Functional brain imaging in survivors of critical illness: A prospective feasibility study and exploration of the association between delirium and brain activation patterns

PURPOSE

We undertook this pilot prospective cohort investigation to examine the feasibility of functional magnetic resonance imaging (fMRI) assessments in survivors of critical illness and to analyze potential associations between delirium and brain activation patterns observed during a working memory task (N-back) at hospital discharge and 3-month follow-up.

MATERIALS AND METHODS

At hospital discharge and 3 months later, fMRI assessed subjects' functional activity during an N-back task. Multiple linear regression was used to examine associations between duration of delirium and brain activity, and elastic net regression was used to assess the relationship between brain activation patterns at 3 months and cognitive outcomes at 12 months.

RESULTS

Of 47 patients who underwent fMRI at discharge, 38 (80%) completed the protocol; of 37 who underwent fMRI at 3 months, 34 (91%) completed the protocol. At discharge, the mean (SD) percentage of correct responses on the most challenging version (the N2 version) of the N-back task was 70.4 (23.2; range of 20-100) compared with 76 (23.4; range of 33-100) at 3 months. No association was observed between delirium duration in the hospital and brain region activity in any brain region at discharge or 3 months after adjusting for relevant covariates (P values across all 11 brain regions of interest were >.25).

CONCLUSIONS

Our data support the feasibility of using fMRI in survivors of critical illness at 3-month follow-up but not at discharge. In this small study, delirium was not associated with distinct or abnormal brain activation patterns, although overall performance on a cognitive task of working memory was poorer than observed in other cohorts of individuals with medically related executive dysfunction, mild cognitive impairment, and mild traumatic brain injury.

Neural and cortisol responses during play with human and computer partners in children with autism

Children with autism spectrum disorder (ASD) exhibit impairment in reciprocal social interactions, including play, which can manifest as failure to show social preference or discrimination between social and nonsocial stimuli. To explore mechanisms underlying these deficits, we collected salivary cortisol from 42 children 8-12 years with ASD or typical development during a playground interaction with a confederate child. Participants underwent functional MRI during a prisoner's dilemma game requiring cooperation or defection with a human (confederate) or computer partner. Search region of interest analyses were based on previous research (e.g. insula, amygdala, temporal parietal junction-TPJ). There were significant group differences in neural activation based on partner and response pattern. When playing with a human partner, children with ASD showed limited engagement of a social salience brain circuit during defection. Reduced insula activation during defection in the ASD children relative to TD children, regardless of partner type, was also a prominent finding. Insula and TPJ BOLD during defection was also associated with stress responsivity and behavior in the ASD group under playground conditions. Children with ASD engage social salience networks less than TD children during conditions of social salience, supporting a fundamental disturbance of social engagement.

Early behavioral intervention is associated with normalized brain activity in young children with autism

OBJECTIVE

A previously published randomized clinical trial indicated that a developmental behavioral intervention, the Early Start Denver Model (ESDM), resulted in gains in IQ, language, and adaptive behavior of children with autism spectrum disorder. This report describes a secondary outcome measurement from this trial, EEG activity.

METHOD

Forty-eight 18- to 30-month-old children with autism spectrum disorder were randomized to receive the ESDM or referral to community intervention for 2 years. After the intervention (age 48 to 77 months), EEG activity (event-related potentials and spectral power) was measured during the presentation of faces versus objects. Age-matched typical children were also assessed.

RESULTS

The ESDM group exhibited greater improvements in autism symptoms, IQ, language, and adaptive and social behaviors than the community intervention group. The ESDM group and typical children showed a shorter Nc latency and increased cortical activation (decreased α power and increased θ power) when viewing faces, whereas the community intervention group showed the opposite pattern (shorter latency event-related potential [ERP] and greater cortical activation when viewing objects). Greater cortical activation while viewing faces was associated with improved social behavior.

CONCLUSIONS

This was the first trial to demonstrate that early behavioral intervention is associated with normalized patterns of brain activity, which is associated with improvements in social behavior, in young children with autism spectrum disorder.

The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*

OBJECTIVE

Delirium duration is predictive of long-term cognitive impairment in intensive care unit survivors. Hypothesizing that a neuroanatomical basis may exist for the relationship between delirium and long-term cognitive impairment, we conducted this exploratory investigation of the associations between delirium duration, brain volumes, and long-term cognitive impairment.

DESIGN, SETTING, AND PATIENTS

A prospective cohort of medical and surgical intensive care unit survivors with respiratory failure or shock.

