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The management of testicular cancer has already been standardized to the greatest extent by consistent performance of clinical trials. While the current aim is to reduce the therapy for early stage disease without jeopardizing the high cure rates, for patients in advanced stages the goal is to achieve further improvement of survival rates. This overview presents new aspects of organ-preserving primary tumor resection, prognostic factors in seminoma, secondary malignancies, high-dose therapy, residual tumor resection, aftercare, and PET/CT.

Primary malignant tumors of the orbit and the orbital adnexal area are rare, variform and in the majority of cases need an interdisciplinary treatment. According to tumor entity, tumor localization, and tumor extent the complete spectrum of radiotherapeutic therapy options is necessary. In the majority of malignant tumors, such as those of the eyelids, lachrymal glands, orbit, metastases, sarcoma or lymphoma, radiotherapy is used as a high energy therapy by means of medical linear accelerators as so-called teletherapy. In addition, new therapy methods, such as stereotactic highly conformal radiation or intensity-modulated radiation therapy (IMRT) were developed to achieve a higher local tumor control by a better configuration of the radiotherapy fields to the tumor borders and to contribute to a reduction of acute and chronic side effects in normal tissue by blurring of the dose. The application of ionizing radiation sources, such as so-called interstitial brachytherapy can also be just as carefully as effectively used. Particle beam radiotherapy is limited only to specially licensed centers and light hydrogen ions as proton therapy or carbon ions as heavy ion radiotherapy are in use. This overview will show the options as well as important progress in the field of radiotherapy in the treatment of tumors of the orbit and periorbital area.

In male patients the pudendal block has been applied only in rare cases as a therapy for neuralgia of the pudendal nerve. Up to now there is no comparison of pudendal block with an anaesthesia form close to the spinal cord. In this pilot study the bilateral perineal infiltration of the pudendal nerve was compared to combined spinal-epidural anaesthesia in high-dose-rate (HDR) brachytherapy.In 30 patients (68.8 +/- 5.4 years) who underwent a core needle biopsy for high-risk prostate carcinoma, an HDR brachytherapy in CSE or NPB was carried out. Both anaesthesia forms were examined concerning the perioperative compatibility, the subjective feeling (German school marks principle 1-6), the pain feeling (VAS, 1-10) and the early postoperative course (mobility, complications).Both anaesthesia procedures were offered to all patients. For 2 patients the NPB was favoured primarily, because they had undergone surgery of the lumbal spine, so that the CSE was not applicable. There was no change of anaesthesia form necessary. The expense of time for NPB was 10.5 +/- 2.5 min, for CSE 30.5 +/- 5.5 min (p0.005). The hollow needles remained in place on average for 79 +/- 11.7 min (p = 0.23). Inter- and postoperative pain feelings were in both groups between 1.3 +/- 1.1 and 1.1 +/- 1.0 (p = 0.61 and p = 0.29). The difference is not significant. The NPB group considered postoperative mobility as an advantage. All patients felt the bladder catheter as annoying, but the NPB group considered postoperative mobility as more important than complete lack of pain. The subjective feeling in the NPB group was described as 2.06 +/- 0.59 and in the CSE group 2.73 +/- 0.79. This is a significant difference (p0.005). No side effects or complications in both anaesthesia forms appeared.The perineal pudendal block is equivalent to epidural anaesthesia in HDR brachytherapy. Concerning the objectifiable pain score measurement and the subjective feeling there are no essential significant differences.

Today's available therapeutic options in head and neck cancer patients have led to better treatment modalities tailored to the individually clinical staging of the patients towards a risk adapted tumour management. This, however, is only possible with an accurately pretherapeutic diagnostic regimen and closely posttherapeutic follow-up.These issues were discussed by nuclear medicine experts, otorhinolaryngologists, oral surgeons, radiologists, radio-oncologists and oncologists in a meeting that took place in Pörtschach, Austria, on 05 May 2006. The aim was to discuss the impact and indications of performing FDG PET/CT in patients with head and neck cancer and to outline possible future perspectives.FDG PET/CT is recommended for a better pretherapeutic staging in stage IV according to UICC and should be the method of choice in CUP with lymph node metastases. FDG PET/CT should be performed 3 - 4 months after radiation-/radiochemotherapy to diagnose viable tumour and to avoid false positive results. To evaluate the position and effectiveness of FDG PET/CT in therapy-monitoring further studies are needed. In case of radiation therapy FDG PET/CT allows a tailored treatment of patients with an accurate design of the target volume to reduce damage to the surrounding tissues.The interdisciplinary consensus reached by the experts is not intended to recommend standard guidelines in the management of head and neck cancer but to summarise and stress the impact of FDG PET/CT on the basis of the present literature and current clinical practise.

Along with the treatment equipment and the planning system the individual doses to the patient also have to be part of quality assurance. To make sure that the dose application to the patient is correct, a two-step concept is used: the check of the planned dose and the in vivo dosimetry.In contrast to the treatment planning where the necessary parameters for a desirable dose distribution and dose are determined in the target volume, the dose in the ICRU point is calculated from the individual setup parameters. This is done by using an Excel Macro program. Additionally, on the occasion of the first treatment session, the entrance dose on the patient surface is measured for each separate treatment field with a semiconductor diode. This dose is compared to the reference value from the treatment planning.Given a tolerance level of 4% for the correspondence of the doses in the ICRU point, 2.1% of the photon treatment plans showed a bigger deviation. The tolerance of the deviation of the measured entrance dose from the dose calculated in the treatment planning was set to +/- 5% for photons without wedge and to +/- 10% for photons with wedge or for electrons. 14% of all treatment fields exceeded the given tolerances without taking possible repeated measurements into account. The corresponding figures for photon fields without wedge, with wedge and for electron fields were 19%, 6% and 9%, respectively.Patient-related checks are essential since transcription and setup errors cannot be excluded. The checks have to be simple, meaningful and unambiguous. One must assume their independence of the individual and the method. If the tolerances are exceeded, actions have to be taken. This has to be taken into account when the tolerances are established.

