The value of treatment planning using CT and an immobilizing shell in radiotherapy for paranasal sinus carcinomas.

This article describes a method which uses CT scans and immobilizing shells radiation treatment planning (CT-assisted planning) for paranasal sinus carcinomas and the value of this method on the treatment outcome. Results of the treatment for 82 patients who had CT-assisted planning were compared with that of 88 patients who had no such treatment planning. It has been concluded that the combined use of CT and the shell in treatment planning permitted a 3-dimensional localization of both the tumor and critical normal structures with great accuracy, leading to an improved long-term survival and a reduced complication rate. The multivariate regression analysis for predicting significant prognostic factors also confirmed the valuable role of CT in terms of survival and primary tumor control. The actuarial 5-year survival rate was 51% in all patients, whereas, by using CT-assisted planning, it was improved to 61%. The improved survival was observed among the patients with tumors of the suprastructures where tumors were located adjacent to the critical organs (brain and eye). Major complications attributable to radiation have included instances of brain and ocular damage. CT-assisted planning, however, has been proven effective in avoiding brain necrosis and preserving eye sight.

Clinical experience--16 months of HU-PACS.

Sixteen months experience with HU-PACS (Hokkaido University PACS) is reported. This report describes the hardware and software aspects of HU-PACS in its working state. Evaluation of the system is also reported, and usefulness of PACS concludes paper.

Early changes in blood flow of the mouse skin after irradiation as measured by the 133Xe clearance method.

The early effects of radiation on the local blood flow in the skin of mice were evaluated by measuring the local clearance rate of 133Xe after its subcutaneous injection; this was done at four to five weeks after irradiation during the animals' normal resting conditions. The fractionation schedules employed were single fractions, two fractions in 15 days and four fractions in 15 days. The dose effect curves with these schedules showed a two-component pattern. There was a uniform reduction in flood flow after 10 to 30 Gy, and a steady increase in flood flow after doses more than 40 Gy. The blood flow after higher-fractionated doses was always lower than after less-fractionated doses. It was considered that radiation doses causing higher severity of acute skin reactions might have predominated a degree of acute vasodilatation over fibrotic changes, thus resulting in increased blood flow. A steady increase in early blood flow was observed with increasing severity of acute skin reactions, but the early blood flow was not a good indicator for predicting late skin reactions, except for a severe leg deformity which was accompanied with a significant increase in early blood flow.

An experience with slit beam rotation therapy (SBRT).

A new rotation therapy technique using slit beams of 10 Mev X-rays (3.3 mm X 50 mm at isocenter FCD 100 cm) was developed. The dose distribution of a 360-degree rotation of the slit beam described above is similar to that of a 137-Cs needle. The axes of a 360-degree rotation of the slit beam were arranged to cover the target volume to produce a dose distribution similar to interstitial irradiation. This technique was named as the slit beam rotation therapy. Twenty patients who had radioresistant tumors or were difficult to control by conventional therapy have been treated with this technique, combined with or without conventional external beam irradiation, since 1982. Eight out of ten extracranial lesions showed good regression and a palliative effect was obtained without severe morbidity. A one year survival rate of 67% in six patients with glioblastoma multiforme was achieved by this method. Although the feasibility study is still in progress, this new treatment technique looks highly promising.

Long-term results of treatment with mild toxicities in small cell lung carcinoma.

Results of treating small cell lung carcinoma with mild toxicities were investigated retrospectively. From 1974 to 1981, 38 patients were treated according to three institutional protocols: radiation alone (RAD), radiation with ifosfamide (IFOS), and radiation with adriamycin, vincristine, and cyclophosphamide (AOC). Of the three five-year survivors, two were treated with IFOS and one with RAD. The time period between admission and the beginning of radiotherapy was longer and the treatment field smaller in AOC than in the other two protocols. IFOS and RAD showed less toxicity. Our study indicated that IFOS and RAD should be regarded as curative treatments for limited disease and are suitable for patients who do not have sufficient bone marrow reserve.

Ultrasonographic measurement of tumor regression in radiation therapy.

Ultrasonography was evaluated as a measurement procedure for investigating the tumor regression of cervical lymph nodes. Preliminary results suggested that interobserver compatibility in the measurement of nodes deteriorates when the diameter of the node is less than 15 mm. There was no systematic disparity between ultrasonographic and manual measurements. The tumor regression line fit the exponential line with a correlation coefficient of more than 0.95 in seven of 16 nodes. During the sequential examination, a central low-echo area suddenly appeared in one node at 15 Gy/6 Fr.

A "supralethal dose phenomenon" revealed by cancer of the maxillary sinus.

