Post-mastectomy radiation therapy in breast reconstruction: a patterns of care study of the Korean Radiation Oncology Group

Purpose@#The details of breast reconstruction and radiation therapy (RT) vary between institutions; therefore, we sought to investigate the practice patterns of radiation oncologists who specialize in breast cancer. @*Materials and Methods@#We identified the practice patterns and inter-hospital variations from a multi-center cohort of women with breast cancer who underwent post-mastectomy RT (PMRT) to the reconstructed breast at 16 institutions between 2015 and 2016. The institutions were requested to contour the target volume and produce RT plans for one representative case with five different clinical scenarios and answer questionnaires which elicited infrastructural information. We assessed the inter-institutional variations in RT in terms of the target, normal organ delineation, and dose-volume histograms. @*Results@#Three hundred fourteen patients were included; 99% of them underwent immediate reconstruction. The most irradiated material was tissue expander (36.9%) followed by transverse rectus abdominis musculocutaneous flap (23.9%) and silicone implant (12.1%). In prosthetic-based reconstruction with tissue expander, most patients received PMRT following partial deflation. Conventional fractionation and hypofractionation RT were used in 66.6% and 33.4% patients, respectively (commonest: 40.05 Gy in 15 fractions [17.5%]). Furthermore, 15.6% of the patients received boost RT and 53.5% were treated with bolus. Overall, 15 physicians responded to the questionnaires and six submitted their contours and RT plans. There was a significant variability in target delineations and RT plans between physicians, and between clinical scenarios. @*Conclusion@#Adjuvant RT following post-mastectomy reconstruction has become a common practice in Korea. The details vary significantly between institutions, which highlights an urgent need for standard protocol in this clinical setting.

Post-mastectomy radiation therapy in breast reconstruction: a patterns of care study of the Korean Radiation Oncology Group

Purpose@#The details of breast reconstruction and radiation therapy (RT) vary between institutions; therefore, we sought to investigate the practice patterns of radiation oncologists who specialize in breast cancer. @*Materials and Methods@#We identified the practice patterns and inter-hospital variations from a multi-center cohort of women with breast cancer who underwent post-mastectomy RT (PMRT) to the reconstructed breast at 16 institutions between 2015 and 2016. The institutions were requested to contour the target volume and produce RT plans for one representative case with five different clinical scenarios and answer questionnaires which elicited infrastructural information. We assessed the inter-institutional variations in RT in terms of the target, normal organ delineation, and dose-volume histograms. @*Results@#Three hundred fourteen patients were included; 99% of them underwent immediate reconstruction. The most irradiated material was tissue expander (36.9%) followed by transverse rectus abdominis musculocutaneous flap (23.9%) and silicone implant (12.1%). In prosthetic-based reconstruction with tissue expander, most patients received PMRT following partial deflation. Conventional fractionation and hypofractionation RT were used in 66.6% and 33.4% patients, respectively (commonest: 40.05 Gy in 15 fractions [17.5%]). Furthermore, 15.6% of the patients received boost RT and 53.5% were treated with bolus. Overall, 15 physicians responded to the questionnaires and six submitted their contours and RT plans. There was a significant variability in target delineations and RT plans between physicians, and between clinical scenarios. @*Conclusion@#Adjuvant RT following post-mastectomy reconstruction has become a common practice in Korea. The details vary significantly between institutions, which highlights an urgent need for standard protocol in this clinical setting.

Intraoperative Frozen Cytology of Central Nervous System Neoplasms: An Ancillary Tool for Frozen Diagnosis

BACKGROUND: Pathologic diagnosis of central nervous system (CNS) neoplasms is made by comparing light microscopic, immunohistochemical, and molecular cytogenetic findings with clinicoradiologic observations. Intraoperative frozen cytology smears can improve the diagnostic accuracy for CNS neoplasms. Here, we evaluate the diagnostic value of cytology in frozen diagnoses of CNS neoplasms. METHODS: Cases were selected from patients undergoing both frozen cytology and frozen sections. Diagnostic accuracy was evaluated. RESULTS: Four hundred and fifty-four cases were included in this retrospective single-center review study covering a span of 10 years. Five discrepant cases (1.1%) were found after excluding 53 deferred cases (31 cases of tentative diagnosis, 22 cases of inadequate frozen sampling). A total of 346 cases of complete concordance and 50 cases of partial concordance were classified as not discordant cases in the present study. Diagnostic accuracy of intraoperative frozen diagnosis was 87.2%, and the accuracy was 98.8% after excluding deferred cases. Discrepancies between frozen and permanent diagnoses (n = 5, 1.1%) were found in cases of nonrepresentative sampling (n = 2) and misinterpretation (n = 3). High concordance was observed more frequently in meningeal tumors (97/98, 99%), metastatic brain tumors (51/52, 98.1%), pituitary adenomas (86/89, 96.6%), schwannomas (45/47, 95.8%), high-grade astrocytic tumors (47/58, 81%), low grade astrocytic tumors (10/13, 76.9%), non-neoplastic lesions (23/36, 63.9%), in decreasing frequency. CONCLUSIONS: Using intraoperative cytology and frozen sections of CNS tumors is a highly accurate diagnostic ancillary method, providing subtyping of CNS neoplasms, especially in frequently encountered entities.

