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Purpose : To review the survival, cure rate, and pattern of relapse or progression of patients with histologically confirmed Stage I testicular seminoma who inderwent orchiectomy and radiation therapy to paraaortic lymphatics only. The pelvic ipsilateral lymph nodes were not irradiated. Methods and Materials : Between 1978 and 1992, 150 patients with Stages I or II testicular seminoma received treatment at the Department of Radiation Oncology of the University of Wuerzburg. The distribution by stage was Stage I, 117 patients of which 93 were pT1 N0 M0 and 24 were pT2 N0 M0. Four patients were staged as Stage II (pT3 N0 M0), and in 29 patients the T Stage was not specified. Eighty-six patients from the 117 Stage I (pT1-pT2, N0 M0 according to the TNM classification) seminoma received postorchiectomy irradiation, and are analyzed for outcome in this article. The distribution of the Stage I patients by pT Stage was 71 pT1 and 15 pT2 patients. All these 86 patients had their paraaortic nodes (the bioligical target volume extending from top of L1 to the bottom of L5) irradiated with four field technique. Tumor dose was specified at normalization point along the central axis. The median tumor dose was 30 Gy given in 1.8−2.0 Gy fractions. Elective irradiation to the ipsilateral hemipelvis (iliac nodes) was totally abandoned. Results : The 10-year disease-free survival and overall survival were 95.3 and 100%. No recurrence in the irradiated field was noted. Four patients (4.7%) experienced relapse of disease outside the treated volume. The most common site of solitary failure was the ipsilateral hemipelvis (one iliacal and one inguinal). One patient developed metastatic disease to the lung. One patient developed a mediastinal recurrence with superior vena cava syndrome and was successfully salvaged by mediastinal irradiation and chemotherapy. Conclusion : Recommendation for the future management of Stage I seminoma include: reduced biological target volume to the paraaortal lymph nodes (from lumbar vertebra L1 to L5). Compute elimination of irradiation to the pelvic nodes is warranted. Radiation dose should no exceed 30 Gy.

Purpose: To define the patterns of failure and outcome of patients presenting supraclavicular lymph node involvement and the prognostic significance of supraclavicular lymph node involvement. Methods and Materials: We reviewed the history of 795 breast cancer patients treated at the Department of Radiation Therapy, University of Wurzburg between 1978 and 1988. The clinical and pathologic features of 21 patients who had ipsilateral supraclavicular lymph node metastases at primary diagnosis and 38 patients who presented supraclavicular lymph node recurrence during the course of disease were reviewed. These were compared with the features of 20 patients who initially had M 1 status at primary diagnosis and 278 patients who had developed distant metastases in the follow-up period. Survival rates were calculated starting from the time of diagnosis of supraclavicular involvement respective of distant metastases. Results: Survival from appearance of supraclavicular lymph node metastases at primary diagnosis or as a recurrence is not different from survival of patients presenting with a primary M 1 stage or presenting distant metastases during the course of disease. Two and 5-year survival rates of patients with supraclavicular lymph node involvement at primary diagnosis were 52% and 34% compared to 50% and 16% 2- and 5-year survival rate of patients with supraclavicular lymph node involvement as a recurrence. Patients who presented a primary M 1 -status had 2- and 5-year survival rates of 56% and 24%. Survival of patients with distant metastases calculated from the onset of metastatic disease was similar to that of the other three groups with a 46% and 16% survival rate at 2 and 5 years. There was no difference in survival rates between the four groups. Conclusion: The prognostic significance of suproclavicular lymph node involvement at primary diagnosis or as a relapse is similar, both have the same significance as the first distant relapse and are characterized by a poor prognosis.

Patients with metastatic breast cancer are considered as a homogeneous group because of the relative rarity of data relating to specific organ metastases. In this study, the clinical course of metastatic breast cancer was documented for 278 female patients registered from 1978 through 1988 at the Clinic for Radiotherapy of the University of Wurzburg. We analysed these 278 patients with metastatic disease to work out the clinical significance of specific organ metastases (SOM). A comparison of the six most frequent specific organ metastatases (SOM), i.e., bone, lung, CNS, liver, lymph node and skin metastases, is presented. Our findings indicate, that the group of patients with metastatic disease is heterogenous relating to age at time of metastatic disease, to metastatic-free intervall and to the influence of specific organ metastases on survival. The heterogeneity in the group of patients with distant metastatic disease has to be taken in consideration, when the results of chemotherapy are reported.

