Radiation therapy of breast cancer in the Nahe Breast Center: first results of an analysis in the context of health services research

BACKGROUND

The first evaluation of radiotherapy results in patients with breast cancer treated as part of a multimodal oncologic therapy in the Nahe Breast Center is presented. Analysis of the results was performed using an in-practice registry.

PATIENTS AND METHODS

From September 2016 to December 2017, 138 patients (median age 62.5 years; range 36-94 years) with breast cancer (right side, n = 67; left side, n = 71) received adjuvant radiation therapy. Of these, 103 patients received gyneco-oncologic care at the Nahe Breast Center, and 35 were referred from outside breast centers. The distribution into stages was as follows: stage I, n = 48; stage II, n = 68; stage III, n = 19; stage IV, n = 3. Neoadjuvant chemotherapy was given to 19 and adjuvant chemotherapy to 50 patients. Endocrine treatment was given to 120 patients. Both 3D conformal (n = 103) and intensity-modulated (n = 35) radiotherapy were performed with a modern linear accelerator.

RESULTS

With a median follow-up of 60 months (1-67), local recurrence occurred in 4/138 (2.9%) and distant metastasis in 8/138 (5.8%) patients; 7/138 (5.1%) patients died of their tumors during the follow-up period. The actuarial 5‑year local recurrence-free survival of all patients was 97.1%, and the actuarial 5‑year overall survival of all patients was 94.9%. We observed no grade 3 or 4 radiogenic side effects.

CONCLUSION

The results of radiotherapy for breast carcinoma at the Nahe Breast Center are comparable to published national and international results. In particular, the local recurrence rates in our study, determined absolutely and actuarially, are excellent, and demonstrate the usefulness of radiotherapy.

Introducing a standardized assessment of patients' interest in and usage of CAM in routine cancer care: chances and risks from patients' and physicians' point of view

BACKGROUND

Cancer patients often use complementary and alternative medicine (CAM), however, standardized assessment in clinical routine is missing. The aim of this study was to evaluate a screening questionnaire on CAM usage that was published in the S3 Guideline Complementary Medicine in the Treatment of Oncological Patients.

METHODS

We developed a survey questionnaire to assess the practicability of the guideline questionnaire and communication on CAM between health care providers (HCPs) and patients. We collected 258 guideline questionnaires and 116 survey questionnaires from ten clinics and held twelve semi-structured interviews with HCPs.

RESULTS

85% used at least one of the listed CAM methods, 54 participants (N = 77) never disclosed usage to a physician. The most frequently used CAM methods were physical activity (76.4%) and vitamin D (46.4%). 25.2% used at least one method, that was labeled risky by the guideline. 53.4% did not know of CAM's risk of interactions and side effects. Introducing the guideline questionnaire in routine cancer care increased the rate of patients talking to an HCP regarding CAM significantly from 35.5 to 87.3%. The HCPs stated positive effects as an initiation of conversation, increased safety within CAM usage and patients feeling thankful and taken seriously. However, due to the limited amount of time available for discussions on CAM, generalized distribution to all patients was not feasible.

CONCLUSION

Institutions should focus on implementing standard procedures and resources that help HCPs discuss CAM on a regular basis. HCPs should meet the patient's demands for CAM counseling and make sure they are equipped professionally.

[Essential trace elements, vitamins, and selected electrolytes in complementary medicine for cancer patients]

OBJECTIVE

Are there any evidence-based medicine (EBM)-supported treatment approaches of complementary and alternative medicine (CAM) methods for urological oncologists?

METHODS

We reviewed the actual German S3 guidelines "Supportive Care" and "Complementary Medicine" as well as the online-tool Onkopedia for recommendations about essential trace elements (Zn, Se, Mn, Fe), vitamins (A, B, C, D, E), and electrolytes (Mg, Ca). Furthermore, we added results of randomized trials to present potential future developments.

RESULTS

Each therapy with micronutrients should be based on laboratory observation of a deficit. There are selected guideline recommendations for selenium, iron and vitamin D. Potential indications were registered for manganese, vitamin A derivates, and vitamin C. No benefit was observed for vitamin B, zinc, and vitamin E.

CONCLUSION

Micronutrients should be substituted in the case of deficit. General supplementation of daily nutrition is not recommended for cancer patients.

Malnutrition and Survival - Bioimpedance Data in Head Neck Cancer Patients

BACKGROUND/AIM

Bioimpedance analysis (BIA) reflects the nutritional status of patients. The aim of this study was to examine whether BIA is able to document the possible impact of malnutrition on survival.

MATERIALS AND METHODS

The registered data of 42 head and neck cancer patients were analyzed. Survival data of 22 women and 20 men were included. The mean age was 67.3±10.77 years. BIA was measured by the Biocorpus 4000 RX (MEDIcal Health Care GmbH Karlsruhe) and summarized in individual phase angle (PA) of each patient.

