BACKGROUND:Radiotherapy plays a pivotal role in tumor treatment. Brachytherapy as an additional radiation technique allows local dose increments in areas at high risk of local failure.PATIENTS AND METHODS:Our past 15-year experience with tissue-equivalent bendy applicator brachytherapy at the University Hospital Münster, Germany was reviewed. A series of 74 consecutive patients who had mainly been treated for sarcomas with perioperative brachytherapy was analyzed with a focus on local relapse-free survival and side-effects.RESULTS:The 5-year local control rate was 73% in primary treatment situations with a significant influence of additional external irradiation, surgical margin depth and tumor entity. Late sequelae of combined modality treatment were observed in 40 patients (54%) and mainly concerned wound healing (n = 18, 24%).CONCLUSION:A high-risk collective, in view of local failure, showed adequate local control rates as well as acceptable late sequelae. Flab brachytherapy is a good treatment option to achieve local radiation dose increments in patients at high risk of local failure.

About 10% of neonates present with angioma in the first days or weeks of life. The main diagnostic and therapeutic problem is the correct differentiation of the various forms of vascular anomalies, which also defines the treatment strategy [21]. Especially the terms ‘hemangioma’ and Vascular malformation’ should be strictly separated from each other. Though both are caused by a disturbance in embryonic vessel development, vascular malformations already exist at the time of birth, while hemangiomas develop during the first days or weeks of life [19]. The initial clinical presentation can be very similar, so that exact history taking and clinical description are of great importance.

BACKGROUND AND PURPOSE:During radiotherapy of localized prostate cancer, organ movements for the dose exposure of organs at risk like rectum, urinary bladder and urethra play, inter alia, a significant role. One possibility of internal organ stabilizing is offered by the usage of a rectal balloon during radiotherapy. The influence on organ movements and dose allocation of the organs at risk is unknown.PATIENTS AND METHODS:Twelve patients (Table 1) were characterized based on planning-CT's regarding organ movements and organ doses using a rectal balloon, inflated with 0 ml and 60 ml air. For the determination of the organ doses, three-dimensional conformal radiation plans (3-field-pelvis box) with a cumulative dose of 59.4 Gy were created, and the dose-volume-histograms for the anterior rectal wall, the posterior rectal wall, the rectal mucosa, the whole rectum, as well as the urinary bladder were compared (Figures 1 and 2).RESULTS:The application of a 60 ml air-filled rectal balloon during each fraction of teletherapy led to significant organ movements of the anterior and posterior rectal wall and to a reduction of the transversal prostate diameter, as well as to a changed organ dose exposure of the organs at risk. A ventral shift of the anterior rectal wall (maximum 0.8 cm, mean 0.4 cm) was shown, as well as a dorsal shift of the posterior rectal wall (maximum 1.2 cm, mean 0.7 cm), associated with a transversal prostate diameter decrease (maximum 0.8 cm, mean 0.3 cm) (Table 2, Figure 3). The organ dose of the anterior rectal wall increased significantly (maximum 1.3 Gy, mean 0.5 Gy) during application of a rectal balloon, the one of the posterior rectal wall decreased significantly (maximum 18.6 Gy, mean 6.5 Gy). Related to the entire rectal mucosa and the rectum as a complete organ, a decrease of the maximum doses was shown (rectal mucosa: maximum 9.1 Gy, mean 3.0 Gy; rectum: maximum 9.4 Gy, mean 3.7 Gy). The organ dose of the urinary bladder did not show significant changes (Tables 3 and 4, Figures 4 to 7).CONCLUSION:The application of a rectal balloon in teletherapy of localized prostate cancer leads to significantly changed dose exposition of organs at risk. The decreased dose exposure of the posterior rectal wall and the rectal mucosa is opposed by the higher organ dose of the anterior rectal wall. It has to be shown weather documented organ dose exposure is associated with short and long-term consequences.

