Cardiac angiosarcoma with metastatic to lung, brain, and bone

Cardiac angiosarcoma is a malignant tumor derived from vascular endothelium with a dismal prognosis. The imaging findings of cardiac angiosarcoma are nonspecific and endomyocardial and pericardial biopsies have insufficient accuracy. For these reasons, the diagnosis is sometimes difficult. Primary and metastatic tumors tend to bleed easily, causing hemoptysis and neurological symptoms. Brain metastases are not often known to be fatal when they cause hemorrhage. We report a 27-year-old man diagnosed with right atrium angiosarcoma, with metastases in the lung, brain, and bone. The patient had only respiratory symptoms at the first visit and did not show any symptoms derived from brain metastases yet died after 27 days due to hemorrhage from brain metastases. If brain metastasis from angiosarcoma is suspected based on imaging findings, urgent radiotherapy should be considered before histological examination for a definitive diagnosis.

The influence of image reconstruction methods on the diagnosis of pulmonary emphysema with convolutional neural network

This study investigated the influence of iterative reconstruction (IR) methods on computed tomography (CT) images when training convolutional neural network (CNN) models to diagnose pulmonary emphysema. To evaluate the influence of the IR algorithm on CNN, the present study comprised two steps: the comparison of noise reduction by IR algorithms using phantom examinations and the change in performance of CNN with IR algorithms using patient data. We retrospectively analyzed 97 patients. Raw CT data were reconstructed using the filtered back-projection (FBP) and adaptive statistical iterative reconstruction V (ASIR-V) algorithms with blending levels of 30%, 50%, and 70%. The models were trained using reconstructed CT images and were named the FBP, ASIR-V30, ASIR-V50, and ASIR-V70 models. The mean and the standard deviation of the CT values were 11.3 ± 21.2 at FBP, 11.0 ± 17.3 at ASIR-V30, 11.0 ± 14.4 at ASIR-V50, and 11.0 ± 11.8 at ASIR-V70. For all the evaluation metrics, the best values were obtained with the FBP model applied to the ASIR-V70 test images. The worst values were obtained with the ASIR-V70 model applied to the FBP test images. The model trained with FBP images exhibited significantly better performance than the models trained using IR images. The reduction in image noise with the IR algorithm on the test images contributed to improving the accuracy of the classification of emphysema subtypes using CNN.

Palliative brachytherapy and external beam radiotherapy for dysphagia from esophageal cancer: a nationwide survey in Japan

BACKGROUND

International guidelines recommend brachytherapy for patients with dysphagia from esophageal cancer, whereas brachytherapy is infrequently used to palliate dysphagia in some countries. To clarify the availability of palliative treatment for dysphagia from esophageal cancer and explain why brachytherapy is not routinely performed are unknown, this study investigated the use of brachytherapy and external beam radiotherapy for dysphagia from esophageal cancer.

METHODS

Japanese Radiation Oncology Study Group members completed a survey and selected the treatment that they would recommend for hypothetical cases of dysphagia from esophageal cancer.

RESULTS

Of the 136 invited facilities, 61 completed the survey (44.9%). Four (6.6%) facilities performed brachytherapy of the esophagus, whereas brachytherapy represented the first-line treatment at three (4.9%) facilities. Conversely, external beam radiotherapy alone and chemoradiotherapy were first-line treatments at 61 and 58 (95.1%) facilities, respectively. In facilities that performed brachytherapy, the main reason why brachytherapy of the esophagus was not performed was high invasiveness (30.2%). Definitive-dose chemoradiotherapy with (≥50 Gy) tended to be used in patients with expected long-term survival.

CONCLUSIONS

Few facilities routinely considered brachytherapy for the treatment of dysphagia from esophageal cancer in Japan. Conversely, most facilities routinely considered external beam radiotherapy. In the future, it will be necessary to optimize external beam radiotherapy.

Practice patterns for postoperative radiation therapy in patients with metastases to the long bones: a survey of the Japanese Radiation Oncology Study Group

Evidence regarding postoperative radiation therapy (PORT) for metastases to the long bones is lacking. Characterizing the current practice patterns and identifying factors that influence dose-fractionation schedules are essential for future clinical trials. An internet-based survey of the palliative RT subgroup of the Japanese Radiation Oncology Study Group was performed in 2017 to collect data regarding PORT prescription practices and dose-fractionation schedules. Responders were also asked to recommend dose-fractionation schedules for four hypothetical cases that involved a patient with impending pathological fractures and one of four clinical features (poor prognosis, solitary metastasis, radio-resistant primary tumor or expected long-term survival). Responders were asked to indicate their preferred irradiation fields and the reasons for the dose fractionation schedule they chose. Responses were obtained from 89 radiation oncologists (67 institutions and 151 RT plans) who used 22 dose-fractionation schedules, with the most commonly used and recommended schedule being 30 Gy in 10 fractions. Local control was the most common reason for preferring longer-course RT. High-dose fractionated schedules were preferred for oligometastasis, and low-dose regimens were preferred for patients with a poor prognosis; however, single-fraction RT was not preferred. Most respondents recommended targeting the entire orthopedic prosthesis. These results indicated that PORT using 30 Gy in 10 fractions to the entire orthopedic prosthesis is preferred in current Japanese practice and that single-fraction RT was not preferred. Oligometastasis and poor prognosis influenced the selection of high- or low-dose regimens.

Evaluation of a Monte Carlo-based algorithm for the influence of totally implantable venous access ports in external radiation therapy

PURPOSE

This study aimed to assess whether a Monte Carlo (MC)-based algorithm reflects the influence of totally implantable venous access ports (TIVAPs) in external radiation therapy.

MATERIALS AND METHODS

The present study comprised two steps: experimental measurements of depth doses and surface doses with and without TIVAPs and calculation with an MC-based algorithm.

RESULTS

The TIVAP-associated maximum dose reduction compared with the dose at the same depths without TIVAPs was 7.8% at 4 MV, 6.9% at 6 MV, and 5.7% at 10 MV in measurement, and 7.4% at 4 MV, 6.6% at 6 MV, and 5.5% at 10 MV in calculation. Relative surface doses were higher with TIVAPs made of titanium, due to a higher fluence of backscattered electrons from the TIVAPs, than with plastic TIVAPs. There were no significant differences in the relative differences between the measured and calculated doses of the titanium TIVAP group and the plastic TIVAP group at 4 MV (p = 0.99), 6 MV (p = 0.67), and 10 MV (p = 0.54).

CONCLUSION

TIVAPs caused target dose reductions and dose increase near the TIVAP, especially when made of titanium. The influences are reflected in the MC-based algorithm.

Japanese structure survey of radiation oncology in 2012

This paper describes the ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution to identify and overcome any existing limitations. From March 2013 to August 2016, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2012. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 213 000 and 251 000, respectively. Additionally, the estimated cancer incidence was 865 238 cases with ~24.6% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 864), telecobalt (n = 0), Gamma Knife (n = 44), 60Co remote afterloading system (RALS; n = 23) and 192Ir RALS (n = 130). The LINAC system used dual-energy functions in 651 units, 3D conformal radiotherapy functions in 759 and intensity-modulated radiotherapy (IMRT) functions in 466. There were 792 Japan Radiological Society/Japanese Society for Radiation Oncology-certified radiation oncologists, 1061.6 full-time equivalent (FTE) radiation oncologists, 2124.2 FTE radiotherapy technologists, 181.3 FTE medical physicists, 170.9 FTE radiotherapy quality managers and 841.5 FTE nurses. The frequency of IMRT use significantly increased during this time. In conclusion, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility although there was a shortage of personnel in 2012.

