Cesium implant for tongue carcinoma with a thickness of 1.5 cm or more: cases successfully treated with a Modified Manchester System.

PURPOSE: Deciding on treatment carcinoma of the tongue when the tumor has a thickness of 1.5 cm or more is difficult. Surgery often requires wide resection and re-construction, leading to considerable functional impairment. A cesium implant is an attractive option, but according to the Manchester System, a two plane implant is needed. MATERIALS AND METHODS: According to the textbook, a tumor is sandwiched between the needles, which are implanted at the edge of the tumor. This may cause an unnecessarily high dose to the outer surface of the tongue, which sometimes leads to a persistent ulcer. To avoid this complication, we invented a modified implantation method, and applied the method to five consecutive patients. RESULTS: With a minimum follow-up of 2 years, all primary tumors in 5 consecutive patients have been controlled. No complications occurred in soft tissue of the tongue or in the mandible. CONCLUSION: Our modified Manchester System was feasible and effective for tumors that has a thickness of 1.5 cm or more.

A comparison of diagnostic tools for Sjögren syndrome, with emphasis on sialography, histopathology, and ultrasonography.

OBJECTIVE: The present study examined the reliability and correlation of sialography, salivary gland biopsy, and ultrasonography for Sjögren syndrome (SS) and evaluated the usefulness of ultrasonography as a diagnostic tool for SS compared with sialography and histopathology. STUDY DESIGN: Seventy-three patients who underwent sialography, ultrasonography, and salivary gland biopsy were included in this study. The study evaluated the diagnostic reliability and correlation of each kind of examination with SS. RESULTS: There was a statistically significant difference in the sensitivities of sialography and histopathology, in the specificities of sialography and ultrasonography, and in the accuracies of sialography and both ultrasonography and histopathology. The correlation coefficient (r) between sialography and ultrasonography was significantly higher than the others and indicated a good correlation. CONCLUSIONS: Ultrasonography can be used as a diagnostic tool for SS, with its advantage of noninvasiveness and ease of use.

Experience of high-dose-rate brachytherapy for head and neck cancer treated by a customized intraoral mold technique.

Radiotherapy of head and neck cancer has become more successful with the advances in treatment modalities and use of a multidisciplinary approach. Higher quality treatment and a team approach to radiotherapy have thus been required for head and neck cancer. This study presents the clinical experience of high-dose-rate (HDR) brachytherapy for head and neck cancer treated by a customized intraoral mold technique. Two patients are reported for whom we created dental prostheses as the radiation carriers for HDR brachytherapy of their head and neck cancers. HDR brachytherapy with the dental prostheses reported here was feasible and effective for eradicating the head and neck cancer. It has been demonstrated that HDR brachytherapy using a customized intraoral technique can be a treatment option for patients who are not candidates for surgery or external irradiation. It is strongly suggested that specialized dentists are needed who are familiar with not only the anatomy and function of the head and neck region but also radiotherapy. Dental radiologists should take responsibility for constructing irradiation prostheses. If they do, they have the potential to improve the quality of life of patients who undergo radiotherapy for head and neck cancer.

A novel approach to advanced carcinoma of the tongue: cases successfully treated with combination of superselective intra-arterial chemotherapy and external/high-dose-rate interstitial radiotherapy.

OBJECTIVE: This study sought to evaluate the efficacy and safety of a novel treatment regimen, intra-arterial cisplatin infusion plus external/high-dose-rate radiotherapy. METHODS: Superselective intra-arterial infusion of cisplatin (100-120 mg) was performed concomitantly with external radiotherapy in four patients with locally advanced carcinoma of the tongue. A high-dose-rate brachytherapy boost was performed after combination therapy in all patients. Brachytherapy was performed after external radiotherapy, and the treatment schedule was twice daily, with a fraction of 600 cGy up to a total of 30-48 Gy. RESULTS: All patients completed the therapy as scheduled. There were no vascular or neurological complications. Grade III acute radiation mucositis developed in all patients but this did not necessitate a treatment break. With a mean follow-up period of 35 months, loco-regional control was obtained for all patients. CONCLUSIONS: The combination of weekly administration of intra-arterial cisplatin plus external/high-dose-rate radiotherapy seems effective for advanced carcinoma of the tongue.

Uncertainty in treatment of head-and-neck tumors by use of intraoral mouthpiece and embedded fiducials.

