I.A. Adamietz

Endovascular irradiation—A new method to avoid recurrent stenosis after stent implantation in peripheral arteries: Technique and preliminary results

PURPOSEnA high dose rate (HDR) afterloading technique for prevention of vascular stenosis or occlusion after percutaneous transluminal arteriography and subsequent stent implantation caused by intimal hyperplasia is presented.nnnMETHODS AND MATERIALSnThe frequency of recurrent stenosis or occlusion following implantation of stents into peripheral arteries is relatively high. The cause of relapse is rapid intimal hyperplasia. To prevent proliferation of the intimal layer, intravascular brachytherapy was performed in cases of recurrent vascular occlusion or severe stenosis. After recanalization by percutaneous transluminal angioplasty and stent implantation, a 9-French-ReKa catheter was placed within the lumen of the stent. This catheter served as a guide for a 5-French flexible applicator. Then after individual calculation of the isodose, 12 Gy were applied to the vessel wall. This procedure was followed by 72 h of heparinization. Follow-up by Doppler digital subtraction angiography and magnetic resonance imaging was done 3, 6, and 12 months after the procedure and later on once a year.nnnRESULTSnIntraluminal irradiation was performed in 13 patients (nine male and four female). All patients had a clinically relevant restenosis or reocclusion in the superficial femoral artery (clinical stage according to Fontaine IIb-III). Follow-up time ranged from 3-27 months. After irradiation the stented area remained patent in all cases and there were no signs of recurrent stenosis in the treated arterial segment.nnnCONCLUSIONnWith high dose rate 192Ir afterloading after percutaneous transluminal angioplasty and subsequent stent implantation restenosis or reocclusion caused by intimal hyperplasia can be prevented.

Prophylaxis with povidone-iodine against induction of oral mucositis by radiochemotherapy.

Oral mucositis is a frequent complication of radiochemotherapy. The origin of radiation-induced mucosal lesions is iatrogenic in nature, although further development of mucositis is essentially influenced by infection. It can be assumed that disinfection measures should decrease the severity of mucositis induced by radiochemotherapy. Therefore, in a prospective randomised study the efficacy of prophylactic oral rinsing with a disinfection agent was investigated. A randomised, prospective comparative trial was conducted with 40 patients undergoing radiochemotherapy of the head and neck region because of malignant disease. The treatment scheme consisted of irradiation to the tumour region and adjacent lymph nodes, with a total dose of 71.3u2009Gy, and simultaneous chemotherapy with carboplatin (60u2009mg/m2) on days 1–5 and 29–34. In all patients mucositis prophylaxis with nystatin, rutosides, panthenol and immunoglobulin was undertaken. In addition, 20 patients rinsed the oral cavity 4 times daily with povidone-iodine solution, while the group for comparison rinsed with sterile water. Clinical examination of the oral mucosa was performed weekly. Onset, grading and duration of mucositis were used as the main variables. Clinically manifest oral mucositis was observed in 14 patients in the iodine group (mean grading: 1.0) and in all 20 patients in the control group (mean grading: 3.0). The total duration (mean) of clinically observed mucositis was 2.75 weeks in treatment patients and 9.25 weeks in control patients. Median AUC (area under curve for grade vs duration) was 2.5 in the iodine rinsing patients and 15.75 in control patients. All differences found between the two groups were statistically significant. Increased iodine incorporation was not observed. A pathologic rise in thyroid hormone levels was not found in the iodine group. The results obtained indicate that incidence, severity and duration of radiochemotherapy-induced mucositis can be significantly reduced by oral rinsing with povidone-iodine in addition to the standard prophylaxis scheme. It can be concluded that rinsing with povidone-iodine is an easy, cheap and safe prophylactic method and can be recommended as a supportive treatment during antineoplastic treatment of the head and neck region.