RESULTS

Patients with normal PA>5.0 had a significantly better survival (p=0.016). The median survival time was 13.84 months (range=0.69-125.19 months) in malnourished patients (PA<5.0) compared to 51.16 months (range=7.02-116.79 months) in normally nourished head and neck cancer (HNC) patients (PA>5.0). Age adjusted body mass index had a similar impact on prognosis, but was not statistically significant (p=0.068) in the investigated study groups.

CONCLUSION

BIA is able to document the impact of malnutrition on the survival of head and neck cancer patients.

Effect of Whole-abdominal Irradiation on Penetration Depth of Doxorubicin in Normal Tissue After Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in a Post-mortem Swine Model

BACKGROUND

This study was performed to evaluate the impact of whole-abdominal irradiation on local penetration of doxorubicin into the peritoneum and the abdominal organs in a post-mortem swine model.

MATERIALS AND METHODS

Doxorubicin was aerosolized into the abdominal cavity of swine at a pressure of 12 mmHg CO₂ at room temperature (25°). One swine was subjected to pressurized intraperitoneal aerosol chemotherapy (PIPAC) using Micropump^© without irradiation; the second one received 2 Gy and the third one 7 Gy whole-abdominal irradiation, 15 min prior to PIPAC application. Samples of the peritoneal surface were extracted at different positions from within the abdominal cavity. In-tissue doxorubicin penetration was measured using fluorescence microscopy on frozen thin sections.

RESULTS

The depth of penetration of doxorubicin was found to be wide-ranging, between 17 μm on the surface of the stomach and 348 μm in the small intestine. The penetration depth into the small intestine was 348 μm, 312 μm and 265 μm for PIPAC alone, PIPAC with 2 Gy irradiation and PIPAC with 7 Gy irradiation, respectively (p<0.05). The penetration into the liver was 64 μm, 55 μm and 40 μm, respectively (p=0.05).

CONCLUSION

Irradiation was not found to increase the depth of doxorubicin penetration into normal tissue in the post-mortem swine model. A reduction of doxorubicin penetration was observed after application of higher irradiation doses. Further studies are warranted to determine if irradiation can be used safely as chemopotentiating agent for patients with peritoneal metastases treated with PIPAC.

Irradiation Does Not Increase the Penetration Depth of Doxorubicin in Normal Tissue After Pressurized Intra-peritoneal Aerosol Chemotherapy (PIPAC) in an Ex Vivo Model

AIM

To compare the impact of single fractional with bi-fractional irradiation on the depth of doxorubicin penetration into the normal tissue after pressurized intra-peritoneal aerosol chemotherapy (PIPAC) in our ex vivo model.

MATERIALS AND METHODS

Fresh post mortem swine peritoneum was cut into 12 proportional sections. Two control samples were treated with PIPAC only (no irradiation), one sample on day 1, the other on day 2. Five samples were irradiated with 1, 2, 4, 7 or 14 Gy followed by PIPAC. Four samples were treated on day one with 0.5, 1, 2, 3.5 or 7 Gy and with the same radiation dose 24 h later followed by PIPAC. Doxorubicin was aerosolized in an ex vivo PIPAC model at 12 mmHg/36°C. In-tissue doxorubicin penetration was measured using fluorescence microscopy on frozen thin sections.

RESULTS

Doxorubicin penetration (DP) after PIPAC for the control samples was 407 μm and 373 μm, respectively. DP for samples with single fraction irradiation was 396 μm after 1 Gy, 384 μm after 2 Gy, 327 μm after 4 Gy, 280 μm after 7 Gy and 243 μm after 14 Gy. DP for samples with 2 fractions of irradiation was 376 μm after 0.5+0.5 Gy, 363 μm after 1+1 Gy, 372 μm after 2+2 Gy, 341 μm after 3.5+3.5 and 301 μm after 7+7 Gy irradiation. Fractionating of the irradiation did not significantly change DP into normal tissue.

CONCLUSION

Irradiation does not increase the penetration depth of doxorubicin into the normal tissue but might have a limiting impact on penetration and distribution of doxorubicin. Further studies are warranted to investigate the impact of addition of irradiation to PIPAC of tumor cells and to find out if irradiation can be used safely as chemopotenting agent for patients with peritoneal metastases treated with PIPAC.

Sport in the Rehabilitation of Patients After Total Laryngectomy

AIM

Laryngectomy due to cancer leads to decreased physical activity of patients. Rehabilitation programs focus on the improvement of voice and swallowing but the role of rehabilitation sports for such patients is unknown.

PATIENTS AND METHODS

We interviewed all 38 patients (five women, 33 men; median age 56 years) of our patient's advocacy group. All had undergone laryngectomy because of cancer. We asked them to report their sporting activities and summarized their descriptions.

RESULTS

Overall, 12 patients were members of our swimming group and had performed aqua gymnastics and swimming training in order to stabilize or improve the muscle structures of the neck and backbone. A further four patients only took part in swimming training. The training frequency was twice per month; when patients were introduced to the program, they increased this frequency to 4-5/month. Three patients started cycling with mountain bikes covering distances of between 30 and 50 km. A further two patients were able to follow our cycling program using e-bikes. Twenty patients reported walking weekly between 10 and 16 km. All patients summarized the positive impact of sports on their personal well-being.

