Risk factor analysis of the development of severe radiation pneumonitis in patients with non-small cell lung cancer treated with curative radiotherapy, with focus on underlying pulmonary disease.

BACKGROUND: We aim to identify the multifaceted risk factors that can affect the development of severe radiation pneumonitis (RP) in patients with non-small cell lung cancer (NSCLC) treated with curative high-dose radiotherapy with or without concurrent chemotherapy. METHODS: We retrospectively reviewed the medical records of 175 patients with stage-I-III NSCLC treated with curative thoracic X-ray radiotherapy at the Korea University Guro Hospital between June 2019 and June 2022. Treatment-related complications were evaluated using the Common Terminology Criteria for Adverse Events (version 4.03). RESULTS: The median follow-up duration was 15 months (range: 3-47 months). Idiopathic pulmonary fibrosis (IPF) as an underlying lung disease (P < 0.001) and clinical stage, regarded as the concurrent use of chemotherapy (P = 0.009), were associated with a high rate of severe RP. In multivariate analyses adjusting confounding variables, the presence of IPF as an underlying disease was significantly associated with severe RP (odds ratio [95% confidence interval] = 48.4 [9.09-347]; P < 0.001). In a subgroup analysis of stage-I-II NSCLC, the incidence of severe RP in the control, chronic obstructive pulmonary disease (COPD), and IPF groups was 3.2%, 4.3%, and 42.9%, respectively (P < 0.001). The incidence of severe RP was 15.2%, 10.7%, and 75.0% in the control, COPD, and IPF groups, respectively (P < 0.001) in the stage-III NSCLC group. CONCLUSIONS: This study revealed that IPF as an underlying lung disease and the concurrent use of chemotherapy are associated with a high rate of severe RP. In contrast, COPD did not increase the risk of pulmonary toxicity after receiving curative high-dose radiotherapy.

Clinical Outcomes of Stereotactic Ablative Radiotherapy for All Stages of Non-Small Cell Lung Cancer; Definitive versus Consolidative.

Background and Objectives: Stereotactic ablative radiotherapy (SABR) is not confined to early stage non-small cell lung cancer (NSCLC) and has a potential role in stage IV disease. We aimed to evaluate the effect of SABR on local control rates and survival outcomes in patients with all stages of NSCLC according to the treatment aim. Materials and Methods: We retrospectively reviewed the medical records of 88 patients with NSCLC who received SABR at the Korea University Guro Hospital between January 2015 and March 2021. Among these, 64 patients with stage I-II NSCLC ineligible for surgery were treated with a definitive aim. Twenty-four patients with stage IV limited metastatic NSCLC showing a favorable response to prior systemic therapy were treated with a consolidative aim. Results: The median follow-up time was 34 (range: 5-88) months. Thirty-one patients developed recurrence (35.2%), with distant metastasis being the most common (25/31, 80.6%). In-field local recurrence occurred in four patients (4/88 patients, 4.5%). For patients treated with definitive SABR, the 3-year overall survival (OS) and disease-free survival (DFS) rates were 91.8% and 58.6%, respectively. In patients treated with consolidative SABR, the 3-year OS and DFS rates were 86.7% and 53.8%, respectively. With respect to treatment-related pulmonary toxicity, grade 3 radiation pneumonitis incidence requiring hospitalization was 2.3% (2/88). Conclusions: Definitive SABR is appropriate for medically inoperable or high surgical risk patients with early stage NSCLC with acceptable treatment-related toxicities. Consolidative SABR improves local control rates and helps achieve long-term survival in patients with limited metastatic NSCLC.

Salvage External Beam Radiotherapy after Incomplete Transarterial Chemoembolization for Hepatocellular Carcinoma: A Meta-Analysis and Systematic Review.

