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Koerber SA, Höcht S, Aebersold D, Albrecht C, Boehmer D, Ganswindt U, Schmidt-Hegemann NS, Hölscher T, Mueller AC, Niehoff P, Peeken JC, Pinkawa M, Polat B, Spohn SKB, Wolf F, Zamboglou C, Zips D, Wiegel T. Prostate cancer and elective nodal radiation therapy for cN0 and pN0-a never ending story? : Recommendations from the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO). Strahlenther Onkol 2024; 200:181-187. [PMID: 38273135 PMCID: PMC10876748 DOI: 10.1007/s00066-023-02193-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024]
Abstract
For prostate cancer, the role of elective nodal irradiation (ENI) for cN0 or pN0 patients has been under discussion for years. Considering the recent publications of randomized controlled trials, the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO) aimed to discuss and summarize the current literature. Modern trials have been recently published for both treatment-naïve patients (POP-RT trial) and patients after surgery (SPPORT trial). Although there are more reliable data to date, we identified several limitations currently complicating the definitions of general recommendations. For patients with cN0 (conventional or PSMA-PET staging) undergoing definitive radiotherapy, only men with high-risk factors for nodal involvement (e.g., cT3a, GS ≥ 8, PSA ≥ 20 ng/ml) seem to benefit from ENI. For biochemical relapse in the postoperative situation (pN0) and no PSMA imaging, ENI may be added to patients with risk factors according to the SPPORT trial (e.g., GS ≥ 8; PSA > 0.7 ng/ml). If PSMA-PET/CT is negative, ENI may be offered for selected men with high-risk factors as an individual treatment approach.
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Affiliation(s)
- S A Koerber
- Department of Radiation Oncology, Barmherzige Brüder Hospital Regensburg, Prüfeninger Straße 86, 93049, Regensburg, Germany.
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - S Höcht
- Department of Radiation Oncology, Ernst von Bergmann Hospital Potsdam, Charlottenstraße 72, 14467, Potsdam, Germany
| | - D Aebersold
- Department of Radiation Oncology, Inselspital-Bern University Hospital, University of Bern, Freiburgstraße 4, 3010, Bern, Switzerland
| | - C Albrecht
- Nordstrahl Radiation Oncology Unit, Nürnberg North Hospital, Prof.-Ernst-Nathan-Str. 1, 90149, Nürnberg, Germany
| | - D Boehmer
- Department of Radiation Oncology, University Hospital Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - U Ganswindt
- Department of Radiation Oncology, University Hospital Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - N-S Schmidt-Hegemann
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - T Hölscher
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Fiedlerstraße 19, 01307, Dresden, Germany
| | - A-C Mueller
- Department of Radiation Oncology, RKH Hospital Ludwigsburg, Posilipostraße 4, 71640, Ludwigsburg, Germany
| | - P Niehoff
- Department of Radiation Oncology, Sana Hospital Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - J C Peeken
- Department of Radiation Oncology, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - M Pinkawa
- Department of Radiation Oncology, Robert Janker Klinik, Villenstraße 8, 53129, Bonn, Germany
| | - B Polat
- Department of Radiation Oncology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - S K B Spohn
- Department of Radiation Oncology, University Hospital Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - F Wolf
- Department of Radiation Oncology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - C Zamboglou
- Department of Radiation Oncology, University Hospital Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
- German Oncology Center, 1, Nikis Avenue, Agios Athanasios, 4108, Limassol, Cyprus
| | - D Zips
- Department of Radiation Oncology, University Hospital Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - T Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
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Gruen A, Tegel K, Kluge A, Budach V, Zips D, Boehmer D. PSMA PET-based stereotactic body radiotherapy for locally recurrent prostate cancer after definitive first-line therapy. Prostate 2023; 83:1298-1305. [PMID: 37394721 DOI: 10.1002/pros.24592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Advances in prostate-specific membrane antigen (PSMA) PET-computed tomography (CT) and magnetic resonance imaging (MRI) allow the detection and localization of exclusively local prostate-cancer-recurrences after definitive first-line therapy. PSMA-based early detection of circumscribed local recurrences followed by hypofractionated high-precision stereotactic body radiotherapy (SBRT) might yield long-term disease control at moderate rates of adverse effects. METHODS Retrospective analysis of 35 patients treated for locally recurrent prostate cancer between November 2012 and December 2021 with PSMA PET- and MRI-based robotic SBRT. RESULTS Thirty-five patients treated with local prostate cancer recurrence post surgery, post surgery, and adjuvant/salvage radiotherapy (RT) and after definitive RT. All but one patients had fractionated SBRT in 3-5 fractions. Median progression-free survival (PFS) was 52.2 months for all patients and 52.2 months in the radical prostatectomy (RPE) group, 31.2 months in the RPE + RT group and not reached in the RT group. The most common event was increased urinary frequency grade 1-2. 54.3% of all patients had no acute and 79.4% no late toxicity during follow-up. DISCUSSION Our PFS of 52.2 months (RPE), 31.2 months (RPE + RT) and not reached (RT) compares favorably with published data. This method constitutes a valid alternative to morbidity-prone invasive approaches or palliative systemic therapy.
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Affiliation(s)
- Arne Gruen
- Department for Radiation Oncology, Campus Virchow-Klinik, Charité-Universitaetsmedizin Berlin, corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Tegel
- Department for Obstetrics and Gynecology, Evangelisches Waldkrankenhaus Spandau Krankenhausbetriebs gGmbH, Berlin, Germany
| | - Anne Kluge
- MVZ Leipzig Strahlentherapie, Leipzig, Germany
| | | | - Daniel Zips
- Department for Radiation Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dirk Boehmer
- Department for Radiation Oncology, Campus Benjamin Franklin, Charité-Universitaetsmedizin Berlin, corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Rabsahl C, Boehmer D, Boeker A, Gauger U, Goerling U, Gollrad J. Depression and anxiety in patients with uveal melanoma undergoing curative proton treatment-A prospective study. Cancer Rep (Hoboken) 2023; 6:e1780. [PMID: 36639921 PMCID: PMC10075284 DOI: 10.1002/cnr2.1780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/26/2022] [Accepted: 12/31/2022] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE We prospectively addressed whether patient characteristics, oncological outcomes, or metastatic risk impacted depression and anxiety in patients undergoing curative proton treatment for uveal melanoma (UM). METHODS We assessed patient-reported outcomes regarding anxiety (GAD-7) before and 2 years after proton therapy and depression (PHQ-9) before, 1, and 2 years after proton therapy. We performed descriptive statistics and used linear mixed effect modeling to analyze how the oncological outcome and baseline characteristics impacted anxiety and depression scores. RESULTS Of 130 (65 female) patients included, six developed metastatic disease and three died during the 2-year follow-up. The mean anxiety declined from 5.86 (SE = 0.56) at baseline to 3.74 (SE = 0.46) at 2 years (β = 2.11; SE = 0.6; p < .001). Depressive symptoms decreased moderately from 4.36 (SE = 0.37) at baseline to 3.67 (SE = 0.38) 2 years later. Patients with unfavorable metastatic risk or disease progression had elevated anxiety and depression scores. Although female patients reported overall higher anxiety scores, both sexes recovered substantially and to a similar extent during the 2-year follow-up (β = 2.35; SE 0.87; p = .007 vs. β = 1.88; SE = 0.60; p = .002). A trend for prolonged depressive symptoms was observed in patients living alone compared to patients living with family members 1 year after the treatment (M = 5.04 [SE = 0.85] vs. M = 3.73 [SE = 0.31], β = 1.32; SE = 0.92; p = .152). Patients with high baseline anxiety levels showed initially more severe depressive symptoms, which improved significantly during follow-up (β = 1.65; SE = 0.68; p = .017). CONCLUSION Most patients undergoing proton therapy for UM experienced mild, transient depressive symptoms and anxiety. Patients with high pre-treatment anxiety, unfavorable prognoses, and patients living alone may be more vulnerable to prolonged depressive symptoms. To these patients a more tailored support could be offered at an early stage of the disease.
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Affiliation(s)
- Christopher Rabsahl
- Department of Radiation Oncology, Charité - Universitätsmedizin, Berlin, Germany
| | - Dirk Boehmer
- Department of Radiation Oncology, Charité - Universitätsmedizin, Berlin, Germany
| | - Alexander Boeker
- Department of Ophthalmology, Charité - Universitätsmedizin, Berlin, Germany
| | | | - Ute Goerling
- Department of Psycho-Oncology, CCCC, Charité - Universitätsmedizin, Berlin, Germany
| | - Johannes Gollrad
- Department of Radiation Oncology, Charité - Universitätsmedizin, Berlin, Germany
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Wegener D, Aebersold DM, Grimm MO, Hammerer P, Froehner M, Graefen M, Boehmer D, Zips D, Wiegel T. Postoperative Radiotherapy of Prostate Cancer: Adjuvant versus Early Salvage. Biomedicines 2022; 10:biomedicines10092256. [PMID: 36140357 PMCID: PMC9496034 DOI: 10.3390/biomedicines10092256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Results of three randomized clinical trials (RCTs) comparing adjuvant radiotherapy (ART) and early salvage radiotherapy (eSRT) of prostate carcinoma and a subsequent meta-analysis of the individual patient data from these RCTs were recently published. The results suggest that early eSRT is as effective and potentially less toxic than ART. Therefore, eSRT should be considered the standard of care. However, due to limitations in the RCTs, ART remains a valid treatment option in patients with the combination of high-risk features such as Gleason Score (GS) 8–10, positive surgical margins (R1) and pathological T-stage 3 or 4 (pT3/4). This article provides a critical appraisal of the RCTs and the rationale for recommendations adopted in the current national guidelines regarding patients with high-risk features after radical prostatectomy (RP): ART should be offered in case of pT3/pT4 and R1 and Gleason Score 8–10; ART can be offered in case of pT3/pT4 and R0 and Gleason Score 8–10 as well as in case of multifocal R1 (including pT2) and Gleason Score 8–10. In any case, the alternative treatment option of eSRT in case of rising PSA should be discussed with the patient.
