Andreas Krüll

Is advanced cancer associated with demoralization and lower global meaning? The role of tumor stage and physical problems in explaining existential distress in cancer patients.

Objective: This longitudinal study examines the extent to which global meaning, existential distress in terms of demoralization, and depression are predicted by tumor stage (UICC stages 0–II vs III/IV), palliative treatment, and physical problems in cancer patients.

Extracapsular spread of nodal metastasis as a prognostic factor in rectal cancer.

PURPOSE To evaluate the prognostic value of lymph node metastasis with extracapsular extension (ECE) for local control and metastasis-free survival in rectal cancer. METHODS AND MATERIALS A total of 145 rectal cancer patients were treated with surgery and postoperative radiochemotherapy. Patients were grouped according to nodal status (node negative, n = 49; node positive without ECE, n = 64; node positive with ECE, n = 32). In addition, well-known prognostic factors such as International Union Against Cancer (UICC) stage, T and N stage, presence of lymphangiosis, and grade were assessed. The end points were analyzed by the Kaplan-Meier method, and prognostic factors were compared in a Cox regression model. RESULTS Of the entire group, the actuarial 5-year local control and distant metastasis-free survival rate was 85% and 66%, respectively, after a median follow-up of 47 months (range, 14-104). Patients with ECE of lymph node metastasis had an impaired 5-year local control rate (58%) compared with node-negative (83%) and node-positive without extracapsular involvement patients (87%, p = 0.041). Metastasis-free survival also differed for the three groups, with a rate of 40% for those with extracapsular involvement, 54% for those without ECE, and 78% for node-negative patients (p <0.0001). The impact of ECE on local control was confirmed in the regression model (risk ratio [RR] 1.6, 95% confidence interval [CI] 1.01-2.7, p = 0.044). T stage was only of borderline significance (RR 2.4, 95% CI 1.0-5.7, p = 0.052). However, only UICC stage (RR 5.1, 95% CI 2.0-13.1, p <0.001) and the presence of lymphangiosis (RR 2.8, 95% CI 1.4-5.3, p = 0.002) were of independent prognostic value for distant metastasis. CONCLUSION ECE of node metastasis is connected with a substantial decline in local control. The frequency of distant metastasis is increased in this patient group as well, but stage and lymphangiosis are the independent factors for assessment of a patients risk of systemic spread.

Ergebnisse der Strahlentherapie von Wirbelkörperangiomen

Fragestellung: Analyse unserer Therapieergebnisse bei der Behandlung von symptomatischen Wirbelkörperangiomen und Bewertung der Literatur. Patienten und Methode: Die Daten von zehn im Zeitraum von 1974 bis 1997 bestrahlten Patienten mit symptomatischen Wirbelkörperangiomen wurden retrospektiv ausgewertet. Als Kriterium für den Therapieerfolg wurde die Besserung der Schmerz- und der neurologischen Beschwerdesymptomatik gewertet. Ergebnisse: Bei vier von zehn Patienten wurde eine dauerhafte Schmerzfreiheit, bei weiteren vier eine Schmerzlinderung erzielt. Die initial bestehenden neurologischen Symptome bei drei Fällen bildeten sich bei zwei Patienten komplett und bei einem teilweise zurück. Die akuten Nebenwirkungen waren geringfügig. Spätnebenwirkungen traten nicht auf. Eine Dosis-Wirkungs-Beziehung wurde nicht nachgewiesen. In keinem Fall kam es zu einem Rezidiv. Schlußfolgerung: Wir empfehlen eine Bestrahlung von 30 Gy bei symptomatischen Angiomen als primäre Therapie. Bei beginnender Querschnittssymptomatik mit notwendiger operativer Entlastung ist eine Strahlentherapie auch bei postoperativer Symptomfreiheit zur Verhinderung eines Progresses bzw. Rezidivs sinnvoll.Purpose: Assessment of treatment results of symptomatic vertebral hemangiomas and review of the literature (Table 3). Patients and Methods: Ten patients treated between 1974 to 1997 were retrospectively analyzed. Efficacy of treatment was determined according to improvement of pain and/or neurological symptoms (Table 1). Results: Improvement was achieved in 8 of 10 patients. The initially existing neurological symptoms of 3 patients disappeared completely in 2 cases and improved in 1 case. Acute side effects were slight. Late side effects were not seen. A dose-effect relationship could not be assessed. There was no relapse. Conclusion: Radiotherapy with 30 Gy for symptomatic vertebral angioma as primary therapy is indicated. In case of neurological symptoms a radiotherapy after operative therapy is recommendable even if the patient is free of symptoms to prevent progress or relapse.

