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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.

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.

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

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.

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.

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.

Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder arising from synovial cells of the tendon sheets and joint capsules. The potential value of external beam radiation therapy in the interdisciplinary management of PVNS is demonstrated by a comprehensive literature review on the clinical use of radiotherapy and the results of national patterns of care study (PCS) which was conducted by the German Cooperative Group on Radiotherapy in Benign Diseases (GCG-BD) in 2008-2009.A structured questionnaire was mailed to all 227 RT institutions in Germany to assess all previous treatments, the RT indication and techniques, the rate of local control, the functional outcome and the possible adverse effects related to the use of external beam radiation therapy (RT). For comparison of the clinical outcome data, a systematic literature research in several international electronic databases and a conventional library search were performed to identify publications addressing the use of RT for PVNS.Based on an overall response rate of 83.2%, the PCS was nationally representative. Ten percent of institutions presented clinical experience with the use of RT for PVNS; from this database a total of 41 treated sites from 14 institutions were evaluable for long-term analysis. The primary therapeutic approach was cytoreductive surgery in all cases. In cases of residual tissue or complete resection of extensive local recurrences, RT was applied in 39 cases (95.1%). An excellent or good functional outcome was noted in 34 cases (82.9%). The use of RT was not associated with early or late toxicity larger than RTOG grade II. The literature review identified 19 published studies (1940-2009) which represented a total of 140 cases or patients, respectively. After follow-up periods ranging from 1-250 months and administration of total doses in the range of 16-50 Gy the overall rate of local control was 84.5%.Both the results of the national PCS and the literature review demonstrate that RT is a very safe and effective treatment option for the prevention of disease progression or recurrence in PVNS after primary surgical interventions. The planned treatment volume should include the whole synovial space and eventually all invasive components of the disease. Currently, total doses in the range of 30-36 Gy are recommended.

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.

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.

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.

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.

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.

In der Onkologie stehen haufig neue Therapiekonzepte auf dem Prufstand. Um deren Vertraglichkeit mit etablierten Standardtherapien vergleichen zu konnen, ist die Einhaltung international verbindlicher Dokumentations-standards notwendig. Im Folgenden soll kurz dargestellt werden, wie die Fortschritte in den Therapiemoglichkeiten umgekehrt auch zur Weiterentwicklung der Dokumentationsstandards gefuhrt haben.

Knochenmetastasen im Verlauf von Tumorerkrankungen sind sehr haufig. Die Pravalenz ossarer Metastasen im Vergleich zu primaren Sarkomen des Knochens liegt etwa 25mal hoher. Prinzipiell ist jeder bosartige Tumor dazu befahigt, in das Skelett zu metastasieren. Es sind aber nur wenige, die das gehauft tun. An erster Stelle steht das Mammakarzinom, gefolgt vom Prostata- und Bronchial-, Schilddrusen- und Nierenzellkarzinom. Diese funf Tumorentitaten sind fur mehr als 80% aller Skelettmetastasen verantwortlich. Etwa 70–80% aller Patienten, die am Mamma- oder Prostatakarzinom versterben, und 50–60% der Patienten, die am Bronchial- oder Schilddrusenkarzinom versterben, weisen autoptisch Knochenmetastasen auf (Tabelle 1). Die durchschnittliche Uberlebenszeit nach Beginn einer Skelettmetastasierung betragt — bei groser Variationsbreite — bei Karzinomen der Brustdruse und der Prostata etwa 2,5 Jahre, beim Bronchialkarzinom deutlich weniger.

Local radiotherapy of a tumor is frequently applied in combination with chemotherapy or surgical measures. Possibly occurring toxicity must therefore be considered within the overall context. The radiosensitivity of the various organs is dependent on the sensitivity of the respective stem or mature end cells, and shows considerable differences within the individual cell systems. Apart from the application of prophylactic procedures, some radiation sequelae can be ameliorated by initiating specific measures (e.g. cosmetic products, drug treatment).