Sixty-two breast cancer patients with central nervous system (CNS) metastases were reviewed. The CNS was the first site of metastatic involvement in 38 cases (61%). The median survival from the primary diagnosis was 3.0 years; from the diagnosis of the CNS metastasis, 6 months. The interval between primary diagnosis and CNS metastasis had a median value of 2.0 years; between the initial extra-cranial metastasis and CNS metastasis this was 0.9 years. Prognostic factors for the appearance of CNS metastasis could not be identified. Subsequent to CNS metastasis appearing, the well-known prognostic factors for the survival time and the metastasis-free interval lose their importance. Brain metastases occur, above all, in patients aged between 50 and 55 years, very often in the first 2.5 years after the first distant metastasis and not later than 10 years from the primary diagnosis.

Follicle centre lymphoma grade I, II (REAL) or centroblastic-centrocytic lymphoma (Kiel classification) present a well defined clinical entity from a clinical point of view. These lymphomas are not curable by chemotherapy in early or advanced stages. They are treated by radiation therapy in early stages, but up to now the curative potency of radiotherapy has not been confirmed by prospective clinical trials.Between January 1986 and August 1993 117 adults with follicle centre lymphoma were recruited from 24 institutions to enter the multicentric prospective, not randomised clinical trial. Patients with histologically proven nodal follicle centre lymphoma of stages I, II and limited III were included. They were treated by a standardised radiotherapy regimen, in stage I by extended field and in stages II and III by total nodal irradiation. Dose per fraction was 1.8 to 2.0 Gy, in the abdominal bath 1.5 Gy up to a total dose of 26 Gy in adjuvant situation and 36 Gy to enlarged lymphoma.All patients developed a complete remission at the end of radiotherapy. Median follow-up is 68 months. Overall survival of all patients in 86 +/- 3% at 5 and 8 years. Stage adjusted survival at 5 and 8 years was 89% for stage I, 86% for stage II and 81% for III. Patients in stages I and II60 years had survival rates of 94% at 5 and 8 years, patients60 years 63% (p0.0001). Recurrence free survival of all patients is 70% at 5 and 60 +/- 5% at 8 years. The number of recurrences is high with 29% at 5 and 41% at 8 years. All recurrences were seen within 7 years. The probability of localised nodal in-field recurrences is 11% and 22% at 5 and 8 years, respectively. Adverse prognostic factors were identified by multivariate analysis: age60 years, treatment breaksor = 7 days and dose deviations20% from prescribed doses. Acute side effects of extended field irradiation were moderate.On the basis of these results radiotherapy is a potentially curative therapeutic approach in stages I, II and limited III of follicle centre lymphoma. The optimal technique is total lymphoid irradiation with doses of 30 Gy in the adjuvant situation and 40 to 44 Gy in enlarged lymphomas. The number of local recurrences leads to the assumption, that the extension of radiotherapy to the total lymphoid system might reduce their frequency.

To analyse if prophylactic cranial irradiation in small cell lung cancer for improved survival is indicated; if adjuvant irradiation could cure the microscopic disease; if and how late effects could be minimized.Data from randomized trials and retrospective studies are critically analysed related to the incidence of central nervous system (CNS) metastases in limited disease patients in complete remission with or without prophylactic cranial irradiation. The mechanisms of late effects on CNS of prophylactic cranial irradiation and combined treatment are presented.Prophylactic cranial irradiation could decrease the incidence of CNS metastases but could not improve survival. A subgroup of patients (9 to 14%) most likely to benefit from prophylactic cranial irradiation includes patients who are likely to have an isolated CNS failure. The actual used total dose in the range 30 to 40 Gy could only conditionally decrease the CNS failure. Higher total and/or daily doses and combined treatment are related with potentially devastating neurologic and intellectual disabilities.No prospective randomized trial has demonstrated a significant survival advantage for patients treated with prophylactic cranial irradiation. Prophylactic cranial irradiation is capable of reducing the incidence of cerebral metastases and delays CNS failure. A subgroup of patients most likely to benefit from prophylactic cranial irradiation (9 to 14%) includes patients who are likely to have an isolated CNS failure, but this had yet to be demonstrated. The toxicity of treatment is difficult to be influenced. Prophylactic cranial irradiation should not be given concurrently with chemotherapy, a larger interval after chemotherapy is indicated. The total dose should be in the range 30 to 36 Gy and the daily fraction size not larger than 2 Gy.

