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Palliative care in cancer has always been an important issue in low and middle income countries. In many occasions most resources have been devoted to expensive treatments although palliative and supportive care approaches are very important. Turkey, as a country, has been trying to take the necessary steps to organise palliative care. The Cancer Control Department of Ministry of Health has started the National Cancer Control Program in 2008 and also prepared a Palliative Care Action Plan. Dokuz Eylul University in Turkey has also organised a multidisciplinary palliative care team to create the necessary future plans and will open the first academic program under the Department of Clinical Oncology.

Purpose: To compare ultrasonographic (US) with computerized tomographic (CT) images in order to choose electron energy for radiotherapy (RT) boost field in patients with breast conserving surgery (BCS)., Methods: Thirty-seven consecutive patients with breast cancer treated by BCS and RT in our department were evaluated. Median age was 49 years (range 32-82). According to the Dokuz Eylul Breast Tumor Group Protocol (DEBTG), in patients with BCS, RT (5000 cGy to the whole breast ± lymphatic area) and boost with electron energy to the primary tumor bed (1000 cGy if surgical margin negative, or 1600 cGy if surgical margin positive was delivered. Before January 2003, the distances between skin-the deepest point of tumor bed (STD), skin-clips (SCD), and skin-fascia (SFD) were measured with US to choose electron energy in boost field. Since then, CT simulation images were used to this purpose. These two imaging systems were compared in this study. Electron energy was selected after measurement of the deepest metallic clips in CT simulation images (90%) or measurement of the STD if no clips were present (10%)., Results: Median measurements with US and CT were as follows: STD: US 12 mm (range 4-35), CT 28 mm (range 2-54); SFD: US 25 mm (range 6-57), CT 31 mm (range 2-93); SCD: US 14 mm (range 7-26), CT 29 mm (range 2-68). The median electron energy was 9 MeV é (range 6-12) for US and 12 MeV é (range 6-21) for CT. Concordance in US and CT measurements was 27%., Conclusion: This preliminary study reveals that CT-based SCD measurements are deeper than US measurements, and selected electron energy with CT is 3 MeV higher than US. These two factors can affect local control and side effects. We noticed only one local recurrence in 37 patients. We did not evaluate side effects in this study. These could be a subject of a future study.

Aim: The relation of anxiety and depression levels with characteristics of coping with the disease and quality of life were evaluated in women under follow-up for breast cancer., Materials and Methods: Patients who had presented to the breast cancer polyclinics for follow-up were evaluated. The Beck Depression and the State-Trait Anxiety inventories were used in the evaluation of depression and anxiety levels. In order to evaluate their power to cope with cancer, the patients were questioned for a social support network. EORTC QLQ-C30 and QLQ-BR23 questionnaires were applied for quality of life evaluations., Results: There were 23 (19%) patients with depression; 3 (2.5%) with grade I anxiety, 94 (77%) grade II, and 23 (19%) grade III anxiety, respectively. Depression and anxiety levels were affected by the following parameters: being unaccompanied by spouse for hospital follow-ups (P < 0.0001); request to get help by a psychologist (P = 0.02); presence of a person to share their problems (P < 0.0001); and using an alternative treatment (P = 0.04). In the quality of life evaluations, difficulty in sleeping, emotional status, fatigue, and body appearance were related with both depression and anxiety (P < 0.05 for all), whereas physical function (P = 0.002), role performance (P = 0.005), cognitive condition (P < 0.0001), social position (P < 0.0001), pain (P < 0.0001), general health (P < 0.0001), treatment methods (P = 0.001), future anxiety (P < 0.0001), and arm symptoms (P = 0.001) were negatively affected in patients with depression., Conclusion: High depression and anxiety levels in patients under follow-up for breast cancer influence the coping with cancer and quality of life adversely.

The purpose of this study is to assess patient, tumour and treatment related factors on quality of life (QoL) outcomes of patients who received definitive or postoperative radiotherapy +/- chemotherapy for head and neck (H&N) cancer. In this cross-sectional study, 110 H&N cancer patients were evaluated in follow-up visit and were asked to fill out the European Organisation for Research and Treatment of Cancer QoL Core Questionnaire (QLQ-C-30) and H&N Module (QLQ-H&N35). Patients were also graded for their late side effects using EORTC/RTOG scoring system. The QLQ C-30 and QLQ-H&N35 mean scores were compared using ANOVA analysis for these variables: age, gender, occupation, educational status, social security status, place of residence, tumour localization, clinical stage, comorbidity, Karnofsky performance score, treatment modality and side effects. Median follow-up was 29 (4-155) months. Tumour localization was significant factor affecting physical (P = 0.03), social (P = 0.01), cognitive (P = 0.002) functioning. Treatment modality had significant impact on the physical (P = 0.02) and cognitive scores (P = 0.008). Global QoL was affected significantly by disease stage (P = 0.01) and occupation (P = 0.01). The QLQ-H&N35 scores were found significantly higher in patients with moderate/severe late morbidity. Tumour localization and the treatment modality are the most important factors affecting the QoL of H&N cancer patients treated definitively.

