Ocular sequelae of multimodal therapy of hematologic malignancies in children.

We retrospectively analyzed the ocular findings after polychemotherapy including intrathecal methotrexate, systemic corticosteroids, and prophylactic cranial irradiation in children with acute lymphoblastic leukemia (n = 16) and non-Hodgkin's lymphoma (n = 2). After a median surveillance time of 4.1 years, asymptomatic ocular abnormalities were observed in 83% of the patients: 7/18 had a decreased tear formation, 5/17 had an opacity of the vitreous body, and 13/18 had an opacity of the lens. It was not possible to determine retrospectively which therapy caused a particular effect. A comparison of the 2 irradiation techniques (with and without blocking of the lacrimal glands) showed that in 5/7 children who developed a reduced eye secretion, the lacrimal glands are within the treatment volume. Therefore, the reduced eye secretion is most likely radiation-induced. Whereas the opacities of the vitreous body were caused by thrombopenia and bleeding during the course of disease, corticoid therapy might have contributed to the lens opacities.

Iridium-192 high dose rate brachytherapy combined with external beam irradiation in non-resectable oesophageal cancer.

Forty-eight patients with non-resectable cancer of the oesophagus and oesophagogastric junction (group A: Stage I/II: n = 32; group B: Stage III/IV: n = 16) underwent intralumenal iridium-192 high dose-rate afterloading brachytherapy (5-7 Gy/session, total dose 5-21 Gy, mean 12.4 Gy) and external beam irradiation (Karnofsky > or = 80%: 50-60 Gy/2 Gy per day; Karnofsky 60%-79%: 30 Gy/3 per day). Prolonged satisfactory palliation (intake of at least semi-solid food) was demonstrated in 96% of patients. The mean survival for group A was 19.1 months and that for group B 6.9 months, with a 12-month survival rate of 66% for group A and 0% for group B (P < 0.001). Local tumour response and complication rate were significantly dose related with a predicted response rate of 70.5% and a complication rate of 50% at extrapolated response dose (ERD) 129.3 GY3 (Gy at alpha/beta = 3).

[Metallic mesh endoprosthesis and intraluminal high dose rate 192Ir brachytherapy in the palliative treatment of malignant bile duct obstruction. Initial results]. / Metallgeflecht-Endoprothese und intraluminare High-dose-rate-192Iridium-Brachytherapie zur palliativen Behandlung maligner Gallengangsobstruktionen. Erste Erfahrungen.

Since December 1989, 9 patients with inoperable malignant biliary tract obstruction were treated palliatively by a combined modality treatment consisting of placement of a permanent biliary endoprosthesis followed by intraluminal high dose-rate 192Ir brachytherapy. A dose of 10 Gy was delivered in a hyperfractionated schedule at the point of reference in a distance of 7.5 mm of centre of the source. External small field radiotherapy (50.4 Gy, 1.8 Gy per day, 5 fractions per week) was also given in six cases (M/O, Karnofsky greater than 60%). In 9/9 cases an unrestrained bile flow and an interruption of pruritus was achieved, in 78% (7/9) of cases the duration of palliation was as long as the survival time (median survival time 7.5 months).

Hyperfractionated radiotherapy and polychemotherapy in brain stem tumors in children.

Between October 1989 and January 1991 five children with brain stem tumors were treated with sequential chemo- and radiotherapy. The polychemotherapy consisted of procarbazine, ifosfamide, etoposide, methotrexate, cisplatin and cytosine arabinoside. Locally, hyperfractionated radiotherapy was delivered at a total dose of 63.8 Gy (1.1 Gy twice daily, 10 fractions per week). After a median observation time of 11.8 (range 4-23) months from diagnosis three children are alive and without evidence of tumor progression. Two patients died from tumor progression 11 and 16 months respectively after initiation of therapy.

Reduction of the dose to the lens in prophylactic cranial irradiation: a comparison of three different treatment techniques and two different beam qualities.

Three treatment techniques using two beam qualities have been compared on the basis of dose to the lens in prophylactic cranial irradiation. The dose to the lens and the globe was measured with thermoluminescent crystals in an anthropomorphic phantom and calculated by a computer-assisted planning system. A comparison was made of large field and small field techniques using 60Co and 8 MV photons. Modifications to the basic techniques studied included angulation of the gantry, angulation of the couch, and placement of an additional eye block close to the surface. The dose to the lens could be reduced to four percent of the midplane dose by applying the small-field technique combined with the use of 8 MV energy photons, by placing an additional block close to the surface, and by five degree occipitally angling the gantry, as well as rotating the treatment couch to account for the divergence of the beam. The use of 60Co produced an underdosage of the posterior segment of the globe in angled treatment techniques.

Bladder and rectal dose of gynecologic high-dose-rate implants: comparison of orthogonal radiographic measurements with in vivo and CT-assisted measurements.

Bladder and rectal doses were retrospectively reviewed in 281 patients who underwent implantation of 575 gynecologic iridium-192 high-dose-rate devices. Dose measurements obtained with orthogonal radiography, in vivo thermoluminescent dosimetry, and computed tomography (CT)-assisted planning were compared. Measurements of bladder dose derived from radiographs revealed a significant difference between bladder neck dose and bladder base dose (P less than .0001). In 17% of cases, the dose to the bladder base was at least double the dose to the bladder neck. The mean dose to the rectum calculated from radiographs was 85.9% (cervix) and 90.2% (vaginal vault) of the prescribed fraction dose. The correlation coefficient factor between doses determined with orthogonal radiographs and doses determined with in vivo measurements was .9694. The dose to the bladder neck and to four rectal points determined with corresponding CT images revealed a deviation of 4% and 7%, respectively. However, calculations at the rectal wall cephalic to the specified rectal points showed higher doses to the rectum, with a ratio of 1-1.6. CT-assisted calculations at the bladder base also revealed doses that were higher than those obtained with radiographs alone by a ratio of 1.4-2.2. CT-assisted dosimetry is the method of choice.

