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Purpose Early restenosis is one of the major complications after successful percutaneous transluminal angioplasty (PTA), in main, as well as peripheral, arteries. The effectiveness of hypofractionated external beam radiotherapy (EBRT) as a prophylaxis for restenosis was examined in a prospective, randomized, double-blind, clinical trial. Methods and materials Forty-eight patients underwent sham RT and 47 were treated with daily RT in 3-Gy fractions, to a total dose of 21 Gy. The follow-up lasted for 12 months, and the examinations included pressure measurements and calculations of the ankle-brachial index or duplex sonography ("peak velocity ratio"). If restenosis was suspected, additional angiography was performed. Results No statistically significant difference was found between the treatment groups: sham RT 16 failures (33.3%) and EBRT group 21 failures (45.7%; p = 0.292). EBRT also showed no substantial effects on subgroups classified by the specific length of the lesion or in diabetic patients. Conclusion External beam radiotherapy does not prevent restenosis. A reduction in the failure rate >8% using fractionated EBRT with doses aimed at keloid prevention can be ruled out with a probability of 97.5%. Endovascular brachytherapy remains the preferred therapeutic method for achieving restenosis prophylaxis through RT.

Purpose To evaluate the role of fractionated stereotactic conformal radiotherapy (FSRT) as a noninvasive method in the management of large chemodectomas of the skull base. Methods and materials Twenty-two patients with chemodectomas of the skull base were treated with FSRT at our institution. Ten patients received primary RT, and 12 patients were treated for recurrent or progressive disease after primary surgery (8 patients) or embolization (4 patients). The median total dose was 57.6 Gy, with a median of 1.8 Gy/fraction. The median target volume was 71.8 cm 3 (range, 10.5–212.2 cm 3 ). The most common symptoms at the initial diagnosis were pulsatile tinnitus (16 patients), hearing loss (14 patients), and balance disturbance (14 patients). Twelve patients had additional cranial nerve deficits. Results The median follow-up was 5.7 years (range, 19–177 months). The actuarial overall survival rate was 89.5% at 5 and 10 years. The actuarial local control rate was 90.4% at 5 and 10 years. Seven patients (32%) had a partial response and 13 (59%) had stable disease of the irradiated chemodectoma. Two symptomatic patients developed recurrence after 19 and 32 months. Neurologic dysfunction improved or completely resolved in 59% and stabilized in 32%; 9% of patients experienced impairment of preexisting neurologic dysfunction. No patient developed new neurologic deficits after FSRT. RT was interrupted in 1 patient because of a maxillary bone abscess. In all other patients, no acute or late adverse reactions greater than Common Toxicity Criteria Grade 2 were seen. Conclusion Fractionated stereotactic conformal radiotherapy is an effective and well-tolerated noninvasive treatment for chemodectomas, with excellent tumor control rates and a low risk of morbidity. It is an option for patients at greater risk of microsurgical resection or with residual and recurrent tumors.

The aim of this paper is to evaluate the benefit of inversely planned intensity modulated radiotherapy (IMRT) in the adjuvant irradiation of breast cancer when internal mammary lymph nodes are included in the treatment volume. 20 patients treated with 3D-planned conventional radiotherapy (CRT) following breast conserving surgery were included in the study. We chose 10 patients with left-sided and 10 patients with right-sided tumors. All treatment volumes included the internal mammary chain. For plan comparison to the applied CRT plan an inverse IMRT-plan in ‘step-and-shoot’-technique was calculated. For all patients IMRT resulted in an improved conformity of dose distribution to the target volume compared to CRT (mean COIN95: 0.798 vs. 0.514 with COIN95 = C1* C2 (C1= fraction of CTV that is covered by > 95% of the prescribed dose and C2 = volume of CTV that is covered by > 95% of the prescribed dose/total volume that is covered by > 95% of the prescribed dose). In all cases with matching adjacent beams, the homogeneity in the target volume was improved. The volume of the ipsilateral lung irradiated with a dose higher than 20 Gy was reduced with IMRT from 24.6% to 13.1% compared to CRT. For left-sided target volume the heart volume with a dose higher than 30 Gy was reduced from 6.2% to 0.2%. The presented plan comparison study for irradiation of the breast and the parasternal lymph nodes showed a substantial improvement of the dose distribution by inversely planned IMRT compared to CRT. This is visible for the target volume, the ipsilateral lung and, in case of left-sided target volume, the heart. Despite an increase in integral dose to the entire normal tissue, the application of IMRT might be clinically advantageous in cases where no satisfying dose distribution can be obtained by CRT.

To investigate the feasibility of raster scanned heavy charged particle therapy in the treatment of prostate cancer (PCa,) with special regard to the influence of internal organ motion on the dose distribution.The CT data of 8 patients with PCa who underwent three-dimensional conformal radiotherapy (RT) were chosen. In addition to the routine treatment planning scan, three to five additional positioning control CT scans were performed. The organs at risk and the target volumes were defined on all CT scans. Primary and boost carbon ion plans were calculated to deliver 66 Gy to the clinical target volume/planning target volume, with an additional 10 Gy to the gross tumor volume (GTV). To estimate the influence of internal organ motion on plan quality, the dose was recalculated on the basis of the control CT scans. The comparative analysis was based on the dose-volume histogram-derived physical parameters.The average 90% target coverage was 99.1% for the GTV. The maximal dose to the rectum was 71.8 Gy. The average rectal mean dose was 19 Gy. The volume of the rectum receiving 70 and 68 Gy was 0.1 and 0.3 cm3. The average difference in the 90% coverage for the GTV on control CT cubes was 3.6%. The maximal rectal dose increased to 76.2 Gy. The deviation in the mean rectal dose was1 Gy on average. The rectal volume receiving 70 and 68 Gy increased to 2.5 and 3.3 cm3.The investigation demonstrated the feasibility of raster scanned carbon ions for PCa RT. Excellent coverage of the target volume and optimal sparing of the rectum were acquired. The combination of photon intensity-modulated RT and a carbon ion boost to the GTV is the most rational solution for the gain of clinical experience in heavy ion RT for PCa patients.