To evaluate results on the functional outcome and to determine prognostic factors and long-term response to low-dose megavoltage irradiation.A total dose of 6.0 Gy given in two weekly fractions of 1.0 Gy was applied to 305 sites (252 patients). After 6 weeks, 97 sites (31.8%) received a second radiotherapy (RT) course. Assessment system was a function score which was documented before RT, at the end of each RT course, and at 6 weeks and 6 months after treatment. After an observation period of/= 24 months, a follow-up examination was attempted to evaluate the late response.At 6-month follow-up, 85.6% responded with a score improvement. The outcome was excellent (score: 90-100) in 135/305 sites (44.3%), good (score: 70-85) in 60/305 sites (19.7%), moderate (score: 45-65) in 63/305 (20.7%) sites, and poor (score: 0-40) in 47/305 sites (15.4%). 231/305 sites (75.7%) had no or mild pain. 296/305 (97,0%) had no or only slight limitations in work and 253/305 (82,9%) in daily activities. 255/305 (83,6%) had no or slight discomfort in gait. The long-term follow-up after a mean observation period of 48.4 months revealed 15 recurrences (7.3%). The patients' age, sex, and the duration of symptoms before initiation of RT (/= 6 months vs.6 months) did not prove to be prognostic factors. No early or late toxicity related to the use of RT was detected.Megavoltage 6-MV photon-beam irradiation is a safe, effective and long-acting treatment modality in the management of heel spur patients. The function score has been proven to be a feasible method in clinical practice for evaluation of treatment outcome.

Cutaneous T-cell lymphoma represent a heterogeneous group of diseases characterized by skin invasion of monoclonal T-lymphocytes. These cutaneous T-cell lymphomas are divided into 3 groups based on clinical, histological and immunohistological characteristics: Indolent with a survival time of over 10 years, aggressive with a survival time less than 10 years and provisional (EORTC classification). Standard treatments such as PUVA, total skin electron beam, methotrexate, polychemotherapy regimens, retinoids and photopheresis have been used for years. Bexarotene is a newly registered drug. To achieve better response rates, several new drugs are being evaluated in clinical trails, including imiquimod, denileukon-diftitox, liposomal doxorubicin, adeno-interferon-gamma and various combination approaches.

Stereotactic radiotherapy of benign tumors of the base of skull shows excellent tumor control and long survival. Aim is to study the impact of high dose radiation therapy on functions of memory and attention over time.21 patients (age 42 +/- 11 years) with tumors of the base of skull (meningiomas, pituitary gland adenomas) were treated by fractionated stereotactic radiotherapy (mean total dose 56.6 Gy/1.8 Gy). Comprehensive neuropsychological tests and MRI brain scans were performed before, 3, 9 and 21 months after therapy. 14 healthy volunteers were tested in parallel at baseline. In the follow-ups patients were their own controls.In pretreatment tests there were significantly worse test results in comparison to the control group in ten of 32 tests. In postradiation tests only few changes were found in the early-delayed period and not much difference was seen in comparison to the baseline tests. In MRI scans tumor recurrences or radiation induced changes were not found.Radiation with high local doses in target volume extremely close to sensitive brain structures like temporal lobes did not induce significant decline of cognitive functions.

The present study focused on the reconstruction of the bremsstrahlung spectrum of a clinical linear accelerator from the measured transmission curve, with the aim of improving the accuracy of this method. The essence of the method was the analytic inverse Laplace transform of a parameter function fitted to the measured transmission curve. We tested known fitting functions, however they resulted in considerable fitting inaccuracy, leading to inaccuracies of the bremsstrahlung spectrum. In order to minimise the fitting errors, we employed a linear combination of n equations with 2n-1 parameters. The fitting errors are now considerably smaller. The measurement of the transmission function requires that the energy-dependent detector response is taken into account. We analysed the underlying physical context and developed a function that corrects for the energy-dependent detector response. The factors of this function were experimentally determined or calculated from tabulated values.

Physician workload directly influences the ability of an institution to provide high standards in radiotherapy services.Data of 189 radiotherapy units of the DEGRO survey 2000 complemented and corrected (Table 1) are analyzed with simple and multiple linear regression (models in Table 2).In 21 private radiotherapy facilities actual numbers of physicians split up in 0.19 for every 1,000 megavoltage courses per year, 1.8 per megavoltage unit, 0.68 for every ten beds for inpatients minus 0.67 or plus 1.2 physicians per facility providing radiotherapy only or combined with other services, respectively. Radiotherapy units in hospitals were analyzed in two groups, i. e. radiotherapy only (n = 69) or in combination with other services (n = 59). In the latter, reported numbers of physicians split up in 3.2 for every 1,000 megavoltage courses per year, minus 0.13 per megavoltage unit, 0.87 for every ten beds for inpatients, plus 2.2 per facility. Units providing radiotherapy only had 0.86 physicians for every 1,000 megavoltage courses per year plus 1.0 per megavoltage unit plus 0.97 for every ten beds plus 1.0 per facility. In 36 radiotherapy university clinics actual numbers of physicians split up in 2.4 for every 1,000 megavoltage courses per year, 1.7 per megavoltage unit, 0.86 for every ten beds for inpatients, plus 1.5 per clinic. For confidence limits see Table 3, for results of univariate analysis Figure 1 and 2.In German radiotherapy facilities, physician workload varies considerably. It exceeds that reported for the USA by a substantial margin.

To evaluate a new therapy protocol for local dose escalation by high dose rate (HDR) brachytherapy for survival, morbidity and prognostic variables in men with localized prostate cancer. The prospectively recorded files of 189 men aged in median 69 years with a mean follow-up of 6 years (12-143 months) receiving curatively intended combined high dose rate (HDR) 192-iridium-brachytherapy (BT) and external beam radiation (EBR) for locally confined prostate cancer were analyzed. Mean age was 68.2 (range 44-84 years). Hundred and twenty-seven patients had T1-2 tumors, and 62 patients had T3-tumors. The total planned dose applied by external beam radiation was 50 Gy in the pelvis, and 40 Gy in the prostate by in-field-dose modification. The HDR-brachytherapy was delivered in two fractions. The dose per fraction amounted 15 Gy. Mean survival was 6 years (range 12-143 months), 76.7% of the patients survived and 86.3% were disease-free. The biochemical non-evidence of disease rate (BNED) was 78%. Univariate survival analysis revealed that low stage (T1-2), low grade (G1-2), normal PSA status after radiation therapy, and no adjuvant hormonal treatment were associated with long survival. However, the stratification for adjuvant hormonal treatment was not according to random. In multivariate analyses PSA status was an independent prognostic factor. The six year results confirm that local dose escalation by HDR-brachytherapy and external beam radiation is curative in men with locally confined prostate cancer. The results are especially in high risk patients encouraging.

Interstitial brachytherapy was first applied using radium needles, with minimum protection of physicians and nurses. Modern techniques involve the use of radionuclide (192)Ir as the source used in computer-controlled remote afterloading machines, which can deliver a high dose rate (HDR). Treatment planning is also undertaken with the use of computers and anatomical cross-section images using CT, ultrasound and MRI. This review presents these modern techniques for tumors of a series of body sites: prostate, head and neck, breast, bladder, brain, and for soft-tissue sarcomas. Low dose rate (LDR) interstitial brachytherapy techniques are also included in this review since in some body sites there is a choice between HDR and LDR.