Between November 2000 and December 2002 endoscopic incision or transurethral scar resection was followed by endourethral brachytherapy (BT) which was performed in patients with recurrent bulbar strictures ( n=9), bladder neck stenosis after transurethral prostatectomy (TUR-P) ( n=3), anastomotic stricture after radical prostatectomy ( n=2) or penile urethral stricture ( n=1). High dose rate (HDR) iridium-192 BT started on the day of the endoscopic incision or resection and continued for the following 3 days. The BT fractionation scheme was 4x3 Gy in the first three patients (until first relapse) and 4x4 Gy in all following patients. The dose was calculated at 3 mm tissue depth using 3-dimensional CT-planning. As of February 2004, the median follow-up of all patients reached 22 months.Seven of 15 patients (46%) are recurrence free. In two patients (13.3%), recurrent strictures developed 12 month later, outside of the region of initial treatment. In six patients (40%) the treatment was considered to be unsuccessful as recurrent strictures were found between 2 and 12 months after the initial or second course of treatment.Endourethral brachytherapy after endoscopic incision or resection is a promising treatment for the prevention of recurrent strictures of the urethra, bladder neck or vesicourethral anastomosis. The initial results have been very good, but with longer follow-up recurrence occurred in the irradiated area in 40% of patients. Prospective randomized studies in patients with a strictly defined type of recurrent stricture, or even after the first internal urethrotomy, should be done in the future.

Regarding orthopedic topics, radiotherapy of degenerative joint disorders is actually not well researched. So far, adequate long-term observations and reliable assessment of symptoms according to objective orthopedic criteria are still missing. From 1984 to 1994, 85 patients with symptomatic knee joint and hip joint osteoarthritis as well as omarthritis and rhizarthritis were treated. A total of 73 patients or 103 joints (due to bilateral symptoms) were documented in a long-term follow-up using orthopedic scores including objective criteria. Of the patients previously resistant to therapy, 63% responded to RT. Endoprosthetic surgery was necessary for only three patients. With regard to the endpoints "complete pain relief" or "major pain relief," only the parameter "symptom exists 2 years or more" indicated a significantly negative prognosis in multivariate analysis ( p0.05). Radiotherapy of degenerative joint disorders is an effective alternative treatment for refractory osteoarthritis compared to conventional conservative treatment options.

Perforation of the wall of the stomach, or positive lymph nodes appreciably worsens the prognosis of resected gastric carcinoma. In such a situation, neither adjuvant chemotherapy [12] nor optimal lymph node resection achieves a significant improvement in overall survival [5-8]. In contrast, a significant benefit of adjuvant radiochemotherapy after curative resection of advanced gastric carcinoma has been demonstrated. Thus, standardized postoperative radiochemotherapy should be applied after standardized surgery with a D1 resection. Optimal supportive treatment, that is, at least 1500 kcal/day, appropriate treatment of reflux or dumping symptoms, and supplementation for iron, vitamin B12 and calcium deficiency, is mandatory, if therapeutic success is not to be compromised [13,14].

The indication for radiotherapy for mamma carcinoma is determined in particular by the macroscopic and microscopic tumor findings, the number of lymph nodes identified, receptor status, the surgical report and (neo)adjuvant chemotherapy. Irradiation is applied in particular in conjunction with breast-preserving first-line treatment in the case of ductal in situ carcinomas, and postoperatively following breast conservation in the case of invasive mamma carcinoma. The indication for irradiation following mastectomy is controversial and is determined by tumor size and location, together with further factors (see the Guidelines of the German Society of Senology). The indications applying to the irradiation of regional lymph nodes are determined by the sites of the respective metastases. The combination of radio- and chemotherapy is carried out in close cooperation between oncologists and radiologists.

Prostate carcinoma patients with bone metastases do not have a dismal prognosis or short life expectancy by itself. Thus, often palliative therapeutic measures are required with respect of a life span beyond one year, especially if no lyphogenic or visceral metastases have developed. Similarly to patients with breast carcinoma the metastatic bone lesions in prostate carcinoma patients have mixed osteolytic and osteoblastic features with increased metabolic bone turn-over. This is the mechanism, in which bisphosphonates interfere and can prevent the pathologic bone resorption by blocking osteoclast activity. This improves not only painful clinical conditions but also reduces the rate of skeletal related events (SRE = hypercalcemia, bone fracture, myelon compression, surgery or radiotherapy to bone etc.). Generally, clinical studies suggest the benefit of bisphosphonates for patients with bone metastases and good life expectancy. For patients with prostate carcinoma large controlled studies have to consolidate this potential benefit.

