Impact of metal artifact reduction algorithm on gross tumor volume delineation in tonsillar cancer: reducing the interobserver variation.

BACKGROUND: Patients with tonsillar cancer (TC) often have dental fillings that can significantly degrade the quality of computed tomography (CT) simulator images due to metal artifacts. We evaluated whether the use of the metal artifact reduction (MAR) algorithm reduced the interobserver variation in delineating gross tumor volume (GTV) of TC. METHODS: Eighteen patients with TC with dental fillings were enrolled in this study. Contrast-enhanced CT simulator images were reconstructed using the conventional (CTCONV) and MAR algorithm (CTMAR). Four board-certified radiation oncologists delineated the GTV of primary tumors using routine clinical data first on CTCONV image datasets (GTVCONV), followed by CTCONV and CTMAR fused image datasets (GTVMAR) at least 2 weeks apart. Intermodality differences in GTV values and Dice similarity coefficient (DSC) were compared using Wilcoxon's signed-rank test. RESULTS: GTVMAR was significantly smaller than GTVCONV for three observers. The other observer showed no significant difference between GTVCONV and GTVMAR values. For all four observers, the mean GTVCONV and GTVMAR values were 14.0 (standard deviation [SD]: 7.4) cm3 and 12.1 (SD: 6.4) cm3, respectively, with the latter significantly lower than the former (p < 0.001). The mean DSC of GTVCONV and GTVMAR was 0.74 (SD: 0.10) and 0.77 (SD: 0.10), respectively, with the latter significantly higher than that of the former (p < 0.001). CONCLUSIONS: The use of the MAR algorithm led to the delineation of smaller GTVs and reduced interobserver variations in delineating GTV of the primary tumors in patients with TC.

Influence of pain duration on pain outcomes following palliative radiotherapy for painful tumors: the sooner the irradiation, the better?

PURPOSE: The influence of pre-radiotherapy pain duration on post-treatment outcomes was assessed. METHODS: Patients that received palliative radiotherapy were analyzed in a prospective observational study investigating curative and palliative radiotherapy. Brief Pain Inventory data were acquired at baseline and 1, 2, and 3 months after commencing irradiation. The pain response in terms of the index pain (i.e., pain caused by the irradiated tumors) was assessed using the International Consensus Endpoint. Patients were diagnosed with predominance of other pain (POP) if non-index pain of malignant or unknown origin was present and showed a higher pain score than the index pain. Competing risk analyses were performed in which deaths without the pain endpoints were considered as competing events. RESULTS: Of 229 patients analyzed, 123 (54%) experienced a pain response and 43 (19%) experienced POP. Multivariable analyses using the Fine-Gray model revealed that patients with shorter pain duration (< 1 month) had higher cumulative incidence of pain response (subdistribution hazard ratio, 2.43; 95% confidence interval [CI], 1.35-4.38) and POP (subdistribution hazard ratio, 4.22; 95% CI, 1.30-13.70) compared with patients with longer pain duration (≥ 4 months). For patients with a pain duration of less than 1 month, cumulative incidence of pain response was estimated to be 69% (95% CI, 53-85%) and cumulative incidence of POP was estimated to be 15% (95% CI, 3-28%) at 1­month follow-up. CONCLUSION: Commencing palliative radiotherapy earlier may improve the probability of patients achieving a pain response, although POP may be more frequent.

Improvement in pain interference after palliative radiotherapy for solid and hematologic painful tumors: a secondary analysis of a prospective observational study.