An analysis of the incidence of brain metastases in small cell lung cancer, time of occurring during the course of disease, and the prognosis of these patients depending on the use of prophylactic cranial irradiation for three well defined patient groups.A retrospective study included 133 unselected patients with histologically proven SCLC who were treated from 1985-1990 in our department. From these, 118 patients without CNS metastases at primary diagnosis were divided into three well defined patient groups: group I consisted of 23 patients who achieved a complete remission after primary therapy and who were subsequently treated with PCI, group II consisted of 23 patients in complete remission without PCI. Group III consisted of 72 patients without CNS metastases at the primary diagnosis and without PCI treatment since they did not achieve a complete response after primary therapy. The primary therapy consisted of combined radiochemotherapy or only chemotherapy. Sixteen patients were treated only by irradiation.The overall incidence of CNS metastases for all 133 patients was 33.1%. The incidence of new CNS metastases in group I was 21.7% in group II 26.1%, and in group III 22.2%. The average time to development of CNS metastases after primary diagnosis was different for the three groups: in group I 15.4 months, in group II 9.5 months and in group III 8.4 months. No statistical significance was noted. Median survival time for group I was 16.1 months, for group II 13.8 months and 8.4 months for the group III. No statistical significance was achieved between group I and II (P0.05).These data suggest that treatment with PCI appears to be ineffective in reducing the incidence of subsequently CNS metastases or to improve survival of SCLC patients. We recommend the use of PCI only in well defined clinical studies.

To show treatment results and to define prognostic subgroups in patients undergoing radiotherapy for brain metastases from malignant melanoma.Between 1985 and 1993 30 patients underwent radiation therapy for brain metastases from malignant melanoma. In 9 patients they had been surgically resected. All except 1 patient received whole brain irradiation with a total dose of 20 to 46 Gy/2 to 5 weeks using daily fractions of 2.0 to 4.0 Gy. In 5 patients a local boost of 20 to 25 Gy/2 weeks was administered. Survival rates were compared using the Cox-method. Univariate and multivariate analyses were performed to define prognostic subgroups.In 6/30 patients (20%) brain metastases were diagnosed at the time of primary manifestation of melanoma. In 83% of patients brain metastases developed during the first 5 years following primary diagnosis. Late manifestation was observed (18 years). Overall survival rate of the whole group was 39% at 6 months and 23% at 1 year. Univariate analysis revealed that age at diagnosis of brain metastases, time to manifestation, number of intracranial metastases and existence of extracerebral distant metastases had significant influence on survival. Sex was not found to influence survival rate. Multivariate analysis identified the existence of extracerebral distant metastases at the time of diagnosis of brain metastases as the most important prognostic factor for survival, followed by age and surgical resection. The role of fractionation was studied separately in a subgroup of patients receiving whole brain irradiation to a total dose of 39 to 42 Gy. Survival rates deteriorated when overall treatment time exceeded 3 weeks.Prognosis following brain metastases from malignant melanoma is very unfavourable. The described prognostic factors can be helpful to choose the adequate therapeutic modality for the patient, especially for selection of patients for radiosurgery. Whole brain irradiation with 13 x 3 Gy/3 weeks seems a safe and well tolerated treatment schedule either in palliative care or following surgical resection or preceding radiosurgical treatment.

To find out the indications for treatment and selection criteria of patients who will profit from curative radiotherapy.A literature review and own data concerning the lymphogenous metastatic pathways and incidence of involvement of loco-regional lymph nodes are used to define the biological treatment volume of a curative irradiation. A retrospective analysis of 266 patients with non-small-cell lung cancer (NSCLC) was performed. The metastatic pathway of the lymphogenous spread was analysed based on pretherapy CT scan as well as clinical examination.Only carefully selected patients under similar selection criteria as for curative surgery are suitable to undergo a curative radiotherapy. The biological treatment volume for curative irradiation has to include the primary with a margin, the ipsilateral hilar nodes as well as the whole mediastinum including the subcarinal lymph nodes, but not the contralateral hilar and supraclavicular lymph nodes. The survival rate of patients with N3 nodal stage are 0%. A 3-step concept for curative radiotherapy until 70 Gy is proposed.A limited number of patients with NSCLC, carefully selected as for surgery, are suitable to undergo a curative radiotherapy with 70 Gy. This will enable to demonstrate a curative value of radiotherapy.

