A Case of Cerebellopontine Angle Diffuse Large B Cell Lymphoma in a Systemic Lupus Erythematosus Patient / 대한내과학회지

Patients with systemic lupus erythematosus (SLE) are at higher risk for malignant lymphomas, among which, however, primary CNS lymphoma (PCNSL) is rare. PCNSL usually occurs within the cerebral hemispheres, occasionally in the cerebellum, but rarely in the cerebellopontine angle (CPA). We report our findings in a 45-year-old man with SLE on azathioprine, who presented with sudden hearing loss and dysphagia. The brain MRI revealed a mass lesion in the right CPA. A biopsy was performed and the final diagnosis was diffuse large B cell lymphoma. This is the first report of CPA lymphoma in a SLE patient. The patient was treated with whole brain radiotherapy only because of recurrent pneumonia that was a result of dysphagia from permanent cranial nerve injury. He has been in complete remission for over 10 months.

Influence of Couch and Collimator on Dose Distribution of RapidArc Treatment Planning for Prostate Cancer in Radiation Therapy / 의학물리

We investigated the influence of photon energy, couch and collimator angle differences between arcs on dose distribution of RapidArc treatment planning for prostate cancer. RapidArc plans were created for 6 MV and 10 MV photons using 2 arcs coplanar and noncoplanar fields. The collimator angle differences between two arcs were 0degrees, 15degrees, 30degrees, 45degrees, 60degrees, 75degrees and 90degrees. The plans were optimized using same dose constrains for target and OAR (organ at risk). To evaluate the dose distribution, plans were analyzed using CI (conformity index), HI (homogeneity index), QOC (quality of coverage), etc. Photon energy, couch and collimator angle differences between arcs had a little influence on the target and OAR. The difference of dosimetric indices was less than 3.6% in the target and OAR. However, there was significant increase in the region exposed to low dose. The increase of V15% in the femur was 6.4% (left) and 5.5% (right) for the 6 MV treatment plan and 23.4% (left), 24.1% (right) for the noncoplanar plan. The increase of V10% in the Far Region distant from target was 54.2 cc for the 6 MV photon energy, 343.4 cc for the noncoplanar and 457.8 cc for the no collimator rotation between arcs.

Prognostic Factors in Patients with Localized Soft Tissue Sarcoma / 대한내과학회지

BACKGROUND/AIMS: We evaluated the independent prognostic factors for overall and disease-free survival in the treatment of soft tissue sarcoma. METHODS: Sixty-seven medical records were retrospectively reviewed. All the patients had presented with localized soft tissue sarcoma and had been treated with conservative surgery, followed by additional therapy or surgery. All were treated at the Yeungnam University Hospital between January 2000 and December 2006. Univariate and multivariate analyses were used to evaluate factors affecting overall and disease-free survival. RESULTS: The median age of the study sample was 50 (range, 15~70) years. Twenty patients (30%) had liposarcoma and nine (13%) had leiomyosarcoma. Seventeen patients (25%) had a tumor measuring greater than 10 cm. Nineteen patients (28%) had positive resection margins. The median overall survival was 62.7 months (95% CI: 25.7~99.4) and the median disease-free survival was 36.1 months (95% CI: 17.9~54.2). Factors that significantly affected the median overall survival were a tumor size greater than 10 cm and performance status. Positive resection margins and tumor site were independent prognostic factors associated with diseasefree survival. Other factors, such as histopathology, gender, age, and tumor grade, did not have prognostic value. Additionally, the chosen modality of treatment after surgery was not an independent predictor of the median overall or disease-free survival. CONCLUSIONS: Tumor size, positive resection margins, tumor site, and performance status were statistically significant independent predictors of poor prognosis.

