Arnulf Hackl

Dosimetry of intracavitary placements for uterine and cervical carcinoma: results of orthogonal film, TLD, and CT-assisted techniques

A total of 720 192Ir high-dose-rate (HDR) applications in 331 patients with gynecological tumors were analyzed to evaluate the dose to normal tissues from brachytherapy. Based on the calculations of bladder base, bladder neck, and rectal doses derived from orthogonal films the planned tumor dose or fractionation was altered in 20.4% of intracavitary placements (ICP) for cervix carcinoma and 9.2% of ICP for treatment of the vaginal vault. In 13.8% of intracervical and 8.1% of intravaginal treatments calculated doses to both the bladder and rectum were greater than or equal to 140% of the initially planned dose fraction. Doses at the bladder base were significantly higher than at the bladder neck (p less than 0.001). In 17.5% of ICP the dose to the bladder base was at least twice as high as to the bladder neck. The ratio of bladder base dose to the bladder neck was 1.5 (+/- 1.19 SD) for intracervical and 1.46 (+/- 1.14 SD) for intravaginal applications. The comparison of calculated doses from orthogonal films with in-vivo readings showed a good correlation of rectal doses with a correlation coefficient factor of 0.9556. CT-assisted dosimetry, however, revealed that the maximum doses to bladder and rectum were generally higher than those obtained from films with ratios of 1-1.7 (average: 1.44) for the bladder neck, 1-5.4 (average: 2.42) for the bladder base, and 1.1-2.7 (average: 1.37) for the rectum. When doses to the specified reference points of bladder neck and rectum from orthogonal film dosimetry were compared with the corresponding points on CT scans, similar values were obtained for both methods with a maximum deviation of +/- 10%. Despite the determination of multiple reference points our study revealed that this information was inadequate to predict doses to the entire rectum and bladder. If conventional methods are used for dosimetry it is recommended that doses to the bladder base should be routinely calculated, since single point measurements at the bladder neck seriously underestimate the dose to the bladder. Also the rectal dose should be determined at several points over the length of the implant due to the wide range of anatomic variations possible.

Prognostic factors in patients with carcinoma of the uterine cervix treated with external beam irradiation and IR-192 high-dose-rate brachytherapy

PURPOSE Prognostic factors in cancer of the cervix for patients treated with external beam irradiation (EBR) and low-dose-rate (LDR) brachytherapy have been characterized. However, despite the increasing use of high-dose-rate (HDR) intracavitary placements (ICP), few studies with adequate follow-up have analyzed prognostic factors. This study investigates pretreatment and treatment factors for their correlation with treatment outcome after EBR and HDR-ICP. METHODS AND MATERIALS Between September 1985 and December 1994, 181 patients with carcinoma of the cervix FIGO stages IB-IV received EBR and HDR brachytherapy. Hemoglobin (Hb) levels were maintained above a level of 11 g/dl during the treatment by transfusion. Patient age ranged from 34 to 84 years (median: 66). The median follow-up time for patients at risk is 69 months (range: 23-140). Pretreatment and treatment parameters analyzed to determine their prognostic value included age, FIGO stage, tumor size, tumor type and grade, pretreatment Hb level, number of HDR-ICP, total dose from HDR-ICP, overall dose to point A, and overall treatment time. Also evaluated was the prognostic value of enlarged lymph nodes noted on pretreatment CAT scan of the abdomen and pelvis. Endpoints studied in uni- and multivariate analyses were disease-specific survival (DSS), freedom from disease (FFD), pelvic control (PC), and probability of distant metastases (DM). RESULTS At 5 years the DSS, FFD, and PC rates for all patients were 60%, 58%, and 67%, respectively. The 5-year FFD by stage was: IB: 94%; II: 63%; IIIB: 43%; and IV: 0%. The PC rates were 94%, 66%, 59%, and 0%, respectively. In univariate analysis the prognostic factors identified for FFD were FIGO stage, tumor size, initial Hb level, and enlarged pelvic and/or paraaortic nodes (all: p < 0.0001). Age was inversely correlated with outcome (p = 0.0081). The 5-year FFD rates for tumors (< 3, > or = 3 < 6, > or = 6 cm) were 97%, 65%, and 24%; patients with initial Hb levels < or = 11g/dl had a FFD of 26% versus 69% for patients with levels > 11g/dl; and those with pelvic and/or paraaortal nodes > or = 1 cm had a survival of 32% versus 68% in patients with negative readings. The same factors were also prognostically significant for DSS, PC, and DM. Patients with persistent disease or pelvic failures had a significantly higher incidence of DM than patients in whom pelvic disease was controlled (p < 0.0001).Histological and treatment parameters including overall treatment time were not of prognostic significance for any of the endpoints studied. In multivariate analysis tumor size was the most powerful parameter for DSS, FFD, PC (p < 0.0001) and DM (p = 0.0001), followed by low initial Hb level (DSS: p = 0.0004, FFD: p = 0.0009, PC: p = 0.0012, DM: p = 0.0265), and enlarged pelvic and/or paraaortic nodes which were predictive for DSS (p = 0.0210) and DM (p = 0.0011). CONCLUSION This study confirms that prognostic factors for patients treated with HDR brachytherapy are similar to those reported in previous series that employed LDR brachytherapy. The significance of tumor size, pretreatment Hb level, and enlarged pelvic and/or paraaortic lymph nodes on CAT scan over FIGO stage of disease were demonstrated. Future prospective trials should be undertaken to confirm the validity of these factors and to elucidate their therapeutic implications.

