Intensity-modulated radiation therapy administered to a previously irradiated spine is effective and well-tolerated.

PURPOSE: This study sought to discern the clinical outcomes of intensity-modulated radiation therapy (IMRT) administered to the spine in patients who had undergone previous radiotherapy. METHODS: A total of 81 sites of 74 patients who underwent previous radiotherapy administered to the spine or peri-spine and subsequently received IMRT for the spine were analyzed in this study. The prescribed dose of 80 Gy in a biologically effective dose (BED) of α/ß = 10 (BED10) was set as the planning target volume. The constraint for the spinal cord and cauda equine was D0.1 cc ≤ 100 Gy and ≤ 150 Gy of BED for re-irradiation alone and the total irradiation dose, respectively. RESULTS: The median follow-up period was 10.1 (0.9-92.1) months after re-irradiation, while the median interval from the last day of the previous radiotherapy to the time of re-irradiation was 15.6 (0.4-210.1) months. Separately, the median prescript dose of re-irradiation was 78.0 (28.0-104.9) of BED10. The median survival time in this study was 13.9 months, with 1-, 3-, and 5-year overall survival rates of 53.7%, 29.3%, and 26.6%, respectively. The 1-, 3-, and 5-year local control rates were 90.8%, 84.0%, and 84.0%, respectively. Neurotoxicity was observed in two of 72 treatments (2.8%) assessed after re-irradiation. CONCLUSION: Re-irradiation for the spine using IMRT seems well-tolerated. Definitive re-irradiation can be a feasible treatment option in patients with the potential for a good prognosis.

Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures.

BACKGROUND: Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging. AIM: To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures. METHODS: The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation." RESULTS: Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures. CONCLUSION: These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.

The use of ultrasonography in the reproductive evaluation of boars.

The objective was to study the use of ultrasound as a complementary test in the breeding soundness evaluation in male pigs and study the pattern of echogenicity of the testicular parenchyma in boars of different racial groups. Twenty-six adult boars from four different racial groups were used, 10 from the Piau breed (group 1), four from the commercial and finishing group (group 2), six Pietrain breed (group 3) and six from the Duroc breed (group 4). All animals were evaluated for breeding soundness evaluation and the ultrasound examination of the testicles. The groups of animals that were evaluated showed no difference in the main semen parameters that were evaluated, except for the sperm volume, concentration of the ejaculated sperm and the supravital staining; the lowest figures were for the animals from the Piau breed (group 1). In relation to the testicular biometrics, Duroc animals (group 4) had a greater scrotal width compared to the other groups. But when we assessed the intensity of pixels of the testicles, there was a difference between groups. The groups 2 (finishing animals), 3 (Pietrain) and 4 had no difference between themselves. Group 3 had greater pixel intensity in relation to group 1. Of the 26 animals studied, five showed an abnormality during ultrasound evaluation, like hydrocele, hyperechoic mass in the testicular parenchyma, cyst in the head of the epididymis and the presence of fluid in the head and tail of the epididymis. The various animal groups studied did not differ in the principal reproductive parameters evaluated, showing that despite the great variability of reproductive traits between breeds and within the same breed, the breeding soundness evaluation, the more complete it is, is essential for the selection of breeders and the ultrasonography of the reproductive system becomes an important addition in this examination.

Adição da proteína específica do oviduto de porcas (pOSP) e da melatonina em meios de maturação e o efeito na clivagem in vitro de embriões suínos / Addition of the oviduct specific protein of porcine (pOSP) and melatonin in maturation media and their effect on the in vitro production of pig embryos

