabolizing enzymes and its antioxidative potentials were assessed in vitro. The extract exhibited α-amylase and α-glucosidase inhibitory activities and also showed antioxidative properties in vitro. Administration of the extract normalized fasting hyperglycemia in vivo by showing 47.24 % reduction in blood glucose levels relative to untreated diabetic rats. Co-administration of E. chlorantha and lisinopril restored serum glucose and serum lipid profile levels. E. chlorantha stem bark displayed antidiabetic potentials as compared with a standard antidiabetic drug (metformin). The study also showed that the plant contained some bioactive compounds which we hypothesize might be responsible for the observed activities. Co-administration of the plant with lisinopril conferred no significant therapeutic advantage on the serum glucose level and lipid profile.

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.

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.

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.

Increase of surface dose using wound dressings during percutaneous radiotherapy with photons and electrons.

Different wound dressings are used for the supportive treatment of patients with radiation-induced skin lesions. Depending on beam quality and energy, an increase of the dose administered to the skin and thus an aggravated skin reaction is to be expected during percutaneous irradiation. The increase of the skin dose during irradiation with photons (Co60, 6 MV, 42 MV) and electrons (7 MeV, 20 MeV, 42 MeV) was determined using thermoluminescence dosimetry. The use of wound dressings during electron irradiation and during soft irradiation therapy does not significantly increase the dose administered to the skin and does not therefore cause any problems. During irradiation with high energy photons only extremely thin dressings should be used; if there is an aggravated skin reaction, the dressing should be taken off before irradiation commences.

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.

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).

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.

Bilateral breast carcinoma versus unilateral disease. Review of 498 patients.

In literature data, an uncertainty exists whether occurrence of bilateral breast cancer decreases the survival probability of affected patients. Therefore, we analyzed the medical records of 498 postoperatively irradiated (1977-1982) female breast cancer patients (T1-4,N0-3,M0). In the follow-up time, in 36 patients a bilateral breast carcinoma treated by surgery with or without radiotherapy was found. The 10-year overall survival rates were 54% in patients who had unilateral disease, compared with 56% in bilateral carcinoma patients, respectively. The incidence of metastasis did not differ between both groups: 24.2% versus 38.8%. Eleven percent of unilateral cancers recurred; in the other group, local failure of the first and second tumor was observed in 19.4% and 11.1%, respectively. We conclude that the occurrence of bilateral breast cancer has no significant impact on survival, although the development of local failures and metastases seems to be more frequent. The therapeutic strategy in bilateral carcinoma should resemble the treatment procedure in unilaterally affected patients.

Can prophylactic application of immunoglobulin decrease radiotherapy-induced oral mucositis?

Therapeutic application of immunoglobulin is reported to be successful in radiation-induced oral and oropharyngeal mucositis. In this study the efficacy of prophylactic application of immunoglobulin was investigated. In 42 patients with head and neck cancer, postoperative radiation treatment or radiation combined with chemotherapy was performed. In 20 consecutive patients, prophylactic mucositis treatment consisted of panthenol (4 x 10 ml/day) and nystatin (4 x 1 ml/day). The 22 following patients received, supplementary to panthenol and nystatin, 800 mg (5 ml) human immunoglobulin intramuscularly once weekly. During the treatment time, the degree of mucositis was examined 3 times a week. The distribution of maximal mucositis degree revealed slightly more severe mucous membrane reaction in the control group compared with the immunoglobulin group (n.s.). The analysis of mean mucositis degrees in both groups demonstrated statistically significant differences (t test, p = 0.031) related to the entire group (n = 42) and to those 16 patients receiving radiation combined with chemotherapy. There was no significant immunoglobulin-induced effect on mucositis in patients treated by radiation alone. The time from the beginning of therapy to the first interruption could be prolonged 5 days in the immunoglobulin group (n.s.). In conclusion, it is demonstrated that the prophylactic application of immunoglobulin seems to lower the degree of radiation-induced mucositis. In comparison to the published data about therapeutically given immunoglobulin, the clinical efficacy of the prophylactic application of immunoglobulin as it is performed in this study is less evident.

Value of a multileaf prescription preparation system for palliative external beam irradiation.

