Multi-center planning study of radiosurgery for intracranial metastases through Automation (MC-PRIMA) by crowdsourcing prior web-based plan challenge study.

BACKGROUND: Planning radiosurgery to multiple intracranial metastases is complex and shows large variability in dosimetric quality among planners and treatment planning systems (TPS). This project aimed to determine whether autoplanning using the Muliple Brain Mets (AutoMBM) software can improve plan quality and reduce inter-planner variability by crowdsourcing results from prior international planning study. METHODS: Twenty-four institutions autoplanned with AutoMBM on a five metastases case from a prior international planning competition from which population statistics (means and variances) of 23 dosimetric metrics and resulting composite plan score (maximum score = 150) of other TPS (Eclipse, Monaco, RayStation, iPlan, GammaPlan, MultiPlan) were crowdsourced. Plan results of AutoMBM and each of the other TPS were compared using two sample t-tests for means and Levene's tests for variances. Plan quality of AutoMBM was correlated with the planner' experience and compared between academic and non-academic centers. RESULTS: AutoMBM produced plans with comparable composite plan score to GammaPlan, MultiPlan, Eclipse and iPlan (127.6 vs. 131.7 vs. 127.3 vs. 127.3 and 126.7; all p > 0.05) and superior to Monaco and RayStation (118.3 and 108.6; both p < 0.05). Inter-planner variability of overall plan quality was lowest for AutoMBM among all TPS (all p < 0.05). AutoMBM's plan quality did not differ between academic and non-academic centers and uncorrelated with planning experience (all p > 0.05). CONCLUSIONS: By plan crowdsourcing prior international plan challenge, AutoMBM produces high and consistent plan quality independent of the planning experience and the institution that is crucial to addressing the technical bottleneck of SRS to intracranial metastases.

A comparison of prone three-dimensional conformal radiotherapy with supine intensity-modulated radiotherapy for prostate cancer: which technique is more effective for rectal sparing?

The purpose of this study was to assess the potential dose reductions to the rectum with three-dimensional conformal radiotherapy in the prone position (prone 3D-CRT) compared with intensity-modulated radiotherapy in the supine position (supine IMRT) for prostate cancer. 17 prostate cancer patients underwent treatment planning CT scans in the supine and prone positions. Prone 3D-CRT and supine IMRT plans were constructed for each patient and compared in terms of the volume of rectum exposed to the V90 (volume of rectum receiving at least 90% of the prescription dose) as the high dose region. It was confirmed that supine IMRT was significantly superior to prone 3D-CRT (p = 0.023). Although, in some cases, the distance between the seminal vesicles and the rectum could change by more than 20 mm in the transition from supine to prone, the change in distance was approximately 5 mm in many other cases. While prone 3D-CRT resulted in significant improvements in some patients in terms of rectal sparing, the degree of the effect may be dependent on a patient's anatomy and physical condition in prone 3D-CRT compared with supine IMRT. If the cases in which prone 3D-CRT was more effective in rectal dose reduction could be extracted using some anatomical predictor before treatment planning, prone 3D-CRT may be appropriate in such a case. We consider that prone 3D-CRT still warrants further investigation because of its advantages in terms of simplicity, cost-effectiveness and labour saving; continued research to find an appropriate anatomical predictor is required.

Recovery oriented phosphorus adsorption process in decentralized advanced Johkasou.

Decentralized advanced wastewater treatment using adsorption and desorption process for recovery and recycling oriented phosphorus removal was developed. Adsorbent particles made of zirconium were set in a column, and it was installed as subsequent stage of BOD and nitrogen removal type Johkasou, a household domestic wastewater treatment facility. The water quality of the effluent of adsorption column in a number of experimental sites was monitored. The effluent phosphorus concentration was kept below 1 mg l(-1) during 90 days at all the sites. Furthermore, over 80% of the sites achieved 1 mg l(-1) of T-P during 200 days. This adsorbent was durable, and deterioration of the particles was not observed over a long duration. The adsorbent collected from each site was immersed in alkali solution to desorb phosphorus. Then the adsorbent was reactivated by soaking in acid solution. The reactivated adsorbent was reused and showed almost the same phosphorus adsorption capacity as a new one. Meanwhile, the desorbed phosphorus was recovered with high purity as trisodium phosphate by crystallization. It is proposed as a new decentralized system for recycling phosphorus that paves the way to high-purity recovery of finite phosphorus.

[A case of advanced esophageal carcinoma successfully treated with chemoradiation therapy with low-dose cisplatin and 5-fluorouracil].

We have experienced a case of advanced esophageal carcinoma successfully treated with chemoradiation therapy together with low-dose cisplatin and 5-fluorouracil, having only minor toxicity. A 55-year-old man was admitted to our hospital because of dysphagia. Cervical esophageal carcinoma was found to have invaded the larynx through endoscopy, and invasion to thyroid gland and trachea was suspected from a cervical CT. We diagnosed the condition as advanced esophageal carcinoma (A2N(-)M0Pl0 Stage III). We then treated the patient by chemoradiation therapy. After the treatment, the carcinoma could not be detected by CT and endoscopy, and endoscopic biopsy revealed there were no active carcinoma cells. The side effects of the therapy were very mild, therefore the patient could be discharged after a short time. No evidence of a tumor relapse was found 5 months after the therapy. We treated 4 patients with esophageal carcinoma using the same regimen, and the results of the therapy were 2 CR, 1 PR, and 1 PD, with an overall response rate of 75%.

