Target delineation of gross tumor volume for radiation therapy planning using fusion images of ¹8F-fluorodeoxyglucose positron emission tomography and computed tomography.

Modern radiation therapy planning (RTP) has been performed using a larger number of images obtained with computed tomography (CT), named 3-dimensional RTP. Recently, F-18-flurodeoxyglucose position emission tomography (FDG-PET) has been used for RTP. FDG-PET can often distinguish between benign and malignant lesions when CT and magnetic resonance cannot. Although FDG-PET images lack anatomical precision (Fig. 1A), fusion images of FDG-PET and CT (PET/CT) have been extremely useful for determining the active sites of malignant disease. Particularly for patients with non-small cell lung carcinoma, both primary lesions and active lymph node matastases are well recognized (Fig. 1B). With PET/CT, which yields fewer false-negative results, smaller target volumes for radiation therapy can be delineated than with other imaging modalities (Fig. 2). The small radiation field (Fig. 3) leads to less toxicity in normal tissue, allows high radiation dose to be administered, and improves local control.

Utility of sonography for evaluation of clinical T1 and T2 glottic carcinoma.

OBJECTIVE: The aim of this study was to evaluate the prognostic impact of sonographically determined tumor features in relation to local control of clinical T1 and T2 glottic carcinoma treated by definitive radiation therapy. METHODS: Between 1999 and 2005, 72 patients with T1 and T2 glottic carcinoma were evaluated by percutaneous sonography in terms of tumor detectability, maximum tumor dimension, involvement of the anterior commissure, presence of supraglottic, subglottic, or paraglottic spread, and thyroid cartilage invasion. Factor analyses for local control included clinical features, sonographic findings, and treatment factors. RESULTS: Forty-one lesions (57%) were detected as hypoechoic masses on sonography. For detectable T2 tumors, sonographic and laryngoscopic findings were in agreement in all cases with respect to spread to anatomic subsites. The 3-year local control rate with radiation therapy alone was 82%. Univariate analysis of the sonographic characteristics revealed that the maximum tumor dimension and thyroid cartilage invasion predicted a loss of local control, whereas none of the clinical or treatment characteristics was significant. Multivariate analysis showed that thyroid cartilage invasion was an independent negative prognostic factor for local control. CONCLUSIONS: Sonography provides information about the likely outcome of radiation therapy for patients with clinical T2 glottic carcinoma, although its utility for T1 lesions is not proven. Thyroid cartilage invasion may be an independent negative predictor of the outcome.

Keloids and Hypertrophic Scars Can Now Be Cured Completely: Recent Progress in Our Understanding of the Pathogenesis of Keloids and Hypertrophic Scars and the Most Promising Current Therapeutic Strategy.

Keloids and hypertrophic scars are fibroproliferative disorders of the skin that are caused by abnormal healing of injured or irritated skin. It is possible that they are both manifestations of the same fibroproliferative skin disorder and just differ in terms of the intensity and duration of inflammation. These features may in turn be influenced by genetic, systemic, and local risk factors. Genetic factors may include single nucleotide polymorphisms, while systemic factors may include hypertension, pregnancy, hormones, and cytokines. The most important local factor is tension on the scar. Over the past 10 years, our understanding of the pathogenesis of keloids and hypertrophic scars has improved markedly. As a result, these previously intractable scars are now regarded as being treatable. There are many therapeutic options, including surgery, radiation, corticosteroids, 5-fluorouracil, cryotherapy, laser therapy, anti-allergy agents, anti-inflammatory agents, bleaching creams and make-up therapies. However, at present, we believe that the following combination of three therapies most reliably achieves a complete cure: surgery, followed by radiation and the use of steroid tape/plaster.

Analysis of the surgical treatments of 63 keloids on the cartilaginous part of the auricle: effectiveness of the core excision method.

