The role of surgical clips in the evaluation of interfractional uncertainty for treatment of hepatobiliary and pancreatic cancer with postoperative radiotherapy

PURPOSE: To evaluate the utility of implanted surgical clips for detecting interfractional errors in the treatment of hepatobiliary and pancreatic cancer with postoperative radiotherapy (PORT). METHODS AND MATERIALS: Twenty patients had been treated with PORT for locally advanced hepatobiliary or pancreatic cancer, from November 2014 to April 2016. Patients underwent computed tomography simulation and were treated in expiratory breathing phase. During treatment, orthogonal kilovoltage (kV) imaging was taken twice a week, and isocenter shifts were made to match bony anatomy. The difference in position of clips between kV images and digitally reconstructed radiographs was determined. Clips were consist of 3 proximal clips (clip_p, ≤2 cm) and 3 distal clips (clip_d, >2 cm), which were classified according to distance from treatment center. The interfractional displacements of clips were measured in the superior-inferior (SI), anterior-posterior (AP), and right-left (RL) directions. RESULTS: The translocation of clip was well correlated with diaphragm movement in 90.4% (190/210) of all images. The clip position errors greater than 5 mm were observed in 26.0% in SI, 1.8% in AP, and 5.4% in RL directions, respectively. Moreover, the clip position errors greater than 10 mm were observed in 1.9% in SI, 0.2% in AP, and 0.2% in RL directions, despite respiratory control. CONCLUSION: Quantitative analysis of surgical clip displacement reflect respiratory motion, setup errors and postoperative change of intraabdominal organ position. Furthermore, position of clips is distinguished easily in verification images. The identification of the surgical clip position may lead to a significant improvement in the accuracy of upper abdominal radiation therapy.

Analysis of the Prognostic Factors for Distant Metastasis after Induction Chemotherapy Followed by Concurrent Chemoradiotherapy for Head and Neck Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The aim of this study is to identify the prognostic factors of distant metastasis (DM) after induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CRT) for locoregionally advanced head and neck cancer (HNC). MATERIALS AND METHODS: A total of 321 patients with HNC who underwent IC followed by CRT treated between January 2005 and December 2010 were analyzed retrospectively. IC consisted of three courses of docetaxel (70 mg/m2) and cisplatin (75 mg/m2) every three weeks, followed by radiotherapy of 66-70 Gy/2 Gy per fraction/5 fractions per week concurrent with weekly cisplatin (40 mg/m2). Tumor/nodal stage, primary site, tumor differentiation, lower neck node involvement (level IV, VB, and supraclavicular regions), number of concurrent chemotherapy cycles, overall duration of radiotherapy, and response to IC were assessed as potential prognostic factors influencing DM and survival outcome. RESULTS: The five-year loco-regional recurrence and DM rates were 23.6% and 18.2%. N stage, overall duration of radiotherapy, lower neck node involvement, and response to IC were significant factors for DM. With a median follow-up period of 52 months (range, 4 to 83 months), the 5-year progression-free, DM-free, and overall survival rates were 41.2%, 50.7%, and 55.1%, respectively. Lower neck node involvement (p=0.008) and poor response to IC (p < 0.001) showed an association with significantly inferior DM-free survival. CONCLUSION: Even with the addition of IC, the DM rate and survival outcome were poor when metastatic lower neck lymph nodes were present or when patients failed to respond after receiving IC.

Three-dimensional conformal radiotherapy for portal vein tumor thrombosis alone in advanced hepatocellular carcinoma