[A case of advanced gastric cancer showing complete disappearance of cancer cells in multiple liver metastases due to low-dose PMUE therapy].

A case of gastric cancer with liver metastasis who responded well to low-dose PMUE (CDDP, MMC, UFT, etoposide) therapy is reported. A 65-year-old man underwent distal partial gastrectomy with D2 lymph node dissection under the diagnosis of type 5 gastric cancer with multiple liver metastases. Pathological findings revealed papillary adenocarcinoma in the primary lesion and metastatic lymph nodes (No. 8a). Low-dose PMUE therapy after resection of primary lesion was effective for the liver metastases. Exacerbation was suspected, so the lesions of metastases were resected again after 2 years and 11 months postoperative course. All 4 resected lesions of metastases became old fibrous tissue with hyalinization, and 2 of 4 lesions were necrotic and surrounded by fibrous connective tissue. None of these 4 lesions included viable cancer cells. The patient has now been followed with no evidence of exacerbation. It was suggested that low-dose PMUE therapy was effective for liver metastasis of gastric cancer, especially the differentiated type.

Correlation between DNA ploidy and clinical features in smooth muscle tumors of the gastrointestinal tract.

Paraffin-embedded tissue samples from 51 surgically resected, gastrointestinal smooth muscle tumors (10 leiomyomas, 5 leiomyoblastomas and 36 leiomyosarcomas) were assayed for nuclear DNA content, and the results were examined for correlation with clinico-pathological variables (tumor size, cellularity and mitosis) and prognosis. Twenty-four (47%) of the 51 tumors, consisting of 3 (30%) of the 10 leiomyomas, 2 (40%) of the 5 leiomyoblastomas and 19 (53%) of the 36 leiomyosarcomas, were identified as aneuploid. A close correlation was found between the mitotic index and the tumor size ( = 0.528; P < 0.001). The DNA ploidy pattern of the leiomyosarcoma was closely correlated with the patient survival periods (P = 0.06). The estimated median survival period was 73 months for patients with diploid tumors, and 51 months for those with aneuploid tumors. The 10-year survival rate for aneuploid tumors was lower than that for diploid tumors (P < 0.001). The measurement of DNA content may provide an index of prognostic value in gastrointestinal leiomyosarcomas.

[A case of gastric cancer with multiple liver metastases effectively treated with PMUE (CDDP, MMC, UFT, etoposide) hepatic arterial chemotherapy].

A 62-year-old male patient with progressive gastric cancer and multiple liver metastases (H3, P0, ss gamma, n4) underwent total gastrectomy (R1). After 2 years and 2 months, he was re-hospitalized with epigastric tumor caused by re-manifestation of liver metastasis as well as inappetence. Since a large focus of liver metastasis and intraportal tumor embolism was identified, a continuous intraarterial infusion tube utilizing Infuse-A-Port was inserted in the hepatic artery. After conducting 2 cycles of PMUE intra-arterial chemotherapy, the tumor size was reduced by 84% (PR); and CEA, which had been high upon rehospitalization, recovered to the normal level. After discharge, the patient has been receiving 5-FU arterial infusion as an outpatient and undergoing UFT oral chemotherapy. The efficacy has continued and he has been well for 3 years since operation. Often operations for gastric cancer accompanied with multiple liver metastasis meet with little success, and almost no case of prolonged survival has been reported. In this case, the effectiveness of PMUE arterial infusion chemotherapy was clear, the patient has been well for 3 years since operation, and is an interesting example with seemingly good prospects for long-survival.

Lymphatic flow in carcinoma of the head of the pancreas.

The lymphatic pathway from the head of the pancreas to the para-aortic lymph nodes was examined on the basis of the frequency of lymph node involvements. Forty-four patients were examined. All patients had extended radical operations. Thirty-one of 44 (70.5%) patients had lymph node involvement. The lymph nodes that had a high metastatic rate included the following: (1) lymph nodes around the common hepatic artery (number 8 lymph node); (2) lymph nodes of the hepatoduodenal ligament (number 12 lymph node); (3) the posterior pancreaticoduodenal lymph node (number 13 lymph node); (4) lymph nodes around the superior mesenteric artery (number 14 lymph node); (5) para-aortic lymph nodes (number 16 lymph node); and (6) the anterior pancreaticoduodenal lymph node (number 17 lymph node). Twenty-eight of these 31 patients had disease in the posterior pancreaticoduodenal lymph node. The patterns of lymph node involvement consisted of four combinations: number 13-number 17, number 13-number 14, number 14-number 16, and number 17-number 8. All of the patients with number 16 nodal involvement had number 14 lymph node metastasis. However, there was no relationship between tumor size and lymph node involvement. Based on these results, the main lymphatic pathway from the head of the pancreas to the para-aortic lymph nodes was thought to be via the lymph nodes around the superior mesenteric artery, assuming that lymphatic flow is anterograde. In addition, this study demonstrates that it is necessary to perform an extensive lymph node dissection, including the para-aortic lymph node, even in patients with small tumors.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis without calcifications is described. Pancreatolithiasis, or calcified pancreas, is recognized as a high risk factor for pancreatic cancer. However, epidemiologic studies have found that carcinoma of the pancreas associated with chronic pancreatitis was rare. The question is whether chronic pancreatitis without calcifications is actually a precancerous background lesion or not. This case suggests that hyperplasia of the pancreatic ductal epithelium may be a precancerous lesion for pancreatic cancer in some patients with chronic pancreatitis.

