Evaluating photoneutron dose equivalents for lung cancer using PMMA phantoms undergoing 15 MV IMRT.

BACKGROUND: According to statistics of the Ministry of Health and Welfare in 2017, the second leading cause of death in Taiwan was lung cancer. OBJECTIVE: Routine treatment planning does not consider photoneutron dose equivalent (PNDE) of patient induced secondary radiation resulting from primary exposure of lung cancer. However, such treatment is potentially important for improving estimates of health risks. METHODS: This study used 10, 30, 50, 70, and 90 kg of polymethylmethacrylate (PMMA) phantoms as patient to measure PNDE varying anatomical area during lung cancer of intensity modulated radiotherapy (IMRT) treatment. Paired thermoluminescent dosimeters (TLD-600 and 700) were calibrated using university reactor neutrons. TLDs were inserted into phantom which was closely corresponded of the represented tissues or organs. RESULTS: Neutron doses (ND) of organ or tissue (N⁢DT) were determined in these phantoms using paired TLDs approach. The risks of incurring fatal secondary malignancies, maximum statistical and total errors were estimated. Evaluated PNDE ranged from 0.80 ± 0.12 to 0.56 ± 0.08 mSv/Gy for these phantoms. CONCLUSION: The estimated N⁢DT decreased with increasing distance that is from the central axis. Evaluated PNDE and N⁢D𝑠𝑘𝑖𝑛 for these phantoms were discussed. This investigation also identified secondary risks associated with PNDE relating to radiation protection.

Prolonged survival of a patient with cervical intramedullary glioblastoma multiforme treated with total resection, radiation therapy, and temozolomide.

We report a case of prolonged survival in a patient with cervical intramedullary glioblastoma multiforme (GBM) treated with total resection, radiotherapy, and temozolomide. A 26-year-old woman complaining of midline lower cervical pain, insidiously progressive motor weakness, paresthesia, and urinary incontinence was admitted to our institution. MRI showed an intramedullary mass lesion in the C2-C6 level, which was considered to be an ependymoma or astrocytoma. Total resection of the tumor was performed at the C2-C6 level by laminoplasty with miniplate, followed by chemoradiotherapy (focal irradiation dose of 5000, at 200 cGy per fraction for over a period of 5 weeks) with concomitant temozolomide (75 mg/m2). Histologic examination of the resected tumor confirmed GBM. The tumor consisted of a markedly pleomorphic neoplasm measuring 4.6 cm×2.6 cm×1.7 cm and characterized by necrosis, atypical mitotic figures, and endothelial proliferation. Postoperative MRI showed a centrally located, postoperative cavity at the C2-C6 level. Recurrence in the cervical spine without brain GBM metastasis was identified 25 months after operation, and temozolomide chemotherapy was reinitiated; however, the tumor progressed, and the patient died 33 months after operation. We suggest that, in addition to potential factors of tumor biology, multimodal treatment consisting of total resection of intramedullary GBM coupled with radiation therapy and temozolomide may have prolonged the survival of this patient.

Prediction of outcome of patients with metastatic breast cancer: evaluation with prognostic factors and Nottingham prognostic index.

