Pr?klinische Bildgebung im Tiermodell bei Strahlentherapie

CLINICAL/METHODICAL ISSUE: Modern radiotherapy benefits from precise and targeted diagnostic and pretherapeutic imaging. STANDARD RADIOLOGICAL METHODS: Standard imaging modalities, such as computed tomography (CT) offer high morphological detail but only limited functional information on tumors. METHODICAL INNOVATIONS: Novel functional and molecular imaging modalities provide biological information about tumors in addition to detailed morphological information. PERFORMANCE: Perfusion magnetic resonance imaging (MRI) CT or ultrasound-based perfusion imaging as well as hybrid modalities, such as positron emission tomography (PET) CT or MRI-PET have the potential to identify and precisely delineate viable and/or perfused tumor areas, enabling optimization of targeted radiotherapy. Functional information on tissue microcirculation and/or glucose metabolism allow a more precise definition and treatment of tumors while reducing the radiation dose and sparing the surrounding healthy tissue. ACHIEVEMENTS: In the development of new imaging methods for planning individualized radiotherapy, preclinical imaging and research plays a pivotal role, as the value of multimodality imaging can only be assessed, tested and adequately developed in a preclinical setting, i.e. in animal tumor models. PRACTICAL RECOMMENDATIONS: New functional imaging modalities will play an increasing role for the surveillance of early treatment response during radiation therapy and in the assessment of the potential value of new combination therapies (e.g. combining anti-angiogenic drugs with radiotherapy).     

Auswirkungen der neuen Euratom-Richtlinie 96/29 („Grundnorm”) im Bereich der Strahlentherapie

Aim

The Council Directive 96/26 will be brought into force by the Member States of the EC until the year 2000. What practical consequences on both mounting and holding radiotherapeutical facilities should be considered?

Methods

Regarding the Council Directive, facts on workers’ actual occupational exposure in medicine and representative calculations on structural shielding the consequences will be evaluated.

Results

Increasing both total number of occupationally exposed workers and number of Category A workers but also enforced structural shielding should be expected. Working in any protected area during pregnancy will be strictly prohibited now.

Conclusions

With respect to the generally sufficient structural shielding no restrictions for existing radiotherapeutical facilities are to be expected. But it is emphasized to carry out further mountings on base of the latest Council Directive 96/26 Euratom.     

Ischämie der unteren Extremität durch eine persistierende A. ischiadica – ein möglicher interventioneller Therapieansatz

The sciatic artery is a rarely seen variant of the vessels of the lower limb. Anatomically it is the prolongation of the inferior gluteal artery and accompanies the sciatic nerve from the sciatic foramen to the knee. More than other vessels, the sciatic artery shows vasculopathies like diffuse dilatation or aneurysms. This report describes an interesting case of embolic acute ischemia, caused by a persistent sciatic artery with an aneurysm. We treated the ischemia with intra-a. lysis and bridged the aneurysm with an covered stent.     

Psychometrische Eigenschaften des Stress Index RadioOnkologie (SIRO) - ein neuer Fragebogen zur Erfassung der Lebensqualit?t bei Patienten unter Strahlentherapie