Das Rektumkarzinom ist eines der haufigsten Malignome, wobei nicht selten jungere Manner erkranken. Wir untersuchten die radiogene Hodenbelastung durch Streustrahlung bei adjuvanter Beckenbestrahlung nach Operation eines Rektumkarzinoms. Die gemessenen Strahlendosen am Hoden wurden zu den Daten der Literatur in Beziehung gesetzt. Wir fuhrten bei 18 Patienten mit Thermolumineszenzdetektoren (TLD) In-vivo-Messungen zur Bestimmung der streustrahlenbedingten Gonadendosis durch. Die TLDs wurden an vier definierten Punkten des Skrotums fixiert. Die Bestrahlung erfolgte 3-D-geplant in Drei-Felder-Technik in Bauchlage im Lochbrett. Die Gesamtdosis betrug 50,4 Gy, die Einzeldosis 1,8 Gy taglich. Nach 45 Gy erfolgte eine Modifikation der Bestrahlungstechnik auf opponierende und kranial verkurzte Gegenfelder zur kompletten Dunndarmschonung. Die mittlere Gonadendosis aller 18 Patienten pro Bestrahlungsfraktion betrug 0,057 Gy (median 0,05 Gy), wobei die Mittelwerte der einzelnen Patienten zwischen 0,035 und 0,114 Gy lagen. Die Standardabweichung betrug 0,02 Gy. Nach 28 Fraktionen, 50,4 Gy entsprechend, errechnete sich kumulativ eine Gesamtdosis am Hoden von 1,60 Gy (0,98–3,19 Gy). Das mannliche Keimepithel reagiert auf Bestrahlung auserordentlich sensibel im Sinne eines negativen Fraktionierungseffektes. Bei Gesamtdosen > 1,5 Gy, fraktioniert appliziert, gilt die Azoospermie als meist irreversibel. Die von uns ermittelte Gonadendosis fuhrt nach den Daten der Literatur sehr wahrscheinlich zu einer dauerhaften Sterilitat. Wegen der geringen Patientenanzahl sind die Daten vorsichtig zu interpretieren, dennoch muss der Patient uber die hohe Wahrscheinlichkeit einer bleibenden Infertilitat aufgeklart werden. Eine mogliche pratherapeutische Spermakryokonservierung sollte mit dem Patienten besprochen werden.

Debus, J., Scholz, M., Haberer, T., Peschke, Jakel, O., Karger, C. P. and Wannenmacher, M. Radiation Tolerance of the Rat Spinal Cord after Single and Split Doses of Photons and Carbon Ions. Radiat. Res. 160, 536–542 (2003). The sensitivity of the rat spinal cord to single and split doses of radiation and the resulting relative biological effectiveness (RBE) were determined for carbon-ion irradiations (12C) in the plateau and Bragg-peak regions. The cranial part of the cervical and thoracic spinal cords of 180 rats were irradiated with one or two fractions of 12C ions or photons, respectively. Dose–response curves for the end point symptomatic myelopathy were established, and the resulting values for the ED50 (dose for 50% complication probability) were used to determine the RBEs. A median latency for myelopathy of 167 days (range, 121–288 days) was found. The ED50 values were 17.1 ± 0.8 Gy, 24.9 ± 0.7 Gy (one and two fractions, 12C plateau) and 13.9 ± 0.8, 15.8 ± 0.7 Gy (one and two fractions, 1...

Intensity-modulated radiotherapy (IMRT) provides better sparing of normal tissue. We evaluated the optimum beam configuration for IMRT based on inverse treatment planning in adjuvant radiotherapy for breast cancer in a case of left-sided tumor. In addition to radiotherapy planning with the conventional technique of tangential wedged 6-MV photon beams and an oblique 15-MeV electron beam, we performed inversely planned IMRT with the step-and-shoot-technique. Dose calculation was carried out using the treatment planning system Virtuos with the inverse optimization module KonRad adapted to it. IMRT plans were generated for 2 to 16 beams. The results were compared with conventional techniques. For a maximum treatment time of 20 minutes, it is shown that IMRT with 12 modulated photon beams and 7 intensity steps is best suited for treatment in the presented case. Compared with a conventional technique with photons combined with electrons, dose conformality and homogeneity of the planning target volume was increased. The mean heart dose was reduced from 9.1 Gy to 6.1 Gy. The volume of heart irradiated with a dose higher than 30 Gy was reduced from 7.6% to 1.9%, and the volume of the left lung from 13.6% to 11.5% as well. Inverse optimization for IMRT with multiple beams is feasible in the adjuvant treatment of breast cancer. Because of the reduction of the high-dose area of a substantial cardiac volume, it is superior to conventional techniques in cases where the parasternal lymph nodes should be integrated into the target volume. Here, a clinical advantage might be detectable.

Objective: To compare the detection rates for rectal cancer cells in blood and bone marrow in patients with or without preoperative chemoradiation. Background Data: Previous reports have postulated a resistance of disseminated tumor cells to antiproliferative agents because of tumor cell dormancy. Methods: Blood samples from 142 patients (pre, intra-, and postoperative samples) and bone marrow samples from 127 patients undergoing resection of rectal adenocarcinoma were analyzed for tumor cells using a cytokeratin (CK) 20-reverse transcription polymerase chain reaction. The results were stratified according to preoperative therapy. Results: In patients without preoperative chemoradiation, tumor cell detection in blood and bone marrow correlated to tumor stage (Cochran Armitage trend test, P < 0.05). Tumor cells were detected in 34 of 103 (33%) bone marrow and 65 of 117 (55.6%) blood samples of patients without neoadjuvant treatment versus in 4 of 24 (16.7%) bone marrow and in 10 of 25 (40%) blood samples of patients with neoadjuvant treatment. The tumor cell detection rate was significantly lower in the group having undergone chemoradiation (binary logistic regression analysis, P < 0.05). The overall and disease-free survival were significantly worse in patients with tumor cell detection in the bone marrow after neoadjuvant therapy. Conclusions: Preoperative chemoradiation is associated with a decreased detection rate of rectal cancer cells in blood and bone marrow. These findings may explain the observed clinical benefit of patients with rectal cancer receiving chemoradiation. This is the first study suggesting that detection of disseminated rectal cancer cells may be useful for assessing the efficacy of neoadjuvant therapy.

Background: In three-dimensional (3-D) precision high-dose radiation therapy of lung tumors, the exact definition of the planning target volume (PTV) is indispensable. Therefore, the feasibility of a 3-D determination of respiratory lung tumor movements by the use of a multislice CT scanner was investigated. Patients and Methods: The respiratory motion of 21 lung tumors in 20 consecutively treated patients was examined. An abdominal pressure device for the reduction of respiratory movement was used in 14 patients. Two regions of the tumor were each scanned repeatedly at the same table position, showing four simultaneously acquired slices for each cycle. Stereotactic coordinates were determined for one anatomic reference point in each tumor region (Figure 1). The 3-D differences of these coordinates between the sequentially obtained cycles were assessed (Figure 2), and a correlation with the tumor localization was performed. Results: In the craniocaudal (Z-)direction the mean tumor movement was 5.1 mm (standard deviation [SD] 2.4 mm, maximum 10 mm), in the ventrodorsal (Y-)direction 3.1 mm (SD 1.5 mm, maximum 6.7 mm), and in the lateral (X-)direction 2.6 mm (SD 1.4 mm, maximum 5.8 mm; Figures 3 to 5). Inter- and intraindividual differences were present in each direction. With an abdominal pressure device no clinically significant difference between tumors in different locations was seen. Conclusion: The 3-D assessment of lung tumor movements due to breathing is possible by the use of multislice CT. The determination, indispensable to the PTV definition, should be performed individually for several regions, because of the inter- and intraindividual deviations detected.