GOALS OF WORK: The purpose of this study is to analyze the survival rate of patients with metastatic breast cancer and to evaluate the outcome of these patients using prognostic factors and Nottingham prognostic index. MATERIALS AND METHODS: From February 1992 to August 2008, 135 patients with metastatic breast cancer were treated at the Changhua Christian Hospital. In these patients, we evaluated the significance of the following factors in predicting the survival rate after the occurrence of metastasis: age, initial stage at primary diagnosis, histological grade, Karnofsky performance status (KPS), estrogen receptor (ER), progesterone receptor status, human epidermoid growth factor receptor 2 overexpression status, number of axillary lymph node metastasis, history of adjuvant radiotherapy and/or chemotherapy, disease-free interval, status of local recurrence, status of various sites of distant metastases, number of distant metastases, and Nottingham prognostic index. MAIN RESULTS: The 1-, 2-, and 5-year survival rates were 53.3%, 25.2%, and 1.5%, respectively. In the univariate analysis, KPS, histological grade, ER status, initial stage at primary diagnosis, number of axillary lymph node metastasis, liver metastasis, disease-free interval, first-/second-/third-line chemotherapy for recurrence or metastasis, number of metastases, and Nottingham prognostic index had significant impact on survival. The median survival of patients determined as corresponding to Nottingham low-risk group, intermediate-risk group, and high-risk group was 29.3, 17.9, and 4.6 months, respectively. In our multivariate analysis, Karnofsky performance status (p = 0.030) and Nottingham prognostic index (p ≤ 0.0001) were significant prognostic factors for survival, while first-/second-/third-line chemotherapy for recurrence or metastasis (p = 0.002) was a significant predictor for the outcome of the treatment. CONCLUSIONS: The prognosis of patients with metastatic breast cancer is poor. In spite of the fact that many advances in treatment have been made, numerous additional questions have arisen; new drugs and therapeutic regimens are needed to improve the outcomes of patients, and further well-designed randomized trials are warranted.

Prognostic significance of lung radiation dose in patients with esophageal cancer treated with neoadjuvant chemoradiotherapy.

BACKGROUND: The prognostic significance of radiation dose to the lung or heart is unknown in esophageal cancer patients receiving neoadjuvant chemoradiotherapy followed by surgery (trimodal therapy). This study aimed to determine the association between lung and heart radiation dose volumes and prognosis of esophageal cancer after trimodal therapy. METHODS: This study reviewed 123 esophageal cancer patients treated with trimodal therapy in two tertiary institutions between 2010 and 2015. The dose-volume histogram parameter of Vx was defined as the percentage of total organ volume receiving a radiation dose of x (Gy) or more. Predictors of overall survival (OS) were identified using Cox regression models. Receiver-operating characteristic curves were used to select cut-off values for dose-volume. RESULTS: Median follow-up was 28.3 months (range: 4.7-92.8 months). Median OS and progression-free survival were 34.0 months (95% confidence interval [CI]: 27.4-40.6 months) and 24.8 months (95% CI, 18.9-30.7 months), respectively. Multivariate analyses showed that lung V20 (hazard ratio, 1.09; 95% CI: 1.04-1.14; p < 0.001) and lung V5 (hazard ratio, 1.02; 95% CI: 1.00-1.05; p = 0.03) were associated with OS when adjusting for surgical margin and pathological treatment response. The 5-year OS for patients with lung V20 ≤ 23% vs. patients with lung V20 > 23% was 54.4% vs. 5% (p < 0.001) whereas that for patients with lung V5 ≤ 56% vs. patients with lung V5 > 56% was 81.5% vs. 23.4% (p < 0.001). Mean heart dose showed no association with survival outcomes. CONCLUSIONS: Lung radiation dose was independently associated with survival outcomes in esophageal cancer patients treated with neoadjuvant chemoradiotherapy and surgery.

Minimally invasive endoscopic nasopharyngectomy in the treatment of recurrent T1-2a nasopharyngeal carcinoma.

OBJECTIVE: To study the efficacy of endoscopic nasopharyngectomy in salvaging recurrent T1 to 2a nasopharyngeal carcinoma (NPC). STUDY DESIGN: An investigation of the outcome of endoscopic nasopharyngectomy. METHODS: Six nasopharyngectomies for patients presenting with locally recurrent T1 to 2a NPC were performed exclusively by way of endoscopic resection by a single surgeon (m.-k.c.) during the period 2001 to 2005. All patients were operated on with curative intent without postoperative radiotherapy. RESULTS: All six operations were successfully performed endoscopically, and no conversions to conventional open resection were necessary. Of the patients who underwent endoscopic excision, three of them had rT1 disease, and the others had rT2a disease. No surgical specimens had microscopic invasion of the resection margins. No complications associated with the operation occurred. The patients were followed up for 16 to 59 (average, 29) months. One local recurrence was noted in this series to date, and the patient was treated with intensity-modulated radiotherapy and chemotherapy. CONCLUSIONS: Exclusively endoscopic nasopharyngectomy is a feasible method for treatment of locally recurrent T1- to 2a-staged NPC.