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Affiliation(s)
- Daniel Wegener
- Department of Radiation Oncology, University Hospital Tuebingen, 72076 Tuebingen, Germany
- Correspondence: ; Tel.: +49-070-7129-86143
| | - Daniel M. Aebersold
- Department of Radiation Oncology, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Marc-Oliver Grimm
- Department of Urology, Jena University Hospital, 07743 Jena, Germany
| | - Peter Hammerer
- Department of Urology, University Hospital Braunschweig, 38106 Braunschweig, Germany
| | - Michael Froehner
- Department of Urology, Zeisigwaldkliniken Bethanien Chemnitz, 09130 Chemnitz, Germany
| | - Markus Graefen
- Martini Clinic, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Dirk Boehmer
- Department of Radiation Oncology, Charité University Medicine Berlin, 10117 Berlin, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tuebingen, 72076 Tuebingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tuebingen, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, 89081 Ulm, Germany
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Gollrad J, Korpusik N, Rabsahl C, Boehmer D, Besserer A, Grittner U, Boeker A, Keilholz U, Joussen A, Budach V, Goerling U. Fear of prognosis? How anxiety, coping, and expected burden impact the decision to have cytogenetic assessment in uveal melanoma patients. Support Care Cancer 2022; 30:5837-5847. [PMID: 35355121 PMCID: PMC9135859 DOI: 10.1007/s00520-022-07006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/22/2022] [Indexed: 11/30/2022]
Abstract
Background Cytogenetic testing (CGT) in uveal melanoma patients reveals prognostic information about the individual risk of developing distant metastasis with dismal prognosis. There is currently no medical intervention strategy with proven effect on the prognosis, rendering the result of the cytogenetic testing purely informative. We explored patients’ socio-demographic backgrounds, psychological preconditions, coping strategies, external influences, and concerns about “knowing their fate” to study their possible interactions with decision-making for CGT. Methods Uveal melanoma patients were asked to complete questionnaires on their interest in undergoing CGT for prognostication and the factors influencing their decision. Data were collected on socio-demographics, baseline anxiety (GAD-7), depression (PHQ-9), coping strategies (Brief COPE), and assumed future concerns regarding the CGT result. Data were analyzed by using multiple ordinal logistic regression and exploring estimated marginal effects. Results Questionnaires were returned by 121 of 131 (92.4%) patients. Fifty-two patients (43%) had no interest in CGT, 34 (28.1%) were undecided, and 35 (28.9%) were interested. We observed no significant differences regarding age, sex, partnership, education, occupation, baseline anxiety, or depression. Decision-making favoring CGT was influenced by the treating physicians, internet resources, and level of baseline anxiety. Patients were likely to reject CGT when they worried that “knowing the result will have an unintended influence” on their life. Conclusion Decision-making about CGT for prognostication in uveal melanoma is burdensome to many patients and in general not guided by medical advice regarding further treatment and screening procedures. The psychological impact of the decision is therefore unique and requires careful support by psycho-oncologists considering the patient’s fears and expectations.
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Affiliation(s)
- Johannes Gollrad
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Nevenka Korpusik
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher Rabsahl
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Boehmer
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Angela Besserer
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology & Berlin Institute of Health at Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Boeker
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich Keilholz
- Charité Comprehensive Cancer Center, CCCC, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonia Joussen
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Goerling
- Department of Psycho-Oncology, CCCC, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Gollrad J, Rabsahl C, Riechardt AI, Heufelder J, Stroux A, Goerling U, Joussen A, Budach V, Boehmer D. Quality of life and treatment-related burden during ocular proton therapy: a prospective trial of 131 patients with uveal melanoma. Radiat Oncol 2021; 16:174. [PMID: 34496895 PMCID: PMC8425039 DOI: 10.1186/s13014-021-01902-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/30/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Proton beam therapy is a well-established treatment option for patients with uveal melanoma (UM). The treatment procedure, in general, includes placing radiopaque clips to ensure exact eye-positioning during radiotherapy, followed by the delivery of proton irradiation. The short-term burden associated with proton therapy in patients with UM has rarely been addressed. In this prospective study, we investigated the physiological and psychological aspects of proton therapy that might affect the well-being of patients during the different stages of treatment. METHODS During the treatment procedure, we conducted longitudinal assessments of the Quality of life (QOL), organ-specific symptoms, and psychological aspects in patients with UM with three questionnaires (EORTC QLQ-C30, EORTC QLQ-OPT30, and GAD-7). Patients completed questionnaires before clip surgery (T0), before proton therapy (T1), after completing treatment (T2), and three months after treatment completion (T3). We also collected data on tumor characteristics and socio-demographics to identify potential risk factors associated with high treatment burdens. RESULTS We prospectively included 131 consecutive patients. Questionnaire data showed a significant, temporary decline in global QOL and an increase in eye-related symptoms, as a result of the clip surgery (T0-T1). After treatment completion (T2), global QOL improved gradually, and none of the eye-related symptoms significantly deteriorated over the course of proton therapy. The global QOL returned to baseline levels three months after treatment (T3). We identified baseline anxiety as an independent risk factor for experiencing an acute treatment-related burden. Furthermore, we found interactions between GAD7 and patient sex showing that anxiety had a more pronounced effect on QOL outcome in female patients. CONCLUSION The short-term treatment-related burden of ocular proton therapy appeared to be largely associated with the preceding clip surgery, rather than the irradiation procedure. We found that anxiety was strongly associated with experiencing QOL issues during the treatment procedure. Our findings could contribute to the development of future strategies for improving the treatment process and psycho-oncologic patient care.
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Affiliation(s)
- Johannes Gollrad
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Christopher Rabsahl
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jens Heufelder
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Stroux
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Goerling
- Department of Psycho-Oncology, CCCC, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonia Joussen
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Boehmer
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Gruen A, Exner S, Kühl JS, von Stackelberg A, Budach V, Stromberger C, Boehmer D. Total body irradiation as part of conditioning regimens in childhood leukemia-long-term outcome, toxicity, and secondary malignancies. Strahlenther Onkol 2021; 198:33-38. [PMID: 34282476 PMCID: PMC8760188 DOI: 10.1007/s00066-021-01810-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/13/2021] [Indexed: 11/28/2022]
Abstract
Background Total body irradiation (TBI) is an established part of conditioning regimens prior to stem cell transplantation in childhood leukemia but is associated with long-term toxicity. We retrospectively analyzed survival, long-term toxicity, and secondary malignancies in a pooled cohort of pediatric patients (pts.) treated with the same TBI regimen. Methods Analyzed were 109 pts. treated between September 1996 and November 2015. Conditioning treatment according to EBMT guidelines and the ALL SCTped 2012 FORUM trial consisted of chemotherapy (CT) and TBI with 2 Gy b.i.d. on 3 consecutive days to a total dose of 12 Gy. Median follow-up was 97.9 months (2–228 months). Results Overall survival (OS) in our cohort at 2, 5, and 10 years was 86.1, 75.5, and 63.0%, respectively. Median survival was not reached. Long-term toxicity developed in 47 pts. After chronically abnormal liver and kidney parameters in 31 and 7 pts., respectively, growth retardation was the most frequent finding as seen in 13 pts. Secondary malignancies were rare (n = 3). Conclusion TBI-containing conditioning regimens in pediatric stem cell transplantation (SCT) are highly effective. Efforts to replace TBI- with CT-containing regimens have only been successful in subgroups of pts. Although we could show long-term toxicity in 43% of pts., overall survival was 63% at 10 years. Still, long-term effects such as growth retardation can permanently impact the pts.’ quality of life and functioning. Along with new substances, efforts should be undertaken to optimize TBI techniques and accompany the treatment by systematic follow-up programs beyond 5 years to improve detection of rare events.
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Affiliation(s)
- Arne Gruen
- Department for Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Clinic, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Sebastian Exner
- Strahlenzentrum Hamburg MVZ, Langenhorner Chaussee 369, 22419, Hamburg, Germany
| | - Jörn-Sven Kühl
- Department for Pediatric Oncology, Hematology and Hemostaseology, University Clinic Leipzig, Liebigstraße 22, Haus 7, 04103, Leipzig, Germany
| | - Arend von Stackelberg
- Department for Pediatric Hematology, Oncology and Stem Cell Transplantation, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Volker Budach
- Department for Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Carmen Stromberger
- Department for Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dirk Boehmer
- Department for Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
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Wang R, Uretzki M, Boehmer D, Hein R, Biedermann T, Posch C. Severe thrombocytopenia and excellent response following combined immune checkpoint inhibition for metastatic malignant melanoma. J Eur Acad Dermatol Venereol 2020; 35:e89-e92. [PMID: 32701189 DOI: 10.1111/jdv.16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- R Wang
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Munich, Germany
| | - M Uretzki
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Munich, Germany
| | - D Boehmer
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Munich, Germany
| | - R Hein
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Munich, Germany
| | - T Biedermann
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Munich, Germany
| | - C Posch
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Munich, Germany
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Boehmer D, Eyerich K, Darsow U, Biedermann T, Zink A. Variable response to low‐dose naltrexone in patients with Darier disease: a case series. J Eur Acad Dermatol Venereol 2019; 33:950-953. [DOI: 10.1111/jdv.15457] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 12/12/2022]
Affiliation(s)
- D. Boehmer
- Dermatology Technical University of Munich Munich Germany
| | - K. Eyerich
- Dermatology Technical University of Munich Munich Germany
| | - U. Darsow
- Dermatology Technical University of Munich Munich Germany
| | - T. Biedermann
- Dermatology Technical University of Munich Munich Germany
| | - A. Zink
- Dermatology Technical University of Munich Munich Germany
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Bolla M, Maingon P, Carrie C, Villa S, Kitsios P, Poortmans PM, Sundar S, van der Steen-Banasik EM, Armstrong J, Bosset JF, Herrera FG, Pieters B, Slot A, Bahl A, Ben-Yosef R, Boehmer D, Scrase C, Renard L, Shash E, Coens C, van den Bergh AC, Collette L. Short Androgen Suppression and Radiation Dose Escalation for Intermediate- and High-Risk Localized Prostate Cancer: Results of EORTC Trial 22991. J Clin Oncol 2016; 34:1748-56. [DOI: 10.1200/jco.2015.64.8055] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose Up to 30% of patients who undergo radiation for intermediate- or high-risk localized prostate cancer relapse biochemically within 5 years. We assessed if biochemical disease-free survival (DFS) is improved by adding 6 months of androgen suppression (AS; two injections of every-3-months depot of luteinizing hormone–releasing hormone agonist) to primary radiotherapy (RT) for intermediate- or high-risk localized prostate cancer. Patients and Methods A total of 819 patients staged: (1) cT1b-c, with prostate-specific antigen (PSA) ≥ 10 ng/mL or Gleason ≥ 7, or (2) cT2a (International Union Against Cancer TNM 1997), with no involvement of pelvic lymph nodes and no clinical evidence of metastatic spread, with PSA ≤ 50 ng/mL, were centrally randomized 1:1 to either RT or RT plus AS started on day 1 of RT. Centers opted for one dose (70, 74, or 78 Gy). Biochemical DFS, the primary end point, was defined from entry until PSA relapse (Phoenix criteria) and clinical relapse by imaging or death of any cause. The trial had 80% power to detect hazard ratio (HR), 0.714 by intent-to-treat analysis stratified by dose of RT at the two-sided α = 5%. Results The median patient age was 70 years. Among patients, 74.8% were intermediate risk and 24.8% were high risk. In the RT arm, 407 of 409 patients received RT; in the RT plus AS arm, 403 patients received RT plus AS and three patients received RT only. At 7.2 years median follow-up, RT plus AS significantly improved biochemical DFS (HR, 0.52; 95% CI, 0.41 to 0.66; P < .001, with 319 events), as well as clinical progression-free survival (205 events, HR, 0.63; 95% CI, 0.48 to 0.84; P = .001). In exploratory analysis, no statistically significant interaction between treatment effect and dose of RT could be evidenced (heterogeneity P = .79 and P = .66, for biochemical DFS and progression-free survival, respectively). Overall survival data are not mature yet. Conclusion Six months of concomitant and adjuvant AS improves biochemical and clinical DFS of intermediate- and high-risk cT1b-c to cT2a (with no involvement of pelvic lymph nodes and no clinical evidence of metastatic spread) prostatic carcinoma, treated by radiation.