In palliative treatment, irregularly shaped fields are used to reduce side-effects and can improve, or avoid, field matching. We investigated the effectiveness of a multileaf collimator (MLC) supported by a digitizing data entry system in the palliative radiotherapy treatment of 66 patients and compared it with conventional shielding with geometrically shaped blocks. After conventional simulation of rectangular fields, irregular field shapes were marked on the simulator film in 17 patients (27%) to reduce radiotherapy related side-effects. Individual leading was performed with an MLC. Digitizing and fitting of the optimum leaf position were carried out using a multileaf preparation system (MLP, Elekta, Crawley, UK). Target volumes included bone metastases in the pelvis, spine and extremities, mediastinal soft tissues, lymph nodes and central nervous system. In 10 patients, treated with a parallel pair for pelvic metastases, MLC and conventional shielding were prospectively compared with regard to time requirements and area shielded. Compared with conventional blocking, the mean simulation, preparation and treatment time required for MLP fields was shorter (9.55 +/- 1.44 min vs 16.90 +/- 2.64 min, and 5.50 +/- 1.14 min vs 8.97 +/- 1.75 min). The mean shielded area was 31 cm2 larger for MLC fields compared with geometrically shaped blocks (p < 0.05). Compared with cerrobend blocking, the use of an MLC, supported by preparation data entry software, is more flexible and reduces radiotherapy resources. Therefore, a preparation data entry system as a separate device, or integrated into the treatment planning system, is a useful tool in palliative treatment.

In vivo dose increase in the presence of dental alloys during 60Co-gamma-ray therapy of the oral cavity.

During irradiation of the mouth cavity, dental metallic materials emit secondary electrons and thus increase the applied radiation dose in their vicinity. Therefore, local destruction of the mucous membrane contacting metallic dental crowns and fillings may be observed. Available data on this dose increase are based on measurements with beam arrangements perpendicular to the metallic surface. Since the dose modification depends on the beam direction in relation to specimen surface, a reliable prediction of dose modification in the close vicinity of dental caps on fillings under complex beam arrangements, as applied in the irradiation of head and neck region from the published data is not possible. Therefore, we measured dose increase in the immediate surrounding of metallic dental material using thermoluminescence dosimetry on the phantom and during routinely applied 60Co gamma ray therapy. Phantom measurements were carried out using several oblique irradiation angles and rotational therapy. In vivo measurements were carried out at alloy specimens containing gold, palladium, and amalgam in six patients and at permanently fixed golden teeth in five patients. In vivo, the following relative dose increase values according to a simultaneously measured reference value were obtained at the surface of different dental materials: 61% for fixed golden caps. 68% for the specimen containing gold, 33% for the specimen of palladium and 61% for the specimen of amalgam. The measured dose increases due to metallic dental material during routinely applied external 60Co beam irradiation are lower compared with those of perpendicular beam arrangements. Although, the extent of dose modification is less than expected, we still advocate protection of the oral mucosa to prevent painful lesion spots.

[The assessment of solitary osteolytic bone lesions in breast carcinoma. A special case report]. / Zur Dignität solitärer osteolytischer Knochenläsionen beim Mammakarzinom. Einzelfallbericht.

BACKGROUND: Solitary bone lesions occurring 10 and more years after primary known breast cancer are usually declared as metastases of this tumor. However, this assumption is not correct. In such cases the probability of a second malignancy has to be concerned as well. PATIENTS AND METHODS: We report the case of a 77-year-old woman, in whom 18 years after primary breast cancer therapy an osteolysis in her right radius occurred. The treatment planning was aggravated by the diagnostic classification of this lesion. RESULTS: The diagnostical differentiation between bone metastases of the known breast cancer or another extramammary solid cancer and a primary tumor of the bone was not possible by clinical and blood examination, X-ray and MRT-imaging. As the diagnostically decisive step a biopsy was performed proving a metastasis of the known breast cancer. CONCLUSIONS: This case pointed out that the diagnostical classification of a solitary osseous lesion exclusively based on anamnestically known primary cancer treated long times ago is not permissible. Before therapeutic decision is correctly fixed, detailed diagnostic examinations according to basic oncological rules are conclusively required.