In this paper a so-called "supralethal dose phenomenon" is reported. Two groups of patients, all of whom were carrying proved squamous cell carcinoma of the same clinical stage in their maxillary sinuses, were compared after radiotherapy in our department. The radiotherapies applied to the two groups were very similar in terms of fraction number, treatment period, dose distribution and immobilization technique, but differed in dose, i.e., 5,500 cGy for one group of 9 patients and 5,750 cGy for the other group of 20 patients. The five-year survival rates of the two groups were 8/9 and 10/20, respectively, and the difference was statistically significant (p less than 0.05). All patients were observed for at least five years. Except for tumor stage, the status of the patients in the two groups, including primary site of the tumor in the sinus, patients' age and cause of death for the failed cases, are also discussed in detail.

CT-aided volumetry and prognosis in cervical carcinoma.

Since January 1981, 128 CT evaluations were systematically applied to 85 patients of histologically proven squamous cell carcinoma of the cervix uteri before and after external irradiation (i.e., at the beginning of intracavitary therapy). CT-measured cervical mass volume and mass-pelvic wall distance were analyzed in relation to prognosis, namely, local control at one year after irradiation and three-year survival. Regardless of clinical stage, CT-measured volume and mass-pelvic wall distance were revealed to be closely related to prognosis. In 46 patients whose cervical mass volume regressed to less than 48 cm3 after external irradiation, 44 (95.6%) were locally controlled for more than a year, and the three-year actuarial survival of this group was 71.6 + 6.2%. On the contrary, in those whose volume was over 48 cm3 at the end of external irradiation, only 3 out of 18 were locally controlled, and the three-year survival was 7.4 + 6.0. Mass-pelvic wall distance was also related to tumor control. CT was found to provide fairly objective, reproducible information for detecting the high-risk subgroup in cervical carcinoma under uniform treatment conditions.

Results of prophylactic adjuvant chemotherapy for early stage non-Hodgkin's lymphoma of the head and neck.

Results were reviewed in 46 patients who had stage I and II head and neck non-Hodgkin's lymphoma, and received five to six cycles of CVP chemotherapy after regional irradiation. Disease-free survival, pattern of relapse, and time of relapse were compared with those of 64 patients, who received regional irradiation alone. Adjuvant, post irradiation CVP significantly improved five-year survival in stage I (and IE) disease, 49.6% to 81.9% (p less than 0.05), but was less successful in patients with heavier tumor burden, such as stage II disease or advanced loco regional disease in Waldeyer's ring (48.3% to 63.7%; p greater than 0.10 in stage II patients). In addition, in those who relapsed, the time and pattern of relapse were not altered by adjuvant CVP chemotherapy. This easily tolerated, mild adjuvant chemotherapy, we conclude, failed to prove significant in preventing relapse, especially in patients with heavier tumor burden.

HU-PACS. 10 months experience.

An outline of the Hokkaido University PACS (HU-PACS) and 10 months experience of its clinical use are reported. It is concluded that HU-PACS is a useful clinical tool, even though some points still remain to be improved.

Telephone line transfer using a local filing system in Hokkaido.

An image-data transfer system using a public telephone line has been constructed between Hokkaido University Hospital (HUH) and Nakashibetsu Town Hospital (NTH). The latter is situated about 420 km from Sapporo and does not have full-time radiologists. A local filing system coupled with a film reader and an optical disk had been installed in HUH in 1986, and in NTH in 1988. Both systems were connected by a public telephone line along which the transfer speed is 9600 bps. Images originating at NTH, mostly CT, were digitized by the film reader and sent to HUH after compression at a ratio of about 5:1 to 10:1. Clinical information concerning a patient was also sent to HUH using facsimile. Radiologists interpreted the transferred data (12 CT images on a film) on the CRT and sent back a written report to NTH using facsimile. The system and its image quality are largely acceptable, especially in an emergency case for brain and abdomen, although the transfer of a film takes about 7 to 20 min.

User requirements and standards for PACS. 2nd Japan-Nordic PACS Symposium.

PACS has been regarded as a system which will bring a new era to image handling, radiology departments and its services to other departments of the hospital. However, many recently held international conferences indicate that a worldwide consensus on 'what is PACS, why is PACS needed and who is PACS for' has not been established. Although the actual PACS implementation will vary among the countries and according to each situation, a worldwide consensus of PACS should be possible. This would help those involved to speed up the implementation of PACS. It is suggested that this consensus needs to be developed by convergence of three points of view; the availability, maturity and cost of the technologies on which PACS is built, the user requirements for PACS and standardization in PACS. These themes were the topics of the 2nd Japan-Nordic PACS Symposium which was arranged in Tampere, Finland, June 9-11th 1991. A summary of the papers and discussions of the symposium is produced in this paper.

[The role of radiotherapy in small cell lung cancer].

From 1974 to 1984, we have treated 70 patients with SCLC using radiotherapy (RT) alone or in combination with chemotherapy (CT). It was demonstrated that a heavy CT regimen causing a severe toxicity did not always cause good results. On the other hand, there was a long-term survivor in those patients who were treated with RT alone. Considering from our results as well as from reviews of literatures, it is evident that RT can reduce a significant number of local relapses but has little effect on systemic disease. Therefore, RT added to CT seems to improve a long-term survival specifically in those patients in whom CR is induced from CT. The characteristics of the long-term survivors treated with combined treatment are: limited disease, thoracic RT, good PS, only single site of metastases. In conclusion, there is no doubt that CT plays an important role in the management of SCLC. However, its efficacy is still far from desired, and a new type of CT is warranted.

