Treatment outcomes and mortality of 94 patients with acromegaly

BACKGROUND

Due to new therapeutic modalities and modified therapeutic goals outcome of patients with acromegaly may change over time and differ by centre. We analysed treatment outcomes and mortality of our patients with acromegaly seen between 1971 and 2003.

METHOD

The cohort consisted of 94 patients who had been followed for 0.3-31 years (mean 10.6 years). Remission criteria were a normalized IGF-I concentration, a nadir GH level during oral glucose load of <1.0 microg/l and a random GH value of <2.5 microg/l.

FINDINGS

Transsphenoidal surgery achieved remission in 80% of patients with micro-adenomas (<1 cm), 65% with meso-adenomas (> or = 1 cm to <2 cm) and 27% with macro-adenomas (> or = 2 cm). Patients with meso-adenomas operated on after 1995 tended to have a better outcome compared to those operated on before 1995 (Remission in 83% vs. 38%). Radiotherapy resulted in disease control in 22 of 47 patients (47%). Intramuscular depot formulation of octreotide (Sandostatin LAR) led to disease control in 17 of 26 patients (65%). After multimodal therapy persistent acromegalic activity remained in 18% of the patients; only one of them had an adenoma of <2 cm. The standardized mortality ratio was 1.30 (95% CI 0.52-2.67) for patients in remission and 1.38 (95% CI 0.51-3.00) for patients with persistent acromegalic activity. CONCLUSIONS. Most patients with adenomas of <2 cm can be expected to achieve remission by transsphenoidal surgery alone. Furthermore, virtually all patients with adenomas of <2 cm and more than 80% of patients with adenomas of > or = 2 cm can be expected to achieve remission by adjuvant treatment. Aggressive multimodal therapy is critical in the management of acromegaly reducing mortality risk close to that of the general population.

Recent advances in the use of radiotherapy to treat early breast cancer

PURPOSE OF REVIEW

The past decade has seen significant advances in the delivery of radiotherapy for breast cancer. This article presents an overview of the most recent advances in radiotherapy for early breast cancer with emphasis on English-language articles published since 1 July 2003.

RECENT FINDINGS

Breast radiotherapy is usually well tolerated. However, the uptake of radiotherapy in the management of breast cancer is less than ideal. Recent research efforts in radiation oncology have concentrated on addressing the uptake of appropriate radiotherapy by quantifying toxicity, further reducing toxicity, and improving the convenience of radiotherapy. Novel radiation techniques such as partial breast irradiation and shortened radiotherapy treatment courses are under development to make radiotherapy more acceptable to patients and referring clinicians. Issues such as the optimal timing of radiotherapy after surgery and integrating the radiation with newer adjuvant systemic therapies remain important research challenges.

SUMMARY

Radiotherapy remains an important component of breast cancer therapy. Improving the acceptance of treatment and minimizing toxicity and inconvenience of treatment should lead to even greater appropriate use.

[A new area for radiotherapy with favourable features]

Radiotherapy is a complex medical speciality involving technology research, biology research and clinical research. All these basic researches are performed in order to optimise the management of cancer treatment patients. The aim of the present review is to present radiotherapy as a moving speciality whatever the concerned section. It will be particularly described the new approaches in terms of technology but also clinical developments.

Waiting for Radiotherapy

BACKGROUND AND PURPOSE

Growing incidence of cancer and the demographic changes of the society can cause severe shortage in radiotherapy services. This can lead to the use of waiting lists, which can serve as an indicator model for shortage of medical service. To investigate whether and how waiting lists are used in Germany, a survey was undertaken among German radio-oncologists. Their opinion concerning the use of waiting lists and their attitude toward the involved ethical problems were the central topics of this study.

MATERIAL AND METHODS

A questionnaire was developed which consisted of 18 items: four items covered general aspects, four were about the management of waiting lists, seven concerned problems of waiting lists, and three were about the future aspects. From all items, at least ten touched ethical aspects such as patient information or the doctor-patient relationship. 19 consecutive radio-oncologists answered the questionnaire via telephone. The main interest of this study was to generate further hypotheses for future research.

RESULTS

From all doctors (n = 19), most did not use waiting lists (n = 12) in their practice, whereas the remaining did use them (n = 7). Limited resources were seen as the central underlying problem (n = 16). Two guiding principles were most often quoted for managing waiting lists: patients with complaints such as pain before those without (n = 18) and curative before palliative radiotherapy (n = 15). Concerning the information given to patients about the use of waiting lists, some doctors voted for detailed information (n = 7), which covers negative side effects of waiting lists such as tumor progression during waiting time, others voted against (n = 11). There was a profound disagreement on the question of whether curative and palliative radiotherapy should be differently treated in the context of waiting lists. 70% of the group, who used waiting lists, could give a moral justification for waiting lists, whereas only 28% of the group, who did not use them, could offer a justification.

CONCLUSION

The survey showed that doctors were most concerned about the ethical aspects of waiting lists. Open questions are: (1) What is the best principle for a fair distribution of limited radiotherapy places? (2) How should patients be informed about waiting lists? (3) What moral justifications can be given for waiting lists? These issues must therefore become topics of future research and national dialogue, because the answers to these questions are necessary for the clinical use of waiting lists in radiotherapy.

