Nachweis des Skelettbefalls maligner Erkrankungen durch Immunszintigraphie des Knochenmarks

Immunszintigraphie des hämatopoetischen Knochenmarks und konventionelle Skelettszintigraphie wurden bei 141 Patienten mit malignen Grunderkrankungen verglichen. Die Immunszintigraphie des Knochenmarks wies in allen Patientenuntergruppen mehr metastasentypische Herdbefunde und einen ausgedehnteren Skelettbefall als das Skelettszintigramm nach. In 323 computertomographisch kontrollierten Skelettabschnitten fanden sich in 83,3% übereinstimmende Befunde zur Knochenmarkszintigraphie. Lediglich in 7 von 2135 (0,3%) Skelettabschnitten von 30 Patienten mit Fieber unklarer Ursache ohne maligne Grunderkrankung fanden sich immunszintigraphisch pathologische Herdbefunde. Bei 36 Patienten mit malignen Lymphomen waren immunszintigraphischer und histologischer/zytologischer Befund bei 14 Patienten übereinstimmend positiv und bei 17 Patienten übereinstimmend negativ. Die Immunszintigraphie des Knochenmarks stellt ein vielversprechendes, einfaches und routinefähiges Verfahren zum empfindlichen nichtinvasiven Nachweis des Skelettbefalls maligner Erkrankungen dar.

Augmentation of Transient Donor Cell Chimerism and Alloantigen-Specific Regulation of Lung Transplants in Miniature Swine

Donor alloantigen infusion induces T cell regulation and transplant tolerance in small animals. Here, we study donor splenocyte infusion in a large animal model of pulmonary transplantation. Major histocompatibility complex-mismatched single lung transplantation was performed in 28 minipigs followed by a 28-day course of methylprednisolone and tacrolimus. Some animals received a perioperative donor or third party splenocyte infusion, with or without low-dose irradiation (IRR) before surgery. Graft survival was significantly prolonged in animals receiving both donor splenocytes and IRR compared with controls with either donor splenocytes or IRR only. In animals with donor splenocytes and IRR, increased donor cell chimerism and CD4(+) CD25(high+) T cell frequencies were detected in peripheral blood associated with decreased interferon-γ production of leukocytes. Secondary third-party kidney transplants more than 2 years after pulmonary transplantation were acutely rejected despite maintained tolerance of the lung allografts. As a cellular control, additional animals received third-party splenocytes or donor splenocyte protein extracts. While animals treated with third-party splenocytes showed significant graft survival prolongation, the subcellular antigen infusion showed no such effect. In conclusion, minipigs conditioned with preoperative IRR and donor, or third-party, splenocyte infusions may develop long-term donor-specific pulmonary allograft survival in the presence of high levels of circulating regulatory T cells.

A validated scoring system to identify long-term survivors after radiotherapy for metastatic spinal cord compression

PURPOSE

This study aimed to develop and validate a scoring system to identify long-term survivors after conventional radiotherapy (RT) for metastatic spinal cord compression (MSCC).

PATIENTS AND METHODS

Data from 1,125 patients who had received long-course RT for MSCC were included in this study. Of these patients, 344 survived for over 12 months and 781 died within a year following RT. Based on differences between the distributions of patient characteristics in the two groups, a scoring system was developed. Scores ranged from 0 to 18 points and 15 points was selected as the cutoff for identifying long-term survivors. Data from the 1,125 long-course RT patients (test group) were compared to data from 773 patients receiving short-course RT (validation group).

RESULTS

A score of ≥ 15 points was associated with a 94 % proportion of long-term survivors. The 15-point cutoff resulted in a specificity of 98 % and a positive predictive value of 94 % for identification of long-term surviving patients. The proportions of long-term survivors for each scoring point in the validation group were very similar to those in the test group.

CONCLUSION

This new scoring system enabled identification of long-term survivors after RT for MSCC with very high specificity and positive predictive value. The score proved to be valid and reproducible.

Impact of zoledronic acid on control of metastatic spinal cord compression

BACKGROUND

Zoledronic acid was demonstrated to reduce the rate of skeletal-related events, a hypernym including various outcomes, in patients with bone metastases. In contrast to other studies, this matched-pair analysis focused solely on the impact of zoledronic acid on metastatic spinal cord compression (MSCC).

PATIENTS AND METHODS

Data from 98 patients with MSCC receiving radiotherapy plus zoledronic acid were matched 1:2 to 196 patients receiving radiotherapy alone for ten potential prognostic factors. Both groups were compared for local control of MSCC within the irradiated region, overall control of MSCC (local and distant MSCC control), and survival.

RESULTS

The 1-year local control rates were 90% after radiotherapy plus zoledronic acid and 81%, after radiotherapy alone (p = 0.042). The 1-year overall control rates were 87% and 75%, respectively (p = 0.016), and the 1-year survival rates were 60% and 52%, respectively (p = 0.17). Results were significant in the Cox proportional hazards model regarding local control (p = 0.024) and overall control (p = 0.008).

CONCLUSION

According to the results of this study, zoledronic acid was associated with improved control of MSCC in irradiated patients.

Do elderly patients benefit from surgery in addition to radiotherapy for treatment of metastatic spinal cord compression?

BACKGROUND

Treatment of elderly cancer patients has gained importance. One question regarding the treatment of metastatic spinal cord compression (MSCC) is whether elderly patients benefit from surgery in addition to radiotherapy? In attempting to answer this question, we performed a matched-pair analysis comparing surgery followed by radiotherapy to radiotherapy alone.