The basal cell carcinoma which is often occurring in the elderly can be well treated by surgery. For large and recurrent lesions and in cosmetically difficult locations external beam radiotherapy provides an equally effective treatment alternative.From 1986 to 1999, 60 females and 39 males received primary radiotherapy for a total of 127 histologically verified basal cell carcinoma lesions. Tumors were mostly localized in the face at the temple, nose and forehead. Radiotherapy was applied with orthovoltage equipment and energies of up to 100 kV. Single doses ranged from 2 to 5 Gy related to the 80%-isodose depth. Weekly doses ranged from 8 to 25 Gy and total doses from 25 to 60 Gy. The mean follow-up period was 36 +/- 21 months. The acute sequelae were scored according to CTC criteria. Radiogenic late effects as single events were related to the radiation portal.3 months after treatment all besides one patient (99%) experienced complete tumor remission (CR). In all cases, acute radiation reaction occurred within the radiation portal: CTC Grade 1 in 100%, CTC Grade 2 in 54% and CTC Grade 3 in 30% of the cases. All side effects regressed under simple local measures without further complications. Late sequelae were observed in three cases. Overall cosmetic outcome was good to excellent in almost all patients (98%). In two cases (2%) a local recurrence was observed 6 and 20 months after radiotherapy.External beam (orthovoltage) radiotherapy is very effective and yields high tumor control rates and good cosmetic results in long-term follow-up. Former dermatological treatment concepts should be replaced by an ICRU-based radiophysical dose prescription and should respect the newer radiobiological fractionation principles.

Since the first description of rapid destruction of dental hard tissues following head and neck radiotherapy 80 years ago, "radiation caries" is an established clinical finding. The internationally accepted clinical evaluation score RTOG/EORTC however is lacking a classification of this frequent radiogenic alteration.Medical records, data and images of radiation effects on the teeth of more than 1,500 patients, who underwent periradiotherapeutic care, were analyzed. Macroscopic alterations regarding the grade of late lesions of tooth crowns were used for a classification into 4 grades according to the RTOG/EORTC guidelines.No early radiation effects were found by macroscopic inspection. In the first 90 days following radiotherapy 1/3 of the patients complained of reversible hypersensitivity, which may be related to a temporary hyperemia of the pulp. It was possible to classify radiation caries as a late radiation effect on a graded scale as known from RTOG/EORTC for other organ systems. This is a prerequisite for the integration of radiation caries into the international nomenclature of the RTOG/EORTC classification.The documentation of early radiation effects on dental hard tissues seems to be neglectable. On the other hand the documentation of Late radiation effects has a high clinical impact. The identification of an initial lesion at the high-risk areas of the neck and incisal part of the tooth can lead to a successful therapy as a major prerequisite for orofacial rehabilitation. An internationally standardized documentation is a basis for the evaluation of the side effects of radiooncotic therapy as well as the effectiveness of protective and supportive procedures.