Japanese Structure Survey of Radiation Oncology in 2011

We evaluated the evolving structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution to identify and overcome any existing limitations. From March 2012 to August 2015, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2011. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 211 000 and 250 000, respectively. Additionally, the estimated cancer incidence was 851 537 cases with approximately 24.8% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 836), telecobalt (n = 3), Gamma Knife (n = 46), 60Co remote afterloading system (RALS; n = 24), and 192Ir RALS (n = 125). The LINAC system used dual-energy functions in 619 units, 3D conformal radiotherapy functions in 719 and intensity-modulated radiotherapy (IMRT) functions in 412. There were 756 JRS or JASTRO-certified radiation oncologists, 1018.5 full-time equivalent (FTE) radiation oncologists, 2026.7 FTE radiotherapy technologists, 149.1 FTE medical physicists, 141.5 FTE radiotherapy quality managers and 716.3 FTE nurses. The frequency of IMRT use significantly increased during this time. To conclude, although there was a shortage of personnel in 2011, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility.

Japanese structure survey of radiation oncology in 2010

We evaluated the evolving structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and overcome any existing limitations. From March 2011 to June 2013, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2010. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 211 000 and 251 000, respectively. Additionally, the estimated cancer incidence was 805 236 cases, with ~26.2% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 829), telecobalt (n = 9), Gamma Knife (n = 46), 60Co remote afterloading system (RALS; n = 28), and 192Ir RALS (n = 131). The LINAC system used dual-energy functions in 586 units, three-dimensional conformal radiotherapy functions in 663, and intensity-modulated radiotherapy (IMRT) functions in 337. There were 564 JASTRO-certified radiation oncologists, 959.2 full-time equivalent (FTE) radiation oncologists, 1841.3 FTE radiotherapy technologists, 131.3 FTE medical physicists, 121.5 FTE radiotherapy quality managers, and 649.6 FTE nurses. The frequency of IMRT use significantly increased during this year. To conclude, although there was a shortage of personnel in 2010, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility.

Effects of Surgery With Salvage Stereotactic Radiosurgery Versus Surgery With Whole-Brain Radiation Therapy in Patients With One to Four Brain Metastases (JCOG0504): A Phase III, Noninferiority, Randomized Controlled Trial

Purpose Whereas whole-brain radiotherapy (WBRT) has been the standard treatment of brain metastases (BMs), stereotactic radiosurgery (SRS) is increasingly preferred to avoid cognitive dysfunction; however, it has not been clearly determined whether treatment with SRS is as effective as that with WBRT or WBRT plus SRS. We thus assessed the noninferiority of salvage SRS to WBRT in patients with BMs. Patients and Methods Patients age 20 to 79 years old with performance status scores of 0 to 2-and 3 if caused only by neurologic deficits-and with four or fewer surgically resected BMs with only one lesion > 3 cm in diameter were eligible. Patients were randomly assigned to WBRT or salvage SRS arms within 21 days of surgery. The primary end point was overall survival. A one-sided α of .05 was used. Results Between January 2006 and May 2014, 137 and 134 patients were enrolled in the WBRT and salvage SRS arms, respectively. Median overall survival was 15.6 months in both arms (hazard ratio, 1.05; 90% CI, 0.83 to 1.33; one-sided P for noninferiority = .027). Median intracranial progression-free survival of patients in the WBRT arm (10.4 months) was longer than that of patients in the salvage SRS arm (4.0 months). The proportions of patients whose Mini-Mental Status Examination and performance status scores that did not worsen at 12 months were similar in both arms; however, 16.4% of patients in the WBRT arm experienced grade 2 to 4 cognitive dysfunction after 91 days postenrollment, whereas only 7.7% of those in the SRS arm did ( P = .048). Conclusion Salvage SRS is noninferior to WBRT and can be established as a standard therapy for patients with four or fewer BMs.

Pulmonary Apical Opacities on Thin-Section Computed Tomography: Relationship to Primary Spontaneous Pneumothorax in Young Male Patients and Corresponding Histopathologic Findings

OBJECTIVE

The purpose of this study was to test the hypothesis that apical opacities on computed tomography (CT) are related to occurrence of primary spontaneous pneumothorax (PSP) in young male patients.

METHODS

We compared the frequency of apical opacities on thin-section CT between 70 male patients with PSP (PSP group) and 74 male patients without a history of PSP (non-PSP group). We also evaluated histopathologic findings of 39 specimens from 37 surgical cases in the PSP group.

RESULTS

Apical opacities were significantly more frequent in the PSP group than in the non-PSP group (right side, P = 0.01; left side, P = 0.005). Histopathologically, subpleural band-like alveolar collapse was seen in 35 specimens (89.7%), which was always accompanied by fibroelastosis and fibroblastic foci.

CONCLUSIONS

Apical opacities on CT were significantly associated with PSP in young male patients. These apical opacities histopathologically correspond to fibrotic pleural thickening with subpleural alveolar collapse.

Stereotactic Radiosurgery With or Without Whole-Brain Radiotherapy for Brain Metastases: Secondary Analysis of the JROSG 99-1 Randomized Clinical Trial

IMPORTANCE

It remains uncertain whether treatment with stereotactic radiosurgery (SRS) alone can be safely applied to all patient populations with 1 to 4 brain metastases (BMs) exhibiting heterogeneous prognoses.

OBJECTIVE

To investigate the feasibility of SRS alone for patients with different prognoses determined by the diagnosis-specific Graded Prognostic Assessment (DS-GPA).

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis (performed in September 2014) of the Japanese Radiation Oncology Study Group (JROSG) 99-1, a phase 3 randomized trial, comparing SRS alone and whole-brain radiotherapy (WBRT) + SRS conducted in 1999 to 2003. Among a total of 132 patients, 88 with non-small-cell lung cancer (NSCLC) and 1 to 4 BMs were included and poststratified by DS-GPA scores to avoid potential bias from BMs from different primary cancer types. The median follow-up time was 8.05 months.

INTERVENTIONS

The WBRT schedule was 30 Gy in 10 fractions over 2 to 2.5 weeks. The mean SRS dose was 21.9 Gy in SRS alone and 16.6 Gy in WBRT + SRS.

MAIN OUTCOMES AND MEASURES

The primary end point was overall survival (OS), and the secondary end points included brain tumor recurrence (BTR), salvage treatment, and radiation toxic effects.

RESULTS

Forty-seven patients had a favorable prognosis, with DS-GPA scores of 2.5 to 4.0 (26 SRS-alone and 21 WBRT + SRS [DS-GPA 2.5-4.0 group]), and 41 had an unfavorable prognosis, with DS-GPA scores of 0.5 to 2.0 (19 SRS-alone and 22 WBRT + SRS [DS-GPA 0.5-2.0 group]). Significantly better OS was observed in the DS-GPA 2.5-4.0 group in WBRT + SRS vs the SRS alone, with a median survival time of 16.7 (95% CI, 7.5-72.9) months vs 10.6 (95% CI, 7.7-15.5) months (P = .04) (hazard ratio [HR], 1.92; 95% CI, 1.01-3.78). However, no such difference was observed in the DS-GPA 0.5-2.0 group (HR, 1.05; 95% CI, 0.55-1.99) (P = .86). This benefit could be explained by the differing BTR rates, in that the prevention against BTR by WBRT had a more significant impact in the DS-GPA 2.5-4.0 group (HR, 8.31; 95% CI, 3.05-29.13) (P < .001) vs the DS-GPA 0.5-2.0 group (HR, 3.57; 95% CI, 1.02-16.49) (P = .04).

CONCLUSIONS AND RELEVANCE

Despite the current trend of using SRS alone, the important role of WBRT for patients with BMs from NSCLC with a favorable prognosis should be considered. Our findings should be validated through appropriately designed prospective studies.

TRIAL REGISTRATION

umin.ac.jp/ctr Identifier: C000000412.

Solitary synovial chondromatosis arising in the gluteus maximus bursa: computed tomography and magnetic resonance imaging findings

Chondral tumors in soft tissue are referred to as soft-tissue chondromas or extraskeletal chondromas, or as synovial chondromatosis if they arise in synovial tissue. We report the case of a 29-year-old man with synovial chondromatosis, also called synovial osteochondromatosis, which appeared in a solitary and extra-articular form. On magnetic resonance imaging (MRI) and computed tomography, the central portion of the tumor showed similar characteristics to bone marrow, despite the absence of any connection to adjacent bone. T2-weighted imaging displayed marked peripheral hyperintensity consistent with a cartilaginous area. These findings suggested the presence of enchondral ossification and were similar to those of skeletal osteochondroma, with the exception of the absence of attachment to bone. MRI is useful for distinguishing solitary synovial chondromatosis from other lesions, such as myositis ossificans, extraskeletal chondrosarcoma, and parosteal osteosarcoma.

