Image fusion-based recurrence patterns and dosimetry after concurrent chemoradiotherapy for thoracic esophageal squamous cell carcinoma / 中华放射医学与防护杂志

Objective:To analyze the local recurrence patterns after concurrent chemoradiotherapy (CCRT) for thoracic esophageal squamous cell carcinoma (ESCC) through image fusion, and to explore the risk factors of local recurrence and its relationships with dosimetric indices.Methods:A retrospective analysis was conducted for 209 thoracic ESCC patients who received radical CCRT in Fourth Hospital of Hebei Medical University during 2016-2019. For the patients diagnosed as the local recurrence of esophageal lesions, their CT images were fused with the original planning CT images using image registration software to identify the recurrence sites. Through 1∶1 propensity score matching (PSM) of the clinal data of patients with local recurrence (the recurrence group, nbefore = 81, nafter = 62) and those without local recurrence (the recurrence-free group, nbefore = 128, nafter=62), the dose and volume parameters of the treatment plans for the two groups were compared. Univariate and multivariate analyses were conducted using the Kaplan-Meier method and the Cox regression model to analyze the factors affecting the overall survival (OS), progression-free survival (PFS), and recurrence-free survival (RFS). Results:All patients had 1-, 3-, and 5-year OS rates of 80.9%, 42.6%, and 33.0%, respectively, 1-, 3-, and 5-year PFS rates of 67.9%, 34.0%, and 27.9%, respectively, and 1-, 3-, and 5-year RFS rates of 71.3%, 39.2%, and 30.5%, respectively. T stage, N stage, and radiation dose were independent prognostic factors for the OS, PFS, and RFS ( HR = 1.42-1.87, P < 0.05) of the patients, respectively. Among 68 patients with local recurrence, 62 cases (91.2%) suffered recurrence within the gross tumor volume (GTV). The dose and volume parameters of patients with local recurrence, such as GTV- D95%, clinical target volume (CTV)- D95%, GTV- D50%, CTV- D50%, and planning target volume (PTV)- D50%, GTV- V60, CTV- V60, and PTV- V60, were significantly lower than those of patients free from the local recurrence ( t=1.90-2.15, P < 0.05). Conclusions:Local recurrence of patients with thoracic ESCC after radical CCRT occurs mainly within the GTV. Increasing radiation doses may contribute to their survival benefits. The D50% for each target volume in the radiotherapy plan may be related to local recurrence, and it is necessary to conduct further research.

Survey of the Period of Tapering of a Strong Opioid Analgesic for Oral Mucositis Resulting from Concomitant Chemoradiotherapy for Head and Neck Cancer after the End of Treatment

Severe pain from mucositis resulting from concomitant chemoradiotherapy (CCRT) is commonly treated with opioid analgesics. However, the period of use of opioid analgesics differs among individuals. We performed a retrospective cohort study of 46 patients who were treated with long-term opioid analgesics after CCRT for head and neck cancer. Among these patients, opioid analgesics were used for a median of 30 days. A comparative study was conducted between patients with long-term use of strong opioid analgesic drugs and those with short-term use. A significantly prolonged use of opioid analgesic agent was associated with cetuximab use (TPF vs. S-1 vs. Cmab, 35.0 vs. 44.1 vs. 180.7, p≤0.001). There were no psychiatric symptoms such as dependence and delirium. When patient background and chemotherapy selection are known, the possibility of severe oropharyngeal mucositis and the potential need for long-term opioid analgesics can be evaluated. Consideration of reduction or discontinuation according to pain after the end of treatment is important.

Avaliação da mudança nas relações interpessoais através do CCRT. Estudo de caso psicanalítico / Assessment of change in interpersonal relationships through the CCRT. A case study of psychoanalysis / Evaluación de los cambios en las relaciones interpersonales a través de la CCRT. Estudio de caso de psicoanálisis

O objetivo foi perceber a evolução das relações interpessoais de uma paciente ao longo da sua psicanálise com a duração de quatro anos. O método Core Conflictual Relationship Theme foi aplicado para identificar os episódios de desejos, respostas do outro e respostas do self. Foram analisadas as notas de sessões em sete momentos diferentes: no início, seis, 12, 18, 24, 30 e 36 meses. Através da análise do conflito central presente nos episódios relacionais observa-se uma evolução ao longo da psicanálise que pôde ser confirmada pelos dados clínicos. A paciente passa de desejos de se opor, magoar e controlar os outros, ser distante e evitar conflitos no início da terapia para o desejo de ser amada, compreendida e ajudar os outros no fim da terapia. Quanto às respostas dos outros a paciente vai alternando ao longo da análise entre senti-los como rejeitantes e que gostam dela. Quanto às respostas do self uma alternância entre sentimentos depressivos e autoaceitação.

