Interstitial round needles should not be used for cervical cancer patient treated with intracavitary/ interstitial brachytherapy using a Venezia applicator : a case report.

BACKGROUND: Image-guided adaptive brachytherapy (IGABT) demonstrates an excellent local control rate and low toxicity while treating cervical cancer. For intracavitary/interstitial (IC/IS) brachytherapy (BT), several applicators are commercially available. Venezia (Elekta, Sweden), an advanced gynecological applicator, is designed for IC/IS BT for treating locally advanced cervical cancer. There are two types of interstitial needles for the Venezia applicator: the round needle and sharp needle. Generally, a round needle is safer because it has less risk of damaging the organ at risk than a sharp needle. However, there is currently no evidence to suggest that a round needle is better than a sharp needle for the Venezia applicator in IC/IS BT. Herein, we documented our experience of using both round and sharp needles with the Venezia applicator in IC/IS BT for cervical cancer. CASE PRESENTATION: A 71-year-old woman was diagnosed with clinical stage T2bN0M0 and the International Federation of Gynecology and Obstetrics stage IIB cervical squamous cell carcinoma. Definitive therapy, including a high-dose-rate BT boost, was planned using a round needle with the Venezia applicator in IC/IS BT. After inserting four interstitial round needles during the first and second BT sessions, an unexpectedly large gap (1.5 cm) was detected between the cervix and ovoid. We therefore used a sharp needle with the Venezia applicator for IC/IS BT during the third and fourth BT sessions. Three sharp needles were firmly inserted during the third and fourth BT sessions. CONCLUSIONS: The study findings suggest that the interstitial round needle should not be used for cervical cancer patients undergoing IC/IS BT using the Venezia applicator.

A novel intra pre-plan method of interstitial needle optimization for cervical cancer patients treated with Venezia applicator brachytherapy: a technical note.

Purpose: Novel hybrid Venezia applicator enables intracavitary and interstitial brachytherapy (BT) for locally advanced cervical cancer. However, the method to determine the optimal interstitial needle number, position, and depth using this applicator is unknown. Therefore, we aimed to establish a method for reliable needle optimization. Material and methods: We produced a template model of the Venezia applicator with whole needles, and acquired computed tomography (CT) images (template CT). Using this template CT as a map, clinicians could define interstitial needle's insertion route in advance. During treatment, we first placed tandem and ovoid, and acquired a CT (tandem + ovoid CT). This was fused to the template CT by matching the contour of applicators with high accuracy. Then, we determined the optimal interstitial needle number, position, and depth to fit high-risk clinical target volume (HR-CTV) and avoid organs at risk (OARs) on the fused CT (intra pre-plan). Next, we re-inserted the tandem and ovoids with interstitial needle into patient's uterus and vagina. We inserted the optimized interstitial needle using insertion tool of optimal depth immediately following the applicator insertion. Lastly, a real-time treatment planning CT was performed, followed by planning and treatment. Results: We achieved a good dose distribution of Venezia applicator BT using intra pre-plan method to optimize the number of interstitial needles, position, and depth. Conclusions: This novel intra pre-plan method of interstitial needle optimization using template CT fusion provides high reproducibility, efficiency, and safety for patients with cervical cancer treated with brachytherapy using Venezia applicator.

Smoking-induced radiation laryngeal necrosis after definitive radiotherapy alone for T1a glottic squamous cell carcinoma: A case report.

BACKGROUND: We report the case of a patient with smoking-induced radiation laryngeal necrosis (RLN) after undergoing definitive radiotherapy (RT) alone for T1a glottic squamous cell carcinoma. CASE: The patient was a 63-year-old man who had a history of heavy smoking. He quit smoking when he was diagnosed with glottic squamous cell carcinoma. The RT dose was 63 Gy, delivered in 28 fractions with the three-dimensional conventional RT technique for the larynx. After RT completion, the initial treatment response was complete response. He then underwent follow-up examinations. At 13 months after RT, the patient resumed smoking. At 2 months after resuming smoking, he had severe sore throat and hoarseness. Laryngoscopy revealed a large tumor in the glottis. Surgical excision was performed, and the patient was histologically diagnosed with RLN, as late toxicity without cancer recurrence. At 3 weeks postoperatively, the patient had dyspnea, and laryngoscopy revealed total laryngeal paralysis. Thus, he underwent an emergent tracheostomy. The administration of steroids affected RLN, and laryngeal paralysis gradually improved. CONCLUSIONS: This case suggests that smoking may have the potential to induce RLN after RT. Moreover, continuing smoking cessation is significantly important for patients with glottic cancer who receive RT. Rather than leaving smoking cessation up to the patient, it would be necessary for clinicians to actively intervene to help patients continue their effort to quit smoking.

