Heinrich Schüller

Intensity-modulated radiotherapy of the prostate: Dynamic ADC monitoring by DWI at 3.0 T

BACKGROUND AND PURPOSE Diffusion weighted imaging (DWI) as a functional MR technique allows for both qualitative and quantitative assessment of tumour cellularity and changes during therapy. The objective of this study was to evaluate changes of apparent diffusion coefficient (ADC) in biopsy proven prostate cancer (PCa) under intensity modulated radiotherapy (IMRT) at 3T. MATERIAL & METHODS Thirteen patients with biopsy proven PCa treated with intensity modulated external beam radiotherapy (IMRT) underwent four standardized MR examinations after approval of the local institutional review board. These included DWI at 3T on a strict time table: before, in between, directly after (between 1 and 4 days after the last radiation), as well as 3 months after IMRT. Quantitative analysis of two different ADCs, - the ADC(0,800) and the ADC(50,800), was performed dynamically over 4 time points in PCa, gluteal muscle and healthy prostate tissue. RESULTS In PCa, a significant increase of ADC(0,800)/ADC(50,800) values was measured under IMRT by about 16%/15% (P=0.00008/0.00017), 21%/21% (P=0.00006/0.00030), and 33%/34% (P=0.00004/0.00002) at the three time points compared to initial value. Healthy prostate tissue did not show any significant increase. CONCLUSION DWI is suitable as a biomarker for radiation therapy response of PCa by allowing the dynamic monitoring of treatment effectiveness.

State-of-the-art classification and multimodality treatment of malignant thymoma

Thymomas are the most common tumors of the anterior mediastinum. Classification, treatment options and understanding of the pathophysiology of thymoma have changed over the past years. It is hoped that novel therapeutic strategies will lead to a survival benefit in these patients. It has turned out that patients with thymoma are best treated with multimodality therapy. In this review, a pathologist, an immunologist, a surgeon, a radiotherapist, a pneumologist and oncologists discuss the current status of classification and strategies for the treatment of thymoma patients.

X-ray diagnosis of impacted upper canines in panoramic radiographs and computed tomographs.

Ten orthodontists were asked to diagnose the number of impacted upper canines and the number of resorbed lateral and/or central incisor roots in 30 panoramic radiographs (P1) from 30 patients. In order to objectify these diagnoses, transversal CT images of all 30 patients were examined in addition.Addition of the recordings in the 30 patients revealed that the 10 orthodontists had diagnosed 350 impacted/displaced canines. On comparison of the P1 and CT results, the latter revealed that, in fact, 390 canines were impacted or displaced, not just 350. Addition of the recordings further showed that, based on P1, the investigators had diagnosed 73 resorptions in the 1,200 incisors examined. However, the CT showed 160 resorptions; this corresponds to a sensitivity value of 45.6%. The CT showed 1,040 incisors with no resorptions, whereas the investigators diagnosed only 925, teeth as not resorbed in the P1. The specificity was thus 88.9%.These results show that, due to their low reliability, panoramic radiographs are not an appropriate means of diagnosing resorptions in front teeth in connection with impacted canines.ZusammenfassungAn 30 Panoramaaufnahmen (P1) von 30 Patienten sollten von zehn Kieferorthopäden die Anzahl retinierter oberer Eckzähne sowie die Anzahl resorbierter seitlicher und/oder mittlerer Schneidezahnwurzeln angegeben werden. Für eine Objektivierung dieser Diagnosen standen uns dazu von allen 30 Patienten transversale CT-Schnittbilder zur Verfügung.Beim Addieren der Befunde von den 30 Patienten diagnostizierten die zehn Kieferorthopäden 350 retinierte/verlagerte Eckzähne. Bei einem Vergleich dieser Befunde anhand der P1 und der CT hätten 390 Eckzähne retiniert/verlagert sein müssen und nicht nur 350. Das Addieren der Befunde anhand der P1 zeigte weiterhin, daß von 1 200 Schneidezähnen nur 73 als resorbiert beurteilt wurden. Nach der Beurteilung der CT waren es aber 160 Resorptionen. Die Werte für die Sensitivität betrugen demnach 45,6%. Von den 1 040 Schneidezähnen, die laut CT keine Resorption aufwiesen, erkannten die Untersucher nur 925 als nicht resorbiert. Somit betrug der Wert für die Spezifität 88,9%.Die Ergebnisse zeigten, daß infolge zu geringer Zuverlässigkeit die Panoramaschichtaufnahme nicht zur Diagnostik von Wurzelresorptionen an Schneidezähnen durch retinierte Eckzähne geeignet ist.