Effect of preoperative concurrent chemoradiotherapy in locally advanced low rectal cancer after radical resection surgery.

To evaluate the outcome of patients with locally advanced low rectal adenocarcinoma who required preoperative concurrent chemoradiotherapy (CCRT), a total of 22 patients underwent preoperative CCRT and radical resection for locally advanced low rectal adenocarcinoma. Patients received concurrent chemotherapy with high-dose 5-fluorouracil (5-FU) in continuous infusion and leucovorin and preoperative radiation with a mean dose of 50.4 Gy (range, 45-50.4 Gy). Radical resection surgery was performed 6 weeks after treatment. Fifty-five percent of patients achieved tumor downstaging, and 14% patients. showed pathological complete remission. No severe hematological and gastrointestinal toxicity of preoperative CCRT was noted. Sphincter-saving rate was 82%, and there were no deaths related to preoperative CCRT and surgery. Overall, 3-year survival rate was 69%, and a rate of locoregional recurrence was 13.6%. This study shows that many patients with locally advanced rectal cancer can be operated on with sphincter-saving radical resection surgery under good local control after preoperative concurrent chemoradiotherapy, which induces tumor downstaging.

Primary breast lymphoma: a pooled analysis of prognostic factors and survival in 93 cases.

BACKGROUND: Primary breast lymphoma is a rare disease. The small number of patients and the paucity of data make large-series studies difficult. We conducted a pooled analysis to evaluate the treatment outcome and prognostic factors in patients with primary breast lymphoma. METHODS: In a search of PUBMED and MEDLINE we found 7 observational studies with 93 patientsthatwere eligible for inclusion. Treatments included single therapy or combined surgery, chemotherapy and radiotherapy. We analyzed the correlation between treatment protocols, tumor relapse and survival. Histopathology and cancer stage were analyzed to evaluate their significance in treatment outcome. RESULTS: All 93 patients were female, with a mean age of 57 years. The histopathology of 63 patients (68%) was diffuse large cell lymphoma. According to Ann Arbor classification, 57% were stage I, 23% were stage II, 4% were stage III, and 16% were stage IV. Thirteen percent received surgery alone, 27% received chemotherapy alone, 7% received radiotherapy alone, 10% received surgery and chemotherapy, 10% received surgery and radiotherapy, 22% received chemotherapy and radiotherapy, and 11% received surgery combined with chemotherapy and radiotherapy. With a median follow-up duration of 34 months (mean, 53 months), 48% had relapse of disease, 50% had no relapse, while 2% had disease progression. The mean time to first tumor relapse after treatment was 20 months. The 3-year and 5-year overall survival rates were 70% and 56%, respectively. Radiotherapy was a significant prognostic factor predicting tumor relapse (P=0.044). Tumor stage was a significant prognostic factor affecting overall survival, disease-free survival and disease-specific survival (P=0.0231, 0.0015, 0.0124, respectively). CONCLUSION: With a 3-year overall survival rate of 70%, the high relapse rate of 48% is a cause for concern. Patients who received chemotherapy and radiotherapy had better survival outcome and a lower relapse rate. We suggestthat chemotherapy and radiotherapy be the initial treatment for patients with primary breast lymphoma.

Prognostic Value of Molecular Markers and Implication for Molecular Targeted Therapies in Nasopharyngeal Carcinoma: An Update in an Era of New Targeted Molecules Development.

