Chemoradiation for small cell esophageal carcinoma: report of 11 cases from multi-institution experience.

Small cell esophageal carcinoma(SCEC) is a rare disease with aggressive behavior and poor prognosis. Because of the rarity of this disease, standard therapy has not yet been established. The objective of this retrospective study was to report the outcomes of SCEC treated with chemotherapy and radiotherapy from a retrospective study of 11 patients. We enrolled 11 SCEC patients who were treated with radiation therapy (more than 50 Gy) and chemotherapy between May 1996 and October 2007. Patients' age ranged from 44 to 77 years (mean: 69 years). In all patients, pathological examination of the specimen obtained by biopsy revealed small cell carcinoma. All patients were treated with chemotherapy and radiation therapy. The mean follow-up time was 14.7 months, and the median overall survival time of all patients was 13.2 months (range: 4.2-43.6 months). The 1-year and 3-year overall survival rates were 63% and 24%, respectively, while the 1-year and 3-year progression-free survival rates were 45% and 14%, respectively. Five of seven patients with complete response (CR) developed recurrent disease. Recurrence sites were distant metastases in four patients and lymph node outside the radiation field in one patient. Chemoradiation should be considered as one of the important treatment options for the loco-regional control in the patients with SCEC.

Spontaneous pneumothorax after stereotactic radiotherapy for non-small-cell lung cancer.

The report presented here describes a case of spontaneous pneumothorax observed after stereotactic radiotherapy (SRT) for non-small-cell lung cancer (NSCLC). An 84-year-old man with a Stage IIB, T3N0M0 NSCLC in the right upper lobe and a Stage IA NSCLC in the right lower lobe of the lung was treated with SRT for both tumors. He received SRT with a total dose of 60.0 Gy in 10 fractions delivered to the right upper lobe, and 48.0 Gy in 4 fractions delivered to the right lower lobe. Two months after completion of the treatment, he developed spontaneous pneumothorax. He was asymptomatic and recovered with conservative management. Spontaneous pneumothorax has occasionally been reported to occur following thoracic radiotherapy for malignancy. Almost all of the reported cases are patients who had received mantle irradiation for Hodgkin's disease. We have been unable to fi nd any reports of spontaneous pneumothorax after SRT, which has recently been used for treating patients with early-stage NSCLC. Because a case of spontaneous pneumothorax after SRT was observed in our institution, its clinical course is described here along with a discussion of possible causes of spontaneous pneumothorax.

Breath-hold monitoring and visual feedback for radiotherapy using a charge-coupled device camera and a head-mounted display: system development and feasibility.

PURPOSE: The aim of this study was to present the technical aspects of the breath-hold technique with respiratory monitoring and visual feedback and to evaluate the feasibility of this system in healthy volunteers. METHODS AND MATERIALS: To monitor respiration, the vertical position of the fiducial marker placed on the patient's abdomen was tracked by a machine vision system with a charge-coupled device camera. A monocular head-mounted display was used to provide the patient with visual feedback about the breathing trace. Five healthy male volunteers were enrolled in this study. They held their breath at the end-inspiration and the end-expiration phases. They performed five repetitions of the same type of 15-s breath-holds with and without a head-mounted display, respectively. A standard deviation of five mean positions of the fiducial marker during a 15-s breath-hold in each breath-hold type was used as the reproducibility value of breath-hold. RESULTS: All five volunteers well tolerated the breath-hold maneuver. For the inspiration breath-hold, the standard deviations with and without visual feedback were 1.74 mm and 0.84 mm, respectively (P = 0.20). For the expiration breath-hold, the standard deviations with and without visual feedback were 0.63 mm and 0.96 mm, respectively (P = 0.025). CONCLUSION: Our newly developed system might help the patient achieve improved breath-hold reproducibility.

Treatment of early tongue carcinoma with brachytherapy: results over a 25-year period.

BACKGROUND: Brachytherapy for patients with early tongue cancer is an accepted method of treatment. PATIENTS AND METHODS: The records of 409 patients with T1/2N0M0 tongue cancer treated with brachytherapy between 1978 and 2004 were reviewed. RESULTS: The overall and disease-free 5-year survival rates were 82.3% and 64.6% for patients with T1 disease, and 72.2% and 56.0% for patients with T2 disease, respectively. The 5-year nodal metastasis-free survival rates for patients treated between 1978 and 1986, 1987 and 1996, and 1997 and 2004 were 64.8%, 74.8% and 81.3% for patients with T1 disease (p=0.22), and 47.4%, 70.4% and 76.4% for patients with T2 disease (p=0.0011), respectively. The 5-year local recurrence-free survival rates for patients treated between 1978 and 1986, 1987 and 1996, and 1997 and 2004 were 91.0%, 84.0% and 96.9% for patients with T1 disease (p=0.31), and 87.6%, 83.3% and 85.8% for patients with T2 disease (p=0.90), respectively. CONCLUSION: The incidence rate of nodal metastasis in patients with early tongue cancer improved over the 25-year period studied, while the local recurrence-free survival rates remained stable.

