Attosecond control in photoionization of hydrogen molecules

We report experiments where hydrogen molecules were dissociatively ionized by an attosecond pulse train in the presence of a near-infrared field. Fragment ion yields from distinguishable ionization channels oscillate with a period that is half the optical cycle of the IR field. For molecules aligned parallel to the laser polarization axis, the oscillations are reproduced in two-electron quantum simulations, and can be explained in terms of an interference between ionization pathways that involve different harmonic orders and a laser-induced coupling between the 1sσ(g) and 2pσ(u) states of the molecular ion. This leads to a situation where the ionization probability is sensitive to the instantaneous polarization of the molecule by the IR electric field and demonstrates that we have probed the IR-induced electron dynamics with attosecond pulses.

[Requirements and performance profile of the Paediatric Radiation Oncology Working Group (APRO): evaluation of the present situation and description of future developments]

BACKGROUND

Radiation therapy is an integral component in the management of childhood malignancies and undergoes a continuous process of optimization within the prospective trials of the GPOH. At present there are approximately 20 active protocols, some specifying radio-oncological study questions, in which about 500 to 600 children annually are given radiotherapy.

MATERIALS/METHODS

The Pediatric Radiation Oncology Working Group (APRO) of the German Society for Radiation Oncology (DEGRO) represents the organizational link between GPOH and DEGRO. Their activities range from phrasing guidelines of radio-oncological therapy, through writing a protocol for a prospective study on radiation-induced late effects (RISK--in co-operation with GPOH, 695 patients registered so far) and organizing meetings for information transfer, to implementing radio-oncology within the prospective studies of the GPOH by establishing study chairs for radio-oncology when radio-oncological questions are a primary focus and/or to function as a reference institution for quality assurance. These activities also include individual case consultations outside the study proper. Twice annually the members of the APRO meet for an update on current knowledge and future directions where a representative of the GPOH is invited to contribute special aspects of pediatric oncology.

CONCLUSIONS

In the future, modern technology (intensity modulated radiotherapy, proton therapy, inclusion of imaging in treatment planning) will be part of disease management in pediatric oncology. A working group for modern radiotherapy technology was established to enhance this development. Prospective studies of the GPOH with primary or secondary radio-oncological questions require the implementation of corresponding tasks (documentation, monitoring, etc.) in order to meet future demands on clinical trials and to achieve the aims of the protocol. Consequently adequate financial support is indispensable.

Survival benefit of switching to anastrozole after 2 years’ treatment with tamoxifen versus continued tamoxifen therapy: The ARNO 95 study

547

Background: Initial adjuvant treatment with anastrozole has significant efficacy and tolerability advantages over tamoxifen in postmenopausal women with hormone-sensitive early breast cancer (EBC) (ATAC Trialists’ Group. Lancet 2005; 365: 60–62). The ARNO 95 study evaluated prospectively switching to anastrozole from tamoxifen after 2 years, compared with continuing tamoxifen therapy. Here, we present an interim efficacy and safety analysis. Methods: This was a prospective, randomized, open-label study conducted in 54 centers in Germany. Postmenopausal women (≤75 years) with hormone receptor-positive, invasive EBC, who had received 2 years of adjuvant tamoxifen without recurrence, were randomized to switch to anastrozole (1 mg/day) or continue on tamoxifen (20 or 30 mg/day) for a further 3 years. No adjuvant chemotherapy was given. The primary end point was disease-free survival (DFS; time to earliest occurrence of local or distant recurrence, new primary breast cancer, or death from any cause); secondary end points included overall survival (OS), safety, and tolerability. Data were analyzed using a log-rank test; a second analysis used a Cox proportional hazards model with covariates of age, tumor size, nodal status, grade, and type of surgery. Results: Overall, 979 patients (mean age 60 years; 74% node-negative; 97% hormone receptor-positive) were enrolled, 489 were randomized to switch to anastrozole, with 490 continuing on tamoxifen. Median follow-up was 30.1 months. Switching to anastrozole significantly improved DFS and OS compared with continuing on tamoxifen ( Table ). Fewer patients who switched to anastrozole reported serious adverse events (22.7%) compared with those who remained on tamoxifen (30.8%). Conclusions: Switching endocrine treatment improved DFS and OS in this well-defined population. Postmenopausal women with hormone-sensitive EBC who have already received 2 years’ adjuvant tamoxifen therapy should be switched to anastrozole.

[Table: see text]

[Table: see text]

Modulation of prion protein structural integrity by geldanamycin

The cellular prion protein PrPc is of crucial importance for the development of neurodegenerative diseases called transmissible spongiform encephalopathies. We investigated if the function of members of the HSP90 family is required for the integrity of the normal, nonpathogenic prion protein called PrPc. Eukaryotic cells were treated with the structurally unrelated HSP90-inhibitors geldanamycin (GA) or radicicol (RC). In either case the cellular prion protein was induced and exhibited faster migrating bands on western blot analysis, whereas geldampicin (GE), an analog of GA known not to bind to HSP90, had no effect. Ongoing protein and messenger RNA synthesis during treatment were found to be necessary for the appearance of these bands. Cotreatment with tunicamycin abrogated any effect of HSP90 inhibitors on the cellular prion protein. Finally, enzymatic deglycosylation with peptide:N-glycosidase F of the normal prion protein as well as the variant induced by benzoquinone ansamycins resulted in very similar band patterns. These experiments indicate that either altered glycosylation, or a change in conformation, or both are involved in the induction of faster migrating bands by HSP90 inhibitors. Thus the inhibition of the function of members of the HSP90 family of molecular chaperones results in profound changes in the physicochemical properties of PrPc.

