Selective Lymph Node Dissection Following Hyperfractionated Accelerated Radio-(Chemo-)Therapy for Advanced Head and Neck Cancer

BACKGROUND: 2-year results of a German multicenter randomized trial showed that accelerated chemoradiation with MMC/5-FU to 70.6 Gy is more effective than accelerated radiation to 77.6 Gy alone at equivalent levels of acute and late radiation morbidity. Frequency, histopathology and impact on local tumor control of selective lymph node dissection were analyzed. PATIENTS AND METHODS: Between February 1996 and October 2000 at Tübingen University 42 randomized patients plus 45 non-randomized patients with stage III/IV MO head and neck cancer were treated according to this protocol. After completion of hyperfractionated accelerated (chemo-)radiation a selective lymph node dissection was performed, if the primary tumor was in complete remission and clinical plus computed tomography proved residual lymph node disease. 17 of 38 patients with residual node metastasis underwent uni- or bilateral selective node dissection, the remaining patients had residual primary tumors, clinical deterioration or refused neck dissection. RESULTS: After a median follow-up of 26 months, the Kaplan-Meier analysis showed a 2-year overall survival of 49%, disease-specific survival of 64% and loco-regional tumor control of 60%, respectively. 3-year loco-regional tumor control in randomized patients was 52% compared to 58% in non-randomized patients (log rank p = 0.23). 2-year loco-regional tumor control in stage cT4cN0 was 76% compared to 57% in cT2-4 cN1-3 tumors. Subgroup analysis of patients with involved nodes revealed a 2-year loco-regional tumor control of 74% after complete remission of primary tumor and neck disease, 53% after complete remission of primary tumor and partial remission of neck disease. In patients with selective lymph node dissection loco-regional tumor control was 62%. Histopathological examination showed viable tumor in eight of 17 patients. CONCLUSIONS: Selective lymph node dissection of residual neck masses after completion of hyperfractionated accelerated radio-(chemo-)therapy is likely to contribute to loco-regional tumor control in advanced head and neck cancer.     

Primary advanced and local recurrent head and neck tumors: effective management with interstitial thermal radiation therapy

Thirty-seven patients with 18 primary advanced or persistent, 16 local recurrent, and three local metastatic tumors of the head and neck were treated with a combination of interstitial low-dose iridium-192 radiation therapy and interstitial 915-MHz microwave hyperthermia supplemented by external radiation therapy. Twenty-eight lesions received an additional external radiation dose of 21-61 Gy. Interstitial hyperthermia was applied immediately before Ir-192 was placed and after its removal for 45-60 minutes at 41 degrees C-44 degrees C. Follow-up ranged from 4 to 45 months. At 3 months, complete remission occurred in 25 lesions (68%); partial remission, in nine (24%); and no change or progressive disease, in three (8%). At 12 months of follow-up in 32 lesions, local control was achieved in 23 (72%), with the patients alive, and in four (12%), with the patients dead. There were five local recurrences, one of which occurred after complete response. Lesion type, tumor volume, radiation dose, and thermal quality at high minimum temperature were identified as prognostic factors influencing complete remission. The combined treatment was well tolerated.     

Radiotherapy of esophageal carcinoma: an assessment of patients treated at Tübingen from 1977 to 1982

We report on the results of therapy of 116 patients with esophagus carcinoma. The patients have been attended to at the Medical Radiation Institute of Tübingen between 1977 and 1982. In 95 cases sole radiation was performed as operation was impossible. The other patients underwent a combined surgical-radiotherapeutical treatment. The joint doses of radiation applied ran from 50 to 70 Gy in five to seven weeks' time. In particular we considered the total survival rate according to tumor stage, the local tumor control and the period until relapse. 22% of the primarily irradiated patients achieved complete remission, 42% reached particular remission and 15% achieved minimal tumor remission (total response rate: 79%). Merely in 8% of the cases the tumor did not respond perceptibly. In the other cases irradiation had to be interrupted because of general worsening, or the patients got lost to post-therapeutical observation. The total survival rates, all stages taken into account, arose as follows: one year: 36.8%, two years: 12.6%, five years: 7.3%. After sole radiotherapy in 67% of the cases which had a radiologically verified relapse more than six months passed by before a local recurrence tumor was stated. The bad prognosis of the esophagus carcinoma, as demonstrated in literature, is entirely confirmed-the negative selection of our patients taken into account. The high rank of radiotherapy in achieving effective palliation is emphasized.     

