Inter-individual differences in the response to an exercise training intervention in patients with metabolic syndrome

Background

Regular physical exercise and standardized exercise training (ET) programmes positively affect a number of metabolic and cardiovascular risk factors. Yet, response to ET varies between patients and between individual risk parameters. We investigated inter-individual responses regarding blood pressure, heart rate, lipids and glucose metabolism, as well as physical fitness to a 16-weeks supervised exercise training protocol in patients with metabolic syndrome (MetS).

Methods

29 MetS patients (20M/9F, age 52–70 y, BMI 24.9–38.2 kg/m2) exercised for 16 weeks in a supervised setting with varying volume and intensity. At baseline and at completion of the programme, blood pressure, heart rate, plasma lipids, glucose and insulin levels, as well as physical fitness were assessed, as were quantitative and morphological leukocyte parameters, cytokines and 86 metabolically relevant plasma proteins. Associations between individual risk parameters, leukocyte profile and plasma proteins were explored by recursive partitioning and network analysis. T-distributed stochastic neighbor embedding and hierarchical clustering were used for clustering based on cardiometabolic target parameters at 16 weeks.

Results

In the whole cohort, VO2peak increased and plasma counts of total leukocytes, neutrophils, monocytes (classical and intermediate), NK cells and effector and regulatory CD4+ lymphocytes, as well as circulating endothelial microvesicles were reduced at the end of the ET programme versus baseline. Plasma levels of carboxylesterase 1 decreased and soluble interleukin-7 receptor increased. Based on patient's cardio-metabolic parameters, three clusters were identified: cluster 1 had lower values of triglycerides, total and LDL cholesterol, cluster 2 had higher levels of triglycerides and cluster 3 had a greater heart rate recovery and lower insulin levels, but higher total and LDL cholesterol levels at follow-up. In cluster 1, absolute and relative NK cell counts were decreased and no morphological activation was observed. In cluster 2, reduced relative counts of NK-T cells were decreased, but their size was increased. In cluster 3, size of most effector leukocyte subtypes (CD8+, CD4+ Teff, NK-T, neutrophils) was increased at follow-up versus baseline. Network analysis suggested four distinct networks of (1) triglycerides, (2) VO2peak, (3) diastolic BP and (4) a cluster containing total and LDL cholesterol, insulin and HR recovery, each associated with partly distinct sets of plasma proteins and leukocyte parameters.

Conclusion

Despite improved physical fitness in all patients participating in the 16 weeks ET programme, inter-individual differences regarding cardio-metabolic target parameters and leukocyte activation was evident. Identification of specific leukocyte responses and of plasma protein “fingerprints” might help to optimize patient-specific prevention programmes, integrating medication and lifestyle optimization.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): DZHK, DSHF

Langerhans cells are negative regulators of the anti-Leishmania response

Langerhans cells suppress the immune response to low-dose Leishmania major infection in part by inducing regulatory T cells.

Migratory skin dendritic cells (DCs) are thought to play an important role in priming T cell immune responses against Leishmania major, but DC subtypes responsible for the induction of protective immunity against this pathogen are still controversial. In this study, we analyzed the role of Langerin⁺ skin-derived DCs in the Leishmania model using inducible in vivo cell ablation. After physiologically relevant low-dose infection with L. major (1,000 parasites), mice depleted of all Langerin⁺ DCs developed significantly smaller ear lesions with decreased parasite loads and a reduced number of CD4⁺ Foxp3⁺ regulatory T cells (T reg cells) as compared with controls. This was accompanied by increased interferon γ production in lymph nodes in the absence of Langerin⁺ DCs. Moreover, selective depletion of Langerhans cells (LCs) demonstrated that the absence of LCs, and not Langerin⁺ dermal DC, was responsible for the reduced T reg cell immigration and the enhanced Th1 response, resulting in attenuated disease. Our data reveal a unique and novel suppressive role for epidermal LCs in L. major infection by driving the expansion of T reg cells. A better understanding of the various roles of different DC subsets in cutaneous leishmaniasis will improve the development of a potent therapeutic/prophylactic vaccine.

IL-1 signalling is dispensable for protective immunity in Leishmania-resistant mice

Leishmaniasis is a parasitic disease affecting ∼12 million people. Control of infection (e.g. in C57BL/6 mice) results from IL-12-dependent production of IFNγ by Th1/Tc1 cells. In contrast, BALB/c mice succumb to infection because of preferential Th2-type cytokine induction. Infected dendritic cells (DC) represent important sources of IL-12. Genetically determined differences in DC IL-1α/β production contribute to disease outcome. Whereas the course of disease was not dramatically altered in IL-1RI(-/-) mice, local administration of IL-1α to infected C57BL/6 mice improved disease outcome. To definitively elucidate the involvement of IL-1 in immunity against leishmaniasis, we now utilized IL-1α/β-double-deficient C57BL/6 mice. C57BL/6 mice are believed to be a good surrogate model for human, self limited cutaneous leishmaniasis (CL). Leishmania major-infected IL-1α/β(-/-) mice were resistant to experimental CL comparable to controls. In addition, DC-based vaccination against leishmaniasis in C57BL/6 mice was independent of IL-1. Thus, in Leishmania-resistant C57BL/6 mice, IL-1 signalling is dispensable for protection.