Phase 3 trials of stereotactic radiosurgery with or without whole-brain radiation therapy for 1 to 4 brain metastases: individual patient data meta-analysis

PURPOSE

To perform an individual patient data (IPD) meta-analysis of randomized controlled trials evaluating stereotactic radiosurgery (SRS) with or without whole-brain radiation therapy (WBRT) for patients presenting with 1 to 4 brain metastases.

METHOD AND MATERIALS

Three trials were identified through a literature search, and IPD were obtained. Outcomes of interest were survival, local failure, and distant brain failure. The treatment effect was estimated after adjustments for age, recursive partitioning analysis (RPA) score, number of brain metastases, and treatment arm.

RESULTS

A total of 364 of the pooled 389 patients met eligibility criteria, of whom 51% were treated with SRS alone and 49% were treated with SRS plus WBRT. For survival, age was a significant effect modifier (P=.04) favoring SRS alone in patients ≤50 years of age, and no significant differences were observed in older patients. Hazard ratios (HRs) for patients 35, 40, 45, and 50 years of age were 0.46 (95% confidence interval [CI] = 0.24-0.90), 0.52 (95% CI = 0.29-0.92), 0.58 (95% CI = 0.35-0.95), and 0.64 (95% CI = 0.42-0.99), respectively. Patients with a single metastasis had significantly better survival than those who had 2 to 4 metastases. For distant brain failure, age was a significant effect modifier (P=.043), with similar rates in the 2 arms for patients ≤50 of age; otherwise, the risk was reduced with WBRT for patients >50 years of age. Patients with a single metastasis also had a significantly lower risk of distant brain failure than patients who had 2 to 4 metastases. Local control significantly favored additional WBRT in all age groups.

CONCLUSIONS

For patients ≤50 years of age, SRS alone favored survival, in addition, the initial omission of WBRT did not impact distant brain relapse rates. SRS alone may be the preferred treatment for this age group.

Imaging of community-acquired pneumonia: Roles of imaging examinations, imaging diagnosis of specific pathogens and discrimination from noninfectious diseases

This article reviews roles of imaging examinations in the management of community-acquired pneumonia (CAP), imaging diagnosis of specific CAP and discrimination between CAP and noninfectious diseases. Chest radiography is usually enough to confirm the diagnosis of CAP, whereas computed tomography is required to suggest specific pathogens and to discriminate from noninfectious diseases. Mycoplasma pneumoniae pneumonia, tuberculosis, Pneumocystis jirovecii pneumonia and some cases of viral pneumonia sometimes show specific imaging findings. Peribronchial nodules, especially tree-in-bud appearance, are fairly specific for infection. Evidences of organization, such as concavity of the opacities, traction bronchiectasis, visualization of air bronchograms over the entire length of the bronchi, or mild parenchymal distortion are suggestive of organizing pneumonia. We will introduce tips to effectively make use of imaging examinations in the management of CAP.

The long-term outcomes of radiosurgery for intracranial hemangioblastomas

BACKGROUND

Optimal timing in the treatment of intracranial hemangioblastoma (HB) remains controversial, particularly for patients of von Hippel-Lindau disease (VHL) with multiple small lesions. We evaluated efficacy of stereotactic radiosurgery (SRS) for intracranial HB based on the longer follow-up data with a larger number of patients and lesions.

METHODS

Twenty-one patients (11 men, 10 women) initially underwent SRS for 57 intracranial HBs. Seven patients had sporadic lesions and 14 had VHL-related lesions. During the follow-up, 40 lesions were additionally treated in VHL patients in 10 SRS treatments. Thus, a total of 97 lesions were included in this study. Median tumor volume was 0.13 cm(3) (range, 0.004-9.5 cm(3)), and median margin dose was 18 Gy (range, 14-20 Gy).

RESULTS

Median duration of follow-up was 96 months (range, 3-235 mo) after initial SRS treatment. Ten tumors in 7 patients showed progression after SRS. Actuarial tumor control rates after SRS at 5 and 10 years were 94% and 80%, respectively. Factors associated with longer control were solid lesion (P = .03), smaller volume (P = .01), and lesions associated with VHL (P = .0005) in univariate analysis. Five- and 10-year tumor control rates were 67% and 44% for sporadic patients and 97% and 83% for VHL patients.

CONCLUSION

SRS could be offered as an effective treatment for small, solid, and VHL-associated HBs. If the tumors show apparent enlargement in size or can possibly become symptomatic along with a slight increase in size, SRS should be recommended before they present with the clinical symptoms.

Variability in the point to which single direct field irradiation is prescribed for spinal bone metastases: a survey of practice patterns in Japan

Direct single fields are commonly used in radiotherapy for spinal bone metastases, and it is crucial to define the point for which the dose is prescribed. According to the guidelines from the International Bone Metastases Consensus Working Party (IBMCWP) updated in 2010, different opinions exist on whether this therapy should be prescribed to the mid-vertebral or anterior vertebral body. To our knowledge, no previous studies have surveyed practice patterns regarding this discrepancy. Therefore, we performed an Internet-based survey of members of the Japanese Radiation Oncology Study Group (JROSG) to investigate the current practice patterns in Japan. The respondents mentioned the point to which they prescribed radiotherapy for a single direct field. A total of 52 radiation oncologists from 50 institutions (36% of JROSG institutions) responded. Respondent prescription for radiotherapy varied widely. Only 21% and 6% of respondents prescribed irradiation to the mid-vertebral body and anterior vertebral body, respectively. A larger proportion of respondents (27%) prescribed irradiation to the spinal cord (center of the spinal canal). Still another group of respondents (27%) stated that they never use a single direct field. In conclusion, the point to which irradiation dosages are prescribed varies widely for a single direct field in cases of spinal bone metastases. This variation may lead some radiation oncologists to misunderstand the tolerance dosage of the spinal cord, especially in cases of re-irradiation. Thus, careful consideration is required before any prescriptions are made.

Pulmonary focal fibrosis associated with microscopic arterio-venous fistula manifesting as focal ground-glass opacity on thin-section CT

BACKGROUND

Focal ground-glass opacity (GGO) on thin-section computed tomography (CT) may be seen in atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ that has recently been renamed from bronchioloalveolar carcinoma (BAC) and various benign conditions.

CASE PRESENTATION

We report a case of pulmonary focal fibrosis associated with microscopic arterio-venous fistula (AVF), which showed a focal area of GGO on thin-section CT. The patient was a 58-year-old woman with a GGO on thin-section CT which had increased in size over the period of 2 years. Slightly dilated vessels and thickened interlobular septa were also noted around the GGO. It was diagnosed preoperatively as adenocarcinoma in situ and a partial lung resection by video-assisted thoracic surgery (VATS) was performed. Pathological examination yielded a diagnosis of focal fibrosis associated with microscopic AVF.

CONCLUSION

We speculate that the focal fibrosis was produced by a prolonged congestion due to the AVF and that the dilated vessels and thickening of interlobular septa on thin-section CT related to the AVF. Microscopic AVF may be one of the etiologies of focal fibrosis showing focal GGO on thins-section CT. Dilated vessels and thickened interlobular septa around the GGO might offer a clue to the diagnosis of this disease entity. In addition, it should be noted that focal fibrosis may increase in size.

Japanese structure survey of radiation oncology in 2009 with special reference to designated cancer care hospitals

BACKGROUND

The structure of radiation oncology in designated cancer care hospitals in Japan was surveyed in terms of equipment, personnel, patient load, and geographic distribution, and compared with the structure in other radiotherapy facilities and the previous survey.

METHODS

The Japanese Society for Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2009. The structures of 365 designated cancer care hospitals and 335 other radiotherapy facilities were compared.