Dose Distribution of Intensity Modulated Radiation Therapy in Prostate Cancer / 의학물리

The aim of this study was to compare the dose distribution of intensity modulated radiation therapy (IMRT) with 3 dimensional conformal radiation therapy (3DCRT) in prostate cancer. The IMRT plan and the 3DCRT plan used the 9 fields technique, respectively. In IMRT, tumor dose was a total dose of 66 Gy at 2.0 Gy per day, 5 days a week for 5 weeks. All cases were following the dose volume histogram (DVH) constraints. The maximum and minimum tumor dose constraints were 6,700 cGy and 6,500 cGy, respectively. The rectum dose constraints were <35% over 50 Gy. The bladder dose constraints were <35% over 40 Gy. The femur head dose constraints were <15% over 20 Gy. Tumor dose in the 3DCRT were 66 Gy. In IMRT, the maximum dose of PTV was 104.4% and minimum dose was 89.5% for given dose. In 3DCRT, the maximum dose of PTV was 105.3% and minimum dose was 85.5% for given dose. The rectum dose was 34.0% over 50 Gy in IMRT compared with 63.3% in 3DCRT. The bladder dose was 30.1% over 40 Gy in IMRT compared with 30.6% in 3DCRT. The right femur head dose was 9.5% over 20 Gy in IMRT compared with 17.5% in 3DCRT. The left femur head dose was 10.6% over 20 Gy in IMRT compared with 18.3% in 3 DCRT. The dose of critical organs (rectum, bladder, and femur head) in IMRT showed to reduce than dose of 3DCRT. The rectum dose over 50 Gy in IMRT was reduced 29.3% than 3DCRT. The bladder dose over 40 Gy in IMRT was similar to 3DCRT. The femur head dose over 20 Gy in IMRT was reduced about 7~8% than 3DCRT.

The Results of Intraoperative Radiotherapy for Stomach Cancer / 대한방사선종양학회지

PURPOSE: We retrospectively analyzed the long-term results of radical surgery and intraoperative radiation therapy (IORT) in patients with stomach cancer. MATERIALS AND METHODS: From 1988 to 1994, 51 patients were treated with curative surgery and IORT. Postoperative external beam radiotherapy (EBRT) was administered to 30 patients, while adjuvant chemotherapy was administered to 35 patients. A dose of 15 Gy was irradiated with a 9 MeV electron beam as the IORT and a median dose of EBRT was 43.2 Gy (range, 7.2 to 45 Gy). The follow-up period ranged from 1~254 months, with a median follow-up period of 64 months. RESULTS: The median age of all the patients was 58 years (range, 30 to 71 years). The distribution of pathologic stage (American Joint Committee on Cancer [AJCC] 2002 tumor-note-metastasis [TNM]) was as follows: 13 stage I (25.5%), 10 stage II (19.6%), 25 stage III (49.0%), and 3 stage IV (5.9%). Distant metastases occurred in 11 patients (10 in the peritoneum and 1 in bone), including one patient with concurrent local recurrence (anastomosis site). The 5-year locoregional control, disease free survival and overall survival rates were 94.7%, 66.5%, and 51.7%, respectively. For the multivariate analysis, age, TNM stage, and EBRT were significant prognostic factors for overall survival, and only TNM stage for disease free survival. CONCLUSION: We could have achieved a high loco-regional control rate in patients with locally advanced stomach cancer by adding IORT to radical surgery. However, the benefit of IORT on survival remains to be elucidated.

A Study of Energy Dependency in Intensity Modulated Radiation Therapy of Lung Cancer / 의학물리

PTV considered for the energy, dose distribution exposed to lung and spinal cord, and the characteristic of DVH (Dose Volume Histogram) were compared and investigated by planning the intensity modulated radiation therapy (IMRT) using the photon energies of 6 MV and 10 MV according to tumor location like as the anterior, middle, and posterior regions of lung, and the mediastinum region in lung cancer patients. Our institution installed the linear accelerator (Varian 21 EX-s, USA) equipped with 120 multileaf collimator for lung cancer patients, which is producing the photon energies of 6 MV and 10 MV, and radiation therapy planning was performed with ECLIPSE system (Varian, SomaVision 6.5, USA), which support inverse treatment planning. The tomographic images of 3 mm slice thickness for lung cancer patients were acquired using planning CT, and acquired tomographic images were sent to the Varis system, and then treatment planning was performed in the ECLIPSE system. The radiation treatment planning of the IMRT was processed from various angles according to the regions of the tumor, and using various beam lines according to the size and location of the tumor. The investigation of the characteristic of dose distributions for the energy of 6 MV and 10 MV according to tumor locations in lung cancer patients resulted that the maximum dose of 10 MV energy was 1.2% less than that of 6 MV energy without depending on the tumor location of lung cancer, and the reduction effects of MU were occurred from 10 to 25 MU. Radiation dose exposed to the lung satisfied the less 30% of V20, however radiation dose in 6 MV energy was from 0.1% to 0.5% less than that in 10 MV energy. Radiation dose exposed to the spinal cord for 6 MV energy was from 0.6% to 2.1% less than that for 6 MV energy.