Dual role of interleukin-1alpha in delayed-type hypersensitivity and airway hyperresponsiveness

BACKGROUND

Using a T helper (Th)1/Th2 disease model, we previously showed that genetically determined Th development depends on dendritic cell-derived interleukin (IL)-1alpha. In Leishmania major infections, Th1 immunity develops if IL-1alpha is present during T cell priming, whereas at later time points, IL-1alpha worsens disease outcome. In the present study, we determined the role of IL-1alpha in other Th2-mediated diseases.

METHODS

BALB/c mice were subjected to delayed-type hypersensitivity (DTH) or ovalbumin (OVA)/alum-induced allergic asthma in the presence or absence of IL-1alpha.

RESULTS

In DTH, mice treated with IL-1alpha during sensitization with keyhole limpet hemocyanin (KLH)/alum developed decreased footpad swelling associated with elevated KLH-specific interferon-gamma levels. In asthma, significantly decreased airway hypersensitivity responses (AHRs) were detected upon treatment with IL-1alpha during T cell priming. In contrast to control mice, IL-1alpha-treated mice showed reduced peribronchial inflammatory infiltrates. The bronchoalveolar lavage (BAL) fluid contained significantly decreased eosinophil numbers (approximately 50%), but 4 times more neutrophils. The BAL fluid of IL-1alpha-treated BALB/c exhibited reduced amounts of IL-5 and OVA-specific IgE serum levels. In contrast, IL-1alpha treatment at later time points after sensitization or during allergen challenge worsened AHR, had no effect on lung inflammation and BAL fluid cell composition. Furthermore, cytokine levels (IL-5, IL-13) and antigen-specific IgE were increased or unaltered under these conditions.

CONCLUSION

Similarly to leishmaniasis, IL-1alpha administration during sensitization of Th2-mediated allergic reactions suppresses the course of disease by shifting the immune response towards Th1, whereas later treatments worsen disease outcome. Future studies will elucidate the therapeutic value of IL-1alpha in asthmatic patients.

IL-17 promotes progression of cutaneous leishmaniasis in susceptible mice

Resistance to leishmaniasis in C57BL/6 mice depends on Th1/Tc1 cells. BALB/c mice preferentially develop Th2 immunity and succumb to infection. We now assessed the role of IL-17 in cutaneous leishmaniasis. During the course of Leishmania major infection, BALB/c CD4 cells and neutrophils produced increased amounts of IL-17 as compared with cells from C57BL/6 mice. This increase was associated with significantly increased IL-23 release from L. major-infected BALB/c dendritic cells (DC), whereas IL-6 and TGF-beta1 production by BALB/c and C57BL/6 DC were comparable. Interestingly, lesion sizes in infected IL-17-deficient BALB/c mice were dramatically smaller and failed to progress as compared with those in control mice. Similar amounts of IL-4, IL-10, and IFN-gamma were produced by T cells from IL-17-deficient mice and control mice consistent with development of Th2-predominant immunity in all animals. Improved disease outcome was associated with decreased CXCL2-accumulation in lesion sites and decreased neutrophil immigration into lesions of infected IL-17-deficient mice confirming prior observations that enhanced neutrophil recruitment contributes to disease susceptibility in BALB/c mice. This study excludes an important facilitating role for IL-17 in Th1/Th2 development in L. major-infected BALB/c mice, and suggests that IL-23 production by L. major-infected DC maintains IL-17(+) cells that influence disease progression via regulation of neutrophil recruitment.

[Palliative culture in the stationary care for the elderly]

Nursing homes are challenged by a significant change in the patient-structure. To care for dying elderly people means to enable them to live in dignity till the end. Helpful therefore is to implement Palliative Care into existing structures. This requires personal and organizational learning and development. The first step is to make central differences and contradictions visible und communicable. We describe three organizational types which leads into different core-processes. Organizational measures supporting the development of a palliative culture and indicators of successful implementation are presented.

[MRI of the prostate after combined radiotherapy (afterloading and percutaneous): histopathologic correlation]

AIM

To identify the MRI changes of the prostate after combined (high-dose rate interstitial with external beam) radiotherapy for, localized prostate cancer and to correlate the findings with histology in order to determine the value of MR imaging in the follow-up of these patients.

MATERIAL AND METHODS

Twenty-three patients underwent MR imaging at 1.5 T between 6 and 24 months after completion of combined radiotherapy. The prostate was imaged with axial and coronal T2-weighted sequences and axial T1-weighted sequences before and after intravenous administration of Gd-DTPA. Quadrant or sextant biopsy was performed in all cases and three patients with proven persistence of the tumor underwent salvage prostatectomy. The MRI findings were compared with the biopsy results or the large-area sections.

RESULTS

On T2-weighted images the fibrotically changed peripheral zone was hypointense while persistent tumor tissue showed hyperintensity. Solid tumors were depicted when they had a diameter of 1 cm or more. Persistent tumors of the diffuse multifocal type escaped detection. Contrast-enhanced T1-weighted imaging yielded no additional information. The accuracy in detecting persistent tumor was 74%.

