Fundamental study on quality assurance (QA) procedures for a real-time tumor tracking radiotherapy (RTRT) system from the viewpoint of imaging devices.

PURPOSE: The real-time tumor tracking radiotherapy (RTRT) system requires periodic quality assurance (QA) and quality control. The goal of this study is to propose QA procedures from the viewpoint of imaging devices in the RTRT system. METHODS: Tracking by the RTRT system (equips two sets of colored image intensifiers (colored I.I.s) fluoroscopy units) for the moving gold-marker (diameter 2.0 mm) in a rotating phantom were performed under various X-ray conditions. To analyze the relationship between fluoroscopic image quality and precision of gold marker coordinate calculation, the standard deviation of the 3D coordinate (σ3D [mm]) of the gold marker, the mean of the pattern recognition score (PRS) and the standard deviation of the distance between rays (DBR) (σDBR [mm]) were evaluated. RESULTS: When tracking with speed of 10-60 mm/s, σDBR increased, though the mean PRS did not change significantly (p>0.05). On the contrary, the mean PRS increased depending on the integral noise equivalent quanta (∫NEQ) that is an indicator of image quality calculated from the modulation transfer function (MTF) as an indicator of spatial resolution and the noise power spectrum (NPS) as an indicator of noise characteristic. CONCLUSION: The indicators of NEQ, MTF, and NPS were useful for managing the tracking accuracy of the RTRT system. We propose observing the change of these indicators as additional QA procedures for each imaging device from the commissioning baseline.

A feasibility study of postoperative adjuvant chemotherapy with fluoropyrimidine S-1 in patients with stage II-IIIA non-small cell lung cancer.

BACKGROUND: Adjuvant chemotherapy with uracil tegafur (UFT) improved survival among patients with completely resected stage I lung adenocarcinoma. S-1, an oral dihydropyrimidine dehydrogenase (DPD)-inhibitory 5-fluorouracil, is a more potent DPD inhibitor than UFT;therefore, we hypothesized that postoperative adjuvant chemotherapy with S-1 would be effective for advanced non-small cell lung cancer (NSCLC). We conducted a feasibility study of S-1 as postoperative adjuvant chemotherapy in patients with curatively resected pathological stage bold I back 10 bold I and bold I back 10 bold I back 20 bold I A NSCLC. METHODS: Adjuvant chemotherapy consisted of 9 courses (4-week administration, 2-week withdrawal) of S-1 at 80-120 mg/body per day. Twenty-four patients with completely resected NSCLC were enrolled in this study from November 2007 through December 2010. The primary endpoint was the rate of completion of the scheduled adjuvant chemotherapy. The secondary endpoints were safety, overall survival, and relapse-free survival. RESULTS: Five patients were censored because of disease recurrence. The planned 9 courses of S-1 were administered to completion in 8 patients. Twelve patients completed more than 70% of the planned courses. Grade 3 adverse reactions, such as elevated total bilirubin (4.2%) and pneumonitis (4.2%), were observed, but there were no Grade 4 adverse reactions. Patients who completed more than 70% of the 9 courses demonstrated better overall survival than those who completed less than 70%. CONCLUSION: Postoperative administration of S-1 may be possible with few severe adverse events as adjuvant chemotherapy for patients with curatively resected pathological stage bold I back 10 bold I -bold I back 10 bold I back 20 bold I A NSCLC. J. Med. Invest. 65:90-95, February, 2018.

[Clinical experience of the use of pemetrexed (PEM) combined with cisplatin (CDDP)/Carboplatin (CBDCA) followed by long-term maintenance PEM in patients with non-squamous non-small cell lung cancer].

This study evaluated the efficacy and safety of pemetrexed and carboplatin (CBDCA) or cisplatin (CDDP) followed by maintenance pemetrexed for cases of advanced non-squamous non-small cell lung cancer (NSCLC) that were treated in our hospital. Patients received pemetrexed (PEM 500mg/m²) and CBDCA(area under the curve, 5 mg/[mL/min]) or CDDP (75 mg/m²) every 21 days. For patients without disease progression after 4-6 courses, pemetrexed was continued until disease progression or unacceptable toxicity. Fourteen patients received maintenance pemetrexed(median, 11.5 courses; range, 4- 43 courses). Among the 14 patients, the median progression-free survival time from the beginning of the induction treatment was 13 months. Continuation maintenance with pemetrexed after cisplatin plus pemetrexed induction is recommended as a first-line treatment for patients who have advanced non-squamous NSCLC and as a maintenance strategy.

