Martina Treiber

Open low-field magnetic resonance imaging in radiation therapy treatment planning

PURPOSE To evaluate the possibilities of an open low-field magnetic resonance imaging (MRI) scanner in external beam radiotherapy treatment (RT) planning. METHODS AND MATERIALS A custom-made flat tabletop was constructed for the open MR, which was compatible with standard therapy positioning devices. To assess and correct image distortion in low-field MRI, a custom-made phantom was constructed and a software algorithm was developed. A total of 243 patients (43 patients with non-small-cell lung cancer, 155 patients with prostate cancer, and 45 patients with brain tumors) received low-field MR imaging in addition to computed tomographic (CT) planning imaging between January 1998 and September 2001 before the start of the irradiation. RESULTS Open low-field MRI provided adequate images for RT planning in nearly 95% of the examined patients. The mean and the maximal distortions 15 cm around the isocenter were reduced from 2.5 mm to 0.9 mm and from 6.1 mm to 2.1 mm respectively. The MRI-assisted planning led to better discrimination of tumor extent in two-thirds of the patients and to an optimization in lung cancer RT planning in one-third of the patients. In prostate cancer planning, low-field MRI resulted in significant reduction (40%) of organ volume and clinical target volume (CTV) compared with CT and to a reduction of the mean percentage of rectal dose of 15%. In brain tumors, low-field MR image quality was superior compared with CT in 39/45 patients for planning purposes. CONCLUSIONS The data presented here show that low-field MRI is feasible in RT treatment planning when image correction regarding system-induced distortions is performed and by selecting MR imaging protocol parameters with the emphasis on adequate images for RT planning.

Decreased detection rate of disseminated tumor cells of rectal cancer patients after preoperative chemoradiation: a first step towards a molecular surrogate marker for neoadjuvant treatment in colorectal cancer.

Objective To compare the detection rates for rectal cancer cells in blood and bone marrow in patients with or without preoperative chemoradiation. Summary Background Data Previous reports have postulated a resistance of disseminated tumor cells to antiproliferative agents because of tumor cell dormancy. Methods Blood samples from 142 patients (pre, intra-, and postoperative samples) and bone marrow samples from 127 patients undergoing resection of rectal adenocarcinoma were analyzed for tumor cells using a cytokeratin (CK) 20-reverse transcription polymerase chain reaction. The results were stratified according to preoperative therapy. Results In patients without preoperative chemoradiation, tumor cell detection in blood and bone marrow correlated to tumor stage (Cochran Armitage trend test, P < 0.05). Tumor cells were detected in 34 of 103 (33%) bone marrow and 65 of 117 (55.6%) blood samples of patients without neoadjuvant treatment versus in 4 of 24 (16.7%) bone marrow and in 10 of 25 (40%) blood samples of patients with neoadjuvant treatment. The tumor cell detection rate was significantly lower in the group having undergone chemoradiation (binary logistic regression analysis, P < 0.05). The overall and disease-free survival were significantly worse in patients with tumor cell detection in the bone marrow after neoadjuvant therapy. Conclusions Preoperative chemoradiation is associated with a decreased detection rate of rectal cancer cells in blood and bone marrow. These findings may explain the observed clinical benefit of patients with rectal cancer receiving chemoradiation. This is the first study suggesting that detection of disseminated rectal cancer cells may be useful for assessing the efficacy of neoadjuvant therapy.

Development and psychometric evaluation of the Basic Documentation for Psycho-Oncology, a tool for standardized assessment of cancer patients