BACKGROUND: We previously demonstrated that patients with painful hematologic tumors were more likely to experience pain response after palliative radiotherapy (RT) than those with painful solid tumors. However, it is unknown whether change in pain interference differs between these two tumor types. In the present study, we carried out a secondary analysis of our previous prospective observational study to investigate this matter. METHODS: From patients undergoing palliative RT to treat painful tumors, Brief Pain Inventory data were collected at the start of RT and at the 1-, 2-, and 3- month follow-ups. The Mann-Whitney U test was used to compare changes in pain interference score from baseline between the two groups. RESULTS: Of the 237 patients, 203 (86%) had solid and 34 (14%) had hematologic index tumors planned to receive RT. At baseline, the groups did not differ significantly in terms of pain score, analgesic use, or pain interference score. At the 1-, 2-, and 3-month follow-ups, the changes in pain interference score from baseline did not differ significantly between the two groups. In both groups, all seven pain interference items, other than sleep in patients with hematologic tumors at the 2-month follow-up, were significantly improved (P < 0.05). CONCLUSIONS: The two groups showed comparable benefit from RT in terms of improvement in pain interference. Patients with tumor-related pain should be offered the option of palliative RT, irrespective of whether the painful tumor is solid or hematologic.

Prognostic Factors of Salvage Esophagectomy for Residual or Recurrent Esophageal Squamous Cell Carcinoma After Definitive Chemoradiotherapy.

BACKGROUND: The aim of this study was to confirm prognostic factors for salvage esophagectomy for remnant or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy. STUDY DESIGN: We retrospectively analyzed clinicopathological backgrounds of 50 patients who underwent salvage esophagectomy between April 2005 and January 2016. Salvage esophagectomy comprised 40 three-incision esophagectomies, two transhiatal esophagectomies and eight pharyngolaryngoesophagectomies. Independent prognostic factors for overall survival were assessed using Cox regression analysis of the factors. RESULTS: Salvage esophagectomy remains a highly invasive surgery and correlated with a higher incidence of all morbidities of Clavien-Dindo classification (CDc) ≥II, severe morbidities of CDc ≥ IIIb, any pulmonary morbidities and chylorrhea, compared with those in patients without preoperative definitive chemoradiotherapy. Cox regression analysis suggested that R0 resection (hazard ratio [HR] 6.39; 95% confidence interval [CI] 2.03-9.68, P = 0.002), absence of severe complications (HR 4.97; 95% CI 1.70-14.81, P = 0.004) and early pStage (0-II) (HR 3.42; 95% CI 1.24-10.12, P = 0.018) were independent prognostic factors for salvage esophagectomy. CONCLUSIONS: Salvage esophagectomy remains correlated with a high incidence of postoperative complications. Avoiding non-curative surgery and reducing the incidence of severe postoperative complications are important if patients are to receive prognostic benefit of this highly invasive surgery.

Predictors of acute hematologic toxicity attributable to palliative radiotherapy: Analysis of patient characteristics and bone marrow dose-volume parameters.

PURPOSE: As predictors of hematologic toxicity (HT) after palliative radiotherapy (RT) have been studied insufficiently, we explored predictors of leukopenia, neutropenia, and thrombocytopenia attributable to palliative RT. METHODS: We retrospectively assessed patients with various solid tumors who had received palliative RT at our institution. Excluded from our study were patients who had undergone chemotherapy from one month before to one month after the start of RT. To measure the bone marrow dose, all bones were delineated, and the absolute volume of bone marrow that had received 5, 10, 20, and 30 Gy was recorded. Univariate and multivariate logistic regression analysis was performed to identify variables associated with leukopenia, neutropenia, or thrombocytopenia of grade 2 or higher (HT2+). RESULTS: Of 68 patients, 17 (25%) developed HT2+. Grade ≥ 2 leukopenia developed in 13 patients (19%), neutropenia in 8 (12%), and thrombocytopenia in 6 (9%). Only one patient experienced ≥ grade 3 toxicity. The median baseline and nadir white blood cell count (WBC) was 6.950 and 4.650x109/l, respectively; the absolute neutrophil count (ANC) was 5.236 and 3.307x109/l, respectively, and the platelet count was 249 and 177.5x109/l, respectively. Multivariate analysis revealed that female gender and a lower baseline WBC and ANC were significant independent predictors of HT2+. No bone marrow dose-volume parameter was a significant predictor of HT2+. CONCLUSIONS: Overall, HT was relatively mild. Female gender and lower baseline WBC and ANC may be predictors of HT elicited by palliative RT.