Carcinoma of the external auditory canal are tumours considered to have a poor prognosis. Improvement of the survival rate by surgical means alone is not possible. Individual therapy modalities as a result of an interdisciplinary approach between otosurgeon and radiotherapist are necessary.A series of 30 patients (3 patients pretreated at other institutions) with carcinoma of the external auditory canal and middle ear treated between 1978 and 1997 in our institutions was analysed with particular reference to tumour size and its relation to surrounding tissues, patterns of neck node involvement, surgical procedures, and radiation techniques. Clinical endpoints were freedom from local failure, overall survival, disease-free survival. The mean follow-up was 4.7 years (range: 0.1 to 18.8 years), median 3 years.Treatment by surgery and radiotherapy resulted in an overall 5-year survival rate of 51%. According to Pittsburgh classification the 5-year survival rate for early disease (T1- and T2-tumours) was 89%, for stage III 67% and for stage IV 39%. Most important prognostic factors were dural infiltration (all patients with dural invasion died within 2.2 years) and the infiltration of surgical margins (the 5-year survival rate of patients with complete tumour resection was 100%, but 54% in patients with tumour beyond surgical margins). 192-iridium HDR afterloading brachytherapy based on 3D CT-treatment planning is an effective tool in the management of local recurrences following surgery and a full course of external beam radiotherapy.Surgical resection followed by radiotherapy adapted to the stage of disease and grade of resection is the preferred treatment of cancer of the external auditory canal and middle ear.

In peripheral non small cell lung cancer without metastasis, surgical resection achieves 5-year survival rates of at least 65%. In functionally inoperable patients radiation therapy offers the second best changes. However, in cases of severe emphysema with severely limited lung function even conventional radiation therapy is prohibited because of possible fibrotic reactions of the lung parenchyma. For such patients high dose rate stereotactic one-time radiation therapy may be an option. According to the study protocol of the DKFZ Heidelberg a dose rate of 24 Gy at the iso-center is applied with the linear accelerator in a single session. The recognisable tumour is irradiated with 22 Gy (90% isodose included). 20 Gy are applied to the tumour plus 6 millimeters safety margin. Prerequisites of such a therapy are a detailed computer-based planning using CT scans and an exact positioning with immobilisation of the patient. The irradiation is ideally performed under general anesthesia with high-frequency jetventilation to avoid movements due to breathing. We report on this new therapeutic modality in a patient with lung emphysema having a T2 tumour.

The treatment of persistent postoperative lymphatic fistulas or lymphoceles is often a problem. Approximately 2% of patients will develop lymphatic fistula after vascular surgery. This can require a long lasting conservative therapy. If spontaneous cure fails, a second operation with wound revision becomes necessary. We studied low-dose percutaneous radiotherapy to be used as an alternative treatment in addition to conservative or surgical therapy.Between 1989 and 1998 29 patients (25 with lymphatic fistulas, 4 with lymphoceles) received radiation therapy. Depending on the depth of the fistula 27 patients were treated with electrons (7 to 18 MeV). Two other patients suffering of retroperitoneal lymphoceles received a treatment with photons (15 MV). In all patients the fractionation was 4- to 5 x 1.0 Gy/week and the dose ranged from 3 to 12 Gy depending upon the onset of the radiation therapy effect.In 27 of 28 evaluable patients a complete disappearance of the fistula or lymphocele was achieved by radiation during therapy or shortly afterwards. In 1 case no benefit was observed after a dose of 11 Gy. This patient required further surgery with wound exploration.Low dose percutaneous radiotherapy (up to 10 to 12 Gy) is effective to heal lymphatic fistulas and lymphoceles without complications. Individual dosage is required because doses even lower than 10 Gy may be effective. Radiation can be effective even after a failed conservative therapy or instead of surgery.

Most malignant meningiomas will recur following surgical resection only. The role of irradiation and radiation dose levels is poorly defined. This study reviews a single institution experience using both, conventional and high dosesor = 60 Gy/CGE radiation regimen.Between 1974 and 1995 16 patients with histologically proven malignant meningioma underwent radiation therapy (RT). Age at diagnosis ranged between 6 and 79 years (median: 49 years). Three patients reported previous irradiation to the head at least 14 years prior to diagnosis. Ten patients were treated for primary, and 6 patients for recurrent disease. Six patients underwent gross total and 10 patients subtotal resection (Table 1). RT was delivered using conventional, megavoltage photons or combined 160 MeV proton and photon irradiation. Except 1 patient, who died during RT, the radiation doses ranged between 40 and 70 Gy/CGE (= Cobalt Gray Equivalent) (median: 58 Gy/CGE, Table 2).With median observation time of 59 months (range: 10 to 155 months), actuarial local control rates at 5 and 8 years were 52% and 17%, respectively. Target dosesor = Gy/CGE resulted in significantly improved tumor control (100%) compared to60 Gy/CGE (17%) (p = 0.0006, Table 3 and Figure 1). Improved local control translated also in increased overall survival: 87% (or = 60 Gy/CGE) versus 15% (60 Gy/CGE) at 5 years (p = 0.025, Figure 2). At time of analysis, 6/16 patients (38%) were alive. Two patients developed symptomatic brain damage at doses of 59.3 and 72 Gy/CGE.Conformal, radiation therapy with target dosesor = 60 Gy/CGE, in this study by use of combined proton and photon irradiation, can significantly improve chances of long-term local control and survival for patients diagnosed with these challenging tumors.

Therapeutic results after radiotherapy in thyroid associated orbitopathy (TAO) often are not comparable, because either different therapeutic methods at the same time or different scores were used in the evaluation. This study focuses on radiotherapy alone by means of different evaluation scores.60 patients (49 women, 11 men) received standard external beam radiotherapy (20 Gy: 10 fractions of each 2 Gy) as ultima ratio after failing different other therapies of thyroid associated orbitopathy. The mean interval from beginning of the symptoms to the radiotherapy was 17 +/- 36 months (between 6 and 240 months). The follow up was documented--classified by means of 4 different scores--before radiotherapy, 6-12 weeks, 1 year after radiotherapy and at last follow up. The changes of symptom categories or grades of the different scores were analysed.Significant changes of the ophthalmic scores were observed when comparing the endpoints at 6-12 weeks, and at 1-year follow up after radiotherapy. The "classical" Werner score at 12 months follow up did not correlate well with the other TAO scores: American thyroid association (ATA) scoring system, Stanford scoring system, International ophthalmopathy index, while all other TAO scores revealed a high correlation among each other. According to the Orbitopathy Index (OI) of Grussendorf an improvement from 14.2 points to 6.0 points was achieved. Soft tissue involvement and corneal involvement demonstrated the highest response rate (83/87%), extraocular muscle involvement and proptosis a good response rate (69/70%). No long-term complications were observed.According to this study there are indications that external beam radiotherapy is a suitable therapy even after pretreatment and a longer course of TAO. The OI, the ATA and the Stanford scoring systems lead to similar results in the assessment of thyroid orbitopathy.

