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BACKGROUND: The National Cancer Plan (NCP) provided the incentives needed to establish a technical infrastructure adequate to meet the medical needs of radiotherapy in cancer care. The goal of this study is to evaluate the development of radiotherapy in South-Eastern Norway Regional Health Authority (S-E NRHA) and to compare it with the aims of NCP. MATERIAL AND METHODS: The material includes the 86,000 courses of radiotherapy performed in S-E NRHA in the period 1985-2008. The data were extracted from existing patient registries and include cancer diagnosis and patient demographic information. The number of treatment series is coupled with cancer incidence of each county and that in S-E NRHA. RESULTS: During the latter half of the 1980s, radiotherapy was only offered to 50 % (range 30-60 % in the various counties) of those who needed it. The situation had improved in 2007, when this figure was close to 80 %, but there was still a significant discrepancy between counties (67-91 %). With respect to the medical needs, 10 000 additional courses of radiotherapy should have been performed in S-E NRHA in the period 2003-2007. INTERPRETATION: The demonstrated insufficient use of radiotherapy and the geographical differences between counties are not acceptable. A prerequisite for optimal use of radiotherapy in cancer treatment is that the medical professions strengthen their oncological competence.

Purpose To estimate actual utilization rates of radiation therapy (RT) in Norway, describe time trends (1997-2010), and compare these estimates with corresponding optimal RT rates. Methods and Materials Data from the population-based Cancer Registry of Norway was used to identify all patients diagnosed with cancer and/or treated by RT for cancer in 1997-2010. Radiation therapy utilization rates (RURs) were calculated as ( 1 ) the proportion of incident cancer cases who received RT at least once within 1 year of diagnosis (RUR 1Y ); and ( 2 ) the proportion who received RT within 5 years of diagnosis (RUR 5Y ). The number of RT treatment courses per incident cancer case (TCI) was also calculated for all cancer sites combined. The actual RURs were compared with corresponding Australian and Canadian epidemiologic- and evidence-based model estimates and criterion-based benchmark estimates of optimal RURs. The TCIs were compared with TCI estimates from the 1997 Norwegian/National Cancer Plan (NCP). Joinpoint regression was used to identify changes in trends and to estimate annual percentage change (APC) in actual RUR 1Y and actual TCI. Results The actual RUR 5Y (all sites) increased significantly to 29% in 2005 but still differed markedly from the Australian epidemiologic- and evidence-based model estimate of 48%. With the exception of RUR 5Y for breast cancer and RUR 1Y for lung cancers, all actual RURs were markedly lower than optimal RUR estimates. The actual TCI increased significantly during the study period, reaching 42.5% in 2010, but was still lower than the 54% recommended in the NCP. The trend for RUR 1Y (all sites) and TCI changed significantly, with the annual percentage change being largest during the first part of the study period. Conclusions Utilization rates of RT in Norway increased after the NCP was implemented and RT capacity was increased, but they still seem to be lower than optimal levels.