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Affiliation(s)
- Michel Bolla
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Philippe Maingon
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Christian Carrie
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Salvador Villa
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Petros Kitsios
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Philip M.P. Poortmans
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Santhanam Sundar
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Elzbieta M. van der Steen-Banasik
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - John Armstrong
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Jean-François Bosset
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Fernanda G. Herrera
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Bradley Pieters
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Annerie Slot
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Amit Bahl
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Rahamim Ben-Yosef
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Dirk Boehmer
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Christopher Scrase
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Laurette Renard
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Emad Shash
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Corneel Coens
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Alphonsus C.M. van den Bergh
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
| | - Laurence Collette
- Michel Bolla, Centre Hospitalier Universitaire de Grenoble, Grenoble; Philippe Maingon, Georges-Francois-Leclerc Centre, Dijon; Christian Carrie, Leon Bérard Center, Lyon; Jean-François Bosset, University Hospital of Besancon–Jean Minjoz Hospital, Besancon, France; Salvador Villa, University Hospital Germans Trias I Pujol, Barcelona, Spain; Petros Kitsios, Bank of Cyprus Oncology Centre, Nicosia, Cyprus; Philip M.P. Poortmans, Radboud University Medical Center Nijmegen, Nijmegen; Elzbieta M. van der
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Friedersdorff F, Aghdassi SJ, Magheli A, Richter M, Stephan C, Busch J, Boehmer D, Miller K, Fuller TF. Staging lymphadenectomy in patients with localized high risk prostate cancer: comparison of the laparoendoscopic single site (LESS) technique with conventional multiport laparoscopy. BMC Urol 2014; 14:92. [PMID: 25412566 PMCID: PMC4247718 DOI: 10.1186/1471-2490-14-92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/30/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In patients with localized high-risk prostate cancer awaiting radiation therapy, pelvic lymphadenectomy (PL) is a reliable minimally invasive staging procedure. We compared outcomes after laparoendoscopic single site PL (LESSPL) with those after conventional multiport laparoscopic PL (MLPL). METHODS A retrospective case-control study was carried out at the authors' center. For LESSPL the reusable X-Cone single port was combined with straight and prebent laparoscopic instruments and an additional 3 mm needlescopic grasper. MLPL was performed via four trocars of different sizes using standard laparoscopic instruments. RESULTS Patients who underwent either LESSPL (n = 20) or MLPL (n = 97) between January 2008 and July 2013, were included in the study. Demographic data were comparable between groups. Patients in the LESSPL group tended to be older and had a significantly higher ASA-score. The mean operating time was 172.4 ± 34.1 min for LESSPL and 116.6 ± 40.1 min for MLPL (P < .001). During LESSPL, no conversion to MLPL was necessary. An average of 12 lymph nodes per patient was retrieved, with no significant difference between study groups. Postoperative pain scores were similar between groups. The hospital stay was 2.3 ± 0.7 days after LESSPL and 3.1 ± 1.2 days after MLPL (P = .01). Two days postoperatively, significantly more patients after LESSPL than after MLPL recovered their normal physical activity (P < .001). Six months postoperatively, no complications were registered in the LESSPL group and cosmetic results were excellent. CONCLUSIONS In the present study, shorter hospitalization and quicker postoperative recovery were major benefits of LESSPL over MLPL. In patients with localized prostate cancer, staging LESS pelvic lymphadenectomy may be a safe alternative to conventional multiport laparoscopy.
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Affiliation(s)
- Frank Friedersdorff
- Department of Urology, Charité University Hospital, Charitéplatz 1, 10117 Berlin, Germany.
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12
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Budach V, Becker ET, Boehmer D, Badakhshi H, Jahn U, Wernecke KD, Stromberger C. Concurrent hyperfractionated accelerated radiotherapy with 5-FU and once weekly cisplatin in locally advanced head and neck cancer. Strahlenther Onkol 2013; 190:250-5. [DOI: 10.1007/s00066-013-0481-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/26/2013] [Indexed: 12/01/2022]
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Badakhshi H, Barelkowski T, Wust P, Budach V, Boehmer D, Graf R. Intrafraction variations in linac-based image-guided radiosurgery of intracranial lesions. Cancer Radiother 2013; 17:664-7. [PMID: 24176665 DOI: 10.1016/j.canrad.2013.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/17/2013] [Accepted: 05/25/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE This study investigated image-guided patient positioning during frameless, mask-based, single-fraction stereotactic radiosurgery of intracranial lesions and intrafractional translational and rotational variations in patient positions. PATIENTS AND METHODS A non-invasive head and neck thermoplastic mask was used for immobilization. The Exactrac/Novalis Body system (BrainLAB AG, Germany) was used for kV X-ray imaging guided positioning. Intrafraction displacement data, obtained by imaging after each new table position, were evaluated. RESULTS There were 269 radiosurgery treatments performed on 190 patients and a total of 967 setups within different angles. The first measured error after each table rotation (mean 2.6) was evaluated (698 measurements). Intrafraction translational errors were (1 standard deviation [SD]) on average 0.8, 0.8, and 0.7mm for the left-right, superior-inferior, and anterior-posterior directions, respectively, with a mean 3D-vector of 1.0mm (SD 0.9mm) and a range from -5mm to +5mm. On average, 12%, 3%, and 1% of the translational deviations exceeded 1, 2, and 3mm, respectively, in the three directions. CONCLUSION The range of intrafraction patient motion in frameless image-guided stereotactic radiosurgery is often not fully mapped by pre- and post-treatment imaging. In the current study, intrafraction motion was assessed by performing measurements at several time points during the course of stereotactic radiosurgery. It was determined that 12% of the intrafraction values in the three dimensions are above 1mm, the usual safety margin applied in stereotactic radiosurgery.
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Affiliation(s)
- H Badakhshi
- Department of Radiation Oncology, Charité School of Medicine and University Hospital, Augustenburger Platz 1, 13353 Berlin, Germany.
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Badakhshi H, Gruen A, Sehouli J, Budach V, Boehmer D. The impact of patient compliance with adjuvant radiotherapy: a comprehensive cohort study. Cancer Med 2013; 2:712-7. [PMID: 24403236 PMCID: PMC3892802 DOI: 10.1002/cam4.114] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 07/10/2013] [Accepted: 07/16/2013] [Indexed: 11/23/2022] Open
Abstract
Postoperative radiotherapy (RT) is the standard of care for early stage breast cancer. It reduces the risk for local recurrence and prolongs survival. We assessed whether, the omission of RT because of patient's preference may influence the prognosis and, thus, the quality of cancer care. Detailed information from a prospectively collected database of a breast cancer center was analyzed. Multiple regression analysis and univariate and multivariate analysis for risk factors for recurrence were performed. The entire cohort of primary breast cancer patients in a given time period was analyzed. Data from 1903 patients undergoing treatment at breast cancer center between 2003 and 2008 were used. All patient underwent breast conserving surgery and RT was performed for all patients of the cohort. Local tumor control and disease-free survival were calculated. After a median follow-up of 2.18 years (maximum 6.39 years), 5.5% of patients did not follow guideline-based recommendations for RT. There was a significant correlation between noncompliance and patient's age, adjuvant hormonal therapy (97.0%), and adjuvant chemotherapy (96.8%). Seventy local recurrences occurred that corresponds to a local recurrence rate of 3.9%. The difference in regard to local recurrence-free 5-year survival between the compliant patients and the noncompliant patients is absolute 17.9 (93.3% and 75.4%). Noncompliant patients had suffered a 5.02-fold increased risk of local recurrence than compliant patients. The omission of RT after breast-conserving surgery results in a higher local failure rate and significantly worsens clinical outcome. Age may play an important role because of the comorbidities of aged patients or the assumed low RT tolerance in this group. On a clinical level, this data suggests that improvement is needed to correct this situation, and the question remains as to how best to improve RT compliance.