Current treatments and promising investigations in a multidisciplinary setting

The care of the patient with squamous cell carcinoma of the head and neck (SCCHN) requires a multidisciplinary approach. For many years, radiotherapy following surgery was considered the standard approach to the treatment of locally advanced resectable disease. Data from randomized trials have confirmed the benefits of concurrent chemotherapy and radiotherapy (chemoradiotherapy) in this setting and this is now the gold standard for treatment. Chemoradiotherapy is also the recommended approach for unresectable disease. Neoadjuvant chemotherapy has been useful in resectable disease where organ preservation is desirable, but a concomitant approach is superior. Although survival benefits have not been consistently demonstrated, the theoretical potential of this approach has lead to continued investigations using newer agents, such as the taxanes. Novel targeted agents, such as antagonists of the epidermal growth factor receptor (EGFR), are showing promise in the treatment of patients with both locally advanced and recurrent/metastatic SCCHN. Treatment issues that require immediate attention include identifying optimal chemoradiotherapy regimens, clarifying the role of neoadjuvant chemotherapy, defining the optimal integration of targeted therapies into combined modality approaches and identifying useful prognostic and predictive factors.

Advances in the biology and treatment of oligodendrogliomas

PURPOSE OF REVIEW

The sensitivity of oligodendroglioma to chemotherapy and the prognostic significance of combined loss of 1p/19q in these tumors are now well established. This review discusses recent molecular, genetic and clinical advances made in studies on oligodendroglioma and mixed oligoastrocytoma.

RECENT FINDINGS

Methylation of genes is a frequent event in oligodendroglioma (OD), but no specific methylation sites have been discovered. In contrast to earlier reports, the expression of the basic helix-loop-helix transcription factors is not specific for OD, but may occur in glial tumors of all lineages. In a number of studies, the prognostic relevance of 1p/19q loss has been confirmed, and several studies have shown that loss of 1p/19q are early events in OD. No candidate genes have so far been identified on 1p36 and 19q13. Gene expression profiling using gene arrays allows the separation of glial tumors according to histology, tumor grade and prognosis. A number of genes have been identified that are significantly more highly expressed in OD. On MRI imaging, OD with combined 1p/19q loss has typical characteristics, including indistinct borders and a mixed signal intensity on T2-weighted images. Despite the large increase in knowledge on the molecular abnormalities in OD, the therapeutic options for these tumors have not improved significantly since the introduction of temozolomide. The increased survival after chemotherapy has been clearly established, but the timing of chemotherapy seems less critical. It is clear that temozolomide is a good alternative to procarbazine, CCNU and vincristine (PCV) chemotherapy, in particular, because it is better tolerated. No randomized trials, however, have compared PCV-chemotherapy to temozolomide. New agents--and probably more targeted therapies--are needed to further improve treatment. Chemo-irradiation deserves further study in anaplastic OD.

SUMMARY

The progress in the understanding of genetic and molecular abnormalities of OD has improved the recognition of treatment-sensitive OD, although this has not yet been mirrored in improved therapies or new treatment options. While chemotherapy improves the outcome of OD, further improvements will likely require new drugs or new treatment concepts.

New radiation techniques in gynecological cancer

Radiation therapy has been a major therapeutic modality for eradicating malignant tumors over the past century. In fact, it was not long after the discovery of radium that the first woman with cervical cancer underwent intracavitary brachytherapy. Progress in the way that this cytotoxic agent is manipulated and delivered has seen an explosive growth over the past two decades with technological developments in physics, computing capabilities, and imaging. Although radiation oncologists are educated in and familiar with the wealth of new revolutionary techniques, it is not easy for other key members of the team to keep up with the rapid progress and its significance. However, to fully exploit these enormous gains and to communicate effectively, medical and gynecological oncologists are expected to be aware of state-of-the-art radiation oncology. Here, we elucidate and illustrate contemporary techniques in radiation oncology, with particular attention paid to the external beam radiotherapy used for adjuvant and primary definitive management of malignancies of the female pelvis.

Subatomic turf wars. Molecular imaging holds the promise of personalized medicine, while pitting radiologists against oncologists, others over diagnostic role

Molecular imaging is expanding radiologists' territory and holds the promise of personalizing treatment. But a turf war is looming over who has the diagnostic role-radiologists, oncologists or others. "We're talking about a whole new way of thinking in terms of diagnosing and treating diseases," David Rollo says.

Current Status of Radiation Therapy and Combined-Modality Treatment for Bladder Cancer

BACKGROUND

Standard treatment for muscle-invasive bladder cancer is radical cystectomy. Combined-modality treatment (CMT), including transurethral resection (TURBT), radiation therapy (RT) and systemic chemotherapy, has been shown to produce survival rates comparable to those of radical cystectomy. With these programs, cystectomy has been reserved for patients with incomplete response or local relapse after trimodality treatment.

METHODS

This review summarizes series of radical RT with different fractionation schedules and focuses on CMT for muscle-invasive bladder cancer. Current protocols of the bladder-sparing approach will be discussed and the background of future developments, including incorporation of promising new chemotherapeutic agents as well as the role of predictive and prognostic factors in selecting patients for the respective treatment alternatives, will be given.

RESULTS

There is moderate evidence that hyperfractionated and accelerated regimens are superior to conventional RT at least in situations where no concomitant chemotherapy is applied. Several phase II studies and one phase III study indicate that concomitant radiochemotherapy is superior to RT alone. In modern series of CMT, 5-year survival rates in the range of 50-60% have been published, and about three quarters of the surviving patients maintained their own bladder. Recent data suggest that incorporation of newer chemotherapeutic agents, particularly gemcitabine and taxanes, in CMT protocols is feasible and promising. Clinical criteria helpful in determining patients for bladder preservation include such variables as early tumor stage, unifocal tumor, a visibly and microscopically complete TURBT, and absence of ureteral obstruction.