PURPOSE: We sought to evaluate the clinical outcomes of 3-dimensional conformal radiation therapy (3D-CRT) for portal vein tumor thrombosis (PVTT) alone in patients with advanced hepatocellular carcinoma. MATERIALS AND METHODS: We retrospectively analyzed data on 46 patients who received 3D-CRT for PVTT alone between June 2002 and December 2011. Response was evaluated following the Response Evaluation Criteria in Solid Tumors. Prognostic factors and 1-year survival rates were compared between responders and non-responders. RESULTS: Thirty-seven patients (80.4%) had category B Child-Pugh scores. The Eastern Cooperative Oncology Group performance status score was 2 in 20 patients. Thirty patients (65.2%) had main or bilateral PVTT. The median irradiation dose was 50 Gy (range, 35 to 60 Gy) and the daily median dose was 2 Gy (range, 2.0 to 2.5 Gy). PVTT response was classified as complete response in 3 patients (6.5%), partial response in 12 (26.1%), stable disease in 19 (41.3%), and progressive disease in 12 (26.1%). There were 2 cases of grade 3 toxicities during or 3 months after radiotherapy. Twelve patients in the responder group (15 patients) received at least 50 Gy irradiation, but about 84% of patients in the non-responder group received less than 50 Gy. The 1-year survival rate was 66.8% in responders and 27.4% in non-responders constituting a statistically significant difference (p = 0.008). CONCLUSION: Conformal radiotherapy for PVTT alone could be chosen as a palliative treatment modality in patients with unfavorable conditions (liver, patient, or tumor factors). However, more than 50 Gy of radiation may be required.

Neoadjuvant intra-arterial chemotherapy combined with radiotherapy and surgery in patients with advanced maxillary sinus cancer

PURPOSE: The optimal treatment of advanced maxillary sinus cancer has been challenging for several decades. Intra-arterial chemotherapy (IAC) for head and neck cancer has been controversial. We have analyzed the long-term outcome of neoadjuvant IAC followed by radiation therapy (RT) and surgery. MATERIALS AND METHODS: Twenty-seven patients with advanced maxillary sinus cancer were treated between 1989 and 2002. Five-fluorouracil (5-FU, 500 mg/m2) was infused intra-arterially, and followed by RT (total 50.4 Gy/28 fractions). A planned surgery was performed 3 to 4 weeks after completion of IAC and RT. RESULTS: At a median follow-up of 77 months (range, 12 to 169 months), the 5-year rates of overall survival in all patients were 63%. The 5-year rates of overall survival of stage T3/T4 patients were 70.0% and 58.8%, respectively. Seven of fourteen patients with disease recurrence had a local recurrence alone. The 5-year actuarial local control rates in patients with stage T3/T4, and in all patients were 20.0%, 32.3%, and 27.4%, respectively. Overall response rate after the completion of IAC and RT was 70.3%. During the follow-up, seven patients (25.9%) showed mild to moderate late complications. The tumor extent (i.e., the involvement of either orbit and/or base of skull) appeared to be related with local recurrence. CONCLUSION: Neoadjuvant IAC with 5-FU followed by RT and surgery may be effective to improve local tumor control in the patients with advanced maxillary sinus cancer. However, local failure was still the major cause of death. Further investigations are required to determine the optimal treatment schedule, radiotherapy techniques and chemotherapy regimens.

Short-course palliative radiotherapy for uterine cervical cancer

PURPOSE: The purpose of this retrospective study was to evaluate the efficacy and feasibility of short-course hypofractionated radiotherapy (RT) for the palliation of uterine cervical cancer. MATERIALS AND METHODS: Seventeen patients with cancer of the uterine cervix, who underwent palliative hypofractionated 3-dimensional conformal radiotherapy between January 2002 and June 2012, were retrospectively analyzed. RT was delivered to symptomatic lesions (both the primary mass and/or metastatic regional lymph nodes). The total dose was 20 to 25 Gy (median, 25 Gy) in 5 Gy daily fractions. RESULTS: The median follow-up duration was 12.2 months (range, 4 to 24 months). The median survival time was 7.8 months (range, 4 to 24 months). Vaginal bleeding was the most common presenting symptom followed by pelvic pain (9 patients). The overall response rates were 93.8% and 66.7% for vaginal bleeding control and pelvic pain, respectively. Nine patients did not have any acute side effects and 7 patients showed minor gastrointestinal toxicity. Only 1 patient had grade 3 diarrhea 1 week after completion of treatment, which was successfully treated conservatively. Late complications occurred in 4 patients; however, none of these were of grade 3 or higher severity. CONCLUSION: Short-course hypofractionated RT was effective and well tolerated as palliative treatment for uterine cervical cancer.