Radiotherapy prevents progression of Dupuytren's contracture. Herein, 1-year results of a prospective randomized trial comparing 2 different dose concepts are presented.129 patients (67 males, 62 females) were included in the study with a minimum 1-year follow-up: 69 had bilateral and 60 unilateral involvement of Dupyutren's disease accounting for 198 irradiated hands. According to Tubiana, 73 hands had Stage N, 61 Stage N/I (or = 10 degrees flexion deformity), 59 Stage I (11 to 45 degrees) and 5 Stage II disease (46 to 90 degrees). Radiotherapy was randomly delivered: group A (63 patients/95 hands) received 10 times 3 Gy (total: 30 Gy) in 2 series (each 5 times 3 Gy) separated by 8 weeks; group B (66 patients/103 hands) received 7 times 3 Gy (total: 21 Gy) within 2 weeks. Orthovoltage radiotherapy (120 kV) with 40 cm standard cones and individual shielding was applied. Patient and disease parameters were equally distributed in both groups. Evaluation (toxicity, efficacy) was performed at 3 and 12 months with regard to subjective (patient's opinion) and objective parameters (palpation, measurements, comparative photographs--physician).Acute toxicity was minimal: 76 (38%) hands had skin reactions CTC Grade 1, 12 (6%) CTC Grade 2. Chronic side effects (dryness, skin atrophy, change of sensation, LENT Grade 1) occurred in 9 (5%) hands without differences between treatment groups. At 3 and 12 months follow-up, subjective symptoms and objective signs, nodules and cords, were reduced in both groups (p0.01) with no differences between groups: a total of 110 (55%) hands (group A: 55, group B: 55) regressed, 74 (37%) hands (group A: 35; group B: 39) were stable. Overall and mean number of nodules, cords and skin changes decreased at 3 and 12 months. 16 of 198 (8%) hands (group A: 7; group B: 9) progressed at 12 months follow-up ("treatment failure"); at 1 year, 7 of 60 patients with unilateral Dupyutren's disease required prophylactic radiotherapy for the contralateral hand due to disease progression.Prophylactic radiotherapy reduces symptoms and prevents disease progression in early-stage Dupyutren's disease. Both treatment concepts are well-tolerated and equally effective. Acute toxicity is slightly increased with treatment concept B (7 times 3 Gy), while chronic sequelae are low in both treatment groups. Long-term evaluation with follow-up of more than 5 years has to be awaited to recommend one or the other dose concept.

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.

In patients at a high risk of developing a local recurrence or distant metastases, external beam radiotherapy used in combination with chemotherapy with 5-FU is indispensable. Adjuvant treatment is indicated for stage II and stage III rectal carcinoma, following tearing or cutting of the tumor, and/or following an R1 or R2 tumor resection. The neoadjuvant strategy comprises preoperative radiochemotherapy in the case of inoperable tumors or local recurrence, with the aim of enabling radical surgery. Radiation is applied to all sites likely to develop a recurrence. The fractionated radiation dose is 1.8-2 Gy/day, applied 5 times a week, for a total dose of 50 Gy at the dose reference point in the pelvis. Side effects include diarrhea, skin erosions and urological affections. Aftercare is provided on an interdisciplinary basis, initially at 6-week intervals, after 6 months at 3-month intervals, after one year every 6 months, and after 3 years once yearly.

The plenty options and high quality of radiation therapy for non-malignant disorders is not well known outside the field of radiology. It is necessary to transfer this information to cooperating general practitioners, surgeons, orthopedics and other specialists. To warrant quality assurance and quality control and to allow a uniform performance of radiotherapy of non-malignant conditions, general guidelines and recommendations according to the German Working Group of Scientific Medical Societies are useful. This paper summarizes the essential aspects of radiotherapy for non-malignant diseases: indication of, informed consent for, documentation and conduct of radiation therapy for non-malignant diseases using orthovoltage equipment and specific recommendations for follow up examinations. Radiotherapy concepts for non-malignant diseases are summarized.

Radical prostatectomy is indicated in patients with an estimated life expectancy of 10 years and with organ defined cancer disease (T1b-T2, No, Mo). Radiotherapy is an effective alternative treatment, especially in patients with an increased comorbidity. Primary hormonal treatment is not indicated for organ-defined cancer. Prognosis of patients with locally advanced prostatic carcinoma (T3,NO,MO) is poor because of micrometastases; tumour progression will occur in 75% of patients independent of local therapy. Orchiectomy or LH-RH treatment is option of first choice in metastatic prostate cancer disease. There is no need for complete androgen deprivation. Ongoing trials measure the effect of intermittant androgen deprivation. Intention for treatment of hormone refractory cancer is improvement of quality of life. Cancer-related symptoms are pain caused by bone metastases, lymphoedemas and urinary retention. Therapeutic options are monochemotherapy, hormonal treatment, analgetic treatment besides palliative radiotherapy.