Radiation-induced Liver Injury after 3D-conformal Radiotherapy for Hepatocellular Carcinoma: Quantitative Assessment Using Gd-EOB-DTPA-enhanced MRI.

Focal liver reaction (FLR) appears in the hepatobiliary-phase images of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA-enhanced MRI) following radiotherapy (RT). We investigated the threshold dose (TD) for FLR development in 13 patients with hepatocellular carcinoma (HCC) who underwent three-dimensional conformal radiotherapy (3D-CRT) with 45 Gy in 15 fractions. FLR volumes (FLRVs) were calculated based on planning CT images by referring to fused hepatobiliary- phase images. We also calculated the TD and the irradiated volumes (IVs) of the liver parenchyma at a given dose of every 5 Gy (IVdose) based on a dose-volume histogram (DVH). The median TD was 35.2 Gy. The median IV20, IV25, IV30, IV35, IV40, and IV45 values were 371.1, 274.8, 233.4, 188.6, 145.8, and 31.0 ml, respectively. The median FLRV was 144.9 ml. There was a significant difference between the FLRV and IV20, IV25, and IV45 (p<0.05), but no significant differences between the FLRV and IV30, IV35, or IV40. These results suggest that the threshold dose of the FLR is approx. 35 Gy in HCC patients who undergo 3D-CRT in 15 fractions. The percentage of the whole liver volume receiving a dose of more than 30-40 Gy (V30-40) is a potential candidate optimal DVH parameter for this fractionation schedule.

Dosimetric Predictors of Treatment-related Lymphopenia induced by Palliative Radiotherapy: Predictive Ability of Dose-volume Parameters based on Body Surface Contour.

BACKGROUND: Radiation-related lymphopenia has been associated with poor patient outcome. Our aim was to identify predictors of lymphopenia after palliative radiotherapy, with a focus on dose-volume parameters. PATIENTS AND METHODS: To retrospectively assess patients with various cancers who had undergone palliative radiotherapy, we delineated three organs at risk: the volume enclosed by the body surface contour (body A), the volume left after excluding air, pleural effusion, ascites, bile, urine, and intestinal content (body B), and the volume of the bone marrow (BM). We then noted the absolute volume of the three organs at risk that had received 5-30 Gy, and assessed the predictive value for post-treatment lymphopenia of grade 3 or higher (LP3+). RESULTS: Of 54 patients, 23 (43%) developed LP3+. Univariate logistic regression analysis showed that body A V5, body A V10, body B V5, body B V10, the number of fractions, and splenic irradiation were significant predictors of LP3+ (p < 0.05). By multivariate analysis, body A V5, body A V10, body B V5, body B V10, and the number of fractions retained significance (p < 0.05). BM dose-volume parameters did not predict lymphopenia. CONCLUSIONS: Higher body A and body B dose-volume parameters and a larger number of fractions may be predictors of severe lymphopenia after palliative radiotherapy.

Influence of the treatment schedule on the physicians' decisions to refer bone metastases patients for palliative radiotherapy: a questionnaire survey of physicians in various specialties.

We investigated whether the treatment schedule influences physicians' decisions to refer their patients for radiotherapy. We presented a questionnaire to 104 physicians in various specialties at three hospitals. It included three hypothetical patients with uncomplicated painful bone metastasis: patients with an expected life span of one year (case 1), 6 months (case 2), and 2 months (case 3). The physicians were asked whether they would refer their patients for radiotherapy when a radiation oncologist presented three different treatment schedules: a short (8 Gy/1 fraction/1 day)-, a medium (20 Gy/5 fractions/1 week)-, and a long (30 Gy/10 fractions/2 weeks) schedule. We used Cochran's Q-test to compare the percentage of physicians across the three schedules and a mixed-effect logistic model to identify predictors of the selection of only the one-day schedule. Of the 104 physicians, 68 (65%) responded. Of these, 37 (54%), 27 (40%), and 26 (38%) chose to refer patients for radiotherapy when the short-, medium-, and long schedules, respectively, were proposed in case 1 (p = 0.14). These numbers were 44 (65%), 29 (43%), and 15 (22%) for case 2 (p < 0.001), and 59 (87%), 12 (18%), and 1 (1%) for case 3 (p < 0.001). Hypothetical patient and the physicians' years of practice and perspective regarding side effects were independently predictive of the selection of only the one-day schedule. In conclusion, the treatment schedule influenced the physicians' decisions to refer patients for radiotherapy.