MEASUREMENTS

Quantitative high resolution 3-Tesla brain magnetic resonance imaging was used to calculate brain volumes at discharge and 3-month follow-up. Delirium was evaluated using the confusion assessment method for the intensive care unit; cognitive outcomes were tested at 3- and 12-month follow-up. Linear regression was used to examine associations between delirium duration and brain volumes, and between brain volumes and cognitive outcomes.

RESULTS

A total of 47 patients completed the magnetic resonance imaging protocol. Patients with longer duration of delirium displayed greater brain atrophy as measured by a larger ventricle-to-brain ratio at hospital discharge (0.76, 95% confidence intervals [0.10, 1.41]; p = .03) and at 3-month follow-up (0.62 [0.02, 1.21], p = .05). Longer duration of delirium was associated with smaller superior frontal lobe (-2.11 cm(3) [-3.89, -0.32]; p = .03) and hippocampal volumes at discharge (-0.58 cm(3) [-0.85, -0.31], p < .001)--regions responsible for executive functioning and memory, respectively. Greater brain atrophy (higher ventricle-to-brain ratio) at 3 months was associated with worse cognitive performances at 12 months (lower Repeatable Battery for the Assessment of Neuropsychological Status score -11.17 [-21.12, -1.22], p = .04). Smaller superior frontal lobes, thalamus, and cerebellar volumes at 3 months were associated with worse executive functioning and visual attention at 12 months.

CONCLUSIONS

These preliminary data show that longer duration of delirium is associated with smaller brain volumes up to 3 months after discharge, and that smaller brain volumes are associated with long-term cognitive impairment up to 12 months. We cannot, however, rule out that smaller preexisting brain volumes explain these findings.

The relationship between delirium duration, white matter integrity, and cognitive impairment in intensive care unit survivors as determined by diffusion tensor imaging: the VISIONS prospective cohort magnetic resonance imaging study*

OBJECTIVE

Evidence is emerging that delirium duration is a predictor of long-term cognitive impairment in intensive care unit survivors. Relationships between 1) delirium duration and brain white matter integrity, and 2) white matter integrity and long-term cognitive impairment are poorly understood and could be explored using magnetic resonance imaging.

DESIGN, SETTING, PATIENTS

A two-center, prospective cohort study incorporating delirium monitoring, neuroimaging, and cognitive testing in intensive care unit survivors.

MEASUREMENTS

Delirium was evaluated with the Confusion Assessment Method for the Intensive Care Unit and cognitive outcomes were tested at 3 and 12-month follow-up. Following the intensive care unit stay, fractional anisotropy, a measure of white matter integrity, was calculated quantitatively using diffusion tensor imaging with a 3-T magnetic resonance imaging scanner at hospital discharge and 3-month follow-up. We examined associations between 1) delirium duration and fractional anisotropy and 2) fractional anisotropy and cognitive outcomes using linear regression adjusted for age and sepsis.

RESULTS

A total of 47 patients with a median age of 50 yrs completed the diffusion tensor imaging-magnetic resonance imaging protocol. Greater duration of delirium (3 vs. 0 days) was associated with lower fractional anisotropy (i.e., reduced fractional anisotropy = white matter disruption) in the genu (-0.02; p = .04) and splenium (-0.01; p = .02) of the corpus callosum and anterior limb of the internal capsule (-0.02; p =.01) at hospital discharge. These associations persisted at 3 months for the genu (-0.02; p =.02) and splenium (-0.01; p = .004). Lower fractional anisotropy in the anterior limb of internal capsule at discharge and in genu of corpus callosum at three months was associated with worse cognitive scores at 3 and 12 months.

CONCLUSIONS

In this pilot investigation, delirium duration in the intensive care unit was associated with white matter disruption at both discharge and 3 months. Similarly, white matter disruption was associated with worse cognitive scores up to 12 months later. This hypothesis-generating investigation may help design future studies to explore these complex relationships in greater depth.

Developmental change in the ERP responses to familiar faces in toddlers with autism spectrum disorders versus typical development

Individuals with autism spectrum disorder (ASD) show differences in face processing abilities from early in development. To examine whether these differences reflect an atypical versus delayed developmental trajectory, neural responses to familiar and unfamiliar faces in twenty-four 18- to 47-month-old children with ASD were compared with responses of thirty-two 12- to 30-month-old typically developing children. Results of 2 experiments revealed that neural responses to faces in children with ASD resembled those observed in younger typically developing children, suggesting delayed development. Electrophysiological responses to faces were also related to parent report of adaptive social behaviors for both children with ASD and typical development. Slower development of the face processing system in ASD may be related to reduced self-directed "expected" experience with faces in early development.