Helical Tomotherapy in Elderly Prostate Cancer Patients

BACKGROUND: Helical tomotherapy is a new form of image-guided intensity modulated radiation therapy that may improve local control and decrease radiation toxicity. The aim of this study was to evaluate if high-dose helical tomotherapy is tolerated by patients aged 75 years or older and if the side effects are comparable with those experienced by younger patients. METHODS: Between January 2011 and August 2012, patients with prostate cancer who underwent helical tomotherapy without elective pelvic irradiation as definitive aim were reviewed and divided into two age groups: > or =75 years and <75 years. Acute genitourinary (GU) and lower gastrointestinal (GI) toxicities between the two groups were compared. RESULTS: Twenty patients aged 75 years or older and 23 patients younger than 75 years were evaluated. Radiotherapy was administered to a total dose of 76-78Gy in 38-39 fractions or 70Gy in 28 fractions. There was no grade 3 or 4 acute toxicity and no grade 2 acute lower GI symptom, but the patients complained of grade 2 acute GU toxicity, 25.0% for the older group and 13.0% for the younger group. There was no significant difference in the rate of acute toxicity between the age groups. Hypofractionation showed a significant association with higher grade 2 acute GU toxicity (p=0.024) with the grade 2 acute GU toxicity having no significant correlation with T-stage, Gleason score, prostate specific antigen level, androgen deprivation therapy, and comorbidities. CONCLUSION: High-dose helical tomotherapy to the prostate without pelvic irradiation was well tolerated by elderly prostate cancer patients 75 years and older.

Treatment Planning for Minimizing Carotid Artery Dose in the Radiotherapy of Early Glottic Cancer / 대한방사선종양학회지

PURPOSE: To examine the feasibility of the treatment planning for minimizing carotid artery dose in the radiotherapy of early glottic cancer. MATERIALS AND METHODS: From 2007 to 2010, computed tomography simulation images of 31 patients treated by radiotherapy for early glottic cancer were analyzed. The virtual planning was used to compare the parallel-opposing fields (POF) with the modified oblique fields (MOF) placed at angles to exclude the ipsilateral carotid arteries. Planning target volume (PTV), irradiated volume, carotid artery, and spinal cord were analyzed at a mean dose, V35, V40, V50 and with a percent dose-volume. RESULTS: The beam angles were arranged 25 degrees anteriorly in 23 patients and 30 degrees anteriorly in 8 patients. The percent dose-volume of PTV shows no statistical difference. Conversely, the cumulative percent dose-volume of carotid artery shows the significant difference (p<0.001). The mean doses of carotid artery were 38.5 Gy for POF and 26.3 Gy for MOF and the difference was statistically significant (p=0.012). Similarly, V35, V40, and V50 also showed significant differences between POF and MOF. CONCLUSION: The modified oblique field was respected to prevent a carotid artery stenosis and reduce the incidence of a stroke based on these results.

Significance of the Failure Patterns in Cervical Lymph Nodes Achieving a Complete Response to Radical Radiotherapy / 대한방사선종양학회지

PURPOSE: This study was performed to examine the neck failure patterns after a complete response (CR) to definitive radiotherapy for advanced head and neck cancer patients, as well as evaluate the clinical significance of the results of this study. MATERIALS AND METHODS: Between 1987 and 2008, the clinical data of patients who had been treated with radical radiotherapy for primary squamous cell carcinomas and enlarged cervical lymph nodes was analyzed retrospectively. Ultimately, the cases that showed CR of the cervical lymph node lesions to full-dose radiotherapy were included in this study. The recurrent rate and sites in the cervical lymphatic area were evaluated periodically by radiologic imaging studies, along with some factors which might have affected the rate of recurrence. RESULTS: A total of 73 patients who achieved CR in neck area after radiotherapy were included in this study. The rate of subsequent neck failure among those patients was 19.2%. There was only a 5.5% failure rate in the 55 patients who underwent radiotherapy in their primary site. Eighty percent of the recurrent cases were found within 3 years (median follow-up, 68 months). The majority of neck recurrent cases (47%) were accompanied with the failure of the primary lesions. The initial response of the primary site and the method of radiotherapy simulation were significant prognostic factors associated with the nodal recurrence rate. CONCLUSION: The recurrence rate of cervical nodes in patients with CR to radiotherapy in the primary site and neck area was about 5%. These patients could be followed up with close observation without a planned neck dissection.

