Susanne Bartelt

Patients with brain metastases: hope for recursive partitioning analysis (RPA) class 3

PURPOSE The objectives of the present study were (a) to validate the prognostic classification derived from recursive partitioning analysis (RPA) of the Radiation Therapy Oncology Group (RTOG); (b) to identify prognostic factors in class 3; (c) to examine the impact of treatment related variables on the prognosis in class 3. PATIENTS AND METHODS Nine hundred and sixteen patients with brain metastases had resection and whole brain radiotherapy (WBRT, n = 257) or WBRT alone (n = 659) at our institution from 1985 to 2000. Patients were grouped into RPA classes 1, 2, and 3 (n = 67, 441, and 408, respectively). RESULTS Median survival of the whole group was 3.4 months. Median survival in classes 1, 2, and 3 was 8.2, 4.9, and 1.8 months, respectively. In class 3, age (<65 years vs. > or =65 years, relative risk (RR) 0.75), status of the primary tumor (controlled vs. uncontrolled, RR 0.86), and the number of brain metastases (single vs. multiple, RR 0.76) were independent prognostic variables. We defined three prognostic subgroups: class 3a (n = 51): age <65 years, controlled primary tumor, single brain metastasis; class 3c (n = 44): age > or =65 years, uncontrolled primary tumor, multiple brain metastases; class 3b (n = 313): all other patients. Median survival in classes 3a, 3b, and 3c was 3.2, 1.9, and 1.2 months, respectively (P < 0.0001). Intra-class comparisons showed that resection followed by WBRT yielded significantly better survival compared with WBRT alone. CONCLUSION Our results validate the RTOG RPA classification for patients with brain metastases. The variables age, status of the primary, and number of brain metastases allow the division of class 3 into prognostic subgroups. Even class 3 patients may benefit from more aggressive treatment strategies.

Brain metastases in patients with cancer of unknown primary.

Between January 1985 and December 2000, 916 patients with brain metastases were treated with whole brain radiation therapy (WBRT) at the Department of Radiotherapy, University Hospital Freiburg. In 47 patients, a primary tumor could not be identified (cancer of unknown primary (CUP)). Sixteen patients had a solitary brain metastasis, 31 patients presented with multiple brain metastases. Surgical resection was performed in 15 patients, biopsy alone in 12 patients. WBRT was applied with daily fractions of 2 or 3Gy to a total dose of 50 or 30Gy, respectively. According to the recursive partitioning analysis (RPA) classes of the Radiation Therapy Oncology Group for patients with brain metastases none of the patients met the criteria for Class I, 23 for Class II, and 24 for Class III.The median overall survival (OS) for all patients with brain metastases (n = 916) was 3.4 and 4.8 months for patients with CUP (p = 0.45). In patients with CUP (n = 47) the median OS for patients with a single brain metastasis was 7.3 versus 3.9 months for patients with multiple brain metastases (p = 0.05). Median OS for patients with a Karnofsky performance status (KPS) ≥70 was 6.3 months versus 3.2 months for KPS <70 (p = 0.01).At multivariate analysis performance status and resection status could be identified as independent prognostic factors for the OS.

Religious belief as a coping strategy: an explorative trial in patients irradiated for head-and-neck cancer.

Purpose:To explore the role of religious belief in coping with disease symptoms and treatment-related side effects in patients with head-and-neck cancer under radiotherapy.Patients and Methods:Prospectively collected data were used with a cohort of head-and-neck cancer patients treated by radiotherapy and epoetin beta or placebo within a double-blind multicenter trial. All patients were divided into believers and nonbelievers. Answers to a quality of life questionnaire at four points in time during radiotherapy were analyzed according to both groups. Clinical parameters and therapy side effects were controlled regularly.Results:62.1% of the patients (66/105) sent back a baseline questionnaire discriminating between believers and nonbelievers. For 34.2% (40/105) data of all four measures could be obtained. On average, believers felt better in all categories of side effects at all points of time before, during and directly after therapy.Conclusion:Religious faith seems to play an important role in coping strategies of radiotherapy patients. More research in this area would be worthwhile.Ziel:Ziel der vorliegenden Untersuchung war es, die Rolle des religiösen Glaubens bei der Verarbeitung („Coping“) von Krankheitssymptomen und behandlungsbedingten Nebenwirkungen an Strahlentherapie-Patienten mit Kopf-Hals-Tumoren zu untersuchen.Patienten und Methodik:Die Studie wurde mit prospektiv erhobenen Daten an einer Kohorte von Patienten mit Kopf-Hals-Tumoren, die in einer doppelblinden Multicenterstudie mit einer Strahlentherapie und Epoetin beta oder Plazebo behandelt wurden, durchgeführt. Die Patienten wurden in zwei Gruppen, „Gläubige“ und „Nichtgläubige“, eingeteilt. Während der Therapie wurden, bezogen auf die beiden Gruppen, die Antworten auf einen Lebensqualitätsfragebogen zu vier Zeitpunkten ausgewertet. Klinische Parameter und Nebenwirkungen der Therapie wurden laufend kontrolliert.Ergebnisse:62,1% der Patienten (66/105) schickten den Basisfragebogen zurück, durch den zwischen Gläubigen und Nichtgläubigen unterschieden wurde. Für 32,2% der Patienten (40/105) konnten die Daten zu allen vier Messzeitpunkten ermittelt werden. Bezüglich aller erfassten Nebenwirkungen fühlten sich die Gläubigen über den gesamten Messzeitraum (vor, während und nach der Strahlentherapie) besser als die Nichtgläubigen.Schlussfolgerung:Der religiöse Glaube scheint für Copingstrategien bei Strahlentherapie-Patienten eine wichtige Rolle zu spielen, so dass dieses Gebiet weiter untersucht werden sollte.