Hintergrund: Die strahlentherapeutische Behandlung von Tumorpatienten ist häufig mit starken psychosozialen Belastungen verbunden, für deren Erfassung es bisher keinen spezifischen Fragebogen gibt. Mit dem Stress Index RadioOnkologie (SIRO), der auf den Analyseergebnissen umfangreicher Voruntersuchungen beruht, soll erstmals ein Screening-Instrument zur Verfügung gestellt werden, mit dem die psychosozialen Belastungen von Tumorpatienten, einschließlich der durch Strahlentherapie induzierten, erfasst werden können. Ziel dieser Studie ist, die Fragebogen-Vorform psychometrisch zu evaluieren und in die endgültige Fragebogenversion (SIRO) zu überführen. Darüber hinaus sollen Informationen über das psychosoziale Belastungsprofil radioonkologischer Patienten zu Beginn einer Strahlentherapie gewonnen werden. Patienten und Methoden: 104 Tumorpatienten (18-85 Jahre) mit unterschiedlichen Diagnosen wurden in die Studie aufgenommen. Die Patientendaten wurden mit der SIRO-Vorform, der Hospital Anxiety and Depression Scale (HADS), der European Organization for Research and Treatment of Cancer Study Group Quality of Life Questionnaire (EORTC QLQ-C30) und der Lebenssituation (LS) erfasst. Mit 25 Patienten wurden halb standardisierte Interviews durchgeführt. Ergebnisse: Die Anforderungen an die Gütekriterien (Reliabilität, Validität) des SIRO wurden erfüllt bzw. übertroffen. In der untersuchten Patientenstichprobe traten die höchsten Belastungswerte in der Skala "Psychophysische Belastungen" auf, gefolgt von den Skalen "Partnerschaftliche Probleme", "Strahlentherapeutische Belastungen" und "Informationsdefizite". Entsprechend waren auf Itemebene die höchsten Belastungen bei den Leistungseinschränkungen und Ängsten zu beobachten. Bei den strahlentherapeutischen Items waren die Patienten am stärksten durch die Angst vor Nebenwirkungen der Strahlentherapie und die Tatsache, dass sie bestrahlt werden, belastet. Patienten mit palliativer Behandlungsoption waren stärker als solche mit kurativer belastet. Schlussfolgerungen: Die Fragebogen-Vorform hat sich als reliabel, valide und praktikabel erwiesen und kann unverändert als neuer Selbstberichts-Fragebogen (SIRO) zur Erfassung der psychosozialen Belastung radioonkologischer Patienten übernommen werden. Purpose: In the course of radiotherapy oncological patients often experience considerable psychosocial distress. For its measurement however, no specific questionnaire is available. The Stress Index RadioOncology (SIRO), which is based upon the results of extensive preliminary studies, will be made available as a screening-instrument to facilitate measurement of psychosocial distress of cancer patients, including radiotherapy-induced distress. The aim of this study is, to psychometrically evaluate the preliminary version of the questionnaire, to transfer it to the final version (SIRO) and to gain information about the psychosocial distress of radiooncological patients at the beginning of radiotherapy. Patients and Methods: 104 cancer patients (18 to 85 years) with different diagnoses have been included in the study (Table 1). The data have been assessed by means of the preliminary version of the new questionnaire SIRO, the HADS, EORTC QLQ-C30 and LS. With 25 patients semistructured clinical interviews have been conducted. Results: The requirements for reliability (Table 3) and validity (Table 4) of the SIRO have either been fulfilled or exceeded. The highest distress value has been found in the scale "Psycho-physical Distress", followed by the scale "Partnership Problems", "Radiotherapeutical Distress", and "Information Deficits" (Figure 1). On the item level, the highest distress was experienced due to reduction of efficiency and anxiety (Table 2). With regard to the radiotherapy items, patients were most distressed by fears of possible side effects and by the fact of being irradiated. Patients with palliative treatment option were higher distressed than those with curative treatment (Table 5). Conclusions: The preliminary version of the new self-report questionnaire (SIRO) has proven to be valid, reliable and practicable, and can therefore be taken unchanged to measure the psychosocial distress of radiooncological patients.     

Funktionelle MRT der Niere zur Erfassung strahleninduzierter Nierensch?digungen

The diagnosis of radiation-induced (especially chronic) renal alterations/damage is difficult and currently relies primarily on clinical evaluation. The importance of renal diagnostic evaluation will increase continuously due to the increasing number of long-term survivors after radiotherapy. This article evaluates the potentia diagnostic contribution of magnetic resonance (MR) imaging with a focus on functional MRI. The following functional MRI approaches are briefly presented and evaluated: blood oxygenation level-dependent imaging (BOLD), diffusion-weighted imaging (DWI) or diffusion tensor imaging (DTI), MR perfusion measurements and (23)Na imaging. In summary, only DWI and contrast-enhanced MR perfusion currently seem to be suitable approaches for a broader, clinical implementation. However, up to now valid data from larger patient studies are lacking for both techniques in regard to radiation-induced renal alterations. The BOLD and (23)Na imaging procedures have a huge potential but are currently neither sufficiently evaluated with regard to radiation-induced renal alterations nor technically simple and reliable for implementation into the clinical routine.     

Technische Grundlagen der Kontrastsonographie im ��berblick und Ausblick in die Zukunft

Ultrasound contrast agents have considerably expanded the range of ultrasound diagnostics. Up to date ultrasound machines with contrast-specific software allow the selective demonstration and quantification of contrast agents in real-time based on the specific signal signature of oscillating contrast agent microbubbles. After intravenous injection the microbubbles are transported with the bloodstream and distributed purely intravascularly. This allows an artefact-free representation of the vascular architecture and delineation of the vascular lumen, independent of blood flow velocity and with high spatial resolution. Traumatic lesions and active bleeding can be detected with high sensitivity. Blood volume in vessels and organs can be assessed qualitatively and quantitatively. The possibility of short-term destruction of microbubbles within the ultrasound field allows the measurement of blood flow velocity during replenishment and based on that the assessment of perfusion in parenchymal tissue. Target-specific microbubbles for imaging of molecular surface structures as well as drug-loaded microbubbles for local ultrasound-mediated therapy are under development.     