To investigate the role of irradiated volumes at intraoperative radiation therapy in the development of ureteral injury in dogs.Sixteen beagle dogs were randomized to receive 30 Gy of intraoperative radiation therapy in the right ureter. Lead shielding ensured that different volumes were irradiated. Six dogs received a 4 x 12-cm field, five dogs a 4 x 8-cm field, and five dogs a 4 x 4-cm field. Follow-up included magnetic resonance (MR) imaging, clinical examination, and resting sequential renography. Twelve months after irradiation, the animals were killed, and autopsy was performed. Functional outcome was defined as MR imaging and renography findings and was evaluated statistically by using the Cochran-Armitage test at a.05 significance level.Twelve months after therapy, ureteral obstruction with consecutive hydronephrosis of the right kidney was observed in four of six animals that received the largest volume of irradiation. Two dogs that received the medium volume developed ureteral obstruction. None of the five dogs that received the smallest volume showed abnormal findings (P.05). The irradiated parts of the ureters in all dogs showed abnormal histopathologic findings, such as fibrosis.The probability of ureteral obstruction following intraoperative radiation therapy increases with the irradiated partial volume of the ureter.

Stereotactic radiosurgery is an alternative option to neurosurgical excision in the management of patients with brain metastases. We retrospectively analyzed patients with brain metastases of malignant melanoma who were treated at our institution for outcome and prognostic factors.64 patients with 122 cerebral metastases were treated with stereotactic radiosurgery between 1986 and 2000. Twelve patients (19%) showed neurologic symptoms at the time of treatment, and 46 patients (72%) had extracerebral tumor manifestation at that time. The median dose to the 80% isodose line, prescribed to encompass the tumor margin, was 20 Gy (range, 15-22 Gy).Neurologic symptoms improved in five of twelve symptomatic patients. 41 patients remained asymptomatic or unchanged in their neurologic symptoms. Only five patients (8%) temporarily worsened neurologically after therapy despite no signs of tumor progression. With a mean follow-up time of 9.4 months, actuarial local control was 81% after 1 year. There was a statistically significant dose and size dependency of local tumor control. Median actuarial survival after treatment was 10.6 months. Patients without extracerebral tumor manifestation showed a superior survival (p = 0.04).Despite high local tumor control rates, the prognosis of patients with cerebral metastases of malignant melanoma remains poor. Stereotactic radiosurgery has the potential of stabilizing or improving neurologic symptoms in these patients in a palliative setting.

Tumor doses > 70 Gy are needed for local control in adenoid cystic carcinomas. These tumor doses cannot be delivered if the tolerance doses to neighboring organs at risk (OAR) are respected. This treatment planning study investigates the physical advantage of combined photon intensity-modulated radiation therapy (IMRT) plus carbon ion boost compared to photon IMRT alone. Patients and Methods: For nine patients, treatment plans were generated using a) photon IMRT alone (integrated boost concept), and b) sum plans consisting of a photon IMRT plan and a carbon ion boost plan. 54 Gy were prescribed to the planning target volume 1 (PTV1), the boost volume (PTV2) received 72 Gy. The tolerance doses of the delineated OAR were strictly adhered to. Plan quality of IMRT plans and sum plans was compared using adequate physical parameters. Results: Both therapy techniques lead to highly conformal dose distributions that allow the prescription of the desired target doses. Target conformality and heterogeneity as well as target coverage for PTV1 are comparable for both techniques. The target coverage for PTV2 can be significantly improved using carbon ion beams (median 95% coverage 93.7% vs 87%; p = 0.039). Furthermore, the mean doses to the OAR can be reduced by 8.3% (median % reduction of mean doses to OAR; p = 0.00001) using carbon ions. Conclusions: The combination of photon IMRT with carbon ions improves the target coverage for the boost volume and offers better sparing of OAR close to the PTV2 (gross tumor volume) in comparison with photon IMRT alone. A clinical study has been initiated to evaluate whether these potential advantages translate into clinical benefit.

Weder die chirurgischen noch die strahlentherapeutischen Fortschritte konnten die Mortalitat des Osophaguskarzinoms signifikant senken. Die seit Jahrzehnten unbefriedigenden Ergebnisse von “Stahl und Strahl” motivieren zu multimodalen Therapiekonzepten.

The aim of this analysis is to evaluate the feasibility of inverse treatment planning and intensity modulated radiation therapy (IMRT) for head and neck cancer in daily clinical routine. A step and shoot IMRT approach was developed which allows the treatment of large target volumes without the need to use a split beam technique. By using the IMRT approach better protection of different organs at risk in the head and neck region may be achieved and an escalation of the dose in the tumor should be possible. We evaluated the feasibility of the treatment technique and the patient tolerance to the treatment. First clinical results are reported.Between 1999 and 2002, 48 patients with a carcinoma of the head and neck region were treated with curative intention. All patients were treated in a patient-specific Scotch-Cast mask. Patients who required treatment of the lymph node levels I-VI, were additionally positioned by a vacuum pillow in order to immobilize the upper part of the thorax. For inverse treatment planning, the software module KonRad was used which was integrated into the VIRTUOS planning system. Each treatment plan was verified using quantitative film dosimetry in a head and neck phantom. The step and shoot IMRT technique with a multileaf collimator integrated in a Primus (Siemens) accelerator was used for treatment. For all target volumes the whole target including the lymph nodes were covered completely by the IMRT treatment.The mean total dose for the target volumes of macroscopic disease ranged between 63.0 and 64.1 Gy. The mean total dose of microscopic disease ranged between 55.2 and 60.1 Gy. The mean percentage of planning target volume receiving90% of the prescribed dose ranged between 3.0 and 11.5%. For the treatment, the median number of beams was seven (range: five to nine). The time to deliver the treatment ranged between 9 and 18 min. The results of the verification revealed a mean deviation between measured and calculated absolute doses for the 48 patients of 0.1+/-1.4%. Including the phantom verification the IMRT treatment of the patients could be started approximately after five working days. The treatment was well tolerated by all patients. The 2-year actuarial overall survival was 92% and the 2-year actuarial local control rate was 93%. According to the Radiation Therapy Oncology Group (RTOG), no higher acute toxicity than Grade 3 was seen. Observation of the late effects revealed only one transient Grade 4 toxicity of the bone and only four patients had a xerostomia higher than Grade 1.The use of an inversely-planned and intensity-modulated step and shoot approach is feasible in clinical routine for head and neck tumors. Treatment could be applied as planned and no increased toxicity was found. Compared to other IMRT approaches for the head and neck region the used technique allows the treatment of the primary tumor and the lymph nodes level I-VI with only one intensity modulated treatment volume. The presented technique avoids to match conventional radiotherapy fields and IMRT fields, and therefore, reduce the risk of overdosage or underdosage at the matching line. Compared to conventional treatment techniques IMRT shows advantages in tumor dose and dose at the organs at risk.