No presente estudo, utilizou-se a melatonina e a proteína específica do oviduto (pOSP) nos meios de maturação in vitro. Foram avaliadas a expansão do complexo cumulus-ovócito (CCOs), as concentrações intracelulares de espécies reativas de oxigênio (ROS) e o desenvolvimento embrionário nos diferentes grupos (C = controle; T1 = somente com melatonina; T2 = com melatonina e pOSP e T3 somente com pOSP). No tocante à expansão do CCOs, houve diferença (P<0,05) dos valores obtidos no grupo C em relação aos valores médios dos grupos T1, T2 e T3, porém não houve diferença entre os valores obtidos nos tratamentos (P>0,05). Na dosagem de ROS, não houve diferença entre os valores médios obtidos no grupo C (26,4±10,9) e o valor verificado no grupo T1 (23,4±7,8), porém no grupo T2 (21,3±9,7) o valor médio mostrou-se satisfatório em relação ao valor do grupo C. No entanto, o valor médio do grupo T3 (16,6±10,5) foi o que demonstrou resultado mais satisfatório quando comparado aos demais grupos (P<0,05). A produção de embriões foi avaliada por meio da taxa de clivagem. Não houve diferença (P >0,05) entre os valores obtidos entre o grupo C (48,9 %) e os valores verificados nos grupos T1 (51,5 %), T2 (50 %), T3 (57,7 %), nem destes entre si. Este estudo permitiu concluir que a proteína específica do oviduto recombinante e a melatonina foram eficientes em melhorar a expansão dos CCOs. Além disso, as células tratadas com pOSP mostraram-se com menor quantidade de ROS, podendo a pOSP ser considerada um antioxidante proteico.(AU)

The present study used melatonin and recombinant oviduct specific protein (pOSP) in in vitro maturation medium (IVM). The expansion of the cumulus-oocyte complexes (COCs), the intracellular concentrations of reactive oxygen species (ROS) and embryo development of the different groups were evaluated (C = control; T1 = melatonin; T2 = melatonin and pOSP and T3 = pOSP). Regarding the COCs expansion, the groups T1, T2 and T3 showed satisfactory results compared with group C (P<0.05), but there was no difference between treatments (P>0.05). In the ROS dosage, there was no difference between the mean values obtained in group C (26.4 ± 10.9) and group 1 (23.4 ± 7.8). However, in group 2 (21.3 ± 9.7), the average value was found to be satisfactory in relation group C. Despite that, the average value of treatment 3 (16.6 ± 10.5) was the most satisfactory result found compared to the other groups (P<0.05). The production of embryos was evaluated by cleavage rate, there was no difference between the values obtained in group C and the values recorded in groups T1 (51.5 %), T2 (50 %), T3 (57.7 %), and among them. This study showed that the pOSP and the melatonin were effective in the improvement of the expansion of COCs cells. In addition, the cells that were treated with pOSP presented a lower amount of ROS, allowing the pOSP to be considered a proteic antioxidant.(AU)

Hyperthermic intraperitoneal chemotherapy using a combination of mitomycin C,5-fluorouracil, and oxaliplatin in patients at high risk of colorectal peritoneal metastasis: A Phase I clinical study.

INTRODUCTION: The drugs and protocols used for hyperthermic intraperitoneal chemotherapy (HIPEC) vary among institutions. Here we show the efficacy of the 3-drug combination of mitomycin C (MMC), 5-fluorouracil (5FU), and oxaliplatin (OHP) in an in vitro simulation of HIPEC and the safety of HIPEC with these drugs during a Phase I study of patients at high risk of developing colorectal peritoneal metastasis. METHODS: To simulate HIPEC, we used HCT116 and WiDr cells to assess the growth inhibitory efficacy of MMC 2 µg/mL, 5FU 200 µg/mL, and OHP 40 µg/mL as single drugs or their combination after an exposure time of 30 min at 37 or 42 °C. In addition, nine patients underwent surgical resection of tumors and HIPEC with MMC, 5FU, and an escalating dose of OHP (90/110/130 mg/m²). Dose-limiting toxicity was monitored. RESULTS: In the simulation, the 3-drug combination showed marked tumor-suppressive effects compared with those from ten times higher dose of OHP 400 µg/mL, with significant augmentation under hyperthermic conditions. No dose-limiting toxicity occurred in the clinical study. Dose escalation was completed at the final level of OHP. CONCLUSIONS: The MMC-5FU-OHP combination showed marked growth inhibition against colorectal cancer cells under hyperthermic conditions in vitro. In the phase I study, the recommended dose of OHP was determined as 130 mg/m² when used with MMC and 5FU; HIPEC using MMC-5FU-OHP appears to be safe and feasible for patients at high risk of colorectal peritoneal metastasis.

