Improved error detection using a divided treatment plan in volume modulated arc therapy.

AIM: We sought to improve error detection ability during volume modulated arc therapy (VMAT) by dividing and evaluating the treatment plan. BACKGROUND: VMAT involves moving a beam source delivering radiation to tumor tissue through an arc, which significantly decreases treatment time. Treatment planning for VMAT involves many parameters. Quality assurance before treatment is a major focus of research. MATERIALS AND METHODS: We used an established VMAT prostate treatment plan and divided it into 12° × 30° sections. In all the sections, only image data that generated errors in one segment and those that were integrally acquired were evaluated by a gamma analysis. This was done with five different patient plans. RESULTS: The integrated image data resulting from errors in each section was 100% (tolerance 0.5 mm/0.5%) in the gamma analysis result in all image data. Division of the treatment plans produced a shift in the mean value of each gamma analysis in the cranial, left, and ventral directions of 94.59%, 98.83%, 96.58%, and the discrimination ability improved. CONCLUSION: The error discrimination ability was improved by dividing and verifying the portal imaging.

Diagnostic Performance of 11C-choline PET/CT and FDG PET/CT in Prostate Cancer.

We compared 11C-choline and FDG PET/CT scan findings for the staging and restaging of prostate cancer. Twenty Japanese prostate cancer patients underwent 11C-choline and FDG PET/CT before (n=5) or after (n=15) treatment. Using a five-point scale, we compared these scanning modalities regarding patient- and lesion-based diagnostic performance for local recurrence, untreated primary tumor, and lymph node and bony metastases. Of the 20 patients, documented local lesions, and node and bony metastases were present in 11 (55.0%), 9 (45.0%), and 13 (65.0%), respectively. The patient-based sensitivity/specificity/accuracy/area under the receiver-operating-characteristic curve (AUC) values for 11C-choline-PET/CT for diagnosing local lesions were 90.9% /100%/ 95.0% / 1.0, whereas those for FDG-PET/CT were 45.5% /100%/ 75.0% / 0.773. Those for 11C-choline-PET/CT for node metastasis were 88.9% /100%/ 95.0% / 0.944, and those for FDG-PET/CT were 44.4%/100%/75.0%/0.722. Those for 11C-choline-PET/CT for bone metastasis were 84.6%/100%/90.0%/0.951, and those for FDG-PET/CT were 76.9% /100%/ 85.0% / 0.962. The AUCs for local lesion and node metastasis differed significantly (p=0.0039, p=0.011, respectively). The lesion-based detection rates of 11C-choline compared to FDG PET/CT for local lesion, and node and bone metastases were 91.7% vs. 41.7%, 92.0% vs. 32.0%, and 94.8% vs. 83.0% (p=0.041, p=0.0030, p<0.0001), respectively. 11C-choline-PET/CT is more useful for the staging and restaging of prostate cancer than FDG-PET/CT in Japanese men.

Utility of intraoral stents in external beam radiotherapy for head and neck cancer.

AIM: This study aimed to assess the utility and stability of intraoral stent during intensity-modulated radiation therapy (IMRT). BACKGROUND: The benefits of intraoral stents in radiotherapy are unclear. MATERIALS AND METHODS: We analyzed 386 setup errors in 12 patients who received IMRT for head and neck cancers without intraoral stents (intraoral stent [-]) and 183 setup errors in 6 patients who received IMRT with intraoral stents (intraoral stent [+]). All patients were matched according to the immobilization method (masks and boards). Setup errors were measured as the distance from the initial setup based on the marking on the skin and mask to the corrected position based on bone matching on cone beam computed tomography. RESULTS: The mean interfractional setup errors in the right-left, craniocaudal, anterior-posterior (AP), and three-dimensional (3D) directions were -0.33, 0.08, -0.25, and 2.75 mm in the intraoral stent (-) group and -0.37, 0.24, -0.63, and 2.42 mm in the intraoral stent (+) group, respectively (P = 0.50, 0.65, 0.01, and 0.02, respectively). The systematic errors for the same directions were 0.89, 1.46, 1.15, and 0.88 mm in the intraoral stent (-) group and 0.62, 1.69, 0.68, and 0.56 mm in the intraoral stents (+) group, respectively. The random errors were 1.43, 1.43, 1.44, and 1.22 mm in the intraoral stent (-) group and 1.06, 1.11, 1.05, and 0.92 mm in the intraoral stents (+) group, respectively. CONCLUSION: Setup errors can be significantly reduced in the AP and 3D-directions by using intraoral stents.