Treatment results were reviewed in a retrospective analysis and compared with literature data. Prognostic factors for freedom from relapse and overall survival were identified.We analyzed the history of 183 patients treated for Hodgkin's disease between 1977 and 1989 at the Department of Radiation Therapy at the University of Würzburg. There were 100 males and 83 females between 16 and 86 years of age. 70.5% of patients presented with early stage Hodgkin's disease (23.5% stage I and 47.0% stage II) and 29.5% had advanced stages (25.1% stage III and 4.4% stage IV). All patients were treated initially with radiotherapy, 114 had radiotherapy alone and 69 patients received combined modality treatment.Hundred and sixty-one patients (88.0%) reached a complete remission. Freedom from relapse was 73.7% at 5 years and 70.3% at 10 years for these patients, overall survival was 74.3% and 62.8% at 5 and 10 years for all patients. Prognostic factors for freedom from relapse were stage IV, B symptoms, age greater than 35 years and more than 3 involved lymph node regions. These factors also were relevant for overall survival, in addition mixed cellularity or lymphocyte depleted subtype, high erythrocyte sedimentation rate, failure to achieve a complete remission following initial treatment and relapse of Hodgkin's disease were identified as negative prognostic factors. Laparotomy staged patients who received radiotherapy only for stage I and II Hodgkin's disease had better outcome than clinically staged patients. Our data suggest that adequate therapy is able to reduce the impact of unfavourable prognostic factors. The outcome for patients with bulky mediastinal disease was similar to that in patients without a mediastinal mass.The optimal choice of treatment for patients with early stage Hodgkin's disease--combined modality treatment/radiotherapy alone/chemotherapy alone?--and for patients with advanced stages--consolidation radiotherapy?--remains an unresolved issue and needs further testing in large randomized trials considering acute and late complications. Staging laparotomy may be used only for a small group of patients who would receive radiotherapy alone as definitive treatment. Modifications of therapy clearly reduce the impact of negative prognostic factors.

Using the pre-therapy CT scans of 266 node positive non-small cell lung cancer patients, we analysed the lymphatic pathways and the incidence of lymph node metastases in regional lymph nodes (as described by CT criteria corresponding to the modified mapping scheme of the American Thoracic Society), in order to develop the target volume for curative irradiation treatment. Among the 105 patients with node positive left sided primaries, the incidence of involvement of the ipsilateral supraclavicular lymph nodes was 9.5%, and the incidence of involvement of the contralateral lymph nodes was 3.8%. The incidence of involvement of the contralateral hilar lymph nodes was 4.8%. Among the 161 patients with nodal positive right sided primaries, the incidence of involvement of the ipsilateral supraclavicular lymph nodes was 8.7% and the incidence of involvement of the contralateral lymph nodes was 1.8%. For this group of patients, the incidence of involvement of the contralateral hilar lymph nodes was 3.7%. All patients with involvement of the contralateral hilar lymph nodes died within 2.5 years of diagnosis. In the cases where there was involvement of the supraclavicular lymph nodes, the patients died within 1.6 years. Involvement of the ipsilateral and/or contralateral supraclavicular lymph nodes, and/or the contralateral hilar lymph nodes, is defined as N3 disease, and is included in Stage IIIb. No curative surgery is indicated for these patients. Why therefore should this group of patients be treated with curative intent by irradiation of the primary, ipsilateral and contralateral hilar lymph nodes, as well as mediastinal, ipsilateral and contralateral supraclavicular lymph nodes? The curative radiation treatment volume for lung cancer has to include the primary tumor and the ipsilateral hilar, and the low and high mediastinal lymph nodes, as is indicated for Stage I, II and IIIa disease.

