Thomas Hendrik Knocke

High-dose-rate (HDR) brachytherapy with or without external beam radiotherapy in the treatment of primary vaginal carcinoma: Long-term results and side effects

PURPOSE To report toxicity, prognostic factors, and outcome of HDR brachytherapy in the primary management of vaginal carcinoma. METHODS AND MATERIALS A total of 86 patients receiving radiotherapy for primary vaginal carcinoma were analyzed. FIGO stages 0-IV were found in 6, 17, 38, 20, and 5 patients, respectively. Early stages of disease (Stages 0-II) were treated with intravaginal HDR brachytherapy alone (n = 26/86), whereas locally advanced diseases (Stages II-IV) received HDR brachytherapy combined with external beam therapy (n = 55/86). Teletherapy only was used in 5 of 86 cases, all of which were treated with palliative intent (i.e., advanced stage, poor general status). Recurrence-free intervals as well as overall- and disease-specific survival rates were determined for all patients. Frequencies of side effects and the influence of prognostic factors and treatment modalities on outcome were analyzed. RESULTS Five-year overall survival rates for Stages 0-IV diseases were 83%, 41%, 43%, 37%, and 0%, respectively. Corresponding 5-year disease-specific survival rates were 100%, 92%, 57%, 59%, and 0%. Regarding 5-year recurrence-free intervals, values of 100%, 77%, 50%, 23%, and 0% (Stages 0-IV) were found, respectively. Tumor stage was the most significant prognostic factor. Chronic side effects G 1-4 were observed in <or=2% (bladder, rectum) and 1%-6% (vagina). CONCLUSION In the treatment of primary vaginal carcinoma, HDR brachytherapy appeared to be well-tolerated and as effective as LDR brachytherapy techniques.

The benefit of Beam's eye view based 3D treatment planning for cervical cancer

PURPOSE The aim of this study was to evaluate the possibility of Beams eye view (BEV) based three dimensional (3D) treatment planning, to reduce portions of organs at risk included in the treated volume without increasing the risk of geographical miss in external beam therapy of cervical cancer. MATERIALS AND METHODS Three dimensional dose distribution of BEV based 3D treatment plans was compared to the 3D dose distribution derived from a four-field-box-technique using standard portals. A total of 20 patients with cervical cancer stage FIGO IIB and FIGO IIIB was included. Dose distribution in the target volumes and in the organs at risk of BEV based treatment planning, was compared to the dose distribution of the standard field technique using dose-volume-histograms. RESULTS In 4/20 patients (20%) a geographical miss at the cervix uteri was observed for the standard field technique. The BEV based treatment planning resulted in an adequate coverage of target volume and additionally in a reduction of portions of bladder and bowel volume included in the treated volume (-13.5, -10%). In contrast the BEV based technique resulted in an increase of portions of the rectum volume included in the treated volume compared to standard portals due to a shift of the rectum by the enlarged cervix uteri from its posterior to a lateral position. An overall 7% reduction of treated volume was observed, although the maximum width of lateral fields increased for the BEV technique. Moreover, we have found a remarkable impact of bladder fillings on the amount of bowel and bladder volume included in the treated volume. CONCLUSION BEV based 3D treatment planning for external beam therapy of cervical cancer offers a possibility to avoid geographical miss of part of the CTV with reduced portions of bladder and bowel volume included in the treated volume.

Treatment of endometrial carcinoma with high‐dose‐rate brachytherapy alone in medically inoperable stage I patients

PURPOSE To review the results of treatment with high-dose-rate brachytherapy alone in 228 patients with stage I endometrial carcinoma who are unfit for surgery. METHODS All patients received an exclusive radiation therapy by means of high-dose-rate Iridium 192 intracavitary brachytherapy without additional external beam radiation. RESULTS At 5 years, the overall survival rate was 59.7% and disease specific survival 85.4% at 10 years 30.2% and 75.1%. In clinical stage Ia disease specific survival was 88.6% at 5 years and 82.7% at 10 years, in stage Ib 80.2% and 63.4%, respectively (p<0.02). Disease specific survival was not affected by tumor grade or age. The rates of local control are related to the size of the uterus but not to the tumor grading. Intrauterine recurrence occurred in 17.5% but extrauterine pelvic relapse in only 0.4% of patients. The calculated probability of severe complications was 4.6% at 5 years. CONCLUSION HDR brachytherapy alone achieves excellent disease specific survival rates in patients with medically inoperable stage I endometrial carcinoma.

