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Purpose To assess acute cardiac toxicity caused by intraoperative radiotherapy (IORT) with low-energy x‑rays for early breast cancer. Methods We prospectively analyzed pre- and postoperative troponin I and NT-proBNP in 94 women who underwent breast-conserving surgery between 2013 and 2017 at the Department of Gynecology and Obstetrics of the University Medical Center Mannheim, Germany. Thirty-nine women received IORT using low-energy x‑rays during breast-conserving surgery while 55 patients without IORT formed the control group. Demographic and surgical parameters as well as cardiac markers were evaluated. Results There were no significant differences concerning age and side of breast cancer between the groups. Furthermore, no significant difference between the troponin I assays of the IORT and control groups could be found (preoperatively: 0.017 ± 0.006 ng/ml vs. 0.018 ± 0.008 ng/ml; p = 0.5105; postoperatively: 0.019 ± 0.012 ng/ml vs. 0.018 ± 0.010 ng/ml; p = 0.6225). N‑terminal fragment of B‑type natriuretic peptide (NT-proBNP) was significantly higher in the control group 24 h after surgery (preoperatively: 158.154 ± 169.427 pg/ml vs. 162.109 ± 147.343 pg/ml; p = 0.56; postoperatively: 168.846 ± 160.227 pg/ml vs. 232.527 ± 188.957 pg/ml; p = 0.0279). Conclusion Troponin I levels as a marker of acute cardiac toxicity did not show any significant differences in patients who received IORT during breast-conserving surgery compared to those who did not.

Randomized trials indicate that electronic or app-based assessment of patient-reported outcomes may improve outcomes in cancer patients. To analyze if an app-based follow-up would be accepted by elderly cancer patients, we conducted a single-center prospective feasibility study (NCT03196050). Cancer patients (≥60 years) without concurrent uncontrolled severe medical conditions and a Karnofsky performance status (KPS) ≥70 were eligible if they were able to use the smartphone app. The primary endpoint was compliance over 1 year, calculated as patient-specific and study date-specific response rate to questions sent as push notifications; in this interim analysis, we report on 4‑month data. Secondary outcomes included a comparison of a subjective health status item (SPHS) with the physician-rated KPS. Out of 225 patients screened, 54 patients agreed to participate and 29 activated the app and participated in the study. The mean age was 66 years (61–78). The individual compliance rate averaged at 58.3% (standard deviation SD = 35%). Daily compliance was 53.3% on average (SD = 10.8%) and declined over time. The average percentage of patients who sent answers at least weekly was 75.0% (SD = 14.8%) and declined from 100% in week 1 to 53.8% in week 17 post-enrollment. Secondary outcomes indicated that questionnaires such as the EORTC-QLQ-C30 are accepted via app and that there is a significant moderate correlation between the SPHS and KPS scores (r = 0.566; p

CINSARC (Complexity INdex in SARComas) is a prognostic signature for soft tissue sarcoma that determines the risk for recurrence and may serve to guide the decision for adjuvant chemotherapy. The aim of this study was to compare the CINSARC signature of pre- and posttreatment biopsies of sarcoma patients treated within a phase I trial evaluating preoperative sunitinib and irradiation.We retrieved 14 pairs of formalin-fixed paraffin-embedded blocks from pretreatment biopsies and posttreatment resection specimens and performed expression profiling of the 67 CINSARC signature genes.In 5/14 patients, both probes were unsuitable for expression analysis because there was no (vital) tissue left in biopsies or resection specimens. Comparing the CINSARC risk classification before and after treatment in the remaining patients, 2/9 shifted from a high- to a low-risk classification for metastatic disease after preoperative treatment with radiation therapy plus sunitinib and 7/9 pairs of pre- and posttreatment biopsies revealed identical results.Concurrent radiation therapy and sunitinib leads to diverging results of prognostic gene array testing in a relevant proportion of sarcoma patients. These changes may reflect tumor heterogeneity, local treatment effects, or prognostic changes of the disease. Caution is advised in the selection of samples and interpretation of test results.HINTERGRUND: CINSARC (Complexity INdex in SARComas) ist eine prognostische Signatur für Weichgewebesarkome, die zur Abschätzung des Metastasierungsrisikos eingesetzt wird und deren Ergebnis die Entscheidung über eine adjuvante Chemotherapie unterstützen kann. Ziel dieser Studie war es, zu untersuchen, inwieweit eine präoperative Therapie mit Bestrahlung und Sunitinib Einfluss auf das CINSARC-Ergebnis hat.In 14 korrespondierenden Paaren von formalinfixierten und paraffineingebetteten Tumorproben (prätherapeutische Biopsie und posttherapeutisches Resektat) erfolgte die Expressionsanalyse der 67 CINSARC-Signaturgene.Bei 5/14 Probenpaaren war ein Vergleich der CINSARC-Signatur nicht möglich, da nach diagnostischer Aufarbeitung bzw. durch Therapieansprechen kein (vitales) Gewebe in den Biopsien oder Resektaten vorhanden war. In 2/9 Patienten verschob sich das Untersuchungsergebnis von einem hohen zu einem niedrigen Metastasierungsrisiko. In 7/9 Probenpaaren blieb die Risikoeinschätzung identisch.Die präoperative Therapie mit Bestrahlung und Sunitinib kann zu abweichenden Ergebnissen prognostischer Gensignaturen führen. Diese Unterschiede können auf Therapieeffekte oder Tumorheterogenität zurückgeführt werden und sollte bei der Probenauswahl und Testinterpretation von prognostischen Signaturen berücksichtigt werden.

