Successful Management of Radiation-Associated Insufficiency Fracture of the Tibial Plateau with Low-Intensity Pulsed Ultrasound.

BACKGROUND Clinical management of radiation-associated pathological fracture is challenging because of a high nonunion rate and potential for morbidity. We report a case of radiation-associated insufficiency fracture of the tibial plateau after surgery, perioperative chemotherapy, and adjuvant radiation therapy for synovial sarcoma of the proximal calf that was successfully treated with low-intensity pulsed ultrasound (LIPUS). CASE REPORT A healthy 52-year-old Japanese woman presented with a slowly growing, painful soft tissue mass over her proximal calf. Histological examination of core needle biopsy specimens led to a pathological diagnosis of synovial sarcoma. After perioperative ifosfamide and doxorubicin chemotherapy and surgical resection, adjuvant radiation therapy was administered, with a total of 60 Gy in 30 fractions. At 5 months after surgery and 2 months after the completion of radiation therapy, she developed an insufficiency pathological fracture of the proximal tibia without any apparent trauma. The patient was treated with LIPUS for 1 year. There was no collapse or deformity of the knee joint. The patient remained free of symptoms and had no recurrences for 2 years after surgery. CONCLUSIONS This is the first report of radiation-associated pathological fracture that was successfully treated with LIPUS. LIPUS could be a safe and effective treatment option in the management of radiation-associated pathological fractures.

Clinical results of carbon-ion radiotherapy with separation surgery for primary spine/paraspinal sarcomas.

PURPOSE: To evaluate the clinical outcome of combination of carbon-ion radiotherapy with separation surgery (CIRT-SS) in patients with primary spinal/paraspinal sarcoma (PSPS) and epidural spinal cord compression (ESCC). METHODS: CIRT-SS was performed in 11 consecutive patients. Patients treated in the primary and salvage settings were categorized into Group A (n = 8) and Group B (n = 3), respectively. Clinical results and imaging findings were collected, with a particular focus on ESCC grade, treatment-associated adverse events (AEs), and the locoregional control (LRC) rate and overall survival (OS). RESULTS: The median follow-up period from the start of CIRT-SS was 25 months (7-57 months). ESCC was improved by SS in all cases. No patients exhibited radiation-induced myelopathy (RIM), but three developed Grade 3 vertebral compression fracture (VCF) during follow-up. Locoregional recurrences were observed in four patients [Group A: 1 (12.5%), Group B: 3 (100%)]. Over the entire follow-up period, three patients developed distant metastases and two patients died. The 2-year LRC rate and OS were 70% and 80%, respectively. CONCLUSION: CIRT-SS in the primary setting achieved acceptable LRC and OS without RIM in patients with PSPS and with ESCC. VCF was the most frequent AE associated with CIRT-SS.

[The timing of the appearance of oral mucositis induced by concurrent chemoradiotherapy with S-1 for head and neck cancer].

Oral mucositis is a frequent adverse event in patients receiving concurrent chemoradiotherapy for head and neck cancer. Although the management of oral mucositis is essential to improve treatment completion rates, no detailed studies on the time of oral mucositis appearance have been reported. We conducted a retrospective study on the timing of the appearance of oral mucositis induced by concurrent chemoradiotherapy with S-1 for head and neck cancer. A total of 11 patients with head and neck cancer who received concurrent chemoradiotherapy with S-1 were examined. All patients developed oral mucositis within 13.8 ± 5.6 days after the initiation of radiotherapy (20.4 ± 8.1 Gy). In addition, the effects of pain-associated symptoms caused by oral mucositis on the patients' nutritional status, including reduction in caloric intake (24.4% ± 31.1%), weight loss (5.2% ± 5.2%), and duration of a regular diet (24.5 ± 17.1 days), were observed and lasted until the completion of radiation therapy. The delineation of the timing of oral mucositis appearance has become a key motivator for the patients to perform oral care proactively to limit severity and serves as a necessary index for monitoring oral health and managing pain and nutrition.

Advantage of early induction of opioid to control pain induced by irradiation in head and neck cancer patients.