Dummy Run of Quality Assurance Program before Prospective Study of Hippocampus-Sparing Whole-Brain Radiotherapy and Simultaneous Integrated Boost for Multiple Brain Metastases from Non-small Cell Lung Cancer: Korean Radiation Oncology Group (KROG) 17-06 Study / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Lung Cancer Subcommittee of Korean Radiation Oncology Group (KROG) has recently launched a prospective clinical trial (KROG 17-06) of hippocampus-sparing whole brain radiotherapy (HS-WBRT) with simultaneous integrated boost (SIB) in treating multiple brain metastases from non-small cell lung cancer. In order to improve trial quality, dummy run studies among the participating institutions were designed. This work reported the results of two-step dummy run procedures of the KROG 17-06 study. MATERIALS AND METHODS: Two steps tested hippocampus contouring variability and radiation therapy planning compliance. In the first step, the variation of the hippocampus delineation was investigated for two representative cases using the Dice similarity coefficients. In the second step, the participating institutions were requested to generate a HS-WBRT with SIB treatment plan for another representative case. The compliance of the treatment plans to the planning protocol was evaluated. RESULTS: In the first step, the median Dice similarity coefficients of the hippocampus contours for two other dummy run cases changed from 0.669 (range, 0.073 to 0.712) to 0.690 (range, 0.522 to 0.750) and from 0.291 (range, 0.219 to 0.522) to 0.412 (range, 0.264 to 0.598) after providing the hippocampus contouring feedback. In the second step, with providing additional plan priority and extended dose constraints to the target volumes and normal structures, we observed the improved compliance of the treatment plans to the planning protocol. CONCLUSION: The dummy run studies demonstrated the notable inter-institutional variability in delineating the hippocampus and treatment plan generation, which could be decreased through feedback from the trial center.

Rare Case of Anal Canal Signet Ring Cell Carcinoma Associated with Perianal and Vulvar Pagetoid Spread

A 61-year-old woman was referred to surgery for incidentally found colonic polyps during a health examination. Physical examination revealed widespread eczematous skin lesion without pruritus in the perianal and vulvar area. Abdominopelvic computed tomography showed an approximately 4-cm-sized, soft tissue lesion in the right perianal area. Inguinal lymph node dissection and Mils' operation extended to perianal and perivulvar skin was performed. Histologically, the anal canal lesion was composed of mucin-containing signet ring cells, which were similar to those found in Pagetoid skin lesions. It was diagnosed as an anal canal signet ring cell carcinoma (SRCC) with perianal and vulvar Pagetoid spread and bilateral inguinal lymph node metastasis. Anal canal SRCC is rare, and the current case is the third reported case in the English literature. Seven additional cases were retrieved from the world literature. Here, we describe this rare case of anal canal SRCC with perianal Pagetoid spread and provide a literature review.

Radiation Pneumonitis in Association with Internal Mammary Node Irradiation in Breast Cancer Patients: An Ancillary Result from the KROG 08-06 Study / 한국유방암학회지

PURPOSE: The aim of this study is to present the incidence of radiation pneumonitis (RP) reported within 6 months after treatment for breast cancer with or without internal mammary node irradiation (IMNI). METHODS: In the Korean Radiation Oncology Group (KROG) 08-06 phase III randomized trial, patients who were node-positive after surgery were randomly assigned to receive radiotherapy either with or without IMNI. A total of 747 patients were enrolled, and three-dimensional treatment planning with computed tomography simulation was performed for all patients. Of the 747 patients, 722 underwent chest X-rays before and within 6 months after radiotherapy. These 722 patients underwent evaluation, and RP was diagnosed on the basis of chest radiography findings and clinical symptoms. The relationship between the incidence of RP and clinical/dosimetric parameters was analyzed. RESULTS: RP developed in 35 patients (4.8%), including grade 1 RP in 26 patients (3.6%), grade 2 RP in nine patients (1.2%); there was no incidence of grade 3 or higher RP. Grade 2 RP cases were observed in only the IMNI group. The risk of developing RP was influenced by IMNI treatment; pneumonitis occurred in 6.5% of patients (n=23/356) who underwent IMNI and in 3.3% of patients (n=12/366) who did not (p=0.047). The differences in lung dosimetric parameters (mean lung dose, V10–40) were statistically significant between the two groups. CONCLUSION: IMNI treatment resulted in increased radiation exposure to the lung and a higher rate of RP, but the incidence and severity of RP was minimal and acceptable. This minor impact on morbidity should be balanced with the impact on survival outcome in future analyses.

