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Definition und Schaffung der notwendigen und geeigneten onkologischen Strukturqualitat dient der flachendeckenden, einheitlichen optimalen Prozessqualitat fur Krebspatienten. Bei konsequenter Umsetzung sind Ergebnisse von einer Qualitat zu erwarten, die auf Prinzipien der evidenzbasierten Medizin aufbauen und dem internationalen Stand entsprechen. Interdisziplinare und interprofessionelle Ablaufe sollen durch spezielle Anweisungen (SOP) bzw. Therapierichtlinien in Form von Leitlinien (LL) schriftlich festgelegt sein. Sie sollen (uber)regional in fachubergreifender Kooperation erarbeitet werden sowie die Patientenebene mit einbeziehen, wie z. B. die LL der Deutschen Krebsgesellschaft (DKG), die zusammen mit den Fachgesellschaften, dem Informationszentrum fur Standards in der Onkologie (ISTO) und der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) erarbeitet wurden. Die regionale Umsetzung erfolgt in onkologischen Schwerpunkten (OSP) und Tumorzentren (TZ) durch themen-, fach- und tumorbezogene Projektgruppen. Das gesamte onkologische Fachpersonal in onkologischen Netzstrukturen und TZ soll am Qualitatsmanagement aktiv teilnehmen. Die verlaufsbegleitende Erfassung aller Tumorfalle im Rahmen klinischer Krebsregister (KKR) ist zur Qualitatssicherung zwingend erforderlich. Qualitatsmanagement ist ein integraler Bestandteil der onkologischen Patientenversorgung, wird derzeit aber nur in Teilprojekten durch die Kostentrager finanziert, wie z. B. die Disease-Management-Programme oder Brustzentren. more...

Strikturen im Bereich der harnableitenden Wege bzw. die zirkulare, mehr oder weniger langstreckige Einengung des Lumens sind das Ergebnis des normalen Heilungsprozesses bzw. der physiologischen Kontraktur einer Narbe, die, wenn sie sich zirkular ausdehnt, zu einer Einengung des Lumens fuhren kann. Unmittelbar nach dem Trauma kommt es dabei zu einer entzundlichen Reaktion, deren Funktion es ist, die Narbenbildung bzw. den Heilungsprozess einzuleiten. Dieser Vorgang lauft unter Umstanden unkontrolliert ab und fuhrt dabei zu einer uberschiesenden Gewebevermehrung mit funktionellen Folgen. Ionisierende Strahlen konnen die Bildung von hypertrophen Narben und Keloiden verhindern, indem sie unmittelbar auf die Funktion und Proliferation von Monozyten und Makrophagen in der initialen Phase der Wundheilung einwirken. 1913 wurde die positive Wirkung von ionisierenden Strahlen auf die hypertrophe Narbenbildung und Keloide erstmals beschrieben. In der Folge wurde die Strahlentherapie erfolgreich zur Vorbeugung bzw. Behandlung von Keloiden, dem Morbus Dupuytren, den heterotopen Ossifikationen und Re-Stenosen von koronaren und peripheren Arterien nach endoluminaler Dilatation eingesetzt. Experimentelle Untersuchungen zeigen, dass Iridium-192, im Afterloading-Verfahren bei einer Dosierungstiefe von 3 mm und einer Fraktionierung von 3–4 Gy bis zu einer Gesamtdosis von 20–25 Gy keine langfristigen Strahlenschaden auslost, die einer moglichen spateren offenen Rekonstruktion entgegenstehen wurden. Diesen Erfahrungen folgend, haben wir die HDR/BT bei Patienten angewandt, die wiederholt an einer endoskopischen oder offenen Rekonstruktion einer Enge im Harntrakt litten und zu deren Behandlung nur therapeutische Alternativen mit weiterreichenden Konsequenzen zur Verfugung stunden. more...