Overall five-year survival for patients in NSCLC clinical stage IV is lower than 5% [1], in surgical stage IV (histologically proven distant metastases) nearly 0%. For patients with brain metastases in general, one-year survival amounts to about 10 /20% after whole-brain radiotherapy (WBRT) [2]. Several attempts to improve local control of brain metastases have been made, including dose escalation (RTOG 85 / 28). No significant difference in survival was found, median survival amounted to 3 /6 months [3]. In recent years, stereotactic radiosurgery has gained importance. One to three metastases of a suitable size (5/4 cm) may be an indication for stereotactic radiosurgery [4,5]. Electron beam intraoperative radiotherapy (IORT) for patients with malignant brain tumors has been performed at our institution since May 1992 [6]. Only few patients with brain metastases have been treated so far. We report a case of longterm control by surgery, IORT and WBRT. In October 1995, a 36-year old female patient (smoker) presented with the accidental diagnosis of a mass in the left upper lobe. CT and bronchoscopy confirmed the suspicion. Histology showed adenocarcinoma grade 1 /2. The tumor was clinically staged as T2N2M0 (stage IIIA). The patient was then recruited for the Muenster lung cancer trial [7]. She received three cycles of neoadjuvant CE chemotherapy followed by combined hyperfractionated radiochemotherapy with 45 Gy, carboplatin and vindesine. Under this regimen, a good partial remission was achieved. Besides a slight dysphagia, no further acute side effects were observed. She then underwent a radical resection (R0) of the left upper lobe with mediastinal lymphadenectomy (pathological tumor stage: ypT1N0G1 /2, SalzerKuntschik grade III). Ten months after the initial diagnosis she experienced severe headaches and scintillations. CT and MRI showed a solitary brain metastasis in the right occipital lobe with a diameter of about 2.5 cm. No further metastases or local recurrence were detected. It was then decided to perform a resection of this metastasis with IORT. No macroscopic residual tumor was left. IORT was carried out at a nondedicated facility with 14 MeV electrons from a linear accelerator using a 5 cm round cone [6]. The applied IORT dose was 20 Gy relative to the 90% isodose. After surgery and IORT, WBRT was done with a dose of 30 Gy in 10 fractions. Three years later, MRI showed a newly developed contrast enhancing structure in the right occipital lobe. Brain SPECT with Tl-201 and I-123-AMT showed a focal tracer uptake with an elevated tumor/ non-tumor ratio. F-18-FDG-PET showed a moderate glucose hypermetabolism. These findings were suspect for tumor recurrence. Because of the possible differential diagnosis of brain necrosis and

For ruthenium plaque therapy of uveal melanoma the precise knowledge of the tumor height is necessary. The purpose of this analysis is to examine systematic differences between ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) measurements of tumor height in uveal melanoma.

Even after surgery and radiotherapy, malignant gliomas still have a poor prognosis. The authors report on their experience with IORT in 71 patients.

The optimum treatment strategy for recurrent high-grade gliomas in preirradiated areas remains undefined. This prospective non-randomized phase II study was undertaken to evaluate a radiochemotherapy protocol against this disease. Fourteen patients (median age 61 years) were treated according to a standardized treatment protocol consisting of sequential radiochemotherapy. The chemotherapy (temozolomide) was carried out over a duration of five sequential days (Mon.–Fri.) with a dose of 200 mg/m2/d. Chemotherapy courses were repeated in 4-week intervals (days 1, 29, 57, etc.) until clinical progression. Radiotherapy with 30 Gy over 3 weeks (5 × 2 Gy/week) was interposed between the first two chemotherapy courses (days 8–26). Eleven/fourteen patients had no acute side effects. One patient suffered from acute thrombocytopenia/leucocytopenia, one patient developed mental degradation (treatment stopped at 24 Gy) and another severe cephalgia. Until now, 10 out of 14 patients have died due to disease progression. Median survival (Kaplan–Meier method) amounts to 30 weeks with a 6-months progression-free survival of 30%. Four of fourteen patients are still alive 8, 10, 11 and 12 months after therapy. Late treatment toxicities have not been observed so far. The reported radiochemotherapy protocol seems to be feasible for these patients with only few treatment alternatives and does not lead to a remarkable increase in acute toxicity. Palliative and survival benefits are modest. Evaluation of late toxicities needs further investigations.

Purpose: The purpose of this study was to analyze the prognostic value of baseline hemoglobin levels before radiotherapy in patients with head and neck tumors. Patients and Methods: Results: Conclusion: Patients and Methods: In a retrospective study with a median follow-up of 43 months, we analyzed the results of 214 patients irradiated for head and neck cancer between January 1, 1990 and January 1, 1998 (180 men and 34 women; median age 58 years). The treatment concept consisted in adjuvant radiotherapy in 58 patients, 77 patients received definitive radiochemotherapy, 42 patients definitive radiotherapy, and 37 patients reirradiation for in-field recurrence. Baseline hemoglobin values were divided in four groups of the same patient number (quartiles). Several known prognostic factors like sex, age, tumor stage, histologic grading, performance status, and treatment scheme were analyzed for their influence on overall and event-free survival and correlated with pretreatment hemoglobin values (Kaplan-Meier method). In addition, univariate und multivariate logistic regression analyses were carried out to evaluate the effect of baseline hemoglobin on response rates. Results: The median survival (event-free survival) of all patients amounted to 15 months (10 months). 25%, 50%, and 75% of patients had hemoglobin values < 11.2 g/dl, < 12.7 g/dl, and < 13.9 g/dl, respectively. In the univariate analysis, the following variables were significant prognostic factors for overall/event-free survival (log-rank test): treatment concept (p < 0.001/ p < 0.001), tumor stage (p < 0.001/p < 0.001), general condition (p < 0.001/p < 0.001), and pretreatment hemoglobin (p = 0.014/p = 0.05). Multivariate analysis (Cox) proved these parameters to be independent of each other. In addition, response rate after radiation showed a strong association between hemoglobin and local control probability (p = 0.02). Conclusion: In this retrospective analysis, baseline hemoglobin level was shown to be an independent significant prognostic factor in radiotherapy of head and neck cancer patients. Therefore, the value of tumor anemia as a prognostic factor should be emphasized more.