A Survey of Stereotactic Body Radiotherapy in Korea / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study is to investigate the current status of stereotactic body radiotherapy (SBRT) in Korea. A nationwide survey was conducted by the Korean Stereotactic Radiosurgery Group of the Korean Society for Radiation Oncology (KROG 13-13). MATERIALS AND METHODS: SBRT was defined as radiotherapy with delivery of a high dose of radiation to an extracranial lesion in < or = 4 fractions. A 16-questionnaire survey was sent by e-mail to the chief of radiation oncology at 85 institutions in June 2013. RESULTS: All institutions (100%) responded to this survey. Of these, 38 institutions (45%) have used SBRT and 47 institutions (55%) have not used SBRT. Regarding the treatment site, the lung (92%) and liver (76%) were the two most common sites. The most common schedules were 60 Gy/4 fractions for non-small cell lung cancer, 48 Gy/4 fractions for lung metastases, 60 Gy/3 fractions for hepatocellular carcinoma, and 45 Gy/3 fractions or 40 Gy/4 fractions for liver metastases. Four-dimensional computed tomography (CT) was the most common method for planning CT (74%). During planning CT, the most common method of immobilization was the use of an alpha cradle/vacuum-lock (42%). CONCLUSION: Based on this survey, conduct of further prospective studies will be needed in order to determine the appropriate prescribed doses and to standardize the practice of SBRT.

Cardiac dose reduction with breathing adapted radiotherapy using self respiration monitoring system for left-sided breast cancer

PURPOSE: To quantify the cardiac dose reduction during breathing adapted radiotherapy using Real-time Position Management (RPM) system in the treatment of left-sided breast cancer. MATERIALS AND METHODS: Twenty-two patients with left-sided breast cancer underwent CT scans during breathing maneuvers including free breathing (FB), deep inspiration breath-hold (DIBH), and end inspiration breath-hold (EIBH). The RPM system was used to monitor respiratory motion, and the in-house self respiration monitoring (SRM) system was used for visual feedback. For each scan, treatment plans were generated and dosimetric parameters from DIBH and EIBH plans were compared to those of FB plans. RESULTS: All patients completed CT scans with different breathing maneuvers. When compared with FB plans, DIBH plans demonstrated significant reductions in irradiated heart volume and the heart V25, with the relative reduction of 71% and 70%, respectively (p < 0.001). EIBH plans also resulted in significantly smaller irradiated heart volume and lower heart V25 than FB plans, with the relative reduction of 39% and 37%, respectively (p = 0.002). Despite of significant expansion of lung volume using inspiration breath-hold, there were no significant differences in left lung V25 among the three plans. CONCLUSION: In comparison with FB, both DIBH and EIBH plans demonstrated a significant reduction of radiation dose to the heart. In the training course, SRM system was useful and effective in terms of positional reproducibility and patient compliance.

Establishment of linear accelerator-based image guided radiotherapy for orthotopic 4T1 mouse mammary tumor model / 한국실험동물학회지

This study was conducted to assess the feasibility of image guided radiotherapy (IGRT) for orthotopic 4T1 mouse mammary tumor using linear accelerator (LINAC). Eighteen Balb/C mice were inoculated with 4T1 cells on left mammary fat pad and nine of them were irradiated using LINAC. Tumors, planning target volumes (PTV), bowels adjacent to tumors, bones and lungs were delineated on planning CT images. IGRT plans were generated to irradiate prescription dose to at least 90% of the PTV and then compared with conventional 2-dimensional plans with anterior-posterior and posterior-anterior beams with 5 mm margins (2D AP/PA plan). Homemade dose-build-up-cradle was designed to encompass mouse bed for homogeneous dose build up. To confirm the irradiated dose, tumor doses were measured using diode detector placed on the surface of tumors. Plan comparison demonstrated equivalent doses to PTV while sparing more doses to normal tissues including bowel (from 90.9% to 40.5%, median value of mean doses) and bone marrow (from 12.9% to 4.7%, median value of mean doses) than 2D AP/PA plan. Quality assurance using diode detector confirmed that IGRT could deliver 95.3-105.3% of the planned doses to PTV. Tumors grew 505.2-1185.8% (mean 873.3%) in the control group and 436.1-771.8% (mean 615.5%) in the irradiated group. These results demonstrate that LINAC-based IGRT provides a reliable approach with accurate dose delivery in the radiobiological study for orthotropic tumor model maintaining tumor microenvironment.

