The toxicity of stereotactic body radiation therapy in the central chest remains an unsettled iss... more The toxicity of stereotactic body radiation therapy in the central chest remains an unsettled issue. The collected data concerning the observed complications are poorly understood and are limited in their quantity and quality, thus hampering a precise delineation of treatment-specific toxicity. The majority of complications scored as toxicity grade 5, namely respiratory failure and fatal hemoptysis, are most likely related to multiple competing risks and occurred at different dose fractionation schemas, e. g., 10-12 fractions of 4-5 Gy, 5 fractions of 10 Gy, 3 fractions of 20-22 Gy, and 1 fraction of 15-30 Gy. Further investigations with longer follow-up and more details of patients' pretreatment and tumor characteristics are required. Furthermore, satisfactory documentation of complications and details of dosimetric parameters, as well as limitation of the wide range of possible fractionation schemes is also warranted for a better understanding of the risk factors relevant for macroscopic damage to the serially organized anatomic structure within the central chest.
Four measuring systems for the evaluation of the quality of screening for breast cancer are in us... more Four measuring systems for the evaluation of the quality of screening for breast cancer are in use in Germany. The following study gives a review from a clinical point of view: the BQS system, created by the “Bundesgeschaftsstelle Qualitatssicherung” (BQS), is inadequate for clinical quality management. Basically the BQS system is a controlling instrument for accounting purposes. A complete analysis of the therapeutic regime is impossible. By linking the stationary episodes of the patients, the indicators' value disappears and the system's incompatibility with other systems results in the necessity of collecting data twice. German medical societies designed OnkoZert, a system of accreditation for breast-cancer centers. An existing quality management system was redefined, but the excessive emphasis on structures, the inexact definitions of data have made this system unwieldy. However, compared to other systems, validation of data down to the level of patients' files is possible. The “Westdeutsche Brust-Centrum GmbH (WBC)” favors a ranking method to benchmark clinics using multidimensional indicators including therapy-relevant paradigms. For anonymization purposes a confidence interval is allocated to the clinics indicating their position in the ranking order. However, as it is difficult to link performance figures to a specific course of treatment, the motivation to challenge current modes of procedure is low. The Disease Management Program (DMP) for breast cancer is an attempt to establish legal medical guidelines. The resulting system of indices aims to demonstrate a better patient care compared to previous therapies and provide a justification for the invested resources. However, the indicators are unsuitable for this purpose.
The advantage of external radiation therapy in renal cell carcinoma is controversial. High compli... more The advantage of external radiation therapy in renal cell carcinoma is controversial. High complication rates reported in previous trials of postoperative radiation therapy can now be avoided by using contemporary modern treatment techniques. Based on both prospective and retrospective data the following indications for adjuvant radiation therapy should be considered and tested in phase III trials: a) unresectable non-metastatic tumours (preoperative irradiation), b) incomplete resection with gross or macroscopically positive margins, c) locally advanced tumour with perinephric fat extension or adrenal invasion.
Die Tatsache, daB die Fernmetastasierungsrate in beiden Behandlungsarmen gleich hoch war, zeigt d... more Die Tatsache, daB die Fernmetastasierungsrate in beiden Behandlungsarmen gleich hoch war, zeigt die Insuffizienz der gegebenen Chemotherapiedosis bei der Beherrsehung der systemischen Tumorausbreitung. Da die h/~matogene Metastasierung mit einer Inzidenz von 60 bis 80% ein Hauptproblem bei de r Behandlung des niehtkleinzelligen Bronchialkarzinotas im Stadium III darstellt, muB neben der Verbesserung des Gesamt a durch verbesserte lokale Kontrol le nach Radioehemotherapie auch der Einsatz der adjuvanten oder neoadjuvanten hochdosierten Chemotherap ie in mul t imodalen Therapiekonzepten weiter verfolgt werden.