The aim was to understand the evolution of the interpersonal relationships of a patient through her four years of psychoanalysis. The Core Conflictual Relationship Theme method was applied to identify episodes in the reported Wishes, the Responses from Others and Responses of the Self. The notes of the sessions were analysed in the beginning, six, 12, 18, 24, 30 and 36 months. The conflict in the relational episodes shows an increase in self-confidence, and positive responses about self, and decrease of negative responses of others. We see a change in the patient from the desire to hurt and control others, being distant and avoiding conflicts at the beginning of the psychoanalysis to the desired to be loved, understood and helping others at the end. On responses of the others she alternates between feeling rejected and they like her. On responses of the self we see an alternation between depressive feelings and self-acceptance.

El objetivo era comprender la evolución de las relaciones interpersonales de un paciente a través de sus cuatro años de psicoanálisis. El método Core Conflictual Relationship Theme se aplicó para identificar los episodios de los deseos reportados, respuestas de los demás y las respuestas de sí mismo. Las notas de las sesiones se analizaron en 7 ocasiones diferentes: principio, seis, 12, 18, 24, 30 y 36 meses. A través del análisis del conflicto central en este episodios relacionales se observa una evolución a lo largo del psicoanálisis que podría ser confirmada por los datos clínicos. El conflicto en los episodios relacionales muestra un aumento de confianza en sí mismo, y las respuestas positivas sobre lo self, y la disminución de las respuestas negativas de los demás. Vemos un cambio en el paciente desde el deseo de herir y controlar a los demás, ser distante y evitar conflictos en el comienzo del psicoanálisis a la que desea ser amado, comprendido y ayudar a otros al final de la terapia. En las respuestas de los demás se alterna entre sentirse rechazada y les gusta ella. En las respuestas del self vemos una alternancia entre sentimientos depresivos y la auto-aceptación.

PET/CT planning during chemoradiotherapy for esophageal cancer

PURPOSE: To evaluate the usefulness of positron emission tomography/computed tomography (PET/CT) for field modification during radiotherapy in esophageal cancer. MATERIALS AND METHODS: We conducted a retrospective study on 33 patients that underwent chemoradiotherapy (CRT). Pathologic findings were squamous cell carcinoma in 32 patients and adenocarcinoma in 1 patient. All patients underwent PET/CT scans before and during CRT (after receiving 40 Gy and before a 20 Gy boost dose). Response evaluation was determined by PET/CT using metabolic tumor volume (MTV), total glycolytic activity (TGA), MTV ratio (rMTV) and TGA ratio (rTGA), or determined by CT. rMTV and rTGA were reduction ratio of MTV and TGA between before and during CRT, respectively. RESULTS: Significant decreases in MTV (MTV2.5: mean 70.09%, p < 0.001) and TGA (TGA2.5: mean 79.08%, p<0.001) were found between before and during CRT. Median rMTV2.5 was 0.299 (range, 0 to 0.98) and median rTGA2.5 was 0.209 (range, 0 to 0.92). During CRT, PET/CT detected newly developed distant metastasis in 1 patient, and this resulted in a treatment strategy change. At a median 4 months (range, 0 to 12 months) after completion of CRT, 8 patients (24.2%) achieved clinically complete response, 11 (33.3%) partial response, 5 (15.2%) stable disease, and 9 (27.3%) disease progression. SUVmax (p = 0.029), rMTV50% (p = 0.016), rMTV75% (p = 0.023) on intra-treatment PET were found to correlate with complete clinical response. CONCLUSION: PET/CT during CRT can provide additional information useful for radiotherapy planning and offer the potential for tumor response evaluation during CRT. rMTV50% during CRT was found to be a useful predictor of clinical response.

Glioblastoma in a Patient with Neurofibromatosis Type 1: A Case Report and Review of the Literature

Neurofibromatosis type 1 (NF1) is an autosomal dominantly inherited familial tumor syndrome. Benign tumors such as pilocytic astrocytoma, optic glioma make up the majority of intracranial neoplasms in patients with NF1. There have only been a handful of cases in which adult glioblastoma presented with NF1. A 32-year-old male presented with headache and radiological studies showing a high grade intra-axial tumor. The patient underwent gross total surgical excision and the pathology revealed glioblastoma. After the surgery, he received concomitant chemo-radiotherapy with temozolomide and adjuvant temozolomide chemotherapy. We report a NF1 patient who developed glioblastoma and reviewed related articles.