Clinical application of RapidArc volumetric modulated arc therapy as a component in whole brain radiation therapy for poor prognostic, four or more multiple brain metastases

PURPOSE: To determine feasibility of RapidArc in sequential or simultaneous integrated tumor boost in whole brain radiation therapy (WBRT) for poor prognostic patients with four or more brain metastases. MATERIALS AND METHODS: Nine patients with multiple (> or =4) brain metastases were analyzed. Three patients were classified as class II in recursive partitioning analysis and 6 were class III. The class III patients presented with hemiparesis, cognitive deficit, or apraxia. The ratio of tumor to whole brain volume was 0.8-7.9%. Six patients received 2-dimensional bilateral WBRT, (30 Gy/10-12 fractions), followed by sequential RapidArc tumor boost (15-30 Gy/4-10 fractions). Three patients received RapidArc WBRT with simultaneous integrated boost to tumors (48-50 Gy) in 10-20 fractions. RESULTS: The median biologically effective dose to metastatic tumors was 68.1 Gy10 and 67.2 Gy10 and the median brain volume irradiated more than 100 Gy3 were 1.9% (24 cm3) and 0.8% (13 cm3) for each group. With less than 3 minutes of treatment time, RapidArc was easily applied to the patients with poor performance status. The follow-up period was 0.3-16.5 months. Tumor responses among the 6 patients who underwent follow-up magnetic resonance imaging were partial and stable in 3 and 3, respectively. Overall survival at 6 and 12 months were 66.7% and 41.7%, respectively. The local progression-free survival at 6 and 12 months were 100% and 62.5%, respectively. CONCLUSION: RapidArc as a component in whole brain radiation therapy for poor prognostic, multiple brain metastases is an effective and safe modality with easy application.

Radiation therapy with chemotherapy for patients with cervical cancer and supraclavicular lymph node involvement / 부인종양

OBJECTIVE: We wanted to evaluate the outcomes of cervical cancer patients with supraclavicular lymph node (SCLN) involvement and who received radiation therapy (RT) combined with chemotherapy. METHODS: From August 2001 to April 2009, nine cervical cancer patients with SCLN involvement were treated by RT and cisplatin-based chemotherapy. Most of the patients (8/9, 88.9%) also had a positive para-aortic lymph node (PALN). The RT field was designed to include the whole pelvis, the involved PALNs and the SCLN area. The median SCLN RT dose was 66.6 Gy (range, 60 to 70 Gy). RESULTS: The median follow-up period was 61 months (range, 13 to 98 months). The 3- and 5-year overall survival rates were 66.7% and 55.6%, respectively and the 3- and 5-year progression-free survival rates were 66.7% and 44.4%, respectively. The acute hematologic toxicities according to the criteria of Radiation Therapy of Oncology Group (RTOG) were G1/2 leucopenia in 3 (33.3%), G3/4 leukopenia in 6 (66.7%), G1/2 anemia in 7 (77.8%), G3 anemia in 1 (11.1%), G2 thrombocytopenia in 2 (22.2%), and G3/4 thrombocytopenia in 2 (22.2%). Within 6 months after RT, most of the patients (5/6, 83.3%) recovered from the G3/4 leukopenia, except for 1 patient who received chemotherapy after completing RT due to subsequent bone metastasis. CONCLUSION: For patients with advanced cervix cancer and SCLN involvement, RT with chemotherapy as active therapy can be expected to provide favorable results, although there is an increased risk of G3/4 hematologic toxicity.

Irinotecan and Cisplatin Combination Chemotherapy Plus Concurrent Thoracic Irradiation for Patients with Limited Disease Small Cell Lung Cancer

PURPOSE: To evaluate the antitumor activity and safety of irinotecan plus cisplatin combination chemotherapy with concurrent thoracic radiotherapy (TRT) in patients with limited disease (LD) small cell lung cancer (SCLC). MATERIALS AND METHODS: Patients with pathologically-confirmed LD SCLC with the following inclusion criteria were retrospectively analyzed: age > or =18 years; measurable lesion; Eastern Cooperative Oncology Group Performance Status 0~2; chemotherapy naive; and adequate bone marrow and organ function. Patients received an intravenous (IV) infusion of irinotecan (35 mg/m2 on days 1, 8, and 15) and cisplatin (60 mg/m2 on day 1), which was repeated every 4 weeks for up to 6 cycles. Concurrent TRT was administered with the beginning of chemotherapy. Irinotecan was increased to 60 mg/m2 after completion of TRT. Patients with a complete response (CR) subsequently received prophylactic cranial irradiation. RESULTS: Nineteen patients were analyzed. There were 8 patients (42.1%) with CR, 9 patients (47.4%) with partial response, and 1 patient each (5.3%) with stable disease and progressive disease (PD). The overall response rate was 89.5%. The median progression-free survival was 7.6 months (95% confidence interval [CI], 1.3~14.0 months) and the median overall survival was 12.4 months (95% CI, 0.5~24.2 months). The 2-year survival rate of the CR patients was 75.0%. No grade 4 hematologic toxicity was reported. Frequently reported toxicities were nausea (10 patients), radiation-induced pneumonitis (10 patients), and neutropenia (6 patients). Radiation-related severe toxicities were frequently reported. Three patients had treatment-related deaths. CONCLUSION: This study supports the activity and tolerability of irinotecan plus cisplatin with concurrent TRT in patients with LD SCLC.

