High-grade glioma has a poor prognosis, and radiation therapy plays a crucial role in its management. Every step of treatment planning should thus be optimised to maximise survival chances and minimise radiation-induced toxicity. Here, we compare structures needed for target volume delineation between an immediate postoperative magnetic resonance imaging (MRI) and a radiation treatment planning MRI to establish the need for the latter. Twenty-eight patients were included, with a median interval between MRIs (range) of 19.5 (8-50) days. There was a mean change in resection cavity position (range) of 3.04 ± 3.90 (0-22.1) mm, with greater positional changes in skull-distant (>25 mm) resection cavity borders when compared to skull-near (≤25 mm) counterparts (p < 0.001). The mean differences in resection cavity and surrounding oedema and FLAIR hyperintensity volumes were -32.0 ± 29.6% and -38.0 ± 25.0%, respectively, whereas the mean difference in midline shift (range) was -2.64 ± 2.73 (0-11) mm. These data indicate marked short-term volumetric changes and support the role of an MRI to aid in target volume delineation as close to radiation treatment start as possible. Planning adapted to the actual anatomy at the time of radiation limits the risk of geographic miss and might thus improve outcomes in patients undergoing adjuvant radiation for high-grade glioma.

A planning study was performed for helical tomotherapy treatment. We evaluated the maximum achievable protection of organs at risk (OARs) in patients with malignant pleural mesothelioma after pleurectomy with simultaneous optimal target coverage.

Radiogenic side effects are frequently seen in patients undergoing radiotherapy for head and neck tumors. Intensified dental and mucosal care reduce oral hygienic deficits. The aim of this study was the optimization of mouth hygiene using dexpanthenol rinsing solution applied with a dental waterjet system (DWS). 30 consecutive head and neck tumor patients (44–75 years) were analyzed, who received intensity-modulated radiation treatment (IMRT; total dose range: 54–66 Gy) with helical Tomotherapy HiArt II. The group under investigation (n = 10) additionally received a professional DWS using dexpanthenol mouthrinse (Bepanthen). The first control group received dexpanthenol mouthrinse alone. The second control group only performed the standardized mouth hygiene protocol. Grade of xerostomia, taste, dysphagia, thrush, and mucositis was evaluated on a daily basis. 29 of 30 patients completed radiation therapy. Change in taste occurred in all patients in all groups, however, with a delay in the study group. The occurrence of grade III stomatitis and Xerostomia grade II was significantly reduced in the study arm. No patient suffered from grade III xerostomia in the study arm versus four patients in the control groups. Dysphagia grade II was observed significantly less frequent in the study group (p = 0.0004). Thrush occurrence showed a delay in the study group. Our study underlines the importance of an intensified mouth hygiene during radiation therapy. The combination of dexpanthenol rinsing solution + DWS reduces the incidence of high-grade early side effects which often lead to a reduced quality of life and abortion of the treatment.

Aim To evaluate the feasibility of early metabolic response assessment with (18) F-FDG PET/CT in patients with breast cancer liver metastases 4 weeks after radioembolization with Yttrium-90 labeled microspheres. Methods 25 patients (mean age 58y, range 40-74) with advanced stage liver metastases of breast cancer were treated with 1.9 +/- 0.4 GBq of 90Y-microspheres in the salvage setting and underwent (18) F-FDG PET/CT at baseline and 4 weeks post-radioembolization. 14 patients (56 %) had an excessive hepatic tumor burden (> 50 % of total liver volume), 21 patients (84 %) had extrahepatic disease. Liver lesions with the highest SUV (max) were selected as target lesions and a cut-off was set at 50 % reduction to separate responders from non-responders. The predictive impact of metabolic response on overall survival (OS) was investigated along with other prognostic factors. Results The median OS in this highly advanced metastatic cohort was 7 months (95 % CI, 5-9). All patients had a reduction in SUV (max) (mean Delta SUV (max) : -49 +/- 26 %) at 4 weeks post-treatment. Patients with > 50 % SUV (max) reduction survived longer (median OS 13 mo, 95 % CI 8-18) than the remaining patients (median OS 4 mo, 95 % CI 2-6; p = 0.001). From all investigated baseline factors including age, performance status, and presence of extra-hepatic disease, only the hepatic tumor burden had a significant impact on OS (p = 0.02). Conclusions This is the first preliminary evidence in breast cancer that early post-radioembolization molecular response assessment of treated liver metastases - as early as 4 weeks posttreatment - may predict survival. If confirmed by larger series, FDG PET/CT could be considered for early response-adapted treatment modifications.