PURPOSE: To reduce setup error and intrafractional movement in head-and-neck treatment, a real-time tumor tracking radiotherapy (RTRT) system was used with the aid of gold markers implanted in a mouthpiece. METHODS AND MATERIALS: Three 2-mm gold markers were implanted into a mouthpiece that had been custom made for each patient before the treatment planning process. Setup errors in the conventional immobilization system using the shell (manual setup) and in the RTRT system (RTRT setup) were compared. Eight patients with pharyngeal tumors were enrolled. RESULTS: The systematic setup errors were 1.8, 1.6, and 1.1 mm in the manual setup and 0.2, 0.3, and 0.3 mm in the RTRT setup in right-left, craniocaudal, and AP directions, respectively. Statistically significant differences were observed with respect to the variances in setup error (p <0.001). The systematic and random intrafractional errors were maintained within the ranges of 0.2-0.6 mm and 1.0-2.0 mm, respectively. The rotational systematic and random intrafractional errors were estimated to be 2.2-3.2 degrees and 1.5-1.6 degrees , respectively. CONCLUSIONS: The setup error and planning target volume margin can be significantly reduced using an RTRT system with a mouthpiece and three gold markers.

Pilot study of modified version of CHOP plus radiotherapy for early-stage aggressive non-Hodgkin's lymphoma of the head and neck.

PURPOSE: To evaluate the safety and efficacy of a modified version of cyclophosphamide, doxorubicin, vincristine, prednisone (pirarubicin, cyclophosphamide, vincristine, and prednisone [THP-COP]) plus radiotherapy for early-stage aggressive non-Hodgkin's lymphoma of the head and neck. METHODS AND MATERIALS: Between December 1993 and December 1999, 41 patients with early-stage non-Hodgkin's lymphoma with intermediate-grade histologic features were enrolled in our study. The mean patient age was 51 years. Of the 41 patients, 27 had Stage I and 14 Stage II disease. The primary site was Waldeyer's ring, a neck node, or an extranodal site in 14, 11, and 16 patients, respectively. The immunophenotype was B cell in 29 and T cell in 12 patients. All patients were in the low-risk category according to the International Prognostic Index. Chemotherapy consisted of 40 mg/m(2) i.v. pirarubicin (THP-Adriamycin), 750 mg/m(2) i.v. cyclophosphamide, and 1.0 mg/m(2) i.v. vincristine, on Day 1 and 40 mg/m(2) p.o. prednisone on Days 1-5. The combination chemotherapy was given twice at a 14-day interval. Radiotherapy was given to involved areas at a fraction size of 2.0-2.5 Gy up to a total of 40 Gy within 4-5 weeks. The mean follow-up period was 63 months. RESULTS: The 5-year overall survival rate was 89%. The 5-year cause-specific survival and progression-free survival rate was 90% and 81%, respectively. The 5-year progression-free survival rate for patients with Waldeyer's ring primaries was 93%. Patients with tumor <5 cm in size had greater 5-year progression-free survival than those with tumor >5 cm in size (85% vs. 33%, p <0.05, log-rank test). Grade 4 neutropenia was seen in 12% of patients; however, 93% of patients (38 of 41) received chemotherapy as scheduled with the support of granulocyte colony-stimulating factor. CONCLUSION: Biweekly THP-COP plus radiotherapy is feasible and effective for Stage I-II low-risk non-Hodgkin's lymphoma.

Marginal resection for carcinoma of the mandibular alveolus and gingiva where radiologically detected bone defects do not extend beyond the mandibular canal.

PURPOSE: The study goal was to investigate the adequacy of marginal resection of the mandibular bone in cases of squamous cell carcinomas of the lower alveolus and gingiva where the radiologically detected bone defect does not extend beyond the mandibular canal. PATIENTS AND METHODS: Sixty-two patients who have had a mandibulectomy performed with or without preoperative radiotherapy and chemotherapy were the study subjects. This retrospective study investigated the correlation between the preoperative radiographic appearance and histopathologic findings of the excised tissue. The results of the treatments were evaluated. RESULTS: In the cases with erosive bone defects, the extent of the bone involvement did not exceed the extent of the radiographically detected bone defects. However, in 7 (36.8%) of the cases with moth-eaten type bone defects, the extent of bone involvement exceeded the bone defects detected by radiography. Further, 10 of the 16 cases with no apparent bone defect showed apparent bone involvement by the tumors histologically. There were no differences in the 5-year cumulative survival rate between the marginal resection and segmental groups. CONCLUSIONS: Marginal resection was effective in controlling mandibular alveolus and gingival cancers when radiologically detected erosive bone defects did not extend beyond the mandibular canal. Marginal resection was inadequate when moth-eaten defects were radiologically detected, except when the bone defects were confined to the alveolar bone.

A multi-institutional retrospective analysis of external radiotherapy for mucosal melanoma of the head and neck in Northern Japan.

