Case Series of 23 Patients Who Developed Fatal Radiation Pneumonitis After Stereotactic Body Radiotherapy for Lung Cancer.

The purpose of this study was to examine the characteristics and treatment plans of patients who experienced fatal radiation pneumonitis after stereotactic body radiation therapy for primary or oligometastatic lung cancer. Records of 1789 patients treated with stereotactic body radiation therapy for primary or oligometastatic lung cancer were retrospectively reviewed to identify those who developed fatal radiation pneumonitis. Twenty-three (1.3%; 18 men and 5 women) patients developed fatal radiation pneumonitis after stereotactic body radiation therapy for lung cancer; their median age was 74 years. The mean Krebs von den Lungen-6 level and percent vital capacity were 1320 U/mL and 82%, respectively. Prestereotactic body radiation therapy computed tomography revealed pulmonary interstitial change in 14 (73.7%) of 19 patients in whom computed tomography data could be reviewed. Seven (30.4%) of 23 patients had regularly used steroids. The median time duration between stereotactic body radiation therapy commencement and pneumonia symptom appearance was 75 (range: 14-204) days. Median survival time following pneumonia symptom appearance was 53 (range: 4-802) days. The 6- and 12-month overall survival rates were 34.8% and 13.0%, respectively. The 6-month overall survival rates in patients with and without heart disease were 50.0%, 16.7%, and 46.7% for heart disease existence, respectively. There were 4 patients in whom fatal radiation pneumonitis occurred within 2 months after stereotactic body radiation therapy and who died within 1 month. Three of them had no pulmonary interstitial change before stereotactic body radiation therapy, but had heart disease. In summary, the survival time in this case series was generally short but varied widely. More than half of the patients had pulmonary interstitial change before stereotactic body radiation therapy, although immediately progressive fatal radiation pneumonitis was also observed in patients without pulmonary interstitial change. True risk factors for fatal radiation pneumonitis should be examined in a prospective study with a larger cohort.

[A Case of Malignant Phyllodes Tumor Effectively Treated by Radiation Therapy as a Palliative Medicine].

The current report presents the case of a 46-year-old woman with phyllodes tumor metastasis to the anterior chest wall treated by radiation therapy. Although the lesion was not controlled with surgery and chemotherapy, the tumor size markedly reduced after radiation therapy, and bleeding and foul odor from the tumor stopped. Radiation therapy for phyllodes tumor appears to be an effective treatment and should be recognized as one choice of palliative medicine.

Contracted bladder developing after prostate brachytherapy.

This report describes an extremely rare case of severely contracted bladder developing after prostate brachytherapy. In April 2001, a 76-year-old man initially presented to our hospital for weak urinary stream. The patient was diagnosed with and treated for benign prostatic hyperplasia. During follow up, prostate-specific antigen level was elevated. In November 2005, the patient underwent transrectal prostate biopsy. Pathology showed adenocarcinoma, Gleason score 3 + 4 = 7. The patient was diagnosed with stage cT1cN0M0 prostate cancer. In January 2006, he underwent brachytherapy for prostate cancer. The procedure of brachytherapy was uneventful and the patient was discharged without any problems. Four months after the implant, the patient was admitted to our hospital for deterioration of kidney function as a result of a contracted bladder. Urinary culture of tuberculosis was negative and urinary cytology was class II. A urethral catheter was indwelled and the patient has been followed every month for catheter replacement. Bladder capacity is now less than 5 mL.

Role of radiotherapy for local control of asymptomatic adrenal metastasis from lung cancer.

INTRODUCTION: Several studies have reported improved survival after adrenalectomy in patients with adrenal metastases from lung cancer. In this study, we evaluated the clinical results of radiotherapy performed for local control in patients with this disease. MATERIALS AND METHODS: We retrospectively reviewed 19 patients with adrenal metastasis from lung cancer, who were treated by radiation therapy between 1999 and 2008. The patients included 18 men and 1 woman, and had a mean age of 63 years. Adrenal metastasis was defined as synchronous and metachronous in 11 and 8 patients, respectively. All tumors were asymptomatic with a median size of 30 mm, and were treated with doses of 30 to 60 Gy (median, 45 Gy) in 1 to 27 fractions (median, 10 fractions). RESULTS: The estimated overall 1-, 2- and 5-year survival rates for all patients were 56%, 33%, and 22%, respectively. More favorable prognosis was observed for patients with a metachronous metastasis, with overall 1-, 2-, and 5- year survival rates following adrenal irradiation of 83%, 56%, and 56%, respectively. CONCLUSION: Our results indicate that radiotherapy may contribute to survival of patients with adrenal metastasis from lung cancer. We suggest that radiotherapy is a treatment option that can be used in addition to surgical resection.