Response to familiar faces, newly familiar faces, and novel faces as assessed by ERPs is intact in adults with autism spectrum disorders

Individuals with autism spectrum disorders (ASD) have pervasive impairments in social functioning, which may include problems with processing and remembering faces. In this study, we examined whether posterior ERP components associated with identity processing (P2, N250 and face-N400) and components associated with early-stage face processing (P1 and N170) are atypical in ASD. We collected ERP responses to a familiar repeated face (Familiar), an unfamiliar repeated face (Other) and novel faces (Novels) in 29 high-functioning adults with ASD and matched controls. For both groups, the P2 and N250 were sensitive to repetition (Other vs. Novels) and personal familiarity (Familiar vs. Other), and the face-N400 was sensitive to repetition. Adults with ASD did not show significantly atypical processing of facial familiarity and repetition in an ERP paradigm, despite showing significantly poorer performance than controls on a behavioral test of face memory. This study found no evidence that early-stage facial identity processing is a primary contributor to the face recognition deficit in high-functioning ASD.

Toddlers with elevated autism symptoms show slowed habituation to faces

We explored social information processing and its relation to social and communicative symptoms in toddlers with Autism Spectrum Disorder (ASD) and their siblings. Toddlers with more severe symptoms of autism showed slower habituation to faces than comparison groups; slower face learning correlated with poorer social skills and lower verbal ability. Unaffected toddlers who were siblings of children with ASD also showed slower habituation to faces compared with toddlers without siblings with ASD. We conclude that slower rates of face learning may be an endophenotype of ASD and is associated with more severe symptoms among affected individuals.

ERP responses differentiate inverted but not upright face processing in adults with ASD

Individuals with autism spectrum disorders (ASD) have documented deficits in face processing, face memory and abnormal activation of the neural circuitry that supports these functions. To examine speed of processing of faces in ASD, high density event-related brain potentials were recorded to images of faces, inverted faces and non-face objects from 32 high-functioning adults with ASD and controls. Participants were instructed to focus on a cross hair prior to stimulus onset; the cross-hair location directed the participant's eye gaze to the eye region at stimulus onset. Although the ASD group preformed more poorly on behavioral tests of face and object memory, both groups demonstrated similar ERP responses, characterized by greater (positive) P1 and (negative) N170 amplitude to faces vs houses. N170 speed of processing to faces did not differ between groups. However, only the control group demonstrated differential responses to upright vs inverted faces. For the ASD group, the differential response to inverted vs upright faces was associated with better performance on face memory and self-reported social skills. It is possible that the use of attention cues may facilitate face processing in high-functioning adults with ASD, suggesting that the underlying neural circuitry can be activated in adults with ASD under specific demands.

A phase I study of bendamustine hydrochloride administered day 1+2 every 3 weeks in patients with solid tumours

The aim of the study was to determine the maximum tolerated dose (MTD), the dose limiting toxicity (DLT), and the pharmacokinetic profile (Pk) of bendamustine (BM) on a day 1 and 2 every 3 weeks schedule and to recommend a safe phase II dose for further testing. Patients with solid tumours beyond standard therapy were eligible. A 30-min intravenous infusion of BM was administered d1+d2 q 3 weeks. The starting dose was 120 mg m(-2) per day and dose increments of 20 mg m(-2) were used. Plasma and urine samples were analysed using validated high-performance liquid chromatography/fluorescence assays. Fifteen patients were enrolled. They received a median of two cycles (range 1-8). The MTD was reached at the fourth dose level. Thrombocytopaenia (grade 4) was dose limiting in two of three patients at 180 mg m(-2). One patient also experienced febrile neutropaenia. Lymphocytopaenia (grade 4) was present in every patient. Nonhaematologic toxicity including cardiac toxicity was not dose limiting with this schedule. Mean plasma Pk values of BM were tmax 35 min, t(1/2) 49.1 min, Vd 18.3 l m(-2), and clearance 265 ml min(-1) m(-2). The mean total amount of BM and its metabolites recovered in the first micturition was 8.3% (range 2.7-26%). The MTD of BM in the present dose schedule was 180 mg m(-2) on day 1+2. Thrombocytopaenia was dose limiting. The recommended dose for future phase II trials with this schedule is 160 mg m(-2) per day.

Treatment of bendamustine and prednisone in patients with newly diagnosed multiple myeloma results in superior complete response rate, prolonged time to treatment failure and improved quality of life compared to treatment with melphalan and prednisone--a randomized phase III study of the East German Study Group of Hematology and Oncology (OSHO)

PURPOSE

This randomized phase III study compared bendamustine and prednisone (BP) to standard melphalan and prednisone (MP) treatment in previously untreated patients with multiple Myeloma (MM).