Evaluation of Skin Dose of Intensity Modulated Radiation Therapy in Breast Cancer Patients / 의학물리

In the case of radiotherapy following breast conservation therapy for breast cancer patients, the characteristic of skin dose was investigated in the treatment of intensity modulated radiation therapy (IMRT) for breast cancer patients by comparing and analysing entrance skin dose irradiated during radiotherapy using tangential technique radiotherpy, and IMRT. The calculation dose irradiated to breast skin was compared with TLD measurement dose in treatment planning by performing the two methods of radiotherapy using tangential technique, and IMRT in treatment planning equipment. The skin absorbed dose was measured to pass a nipple by spacing of 1 cm distance from center to edge of body. In the radiotherapy of tangential technique, for the irradiation of 180 cGy to PTV, the calculation dose was ranged from 103.6 cGy to 155.2 cGy, measurement dose was ranged from 107.5 cGy to 156.2 cGy, and skin dose in the center was maximum 1.45 times more irradiated than that in the edge. In the IMRT, for the irradiation of 180 cGy to PTV, the calculation dose was ranged 9.8 cGy at 80.2 cGy, measurement dose was ranged 8.9 cGy at 77.2 cGy, and skin dose in the center was maximum 0.23 times less irradiated than that in the edge. IMRT was more effective for skin radiation risks because radiation dose irradiated to skin in IMRT was much less than that in radiotherapy of tangential field technique.

Dosimetric Characteristics of Multileaf Collimator-based Intensity-modulated Arc Therapy for Stereotactic Radiosurgery / 의학물리

This study was designed to evaluate radiosurgery technique using multiple noncoplanar arc therapy with intensity modulated fine MLC shaped photon beam. The stereotactic radiosurgery was performed with 6-MV X-ray beams from a Clinac 21EX LINAC (Varian, Palo Alto, CA, USA) with a MLC-120, which features a full 40 x 40 cm field and is the first MLC for general use that offers 0.5 cm resolution for high precision treatment of small and irregular fields. We used a single isocenter and five gantry-couch combinations with a set of intensity modulated arc therapy. We investigated dosimetric characteristics of 2 cm sized spherical target volume with film (X-OMAT V2 film, Kodak Inc, Rochester NY, USA) dosimetry within 25 x 25 cm acrylic phantom. A simulated single isocentric treatment using inversely planned 3D radiotherapy planning system demonstrated the ability to conform the dose distribution to an spherical target volume. The 80% dose level was adequate to encompass the target volume in frontal, sagittal, and transverse planes, and the region between the 40% and 80% isodose lines was 4.0~4.5 mm and comparable to the dose distribution of the Boston Arcs. We expect that our radiosurgery technique could be a treatment option for irregular-shaped large intracranial target.

A Study on Dose Distribution using Virtual Wedge in Breast Cancer / 의학물리

In the radiation therapy for breast cancer patients, wedge shaped compensators are essentially used to achieve appropriate dose distribution because of thickness difference according to breast shapes. Tangential irradiation technique has usually been applied to radiation therapy for breast cancer patients treated with breast conservative surgery. When a primary beam is incident on wedge shaped compensators from medial direction in tangential irradiation technique, low energy scattered radiation is generated and gives additional dose to the breast surface. As a method to reduced additional dose to breast surface, the use of virtual wedge shaped compensator is possible. Eclipse radiation treatment planning (RTP) systems installed at our institution have virtual wedge shaped compensator for radiation therapy treatment planning. The dose distributions of 15, 30, 45, 60 degree physical wedges and virtual wedges were measured and compared. Results showed that there was no significant differences in symmetry of 10 x 10 field among various wedge angles. When the transmission factor was compared, transmission factor increased linearly as the wedge angle increased. These results indicates that the application of virtual wedge in clinical use is appropriate.