BACKGROUND: Treatments for keloids on the cartilaginous part of the auricle (i.e., the upper part of the ear excluding the earlobe) include surgical excision, cryosurgery, postoperative radiation therapy, steroid injection, taping stabilization, and pressure therapy. However, to date, there is no universally accepted treatment strategy for auricle keloids. METHODS: In this retrospective cohort study, the 63 primary auricle keloids in all 57 patients who underwent surgery from 2006 to 2012 were included. Mild scars such as hypertrophic scars were excluded. All 63 scars were treated with surgery, namely, total excision or intralesional excision (core excision method), and postoperative adjuvant radiation therapy and self-managed scar stabilization with surgical tape. The postsurgical radiation therapy consisted of 15 Gy administered in three fractions over 3 days. The recurrence rates associated with the two surgical methods over 18 months of follow-up were recorded. RESULTS: Of the 57 patients, 91.2 percent were women. Of the 63 lesions, 95.2 percent and 4.8 percent were caused by piercing and trauma, respectively. All were primary keloids. Before 2009, all lesions (n = 37) were treated by total excision. After 2009, all lesions (n = 26) were treated by core excision. These methods were associated with recurrence rates of 8.1 percent and 0 percent, respectively, although this difference did not achieve statistical significance (p > 0.05). The overall recurrence rate was 4.8 percent. Complications such as wound dehiscence and pigmentation during the 18-month follow-up period were not observed. CONCLUSION: Auricle keloids can be treated by customized plans consisting of appropriate surgical modalities, postoperative radiotherapy, and self-management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ultrasonographic demonstration of retropharyngeal lymph nodes: preliminary report.

The aim of this study was to describe the results of ultrasonography of upper retropharyngeal lymph node (RPN) metastasis in patients with pharyngeal carcinomas. A total of 10 patients with metastatic RPN were examined using percutaneous ultrasound (US) with 3.5-MHz probes. Primary cancer sites were the nasopharynx in two patients, the oropharynx in three and the hypopharynx in five. Metastatic RPNs lay in the level of occipital bone in five patients, C1 in nine, and C2 in five. US images were compared with previously obtained computerized tomography (CT) images based on size and depth. In all of the 10 patients, metastatic RPNs were ultrasonographically demonstrated as hypoechoic masses. Nodal sizes ranged from 1.5 cm to 3.5 cm both in CT and in US. Depths of the RPN centers were from 3.5 cm to 7.0 cm in CT, and from 3.5 cm to 6.5 cm in US. Differences of sizes and depths between CT and US were from -0.5 cm to 0.5 cm and from 0.0 cm to 1.0 cm, respectively. RPNs that are 1.5 cm or more in size can be demonstrated with percutaneous US using CT guidance. This technique should be utilized for the purpose of monitoring in a radiation therapy setting.

[A report of questionnaire survey asking teaching staff concerning evaluation of faculty teaching from the students in Nippon Medical School].

A questionnaire survey was conducted to ask teaching staffs about the present activities and opinions of evaluation of faculty teaching from the students (EFS). One hundred and eighty-eight among 336 members (56.1%) responded. Among them sixty-four (34%) replied that they had tried at least once EFS of their lectures and/or practices. Approximately 70% had a opinion that EFS would benefit them for improving their lectures and practices, and/or for improving course planning. Fifty-four per cent of members supported EFS to be introduced, 34% depended upon how to evaluate, and remaining 5% did not support it. These results indicate that the staff members are highly concerned with EFS which should be provided for introduction after a full discussion how to evaluate.

[Strategy to reduce esophageal cancer by dietary reformation].