Die Strahlentherapie degenerativer Gelenkerkrankungen ist gerade in neuerer Zeit und aus orthopadischer Sicht unzureichend erforscht. Bisher fehlen trotz meist alterer Publikationen von strahlentherapeutisch tatigen Kollegen ausreichende Langzeitbeobachtungen sowie eine Bewertung nach objektiven orthopadischen Kriterien. Von 1984–1994 wurden an der Strahlentherapeutischen Universitatsklinik Erlangen insgesamt 85 Patienten wegen Schmerzen aufgrund arthrotischer Gelenkveranderungen im Bereich der Huft-, Knie-, Schulter- und des Daumensattelgelenks behandelt. In der vorliegenden Studie wurden bei 73 Patienten 103 bestrahlte Gelenke langfristig nachuntersucht. Die Beurteilung erfolgte retrospektiv durch orthopadisch etablierte Scores unter Einbeziehung objektivierbarer Parameter. 63% der bisher therapieresistenten Patienten sprachen auf die Radiotherapie (RT) an. Lediglich 3 Patienten mussten sich im Nachuntersuchungszeitraum schlieslich doch einer endoprothetischen Versorgung unterziehen. Hinsichtlich des Zielkriteriums "komplette Beschwerdefreiheit" bzw. "wesentliche Besserung" der Beschwerden hatte nur die langere Symptomdauer als einziger Parameter in multivariater Analyse einen negative prognostische Bedeutung (p more...

Viele wissenschaftliche und gesundheitspolitische Bemuhungen auf nationaler und internationaler Ebene richten sich zur Zeit auf die Entwicklung von speziellen Leitlinien und Richtlinien in den verschiedenen medizinischen Fachdisziplinen. Sie sollen eine bessere Transparenz im Gesundheitswesen und eine verbesserte Versorgung der einzelnen Patienten gewahrleisten. Auch fur die Radioonkologie mussen entsprechende Leitlinien erarbeitet werden. Ausgehend von einer definitorischen Bestimmung der Begriffe „Standard”, „Leitlinie”, „Richtlinie” und „Empfehlung” und der grundsatzlichen Darstellung der Entwicklung von Leitlinien werden die derzeitigen Aktivitaten der seit zwei Jahren arbeitenden Leikommission „Qualitatssicherung in der Radioonkologie” der DEGRO vorgestellt. Die Komplettierung einer detaillierten Sammlung von Leitlinien ist fur das Ende des Jahres 1997 zu erwarten. more...

Patients with locally recurrent and metastatic breast carcinoma require effective palliation of pain and complicating cutaneous, soft tissue, and lymph node metastases. Since October 1989, 48 consecutive patients with recurrent breast carcinoma after mastectomy and no further surgical option were entered in a phase I-II study comparing two radiochemotherapy (RCT) regimens. Treatment-related toxicity was analyzed in 48 patients together with short- and long-term efficacy in 44 patients who had a minimum follow-up of at least 1 year. Since October 1989, group A (28 patients) received 60 Gy "split-course" radiotherapy (RT) over 10 weeks with two breaks of 2 weeks each after the second and fourth week of RT. Simultaneous 5-fluorouracil, methotrexate, and cyclophosphamide (CMF) was given during RT. From October 1991 to April 1993, group B (20 patients) received 54-60 Gy "conventional" RT over 6 weeks. Simultaneous 5-fluorouracil/mitomycin C was applied in the first and fifth week. Overall response [complete response (CR) + partial response (PR)] was 82% in group A (CR, 21%). Five of 28 patients developed grade 3-4 toxicity (EORTC/RTOG/WHO). Overall response rate in group B was 87% (CR, 19%). In this group, 6 of 20 patients experienced grade 3-4 toxicities. In both groups, the rate of local response was remarkably lower in patients with distant metastases and a short relapse interval < 2 years. Although both regimens achieved a similar local response rate, group B patients experienced a higher toxicity rate than did group A patients, but the treatment duration was considerably shorter. The local tumor response was greatly influenced by the extent of systemic disease. more...