PATIENTS AND METHODS

Data from 42 elderly (age > 65 years) patients receiving surgery plus radiotherapy (S + RT) were matched to 84 patients (1:2) receiving radiotherapy alone (RT). Groups were matched for ten potential prognostic factors and compared regarding motor function, local control, and survival. Additional matched-pair analyses were performed for the subgroups of patients receiving direct decompressive surgery plus stabilization of involved vertebrae (DDSS, n = 81) and receiving laminectomy (LE, n = 45).

RESULTS

Improvement of motor function occurred in 21% after S + RT and 24% after RT (p = 0.39). The 1-year local control rates were 81% and 91% (p = 0.44), while the 1-year survival rates were 46% and 39% (p = 0.71). In the matched-pair analysis of patients receiving DDSS, improvement of motor function occurred in 22% after DDSS + RT and 24% after RT alone (p = 0.92). The 1-year local control rates were 95% and 89% (p = 0.62), and the 1-year survival rates were 54% and 43% (p = 0.30). In the matched-pair analysis of patients receiving LE, improvement of motor function occurred in 20% after LE + RT and 23% after RT alone (p = 0.06). The 1-year local control rates were 50% and 92% (p = 0.33). The 1-year survival rates were 32% and 32% (p = 0.55).

CONCLUSION

Elderly patients with MSCC did not benefit from surgery in addition to radiotherapy regarding functional outcome, local control of MSCC, or survival.

High frequency and allele-specific differences of BRCA1 founder mutations in breast cancer and ovarian cancer patients from Belarus

Breast cancer and ovarian cancer are common malignancies in Belarus accounting for about 3500 and 800 new cases per year, respectively. For breast cancer, the rates and age of onset appear to vary significantly in regions differentially affected by the Chernobyl accident. We assessed the frequency and distribution of three BRCA1 founder mutations 5382insC, 4153delA and Cys61Gly in two hospital-based series of 1945 unselected breast cancer patients and of 201 unselected ovarian cancer patients from Belarus as well as in 1019 healthy control females from the same population. Any of these mutations were identified in 4.4% of the breast cancer patients, 26.4% of the ovarian cancer patients and 0.5% of the controls. In the breast cancer patients, BRCA1 mutations were strongly associated with earlier age at diagnosis, with oestrogen receptor (ER) negative tumours and with a first-degree family history of breast cancer, although only 35% of the identified BRCA1 mutation carriers had such a family history. There were no marked differences in the regional distribution of BRCA1 mutations, so that the significant differences in age at diagnosis and family history of breast cancer patients from areas afflicted by the Chernobyl accident could not be explained by BRCA1. We next observed a higher impact and a shifted mutational spectrum of BRCA1 in the series of Byelorussian ovarian cancer patients where the three founder mutations accounted for 26.4% (53/201). While the Cys61Gly mutation appeared underrepresented in ovarian cancer as compared with breast cancer cases from the same population (p = 0.01), the 4153delA mutation made a higher contribution to ovarian cancer than to breast cancer (p < 0.01). BRCA1 mutations were significantly enriched among ovarian cancer cases with a first-degree family history of breast or ovarian cancer, whereas the median age at ovarian cancer diagnosis was not different between mutation carriers and non-carriers. Taken together, these results identify three BRCA1 founder mutations as key components of inherited breast and ovarian cancer susceptibility in Belarus and might have implications for cancer prevention, treatment and genetic counselling in this population.

[Preoperative radiochemotherapy of advanced resectable cancer of the oral cavity with cisplatin vs paclitaxel/carboplatin. Analysis of two multimodality treatment concepts]

PURPOSE

The purpose of simultaneous chemoradiotherapy is to increase local tumor control and to decrease the incidence of distant metastases. Platinum-based chemotherapy regimens are widely accepted as standard treatment in advanced head and neck cancer. Due to their remarkable activity as well as radiosensitizing effects, taxanes play in increasing role in multimodality treatment concepts of solid tumors.

MATERIAL AND METHODS

Since 1989 a total of 85 patients with advanced squamous cell carcinoma of the oral cavity and oropharynx were recruited to participate in two different prospective clinical trials of preoperative chemoradiation. Both treatment concepts (study A: cisplatin 12.5 mg/m(2) plus radiation 36 Gy vs study B: Taxol 40 mg/m(2)/carboplatin AUC 1.5 plus radiation 40 Gy) were compared and further statistical analysis including descriptive analysis as well as univariate and multivariate analysis was performed.

RESULTS

At the time of the analysis a total of 47 patients (55.3%) were alive, 38 patients (44.7%) died from tumor-related causes. The overall survival for both patient groups at 5 years was 45.1% (study A) and 84.9% (study B) and after 10 years 32.4% for study group A. A comparative analysis of both groups revealed a highly significant survival benefit at 4 years for study B (p=0.0015). In various calculation models of the multivariate analysis the regimen containing Taxol/carboplatin (study B) was superior to the cisplatin regimen (study A).

CONCLUSION

Based on a retrospective analysis of two different concepts of preoperative chemoradiation and supported by recent data from the literature it is justified to conclude that taxane-based combination regimens are more effective compared to cisplatin-based regimens.

[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.

