Clinical results of image-guided interstitial brachytherapy with or without external beam radiotherapy for postsurgical vaginal recurrence of cervical and endometrial cancers.

PURPOSE: This study aimed to evaluate the clinical outcome and efficacy of image-guided interstitial brachytherapy (ISBT) for postsurgical vaginal recurrence of cervical and endometrial cancers. MATERIALS AND METHODS: The study included 11 patients who received CT-based image-guided high-dose-rate ISBT with or without external beam radiotherapy (EBRT). Local control, progression-free survival, and treatment-related toxicities were evaluated retrospectively. RESULTS: Of the 11 patients, 4 underwent ISBT with EBRT and the other 7 ISBT alone; two of the latter patients received previous pelvic radiotherapy. After a median follow-up of 43.9 months (range 3.9-92.7 months), the 2-year local control rate was 100%. The median equivalent doses in 2 Gy fractions received by at least 90% of the clinical target volume for ISBT with versus without EBRT were 82.2 Gy (range 60.4-84.2 Gy) versus 69.0 Gy (range 50.8-98.2 Gy). The 2-year progression-free survival rates after ISBT with versus without EBRT were 75% versus 80%, and the difference was not significant (p = 0.74). Grade 3 late toxicities occurred in two patients. CONCLUSION: Our radiotherapy strategy using image-guided ISBT, either with or without EBRT, for postsurgical vaginal recurrence showed effective treatment outcomes.

Achieving PSA < 0.2 ng/ml before Radiation Therapy Is a Strong Predictor of Treatment Success in Patients with High-Risk Locally Advanced Prostate Cancer.

BACKGROUND: To predict long-term treatment outcome of radiation therapy (RT) plus androgen deprivation therapy (ADT) for high-risk locally advanced prostate cancer. METHODS: In total, 204 patients with the National Comprehensive Cancer Network (NCCN) high risk locally advanced prostate cancer (PSA > 20 ng/ml, Gleason score ≧ 8, clinical T stage ≧ 3a) were treated with definitive RT with ADT. Median follow up period was 113 months (IQR: 95-128). Median neoadjuvant ADT and total ADT duration were 7 months (IQR: 6-10) and 27 months (IQR: 14-38), respectively. RESULTS: PSA recurrence-free survival (PSA-RFS), cancer specific survival (CSS), and overall survival (OS) rates at 5 years were 84.1%, 98.5%, and 93.6%, respectively, and 67.9%, 91.2%, and 78.1%, respectively, at 10 years. Pre-RT PSA less than 0.2 ng/ml was associated with superior outcomes of PSA-RFS (HR = 0.42, 95% CI: 0.25-0.70, p = 0.001), CSS (HR = 0.27, 95% CI: 0.09-0.82, p = 0.013), and OS (HR = 0.48, 95% CI: 0.26-0.91, p = 0.021). On multivariate analysis, age (≥70 y.o.) and pre-RT PSA (≥0.2 ng/ml) were factors predictive of poorer OS (p = 0.032) , but iPSA, T stage, Gleason score, number of NCCN high-risk criteria, a combination with anti-androgen therapy and neoadjuvant ADT duration were not predictive of treatment outcome. CONCLUSION: In patient with high-risk prostate cancer, RT plus ADT achieved good oncologic outcomes. PSA < 0.2 ng/ml before radiation therapy is a strong independent predictor for long overall survival.

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.

A case of pancreatic neuroendocrine tumors.

Pancreatic neuroendocrine tumors (pNETs) are an uncommon malignancy arising from the neuroendocrine cells of pancreas. Most cases of pNETs present with metastatic disease, but there are few reports in the literature describing pNETs metastasis to the lung and mediastinal lymph nodes [1]. Moreover, although a multimodal treatment including surgical resection and chemotherapy is acceptable for management of pNETs, advanced pNETs still remain a difficult therapeutic challenge [2, 3]. Radiotherapy or combined chemoradiotherapy has not been standard in the treatment of pNETs. An 80-year-old female was admitted to our hospital with cough and anorexia. She had been diagnosed and resected pNETs 8 years ago. Mass shadow was pointed out with chest X-ray, and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed. Pathological examination revealed neuroendocrine tumors, so the lung mass was considered as metastasis of pNETs. Then, we discussed her treatment at Cancer Board, and radiotherapy was chosen. We hope this case suggests that radiotherapy will be one of the treatment options for metastatic pNETs.

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 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.

Radiation-induced cancer after radiotherapy for non-Hodgkin's lymphoma of the head and neck: a retrospective study.

BACKGROUND: survivors of non-Hodgkin's lymphoma (NHL) are well known to be at an increased risk of second malignancies. In this study, we evaluated the incidence and clinical features of head and neck cancer (HNC) occurring after radiotherapy (RT) for NHL. MATERIALS AND METHODS: We investigated the clinical records of 322 patients who had received RT for early-stage NHL of the head and neck at our institute between 1952 and 2000. RESULTS: There were 4 patients with a second HNC developing in the irradiated field, consisting of 2 patients with gum cancer, 1 case with tongue cancer and 1 case with maxillary sinus cancer. The pathological diagnosis in all the 4 patients was squamous cell carcinoma (SCC). Two of the patients (one with gum cancer and one with maxillary sinus cancer) died of the second HNC, while the remaining 2 patients are still living at the time of writing after therapy for the second HNC, with neither recurrence of the second tumor nor relapse of the primary tumor. The ratio of the observed to the expected number (O/E ratio) of a second HNC was calculated to be 12.7 (95%CI, 4.07-35.0), and the absolute excess risk (AER) per 10,000 person-years was 13.3. The median interval between the RT and the diagnosis of the second HNC was 17.0 years (range, 8.7 to 22.7 years). CONCLUSION: The risk of HNC significantly increased after RT for early-stage NHL. These results suggest that second HNC can be regarded as one of the late complications of RT for NHL of the head and neck.