BACKGROUND AND OBJECTIVE: From 1920 to 1940, many people were affected by esophageal carcinoma in villages in the mountains of Nara Prefecture in Japan. However, a movement for the improvement of living conditions, especially concerning food, diminished the incidence of cancer of the esophagus. Today Xinjiang in China, esophageal cancer is also one of the main causes of death. Therefore, we analyzed in Xinjiang whether the improvement of dietary habits can reduce mortality of esophageal cancer. METHODS: The mortality of esophageal cancer and related matters obtained from the Japanese Literature and Governmental Information, Xinjiang Medical School Cancer Center Hospital, and the Chinese Literature were analyzed. RESULTS: The Kazaks have a higher incidence of esophageal cancer and a lower male/female ratio than other ethnic groups and Japanese people. Kazaks eat very hot meals rapidly, and male Kazaks are more likely to drink hard liquors. In Japan, people in regions with high alcohol consumption tend to have increased mortality of esophageal cancer, but regions with high smoking rates show no correlation with esophageal cancer mortality. There were no data relevant to the incidence of esophageal cancer and alcohol consumption or smoking rates in Xinjiang. The male mortality rate in Nara Prefecture was much higher than that in other areas in the 1930s, but it decreased gradually and eventually reached national levels. The female mortality rate in Nara decreased at a sluggish pace, but retained a several-fold incidence rate until the 1980s. In 1995, women in Nara reached the national level at last. The male/female ratio was low in Nara all the time, and alcohol consumption in Nara was low, too. CONCLUSION: Recently, it has been indicated that alcohol consumption is strongly related to esophageal cancer. However, women in Xinjiang do not drink strong liquor at all. One of their causes of esophageal cancer is dietary habits, which concerns both genders. Therefore, the incidence of esophageal carcinoma could be reduced by dietary reform in Xinjiang, where women as well as the overall population have a high incidence of esophageal carcinoma.

Implementation of integrated medical curriculum in Japanese medical schools.

Recently, various integrated medical curricula, which can be defined as courses with subject matter classified by organ systems rather than according to departments such as surgery and internal medicine, are beginning to be introduced to bedside-learning in Japan. For example, in such an integrated medical curriculum, lectures in the course on neurological diseases would be given by a team that would include neurosurgeons, neurologists, and pathologists. Using medical education on neurological diseases as an example of an integrated medical curriculum, we analyzed the factors related to the neurological disease course as an example of an integrated medical curriculum in the clinical medicine course at our school. We also compared our course with those of all private medical schools in Japan, using the syllabuses of these private medical schools for the comparison, and considered elements that measured interdisciplinary participation in presenting the curriculum. For an integrated medical curriculum to gain interdisciplinary acceptance, the curriculum should be constituted using all medical disciplines related to the specific organ involved in the disease process under study, including both basic medicine and clinical medicine. In addition, teachers should be informed of the rationale for such a curriculum to promote their participation and a textbook on the integrated medical curriculum is needed. A curriculum committee should play an important role in promoting this type of medical education.

Breast-conserving therapy in the management of early stage breast cancer: Our experience in 103 cases.

PURPOSE: The aim of this study is to determine whether our results in breastconserving therapy of 103 patients with earlystage breast cancer are comparable to those of other facilities or not. MATERIALS AND METHODS: From January 1990 to October 1999, 103 patients with earlystage breast cancer were treated by breastconserving surgery and whole breast irradiation. All patients were of Stages I or II, and the greatest dimensions of primary tumor were less than 3 cm. The median followup time was 47 months from the completion of postoperative radiotherapy. Local, regional and distant failure rates, and survival rate were presumed using the KaplanMeyer method. RESULTS: One patient suffered from local recurrence 30 months later. She was followed by simple mastectomy and kept from further recurrence. No regional relapse occurred. Distant metastases were seen in three patients:two patients in bones, and one patient in a bone and the liver after 19, 35, and 32 months, respectively. One patient died from disseminated cancer in 41 months. Only one patient died due to intercurrent disease. Both 5year and 10year diseasefree survival rates were 94.2%, and both 5year and 10year causespecific survival rates were 98.3%. CONCLUSION: Our results were comparable to previously reported data. In this stage although the followup time was too short to define the longterm outcome, it suggested that breast conserving therapy was acceptable and effective in the management of earlystage breast cancer.

[Effect of nedaplatin, 5-FU, and leucovorin combined with radiation therapy in unresectable esophageal carcinoma].