PURPOSE: A multi-institutional retrospective study was performed in northern Japan to analyze the outcome of external radiotherapy as the definitive treatment modality for localized mucosal melanoma of the head and neck. PATIENTS AND METHODS: Thirty-one patients with localized mucosal melanoma of the head and neck treated by external radiotherapy at nine institutions of the Northern Japan Radiation Therapy Oncology Group between 1980 and 1999 were enrolled in this study. Radiotherapy alone was performed in 21 patients, and the remaining 10 patients received postoperative radiotherapy for gross residual tumors. The fraction size of radiotherapy varied from 1.5-13.8 Gy, with the total dose ranging from 32-64 Gy (median, 50 Gy). The follow-up periods ranged from 1-214 months (median, 16 months). RESULTS: Complete or partial responses were observed in 9 patients (29%) and 18 patients (58%), respectively. Local recurrence occurred in 13 patients (41.9%) and distant metastasis occurred in 11 patients (35.5%). Most incidences of local recurrence and distant metastasis developed within 2 years after the initial treatment. Overall cause-specific survival rates of patients at 1 and 3 years were 73% and 33%, respectively. Univariate analysis showed that high dose per fractionated radiotherapy doses (>or=3 Gy) was associated with better prognosis for both local control (p = 0.048) and survival (p = 0.045). Multivariate analysis indicated that age (better prognosis in younger patients, p = 0.046) was the only significant factor. Radiotherapy for gross residual lesions after surgery did not seem to impact the significant gain of local control and survival. We observed two fatal late complications of mucosal ulcer and bleeding in the high dose per fractionated radiotherapy group. CONCLUSION: Radiotherapy at a dose of 3 Gy or more per fraction was effective in gaining local control in patients with localized mucosal melanoma of the head and neck, and subsequently better survival was possible, especially in younger patients.

Clinical study of a spacer to help prevent osteoradionecrosis resulting from brachytherapy for tongue cancer.

OBJECTIVE: We sought to describe a simple method to construct a spacer and to evaluate with the use of computed tomography the spacer's effectiveness in preventing osteoradionecrosis of the mandible. STUDY DESIGN: Fifty-three patients with oral tongue cancers who were treated by means of interstitial brachytherapy were included in this study. Patients underwent a computed tomography examination immediately after the implantation of radioactive sources, with the spacers in place. Distances between the radioactive sources and the lingual surfaces of the mandible were measured on transverse computed tomographs and were evaluated in terms of the development of osteoradionecrosis in the mandible. RESULTS: Statistically significant differences in the frequency of osteoradionecrosis were observed between patients who had received spacers equal to or thicker than 5 mm and those who had received spacers less than 5 mm thick. CONCLUSION: A spacer should have a minimum thickness of 5 mm on its lingual flange to prevent the development of osteoradionecrosis of the mandible.

Image fusion between 18FDG-PET and MRI/CT for radiotherapy planning of oropharyngeal and nasopharyngeal carcinomas.

PURPOSE: Accurate diagnosis of tumor extent is important in three-dimensional conformal radiotherapy. This study reports the use of image fusion between (18)F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) and magnetic resonance imaging/computed tomography (MRI/CT) for better targets delineation in radiotherapy planning of head-and-neck cancers. METHODS AND MATERIALS: The subjects consisted of 12 patients with oropharyngeal carcinoma and 9 patients with nasopharyngeal carcinoma (NPC) who were treated with radical radiotherapy between July 1999 and February 2001. Image fusion between 18FDG-PET and MRI/CT was performed using an automatic multimodality image registration algorithm, which used the brain as an internal reference for registration. Gross tumor volume (GTV) was determined based on clinical examination and 18FDG uptake on the fusion images. Clinical target volume (CTV) was determined following the usual pattern of lymph node spread for each disease entity along with the clinical presentation of each patient. RESULTS: Except for 3 cases with superficial tumors, all the other primary tumors were detected by 18FDG-PET. The GTV volumes for primary tumors were not changed by image fusion in 19 cases (89%), increased by 49% in one NPC, and decreased by 45% in another NPC. Normal tissue sparing was more easily performed based on clearer GTV and CTV determination on the fusion images. In particular, parotid sparing became possible in 15 patients (71%) whose upper neck areas near the parotid glands were tumor-free by 18FDG-PET. Within a mean follow-up period of 18 months, no recurrence occurred in the areas defined as CTV, which was treated prophylactically, except for 1 patient who experienced nodal recurrence in the CTV and simultaneous primary site recurrence. CONCLUSION: This preliminary study showed that image fusion between 18FDG-PET and MRI/CT was useful in GTV and CTV determination in conformal RT, thus sparing normal tissues.