Evaluation of the Treatment Response after Hypofractionated Radiotherapy in Patients with Advanced Head and Neck Cancers / 대한방사선종양학회지

PURPOSE: This study was performed to objectively evaluate the rate of tumor response to hypofractionated radiotherapy for advanced squamous cell carcinomas of the head and neck. MATERIALS AND METHODS: Thirty-one patients with advanced squamous cell carcinoma of the head and neck, who were treated by hypofractionated radiotherapy with 3 Gy per fraction for palliative purpose between 1998 and 2008, were reviewed retrospectively. Every tumor-volume was measured and evaluated from CT (computed tomography) images obtained before and 2~3 months after radiotherapy. The radiation toxicity was assessed during and after radiotherapy. A statistical analysis was performed to investigate overall survival, progression-free survival, and the prognostic factors for survival and response. RESULTS: The median age of the study patients was 70 years. In addition, 85% of the patients were in stage 4 cancer and 66.7% had an ECOG performance status of 1~2. The mean tumor-volume was 128.4 cc. Radiotherapy was administered with a total dose of 24~45 Gy (median: 36 Gy) over 10~25 days. Twenty-nine patients were treated with 30 Gy or more. The observed complete response rate was 12.9% and the partial response rate was 61.3%. Median survival time was 8.9 months and the 1-year progression-free survival rate was 12.9%. The treatment response rate was confirmed as a prognostic factor in the rate of survival. The primary site, stage, tumor-volume, radiotherapy field and overall radiation-dose showed a significant relationship with survival and treatment response. No grade 4 toxicity was observed during and after radiotherapy. CONCLUSION: There was an objective tumor-regression in about 74% of patients treated by hypofractionated radiotherapy. Further evaluation is needed to select the appropriate fraction-size and patient who may require the additional radiotherapy.

Evaluation and Comparison of Myocardial Perfusion Defects in Patients with Early Breast Cancer Subjected to Different Radiation Simulation Techniques / 대한방사선종양학회지

PURPOSE: The aim of this study is to evaluate and compare the incidence and aspects of myocardial perfusion defects in patients who were subjected to either two-dimensional or three-dimensional simulation techniques for early left-sided breast cancer. The myocardial perfusion defects were determined from using single photon emitted computerized tomography (SPECT) myocardial perfusion images. MATERIALS AND METHODS: Between January 2002 and August 2003, 32 patients were enrolled in this study. The patients were diagnosed as having early (AJCC stage T1-T2N0M0) left-sided breast cancer and were treated with tangential irradiation after breast-conserving surgery and systemic chemotherapy. The patients were divided into two groups according to the type of simulation received: two-dimensional simulation using an X-ray fluoroscope simulator or three-dimensional simulation with a CT simulator. All patients underwent technetium- 99m-sestamibi gated perfusion SPECT at least 3 years after radiotherapy. The incidence and area of myocardial perfusion defects were evaluated and were compared in the two groups, and at the same time left ventricular ejection fraction and cardiac wall motion were also analyzed. The cardiac volume included in the radiation fields was calculated and evaluated to check for a correlation between the amount of irradiated cardiac volume and aspects of myocardial perfusion defects. RESULTS: A myocardial perfusion defect was detected in 11 of 32 patients (34.4%). There were 7 (46.7%) perfusion defect cases in 15 patients who underwent the two-dimensional simulation technique and 4 (23.5%) patients with perfusion defects in the three-dimensional simulation group (p=0.0312). In 10 of 11 patients who had myocardial perfusion changes, the perfusion defects were observed in the cardiac apex. The left ventricular ejection fraction was within the normal range and cardiac wall motion was normal in all patients. The irradiated cardiac volume of patients in the three-dimensional simulation group was less than that of patients who received the two-dimensional simulation technique, but there was no statistical significance as compared to the incidence of perfusion defects. CONCLUSION: Radiotherapy with a CT simulator (three-dimensional simulation technique) for early left-sided breast cancer may reduce the size of the irradiated cardiac volume and the incidence of myocardial perfusion defects. Further investigation and a longer follow-up duration are needed to analyze the relationship between myocardial perfusion defects and clinical ischemic heart disease.