In recent years the multimodal therapy concept has been established for high-grade intracerebral ... more In recent years the multimodal therapy concept has been established for high-grade intracerebral arteriovenous malformations (AVM). One strategy of a multimodal treatment approach for patients with AVM (Spetzler grade V) is reported. After endovascular embolization, the patient underwent radiosurgical treatment of the remaining nidus with a linear accelerator, after which he developed a left-sided hemiparesis in conjunction with severe edema. Angiographic control 44 months after radiation showed an occlusion of the radiosurgically treated nidus. The remaining nidus could be removed by microsurgery. The combination of embolization and radiosurgery may provoke prolonged edema and permanent neurological deficits due to inflammatory perivascular changes.
To identify endoscopic pathological findings prior to radiotherapy and a possible correlation wit... more To identify endoscopic pathological findings prior to radiotherapy and a possible correlation with acute or chronic rectal side effects after three-dimensional conformal radiotherapy (3D-CRT) for prostate cancer. Between 03/99 and 07/02, a total of 298 patients, who consented in a voluntary rectoscopy prior to radiotherapy were included into the analysis. Patients were treated with a total dose of either 70 or 74 Gy. Pathological rectoscopic findings like hemorrhoids, polyps or diverticula were documented. Acute and late rectal side effects were scored using the EORTC/RTOG score. The most frequent pathological endosopic findings were hemorrhoids (35%), polyps (24%) and diverticula (13%). Rectal toxicity was mostly low to moderate. Grade 0/1 cumulative acute and late rectal side effects were 82 and 84%, grade 2 were 18 and 17%, respectively. We could not identify any correlation between preexisting pathological findings and rectal side effects by statistical analysis. There is no evidence that prostate cancer patients presenting with endoscopic verified pathological findings in the rectal mucosa at diagnosis are at an increased risk to develop rectal side effects when treated with 3D-CRT of the prostatic region.
To retrospectively investigate the effectiveness of linear accelerator based radiosurgery (RS) in... more To retrospectively investigate the effectiveness of linear accelerator based radiosurgery (RS) in the treatment of brain metastases (BM). Of 55 patients with a total of 72 BM, 41 patients had a single brain metastasis and 14 patients had two or three metastases. Median tumour dose of 15Gy (range 8-20Gy) was prescribed to a median isodose surface of 90% (range 70-100%) encompassing the target volume. The median survival time (MST) for all 55 patients was 7 months [95% confidence interval (CI), 5-10 months] and 2-year survival is 18%. There was no significant difference between patients who had one brain metastasis and those with either two or three metastases (log rank P=0.7565). Multivariate analysis in patients with a single BM showed that interval between primary diagnosis (PD) to BM, maximum size of metastasis, and histology (renal cell carcinoma and melanoma versus others) were independent prognostic factors influencing survival. Local control was obtained in 66/72 (92%) metastases. Actuarial local control at 24 months was 52%. Only age (<or=50 years vs >50 years) and histology (renal cell versus others) influenced local control in the univariate analysis in patients with a single BM. In multivariate analysis, size, histology (renal cell and melanoma versus others), activity of extracranial metastatic disease, age, interval from PD to BM and location (midline versus other) independently influenced local control, while the dose was not significant for our patient group. Only one patient developed radiographically suspected RS-induced necrosis after previous whole brain RT. RS was effective and little toxic in BM. Identification of prognostic factors must be performed to gain knowledge on patients most likely to benefit from this procedure.
Of all types of Kaposi's sarcoma (KS), only AIDS (acquire... more Of all types of Kaposi's sarcoma (KS), only AIDS (acquired immunodeficiency syndrome)-related KS is of clinical importance, although its incidence has significantly declined in the last years. KS is considered a radiosensitive tumor, and good palliation of symptoms can be achieved with radiotherapy. Evident radiotherapy data in the available literature were reviewed to analyze and evaluate indications, techniques, dose concepts and outcomes in radiation treatment of KS. Good palliation of KS symptoms can be achieved by radiotherapy, with more than 90% response and 70% complete remission. For patients with far advanced AIDS, a single dose of 8 Gy is preferable. The following doses have been shown to be sufficient: 15 Gy for oral lesions, 20 Gy for lesions involving the eyelids, conjunctivae and genitals, 30-40 Gy in single doses of 2 Gy for cutaneous lesions. Side effects are rare, and radiation is usually well tolerated, with minimal skin reactions -- except for patients with mucosa lesions, where a high degree of mucositis is often observed. Radiotherapy has its place in the management of KS as an efficient treatment, often representing the optimal local therapy for palliation of pain, bleeding or edema.