Intraoperative Strahlentherapie (IORT) in der Behandlung des Mammakarzinoms – eine neue therapeutische Alternative im Rahmen der brusterhaltenden Therapie? Stellenwert und Zukunftsperspektiven. Erfahrungsbericht aus dem European Institute of Oncology (EIO), Mailand

BACKGROUND: External beam radiation therapy (EBRT) represents an integral component of breast-conserving treatment. In published series it has been demonstrated that the external boost can be replaced by intraoperative radiotherapy (IORT) where irradiation at a single dose from 10 up to 15 Gy was safely delivered directly to the tumor bed. PATIENTS AND METHODS: At the European Institute of Oncology, Milan, we initiated a dose escalation study to investigate the feasibility of applying single doses of IORT from 10 Gy up to 22 Gy. A portable IORT equipment with different electron energies was used. From July to December 1999, a total of 65 patients with T1-2 (max. 2.5 cm) No-1 breast cancer, median age 58 years (range 33-80 years) was treated. Ten patients received 10 Gy, eight patients were treated with an IORT of 15 Gy, eight received 17 Gy, six had 19 Gy, and 33 were treated with 21-22 Gy. Patients with 10 and 15 Gy received an additional EBRT of 44 and 40 Gy, respectively. In all other patients IORT was the sole radiation treatment. RESULTS: No acute side effects or intermediate untoward effects after a follow-up from three to nine months related to IORT were observed. CONCLUSIONS: Since the applicator can be safely placed under the control of the surgeon and radiotherapist IORT has the potential of accurately treating the tumor bed. Skin and subcutaneous tissue are not irradiated thus decreasing the potential risk of fibrosis and eventually obtaining a better cosmesis. With IORT single doses of 22 Gy being equivalent to a 60 Gy EBRT can safely be delivered. Even so the average time of operation was prolonged by around 20 minutes IORT application ultimately improves the quality of life of the patients in shortening overall treatment. Long-term follow-up is necessary to demonstrate whether large single doses of IORT might have the potential of sufficient local tumor control without major side effects. As a future perspective a randomized trial comparing EBRT with IORT as sole treatment will be performed.     

Für welche Tumorentit?ten ist ein Einfluss der Gesamtbehandlungszeit auf die Ergebnisse der Strahlentherapie evident?

BACKGROUND AND METHOD: The effect of overall treatment time on therapeutic outcome was analyzed comparing the randomized trials on accelerated fractionation for the different tumor entities. Only studies using radiotherapy as the definitive locoregional treatment modality were included. RESULTS AND CONCLUSION: Randomized studies were performed for squamous cell carcinomas of the head and neck region as well as for small-cell and non-small-cell carcinomas of the lung. These studies showed, that locoregional control can be improved by accelerated fractionation in comparison to conventional fractionation with the same total dose. With the same antitumor effectiveness of both fractionation schedules, total dose can be reduced using accelerated fractionation.     

Für welche Tumorentit?ten ist ein Einfluss der Gesamtbehandlungszeit auf die Ergebnisse der Strahlentherapie evident?

Fragestellung und Methodik: Zur Beantwortung der Frage nach dem Effekt der Gesamtbehandlungszeit der Strahlentherapie auf das Therapieergebnis bei verschiedenen Tumorentitäten wurden die randomisierten Studien zur akzelierten Fraktionierung vergleichend in einer Übersicht dargestellt. Es wurden nur Studien aufgenommen, bei denen die Strahlentherapie die definitive lokoregionale Therapie war. Ergebnisse und Schlussfolgerung: Sowohl bei den Plattenepithelkarzinomen der Kopf-Hals-Region als auch bei kleinzelligen und nichtkleinzelligen Bronchialkarzinomen liegen Studienergebnisse vor. Diese zeigen, dass bei konstanter Gesamtdosis im Vergleich zur konventionellen die lokoregionale Kontrolle durch akzelerierte Fraktionierung erhöht wird. Bei gleicher Effektivität beider Fraktionierungschemata gegen den Tumor kann die Gesamtdosis bei akzelerierte Fraktionierung reduziert werden. Background and Method: The effect of overall treatment time on therapeutic outcome was analyzed comparing the randomized trials on accelerated fractionation for different tumor entities. Only studies using radiotherapy as the definitive locoregional treatment modality were included. Results and Conclusion: Randomized studies were performed for squamous cell carcinomas of the head and neck region as well as for small-cell and non-small-cell carcinomas of the lung. These studies showed, that locoregional control can be improved by accelerated fractionation in comparison to conventional fractionation with the same total dose. With the same antitumor effectiveness of both fractionation schedules, total dose can be reduced using accelerated fractionation.     