CONCLUSIONS

Histopathologic changes seen after combined radiotherapy correlate with the findings on T2-weighted MR images. MR imaging cannot replace follow-up by routine biopsy. Its only role is assessing local operability in cases found to have increasing PSA levels during follow-up. Further studies are needed to determine the role of MR imaging in this patient population.

Impact of the filling status of the bladder and rectum on their integral dose distribution and the movement of the uterus in the treatment planning of gynaecological cancer

PURPOSE

Determination of the impact of the filling status of the organs at risk (bladder and rectum) on the uterus mobility and on their integral dose distribution in radiotherapy of gynaecological cancer.

METHODS

In 29 women suffering from cervical or endometrial cancer two CT scans were carried out for treatment planning, one with an empty bladder and rectum, the second one with bladder and rectum filled. The volumes of the organs at risk were calculated and in 14 patients, receiving a definitive radiotherapy, the position of the uterus within the pelvis was shown using multiplanar reconstructions. After generation of a 3D treatment plan the dose volume histograms were compared for empty and filled organs at risk.

RESULTS

The mobility for the corpus uteri with/without bladder and rectum filling was in median 7 mm (95%-confidence interval: 3-15 mm) in cranial/caudal direction and 4 mm (0-9 mm) in posterior/anterior direction. Likewise, cervical mobility was observed to be 4 mm (-1-6 mm) mm in cranial/caudal direction. A full bladder led to a mean reduction in organ dose in median from 94-87% calculated for 50% of the bladder volume (P < 0.05, Wilcoxon's matched-pairs signed-ranks test). For 66% of the bladder volume the dose could be reduced in median from 78 to 61% (P < 0.005) and for the whole bladder from 42 to 39% (P < 0.005), respectively. No significant contribution of the filling status of the rectum to its integral dose burden was noticed.

CONCLUSIONS

Due to the mobility of the uterus increased margins between CTV and PTV superiorly, inferiorly, anteriorly and posteriorly of 15, 6 and 9 mm each, respectively, should be used. A full bladder is the prerequisite for an integral dose reduction.

[Comparison of different 3-dimensional irradiation techniques in local radiotherapy of prostatic carcinoma]

PURPOSE

Four different three-dimensional planning techniques for localized radiotherapy of prostate cancer were compared with regard to dose homogeneity within the target volume and dose to organs at risk, dependent upon tumor stage.

PATIENTS AND METHODS

Six patients with stage T1, 7 patients with stage T2 and 4 patients with stage T3 were included in this study. Four different 3D treatment plans (rotation, 4-field, 5-field and 6-field technique) were calculated for each patient. Dose was calculated with the reference point at the isocenter (100%). The planning target volume was encompassed within the 95% isodose surface. All the techniques used different shaped portal for each beam. Dose volume histograms were created and compared for the planning target volume and the organs at risk (33%, 50%, 66% volume level) in all techniques.

RESULTS

The 4 different three-dimensional planning techniques revealed no differences concerning dose homogeneity within the planning target volume. The dose volume distribution at organs at risk show differences between the calculated techniques. In our study the best protection for bladder and rectum in stage T1 and T2 was achieved by the 6-field technique. A significant difference was achieved between 6-field and 4-field technique only in the 50% volume of the bladder (p = 0.034), between the 6-field and rotation technique (all volume levels) and between 5-field and rotation technique (all volume levels). In stage T1, T2 6-field and 4-field technique in 50% (p = 0.033) and 66% (p = 0.011) of the rectum volume. In stage T3 a significant difference was not observed between the 4 techniques. The best protection of head of the femur was achieved by the rotation technique.

CONCLUSION

In the localized radiotherapy of prostate cancer in stage T1 or T2 the best protection for bladder and rectum was achieved by a 3D-planned conformal 6-field technique. If the seminal vesicles have been included in the target volume and in the case of large planning target volume other techniques should be taken for a better protection for organs at risk e. g. a 3D-planned 4-field technique box technique.

Comparison of conventional and virtual simulation for radiation treatment planning of malignant lymphoma

PURPOSE

The exact coverage of the lymph nodes and optimal shielding of the organs at risk are necessary for patients with Hodgkin's disease or malignant lymphoma to guarantee a high cure rate and a low rate of late effects for normal tissue. The purpose of this study was to compare conventional simulation and blocking with virtual simulation in terms of coverage of the target volume and shielding of the organs at risk in this highly curative patient group.

PATIENTS AND METHODS

In 10 patients diagnosed with Hodgkin's disease and 5 patients with a Non-Hodgkin lymphoma radiation treatment planning for a mantle field or para-aortic field with inclusion of the spleen was performed in a conventional manner and with virtual simulation. With conventional technique, irradiation portals were defined during fluoroscopy and shielding of the organs at risk was drawn onto the simulation films, based on the information from previous X-ray films, CT or MRI scans. For virtual simulation, contouring of the target volumes and organs at risk (e.g. the kidneys) and the definition of the irradiation portals were performed with the AcQSim software package on a VoxelQ workstation (Picker Inc.) This was done in a beam's eye view environment on a currently driven CT scan in the treatment position. Both irradiation portals were compared in terms of coverage of the target volume and shielding of the organs at risk.

