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Background: Many young adults with cancer of good prognosis seek advice from their doctors, because they are concerned about their ability to have children and about potential hereditary diseases in the children conceived or fathered after cancer therapy., Patients and Methods: Results of repeated examinations of 61 children over a period of 20 years are reported. One of their parents had received radiotherapy for malignant disease (only three had additional chemotherapy). Radiation doses to the gonads ranged from 0.01 to 2 Gy. The most frequent indications for radiotherapy were Hodgkin's disease (n=25), seminomas (n=7), thyroid cancer (n=3), and malignant melanomas (n=3), Results: There was a trend to premature birth with 52.5% of the babies born before term. Yet, all had normal birth weight and delivery was inconspicuous. The skeletal maturation was retarded, but development was still in the normal range of German children. There were no chromosome aberrations, normal mental and intellectual development, and no malignancy among these children. A trend to an increased frequency of developmental disturbances and four moderately severe malformations were observed; however, no direct association with radiation treatment could be demonstrated. One child had a balanced translocation (5;17) which it inherited from the unirradiated parent., Conclusion: During the first consultation of young adult cancer patients, before the start of treatment, the problems of fertility and of therapy-induced mutations and hereditary diseases as well as developmental damage of the offspring need to be addressed directly by the radiation oncologist. Decisions on cryoconservation of sperm, fixation of the ovaries and dosimetry of the gonads during radiotherapy have to be made before the start of treatment. The rate of radiation-induced hereditary diseases and developmental damage in the children conceived or fathered after curative radiotherapy of one parent is estimated to increase by <0.1% (after gonadal exposure of 1 Gy). However, at present, heritable damage potentially induced by chemotherapy cannot be adequately quantified yet.

Purpose: Conversion coefficients are commonly used to estimate the radiation dose in projectional radiography from the dose-area product (DAP). This study investigates whether conversion coefficients can also be used for dosimetry in fluoroscopic procedures., Materials and Methods: Thermoluminescence dosimeters (TLD) were placed into an anthropomorphic phantom (Alderson Rando Phantom) to measure the dose absorbed by the gonads and uterus. A standardized enteroclysis in double contrast technique (Sellink/Herlinger) was simulated and the DAP was measured. Three examinations with 70, 80 and 90 kV were carried out with a fluoroscopy time of 15 minutes each. The relations between the DAP and the organ dose were analyzed and a linear regression was performed to determine the conversion coefficients [mSv/cGycm (2)]., Results: The DAP and the organ dose measured by TLD were strongly correlated (r > 0.95) for all examined organs., Conclusion: The strong correlations between TLD-measured organ doses and DAP recommend the use of conversion coefficients for the dosimetry of fluoroscopic procedures.

Background: Rectal cancer is a common malignant disease and occurs not infrequently in younger men. We verified the dose to the testes from scattered radiation in adjuvant pelvic irradiation following anterior resection of rectal cancer., Patients and Method: We measured the scattered gonadal dose of 18 patients in vivo with thermoluminescence detectors, which were fixed on four defined points on the scrotum during radiation on three consecutive days. All patients were treated three-dimensionally planned using a three-field box lying in prone position in a bellyboard. A total dose of 50.4 Gy was given in 28 fractions of 1.8 Gy. From 45 up to 50.4 Gy the radiation fields were modified to lateral-opposing fields which were shortened from the top to protect the small bowel., Results: The mean gonadal dose per fraction of all patients was 0.057 Gy (median 0.05 Gy) with a range between 0.035 and 0.114 Gy. The standard deviation was 0.02 Gy. The calculated cumulative mean gonadal dose after 28 fractions was 1.60 Gy (0.98-3.19 Gy)., Conclusions: Germinal epithelium is very sensitive to low-dose irradiation, according to a negative fractionation effect. It is known that gonadal total doses of 1 Gy with single doses of 0.03-0.05 Gy can result in a temporary azoospermia with following recovery in most cases. If gonadal total doses exceed 1.5 Gy a substantial increase in irreversible azoospermia must be expected. With respect to the data reported in the literature our measured mean gonadal total dose of 1.60 Gy will lead with high probability to an irreversible infertility. Because of the small number of patients in our study, the data must be interpreted with caution, however, it is very important in patient's informed consent to draw attention to the high risk of infertility. The possibility of sperm cryoconservation should be discussed with the patient.