[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.

[The value of conventionally fractionated radiotherapy in the local treatment of HIV-related Kaposi's sarcoma]. / Wertigkeit konventionell fraktionierter Radiotherapie bei der lokalen Behandlung des HIV-assoziierten Kaposi-Sarkoms.

BACKGROUND: During the course of AIDS, 25 to 44% of homosexual patients infected with the human immunodeficiency virus develop Kaposi's sarcoma. Main manifestation is the skin. Response rates of 80 to 100% can be achieved with total dosage up to 50 Gy. Nevertheless, remissions can also be attained with 20 Gy of fractionated radiotherapy. As clinical data on low dose conventional fractionated radiotherapy are insufficient we analysed the response rates of an overall dose of 20 Gy in conventional fractionation. PATIENTS AND METHODS: From June 1991 to June 1993, 43 patients with 111 HIV-associated Kaposi's sarcoma of the skin or oral cavity were treated. Lesions were irradiated with 5 to 12 MeV electrons or 60Co gamma-rays. The fractionation scheme was 5 times 2 Gy/week for skin and endoral lesions with a total reference dosage of up to 20 Gy. Side effects were assessed during therapy and the therapeutic result 6 weeks after end of treatment. RESULTS: Thirty-eight out of 111 lesions were judged as complete response (CR) (34%), 61/111 as partial response (PR) (55%) and 12/111 were judged as no change (NC) (11%). Overall response (CR + PR) was 89%. Two patients with lesions of oral cavity suffered from RTOG grade-IV mucositis after 10 and 14 Gy. In 71/106 skin lesions (67%), radiation induced RTOG grade-1 reactions were observed. CONCLUSION: In patients with HIV associated Kaposi's sarcoma effective palliation can be achieved by means of radiotherapy with an overall dose of 20 Gy in conventional fractionation. Yet, the fraction of patients with complete responses is with 34 to 47% lower compared with doses above 20 Gy (66 to 100%). With reference to the reported data our results point to a dose-response relationship for Kaposi's sarcoma. Therefore higher total reference doses, e.g. 30 Gy with weekly 5 times 2 Gy or 24 Gy with 5 times 1.6 Gy for mucous lesions, respectively, are suggested as by this mean the complete response rate can be doubled.

[Which factors modify the reproducibility of patient positioning in the daily irradiation routine?]. / Welche Faktoren beeinflussen die Reproduzierbarkeit der Patientenlagerung in der täglichen Bestrahlungsroutine?

AIM: Factors which influence the accuracy of the field application during daily irradiation routine are not well known. The aim of this prospective analysis was to determine the significance of these factors on the occurrence of field misadjustments in irradiation without immobilization and to evaluate their clinical relevance. PATIENTS AND METHODS: Fifty-three patients received external cobalt-60 beam irradiation without fixation. Once weekly portal images of all treatment fields were carried out. In addition to objective patient data (age, weight, height, general condition, irradiation indication), the psychological situation of the patient during treatment (anxiety, restlessness, pain) and work circumstances of the medical staff during treatment were evaluated once weekly. The distance of clearly visible anatomic structures to the field borders of the portal images were measured and the deviation to the corresponding simulator images was calculated. Patient data were correlated to the number of field misadjustments (deviation larger than 1 cm). RESULTS: Patients whose condition is generally poor and patients being treated palliatively, patients with feeling of anxiety, restlessness or pain during simulation or irradiation and heavy patients (90 kg and more) were more often misadjusted. The number of field misadjustments increased with the stress of the medical staff. CONCLUSIONS: The problem of reproducibility of external beam irradiation without fixation in palliative treatment is of clinical relevance. Effective analgesic therapy and a comfortable and painfree patient set-up reduce misadjustments. In curative treatment, immobilization techniques should be used.

HIV-associated cutaneous Kaposi's sarcoma--palliative local treatment by radiotherapy.

