20 MHz ultrasonic imaging for quantitative assessment and documentation of early and late postradiation skin reactions in breast cancer patients.

BACKGROUND AND PURPOSE: In dermatology high resolution ultrasonic systems proved to be valuable in following up genuine and experimental inflammatory dermatoses. The opportunities of 20 MHz ultrasonic imaging for quantitative assessment of early and late postradiation skin reactions are investigated. MATERIAL AND METHODS: Between April and November 1996, 96 high resolution ultrasound examinations of the skin in 29 patients treated for breast cancer at the University of Ulm were analyzed. Total doses between 46 and 60 Gy were applied. The time interval between the completion of radiotherapy and ultrasonic examination was < or =3 months in 18 patients and 6-135 months in 11 patients. For examinations we used a digital high resolution ultrasonic system with a ceramic 20 MHz transducer. Irradiated and non-irradiated skin were compared. RESULTS: A change of thickness and texture of the dermis depending on the time interval between the completion of radiotherapy and ultrasonic examination and on the administered radiation dose was found. There were significant differences between irradiated and non-irradiated skin regarding the dermal thickness in early (P < 0.001) as well as in late (P = 0.0018) reactions. Echogenicity of the upper and lower corium of irradiated skin decreased in early and late reaction. In upper corium the greatest reduction of signal intensity occurred in early reactions (P = 0.0001). Early reactions of the lower corium differed significantly from late changes (P = 0.001). Discrepancies between visible skin reactions described by examining physicians and ultrasonically proven changes were obvious mainly in late reactions. CONCLUSIONS: There are specific textures of early and late postradiation skin reactions in comparison to non-irradiated skin. High resolution digital 20 MHz ultrasound is non-invasive and quantitative, and in contrast to physical examination, an easy reproducible method for assessing and documenting early and late skin reaction during and after radiation therapy treatment.

Incomplete axillary dissection in early breast-cancer and the risk of erroneous staging.

Maximum control of local disease in early breast cancer is obtained by breast conserving surgery, minimally invasive surgery of the axilla and consecutive selection for adjuvant therapy based on the number of involved axillary level I nodes. The answer to the question what is a 'node negative' patient? by defining the number of lymph nodes excised at operation exclusively, and the number of involved nodes found by the pathologist is given. Based on the data of Veronesi et al (Eur J Surg Oncol 16: 127-133, 1990) on 1446 complete axillary dissections performed between 1983-1986, the mathematical basis of the incomplete axillary dissection of the axilla in early breast cancer is presented: (i) To achieve a degree of confidence of 90% of the entire axilla being negative, histological examination of 10 level I nodes for a T1 tumor and 11 level I nodes for a T2 primary are necessary. In order to obtain these lymph nodes a total en bloc dissection of level I is indicated. (ii) The axillary status was considered negative if 10 or more lymph nodes for T1 or 11 or more in T2 tumors were found and were negative. (iii) The axillary status was considered positive, if <10 lymph nodes in T1 or <11 nodes in T2 tumors were found, even if they all were negative. If positive lymph nodes are left or estimated in the axilla after incomplete dissection, surgical treatment of the axilla is mandatory.

Radiation treatment related factors influencing outcome in vulvar cancer patients.

The objective of this research is to identify the impact of radiation treatment factors on survival in vulvar cancer patients. We performed a follow-up study on 60 women with squamous cell carcinoma of the vulva treated at the Department of Radiotherapy of the University of Ulm from 1980 to 1997. The follow-up time ranged from 0.5 to 17 years (mean 6.5 years). The irradiated volume included vulva and regional lymph nodes. The influence of treatment factors (tumor resection versus no tumor resection, treatment time, dose) on overall and disease-free survival was examined. In addition, applied doses were corrected for treatment time using the extended alpha/beta-model for calculating the biologically effective doses. The applied dose was 48.1 +/- 13.2 Gy (median: 50 Gy). Treatment time was 40.4 +/- 19.4 days (median: 38 days). 34/60 patients underwent surgery with complete resection of macroscopic tumor. 26 of 60 patients were resected incompletely or only a biopsy was taken. In univariate analysis prognostic factors influencing overall and disease-free survival were, along with T- and N-stage, treatment time, and biologically effective dose. In multivariate analysis, biologically effective dose was the only significant factor. We conclude that biologically effective dose and treatment time are important treatment factors influencing overall and disease-free survival vulvar cancer patients.