Testicular intraepithelial neoplasia (TIN; also called carcinoma in situ of the testis) is the uniform precursor of testicular germ cell tumors. There is general agreement on the biological significance of TIN, however, the treatment is still a matter of dispute. The present review summarizes the treatment options currently available. In general, the management of TIN has to be adapted to the particular clinical situation of the patient. Eradication of TIN usually implies the loss of fertility. Therefore, fertility aspects should be considered before any kind of treatment is employed. Usually, patients with TIN have only small residual potential of fertility. Nonetheless, individual patients may qualify for sperm banking or cryopreservation of testicular tissue for future sperm extraction (TESE) and assisted fertilization. The most common clinical situation is the case of contralateral TIN in the presence of unilateral testicular cancer. Low dose radiotherapy to the testis with 18 Gy is the standard management option in these patients. The same procedure may be applied to solitary testicles after partial orchiectomy for germ cell tumors. During follow-up, testosterone levels should be evaluated every six months. If chemotherapy is required due to metastatic disease of the primary tumor management of TIN should be deferred. After chemotherapy 30% of TIN cases will persist and approximately 42% will recur in the later course. Repeat biopsy should be done six months after completion of chemotherapy or later. Only in cases with persistent TIN additional radiotherapy should be administered. If one testicle is afflicted with TIN while the other testis is in healthy condition (conceivable in infertility cases or patients with primary extragonadal germ cell tumors), then the TIN-bearing testis should be excised. Radiotherapy is not feasible in these cases because of shielding problems with the healthy testis.

Background: This article should demonstrate the problems concerning gonadal dose in seminoma patients, the impact of shielding and possible consequences for therapy and advising of patients with desire to have children., Patients and Method: Since November 1993 gonadal doses of 43 patients (Stage I/II, Royal Marsden) have been determined in 80 measurements with 2 ionization chambers on the ipsi- and contralateral side of the remaining testicle. The patients were all treated with ap/pa "hockey-stick"-shaped fields on a 6 MV linear accelerator. With single doses of 1.8 Gy in midplane, total doses of 34.2 Gy were applied in 13, and 30.6 Gy in 30 men. Protection was used in 33 patients, 6 times with conventional shielding, later plus an additional clam-shell from ap. The results of 22 measurements on 6 men with and without protection are of special interest. In 25 patients a sperm analysis before radiotherapy was conducted., Results: Before the beginning of radiotherapy (RT) 56% of available patients have shown an impaired spermatogenesis. The mean gonadal doses were 2.4% of midplane dose-MD (4.8 cGy), 1.8% MD (3.2 cGy) and 1% MD (1.8 cGy) per fraction for patients without (n-patients = 10, m-measurements = 15), with conventional (n = 6, m = 7), and additional clam-shell shielding (n = 33, m = 58). The corresponding median values were 2.1% (SD 1.07), 1.7% (SD 0.28) and 1% (SD 0.41) of midplane dose (Table 1, Figure 1). According to direct comparisons, a dose reduction of about half can be expected in most cases (Figure 2). Mean dose fluctuations of 11.6% (median 10%) have to be taken into account., Conclusion: Effective shielding can diminish gonadal dose in seminoma patients to about 1% of midplane and gives a good possibility of taking the maintenance of fertility and the desire to have children into account (Table 2). The application should be considered especially for patients with impaired spermatogenesis before RT. Eventual fluctuations induced us to determine the gonadal dose 3 times per patient in direct measurements (Table 3).