Purpose To integrate MRI into CT-based 3D-brachytherapy treatment planning using a software system for image registration and fusion. Methods and Materials Sixteen patients with recurrent head-and-neck cancer, vulvar cancer, liposarcoma, and cervical cancer were treated with interstitial (n = 12) and endocavitary (n = 4) brachytherapy. CT and MRI scans were performed after implantation and prior to treatment planning. Image registration to integrate the CT and MR information into a single geometric framework was performed using a software algorithm based on mutual information. Conventional 3D-brachytherapy planning based on CT-information alone was compared to brachytherapy planning based on fused CT and MRI data. The accuracy of the image fusion was measured using predefined corresponding landmarks in the CT and MRI data. Results The presented automated algorithm proved to be robust and reliable (mean registration error 1.8 mm, range 0.8–4.1 mm, SD 0.9 mm). Tumor visualization was difficult using CT alone in all cases. Brachytherapy treatment planning based on fused CT and MRI data enabled better definition of target volume and risk structures as compared to treatment planning based on CT alone. Conclusions Image registration and fusion is feasible for afterloading brachytherapy treatment planning. Treatment planning based on fused CT and MRI data resulted in improved target volume and risk structure definition.

Eine 44-jahrige Patientin mit der Indikation zur Bestrahlung bei brusterhaltender Therapie eines Mammakarzinoms war zugewiesen worden, da bei ausgepragter Trichterbrust mit konventionellen Techniken keine zufrieden stellende Dosisverteilung erreicht werden konnte. Daher erfolgte die Bestrahlung als intensitatsmodulierte Strahlentherapie (IMRT) mit inverser Bestrahlungsplanung. Die IMRT wurde hinsichtlich der erzielten Dosisverteilung und der Durchfuhrtbarkeit mit konventionellen Techniken verglichen. Patientin und Methoden: Bei Tumorsitz rechts unten innen beinhaltete das Zielvolumen die rechte Restbrust und den ipsilateralen parasternalen Lymphabfluss. Nach inverser Optimierung erfolgte die Bestrahlung in “Step-and-shoot”-Technik mit zwolf IMRT-Feldern mit sechs Intensitatsstufen an einem 6-MV-Linearbeschleuniger. Es wurden 50,4 Gy im Zielvolumen appliziert. Zum Vergleich wurden Bestrahlungsplane in konventioneller Technik mit zwei tangentialen irregularen 6-MV-Photonen-Feldern (Technik A) und in kombinierter Form mit zusatzlichem 15-MeV-Elektronen-Feld (Technik B) erstellt. Untersucht wurden Konformitat und Homogenitat im Zielvolumen und die Dosisverteilung im Normalgewebe. Ergebnisse: Die Konformitat an beide Zielvolumina konnte mit IMRT erheblich verbessert werden. Die Homogenitat im Zielvolumen war nur geringgradig schlechter als mit Technik A. Das Lungenvolumen, das mehr als 20 Gy erhalt, konnte von 56,8% mit Technik A bzw. 40,1% mit Technik B auf 22,1% reduziert werden. Die Therapie wurde ohne nennenswerte Nebenwirkungen toleriert. Die mittlere Behandlungszeit pro Sitzung betrug 19,5 min. Schlussfolgerungen: Eine invers geplante IMRT in Vielfeldertechnik ist in der adjuvanten Situation beim Mammakarzinom einsetzbar. Im vorliegenden Fall einer Patientin mit Trichterbrust konnte im Vergleich zu konventionellen Techniken eine massive Dosisreduktion der ipsilateralen Lunge ohne Dosiseinbusen im Zielvolumen erreicht werden. Inwieweit der hohere technische Aufwand der IMRT bei der brusterhaltenden Therapie zu einem klinisch detektierbaren Vorteil fuhrt, wird derzeit im Rahmen einer kontrollierten Studie untersucht.

Purpose: To investigate outcome and toxicity after fractionated stereotactic radiation therapy (FSRT) in patients with craniopharyngiomas. Methods and Materials: Twenty-six patients with craniopharyngiomas were treated with FSRT between May 1989 and February 2001. Median age was 33.5 years (range: 5–57 years). Nine patients received FSRT after surgery as primary treatment, and 17 patients were irradiated for recurrent tumor or progressive growth after initial surgery. Median target dose was 52.2 Gy (range: 50.0–57.6 Gy) with conventional fractionation. Follow-up included MRI and neurologic, ophthalmologic, and endocrinologic examinations. Results: The median follow-up was 43 months (range: 7–143 months). The actuarial local control rate and actuarial overall survival rates were 100% and 100%, respectively, at 5 years and 100% and 83%, respectively, at 10 years. Four patients showed complete response, 14 patients showed partial response, and 8 patients remained stable. In 5 patients, vision improved after radiation therapy. Acute toxicity was mild. One patient required cyst drainage 3 months after radiotherapy. Late toxicity after radiotherapy included impairment of hormone function in 3 out of 18 patients at risk. We did not observe any vision impairment, radionecrosis, or secondary malignancies. Conclusions: FSRT is effective and safe in the treatment of cystic craniopharyngiomas. Toxicity is extremely low using this conformal technique.

Inverse treatment planning and intensity-modulated radiation therapy (IMRT) promise advantages in the treatment of tumors of the head and neck region. Currently published studies use IMRT only in the treatment of the primary tumor. In these studies, the lymph nodes of the neck were treated using conventional techniques. The feasibility of an IMRT technique with allows treatment of the complete target volume, including the primary tumor and lymph nodes, without a beam split is described.