Incidence of dermatitis in head and neck cancer patients treated with primary radiotherapy and cetuximab

Purpose:To retrospectively assess the incidence of radiation dermatitis in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) who received primary radiotherapy in combination with cetuximab in a curative intent.Patients and Methods:A total of 112 consecutively treated patients who received cetuximab in combination with radiotherapy at the Departments of Radiotherapy at the Medical University in Vienna and the Hospital Hietzing (Vienna) were analyzed. Radiotherapy was administered either as conventional radiotherapy (70 Gy in 7 weeks) or using a concomitant boost protocol (72 Gy in 6 weeks). The incidence of dermatitis and mucositis within the radiation portals in 103 eligible patients was compared with a historical control group treated at the Medical University of Vienna as well as with published data.Results:The incidence of grade 1/2, 3, and 4 dermatitis was 57%, 29%, and 1% in the radiotherapy plus cetuximab treated collective. The incidence of grade 1/2, 3, and 4 mucositis was 37%, 47%, and 4%, respectively. The incidence of grade 3 dermatitis during concurrent radiotherapy plus cetuximab was 29% in our patient collective. Only one case of grade 4 dermatitis was observed.Conclusion:These results do not statistically differ significantly from the incidence reported in the Bonner trial and indicate that cetuximab in combination with radiotherapy is well tolerated.Ziel:Retrospektive Prüfung der Inzidenz der Strahlendermatitis bei Patienten mit lokal fortgeschrittenen nicht-resektablen Tumoren der Kopf-Hals-Region, die eine primäre Radiotherapie in Kombination mit Cetuximab in kurativer Intention erhielten.Patienten und Methodik:Insgesamt wurden 112 konsekutiv behandelte Patienten analysiert, die Cetuximab in Kombination mit Radiotherapie an den Abteilungen für Strahlentherapie der Medizinischen Universität Wien und des Krankenhauses Hietzing (Wien) erhielten. Die Strahlentherapie bestand entweder aus einer konventionellen Radiotherapie (70 Gy in 7 Wochen) oder aus einem konkomitanten Boost-Protokoll (72 Gy in 6 Wochen). Die Inzidenz an Dermatitis und Mukositis innerhalb der Bestrahlungsfelder wurde von 103 auswertbaren Patienten ermittelt und mit einer historischen Kontrollgruppe der Medizinischen Universität Wien wie auch mit publizierten Daten verglichen.Ergebnisse:Die Inzidenz von Grad-1/2-, -3- und -4-Dermatitis betrug jeweils 57%, 29% und 1% in der Radiotherapie-plus-Cetuximab-Gruppe. Die Inzidenz an Grad-1/2-, -3- und -4-Mukositis betrug jeweils 37%, 47% und 4%. Die Inzidenz von Grad-3-Dermatitis während einer konkomitanten Radiotherapie und Cetuximab betrug 29% in unserem Patientenkollektiv. Nur ein Fall einer Grad-4-Dermatitis wurde beobachtet.Schlussfolgerung:Die Ergebnisse unterscheiden sich in statistischer Weise nicht signifikant von der in der Bonner-Studie publizierten Inzidenz und weisen darauf hin, dass Cetuximab in Kombination mit Bestrahlung gut vertragen wird.

Radiotherapy alone for invasive vaginal cancer: outcome with intracavitary high dose rate brachytherapy versus conventional low dose rate brachytherapy

Purpose. Our aim was to compare the role of remote afterloaded high‐dose‐rate brachytherapy (HDRB) with traditional low‐dose‐rate brachytherapy (LDRB) for patients with invasive primary vaginal carcinoma.