The use of isodose curves on radiographs and on CT scans in interstitial brachytherapy.

In brachytherapy an accurate dose distribution is usually not definable, and therefore not required. If flexible catheters are implanted, such as in head and neck cancer, resulting isodose curves only rarely fit exactly to radiographic films, and the target volume is not easily reconstructed. Usually no clear relationship exists between the three-dimensional (3D) dose distribution and target volume on the one hand and the two-dimensional (2D) radiographic films on the other. Dose distributions on radiographs are not sufficient to define the target absorbed dose and doses that critical areas will receive. A 3D imaging system, like computed tomographic (CT) scans, is needed in order to visualize underdosage inside the target volume and non-tolerable hot spots outside the tumour. Large-scale and expensive techniques exist to tackle these problems. Our inexpensive and verifiable approach to solve these problems combines localization radiographs with CT scans. Whereas tumour and critical areas are displayed on CT scans, flexible catheters loaded with dummy sources are best seen on radiographic films. With the help of a self-developed computer program, dose distributions are superimposed on CT scans. Doses to the target and critical organs are easily read and verified by external and internal detectors.

Relapses in early-stage testicular seminoma: radiation therapy versus retroperitoneal lymphadenectomy.

Being among the most radiosensitive tumours, radiation therapy has replaced retroperitoneal lymphadenectomy in the treatment of early-stage testicular seminoma. One hundred and sixty-one patients who were treated from 1975 through to 1991 with histologically confirmed testicular seminoma of stages I and II were analyses retrospectively. After high semicastration, 98 patients were treated by radiation therapy of regional lymph nodes and 63 patients received retroperitoneal lymphadenectomy. Until 1985 retroperitoneal lymphadenectomy was preferred, but after 1985 radiotherapy outweighed retroperitoneal lymphadenectomy. The follow-up ranged from 11 months to 13.5 years, with a median of 79 months. Retroperitoneally, in-field relapses occurred in 9.5% (6/63 patients) after retroperitoneal lymphadenectomy and in 2.0% (2/98 patients) after radiation therapy (Fisher exact test, p = 0.057). A trend to a higher frequency of retroperitoneal relapses after retroperitoneal lymphadenectomy seemed to be apparent. Relapses outside the operation site or radiation fields were registered with non-significantly different frequencies (p = 0.741) of 4.8% (3/63 patients) and 7.1% (7/98 patients), respectively. Relapses increased from 4.1% for stage I (5/121 patients) up to 58.3% for stage IIC (7/12 patients).

[Interstitial HDR afterloading therapy with flexible catheters]. / Interstitielle HDR-Afterloading-Therapie mit flexiblen Kathetern.

At the department of radiation therapy of the university of Würzburg flexible catheters are in use since 1989 for interstitial brachytherapy in high dose rate mode as the sole treatment modality or in combination with external beam therapy. The afterloading technique is applied in carcinoma of the oropharynx, of the oral cave, of the pancreas and in brain tumors. As flexible catheters are well tolerated, high radiation doses are given in fractions over several days up to two weeks. Localisation radiographs and CT scans are needed, in order to calculate exactly the dose distribution of target volume and adjacent healthy tissue. Doses up to 30 Gy for the target volume in 10 to 15 fractions are well tolerated. The patients daily activities are not restricted during the whole treatment time. Excellent palliations are achieved with minimal side effects.

Combined isodose curves of high-dose rate interstitial brachytherapy with external-beam radiation therapy in pancreatic carcinoma.