[Evaluation of irradiation techniques in breast carcinoma using dose-volume histograms. Comparison of the heart and lung exposure]. / Die Beurteilung von Bestrahlungstechniken beim Mammakarzinom mit Hilfe von Dosis-Volumen-Histogrammen. Eine Gegenüberstellung der Herz- und Lungenbelastung.

For irradiation of the internal mammary lymph nodes (IMN), together with irradiation of the breast the commonly used treatment techniques are of three types: 1. two tangential opposed fields, 2. three field plans with a separate "straight on" IMN-field, or 3. with a separate "angled" IMN-field. To determine lung and heart volumes and doses for these techniques, dose-volume-histograms in 30 patients were analyzed. The optimum dose distribution was achieved with the "angled" field technique and an appropriate combination of electrons and 60Co gamma radiation for the IMN-field. (The beam mixture used was 40% 60Co beam and 60% electron beam.) The least possible dose to the lung was obtained with the "straight-on" field technique and the least possible dose to the heart with the separate "angled" IMN-field technique.

[Interstitial Ir-192 afterloading therapy with sequential warm-water hyperthermia]. / Interstitielle Ir-192-Afterloadingtherapie mit sequentieller Warmwasserhyperthermie.

For selective heating of superficially located or easily accessible tumors interstitial hyperthermia has become an increasing popular method in combination with interstitial radioactive implants. At our institution the hyperthermia treatment is performed utilizing the warm water system KHS-9, which is adapted to our Ir-192 high-dose-rate afterloading device, so that the same hollow needles for the interstitial radiation can be used for the heating procedure. So far, this technique has been applied for the treatment of primary and carcinomas, gynecological recurrences, and metastases of malignant melanomas after preceding in vitro measurements of temperature distribution. As a result both, in vitro and in vivo investigations showed good homogeneity of the temperature throughout the heated volume. Analysing the temperature data of in vivo measurements the maximum deviation of temperature was found to be 1.5 degrees C. When using a needle spacing of 8 mm, the temperature required for clinical application (42.5 degrees C) could be maintained in all heat treatments with a preselected water temperature of 46 degrees C to 49.5 degrees C.

[Optimizing target volume assessment in irradiation of intraocular melanomas with ruthenium applicators]. / Optimierung der Zielvolumserfassung bei der Bestrahlung intraokularer Melanome mittels Rutheniumapplikatoren.

Radioactive applicators have been used for conservative therapy of melanomas in the vicinity of the nervus opticus and of melanomas of the ciliary body for a few years. The aim of optimal radiotherapy is to destroy all tumor cells and to protect the optic nerve and macula. Therefore, we calculated the dose distributions and isodoses for ruthenium applicators. Isodoses show underdosage or overdosage in the tumor area. We also present a calculation model with which it is possible to simulate selective shielding of activated parts of the applicator.

[Treatment of primary cancer of the fallopian tube]. / Die Behandlung des primären Karzinoms der Tuba Fallopii.

33 patients treated since 1970 at the Medical School of the University of Graz, were classified using the FIGO system for ovarian carcinoma, fourteen were in stage I, 8 stage II, 8 stage III and 3 stage IV. In 17 patients, surgery consisted of total abdominal or vaginal hysterectomy with bilateral salpingo-oophorectomy; 12 patients underwent additional pelvic +/- paraaortic lymph node extirpation and in 4 the tumour excision was incomplete. Treatment in 6 patients was surgery alone (2/stage I, 4 with advanced disease) (Group A). Adjuvant radiotherapy was performed in 14 patients (Group B); the remaining patients were treated with single (2/13) or multiple agent chemotherapy (11/13) (Group C). The 3-year survival rate was 55% for stage I, 42% for stage II; 10/11 of the stage III/IV patients died within 26 months. The 4-year actuarial survival rate for group B was 68%, for group C 11%. There was no difference between the short-time results of stage II tumours when comparing radiotherapy against chemotherapy. The tumour progression rate was 60%, indicating the need for radical surgery as well as for more aggressive adjuvant treatment. Surgery alone is recommended for stage I disease confined to the mucosa. More advanced disease (extension to the serosa, stage Ic, stage II) requires whole abdominal irradiation with a boost to the pelvic lymph nodes. For stage III/IV tumours a multi-modality treatment is recommended. Chemotherapy (cis-platinum, cyclophosphamide) for recurrent disease resulted in remission in some cases.

[A therapeutic concept for the treatment of inoperable esophageal carcinoma]. / Ein Therapiekonzept zur Behandlung inoperabler Osophaguskarzinome.

From 1/87 to 12/88, 20 patients with anatomically or functionally inoperable carcinomas of the esophagus (cT1-3/N0-2/M0-1) were treated by endoluminal Ir-192 HDR brachytherapy (1-3 sessions, each 5-7 Gy) and percutaneous irradiation (50-70 Gy/2 Gy). In 10 cases a bouginage or combined dilatation and retrograde Nd-Yag-laser debulking was done before irradiation. The response of the treatment was documented by endoscopy (degree of stenoses) and symptoms (dysphagia score according to De Meester). In 95% of all cases the degree of stenoses was diminished and an improvement of dysphagia was found in 100%. The mean duration of oral uptake of properly chewed food could be prolonged to 308 days.