Aims and Background: Assessing psychosexual and body image aspects of quality of life in Turkish breast cancer patients treated by either mastectomy or breast conserving treatment (BCT)., Methods: The study group consisted of 112 patients who had undergone all treatment at a single institution under the care of a multidisciplinary breast team. Following surgery, all patients underwent adjuvant radiotherapy with or without chemotherapy and hormone therapy. At the time of this study all patients were disease free with at least 2 years' follow-up. Twenty percent of the patients were premenopausal and 80% postmenopausal. The patients completed a questionnaire consisting of 42 questions related to their sexual relations and body image., Results: Forty-one percent of sexually active patients had experienced a deterioration of sexual functioning after treatment. This was mainly due to loss of libido (80%), loss of interest in partner (54%), and sexual dissatisfaction (59%). Problems tended to develop early in the course of treatment. Decreased sexual desire was significantly more frequent in patients undergoing mastectomy versus BCT (80% vs 61%; P = 0.043) and in premenopausal versus postmenopausal patients (P = 0.024). Although 80% of patients were satisfied with their appearance as a whole, only 54% liked their naked bodies. There was no significant difference in body image scores between patients undergoing mastectomy or BCT apart from a general feeling of physical unattractiveness in mastectomy patients (3.4 vs 2.8; P = 0.03)., Conclusions: Significant, similar psychosexual and body image problems occur in patients treated for breast cancer with either mastectomy or BCT. Problems arise early in the course of the disease and therefore detection and treatment of these problems should be addressed during the patients' initial assessment and at the start of treatment. These findings are similar to those reported on similar groups of treated women in American and European populations.

Purpose: To determine reirradiation results of patients with recurrent non-metastatic non-small cell lung cancer (NSCLC)., Patients and Methods: 38 NSCLC patients who showed clinical and/or radiological progression and were retreated with hypofractionated irradiation (RT) were retrospectively evaluated. Two parallel or oblique opposed fields were used for reirradiation of the recurrent tumor while excluding the spinal cord. "Improvement" and "complete or near complete response" were defined as > or = 50% and 75-100% regression of symptoms, respectively. Log-rank test, chi-square test and Cox regression analysis were used for statistical analyses., Results: Median age was 58 years (range 33-80) and only 3 patients were females. Median follow-up was 13.5 months (range 4-65). In the initial and second course of RT the total dose was 30 Gy (range 28.8-67.2) and 25 Gy (range 5-30) and the number of fractions was 10 (range 9-33) and 10 (range 1-10), respectively. The median interval between the two RT courses was 35 weeks (range 4-189). After reirradiation improvement was observed in 86% of the patients assessable for hemoptysis, in 77% with cough, in 69% with dyspnea, and in 60% with thoracic pain. After reirradiation, the median survival time was 3 months (range 0-55). Two-year survival rates from diagnosis were 28.8% and from reirradiation 5.8%. An interval more than 35 weeks between the end of initial RT and the start of reirradiation was found as the only independent prognostic factor affecting survival. No grade III-IV RTOG late side effects were observed., Conclusion: In initially non-metastatic NSCLC patients, reirradiation can be a safe and effective treatment for palliation after recurrence. Large prospective studies are needed to confirm the safety, effectiveness and economical advantages of this modality.

Purpose: To determine the patterns of care for lung cancer in Turkish radiation oncology centers., Methods and Materials: Questionnaire forms from 21 of 24 (87.5%) centers that responded were evaluated., Results: The most frequent histology was non-small cell lung cancer (NSCLC) (81%). The most common postoperative radiotherapy (RT) indications were close/(+) surgical margins (95%) and presence of pN2 disease (91%). The most common indications for postoperative chemotherapy (CHT) were ">/= IB" disease (19%) and the presence of pN2 disease (19%). In Stage IIIA potentially resectable NSCLC, the most frequent treatment approach was neoadjuvant concomitant chemoradiotherapy (CHRT) (57%). In Stage IIIA unresectable and Stage IIIB disease, the most frequent approach was definitive concomitant CHRT (91%). In limited SCLC, the most common treatment approach was concomitant CHRT with cisplatin+etoposide for cycles 1-3, completion of CHT to cycles 4-6, and finally prophylactic cranial irradiation in patients with complete response (71%). Six cycles of cisplatin + etoposide CHT and palliative thoracic RT, when required, was the most commonly used treatment (81%) in extensive SCLC. Sixty-two percent of centers did not have endobronchial brachytherapy (EBB) facilities., Conclusion: There is great variation in diagnostic testing, treatment strategies, indications for postoperative RT and CHT, RT features, and EBB availability for LC cases. To establish standards, national guidelines should be prepared using a multidisciplinary approach.