OBJECTIVE: Although radiotherapy is effective for head and neck cancer patients, the local pain evoked by the irradiation itself reduces food intake and frequently halts the treatment. Thus, pain control is an important problem in radiotherapy for head and neck cancer. We performed to examine whether early induction of low-dose, opioid from mild pain improves dietary and caloric intake, while reducing weight loss. METHODS: The subjects were 43 patients who were hospitalized for head and neck cancer from 2004 to 2008. They were patients who underwent radiation treatment but those who did not undergo preoperative treatment. They were divided into two groups, depending on whether the pain was mild or moderate when an opioid was introduced (MILD and MODERATE, N=23 and 20, respectively). RESULTS: The visual analog scale scores for pain were significantly lower in the MILD than in the MODERATE group at between 25 and 50 Gy. The amount of oxycodone used for pain was significantly lower in the MILD than the MODERATE group. A regular diet was maintained for significantly longer in the MILD group. Caloric intake was significantly higher in the MILD group at over 20 Gy. Weight loss was significantly lower in the MILD group at over 20 Gy. The incidence of side effects was equal in both groups. CONCLUSION: Our results indicated that the introduction of opioids for mild pain during radiotherapy controls the level of pain, improving food intake in head and neck cancer patients.

A Case of Radiation Fibrosis Appearing as Mass-Like Consolidation after SBRT with Elevation of Serum CEA.

We report a case of radiation fibrosis appearing as mass-like consolidation, which was difficult to distinguish from local recurrence. A 72-year-old woman was diagnosed as having primary lung cancer (cT1N0M0 stage IA) in the right upper lobe and was treated with SBRT of 48 Gy in 4 fractions. After 12 months, mass-like consolidation appeared around the irradiated area, and after 13 months, it had increased in size. FDG-PET revealed high uptake (SUV max = 5.61) for the consolidation. CT-guided biopsy was performed, but we could not confirm the diagnosis. Considering her poor respiratory function and her age, short-interval follow-up was performed. After 15 months, the consolidation enlarged at the dorsal side, and carcinoembryonic antigen (CEA) became elevated (14.6 ng/mL). Serum KL-6 (436 U/mL) and SP-D (204 ng/mL) were also elevated. However, after 16 months, serum CEA slightly decreased. The consolidation gradually retracted on follow-up CT images. CEA, KL-6, and SP-D were also decreased by degrees. After 40 months, there is no evidence of local recurrence.

Carboplatin and etoposide combined with radiotherapy for limited-stage small-cell esophageal carcinoma: three cases and review of the literature.

PURPOSE: Small-cell esophageal carcinoma (SCEC) is a rare disease for which standard therapy has not yet been established. We report the results of three cases of limited-stage SCEC treated with combination therapy using carboplatin (CBDCA) and etoposide (VP-16) and radiotherapy. MATERIALS AND METHODS: The clinical stage according to the Japanese Classification of Esophageal Cancer 7th ed. was stage III in 2 cases and stage IVa in 1. These patients with limited-stage SCEC were treated at our institution with four cycles of CBDCA and VP-16, either concurrent with radiotherapy for the second two cycles (n = 2) or followed by radiotherapy after the last cycle (n = 1). RESULTS: A complete response (CR) was obtained for all three patients, resulting in a response rate of 100%. Two patients are alive at 16.4 and 22.5 months after initial treatment. One patient died with myeloid leukemia at 43.5 months after initial treatment. None of the patients had loco-regional recurrence. Brain metastasis was detected in one patient at 7 months after initial therapy and was treated with stereotactic radiotherapy combined with whole brain irradiation. CONCLUSION: CBDCA and VP-16 in combination with radiotherapy should be considered an important treatment option for SCEC.

Chemoradiation for small cell esophageal carcinoma: report of 11 cases from multi-institution experience.

Small cell esophageal carcinoma(SCEC) is a rare disease with aggressive behavior and poor prognosis. Because of the rarity of this disease, standard therapy has not yet been established. The objective of this retrospective study was to report the outcomes of SCEC treated with chemotherapy and radiotherapy from a retrospective study of 11 patients. We enrolled 11 SCEC patients who were treated with radiation therapy (more than 50 Gy) and chemotherapy between May 1996 and October 2007. Patients' age ranged from 44 to 77 years (mean: 69 years). In all patients, pathological examination of the specimen obtained by biopsy revealed small cell carcinoma. All patients were treated with chemotherapy and radiation therapy. The mean follow-up time was 14.7 months, and the median overall survival time of all patients was 13.2 months (range: 4.2-43.6 months). The 1-year and 3-year overall survival rates were 63% and 24%, respectively, while the 1-year and 3-year progression-free survival rates were 45% and 14%, respectively. Five of seven patients with complete response (CR) developed recurrent disease. Recurrence sites were distant metastases in four patients and lymph node outside the radiation field in one patient. Chemoradiation should be considered as one of the important treatment options for the loco-regional control in the patients with SCEC.