The efficacy of concurrent cisplatin and 5-flurouracil chemotherapy and radiation therapy for locally advanced cancer of the uterine cervix / 부인종양

OBJECTIVE: To evaluate the efficacy of concurrent chemoradiation (CCRT) using 5-flurouracil (5-FU) and cisplatin for locally advanced cervical cancer. METHODS: We reviewed the medical records of 57 patients with locally advanced cervical cancer (stage IIB-IVA and bulky IB2-IIA tumor) who underwent the CCRT at Dong-A University Hospital from January 1997 to June 2007. The CCRT consisted of 5-FU, cisplatin and pelvic radiation. Every three weeks, 75 mg/m(2) cisplatin was administered on the first day of each cycle and 5-FU was infused at the dose of 1,000 mg/m(2)/d from the second day to the fifth day of each cycle. Radiation was administered to the pelvis at a daily dose of 1.8 Gy for five days per week until a medium accumulated dose reached to 50.4 Gy. If necessary, the radiation field was extended to include paraaortic lymph nodes. Consolidation chemotherapy was performed using 5-FU and cisplatin. RESULTS: Fifty-seven patients were enrolled and the median follow-up duration was 53 months (range 7-120 months). The overall response rate was 91.5% (74% complete response and 17.5% partial response). The 5-year overall survival and 3-year progression free survival rates were 69.4% and 74.9%, respectively. During the follow-up period (median 23 months, range 7-60 months), fourteen patients were diagnosed as recurrent disease. CONCLUSION: CCRT with 5-FU and cisplatin which is the primary treatment for patients with locally advanced cervical cancer was effective and well tolerated.

Laparoscopic Assisted Distal Rectal Cancer Resection with Preoperative Concurrent Chemoradiotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Anatomy of deep pelvis, narrow distal margin and tumor invasion into neighbor organ are obstacles for curative radical resection for advanced cancer of distal rectum. Technically, laparoscopic application after downstaging the tumor with preoperative concurrent chemotherapy (CCRT) may give a solution to overcome the anatomical difficulties. We compared the results of laparoscopic surgery in the patients who received CCRT with those of patients who had conventional surgery. MATERIALS AND METHODS: A continuous infusion of 5FU plus leucovorin and radiotherapy (50.4 Gy) in 28 fractions was given each patient as CCRT. They underwent D2 radical resection with TME and ANP for the rectal cancer in 4 weeks. RESULTS: Thirty three patients had laparoscopic resection such as LAR, colo-anal anastomosis and APR. The results were compared with 12 cases of the conventional resections. As a result of preoperative CCRT, the cancer was down-staged in 71%. Two year disease free survival was 75% and 74% in the group of conventional and laparoscopic resection, respectively (p=0.427). Ileus, voiding difficulty and leakage after surgery were not different between two groups. Weakness of ejaculation was noted in 9~11% of both groups. The DFS of the preoperative CCRT followed by radical resection in the groups with a response was more favorable than that in the group with progressive or stable disease. CONCLUSION: Radical resection of advanced distal rectal cancer could be done with performing a laparoscopic assisted operation after CCRT induced down-staging. We may suggest that laparoscopic assisted resection is a good treatment option as it doesn't increase the complications and it has a compatible survival rate to conventional surgery.

The value of inducible nitric oxide synthase to select the project of treatment in nasopharyngeal carcinoma / 中国癌症杂志

