Irenaeus Anton Adamietz

Validation and simplification of a score predicting survival in patients irradiated for metastatic spinal cord compression

Based on an analysis of 1852 retrospectively evaluated patients with metastatic spinal cord compression (MSCC), a scoring system was developed to predict survival. This study was performed to validate the scoring system in a new data set.

Surgery Followed by Radiotherapy Versus Radiotherapy Alone for Metastatic Spinal Cord Compression From Unfavorable Tumors

PURPOSE Despite a previously published randomized trial, controversy exists regarding the benefit of adding surgery to radiotherapy for metastatic spinal cord compression (MSCC). It is thought that patients with MSCC from relatively radioresistant tumors or tumors associated with poor functional outcome after radiotherapy alone may benefit from surgery. This study focuses on these tumors. METHODS AND MATERIALS Data from 67 patients receiving surgery plus radiotherapy (S+RT) were matched to 134 patients (1:2) receiving radiotherapy alone (RT). Groups were matched for 10 factors and compared for motor function, ambulatory status, local control, and survival. Additional separate matched-pair analyses were performed for patients receiving direct decompressive surgery plus stabilization of involved vertebrae (DDSS) and patients receiving laminectomy (LE). RESULTS Improvement of motor function occurred in 22% of patients after S+RT and 16% after RT (p=0.25). Posttreatment ambulatory rates were 67% and 61%, respectively (p=0.68). Of nonambulatory patients, 29% and 19% (p=0.53) regained ambulatory status. One-year local control rates were 85% and 89% (p=0.87). One-year survival rates were 38% and 24% (p=0.20). The matched-pair analysis of patients receiving LE showed no significant differences between both therapies. In the matched-pair analysis of patients receiving DDSS, improvement of motor function occurred more often after DDSS+RT than RT (28% vs. 19%, p=0.024). Posttreatment ambulatory rates were 86% and 67% (p=0.30); 45% and 18% of patients regained ambulatory status (p=0.29). CONCLUSIONS Patients with MSCC from an unfavorable primary tumor appeared to benefit from DDSS but not LE when added to radiotherapy in terms of improved functional outcome.

Radiotherapy for Oligometastatic Disease in Patients with Spinal Cord Compression (MSCC) from Relatively Radioresistant Tumors

Background:Radiotherapy alone is the most common treatment for metastatic spinal cord compression (MSCC). Patients with relatively radioresistant tumors and oligometastatic disease may benefit from more intensive therapies (surgery, high-precision radiotherapy). If such therapies are not available, one can speculate whether patients benefit from dose escalation beyond the standard regimen 30 Gy in ten fractions.Patients and Methods:Of 206 patients with MSCC from relatively radioresistant tumors (renal cell carcinoma, colorectal cancer, malignant melanoma), 51 had oligometastatic disease (no visceral or other bone metastases, involvement of only one to three vertebrae). In this subset, 21 patients receiving 30 Gy in ten fractions were retrospectively compared to 30 patients receiving higher doses. Seven further potential prognostic factors were investigated: age, gender, tumor type, performance status, interval from tumor diagnosis to radiotherapy of MSCC, pretreatment ambulatory status, and time developing motor deficits before radiotherapy.Results:Motor function improved in 52% of patients after 30 Gy and 40% after higher doses (p = 0.44). On multivariate analysis, functional outcome was associated with interval from tumor diagnosis to radiotherapy (p = 0.020). 1-year local control rates were 84% after 30 Gy and 82% after higher doses (p = 0.75). No factor was associated with local control. 1-year survival rates were 76% after 30 Gy and 63% after higher doses (p = 0.52). On multivariate analysis, survival was associated with performance status (p = 0.022) and interval from tumor diagnosis to radiotherapy (p = 0.039), and almost with pretreatment ambulatory status (p = 0.069).Conclusion:Dose escalation beyond 30 Gy in ten fractions did not improve motor function, local control, and survival in MSCC patients with oligometastatic disease from relatively radioresistant tumors.ZusammenfassungHintergrund:Die alleinige Strahlentherapie ist die häufigste Behandlung der metastatisch bedingten Rückenmarkkompression (MSCC). Patienten mit relativ strahlenresistenten Tumoren und oligometastatischer Erkrankung könnten von intensiveren Therapien (Operation, Hochpräzisionsstrahlentherapie) profitieren. Sind diese nicht verfügbar, stellt sich die Frage, ob eine Dosiseskalation über das Standardregime 30 Gy in zehn Fraktionen hinaus zu einer Verbesserung der Prognose führt.Patienten und Methodik:Von 206 Patienten mit MSCC und relativ strahlenresistenten Tumoren (Nierenzellkarzinom, kolorektale Karzinome, malignes Melanom) hatten 51 eine oligometastatische Erkrankung (keine Organ- oder weiteren Knochenmetastasen, nur ein bis drei Wirbelkörper betroffen). 21 Patienten, die 30 Gy in zehn Fraktionen erhielten, wurden mit 30 Patienten, die höhere Dosen erhielten, verglichen (Tabelle 1). Sieben weitere mögliche Prognosefaktoren wurden untersucht: Alter, Geschlecht, Tumorart, Allgemeinzustand, Intervall von Erstdiagnose der Tumorerkrankung bis Strahlentherapie, Gehfähigkeit und Entwicklungszeit motorischer Defizite.Ergebnisse:52% der Patienten nach 30 Gy sowie 40% nach höheren Dosen zeigten eine Verbesserung der motorischen Funktion (p = 0,44; Abbildung 1, Tabelle 2). In der Multivarianzanalyse war die posttherapeutische motorische Funktion mit dem Intervall von Erstdiagnose bis Strahlentherapie assoziiert (p = 0,020). Die lokale Kontrolle nach 1 Jahr betrug 84% nach 30 Gy und 82% nach höheren Dosen (p = 0,75; Abbildung 2, Tabelle 3). Kein Faktor war signifikant mit der lokalen Kontrolle assoziiert. Das Überleben nach 1 Jahr betrug 76% nach 30 Gy und 63% nach höheren Dosen (p = 0,52; Abbildung 3, Tabelle 4). In der Multivarianzanalyse war das Überleben mit dem Allgemeinzustand (p = 0,022) und dem Intervall von Erstdiagnose bis Strahlentherapie (p = 0,039) assoziiert.Schlussfolgerung:Eine Dosiseskalation über 30 Gy in zehn Fraktionen hinaus führte nicht zu einer Verbesserung von motorischer Funktion, lokaler Kontrolle und Überleben bei MSCC-Patienten mit oligometastatischer Erkrankung und relativ strahlenresistenten Tumoren.