Corrugated fiberboard as a positioning insert for patients undergoing radiotherapy.

We have developed a new body fixation system for single patient use, which consists of a vacuum cushion, a thermoplastic fixation sheet which is used to suppress involuntary and voluntary patient movement, and a triple-wall corrugated fiberboard base plate to which both the vacuum cushion and the thermoplastic sheet are affixed. To evaluate the characteristics of the fiberboard as a patient-positioning insert, the photon beam attenuation of a fiberboard base plate, a carbon-fiber base plate, and a vacuum-formed cushion were compared. The strength of the fiberboard was also evaluated. The attenuation for the carbon-fiber base plate was 3.7% and 2.6% in 4 MV and 10 MV photon beams, respectively, while the results were less for the fiberboard base plate, i.e. 1.9% and 1.6%. The vacuum-formed cushion had a minimal effect on transmission. None of the materials subsided under the weight loading of 20 g/cm(2). There was no difference between the thicknesses of the fiberboard before and after a 50 times daily load with the 60 kg weight of a volunteer. Corrugated fiberboard is a robust and low attenuating material that functions well as a patient-positioning insert.

Predictive factors of esophageal stenosis associated with tumor regression in radiation therapy for locally advanced esophageal cancer.

The purpose of this retrospective study was to clarify the predictive factors correlated with esophageal stenosis within three months after radiation therapy for locally advanced esophageal cancer. We enrolled 47 patients with advanced esophageal cancer with T2-4 and stage II-III who were treated with definitive radiation therapy and achieving complete response of primary lesion at Kyushu University Hospital between January 1998 and December 2005. Esophagography was performed for all patients before treatment and within three months after completion of the radiation therapy, the esophageal stenotic ratio was evaluated. The stenotic ratio was used to define four levels of stenosis: stenosis level 1, stenotic ratio of 0-25%; 2, 25-50%; 3,50-75%; 4,75-100%. We then estimated the correlation between the esophageal stenosis level after radiation therapy and each of numerous factors. The numbers and total percentages of patients at each stenosis level were as follows: level 1: n = 14 (30%); level 2: 8 (17%); level 3: 14 (30%); and level 4: 11 (23%). Esophageal stenosis in the case of full circumference involvement tended to be more severe and more frequent. Increases in wall thickness tended to be associated with increases in esophageal stenosis severity and frequency. The extent of involved circumference and wall thickness of tumor region were significantly correlated with esophageal stenosis associated with tumor regression in radiation therapy (p = 0.0006, p = 0.005). For predicting the possibility of esophageal stenosis with tumor regression within three months in radiation therapy, the extent of involved circumference and esophageal wall thickness of the tumor region may be useful.

Advanced olfactory neuroblastoma treated with combined conventional and hypofractionated stereotactic radiotherapy.

Three patients with olfactory neuroblastoma (ONB) of the nasal and/or paranasal cavity were treated with a combination of conventional radiotherapy (RT) and hypofractionated stereotactic radiation therapy (SRT). Radiation doses of 30 to 50 Gy were delivered in 12 to 25 fractions using conventional RT, and then an additional 20 to 25 Gy was delivered in 5 fractions using SRT. Follow-up time was 42, 53, 65 months, three patients were alive, and local control was obtained in all, complete response (CR) in 2 and partial response (PR) in 1. Two patients had recurrence out of the radiation field and received salvage therapy. According to the Radiation Therapy Oncology Group (RTOG) acute/late radiation morbidity scoring criteria, there were no adverse effects of grade 3 or higher. The combined treatment with conventional RT and hypofractionated SRT achieved excellent local control without serious adverse effects.

Effective palliative radiotherapy in primary malignant melanoma of the esophagus: a case report.

INTRODUCTION: Primary malignant melanoma of the esophagus is a rare but highly aggressive tumor with poor prognosis. Surgical resection is the treatment of choice. However, some cases may be diagnosed with advanced inoperable disease. Palliative radiotherapy may be used to relieve symptoms caused by the esophageal tumor. CASE PRESENTATION: We report on a case of advanced inoperable primary malignant melanoma of the esophagus treated with palliative radiotherapy. The patient's dysphagia resolved with radiotherapy. CONCLUSION: Malignant melanoma of the esophagus is rare. Patients with advanced inoperable malignant melanomas of the esophagus benefit from radiation therapy. Radiation therapy is effective for palliation.