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Affiliation(s)
- Harun Badakhshi
- Department of Radiation Oncology, Charité School of Medicine and University Hospital, Berlin, Germany
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Badakhshi H, Grün A, Stromberger C, Budach V, Boehmer D. Oligometastases: the new paradigm and options for radiotherapy. A critical review. Strahlenther Onkol 2013; 189:357-62. [PMID: 23512205 DOI: 10.1007/s00066-013-0326-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/06/2013] [Indexed: 01/22/2023]
Abstract
Traditional oncology distinguishes between two separate and incommensurable states in the evolution of solid malignancies: the localized disease, which is curable; and the disseminated status, which is per se palliative. Recently, a huge body of evidence suggests a fundamental change in the understanding of cancer, indicating an intermediate state in the trajectory of solid malignancies: the oligometastatic state. The following review will critically analyse existing hypotheses and facts from the basic sciences and try to contextualize it in regard to the clinical evidence available to date. Consecutively, it will try to draw possible clinical consequences for application of radiotherapy in this specific clinical scenario.
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Affiliation(s)
- H Badakhshi
- Department for Radiation Oncology, Charité University Medicine, Augustenburger Platz 1, 13353, Berlin, Germany.
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Sehouli J, Runnebaum IB, Fotopoulou C, Blohmer U, Belau A, Leber H, Hanker LC, Hartmann W, Richter R, Keyver-Paik MD, Oberhoff C, Heinrich G, du Bois A, Olbrich C, Simon E, Friese K, Kimmig R, Boehmer D, Lichtenegger W, Kuemmel S. A randomized phase III adjuvant study in high-risk cervical cancer: simultaneous radiochemotherapy with cisplatin (S-RC) versus systemic paclitaxel and carboplatin followed by percutaneous radiation (PC-R): a NOGGO-AGO Intergroup Study. Ann Oncol 2012; 23:2259-2264. [PMID: 22357252 DOI: 10.1093/annonc/mdr628] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Simultaneous adjuvant platinum-based radiochemotherapy in high-risk cervical cancer (CC) is an established treatment strategy. Sequential paclitaxel (Taxol) and platinum followed by radiotherapy may offer further advantages regarding toxicity. PATIENTS AND METHODS An open-labeled randomized phase III trial was conducted to compare paclitaxel (175 mg/m(2)) plus carboplatin (AUC5) followed by radiation (50.4 Gy) (experimental arm-A) versus simultaneous radiochemotherapy with cisplatin (40 mg/m(2)/week) (arm-B) in patients with stage IB-IIB CC after surgery. Primary objective was progression-free survival (PFS). RESULTS Overall, 271 patients were randomized and 263 were eligible for evaluation; 132 in arm-A and 131 in arm-B appropriately balanced. The estimated 2-year PFS was 81.8% [95% confidence interval (CI) 74.4-89.1] in arm-B versus 87.2% (95% CI 81.2-93.3) in arm-A (P = 0.235) and the corresponding 5-year survival rates were 85.8% in arm-A and 78.9% in arm-B (P = 0.25). Hematological grade 3/4 toxicity was higher in arm-B. Alopecia (87.9% versus 4.1%; P < 0.001) and neurotoxicity (65.9% versus 15.6%; P < 0.001) were significantly higher in arm-A. Early treatment termination was significantly more frequent in arm-B than in arm-A (32.1% versus 12.9%; P = 0.001). CONCLUSIONS Sequential chemotherapy and radiation in high-risk CC could not show any significant survival benefit; however, a different toxicity profile appeared. This sequential regime may constitute an alternative option when contraindications for immediate postoperative radiation are present.
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Affiliation(s)
- J Sehouli
- Department of Gynecology, European Competence Centre for Ovarian Cancer, Charité-University Hospital, Berlin.
| | - I B Runnebaum
- Department of Gynecology, Jena University Hospital, Jena
| | - C Fotopoulou
- Department of Gynecology, European Competence Centre for Ovarian Cancer, Charité-University Hospital, Berlin
| | - U Blohmer
- Brustzentrum, Sankt-Gertrauden-Krankenhaus, Berlin
| | - A Belau
- Department of Gynecology, Ernst-Moritz-Arndt-Universität Greifswald, Greifswald
| | - H Leber
- Klinik fuer Strahlentherapie, Bruederkrankenhaus St Josef, Paderborn
| | - L C Hanker
- Department of Obstetrics and Gynecology, J.W. Goethe-University, Frankfurt
| | - W Hartmann
- Department of Gynecology, Klinikum Frankfurt (Oder) GmbH, Frankfurt-Oder
| | - R Richter
- Department of Gynecology, European Competence Centre for Ovarian Cancer, Charité-University Hospital, Berlin
| | | | - C Oberhoff
- Department of Gynecology, Kath. Kliniken Essen-Nord Marienhospital, Altenessen
| | | | - A du Bois
- Department of Gynecology, Horst Schmidt Klinik, Wiesbaden
| | - C Olbrich
- Department of Gynecology, DRK Kliniken Berlin Westend, Berlin
| | - E Simon
- Department of Gynecology, Kreiskrankenhaus Torgau Johann Kentmann GmbH, Torgau
| | - K Friese
- Department of Gynecology, Universitätsklinik LMU, Munich
| | - R Kimmig
- Department of Gynecology, Universitätsklinikum Essen, Essen
| | - D Boehmer
- Department of Radiation Oncology, Charite-University Medicine Berlin, Campus Virchow-Klinikum, Berlin
| | - W Lichtenegger
- Department of Gynecology, European Competence Centre for Ovarian Cancer, Charité-University Hospital, Berlin
| | - S Kuemmel
- Brustzentrum, Kliniken Essen-Mitte, Essen, Germany
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Graf R, Boehmer D, Nadobny J, Budach V, Wust P. Appropriate patient instructions can reduce prostate motion. Radiat Oncol 2012; 7:125. [PMID: 22852559 PMCID: PMC3447725 DOI: 10.1186/1748-717x-7-125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 07/17/2012] [Indexed: 11/15/2022] Open
Abstract
Background Interfraction prostate motion must be compensated by increased safety margins. If filling status of rectum and bladder is constant, motion should be reduced. We attempted to reduce interfraction motion errors by proper patient instruction. Method In 38 patients pairs of radio-opaque fiducial markers were implanted prior to definitive radiotherapy. Patients were positioned either according to skin marks or infrared body marker. We measured prostate displacement, i.e. pelvic bones versus intraprostatic marker position, via ExacTrac (two orthogonal radiographies) in 1252 fractions. Systematic and random setup and displacement errors were determined and safety margins estimated. Results In our study interfraction prostate displacement is < 1 mm in RL direction, and < 2 mm in AP and SI direction. Systematic errors are slightly below random errors (< 1.5 mm). Positioning according skin marks results in higher inaccuracies of ±1.5 – 2 mm in RL and ±2 – 2.5 mm in AP/SI direction. Conclusions In case of appropriate patient instructions (constant organ filling) the positioning via bone fusion requires CTV-PTV margins of 2 mm in RL, 4 mm in AP, and 5 mm in SI direction. Studies without any description of patient instruction found much higher margins of > 1 cm in AP and SI direction.
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Affiliation(s)
- Reinhold Graf
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Graf R, Boehmer D, Budach V, Wust P. Interfraction rotation of the prostate as evaluated by kilovoltage X-ray fiducial marker imaging in intensity-modulated radiotherapy of localized prostate cancer. Med Dosim 2012; 37:396-400. [PMID: 22534137 DOI: 10.1016/j.meddos.2012.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 02/10/2012] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
Abstract
To quantify the daily rotation of the prostate during a radiotherapy course using stereoscopic kilovoltage (kV) x-ray imaging and intraprostatic fiducials for localization and positioning correction. From 2005 to 2009, radio-opaque fiducial markers were inserted into 38 patients via perineum into the prostate. The ExacTrac/Novalis Body X-ray 6-day image acquisition system (ET/NB; BrainLab AG, Feldkirchen, Germany) was used to determine and correct the target position. During the first period in 10 patients we recorded all rotation errors but used only Y (table) for correction. For the next 28 patients we used for correction all rotational coordinates, i.e., in addition Z (superior-inferior [SI] or roll) and X (left-right [LR] or tilt/pitch) according to the fiducial marker position by use of the Robotic Tilt Module and Varian Exact Couch. Rotation correction was applied above a threshold of 1° displacement. The systematic and random errors were specified. Overall, 993 software-assisted rotational corrections were performed. The interfraction rotation errors of the prostate as assessed from the radiodense surrogate markers around the three axes Y, Z, and X were on average 0.09, -0.52, and -0.01° with standard deviations of 2.01, 2.30, and 3.95°, respectively. The systematic uncertainty per patient for prostate rotation was estimated with 2.30, 1.56, and 4.13° and the mean random components with 1.81, 2.02, and 3.09°. The largest rotational errors occurred around the X-axis (pitch), but without preferring a certain orientation. Although the error around Z (roll) can be compensated on average by a transformation with 4 coordinates, a significant error around X remains and advocates the full correction with 6 coordinates. Rotational errors as assessed via daily stereoscopic online imaging are significant and dominate around X. Rotation possibly degrades the dosimetric coverage of the target volume and may require suitable strategies for correction.
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Affiliation(s)
- Reinhold Graf
- Charité Universitätsmedizin Berlin, Department of Radiation Oncology, Campus Virchow-Klinikum, Berlin, Germany
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Blohmer JU, Paepke S, Sehouli J, Boehmer D, Kolben M, Würschmidt F, Petry KU, Kimmig R, Elling D, Thomssen C, von Minckwitz G, Möbus V, Hinke A, Kümmel S, Budach V, Lichtenegger W, Schmid P. Randomized Phase III Trial of Sequential Adjuvant Chemoradiotherapy With or Without Erythropoietin Alfa in Patients With High-Risk Cervical Cancer: Results of the NOGGO-AGO Intergroup Study. J Clin Oncol 2011; 29:3791-7. [DOI: 10.1200/jco.2010.30.4899] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This open-label, randomized phase III study was designed to investigate the effects of erythropoietin alfa (EPO) in addition to adjuvant chemotherapy and pelvic radiotherapy (CRT) in patients with stage IB to II cervical cancer who had undergone radical hysterectomy. Patients and Methods Two hundred fifty-seven patients were randomly assigned to four cycles of carboplatin/ifosfamide chemotherapy followed by external-beam pelvic radiotherapy (CRT group) or four cycles of carboplatin/ifosfamide chemotherapy and EPO followed by pelvic radiotherapy and EPO (CRT + EPO group). The primary end point was recurrence-free survival (RFS). Secondary end points included overall survival (OS), change in hemoglobin levels, and safety, including thromboembolic events. Results The estimated 5-year RFS rates were 78% for patients receiving CRT + EPO and 70% for patients receiving CRT. There was no statistically significant difference in RFS, although a trend favoring patients treated with CRT + EPO was observed (hazard ratio [HR], 0.66; 95% CI, 0.39 to 1.12; log-rank P = .06). Exploratory analyses suggest a benefit with CRT + EPO for patients with stage IB to IIA disease (HR, 0.39; 95% CI, 0.18 to 0.85; P = .014) or patients with complete resection (HR, 0.55; 95% CI, 0.31 to 0.98; P = .039). OS was similar in both groups (HR, 0.88; 95% CI, 0.51 to 1.50; log-rank P = .63). Patients treated with EPO maintained higher hemoglobin levels throughout CRT. No significant differences in safety profiles were observed between the two groups. Incidence of thrombovascular events was low (2%) and comparable between both groups. Conclusion This study confirms that EPO can be added safely to CRT in patients with cervical cancer, but it failed to demonstrate a significant benefit in RFS and OS.