The aim of this study was the validation of the visual image quality of electronic portal imaging devices (EPID) and conventional verification films from the point of view of the end-viewers of portal films, the radiotherapists. Material and Methods: The verification image was represented in two different forms, viz. an electronic portal image employing Siemens Beamview Plus® (on a computer monitor) and two different portal films using the conventional verification films CEA-TVS® and DuPont CQL-7® (on a negatoscope). A total of 270 image sets (simulation film and portal image) were evaluated by each radiotherapist, evaluation extending to 90 sets of each type of verification film. Each set was evaluated by three specialists in radiotherapy examining subjective visual image quality whereby the following aspects served as evaluation criteria: contrast, artifacts, determination of actual radiation field edge position, anatomical structures and main structural feature for the determination of treatment field position. In addition, the anatomical structures employed for visual feature correlation between reference and portal films were classified according to their importance. Results: In general the electronic portal image was rated significantly “visible” or better. Only the evaluation of artifacts showed an appreciable disadvantage for electronic portal imaging caused by physical artifacts due to radiographic technique and data processing aspects peculiar to the Siemens Beamview Plus 1.1.® and also caused by different image processing tools reducing physical artifacts and enhancing the visibility of anatomical structures and likewise of anatomical artifacts (e.g. intestinal gas). By calculating the Spearman correlation coefficient to detect a possible relationship between the different criteria of subjective visual image quality, the research demonstrated that artifacts when limited to a tolerable proportion had no significant impact on the other criteria. Conclusions: As data of EPIDS are digital, images can be postprocessed and enhanced in a wide variety of ways. Using this tool the electronic portal imaging device provides images that, in terms of visual image quality, are at least comparable to the two evaluated types of radiographic films and also have the added advantage that such images are stored and can be transferred electronically being presupposition for digital patient documentation.

Purpose: To evaluate the possibilities of an open low-field magnetic resonance imaging (MRI) scanner in external beam radiotherapy treatment (RT) planning. Methods and Materials: A custom-made flat tabletop was constructed for the open MR, which was compatible with standard therapy positioning devices. To assess and correct image distortion in low-field MRI, a custom-made phantom was constructed and a software algorithm was developed. A total of 243 patients (43 patients with non-small-cell lung cancer, 155 patients with prostate cancer, and 45 patients with brain tumors) received low-field MR imaging in addition to computed tomographic (CT) planning imaging between January 1998 and September 2001 before the start of the irradiation. Results: Open low-field MRI provided adequate images for RT planning in nearly 95% of the examined patients. The mean and the maximal distortions 15 cm around the isocenter were reduced from 2.5 mm to 0.9 mm and from 6.1 mm to 2.1 mm respectively. The MRI-assisted planning led to better discrimination of tumor extent in two-thirds of the patients and to an optimization in lung cancer RT planning in one-third of the patients. In prostate cancer planning, low-field MRI resulted in significant reduction (40%) of organ volume and clinical target volume (CTV) compared with CT and to a reduction of the mean percentage of rectal dose of 15%. In brain tumors, low-field MR image quality was superior compared with CT in 39/45 patients for planning purposes. Conclusions: The data presented here show that low-field MRI is feasible in RT treatment planning when image correction regarding system-induced distortions is performed and by selecting MR imaging protocol parameters with the emphasis on adequate images for RT planning.

A restrospective study of patients with brain metastases from non-small cell lung cancer (NSCLC) is performed to identify patients who benefit from radiosurgery and to determine prognostic factors for survival. Eighty-six consecutive patients with a total of 110 brain metastases from NSCLC were treated with linac-based radiosurgery. Six patients with eight brain metastases who received radiosurgery as a focal boost to whole brain radiotherapy where excluded. Median age at treatment was 60 years. Median dose was 20 Gy/80%-isodose. A chi(2)-test was used to identify potential prognostic factors for local control of brain metastases and survival of the patients. Median follow-up was 6 months (range 1 1/2-77 months) with 17/80 patients still alive. Median actuarial survival was significantly longer (P0.004) in patients with metachronous onset of brain metastases in comparison to synchronous onset (8.3 vs. 3.3 months). Survival was significantly increased after radiosurgery in the absence of extracranial tumor progression (P0.03). Eleven patients (14%) developed new brain metastases after radiosurgery after a latency of median 5 months. Actuarial local control rate was 96% after 3 months. Local control was significantly increased with a prescribed doseor=18 Gy/80%-isodose (P0.01). We conclude that especially patients with poor prognostic factors and a limited number of brain metastases may be palliatively treated with radiosurgery alone. This approach allows to effectively control CNS manifestation of the disease and can be integrated into chemotherapeutic protocols.

Current methods for intensity-modulated radiotherapy (IMRT) in breast cancer use forward planning based on equivalent radiological path length to design intensity modulated tangential beams. Compared to conventional tangential techniques, dose reduction of organs at risk is limited using these techniques. We developed a method for intensity modulation of multiple beams for adjuvant radiotherapy of breast cancer by application of a virtual bolus defined on CT for inverse optimization. This method enables multibeam IMRT, which provides improved sparing of lung and heart tissue. In this paper, we present the general aspects of this approach and an evaluation of the optimum beam configuration for IMRT based on inverse treatment planning. We compared this method to conventional techniques. Different clinical examples illustrate the possible indications and feasibility of this new approach. This method is superior to conventional techniques because of the reduction of high-dose area of a substantial cardiac volume in those cases where the parasternal lymph nodes are part of the target volume.

Purpose: Compared to photon irradiation, carbon ions provide physical and biologic advantages that may be exploited in chordomas and chondrosarcomas. Methods and Materials: Between August 1998 and December 2000, 37 patients with chordomas ( n = 24) and chondrosarcomas ( n = 13) were treated with carbon ion radiotherapy within a Phase I/II trial. Tumor conformal application of carbon ion beams was realized by intensity-controlled raster scanning with pulse-to-pulse energy variation. Three-dimensional treatment planning included biologic plan optimization. The median tumor dose was 60 GyE (GyE = Gy × relative biologic effectiveness). Results: The mean follow-up was 13 months. The local control rate after 1 and 2 years was 96% and 90%, respectively. We observed 2 recurrences outside the gross tumor volume in patients with chordomas. Progression-free survival was 100% for chondrosarcomas and 83% for chordomas at 2 years. Partial remission after carbon ion radiotherapy was observed in 6 patients. Treatment toxicity was mild. Conclusion: These are the first data demonstrating the clinical feasibility, safety, and effectiveness of scanning beam delivery of ion beams in patients with skull base tumors. The preliminary results in patients with skull base chordomas and low-grade chondrosarcomas are encouraging, although the follow-up was too short to draw definite conclusions concerning outcome. In the absence of major toxicity, dose escalation might be considered.

