Michael Heinrich Seegenschmiedt

Radiation prophylaxis for heterotopic ossification about the hip joint—a multicenter study

PURPOSE Prophylactic radiotherapy (RT) can prevent ectopic bone formation about the hip after total hip arthroplasty. The German Cooperative Group on Radiotherapy for Benign Diseases conducted a patterns of care study about this indication addressing the involved institutions, RT dose concepts, clinical handling, and treatment outcome of prophylactic RT about the hip joint. METHODS AND MATERIALS In 1999, a patterns of care study was conducted in all German institutions to analyze the accrual pattern, number of patients, and different indications for the use and performance of prophylactic RT about the hip. The applied RT concepts of prophylactic RT were evaluated with regard to the RT technique, timing of RT (pre- or postoperative), RT dose prescription (median, range of single and total doses), and treatment outcome. All institutions were asked about the radiologic and functional failure rates at least 1 year after the completion of RT using the established radiologic (Brooker) and functional (Harris) scores with objective and subjective evaluation components. RESULTS One hundred fourteen institutions reported their clinical experience with prophylactic RT for the prevention of heterotopic ossification about the hip joint: 70 community hospitals, 23 university hospitals, and 21 private RT practices. In 1999, 5677 patients (5989 hips) had received prophylactic RT. The median number per institution was 36 patients (range 8-240). The interdisciplinary referral included orthopedic surgery (89 institutions; 3763 patients), trauma surgery (82 institutions; 1611 patients), or other disciplines (8 institutions; 298 patients). Preoperative RT was applied in 53 institutions 0.5-24 h before surgery, and postoperative RT was applied in 54 institutions 1-120 h after surgery. Most patients received 1 x 7 Gy either pre- or postoperatively. The total dose range was 5-10 Gy (preoperative RT) or 5-16 Gy (postoperative RT); the median total RT dose of both RT concepts was 7 Gy. Cobalt-60 (n = 15), linear accelerators (n = 95), and a few lower energy units (n = 4) were used. Bony structures or prostheses were shielded with standard blocks in 31 and with individual blocks in 27 institutions. Long-term clinical evaluation was available in 30 institutions from 4377 hips. Of those, 475 (11%) developed radiologic failures according to Brookers criteria. Functional hip evaluation was available in 5 institutions from 685 hips. Of those, 34 (5%) had functional failures according to the criteria of Harris. No difference in outcome was found between pre- and postoperative RT, but was with regard to the patients referral and the timing of RT. The patients who were treated >8 h before surgery or >72 h after surgery experienced a higher radiologic failure rate; radiologic failures were an important precondition for functional failures (p <0.05). CONCLUSION This patterns of care study comprises the largest number of cases reported for prophylactic hip RT to date. The results reveal that both preoperative (within 24 h) and postoperative RT (within 72 h) are effective in preventing heterotopic ossification after hip surgery. Both RT concepts achieved a similar low radiologic and functional failure rate. Single-dose RT concepts, especially, can be recommended as an excellent treatment alternative for patients with contraindications to long-term steroid or nonsteroidal anti-inflammatory agents, and this approach has become standard in most German RT institutions.

Strahlentherapie des Basalzellkarzinoms : Lokale Kontrolle und kosmetisches Ergebnis

