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Background and Objective: Data on enteral tube feeding in head and neck cancer (HNC) patients undergoing chemoradiotherapy vary considerably between German institutions. This survey aims to investigate the management of feeding tubes in an interdisciplinary context across Germany., Materials and Methods: Between December 2022 and May 2023, 70 participants (42 radiation oncologists, 12 medical oncologists, 14 head and neck surgeons, and 2 physicians covering several specialties) responded to our web-based survey. In addition to the type of institution (university hospital, private practice, etc.), their age, and professional experience (in years), participants were asked several questions on the indication and institutional policy for tube placement and management (prophylactic/reactive nasogastric or gastrostomy tube). All questions were mandatory single- or multiple-choice questions, while additional comments were possible by email., Results: Most participants were employed at a university hospital (n = 52; 74.3%) and came from a radiation oncology background (n = 42; 60%). Fifty-four contributors (77.1%) reported that no nutritional risk screening prior to chemoradiotherapy was routinely performed, and 71.4% (n = 50) stated that no standardized protocol was used at the institution to set the indication for tube placement. Generally, policies and methods of tube feeding vary considerably between the individual institutions and specialties. However, the majority (n = 56, 80%) recommended a prophylactic percutaneous enteral gastrostomy (PEG) tube to their patients before chemoradiotherapy. Still, there was no consistent trend regarding the approach for reactive tube feeding., Conclusion: The policies and methods of tube feeding vary considerably between the individual institutions and specialties in Germany. In the era of individualized medicine, uniform protocols are difficult to establish. However, a baseline nutritional risk screening could simplify decision-making in clinical practice., (© 2024. The Author(s).)

Purpose: The aim of this work was to assess the current state of digitalization in radiation oncology departments in Germany, Austria, and Switzerland., Methods: A comprehensive survey was conducted in a digital format, consisting of 53 questions that covered various aspects of digitalization including patient workflow, departmental organization, radiotherapy planning, and employee-related aspects., Results: Overall, 120 forms were eligible for evaluation. Participants were mainly physicians or medical physicists responsible for digitalization aspects in their departments. Nearly 70% of the institutions used electronic patient records, with 50% being completely paperless. However, the use of smartphone apps for electronic patient reported outcomes (ePROMs) and digital health applications (DIGA) was limited (9% and 4.9%, respectively). In total, 70.8% of the radio-oncology departments had interfaces with diagnostic departments, and 36% had digital interchanges with other clinics. Communication with external partners was realized mainly through fax (72%), e‑mails (55%), postal letters (63%), or other digital exchange formats (28%). Almost half of the institutions (49%) had dedicated IT staff for their operations., Conclusion: To the best of our knowledge, this survey is the first of its kind conducted in German-speaking radiation oncology departments within the medical field. The findings suggest that there is a varied level of digitalization implementation within these departments, with certain areas exhibiting lower rates of digitalization that could benefit from targeted improvement initiatives., (© 2023. The Author(s).)