RESULTS

Designated cancer care hospitals accounted for 50.0% of all the radiotherapy facilities in Japan. The patterns of equipment and personnel in designated cancer care hospitals and the other radiotherapy facilities were, respectively, as follows: linear accelerators per facility: 1.4 and 1.0; dual-energy function: 78.6 and 61.3%; three-dimensional conformal radiotherapy function: 88.5 and 70.0%; intensity-modulated radiotherapy function: 51.6 and 25.3%; annual number of patients per linear accelerator: 301.3 and 185.2; Ir-192 remote-controlled after-loading systems: 31.8 and 4.2%; and average number of full-time equivalent radiation oncologists per facility: 1.8 and 0.8. Compared with the previous survey, the ownership ratio of equipment and personnel improved in both designated cancer care hospitals and the other radiotherapy facilities. Annual patient loads per full-time equivalent radiation oncologist in the designated cancer care hospitals and the other radiotherapy facilities were 225.5 and 247.6, respectively. These values exceeded the standard guidelines level of 200.

CONCLUSIONS

The structure of radiation oncology in designated Japanese cancer care hospitals was more mature than that in the other radiotherapy facilities. There is still a shortage of personnel. The serious understaffing problem in radiation oncology should be corrected in the future.

Japanese structure survey of radiation oncology in 2009 based on institutional stratification of the Patterns of Care Study

The ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution was evaluated in order to radiation identify and improve any deficiencies. A questionnaire-based national structure survey was conducted from March 2010 to January 2011 by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO). These data were analyzed in terms of the institutional stratification of the Patterns of Care Study (PCS). The total numbers of new cancer patients and total of cancer patients (new and repeat) treated with radiation in 2009 were estimated at 201,000 and 240,000, respectively. The type and numbers of systems in actual use consisted of Linac (816), telecobalt (9), Gamma Knife (46), (60)Co remote afterloading system (RALS) (29) and (192)Ir RALS systems (130). The Linac systems used dual energy function for 586 (71.8%), 3DCRT for 663 (81.3%) and IMRT for 337 units (41.3%). There were 529 JASTRO-certified radiation oncologists (ROs), 939.4 full-time equivalent (FTE) ROs, 113.1 FTE medical physicists and 1836 FTE radiation therapists. The frequency of interstitial radiation therapy use for prostate and of intensity-modulated radiotherapy increased significantly. PCS stratification can clearly identify the maturity of structures based on their academic nature and caseload. Geographically, the more JASTRO-certified physicians there were in a given area, the more radiation therapy tended to be used for cancer patients. In conclusion, the Japanese structure has clearly improved during the past 19 years in terms of equipment and its use, although a shortage of manpower and variations in maturity disclosed by PCS stratification remained problematic in 2009.

Use of an oral effervescent agent in the evaluation of gastric 67Ga uptake

OBJECTIVE

Gastric uptake of (67)Ga may be observed in patients with no obvious gastric lesions, as well as those with gastric malignancy. The aim of this study was to investigate whether the use of an effervescent agent aids in evaluating gastric (67)Ga uptake.

METHODS

Twenty patients having or suspected of having gastric uptake on whole-body (67)Ga scintigrams were studied. Anterior abdominal images were obtained at baseline and after the oral intake of the effervescent agent (gas contrast image). The presence or absence of malignant gastric uptake was judged visually using the baseline image or gas contrast image. The judgment was compared with the clinical diagnosis, and the clinical usefulness of the gas contrast technique was assessed.

RESULTS

In all patients, successful distension of the stomach was indicated in the gas contrast image. Clinical assessment showed gastric lesions in six patients (gastric involvement of lymphoma in 3, primary gastric lymphoma in 2, and adenocarcinoma in 1). The gas contrast image yielded accurate judgments of malignant gastric uptake in all patients except one with adenocarcinoma. Imaging after gastric distension induced by the oral effervescent agent contributed to excluding malignant gastric uptake in eight patients and demonstrating malignant gastric uptake in four patients.

CONCLUSIONS

Benign gastric uptake may complicate the assessment of gastric lesions in (67)Ga scintigraphy. Additional spot imaging after oral intake of an effervescent agent can aid in evaluating malignant gastric lesions through gastric distension.

Japanese structure survey of radiation oncology in 2007 with special reference to designated cancer care hospitals

BACKGROUND AND PURPOSE

The structure of radiation oncology in designated cancer care hospitals in Japan was investigated in terms of equipment, personnel, patient load, and geographic distribution. The effect of changes in the health care policy in Japan on radiotherapy structure was also examined.

MATERIAL AND METHODS

The Japanese Society of Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2007. The structures of 349 designated cancer care hospitals and 372 other radiotherapy facilities were compared.

RESULTS

Respective findings for equipment and personnel at designated cancer care hospitals and other facilities included the following: linear accelerators/facility: 1.3 and 1.0; annual patients/linear accelerator: 296.5 and 175.0; and annual patient load/full-time equivalent radiation oncologist was 237.0 and 273.3, respectively. Geographically, the number of designated cancer care hospitals was associated with population size.

CONCLUSION

The structure of radiation oncology in Japan in terms of equipment, especially for designated cancer care hospitals, was as mature as that in European countries and the United States, even though the medical costs in relation to GDP in Japan are lower. There is still a shortage of manpower. The survey data proved to be important to fully understand the radiation oncology medical care system in Japan.

Japanese structure survey of radiation oncology in 2007 based on institutional stratification of patterns of care study

PURPOSE

To evaluate the ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies.

METHODS AND MATERIALS

A questionnaire-based national structure survey was conducted from March to December 2008 by the Japanese Society of Therapeutic Radiology and Oncology (JASTRO). These data were analyzed in terms of the institutional stratification of the Patterns of Care Study.

RESULTS

The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiation in 2007 were estimated at 181,000 and 218,000, respectively. There were 807 linear accelerator, 15 telecobalt, 46 Gamma Knife, 45 (60)Co remote-controlled after-loading, and 123 (192)Ir remote-controlled after-loading systems in actual use. The linear accelerator systems used dual-energy function in 539 units (66.8%), three-dimensional conformal radiation therapy in 555 (68.8%), and intensity-modulated radiation therapy in 235 (29.1%). There were 477 JASTRO-certified radiation oncologists, 826.3 full-time equivalent (FTE) radiation oncologists, 68.4 FTE medical physicists, and 1,634 FTE radiation therapists. The number of interstitial radiotherapy (RT) administrations for prostate, stereotactic body radiotherapy, and intensity-modulated radiation therapy increased significantly. Patterns of Care Study stratification can clearly identify the maturity of structures based on their academic nature and caseload. Geographically, the more JASTRO-certified physicians there were in a given area, the more RT tended to be used for cancer patients.

CONCLUSIONS

The Japanese structure has clearly improved during the past 17 years in terms of equipment and its use, although a shortage of personnel and variations in maturity disclosed by Patterns of Care Study stratification were still problematic in 2007.

Stereotactic radiosurgery for skull base meningioma

Stereotactic radiosurgery is now a treatment option for meningiomas, especially for high-risk patients such as those with skull base lesions. The clinical outcomes were retrospectively analyzed of stereotactic radiosurgery using the Leksell Gamma Knife((R)) performed for 98 patients with 106 skull base meningiomas at the University of Tokyo Hospital between June 1990 and April 2006 and followed up for more than a year. After a median follow-up period of 53.2 months (range 12.2-204.4 months), local tumor control rates were 86.9% and 78.9% at 5 years and 10 years, respectively. Tumors with volume of 4 cm(3) or smaller (97.5% vs. 76.1% at 5 years, p = 0.001) and tumors completely included within the isodose line of 14 Gy or more (97.5% vs. 67.2% at 5 years, p = 0.0006) had higher local control rates. Postoperative residual tumors treated by stereotactic radiosurgery were controlled in all 25 cases. Cranial nerve deficits were improved, stable, and deteriorated in 12, 64, and 3 patients, respectively, after stereotactic radiosurgery. Stereotactic radiosurgery was effective treatment method for local control of skull base meningiomas, especially for small or postoperative residual tumors. Correct combination of microsurgery and radiosurgery leads to excellent local control.