BACKGROUND The basal cell carcinoma which is often occurring in the elderly can be well treated by surgery. For large and recurrent lesions and in cosmetically difficult locations external beam radiotherapy provides an equally effective treatment alternative. PATIENTS AND METHODS From 1986 to 1999, 60 females and 39 males received primary radiotherapy for a total of 127 histologically verified basal cell carcinoma lesions. Tumors were mostly localized in the face at the temple, nose and forehead. Radiotherapy was applied with orthovoltage equipment and energies of up to 100 kV. Single doses ranged from 2 to 5 Gy related to the 80%-isodose depth. Weekly doses ranged from 8 to 25 Gy and total doses from 25 to 60 Gy. The mean follow-up period was 36 +/- 21 months. The acute sequelae were scored according to CTC criteria. Radiogenic late effects as single events were related to the radiation portal. RESULTS 3 months after treatment all besides one patient (99%) experienced complete tumor remission (CR). In all cases, acute radiation reaction occurred within the radiation portal: CTC Grade 1 in 100%, CTC Grade 2 in 54% and CTC Grade 3 in 30% of the cases. All side effects regressed under simple local measures without further complications. Late sequelae were observed in three cases. Overall cosmetic outcome was good to excellent in almost all patients (98%). In two cases (2%) a local recurrence was observed 6 and 20 months after radiotherapy. CONCLUSION External beam (orthovoltage) radiotherapy is very effective and yields high tumor control rates and good cosmetic results in long-term follow-up. Former dermatological treatment concepts should be replaced by an ICRU-based radiophysical dose prescription and should respect the newer radiobiological fractionation principles.Hintergrund: Das Basaliom oder Basalzellkarzinom ist ein im Alter häufig vorkommender Hauttumor, der chirurgisch gut behandelbar ist. Bei großen und rezidivierenden Tumoren und in kosmetisch ungünstiger Lokalisation stellt die perkutane Radiotherapie eine ebenso gute Therapieform dar. Patienten und Methode: Von 1986 bis 1999 wurden 60 Frauen und 39 Männer mit 127 histologisch gesicherten Basaliomen primär bestrahlt. Die Tumoren lagen meistens im Gesichtsbereich an Schläfe, Nase und Stirn. Die Radiotherapie erfolgte am Orthovoltgerät mit Energien bis 100 kV. Die Einzeldosis schwankte zwischen 2 und 5 Gy bezogen auf die 80%-Isodosentiefe; die Wochendosis betrug 8–25 Gy und die Gesamtdosis 25–60 Gy. Die Nachbeobachtung des Kollektivs betrug im Mittel 36±21 Monate. Die akuten Nebenwirkungen wurden nach CTC-Kriterien und die radiogenen Spätfolgen als Einzelereignisse bezogen auf das Bestrahlungsfeld beurteilt. Ergebnisse: Bis auf einen Patienten erzielten alle (99%) 3 Monate nach Therapieabschluss eine komplette Tumorremission (CR). Bei allen Fällen wurde eine akute Strahlenreaktion im Bestrahlungsfeld beobachtet: CTC-Grad 1 in 100%, CTC-Grad 2 in 54% und CTC-Grad 3 in 30% der Fälle. Alle Nebenwirkungen heilten unter einfachen lokalen Maßnahmen komplikationslos ab. Spätfolgen traten nur in drei Fällen (3%) auf. Das kosmetische Gesamtergebnis war bei allen bis auf zwei Patienten (98%) gut bis ausgezeichnet. Bei zwei Fällen (2%) kam es zu einem Lokalrezidiv 6 bzw. 20 Monate nach Ende der Strahlentherapie. Schlussfolgerung: Die perkutane Radiotherapie erzielt sehr gute Tumorkontrollraten und ein gutes kosmetisches Ergebnis im Langzeitverlauf. Die von Dermatologen geprägte empirische Dosisverschreibung muss in Zukunft der strahlenphysikalischen ICRU-Dosisverschreibung und den neuen radiobiologischen Erkenntnissen zur Fraktionierung Rechnung tragen.Background: The basal cell carcinoma which is often occurring in the elderly can be well treated by surgery. For large and recurrent lesions and in cosmetically difficult locations external beam radiotherapy provides an equally effective treatment alternative. Patients and Methods: From 1986 to 1999, 60 females and 39 males received primary radiotherapy for a total of 127 histologically verified basal cell carcinoma lesions. Tumors were mostly localized in the face at the temple, nose and forehead. Radiotherapy was applied with orthovoltage equipment and energies of up to 100 kV. Single doses ranged from 2 to 5 Gy related to the 80%-isodose depth. Weekly doses ranged from 8 to 25 Gy and total doses from 25 to 60 Gy. The mean follow-up period was 36±21 months. The acute sequelae were scored according to CTC criteria. Radiogenic late effects as single events were related to the radiation portal. Results: 3 months after treatment all besides one patient (99%) experienced complete tumor remission (CR). In all cases, acute radiation reaction occurred within the radiation portal: CTC Grade 1 in 100%, CTC Grade 2 in 54% and CTC Grade 3 in 30% of the cases. All side effects regressed under simple local measures without further complications. Late sequelae were observed in three cases. Overall cosmetic outcome was good to excellent in almost all patients (98%). In two cases (2%) a local recurrence was observed 6 and 20 months after radiotherapy. Conclusion: External beam (orthovoltage) radiotherapy is very effective and yields high tumor control rates and good cosmetic results in long-term follow-up. Former dermatological treatment concepts should be replaced by an ICRU-based radiophysical dose prescription and should respect the newer radiobiological fractionation principles.

Radiotherapy of basal cell carcinoma of the face and head: Importance of low dose per fraction on long-term outcome

Background: Radiotherapy plays an important role in the treatment of basal cell carcinoma of the face and head and achieves cure rates of 92‐96 %. Different fractionation concepts of radiotherapy have been described.This study investigates the efficacy, as well as acute and chronic toxicity, of a slightly hypofractionated radiotherapy schedule.