Positron emission tomography with 11C-acetate and 18F-FDG in prostate cancer patients

Visualisation of primary prostate cancer, its relapse and its metastases is a clinically relevant problem despite the availability of state-of-the-art methods such as CT, MRI, transrectal ultrasound and fluorine-18 fluorodeoxyglucose positron emission tomography ((18)F-FDG PET). The aim of this study was to evaluate the efficacy of carbon-11 acetate and (18)F-FDG PET in the detection of prostate cancer and its metastases. Twenty-five patients were investigated during the follow-up of primary prostate cancer, suspected relapse or metastatic disease using (11)C-acetate PET; 15 of these patients were additionally investigated using (18)F-FDG PET. Fourteen patients were receiving anti-androgen treatment at the time of the investigation. Lesions were detected in 20/24 (83%) patients using (11)C-acetate PET and in 10/15 (75%) patients using (18)F-FDG PET. Based on the results of both PET scans, one patient was diagnosed with recurrent lung cancer. Median (18)F-FDG uptake exceeded that of (11)C-acetate in distant metastases (SUV =3.2 vs 2.3). However, in local recurrence and in regional lymph node metastases, (11)C-acetate uptake (median SUVs =2.9 and 3.8, respectively) was higher than that of (18)F-FDG (median SUVs =1.0 and 1.1, respectively). A positive correlation was observed between serum PSA level and both (11)C-acetate uptake and (18)F-FDG uptake. (11)C-acetate seems more useful than (18)F-FDG in the detection of local recurrences and regional lymph node metastases. (18)F-FDG, however, appears to be more accurate in visualising distant metastases. There may be a role for combined (11)C-acetate/(18)F-FDG PET in the follow-up of patients with prostate cancer and persisting or increasing PSA.

[Prospective phase II study of neoadjuvant radiochemotherapy in advanced operable carcinoma of the mouth cavity. 3-year outcome]

PURPOSE

The purpose of simultaneous chemoradiotherapy is to increase local-regional control and to decrease the incidence of distant metastases. Regimens containing cisplatin/5-FU chemotherapy are widely accepted as standard treatment in advanced head and neck cancer. Most studies reported promising response and survival data, but also severe mucosal toxicity. In recent years the newly developed drug Taxol demonstrated interesting activity in head and neck cancer as a single agent as well as in combination drug regimens. In the present outpatient phase II trial, we investigated the combination of Taxol/carboplatin with 40 Gy radiotherapy in a neoadjuvant setting of operable stage III/IV squamous cell carcinoma of the oral cavity and oropharynx.

PATIENTS AND METHODS

Fifty-three patients were enrolled in this trial during the period from May 1998 to October 2000 and received five cycles weekly of Taxol (40 mg/m2) and carboplatin (AUC 1.5) with conventional radiotherapy (40 Gy). Within 3-4 weeks after chemoradiotherapy resection of the primary tumor and the regional neck nodes was performed.

RESULTS

Fifty-two patients were evaluable for toxicity and response. Complete response was observed in 31 of 52 patients (CR 60%), and partial remission was seen in 21 of 52 patients (PR 40%). In 30 of 52 patients complete pathologic response (pCR 58%) was documented in the resection specimens. The 1-, 2-, and 3-year overall survival rate was calculated as 84%.

CONCLUSION

Our present results demonstrated impressive clinical and pathological response rates of concurrent Taxol/carboplatin and radiotherapy as a preoperative treatment modality in advanced oral and oropharyngeal cancer.

[Spermatocytic seminoma. Report of 2 personal cases and review of the literature]

The spermatocytic seminoma is a distinct testicular neoplasm with a low tendency to metastasize. Two own cases with the diagnosis of a spermatocytic seminoma are presented. A third patient is described, where the initial diagnosis of a spermatocytic seminoma was retrospectively changed to classical seminoma after developing retroperitoneal relapse during surveillance. A literature review revealed distinct histopathological characteristics and a remarkably good prognosis for spermatocytic seminoma. With only one case of relapse confirmed in the literature, in these patients postoperative treatment can safely be omitted in favor of surveillance. In case of spermatocytic seminoma diagnosis should be confirmed by a second pathologist.

Spectrum of ATM gene mutations in a hospital-based series of unselected breast cancer patients

Blood relatives of patients with the inherited disease ataxia telangiectasia (A-T) have an increased susceptibility for breast cancer. We therefore looked for sequence alterations of the ATM gene in a large hospital-based series of unselected breast cancer patients. The whole ATM coding sequence was analyzed in genomic DNA samples from a core group of 192 consecutive breast cancer cases to define the spectrum of ATM gene mutations. Common sequence alterations were then screened in the whole series of 1000 breast cancer patients and in 500 random individuals. In the core group, 21 distinct sequence alterations were identified throughout the ATM coding region, and 1 common splicing mutation was uncovered in intron 10. Almost half of the breast cancer patients (46%) were heterozygotes for 1 of 16 different amino acid substitutions, and three patients (1.6%) carried a truncating mutation. These data indicate that approximately 1 in 50 German breast cancer patients is heterozygous for an A-T-causing mutation. In our extended series, the most common A-T mutation 1066-6T-->G was disclosed in 7 of 1000 (0.7%) breast cancer patients. Transcript analyses indicated that the loss of exon 11 in the ATM mRNA was the pathogenic consequence of this splicing mutation, which produced a <10% of full-length ATM mRNA and ATM protein in a homozygous A-T patient. We also found an excess of rare missense substitutions in the breast cancer cohort compared with random individuals (7.9% versus 5.3% of alleles; odds ratio = 1.6; P < 0.01). One missense substitution, S707P in exon 15, was two times more frequent in breast cancer patients (odds ratio = 2.4; 95% confidence interval, 1.0-5.8) and five times more frequent in patients with bilateral disease than in random individuals (P < 0.001). We conclude that a large variety of distinct ATM mutations and variants exist among breast cancer patients, some of which can contribute to the etiology and progression of the malignancy. Screening for frequent A-T mutations such as the 1066-6-->G splice site substitution can be effective to prospectively identify A-T heterozygotes in an unselected cancer patient population.