Additional rituximab-CHOP (R-CHOP) versus involved-field radiotherapy after a brief course of R-CHOP in limited, non-bulky diffuse large B-cell lymphoma: a retrospective analysis / 대한혈액학회지

BACKGROUND: Standard treatment for stage I or non-bulky stage II diffuse large B-cell lymphoma (DLBCL) has been either a brief course of chemotherapy plus involved-field radiotherapy (IFRT) or prolonged cycles of chemotherapy. The introduction of rituximab has necessitated re-evaluation of the treatment for limited disease (LD) DLBCL. METHODS: Thirty-nine LD DLBCL patients (median age, 52 years; range, 24-85) treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) were retrospectively analyzed. Treatment outcomes were evaluated, and toxicity, event-free survival (EFS), and overall survival (OS) were compared according to the treatment and risk factors. RESULTS: The median follow-up duration was 34.6 months (range, 9.1-65.4). The 3-year EFS and OS were 76.0% and 86.0%, respectively. Among the 36 patients who underwent either 3-4 cycles of R-CHOP followed by IFRT (N=22) or 6-8 cycles of R-CHOP (N=14), there was no difference in the 3-year EFS (79.4% vs. 71.6%, P=0.638) and 3-year OS (85.7% vs. 92.9%, P=0.732). Severe neutropenia and neutropenic fever were more frequent in patients treated with R-CHOP alone, with 1 treatment-related mortality. Among the IFRT patients, 1 required hospital admission for IFRT-related complications. No events or deaths were reported among patients without adverse risk factors. CONCLUSION: The difference in outcomes between the 2 treatment options was not significant. Analysis of treatment outcomes suggested that baseline characteristics and expected toxicities should be considered in LD DLBCL treatment. Further studies are needed to define the optimal treatment in the rituximab era.

Analysis of the Radiation Therapy Outcomes and Prognostic Factors of Thymoma / 대한방사선종양학회지

PURPOSE: This retrospective study was performed to evaluate the efficacy of radiation therapy (RT) and to investigate the prognostic factors for thymoma when treated with RT. MATERIALS AND METHODS: We analyzed 21 patients with thymoma and also received RT from March 2002 to January 2008. The median follow-up time was 37 months (range, 3 to 89 months). The median patient age was 57 years (range, 24 to 77 years) and the gender ratio of males to females was 4:3. Of the 21 patients, complete resections (trans-sternal thymectomy) and R2 resections were performed in 14 and 1 patient, respectively. A biopsy was performed in 6 patients (28.7%). The WHO cell types in the 21 patients were as follows: 1 patient (4.8%) had type A, 10 patients (47.6%) had type B1-3, and 10 patients (47.6%) had type C. Based on Masaoka staging, 10 patients (47.6%) were stage II, 7 patients (33.3%) were stage III, and 4 patients (19.1%) were stage IVa. Three-dimensional RT was adminstered to the tumor volume (planned target volume), including the anterior mediastinum and the residual disease. The total RT dose ranged from 52.0 to 70.2 Gy (median dose, 54 Gy). Consistent with the WHO criteria, the response rate was only analyzed for the 6 patients who received a biopsy only. The prognostic factors analyzed for an estimate of survival included age, gender, tumor size, tumor pathology, Masaoka stage, the possibility of treatment by performing surgery, the presence of myasthenia gravis, and RT dose. RESULTS: The 3-year overall survival rate (OS) and the progression free survival rate (PFS) were 80.7% and 78.2%, respectively. Among the 10 patients with WHO cell type C, 3 of 4 patients (75%) who underwent a complete resection and 3 of 6 patients (50%) who underwent a biopsy survived. Distant metastasis developed in 4 patients (19.1%). The overall response rate in the 6 patients who received biopsy only were as follows: partial remission in 4 patients (66.7%), stable disease in 1 patient (16.6%), and progressive disease in 1 patient (16.6%). Acute RTOG radiation pneumonitis occurred in 1 patient (4.8%), grade 2 occurred in 2 patients (9.5%), grade 3 occurred in 1 patient (4.8%), and grade 4 occurred in 1 patient (4.8%). A univariate analysis revealed that the significant prognostic factors for OS were age (> or =60, 58.3%; <60, 100%; p=0.0194), pathology (WHO cell type A-B3, 100%; C, 58.3%; p=0.0194) and, whether the patient underwent surgery (yes, 93.3%; no, 50%; p=0.0096). CONCLUSION: For the 15 patients who received surgery, there was no local failure within the radiation field. In patients with WHO cell type C, surgical procedures could have resulted in a more favorable outcome than biopsy alone. We report here our clinical experience in 21 patients with thymoma who were treated by radiation therapy.