Use of real-time quantitative PCR to identify high expressed genes in head and neck squamous cell carcinoma cell lines

Head and neck squamous cell carcinoma(HNSCC) is the sixth most common cancer among men in the developed world affecting the tongue, pharynx, larynx and oral cavity. HNSCC is thought to represent a multistep process whereby carcinogen exposure leads to genetic instability in the tissue and accumulation of specific genetic events, which result in dysregulation of proliferation, differentiation, and cell loss and the acquisition of invasive capacity. Despite therapeutic and diagnostic progress in oncology during the past decades, the prognosis of HNSCC remains poor. Thus it seems that finding a biological tumor markers which will increase the early diagnosis and treatment monitoring rates, is of paramount importance in respect to improving prognosis. In an effort to identify gene expression signatures that may serve as biomarkers, this study several genes were selected, such as H3,3A, S100A7, UCHL1, GSTP1, PAI-2, PLK, TGFbeta1 and bFGF, and used 7 HNSCC cell lines that were established various anatomical sites, and also 17 other cancer cell lines were used for control group using real-time quantitative RT-PCR and immunocytochemical analysis with a monoclonal antibody. In this study, S100A7 showed a clearly restricted occurrence in tongue originated cell line, and GSTP1 expression level in the pharynx originated cell line was very increased, relative to corresponding other cell lines. These results suggest that S100A7 and GSTP1 genes' expression can occur during tongue and pharynx originated head and neck tumorigenesis and that genetic change is an important driving force in the carcinogenesis process. This data indicate that S100A7 and GSTP1 expression pattern in HNSCC reflect both diagnostic clue and biological marker. And this is provides a foundation for the development of site-specific diagnostic strategies and treatments for HNSCC.

Effectiveness of Fentanyl Transdermal Patch (Fentanyl-TTS, Durogegic(R)) for Radiotherapy Induced Pain and Cancer Pain: Multi-center Trial / 대한방사선종양학회지

PURPOSE: To evaluate the effectiveness and safety of fentanyl-TTS in the management of radiotherapy induced acute pain and cancer pain treated with radiotherapy. MATERIALS AND METHODS: Our study was open labelled prospective phase IV multi-center study. the study population included patients with more 4 numeric rating scale(NRS) score pain although managed with other analgesics or more than 6 NRS score pain without analgesics. Patients divided into two groups; patients with radiotherapy induced pain (Group A) and patients with cancer pain treated with radiotherapy (Group B). All patients received 25 ug/hr of fentanyl transdermal patch. Primary end point was pain relief; second end points were change in patient quality of life, a degree of satisfaction for patients and clinician, side effects. RESULTS: Between March 2005 and June 2005, 312 patients from 26 participating institutes were registered, but 249 patients completed this study. Total number of patients in each group was 185 in Group A, 64 in Group B. Mean age was 60 years and male to female ratio was 76:24. Severe pain NRS score at 2 weeks after the application of fentanyl was decreased from 7.03 to 4.01, p=0.003. There was a significant improvement in insomnia, social functioning, and quality of life. A degree of satisfaction for patients and clinician was very high. The most common reasons of patients' satisfactions was good pain control. Ninety six patients reported side effect. Nausea was the most common side effect. There was no serious side effect. CONCLUSION: Fentanyl-TTS was effective in both relieving pain with good tolerability and improving the quality of life for patients with radiotherapy induced acute pain and cancer pain treated with radiotherapy. The satisfaction of the patients and doctors was good. There was no major side effect.

Efficacy of weekly paclitaxel and concurrent radiation therapy for locally advanced non-small cell lung cancer / 대한내과학회지

BACKGROUND: Combined modality therapy is standard treatment of unresectable, locally advanced stage III non-small cell lung cancer (NSCLC). However, the optimal chemotherapy regimen and duration of chemotherapy remain a matter of debate. We evaluated the efficacy and feasibility of concurrent chemoradiation therapy (CCRT) in patients with locally advanced NSCLC. METHODS: PS 0-2 patients with histologically proven inoperable stage III NSCLC were eligible for this trial. The patients received paclitaxel (60mg/m2) on days 1, 8, 15, 22, 29, 36 with a concurrent radiotherapy (5days/week, 1.8Gy/day) starting day 1 with a total dose of 63 Gy. After CCRT, four cycles of consolidation chemotherapy with paclitaxel (140mg/m2) and carboplatin (AUC 5) was administered to patients with a partial, complete remission or stable disease. RESULTS: Twenty eight patients with locally advanced NSCLC enrolled in this study. The median age of the patients was 60 years. Of the 28 patients, 19 received scheduled CCRT. Overall response rate was 71.4% including 5 complete responses and 15 partial responses. Grade 3 or 4 pulmonary complication was observed in 7 patients and 3 patients died of pneumonitis. The median overall survival was 17.5 months (95% CI, 12.5-22.5). The median progression free survival was 8.0 months (95% CI, 4.1-11.9). CONCLUSIONS: CCRT including paclitaxel in patients with locally advanced NSCLC led to an encouraging response rate and survival, but resulted in high incidence of severe pulmonary complication.