Strahlentherapie beim Morbus Ledderhose—Indikation und klinische Ergebnisse

Hintergrund:Der Morbus Ledderhose (ML) ist eine hyperproliferative Erkrankung der Plantaraponeurose, die dem Morbus Dupuytren (MD) sehr ähnlich ist. Wir prüften, ob eine Bestrahlung die Symptome lindern und die Progression der Erkrankung aufhalten kann.Patienten und Methoden:Von Juni 1996 bis Dezember 2002 wurden zwölf Frauen und 13 Männer im Alter von 9–76 (median 56) Jahren mit symptomatischem ML bestrahlt und mindestens 1 Jahr kontrolliert. Insgesamt wurden 36 Füße (16 rechts, 20 links) bestrahlt, da elf Patienten beidseits einen Befall hatten. Zwölf (48%) Patienten hatten auch einen MD. An 36 Füßen lagen 63 Knoten (mit 0,5–6,5 cm Größe) und an 13 (52%) Füßen 20 Stränge (mit 1–4 cm Länge) vor. Zusätzlich bestanden 14-mal (56%) starke Fußschmerzen, achtmal (32%) Probleme beim Laufen, zwölfmal (48%) andere Symptome (Druck, Schwellung, Spannung). Die Orthovolt-Radiotherapie erfasste alle tastbaren Knoten und Stränge. Es wurden zwei Serien zu je 5 x 3 Gy pro Woche (gesamt: 30 Gy) im Abstand von 8–12 Wochen gegeben. Die Auswertung erfolgte am Ende der RT, nach 3 und 12 Monaten und zuletzt im Dezember 2002. Primärer Endpunkt war die Vermeidung einer Progression bzw. Operation; sekundäre Endpunkte waren mehrere objektive morphologisch-funktionelle sowie subjektive Parameter (Visuelle Analogskala (VAS)).Ergebnisse:Nach 38 (12–67) Monaten medianem FU war kein Fuß progredient oder musste operiert werden. Bei 11 von 36 (44%) Füßen nahm die Zahl (minus 16) oder die Größe der Knoten und bei 7 von 13 (54%) Füßen die Zahl (–9) oder die Länge der Stränge ab; normale Gehfunktion erreichten sechs von zwölf (50%) Füßen; die Schmerzen verschwanden ganz oder teilweise bei 9 von 15 (60%) Füßen, die übrigen Symptome verschwanden bei 8 von 18 (44%) Füßen. Für 28 von 36 (78%) Füßen gaben 20 (80%) Patienten eine Besserung an, die übrigen blieben stabil. Die Verbesserung erreichte im Median 50% (0–100%) auf der VAS. Die Nebenwirkungen waren insgesamt gering: Während und bis zu 3 Monaten nach der RT hatten fünf (14%) Füße eine leichte Hautrötung (CTC 1°) im RT-Feld; bei drei (8%) Füßen blieb die Haut langfristig (> 12 Monate) trocken.Schlussfolgerungen:Die Bestrahlung ist bei ML wirksam und sollte noch vor einer Operation eingesetzt werden. Knoten, Stränge und Symptome können sich zurückbilden. Langzeitstudien und prospektive multizentrische Studien müssen diese Resultate noch bestätigen.Background:Morbus Ledderhose (ML) is a rare hyperproliferative disorder of the plantar aponeurosis which is similar in its clinical course to Morbus Dupuytren (MD). We examined whether radiotherapy (RT) can effect symptoms and prevent disease progression.Patients and Methods:From June 1996 to December 2001, 25 patients (12 female/13 male) aged 9–76 (median: 56) years had radiotherapy (RT) for symptomatic ML. Follow-up (FU) was at least 1 year. 36 feet (16 right/20 left) were treated, as eleven patients had bilateral disease. Twelve (48%) patients had MD. There were 63 nodules (with 0,5–6,5 cm diameter) on all feet and 20 cords (with 1–4 cm length) on 13 (52%) feet prior to RT. 21 (84%) patients had one or more signs: 14 (56%) severe local pain, eight (32%) walking difficulties, twelve (48%) other symptoms, pressure or tension sensation. The RT field involved all nodules and cords plus safety margin. Two RT-series were applied (each 5 3 Gy in 1 week) separated by 8–12 weeks up to a total dose of 30 Gy. Evaluation was performed at the end of RT, after 3 and 12 months FU and in December 2002. The primary endpoint was prevention of disease progression and avoidance of surgery. Secondary endpoints were objective changes of morphological and functional parameters and patient’s satisfaction measured on a visual analogue scale (VAS).Results:With a median FU of 38 (12–67) months no patient experienced progression or underwent surgery: 11 of 36 (44%) feet had a reduced number (overall: –16) or size of nodules, 7 of 13 (54%) feet had a reduced number (overall: –9) or length of cords; gait was improved in six of twelve (50%) feet; pain was reduced or had completely disappeared in 9 of 15 (60%) feet, and other symptoms disappeared in 8 of 18 (44%) symptomatic feet. 20 (80%) patients regarded 28 of 36 (78%) treated feet as improved and 8 (22%) in stable condition. The median relative improvement stated by patients on the VAS was 50% (0–100%). Treatment side effects were minimal: During and within 3 months of the RT course only a slight erythema (CTC 1°) was seen in five treated lesions, while dry skin changes within the RT portal were observed in three cases (11%) in long term FU (> 12 months).Conclusions:Radiotherapy is effective in treating ML and may prevent otherwise necessary surgical interventions. Nodules, cords and symptoms regress, but long-term outcome of at least 5 years has to be awaited. Prospective phase III studies should confirm these results.

Radiotherapy of Langerhans' Cell Histiocytosis : Results and Implications of a National Patterns-of-Care Study.