Purpose: The intention of this article is to summarize the effects of radiation therapy on the female and male gonadal function., Results: In woman a decreasing tolerance to radiation is observed with increasing age, due to the decreasing number of follicles. The mean tolerance dose for sterilization is between 5 and 10 Gy. If both ovaries receive only scattered doses-radiation effects on the ovaries are dependent on the age of the women at the time of treatment. However, if both ovaries are included in the treatment volume of a tumor radiation therapy, sterilisation is unavoidable. In man even scattered doses are able to decrease the sperm cell counts in the range of 2 to 3 Gy in conventional fractionation regimes. Complete restoration of spermatogenesis is possible during the first 2 years after treatment, but is unlikely after 3 years. In contrast to the situation in female, impairment of male endocrine gonadal functions are observed only after testicular doses higher than 20 to 30 Gy. In female children the tolerance dose of the ovaries is higher than in the adult woman, while the gonadal endocrine function in boys is more sensitive than in adult men. In contrast, spermatogenesis is not initiated in young boys, and hence less radiation effects are induced., Conclusions: In all treatment situations-in adults as well as in children-an additive effect of the combination of chemotherapy with radiation on gonadal function has been shown. However, the severity of damage by radio-chemotherapy is highly dependent on the drugs used.

Aim: The genetic risk for the offspring of patients treated with high doses of radioiodine was to be assessed with special regard to the gonadal dose caused by diagnostic and therapeutic procedures., Methods: 41 young females (aged between 19 and 39 years) and four young males (aged 26 to 36 years) treated with radioiodine because of a thyroid carcinoma were interviewed by use of a questionnaire. The course of pregnancy and birth history could be documented as well as the congenital and developmental conditions of 56 children., Results: The amount of radioactivity applied for therapy and whole body scans ranged over 4.144 and 35.15 GBq 1-131; the individual gonadal dose was calculated based on the MIRD model and ranged over 0.2 and 2.2 Sv (0.51 Sv at a mean). The period of time between the last radioiodine application and confinement was at least 9 months, not exceeding 14 years. As to the course of pregnancy and birth two early abortions, one extrauterine gravidity and one premature birth due to an insufficiency of the placenta were stated. In one case a chromosomal translocation 7/14 occurred as a genetic defect which lead to an interruption. The children's development was unconspicuous except of two cases of neurodermatitis as well as multiple allergies and an early closure of the anterior fontanelle in one child each., Conclusion: Although the genetic risk is supposed to increase with the gonadal dose achieved (doubling dose 1 Sv) and the increased risk of any congenital anomaly was calculated as about 13% at a mean in our patients, the rate of genetic determined diseases was not elevated (1.8% or 1/57). Thus, no increase of genetic defects or congenital malformations was reported in a total of 408 children described in the literature and in our group.

Purpose: Investigation of the efficacy of lead apron, testis capsule and thyroid collar for dose reduction in uterus, ovaries, testes and thyroid gland in computed tomography examinations., Methods: At an Alderson-Rando phantom dose of uterus, ovaries, testes and thyroid gland was measured with thermoluminescent dose meters. CT of the upper abdomen, the whole abdomen and the skull were simulated without and with lead shielding. As lead shielding, a lead apron was attached around the pelvis of the phantom in case of CT of the upper abdomen, a testis capsule was used in CT of the whole abdomen and a thyroid collar in CT of the skull., Results: In CT of the upper abdomen the lead apron did not lead to any recognisable dose reduction in uterus and ovaries. In CT of the whole abdomen the testis capsule led to a dose reduction in testes of 95% (1.39 mSv) and in CT of the skull the thyroid collar to a dose reduction in thyroid gland of 23% (0.19 mSv)., Conclusions: In abdominal CT examinations the testis capsule is an important instrument to reduce the dose of the testes whereas the lead apron is not appropriate for a dose reduction in the uterus and ovaries. In CT of the skull the thyroid collar can remarkably reduce the scattered radiation exposure of the thyroid gland and should be recommended.

