Acta Oncologica

ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: https://www.tandfonline.com/loi/ionc20

Radiotherapy in oncological emergencies – final

results of a patterns of care study in Germany,
Austria and Switzerland

Elmar Christian, Irinaeus A. Adamietz, Normann Willich, Ulrich Schäfer,

Oliver Micke & (for the German Working Group “Palliative Radiotherapy” of
the German Society for Radiation Oncology (DEGRO))

To cite this article: Elmar Christian, Irinaeus A. Adamietz, Normann Willich, Ulrich Schäfer, Oliver
Micke & (for the German Working Group “Palliative Radiotherapy” of the German Society for
Radiation Oncology (DEGRO)) (2008) Radiotherapy in oncological emergencies – final results of
a patterns of care study in Germany, Austria and Switzerland, Acta Oncologica, 47:1, 81-89, DOI:
10.1080/02841860701481554

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Acta Oncologica, 2008; 47: 81
89

ORIGINAL ARTICLE

Radiotherapy in oncological emergencies final results of a patterns of

care study in Germany, Austria and Switzerland


ELMAR CHRISTIAN1, IRINAEUS A. ADAMIETZ2, NORMANN WILLICH3,
ULRICH SCHÄFER3,4 & OLIVER MICKE4,5 (for the German Working Group ‘‘Palliative
Radiotherapy’’ of the German Society for Radiation Oncology (DEGRO))
1
Department of Internal Medicine, Paracelsus Hospital, Glückstadt, Germany, 2Department of Radiotherapy,
Marienhospital, Herne, Germany, 3Department of Radiotherapy, Münster University Hospital, Münster, Germany,
4
Department of Radiotherapy, Lippe Hospital, Lemgo, Germany and 5Department of Radiotherapy and Radiation Oncology,
Franziskus Hospital, Bielefeld, Germany

Abstract
Radiotherapy (RT) is an important treatment option for emergencies in oncology. A multicenter patterns of care study
(PCS) was conducted in all RT institutions in Germany, Austria and Switzerland.
In 2003 a standardized structured questionnaire was sent to all RT institutions. Number and type of staff involved,
number of patients, over time distribution and expense, treatment indications and concepts of emergency RT were assessed.
In addition, treatment outcome for the different indications was evaluated. The PCS was structured and analyzed according
to the model for quality assessment set up by Donabedian in three major components: structure, process and outcome.
One hundred and forty institutions (70%) answered the questionnaire. For the baseline of 2003 a total of 3 244
emergency radiotherapy indications with a mean of 28 per institution were reported. Forty percent of all institutions provide
a special 24 h service at night or weekends. Seventy percent of the emergency indications were irradiated between Monday
and Thursday, 30% between Friday and Sunday. Ninety percent of all emergencies were referred to RT between 8 a.m. and
6 p.m., 10% between 6 p.m. and 8 a.m.
The applied doses for emergency RT ranged between 2 Gy and 8 Gy (median: 3.5 Gy). Time expense was reported with a
median of 90 min.
The outcome analysis based on the treatment results of 1 033 patients: There was an improvement of myelocompression
in 50% of the cases, vena cava superior compression in 70%, bronchial obstruction in 70% and bleedings in 80%. A clear
dose-response relationship could not be established, but single doses of over 3 Gy in vena cava superior syndrome exhibited
a significant advantage.
This study represents the largest database in literature on emergency RT. RT was shown to be fast, time sparing and a very
effective treatment option for special oncological emergencies.

Emergency conditions in radiation oncology are a Generally, in oncological emergency conditions an

heterogeneous and ill-defined group of disorders
with some authors even questioning if they really
exist [1,2].
Nevertheless, radiotherapy (RT) is one of the
most important treatment options for emergencies
in oncology. In particular it can be used in acute
myelocompression, vena cava superior syndrome,
bronchial obstruction, increased intracranial pres-
sure due to brain metastasis and tumor bleeding
complications [3].
immediate intervention is needed to preserve the
patient’s corporal integrity and quality of life and
prevent the menacing deterioration of the patient’s
health conditions. Even the use of nights and week-
ends is at times necessary. Despite some reports about
the high efficacy of radiation treatment for oncologi-
cal emergencies, a standard of care is not well defined
and the cost and personal intensity of this method is
still controversial while the clinical value remains
unclear. There are only a few publications in the