Acute pancreatitis associated with anomalous union of the pancreaticobiliary ductal system.

Between 1978 and 1989, 13 of 48 patients with anomalous union of the pancreaticobiliary ductal system (AUPBD) were diagnosed as having acute pancreatitis. We have studied the clinical, radiologic, and surgical features of these 13 patients. A transient rise in the intraductal pressure of the pancreatic duct during an episode of abdominal pain is responsible for pancreatitis in patients with AUPBD. This rise in the intraductal pressure must be due to bile reflux into the pancreatic duct when an abnormally long common channel is blocked by cholelithiasis, protein plug, or dysfunction of the sphincter of Oddi. The pancreatitis resolves when the common channel obstruction is removed, and bile and pancreatic juice flow easily into the duodenum. We believe that this phenomenon is responsible for acute relapsing pancreatitis. It is our belief that the pancreas appears almost normal during symptom-free intervals.

Prognostic factors in primary gastrointestinal leiomyosarcoma: a retrospective study.

Thirty-six patients who were admitted for surgical resection of leiomyosarcomas of the gastrointestinal tract to the Department of Surgery II, Kanazawa University Hospital, Kanazawa, Japan and its affiliates are included in the study. Follow-up data on survival is available for 32 patients. The clinico-pharmacologic variables, such as tumor site, tumor size, cellularity, mitotic index, and DNA ploidy pattern were analyzed and the results proved to correlate with the prognosis. Thirteen (41%) of the patients presented with distant metastases and/or recurrences, with hematogenous metastasis being the predominant type of recurrence. Local recurrences and/or distant metastases were significantly correlated with survival (p less than 0.001), as was tumor site (p less than 0.03), tumor size (p less than 0.04), surgical treatment (p = 0.05), and DNA ploidy pattern (p = 0.06). Neither the mitotic index nor the cellularity proved to be significantly correlated with survival. Furthermore, some of the patients with local recurrences or distant metastases survived long after resection of recurrent tumors. In view of the results, aggressive surgical resection may be an efficient treatment of recurrences.

[Candidiasis in the field of gastroenterological surgery].

Postoperative candidiasis in the gastroenterological surgery has an increasing tendency with poor prognosis particularly in generalized cases. Candida is difficult to be specified as infectious agent only by culture findings, and has a problem on rapidity and sensitivity. Furthermore, also as for the time starting antifungal treatment, the start after the blood culture has given positive result is problematic. We analyzed the present state of candidiasis in our department and studied its background factors. Totaling of 4,424 samples from all of bacterial and fungal culture tests performed at our department for recent 9 years revealed detection of Candida with the incidence of 24%. The incidence was about 2.5 times increased in the former half of the period as compared with the later half of the period. The background factors were intravenous hyperalimentation, major operations (long operative time, insertion of many drains), splenectomy, pancreatectomy, intensive chemotherapy, radiation therapy, hyperthermia therapy, aging, continuous use of steroids, etc. Then, we determined concentrations of beta-D-glucan, a fungal component, and evaluated the results since it is being applied to early diagnosis of candidiasis. We performed early antifungal treatment before confirmation of positive culture finding in high risk group of candidiasis and obtained effective results.

[A clinicopathological studies on gastrointestinal leiomyosarcomas, with special reference to prognosis].

Twenty-five cases of gastrointestinal leiomyosarcomas were subjected to clinico-pathological studies in an attempt to correlate the prognosis with tumor size, mitosis, cellularity and DNA ploidy pattern. Leiomyosarcomas greater than 5cm in diameter had poorer prognosis. Those with mitotic index larger than 3.0/mm2, cellularity larger than 3.0/0.0004mm2, DNA aneuploidy had poorer prognosis. By multiple regression analysis, mitotic index was useful for the prediction of tumor recurrence in earlier postoperative period, but cellularity, tumor size were useful for the prediction of recurrence in later postoperative period. As for the type of tumor recurrence, hematogenous metastasis was observed in 7 cases, peritoneal dissemination in 2 and local recurrence in 4. Four cases with local recurrence had all hematogenous metastasis. Two cases of gastric leiomyosarcomas developing local recurrence were greater than 10cm in diameter and gastric local resection was done for them. One case was diagnosed benign leiomyoma in the rectum histologically, but after trans-anal tumor resection local recurrence and metastasis to the lung occurred. We must pay attention to the surgical margin and the surface of tumor dissection during of the tumor, especially in larger tumors. Aggressive surgical resection is efficient for the treatment of recurrent tumors.