Superiority of a soft tissue-based setup using cone-beam computed tomography over a bony structure-based setup in intensity-modulated radiotherapy for prostate cancer.

The purpose of this study was to test the superiority of a soft tissue-based setup using cone-beam computed tomography (CBCT) to a bony structure-based setup using the ExacTrac system in intensity-modulated radiotherapy (IMRT) for prostate cancer. We studied 20 patients with localized prostate cancer who received IMRT between November 2010 and February 2012. After the initial setup, the pelvic bony structure-based setup and ExacTrac system were applied. After that, CBCT and a soft tissue-based setup were used. A shift in the isocenter between the ExacTrac-based and CBCT-based setup was recorded in the anterior-posterior (AP), superior-inferior (SI), and left-right (LR) axes. The shift was considered an interfractional prostate shift. Post-treatment CBCT was also taken once a week to measure the intrafractional prostate shift, based on the coordinates of the isocenter between pre- and post-treatment CBCT. The planning target volume (PTV) margins were determined using van Herk's method. We measured the elapsed time required for soft tissue matching and the entire treatment time using CBCT. The means ± standard deviation (SD) of the inter- and intrafractional shifts were 0.9 ± 2.8 mm and -0.3 ± 1.4 mm in the AP, 0.9 ± 2.2 mm and -0.1 ± 1.2 mm in the SI, and 0.1 ± 0.7 mm and -0.1 ± 0.7 mm in the LR directions. The PTV margins in the cases of bony structure-based and soft tissue-based setups were 7.3 mm and 2.7 mm in the AP, 5.8 mm and 2.3 mm in the SI, and 1.9 mm and 1.2 mm in the LR directions. Even though the median elapsed time using CBCT was expanded in 5.9 min, the PTV margins were significantly reduced. We found the calculated PTV margins in the soft tissue-based setup using CBCT were small, and this arrangement was superior to the bony structure-based setup in prostate IMRT.

The association between oral candidiasis and severity of chemoradiotherapy-induced dysphagia in head and neck cancer patients: A retrospective cohort study.

BACKGROUND AND PURPOSE: Concurrent chemoradiotherapy (CCRT) for head and neck cancer (HNC) is a risk factor for oral candidiasis (OC). As Candida spp. are highly virulent, we conducted a retrospective study to determine whether OC increases the severity of dysphagia related to mucositis in HNC patients. PATIENTS AND METHODS: We retrospectively analyzed the cases of consecutive patients with carcinomas of the oral cavity, pharynx, and larynx who underwent CCRT containing cisplatin (CDDP) at our hospital. The diagnosis of OC was based on gross mucosal appearance. We performed a multivariate analysis to determine whether OC was associated with the development of grade 3 dysphagia in the Radiation Therapy Oncology Group (RTOG) Acute Toxicity Criteria. The maximum of the daily opioid doses was compared between the patients with and without OC. RESULTS: We identified 138 HNC patients. OC was observed in 51 patients (37%). By the time of their OC diagnosis, 19 (37%) had already developed grade 3 dysphagia. Among the 30 patients receiving antifungal therapy, 12 (40%) showed clinical deterioration. In the multivariate analysis, OC was independently associated with grade 3 dysphagia (OR 2.75; 95%CI 1.22-6.23; p = 0.015). The patients with OC required significantly higher morphine-equivalent doses of opioids (45 vs. 30 mg/day; p = 0.029). CONCLUSION: Candida infection causes refractory dysphagia. It is worth investigating whether antifungal prophylaxis reduces severe dysphagia related to candidiasis.

Efficacy and Safety of the Radiotherapy for Liver Cancer: Assessment of Local Controllability and its Role in Multidisciplinary Therapy.