Radiotherapy of esophageal cancer--indications, methods and attainable results

From 1965-1985, in the Department of Radiotherapy of the University Hospital of Freiburg 226 patients with esophageal carcinoma have been treated with primary radiotherapy at a sufficient tumor dose - 138 of them with curative and 66 patients with palliative intention. With curative irradiation the survival rates between 1 at 5 years were 28.6%, 14.1%, 8.2%, 5.8% and 3.5%. To palliative indication the 1 year survival rate was 10.4%, none of these patients reached the two years' limit. Apparently relevant prognostic factors are: length of history, overall state of health, histologic classification, tumor stage, state of clinical remission, localization of the tumor. Our findings were compared with observations between 1965 and 1985. This paper deals with the problems of pre- and post-therapeutic irradiation, in combination with chemotherapy. Indications for radiotherapy, definition of the target volume and the different techniques of radiation planning and performance are discussed, especially with reference to comparison of stimulator- and CT-assisted radiation planning. We demonstrate the possibilities of rotation therapy with an electronically controlled diaphragm device developed in our department.     

Salvage radiotherapy in postoperative recurrences of rectal and rectosigmoid carcinomas]

One hundred and twenty-five patients, previously operated for rectal or rectosigmoid cancer, have been submitted to external radiation therapy from 1964 to 1985 on pelvic and/or perineal recurrence (50 perineal, 66 pelvic, 9 both). Fifty-seven per cent received more than 50 Gy, but only 14% more than 60 Gy. Overall survival has been poor (66% at 1 year, 20% at 3 years, 15% at 5 years) whereas better results have been achieved for pain relief: complete remission in 49% and partial remission in 26% of 77 symptomatic patients. Among 94 patients, evaluable for tumor size before and after treatment, radiation significantly decreased the size of the recurrence in 63% (27% CR). Among prognostic factors (recurrence site, radiation dose, age, pain relief and disease-free interval since surgery) only perineal recurrence without pelvic involvement, if treated with high doses (greater than 50 Gy), seems to be related to a significantly improved prognosis.     

Therapy of vulvar carcinoma]

Thirty-five of totally 50 patients with carcinoma vulvae were treated with bleomycin. Most of the patients were older people and had more advanced disease. They were grouped according to the TNM system and the age. Bleomycin alone (2 X 15 mg/m2 weekly; 390 and 420 mg total dose) was given to two patients. One of the patients had a complete remission and the other one a partial remission with reduction in tumor size of more than 50%. Nineteen patients received bleomycin (2 X 10 up to 2 X 15 mg/m2 weekly: 200-300 mg total dose) in combination with radiation therapy using fast electrons (betatron; 3000-5000 R). In this group 21,1% of the patients had complete remission and 31,5% of patients had a partial remission of more than 50% tumor size reduction (objective remission rate 52,6%). Bleomycin was also beneficial when combined with surgery plus irradiation. Palliative irradiation was used in four patients with a very advanced disease. Eleven patients were irradiated postoperatively with fast electrons (4000-6000 R). In this group, 65% of the patients were free from recurrences more than one year after the beginning of the treatment. Our results indicate that combined therapies using bleomycin, surgery and radiation therapy were more effective in the treatment of vulvar carcinoma than single treatments alone. It should be emphasized that bleomycin is effective as a palliative treatment of squamous cell carcinoma of the vulva.     