Hyperbaric oxygen – an effective tool to treat radiation morbidity in prostate cancer

PURPOSE We report the results of hyperbaric oxygen therapy (HBO) used in the treatment of radiation cystitis and proctitis following irradiation of prostate cancer. MATERIALS AND METHODS Between June 1995 and March 2000, 18 men (median age 71 years) with radiation proctitis (n=7), cystitis (n=8), and combined proctitis/cystitis (n=3) underwent HBO therapy in a multiplace chamber for a median of 26 sessions (range 2-60). The treatment schedule (2.2-2.4 atmospheres absolute, 60 min bottom time, once-a-day, 7 days a week) was set at a lower limit of 20 sessions; the upper limit was left open to symptom-related adjustment. Prior to HBO treatment, RTOG/EORTC late genitourinal (GU) morbidity was Grade 2 (n=3), Grade 3 (n=6) or Grade 4 (n=2); modified RTOG/EORTC late gastrointestinal (GI) morbidity was either Grade 2 (n=4) or Grade 3 (n=6). RESULTS Sixteen patients underwent an adequate number of sessions. RTOG/EORTC late GU as well as modified GI morbidity scores showed a significant improvement after HBO (GI, P=0.004; GU, P=0.004; exact Wilcoxon signed rank test); bleeding ceased in five out of five patients with proctitis and in six out of eight patients with cystitis; one of those two patients, in whom an ineffective treatment outcome was obtained, went on to have a cystectomy. CONCLUSIONS HBO treatment seems to be an effective tool to treat those patients with late GI and GU morbidity when conventional treatment has led to unsatisfactory results. Particularly in patients with radiation cystitis, HBO should not be delayed too long, as in the case of extensive bladder shrinkage improvement is hard to achieve.

Carcinoma of the cervix: analysis of complications after primary external beam radiation and Ir-192 HDR brachytherapy.

