Adjuvant Radiotherapy after Surgical Excision in Keloids.

Keloids are a benign fibroproliferative disease with a high tendency of recurrence. Keloids cause functional impairment, disfigurement, pruritus, and low quality of life. Many therapeutic options have been used for keloids. However, the high recurrence rates have led to the use of adjuvant therapy after surgical keloid excision. There are different radiotherapy regimens available, and the advantages and disadvantages of each are still unclear. The aim of this review is to explain the appropriate radiotherapy regimen for keloids as well as discuss the recent reports on keloid management with radiotherapy. Adjuvant radiotherapy after surgical excision for keloids yields excellent local control with tolerable side effects. Hypofractionated radiotherapy with a BED of more than 28 Gy (α/ß value of 10) after excision is recommended in the light of its biologic background.

Bullying perpetration and victimization in elementary school students diagnosed with attention-deficit/hyperactivity disorder.

Previous research has found that attention-deficit/hyperactivity disorder (ADHD) in children is related to bullying perpetration. This study examined the correlation between ADHD and bullying perpetration, and aimed to identify which factors, including bullying victimization, predicted bullying. Forty-nine elementary school students, aged 6-12, participated voluntarily in a comparative study between children with ADHD and non-ADHD control children; none of them had previously undergone psychiatric treatment. Both parents' and participants' social demographic information (gender, age) and clinical variables were obtained from self-report questionnaires. The participants' bullying victimization experience, impulsivity, and parents' history of ADHD had significant relationships with bullying. The status of ADHD and other self-reported scales had no significant relationships with bullying. The association between bullying victimization and bullying perpetration was notable among all factors examined. This was consistent with the claims of prior studies that past victimization led to perpetration of bullying. Therefore, it seems that when treating victims of bullying, care should be taken, through proper intervention, to ensure the incident is neither repeated nor replicated. Characteristics associated with ADHD, including impulsivity and parents' history of ADHD, were significantly related to bullying. However, we could not confirm our hypothesis that ADHD itself might be associated with bullying behavior.

Pretreatment Neutrophil-to-Lymphocyte Ratio Combined with Platelet-to-Lymphocyte Ratio as a Predictor of Survival Outcomes after Definitive Concurrent Chemoradiotherapy for Cervical Cancer.

The aim of the study was to evaluate pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as prognostic factors for predicting clinical outcomes after definitive concurrent chemoradiotherapy (CCRT) for cervical cancer. The cases were divided into two groups based on the values of NLR and PLR: High NLR-PLR (high value in both NLR and PLR) and Low NLR-PLR (low value in either NLR or PLR). The relationships between survival outcomes and the pretreatment NLR-PLR were investigated. Of the 148 patients enrolled in the study, 30 patients died during the median follow-up of 75 months. Based on receiver operating curves, NLR and PLR cut-off values for survival analysis were 2.34 and 148.89. The 10-year overall survival and disease-free survival rates for high NLR-PLR vs. low NLR-PLR were 63.6% vs. 86.2% (p = 0.001) and 63.3% vs. 77.5% (p = 0.026), respectively. Based on a multivariate analysis, independent predictors of overall survival were high NLR-PLR (hazard ratio [HR], 2.435; 95% confidence interval [CI], 1.106-5.361; p = 0.027) and stage (HR 2.659; 95% CI, 1.146-6.613; p = 0.024). Increases in both NLR and PLR are associated with poor survival. Elevation in both NLR and PLR before initiation of CCRT may be a useful biomarker for predicting clinical outcomes.

Volume Change of Muscle and Fat Portions of Latissimus Dorsi Myocutaneous Flap after Breast Reconstruction.

BACKGROUND: Myocutaneous flaps are composed of muscle and fat portions, and exhibit volume changes with time. However, no consideration is generally given to volume changes of muscle and fat portions occurring in the flap. Therefore, we conducted this study to analyze the volume changes of muscle and fat portions of pedicled latissimus dorsi myocutaneous flaps over time. METHODS: Sixteen patients who underwent breast reconstruction using a latissimus dorsi myocutaneous flap between 2009 and 2017 were enrolled in this study. Using their postoperative computed tomography scan data, we measured the volume of muscle and fat portions of the flap, and performed a statistical analysis of volume changes over time. We also measured the volume of latissimus dorsi muscle on the opposite side and compared the difference in muscle volume. RESULTS: The volume of the muscle portion of latissimus dorsi myocutaneous flap decreased by approximately 24%, from 6 months to postoperative year 2; from the third year, it shrank with a decrease rate similar to that of normal muscle. The fat portion of the flap showed no regular volume changes. CONCLUSIONS: Atrophy of the muscle portion is the primary cause of volume change of latissimus dorsi myocutaneous flaps over time. it is necessary to understand the difference in the volume change patterns of the muscle and fat. To maintain a long-term satisfactory result, it is better to make the maximum possible use of the relatively stable fat portion rather than the muscle portion.

