Active small bowel sparing in intracavitary brachytherapy for cervical cancer.

OBJECTIVE: To propose and evaluate an active method for sparing the small bowel in the treatment field of cervical cancer brachytherapy by prone position procedure. METHODS: The prone position procedure consists of five steps: making bladder empty, prone-positioning a patient on belly board, making the small bowel move to abdomen, filling the bladder with Foley catheter and finally turning the patient into the supine position. The proposed method was applied for the treatment of seven cervical cancer patients. Its effectiveness was evaluated and a correlation between the patient characteristics and the volumetric dose reduction of small bowel was also investigated. Brachytherapy treatment plans were built before and after the proposed method, and their dose-volume histograms were compared for targets and organs-at-risk. In this comparison, all plans were normalized to satisfy the same D90% for high-risk clinical target volume. RESULTS: For the enrolled patients, the average dose of small bowel was significantly reduced from 75.2 ± 4.9 Gy before to 60.2 ± 4.0 Gy after the prone position procedure, while minor dosimetric changes were observed in rectum, sigmoid and bladder. The linear correlation to body mass index, thickness and width of abdominopelvic cavity and bladder volume were 76.2, 69.7, 28.8 and -36.3%, respectively. CONCLUSIONS: The application of prone position procedure could effectively lower the volumetric dose of the small bowel. The dose reduction in the small bowel had a strong correlation with the patient's obesity and abdominal thickness. This means the patients for whom the proposed method would be beneficial can be judiciously selected for safe brachytherapy.

Regression and pseudoprogression of pediatric optic pathway glioma in patients treated with proton beam therapy.

PURPOSE: We examined regression patterns in pediatric optic pathway gliomas (OPGs) after proton beam therapy (PBT) and evaluated local control and visual outcomes. METHODS: A total of 42 brain magnetic resonance imaging (MRI) scans from seven consecutive sporadic OPGs that were initially treated with chemotherapy and received PBT between June 2007 and September 2016 at the National Cancer Center, Korea were analyzed. Patients underwent brain MRI regularly before and after PBT. Total tumor, cystic lesion, and solid enhancing lesion area delineation and volume calculations were performed on gadolinium-enhanced T1-weighted MRI using Eclipse version 13, Varian. RESULTS: The median follow-up period after PBT was 70 months (range 47-88). The median age at the time of PBT was 7 years (range 4-16) and the median duration of chemotherapy before referral to PBT center was 25 months (range 3-70). The median time to the greatest increase in cystic volume was 32 months (range 12-43) after PBT. Solid enhancing lesion volume gradually decreased throughout the follow-up period. On an individual basis, total volume change was varied. However, on average, it regressed, although at a slower rate than solid enhancing lesion volume did. The local control rate was 85.7% (5-year progression-free survival rate, 80%; 5-year overall survival rate, 100%) and the rate of vision preservation was 71.4% (five of seven patients). CONCLUSION: The regression patterns in pediatric OPGs after PBT involve significant cystic change. Therefore, total volume is not appropriate for evaluating response. Care by a multidisciplinary team is necessary to manage clinical symptoms related to radiologic changes.

Neurocognitive and psychological functioning of pediatric brain tumor patients undergoing proton beam therapy for three different tumor types.

BACKGROUND: A high proportion of pediatric patients with brain tumors (BTs) are known to experience a decline in neurocognitive function after treatment. We prospectively examined neuropsychological functioning of patients with BTs of varying tumor types at different time points before, during, and after proton beam therapy. MATERIALS AND METHODS: A total of 98 patients with posterior fossa tumors (PFTs; n = 33), germ cell tumors (GCTs; n = 52), and other supratentorial tumors (STTs; n = 13) underwent baseline neuropsychological assessments and 57 patients underwent follow-up assessments. RESULTS: All groups displayed significantly lower performance intelligence quotient (PIQ) and processing speed (PS) scores than the normative means at baseline. The PFT group exhibited significantly lower scores for full-scale IQ, PIQ, PS, attention, and executive function. The GCT group displayed full-scale IQ scores within the normal range, but a significantly high proportion had memory deficits. In the STT group, all functions except for the PIQ and PS were intact. Longitudinal evaluations demonstrated stable global IQ scores over time in all groups. In the PFT group, verbal comprehension, attention, and PS improved over time. However, in the GCT group, verbal IQ scores declined significantly and psychological problems worsened over time, which were correlated with poorer neurocognitive function at 3-5 years after treatment. In the STT group, no significant changes were observed. CONCLUSION: Because patients with BTs exhibit various types of neurocognitive deficit before radiotherapy, early cognitive treatment tailored to the tumor type maybe beneficial. Interventions for psychological problems and memory function may be necessary, especially for patients with GCT.