Laminaria tent insertion in preplanning MRI for CT-based cervical cancer brachytherapy.

PURPOSE: Preplanning magnetic resonance imaging (MRI) is routinely used in image-guided adaptive brachytherapy (IGABT) for cervical cancer. However, a preplanning MRI performed without an applicator does not have good accuracy of image fusion with a planning computed tomography (CT) performed with an applicator. This study aimed to evaluate the efficacy of laminaria tent insertion during pre-planning MRI for cervical cancer brachytherapy (BT). METHODS AND MATERIALS: Sixteen patients with cervical cancer were enrolled in the study. Images obtained from a single preplanning MRI performed with a laminaria tent inserted into the cervix were fused with images from the planning CT performed with an applicator during each BT session. The alignment between the high-risk clinical target volume on MRI (HR-CTVMRI) and planning CT (HR-CTVCT) was assessed. Image fusion accuracy was classified as follows: maximum misalignment between HR-CTVMRI and HR-CTVCT <5 mm was excellent, 5-10 mm as available, and >10 mm as not available. Image fusion accuracy was reviewed by two radiation oncologists. RESULTS: Fifty-nine BT sessions were analyzed. Fusion images for 39 (66%) sessions were categorized as excellent, and those for the remaining 12 (20%) sessions were available, and 8 (14%) were not available. Complications reported after laminaria tent insertion were grade-1 fever for 5 (8%) BT sessions in 5 patients and grade-1 pain for 8 (13%) sessions in 5 patients. CONCLUSION: Laminaria tent insertion during pre-planning MRI may improve the accuracy of image fusion with planning CT and may help delineate the HR-CTV in CT-based IGABT for cervical cancer.

A multi-institutional survey of the quality of life after treatment for uterine cervical cancer: a comparison between radical radiotherapy and surgery in Japan.

This study aimed to research the post-treatment quality of life (QOL) between radiotherapy (RT)- and operation (OP)-treated early cervical cancer survivors, using separate questionnaires for physicians and patients. We administered an observational questionnaire to patients aged 20-70 years old with Stages IB1-IIB cervical cancer who had undergone RT or OP and without recurrence as outpatients for ≥6 months after treatment. We divided 100 registered patients equally into two treatment groups (n = 50 each). The average age was 53 and 44 years in the RT and OP groups, respectively. The RT group included 34 and 66% Stage I and II patients, respectively, whereas the OP group included 66 and 34% Stage I and II patients, respectively. The OP group included 58% of patients with postoperative RT. Combination chemotherapy was performed in 84 and 48% of patients in the RT and OP groups, respectively. On the physicians' questionnaire, we observed significant differences in bone marrow suppression (RT) and leg edema (OP). On the patients' questionnaire, significantly more patients had dysuria and leg edema in the OP group than in the RT group, and severe (Score 4-5) leg edema was significantly higher in the post-operative RT group than in the OP only group. The frequency of sexual intercourse decreased after treatment in both groups. On the patients' questionnaire, there were no significant differences between the two groups regarding sexual activity. These findings are useful to patients and physicians for shared decision-making in treatment choices. The guidance of everyday life and health information including sexual life after treatment is important.

Treatment outcome of medium-dose-rate intracavitary brachytherapy for carcinoma of the uterine cervix: comparison with low-dose-rate intracavitary brachytherapy.

PURPOSE: To evaluate and compare the efficacy of medium-dose-rate (MDR) and low-dose-rate (LDR) intracavitary brachytherapy (ICBT) for uterine cervical cancer. METHODS AND MATERIALS: We evaluated 419 patients with squamous cell carcinoma of the cervix who were treated by radical radiotherapy with curative intent at Tokyo Women's Medical University from 1969 to 1999. LDR was used from 1969 to 1986, and MDR has been used since July 1987. When compared with LDR, fraction dose was decreased and fraction size was increased (1 or 2 fractions) for MDR to make the total dose of MDR equal to that of LDR. In general, the patients received a total dose of 60 to 70 Gy at Point A with external beam radiotherapy combined with brachytherapy according to the International Federation of Gynecology and Obstetrics stage. In the LDR group, 32 patients had Stage I disease, 81 had Stage II, 182 had Stage III, and 29 had Stage IVA; in the MDR group, 9 patients had Stage I disease, 19 had Stage II, 55 had Stage III, and 12 had Stage IVA. RESULTS: The 5-year overall survival rates for Stages I, II, III, and IVA in the LDR group were 78%, 72%, 55%, and 34%, respectively. In the MDR group, the 5-year overall survival rates were 100%, 68%, 52%, and 42%, respectively. No significant statistical differences were seen between the two groups. The actuarial rates of late complications Grade 2 or greater at 5 years for the rectum, bladder, and small intestine in the LDR group were 11.1%, 5.8%, and 2.0%, respectively. The rates for the MDR group were 11.7%, 4.2%, and 2.6%, respectively, all of which were without statistical differences. CONCLUSION: These data suggest that MDR ICBT is effective, useful, and equally as good as LDR ICBT in daytime (about 5 hours) treatments of patients with cervical cancer.