Dosage measurements in brachytherapy of cervix carcinoma are usually obtained with semiconductor dosimeters intrarectally and calculated using approximation methods for additional points, e.g. chosen according to ICRU Report 38. This procedure allows minimizing organ risk dosages and avoiding side effects. This study compares actual dosage measurements with computed approximations.In 75 applications the measured actual rectum dosage was analyzed retrospectively. Using graphic approximation methods in conjunction with the localization radiographs the expected dose values at 5 detector points of the intrarectal semiconductor dosimeter and at the ICRU rectal reference point were determined. Prospectively for 11 additional applications the expected dosage for various points within the rectum were computed during therapy planning and additionally for specific reference points corresponding to Fletcher's lymphatic trapezoid and Chassagne's pelvic wall points.The retrospective evaluation showed that 95% of values determined by graphic approximation methods varied by as much as +/- 30% from measured values. Factors causing errors were incorrect assessment of the applicator's spatial positioning, non-orthogonal radiographs, incorrect calibration of the semiconductor probe, movement of applicator and/or probe in the time between radiograph and application. In the prospective group 95% of deviations between measured and calculated values lay within an interval of +/- 40% (Figure 1). Possible sources of error could be similar to those in using the graphic approximation, although the reconstruction of spatial positioning of the applicator is possibly more exact. Doses determined at the ICRU rectal reference point were 5.6 +/- 2.5 Gy in the retrospective analysis and 6.1 +/- 1.6 Gy in the prospective study (Figure 2). The standard deviation of measured values at the specific reference points was +/- 30%. The mean dosage distribution was nearly symmetrical with regard to the body axis, i.e. to the applicator position. Reasons for the relatively large standard deviation are e.g. difficulties in defining the reference points as well as in identifying them on the radiographs, also differences in applicator positioning.The retrospective analysis led to a larger error than the prospective one. The graphic approximation method should only be utilized when computer-assisted treatment planning is not possible. Conspicuous are the differences between values obtained in computer planning and actual measured values. As these deviations cannot always be explained unequivocally, both computation and measurement should always be conducted in order to obtain an adequate survey of dosage distribution within the rectum. Computer planning offers the additional advantage of determining the dose at various other reference points.

Patients with carcinomas of the upper aero-digestive tract often suffer from ear pain as a tumor associated syndrome. This prospective study examines the predictive and prognostic value of this symptom.Ninety-six consecutive patients who completed a locally radiotherapy of a carcinoma of the oropharynx were prospectively evaluated and followed. Forty-nine out of 96 patients stated the symptom, either spontaneously or after questioning. The 2 groups showed no difference regarding TNM-classification, histology and total dose. Overall survival, local control and disease specific survival were calculated according to Kaplan-Meier and compared by the log-rank test.A clinically complete remission was obtained in significantly fewer patients with reflex-otalgia as compared to patients without reflex-otalgia, 61.2% versus 89.3%, p0.002. Local control of patients with reflex-otalgia was significantly less with 49%, mean follow-up 564 days, in comparison to local control in patients without reflex-otalgia, mean follow-up 613 days, p = 0.01. Disease specific survival was significantly worse for patients with reflex-otalgia, p0.012. The probability of local control of T1/T2 tumors with reflex-otalgia was similar to T3/T4 tumors without reflex-otalgia. Local control for all tumor categories combined is 74% for patients without reflex-otalgia versus 49% for patients with reflex-otalgia.In our patients, reflex-otalgia is a new and statistically significant parameter for the probability of local control and disease specific survival.

The most important side effect in radiotherapy of lung cancer is pneumonitis. The incidence of pneumonitis was evaluated in a retrospective study in the patient collective of the University of Heidelberg. Therapy related and therapy independent factors have been evaluated.In 348 of 392 cases with lung cancer who were treated by local irradiation between January 1989 and January 1992 the patient's records were evaluable for response and toxicity. All patients were treated by megavolt equipment with a conventional fractionation in most cases. Standard target volumes were irradiated including the lymphatic drainage. From a dose of above 30 Gy a technique sparing the spinal cord was chosen. Retrospectively pneumonitis was classified into 4 grades starting from slight symptoms to respiratory insufficiency requiring O2. Grade I and II were summarized to slight, grade III and IV to severe pneumonitis.Regarding the treatment prior to irradiation patients with primary irradiation were affected in 26.5% (17% slight, 9.5% severe), with postoperative irradiation in 14% (9.3% slight, 4.7% severe), with radiochemotherapy of small cell lung cancer (SCLC) in 15.4% (12% slight, 3.4% severe) by this side effect. These differences were not significant (p = 0.32). The median onset of pneumonitis was 31 days after end of irradiation (severe 23 days, slight 44 days, p = 0.026). By a univariate analysis the total dose at the prescription point was the most important factor (30 to 50.5 Gy 11%, 52 to 59 Gy 15%, 60 to 74 Gy 26%, p = 0.007). High single doses (2.5 Gy) were only applied within a study of radiochemotherapy with a randomised sequential and alternating schedule. So that the increased rate of pneumonitis (42%) is not clearly separable from other influencing variables. A correlation between the applied techniques and the irradiated volume (measured by planimetric methods) was not demonstrable. Regarding the independent factors a high age, female sex and a low FeV1 were unfavourable. However, age and sex corrected FeV1 was not predictive.The observed incidence is within the range of literature. By a clinical point of view the total dose is an obvious factor. Also single doses above 2 Gy have to be seen critically (a total dose of 50 Gy). The results confirm the fact that patients with a low FeV1 are not suitable to a high dose irradiation of the chest. In this connection old patients and women also should be seen as patients at risk.