For laryngeal cancer, surgical excision of the primary tumor should be undertaken with the aim of achieving tumor-free margins. Adequate pathological assessment of the specimen and the competency of the treatment center play a crucial role in achieving cure. The present study aimed to analyze the significance of place of surgery on the outcome of patients with laryngeal cancer who underwent surgical operation in other centers and were subsequently referred to Doküz Eylul University Head and Neck Tumour Group (DEHNTG) for postoperative irradiation. Patients were divided into three groups according to their place of surgery. The first group (Group I) consisted of patients who had their surgical operation at DEUH. Patients in the second group (Group II) were referred from centers with oncological surgical experience. The third group (Group III) consisted of patients referred from hospitals with no surgical teams experienced in head and neck cancer treatment. The clinical and pathological features of patients in these three groups were analyzed to assess the impact of place of surgery on clinical outcome as well as the prognostic factors for survival. The study population consisted of 253 patients who were treated between 1991 and 2006 with locally advanced laryngeal cancer according to the protocol of DEHNTG. The median follow-up was 48 (3-181) months. The 5 years overall, loco-regional disease-free and distant disease-free survivals were 66, 88 and 91%, respectively. When patients' clinical and histopathological features were analyzed for the impact of place of surgery, surgical margin positivity rates were found to be higher in Group III (P = 0.032), although the other two groups had more advanced clinical and pathological N stage disease (P = 0.012, P = 0.001). In multivariate analysis, older age (P < 0.0001), presence of perinodal invasion (P = 0.012), time interval between surgery and radiotherapy longer than 6 weeks (P = 0.003) and tumor grade (P = 0.049) were the most significant factors. For loco-regional failure-free survival, advanced clinical stage (P = 0.002), place of surgery (P = 0.031) and presence of clinical subglottic invasion (P = 0.029) were shown to be important prognostic factors. For distant metastasis-free survival, only pathological (+) lymph node status (P = 0.046) was a significant factor in multivariate analysis. The significance of place of surgery as well as other well-known prognostic factors underlines the importance of an experienced multidisciplinary treatment team if best results are to be obtained for the patient.

A pilot study was performed for setting up the Dokuz Eylül University Breast Tumor DNA Bank (DEUBTB) to facilitate the sharing of tumor DNA/RNA samples and related data from cases collected by collaborators specializing in the breast cancer diseases between 2004 and 2006. The pilot study aimed to provide answers for certain questions on: (1) ethical concerns (informing the volunteer for donating specimen, anonymizing the sample information, procedure on sample request), (2) obtaining and processing samples (technical issues, flowchart), (3) storing samples and their products (storing forms and conditions), (4) clinical database (which clinical data to store), (5) management organization (quality and quantity of personnel, flowchart for management relations), (6) financial issues (establishment and maintenance costs). When the bank had 64 samples, even though it is quite ready to supply samples for a research project, it revealed many questions on details that may be answered in more than one way, pointing that all biobanks need to be controlled by a higher degree of management party which develops and offers quality standards for these establishments.

Objective: To assess thyroid dysfunction in head and neck cancer patients who have received external beam radiotherapy according to radiotherapy fields and dose, tumor site and other local or systemic treatments retrospectively and prospectively and propose a follow-up schedule., Material and Methods: A total of 378 patients was classified into two groups. Group I (n = 345) consisted of surgically treated 153 laryngeal, 80 nasopharyngeal and 112 oral cavity/oropharyngeal carcinoma patients; these patients were evaluated retrospectively for treatment-related thyroid dysfunction using their data files. Group II included 33 patients with head and neck cancer who were evaluated prospectively. Thyroid function tests were performed at the beginning of the radiotherapy and every three months after the radiotherapy course, and thyroid dysfunction regarding surgery, radiotherapy and chemotherapy was evaluated., Results: In Group I, the median follow-up for 153 operated laryngeal carcinoma patients was 44 months. Four (2.6%) of them were found to have clinically apparent hypothyroidism. After a median follow-up of 36 months, none of the 80 nasopharyngeal carcinoma patients showed signs of hypothyroidism. Clinically apparent hypothyroidism was detected in only 1 (0.8%) of the oral cavity/oropharyngeal carcinoma patients after a median follow-up of 25 months. In Group II, 1 (3%) patient was found to have thyroid dysfunction postoperatively prior to radiotherapy. At the time of analysis, 29 (87.8%) patients were euthyroidic, 2 (6.1%) patients had subclinical and 2 (6.1%) patients had clinical hypothyroidism. All patients with thyroid dysfunction have had combined surgery and radiotherapy, and none of the patients treated with radical radiotherapy has experienced hypothyroidism., Conclusions: Even after a short follow-up, the incidence of thyroid dysfunction was 12.2% in head and neck cancer patients treated with combined surgery and radiotherapy. We recommend thyroid function tests in these patients prior to and once every 3-6 months after the radiotherapy course.