Background: In order to estimate the somatic and genetic risk associated with a non-coplanar linac-based radiation technique of the pituitary gland, systematic secondary-dose measurements in a phantom and sample measurements of the dose near critical organs of patients were performed., Patients and Methods: For measurements of the dose outside the primary radiation field an acrylic-PVC phantom was used which was irradiated with a single field (4 x 4 cm2). Eight patients with pituitary tumors were treated isocentrically with a combination of sagittal and transverse rotational arcs. To measure the dose in critical organs. LiF thermoluminescence dosimeters (TLD) in chip form were placed onto 1 eyelid, the skin over the thyroid, and the patient's clothes covering the region of breasts and ovaries of female patients and the testicles of male patients. Measurements were performed for all patients during 1 sagittal irradiation and for the majority of patients during 1 transverse irradiation., Results: The phantom measurements demonstrated that the secondary dose measured on the patients surface can be considered as a good approximation for the dose in adjacent organs. The median dose in critical organs for sagittal irradiation was in the range of 25.8 mGy (eyes) to 1.9 mGy (testicles), and for transverse irradiation in the range of 23.3 mGy (eyes) to 1.3 mGy (testicles). The ratio of median organ doses for sagittal and transverse irradiation was 2.1 for the thyroid gland, 1.1 for the eyes, and 1.5 for the other organs., Conclusions: The dose in critical organs due to non-coplanar irradiation of the pituitary gland is only a small fraction of the dose delivered to the reference point of the planning target volume. The risk of a radiation-induced tumor and a genetic consequence associated with these small doses is generally less than 1% and 0.1%, respectively.

Purpose: Prospective evaluation of different radiation exposure parameters in a large series of varicoceles. The dependency of the square area product on the different therapists was calculated in addition., Material and Method: Between 5/91 and 12/93 a total of 737 sclerotherapies were performed on 465 patients. The following parameters were measured prospectively: Square area product (n = 737), fluorotime (n = 737), symphysis surface doses (n = 24), gonadal doses (n = 49), catheterisation time (n = 737). 608 of the sclerotherapies were performed by 4 similar experienced radiologists (U1 - U4). The individual fluorotimes, square area products and the average square area product per minute fluorotime were calculated., Results: The average gonadal doses was 0.01 mSv. Calculation of the square area product per minute fluorotime revealed a useful parameter to demonstrate the potential for further dose reduction, because the results ranged from 566 mGy x cm2/min to 988 mGy x cm2/min. There is no need for a time limit for this interventional procedure., Conclusion: The gonadal doses is so low that it can be considered negligible. However, in view of the considerable differences in the square area product per minute, close attention must be paid to the technique by which th fluorotime is determined.

By morphologic and morphometric investigations of the residual testis after treatment of testicular cancer the deleterious effect of chemo- and radiotherapy are estimated. Approximately 4-5 years after treatment the reversibility of spermatogenesis is better in patients chemotherapy than in patients after radiotherapy.

Described in this paper are morphological and morphometric alterations that occurred to the remaining testicles in patients who had undergone chemotherapy or radiotherapy for malignant testicular tumours, with findings, on average, being recorded 4.5 years after treatment. Qualitative histological investigations of testicular tissue exhibited differentiated characteristics, with radiotherapy resulting in significantly stronger phenomena. Epithelial height was clearly reduced in conjunction with increase in wall thickness, especially after radiotherapy. Tubular lumens, in the wake of radiotherapy, were more often filled with hyalin than after chemotherapy. Unambiguous evidence was produced to impairment of fertility in response to both chemotherapy and radiotherapy.

We have analysed spermatogenetic cells by flow cytometry to quantify effects of ionizing radiation. The radiation-induced reductions of testicular DNA-synthesizing cells, primary spermatocytes, haploid round and elongated spermatids as well as the increases of numerical chromosome aberrations (abnormal diploid spermatids and aneuploidies) in NMRI inbred mice are described. Testicular weights were determined as a parameter of germ cell decrease, and histologic cross sections of the testes were analysed. Since even an exposure of 0.05 Gy (= 5 rad) may be detected by a reduction of DNA-synthesizing cells (Acta Radiol. Oncol. Radiat. Phys. Biol. 21, 349-351 (1982) [1]), the use of the in vivo system "spermatogenesis" as a biological dosimeter to monitor low dose effects and to determine RBE values of different radiation qualities is suggested.

During the course of 50 ERCPs and 70 pneumo-colons, the surface dose in the field and the scatter was measured by CaF2-thermoluminescence dosimetry. The organ dose for both procedures was calculated by using an Alderson-Rando phantom. The results were used for calculating somatic dose indices in order to evaluate the individual and collective risks. Radiological examination of the colon results in two hundred times the gonadal dose produced by ERCP, but produces less radiation to the thyroid, lung and female breast.