Electromagnetic Fields in General Hospital / 영남의대학술지

BACKGROUND: Electromagnetic fields (EMF) are ubiquitous in modern society including medical field. As the technology of medical instruments and telecommunications has developed rapidly, it has influenced on our lives in many ways. Modern medical practice requires high quality medical equipments, which have a great deal of electromagnetic interference and susceptibility. The purpose of this study were to evaluate electromagnetic condition under usual clinical condition and to suggest a practical guideline in general hospital. MATERIALS AND METHODS: The actual state of the electromagnetic interference in the medical field was studied under usual clinical conditions including operating rooms, intensive care units, magnetic resonance imaging unit, and hyperthermia unit. RESULTS: There was considerable noise as a result of electromagnetic fields from medical equipments including electrosurgical units and hyperthermia unit, and cellular phones, which could induce serious functional derangements of functioning medical devices. CONCLUSION: It will be necessary to evaluate the individual electromagnetic situations under various medical conditions and to define a limited zone for cellular phone as well as reposition medical equipments to secure a safer medical practice and to minimize electromagnetic interference.

Clinical Results of Postoperative Chemoradiation on Advanced Rectal Cancers: Tumor Response, Toxicities, and Morbidity

PURPOSE: Adjuvant chemotherapy and radiotherapy have been considered effective treatments in advanced rectal cancers. Recently, several studies have reported that preoperative chemoradiation (CRT) may have advantages over postoperative CRT, particularly in reducing local recurrence and preserving the anal sphincter. We studied the short-term efficacy of preoperative CRT for locally advanced rectal cancers. METHODS: Between Jun. 2000 and Aug. 2003, 23 patients were treated with preoperative CRT, followed by surgery (pre-CRT) and 31 patients were treated with chemoradiation postoperatively (post-CRT). We compared these two groups for the incidence and degree of side effects from CRT, postoperative complications, type of surgery, including anal sphincter preservation, and short-term recurrence. RESULTS: The average age and male-to-female ratio of the pre- and the post-CRT groups were 58+/-11, years and 13:10, and 61+/-14 and 14:17, respectively. T downstagings were observed in 17 of 23 (74%) pre-CRT patients. On the RTOG-EORTC scale, the patients who showed hematological, intestinal and dermal side effects in the pre-CRT group and in the post-CRT group were 5, 5, 2 and 5, 2, 4, respectively and the difference was not statistically significant (P=0.41). Anal sphincter preserving surgical procedures were performed 91.3% (21/23) and 83.9% (26/31) of the patients in the pre- and the post-CRT groups, respectively. But this difference was not statistically significant (P=0.4). Postoperative complications in the pre-CRT group were anastomosis site leakages (n=3) and rectovaginal fistula (n=1). In the post-CRT group, complications were two anastomosis site leakages. Four of the 31 post-CRT group patients had recurrences such as locoregional area (n=2), liver (n=1), and lung (n=1) while no patient was observed in pre- CRT group. CONCLUSIONS: Although pre-CRT group showed higher incidence of complications than post-CRT group, these were managed easily and safely. Pre-CRT seems to be an effective modality for treating advanced rectal cancers particularly for preserving anal sphincter. Long-term follow- up data are needed to clarify the effect of pre-CRT.