Purpose:This patterns-of-care study was performed to define the current clinical experience with radiotherapy of Langerhans’ cell histiocytosis in adults in Germany and to define open questions resulting from this study.Material and Methods:A standardized questionnaire was sent to 198 German radiotherapy institutions. Data about patient characteristics, stage of disease, practice and fractionation of radiotherapy, outcome of therapy, etc. were systematically evaluated. 123 of 198 institutions answered the complete questionnaire (62.1%).Results:Only 23 of the 123 institutions (18.7%) reported experience with radiotherapy of Langerhans’ cell histiocytosis of adults. 18 institutions with 98 patients were evaluable. The majority of patients (72 of 98) was treated on a linear accelerator. The median single dose of radiotherapy was 2 Gy, while the median total dose was 24 Gy. 81 of 89 evaluable patients (91%) reached a local control of the treated lesion(s), 69 of those had a complete remission. Eight of 89 patients (9%) developed an in-field recurrence. 87.8% of patients experienced no acute and 97% of patients no late side effects of radiotherapy.Conclusion:Clinical experience with radiotherapy of Langerhans’ cell histiocytosis in adults in Germany is still very limited. Nevertheless, the clinical results—with high remission and local control rates—confirm the effectiveness of radiotherapy in the multidisciplinary treatment of this disease. Due to the small number of patients in this study despite higher incidence rates, the knowledge of this disease has to be multiplied in Germany. Future patients should be systematically included into a prospective radiotherapy registry.Ziel:Diese Patterns-of-Care-Studie diente der Erhebung des gegenwärtigen Stands der Erfahrung mit der Strahlentherapie der Langerhans-Zell-Histiozytose bei Erwachsenen in Deutschland und der Definition daraus resultierender Fragen.Material und Methodik:Ein standardisierter Fragebogen wurde 198 deutschen Strahlentherapieinstitutionen zugesandt. Systematisch wurden Daten zu Patientenmerkmalen, Krankheitsstadium, Durchführung und Fraktionierung der Strahlentherapie, Behandlungsergebnis etc. ausgewertet. 123 von 198 Institutionen beantworteten den kompletten Fragebogen (62,1%).Ergebnisse:Nur 23 der 123 Institutionen (18,7%) berichteten über Erfahrung mit einer Strahlentherapie der Langerhans-Zell-Histiozytose bei Erwachsenen. 18 Institutionen mit 98 Patienten waren auswertbar. Die Mehrzahl der Patienten (72 von 98) wurde am Linearbeschleuniger behandelt. Die mediane Einzeldosis der Strahlentherapie betrug 2 Gy, die mediane Gesamtdosis 24 Gy. 81 der auswertbaren 89 Patienten (91%) erreichten eine lokale Kontrolle der behandelten Läsion(en), 69 von ihnen hatten eine komplette Remission. Acht der 89 Patienten (9%) bekamen ein In-Field-Rezidiv. Bei 87,8% der Patienten traten keine akuten und bei 97% der Patienten keine späten Nebenwirkungen der Strahlentherapie auf.Schlussfolgerung:Die klinische Erfahrung mit der Strahlentherapie der Langerhans-Zell-Histiozytose bei Erwachsenen in Deutschland ist noch sehr begrenzt. Nichtsdestoweniger bestätigen die Ergebnisse—mit hohen Remissions- und lokalen Kontrollraten—die Wirksamkeit der Strahlentherapie in der multidisziplinären Behandlung dieses Krankheitsbildes. Aufgrund der geringen Patientenzahl in der vorliegenden Studie trotz höherer Inzidenzrate sollte das Wissen über diese Erkrankung in Deutschland verbreitet werden. Künftige Patienten sollten systematisch in ein prospektives Strahlentherapieregister eingeschlossen werden.

[Radiotherapy of keloids. Patterns of care study -- results].

Hintergrund: Keloide stellen eine gutartige Gewebswucherung der Haut dar. Wegen der hohen Rezidivwahrscheinlichkeit nach alleiniger operativer Entfernung wird vielfach eine postoperative Strahlentherapie eingesetzt. Um Therapierichtlinien aufstellen zu können, ist die Erfassung der gegenwärtigen Therapiedurchführung und der dadurch erzielten Ergebnisse sowie Nebenwirkungen sinnvoll. Die Deutsche Gesellschaft für Radioonkologie (DEGRO) ermittelt daher in Patterns-of-Care-Studien entsprechende Daten. Patienten und Methode: Durch eine Umfrage an 250 Strahlentherapiekliniken/-praxen in Deutschland 1997/2000 wurden Daten zur Keloidbehandlung bezüglich der Therapiedurchführung, Ergebnisse und Nebenwirkungen ermittelt. Keloide wurden in 101 Kliniken/Praxen bestrahlt. In einem Erfassungszeitraum von bis zu 35 Jahren wurden 1672 Patienten bestrahlt und 880 Patienten nach der Therapie kontrolliert. Ergebnisse: Die Strahlentherapie erfolgte überwiegend kurzfristig postoperativ mit konventioneller Röntgenstrahlentherapie und Beschleunigerelektronen von 4–12 MeV Energie bei einer Fraktionierung von 3 bis 5 ×/Woche bei Einzeldosen von 2–3 Gy und Gesamtdosen von 10–20 Gy. Es wurden 101 Rezidive entsprechend einer Häufigkeit von 11,4% beobachtet, die den Angaben in der Literatur entspricht. Die Rezidive traten im Zeitraum von Wochen bis zu 2 Jahren nach der Therapie auf. Die beobachteten Nebenwirkungen waren gering, insbesondere wurde keine Malignombildung festgestellt. Schlussfolgerung: Die postoperative Strahlentherapie des Keloids wird in Deutschland überwiegend uner ähnlichen Bedingungen durchgeführt und bietet bei guter Verträglichkeit und nur geringen Nebenwirkungen eine wirksame Rezidivprophylaxe. Zur Beurteilung des Therapieerfolges ist eine Nachuntersuchung über mindestens 2 Jahre erforderlich.Background: Keloids are benign diseases of the scin. Because of the high rate of relapses after operation often postoperative irradiation is used. Treatment modalities must be collected by Patterns of Care Studies before therapy advices may be given from DEGRO. Patients and Method: Dates of investigations with questionnaire on mail of 250 radiotherapy institutions in Germany in 1997/2000 were collected to know therapy modalities, results and side effects. Keloids were irradiated in 101 institutions. During a time up to 35 years 1672 patients were irradiated, 880 patients had a follow-up. Results: Mostly radiotherapy was applicated soon postoperatively with kilovoltage radiotherapy or elektrons 4–12 MeV fractionated 3–5 times a week and single doses of 2–3 Gy up to total doses of 10–20 Gy. 101 relapses were seen, the frequency of 11.4% is in the range of literature. Relapses were seen in the interval of some weeks up to 2 years after therapy. Side effects of irradiation were low, no malignant transformation was reported. Conclusion: Postoperative radiotherapy for keloids is applicated in Germany mostly under equal conditions. This therapy offers effective relaps prophylaxis with nearly no side effects. A follow-up for 2 years is necessary to see outcome and relapses of irradiation.