Background and objective: Although transarterial chemoembolization (TACE) has been the commonest local modality for hepatocellular carcinoma (HCC), incomplete repsonse occurs especially for tumors with a large size or difficult tumor accessment. The present meta-analysis assessed the efficacy and feasibility of external beam radiotherapy (EBRT) as a salvage modality after incomplete TACE. Materials and Methods: We systematically searched the PubMed, Embase, Medline, and Cochrane databases. The primary endpoint was overall survival (OS), and the secondary endpoints included the response ratem toxicity of grade 3, and local control. Results: Twelve studies involving 757 patients were included; the median of portal vein thrombosis rate was 25%, and the pooled median of tumor size was 5.8 cm. The median prescribed dose ranged from 37.3 to 150 Gy (pooled median: 54 Gy in *EQD2). The pooled one- and two-year OS rates were 72.3% (95% confidence interval (CI): 60.2-81.9%) and 50.5% (95% CI: 35.6-65.4%), respectively; the pooled response and local control rates were 72.2% (95% CI: 65.4-78.1%) and 86.6 (95% CI: 80.1-91.2%) respectively. The pooled rates of grade ≥3 gastrointestinal toxicity, radiation-induced liver disease, hepatotoxicity, and hematotoxicity were 4.1%, 3.5%, 5.7%, and 4.9%, respectively. Local control was not correlated with intrahepatic (p = 0.6341) or extrahepatic recurrences (p = 0.8529) on meta-regression analyses. Conclusion: EBRT was feasible and efficient in regard to tumor response and control; after incomplete TACE. Out-field recurrence, despite favorable local control, necessitates the combination of EBRT with systemic treatments. *Equivalent dose in 2 Gy per fraction scheme.

Physical activity status in relation to quality of life and dietary habits in breast cancer survivors: subset analyses of KROG 14-09 nationwide questionnaire study.

PURPOSE: We investigated the relationship of physical activity with dietary habits and quality of life (QoL) in breast cancer survivors in accordance with the recommendations of the American Cancer Society. METHODS: Data of 928 breast cancer survivors were obtained from the KROG 14-09 study to measure QoL in early phase after adjuvant radiotherapy. According to the extent of physical activity, survivors were divided into four groups: inactivity (0-149 min/week, N = 144), regular activity (150-450 min/week, N = 309), moderate activity (451-900 min/week, N = 229), and marked activity (901-1800 min/week, N = 164) excluding hyperactivity (> 1800 min/week, N = 82) as it is a difficult condition to recommend to survivors. Global physical activity questionnaire, 5-dimensional questionnaire by EuroQoL (EQ-5D-3L), QoL Questionnaire-breast cancer (QLQ-BR23) from EORTC, and dietary habits were surveyed. A linear-to-linear association test for EQ-5D-3L and Kruskal-Wallis analysis for QLQ-BR23 and dietary habit were conducted. RESULTS: Overall, 15.5% respondents (144/928) were classified as physically inactive. The trends of frequent intake of fruits (p = 0.001) and vegetable (p = 0.005) and reluctance toward fatty food (p < 0.001) were observed in physically active groups. Mobility (p = 0.021) and anxiety (p = 0.030) of EQ-5D-3L, and systemic therapy side effect (p = 0.027) and future perspective (p = 0.008) of QLQ-BR23 were better in physically active groups besides body image (p = 0.003) for the survivors with breast-conserving surgery. However, moderate and marked activities did not further improve QoL than regular activity. CONCLUSION: Physicians and care-givers have to pay attention to inactive survivors to boost their physical activity, thereby facilitating a better QoL and dietary habit.

Questionnaire study of the dietary habits of breast cancer survivors and their relationship to quality of life (KROG 14-09).