Exploring spiritual needs and their associated factors in an urban sample of early and advanced cancer patients.

Although it is widely recognised that people turn to spirituality in times of crises, the interest in exploring the spiritual needs of cancer patients is just beginning to grow. The purpose of this study was to conduct a spiritual needs assessment with cancer patients living in a Northern European metropolitan region in order to (a) examine the relevance and nature of spiritual needs; (b) to clarify the role of demographic and clinical characteristics in spiritual needs; and (c) to identify their associations with dimensions of psychological distress. N = 285 outpatients with mixed cancer sites and of all tumour stages were surveyed cross-sectionally. Instruments included the Spiritual Needs Questionnaire (SpNQ) and measures of anxiety, distress, hopelessness and meaning-related life attitudes. Almost all patients (94%) reported at least one spiritual need. The needs for Inner Peace and Actively Giving emerged to be of greatest importance. Significant, but weak differences were found for age, gender and being in a partnership. No associations for medical characteristics were observed. Regression analyses revealed anxiety as the strongest predictor for the subscales Existential Needs, Inner Peace and Actively Giving. The results emphasise the relevance of spiritual needs in cancer patients. The call for spiritual assessment and interventions to meet spiritual needs in cancer patients is strengthened.

Results of Three Dimensional Conformal Radiotherapy and Hormonal Therapy for Local Recurrence after Radical Prostatectomy

Background and Purpose:Analysis of treatment results of combined three–dimensional conformal radiotherapy (3DCRT) and hormonal therapy in patients with locally recurrent prostate cancer after radical prostatectomy.Patients and Methods:Between 1992 and 1998, 24 patients presented with a rising prostate–specific antigen (PSA) between 4 and 152 months following radical prostatectomy and a local recurrence demonstrated by imaging. Recurrence was biopsy–proven in 13 cases. All patients were treated with 3DCRT to a total dose of 60–70 Gy. 21 patients (88%) received adjuvant hormone therapy up to a maximum of 6 months.Results:All patients showed a response in PSA values after therapy. Median follow–up is 43 months. Overall survival is 80% and 67% at 3 and 5 years, respectively. Biochemical control rates are 53% and 38% at 3 and 5 years, respectively. 14 patients developed a second PSA relapse. Acute and late toxicities, classified with the RTOG score, were moderate.Conclusion:Radiotherapy and short–term adjuvant hormone therapy represent an effective and well–tolerated treatment for locally recurrent prostate cancer after radical prostatectomy resulting in good local control. Long–term prognosis in terms of biochemical control and disease–specific survival remains poor.Hintergrund und Ziel:Die Ergebnisse der kombinierten konformalen Radiotherapie und Hormontherapie von Lokalrezidiven nach radikaler Prostatektomie werden analysiert.Patienten und Methodik:Zwischen 1992 und 1998 wurde bei 24 Patienten mit steigenden PSA–Werten (prostataspezifisches Antigen) 4–152 Monate nach radikaler Prostatektomie ein Lokalrezidiv in der Bildgebung nachgewiesen. Das Lokalrezidiv wurde in 13 Fällen histologisch überprüft. Alle Patienten wurden konformal mit Dosen zwischen 60 und 70 Gy bestrahlt. Bei 21 Patienten wurde zusätzlich eine bis zu 6–monatige Hormontherapie durchgeführt.Ergebnisse:Bei allen Patienten kam es nach der Therapie zu einem Absinken der PSA–Werte. Die mediane Nachbeobachtungszeit beträgt 43 Monate. Die Gesamtüberlebensraten liegen bei 80% und 67% nach 3 und 5 Jahren. Das biochemisch ereignisfreie Überleben beträgt 53% und 38% nach 3 und 5 Jahren. 14 Patienten entwickelten ein zweites PSA–Rezidiv. Akut– und Spättoxizität waren gering.Schlussfolgerung:Konformale Radiotherapie und kurzzeitige Hormontherapie sind eine effektive und gut verträgliche Behandlung für Lokalrezidive nach radikaler Prostatektomie mit guter lokaler Kontrolle. Die langfristige Prognose in Hinblick auf die biochemische Rezidivfreiheit ist schlecht.