PATIENTS AND METHODS

To be included, patients had to have histologically and cytologically proven stage II with progressive diseases or stage III MM. They were randomly assigned to receive BP (n=68) or MP (n=63). The primary endpoint was the time to treatment failure (TTF). Secondary endpoints included survival, remission rate, toxicity and quality of life.

RESULTS

The overall response rate was 75% in the BP and 70% in the MP group. A significantly higher number of patients treated with BP achieved a complete remission than did patients receiving MP (32 vs. 13%; P=0.007), and the maximum response was achieved more rapidly in patients treated with BP compared to those receiving MP (6.8 vs. 8.7 cycles; P<0.02). TTF and remission duration were significantly longer in the BP group. Patients receiving BP had higher QoL scores and reported pain less frequently than patients receiving MP.

CONCLUSION

BP is superior to MP with respect to complete remission rate, TTF, cycles needed to achieve maximum remission and quality of life and should be considered the new standard in first-line treatment of MM patients not eligible for transplantation.

Regression of brain metastases from breast carcinoma after chemotherapy with bendamustine

PURPOSE

Bendamustinehydrochloride (bendamustine) is an alkylator with anticipated antimetabolic activity. It has shown activity in malignant lymphoma and breast cancer. Up to now there are no reports about the activity of bendamustine in the treatment of brain metastases. We report on a 38-year-old woman with brain metastases from breast cancer. The first diagnosis of an invasive ductal, hormone receptor negative breast cancer was made in October 1997, stage pT1c pN2 (11/11)cM0 - G3. After lumpectomy and resection of axillary lymph nodes, the patient received adjuvant chemo- and radiotherapy. Twenty six months after the first diagnosis, bone metastases occurred and were treated with radiotherapy. One month later, multiple liver metastases developed which were treated with trastuzumab and paclitaxel. Four months later, progress of the liver metastases and malignant infiltration of bone marrow with thrombopenia occurred.

METHODS

Chemotherapy with bendamustine at a dose of 150 mg/m(2) on day 1 and 2 was initiated. Two days later, the patient suffered from central facial palsy and subsequent computed tomography (CT) revealed three brain metastases in the frontal, parietal and occipital region. Because of the advanced liver metastases with clinical and laboratory signs of liver insufficiency and the reduced performance status of the patient, chemotherapy with bendamustine was continued and no local treatment of the brain metastases was performed.

RESULTS

After two courses of bendamustine, ultrasound showed regression of the liver metastases. Liver enzymes decreased, platelets increased, and the patient's performance status improved. Additionally, two of the three brain metastases were no longer detectable by CT, the third had decreased compared to the time of diagnosis.

CONCLUSION

To the best of our knowledge, this is the first report describing major activity of bendamustine in cerebral metastases. Thus, it may be considered as another therapeutic strategy against metastatic brain cancer. However, this finding warrants further investigation in clinical trials.

Weekly administration of bendamustine: a phase I study in patients with advanced progressive solid tumours

BACKGROUND

The cytotoxic agent bendamustine combines a purine-like benzimidazol and alkylating nitrogen mustard group. The clinically tolerated dose for single bolus bendamustine is 215 mg/m2, for fractionated therapy on four consecutive days 85 mg/m2. The maximum tolerated dose of a day 1 and 8 (q4w) 30 min infusion schedule was recently found to be 160 mg/m2, mouth dryness and fatigue were dose-limiting. Our current phase I trial was designed to define the recommended dose of a new weekly short infusion schedule.

PATIENTS AND METHODS

Patients with refractory malignant tumours qualified for the trial after written informed consent was obtained. Bendamustine was given as a 30-min i.v. infusion weekly for up to eight consecutive weeks.

RESULTS

Twelve patients (8 male, 4 female, median age 57.5 years, range 42-64) were enrolled in this trial. At the starting dose of 80 mg/m2, two patients had dose-limiting toxicity (fatigue grade 3, mouth dryness grade 3, fever grade 4 Common Toxicity Criteria). No dose-limiting events were observed in six patients treated at 60 mg/m2. An intermediate dose level of 70 mg/m2 was studied in three younger, less heavily pretreated patients, was well tolerated and not associated with dose-limiting events. Haematological toxicity was mild except for grade 3-4 lymphocytopenia, occurring in 11 of 12 patients. Bendamustine was found to induce long-lasting panlymphocytopenia with predominant B-cell cytotoxicity.

CONCLUSIONS

The maximum tolerated dose of weekly bendamustine given as a 30-min i.v. infusion is 80 mg/m2, mouth dryness, fatigue and fever are dose-limiting. The recommended dose for phase II trials is 60 mg/m2.