Correspondence: Oliver Micke, Klinik für Strahlentherapie und Radioonkologie, Franziskus Hospital, Kiskerstraße 26, D-33615 Bielefeld, Germany. Tel: 49
521 5891801. Fax: 49 521 5891804. E-mail: strahlenklinik@web.de

(Received 30 January 2007; accepted 28 May 2007)

ISSN 0284-186X print/ISSN 1651-226X online # 2008 Taylor & Francis
DOI: 10.1080/02841860701481554
82 E. Christian et al.
literature dedicated primarily to emergency radiation
oncology [1
4].
Patterns of care studies (PCS) provide an impor-
tant instrument for defining and evaluating treat-
ment standards and quality assurance in radiation
oncology; thereby, practice standards, treatment
guidelines and accomplishments can be assessed
continuously [5
7].
For this purpose, the PCS have been established
for a large variety of malignant as well benign
conditions [8].
Therefore, the German Working Group ‘‘Palliative
Radiotherapy’’ of the German Society for Radiation
Oncology (DEGRO) conducted a multi-center pat-
terns of care study (PCS) in all RT institutions in
Germany, Austria and Switzerland.
The aim of this PCS was to evaluate whether the
instrument of PCS is suitable in this context and to
analyze the standard of care applied in emergency RT.
Material and methods
In 2003, a Patterns of Care Study Panel of German
Working Group ‘‘Palliative Radiotherapy’’ of the
German Society for Radiation Oncology (DEGRO)
developed a structured and standardized question-
naire (Appendix A) and mailed it to all RT depart-
ments in Germany, Austria and Switzerland with the
aim of identifying their institutional experience with
radiotherapy for oncological emergencies.
In this systematic approach the use of a dedicated
24-hour service, the number and type of staff
involved, RT equipments, total number of patients,
distribution over time, treatment indications, time
expense and treatment concepts and of emergency
RT was assessed. Treatment outcomes of the differ-
ent emergency indications were analyzed. In case of
unclear or incomplete data acquisition, interviews or
visits to the institutions were applied to acquire the
appropriate institutional and clinical information.
The relatively high response rate [140 (70%)]
allowed an extensive and representative data analysis
for Germany, Austria and Switzerland. A total of
1 033 patients were clinically retrospectively evalu-
ated to obtain outcome data.
The statistical description of all relevant para-
meters included the median, mean, standard devia-
tion, and range for all continuous variables, and the
absolute and relative values for all categorical vari-
ables. The differences between the frequencies of
groups were analyzed with the Fisher’s exact and x2
tests; the mean values of group frequencies were
analyzed with the Student’s t-test. All statistical
analyses were performed using the commercially
available program package SPSS 11.5.1 (SPSS,
Chicago, IL).
As suggested by Hanks [6,9] and Coia et al. [10],
this PCS was structured und analyzed according to
the model for quality assessment instituted by
Donabedian [11,12] in three major components:
structure, process and outcome.
To facilitate the outcome evaluation in the differ-
ent participating institution, only crude outcome
data as percentage were requested. This approach
has been proven of value in prior PCS [13
16].
Improvement was defined as a symptomatic re-
sponse. A symptomatic response is defined by more
than a 25% decrease of symptoms intensity.
To determine the interrelationship between these
factors a multivariate analysis was performed by
analysis of variance (ANOVA).
Results
Structural data
Of the 140 institutions participating in the survey,
there were 37 university hospitals (26.4%), 88
community hospitals (62.9%), and 15 private in-
stitutions (10.7%) (Table I).
As a baseline, in the year 2003, the participating
institutions reported a total of 3 244 patients treated
per annum with emergency RT. There was a median
number of patients per institution of 18 (mean 28)
cases with a range between one and 220 cases.
Emergency RT represented 3.1% of all RT indica-
tions of the participating RT facilities.
Overall, 126 (90%) RT institutions in Germany,
10 (7.1%) in Switzerland and 4 (2.9%) in Austria
participated in the PCS.
The most frequent indications for emergency RT
were acute myelocompression (42.3%), vena cava
superior syndrome (27.7%), bronchial obstruction
(8.2%), tumor bleeding (8.5%), increased brain
pressure (11.3%) and other not specified indications
(2%) (Figure 1).
Process data
A total of 39.3% (55/140) of RT institutions provide
a special dedicated 24-hour service at night or on
weekends. During this period patients were evalu-
ated and radiation treated.
Table I. Type and distribution of participating institutions.
Type of Hospital Number of Participating
140 of 200 (70%) Institutions
University Hospitals 37 (26.4%)
Community Hospitals 88 (62.9%)
Private Institutions 15 (10.7%)