Trimodality strategy for treating malignant pleural mesothelioma: results of a feasibility study of induction pemetrexed plus cisplatin followed by extrapleural pneumonectomy and postoperative hemithoracic radiation (Japan Mesothelioma Interest Group 0601 Trial).

PURPOSE: We conducted a prospective multi-institutional study to determine the feasibility of trimodality therapy (TMT) comprising induction chemotherapy followed by extrapleural pneumonectomy (EPP) and radiation therapy in Japanese patients with malignant pleural mesothelioma (MPM). METHODS: Major eligibility criteria were histologically confirmed diagnosis of MPM, including clinical subtypes T0-3, N0-2, M0 disease; no prior treatment for the disease; age 20-75 years; Eastern Cooperative Oncology Group performance status 0 or 1; predicted postoperative forced expiratory volume >1000 ml in 1 s; written informed consent. Treatment methods comprised induction chemotherapy using pemetrexed (500 mg/m(2)) plus cisplatin (60 mg/m(2)) for three cycles, followed by EPP and postoperative hemithoracic radiation therapy (54 Gy). Primary endpoints were macroscopic complete resection (MCR) rate for EPP and treatment-related mortality for TMT. RESULTS: Forty-two eligible patients were enrolled: median age 64.5 (range 43-74) years; M:F = 39:3, clinical stage I:II:III = 14:13:15; histological type epithelioid were sarcomatoid; biphasic; others = 28:1:9:4. Of 42 patients, 30 completed EPP with MCR and 17 completed TMT. The trial met the primary endpoints, with an MCR rate of 71 % (30/42) and treatment-related mortality of 9.5 % (4/42). Overall median survival time and 2-year survival rate for 42 registered patients were 19.9 months and 42.9 %, respectively. Two-year relapse-free survival rate of 30 patients who completed EPP with MCR was 37.0 %. CONCLUSION: This phase II study met the predefined primary endpoints, but its risk/benefit ratio was not satisfactory.

The short-term outcomes of induction SOX (S-1 + oxaliplatin) ± cetuximab chemotherapy followed by short-course chemoradiotherapy in patients with poor-risk locally advanced rectal cancer.

PURPOSE: To evaluate the safety and efficacy of induction SOX (S-1 + oxaliplatin) ± cetuximab chemotherapy followed by short-course chemoradiotherapy and surgery in patients with poor-risk locally advanced rectal cancer. METHODS: We enrolled eligible patients with poor-risk rectal cancer defined as T3 lower rectal cancer with mesorectal fascia involvement, T4a or T4b tumors or cases with lateral lymph node swelling. The primary endpoint was a pathological complete response (pCR), and the secondary endpoints were the objective response rate (ORR) and the pathological high response rate (Grade 2 plus 3). RESULTS: Twenty eligible patients were enrolled. The majority (75.0 %, 15/20) of the patients completed four cycles of induction chemotherapy, and all patients completed the radiotherapy (25 Gy/10 fractions/5 days). The global rate of Grade 3-4 toxicities was 30.0 % (6/20 patients). The ORRs were 85.0 % (17/20) and 95.0 % (19/20) in the patients who underwent R0 and R1 resection, respectively. The pathological high response rate was 70.0 % (14/20) and the pCR was 10.0 % (2/20). CONCLUSION: The regimen of induction SOX (S-1 + oxaliplatin) ± cetuximab chemotherapy followed by short-course chemoradiotherapy is safe and is associated with good tumor regression in patients with poor-risk locally advanced rectal cancer.