Reproducibility of the abdominal and chest wall position by voluntary breath-hold technique using a laser-based monitoring and visual feedback system.

PURPOSE: The voluntary breath-hold (BH) technique is a simple method to control the respiration-related motion of a tumor during irradiation. However, the abdominal and chest wall position may not be accurately reproduced using the BH technique. The purpose of this study was to examine whether visual feedback can reduce the fluctuation in wall motion during BH using a new respiratory monitoring device. METHODS AND MATERIALS: We developed a laser-based BH monitoring and visual feedback system. For this study, five healthy volunteers were enrolled. The volunteers, practicing abdominal breathing, performed shallow end-expiration BH (SEBH), shallow end-inspiration BH (SIBH), and deep end-inspiration BH (DIBH) with or without visual feedback. The abdominal and chest wall positions were measured at 80-ms intervals during BHs. RESULTS: The fluctuation in the chest wall position was smaller than that of the abdominal wall position. The reproducibility of the wall position was improved by visual feedback. With a monitoring device, visual feedback reduced the mean deviation of the abdominal wall from 2.1 +/- 1.3 mm to 1.5 +/- 0.5 mm, 2.5 +/- 1.9 mm to 1.1 +/- 0.4 mm, and 6.6 +/- 2.4 mm to 2.6 +/- 1.4 mm in SEBH, SIBH, and DIBH, respectively. CONCLUSIONS: Volunteers can perform the BH maneuver in a highly reproducible fashion when informed about the position of the wall, although in the case of DIBH, the deviation in the wall position remained substantial.

Radiation therapy for recurrent esophageal cancer after surgery: clinical results and prognostic factors.

OBJECTIVE: To evaluate the outcome of radiotherapy for recurrent esophageal cancer after surgery and to determine the prognostic factors. METHODS: From 1987 through 2002, 82 patients treated with radiotherapy for loco-regional recurrences of esophageal cancer after surgery were retrospectively reviewed. The stage at initial surgery was I in 16, II in 41, III or higher in 24 and unknown in 1. The median size of recurrent tumors was 3.5 cm in diameter. Fifty-two patients were treated with radiotherapy alone, and 30 were treated with radiotherapy combined with chemotherapy. The median total dose of external radiotherapy given was 50.4 Gy in 28 fractions. RESULTS: The median survival period after recurrence was 7.0 months. The 2- and 5-year overall survival rate for all patients was 22 and 11%, respectively. In univariate analysis, the patients with performance status (PS) = 0-1, or tumor size <3.5 cm, and those treated with total dose >/=50 Gy showed a better survival outcome than each the other groups. The patients with a history of previous radiotherapy showed a poorer survival outcome in univariate analysis than each the other groups. In multivariate analysis, tumor size, PS and radiation dose were independent prognostic factors for overall survival. CONCLUSION: The prognosis of patients with post-operative loco-regional recurrence of esophageal cancer is poor. However, a long-term survival may be expected by definitive radiotherapy for the patients with small-size tumors and with a good PS.

Long-term functional outcome of brachytherapy for carcinoma of the mobile tongue: focus on the atrophic change of irradiated tongue.

OBJECTIVE: To assess tongue atrophy and long-term functional outcome of mobile tongue cancer patients after interstitial radiotherapy. METHODS: Of 493 patients whose squamous cell carcinoma of the mobile tongue had been treated with low dose rate brachytherapy, there were 57 patients evaluated between July 2002 and April 2004 whose tongue had not been modified by surgical procedures and who had no primary recurrence. The median time from treatment to evaluation was 96 months (range: 9-214 months). Almost all of the patients belonged to the early stage tongue cancer (T1/T2/T3/T4=30:24:3:0), and all had received interstitial radiotherapy with a single-plane implant. To evaluate the deformity of the tongue, we used a grading system that classified the atrophic changes of the tongue into four categories (G0-G3). RESULTS: Thirty-nine patients (70%) showed mild tongue hemiatrophy (G1 or G2) in the irradiated side. However, no patients showed severe atrophy where the tongue cannot be made to protrude beyond the incisors (G3). The length of time after brachytherapy was >72 months and the age of the patients at brachytherapy had the same statistical significance (P=0.0366). As for functional outcome, understandability of speech and a normal diet were preserved for almost all patients. CONCLUSION: The progression of atrophic change in the irradiated tongue occurred over a long term after brachytherapy. However, most patients could maintain their activities of daily life without severe restriction.