Heat-shock protein 90: potential involvement in the pathogenesis of malignancy and pharmacological intervention

Heat-shock protein 90 (Hsp90) is an essential, cytosolic protein. Its overexpression in a wide variety of malignant tumors makes it a candidate target for pharmacological intervention. The association with Hsp90 stabilizes key regulatory proteins like Fak, Bcr-Abl, ErbB2, mutant p53 and Raf-1. The disruption of these heterocomplexes by Hsp90 inhibitors causes the rapid degradation of Hsp90-client proteins by the proteasome. Benzoquinone ansamycins were the first group of compounds for which interference with Hsp90 function was shown to be the major mechanism of action. They are in the early phase of clinical development. Radicicol and its derivatives are functional analogues of benzoquinone ansamycins without structural similarity. Flavonoids and stresgenin B share the ability to suppress heat-shock protein synthesis. Recently, it became apparent that coumarin antibiotics, cisplatin and paclitaxel also bind to Hsp90. The clinical value of the newly characterized agents with activity towards Hsp90 remains to be determined.

[Metastatic epidural spinal compression: prognostic factors and results of radiotherapy]

BACKGROUND

The metastatic epidural spinal cord compression is an oncologic emergency. Presently, there is no agreement on a standard diagnostic or therapeutic algorithm. In spite of improvement in diagnostic imaging, a great proportion of patients are plegic at the time of the first presentation.

PATIENTS AND METHODS

Therapy charts of 53 consecutive patients--31 male and 22 female--with metastatic epidural spinal cord compression treated with radiation therapy only have been analyzed. Median age was 60 years. The most frequent primary tumors were bronchogenic carcinoma (13 patients), breast cancer (ten patients) and prostate cancer (ten patients).

RESULTS

MRI was the most sensitive diagnostic tool in detecting spinal cord compression. Plain X-ray films were not useful. Pain symptoms were improved in 66% of the patients. The most important prognostic factor was the pretreatment mobility status. 94% of the ambulatory patients kept their walking ability, but only one plegic patient could walk again after radiation therapy (p < 0.001). Patients whose back pain was presented to an oncologist were more likely to keep their walking ability by the end of the therapy. Patients with bronchogenic cancer and plegic patients had a significantly worse survival.

CONCLUSION

Patients with a known malignant tumor and progressive or axial back pain should undergo MRI scan to rule out spinal cord compression. For patients without severe neurologic deficit and MRI proven epidural compression, radiation therapy is able to preserve walking ability and reduce pain. For patients with neurologic symptoms radiation therapy should start within 24 hours.

[Preoperative chemotherapy in primary operable breast cancer with a dose-dense combination of doxorubicin and docetaxel (ADoc) - Experience of the GEPARDO-GABG study group]

OBJECTIVE

The German Adjuvant Breast Cancer Study Group (GABG) conducts trials of preoperative chemotherapy in patients with primary breast cancer using a combination of doxorubicin and docetaxel (ADoc). -

PATIENTS AND METHODS

We conducted a parallel-grouped phase IIa-study with 42 patients with a conventionally dosed and a dose-dense ADoc-schedule (4 cycles of Doxorubicin 50 mg/m(2), Docetaxel 75 mg/m(2) i. v. day 1, q day 15 or 22; G-CSF day 3-15 only for the dose-dense schedule) and a randomized phase IIb-study (GEPARDO-Study) with 250 patients with ADoc +/- Tamoxifen. Biological factors were determined immunohistochemically on 197 core biopsies before treatment. A comparison to a sequential AC-Doc regimen including 913 patients has been completed recently. -

RESULTS

ADoc can be applicated on schedule in 93 % of all patients. The dose-dense regimen shows a tendency to more toxicity but also to more efficacy. The rate of complete pathological remissions (pCR) was 9.7 %. No difference was found between chemo- and chemoendocrine treatment. Clinically negative lymphnodes and a negative estrogen receptor status is predictive for a higher pCR-rate. To date no differences in toxicity could be found between ADoc and AC-Doc. -

CONCLUSIONS

The dose-dense ADoc regimen is well tolerated and highly effective as preoperative therapy of breast cancer.

Dose-dense doxorubicin, docetaxel, and granulocyte colony-stimulating factor support with or without tamoxifen as preoperative therapy in patients with operable carcinoma of the breast: a randomized, controlled, open phase IIb study

PURPOSE

To investigate the effect of adding tamoxifen to a preoperative dose-dense doxorubicin and docetaxel regimen on the pathologic response of primary operable breast cancer.

PATIENTS AND METHODS

Patients (tumor size > or = 3 cm, N0 to 2, M0) were prospectively randomized to receive every 14 days a total of four cycles of doxorubicin 50 mg/m2 and docetaxel 75 mg/m(2), either with (ADocT) or without (ADoc) simultaneous tamoxifen. Granulocyte colony-stimulating factor (G-CSF) was routinely given on days 5 to 10. Surgery followed 8 to 10 weeks after the start of treatment.