From September 1989 until March 1992 nine patients with unresectable, though localized carcinoma of the pancreas were treated by a multimodality therapy consisting of palliative surgery, interstitial conformal brachytherapy in high-dose rate mode (HDRBT) with iridium-192 up to 30 Gy and external-beam radiation therapy (EBRT) of about 52 Gy. Four patients simultaneously received two cycles of chemotherapy consisting of 5-FU and Leucovorin. Since high radiation doses are applied which are not tolerated in adjacent healthy tissues, doses to tumor and critical areas need to be known precisely and are to be adjusted before treatment. A three-dimensional imaging system is required. A self developed method combines the data of simulation radiographs and those of CT scans. The prescribed minimum target absorbed dose in HDRBT is adjusted to the target volume sparing organs at risk. The specialized quality assurance is adapted to this method. Differences between measured and calculated doses do not exceed 5%. The addition of isodoses of HDRBT and EBRT on CT scans is demonstrated. Due to patients' selection the treatment concept did not reveal any positive effects on survival. However, excellent palliative results were obtained without severe side-effects.

[Radiotherapy of regional lymph nodes compared to retroperitoneal lymphadenectomy in the treatment of seminomas. Retrospective analysis of 161 patients]. / Die Strahlentherapie der regionären Lymphknotenstationen bei der Behandlung des Seminoms im Vergleich zur retroperitonealen Lymphadenektomie. Eine retrospektive Auswertung von 161 Patienten.

BACKGROUND: Retroperitoneal lymphadenectomy is obsolete for treatment of seminomas, radiation therapy is the treatment of choice. As no literature is available about a comparison of both methods, we refer to data of the University of Magdeburg. PATIENTS AND METHODS: Hundred and sixty-one patients with seminoma of stage I and II were retrospectively analysed. They were treated at the University of Magdeburg between 1975 and 1991 by radiation therapy of regional lymph nodes or by retroperitoneal lymphadenectomy. After high semicastration, 98 patients were irradiated, 63 patients received a retroperitoneal lymphadenectomy. Twenty-one patients were treated by adjuvant chemotherapy, too. RESULTS: The 5-year survival-rates according to Kaplan-Meier were 96% for stage I, 85% for stage IIA, 92% for state IIB, and 68% for stage IIC. The overall survival rates for all stages were 95% after 2 years, 92% after 5 years, and 89% after 10 years. Relapses located retroperitoneally occurred significantly more often after retroperitoneal lymphadenectomy (9.5%) compared with radiation therapy (2.0%), relapses outside the operation situs or radiation fields, respectively, were registrated at the same frequency (4.8% and 7.1%, respectively). Disease-free survival rates decreased significantly with increasing stages (p < 0.001, Wilcoxon-test). Relapses increased from 4.1% for stage I up to 58.3% for stage IIC. CONCLUSION: After semicastration for primary treatment of seminomas radiation therapy of the regional lymph nodes is the treatment of choice. Retroperitoneal lymphadenectomy is obsolete.

[Effect of therapy on survival of patients with pancreatic carcinoma]. / Der Einfluss der Therapie auf das Uberleben von Patienten mit Pankreaskarzinom. Eine Analyse von Einzelfaktoren.

PURPOSE: To identify the impact of treatment factors on overall survival in patients with pancreatic carcinoma. PATIENTS AND METHODS: We performed a follow-up study on 38 patients with adenocarcinoma of the pancreas treated from 1984 to 1998. 18/38 patients were resected. Irradiated volume included the primary tumor (or tumor bed) and regional lymph nodes. Thirty-seven patients received in addition chemotherapy consisting of mitoxantrone, 5-fluorouracil and cis-platin, either i.v. (14/38) or i.a. (23/38). The influence of treatment related factors on the overall survival was tested. Biologically effective dose was calculated by the linear-quadratic model (alpha/beta = 25 Gy) and by losing 0.85 Gy per day starting accelerated repopulation at day 28. RESULTS: Treatment factors influencing overall survival were resection (p = 0.02), overall treatment time (p = 0.03) and biologically effective dose (p < 0.002). Total dose and kind of chemotherapy had no significant influence. Treatment volume had a negative correlation (r = -0.5, p = 0.06) with overall survival, without any correlation between tumor size, tumor stage, and treatment volume. In multivariate analysis only biologically effective dose remained significant (p = 0.02). CONCLUSIONS: Among with surgery, biologically effective dose strongly influences overall survival in patients treated for pancreatic carcinoma. Treatment volume should be kept as small as possible and all efforts should be made to avoid treatment splits in radiation therapy.