BACKGROUND AND PURPOSE There is still a concern that the use of HDR brachytherapy might result in an increase of late tissue damage. This restrospective study evaluates the incidence and severity of late complications in patients with carcinoma of the cervix who underwent combined external beam radiation (EBR) and Ir-192 HDR brachytherapy and attempts to identify pretreatment and treatment parameters correlating with late complications. MATERIAL AND METHODS Between 1985 and 1992, 161 patients with carcinoma of the cervix (FIGO stages IB-IVB) received EBR to the pelvis (ave, max. dose 48.8 Gy) followed by 1-6 Ir-192 HDR placements (median 2). Doses to point A ranged from 8.5 to 38.7 Gy (median 17 Gy). Parameters examined included age, diabetes, obesity, history of inflammatory bowel disease or diverticulitis, prior surgery, hemoglobin level, FIGO stage, EBR dose, technique and daily dose fraction, number of HDR treatments and total dose to point A, maximum doses to bladder and rectum delivered by brachytherapy and cumulative dose to point A. Median follow-up for all patients was 37 months. Complications were rated using an in-house scoring system and according to the French-Italian Glossary (FIG). RESULTS Actuarial 5-year survival was 93%, 57%, 46%, and 0% for stages IB, II, IIIB, and IV, respectively. Of 161 patients, 11% developed moderate and 3.7% severe sequelae (FIG: 2.5%, 3.7%). Since some patients experienced more than one complication, the overall incidence was 13.6% and 4.9% (FIG: 3.1%, 4.9%) with respective 5-year actuarial rates of 14% and 5% for moderate, and 2% and 8% for severe bowel and genitourinary tract complications (FIG: 3.5%, 0, and 2%, 8%). All severe bowel complications occurred within 1.5 years whereas urinary tract sequelae continued to develop throughout the follow-up period. FIGO stage was associated with a significant increase in late sequelae (P = 0.015). Analysis of the remaining pretreatment and treatment parameters failed to reveal any statistically significant correlation with moderate or severe sequelae. CONCLUSION In our series using HDR brachytherapy, complication and survival rates were comparable with other series employing either LDR or HDR procedures. Of all parameters analysed, stage of disease was the only parameter significantly correlated with complications in univariate and multivariate analysis.

Radiotherapy for invasive thymoma and thymic carcinoma. Clinicopathological review.