Vena Cava Syndrome
27.7%
Bronchial Obstructions
8.2%
Tumor Bleeding
8.5%
Brain Pressure
11.3%
Other not spec.
2.0%
Myelocompression
42.3%
Figure 1. Distribution of indications for emergency RT treat-
ment.
This service was significantly more frequently
provided in university hospitals (70.3%), compared
to community hospital (28.4%) or private institu-
tions (26.7%) (p B0.001), whereas the distribution
of emergency indications is nearly the same in all
institution.
Nevertheless, the most emergency RT treatments
were performed in community hospitals (1 833/3 244;
56.5%), followed by university hospitals (1 291/
3 244; 39.8%). Only a minor percentage of emer-
gency RT treatments were performed in private
institutions (120/3 244; 3.7%).
A median of 70% of the emergency indications
were irradiated between Monday and Thursday,
30% between Friday and Sunday. Overall, 90% of
all emergencies presented in the RT departement
between 8 a.m. and 6 p.m., while only 10%
presented between 6 p.m. and 8 a.m. (Figure 2).
The personal equipment held up for emergency RT
consisted of 0.80.404 (meanstandard deviation)
radiation oncologists, 0.480.504 residents/interns,
and 0.410.567 technicians.
Radiotherapy in oncological emergencies 83
In 112 of 140 institutions (80%) the technical
equipment for application of emergency RT consisted
of linear accelerators, 25 (17.9%) used Cobalt-60
machines, 44 (31.4%) brachytherapy units, and eight
(5.7%) not specified treatment units. Treatment
simulators were generally not utilized, in the majority
of patients treatment set-up was done clinically.
The median time interval between presentation of
the patient for emergency RT and the beginning of
RT was 2 hours (range: 0.5 to 36 hours).
The particular time expense was reported to be a
median of 90 minutes (range. 20 to 180 minutes)
(Figure 3).
A special range of RT dose and fractionation
concepts were applied. The dose used for single
fractions at the commencement of emergency RT
ranged from 2 to 8 Gy with a median dose of 3.5 Gy
(Figure 4). The most often used fractionation
scheme was ten times 3 Gy (30 Gy total).
As additional medication 113 institutions (80.7%)
gave corticosteroids with a median dose of 24 mg
dexamethasone. Thirty institutions apply osmotic
substances (21.4%) and 36 (25.7%) gave other non-
specified medications.
Outcome data
A total of 117 (85.7%) institutions provided detailed
data for clinical evaluation of treatment outcome.
Thus, clinical data and treatment results of 1 033
patients treated with emergency RT are retrospec-
tively reported herein. The median improvement
rates in myleocompression were reported to be 50%,
70% in vena cava syndrome, 70% in bronchial
obstruction, 80% in tumor bleeding, 70% in brain
pressure, and 80% in other indications (Figure 5).
Sixty percent of all radiation oncologists in
this national survey considered RT in oncological

[%] 100 n 40
90
35
80
70 30

60 25
50 20
87 37
40
15 28
30 63
10
20 37 17
14
10 5 9
13
0 0
Mo - Do Fr - So 8.00 - 18.00 18.00 - 8.00 <= 30 min 31-60 min 61-90 min 91-120 min > 120 min