Spectrophotometric skin measurements correlate with EORTC/RTOG-common toxicity criteria.

Purpose:It was investigated whether the elementary EORTC/RTOG-CTC score (Common Toxicity Criteria) for radiotherapy skin reactions correlates with spectrophotometric measurements of the skin color.Patients, Material, and Methods:In 41 patients irradiated for unilateral breast cancer the regular scoring by CTC was done during radiotherapy. In parallel, a total of 4,920 spectrophotometric measurements to determine the skin color were performed at baseline, at the beginning of radiotherapy, and at 20, 40 and 60 Gy. The nonirradiated contralateral breast was used for control measurements.Results:As expected, the skin color (especially red) depended on the radiation dose applied to the skin. The objective spectrophotometric measurements were found to correlate well with the subjective CTC scores.Conclusion:For classification of acute radiation toxicity there seems to be no need to replace the common CTC scoring by technical methods.Ziel:Es wurde untersucht, ob der einfach zu handhabende EORTC/RTOG-CTC-Score („Common Toxicity Criteria“) zur Bestimmung der Hauttoxizität einer Strahlentherapie mit spektralphotometrischen Messungen der Hautfarbe korreliert.Patienten, Material und Methodik:Bei 41 Patientinnen, die wegen eines unilateralen Mammakarzinoms bestrahlt wurden, wurde während der Strahlentherapie regelmäßig der CTC-Score für die Haut im Strahlenfeld erhoben. Parallel dazu wurden insgesamt 4 920 spektralphotometrische Messungen der Hautfarbe bei Studieneinschluss sowie vor Beginn der Bestrahlung und bei 20, 40 und 60 Gy durchgeführt. Die nicht bestrahlte kontralaterale Brust diente als Kontrolle.Ergebnisse:Erwartungsgemäß war die Hautfarbe von der Strahlendosis an der Haut abhängig (Abbildung 1). Die Ergebnisse der spektralphotometrischen Messungen korrelierten stark mit den subjektiven Bewertungen anhand der CTC-Klassifikation (Abbildung 2).Schlussfolgerung:Bei der Bewertung akuter Strahlennebenwirkungen scheint es keine Notwendigkeit zu geben, die bewährte CTC-Klassifikation durch technische Messmethoden zu ersetzen.

Malignant germ cell tumors metastatic to the brain: a model for a curable neoplasm? The Freiburg experience and a review of the literature.

The aim of this study on malignant germ cell tumors metastasizing to the brain is (a) to report our institutional experience, (b) to present three patients surviving for more than seven years, and (c) to review the literature with regard to long-term survival.From 1985 to 2000, 916 consecutive patients were treated with whole brain radiation therapy for brain metastases at our hospital. Eleven patients had cerebral lesions from histologically proven malignant germ cell tumors. Brain metastases were diagnosed at presentation (n = 2), following complete remission (n = 3), or along with extracerebral tumor progression (n = 6). Seven patients had a single brain metastasis. Three patients underwent resection. Eight patients reached the planned total dose of 50 Gy. Eight patients had chemotherapy.Median survival was 6.6 months. The long-term survivors all had an isolated cerebral relapse after complete remission, presented with a single brain metastasis, and were treated with resection and whole brain radiation therapy to a total dose of 50 Gy. The first patient died from a late relapse 89 months after the diagnosis of brain metastasis, the second patient is well and alive at 95 months. The third patient is currently being treated for a second malignancy originating from the lung. He is alive at 194 months, the longest survival for brain metastases from malignant germ cell tumors ever reported.Altogether, our study demonstrates that advanced extracerebral disease at initial diagnosis and isolated cerebral relapse after complete remission do not preclude long-term survival. Resection and whole brain radiation therapy might result in durable cerebral control with minimal morbidity.