Skin-sparing (SSME) and nipple-sparing mastectomy (NSME) were developed to improve the cosmetic results for breast cancer (BC) patients, both allowing for immediate breast reconstruction. Recommendations for post-mastectomy radiotherapy (PMRT) are primarily derived from trials where patients were treated by standard mastectomies. Due to their more conservative character, SSME and especially NSME potentially leave more glandular tissue at risk for subclinical disease. Rates and sites of locoregional failures following SSME and NSME plus/minus reconstruction were analyzed regarding tumor stage and biological risk factors. In particular, the role of PMRT in “intermediate”-risk and early stage high-risk breast cancer patients was revisited. Implications on targeting and dose delivery of PMRT were critically reviewed. The value of PMRT in stage III BC remains undisputed. For node-negative BC patients, the majority of reports classify clinical and biological features such as tumor size, close surgical margins, premenopausal status, multicentricity, lymphangiosis, triple-negativity, HER2-overexpression, and poor tumor grading as associated with higher rates of locoregional relapse, thus, building an “intermediate” risk group. Surveys revealed that the majority of radiation oncologists use risk-adaptive models also considering the number of coinciding factors for the estimation of recurrence probability following SSME and NSME. Constellations with a 10-year locoregional recurrence risk of >10% are usually triggering the indication for PMRT. There was no common belief that the amount of residual tissue, e.g., tissue thickness over flaps, serves as additional decision aid. Modern treatment planning can ensure optimal dose distribution for PMRT in almost all patients with SSME. There are no reliable data supporting a reduction of the treatment volume from the CTV chest wall, e.g., to the nipple-areola complex, to the dorsal aspect behind the implant volume, the pectoralis muscle, nor the regional interpectoral, axillary, or complete regional lymph nodes only. The omission of a skin bolus in intermediate-risk BC does not compromise oncological safety. For intermediate-risk as well as early stage high-risk BC patients, the DEGRO Breast Cancer Expert Panel recommends the use of PMRT following SSME and NSME when a 10-year locoregional recurrence risk is likely to be greater than 10%, as estimated by clinical and biological risk factors. Subvolume-only radiation is discouraged outside of trials. The impact of adequate systemic treatment and the value of radiotherapy on optimal locoregional tumor control, with the goal of less than 5% LRR at 10-years follow-up, has to be verified in prospective trials.

Background Late cardiac toxicities caused by (particularly left-sided) breast radiotherapy (RT) are now recognized as rare but relevant sequelae, which has prompted research on risk structure identification and definition of threshold doses to heart subvolumes. The aim of the present review was to critically discuss the clinical evidence on late cardiac reactions based on dose-dependent outcome reports for mean heart doses as well as doses to cardiac substructures. Methods A literature review was performed to examine clinical evidence on radiation-induced heart toxicities. Mean heart doses and doses to cardiac substructures were focused upon based on dose-dependent outcome reports. Furthermore, an overview of radiation techniques for heart protection is given and non-radiotherapeutic aspects of cardiotoxicity in the multimodal setting of breast cancer treatment are discussed. Results Based on available findings, the DEGRO breast cancer expert panel recommends the following constraints: mean heart dose meanLV (mean dose left ventricle) LV (volume of LV receiving ≥5 Gy) LV (volume of LV receiving ≥23 Gy) meanLAD (mean dose left descending artery) LAD (volume of LAD receiving ≥30 Gy) LAD (volume of LAD receiving ≥40 Gy) Conclusion In addition to mean heart dose, breast cancer RT treatment planning should also include constraints for cardiac subvolumes such as LV and LAD. The given constraints serve as a clinicians’ aid for ensuring adequate heart protection. The individual decision between sufficient protection of cardiac structures versus optimal target volume coverage remains in the physician’s hand. The risk of breast cancer-specific mortality and a patient’s cardiac risk factors must be individually weighed up against the risk of radiation-induced cardiotoxicity.

Background Late cardiac toxicities caused by (particularly left-sided) breast radiotherapy (RT) are now recognized as rare but relevant sequelae, which has prompted research on risk structure identification and definition of threshold doses to heart subvolumes. The aim of the present review was to critically discuss the clinical evidence on late cardiac reactions based on dose-dependent outcome reports for mean heart doses as well as doses to cardiac substructures. Methods A literature review was performed to examine clinical evidence on radiation-induced heart toxicities. Mean heart doses and doses to cardiac substructures were focused upon based on dose-dependent outcome reports. Furthermore, an overview of radiation techniques for heart protection is given and non-radiotherapeutic aspects of cardiotoxicity in the multimodal setting of breast cancer treatment are discussed. Results Based on available findings, the DEGRO breast cancer expert panel recommends the following constraints: mean heart dose

To review the evidence regarding post-mastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after neoadjuvant chemotherapy (NACT) for breast cancer, with a special focus on individualization of adjuvant radiotherapy based on treatment response. A systematic literature search using the PubMed/Medline database was performed. We included prospective and retrospective reports with a minimum of 10 patients that had been published since 1st January 2000, and provided clinical outcome data analyzed by treatment response and radiotherapy. Out of 763 articles identified via PubMed/Medline and hand search, 68 full text-articles were assessed for eligibility after screening of title and abstract. 13 studies were included in the systematic review, 9 for PMRT and 5 for RNI. All included studies were retrospective reports. There is a considerable lack of evidence regarding the role of adjuvant radiotherapy and its individualization based on treatment response after NACT. Results of prospective randomized trials such as NSABP B‑51/RTOG 1304 and Alliance A11202 are eagerly awaited.