Radiotherapy (RT) is used as last resort for patients with advanced cutaneous malignant melanoma (MM). Herein our 20-year clinical experience is presented analyzing different endpoints and prognostic factors in patients with locally advanced, recurrent or metastatic MM.From 1977 to 1995, 2,917 consecutive patients were entered in the MM registry of our university hospital. RT was indicated in 121 patients (56 females, 65 males) for palliation in locally advanced recurrent and metastatic MM stages UICC IIB to IV. At the time of RT initiation, 11 patients had primary or recurrent lesions which were either not eligible for surgery or had residual disease (R2) after resection of a primary or recurrent MM lesion (UICC IIB); 57 patients had lymph node (n = 33) or in-transit metastases (n = 24) (UICC III), and 53 had distant organ metastases (7 M1a, 46 M1b) (UICC IV). The time from first diagnosis to on-study RT averaged overall 19 months (median: 18; range: 3 to 186 months). In 77 patients conventional RT and in 44 patients hypofractionted RT was applied with 2 to 6 Gy fractions up to a mean total RT dose of 45 (median: 48; range: 20 to 66) Gy.At 3 months follow-up, complete response (CR) was achieved in 7 (64%), overall response (CR + PR) in all (100%) UICC IIB patients, in 25 (44%) and 44 (77%) of 57 UICC III patients, and in 9 (17%) and 26 (49%) of 53 UICC IV patients. Tumor progression during RT occurred in 25 (21%) patients. Patients with CR survived longer (median: 40 months) than those without CR (median 10 months) (p0.01). At the time of evaluation and last FU (December 31, 1996), 26 patients were still alive: 6 (55%) stage UICC IIB, 17 (30%) stage UICC III, and 3 (6%) stage UICC IV patients (p0.01). Univariate analysis revealed following prognostic factors for CR and long-term survival: UICC stage (p0.001), primary location in the head and neck, total RT dose40 Gy (all p0.05), while age, gender and primary histological subtype had no impact. In multivariate analysis, UICC stage was the only independent favorable prognostic factor for achievement of CR and long-term survival (p0.001).External RT provides effective palliation in advanced UICC stages. The UICC staging system is a good predictor of initial and long-term tumor response in metastatic MM. Prospective randomized trials using RT with or without adjuvant therapy for advanced MM are justified.

The 20-year radiotherapy (RT) experience in patients with locally advanced, recurrent or metastatic malignant melanoma (MM) is analyzed with respect to different endpoints and prognostic factors. From 1977 to 1995, 2917 consecutive patients were entered in our MM registry. RT was indicated in 121 patients (56 females, 65 males) for palliation in advanced MM stages. The histology of the primary lesion was nodular in 51, superficial spreading in 35, acral-lentiginous in 8 and lentigo maligna in 4 patients); 22 were missing or could not be reclassified. Eleven patients had primary or recurrent lesions which were ineligible for surgery or had residual disease (R2) after resection of a primary or recurrent lesion (UICC IIB); 57 patients had lymph node (33) or in-transit metastases (24) (UICC III), 53 had distant organ metastases (7 M1a; 46 M1b) (UICC IV). Time from first diagnosis to on-study RT averaged 19 (median: 18; range: 3-186) months. In most cases conventional RT was applied (2-6 Gy single fractions) up to a mean total RT dose of 45 (median: 48; range: 20-66) Gy. At 3 months follow-up (FU), complete response (CR) was achieved in 7 (64%) and overall response (CR+PR) in all (100%) UICC IIB patients, in 25 (44%)/44 (77%) of 57 UICC III patients, and in 9 (17%)/26 (49%) of 53 UICC IV patients. Progression during RT occurred in 25 (21%) patients. Patients with CR survived longer (median: 40 months) than those without CR (median: 10 months) (p0. 01). At last FU, 26 patients were alive: 6 (55%) UICC IIB, 17 (30%) UICC III, and 3 (6%) UICC IV patients (p0.01). In univariate analysis following favorable prognostic factors for CR and long-term survival were identified: low UICC stage (p0.001), primary site head and neck and total dose40 Gy (all p0).

Since 1994 the German Radiooncological Society has established a special commission for quality assurance in radiation oncology. The working agenda covers guidelines for dosimetry, infrastructure and organisation of a radiooncological department. The efforts are in close cooperation with the quality assurance programs of the EORTC. Corresponding guidelines are being published. They can be applied to create a quality assurance system in a radiooncological department. They are not considered definitive and are still receptive to benefit from further modifications.