F-18 FDG PET/CT findings in two patients with pyothorax-associated lymphoma.

We report 2 cases of pyothorax-associated lymphoma that underwent F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) examinations during pre- and post-treatment states. The FDG PET/CT examinations were able to define the massive lesions as areas of intensive FDG uptake. After radiotherapy, follow-up PET/CT examinations showed the disappearance of the abnormal FDG uptake, although the residual masses remained in the original regions. Finally, we concluded that these lesions had entered remission based on the PET/CT findings. These cases indicate that PET/CT is a useful modality for detecting pyothorax-associated lymphoma and for evaluating the efficacy of treatments.

The management of pyothorax-associated lymphoma using 18F-FDG PET/CT.

OBJECTIVE: Pyothorax-associated lymphoma (PAL) is a rare form of lymphoma and its management on (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) combined computed tomography (CT) has not been well reported. The purpose of this study was to evaluate the usefulness of FDG PET/CT in patients with PAL. MATERIALS AND METHODS: Twenty-four PET/CT images in seven patients (5 men and 2 women) with PAL were studied retrospectively. Five of the 24 PET/CT scans were done for diagnosis and staging, 6 for restaging, 3 for follow-up, and 10 to evaluate the treatment response. PET/CT scan interpretations were performed visually and using the maximum standardized uptake values (SUVmax). Additionally, the efficacy of the enhanced CT findings in pre- and post-treatments was described. RESULTS: Six of the 7 patients with PAL received radiotherapy, and the efficacy of treatment was observed in their lesions. The percentage decrease of SUVmax in PAL was useful in providing complementary information. Enhanced CT findings showed decreasing enhancement of PAL after treatment; however, in five cases, residual masses were confirmed after treatment. CONCLUSION: FDG PET/CT may be an ideal modality for reducing the false-positive interpretation of residual masses occurring after treatment for PAL. The SUVmax provides complementary information for the management of PAL.

Swelling of the prostate gland by permanent brachytherapy may affect seed migration.

OBJECTIVE: The purpose was to monitor implanted seeds and to determine factors contributing to seed migration after permanent prostate brachytherapy. METHODS: Sixty-two consecutive patients with Stage 1 prostate cancer who underwent brachytherapy with (125)I seeds between February 2008 and May 2009 were studied prospectively. On post-operative days 1, 7 and 30, scintigraphy was added to conventional radiography to monitor the migration of the implanted seeds. The prostate volume was measured during the pre-planning stage using ultrasound and during the post-planning stage using computed tomography on post-operative days 0 and 30. Magnetic resonance imaging was performed on day 30. RESULTS: Of the 4843 seeds implanted in the prostates of 62 patients, 108 seeds (2.2%) in 43 patients (69.4%) exhibited seed migration. Thirty-five seeds could not be identified using any of the imaging modalities and were likely passed during urination (0.7% of the total number of seeds). The maximum number of migrated seeds in one patient was 10 of the 85 implanted seeds. The fraction of patients with seed migration or loss increased from 27.4% on day 1 to 69.4% on day 30. The number of seeds that had migrated from the prostate increased from 48 (0.1% of the total number of seeds) on 1 day to 78 (1.0%) on day 7 and 108 (2.2%) on day 30. Of the seeds lost from the prostate, 38.9% embolized to the lungs. The seed loss during the first post-operative month was closely correlated with the swelling of the prostate gland between the pre-planning measurement and the post-planning measurement performed on day 0 (P < 0.0001). CONCLUSIONS: Prostate swelling between the pre-planning and post-planning (day 0) measurements was significantly associated with seed migration, and adequate attention should be given to this issue.

Stereotactic body radiotherapy for lung tumors at the pulmonary hilum.