The value of image coregistration during stereotactic radiosurgery

BACKGROUND

Coregistration of any neuroimaging studies into treatment planning for stereotactic radiosurgery became easily applicable using the Leksell Gamma Knife 4C, a new model of gamma knife. The authors investigated the advantage of this image processing.

METHOD

Since installation of the Leksell Gamma Knife 4C at the authors' institute, 180 sessions of radiosurgery were performed. Before completion of planning, coregistration of frameless images of other modalities or previous images was considered to refine planning. Treatment parameters were compared for planning before and after refinement by use of coregistered images.

FINDINGS

Coregistered computed tomography clarified the anatomical structures indistinct on magnetic resonance imaging. Positron emission tomography visualized lesions disclosing metabolically high activity. Coregistration of prior imaging distinguished progressing lesions from stable ones. Diffusion-tensor tractography was integrated for lesions adjacent to the corticospinal tract or the optic radiation. After refinement of planning in 36 sessions, excess treated volume decreased (p = 0.0062) and Paddick conformity index improved (p < 0.001). Maximal dose to the white matter tracts was decreased (p < 0.001).

CONCLUSION

Image coregistration provided direct information on anatomy, metabolic activity, chronological changes, and adjacent critical structures. This gathered information was sufficiently informative during treatment planning to supplement ambiguous information on stereotactic images, and was useful especially in reducing irradiation to surrounding normal structures.

Optimal timing for Gamma Knife surgery after hemorrhage from brain arteriovenous malformations

OBJECT

Optimal timing of Gamma Knife surgery (GKS) after hemorrhage from brain arteriovenous malformations (AVMs) is unclear and of concern to neurosurgeons because GKS is usually performed after absorption of the hematoma. The authors investigated whether waiting for hematoma absorption is beneficial and aimed to clarify the optimal treatment timing.

METHODS

The authors retrospectively studied 211 patients with AVMs who presented with hemorrhage and underwent GKS as the initial treatment. Patients were categorized into 3 groups according to the interval between the time of first hemorrhage and GKS, as follows: Group 1, 0-3 months (70 patients); Group 2, 3-6 months (62 patients); and Group 3, > 6 months (79 patients). The obliteration rates, number of hemorrhages before and after GKS, and complication rates were compared between these 3 groups. The authors also analyzed a subgroup of 127 patients who presented with intracerebral hemorrhage (ICH) to identify the influence of ICH on outcome.

RESULTS

After a median follow-up of 6.3 years, the rates of obliteration, hemorrhage after treatment, and complication were not significantly different between the 3 groups even though the patients with a longer interval before GKS (Group 3) had more AVMs in eloquent areas and neurological deficits. However, the numbers of patients with preoperative hemorrhage in the interval before GKS was significantly higher in Group 3 (1, 3, and 20 patients in Group 1, 2, and 3, respectively). These results were similar in the analyses of 127 patients presenting with ICH.

CONCLUSIONS

No benefit was detected in waiting for hematoma absorption until GKS after hemorrhage from AVM. Because of higher hemorrhagic risk until GKS > 6 months after hemorrhage, the authors recommend GKS within 6 months after hemorrhage.

Preoperative radiation response evaluated by 18-fluorodeoxyglucose positron emission tomography predicts survival in locally advanced rectal cancer

PURPOSE

This study focuses on the prognostic survival value of postirradiation metabolic activity in primary rectal cancer as measured with 18-fluorodeoxyglucose positron emission tomography.

METHODS

From July 1995 to March 2002, all 59 patients underwent two series of fluorodeoxyglucose positron emission tomography: one before preoperative radiation (standardized uptake values-1), and the other two to three weeks after radiation (standardized uptake values-2). Standardized uptake values-1 and standardized uptake values-2 correspond to before and after radiation, respectively.

RESULTS

In univariate analysis, the following emerged as significant prognostic variables: with or without residual tumor, pathologic differentiation, with or without recurrence, standardized uptake values-2, and with or without lymph node metastases. In multivariate analysis, residual tumor and standardized uptake values-2 were significant prognostic factors for survival. The median survival and the five-year overall survival rate comparing standardized uptake values-2 values <5 vs. >5 were 95 vs. 42 months and 70 vs. 44 percent, respectively (P = 0.042).

CONCLUSION

A significant survival benefit was observed in patients with low fluorodeoxyglucose uptake after preoperative radiotherapy in primary tumors of rectal cancer.

Japanese structure survey of radiation oncology in 2005 based on institutional stratification of patterns of care study

PURPOSE

To evaluate the structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies.

METHODS AND MATERIALS

A questionnaire-based national structure survey was conducted between March 2006 and February 2007 by the Japanese Society of Therapeutic Radiology and Oncology. These data were analyzed in terms of the institutional stratification of the Patterns of Care Study.

RESULTS

The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiotherapy in 2005 were estimated at approximately 162,000 and 198,000, respectively. In actual use were 765 linear accelerators, 11 telecobalt machines, 48 GammaKnife machines, 64 60Co remote-controlled after-loading systems, and 119 192Ir remote-controlled after-loading systems. The linear accelerator systems used dual-energy function in 498 systems (65%), three-dimensional conformal radiotherapy in 462 (60%), and intensity-modulated radiotherapy in 170 (22%). There were 426 Japanese Society of Therapeutic Radiology and Oncology-certified radiation oncologists, 774 full-time equivalent radiation oncologists, 117 medical physicists, and 1,635 radiation therapists. Geographically, a significant variation was found in the use of radiotherapy, from 0.9 to 2.1 patients/1,000 population. The annual patient load/FTE radiation oncologist was 247, exceeding the Blue Book guidelines level. Patterns of Care Study stratification can clearly discriminate the maturity of structures according to their academic nature and caseload.

CONCLUSIONS

The Japanese structure has clearly improved during the past 15 years in terms of equipment and its use, although the shortage of manpower and variations in maturity disclosed by this Patterns of Care Study stratification remain problematic. These constitute the targets for nationwide improvement in quality assurance and quality control.

Optic radiation tractography integrated into simulated treatment planning for Gamma Knife surgery

OBJECT

No definitive method of preventing visual field deficits after stereotactic radiosurgery for lesions near the optic radiation (OR) has been available so far. The authors report the results of integrating OR tractography based on diffusion tensor (DT) magnetic resonance imaging into simulated treatment planning for Gamma Knife surgery (GKS).

METHODS

Data from imaging studies performed in 10 patients who underwent GKS for treatment of arteriovenous malformations (AVMs) located adjacent to the OR were used for the simulated treatment planning. Diffusion tensor images performed without the patient's head being secured by a stereotactic frame were used for DT tractography, and the OR was visualized by means of software developed by the authors. Data from stereotactic 3D imaging studies performed after frame fixation were coregistered with the data from DT tractography. The combined images were transferred to a GKS treatment-planning workstation. Delivered doses and distances between the treated lesions and the OR were analyzed and correlated with posttreatment neurological changes.

RESULTS

In patients presenting with migraine with visual aura or occipital lobe epilepsy, the OR was located within 11 mm from AVMs. In a patient who developed new quadrantanopia after GKS, the OR had received 32 Gy. A maximum dose to the OR of less than 12 Gy did not cause new visual field deficits. A maximum dose to the OR of 8 Gy or more was significantly related to neurological change (p < 0.05), including visual field deficits and development or improvement of migraine.

CONCLUSIONS

Integration of OR tractography into GKS represents a promising tool for preventing GKS-induced visual disturbances and headaches. Single-session irradiation at a dose of 8 Gy or more was associated with neurological change.

Tolerance of pyramidal tract to gamma knife radiosurgery based on diffusion-tensor tractography

PURPOSE

To minimize the morbidity of radiosurgery for critically located lesions, we integrated diffusion-tensor tractography into treatment planning for gamma-knife radiosurgery. We calculated the refined tolerance of the pyramidal tract (PT) after prospective application of the technique to additional patients.

METHODS AND MATERIALS

The relationship between the dosimetry during treatment planning and the development of subsequent motor complications was investigated in 24 patients, 9 studied retrospectively and 15 studied prospectively. The maximal dose to the PT and the volumes of the PT that received > or = 20 Gy (20-Gy volume) and > or = 25 Gy (25-Gy volume) were calculated. Univariate logistic regression analyses were used to produce dose-response curves. Differences in the tolerable dose according to the PT location were calculated.