Multicenter, Phase III Trial Comparing Selenium Supplementation With Observation in Gynecologic Radiation Oncology: Follow-Up Analysis of the Survival Data 6 Years After Cessation of Randomization

Purpose. In 2010, we reported that selenium (Se) supplementation during radiation therapy (RT) is effective for increasing blood Se levels in Se-deficient cervical and uterine cancer patients, and reduced the number of episodes and severity of RT-induced diarrhea. In the current study, we examine whether of Se supplementation during adjuvant RT affects long-term survival of these patients. Patients and Methods. Former patients were identified and questioned with respect to their health and well-being. Results. A total of 81 patients were randomized in the initial supplementation study, 39 of whom received Se (selenium group, SeG) and 42 of whom served as controls (control group, CG). When former patients were reidentified after a median follow-up of 70 months (range = 0-136), the actuarial 10-year disease-free survival rate in the SeG was 80.1% compared to 83.2% in the CG (P = .65), and the actuarial 10-year overall survival rate of patients in the SeG was 55.3% compared to 42.7% in the CG (P = .09). Conclusions. Our extended follow-up analysis demonstrates that Se supplementation had no influence on the effectiveness of the anticancer irradiation therapy and did not negatively affect patients’ long-term survival. In view of its positive effects on RT-induced diarrhea, we consider Se supplementation to be a meaningful and beneficial adjuvant treatment in Se-deficient cervical and uterine cancer patients while undergoing pelvic radiation therapy.

Radiotherapy With 4 Gy × 5 Versus 3 Gy × 10 for Metastatic Epidural Spinal Cord Compression: Final Results of the SCORE-2 Trial (ARO 2009/01)

PURPOSE To compare short-course radiotherapy (RT) (4 Gy × 5) to longer-course RT (3 Gy × 10) for metastatic epidural spinal cord compression (MESCC). PATIENTS AND METHODS Two-hundred three patients with MESCC and poor to intermediate expected survival were randomly assigned to 4 Gy × 5 in 1 week (n = 101) or 3 Gy × 10 in 2 weeks (n = 102). Patients were stratified according to ambulatory status, time developing motor deficits, and primary tumor type. Seventy-eight and 77 patients, respectively, were evaluable for the primary end point, 1-month overall response regarding motor function defined as improvement or no further progression of motor deficits. Other study end points included ambulatory status, local progression-free survival, and overall survival. End points were evaluated immediately after RT and at 1, 3, and 6 months thereafter. RESULTS At 1 month, overall response rates regarding motor function were 87.2% after 4 Gy × 5 and 89.6% after 3 Gy × 10 (P = .73). Improvement rates were 38.5% and 44.2%, respectively, no further progression rates 48.7% and 45.5%, respectively, and deterioration rates 12.8% and 10.4%, respectively (P = .44). Ambulatory rates at 1 month were 71.8% and 74.0%, respectively (P = .86). At other times after RT, the results were also not significantly different. Six-month local progression-free survival was 75.2% after 4 Gy × 5 and 81.8% after 3 Gy × 10 (P = .51); 6-month overall survival was 42.3% and 37.8% (P = .68). CONCLUSION Short-course RT with 4 Gy × 5 was not significantly inferior to 3 Gy × 10 in patients with MESCC and poor to intermediate expected survival.