Factors Associated with the Quality of Life of Patients with Cancer Undergoing Radiotherapy.

OBJECTIVE: Approximately half of patients with cancer have comorbidities, such as adjustment disorder, major depressive disorder, and delirium. Radiotherapy can cause psychological problems, e.g., the fear of treatment and its side effects, anxiety, depression, and social isolation. Health-related quality of life (QoL) must be determined to evaluate the effectiveness of cancer treatment. We analyzed the clinical, psychological, and sociodemographic factors influencing the QoL of patients with cancer who were undergoing radiotherapy. METHODS: Twenty-six patients undergoing radiotherapy (10 male, 16 female) were included. Sociodemographic and clinical data were collected prior to radiotherapy. Psychosocial factors were assessed by self-reported questionnaires before, immediately after, and 3 months after radiotherapy. A multivariate regression analysis identified factors affecting QoL at each time point. RESULTS: Patients' diagnoses were breast, cervical, prostate, endometrial, rectal, hypopharyngeal, laryngeal, liver, gallbladder, esophageal, ovarian, lung, and skin cancers. Before radiotherapy, better resilience was significantly associated with a higher QoL score (R2=0.199, p=0.033). Immediately after radiotherapy, financial difficulty was significantly associated with a lower QoL score (R2=0.274, p=0.010). Three months after radiotherapy, the presence of chronic disease (R2=0.398, p=0.002) and the severity of nausea and vomiting were significantly associated with a lower QoL score (R2=0.278, p=0.014). CONCLUSION: Resilience, financial difficulty, the presence of chronic diseases, and the severity of nausea and vomiting significantly influenced the QoL of patients with cancer who were undergoing radiotherapy. Factors affecting QoL varied at each time point. Thus, patients with cancer should undergo regular mental health assessments, including assessments of QoL. Multidimensional (physical, psychological, and social) approaches and individualized time-based interventions are needed to improve the QoL of cancer patients undergoing radiotherapy.

Clinical significance of lymph node size in locally advanced cervical cancer treated with concurrent chemoradiotherapy.

Background: This study aimed to assess the in-field lymph node (LN) failure rate according to LN size and to investigate effect of LN size on the survival outcome of patients with locally advanced cervical carcinoma treated with concurrent chemoradiotherapy (CCRT). Methods: A total of 310 patients with locally advanced cervical carcinoma treated with CCRT were enrolled in retrospective study. LN status was evaluated by magnetic resonance imaging. All patients received conventional external beam irradiation and high-dose rate brachytherapy, and concurrent cisplatin-based chemotherapy. In-field LN failure rate according to LN size was analyzed. Results: The median follow-up period was 83 months (range, 3-201 months). In-field LN failure rate in patients with pelvic LN size more than 10 mm was significantly higher than that in patients with pelvic LN size less than 10 mm (p<0.001). A similar finding was observed in the in-field para-aortic LN (PALN) failure rate (p=0.024). The pelvic and PALN size (≥10 mm) was a significant prognostic factor of overall-survival (OS) and disease-free survival rate in univariate and multivariate analyses. The OS rate was significantly different between groups according to LN size (<10 mm vs. ≥10 mm). Conclusion: A LN of less than 10 mm in size in an imaging study is controlled by CCRT. On the other hand, in LN of more than 10 mm in size, the in-field LN failure rate increase and the prognosis deteriorate. Therefore, a more aggressive treatment strategy is needed.

Inevitable high-dose irradiation to lead of implantable cardioverter defibrillator in small cell lung cancer: a case report.