The probability to induce leukemia or malignoma by roentgenexamination of the gastrointestinal tract is quite small. Basing on riskestimations of the ICRP and own measurements, the probability is about 1:25,000 in angiography. For x-ray examination of the stomach-duodenum, the small bowl, and the colon the radiation risk is approximatively 1:300,000 to 1:800,000. The probability to provoque radiation induced mutations, manifesting themselves in future children or grandchildren, is quite similair for male patients. On the other hand the risk for future children and grandchildren of female patients is a bit higher. An exception is the roentgenexamination of the colon, because direct exposure of the testes is in general inevitable.

The radiation exposure of the risk organs kidneys, spinal marrow, gonads, liver, and pancreas was determined for three different photon energies (Co-60, continuous radiation with 6 MV and 10 MV) at the inverted Y field, as it is applied generally for the infradiaphragmatic segment irradiation of malignant lymphomas. For this purpose, the authors made use of the thermoluminescence dosimetry and film dosimetry in the Alderson phantom. The most important results are: More than half of the left kidney receives more than 50% of the applied focal dose, about 20% receive more than 90% of the focal dose. The participation of the right kidney is minimal. If the dose exceeds 20 Gy, the lumbar spinal marrow is sufficiently protected by a satellite in the dv field. A displacement of the ovaries in caudomedial direction behind the vesical absorber does not protect the ovarian function in a satisfactory manner; the ovaries should be displaced in craniolateral direction on the alae ossis ilii. We recommend the use of a testicular lead protection even if the inguinal lymph nodes are only irradiated with the vd field.

Vague notions concerning the radiation dose to the gonads during sclerosing treatment of varicoceles have lead to the unjust neglect of this form of therapy. Accurate measurements have shown that the dose is less than the dose to the female breast resulting from chest radiographs in two planes, if the treatment proceeds without complication. Although the dose is so low, an attempt has been made to evaluate the risk.

In gastrointestinal roentgendiagnostic of the child the exposure of the skin and the testis depends on body height and body weight. The dose grows with the age. The squaredose product (Rcm2) and the energy absorbed by the body (integraldose, rdkg) increases comparably. On the other hand the quotient integraldosis/body weight is similar for the different age-groups. The radiation risk (the probability to die as consequence of a roentgenray induced disease) is approximately 1:100,000 to 1:10,000,000.

Yttrium-90 radiosynoviorthesis of the knee joint in rheumatic inflammatory diseases shows favourable results. Because of the supposed exposure of the patients gonads, Yttrium synoviorthesis has rarely been performed in patients below the age of 40. Scintigraphic studies in 20 patients with rheumatoid arthritis showed no significant leakage of the radionuclide from the knee joint. Gamma camera measurements both phantom and in vivo in the regions of ovary and testes revealed a local dose of 1.05 microGy/MBq (3.9 mrd/mCi) or 1.1 microGy/MBq (4.1 mrd/mCi) of the injected radioactivity. Calculation of the maximum possible load of the gonads, supposing even total leakage of the injected 90-Yttrium from the knee joint, yielded a maximum possible dose of 6 mGy (600 mrd). We conclude from these studies and calculations that Yttrium-90 synoviorthesis of the knee joint can safely be carried out in patients below the age of 40.

Measurements of gonadal doses of 92 children during intravenous urography and voiding cystourethrography are reported. The high deviation of doses in the testes is discussed. The application of a lead protector for the testes is demanded to decrease exposure by a factor 15 in the central beam and a factor 1.3-2 in scattered radiation. By choice of spot film radiography instead of large radiography the ovarian dose is reduced to a factor 7-40. The gonadal dose is clearly lower if 70 mm technique instead of large film technique is used. A correlation between area ionisation product and gonadal dose could not be found; therefore the genetic radiation dose cannot be calculated by data recorded as required by law.