Advanced stage cutaneous T-cell lymphoma treated with high-dose external beam radiation therapy: A case report.

INTRODUCTION: The treatment for advanced-stage or refractory cutaneous T-cell lymphoma (CTCL) is largely palliative. Due to the rarity of the disease, there are few randomized controlled trials and large-scale prospective studies. Therefore, the treatment of advanced-stage CTCL remains challenging. PATIENT CONCERNS AND DIAGNOSIS: A 64-years-old man who had received narrowband UVB phototherapy for several years presented with a generalized rash with widespread polycyclic erosions and painful ulcers on his hands and feet. We restaged him as stage III CTCL. INTERVENTIONS AND OUTCOMES: He was treated with high-dose radiation for curative purposes and 3-dimensional conformal radiation therapy to both hands and feet. At the 2-year follow-up after the end of radiotherapy, the irradiated skin had recovered to normal soft, smooth skin with localized fibrosis and hypopigmented skin. He reported an excellent quality of life, and his hands and feet were free to move. CONCLUSION: CTCL at an advanced stage could require dose escalation with local radiotherapy for curative purposes. High-dose 3-dementional conformal radiation therapy could be effective and has tolerable toxicities.

Beam Angle Optimization for Double-Scattering Proton Delivery Technique Using an Eclipse Application Programming Interface and Convolutional Neural Network.

To automatically identify optimal beam angles for proton therapy configured with the double-scattering delivery technique, a beam angle optimization method based on a convolutional neural network (BAODS-Net) is proposed. Fifty liver plans were used for training in BAODS-Net. To generate a sequence of input data, 25 rays on the eye view of the beam were determined per angle. Each ray collects nine features, including the normalized Hounsfield unit and the position information of eight structures per 2° of gantry angle. The outputs are a set of beam angle ranking scores (S beam) ranging from 0° to 359°, with a step size of 1°. Based on these input and output designs, BAODS-Net consists of eight convolution layers and four fully connected layers. To evaluate the plan qualities of deep-learning, equi-spaced, and clinical plans, we compared the performances of three types of loss functions and performed K-fold cross-validation (K = 5). For statistical analysis, the volumes V27Gy and V30Gy as well as the mean, minimum, and maximum doses were calculated for organs-at-risk by using a paired-samples t-test. As a result, smooth-L1 loss showed the best optimization performance. At the end of the training procedure, the mean squared errors between the reference and predicted S beam were 0.031, 0.011, and 0.004 for L1, L2, and smooth-L1 loss, respectively. In terms of the plan quality, statistically, PlanBAO has no significant difference from PlanClinic (P >.05). In our test, a deep-learning based beam angle optimization method for proton double-scattering treatments was developed and verified. Using Eclipse API and BAODS-Net, a plan with clinically acceptable quality was created within 5 min.

Efficacy and feasibility of proton beam radiotherapy using the simultaneous integrated boost technique for locally advanced pancreatic cancer.

To evaluate the clinical efficacy and feasibility of proton beam radiotherapy (PBT) using the simultaneous integrated boost (SIB) technique in locally advanced pancreatic cancer (LAPC), 81 LAPC patients receiving PBT using SIB technique were analyzed. The prescribed doses to planning target volume (PTV)1 and PTV2 were 45 or 50 GyE and 30 GyE in 10 fractions, respectively. Of 81 patients, 18 patients received PBT without upfront and maintenance chemotherapy (group I), 44 received PBT followed by maintenance chemotherapy (group II), and 19 received PBT after upfront chemotherapy followed by maintenance chemotherapy (n = 16) (group III). The median follow-up time was 19.6 months (range 2.3-57.6 months), and the median overall survival (OS) times of all patients and of those in groups I, II, and III were 19.3 months (95% confidence interval [CI] 16.8-21.7 months), 15.3 months (95% CI 12.9-17.7 months), 18.3 months (95% CI 15.9-20.7 months), and 26.1 months (95% CI 17.8-34.3 months), respectively (p = 0.043). Acute and late grade ≥ 3 toxicities related to PBT were not observed. PBT with the SIB technique showed promising OS for LAPC patients with a safe toxicity profile, and intensive combinations of PBT and chemotherapy could improve OS in these patients.

Prognostic significance of smoking and alcohol history in young age oral cavity cancer.