Examination of the influence of total tumor dose, additional therapy and age on the development of radiation pneumonitis and lung fibrosis.Two hundred and sixteen patients with squamous cell carcinoma of the lung were examined retrospectively. Hundred and eighty-three of them received a percutaneous radiation therapy of the primary tumor and the mediastinal and ipsilateral hilar lymph nodes. The majority of 130 patients was given radiotherapy as only treatment, 27 were irradiated after resection and 26 received chemo- and radiotherapy. Treatment volume was determined by three-dimensional planning using chest CT-scan. The irradiation was administered in a first series of 56 Gy and a following boost to the primary and involved lymph nodes to a total dose of 70 Gy. There was one daily irradiation with 2 Gy 5 days a week. Post-resectional radiation encompassed the bronchus stump and the mediastinum with a total dose of about 60 Gy.Sixty-eight of the 183 irradiated patients developed a pneumonitis (37.2%) and 60 a lung fibrosis (32.8%). The most important factor was the administered total irradiation dose (p0.001). There was no pneumonitis documented below 36 Gy and no fibrosis below 40 Gy. An additional chemotherapy did not increase the incidence (pneumonitis after radiotherapy 35.4%, after radio- and chemotherapy 34.6%; fibrosis after radiotherapy 33.9%, after radio- and chemotherapy 38.5%). Particularly high was the incidence of pneumonitis when radiotherapy followed resection (48.2%) while the rate of fibrosis in this group of patients was relatively low (22.2%). Age of patients did not affect the frequency of pneumonitis while fibrosis significantly occurred more often with increasing age (p = 0.037).The total dose affecting the normal lung tissue is the most important factor for the development of radiation pneumonitis and lung fibrosis. It is recommended to keep the treatment volume appropriate to the individual extend of tumor. Good results are achieved with a computer supported CT-planning which helps to gain minimal burdening of normal tissue.

Prognostic factors in breast cancer have been frequently discussed in the oncologic literature. We reviewed our data of 795 patients who were referred to the Department of Radiation Oncology of the University of Wuerzburg between 1978 and 1988 in order to find out, whether the well known and proven prognostic factors in breast cancer were sufficiently in use in clinical routine, even out of university oncologic centres. We found, that beside of determination of the histological tumor-type the assessment of tumor size (= pT-status) and axillary (= pN-)status is performed nowadays in all patients. In contrary, the determination of the hormonal receptor status (HRS) had a slow beginning. From 1980 the rate of determinated HRS arose from 5% to 80% nowadays. The demand of removal and examination of at least 12 axillary lymph nodes in axillary dissection in order to determine correctly the axillary status is not yet part of the oncological routine. In 1988 in only 40% of the referred patients axillary diagnosis was done in a manner corresponding to international rules.

Local-regional recurrence following mastectomy is not always a sign of poor prognosis. In an attempt to determine these subgroups of patients we analysed 149 patients of our radiation oncology clinic treated between 1978 and 1988 with local or regional recurrence (LR) following mastectomy. Average follow up was 66 months, 47% of these patients developed their recurrence in the first two years, 78% in five years, 90% of the local-regional recurrence appeared in the first ten years. Prognostic features which predicted a poor prognosis in combination with locoregional recurrence after mastectomy were identified; early local recurrence (less than two years from mastectomy) (p less than 0.001), large tumor size T3 and T4 primary) (p less than 0.001), less than five involved axillary lymph nodes (p less than 0.001), negative hormone receptor status, histological grading 3 and 4, lymphangiosis carcinomatosa in the tumor site (p less than 0.05), the presence of tumor-necrosis in the primary tumor (p less than 0.001) and appearance despite of postoperative irradiation (p less than 0.05). Prognosis of patients with more than five involved axillary lymph nodes did not change by local-regional recurrence. The local recurrence did not influence survival in: late local recurrence (more than two years from mastectomy), small tumor size (T1 and T2), negative axillary status, positive hormonal status, histologic grading 1 and 2 and absence of tumor-necrosis or lymphangiosis carcinomatosa in the primary tumor. We conclude that local-regional recurrence is in fact under the above defined circumstances not a sign of systemic disease. With insufficient local therapy it can under these conditions be cause of progressive tumor spread. Thus we strongly support intensive local therapy for local-regional recurrence.

Das Mammakarzinom metastasiert ahnlich haufig wie andere Karzinome, z. B. Bronchialkarzinome, maligne Melanome, Hypernephrome u. a. in das zentrale Nervensystem [1,4,7]. Wie allgemein bekannt ist, bringt die ZNS-Metastasierung eine schlechte Prognose mit sich, trotz aller bisherigen Therapieanstrengungen.