Background/aim: Differences between radiotherapy for metastases in Northern Germany and Southern Denmark were previously identified, which led to a consensus conference., Patients and Methods: A consensus conference was held between three centers to harmonize radiotherapy regimens for bone and brain metastases., Results: Centers agreed on 1×8 Gy for painful bone metastases in patients with poor or intermediate survival prognoses and 10×3 Gy for favorable-prognosis patients. For complicated bone metastases, 5-6×4 Gy was preferred for poor-prognosis, 10×3 Gy for intermediate-prognosis, and longer-course radiotherapy for favorable-prognosis patients. For ≥5 brain metastases, centers agreed on whole-brain irradiation (WBI) with 5×4 Gy in poor-prognosis and longer-course regimens in other patients. For single brain lesions and patients with 2-4 lesions and intermediate/favorable prognoses, fractionated stereotactic radiotherapy (FSRT) or radiosurgery were recommended. No consensus was reached for 2-4 lesions in poor-prognosis patients; two centers preferred FSRT, one center WBI. Preferred radiotherapy regimens were similar for different age groups including elderly and very elderly patients, but age-specific survival scores were recommended., Conclusion: The consensus conference was successful, since harmonization of radiotherapy regimens was achieved for 32 of 33 possible situations., (Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: We investigated the prevalence of human papillomavirus (HPV) in a prospective cohort of patients with squamous cell carcinoma of the oral cavity (OSCC) using both p16 INK4a and HPV DNA, i.e., double positivity, as a definition criterion. Additionally, we examined the association of HPV with survival., Patients and Methods: Samples from 280 OSCC patients were analyzed for HPV-positivity using p16 INK4a immunohistochemistry (IHC) and in situ hybridization (ISH)/LCD arrays, for HPV low and high-risk types. Only patients positive for both p16 INK4a and HPV DNA were considered as HPV-positive. Survival probabilities and 95% confidence intervals were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to assess HPV association with disease-free survival (DFS), cause-specific survival (CSS) and overall survival (OS) in a competing risks scenario., Results: Specimen from 30 (10.7%) patients were p16+ and HPV DNA+, while 31 (11.0%) were either p16+ or HPV DNA+ only. OS probabilities at five years for HPV-positive and -negative groups were 50.9% (35.4%-73.1%) and 52.9% (47.0%-59.5%), respectively. HPV double positivity influenced neither OS, CSS nor DFS: HR=0.84 (0.43-1.63), 1.64 (0.76-3.54) and 1.13 (0.55-2.35), respectively., Conclusion: In contrast to oropharyngeal cancer, the prevalence of HPV in OSCC is low and the presence of HPV does not influence survival outcomes. Hence, there is no evidence to support a parallel transfer of therapy regimen for HPV-positive OPC to OSCC, in terms of therapy de-escalation and/or vaccination., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Aim: To quantify the prevalence of brain metastases involving the hypothalamic-pituitary (HT-P) area., Introduction: Cognitive impairment and fatigue are common side effects of whole brain irradiation (WBI) comprising the quality of life (QoL) for survivors. While the former is related to radiation-induced hippocampal injury, the latter could be secondary to hormonal disbalance as a consequence of radiation of the HT-P area. Thus, sparing both regions from higher irradiation doses could reduce these sequelae., Methods: T1 contrast medium enhanced magnetic resonance imaging (MRI) scans of 865 patients with brain metastases (4,280 metastases) were reviewed. HT-P area was individually contoured with a margin of 5 mm in order to evaluate the prevalence of brain metastases in this region., Results: Involvement of the hypothalamic region was found in 26 patients (involvement rate of 3% for patients and 1% for metastases), involvement of the pituitary gland in 9 patients (1% for patients and < 1% for metastases). Binary logistical regression analysis revealed the presence of > 10 brain metastases as the only factor associated with hypothalamic involvement while no distinct factor was associated with an involvement of the pituitary gland., Conclusion: The low prevalence of metastases within the HT-P area in patients with brain metastases calls for further studies examining whether sparing of this region might improve patients QoL.