[The maxillary sixth-year molar and its relation to the maxillary sinus. A comparative study between the panoramic tomogram and the computed tomogram].

Panoramic radiographs (OPGs) and computer tomograms (CTs) of 30 patients, the latter taken on average 2.5 months later, were evaluated for the purpose of comparing the relation of their roots to the bottom of the maxillary sinus. The CT and OPG images yielded significant differences in the topographic relations between the roots and the maxillary sinus. In the OPG 64 out of 129 roots seemed to penetrate the maxillary sinus. In the CT transversal slices, on the other hand, penetration could be observed for only 37 roots. This phenomenon became more apparent when the relations between the mesial, distal, buccal, and oral root surfaces and their relations to the sinus were assessed. Applying a three stage scoring scheme, it was found that in the large majority of cases only the apices were in contact with the mucosa of the sinus. Thus, the possible loss of anchorage in these cases is below five percent.ZusammenfassungVon 30 Patienten wurden die konventionellen Panoramaschichtaufnahmen (OPG) mit im Durchschnitt 2,5 Monate später erstellten Transversalbildern von Computertomogrammen (CT) ausgewertet und die Beziehung der Sechsjahrmolarwurzeln zur Kieferhöhle in beiden Darstellungen verglichen. Zwischen OPG und CT ergaben sich erhebliche Unterschiede: Weder die Eindringtiefe noch die Anzahl der Wurzeln, die im Kontakt mit der Kieferhöhlenkortikalis standen, zeigten eine Übereinstimmung. Nach einem dreistufigen Einteilungsraster befanden sich im OPG von 169 Wurzeln 64 in der Kieferhöhle, im CT dagegen nur 37 Wurzeln. Deutlich wurde der teilweise krasse Gegensatz zwischen der Stufenzugehörigkeit im Röntgenbild und der Wurzel-Kieferhöhlen-Beziehung im CT erst bei der differenzierten wurzelflächenbezogenen Stufenzuteilung. Das OPG war nur sehr eingeschränkt geeignet, die Interaktion zwischen Molarenwurzeln und Kieferhöhle zu beurteilen. Durch die Divergenz der Molarenwurzeln stellten sich die strukturellen Beziehungen im CT wesentlich günstiger dar. Dennoch sollte die vorliegende Grenzsituation wegen der Nähe der Wurzeln zur vestibulären Kortikalis bei Verankerungsmaßnahmen bedacht werden.SummaryPanoramic radiographs (OPGs) and computer tomograms (CTs) of 30 patients, the latter taken on average 2.5 months later, were evaluated for the purpose of comparing the relation of their roots to the bottom of the maxillary sinus. The CT and OPG images yielded significant differences in the topographic relations between the roots and the maxillary sinius. In the OPG 64 out of 129 roots seemed to penetrate the maxillary sinus. In the CT transversal slices, on the other hand, penetration could be observed for only 37 roots. This phenomenon became more apparent when the relations between the mesial, distal, buccal, and oral root surfacess and their relations to the sinus were assessed. Applying a three stage scoring scheme, it was found that in the large majority of cases only the apices were in contact with the mucosa of the sinus. Thus, the possible loss of anchorage in these cases is below five percent.

Disclosing the cancer diagnosis: what contributes to patient satisfaction?

Despite the growing attention to the how, when and where of disclosing a cancer diagnosis, not all patients are satisfied with how the news is broken to them. As in German-speaking countries there is a lack of empirical studies on this subject, this analysis was conducted to determine how the cancer diagnosis was given in a German sample, and how satisfied the patients are with the disclosure experience. Patients and Methods: 162 outpatients received a self-report questionnaire focusing on their experiences with physician-patient communication when the diagnosis was disclosed. Results: Guidelines had been respected in most cases. 17% of patients were dissatisfied with the diagnosis disclosure. They reported a significantly shorter duration of the interaction, lack of privacy, deficits in understanding the information, and less emotional support by the physician. Conclusion: Adherence to guidelines of diagnosis disclosure in the German sample was fairly high. Respecting both informational and emotional needs is essential for patient satisfaction and can be taught in communication training.