International Journal of Radiation Oncology*Biology*Physics, 2002
To evaluate the effectiveness of stereotactic fractionated radiotherapy (SFRT) in the treatment o... more To evaluate the effectiveness of stereotactic fractionated radiotherapy (SFRT) in the treatment of optic nerve sheath meningioma (ONSM). METHODS AND MARERIALS: Between 1994 and 2000, a total of 39 patients with either primary (n = 15) or secondary (n = 24) ONSM were treated with SFRT and received a median total tumor dose of 54 Gy using 1.8 Gy/fraction. The radiographic response to SFRT was documented in all patients as stable disease (no change) except for 1 patient with a partial response. After a median follow-up of 35.5 months, all patients with ONSM were alive without recurrence. The visual fields and visual acuity were improved in 6 of 15 and 1 of 16 examined eyes in patients with primary ONSM, respectively, and in 6 of 24 and 7 of 26 examined eyes in patients with secondary ONSM, respectively. Stable visual fields and visual acuity was observed in 8 of 14 and 15 of 16 patients with primary ONSM, respectively, and in 17 of 24 and 19 of 26 patients with secondary ONSM, respectively. Except for reversible alopecia and erythema, no other SFRT-related toxicity was observed. SFRT represents a very effective and low-toxic treatment modality for ONSM. Despite a median follow-up of 3 years, this series of primary ONSM holds promise for future studies. It adds substantial evidence that SFRT may definitely become a standard treatment approach in selected cases of ONSM.
The toxicity of stereotactic body radiation therapy in the central chest remains an unsettled iss... more The toxicity of stereotactic body radiation therapy in the central chest remains an unsettled issue. The collected data concerning the observed complications are poorly understood and are limited in their quantity and quality, thus hampering a precise delineation of treatment-specific toxicity. The majority of complications scored as toxicity grade 5, namely respiratory failure and fatal hemoptysis, are most likely related to multiple competing risks and occurred at different dose fractionation schemas, e. g., 10-12 fractions of 4-5 Gy, 5 fractions of 10 Gy, 3 fractions of 20-22 Gy, and 1 fraction of 15-30 Gy. Further investigations with longer follow-up and more details of patients' pretreatment and tumor characteristics are required. Furthermore, satisfactory documentation of complications and details of dosimetric parameters, as well as limitation of the wide range of possible fractionation schemes is also warranted for a better understanding of the risk factors relevant for macroscopic damage to the serially organized anatomic structure within the central chest.
Four measuring systems for the evaluation of the quality of screening for breast cancer are in us... more Four measuring systems for the evaluation of the quality of screening for breast cancer are in use in Germany. The following study gives a review from a clinical point of view: the BQS system, created by the “Bundesgeschaftsstelle Qualitatssicherung” (BQS), is inadequate for clinical quality management. Basically the BQS system is a controlling instrument for accounting purposes. A complete analysis of the therapeutic regime is impossible. By linking the stationary episodes of the patients, the indicators' value disappears and the system's incompatibility with other systems results in the necessity of collecting data twice. German medical societies designed OnkoZert, a system of accreditation for breast-cancer centers. An existing quality management system was redefined, but the excessive emphasis on structures, the inexact definitions of data have made this system unwieldy. However, compared to other systems, validation of data down to the level of patients' files is possible. The “Westdeutsche Brust-Centrum GmbH (WBC)” favors a ranking method to benchmark clinics using multidimensional indicators including therapy-relevant paradigms. For anonymization purposes a confidence interval is allocated to the clinics indicating their position in the ranking order. However, as it is difficult to link performance figures to a specific course of treatment, the motivation to challenge current modes of procedure is low. The Disease Management Program (DMP) for breast cancer is an attempt to establish legal medical guidelines. The resulting system of indices aims to demonstrate a better patient care compared to previous therapies and provide a justification for the invested resources. However, the indicators are unsuitable for this purpose.