OBJECTIVE: To assess prognostic factors of patients with operable oral cavity squamous cell carcinoma (OSCC), focusing on the associations with smoking/alcohol exposure and age. MATERIALS AND METHODS: A total of 247 patients with OSCC who received curative surgery ± adjuvant radiotherapy were analyzed. The patient subgroups were divided according to pretreatment smoking/alcohol exposure. Individuals aged 45 years or less were classified as younger patients. RESULTS: The median follow-up was 52.2 months. The 5-year locoregional progression-free survival (LRFFS), distant metastasis-free survival (DMFS), overall survival (OS), and cancer-specific survival (CSS) rates were 85.2%, 88.3%, 78.1%, and 83.5%, respectively. An advanced stage, differentiation, and lympho-vascular space invasion were significantly associated with lower OS and CSS. In a subgroup analysis of younger patients (n = 49), more smoking/alcohol exposure was significantly associated with better OS (hazard ratio [HR]: 0.21, 95% confidence interval [CI]: 0.05-0.95, p = .043). With increasing age, the HR for smoking/alcohol exposure with respect to OS increased up to 11.59 (95% CI: 1.49-89.84, p = .019) in older patients. CONCLUSION: Younger OSCC patients with non- or less smoking/alcohol exposure showed unfavorable outcomes. The prognostic significance of pretreatment smoking/alcohol exposure changed from favorable to detrimental with increasing age in operable OSCC.

Phase II Study of Hypofractionated Proton Beam Therapy for Hepatocellular Carcinoma.

Background: Proton beam has an excellent depth dose distribution due to its unique physical properties, and thus proton beam therapy (PBT) has been tried and showed promising outcomes in hepatocellular carcinoma (HCC). The purpose of this phase II study is to evaluate the efficacy of hypofractionated PBT in HCC. Methods: The eligibility criteria for this study were as follows: patients with HCC lesion(s) who were failed after, were difficult to treat with, or refused to other local treatments; tumor size and number of ≤7 and ≤2 cm, respectively, and HCC lesion(s) of ≥2 cm from gastrointestinal organs; Child-Pugh score of ≤7; Eastern Cooperative Oncology Group performance status ≤1; and age ≥18 years. The prescribed dose of PBT was 70 Gy equivalent in 10 fractions. The primary endpoint was 3-year local progression-free survival (LPFS) rate. Results: Forty-five patients were prospectively enrolled, and there were 35 men and 10 women with a median age of 63 years (range, 46-78 years). Thirty-seven patients had recurrent and/or residual disease, and eight patients had treatment-naive disease. All patients received the planned treatments without treatment interruption, and grade ≥3 acute toxicity did not occur. The median follow-up duration was 35.1 months (range, 11.2-56.3 months) and local progression occurred in two patients (8.7%). The 3-year rates of LPFS and overall survival (OS) were 95.2% (95% confidence interval [CI], 89.1%-100%) and 86.4% (95% CI, 72.9-99.9%), respectively. Conclusion: Hypofractionated PBT showed promising LPFS and OS, and further studies are warranted to compare PBT with other local modalities.

Effect of addition of bevacizumab to chemoradiotherapy in newly diagnosed stage IVB cervical cancer: a single institution experience in Korea.

OBJECTIVE: The aim of this study was to compare the clinical outcomes of chemoradiotherapy with or without bevacizumab in patients with newly diagnosed International Federation of Gynecology and Obstetrics (FIGO) stage IVB cervical cancer. METHODS: 41 patients with stage IVB cervical cancer who underwent chemoradiotherapy between August 2015 and December 2017 were retrospectively analyzed. This study included 11 patients who received bevacizumab before or after radiotherapy (group A) and 30 patients who received conventional chemoradiotherapy without bevacizumab (group B). We excluded the following patients: those with dual primary cancers; those whose pathologic diagnosis was neither squamous cell carcinoma nor adenocarcinoma; those who did not undergo radiotherapy; or those from whom follow-up data could not be collected. We analyzed the treatment responses, toxicities, progression-free survival, and overall survival rates. RESULTS: A total of 41 patients were included in the analysis. The median follow-up was 19 months (range 3-108). The response rates at 3 months after treatment were 90.9% in group A and 83.3% in group B (p=0.54). After completing all treatments, the complete response rates were 81.8% in group A and 47% in group B (p=0.04). Grade ≥3 gastrointestinal toxicities, including bleeding, fistula, perforation, and obstruction, were more frequent in group A (54.5%) than in group B (6.7%) (p=0.003). The 12 month progression-free survival and overall survival rates were similar in both arms (12 month progression-free survival: 45.5% vs 46.7%, respectively, p=0.22; 12 month overall survival: 81.8% vs 72.9%, respectively, p=0.57). Patients with node-only metastasis had better 12 month progression-free survival in group B than in group A (59.1% vs 42.9%, respectively, p=0.04). However, the responses to both treatments did not differ in patients with organ metastasis. CONCLUSIONS: Bevacizumab for stage IVB cervical cancer is associated with higher complete response rates. However, patients treated with bevacizumab experienced more bowel toxicities. Bevacizumab did not improve progression-free survival among patients with node-only metastasis.