Background and Purpose: To investigate the potential prognostic role of tumor cell podoplanin expression in patients treated with resection followed by irradiation or chemoradiotherapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN)., Materials and Methods: Podoplanin expression (≤10 % versus > 10 %) and 12 other factors were evaluated in 160 patients for their association with locoregional control (LRC), metastases-free (MFS) and overall survival (OS). Other factors were age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, preradiotherapy (pre-RT) hemoglobin level, tumor site, histological grading, T category, N category, American Joint Committee on Cancer (AJCC) stage, human papillomavirus (HPV) status, extent of resection and concurrent chemotherapy., Results: In multivariate analysis, ECOG performance status 0-1 (risk ratio, RR: 3.01; 95 % confidence interval, CI: 1.42-7.14; p = 0.003), pre-RT hemoglobin levels ≥ 7.45 mmol/l (12 g/dl; RR: 2.03; 95 % CI: 1.04-3.94; p = 0.038), oropharyngeal cancer (RR: 1.25; 95 % CI: 1.01-1.55; p = 0.038) and T category T1-2 (RR: 1.81; 95 % CI: 1.24-2.79; p = 0.002) were significantly associated with improved LRC. T category T1-2 (RR: 1.90; 95 % CI: 1.25-3.06; p = 0.002) and N category N0-2a (RR: 5.22; 95 % CI: 1.96-18.09; p < 0.001) were significantly associated with better MFS. Pre-RT hemoglobin levels ≥ 7.45 mmol/l (RR: 2.44; 95 % CI: 1.27-4.74; p = 0.007), T category T1-2 (RR: 1.97; 95 % CI: 1.36-3.04; p < 0.001) and N category N0-2a (RR: 2.87; 95 % CI: 1.37-6.61; p = 0.005) were significantly associated with improved OS. Podoplanin expression ≤ 10 % showed a trend towards improved OS on both univariate (p = 0.050) and multivariate analysis (RR: 1.86; 95 % CI: 0.96-3.59; p = 0.07)., Conclusion: Treatment outcomes were significantly associated with performance status, pre-RT hemoglobin level, tumor site and tumor stage. Tumor cell expression of podoplanin ≤ 10 % showed a trend towards improved OS when compared to podoplanin expression of > 10 %.

Background and Purpose: This study aimed to develop a validated survival score for elderly patients with metastatic spinal cord compression (MSCC)., Patients and Methods: In all, 1,128 patients were randomly assigned to the test (n = 564) or validation group (n = 564). In the test group, ten pretreatment factors (age, gender, performance status, primary tumor, number of involved vertebrae, ambulatory status, other bone metastases, visceral metastases, interval from cancer diagnosis to radiotherapy of MSCC, time to developing motor deficits) plus the radiation regimen were retrospectively evaluated. Factors significantly associated with survival on multivariate analysis were included in the survival score. The score for each factor was determined by dividing the 6-month survival rate (%) by 10. The prognostic score represented the sum of the scores for each factor., Results: In the multivariate analysis of the test group, age, performance status, primary tumor type, ambulatory status, other bone metastases, visceral metastases, interval from cancer diagnosis to radiotherapy of MSCC, and time to developing motor deficits were significantly associated with survival. Total scores ranged from 25 to 57 points. In the test group, 6-month survival rates were 11 % for 25-39 points, 56 % for 40-48 points, and 97 % for 49-57 points (p < 0.001). In the validation group, 6-month survival rates were 10, 53, and 94 %, respectively (p < 0.001)., Conclusion: Based on the survival scores of the test group, three prognostic groups were identified. The survival rates of the validation group were similar to the test group. This score appears reproducible and can help select the appropriate treatment for elderly patients with MSCC.

This study aimed to identify clinical factors associated with survival and to develop a prognostic tool in patients receiving radiosurgery alone for very few cerebral metastases from melanoma. Ten characteristics of 69 patients treated with radiosurgery alone for 1-3 cerebral metastases from melanoma were retrospectively analyzed for survival. Serum lactate dehydrogenase levels before radiosurgery, Karnofsky performance score, maximum diameter of all irradiated cerebral lesions, and extracranial lesions were significantly associated with survival and included in the tool. Twelve-month survival rate (in %) divided by 10 was calculated for each of these four factors. The four scores were summed resulting in total scores ranging 9-22 points. Based on the 12-month survival rates, three groups were formed: less than 15 points (group I, n = 25); 15-20 points (group II, n = 34); and more than 20 points (group III, n = 10). Corresponding 12-month survival rates were 10 ± 6%, 51 ± 9% and 90 ± 9%, respectively (P < 0.001). In group I, death within 12 months following radiosurgery occurred mostly due to extracranial progression, whereas cerebral progression was the major cause of death in group II. In group III, only one of 10 patients died within 1 year. This new prognostic tool helps predict the survival time following radiosurgery of very few cerebral metastases from melanoma. An individual treatment approach should consider a patient's survival time and the most likely cause of death (cerebral or extracranial progression)., (© 2014 Japanese Dermatological Association.)