RESULTS

Planning of a mantle field in the conventional way resulted in an incomplete coverage of the right hilus in 4/15 cases and of the left in 1/15 cases, respectively. The spleen and the spleen hilus were not covered completely in 5/15 and 6/15 cases, respectively. The left kidney was adequately shielded in only two thirds (10/15) of the conventionally planned fields. The planning time required for virtual simulation was reduced for the patient, but was increased for the physician because of the more time consuming contouring procedure compared to conventional simulation.

CONCLUSIONS

Virtual simulation based on CT scans for radiation treatment planning of malignant lymphoma gives more information about soft tissue structures than conventional treatment planning. Therefore, it allows a more precise coverage of the target volumes and better shielding of the organs at risk. However, the time required for the whole procedure is increased. This is justified because of the often highly curative intention when treating this group of patients.

Verification of set-up deviations in patients with breast cancer using portal imaging in clinical practice

AIM

The aim of this study was to determine set-up deviations during irradiation of patients with breast cancer using Electronic Portal Imaging (EPI).

PATIENTS AND METHOD

In order to monitor the intrafractional set-up deviations multiple portal image readings were carried out on 5 patients with breast cancer. Moreover interfractional set-up deviations were determined by the acquisition of daily EPIs in a total of 20 patients.

RESULTS

The results of intrafractional set-up deviation based on 130 EPIs revealed a maximum lateral and longitudinal (cranio-caudal) deviation of 2 mm (range:-10 mm to 8 mm) as well as 1 degree in rotation (range: -2 degree to 2 degrees). The interfractional set-up deviations in 20 breast cancer patients during a treatment series of 25 fractions showed mean standard deviations of 5 mm in lateral and longitudinal direction, respectively. Only in few cases deviations up to maximally 24 mm were observed. The mean standard deviation of the rotational error was 2 degrees and reached a maximum of 6.5 degrees.

CONCLUSION

These results show that intrafractional set-up deviations in breast cancer patients are negligible in clinical practice. They can be attributed to random errors due to patient movement and breathing. The set-up deviations during a treatment series can be differentiated in systematic and random errors. Patient fixation and immobilization is crucial in minimizing random errors. Taking into account 10 mm safety margins as used in our department around the "clinical target volume" (CTV), set-up errors outside of this volume (PTV) were exceptional. The enlarged PTV definition of 15 mm for lateral and cranio-caudal field margins, respectively as used in this study covers 99% of the CTV in all patients.

Combined treatment of inoperable carcinomas of the uterine cervix with radiotherapy and regional hyperthermia. Results of a phase II trial

AIM

The disappointing results for inoperable, advanced tumors of the uterine cervix after conventional radiotherapy alone necessitates improving of radiation therapy. Simultaneous chemotherapy or altered radiation fractionation, such as accelerated regimen, increase acute toxicity and treatment is often difficult to deliver in the planned manner. The purpose of this phase II study was to investigate the toxicity and effectiveness of a combined approach with radiotherapy and regional hyperthermia.

PATIENTS AND METHODS

From January 1994 to October 1995 18 patients with advanced carcinomas of the uterine cervix were treated in combination with radiotherapy and hyperthermia. The patients were treated with 6 to 20 MV photons delivered by a linear accelerator in a 4-field-box technique to a total dose of 50.4 Gy in 28 fractions. In the first and fourth week 2 regional hyperthermia treatments were each applied with the Sigma-60 applicator from a BSD-2000 unit. After this a boost to the primary tumor was given with high-dose-rate iridium-192 brachytherapy by an afterloading technique with 4 x 5 Gy at point A to a total of 20 Gy and for the involved parametrium anterioposterior-posterioanterior to 9 Gy in 5 fractions.

RESULTS

The acute toxicity was low and similar to an external radiotherapy alone treatment. No Grade III/IV acute toxicity was found. The median age was 47 years (range 34 to 67 years). In 16 of 18 patients a rapid tumor regression was observed during combined thermo-radiotherapy, which allowed the use of intracavitary high-dose-rate brachytherapy in these cases. Complete and partial remission were observed in 13 and 4 cases, respectively. One patient did not respond to the treatment. The median follow-up was 24 months (range 17 to 36 months). The local tumor control rate was 48% at 2 years. Median T20, T50 and T90 values were 41.7 degrees C (range 40.3 to 43.2 degrees C), 41.1 degrees C (range 39.2 to 42.5 degrees C) and 39.9 degrees C (range 37.7 to 41.9 degrees C), respectively. Cumulative minutes of T90 > 40 degrees C (Cum40T90) and cumulative minutes, which were isoeffective to 43 degrees C, were calculated (CEM43T90, CEM43T50, CEM43T20). CEM43T90 was found to be a significant parameter in terms of local tumor control for the 4 hyperthermia treatments (p = 0.019).

CONCLUSIONS

This treatment modality has proved to be feasible and well tolerable. The rapid tumor shrinkage in the combined approach of radiotherapy with hyperthermia before beginning brachytherapy seems to be a good prerequisite for improving of the disappointing results in cure of advanced cancer of the uterine cervix.

High-dose rate interstitial with external beam irradiation for localized prostate cancer--results of a prospective trial

PURPOSE

A prospective phase II trial was carried out to test the feasibility and effectiveness of a combined interstitial with external beam radiotherapy approach for localized prostate cancer.