CONCLUSION

Swimming, aqua-fitness, cycling and (Nordic) walking are favourable sport disciplines for patients after laryngectomy for laryngeal cancer. Special training programs should be developed and included in rehabilitation procedures for patients after multimodal therapy of laryngeal cancer.

The prognostic value of irradiated lung volumes on the prediction of intra-/ post-operative mortality in patients after neoadjuvant radiochemotherapy for esophageal cancer. A retrospective multicenter study

PURPOSE

To assess the association between dosimetric factors of the lung and incidence of intra- and postoperative mortality among esophageal cancer (EC) patients treated with neoadjuvant radiochemotherapy (N-RCT) followed by surgery (S).

METHODS AND MATERIALS

Inclusion criteria were: age < 85 years, no distant metastases at the time of diagnosis, no induction chemotherapy, conformal radiotherapy, total dose ≤ 50.4 Gy, and available dose volume histogram (DVH) data. One-hundred thirty-five patients met our inclusion criteria. Median age was 62 years. N-RCT consisted of 36 - 50.4 Gy (median 45 Gy), 1.8 - 2 Gy per fraction. Concomitant chemotherapy consisted of 5-Fluoruracil (5-FU) and cisplatin in 113 patients and cisplatin and taxan-derivates in 15 patients. Seven patients received a single cytotoxic agent. In 130 patients an abdominothoracal and in 5 patients a transhiatal resection was performed. The following dosimetric parameters were generated from the total lung DVH: mean dose, V5, V10, V15, V20, V30, V40, V45 and V50. The primary endpoint was the rate of intra- and postoperative mortality (from the start of N-RCT to 60 days after surgical resection).

RESULTS

A total of ten postoperative deaths (7%) were observed: 3 within 30 days (2%) and 7 between 30 and 60 days after surgical intervention (5%); no patient died during the operation. In the univariate analysis, weight loss (≥10% in 6 months prior to diagnosis, risk ratio: 1.60, 95%CI: 0.856-2.992, p=0.043), Eastern Cooperative Oncology Group-performance status (ECOG 2 vs. 1, risk ratio: 1.931, 95%CI: 0.898-4.150, p=0.018) and postoperative pulmonary plus non-pulmonary complications (risk ratio: 2.533, 95%CI: 0.978-6.563, p=0.004) were significantly associated with postoperative mortality. There was no significant association between postoperative mortality and irradiated lung volumes. Lung V45 was the only variable which was significantly associated with higher incidence of postoperative pulmonary plus non-pulmonary complications (Exp(B): 1.285, 95%CI 1.029-1.606, p=0.027), but not with the postoperative pulmonary complications (Exp(B): 1.249, 95%CI 0.999-1.561, p=0.051).

CONCLUSIONS

Irradiated lung volumes did not show relevant associations with intra- and postoperative mortality of patients treated with moderate dose (36 - 50.4 Gy) conventionally fractionated conformal radiotherapy combined with widely used radiosensitizers. Postoperative mortality was significantly associated with greater weight loss, poor performance status and development of postoperative complications, but not with treatment-related factors. Limiting the volume of lung receiving higher radiation doses appears prudent because of the observed association with risk of postoperative complications.

Patients with advanced cancer and their usage of complementary and alternative medicine

PURPOSE

A total of 40 % of cancer patients use complementary and alternative medicine (CAM), and patients with advanced cancer use CAM more often than others. The aim of our study was to gather data on CAM use and reasons to use CAM of patients with advanced cancer being admitted for residential palliative care and their relatives.

METHODS

Structured interviews were carried out with 25 patients and 25 relatives of those patients, respectively, of a German comprehensive cancer center based on a standardized questionnaire of the working group Prevention and Integrative Oncology of the German Cancer Society.

RESULTS

Median age of patients was 64.5 years (relatives: 53.5); 15 patients were male and 10 were female (relatives: 7 and 18). In total, 40 % of all patients used some CAM method at the time of the study, supplements and prayer being the most frequent method. Main reasons for using CAM were to sustain one's own strength (52 % for patients and 72 % for relatives) and to be able to do something by oneself (36 and 40 %). Sources of information were television/radio (48 and 28 %) and family/friends (40 and 48 %). Relatives also use the Internet (40 %).

CONCLUSIONS

Also for patients in palliative care and their relatives, CAM is important. Reasons for using CAM are similar for patients with less advanced cancer. As most patients do not discuss using CAM with their physician, side effects and interactions of biologically based treatments may be dangerous. The desire of patients to act autonomously should be encouraged. Yet, physicians should ensure safe administration of complementary methods by including CAM in their communication with the patient and the family.