Comparative clinical evaluation of atlas and deep-learning-based auto-segmentation of organ structures in liver cancer.

BACKGROUND: Accurate and standardized descriptions of organs at risk (OARs) are essential in radiation therapy for treatment planning and evaluation. Traditionally, physicians have contoured patient images manually, which, is time-consuming and subject to inter-observer variability. This study aims to a) investigate whether customized, deep-learning-based auto-segmentation could overcome the limitations of manual contouring and b) compare its performance against a typical, atlas-based auto-segmentation method organ structures in liver cancer. METHODS: On-contrast computer tomography image sets of 70 liver cancer patients were used, and four OARs (heart, liver, kidney, and stomach) were manually delineated by three experienced physicians as reference structures. Atlas and deep learning auto-segmentations were respectively performed with MIM Maestro 6.5 (MIM Software Inc., Cleveland, OH) and, with a deep convolution neural network (DCNN). The Hausdorff distance (HD) and, dice similarity coefficient (DSC), volume overlap error (VOE), and relative volume difference (RVD) were used to quantitatively evaluate the four different methods in the case of the reference set of the four OAR structures. RESULTS: The atlas-based method yielded the following average DSC and standard deviation values (SD) for the heart, liver, right kidney, left kidney, and stomach: 0.92 ± 0.04 (DSC ± SD), 0.93 ± 0.02, 0.86 ± 0.07, 0.85 ± 0.11, and 0.60 ± 0.13 respectively. The deep-learning-based method yielded corresponding values for the OARs of 0.94 ± 0.01, 0.93 ± 0.01, 0.88 ± 0.03, 0.86 ± 0.03, and 0.73 ± 0.09. The segmentation results show that the deep learning framework is superior to the atlas-based framwork except in the case of the liver. Specifically, in the case of the stomach, the DSC, VOE, and RVD showed a maximum difference of 21.67, 25.11, 28.80% respectively. CONCLUSIONS: In this study, we demonstrated that a deep learning framework could be used more effectively and efficiently compared to atlas-based auto-segmentation for most OARs in human liver cancer. Extended use of the deep-learning-based framework is anticipated for auto-segmentations of other body sites.

Benefit of Adjuvant Chemoradiotherapy in Resected Gallbladder Carcinoma.

To evaluate the benefit of adjuvant treatments, such as chemoradiotherapy (CRT) and chemotherapy (CTx), compared with no adjuvant treatment (No-AT) in resected gallbladder (GB) cancer patients, 151 patients were analyzed: 98 (64.9%) patients received adjuvant treatment with CRT (n = 59, 39.1%) or CTx (n = 39, 25.8%), and the remaining 53 (35.1%) did not (No-AT). The clinicopathological factors, patterns of failure, locoregional recurrence-free survival (LRFS), recurrence-free survival (RFS) and overall survival (OS) were compared among the three groups according to tumor stage. In patients with T2-3N0M0 stage disease, the incidences of locoregional recurrence and distant recurrence and 5-year LRFS, RFS and OS rates were not significantly different among the No-AT, CTx, and CRT groups (p > 0.05 each). In those with T2-3N1-2M0 stage disease, the incidences of locoregional recurrence (11.4%, 78.1%, and 68.4%, respectively) and distant recurrence (42.8%, 73.9% and 66.7%, respectively) in the CRT group were significantly lower than those in the No-AT and CTx groups (p < 0.05), and the CRT group had significantly higher 5-year LRFS (82,1%, 26.8%, and 19.0%), RFS (53.3%, 11.6% and 16.7%) and OS rates (64.0%, 22.7% and 4.3%) than the CTx and No-AT groups (p < 0.05 each). Therefore, adjuvant CRT may improve the LRFS and RFS and subsequently improve OS in lymph node-positive resected GB cancer.

Clinical outcome of proton therapy for patients with chordomas.