An improved design of a previously described intracavitary microwave hyperthermia applicator is presented. The applicator consists of a coaxial choke antenna designed to be positioned into a perspex obturator. The antenna can be fitted in the obturator in three defined positions depending on the specific clinical situation: the selected median, paramedian or lateral position can each provide differently directed heating patterns. This feature combined with the additional axial variability of the antenna position within the obturator can lead to a highly targeted heating of tumours and a reduced risk of unwanted heating of normal tissues. Various phantom studies were conducted using both liquid and solid phantoms. The saline phantom was used to check the typical action of the choke of the antenna where it was found that the antenna choke is efficiently working resulting in a heating pattern which is dependent of the insertion depth of the antenna. The solid phantom was used to measure the typical specific absorption rate (SAR) distribution of each antenna/obturator configuration. more...

In a 4 1/2-year, 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 failure 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 RT groups. High RT dose with a short duration (< or = 9 days) and use of an NSAID was significantly (P = .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 excellent alternative for patients with contraindications to long-term medication with either NSAIDs or corticosteroids. more...

General Background.- Radiobiological Principles.- Side Effects and Long-Term Risks from Radiotherapy of Non-malignant Diseases.- Risk Assessment and Carcinogenesis Modelling.- Radiophysical Principles.- Clinical Principles.- Irradiation of Non-malignant Diseases: An International Survey.- Patterns-of-Care Study for Non-malignant Diseases in Germany.- Skin and Soft Tissue Disorders.- Non-malignant Skin Disorders: Tumors, Hyperplasia, Dermatoses.- Morbus Dupuytren/Morbus Ledderhose.- Pronie's Disease.- Keloids and Hypertrophie Scars.- Aggressive Fibromatosis/Desmoid Tumors.- Bone and Joint Disorders.- Orthopaedic Examination, Tests and Clinical Scores.- Rotator Cuff Syndrome (RCS).- Humeral Epicondylopathia (HEP), Lateral and Medial Humeral Epicondylitis.- Calcaneodynia: Plantar and Dorsal Heel Spur/Heel Spur Syndrome.- Degenerative Joint Disease Activated Osteoarthrosis Deformans: Hip, Knee, Shoulder and Other Joints.- Heterotopic Ossifications: General Survey for All Sites.- Heterotopic Ossification Prophylaxis - The Hip.- Heterotopic Ossifications after Head and Spinal Cord Injuries (HSCI).- Pigmented Villonodular Synovitis (PVNS).- Langerhans? Cell Histiocytosis (LCH).- Vertebral Hemangioma (VH).- Aneurysmal Bone Cyst (ABC).- Vascular Disorders.- Giant Hemangioma/Kasabach-Merritt Syndrome.- Eye Disorders.- Graves' Orbitopathy.- Pseudotumor Orbitae.- Pterygium.- Hemangiomas and Vascular Tumors of the Eye.- Local and Systemic Inflammatory Disorders.- Inflammatory Disorders: Furunculitis, Hidradenitis, Panaritium and Paronychia.- Lymphocutaneous Fistulas and Lymphoceles.- Local Rheumatoid Arthritis and Radiation Synovectomy.- Head and Neck.- Non-Malignant Disorders of the Head Region.- CNS and Brain.- Arterio-Venous Malformations.- Meningioma.- Vestibular Schwannoma (Acoustic Neuroma).- Pituitary Adenoma.- Trigeminal Neuralgia.- Radiosurgical Treatment Options for Epileptic Disorders.- Where There is No Evidence: Registry for Rare Benign Diseases. more...