We evaluated the dietary habits of breast cancer survivors and investigated the relationship with quality of life (QoL), with 1,156 survivors recruited from 17 institutions. We used the Questionnaire Survey of Dietary Habits of Korean Adults (Q-DH-KOR) comprising 25 questions. The following indices were derived as follows: (1) quality of healthy dietary habits (Q-HD)-eight questions on number of meals, regularity, quantity, duration, skipping breakfast, dinner with companion(s), overeating and late-night snacks; (2) habits of nutritional balance (H-NB)-questions on consuming five food categories (grains, fruits, proteins, vegetables and dairy products); and (3) habits of unhealthy foods (H-UF)-questions on consuming three food categories (fatty, instant and fast foods). The times and regularity of meals, frequency of skipping breakfast, dinner with companion(s) and overeating were better in groups with high symptomatic and functional QoL. Symptomatic QoL positively affected Q-HD and H-NB (p < 0.001 and p = 0.024 respectively) and negatively affected H-UF (p = 0.02). Breast cancer survivors more frequently ate from the fruit, protein and vegetable categories than did the control group, with lower H-UF and higher Q-HD values (p < 0.001 and p < 0.001 respectively). Our findings supported the relationship between QoL and dietary habit and showed healthier dietary habits of breast cancer survivors than controls.

Factors predicting intolerance to definitive conventional radiotherapy in geriatric patients.

PURPOSE: Although radiotherapy can be administered with a relatively low therapeutic burden, many elderly patients do not complete radiotherapy. In order to predict intolerance during radiotherapy, this study retrospectively analyzed the frequency of and risk factors for radiotherapy interruption among geriatric patients. METHODS: From September 2009 to December 2016, 353 patients aged ≥70 years received definitive radiotherapy with a conventionally fractionated schedule. "Total interruption" included completion of ≤90% of a planned radiotherapy, temporary discontinuation, and treatment-related mortality within 2 months. "Early-phase incompletion" and "mid-phase incompletion" represented completion of ≤50 and ≤80% of a planned radiotherapy, respectively. RESULTS: The median age of patients was 74 years. Early- and mid-phase incompletions and total interruption occurred in 4.2, 9.3, and 19.3% of patients, respectively. Total interruption occurred frequently in cancers involving the thorax (27.4%), head and neck (23.1%), abdomen (20.0%), pelvis (17.4%), and breast/extremity (8.1%). The Eastern Cooperative Oncology Group (ECOG) performance score (P = 0.004 and 0.002), serum albumin level (P = 0.016 and 0.002), and the expected 5­year survival (P = 0.033 and 0.034) were significant factors for mid-phase incompletion and total interruption. Age ≥ 75 years (P = 0.008), concurrent chemotherapy (P = 0.017), and the extent of radiation field (P = 0.027) were factors associated with total interruption. CONCLUSION: Overall, 19.3% of the elderly patients showed treatment intolerance during conventional radiotherapy. Serum albumin level and ECOG performance score should be considered as surrogate markers for radiotherapy interruption prior to the decision regarding definite conventional radiotherapy.

An assessment of quality of life for early phase after adjuvant radiotherapy in breast cancer survivors: a Korean multicenter survey (KROG 14-09).

BACKGROUNDS: Quality of life (QoL) has become a major concern as the survival time of breast cancer increases. We investigated the changes in QoL through comprehensive categorical analysis, for the first three years after breast cancer treatment including radiotherapy. METHODS: A total of 1156 patients were enrolled from 17 institutions. All survivors were grouped according to a surveillance period of 9-15 months (first year), 21-27 months (second year), and 33-39 months (third year) from the end of radiotherapy. The 5-dimensional questionnaire by the EuroQol group (EQ-5D) and the EORTC Quality of Life Questionnaire; breast cancer specific module (QLQ-BR23) were checked by self-administrated method. RESULTS: First, second and third year groups comprised 51.0, 28.9, and 21.0%. In EQ-5D-3 L (3-Likert scale) analysis, pain/discomfort and anxiety/depression categories showed lower QoL. In multivariate analyses of EQ-5D-VAS (visual-analogue scale), categories of pain/discomfort and self-care were improved with time; axillary dissection was a significant clinical factor deteriorates pain/discomfort, self-care and usual activities. In QLQ-BR23 analysis, the lowest scored category was sexual activity, followed by sexual enjoyment, future perspective, and hair loss, and the best scored category was breast symptoms. In multivariate analyses, arm symptoms, breast symptoms and body image were improved with time. CONCLUSIONS: Categories of pain/discomfort and self-care in EQ-5D-VAS, arm/breast symptoms and body image in QLQ-BR23 were improved, while categories of anxiety/depression and future perspective BR23 were not, suggesting necessity of psychosocial support. This research provides comprehensive information on the categorical aspects of QoL and changes during early follow-up after breast cancer treatment.