Analysis of Outcomes and Prognostic Factors Associated with Surgical Treatment Plus Postoperative Radiation Therapy for Stage II/III Pancreatic Cancer

PURPOSE: To evaluate treatment outcomes for patients with stage II/III pancreatic cancer who are treated with radiation therapy (RT) with or without chemotherapy (CTx) following surgery. METHODS: We retrospectively analyzed data from 17 patients who underwent surgery and post-operative RT with or without CTx between January 2000 and December 2008. Seven patients (41%) had stage II cancer and 10 (59%) had stage III cancer. Most were male (13 of 17; 76.5%). Age at diagnosis ranged from 42 to 82 (median 69) years. Whipple's operation was done in 9 patients (53%), distal pancreatectomy in 7 (41%), and subtotal pancreatectomy in 1 (6%). All patients received RT using a three-dimensional RT technique to spare critical normal structures. Median radiation dose was 54 Gy (range, 50.4~55.8 Gy). Variable CTx regimens were combined in 10 patients (58.8%); 5-FU in 4, UFTE-G in 4, gemcitabine in 1, and xeloda in 1. Acute toxicity was evaluated according to RTOG toxicity criteria. Survival analysis was done using the Kaplan-Meyer method. Univariate and multivariate prognostic factor analysis were done, respectively, using a log-rank test and Cox's proportional hazards model. RESULTS: The median follow-up period was 12.6 months. Locoregional and distant failures occurred in 8 (47.1%) and 8 patients (47.1%), respectively. Five patients (29.4%) developed both loco-regional recurrence and distant metastasis. The metastatic sites were liver in 4 patients, lung in 3, peritoneum in 1, and kidney in 1. Median overall survival (OS) was 12.6 months. The 1- and 2-year OS rates were, respectively, 58.8% and 24.5%. Median disease-free survival (DFS) was 8.3 months and the 1- and 2-year DFS rates were 46.3% and 30.9%, respectively. The 2-year OS was not different between RT and RT with CTx : survival rates were 28.6% and 17.5%, respectively (p=0.764). T stage and a postoperative CA 19-9 level of > or =180 U/ml were significant prognostic factors for OS in both univariate and multivariate analysis: the 2-year OS for T3 and T4 were 34.1% and 16.7%, respectively (p=0.0022), the 2-year OS for or =180 U/ml were 32.5% and 0%, respectively (p=0.0142) Acute toxicities were RTOG grade 1 (G1) nausea in 1 patient (5.9%), G1 vomiting in 2 (11.8%), and G1-2 enteritis in 5 (29.4%). The hematologic toxicities were G1 leukopenia in 5 patients (29.4%), G2 leukopenia 1 (5.9%), G1 thrombocytopenia in 1 (5.9%), and G1~2 anemia in 6 (35.3%). CONCLUSION: Survival results of the present study are comparable to those in other reports with acceptable toxicity. Significant prognostic factors for overall survival in pancreatic cancer are tumor stage and postoperative CA 19-9 level.

A Retrospective Study of the Radiotherapy Care Patterns for Patients with Laryngeal Cancer and Comparison of Different Korean Hospitals Treated from 1998 through 1999 / 대한방사선종양학회지

PURPOSE: To investigate the care patterns for radiation therapy and to determine inter-hospital differences for patients with laryngeal carcinoma in Korea. MATERIALS AND METHODS: A total of 237 cases of laryngeal carcinoma (glottis, 144; supraglottis, 93) assembled from 23 hospitals, who underwent irradiation in the year of 1998 and 1999, were retrospectively analyzed to investigate inter-hospital differences with respect to radiotherapy treatment. We grouped the 23 hospitals based on the number of new patients annually irradiated in 1998; and designated them as group A (> or =900 patients), group B (> or =400 patients and <900 patients), and group C (<400 patients). RESULTS: The median age of the 237 patients was 62 years (range, 25 to 88 years), of which 216 were male and 21 were female. The clinical stages were distributed as follows: for glottis cancer, I; 61.8%, II; 21.5%, III; 4.2%, IVa; 11.1%, IVb; 1.4%, and in supraglottic cancer, I; 4.3%, II; 19.4%, III; 28.0%, IVa; 43.0%, IVb; 5.4%, respectively. Some differences were observed among the 3 groups with respect to the dose calculation method, radiation energy, field arrangement, and use of an immobilization device. No significant difference among 3 hospital groups was observed with respect to treatment modality, irradiation volume, and median total dose delivered to the primary site. CONCLUSION: This study revealed that radiotherapy process and patterns of care are relatively uniform in laryngeal cancer patients in Korean hospitals, and we hope this nationwide data can be used as a basis for the standardization of radiotherapy for the treatment of laryngeal cancer.