Treatment of non-small-cell bronchial carcinoma with cisplatin, ifosfamide, vindesine and VP 16

Hitherto, the objective of chemotherapy in case of the non-small cell bronchial carcinoma is only of a palliative nature. Thus a critical indication is necessary. This is confirmed by our investigations with the combinations of cis-platinum and ifosfamide (80 patients, remission rate 35%, median survival time of patients with remission 11,5 months), cis-platinum and vindesine (29 patients, remission rate 28%, median survival time of patients with remission 14,5 months), and ifosfamide and vepeside (63 patients, remission rate 27%, median survival time of patients with remission 12 months). The combination ifosfamide-vepeside was much better tolerated by the patients and, with its comparable remission rates and survival times, was superior to the cis-platine combinations. For the chemotherapy of the non-small cell bronchial carcinoma it has to be considered that the treatment result may be more influenced by tumor stage and activity index of the patient than by the therapy method.     

Bronchial artery infusion of mitomycin C in carcinoma of the lung

Fifteen patients with bronchial carcinoma were treated with infusions of 10 mg Mitomycin C (MMC) in the bronchial artery feeding the tumor. The treatment was repeated three times with 2–3 weeks interval between treatments. Half of the patients then received radiation to the tumor area and mediastinum. All tumors decreased in size, complete remission occurred in two and partial remission in five patients. Survival time, however, was not prolonged and esophageal complications occurred in several patients.     

Reirradiation for Recurrent Neck Metastases of Head-and-Neck Tumors Using CT-Guided Interstitial 192Ir HDR Brachytherapy

PURPOSE: To report the therapeutic results obtained with CT-guided interstitial high-dose-rate brachytherapy (HDR-BRT) as exclusive treatment for recurrent neck metastases of head-and-neck tumors. PATIENTS AND METHODS: Between 1995 and 1999, 49 patients with prior radiation therapy (RT) with or without surgery for primary head-and-neck tumors were treated for recurrent neck metastases located within previously irradiated volumes. All patients had fixed lymphadenopathy with a mean tumor volume of 96 cm(3) (range, 15-452 cm(3)). There were 38 males and eleven females with a mean age of 60 years (range, 28-79 years). All patients had previously received RT as primary or adjuvant treatment with a mean dose of 54 Gy (range, 45-80 Gy). 36 patients (73%) underwent surgery, and 26 (53%) received adjuvant or palliative chemotherapy. The accelerated hyperfractionated interstitial HDR-BRT (2 x 3.0 Gy/day) delivered 30 Gy in 37/49 (75%) and 36 Gy in 12/49 implants (25%). RESULTS: At a minimum 6-week follow-up, the response rate was 83% (41/49) with complete remission in 20% (10/49) and partial remission in 63% (31/49) of the implanted tumor sites. 8/49 patients (17%) did not respond to the treatment. After 19 months of median follow-up, the local control rate was 69% and a total of 15/49 patients (30%) experienced local disease progression. Of these, nine (18%) had locoregional progression and six (12%) progression within the treated volume. The median post-BRT survival was 14 months. The overall survival rate was 52% at 1 year, 31% at 2 years, and 6% at 3 years. CONCLUSION: In patients with recurrent cervical lymphadenopathy of head-and-neck tumors, exclusive interstitial HDR-BRT can provide palliation and tumor control.     

Phases IB and II multidose trial of gadolinium texaphyrin, a radiation sensitizer detectable at MR imaging: preliminary results in brain metastases.

PURPOSE: To evaluate magnetic resonance (MR) imaging results after administration of gadolinium texaphyrin, a tumor-selective radiation sensitizer that is detectable at MR imaging, and to determine an appropriate intravenous dose of gadolinium texaphyrin for repeated injections during radiation therapy, the dose-limiting toxicity of reiterated doses of gadolinium texaphyrin, the maximal tolerated dose, the biolocalization of gadolinium texaphyrin (as assessed at MR examinations), and the response to treatment. MATERIALS AND METHODS: Ten daily intravenous injections of gadolinium texaphyrin, each followed by whole-brain radiation therapy (total of 10 fractions, 30 Gy), were administered to patients with brain metastases in a multicenter study. At the study institution, 11 patients underwent MR imaging before and after the first injection, after the 10th injection, and 8 weeks after entry into the study. RESULTS: MR imaging revealed selective drug uptake in metastases, without enhancement of normal brain tissue. In 10 patients, tumor uptake was higher after the 10th injection than after the first injection, which indicated accumulation of gadolinium texaphyrin in metastases. One lesion was visible only after the 10th injection and not at the pretherapeutic MR examination with injection of conventional gadolinium-based contrast material. Response to treatment was defined as a reduction in the size of the metastases between the preinjection MR study and the last MR study; seven patients achieved partial remission with tumor regression exceeding 50% of the initial size, and four achieved a minor response with less than 50% tumor regression. CONCLUSION: These preliminary results indicate that gadolinium texaphyrin is tumor selective and that brain metastases can be depicted at MR imaging long after the administration of gadolinium texaphyrin.     

