Primäre Strahlentherapie des Larynxkarzinoms

Purpose

In the treatment of laryngeal carcinoma definitive radiotherapy results in a similar outcome as surgical treatment in the early stages with a lower morbidity rate and good functional results. In fact no randomized studies exist, so far, and the optimal treatment concept for the different stages is not well defined. The following study analyses retrospectively the treatment results and the recurrence data in patients with a squamous cell carcinoma of the larynx treated with definitive radiotherapy.

Patients and Method

Two hundreds and eighty-three patients with carcinoma of the larynx were treated with radiation therapy in the department of radiology of the LMU München between September 1971 and June 1986. Twenty-six patients (9.2%) were female and 257 (73.1%) male. The median age was 68.5 years, respectively 70 years. All patients had a histologically confirmed squamous cell carcinoma of the larynx. No true subglottic cases were observed. Forty-one (14.5%) tumors were localized supraglottically, 207 (73.1%) glottically. Thirty-five patients had a T4 tumor with glottic and supraglottic involvement. In 147 patients the histopathological grading was evaluable: 32 tumors were classified as G1, 95 as G2, 15 as G3 and 5 as G4. According to the UICC classification of 1979 25 patients had a carcinoma in situ (Tis), 93 patients had a stage T1, 90 stage T2, 40 stage T3 and 35 stage T4. Two hundreds and thirty-three of 283 (82.3%) had no lymph node involvement. In 50 patients clinically a lymph node involvement was observed. 22 patients had a stage N1, 5 patients stage N2 and 23 patients stage N3. An external beam radiation mostly with cobalt-60 was performed with a mean dose of 61.9 Gy.

Results

The 5-years relapse free survival for the whole group was 61.7%. The probability for “no evidence of disease” (NED) depended on tumor stage and-localisation (glottic tumors: Tis/T1 90.5%; T2 59.4%; T3 39.6%; [5-year NED]; supraglottic tumors: T1 64.2%; T2/3 28.6%; T4/N3 24.7% [3-year NED]). Other signifikant prognostic factors besides T-stage were N-stage (N0 vs. N1–3: 3-year recurrence-free survival 68% vs. 37.2%, p<0.001) and histopathologic grading (G1 vs. G3/4: 3-year recurrence-free survival 74% vs. 37.1%, p<0.01). One hundred and twenty-two (43.1%) patients had a recurrence, which occurred in 75.4% local, in 12.3% locoregional, in 8.2% with distant metastases and 4.1% combined. In 50 patients with a recurrent disease a salvage-therapy was carried out. Thereby 17 patients achieved a complete response.

Conclusion

Even for the here described negatively selected patient group with a high median age and multimorbidity, good local controlrates could be achieved escpecially in early stages with definitive radiation therapy. In more advanced stages even in elderly patients a combined surgical-radiotherapeutic treatment should be performed.     

Primäre Degeneration des ZNS im Alter

Despite further development of new magnetic resonance imaging techniques, e.g., diffusion tensor imaging and 1H magnetic resonance spectroscopy, structural imaging will continue to play a major role in the diagnosis of primary central nervous system degeneration in ageing. Characteristic imaging patterns of multisystem atrophies and primary dementias as well as differential diagnostic features are demonstrated. While such features may have high specificity, their sensitivity is low especially in cross-sectional studies. Longitudinal studies are the optimal method to characterize the dynamic neuroanatomical correlates of the disease. However, according to disease duration and progression, neuroimaging will show increased overlapping and convergence of pathological changes in multisystem atrophy as well as in dementia.     

Primäre Radiochemotherapie inoperabler fortgeschrittener Ösophaguskarzinome

BACKGROUND: Neither surgical advances nor those in therapeutic radiology have been able to significantly reduce the mortality related to esophageal carcinomas. The results of combining: first surgery, then radiation therapy, which have been unsatisfactory for decades, encourage therapeutic concepts involving a variety of modalities. PATIENTS AND METHODS: For 50 patients with unresectable locally advanced esophageal carcinomas, a palliative concurrent chemotherapy and radiation therapy was carried out according to the "intent to treat" principle. The aim was a minimal dose of 40 Gy. The concurrent chemotherapy was carried out using cisplatin/5-FU during the 1st and 4th weeks of radiation therapy. In the case of partial or complete remission, the chemotherapy was to be continued as maintenance therapy with a maximum of four cycles. In the case of no change or minor response, instead of maintenance chemotherapy, the dose of local radiation was to be increased by means of brachytherapy. RESULTS: The median survival rate for the entire population under study was 8.7 months. The survival rates of 1, 2, 3, 4, and 5 years were, respectively, 38%, 20.5%, 13.7%, 6.8%, and 6.8%. The remission rates were as follows: NC: 14 patients (28%), PR: 32 patients (64%), CR: 4 patients (8%). 17 patients (34%) tolerated the full concurrent chemotherapy; only twelve patients (24%) tolerated supportive chemotherapy. The following factors exhibited a significant correlation to survival: the intensity of the chemotherapy, the Karnofsky index, the age of the patients, and the improvement of oral food intake. CONCLUSIONS: The concurrent chemotherapy was toxic and the benefit to the patients questionable. At best, meta-analyses of randomized studies along the lines of "evidence-based medicine" demonstrate for concurrent chemotherapy and radiation therapy an improvement of 2-year survival rates, but with these also involving a high level of toxicity. Due to the heterogeneous data available, the value of the primary, sequential treatment combining chemotherapy and radiation therapy is uncertain.     