PurposeThis study reports clinicopathological features and outcome of thymic tumors. Twenty-seven patients with invasive thymoma and 6 patients with thymic carcinoma who had received radiotherapy either primary or postoperatively were analyzed retrospectively.Patients and MethodsAll 33 patients were irradiated with a mean dose of 50 Gy after complete resection (16 patients), partial resection (9 patients) or biopsy (8 patients). Staging was done according to the Masaoka classification; there were 12 Stage II, 12 Stage III and 9 Stage IV patients.ResultsIn patients with invasive thymoma Stage II to IV (median follow-up 54.4 months) Kaplan-Meier estimates of overall survival (OS), disease-specific (DSS) and disease-free survival (DFS) at 5 years were 63.7% (95% confidence interval [CI], 42 to 84%), 88.3% (CI, 75 to 100%) and 77.4% (CI, 58 to 95%), respectively. Among the prognostic factors tested, such as age, myasthenia gravis, completeness of surgery and histologic subclassification, total radiation dose, and Masaoka Stage, the latter was the only significant predictor of improved survival (p = 0.04). Considering local control, radiation dose was a significant prognostic factor (p = 0.0006). In patients with thymic carcinoma (median follow-up 43.4 months) 5-year DSS, and DFS were 22.2% (CI, 0 to 60%) and 16.7% (CI, 0 to 46%), respectively. Thymoma as compared to thymic carcinoma had a statistically significant better DSS (p = 0.007) and DFS (p = 0.0007).ConclusionPostoperative radiotherapy with sufficient doses plays an important role as adjuvant treatment in complete or incomplete resected invasive Stage II to III thymoma. In unresectable thymoma Stage III to IV as well as in thymic carcinoma a multimodality approach should be considered to improve survival.ZusammenfassungZielBericht über 27 Patienten mit invasivem Thymom und sechs Patienten mit Thymuskarzinom nach primärer oder postoperativer Strahlentherapie unter besonderer Berücksichtigung der pathohistologischen Befunde und klinischen Ergebnisse.Patienten und MethodenAlle 33 Patienten wurden nach kompletter Resektion (n = 16), Teilresektion (n = 9) oder Biopsie (n = 8) mit einer mittleren Dosis von 50 Gy (30 bis 60 Gy) bestrahlt. Die Stadieneinteilung nach Masaoka (Tabelle 1) ergab jeweils zwolf Patienten in Stadium II und III sowie neun Patienten im Stadium IV (Tabelle 2).ErgebnissePatienten mit einem invasivem Thymom Masaoka-Stadium II bis IV (mediane Nachsorgezeit 54,4 Monate) hatten ein Fünf-Jahres-Gesamüberleben, krankheitsspezifisches und krankheitsfreies Überleben von 63,7% (95%Konfidenzintervall [KI] 42 bis 84%), 88,3% (KI 75 bis 100%) sowie 77,4% (KI 58 bis 95%). Bei den untersuchten prognostischen Faktoren, wie Alter, Myasthenia gravis, chirurgische Radikalität, histologische Subgruppe, Bestrahlungsdosis und Masaoka-Stadium, hatte nur letzteres einen stätistisch signifikanten Einfluß auf das Überleben (p = 0.04). (Tabelle 8). Bei alleiniger Berücksichtigung der lokalen Kontrolle war die Bestrahlungsdosis ein stätistisch signifikanter prognostischer Parameter (p = 0,0006) (Tabelle 7). Patienten mit Thymuskarzinom (mediane Nachsorgezeit 43,3 Monate) hatten ein krankheitsspezifisches und krankheitsfreies Fünf-Jahres-Überleben von 22,2% (KI 0 bis 60%) sowie 16,7% (KI 0 bis 46%). Patienten mit Thymomen hatten im Vergleich zu Patienten mit Thymuskarzinomen sowohl ein statistisch signifikant besseres krankheitsspezifisches (p = 0,007) als auch krankheitsfreies Überleben (p = 0,0007) (Abbildung 1).SchlußfolgerungPostoperative Strahlentherapie mit adäquater Dosis spielt eine wichtige Rolle als adjuvante Therapie bei inkomplett und komplett resezierten invasiven Thymomen Stadium II bis III. Bei primär inoperablen Thymomen und bei Thymuskarzinom sollte ein multimodales Vorgehen in Erwägung gezogen werden, urn die Überlebensraten zu verbessern.

Adjuvant radiotherapy in male breast cancer

PURPOSE To determine retrospectively the outcome of postoperative radiation therapy in male breast cancer. Local/distant control was assessed with attention to age, stage, lymph node involvement, histopathological differentiation and hormone receptor status. MATERIALS AND METHODS Thirty-one male patients were irradiated postoperatively at the chest wall (mean dose 50 Gy) and 16 patients received radiation to regional lymph nodes. Tumour distribution by stage was: stage 0 (9.7%), stage I (22.6%), stage II (32.2%) and stage III (35.5%). Nine patients were subjected to additional hormone therapy and three patients to chemotherapy. RESULTS Local control was achieved in 30/31 (96.8%) patients. Kaplan-Meier estimates of overall survival (OS), disease specific (DSS) and disease free survival (DFS) at 5 years were 77% (95% confidence interval (CI), 0.61-0.93), 84% (CI, 0.69-0.98) and 73% (CI, 0.57-0.91), respectively. Five-year DFS for stage 0 + I, II and III was 100, 56.3 and 67.3%, respectively. Favourable results were observed in patients with negative axillary nodes with 5-year OS/DFS of 90.9% (CI, 0.74-1.0). For lymph node positive patients DFS was 71% (CI, 0.4-1.0). Patients who presented lymph node metastases with extracapsular extension the 5-year OS was 80% (CI, 0.45-1.00), but the DFS was 0%. Stage of disease, lymph node involvement and histological differentiation were found to have statistically significant influence on DFS, but not on OS. CONCLUSION Application of postoperative radiotherapy approved in females resulted in one local relapse in our study population. Other treatment modalities (hormone therapy/chemotherapy) should continue to be considered a necessary treatment option for appropriately selected patients.