CONCLUSION

CMT for bladder cancer is a reasonable treatment option for patients who are deemed medically unfit for cystectomy and for those seeking an alternative to radical cystectomy.

Radiation Therapy for Nonmalignant Diseases in Germany

BACKGROUND

Radiotherapy (RT) of nonmalignant diseases has a long-standing tradition in Germany. Over the past decade significant theoretical and clinical progress has been made in this field to be internationally recognized as an important segment of clinical RT. This development is reflected in a national patterns-of-care study (PCS) conducted during the years 2001-2002.

MATERIAL AND METHODS

In 2001 and 2002, a questionnaire was mailed to all RT facilities in Germany to assess equipment, patient accrual, RT indications, and treatment concepts. 146 of 180 institutions (81%) returned all requested data: 23 university hospitals (UNI), 95 community hospitals (COM), and 28 private institutions (PRIV). The specific diseases treated at each institution and the RT concepts were analyzed for frequencies and ratios between the different institution types. All data were compared to the first PCS in 1994-1996.

RESULTS

In 137 institutions (94%) 415 megavoltage units (mean 1.7; range 1-4), and in 78 institutions (53%) 112 orthovoltage units (mean 1.1; range 0-2) were available. A mean of 37,410 patients were treated per year in all institutions: 503 (1.3%) for inflammatory disorders, 23,752 (63.5%) for degenerative, 1,252 (3.3%) for hypertrophic, and 11,051 (29.5%) for functional, other and unspecified disorders. In comparison to the first PCS there was a significant increase of patients per year (from 20,082 to 37,410; +86.3%) in most nonmalignant diseases during the past 7-8 years. Most disorders were treated in accordance with the national consensus guidelines: the prescribed dose concepts (single and total doses) varied much less during the period 2001-2002 in comparison with the previous PCS in 1994-1996. Only five institutions (3.4%) received recommendations to change single or total doses and/or treatment delivery. Univariate analysis detected significant institutional differences in the use of RT for various disorders.

CONCLUSION

RT is increasingly accepted in Germany as a reasonable treatment option for many nonmalignant diseases. The long-term perspective and research plan will have to include various updates of PCS, re-writing of consensus guidelines, introduction of registries for rare nonmalignant disorders, and clinical controlled studies even for so-called established indications, as international acceptance is based on the criteria of evidence-based medicine.

[Current status and potential perspectives in classical radiotherapy technology]

INTRODUCTION AND POTENTIALS OF CLASSICAL RADIOTHERAPY

After purchase of radiotherapy equipment in 2003, classic radiation therapy in Serbia will reach the highest world level. In order to define the highest standards in radiation technology, we analyzed the current status and potential perspectives of radiation therapy.

TECHNOLOGICAL LEVELS OF RADIOTHERAPY IN DEVELOPED COUNTRIES

An analysis of present situation in the USA, assumed as the most developed in the world, was done. Available data, collected in the last 3 years (equipment assortment, therapy modalities, workload and manpower) for 284 radiotherapy centers, out of potential 2050, were analyzed. Results were presented as crude percentage and matched to point current status.

RESULTS OF ANALYSIS AND DISCUSSION

The analysis showed that CLINAC accelerators are the most popular (82.7%), as well as, ADAC (43.7%) and Focus (CMS) (27.4%) systems for therapy planning. Movement towards virtual simulation is evident (59.3%), although classic "simulation" is not fully eliminated from the radiotherapy chain. The most popular brachytherapy afterloader is Microselectron HDR (71%). About 64.4% centers use IMPAC communication/verification/record system that seems more open than Varis. All centers practice modern radiotherapy modalities and techniques (CPRT, IMRT, SRS/SRT, TBI, IORT, IVBHRT, HDR BHRT, etc.). CT and MRI availability is out of question, but PET is available in 3% of centers, however this percentage is rapidly growing. Up to 350 new patients per year are treated by one accelerator (about 35 pts. a day). Centers are relatively small and utilize 2-3 accelerators on average. Average FTE staffing norm is 4 radiation oncologists, 2-3 medical radiotherapy physicists, about 3 certified medical dosimetrists and about 6 radiotherapy technologists.

TECHNOLOGICAL ASPECTS AND CONCLUSION

In the past 5 years relative stagnation in classic radiotherapy has been observed. In spite of substantial investments in technology and consequent improvements, as well as wide introduction of computers in radiotherapy, radiotherapy results have not changed significantly. Vendor developement strategies do not point that this trend will change in the next 5 years. On the other hand, wide introduction of the PET in each radiotherapy chain ring (diagnostics, planning, follow-up), could improve results (local and regional control, as well as quality of patients' life).

A historical perspective of the radiation oncology workforce and ongoing initiatives to impact recruitment and retention

The field of radiation oncology has evolved into an exceptionally technologically driven and multi-disciplinary discipline over the last two decades. This specialty of medicine is one that requires not only the command of highly complex modalities but also the assembly of a competent and expertly skilled team of medical professionals. Although the profession has grown tremendously in the past years, the workforce has not been able to meet the demands of the practice. A significant shortage of radiation therapists, dosimetrists, and oncology nurses exists in the United States today and will almost certainly increase in severity over the next several years. A similar crisis has been seen in several other countries-most notably Canada and Australia and has contributed to prolonged delays in cancer treatment for many patients.