Clinicopathological outcomes of preoperative chemoradiotherapy using S-1 plus Irinotecan for T4 lower rectal cancer.

PURPOSE: To investigate the clinicopathological outcomes of patients with T4 lower rectal cancer treated using preoperative chemoradiotherapy with S-1 plus Irinotecan. METHODS: Between 2005 and 2011, 35 patients with T4M0 lower rectal cancer, diagnosed initially as T4a in 12 and as T4b in 23, were treated with 45 Gy of radiotherapy concomitantly with S-1 plus Irinotecan. The median follow-up period was 50.6 months (range 2-123 months). RESULTS: A total of 32 patients (91.4 %) completed the radiotherapy and 26 (74.3 %) completed the full chemotherapy regimen. Radical surgery was then performed in 33 (94.3 %) of the 35 patients after the exclusion of two patients, who had macroscopic residual disease. The pathological diagnosis was downstaged from T4a to ypT0-3 in all 12 of those patients (100 %) and from T4b to ypT0-4a in 20 of those 23 patients (87.0 %). The tumor regression grade of 1a/1b/2/3 (complete response) was 10/8/15/2, respectively. In terms of long-term survival, the 5-year local relapse-free survival rate was 74.8 % and the recurrence-free survival rate was 52.0 %. CONCLUSIONS: This regimen may result in favorable downstaging. Moreover, in this series, pathological evidence of involvement of adjacent organs was rare following preoperative chemoradiotherapy, in the patients with disease diagnosed as T4b at the initial staging.

Radiotherapy in late elderly (aged 75 or older) patients with paranasal sinus carcinoma: a single institution experience.

The purpose of our study was to assess the feasibility of radiotherapy (RT) for locally advanced paranasal sinus carcinomas in late elderly patients (aged ≥75 years) from a single institution in Japan. From 2000 to 2015, we retrospectively analyzed 14 patients (11 maxillary and 3 ethmoid sinus carcinoma patients) who underwent RT for pathologically confirmed paranasal sinus carcinomas. RT was performed without unexpected cessations. Two patients, however, developed Grade 3 mucositis. The median follow-up duration was 13 months (range 2-54 months). The 1- and 2-year overall survival (OS) rates were 81.8 and 54.5 %, respectively. The local response rate after the initial treatment was 85.7 %. The 1- and 2-year progression-free survival (PFS) rates were 46.2 and 24.8 %, respectively. Univariate analysis of different clinicopathological parameters was conducted to identify associations with OS and PFS. We demonstrated that intensity modulated radiation therapy (IMRT) of >60 Gy with concomitant intra-arterial (cisplatin-based) infusion chemoradiotherapy led to improved OS and PFS rates, although no statistical significance was observed. Moreover, none of the squamous cell carcinoma (SCC) patients who received 33 fractions of 66 Gy in IMRT died during the median follow-up period of 13 months (range 12-25 months). In conclusion, RT with concomitant intra-arterial (cisplatin-based) infusion chemoradiotherapy can be considered an effective, well-tolerated, and feasible treatment option for late elderly patients with paranasal sinus carcinomas. In addition, >60 Gy of RT in IMRT led to improved survival outcomes in elderly paranasal sinus carcinoma patients.

Feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer.