Survival of very young children with medulloblastoma (primitive neuroectodermal tumor of the posterior fossa) treated with craniospinal irradiation

PURPOSEnVery young children with medulloblastoma are considered to have a worse prognosis than older children. As radiotherapy remains an important part of the treatment, the adverse prognosis could be due to inadequate radiation treatment rather than biological factors. We analyzed the published literature to examine the impact of radiotherapy on survival in this group.nnnMETHODS AND MATERIALSnA Medline search was performed and we reviewed studies of treatment of medulloblastoma where radiotherapy was delivered using megavoltage equipment and the minimum follow-up allowed the calculation of 5-year survival rates.nnnRESULTSnThirty-nine studies were published between 1979 and 1996 with a treatment including craniospinal irradiation and boost to the posterior fossa. Eleven studies comprising 1366 patients analyzed survival by age at diagnosis. Eight of 11 studies showed a worse 5-year survival for the younger patient group which reached statistical significance in two. There is also a suggestion of a higher proportion of children with metastatic disease at presentation in the very young age group. The usual policy in younger children was to give a lower dose of radiotherapy to the craniospinal axis (CSA) and posterior fossa (PF) with reduction of dose in the range of 15 to 25% compared to standard treatment. As dose reduction to the posterior fossa is associated with worse survival and local recurrence is the predominant site of failure, the major determinant of worse survival in very young children with medulloblastoma may be suboptimal radiotherapy. Protocols including postoperative chemotherapy with delayed, omitted, or only local tumor irradiation do not reach survival rates of protocols with standard radiotherapy, also suggesting a continued importance for irradiation.nnnCONCLUSIONnVery young children with medulloblastoma have a worse prognosis than older children. Inadequate radiation dose and technique to the primary tumor region may be a major contributing factor. Current chemotherapeutic regimes alone are not sufficient to compensate for reduced radiation doses and volumes.

The Use of a Standardized Positioning Support Cushion During Daily Routine of Breast Irradiation

PURPOSEnThe use of positioning and immobilization techniques during external beam irradiation of the female breast is time consuming and expensive. The currently available standardized positioning devices are insufficient. For this reason, we designed a new and generally useable hard foam positioning support cushion for the use during breast irradiation, and tested its clinical usefulness in a prospective study.nnnMETHODS AND MATERIALSnFifty-five female breast cancer patients receiving adjuvant radiotherapy following breast-conservative surgery were irradiated either without immobilization (n = 27) or with the positioning support cushion (n = 28). The time necessary for patient setup, the lying subjective comfort and--comparing portal images with simulator images--the reproducibility of the set up were determined.nnnRESULTSnIrradiation reproducibility was significantly improved (average deviation without positioning support cushion: 8.4 mm, with positioning support cushion: 6.1 mm, p < 0.001). The time required for the positioning of the patient with positioning support cushion was in average 73 s, without cushion it was 55 s. A significantly higher proportion of patients (72%) found the position with the positioning support cushion as pleasant, whereas only 46% of patients were pleased with the position without cushion.nnnCONCLUSIONnThe positioning support cushion designed in our department makes a substantial contribution to quality assurance in breast irradiation. It significantly increases the patients comfort in a supine position. In contrast to conventional positioning and fixation aids it may be quickly and easily applied at low costs. Therefore, its use can be recommended.

A Novel Technetium-99M Labeled Monoclonal Antibody (174H.64) For Staging Head and Neck Cancer by Immuno-Spect

A novel murine monoclonal antibody (MAb 174H.64) was labeled with 99mTc by a direct method. MAb 174H.64 detects a cytokeratin-associated antigen which is expressed by over 90% of all squamous cell carcinomas. Panendoscopy, sonography and computerized tomography scan were performed in all cases as well as magnetic resonance imaging (in selected patients). Pre-operative immunoscintigraphy was performed in 21 patients with histologically proven primary carcinomas (18 with remaining primary tumors and 3 with lymph node recurrences). Scintigraphic images were obtained 4-6 h after injection of 1.1 GBq of the 99mTc-labeled antibody (2 mg). Late images were acquired 18 to 24 h after injection. Single-Photon-Emission-Computed Tomography (SPECT) of the head and thorax was performed in all patients. The primary tumors were immunoscintigraphically visualized in all 18 patients with remaining primary tumor. Fifteen of 18 loco-regional lymph node metastases were visualized by immunoscintigraphy (the smallest lesions had a diameter of < 1 cm), in one patient lymph node metastases were detected by immunoscan only. Two metastatically involved lymph nodes were identified by histology only (micrometastases). Distant metastases were present in 3 patients, of which two were identified by immunoscintigraphy. Immuno-SPECT according to this method was a sensitive and specific imaging modality for preoperative staging of patients with squamous cell carcinoma of the head and neck and detected lymph node metastases with higher accuracy than conventional clinical and imaging modalities.