A 51-year-old male was assessed as having esophageal squamous cell carcinoma with trachea invasion and cervical lymph node metastasis. After one course of chemotherapy using cisplatin (CDDP), 5-fluorouracil (5-FU) and Leucovorin (LV), the patient had progressive disease (PD) of the primary lesion and metastatic lymph nodes, and a side effect of severe nausea. One course of nedaplatin, 5-FU and LV combined with radiation was performed alternatively. The effect was evaluated as a partial response (PR) of the primary lesion and metastatic lymph nodes. There were no adverse side effects such as nausea or renal dysfunction except for pancytopenia of grade 2. Increased serum levels of vascular endothelial growth factor (s-VEGF) decreased after the chemoradiotherapy and increased again during continued radiotherapy alone. More information is needed as to whether changes in s-VEGF relate to the clinical effects of the treatment.

Analysis of surgical treatments for earlobe keloids: analysis of 174 lesions in 145 patients.

BACKGROUND: Treatments for earlobe keloids include surgical excision, postoperative radiotherapy, steroid injection, taping stabilization, and pressure therapy. However, to date, there is no universally accepted treatment strategy for earlobe keloid therapy. METHODS: A total of 174 lesions in 145 patients who attended the keloid/scar specialist clinic at the Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, between 2006 and 2011 were included and were classified as having primary keloids or recurring keloids. Mild scars, such as hypertrophic scars, were excluded from this study. Appropriate surgical approaches, postoperative adjuvant therapies, such as radiotherapy, and postsurgical self-management were applied. The postsurgical radiotherapy modalities were 15 Gy administered in three fractions over 3 days and 10 Gy administered in two fractions over 2 days. Recurrence during the following 18-month follow-up period was recorded. RESULTS: Of the 174 lesions, 85.6 percent were primary keloids and 14.4 percent were recurrent keloids. Their recurrence rates were 4.7 percent and 0 percent, respectively. The overall recurrence rate was 4.0 percent. Complications during the 18-month follow-up period were not observed. The groups treated with 15-Gy and 10-Gy postsurgical radiotherapy did not differ significantly in terms of recurrence rate (p>0.05). CONCLUSIONS: Earlobe keloids can be treated by customized plans that involve appropriate surgical modalities, postoperative radiotherapy, and self-management. Postsurgical radiotherapy with 10 Gy of radiotherapy administered in two fractions over 2 days can be used successfully to treat earlobe keloids. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Clinical clerkship course for medical students on lumbar puncture using simulators.

Lumbar puncture is a medical technique that physicians must learn and is, therefore, considered a basic medical procedure. The lumbar puncture simulators Lumbar-Kun (Lumbar Puncture Simulator) and Lumbar-Kun II (Lumbar Puncture Simulator II) (Kyoto Kagaku, Kyoto, Japan) are teaching aids designed for practicing spinal insertions. We describe and results of a lumbar puncture clerkship course, provided to 5th-year medical students during clinical clerkship activity. The aim of this study was to evaluate the effectiveness of the lumbar puncture clerkship course in the medical education program. Comprehension, technical achievement, and satisfaction were scored by students and instructors using a 6-point Likert scale. Scores for both comprehension and technical achievement were high, but technical achievement scores tended to be higher than comprehension scores. In addition, the scores students gave themselves were higher than the scores they were given by instructors. Student satisfaction was high. The lumbar puncture simulators, Lumbar-Kun and Lumbar-Kun II, achieved excellent overall impressions and represent useful tools for training in lumbar puncture procedures. In addition to the simulators, an appropriate preparatory text and a short lecture before training seemed to increase the educational effect of this lumbar puncture clerkship course for medical students.

Post-keloidectomy irradiation using high-dose-rate superficial brachytherapy.