Objectives: This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System., Methods: Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n=113) and SRS (n=260). Propensity score matching was used to adjust for selection bias (n=98 each); means of survival time and survival curves were defined by the Kaplan-Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty., Results: Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P=0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P=0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R(2)=0.249; P=0.006). SRS had a lower average cost per patient (€9964 - SD: 1047; Skewness: 7273) than SR (€11647 - SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €-3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years., Conclusion: SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The surgical treatment of spinal metastases is evolving. The major problem is the selection of patients who may benefit from surgical treatment. One of the criteria is an expected survival of at least 3 months. A prediction model has been previously developed. The present study has been performed in order to validate externally the model and to demonstrate that this model can be generalized to other institutions and other countries than the Netherlands. Data of 356 patients from five centers in Germany, Spain, Sweden, and the Netherlands who were treated for metastatic epidural spinal cord compression were collected. Hazard ratios in the test population corresponded with those of the developmental population. However, the observed and the expected survival were different. Analysis revealed that the baseline hazard function was significantly different. This tempted us to combine the data and develop a new prediction model. Estimating iteratively, a baseline hazard was composed. An adapted prediction model is presented. External validation of a prediction model revealed a difference in expected survival, although the relative contribution of the specific hazard ratios was the same as in the developmental population. This study emphasized the need to check the baseline hazard function in external validation. A new model has been developed using an estimated baseline hazard., (© Springer Science+Business Media, LLC 2011)

Purpose: Many patients with metastatic spinal cord compression (MSCC) live long enough to develop a recurrence in the irradiated spinal area. This is the first prospective study that has compared local control of different radiotherapy schedules for MSCC., Methods and Materials: A total of 265 patients treated with radiotherapy alone were included in this prospective nonrandomized study. The primary goal was to compare local control from short-course (1 × 8 Gy/5 × 4 Gy, n = 131) and long-course radiotherapy (10 × 3 Gy/15 × 2.5 Gy/20 × 2 Gy, n = 134). Secondary end points were motor function and survival. The analysis of local control (no MSCC recurrence in the irradiated spinal area) included the 224 patients with improvement or no change of motor deficits during radiotherapy. Eleven additional factors were evaluated for outcomes., Results: One-year local control was 61% after short-course and 81% after long-course radiotherapy (p = 0.005). On multivariate analysis (MVA), improved local control was associated with long-course radiotherapy (p = 0.018). Motor function improved in 37% after short-course and 39% after long-course radiotherapy (p = 0.95). Improved motor function was associated with better performance status (p = 0.015), favorable tumor type (p = 0.034), and slower development of motor deficits (p < 0.001). One-year survival rates were 23% after short-course and 30% after long-course radiotherapy (p = 0.28). On MVA, improved survival was associated with better performance status (p < 0.001), no visceral metastases (p < 0.001), involvement of only one to three vertebrae (p = 0.040), ambulatory status (p = 0.038), and bisphosphonate administration after radiotherapy (p < 0.001)., Conclusions: Long-course radiotherapy was associated with better local control, similar functional outcome, and similar survival compared to short-course radiotherapy. Patients with a relatively favorable expected survival should receive long-course radiotherapy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: Whole-brain radiotherapy (WBRT) is the most common treatment for brain metastases from renal cell carcinoma (RCC). Most patients cannot receive more aggressive therapies including surgery or radiosurgery. The standard WBRT regimen, 30 Gy/10 fractions (10 × 3 Gy), has resulted in poor survival (OS). This study investigates whether escalation of the WBRT dose improves treatment outcomes., Methods and Materials: Data from 60 patients receiving WBRT for brain metastases from RCC were retrospectively analyzed. A dose of 10 × 3 Gy (n = 31) was compared with higher doses (40 Gy/20 fractions or 45 Gy/15 fractions; n = 29) for OS and local control (LC). Additional factors evaluated were patient age, sex, performance status, number of metastases, interval from diagnosis of RCC to WBRT, extracerebral metastases, recursive partitioning analysis (RPA) class, and year of WBRT., Results: The OS at 6 months was 29% after 10 × 3 Gy and 52% after higher doses (p = 0.003). The OS at 12 months was 13% and 47%, respectively. On multivariate analysis, higher WBRT doses (p = 0.022), Karnofsky performance status score ≥70 (p = 0.017), fewer than four brain metastases (p = 0.035), and RPA Class 1 (p = 0.003) resulted in better OS. The LC at 6 months was 21% after 10 × 3 Gy and 57% after higher doses (p = 0.013). The LC at 12 months was 7% and 35%, respectively. On multivariate analysis, fewer than four brain metastases (p < 0.001) were associated with LC. A trend was found for WBRT regimen (p = 0.06) and RPA class (p = 0.06)., Conclusions: The findings suggest that escalation of the WBRT dose beyond 10 × 3 Gy improves outcomes in patients with brain metastases from RCC. The results should be confirmed in a randomized trial stratifying for significant prognostic factors., (2010 Elsevier Inc. All rights reserved.)