Radiation Therapy and Chemotherapy after Breast Conserving Surgery for Invasive Breast Cancer: An Intermediate Result / 대한방사선종양학회지

PURPOSE: Breast conserving surgery (BCS) followed by chemotherapy (CTx.) and radiation therapy (RT) is widely performed for the treatment of early breast cancer. This retrospective study was undertaken to evaluate our interim results in terms of failure patterns, survival and relative risk factors. MATERIALS AND METHODS: From January 1999 through December 2003, 129 patients diagnosed with invasive breast cancer and treated with BCS followed by RT were subject to retrospective review. The median age of the patients was 45 years (age distribution, 27~76 years). The proportions of patients according to their tumor, nodes, and metastases (TNM) stage were 65 (50.4%) in stage I, 41 (31.7%) in stage IIa, 13 (10.1%) in stage IIb, 9 (7.0%) in stage III, and 1 patient (0.8%) in stage IIIc. For 32 patients (24.8%), axillary node metastasis was found after dissection. BCS consisted of quadrantectomy in 115 patients (89.1%) and lumpectomy in 14 patients (10.6%). Axillary node dissection at axillary level I and II was performed for 120 patients (93%). For 7 patients (5.4%), only sentinel node dissection was performed with BCS. For 2 patients (1.6%) axillary dissection of any type was not performed. Postoperative RT was given with 6 MV X-rays. A tumor dose of 50.4 Gy was delivered to the entire breast area using a tangential field with a wedge compensator. An aditional dose of 9~16 Gy was given to the primary tumor bed areas with electron beams. In 30 patients (23.3%), RT was delivered to the supraclavicular node. Most patients had adjuvant CTx. with 4~6 cycles of CMF (cyclophosphamide, methotrexate, 5-fluorouracil) regimens. The median follow-up period was 50 months (range: 17~93 months). RESULTS: The actuarial 5 year survival rate (5Y-OSR) was 96.9%, and the 5 year disease free survival rate (5Y-DFSR) was 93.7%. Local recurrences were noted in 2 patients (true: 2, regional node: 1) as the first sign of recurrence at a mean time of 29.3 months after surgery. Five patients developed distant metastases as the first sign of recurrence at 6~33 months (mean 21 months). Sites of distant metastatic sites were bone in 3 patients, liver in 1 patient and systemic lesions in 1 patient. Among the patients with distant metastatic sites, two patients died at 17 and 25 months during the follow-up period. According to stage, the 5Y-OSR was 95.5%, 100%, 84.6%, and 100% for stage I, IIa, IIb, and III respectively. The 5Y-DFSR was 96.8%, 92.7%, 76.9%, and 100% for stage I, IIa, IIb, and III respectively. Stage was the only risk factor for local recurrence based on univariate analysis. Ten stage III patients included in this analysis had a primary tumor size of less than 3 cm and had more than 4 axillary lymph node metastases. The 10 stage III patients received not only breast RT but also received posterior axillary boost RT to the supraclavicular node. During the median 53.3 months follow-up period, no any local or distant failure was found. Complications were asymptomatic radiation pneumonitis in 10 patients, symptomatic pneumonitis in 1 patient and lymphedema in 8 patients. CONCLUSION: Although our follow up period is short, we had excellent local control and survival results and reaffirmed that BCS followed by RT and CTx. appears to be an adequate treatment method. These results also provide evidence that distant failure occurrs earlier and more frequent as compared with local failure. Further studies and a longer follow-up period are needed to assess the effectiveness of BCS followed by RT for the patients with less than a 3 cm primary tumor and more than 4 axillary node metastases.

Concurrent chemoradiation therapy in cervical cancer with para-aortic lymph node involvement / 부인종양

OBJECTIVE: This study was undertaken to evaluate the therapeutic results and complications after concurrent chemoradiation therapy and to investigate the prognostic factors for cervical cancer with para-aortic lymph node involvement. METHODS: From May 1999 to August 2005, thirty eight patients with cervical cancer, treated by combined platinum base chemotherapy and extended field radiation therapy in Gachon University Gil medical center. All patients were diagnosed as paraaortic lymphnode involvement with imaging studies. The radiation dose of external beam was 34.2-64.4 Gy to whole pelvis and 32.4-59.4 Gy to paraaortic area. Cisplatin based chemotherapy was done simultaneously. We evaluated the prognostic factors such as stage, tumor size, inguinal and supraclavicular lymphnode status, and radiation doses. RESULTS: Median follow-up period is 34 months (7-85 months). The 3 year overall and disease free survival rates were 63.6% and 56.4%, respectively. There was no case of recurrence after 3 years of treatment. In 2 patients, the treatment was not completed because of Grade III or IV gastroenteral complications; abdominal pain and diarrhea. Grade III or IV hematologic complications were occurred in fifteen patients, but all patients were recovered without serious complications. We could not find any significant prognostic factors in this study. CONCLUSION: Concurrent chemoradiation therapy for cervical cancer with paraaortic lymph node involvement is well tolerable and effective treatment.