RESULTS

Univariate logistic regression analysis of the motor complications revealed a significant independent correlation with the maximal dose to the PT and the 20- and 25-Gy volumes. The maximal dose to the PT with a 5% risk of motor complications was 23 Gy compared with 15 Gy in our previous report. The risk of motor complications was significantly greater in the internal capsule than in the corona radiata for the 20- and 25-Gy volumes in generalized Wilcoxon tests (p = 0.031), although no significant difference was observed for the maximal dose.

CONCLUSION

The tolerable dose of the PT was greater than that previously reported. The internal capsule was more sensitive to high-dose irradiation over a wide area of the PT, probably owing to the dense concentration of motor fibers.

Neurocognitive Function of Patients with Brain Metastasis Who Received Either Whole Brain Radiotherapy Plus Stereotactic Radiosurgery or Radiosurgery Alone

PURPOSE

To determine how the omission of whole brain radiotherapy (WBRT) affects the neurocognitive function of patients with one to four brain metastases who have been treated with stereotactic radiosurgery (SRS).

METHODS AND MATERIALS

In a prospective randomized trial between WBRT+SRS and SRS alone for patients with one to four brain metastases, we assessed the neurocognitive function using the Mini-Mental State Examination (MMSE). Of the 132 enrolled patients, MMSE scores were available for 110.

RESULTS

In the baseline MMSE analyses, statistically significant differences were observed for total tumor volume, extent of tumor edema, age, and Karnofsky performance status. Of the 92 patients who underwent the follow-up MMSE, 39 had a baseline MMSE score of < or =27 (17 in the WBRT+SRS group and 22 in the SRS-alone group). Improvements of > or =3 points in the MMSEs of 9 WBRT+SRS patients and 11 SRS-alone patients (p = 0.85) were observed. Of the 82 patients with a baseline MMSE score of > or =27 or whose baseline MMSE score was < or =26 but had improved to > or =27 after the initial brain treatment, the 12-, 24-, and 36-month actuarial free rate of the 3-point drop in the MMSE was 76.1%, 68.5%, and 14.7% in the WBRT+SRS group and 59.3%, 51.9%, and 51.9% in the SRS-alone group, respectively. The average duration until deterioration was 16.5 months in the WBRT+SRS group and 7.6 months in the SRS-alone group (p = 0.05).

CONCLUSION

The results of the present study have revealed that, for most brain metastatic patients, control of the brain tumor is the most important factor for stabilizing neurocognitive function. However, the long-term adverse effects of WBRT on neurocognitive function might not be negligible.

Exceptionally high incidence of symptomatic grade 2-5 radiation pneumonitis after stereotactic radiation therapy for lung tumors

BACKGROUND

To determine the usefulness of dose volume histogram (DVH) factors for predicting the occurrence of radiation pneumonitis (RP) after application of stereotactic radiation therapy (SRT) for lung tumors, DVH factors were measured before irradiation.

METHODS

From May 2004 to April 2006, 25 patients were treated with SRT at the University of Tokyo Hospital. Eighteen patients had primary lung cancer and seven had metastatic lung cancer. SRT was given in 6-7 fields with an isocenter dose of 48 Gy in four fractions over 5-8 days by linear accelerator.

RESULTS

Seven of the 25 patients suffered from RP of symptomatic grade 2-5 according to the NCI-CTC version 3.0. The overall incidence rate of RP grade2 or more was 29% at 18 months after completing SRT and three patients died from RP. RP occurred at significantly increased frequencies in patients with higher conformity index (CI) (p = 0.0394). Mean lung dose (MLD) showed a significant correlation with V5-V20 (irradiated lung volume) (p < 0.001) but showed no correlation with CI. RP did not statistically correlate with MLD. MLD had the strongest correlation with V5.

CONCLUSION

Even in SRT, when large volumes of lung parenchyma are irradiated to such high doses as the minimum dose within planning target volume, the incidence of lung toxicity can become high.

Radiotherapy for lymph node metastases in patients with hepatocellular carcinoma: retrospective study

AIM

This study was conducted to evaluate the effect of external radiation therapy on lymph node metastases from hepatocellular carcinoma (HCC).

METHODS

A total 28 patients with cytopathologically proven HCC were subjected to radiation therapy over a 5-year period, and treatment was continued in all cases. All patients underwent irradiation with a total dose ranging between 46 and 60 Gy in daily 2.0-Gy fractions, five times a week.

RESULTS

Among the metastatic lesions treated, 18 (64%) and five (18%) patients achieved partial responses and complete responses, respectively. The 1- and 2-year overall survival rates and the median survival time were 53% and 33%, respectively, and 13 months in patients given external beam radiation therapy (EBRT) for a non-palliative, near-cure intent (n = 21).

CONCLUSIONS

Although lymph node metastasis from HCC is sensitive to EBRT, the intent of EBRT should be limited to palliation. For palliative purposes, it is useful in treatment with 50 Gy in 25 fractions for these patients.

RADIOSURGERY TO REDUCE THE RISK OF FIRST HEMORRHAGE FROM BRAIN ARTERIOVENOUS MALFORMATIONS

OBJECTIVE

It remains unclear whether or not and to what extent stereotactic radiosurgery can reduce the risk of first intracranial hemorrhage from brain arteriovenous malformations.

METHODS

We performed a retrospective observational investigation of 500 patients with arteriovenous malformations who were treated with gamma knife radiosurgery. The risk of first hemorrhage was analyzed using the Cox proportional-hazards model with age at radiosurgery and angiographic obliteration included as time-dependent covariates. Three periods were defined: from birth to radiosurgery (before radiosurgery); from radiosurgery to angiographic obliteration (latency period); and from angiographic obliteration to end of the follow-up period (after obliteration).

RESULTS

Hemorrhage was documented before radiosurgery in 318 patients (median observation period, 30.0 yr), during the latency period in 11 patients (median observation period, 2.2 yr), and after obliteration in two patients (median observation period, 5.5 yr). Compared with the period before radiosurgery, the risk of hemorrhage decreased by 86% after obliteration (hazard ratio, 0.14; 95% confidence interval, 0.03–0.55; P = 0.005), whereas the reduction observed during the latency period was not statistically significant (hazard ratio, 0.56; 95% confidence interval, 0.31–1.04; P = 0.07). Irrespective of obliteration, the risk of hemorrhage decreased by 62% after radiosurgery (hazard ratio, 0.38; 95% confidence interval, 0.22–0.67; P = 0.001). Similar results were observed when the 33 patients who had undergone previous therapy were excluded from the analysis.

CONCLUSION

Stereotactic radiosurgery significantly reduces the risk of first hemorrhage from brain arteriovenous malformations. The extent of the decrease might be greater if angiography indicates the evidence of obliteration.

A retrospective study of radiotherapy for spinal bone metastases from hepatocellular carcinoma (HCC)

OBJECTIVE

To evaluate the therapeutic effects of radiotherapy on spinal bone metastases from hepatocellular carcinoma (HCC).

METHODS

A retrospective review was conducted on 24 ambulatory patients with spinal bone metastases from HCC treated by radiotherapy from 1995 to 2004. Ambulatory rate and local progression-free rate after radiotherapy were analyzed. Eight (33%) of 24 patients had radiographic spinal cord compression from the spinal bone metastases before the treatment. Two (8.3%) of the 24 patients had some spinal deficits before the treatment. Biological equivalent dose (BED) with alpha/beta ratios of 10 ranged from 39 to 50.7 Gy (median 44.8 Gy).

RESULTS

The median observation period was 5.1 months ranging from 0.9 to 36.0 months. Among the 24 patients, five (21%) underwent salvage therapies, while of the remaining 19 patients four (21%) became nonambulatory by the last follow-up. The ambulatory rates at 3 months and 6 months were 85 and 63%, respectively. The local progression-free rates at 3 months and 6 months were 53 and 47%, respectively.

