E. van der Schueren

Causes of death after therapy for early stage Hodgkin's disease entered on EORTC protocols

The risk of dying from different causes after Hodgkins disease (HD) therapy has been quantified from a series of 1,449 patients with early stages included in four successive clinical trials conducted by the European Organization for Research and Treatment of Cancer (EORTC) Lymphoma Cooperative Group since 1963. Overall, 240 patients died and the 15-year survival rate was 69% whereas the expected rate was 95%. The standardized mortality ratio (SMR) technique was used to quantify excess deaths as a function of time since first therapy. At each interval, SMR was significantly increased, giving: 0–3 year, 8.86 (p < 0.001); 4–6 year, 9.25 (p < 0.001); 7–9 year, 7.08 (p < 0.001); 10–12 year, 9.53 (p < 0.001); 13–15 year, 4.37 (p < 0.01); and 16+ years, 3.80 (p < 0.05). While the proportion of deaths as a consequence of HD progression, treatment side-effect, and intercurrent disease decreased with time, that of second cancer and cardiac failure peaked during the 10–12 year post-treatment interval. After 15 years of follow-up, the risk of dying from causes other than HD continued to increase. These findings indicate that although probably cured from HD, patients are at higher risk for death than expected, a risk that might be a consequence of therapy.The risk of dying from different causes after Hodgkins disease (HD) therapy has been quantified from a series of 1,449 patients with early stages included in four successive clinical trials conducted by the European Organization for Research and Treatment of Cancer (EORTC) Lymphoma Cooperative Group since 1963. Overall, 240 patients died and the 15-year survival rate was 69% whereas the expected rate was 95%. The standardized mortality ratio (SMR) technique was used to quantify excess deaths as a function of time since first therapy. At each interval, SMR was significantly increased, giving: 0-3 year, 8.86 (p less than 0.001); 4-6 year, 9.25 (p less than 0.001); 7-9 year, 7.08 (p less than 0.001); 10-12 year, 9.53 (p less than 0.001); 13-15 year, 4.37 (p less than 0.01); and 16+ years, 3.80 (p less than 0.05). While the proportion of deaths as a consequence of HD progression, treatment side-effect, and intercurrent disease decreased with time, that of second cancer and cardiac failure peaked during the 10-12 year post-treatment interval. After 15 years of follow-up, the risk of dying from causes other than HD continued to increase. These findings indicate that although probably cured from HD, patients are at higher risk for death than expected, a risk that might be a consequence of therapy.

Black and white in accuracy assessment of megavoltage images: the medical decision is often grey

Using different criteria for acceptance of the portal film taken at the first treatment session, a comparison was made of the relevance of the information obtained from such a single check for the subsequent irradiations. A total number of 234 verification films have been taken on 29 fields for 27 head and neck patients. Patients were immobilised with individual plastic masks fixed to the couch and treated on a 6-MV linac fitted with an automatic verification system. Field alignment was checked with a measurement in the anteroposterior (AP) and craniocaudal (CC) direction on each film. Referring to the simulated field, this group of patients was treated with excellent average precision (mean, -0.7 mm) and reasonable spread (s = 5 mm). The percentage of large deviations (> or = 6 mm) occurring during the whole treatment course is proportional to the upper limit of deviation accepted in the first assessed field (for an upper limit < 6 mm): it goes progressively up from 5% (AP-CC direction) to 17% (AP) and 13% (CC) for accepted magnitudes of deviation going from 2 mm to 6 mm in the first film. As the reproducibility of the different treatment series (s = 2 mm) is independent of the upper level of error accepted on the first film, this means that errors are mainly systematic errors coming from the transfer of the simulation unit to the treatment unit. Precision in a series of set-ups is always expressed by a Gaussian curve.(ABSTRACT TRUNCATED AT 250 WORDS)

Minumum requirements for quality assurance in radiotherapy

(1) A quality assurance (QA) programme is a mandatory prerequisite when aiming at high dose, high precision radiotherapy. Such a programme includes procedures monitored by the local centre staff and procedures monitored by independent experts of the cooperative group. (2) The structure of a radiotherapy department should comply with minimum requirements to ensure the feasibility of that QA Programme. The following figures, expressed with workload (number of patients treated per year) can constitute a reasonable estimate, with some adjustments depending upon local organisation and upon the ratio of curative to palliative patients): (4) The methodology of QA in radiation physics is as follows.

Glottic Carcinoma Limited to the Vocal Cords

Radiation therapy is generally considered to be the best primary treatment for early glottic carcinoma, with surgery reserved for local failure. In a series of 150 cases of T1 glottic carcinoma 138 were given radiation alone. In these patients the survival was 88 per cent at 3 years and 77 per cent at 5 years. Local control remained unchanged at 82 per cent after 6 years. When the results of surgery are included, local control was raised to 93 per cent. Preservation of the larynx was obtained in 92 per cent of survivors. Local extension or radiation dose levels had no influence on local control. The optimum dose could be lower than generally recommended. Voice quality after radiation therapy is superior to postsurgical laryngeal function. Since survival rates are identical, radiation therapy alone is the treatment of choice in all early glottic carcinomas.