MATERIALS AND METHODS

Between October 1992 and December 1994, 82 evaluable patients were treated. T2 and T3 tumours, according to the AJCC classification system of 1992, were found in 21 and 61 cases, respectively. The median follow-up was 24 months; three patients were lost during follow-up. All of the patients were pathologically proven to be node-negative by laparoscopic node dissection of the fossa obturatoria region. A dose of 9 Gy a week was prescribed during the first and second weeks of treatment (10 Gy each week from October 1992 to December 1993) interstitially with high-dose rate Iridium-192 brachytherapy to the prostate and tumour extension beyond the capsule. External beam four-field box irradiation was then given to the prostate to a dose of 45 Gy/25 fractions (40 Gy/20 fractions from October 1992 to December 1993).

RESULTS

Before starting treatment, a PSA value of > or =10 ng/ml was found in 64.6% (53/82) of patients with a median PSA of 14.0 ng/ml. The median PSA 3, 12 and 24 months after completion of therapy was 1.20, 0.78 and 0.70 ng/ml, respectively. The PSA value was < 1.0 ng/ ml in 52.9% of patients at 2 years. Negative punch biopsies 12 and 24 months after therapy were observed in 69.8% (44/63) and 73. 1% (38/ 52) of patients, respectively. A positive biopsy combined with a PSA value of > 1.0 ng/ml was considered as local failure. The local tumour control rate was 79.5% at 2 years. Acute side-effects were not increased relative to external beam irradiation alone. Severe side-effects were observed in three patients (two of the three patients had additional risk factors (colitis ulcerosa and diabetes mellitus)); they developed rectourethral fistulae requiring colostomy after biopsies from the anterior rectal wall.

CONCLUSION

The described method is feasible and well tolerable. The three complications observed were not caused by irradiation alone. Biopsies from the anterior rectal wall after definitive high-dose radiotherapy for prostate cancer have to be seen as obsolete. The rate of negative prostate biopsies of 73.1% after 24 months represents an encouraging result.

Rationale for using invasive thermometry for regional hyperthermia of pelvic tumors

PURPOSE

Invasive thermometry for regional hyperthermia is time-consuming, uncomfortable, and risky for the patient. We tried to estimate the benefit/cost ratio of invasive thermometry in regional hyperthermia using the radiofrequency system BSD-2000.

METHODS AND MATERIALS

We evaluated 182 patients with locally advanced pelvic tumors that underwent regional hyperthermia. In every patient a tumor-related temperature measurement point was obtained either by invasive or minimally invasive catheter measurement tracks. In the earlier period for every patient an intratumoral measurement point was decided as obligatory and intratumoral catheters were implanted intraoperatively, CT guided, or under fluoroscopy. In the later period, invasive thermometry often was avoided, if a measurement point in or near the tumor was reached by an endoluminally inserted catheter (rectal, vaginal, cervical, urethral, or vesical). For every patient side effects and complications referred to thermometry were evaluated and compared with the potential benefit of the invasively achieved temperature data. The suitability of endolumimally registered temperatures is analyzed to estimate local feasibility (specific absorption rate achieved) and local effectiveness (thermal parameters correlated with response).

RESULTS

In 74 of 182 patients invasive thermometry was performed, at most CT-guided for soft tissue sarcomas and rectal recurrences. In 14 of 74 (19%) side effects such as local inflammation, pain, or abscess formation occurred that enforced removal of the catheter. However, local problems were strongly correlated with the dwell time of the catheter and nearly never occurred for dwell times less than 5 days. Fortunately, no fatal complications (e.g., bleeding or perforation) occurred during or after implantation which could be attributed to the invasive thermometry procedure. Endoluminal tumor-related temperature rises per time unit (to estimate power density) were correlated with intratumoral rises at the same patients (where both measurements were available). For a subgroup of patients pooled in two Phase II studies with rectal (n = 37) and cervical (n = 18) carcinomas thermal parameters derived from endoluminal measurements were correlated with response or local control, resp.

CONCLUSIONS

If a tumor-related endoluminal temperature measurement point is available, additional invasive thermometry gives no further information to improve the power deposition pattern. For primary rectal and cervical cancer, and probably as well for prostate, bladder and anal cancer, endoluminal measurements are suitable to estimate local feasibility and effectiveness. Therefore, invasive thermometry is dispensable in the majority of patients. In some selected cases, temperature measurement in the tumor center is required to estimate the maximum temperature. In those cases, dwell time of catheters should be minimized--and it should be considered to perform invasive thermometry at the beginning (one or two heat treatments).

High-dose rate iridium192 afterloading therapy in combination with external beam irradiation for localized prostate cancer

Development of afterloading techniques in combination with external radiotherapy allows for curative therapy modality for stage C prostate cancer. Between 10/92 and 12/95 128 patients were treated. Stage B and C tumors were found in 36 and 89 cases, respectively. All patients were pathologically proven to be node-negative by laparoscopic node dissection of the fossa obturatoria region. 9 Gy a week was applied during the first and second weeks of treatment (10/92-12/93: 10 Gy each week) interstitially with high-dose rate iridium192 brachytherapy to the prostate. After this, a four-field box of external beam radiation therapy was given to the prostate to a dose of 45 Gy/25 fractions (10/92-12/93: 40 Gy/20 fractions). Before starting treatment median PSA was 13.8 ng/ml. The median PSA 3, 12, and 24 months after completion of therapy was 1.2, 0.78, and 0.75 ng/ml, respectively. Negative biopsies 12 and 24 months after therapy were observed in 56% (49/87) and 72% (31/43), respectively.