Interstitial hyperthermia (IHT) combined with brachycurietherapy (thermoradiotherapy) has gained increasing popularity among radiation oncologists due to its potential as an effective radio- and chemosensitizer. IHT offers considerable advantages over percutaneous methods: confined treatment volume, better sparing of normal tissue, accessibility of deeper tumors, more homogeneous therapeutic temperature distribution, and better control and evaluation of thermal parameters using extensive "thermal mapping" procedures. This article addresses technical principles and clinical applications of IHT methods, radiofrequency (RF), microwave (MW), and hot source (HS) hyperthermia. Clinical phase I/II studies have used IHT palliatively for primary advanced, persistent, or local recurrent tumors, which have responded poorly to conventional treatment. The preliminary clinical data on greater than 500 patients treated with interstitial thermoradiotherapy are extremely promising despite the broad variation among the different treatment approaches. The observed complete response (CR) rate in various clinical trials ranges between 11 and 74%. The differences between the various techniques are minor, with a CR of 57% for interstitial RF hyperthermia (169 of 299 patients) and 60% for interstitial MW hyperthermia (130 of 215 patients). Despite extensive pretreatment, the total observed compliation rate of 22% for RF hyperthermia (67 of 299) and 21% for MW hyperthermia (45 of 215) is acceptable. The prognostic treatment factors identified are tumor volume, applied radiation dose, sufficiently high minimum tumor temperatures, and good thermal parameters, i.e., good quality of the hyperthermia treatment sessions. Technical innovations may facilitate and improve clinical applications and should allow broad clinical implementations of IHT, e.g., intraoperative hyperthermia, and even intracavitary hyperthermia. From these experiences it would appear that IHT is an effective and safe treatment modality, especially when combined with radiotherapy for tumor palliation. Prospective randomized multicentric studies have already been initiated to investigate its role in palliative and adjuvant tumor therapy. more...

Thirty-seven patients with 18 primary advanced or persistent, 16 local recurrent, and three local metastatic tumors of the head and neck were treated with a combination of interstitial low-dose iridium-192 radiation therapy and interstitial 915-MHz microwave hyperthermia supplemented by external radiation therapy. Twenty-eight lesions received an additional external radiation dose of 21-61 Gy. Interstitial hyperthermia was applied immediately before Ir-192 was placed and after its removal for 45-60 minutes at 41 degrees C-44 degrees C. Follow-up ranged from 4 to 45 months. At 3 months, complete remission occurred in 25 lesions (68%); partial remission, in nine (24%); and no change or progressive disease, in three (8%). At 12 months of follow-up in 32 lesions, local control was achieved in 23 (72%), with the patients alive, and in four (12%), with the patients dead. There were five local recurrences, one of which occurred after complete response. Lesion type, tumor volume, radiation dose, and thermal quality at high minimum temperature were identified as prognostic factors influencing complete remission. The combined treatment was well tolerated. more...

Every year in Germany about 50,000 patients are referred and treated by radiotherapy (RT) for “non-malignant disorders”. This highly successful treatment is applied only for specific indications such as preservation or recovery of the quality of life by means of pain reduction or resolution and/or an improvement of formerly impaired physical body function owing to specific disease-related symptoms. Since 1995, German radiation oncologists have treated non-malignant disorders according to national consensus guidelines; these guidelines were updated and further developed over 3 years by implementation of a systematic consensus process to achieve national upgraded and accepted S2e clinical practice guidelines. Throughout this process, international standards of evaluation were implemented. This review summarizes most of the generally accepted indications for the application of RT for non-malignant diseases and presents the special treatment concepts. The following disease groups are addressed: painful degenerative skeletal disorders, hyperproliferative disorders and symptomatic functional disorders. These state of the art guidelines may serve as a platform for daily clinical work; they provide a new starting point for quality assessment, future clinical research, including the design of prospective clinical trials, and outcome research in the underrepresented and less appreciated field of RT for non-malignant disorders. more...

Between January 1986 and June 1989, 45 lesions (30 head and neck, 11 pelvic and 4 other lesions) in 44 patients (24 males/20 females, 18 to 81 years) received interstitial Iridium-192 radiotherapy (IRT) and interstitial 915 MHz MW hyperthermia (IHT) supplemented by external beam radiotherapy (ERT). Minimum follow-up (FU) was 6 months (range: 6 to 39 months; mean: 16 months, SD ±9). Tumors were classified as advanced primary (AP, n=21), local recurrent (LR, n=18) and local metastatic (LM, n=6) lesions; LR and LM lesions were previously treated: surgery (n=30), chemotherapy (n=23) and prior external RT between 40 and 70 Gy (n=24). The mean dimension for 42 lesions was 4.5×4.0×3.0 ccm with (range: 12 to 135 ccm; mean: 54 ccm); 3 lesions had extensive tumor volumes >225 ccm. more...