Postprostatectomy radiotherapy for high-risk prostate cancer

OBJECTIVES To assess the biochemical and clinical results of postprostatectomy radiotherapy (RT) for high-risk, mostly non-rgan-confined prostate cancer. METHODS After radical prostatectomy, 66 consecutive patients received either adjuvant (n = 29) or therapeutic (n = 37) postoperative RT. Therapeutic RT was given for persistently elevated postoperative prostate-specific antigen (PSA) levels (n = 14), gradually rising PSA levels (n = 6), or clinical local recurrence (n = 17). The selection of time and referral for RT was at the discretion of the treating urologists. RESULTS The mean and median follow-up after surgery was 56.8 and 54.2 months, and after radiotherapy, it was 43.2 and 35.0 months, respectively. At 5 years, the actuarial biochemical control for the whole collective was 59.7% (95% confidence interval [CI] 43.3% to 72.8%). Patients treated with adjuvant RT had statistically improved biochemical control (85.2% versus 34.0%, P = 0.001), but not disease-free survival (91% versus 73%, P = 0.09). Advanced tumor stage (pT3b-4) (relative risk 16.6; 95% CI 0.9 to 313.3; P = 0.01), poorly differentiated histologic features (relative risk 4.63; 95% CI 1.8 to 12.2; P = 0.001), and pre-RT PSA (relative risk 1.15, 95% CI 1.06 to 1.25; P = 0.003) were associated with a statistically significant increased risk of biochemical failure. CONCLUSIONS Although adjuvant postoperative RT resulted in improved biochemical control, no significant difference in disease-free survival has been obtained to date. It therefore remains to be determined whether the better biochemical control observed will ultimately translate into a survival benefit after longer follow-up and prospective trials.

Radiotherapy as Adjunct to Surgery for Malignant Carotid Body Paragangliomas Presenting with Lymph Node Metastases

Purpose: Three cases of malignant carotid body paragangliomas with nodal metastases are reported. Patients and Methods: Between 1985 and 1994, 3 female patients (51 to 65 years of age) were referred for postoperative radiotherapy after complete (2) or incomplete (1) surgical excision of a malignant carotid paraganglioma (Shamblin III). Preoperative angiographic embolization of the tumor-supplying arteries was performed in all cases. In 2 patients resection of the internal carotid artery and reconstruction by saphenous vein graft was necessary. Continuous course radiotherapy of the tumor bed (50 to 56 Gy/2 Gy) and regional lymph nodes (50 Gy) using photon beams was delivered in 2 patients. The third patient having had incomplete resection cancelled radiotherapy after 4 Gy. Results: Within an observation time of 110 and 119 months no evidence of recurrence was obtained in both patients irradiated postoperatively. The third patient died of progressive disease. Twelve months after the withdrawn irradiation she presented with a tumor progression into the brain and an ulcerated mass on the right side of the neck and was irradiated consecutively for palliation (Figures 1a to 1f). In none of the patients severe acute or late radiation-induced complications were observed. Conclusion: In patients with malignant paraganglioma moderate dose postoperative radiotherapy of the tumor bed and regional lymph nodes is well tolerated. It seems to be effective to prolong local control after surgery, to eradicate microscopic lymphatic disease and eventually to postpone further spreading.Hintergrund: Bericht über drei Patienten mit einem malignen Paraganglioma caroticum mit histologisch verifizierten regionären Lymphknotenmetastasen. Patienten und Methode: Zwischen 1985 und 1994 wurden drei Patientinnen (Alter 51 bis 65 Jahre) nach kompletter (zwei) bzw. inkompletter (eine) Resektion eines malignen Paragangliome caroticum (Shamblin III) zur postoperativen Bestrahlung zugewiesen. Präoperativ war bei allen drei Patientinnen eine angiographische Embolisation durchgeführt worden, um den intraoperativen Blutverlust zu vermindern. In zwei Fällen war eine Rekonstruktion der Arteria carotis interna mittels Saphenusinterponat notwendig. Bei allen drei Patientinnen war eine postoperative Bestrahlungsserie vorgesehen, doch diese wurde nur bei zwei Patientinnen zu Ende geführt. Bestrahlt wurde das Tumorbett mit Sicherheitssaum (50 bzw. 56 Gy/2 Gy) und der regionale Lymphabfluss (50 Gy/2 Gy). Die dritte Patientin, bei der nur eine inkomplette Resektion möglich gewesen war, brach die Bestrahlung nach 4 Gy ab. Resultate: Nach einer Nachbeobachtungszeit von 110 bzw. 119 Monaten waren die beiden postoperative bestrahlten Patientinnen tumorfrei. Die dritte Patientin verstarb am lokalen Tumorprogress; zwölf Monate nach Abbruch der Bestrahlung war es zu einem ausgedehnten Tumorwachstum mit Infiltration bis in das Hirn und zu exulzerierten Lymphknotenmetastasen gekommen, sodass zu diesem Zeitpunkt nur mehr eine Bestrahlung in palliativer Intention möglich war (Abbildungen 1a bis 1f). Bei keinem Patienten traten schwere akute oder chronische bestrahlungsbedingte Nebenwirkungen auf. Schlussfolgerung: Die mit moderaten Dosen durchgeführte adjuvante Bestrahlung des Tumorbettes und des regionalen Lymphabflussgebietes wurde gut toleriert. Die postoperative Bestrahlung scheint zur Erhaltung der lokalen Kontrolle beizutragen, durch die Sterilisierung von Mikrometastasen in den regionalen Lymphknoten könnte eventuell eine weitere Metastasierung verzögert werden.