Repeated administration of short infusions of bendamustine: a phase I study in patients with advanced progressive solid tumours

PURPOSE

The cytotoxic agent bendamustine combines a purine-like benzimidazol and bifunctionally alkylating nitrogen mustard group. The drug has clinical antitumour activity in lymphoma, myeloma and breast cancer. In earlier dose-finding studies, the clinically tolerated dose for single-bolus bendamustine was 215 mg/m2; for fractionated therapy on 4 consecutive days it was 85 mg/m2. Anticholinergic symptoms, myelosuppression and cardiac dysrhythmia were dose-limiting. Our trial was designed to define the maximum tolerated dose of a short infusion schedule and to establish a recommended dose for ongoing and future clinical studies.

METHODS

Patients with refractory malignant tumours qualified for the trial after written informed consent had been obtained. Bendamustine was given as a 30-min iv. infusion on days 1 and 8 of a 4 week cycle, with a starting dose of 100 mg/m2 and an increment per group of 20 mg/m2.

RESULTS

Nineteen patients (13 male, 6 female; median age 57 years, range 37-74 years) were treated for one to two cycles with up to 180 mg/m2 bendamustine. At 160 mg/m2, fatigue grade 3 (NCI Common Toxicity Criteria) and dryness of the mouth grade 3 occurred in 2 patients, diarrhoea grade 3 in 1 patient; another patient with a history of myocardial infarction and arrhythmia developed a reversible total atrioventricular block after the first administration of 160 mg/m2 bendamustine. Other events, such as nausea/vomiting, loss of appetite, fever or chills, were not dose-limiting. Haematological toxicity was mild, except for sudden and long-lasting grade 3-4 lymphocytopenia, which occurred in all treatment cycles. Opportunistic infections were not observed.

CONCLUSIONS

The maximum tolerated dose of a days-1 and -8 schedule of bendamustine, given as a 30-min i.v. infusion, is 160 mg/ m2; mouth dryness and fatigue are dose-limiting. The recommended dose for future trials is 140 mg/m2.

The effects of sample preparation methods on the variability of the electrospray ionization response for model drug compounds

A post-column infusion system was developed in order to analyze suppression of electrospray ionization (ESI) tandem mass spectrometry response in the presence of endogenous plasma interferences. By enabling direct detection of these interfering components, this experimental system was used to analyze the ability of several common extraction procedures to remove endogenous plasma components that cause changes in the ESI response of model drug substances. Methyl-t-butyl ether (MTBE) liquid-liquid, Oasis and Empore solid-phase, and acetonitrile (ACN) protein precipitation sample preparation methods were tested using the post-column infusion system. In all cases, ACN protein precipitation samples showed the greatest amount of ESI response suppression while liquid-liquid extracts demonstrated the least. In addition, the three test compounds, phenacetin, caffeine, and a representative Merck compound, demonstrated that ESI response suppression is compound dependent. Suppression was greatest with caffeine, the most polar analyte, and the smallest for the Merck compound, the least polar analyte. Copyright 1999 John Wiley & Sons, Ltd.

The effects of sample preparation methods on the variability of the electrospray ionization response for model drug compounds

A post-column infusion system was developed in order to analyze suppression of electrospray ionization (ESI) tandem mass spectrometry response in the presence of endogenous plasma interferences. By enabling direct detection of these interfering components, this experimental system was used to analyze the ability of several common extraction procedures to remove endogenous plasma components that cause changes in the ESI response of model drug substances. Methyl-t-butyl ether (MTBE) liquid-liquid, Oasis and Empore solid-phase, and acetonitrile (ACN) protein precipitation sample preparation methods were tested using the post-column infusion system. In all cases, ACN protein precipitation samples showed the greatest amount of ESI response suppression while liquid-liquid extracts demonstrated the least. In addition, the three test compounds, phenacetin, caffeine, and a representative Merck compound, demonstrated that ESI response suppression is compound dependent. Suppression was greatest with caffeine, the most polar analyte, and the smallest for the Merck compound, the least polar analyte. Copyright 1999 John Wiley & Sons, Ltd.