Nach einer Tumorbehandlung konnen Spateffekte (chronische Nebenwirkungen, Folgestorungen und -erkrankungen) noch mehrere Monate bis Jahre nach dem Abklingen von akuten Nebenwirkungen (bis 90. Tag nach Therapie) neu auftreten und in ihrer Auswirkung zunehmen. Chronische Nebenwirkungen (ab 91. Tag nach Therapie) bzw. Langzeitfolgen sind im einzelnen kaum vorhersehbar, da meist viele Disparitaten zwischen dem Schweregrad und der spezifischen Auspragung von akuten und chronischen Nebenwirkungen bestehen. Die Klassifikation der EORTC/RTOG zur „Bewertung von chronischen Nebenwirkungen nach Radiotherapie“ ist zwar schon seit Jahren im Gebrauch, doch ist sie bislang fast nur unter Radioonkologen bekannt, und auch innerhalb dieser Fachgruppe wird die Systematik nicht regelmasig und prospektiv in klinischen Studien eingesetzt (Dische et al. 1989a,b). Dadurch gehen bislang noch wichtige Aussagen zu einem entscheidenden Endpunkt in vielen klinisch-onkologischen Studien verloren. more...

Im Rahmen von multizentrischen Therapiestudien, die seit Ende der 70er und Anfang der 80er Jahre von der RTOG (Radiation Therapy Oncology Group) und der EORTC (European Organistion for Research and Treatment of Cancer) durchgefuhrt worden sind, wurden 2 Systeme zur Klassifikation von radioonkologischen Nebenwirkungen eingesetzt. Dabei war eine grundsatzliche Unterscheidung zwischen akuten / subakuten Nebenwirkungen (Akuttoxizitat, 1.–90. Tag nach Beginn der Radiotherapie) und chronischen Nebenwirkungen (Spattoxizitat, ab dem 91. Tag nach Beginn der Radiotherapie) bzw. chronischen Langzeitfolgen der Therapie vorgesehen (Perez & Brady, 1993 a/b). more...

Bei der Beurteilung der Toxizitat einer onkologischen Therapie sollte grundsatzlich zwischen akuten / subakuten Nebenwirkungen (sog. Akuttoxizitat, 1. – 90. Tag nach der Therapie) und chronischen Nebenwirkungen (sog. Spattoxizitat, ab dem 91. Tag nach der Therapie) bzw. chronischen Langzeitfolgen der Therapie unterschieden werden. more...

The development of a treatment modality requires a cooperative effort of many investigators, clinicians, and technologists for the purpose of demonstrating safety and efficacy. In order to ensure reproducibility, appropriate quality assurance (QA) methods must be developed and employed. It is the purpose of this chapter to describe efforts that have been made to develop standards for data in clinical hyperthermia trials and to propose additional components that will continue to allow the acceptance and use of these standards. more...