BACKGROUND: 5-Fluorouracil-based chemotherapy is considered to be a radiosensitizer; however, conventional short-course radiotherapy combined with chemotherapy is generally thought to not be feasible because of the prevalence of side effects. OBJECTIVE: The aim of this study was to evaluate the feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer. DESIGN AND SETTINGS: This study was retrospective in nature and used a prospectively collected database. PATIENTS: Patients with T3 rectal cancer located below the peritoneum reflection were selected. INTERVENTIONS: A total dose of 25 Gy of radiotherapy was administered in 10 fractions of 2.5 Gy each for 5 days. Radiotherapy was performed with S-1 as a radiosensitizer from day 1 to day 10. Surgery was targeted to be performed 4 weeks after radiotherapy. MAIN OUTCOME MEASUREMENTS: The morbidity, sphincter-preserving rate, anal function, and long-term outcomes were assessed. RESULTS: All patients (n = 170) completed the radiotherapy regimen and 166 (97.6%) completed the combination regimen with chemotherapy. A total of 149 patients (87.6%) had sphincter-preserving surgery (double stapling technique (DST), 58 patients; intersphincteric resection (ISR), 91 patients), and postoperative complications were relatively mild (anastomotic leakage, 15.4%; intra-abdominal infection, 8.2%). Among those undergoing sphincter preserving surgery, the 5-year local relapse-free survival rate was 94.3% in the DST group, and 89.8% in the ISR group. With respect to the anal function, the Wexner score the first year after stoma closure for the double-stapling technique group was 6 and that for intersphincteric resection was 15; however, the score for the intersphincteric resection group was improved to 8 at 4 years after stoma closure. LIMITATIONS: This study had limitations because it was an uncontrolled, 1-arm, retrospective review with a small sample size. CONCLUSIONS: Modified short-course radiotherapy combined with chemoradiosensitizer is a feasible approach for treating T3 rectal cancer. With the use of the short-course approach, efforts to reduce the incidence of side effects by appropriately prolonging the waiting period enable the administration of combination treatment with short-course radiotherapy and chemotherapy.

Comparison of the pathological response of the mesorectal positive nodes between short-course chemoradiotherapy with delayed surgery and long-course chemoradiotherapy in patients with rectal cancer.

BACKGROUND: The aim of this study was to compare the pathological response of mesorectal positive nodes between short-course chemoradiotherapy with delayed surgery (SCRT-delay) and long-course chemoradiotherapy (LC-CRT) in patients with rectal cancer. METHOD: The resected primary tumor specimens following the two different approaches were assessed utilizing the tumor regression grade (TRG 0-4), and each positive lymph node was assessed according to the lymph node regression grade (LRG 1-3), with TRG 4 and LRG 3 indicating total regression. The lymph node sizes were measured to elucidate any correlation with LRG scores. RESULTS: Seventy-four patients with ypN-positive rectal cancer had 220 positive lymph nodes following the SCRT-delay, and 48 patients had 141 positive lymph nodes following the LC-CRT. The distribution of LRG 1/2/3 in the two groups was 123/72/25 and 60/31/50 (p < 0.001), respectively, and the distribution of TRG 0/1/2/3/4 in the two groups was 36/19/19/0 and 12/15/20/1 (p = 0.005), respectively. The requirements of total regression of positive lymph nodes were a primary tumor degenerated to TRG 3 with a size less than 6 mm in SCRT-delay (sensitivity, 60.9 %) or a primary tumor degenerated to TRG 2-4 with a size less than 5 mm at TRG 2 (sensitivity, 57.6 %) or 6 mm at TRG 3 and 4 (sensitivity, 84.2 %) in LC-CRT as indicated by the receiver operating characteristic curve analysis. CONCLUSION: The tumor regression effect of LC-CRT on the primary tumor and positive nodes was more favorable than SCRT-delay, and LC-CRT is able to predict the LRG 3 response with a high sensitivity.

The timing of surgery after preoperative short-course S-1 chemoradiotherapy with delayed surgery for T3 lower rectal cancer.