AIM This article gives an overview on the current status of hypofractionated radiotherapy in the treatment of prostate cancer with a special focus on the applicability in routine use. METHODS Based on a recently published systematic review the German Society of Radiation Oncology (DEGRO) expert panel added additional information that has become available since then and assessed the validity of the information on outcome parameters especially with respect to long-term toxicity and long-term disease control. RESULTS Several large-scale trials on moderate hypofractionation with single doses from 2.4-3.4 Gy have recently finished recruiting or have published first results suggestive of equivalent outcomes although there might be a trend for increased short-term and possibly even long-term toxicity. Large phase 3 trials on extreme hypofractionation with single doses above 4.0 Gy are lacking and only very few prospective trials have follow-up periods covering more than just 2-3 years. CONCLUSION Until the results on long-term follow-up of several well-designed phase 3 trials become available, moderate hypofractionation should not be used in routine practice without special precautions and without adherence to the highest quality standards and evidence-based dose fractionation regimens. Extreme hypofractionation should be restricted to prospective clinical trials.

Combined kV-MV cone-beam CT (CBCT) is a promising approach to accelerate imaging for patients with lung tumors treated with deep inspiration breath-hold. During a single breath-hold (15 s), a 3D kV-MV CBCT can be acquired, thus minimizing motion artifacts and increasing patient comfort. Prior to clinical implementation, positioning accuracy was evaluated and compared to clinically established imaging techniques. An inhomogeneous thorax phantom with four tumor-mimicking inlays was imaged in 10 predefined positions and registered to a planning CT. Novel kV-MV CBCT imaging (90° arc) was compared to clinically established kV-chest CBCT (360°) as well as nonclinical kV-CBCT and low-dose MV-CBCT (each 180°). Manual registration, automatic registration provided by the manufacturer and an additional in-house developed manufacturer-independent framework based on the MATLAB registration toolkit were applied. Systematic setup error was reduced to 0.05 mm by high-precision phantom positioning with optical tracking. Stochastic mean displacement errors were 0.5 ± 0.3 mm in right–left, 0.4 ± 0.4 mm in anteroposterior and 0.0 ± 0.4 mm in craniocaudal directions for kV-MV CBCT with manual registration (maximum errors of no more than 1.4 mm). Clinical kV-chest CBCT resulted in mean errors of 0.2 mm (other modalities: 0.4–0.8 mm). Similar results were achieved with both automatic registration methods. The comparison study of repositioning accuracy between novel kV-MV CBCT and clinically established volume imaging demonstrated that registration accuracy is maintained below 1 mm. Since imaging time is reduced to one breath-hold, kV-MV CBCT is ideal for image guidance, e.g., in lung stereotactic ablative radiotherapy.

Hintergrund und Ziel Bei Anwendung ionisierender Strahlung in der medizinischen Forschung ist in klinischen Studien im Bereich der Radioonkologie in Deutschland eine Genehmigung durch das Bundesamt fur Strahlenschutz (BfS) notwendig. Bei der Abgrenzung zwischen „Heilkunde“ und „medizinischer Forschung“ kommt es bei radioonkologischen Studien immer wieder zu widerspruchlichen Einschatzungen. Ziel ist es, eine Handreichung fur Antragsteller, im Beantragungsprozess involvierte Personen und Institutionen sowie Ethikkommissionen zu liefern.

Tumors larger than 5 cm or tumors infiltrating the chest wall or skin (T3/T4), fixated axillary lymph nodes (N2), involved infra- or supraclavicular lymph nodes, or involved lymph nodes in the internal mammary chain (N3) are regarded as locally advanced breast cancer and are generally considered as not amenable for primary surgery. Inflammatory breast cancer (T4d) accounts for approximately 10–15 % of locally advanced breast cancer. Historical results with radiotherapy as sole treatment reported 5-year survival rates in locally advanced breast cancer without systemic treatment of approximately 30 % and in inflammatory breast cancer of 5 % [1]. Distant metastases at the time of breast cancer diagnosis are detected in about 4 % of all breast cancer patients, but are observed in 14 % of T3 and 26 % of T4 patients (Munich Cancer Registry 2013). Nowadays, primary systemic treatment is considered standard of care for breast cancer patients with locally advanced and inflammatory breast cancer, as well as in patients with synchronous distant metastases [2, 3]. Response to systemic treatment, especially pathologically complete response (pCR), has been shown to be associated with improved survival in all these situations [4]. The development of modern neoadjuvant treatment in less advanced breast cancer was based on experience in locally advanced and inflammatory breast cancer. Randomized clinical trials have focused on further development of more effective systemic treatment regimen, whereas radiotherapy was an integrated part of the treatment in these trials, since its importance for locoregional control was not challenged. This has changed to some extent, since a substantial portion of the patients are meanwhile amenable for surgery after partial or complete clinical remission following neoadjuvant systemic treatment. Especially in case of pCR after mastectomy the impact of radiotherapy has been questioned. The aim of this paper is to review the role of radiotherapy in locally advanced and inflammatory breast cancer, and for patients with synchronous distant metastases and to provide practical treatment guidelines relating to and supplementing the current German S3 guidelines and the previous practical DEGRO guideline [5].

An increasing number of patients undergoing radiotherapy (RT) have cardiac implantable electronic devices [CIEDs, cardiac pacemakers (PMs) and implanted cardioverters/defibrillators (ICDs)]. Ionizing radiation can cause latent and permanent damage to CIEDs, which may result in loss of function in patients with asystole or ventricular fibrillation. Reviewing the current literature, the interdisciplinary German guideline (DEGRO/DGK) was developed reflecting patient risk according to type of CIED, cardiac condition, and estimated radiation dose to the CIED. Planning for RT should consider the CIED specifications as well as patient-related characteristics (pacing-dependent, previous ventricular tachycardia/fibrillation). Antitachyarrhythmia therapy should be suspended in patients with ICDs, who should be under electrocardiographic monitoring with an external defibrillator on stand-by. The beam energy should be limited to 6 (to 10) MV CIEDs should never be located in the beam, and the cumulative scatter radiation dose should be limited to 2 Gy. Personnel must be able to respond adequately in the case of a cardiac emergency and initiate basic life support, while an emergency team capable of advanced life support should be available within 5 min. CIEDs need to be interrogated 1, 3, and 6 months after the last RT due to the risk of latent damage.