[The value of positron emission tomography (PET) in the treatment of patients with cancer of unknown primary (CUP)]

BACKGROUND

In patients with cancer of unknown primary median survival for localized disease is 20, for disseminated disease 7 months. After diagnostic procedures including MRI or endoscopy, the primary tumor is detected in less than 25%. In the study presented here the value of PET for detection of the primary tumor and a possible dissemination has been investigated and related to therapeutic regimens.

PATIENTS AND METHODS

Between May 1998 and February 2001 a total of 52 patients with CUP syndrome, 18 females and 34 males, have been included. At first diagnosis, stage of disease was localized in 43 patients (35 lymphonodal, eight visceral), and disseminated in nine patients (Table 1). After a median of seven (range three to eleven) diagnostic procedures without detection of the primary tumor (Table 2) PET with fluorine-18-fluorodeoxyglucose was performed.

RESULTS

Due to the PET result a primary tumor was suggested in 31/52 patients (60%), and confirmed in 21/52 patients (40%). In 16/43 patients (37%) with initially (before PET) localized disease dissemination was detected by PET only, despite various preceding diagnostic procedures (Figure 1). Overall, in 33/52 patients (63%) the PET result had major impact on selection of an individual treatment (Table 3), in case of initially localized disease in 30/43 patients (70%).

CONCLUSION

In patients with CUP the PET result is not only of great value for detection of the primary tumor, but in case of initially localized disease also for diagnosis of a possible dissemination. The PET result often has relevant influence on therapeutic management.

Therapeutic options for meningeal melanocytoma. Case report

Meningeal melanocytomas are uncommon lesions. They are generally considered to be benign tumors that derive from leptomeningeal melanocytes. A rare case of a metastatic spinal meningeal melanocytoma is presented. All relevant cases reported in literature since 1972, when the term "meningeal melanocytoma" was first used, were reviewed. Rates of tumor recurrence from 1 to 5 years were calculated for this rare lesion, based on published data and on additional information obtained from personal contact with most of the authors. Recurrency rates of 47 patients suitable for evaluation were correlated with the different therapeutic approaches. Complete tumor resection alone and incomplete resection alone followed by irradiation appeared to be superior to incomplete resection alone in terms of disease-free survival. Statistical significance was achieved for complete tumor resection at follow up between I and 4 years (range p = 0.010-0.050) and for incomplete resection combined with radiotherapy after 2 years (p = 0.034). Complete tumor resection should be considered the best therapeutic option, followed by incomplete resection combined with postoperative radiotherapy.

Metastatic malignant ameloblastoma responding to chemotherapy with paclitaxel and carboplatin

We report an unusual case of metastatic ameloblastoma, involving lung and pleura. that repeatedly responded to systemic treatment with paclitaxel and carboplatin. suggesting principle chemosensitivity of this rare disease.

Mutations of the BRCA1 and BRCA2 genes in patients with bilateral breast cancer

Mutations of the BRCA1 or BRCA2 genes have been shown to strongly predispose towards the development of contralateral breast cancer in patients from large multi-case families. In order to test the hypothesis that BRCA1 and BRCA2 mutations are more frequent in patients with bilateral breast cancer, we have investigated a hospital-based series of 75 consecutive patients with bilateral breast cancer and a comparison group of 75 patients with unilateral breast cancer, pairwise matched by age and family history, for mutations in the BRCA1 and BRCA2 genes. Five frameshift deletions (517delGT in BRCA1; 4772delA, 5946delCT, 6174delT and 8138del5 in BRCA2) were identified in patients with bilateral disease. No further mutations, apart from polymorphisms and 3 rare unclassified variants, were found after scanning the whole BRCA1 and BRCA2 coding sequence. Three pathogenic BRCA1 mutations (Cys61Gly, 3814del5, 5382insC) were identified in the group of patients with unilateral breast cancer. The frequencies of common BRCA1 and BRCA2 missense variants were not different between the 2 groups. In summary, we did not find a significantly increased prevalence of BRCA1 and BRCA2 mutations in a hospital-based cohort of German patients with bilateral breast cancer. We conclude that bilaterality of breast cancer on its own is not strongly associated with BRCA1 and BRCA2 mutations when adjusted for age and family history. The high frequency of bilateral disease in multi-case breast cancer families may be due to a familial aggregation of additional susceptibility factors modifying the penetrance of BRCA1 and BRCA2 mutations.

Time of developing motor deficits before radiotherapy as a new and relevant prognostic factor in metastatic spinal cord compression: final results of a retrospective analysis

The aim of this retrospective analysis was to determine the prognostic value of the time of developing motor deficits before radiotherapy (RT) and to confirm our preliminary results by achieving statistical significance. Of 529 patients receiving spinal irradiation (1994-1998) 131 fulfilled the selection criteria. Three groups were formed according to time of developing motor deficits: 1-7 days (n = 51), 8-14 days (40), >14 days (40). Motor function was graded before, 2 weeks and 3 months after RT. After 2 weeks, patients developing motor deficits for >14 days showed improvement more often than patients of the other groups (65 versus 32.5 and 4%, p < 0.001). After 3 months results were comparable (p < 0.001). A slower development of motor deficits predicts a better functional outcome. Time of developing motor deficits before RT is a relevant prognostic factor in metastatic spinal cord compression.