Stereotactic body radiotherapy for pulmonary metastases. Prognostic factors and adverse respiratory events.

PURPOSE: The aim of this retrospective study was to evaluate the feasibility, safety, and effectiveness of stereotactic body radiotherapy (SBRT) for pulmonary metastases. PATIENTS AND METHODS: Between April 2007 and March 2011, 87 patients underwent SBRT for pulmonary metastases using the in-house Air-Bag System(TM) to obtain the four-dimensional image for treatment planning and to reduce intrafractional intrathoracic organ motion with abdominal compression to reduce the risk of radiation pneumonitis. Survival and respiratory adverse events were analyzed. RESULTS: The 2- and 3-year overall survival (OS) rates were 47 and 32 %, and the corresponding cause-specific survivals were 52 and 36 %. The 2- and 3-year OS rates were 57 and 49 % for patients in group 1, respectively, while the corresponding OS rates were 48 and 21 %, and 40 and 32 % for patients in groups 2 and 3, respectively. The 2- and 3-year local control (LC) rates were 80 and 80 %, respectively. The corresponding intrathoracic progression-free survival rates were 40 and 32 %, respectively. Concerning adverse respiratory events after SBRT for pulmonary metastases, 14 % were grade 0 (G0), 66 % G1, 13 % G2, 6 % G3, and 1 % G4. Concerning the adverse respiratory events (NCI-CTC) by grade scale, 1- and 2-year cumulative probabilities of radiation pneumonitis were 12 and 20 % for G2 and 4 and 10 % for G3/4, respectively. The mean values for cumulative V20 were 11.6 ± 8.5 %, 29.8 ± 18.6 %, and 25.7 ± 12.8 % in G0/1, G2, and G3/4, respectively. The number of pulmonary metastases that could be safely treated with SBRT was 6 PTVs (or seven gross tumor volumes) within a cumulative V20 of 30 % under the restricted intrafractional respiratory tumor motion using the Air-Bag System(TM). CONCLUSION: We propose that the number of pulmonary metastases that can be safely treated with SBRT is 6 PTVs with a cumulative V20 of 30 % under the restricted respiratory tumor motion using the Air-Bag System(TM). SBRT for pulmonary metastases offers locally effective treatment for recurrent or residual lesions after first line chemotherapy.

Respiration tracking in radiosurgery without fiducials.

In robotic radiosurgery, a focused beam of radiation is moved by a robot arm. We investigated methods for soft-tissue navigation using robotic radiosurgery. In previous work we described a method for real-time tracking based on correlation between the motion of implanted fiducial markers and external skin markers. In this work we extend our method of correlation-based tracking to tracking without implanted fiducials. We propose to use deformation algorithms on CT data sets combined with registration of digitally reconstructed radiographs and intra-treatment X-ray images to obtain intermittent information on the target location. This information is then combined with our basic correlation method to achieve real-time tracking. Our study investigates the feasibility of this approach from the point of view of computing time and required level of user interaction. The term 7D registration is coined to describe the underlying method for performing this task.

Feasibility of four-dimensional conformal planning for robotic radiosurgery.

