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Lin YH, Hung SK, Chiou WY, Lee MS, Shen MD BJ, Chen LC, Liu DW, Tsai WT, Lin PH, Shih YT, Hsu FC, Tsai SJ, Chan MW, Lin HY. Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma: A care-compliant case report. Medicine (Baltimore) 2016; 95:e4717. [PMID: 27559982 PMCID: PMC5400349 DOI: 10.1097/md.0000000000004717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 07/18/2016] [Accepted: 08/03/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Clinically, elderly patients with unresectable bulky hepatocellular carcinoma (HCC) are difficult to manage, especially in those with co-infections of hepatitis B and C virus. Herein, we reported such a case treated with radiotherapy (RT) by using combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy (SIEB-VMAT). After RT, significant symptoms alleviation and durable tumor control were observed. CASE SUMMARY At presentation, an 85-year-old male patient complained abdominal distention/pain, poor appetite, and swelling over bilateral lower limbs for 1 month. On physical examination, a jaundice pattern was noted. Laboratory studies showed impaired liver and renal function. Abdominal computed tomography (CT) revealed a 12.5-cm bulky tumor over the caudate lobe of the liver. Biopsy was done, and hepatocellular carcinoma (HCC) was reported histopathologically. As a result, AJCC stage IIIA (cT3aN0M0) and BCLC stage C were classified. Surgery, radiofrequency ablation (RFA), trans-catheter arterial chemoembolization (TACE), and sorafenib were not recommended because of his old age, central bulky tumor, and a bleeding tendency. Thus, RT with SIEB-VMAT technique was given alternatively. RT was delivered in 26 fractions, with dose gradience as follows: 39 Gy on the outer Plan Target Volume (PTV), 52 Gy in the middle PTV, and 57.2 Gy in the inner PTV. Unexpectedly, cyproheptadine (a newly recognized potential anti-HCC agent) was retrospectively found to be prescribed for alleviating skin itching and allergic rhinitis since the last 2 weeks of the RT course (2 mg by mouth Q12h for 24 months).After RT, significant symptoms alleviation and tumor volume reduction were observed for 32 months till multiple bone metastases. Before and after RT, a large tumor volume reduction rate of 88.7% was observed (from 608.4 c.c. to 68.7 c.c.). No severe treatment toxicity was noted during and after RT. The patient died due to aspiration pneumonia with septic shock at 4 months after bone metastases identified. CONCLUSIONS SIEB-VMAT physically demonstrated double benefits of intratumor dose escalation and extra-tumor dose attenuation. Significant tumor regression and symptoms alleviation were observed in this elderly patient with unresectable bulky HCC. Further prospective randomized trials are encouraged to demarcate effective size of SIEB-VMAT with or without cyproheptadine.
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Affiliation(s)
- Young-Hsiang Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Bing-Jie Shen MD
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Dai-Wei Liu
- Department of Radiation Oncology, Buddhist Tzu Chi General Hospital
- School of Medicine, Tzu Chi University, Hualien
| | - Wei-Ta Tsai
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei
- Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung
| | - Po-Hao Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Yi-Ting Shih
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Feng-Chun Hsu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shiang-Jiun Tsai
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Michael W.Y. Chan
- Institute of Molecular Biology, Department of Life Science
- Human Epigenomics Center
- National Chung Cheng University, Min-Hsiung, Chia-Yi, Taiwan, ROC
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
- Institute of Molecular Biology, Department of Life Science
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Jin P, van der Horst A, de Jong R, van Hooft JE, Kamphuis M, van Wieringen N, Machiels M, Bel A, Hulshof MCCM, Alderliesten T. Marker-based quantification of interfractional tumor position variation and the use of markers for setup verification in radiation therapy for esophageal cancer. Radiother Oncol 2015; 117:412-8. [PMID: 26475250 DOI: 10.1016/j.radonc.2015.