Patrick Schueller

12 years' experience with intraoperative radiotherapy (IORT) of malignant gliomas

Background:Even after surgery and radiotherapy, malignant gliomas still have a poor prognosis. The authors report on their experience with IORT in 71 patients.Patients and Methods:From May 1992 to February 2004, 71 patients with malignant gliomas were treated with IORT. 26 patients suffered from grade III gliomas, 45 patients from glioblastomas (GBM). IORT was carried out using a standard electron tube and 9- to 18-MeV electrons. 52/71 patients who were primarily treated received 20 Gy IORT + 60 Gy postoperative radiotherapy, 19/71 patients with recurrences only received IORT (20–25 Gy).Results:The complication rates were 1.4% for wound infections and 5.6% for hemorrhage. Median disease-specific survival amounted to 14.9 months (gliomas III) and 14.2 months (GBM). The 2-year survival rates amounted to 26.9% (gliomas III) and 6.8% (GBM; p = 0.0296). Total versus subtotal resection had no significant influence on survival (p = 0.0741), nor had age, sex, tumor site, performance status, size, primary versus recurrence, and radiation dose. A comparison to a conventionally treated patient group did not show a significant survival improvement. 3 months after treatment, initial symptoms had improved in 59% (hemiparesis), 50% (aphasia), 50% (hemianopsia), and 60% (convulsions).Conclusion:IORT has been shown to be feasible; perioperative complication rates were not increased. Survival was generally not improved compared to a historical control group. Recurrences achieved the same survival as primary tumors, and GBM also had a slightly increased survival, thus being possible indications for IORT.Hintergrund:Auch nach Resektion und Strahlentherapie haben maligne Gliome nach wie vor eine schlechte Prognose. Die Autoren berichten über ihre Erfahrungen mit der IORT bei 71 Patienten.Patienten und Methodik:Von Mai 1992 bis Februar 2004 wurden 71 Patienten mit malignen Gliomen mit IORT behandelt. 26 Patienten hatten Grad-III-Gliome, 45 Patienten Glioblastome (GBM). Die IORT wurde mittels eines üblichen Elektronentubus und 9- bis 18-MeV-Elektronen durchgeführt. 52/71 Patienten wurden primär mit 20 Gy IORT + 60 Gy postoperativer Radiotherapie behandelt, 19/71 Patienten mit Rezidiven erhielten nur eine IORT (20–25 Gy).Ergebnisse:Die Komplikationsraten betrugen 1,4% für Wundinfektionen und 5,6% für Blutungen. Das mediane krankheitsspezifische Überleben lag bei 14,9 Monaten (Gliome III) und 14,2 Monaten (GBM). Die 2-Jahres-Überlebensraten betrugen 26,9% (Gliome III) und 6,8% (GBM; p = 0,0296). Der Resektionsstatus hatte keinen signifikanten Einfluss (p = 0,0741), ebenso wenig Alter, Geschlecht, Lokalisation, Allgemeinzustand, Größe, Primärtumor versus Rezidiv und Bestrahlungsdosis. Ein Vergleich mit einem konventionell behandelten Patientenkollektiv zeigte keine signifikante Verbesserung des Überlebens. 3 Monate nach Therapie hatten sich die initialen Symptome in 59% (Hemiparese), 50% (Aphasie), 50% (Hemianopsie) und 60% (Krampfanfälle) gebessert.Schlussfolgerung:Die IORT ist gut durchführbar; die perioperative Komplikationsrate war nicht erhöht. Das Überleben konnte im Vergleich zu einer historischen Kontrollgruppe insgesamt nicht verbessert werden. Rezidive erzielten dasselbe Überleben wie Primärtumoren, und auch GBM erreichten ein etwas besseres Überleben; diese beiden Gruppen sind am ehesten mögliche Indikationen für die IORT.

Does the Imaging Method Have an Influence on the Measured Tumor Height in Ruthenium Plaque Therapy of Uveal Melanoma