BACKGROUND: Radiotherapy has been shown to cause malfunction of implantable cardioverter-defibrillators, and there are few studies of implantable cardioverter-defibrillators and radiotherapy. We report an unusual case of small cell lung cancer in a patient with an implantable cardioverter-defibrillator in whom direct irradiation to the electrode and lead could not be avoided. CASE PRESENTATION: We report a case of radiotherapy in a 72-year-old Korean man with a limited stage of small cell lung cancer who had undergone insertion of an implantable cardioverter-defibrillator because of ventricular fibrillation. The radiation dose was 60 Gy in 30 fractions to the thorax. The mean dose and maximum dose estimated at the body of the implantable cardioverter-defibrillator were 0.89 Gy and 2.23 Gy, respectively. The mean and maximum doses of the lead and electrode were 17.12 Gy and 55.72 Gy in the lead and 1.81 Gy and 7.10 Gy in the electrode, respectively, because part of the lead and electrode was inevitably in the irradiated fields. The function of the patient's implantable cardioverter-defibrillator was checked daily, and no change in implantable cardioverter-defibrillator function was observed for the duration of radiotherapy. The patient was tolerated the treatment well without severe complications. Computed tomography performed at 4 weeks after radiotherapy showed a good response with regression of the tumor. The patient was alive with complete remission of the tumor and without any implantable cardioverter-defibrillator dysfunction more than 36 months after the end of treatment. CONCLUSIONS: This case demonstrates that radiotherapy may be a safe and effective treatment modality through careful monitoring of implantable cardioverter-defibrillators in patients with lung cancer who have implantable cardioverter-defibrillators.

Dummy Run of Quality Assurance Program before Prospective Study of Hippocampus-Sparing Whole-Brain Radiotherapy and Simultaneous Integrated Boost for Multiple Brain Metastases from Non-small Cell Lung Cancer: Korean Radiation Oncology Group (KROG) 17-06 Study.

PURPOSE: Lung Cancer Subcommittee of Korean Radiation Oncology Group (KROG) has recently launched a prospective clinical trial (KROG 17-06) of hippocampus-sparing whole brain radiotherapy (HS-WBRT) with simultaneous integrated boost (SIB) in treating multiple brain metastases from non-small cell lung cancer. In order to improve trial quality, dummy run studies among the participating institutions were designed. This work reported the results of two-step dummy run procedures of the KROG 17-06 study. MATERIALS AND METHODS: Two steps tested hippocampus contouring variability and radiation therapy planning compliance. In the first step, the variation of the hippocampus delineation was investigated for two representative cases using the Dice similarity coefficients. In the second step, the participating institutions were requested to generate a HS-WBRT with SIB treatment plan for another representative case. The compliance of the treatment plans to the planning protocol was evaluated. RESULTS: In the first step, the median Dice similarity coefficients of the hippocampus contours for two other dummy run cases changed from 0.669 (range, 0.073 to 0.712) to 0.690 (range, 0.522 to 0.750) and from 0.291 (range, 0.219 to 0.522) to 0.412 (range, 0.264 to 0.598) after providing the hippocampus contouring feedback. In the second step, with providing additional plan priority and extended dose constraints to the target volumes and normal structures, we observed the improved compliance of the treatment plans to the planning protocol. CONCLUSION: The dummy run studies demonstrated the notable inter-institutional variability in delineating the hippocampus and treatment plan generation, which could be decreased through feedback from the trial center.

Salvage para-aortic lymphadenectomy in recurrent cervical cancer after visualization with 3-dimensional computed tomography angiography.

We report a case of salvage lymphadenectomy for an isolated metastatic lesion in the para-aortic lymph node (LN) in a 49-year old woman with a history of cervical cancer, initially treated with radical hysterectomy and adjuvant radiotherapy. Preoperative 3-dimensional (3D) computed tomography (CT) angiography clearly revealed a huge retro-crural metastatic LN with distinct demarcation. A metastatic lesion, more than 10 cm in size, was located behind the vena cava, aorta, and left kidney, encompassing the left renal and lumbar arteries. The metastatic LN was excised along with the left kidney. On histologic examination, the tumor was found to have invaded the pelvis of the left kidney. Compared with conventional imaging techniques, 3D CT angiography can more clearly visualize such lesions. Thus, 3D CT angiography provides useful anatomical information, such as the exact size and location, and provides clear visualization and demarcation.

Theta-phase gamma-amplitude coupling as a neurophysiological marker in neuroleptic-naïve schizophrenia.