Radiotherapy for age-related macular degeneration: Is there a benefit for classic CNV?

Aim: To evaluate the efficacy of radiotherapy in the treatment of subfoveal classic and occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD) under strict fixation control. Methods: Twenty-seven eyes of 27 patients with subfoveal CNV as a result of AMD were treated with a total dose of 20 Gy in 10fractions (10 well-defined, 17 occult). Fixation monitoring was achieved by installing a TV camera with an attached fixation light 3 cm from the cornea of the eye being treated. Visual acuity and fluorescein angiography were obtained before and 6 months after treatment. Fifteen eyes of 15 patients served as controls (4 well-defined, 11 occult).Results: After 6 months the treated group showed an average decrease in visualacuity of 27%; the control group experienced a decrease of 31%. Membrane size increased by 56% in the treated group and by 28% in the control group. There was no statistically significant difference. Within the subgroup analysis, however, patientswith classic CNV suffered significantly less visual loss than in the control group.Conclusion: Radiation therapy under optimized treatment conditions by fixation monitoring failed to control further growth in membrane size in both classic and occult CNV. Regarding visual acuity, however, patients with classic CNV seem to benefit fromradiation treatment compared to the natural course.

Assessment of the space for the lower wisdom teeth

SummaryFrom 13 patients a computed tomograph (CT-scan) and a panoramic radiograph (Orthophos, program 1, P1) were examined with respect to the spatial conditions of the lower wisdom teeth. In the panoramic radiograph the available space for the third molars of the lower jaw was determined by calculating the ratio (Q) of 2 distances: the mesiodistal crown diameter and the retromolar space. In the axial CT 3 different positions of the third molar were distinguished: third molar located anterior to the ramus mandibulae=sufficient space, partially within the ramus=restricted space, totally within the ramus=deficient space. These positions were compared with the findings in the panoramic radiograph, firstly in relation to the ramus and secondly in relation to a line (L) perpendicular to the occlusal plane at the intersection of the anterior border of the ramus and the crista temporalis. Furthermore, the mesial rotation of the third molar was measured and the relation of the bony structures surrounding the teeth were described. Comparison of the CT results with the quotients of the P1 showed that, for those wisdom teeth molars with an available space above 50% to under 100%, any of the 3 CT gradings was found. Assessing the projection of the ramus over the third molar as seen in the P1, 60% of the P1- and CT-results corresponded. The relation between the line L and the third molar showed coincidence in 76% of all cases. These results and the mesial rotation of the wisdom teeth as well as their different relation to the bony environment are possibly important factors concerning their eruption prognosis. The three-dimensional CT-scan gives new posibilities for further investigations of third-molar problems.ZusammenfassungVon 13 Patienten standen je ein axial geschichtetes Computertomogramm (CT) des Unterkiefers und eine Panoramaschichtaufnahme (Orthophos, Programm P1) zur Verfügung. Die Platzverhältnisse für die Unterkieferweisheitszähne wurden in der P1-Aufnahme metrisch über die Quotientenbildung zweier Strecken bestimmt. Im CT wurden drei M3-Positionen unterschieden: der M3 lag vor dem Ramus mandibulae=ausreichendes Platzangebot, teilweise im Ramus=eingeschränktes Platzangebot, im kaudalen Abschnitt des Ramus=mangelhaftes Platzangebot. Diese M3-Positionen wurden den Weisheitszähnen in der P1-Aufnahme zugeordnet: in bezug zum Ramus und in bezug auf das Lot (L) (eine Vertikale zur Okklusionslinie im projektorischen Schnittpunkt des vorderen Ramusrandes mit dem Schatten der Crista temporalis). Am CT wurde zudem die mesiale Rotation der M3 gemessen und die Beziehung der M3 zu den umgebenden Knochenstrukturen beschrieben. Der Vergleich zwischen CT-Befund und dem Quotienten zeigte, daß für Weisheitszähne mit einem retromolaren Platzangebot im Quotientenbereich über 50% bis unter 100% jede der drei Weisheitszahnpositionen im CT vorkam. Beim Vergleich der M3-Befunde in bezug auf die Ramusüberprojektion in der P1-Aufnahme mit der Beurteilung im CT stimmten 60% der M3 mit dem CT-Befund überein. Wurde der M3 in bezug auf das Lot beurteilt, so erhöhten sich die mit dem CT übereinstimmenden Befunde auf 76%. Diese Befunde sowie die in der P1-Aufnahme nicht erkennbare Mesialrotation der M3 und ihre unterschiedliche Beziehung zur knöchernen Umgebungsstruktur ergaben neue Aspekte, die möglicherweise die M3-Durchbruchsprognose beeinflussen. Die dreidimensionale Betrachtungsweise mit dem CT bietet neue Möglichkeiten für weitere Untersuchungen der M3-Problematik.