In the treatment of laryngeal carcinoma definitive radiotherapy results in a similar outcome as surgical treatment in the early stages with a lower morbidity rate and good functional results. In fact no randomized studies exist, so far, and the optimal treatment concept for the different stages is not well defined. The following study analyses retrospectively the treatment results and the recurrence data in patients with a squamous cell carcinoma of the larynx treated with definitive radiotherapy.Two hundreds and eighty-three patients with carcinoma of the larynx were treated with radiation therapy in the department of radiology of the LMU München between September 1971 and June 1986. Twenty-six patients (9.2%) were female and 257 (73.1%) male. The median age was 68.5 years, respectively 70 years. All patients had a histologically confirmed squamous cell carcinoma of the larynx. No true subglottic cases were observed. Forty-one (14.5%) tumors were localized supraglottically, 207 (73.1%) glottically. Thirty-five patients had a T4 tumor with glottic and supraglottic involvement. In 147 patients the histopathological grading was evaluable: 32 tumors were classified as G1, 95 as G2, 15 as G3 and 5 as G4. According to the UICC classification of 1979 25 patients had a carcinoma in situ (Tis), 93 patients had a stage T1, 90 stage T2, 40 stage T3 and 35 stage T4. Two hundreds and thirty-three of 283 (82.3%) had no lymph node involvement. In 50 patients clinically a lymph node involvement was observed. 22 patients had a stage N1, 5 patients stage N2 and 23 patients stage N3. An external beam radiation mostly with cobalt-60 was performed with a mean dose of 61.9 Gy.The 5-years relapse-free survival for the whole group was 61.7%. The probability for "no evidence of disease" (NED) depended on tumor stage and localisation (glottic tumors: Tis/T1 90.5%: T2 59.4%: T3 39.6%: [5-year NED]; supraglottic tumors T1 64.2%: T2/3 28.6%: T4/N3 24.7% [3-year NED]). Other significant prognostic factors besides T-stage were N-stage (NO vs. N1-3: 3-year recurrence-free survival 68% vs. 37.2%, p0.001) and histopathologic grading (G1 vs. G3/4: 3-year recurrence-free survival 74% vs. 37.1%, p0.01). One hundred and twenty-two (43.1%) patients had a recurrence, which occurred in 75.4% local, in 12.3% loco regional, in 8.2%, with distant metastases and 4.1% combined. In 50 patients with a recurrent disease a salvage therapy was carried out. Thereby 17 patients achieved a complete response.Even for the here described negatively selected patient group with a high median age and multimorbidity, good local control rates could be achieved especially in early stages with definitive radiation therapy. In more advanced stages even in elderly patients a combined surgical-radiotherapeutic treatment should be performed.

Doubtlessly modern high voltage radiation treatment has less side effects than former techniques. It may be better than conventional methods with respect to 5-year survival rates, but that has to be proven using a large number of cases.Retrospective study using the material of one department of gynecology and obstetrics, practicing both operation and irradiation. 1830 cervical carcinomas are differentiated in stages and then divided in 3 historical collectives. From 1959 to 1968 there was a combination of traditional contact therapy with conventional X-ray irradiation. The period from 1969 to 1972 is characterized as a changing one with partly therapy as described above, partly traditional contact therapy was combined with biaxial telecobalt therapy. From 1973 to 1986 a reduced contact therapy doses was applied to pelvic high voltage irradiation.Five-year survival rate in stage I was 79% in conventional treatment and with ultra high energy 77%. The corresponding figures in stage II are 56% respectively 52%, in stage III 26% respectively 25% (Table 1) of gynecology and obstetrics, practicing both operation and irradiation.Application of ultra high energy radiation in higher doses in Rostock had not the consequence of elevating the 5-year survival rate, but the quality of life is much better.

Between 1989 and 1992, 38 patients with advanced squamous cell carcinomas of the head and neck were treated by an accelerated hyperfractionated split-course radiochemotherapy (SCRC). This therapy was carried out at the ENT department and department of radiooncology of the University of Heidelberg. Within 51 days, 70.2 Gy were applied in three courses. In every course, simultaneous chemotherapy with cisplatin (60 mg/m2/week)/5 Fu (bolus: 350 mg/m2/d)/Leucovorin (bolus: 50 mg/m2 + 100 mg/m2/24 h) was carried out. Between 1992 and 1994, 50 patients suffering from advanced head and neck cancer (stage III, V) were also treated with an accelerated hyperfractionated concomitant-boost radiochemotherapy (CBRC) at the same departments. A total dose of 66 Gy, was applied within 33 days. The patients were also treated with simultaneous chemotherapy with carboplatin (70 mg/m2/24 h) in the first and fifth week.In about 50% of the patients treated with SCRC, the therapy was more than 10 days longer than the scheduled period. The lack of compliance due to toxicity was considered as one of the main reasons for this delay. After the first course of SCRC, eight of 38 patients showed mucositis of the upper aerodigestive tract (WHO grade3); after the second course, 11 of 38 patients; and after the third course, 15 of 38 patients. Fifty-two percent of the patients developed emesis, 10% leucopenia1 nl, 10% nephrotoxicity, 3% pancreatitis, 3% thrombosis, 3% gastritis, and 3% auditory threshold shifts of about more than 10 dB. In about 7.5% of the patients treated with CBRC, the therapy was more than 10 days longer than the scheduled period. The mucositis of the upper aerodigestive tract (50% of the patients showed WHO-grade3) was considered to be the main reason for this. In four patients a neutropenia1 nl was detected, in one patient anemia7 g/dl and n 33 patients thrombocytopenia100/nl.In conclusion, the concomitant boost radiochemotherapy showed a lower toxicity and higher acceptance than the split-course radiochemotherapy. This is documented in lower protocol delays and better results in the two-years survival time in case of concomitant boost radiotherapy.

Facts and figures about German radio-oncologic centers are scarcely available. A first glance was made possible by the accumulation of data published by the German Röntgen Society ("Abteilungen und Praxen für Strahlentherapie in der Bundesrepublik Deutschland, 1994"[4]). Detailed and up-to-date information is difficult to collect from the whole Federal Republic. Therefore, a regional data-base limited to the 6 northern German states was created in order to get correct, detailed and current facts and figures from radio-oncologic departments of this region.Traditionally there was a close cooperation between the Röntgen Society of Northern Germany and the Society of "Niedersachsen" and "Sachsen-Anhalt". Therefore, hospital departments and free standing office-type facilities in radio-oncology from 6 states have put together a regional North German data-base. Detailed questionnaires were sent out in order to get data on heads of departments, professional staff, technical equipment, workload, diagnoses and training facilities. The collected data were distributed to all participating centers for confidential individual analysis. This paper reports the data collected.The survey 1995/96 had an unexpected return. Thirty-six from 38 centers in a region with 17.36 million inhabitants in 6 states (21.3% of Germany) took part. There were 73 megavolt machines and 31 afterloading facilities. Two hundred and forty physicians, 110 physicists, and 350 radiographers were working in radio-oncology; and there were 852 hospital beds specifically assigned to radio-oncology for the care of in-patients. In 1995, 32,000 patients were treated with 37,000 series, 570,000 treatment visits and 1,600,000 radiation fields. The average patient got 1.2 series, 18 treatment visits and 50 fields. Equipment-wise, an average department runs a mean of 2 megavolt machines and 1 afterloading facility. The corresponding data for 1 megavolt machine were 3.5 physicians, 1.6 physicists, 5 radiographers and 13 hospital beds. There was 1 machine for 240,000 inhabitants. The average workload of a megavolt machine was 439 patients a year with 513 series, 7,813 treatment visits and 21,845 radiation fields.A regional data-base for radio-oncology is being described. It is demonstrated that it is possible to get detailed and current data by this method. It provides transparent data on equipment, personnel and workload in radio-oncology. It should set an example for other regions to collect their data in the same fashion, and then compile all such data for the whole country to identify and correct potential deficiencies for improvement of care.