BACKGROUND AND PURPOSE: High-dose irradiation to the pulmonary hilar region is generally considered to be of high risk in causing bronchial injury. The aim of this retrospective study is to investigate the safety and efficacy of stereotactic body radiotherapy (SBRT) for patients with lung tumors in the pulmonary hilum. PATIENTS AND METHODS: 21 patients who underwent SBRT for lung tumors within 2 cm from a major bronchus were retrospectively analyzed. The total biologically effective doses ranging from 50.7 to 157.5 Gy (median, 100 Gy) were given to the tumors by SBRT. RESULTS: The overall survival rates at 1 and 2 years after SBRT were 90.0% and 62.2%, respectively. Nine patients were alive and 15 irradiated tumors were controlled during the follow-up period of 10-54 months (median, 20 months). Nine patients died of tumor progression and one patient each died of hemoptysis, infectious pneumonia, and epidural hemorrhage. Severe late toxicity (>or= grade 3) was seen in three patients of whom two had previously received repeated radiotherapy. CONCLUSION: SBRT for lung tumors located in the pulmonary hilar region may be tolerable and acceptable, if multiple treatments to the same major bronchus are avoided, and irradiated volumes are carefully taken into consideration.

Clinical outcomes of single-fraction stereotactic radiation therapy of lung tumors.

BACKGROUND: The objective of the current study was to investigate the effects and the morbidities of single-fraction stereotactic radiation therapy (SRT) for lung tumors. METHODS: A Microtron device was modified to deliver stereotactic irradiation under respiratory gating. Between August 1998 and December 2004, 59 malignant lung tumors (11 primary tumors, 48 metastases) that measured < 40 mm in greatest dimension were treated by single-fraction SRT. Nine tumors received a minimal dose of < 30 grays (Gy), and 50 tumors received a minimal dose of > or = 30 Gy. The macroscopic target volume ranged from 1 cc to 19 cc (mean, 5 cc). RESULTS: The 1-year and 2-year local progression-free rates (LPFRs) were 93% and 78%, respectively. The overall survival rate was 76.5% at 1 year and 41% at 2 years. Local regrowth of the irradiated tumor was a direct cause of death in two patients. Only the minimal radiation dose to the reference target volume tended to have an influence on the LPFR (P = 0.068). The 2-year LPFRs for patients who received irradiation doses of > or = 30 Gy and < 30 Gy were 83% and 52%, respectively. With regard to morbidities, Grade 3 respiratory symptoms (according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer late radiation morbidity scoring scheme) were noted in one patient. CONCLUSIONS: The results from the current study suggested that single-fraction SRT was tolerable and was capable of attaining excellent local control in patients who had malignant lung tumors that measured < 4 cm in greatest dimension.

Toxicities and effects of involved-field irradiation with concurrent cisplatin for unresectable carcinoma of the pancreas.

PURPOSE: To evaluate local effects and acute toxicities of involved field irradiation with concurrent cisplatin (CDDP) for unresectable pancreatic carcinoma. MATERIALS AND METHODS: Thirty-three patients with unresectable pancreatic carcinoma were treated with chemoradiotherapy. Sixteen were Stage IVA; 17 were Stage IVB. The total prescribed dose of radiotherapy was 50 Gy/25 fractions or 50.4 Gy/28 fractions, using a three-dimensionally determined involved-field that included only the primary tumor and clinically enlarged lymph nodes. Twelve patients received a daily i.v. infusion of CDDP; 21 patients received a combination of CDDP and 5-fluorouracil either i.v. or through the proper hepatic artery. RESULTS: Twenty-seven (82%) patients completed planned chemoradiotherapy. Nausea was the most frequent complaint. No patient experienced Grade 4 toxicities. More than half achieved pain relief. As for the primary site, only 4 patients (12%) achieved a partial response at 4 weeks; however, 3 additional patients attained >50% tumor reduction thereafter. The most frequent site of disease progression was the liver, and only 3 patients developed local progression alone. No regional lymph nodal progression outside the treatment field was seen. Median survival time and survival at 1 year were 7.1 months and 27%, respectively, for the entire group. Difference in overall survival between patients with and without distant metastases was significant (p = 0.01). CONCLUSIONS: Involved-field irradiation with concurrent daily CDDP was well tolerated without compromising locoregional effects.

Weekly cisplatin administration concurrent with radiation therapy for locoregionally advanced nasopharyngeal carcinoma.

Radiation therapy (RT) with concurrent and adjuvant chemotherapy has been a widely accepted treatment for patients with locoregionally advanced nasopharyngeal carcinoma (NPC). We administered 40 mg/m2 cisplatin (CDDP) weekly, concurrently with RT, to six consecutive patients with locoregionally advanced NPC to evaluate its toxicity and efficacy. The median number of courses of CDDP administration was 4.5 and the median radiation dose was 69.7 Gy. Grade 3 leukopenia was observed in three patients. All but one patient experienced grade 3 or 4 skin reactions, pharyngitis, or dysphagia. All but one patient achieved a complete response, and the remaining patient received radical neck dissection for persistent cervical lymphadenopathies, which contained no cancer cells. All six patients were disease-free at last contact, with a median follow up of 23.5 months. This regimen is well tolerated in patients with locoregionally advanced NPC.