Long-Term Outcome of Radiotherapy for Early Stage Dupuytren’s Disease: A Phase III Clinical Study

Purpose: Several retrospective studies have shown that radiotherapy (RT) can prevent progression of Dupuytren’s disease (DD), but so far no dose-response relationship has been established. This chapter presents long-term results of our previously published prospective randomized trial comparing two different RT doses with a control group without RT. Methods: From January 1997 to December 2009 over 600 patients with DD were referred to our clinic for RT to prevent further disease progression. As of January 2011, 489 pts (291 males; 198 females) with at least five (range 5–13; mean 8.5) years follow-up (FU) were included in the analysis. Due to bilateral affliction, a total of 718 hands (sites) were evaluated. Overall 73% of all hands were affected, 230 (47%) on both hands; according to Tubiana’s classification, 470 (65.5%) hands had stage N (nodules/cords, no extension deficit), 124 (17%) had stage N/I (≤ 10° deficit), 106 (15%) had stage I (11–45° deficit), and 18 (2.5%) had stage II (46–90° deficit) or more. After clinical assessment and informed consent, patients could choose between observation only (83 patients with 122 affected hands) and RT (406 patients with 596 affected hands); all patients in the RT group were randomized into two different RT concepts: One group (207 patients with 303 affected hands) received 10 × 3 Gy (total 30 Gy) in 2 series of each 5 × 3 Gy separated by a break of 12 weeks; the other group (199 patients with 297 affected hands) received 7 × 3 Gy (total 21 Gy) in one series within 2 weeks. Orthovoltage RT (120 kV) was applied using standard cones and individual shielding of uninvolved areas of the palm. The relevant patient and disease parameters were equally distributed between control and both RT groups. The clinical evaluation (side effects, efficacy) was performed at 3 and 12 months after RT and at last follow-up (FU) in December 2010. Subjective (patient’s satisfaction) and objective parameters (palpation, measurements, and comparative photographs) were applied to assess the response. The primary endpoints were objective clinical progression and necessity of salvage surgery. Secondary endpoints were treatment of side effects and specific objective disease parameters (number and size of nodules, cords) and patient’s subjective satisfaction. Results: The acute radiogenic toxicity was low with 26.5% CTC grade 1 and 2.5% CTC grade 2; late effects, such as dry skin, were acceptable low with 14% LENT grade 1; no secondary cancer was observed in the long-term follow-up. After a minimum FU of >5 and a mean FU of 8.5 years, a total of 119 (16.5%) sites showed remission of nodules, cords or stage; 383 (53%) remained stable and 206 (29%) progressed and of those 97 (13.5%) required surgery. The progression rate in the control group (any progression 62%, surgery 30%) as compared to RT groups (21 Gy: 24%/surgery 12%; 30 Gy: 19.5%/surgery 8%) was significantly higher (p < 0.0001). Similarly, the overall and mean number of nodules, cords, and other changes decreased in the RT groups as compared to the progression in the control group (p < 0.01). Tubiana’s classification at last FU revealed a stage progression in the control group in 63 (52%) sites as compared to 64 (22%) and 49 (16%) in the 21 and 30 Gy RT group. There were 50 (8%) relapses inside and 114 (19%) outside the RT field in the RT group as compared to 52% and 28% potential relapses in the control group. Salvage surgery was possible without healing problems. Symptomatic relief was achieved in 4 (8%) sites of the control group as compared to 24 (21%) and 32 (26%) sites in the 21 and 30 Gy group, respectively. Uni- and multivariate prognostic factors for disease progression were smoking habit (trend), symptom duration prior to RT over 24 months, Dupuytren stage, extension deficit, and digital involvement (all p < 0.05). The most important independent factor was the implementation of RT as compared to the control without RT. Conclusions: RT is effective to prevent progression of Dupuytren’s disease; it reduces the necessity of hand surgery which is required due to disease progression at a minimum FU of 5 years. In addition, RT can reduce disease-related symptoms or helps to avoid their progression. Both RT protocols have been found to be effective and well tolerated, with slight advantage for the 30 Gy group as compared to 21 Gy group. Both acute and chronic side effects were well accepted and tolerated by the patients; so far no secondary malignancy was observed. From the radiobiologic background and rationale of radiotherapy, it appears possible not only to implement radiotherapy in the beginning of the disease process but also during active disease periods, e.g., for early relapses after surgical procedures.