“Adjuvant” external radiation of the mediastinum in radically resected non-small cell lung cancer

OBJECTIVE The effect of postoperative external beam radiation in MO non-small cell lung cancer resected with curative intention was evaluated in a randomized trial. METHODS In 155 patients (121 males, 34 females; mean age: 59 years) 105 lobectomies, 12 bilobectomies and 38 pneumonectomies with radical lymph node dissection to the contralateral side were carried out. Histology revealed squamous cell (n = 68), adeno- (n = 53), large cell (n = 21), adenosquamous (n = 6) or bronchioloalveolar type (n = 7) carcinomas. The pathologic stages T1 (n = 38), T2 (n = 89), T3 (n = 28); NO (n = 39), N1 (n = 67), and N2 (n = 49) were evenly distributed between the two treatment groups: group A (72 patients) had no further oncologic treatment, while group B (83 patients) had external beam radiation to the mediastinum (50-56 Gy, 8 or 23 MeV photons, 2 Gy/day, 5 days a week) beginning 4 weeks after the operation. RESULTS The overall 5-year survival rate of the whole collective was 24.1% without any significant difference between the radiotherapy group B (29.7%) and the control group A (20.4%) (log-rank test: P > 0.05). The overall 5-year recurrence-free survival rate was 20.1%, with no difference between groups B and A (radiotherapy: 22.7, controls: 15.6%, long-rank test: P > 0.05). There was no difference in the incidence of distant metastases (external beam radiation: n = 32; controls: n = 38). The rate of local recurrences at the bronchial stump or in the mediastinum, however, was significantly reduced in the radiotherapy group (n = 5) compared with 17 in the controls (P < 0.01 chi-square test). A multivariate analysis confirmed the independent influence of postoperative radiotherapy on the incidence of local recurrence. CONCLUSIONS External radiation of the mediastinum in radically resected non-small cell lung cancer reduces the risk of local recurrence, but has no influence on distant metastastic spread and overall survival.