Today, whenever possible, mamma carcinoma is operated on by preserving as much breast as possible, and is followed by postoperative radiotherapy of the thoracic wall. This form of treatment can lead to alterations of the skin and parenchyma, visible in mammogram, which may make evaluation of these mammographies difficult with regard to recidive. This paper presented describes nature and frequency of changes of treated breast caused by therapy.Three hundred and eighty mammographies of 50 female patients were evaluated on alterations of skin and parenchyma caused by combined therapy. Inclusive criteria were among others 2 mammographies in the 1st year after therapy, no advanced or parallel chemotherapy and a follow-up time of at least 5 years.Thirty-two patients (64%) showed no fibrotic changes of breast, 5 patients (10%) initially developed denseness of parenchyma which then, however, reverted back to a completely normal state. Only 13 patients (26%) had irreversible fibrotic alterations of parenchyma, only 3 (6%) of which showed extensive fibrosis which definitely might make recidive diagnostic difficult.Major changes of parenchyma caused by preparatory treatment which can be registered by mammography are relatively rare. For this reason, mammography maintains its unchanged high position within post-tumorous treatment, especially as it even today is the only diagnostic method to evidence microcalcifications suspect of being malignant.

Keratoacanthoma is a fairly common, benign, usually self-resolving skin lesion that arises from the hair follicle. This nodular lesion shows a predilection for areas exposed to light, mainly for the face. We report on the intensive radiation therapy of 2 cases of a rare subset of keratoacanthoma which showed a locally aggressive, seriously destructive growth.Two female patients with previously treated, confluent-destructive growing keratoacanthoma were treated by multimodal, high-dose radiotherapy. Patient 1 showed a rapid progress of midfacial tumor with destructive infiltration of the left cheek, nasal cartilage, the cribriform plate of ethmoid and congestion of the conjunctiva close to the lacrimal caruncle. This could be shown in clinical and histopathological investigations and CT-scans. The coexistence of cutaneous and conjunctival lesions in locally rapidly enlarging keratoacanthoma of the face is unusual and unreported to our knowledge. One case of simultaneous conjunctival and multiple, eruptive keratoacanthoma of the body has been reported. Patient 2 had received soft X-ray pretreatment because of a large, relapsing keratoacanthoma of the left cheek.Patient 1 underwent a parallel, intensive treatment of the conjunctiva with 90Sr-contact therapy, percutaneous high-dose 60Co-gamma- and megavoltage electron treatment (10 and 18 MeV) of the midfacial lesions. Conjunctiva and caruncle showed a complete remission of keratoacanthoma. In the other facial areas no long-term regression could be reached, despite giving a fully cancericidal, total dose of more than 100 Gy in some regions. Patient 2: Further high dose radiotherapy using megavoltage electron treatment with a total dose of 50 Gy showed a complete remission of the lesion for 5 months. Another relapse of this keratoacanthoma could be operated successfully. There was no more relapse established in follow-up checks.The 2 case reports show that in treatment of locally destructive growing subsets of keratoacanthoma a sufficient therapy should be initiated in time. Keratoacanthoma and subsets of this lesion that do not respond well to initial treatment, recur early or show seriously aggressive growth should be treated early by combined therapy that takes previous experiences into consideration.

Surgery is no longer necessary for pathologic diagnosis and staging of gastric lymphoma because of improved endoscopic biopsy and modern imaging techniques. At least equal results may be achieved compared to surgery by wide-field megavoltage radiotherapy and polychemotherapy without prior resection.

Chronic myelocytic leukemia is a disease of myeloproliferative disorder. In chronic myelocytic leukemia occasionally myelosarcomas occur as defined tumors which can cause localized symptoms. We report a case of successful palliative radiotherapy.A 44-year-old patient with total destruction of the left humerus caused by myelosarcoma of the bone in chronic myelocytic leukemia was treated with percutaneous megavoltage radiotherapy, the total applied dose was 40 Gy. After radiotherapy the patient was free of pain. The tumorous swelling of soft tissue subsided completely, there was total formation of callus in the affected humerus and the patient could be mobilized.This case report confirms the high effectiveness of palliative radiotherapy even in advanced cases of myelosarcomas which has been described in literature.

The usual therapeutic approach to circumscribed choroidal hemangiomas of the posterior pole consists of scatter photocoagulation of the tumor surface. This may often require repetitive treatment or additional invasive measures prior to coagulation due to massive exudative detachment of the retina. In this study, external beam irradiation with high-energy photons (total absorbed dose: 20 Gy) was applied to 36 symptomatic patients. The indication for treatment was exudative retinal detachment including or threatening the fovea. The mean duration of follow-up was 4.5 years (4 months to 24 years, median 4 years). In 23 cases (63.8%) complete resolution of the subretinal fluid could be achieved; 13 cases (36.2%) showed residual serous detachment at some distance from the fovea. The visual acuity improved by two or more lines in 14 cases (38.9%), remained stable in 14 cases and decreased in only 8 cases (22.2%). The functional success was dependent on the interval between onset of first subjective symptoms and treatment. External beam irradiation is a successful form of treatment for choroidal hemangiomas.

Intraoperative radiotherapy has proved its worth for curative and palliative treatment of gastrointestinal tumors. IORT indications comprise cancer of the stomach, of the pancreas and colorectal carcinomas. Most authors are cautious to apply it to carcinoma of the esophagus, of the small intestine and of the hepatobiliary system. IORT is applied as adjuvant treatment alone or in combination with postoperative external-beam photon irradiation +/- chemotherapy. There is evidence of an improved local control rate. Pain can be relieved in symptomatic patients by an IORT dose ofor = 20 Gy. Until now, however, there is no evidence of a prolonged relapse-free and overall survival.