Purpose: To determine the effect of socioeconomic factors on quality of life (QoL) after treatment in patients with head and neck carcinoma (HNC)., Patients and Methods: The study population included 50 HNC patients seen in their control examinations after radiotherapy during a 2-month interval and who were willing to complete the Short-Form 36 QoL questionnaire. Socioeconomic, demographic, and tumor- and treatment-related factors were analyzed for their effect on physical component summary score (PCS) and mental component summary score (MCS) using the Mann-Whitney U test., Results: All patients received radiotherapy, and 33 patients (66%) underwent surgery for the primary tumor and/or neck disease. Chemotherapy was given in 9 patients (18%). Mean PCS and MCS were 47.9 (range, 24.8-59.3) and 46.7 (range, 22-63.3) for the whole patient population. There was no significant factor affecting PCS. Education level of "middle school or higher," perceived economic status of "medium or higher," social security status of not being "absent or minimally covered," and unilateral type of neck surgery were found to increase MCS significantly. According to separate linear regression analyses performed for three socioeconomic variables, the most significant factor for MCS was social security status compared with education level and perceived economic status. It was the only parameter that retained its significance when all five parameters were combined in a linear regression model., Conclusion: This study demonstrated that educational status, perceived economic status, and social security status showed a significant effect on the QoL of HNC patients after radiotherapy. When all variables were taken into account, only "social security status" remained significant.

Objective: To evaluate the interindividual and intraindividual applicator position variability in high dose rate ring and tandem intracavitary brachytherapy applications in locally advanced cervical cancer., Patients and Methods: Eight patients with locally advanced cervical cancer formed the study population. They had been treated in Dokuz Eylül University Department of Radiation Oncology between the years 2000 and 2005 with high dose rate intracavitary brachytherapy using ring and tandem applicators. The 3-dimensional geometric variation of the applicator center in craniocaudal, mediolateral and anteroposterior directions was determined on the basis of bony reference points in 24 pairs of orthogonal films obtained in the conventional simulator. Then the following evaluations were performed: 1) the applicator position variability in all applications (interindividual variability), 2) the intraindividual applicator position variability relative to the first application, 3) the intraindividual applicator position variability relative to the average of three applications. Among the potential factors that might influence the reproducibility of ring and tandem applications, age, stage, the period between external radiotherapy and brachytherapy were evaluated by univariate analysis., Results: Standard deviation of interindividual applicator variability was 3.83 mm in craniocaudal, 0.39 mm in mediolateral and 2.86 mm in anteroposterior directions. The standard deviation of intraindividual variability relative to the first application was 1.91 mm in craniocaudal, 0.4 mm in mediolateral, and 4.26 mm in anteroposterior directions. The standard deviation of intraindividual variability relative to the average of three applications was 0.95 mm in craniocaudal, 1.86 mm in mediolateral, and 1.24 mm in anteroposterior directions. According to univariate analysis, no factor influenced applicator position variability., Conclusions: In order to extract definitive conclusions about factors that affect positional reproducibility of ring and tandem applicators, studies are needed that include larger numbers of patients.

We report on a case of a premenopausal woman with breast cancer and unusual dissemination with isolated inguinal and iliac lymph node metastasis. The primary tumor was T2N0M0. After mastectomy the patient received adjuvant chemotherpy, hormonotherapy and radiotherapy (RT). Painful edema developed at the right leg 69 months after the operation. Diagnostic investigations revealed isolated right inguinal and iliac lymphadenopathy (LAP). Tru-cut aspiration biopsy was reported as negative. Four months later, abdominal magnetic resonance imaging (MRI) disclosed paraaortic and bilateral iliac and inguinal LAP. Pathological assessment of the right inguinal LAP confirmed a metastasis from breast cancer. After unsuccesful chemotherapy, palliative RT was performed to the inguinal, iliac and paraaortic lymph nodes, resulting in partial response. The patient ultimately died because of disease progression. Clinicians should maintain a high degree of suspicion when coming across with unusual complaints and findings in patients with breast cancer.

Purpose: To evaluate the combined modality treatment results of patients with limited-stage small cell lung cancer (SCLC), who were treated and followed by the DELCSG., Patients and Methods: Sixty-three patients with limited-stage SCLC diagnosed between April 1991 and December 2002 were included. All patients were treated with combined chemotherapy and thoracic radiotherapy. Median age was 59 years (range 36-84), and all patients were male except 4. Surgery was performed for diagnosis in 3 patients. Four cycles of chemotherapy (median) were administered, composed of cisplatin-etoposide (CE) (26 patients), cyclophosphamide-vincristine-adriamycin (CAV) (10 patients) or alternated CE and CAV (18 patients). Nine patients received various chemotherapy regimes other than CE and/or CAV. A total dose of 5000 cGy with 180-200 cGy daily fractions was given to the primary tumor and mediastinum, excluding the spinal cord after 4500 cGy. Prophylactic cranial irradiation (PCI) was performed in 13 (20%) patients. Overall survival (OS) and progression-free survival (PFS) were calculated, beginning from the date of diagnosis and the end of radiotherapy, respectively. Kaplan-Meier method was used for obtaining survival rates. Log-rank test and Cox proportional hazards model were used for univariate and multivariate analyses, respectively., Results: Median follow-up time was 17 months (range 3-131). Median PFS and OS were 12 (range 1-131) and 17 (range 3-131) months, respectively. Two-years PFS and OS rates were 27 % and 38 %, respectively. During follow-up, 27 (43%) patients developed brain metastasis; among them only 3 had received PCI. Univariate analysis showed that addition of PCI significantly improved PFS (p=0.025) and advanced age was a favorable prognostic factor for OS (p=0.039). In the multivariate analysis, advanced age (p=0.034) and addition of PCI (p=0.004) were independent factors increasing PFS, however no significant prognostic factor influencing OS was found., Conclusion: Our treatment results are in accordance with the relevant literature. It is also concluded that PCI should be given to all patients with complete response to chemotherapy. However, analysis of prognostic factors should be cautiously evaluated because of small number and heterogeneous distribution of patients in subgroups. Prospective studies are necessary for better determination of prognostic factors.