CONCLUSIONS

Radiotherapy with a BED of 39-50.7 Gy (median 44.8 Gy) is not sufficiently effective for the patients with spinal bone metastases from HCC to prevent paralysis. Dose escalation with a highly precise radiation technique will need to be evaluated.

A retrospective study of radiotherapy for spinal bone metastases from hepatocellular carcinoma (HCC)

OBJECTIVE

To evaluate the therapeutic effects of radiotherapy on spinal bone metastases from hepatocellular carcinoma (HCC).

METHODS

A retrospective review was conducted on 24 ambulatory patients with spinal bone metastases from HCC treated by radiotherapy from 1995 to 2004. Ambulatory rate and local progression-free rate after radiotherapy were analyzed. Eight (33%) of 24 patients had radiographic spinal cord compression from the spinal bone metastases before the treatment. Two (8.3%) of the 24 patients had some spinal deficits before the treatment. Biological equivalent dose (BED) with alpha/beta ratios of 10 ranged from 39 to 50.7 Gy (median 44.8 Gy).

RESULTS

The median observation period was 5.1 months ranging from 0.9 to 36.0 months. Among the 24 patients, five (21%) underwent salvage therapies, while of the remaining 19 patients four (21%) became nonambulatory by the last follow-up. The ambulatory rates at 3 months and 6 months were 85 and 63%, respectively. The local progression-free rates at 3 months and 6 months were 53 and 47%, respectively.

CONCLUSIONS

Radiotherapy with a BED of 39-50.7 Gy (median 44.8 Gy) is not sufficiently effective for the patients with spinal bone metastases from HCC to prevent paralysis. Dose escalation with a highly precise radiation technique will need to be evaluated.

Management and outcome of hemorrhage after Gamma Knife surgery for arteriovenous malformations of the brain

Object

Appropriate management of hemorrhage after Gamma Knife surgery (GKS) for arteriovenous malformations (AVMs) of the brain is poorly understood, although a certain proportion of patients suffer from hemorrhage.

Methods

Among 500 patients observed for 1 to 183 months (median 70 months) after GKS, 32 patients (6.4%) suffered a hemorrhage. Hemorrhage developed even after angiographically documented obliteration of the AVM in five (2%) of 250 patients followed for 1 to 133 months (median 75 months) post-GKS. These patients had been treated according to their pathological condition. Treatment of these patients and their outcomes were retrospectively reviewed. As a management strategy in patients with preobliteration hemorrhage, the intracerebral hematoma and the AVM nidus were removed in four patients, and chronic encapsulated hematoma was removed in three. Among 11 patients who were conservatively treated, AVMs were ultimately obliterated in five, including three patients who underwent repeated GKS. Intracerebral hematoma from angiographically documented obliterated AVMs was radically resected in two patients, including one who also underwent aspiration of an accompanying symptomatic cyst. Intraoperative bleeding was easily controlled in these patients. Outcomes after hemorrhage, measured with the modified Rankin Scale, were significantly better in patients with postobliteration hemorrhage than in those with preobliteration hemorrhage (p < 0.05).

Conclusions

Various types of hemorrhagic complications after GKS for AVMs can be properly managed based on an understanding of each pathological condition. Although a small risk of bleeding remains after angiographically demonstrated obliteration, surgery for such AVMs is safe, and the patient outcomes are more favorable. Radical resection to prevent further hemorrhage is recommended for ruptured AVMs after obliteration because such AVMs can cause repeated hemorrhages.

The intergroup/RTOG 85-01 concurrent chemoradiation regimen for Japanese esophageal cancer

BACKGROUND/AIMS

To evaluate outcome of the U.S. RTOG/Intergroup Protocol 85-01 for 44 Japanese esophageal cancer patients.

METHODOLOGY

Between 1996 and 2004, patients with esophageal cancer received the Intergroup concurrent chemoradiation therapy regimen for the primary treatment (n=44, group A). We compared the data with those of patients receiving radiotherapy (RT) combined with the weekly chemotherapy regimen (n=12, group B) and with those of patients receiving RT combined with the daily low-dose chemotherapy regimen (n=24, group C).

RESULTS

The median survival period was 14.9 months in group A, 5.7 months in group B, and 6.3 months in group C. The survival rates at 1 and 3 years were 56% and 26% in group A, 42% and 21% in group B (p=0.3307), and 27% and 18% in group C (p=0.0462), respectively.

CONCLUSIONS

The prognosis of patients who received the Intergroup regimen for esophageal cancer was significantly better than that of patients who received the daily low-dose chemotherapy regimen. The Intergroup regimen is well tolerable for the Japanese patients too.

External beam radiotherapy to treat intra- and extra-hepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation

BACKGROUND

Radiofrequency ablation (RFA) is an alternative to percutaneous ethanol injection therapy (PEIT) for single non-surgical hepatocellular carcinoma. However, the risk of seeding along the needle track has been reported.

METHODS

Seven patients presenting with neoplastic seeding after RFA or PEIT were treated with external beam radiotherapy using conventional fractionation. All patients underwent irradiation with a total dose in the range of 44-61 Gy (median and mode value: 50 Gy).

RESULTS

An objective response to treatment was achieved in six of seven patients (86%). A complete response was obtained in two patients (29%). The median survival time was 14.7 months and the actuarial 1- and 2-year survivals were 67% and 50%, respectively.

CONCLUSIONS

The response to treatment was relatively good without serious complications. Seeding from hepatocellular carcinoma is sensitive to external beam radiotherapy. It is useful in the treatment of these patients with 50 Gy in 25 fractions.

Small bowel perforation without tumor recurrence after radiotherapy for cervical carcinoma: report of seven cases

AIM

We describe the clinical presentation, evaluation, management and outcome of patients experiencing small bowel perforation following radiation therapy for cervical cancer.

METHODS AND MATERIALS

A database consisting of 95 Japanese women with stage 0-4 A cervix cancer treated between 1991 and 2004 contained seven patients (7.4%) with small bowel perforation.

RESULTS

The median age at the time of perforation was 72.5 years (range 62-78). The median time from completion of radiotherapy to perforation was 6 months (range 2-58). Surgery (one small bowel resection and anastomosis with diversion; six small bowel resection and anastomosis) was performed immediately in all seven patients. One of seven patients died of small bowel perforation (i.e. mortality rate was 14%). Bowel adhesion was detected during the operation in only three cases (43%). Signs of peritonitis were absent in six cases (86%). Severe abdominal pain was seen in all seven patients. The perforation site was ileum in all seven cases. In all patients, pathological changes were compatible with postirradiation injury of the gastrointestinal tract.

CONCLUSIONS

The presenting complaints of patients with bowel perforation following radiotherapy vary, and signs of peritonitis may be absent. Emergency physicians must be alert for these complications in patients who have been treated with radiotherapy.

Treatment planning and dosimetry of a multi-axis dynamic arc technique for prostate cancer: A comparison with IMRT

PURPOSE

Intensity-modulated radiation therapy (IMRT) allows greater dose conformity to the tumor target. However, IMRT, especially static delivery, usually requires more time to deliver a dose fraction than conventional external beam radiotherapy (EBRT). The authors have been using a "two-axis dynamic arc therapy" (2A-DAT) technique for prostate cancer treatment to make a concave dose distribution to spare the rectum and bladder while working with limited time and human resources. The objectives of this study were to (1) clinically implement the 2A-DAT technique, (2) evaluate the dosimetry in comparison with IMRT, and (3) analyze the initial treatment outcome.

MATERIALS AND METHODS

The 2A-DAT consists of two dynamic arc therapies (DATs) with half rotation around two isocenters each in two separate symmetrical rhombi. Treatment planning is forward and on a trial-and-error basis. Thirty-four patients received 2A-DAT with a median prescribed dose of 70 Gy.

RESULTS

Although inferior in dose uniformity, the 2A-DAT provided equivalent sparing of normal structures to IMRT. Daily fraction delivery time for the 34 patients ranged from 6.4 to 9.6 minutes, with an average of 7.4 minutes. Five-year survival and five-year prostate specific autigen (PSA) failure-free survival were 89.3% and 79.5%, respectively. Three patients developed grade 2 proctitis.