Hyperfractionated radiation therapy for locoregionally advanced nasopharyngeal cancer.

OBJECTIVE: The purpose of this study is to clarify the efficacy and toxicity of hyperfractionated radiation therapy (RT) for patients with nasopharyngeal cancer (NPC). METHODS: Twenty-two patients with NPC treated at our hospital between April 1994 and December 2002 were the subjects of this study. They received hyperfractionated RT with a fraction size of 1.2 Gy, with a median tumor dose of 72 Gy (range 64.8-80.4). During this study period, our institutional strategy for locoregionally advanced NPC included neoadjuvant or concurrent chemotherapy combined with hyperfractionated RT, and 17 patients received some forms of cisplatin-containing chemotherapy. RESULTS: With a median follow-up of 59 months, the estimated 5-year disease-free survival rate and overall survival rate were 72.7 and 85.2%, respectively. Acute hematological toxicities were acceptable and manageable. However, >50% of patients required nutritional support, and experienced severe pharyngitis, skin reaction and body weight loss. With regard to late sequelae, one patient developed grade 3 osteomyelitis, and one patient each developed grade 4 passage disturbance and laryngeal edema. No patients experienced any grades of optic nerve injury or temporal lobe necrosis. CONCLUSIONS: Hyperfractionated RT using 1.2 Gy per fraction, for a total dose of 72 Gy, produces a comparable treatment outcome. Although deleterious neurological sequelae were not observed in this study, caution should be exercised regarding other late sequelae, such as osteomyelitis and passage disturbance.

Concurrent chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: is intergroup study 0099 feasible in Japanese patients?

BACKGROUND: Since the publication of the significant results of the Intergroup Study 0099 (IGS) in 1998, radical radiation therapy (RT) with concurrent and adjuvant chemotherapy has become the standard care for patients with locoregionally advanced nasopharyngeal carcinoma (NPC) in the United States. An update in 2001 further strengthened the findings of the interim analysis, however, no prospective randomized trials other than this study have confirmed the feasibility of this strategy. METHODS: We attempted to adopt the same combined modality treatment for three consecutive Japanese patients with locoregionally advanced NPC to evaluate its toxicity and efficacy. They were planned to receive radical RT concurrently with cisplatin every 3 weeks, and to receive adjuvant chemotherapy thereafter. RESULTS: The hematological toxicities were mild and well tolerated in all three patients; however, they all experienced severe (grade 3 and/or 4) skin reactions, pharyngitis and dysphagia, which led to the discontinuation of the planned chemotherapy. They were able to complete RT without treatment breaks, and all three patients achieved complete response at the end of treatment. However, two experienced recurrences after 8 and 10 months, respectively, and died of their disease. CONCLUSIONS: Due to these severe acute adverse events, poor compliance and unsatisfactory outcomes, we have concluded that physicians should be careful in applying the concurrent chemoradiotherapy protocol employed by the IGS for locoregionally advanced Japanese NPC patients.

Radiation bronchitis in lung cancer patient treated with stereotactic radiation therapy.

We report a case of chronic radiation bronchitis that developed in a patient with lung cancer treated with fractionated stereotactic radiation therapy. A 73-year-old woman with a medically inoperable T1N0M0 adenocarcinoma of the lung was treated with stereotactic radiation therapy. By using eight non-coplanar ports, 50 Gy/5 fractions was delivered in two weeks. At four weeks, a partial response was obtained with no acute adverse reaction. She developed severe cough at six months. Fiberoptic bronchoscopy revealed thick circumferentially coated bronchial mucosa in close proximity to the tumor site. At 12 months, follow-up study confirmed marked stenotic change in the B6 segmental bronchus without tumor progression.

Consolidation radiotherapy following brief chemotherapy for localized diffuse large B-cell lymphoma: a prospective study.