Analyse unterschiedlicher Applikationsformen und CT-gestützter Planungsvarianten in der Behandlung primärer Endometriumkarzinome

ZusammenfassungHintergrundIn der Primärbehandlung des Endometriumkarzinoms bei inoperablen Patientinnen stellt die intrakorporale Brachytherapie einen wesentlichen Bestandteil dar. Bei häufig unklarer Tumorausdehnung betrachtet man hierbei den gesamten Uterus als zu behandelndes Zielvolumen. Im Rahmen dieser Analyse werden unterschiedliche Applikations-und Planungsvarianten des intrakavitären Afterloadings hinsichtlich der Korrelation zwischen Ziel- und Behandlungsvolumen vergleichend gegenübergestellt.Patienten und MethodeBei zehn aufeinanderfolgenden Patientinnen mit primär bestrahlten Endometriumkarzinomen wurden die Ziel- und Behandlungsvolumina bei Verwendung eines standardisierten Ein-Kanal-Applikators sowie individueller Heyman-Applikatoren bestimmt. Die Berechnung der individuellen Zielvolumina (Uterusvolumina) erfolgte am 3D-Planungssystem anhand der computertomographischen (CT) Aufnahmen mit liegenden Applikatoren. Analog der gemessenen Länge des Cavum uteri (Sondenlänge) wurde das entsprechende standardisierte Bestrahlungsprogramm mit resultierendem Behandlungsvolumen ermittelt. In bezug auf die individuellen Heyman-Applikationen wurden zwei unterschiedliche — als standardisiert bzw. optimiert bezeichnete — Planungsvarianten durchgeführt, um die Verbesserungsmöglichkeiten einer detaillierteren Planungsform zu ermitteln.ErgebnisseDas mittlere Uterusvolumen belief sich auf 180 cm3 (Streubreite 57 bis 316 cm3). In 40% der Fälle lag eine asymmetrische Uteruskonfiguration mit koronaren bzw. sagittalen Seitendifferenzen von mehr als 1 cm vor. Bei Verwendung eines standardisierten Ein-Kanal-Applikators wurden durchschnittlich 47% (Streubreite 25 bis 89%) des Uterusvolumens erfaßt. Im Vergleich hierzu betrug der entsprechende Durchschnittswert bei individueller Heyman-Applikation insgesamt 70% (Streubreite 36 bis 110%). Differenziert man dieses Ergebnis je nach durchgeführter Planungsform, so ergaben sich durchschnittlich 66% (Streubreite 36 bis 110%) bei der standardisierten sowie durchschnittlich 73% (Streubreite 48 bis 95%) bei der optimierten Variante. In bezug auf die individuellen Heyman-Applikationen konnte mittels optimierter Planungsform eine verbesserte Zielvoluminaerfassung in fünf von zehn Fällen erreicht werden, was mit einem Anstieg des Behandlungsvolumens um durchschnittlich 20% einherging (Streubreite 11 bis 32%). In drei Fällen ergaben sich Veränderungen des Behandlungsvolumens von weniger als 5% (keine Verbesserungen). In zwei Fällen wurde das Volumen zur Schonung der Risikoorgane um 19% bzw. 40% reduziert.SchlußfolgerungenIn der brachytherapeutischen Behandlung des primären Endometriumkarzinoms konnten durch Verwendung individualisierter Applikations- und Planungstechniken verbesserte Zielvoluminaerfassungen erreicht werden. Eine vollständige Erfassung des Uterus, was der eigentlichen Zielsetzung entspricht, war jedoch nicht möglich. Im Rahmen einer optimierten, brachytherapeutischen Behandlung erschein die Berücksichtigung der individuellen Tumorausdehnung bzw. Uteruskonfiguration erforderlich. In diesem Zusammenhang ist die Verwendung von entsprechend unterschiedlichen Applikatoren sicherlich notwendig.AbstractBackgroundIntracorporal brachytherapy is regarded as the definitive component of treatment for inoperable patients with endometrial carcinoma. Until now the whole uterus has been claimed to represent the target volume independent of individual tumor spread. The purpose of this work is to analyse the correlation between target volume and treated volume using different application- and planning procedures.Patients and MethodsIn a consecutive series of 10 patients with primary irradiated endometrial carcinoma we analyzed the correlation between target volume and treated volume using either standard 1-channel applicators or individual Heyman-applicators. Application of the ovoids was followed by a planning CT scan for all patients. Based on this, target volume (uterus volume) was estimated on a 3D-planning system. According to the measurable length of the uterus cavity we determined the corresponding standard 1-channel applicator and calculated the respectively