PURPOSE: The purpose of this study was to analyze the influence of variations in clinical practice regarding the timing of surgery with short-course chemoradiotherapy with delayed surgery (SCRT-delay) for lower rectal cancer. METHODS: A total of 171 patients with T3 N0-2 lower rectal cancer treated with SCRT-delay (25 Gy/10 fractions/5 days (S-1); days 1-10) were retrospectively evaluated. The median waiting period of 30 days was used as a discriminator (group A: waiting period, ≤30 days; group B: waiting period, ≥31 days). Preoperative treatment responses and oncological outcomes were analyzed. RESULTS: The mean waiting periods for groups A and B were 24.4 ± 5.3 and 41.4 ± 12.3 days, respectively. There were no statistically significant differences between the two groups in any of the clinical variables. The clinicopathological outcomes were as follows: T downstaging (43.5 vs 37.2 %; p = 0.400), negative yp N (67.1 vs 75.6 %; p = 0.218), pCR (7.1 vs 1.2 %; p = 0.119). The 5-year local recurrence-free survival (89.3 vs 87.6 %; p = 0.956), the recurrence-free survival (82.2 vs 78.8 %; p = 0.662), and the overall survival (88.5 vs 84.4 %; p = 0.741), all of which were similar between the two groups. CONCLUSIONS: The longer waiting period did not increase the tumor downstaging and not improve the oncological outcomes for T3 lower rectal cancer treated with SCRT-delay. In addition, considering that the impaired leukocyte response occurred during the sub-acute period, any time after the sub-acute period (day 12) up to 30 days after radiotherapy would be a suitable waiting period.

Japanese structure survey of radiation oncology in 2009 with special reference to designated cancer care hospitals.

BACKGROUND: The structure of radiation oncology in designated cancer care hospitals in Japan was surveyed in terms of equipment, personnel, patient load, and geographic distribution, and compared with the structure in other radiotherapy facilities and the previous survey. METHODS: The Japanese Society for Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2009. The structures of 365 designated cancer care hospitals and 335 other radiotherapy facilities were compared. RESULTS: Designated cancer care hospitals accounted for 50.0% of all the radiotherapy facilities in Japan. The patterns of equipment and personnel in designated cancer care hospitals and the other radiotherapy facilities were, respectively, as follows: linear accelerators per facility: 1.4 and 1.0; dual-energy function: 78.6 and 61.3%; three-dimensional conformal radiotherapy function: 88.5 and 70.0%; intensity-modulated radiotherapy function: 51.6 and 25.3%; annual number of patients per linear accelerator: 301.3 and 185.2; Ir-192 remote-controlled after-loading systems: 31.8 and 4.2%; and average number of full-time equivalent radiation oncologists per facility: 1.8 and 0.8. Compared with the previous survey, the ownership ratio of equipment and personnel improved in both designated cancer care hospitals and the other radiotherapy facilities. Annual patient loads per full-time equivalent radiation oncologist in the designated cancer care hospitals and the other radiotherapy facilities were 225.5 and 247.6, respectively. These values exceeded the standard guidelines level of 200. CONCLUSIONS: The structure of radiation oncology in designated Japanese cancer care hospitals was more mature than that in the other radiotherapy facilities. There is still a shortage of personnel. The serious understaffing problem in radiation oncology should be corrected in the future.

The oncoprotein and stem cell renewal factor BMI1 associates with poor clinical outcome in oesophageal cancer patients undergoing preoperative chemoradiotherapy.

BACKGROUND: The polycomb group (PcG) family BMI1, acting downstream of the hedgehog (Hh) pathway, plays an essential role in the self-renewal of haematopoietic, neural, and intestinal stem cells, and is dysregulated in many types of cancer. Our recent report has demonstrated that Hh signalling activation can predict very earlier relapse of oesophageal cancers. As data were not available on the clinical role of BMI1 expression in oesophageal cancers after chemoradiotherapy (CRT), we analysed whether it could be also used to predict disease progression and prognosis in oesophageal cancer patients undergoing trimodality therapy of preoperative CRT and oesophagectomy. METHODS: Expressions of BMI1 and p16INK4A, a downstream target of PcG, were analysed in 78 patients with histologically confirmed oesophageal squamous cell carcinoma (ESCC) after preoperative CRT by immunohistochemical staining. The association of BMI1 and p16INK4A expression with clinicopathologic characteristics was analysed by χ2-test. Survival analysis was carried out by the log-rank test using Kaplan-Meier method. RESULTS: Among 78 ESCC patients, 24 patients (30.8%) showed BMI1 positivity, mainly localised in the nuclei of tumour cells. Patients harbouring BMI1-positive tumour cells showed significantly poorer prognoses than those without such cells or residual tumours (mean disease-free survival (DFS) time 16.8 vs 71.2 months; 3-yr DFS 13.3% vs 49.9%, P=0.002; mean OS time 21.8 vs 76.6 months; 3-yr OS 16.2% vs 54.9%, P=0.0005). There was no significant correlation between p16INK4A expression and BMI1 expression. CONCLUSIONS: Our study shows that BMI1 expression is a predictor of early relapse and poor prognosis in ESCC after CRT. These findings suggest that BMI1 signal activation might be involved in promoting cancer regrowth and progression after CRT, and might be indicative of emergence of 'more aggressive' cancer progenitor cells.