Combined radiochemotherapy (RCT) for gastric cancer with three-dimensional conformal radiotherapy (3D-CRT) results in ablative doses to the upper left kidney, while image-guided intensity-modulated radiotherapy (IG-IMRT) allows kidney sparing despite improved target coverage. Renal function in long-term gastric cancer survivors was evaluated with 3T functional magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) and (23)Na imaging.Five healthy volunteers and 13 patients after radiotherapy were included: 11×IG-IMRT; 1×3D-CRT; 1× "positive control" with stereotactic body radiotherapy (SBRT) of a metastasis between the spleen/left kidney. Radiation doses were documented for the upper/middle/lower kidney subvolumes. Late toxicity was evaluated based on CTC criteria, questionnaire, and creatinine values. Morphological sequences, DWI images, and (23)Na images were acquired using a (1)H/(23)Na-tuned body-coil before/after intravenous water load (WL). Statistics for [(23)Na] (concentration) and apparent diffusion coefficient (ADC) values were calculated for upper/middle/lower renal subvolumes. Corticomedullary [(23)Na] gradients and [(23)Na] differences after WL were determined.No major morphological alteration was detected in any patient. Minor scars were observed in the cranial subvolume of the left kidney of the 3D-CRT and the whole kidney of the control SBRT patient. All participants presented a corticomedullary [(23)Na] gradient. After WL, a significant physiological [(23)Na] gradient decrease (p 0.001) was observed in all HV and IG-IMRT patients. In the cranial left kidney of the 3D-CRT patient and the positive control SBRT patient, the decrease was nonsignificant (p = 0.01, p = 0.02). ADC values were altered nonsignificantly in all renal subvolumes (all participants). Renal subvolumes with doses ≥ 35 Gy showed a reduced change of the [(23)Na] gradient after WL (p = 0.043). No participants showed clinical renal impairment.Functional parameters of renal (23)Na MRI after gastric IG-IMRT are identical to those of healthy volunteers, in contrast to renal subvolumes after ablative doses in the control and 3D-CRT patient. While kidney doses to the cortex below 20-25 Gy in fractional doses of ~ 1 Gy in IG-IMRT (combined with intensified chemotherapy) do not seem to cause significant MRI morphological or functional alterations, doses of 35 Gy in 1.5-2 Gy fractions clearly result in impairment.

The purpose of this work is to update the practical guidelines for adjuvant radiotherapy of the regional lymphatics of breast cancer published in 2008 by the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO). A comprehensive survey of the literature concerning regional nodal irradiation (RNI) was performed using the following search terms: “breast cancer”, “radiotherapy”, “regional node irradiation”. Recent randomized trials were analyzed for outcome as well as for differences in target definition. Field arrangements in the different studies were reproduced and superimposed on CT slices with individually contoured node areas. Moreover, data from recently published meta-analyses and guidelines of international breast cancer societies, yielding new aspects compared to 2008, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the German interdisciplinary S3 guidelines updated in 2012, this paper addresses indications, targeting, and techniques of radiotherapy of the lymphatic pathways after surgery for breast cancer. International guidelines reveal substantial differences regarding indications for RNI. Patients with 1–3 positive nodes seem to profit from RNI compared to whole breast (WBI) or chest wall irradiation alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular, and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and one meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection (ALND), while reducing the rate of lymph edema. Data concerning the impact of 1–2 macroscopically affected sentinel node (SN) or microscopic metastases on prognosis are conflicting. Recent data suggest that the current restrictive use of RNI should be scrutinized because the risk–benefit relationship appears to shift towards an improvement of outcome.

Background and purpose The aim of the present paper is to update the practical guidelines for postoperative adjuvant radiotherapy of breast cancer published in 2007 by the breast cancer expert panel of the German Society for Radiooncology (Deutsche Gesellschaft für Radioonkologie, DEGRO). The present recommendations are based on a revision of the German interdisciplinary S-3 guidelines published in July 2012. Methods A comprehensive survey of the literature concerning radiotherapy following breast conserving therapy (BCT) was performed using the search terms “breast cancer”, “radiotherapy”, and “breast conserving therapy”. Data from lately published meta-analyses, recent randomized trials, and guidelines of international breast cancer societies, yielding new aspects compared to 2007, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the DKG (Deutsche Krebsgesellschaft), this paper addresses indications, target definition, dosage, and technique of radiotherapy of the breast after conservative surgery for invasive breast cancer. Results Among numerous reports on the effect of radiotherapy during BCT published since the last recommendations, the recent EBCTCG report builds the largest meta-analysis so far available. In a 15 year follow-up on 10,801 patients, whole breast irradiation (WBI) halves the average annual rate of disease recurrence (RR 0.52, 0.48–0.56) and reduces the annual breast cancer death rate by about one sixth (RR 0.82, 0.75–0.90), with a similar proportional, but different absolute benefit in prognostic subgroups (EBCTCG 2011). Furthermore, there is growing evidence that risk-adapted dose augmentation strategies to the tumor bed as well as the implementation of high precision RT techniques (e.g., intraoperative radiotherapy) contribute substantially to a further reduction of local relapse rates. A main focus of ongoing research lies in partial breast irradiation strategies as well as WBI hypofractionation schedules. The potential of both in replacing normofractionated WBI has not yet been finally clarified. Conclusion After breast conserving surgery, no subgroup even in low risk patients has yet been identified for whom radiotherapy can be safely omitted without compromising local control and, hence, cancer-specific survival. In most patients, this translates into an overall survival benefit.