Radiation-Induced Myonecrosis: A Case Report of a Cervical Cancer Patient With a History of Systemic Lupus Erythematosus.

Radiation-induced myonecrosis is a rare but serious complication of radiation therapy. We present a case of a 49-year-old woman with systemic lupus erythematosus who developed radiation-induced myonecrosis after concurrent chemoradiation for cervical cancer. She underwent external-beam radiation therapy, weekly cisplatin chemotherapy (40 mg/m2), and intracavitary brachytherapy. One month later, she received one cycle of nedaplatin (80 mg/m2) and irinotecan (60 mg/m2). Two months after treatment, she experienced pain in the left inguinal region. An MRI revealed a mass in the left obturator externus muscle and right pectineus muscle suggestive of myonecrosis. A biopsy confirmed the diagnosis. She received hyperbaric oxygen therapy, and her symptoms improved. The masses resolved completely.

Radiation Therapy Oncology Group 8502 "QUAD shot" regimen using volumetric modulated arc therapy for incurable head and neck cancer.

OBJECTIVES: We aimed to evaluate the outcomes of the Radiation Therapy Oncology Group 8502 "QUAD shot" regimen using volumetric modulated arc therapy (VMAT) for incurable head and neck cancer (HNC). MATERIALS AND METHODS: We included 105 patients with HNC in the study, undergoing at least one QUAD shot regimen cycle. We planned the radiotherapy using VMAT with 6 MV photons. One QUAD shot cycle included 14.8 Gy in 4 fractions with at least 6-hour intervals over 2 consecutive days, repeated every 3-6 weeks up to 3 cycles. RESULTS: We completed 1, 2, and 3 cycles in 11 (10 %), 17 (16 %), and 77 (73 %) patients, respectively. We concurrently performed systemic therapy in 13 (12 %) patients. Tumor response was observed in 92 (88 %) patients and at least one symptom relief in 51 (71 %) of 72 patients. We observed an overall response (tumor response or symptom relief) in 98 (93 %) patients with all patients who completed 3 cycles achieving it. The median overall survival (OS) was 6.8 months. Our multivariate analysis revealed that non-squamous cell carcinoma (p < 0.001), T category of 0-2 (p = 0.021), and 3 QUAD shot cycles (p < 0.001) were independent prognostic factors of better OS. We observed Grade 3 toxicity in 2 (2 %) patients while no ≥ Grade 4 acute or ≥ Grade 3 late toxicity. CONCLUSIONS: The QUAD shot regimen using VMAT exerts appropriate palliative effect in patients with incurable HNC. Treatment with higher QUAD shot cycle number would be recommended for better treatment outcomes.

Influence of Respiratory Motion on Dose Distribution in Gastric Mucosa-associated Lymphoid Tissue Lymphoma Radiotherapy.

BACKGROUND/AIM: The present study investigated the effect of respiratory motion on planned radiotherapy (RT) dose for gastric mucosa-associated lymphoid tissue (MALT) lymphoma using four-dimensional dose (4D-dose) accumulation. PATIENTS AND METHODS: 4D-computed tomography (4D-CT) images of 10 patients with gastric MALT lymphomas were divided into 10 respiratory phases. Further, the 3D-dose was calculated using 3D conformal RT (3D-CRT) and volumetric modulated arc therapy (VMAT) plans based on the average intensity projection (AIP) images. Then, both plans were recalculated according to each phase image. Moreover, the dose distributions in each phase were transferred to the AIP images using deformable image registration. The 4D-dose distribution was calculated by summing the doses of each phase, and it was compared with the dosimetric parameters of the 3D-dose distribution. RESULTS: For 3D-CRT, the D95 and D99 of the 4D-dose in the planning target volume (PTV) were significantly lower than those of the 3D-dose, with mean differences of 0.2 (p=0.009) and 0.1 Gy (p=0.021), respectively. There were no significant differences in the other PTV and organ-at-risk dosimetric parameters of 3D-CRT or in any dosimetric parameters of VMAT between the 3D- and 4D-dose distributions. CONCLUSION: The effect of respiratory motion on the planned 3D-CRT and VMAT dose distributions for gastric MALT lymphoma is minimal and clinically negligible.