Optimization of fluoroscopy parameters using pattern matching prediction in the real-time tumor-tracking radiotherapy system.

In the real-time tumor-tracking radiotherapy system, fluoroscopy is used to determine the real-time position of internal fiducial markers. The pattern recognition score (PRS) ranging from 0 to 100 is computed by a template pattern matching technique in order to determine the marker position on the fluoroscopic image. The PRS depends on the quality of the fluoroscopic image. However, the fluoroscopy parameters such as tube voltage, current and exposure duration are selected manually and empirically in the clinical situation. This may result in an unnecessary imaging dose from the fluoroscopy or loss of the marker because of too much or insufficient x-ray exposure. In this study, a novel optimization method is proposed in order to minimize the fluoroscopic dose while keeping the image quality usable for marker tracking. The PRS can be predicted in a region where the marker appears to move in the fluoroscopic image by the proposed method. The predicted PRS can be utilized to judge whether the marker can be tracked with accuracy. In this paper, experiments were performed to show the feasibility of the PRS prediction method under various conditions. The predicted PRS showed good agreement with the measured PRS. The root mean square error between the predicted PRS and the measured PRS was within 1.44. An experiment using a motion controller and an anthropomorphic chest phantom was also performed in order to imitate a clinical fluoroscopy situation. The result shows that the proposed prediction method is expected to be applicable in a real clinical situation.

Resection of an azygos vein aneurysm with thrombosis.

Aneurysm of the azygos vein is rare. We describe the case of a 51-year-old nonsmoking woman with a posterior mediastinal mass caused by a giant azygos vein aneurysm with subtotal thrombosis. Surgical resection of the azygos vein was offered to our patient as a treatment option owing to theoretical risks of rupture and pulmonary embolism. After taping the azygos vein proximally and distally, the aneurysm was resected with video-assisted thoracoscopy. Approximately 30 cases have been reported in the literature to date. Dynamic computed tomography and a videoassisted approach were useful for the diagnosis and treatment for this abnormality.

Lymphoepithelial cyst of the pancreas that was difficult to distinguish from branch duct-type intraductal papillary mucinous neoplasm: report of a case.

A 58-year-old woman was admitted to our hospital to optimize the management of her diabetes mellitus. A computed tomography (CT) scan showed a 30-mmdiameter, multilocular cyst in the head of the pancreas. The tumor markers, including DUPAN 2, SPAN-1, and carbohydrate antigen 19-9, were within the normal ranges. A contrast-enhanced CT scan showed a nonenhanced, multilocular cyst. Abdominal magnetic resonance imaging showed a multilocular cyst. Endoscopic retrograde cholangiopancreatography showed that the main pancreatic duct was normal. Based on these findings, we suspected a branch duct type intraductal papillary mucinous neoplasm. A distal pancreatectomy with a splenectomy was performed, since more of the mass was located on the dorsolateral side, inconsistent with the preoperative imaging results. On the resected specimen, a 4-cm-diameter, multilocular cyst containing serous fluid was found. Pathologically, the cyst wall was lined with squamous epithelium surrounded by abundant lymphoid tissue with follicles, consistent with a lymphoepithelial cyst of the pancreas, which is an unusual benign cyst.

Hepatobiliary cystadenoma exhibiting morphologic changes from simple hepatic cyst shown by 11-year follow up imagings.