RESULTS

Within 14 months, 250 patients were included in the study at 56 centers. Of 992 planned cycles, 97.9% were administered. Pathologically complete remission (pCR) with no detectable viable tumor cells was achieved in 9.7%. There was a nonsignificant difference of -1.2% in favor of ADoc, with a 95% confidence interval of -8.6% to 6.2%. A further 2.4% had only noninvasive tumor residues, and 13.8% had focal invasive residues. Complete and partial responses detected by palpation were observed in 28.9% and 52.4%, respectively. The response rates (complete and partial) by best appropriate imaging methods were 77.5% and 67.5% for ADocT and ADoc, respectively. Breast conservation was possible in 68.8% of the patients. A tendency toward more frequent toxic events was observed with ADocT treatment. Significant predictors of pCR to chemotherapy were negative lymph node and negative estrogen receptor status.

CONCLUSION

A dose-dense regimen of ADoc with G-CSF offers high compliance, moderate toxicity, and rapid efficacy as a form of preoperative chemotherapy in operable breast cancer. Concurrent treatment with tamoxifen for 8 weeks could not improve the pathologic response rate.

[Coping in patients with malignant glioma in the course of radiation therapy]

Twenty-one patients with malignant glioma were interviewed in the course of radiation therapy (before start, in the middle and at the end of treatment and six weeks later). We used the "Freiburger Fragebogen zur Krankheitsverarbeitung (FKV)", an assessment of coping strategies, the "State-Trait-Anxiety-Inventory (STAI)", the "Beck-Depression-Scale (BDI)", and the QLQ-C 30 questionnaire of the EORTC.

RESULTS

The coping strategies of our patients are comparable with other cancer patients. They are mainly characterized by "self-encouragement", "compliance" and "trust in the treating physician". Anxiety was low and showed no significant changes. Depressivity was higher than in the normal population, however, it also showed no significant changes in the course of therapy. Quality of life scores remained constant, despite an increase of fatigue. In our patients with malignant glioma, the influence of radiation on coping, anxiety, depression and quality of life seems insignificant in comparison to that of the diagnosis of cancer.

Radiation therapy for benign diseases: patterns of care study in Germany

BACKGROUND

Radiotherapy of benign diseases is controversial and rarely applied in Anglo-American countries, whereas in other parts of the world it is commonly practiced for several benign disorders. Similar to a European survey, a patterns of care study was conducted in Germany.

METHOD

Using a mailed questionnaire, radiation equipment, treatment indication, number of patients, and treatment concepts were assessed in 1994, 1995, and 1996 in 134 of 152 German institutions (88%): 22 in East and 112 in West Germany; 30 in university hospitals and 104 in community hospitals. Average numbers of each institution and of all institutions were analyzed for frequencies and ratios between regions and among institutions. Radiation treatment concepts were analyzed.

RESULTS

A mean of 2 (range 1-7) megavoltage and 1.4 (range 0-4) orthovoltage units were available per institution; 32 institutions (24%) had no orthovoltage equipment. A mean of 20,082 patients were treated annually: 456 (2%) for inflammatory diseases (221 hidradenitis, 78 local infection, 23 parotitis; 134 not specified) 12,600 (63%) for degenerative diseases (2711 peritendinitis humeroscapularis, 1555 epicondylitis humeri; 1382 plantar/dorsal heel spur; 2434 degenerative osteoarthritis; 4518 not specified); 927 (5%) for hyperproliferative diseases (146 Dupuytren's contracture, 382 keloids; 155 Peyronie's disease; 244 not specified); 1210 (6%) for functional disorders (853 Graves' orbitopathy; 357 not specified); and 4889 (24%) for other disorders (e.g., 3680 heterotopic ossification prophylaxis). In univariate analysis, there were geographic (West vs. East Germany) differences in using radiation therapy (RT) for inflammatory and degenerative disorders, and institutional differences (university versus community hospitals) in using RT for hyperproliferative and functional disorders (p < 0.05). The prescribed dose concepts were mostly in the low dose range, <10 Gy but varied widely and inconsistently within geographic regions and institutions.

CONCLUSION

Radiation therapy is a well-accepted and frequently practiced treatment for several benign diseases in Germany; however, there are significant geographic and institutional differences. As the number of orthovoltage units decreases, an increasing patient load will demand more megavoltage units, which may compromise the cost-effectiveness of this treatment. Only 4% of all clinical institutions have been involved in controlled clinical trials. To maintain a high level of RT service to other disciplines, RT treatment guidelines, quality control, and continuing medical education are required.

[Radiotherapy of benign diseases: a pattern of care study in Germany]

BACKGROUND

Radiation therapy of benign diseases is controversially discussed and rarely applied in Anglo-American countries, while in other parts of the world, especially Central and East Europe, it is commonly practised for several benign disorders. Similar to the European Society of Therapeutic Radiology and Oncology survey, a patterns of care study was performed in Germany.

METHOD

A questionnaire was mailed in 3 years (1994, 1995, 1996) to all radiation facilities in Germany, which assessed equipment, indications, number of patients and treatment concepts. A total of 134 (88%) institutions returned all requested data: 22 in East and 112 in West Germany; 30 in university and 104 in community/private hospitals. The average data of each institution and of all institutions were analyzed for frequencies and ratios between different regions and institutions.