Comparison of two strategies for the treatment of radiogenic leukopenia using granulocyte colony stimulating factor

PURPOSEnRadiation-induced leukopenia can cause a delay or discontinuation of radiotherapy. This complication can be overcome with the use of granulocyte colony-stimulating factor (G-CSF). However, an uncertainty exists regarding the mode of application of G-CSF in patients treated with radiotherapy. For this reason, the efficacy of two strategies for the administration of G-CSF in irradiated patients was compared in a prospective randomized clinical study.nnnMETHODS AND MATERIALSnForty-one patients who developed leukopenia (< 2.5 x 10(9) per liter) while undergoing radiotherapy were treated with G-CSF at a daily dose of 5 microg/kg. The first group received single injections of G-CSF as required (n = 21). The second group received G-CSF on at least 3 consecutive days (n = 20). An analysis was made of the changes in leukocyte counts, the number of days on which radiotherapy had to be interrupted, and the side effects of growth-factor treatment.nnnRESULTSnAn increase in leukocyte values in the peripheral blood was observed in all patients treated with G-CSF. In the group which received G-CSF when required, two injections (range: 1-8) were administered in most cases. In the second group, most of the patients received three injections (range: 3-9). The average duration of therapy interruptions due to leukopenia was 4.8 days (0-28) in the first therapy arm and 2.5 (0-20) in the second arm. The variance in the duration of therapy interruptions between the two groups was not significant (p = 0.2). Radiotherapy had to be terminated in two patients due to thrombocytopenia but the application of G-CSF did not seem to be a reason of decreasing platelet counts.nnnCONCLUSIONSnOur results reveal that G-CSF is safe and effective in the treatment of radiation-induced leukopenia regardless of the mode of application. Because the calculated difference related to radiation treatment interruptions has no clinical relevance, both approaches examined in our study appear reasonable.