[Micronutrients in oncology. Current data about vitamin D, selenium, L-carnitine and vitamin C]

Many patients receiving cancer treatment use micronutrient supplements, with the intention to complement their cancer treatment, or help them cope with the therapy- and disease-associated side-effects. Up to 90% of the cancer patients are adding antioxidants without the knowledge of the treating physician. There are many concerns that antioxidants might decrease the effectiveness of chemotherapy, but increasing evidence suggests a benefit when antioxidants and other micronutrients, such as selenium, L-carnitine and vitamin D are added to conventional cytotoxic therapies. It is imperative that physicians discuss the use ofantioxidant and other micronutrient supplements with their cancer patients and educate them about potentially negative, but also potentially beneficial effects.

How are Interactions Taken into Account in Studies on Conventional and Complementary Therapies for Breast Cancer Patients with Menopausal Complaints?

Introduction: Postmenopausal symptoms in breast cancer patients undergoing antihormone treatment lead to high drop-out rates from the therapy. From the therapeutic point of view, methods of both conventional and complementary medicine are concerned. Interactions are being discussed in cases of natural substances. However, they are also relevant for conventional medical substances. The aim of this analysis is to answer the question as to what extent potential interactions are taken into account in clinical studies and reviews on supportive therapies. Materials and Methods: Clinical studies and reviews were identified by means of a systematic search and analysed with regard to the consideration of potential interactions. Results: Altogether 46 clinical studies and one Cochrane review were found. Among the 35 studies on conventional drug therapies, 5 (14 %) took possible interactions into account. Among the 17 studies on complementary medicine, there were 2 (11.7 %) such publications. The Cochrane review did not mention interactions. Discussion: For future studies in which interactions cannot be excluded, a strategy to control for their clinically relevant consequences should be developed. The present authors suggest that the use of survival and recurrence data as secondary endpoints, also for studies on purely supportive therapies, is a reasonable approach. The resulting considerations for study routines are listed thematically.

Radiotherapy for giant cell tumors of the bone: a safe and effective treatment modality

BACKGROUND

Giant cell tumor of the bone (GCTB) is a benign or sometimes semi-malignant neoplasm accounting for 5% of all primary bone tumors. This type of tumor has been historically considered as radioresistant, but nowadays radiotherapy (RT) is used in unresectable, recurrent or incompletely resected cases. Since the value of RT is not well defined, a national cohort study was conducted.

PATIENTS AND METHODS

Six German institutions collected data from 35 patients treated during the last 35 years and analyzed them.

RESULTS

From 1975-2010 16 male and 19 female patients with 39 lesions were irradiated for GCTB. The median age was 30 years and the median follow-up 65 months. Nineteen patients had undergone RT for recurrent or unresectable disease and 16 patients for non-in-sano resection. The actuarial 5-year overall and disease-free survival rates were 90% and 59%, respectively.

CONCLUSION

RT is an easy, safe and effective method for the treatment of GCTB. It may provide an attractive alternative to mutilating surgery.

Nutritional parameters for patients with head and neck cancer

AIM

Determination of the optimal nutritional parameter to provide useful information for the individual patient and assessing the impact of nutritional status have on the prognosis of head and neck cancer.

PATIENTS AND METHODS

Firstly a retrospective study analysed the outcome of 110 patients in relation to initial weight loss and weight loss at the end of radiotherapy. A second study investigated the changing bioimpedance (BIA) data of 27 survivors and 39 patients who died between their first and last measurement during nutritional therapy (at least four weeks).

RESULTS

A critical initial weight loss is 10 kg or more at the point of diagnosis. At the end of radiotherapy the body mass reduction should be less than 15 kg. Raw data of BIA reflect the changing nutritional status at the end of life. We observed a stabilized phase angle in survivors (4.7° to 5.2°) whereas patients who died exhibited a significant lower phase angle (4.6° to 3.7°, p<0.05).

CONCLUSION

The prognosis of head and neck cancer patients is highly related to their nutritional status. Specific nutritional anamnesis (initial weight loss, total weight loss, body mass index) and additional biophysical measurements such as BIA are recommended to monitor the individual status during the follow-up.

Selenium substitution during radiotherapy of solid tumours - laboratory data from two observation studies in gynaecological and head and neck cancer patients

OBJECTIVE

Selenium is an essential cofactor of the enzyme glutathione peroxidase (GSH-Px), which is important for the endogenous detoxification of free radicals. A reduced activity of GSH-Px is related to increased toxicities due to radiation therapy during primary cancer treatment. Therefore, selenium substitution may be a new supportive strategy to diminish radiation-associated side effects.

PATIENTS AND METHODS

The selenium blood concentrations of 121 radiotherapy patients were measured in two randomized observation studies (81 gynaecological tumours, 40 head and neck tumours). Measurements (atom absorption spectrometry) were performed on serum and whole blood (WB) samples before, in the middle of, at the end, and 6 weeks after radiotherapy. In cases of decreased selenium levels in WB, 63 patients (mean age 63.83+/-9.23 a) received selenium substitution (500 microg sodium selenite at RT days, 300 microg at the weekend) and 64 patients (mean age 63.03+/-10.47 years) were evaluated as control group without any selenium substitution. Both groups were well balanced according to tumour localization and stage. Reference values were 85-162 microg/l WB-selenium, and 65-135 microg/l serum-selenium.