Strahlentherapie des Keloids in Deutschland Patterns-of-Care-Studie – Ergebnisse einer Umfrage

Hintergrund: Keloide stellen eine gutartige Gewebswucherung der Haut dar. Wegen der hohen Rezidivwahrscheinlichkeit nach alleiniger operativer Entfernung wird vielfach eine postoperative Strahlentherapie eingesetzt. Um Therapierichtlinien aufstellen zu können, ist die Erfassung der gegenwärtigen Therapiedurchführung und der dadurch erzielten Ergebnisse sowie Nebenwirkungen sinnvoll. Die Deutsche Gesellschaft für Radioonkologie (DEGRO) ermittelt daher in Patterns-of-Care-Studien entsprechende Daten. Patienten und Methode: Durch eine Umfrage an 250 Strahlentherapiekliniken/-praxen in Deutschland 1997/2000 wurden Daten zur Keloidbehandlung bezüglich der Therapiedurchführung, Ergebnisse und Nebenwirkungen ermittelt. Keloide wurden in 101 Kliniken/Praxen bestrahlt. In einem Erfassungszeitraum von bis zu 35 Jahren wurden 1672 Patienten bestrahlt und 880 Patienten nach der Therapie kontrolliert. Ergebnisse: Die Strahlentherapie erfolgte überwiegend kurzfristig postoperativ mit konventioneller Röntgenstrahlentherapie und Beschleunigerelektronen von 4–12 MeV Energie bei einer Fraktionierung von 3 bis 5 ×/Woche bei Einzeldosen von 2–3 Gy und Gesamtdosen von 10–20 Gy. Es wurden 101 Rezidive entsprechend einer Häufigkeit von 11,4% beobachtet, die den Angaben in der Literatur entspricht. Die Rezidive traten im Zeitraum von Wochen bis zu 2 Jahren nach der Therapie auf. Die beobachteten Nebenwirkungen waren gering, insbesondere wurde keine Malignombildung festgestellt. Schlussfolgerung: Die postoperative Strahlentherapie des Keloids wird in Deutschland überwiegend uner ähnlichen Bedingungen durchgeführt und bietet bei guter Verträglichkeit und nur geringen Nebenwirkungen eine wirksame Rezidivprophylaxe. Zur Beurteilung des Therapieerfolges ist eine Nachuntersuchung über mindestens 2 Jahre erforderlich.Background: Keloids are benign diseases of the scin. Because of the high rate of relapses after operation often postoperative irradiation is used. Treatment modalities must be collected by Patterns of Care Studies before therapy advices may be given from DEGRO. Patients and Method: Dates of investigations with questionnaire on mail of 250 radiotherapy institutions in Germany in 1997/2000 were collected to know therapy modalities, results and side effects. Keloids were irradiated in 101 institutions. During a time up to 35 years 1672 patients were irradiated, 880 patients had a follow-up. Results: Mostly radiotherapy was applicated soon postoperatively with kilovoltage radiotherapy or elektrons 4–12 MeV fractionated 3–5 times a week and single doses of 2–3 Gy up to total doses of 10–20 Gy. 101 relapses were seen, the frequency of 11.4% is in the range of literature. Relapses were seen in the interval of some weeks up to 2 years after therapy. Side effects of irradiation were low, no malignant transformation was reported. Conclusion: Postoperative radiotherapy for keloids is applicated in Germany mostly under equal conditions. This therapy offers effective relaps prophylaxis with nearly no side effects. A follow-up for 2 years is necessary to see outcome and relapses of irradiation.