YKL-40 expression could be a poor prognostic marker in the breast cancer tissue.

YKL-40 is a glycoprotein involved in cellular growth, migration, and the inflammatory process. Elevation in serum levels of YKL-40 has been associated with worse prognosis in various cancers, including breast cancer. Given that the clinical significance of YKL-40 expression in breast cancer tissue is unclear, we aimed to determine the prognostic value of YKL-40 expression in breast cancer tissue using immunohistochemistry. We performed tissue microarray (TMA) analysis of 425 breast cancer tissues collected during operation. Immunohistochemical staining was performed to measure expression of YKL-40 and several breast cancer biomarkers, such as aldehyde dehyadrogenase1, TGF-beta, and Gli-1 as well as hormonal receptor and Her-2/neu status. Statistical analysis of the relationship of YKL-40 expression with clinicopathological characteristics was performed for 390 TMA samples. YKL-40 was expressed to varying degrees in 84.9% of breast cancer tissues. YKL-40 expression was correlated with estrogen receptor and progesterone receptor negativity and was positively correlated with TGF-beta and Gli-1 expression. Strong YKL-40 expression was associated with a larger proportion of Her-2/neu-enriched and basal-like tumors. The results of this study demonstrate that YKL-40 expression in breast cancer tissues is associated with hormone receptor negativity and Her-2/neu-enriched molecular subtypes of breast cancer, and therefore could be considered a poor prognostic predictor.

Intraoperative Radiation Therapy for Gallbladder Cancer: Experience at a Single Institution.

BACKGROUND/AIMS: To investigate the survival outcome of intraoperative radiation therapy for patients with gallbladder cancer on the basis of experience at a single institution. METHODOLOGY: The medical records of 8 patients with gallbladder cancer who were treated with intraoperative radiation therapy during surgical resection or palliative surgery were retrospectively analyzed. The primary endpoint was overall survival. The median follow-up time was 20.8 months. RESULTS: The median survival time was 15.0 months. Overall survival for all patients was 75.0% at 1 year, 37.5% at 3 years, and 25.0% at 5 years. Three patients underwent complete resection, and 5 patients had residual tumor after resection or palliative surgery. The 3-year OS rate for 3 patients with no residual tumor after curative resection was 66.7%, with a mean survival time of 122.6 months, whereas the 3-year OS rate for 5 patients with macroscopic residual diseasewas 0% with a mean survival time of 13.5 months (P = 0.014). CONCLUSIONS: The results of the present study suggest that intraoperative radiation therapy with or without external beam radiation therapy was safe and beneficial for patients who underwent curative resection with negative margins and allows the possibility of long-term survival.

Primary malignant melanoma of uterine cervix: a suggestion of new scheme of treatment combination.

Historically, the lack of melanocytes in the vaginal and cervical mucus membranes has deterred the findings of primary melanomas. Mainly due to its rarity, difficulty to diagnose, and poor prognosis, there has been no absolute agreement on comprehensive treatment so far. In this case report, we present a case of a 46-year-old woman with primary malignant melanoma of uterine cervix. She underwent neo-adjuvant chemotherapy initially followed by a radical hysterectomy. After adjuvant concurrent chemo-radiation, the patient has been followed up for 24 months. So far, she has not shown any symptoms or signs of recurrence. Further studies with more cases based on variable combinations of treatment regimen have been on the way.

