Chemoradiotherapy for localized extranodal natural killer/T-cell lymphoma, nasal type, using a shrinking-field radiation strategy: multi-institutional experience.

PURPOSES: The prognosis of localized extranodal natural killer/T-cell lymphoma, nasal type (ENKTL), has improved with the development of chemoradiotherapy. However, conventional extended-field radiotherapy may cause optic disorders. Our group has employed smaller radiation fields in an attempt to avoid toxicity. The efficacy and toxicity of treatments were evaluated. MATERIALS AND METHODS: Chemoradiotherapy was delivered with a shrinking-field radiotherapy strategy. The endpoints of this study were overall survival (OS), local control (LC), progression-free survival (PFS), and toxicity. RESULTS: Fifteen patients with localized ENKTL were treated. After irradiation (median, 40 Gy) to the tumor plus a prophylactic volume, a reduced treatment volume to the tumor was boosted (median, 10 Gy). Twelve patients underwent chemoradiotherapy and 3 patients received radiotherapy alone. A complete response was achieved in 12 and a partial response in 3 patients. The 5-year OS, PFS, and LC rates were 80, 67, and 93 %, respectively. Distant recurrence occurred in 4 patients and locoregional and distant recurrence in 1 patient. Cataract (grade 3) and dry eye (grade 2) were observed as late adverse events in 1 patient each. CONCLUSIONS: Sufficiently high OS and LC were achieved with acceptable toxicities. Appropriate target volumes may be smaller with newer chemotherapy regimens.

Usefulness of CT-guided hookwire marking before video-assisted thoracoscopic surgery for small pulmonary lesions.

PURPOSE: The aim of this study was to evaluate the technical and clinical efficacy and safety of CT-guided hookwire marking before video-assisted thoracoscopic surgery (VATS) for small pulmonary lesions. MATERIALS AND METHODS: This procedure was performed on 161 lesions in 154 patients (75 men and 79 women; median age, 62 years; age range 23-89 years). Medical records and images were reviewed, and the technical success rate, surgical success rate and complications were evaluated. Technical success was defined as successful hookwire marking at the target site without marker dropping before VATS. Surgical success was defined as negative surgical margins on pathological examination after VATS. RESULTS: There were 97 nodules and 64 ground-glass opacities, and their mean size was 9.8 mm (range 2-34). The technical success rate was 97.5% (157/161). In three of the four failed cases, another hookwire marker was placed, and in the remaining case, VATS was performed without a marker. The surgical success rate was 98.1% (158/161). In the three failed cases, the margin was positive, so lung lobectomy was performed in one case, and the other two cases were observed carefully. Complication rates were as follows: pneumothorax, 37.9% (61/161); focal intrapulmonary haemorrhage, 34.8% (58/139); haemoptysis, 0.6% (1/161); haemothorax, 0% (0/161); air embolism, 0.6% (1/161); dissemination, 0% (0/161); and death, 0% (0/161). CONCLUSION: CT-guided hookwire marking appears to be useful for VATS, but the procedure may, although rarely, cause severe complications such as air embolism.

Treatment and prognosis of patients with late rectal bleeding after intensity-modulated radiation therapy for prostate cancer.

BACKGROUND: Radiation proctitis after intensity-modulated radiation therapy (IMRT) differs from that seen after pelvic irradiation in that this adverse event is a result of high-dose radiation to a very small area in the rectum. We evaluated the results of treatment for hemorrhagic proctitis after IMRT for prostate cancer. METHODS: Between November 2004 and February 2010, 403 patients with prostate cancer were treated with IMRT at 2 institutions. Among these patients, 64 patients who developed late rectal bleeding were evaluated. Forty patients had received IMRT using a linear accelerator and 24 by tomotherapy. Their median age was 72 years. Each patient was assessed clinically and/or endoscopically. Depending on the severity, steroid suppositories or enemas were administered up to twice daily and Argon plasma coagulation (APC) was performed up to 3 times. Response to treatment was evaluated using the Rectal Bleeding Score (RBS), which is the sum of Frequency Score (graded from 1 to 3 by frequency of bleeding) and Amount Score (graded from 1 to 3 by amount of bleeding). Stoppage of bleeding over 3 months was scored as RBS 1. RESULTS: The median follow-up period for treatment of rectal bleeding was 35 months (range, 12-69 months). Grade of bleeding was 1 in 31 patients, 2 in 26, and 3 in 7. Nineteen of 45 patients (42%) observed without treatment showed improvement and bleeding stopped in 17 (38%), although mean RBS did not change significantly. Eighteen of 29 patients (62%) treated with steroid suppositories or enemas showed improvement (mean RBS, from 4.1 ± 1.0 to 3.0 ± 1.8, p = 0.003) and bleeding stopped in 9 (31%). One patient treated with steroid enema 0.5-2 times a day for 12 months developed septic shock and died of multiple organ failure. All 12 patients treated with APC showed improvement (mean RBS, 4.7 ± 1.2 to 2.3 ± 1.4, p < 0.001) and bleeding stopped in 5 (42%). CONCLUSIONS: After adequate periods of observation, steroid suppositories/enemas are expected to be effective. However, short duration of administration with appropriate dosage should be appropriate. Even when patients have no response to pharmacotherapy, APC is effective.