Interdisziplinäre Aufklärung eines ungewöhnlichen Stromunfalls

For forensic pathologists it can be difficult to diagnose death from electrocution only from the results of autopsy and histology. Therefore, interdisciplinary forensic investigations are indispensable in doubtful cases. This report describes the case of a 40-year-old man who was found dead in the area of garden pond facilities. Electrocution was suspected after autopsy because of suspicious skin findings. This was confirmed by means of physical investigations and the examination of the locality by an electrical engineering expert.     

Das lokoregionäre Rezidiv des Rektumkarzinoms

Background

In the adjuvant postoperative radiotherapy of rectal carcinoma the knowledge of the predominant areas of recurrences is of major importance for the definition of the target volume. We analysed the pattern and locations of tumor recurrences in the CT-scans of 155 Patients and correlated the findings with the primary tumor location (above and below the peritoneal duplication) and the operating method (abdominoperineal exstirpation, anterior resection, Hartmann procedure).

Patients and Method

Hundred and fifty-five patients with the diagnosis of rectal carcinoma recurrences were treated in our institution between 1980 and 1995. To determine the extension of the recurrent tumor within the pelvic levels (präsacral levels S1–S5, precoccygeal-, pelvic floor level and perineal level) and the tumor infiltration of pelvic organs and muscles we analysed the pretherapeutic CT-images. The lymphnode recurrences were classified as: pararectal-, presacral-, iliac internal-, iliac external-, iliac communis- and paraaortal recurrences.

Results

Sixty-one percent of the patients with rectum exstirpation and 66% with anterior resection showed a combined local and nodal recurrence. Isolated lymph node recurrences were rare (4% and 5%) (Tables 2 and 3). The local recurrence was mostly situated in the presacral pelvis, predominantly there was an infiltration of the presacral space at the level of S4, S5, and os coccygis regardless of the operating method and the primary tumor location (Figure 1). The anastomosis was involved in the tumor recurrence in 93% of the anteriorly resected patients (Table 3). In 9 out of 96 patients after rectum exstirpation the pelvic region caudal of the tip of the coccyx was the origin of the recurrent tumor (Table 2, Figure 2). Primarily all 9 patients had a deep-seated carcinoma (<6 cm ab ano). Only 2 patients showed an isolated perineal recurrence after rectum exstirpation (Table 2, Figure 2). Two thirds of the deepseated tumors showed a vaginal involvement (Figures 3 and 4). The incidence of iliac internal- and presacral nodal recurrence was 47 to 59% (Figures 3 and 4). The incidence of iliac external lymph node recurrences was 7% after rectum exstirpation and 2% after anterior resection/Hartmann procedure.

Conclusion

Our data demonstrate that 2/3 of the patients with tumorbed recurrences also show lymph node recurrences predominantly in the iliac internal- and presacral groups. This had to be considered in the definition of the boost target volume. The target volume must also include the dorsal wall of the urogenital organs. A ventral extension of target volume up to iliac external lymph nodes is not necessary.     

Endovaskuläre Therapie des thorakalen Aortenaneurysmas

Clinical issue of thoracic aneurysms

Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice.

Standard radiological methods

CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging.

Threshold for treatment

In the ascending aorta a diameter larger than 5–5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment.

Thoracic endovascular aortic repair

The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years.

Practical recommendations

Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.     

Solide pseudopapilläre Tumoren des Pankreas

Solid pseudopapillary tumors of the pancreas (SPTP) are rare tumors of the pancreas with low malignancy potential and a very good prognostic outcome after surgery. They typically occur in young women or adolescents and consist of solid, cystic and cystic-hemorrhagic components.Imaging findings in these tumors are characteristic and include a fibrotic capsule with a clear delineation and exhibit solid and cystic-hemorrhagic signal and density characteristics. Calcifications may be present in the periphery of the tumor. The tumor capsule shows contrast enhancement, the solid components in the periphery enhance in the early phase and gradually and inhomogeneously in late phases. MRI is superior to CT and other imaging modalities for characterization of SPTP. Awareness and knowledge of this tumor entity with an excellent prognosis is crucial to guide the patient towards effective, predominantly organ-sparing surgical treatment.     

Die Entwicklung der Strahlentherapie des Zervixkarzinoms am Universitätsklinikum Rostock

Purpose

Doubtlessly modern high voltage radiation treatment has less side effects than former techniques. It may be better than conventional methods with respect to 5-year survival rates, but that has to be proven using a large number of cases.