Organ motion can have a severe impact on the dose delivered by radiation therapy, and different procedures have been developed to address its effects. Conventional techniques include breath hold methods and gating. A different approach is the compensation for target motion by moving the treatment beams synchronously. Practical results have been reported for robot based radiosurgery, where a linear accelerator mounted on a robotic arm delivers the dose. However, not all organs move in the same way, which results in a relative motion of the beams with respect to the body and the tissues in the proximity of the tumor. This relative motion can severely effect the dose delivered to critical structures. We propose a method to incorporate motion in the treatment planning for robotic radiosurgery to avoid potential overdosing of organs surrounding the target. The method takes into account the motion of all considered volumes, which is discretized for dose calculations. Similarly, the beam motion is taken into account and the aggregated dose coefficient over all discrete steps is used for planning. We simulated the treatment of a moving target with three different planning methods. First, we computed beam weights based on a 3D planning situation and simulated treatment with organ motion and the beams moving synchronously to the target. Second, beam weights were computed by the 4D planning method incorporating the organ and beam motion and treatment was simulated for beams moving synchronously to the target. Third, the beam weights were determined by the 4D planning method with the beams fixed during planning and simulation. For comparison we also give results for the 3D treatment plan if there was no organ motion and when the plan is delivered by fixed beams in the presence of organ motion. The results indicate that the new 4D method is preferable and can further improve the overall conformality of motion compensated robotic radiosurgery.

[Clinical experience of new stereotactic radiotherapy system named CyberKnife].

The CyberKnife is a small linear accelerator mounted on a robot. The CyberKinfe has the IPS(Image Processing System) that evaluates the patient position during the treatment. If there is any movement of the patient, the robot chases the tumor. Invasive flame to fix the patient skull is not needed. From April 1998 through July 2000, we applied the CyberKnife treatment for 136 sites in 94 patients. Sixty-seven of 136 sites were metastatic brain tumors. Progression-free rate of tumors treated with 24-27 Gy at 3 months after treatment was 89%. There was no severe adverse effects except epilation. The CyberKnife treatment was applied for tumors in the body in USA. It will be available in Japan in near future.

High-dose-rate interstitial brachytherapy as a monotherapy for localized prostate cancer: treatment description and preliminary results of a phase I/II clinical trial.

PURPOSE: To improve results for localized prostate cancer, a prospective clinical trial of hyperfractionated Iridium-192 high-dose-rate (HDR) brachytherapy as a monotherapy was initiated. METHODS AND MATERIALS: Between May 1995 and September 1998, 22 implants were performed on 22 patients with localized prostate cancer (T1:T2:T3:T4 = 4:6:9:3) at Osaka University Hospital. Nineteen patients, who had T3-T4 tumors or pretreatment PSA >/= 20.0 ng/mL, received hormone therapy. No patient had external beam radiation. Transperineal needle implants using real-time ultrasound guidance were performed, followed by dose optimization program. Patients were irradiated twice a day, with a time interval of more than 6 h. Total dose was 48 Gy/8 fractions/5 days or 54 Gy/9 fractions/5 days. Acute toxicity was scored using the Radiation Therapy Oncology Group (RTOG) radiation morbidity scoring criteria. Median follow-up time was 31 months. RESULTS: HDR brachytherapy as a monotherapy was well-tolerated. No significant intra- or peri-operative complications occurred. No patient experienced acute toxicity of grade 3 or more. PSA levels normalized in 95% of patients within 20 months after irradiation. Four-year clinical and biochemical relapse-free rates were 95% and 55%, respectively. CONCLUSION: Acute toxicity with this method was acceptable. Further patient accrual and longer follow-up will allow comparison to other techniques.

Quality assurance for an image-guided frameless radiosurgery system using radiochromic film.

PURPOSE: The CyberKnife, a new type of machine for stereotactic irradiation, is composed of a combination of a robot (manipulator) and a linear accelerator; We measured the total pointing error of the therapy beam, aiming at improvement in the accuracy of the CyberKnife. METHODS AND MATERIALS: The CyberKnife keeps a number of coordinate systems such as the patient's coordinates, robotic coordinates, and IPS (image processing system) coordinates. Precise irradiation is possible if these coordinate systems are matched accurately. We always calculate the overall irradiation error using GAF MD-55 radiochromic film before irradiation treatment of the patient, and we have attempted to improve the accuracy of irradiation with the CyberKnife by feeding back the errors. RESULTS: The median of the error immediately after introducing the CyberKnife was 1.2 mm, and as a result of correction, we succeeded in reducing the error to 0.7 mm (median). Total pointing error after correction was significantly lower than that before correction (p=0.0023). CONCLUSIONS: This approach allowed us to reduce errors and establish a method for providing patients with highly accurate stereotactic irradiation. We believe these results endorse the validity of the method presented in this paper.