Protective Effect of Polaprezinc and Hyperbaric Oxygen Therapy on Radiation-induced Small Intestinal Damage in Mice.

BACKGROUND/AIM: To investigate the effect of polaprezinc (antioxidant) administration and hyperbaric oxygen therapy on radiation-induced intestinal injury. MATERIALS AND METHODS: Forty-five C57BL/6J mice underwent total body radiation of 2 Gy. Polaprezinc was given in 12 mice, hyperbaric oxygen in 12 mice, and both in 12 mice. The other 9 mice did not undergo any treatment. Mice were sacrificed 2, 4, and 6 h after radiation, and 9 specimens (3 each from the duodenum, jejunum, and ileum) were harvested. Apoptotic intestinal crypt cells were histologically evaluated by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. RESULTS: Apoptotic cell number per 1,000 crypt cells was 31.0±6.7 at 2 h, 28.4±5.2 at 4 h, and 32.9±5.1 at 6 h in the mice group treated by radiation alone. Both polaprezinc administration and hyperbaric oxygen therapy significantly suppressed apoptosis. Although the effect of polaprezinc administration on suppressing apoptosis became less over time (4.9±5.7 and 19.4±13.2 at 2 and 6 h, respectively), that of hyperbaric oxygen therapy was stable regardless of time (23.6±4.8 and 25.8±4.1 at 2 and 6 h). Administration of both polaprezinc and hyperbaric oxygen showed a significant synergetic or additive effect on suppressing apoptosis at 6 h (11.4±10.5, p<0.0035 vs. polaprezinc, p<0.0001 vs. hyperbaric oxygen). CONCLUSION: Both polaprezinc administration and hyperbaric oxygen therapy are effective in relieving radiation-induced small intestinal damage, and a synergistic or additive effect is expected when using both.

Neoadjuvant Modified Short-course Radiotherapy for Stage IV Rectal Cancer.

BACKGROUND/AIM: This study aimed to assess the clinical outcomes of neoadjuvant modified short-course radiotherapy (mSC-RT) for rectal metastatic adenocarcinoma. PATIENTS AND METHODS: Data from 14 patients who underwent mSC-RT followed by surgery for primary tumors were retrospectively analyzed. Twelve patients received systemic chemotherapy for 18 weeks. A 2.5 Gy dose twice daily, up to a total dose of 25 Gy in 10 fractions, over 5 consecutive days was administered through mSC-RT. Surgery for primary tumor was performed five weeks (range=3-7 weeks) after mSC-RT. Nine patients underwent adjuvant chemotherapy. The median follow-up was 38.5 months. RESULTS: No patients developed grade ≥3 toxicities before surgery. Three patients developed local failures and 10 died during the follow-up period. The 1-, and 3-year local control rates were 91.7% and 71.3%, respectively. The median overall survival (OS) was 45.1 months. The 1-, and 3-year OS rates were 85.7% and 56.3%, respectively. Patients with stage IVA showed significantly better OS than those with stage IVB disease. CONCLUSION: mSC-RT followed by delayed surgery was well-tolerated and led to good local control in patients with rectal metastatic adenocarcinoma. mSC-RT could be a treatment option for patients with rectal metastatic adenocarcinoma as it is less likely to lead to cessation of systemic chemotherapy.

Japanese structure survey of radiation oncology in 2007 with special reference to designated cancer care hospitals.

