Role of definitive chemoradiotherapy using docetaxel and 5-fluorouracil in patients with unresectable locally advanced esophageal squamous cell carcinoma: a phase II study.

Definitive chemoradiotherapy (CRT) with docetaxel (DOC) and 5-fluorouracil (5-FU) is a unique regimen for esophageal cancer. In this prospective phase II study, antitumor effect and safety of CRT using DOC and 5-FU for inoperable locally advanced esophageal cancer were evaluated. DOC 7.5 mg/m2 was infused on days 1, 8, 22, and 29. 5-FU 250 mg/m2 /day was infused continuously on days 1-5, 8-12, 15-19, 22-26, 29-33, 36-40, and 43-45. Radiotherapy was given to 66 Gy in 33 fractions. Eleven patients with thoracic and five with cervical esophageal cancer were eligible. All patients had esophageal squamous cell carcinoma (ESCC). The response rate was 94%, with complete response in five patients (31%) and partial response in 10 (63%). Hematologic toxicity was mild; only one patient (6%) had Grade 1 leukopenia. Nonhematologic Grade 3 or higher adverse events were esophagitis (31%), anorexia (6%), and esophago-bronchial fistula (6%). No treatment-related deaths occurred. The median time to progression was 20 months and overall 3-year and 5-year survival were 44% and 31%, respectively. Definitive CRT using DOC and 5-FU could be performed safely, and it demonstrated a favorable antitumor effect for ESCC. This regimen might be indicated in patients in whom it is desirable to avoid myelosuppression and progression of renal impairment.

Evaluation of the basic properties of the BANGkit gel dosimeter.

We evaluated the basic properties of a commercially available BANGkit gel dosimeter, which is a normoxic type of BANG gel. This gel-kit has the same composition as the BANG 3 gel, but is fully oxygenated. To exclude oxygen, oxygen scavenging ascorbic acid and copper sulfate as a catalyst are used. The properties that we examined are the effects of the concentrations of copper sulfate and ascorbic acid on the response, the reproducibility, the long-term stability, the temperature effect at irradiation and the dose-rate effect. In our results, the excellent linear fit of the R2-dose response in a dose range for clinical use and its reproducibility were observed. The precision of a linear fit was preserved for about 3 weeks. The temperature at irradiation showed a significant effect on the dose response. Although the dose-rate dependence in the high-dose range was observed, it was negligible for the clinical dose range up to 270 cGy. In conclusion, this gel dosimeter is thought to be utilizable in clinical practice, while we have to pay attention to the temperature during the entire measurement processes, and additionally there is room for improvement in the linearity and the dose-rate dependence in the high-dose range.

Optimum fractionation for high-dose-rate endoesophageal brachytherapy following external irradiation of early stage esophageal cancer.

PURPOSE: To establish the optimum fractionation for high-dose-rate (HDR) endoesophageal brachytherapy (EBT) for early stage esophageal cancer from retrospective data of patients treated with different HDR schedules following external beam irradiation (EBI). METHODS AND MATERIALS: The study population consisted of 35 consecutive early stage esophageal cancer patients who received EBI to the mediastinum, plus EBT, between May 1992 and November 1995 at the Hiroshima University Medical Center and Hiroshima City Hospital. All patients were treated with EBI, with doses ranging from 50 to 61 Gy. The spinal cord was spared after 44-45 Gy. HDR EBT was performed using a double-balloon applicator in conjunction with an Ir-192 remote afterloading system. One group of 10 patients was given a weekly endoesophageal boost of 4 or 5 Gy at a distance of 5 mm from the applicator surface over a period of 1-2 weeks. Another group of 25 patients was treated with 4 or 5 endoesophageal boosts with a fraction dose of either 2.5 or 2 Gy for 1 week. The linear quadratic (LQ) formula was used to calculate the biologically effective dose (BED) for tumor (Gy10) and esophageal mucosa (Gy3); Gy10 means alpha/beta equals 10 Gy, and Gy3 means alpha/beta equals 3 Gy. The Kaplan-Meier method was used to calculate the local control and late complication rates, while the Cox-Mantel test was used to evaluate statistical significance (p < 0.01). RESULTS: Nine (26%) of the 35 patients recurred locally and 7 (20%) had late complications (esophageal ulcer grade by RTOG/EORTC criteria > 1). The 5-year overall survival, local control, and late complication rates were 38%, 57%, and 26%, respectively. The probability of local recurrence was not affected by the treatment parameters. Results from the LQ formula significantly correlate with data on late complications. A BED > 134 Gy3 and a fraction number = < 3 were associated with late complications (grade > 1). BED analysis showed that the fractionation dose should be decreased to 2.5 or 2.0 Gy at a distance of 5 mm from the applicator surface, and the number of doses increased to 4 or 5, respectively, to yield a satisfactory BED (< 134 Gy3). CONCLUSION: A significant reduction in endoesophageal brachytherapy dose per fraction is necessary to reduce late complications. Our current treatment protocol for early-stage esophageal cancer consists of EBI of 60 Gy followed by 4 EBT doses at a fraction dose of 2.5 Gy applied over 1 week.

[Total repair of tetoralogy of Fallot in an adult: report of a case without prior treatment at 59 years of age].