[Virtual simulation. First clinical results in patients with prostate cancer]

AIM

Investigation of options of virtual simulation in patients with localized prostate cancer.

PATIENTS AND METHODS

Twenty-four patients suffering from prostate cancer were virtual simulated. The clinical target volume was contoured and the planning target volume was defined after CT scan. The isocenter of the planning target volume was determined and marked at patient's skin. The precision of patients marking was controlled with conventional simulation after physical radiation treatment planning.

RESULTS

Mean differences of the patient's mark revealed between the 2 simulations in all room axes around 1 mm. The organs at risk were visualized in the digital reconstructed radiographs.

CONCLUSIONS

The precise patient's mark of the isocentre by virtual simulation allows to skip the conventional simulation. The visualisation of organs at risk leeds to an unnecessarily of an application of contrast medium and to a further relieve of the patient. The personal requirement is not higher in virtual simulation than in conventional CT based radiation treatment planning.

[Combined iridium 192 afterloading therapy of prostate carcinoma]

The goal of radiation therapy is to deliver a high dose to the tumor while preserving normal surrounding tissue. For early-stage prostate cancer, the ultimate conformal irradiation is to place radioactive sources directly into the gland as permanent or temporary seeds. Contemporary prostate brachytherapy incorporates advances in computer analysis, imaging technology, and delivery apparatus, allowing exact and reproducible results. Accurate comparison of brachytherapy to surgery and external beam irradiation requires a randomized study. Comparisons of retrospective studies are fraught with the problems of the heterogeneous nature of early-stage prostate cancer. Pretreatment PSA and grade appear to be more sensitive variables than stage in predicting failure after irradiation. The treatment results based on biopsy are promising for the first two years. Brachytherapy may be considered as a therapeutic option: as monotherapy for early-stage disease and also as a boost following moderate doses of external beam irradiation for locally advanced disease.

Chemo-radiotherapy for locally advanced head and neck cancer--long-term results of a phase II trial

The feasibility and effectiveness of a combined chemo-radiotherapy treatment modality for locally advanced head and neck cancer was tested in a phase II trial. Between 1990 and 1993, 74 patients (20 female/54 male) with head and neck cancer stage III (n = 12) and IV (n = 62) were treated with accelerated radiotherapy (72 Gy) and simultaneous chemotherapy (5-FU, folinic acid, mitomycin C). The median follow-up time was 43 months (1-72). Complete remission (CR) was absent in 76% (56/74) of patients and, after subsequent resection of residual lymph nodes, another 8 patients achieved CR. The cumulative local control rate was 72% and disease-specific survival rate was 59% at 4 years. Two patients died with treatment-related conditions (pancytopenia, larynx oedema). By multivariate analysis, only lymph node status was an independent parameter for local control (P = 0.04). This treatment was feasible and toxicity was not a treatment-limiting factor. As a consequence, a German multicentre phase III trial was initiated in 1995.

Correlation between primary chemo- and radiation sensitivity in a panel of highly malignant human soft tissue sarcoma xenografts

BACKGROUND AND PURPOSE

Sensitivity to radiation and sensitivity to cytotoxic drugs have been proposed to be independent properties of tumour cells. However, very few clinical or experimental studies have tested this hypothesis. Therefore, we evaluated the response to ionizing radiation and to four cytotoxic drugs in a panel of 12 human soft tissue sarcoma cell lines using the xenograft system.

MATERIAL AND METHODS

NMRI-nu/nu nude mice with subcutaneous tumours received at a tumour volume of 120-200 mm3 either single dose, single agent chemotherapy with 350 mg/kg ifosfamide, 200 mg/kg dacarbazine, 10 mg/kg doxorubicin, 6.6 mg/kg cisplatin, or 24 Gy local tumour irradiation under acutely hypoxic conditions from a cobalt-60 source. Tumour response to radiotherapy and chemotherapy was measured as specific growth delay (SGD).

RESULTS

A significant correlation was found between SGD after radiotherapy and SGD after decarbazine (P < 0.001) and doxorubicin (P = 0.05), whereas no correlation could be demonstrated for cisplatin. For ifosfamide, the correlation reached borderline significance. The maximal response to any of the four tested chemotherapeutic drugs correlated very well with the response to radiotherapy (P < 0.001).

CONCLUSION

The results suggest that radiation sensitivity and chemosensitivity are not independent properties of soft tissue sarcoma cell lines.