The aim of the study was to evaluate the prognostic significance of molecular biomarkers which could provide information for more accurate prognostication and development of novel therapeutic strategies for nasopharyngeal carcinoma (NPC). NPC is a unique malignant epithelial carcinoma of head and neck region, with an intimate association with the Epstein-Barr virus (EBV). Currently, the prediction of NPC prognosis is mainly based on the clinical TNM staging; however, NPC patients with the same clinical stage often present different clinical outcomes, suggesting that the TNM stage is insufficient to precisely predict the prognosis of this disease. In this review, we give an overview of the prognostic value of molecular markers in NPC and discuss potential strategies of targeted therapies for treatment of NPC. Molecular biomarkers, which play roles in abnormal proliferation signaling pathways (such as Wnt/ß-catenin pathway), intracellular mitogenic signal aberration (such as hypoxia-inducible factor (HIF)-1α), receptor-mediated aberrations (such as vascular endothelial growth factor (VEGF)), tumor suppressors (such as p16 and p27 activity), cell cycle aberrations (such as cyclin D1 and cyclin E), cell adhesion aberrations (such as E-cadherin), apoptosis dysregualtion (such as survivin) and centromere aberration (centromere protein H), are prognostic markers for NPC. Plasma EBV DNA concentrations and EBV-encoded latent membrane proteins are also prognostic markers for NPC. Implication of molecular targeted therapies in NPC was discussed. Such therapies could have potential in combination with different cytotoxic agents to combat and eradicate tumor cells. In order to further improve overall survival for patients with loco-regionally advanced NPC, the development of innovative strategies, including prognostic molecular markers and molecular targeted agents is needed.

The effect of a metal hip prosthesis on the radiation dose in therapeutic photon beam irradiations.

Prostate and cervical cancer patients are often treated with external X-ray beams of bi-lateral incidence. Such treatment may incur some dose effect that cannot be predicted precisely in commercial treatment planning systems (TPS) for patients having undergone total hip replacement. This study performs a Monte Carlo (MC) simulation and an analytical calculation (convolution superposition algorithm which is implemented in ADAC TPS) of a 6 MV, 5 x 5 cm2 X-ray beam incident into water with the existence of hip prosthesis, e.g. Ti6A14V and CoCrMo alloy. The results indicate that ADAC TPS cannot precisely account for the scatter and backscatter radiation that a metal hip prosthesis causes. For percent depth dose (PDD) curves, the maximum underdosage of ADAC TPS up to 5mm above the interface between dense material and water is 5%, 20% and 27% for PDD(Bone), PDD(Ti) and PDD(Co), respectively. The dose re-buildup, which occurs behind the hip region, becomes more and more obvious for denser medium existed in water. Increasing inhomogeneity also enhances the underdosage of ADAC for greater depth (> 10cm), as the figures of nearly 2% in PDD(Bone), PDD(Ti) and 4-5% in PDD(Co) reveal. Overestimating the attenuated power of high-density non-water material in ADAC TPS causes this underdosage. For dose profiles, no significant differences were found in Profile(Bone) at any depth. Profile(Ti) reveals that MC slightly exceeds ADAC at off-axis position 1.0-2.0 cm. Profile(Co) reveals this more obviously. This finding means that scatter radiation from these denser materials is significant and cannot be predicted precisely in ADAC.

Chemotherapy with modified docetaxel, cisplatin, and 5-fluorouracil in patients with metastatic head and neck cancer.

INTRODUCTION: This retrospective study evaluates the efficacy of palliative chemotherapy with a modified docetaxel, cisplatin, 5-fluorouracil (5-FU; "TPF" regimen) regimen (mTPF; reduced doses of docetaxel, cisplatin, and 5-FU with reduction of intravenous 5-FU from 4 days to 2 days) in Asian patients with recurrent and metastatic squamous cell carcinoma of head and neck (HNSCC) after surgery and adjuvant chemoradiation. METHODS: The mTPF regimen was used in this study. Fifty-five patients (from January 2007 to October 2009) received docetaxel on day 1, followed by cisplatin and 5-FU administered continuous infusion on day 2 for another 48 hours every 3 weeks for three to six cycles. RESULTS: The disease control rate was 81%. The overall response rate was 56%. Five patients achieved complete remission; 26 patients had partial remission; 14 patients had stable disease. Ten patients had disease progression. The metastatic sites that responded well to mTPF regimen (either complete or partial remission) were: neck lymph node, lung, liver, and skin. The median follow-up was 15 months (range 1-28 months). The median overall survival was 10 months (range 2-28 months). The common nonhematological toxicity was alopecia and the most common hematological adverse event was neutropenia. Thirty-one patients (56%) had grade 3-4 neutropenia. CONCLUSION: The mTPF chemotherapy regimen is efficacious for the palliative treatment of recurrent and metastatic HNSCC in Asian patients.