Primary non-Hodgkin's lymphoma occurs quite seldom in the nasopharynx, therefore reports on this topic are rare in medical literature. The treatment results of 30 irradiated patients (40 to 60 Gy) are presented. The period of the study ranges from 1960 to 1985. 13 patients with low grade lymphoma and 17 patients with high grade lymphoma according to the Kiel classification form the basis of this study. The overall actuarial 5-year survival rate is 24%. This also applies for the subgroups of low grade and high grade lymphomas with a 5-year survival rate of 24%, respectively. The evaluation of the patients without generalization in the course of disease shows that the prognosis of stage IE patients with 43% was superior to the one of stage IIE patients with 25% (p less than 0.001). Only patients with lymphoma limited to the nasopharynx survived longer than five years (46%), but none of the patients with simultaneous spread to the nasal cavity, the oropharynx and/or the base of the skull. Local and regional recurrences were rare. However, a generalization of the disease occurred more often (20%), mainly due to insufficient staging in former years. Long-term sequelae of the radiation therapy like rhinitis or pharyngitis sicca were registered occasionally. At present, locoregional radiation therapy is recommended for stage IE and IIE low grade lymphomas and stage IE high grade lymphomas of the nasopharynx.

Based on the postoperative data evaluated in September 1989, the results of a regional prospective treatment study conducted by the DOSAK on preoperative radio-chemotherapy and radical surgery for carcinomas of the oral cavity and the oropharynx are presented. In the univariate analysis the histologic lymph node findings after pretreatment, the histologic grading, and the TPI correlated well with the survival rates. The multivariate analysis confirmed that the histologic demonstration of vital tumor cells in the neck lymph nodes after the end of pretreatment is of grat prognostic relevance. The histologic degree of differentiation, the demonstration of vital tumor cells in the primary tumor area after pretreatment and the length of time between radiotherapy and surgery were of secondary importance.

434 CT examinations of 133 patients with histologically proven bronchogenic carcinoma (22 out of 133 with small cell lung cancer) were analysed before and after radiotherapy. The study evaluates the use of CT for determining target volume, tumour volume and remission rate: 1. Concerning determination of target volume conventional roentgen diagnostic simulator methods are much inferior to CT aided planning: as for our patients changes of the target volume were necessary in 50%, in 22% the changes were crucial. This happened more often in non-small cell lung cancer than in small cell carcinomas. 2. The response rate (CR + PR) after radiotherapy (based on the calculated tumour volumes by CT) was 70 to 80%. The rate of CR of the primary was 45% (non-small cell carcinoma) and 67% (small cell carcinoma). 3. The crucial point for the evaluation of tumour remission after radiotherapy is the point of time. One to three months and four to nine months after irradiation we found complete remissions in 19% and 62%, respectively. Hence, the evaluation of treatment results earlier than three months after radiotherapy may be incorrect. We deem it indispensable to use CT for determination of target, calculation of dose distribution and accurate evaluation of tumour remission and side effects during and after irradiation of patients with bronchogenic carcinoma.

The volumetric analysis of a tumour by CT is a reliable and clinically important method of examination which is rarely used. As for oncology, the importance of this method is based upon the determination of the stage of remission post-therapeutically, especially in those cases which respond to therapy without a roentgenologic change in comparison to pretherapeutic findings. This applies in particular for the evaluation of CT images. In this study 115 CT examinations of 38 patients with recurrent rectal cancer were evaluated and the tumour remission was measured by an exact determination of the tumour volume before and after radiotherapy. The results were compared with the CT findings without volumetric analysis. A change of the tumour size up to 20% of the pretherapeutic volume which eludes from the visual perception can be revealed by a subtle CT-assisted volumetric analysis. Formulas for calculation of the volume or the data concerning length, width and depth of a mass prove to be insufficient or incorrect. Therefore the correct evaluation of a tumour regression or progression should be done more often by CT-assisted volumetric analysis.