RESULTS

A mean of 2 (range 1 to 7) megavoltage (Linac/Cobalt 60) and 1.4 (range 0 to 4) orthovoltage units were available per institution; 32 (24%) institutions had no orthovoltage equipment. A mean of 20,082 patients were treated per year: 456 (2%) for inflammatory diseases (221 hidradenitis, 78 nail bed infection, 23 parotitis, 134 not specified), 12,600 (63%) for degenerative diseases (2,711 peritendinitis humeroscapularis, 1,555 epicondylitis humeri, 1,382 heel spur, 2,434 degenerative osteoarthritis, 4,518 not specified), 927 (5%) for hypertrophic diseases (146 Dupuytren's contracture, 382 keloids, 155 Peyronie's disease, 244 not specified), 1,210 (6%) for functional disorders (853 Graves' orbitopathy, 357 not specified), and 4,889 (24%) for other disorders (e.g. 3,680 heterotopic ossification prophylaxis). In univariate analysis, there were significant geographical (West vs East Germany) differences in the use of radiotherapy for inflammatory and degenerative disorders and institutional differences (university vs community/private hospitals) in the use of radiotherapy for hypertrophic and functional disorders (p < 0.05). The prescribed dose concepts were mostly in the low dose range (< 10 Gy), but varied widely and inconsistently within geographic regions and institution types.

CONCLUSION

Radiotherapy is a well accepted and frequently practised treatment for several benign diseases in Germany, however, there are significant geographical and institutional differences. As the number of orthovoltage units decreases, an increasing patient load is in demand of more megavoltage units, which may compromise the cost-effectiveness of this treatment. Only 4% of all clinical institutions are involved in controlled clinical trials. To maintain a high level of radiotherapy service to other disciplines, radiotherapy treatment guidelines, quality control and continuing medical education are required.

Management of cerebral metastases from malignant melanoma: results of a combined, simultaneous treatment with fotemustine and irradiation

We report results of a conservative treatment for brain metastases from malignant melanoma with a combination of irradiation and chemotherapy (fotemustine and/or DTIC). To date, 12 patients have been treated. There was a complete remission of the brain metastases in four patients. In two patients a partial remission was observed. The mean survival of the responder was 8.2 months (95% confidence interval 3.8-12.6 months). The most common side effects were thrombocytopenia, leukopenia, and alopecia. Altogether, the treatment was well tolerated. As the outcome of patients with brain metastases from malignant melanoma is generally poor, this combined chemo- and radiation therapy may provide improved care for such patients.

The role of docetaxel (Taxotere) in neoadjuvant chemotherapy of breast cancer

Neoadjuvant chemotherapy has become standard therapy in the management of breast cancer patients with locally advanced disease with inoperable tumors and inflammatory breast cancer. Patients with earlier stage breast cancer and operable tumors may also benefit from treatment with neoadjuvant chemotherapy. Docetaxel (Taxotere; Rhône-Poulenc Rorer, Collegeville, PA) is thought to be one of the most potent agents in the treatment of metastatic breast cancer and is therefore being investigated for its likely benefit in preoperative, neoadjuvant regimens. Several large phase II and randomized phase III trials are evaluating docetaxel as a single agent, in combination, and/or sequentially in the preoperative setting. Preliminary findings demonstrate high complete and partial response rates and a tolerable toxicity profile. These results are consistent with the view that incorporation of docetaxel in neoadjuvant chemotherapy regimens will contribute to improved patient outcome. Ongoing studies will provide important information regarding the most appropriate regimens and schedules of docetaxel to use in the preoperative, neoadjuvant setting.

[Use of G-CSF (Neupogen) in multimodal treatment in radiotherapy]

BACKGROUND

Therapy-induced leukopenias with corresponding consequences repeatedly occur in radiotherapy using combined modalities treatment. In radiotherapy, where G-CSF (granulocyte-colony-stimulating-factor) is not licensed, G-CSF has been used successfully under individual circumstances. These results were confirmed in several studies with small patient groups. The aim of this study was to check former results in a larger patient group, to verify postulated side effects and specially to define a cost-effective schedule in the treatment with G-CSF (Neupogen).

PATIENTS AND METHODS

In this surveillance trial 50, partially previously treated patients with different malignant tumors were treated with G-CSF. According to the probability of a leucocytosis lower than 1000/mm3, G-CSF (Neuropogen) was already given at leukocyte values lower than 2500/mm3 (500/mm3 bis 2450/mm3). It administered subcutaneously every other day, based on body weight until reaching normal leucocyte levels.

RESULTS

In 92% of the patients the increase of leucocytes occurred in the first 24 hours. On average G-CSF was given 4.9 times per patient. Patients without prior therapies or less complex therapies needed less G-CSF applications (3.5 to 5.8 applications). Due to individually varying leucocyte courses the G-CSF therapy was started with leucocyte values between 500/mm3 and 2450/mm3. Patients who were treated with up to 3 G-CSF applications had higher leucocyte levels than those with 4 or more applications (1620/mm3 to 1250/mm3). Leucopenia related infections, therapy interruptions or break-offs did not occur. Besides light "flu like" symptoms in 14% of the patients, no side effects were observed.