The advantage of external radiation therapy in renal cell carcinoma is controversial. High compli... more The advantage of external radiation therapy in renal cell carcinoma is controversial. High complication rates reported in previous trials of postoperative radiation therapy can now be avoided by using contemporary modern treatment techniques. Based on both prospective and retrospective data the following indications for adjuvant radiation therapy should be considered and tested in phase III trials: a) unresectable non-metastatic tumours (preoperative irradiation), b) incomplete resection with gross or macroscopically positive margins, c) locally advanced tumour with perinephric fat extension or adrenal invasion.
Die Tatsache, daB die Fernmetastasierungsrate in beiden Behandlungsarmen gleich hoch war, zeigt d... more Die Tatsache, daB die Fernmetastasierungsrate in beiden Behandlungsarmen gleich hoch war, zeigt die Insuffizienz der gegebenen Chemotherapiedosis bei der Beherrsehung der systemischen Tumorausbreitung. Da die h/~matogene Metastasierung mit einer Inzidenz von 60 bis 80% ein Hauptproblem bei de r Behandlung des niehtkleinzelligen Bronchialkarzinotas im Stadium III darstellt, muB neben der Verbesserung des Gesamt a durch verbesserte lokale Kontrol le nach Radioehemotherapie auch der Einsatz der adjuvanten oder neoadjuvanten hochdosierten Chemotherap ie in mul t imodalen Therapiekonzepten weiter verfolgt werden.
In recent years the multimodal therapy concept has been established for high-grade intracerebral ... more In recent years the multimodal therapy concept has been established for high-grade intracerebral arteriovenous malformations (AVM). One strategy of a multimodal treatment approach for patients with AVM (Spetzler grade V) is reported. After endovascular embolization, the patient underwent radiosurgical treatment of the remaining nidus with a linear accelerator, after which he developed a left-sided hemiparesis in conjunction with severe edema. Angiographic control 44 months after radiation showed an occlusion of the radiosurgically treated nidus. The remaining nidus could be removed by microsurgery. The combination of embolization and radiosurgery may provoke prolonged edema and permanent neurological deficits due to inflammatory perivascular changes.
To identify endoscopic pathological findings prior to radiotherapy and a possible correlation wit... more To identify endoscopic pathological findings prior to radiotherapy and a possible correlation with acute or chronic rectal side effects after three-dimensional conformal radiotherapy (3D-CRT) for prostate cancer. Between 03/99 and 07/02, a total of 298 patients, who consented in a voluntary rectoscopy prior to radiotherapy were included into the analysis. Patients were treated with a total dose of either 70 or 74 Gy. Pathological rectoscopic findings like hemorrhoids, polyps or diverticula were documented. Acute and late rectal side effects were scored using the EORTC/RTOG score. The most frequent pathological endosopic findings were hemorrhoids (35%), polyps (24%) and diverticula (13%). Rectal toxicity was mostly low to moderate. Grade 0/1 cumulative acute and late rectal side effects were 82 and 84%, grade 2 were 18 and 17%, respectively. We could not identify any correlation between preexisting pathological findings and rectal side effects by statistical analysis. There is no evidence that prostate cancer patients presenting with endoscopic verified pathological findings in the rectal mucosa at diagnosis are at an increased risk to develop rectal side effects when treated with 3D-CRT of the prostatic region.