In a joint retrospective study by 17 radiotherapy clinics in German-speaking countries the results of treatment of bronchial carcinoma after radiotherapy were analysed in 7503 cases. The age peak was between the 60th and 70th year. Squamous-cell carcinoma was the most frequent histological type, followed by anaplastic carcinoma, with adenocarcinoma being rare. There was a high proportion of histologically not clearly identified cases (27% in central and 35% in peripheral carcinomas). Survival rate at one year was 31% for central (3662 patients) and peripheral (961 patients) tumours, but only 2% at five years. Prognostically there was no difference between histological types and kind of radiotherapy or technique, but total dose affected survival rate. At a total dose of less than 5000 rd the survival rate at five years was minimal. The prognosis of combined surgical and radiotherapeutic measures was slightly better than with a radiotherapy alone, but results were unpredictable for the individual case. It is concluded that radiotherapy aiming at cure should be used in imoperable bronchial carcinoma if the tumour state and general condition of the patient appear to make a cure possible. But if this is not the case, radiotherapy should be used only palliatively, i.e. only to ameliorate symptoms.

The object of this survey concerning 710 patients in Berlin and 418 patients in Wuerzburg/FRG with carcinoma of the larynx is to determine the prognostic factors which are important for the results and the choice of the treatment.

Experiments were carried out to obtain best results in the direct radiographic check of field positioning in telecobalt therapy. By using highly sensitive fine-grain films of high contrast it is possible to obtain radiographs which permit a satisfactory assessment of the situation on the focus of disease with exposure times of 1 to 3 sec. Industrial films in combination with salt and lead screens have proved to be particularly suitable.

An account is given of the advantages of checking the positioned field with the help of radiographs taken directly with the source of radiation used. By choosing suitable film and screen combinations (lead screens or high definition screens) sufficient contrast is obtained even with Co60 gamma rays. The radiographs thus produced differ in character from the conventional radiographs and must be interpreted in a way similar to that required for high k radiographs. Radiographs consisting of the superposition of one picture obtained with fully opened diaphragms for general orientation and a second exposure on the same film with the planned size of field increases the accuracy of positioning in telecobalt treatment considerably. They provide a simple check of size and alignment of the field within its surroundings.

Three boys with osteosarcoma of tibia or femur were locally irradiated with 97.5-100 Gy. Additionally they got chemotherapy according to T4-protocol. After 14-26 month two of them relapsed within, the third below the radiation field. There were no serious side effects of radiotherapy. In spite of amputation and chemotherapy they all developed metastases of lung within 18, 19 or 81 months. Two of them died and one is living with disease. We were not able to cure our three patients by combination of radiotherapy and chemotherapy. Radiotherapy is to date no adequate alternative to radically surgery. Only extraordinary cases should be treated by irradiation.

From 1960 through 1972, altogether 418 patients with laryngeal carcinoma have been treated at Würzburg, 333 = 82% of these by primary radiation therapy with Co-60 gamma-rays. The results are reported and analyzed in dependence on prognostic factors as tumor site and extension, formation of metastases and age of the patient. Five-year survival of primarily irradiated cases from 1960 to 1967; Glottic T1 = 90%, T2 = 70%, T3 -31%. Supraglottic T2 = 51%, T3 =20%, T4 = 16%. Quota of cases with posterior surgical treatment: Glottic = 8% supraglottic = 28%. The attempt to preserve the larnyx function by means of radiation therapy as an initial measure does not bring along any risk for the patient. The incidence of recurrences with secondary surgical treatment is not smaller than with irradiation only.

In a joint retrospective study by 17 radiotherapy clinics in German-speaking countries the results of treatment of bronchial carcinoma after radiotherapy were analysed in 7503 cases. The age peak was between the 60th and 70th year. Squamous-cell carcinoma was the most frequent histological type, followed by anaplastic carcinoma, with adenocarcinoma being rare. There was a high proportion of histologically not clearly identified cases (27% in central and 35% in peripheral carcinomas). Survival rate at one year was 31% for central (3662 patients) and peripheral (961 patients) tumours, but only 2% at five years. Prognostically there was no difference between histological types and kind of radiotherapy or technique, but total dose affected survival rate. At a total dose of less than 5000 rd the survival rate at five years was minimal. The prognosis of combined surgical and radiotherapeutic measures was slightly better than with a radiotherapy alone, but results were unpredictable for the individual case. It is concluded that radiotherapy aiming at cure should be used in imoperable bronchial carcinoma if the tumour state and general condition of the patient appear to make a cure possible. But if this is not the case, radiotherapy should be used only palliatively, i.e. only to ameliorate symptoms.