CONCLUSIONS

When a decrease of leucocyte values lower than 1000/mm3 is expected, the most cost-effective treatment is given when starting the interventional G-CSF administration already at leucocyte values around 1600/mm3. Leucopenias can be treated effectively, with little side effects and in a cost-effective way when G-CSF is given on time.

Using an artificial neural network to define the planning target volume in radiotherapy

A neural network for predicting the planning target volume in radiotherapy from the shape of the detected tumor is designed and tested in this research project. The proposed neural network is able to generalize expert medical knowledge and predict the planning target volume from a three-dimensional image of the detected tumor. Initial results for simple shaped brain tumors are presented in this paper.

Nasopharyngeal carcinoma in childhood and adolescence: concept and preliminary results of the cooperative GPOH study NPC-91. Gesellschaft für Pädiatrische Onkologie und Hämatologie

BACKGROUND

The increasing use of chemotherapy has improved the prognosis of patients with nasopharyngeal carcinoma (NPC), and the authors demonstrated the beneficial effect of adjuvant interferon (IFN)-beta in a previous pilot study of children with advanced stage NPC. The current multi-institutional, cooperative GPOH (Gesellschaft für Pädiatrische Onkologie und Hämatologie) study NPC-91 was begun in 1992 to determine the efficacy of preradiation chemotherapy, radiotherapy, and adjuvant IFN-beta, in the treatment of advanced stage NPC.

METHODS

Of a total of 22 patients, 21 had American Joint Committee on Cancer Stage III or IV disease, and 1 had Stage II disease. The median age was 12 years (range, 8-16 years). Twenty of 22 received 3 courses of preradiation chemotherapy consisting of methotrexate 120 mg/m2 on Day 1, cisplatin 100 mg/m2 on Day 1, and 5-fluorouracil 1000 mg/m2 for five days as well as 6 doses of leucovorin 25 mg/m2 every six hours beginning on Day 2. The Stage II patient received no chemotherapy, and chemotherapy was terminated for another during the first course. All patients had radiation therapy, stratified by stage. The cumulative dose to the primary sites was 59.4 gray (Gy), with single doses of 1.8 Gy. A total of 45 Gy was delivered to the neck area. Finally, all patients were treated with recombinant IFN-beta (10(5) U per kg of body weight) 3 times a week for 6 months.

RESULTS

The response rate was 91%. These patients stayed in first remission during a median follow-up of 32 months. With the exception of one reversible cardiotoxicity, moderate chemotherapy-related toxicity was observed.

CONCLUSIONS

In this study, patients with advanced stage NPC had a good prognosis with treatment consisting of neoadjuvant cisplatin and 5-fluorouracil, radiotherapy, and adjuvant IFN-beta. It is particularly noteworthy that distant metastases did not develop.

[Spectrographic studies on the radioresistance of Miltex and miltefosine]

AIM

With simultaneous application of Miltex and radiation therapy in the combined treatment of topical relapses and skin metastases in breast carcinoma patients the question arises, how radioresistant is the new cytotoxic agent. Because of the long penetration times of the active agent miltefosine the answer is important with particular regard to the time of the external application of Miltex.

MATERIAL AND METHOD

After the application of a single dose of 10 Gy we studied the stability of the commercial preparation and its active agent miltefosine by means of absorption spectroscopy.

RESULTS

Immediately following the irradiation no alterations in absorption spectra of Miltex and miltefosine were found. However, 2 and 8 h post radiation the absorption curves of Miltex and miltefosine solutions were distinctly changed. The radiation induced changes of Miltex dilutions were smaller than those of the miltefosine solutions. For the commercial preparation the amount of the radiation-induced destruction is 0.10.

CONCLUSIONS

Consequently Miltex has shown a sufficient radioresistance or its decrease in the effectiveness is small. With daily single doses of 2 Gy in the radiotherapy of the topical relapses and skin metastases the destruction degree should be reduced to 0.02 assuming linear changes. Because of the distinct changes in the spectra and relative slow penetration of miltefosine in various cell lines [10, 11, 14] we will propose an application of the commercial cytotoxic agent 5 h before the radiation fractions. The smaller effect on Miltex is discussed in relation to the solution mediators of the active agent.

[Radiotherapy of regional lymph nodes compared to retroperitoneal lymphadenectomy in the treatment of seminomas. Retrospective analysis of 161 patients]

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.

[The initial results in the fractionated 3-dimensional stereotactic irradiation of clivus chordomas]

BACKGROUND

The purpose of this study is to determine the impact of fractionated three-dimensional stereotactic radiotherapy on local tumor control and radiation induced side effects in patients with spheno-occipital chordoma.

PATIENTS, MATERIAL AND METHODS

13 patients with chordoma of the clivus (8 female, 5 male, median age at radiotherapy 42 years) were treated with a three-dimensional non-coplanar stereotactic irradiation technique using 15 MeV-photons. Median dose applied was 70 Gy. Irradiation was performed in 2 patients after biopsy and in 11 patients after resection of chordoma (2 R1-resections and 9 R2-resections).

RESULTS

After a median follow-up period of 32 months (4 to 80 months) 12 patients are alive (92%). One patient died 4 months after radiotherapy due to tumor progression. Three of the surviving patients developed local recurrence. Until now local tumor control is 69%. In two patients who had macroscopic tumor after surgery a complete regression occurred (verified by CT and MRI respectively). Early radiation complications were moderate, only headache and dizziness were observed. Also late radiation complications were low. Only one patient developed an endocrine dysfunction due to pituitary injury. Ongoing hormone replacement was necessary in this case. No patient developed sequelae of the optic system, cranial nerves or brain stem.