Distribution of spatial photoneutrons inside a 70kg water phantom via neutron activation analysis.

This study evaluated spatial Phi(th) inside a 70kg water phantom using the NAA method. Fifty indium foils were placed inside the water phantom and exposed under 15MV LINAC for 2.5min to yield the 10Gy X-ray dose. The Phi(th) value at the isocenter of the water was 1.03x10(6)ncm(-2)/Gy-X, and the maximum quantity of Phi(th) appeared at the water surface along the z-axis, 3.99x10(6)ncm(-2)/Gy-X. The thermal neutron dose at isocenter of the water phantom occupied approximately 0.151% of the whole photo and neutron dose.

Small cell carcinoma of the head and neck: a single institution's experience and review of the literature.

OBJECTIVES: It is well known that small cell carcinoma (SmCC) arising at extrapulmonary sites leads to a poor prognosis for patients. Owing to the infrequency of primary SmCC of the head and neck, it is very unlikely that any large, controlled study will ever be performed. For this reason, recommendations for the treatment of SmCC arising in the head and neck are based primarily on retrospective data from various small case series. PATIENTS AND METHODS: We report five patients with SmCC of the head and neck seen between 2001 and 2007. In two patients, the SmCCs are in the larynx; in another two patients, in the sinonasal region; and in one patient, in the tonsil. RESULTS: Four patients accepted concurrent chemoradiation therapy (CCRT). Their outcomes are as follows: two patients died, one has adrenal and bone metastasis but is still alive, and one shows no evidence of disease after treatment. One patient refused CCRT and died within 6 months. CONCLUSIONS: The prognosis for patients with primary SmCC of the head and neck is generally poor. Treatment most often involves a combination of radiotherapy and chemotherapy, and hope for improved outcomes hinges principally on the development of improved chemotherapies and other systemic treatments.

Prognostic factors affecting the outcome of brain metastases from breast cancer.

GOALS OF WORK: The purpose of this study is to analyze the overall survival rate of patients with brain metastases from breast cancer and to determine prognostic factors affecting outcomes of these patients. PATIENTS AND METHODS: From July 1988 to December 2004, 48 female patients with brain metastases from breast cancer underwent full-dose whole-brain radiotherapy (WBRT). In these patients we evaluated the significance of the following factors in predicting the survival rate after WBRT: age, extracranial metastases, number of brain metastases, total dose of WBRT, Karnofsky performance status (KPS), and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class. RESULTS: The median overall survival rate was 7.3 months. The 1- and 2-year overall survival rates were 37 and 20%, respectively. In univariate analysis, KPS (p<0.0001), number of lesions of brain metastases (p=0.0149), age (p=0.0452), and RPA class (p<0.0001) were statistically significant prognostic factors for overall survival. In multivariate analysis, KPS (p<0.001) and number of brain metastases (p=0.039) were significant prognostic factors for overall survival. CONCLUSIONS: Survival of breast cancer patients with brain metastases treated with WBRT is poor. To improve survival, enrollment of more patients with brain metastases from breast cancer for prospective trials involving a multimodality approach that combines radiation and systemic therapies based on appropriate patient triage is warranted.

The effect of primary tumor volumes in advanced T-staged nasopharyngeal tumors.