Patients and Methods

Retrospective study using the material of one department of gynecology and obstetrics, practizing both operation and irradiation. 1830 cervical carcinomas are differentiated in stages and then divided in 3 historical collectives. From 1959 to 1968 there was a combination of traditional contact therapy with conventional X-ray irradiation. The period from 1969 to 1972 is characterized as a changing one with partly therapy as described above, partly traditional contact therapy was combined with biaxial telecobalttherapy. From 1973 to 1986 a reduced contact therapy dosis was applied to pelvine high voltage irradiation.

Results

Five-year survival rate in stage I was 79% in conventional treatment and with ultra high energy 77%. The corresponding figures in stage II are 56% respectively 52%, in stage III 26% respectively 25% (Table 1) of gynecology and obstetrics, practizing both operation and irradiation.

Conclusion

Application of ultra high energy radiation in higher doses, in Rostock had not the consequence of elevating the 5-year survival rate, but the quality of life is much better.     

Stellenwert der Radiochirurgie in der Primärtherapie des Glioblastoma multiforme

Aim

To describe the clinical results and the feasibility of a phase II dose escalation study of small boost target volumes with a radiosurgical technique in patients with positive early postoperative MRI scan.

Patients and Method

Since 1986, 35 patients were treated within a concept for first line therapy. Including criteria were residual tumor ≤5 cm and Karnofsky performance score ≥70. The mean age was 54.5 years. The treatment concept included an operation for reduction of tumor volume and a postoperative irradiation. The postoperative irradiation was divided in 2 parts: first, a hyperfractionated (1.8 Gy single dose twice a day, 54 Gy total dose) irradiation was performed containing the tumor and the edema with a 2 cm safety margin. Secondly, a radiosurgical boost dose was delivered. The target volume of this radiosurgery was the contrast enhancing residual tumor in early postoperative MRI scans. The median boost dose was 15 Gy. Survival curves were calculated according to the Kaplan-Meier method. Quality of life was evaluated using objective criteria such as neurological findings, frequency of seizures and steroid medication

Results

The median survival calculated from the time of diagnosis was 10.1 months. The 1- and 2-year survival rate were 35% and 6%, respectively. Young age tended to longer survival, patients younger than 53 years had a median survival of 10.4 months whereas patients older than 53 years showed a median survival of 9.2 months. The mean value of the boost volume was 22 cm³. Patients with smaller volumes had a median survival of 10.1 months and patients with bigger volumes showed a median survival of 9.9 months. 4.5 months after therapy, 75% of the patients showed improved or stable quality of life.

Conclusion

The feasibility of a radiosurgically delivered boost dose after postoperative irradiation could be demonstrated. The observed survival rate is comparable to the survival rates reported in the literature. Whether or not the radiosur gery after postoperative irradiation is able to prolong survival can only be evaluated in a randomized phase III trial.     

Das akute ossäre Trauma des Schultergürtels

Traumatic injuries to the shoulder girdle are common lesions and occur from birth on through the whole life. Depending on the patient's age, localization and type of injury change. Diagnosis of acute osseous traumatic lesions to the shoulder is based on evaluation of trauma mechanism, patient's examination and, as for the most cases, conventional radiographs. Only in certain cases additional radiological examinations are necessary. As a minimum, two to three images in different planes, anteriorposterior, lateral and axillary, are recommended in order to display all components of the shoulder girdle without superposition. Knowledge of common clinical classifications systems is necessary for exact diagnosis in order to permit decision on conservative or operative treatment of injury.     

Haftung des gerichtlichen Sachverständigen wegen Erstellung eines unrichtigen Gutachtens

Zusammenfassung  Die Geltendmachung von Schadensersatz gegen einen Sachverst?ndigen gem. § 839a BGB setzt eine detaillierte Auseinandersetzung mit dem Inhalt des Gutachtens voraus und erfordert einen substantiierten Sachvortrag zu der vorgetragenen Behauptung einer vors?tzlichen bzw. grob fahrl?ssigen Erstattung eines unrichtigen Gutachtens. Lediglich subjektive Zweifel an der Richtigkeit des Gutachtens begründen noch keinen Anspruch. (Leitsatz der Bearbeiterin)     

Die interventionelle/endovaskuläre Therapie des infrarenalen abdominellen Aortenaneurysmas

The catheter-based interventional therapy (endovascular aortic repair EVAR) of abdominal aortic aneurysms (AAA) has gained an established place in the spectrum of therapeutic options. The procedure is characterized by low peri-interventional morbidity and mortality. Multislice computed tomography (CT) has a dominant role in defining the correct indications and in selecting an appropriate stent graft prior to the intervention. The rate of acute conversions could be reduced from 2.9 % to 0?% in our own elective patient population since 2010. In our vascular centre the proportion of patients treated by EVAR was 39.5?% (102 out of 258). The procedure is used routinely in patients who have an increased risk for general anesthesia or open surgery due to concomitant diseases. It is also used in patients with a reduced local operability due to prior surgery, abdominal diseases or radiation therapy. Arterial closure devices allow a completely percutaneous approach in a certain group of patients. However, after EVAR a life-long surveillance is mandatory because delayed therapy failure has been described. In younger patients who do not have a higher risk open surgery is still an option. The paper describes techniques, results und complications of EVAR.