Radiation-induced damage to the spinal cord and the closer nervous structures may either result in a transient myelopathy, or in a chronic progressive syndrome ( I -4). In transient myelopathy. symptoms appear within 4 months after therapy and disappear spontaneously within 2-9 months. The chronic progressive syndromes are heterogenous and include classic radiation myelopathy. plexopathy, and neuropathy. A I-are type of neuropathy with isolated motor symptoms, amyotrophy. paresis and fasciculations has been described (4-5). We report a new case, and discuss briefly differential diagnostic considerations, etiological niechanisms, prognosis and therapeutical possibilities. C u e reporr. In 1981, a 26-year-old patient was orchiectomized because of a right-sided seminoma. There was no evidence of metastasis. He received high voltage photon radiotherapy (8 MV). The lumbar and right-sided iliac lymphnodes were irradiated by opposing anterior and posterior fields (2 Gy daily x 1815 days per week). The lumbar target volume included the column from Th 12 to L5 with a field width of 6.7 cm. In addition the patient received electron beam radiotherapy (13 MeV) in the right groin (12 x 13 cm with a triangled block proximal to the inguinal ligament). The daily dose in the inguinal field was 2.9 Gy applied 1 I times. In 1984, the left testicle was removed due to seminoma with histologically verified inguinal lymph metastases but without metastases in the paraaortic region. The patient was retreated with photon radiotherapy (7 MV). The opposing anterior and posterior radiation fields were exposed daily and included the lumbar region from SI to the tenth vertebra (field width: 8.7cm). The risk of damage to the spinal cord was estimated on the basis of the ED formula established by Wara et al. (6, 7). A dose of 32.4 Gy in 0.9 Gy fractions given 9 times a week was chosen as the best compromise between optimal tumor control and risk of cord damage. The interaction interval was 6 h for fractions given on the same day for 16 of the 36 fractions. The dosimetry was reviewed for both treatment series. The total dose i n the lower spinal cord corresponding to the lumbar vertebrae was thus 68.4 Gy. The left iliac inguinal region was irradiated by 20 fractions of 2 Gy ( 5 fractions per week) with opposing fields to the iliac lymph nodes and an anterior field to the inguinal lymph nodes. H e was subsequently treated with Primoteston Depot (180 mg i.m. weekly) and has since remained without sign of tumor or metastasis. About 10 months after the completion of the second radiotherapy series, he noticed impairing strength of the right foot and pain in the right calf muscles after exercise. Similar symptoms appeared 3 years later in the left foot. At this point, a clinical neurological examination revealed only fasciculations in the muscles of both calves and thighs and weak reflexes in both legs. Objective muscle strength and sensibility were unimpaired. Cerebrospinal fluid (CSF) examination showed a total protein of 2.0 g/l, transudative changes at electrophoresis (unspecific protein increase), and normal cytology. EMG was indicative of neurogenic affection with a few fibrillation potentials and nerve velocities were normal. A new examination 4 years later revealed unchanged fasciculations in both legs, amyotrophy in both calves and thighs though the muscular strength was still good. and areflexia. The CSF protein was 2.1 g/l. Peripheral motor and sensory conductions velocities were normal but lower in the tibial posterior nerve than at the previous examination. The F-wave latencies were normal, and the EMG showed polyphasy and decreased amplitude of the motor unit potentials. An MRI examination of the thoracal and lumbo-sacral medulla was normal. Nerve biopsy was not performed. One year later, the clinical status was very much unchanged. The E M G showed more clearly neurogenic affection, the F-wave latencies could not be recorded for the peroneus nerves and were increased for the tibial nerve. There were no sphincter disturbances and sensibility was unimpaired. Discussion. The relevant differential diagnoses in our patient were tumor infiltration in the medulla, amyotrophic lateral sclerosis. motor polyneuropathy and radiation neuropathy. The first possibility was excluded by a normal MRI, clinical and electromyographic examinations excluded the next two. Radiation neuropathy remained the definite diagnosis. The clinical picture in our patient was dominated by amyotrophy, flaccid paresis in the lower limbs, and the absence of sphincter disturbances and sensory symptoms. A similar syndrome was first described by Greenfield & Stark in 1947 ( I ) , and reported later by 7 authors (8-14) bringing the total number of cases to 30. The syndrome has been given different names, which reflects both its rare incidence, and lack of knowledge about the exact localization and nature of the radiation damage. It is mostly described as a postirradiation lower neuron syndrome (PLMNS). The lack of oedema and fibrosis induration

According to the Medical Birth Registry (MBR) of Norway, 69 of about 430 patients irradiated for testicular cancer (stage I + II) during 1966-1978 fathered at least one child after radiation therapy (median observation time 136 months, range 36-191 months). A total of 95 children were born. Between 10 and 122 months elapsed between discontinuation of irradiation and the birth of the first child born after radiation therapy. Though the total doses to the abdominal irradiation field were higher in patients irradiated by a linear accelerator (1971-1978), than in those treated by a betatron (1966-1970), the gonadal doses were generally lower in the former group due to better gonadal shielding. In the children, the sex ratio and the median weight and length at birth were comparable to those values seen in a control group from the MBR. No increased frequency of malformations was observed. It is concluded that modern radiation therapy techniques allow post-irradiation fathership in a significant number of patients, without increased risk of neonatal problems or malformations in the children.

Sperm analysis and serum hormone measurements (LH, FSH, testosterone) were performed in 29 patients after orchiectomy for seminoma before and after irradiation. Before radiotherapy 14 of 20 orchiectomized patients were azoospermic or had impaired spermatogenesis. A minimum sperm count was found 1 year after radiotherapy with gradual improvement up to 2 years. The recovery of sperm cell production was impaired most in patients with pre-treatment sperm counts less than 3 million/ml. Serum testosterone remained at low normal levels throughout the observation period. The mean serum FSH was increased 1 year after radiotherapy but returned to normal in 50% of patients within 3 years after treatment. This post-treatment increase in FSH was significantly correlated with increased pre-treatment FSH but not with the gonadal dose, which was 1 to 3% of the target dose. Severe disturbances in spermatogenesis, observed 2 to 3 years after radiotherapy for early seminoma, are likely to be the expression of a highly impaired pre-treatment sperm cell production and only to a lesser degree dependent on the irradiation of the remaining testicle.

A 32-year-old man underwent an operation for an oligodendroglioma of the left frontal lobe. Post-operatively he was irradiated to a target dose of 54 Gy. One year later he developed bilateral retinopathy quite similar to diabetic retinopathy. There were no clinical or biochemical signs of diabetes or hematological disease. The calculated maximum dose to the retina was 11 Gy. This is to our knowledge the lowest retinal dose of ionizing radiation reported to produce retinopathy.