BACKGROUND: A long-term follow up case of hepatobiliary cystadenoma originating from simple hepatic cyst is rare. CASE PRESENTATION: We report a case of progressive morphologic changes from simple hepatic cyst to hepatobiliary cystadenoma by 11 - year follow up imaging. A 25-year-old man visited our hospital in 1993 for a simple hepatic cyst. The cyst was located in the left lobe of the liver, was 6 cm in diameter, and did not exhibit calcification, septa or papillary projections. No surgical treatment was performed, although the cyst was observed to gradually enlarge upon subsequent examination. The patient was admitted to our hospital in 2004 due to epigastralgia. Re-examination of the simple hepatic cyst revealed mounting calcification and septa. Abdominal CT on admission revealed a hepatic cyst over 10 cm in diameter and a high-density area within the thickened wall. MRI revealed a mass of low intensity and partly high intensity on a T1-weighted image. Abdominal angiography revealed hypovascular tumor. The serum levels of AST and ALT were elevated slightly, but tumor markers were within normal ranges. Left lobectomy of the liver was performed with diagnosis of hepatobiliary cystadenoma or hepatobiliary cystadenocarcinoma. The resected specimen had a solid component with papillary projections and the cyst was filled with liquid-like muddy bile. Histologically, the inner layer of the cyst was lined with columnar epithelium showing mild grade dysplasia. On the basis of these findings, hepatobiliary cystadenoma was diagnosed. CONCLUSION: We believe this case provides evidence of a simple hepatic cyst gradually changing into hepatobiliary cystadenoma.

[A case of disseminated bone marrow carcinosis with disseminated intravascular coagulation successfully controlled with S-1 after total gastrectomy for advanced gastric cancer].

Bone marrow carcinosis due to gastric cancer with disseminated intravascular coagulation(DIC)occurs suddenly, progresses rapidly, and has a very poor prognosis. In addition, physical status tends to be bad at the time of the episode, and palliative care is generally selected as the treatment method. The case was a 70-year-old woman who underwent total gastrectomy for scirrhous stomach cancer five years previously. She recently noticed gingival hemorrhage, and was referred to our hospital by a nearby doctor. As a result of her examination, she was diagnosed with disseminated bone marrow carcinosis as a postoperative recurrence of gastric cancer that resulted in DIC. We transfused blood platelets and fresh frozen plasma into her, and controlled the bleeding tendency temporarily. She was started on oral administration of S-1 for improvement of DIC, and the therapy was successful without loss of QOL. It is easy to continue S-1 therapy as chemotherapy in the outpatient department, because it is a matter of internal medicine.

Giant pulmonary cyst associated with congenital pericardial defect.

Congenital defects of the pericardium are rare. This report describes a young woman with a congenital complete pericardial defect who developed a giant pulmonary cyst. After operation the patient experienced chest pain caused by myocardial ischemia due to cardiac displacement. It is important to note that heart lability in patients with congenital pericardial defects may cause grave complications after thoracotomy associated with volume loss of the residual lung.

The use of flexible silastic drains after chest surgery: novel thoracic drainage.

PURPOSE: We report a new strategy for drainage with silicon thoracic tube (Blake drain) after chest surgery. DESCRIPTION: To confirm the effect of Blake drain, we have performed a three-part study including in vitro and clinical investigations compared with those of conventional chest tubes. We carried out an in vitro analysis to achieve the best possible drainage; in the second part, we used this drain in a cohort of 30 patients to establish safety and efficacy; and in a third substudy, we carried out a nonrandomized comparison with an earlier cohort between the Blake drain group and standard, rigid drain group. EVALUATION: In vitro tests demonstrate that the drainage capability of the Blake drain depends on sufficient length in the fluted part of the structure. Clinical outcome demonstrates no significant differences. The Silastic drain (Ethicon, Inc, Somerville, NJ) group had a significantly shorter period of tube drainage compared with the conventional drain group. CONCLUSIONS: From this small study the Blake drains seem to be safe and effective. Therefore, a prospective, randomized comparison should be carried out.

[A case of rectal cancer treated by preoperative chemoradiation].