[Radiotherapy for head and neck cancer]

Radiotherapy plays an important role in therapy for head and neck cancers from the aspect of functional and cosmetic conservation. In 2001, 130,000 patients underwent radiotherapy for the first time, and those with head and neck cancer accounted for 12.5% of this population. However, we cannot consider the management of head and neck cancer without understanding the similarities and differences among the primary sub-sites, because there is a significant difference in the natural history of cancer among these sub-sites. Treatment results are improving with the popularization of stereotactic radiotherapy and concurrent chemotherapy, in addition to traditional brachytherapy. Trends in radiotherapy for head and neck cancer are summarized in this article by discussing the specificities and similarities among sub-sites.

Recent Advances in Radiation Oncology

The field of radiation oncology has experienced dramatic progress in recent years. Advances in areas of tumor delineation, treatment planning, delivery, and verification allow modern radiotherapy to deliver high doses with great accuracy, less patient morbidity, and in a highly individualized manner. A good understanding of what can be achieved with modern radiotherapy is important in ensuring an effective multidisciplinary approach to the management of cancer and other benign, yet rapidly proliferating, lesions.

[On past practices and future directions of informed consent in (radiation) oncology]

BACKGROUND AND PURPOSE

Informed consent, especially in oncology, is predominantly seen from a legal point of view. Such a limited perspective runs the risk of reducing informed consent to some tiresome formalism. The present article highlights how the relationship between patient and physician might be enriched by a comprehensive historicocultural understanding of informed consent. The authors show in which future directions the practice of informed consent might develop.

MATERIAL AND METHODS

Analysis of historical and forensic literature regarding informed consent.

RESULTS

With the terms "information" and "consent" the last 2500 years of medical history can schematically be divided in three epochs: the first epoch started around 500 years BC, lasted until the 19th century AC and was dominated by the principle of "salus aegroti suprema lex". The patient's benefit was exclusively defined by the treating physician. Formal consent was not required in those times. The era of enlightment brought new ideas to Europe, especially the principle of individual autonomy. In 1894, the Supreme Court of the German Reich decided that any medical intervention without the patient's consent was regarded as physical injury and was thus illegal. Systematic requirements regarding patient information on planned medical interventions were not known. The beginning of the third epoch is marked by the introduction of the term "informed consent" in modern medicine in 1957. Since then, a comprehensive information of the patient is seen as a prerequisite for consent. The patient's right of self-determination is attributed a higher legal and moral value than the physician's concept of the proposed treatment. Nowadays, the debate regarding informed consent is dominated by the continuing differentiation of modern medicine, the development of medical practice as part of the service sector, and the changing ways how patients see themselves.

CONCLUSIONS

Social and legal developments have strongly influenced medical practice in the past. The importance of informed consent will continue to rise in the future, while the emphasis of the physician's task will shift from information to counseling. Informed consent will be increasingly established as independent service.

Changing trends in national practice for external beam radiotherapy for clinically localized prostate cancer: 1999 patterns of care survey for prostate cancer

PURPOSE

To report changing trends in external beam radiotherapy (EBRT) delivery practice for clinically localized prostate cancer as determined from the 1999 survey from the American College of Radiology National Patterns of Care Study.

METHODS AND MATERIALS

The 1999 survey included a weighted sample of 36,496 patient records obtained from a stratified two-stage sample of 554 patient records. Patients were surveyed from 58 institutions and were treated between January 1999 and December 1999. Of these, 36% (weighted sample size, 13,293; unweighted sample size, 162) were treated with brachytherapy with or without EBRT and 64% (weighted sample size, 23,203; unweighted sample size, 392) were treated with EBRT only. The latter group is the subject of this report. The following trends in clinical practice were analyzed according to prognostic risk groups and other variables and compared with the results of the prior surveys: use of androgen deprivation therapy (ADT) in combination with EBRT, higher prescription dose levels, and administration of elective whole pelvic RT (WPRT).

RESULTS

The incidence of ADT use for favorable, intermediate, and unfavorable-risk groups was 31%, 54%, and 79%, respectively. A multivariate logistic regression analysis revealed a statistically significantly increased likelihood of intermediate (p = 0.001) and unfavorable (p <0.0001) risk groups treated with ADT in conjunction with EBRT compared with favorable-risk patients. ADT use was more prevalent among treated patients in the 1999 survey than in the 1994 survey (51% vs. 8%, p <0.0001). Compared with the prior survey, a greater percentage of patients were treated with higher radiation doses in the 1999 survey (> or =72 Gy, 45% in 1999 vs. 3% in 1994, p <0.0001). In the 1999 survey, the proportion of patients with favorable, intermediate, and unfavorable tumors treated to doses > or =72 Gy was 43%, 38%, and 60%, respectively, compared with 4%, 3%, and 1%, respectively, in the 1994 survey. Compared with the 1994 survey, a large increase in the number of patients treated with brachytherapy (36% vs. 3%, p <0.0001). The frequency of WPRT use decreased from 92% in 1989 to 52% in 1994 to 23% in 1999. For the 1999 survey, a multivariate analysis indicated that unfavorable-risk patients (p = 0.016) and intermediate-risk patients (p = 0.018) were more likely to be treated with WPRT compared with favorable-risk patients. Nevertheless, even among unfavorable-risk patients, a substantial decline had occurred in the use of WPRT for the 1999 survey (70% for the 1994 survey compared with the 31% for the current survey; p = 0.003).