Validation of a Score Predicting Post-Treatment Ambulatory Status After Radiotherapy for Metastatic Spinal Cord Compression

PURPOSE A score predicting post-radiotherapy (RT) ambulatory status was developed based on 2,096 retrospectively evaluated metastatic spinal cord compression (MSCC) patients. This study aimed to validate the score in a prospective series. METHODS AND MATERIALS The score included five factors associated with post-RT ambulatory status: tumor type, interval tumor diagnosis to MSCC, visceral metastases, pre-RT motor function, time developing motor deficits. Patients were divided into five groups: 21-28, 29-31, 32-34, 35-37, 38-44 points. In this study, 653 prospectively followed patients were divided into the same groups. Furthermore, the number of prognostic groups was reduced from five to three (21-28, 29-37, 38-44 points). Post-RT ambulatory rates from this series were compared with the retrospective series. Additionally, this series was compared with 104 patients receiving decompressive surgery plus RT (41 laminectomy, 63 laminectomy plus stabilization of vertebrae). RESULTS In this study, post-RT ambulatory rates were 10.6% (21-28 points), 43.5% (29-31 points), 71.0% (32-34 points), 89.5% (35-37 points), and 98.5% (38-44 points). Ambulatory rates from the retrospective study were 6.2%, 43.5%, 70.0%, 86.1%, and 98.7%. After regrouping, ambulatory rates were 10.6% (21-28 points), 70.9% (29-37 points), and 98.5% (38-44 points) in this series, and 6.2%, 68.4%, and 98.7% in the retrospective series. Ambulatory rates were 0%, 62.5%, and 90.9% in the laminectomy plus RT group, and 14.3%, 83.9%, and 100% in the laminectomy + stabilization plus RT group. CONCLUSIONS Ambulatory rates in the different groups in this study were similar to those in the retrospective study demonstrating the validity of the score. Using only three groups is simpler for clinical routine.

Results of a nationwide survey on radiotherapy of bone metastases in Germany.

Background: Assuming interinstitutional differences in the treatment of bone metastases, a survey of German radiotherapy institutions was carried out. The goal was to demonstrate regional strategies in pretherapeutic diagnosis, radiation treatment, and follow-up. Patients and Methods: A structured questionnaire (eleve multiple-choice questions, ten tables to complete) was sent to all institutions primarily performing radiotherapy. The reply rate was 63.7% (86/135). Results: The estimated proportion of patients with irradiated bone metastases was 18.2% (5–60%). The overall number of treated patients with bone metastases has increased. 45% of all radiation treatments for bone metastases wer performed in patients with mammary carcinoma, followed by lung carcinoma (17%). Central beam dose calculation was performed in 72% of patients, in other cases computer-assisted planning (23%) and 3-D planning (5%) were carried out. Special techniques (individual shielding, special fixations) were used in 57 institutions in 19.8% of patients. The applied single dose varied between 1 and 10 Gy, and the total dose between 5 and 60 Gy. The majority of institutions vary their treatment schemes. In most institutions, the definitive result assessment followed 4–6 weeks after the end of irradiation. Conventional X-rays play the most important role in evaluation of the radiation result. Approximately a quarter of patients are permanently included in the radiation oncological follow-up. Conclusions: The therapeutic variety corresponds with the greatly varing recommendations in the literature. There were no major differences between private practices, hospitals and university facilities. Considering the standards of diagnosis, treatment, and results assessment, a high quality of palliative treatment can be assumed.Hintergrund: Unter der Annahme interinstitutioneller Unterschiede bei der Behandlung von Knochenmetastasen erfolgte eine schriftliche Umfrage in allen deutschen radiotherapeutischen Einrichtungen. Das Ziel war die Erfassung der regionalen Strategien in der prätherapeutischen Diagnostik, in der Durchführung der Bestrahlung und in der Nachsorge. Patienten und Methode: An alle Institutionen, die Radiotherapie schwerpunktmäßig betreiben, wurde ein strukturierter Fragebogen (elf Multiple-Choice-Fragen, zehn Tabellen zum Ergänzen) verschickt. Die Rückantwortrate betrug 63,7% (86/135). Ergebnisse: Der geschätzte Anteil der Patienten mit bestrahlten Knochenmetastasen beträgt im Durchschnitt 18,2% (5–60%). Die Zahl der bestrahlten Knochenmetastasen zeigte eine konstante bis leicht zunehmende Tendenz. 45% aller Radiotherapien der Skelettmetastasen erfolgen bei Mammakarzinomen, gefolgt von Bronchialkarzinomen (17%). Die Zentralstrahldosisberechnung wird bei 72% der Patienten durchgeführt, bei den restlichen kommt computergestützte (23%) und dreidimensionale Planung (5%) zum Einsatz. Besondere Techniken (individuelle Blöcke, spezielle Fixierung) kamen in 57 Institutionen (66,3%) zur Anwendung. Die applizierte Einzeldosis variierte zwischen 1 und 10 Gy, die Gesamtdosis zwischen 5 und 60 Gy. Die Mehrheit der Einrichtungen verwendet kein festes Dosierungs- und Fraktionierungsschema. Die abschließende Beurteilung des Resultates der Behandlung erfolgte bei den meisten Institutionen 4–6 Wochen nach Abschluss der Bestrahlung. Konventionelle Röntgenuntersuchung überwog bei der Bewertung des Therapieerfolges. Etwa ein Viertel der Patienten bleibt dauerhaft in der radioonkologischen Nachsorge. Schlussfolgerungen: Die Vielfalt der therapeutischen Strategien entspricht den stark variierenden Literaturdaten, dabei sind die Unterschiede zwischen Krankenhäusern, Praxen und Universitätskliniken nicht wesentlich. Die Antworten zur Diagnostik, Durchführung und Kontrolle des Therapieresultates lassen bei vielen Institutionen eine hohe Qualität der Behandlung vermuten.