OBJECTIVE This study describes the development and psychometric evaluation of the Basic Documentation for Psycho-Oncology (PO-Bado), an expert rating scale designed for the comprehensive assessment of psychosocial and physical distress in cancer patients. While there are many self-report measures (usually used for screening purposes), the PO-Bado is the first standardized clinician-administered instrument to guide professionals in a focused and structured psycho-oncological assessment. METHODS The validation procedure was performed in 596 patients from different settings of cancer care, including all cancer sites and stages of the disease. The psychometric evaluation included (a) determination of the factorial structure, (b) homogeneity of scales and interrater reliability, (c) convergent and discriminant validities, and (d) examination of sensitivity to change. RESULTS The final version of the PO-Bado includes two scales: the physical distress scale (four items) and the psychological distress scale (eight items). A manual and an interview guideline were developed alongside. The psychometric properties suggest that the PO-Bado is a reliable and valid tool used to assess and to differentiate the distress of patients with cancer, as well as treatment-related changes in distress. CONCLUSION We suggest that the PO-Bado is a useful tool that is applicable in different oncology settings. It complements self-report measures and provides a structured format for focused psycho-oncological assessment and intervention. The two-dimensional structure allows differentiation between physical and psychological problems, assisting professionals in their diagnostic efforts and in providing appropriate support or treatment. When used consistently across professions and settings, the PO-Bado can form the basis for audit and interdisciplinary communication.

Influence of Intraoperative and Postoperative Radiotherapy on Functional Outcome in Patients Undergoing Standard and Deep Anterior Resection for Rectal Cancer

PurposeThis study was designed to investigate the influence of intraoperative and postoperative radiotherapy on functional outcome after rectal resection for rectal cancer.MethodsOne hundred patients who underwent deep or standard anterior resection for rectal cancer were included in this follow-up study. All patients filled out questionnaires regarding morbidity and functional outcome; a subgroup (n = 63) underwent further clinical evaluation. The results were stratified according to radiation: Group I, no radiation (n = 37); Group II, only intraoperative radiation (n = 12); Group III, intraoperative and postoperative radiation (n = 51).ResultsAnal continence measured by Kirwan-Parks classification and Wexner score was significantly different within the three groups (P < 0.005, P < 0.0001), whereas continence impairment was least in Group I and greatest in Group III. Patients in Group III demonstrated a significantly worsecategory in the Kirwan-Parks classification and worse Wexner scores compared with patients in Group I (P < 0.0001). Patients only having undergone intraoperative radiotherapy had a significantly worse continence (Kirwan-Parks classification) than patients without any radiotherapy (P < 0.05). More patients after intraoperative and postoperative radiation therapy complained of fragmented stools (P < 0.05) and urgency (P < 0.05) compared with patients only having undergone surgery; the need towear pads was higher (P = 0.001). Vector volume manometry revealed better resting sphincter function in Group I compared with Group III (P ≤ 0.005).ConclusionsPatients with anterior resection for rectal cancer who undergo full-dose radiotherapy have significantly more impairment of anorectal function than patients without radiotherapy. Patients who were only exposed to intraoperative radiotherapy showed moderate impairment of continence function, suggesting that the influence of radiotherapy on anal function may be dose-dependent and application-dependent.

Moderate dose intraoperative and external beam radiotherapy for locally recurrent rectal carcinoma

BACKGROUND AND PURPOSE Late adverse effects (i.e. neuropathy, chronic bowel obstruction) limit the effective dose given in intraoperative radiotherapy (IORT) and external beam radiotherapy (EBRT). Initial results of a multi-modality treatment approach using moderate dose IORT and moderate dose EBRT are presented. PATIENTS AND METHODS Thirty-one consecutive patients with recurrent rectal carcinomas had IORT and EBRT after complete (R0, n = 14) or incomplete resection (R1, n = 9; R2, n = 8). The mean [ORT dose was 13.7 Gy (range 12-20 Gy) supplemented with an EBRT dose of 41.4 Gy. Twenty-two patients had preoperative EBRT and 22 patients had concomitant chemotherapy (5-FU, Leucovorine). RESULTS After a median follow-up of 28 months, 16 patients had re-recurrent disease and 11 patients had died. Nine patients failed locally (four in-field, four marginal and one anastomotic re-recurrence), three combined with distant metastasis, resulting in overall and IORT infield local control rates of 71% and 87%, respectively. Distant metastases alone were found in seven patients. The 4-year overall and relapse-free survival rates were 58% and 48%, respectively. After incomplete resection the local failure rate increased (R0 21%, R1/2 35%) and the 4-year relapse-free survival rate decreased significantly (29% versus 71%) due to a markedly increased distant metastasis rate (53% versus 7%). Acute and late toxicities were not increased. CONCLUSION The combination of moderate dose IORT and EBRT is a safe and efficacious component in a multi-modality treatment approach.