CONCLUSION

The significantly increased use of ADT for high-risk patients and higher radiation doses, especially for intermediate- and high-risk patients, reflects the penetration and growing acceptance of clinical trial results that have demonstrated the efficacy of these treatment approaches. The relatively high proportion of favorable-risk patients treated with high radiation dose levels was greater than expected. A large increase in brachytherapy was observed compared with prior surveys. Most treated patients with high-risk disease did not undergo elective WPRT, which likely reflects the influences of prior trials, stage migration, and the commonly held belief that WPRT provides minimal benefit in the setting of higher radiation doses.

Long-term complications following childhood and adolescent cancer: foundations for providing risk-based health care for survivors

Survivors of childhood and adolescent cancer are one of the higher risk populations seen by health care professionals. The curative therapy administered for the cancer also affects growing and developing tissues. Following chemotherapy, radiation therapy, and surgery, many survivors will experience chronic or late-occurring health problems, often not becoming clinically apparent until decades after therapy. Survivors face an increased risk of morbidity, mortality, and diminished quality of life associated with their previous cancer therapy. Risk is further modified by the survivor's genetics, lifestyle habits, and comorbid health conditions. Over their lifetime, survivors will see health care professionals from an array of specialties and disciplines. The aim of this review is threefold: (1) to convey a sense of the risk faced by survivors to clinicians unfamiliar with the population; (2) to provide an up-to-date tool for clinicians, regardless of specialty or discipline, when providing care for a survivor; and (3) to complement the recently completed recommendations for screening, prevention, and management of childhood cancer survivors.

Development of targeted somatostatin-based antiangiogenic therapy: a review and future perspectives

Angiogenesis, the development of new blood vessels, is a critical determinant of tumor growth and the dissemination of metastasis. A number of antiangiogenic therapies have been introduced into clinical trials, though few of these are targeted therapies. Somatostatin analogs may be an excellent candidate to develop as targeted antiangiogenic agents alone, or in combination with cytotoxic or cytostatic compounds. Somatostatin analog inhibition of angiogenesis has been demonstrated in the chicken chorioallantoic membrane (CAM) model, the human umbilical vein endothelial cell (HUVEC) proliferation model, and the human placental vein angiogenesis model (HPVAM). This inhibition appears to be the result of a unique upregulation of somatostatin receptor subtype 2 (sst 2) during the angiogenic switch from resting to proliferating endothelium. The distinct overexpression of this receptor provides a unique target for these somatostatin analogs or somatostatin analog conjugates. This manuscript reviews the development of somatostatin analogs as antiangiogenics in both their unlabeled and radiolabeled forms and postulates on future developments in this field.

Receptor radionuclide therapy with 90Y-[DOTA]0-Tyr3-octreotide (90Y-DOTATOC) in neuroendocrine tumours

Somatostatin receptors are over-expressed in many tumours, mainly of neuroendocrine origin, thus enabling treatment with somatostatin analogues. Almost a decade of clinical experience of receptor radionuclide therapy with the analogue (90)Y-[DOTA](0)-Tyr(3)-octreotide [(90)Y-DOTATOC] has now been obtained at a few centres of excellence. This review reports on the present state of the art of receptor radionuclide therapy and discusses new perspectives.

Medical health physics: a review

Medical health physics is the profession dedicated to the protection of healthcare providers, members of the public, and patients from unwarranted radiation exposure. Medical health physicists must be knowledgeable in the principles of health physics and in the applications of radiation in medicine. Advances in medical health physics require the definition of problems, testing of hypotheses, and gathering of evidence to defend changes in health physics practice and to assist medical practitioners in making changes in their practices as appropriate. Advances in radiation medicine have resulted in new modalities and procedures, some of which have significant potential to cause serious harm. Examples included in this review include radiologic procedures that require very long fluoroscopy times, radiolabeled monoclonal antibodies, and intravascular brachytherapy. This review summarizes evidence that supports changes in consensus recommendations, regulations, and health physics practices associated with recent advances in radiology, nuclear medicine, and radiation oncology. Medical health physicists must continue to gather evidence to support intelligent but practical methods for protection of personnel, the public, and patients as modalities and applications evolve in the practice of medicine.

[Radioiodine therapy for Graves' disease: problems and new developments]

In Germany, patients with Graves' disease are usually treated with radioiodine after unsuccessful antithyroid drug medication, occurrence of side effects from antithyroid drugs or an increased risk from surgery. In patients with normal or only slightly enlarged thyroid glands (volume < or = 50 ml), radioiodine therapy is particularly effective. Radioiodine is the preferential treatment for Graves' patients with high titres of TSH-receptor antibodies and cigarette smoking. Children are still rarely treated with radioiodine in Germany. In contrast, treatment with radioiodine should be more liberally applied in elderly patients with subclinical hyperthyroidism and cardiac symptoms. Individual dosimetry to determine the therapeutic activity is mandatory in Germany. Patients with large goitres obviously need higher organ doses than patients with smaller goitres or normal thyroid glands. Antithyroid drug treatment may interfere with radioiodine therapy. Therefore, it is recommendable to withdraw antithyroid drugs several days before treatment with radioiodine is initiated (and a preceding radioiodine uptake test is performed). In patients with Graves' orbitopathy prophylaxis with corticosteroids can prevent the worsening of symptoms that may be induced by radioiodine treatment. Currently, a risk adapted procedure is recommended according to which prophylactic medication with corticosteroids before applying radioiodine treatment is not necessary in patients with symptoms of orbitopathy and lack of other risk factors (cigarette smoking, in particular). Present results suggest that the risks of radioiodine treatment in Graves' disease patients are very low, while at the same time the cost-effectiveness of this treatment regimen is high.