Purpose: Total body irradiation (TBI) is an important procedure in the conditioning for bone marrow and hematopoietic stem cell transplantation. Doses up to 12 Gy are delivered in hyperfractionated regimes. TBI performed with helical Tomotherapy (R) (Accuray, Madison, Wisconsin, USA) is an alternative to conventional techniques to deliver dose in extended target volumes with the possibility of simultaneous dose sparing to organs at risk. In this study we focused on maximum dose reduction to the lungs in TBI using helical Tomotherapy (R). Material and methods: Forty treatment plans of patients who received TBI were calculated with TomoH (R) (Accuray, Madison, Wisconsin, USA, Version 2.0.4) with a dose of 12 Gy delivered in six equal fractions (2 x 2 Gy/day). Planning iterations necessary to accomplish ICRU 83 report should be less than 250. Treatment time should be practicable in daily routine (<60 min.). Besides the usual contouring of organs at risk special contouring was required for optimization processes which focused on maximum dose sparing in the central lung tissue. Dose constraints (D2, D98, D99) were predefined for target volumes (i.e. PTV TBI D99: 90% of prescribed dose). Homogeneity index <0.15 was defined for acceptability of the treatment plan. Results: For all patients acceptable treatment plan fulfilling the predefined constraints were achievable. An average time of 46 min is required for treatment. Thirty-four of forty patients fulfilled D2 in the PTV TBI. Four patients failed D2 due to a high BMI >28 (maximum dose 13.76 Gy = 114.7%). The D98 in the PTV TBI was not reached by 2 / 4 0 patients due to BMI > 31 (minimum dose 11.31 Gy = dose coverage of 94.2%). Also these two patients failed the homogeneity index <0.15. The mean lung dose over all patients of the right lung was 7.18 Gy (range 6.4-9.5 Gy). The left lung showed a median (D50) dose of 7.9 Gy (range 6.7-9.3 Gy). Central lung dose showed a mean dose (D50) of 5.16 Gy (range 4.02-7.29 Gy). The D80 of the central lung showed an average dose of 3.87 Gy. Conclusions: Total body irradiation using helical Tomotherapy (R) can be delivered with maximum lung tissue sparing (<6 Gy) but without compromise in adjacent PTV TBI structures (i.e. ribs, heart). High conformity and homogeneity in extended radiation volumes can be reached with this technique in an acceptable planning and treatment time. Limitations may occurred in patients with high body mass index.

Purpose: Radiation-induced skin injury represents one of the most common side effects in breast cancer patients receiving adjuvant whole-breast radiotherapy. Numerous systemic and topical treatments have been studied in the prevention and management of radiation-induced skin injury without providing sustainable treatment strategies. While superficial barrier-forming skin products such as dressings are the standard of care in wound care management, their utilization as preventive treatment approach in radiotherapy has barely attracted attention. Methods: In this prospective, intra-patient randomized study, Hydrofilm polyurethane film dressings were applied prophylactically to either the medial or lateral breast half of 62 patients with breast cancer undergoing adjuvant radiation therapy following breast conserving surgery. The breast half contralateral to the film dressing was concurrently treated with 5% urea lotion as control skin care. Maximum severity of radiation dermatitis was assessed using RTOG/EORTC toxicity scores, photospectrometric erythema measurements and patient-assessed modified RISRAS scale. Results: In the Hydrofilm compartments, mean maximum RTOG/EORTC radiation dermatitis severity grades were significantly reduced from 133 to 0.35 and photospectrometric measurements showed significantly reduced erythema severity, as compared to the control compartments, with an overall response rate of 89.3%. Hydrofilm completely prevented moist desquamation and significantly reduced patients' subjective experience of itching and pain. Conclusion: The obtained results along with a favorable cost-benefit ratio and an easy and quick application suggest a prophylactic application of Hydrofilm in adjuvant radiotherapy of breast cancer patients to reduce or even prevent radiation dermatitis.

To evaluate the interfractional variations of patient positioning during intensity-modulated radiotherapy (IMRT) with helical tomotherapy in head and neck cancer and to calculate the required safety margins (sm) for bony landmarks resulting from the necessary table adjustments.