Magnetic resonance imaging of bone marrow metastasis with fluid-fluid levels from small cell neuroendocrine carcinoma of the urinary bladder

Fluid-fluid levels have been reported as an extremely infrequent and non-specific condition in many benign and malignant bone lesions. We present the first reported MRI findings of bone marrow metastasis with fluid-fluid levels from small cell neuroendocrine carcinoma of the urinary bladder to the lumbar spine. Radiologists should be aware of the MRI appearance of these extraordinary lesions in order to provide a complete differential diagnosis and to guide clinicians in adequate treatment.

Serum selenium deficiency in patients with hematological malignancies: is a supplementation study mandatory?

a Department of Radiotherapy, Lippe Hospital, Lemgo , b Department of Radiotherapy and Radiation Oncology, Franziskus Hospital, Bielefeld , c Institute for Experimental Endocrinology, Charité Universitätsmedizin, Berlin , d Department of Otolaryngology, Südharz Hospital, Nordhausen , e Department of Radiotherapy and Radiation Oncology, Marien Hospital Herne, Ruhr University Bochum, Bochum , and f Working Group Integrative Oncology, Dr. Senckenberg Chronomedical Institute, J.W. Goethe University Frankfurt, Frankfurt , Germany

Selenium in Radiation Oncology—15 Years of Experiences in Germany

Introduction: Se measurement and supplementation in radiation oncology is a controversial issue. The German Working Group Trace Elements and Electrolytes in Oncology (AKTE) has conducted a number of studies on this issue, which are summarized in this review. Strategies have been tested and developed, aiming to stratify the patients with a potential need for supplemental Se and how best to monitor Se supplementation with respect to health effects and risks. Methods: We analyzed blood and tissue Se-levels of different tumor patients (n = 512). Two randomized phase III clinical studies were conducted for testing a potential radioprotective effect of supplemental Se during radiation therapy in patients with uterine cancer (n = 81) and head and neck tumor patients (n = 39). Results: A relative Se deficit in whole blood or serum was detected in the majority of tumor patients (carcinomas of the uterus, head and neck, lung, rectal or prostate cancer). In prostate cancer, tissue Se concentrations were relatively elevated in the carcinoma centre as compared to the surrounding compartment or as compared to tumor samples from patients with benign prostatic hyperplasia. Adjuvant Se supplementation successfully corrected Se-deficiency in the patients analyzed and decreased radiotherapy-induced diarrhea in a randomized study of radiotherapy patients with carcinomas of the uterus. Survival data imply that Se supplementation did not interfere with radiation success. Some positive effects of supplemental Se in the prevention of ageusia (loss of taste) and dysphagia due to radiotherapy were noted in a second randomized trial in patients with head and neck cancer. We have not observed any adverse effects of supplemental Se in our studies. Conclusions: Se supplementation yielded promising results concerning radioprotection in tumor patients and should be considered as a promising adjuvant treatment option in subjects with a relative Se deficit.