BACKGROUND AND PURPOSE: The structure of radiation oncology in designated cancer care hospitals in Japan was investigated in terms of equipment, personnel, patient load, and geographic distribution. The effect of changes in the health care policy in Japan on radiotherapy structure was also examined. MATERIAL AND METHODS: The Japanese Society of Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2007. The structures of 349 designated cancer care hospitals and 372 other radiotherapy facilities were compared. RESULTS: Respective findings for equipment and personnel at designated cancer care hospitals and other facilities included the following: linear accelerators/facility: 1.3 and 1.0; annual patients/linear accelerator: 296.5 and 175.0; and annual patient load/full-time equivalent radiation oncologist was 237.0 and 273.3, respectively. Geographically, the number of designated cancer care hospitals was associated with population size. CONCLUSION: The structure of radiation oncology in Japan in terms of equipment, especially for designated cancer care hospitals, was as mature as that in European countries and the United States, even though the medical costs in relation to GDP in Japan are lower. There is still a shortage of manpower. The survey data proved to be important to fully understand the radiation oncology medical care system in Japan.

[Current status and future direction of Japan's clinical trial for malignant pleural mesothelioma].

The feasibility and efficacy of trimodality therapy for malignant pleural mesothelioma (MPM) are still controversial mainly due to the lack of clinical evidence. Although three major clinical trials on this therapy have been recently reported from North America and Europe, it remains unclear whether results in Caucasian populations may be directly applicable to Asian populations. In this context, as a project of the "Comprehensive approach on asbestos-related diseases" supported by the "Special Coordination Fund for Promoting Science and Technology of MEXT, Japan", a prospective multi-institutional study has been planned to evaluate the feasibility of induction chemotherapy using pemetrexed plus cisplatin, followed by extrapleural pneumonectomy (EPP) and postoperative hemithoracic radiation in patients with resectable MPM. Primary endpoints are macroscopic complete resection rate by EPP and treatment-related mortality for trimodality therapy. The study was initiated in May 2008 and patient enrollment was finished in November 2010.

[A case report of pathologically complete response of rectal cancer after preoperative treatment of CPT-11, S-1, and radiation therapy].

A 52-year-old woman diagnosed with lower rectal cancer was referred to our hospital for the operation of anal sphincter preservation. Rectal examination and colonoscopy showed a type 2 semicircular tumor on the posterior wall at 4 .5-7 cm from anal verge with incomplete mobility (cT3). She was diagnosed as the moderately differentiated tubular adenocarcinoma by biopsy. Computed tomography and magnetic resonance imaging showed no sign of invasion to the surrounding organs and metastasis to lymph nodes or the other organs (cN0, cM0). We performed a preoperative chemoradiotherapy (CRT) combined with S-1 and CPT-11. Radiation (1.8 Gy) was administered a total of 45 Gy( day 1-5, 8-12, 15-19, 22-26, 29-33). S-1 was taken orally( 100 mg/day: day 1-5, 8-12, 22-26, 29-33), and CPT-11 was administered intravenously (60 mg/m²: day 1, 8, 22, 29). Endoscopy after CRT showed a reduction of the tumor size (from semicircular to quarter-circular) and lowering of marginal wall. Rectal examination revealed an improvement of tumor mobility. Eight weeks after CRT, the patient underwent ISR with partial ESR and covering ileostomy pathological examination demonstrated no residual cancer cell in the primary lesion and lymph node (Grade 3, pCR). Preoperative CRT can be a promising tool for locally advanced rectal cancer.

Neoadjuvant Modified Short-Course Radiotherapy Followed by Delayed Surgery for Locally Advanced Rectal Cancer.