Prophylaxe der radiochemotherapeutisch bedingten Mukositis

BACKGROUNDnOral mucositis is a frequent complication of radiochemotherapy. The origin of radiation-induced mucosa lesions is of iatrogenic nature although further development of mucositis is essentially influenced by infection. It can be assumed that disinfection measures should decrease the severity of mucositis induced by radiochemotherapy. Therefore, in a prospective randomised study the efficacy of prophylactic oral rinsing with a disinfection agent was investigated.nnnPATIENTS AND METHODnAn open, randomised, prospective comparative trial was conducted with 40 patients undergoing radiochemotherapy of head and neck region due to malignant disease. The treatment scheme consisted of irradiation to tumor region and adjacent lymph nodes with a total dose of 71.3 Gy and simultaneous chemotherapy with carboplatin (60 mg/m2) on days 1 to 5 and 29 to 34. In all patients, a prophylaxis of mucositis with nystatine, rutosides, panthenol and immunoglobulin was undertaken. In addition, 20 patients rinsed oral cavity 4 times daily with povidone-iodine-solution, the comparative group rinsed with sterile water. Clinical examination of the oral mucosa was performed weekly. Onset, grading and duration of mucositis were used as main variables.nnnRESULTSnClinically manifested oral mucositis was observed in 14 patients of the iodine group (mean grading: 1.0) and all 20 patients of the control group (mean grading: 3.0). Total duration (mean) of clinically observed mucositis was 2.75 weeks in treatment patients and 9.25 in control patients. Median AUC (area under curve for grade vs duration) was 2.5 in iodine rinsing patients and 15.75 in control patients. All differences found between the 2 groups were statistically significant. Increased iodine incorporation was not observed. A pathological increase of thyroid hormone levels in the iodine group was not found.nnnCONCLUSIONSnThe gained results indicate that incidence, severity and duration of radiochemotherapy-induced mucositis can be significantly reduced by oral rinsing with povidone-iodine performed additionally to the standard prophylaxis scheme.ZusammenfassungHintergrundMukositis ist eine häufige Komplikation der Radiochemotherapie von Kopf-Hals-Tumoren. Obwohl der Ursprung von Mukosaläsionen iatrogener Natur ist, wird die weitere Entwicklung im wesentlichen durch die Infektion beeinflußt. Es ist deshalb anzunehmen, daß antiseptische Maßnahmen die Häufigkeit der radiochemotherapeutisch induzierten Mukositis herabsetzen. Aus diesem Grunde wurde in einer prospektiven, randomisierten Studie die Wirksamkeit der prophylaktischen Mundspülungen mit Polyvidon-Iod zur Vorbeugung der radiogenen Mukositis untersucht.Patienten und MethodeDie Untersuchung erfolgte in einer offenen, randomisierten, prospektiven Vergleichsstudie an 40 Patienten, die wegen maligner Erkrankung einer Radiochemotherapie im Kopf-Hals-Bereich unterzogen wurden. Das Therapieschema bestand aus Bestrahlung der Tumorregion und der Lymphabflußwege mit einer Gesamtdosis von 71,3 Gy sowie einer simultanen Chemotherapie mit Carboplatin (60 mg/m2 der Körperoberfläche) an den Tagen 1 bis 5 und 29 bis 34. Bei sämtlichen Patienten wurde eine Mukositisprophylaxe mit Nystatin, Rutosiden, Panthenol und Immunglobulin vorgenommen. Bei 20 Patienten erfolgte zusätzlich viermal täglich eine Mundspülung mit PVP-Iodlösung, 20 Patienten (Kontrollgruppe) spülten mit sterilem Wasser. Eine klinische Untersuchung der Mundschleimhaut erfolgte einmal wöchentlich. Als Zielvariablen dienten: Zeitpunkt des Mukositisbeginns, die Ausprägung und Dauer der Mukositis.ErgebnisseIn der PVP-Iod-Gruppe trat bei 14 Patienten eine klinisch manifeste Mukositis auf (mittlere Ausprägung: Grad 1,0) bei der Kontrollgruppe bei allen 20 Patienten (Grad 3,0). Die Gesamtdauer der klinisch feststellbaren Mukositis (Größe=WHO I) betrug in der PVP-Iod-Gruppe 2,75 und in der Kontrollgruppe 9,25 Wochen. Die medianen AUC-Werte (Ausprägung über Dauer) betrugen 2,5 für die PVP-Iod-Gruppe und 15,75 für die Kontrollgruppe. Alle Prüfgrößen zeigten statistisch signifikante Unterschiede zwischen den beiden Gruppen. Eine pathologische Erhöhung der Schilddrüsenwerte konnte in der mit Iod behandelten Gruppe nicht festgestellt werden.SchlußfolgerungDie erhobenen Ergebnisse deuten darauf hin, daß eine zusätzlich zu einem üblichen Prophylaxeschema durchgeführte Mundspülung mit einer PVP-Iodlösung sowohl Inzidenz, Schweregrad als auch Dauer einer radiochemotherapeutisch bedingten Mukositis der Mundhöhle signifikant vermindern kann.AbstractBackgroundOral mucositis is a frequent complication of radiochemotherapy. The origin of radiation-induced mucosa lesions is of iatrogenic nature although further development of mucositis is essentially influenced by infection. It can be assumed that disinfection measures should decrease the severity of mucositis induced by radiochemotherapy. Therefore, in a prospective randomised study the efficacy of prophylactic oral rinsing with a disinfection agent was investigated.Patients and MethodAn open, randomised, prospective comparative trial was conducted with 40 patients undergoing radiochemotherapy of head and neck region due to malignant disease. The treatment scheme consisted of irradiation to tumor region and adjacent lymph, nodes with a total dose of 71.3 Gy and simultaneous chemotherapy with carboplatin (60 mg/m2) on days 1 to 5 and 29 to 34. In all patients, a prophylaxis of mucositis with nystatine, rutosides, panthenol and immunoglobulin was undertaken. In addition, 20 patients rinsed oral cavity 4 times daily with povidone-iodine-solution, the comparative group rinsed with sterile water. Clinical examination of the oral mucosa was performed weekly. Onset, grading and duration of mucositis were used as main variables.ResultsClinically manifested oral mucositis was observed in 14 patients of the iodine group (mean grading: 1.0) and all 20 patients of the control group (mean grading: 3.0). Total duration (mean) of clinically observed mucositis was 2.75 weeks in treatment patients and 9.25 in control patients. Median AUC (area under curve for grade vs duration) was 2.5 in iodine rinsing patients and 15.75 in control patients. All differences found between the 2 groups were statistically significant. Increased iodine incorporation was not observed. A pathological increase of thyroid hormone levels in the iodine group was not found.ConclusionsThe gained results indicate that incidence, severity and duration of radiochemotherapy-induced mucositis can be significantly reduced by oral rinsing with povidone-iodine performed additionally to the standard prophylaxis scheme.