A report is given on 117 patients with tumors of the epipharynx. All these patients were irradiated. 67% had early metastases in the neck region. 8% had remote metastases which became manifest within two years. The five-year survival rate was 29%, the ten-year survival rate 23%. The results in cases of carcinomas were slightly better than those of the sarcomas. A manifestation of metastases can be prevented by prophylactic irradiations of No regions. Manifest metastases can be healed by radiotherapy.

165 patients with carcinomas of the oral cavity or oropharynx, clinically appearing operable, were treated between 1985 and 1987 within the framework of a prospective multicenter study. The treatment concept consisted in preoperative irradiation with 32 Gy, cisplatin sensitization with 5 X 20 mg per m2 body surface area and subsequent radical removal of the primary tumor and the regional cervical lymph nodes. Regarding recurrence and survival rates the patient data were analyzed using one- and multi-dimensional statistical methods. The observed survival rates were compared with those assessed with the aid of the treatment-dependent prognosis index TPI (Platz et al. 1982). After 1 years the survival rates under the selected combination therapy were 12% and after 2 years 19% above the assessed survival rates under radical surgery alone.

The skip-technique may be used either for screening or lessening the radiation load to sensitive sound organs or for an adjusted formation of the isodoses or for both. To show the possibilities of application of this elegant and quite practicable method, some examples are reported concerning spondylous processes, para-aortic lymph nodes and tumors in the small pelvis. The loss of radiation dose because of the additional opening and closing procedure of the diaphragm demands a correction of the duration of irradiation.

This report concerns 1092 patients with bronchial carcinoma, exclusively irradiated by means of the split-course method. Only squamous cell carcinomas have a chance to survive the 5-year limit: all stages in 9/328 = 2.7%, T1 and T2 in 5/48 = 10%. The dependence of the effect on the radiation dose can be confirmed for squamous cell carcinoma but not for anaplastic tumors. Doses higher than 4500 rad do not bring about a longer survival for the latter. Advantages of the split-course method are: The treatment is better tolerated, operability of questionably operable cases can be checked once again after the first irradiation, series, the dose may be determined from the therapy effect in every individual case.

Only few patients are able to exactly maintain during the irradiation a given position of the head without fixation. However, every movement of the head leads to a dose decrease up to 50% within the target volume. Today, fixation and reproducible field adjustment are the conditions of curative radiotherapy. The Würzburg model is presented.

The present system stores the patients' data and is well adapted to the needs of radiation therapy. With a large computer available, there is no hardware required for clinical use but an intelligent terminal, a double drive mechanism for floppy disks, and a printer. Data acquisition is realized by means of marking sheets and screen display. The structure of the data, organization of the data bank, guarantee of data protection and of authenticity of the data, the evaluations possible until now and, finally, the practical procedure are described.

Small glomus jugulare tumors can be operated on successfully. The intraoperative risk of bleeding may be reduced by preoperative irradiation or angiographic embolisation. Patients with advanced tumors (bone destruction, paralysis or cranial nerves and/or invasion of brain) are at high risk if they are operated on. In these cases radiotherapy is an effective alternative with a fairly low complication rate. Prerequisites for successful irradiation are assessment of treatment volume and treatment planning by CT, sophisticated stereotactic irradiation techniques, application of high energy photons and reliable immobilisation measures. Furthermore it is possible to deliver higher doses, leading to regression of the tumor and its symptoms. The technique is illustrated by two characteristic cases. Although irradiation alone can achieve tumor remission the long term prognosis remains doubtful.

The role of barium pharyngograms in the pre- and post-therapeutic evaluation of pharyngeal tumors is described. The intralumenal part of the tumor is well shown by high spatial and contrast resolution of the pharyngeal mucosa. Barium pharyngogram is the only imaging method which can record the course of the swallowing act at the pharyngeal level. Post-operatively, barium pharyngography reliably demonstrates altered pharyngeal morphology; fibrotic stenoses may be distinguished from narrowing due to recurrence. The result of primary radiotherapy is easy to document.

The object of this survey concerning 710 patients in Berlin and 418 patients in Wuerzburg/FRG with carcinoma of the larynx is to determine the prognostic factors which are important for the results and the choice of the treatment.