Psychometrische Eigenschaften des Stress Index RadioOnkologie (SIRO) – ein neuer Fragebogen zur Erfassung der Lebensqualität bei Patienten unter Strahlentherapie

PURPOSE: In the course of radiotherapy oncological patients often experience considerable psychosocial distress. For its measurement however, no specific questionnaire is available. The Stress Index RadioOncology (SIRO), which is based upon the results of extensive preliminary studies, will be made available as a screening-instrument to facilitate measurement of psychosocial distress of cancer patients, including radiotherapy-induced distress. The aim of this study is, to psychometrically evaluate the preliminary version of the questionnaire, to transfer it to the final version (SIRO) and to gain information about the psychosocial distress of radiooncological patients at the beginning of radiotherapy. PATIENTS AND METHODS: 104 cancer patients (18 to 85 years) with different diagnoses have been included in the study (Table 1). The data have been assessed by means of the preliminary version of the new questionnaire SIRO, the HADS, EORTC QLQ-C30 and LS. With 25 patients semistructured clinical interviews have been conducted. RESULTS: The requirements for reliability (Table 3) and validity (Table 4) of the SIRO have either been fulfilled or exceeded. The highest distress value has been found in the scale "Psycho-physical Distress", followed by the scale "Partnership Problems", "Radiotherapeutical Distress", and "Information Deficits" (Figure 1). On the item level, the highest distress was experienced due to reduction of efficiency and anxiety (Table 2). With regard to the radiotherapy items, patients were most distressed by fears of possible side effects and by the fact of being irradiated. Patients with palliative treatment option were higher distressed than those with curative treatment (Table 5). CONCLUSIONS: The preliminary version of the new self-report questionnaire (SIRO) has proven to be valid, reliable and practicable, and can therefore be taken unchanged to measure the psychosocial distress of radiooncological patients.     

Führte eine Blutung im Paraganglion caroticum den Tod herbei?

Zusammenfassung Nach einer geringfügigen Gewalteinwirkung kam es zu einer histologisch nachgewiesenen einseitigen Blutung im Paraganglion caroticum. Der ursächliche Zusammenhang zwischen der Blutung und dem eingetretenen Tod wird in Analogie zum sog. Carotistod diskutiert.     

Ganzk?rper-MRT in der ?Study of Health in Pomerania��

Population-based whole-body MRI examinations have been evaluated for the first time within the Study of Health in Pomerania (SHIP). This ongoing cohort study investigates associations of overweight (57.9% of the female and 74.1% of the male population) and obesity (25.1% and 26.0%, respectively) with cardiovascular and metabolic diseases in a population with decreased life expectancy compared to the total German average. Whole-body MRI offers the possibility to evaluate parameters, such as the amount of visceral and liver fat and can contribute to further conclusions on these common diseases.     

Entz��ndliche Erkrankungen der Wirbels?ule und des Myelons

Inflammatory diseases of the spine and the spinal cord (myelon) can be caused by a wide range of pathological conditions. Except for degenerative inflammatory diseases of the spine, infectious and autoimmune disorders are relatively rare. The latter can also be a significant source of pain and disability, especially if these hard to diagnose conditions go untreated. In cases of advanced disease some entities, such as spondylodiscitis or rheumatoid arthritis can cause severe neurological impairment especially by progressive intraspinal spread. Inflammation of the myelon cannot be depicted with conventional radiographs in general and by computed tomography only occasionally. In these cases magnetic resonance imaging is the method of choice to detect early abnormalities of the myelon and to provide detailed information for the differential diagnosis.     