Interstitial thermal radiation therapy: five-year experience with head and neck tumors.

Sixty-two patients with 24 primary advanced, six persistent, 28 locally recurrent, and four metastatic tumors of the head and neck were treated with combined interstitial low-dose iridium-192 radiation therapy, interstitial 915-MHz microwave hyperthermia (IHT), and external-beam radiation therapy. Diagnoses were squamous cell carcinoma in 56, adenocarcinoma in three, and soft-tissue sarcoma in three lesions. IHT was applied immediately before Ir-192 was placed and after its removal for 45-60 minutes at 41 degrees C-44 degrees C. At 3 months, complete remission had occurred in 39 lesions; partial remission, in 18; and no change or progressive disease, in five. At 12-month follow-up, local control was achieved in 29 of 50 patients; seven other patients had slow ongoing tumor regression with an unclear residual mass at computed tomography or magnetic resonance imaging. Lesion type, tumor volume, total radiation dose, and thermal parameters with "good quality of heating" at high minimum tumor temperature were identified as statistically significant (P less than .05) prognostic factors influencing initial and long-term tumor response. There was no prognostic factor for acute or late thermal damage.     

放射性肺改变相关因素高分辨CT表现与预后的关系

目的 分析引起放射性肺损伤的相关因素，高分辨CT(HRCT)表现与预后的关系。方法 对580例胸部肿瘤中放射性肺损伤的86例行HRCT检查，观察其征象与预后的关系。结果 总结7种引起放射性肺损伤的相关因素。将HRCT表现分为4种类型：片状渗出型(8例)，补丁实变型(18例)，含气不全型(27例)和浓密纤维化型(33例)，其HRCT表现不可逆，治疗只能缓解症状。结论 阐述引起放射性肺损伤的相关因素及HRCT表现与各型放射件肺炎预后的关系。正确使用肺组织的放射剂量，定期HRCT检查对早期诊断和治疗有指导意义。     

Late results of radiotherapy of soft tissue sarcoma

PURPOSE: To evaluate the effect of radiation therapy in the treatment of soft-tissue sarcomas. MATERIALS AND METHODS: Between March 1970 and January 1990, 58 patients with soft-tissue sarcoma were referred for radiation therapy. The most frequent histologic diagnoses included fibrosarcoma (n = 15), neurofibrosarcoma (n = 5) and rhabdomyosarcoma (n = 5). Central tumor sites in the trunk (n = 31) were much more frequent than in the head and neck region (n = 14) or the extremities (n = 13). Thirty-nine of 58 primary tumors were bigger than 5 centimeters. Forty-five patients were irradiated after surgery, 5 patients prior to surgery; in 8 cases only radiation therapy was used. Radiation therapy was performed with Co-60 photons and an average total dose of 58 Gy, fractionated in single doses of 2 Gy. The treatment results were obtained by actual follow-up examinations. RESULTS: Twenty-three of 58 patients survived at least 5 years (39.9%). Of 15 patients with R0 resection 11 were alive after 5 years (73.3%). Local tumor control was achieved in 34 of 58 patients (58.6%). Low 5-year-survival rates were associated with dedifferentiation of the primary tumor (three survivors in 10 patients with G3 tumor), tumor diameters over 5 cm (13 survivors of 39), R2 resection (3 survivors of 16) and tumor sites in the body trunk (11 survivors of 31). CONCLUSIONS: (1) The best results of radiation therapy were achieved after R0 resection of the primary tumor. (2) Tumors in the trunk are prognostically worse because of bigger tumor diameters due to later diagnosis.     

Stage I-II low grade non-Hodgkin's lymphoma: prognostic factors and treatment results.