To retrospectively investigate the effectiveness of linear accelerator based radiosurgery (RS) in... more To retrospectively investigate the effectiveness of linear accelerator based radiosurgery (RS) in the treatment of brain metastases (BM). Of 55 patients with a total of 72 BM, 41 patients had a single brain metastasis and 14 patients had two or three metastases. Median tumour dose of 15Gy (range 8-20Gy) was prescribed to a median isodose surface of 90% (range 70-100%) encompassing the target volume. The median survival time (MST) for all 55 patients was 7 months [95% confidence interval (CI), 5-10 months] and 2-year survival is 18%. There was no significant difference between patients who had one brain metastasis and those with either two or three metastases (log rank P=0.7565). Multivariate analysis in patients with a single BM showed that interval between primary diagnosis (PD) to BM, maximum size of metastasis, and histology (renal cell carcinoma and melanoma versus others) were independent prognostic factors influencing survival. Local control was obtained in 66/72 (92%) metastases. Actuarial local control at 24 months was 52%. Only age (<or=50 years vs >50 years) and histology (renal cell versus others) influenced local control in the univariate analysis in patients with a single BM. In multivariate analysis, size, histology (renal cell and melanoma versus others), activity of extracranial metastatic disease, age, interval from PD to BM and location (midline versus other) independently influenced local control, while the dose was not significant for our patient group. Only one patient developed radiographically suspected RS-induced necrosis after previous whole brain RT. RS was effective and little toxic in BM. Identification of prognostic factors must be performed to gain knowledge on patients most likely to benefit from this procedure.
Of all types of Kaposi's sarcoma (KS), only AIDS (acquire... more Of all types of Kaposi's sarcoma (KS), only AIDS (acquired immunodeficiency syndrome)-related KS is of clinical importance, although its incidence has significantly declined in the last years. KS is considered a radiosensitive tumor, and good palliation of symptoms can be achieved with radiotherapy. Evident radiotherapy data in the available literature were reviewed to analyze and evaluate indications, techniques, dose concepts and outcomes in radiation treatment of KS. Good palliation of KS symptoms can be achieved by radiotherapy, with more than 90% response and 70% complete remission. For patients with far advanced AIDS, a single dose of 8 Gy is preferable. The following doses have been shown to be sufficient: 15 Gy for oral lesions, 20 Gy for lesions involving the eyelids, conjunctivae and genitals, 30-40 Gy in single doses of 2 Gy for cutaneous lesions. Side effects are rare, and radiation is usually well tolerated, with minimal skin reactions -- except for patients with mucosa lesions, where a high degree of mucositis is often observed. Radiotherapy has its place in the management of KS as an efficient treatment, often representing the optimal local therapy for palliation of pain, bleeding or edema.
International Journal of Radiation Oncology*Biology*Physics, 2002
To evaluate the effectiveness of stereotactic fractionated radiotherapy (SFRT) in the treatment o... more To evaluate the effectiveness of stereotactic fractionated radiotherapy (SFRT) in the treatment of optic nerve sheath meningioma (ONSM). METHODS AND MARERIALS: Between 1994 and 2000, a total of 39 patients with either primary (n = 15) or secondary (n = 24) ONSM were treated with SFRT and received a median total tumor dose of 54 Gy using 1.8 Gy/fraction. The radiographic response to SFRT was documented in all patients as stable disease (no change) except for 1 patient with a partial response. After a median follow-up of 35.5 months, all patients with ONSM were alive without recurrence. The visual fields and visual acuity were improved in 6 of 15 and 1 of 16 examined eyes in patients with primary ONSM, respectively, and in 6 of 24 and 7 of 26 examined eyes in patients with secondary ONSM, respectively. Stable visual fields and visual acuity was observed in 8 of 14 and 15 of 16 patients with primary ONSM, respectively, and in 17 of 24 and 19 of 26 patients with secondary ONSM, respectively. Except for reversible alopecia and erythema, no other SFRT-related toxicity was observed. SFRT represents a very effective and low-toxic treatment modality for ONSM. Despite a median follow-up of 3 years, this series of primary ONSM holds promise for future studies. It adds substantial evidence that SFRT may definitely become a standard treatment approach in selected cases of ONSM.
Uploads
Papers by Gerd Becker