Electron therapy for orbital and periorbital lesions using customized lead eye shields.

PURPOSE: To establish the protective efficacy against late complications of electron therapy using customized lead eye shields in cases with orbital and periorbital lesions. METHODS: Between 1982 and 2006, 16 patients with 22 orbital and periorbital lesions were treated by electron therapy. Customized lead eye shields were prepared and placed in the respective patients' eyes during each fraction of electron therapy. The toxicity and local control rates were analyzed. RESULTS: The preparation period for the customized lead eye shields was 2 days. The shields could be used throughout the treatment period in all the patients. No evidence of radiation cataract was observed in 15 of the 16 patients. None of the patients developed corneal ulceration or evidence of lead poisoning. CONCLUSION: Customized lead eye shields could be made relatively quickly, and electron therapy for orbital and periorbital lesions could be undertaken safely without any late complication.

Quality of life of oral cancer patients after low-dose-rate interstitial brachytherapy.

PURPOSE: To assess the quality of life (QOL) of oral cancer patients treated with low-dose-rate interstitial brachytherapy (LDR-BT) alone. METHODS AND MATERIALS: Between June 2005 and July 2006, a total of 56 patients with oral cancer were enrolled in this prospective study. QOL was assessed by means of the core questionnaire and head and neck questionnaire module of the European Organization for Research and Treatment of Cancer (EORTC Quality of Life Questionnaire-Core 30 [QLQ-C30] and QLQ Head and Neck 35 [H&N35]). The questionnaires were distributed to the patients before the start of treatment and 3 months, 6 months, and 12 months after the start of LDR-BT. RESULTS: It was possible to analyze the results for 20 of the initial 56 patients because they did not experience metastasis or recurrence during this study. No functions or symptoms asked about in the QLQ-C30 deteriorated during the first year. The emotional function score steadily and significantly increased. No symptoms in the QLQ-H&N35 significantly deteriorated. The scores for pain, trouble with social eating, and weight loss on the QLQ-H&N35 steadily and significantly decreased. Age, gender, and LDR-BT source had no effect on the change in QOL during the first year, but T-stage significantly affected the change in global health status, tumor site affected the changes in swallowing, sensory problems, sticky saliva, and complications affected the changes in pain, swallowing, and mouth opening. CONCLUSIONS: QOL of oral cancer patients treated with LDR-BT is high. However, tumor stage, tumor site, and complications affected the changes in a few functions and symptoms during the first year.

Radiotherapy doses at special reference points correlate with the outcome of cervical cancer therapy.

PURPOSE: The authors analyzed the correlation between radiotherapy doses at reference points on the uterine edge and the rectal wall and both pelvic control and late rectal complications of cervical cancer therapy. METHODS AND MATERIALS: Between 1997 and 2005, 57 patients with Stages IB-IVA cancer of uterine cervix were treated with a combination of external beam radiotherapy and high-dose-rate intracavitary brachytherapy. Their high-dose-rate intracavitary brachytherapy was planned by dose-point optimization at six dose points located on the edge of uterus by computed tomography. A rectal reference point located on the anterior wall of the rectum by computed tomography was also used. The pelvic control rate and the rate of late rectal complications were calculated according to the biologically effective dose (BED) at each point and several clinical parameters. RESULTS: The overall 3-year pelvic control rate was 69.4%. The patients with a BED >80 Gy10 at the point on the edge of the uterine cervix had better pelvic control (78.4% at 3 years) than the patients with a BED < or =80 Gy10 (54.4% at 3 years), and the difference was significant. The difference in the BED (Gy3) at the rectal reference point between the patients with Grade 0-1 late rectal complications (median, 114 Gy) and the patients who developed Grade > or =2 late rectal complications (median, 178 Gy) was significant. Chemotherapy was a borderline significant parameter in regard to correlation with pelvic control and late rectal complications, but there were no correlations with other dosimetric or clinical parameters. CONCLUSIONS: The radiotherapy dose at the reference point on the edge of the cervix affected pelvic control more than the clinical parameters, and the dose at the rectal reference point was more strongly correlated with the occurrence of late rectal complications.

Curative brachytherapy for recurrent/residual tongue cancer.

PURPOSE: The efficacy of curative low-dose-rate (LDR) brachytherapy for recurrent and/or residual cancer following radical operation or irradiation and posttreatment quality of life (QoL) were assessed. PATIENTS AND METHODS: Between January 1979 and April 2004, 88 patients who had received curative LDR brachytherapy (28 with postoperative close or positive margins, six with postoperative recurrence, six with recurrence after external-beam irradiation, and 48 with recurrent/residual cancer after curative brachytherapy) were analyzed retrospectively. Late complications were assessed based on the RTOG/EORTC late radiation morbidity score scheme. RESULTS: The 5-year relapse-free and cause-specific survival rates were 92% and 96%, respectively, in the close/positive margin group and 52% and 56%, respectively, in the postbrachytherapy recurrence or residual cancer group. The incidence of late side effects was 8% (2/26) in the close or positive margin group and 22% (4/18) in the postbrachytherapy group. The only grade 4 late complication (bone exposure) was observed in one patient in the postbrachytherapy group. CONCLUSION: LDR brachytherapy as reirradiation for recurrent/residual tongue cancer was effective, and there was no increase in complications.