[Bilateral breast carcinoma and local recurrence: prevalence of BRCA-1 and BRCA-2 gene mutations in an unselected patient sample]

BACKGROUND

Mutations of the BRCA 1/BRCA 2 genes strongly predispose towards the development of contralateral breast cancer. We therefore investigated a hospital-based series of patients with bilateral breast cancer and a comparison group of patients with unilateral breast cancer, pairwise matched by age and family history, for mutations of the BRCA 1/BRCA 2 genes.

PATIENTS AND METHODS

Between 1995 and 2000 genomic DNA from blood samples of 75 patients with bilateral breast cancer, who received postoperative radiotherapy, was analyzed for mutations of all coding regions and flanking intron sequences of the BRCA 1/BRCA 2 genes by single strand conformation polymorphism analysis (SSCP) and sequencing of aberrant findings. The results were compared to 75 unilateral breast cancer patients who were screened for common mutations in the BRCA 1 and BRCA 2 genes. Treatment results of patients with bilateral disease were analyzed with regard to a possible carriership of a BRCA 1/BRCA 2 gene mutation.

RESULTS

Five distinct frameshift deletions (one in BRCA 1, four in BRCA 2) were identified in six patients with bilateral breast cancer. Three of six carriers developed local relapse, whereas this was the case in only nine of 69 non-carriers. After radiotherapy local relapse occurred in five patients (five of 126 irradiated breasts or chest walls). Three of these patients (60%) were carriers of a pathogenic BRCA 1/BRCA 2 mutation. In the comparison group of patients with unilateral breast cancer three pathogenic BRCA 1 mutations were identified.

CONCLUSIONS

We failed to confirm an increased prevalence of BRCA 1/BRCA 2 mutations in our hospital-based series of patients with bilateral breast cancer. However, local relapse, especially when occurring after radiotherapy, may be predictive for an underlying pathogenic BRCA 1 and BRCA 2 gene mutation in patients with bilateral breast cancer.

Spondylodiscitis in patients with spinal cord compression: a possible pitfall in radiation oncology

PURPOSE

In patients presented for spinal irradiation it may be difficult to distinguish between malignant and benign lesions if only plain X-rays and computed tomography (CT)-scans are available. Spinal magnetic resonance imaging (MRI) can be of great diagnostic value.

METHODS

From 11/1995 to 05/2000 447 patients were presented for spinal irradiation, 264 beyond regular operating hours. At presentation no spinal MRI was available in 170/447 and 132/264 patients.

RESULTS

After spinal MRI, diagnosis was changed from vertebral metastases to spondylodiscitis in 10/170 and 8/132 patients. Six of these patients were already known as cancer patients.

CONCLUSION

In patients presented for spinal irradiation spondylodiscitis is not very uncommon. If there is any doubt about metastatic disease as the cause for spinal cord compression a spinal MRI has to be demanded, even beyond regular operating hours.

Adjuvant versus neoadjuvant radiochemotherapy for locally advanced rectal cancer. A progress report of a phase-III randomized trial (protocol CAO/ARO/AIO-94)

AIM

The standard treatment for patients with clinically resectable rectal cancer is surgery. Postoperative radiochemotherapy is recommended for patients with advanced disease (pT3/4 or pN+). In recent years, encouraging results of preoperative radiotherapy have been reported. This prospective randomized phase-III trial (CAO/ARO/AIO-94) compares the efficacy of neoadjuvant radiochemotherapy to standard postoperative radiochemotherapy. We report on the design of the study and first results with regard to toxicity of radiochemotherapy and postoperative morbidity.

PATIENTS AND METHODS

Patients with locally advanced operable rectal cancer (uT3/4 or uN+, Mason CS III/IV) were randomly assigned to pre- or postoperative radiochemotherapy: A total dose of 50.4 Gy (single dose 1.8 Gy) was applied to the tumor and the pelvic lymph nodes. 5-FU (1,000 mg/m2/d) was administered concomitantly in the first and fifth week of radiation as 120-h continuous infusion. Four additional cycles of 5-FU chemotherapy (500 mg/m2/d, i.v. bolus) were applied. Radiochemotherapy was identical in both arms except for a small-volume boost of 5.4 Gy in the postoperative setting. Time interval between radiochemotherapy and surgery was 4-6 weeks in both arms. Techniques of surgery were standardized and included total mesorectal excision. In addition, stratification according to surgeons involved has been provided for. Primary endpoints of the study are 5-year overall-survival, local and distant control, secondary endpoints include rate of curative (R0) resections and sphincter saving procedures, toxicity of radiochemotherapy, surgical complications and quality of life.

RESULTS

As of 15th November 2000, 628 patients were randomized from 26 participating institutions: 310 patients were randomized to postoperative radiochemotherapy, 318 patients to preoperative radiochemotherapy. Acute toxicity (WHO) of radiochemotherapy was low, with less than 15% of patients experiencing Grade 3 or higher toxicity: The principal toxicity was diarrhea, with 12% in the postoperative radiochemotherapy arm and 10% in the preoperative radiochemotherapy arm having Grade-3, and 1% in either arm having Grade-4 diarrhea. Erythema, nausea and leukopenia were the next common toxicities, with less than 3% of patients in either arm suffering Grade 3 or greater leukopenia or nausea. Postoperative complication rates were similar in both arms, with 12% (postoperative radiochemotherapy) and 13% (preoperative radiochemotherapy) of patients, respectively, suffering from anastomotic leakage, 4% (postoperative radiochemotherapy) and 3% (preoperative radiochemotherapy) from postoperative bleeding, and 6% (postoperative radiochemotherapy) and 5% (preoperative radiochemotherapy) from delayed wound healing.

