Multi-institutional feasibility study of intensity-modulated radiotherapy with chemotherapy for locally advanced non-small cell lung cancer.

BACKGROUND: This multi-institutional clinical trial evaluated the feasibility of intensity-modulated radiotherapy (IMRT) for patients with locally advanced non-small cell lung cancer (NSCLC). METHODS: The major inclusion criteria were clinical stage III NSCLC, age 20-74 years, and Eastern Cooperative Oncology Group performance status 0-1. Patients were treated with either cisplatin + S-1 (CS; four cycles every 4 weeks) or carboplatin + paclitaxel (CP; administered weekly with thoracic radiotherapy [RT], plus two consolidation cycles) concurrently with IMRT (60 Gy in 30 fractions). The primary endpoint was a treatment completion rate, defined as at least two cycles of CS or five cycles of CP during IMRT and completing 60 Gy IMRT within 56 days after the start of treatment, assumed its 90% confidence interval exceeds 60%. RT quality assurance was mandatory for all the patients. RESULTS: Twenty-two patients were registered. One patient withdrew due to pulmonary infection before starting treatment. RT plans were reviewed and none was judged as a protocol violation. Grade 2 and 3 pneumonitis occurred in four (19%) and one (5%) patients, respectively. Seventeen patients met the primary endpoint, with a treatment completion rate of 77.3% (90% confidence interval [CI] 58.0%-90.6%). Four patients failed to complete chemotherapy due to chemotherapy-related adverse events, but 20 patients completed IMRT. There were no treatment-related deaths. The 2-year progression-free and overall survival rates were 31.8% (95% CI 17.3%-58.7%) and 77.3% (95% CI 61.6%-96.9%), respectively. CONCLUSION: The treatment completion rate did not meet the primary endpoint, but 20 of 22 patients completed IMRT.

A simpler method for total scalp irradiation: the multijaw-size concave arc technique.

The lateral electron-photon technique (LEPT) and intensity-modulated radiation therapy (IMRT) are commonly used for total scalp irradiation. However, the treatment planning and irradiation are laborious and time-consuming. We herein present the multijaw-size concave arc technique (MCAT) as a total scalp irradiation method that overcomes these problems. CT datasets for eight patients previously treated for angiosarcoma of the scalp were replanned using MCAT, LEPT, and IMRT. The MCAT was designed with a dynamic conformal arc for the total scalp, with a multileaf collimator to shield the brain. Two additional conformal arcs with a decreased upper-jaw position of the first dynamic conformal arc were used to reduce the cranial hotspots. The prescribed dose was 40 Gy (2 Gy/fraction) to 95% of the planning target volume (PTV, defined as the total scalp plus a 4 mm margin). MCAT was compared with LEPT and IMRT with respect to the PTV dose homogeneity (D5%-95%), underdosage (V < 90%), overdosage (V > 110%), doses to the brain, and the delivery time and monitor units (MUs) for single irradiation. We were able to formulate treatment plans for all three techniques that could deliver the prescription dose in all patients. MCAT was significantly superior to LEPT with respect to PTV dose homogeneity, overdosage, and underdosage, although MCAT was inferior to IMRT with respect to dose homogeneity and overdosage. The mean brain dose and high-dosage volume of all three techniques were low, but IMRT provided larger volume to the brain than did the other two techniques in the low dosage region. In MCAT, the mean delivery time could be reduced by approximately half or more, and the mean MUs could be reduced by at least 100 compared to the other two techniques. MCAT can achieve total scalp irradiation with substantially fewer MUs and a shorter delivery time than LEPT and IMRT.

Wedged field using the half-field method with a flattening filter-free photon beam.

In this study, we propose a novel wedged field using a half-field flattening filter-free beam without a metallic filter or a moving jaw, and investigate the characteristics of the proposed technique. Dose distributions of the proposed method were first determined in virtual-water or anthropomorphic phantom using a radiotherapy planning system. We evaluated the wedge angle as a function of the field size, collimator rotation, and depth. The wedge angle at 10 MV was observed to be greater than that at 6 MV. The minimum angles at 6 and 10 MV were 17.7° and 40.4°, respectively, while the maximum angles were 33.9° and 48.4°, respectively. We determined that the wedge angle depended on the nominal beam energy and field size, and we verified that the proposed method is capable of delivering a gradient dose distribution and reducing treatment time.