Clinical Applications of Hyperthermia.- 1 Clinical Rationale for Thermoradiotherapy.- 2 Clinical Rationale for Thermochemotherapy.- 3 Thermoradiotherapy for Advanced and Recurrent Breast Tumors.- 4 Thermoradiotherapy for Head and Neck Tumors.- 5 Thermoradiotherapy of Malignant Melanoma.- 6 Thermoradiotherapy combined with Chemotherapy for Esophageal Tumors.- 7 Thermoradiotherapy for Upper Abdominal Tumors.- 8 Thermoradiotherapy for Tumors of the Lower Gastrointestinal Tract.- 9 Thermoradiotherapy for Genitourinary and Gynecological Tumors.- 10 Thermoradiotherapy of Uterine Carcinoma.- 11 Thermoradiotherapy and Thermochemotherapy for Sarcomas.- 12 Thermoradiotherapy for Brain Tumors.- 13 Thermoradiotherapy for Eye Tumors.- 14 Thermoradiotherapy and Thermochemotherapy for Pediatric Tumors.- 15 Clinical Practice of Interstitial Thermoradiotherapy.- 16 Clinical Practice of Intracavitary Thermoradiotherapy.- 17 Clinical Practice of Intraoperative Thermoradiotherapy.- 18 Clinical Practice of Whole-Body Hyperthermia: New Directions.- 19 Clinical Practice of Hyperthermic Extremity Perfusion in Combination with Radiotherapy and Chemotherapy.- Multicenter Trials and Future Clinical Research.- 20 Prognostic Factors in Thermoradiotherapy Clinical Trials.- 21 Considerations for Hyperthermia Clinical Trials Design.- 22 Review of Biostatistical Methods and Interpretation of Hyperthermia Clinical Trials.- 23 Standardized Thermoradiotherapy Treatment Documentation.- 24 Appendix: Tabulation of Parameters for Hyperthermic Data Evaluation.- List of Contributors.- of Volume 1 (Biology, Physiology, Physics). more...

“Cancer” today means a “malignant growing tumor” which nearly always threatens life if it has reached its advanced form, but may be“curable” if detected in any early stage of development. One special section of medicine called“oncology” deals with these malignant diseases. Despite extensive research in the past, the etiology, possible preventive measures, and the diagnostic assessment are still incompletely understood; similarly, the therapeutic management of cancer is still not too well established in our present health care system. By the public, cancer is mostly perceived as a fatal disease which is often associated with pain or other dreadful symptoms, malnutrition, severe individual discomfort, and many psychosocial problems. more...

There is growing interest in combining radiotherapy or chemotherapy with hyperthermia in the treatment of cancer since it has been shown that hyperthermia in the range of 43°C applied for about 60 min enhances the effect of both radiotherapy and chemotherapy. Clinical work has been focused on combined local hyperthermia treatment and radiotherapy of, for example, malignant melanoma and neck nodes (Overgaard and Overgaard1987; Valdagni et al. 1988). The main techniques utilised for inducing external localised hyperthermia involve the use of microwave antennas in various forms (hyperthermia applicators), but radiofrequency applicators coupled to the tissue inductively or capacitively are also used extensively. Another field of interest is deep heating, where microwaves, radiofrequency or ultrasound techniques have been used to reach various target volumes inside the body. Deep local heating of small target volumes can be performed using microwave antennas or ultrasound transducers in the form of phased arrays or scanning or focusing devices. more...

Twenty-six patients (20 females, 6 males) with localized tumors of the pelvis, including 3 primary advanced (PRIM), 7 persistent (PERS), 10 recurrent (REC), and 6 metastatic (MET) tumors, were treated with a combination of low-dose rate (LDR) iridium 192 interstitial radiotherapy (IRT), interstitial 915 MHz microwave hyperthermia (IHT), and external beam radiotherapy (RT). Histological diagnoses were squamous cell carcinoma in 13 (50%), adenocarcinoma in 12 (46%) and soft tissue sarcoma in 1 (4%) lesion. Tumor sites were cervix in 8 (31%), colorectum in 6 (23%), vagina in 4 (15%), anus in 3 (12%), ovary in 2 (8%), and other sites in 3 (12%) lesions. IHT was administered immediately before iridium 192 was placed and after its removal for 45-60 minutes at 41-44 degrees C. On December 31, 1991 median follow-up was 25 months (mean: 23 months; range: 5-65 months). At 3 months follow-up (FU), complete remission (CR) occurred in 17 (65%), partial remission (PR) in 7 (27%), and no change or progressive disease (NC/PD), in 2 (8%) lesions. At 12 months FU, in 16 of 21 patients (76%) local control (LC) was achieved, with 1 (5%) patient exhibiting a slow tumor regression. After combined IRT-IHT locoregional relapse or tumor regrowth occurred in 8/26 (31%): 5 (19%) outside and 3 (12%), inside the previously treated volume; relapses occurred within 8-30 (mean: 18) months of follow-up. Factors influencing initial (3 months FU) and long-term tumor response (12 months FU) included tumor class, tumor volume, total radiation dose, and thermal parameters with "good quality of heating" (TQ 41 degrees C > or = 75%) and high minimum tumor temperature (Tmin(av) > or = 41 degrees C). Treatment toxicity was acceptable: whereas 8 (31%) patients experienced acute side effects, which subsided within weeks, 7 (27%) developed long-term complications. Thermal damage was associated with IHT treatments exceeding maximum average temperatures of > or = 44 degrees C and maximum peak temperatures of > or = 45 degrees C. more...