In vivo dose increase in the presence of dental alloys during 60Co-gamma-ray therapy of the oral cavity

During irradiation of the mouth cavity, dental metallic materials emit secondary electrons and thus increase the applied radiation dose in their vicinity. Therefore, local destruction of the mucous membrane contacting metallic dental crowns and fillings may be observed. Available data on this dose increase are based on measurements with beam arrangements perpendicular to the metallic surface. Since the dose modification depends on the beam direction in relation to specimen surface, a reliable prediction of dose modification in the close vicinity of dental caps on fillings under complex beam arrangements, as applied in the irradiation of head and neck region from the published data is not possible. Therefore, we measured dose increase in the immediate surrounding of metallic dental material using thermoluminescence dosimetry on the phantom and during routinely applied 60Co gamma ray therapy. Phantom measurements were carried out using several oblique irradiation angles and rotational therapy. In vivo measurements were carried out at alloy specimens containing gold, palladium, and amalgam in six patients and at permanently fixed golden teeth in five patients. In vivo, the following relative dose increase values according to a simultaneously measured reference value were obtained at the surface of different dental materials: 61% for fixed golden caps. 68% for the specimen containing gold, 33% for the specimen of palladium and 61% for the specimen of amalgam. The measured dose increases due to metallic dental material during routinely applied external 60Co beam irradiation are lower compared with those of perpendicular beam arrangements. Although, the extent of dose modification is less than expected, we still advocate protection of the oral mucosa to prevent painful lesion spots.

Verbesserte Reproduzierbarkeit und erhöhter Komfort durch standardisierte Lagerungshilfe bei der Bestrahlung der weiblichen Brust