Many physicians administer involved field radiation therapy (RT) following brief chemotherapy for localized aggressive non-Hodgkin's lymphoma. Involved field irradiation usually implies treatment to the involved nodal regions with and without the contiguous lymphatic region, however, there is no agreements about its definition. Here we assess the appropriateness of RT irrespective of lymph node regions (localized field) following chemotherapy for patients with early stage diffuse large B-cell lymphoma. The localized field encompassed all original gross tumor volumes before chemotherapy with at least a 2- to 3-cm margin irrespective of lymphatic regions. We also evaluated the suitable radiation dose on the basis of response to chemotherapy. Twenty five eligible patients were treated with 3 cycles of chemotherapy (CHOP) followed by RT. All 25 patients had disease confined to Waldeyer's ring and/or cervical lymph nodes. Twenty two patients in complete response following chemotherapy received 30 Gy, and the remaining 3 in partial response received 40 Gy. With a median follow up of 42 months, both event free and overall survival rates at 2 years were 96.0%. There were no in-field recurrences, however, two patients experienced relapses. One developed central nervous system involvement and subsequently died of his disease. The other had mediastinal and submental lymph node relapse at 32 months, and is alive after salvage chemotherapy. Our study demonstrated that it should be possible to reduce treatment volume to less than the conventional involved field, and to limit the dose of RT in the range of 30-40 Gy.

Preoperative radiation therapy for carcinoma of the oropharynx: prognostic factors for locoregional control and survival.

BACKGROUND: To assess the role of preoperative irradiation and surgery in patients with oropharyneal cancer. MATERIALS AND METHODS: Seventy-five patients were treated with radiotherapy alone or followed by surgery. The stage distribution was stage II in 15 patients, stage III in 16 patients, stage IVA in 38 patients and stage IVB in 6 patients. RESULTS: Thirty-five patients were treated with radiotherapy alone and the remaining 40 underwent definitive surgery after radiation therapy. In the multivariate analysis, both good Karnofsky Performance Status (KPS) and complete response (CR) after radiation therapy had positive impact on locoregional control and survival. Overall survival at 5 years was 65% and 20% for KPS > or = 90% and KPS < 90%, respectively (p < 0.0001). Corresponding values for CR and non-CR were 80% and 35%, respectively (p = 0.0001). CONCLUSION: The results indicated that the KPS and complete response after radiation therapy were very sensitive surrogates for locoregional control and survival for cancer of the oropharynx.

Adjuvant pelvic irradiation in patients with node-negative carcinoma of the uterine cervix.

BACKGROUND: To assess the role of post-operative pelvic radiotherapy in cervical cancer patients without lymph node metastases. MATERIALS AND METHODS: The records of 61 patients with cervical cancer treated with radical hysterectomy and bilateral pelvic lymphadenectomy followed by pelvic irradiation were reviewed. The distribution of FIGO stage was IB in 34, II4 in 5 and IIB in 22. The patients were treated with 10-18 MV X-rays using a fractional daily dose of 1.8-2.0 Gy to a median total dose of 50 Gy. RESULTS: The actuarial 5-year pelvic control rate was 95%. There was no isolated pelvic lymph node recurrence. The overall 5-year survival of the entire group was 89%. The mean age of the patients who developed recurrence was lower than the other patients (46 years vs. 53 years, p=0.07). CONCLUSION: The results indicated that post-operative pelvic irradiation was effective in preventing pelvic recurrence in patients with node-negative cervical cancer.

[Development of stereotactic irradiation system of body tumors under respiratory gating].

Stereotactic radiosurgery for body tumors is hampered by the difficulties in body fixation and respiratory motions of the tumor. We have developed a Microton-based system for the stereotactic irradiation of body tumors, which delivers radiation at a predetermined respiratory phase. The patients are fixed non-invasively in the custom-made bed, and CT images are obtained. The isocentor is calculated with reference to those images and is marked onto the patient's skin and the custom-made bed. The patient lying on the bed is transferred to the treatment couch of the Microtoron. After reproducing the isocenter, actual treatment is started. The treatment couch as well as the gantry move automatically around the isocenter according to the treatment planning. The circular collimator moves by computer control to reduce geometrical errors to less than 0.5 mm, which is evoked by gantry movement. Respiratory movement of the abdominal wall is measured by laser displacement monitor. The Microtron delivers X-rays at a predetermined respiratory phase with a lag time of 20 msec after the on-signal from the monitor.

Stereotactic single high dose irradiation of lung tumors under respiratory gating.

PURPOSE: To investigate the feasibility of a stereotactic single high dose irradiation of lung tumors under respiratory gating and the clinical response. METHODS AND MATERIALS: Twenty-three malignant lung tumors less than 40mm in diameter were treated by a single fractional irradiation. RESULTS AND DISCUSSION: Local regrowth was seen in three of ten tumors irradiated less than 30Gy, the minimal dose. Only one regrowth was observed in the tumors treated by 30Gy of with a follow up length of 3-24 months. Apparently 30Gy is able to control the lung tumors with a diameter less than 40mm.