Chronic lymphocytic alveolitis with migrating pulmonary infiltrates after localized chest wall irradiation

In a number of patients, radiotherapy following surgery for breast carcinoma may induce radiation injury to the lungs. This has classically been divided into an early radiation pneumonitis and a late fibrosis, both confined to the irradiated lung volume. However we observed a female patient who similarly to other recent reports in the literature developed a recurring pneumonitis migrating from one lung to the other after radiotherapy for breast carcinoma. This migratory BOOP (bronchiolitis obliterans organizing pneumonia) was characterized by a lymphocytic alveolitis and responded well to corticosteroids. Clinicians should be aware of the possibility of a lymphocytic pneumonitis in both lungs after unilateral thoracic irradiation and recognize the distinctive features of fever, cough, dyspnoea and malaise in order to start an effective treatment with corticosteroids. They should also be aware of the high tendency for recurrence when tapering off.

Paget's disease of the male breast treated by radiotherapy

Breast cancer is a rare disease in men; the female: male ratio is around 100:1 (Treves, 1954; Haagensen, 1986). Aetiological factors in male breast cancer are obscure. A marked increase in its incidence has been reported in Klinefelters syndrome, a condition associated with diminished testosterone levels and an increased incidence of gynecomastia (Rosen et al, 1976; Erlichman et al, 1984). Pagets disease of the nipple is an early presentation of breast cancer (Nance et al, 1970). In this report, we describe a case in a 74-year-old patient. Since carcinoma of the male breast is a relatively rare malignancy, it is reasonable that the management of this disease should be based on the knowledge available for carcinoma of the female breast. Breast conserving treatment in females has been demonstrated to be equivalent to radical surgery. Therefore, we suggest that radiation therapy is the treatment of choice also in male patients with Pagets disease, as was done in the case reported. A 74-year-old man notice...

Radiotherapy of Malignant Gliomas

This chapter is restricted to selected aspects of radiation therapy of malignant gliomas. Extensive details on this topic have been reported in the recent literature and reviewed by other authors in this book, who provide numerous references.

Surgery for Breast Cancer

This issue of the Journal contains some results of two multicenter studies by the National Surgical Adjuvant Breast and Bowel Project,1 , 2 which go far toward defining a new rationale for surgical...

Quality assurance network in central Europe: External audit on output calibration for photon beams

The EROPAQ project for TLD monitoring of photon beams started in June 1994 with the set-up of the TLD system: calibration, reading and evaluation procedures. The acceptance level of +/- 3% was set for the TLD intercomparisons. The policy of the project was to check all beams in 47 participating radiotherapy centres and to recheck all the beams in those centres, where a deviation exceeding +/- 3% occurred in one or more of the beams. Out of 129 beams checked, 100 beams (78%) were found within the +/- 3% limit. Eleven beams show deviations larger than +/- 6%, and immediate corrective action was undertaken. Out of 47 centres checked, 22 did not participate in any external audit in a preceding 5 years. In these centres 68% (34/50) of the total number of gamma and x-ray beams checked but only 59% (20/34) of gamma beams were within the acceptance level, while in the 25 centres, which participated in an external audit before, these figures were 84% (66/79) and 88% (35/40) respectively. The sources of discrepancies were thoroughly investigated, discussed with the participants and the errors corrected. Poor results were in several cases associated with very old design of radiotherapy units and old dosimetry systems, equipped with inadequate ionization chambers. In several centres, an insufficient training of the physicists in clinical dosimetry was observed. Thanks to the corrective action, a great improvement of calibration of the beams was achieved. Standard deviation of the distribution of the results for all x and gamma beams checked decreased from SD = 7.4% at the first check to SD = 2.5% at the second check.

821 Glucose utilization and in vivo cell kinetics in rectal cancer, before and after preoperative radiotherapy

Patients with T3/T4 rectal cancers were injected i. v. with 400–555 MBq F–18 FDG. Dynamic imaging was immediately started. Maximum tumor glucose utilization was calculated. Cell kinetics were measured by flow cytometry 6–8 hrs after i. v. injection of IUdR. Two groups of patients were studied: 1) surgery only (nxa0=xa08); and 2) preoperative radiotherapy (30 Gy/10 fractions) followed by surgery (RT, nxa0=xa06). At baseline, TuGluc for group I was 280xa0±xa0141 (SD) nmo1/min/ml, and for group 2:269xa0±xa0161 (Pxa0=xa0NS). After RT, TuGluc decreased to 109xa0±xa061 (Pxa0>xa00.05). T pot was 3.50xa0±xa01.21 days for group I and 3.23xa0±xa02.23 days for group 2 before RT (Pxa0=xa0NS). A negative correlation was found between TuGluc and Tpot, suggesting increasing glucose utilization for faster dividing cells. After RT, Tpot did not change significantly (4.88xa0±xa03.80 days), whereas TuGluc fell significantly. In conclusion these results show a direct correlation between tumor cell metabolism and tumor cell proliferation in vivo. RT results in a decrease in TuGluc utilization indicating cell loss due to RT, because the proliferating cells don’t proliferate more slowly, and so should not have a smaller TuGluc.