BACKGROUND: Tumor volume is an important prognostic factor in patients with malignancy treated with primary radiotherapy. It is necessary to have a clear understanding of the nasopharyngeal primary tumor volume and the treatment outcome, especially in the advanced T-staged tumors. METHODS: From 1994-1996, 76 newly diagnosed patients with advanced T-staged nasopharyngeal carcinomas who were treated with high-dose radiotherapy with or without chemotherapy were included in this study. CT-derived primary tumor volume was obtained after the summation of area technique. RESULTS: The median primary tumor volume was 29.6 mL in T3 disease and 54.1 mL in T4 disease, with a range of 8.0-131.8 in T3 disease, and 6.7-223.1 ml in T4 disease. Large primary tumor volume was associated with a significantly poor disease-specific survival (p <.0001), whereas the T stage carried no prognostic significance (p =.43). CONCLUSIONS: In advanced T-staged (T3 and T4) nasopharyngeal tumors, a substantial variation of primary tumor volume was present within the same T stage, and primary tumor volume represented a more important prognostic factor for treatment outcome. Volumetric measurements of primary tumors in advanced nasopharyngeal tumors would refine the TNM staging system. Patients with large primary tumor volume should be treated more aggressively.

Nasopharyngeal carcinoma volume measurements determined with computed tomography: study of intraobserver and interobserver variability.

OBJECTIVE: To investigate the intraobserver and interobserver variability of computed tomography-based volume measurements of nasopharyngeal carcinoma. DESIGN: Prospective study. SETTING: Tertiary care centre. METHODS: The primary tumour volume of 13 nasopharyngeal carcinomas was repeatedly measured by two trained observers independently in two different sessions, using the summation of area technique. MAIN OUTCOME MEASURES: Mean tumour volume and its standard deviation were calculated for each tumour. Statistical analysis was done with multivariate analysis, linear regression, and a two-way analysis of variance (ANOVA) random effects model. RESULTS: The coefficient of variation was less than 20% in 11 volume measurements, but a large discrepancy between observers was noted in two tumours with involvement of the paranasal sinuses. A good linear correlation was found between mean tumour volume and its standard deviation: standard deviation = 0.26 volume - 2.48 (r = .80). When the two tumours with a large coefficient of variation were excluded, the two-way ANOVA random effects model revealed that both the interobserver (p = .83) and the intraobserver (p = .90) effect are not statistically significant; interobserver variability was the major component of total variability (71.0%). CONCLUSIONS: Total variability in the computed tomography-based measurement of nasopharyngeal carcinoma volume is small by having the measurements done by a trained observer, except in tumours with involvement of the paranasal sinuses.

Prognostic factors affecting the outcome of nasopharyngeal carcinoma.

BACKGROUND: The aim of the study is to evaluate patients with nasopharyngeal carcinoma treated with multisegmental intensity-modulated radiotherapy with or without chemotherapy and analyze patient, tumor and treatment characteristics, determining outcome. METHODS: From June 1999 through to April 2003, we treated in our institution 83 patients with nasopharyngeal carcinoma, 70 males and 13 females, their ages ranging from 25 to 85 years (median, 48 years). Nineteen patients had T1 tumors, 35 had T2 tumors, six had T3 tumors and 23 had T4 tumors. Sixty-four patients had cervical lymph node metastasis. Twenty patients were treated with radiation therapy alone and 63 patients with concurrent chemoradiotherapy. Cumulative radiation dose to primary tumor ranged from 70.2 to 77.4 Gy (median, 75.6 Gy). Follow-up ranged from 3 to 41.53 months (median, 17 months). RESULTS: Local complete response was achieved in 81 patients (97.5%). Local failure was observed in two patients, nodal failure in one patient and systemic failure in 14 patients. Overall survival, disease-free survival and disease-specific survival were 83, 84 and 93%, respectively, at 1 year, 82, 74 and 88%, respectively, at 2 years and 82, 61 and 88%, respectively, at 3 years. In univariate analysis, T stage of disease was a significant predictor of disease-free survival favoring those with early-stage (T1 + T2) disease (P = 0.040). Cumulative radiation dose to primary tumor was a significant predictor of disease-specific survival favoring those with >75.6 Gy (P = 0.010). Stage of disease (P = 0.007), N-classification (P = 0.046) and cumulative dose to primary tumor (P = 0.046) were significant prognostic factors for overall survival. CONCLUSIONS: High locoregional control for nasopharyngeal carcinoma was achieved with multisegmental intensity-modulated radiotherapy. Distant metastases are still the main impact on survival. More effective chemotherapy regimens and other systemic agents are needed to decrease the rate of distant metastasis.