Recent advances in light ion radiation therapy

BACKGROUND

The fast development of energy- and intensity-modulated radiation therapy during the last two decades using photon and electron beams has when implemented resulted in a considerable improvement of radiation therapy, particularly if combined with radiobiologically based treatment optimization techniques. This has made intensity-modulated electron and photon beams as powerful as today's uniform dose proton therapy. To be able to cure also the most advanced hypoxic and radiation-resistant tumors of complex local spread, intensity-modulated light ion beams are really the ultimate tool and in clinical practice 2 to 3 times less expensive per patient treated than proton therapy. This development and the recent development of advanced tumor diagnostics based on PET-CT imaging of the tumor cell density open the field for new powerful radiobiologically based treatment optimization methods. The ultimate step is to use the unique radiobiologic and dose distributional advantages of light ion beams for truly optimized bioeffect planning where the integral three-dimensional dose delivery and tumor cell survival can be monitored by PET-CT imaging and corrected by biologically based adaptive therapy optimization methods.

PURPOSE

The main purpose of the present paper is to discuss the principal areas of development of therapy optimization, by considering the therapy chain from tumor diagnostics and the use of three-dimensional predictive assay to biologically based treatment optimization with special focus on the rapid clinical development of advanced light ion therapy.

METHODS

Besides the "classical" approaches using low ionization density hydrogen ions (protons, but also possibly deuterons and tritium nuclei) and high ionization density carbon ions, two new approaches will be discussed. In the first one, lithium or beryllium or boron ions, which induce the least detrimental biologic effect to normal tissues for a given biologic effect in a small volume of the tumor, will be key particles. In the second approach, referred patients will be given a high-dose, high-precision "boost" treatment with carbon or oxygen ions during 1 week preceding the final treatment with conventional radiation in the referring hospital. The rationale behind these approaches is to minimize the high ionization density dose to the normal-tissue stroma outside but sometimes also inside the tumor bed and to ensure a more uniform and optimal biologic effectiveness in the tumor, also on the microscopic scale. The present discussion indicates that BIologically Optimized predictive Assay based light ion Radiation Therapy (Bio-Art) is really the ultimate way to perform high-precision radiation therapy using checkpoints of the integral dose delivery and the tumor response and, based on this information, perform compensating corrections of the dose delivery. By using biologically optimized scanned high-energy photon or ion beams, it is possible to measure in vivo the three-dimensional dose delivery using the same PET-CT camera that was used for diagnosing the tumor spread. This method thus opens up the door for truly three-dimensional biologically optimized adaptive radiation therapy, where the measured dose delivery to the true target tissues can be used to fine-adjust the incoming beams, so that possible errors in the integral therapy process are eliminated toward the end of the treatment. Interestingly enough, practically all major error sources--such as organ motion, treatment planning errors, patient setup errors, and dose delivery problems due to gantry, multileaf, or scanning beam errors--can be corrected for in this way.

RESULTS AND CONCLUSIONS

Radiobiologically optimized dose delivery using intensity and radiation quality modulation based on high-resolution PET-CT or Magnetic Resonance Spectroscopic Imaging (MRSI)-based tumor and normal-tissue imaging is probably the ultimate development of radiation therapy, taking the unique physical and biologic advantages of light ions fully into account in truly patient-individualized curative treatment schedules. Using recently available biologically based treatment ilable biologically based treatment optimization algorithms, it is possible to improve the treatment outcome for advanced tumors by as much as 10-40%. The adaptive radiotherapy process based both on three-dimensional tumor cell survival and dose delivery monitoring has the potential of percent accuracy in tumor response and dose delivery monitoring, using two-dimensional, narrow high-energy photon beam scanning and three-dimensional (11)C Bragg peak scanning for radiation quality and intensity-modulated dose delivery. There is no doubt that the future of radiation therapy is very promising, and gradually more and more patients may not even need advanced surgery. Instead, they could be cured by biologically optimized electron, photon, or light ion therapy, where the densely ionizing Bragg peak is placed solely in the gross tumor, and a lower ionization density is used in microscopically invasive tumor volumes.

Proton beams to replace photon beams in radical dose treatments

With proton beam radiation therapy a smaller volume of normal tissues is irradiated at high dose levels for most anatomic sites than is feasible with any photon technique. This is due to the Laws of Physics, which determine the absorption of energy from photons and protons. In other words, the dose from a photon beam decreases exponentially with depth in the irradiated material. In contrast, protons have a finite range and that range is energy dependent. Accordingly, by appropriate distribution of proton energies, the dose can be uniform across the target and essentially zero deep to the target and the atomic composition of the irradiated material. The dose proximal to the target is lower compared with that in photon techniques, for all except superficial targets This resultant closer approximation of the planning treatment volume (PTV) to the CTV/GTV (grossly evident tumor volume/subclinical tumor extensions) constitutes a clinical gain by definition; i.e. a smaller treatment volume that covers the target three dimensionally for the entirety of each treatment session provides a clinical advantage. Several illustrative clinical dose distributions are presented and the clinical outcome results are reviewed briefly. An important technical advance will be the use of intensity modulated proton radiation therapy, which achieves contouring of the proximal edge of the SOBP (spread out Bragg peak) as well as the distal edge. This technique uses pencil beam scanning. To permit further progressive reductions of the PTV, 4-D treatment planning and delivery is required. The fourth dimension is time, as the position and contours of the tumor and the adjacent critical normal tissues are not constant. A potentially valuable new method for assessing the clinical merits of each of a large number of treatment plans is the evaluation of multidimensional plots of the complication probabilities for each of 'n' critical normal tissues/ structures for a specified tumor control probability. The cost of proton therapy compared with that of very high technology photon therapy is estimated and evaluated. The differential is estimated to be approximately 1.5 provided there were to be no charge for the original facility and that there were sufficient patients for operating on an extended schedule (6-7 days of 14-16 h) with > or = two gantries and one fixed horizontal beam.