This study investigated the efficacy and safety of radiotherapy as part of multidisciplinary therapy for advanced hepatocellular carcinoma (HCC). Clinical data of 49 HCC patients treated with radiotherapy were assessed retrospectively. The efficacy of radiotherapy was assessed by progression-free survival, disease control rate, and overall survival. Safety was assessed by symptoms and hematological assay, and changes in hepatic reserve function were determined by Child-Pugh score and albumin-bilirubin (ALBI) score. Forty patients underwent curative radiotherapy, and nine patients with portal vein tumor thrombus (PVTT) underwent palliative radiotherapy as part of multidisciplinary therapy. Local disease control for curative therapy was 80.0% and stereotactic body radiotherapy was 86.7% which was greater than that of conventional radiotherapy (60.0%). Patients with PVTT had a median observation period of 651 days and 75% three-year survival when treated with multitherapy, including radiotherapy for palliative intent, transcatheter arterial chemoembolization, and administration of molecular targeted agents. No adverse events higher than grade 3 and no changes in the Child-Pugh score and ALBI score were seen. Radiotherapy is safe and effective for HCC treatment and can be a part of multidisciplinary therapy.

Risk Factors and Time to Occurrence of Genitourinary Toxicity After External Beam Radiotherapy for Prostate Cancer.

AIM: To retrospectively investigate the risk factors and time to occurrence of genitourinary (GU) toxicity after radiotherapy for localized prostate cancer. PATIENTS AND METHODS: The study included 320 patients. The radiotherapy planning target volume encompassed the prostate with a 1-cm margin in the transverse plane and a 1-cm margin (Group A) or a 1.5-cm margin (Group B) in the longitudinal plane. Incidence rates, risk factors and time to occurrence of GU toxicity were evaluated. RESULTS: After a median follow-up of 38.2 months, the rate of late grade 2-3 GU toxicity was 5.9% and the median interval was 18.3 months. The wider longitudinal margin was the single significant independent factor. The 2-year cumulative incidence rates of late grade ≥2 GU toxicity were 2.8% and 7.5% in Group A and B patients. CONCLUSION: A wider radiotherapy margin increased the risk of GU toxicity and led to earlier occurrence.

Two-fraction high-dose-rate brachytherapy within a single day combined with external beam radiotherapy for prostate cancer: single institution experience and outcomes.

We investigated the outcomes of treatment for patients with localized prostate cancer (PCa) treated with 3D conformal radiation therapy (3D-CRT) followed by two-fraction high-dose-rate brachytherapy within a single day (2-fr.-HDR-BT/day) at a single institution. A total of 156 consecutive Asian males (median age, 67 years) were enrolled. To compare our findings with those of other studies, we analyzed our results using the D'Amico classification, assigning the patients to low- ( N =: 5; 3.2%), intermediate- ( N =: 36; 23.1%) and high-risk ( N =: 115; 73.7%) groups (Stage T3 PCa patients were classified as high-risk). One patient in the D'Amico low-risk group (20%), 13 intermediate-risk patients (36.1%) and 99 high-risk patients (86.1%) underwent androgen deprivation therapy. We administered a prescription dose of 39 Gy in 13 fractions of 3D-CRT combined with 18 Gy of HDR-BT in two 9-Gy fractions delivered within a single day. We did not distinguish between risk groups in determining the prescription dose. The median follow-up period was 38 months. Of the 156 patients, one died from primary disease and five died from other diseases. The 3-year overall survival (OS) rates were 100%, 100% and 93.7%, and the 3-year 'biochemical no evidence of disease (bNED)' rates were 100%, 100% and 96.9% for the D'Amico low-, intermediate- and high-risk groups, respectively. No patient developed ≥ Grade 3 early toxicity. The Grade 3 late genitourinary toxicity rate was 2.6%, and no ≥ Grade 3 late gastrointestinal toxicity occurred. The efficacy and safety of this study were satisfactory, and longer-term follow-up is necessary.

The effectiveness of endoscopic submucosal dissection followed by chemoradiotherapy for superficial esophageal cancer.