Theta-phase gamma-amplitude coupling (TGC) was used as an evidence-based tool to reflect the dysfunctional cortico-thalamic interaction in patients with schizophrenia. The aim of the present study was to evaluate the diagnostic utility of TGC. The subjects included 90 patients with schizophrenia and 90 healthy controls. We compared the TGC results between the groups using an analysis of covariance (ANCOVA) to adjust for age and sex and receiver operator characteristic (ROC) curve analyses to examine the discrimination ability of delta to gamma frequency bands and TGC. Patients with schizophrenia showed a significant increase in the resting-state TGC at all 19 electrodes. The analysis of the ROC curves for each frequency band exhibited relatively low classification accuracies for the delta, theta, slow alpha, fast alpha, and beta power. The TGC generated the most accurate results among the electroencephalography (EEG) measures, with an overall classification accuracy of 92.5%. The resting-state TGC value was increased in patients with schizophrenia compared to that in healthy controls and had a higher discriminating ability than the other parameters. These findings may be related to the compensatory hyper-arousal patterns of the dysfunctional default-mode network (DMN) in schizophrenia. Therefore, resting-state TGC is a promising neurophysiological marker of schizophrenia.

Age and sex-related differences in risk factors for elderly suicide: Differentiating between suicide ideation and attempts.

OBJECTIVE: The purpose of this study was to analyze the age and sex-related differences in socio-demographic factors that influence suicide ideation and attempts in the elderly. METHODS: The total number of subjects was 93 151, of whom 8441 belonged to the high suicide-risk group (2064 male; 6377 female). Following this identification, we investigated their socio-demographic information, health status, and depressive symptoms, which might have influenced their suicide ideation and attempts. RESULTS: Residence in an urban area was identified as a risk factor for both male and female elderly in their 60s and 70s and female elderly in their 80s. Marital status showed a different influence on suicide ideation depending on age and sex. A negative perception of one's own health status was a significant risk factor that increased the likelihood of suicide ideation in all ages, except the female elderly in their 60s. No factor was identified that significantly influenced suicide attempts in the male elderly. However, in the female elderly, residence in an urban area and a negative perception of one's own health status were identified as significant risk factors. CONCLUSIONS: This study revealed that factors known to influence suicide ideation in the elderly from previous studies, such as residence area, separation from a spouse, education level, religion, and drinking, show changed influence as the elderly reach their 70s and 80s. However, a negative perception of one's own health status was a risk factor that encompassed most ages and sexes.

Prophylactic extended-field irradiation with concurrent chemotherapy for pelvic lymph node-positive cervical cancer.

PURPOSE: This study aimed to evaluate whether prophylactic extended-field pelvic radiotherapy (EF-PRT) yields better results than standard whole pelvic radiotherapy (WPRT) in patients with pelvic lymph node-positive cervical cancer treated with concurrent chemoradiotherapy (CCRT). MATERIALS AND METHODS: A total of 126 cases of stage IB-IVA cervical cancer that had pelvic lymph node involvement in magnetic resonance imaging and were treated with CCRT between 2000 and 2016 were reviewed. None of the patients had paraaortic lymph node (PALN) metastases. The patients were classified to two groups, namely, those treated with EF-PRT, including prophylactic para-aortic radiotherapy, and those treated only with WPRT. The median dose to the PALN area in patients treated with EF-PRT was 45 Gy. All patients received concurrent cisplatin-based chemotherapy. RESULTS: Overall, 52 and 74 patients underwent EF-PRT and WPRT, respectively. Patient characteristics and irradiated dose were not significantly different, except the dose to the para-aortic area, between the two groups. The median follow-up period was 75.5 months (range, 5 to 195 months). The 10-year cumulative recurrence rate of PALN for EF-PRT vs. WPRT was 6.9% and 10.1% (p = 0.421), respectively. The 10-year disease-free survival and overall survival for EF-PRT vs. WPRT were 69.7% vs. 66.1% (p = 0.748) and 71.7% vs. 72.3% (p = 0.845), respectively. Acute gastrointestinal complications were significantly higher in EF-PRT (n = 21; 40.4%) than WPRT (n = 26; 35.1%) (p = 0.046). Late toxicities were not significantly different in both groups. CONCLUSION: In this study, prophylactic radiotherapy for PALN does not have an additional benefit in patients with pelvic lymph node-positive cervical cancer treated with CCRT.

Salvage radiotherapy for regional lymph node oligo-recurrence after radical surgery of non-small cell lung cancer.