Intraoperative Strahlentherapie (IORT) in der Behandlung des Mammakarzinoms - eine neue therapeutische Alternative im Rahmen der brusterhaltenden Therapie? Stellenwert und Zukunftsperspektiven. Erfahrungsbericht aus dem European Institute of Oncology (EIO), Mailand

Hintergrund: Die externe Strahlentherapie (EBRT) ist ein integraler Bestandteil der brusterhaltenden Behandlung des Mammakarzinoms. In zwei publizierten Studien konnte gezeigt werden, dass der externe Boost durch eine intraoperative Applikation einer Einzeldosis von 10-25 Gy direkt auf das Tumorbett ohne Einbuße der lokalen Kontrolle ersetzt werden kann. Patientinnen und Methode: Um die Anwendbarkeit höherer intraoperativer Strahlendosen zu untersuchen, wurde am European Institute of Oncology in Mailand eine Dosiseskalationsstudie initiiert. Mittels einer portablen Elektronenstrahlenquelle mit variablen Strahlenenergien wurden intraoperative Dosen zwischen 10 und 22 Gy appliziert. Von Juli bis Dezember 1999 wurden 65 Patientinnen mit einem Mammakarzinom mit maximalem Tumordurchmesser bis 2,5 cm NO-1 mit einem medianen Alter von 58 Jahren (33-80 Jahren) intraoperativ bestrahlt. Zehn Patientinnen wurden mit 10 Gy, acht mit 15 Gy, acht mit 17 Gy, sechs mit 19 Gy und 33 mit 21-22 Gy behandelt. Patientinnen, bei denen 10 bzw. 15 Gy verabreicht wurden, erhielten zusätzlich eine externe Bestrahlung von 44 bzw. 40 Gy. Bei allen übrigen war die IORT die alleinige strahlentherapeutische Behandlung. Ergebnisse: Es wurden keine akuten bzw. intermediären Nebenwirkungen nach 3-9 Monaten in Zusammenhang mit der intraoperativen Strahlentherapie (IORT) beobachtet. Schlussfolgerungen: Die exakte intraoperative Platzierung des Tubus unter Sichtkontrolle durch Chirurgen und Strahlentherapeuten ermöglicht ein Höchstmaß an Präzision bei der Strahlenapplikation. Durch Vermeidung einer Mitbestrahlung von Haut und Subkutangewebe wird das potentielle Risiko einer Fibrosierung verringert; somit dürfte ein besseres kosmetisches Ergebnis zu erwarten sein. IORT-Dosen bis zu 22 Gy (entsprechend einer Äquivalenzdosis von 60 Gy EBRT) können sicher appliziert werden. Obwohl durch die IORT die Operationsdauer um ca. 20 Minuten verlängert wird, resultiert für die Patientin durch eine deutliche Verkürzung der Gesamtbehandlungszeit eine Verbesserung der Lebensqualität. Langzeitnachbeobachtungen sind erforderlich, um die Sicherheit der IORT hinsichtlich einer suffizienten lokalen Tumorkontrolle beurteilen zu können. Als nächster Schritt ist die Durchführung einer randomisierten Studie zum Vergleich der IORT als alleiniger Strahlentherapie mit der EBRT geplant. Background: External beam radiation therapy (EBRT) represnet an integral component of breast-conserving treatment. In published series it has been demonstrated that the external boost can be replaced by intraoperative radiotherapy (IORT) where irradiation at a single dose from 10 up to 15 Gy was safely delivered directly to the tumor bed. Patients and Methods: At the European Institute of Oncology, Milan, we initiated a dose escalation study to investigate the feasibility of applying single doses of IORT from 10 Gy up to 22 Gy. A portable IORT equipment with different electron energies was used. From July to December 1999, a total of 65 patients with T1-2 (max. 2.5 cm) NO-1 breast cancer, median age 58 years (range 33-80 years) was treated. Ten patients received 10 Gy, eight patients were treated with an IORT of 15 Gy, eight received 17 Gy, six had 19 Gy, and 33 were treated with 21-22 Gy. Patients with 10 and 15 Gy received an additional EBRT of 44 and 40 Gy, respectively. In all other patients IORT was the sole radiation treatment. Results: No acute side effects or intermediate untoward effects after a follow-up from three to nine months related to IORT were observed. Conclusions: Since the applicator can be safely placed under the control of the surgeon and radiotherapist IORT has the potential of accurately treating the tumor bed. Skin and subcutaneous tissue are not irradiated thus decreasing the potential risk of fibrosis and eventually obtaining a better cosmesis. With IORT single doses of 22 Gy being equivalent to a 60 Gy EBRT can sefely be delivered. Even so the average time of operation was prolonged by around 20 minutes IORT application ultimately improves the quality of life of the patients in shortening overall treatment. Long-term follow-up is necessary to demonstrate whether large single doses of IORT might have the potential of sufficient local tumor control without major side effects. As a future perspective a randomized trial comparing EBRT with IORT as sole treatment will be performed.