Ziel der Studie war die Erfassung moglicher Veranderungen der neuropsychologischen Leistungsfahigkeit nach Ganzhirnbestrahlung.

Die intensitatsmodulierte Strahlenbehandlung (IMRT) verspricht eine verbesserte Schonung fur Risikostrukturen. Wir untersuchten, in welcher Form eine inverse Bestrahlungsplanung zur IMRT der Restbrust beim Mammakarzinom durchfuhrbar ist. Methodik: Neben einer Bestrahlungsplanung in konventionller Technik mit tangentialen 6-MV-Keilfilter-Feldern wurde eine IMRT-Bestrahlungsplanung mit inverser Planoptimierung (KonRad®) durchgefuhrt. Im Planungs-CT wurde ein Bolus von 10 mm Dicke und einer Dichte von −60 HE definiert. Der Einfluss des Bolus auf die Planoptimierung wurde bestimmt, indem die Optimierung ohne Bolus, die nachfolgende Dosisberechnung ohne und mit Bolus durchgefuhrt wurden. Um den Einfluss des Bolus auf die Dosisberechnung zu bestimmen, erfolgte nach Optimierung mit Bolus eine Dosisberechnung ohne Bolus und mit verschiedenen Bolusdicken. Die Planungsergebnisse wurden jeweils mit der Dosisverteilung einer konventionellen Bestrahlung verglichen. Ergebnisse: Die inverse Planungsoptimierung mit einem Dosisalgorithmus, der Gewebeinhomogenitaten berucksichtigt, fuhrt zu einer erhohten Hautbelastung. Diese lasst sich reduzieren, indem man ausschlieslich zur inversen Optimierung einen Hilfsbolus verwendet. Es lasst sich damit eine Hautschonung entsprechend der konventionellen Therapie erreichen. Die Relativdosisverteilung bleibt von der Verwendung des Bolus bei einer Dicke von 10 mm weitgehend unbeeinflusst. Die Absolutdosis unterscheidet sich bei Dosisberechnung mit und ohne Bolus um 3,4%. Daher muss der Bolus im Sinne eines virtuellen Bolus vor der abschliesenden Dosisberechnung wieder entfernt werden. Schlussfolgerungen: Zur inversen Optimierung einer IMRT der Restbrust ist ein virtueller Bolus erforderlich. Damit ist eine IMRT-Bestrahlung gemas Konsensus von EORTC, BCCG und EUSOMA (1991) moglich. Insbesondere kann die gleiche Zielvolumendefinition wie bei der konventionellen Therapie verwendet werden. Es sind hiermit IMRT-Techniken in konventioneller Feldgeometrie und in Vielfeldertechnik realisierbar.

In a case of partially resected sacral chordoma, the planning target volume (PTV) received 60 Gy and the gross target volume (GTV) 72 Gy using inversely planned, intensity-modulated, radiation therapy (IMRT). IMRT was compared with 3D-conformal radiotherapy (CRT). With IMRT, it was found that dose distribution is more homogeneous within the PTV outside the GTV and allows simultaneous dose escalation within the GTV. The volume of bowel receiving a dose higher than 40 Gy was reduced from 400 cc with CRT to 220 cc with IMRT. If particle therapy is not available, IMRT seems to be a promising alternative in the treatment of sacral chordomas.

Purpose: To evaluate survival rates and side effects after stereotactically-guided radiotherapy (SRT) in patients with recurrent medulloblastoma of the brain.

To investigate the patterns of failure and survival after involved-field or more extensive radiotherapy for centroblastic-centrocytic non-Hodgkin's lymphoma (NHL) as well as the impact of radiotherapy dose on local control.47 patients with Stage I-III centroblastic-centrocytic NHL were treated with involved-field (IF) extended-field radiotherapy (EF-RT) or total lymphatic irradiation (TLI). The involved regions received 25.5-50 Gy, non-involved regions were treated with a dose of 26 Gy in most cases.In Stage I/II, the majority of relapses (64%) were nodal and were located adjacent or distant to the former radiation portals. 79% of relapses occurred after IF-RT, 21% after EF-RT or TLI. 5-year overall survival (OAS) after EF-RT/TLI and IF-RT for Stages I/II was 85% and 83%, respectively (n.s.); relapse free survival (RFS) was 73% and 61%, respectively (n.s.). A tendency for better overall survival was found for patients who relapsed at one or two sites (5-year overall survival 100%) compared to patients with three or more relapse sites (5-year overall survival 0%). For Stage III overall survival was 72%, freedom from progression (FFP) was 27% at 5 years. We found a dose-effect correlation for local control with a relapse rate of 31% after 26-34 Gy and 4% after application of 36 Gy; no relapses occurred after doses of 40 Gy or more.In involved lymph node regions a relatively small number of relapses was observed after application of a minimal dose of 36 Gy. In Stages I/II most relapses were located outside the radiation portals, yet EF-RT was not superior to IF-RT in terms of overall survival and relapse free survival. Prospective randomized trials are necessary to prove a potentially favorable effect of more extended radiotherapy portals (TLI or TNI [total nodal irradiation]) and to evaluate the optimal radiotherapy dose.

Purpose: To assess regional cerebral blood volume (rCBV) as a surrogate marker of angiogenesis in patients with low-grade fibrillary astrocytoma before radiation therapy and to correlate measured values with clinical outcome after fractionated stereotactic radiotherapy (FSRT). Methods: Twenty-five patients with histologically proven fibrillary astrocytomas were examined using dynamic susceptibility contrast-enhanced MRI before radiotherapy. Radiotherapy was delivered to mean and median total doses of 60.9 and 60 Gy, respectively (range 55.8–66 Gy). During MRI for treatment planning, 55 T2∗-weighted gradient echo images were acquired before, during, and after i.v. contrast-bolus injection. The acquired signal-time curves were converted into concentration-time curves. By normalization to an arterial input function, absolute and relative rCBV values were calculated. Measured pretherapeutic rCBV data were correlated to outcome in terms of local control after FSRT. Results: Mean pretherapeutic rCBV for astrocytomas was 6.5 ± 3.7 ml/100 g tissue. Mean and median follow-up times were 47.8 and 52 months, respectively. Fifteen tumors recurred during the period, with a mean and median latency of 39.1 and 42 months, respectively. Tumors recurring earlier than 42 months after FSRT showed a higher pretreatment rCBV than tumors recurring later and tumors in continued local control (8.12 ± 4.48 ml/100 g vs. 6.0 ± 2.3 ml/100 g and 4.73 ± 2.47 ml/100 g; p = 0.02 and p = 0.03). The respective ratios of tumor rCBV in early recurrent tumors to gray matter and white matter rCBV were 0.98 ± 0.38 and 2.17 ± 1.36 as compared with 0.79 ± 0.14 and 1.44 ± 0.29 in locally controlled tumors ( p = 0.074 and p = 0.056). Conclusions: In fibrillary low-grade astrocytomas, a noninvasive assessment of angiogenesis as indicated by rCBV measurement was feasible. The present data suggest that high pretherapeutic angiogenic activity in low-grade astrocytomas indicates a subgroup of tumors at higher risk for early local recurrence or malignant transformation after FSRT.