This study aimed to assess the clinical outcomes and predictive factors of neoadjuvant modified short-course radiotherapy (mSC-RT) for locally advanced rectal cancer (LARC). Data from 97 patients undergoing mSC-RT followed by radical surgery for LARC were retrospectively analyzed. A 2.5 Gy dose twice daily up to a total dose of 25 Gy in 10 fractions was administered through mSC-RT, and this was delivered with oral chemotherapy in 95 (97.9%) patients. Radical surgery was performed 6 (range, 3-13) weeks after mSC-RT. The median follow-up among surviving patients was 43 (8-86) months. All patients completed neoadjuvant radiotherapy with no acute toxicity grade ≥ 3. Three- and five-year local control rates were 96.3% and 96.3%, respectively. Three- and five-year overall survival (OS) rates were 92.7% and 79.8%, respectively. Univariate analyses revealed that poor OS was associated with no concurrent administration of capecitabine, C-reactive-protein-to-albumin ratio ≥ 0.053, carcinoembryonic antigen ≥ 3.4 ng/mL, and neutrophil-to-lymphocyte ratio (NLR) ≥ 1.83 (P = 0.045, 0.001, 0.041, and 0.001, respectively). Multivariate analyses indicated that NLR ≥ 1.83 was independently associated with poor OS (p = 0.018). mSC-RT followed by delayed surgery for LARC was deemed feasible and resulted in good clinical outcomes, whereas poor OS was associated with high NLR.

Radiation Pneumonitis After Volumetric Modulated Arc Therapy for Non-small Cell Lung Cancer.

BACKGROUND/AIM: To evaluate the incidence and grade of radiation pneumonitis after volumetric modulated arc therapy (VMAT) performed for the treatment of non-small cell cancer (NSCLC). PATIENTS AND METHODS: Fifty consecutive non-surgical candidates with NSCLC underwent VMAT. Thirty-five patients had stage-III tumors and 15 had recurrent tumors. The prescribed radiation dose for the gross tumor and the elective nodal area was 69 Gy in 30 fractions and 51 Gy in 30 fractions, respectively. RESULTS: Radiation pneumonitis developed in 38 patients (76%, 38/50), and grade ≥2 radiation pneumonitis developed in 11 patients (22%, 11/50). The percentage of lung volume that received a dose in excess of 5 Gy (V5), V10, V20, V30, and the mean lung dose (MLD) in the bilateral and ipsilateral lung were significantly associated with the development of grade ≥2 radiation pneumonitis. CONCLUSION: The incidence and degree of radiation pneumonitis are acceptable following treatment of NSCLC with VMAT.

Influence of chemoradiotherapy on nutritional status in locally advanced rectal cancer: Prospective multicenter study.

OBJECTIVE: The aim of this study was to investigate the influence of chemoradiotherapy (CRT) on nutritional status and the association between changes in nutritional status and clinical outcomes (treatment completion, adverse events, perioperative complications, and relapse-free survival [RFS]) in patients with locally advanced rectal cancer (LARC). METHODS: In this multicenter, phase II study, 41 patients with LARC underwent CRT for 5 wk, followed by a 6- to 8-wk interval before surgery. Body weight, body mass index (BMI), lean body mass, serum albumin, and prealbumin levels were measured before (pre-), during, and after CRT, and before surgery. Changes in these data and scores on the Malnutrition Universal Screening Tool (MUST) were calculated based on pre-CRT status. RESULTS: Twelve patients (29.3%) experienced body weight loss (BWL) ≥5% (defined as malnutrition) after CRT (P < 0.001) and before surgery (P = 0.035). Significant changes were seen in serum albumin levels and BMI during and after CRT (P < 0.001), and in MUST scores after CRT (P = 0.003) and before surgery (P = 0.035). Treatment completion was significantly associated with BWL (P = 0.028), MUST score (P = 0.013), and decreased serum albumin level (P = 0.001) after CRT. Regarding adverse events, MUST score before surgery (P = 0.009) and serum albumin level after CRT (P = 0.002) were significantly associated with diarrhea severity. Serum albumin level during CRT was associated with the onset of neutropenia (P = 0.005). No association was found between BWL and RFS. CONCLUSIONS: These findings suggest that malnutrition and changes in nutritional status are not only commonly observed after CRT, but also associated with treatment completion and adverse events.