48 patients with stage I-II low-grade non-Hodgkin's lymphoma were treated by radiation and/or chemotherapy between 1970 and 1986. The histologic types were diffuse lymphocytic well differentiated, eleven patients; nodular lymphocytic poorly differentiated, 28 patients; nodular mixed, nine patients. Complete remission was obtained in 45 patients (94%). Overall survival was 83% and 68% at five and ten years, respectively. Five and ten-year relapse-free survival of complete responders was 71% and 57%, respectively. Univariate analysis of potential prognosticators showed the following to significantly increase the survival rate: one or two sites of disease (p less than 0.01), stage I (p less than 0.02), age less than 65 years (p less than 0.02), complete excision of tumor mass (p less than 0.03), and the use of radiotherapy (p less than 0.02). The extent of radiotherapy field did not affect survival. Multivariate analysis by the stepwise proportional hazards model of Cox showed that the use of radiotherapy was the factor which significantly produced better survival figures (p less than 0.03). It is concluded that two thirds of stage I-II low-grade lymphoma patients are potentially curable; radiotherapy plays a major role in the management.     

Selective Lymph Node Dissection Following Hyperfractionated Accelerated Radio-(Chemo-)Therapy for Advanced Head and Neck Cancer

Background: 2-year results of a German multicenter randomized trial showed that accelerated chemoradiation with MMC/5-FU to 70.6 Gy is more effective than accelerated radiation to 77.6 Gy alone at equivalent levels of acute and late radiation morbidity. Frequency, histopathology and impact on local tumor control of selective lymph node dissection were analyzed. Patients and Methods: Between February 1996 and October 2000 at Tübingen University 42 randomized patients plus 45 non-randomized patients with stage III/IV M0 head and neck cancer were treated according to this protocol. After completion of hyperfractionated accelerated (chemo-)radiation a selective lymph node dissection was performed, if the primary tumor was in complete remission and clinical plus computed tomography proved residual lymph node disease. 17 of 38 patients with residual node metastasis underwent uni- or bilateral selective node dissection, the remaining patients had residual primary tumors, clinical deterioration or refused neck dissection. Results: After a median follow-up 26 months, the Kaplan-Meier analysis showed a 2-year overall survival of 49%, disease-specific survival of 64% and loco-regional tumor control of 60%, respectively. 3-year loco-regional tumor control in randomized patients was 52% compared to 58% in non-randomized patients (log rank p = 0.23). 2-year loco-regional tumor control in stage cT4cN0 was 76% compared to 57% in cT2-4 cN1-3 tumors. Subgroup analysis of patients with involved nodes revealed a 2-year loco-regional tumor control of 74% after complete remission of primary tumor and neck disease, 53% after complete remission of primary tumor and partial remission of neck disease. In patients with selective lymph node dissection loco-regional tumor control was 62%. Histopathological examination showed viable tumor in eight of 17 patients. Conclusions: Selective lymph node dissection of residual neck masses after completion of hyperfractionated accelerated radio-(chemo-)therapy is likely to contribute to loco-regional tumor control in advanced head and neck cancer. Hintergrund: Die multizentrische Phase-III-Studie (ARO 95-6) zur akzelerierten hyperfraktionierten Strahlentherapie - 5-Fluorouracil/Mitomycin C bei lokal fortgeschrittenen Kopf-Hals-Tumoren konnte nachweisen, dass die kombinierte Radiochemotherapie bezüglich lokaler Tumorkontrolle und Gesamtüberleben wirksamer ist als die alleinige Strahlentherapie. Wir untersuchen Häufigkeit, histopathologisches Ergebnis und den Einfluss der selektiven Neck-Dissection auf die lokale Tumorkontrolle. Patienten und Methoden: Zwischen Februar 1996 und October 2000 wurden in Tübingen insgesamt 42 randomisierte und 45 nicht randomisierte Patienten mit fortgeschrittenen Kopf-Hals-Tumoren im Stadium III/IV M0 nach diesem Protokoll behandelt. Nach Abschluss der akzelerierten hyperfraktionierten Strahlentherapie - 5-Fluorouracil/Mitomycin C wurde eine selektive Neck-Dissection bei kompletter Remission des Primärtumors und partieller Remission der Halslymphknotenmetastasen angestrebt. Bei 17 von 38 Patienten mit residuellen Halslymphknotenmetastasen wurde eine uni- oder bilaterale selektive Neck-Dissection durchgeführt. Bei 21 Patienten wurde die Neck-Dissection wegen partieller Remission des Primärtumors, klinischer Verschlechterung oder Ablehnung durch den Patienten nicht durchgeführt. Ergebnisse: Nach einem medianen Follow-up von 26 Monaten betrugen das 2-Jahres-Gesamtüberleben 49%, das krankheitsspezifische Überleben 64% und die lokoregionäre Tumorkontrolle 60% (Kaplan-meier-Analyse). Für cT4-cN0-Tumoren betrug die lokoregionäre 2-Jahres-Tumorkontrolle 76% im Vergleich zu 57% bei cT2-cN1-3-Tumoren. Es bestand kein Unterschied bezüglich der lokoregionären Tumorkontrolle zwischen randomisierten und nicht randomisierten Patienten. Bei kompletter Remission des Primärtumors und der lokoregionären Lymphknoten betrug die 2-Jahres-Tumorkontrolle 74%, bei partieller Remission der lokoregionären Lymphknoten 53%. Nach partieller Remission der lokoregionären Lymphknoten und selektiver Neck-Dissection betrug die 2-Jahres-Tumorkontrolle 62% (Abbildung 3). Die histopathologische Aufarbeitung wies bei acht von 17 Patienten vitale Tumorzellen nach. Schlussfolgerungen: Die selektive Neck-Dissection von residuellen Halslymphknotenmetastasen nach akzelerierter hyperfraktionierter Strahlentherapie - 5-Fluorouracil/Mitomycin C bei lokal fortgeschrittenen Kopf-Hals-Tumoren kann möglicherweise zur lokalen Tumorkontrolle beitragen.     