Purpose: We evaluated survival rates and side effects after fractionated stereotactically guided radiotherapy (SCRT) and radiosurgery in patients with pituitary adenoma. Methods and Materials: Between 1989 and 1998, 68 patients were treated with FSRT (n = 63) or radiosurgery (n = 5) for pituitary adenomas. Twenty-six had functional and 42 had nonfunctional adenomas. Follow-up included CT/MRI, endocrinologic, and ophthalmologic examinations. Mean follow-up was 38.7 months. Seven patients received radiotherapy as primary treatment and 39 patients received it postoperatively for residual disease. Twenty-two patients were treated for recurrent disease after surgery. Mean total dose was 52.2 Gy for SCRT, and 15 Gy for radiosurgery. Results: Overall local tumor control was 93% (60/65 patients). Forty-three patients had stable disease based on CT/MRI, while 15 had a reduction of tumor volume. After FSRT, 26% with a functional adenoma had a complete remission and 19% had a reduction of hormonal overproduction after 34 months’ mean. Two patients with STH-secreting adenomas had an endocrinologic recurrence, one with an ACTH-secreting adenoma radiologic recurrence, within 54 months. Reduction of visual acuity was seen in 4 patients and partial hypopituitarism in 3 patients. None of the patients developed brain radionecrosis or radiation-induced gliomas. Conclusion: Stereotactically guided radiotherapy is effective and safe in the treatment of pituitary adenomas to improve local control and reduce hormonal overproduction.

PURPOSE: Large skull-base meningiomas are difficult to treat due to their proximity or adherence to critical structures. We analyzed the long-term results of patients with skull-base meningiomas treated by a new approach with high-precision fractionated stereotactic radiotherapy. PATIENTS AND METHODS: One hundred eighty-nine patients with benign meningiomas were treated with conformal fractionated stereotactic radiotherapy between 1985 and 1998. Patients were undergoing a course of radiotherapy either as primary treatment, following subtotal resection, or for recurrent disease. The median target volume was 52.5 mL (range, 5.2 to 370 mL). The mean radiation dose was 56.8 Gy (± 4.4 Gy). Follow-up examinations, including magnetic resonance imaging, were performed at 6-month intervals thereafter. RESULTS: The median follow-up period was 35 months (range, 3 months to 12 years). Overall actuarial survival for patients with World Health Organization (WHO) grade I meningiomas was 97% after 5 years and 96% after 10 years. Local tumor failure was observed in three of 180 patients with WHO grade I tumors and was significantly higher in two of nine patients with WHO grade II tumors. A volume reduction of more than 50% was observed in 26 patients (14%). Preexisting cranial nerve symptoms resolved completely in 28% of the patients. Clinically significant treatment-induced toxicity was seen in 1.6% of the patients. No treatment-related deaths occurred. CONCLUSION: The results of this study demonstrate that fractionated stereotactic radiotherapy is safe and effective in the therapy of subtotally resected or unresectable meningiomas. The overall morbidity and incidence subacute and late side effects of this conformal radiotherapy approach were low.

Mit dieser Untersuchung werden Spateffekte nach einer kleinvolumigen radiochirurgischen Einzeitbestrahlung am Rattenhirn autoradiographisch und histomorphologisch charakterisiert.

Die Strahlentherapie spielt bei der kurativen Behandlung der Fruhstadien follikularer Keimzentrumslymphome die entscheidende Rolle. Therapiebegleitende Nebenwirkungen sind haufig Panzytopenie, Nausea und abdominelle Beschwerden. Eine radiogen induzierte Leberschadigung mit klinisch manifester Symptomatik und schwerer Leberfunktionsstorung ist dagegen auserst selten. Fallbeschreibung: Bei einem 49-jahrigen Patienten mit einem zentrozytisch-zentroblastischen Non-Hodgkin-Lymphom, Stadium IA (Lokalisation: linke Leiste) wurde die gesamte Abdomen- und Beckenregion (“abdominelles Bad”) bestrahlt. Bei einer wochentlichen Fraktionierung von funfmal 1,5 Gy wurde eine Gesamtdosis von 30 Gy appliziert. Zum Schutz der Risikoorgane wurden Nierenblocke nach 13,5 Gy und Leberblocke nach 25 Gy eingesetzt. Wahrend der letzten beiden Therapietage kam es zur Verschlechterung des Allgemeinzustandes des Patienten mit Gewichtszunahme, Vergroserung des Bauchumfangs, Dyspnoe und einem Anstieg der Leberwerte. Die weiterfuhrende Diagnostik ergab eine Hepatosplenomegalie mit ausgepragter Aszitesbildung und einen erhohten portosystemischen Druckgradienten. Im Leberbiopsat wurde eine Venenverschlusskrankheit gefunden. Innerhalb 1 Woche nach Anlage eines transjugularen intrahepatischen portosystemischen Stent-Shunts (TIPPS), Vollheparinisierung und unter Diuretikagabe war der Patient beschwerdefrei. Die Leberwerte sind im Normbereich. Schlussfolgerung: Die Venenverschlusskrankheit der Leber (VOD) ist eine sehr seltene Nebenwirkung bei der abdominellen Bestrahlung nicht vorbehandelter follikularer Keimzentrumslymphome. Bei Oberbauchbeschwerden, Anstieg der Leberenzyme sowie Aszitesbildung, insbesondere in einem Zeitraum von bis zu 4 Monaten nach Therapieabschluss, muss an diese Komplikation gedacht werden. Genese, Diagnostik und Therapie der Venenverschlusskrankheit der Leber werden im Literaturuberblick prasentiert.

Postoperative Metallartefakte sind ein groses Problem sowohl in der Diagnostik als auch in der Strahlentherapieplanung von Tumoren wie dem Chordom der Wirbelsaule da haufig weder CT noch MRT ausreichend exaktes Bildermaterial als Basis fur eine hochdosierte Radiotherapie liefern konnen. Wir untersuchten die Anwendung der CT-Myelographie zur Bestrahlungsplanung.