RESULTS

We measured the following WB selenium (Se) levels (Se-group vs. control group, U-test): begin RT 64.17+/-13.98 microg/l vs. 64.50+/-14.47 microg/l (p=0.869); mid RT 92.48+/-26.68 microg/l vs. 65.80+/-18.04 microg/l (p<0.001); end RT 93.78+/-25.90 microg/l vs. 64.06+/-17.54 microg/l (p<0.001); 6 weeks after RT 74.01+/-20.06 microg/l vs. 69.66+/-17.83 microg/l (p=0.183). The serum levels were as follows: begin RT 59.18+/-13.49 microg/l vs. 61.99+/-15.72 microg/l (p=0.427); mid RT 104.75+/-31.41 microg/l vs. 62.37+/-16.23 microg/l (p<0.001); end RT 100.63+/-31.12 microg/l vs. 62.29+/-16.11 microg/l (p<0.001); 6 weeks after RT 72.73+/-26.53 microg/l vs. 64.17+/-17.22 microg/l (p=0.170).

CONCLUSION

The used dosage of 500 microg sodium selenite per day is sufficient to treat selenium deficiency during radiotherapy. After substitution, the patient returns to their individual selenium status.

Limited effects of selenium substitution in the prevention of radiation-associated toxicities. results of a randomized study in head and neck cancer patients

OBJECTIVE

The substitution of selenium activates the selenium-dependent enzyme glutathione peroxidase, which is important for scavenging free radicals. To date, only limited data are available about the clinical impact of selenium regarding the toxicities due to free radical producing therapies, e.g. irradiation or chemotherapy, and therefore the objective of this study was to investigate the clinical impact of selenium in such therapies.

PATIENTS AND METHODS

39 patients (8 female, 31 male) with advanced head and neck cancer were included in a randomised phase II study. The mean age was 63.52+/-9.31 years. Tumour localizations: oral cavity 15 patients, oropharynx 19 patients, hypopharynx 5 patients, carcinoma of unknown primary 1 patient. Group A (n=22) received 500 microg sodium selenite on the days of radiotherapy and 300 microg sodium selenite on days without radiotherapy. Group B (17) was irradiated without any selenium substitution. Both groups were well balanced according to age, gender, localization and stage of the tumour. The RTOG grade of radiation-associated toxicities was evaluated once per week.

RESULTS

The following serious toxicities were observed (group A vs. group B): dysphagia 22.7% vs. 35.3%, loss of taste 22.7% vs. 47.1%, dry mouth 22.7% vs. 23.5%, and stomatitis 36.4% vs. 23.5%. A statistical trend (Fisher's exact test) was only seen for the loss of taste (p=0.172). The weekly patient analysis (Student's t-test) showed a significant reduction of dysphagia in the selenium group (Group 1) at the last week of irradiation.

CONCLUSION

This small randomised trial showed limited effects of selenium in the prevention of ageusia (loss of taste) and dysphagia due to radiotherapy of head and neck cancer.

Complementary and alternative medicine in lung cancer patients: a neglected phenomenon?

Study on the use of complementary and alternative medicine (CAM) in lung cancer patients has been widely neglected. Therefore, we initiated a study on the use of CAM in lung cancer patients in addition to radiation treatment. Overall, 120 patients from 3 institutions were interviewed by a standardized questionnaire. Besides the tumor parameters and the use of CAM, the reason for the use, patient information of the medication, the information sources and the subjective condition of the patient. Altogether, 54% of the patients reported using CAM (66% of female patients, 52% of male patients). The most frequently used CAM measures were vitamin combinations (17%), mistletoe (15%), and selenium (12%). A total of 52% reported the wish to support the tumor treatment as a reason for using CAM and 27% had a 'better feeling' using CAM. 50% of CAM was bought by the patients themselves and 50% were prescribed by their family physicians. The use of CAM is frequent in lung cancer patients. Our results suggest that it is very important to obtain information on the CAM use of patients and, particularly in controlled clinical trials, to prospectively document it.

Zinc concentrations in serum during head and neck cancer progression

Reduced serum-zinc concentrations are well known as typical laboratory characteristics in advanced head and neck cancer. Our aim was to follow the development of this phenomenon during the disease.

PATIENTS AND METHODS

A total of 21 patients were included in this pilot-study (1 female, 20 male). The median age was 64 years, range 43-80 years. The following tumour localizations were registered: 11 larynx, 4 oropharynx, 2 hypopharynx and 4 other. Serum zinc levels were registered at baseline and during the follow-up investigations using flame atomic absorption spectrometry.