Laser scanning-based patient surface positioning and surveillance may complement image-guided radiotherapy (IGRT) as a nonradiation-based approach. We investigated the performance of an optical system compared to standard kilovoltage cone-beam computed tomography (CBCT) and its potential to reduce the number of daily CBCTs.We analyzed the patient positioning of 153 treatment fractions in 21 patients applied to three different treatment regions. Patients were first scanned with CBCT, shifted to the optimal isocenter position, and an optical scan was performed to verify the matching in relation to CBCT.For the head-and-neck region, the lateral/longitudinal/vertical/rotational/roll and pitch shift was 0.9 ± 1.8 mm/-2.7 ± 3.8 mm/-0.8 ± 3.6 mm/0.0 ± 1.1°/-0.5 ± 2.1°/0.2 ± 1.6°. For the thorax, the lateral/longitudinal/vertical/roll and pitch shift was -1.2 ± 3.6 mm/0.8 ± 5.1 mm/0.8 ± 4.3 mm/0.6 ± 1.4°/0.1 ± 0.9°/0.3 ± 1.0°. For the pelvis, the respective values were -2.5 ± 4.1 mm/4.6 ± 7.3 mm/-5.1 ± 7.4 mm/0.3 ± 1.1°/-0.5 ± 1.0°/0.3 ± 2.1°. In total, the recorded disagreement was -1.0 ± 3.6 mm/1.0 ± 6.3 mm/-1.8 ± 5.9 mm/0.3 ± 1.2°/-0.3 ± 1.5°/0.2 ± 1.7°.This analysis showed good agreement between the optical scanner approach and CBCT. The optical system holds potential to ensure precise patient positioning and reduced CBCT frequency in tumor locations with fixed relation to surface structures.

Immer komplexere Bestrahlungstechniken wie z. B. dynamische Techniken sind nur noch digital und bildgesteuert sinnvoll einsetzbar. Dadurch erhohen sich standig die Anforderungen an die Bilddokumentation und -archivierung. Diese Arbeit soll detailliert die aktuellen Anforderungen an das Bildmanagement in der Radioonkologie und mogliche Bildadministrationsstrategien darstellen. Es werden die Grundlagen der Bildspeicherung und -administration (DICOM-Standard, Besonderheiten in der Strahlentherapie) entlang des typischen Patientenpfads beschrieben (demografische Daten, Bestrahlungsplanung, Signatur/Approval und Archivierung von Plan- und Bildinformationen). Verschiedene Strategien des Bildmanagements werden konzeptionell gegenubergestellt (applikationsbezogene Bildarchivierung vs. integraler Ansatz mit zentraler Datenspeicherung in einem DICOM-RT-fahigen PACS unter Steuerung eines Radioonkologie-Informationssystems (ROKIS)). Anforderungen an die Infrastruktur (Speicherbedarf abhangig vom Bildaufkommen etc.) werden diskutiert. Applikationsbezogenes Bildmanagement ermoglicht gegenwartig jeweils unmittelbar den vollumfanglichen Zugriff auf Bilddaten einschlieslich aller relevanten Zusatze. Dieser Ansatz ist aber aufgrund zu erwartender Systemmigrationen wenig zukunftssicher. Eine zentrale, patienten- und behandlungsschrittbezogene und primar applikationsunabhangige Bildarchivierung ist daher, trotz gelegentlicher Schwierigkeiten bei der Visualisierung bestimmter Datenelemente, vorzuziehen. Die Speicherung von Bilddaten im DICOM-Format ist unabdingbare Voraussetzung.

To assess self-reported quality of life (QoL) experienced by anal cancer patients after radiochemotherapy, and to identify patient- and disease-related factors associated with QoL. A total of 88 patients treated for anal cancer at our institution between 1990 and 2006 were identified from our database. Of these, 15 patients had died, and 4 were lost to follow-up. QoL was assessed using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the colorectal cancer module QLQ-CR38 (site-specific QoL); 52 responses were received. The median follow-up was 36 months (range, 5–137 months). As for cancer-specific QoL, global health QoL score (mean 60.4) was similar to the general German population, whereas most of the function and symptom scale scores were considerably lower/higher in anal cancer patients. The most prominent mean score differences were observed in role functioning (–21.8 points), emotional functioning (–20.7 points), social functioning (–28.9 points), diarrhea (+34.6 points), and financial difficulties (+26.9 points; p < 0.001). As for site-specific QoL, the mean function scale scores ranged from 22.1 (sexual function) to 63.2 (body image), and the mean symptom scale scores from 14.7 (weight loss) to 69.0 (stoma-related problems, 4 patients) and 67.9 (male sexual dysfunction), respectively. Most of the QoL scores were not affected by late toxicity, patient- or disease-related factors. Fatigue (+18.2 points) emerged as the strongest predictor of impaired QoL. The global health QoL of anal cancer patients is comparable with that of the general German population, but there are specific limitations, e.g., sexual dysfunction, urological/gastrointestinal complaints, financial difficulties, fatigue, and a reduction in emotional and social well-being.