We reported successful repair of tetoralogy of Fallot of a male case aged 59 years old. There was no palliative operation prior to this correction. The preoperative clinical features were as follows: dyspnea on effort and at rest, cyanosis and clubbing, multiple cerebral thrombosis without symptoms. Polycytemia was remarkable at Hb 23.3 g/dl and Ht 73.8%. PaO2 was 39.2 mmHg and hypoxemia was recognized. CTR was 59% and pulmonary vascular shadows were decreased but bilateral pulmonary arteries were well developed. Cardiac catheterization showed that high RV systolic pressure equal to that of LV and severe RV outflow obstruction. Pulmonary artery was well developed (the diameter ratio of PA and aorta: 0.84). Collateral arteries to the pulmonary vascular system were not significant by aortography. The surgical procedures were performed under conventional method. Pulmonary valvular stenosis was released by comissurotomy and RV outflow tract obstruction was also released through minimal right ventriculotomy. The conus branch of coronary artery crossed the outflow tract, so that we preserved this artery for preventing right ventricular failure post-operatively. There was no need to use trans-annular patch for reconstruction of the outflow tract. In post operative course, only a low dosage of catecholamin was required but no other special treatment was needed. Ventricular and supraventricular arrhythmia had appeared in short period but after administration of anti arrhythmic drugs, heart rhythm was converted to sinus rhythm easily. Pathological findings of RV muscle which resected at the operation showed marked fibrous degeneration and irregularity of cells, and it suggested that sever hypoxia and high pressure for long time affected the ventricular muscle. We concluded that even older patients of tetralogy of Fallot were corrected safely and were able to get good quality of life after operation.

[Aneurysmal bone cyst of the left 5th rib].

A case of aneurysmal bone cyst of the left 5th rib is reported. A 57-year-old male complained of palpable lump and pain on his back. Chest X ray and CT showed expansive tumor arid pathological fracture of the left 5th rib. The tumor and the adjacent segments of the 4th and 5th ribs were resected en bloc. The pathological examination showed multiple blood filled spaces and fibrous trabeculae, confirming the diagnosis of aneurysmal bone cyst. He has been followed up for 3 years and 6 months with no signs of recurrence.

Interbreath-hold reproducibility of lung tumour position and reduction of the internal target volume using a voluntary breath-hold method with spirometer during stereotactic radiotherapy for lung tumours.

The purpose of this study was to evaluate the interbreath-hold reproducibility of the tumour (gross tumour volume, GTV) position and relative reduction of the internal target volume (ITV) using a voluntary breath-hold method with a spirometer in a clinical setting of stereotactic radiotherapy (SRT) for lung tumours 11 patients with 14 lung tumours were enrolled in this study. CT scans were performed once at the free breathing phase and five times at the breath holding phase before the first treatment day. Patients held their breath at the end-expiration phase under spirometer-based monitoring. All GTVs were delineated by a physician and the GTV centroid was calculated automatically. To evaluate the interbreath-hold reproducibility of the tumour position, we measured the distance of three dimensions (craniocaudal, CC; left-right, LR; anteroposterior, AP) and vectors between the GTV centroid and bony landmark. The reproducibility was defined as the average of the differences between the GTV centroid and bony landmark from the second to fifth CT scans with regard to that from the first CT scans. We also evaluated the relative reduction of ITV between the free breathing and breath-holding phase. The interbreath-hold reproducibility of the tumour position was 1.3+/-1.3 mm, 1.4+/-1.8 mm, 2.1+/-1.6 mm and 3.3+/-2.2 mm in CC, LR and AP directions and vectors, respectively. ITV at the breath-holding phase was significantly smaller than that at the free breathing phase (P<0.01). In conclusion, the voluntary breath-hold method with a spirometer is feasible, with relatively good reproducibility of the tumour position for SRT in the clinical setting.

Early clinical outcomes of 3D-conformal radiotherapy using accelerated hyperfractionation without intracavitary brachytherapy for cervical cancer.

PURPOSE/OBJECTIVE: To evaluate the outcome of cervical cancer patients unable to undergo conventional intracavitary brachytherapy (ICBT) treated with 3D-conformal radiotherapy (3DCRT) alone using accelerated hyperfractionation (AHF). METHODS AND MATERIALS: We reviewed the records of 7 patients who had received definitive radiotherapy with 3DCRT alone using AHF for cervical cancer between 2002 and 2005. FIGO stage was IB (1), IIB (2), IIIA (1), IIIB (2), and IVA (1). The reason we did not perform ICBT was due to patient refusal. In 1 patient with stage IB, a total dose of 65.4 Gy was delivered by local irradiation (LI) only. In 1 patient with stage IIIA, a total dose of 60 Gy was delivered by LI only. In 5 patients with Stage IIB-IV, a median total dose of 70.8 Gy was delivered by combination of whole pelvic irradiation (median dose of 45 Gy) with LI. Median overall treatment time was 42 days. RESULTS: Median follow-up for survival patients was 17 months. Out of 7 patients, 6 patients had CR and 1 patient had PR. The response rate was 100%. The 2-year local control rate was 85.7%. Of these patients, 5 are alive without disease and 1 is alive with lung metastasis. CONCLUSIONS: Our outcomes suggest that 3DCRT using AHF may be a promising as a definitive treatment for cervical cancer when ICBT is not able to be performed.