Bias due to statistical handling of death and reirradiation in the assessment of duration of response after palliative radiotherapy: a scoping review and analysis of clinical data.

OBJECTIVES: We investigated the influence of handling death and reirradiation on the estimation of duration of response (DOR). METHODS: First, we performed a scoping review on methods to assess DOR in palliative radiotherapy. Second, we performed three different analyses on a subgroup of patients from a previously published prospective study. The first analysis was a competing risks analysis considering relapse of pain as the event of interest and death and reirradiation as competing events (Analysis A). The second and third analyses were standard survival analyses where the event of interest was a composite outcome of relapse of pain, death, or reirradiation (Analysis B) and relapse of pain (Analysis C), respectively. RESULTS: Death was considered as an event of interest in less than half of the papers, while reirradiation was not considered in any of the studies. Competing risks analysis was not performed in any of the studies. In the analysis of clinical data, competing risks analysis showed that relapse of pain predominated as the cause of the end of response. Median DOR was correctly estimated to be 4.1 months in Analyses A and B, but was overestimated to be 8.1 months in Analysis C. CONCLUSIONS: Death and reirradiation should be treated as the events of interest that mark the end of response (as in Analyses A and B) to avoid overestimation of treatment efficacy and an invalid assumption of independent censoring. ADVANCES IN KNOWLEDGE: The definition of end of response remains inconclusive in the assessment of DOR. We recommend competing risks analysis (Analysis A), by which we can estimate cumulative incidence of each event type and evaluate the necessity of reirradiation.

A Case of Tumor Lysis Syndrome during Palliative Radiotherapy for Breast Cancer Metastases.

Tumor lysis syndrome (TLS) is the rapid disintegration of a malignant tumor treated with anticancer drugs or radiation, causing electrolyte abnormalities such as elevated uric acid levels, elevated potassium and phosphorus levels, and decreased calcium levels. These abnormalities can lead to hypotension, renal dysfunction, consciousness disorders, and even death in some cases. The current patient was a 65-year-old woman who had breast cancer with local invasion, lung metastasis, and bone metastasis from the time of the initial disease onset. Despite the administration of various chemotherapy and hormone therapy regimens, the tumor increased gradually, and at 2 years and 5 months after the initial onset, pain and bleeding from metastatic infiltration of the cervical lymph nodes were noted. Therefore, radiotherapy was indicated for palliation of pain and bleeding caused by metastatic invasion of the cervical lymph nodes. Irradiation (30 Gy/10fr) was planned with a 3-field technique using 4MVX and 10MVX. Approximately 11 h after the initial irradiation, symptoms such as respiratory distress, tachycardia, and hypotension were observed. Blood tests revealed hyperuricemia and hyperkalemia, leading to a diagnosis of TLS. Dialysis and electrolyte correction were immediately initiated resulting in normalization of electrolytes and stabilization of the blood pressure. It is crucial to understand that TLS is relatively rare but can occur after radiation therapy or in solid tumors, and warrants a prompt response if suspected based on symptoms or blood findings.

Prevalence and risk factors for retropharyngeal and retro-styloid lymph node metastasis in hypopharyngeal carcinoma.