Background and purpose:Concurrent chemo-radiotherapy(CCRT) was considered the best treatment plan for advanced nasopharyngeal carcinoma(NPC),but there was no uniform conclusion as to which category of patients and which chemotherapy associated radiotherapy would have the best therapeutic effect. As the standard treatment plan for advanced NPC, DDP concurrent chemo-radiotherapy was recommended by some scholars. DDP can raise the expression of inducible nitric oxide synthase(iNOS) protein and synthesize nitric oxide (NO) with anti-tumor effects, so we considered whether the therapeutic effect could be predicted and the corresponding treatment plan could be selectived to detect the iNOS expression in the pretherapy NPC tissues.The purpose of this study was to investigate the relation between the expression of iNOS protein and the nasopharyngeal tumor with complete response or with residue after DDP concurrent chemo-radiotherapy, so that the most appropriate plan of treatment can be adopted and the complete response rate of nasopharyngeal tumor can be raised. Methods:All patients were poorly differentiated NPC.The expression of iNOS protein was examined in 30 patients of nasopharyngeal tumor with complete response and 30 patients with residual tumor after DDP concurrent chemo-radiotherapy by immunohistochemical staining (SP method).None of the patients had received radiotherapy and chemotherapy.Results:Immunohistochemical examination revealed that iNOS expression in the NPC tissues was located in both the nucleus and cytoplasm of the tumorous tissues. The intensity of iNOS expression was stronger in the nucleus than in the cytoplasm of the tumorous tissues.The positive rates of iNOS protein expressions were 71.67%(43/60) in NPC tissues. It was 86.67% and 53.33% in 30 tumors with complete response and with residual tumor, respectively. The difference was statistically significant.The rate of iNOS strong postive expressions in the group of residual tumors was higher than that of the group with complete response. It was statistically different,but weak and moderate postive expressions did not have statistical difference.Conclusions:According to the difference of iNOS expression, it is a valuable method to select the most appropriate plan of treatment and the complete response rate of nasopharyngeal tumor can be raised.

Prediction of Prognosis to Concurrent Chemo-Radiotherapy by Standardized Uptake Value of 2-18F Fluoro-2-Deoxy-D-Glucose for Nasopharyngeal Carcinomas / 대한방사선종양학회지

PURPOSE: To prospectively evaluate the use of positron emission tomography with the glucose analog fluorodeoxyglucose (FDG-PET) to predict disease-free survival (DFS) after concurrent chemo-radiotherapy (CCRT) in patients with non-disseminated nasopharyngeal carcinoma (NPC). MATERIASL AND METHODS: We studied 41 patients with non-disseminated NPC scheduled to undergo platinum- based CCRT were eligible for this study. Patients were studied by FDG-PET prior to the CCRT. FDG uptake of tumors were measured with the maximal standardized uptake value (SUV). RESULTS: Complete response rate was 100%. In ten patients who presented with any component of treatment failure, the median SUVmax was 8.55 (range: 2.49~14.81) in any component of failure and the median SUVmax was 6.48 (range: 2.31~26.07) in the remaining patients without any such failure. Patients having tumors with high FDG uptake had a significantly lower 3-year DFS (51% v 91%, P=0.0070) compared with patients having low uptake tumors. CONCLUSION: FDG uptake, as measured by the SUV, has potential value in predicting DFS in NPC treated by CCRT. High FDG uptake may be a useful parameter for identifying patients requiring more aggressive treatment approaches.

Phase II Study of 3-D Conformal Radiotherapy and Concurrent MVP (Mitomycin-C+Vinblastine+Cisplatin) Chemotherapy for Unresectable Non-Small Cell Lung Cancer

PURPOSE: To evaluate the feasibility, treatment outcome, and toxicity of hyperfractionated 3-D conformal radiotherapy and concurrent MVP chemotherapy in locally advanced, unresectable stage III non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: From August 1993 to December 1996, 161 patients with unresectable stage III NSCLC were entered into this trial, and 146 (91%) completed the treatment. Hyperfractionated radiotherapy was given to a total dose of 64.8~70 Gy (1.2 Gy/fx, bid) with 2 cycles of concurrent MVP (Mitomycin-C 6 mg/m2 d2 and d29, Vinblastine 6 mg/m2 d2 and d 29, and Cisplatin 60 mg/m2 d1 and d28) chemotherapy. Of the 146 patients who completed the treatment, 78 received noncoplanar 3D conformal radiotherapy using 4~6 fields and 17 received coplanar-segmented conformal radiotherapy. Clinical tumor response was assessed one month after the completion of radiotherapy by a computerized tomography (CT) scan. Toxicity was graded using the SWOG criteria. Normal tissue complication probability (NTCP) for the lung was calculated to determine any the correlation with radiation pneumonitis. Nineteen (13%) had stage IIIa and 127 (87%) had IIIb disease, which included 16 patients with pleural effusion and 20 with supraclavicular lymph node metastasis. RESULTS: The response rate was 75%, composed of 22% complete responders and 53% partial responders. With a minimum follow up of 45 months, overall survival was 51.2% at 1 year, 25.1% at 2 years and 14.8% at 5 years; median survival was 12 months. Patients achieving complete response (n=32) had a 2-year overall survival of 49.8% and a 5 year survival of 39.2%, compared to 22.5% and 11.4% survival for the partial responders (n=78) (p=0.0001). Actuarial local progression free survivals for all patients were 65% at 1 year, 42% at 2 years and 36% at 4 years, and actuarial distant free survival was 58% at 1 year, 49% at 2 years and 41% at 5 years. Severe weight loss (more than 10%) occurred in 20 of the 146 patients (13.7%) during treatment, 42 patients (29%) developed radiation pneumonitis, 29 had grade 1 and 13 showed grade 2. The average NTCP value of the patients who showed radiation pneumonitis was significantly higher than that of patients without pneumonitis (66.0% vs. 26.4%). Four patients died of treatment related toxicity. CONCLUSION: Hyperfractionated 3D conformal radiotherapy and concurrent chemotherapy, as described here, is a well tolerate regimen with acceptable toxicity. More effective treatment scheme will be required to improve on local disease control and overall survival.