Radiotherapie im frühen Stadium des Morbus Dupuytren

ZusammenfassungHintergrundUm die Progredienz der Dupuytrenschen Kontraktur zu verhindern, wurden Patienten an unserer Klinik im Frühstadium der Erkrankung bestrahlt. Die kurz- und langfristigen Ergebnisse sowie akute und chronische Nebenwirkungen der Radiotherapie werden vorgestellt.Patienten und MethodeVon 1982 bis 1993 wurden 96 Patienten (142 Hände) mit Orthovolt-Radiotherapie bestrahlt. Dazu wurden zwei Kurse zu je 5×3 Gy täglich fraktioniert im Abstand von sechs Wochen verabreicht (insgesamt 30 Gy). Das klinische Stadium der Dupuytrenschen Kontraktur wurde nach Tubiana et al. [38] bestimmt. Die initiale Beurteilung erfolgte drei Monate nach Radiotherapie; das langfristige Ergebnis wurde zwischen Februar und April 1994 ermittelt. Die Nachbeobachtungszeit betrug damit 6±2 (1 bis 12) Jahre. 57 Patienten mit einem minimalen Follow-up von fünf (Median 7,5; 5 bis 12) Jahren wurden in bezug auf langfristige Resultate (Stabilisierung, Progression) gesondert ausgewertet. Die akute und chronische Toxizität der Radiotherapie wurde gemäß der RTOG/EORTC-Kriterien bestimmt.ErgebnisseBezogen auf das Stadium, waren 130 (92%) Hände drei Monate nach Radiotherapie stabil, zehn (7%) verbesserten und zwei Hände (1%) verschlechterten sich. Eine objektivierbare Reduktion von Knoten und Strängen wurde bei 107 (75%) Fällen erzielt. Zusätzlich bemerkten 84 (87%) Patienten einen Rückgang der Symptomatik. Zum aktuellen Follow-up waren 16 von 142 (11%) Fällen progredient im Stadium. In der Gruppe mit einem Follow-up von ≥5 Jahren (n=57) waren 44 (77%) Fälle stabil und 13 (23%) progredient, achtmal innerhalb und fünfmal außerhalb des Radiotherapie-Feldes. Einige „Versager” hätten vermieden werden können, wenn ein größerer Sicherheitssaum bei der Radiotherapie berücksichtigt worden wäre; einige Versager wurden jedoch noch ein weiteres Mal erfolgreich bestrahlt oder operiert.SchlußfolgerungDie Radiotherapie verhindert wirksam eine Progression im Frühstadium des Morbus Dupuytren. Damit können andernfalls notwendige chirurgische Eingriffe in den fortgeschritteneren Stadien der Dupuytrenschen Kontraktur vermieden werden. Im Falle einer Progression ist eine Operation immer noch möglich.AbstractAimRadiotherapy was applied in our clinic to prevent the disease progression in early stage Dupuytren’s contracture. Initial response, long-term outcome, acute and late toxicity of the treatment were evaluated in a retrospective analysis.Patients and MethodBetween 1982 and 1993, 96 patients (142 hands) received orthovoltage radiotherapy, which consisted of 2 radiotherapy courses with daily fractionation of 5×3 Gy (total dose: 30 Gy) separated by a 6 weeks interval. The Dupuytren’s contracture was staged according to the classification of Tubiana et al. [38]. The initial evaluation was performed 3 months after completion of radiotherapy, while long-term outcome was analysed at last follow-up between February and April 1994. The mean follow-up was 6±2 (range 1 to 12) years. Fifty-seven patients with a follow-up of ≥5 (median 7,5; mean 9,5 to 12) years were separately evaluated for long-term outcome, i. e. prevention of disease progression. Acute and late treatment toxicity was assessed using the RTOG/EORTC criteria.ResultsAccording to stage, 130 (92%) cases remained stable at 3 months follow-up, 10 (7%) improved and 2 (1%) progressed. An objective reduction of symptomatic cords and nodules was achieved in 107 (75%) cases at 3 months follow-up. Moreover, 87% of the patients reported a subjective relief of symptoms. In long-term follow-up, only 16 of 142 (11%) cases had progressed according to stage. In the group with a minimum follow-up of 5 years (n=57), 44 (77%) patients experienced no progression, while 13 (23%) progressed inside (8 cases) or outside (5 cases) of the radiotherapy field. Many “failures” could have been avoided with appropriate choice of larger safety margins included in the treated portals, however, most failures were successfully managed by a second radiotherapy or hand surgery.ConclusionRadiotherapy prevents disease progression for early stage Dupuytren’s contracture. Thus, an otherwise necessary surgical procedure in adavanced stages of Dupuytren’s contracture can be avoided. Moreover, in case of disease progression despite radiotherapy a second radiotherapy or salvage operation is still feasible.

[Radiotherapy in painful gonarthrosis. Results of a national patterns-of-care study].