Purpose: The current study analyzes the potential role of radiotherapy (RT) in symptomatic vertebral hemangioma (SVH)., Methods and Materials: Seven cooperating German institutions collected clinical information, treatment plans, and outcome data for all patients with SVH referred for local RT., Results: From 1969 to 2008, a total of 84 patients with 96 symptomatic lesions were irradiated for SVH. The primary indication for radiotherapy was pain (97.6%), and 28.6% of patients had additional neurological symptoms. RT was performed at a median total dose of 34 Gy, with a median single dose of 2.0 Gy. After receiving a median follow-up of 68 months, the overall patient response rate was 90.5%. Complete symptom remission occurred in 61.9% of patients, 28.6% of patients had partial pain relief, and 9.5% of patients had no pain relief. In 26.2% of patients, radiological signs of reossification were observed in long-term follow-up but not significantly correlated with pain relief. Most importantly, total doses of >/=34 Gy resulted in significantly greater symptomatic relief and control rate than total doses of <34 Gy., Conclusions: This study consists of the largest database of cases reported so far using RT for SVH. RT is easy, safe, and effective for pain relief treatment for SVH. Total doses of at least 34 Gy give the best symptomatic response.

Purpose: To investigate the effect of smoking during radiotherapy (RT), respiratory insufficiency before RT, hemoglobin levels during RT, and additional factors on overall survival, locoregional control (LRC), and metastasis-free survival in non-small-cell lung cancer patients., Methods and Materials: The following factors were investigated in 181 patients who underwent RT for non-small-cell lung cancer: age, gender, Karnofsky performance score, histologic type, grade, T/N stage, American Joint Committee on Cancer stage, surgery, chemotherapy, respiratory insufficiency before RT, pack-years, smoking during RT, and hemoglobin levels during RT. Additionally, in the 129 patients who did not undergo surgery, the effect of the equivalent dose in 2-Gy fractions (EQD2) (<60 Gy vs. 60 Gy vs. >60 Gy) on outcome was investigated., Results: On multivariate analysis, improved overall survival was associated with a lower T stage (p = 0.004), lower N stage (p = 0.040), surgery (p = 0.010), and no respiratory insufficiency (p = 0.023). A Karnofsky performance score >70 achieved borderline significance (p = 0.056). Improved LRC was associated with a lower T stage (p = 0.007) and no smoking during RT (p = 0.029). Improved metastasis-free survival was associated with lower T stage (p < 0.001) and lower N stage (p < 0.001). In those patients who did not undergo surgery, an EQD2 of > or =60 Gy was associated with a better outcome than an EQD2 of <60 Gy. Furthermore, an EQD2 >60 Gy resulted in better LRC than did an EQD2 of < or =60 Gy., Conclusions: Smoking during RT had a significant effect on LRC, but we did not find that hemoglobin levels or respiratory insufficiency significantly affected LRC or metastasis-free survival in our patient population. Furthermore, our data suggest a dose-effect relationship in those patients who did not undergo surgery.