CONCLUSION

The patient accrual of our trial is satisfactory, neoadjuvant radiochemotherapy is well tolerated and bears no higher risk for postoperative morbidity.

Application of a new verification technique allowing craniospinal irradiation in supine position

To minimize anaesthesia related risks during craniospinal irradiation in children, treatment in supine position would be preferable. Verification especially of the cervical three-field junction causes problems, because direct visual control is not possible. We present clinical experiences with a new verification technique with all three fields exposed on one single film.

Prognostic significance of the time of developing motor deficits before radiation therapy in metastatic spinal cord compression: one-year results of a prospective trial

PURPOSE

To investigate prospectively the prognostic value of the time of developing motor deficits before radiation therapy (RT) for post-treatment functional outcome in metastatic spinal cord compression.

METHODS AND MATERIALS

From November 1998 until October 1999, 57 patients were included. Two subgroups were formed according to the time of developing motor deficits before RT: 1-14 days (n = 29) and > 14 days (n = 28). Therapeutic effect on motor function was evaluated by an 8-point scale directly, 6, 12, and 24 weeks after RT. Patients with rapid deterioration of motor function within 48 h before RT (n = 14) were evaluated separately.

RESULTS

Directly after RT, 26/28 patients (93%) of the group developing motor deficits > 14 days showed improvement of motor function, in comparison to 3/29 patients (10%) of the group 1-14 days (p < 0.001). Deterioration rates were 0% (> 14 days) and 45% (1-14 days). In patients with rapid deterioration of motor function within 48 h before RT, prognosis was poor (improvement 0%, no change 43%, deterioration 57%). Results were comparable 6, 12, and 24 weeks after RT.

CONCLUSION

A slower development of motor deficits before RT predicts a better post-treatment functional outcome. In patients with rapid deterioration of motor function within 48 h before RT, prognosis was extraordinarily poor. These results support the findings of our preceding retrospective analysis.

[Simultaneous radiochemotherapy with taxol/carboplatin in advanced operable head-neck tumors. Preliminary results]

BACKGROUND

The purpose of simultaneous chemoradiotherapy is to increase local-regional control and to decrease the incidence of distant metastases. Regimens containing cisplatin/5-FU chemotherapy are widely accepted as standard treatment in advanced head and neck cancer. Most studies reported promising response and survival data, but also severe mucosal toxicity. In recent years the newly developed drug Taxol demonstrated interesting activity in head and neck cancer as a single agent and as well in combination drug regimens. In the present outpatient phase-II trial we investigated the combination of Taxol/carboplatin with 40 Gy radiotherapy in a neoadjuvant setting of operable Stage-III/IV squamous cell carcinoma of the oral cavity and oropharynx.

PATIENTS AND METHODS

Twelve patients were enrolled in this ongoing trial with a projected number of 30 patients and received 5 cycles of weekly Taxol (40 mg/m2) and carboplatin (AUC 1.5) with conventional radiotherapy (40 Gy). Within 3 to 4 weeks after chemoradiotherapy resection of the primary tumor and the regional neck nodes was performed.

RESULTS

So far 12 patients were evaluable for toxicity and response. Complete response was noted in 8/12 patients (CR 66%). In 6/10 patients (60%) complete pathologic response was documented in the resection specimens.

CONCLUSION

Our preliminary results demonstrated excellent clinical and pathological response rates of concurrent Taxol/carboplatin and radiotherapy as preoperative treatment modality in advanced oral and oropharyngeal cancer.

Effectiveness of hypofractionated radiotherapy in painful bone metastases. Two prospective studies with 1 x 4 Gy and 4 x 4 Gy

BACKGROUND

Although effectiveness of fractionated radiotherapy for painful bone metastases is well documented, there are unanswered questions regarding the adequacy of low-dose short radiation schedules for long-term pain control which give maximum benefit in patients with a short life expectancy.

PATIENTS AND METHODS

Two consecutive non-randomized prospective follow-up studies were performed at a single institution to analyze pain response and duration of response in patients with a variety of primary tumors. Included were only patients with symptomatic nonvertebral bone metastases and without impending pathologic fracture. Forty-five patients received 1 x 4 Gy to 50 different sites (group I) while 86 patients received 4 x 4 Gy to 96 sites (group II). Pain relief to irradiation was evaluated according to patient interviews using a 4-point categorical scale. Follow-up was performed 7 and 90 days after radiotherapy.

RESULTS

Pain relief after 4 x 4 Gy was significantly superior to 1 x 4 Gy with pain control rates being 86.5% vs 48% at day 7 (after end of treatment) and 80% vs 55% at day 90, respectively. A subgroup analysis of patients treated with 4 x 4 Gy demonstrated a more favorable outcome for breast cancer patients in comparison to patients with other primaries concerning pain relief (96% vs 81%), pain control after 90 days (93% vs 72%), median time to pain progression (9 vs 3 months), and median overall survival (14 vs 5.5 months).