BACKGROUND: We evaluated the prevalence and identified the risk factors for retropharyngeal and retro-styloid lymph node metastasis (LNM) in patients with hypopharyngeal carcinoma (HPC). This was achieved using a combination of magnetic resonance (MR) and [18 F]-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) images. METHODS: Two board-certified radiation oncologists retrospectively reviewed pretreatment FDG-PET/CT images and contrast-enhanced thin-slice CT and MR images of 155 patients with HPC who underwent radiotherapy. Fisher's exact tests and logistic regression analyses were performed to assess the risk factors for LNM. RESULTS: Retropharyngeal LNM (RPLNM) was confirmed in 20 (13%) patients. Posterior wall (PW) tumors (odds ratio [OR]: 4.128, 95% confidence interval [CI]: 1.339-12.727; p = 0.014) and bilateral or contralateral cervical LNM (OR: 11.577, 95% CI: 2.135-62.789; p = 0.005) were significantly correlated with RPLNM. The RPLNM was found in 9 (32%) of the 28 patients with PW tumors. Of these 9 patients, 2 (7%) had ipsilateral RPLNM, 3 (11%) had contralateral RPLNM, and 4 (14%) had bilateral RPLNM. The PW tumors were significantly associated with contralateral RPLNM (p < 0.001). Retro-styloid LNM (RSLNM) was confirmed in two (1%) patients, both of whom had ipsilateral RSLNM with lymph nodes (LNs) of ≥ 15 mm in the upper limit of ipsilateral level II. A significant association was found between LNs of ≥ 15 mm in the upper limit of ipsilateral level II and ipsilateral RSLNM (p = 0.001). CONCLUSIONS: The RPLNM was identified in 13% of patients with HPC. The PW tumors and bilateral or contralateral cervical LNM were risk factors for RPLNM; particularly, PW tumors were a specific risk factor for contralateral RPLNM. Although the RSLNM was rare, LNs of ≥ 15 mm in the upper limit of ipsilateral level II were a risk factor for ipsilateral RSLNM.

A prospective comparison of adaptive and fixed boost plans in radiotherapy for glioblastoma.

PURPOSE: To analyze the efficacy of adaptive radiotherapy (ART) for glioblastoma. METHODS: Sixty-one glioblastoma patients who received ART were prospectively evaluated. The initial clinical target volume (CTVinitial) was represented by T2 hyperintensity on postoperative MRIs (pre-RT MRI [MRIpre])plus 10 mm. The initial planning target volume (PTVinitial) was the CTVinitial plus a 5-mm margin. The PTVinitial received 40 Gy. An MRI and a second planning CT were performed during radiotherapy (MRImid). Two types of boost CTVs (the resection cavity and residual tumor on enhanced T1-weighted MRI plus 10 mm) were created based on the MRIpre and MRImid (CTVboost-pre and -mid). The boost PTV (PTVboost) was the CTVboost plus 5 mm. Two types of boost plans (fixed and adaptive boost plans in the first and second planning CT, respectively) of 20 Gy were created. The PTV based on the post-RT MRI (PTVboost-post) was created, and the dose-volume histograms of the PTVboost-post in the fixed and adaptive boost plans were compared. Additionally, the conformity indices (CIs) of the fixed and adaptive boost plans were compared. RESULTS: The median V95 of the PTVboost-post of the fixed and adaptive boost plans (V95pre and V95mid) were 95.6% and 98.3%, respectively (P < 0.01). The median V95pre and V95mid of patients after gross total resection (GTR) were 97.4% and 98.8%, respectively (P = 0.41); in contrast, the median values of patients after non-GTR were 91.9% and 98.2%, respectively (P < 0.01). The median CIs of the fixed and adaptive boost plans in all patients were 1.45 and 1.47, respectively (P = 0.31). The median CIs of the fixed and adaptive boost plans in patients after GTR were 1.61 and 1.48, respectively (P = 0.01); in contrast, those in patients after non-GTR were 1.36 and 1.44, respectively (P = 0.13). CONCLUSION: ART for glioblastoma improved the target coverage and dose reduction for the normal brain. By analyzing the results according to the resection rate, we can expect a decrease in normal brain dose in patients with GTR and an increase in coverage in those with partial resection or biopsy.