Purpose : To compare retrospectively radiotherapy with neutrons, photons, and a photon/neutron mixed beam in patients with advanced adenoid cystic carcinoma of the head and neck. Local control, survival, distant failure, and complications were analyzed. Materials and methods : Between 1983 and 1995, 75 patients with inoperable, recurrent, or incompletely resected adenoid cystic carcinoma of the head and neck received radiotherapy that consisted of either fast 14.1 MV DT neutrons (median dose 16 neutron Gy), linac-based photon irradiation (median dose 64 photon Gy), or both (median dose 8 neutron Gy and 32 photon Gy). Follow-up ranged from 1 to 160 months (median 51 months), and the surviving patients had a minimum follow-up of 3 years at the time of analysis. Results : The actuarial 5-year local control was 75% for neutrons, and 32% for both mixed beam and photons ( P =0.015, log-rank). This advantage for neutrons in local control was not transferred to significant differences in survival ( P >0.1). The survival is dictated by the tumor diseases due to distant metastases occurring in 29 (39%) of the 75 patients. Positive lymph nodes were the only significant factor ( P =0.001) associated with the development of distant metastases although negative lymph nodes did not predict absence of distant metastases, but predicted a delay of occurrence. In multivariate analysis postoperative radiotherapy ( P =0.003) and small tumor size ( P =0.01) were associated with high local control, while primary therapy ( P =0.006) and negative lymph nodes ( P =0.01) were associated with longer survival. While acute toxicity was similar in all three radiotherapy groups, severe late grade 3 and 4 toxicity tended to be more prevalent ( P >0.1) with neutrons (19%) than with mixed beam (10%) and photons (4%). Conclusion : Fast neutron radiotherapy provides higher local control rates than a mixed beam and photons in advanced, recurrent or not completely resected adenoid cystic carcinoma of the major and minor salivary glands. Neutron radiotherapy can be recommended in patients with bad prognosis with gross residual disease (R2), with unresectable tumors, or inoperable tumors. The type of radiation does not impact survival, which is dominated by the high number of distant metastases.

We report our long-term experience with autologous bone marrow transplantation (ABMT) for 32 adult patients with acute lymphocytic leukaemia (ALL) in second or later remission (CR), or in first CR but with high-risk. Bone marrow was purged with mafosfamide (n = 25) or with immunomagnetic beads and monoclonal antibodies (n = 7). Retrospective analysis showed that 12 out of 32 patients were in continuous complete remission (CCR) at a median of 143 months (range 66-181 months). A plateau was reached at 50 months and the disease-free and overall survival rates were both 37.5%. It was notable that durable CCR could be achieved for patients in second (three out of nine) or third (one out of six) CR. ABMT could produce durable CCR and the long-term outcome compared favourably with those reported for allogeneic transplantation.

Purpose: We report in a retrospective study on the effect and toxicity of chest wall reirradiation using pulsed-dose-rate (PDR) afterloading molds. Methods and Materials: Between 1993 and 1999, a total of 58 patients were treated. All patients presented with locally recurrent breast cancer (31 patients had concomitant distant metastases) after mastectomy and a previously completed course of radiation therapy (median, 54 Gy; range, 36–70). Indication for reirradiation was a progressive macroscopic skin recurrence in 30 cases and an incomplete surgical resection in 28 patients. Standard treatment consisted of a split course with two fractions of 20 Gy (interval, 31 days). The reference dose was prescribed to the skin surface at 5 mm distance from the source. PDR brachytherapy (37 GBq, 192 Ir) was carried out after geometric distance optimization with 0.5–1 Gy/pulse/h. The irradiated median area was 423 cm 2 (range, 100–919). The median follow-up was 18 months (range, 7–84). Results: The actuarial 1-, 2- and 3-year local recurrence-free survival rates in patients treated for macroscopic disease (microscopic disease in parenthesis) were 89% (96%), 81% (85%), and 75% (71%). Local control was obtained in 24/30 (22/28) patients. Twenty-nine of the 34 patients (85%) who deceased during follow-up were locally controlled. 9/58 patients experienced Grade III acute toxicity, 35/58 patients Grade III (29/58 telangiectasia, 6/58 contracture), and 4/58 Grade IV late toxicity (RTOG/EORTC). Conclusion: Reirradiation of the chest wall using PDR brachytherapy molds is effective and provides a high local control rate with acceptable toxicity.

Local recurrence following potentially curative tumor resection is a major problem in patients with gastrointestinal cancer. To augment surgical excision and to avoid the disadvantages of external beam irradiation, intraoperative radiotherapy (IORT) has been applied to primary and recurrent gastrointestinal cancer, both with curative intent and for palliation. There is ample evidence that the combination of radical surgery and IORT can improve local control. Whether this eventually can translate into improved overall survival has not yet been studied in adequately powered randomized and controlled trials. Semin. Surg. Oncol. 20:40–49, 2001. © 2001 Wiley-Liss, Inc.

Purpose: Analysis of local tumor control and functional outcome following conventionally fractionated stereotactic radiotherapy (FSRT) for acoustic neuromas. Patients and Methods: From 11/1989 to 9/1999 51 patients with acoustic neuromas have been treated by FSRT. Mean total dose was 57.6 ± 2.5 Gy. Forty-two patients have been followed for at least 12 months and were subject of an outcome analysis. Mean follow-up was 42 months. We analyzed local control, hearing preservation, and facial and trigeminal nerve functional preservation. We evaluated influences of tumor size, age, and association with neurofibromatosis Type 2 (NF2) on outcome and treatment related toxicity. Results: Actuarial 2- and 5-year tumor control rates were 100% and 97.7%, respectively. Actuarial useful hearing preservation rate was 85% at 2 and 5 years. New hearing loss was diagnosed in 4 NF2 patients. Pretreatment normal facial nerve function was preserved in all cases. Two cases of new or impaired trigeminal nerve dysesthesia required medication. No other cranial nerve deficit was observed. In Patients without NF2 tumor size or age had no influence on tumor control and cranial nerve toxicity. Diagnosis of NF2 was associated with higher risk of hearing impairment ( p = 0.0002), the hearing preservation rate in this subgroup was 60%. Conclusion: FSRT has been shown to be an effective means of local tumor control. Excellent hearing preservation rates and 5th and 7th nerve functional preservation rates were achieved. The results support the conclusion that FSRT can be recommended to patients with acoustic neuromas where special attention has to be taken to preserve useful hearing and normal cranial nerve function. For NF2 patients, FSRT may be the treatment of choice with superior functional outcome compared to treatment alternatives.