Effect of primary tumour volumes in early T-stage nasopharyngeal carcinoma.

OBJECTIVE: To investigate the relationship between primary tumour volumes and treatment outcomes in early T-stage nasopharyngeal carcinoma. DESIGN: Retrospective study. SETTING: Tertiary care centre. METHOD: A consecutive series of 52 newly diagnosed patients of early T-stage nasopharyngeal carcinoma who were treated with high-dose radiotherapy. MAIN OUTCOME MEASURES: Computed tomography-derived primary tumour volume was obtained following the summation of area technique. The cancer-related survival according to T stage and primary tumour volumes was analyzed. RESULTS: The median primary tumour volume was 5.48 mL in T1 disease, 17.95 mL in T2a disease, and 19.15 mL in T2b disease, with a range of 3.23 to 9.65 mL in T1 disease, 6.31 to 64.54 mL in T2a disease, and 11.27 to 131.82 mL in T2b disease. Large primary tumour volume was associated with a significantly poor disease-specific survival (p = .0003), whereas the T stage that segregated into T2a and T2b carried no prognostic significance (p = .441). CONCLUSIONS: A substantial variation of primary tumour volume was present within the T2a and T2b stages, and primary tumour volume represented a more important prognostic factor. Volumetric measurements of primary tumours in early T-stage nasopharyngeal tumours would better refine the tumour, node, metastasis staging system. Patients with large primary tumour volume should be treated more aggressively.

Three-dimensional conformal radiation therapy for unresectable hepatocellular carcinoma patients who had failed with or were unsuited for transcatheter arterial chemoembolization.

BACKGROUND: The purpose of our study was to evaluate the outcome of unresectable hepatocellular carcinoma (HCC) patients, who had either failed with or were unsuited for transcatheter arterial chemoembolization (TACE), treated with three-dimensional conformal radiation therapy (3DCRT) and to determine the prognostic outcome factors. METHODS: From September 1999 to March 2003, 44 patients with unresectable HCC underwent 3DCRT. Thirty-seven patients were male and seven female. Mean age was 62 years, ranging from 34 to 88. Eastern Cooperative Oncology Group (ECOG) performance status was 0 in 10 patients, 1 in 19 patients, and 2 in 15 patients. According to Child-Pugh classification for cirrhosis of the liver, 32 patients were in class A and 12 patients in class B. There were 14 patients with main portal vein thrombosis. Twenty patients had alpha-fetoprotein (AFP) level >400 ng/ml. Tumor size was <5 cm in 16 patients, 5-10 cm in 16 patients, and >10 cm in 12 patients. Thirty-two patients had tumors of confluent type, the remaining patients presented a single hepatic tumor. Serum hepatitis antigen markers were positive for type B in 35 patients and type C in nine patients. Twenty-one patients had Okuda Stage I, 22 patients Stage II, and one patient Stage III. According to the AJCC staging system (5th edition), eight patients were in Stage II (T2N0M0), 19 in Stage IIIA (T3N0M0) and 17 in Stage IVA (T4N0M0). RESULTS: An objective response was observed in 27 of 44 patients, giving a response rate of 61.4%. The survival rates at 1, 2 and 3 years were 60.5%, 40.3% and 32.0%, respectively. In the analysis of prognostic factors, Okuda stage, AJCC stage, portal vein thrombosis, pretreatment AFP level, and total dose of radiotherapy all had significant impact on survival. CONCLUSIONS: 3DCRT induced a substantial tumor response rate of 61.4% with survival rates at 1, 2 and 3 years of 60.5%, 40.3% and 32.0%, respectively, and a median survival time of 15.2 months in patients with unresectable HCC who had either failed with or were unsuited for TACE. The complications are acceptable and can be managed with conservative treatment. Although we do not know whether there is a survival benefit through the use of this treatment, 3DCRT seems to be a practical method of salvage for this subset of patients. Further study is warranted to evaluate the survival of such patients with and without this treatment.