BACKGROUNDnPositioning and immobilisation techniques are essential for precise radiotherapy. The currently available standardised positioning devices are insufficient. For this reason, we designed a new and generally usable hard foam positioning support cushion for the breast irradiation and tested its usefulness in a prospective study.nnnPATIENTS AND METHODSnFifty-five female breast cancer patients receiving adjuvant radiotherapy following breast conservative surgery were irradiated either without immobilisation (n = 27) or with the developed positioning support cushion (n = 28). The time necessary for patient set-up, the subjective lying comfort and--comparing portal images with simulator images--the reproducibility of the set-up were determined.nnnRESULTSnIt was possible to improve irradiation reproducibility significantly (average deviation without positioning support cushion: 8.4 mm, with positioning support cushion: 6.1 mm, p < 0.001). The additional time required for the positioning of the patient was in average 19 s (with positioning support cushion: 74 s, without cushion: 55 s). A significantly higher proportion of patients (72%) found the position with the hard foam cushion was pleasant, whereas only 46% of patients were pleased with the position without cushion.nnnCONCLUSIONnThe positioning support cushion designed in our department seems to play an important role in quality assurance of external beam irradiation of the breast and significantly increases the patients comfort in a supine position. Compared to conventional positioning and fixation devices it may be quickly and easily applied at low cost. Therefore, its use can be recommended.ZusammenfassungHintergrundLagerungs-und Fixationstechniken sind Voraussetzung für eine präzise Radiotherapie. Die angebotenen standardisierten Lagerungshilfen sind unzureichend. Daher wurde von uns eine neue, allgemein anwendbare Lagerungshilfe aus Hartschaumstoff zur Mammabestrahlung entworfen und in einer prospektiven Studie auf klinische Eignung geprüft.Patienten und MethodeBei 55 Patientinnen, die nach brusterhaltender Operation bei Mammakarzinom adjuvant radiotherapiert wurden, erfolgte die Bestrahlung in freier Lagerung (n=27) bzw. mit der von uns entwickelten Lagerungshilfe (n=28). Es wurden die zur Lagerung benötigte Zeit, der subjektive Liegekomfort und aus dem Vergleich der Verifikations- mit den Simulationsaufnahmen die Reproduzierbarkeit der Lagerung ermittelt.ErgebnisseDie Reproduzierbarkeit der Bestrahlung konnte signifikant verbessert werden (mittlere Abweichung ohen Lagerungshilfe: 8,4 mm, mit Lagerungshilfe: 6,1 mm, p<0,001). Der zusätzliche Zeitaufwand zur Patientenlagerung betrug im Mittel 19 s (mit Lagerungshilfe: 74 s, ohne: 55s). Signifikant mehr Patientinnen (72%) empfanden die Lagerung mit der untersuchten Lagerungshilfe als angenehm, während nur 46% die freie Lagerung als angenehm beurteilten.SchlußfolgerungenDie von uns entworfene Lagerungshilfe trägt zur Qualitätssicherung bei der Mammabestrahlung bei und erhöht deutlich den Liegekomfort. Im Vergleich zu üblichen Lagerungs- und Fixationshilfen ist sie bei geringem Kostenaufwand schnell und einfach anwendbar. Daher ist ihr Einsatz zu empfehlen.BackgroundPositioning and immobilisation techniques are essential for precise radiotherapy. The currently available standardised positioning devices are insufficient. For this reason, we designed a new and generally usable hard foam positioning support cushion for the breast irradiation and tested its usefulness in a prospective study.Patients and MethodsFifty-five female breast cancer patients receiving adjuvant radiotherapy following breast conservative surgery were irradiated either without immobilisation (n=27) or with the developed positioning support cushion (n=28). The time necessary for patient set-up, the subjective lying comfort and — comparing portal images with simulator images — the reproducibility of the set-up were determined.ResultsIt was possible to improve irradiation reproducibility significantly (average deviation without positioning support cushion: 8.4 mm, with positioning support cushion: 6.1 mm, p<0.001). The additional time required for the positioning of the patient was in average 19 s (with positioning support cushion: 74 s, without cushion: 55 s). A significantly higher proportion of patients (72%) found the position with the hard foam cushion was pleasant, whereas only 46% of patients were pleased with the position without cushion.ConclusionThe positioning support cushion designed in our department seems to play an important role in quality assurance of external beam irradiation of the breast and significantly increases the patients’ comfort in a supine position. Compared to conventional positioning and fixation devices it may be quickly and easily applied at low cost. Therefore, its use can be recommended.

INCREASE OF SURFACE DOSE USING WOUND DRESSINGS DURING PERCUTANEOUS RADIOTHERAPY WITH PHOTONS AND ELECTRONS

Different wound dressings are used for the supportive treatment of patients with radiation-induced skin lesions. Depending on beam quality and energy, an increase of the dose administered to the skin and thus an aggravated skin reaction is to be expected during percutaneous irradiation. The increase of the skin dose during irradiation with photons (Co60, 6 MV, 42 MV) and electrons (7 MeV, 20 MeV, 42 MeV) was determined using thermoluminescence dosimetry. The use of wound dressings during electron irradiation and during soft irradiation therapy does not significantly increase the dose administered to the skin and does not therefore cause any problems. During irradiation with high energy photons only extremely thin dressings should be used; if there is an aggravated skin reaction, the dressing should be taken off before irradiation commences.