The objective of both interstitial hyperthermia and interstitial radiotherapy is to increase local control. The main advantage of brachytherapy is that it delivers a high dose to a well-circumscribed area without excessive irradiation to the surrounding structures. For head and neck tumors, low dose rate radioactive sources are used in nearly all institutions; a dose of 20–30 Gy can be applied within 3–5 days at a rate of 30–70 cGy/h. According to Hall (1985), the radiobiology of low dose irradiation is characterized by increased repair of sub- lethal and lethal damage. This is responsible for the broad initial shoulder of the cell survival curve during acute low dose rate exposure. Consideration also has to be given to the “inverse dose rate effect,” i.e., for a limited range of dose rates the survival curve steepens again as cells progress through the cell cycle and pile up at a G2 block, which is a radiosensitive phase during which the cells cannot divide. A further lowering of the dose rate allows cells to escape the G2 block and divide. more...

The first interstitial procedure for local hyperthermia (HT) was described by James Doss in 1975 at the First International Symposium on Cancer Therapy by Hyperthermia and Radiation in Washington D.C.: “I want to talk … about a modality for the use of electromagnetic energy which is really quite different from (external) microwaves. It has a disadvantage - that is, the technique … is usually very invasive …” (Doss 1975). At that time the use of “external” heating techniques was preferred by most groups involved in clinical hyperthermia research. Although Doss proposed a specific radiofrequency (RF) technique (Doss and McCabe 1976), the idea of placing a heating source directly inside the human body or even the tumor itself stimulated researchers worldwide to invent and implement other internal heating techniques. Interstitial HT (IHT), however, is just one type of “internal” thermotherapy by which energy is supplied directly to the tumor tissue in situ; other internal heating techniques include (a) endocavitary HT using applicators introduced into natural body cavities (Roos, this volume, Chap. 10), (b) perfusional HT by means of extracorporeal blood perfusion, and (c) intraoperative HT using different HT technologies during a surgical procedure. more...

Clinical trials are ideally scientifically of three types — phase I (determination of toxicity and dose), phase II (evaluation of tumour suitability), and phase III (randomised comparison) (Overgarrd 1984) and all three must be performed before treatment becomes routine clinical practice. While phase III trials may be an effective screening method for many treatments, they may not be so straightforward in the case of hyperthermia, the levels of efficiency of which are difficult to appraise and compare owing to the unpredictability of heating. It may be more correct to refer to extended, but randomised phase II studies in such situations (van Putten 1991). Especially for superficial and interstitial (and to a lesser degree for deep) hyperthermia, technology has now advanced to a level that we should be and are now conducting phase II/III studies. It is vital that trials are designed in such a way that the correct question is posed and the answer given in convincing manner. more...

Malignancies localized in the pelvis are characterized by an increasing incidence and a high mortality due to local tumor progression. In 1990 the cancer facts and figures of the American Cancer Society indicated an estimated 45 000 new cases of and 7600 deaths from rectal cancer, 46 500 new cases of and 10000 deaths from uterine (cervix uteri and corpus/endometrium) cancer, 49 000 new cases of and 9700 deaths from bladder cancer, and 106000 new cases of and 30000 deaths from prostate cancer (American Cancer Society 1990). more...