Long-term local control of recurrent adenoid cystic carcinoma in the parotid gland with radiotherapy and intraarterial infusion chemotherapy.

We report a case of postoperative recurrence of adenoid cystic carcinoma in the left parotid gland treated with radiotherapy and arterial infusion chemotherapy. A 52-year-old woman had a history of surgical resection for an adenoid cystic carcinoma arising from the left parotid gland 25 years before. Despite two reoperations for local recurrence after the initial surgery, she had a third local recurrence in the remnant of the left parotid gland. The patient was treated with a concurrent combination of radiotherapy (60 Gy/30F) and intraarterial infusion chemotherapy with carboplatin (750 mg/30 days) from which she obtained a complete response. The patient has remained free of local progression 54 months after treatment. Radiotherapy and arterial infusion chemotherapy is effective treatment for local recurrence of adenoid cystic carcinoma in the head and neck.

Low pre-radiotherapy prostate-specific antigen level is a significant predictor of treatment success for postoperative radiotherapy in patients with prostate cancer.

BACKGROUND: The optimal role of postoperative radiotherapy for patients with prostate cancer remains undefined. MATERIALS AND METHODS: The medical records of 70 patients (median age: 66 years), who had received radical radiotherapy (RT) between the years 1996 and 2004 after radical prostatectomy (RP), were analyzed. Fifteen patients had received immediate adjuvant RT, while the other 55 patients had received salvage therapy. Hormonal therapy had been performed in 28 patients before RT and continued in two of them concurrently with RT. A median dose of 60 Gy was delivered to the prostate bed. Pelvic node irradiation was performed in all patients. RESULTS: After a median follow-up period of 23 months, 21 patients had experienced biochemical failure. Actuarial 3- and 5-year biochemical relapse-free survival estimates were 67.4%. No patient had local failure, although distant metastases with biochemical failure were found in five patients. On univariate analysis, the following were significant for biochemical failures: seminar vesicle involvement, serum PSA level >1 ng/ml before RT, pathological pelvic node involvement, RT indication (adjuvant vs. salvage) and Gleason score. However, only the serum PSA level before RT was significant on multivariate analysis. CONCLUSION: Postoperative RT with a pre-RT PSA level <0.1 ng/ml seemed to be effective in patients with prostate cancer.

Multi-institutional analysis of early squamous cell carcinoma of the hypopharynx treated with radical radiotherapy.

PURPOSE: To analyze the outcomes of patients with early hypopharyngeal cancer treated with radical radiotherapy (RT). METHODS AND MATERIALS: Ten institutions combined the data from 115 patients with Stage I-II hypopharyngeal squamous cell carcinoma treated with definitive RT between 1990 and 2001. The median patient age was 67 years; 99 patients were men and 16 were women. Of the 115 patients, 39 had Stage I and 76 had Stage II disease. Conventional fractionation was used in 98 patients and twice-daily RT in 17 patients; chemotherapy was combined with RT in 57 patients. The median follow-up period was 47 months. RESULTS: The overall and disease-specific 5-year survival rate for 95 patients without synchronous malignancies was 66.0% and 77.4%, respectively. The 5-year disease-specific survival rate by T stage was 95.8% for patients with T1 disease and 70.1% for patients with T2 disease (p=0.02). Of the 115 patients, local control with laryngeal voice preservation was achieved in 34 of 39 patients with T1 lesions, including 7 patients successfully salvaged, and in 56 of 76 patients with T2 lesions. Sixty-five patients (56.5%) had synchronous or metachronous cancers. Of the 115 patients, 19 died of hypopharyngeal cancer, 10 died of second primary cancers, and 14 died of other causes during the study and follow-up periods. CONCLUSIONS: Patients with early hypopharyngeal cancer tended to have a good prognosis after RT. However, second malignancies had an adverse effect on the overall outcomes of patients with early hypopharyngeal cancer.

Stereotactic radiotherapy for lung and liver tumors using a body cast system: setup accuracy and preliminary clinical outcome.