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Affiliation(s)
- Jens-Uwe Blohmer
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Stefan Paepke
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Jalid Sehouli
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Dirk Boehmer
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Martin Kolben
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Florian Würschmidt
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Karl U. Petry
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Rainer Kimmig
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Dirk Elling
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Christoph Thomssen
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Gunter von Minckwitz
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Volker Möbus
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Axel Hinke
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Sherko Kümmel
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Volker Budach
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Werner Lichtenegger
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
| | - Peter Schmid
- Jens-Uwe Blohmer, Sankt Gertrauden-Krankenhaus; Jalid Sehouli, Dirk Boehmer, Volker Budach, Werner Lichtenegger, Charité University Hospital; Dirk Elling, Sana Klinikum Lichtenberg, Berlin; Stefan Paepke, Martin Kolben, Technical University München, Munich; Florian Würschmidt, Clinic for Radiology and Radio-oncology, Hamburg; Karl U. Petry, Klinikum Wolfsburg, Wolfsburg; Rainer Kimmig, University of Essen; Sherko Kümmel, Breast Cancer Centre, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen
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Graf R, Boehmer D, Budach V, Wust P. Residual translational and rotational errors after kV X-ray image-guided correction of prostate location using implanted fiducials. Strahlenther Onkol 2010; 186:544-50. [PMID: 20936461 DOI: 10.1007/s00066-010-2030-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 07/19/2010] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the residual errors and required safety margins after stereoscopic kilovoltage (kV) X-ray target localization of the prostate in image-guided radiotherapy (IGRT) using internal fiducials. PATIENTS AND METHODS Radiopaque fiducial markers (FMs) have been inserted into the prostate in a cohort of 33 patients. The ExacTrac/Novalis Body™ X-ray 6d image acquisition system (BrainLAB AG, Feldkirchen, Germany) was used. Corrections were performed in left-right (LR), anterior-posterior (AP), and superior-inferior (SI) direction. Rotational errors around LR (x-axis), AP (y) and SI (z) have been recorded for the first series of nine patients, and since 2007 for the subsequent 24 patients in addition corrected in each fraction by using the Robotic Tilt Module™ and Varian Exact Couch™. After positioning, a second set of X-ray images was acquired for verification purposes. Residual errors were registered and again corrected. RESULTS Standard deviations (SD) of residual translational random errors in LR, AP, and SI coordinates were 1.3, 1.7, and 2.2 mm. Residual random rotation errors were found for lateral (around x, tilt), vertical (around y, table), and longitudinal (around z, roll) and of 3.2°, 1.8°, and 1.5°. Planning target volume (PTV)-clinical target volume (CTV) margins were calculated in LR, AP, and SI direction to 2.3, 3.0, and 3.7 mm. After a second repositioning, the margins could be reduced to 1.8, 2.1, and 1.8 mm. CONCLUSION On the basis of the residual setup error measurements, the margin required after one to two online X-ray corrections for the patients enrolled in this study would be at minimum 2 mm. The contribution of intrafractional motion to residual random errors has to be evaluated.
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Affiliation(s)
- Reinhold Graf
- Department of Radiation Oncology, Charite - University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany
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21
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Sehouli J, Pietzner K, Harter P, Münstedt K, Mahner S, Hasenburg A, Camara O, Wimberger P, Boehmer D, Buehling KJ, Richter R, El Khalfaoui K, Oskay-Ozcelik G. Prognostic role of platinum sensitivity in patients with brain metastases from ovarian cancer: results of a German multicenter study. Ann Oncol 2010; 21:2201-2205. [PMID: 20439341 DOI: 10.1093/annonc/mdq229] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Ovarian cancer is the leading cause of death in women with gynecological malignancies. Brain metastases are considered an uncommon metastatic site. Only few data exist on prognostic factors for this patient collective. PATIENTS AND METHODS A multicenter retrospective chart review was carried out including all patients with histologically confirmed ovarian cancer from six different German hospitals from 1981 to 2008. Overall, 4277 cases of patients with ovarian cancer were screened and patients with brain metastasis were identified and analyzed regarding various clinical variables and survival. RESULTS A total of 74 women with brain metastases were identified, resulting in an incidence of 1.73%. In multivariate analysis, the following clinical parameters had a significant impact on overall survival: multiple lesions [hazard ratio (HR) 4.4, 95% confidence interval (CI) 2.0-9.7] and low grading (HR 3.1, 95% CI 1.7-5.8) were associated with a negative impact. Platinum sensitivity (HR 0.23, 95% CI 0.12-0.48) was significantly associated with a favorable outcome. Good performance status (60%-80% HR 0.48, 95% CI 0.23-0.99 and 90%-100% HR 0.21, 95% CI 0.08-0.53) also had a positive impact on overall survival. CONCLUSIONS Platinum sensitivity is the most important prognostic factor in patients with ovarian cancer metastatic to the brain. This novel finding should be considered in the strategy of multimodal therapy for brain metastases in ovarian cancer.
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Affiliation(s)
- J Sehouli
- Department of Gynecology and Obstetrics, Charité-Campus Virchow Klinikum, University Medicine of Berlin, Berlin.
| | - K Pietzner
- Department of Gynecology and Obstetrics, Charité-Campus Virchow Klinikum, University Medicine of Berlin, Berlin
| | - P Harter
- Department of Gynecology & Gynecologic Oncology, Dr. Horst Schmidt Klinik (HSK), Wiesbaden
| | - K Münstedt
- Department of Obstetrics and Gynecology, Justus-Liebig-University of Giessen, Giessen
| | - S Mahner
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - A Hasenburg
- Department of Obstetrics and Gynecology, Freiburg University Medical Center, Freiburg
| | - O Camara
- Department of Gynaecology and Obstetrics, Friedrich Schiller University, Jena
| | - P Wimberger
- Department of Gynecology and Obstetrics, University Hospital Essen, Essen
| | - D Boehmer
- Department of Radiation Oncology and Radiotherapy, Charité-Campus Virchow Klinikum, University Medicine of Berlin, Berlin, Germany
| | - K J Buehling
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - R Richter
- Department of Gynecology and Obstetrics, Charité-Campus Virchow Klinikum, University Medicine of Berlin, Berlin
| | - K El Khalfaoui
- Department of Gynecology and Obstetrics, Charité-Campus Virchow Klinikum, University Medicine of Berlin, Berlin
| | - G Oskay-Ozcelik
- Department of Gynecology and Obstetrics, Charité-Campus Virchow Klinikum, University Medicine of Berlin, Berlin
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Pietzner K, Oskay-Oezcelik G, El Khalfaoui K, Boehmer D, Lichtenegger W, Sehouli J. Brain metastases from epithelial ovarian cancer: overview and optimal management. Anticancer Res 2009; 29:2793-2798. [PMID: 19596963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Central nervous system involvement is a rare finding in the management of epithelial ovarian cancer with an incidence between 1-2%. A sharp rise in the incidence has been widely and repeatedly proclaimed for nearly two decades now, but has to be treated with scepticism after a careful review of the current literature. Brain metastases from ovarian cancer are known to be related to a very poor prognosis. Since brain imaging is not part of the routine follow-up care for ovarian cancer patients, and since CA-125--one of the standard tools--cannot be relied upon to detect central nervous system relapse, brain lesions are mostly traced by unspecific neurological symptoms only. Several prognostic factors are still being discussed today. But only a high performance status and the absence of an extra cranial disease at the time of CNS relapse have been accepted throughout the current literature as having a highly significant positive impact on survival. In the past, therapeutic efforts have focused on symptom palliation with corticosteroids and whole-brain radiation therapy (WBRT). During the last years several other therapy options have evolved from encouraging efforts made by several study groups, including chemotherapy, neurosurgery and radiosurgery. It has been shown that a multi-modal approach, combining these strategies, promises the best prolongation of survival and in some cases even resulted in long-term remissions. The present article gives an overview of brain metastases in epithelial ovarian cancer and discusses the current treatment options.
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Affiliation(s)
- Klaus Pietzner
- Department of Gynaecology and Obstetrics, Charité-Campus Virchow-Klinikum, Medical University of Berlin, Berlin, Germany
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Graf R, Wust P, Budach V, Boehmer D. Potentials of on-line repositioning based on implanted fiducial markers and electronic portal imaging in prostate cancer radiotherapy. Radiat Oncol 2009; 4:13. [PMID: 19397824 PMCID: PMC2683853 DOI: 10.1186/1748-717x-4-13] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Accepted: 04/27/2009] [Indexed: 12/25/2022] Open
Abstract
Background To evaluate the benefit of an on-line correction protocol based on implanted markers and weekly portal imaging in external beam radiotherapy of prostate cancer. To compare the use of bony anatomy versus implanted markers for calculation of setup-error plus/minus prostate movement. To estimate the error reduction (and the corresponding margin reduction) by reducing the total error to 3 mm once a week, three times per week or every treatment day. Methods 23 patients had three to five, 2.5 mm Ø spherical gold markers transrectally inserted into the prostate before radiotherapy. Verification and correction of treatment position by analysis of orthogonal portal images was performed on a weekly basis. We registered with respect to the bony contours (setup error) and to the marker position (prostate motion) and determined the total error. The systematic and random errors are specified. Positioning correction was applied with a threshold of 5 mm displacement. Results The systematic error (1 standard deviation [SD]) in left-right (LR), superior-inferior (SI) and anterior-posterior (AP) direction contributes for the setup 1.6 mm, 2.1 mm and 2.4 mm and for prostate motion 1.1 mm, 1.9 mm and 2.3 mm. The random error (1 SD) in LR, SI and AP direction amounts for the setup 2.3 mm, 2.7 mm and 2.7 mm and for motion 1.4 mm, 2.3 mm and 2.7 mm. The resulting total error suggests margins of 7.0 mm (LR), 9.5 mm (SI) and 9.5 mm (AP) between clinical target volume (CTV) and planning target volume (PTV). After correction once a week the margins were lowered to 6.7, 8.2 and 8.7 mm and furthermore down to 4.9, 5.1 and 4.8 mm after correcting every treatment day. Conclusion Prostate movement relative to adjacent bony anatomy is significant and contributes substantially to the target position variability. Performing on-line setup correction using implanted radioopaque markers and megavoltage radiography results in reduced treatment margins depending on the online imaging protocol (once a week or more frequently).