Patients with cutaneous T-cell lymphoma are treated in Germany mostly by dermatological local therapy like corticosteroids or PUVA-irradiation. Total skin electron beam irradiation is used rarely, even though it has a potentially curative character. We present an analysis of patients, who received a total skin electron beam irradiation after having progressive disease following other treatment modalities.Twenty-one patients (mean age 58.9 years) in different stages were treated (stage IB and IIA n = 4, stage IIB n = 8, stage III n = 3, stage IV n = 6). All patients had progressive disease under other forms of local therapy. The irradiation was performed from 6 directions per hemibody using 2 axial fields which have each an 18 degree angle to the horizontal level. Six and 7 MeV fast electrons were used. Total dose was between 8 and 36 Gy in single dosis of 1 x 4 up to 5 x 2 Gy per week. In underdosed areas and areas of tumors of the skin boost irradiation with small fields was given.All patients had a good tumor regression (complete remission: n = 10, partial remission: n = 11). With the follow-up between 4 and 93 months total- and recurrence-free survival was 18 and 7 months (median). Patients in early stages with slow but complete remission of the symptoms had the best prognosis. Because of the small case number there was no significant difference between the groups. There were no severe side effects of the radiotherapy noted.Our analysis shows on a small patient number, that total skin electron beam irradiation has a good palliative effect on patients who have progressive disease following other types of treatment like PUVA or corticosteroids. The recurrence-free survival of 2 out of 4 patients with early stage disease (I-IIA) up to 93 month shows the potentially curative character of the treatment.

Periarticular ossification is one of the main problems of total hip replacement. Irradiation with megavolt photons is known to be a well recognized means of prevention of heterotopic ossification. So far only little scientific basis exists about the most favourable way of radiotherapy for prevention of ectopic ossification. In this study two theoretically equivalent doses are compared. Allogeneic bone matrix was implanted into both thighs of 50 adult male Wistar rats for experimental induction of heterotopic ossification. Immediately after operation the thigh implants were irradiated with a single dose of 7 Gy or a total dose of 10 Gy given in 5 fractions of 2 Gy each. In the model of matrix-induced osteogenesis in rats fractionated irradiation by 5 x 2 Gy leaded to a highly-significant (p = 0.001) better suppression of ectopic ossification compared to irradiation by 1 x 7 Gy. Once-only irradiation with 1 x 7 Gy leads to a reduction of the calcium contents by 27.5%, split irradiation by 5 x 2 Gy obtained a reduction by 66.9% compared to the calcium contents of thigh implants not exposed to radiation. In view of experimentally proven better effects, fractionated irradiation has to be preferred to single dose radiation also considering less side effects in split radiation.

Choroidal metastasis from other primaries than breast cancer or lung cancer is a rare event. There is no documented case in the literature of a choroid metastasis in a patient with adenocarcinoma of the uterine cervix.The case of a pregnant 25-year-old woman with cervix carcinoma (stage FIGO Ib) is presented. Following abortion and radical surgery no additional treatment was performed. Two years later the patient developed the signs of retinal detachment and a partial visus lost in her left eye. A solitary choroidal metastasis in the left eye was diagnosed by an ophthalmologist. The additional CT of the lung showed pulmonary metastases. Histological examination of a biopsy revealed lung metastases from the cervix carcinoma.The choroid was irradiated up to a total dose of 40 Gy, 5 times a week with a single dose of 2 Gy. Then an additional chemotherapy was performed. Within the time of radiotherapy a relief of the symptom was obtained. Eight weeks after the end of radiotherapy there was no detectable tumor any more in the left eye (complete remission).The case illustrates the importance of rapidly responding to ophthalmologic complications in patients with cancer in general. Radiotherapy is a very effective treatment in reducing ophthalmologic symptoms in the case of choroidal metastases.

At the University of Freiburg, a consensus was arrived at concerning the place of external radiotherapy in the management of thyroid cancer. External irradiation is always indicated in papillary and folliculary carcinoma in the pT4 stage of pTNM classification but not in those in pT1-3 pN0 stage. In the presence of lymph-node metastases and distant metastases, an individual treatment concept is recommended, which should be set up in an interdisciplinary conference regarding all risk factors, especially the age and sex of the patient, the histology and grading of the tumor and the completeness of tumor resection. Finally, radiotherapy is usually not indicated in medullary thyroid carcinoma, whereas it is always indicated in anaplastic carcinoma.

Treatment verification for reasons of quality control takes an important place in daily radiotherapeutic work. The quality of conventional, e.g. not digital imaging methods, is often poor. Moreover, portal and verification imaging are commonly used only for photon beam control; even digital portal radiographs were not suitable for verification of electron beams, rotation beams, conformation therapy or dynamic multileaf collimation yet.We developed a method, using digital luminescence radiography (DLR), not only for portal imaging of photon beams in an excellent quality, but also for verification of electron beams. Further on, DLR was used as basic instrument for image fusion of portal and verification film and simulation film respectively for image processing in "beams-eye-view" verification (BEVV) of rotating beams or conformation therapy.Digital radiographs of an excellent quality are gained for verification of photon and electron beams. In photon beams, quality improvement vs. conventional portal imaging may be dramatic, even more for high energy beams (e.g. 15-MV-photon beams) than for Co-60. In electron beams, excellent results may be easily obtained. By digital image fusion of 1 or more verification films on simulation film or MRI-planning film, more precise judgement even on small differences between simulation and verification films becomes possible. Using BEVV, it is possible to compare computer aided simulation in rotating beams or conformation therapy with the really applied treatment. The basic principle of BEVV is also suitable for dynamic multileaf collimation.DLR is a multipotent and suitable method for many aspects of imaging treatment verification.

Ileum neobladder after cystectomy is mainly reserved for male patients. Female patients are normally excluded from this kind of urinary diversion for fear of incontinence following orthotopic bladder substitution. In addition as in the male, the question of urethral recurrence of urothelial carcinoma is still not settled. We report on seven cases of successful orthotopic bladder reconstruction in females by means of an ileum neobladder according to Hautmann with follow up of up to 4.5 years. One of these patients had a complicated bladder-vaginal fistula and almost complete loss of bladder function because of a shrunken bladder after radiation therapy for a cervical carcinoma and the other six had undergone radical cystectomy because of bladder carcinoma. The ileum neobladder is anastomosed with the preserved urethral stump. The original method of ileum neobladder is extended by a colposuspension plasty according to Marshall-Marchetti, which is the means of achieving continence. The first results are encouraging and open further possibilities for bladder reconstruction in the female.