Spontaneous pneumothorax after stereotactic radiotherapy for non-small-cell lung cancer.

The report presented here describes a case of spontaneous pneumothorax observed after stereotactic radiotherapy (SRT) for non-small-cell lung cancer (NSCLC). An 84-year-old man with a Stage IIB, T3N0M0 NSCLC in the right upper lobe and a Stage IA NSCLC in the right lower lobe of the lung was treated with SRT for both tumors. He received SRT with a total dose of 60.0 Gy in 10 fractions delivered to the right upper lobe, and 48.0 Gy in 4 fractions delivered to the right lower lobe. Two months after completion of the treatment, he developed spontaneous pneumothorax. He was asymptomatic and recovered with conservative management. Spontaneous pneumothorax has occasionally been reported to occur following thoracic radiotherapy for malignancy. Almost all of the reported cases are patients who had received mantle irradiation for Hodgkin's disease. We have been unable to fi nd any reports of spontaneous pneumothorax after SRT, which has recently been used for treating patients with early-stage NSCLC. Because a case of spontaneous pneumothorax after SRT was observed in our institution, its clinical course is described here along with a discussion of possible causes of spontaneous pneumothorax.

Preliminary results of radiation therapy for locally advanced or recurrent adenoid cystic carcinomas of the head and neck using combined conventional radiation therapy and hypofractionated inverse planned stereotactic radiation therapy.

PURPOSE: To investigate the clinical outcomes and feasibility of combined conventional radiation therapy (RT) and hypofractionated inverse planned stereotactic radiation therapy (SRT) for locally advanced or recurrent adenoid cystic carcinomas (ACCs) of the head and neck. PATIENTS AND METHODS: Five patients with ACCs of the head and neck were treated with combined conventional RT and inverse planned SRT. Radiation doses of 40 to 50 Gy were delivered with 20 to 25 fractions using conventional RT, and then an additional 20 to 25 Gy was delivered by 4 to 5 fractions of SRT. RESULTS: Median follow-up was 12 months. Local control was obtained in all 5 patients, PR in 2 patients and SD in 3 patients. According to the Radiation Therapy Oncology Group (RTOG) late-radiation morbidity scoring criteria, adverse effects included Grade 2 xerostomia in 1 patient, Grade 2 trismus in 1 patient, and Grade 4 mucosal ulceration in 1 patient. CONCLUSION: Combined treatment with conventional RT and hypofractionated inverse planned SRT may be effective for short-term local control in patients with locally advanced or recurrent ACCs. Further evaluation is needed for long-term follow-up.

Malignant myoepithelioma in the maxillary sinus: case report and review of the literature.

Malignant myoepithelioma of the head and neck usually arises in the salivary glands. We experienced a rare case with malignant myoepithelioma in the maxillary sinus. A 47-year-old woman with malignant myoepithelioma in the maxillary sinus underwent partial maxillectomy. However, local recurrence occurred 28 months after surgery and she was subsequently treated with radiation therapy with proton beams. The recurrent tumor showed complete response and the patient was alive with no evidence of disease 30 months after irradiation. No therapy-related severe toxicities were observed. A rare case with malignant myoepithelioma in the maxillary sinus was successfully treated with radiation therapy.

Retrospective analysis: concurrent chemoradiotherapy and adjuvant chemotherapy for T2N0 glottic squamous cell carcinoma.

This study aimed to evaluate the efficacy and toxicity of concurrent chemoradiotherapy and adjuvant chemotherapy for T2N0 glottic squamous cell carcinoma. Between May 1993 and March 2004, 32 patients with T2N0 glottic squamous cell carcinoma received concurrent chemoradiotherapy as the primary treatment modality for larynx preservation. Radiotherapy was delivered five days a week using a once-daily fractionation of 2.0 Gy (median total dose: 70 Gy). The chemotherapy regimen comprised carboplatin in 4 patients, carboplatin and tegafur and uracil in 7, carboplatin and futraful in 2, and futraful in 19 patients. Twenty-four patients received adjuvant chemotherapy with tegafur and uracil. Initial local tumor control was achieved in 30 patients (94%). The 5-year overall survival and 5-year local control rates were 97% and 70%, respectively. Univariate analysis revealed adjuvant chemotherapy as a significant prognostic factor for the local control rate (P = 0.038). The 5-year local control rate in patients treated or not treated with adjuvant chemotherapy was 82% and 42%, respectively. No significant differences in the local control rate were noted in overall treatment time, total radiation dose, age, and disease extension to the subglottis. With regard to adverse reactions, grade 3 neutropenia and grade 3 hepatotoxicity were observed in 1 and 2 patients, respectively. We observed no severe late complications (RTOG/EORTC criteria Grade 3-4) related to this combination therapy. Concurrent chemoradiotherapy and adjuvant chemotherapy was effective but with mild toxicity, and adjuvant chemotherapy significantly improved local control. We suggest the use of this combination therapy for achieving a local control of T2N0 glottic squamous cell carcinoma.