Combined Modality Treatment in Nasopharyngeal Carcinoma / 대한방사선종양학회지

PURPOSE: We performed a retrospective analysis to compare short term results of induction chemotherapy-radiotherapy versus concurrent chemo-radiotherapy in patients with locally advanced nasopharyngeal carcinoma. MATERIALS AND METHODS: From Oct. 1989 to May 1998, 62 patients with locally advanced nasopharyngeal carcinoma were treated with induction chemotherapy followed by radiotherapy (induction group) or concurrent chemo-radiotherapy (concurrent group). Induction chemotherapy was done for 50 patients, and concurrent chemotherapy for 12 patients. Age, sex, performance status, and pathologic types were evenly distributed between two groups. Stage distribution showed 32% with IIB, 30% with III, and 38% with IV in induction group, and 50%, 33.3%, and 16.7% in concurrent group, respectively. Chemotherapy regimen was CF (cisplatin and 5-FU) in both groups, and drug delivery method also same. Cisplatin 100 mg/m2 was intravenously infused on day 1, and 5-FU 1,000 mg/m2 on day 2~6. This was repeated at 3 weeks interval. At the end of radiotherapy, total cycles of chemotherapy were 1~3 (median 2) in both groups. Conventionally fractionated radiotherapy with daily fraction size 1.8~2.0 Gy and 5 fractions/week was done. Total dose was 69.4~86 Gy(median 73.4 Gy) for induction group, and 69.4~75.4 Gy (median 70.8 Gy) for concurrent group. Follow-up time was 9~116 months (median 40.5 months) for induction group, 14~29 months (median 21 months) for concurrent group, respectively. RESULTS: Overall 2 year survival rate (2YSR) for all patients was 78.7%. According to treatment modality, 2YSR were 77% for induction group, 87% for concurrent group (p>0.05). 2 year disease-free survival rate were 56% and 81% (p>0.05), respectively. Complete response to treatment were 75.5% for induction group and 91.7% for concurrent group, but there was no statistical difference. The incidence of grade 3~4 hematologic toxicity during radiotherapy was not differ between two groups, but grade 2 leukopenia was more frequent in concurrent group (18% vs 66.7%). Grade 3~4 mucositis was more frequent in concurrent group (4.0% vs 33.3%). Overall incidence of grade 3~4 acute toxicity during radiotherapy was more frequent in concurrent group (6.0% vs 41.7%, p=0.005). CONCLUSION: Concurrent chemo-radiotherapy showed a trend of improvement in short-term survival and in treatment response when compared with induction chemotherapy-radiotherapy in locally advanced nasopharyngeal carcinoma. More controlled randomized trial are needed.

Induction Chemotherapy and Radiotherapy in Locally Advanced Non-Small Cell Lung Cancer (NSCLC) / 대한방사선종양학회지

PURPOSE: We performed this study to evaluate the prognostic factors and the effect of induction chemotherapy in locally advanced non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: A retrospective analysis was done for 130 patients with locally advanced NSCLC treated with curative radiotherapy alone or induction chemo-radiotherapy from January 1986 to October 1996. Eighty-five patients were treated with radiotherapy alone, forty-five with induction chemotherapy and radiotherapy. Age, sex, performance status, histopathologic type, and stage were evenly distributed in both groups. The patients were treated with 6 MV or 10 MV X-ray. Conventional fractionation with daily fraction size 1.8~2.0 Gy was done. Of the patients, 129 patients received total dose above 59.6 Gy (56~66 Gy, median 60 Gy). Induction chemotherapy regimen were CAP (Cyclophosphamide, Adriamycin, Cisplatin) in 6 patients, MVP (Mitomycin, Vinblastine, Cisplatin) in 9 patients, MIC (Mitomycin, Ifosfamide Cisplatin) in 13 patients, and EP (Etoposide, Cisplatin) in 17 patients. Chemotherapy was done in 2~5 cycles (median 2). RESULTS: Overall 1-, 2-, and 3-year survival rate (YSR) for all patients were 41.5%, 13.7%, and 7%, respectively (median survival time 11 months). According to treatment modality, median survival time, overall 1-, 2-, and 3-YSR were 9 months, 32.9%, 10.5%, 6% for radiotherapy alone group, and 14 months, 57.8%, 20%, 7.6% for induction chemotherapy group, respectively (p=0.0005). Complete response (CR) to overall treatments was 25% (21/84) in radiotherapy alone and 40.5% (17/42) in induction chemotherapy group (p=0.09). The prognostic factors affecting overall survival were hemoglobin level (p=0.04), NSE (neuron-specific enolase) level (p=0.004), and response to overall treatment(p= 0.004). According to treatment modalities, NSE (neuron-specific enolase) (p=0.006) and response to overall treatment (p=0.003) were associated with overall survival in radiotherapy alone group, and response to overall treatment (p=0.007) in induction chemotherapy group. The failure pattern analysis revealed no significant difference between treatment modalities. But, in patients with CR to overall treatment, distant metastasis were found in 11/19 patients with radiotherapy alone, and 3/13 patients with induction chemotherapy and radiotherapy (p=0.07). Locoregional failure patterns were not different between two groups (10/19 vs 6/13). CONCLUSION: Induction chemotherapy and radiotherapy achieved increased 2YSR compared to radio therapy alone. At least in CR patients, there was decreased tendency in distant metastasis with induction chemotherapy. But, locoregional failures and long-term survival were not improved. Thus, there is need of more effort to increasing local control and further decreasing distant metastasis.