Fixation monitoring during radiation therapy for subfoveal neovascularization

Abstract · Purpose: The aim of the study was to determine movement of the fovea during each irradiation session by monitoring movement of the cornea. Knowing the extent of foveal deviation permits minimization of the field size. · Methods: (1) Eye movement was monitored in 10 patients during irradiation. A TV camera with an attached fixation light was installed 3 cm away from the cornea of the treated eye. The fixation light was positioned at a 10° angle to the TV camera on the opposite side of the gantry, resulting in a 90° angle between the optical axis of the eye and the irradiation beam. (2) The relationship between movement of the anterior and posterior eye segments of 10 volunteers was examined using a scanning laser ophthalmoscope (SLO). Volunteers were asked to fix their gaze on positioning lights installed in the SLO. Gaze movements of the anterior and posterior eye segments were recorded simultaneously. · Results: (1) The patients’ ability to retain fixation differed interindividually. The median corneal deviation during 10 irradiation sessions was 1 mm medio-laterally and 0.7 mm craniocaudally. (2) Deviation of the fovea could be determined by monitoring deviation of the cornea. Measured by SLO, the correlation between movements of the anterior and posterior eye segments was 1:0.9 horizontally and 1:1.5 vertically. · Conclusion: (1) Irradiation field size can be reduced, depending on the patient’s fixation stability. (2) If monitoring reveals a foveal deviation beyond the 95% isodose, irradiation can be interrupted.