Objective: To evaluate diffusion-weighted whole-body MRI with background body signal suppression (DWIBS) at 3.0 T for pulmonary lesion detection and characterization. Materials and Methods: 19 patients with 25 pulmonary lesions were examined with DWIBS using 2 b-values (b = 0 and 1000 s/mm2) and partly additionally with DWIBS using 3 b-values (b = 0, 50, 1000 s/mm2). DWIBS was compared to FDG PET. For characterization of hyperintense lesions by DWIBS, Lesion-to-Spinal cord Ratio (LSR) and apparent diffusion coefficient ADC were analyzed. From repeated measurements, the Coefficient of Variation (CV) was calculated. From 3-b-value data, the ADC(0,1000) and ADC(50,1000) values were compared in order to assess perfusion influences. Results: Sensitivity and specificity of detecting malignant lesions were comparable for DWIBS and FDG PET. Malignant compared to benign lesions had lower ADC(0,1000) and higher LSR values. CV of LSR was more than a factor of 8 higher than CV of ADC(0,1000) (23.9% vs 2.9%, P = 0.012). Perfusion effects were largest for metastases, medium for adenocarcinoma and benign lesions, and lowest for squamous cell carcinoma. Conclusion: DWIBS at 3.0 T is appropriate for lesion detection and characterization. ADC analysis is superior to signal intensity ratio determination with respect to repeatability. An analysis of perfusion influences provides additional information.

Funktionelle Bildgebungsmethoden wie die MRT-Diffusionswichtung (DWI) können ein Therapieansprechen oftmals vor morphologisch fassbaren Änderungen aufzeigen. Zur Therapieplanung lokal-interventioneller Behandlungsverfahren ist es wünschenswert, die Erfolgsaussichten bereits vor Therapiebeginn abschätzen zu können. Ziel dieser Studie war es daher zu prüfen, ob sich die DWI mittels quantitativer Analyse des Diffusionskoeffizienten (ADC) zur Vorhersage des progressionsfreien (PFS) und Gesamtüberlebens (OS) von Patienten mit kolorektalen Lebermetastasen vor Radioembolisation (RE) eignet.

There is lack of data on the specific benefit of peptide receptor radionuclide therapy (PRRT) in neuroendocrine tumors (NET) of pulmonary origin. This dual- centre study aimed to assess outcome and toxicity of standardized PRRT with 177Lu-octreotate in a patient population of advanced pulmonary NET of grade 1-2. We retrospectively assessed 22 consecutively patients treated with 4 intended cycles at 3 monthly intervals (mean activity per cycle 7.8±0.68 GBq). In a median follow-up period of 54 months, no significant nephrotoxicity (≥ grade 3) was observed. Reversible hematotoxicity (grade 3) occurred in 3 patients (13.6%). Treatment response consisted of partial response in 6 (27.3%), stable disease in 9 (40.9%), and progressive disease in 7 (31.8%) patients. Median progression-free survival (PFS) and overall survival (OS) was 27 (95% CI, 9-45) and 42 months (95% CI, 25-59), respectively. High hepatic tumor load (> 50%) and high plasma chromogranin A (> 600 ng/mL) were negative baseline predictors for PFS and OS on univariate analysis, CgA remained significant on multivariate analysis (PFS, P=0.011; OS, P=0.026). Disease progression despite PRRT was associated with shorter survival (median OS 15 vs 53 mo, P<0.001). Despite a higher incidence of treatment failure compared to NET of other origins, the observed substantial and sustained disease stabilization (median PFS of 27 mo, disease control rate of > 2/3 of pts) indicates considerable efficacy of 177Lu-octreotate in pulmonary NET.

Ein 79-jähriger Patient mit bekanntem metastasiertem malignem Melanom wurde bei seit einigen Tagen reduziertem Allgemeinzustand, starkem Husten und Koordinationsstörungen vorstellig. Der Patient hatte zum Aufnahmezeitpunkt insgesamt 4 Gaben des PD-1-Inhibitors Pembrolizumab erhalten (Erstgabe 4 Monate vor stationärer Aufnahme). Da man aufgrund der beschriebenen Symptomatik einen bronchopulmonalen Infekt vermutet hatte, war der Patient zuvor auswärts frustran i. v. antibiotisch behandelt worden. Bei uns wurde nun eine Computertomografie (CT) durchgeführt. FRAGEN ▪ Was sehen Sie in den CT-Bildern? ▪ Welche Diagnose stellen Sie? ▪ Was ist Ihre Therapie? ▪ Erläutern Sie den Pathomechanismus. ▶ Abb. 1 CT-Aufnahmen a Transversalebene b Sagittalebene. Mediquiz

To investigate whether quantifications of apparent diffusion coefficient (ADC) on diffusion-weighted imaging (DWI) can predict overall survival (OS) in patients with liver-predominant metastatic colorectal cancer (CRC) following selective internal radiation therapy with 90Yttrium-microspheres (SIRT).