Figure 2. Time distribution of emergency radiotherapy related to Figure 3. Distribution of time expenditure especially dedicated to
week day and day time. emergency RT.
84 E. Christian et al.
n 50 other treatment indications there was no significant
45 difference in outcome.
40 Providing a special 24-hour service for emergency
35 RT showed a tendency (p 0.084) for a better
30 outcome in spinal cord compression.
25
44
20 39
15 Discussion
10 18 Since their first implementation in the United States
5 9
6 in 1973, the Patterns of Care Study (PCS) has been
0
< 3 Gy 3 Gy 3,5 Gy 4 Gy > 4 Gy established as a valuable tool for periodic evaluation
of the radiotherapy practice [7,17]. Its primary
Figure 4. Different fractionation concepts.
function is, as the founder Simon Kramer stated, to
improve the quality and accessibility of radiation care in
the United States. To this end the PCS seeks to establish
emergencies as a worthwhile and necessary treat-
how and by whom radiation therapy is being practiced in
ment indication.
the United States and to evaluate the factors, which affect
the levels of care presently being delivered [18]. Since
Interaction of components these early steps, evaluation of the quality of care has
become a most critical issue in the medical practice,
There was no statistical relationship between coun- and it is particularly important in the multidisciplin-
try, type of institution, overall treatment concepts ary management of cancer patients [19,20]. Subse-
and outcome. quently, the method of PCS was successfully
A clear dose-response relationship could not be transported to many other countries outside the
established, although there was a weak significance USA, e.g. Japan and Germany [21,22].
(p 0.048) favoring single doses of over 3 Gy in vena PCS analyzes the patient with regard to technical
cava superior syndrome. and interpersonal components with three criteria:
Relating the time interval until the start of structure, process and outcome [11,12]. Under-
emergency RT to outcome data, only vena cava standing the relationships of these three factors leads
superior syndrome showed a significant (p 0.021) to the measurement of quality in any specialty [6].
improved outcome with an earlier (52 hours) One major concern against PCS is that one must
beginning of emergency radiation treatment. In all rely on the statements of the participating institutions,
which may be subjective or inaccurate. As demon-
strated in our previous PCS reliable data can be
produced by controlling inconsistent or non-plausi-
80
ble information [13
16]. Furthermore PCS are able
70 to provide a larger data base in disease, even if the
60 incidence would not allow large prospective con-
Improvement [%]

trolled clinical trials by a single or few institutions.

50
Our PCS describes the current status of emer-
40 80 80 gency RT in Germany, Austria and Switzerland. It is
70 70 70
30 the first and the largest examination to our knowl-
50 edge on emergency RT in the literature.
20

10
Structure data
0
er
n
n

re
ng
e

The structural analysis revealed that despite 3 244

io
sio

om

th
su
di
ct
es

O
es
dr

ee
ru
pr

Pr

emergency RT treatments per year in Germany,

Bl
n

t
bs
Sy
om

n
or
O

ai
or
c

Austria and Switzerland, this only represent 3.1% of

Br
lo

l
ia
ri

Tu
o

pe

ch
ye

Su

on
M

all RT indications. The distribution of academic

Br
a
av

versus non-academic institution (approximately 1:3)

C
n a
Ve

is similar to that described in the former general PCS

Figure 5. Treatment results (improvement rates) for the different and in other PCS on malignant or benign disorders
indications (Outcome data). [8,10,21].