CONCLUSION

With regard to local tumor control our results are in the more favorable range compared to the results obtained with conventional photon irradiation techniques. In spite of the high doses applied both early and late radiation complications were in an acceptable range. Further adequate follow-up must prove, whether these promising results will be corroborated in the future.

[Three-dimensional planned radiotherapy in rectal cancer. Feasibility study and preliminary clinical results]

PURPOSE

Since 1991 the use of three-dimensional planned radiation therapy for rectal cancer was evaluated as a part of a clinical project funded by the Deutsche Krebshilfe at the Radiological Department of the University of Heidelberg. First clinical experiences are reported.

PATIENTS AND METHODS

32 patients who were irradiated loco-regional for rectal cancer were analysed retrospectively. Radiation therapy techniques: patient's position was prone by the use of a belly board. Three-dimensional treatment (3D) planning system was voxelplan. The radiation therapy was started using a 3-field-box technique modified by 3D-technique after 22 to 42 Gy, depending on therapeutic concept.

RESULTS

On average 92% of the planning target volume were encompassed with the 80% isodose. The average maximum dose was 108% (isocenter = 100%), of the small bowel volume received less than 34% of the dose, 70% of the bladder volume less than 40% respectively. Total average dose was 52.4% Gy. Irregular fields were used in all patients, a non-coplanar field was used to optimize dose-distribution in 41% of the patients, 21 patients received chemotherapy simultaneously. Acute side effects according to gastrointestinal tract reached grade 1 (WHO) in 9 patients, grade 2 in 2 patients. Side effects according to bladder reached grade 1 in 5 patients grade 2 in 1 patient respectively. In 4 patients suffered from acute side effects concerning the bladder. In one patient acute side effects grade 1 concerning gastrointestinal tract was observed. Portal films were analysed to evaluate precision of radiation therapy. On average the error was 3.1/4.5/4.0 mm in the x/y/z direction respectively. The standard deviation was 4.4/6.8/6.3 mm for x/y/z respectively. A median time of 2 hours was necessary for all planning procedures.

CONCLUSIONS

Three-dimensional treatment planning optimizes dose-distribution in a relevant number of patients. Its clinical use for treatment of large targets or in order to applicate high doses is justified. Planning target volume should cover the clinical target volume with a margin of 1.5 cm.

[Radiotherapy of prostatic cancer]

In most cases, surgery and radiotherapy are used for primary local treatment of prostate carcinoma. The treatment decision depends to varying extents on the involvement of the two clinical fields urology and radio-oncology. Radiotherapy seems to have more weight in the treatment of prostate carcinoma in the USA than in Germany, albeit with local differences. For the early stages prospective observation of the tumour is recommended. Surgery, as far as possible nerve conserving procedures, is indicated for localized tumours with no infiltration of the capsule or seminal vesicles. This does not mean that the clinical results after radiotherapy are worse in these patients. With both treatment modalities the survival data are comparable with those in a healthy population. Surgery is limited to the exploration of the pelvic lymph nodes in the stages C and D1. Radiotherapy has been shown to be effective in these tumours, but is still not satisfactory, with a relapse rate of ca. 30% for stage C after 10 years. This means new research and developments are necessary in conformation radiotherapy, neutron therapy, brachytherapy and hyperthermia. Side-effects after radiotherapy are rare, with late complications in only a low percentage of patients. Recurrences after radical prostatectomy can be followed for at least 5 years without evidence of disease. Radiotherapy has a good palliative effect in bone and brain metastases.

Stereotactically guided fractionated radiotherapy: technical aspects

A system for high precision radiotherapy in the head and neck region has been developed. The components of the system are a head mask connected to a stereotactic frame, a localization unit that can be used during CT- and MR-imaging and a stereotactic target positioner. Conformal precision radiotherapy is planned with a new treatment planning system (Voxelplan-Heidelberg). Three different multi-leaf collimator systems are used. An evaluation of the precision and accuracy of the head fixation system, which was performed with a photogrammetry system, is presented.

Fractionated stereotactically guided radiotherapy of head and neck tumors: a report on clinical use of a new system in 195 cases

Between November 1988 and December 1992, 195 patients with tumors of the head and neck (low grade gliomas, meningiomas, neurinomas, chordomas and miscellaneous) were treated with a newly developed stereotactical system for fractionated, conformal, high-precision radiotherapy. The overall preparation time, including head mask production for fixation, CT, MRI, 3-D treatment planning and stereotactical localisation could be reduced to 4-5 h per patient. The use of MR in the target definition was increased to a mean of about 60%. The medial follow-up time is 22 months. Three different patient groups were selected according to pretreatment. Patients with full high-precision radiotherapy survived in 95% of cases, patients with boost treatment in 86% and patients with preirradiated recurrent disease in 64%. Meningiomas as the largest histology group (n = 62) showed partial response in 27% and complete response in 10% of cases. Progression occurred in two patients. All patients are alive. Acute side-effects were minimal and of the order of 10%, no late complications occurred despite tumor doses ranging up to 72 Gy. High-precision radiotherapy as it is performed in Heidelberg can be regarded as an effective, reliable and tolerable system for selected tumors of the head and neck.