RESULTS

The median follow-up time was 17 months, range 6-43 months. During the follow-up, 9/21 patients died tumour-dependently, 2 patients were living with cancer, 8 patients showed NED, and a further 2 patients died of non-cancer related causes. The zinc concentration decreased from 0.76 mmol/l (0.48-1.07 mmol/l) to 0.55 mmol/l (0.32-1.01 mmol/l). Nine of 11 patients with cancer developed extremely low serum zinc concentration 4-6 weeks before dying.

CONCLUSION

The serum zinc concentration may be a marker for definitive palliative situations in head and neck cancer patients.

Influence of amifostine on late radiation-toxicity in head and neck cancer--a follow-up study

AIM

The late toxicities due to multimodal therapy of advanced head and neck cancers were analysed. The impact of cytoprotection with amifostine is the specific objective of this report.

PATIENTS AND METHODS

A total of 851 patients (717 men, 134 women) with head and neck cancer were included in this prospective study. Of these patients, 519/851 had received amifostine before radio(chemo)therapy, while 332 control patients had not received any kind of cytoprotection before irradiation. Primary radiochemotherapy was performed in 282 patients and adjuvant radiation was administered in 569. The follow-up examination was carried out at our outpatient department 21.4 months (median, range 2.3 to 149 months) after the primary therapy.

RESULTS

Late xerostomia was seen in 765/851 patients (89.9%). Altered taste was reported by 284/851 (33.5%). These symptoms were reduced significantly by amifostine. No influence was seen on interstitial lymph edema (48.4%), or stenosis of the cervical esophagus (20.4%). Secondary symptoms such as dysphagia (78.8%) also had a trend for reduction.

CONCLUSION

The administration of amifostine offers an opportunity to reduce selected long-term toxicities for survivors of head and neck cancer.

[Plantar fasciitis and radiotherapy. Clinical and radiobiological treatment results]

Patients with plantar fasciitis and pain refractory to conventional therapy are treated with low-dose radiotherapy (RT), but no conclusive evidence-based and radiobiological studies had been performed. In 2001 the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) carried out a study by mailing a standardized questionnaire. A total of 136 institutions treated 3621 patients/year with chronic or refractory pain. The median total dose was 6 Gy (median single dose: 1 Gy); 76 institutions reported data of their clinical evaluation of a total of 7947 patients. Pain relief lasting for at least 3 months was reported in 70% and persistent pain relief in 65%. There were no acute or chronic radiogenic side effects observed. The radiobiological studies showed a significant increase of granulocyte function at 1.5 Gy and a significant decrease at 3.5 and 4.0 Gy. These results may provide a possible explanation for a local anti-inflammatory effect of low-dose RT. RT may be an excellent alternative for patients with contraindications to long-term treatment with steroids or NSAID.

Serum selenium in head and neck cancer patients--a new marker of tumor activity?

OBJECTIVE

The purpose of this work was to investigate the relationship between the tumor volume and the endogenous selenium levels in untreated head and neck cancer patients.

MATERIALS AND METHODS

One hundred consecutive patients were included in this study. We measured the endogenous levels of selenium in the serum and the whole blood of all patients by atomic absorption spectrometry. Additionally, the activity of glutathione peroxidase and the concentration of malonedialdehyde were observed. The resectability of the tumor was used as an independent marker of the tumor volume.

RESULTS

Thirty-one out of 100 patients had resectable tumors, while 69 patients were characterized as unresectable. The following median results were obtained (resectable versus unresectable): Serum Se 0.90 micromol/l versus 0.78 micromol/l (p=0.024); whole blood Se 1.00 micromol/l versus 0.93 micromol/l (p=0.139); glutathione peroxidase 145 U/l versus 148 U/l (p=0.93); and malonedialdehyde 2.21 mmol/l versus 2.6 mmol/l (p=0.84).

CONCLUSION

The concentration of serum selenium shows a significant relationship with tumor resectability in patients with advanced head and neck cancer.

Selenium in the treatment of head and neck lymphedema

OBJECTIVE

To investigate the impact of selenium in the treatment of lymphedema of the head and neck region after radiotherapy alone or in combination with surgery.

SUBJECTS AND MATERIALS

Between June 1996 and June 2001 a total of 36 cancer patients (29 male, 7 female; median age 61 years) were treated with selenium for persistent, extensive or progressive lymphedema of the head and neck region. Twenty had interstitial endolaryngeal edema associated with stridor and dyspnea. All patients received 350 microg/m(2) body surface sodium selenite medication p.o. daily (total dose 50 microg per day) for a period of 4-6 weeks after radiotherapy. The optimal effect of the selenium treatment was assessed after 4 weeks of therapy using the Miller score system. A visual analogue scale on a scale of 0-10 was used to assess the patient's quality of life prior to and after selenium.

RESULTS

75% of the patients had an improvement of the Miller score of one stage or more. The self-assessment of quality of life using the visual analogue scale improved significantly after selenium treatment with a reduction of 4.4 points (p < 0.05). Of the 20 patients with endolaryngeal edema tracheostomy was not necessary in 13 patients (65%), but 5 and 2 received a temporary or permanent tracheostomy, respectively. No episode of erysipelas was observed in all study patients.