Preliminary Results of Developing Imaging Complexity Biomarkers for the Incidence of Severe Radiation Pneumonitis Following Radiotherapy in Non-Small Cell Lung Cancer Patients with Underlying Idiopathic Pulmonary Fibrosis.

Background: Idiopathic pulmonary fibrosis (IPF) has the potential to cause fatal pulmonary toxicity after radiotherapy and can increase the morbidity and mortality of non-small-cell lung cancer (NSCLC) patients. In this context, we aimed to develop imaging complexity biomarkers to predict the incidence of severe pulmonary toxicity in patients with NSCLC who have underlying IPF and are treated with radiotherapy. Methods: We retrospectively reviewed the medical records of 19 patients with NSCLC who had underlying IPF and were treated with radiotherapy at the Korea University Guro Hospital between March 2018 and December 2022. To quantify the morphometric complexity of the lung parenchyma, box-counting fractal dimensions and lacunarity analyses were performed on pre-radiotherapy simulation chest computed tomography scans. Results: Of the 19 patients, the incidence of grade 3 or higher radiation pneumonitis was observed in 8 (42.1%). After adjusting for age, sex, smoking status, histology, and diffusing capacity of the lung for carbon monoxide, eight patients with a lower fractal dimension showed a significantly higher hazard ratio of 7.755 (1.168-51.51) for grade 3 or higher pneumonitis than those with a higher fractal dimension. Patients with lower lacunarity exhibited significantly lower hazards in all models, both with and without adjustments. The lower-than-median lacunarity group also showed significantly lower incidence curves for all models built in this study. Conclusions: We devised a technique for quantifying morphometric complexity in NSCLC patients with IPF on radiotherapy and discovered lacunarity as a potential imaging biomarker for grade 3 or higher pneumonitis.

Clinical experience of consolidative radiotherapy for localized metastatic non-small cell lung cancer who showed favorable tumor response after systemic treatment.

BACKGROUND: Our study has aimed to assess the effects of consolidative high-dose radiotherapy on clinical outcomes in patients with localized metastatic non-small cell lung cancer (NSCLC) who showed favorable tumor response after systemic treatment. METHODS: We retrospectively reviewed the medical records of 83 patients with localized metastatic NSCLC, who received systemic therapy followed by consolidative local radiotherapy at the Korea University Guro Hospital between March 2017 and June 2022. In the current study, we defined localized metastatic disease as the presence of one to three metastatic sites at the time of diagnosis. And patients who showed favorable tumor response after systemic treatment, including oligo-progressive disease at the thoracic site which was amenable to curative high-dose local radiotherapy, were included. The planned total dose and fraction size mainly depended on the location of lesions. RESULTS: The median follow-up time after consolidative radiotherapy was 16 months (range: 5-52 months). The overall 2-year progression-free survival rates were 81.4%. Of 83 patients, only four (4.3%), treated with intensity-modulated radiation therapy, showed an in-field local recurrence. Interestingly, only one patient experienced a local failure among the 20 patients who showed an oligo-progressive disease at the thoracic site on the tumor response evaluation after systemic treatment. Regarding treatment-related pulmonary toxicity, three patients with grade-3 and one patient with grade-4 radiation pneumonitis were presented. CONCLUSIONS: If the disease is sufficiently controlled and localized by systemic therapy, local consolidative radiotherapy is thought to improves local control rates with acceptable treatment-related toxicities in patients with localized metastatic NSCLC, especially those with oligo-progressive disease.

The relationship between preeclampsia, pregnancy-induced hypertension and maternal risk of breast cancer: a meta-analysis.