Background and Purpose:For ruthenium plaque therapy of uveal melanoma the precise knowledge of the tumor height is necessary. The purpose of this analysis is to examine systematic differences between ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) measurements of tumor height in uveal melanoma.Material and Methods:From 1993 to 2000, 208 patients with uveal melanoma were treated with ruthenium therapy. US was done in 190/208 patients, CT in 147/208 patients, and MRI in 81/208 patients. The measurements from the imaging modalities were compared to each other. Separate comparisons were carried out for tumor size and localization and between two-dimensional (2-D) and three-dimensional (3-D) measurements in reconstructed planes.Results:In direct comparison, CT measurements (median: 4.5 mm; range: 1.6–10.5 mm) were nearly identical to MRI measurements (median: 4.5 mm; range: 2.0–11.4 mm), while US yielded the highest values (median: 5.2 mm; range: 2.5–13.4 mm). Linear regression yielded the following values: CT versus US (R2 = 0.88, correlation coefficient = 1.04), MRI versus US (R2 = 0.79, correlation coefficient = 0.92), MRI versus CT (R2 = 0.84, correlation coefficient = 0.90), and “2-D” versus reconstructed “3-D” (R2 = 0.93, correlation coefficient = 0.98).Conclusion:Differences between the measurements from all three modalities were generally acceptable, except for small tumors (≤4 mm; limited spatial resolution of CT/MRI) and temporal or peripheral lesions (angular distortion in US). In special anatomic situations, CT/MRI measurements can also result in distortions. “3-D” measurements can sometimes help in these situations.Hintergrund und Ziel:Für die Rutheniumbestrahlung des Aderhautmelanoms ist die genaue Kenntnis der Tumorprominenz notwendig. Ziel dieser Arbeit ist deshalb die Untersuchung systematischer Unterschiede zwischen den Messungen der Tumorprominenz mittels Ultraschall (US), Computertomographie (CT) und Magnetresonanztomographie (MRT).Material und Methodik:Von 1993 bis 2000 wurden 208 Patienten mit Aderhautmelanomen mit Rutheniumplaques behandelt. US wurde bei 190/208 Patienten, CT bei 147/208 Patienten und MRT bei 81/208 Patienten durchgeführt. Die Messungen der verschiedenen bildgebenden Verfahren wurden miteinander verglichen. Des Weiteren wurde nach Tumorgröße und -lage differenziert, und zweidimensionale (2-D) Messungen wurden mit „dreidimensionalen“ (3-D) in rekonstruierten Ebenen korreliert.Ergebnisse:Im direkten Vergleich waren die im CT gemessenen Werte (Median: 4,5 mm; Bereich: 1,6–10,5 mm) nahezu identisch mit den MRT-Messungen (Median: 4,5 mm; Bereich: 2,0–11,4 mm), während der US die höchsten Werte lieferte (Median: 5,2 mm; Bereich: 2,5–13,4 mm). Die lineare Regression ergab folgende Werte: CT versus US (R2 = 0,88, Korrelationskoeffizient = 1,04), MRT versus US (R2 = 0,79, Korrelationskoeffizient = 0,92), MRT versus CT (R2 = 0,84, Korrelationskoeffizient = 0,90) und „2-D“- versus rekonstruierte „3-D“-Messungen (R2 = 0,93, Korrelationskoeffizient = 0,98).Schlussfolgerung:Die Abweichungen zwischen den Messungen aller drei Verfahren waren insgesamt akzeptabel, außer bei kleinen Tumoren (≤4 mm; begrenzte Auflösung von CT/MRT) und temporalen oder peripheren Läsionen (Winkelverzerrung im US). In speziellen anatomischen Situationen können CT/MRT-Messungen auch zu Verzerrungen führen. „3-D“-Messungen können manchmal Abhilfe schaffen.

Giant Hemangioma/Kasabach-Merritt Syndrome

About 10% of neonates present with angioma in the first days or weeks of life. The main diagnostic and therapeutic problem is the correct differentiation of the various forms of vascular anomalies, which also defines the treatment strategy [21]. Especially the terms ‘hemangioma’ and Vascular malformation’ should be strictly separated from each other. Though both are caused by a disturbance in embryonic vessel development, vascular malformations already exist at the time of birth, while hemangiomas develop during the first days or weeks of life [19]. The initial clinical presentation can be very similar, so that exact history taking and clinical description are of great importance.

9 years tumor free survival after resection, intraoperative radiotherapy (IORT) and whole brain radiotherapy of a solitary brain metastasis of non-small cell lung cancer

Overall five-year survival for patients in NSCLC clinical stage IV is lower than 5% [1], in surgical stage IV (histologically proven distant metastases) nearly 0%. For patients with brain metastases in general, one-year survival amounts to about 10 /20% after whole-brain radiotherapy (WBRT) [2]. Several attempts to improve local control of brain metastases have been made, including dose escalation (RTOG 85 / 28). No significant difference in survival was found, median survival amounted to 3 /6 months [3]. In recent years, stereotactic radiosurgery has gained importance. One to three metastases of a suitable size (5/4 cm) may be an indication for stereotactic radiosurgery [4,5]. Electron beam intraoperative radiotherapy (IORT) for patients with malignant brain tumors has been performed at our institution since May 1992 [6]. Only few patients with brain metastases have been treated so far. We report a case of longterm control by surgery, IORT and WBRT. In October 1995, a 36-year old female patient (smoker) presented with the accidental diagnosis of a mass in the left upper lobe. CT and bronchoscopy confirmed the suspicion. Histology showed adenocarcinoma grade 1 /2. The tumor was clinically staged as T2N2M0 (stage IIIA). The patient was then recruited for the Muenster lung cancer trial [7]. She received three cycles of neoadjuvant CE chemotherapy followed by combined hyperfractionated radiochemotherapy with 45 Gy, carboplatin and vindesine. Under this regimen, a good partial remission was achieved. Besides a slight dysphagia, no further acute side effects were observed. She then underwent a radical resection (R0) of the left upper lobe with mediastinal lymphadenectomy (pathological tumor stage: ypT1N0G1 /2, SalzerKuntschik grade III). Ten months after the initial diagnosis she experienced severe headaches and scintillations. CT and MRI showed a solitary brain metastasis in the right occipital lobe with a diameter of about 2.5 cm. No further metastases or local recurrence were detected. It was then decided to perform a resection of this metastasis with IORT. No macroscopic residual tumor was left. IORT was carried out at a nondedicated facility with 14 MeV electrons from a linear accelerator using a 5 cm round cone [6]. The applied IORT dose was 20 Gy relative to the 90% isodose. After surgery and IORT, WBRT was done with a dose of 30 Gy in 10 fractions. Three years later, MRI showed a newly developed contrast enhancing structure in the right occipital lobe. Brain SPECT with Tl-201 and I-123-AMT showed a focal tracer uptake with an elevated tumor/ non-tumor ratio. F-18-FDG-PET showed a moderate glucose hypermetabolism. These findings were suspect for tumor recurrence. Because of the possible differential diagnosis of brain necrosis and