CONCLUSIONS

In this study 4 x 4 Gy proved to be clearly superior to 1 x 4 Gy in relieving pain from symptomatic nonvertebral bone metastases without impending pathologic fracture. Even if radiotherapy with 1 single fraction seems to be applicable in specific cases doses higher than 4 Gy should be chosen. In breast cancer patients pain control seems to be better compared to other primaries.

Craniospinal axis irradiation in children. Treatment in supine position including field verification as a prerequisite for anesthesia without intubation

PURPOSE

For craniospinal axis irradiation in young children sometimes anesthesia is required. In order to minimize risks from the anesthesist's point of view supine position would be preferable to standard prone position. In case of irradiation in supine position verification of the 3-field junction in the cervical region causes problems, because there is no direct visual control. For such situations the clinical application of a new technique is presented.

PATIENTS AND METHODS

For treatment planning a modern 3D planning system was necessary. Patient's positioning was done by using a vacuum-form body immobilizer and an integrated head mask. Radiation fields were placed only by table movements being calculated by the planning system in relation to a reference point at the patient's surface. In addition to common verification films specially prepared small films were used for the 3-field junction in the cervical region. These films were placed close to the patient for the whole time of each radiation session being exposed by every radiation field.

RESULTS

Two children (age 3 and 5 years, respectively) were irradiated as described. Twenty-eight of those specially prepared films were exposed. Two films (7%) had to be excluded because of inadequate exposure. An overlap of radiation fields was seen on 1 of the 26 remaining films (4%), whereas an unacceptable gap was not found. Acute skin reactions were comparable to those observed in patients being irradiated in standard prone position.

CONCLUSION

The presented technique for craniospinal axis irradiation in supine position including field verification was not only precise and reproducable, but also comfortable and safe for the patient. We suggest it as a new option for craniospinal axis irradiation in children.

Metastatic spinal cord compression. Influence of time between onset of motoric deficits and start of irradiation on therapeutic effect

BACKGROUND

In a retrospective analysis we investigated the prognostic significance of the interval between first appearance of motoric deficits and the beginning of radiation therapy (RT) with regard to posttreatment motoric function.

MATERIAL AND METHODS

Data of more than 400 consecutive patients being irradiated at our department between 1994 and 1997 because of vertebral metastases were reviewed. Ninety-six patients fulfilled selection criteria including motoric deficits, no preceding surgical or radiotherapeutic treatment of the spine, minimum total dose of 24 Gy referred to spinal cord, and additional treatment with dexamethasone. Two subgroups with a similar number of patients for better comparability were formed according to the time of developing motoric deficits: 1 to 13 days (49 patients) and > or = 14 days (47 patients). Effect of irradiation on motoric function was evaluated 2 weeks and about 3 months after radiotherapy. Patients with severe deterioration of motoric function within 48 hours before radiation therapy (31 patients) were looked at separately.

RESULTS

Two weeks after radiotherapy 42/47 patients (89%) developing motoric deficits > or = 14 days showed improvement of motoric function in comparison to 6/49 patients (12%) of the other group. Deterioration occurred in 1/47 patients (2%) of the first and in 24/49 patients (49%) of the latter group. In case of severe deterioration of motoric function within 48 hours before radiation therapy only 2/31 patients (6%) showed improvement, but 20/31 (65%) deterioration. About 3 months after radiotherapy comparable results were observed. Median survival time was 4 months.

CONCLUSION

A slower development of motoric deficits before beginning of radiotherapy means a better therapeutic effect and a more favorable functional outcome after treatment. The prognosis is extraordinarily poor if severe deterioration of motoric function occurs within 48 hours before radiotherapy.

[Nasal T-cell lymphoma of the lethal midline type. Case report and current aspects in the literature]

A case of nasal T-cell lymphoma as a cause of lethal midline granuloma in a 41-year-old woman is described. Primary chemotherapy as management failed, and tumor control was achieved thereafter by local radiotherapy to a dose of 52 Gy. Fourteen months after diagnosis the patient died in multiorgan failure with involvement of her skin, lung and liver. Present studies give strong evidence that lethal midline granuloma is very often a type of T-cell lymphoma that might be caused by Epstein-Barr virus. According to the literature our findings support the hypothesis that tumors are best treated by local high-dose irradiation.

Frequency of BRCA1 mutation 5382insC in German breast cancer patients

OBJECTIVE

The aim of the study was to determine the frequency of the BRCA1 mutation 5382insC in German breast cancer patients with and without prior knowledge of a family history of breast cancer.

METHODS

Two groups of breast cancer patients were tested for the presence or absence of the 5382insC mutation using a PCR primer mismatch assay. A sample of 248 patients unrelated by genealogy was selected based on a history of breast and/or ovarian cancer in the families. In addition, a population-based sample of 800 unselected breast cancer patients was included in the analysis. Three intragenic DNA markers D17S1323, D17S1322, and D17S855, located at BRCA1 introns 12, 19, and 20, respectively, were utilized for allelic association studies as well as for haplotype analysis in 4 breast/ovarian cancer families.

RESULTS

The 5382insC mutation was identified in 10/248 (4.0%) familial breast cancer patients and in 8/800 (1.0%) unselected cases. Allelic association studies and haplotype analysis revealed an association of allele Nos. "6" at D17S1323 (chi2 value = 9.34, P = 0.007), "5" at D17S1322 (chi2 value = 3.62, P = 0.171), and "4" at D17S855 (chi2 value = 11.34, P = 0. 002) with the mutation 5382insC.