treated volume. Estimating the advantages of an optimized treatment planning strategy for individual Heyman- applications we compared the treated volumes, which result from a standardized and optimized treatment planning procedure.Resultsthe mean uterus volume was 180 cm3 (range 57 to 316 cm3). Asymmetric uterus configurations with longitudinal or sagittal side differences exceeding 1 cm were found in 40% of the cases. Using standard 1-channel applicators on average 47% (range 25 to 89%) of the uterus volume were enclosed by the treated volume compared to 70% for Heymanapplications. Differentiating these individual applications according to the variable treatment modality values of mean 66% (range 36 to 110%) for the standardized and 73% (range 48 to 95%) for the optimized treatment planning strategy were found. Moreover optimized planning modalities led to an improved coverage of the target volume in 5 out of 10 cases with an increase in volume of 20% on average (range 11 to 32%). In 3 cases changes of less than 5% were noticed (no improvement). In order to protect organs at risk treated volume had to be decreased in 2 cases for 19% and 40% respectively.ConclusionsIntracavitary brachytherapy of primary endometrial carcinoma was improved by individualized application-and planning procedures, which led to better adaptations of the treated volumes to the target volumes. Nevertheless a complete coverage — corresponding to the primary intent — was not possible. Individualized and optimized brachytherapy must be performed according to the individual tumor spread and uterus configuration. Therefore, different applicators are required.BACKGROUND Intracorporal brachytherapy is regarded as the definitive component of treatment for inoperable patients with endometrial carcinoma. Until now the whole uterus has been claimed to represent the target volume independent of individual tumor spread. The purpose of this work is to analyse the correlation between target volume and treated volume using different application- and planning procedures. PATIENTS AND METHODS In a consecutive series of 10 patients with primary irradiated endometrial carcinoma we analyzed the correlation between target volume and treated volume using either standard 1-channel applicators or individual Heyman-applicators. Application of the ovoids was followed by a planning CT scan for all patients. Based on this, target volume (uterus volume) was estimated on a 3D-planning system. According to the measurable length of the uterus cavity we determined the corresponding standard 1-channel applicator and calculated the respectively treated volume. Estimating the advantages of an optimized treatment planning strategy for individual Heyman-applications were compared the treated volumes, which result from a standardized and optimized treatment planning procedure. RESULTS The mean uterus volume was 180 cm3 (range 57 to 316 cm3). Asymmetric uterus configurations with longitudinal or sagittal side differences exceeding 1 cm were found in 40% of the cases. Using standard 1-channel applicators on average 47% (range 25 to 89%) of the uterus volume were enclosed by the treated volume compared to 70% for Heyman-applications. Differentiating these individual applications according to the variable treatment modality values of mean 66% (range 36 to 110%) for the standardized and 73% (range 48 to 95%) for the optimized treatment planning strategy were found. Moreover optimized planning modalities led to an improved coverage of the target volume in 5 out of 10 cases with an increase in volume of 20% on average (range 11 to 32%). In 3 cases changes of less than 5% were noticed (no improvement). In order to protect organs at risk treated volume had to be decreased in 2 cases for 19% and 40% respectively. CONCLUSIONS Intracavitary brachytherapy of primary endometrial carcinoma was improved by individualized application- and planning procedures, which led to better adaptations of the treated volumes to the target volumes. Nevertheless a complete coverage--corresponding to the primary intent--was not possible. Individualized and optimized brachy-therapy must be performed according to the individual tumor spread and uterus configuration. Therefore, different applicators are required.