Cure in a patient with multiple osseus metastases in non-small cell lung cancer: a case report

PURPOSE

This case was reported to describe a case of cure in a 61-year old patient with squamous cell lung cancer and multiple extrathoracic metastasis.

METHODS AND MATERIALS

A left upper lobectomy of lung for a squamous cell carcinoma was performed on a 61-year old man with curative intent. Four months later two osseus metastases were irradiated with Cobalt 60 up to 40 Gy.

RESULTS

The two irradiated lesions showed continuously shrinkage as well as signs of recalcification. Eleven years later the patient shows clinically absolute well being and on CT there are no signs of recurrent disease of the lung or bone anymore.

DISCUSSION

To our knowledge has nobody so far reported of a case of as squamous cell lung cancer which was operated and irradiated on thus resulting in cure. Further on the authors discuss that it might well be worthwhile to define subgroups in stage 4 non-small cell lung cancer (presence of extrathoracic metastases) which might benefit from a more aggressive treatment approach than pure palliation.

Renal tolerance to nonhomogenous irradiation: comparison of observed effects to predictions of normal tissue complication probability from different biophysical models

PURPOSE

A patient series was analyzed retrospectively as an example of whole organ kidney irradiation with an inhomogenous dose distribution to test the validity of biophysical models predicting normal tissue tolerance to radiotherapy.

METHODS AND MATERIAL

From 1969 to 1984, 142 patients with seminoma were irradiated to the paraaortic region using predominantly rotational techniques which led to variable but partly substantial exposure of the kidneys. Median follow up was 8.2 (2.1-21) years and actuarial 10-year survival (Kaplan-Meier estimate) 82.8%. For all patients 3-dimensional dose distributions were reconstructed and normal tissue complication probabilities for the kidneys were generated from the individual dose volume histograms. To this respect different published biophysical algorithms had been introduced in a 3-dimensional-treatment planning system.

RESULTS

In seven patients clinical manifest renal impairment was observed (interval 10-84 months). An excellent agreement between predicted and observed effects was seen for two volume-oriented models, whereas complications were overestimated by an algorithm based on critical element assumptions.

CONCLUSIONS

Should these observations be confirmed and extended to different types of organs corresponding algorithms could easily be integrated into 3-dimensional-treatment planning programs and be used for comparing and judging different plans on a more biologically oriented basis.

[The value of radiotherapy for liver metastases]

The role of palliative irradiation was analysed in 55 patients with liver metastases from colorectal (n = 35), breast (n = 10) and lung cancer (n = 10), treated between January 1982 and June 1992 with irradiation doses more than 10 Gy. In 47 patients irradiation alone was done. The great majority of patients were treated because of pain (n = 21) or cholestasis (n = 22). In 29 patients the disease involved not only the liver, but was disseminated. A mean dose of 23.8 Gy was delivered, with daily fractions of 1.5 (n = 30), 1.8 (n = 1) or 2 Gy (n = 16). Complete and near complete pain relief was obtained in six (28.6%) and nine (42.9%) patients. Normalized and near normalized values of bilirubin serum levels were obtained in five (22.7%) and seven (31.9%) patients. As well relief of pain as normalisation of cholestasis were significantly correlated with the irradiation doses applied. Median survival was 36.5 days for patients with lung cancer, 70.5 and 73 days for patients with breast and colorectal cancer. Irradiation doses given (10 to 18 Gy vs. 19 to 28 Gy vs. 29 to 48 Gy) and the status of disease (liver only vs. disseminated) were significantly correlated to prognosis (p = 0.00001, p = 0.0007). Patients of the high-dose group or patients with liver metastases alone revealed a median survival of 174 or 175 days. Since May 1991 simultaneous radio-chemotherapy, with the systemic application of leukovorine and 5-FU, was performed in eight patients with colorectal cancer. After performing a three-dimensional radiotherapy planning, which enclosed the whole liver inside the target volume, a mean dose of 29.4 Gy, with daily single fractions of 1.5 Gy was delivered. The follow-up, done with CT or NMR revealed in seven patients a progression free interval of three to 8.5 (5.5) months. After a median follow-up of 221 days the median survival was 333 days. In the treatment of patients with liver metastases a clear therapeutic selection has to be done according to valid prognostic criteria. In the majority of our patients with clinical symptoms, i.e. pain or cholestasis, irradiation alone was sufficient for palliation of these symptoms. Prognosis is limited because of the disseminated state of disease in 62% of the patients. In a group of patients, suffering from colorectal cancer with good prognostic criteria, the simultaneous application of radiotherapy and systemic chemotherapy was able to increase significantly the survival with minor toxicity.(ABSTRACT TRUNCATED AT 400 WORDS)

[Three-dimensional radiation planning. Studies on clinical integration]

The routine use of three-dimensional treatment planning was evaluated in a clinical project funded by the German Krebshilfe at the Radiological Department of the University of Heidelberg. 166 patients entered the prospective study within 14 months, 155 of them were treated according to the 3D-plans. More than 50% of the patients had thoracic tumors, followed by pelvic tumors. One medicine physicist and one specially trained technician performed the treatment planning. The target volumes were contoured in the CT slices at the planning computer by the responsible radiotherapists. A mean of 6.5 hours per patient was necessary for all planning procedures, however, this time consumption shows a trend toward less time of only four hours including about ten optimization steps. Meanwhile approximately 20 to 30% of all computer assisted planning are performed in 3D, corresponding to about one plan per day. The achieved time consumption is a clinically accepted quantity, that allows the introduction of 3D-planning into clinical routine.