CONCLUSION

5382insC constitutes a frequent BRCA1 mutation in German breast cancer patients. The significant allelic association between this mutation and two intragenic DNA markers (D17S1323, D17S855) and the elevated allele frequency at marker D17S1322 suggest an ancient founder in the German breast cancer population. The PCR primer mismatch assay described herein provides a rapid and reliable detection method for the recurrent 5382insC mutation and will be useful for the analysis of large breast cancer populations.

[Malignoma versus bacterial spondylodiscitis: value of spinal MRI for the differential diagnosis in an emergency situation. Description in an acute case with progressive paraplegia]

BACKGROUND

For the radiation oncologist in an emergency situation with acute progressive paraplegia distinguishing between benign versus malignant vertebral compression fracture without known malignoma may cause a severe diagnostic problem, when a rapid therapeutic decision is required.

PATIENT AND METHOD

A case of an elderly diabetic patient with acute onset of a progressive neurologic deficit is reported. No malignancy was known so far. The CT of the spine showed a destruction of the 7th and 8th thoracic vertebral body with compression of the spinal cord. The patient was referred to the radiotherapist for radiation of a presumed malignant spinal process.

RESULT

For differential diagnosis a magnetic resonance imaging (MRI) of the spine was performed and could lead to the correct diagnosis of an infectious spondylodiscitis.

CONCLUSION

The MRI of the spine has a potential role for correct differentiation between benign and malignant spinal lesions and may thereby assist the radiotherapist in the decision making in an emergency situation.

A frequent polymorphism of the gene mutated in ataxia telangiectasia

The gene mutated in ataxia telangiectasia (AT), the ATM gene, has recently been cloned and shown to encode a multi-domain protein with homology to cell-cycle regulators. We report here an intragenic restriction fragment length polymorphism of the ATM gene that is common in the German population with allele frequencies of 0.56 and 0.44, respectively. Observed heterozygosity approximated 50% in healthy individuals as well as in 152 randomly selected breast cancer patients. We present a simple and rapid polymerase chain reaction (PCR)-based assay for this dimorphism that should be useful to trace the inheritance of ATM alleles in ataxia telangiectasia and breast cancer families and to study loss of heterozygosity in primary tumours.

[Detection of bone involvement in malignant diseases by immunoscintigraphy of the bone marrow]

The results of immunoscintigraphy of haematopoetic bone marrow were compared with those of conventional bone scanning in 141 patients with malignant diseases. Marrow scans showed more metastatic lesions than bone scanning in all patient subgroups, resulting in a significantly more extended skeletal involvement. CT was concordant in 83.3% of 323 skeletal regions with bone marrow scanning. Bone marrow scans of 30 control patients with benign disease were abnormal only in 7 of 2135 skeletal regions in 3 patients. In malignant lymphoma, bone marrow histology or aspiration cytology was concordantly positive in 14 or negative in 17 patients. Immunoscintigraphy of haematopoetic bone marrow provides a reliable, sensitive and safe novel approach towards the non-invasive evaluation of metastatic spread to the skeleton.

[Portal films and daylight film developing]

Automatic daylight film handling systems in radiotherapeutic departments are useful to process simulation films. Plastic film cassettes with two polished stainless steel screens (2 mm at the front and 0.5 mm at the back) instead of the fluorescent intensifying screens are used. Regular diagnostic films are exposed with five monitor units. Loading and unloading of the cassettes are performed automatically. Exposed films are rapidly available with sufficient quality.

Initial tumor size and local control in stage III non-small cell lung cancer treated by radio-chemotherapy

In stage III non small cell lung cancer initial tumor size is a neglected prognostic factor. 22 patients with stage III disease have been treated with radio-chemotherapy (cisplatin/vindesine). A significant (p less than 0.001) influence of initial tumor size on local control can be demonstrated. Future treatment strategies should include initial tumor size.

[Detection of bone marrow involvement in breast cancer and malignant lymphoma using immunoscintigraphy of the hematopoietic bone marrow]

Radioimmunoimaging of bone marrow was performed for non-invasive detection of skeletal involvement in 15 patients with carcinoma of the breast and 17 patients with malignant lymphomas. Bone marrow scans were performed by means of a monoclonal 99mTc-labelled antibody, directed against NCA-95 and CEA. The presence and extent of skeletal involvement were controlled by skeletal scintigraphy, plain radiographs and CT; bone marrow biopsies were obtained in 19 patients as well. 20 subjects without suspected malignant disease served as controls. Haematopoietic bone marrow was imaged homogeneously and with high contrast in all controls. 15/15 patients with carcinoma of the breast and 10/17 patients with malignant lymphomas had multifocal bone marrow defects due to skeletal metastases. Bone marrow scans revealed significantly more lesions than skeletal scintigraphy both in carcinoma of the breast (p = 0.027) and malignant lymphomas (p = 0.015). Thus, radioimmunoscintigraphy of bone marrow may provide a new, sensitive approach for non-invasive detection of metastatic spread to the skeletal system.

Radioimmunoimaging for diagnosis of bone marrow involvement in breast cancer and malignant lymphoma

Granulopoietic bone-marrow was scintigraphically imaged in 15 patients with carcinoma of the breast and known skeletal metastases, 10 patients with malignant lymphomas, and 15 controls without suspected malignant disease, with a technetium-99m labelled murine monoclonal IgG1 antibody directed against nonspecific cross-reacting antigen (NCA-95) and carcinoembryonic antigen. Immunoscintigraphy revealed more lesions than did bone scanning in both patient groups. This method offers a sensitive, cost-effective, and easy-to-perform whole body technique for evaluating metastatic spread.