CONCLUSION

This technique is a possible alternative to IMRT in EBRT of prostate cancer.

Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial

CONTEXT

In patients with brain metastases, it is unclear whether adding up-front whole-brain radiation therapy (WBRT) to stereotactic radiosurgery (SRS) has beneficial effects on mortality or neurologic function compared with SRS alone.

OBJECTIVE

To determine if WBRT combined with SRS results in improvements in survival, brain tumor control, functional preservation rate, and frequency of neurologic death.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial of 132 patients with 1 to 4 brain metastases, each less than 3 cm in diameter, enrolled at 11 hospitals in Japan between October 1999 and December 2003.

INTERVENTIONS

Patients were randomly assigned to receive WBRT plus SRS (65 patients) or SRS alone (67 patients).

MAIN OUTCOME MEASURES

The primary end point was overall survival; secondary end points were brain tumor recurrence, salvage brain treatment, functional preservation, toxic effects of radiation, and cause of death.

RESULTS

The median survival time and the 1-year actuarial survival rate were 7.5 months and 38.5% (95% confidence interval, 26.7%-50.3%) in the WBRT + SRS group and 8.0 months and 28.4% (95% confidence interval, 17.6%-39.2%) for SRS alone (P = .42). The 12-month brain tumor recurrence rate was 46.8% in the WBRT + SRS group and 76.4% for SRS alone group (P<.001). Salvage brain treatment was less frequently required in the WBRT + SRS group (n = 10) than with SRS alone (n = 29) (P<.001). Death was attributed to neurologic causes in 22.8% of patients in the WBRT + SRS group and in 19.3% of those treated with SRS alone (P = .64). There were no significant differences in systemic and neurologic functional preservation and toxic effects of radiation.

CONCLUSIONS

Compared with SRS alone, the use of WBRT plus SRS did not improve survival for patients with 1 to 4 brain metastases, but intracranial relapse occurred considerably more frequently in those who did not receive WBRT. Consequently, salvage treatment is frequently required when up-front WBRT is not used.

TRIAL REGISTRATION

umin.ac.jp/ctr Identifier: C000000412.

Treatment results of chemoradiation therapy for localized aggressive lymphomas: A retrospective 20-year study

In this study we analyzed our cases of localized aggressive lymphoma treated in our institution during the last 20 years to compare the finding of this study with those of previous studies. Forty patients with Ann Arbor stage I-II aggressive lymphoma were treated with 3-6 cycles of a CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and radiation therapy (30 or 40 Gy with involved field). Between 1985 and 2003, 40 patients with stage I (N = 25) or stage II (N = 15) disease were treated. Chemotherapy mainly preceded radiotherapy, although the sequence of radiotherapy and chemotherapy was determined by individual physicians and patients' choice. Median and mean age was 50.5 and 48.6 years, respectively, at the time of diagnosis, with a male to female ratio of 19:21. Analyses were undertaken to determine (1) response to treatment according to age, international prognostic index (IPI), lactate dehydrogenase (LDH) value, serum interleukin 2 receptor (sIL-2R) value, cell type, stage, extent of maximum local disease, with or without mediastinal lymph nodes, number of sites, anatomic distribution, and irradiation dose, and (2) relapse patterns. Complete follow-up was obtained in all patients. The follow-up period of surviving 33 patients ranged from 24.7 to 180 months with a median of 69 and a mean of 72.7 months. A complete remission (CR) was achieved in 37 patients (93%). A study of relapse patterns after a CR showed that four patients had a first relapse within a radiation field and the other one patient had an extranodal distant relapse. Significant prognostic factors were not identified by multivariate analysis. Combined chemotherapy and radiation therapy is safe, highly effective, and probably curative for most patients with stage I-II aggressive lymphoma.

Radiation therapy for portal venous invasion by hepatocellular carcinoma

AIM

To clarify the efficacy and safety of three-dimensional conformal radiotherapy (3-D CRT) for this disease and to specify patient subgroups suitable for this treatment.

METHODS

Fifty-two patients with HCC received PVI-targeted radiation therapy from January 1995 through December 2003. Portal venous invasion (PVI) was found in the second or lower order branches of the portal vein in 6 patients, in the first branch in 24 patients and in the main trunk in 22 patients. Child classifications of liver function before radiation therapy were A, B, and C for 19, 24 and 2 patients, respectively. All patients received three-dimensional conformal radiotherapy with a total dose ranging from 39 to 60 Gy (57.0 Gy in average).

RESULTS

Overall survival rates at 1, 2, 3, 4, and 5 years were 45.1%, 25.3%, 15.2%, 10.1%, and 5.1%, respectively. Univariate analysis revealed that Child status, the number of tumor foci, tumor type, transcatheter arterial embolization (TAE) after radiation therapy were statistically significant prognostic factors. Multivariate analysis showed that the number of tumor foci and TAE after radiation therapy were statistically significant.

CONCLUSION

The results of this study strongly suggest the efficacy of 3-D CRT as treatment for PVI in HCC. 3-D CRT is recommended in combination with post-radiation TAE for PVI of HCC with 5 tumor foci or less in the liver and with Child A liver function.

Radiation therapy combined with cis-diammine-glycolatoplatinum (nedaplatin) and 5-fluorouracil for Japanese stage II-IV esophageal cancer compared with cisplatin plus 5-fluorouracil regimen: a retrospective study

To evaluate the treatment outcome of radiotherapy combined with cis-diammine-glycolatoplatinum (nedaplatin) plus 5-fluorouracil (5-FU) for esophageal cancer. From January 2000 to December 2004, a total of 12 esophageal cancer patients with locally advanced and metastatic esophageal cancer (stages II-IVB) were treated with radiation therapy (50.4 Gy) combined with nedaplatin (80 mg/m(2), bolus infusion) and 5-FU (800 mg/m(2)/24 h, continuous infusion for 4 days) (NDP group). We compared the data with those of patients during the same period receiving a different chemotherapy regimen consisting of cisplatin (75 mg/m(2), bolus infusion) and 5-FU (1000 mg/m(2)/24 h, continuous infusion for 4 days) (n = 29, CDDP group) combined with the same radiation therapy. The median survival period was 11.5 months in the NDP group and 13.1 months in the CDDP group. The overall survival rates at 1-, 2-, and 3-years were 40%, 13%, and 13% in the NDP group and 56%, 42%, and 8% in the CDDP group (P = 0.2472), respectively. Grade III and IV leukocytopenia was observed in six (50%) and none of the patients in the NDP group and 14 (48%) and seven (24%) in the CDDP group, respectively. Grade III thrombocytopenia was observed in three (25%) in the NDP group and four (14%) in the CDDP group. Radiation combined with nedaplatin and 5-FU is a safe and effective method for treating esophageal cancer. We recommend that NDP should be used rather than dose-reduction of CDDP combined with 5-FU in patients with impaired renal function as indicated by low creatinine clearance value (40-60 mL/min).

Treatment results of preoperative concurrent chemoradiotherapy followed by surgery for stage III or IV esophageal squamous cell carcinoma

PURPOSE

To evaluate the treatment outcome of preoperative neoadjuvant radiotherapy combined with chemotherapy (CTx) for 17 esophageal cancer patients.

MATERIALS AND METHODS

Between 1992 and 2004, patients with locally advanced esophageal cancer (stage III or IV) before curative-intent surgery received radiotherapy (RT) combined with CTx (Cisplatin: 75 mg/m2, bolus infusion, and 5-fluorouracil (5-FU): 1,000 mg/m2/24 h, continuous infusion for 4 days) at a median total dose of 30 Gy (n=17).

RESULTS

The median survival period was 13.8 months. The overall survival rates at 1, 2, and 3 years were 75%, 40%, and 20%, respectively. According to univariate analysis, no factor of worse prognosis was found. Pathological markedly (Grade 3) or moderately (Grade 2) effects were observed in 4 patients (24%) and 8 patients (47%), respectively.

CONCLUSION

These results indicate that, although this regimen was effective in terms of pathological effect, it is unclear whether it made a contribution to the improvement of survival