Temporary tracheobronchial stenting in malignant stenoses

Endobronchial stent implantation has been successfully employed in malignant stenoses. The aim of this prospective study was to investigate the temporary use of tracheobronchial stents combined with tumour-specific therapy. All patients received stents for primary palliation of dyspnoea followed by radio- or chemotherapy with the aim of stent removal after reduction of the stenosis. In 22 patients suffering from severe malignant strictures, 34 endobronchial stents (29 Strecker-, 3 Dumon-, 1 Orlowski-, 1 Dynamic-Y-stents) were implanted (in 9 patients, 2 stents were necessary). Patients were treated by irradiation (n = 18) or chemotherapy (n = 4) after stent implantation. Significant improvement of dyspnoea (P < 0.001) and partial oxygen pressure (P < 0.01) was observed. In 11 out of 22 cases (50%), the stents could be removed after successful tumour-specific therapy which led to reduction of stenosis after a mean interval of 31.7 (6-104) days (temporary stenting). During the period of tumour-specific therapy, 9 patients died after a mean interval of 132 (13-347) days (definite stenting). In two cases, stents had to be removed after stent compression, stent dislocation and severe cough. The results suggest that temporary stenting, characterised by subsequent successful tumour-specific therapy, is a new valuable therapeutic strategy. It can "bridge the gap" before tumour-specific therapy can take effect. If tumour-specific therapy is ineffective, definite stenting is the palliative method of choice in severe dyspnoea in bronchial carcinoma.

[Accelerated hyperfractionated radiotherapy combined with simultaneous chemotherapy in locally advanced pharyngeal and oral carcinomas]

PURPOSE

To evaluate the feasibility and effectiveness of a concurrent radio-chemotherapy regimen for locally advanced carcinomas of the pharynx and floor of the mouth.

PATIENTS AND METHODS

Since January 1990, 97 patients with locally advanced carcinomas of the naso-, oro-, hypopharynx and the oral cavity in UICC stages III and IV were treated according to an accelerated hyperfractionated radiotherapy schedule with concurrent chemotherapy. The primary tumor and positive lymph nodes received a total dose of 72 Gy in 6 weeks. In the first 3 weeks, large fields were irradiated 5 times per week with 2 Gy per fraction. Thereafter, treatment was accelerated, giving 2 daily fractions of 1.4 Gy with minimal intervals of 6 hours. Target volumes were reduced after 49.6 and 59.4 Gy, excluding clinically uninvolved lymph node regions of low and high risk. On day 1, 350 mg/m2 5-FU and 50 mg/m2 folinic acid were given as intravenous bolus followed by continuous infusion of 350 mg/m2 5-FU and 100 mg/m2 folinic acid, days 1 to 5. 10 mg/m2 mitomycin C was given on day 5 and 36 of the treatment. Salvage surgery was offered for residual disease 5 to 6 weeks after the end of radiotherapy.

PATIENT CHARACTERISTICS

70 male, 27 female; age: 27 to 81 years; T2/T3/T4: 7/30/60; N0/N1/N2/N3: 20/18/53/6; nasopharynx/oropharynx/hypopharynx/oral cavity: 16/33/36/12. Median follow-up is 26 months.

RESULTS

Overall survival and recurrence-free survival at 2 years were

RESULTS

Overall survival and recurrence-free survival at 2 years were 68 +/- 5% and 74 +/- 5%. Multivariate analysis revealed a significant influence of the geometric mean neck node diameter or the N-stage on loco-regional control and survival. T-stage, tumor volume, or tumor localisation did not become significant. Acute toxicity of this schedule was acceptable but required optimised supportive care. Treatment related grade 4+ late toxicity of mucosa, soft tissue and bone were observed with a cumulative frequency of 13% at 2 years. Two patients died during a phase of severe leuko- or thrombocytopenia.

CONCLUSION

This phase I to II trial shows favourable results using an intensified treatment radio-chemotherapy protocol. A phase III study is now planned, comparing this regime with an accelerated hyperfractionated radio-therapy alone to an increased total dose of 77.6 Gy.

Local recurrences of soft tissue sarcomas in adults: a retrospective analysis of prognostic factors in 102 cases after surgery and radiation therapy

Between 1974 and 1990, 102 adult patients (age 18-86 years) with the diagnosis of a soft tissue sarcoma (STS) were treated with photons and/or electrons in combination with surgery. The total doses in the initial treatment volume (second order target volume) was 40-50 Gy. For the coning down volume (first order target volume) the median total dose was 59 Gy (range 45-72 Gy). A total of 18% (18/102) local failures was observed. In multivariate analysis, prognostic factors for the occurrence of a local failure were identified as follows: treatment of a primary or recurrent STS (P = 0.02), total dose (P = 0.025) and tumour grade (P = 0.05). Mode of surgery, tumour size (trunk versus extremity), pre- or postoperative radiotherapy, combined chemotherapy and tumour size (T1 versus T2) had no significant impact on the local relapse-free survival. These data give further evidence that combined surgery and radiotherapy is an effective modality in treatment of soft tissue sarcomas.