According to the American Cancer Society an estimated 30 500 new cases of and 8350 deaths from oral cancer (buccal cavity and pharynx) occurred in the United States in 1990. About 40% of annual deaths due to oral cancer result from local failure (Rubin and Carter 1976). With smoking and use of alcohol expanding worldwide, the incidence of head and neck tumors is still increasing. Standard therapy, including surgery, radiotherapy (RT), or chemotherapy (ChT) alone or in combination, still fails to sufficiently control local, regional, and systemic spread of this malignant disease. more...

Sixty-two patients with 24 primary advanced, six persistent, 28 locally recurrent, and four metastatic tumors of the head and neck were treated with combined interstitial low-dose iridium-192 radiation therapy, interstitial 915-MHz microwave hyperthermia (IHT), and external-beam radiation therapy. Diagnoses were squamous cell carcinoma in 56, adenocarcinoma in three, and soft-tissue sarcoma in three lesions. IHT was applied immediately before Ir-192 was placed and after its removal for 45-60 minutes at 41 degrees C-44 degrees C. At 3 months, complete remission had occurred in 39 lesions; partial remission, in 18; and no change or progressive disease, in five. At 12-month follow-up, local control was achieved in 29 of 50 patients; seven other patients had slow ongoing tumor regression with an unclear residual mass at computed tomography or magnetic resonance imaging. Lesion type, tumor volume, total radiation dose, and thermal parameters with "good quality of heating" at high minimum tumor temperature were identified as statistically significant (P less than .05) prognostic factors influencing initial and long-term tumor response. There was no prognostic factor for acute or late thermal damage. more...

4511 Background: Perioperative treatment is common in localized adenocarcinomas of the upper GI-tract. By now, there is no randomized data about the contribution of preoperative radiotherapy additional to chemotherapy. Methods: Based on phase II results of our group we targeted 394 patients to test whether chemoradiation will increase the 3-year survival rate by 10% compared with chemotherapy. Patients with stage T3–4 NX M0 according to EGD, EUS, CT and laparoscopy were included. Patients were randomized to treatment with either (arm A) 2.5 courses of chemotherapy (cisplatin 50mg/m2, d 1,15,29, folinic acid 500 mg/m2 and 5-FU 2g/m2 24h-infusion, weekly times 6, qd 49 or (arm B) 2 courses of the same chemotherapy followed by three weeks of chemoradiotherapy (30 Gy, cisplatin 50 mg/m2 d 2+8 and etoposide 80 mg/m2 d 3–5). Epoetin alpha was recommended to keep the hemoglobin above 12.5 g/dl. Tumor resection was planned 3 to 4 weeks after the end of preoperative therapy for both groups. Results: A total of 126 patients were randomized into the study between 12/00 and 12/05 when the trial was closed due to poor accrual. 120 pts. were eligible (CTX 60, CRTX 60). The toxicitiy of CTX was low. Severe leucocytopenia and thrombocytopenia was 35% and 16%, respectively during CRTX. Until 12/06 ninety pts. underwent surgery and had complete reports. A complete resection was possible in 77% and 85% of operated pts. in arm A and arm B, respectively. The rate of complete histologic response was 2.5% after CTX and it reached 17% after CRTX (p=0.06). Despite increased postoperative mortality after chemoradiotherapy (5 vs. 2 pts.) the median survival time (32.8 mo) and the 3- year survival rate (43%) were improved in this patients group compared with patients of arm A (21.1 mo, 27%)(logrank p=0.14). Conclusions: This randomized study demonstrates that albeit its increased mortality preoperative chemoradiotherapy appears to prolong survival compared with preoperative chemotherapy in locally advanved esophago-gastric adenocarcinomas. Although accrual was below that planned, the observed difference in survival is clinically important and calls for further randomized trials in patients with this disease. No significant financial relationships to disclose. more...

Extensive superficial chest wall malignancies after surgery, full-dose radiation and/or chemotherapy cause significant morbidity with impaired quality of life. Local tumor control at the chest wall is important for those patients, even if no survival benefit is achieved. more...