Planning mantle radiation therapy in patients with Hodgkin disease: role of gallium-67 scintigraphy

Detection of all sites of lymphoma is imperative for accurate planning of radiation therapy. In patients with Hodgkin disease, mantle radiation is used to treat the thoracic lymph nodes; in those with early-stage or nonbulky disease, mantle and paraaortic radiation may be the only treatment given. CT scanning of the chest adds important information to that obtained from chest radiographs. Gallium-67 scintigraphy has also been used to provide additional information on sites of active tumor. To determine the usefulness of 67Ga-citrate scintigraphy in planning the portals for radiation therapy, we analyzed the radiation treatment plans in 26 consecutive patients with Hodgkin disease; in all 26 patients, the disease had been staged by chest radiographs, chest CT scans, and gallium-67 images. Gallium-67 imaging alone provided unique information that affected the treatment plans in three patients (12%). The combined results of gallium-67 imaging and CT scans influenced the planning of radiation therapy in eight patients (31%). Gallium-67 imaging was found to be an important adjunctive study for optimal planning of radiation therapy in patients with Hodgkin disease.     

Attenuation of radiation dose by the skull base bone in patients with nasopharyngeal carcinoma: clinical importance

PURPOSE: To measure the degree of attenuation of radiation dose by the skull base bone in patients with nasopharyngeal carcinoma (NPC) and to study its clinical importance. MATERIALS AND METHODS: Isodose distribution in 11 patients with NPC who received bilaterally opposed large-field irradiation (1.8 Gy per fraction) was studied with a three-dimensional treatment planning system with tissue inhomogeneity correction. Also studied were the sites of local tumor recurrence in 37 patients with NPC and skull base destruction (>/=0.5 cm) or intracranial invasion treated with radiation therapy from January 1989 to December 1992. Regression analyses were performed. RESULTS: In the dosimetric study, the low-dose areas (<1.65 Gy) were located at the level of the skull base in all 11 patients. A significantly positive correlation between the maximum width of the skull base bone and the low-dose volume (<1.65 Gy) was demonstrated (P =.003, linear regression). In the clinical study, local tumor recurrence was noted in 18 patients (49%). The sites of local recurrence included skull base in 16 patients (43%) and nasopharynx in six patients (16%). Wider skull base bone was a significant predictor of skull base recurrence after radiation therapy (P =.03, logistic regression). CONCLUSION: Herein demonstrated is the inadequacy of the radiation dose over the skull base due to attenuation by the skull base bone. The relationship between width of skull base bone and skull base tumor recurrence also is established.     