PURPOSE: To evaluate the feasibility and treatment outcomes of stereotactic radiotherapy (SRT) using a newly developed simple body cast system for lung and liver tumors. MATERIALS AND METHODS: From April 2003 to July 2004, 20 patients were treated with SRT at the Kyushu University Hospital. Thirteen patients had primary lung cancer, 5 had metastatic lung cancer, and 2 had hepatocellular carcinoma. All patients were fixed with a thermoplastic body cast combined with a vacuum pillow, arm and leg support, and a carbon plate. SRT was given in 5-8 fields with an isocenter dose of 48-60 Gy in 4-10 fractions. Target verification was performed by computed tomography (CT) during the first session, and by anterior-posterior (A-P) and lateral portal images during the second and subsequent sessions. RESULTS: The average setup errors and deviation in the first treatment session were 1.4 +/- 1.2, 1.1 +/- 1.0, and 3.3 +/- 2.8 mm in the lateral, A-P, and cranio-caudal (C-C) directions, respectively. The setup errors in the second and subsequent sessions were 2.4 +/- 0.5, 1.4 +/- 1.8, and 3.7 +/- 2.6 mm in the lateral, A-P, and C-C directions, respectively. The patient's movement during a treatment session was within 5 mm in any direction. Despite the short follow-up periods (1-15 months), complete response was shown in 4 lesions, and partial response was shown in 15 lesions. Neither local progression nor serious complication was observed in any patient. CONCLUSION: SRT using our body cast system was a safe and reliable treatment method for extracranial tumors.

A machine vision system with CCD cameras for patient positioning in radiotherapy: a preliminary report.

PURPOSE: To determine positioning accuracy of a machine vision system in radiotherapy. MATERIALS AND METHODS: The machine vision system was composed of 640 x 480 pixel CCD cameras and computerized control systems. For image acquisition, the phantom was set up for the reference position and a single CCD camera was positioned 1.5 m from the isocenter. The image data of the fiducial marker with 1.5 mm lead pellet on the lateral surface of the phantom was captured onto the CCD, and then the position of the marker was accurately calculated. The phantom was moved 0.25, 0.50, 0.75, 1.00, 2.00, and 3.00 mm from the reference position, using a micrometer head. The position of the fiducial marker was analyzed using a kilo-voltage fluoroscopic imaging system and a machine vision system. RESULTS: Using fluoroscopic images, the discrepancy between the actual movement of the phantom by micrometer heads and the measurement was found to be 0.12 +/- 0.05 mm (mean +/- standard deviation). In contrast, the detection of the movement by the machine vision system coincided with the discrepancy of 0.0067 +/- 0.0048 mm. CONCLUSION: This study suggests that the machine vision system can be used to measure small changes in patient position with a resolution of less than 0.1 mm.

Adult rhabdomyosarcoma in the nasal and paranasal sinuses showing complete local response to a combination of chemotherapy and radiotherapy using 3D-CRT and IMRT.

We report on a 69-year-old woman with rhabdomyosarcoma arising from the nasal and paranasal sinuses. She was referred to our hospital with a reduced ability to smell and impaired bilateral vision, narrowing of the visual field, and left facial pain. Computed tomography (CT) revealed a large tumor in the nasal and left paranasal sinuses invading the left orbital cavity and anterior skull base, and lymph node swellings in the submental and left accessory nerve areas. A biopsy specimen from the nasal tumor was diagnosed histologically as a rhabdomyosarcoma, alveolar type. Because the intracranial direct invasion and distant metastases to the thoracic spine were suspected by pretreatment examination, our case was determined to be inoperable by a head and neck surgeon. Radiotherapy with a total dose of 60 Gy was carried out to control the primary disease. The three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) techniques were used in order to reduce the doses to risk organs. Combined with radiotherapy, chemotherapy was also performed for the treatment of lymph-node metastases and distant diseases. After the treatment was completed, the primary tumor and lymph-node metastases disappeared completely; there was no sign of re-growth during the follow-up period. Chemoradiotherapy may be an effective treatment also for inoperable adult rhabdomyosarcoma in the head and neck region. Furthermore, the 3D-CRT and IMRT techniques are both useful methods of radiotherapy for this disease.

[A case of advanced esophageal cancer with multiple lymph node metastases successfully treated with induction chemotherapy consisting of nedaplatin and 5-FU followed by chemoradiotherapy].

A 61-year-old male patient had esophageal carcinoma with multiple mediastinal and right supraclavicular lymph node metastases. Chemotherapy consisting of infusion of nedaplatin and continuous infusion of 5-fluorouracil was performed. After three courses of the chemotherapy, the patient was treated with a combination of cisplatin and 5-FU and radiotherapy. However, only radiotherapy was performed after 18 Gy because of grade 3 leukocytonenia during the chemoradiotherapy. The patient achieved a partial response (nearly complete response) for 9 months after the initiation of the treatment. In conclusion, chemotherapy with NDP and 5-FU followed by chemoradiotherapy is effective and safe for patients with esophageal carcinoma with multiple lymph node metastases.