BACKGROUND: It has long been recognized that some human breast cancers are hormone dependent. Preeclampsia is a syndrome of pregnancy defined by the onset of hypertension and proteinuria and characterized by dysfunction of the maternal endothelium. Many hormonal changes occur with preeclampsia, and we hypothesize that these changes may influence the risk of maternal breast cancer. We also analyzed the relation between pregnancy-induced hypertension (PIH) and maternal risk of breast cancer. METHODS: Among 13 relevant publications about preeclampsia and six relevant publications about PIH, some studies find preeclampsia associated with a lower risk of breast cancer, but others did not. Therefore, these results are inconclusive. We conducted meta-analysis to evaluate more precisely the relationship between preeclampsia, PIH and maternal risk of breast cancer. RESULTS: The pooled estimate of the hazard ratio (HR) associated with preeclampsia was 0.86 (95% CI 0.73-1.01), and that associated with PIH was 0.83 (0.66-1.06), both based on the random effects model. CONCLUSION: Some suggestive but not entirely consistent nor conclusive evidence was found on the association between the history of preeclampsia or PIH with the subsequent risk of breast cancer.

Consolidative high-dose thoracic radiotherapy for limited metastatic nonsmall cell lung cancer: Focusing on oligo-progressive disease.

AIM: Prior clinical data have shown a significant survival benefit of consolidative local radiotherapy for patients with limited metastatic non-small cell lung cancer (NSCLC). Therefore, this study aimed to evaluate the impact of consolidative high-dose thoracic radiotherapy on local control rates and survivals in patients with limited metastatic NSCLC, especially focusing on oligo-progressive disease. METHODS: We retrospectively reviewed the medical records of 45 patients with limited metastatic NSCLC who received consolidative high-dose thoracic radiotherapy at the Korea University Guro Hospital between March 2015 and December 2020. In the current study, we included patients who showed partial response, stable disease, or oligo-progressive disease on tumor response evaluation after systemic treatment. All patients underwent stereotactic body radiation therapy (23 patients) or intensity-modulated radiation therapy (IMRT, 22 patients). RESULTS: The median follow-up time was 42 months (range: 5-88 months). The overall 2-year disease-free survival (DFS) and overall survival (OS) rates were 80.7% and 88.4%, respectively. Among the 45 patients, only two patients treated with IMRT showed in-field local recurrence. There was no local failure among the patients who showed oligo-progressive disease after systemic treatment. In addition, the response to systemic treatment was not a significant factor for either DFS or OS rates (p = .471 and p = .414, respectively) in univariate analysis. CONCLUSIONS: Consolidative high-dose thoracic radiotherapy improves local control rates and helps achieve long-term survival in patients with limited metastatic NSCLC. It is also effective and should be considered in patients with oligo-progressive disease after systemic treatment.

Role of local ablative treatment in oligometastatic non-small cell lung cancer: a meta-analysis.

INTRODUCTION: This meta-analysis analyzed the oncologic role of local ablative treatment (LAT) in oligometastatic nonsmall cell lung cancer. METHOD: Pubmed, MEDLINE, Embase, and Cochrane Library were searched until October, 2022. Studies comparing LAT with standard care (control) were included. Sensitivity analyses were performed including randomized controlled studies (RCTs). Subgroup analyses were performed according to specific categories and metastatic burden. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Considering the median OS and PFS from landmark studies, 2-year OS and 1-year PFS rates were used to calculate pooled odds ratios (ORs). RESULTS: A total of 20 studies (four RCTs) encompassing 1750 patients were included. Surgery and radiotherapy (60 and 90% of studies) were mainly used as LATs. Pooled ORs of OS and PFS were 3.492 (95% CI:2.612-4.699, P <0.001) and 3.743 (95% CI: 2.586-5.419, P <0.001), favoring LAT, respectively. Sensitivity analyses, including RCTs showed ORs of 4.111 ( P <0.001) and 4.959 ( P =0.001) regarding OS and PFS, favoring LCT, respectively. Pooled 1-year and 2-year OS rates were 83.8 and 58.4% in LAT arms, whereas 64.4 and 31% in control arms; pooled 1-year and 2-year PFS rates were 64.6 and 32.8% in LAT arms, and 36.1 and 10% in control arms. In subgroup analyses, the pooled ORs were 3.981 ( P <0.001), 3.355 ( P <0.001), and 1.726 ( P =0.373) in synchronous, oligopersistence, and oligoprogression/recurrence subgroups, respectively. Regarding PFS comparison, pooled ORs were 5.631 ( P <0.001), 3.484 ( P <0.001), and 1.777 ( P =0.07), respectively. According to metastatic burden categories, pooled ORs favored LAT arms in both analyses including low-metastatic and high-metastatic burden subgroups. CONCLUSION: The present study supports the role of LAT in treating nonsmall cell lung cancer oligometastasis. The oligoprogression/recurrence disease could have less LAT benefit than synchronous or oligopersistent disease.