Radiotherapy of Metastatic Neck Nodes from an Unknown Primary Site / 대한치료방사선과학회지

PURPOSE: This study was to evaluate survival, failure patterns, and prognostic factors of patients with metastatic neck nodes from an unknown primary site. MATERIALS AND METHODS: A retrospective analysis was done for 35 patients with metastatic neck nodes from an unknown primary site who were treated with radiation from January 1986 to September 1994. There were 26 male and 9 female patients. Patients' age ranged from 41 to 74 years (median 58 years). Stage distribution showed 1 patient with N1, 27 with N2, and 7 with N3. Amomg these patients, 7 with a supraclavicular lymph node alone were included. The histologic type was squamous cell carcinoma in 22 patients, undifferentiated carcinoma in 6, adenocarcinoma in 4. We could not classify a histologic type in 3 patients. Radiation therapy alone was done in 7 patients, induction chemotherapy and radiation therapy in 10, and postoperative radiation therapy in 18. Radiation therapy fields included both neck and pharyngeal axis, and total dose was 40-95.6Gy (median 60Gy) using 6MV X-ray. Chemotherapy consisted of 2 cycles of 5-fluorouracil and cisplatin. Surgical methods were a radical neck dissection in 17 patients and an excisional biopsy in 1 patient. Follow-up time ranged from 2 to 95 months, median 15 months. RESULTS: Overall and disease-free survival rate at 4 years were 33.4% and 33.9%, respectively. The factors associated with the overall survival rate were histologic type(adenocarcinoma vs. non-adenocarcinoma, p=0.0005), N stage(p=0.023), and the site of involved nodes(p=0.021). According to the treatment modality, 2-year survival rate was 14.3% in radiation therapy alone group, 35.8% in induction chemotherapy and radiation thrapy, and 37.5% in postoperative radiation therapy(Fig. 4, p=0.05), which might be due to the difference of N stage distribution. The failure patterns were analyzed in 25 patients with a complete response to the treatment. Local failure wasnoted in 7 patients, distant metastases in 6, local failure and distantmetastases in 1. Excluding the 7 patients with supraclavicular lymph node metastaes alone, 28%(7/25) of the patients had distant metastases. During the follow-up period, 11%(3/35) of the patients showed a delayed primary site, 1 in oral cavity, 1 in nasopharynx, and 1 in hypopharynx. CONCLUSION: N stage, the site of involved node, and histologic type were associated with survival rate. In patients with advanced N stage, curative rather than inductive chemotherapy is needed because combined surgery and radiation therapy achieved poor results and considerable patients developed distant metastases.