Bendamustine as salvage treatment in patients with advanced progressive breast cancer: a phase II study

A phase II pilot study of bendamustine as salvage treatment in patients with advanced breast cancer was performed to determine the objective response rates and make further observations on the toxicity of this drug. A group of 37 patients, pretreated with chemotherapy for advanced disease, entered the trial. Treatment consisted of 150 mg/m2 bendamustine on days 1 and 2 of a 4-week treatment course. Patients continued to receive treatment until complete remission and then two further courses, until tumour progression or unacceptable toxicity ensued. A total of 36 patients received at least one treatment course and were assessable for toxicity; 33 patients were evaluable for treatment results. Dose-limiting grade 3 and 4 WHO toxicity occurred in 5 and 3 patients respectively; 27% of patients entered complete or partial tumour remission. The median time to tumour progression was 2 months with a range of 1-14 months. The efficacy of bendamustine was apparently independent of pretreatment with anthracyclines, suggesting a lack of cross-resistance between bendamustine and anthracyclines. It can be concluded that bendamustine in the dose and application schedule used here is active in the salvage therapy of women with advanced breast cancer. The toxicity was acceptable. Future studies have to confirm the data of this pilot trial and to define the role of bendamustine in the combination chemotherapy of metastatic breast cancer that has been suggested by previous trials.

[Clinical and radiologic results of surgically treated patellar dislocation]

In this retrospective study 72 patients were followed up clinically and radiologically after surgical treatment for dislocation of the patella. The period of observation varied between 13 and 76 months, with an average of 32 months. Acute traumatic dislocation of the patella was only rarely encountered (n = 6 [8%]). Primary dislocation occurred most frequently during the second and third decades of life. Chondral and osteochondral fractures were fairly frequent (n = 24 [33%]). Additional injuries involved the anterior cruciate ligament, the medial collateral ligament and the menisci. At clinical examination 32 patients (44%) could be assessed as "very good" and "good" (classification of Larsen and Lauridsen). Redislocation occurred in 12 patients (16.7%). The radiological condition of the patella and that of the trochlea femoris were assessed in terms of the classification of Wiberg and Baumgartl and of Hepp, respectively. The condylar-joint angle (Brattström) and the condylar depth index (Ficat and Bizou) were also evaluated.

[The radiation-sensitizing effect of isometronidazole following its intravesical application in bladder carcinoma. A clinical phase-II study]

The radiosensitizing efficacy of iso-metronidazole, a 4-nitroimidazole derivative, was evaluated in a prospective clinical phase-II study. The results of combined radiotherapy of 25 patients with bladder cancer were compared with those of a control group of 25 patients treated with radiotherapy only. Tumor regression six months after radiotherapy was used as an endpoint. The surgical procedure was performed as double TUR. Evaluating the local tumor control after additional application of iso-metronidazole a gain factor of 1.2 is obtained.

[Experiences with intensive radiotherapy of prostatic cancer in conjunction with surgery (transurethral resection, pelvic lymph node excision)]

Since 1981 a curative radiation treatment was performed in 84 patients with prostatic carcinoma. Previously, in 37 cases a transurethral resection of bladder outlet obstruction was done and in 18 patients a pelvic lymph node dissection was performed, whereas 29 patients were without operative therapy. Mild side effects of radiation could observed in all 3 groups in nearly the same portion (59/56/65%). However, in the group with transurethral resection after follow-up of 4,4 years severe late complications were found (cystitis, incontinence, urethral fistula). Therefore, radiation treatment of prostatic carcinoma after transurethral resection was abandoned. The cumulative 5-year-survival rate was 63% and in the TUR group only 41%. 9 out of 10 patients with histological verified lymph node metastases and radiation treatment are alive after mean follow-up time of 3.1 years without evidence of recurrent disease.

A randomized clinical trial comparing systemic radiotherapy versus chemotherapy versus local radiotherapy in small cell lung cancer

Between 1982 and 1987 a prospectively randomized trial of sequential hemibody irradiation (SHBI) (A), a non-cross-resistant chemotherapy drug combination (B) and local and/or locoregional radiotherapy (C) in small cell lung cancer (SCLC) was conducted. Previously untreated patients with extensive SCLC were randomized into three arms: A = 31 patients, B = 37, C = 31. In the chemotherapy combination, the following were used: etoposide, doxorubicin, methotrexate (VAM) and procarbacine, vincristine, cyclophosphamide, lomustine (POCC) and prophylactic cranial irradiation (30 Gy). The results show that the median survival was significantly (P less than 0.01) better in chemotherapy (44 weeks) compared with 17 and 20 weeks in arms A and C, respectively. One year and 2 year survival rates were better for the chemotherapy arm. No differences were found between groups A and C. In comparing the total hospitalization time expressed as a percentage of overall survival, an advantage for group B was shown. In conclusion, high dose SHBI cannot be recommended as a standard therapy for extensive SCLC.