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/30/2015] [Accepted: 10/04/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study was to quantify interfractional esophageal tumor position variation using markers and investigate the use of markers for setup verification. MATERIALS AND METHODS Sixty-five markers placed in the tumor volumes of 24 esophageal cancer patients were identified in computed tomography (CT) and follow-up cone-beam CT. For each patient we calculated pairwise distances between markers over time to evaluate geometric tumor volume variation. We then quantified marker displacements relative to bony anatomy and estimated the variation of systematic (Σ) and random errors (σ). During bony anatomy-based setup verification, we visually inspected whether the markers were inside the planning target volume (PTV) and attempted marker-based registration. RESULTS Minor time trends with substantial fluctuations in pairwise distances implied tissue deformation. Overall, Σ(σ) in the left-right/cranial-caudal/anterior-posterior direction was 2.9(2.4)/4.1(2.4)/2.2(1.8) mm; for the proximal stomach, it was 5.4(4.3)/4.9(3.2)/1.9(2.4) mm. After bony anatomy-based setup correction, all markers were inside the PTV. However, due to large tissue deformation, marker-based registration was not feasible. CONCLUSIONS Generally, the interfractional position variation of esophageal tumors is more pronounced in the cranial-caudal direction and in the proximal stomach. Currently, marker-based setup verification is not feasible for clinical routine use, but markers can facilitate the setup verification by inspecting whether the PTV covers the tumor volume adequately.
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Affiliation(s)
- Peng Jin
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands.
| | - Astrid van der Horst
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Rianne de Jong
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Martijn Kamphuis
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Niek van Wieringen
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Melanie Machiels
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
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Liu SL, Yang H, Zhang P, Zhang L, Zhao L, Luo LL, Fu JH, Liu MZ, Xi M. Neoadjuvant chemoradiotherapy with cisplatin plus vinorelbine versus cisplatin plus fluorouracil for esophageal squamous cell carcinoma: A matched case-control study. Radiother Oncol 2015; 116:262-8. [PMID: 26243678 DOI: 10.1016/j.radonc.2015.07.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 06/16/2015] [Accepted: 07/16/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND To compare the clinical outcomes of neoadjuvant chemoradiotherapy (CRT) with cisplatin/vinorelbine versus cisplatin/fluorouracil in patients with locally advanced esophageal cancer. METHODS Between 2000 and 2012, 279 patients with thoracic esophageal squamous cell carcinoma (SCC) undergoing neoadjuvant CRT followed by surgery were reviewed. Through a matched case-control study, 57 patients treated with cisplatin/vinorelbine were matched 1:1 to patients who received cisplatin/fluorouracil according to age, sex, performance status, tumor location, tumor length, and pretreatment TNM stage. RESULTS Patient and disease-related characteristics were comparable between the two groups. The pathologic complete response (pCR) rate was 47.4% for the cisplatin/vinorelbine group and 28.1% for the cisplatin/fluorouracil group (P=0.034). Median overall survival (OS) in the cisplatin/vinorelbine group was significantly better compared with the cisplatin/fluorouracil group (52.8 vs. 25.2 months), with 3-year OS rates of 64.3% vs. 31.3%, respectively (P=0.001). However, cisplatin/vinorelbine was associated with a significantly higher rate of grade 3-4 leukopenia than cisplatin/fluorouracil (P=0.03). Multivariate analysis showed that being female, age ⩾55 years, pCR after CRT, and chemotherapy with cisplatin/vinorelbine were independent positive prognostic factors for survival. CONCLUSIONS Cisplatin/vinorelbine might lead to a higher pCR rate and better survival outcomes than cisplatin/fluorouracil in esophageal SCC. The incidence of hematologic toxicity is increased with cisplatin/vinorelbine, but is tolerable and manageable. Prospective controlled studies are required to confirm the efficacy of this regimen.
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Affiliation(s)
- Shi-Liang Liu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Hong Yang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Thoracic Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Peng Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Li Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Lei Zhao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Li-Ling Luo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Jian-Hua Fu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Thoracic Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Meng-Zhong Liu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Mian Xi
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, China.
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