The relationship between twin births and maternal risk of breast cancer: a meta-analysis.

Women who undergo a greater number of menstrual cycles may be at increased risk of breast cancer, possibly due to cumulative exposure to ovarian hormones. Pregnancy reduces the lifetime number of menstrual cycles and also influences the levels of ovarian hormones. Twin pregnancies differ from singleton pregnancies in both hormone levels and perinatal changes. To date, a meta-analysis on the effects of twin birth on the risk of maternal breast cancer has not been conducted. Among 17 relevant publications identified in a systematic search, some suggest that twin births may be associated with lower breast cancer risk but others do not; therefore, the results are inconclusive. Although our pooled results of all 17 published studies did not show a reduced maternal risk of breast cancer for twin births (HR 0.94; 95% CI = 0.87-1.02; P = 0.127), a trend toward reduced maternal risk of breast cancer was identified in a subgroup analysis of cohort studies (HR 0.91; 95% CI = 0.83-1.01; P = 0.068). The results of this meta-analysis suggest that twin pregnancy does not significantly decrease the maternal risk of breast cancer.

Effectiveness of high-dose three-dimensional conformal radiotherapy in hepatocellular carcinoma with portal vein thrombosis.

OBJECTIVE: To evaluate the treatment outcome of three-dimensional conformal radiotherapy in hepatocellular carcinoma patients with portal vein thrombosis, concerning survival and treatment response of thrombosis. METHODS: Forty-five patients with hepatocellular carcinoma who had portal vein thrombosis treated from March 2005 to March 2011 were the subjects of this study. The median total dose was 61.2 Gy (range 38-65 Gy). A daily radiation dose of 1.8-2.5 Gy was administered at a frequency of five fractions per week. The clinical target volume included portal vein thrombosis with or without primary tumour with clinical consideration. RESULTS: Three of the 45 patients (6.7%) showed complete remission of portal vein thrombosis, 25 patients (55.6%) showed partial response, 14 patients (31%) had stable disease and 3 patients (6.7%) had progressive disease. The median and the 1-year survival rate of the responders (complete remission + progressive disease) were 16.7 months and 63.7%, respectively, and those of the non-responders were 8 months and 28.2%, respectively (P= 0.003). A univariate analysis revealed that thrombosis response, Eastern Cooperative Oncology Group performance status, maximum tumour size, tumour bilaterality, Cancer of the Liver Italian Program stage, Okuda stage, hepatic arterial infusion, hepatitis B 'e' antigen and hepatitis C antibody were statistically significant prognostic factors affecting survival. In a multivariate analysis, thrombosis response, Cancer of the Liver Italian Program stage and Okuda stage were found to be statistically significant. No clinically significant radiation-induced liver disease was noted. One grade 3 late complication (duodenal ulcer) was reported. CONCLUSIONS: High-dose three-dimensional conformal radiotherapy yielded a response rate of 62.3%. It is a safe and effective treatment prolonging the survival of hepatocellular carcinoma patients with portal vein thrombosis.

The extent and serial pattern of interfractional variation in patients with whole pelvic irradiation: a study using a kilovoltage orthogonal on-board imager.