Postoperative electron beam radiotherapy for keloids: objective findings and patient satisfaction in self-assessment.

Aim  To evaluate the role of postoperative radiotherapy in the management of keloids.

Combination of early bisphosphonate administration and irradiation leads to improved remineralization and restabilization of osteolytic bone metastases in an animal tumor model.

The goal of the current study was to analyze the combined effect of bisphosphonates (BPs) and irradiation on remineralization and restabilization of osteolytic bone metastases in an animal tumor model.

Indolent Stage IE Non-Hodgkin’s Lymphoma of the Orbit: Results after Primary Radiotherapy

Aims: Primary non-Hodgkin’s lymphoma (NHL) of the orbit is uncommon, representing approximately 8% of extranodal NHLs. Twenty-two patients with indolent stage IE NHL were reviewed retrospectively to analyze the outcome and late effects of primary local radiotherapy. Materials and Methods: The median age at first diagnosis was 63.5 years (range 24–82 years). Extranodal mucosa-associated lymphoid tissue lymphoma (n = 15) was the most common histological subtype of NHL, followed by follicular (n = 6) and lymphoplasmacytic lymphoma (n = 1). Radiotherapy was performed using a linear accelerator. The median radiation dose was 40 Gy (range 30–46 Gy). None of the patients received chemotherapy before irradiation. The follow-up period was 62 months (range 8–136 months). Results:A complete response was achieved in all patients. The 5-year local control rate was 100%. Distant relapse occurred in 2 patients, resulting in a 5-year distant relapse-free survival rate of 88%. The 5-year overall survival rate was 89%; there were no lymphoma-related deaths. No serious acute complications (grade 3/4) were observed. Grade 1/2 late effects were documented in 44% of patients. Grade 3 complications (cataract: 2, dryness: 2) were observed in 4 patients (18%). Conclusions: Indolent early stage orbital NHL can be controlled with local radiotherapy. Morbidity is low. Regular follow-up examinations are necessary to detect rare cases of distant relapse.

Intraoperative Radiotherapy for Rectal Carcinoma

Local recurrence following curative resection of rectal carcinoma is still a major problem. Recurrence rates of more than 30% have been reported in the past, but total mesorectal excision has reduced the incidence to considerably less than 10%. Still, the severe morbidity associated with local recurrence demands additional efforts to guarantee local control. Moreover, it may be hoped that a reduction of local recurrence translates into improved overall survival. Postoperative adjuvant radiotherapy allows treatment after precise pathological staging, thus preventing over-therapy. The target area, however, includes radiosensitive tissues such as urinary bladder, ureters and intestines as well as a hypoxic postsurgical tumor bed with potentially reduced radiosensitivity. Neoadjuvant therapy can render resectability in locally advanced tumors and often facilitates sphincter preservation in low rectal cancer [19, 22]. It also reduces the spread of viable tumor cells and seems to decrease side effects concerning the small bowel. Finally radiosensitivity is expected to be better, because tumor cell oxygenation is not compromised preoperatively. Many randomized trials have confirmed that adjuvant as well as neoadjuvant radiotherapy can reduce the incidence of local recurrence in UICC stage II and III rectal carcinoma by half [13] and neoadjuvant accelerated 5×5-Gy radiotherapy was associated with improved survival [20, 11].

Adjuvant Radiochemotherapy for Rectal Cancer

One of the basic questions for radiation oncologists is what we hope to achieve from treatments that are adjuvant to surgery. Can we achieve a better local control? Is there a decrease in metastatic disease? Can we see an effect on overall survival? Although some questions remain to be answered, some general recommendations for the treatment of rectal cancer can be given. Since the NIH recommendations in 1990, the majority of patients with rectal cancer are treated by a multimodality approach. Today surgery with total mesorectal excision (TME) is the standard therapy for cancers of the middle and low rectum in stages T1/2 N0. Radiochemotherapy (adjuvant or neoadjuvant) and short-term preoperative radiotherapy are both feasible approaches for the treatment of stage II and stage III rectal carcinomas. The superiority of any of these concepts is awaited clarifying by randomized trials. Patients with locally advanced rectal cancers (T4) should undergo long-term neoadjuvant radiochemotherapy with consecutive oncological resection.