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Affiliation(s)
- Reinhold Graf
- Charité Universitätsmedizin Berlin, Department of Radiotherapy, Germany.
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Kasprowicz NS, Fotopoulou C, Oskay-Ozcelik G, El KK, Boehmer D, Sehouli J. Brain metastases in relapsed epithelial ovarian cancer after chemotherapy with pegylated liposomal doxorubicin. Anticancer Res 2008; 28:1943-1946. [PMID: 18630485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Brain metastases in epithelial ovarian cancer (EOC) occur rarely and are associated with a poor prognosis. No significant risk factors have been identified and no evidence-based treatment guidelines are currently available. CASE REPORT A 56-year-old EOC patient presented with seizure at the Emergency Department eleven days after completion of fourth-line chemotherapy with pegylated liposomal doxorubicin (PLD). A computed tomography (CT) scan revealed multiple metastases. The patient received radiotherapy with a total dose of 30.8 Gy and 8 cycles of paclitaxel resulting in stable disease. Based on the current literature, treatment options are discussed. CONCLUSION Therapeutic options for brain metastases include radiation, systemic or intrathecal chemotherapy, surgery or a combination regime. Since the effectiveness of systemic chemotherapy remains controversial, current research focuses on developing new anticancer drugs that penetrate the blood-brain barrier in order to prevent and/or treat brain metastases.
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Affiliation(s)
- Nikola Serena Kasprowicz
- Department of Obstetrics and Gynecology, Charité, Campus Virchow-Clinic, Augustenburger Platz 1, 13353 Berlin, Germany
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Chekerov R, Denkert C, Boehmer D, Suesse A, Widing A, Ruhmland B, Giese A, Mustea A, Lichtenegger W, Sehouli J. Online tumor conference in the clinical management of gynecological cancer: experience from a pilot study in Germany. Int J Gynecol Cancer 2008; 18:1-7. [PMID: 17466034 DOI: 10.1111/j.1525-1438.2007.00971.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The concept of the online tumor conference was established in 2004 as a pilot project. We developed specific web-based software to organize and conduct online tumor board meetings of gynecologists, surgeons, radiologists, oncologists, and pathologists from different hospitals and gynecological practitioners, discussing individual patient's cases, defining therapy options, and exchanging clinical experience. Following a didactic approach, patient data are presented to the participants, with a special focus toward patient's preference and late toxicity from prior therapy. Then different national (eg, Arbeitsgemeinschaft Gynaekologische Onkologie, Deutsche Gesellschag fur Gynaekologic und Geburtshilfe) and international guidelines (eg, American Society of Clinical Oncology, National Cancer Institute), current study results based on literature review and open clinical trials are discussed. An individual diagnosis and therapy recommendation for each patient is reached by consensus. All protocols, guidelines, and publication data are upgraded and dispersed via Internet for all participants. In the period from December 2004 to August 2006, 39 tumor board conferences were performed with a total of 667 participants. One hundred forty-four patients' cases were presented, and 121 peer-reviewed second-opinions were sought. In an anonymous survey, 84% of the participants reported to be satisfied with the information content and 72% with the technical support. Overall 98% of the individual therapy recommendations were accepted and implemented. The tumor board conference presents an optimal possibility for extensive scientific discussions and exchange (92%) and improves advanced educational training (81%). In conclusion, the online tumor conference is feasible and represents a time-saving possibility for gynecological oncologist to receive a treatment recommendation based on the best available clinical and scientific evidence.
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Affiliation(s)
- R Chekerov
- Department of Obstetrics and Gynecology, Campus Virchow, Charité University Hospital, Berlin, Germany
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Abstract
The use of hormonal therapy as an adjunct to radiotherapy has been discussed controversially for years. Results of large RTOG and EORTC trials indicate that the combination of these treatment modalities may improve survival in subsets of patients. Many questions with respect to onset, duration, type of hormonal therapy and appropriate patient selection are still under investigation. Following a short overview of the corresponding literature, evidence-based recommendations for daily clinical practice are provided.
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Affiliation(s)
- Dirk Boehmer
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin , Germany
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Budach V, Badakhshi H, Boehmer D, Schlenger L, WerNecke K. 4-Year Results of a Phase II Trial Using Hyperfractionated Accelerated Radiation with Concurrent Once-Weekly cis-Platinum and 5-FU (C-HART) in Locally Advanced Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2007. [DOI: 10.1016/j.ijrobp.2007.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Poortmans P, Bossi A, Vandeputte K, Bosset M, Miralbell R, Maingon P, Boehmer D, Budiharto T, Symon Z, van den Bergh ACM, Scrase C, Van Poppel H, Bolla M. Guidelines for target volume definition in post-operative radiotherapy for prostate cancer, on behalf of the EORTC Radiation Oncology Group. Radiother Oncol 2007; 84:121-7. [PMID: 17706307 DOI: 10.1016/j.radonc.2007.07.017] [Citation(s) in RCA: 227] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 07/07/2007] [Accepted: 07/14/2007] [Indexed: 01/03/2023]
Abstract
The appropriate application of 3-D conformal radiotherapy, intensity modulated radiotherapy or image guided radiotherapy for patients undergoing post-operative radiotherapy for prostate cancer requires a standardisation of the target volume definition and delineation as well as standardisation of the clinical quality assurance procedures. Recommendations for this are presented on behalf of the European Organisation for Research and Treatment of Cancer (EORTC) Radiation Oncology Group and in addition to the already published guidelines for radiotherapy as the primary treatment.
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Affiliation(s)
- Philip Poortmans
- Department of Radiotherapy, Dr. B. Verbeeten Institute, Tilburg, The Netherlands.
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Abstract
Adenocarcinoma of the prostate is one of the most frequently diagnosed cancers of men in the Western hemisphere and is second only to lung cancer for male cancer mortality. Most patients are diagnosed in the early/clinically localized stage, which can be treated curatively with radiation therapy alone. Innovative methods such as brachytherapy, three-dimensional conformal radiotherapy (3D-CRT), and IMRT (intensity modulated radiotherapy) are able to deliver very high tumoricidal doses to the diseased prostate, with minimal side effects to the surrounding tissue. Radiation therapy combined with hormonal treatment can be curative in locally advanced disease. Radiation therapy is also very effective in alleviating symptoms of metastatic prostate cancer (bone metastases, spinal cord compression, and bladder outlet obstruction).
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Affiliation(s)
- Moshe E Stein
- Department of Oncology and Radiation Therapy, Rambam Medical Center, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
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Boehmer D, Kuczer D, Badakhshi H, Stiefel S, Kuschke W, Wernecke KD, Budach V. Influence of organ at risk definition on rectal dose-volume histograms in patients with prostate cancer undergoing external-beam radiotherapy. Strahlenther Onkol 2006; 182:277-82. [PMID: 16673061 DOI: 10.1007/s00066-006-1462-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2005] [Revised: 02/13/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate rectal dose-volume relations during three-dimensional conformal radiotherapy of patients with prostate cancer by means of different rectal volume contours. PATIENTS AND METHODS 55 patients with prostate cancer underwent three-dimensional conformal external-beam radiotherapy. Rectal dose-volume histograms were calculated for four separately contoured rectal volumes in all patients resulting in four groups. In group 1 the outer rectal wall was contoured two CT slices above and below the planning target volume. The rectal contour of group 2 was drawn from the anal verge up to the sigmoid. Furthermore, the posterior half of the rectum was contoured for both volumes mentioned above (groups 1a and 2a). Statistical analysis was then performed using nonparametric Wilcoxon tests. RESULTS The mean target dose was 72.9 Gy (standard deviation [SD] +/- 2.1 Gy). The minimum target dose was 70.2 Gy. Mean rectum dose (+/- SD) over all patients was 50.7 Gy (+/- 4.6 Gy), 45.2 Gy (+/- 5.4 Gy), 43.2 Gy (+/- 4.2 Gy), and 38.7 Gy (+/- 5.5 Gy) for group 1, 2, 1a, and 2a, respectively. The corresponding volumes receiving > or = 70 Gy for groups 1 and 2 were 14.0% (+/- 5.3%) and 11.9% (+/- 4.5%). These differences were statistically significant. Comparison of minimum and mean rectal dose also revealed a statistically significant difference toward higher doses in groups 1 and 1a (p < 0.001). Maximum rectal doses for groups 1 and 2 as well as for groups 1a and 2a revealed no statistically significant difference (p = 1.0). CONCLUSION Data from the literature on normal-tissue complication probability (rectal bleeding) refer to different rectal contours. When applying dose restrictions to the rectum, contouring becomes a significant factor that determines the risk of rectal toxicity. The results of this study show that different ways of rectal contouring significantly influence doses to the rectum. The influence of organ at risk contouring should be considered thoroughly in conformal radiotherapy of prostate cancer patients, especially in dose escalation studies. It is recommended to calculate the doses for absolute rectal volumes and correlate these data with toxicity in order to be able to achieve comparable results among different institutions.
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Affiliation(s)
- Dirk Boehmer
- Department of Radiation Oncology, University Clinic Charité, Campus Mitte, Berlin, Germany.