BACKGROUND: Currently, evidence-based guidelines for salvage therapy to treat mediastinal lymph node (LN) oligo-recurrence in post-resection non-small cell lung cancer (NSCLC) are limited. In patients previously treated by surgery without irradiation, radiotherapy (RT) might be safely utilized. We evaluate the clinical outcomes of salvage RT for patients with LN oligo-recurrence that developed after radical surgery for NSCLC. METHODS: Thirty-one patients with stage I-IIIA NSCLC who developed regional LN oligo-recurrence between 2008 and 2013 were reviewed. The median time from surgery to recurrence was 12 months. Fifteen patients (48.4%) had single LN recurrence. All patients were irradiated by 3-dimensional conformal RT at the recurrent LN area with daily fractions of 2-3 Gy, with a median dose of 66 Gy (range 51-66). Sixteen patients also received chemotherapy. RESULTS: After salvage RT, 16 patients achieved a complete response, nine a partial response, and six had stable disease. The median follow-up was 14 months (range 3-76). One and two-year in-field control rates were 88.4% and 75.8%, respectively. One and two-year progression-free survival rates were 73.1% and 50.9%, respectively. Progression sites were predominantly distant. Ten of the 31 patients (32.3%) met the revised Response Evaluation Criteria for Solid Tumors for a complete response by the final follow-up. Recurrent LN size (<3 vs. ≥3 cm) was a significant prognostic factor for progression-free survival (P = 0.013). CONCLUSION: Salvage RT for patients with regional LN oligo-recurrence after radical surgery was an effective treatment option with an acceptable level of toxicity.

Patterns of failure after the reduced volume approach for elective nodal irradiation in nasopharyngeal carcinoma.

PURPOSE: To evaluate the patterns of nodal failure after radiotherapy (RT) with the reduced volume approach for elective neck nodal irradiation (ENI) in nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS: Fifty-six NPC patients who underwent definitive chemoradiotherapy with the reduced volume approach for ENI were reviewed. The ENI included retropharyngeal and level II lymph nodes, and only encompassed the echelon inferior to the involved level to eliminate the entire neck irradiation. Patients received either moderate hypofractionated intensity-modulated RT for a total of 72.6 Gy (49.5 Gy to elective nodal areas) or a conventional fractionated three-dimensional conformal RT for a total of 68.4-72 Gy (39.6-45 Gy to elective nodal areas). Patterns of failure, locoregional control, and survival were analyzed. RESULTS: The median follow-up was 38 months (range, 3 to 80 months). The out-of-field nodal failure when omitting ENI was none. Three patients developed neck recurrences (one in-field recurrence in the 72.6 Gy irradiated nodal area and two in the elective irradiated region of 39.6 Gy). Overall disease failure at any site developed in 11 patients (19.6%). Among these, there were six local failures (10.7%), three regional failures (5.4%), and five distant metastases (8.9%). The 3-year locoregional control rate was 87.1%, and the distant failure-free rate was 90.4%; disease-free survival and overall survival at 3 years was 80% and 86.8%, respectively. CONCLUSION: No patient developed nodal failure in the omitted ENI site. Our investigation has demonstrated that the reduced volume approach for ENI appears to be a safe treatment approach in NPC.

PET/CT planning during chemoradiotherapy for esophageal cancer.

PURPOSE: To evaluate the usefulness of positron emission tomography/computed tomography (PET/CT) for field modification during radiotherapy in esophageal cancer. MATERIALS AND METHODS: We conducted a retrospective study on 33 patients that underwent chemoradiotherapy (CRT). Pathologic findings were squamous cell carcinoma in 32 patients and adenocarcinoma in 1 patient. All patients underwent PET/CT scans before and during CRT (after receiving 40 Gy and before a 20 Gy boost dose). Response evaluation was determined by PET/CT using metabolic tumor volume (MTV), total glycolytic activity (TGA), MTV ratio (rMTV) and TGA ratio (rTGA), or determined by CT. rMTV and rTGA were reduction ratio of MTV and TGA between before and during CRT, respectively. RESULTS: Significant decreases in MTV (MTV2.5: mean 70.09%, p < 0.001) and TGA (TGA2.5: mean 79.08%, p<0.001) were found between before and during CRT. Median rMTV2.5 was 0.299 (range, 0 to 0.98) and median rTGA2.5 was 0.209 (range, 0 to 0.92). During CRT, PET/CT detected newly developed distant metastasis in 1 patient, and this resulted in a treatment strategy change. At a median 4 months (range, 0 to 12 months) after completion of CRT, 8 patients (24.2%) achieved clinically complete response, 11 (33.3%) partial response, 5 (15.2%) stable disease, and 9 (27.3%) disease progression. SUVmax (p = 0.029), rMTV50% (p = 0.016), rMTV75% (p = 0.023) on intra-treatment PET were found to correlate with complete clinical response. CONCLUSION: PET/CT during CRT can provide additional information useful for radiotherapy planning and offer the potential for tumor response evaluation during CRT. rMTV50% during CRT was found to be a useful predictor of clinical response.