Objective: A positive relationship between epidermal growth factor receptor (EGFR) expression and radioresistance has been shown both in vitro and in vivo. In a group of 31 patients with early glottic cancer treated with definitive radiotherapy, the relationship of EGFR expression with patient and tumor related parameters were analyzed and the prognostic effect of EGFR expression on local control (LC) was assessed., Material and Method: Between 1991 and 2001, 114 patients with early glottic (Tis-T2N0M0) squamous cell carcinoma were treated with radiotherapy at our institution. Among these, 31 patients whose pretreatment pathology specimens were available for immunohistochemical analysis formed the study population. Median age was 64 (46-77). Anterior commissure involvement was evident in 12 (38.7%) patients. Distribution according to T stage was as follows: Tis 6 (19.3%), T1 22 (71%), and T2 3 (9.7%). Histopathological grades of the 25 T1-2 tumors were 10/25 (40%) grade 1, 9/25 (36%) grade 2 and 6/25 (24%) grade 3. Our radiotherapy regimen was 66-70 Gy in 33-35 fractions over 6.5-7 weeks. The median follow-up period was 45 months (range, 5-116). Following immunohistochemical staining, quantitative immunohistochemistry (IHC) was performed by image analysis software and stained tumoral area percentage (STAP) was identified. The cut-off value was < or =5% versus >5%. The relationship of EGFR expression with patient (age) and tumor related (T stage, histopathological grade, and anterior commissure involvement) parameters was evaluated using chi-square test. Prognostic significance of EGFR expression, age, T stage, histopathological grade, and anterior commissure involvement on LC was assessed using log-rank test., Results: No difference was found in EGFR content distribution in relation to age, T stage, histopathological grade, and anterior commissure involvement. In the univariate analysis including age (< or =60 versus >60), T stage (Tis and T1 versus T2), histopathological grade (grade 1 and 2 versus grade 3), anterior commissure involvement (present versus absent), and EGFR expression (high versus low), only T stage and EGFR expression were found to be significant prognostic factors affecting LC (P = 0.0006 and P = 0.03, respectively)., Conclusion: The results of this series support that EGFR expression is an unfavorable prognostic factor in early glottic carcinomas. For this reason EGFR IHC may be considered for selecting patients for more aggressive therapies (radiotherapy with different fractionation schemes or surgery) or enrollment into trials targeting EGFR signaling pathways.

Aim: To develop a structured logbook for trainees in the medical specialty of radiotherapy with Europe that records the increasing experience throughout their training period., Material and Methods: A working party appointed by the European Board of Radiotherapy developed a draft version of a European logbook for trainees in radiotherapy. For development, the update European Core Curriculum for Radiotherapists (Radiation Oncologists) was taken into consideration. The logbook is composed of six sections: (1) biodata of the trainee, (2) scientific training documentation, (3) clinical training documentation, (4) record of formal presentations by the trainee, (5) publications, (6) training courses. Decisions were made to suggest that the clinical section of the logbook should: (a) only collect data that was essential for the purposes of appraisal, assessment and regulation, (b) be as user friendly as possible, (c) concentrate on quality of the data and not volume. The logbook was tested by trainees in several European training departments and adapted according to their suggestions. A final draft of the logbook was circulated among the national and professional societies for radiotherapy in Europe for review before a European consensus conference took place in Brussels in December 2002., Results: The European training logbook for radiotherapy was endorsed by representatives of 35 European nations during the Brussels consensus conference on December 14, 2002., Conclusion: Keeping a training logbook is an essential feature of the record of training for all EU trainees who wish to retain an opportunity to spend part of their training time in another country of the Union, important for someone who seeks an appointment as a specialist in another country within a few years of achieving specialist accreditation, and good professional practice for all other trainees. The European training logbook for radiotherapy is a robust instrument that allows the systematic collection of the information that needs to be recorded to monitor the professional development of European trainees in Radiation Oncology.