Preliminary Report of the 1998~1999 Patterns of Care Study of Radiation Therapy for Esophageal Cancer in Korea / 대한방사선종양학회지

PURPOSE: For the first time, a nationwide survey in the Republic of Korea was conducted to determine the basic parameters for the treatment of esophageal cancer and to offer a solid cooperative system for the Korean Pattern of Care Study database. MATERIALS AND METHODS: During 1998~1999, biopsy-confirmed 246 esophageal cancer patients that received radiotherapy were enrolled from 23 different institutions in South Korea. Random sampling was based on power allocation method. Patient parameters and specific information regarding tumor characteristics and treatment methods were collected and registered through the web based PCS system. The data was analyzed by the use of the Chi-squared test. RESULTS: The median age of the collected patients was 62 years. The male to female ratio was about 91 to 9 with an absolute male predominance. The performance status ranged from ECOG 0 to 1 in 82.5% of the patients. Diagnostic procedures included an esophagogram (228 patients, 92.7%), endoscopy (226 patients, 91.9%), and a chest CT scan (238 patients, 96.7%). Squamous cell carcinoma was diagnosed in 96.3% of the patients; mid-thoracic esophageal cancer was most prevalent (110 patients, 44.7%) and 135 patients presented with clinical stage III disease. Fifty seven patients received radiotherapy alone and 37 patients received surgery with adjuvant postoperative radiotherapy. Half of the patients (123 patients) received chemotherapy together with RT and 70 patients (56.9%) received it as concurrent chemoradiotherapy. The most frequently used chemotherapeutic agent was a combination of cisplatin and 5-FU. Most patients received radiotherapy either with 6 MV (116 patients, 47.2%) or with 10 MV photons (87 patients, 35.4%). Radiotherapy was delivered through a conventional AP-PA field for 206 patients (83.7%) without using a CT plan and the median delivered dose was 3,600 cGy. The median total dose of postoperative radiotherapy was 5,040 cGy while for the non-operative patients the median total dose was 5,970 cGy. Thirty-four patients received intraluminal brachytherapy with high dose rate Iridium-192. Brachytherapy was delivered with a median dose of 300 cGy in each fraction and was typically delivered 3~4 times. The most frequently encountered complication during the radiotherapy treatment was esophagitis in 155 patients (63.0%). CONCLUSION: For the evaluation and treatment of esophageal cancer patients at radiation facilities in Korea, this study will provide guidelines and benchmark data for the solid cooperative systems of the Korean PCS. Although some differences were noted between institutions, there was no major difference in the treatment modalities and RT techniques.

Effect of concurrent chemoradiotherapy with cisplatin and 5-fluorouracil for FIGO stage IIB of the uterine cervix / 부인종양

OBJECTIVE: To determine effect of concurrent chemoradiotherapy (CCRT) in treatment of FIGO stage IIB cervical cancer the uterus and of consolidation chemotherapy using same chemotherpeutic regimens. METHODS: The study population consisted of total number of 41 patients diagnosed as having cervical cancer FIGO stage IIB between January 1999 and December 2003 and treated with CCRT. We were divided into 2 groups according to number of cycles of chemotherapy received [e.g., 3 (n=22, controls) cycles]. Both groups had received the chemotherapeutic regimens which consist of cisplatin 60 mg/m2 followed by five consecutive daily infusions of 5-fluorouracil (5-FU) 1,000 mg/m2 every 3 weeks. RESULTS: 5 years survival rate and 3 years progression free survival are 80.1% and 60.6% in 45 months median follow up duration (range 6-81 months). The median duration of follow up for case and control is 42 months (range 6-81 months) and 52.5 months (range 11-74 months) respectively (p=0.89). Both progression free survival rate (p=0.77) and survival rate (p=0.39) of the groups were revealed to be without statistical significance. CONCLUSION: This study shows similar results to compare with previous CCRT reports and that CCRT is primary treatment of cervical cancer IIB.We may not improve remarkably survival with many chemotherapy cycles. But because of small population and retrospective study, further study of a large number of patients,prospective and long term follow up will be necessary to test the efficacy of the consolidation chemotherapy.