Head and neck tumors are often treated by a multiple-field technique, using a combination of opposing photon fields and electron beams in order to stay within the limit of the myelon tolerance dose. Dose inhomogeneities at field margins must be minimalized to avoid an increased rate of local recurrences or late complications.A polystyrene phantom with a base of 12 x 16 cm was used to investigate the optimal conditions of field matching, using 9 MV photon beams and 8 to 10 MeV electron beams. The evaluation was performed by using an automatic video-densitometer and digital image processing. Dose distributions are presented as 3-dimensional plots and as dose profiles in a depth of 1.2 and 2.5 cm.In the neck region photon and electron fields cannot exceed a field width of 6 to 7 cm. With unmodified electron fields and opposing photon fields with a 5 mm penumbra optimal geometrical matching is achieved by using an overlap of 2 mm referring to the field margins. Related to a reference dose of 100% the dose in 1.2 and 2.5 cm depth varied between 90% and 115%. Geometrical variations at the field margins, using a gap of 3 mm or an overlap of 5 mm, result in a local underdosage of 75 to 80%, respectively an overdosage of 135 to 150% referring to the reference dose. This dose inhomogeneity occurs at a width of 1 cm around the field margins.Regarding clinical and physical aspects the matching of unmodified beams seems to have an advantage compared to the matching of fields with broadened penumbras. For the treatment of patients an immobilisation technique and a precise daily set up is required.

Local radiotherapy plays an important and responsible role in the management of bone metastases. The valence will be described according to the different treatment objectives in the sense of pain relief, remineralization and cord decompression. Radiotherapy schedules, aimed at the relief pain, need to take into consideration life expectancy. Patients with a reduced life expectancy could have a good high chance of achieving pain relief with a single dose of 8 Gy. Patients with a solitary metastasis, patients with a longer life expectancy and patients with a pathological fracture should be treated with 'curative' irradiation doses, aimed at killing the maximum number of tumor cells. In addition to pain relief, remineralization is also an important treatment goal. Conventional radiotherapy with doses of 40-50 Gy resulted in pain relief in 70-100% and in remineralization in 60-80% of the patients. Remineralization could not be accelerated by short-course fractionation courses, but resulted in faster pain relief. Short-course fractionation schedules are not indicated as a 'standard' treatment in the vertebral column. Surgery is the treatment of choice for immediate cord decompression and stabilization of a pathological vertebral fracture. Radiotherapy alone could decrease neurological impairment and is suitable for patients with gradual onset and progression of symptoms, no spinal instability and lesions of the cauda equina.

We tested, whether inhalation a of gas mixture containing 8.0 to 8.5% O2 reduces the radiosensitivity of healthy tissue in order to deliver higher tumor doses without increasing the side effects of radiation therapy.In this study 165 patients were treated in the Clinic of Radiation Oncology Erlangen (Germany) and in the Institute of Oncology in Brno (Czech Republic) in the period of January 1986 to December 1993. In 108 patients external irradiation was applied using acute hypoxia (group A--hypoxyradiotherapy). This group was compared with a conventional therapy group of 57 patients (group B). The majority of the patients had advanced tumor of cervix uteri or of rectum. In 89% of patients of group A and in 61% patients of group B external irradiation was applied with portals20 x 15 cm2 (p0.01). The mean dose in the group A was increased about 30% compared to the mean dose of group B (55.2 Gy vs. 43.6 Gy; p0.01).Despite this increase in dose and large-field irradiation in most cases in group A no differences were found between group A and B concerning acute or late effects of radiation therapy.The aerogen acute hypoxia (hypoxyradiotherapy) is so far not only the simplest, but also one of the most effective selective radioprotective methods.

The role of prostate-specific antigen (PSA) in the follow-up of patients after radiation therapy for prostate cancer is not well defined. There are no reports on long-term follow-up with PSA and serial PSA determinations, respectively. We followed 113 patients after radiotherapy for clinical stages A through D1 prostate cancer with multiple PSA measurements. External beam radiation has been applied to 98 patients and 15 received 125-iodine implantation. Eighty-eight of the 113 patients (78%) had a precipitously rising PSA with median doubling times of 14 (stage A), 15 (stage B), 7 (stage C), and 8 (Stage D1) months, respectively, at a mean follow-up of 5 years after radiotherapy. Twenty-three of the 113 patients (20%) appeared cured with a PSA of 1.7 ng/ml or less at a mean follow-up of 9 years. Two of the 113 patients (2%) continued to have a decreasing PSA 3 years after irradiation. Among the cured patients there was no relationship to clinical stage or histological grade. We conclude that about 20% of patients with clinical stages A-D1 prostate cancer can be cured by radiotherapy. They can be identified by a very low serum PSA level which seems to persist indefinitely. The remaining 80% who fail radiation therapy appear to have an accelerated growth rate suggesting tumor clonogen repopulation during radiotherapy.

In a prospectively randomized study, 137 patients with 141 hips at high risk for heterotopic ossification (HO) received prophylactic radiation therapy (RT). Patients were randomly assigned to a low-dose regimen of five fractions of 2 Gy each (n = 73) or a high-dose regimen of either 10 fractions of 2 Gy each (n = 7) or five fractions of 3.5 Gy each (n = 61). Treatment outcome was assessed by comparing immediately postoperative radiographs with radiographs obtained at least 6 months after hip surgery (Brooker grading score). Positive responses (ie, effective prophylaxis of HO) were seen in 129 (91.5%) hips. Treatment failures were observed in 12 (8.5%). Use of a nonsteroidal antiinflammatory drug (NSAID) lowered the failure rate in both groups. High RT dose with a short duration (or = 9 days) and use of an NSAID was significantly (p = 0.009) correlated with treatment success. RT delivered within a few days after hip surgery is effective in preventing HO, even in high-risk patients, and provides an alternative of at least equal value for patients with contraindications to long-term medication with either NSAIDs or corticosteroids.

Until now, radical irradiation has been the treatment of choice for patients with unresectable squamous cell carcinomas of the head and neck. In spite of improved radiation techniques, conventional radiotherapy remains mainly palliative for patients with advanced and unresectable disease stages. Our own results with accelerated radiotherapy (2 x 2.1 Gy/day, day 1-4 in week 1, 2, 5 and 6, total dose of 67.2 Gy) and simultaneous chemotherapy with carboplatin (50 mg/m2/treatment day) suggest that combined radiochemotherapy might improve the poor results achieved with conventional radiotherapy or sequential chemoradiotherapy in these patients. However, further studies are necessary to clarify whether modified radiotherapy or simultaneous chemotherapy or the combination of both are the reason for the improved treatment results. Furthermore, accelerated radiotherapy and simultaneous chemotherapy should also be investigated as an adjuvant postoperative treatment modality in primary resectable patients with advanced stage of disease to improve their poor prognosis.