This multicentric study aimed to bring neuroblastoma patients together under IPOG-NBL-92 protocol and evaluate the results within the period between 1992 and 2001 in Izmir. Sixty-seven neuroblastoma patients from 4 pediatric oncology centers in Izmir were included in the study. IPOG-NBL-92 protocol modified from German Pediatric Oncology (GPO)-NB-90 protocol was applied: Patients in stage 1 received only surgery, while surgery plus 4 chemotherapy courses (cisplatin, vincristine, ifosfamide) were given in stage 2 and surgery plus 6 chemotherapy courses (cisplatin, vincristine, ifosfamide, epirubicin, cyclophosphamide) were given in stages 3 and 4 patients. In patients who were kept in complete remission (CR), a maintenance therapy of one year was applied. Radiotherapy was given to the primary site following induction chemotherapy plus surgery in stages 3 and 4 patients with partial remission (PR). The stages of the patients were as follows: 5% in stage 1, 39% in stage 3, 49% in stage 4, and 7% in stage 4S. Primary tumor site was abdomen in 88% of cases. CR rates were as 100% in stage 1, 76% in stage 3, 35% in stage 4, and 75% in stage 4S. Relapse was observed in 32% of patients in a median of 19 months. The median follow-up time for survivors was 33 (17-102) months. Five-year OS rate was 31% and the EFS rate was 30% in all patients. Five-year overall and event-free survival rates were 63 and 30% in stage 3, but 6 and 5%, respectively, in stage 4 patients. Univariate analysis established that the age, stage, primary tumor site, and high LDH and NSE levels conferred a significant difference. The IPOG-NBL-92 protocol has proved to be satisfactory with tolerable toxicity and reasonable CR and survival rates. However, more effective treatments suitable to Turkey's social and economic conditions are urgently needed for children over 1 year of age with advanced neuroblastoma.

Purpose: It is reported that low dose radiation received by the contralateral breast (CLB) during adjuvant radiotherapy (RT) is carcinogenic. This trial was planned to evaluate the CLB skin doses received during adjuvant RT of breast carcinoma., Patients and Methods: Twenty-four breast carcinoma patients treated locally or locoregionally with adjuvant RT were included. RT was performed with only tangential fields (TA) in 6 patients whereas 9 patients had an extra internal mammary (IM) field (TAIM). The remaining 9 patients received 5-field locoregional RT (5FLR). All patients were treated with wedge filters except for 3 TA patients. Of 9 5FLR patients IM fields were treated with Co60 in 5 and with electrons in the remaining 4 patients. LiF(2)-based Ribbon type thermoluminescent dosimeters (TLD) were used for dose evaluation. An average of 10 TLD's, placed with 1 cm gaps beginning from the medial border of the treatment field along the central axis were used to obtain dose measurements. Median measure of TLD's between 2-8 cm and maximum dose point (MDP) values in the same range were used to evaluate the CLB dose., Results: In TA patients the CLB skin received 6.3% of the total dose in patients treated with wedge filters and 7.13% with half-beam blocks. For 6 TAIM patients with IM fields treated with Co60, the CLB dose was 7.24%. In 5 of 9 5FLR patients, whose IM fields were treated with Co60 the CLB skin received 8.8% of the total dose, while for electron beam therapy the CLB dose was 5.44%. CLB median MDP values were as follows: 12.76% in TA patients treated with wedge filters and 11.45% with half-beam blocking; 11.89% in TAIM patients with IM fields treated with Co60 and 7.83% with electron beams; 12.29% in 5FLR patients of whose IM fields were treated with Co60 and 8.94% with electron beams., Conclusion: When compared to wedge filters, halfbeam blocks caused 13% increase in CLB doses. If IM fields were added, 27.5% and 62% increases at CLB doses were established with Co60 when compared to electron beam RT in 3-field and 5-field treatments, respectively. CLB doses increased by 15-40% with the increased number of treatment fields. MDP values were also found to be higher with IM fields treated with Co60, but the number of treatment fields and accessories used seemed to have no effect on MDP doses. We conclude that by using wedge filters instead of half-beam blocks and by increasing the number of fractions treated with electron energies for IM fields, apparent decreases in CLB doses can be obtained. Large number of cases is needed to statistically establish the significant differences between subgroups.

Background: The basic level of cancer knowledge of the population is as important in controlling cancer as diagnostic tools, screening, and new approaches to prevention, early diagnosis, and treatment., Methods: A questionnaire consisting of 24 questions was given to 630 healthy Turkish people to determine their basic knowledge and attitudes regarding cancer., Results: The majority of respondents (78%) were found to have little knowledge of cancer despite the fact that the average level of education of the sample was superior to that of the general population. Educational level was the major predictive factor influencing the basic knowledge and attitudes of the respondents., Conclusion: The overall education of the public as well as the basic level of knowledge of cancer must be improved in cooperation with oncology societies and media in order to overcome the cancer burden in Turkey.