CONCLUSION

Our results suggest a short positive effect of sodium selenite on secondary head and neck lymphedema caused by radiotherapy alone or in combination with surgery.

Anwendung komplementärer/alternativer Therapiemassnahmen bei Patientinnen mit Brustkrebs

BACKGROUND

Complementary/alternative medicine (CAM) is gaining increasing importance especially in the treatment of patients with breast carcinoma. The purpose of this analysis was to investigate the prevalence of CAM in patients with breast carcinoma, to statistically describe the preparations and therapies used, and to determine the reasons for their use, the source of information and the individual perception.

PATIENTS AND METHODS

The statements of 203 patients with breast carcinoma who underwent radiotherapy were analyzed. The median age was 54 years (range 38-77 years). All patients underwent surgery as first therapy. 36 patients received a second-line radiotherapy because of metastases (27 patients) or local recurrence (9 patients).

RESULTS

159 patients (78%) stated to carry out an additional treatment. 31 out of the 36 patients with metastases or local recurrence used CAM. Vitamin preparations (67%), mistletoe therapy (59%), and mineral preparations (33%) were used most frequently. 70% of the patients used a combination of two or more preparations/therapies. The most cited reason for using CAM was the aim of increasing quality of life (28%) and improving the immune system (27%). 72% stated an improvement of their individual perception. The main source of information was the general practitioner or the gynecologist.

CONCLUSION

The radiotherapist has to take these complementary/alternative therapies into consideration; their importance should be evaluated in further studies.

Low-dose radiotherapy for painful heel spur. Retrospective study of 117 patients

PURPOSE

Retrospective analysis of 117 patients treated between 1996 and 2000 with low-dose radiotherapy (RT) for painful heel spurs.

PATIENTS AND METHODS

71 women and 46 men were irradiated on 136 painful heel spurs in one (n = 104) or two radiation series (n = 13). The painful spurs were located either at the plantar (n = 94), dorsal (n = 5) or bilateral heel (n = 18). 82 patients had prior treatments, in 35 patients RT was the primary treatment. Low-dose RT was performed twice a week with one 6-MV photon field. Ten fractions of 0.5 Gy were applied to a total dose of 5 Gy. Evaluation was done on completion and during follow-up using the four-scale von Pannewitz score.

RESULTS

On completion of RT, 27 patients were free of pain, 40 were much improved, 31 reported slight improvement, and 19 experienced no change. After a mean follow-up of 20 months, 75 out of 100 patients were free of pain, twelve had marked and three some improvement. Ten patients reported no change of symptoms. Mean duration of pain before RT was 6 months. RT applied < or = 6 months after the onset of clinical symptoms resulted in improvement in 94%. By contrast, an interval of > 6 months until the initiation of RT resulted in only 73% of patients with clinical improvement.

CONCLUSION

Low-dose RT reveals a benefit in > 80% of the patients. RT should start during the first 6 months of symptoms. Prospective clinical studies with validated symptom scores should be conducted to assess optimal dose and fractionation scheme of RT.

Selenium in the treatment of radiation-associated secondary lymphedema

PURPOSE

The aim of this explorative study was to evaluate the impact of selenium in the treatment of lymphedema after radiotherapy.

MATERIALS AND METHODS

Between June 1996 and June 2001, 12 patients with edema of the arm and 36 patients with edema of the head-and-neck region were treated with selenium for therapy-related lymphedema. Of these 36 patients, 20 had interstitial endolaryngeal edema associated with stridor and dyspnea. All patients received sodium selenite over 4 to 6 weeks.

RESULTS

Self-assessment using a visual analog scale (n = 48) showed a reduction of 4.3 points when comparing pre- and posttreatment values (p < 0.05). Of 20 patients with endolaryngeal edema, 13 underwent no tracheostomy, 5 underwent a temporary tracheostomy, and only 2 underwent a permanent tracheostomy. Ten of 12 patients with arm edema showed a circumference reduction of the edematous limb and improvement in the Skin-Fold Index by 23.3 points. An improvement of one stage or more was shown by the Földi or the Miller score (n = 28) in 22 (Földi score) and in 24 (Miller score) patients.

CONCLUSIONS

Treatment with sodium selenite is well tolerated and easy to deliver. Additionally, our results suggest that sodium selenite has a positive effect on secondary-developing lymphedema caused by radiation therapy alone or by irradiation after surgery.

Spectroscopic gas analyzers based on indium-phosphide, antimonide and lead-salt diode-lasers

Currently available semiconductor lasers for spectroscopy in the near- and mid-infrared region based on direct band-to-band transitions as gallium-arsenide, indium-phosphide, antimonides and lead-salt containing compounds will be discussed together with the main features of different tunable diode-laser absorption spectrometers for trace gas analysis. Measurements of atmospheric carbon dioxide with a room-temperature 2 microm indium-phosphide laser, applications of antimonide lasers for methane and formaldehyde sensing in the 3-4 microm range and a fast chemical sensor for methane flux measurements based on lead-salt diode-lasers operating near 7.8 microm will be presented.