Stereotactic body radiotherapy using a radiobiology-based regimen for stage I nonsmall cell lung cancer: a multicenter study.

BACKGROUND: The most common regimen of stereotactic body radiotherapy (SBRT) for stage I nonsmall cell lung cancer in Japan is 48 grays (Gy) in 4 fractions over 4 days. Radiobiologically, however, higher doses are necessary to control larger tumors, and interfraction intervals should be >24 hours to take advantage of reoxygenation. In this study, the authors tested the following regimen: For tumors that measured <1.5 cm, 1.5 to 3.0 cm, and >3.0 cm in greatest dimension, radiation doses of 44 Gy, 48 Gy, and 52 Gy, respectively, were given in 4 fractions with interfraction intervals of ≥3 days. METHODS: Among 180 patients with histologically proven disease who entered the study, 120 were medically inoperable, and 60 were operable. The median patient age was 77 years (range, 29-92 years). SBRT was performed with 6-megavolt photons using 4 noncoplanar beams and 3 coplanar beams. Isocenter doses of 44 Gy, 48 Gy, and 52 Gy were received by 4 patients, 124 patients, and 52 patients, respectively. RESULTS: The overall survival rate for all 180 patients was 69% at 3 years and 52% at 5 years. The 3-year survival rate was 74% for operable patients and 59% for medically inoperable patients (P = .080). The 3-year local control rate was 86% for tumors ≤3 cm (44/48 Gy) and 73% for tumors >3 cm (52 Gy; P = .050). Grade ≥2 radiation pneumonitis developed in 13% of patients (10% of the 44-Gy/48-Gy group and 21% of the 52-Gy group; P = .056). All other grade 2 toxicities developed in <4% of patients. CONCLUSIONS: The SBRT protocol used in this study yielded reasonable local control and overall survival rates and acceptable toxicity. Dose escalation is being investigated.

Results of primary central nervous system lymphoma treated by radiation and chemotherapy: retrospective analysis of twelve institutions in the Tokai District of Japan, 1995-1999.

PURPOSE: We analyzed the therapeutic results and prognostic factors of 46 primary central nervous system lymphoma (PCNSL) patients who were treated at twelve institutions in the Tokai district of Japan between 1995 and 1999. We compared the results with those of a Japanese nationwide survey performed in the past. MATERIALS AND METHODS: We sent each institution a questionnaire about the state of patients' disease, pathological type, method and doses of radiotherapy, regimen and intensity of chemotherapy, and patients' prognoses. The range of patients' ages was 33 to 93 years (median, 61 years). Thirty-one were men and 15 were women. The most prevalent histology was diffuse large B cell type (33 patients). We used the Kaplan-Meier method to calculate the survival rate and Cox's proportional hazards model to analyze the prognostic factors. RESULTS: The five-year cumulative survival rate was 25%, and the median survival time was 22.7 months. The five-year disease-free survival rate was 23%. In monovariate analysis, patients who were both younger than 60 years old and had a WHO performance status (PS) score equal to or less than 2 showed a better survival rate. Furthermore, the patients receiving systemic chemotherapy showed a significantly better local control rate. In addition, patients who received systemic chemotherapy achieved a higher complete remission rate than those not receiving it. However, no factors that significantly influenced survival rate were identified in multivariate analysis. CONCLUSION: We demonstrated that the therapeutic outcome of PCNSL patients has recently improved. In particular, patients with good PS showed better local control than those with poor PS. However, we could not identify any significant prognostic factors in PCNSL patients.

CNS germinoma with elevated serum human chorionic gonadotropin level: clinical characteristics and treatment outcome.

PURPOSE: The prognostic significance of human chorionic gonadotropin (HCG) level in central nervous system germinoma remains controversial. The purpose of this study was to compare clinical characteristics and prognosis of germinoma patients with normal and high HCG titers in the serum. METHODS AND MATERIALS: We undertook a multi-institutional retrospective analysis of 103 patients with central nervous system germinoma whose serum HCG and/or beta-HCG level had been measured before treatment between 1984 and 2002. All patients had been treated with radiation therapy either alone (n = 66) or in combination with chemotherapy (n = 37) with a median dose of 47.8 Gy. RESULTS: HCG and/or beta-HCG level in the serum was high in 39% of all patients. The proportion of HCG-producing tumors was higher in the lesions at the basal ganglia than in the lesions at the other sites. No correlation was found between tumor size and HCG level, but there seemed to be a weak correlation between size and beta-HCG. The 5- and 10-year survival rates were 96% and 94%, respectively, in both patient groups with normal and high HCG (p = 0.99). The 5- and 10-year relapse-free survival rates were 87% and 82%, respectively, in patients with normal HCG level and were both 87% in patients with high HCG (p = 0.74). Also, no other patient-, tumor-, or treatment-related factors seemed to influence the prognosis of the patients. CONCLUSION: Serum HCG level does not seem to influence patient prognosis when treated with sufficient doses of radiation. Relationship between tumor size and site and HCG level should be investigated further.