Prediction of Clinical Course of Glioblastomas by MRI during Radiotherapy

ZusammenfassungZiel:Trotz verbesserter therapeutischer Möglichkeiten ist der klinische Verlauf höhergradiger Gliome bislang unbefriedigend. Eine möglichst frühzeitige Abschätzung der Prognose könnte helfen, individuelle Therapieansätze zu finden. Ziel war es, zu eruieren, ob dies mithilfe von MRT-Verlaufskontrollen unter Strahlentherapie möglich ist.Patienten und Methodik:33 radiotherapeutisch behandelte Glioblastom-Patienten erhielten MRT-Verlaufskontrollen: vor Radiotherapiebeginn, nach ca. der Hälfte der Dosis (30 Gy), bei Radiotherapieabschluss (60 Gy) und in der Nachsorge. Die MRTUntersuchungsbefunde bei 30 und 60 Gy (drei Kategorien: Status idem, fraglicher Progress, Progress) wurden mit dem klinischen Verlauf über einen medianen Zeitraum von 11 Monaten korreliert.Ergebnisse:Nach 30 Gy zeigten 23/33 (70%) einen Status idem im MRT. 10/33 (30%) zeigten einen sicheren (n = 6) oder fraglichen Progress (n = 4). Diese Tumoren waren schneller progredient (weiterer Progress: 1 vs. 8 Monate nach Radiotherapieabschluss) und die Patienten verstarben früher (9 vs. 22 Monate) als diejenigen mit Status idem. Nach 60 Gy zeigten 14/33 Fällen (42%) einen sicheren (n = 8) oder fraglichen (n = 6) Progress. Ebenso wie bei der Kontrolle bei 30 Gy waren diese Tumoren schneller weiter progredient (1 vs. 9 Monate nach Radiotherapieabschluss) und die Patienten verstarben früher (9 vs. 22 Monate) als diejenigen mit Status idem.Schlussfolgerung:Die MRT-Verlaufskontrolle nach 30 Gy erlaubt eine Abschätzung der weiteren Prognose. Ergeben sich Hinweise auf einen Progress, verkürzt sich das mediane Überleben auf 9 Monate. Auf dieser Grundlage kann zu diesem Zeitpunkt eine Anpassung der Therapie diskutiert werden.AbstractPurpose:Determine the value of MR studies in patients undergoing radiotherapy for glioblastomas pre and during radiotherapy to predict the clinical course.Patients and Methods:MR follow-up studies were performed in 33 patients with glioblastomas before radiotherapy, after 30 Gy, after 60 Gy, and in the treatment follow-up. Findings on MR were categorized into: definite progress, questionable progress, status idem. Patients were followed clinically (median for 11 months).Results:After 30 Gy 23/33 (70%) of the MR examination showed status idem. 10/33 (30%) demonstrated definite (n = 6) or questionable (n = 4) progress. Further tumor progress was faster in these patients and patients succumb to their disease earlier (9 vs. 22 months). The 60 Gy study showed definite (n = 8) and questionable (n = 6) progress in 14/33 (42%) cases. All these tumors were progressing faster and were associated with a comparatively reduced life expectancy.Conclusion:MR follow-up studies after 30 Gy in patients undergoing radiotherapy for glioblastomas allow for prognostic appraisal, and potentially early modification of treatment.PURPOSE determine the value of MR studies in patients undergoing radiotherapy for glioblastomas pre and during radiotherapy to predict the clinical course. PATIENTS AND METHODS MR follow-up studies were performed in 33 patients with glioblastomas before radiotherapy, after 30 Gy, after 60 Gy, and in the treatment follow-up. Findings on MR were categorized into: definite progress, questionable progress, status idem. Patients were followed clinically (median for 11 months). RESULTS after 30 Gy 23/33 (70%) of the MR examination showed status idem. 10/33 (30%) demonstrated definite (n = 6) or questionable (n = 4) progress. Further tumor progress was faster in these patients and patients succumb to their disease earlier (9 vs. 22 months). The 60 Gy study showed definite (n = 8) and questionable (n = 6) progress in 14/33 (42%) cases. All these tumors were progressing faster and were associated with a comparatively reduced life expectancy. CONCLUSION MR follow-up studies after 30 Gy in patients undergoing radiotherapy for glioblastomas allow for prognostic appraisal, and potentially early modification of treatment.

Radiotherapy for age related macular degeneration causes transient lens transparency changes

AIM Evaluation of potential side effects of photon radiotherapy on the transparency of the lens. METHODS The anterior segments of 14 phakic eyes from patients suffering from subfoveal neovascularisation as a result of age related macular degeneration (AMD) were documented by Scheimpflug photography (Topcon SL-45, Kodak Tmax 400) before the start of radiotherapy as well as 6 and 12 months afterwards. All negatives were evaluated by microdensitometry, and peak heights for distinct layers of the lens were used for statistical comparison. External beam radiotherapy (6 MeV photons) consisted of a total dose of 20 Gy, delivered as 10 fractions of 2 Gy. RESULTS Six and 12 months following irradiation statistical comparison of the ratios in density change of lenses from irradiated versus non-irradiated fellow eyes revealed statistically significant (p⩽0.05) loss of transparency of layers 5 and 7 of the nuclear region. In layer 1 (capsuloepithelial complex) the changes were close to significance. At the 12 month examination, however, all of these significant changes had disappeared. CONCLUSION Six months following radiotherapy for AMD, both the anterior capsuloepithelial region and the nuclear layers showed precataractous changes. As most of these significant differences had disappeared after 12 months, it is obvious that these findings reflect acute radiation damage to the lens epithelial cells and an ionising effect on the proteins of the lens nucleus. Long term studies will have to be carried out to demonstrate whether or not this acute radiation damage, which is expressed as a transient increase in light scattering of some layers of the lens, actually does lead to permanent transparency changes, thus reflecting radiation cataractogenesis, and if so, after what time interval and to what extent cataract occurs.