Training logbook for radiotherapy

AIM

To develop a structured logbook for trainees in the medical specialty of radiotherapy with Europe that records the increasing experience throughout their training period.

MATERIAL AND METHODS

A working party appointed by the European Board of Radiotherapy developed a draft version of a European logbook for trainees in radiotherapy. For development, the update European Core Curriculum for Radiotherapists (Radiation Oncologists) was taken into consideration. The logbook is composed of six sections: (1) biodata of the trainee, (2) scientific training documentation, (3) clinical training documentation, (4) record of formal presentations by the trainee, (5) publications, (6) training courses. Decisions were made to suggest that the clinical section of the logbook should: (a) only collect data that was essential for the purposes of appraisal, assessment and regulation, (b) be as user friendly as possible, (c) concentrate on quality of the data and not volume. The logbook was tested by trainees in several European training departments and adapted according to their suggestions. A final draft of the logbook was circulated among the national and professional societies for radiotherapy in Europe for review before a European consensus conference took place in Brussels in December 2002.

RESULTS

The European training logbook for radiotherapy was endorsed by representatives of 35 European nations during the Brussels consensus conference on December 14, 2002.

CONCLUSION

Keeping a training logbook is an essential feature of the record of training for all EU trainees who wish to retain an opportunity to spend part of their training time in another country of the Union, important for someone who seeks an appointment as a specialist in another country within a few years of achieving specialist accreditation, and good professional practice for all other trainees. The European training logbook for radiotherapy is a robust instrument that allows the systematic collection of the information that needs to be recorded to monitor the professional development of European trainees in Radiation Oncology.

Guidelines for the infrastructure of training institutes and teaching departments for radiotherapy in Europe

AIM

To develop guidelines for the infrastructure of training institutes and teaching departments for medical specialist training in radiotherapy within Europe.

MATERIAL AND METHODS

Guidelines for teaching departments were developed under consideration of the updated European Core Curriculum for Radiotherapists (Radiation Oncologists) by an expert panel jointly appointed by the European Union of Medical Specialists and the European Society of Therapeutic Radiology and Oncology. The group approached national professional and scientific societies for information on national requirements for teaching departments. Based on this information, a draft document was circulated among the national and professional societies for radiotherapy in Europe for review before a European consensus conference took place in Brussels in December 2002.

RESULTS

The guidelines for the infrastructure of training institutes and teaching departments for medical specialist training in radiotherapy within Europe were endorsed by representatives of 35 European nations during the Brussels consensus conference on December 14, 2002.

CONCLUSION

The infrastructure guidelines represent an important instrument that can be used by teaching departments for comparison of their situation with that of other departments in Europe as a basis for negotiations with authorities on resources provided for training.

Nuclear medicine practice in Japan: A report of the 5th nationwide survey in 2002

The Subcommittee on Survey of Nuclear Medicine Practice in Japan has performed a nationwide survey of nuclear medicine practice every five years since 1982 to provide detailed information on its current status.

METHODS

Questionnaires were sent to every institution known to the Japan Radioisotope Association to provide nuclear medicine examinations. The questionnaires address the number and kind of nuclear medicine examinations performed as well as the kind and dose of the radiopharmaceuticals used during the month of June 2002. The annual number of total or specific examinations was then estimated.

RESULTS

Of the institutions sent questionnaires, 1,204 were for in vivo study, 124 were for in vitro study, and 36 were for positron emission tomography (PET) study. Out of these, 95.8% answered them. A total of 1,697 gamma cameras were installed in 1,160 facilities, of which 50% were dual-head cameras. The estimated total annual number of examinations expressed by the number of administered radiopharmaceuticals was 1.60 million, similar to that of the previous survey (1997). The frequency of study with single photon emission computed tomography (SPECT) increased to 40%, from 30% in the previous survey. The scintigraphy most frequently performed was bone (35%), followed by myocardium (24%) and brain perfusion (12%). All showed a continuous increase over the past 20 years. Tumor imaging, however, fell from third to fourth place. The most commonly used radiopharmaceutical for each scintigraphy was 99mTc-HMDP for bone, 201Tl-chloride for myocardium, 67Ga-citrate for tumor, and 123I-IMP for brain. A total of 29,376 PET studies were performed yearly. Among them, 18F-FDG rapidly increased 3.7-fold. 131I therapy for thyroid cancer and hyperthyroidism was conducted yearly in 1,647 and 3,347 patients, respectively. A total of 31.35 million in vitro radioassays were carried out yearly, the number of which has been decreasing continuously since 1992.