Regional nodal recurrence in the management of breast cancer patients with one to three positive axillary lymph nodes: Outcome of patients following tangential irradiation without a separate nodal field

Purpose:To examine the prognosis of breast cancer patients (T1–3, one to three positive axillary lymph nodes) and locoregional failure rate after breast-conserving therapy/modified radical mastectomy and adequate axillary dissection following tangential radiotherapy without irradiation of the regional lymph nodes.Patients and Methods:From 1994 to 2002, the medical records of 183 breast cancer patients (T1–3, one to three involved axillary lymph nodes) were examined in order to identify those experiencing regional nodal recurrence, with or without local recurrence. The median age of the patient population was 58 years (range, 28–86 years). All patients underwent surgical treatment, either breast-conserving therapy (n = 146) or modified radical mastectomy (n = 37). The median number of lymph nodes removed was twelve (range, seven to 26 nodes). Irradiation was given to the breast through tangential fields. Chemotherapy was administered to 101 patients (55%), hormonal therapy to 124 (60%), and combined systemic treatment to 47 (26%).Results:The median observation time was 44.4 months (range, 11–102 months). Of the 14 patients (7.7%) with a relapse, six (3.3%) had a local recurrence, five (2.8%) a regional relapse, and three (1.6%) a simultaneous recurrence. Nine out of 14 patients with locoregional relapse developed distant failure subsequently and seven of them (78%) died of the disease.Conclusion:Regional recurrence is uncommon among patients with one to three positive axillary lymph nodes treated with surgery, adequate axillary dissection, and tangential field irradiation only. The authors conclude that regional nodal irradiation should not routinely be given following adequate axillary dissection when only one to three lymph nodes are positive.Ziel:Prognose und lokoregionäre Rezidivrate von Patientinnen mit Mammakarzinom (T1–3, ein bis drei positive axilläre Lymphknoten) nach brusterhaltender Therapie bzw. modifizierter radikaler Mastektomie und adäquater axillärer Dissektion. Ergebnisse nach tangentialer Bestrahlung ohne separates nodales Feld.Patienten und Methodik:Zwischen 1994 und 2002 wurden 183 Patientinnen mit Mammakarzinom (T1–3, ein bis drei positive axilläre Lymphknoten) im Hinblick auf ihre Rezidivrate (lokal bzw. lokoregionär) untersucht. Das mediane Alter lag bei 58 Jahren (Bereich: 28–86 Jahre). Alle Patientinnen wurden im Rahmen des Primäreingriffs (n = 146 brusterhaltende Operation; n = 37 modifizierte radikale Mastektomie) einer axillären Dissektion unterzogen. Im Durchschnitt wurden zwölf axilläre Lymphknoten entfernt (Bereich: sieben bis 26 Lymphknoten). Die postoperative adjuvante Strahlentherapie erfolgte über zwei tangentiale Stehfelder ohne separates nodales Feld. Bei 101 Patientinnen (55%) wurde zusätzlich eine Chemotherapie angewendet, bei 124 (60%) eine Hormontherapie und bei 47 (26%) eine kombinierte Systemtherapie.Ergebnisse:Die mediane Nachbeobachtungszeit lag bei 44,4 Monaten (Bereich: 11–102 Monate). Von den 14 Patientinnen (7,7%) mit Rezidiven hatten sechs (3,3%) ein lokales, fünf (2,8%) ein isoliertes regionäres und drei (1,6%) ein simultanes lokales und regionäres Rezidiv (Tabelle 2). Neun von 14 Patientinnen mit lokoregionärem Rezidiv entwickelten Fernmetastasen, und sieben der neun Patientinnen (78%) verstarben an den Folgen der Generalisierung.Schlussfolgerung:Das lokoregionäre Rezidiv ist bei Patientinnen mit Mammakarzinom (T1–T3, ein bis drei positive Lymphknoten) nach chirurgischer Intervention mit adäquater axillärer Dissektion und tangentialer Bestrahlung ein seltenes Ereignis. Aufgrund ihrer Ergebnisse empfehlen die Autoren für Patienten mit ein bis drei positiven axillären Lymphknoten nach adäquater axillärer Dissektion die tangentiale Bestrahlung der Restbrust bzw. der Thoraxwand ohne zusätzliches nodales Feld.