Breath-hold monitoring and visual feedback for radiotherapy using a charge-coupled device camera and a head-mounted display: system development and feasibility.

PURPOSE: The aim of this study was to present the technical aspects of the breath-hold technique with respiratory monitoring and visual feedback and to evaluate the feasibility of this system in healthy volunteers. METHODS AND MATERIALS: To monitor respiration, the vertical position of the fiducial marker placed on the patient's abdomen was tracked by a machine vision system with a charge-coupled device camera. A monocular head-mounted display was used to provide the patient with visual feedback about the breathing trace. Five healthy male volunteers were enrolled in this study. They held their breath at the end-inspiration and the end-expiration phases. They performed five repetitions of the same type of 15-s breath-holds with and without a head-mounted display, respectively. A standard deviation of five mean positions of the fiducial marker during a 15-s breath-hold in each breath-hold type was used as the reproducibility value of breath-hold. RESULTS: All five volunteers well tolerated the breath-hold maneuver. For the inspiration breath-hold, the standard deviations with and without visual feedback were 1.74 mm and 0.84 mm, respectively (P = 0.20). For the expiration breath-hold, the standard deviations with and without visual feedback were 0.63 mm and 0.96 mm, respectively (P = 0.025). CONCLUSION: Our newly developed system might help the patient achieve improved breath-hold reproducibility.

Radiation therapy for recurrent esophageal cancer after surgery: clinical results and prognostic factors.

OBJECTIVE: To evaluate the outcome of radiotherapy for recurrent esophageal cancer after surgery and to determine the prognostic factors. METHODS: From 1987 through 2002, 82 patients treated with radiotherapy for loco-regional recurrences of esophageal cancer after surgery were retrospectively reviewed. The stage at initial surgery was I in 16, II in 41, III or higher in 24 and unknown in 1. The median size of recurrent tumors was 3.5 cm in diameter. Fifty-two patients were treated with radiotherapy alone, and 30 were treated with radiotherapy combined with chemotherapy. The median total dose of external radiotherapy given was 50.4 Gy in 28 fractions. RESULTS: The median survival period after recurrence was 7.0 months. The 2- and 5-year overall survival rate for all patients was 22 and 11%, respectively. In univariate analysis, the patients with performance status (PS) = 0-1, or tumor size <3.5 cm, and those treated with total dose >/=50 Gy showed a better survival outcome than each the other groups. The patients with a history of previous radiotherapy showed a poorer survival outcome in univariate analysis than each the other groups. In multivariate analysis, tumor size, PS and radiation dose were independent prognostic factors for overall survival. CONCLUSION: The prognosis of patients with post-operative loco-regional recurrence of esophageal cancer is poor. However, a long-term survival may be expected by definitive radiotherapy for the patients with small-size tumors and with a good PS.

Long-term local control of recurrent adenoid cystic carcinoma in the parotid gland with radiotherapy and intraarterial infusion chemotherapy.

We report a case of postoperative recurrence of adenoid cystic carcinoma in the left parotid gland treated with radiotherapy and arterial infusion chemotherapy. A 52-year-old woman had a history of surgical resection for an adenoid cystic carcinoma arising from the left parotid gland 25 years before. Despite two reoperations for local recurrence after the initial surgery, she had a third local recurrence in the remnant of the left parotid gland. The patient was treated with a concurrent combination of radiotherapy (60 Gy/30F) and intraarterial infusion chemotherapy with carboplatin (750 mg/30 days) from which she obtained a complete response. The patient has remained free of local progression 54 months after treatment. Radiotherapy and arterial infusion chemotherapy is effective treatment for local recurrence of adenoid cystic carcinoma in the head and neck.