PURPOSE: To investigate the clinical outcome of proton therapy (PT) in patients with chordoma. MATERIALS AND METHODS: Fifty-eight patients with chordoma treated with PT between June 2007 and December 2015 at the National Cancer Center, Korea, were retrospectively analyzed. The median total dose was 69.6 cobalt gray equivalent (CGE; range, 64.8 to 79.2 CGE). Local progression-free survival (LPFS), distant metastasis-free survival (DMFS), overall survival (OS), and diseasespecific survival (DSS) rates were calculated by the Kaplan-Meier method. RESULTS: With the median follow-up of 42.8 months (range, 4 to 174 months), the 5-year LPFS, DMFS, OS, and DSS rates were 87.9%, 86.7%, 88.3%, and 92.9%, respectively. The tumor location was associated with the patterns of failure: the LPFS rates were lower for cervical tumors (57.1%) than for non-cervical tumors (93.1%) (p = 0.02), and the DMFS rates were lower for sacral tumors (53.5%) than for non-sacral tumors (100%) (p = 0.001). The total dose was associated with both the LPFS rate and DMFS rate. The initial tumor size was associated with the DMFS rate, but was not associated with the LPFS rate. Three patients had grade 3 late toxicity with none ≥grade 4. CONCLUSION: PT is an effective and safe treatment in patients with chordomas. The tumor location was associated with the patterns of failure: local failure was common in cervical tumors, and distant failure was common in sacral tumors. Further refinement of PT, such as the utilization of intensity modulated PT for cervical tumors, is warranted to improve the outcome.

Effectiveness and feasibility of concurrent chemoradiotherapy using simultaneous integrated boost-intensity modulated radiotherapy with and without induction chemotherapy for locally advanced pancreatic cancer.

PURPOSE: To evaluate the effectiveness and feasibility of chemoradiotherapy (CRT) using simultaneous integrated boost-intensity modulated radiotherapy (SIB-IMRT) in locally advanced pancreatic cancer (LAPC) patients. MATERIALS AND METHODS: Between January 2011 and May 2015, 47 LAPC patients received CRT using SIB-IMRT. Prior to SIBIMRT, 37 patients (78.7%) received induction chemotherapy (IC-CRT group) and remaining 10 patients (21.3%) did not received induction chemotherapy (CRT group). During SIB-IMRT, all patients received concomitant chemotherapy, with gemcitabine (n = 37) and capecitabine (n = 10). RESULTS: At the time of analysis, 45 patients had died and 2 patients remained alive and the median follow-up time was 14.2 months (range, 3.3 to 51.4 months). For all patients, the median times of local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were 18.1, 10.3, and 14.2 months, respectively. The median time of LPFS between IC-CRT and CRT groups was similar (18.1 months vs. 18.3 months, p = 0.711). IC-CRT group had a higher trend in PFS (10.9 months vs. 4.1 months, p = 0.054) and had significantly higher OS (15.4 months vs. 9.5 months, p = 0.007) than CRT group. In multivariate analysis, the use of induction chemotherapy and tumor response were significant factors associated with OS (p < 0.05, each). During SIBIMRT, toxicity of grade ≥3 was observed in 7 patients (14.9%) in all patients. CONCLUSION: CRT using SIB-IMRT is feasible and promising in LAPC patients.

Redox property and regulation of PpsR, a transcriptional repressor of photosystem gene expression in Rhodobacter sphaeroides.

PpsR from Rhodobacter sphaeroides is involved in the repression of photosystem gene expression. The PpsR protein was heterologously overexpressed and purified to homogeneity. Gel mobility shift assay showed that the purified PpsR has DNA-binding activity. SDS-PAGE analysis showed that some portions of PpsR were oxidized, indicating that intramolecular or intermolecular disulphide bonds were formed between the two cysteines in each subunit. When the disulphide bond of PpsR was reduced by DTT, the binding activity of PpsR to the puc promoter region distinctly increased. The changes in protein level and DNA-binding activity of PpsR were observed in a conjugant with an extra copy of the ppsR gene and in a PpsR-null mutant (PPS1), respectively. Both cysteines in PpsR existed in their reduced form under aerobic, anaerobic-dark and anaerobic-light growth conditions, as determined using thiol-specific chemical modification. In an AppA-null mutant (APP11), the binding activity and the amount of PpsR decreased compared to those of the wild-type and an appA-complemented strain, and decreased even more under anaerobic-dark conditions than under aerobic conditions. PpsR had a redox-sensitive property but retained its reduced state in the cell, and its amount was reduced by disruption of AppA.