[Principles of dosimetric planning in contact therapy with highly active Cf-252 sources]

In clinical practice, some dosimetric problems of contact therapy with CF-252 are not yet sufficiently clarified. One possibility to solve these problems is to apply the conception of total photon-equivalent energy doses. This conception serves to calculate clinical guidance values of the RBE of the Cf-252 neutron constituent for radiogenic late effects in dependence on the total dose rate of the mixed radiation. The correlations indicated are valid for dose rates of 0.05 to 4 Gy/h and 4 to 1.25.10(4) Gy/h. On the basis of these functional correlations and taking into consideration the critical normal tissues of rectum and urinary bladder, the minimum RBE values of the tumors are indicated which allow a therapeutic effect of more than 1 in case of application of Cf-252. The formulas for the RBE dependence of the Cf-252 neutron constituent on the total dose rate permit to take into account any modifications of this value caused by varying source distances in contact therapy. It is concluded from these investigations that in oncologic patients, better results are to be expected from a treatment with high-energy Cf-252 sources, if the other treatment conditions are identical.

[Results of irradiation using different radiation sources in the treatment of malignant parotid tumors]

Patients with malignant parotid tumors were treated at two different centres with slightly ionizing radiation (110 patients) and neutron therapy (15 patients). The treatment results are compared. The principles of comparison applied in this analysis are identical. The histologic classification was made according to the W.H.O. recommendation of 1972 and the staging according to Becske. Local tumor control is the criterion applied in the comparative assessment of both methods. The analysis has shown that there is no significant difference in the treatment results within the individual stages of tumor's advancement after application of an orthovolt therapy and a telecobalt therapy. Patients treated in early stages (stages I and III) had a substantially higher rate of local tumor control (72%) than patients in advanced stages (46%, stages III and IV). A more favorable treatment results was achieved by neutron therapy in all stages of tumor's advancement. In this case the rate of patients with local tumor control (87%) was significantly higher than after radiotherapy with slightly ionizing radiation (46%).

[Topometric preparation of patients with cervix cancer for intracavitary irradiation on the ANET-B apparatus]

The authors worked out methods of topometric investigation of cervical cancer patients during preparation for intracavitary irradiation using 252Cf fast neutron sources. The use of balloon catheters made it possible to determine a coefficient of projection enlargement in the point of interest, to determine accurately the distance between endostats, sources and contrasted organs of interest: the bladder and rectum. The results of the studies were used for individual design of intracavitary treatment as well as for the determination of radiation exposure of the pelvic organs in 38 patients. The patients received a total of 138 investigations.

[The role of computerized tomography in the diagnosis and treatment planning of prostatic cancer]

The influence of computerized tomography on planning the therapy of 58 patients with histologically confirmed carcinoma of the prostate gland was examined. In classifying the early tumour stages there were differences from the clinical findings. With more advanced stages CT in some cases gave much more detail for diagnosing the extension. In 11.5% of the cases this led to the irradiation field being either enlarged or reduced. CT also proved to be useful for follow-up, especially as regards decisions on increasing the irradiation dose.

[Computed tomography in the diagnosis of ovarian, cervix and uterine cancer]

By means of computer assisted tomography (CAT) 22 patients with ovarian and 13 with uterus cancer were examined for diagnostic reasons. The results were compared with surgical findings. The advantage of CAT over objective clinical examination was shown particularly in cases where the tumour goes beyond the organ and lymphnodes are affected. In spite of the high information value of the CAT a differential diagnosis is difficult in cases of ovarian cancer. The method is little effective in case of corpus carcinoma in the stage I. In 14 patients with cervix cancer it could be shown, that CAT is inefficient for an early detection of malignant tumours of this localisation. By means of CAT, however, one can get additional information about the spreading of the process, particularly in cases with relatively high localized and not well detectable by bimanuel examination and information to clear up concomitant diseases of pelvic organs as well.

[Conventional roentgenologic methods and computerized tomography in the preirradiation planning for patients with esophageal cancer]

During the planning of irradiation of patients with esophageal cancer significant divergence is frequently noted between topometric maps obtained by conventional x-ray methods including axial tomography, and computerized tomography. Topometric maps based on these two methods were compared. Using a typical example of a series of 12 patients, divergences in expected dose loads on critical points were analysed on the basis of 3 variants of superposed topometric maps. Divergences in topometric maps result from errors in topometric methods and from an impossibility to reproduce precisely the level of a section and physiological conditions during repeated layings of a patient. Divergences in a focal dose (on the esophagus) can reach 8% in rotation radiotherapy, 20% in static irradiation, and on the vertebral canal 28 and 13% respectively. Factors that influence such divergences are discussed.