Prognostic Factors Influencing the Result of Postoperative Radiotherapy in Endometrial Carcinoma / 대한방사선종양학회지

PURPOSE: This study was performed to determine the prognostic factors influencing relapse pattern, overall and disease-free survival in patients treated with postoperative radiotherapy for endometrial carcinoma. MATERIALS AND METHODS: The records of 54 patients with endometrial adenocarcinoma treated postoperative radiotherapy at Pusan National University Hospital between April 1992 and May 2003 were reviewed retrospectively. Median age of the patients was 55 (range 35~76). The distribution by surgical FIGO stages were 63.0% for 0Stage I, 14.8% for Stage II, 22.2% for Stage III. All patients received postoperative external radiotherapy up to 41.4~54 Gy (median: 50.4 Gy). Additional intravaginal brachytherapy was applied to 20 patients (37.0% of all). Median follow-up time was 35 months (5~115 months). Significant factors of this study: histologic grade, lymphovascular space invasion and myometrial invasion depth were scored (GLM score) and analyzed. Survival analysis was performed using Kaplan-Meier method. The log-rank test was used for univariate analysis and the Cox regression model for multivariate analysis. RESULTS: 5-year overall and disease-free survival rates were 87.7% and 87.1%, respectively. Prognostic factors related with overall and disease-free survival were histologic grade, lymphovascular space invasion and myometrial invasion according to the univariate analysis. According to the multivariate analysis, lymphovascular space invasion was associated with decreased disease-free survival. GLM score was a meaningful factor affecting overall and disease-free survival (p=0.0090, p=0.0073, respectively) and distant recurrence (p=0.0132), which was the sum of points of histologic grade, lymphovascular space invasion and myometrial invasion. Total failure rate was 11% with 6 patients. Relapse sites were 2 para-aortic lymph nodes, 2 lungs, a supraclavicular lymph node and a vagina. CONCLUSION: The prognosis in patients with endometrial carcinoma treated by postoperative radiotherapy was closely related with surgical histopathology. If further explorations confirm the system of prognostic factors in endometrial carcinoma, it will help us to predict the progression pattern and to manage.

The Role of Postoperative Radiotherapy for Ameloblastic Carcinoma of the Mandible: Case Report / 대한방사선종양학회지

An ameloblastic carcinoma is a very rare odontogenic malignant tumor, which sometimes have a benign clinical nature, but typically have aggressive features, with large ulcerative lesion and extensive local destruction. These clinical characteristics make the complete surgical removal of a tumor difficult. As a consequence, a poor prognosis may result due to local recurrence and distant metastasis. For this reason, it is important to consider adjuvant therapies for high-risk ameloblastic carcinoma patients. Here, the case of a recurrent ameloblastic carcinoma that occurred in the mandible after primary surgery is reported. The lesion was treated with further local excision, followed by postoperative radiotherapy. Also, a few remarks on the role of postoperative radiotherapy in patient with ameloblastic carcinoma have been made from a review of the current literatures on the treatment of this type of lesion.

The Role of Postoperative Radiotherapy for Ameloblastic Carcinoma of the Mandible: Case Report / 대한방사선종양학회지

An ameloblastic carcinoma is a very rare odontogenic malignant tumor, which sometimes have a benign clinical nature, but typically have aggressive features, with large ulcerative lesion and extensive local destruction. These clinical characteristics make the complete surgical removal of a tumor difficult. As a consequence, a poor prognosis may result due to local recurrence and distant metastasis. For this reason, it is important to consider adjuvant therapies for high-risk ameloblastic carcinoma patients. Here, the case of a recurrent ameloblastic carcinoma that occurred in the mandible after primary surgery is reported. The lesion was treated with further local excision, followed by postoperative radiotherapy. Also, a few remarks on the role of postoperative radiotherapy in patient with ameloblastic carcinoma have been made from a review of the current literatures on the treatment of this type of lesion.