CONCLUSIONS

It was proved that the content of nuclear medicine practice in Japan has changed in the past five years. This report might be useful for understanding the current trends of nuclear medicine practice in Japan.

Updated European core curriculum for radiotherapists (radiation oncologists). Recommended curriculum for the specialist training of medical practitioners in radiotherapy (radiation oncology) within Europe

AIM

To produce updated state-of-the-art recommendations for harmonised medical specialist training in radiotherapy within Europe.

MATERIAL AND METHODS

The Minimum Curriculum for the Theoretical Education in Radiation Oncology in Europe from 1991 was updated under consideration of new developments in medicine in general, and in radiotherapy and its basic sciences in particular. Recent medical developments, national guidelines and training programmes from European countries, as well as equivalent documents from the USA and Australia were reviewed by an expert panel jointly appointed by the European Society of Therapeutic Radiology and Oncology and the European Board of Radiotherapy. A draft document prepared by this group was circulated among the national and professional societies for radiotherapy in Europe for review before a European consensus conference took place in Brussels in December 2002.

RESULTS

The updated European Core Curriculum for Radiotherapists (Radiation Oncologists) was endorsed by representatives of 35 European nations during the Brussels consensus conference on December 14, 2002. Compared to the earlier version the updated document contains specific recommendations not only for the 5 year training curriculum but also for organisatoric and infrastructural aspects of teaching departments, and for supplementation of the training by formal teaching courses.

CONCLUSION

The updated European core curriculum is an important step on the way to fully harmonise medical specialist training in Europe and to guarantee equal access for all European citizens to highest quality medical care. The responsibility for the implementation of the standards and guidelines set in the updated Core Curriculum for radiotherapy (radiation oncology) will lie with the local and/or national training bodies and authorities.

Guidelines for education and training of medical physicists in radiotherapy

PURPOSE

To provide a guideline curriculum covering theoretical and practical aspects of education and training for medical physicists in radiotherapy within Europe.

MATERIAL AND METHODS

Guidelines have been developed for the specialist theoretical knowledge and practical experience required to practice as a medical physicist in radiotherapy. It is assumed that the typical entrant into training will have a good initial degree in the physical sciences, therefore these guidelines also require that and are additional to it. National training programmes of medical physics, radiation physics and radiotherapy physics from a range of European countries and from North America were reviewed by an expert panel set up by the European Society of Therapeutic Radiology and Oncology (ESTRO) and the European Federation of Organisations for Medical Physics (EFOMP). A draft document prepared by this group was circulated, via the EFOMP infrastructure, among national professional medical physics societies in Europe for review and comment and was also discussed in an education session in the May 2003 EFOMP scientific meeting in Eindhoven.

RESULTS

The resulting guideline curriculum for education and training of medical physicists in radiotherapy within Europe discusses the EFOMP terms, qualified medical physicist (QMP) and specialist medical physicist (SMP), and the group's view of the links to the EU (Directive 97/43) term, medical physics expert (MPE). The minimum level expected in each topic in the theoretical knowledge and practical experience sections is intended to bring trainees up to the requirements of a QMP. The responses from the circulation of the document to national societies and its discussion were either to agree its content, with no changes required, or to suggest changes, which were taken into account after consideration by the expert group. Following this the guidelines have been endorsed by the parent organisations.

CONCLUSIONS

This new joint ESTRO/EFOMP European guideline curriculum is a first step to harmonise specialist training of medical physicists in radiotherapy within Europe. It provides a common framework for national medical physics societies to develop or benchmark their own curricula, but is also flexible enough to suit different situations of initial physics qualifications, medical physics training programmes, accreditation structures, etc. The responsibility for the implementation of these standards and guidelines will lie with the national training bodies and authorities.

26th Annual San Antonio Breast Cancer Symposium, San Antonio, Texas, USA, 3-6 December 2003: update on clinical research

The San Antonio Breast Cancer Symposium is an international meeting dedicated to the translation of advances in cellular and molecular biology of breast disease into clinical improvements in prevention, diagnosis and treatment. This report summarizes the clinical highlights of the 26th annual meeting held in San Antonio, Texas on 3–6 December 2003. Breast care for women will be improved by reports concerning optimal adjuvant hormonal therapy, advances in chemotherapy and a shift in the clinical philosophy of breast cancer care from maximum tolerable treatment to minimum effective therapy.

Radiotherapy in Australia one year after the Baume report: vision or mirage?

Radiotherapy should be an integral part of a comprehensive national cancer control plan.

Current status of radiotherapy in Vietnam, 2002

PURPOSE

Resources for radiation therapy in Vietnam were analyzed to obtain an understanding of the current status of radiation oncological practice in Vietnam.

MATERIALS AND METHODS

Data were obtained through a report on the locations of major equipment and personnel.

RESULTS

The availability of both teletherapy and brachytherapy was related to the economic status of the country. Most departments were found to treat patients without simulator or treatment planning systems.

CONCLUSIONS

The information in the report is currently available for radiation oncological practices in Vietnam and provides for planning of development programs on radiation oncology.

Paediatric radiotherapy in Australia and New Zealand: An anachronism in 2003?

This report reviews the activities of the Paediatric Special Interest Group of the Royal Australian and New Zealand College of Radiologists in terms of its involvement with the Australian and New Zealand Children's Cancer Study Group and its research and educational activities. Examples of when and how radiotherapy is currently used in the management of paediatric malignancies are provided. Some thoughts for the future of both paediatric radiotherapy and our subspecialty are also presented.