The results of a longterm study on 55 children are presented whose parents were treated by radiotherapy. Five or ten years after a first examination, these children were submitted to a check-up investigation of their physical and intellectual development. The group of twenty irradiated fathers received an average dose to the gonads of 0.55 Gy (0.01 to 6.4 Gy), the group of twenty irradiated mothers 0.72 Gy (0.01 to 8.0 Gy). In all parents the most frequent finding was Hodgkin's disease, which was diagnosed as a neoplasm in 23 cases. Chemotherapy was applied in two out of 40 patients. The proof of paternity was made with a 86% accuracy for ten out of twenty fathers by determination of HLA types. A conception was demonstrated beyond all doubt after a dose to the testicles of 1.2 Gy in the irradiated fathers and after a dose to the ovaries of 3.0 Gy in the irradiated mothers. The offspring of the F1 generation showed no modification in the sex ratio. In the primary examination, a rate of 5.5% of severe malformations was found (trisomy E, bradyacousia of the inner ear, cleft hands and feet). 24% of the children had malformations which needed a treatment (hernias, torticollis, hip dysplasia). 18 out of 55 children (33%) presented abnormalities in the widest sense of the word. Three children (5.5%) were premature infants, and there is a general tendency towards shortened pregnancy (-3.6 days). Hernias (7/55) are a frequent finding. In children of both sexes, carporadiography shows a delayed development which is not compensated in the check-up examinations at five or ten years, but does not cause an underdevelopment in body height as compared to great normal collectives. The results suggest a slightly increased malformation rate among children whose parents were treated by radiotherapy. Above all the connective and supporting tissue seems involved. Some proposals are made how to give a radiogenetic advice to tumor patients who want to have children.

After the very rapid perception in the beginning of this century, that a fractionated radiotherapy is favourable on the ground of intracellular recovery, it has lasted for a long time until conceptions have been indicated for the timing of dose distribution. The used formalisms have been based on clinical empiricism. More recent concepts have shown that dose effect relations can be described by a linear-quadratic function of dose not only for cell killing but also for tumour control and radiation effects in tissues. This concept has been discussed. Some examples of fractionated irradiation have been described for which the linear-quadratic dose model gives good results and these can be described by the alpha-/beta-ratio. However, it has been demonstrated that besides intracellular recovery the repopulation of cells has a considerable significance which is considered only to a small degree by the linear-quadratic model. These factors which are very different in individual cases have to be considered in the future.

A telecobalt therapy of lymph node groups was simulated on the Alderson phantom and the gonad dose caused by each irradiation field was measured with LiF dosimeters. When the supradiaphragmatic and the para-aortal lymph nodes were irradiated, the ovary dose showed rates up to 20% of the dose maximum. The irradiation of the same zones brought about a testicle dose of less than 50% of the dose maximum, and only 1/20 of this rate was achieved when a lead plate of about four cm was used in order to protect the testicles. The results are discussed under the point of view of the genetic risk.

The article is a compilation of data on the radiation exposure during the most important CT examinations. The influencing parameters are assessed and their effects are discussed. Conclusions are drawn to modify the practical approach. These results are compared with those reported in international literature.

From 1970 to 1986 forty-nine patients suffering from Induratio penis plastica (IPP) were treated by irradiation. It was used x-rays as soft-ray therapy and half-depth therapy, respectively, and fast electrons with an energy level ranged from 6 to 8 MeV. The follow-up observation time ranged from 8 months to 12 years. Very good to satisfactory results were obtained in 28 patients (57.1%). The treatment results were different clearly in dependence on the onset of symptoms and therapy, respectively. The possibilities of the irradiation therapy with lower side-effects and advantages as against other therapeutic approaches are described.

Thermoluminescence dosimetry was done in patients who had head-neck-, mantel- and abdominal fields with Cobalt 60 or Linac. Critical levels for the gonads were only reached by abdominal irradiation. The testicular dose of 2 Gy accumulated as 5% of a 40 Gy tumor dose may lead to permanent azoospermia. Testicular shielding by 2 or 4 mm lead capsules does not lead to dose reduction.

The gonadal load was measured during radiation therapy of humeroscapular periarthritis, coxarthrosis, diseases of the vertebral column and of the sacro-iliac joint (disease Bechterew) for different irradiation techniques. All measurements have been performed by LiF dosimeters and with an Alderson phantom using 250 kV X-radiation. The gonadal dose with respect to the surface dose was in the range of tenths of one per mill in case of humeroscapular periarthritis and reached values up to about 30 per cent in coxarthrosis and Bechterew disease. Measurements during irradiation of the vertebral column yielded most differing values of the gonadal load depending on gonadal distances from the region exposed.