Evaluation of Indoor Air Quality in a Department of Radiation Oncology Located Underground / 대한방사선종양학회지

PURPOSE: Indoor air quality (IAQ) in the radiation treatment center which is generally located underground is important to the health of hospital workers and patients treated over a long period of time. This study was conducted to measure and analyze the factors related to IAQ and subjective symptoms of sick building syndrome, and to establish the causes influencing IAQ and find a solution to the problems. METHODS AND MATERIALS: Self administrated questionnaire was conducted to check the workers' symptoms and understanding of the work environment. Based on a preliminary investigation, the factors related to IAQ such as temperature, humidity, fine particulate. carbon dioxide, carbon monoxide, formaldehyde, total volatile organic compounds (TVOC), and radon gas were selected and measured for a certain period of time in specific sites where hospital workers stay long in a day. And we also evaluated the surrounding environment and the efficiency of the ventilating system simultaneously, and measured the same factors at the first floor (outdoor) to compare with outdoor air quality. All collected data were assessed by the recommended standard for IAQ of the domestic and international environmental organizations. RESULTS: Hospital workers were discontented with foul odors, humidity and particulate. They complained symptoms related to musculo-skeletal system, neurologic system, and mucosal-irritatation. Most of the factors were not greater than the recommended standard, but the level of TVOC was third or fourth times as much as the measuring level of some offices in the United States. The frequency and the amount of the ventilating system were adequate, however, the problem arising in the position of outdoor-air inlets and indoor-air outlets involved a risk of the indraft of contaminated air. A careful attention was a requirement in handling and keeping chemical substances including a developing solution which has a risk of TVOC emissions, and repositioning the ventilating system was needed to solve the contaminated-air circulation immediately. CONCLUSION: We verified that some IAQ-related factors and inadequate ventilating system could cause subjective symptoms in hospital workers. The evaluation of IAQ was surely needed to improve the underground working environments for hospital workers and patients. On the basis of these data, from now on, we should actively engage in designs of the department of radiation oncology or improvement in environments of the existing facilities.

The Results of Postoperative Radiotherapy for Hypopharyngeal Carcinoma / 대한방사선종양학회지

PURPOSE: This study was carried out to confirm clinical values and limitations of postoperative radiotherapy for hypopharyngeal carcinoma, to evaluate various prognostic factors which may affect to the treatment results and to use these results as fundamental data for making a new treatment strategy. METHODS AND MATERIALS: A retrospective analysis was performed on 64 previously untreated patients with squamous cell carcinoma of the hypopharynx, seen between 1988 and 1999 at Pusan National University Hospital. Most of patients were treated by laryngopharyngectomy and neck dissection followed by conventional fractionated postoperative radiotherapy on surgical bed and cervical nodal areas. RESULTS: The five-year overall survival rate and cause-specific survival rate were 42.2 percent and 51.6 percent, respectively. Univariate analysis of various clinical and pathologic factors confirmed the overall stage, TN-stage, secondary primary cancers, surgical positive margin, nodal extracapsular extension, total radiation doses as significant prognostic factors of hypopharyngeal carcinomas. But in multivariate analysis, TN-stage, surgical positive margin and extracapsular extesion were only statistically significant. CONCLUSION: In resectable cases of hypopharyngeal carcinoma, combined surgery and postoperative radiotherapy obtained good treatement results, even though sacrificing the function of larynx and pharynx. But in advanced and unresectable cases, with respect to survivals and quality of life issues, we were able to confirm some limitations of combined therapy. So we recommend that comparative studies of recent various chemo-radiotherapy methods and advanced radiotherapy techniques with these data should be needed.