Occult breast cancer presenting axillary nodal metastasis: a case report.

We report a case of a 42-year-old female with occult breast cancer presenting axillary nodal metastasis. She complained of a swelling of the right axillary lymph node, but no breast mass was palpable. Biopsy of the lymph node was performed and histological examination showed a metastatic ductal carcinoma with papillotubular formation. Estrogen receptor of the lymph node was positive. No pathological findings were obtained by mammography and ultrasonography and systemic examinations revealed no extramammary primary lesion. All these data suggested an occult carcinoma of the breast and modified radical mastectomy was performed. Pathological findings of the removed specimen failed to find the primary breast cancer lesion. The patient has been treated with hormonal therapy and she is well without evidence of disease 5 years after surgery.

Cellular distribution and clinical value of urokinase-type plasminogen activator, its receptor, and plasminogen activator inhibitor-2 in esophageal squamous cell carcinoma.

To assess the participation of the plasminogen activation system in the invasiveness of esophageal squamous cell carcinoma, we performed immunohistochemistry and in situ hybridization to study the distribution of a urokinase-type plasminogen activator (u-PA), u-PA receptor (u-PAR), and plasminogen activator inhibitor-2 (PAI-2). u-PA and PAI-2 were expressed heterogeneously in cancer cells, and restricted expression was found in stromal cells, especially fibroblasts, that were located in the immediate proximity of the cancerous cells. u-PAR was found only in cancer cells located at the periphery of tumors. Compared with patients with u-PA-negative cancer cells, patients with u-PA-positive cancer cells more frequently showed a neoplastic invasion beyond the muscularis propria and lymph node metastases. They also showed a significantly shorter 5-year overall survival. Patients with PAI-2-positive fibroblasts showed significantly lower levels of local invasiveness, represented by a neoplastic invasion beyond the muscularis propria, than those who were PAI-2 negative. Our results suggest that the expression of u-PA in esophageal squamous cell carcinoma is predictive of poor survival, whereas the expression of PAI-2 in the fibroblasts surrounding them is protective. An analysis of u-PA and PAI-2 expression in cancer cells and their surrounding fibroblasts may be useful for predicting the prognosis of patients with esophageal squamous cell carcinoma.

[Pharmacological aspects of mammalian hibernation: central thermoregulation factors in hibernation cycle].

Hibernation in mammalians such as hamsters is a physiological state characterized by an extreme reduction of various functions such as body temperature and metabolism. Under such severe conditions, the central nervous system (CNS) activity is maintained at a functionally responsive level. Although hibernation is an interesting behavioral state, the physiological mechanisms of the introduction to and/or the arousal from hibernation have not been clearly defined. Intracerebroventricularly (i.c.v.) injected adenosine produces hypothermia in various animals. The effect of adenosine is generated by A1-receptors and is caused by the suppression of the thermogenesis center of the posterior hypothalamus. At on ambient temperature of 5, i.c.v. injected N6-cyclohexyladenosine (CHA) adenosine A1-receptor agonist induces profound hypothermia in hamsters. Although the time course of the descent of body temperature coincided with that of entry into natural hibernation, the effect was not antagonized by 8-cyclopentyltheophyllin (CPT), an adenosine A1-receptor antagonist. However, i.c.v. injection of CPT elevated the body temperature and interrupted hibernation, albeit the deep-phase (post-entry 30 h) was unaffected. This result suggests that a different system may suppress the thermogenesis center in the deep hibernation phase. Interestingly, i.c.v. injected thyrotropin releasing hormone (TRH) elevated the body temperature in both hibernation phases in hamsters. These findings suggest that the central adenosine and TRH play important roles in thermoregulation and that the new thermogenesis system, activating in low-body temperature, is induced in naturally hibernating animals.