Radiotherapy treatment planning of basal meningiomas: improved tumor localization by correlation of CT and MR imaging data

A localization technique, based on three-dimensional CT and MR imaging data for precision radiotherapy of basal meningiomas, is presented. Indications for radiotherapy included unresected tumors, gross disease remaining despite surgery, and recurrences. The patient's head was fixed in a stereotactic localization system which is usable at the CT, MR and the linear accelerator installations. The geometrical distortion of MR imaging data was evaluated in three dimensions by phantom measurements. The geometrical distortion was "corrected" (reducing displacements to the size of a pixel) by calculations based on modelling the distortion as a fourth order two-dimensional polynomial. The target volume was defined in three-dimensional MR imaging data after application of 0.1 mmol/kg b.w. Gd-DTPA solution and transferred precisely from MR onto CT data to provide a map of the radiation attenuation coefficient for dose calculation. The superior soft tissue contrast of MR showed an excellent tumor delineation especially when the bony base of the skull obscured the target in CT images. Target volume, calculated dose distribution, and critical structures could be transferred between CT and MR imaging data and displayed as three-dimensional shaded structures for better assessment for matching of target volume and dose distribution. With the described planning system a more precise target definition of basal meningiomas was possible by integration of the superior tumor delineation in MR compared with CT.

Use of MR angiography for stereotactic planning

With the introduction of MR angiography (MRA) into clinical routine MR protocols, it has become possible now to image flowing as well as stationary tissue with excellent contrast using a single modality. This has opened up new perspectives for planning stereotactic approaches, which are characterized by high risks for damaging intracerebral vessels or vital brain structures. In this article we present an MRA based planning method for the treatment of arteriovenous malformations by stereotactic radiosurgery. It includes flow compensated gradient echo pulse sequences for the acquisition of angiographic MR datasets, a stereotactic MR marker system, an algorithm for the correction of geometric distortion of MR image data, and a three-dimensional workstation system for the creation and evaluation of treatment plans. The latter is based on the concept of simultaneously displaying both MR slice and angiographic projection images. This allows the evaluation of intracerebral vasculature together with brain anatomy. The MRA guided planning approach was tested and compared to a conventional X-ray angiographic technique in a clinical study. Our satisfactory results suggest that MRA is a technique that can be used advantageously for stereotactic planning.

Computer systems and mechanical tools for stereotactically guided conformation therapy with linear accelerators

An integrated system for fractionated, stereotactically guided conformation radiotherapy has been developed. The system components are a stereotactic fixation system that can be used each treatment day, a localization, and positioning unit that can be used during x-ray computer tomography, magnetic resonance imaging, positron emission tomography, and radiographical examinations as well as for treatment. Conformal precision radiotherapy is planned with a new three-dimensional treatment planning system (Voxel-Plan-Heidelberg) which comprises, among others options, a three-dimensional image correlation procedure as well as routines for the calculation of coplanar and non-coplanar irradiations with irregularly shaped fields. Two different multi-leaf collimators have been designed for precision radiotherapy in the head and neck region. A manual multi-leaf collimator is used for irradiations with stationary beams or for moving beam treatments with invariable irregularly shaped fields. This collimator system is now being used for patient treatments. The design of a computer controlled multi-leaf collimator unit for multiple fixed field irradiation techniques is discussed. All system components are aimed at conforming dose distributions for fractionated radiotherapy treatments to the target to improve sparing of adjacent normal tissues, and at achieving a sufficient geometrical accuracy in the dose application.

Charged particle therapy to pediatric tumors of the retroperitoneal region: a possible indication

Despite a very successful interdisciplinary therapy regimen for pediatric solid tumors dominated by surgery and chemotherapy, the role of radiotherapy might become again more important if new techniques will allow a better dose localization to the target volume combined with a better protection of the normal tissue. This characteristic is known for charged particle beams. In a field study based on German cooperative trials, the possibility of a charged particle radiotherapy to retroperitoneal tumors of childhood will be discussed regarding indications in risk groups and recurrences. Absolute patient numbers are estimated from the clinical experiences and the incidences of the diseases. A stepwise introduction of this new therapy modality is proposed.

[Aspergillosis of the central nervous system in glioblastoma multiforme]

A 45 year-old male with a butterfly glioma received stereotactic biopsy for histologic confirmation of the clinical diagnosis. Microscopically, the results were controversial since some biopsy specimens showed distinct inflammatory changes, while others displayed typical features of a malignant glioma. The patient died four days after the stereotactic approach due to therapy-resistant intracranial pressure rise. In addition to a large butterfly glioblastoma originating from the frontal part of the corpus callosum, neuropathologic examination revealed a mycotic encephalitis with formation of numerous fungi-containing inflammatory foci in all parts of the brain and in the glioma. General autopsy disclosed pulmonary aspergillosis as the source of the inflammatory spread. A previous steroid medication over several weeks for treatment of increased intracranial pressure may be considered as an important factor in the origin of the pulmonary aspergillosis complicating the butterfly glioma.