Radiotherapy Results of Midline Malignant Reticulosis (MMR) / 대한치료방사선과학회지

PURPOSE: This study was performed to evaluate survival, failure patterns, and prognositc factors of MMR patients after radiation therapy. We also discussed the need for chemotherapy. MATERIALS AND METHODS: A retrospective analysis was done for 23 patients with MMR who were treated with radiation therapy form June 1985 to November 1992. There were 19 male and 4 female patients. The patients' age ranged from 17 to 71 years(median 39 years). Systemic symptoms including fever, weight loss, or malaise were found in 30% of the patients. He nasal cavity was most frequently involved. No patients had nodal involvement at diagnosis. There were 2 patients with distant metastasis at presentation. Radiation therapy was delivered five times a week, 1.8 Gy daily, total 45~54 Gy(median 50.4 Gy) using 6 MV X-ray. No patients received chemotherapy as initial treatment. RESULTS: Overall 5-year and 10-yar survival rates were 52.4% and 44.1%, respectively. Seventy percent(12/17) of the patients achieved complete response to radiotherapy., and 29.4%(5/17) achieved partial response. The patients with complete response showed a better 5-year survival rate than those with partial response (66.9% vs. 20%, p-0.004). Symptom duration before diagnosis, the presence of systemic symptom, ad the number of primary sites had no influence on survival. The patterns of failure were as flows: local failure(1), failure in adjacent site(1), local and distant failure(1), distant metastasis(2), and conversion to malignant lymphoma(1). W could not find factors associated with the patterns of failure. CONCLUSION: The most important factor associated with survival was the response to radiotherapy. Seventeen percent of the patients had distant metastasis, and the salvage after distant metastasis was not successful. However, about 50% of the patients could achieve long-term survival with local radiation therapy alone. Therefore, chemotherapy of MMR should be done after a prospective randomized study for the factors associated with distant metastasis.

The Effects of Neck Irradiation on Thyroid Gland for Tumors of the head and Neck / 대한치료방사선과학회지

Seventy-five patients with tumors of the head and neck treated with either radiation therapy alone or combined with surgery or chemotherapy were studied prospectively to evaluate the effects of radiation therapy to the neck on thyroid gland between September 1986 and October 1992. All patients were serially monitored for thyroid function tests before and after radiation therapy. Radiation dose to the thyroid gland ranged from 35 to 60 Gy with a median dose of 50 Gy. Median follow-up time was 30 months with a range of 11 to 85 months. The incidence of thyroid dysfunction was 40%; forty-five patients (60%) euthyroid, 2 patients (3%) clinical hypothyroidism, 27 patients (36%) subclinical hypothyroidism and 1 patient (1%) hyperthyroidism. No thyroid nodules or thyroid cancer were detected in any patients. Thyroid dysfunction appeared earlier in patients who underwent surgery than in those patients treated with radiation therapy alone or combination of chemotherapy and radiation therapy (p=0.0013). By multivariate analysis, risk factors that significantly influenced a higher incidence of thyroid dysfunction were female sex (p=0.0293) and combination of total larygectomy and radiation therapy (p=0.0045). In conclusion, evaluation of thyroid function before and after radiation therapy with periodic thyroid function tests are recommended to detect thyroid dysfunction in time and thyroid hormone replacement therapy is recommended whenever thyroid dysfunction develops.

Sequential Chemotherapy and Radiation Therapy for Advanced Nasopharyngeal Carcinoma / 대한치료방사선과학회지

Between January 1985 and July 1592, 52 patients with locally advanced nasopharyngeal carcinoma were studied retrospectively for the effectiveness of sequential chemotherapy and radiation therapy. The male to female ratio was 3.3:1 with a median age of 41 years. Forty patients had squamous cell carcinoma and the remaining 12 had undifferentiated carcinoma. Seven patients had stage III disease and the remainder had stage IV disease at time of presentation. All patients were treated two courses of chemotherapy followed by radiation therapy Chemotherapy consisted of either CVB(cisplatin, vincristine and bleomycin) of CF(cisplatin and 5-FU). Total radiation dose to the primary site ranged from 6000 cGy to 7500 cGy. Neck nodes were given booster treatment to maximum of 7000 cGy, depending on the extent of disease. Local control, overall survival and disease-free survival rates were analyzed. The complete response(CR) rate to chemotherapy was 15%, and the partial response(PR) rate was 46% for overall major response rate of 61%. The CR rate was 87% after radiation therapy. Median follow-up time was 51 months. The overall survival and disease-free survival rates at 36 months were 54% and 49%, respectively. Median time to relapse was 15 months. The patterns of initial relapse in CR patients was as follows: locoregional failure only, 12 patients; distant metastasis only, 11; both, 2. Cox's multivariate regression model revealed that nodal status was the single most important independent prognostic factor influencing disease-free survival(p=0.001). Comparison of these results with other published reports with radiation therapy alone showed that a high rate of initial response to chemotherapy did not translate into local control or survival. At present time radiation therapy alone remains the standard treatment for locoregional cancer of the nasopharyngeal cancer. More controlled clinical trials must be completed before acceptance of chemotherapy as a part of treatment of advanced nasopharyngeal carcinoma.