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Boehmer D, Maingon P, Poortmans P, Baron MH, Miralbell R, Remouchamps V, Scrase C, Bossi A, Bolla M. Guidelines for primary radiotherapy of patients with prostate cancer. Radiother Oncol 2006; 79:259-69. [PMID: 16797094 DOI: 10.1016/j.radonc.2006.05.012] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 05/15/2006] [Accepted: 05/23/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSES The appropriate application of 3-D conformal radiotherapy, intensity modulated radiotherapy or image guided radiotherapy for patients undergoing radiotherapy for prostate cancer requires a standardisation of target delineation as well as clinical quality assurance procedures. PATIENTS AND METHODS Pathological and imaging studies provide valuable information on tumour extension. In addition, clinical investigations on patient positioning and immobilisation as well as treatment verification data offer an abundance of information. RESULTS Target volume definitions for different risk groups of prostate cancer patients based on pathological and imaging studies are provided. Available imaging modalities, patient positioning and treatment preparation studies as well as verification procedures are collected from literature studies. These studies are summarised and recommendations are given where appropriate. CONCLUSIONS On behalf of the European Organisation for Research and Treatment of Cancer (EORTC) Radiation Oncology Group this article presents a common set of recommendations for external beam radiotherapy of patients with prostate cancer.
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Affiliation(s)
- Dirk Boehmer
- Klinik f. Strahlentherapie, Universitätsmedizin Berlin, Charité Campus Mitte, Germany.
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Deger S, Boehmer D, Roigas J, Schink T, Wernecke KD, Wiegel T, Hinkelbein W, Budach V, Loening SA. High Dose Rate (HDR) Brachytherapy with Conformal Radiation Therapy for Localized Prostate Cancer. Eur Urol 2005; 47:441-8. [PMID: 15774239 DOI: 10.1016/j.eururo.2004.11.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2004] [Accepted: 11/30/2004] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the outcome of high dose rate (HDR) brachytherapy with iridium 192 (Ir(192)) and 3D conformal external beam radiotherapy in patients with localized prostate cancer. METHODS A total of 442 patients with localized prostate cancer underwent combined radiotherapy with interstitial brachytherapy with Ir(192) and 3D conformal external beam radiotherapy between December 1992 and March 2001. Patients underwent laparoscopic pelvic lymph node dissection to exclude patients with lymphatic involvement. Iridium 192 was delivered twice with a one-week interval in afterloading technique. 247 patients (56%) had clinical T3 disease and 128 patients (29%) had an initial PSA of more than 20 ng/ml. Progression was defined as biochemical failure according to ASTRO criteria. Patients were divided according to pretreatment variables that independently affected prostate-specific antigen (PSA) relapse-free survival in three risk groups. Low risk was defined as cT1c-cT2 and G1-G2 and PSA<10 ng/ml (n=94). Intermediate risk included patients with cT1c-cT2 and G1-G2 and PSA between 10 and 20 ng/ml (n=53). High risk group patients were cT3 or G3 or PSA>20 ng/ml (n=295). RESULTS Median follow-up was 5 years. Late grade 3-4 complications according to RTOG/EORTC criteria occurred in 50 patients (11%). The initial PSA value decreased from median 11.8 ng/ml to 0.98 ng/ml 12 months after treatment, to 0.3 ng/ml after 60 months and to 0.1 ng/ml 10 years after therapy. 53% of the patients (n=235) reached a PSA nadir of 0.5 ng/ml. 66 patients (15%) had a local recurrence, 54 (12%) developed systemic disease and 12 (3%) had both local and systemic failure. The progression free survival rate was 65% at 5-year follow-up. Five-year progression free survival was 81% in the low risk group, 65% in the intermediate risk group and 59% in the high risk group. Five-year overall survival was 87% and 5-year disease specific survival 94%. Initial PSA value, risk group and age were significantly related to progression free survival. CONCLUSIONS Combined HDR brachytherapy with Iridium 192 is an alternative treatment option for patients with localized prostate cancer. Initial PSA value, risk group, and age are important prognostic factors for progression free survival.
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Affiliation(s)
- Serdar Deger
- Department of Urology, Charité Campus Mitte, Charité -- University Medicine Berlin, Berlin, Germany.
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Boehmer D, Badakhshi H, Kuschke W, Bohsung J, Budach V. Testicular Dose in Prostate Cancer Radiotherapy. Strahlenther Onkol 2005; 181:179-84. [PMID: 15756522 DOI: 10.1007/s00066-005-1282-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Accepted: 12/09/2004] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the dose received by the unshielded testicles during a course of 20-MV conventional external-beam radiotherapy for patients with localized prostate cancer. Critical evaluation of the potential impact on fertility and hormonal impairment in these patients according to the literature. PATIENTS AND METHODS The absolute dose received by the testicles of 20 randomly selected patients undergoing radiotherapy of prostate cancer was measured by on-line thermoluminescence dosimetry. Patients were treated in supine position with an immobilization cushion under their knees. A flexible tube, containing three calibrated thermoluminescence dosimeters (TLDs) was placed on top or underneath the testicle closest to the perineal region with a day-to-day alternation. The single dose to the planning target volume was 1.8 Gy. Ten subsequent testicle measurements were performed on each patient. The individual TLDs were then read out and the total absorbed dose was calculated. RESULTS The mean total dose (+/- standard deviation) measured in a series of 10 subsequent treatment days in all patients was 49 cGy (+/- 36 cGy). The calculated projected doses made on a standard series of 40 fractions of external-beam radiotherapy were 196 cGy (+/- 145 cGy). The results of this study are appraised with the available data in the literature. CONCLUSION The dose received by the unshielded testes can be assessed as a risk for permanent infertility and impairment of hormonal function in prostate cancer patients treated with external-beam radiotherapy.
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Affiliation(s)
- Dirk Boehmer
- Department of Radiation Oncology, Charité-University Clinic - Campus Mitte, Berlin, Germany.
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Badakhshi H, Boehmer D, Moser L, Schlenger L, Wernecke K, Lammert I, Budach V. Results of a phase-ii trial using hyperfractionated accelerated radiation with concurrent cis-platinum/5-FU (C-HART) in locally advanced head and neck cancer. Int J Radiat Oncol Biol Phys 2004. [DOI: 10.1016/j.ijrobp.2004.07.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Deger S, Taymoorian K, Boehmer D, Schink T, Roigas J, Wille AH, Budach V, Wernecke KD, Loening SA. Thermoradiotherapy using interstitial self-regulating thermoseeds: an intermediate analysis of a phase II trial. Eur Urol 2004; 45:574-9; discussion 580. [PMID: 15082198 DOI: 10.1016/j.eururo.2003.11.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Thermoradiotherapy in the treatment of prostate cancer is based on a variety of experimental and clinical phase I data which have proven the synergistic effects of this combination. We report on a phase II trial in a special hyperthermia research group (SFB 273) of the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) to determine feasibility, acute toxicity and efficacy of this combination for prostate cancer. METHODS 57 patients with localized prostate cancer were treated with interstitial hyperthermia using cobalt-palladium thermoseeds and conformal radiation between July 1997 and December 2000. Thermoseeds were placed into the prostate homogeneously. Hyperthermia was created using a magnetic field and was delivered in six sessions once weekly for one hour. 3D-conformal radiotherapy of 68.4Gy was given simultaneously in daily fractions of 1.8Gy. RESULTS Intraprostatic temperatures were between 42 and 46 degrees C. No major side effects were observed during hyperthermia. Median follow-up was 36 months (range 3-72 months). Median PSA value decreased from 11.6ng/ml to 2.4ng/ml 3 months after treatment, to 1.3ng/ml 12 months after treatment and to 0.55ng/ml 2 years after therapy. CONCLUSION Interstitial hyperthermia is feasible, well tolerated and led to a steep decrease of PSA values. Combining effective interstitial hyperthermia with conformal radiotherapy may be an exciting innovative treatment option for prostate cancer.
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Affiliation(s)
- Serdar Deger
- Department of Urology, Charité-Campus-Mitte, Humboldt University of Berlin, Schumannstrasse 20/21, 10098 Berlin, Germany.
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Boehmer D, Bohsung J, Eichwurzel I, Moys A, Budach V. Clinical and physical quality assurance for intensity modulated radiotherapy of prostate cancer. Radiother Oncol 2004; 71:319-25. [PMID: 15172148 DOI: 10.1016/j.radonc.2004.02.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2003] [Revised: 02/11/2004] [Accepted: 02/23/2004] [Indexed: 11/20/2022]
Abstract
The implementation of intensity modulated radiotherapy (IMRT) for patients with prostate cancer in daily routine has been elaborated at our department. Our quality assurance (QA) concept is one method to pave the way for initiating IMRT treatments for starting institutions. A clinical quality assurance (CQA) procedure has been set-up for all patients before and throughout the course of radiotherapy. Simultaneously medical physicists established a physical quality assurance (PQA) concept that has been followed for all patients as well. Alternative CQA and PQA procedures are discussed. The literature is reviewed and discussed with special respect to quality assurance in IMRT of prostate cancer patients.
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Affiliation(s)
- Dirk Boehmer
- Department of Radiation Oncology, Charité-University Clinic-Campus Mitte, Schumannstr. 20/21, 10117 Berlin, Germany
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Deger S, Boehmer D, Türk I, Roigas J, Budach V, Loening SA. Interstitial hyperthermia using self-regulating thermoseeds combined with conformal radiation therapy. Eur Urol 2002; 42:147-53. [PMID: 12160585 DOI: 10.1016/s0302-2838(02)00277-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The combination of hyperthermia and radiation in the treatment of malignancies is based on a variety of experimental data which have proven the synergistic effects of these two treatment modalities. We planned a phase II trial in a special hyperthermia research group (SFB 273) of the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) to determine feasibility, acute toxicity and efficacy of this combination for prostate cancer. METHODS A total of 57 patients with localized prostate cancer were treated with interstitial hyperthermia using cobalt-palladium thermoseeds and conformal radiation between July 1997 and December 2000. Thermoseeds were placed into the prostate homogeneously. Hyperthermia was created using a magnetic field and was delivered in six sessions once weekly. 3D-conformal radiotherapy of 68.4Gy was given simultaneously in daily fractions of 1.8Gy. RESULTS Intra-prostatic temperatures were between 42 and 46 degrees C. No major side effects were observed during hyperthermia. Median follow-up was 12 months (range: 3-26 months). Median prostate specific antigen (PSA) value decreased from 11.6 to 2.4 ng/ml 3 months after treatment, to 1.3ng/ml 12 months after treatment and to 0.55 ng/ml 2 years after the therapy. CONCLUSION Interstitial hyperthermia is feasible, well tolerated and led to a steep decrease of PSA values. Our current follow-up is too short to comment about efficacy. Combining effective interstitial hyperthermia with conformal radiotherapy may be an exciting innovative treatment option for prostate cancer.