TACE联合125I放射性粒子植入治疗原发性肝癌的疗效观察

目的探讨TACE联合125I粒子植入治疗肝癌的疗效。方法 14例患者均接受TACE治疗2周后CT扫描,根据扫描确定术前计划,计算放射粒子数量,勾画肿瘤区域。结果 14例患者完全缓解2例,部分缓解8例,无变化3例,进展1例,总有效率70%。术后6个月、12个月随访,除1例死亡,其余患者均生存。结论 TACE联合125I粒子植入术是治疗肝癌安全有效的方法,可提高疗效,创伤小恢复快。     

Treatment of human superficial tumors by ionizing radiation combined with ultrasound

Short-term treatment (3 minutes) with low intensity (1.8 w/cm2) ultrasound was applied to human tumors in combined treatment with ionizing radiation. Tumor regression was observed with the dose below TDF (time dose fractionation) 40, and 50% reduction in tumor masses was observed at doses with TDF 45 to 62, and the mean dose was TDF 52. Complete remission of tumor masses was recognized with doses of TDF 62 to 113 in 9 of 10 treated lesions. Five cases, with multiple lesions, were treated with controlled ionizing radiation without ultrasound. Fifty percent reduction in tumor masses was observed with doses of TDF 74 to 113, and the mean dose was TDF 86. Complete remission of tumor mass was not observed. Radioenhancement ratio by ultrasound was 1.6 for 50% tumor reduction. Skin temperature was elevated to about 3 degrees C as measured by thermography, but intradermal temperature was not apparently elevated. Ultrasound potentiates the effects of localized radiotherapy not due to hyperthermia but to the other factors.     

Therapiemonitoring mittels 2-[18F]-FDG-Positronenemissionstomographie nach neoadjuvanter Strahlenbehandlung des Mundhöhlenkarzinoms

BACKGROUND: Combined protocols of radiation therapy and surgical resection, as applied in advanced oral cancer, rely on objective and early assessment of treatment response to radiation therapy. Non-responders require immediate radical salvage surgery even in spite of substantial operative risks, while complete or subtotal response may give reasons for continuing the conservative approach. Therefore, we investigated radiation response by FDG-PET for early monitoring of oral cancer. PATIENTS AND METHODS: In 30 patients with advanced stages of oral cancer (Table 1), FDG-PET (Siemens, ECAT EXACT 922) was performed within 4 weeks after completion of preoperative radiation therapy (36 Gy). SUV of tumor regions were compared to the histologic degree of tumor regression in complete resection specimens. Statistic evaluation included correlation analysis of SUV vs tumor regression and ROC analysis for SUV cut-off values. RESULTS: While low FDG accumulation was found in tumors with histological complete remission (2.3 +/- 0.4) as well as in cases of residual tumor (3.4 +/- 1.8), high FDG uptake was a rather specific indicator of vital tumor tissue (Figure 2). Significant correlation (p = 0.045) between postradiotherapeutic FDG-uptake and histological tumor regression was recognized. A SUV > 2.75 as a clinically practicable threshold value for the identification of residual vital tumor resulted in a specificity of 88%, sensitivity of 68%, a positive predictive value of 94% and a negative predictive value of 50% (Figure 3). Based on our actual follow-up data we could not confirm a significant correlation between postradiotherapeutic SUV and patients' survival. CONCLUSION: Within a standardized protocol, FDG-PET recognize treatment response to radiation therapy in oral squamous cell carcinoma with a reasonable specificity and thus provides a basis for further therapeutic decisions. An increased SUV (> 2.75) may be the rational to justify an aggressive surgical approach even when patients face substantial surgical or anesthesiological risk. However, the posttherapeutic pattern of glucose uptake varies with the applied treatment modalities and has to be explored for the protocol applied.