Concurrent Chemoradiotherapy With Docetaxel, Cisplatin, and 5-Fluorouracil for T3 N0 Glottic Carcinoma Without Vocal Cord Fixation.

BACKGROUND/AIM: We retrospectively evaluated the efficacy and toxicity of concurrent chemoradiotherapy (CCRT) with docetaxel, cisplatin, and 5-fluorouracil (TPF) for T3 N0 glottic carcinoma without vocal cord fixation. PATIENTS AND METHODS: Twenty-five patients underwent TPF-CCRT without elective nodal irradiaion (ENI). After the RT of 40 Gy, five patients (20%) without tumor regression underwent surgery. Others underwent RT with a median total dose of 66 Gy. RESULTS: Of the five patients who underwent surgery after the RT of 40 Gy, two showed residual carcinoma pathologically and the other three were confirmed to have complete pathological response to the treatment. The 5-year local control rate was 87%. No patients exhibited regional failure. No acute toxicities of grade 5 or late toxicities ≥grade 3 were observed. CONCLUSION: TPF-CCRT provides excellent tumor control with acceptable toxicities. CCRT while omitting ENI is a reasonable approach for T3 N0 glottic carcinoma without vocal cord fixation.

Prevalence and risk factors of retro-styloid lymph node metastasis in oropharyngeal carcinoma.

BACKGROUND: Supporting data defining the selection criteria of level VIIb for inclusion in the target volume in radiotherapy (RT) planning are insufficient. We evaluated the prevalence of level VIIb retro-styloid lymph node metastasis (RSLNM) and associated risk factors in patients with oropharyngeal carcinoma (OPC). MATERIALS AND METHODS: We retrospectively reviewed pre-treatment [18F]-fluoro-2-deoxy-d-glucose-positron emission tomography/computed tomography (CT) along with contrast-enhanced thin slice CT and magnetic resonance (MR) images of 137 patients pathologically confirmed as having OPC who underwent RT. The location of lymph nodes (LNs) was confirmed on the planning CT images. Fisher's exact test and logistic regression analyses were made to determine the risk factors of RSLNM. RESULTS: RSLNM was confirmed in 18 (13%) patients. All RSLNMs were located within level VIIb on the planning CT images. No patients exhibited LNM in contralateral level VIIb. Furthermore, no patients with negative or single ipsilateral cervical LNM had RSLNM. Fisher's exact test revealed that smoking status (p=.027), multiple ipsilateral cervical LNM (p=.045) and LN ≥15 mm in the upper limit of ipsilateral level II (p<.001) were significantly associated with RSLNM. Logistic regression analyses revealed that the presence of LNs ≥15 mm in upper limit of ipsilateral level II was significantly associated with RSLNM (odds ratio: 977.297; 95% confidence interval: 57.629-16573.308; p<.001). CONCLUSIONS: RSLNM is relatively common in patients with OPC with a prevalence rate of approximately 10%. The prevalence of RSLNM in patients with negative or single ipsilateral cervical LNM and contralateral RSLNM is extremely low; therefore, level VIIb can be excluded from the target volume in such patients. LN ≥15 mm in the upper limit of ipsilateral level II is a risk factor for RSLNM. Ipsilateral level VIIb should be included in the target volume for patients with this risk factor.KEY MESSAGERetro-styloid lymph node metastasis (RSLNM) prevalence is ∼10% in oropharyngeal carcinoma.Lymph node ≥15 mm in ipsilateral level II upper limit is a risk factor for RSLNM.

Implementation of 99mTc-GSA SPECT Image-guided Inverse Planning into Palliative Radiotherapy for Diffuse Liver Metastases: A Novel Approach.