[Experience in using echotomography in planning the irradiation of cervical cancer patients]

A possibility to use echotomography (ET) in the topometric preparation of patients with cervical cancer for radiation therapy is shown. In addition to ET computerized tomography (CT) was performed to 15 patients at the level of classic points A and B. Proceeding from the results of both studies topometric maps were prepared. Using the maps distances between points of interest were compared. It was shown that the mean value of the distance from the middle of the uterine cervix to the bladder posterior wall was 24 and 23 mm in ET and CT, respectively. Some methodological problems of ET for irradiation planning are discussed. It should be noted that ET provides ample information on the small pelvic anatomical structures that are of interest in gamma-beam and intracavitary radiation therapy of cervical cancer. ET positive features are its safety for a patient, insignificant costs and an opportunity to get information for a 3-dimensional irradiation planning.

[Computer tomography in determining lung density for irradiation planning]

The paper is concerned with the problems of the determination of lung density in the irradiation planning for thoracic tumors using CT. The mean value of density that was equal to 0.252 +/- 0.118 g/cm3 was obtained proceeding from a study of 118 CT sections of the lungs during quiet breathing. The respective value gets equal to 0.162 +/- 0.022 g/cm3 in deep breathing and 0.282 + 0.050 g/cm3 in full expiration. The values of lung density can vary in different persons. The range of measured values is equal to 0.119 = 0.441 g/cm3 in quiet breathing. The values of lung density vary within the limits of one section from the minimum value in its front part to the maximum one in the rear part. To determine lung densities that are representative for radiation therapy, CT should be performed with a patient breathing quietly in an uninterrupted manner. In significant deviations of density values from those accepted for isodose value calculation, individual consideration of lung density for each person is found appropriate.

[The Abris semi-automatic device for plotting the contours of the surface plane of the human body]

Semiautomatic contact contour plotter is designed to cope human body sections in supine position. Its operating principle and a design are presented. Experimental tests have shown that the error in contour plotting does not exceed 1--2 mm. It is useful in planning radiation therapy.

[2-dimensional ultrasonic scanning for irradiation planning]

The paper is concerned with the results of the utilization of echotomography in the topometric preparation of patients with malignant tumors for irradiation. Proceeding from the examination of 600 cancer patients in the All-Union Cancer Research Center. USSR AMS, it has been established that echotomography makes it possible not only to define the borders of pathology in the peritoneal cavity and retroperitoneal space but also to specify the relative position of the adjacent internal organs. Some practical aspects of the use of ultrasound for topometry are discussed. A possibility of using this method for the three-dimensional planning of irradiation is indicated. Using an echotomoscope one can obtain a contour of the section of a soft phantom with an accuracy of 5 +/- 1 mm that significantly exceeds the limits of precision of a contour measured with the help of a lead band where it equals 10 +/- 7 mm. Echotomography makes it possible to get a contour in any plane. In view of certain limitations of the echotomographic method one should also resort to x-ray methods for the topometric planning of irradiation to specify the position and size of the bearing osseous structures. While converting reduced ultrasound images in the scale of 1:1 the optic method with an episcope proved to be the most accurate one where an error of reproducibility of a contour reaches 1 mm. In the use of an optical-electronic device this value exceeds 10 mm and corresponds to 4 mm while utilizing a pantograph.

[Use of computed tomography for planning intracavitary radiotherapy of cervical cancer]

CT potentialities for irradiation planning have been demonstrated as a result of a study of 20 cervical cancer patients, Stages I-II, using a computerized tomograph for topometric preparation for intracavitary therapy with afterloading units, and subsequent gamma-beam therapy. Complete information on sections that are necessary for clinicodosimetric irradiation planning, has been obtained with the help of digital radiography, transversal tomography and mathematical reconstruction of secondary sections. The study was performed by inserting a centering mount and metrocolpostat after a preliminary determination of A point on the simulator. An effect of the degree of the bladder filling on the organs located in a given section has been shown. It has been established that the degree of the bladder filling at the level of A and B points does not influence a distance from its posterior wall to the metrostat. It is assumed that intestinal radiation injuries can be prevented by controlling the degree of the bladder filling.

Variation in U.V. primary fluorescence-intensity of vital cells depending on 60Co gamma-radiation dose

Using impulse-cytofluorophotometry in the ultra-violet spectral region the author has shown on vital, unstained Ehrlich ascites tumour cells that the primary fluorescence intensity of this tumour is on day 11 after transplantation 20 per cent higher than on day 8. Storage of the vital cells for 25 min at 20 degrees C has no effect on this result. When the cells are exposed to 60Co to gamma-radiation on day 6, a new stable fluorescence level is established afted 20 hours. Measurements of the primary fluorescence intensity depending on dose have shown a significant rise starting from 75 rad at 48 hours after irradiation. The fluorescence intensity rises by 42.5 per cent of the control value at 3000 rad, but only by 31.5 per cent on exposure to 4000 rad.