Ultrasonographic monitoring of high dose rate interstitial implant using template technique for oral tongue cancer.

192Ir high dose rate (HDR) fractionated interstitial brachytherapy was performed on two patients with tongue cancer with the aid of real-time intraoral ultrasonographic (US) guidance and the template technique. Blind-ended catheters with metallic rods (Obturator, Nucletron, the Netherlands) were inserted into the tongue from the submandibular region. This US monitoring allows for detection of the accurate location of both tumor and catheters in real-time motion. After implantation, we reconfirmed the position of the catheters by CT examination. Intraoral US monitoring was thus found to be a useful procedure for accurate implantation of brachytherapy for tongue cancer.

Attenuation by PACAP of glutamate-induced neurotoxicity in cultured retinal neurons.

The effects of pituitary adenylate cyclase activating polypeptides (PACAPs: PACAP27, PACAP38) on glutamate-induced neurotoxicity were examined using cultured retinal neurons obtained from 3- to 5-day old Wistar rats. Cell viability was evaluated by double staining with fluorescein diacetate and propidium iodide. Effects of PACAPs on the increase in intracellular Ca(2+) concentration ([Ca(2+)](i)) in retinal neurons was investigated using the Ca(2+) image analyzing system with fura-2. The cAMP contents and the mitogen-activated protein (MAP) kinase activity in retinal cultures were measured by radioimmunoassay. Concomitant application of PACAPs (10 nM-1 microM) with glutamate (1 mM) for 10 min inhibited the delayed death of retinal neurons, which was observed 24 h after glutamate (1 mM) treatment in a dose-dependent manner. Protection by PACAPs (100 nM) against glutamate-induced neurotoxicity was antagonized by PACAP6-38 (1 microM), a PACAP antagonist, and H-89 (1 microM), a protein kinase A (PKA) inhibitor. However, PACAPs did not affect the glutamate-induced increase in [Ca(2+)](i), but PACAPs (1-100 nM) increased the cAMP levels in a dose-dependent manner. In addition, activation of MAP kinase by PACAP38 (1 microM) was inhibited by simultaneous application with H-89 (1 microM). These findings suggest that PACAPs attenuate glutamate-induced delayed neurotoxicity in cultured retinal neurons by activating MAP kinase through the activation of cAMP-stimulated PKA.

Radiotherapy of early tongue cancer in patients less than 40 years old.

PURPOSE: To evaluate the results of treatment for early mobile tongue cancer in patients less than 40 years. METHODS AND MATERIALS: Between January 1967 and September 1992, 70 patients less than 40 years old (young age group) with early tongue cancer (T1-2N0M0) were treated with low-dose-rate (LDR) interstitial radiotherapy at the Osaka University Hospital (OUH). All patients had a minimum 2-year follow-up (median: 13 years). External radiotherapy (median: 30 Gy) was combined in 25 cases. The treatment results were compared with those for two older age groups (middle age: 40-64 years old; old age: 65 years old or more). RESULTS: The 5-year probability of cause-specific survival (CSS) rate for the young age group was 80%, which was not significantly different from the two older groups: 81% for middle age and 71% for old age. However, male patients of young age showed significantly worse rates than those of middle and old age (p = 0.02). The 5-year local control rate for the young age group was 78%. It was not significantly different from the two older groups: 81% for middle age and 70% for old age. The incidence of regional lymph node metastasis was 32% for T1, 48% for T2, 56% for males, and 24% for females. The regional failure rate of young males was significantly higher than those of the two older groups: 32% for middle and 22% for old age (p = 0.001). CONCLUSION: The overall treatment results for patients with early tongue cancer less than 40 years old were not worse than those of older age groups. However, male gender was a risk factor for lymph node metastasis and CSS.