To investigate the clinical potential of pretreatment apparent diffusion coefficient (ADC) on diffusion-weighted magnetic resonance imaging (DWI) for therapy response and outcome prediction in patients with liver-predominant metastatic colorectal cancer (CRC) undergoing radioembolization with 90Yttrium-microspheres (90Y-RE).

To evaluate the role of magnetic resonance imaging (MRI) as a predictor for the clinical course in patients with glioblastoma.

Größenbasierte Verfahren zur Therapieerfolgsmessung lokal interventioneller Therapieverfahren, z.B. RECIST, können ein frühes Therapieansprechen häufig nur unzureichend erfassen. Aktuelle Studienergebnisse weisen darauf hin, dass die MRT-Diffusionsbildgebung (DWI) ein Therapieansprechen bereits vor morphologisch fassbaren Änderungen aufzeigt. Ziel dieser Studie war es daher zu prüfen, ob sich die DWI mittels quantitativer Analyse des Diffusionskoeffizienten (ADC) zur frühen Vorhersage des Gesamtüberlebens (OS) von Patienten mit hepatisch metastasiertem kolorektalem Karzinom nach selektiver interner Radiotherapie (SIRT) eignet.

BACKGROUND:We observed visual sensations (VSs) in patients undergoing intensity modulated radiotherapy (IMRT) of the brain without the beam passing through ocular structures. We analyzed this phenomenon especially with regards to reproducibility, and origin.METHODS AND FINDINGS:Analyzed were ten consecutive patients (aged 41-71 years) with glioblastoma multiforme who received pulsed IMRT (total dose 60Gy) with helical tomotherapy (TT). A megavolt-CT (MVCT) was performed daily before treatment. VSs were reported and recorded using a triggered event recorder. The frequency of VSs was calculated and VSs were correlated with beam direction and couch position. Subjective patient perception was plotted on an 8x8 visual field (VF) matrix. Distance to the orbital roof (OR) from the first beam causing a VS was calculated from the Dicom radiation therapy data and MVCT data. During 175 treatment sessions (average 17.5 per patient) 5959 VSs were recorded and analyzed. VSs occurred only during the treatment session not during the MVCTs. Plotting events over time revealed patient-specific patterns. The average cranio-caudad extension of VS-inducing area was 63.4mm (range 43.24-92.1mm). The maximum distance between the first VS and the OR was 56.1mm so that direct interaction with the retina is unlikely. Data on subjective visual perception showed that VSs occurred mainly in the upper right and left quadrants of the VF. Within the visual pathways the highest probability for origin of VSs was seen in the optic chiasm and the optic tract (22%).CONCLUSIONS:There is clear evidence that interaction of photon irradiation with neuronal structures distant from the eye can lead to VSs.

Aim: Clinical differentiation of psoriatic arthritis (PsA) and rheumatoid arthritis (rA) based on the pattern of joint involvement can be difficult; the frequent form of PsA with polyarthritis of the peripheral joints may sometime resemble rA. We investigated a metabolic joint asymmetry score (MJAS), reflecting the overall asymmetric joint involvement on conventional bone scintigraphy, for differentiating PsA from rA in patients presenting with peripheral polyarthritis. Patients, methods: 106 patients (n = 61, PsA; n = 45, rA) with peripheral polyarthritis (≥ 5 joints) as well as 26 control subjects with no history of chronic joint disorders were analyzed. The intensity of articular 99mTc-MDP uptake in 40 peripheral joint pairs was scored regarding the bilateral difference of each joint based on a scale of 0–2 (no significant, moderate, and marked asymmetry, respectively). The patient’s MJAS was defined as the sum of uptake difference scores of all joint pairs. The association of MJAS with the underlying condition (Psoriasis criteria, Revised Criteria of the ACR) was examined. Results: 5280 peripheral joint pairs were investigated. There was no significant difference in the total number of involved joints in PsA 15.0 ± 8.2 versus rA 17.5 ± 8.8 patients (p = 0.132), but significantly less involvement in the control group (6.7 ± 5.0, p < 0.001). MJAS was markedly higher in PsA (17.0 ± 9.6) than in rA (4.8 ± 3.9, p < 0.001), and correlated with the total number of involved joints in PsA (r = 0.516, p < 0.001), but not in rA (r = 0.078, p = 0.380). The MJAS disparity between PsA and rA persisted after exclusion of the DIP joints (14.4 ± 7.7 vs. 4.4 ± 3.3; p