The aim of this study was to evaluate retrospectively the treatment results of non-small cell lung cancer (NSCLC) patients treated with palliative intent in Dokuz Eylul University Hospital, Radiation Oncology Department. One hundred and fifteen inoperable, non-metastatic and symptomatic NSCLC patients were treated with palliative radiotherapy (PRT) between July 1991 and May 2000. PRT was used in patients with low performance status, weight loss more than 10% within last 6 months, secondary malignancies, co-morbid diseases and socio-economic problems. Parallelly opposed isocentric antero-posterior fields including both the parenchymal and mediastinal masses were used. 10-55 Gy total doses were delivered in 1-23 fractions with a median of 30 Gy. Nineteen patients received systemic chemotherapy before PRT. Survival analysis was made from the treatment beginning date, and subjective palliation rates were assessed according to clinical improvements in symptomatology evaluated 1-6 weeks after PRT. The median follow-up time was 28 weeks (1-234 weeks). Totally, 245 disease-related symptoms were detected in 115 patients. Overall "improvement" in symptomatology was found to be 90% (221/245) with a "near-total response" rate of 46% (113/245). Hemoptysis was the best palliated symptom. Median survival time was 30 weeks. Karnofsky performance status (KPS) (p=0.015), weight loss (p=0.0015), histologic tumor type (p=0.0024) and tumor size (p=0.02) were found to effect overall survival rates significantly in uni-variant analysis. Multi-variant analysis revealed statistically significant effect with histological tumor type and weight loss status. Only 16% of patients (3/19) showed partial and 5% (1/19) complete response to systemic treatment. Median survival time was 46 weeks in this group. In conclusion, this retrospective study of patients with poor prognostic factors confirms that PRT is an effective treatment modality in symptomatic locally advanced NSCLC patients resulting in 90% symptomatic improvement rate and a median survival of 30 weeks.

Background and Purpose: High dose rate (HDR) remote afterloading intracavitary brachytherapy is an effective treatment modality which has some advantages over low dose rate (LDR) techniques for gynaecological cancer. Optimization is one of the possibilities of modern brachytherapy techniques, especially the stepping source technology. The use of the term 'optimization' implies achieving the desired optimum dose distribution by changing some parameters of the treatment. The aim of this study was to theoretically evaluate the optimization possibilities by modifying dwell times and dwell positions of the uterine and vaginal sources., Materials and Methods: Working on a virtual utero-vaginal model, the dose distribution variations in the rectum, bladder, mean point B reference points and volume parameters were investigated whilst giving a standard dose to point A in the Manchester system. In this model, the intrauterine tandem consisted of 27 dwell positions for 2.5 mm steps and 14 dwell positions for 5 mm steps. Vaginal colpostats consisted of five dwell positions each for 2.5 mm steps. Using a Nucletron Plato treatment planning system and a Microselectron Ir-192 HDR stepping source unit, the dwell times of the intrauterine (T(u)) and vaginal sources (T(v)) were modified at the ratios of (T(u)/T(v)) 1:1; 1:2; 1:3; 1:4; 1:0.50; 1:0.33; and 1:0.25 for the two different dwell positions, 2.5 and 5 mm steps, of the intrauterine tandem., Results: All evaluated parameters decreased with increasing dwell time ratios of uterine tandem to vaginal colpostats, with the greatest fall in the percentage of rectum reference dose (D(R) %), 23 and 28% for 2.5 and 5 mm dwell positions respectively; in addition, the reference isodose volume decreased by 14 and 17% for 2.5 and 5 mm dwell positions, respectively. All evaluated parameters increased with decreasing dwell time ratios of uterine tandem to vaginal colpostats for both dwell positions. The DR% of 1:1-1:4 (T(u)/T(v)) weightings showed an increase from 40.6 to 58.3 (44%) for 2.5 mm and from 49.2 to 67.5 (37%) for 5 mm dwell positions. The volume was increased by 27 and 37% for 2.5 and 5 mm dwell positions respectively., Conclusion: Modern brachytherapy techniques enable the individualization of treatments by optimization procedures in gynaecological brachytherapy applications. By altering the dwell time and position, some important changes in reference points, volume and treatment time can be achieved, whilst maintaining a standard dose to point A.

Background and Purpose: Metastasis to the brain develops in 25% of all patients with lung cancer. Although the outcome is usually poor, there seems to be a subset of patients with favorable prognostic factors who may live longer. Prognostic factors were analyzed retrospectively in 103 patients with brain metastases from lung carcinoma to identify patients who would benefit from more intensive treatment strategies., Materials and Methods: Between October 1991 and December 1994, 103 patients with brain metastasis from lung cancer were irradiated with palliative intent. Palliation was defined as 50% or more regression of neurological signs and symptoms 2 weeks after the completion of cranial radiotherapy. Local (related to the lung tumor) symptom status at the time of brain metastasis, the presence of metastases other than brain, multiplicity of brain metastases on CT scan and time of occurrence of brain metastasis were the factors which were evaluated with multivariate analysis., Results: Palliation was accomplished in 85% of cases. Palliation duration ranged from 0.5 to 54 months (median 3 months). The overall median survival was 5 months. Only one patient is under follow-up without any symptoms related to the brain metastasis. According to the multivariate analysis survival was significantly decreased in the presence of symptoms related to the primary tumor (P = 0.001)., Conclusion: The presence of symptoms related to the primary tumor at the time of brain metastasis is one of the factors that can be used to distinguish patients with a favorable outcome. In patients with favorable prognostic factors and thus longer survival probability, the role of boost dose after whole brain radiotherapy or surgical resection in suitable cases needs to be investigated.

Spinal canal involvement is not a common pattern of metastasis in Wilms' tumor. Although early detection and treatment can achieve improvement of neurological deficit, mortality remains high. We present a 5-year-old girl who had an epidural metastasis while she was receiving chemotherapy for stage IV Wilms' tumor. Within 2 months following laminectomy, total removal of tumor, radiotherapy, and adjuvant chemotherapy some of the neurological signs improved.