The documentation of acute and chronic treatment sequelae is a decisive precondition for the appropriate evaluation of the treatment quality of any cancer therapy.Interdisciplinary (inter)national efforts have resulted in a new consensus for recording of treatment sequelae in oncology. While the acute treatment side effects (day 1 to 90 after treatment) are recommended to be documented and evaluated using the Common Toxicity Criteria (CTC), for the chronic treatment side effects (day 91 and thereafter) the Late Effect Normal Tissue (LENT) criteria are to be implemented. The latter classification system allows to differentiate between the Subjective, Objective, Management and Analytic (SOMA) toxicity aspects. Both classification systems can be implemented not only for clinical applications using radiotherapy or chemotherapy alone but also for combinations with each other or with other treatment modalities. This allows for an effective interdisciplinary comparison between different treatment concepts not only within each institution but also in multicenter trials.Prospective documentation and evaluation of treatment toxicity in oncology should be intensified and systematically included in future mono- and multi-institutional clinical trials.

The clinical knowledge on the frequency and severity of acute radiation morbidity is very sparse. With established morbidity recording, only severe side effects are revealed. The lower morbidity (I/II degree) as a major part of the data base is neglected. Another problem may be the lack of interdisciplinary and international compatibility in other systems. For these reasons, our intention was to create an easily acceptable, international and interdisciplinary compatible documentation form for routine use in radiotherapy.A detailed topographic documentation sheet for each major topographic site of clinical radiation oncology has been developed (CNS, head and neck, thorax, female breast, abdomen, extremities). It is based upon existing toxicity codes and documentation systems (CTC[WHO], RTOG and EORTC, DEGRO, ADT, KIEL). Furthermore, basic oncological data like TNM, previous surgery or chemotherapy, drugs and more are included. For each topographic body site, one DIN A4 format is required for documentation of a 6 to 7-week treatment course. The toxicity prescription is coded according to the "DEGRO/RTOG Coding System for acute side effects" and to the "EORTC Acute Toxicity Code" to achieve optimal international and interdisciplinary compatibility.Complete documentation of toxicities level 0 to 4 is to be performed within 2 to 5 minutes per week/patient within preformed marks. The clinical performance has proven excellent. Not only level III/IV toxicities are recorded, but also level I/II morbidity.The topographic documentation system improves recording of acute morbidity in radiation oncology not only by time, but also in quality. Experimental, radiobiological and former clinical data may be proved for their actual plausibility.

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.

This study compares 4 classifications in patients with progressive refractory Graves orbitopathy (GO) and examines their prognostic value in long-term follow-up.From 1984 to 1994, 60 consecutive patients (49 female, 11 male) received 20 Gy (10 x 2 Gy) radiotherapy with 6 MV Linac photons. Ocular symptoms and functional impairment was evaluated according to 4 GO-classification systems: Werner-, modified ATA- and Stanford-Score and Ophthalmopathy-Index (OI) according to Grussendorf. In addition, all patients noted their subjective response on a linear scale (0 to 100%).Improvement was achieved within 1 year after radiotherapy according to the Werner-Score in 28 (47%) patients inor = 1 symptom category, according to the modified ATA-score in 48 (80%), the Stanford-score in 47 (78%) and the OI-Score in 55 (92%) patients (reduction of2 points). The Werner-Score correlated less to the other scores (coefficient r0.5) than the other scores among themselves (r approximately 0.9). The ATA-Score improved in the different symptom categories between 47% (stage VI) and 87% (stage V). The OI-Score was reduced by a mean of 6 points. The patients reached a mean subjective improvement of +70 +/- 25%. Acute or chronic side effects were not observed. In multivariate analysis the "male gender" (p = 0.08), a "symptom duration prior to radiotherapy1 year" (p = 0.14) and a "high symptom category" (p = 0.11) indicated a negative prognostic trend.External radiotherapy is effective for severe, progressive GO after pretreatment. A minimum follow-up of at least 12 months and standardized classification and success criteria are required.