[Malignant paragangliomas--the results of radiotherapy in 6 patients]

Between February 1984 and May 1989, six patients (four male, two female) with malignant paragangliomas of the carotid body (n = 4) and glomus jugulare (n = 2) were irradiated in the Department of Radiation Oncology at Essen University. All patients had macroscopic (residual) tumor at the start of treatment. Five out of six paragangliomas had to be considered malignant, since histological lymph node involvement or distant metastasis was confirmed. In the sixth case extra- and intracranial tumor growth was observed. Total doses between 40 and 55 Gy using cobalt 60, 10 or 15 MeV photons were administered. Radiation therapy was canceled at 30.6 Gy in one patient because of multiple distant metastasis. Three out of four patients, who received curative treatments, were locally controlled (25 to 91 months). A local recurrence in one patient was detected 18 months after irradiation; this patient died of distant metastasis 23 months after treatment. In one out of two palliatively irradiated patients, local control could be achieved until the patient died of distant metastasis twelve months after treatment. Grade III- or grade IV-treatment toxicity was not observed. Radiation therapy of malignant paragangliomas with doses between 45 and 54 Gy in five to six weeks is an effective treatment with low toxicity and should be preferred to surgery in glomus jugulare and advanced carotid body tumors.

The TCD50 and regrowth delay assay in human tumor xenografts: differences and implications

The response to irradiation of five human xenograft cell lines--a malignant paraganglioma, a neurogenic sarcoma, a malignant histiocytoma, a primary lymphoma of the brain, and a squamous cell carcinoma--were tested in nude mice. All mice underwent 5 Gy whole body irradiation prior to xenotransplantation to minimize the residual immune response. The subcutaneous tumors were irradiated at a tumor volume of 120mm3 under acutely hypoxic conditions with single doses between 8 Gy and 80 Gy depending on the expected radiation sensitivity of the tumor line. Endpoints of the study were the tumor control dose 50% (TCD50) and the regrowth delay endpoints growth delay, specific growth delay, and the tumor bed effect corrected specific growth delay. Specific growth delay and corrected specific growth delay at 76% of the TCD50 was used in order to compare the data to previously published data from spheroids. The lowest TCD50 was found in the lymphoma with 24.9 Gy, whereas the TCD50 of the soft tissue sarcomas and the squamous cell carcinoma ranged from 57.8 Gy to 65.6 Gy. The isoeffective dose levels for the induction of 30 days growth delay, a specific growth delay of 3, and a corrected specific growth delay of 3 ranged from 15.5 Gy (ECL1) to 37.1 Gy (FADU), from 7.2 Gy (ENE2) to 45.6 Gy (EPG1) and from 9.2 Gy (ENE2) to 37.6 Gy (EPG1), respectively. The corrected specific growth delay at 76% of the TCD50 was correlated with the number of tumor rescue units per 100 cells in spheroids, which was available for three tumor lines, and with the tumor doubling time in xenografts (n = 5). The TCD50 values corresponded better to the clinical experience than the regrowth delay data. There was no correlation between TCD50 and any of the regrowth delay endpoints. This missing correlation was most likely a result of large differences in the number of tumor rescue units in human xenografts of the same size.

[Radiotherapeutic strategies for soft tissue sarcomas in adults]

Soft tissue sarcomas account for under 1% of all cancers in adults. Most soft tissue tumours are benign, only about 1% being characterized clinically and histomorphologically as malignant neoplasms. Since these tumours are often treated by excisional biopsies without any further diagnostic imaging, precise planning of postoperative irradiation therapy is often difficult to achieve. Therefore, all soft tissue tumours with a short history should be regarded as malignant until the contrary has been proven. In general, the mode of tumour resection should be postponed until CT or MR diagnosis is complete and a biopsy of the tumour has been carried out. Whereas benign lesions need only marginal tumour resection, malignant lesions require considerable safety margins. In soft tissue sarcomas of the extremities, which account for 50-60% of all sarcomas, a wide local resection followed by postoperative irradiation with about 66 Gy can guarantee local control rates above 80% and preserve the function of the limb. Radical surgery alone can achieve the same local control, but without the high level of functional integrity. In the case of marginally resectable tumours, preoperative irradiation can induce partial tumour remission and thus allow definitive limb-sparing tumour resection. Recently, multimodal and neoadjuvant therapeutic strategies have been developed. The efficacy of these experimental strategies is not yet proven.

Neutron boost irradiation of soft tissue and chondrosarcomas at the West German Tumour Centre in Essen

In this retrospective study, the results of postoperative neutron boost therapy for 40 soft tissue- and 18 chondrosarcomas are presented. In 65.5% and 34.5% of all cases, microscopic to macroscopic tumour residual was left postoperatively. Locally advanced and moderate to highly malignant tumours were found at surgery in 81% and 69%, respectively. Except for seven patients with a whole series of neutrons to 16 Gy, the other cases were treated with initially 40 to 50 Gy photons and a subsequent neutron boost of 4 to 6 Gy. The median follow-up was 29.3 and 36.2 months for the soft tissue- and chondrosarcomas. The actuarial three-year local control and overall survival rates were 69.3% and 91% for soft tissue- vs. 55.6% and 62.9% for chondrosarcomas. With regard to the extension of surgery (microscopic or macroscopic residual), local control rates of 80% and 60% for soft tissue- vs. 62.5% and 40% for chondrosarcomas were observed. The overall local failure rate was 32.8% with a median disease-free interval of ten respectively eleven months for soft tissue and chondrosarcomas. 17 out of 19 local recurrences were due to inadequate irradiation portals for the neutron boost or to insufficient total doses in the initially treated photon target volume.