A significantly higher percentage of university
hospitals provided a dedicated service for emergency
RT, although the largest number of patients were
treated by community hospitals, which primarily
contribute to the national coverage with emergency
RT.
The most frequent reported indication for emer-
gency RT treatment was the malignant myelocom-
pression, followed by vena cava superior syndrome,
which are the most important indications reported in
the literature [1,3,4,23
27]. Other indications such
as malignant brain pressure, bronchial obstructions
or tumor bleeding play only a minor role [1,3,4].
In our study the number of patients with spinal
cord compression is low compared to vena cava
superior compression. One reason can be that, the
institutions follow the new recommendations to use
primarily surgery in these indications and perform
irradiation only in inoperable cases [24,28].
Process data
About 40% of RT institutions provide a special
dedicated 24-hour service at nights or on weekends.
The service was significantly more frequently pro-
vided in university hospitals. Nevertheless, most
emergency RT treatments were performed in com-
munity hospitals. This reflects the fact that the main
coverage of radiation treatment and consequently of
emergency RT is provided by community hospitals.
About a third of all emergency treatment was
performed from Friday to Sunday. This data cannot
prove or exclude the so called ‘‘Friday phenom-
enon’’, the personal experience, that most indica-
tions for emergency RT were referred on Friday
afternoons or evenings [29].
Only 10% of all emergency RT treatments were
carried out at night between 6 p.m. and 8 a.m. This
is related to significant personal efforts, which may
be questioned by the fact that only a minority of
emergency RTs are performed at nights [29]. From
the standpoint of cost-effectiveness it is questionable
to keep personnel on call during nights. On the other
hand emergency radiotherapy should be available
every day.
The applied technical equipment described in this
PCS is predominated by linear accelerators (80%).
Cobalt-60 units play only a minor role, correspond-
ing to the decreasing part of Cobalt-60 machines in
radiation oncology in the overlooked countries [8].
Emergency RT can be provided within a median
duration of 2 hours. This short duration is primarily
important in patients with metastatic spinal cord
compression. Even so, the prognosis for complete
neurological restoration in these patients is poor, and
it is known that a short interval between paresis and
Radiotherapy in oncological emergencies 85
commencement of treatment is of prognostic rele-
vance [1,3,4,23,24,28,30].
A special dose range is applied with a strong
tendency to give higher single doses at the beginning
of the treatment. This is also described in the
literature. The total dose and fractionation sched-
ule should be tailored to the disease setting and the
life expectancy of the patients in this palliative
situation [1,3,30,31].
Most institutions give corticosteroids in addition
to radiation treatment, which is strongly recom-
mended in the literature [23,32].
Outcome
Outcome analysis in the context of PCS is an
important tool to set up a national benchmark on
treatment outcome, which can be expected from the
use of RT in a specific disorders [5,6,17].
In our PCS we observed the clinical data and
treatment results of more than 1 000 patients treated
by emergency RT, provided by a representative
number of RT institutions. This is the largest
collective reported in the literature.
Our study showed high improvement rates in vena
cava superior syndrome and in tumor bleedings
underlining the importance of RT for these indica-
tions [32,33]. In myelocompression, emergency RT
is less successful with only 50% improvement rate.
This confirms that surgery in metastatic spinal cord
compression is the first treatment option and only in
cases where surgery is not applicable, should RT be
used. There has been a remarkable change in the
recommendations for the management of spinal cord
compression in the last few years. Previously, RT was
advised to be the primary treatment [28]. In light of
new studies the approach has been changed to a
preference of primary surgical intervention followed
by irradiation [24].
We could not establish a clear dose-response
relationship, but there was a weak significance favor-
ing single doses of over 3 Gy in vena cava superior
syndrome. Armstrong et al. reported similar results in
a retrospective analysis of 125 patients. High initial-
dose radiation therapy (3
4 Gy) yielded good symp-
tomatic relief in less than 2 weeks in 70% of the
patients, compared to conventional-dose fractiona-
tion (2 Gy daily for five weekly fractions) with a
response of 56% [25]. These findings were also
supported by Egelmeers et al. [26] in a smaller
number of patients (n 34), but the reported median
overall survival was only 6 months. Kwok et al.
recommend in rapidly progressing vena cava syn-
drome or otherwise unstable patients the initiation of
radiation treatment on an emergent basis, even with-
out a tissue diagnosis [3]. On the other hand, it must
86 E. Christian et al.
be considered that a radiation treatment, even with a
few high doses, can make the histological diagnosis
difficult or impossible. Gauden [27] even denies that
vena cave superior compression induced by broncho-
genic carcinoma is a real oncological emergency,
because there is no observed mortality due to venous
compression, a relatively low response rate and a poor
survival outcome (6 months in responders and one
months in non-responders).
Our multivariate analysis revealed a significant
advantage for an earlier beginning in vena cava
superior syndrome, which is controversial in the
literature [25
27], and a tendency toward a better
outcome in spinal cord compression when a special
24-hour service for emergency RT is provided.
Several authors describe a better outcome in spinal
cord compression when radiation treatment is
started earlier [1,3,4,23,24,28,30].
Radiotherapy in emergencies is very important for
daily oncology practice. Nevertheless there were only
few reports in the literature mainly focusing on this
special indication [1
4]. Their clinical data support
the findings in our study. Donato et al. [1] treated 43
patients with superior vena cava syndrome, 37
patients with spinal cord compression, and 108
patients with endocranial hypertension secondary to
brain metastasis with different radiation schedules.
They concluded that histology, pretreatment and
performance status were important prognostic factors
for the response to therapy. Their results demon-
strated no significant difference among different
schedules of radiotherapy and confirmed the impor-
tance of radiotherapy for oncological emergencies.
Similar conclusion came from Ozarda et al. [2]. They
generally recommend the use of hypofractioned
schemes withhigher single doses in oncological emer-
gencies. Wierecky and Bokemeyer unlined the im-
portance of an immediate commencement of
radiation or surgical treatment [4]. Accurate diag-
nosis of the underlying etiology needs to be estab-
lished before treatment. Interdisciplinary cooperation
is crucial in this setting. Kwok et al. pointed [3] out,
that the optimal management hinges on efficient
multidisciplinary evaluation and communication to
arrive at a treatment plan tailored to the individual
patient. Optimal management may include steroids,
surgery, chemotherapy, or bronchoscopic interven-
tion.
Conclusion
This study represents the largest database in litera-
ture on emergency RT. It was demonstrated that the
instrument of PCS is also suitable in the context of
emergency RT. RT could be shown to be fast, time
sparing and very effective treatment option for
special oncological emergencies. The delivery of
radiation is accomplished by a variety of techniques
and fractionation schedules. The selection of treat-
ment technique and fractionation schedule should
depend on the patient’s condition and the disease
entity, volume and site.
Acknowledgements
The authors and the German Working Group
‘‘Palliative Radiotherapy’’ of the German Society
for Radiation Oncology (DEGRO) are grateful to all
institutions and radiation oncologists who partici-
pated in this study. Their cooperation in providing
information made this unique national survey pos-
sible.
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88 E. Christian et al.
Appendix A