Background: After the introduction of intensified multimodal therapies, we have been observing an increasing number of head and neck cancer patients with interstitial lymphedema. Among these patients, those with endolaryngeal edema represent a group that needs to be effectively treated in order to avoid tracheostomy. The objective of this paper is to determine the role of antioxidative substances like sodium selenite in the treatment of interstitial lymphedema of the ENT region. Material and methods: Between 1996 and 2000, we have enrolled 30 patients suffering from interstitial lymphedema due to irradiation of the head and neck area. All patients (26 men, 4 women) had advanced squamous cell carcinomas of the head and neck and had received simultaneous radiochemotherapy with carboplatin as a radiosensitizer. When lymphedema was present, we administered 200 mug sodium selenite p.o. three times per day over a period of 8 weeks. Sodium selenite was given as a drinking fluid. If the response was not effective after 4 weeks, additional proteolytic enzymes were given. Results: Edema occurred after a median interval of 4 months after the end of radiotherapy. Twenty of 30 patients showed signs of endolaryngeal edema associate wit stridor and dyspnea. After the application of sodium selenite, we observed a noticeable reduction of edema in 18/30 patients. Twelve of 30 patients received additional proteolytic enzymes. These drugs only proved to be effective in 2/12 cases. No tracheostomy was necessary in 13/20 patients with endolaryngeal edema, further 5 patients received temporary tracheostomy and only 2 patients had to be treated with permanent tracheostomy. The subjective improvement in breathing capacity was reflected by the patients' answers given after 8 weeks of treatment. Conclusion: The administration of sodium selenite seems to be able to reduce the severity of interstitial lymphedema due to irradiation of the head and neck area. Limitations of this analysis are the retrospective design and the still incomplete knowledge of the pathomechanisms of interstitial lymphodema. Additional investigations regarding both issues are necessary to further validate the use of selenium in lymphedema in head and neck cancer patients.

OBJECTIVES:In the primary treatment of breast cancer, postoperative radiotherapy is performed in high-risk patients after mastectomy and in patients who received breast conserving surgery. In a retrospective analysis, our mono-institutional results of postoperative irradiation have been evaluated.PATIENTS AND METHODS:Between 1992 and 1996, 500 patients have been irradiated after surgery for primary breast cancer. Of these, 489 patients had no initial metastases. 89 patients with loco-regional disease had a mastectomy, 400 patients were irradiated after breast conserving surgery. Radiotherapy at the chest wall was performed with 50 Gy and 2 Gy fractions. After microscopically incomplete resection, an electron boost of 10 Gy was given. The ipsilateral lymph nodes were irradiated with 50 Gy when there was extensive lymph node involvement or invasion of tumor in the axillary fat tissue.RESULTS:The 5-year local control rate after mastectomy was 97.4% and 91.2% after breast conserving surgery. The only statistically significant risk factor for local failure was microscopically incomplete resection. The corresponding 5-year local control rates for microscopically incomplete and complete resections were 76.4% and 92.7% (p = 0.01). The risk of local relapse was increased with both marginal invasive and marginal DCIS-tissue. 86.6% of local relapses were in the same quadrant.CONCLUSIONS:High-risk patients after mastectomy and patients with breast conserving surgery achieve a high local control rate with postoperative irradiation. After microscopically incomplete resection, there is an increased risk for local relapse.

To evaluate the frequency and amount of displacements after repositioning a patient on the physical simulator following virtual simulation.

BACKGROUND:The low incidence of ependymomas results in limited treatment experience. While standard therapy consists of surgery and postoperative radiotherapy, irradiation techniques are still subject to discussion. We report the experience from Münster over the last 35 years.PATIENTS AND METHODS:Since 1961, 25 evaluable patients with ependymoma were irradiated in Münster: 17 intracranial and 8 spinal tumors. Fourteen of 25 patients underwent subtotal resection. Fifteen of 25 patients were treated by local irradiation, 10 of 25 with large-field techniques (whole-brain/cranio-spinal irradiation) and an additional tumor boost. The median tumor dose amounted to 50 Gy (16 to 65 Gy). Sites of recurrence were analyzed and correlated with the irradiated region.RESULTS:Twelve recurrences were observed. Six of 12 could be exactly related to the irradiation portals and were found well inside the local or boost fields. The remaining 6 tumors also recurred locally; whether they were in-field or field margin recurrences was not to be discerned by the imaging available at the time. No out-field recurrences or spinal seeding were observed. For 8 of 17 locally irradiated patients with intracranial ependymomas, 5 local recurrences were recorded. In 9 of 17 patients receiving whole-brain or cranio-spinal irradiation, 6 local recurrences were found. Two of 8 spinal tumors recurred locally.CONCLUSIONS:All tumors recurred within the former tumor bed. In the remaining cranio-spinal axis no recurrences or metastases were found. Similar results are reported from current literature. The value of large-field techniques (whole brain/spinal irradiation) is to be questioned. Modern methods like IORT or stereotactic radiotherapy might be able to deliver a higher tumor dose without increasing toxicity.