The increasing number of HIV-infected patients makes palliative treatment of HIV-associated Kaposi's sarcoma more common. We retrospectively evaluated a reduced fractionated radiotherapy with 20 Gy in respect to response rates and acute side-effects. From January 1992 to January 1995, 52 patients with HIV-associated Kaposi's sarcoma were treated with 133 single portals. Six weeks after the end of radiotherapy 42 patients with 124 portals were evaluable with respect to response rates and side-effects. Of the treated portals 32% were judged as complete responses (CR), 55% as partial responses (PR) and 12% as no change (NC). Skin reactions RTOG, grade 1 were seen in 74% of the patients. Compared with literature data the reduced overall dose of 20 Gy in 10 fractions led to a reduction of CRs by approximately 50% while the overall response rate remained equal. The success of radiotherapy for the nodular component of Kaposi's sarcoma can be improved, if a dose exceeding 20 Gy in 10 fractions is applied but at the cost of increasing side-effects in case that non-conventional fractionation schemes are used.

[The prognosis of bilateral breast carcinoma compared to unilateral breast tumor. 5- and 10-year follow-ups]. / Die Prognose des bilateralen Mammakarzinoms im Vergleich zum unilateralen Mammatumor. Follow-up nach fünf und zehn Jahren.

PURPOSE: A review of published data does not provide a certainty whether survival rates are comparable or worse in women with bilateral breast cancer versus patients with an unilateral tumor. Therefore results of therapy in one-sided and both-sided breast cancer were retrospectively analysed. PATIENTS AND METHODS: In a period from 1977 to 1982 (follow-up 5 to 12 years) 531 breast cancer patients with T1-4 N0-3 M0 tumors were treated with mastectomy (n = 416) and breast conserving therapy (n = 115). Postoperative radiotherapy was performed in all patients (50 Gy, 2 Gy/day 5 times/weekly; chest wall/breast and regional lymph nodes). Patients with positive lymph nodes received chemotherapy. Forty patients developed bilateral breast cancer (simultaneous n = 10, metachronous n = 30) that was treated by mastectomy (n = 28) and conservative surgery (n = 12), respectively, followed by radiotherapy in 26 women. RESULTS: Five- and 10-year survival was 74% and 56% in unilateral affected women. In 83% and 67% there were no metastases, respectively. Incidence of metastases was 27.9%. In bilateral breast cancer group survival rates were 85% and 59% and without evidence of metastases 87% and 60%, respectively. Distant disease was diagnosed in 35%. Differences between the 2 groups were statistically not significant. Whereas in time of follow-up 11% of unilateral cancer locally failed in bilateral cancer patients recurrences of the first and second tumor were seen in 20% and 10%, respectively. CONCLUSIONS: Survival of patients with bilateral breast cancer is not significantly decreased compared with unilateral disease although in patients with both-sided carcinoma local recurrences and metastases seem to occur more frequently.

[Improved reproducibility and comfort by standardized postural support in the irradiation of the female breast]. / Verbesserte Reproduzierbarkeit und erhöhter Komfort durch standardisierte Lagerungshilfe bei der Bestrahlung der weiblichen Brust.

BACKGROUND: Positioning and immobilisation techniques are essential for precise radiotherapy. The currently available standardised positioning devices are insufficient. For this reason, we designed a new and generally usable hard foam positioning support cushion for the breast irradiation and tested its usefulness in a prospective study. PATIENTS AND METHODS: Fifty-five female breast cancer patients receiving adjuvant radiotherapy following breast conservative surgery were irradiated either without immobilisation (n = 27) or with the developed positioning support cushion (n = 28). The time necessary for patient set-up, the subjective lying comfort and--comparing portal images with simulator images--the reproducibility of the set-up were determined. RESULTS: It was possible to improve irradiation reproducibility significantly (average deviation without positioning support cushion: 8.4 mm, with positioning support cushion: 6.1 mm, p < 0.001). The additional time required for the positioning of the patient was in average 19 s (with positioning support cushion: 74 s, without cushion: 55 s). A significantly higher proportion of patients (72%) found the position with the hard foam cushion was pleasant, whereas only 46% of patients were pleased with the position without cushion. CONCLUSION: The positioning support cushion designed in our department seems to play an important role in quality assurance of external beam irradiation of the breast and significantly increases the patients' comfort in a supine position. Compared to conventional positioning and fixation devices it may be quickly and easily applied at low cost. Therefore, its use can be recommended.