Fifty-one-year-old male visited our hospital suffering from anal pain and subileus. Further examination revealed that advanced rectal cancer which invaded to presacral space (Ai, N 0, P 0, H 0, M(-), stage IIIa) caused such symptom. We administered neo-adjuvant chemoradiotherapy for fear of non curative resection of the rectum. The regimen was once weekly administration of intravenous CPT-11 40 mg, plus daily oral administration of UFT-E 600 mg/day and Uzel 75 mg/day for 4 weeks. In addition we underwent radiation 2.4 Gy/day and intravenous low-dose cisplatin (CDDP) 5 mg/day, 5 days/week for 3 weeks. Four weeks after the first administration, a partial response was confirmed on CT, and so we carried out an abdominoperineal resection. The postoperative course is almost uneventful without a little perineal infection. The specimen revealed that no malignant lesion remained, which changed to necrotic tissue. The side effects were not so severe. For example, diarrhea, nausea, and mucosal dysfunction were each less than grade 2, and there was much tolerate for renal, liver, and bone marrow function. This combination chemoradiotherapy is considered to be effective for locally advanced rectal cancer.

Thymidylate synthase and dihydropyrimidine dehydrogenase in non-small cell lung cancer: relationship between mRNA expression and activity.

BACKGROUND: UFT (Tegafur + Uracil) has been reported to be effective for postoperative adjuvant chemotherapy of non-small cell lung cancer (NSCLC) in a randomized prospective study. Recently, many clinical studies have demonstrated that UFT is effective for cancer with a low activity of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD). In the present study, we investigated TS and DPD activity in resected tumors and corresponding normal lungs and the relationship between the activity and the mRNA expression of TS and DPD in NSCLC. MATERIALS AND METHODS: Seventy-seven patients underwent complete surgical resection and lymph node dissection for NSCLC. The activity of TS was determined by the FdUMP binding assay combined with gel filtration. The activity of DPD was determined by radio-enzymatic assay. Tumor tissues and their paired non-cancerous tissues were assayed. Furthermore, the mRNA expressions of TS and DPD were examined by real-time RT-PCR. RESULTS: The mean TS and DPD activities in NSCLC were approximately 2.4-fold and 5-fold of those in normal lungs. The mean TS and DPD activities of NSCLC were 0.099 pmol/mg and 407 pmol/mg/min, respectively. Although both TS and DPD activities showed a tendency to be high for adenocarcinoma, there was no significant difference between TS and/or DPD activities and any clinical findings (age, gender, stage and histological type). The mRNA expression of DPD was correlated with DPD activity (rs=0.846, p<0.001). The mRNA expression of TS was weakly correlated with TS activity (rs=0.757, p<0.001). CONCLUSION: TS and DPD activities in NSCLC were higher than those in normal lungs. Assay of DPD mRNA and TS mRNA by real-time RT-PCR can be used as an indicator for the use of UFT.

WHO histologic classification is a prognostic indicator in thymoma.

BACKGROUND: The histologic classification of thymoma has remained a subject of controversy for many years. In 1999, the World Health Organization Consensus Committee published a histologic typing system for tumors of the thymus. METHODS: We reclassified a series of 100 thymomas resected at Tokushima University Hospital and four affiliated hospitals in Japan between 1973 and 2001 according to the World Health Organization histologic classification and reported its clinicopathologic relationship and prognostic relevance. RESULTS: There were 8 type A, 17 type AB, 27 type B1, 8 type B2, 12 type B3, and 28 type C thymomas. The frequency of invasion to neighboring organs increased according to tumor subtype in the order A (0%), AB (6%), B1 (19%), B2 (25%), B3 (42%), and C (89%). There was no recurrence in patients with type A, AB, or B2 thymoma. The recurrence rates of patients with B1, B3, or C thymoma were 15%, 36%, and 47%, respectively. The disease-free survival rates were 100% for types A and AB, 83% for types B1 and B2, 36% for type B3, and 28% for type C thymoma at 10 years. There were significant differences in disease-free survival between types A and AB and types B1 and B2 (p = 0.0436), and between type B3 and type C (p = 0.042). By multivariate analysis, only Masaoka clinical stage (p = 0.002) showed significant independent effects on disease-free survival. The 10-year survival rates of types A and AB, types B1 and B2, type B3, and type C thymoma were 100%, 94%, 92%, and 58%, respectively. CONCLUSIONS: The current study confirmed the World Health Organization histologic classification as a good prognostic factor.