Prognostic significance of dysadherin and E-cadherin expression in patients with head and neck cancer treated by radiation therapy.

BACKGROUND: The aim of this study was to evaluate the impact of dysadherin and E-cadherin expression on the clinical outcomes, including the treatment outcomes and recurrence pattern, in patients with head and neck cancer. PATIENTS AND METHODS: Tumor specimens were obtained from 48 head and neck cancer patients who were treated by radiation therapy and the specimens were immunohistochemically stained for dysadherin and E-cadherin. The expressions were graded according to the percentage area occupied by cancer cells showing positive staining for E-cadherin and dysadherin as follows: grade 0, less than 10%; grade 1, 10-50%; grade 2, more than 50%. The correlations between the expression of E-cadherin and dysadherin and the clinical outcomes, including the treatment outcomes and recurrence pattern, were analyzed. RESULTS: The complete response (CR) rate in the patients with a dysadherin expression grade of 0 or 1 was 70% and that in the patients with dysadherin expression grade of 2 was 38%; the difference was significant (p < 0.05). Regarding the pattern of recurrence, the expression grade of dysadherin or E-cadherin alone was not correlated with the recurrence pattern; however, patients with a difference in the expression grade between dysadherin and E-cadherin (Dys-Ecad value) of 1 or 2 showed a significantly higher rate of lymph node and/or distant metastasis (55%) as compared with those with a Dys-Ecad value of < 1 (22%) (p < 0.05). CONCLUSION: Dysadherin and E-cadherin expression might serve as useful prognostic factors in patients with head and neck cancer treated by definitive radiation therapy.

Adnexal torsion of mature cystic teratoma with hemorrhagic infarction: helpful findings on successive plain abdominal radiographs.

Adnexal torsion is a relatively rare cause of lower abdominal pain in women, but in many cases it leads to a serious condition. We present a case of adnexal torsion of a mature cystic teratoma in which hemorrhagic infarction was reflected by progressive enlargement and wall thickening on successive plain abdominal radiographs. There has been no other report describing such changes of adnexal torsion on plain abdominal radiographs.

Phase III double-blind randomized trial of radiation therapy for stage IIIb cervical cancer in combination with low- or high-dose Z-100: treatment with immunomodulator, more is not better.

BACKGROUND: To evaluate the efficacy of low or high-dose immunomodulator, Z-100, in combination with radiotherapy for cervical cancer. METHODS: Between 1995 and 1999, 221 patients with stage IIIb squamous cell carcinoma of the cervix were randomly assigned to treatment with Z-100 either at 0.2 microg or 40 microg in a double-blind manner in combination with radiotherapy. RESULTS: The 5-year survival of patients with high-dose and low-dose Z-100 was 41.5% (95% CI: 31.7-51.3%) and 58.2% (95% CI: 48.7-67.7%), respectively, showing a 30% reduction in the death rate (hazard ratio: 0.670 [95% CI: 0.458-0.980], P = 0.039). Survival of high-dose group was equivalent to the 4-year survival of the radiotherapy plus hydroxyurea arm (49.7%) of GOG120 study, and that of low-dose group was similar to the survival of the cisplatin-based chemoradiation arm. The progression-free survival was also significantly improved in favor of low-dose group (hazard ratio: 0.667 [95% CI: 0.447-0.997], P = 0.048). The survival of low-dose group was similar to the survival of the cisplatin-based chemoradiation arms of the GOG120 study. CONCLUSIONS: Unexpectedly, the survival of patients with advanced cervical cancer treated by lower dose of Z-100 in combination with radiotherapy was significantly better than those treated with higher dose Z-100, which was equivalent to the survival with radiotherapy alone. The hypothesis that lower dose of Z-100 enhances the efficacy of radiation therapy is now being tested by placebo-controlled randomized trial.