[Contribution of CT and MRI to radiation therapy].

The contribution of CT to radiation therapy has been enormous. The most basic contribution has been that CT has made almost all malignant tumors visible, which has improved radiation therapy not only in the planning phase but also in the effect-estimating phase. As some examples, CT has improved the effects of radiation therapy for cancer of the maxillary sinus and of the uterine cervix, and the results from our department have already been published. The contribution of MRI to radiation therapy should be very great in future wherever MRI diagnostics are established. Even now, however, its ability to visualize cross-sectional anatomy in any area is an aid to radiation therapy both in planning and in estimating the degree of effect.

[Combined chemotherapy and radiotherapy in recurrent tumors of the head and neck region].

Over the past four years, 27 patients with recurrent tumors of the head and neck region have been treated with chemotherapy. The regimens used were BCMF (bleomycin 15 mg i.v. for 3 days, cyclophosphamide 500 mg i.v., methotrexate 50 mg i.v. and 5-fluorouracil 500 mg i.v.) and CMU (cyclophosphamide 350 mg/m2 i.v., methotrexate 30 mg/m2 i.v. and UFT 600 mg p.o. for 14 days). Of the 27 patients, eight were treated with combined radiation and chemotherapy, and either CR or PR was obtained. Nineteen patients were treated with chemotherapy alone, for which the response (CR + PR) rates were 8% (1/12) for BCMF and 43% (3/7) for CMU, respectively. No serious toxicities were observed as a result of these regimens. It was thus demonstrated that the CMU regimen was of great value in terms of improved response and minor toxicity in the treatment of head and neck tumors.

[A case of icteric hepatoma which succeeded internal fistulation after radiotherapy].

A case of icteric hepatoma was treated by TAE, arterial chemoinfusion and photoirradiation to the hepatic hilum. The patient was successfully discharged after radiotherapy, which was most effective for internal fistulation of obstructed bile duct and decreasing the size of portal tumor thrombus.

[Cystic thyroid masses: ultrasonographic and pathologic correlation].

Forty-nine patients with 63 cystic thyroid masses who had undergone preoperative sonography were retrospectively reviewed. 52 lesions (83%) were benign and others (17%) were malignant. Among various sonographic findings of cystic thyroid masses, oval cystic lesions with polyp or dome like solid component projecting into the lumen were all diagnosed adenomatous goiter. Irregular cystic structures with more than 2 cm finger like pedunculated mass extended into and/or out of the lumen were all diagnosed papillary carcinoma. Small oval cysts (less than or equal to 1 cm) with strong echo were all diagnosed colloid goiter. The other sonographic type of cystic thyroid masses had somewhat malignancy (12-30%), not having characteristics which differentiate benign from malignant lesions. Pathologic findings of malignant lesions showed that cancer cells existed rather in pericystic portion than in cyst wall except for finger like solid component projecting into the lumen which was papillary carcinoma itself. Ultrasonically guided needle biopsy should be performed to get samples of above portions.

[Thirty years of Radiology Department in Hokkaido University Hospital (author's transl)].

Thirty year's history of the Radiology Department of the Medical School of Hokkaido University, the first department of its kind in Hokkaido, is shortly reviewed. Statistics include the number of staff, equipment and patients diagnosed or/and treated in the department. Sections have been formed in the department since several years ago and are functioning to a certain extent independently in order to keep pace with the development of modern medicine and to meet the needs of our hospital. These sections are mainly radiation therapy, nuclear medicine, neuroradiology, X-ray diagnosis in angiology and for the digestive tract. Diagnosis based upon ultrasonography and CT are also becoming recognized sections in the department recently. Further more data processing and statistics seem to grow to become a section in the near future. In conclusion the number of staff, equipment and patients has been and perhaps will be growing increasingly fast. The increasing number of sections which resulted from the establishment of new specialities makes us to anticipate the new and independent departments in addition to the existing one.

[Ultrasonography of the extremities: nontumor lesions].

Ultrasonographic imagings of non-tumor disorders in extremities were reviewed and discussed. All cases underwent surgery. In our retrospective evaluation, US was found to be effective in cases of tendon injuries, articular osteochondritis, tenosynovitis and the displacement of chondral navicula in infantile club foot, etc.

[CT of pulmonary eosinophilic granuloma].

CT findings of four cases of pulmonary eosinophilic Granuloma were discussed. In three cases, multiple nodular shadows or multiple cavitary lesions were observed in upper and middle lung field predominant. However, in one patient who had history of recurrent pneumothorax, CT revealed a honeycomb appearance and some bullous change as well. These findings seemed to represent a far advanced state of the disease. X-ray CT is excellent in demonstrating such pathological changes, and is indispensable in the diagnosis and follow up study of pulmonary eosinophilic granuloma.