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Affiliation(s)
- Serdar Deger
- Department of Urology, Charité-Campus-Mitte, Humboldt University of Berlin, Schumannstrasse 20/21, 10098, Berlin, Germany.
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Deger S, Boehmer D, Türk I, Roigas J, Wernecke KD, Wiegel T, Hinkelbein W, Dinges S, Budach V, Loening SA. High dose rate brachytherapy of localized prostate cancer. Eur Urol 2002; 41:420-6. [PMID: 12074814 DOI: 10.1016/s0302-2838(02)00016-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We evaluated the safety and efficacy of high dose rate (HDR) brachytherapy using Iridium-192 (Ir 192) and 3D conformal external beam radiotherapy in patients with localized prostate cancer. METHODS A total of 444 patients with localized prostate cancer underwent combined radiotherapy with interstitial Ir 192 and 3D conformal external beam radiotherapy between December 1992 and March 2001. The 230 patients, treated between December 1992 and December 1997 were analyzed. All patients underwent laparoscopic pelvic lymph node dissection to exclude patients with lymphatic involvement. Ir 192 was delivered twice with a 1-week interval in HDR remote control technique. The interstitial dose from December 1992 to December 1993 was 10Gy, after December 1993 the dose was reduced to 9Gy per treatment session. The interstitial application was followed by external beam radiation of 45Gy for cT1-cT2 and 50.4Gy for cT3 tumor (40Gy from December 1992 to December 1993). Progression was defined as biochemical failure according to ASTRO criteria, e.g. three consecutive PSA rises following the PSA nadir. RESULTS The median PSA value decreased from 12.8 to 0.93ng/ml 12 months after treatment. Median PSA value was 0.47 after 24 months, 0.30ng/ml after 36 months and 0.18ng/ml after 60 months. 68% of the biopsies were negative 24 months after therapy. Progression-free rate was 100% for cT1 tumors, 75% for cT2 and 60% for stage-cT3 on 5-year follow-up. Five-year overall survival was 93%, 5-year disease-specific survival was 98%. Initial PSA value <10ng/ml, low stage and low grade were significantly related to 5-year progression-free survival. CONCLUSIONS Combined HDR brachytherapy with Ir 192 is an alternative treatment option especially for patients with cT3 prostate cancer. Initial PSA value, stage and grade, are important prognostic factors.
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Affiliation(s)
- Serdar Deger
- Department of Urology, Charité-Campus-Mitte, Humboldt University of Berlin, Schumannstrasse 20/21, D-10098 Berlin, Germany.
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Deger S, Boehmer D, Roigas J, Türk I, Schnorr D, Dinges S, Budach V, Loening SA. 81 Iridium 192 afterloading, high dose rate brachytherapy of prostate cancer. Radiother Oncol 2000. [DOI: 10.1016/s0167-8140(00)81402-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Boehmer D, Buchali A, Deger S, Loening SA, Budach V. [Value of radiotherapy in urology]. Urologe A 2000; 39:120-5. [PMID: 10768221 DOI: 10.1007/s001200050019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Radiotherapy of patients with prostate cancer offers an alternative to radical prostatectomy in early stages (T1-T2). In locally advanced prostate cancer a high dose or combined radiotherapy is more effective than radical surgery with concurrent lower morbidity and mortality. Recent developments in linear accelerator technique, the progress in dose calculation and planning techniques provide the means to apply higher doses to a given tumor volume while effectively protecting the surrounding normal tissue at the same time. These improvements may possibly reduce the rate of therapy related side effects or complications significantly. The combination of external beam radiotherapy and interstitial brachytherapy as well as the combination of hormone therapy and external beam radiotherapy are most likely more effective than percutaneous irradiation alone. In special cases with a very low risk of recurrent tumor an interstitial permanent brachytherapy alone is indicated. Future developments (i.e. intensity modulated radiotherapy-IMRT, combined thermo-radiotherapy, proton- or neutrontherapy) may further increase the rate of curative treatments in patients with prostate cancer.
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Affiliation(s)
- D Boehmer
- Klinik für Strahlentherapie, Humboldt-Universität Berlin.
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Boehmer D, Koswig S, Budach V. [Radiotherapy of distant metastases of urological malignant tumors]. Urologe A 2000; 39:133-40. [PMID: 10768223 DOI: 10.1007/s001200050021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The largest subgroup of patients with metastasised urological malignancies are those with metastases of the bone. Lesions of bones frequently reduce the patients quality of life. Therefore a sufficient therapy is crucial. First of all the appropriate diagnostic procedure of the lesion/lesions is necessary because e the right choice of diagnostic measures may already improve quality of life. Besides the most frequently used local irradiation a systemic radiotherapy may be the adequate therapy in patients with disseminated disease. Renal cell-, bladder and penile cancer respectively are the urological malignancies frequently metastasising into the brain. Adequate diagnostic procedures and therapy are crucial to the patients quality of life for the remaining lifetime. Besides a whole brain irradiation as standard therapy stereotactic radiotherapy is a high precision tool to destroy intracerebral tumour. There are many other locations of metastatic disease (i.e. lymph node or soft tissue metastasis, et cetera) where palliative external beam irradiation may provide relief from symptoms such as pain, lymph oedema or bleeding and thus increase quality of life. Psychological and social care are of great value besides symptom oriented therapy (i.e. radiotherapy, drugs, et cetera) to achieve an optimal palliation/quality of life.
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Affiliation(s)
- D Boehmer
- Klinik für Strahlentherapie, Humboldt-Universität zu Berlin.
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Dinges S, Deger S, Koswig S, Boehmer D, Schnorr D, Wiegel T, Loening SA, Dietel M, Hinkelbein W, Budach V. High-dose rate interstitial with external beam irradiation for localized prostate cancer--results of a prospective trial. Radiother Oncol 1998; 48:197-202. [PMID: 9783892 DOI: 10.1016/s0167-8140(98)00054-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE A prospective phase II trial was carried out to test the feasibility and effectiveness of a combined interstitial with external beam radiotherapy approach for localized prostate cancer. MATERIALS AND METHODS Between October 1992 and December 1994, 82 evaluable patients were treated. T2 and T3 tumours, according to the AJCC classification system of 1992, were found in 21 and 61 cases, respectively. The median follow-up was 24 months; three patients were lost during follow-up. All of the patients were pathologically proven to be node-negative by laparoscopic node dissection of the fossa obturatoria region. A dose of 9 Gy a week was prescribed during the first and second weeks of treatment (10 Gy each week from October 1992 to December 1993) interstitially with high-dose rate Iridium-192 brachytherapy to the prostate and tumour extension beyond the capsule. External beam four-field box irradiation was then given to the prostate to a dose of 45 Gy/25 fractions (40 Gy/20 fractions from October 1992 to December 1993). RESULTS Before starting treatment, a PSA value of > or =10 ng/ml was found in 64.6% (53/82) of patients with a median PSA of 14.0 ng/ml. The median PSA 3, 12 and 24 months after completion of therapy was 1.20, 0.78 and 0.70 ng/ml, respectively. The PSA value was < 1.0 ng/ ml in 52.9% of patients at 2 years. Negative punch biopsies 12 and 24 months after therapy were observed in 69.8% (44/63) and 73. 1% (38/ 52) of patients, respectively. A positive biopsy combined with a PSA value of > 1.0 ng/ml was considered as local failure. The local tumour control rate was 79.5% at 2 years. Acute side-effects were not increased relative to external beam irradiation alone. Severe side-effects were observed in three patients (two of the three patients had additional risk factors (colitis ulcerosa and diabetes mellitus)); they developed rectourethral fistulae requiring colostomy after biopsies from the anterior rectal wall. CONCLUSION The described method is feasible and well tolerable. The three complications observed were not caused by irradiation alone. Biopsies from the anterior rectal wall after definitive high-dose radiotherapy for prostate cancer have to be seen as obsolete. The rate of negative prostate biopsies of 73.1% after 24 months represents an encouraging result.
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Affiliation(s)
- S Dinges
- Department of Radiotherapy, Charité, Humboldt University of Berlin, Germany
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Dinges S, Budach V, Stuschke M, Budach W, Boehmer D, Schrader M, Jahnke K, Sack H. Chemo-radiotherapy for locally advanced head and neck cancer--long-term results of a phase II trial. Eur J Cancer 1997; 33:1152-5. [PMID: 9376198 DOI: 10.1016/s0959-8049(97)00099-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The feasibility and effectiveness of a combined chemo-radiotherapy treatment modality for locally advanced head and neck cancer was tested in a phase II trial. Between 1990 and 1993, 74 patients (20 female/54 male) with head and neck cancer stage III (n = 12) and IV (n = 62) were treated with accelerated radiotherapy (72 Gy) and simultaneous chemotherapy (5-FU, folinic acid, mitomycin C). The median follow-up time was 43 months (1-72). Complete remission (CR) was absent in 76% (56/74) of patients and, after subsequent resection of residual lymph nodes, another 8 patients achieved CR. The cumulative local control rate was 72% and disease-specific survival rate was 59% at 4 years. Two patients died with treatment-related conditions (pancytopenia, larynx oedema). By multivariate analysis, only lymph node status was an independent parameter for local control (P = 0.04). This treatment was feasible and toxicity was not a treatment-limiting factor. As a consequence, a German multicentre phase III trial was initiated in 1995.
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Affiliation(s)
- S Dinges
- Department of Radiotherapy, Charité Humboldt University of Berlin, Germany
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Tomo I, Brezanyova J, Kriska M, Boehmer D, Handzo I. Teratoepidemiologic study—drug intervention system monitoring. Reprod Toxicol 1992. [DOI: 10.1016/0890-6238(92)90161-l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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