BACKGROUND AND PURPOSE After a patterns-of-care study (PCS) in 2003/2004 addressing benign disorders in general, the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) conducted several multicenter cohort studies including the use of radiotherapy (RT) in painful gonarthrosis (GNA). MATERIAL AND METHODS From 2006 to 2008, a PCS for GNA was conducted in all German RT institutions using a standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment indications, RT technique, and target volume concepts for painful GNA were assessed. In addition, the long-term functional and subjective outcomes were evaluated. RESULTS 238/248 institutions (95.9%) returned the questionnaire: 50 (21%) reported no clinical experience with RT in GNA, while 188 (79%) institutions treated 4,544 patients annually (median 15; range one to 846 cases per institution). Indications for treatment were acute pain symptoms in 18.9%, chronic pain in 95.3%, and treatment-refractory pain in 81.1%. The median total dose was 6 Gy (range 3-12 Gy), with a median single dose of 1 Gy (0.25-3 Gy). 40.4% of the institutions applied two fractions and 51.4% three fractions weekly. RT was delivered with orthovoltage units (25%), linear accelerators (79.6%), and cobalt-60 units (8.3%). 42 institutions evaluated the long-term clinical outcome in a total of 5,069 cases. Median pain reduction for at least 3 months was reported in 60% (5-100%), median pain reduction for at least 12 months in 40% (10-100%), and median persistent pain reduction in 27.8% (10-85%) of the treated patients. In 30% of patients (7-100%), a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic acute or chronic side effects were observed. CONCLUSION This PCS comprises the largest number of cases reported for RT in painful and refractory GNA. Despite variations in daily RT practice, high response and low toxicity for this treatment in a very large number of painful and refractory GNA cases renders low-dose RT an effective conservative therapy which can be applied prior to surgical procedures.Hintergrund und Ziel:Nach einer Patterns-of-Care-Studie (PCS) der AG Strahlentherapie gutartiger Erkrankungen der Deutschen Gesellschaft für Radioonkologie (DEGRO) 2003/2004 ist eine Vielzahl von einzelnen PCS zu unterschiedlichen gutartigen Erkrankungen durchgeführt worden. Hier wird nun die PCS betreffend Radiotherapie (RT) bei schmerzhafter Gonarthrose (GNA) vorgestellt.Material und Methodik:Von 2006 bis 2008 wurden alle deutschen strahlentherapeutischen Institutionen mit Hilfe eines standardisierten Fragebogens hinsichtlich Patientenzuweisung und -anzahl, Anamnese, Vorbehandlungen, Bestrahlungsindikationen und -techniken, Zielvolumenkonzepten usw. sowie Behandlungsergebnissen betreffend RT bei schmerzhafter GNA befragt.Ergebnisse:Insgesamt beantworteten 238/248 (95,9%) der strahlentherapeutischen Einrichtungen in Deutschland den Fragebogen. 188/238 (79%) der strahlentherapeutischen Einrichtungen führen eine RT bei schmerzhafter GNA durch. Jährlich wurden in Deutschland 4 544 Patienten (im Median 15 pro Institution; ein bis 846) mit schmerzhafter GNA bestrahlt. Indikationen waren akute Schmerzen in 18,9%, chronische Schmerzen in 95,3% sowie therapierefraktäre Schmerzen in 81,1%. Die im Median applizierte Gesamtdosis betrug 6 Gy (3–12 Gy) bei einer medianen Einzeldosis von 1 Gy (0,25–3 Gy). 40,4% der Institutionen bestrahlten zweimal pro Woche, 51,4% dreimal pro Woche. Die RT wurde in 25% der Fälle mit einem Orthovoltgerät, in 79,6% mit einem Linearbeschleuniger und in 8,3% mit einem Cobalt-60-Gerät durchgeführt. 42 Einrichtungen evaluierten die Resultate der RT von insgesamt 5 069 behandelten Patienten. Eine mediane Schmerzreduktion von mindestens 3 Monaten konnte in 60% (5–100%), eine mediane Schmerzreduktion von mindestens 12 Monaten in 40% (10–100%) und eine mediane dauerhafte Schmerzreduktion in 27,8% (10–85%) der bestrahlten Patienten erreicht werden. Im Median erhielten 30% (7–100%) der Patienten eine zweite Bestrahlungsserie. Es wurden keine radiogenen Akut- und Spätreaktionen angegeben.Schlussfolgerung:Die vorliegende PCS bestätigt mit der bisher weltweit größten Fallzahl die traditionell weite Verbreitung der RT bei der schmerzhaften GNA in Deutschland sowie die damit verbundenen sehr guten Resultate. Die RT bei schmerzhafter GNA kann als effektive und nebenwirkungsfreie Option vor operativen Eingriffen durchgeführt werden.Backgroud and Purpose:After a patterns-of-care study (PCS) in 2003/2004 addressing benign disorders in general, the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) conducted several multicenter cohort studies including the use of radiotherapy (RT) in painful gonarthrosis (GNA).Material and Methods:From 2006 to 2008, a PCS for GNA was conducted in all German RT institutions using a standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment indications, RT technique, and target volume concepts for painful GNA were assessed. In addition, the long-term functional and subjective outcomes were evaluated.Results:238/248 institutions (95.9%) returned the questionnaire: 50 (21%) reported no clinical experience with RT in GNA, while 188 (79%) institutions treated 4,544 patients annually (median 15; range one to 846 cases per institution). Indications for treatment were acute pain symptoms in 18.9%, chronic pain in 95.3%, and treatment-refractory pain in 81.1%. The median total dose was 6 Gy (range 3–12 Gy), with a median single dose of 1 Gy (0.25–3 Gy). 40.4% of the institutions applied two fractions and 51.4% three fractions weekly. RT was delivered with orthovoltage units (25%), linear accelerators (79.6%), and cobalt-60 units (8.3%). 42 institutions evaluated the long-term clinical outcome in a total of 5,069 cases. Median pain reduction for at least 3 months was reported in 60% (5–100%), median pain reduction for at least 12 months in 40% (10–100%), and median persistent pain reduction in 27.8% (10–85%) of the treated patients. In 30% of patients (7–100%), a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic acute or chronic side effects were observed.Conclusion:This PCS comprises the largest number of cases reported for RT in painful and refractory GNA. Despite variations in daily RT practice, high response and low toxicity for this treatment in a very large number of painful and refractory GNA cases renders low-dose RT an effective conservative therapy which can be applied prior to surgical procedures.