BACKGROUND/AIM: This is a report of the first clinical implementation of 99mTc-labeled diethylene triamine pentaacetate-galactosyl human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT) image-guided inverse planning into palliative radiotherapy (RT) for diffuse liver metastases. CASE REPORT: A 48-year-old man developed chemo-refractory diffuse liver metastases from thymic carcinoma characterized by abdominal pain and distension. Palliative RT was performed with a total dose of 20 Gy in five fractions using double arc volumetric modulated arc therapy to reduce the dose to functional liver defined by 99mTc-GSA SPECT images. His symptoms were immediately relieved after RT and did not experience radiation-induced liver disease. Both Functional Assessment of Cancer Therapy (FACT)-G and FACT-Hep total scores improved after 2 weeks of RT initiation and did not become worse than baseline scores. CONCLUSION: The 99mTc-GSA SPECT image-guided palliative RT is an effective and safe treatment for patients with diffuse liver metastases.

Reduced-dose WBRT combined with SRS for 1-4 brain metastases aiming at minimizing neurocognitive function deterioration without compromising brain tumor control.

Background and purpose: To minimize cognitive decline without increasing brain tumor recurrence (BTR) by reduced-dose whole-brain radiotherapy (RD-WBRT) (25 Gy, 10 fractions) + stereotactic radiosurgery (SRS) in patients with ≤ 4 brain metastases. Materials and methods: Eligible patients with ≤ 4 brain metastases on contrast-enhanced MRI and Karnofsky Performance Status ≥ 70. The primary endpoint was the non-inferiority of BTR at distant sites in the brain (BTR-distant)-free survival at 6 months compared to that of the standard dose (SD)-WBRT (30 Gy, 10 fractions) + SRS arm in a randomized clinical trial (JROSG99-1) of SRS with/without SD-WBRT. Secondary endpoints included BTR at any brain sites (BTR-all) and neurocognitive function assessed by a six-test standardized battery. Results: Forty patients from seven institutions were enrolled (median age 69 years). The primary tumor site was a lung in 28 patients; 20 patients had a solitary brain metastasis. The median survival time was 19.0 months (95 %CI: 13.8 %-27.5 %). The BTR-distant-free survival at 6 months was 76.9 % (59.5 %-87.7 %), which is comparable to that of historical control although predetermined non-inferiority (>71 %) could not be confirmed (p = 0.16). The cumulative incidence of BTR-all at 6 months accounting for the competing risk of death was 23.0 % (11.4-37.1), which was not worse than that of historical control (p = 0.774). The frequency of the cumulative incidence of persistent cognitive decline at 6 months was 48.6 % under the [>2.0 SD in ≥ 1 test] definition. Conclusions: RD-WBRT may yield comparable intracranial tumor control when combined with SRS, and may reduce the risk of neurocognitive decline compared to that after SD-WBRT.

Perioperative intra-arterial and systemic chemotherapy for pancreatic cancer.

BACKGROUND: Even after curative resection of pancreatic cancer, there is a high probability of systemic recurrence. This indicates that subclinical metastases are already present at the time of operation. The purpose of this study was to assess the feasibility and outcomes of patients who received a novel multimodality therapy combining pancreatic resection and intraoperative radiation therapy (IORT) with pre- and postoperative chemotherapy for pancreatic cancer. METHODS: For eligible patients with pancreatic cancer, 5-FU was administered at a dose of 125 mg/m(2)/day on days 1-5 every week as a continuous pancreatic and hepatic arterial infusion, and gemcitabine was infused intravenously at a dose of 800 mg/m(2) per day once per week for 2 weeks for preoperative chemotherapy. Pancreatic resection combined with IORT was performed 1 week after preoperative chemotherapy. Postoperative chemotherapy was performed in the same way as preoperative chemotherapy. We performed an intention-to-treat analysis for all enrolled patients. RESULTS: This study enrolled 44 patients. The most common toxicities were hematological and gastrointestinal events. Grade 3/4 hematological toxicities were observed during preoperative chemotherapy, although there were no grade 3/4 nonhematological events. Postoperative chemotherapy-related toxicities were more critical and frequent than preoperative ones. There were no pre- or postoperative chemotherapy-associated deaths. Median overall survival was 36.5 months with 30.5% overall 5-year survival. CONCLUSIONS: This multimodality therapy is feasible and promises to contribute to survival. It should be evaluated in a phase III setting.