The purpose of this study is to assess the extent and serial pattern of setup error of conventional fractionated whole pelvic irradiation using a kilovoltage on-board imager. The daily on-board images of 69 patients were matched with the digitally reconstructed radiographs of simulation on the basis of pelvic bony structure. The shifts along x- (lateral), y- (longitudinal), and z- (vertical) axes, and the 3D vector, were measured. The shift between an origin of the first fraction and each fraction (Δshift(1st)) and the shift between an isocenter of simulation and each fraction (Δshift(Sim)) were calculated. To evaluate serial changes, the shifts of each fraction were classified into four consecutive sessions, and an ANOVA and chi-square test were used. The systematic error of the Δshift(Sim) and Δshift(1st) were 2.72 and 1.43 mm along the x-axis, 2.98 and 1.28 mm along the y-axis, and 4.26 and 2.39 mm along the z-axis, respectively. The Δshift(Sim) and Δshift(1st) ≥ 5 mm of the 3D vector occurred in 54.3% and 23.1%, respectively. The recommended margins to cover setup error in case of using Δshift(1st) were 3.81, 3.54, and 6.01 mm along x-, y-, and z-axes, whereas those using Δshift(Sim) were 6.39, 6.95, and 9.95 mm, respectively. With the passage of time, the Δshift(1st) ≥ 5 mm of 3D vector and along any axis in supine setup increased from 14.1% for first session to 22.5% for fourth session (p=0.027) and from 10.8% to 18.5% (p = 0.034), respectively. In prone setup, first session was better than others in the Δshift(1st) ≥ 5 mm of 3D vector and along any axis. It is expected that the correction using the on-board images on the first fraction improves geometrical uncertainties and reduces the margin for target coverage. Daily continuous OBI follow-up during conventional fractionated pelvic irradiation can increase the reproducibility and be more effective in the late period.

Evaluation of mechanical accuracy for couch-based tracking system (CBTS).

This study evaluated the mechanical accuracy of an in-house-developed couch-based tracking system (CBTS) according to respiration data. The overall delay time of the CBTS was calculated, and the accuracy, reproducibility, and loading effect of the CBTS were evaluated according to the sinusoidal waveform and various respiratory motion data of real patients with and without a volunteer weighing 75kg. The root mean square (rms) error of the accuracy, the reproducibility, and the sagging measurements were calculated for the three axes (X, Y, and Z directions) of the CBTS. The overall delay time of the CBTS was 0.251 sec. The accuracy and reproducibility in the Z direction in real patient data were poor, as indicated by high rms errors. The results of the loading effect were within 1.0 mm in all directions. This novel CBTS has the potential for clinical application for tumor tracking in radiation therapy.

Protective effect of triphala on radiation induced acute intestinal mucosal damage in Sprague Dawley rats.

Aim of the study was to determine protective effect of triphala on radiation-induced rectal mucosal damage. Male Sprague Dawley rats (30) were divided into 5 groups. Rats in group A were sham irradiated and rats in group B underwent only irradiation. Rats in group C were administered triphala 1 g/kg/day orally for 5 consecutive days before irradiation. Rats in group D and E were administered triphala 1 and 1.5 g/kg/day orally for 10 consecutive days, respectively. Rectal mucosal damage was induced by a single fraction of 12.5Gy gamma irradiation (Ir-192) on 5th day. All the rats were autopsied on 11th day and histological changes in surface epithelium, glands, and lamina propria were assessed. Proctitis showed significant improvement in surface epithelium (P < 0.024), glands (P < 0.000) and lamina propria (P < 0.002) in group E compared to group B. Rats in group E showed significantly less change in glands (P < 0.000) compared to rats in group D, All histological variables (surface epithelium, P < 0.001; glands, P < 0.000; lamina propria, P < 0.003) compared to rats in group C. In a Tukey-b test, group E had a significantly recovered grade for glands (P < 0.000) compared to groups B, C and D. Results of the present study showed that high-dose triphala improved radiation-induced damage of glands.