Interstitial high-dose rate brachytherapy with iridium-192 in patients with oral squamous cell carcinoma

Thirty-four patients with recurrent oral and oropharyngeal carcinomas were treated over a period of 4 years, by interstitial high-dose rate (HDR) brachytherapy (BT) using an iridium-192 source (Gammamed 2i and 12i equipment, Sauerwein, Germany) and fractionated application (1 up to 3 times, weekly recovery phases, single maximum dose 10 Gy). Pretreatment characteristics of patients in terms of irradiation (RT) and surgery differed (22 had external RT alone, with a total dose between 60.0 and 75.6 Gy; RT and surgery: 7; surgery alone: 1). The initial TNM-stages (UICC, Hermanek et al., 1987) of patients were: I = 2, II =3, III = 7, IV = 22. In the majority of cases, clinical indications for HDR-BT included tumour recurrence or progression following external RT, and second primary tumours of the oral cavity. Therapy was successful in most cases, i.e. complete remission: 11, partial remission: 16, no change: 2, progression: 5. Local control and overall survival rates, including patients surgically treated after BT, were at 6 months 58% and 62%, and 44% and 53% at 12 months, respectively. This type of treatment is recommended in patients with local recurrence or second primary tumours after previous external RT in the head and neck region. However, the benefit of interstitial HDR-BT remains questionable, particularly in patients with large tumours and lymph node metastases.

Salvagebehandlung fortgeschrittener Plattenepithelkarzinome der Mundhöhle und des Oropharynx

ZusammenfassungHintergrundEs wurde retrospektiv der Einfluß der interstitiellen High-dose-rate-(HDR-)Brachytherapie mit Iridium 192 auf die lokale Tumorkontrolle und Gesamtüberlebenszeit von Patienten mit fortgeschrittenen, perkutan vorbestrahlten Mundhöhlen- und Oropharynxkarzinomen untersucht.Patienten und Methode38 Patienten mit Plattenepithelkarzinomen der Mundhöhle und des Oropharynx wurden während eines Zeitraums von sieben Jahren (1988 bis 1994) mit der interstitiellen Brachytherapie nach dem HDR-Afterloading-Verfahren (Gammamed® 12i, Iridium 192) behandelt. Die Vorbehandlung von 34 Patienten variierte entsprechend der individuellen Krankheitsverläufe: perkutane Strahlentherapie bei 33 Patienten (60 bis 75,6 Gy), davon bei acht Patienten Bestrahlung und ablative Tumoroperation. Ein Patient war non in sano voroperiert. Vier Patienten waren weder operiert noch perkutan bestrahlt worden. Die Indikationen zur Brachytherapie waren überwiegend Rest- oder Rezidivtumoren nach vorausgegangener externer Strahlentherapie.ErgebnisseDie klinische und morphologische Beurteilung ergab eine komplette Remission in zwölf, eine partielle Remission in 19, keine Veränderung in zwei und einen lokalen Progreß in fünf Fällen. Nach einer mittleren Nachbeobachtungszeit von 15 Monaten betrug die lokale Tumorkontrolle nach sechs Monaten 59% und nach zwölf Monaten 47%. Die Überlebensrate der Patienten nach diesen Zeiten lag bei 81% bzw. 49%.Schlußfolgerung enDie interstitielle Brachytherapie nach dem HDR-Afterloading-Verfahren wird empfohlen für Patienten mit Lokalrezidiven und Zweitkarzinomen von Plattenepithelkarzinomen der Mundhöhle und des Oropharynx, die bereits perkutan bestrahlt worden sind und für die keine erneute perkutane Bestrahlung mehr anwendbar ist. Eine Kombination der interstitiellen Brachytherapie mit chirurgischer Sanierung ist für diese Patienten anzustreben.AbstractPurposeThe clinical effect of high-dose-rate (HDR) interstitial brachytherapy combined with tumor resection was investigated in this retrospective study on patients with recurrent oral and oropharyngeal squamous cell carcinoma.Patients and MethodsOral and oropharyngeal squamous cell carcinoma in 38 patients were treated over a period of 7 years (1988–1994) by HDR interstitial brachytherapy using Gammamed 12i® equipment. Pretreatment of patients in terms of irradiation and surgery differed (33 irradiated with a total dose between 60.0 and 75.6 Gy, including 8 patients with additional surgery; 1 patient with surgery alone, and 4 patients without any pretreatment). Indications for interstitial brachytherapy differed according to individual responses to treatment and medical histories.ResultsInterstitial brachytherapy was successful in the majority of patients, i. e. complete remission: 12, partial remission: 19, no change: 2, progression: 5. Local control and overall survival including patients with surgical treatment was 59% and 81% at 6 months and 47% and 49% after 12 months, respectively.ConclusionInterstitial HDR brachytherapy with Iridium 192 is recommended in patients with local recurrences or second primary carcinomas after previous external radiotherapy in the head and neck region. Combination of interstitial brachytherapy and surgery is preferable for these patients.PURPOSE The clinical effect of high-dose-rate (HDR) interstitial brachytherapy combined with tumor resection was investigated in this retrospective study on patients with recurrent oral and oropharyngeal squamous cell carcinoma. PATIENTS AND METHODS Oral and oropharyngeal squamous cell carcinoma in 38 patients were treated over a period of 7 years (1988-1994) by HDR interstitial brachytherapy using Gammamed 12i equipment. Pretreatment of patients in terms of irradiation and surgery differed (33 irradiated with a total dose between 60.0 and 75.6 Gy, including 8 patients with additional surgery; 1 patient with surgery alone, and 4 patients without any pretreatment). Indications for interstitial brachytherapy differed according to individual responses to treatment and medical histories. RESULTS Interstitial brachytherapy was successful in the majority of patients, i.e. complete remission: 12, partial remission: 19, no change: 2, progression: 5. Local control and overall survival including patients with surgical treatment was 59% and 81% at 6 months and 47% and 49% after 12 months, respectively. CONCLUSION Interstitial HDR brachytherapy with Iridium 192 is recommended in patients with local recurrences or second primary carcinomas after previous external radiotherapy in the head and neck region. Combination of interstitial brachytherapy and surgery is preferable for these patients.