In the era of preoperative chemoradiotherapy (CRT) and total mesorectal excision (TME), the development of distant metastases is the predominant mode of failure in rectal cancer patients today. Integrating more effective systemic therapy into combined modality programs is the challenge. The question that needs to be addressed is how and when to apply systemic treatment with adequate dose and intensity. This review article focuses on phase II–III trials designed to improve 5-fluorouracil (5-FU)-based combined modality treatment for rectal cancer patients through the inclusion of concurrent, adjuvant or, most recently, induction combination chemotherapy. Computerized bibliographic searches of PubMed were supplemented with hand searches of reference lists and abstracts of ASCO/ASTRO/ESTRO meetings. After preoperative CRT and surgical resection, approximately one third of patients do not receive adjuvant chemotherapy, mainly due to surgical complications, patients’ refusal, or investigator’s discretion. In order to be able to apply chemotherapy with sufficient dose and intensity, an innovative approach is to deliver systemic therapy prior to preoperative CRT rather than adjuvant chemotherapy. Emerging evidence from several phase II trials and, recently, randomized phase II trials indicate that induction chemotherapy is feasible, does not compromise CRT or surgical resection, and enables the delivery of chemotherapy in adequate dose and intensity. Although this approach did not increase local efficacy in recent trials (e.g., pathological complete response rates, tumor regression, R0 resection rates, local control), it may help to improve control of distant disease. Whether this improvement in applicability and dose density of chemotherapy will ultimately translate into improved disease-free survival will have to be tested in a larger phase III trial.

Intraoperative radiotherapy (IORT) was originally introduced in breast cancer treatment as an “anticipated boost” during the procedure of breast conserving surgery (BCS). In addition to whole breast irradiation (WBI), it has yielded excellent long-term results [31, 38]. Under the assumption that the majority of in-breast tumor recurrences (IBTR) occur in the originally affected site, accelerated partial breast irradiation (APBI) as the sole treatment modality was initiated in several studies and with different techniques, one of which was IORT first with electrons, later also with conventional x-rays [29]. The question whether and for whom the gold standard of WBI may be replaced by APBI – especially IORT – alone has recently been one of the most controversial issues of adjuvant therapy for breast cancer. Two recently published studies by Veronesi et al. [36] and Vaidya et al. [35] presenting shortterm results of single shot IORT with electrons (ELIOT) and with an orthovoltage system (TARGIT), respectively, have further invigorated this discussion as illustrated by several letters to the editor commenting on the TARGIT study. While Vaidya et al. [35] indicate their results of IORT alone as “an alternative to WBI for selected patients” and one editorial even proclaims it as standard [6], all the authors of the respective letters [10, 16, 27, 33] strongly disagree with this conclusion. The present editorial comments on the two publications and, furthermore, provides respective statements of the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO).

Volumetric modulated arc therapy (VMAT) has the potential to deliver dose distributions comparable to the established intensity-modulated radiotherapy techniques for a multitude of target paradigms. Prior to implementing VMAT into their clinical routine in December 2008, the authors evaluated the dose calculation/delivery accuracy of 24 sample VMAT plans (prostate and anal cancer target paradigms) with film and ionization dosimetry. After the start of the clinical program, in vivo measurements with a rectal probe were performed.The VMAT plans were generated by the treatment-planning system (TPS) ERGO++ (Elekta, Crawley, UK) and transferred to a phantom. Film dosimetry was performed with Kodak EDR2 films, and evaluated with dose profiles and gamma-index analysis. Appropriate ionization chambers were used for absolute dose measurements in the phantom and for in vivo measurements. The ionization chamber was used with localization of the measurement volume based on positioning cone-beam computed tomography.Plans were transferred from ERGO++ to the record and verify (RV) system/linear accelerator (linac). The absolute dose deviations recorded with the ionization chamber were 1.74% +/- 1.62% across both indications. The gamma-index analysis of the film dosimetry showed no deviation3%/3 mm in the high-dose region. On in vivo measurements, a deviation between calculation and measurement of 2.09% +/- 2.4% was recorded, when the chamber was successfully positioned in the high-dose region.VMAT plans can be planned and treated reproducibly in high quality after the commissioning of the complete delivery chain consisting of TPS, RV system and linac. The results of the individual plan verification meet the commonly accepted requirements. The first in vivo measurements confirm the reproducible precision of the delivered dose during clinical treatments.

Darstellung der Strukturqualitat (Personal, Beschleuniger, Patienten) der strahlentherapeutischen Abteilungen am Beispiel Baden-Wurttemberg, basierend auf Vor-Ort-Audits und der Unterbreitung von Verbesserungsvorschlagen durch die Gutachter der Arztlichen Stelle (AS). Auf der Grundlage der Richtlinie und des bundeseinheitlichen Bewertungssystems fur AS wurden die strahlentherapeutischen Abteilungen in Baden-Wurttemberg bewertet. Gemas der Richtlinie besteht die Kommission aus mindestens zwei Facharzten, einem Medizinphysikexperten (MPE) und einem organisatorischen Mitglied der AS. Im Zeitraum 2005–2007 wurden 24 strahlentherapeutische Einheiten mit 60 Linearbeschleunigern bezogen auf eine Bevolkerung von ungefahr 10,7 Mio. Einwohnern uberpruft (178 000 Einwohner/Beschleuniger). An diesen 60 Linearbeschleunigern wurden im Jahr 2007 28 210 Patienten (Behandlungsfalle) mit bosartigen Tumoren bestrahlt. Insgesamt arbeiten 127 Facharzte, 83 MPE und 235 medizinisch-technische Radiologieassistenten (MTRA) in diesen Zentren. Bezogen auf das Personal und Jahr bedeutet dies ein durchschnittliches Zahlenverhaltnis von 222 behandelten Patienten pro Facharzt (Spannweite 85–400 Patienten), 339 Patienten pro MPE (Spannweite 170–538 Patienten) und 120 Patienten pro MTRA (Spannweite 48–189 Patienten). Neues Personal (Arzte, MPE, MTRA) wurde aufgrund der Empfehlungen der Gutachterkommission bei funf von sieben (71%) Betreibern eingestellt, und elf neue Stellen wurden bewilligt. Basierend auf der konkreten Ist-Analyse der Audits durch die AS stehen erstmalig konkrete Personalzahlen fur die Berufsgruppen an unterschiedlichen strahlentherapeutischen Institutionen zur Verfugung. Hierbei zeigt sich, dass neben der durchschnittlichen Personalbedarfszahl auch „Sonderaufgaben“, wie Forschung und Ausbildung, im Alltag mitberucksichtigt werden sollten.