[Hemiplegia cruciata and severe facial pain due to infarction of the cervicomedullary junction: a case report].

We report the case of a 66-year-old female with hemiplegia cruciata and severe facial pain due to infarction of the cervicomedullary junction. She presented to the hospital with complaints of acute-onset left facial pain and gait disturbance. Neurological examination revealed narrow left palpebral fissure, severe left facial pain and hypothermoesthesia, weakness predominantly in the left upper and right lower extremities, decreased pain and temperature sensation in the right lower extremity, decreased vibration sensation in the left lower extremity, hyperreflexia in the left upper extremity, and mild ataxia in the left upper and lower extremities. Brain MRI revealed a high-intensity lesion in the left cervicomedullary junction on diffusion-weighted and fluid-attenuated inversion recovery images. Hemiplegia cruciata due to the pyramidal tract injury at the cervicomedullary junction is an uncommon clinical manifestation. However, in patients with hemiplegia cruciata, identifying the lesion location may be difficult. Clinicians should consider the possibility of pyramidal decussation lesions. Anatomical differences, in the course of pyramidal tract fibers between the upper and lower limbs have been considered in the pyramidal decussation. Hemiplegia cruciata in this case was primarily caused by the impairment of the left upper limb pyramidal fibers after the pyramidal decussation and the right lower limb pyramidal fibers before the pyramidal decussation.

Accuracy of digital models generated by conventional impression/plaster-model methods and intraoral scanning.

We compared the accuracy of digital models generated by desktop-scanning of conventional impression/plaster models versus intraoral scanning. Eight ceramic spheres were attached to the buccal molar regions of dental epoxy models, and reference linear-distance measurement were determined using a contact-type coordinate measuring instrument. Alginate (AI group) and silicone (SI group) impressions were taken and converted into cast models using dental stone; the models were scanned using desktop scanner. As an alternative, intraoral scans were taken using an intraoral scanner, and digital models were generated from these scans (IOS group). Twelve linear-distance measurement combinations were calculated between different sphere-centers for all digital models. There were no significant differences among the three groups using total of six linear-distance measurements. When limited to five lineardistance measurement, the IOS group showed significantly higher accuracy compared to the AI and SI groups. Intraoral scans may be more accurate compared to scans of conventional impression/plaster models.

Assessment of organ dose reduction and secondary cancer risk associated with the use of proton beam therapy and intensity modulated radiation therapy in treatment of neuroblastomas.

BACKGROUND: To compare proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT) with conformal radiation therapy (CRT) in terms of their organ doses and ability to cause secondary cancer in normal organs. METHODS: Five patients (median age, 4 years; range, 2-11 years) who underwent PBT for retroperitoneal neuroblastoma were selected for treatment planning simulation. Four patients had stage 4 tumors and one had stage 2A tumor, according to the International Neuroblastoma Staging System. Two patients received 36 Gy, two received 21.6 Gy, and one received 41.4 Gy of radiation. The volume structures of these patients were used for simulations of CRT and IMRT treatment. Dose-volume analyses of liver, stomach, colon, small intestine, pancreas, and bone were performed for the simulations. Secondary cancer risks in these organs were calculated using the organ equivalent dose (OED) model, which took into account the rates of cell killing, repopulation, and the neutron dose from the treatment machine. RESULTS: In all evaluated organs, the mean dose in PBT was 20-80% of that in CRT. IMRT also showed lower mean doses than CRT for two organs (20% and 65%), but higher mean doses for the other four organs (110-120%). The risk of secondary cancer in PBT was 24-83% of that in CRT for five organs, but 121% of that in CRT for pancreas. The risk of secondary cancer in IMRT was equal to or higher than CRT for four organs (range 100-124%). CONCLUSION: Low radiation doses in normal organs are more frequently observed in PBT than in IMRT. Assessments of secondary cancer risk showed that PBT reduces the risk of secondary cancer in most organs, whereas IMRT is associated with a higher risk than CRT.