Combined radiotherapy and temozolomide in patients with recurrent high grade glioma

AIMS AND BACKGROUND

There is only little preliminary information about combined-modality treatment with radiotherapy and temozolamide. The purpose of this analysis was to document the feasibility of such combined-modality treatment.

METHODS

We treated 25 patients with recurrent high grade gliomas after standard therapy (surgery and radiation) with the following schedule: 400 mg temozolomide orally for five days repeated every 28 days, and radiotherapy at a dose of 20-30 Gy (2 x 1.2 Gy per day). Four of these patients underwent a second operation without complete tumor resection.

RESULTS

After 125 courses of temozolomide, grade 1 (NCI-CTC) thrombocytopenia was found in four patients and grade 2 in two patients. Two patients developed grade 1 leukocytopenia and two others grade 2. CTC grade 1-2 nausea was observed in eight patients. For one patient we reduced the dose of temozolomide to 300 mg/day because of thrombocytopenia. One patient discontinued therapy after the first course because of leukocytopenia and nausea. CTC grade 3-4 side effects did not occur. Combined-modality treatment showed no more side effects than treatment with temozolomide alone. The median duration of response was seven months.

CONCLUSION

The observed side effects were tolerable. Combined treatment with radiotherapy and temozolomide is feasible. Further investigation of this agent is necessary.

[First results of neoadjuvant simultaneious radiochemotherapy in advanced rectal carcinoma]

PURPOSE

In locally advanced rectal cancer tumor-negative margins often cannot be obtained by surgery alone. Nevertheless only patients with complete tumor resection can be cured. Due to the poor prognosis of patients with R1/R2 resection the "Deutsche Krebsgesellschaft" recommends concurrent preoperative radiochemotherapy for patients with locally advanced rectal cancer.

PATIENTS AND METHODS

Between May 1997 and November 1999 22 patients were treated with preoperative radiochemotherapy. A total dose of 45 Gy with a small-volume boost of 5.4 Gy was delivered in conventional fractionation (single dose 1.8 Gy). On days 1 to 5 and 29 to 33 patients received concurrently 5-fluorouracil (5-FU) as continuous infusion of 1,000 mg/m2. If there was any sign of cardiac toxicity chemotherapy was changed to 5-FU/folinic acid or ralitrexed.

RESULTS

Surgery following radiochemotherapy was performed in 19/22 patients. Resections with negative margins were achieved in 16/19 (84%) patients. Sphincter-conserving surgery was possible in 9/19 (47%) patients. A downstaging of at least 1 T category was found in 12/19 (63%) patients. With a median follow-up of 16 months no locoregional recurrences occurred in patients who underwent surgery. Two-year disease-free survival of resected patients is 62%, 2-year overall survival is 89%, of the whole population 76%.

CONCLUSION

Preoperative radiochemotherapy followed by surgery is able to achieve clear resection margins in more than 70% of patients with locally advanced rectal cancer and may improve the rate of sphincter-conserving surgery.

[The multimodality therapy of advanced inoperable esophageal carcinoma. A retrospective analysis]

BACKGROUND

The records of 161 patients with inoperable esophageal carcinoma were reviewed to determine the influence of concurrent radiochemotherapy and brachytherapy on overall survival.

PATIENTS AND METHODS

From 1984 to 1999 161 patients suffering from advanced esophageal carcinoma Stage II to IV were treated with radiotherapy alone (131) or radiochemotherapy (30). In 48 patients additional brachytherapy was given. Median follow-up was 8 months (1 to 64 months), the median external beam doses was 51 Gy (18 to 66.6 Gy) and the median brachytherapy dose was 10 Gy (4 to 25 Gy). Chemotherapy consisted of cisplatin and 5-fluorouracil.

RESULTS

Median survival for all patients was 10 months, 3-year survival rate 13% and the 5-year survival 5.2%. In univariate analysis the best results were achieved by concurrent radiochemotherapy with a median overall survival of 13 months, a 4-year survival of 18% (p = 0.0368), the combination of external radiotherapy and additional brachytherapy with a median overall survival of 14 months, a 4-year survival of 12.2% (p = 0.0008). After combination of concurrent radiochemotherapy and brachytherapy the 2-year survival rate is 58%. Multivariate analysis revealed simultaneous radiochemotherapy, external beam dose and additional brachytherapy as prognostic factors. Combination of concurrent radiochemotherapy and brachytherapy was possible without significant increase of local toxicity.

CONCLUSIONS

Our retrospective analysis demonstrates that concurrent radiochemotherapy and additional brachytherapy are effective treatment schedules without significant increase of toxicity and may improve overall survival of patients with inoperable carcinoma of the esophagus. According to the results of this retrospective study, it would be appropriate to conduct a randomized trial to evaluate the benefit of combination of concurrent radiochemotherapy and brachytherapy.