To provide practice guidelines and clinical recommendations on preferred standard palliative radiation therapy of bone metastases as well as metastatic spinal cord compression (MSCC) for metastatic breast cancer patients. The breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) performed a comprehensive survey of the literature comprising recently published data from clinical controlled trials. The literature search encompassed the period 1995–2008 using databases of PubMed and Guidelines International Network (G-I-N). Search terms were “breast cancer”, “bone metastasis”, “osseous metastasis”, “metastatic spinal cord compression” as well as “radiotherapy” and “radiation therapy”. Clinical recommendations were formulated based on the panel’s interpretation of the level of evidence referring to the criteria of evidence-based medicine. Different therapeutic goals (pain relief, local tumor control, prevention or improvement of motor deficits, stabilization of the spine or other bones) require complex approaches considering individual factors (i.e., life expectancy, tumor progression at other sites). Best results are achieved by close interdisciplinary cooperation minimizing the interval between diagnosis and onset of treatment. Most important criteria for prognosis and choice of treatment (mostly combined multimodal therapy) are neurologic status at diagnosis of MSCC, time course of duration and progression of the neurologic symptoms. Radiation therapy is effective and regarded as treatment of choice for MSCC with or without motor deficits and/or bone metastases, which do not need immediate surgical intervention. It may be used either postoperatively or as primary treatment in case of inoperability. An optimal dose fractionation schedule or optimal standard dose for treatment of bone metastases has not been established. With regard to different therapeutic goals, different dose concepts and fractionation schedules, single- versus multifraction palliative radiation therapy (1 × 8, 5 × 4, 10 × 3, 15 × 2.5, 20 × 2 Gy), should be adapted individually. Bone metastases as well as MSCC should be managed in an interdisciplinary approach mostly as combined-modality treatment according to the specific clinical situation. The present practice guidelines offer criteria and recommendations for different radiooncologic treatment schedules based on the best available levels of evidence. Preferred technique, targeting and different dose schedules are described in detail.

Die postoperative Strahlentherapie bei Mammakarzinom kann die Lokalrezidivwahrscheinlichkeit deutlich reduzieren. Ein Uberlebensvorteil durch die Strahlentherapie nach brusterhaltender Operation war allerdings lange Zeit nicht nachweisbar, was sich u.a. auf eine durch Kardiotoxizitat bedingte Ubersterblichkeit der bestrahlten Patientinnen zuruckfuhren lies. Die vorliegende Literatur zur Bestrahlung des Mammakarzinoms wurde hinsichtlich der Kardiotoxizitat gesichtet und diente als Basis zur Hypothesenbildung. Zahlreiche Studien untersuchten in der Vergangenheit das kardiotoxische Potential der Mammabestrahlung. In der Synopsis zeichnet sich dabei folgendes Muster ab: Serien mit eindeutig dokumentierter hoher Herzbelastung (Postmastektomie- und Postlumpektomie-Bestrahlung) gingen mit klar erhohter kardialer Toxizitat einher. Wenn technikbedingt fur beide Behandlungsparadigmata eine Herzbelastung durch den Primarstrahl ausgeschlossen werden konnte (uberwiegend jungere Postlumpektomieserien), war keine Toxizitat nachweisbar. Unter den Serien mit unklarer Herzbelastung fanden sich sowohl solche mit als auch ohne erhohte Kardiotoxizitat. Eine exakte Quantifizierung, welche Toleranzdosen abhangig von unterschiedlichen geometrischen Dosisverteilungen gelten, ist aufgrund der retrospektiv oft nicht eindeutig feststellbaren individuellen Dosisbelastung bisher kaum moglich. Insbesondere kann gegenwartig nicht abgeschatzt werden, ab welchem linksseitig durch Tangentenbestrahlung mit hohen Dosen bestrahlten Herzvolumen eine intensitatsmodulierte Strahlentherapie (IMRT) mit ihrer typischen Dosisverteilungscharakteristik (groseres exponiertes Volumen mit niedriger Gesamt- und Einzelmaximaldosis, aber hoherer mittlerer/medianer Herzdosis) vorzuziehen ware. Die vorliegende Ubersichtsarbeit aktualisiert die Datenbasis zur Kardiotoxizitat der Mammabestrahlung und betrachtet diese besonders im Hinblick auf die Konsequenzen, die sich fur die klinische Einfuhrung der Mamma-IMRT ergeben. Die Mehrfelder-IMRT kann moglicherweise fur die kleine Hochrisikogruppe mit ungunstiger Thoraxgeometrie das kardiale Risiko senken. Aufgrund der weiterbestehenden Unsicherheiten bezuglich des Zweittumorrisikos in der kontralateralen Mamma, der kardialen Auswirkung niedriger/intermediarer Dosen auf grosere Herzvolumina und der langen Latenz bis zur klinischen Manifestation kardialer Toxizitat sollte die klinische Einfuhrung der Mamma-IMRT kontrolliert unter Uberwachung mit funktionellen Untersuchungen geschehen.