Permanente interstitielle Brachytherapie (Seeds) bei Patienten mit primär lokalisiertem Prostatakarzinom: Analyse von 100 Patienten

SummaryINTRODUCTION: The aim of this retrospective study was to evaluate late toxicity and biochemical disease-free survival of patients with primary localised prostate cancer, who had been treated with permanent seed implantation at the radiotherapy department of the Medical University of Vienna. METHODS AND MATERIALS: Between 08/1999 and 11/2006 100 patients were treated with ultrasound guided transperineal seed implantation (94 patients with Iodine and 6 patients with Palladium). 53 patients received additional hormone therapy. According to T-stage, Gleason Score and PSA, patients were divided into three risk groups (low, intermediate and high risk). Late gastrointestinal and genitourinary side effects and biochemical disease-free survival were evaluated. RESULTS: The patients were followed up at a median time of 28 months (3–88 months). The median patient age was 67.5 years (47–79 years). The distribution of low, intermediate and high risk group patients was 63%, 35% and 2%. The 2-year actuarial rates of late Grade ≥2 gastrointestinal and genitourinary side effects were 5% and 65%. The 2-year biochemical disease-free survival rate was 88% (all patients), 90% (low risk) and 88% (intermediate risk), respectively. Multivariate analysis demonstrated T-stage (p = 0.03), PSA (p = 0.02) and patient age (p = 0.02) to be significant factors influencing biochemical disease-free survival. CONCLUSION: Ultrasound guided transperineal seed implantation in patients with low-risk prostate cancer is an additional treatment option showing promising results.ZusammenfassungEINLEITUNG: Ziel der retrospektiven Studie war es, die klinischen Ergebnisse der ersten 100 Patienten mit primär lokalisiertem Prostatakarzinom, welche mittels Seed-Applikation an der Klinik für Strahlentherapie im AKH Wien behandelt wurden, auszuwerten. MATERIAL UND METHODE: Von 08/1999 bis 11/2006 wurden 94 Patienten mittels Jod- und 6 Patienten mittels Palladium-Seeds behandelt. Eine begleitende Hormontherapie erhielten 53 Patienten. Die Patienten wurden entsprechend dem Tumorstadium, dem Gleason Score und dem maximalen prätherapeutischen PSA-Wertes in eine Niedrig-, Mittel- und Hochrisikogruppe unterteilt. Das biochemische rezidivfreie Überleben sowie die gastrointestinalen und urogenitalen Spätnebenwirkungen wurden erhoben. ERGEBNISSE: Die mittlere Nachbeobachtungszeit betrug 28 Monate (3–88 Monate). Das mittlere Alter der Patienten lag bei 67,5 Jahren (47–79 Jahren). Die Verteilung bezüglich Niedrig-, Mittel- und Hochrisikogruppe zeigte 63%, 35% und 2%. Zwei Jahre nach Therapie zeigte die aktuarische Rate von Grad ≥2 gastrointestinalen und urogenitalen Spätnebenwirkungen Werte von 5% und 65%. Das biochemische rezidivfreie Überleben betrug 88% nach 2 Jahren (Niedrigrisikogruppe bei 90% und Mittelrisikogruppe bei 88%). In der multivariaten Analyse zeigten sich das Tumor-Stadium (p = 0,03), der maximale prätherapeutische PSA-Wert (p = 0,02) und das Alter (p = 0,02) als signifikante Einflussfaktoren auf das biochemisch rezidivfreie Überleben. SCHLUSSFOLGERUNG: Die interstitielle Seeds-Implantation ist vor allem für Patienten mit niedrigem Risikoprofil bei lokalisierten Prostatakarzinom eine weitere Therapieoption neben der radikalen Prostatektomie und der externen Strahlentherapie.