Patterns of Care Study:

Palliative Radiotherapy for Oncological Emergencies
German Working Group “Palliative Radiotherapy”

General Institutional Data: [ .. ] = Please mark [ X ] !

Institution: [ ] University Hospital [ ] Community Hospital

[ ] Private Institution [ ] Other: ........................

Address (Stamp): ..............................................................................................................

...............................................................................................................

Contact person: ................................................................................................................

Experience with palliative radiotherapy (RT) for oncological emergencies: [ ] Yes [ ] No

If yes, please provide further information: Average cumber of cases per year: ...............................

Special information on Emergency Radiotherapy:

Do you provide a dedicated 24-hour service for emergency RT? [ ] Yes [ ] No

Personal equipment:
[ ] Radiation Oncologists [ ] Residents/Interns [ ] Technicians [ ] Physicists
Number: __________________ ______________ _________ ________

RT-Equipment: [ ] Linac: ....... (MV) [ ] Cobalt-60 [ ] Brachytherapy

[ ] Other: …………………………………………………………………….

Percentage of emergencies related to week days: Monday-Thursday.: ______ %

Friday-Sunday: ______ %

Percentage of emergencies related to day time: 8.00-18.00: ______ % 18.00-8.00: ______ %

Mean interval to the start of emergency RT: ____________ hours

Indications: [ ] Myelocompression [ ] Bronchial obstruction

Percentage: _______ % Percentage: _______ %
[ ] Vena cava syndrome [ ] Tumor bleeding
Percentage: _______ % Percentage: _______ %
[ ] Brain pressure [ ] Other: ___________________
Percentage: _______ % Percentage: _______ %

Mean dose of emergency RT:

Single dose: _______ Gy Total dose: _______ Gy Number of RT fractions: _______

Mean time expense for emergency RT:

__________ hours __________ minutes

 Radiotherapy in oncological emergencies 89
Additional medications:

[ ] Corticosteroids: __________, Dose: __________ mg

[ ] Osmotic substances: __________, Dose: __________ mg

[ ] Other: __________, Dose: __________ mg

Results of emergency RT:

[ ] Myelocompression, Improvement in __________ %

[ ] Bronchial obstruction, Improvement in __________ %

[ ] Vena cava syndrome, Improvement in __________ %

[ ] Bleeding complications, Improvement in __________ %

[ ] Brain pressure, Improvement in __________ %

[ ] Other, Improvement in __________ %

Side effects of treatment: [ ] Yes [ ] No,

please specify: ___________________

Radiogenic side effects ? [ ] No [ ] Yes: ............... (Number) .............. (Percentage)

If yes, which ? ......................................................................................................................

Publications [ ] No [ ] Yes If yes, which ? (Source, possibly send copy!)

and/or Abstracts ................................................................................................................................
................................................................................................................................

Personal Estimation:

Personally, I consider the RT for oncological emergencies as:

[ ] very worthwhile [ ] worthwhile [ ] less worthwhile [ ] not worthwhile [ ] indecisive

Please send back to: Dr. Oliver Micke

Klinik und Poliklinik für Strahlentherapie – Radioonkologie
Universitätsklinikum Münster (UKM)
Albert-Schweitzer-Strasse 33, 48129 Münster

Fax : +49 (0) 251 / 834-7355

Thank you for your Cooperation!