A 4 1/2-year-old girl with a primary osteosarcoma of the seventh cervical vertebra, treated by surgery and chemotherapy, and who is off therapy for 24 months with no evidence of disease is presented and the literature reviewed.

Germ cell tumors, in particular teratomas, are some of the most commonly found tumors in childhood. Six percent of all germ cell tumors are located in the head and neck region. Endodermal sinus tumors (yolk sac tumors) of the head and neck, exclusive of the central nervous system, are rare. This study reports a 20-month-old girl with a mass of 5 x 5 cm on the left temporal area and with bone destruction on CT. The histopathological examination of the excised mass revealed an endodermal sinus tumor. The serum AFP and the LDH levels were elevated at diagnosis. The patient was treated by the BEP protocol (bleomycin, etoposide, and cisplatin), six cycles every three weeks. Partial response was attained after the first and complete response after the fourth cycle. The patient, who is being followed up, has been in remission for five months.

The serum concentration of neuraminic acid and the carcino-embryonic antigen (CEA) were measured in 178 patients with diagnosed mammary carcinoma and 114 control patients. Among these 178 patients, 16 showed a local recurrence, 68 were tumor-free, and 94 had distant metastases. Only 42 out of these 94 patients kept the check-up appointments. During six months, they were regularly examined and treated with cytostatic drugs. The neuraminic acid levels corresponded mostly to the clinical state and the response to chemotherapy of these patients. All of the 94 patients with generalized mammary carcinoma had a significantly increased neuraminic acid concentration in the serum (p less than 0.001). The serum levels were not modified in 16 patients with local recurrences and in 68 tumor-free patients. The CEA values did not correspond to the serum neuraminic acid levels and the clinical state of the patients. The increase of the neuraminic acid concentration in the serum of these 42 patients with metastatic mammary carcinomas show that this parameter is a valuable indicator for the progression of this disease.

Two children who were brought to the Istanbul Children's Hospital with congestive heart failure caused by extension of Wilms' tumor to the right atrium are presented. In both cases a large mass was noted in the right atrium by two-dimensional echocardiography. The tumors were successfully removed at open heart surgery, and chemotherapy and radiotherapy were started postoperatively. The patients are both alive and symptom-free; one, three and a half years and the other two years postoperatively.

A new tube system for the betatron, which normally is only applied in percutaneous electron therapy, was developed at the Radiotherapeutic Department of the Medical Faculty of Istanbul. The new system allows to use the betatron also in transvaginal irradiation of the uterine cervix cancer. The authors describe the technical features of this system, its clinical application, and the results achieved. In great tumor centres where every type of malignant disease is treated, it is indispensable to dispose of the equipment necessary for certain very special cases, even if this equipment is not used frequently. In recent years, applicators for cavitary therapy and high voltage units for percutaneous therapy have been gradually substituted for the tube system employed in former times with orthovolt therapy units in intravaginal irradiation of cervical and vaginal carcinomas. There are cases, however, where the therapy techniques used nowadays are not sufficient or where a cavitary therapy should be used. Furthermore electrons which today can easily be produced for percutaneous surface therapy with linear accelerators can also be used for transvaginal therapy. We, too, have developed a new tube system which was attached to the betatron and used in intravaginal irradiation. This study describes the tube system, its clinical application, and the results achieved.

The serum concentrations of neuraminic acid, CEA, gamma-Gt, 5-nucleotidase, haptoglobin, and alkaline phosphatase were determined before therapy and three and six months after the initiation of therapy in 42 patients with small cell bronchial carcinomas. Before therapy, a significantly increased serum concentration as compared to normal values was found for neuraminic acid in 97% of patients (43/44), for CEA in 54.7% (23/42), for gamma-Gt in 19% (8/42), for 5-nucleotidase in 11.9% (5/42), for haptoglobin in 36.3% (14/44), and for alkaline phosphatase in 9.5% of all patients (4/42). Three and six months later, these laboratory investigations did not give any valuable hint with respect to therapy results, with the exception of neuraminic acid (p less than 0.05). Prior to therapy, the concentrations of neuraminic acid were considerably increased in patients (mean = 3.16 +/- 0.47 mumol/ml) with regard to normal values (mean = 1.90 +/- 0.14 mumol/ml). Within the total group of 42 patients suffering from small cell bronchial carcinomas, there was no significant difference between the serum concentrations of neuraminic acid of eleven patients with localized tumors (mean = 3.12 +/- 0.53) and those of 31 advanced tumor patients (mean = 3.16 +/- 0.45) (p less than 0.05). During the six months' treatment period, the concentration of neuraminic acid was valuable as clinical parameter in 36 patients, i.e. 85% of all cases (0.001 less than p less than 0.01). It was shown that the serum concentration of neuraminic acid indicated a regression of the disease in 23 patients (p less than 0.001), a progression in 8 patients (0.02 less than p less than 0.05), and a regression with subsequent progression of the tumor in 5 patients (0.001 less than p less than 0.01).