A study was conducted to evaluate the early results of high-dose-rate superficial brachytherapy (HDR-SB) after keloidectomy. Between April 2008 and April 2009, 21 patients with 36 histologically confirmed keloids were treated with postoperative HDR-SB. The tube applicator was placed on the skin to match the area of the surgical wound, and a spacer 5 mm thick was placed between the skin and the applicator. A dose evaluation point was established below 2 mm from skin surface, and 20 Gy was delivered in 4 daily fractions to keloidectomy scars on the anterior chest wall, scapular region, lower jaw and suprapubic region. A dose of 15 Gy was delivered in 3 daily fractions to lesions in other areas. The median follow-up period was 18 months (range, 9 to 29 months). Therapeutic outcome was judged in terms of recurrence, control, or acute side effects. Three keloids (9.7%) in two patients showed local recurrence, with a median time to failure after HDR-SB of 12 months. All recurrences affected the anterior chest wall. Dysraphia occurred in only one patient with an anterior chest wall lesion. Excluding the cases of recurrence, acceptable cosmetic results were achieved. Our results indicate that HDR-SB is effective and safe for preventing recurrence of keloids.

Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis.

BACKGROUND: Keloids have been treated by using radiation for over a century, and it is currently suggested that keloids are best treated by a combination of surgery and postoperative radiation therapy, although randomized controlled trials testing this are still lacking. However, plastic surgeons tend to avoid radiation therapy for keloids for fear of inducing malignant tumors. Thus, the authors searched for previous reports of associations between carcinogenesis and keloid radiation therapy, and examined the evidence-based opinions of radiation oncologists regarding the acceptability of using radiation to treat keloids. METHODS: A computerized literature search was carried out using PubMed that included citations from MEDLINE and PubMed Central between 1901 and March of 2009. The following search terms were used: "keloid(s)," "hypertrophic scar(s)," "radiation," "radiation therapy," "radiotherapy," "carcinogenesis," "carcinoma," "cancer," "complications," and "side effects." Moreover, the references for each report were also retrieved. RESULTS: The authors located five cases of carcinogenesis (i.e., fibrosarcoma, basal cell carcinoma, thyroid carcinoma, and breast carcinoma) that were associated with radiation therapy for keloids. However, it was unclear whether an appropriate dose of radiation was used and whether sufficient protection of surrounding tissues was provided. Moreover, a questionnaire study of radiation oncologists around the world revealed that approximately 80 percent considered radiation to be acceptable for treating keloids. CONCLUSIONS: The authors conclude that the risk of carcinogenesis attributable to keloid radiation therapy is very low when surrounding tissues, including the thyroid and mammary glands, especially in children and infants, are adequately protected, and that radiation therapy is acceptable as a keloid treatment modality.

Postoperative radiation protocol for keloids and hypertrophic scars: statistical analysis of 370 sites followed for over 18 months.

BACKGROUND: Before 2002, keloids and intractable hypertrophic scars were treated at our facility with postoperative irradiation of 15 Gy (the traditional protocol). Analysis of the therapeutic outcomes of patients treated with this protocol showed that the recurrence rates of keloids and intractable hypertrophic scars in the anterior chest wall, as well as the scapular and suprapubic regions, were statistically higher than at other sites, while the recurrence rates in earlobes were lower. Thus, we customized doses for various sites. This report describes our trial of postoperative radiation therapy. METHODS: Between January 2002 and September 2004, 109 patients with 121 keloid and intractable hypertrophic scar sites were treated with surgical excision following the new protocol: electron-beam irradiation at total doses of 10, 15, or 20 Gy, depending on the site. The recurrence rates and toxicities were historically followed in 218 patients with 249 keloid and intractable hypertrophic scar sites treated with the old protocol of surgical removal followed by irradiation at 15 Gy (without variation by site). The minimal follow-up time was 18 months. Statistical analysis was performed using Fisher exact probability test. RESULTS: Total recurrence rates were 29.3% before 2002 and 14.0% after 2003. The recurrence rate in the anterior chest wall was statistically reduced. Outcomes of earlobe did not differ between irradiation with 15 Gy or 10 Gy. CONCLUSIONS: Keloids and intractable hypertrophic scars should be treated with dose protocols customized by site. Our results suggest that keloid and intractable hypertrophic scar sites with a high risk of recurrence should be treated with 20 Gy in 4 fractions over 4 days and that earlobe should be treated with 10 Gy in 2 fractions over 2 days.