Purpose: To compare radio(chemo)therapy with 41.4-50.4 Gy (moderate dose, MD-RCT) plus resection versus radio(chemo)therapy with 59.4-66.6 Gy (higher dose, HD-RCT) alone for outcome in stage III esophageal cancer, and to investigate potential prognostic factors including preradiotherapy (pre-RT) hemoglobin., Patients and Methods: 148 patients with stage III esophageal cancer, treated with MD-RCT plus resection (n = 41) or HD-RCT alone (n = 107), were retrospectively evaluated for age, gender, performance status, tumor location, tumor length, stage, histology, grading, number of chemotherapy courses, pre-RT hemoglobin, resection, overall survival (OS), metastases-free survival (MFS), and locoregional control (LC)., Results: On univariate analysis, MD-RCT plus resection resulted in better 2-year OS (57% vs. 25%; p = 0.049), 2-year MFS (71% vs. 39%; p = 0.041), and 2-year LC (76% vs. 39%; p = 0.003). On multivariate analysis, results maintained significance for LC (p = 0.021). According to multivariate analysis, pre-RT hemoglobin was associated with OS (p = 0.003), MFS (p = 0.043), and LC (p = 0.041), tumor length with OS (p = 0.002) and MFS (p = 0.017), and the number of chemotherapy courses with OS (p = 0.008). Complications were more frequent in the MD-RCT-plus-surgery group (p < 0.001). Acute (p = 0.47) and late toxicity (p = 0.86) were similar in both groups. In patients receiving surgery, R0 resection was superior to R1/2 resection for OS (p < 0.001), MFS (p = 0.030), and LC (p < 0.001). MD-RCT plus R0 resection was also superior to HD-RCT alone., Conclusion: MD-RCT plus resection resulted in better LC than HD-RCT alone. If R0 resection is possible, MD-RCT plus resection appears preferable, as it results in better outcome. If only R1/2 resection can be performed, HD-RCT alone appears preferable regarding outcome and the greater morbidity associated with resection.

Purpose: Aim was to compare the functional status in long-term breast cancer survivors related to age at diagnosis and to asses the effects of adjuvant therapy on health-related quality of life (HRQoL)., Patients and Methods: Data were obtained from 370 patients after breast conserving therapy (BCT) at follow-up (F/U) visit. The self-administered EORTC QoL questionnaire (C30) and the breast module (QLQ-BR23) measuring global health, global QoL, physical, role, emotional, cognitive and social functioning, body image, sexual function, future perspective and arm/breast symptoms were used. Patients were grouped according to F/U (12 years, 7 years), age at therapy (< 50 years, 50-65 years, >65 years) and adjuvant treatment (none, chemotherapy, hormone replacement therapy)., Results: The global HRQoL was increased in patients with longer F/U (p < 0.01). Physical functioning, role functioning and sexual functioning were decreased in patients being older at therapy (> 65 years, p < 0.01). Increased arm symptoms were noticed in older women at longer follow-up. Younger women at therapy complained financial difficulties at follow-up (p < 0.006). Adjuvant chemotherapy and hormone replacement therapy did not affect physical and mental functioning., Conclusion: Women of different age treated with BCT for breast cancer should be considered at a different risk for HRQoL disturbance at long term F/U in both, physical and psychological dimensions. In clinical practice, specific identification of those women with negative impact of diagnosis and treatment on long term HRQoL would help for targeted interventions. In clinical studies focusing on HRQoL, the compared groups need to be age-adjusted.