PRESENT RESULTS OF NEUTRON THERAPY : THE GERMAN EXPERIENCE

Results of fast neutron therapy are reviewed with special reference to the main indications for this type of treatment and the experience of five German centers. Neutron therapy seems beneficial compared to conventional radiotherapy in advanced salivary gland tumors, inoperable or unresectable soft tissue sarcomas, some bone tumors, prostate cancer stage C and some rare low-grade tumors. About 3,000 patients with malignancies have been treated with neutrons at the German centers Berlin/Rossendorf, Essen, Hamburg, Heidelberg and Münster. Treatment results and treatment-related morbidity depend on the treatment techniques and the physical selectivity of the neutron machines. A critical appraisal suggests that fast neutrons are of advantage in about 5% of all radiotherapy patients.

Partial body irradiation of small laboratory animals with an industrial X-ray tube

AIMS Dedicated precise small laboratory animal irradiation sources are needed for basic cancer research and to meet this need expensive high precision radiation devices have been developed. To avoid such expenses a cost efficient way is presented to construct a device for partial body irradiation of small laboratory animals by adding specific components to an industrial X-ray tube. METHODS AND MATERIALS A custom made radiation field tube was added to an industrial 200 kV X-ray tube. A light field display as well as a monitor ionization chamber were implemented. The field size can rapidly be changed by individual inserts of MCP96 that are used for secondary collimation of the beam. Depth dose curves and cross sectional profiles were determined with the use of a custom made water phantom. More components like positioning lasers, a custom made treatment couch, and a commercial isoflurane anesthesia unit were added to complete the system. RESULTS With the accessories described secondary small field sizes down to 10 by 10 mm2 (secondary collimator size) could be achieved. The dosimetry of the beam was constructed like those for conventional stereotactical clinical linear accelerators. The water phantom created showed an accuracy of 1 mm and was well suited for all measurements. With the anesthesia unit attached to the custom made treatment couch the system is ideal for the radiation treatment of small laboratory animals like mice. CONCLUSION It was feasible to shrink the field size of an industrial X-ray tube from whole animal irradiation to precise partial body irradiation of small laboratory animals. Even smaller secondary collimator sizes than 10 by 10 mm2 are feasible with adequate secondary collimator inserts. Our custom made water phantom was well suited for the basic dosimetry of the X-ray tube.

Survival and overall treatment time after postoperative radio(chemo)therapy in patients with head and neck cancer.

Generally, overall treatment time for patients with locally advanced head and neck cancer should be as short as reasonably possible. This analysis was undertaken to determine at what overall treatment time additional survival/locoregional control benefits could be achieved compared to a 100‐day cutoff.