Religious Belief as a Coping Strategy

Purpose:To explore the role of religious belief in coping with disease symptoms and treatment-related side effects in patients with head-and-neck cancer under radiotherapy.Patients and Methods:Prospectively collected data were used with a cohort of head-and-neck cancer patients treated by radiotherapy and epoetin beta or placebo within a double-blind multicenter trial. All patients were divided into believers and nonbelievers. Answers to a quality of life questionnaire at four points in time during radiotherapy were analyzed according to both groups. Clinical parameters and therapy side effects were controlled regularly.Results:62.1% of the patients (66/105) sent back a baseline questionnaire discriminating between believers and nonbelievers. For 34.2% (40/105) data of all four measures could be obtained. On average, believers felt better in all categories of side effects at all points of time before, during and directly after therapy.Conclusion:Religious faith seems to play an important role in coping strategies of radiotherapy patients. More research in this area would be worthwhile.Ziel:Ziel der vorliegenden Untersuchung war es, die Rolle des religiösen Glaubens bei der Verarbeitung („Coping“) von Krankheitssymptomen und behandlungsbedingten Nebenwirkungen an Strahlentherapie-Patienten mit Kopf-Hals-Tumoren zu untersuchen.Patienten und Methodik:Die Studie wurde mit prospektiv erhobenen Daten an einer Kohorte von Patienten mit Kopf-Hals-Tumoren, die in einer doppelblinden Multicenterstudie mit einer Strahlentherapie und Epoetin beta oder Plazebo behandelt wurden, durchgeführt. Die Patienten wurden in zwei Gruppen, „Gläubige“ und „Nichtgläubige“, eingeteilt. Während der Therapie wurden, bezogen auf die beiden Gruppen, die Antworten auf einen Lebensqualitätsfragebogen zu vier Zeitpunkten ausgewertet. Klinische Parameter und Nebenwirkungen der Therapie wurden laufend kontrolliert.Ergebnisse:62,1% der Patienten (66/105) schickten den Basisfragebogen zurück, durch den zwischen Gläubigen und Nichtgläubigen unterschieden wurde. Für 32,2% der Patienten (40/105) konnten die Daten zu allen vier Messzeitpunkten ermittelt werden. Bezüglich aller erfassten Nebenwirkungen fühlten sich die Gläubigen über den gesamten Messzeitraum (vor, während und nach der Strahlentherapie) besser als die Nichtgläubigen.Schlussfolgerung:Der religiöse Glaube scheint für Copingstrategien bei Strahlentherapie-Patienten eine wichtige Rolle zu spielen, so dass dieses Gebiet weiter untersucht werden sollte.

VMAT techniques for lymph node-positive left sided breast cancer.

PURPOSE To investigate the plan quality of two different volumetric modulated arc therapy (VMAT) techniques for lymph node-positive left-sided breast cancer. METHODS Two VMAT plans were generated for 10 lymph node-positive left-sided breast cancer patients: one plan using one single segment of a full rotation, typically an arc segment of 230° (1s-VMAT); and a second plan consisting of 2 small tangential arc segments of about 50° (2s-VMAT). For plan comparison, various dose and dose volume metrics (Dmean, D98%, D2% for target volumes, D2%, Dmean and Vx% for organs at risk (OAR)) were evaluated. RESULTS Both techniques fulfilled both clinical target dose and OAR goals. 1s-VMAT achieved a slightly better homogeneity and better target coverage (D2%= 54.2 ± 0.7 Gy, D98%= 30.3 ± 1.8 Gy) compared to 2s-VMAT (D2%= 55.0 ± 1.1 Gy, D98%= 29.9 ± 1.7 Gy). For geometrical reasons, OAR sparing was noticeable but not significant better using 2s-VMAT, particularly heart and contralateral breast. The heart received a mean dose of 4.4 ± 0.8 Gy using 1s-VMAT and 3.3 ± 1.0 Gy using 2s-VMAT; the contralateral breast received 1.5 ± 0.3 Gy and 0.9 ± 0.3 Gy, respectively. CONCLUSIONS A VMAT technique based on two small tangential arc segments enables improved OAR sparing; the differences between the two techniques in target coverage and homogeneity are minor. Patient age and -anatomy must be considered for each individual case when deciding which technique to be used.