BACKGROUND: To evaluate the risks and benefits of endoscopic submucosal dissection (ESD) in addition to chemoradiotherapy (CRT) for the treatment of superficial esophageal squamous cell carcinoma (SESCC). METHODS AND MATERIALS: We retrospectively reviewed the treatment outcomes of 47 patients with SESCC treated between October 2000 and December 2011. Sixteen patients with invasion into the submucosal layer (T1b) or the muscularis mucosa (m3) with positive vascular invasion were treated with CRT after ESD (ESD-CRT group). The lymph node area was irradiated to a total dose of 40-44 Gy and a boost radiation was administered if PET-positive lymph nodes or positive margins were observed. The remaining 31 patients received definitive CRT only (dCRT group). RESULTS: The radiation field was significantly larger in the ESD-CRT group; the "long T" was used in 11 patients (35.4%) in the dCRT group and 15 (93.7%) in the ESD-CRT group (p = 0.0001). The total radiation dose was smaller in the ESD-CRT group; 40 Gy was used in 10 patients (62.5%) in the ESD-CRT group and all but one patient in the dCRT group received ≥60 Gy (p = 0.00001). The 3-year overall survival rates in the dCRT and ESD-CRT groups were 63.2% and 90.0% respectively (p = 0.118). Recurrence developed in nine patients (29.0%) in the dCRT group and one (6.3%) in the ESD-CRT group. Local recurrence was observed in six patients (19%) in the dCRT group and none in the ESD-CRT-group (p = 0.029). Pericardial effusion (≥Grade 3) occurred in three patients (9.7%) in the dCRT group and none in the ESD-CRT group. CONCLUSIONS: ESD followed by CRT is an effective and safe approach for SESCC at m3 or T1b. This combination of ESD and CRT improves the local control rate, and it could decrease the number of cardiac toxicities due to a radiation-dose reduction relative to CRT alone.

Long-term results of chemoradiotherapy for locally advanced esophageal cancer, using daily low-dose 5-fluorouracil and cis-diammine-dichloro-platinum (CDDP).

BACKGROUND: We evaluated the efficacy and toxicity of radiation combined with daily, low-dose protracted chemotherapy for locally advanced esophageal cancer. METHODS: We analyzed data for 68 patients with locally advanced esophageal cancer, including 18 surgical candidates. Standard fractionation (total dose range, 60 to 70 Gy) was used for radiotherapy. The chemotherapy consisted of a daily 5-fluorouracil dose of 250 mg/m2, with a cis-diammine-dichloro-platinum dose of 3 mg/m2 administered on radiotherapy days. RESULTS: Sixty-four patients (94%) received at least 60 Gy. Grade 3 acute hematological toxicity was observed in 13 (19%) patients; there was no grade 4 hematological toxicity. Complete response, partial response, no change, and progressive disease were obtained in 22, 35, 7, and 4 patients, respectively. Minimum follow-up for surviving patients was 45 months. Locoregional progression-free rates at 3 and 5 years were 47% and 47%. Four patients died of late cardiac toxicity; the primary site for all 4 patients was the middle thoracic esophagus. Overall survival rates at 2, 3, and 5 years were 40%, 32%, and 20%. The 3- and 5-year survival rates in patients with T2-3M0 disease were 43% and 27%, and the rates were 24% and 15% in patients with T4/M1. CONCLUSION: Given the large proportion of patients in this study with inoperable disease (roughly three quarters), our treatment seemed to provide equivalent efficacy and less hematological toxicity than standard-dose chemoradiotherapy.

Cardiac metastasis from Merkel cell skin carcinoma.

A 54-year-old woman presented with cardiac metastasis of a Merkel cell carcinoma. Chemotherapy was not effective for the metastasis sites; therefore, radiotherapy was performed for the metastatic cardiac tumors, and it reduced the volume of the cardiac tumors. Cardiac metastasis from Merkel cell carcinoma is rare. Radiotherapy for metastatic cardiac tumors from Merkel cell carcinoma is useful as palliative treatment when the response to chemotherapy is poor.