Permanente interstitielle Brachytherapie (Seeds) bei Patienten mit primär lokalisiertem Prostatakarzinom: Analyse von 100 Patienten@@@Permanent interstitial brachytherapy (seeds) for patients with primary localized prostate cancer: analysis of 100 patients

SummaryINTRODUCTION: The aim of this retrospective study was to evaluate late toxicity and biochemical disease-free survival of patients with primary localised prostate cancer, who had been treated with permanent seed implantation at the radiotherapy department of the Medical University of Vienna. METHODS AND MATERIALS: Between 08/1999 and 11/2006 100 patients were treated with ultrasound guided transperineal seed implantation (94 patients with Iodine and 6 patients with Palladium). 53 patients received additional hormone therapy. According to T-stage, Gleason Score and PSA, patients were divided into three risk groups (low, intermediate and high risk). Late gastrointestinal and genitourinary side effects and biochemical disease-free survival were evaluated. RESULTS: The patients were followed up at a median time of 28 months (3–88 months). The median patient age was 67.5 years (47–79 years). The distribution of low, intermediate and high risk group patients was 63%, 35% and 2%. The 2-year actuarial rates of late Grade ≥2 gastrointestinal and genitourinary side effects were 5% and 65%. The 2-year biochemical disease-free survival rate was 88% (all patients), 90% (low risk) and 88% (intermediate risk), respectively. Multivariate analysis demonstrated T-stage (p = 0.03), PSA (p = 0.02) and patient age (p = 0.02) to be significant factors influencing biochemical disease-free survival. CONCLUSION: Ultrasound guided transperineal seed implantation in patients with low-risk prostate cancer is an additional treatment option showing promising results.ZusammenfassungEINLEITUNG: Ziel der retrospektiven Studie war es, die klinischen Ergebnisse der ersten 100 Patienten mit primär lokalisiertem Prostatakarzinom, welche mittels Seed-Applikation an der Klinik für Strahlentherapie im AKH Wien behandelt wurden, auszuwerten. MATERIAL UND METHODE: Von 08/1999 bis 11/2006 wurden 94 Patienten mittels Jod- und 6 Patienten mittels Palladium-Seeds behandelt. Eine begleitende Hormontherapie erhielten 53 Patienten. Die Patienten wurden entsprechend dem Tumorstadium, dem Gleason Score und dem maximalen prätherapeutischen PSA-Wertes in eine Niedrig-, Mittel- und Hochrisikogruppe unterteilt. Das biochemische rezidivfreie Überleben sowie die gastrointestinalen und urogenitalen Spätnebenwirkungen wurden erhoben. ERGEBNISSE: Die mittlere Nachbeobachtungszeit betrug 28 Monate (3–88 Monate). Das mittlere Alter der Patienten lag bei 67,5 Jahren (47–79 Jahren). Die Verteilung bezüglich Niedrig-, Mittel- und Hochrisikogruppe zeigte 63%, 35% und 2%. Zwei Jahre nach Therapie zeigte die aktuarische Rate von Grad ≥2 gastrointestinalen und urogenitalen Spätnebenwirkungen Werte von 5% und 65%. Das biochemische rezidivfreie Überleben betrug 88% nach 2 Jahren (Niedrigrisikogruppe bei 90% und Mittelrisikogruppe bei 88%). In der multivariaten Analyse zeigten sich das Tumor-Stadium (p = 0,03), der maximale prätherapeutische PSA-Wert (p = 0,02) und das Alter (p = 0,02) als signifikante Einflussfaktoren auf das biochemisch rezidivfreie Überleben. SCHLUSSFOLGERUNG: Die interstitielle Seeds-Implantation ist vor allem für Patienten mit niedrigem Risikoprofil bei lokalisierten Prostatakarzinom eine weitere Therapieoption neben der radikalen Prostatektomie und der externen Strahlentherapie.