Der Arbeitsablauf (Workflow) in der Radiotherapie (RT) ist gegenwartig durch neue Techniken und Behandlungsparadigmen wie intensitatsmodulierte Radiotherapie (IMRT) und zunehmende bildgestutzte Radiotherapie (IGRT [„image-guided radiotherapy“]) im Umbruch. Daraus resultiert eine starke Zunahme von Daten verschiedener Datenklassen. Dies erfordert fur die Steuerbarkeit einer Abteilung eine zunehmende patienten- und behandlungsserienzentrierte Integration verschiedener Systeme. Der Workflow in einer RT-Abteilung ist multidimensional und multidirektional und umfasst mindestens funf Datenklassen (RT-/Bestrahlungsdaten, patientenbezogene Dokumente wie z.B. Befunde und Arztbriefe, arztliche Akteneintrage, Bilddaten im DICOM-Format [Digital Imaging and Communications in Medicine] sowie Non-DICOM-Bilddaten). Diese Daten mussen sequentiell, u.U. auch im Rahmen von adaptiven Feedbackschleifen in die Patientenhistorie eingebunden werden. Dieses Vorgehen kontrastiert stark mit einer diagnostischen Radiologieabteilung, in der im Wesentlichen DICOM-Bilddaten und Befunde erzeugt werden und im Zugriff bleiben. Diese Daten mussen nach Abschluss des Prozesses kaum noch manipuliert werden. Es handelt sich also um einen uberwiegend unidirektionalen Prozess. Im Gegensatz zu dieser innerhalb der diagnostischen Radiologie etablierten Standardkombination aus Radiologie-Informationssystem (RIS) und Picture Archiving and Communication System (PACS) muss ein integriertes elektronisches Radio-Onkologie-Klinik-Informationssystem (ROKIS) mit Moglichkeiten zur Speicherung/Administration von Bilddaten zusatzliche gesetzliche Rahmenbedingungen berucksichtigen (langere Speicherfristen, prozesssichere Dokumentation von wesentlichen Therapieentscheidungen sowie Abzeichnen von Bestrahlungsplanen und Dosisverschreibungen, komplexe Patienteneinverstandnisse etc.). Der Ubergang zu einer papier- und filmlosen Arbeitsumgebung in der Medizin, insbesondere in der Strahlentherapie, ist vor dem Hintergrund notwendiger Effizienzsteigerungen und steigender Archivierungskosten unausweichlich. Die vorliegende Ubersichtsarbeit stellt eine mogliche apparative und organisatorische Struktur fur ein ROKIS unter Fuhrung eines Krankenhaus-Informationssystems (KIS) vor. Ein solches System vereinigt in einer Kombination und Erweiterung der originaren Merkmale eines Record-and-Verify-(R&V-)Systems Merkmale einer elektronischen Patienten-/Fallakte (ePA) und integriertes Bildmanagement mit einem PACS.

The objective of the current study was to evaluate the acute effects of cranial radiation therapy (CNS-RT) using different radiation doses (0, 1.8, 2, 3,or=20 Gy) on cognitive function with special emphasis on memory. We assessed patients with and without intracranial tumors to distinguish between direct and indirect radiation effects on brain tissue.Eighty-two patients were evaluated with neuropsychological testing before and acutely after radiotherapy (RT). Sixty-four patients received RT to the brain (55 with, 9 without intracranial tumor). Eighteen patients treated with RT to the breast served as controls.Patients with intracranial tumor demonstrated attention (19-38th percentile) and verbal memory scores (34-46th percentile) below the population average at baseline. The average Verbal Memory score was significantly different between patients with intracranial tumor and controls both at baseline (38th vs. 58th percentile) and after irradiation (27th vs. 52th percentile). Patients with preexisting peritumoral edema performed worse than patients without edema and controls. Radiation dose-related deficits were seen for working memory performance in patients with intracranial tumor.Our data indicate no measurable impairment of cognitive functioning acutely after prophylactic cranial irradiation. Patients with intracranial tumor show a deterioration of almost all memory functions with a dose-dependent impairment in working memory. Patients with preexisting peritumoral brain edema show the strongest deterioration.

To evaluate the effect of image guided radiotherapy with stereotactic ultrasound BAT (B-mode acquisition and targeting system) on rectal toxicity in conformal radiotherapy of prostate cancer.42 sequential patients with prostate cancer undergoing radiotherapy before and after the introduction of BAT were included. Planning computed tomography (CT) was performed with empty rectum and moderately filled bladder. The planning target volume (PTV) included the prostate and seminal vesicles with a safety margin of 1.5 cm in anterior and lateral direction. In posterior direction the anterior 1/3 of the rectum circumference were included. Total dose was 66 Gy and a boost of 4 Gy excluding the seminal vesicles. 22 patients (BAT group) were treated with daily stereotactic ultrasound positioning, for the other 20 patients (NoBAT group) an EPID (electronic portal imaging device) was performed once a week. Acute and late genito-urinary (GU) and rectal toxicity and PSA values were evaluated after 1.5, 3, 6, 9 and 12 months. The total median follow up of toxicity was 3 years in the BAT group and 4 years in the NoBAT group.In the NoBAT group significant more rectal toxicity occurred, while in GU toxicity no difference was seen. Two patients in the NoBAT group showed late rectal toxicity grade 3, no toxicitygrade 2 occurred in the BAT group. There was no significant difference in PSA reduction between the groups.Without BAT significant more acute and a trend to more late rectal toxicity was found. With regard to dose escalation this aspect is currently evaluated with a larger number of patients using intensity-modulated radiotherapy (IMRT).