Radiotherapy for Locally Advanced Lung Cancer

Lung cancer is the leading cause of cancer deaths. Non-small cell lung cancer constitutes approximately 75% of lung cancers, and 40% will present as advanced stage IIIa or IIIb, which are ineffectively treated by primary surgery. Radiation of a primary tumor, and the regional lymphatics, has been the traditional treatment for an unresectable locally advanced disease, but few patients achieved a complete response. Due to the limited benefits provided by radiation therapy, we explored the use of combined chemoradiotherapy in patients with locally advanced, unresectable NSCLC. Combined chemoradiotherapy appears to have improved the outcome of patients with locally advanced unresectable stage III NSCLC, with a median survival of 13 to 14 months, with 5 year survival rates as high as 15 to 20%, nearly three times that reported with radiation therapy alone. Various agents have been used either sequentially or concomitantly in clinical trials of combined chemoradiotherapy for NSCLC. The interactions of chemotherapy and radiation therapy are complex, and Texanes interact with radiation at many levels. Cell-cycle synchronization, through mitotic arrest, has been consistently shown to play a major role in radiation enhancement, but increased apoptosis and tumor reoxygenation may be additional mechanisms. Clearly, the interaction is multifactorial, and the dominant mechanism may be affected by specific settings, which include drug exposure and concentration, tumor type and radiation dosimetry. Recent studies have demonstrated that shorter, high-dose, radiotherapy schedules cause a statistically significant increase in the control of a local tumor in NSCLC. Radiation dose escalation, utilizing conventional fractionation techniques, would be likely to cause prohibitive toxicity. Threedimensional conformal radiation therapy (3-DCRT) has the potential to deliver high dose radiation >70 Gy), with minimal under-dosing and concomitant relative sparing of normal tissues. This technical demonstration of the enhanced therapeutic ratio is used as the basis for the evolving clinical utilization of 3-DCRT for NSCLC. Preliminary experience of the technique has resulted in promising survival rates, following three-dimensional conformal radiation therapy alone, for locally advanced NSCLC. A greater follow-up and experience will help determine its late toxicity, maximum dose and efficacy of dose escalation. Strategies should be developed to integrate this modality into combined treatments for locally advanced NSCLC. Biotechnological developments within the last decade have resulted in the identification of important biological and biophysiological pathways in lung carcinogenesis, and new agents are being developed to target difficult levels of these important pathways. Preclinical and clinical studies using these specific targeted therapies in lung cancer have been very promising. Targeted therapies in lung cancer, and the potential of combining these agents with chemotherapy and radiotherapy, are under investigation.

Chemo-radiation Therapy for Locally Advanced Non-Small Cell Lung Cancer

PURPOSE: Chemotherapy, followed by radiation therapy, improves the survival of patients with locally advanced non-small cell lung cancer (NSCLC). However, it is not clear whether chemotherapy, followed by concurrent chemo-radiation therapy, can improve survivals compared to only concurrent chemo-radiation therapy. We conducted this study to evaluate the role played by induction chemotherapy followed by concurrent chemo-radiation therapy. MATERIALS AND METHODS: Between 1995 and 2000, 55 patients with locally advanced NSCLC were treated with concurrent chemo-radiation therapy. Twenty-seven patients received the induction chemotherapy prior to the chemo-radiation therapy, and their characteristics and survival compared. RESULTS: There were no significant differences in patient characteristics, with the exception of weight loss. The group receiving the induction chemotherapy showed a lesser weight loss, but with no statistical difference in the survival results. CONCLUSION: No advantage was shown with the induction chemotherapy when followed by concurrent chemo-radiation therapy in the treatment of locally advanced NSCLC.