Outcome of Radiation Therapy for Locally Advanced Vulvar Carcinoma: Analysis of Inguinal Lymph Node

BACKGROUND/AIM

The aim of this study was to define the outcome of radiation therapy for vulvar carcinoma, and to investigate the effectiveness of therapeutic and prophylactic inguinal lymph node (ILN) irradiation. Because reports about the treatment of ILN were limited.

PATIENTS AND METHODS

Thirty consecutive vulvar carcinoma patients were treated using external beam radiation therapy (EBRT) for definitive disease (n=25) or postoperatively (n=5). Twenty-four (80%) had squamous cell carcinoma (SCC). Tumor stages (2002 UICC) ranged from 0 to IVB, with no distant metastases.

RESULTS

The median total prescribed dose for primary tumor was 64.8 Gy. The 2-year overall survival rate was 25.3%. The outcome was significantly better in patients with ILNs<30 mm (p=0.005) and patients receiving prescribed doses >60 Gy (p=0.002).

CONCLUSIONS

ILN diameters ≤30 mm and prescribed doses over 60 Gy were associated with ILN control in patients with vulvar carcinoma.

Outcome of postoperative radiation therapy for cholangiocarcinoma and analysis of dose-volume histogram of remnant liver

The aim of this study was to analyze dose-volume histogram (DVH) of the remnant liver for postoperative cholangiocarcinoma (CCA) patients, to find toxicity rates, and to confirm efficacy of postoperative radiation therapy (RT).Thirty-two postoperative CCA patients received partial liver resection and postoperative RT with curative intent. The "liver reduction rate" was calculated by contouring liver volume at computed tomography (CT) just before the surgery and at CT for planning the RT. To evaluate late toxicity, the radiation-induced hepatic toxicity (RIHT) was determined by the common terminology criteria for adverse events toxicity grade of bilirubin, aspartate transaminase, alanine transaminase, alkaline phosphatase, and albumin, and was defined from 3 months after RT until liver metastasis was revealed. The radiation-induced liver disease (RILD) was also evaluated.Tumor stages were distributed as follows: I: 1, II: 8, IIIA: 1, IIIB: 6, IIIC: 14, IVA: 2. Median prescribed total dose was 50 Gy. Median follow-up time was 27 months. Two-year overall survival (OS): 72.4%, disease-free survival: 47.7%, local control: 65.3%, and the median survival time was 40 months. The median "liver reduction rate" was 21%. The OS had statistically significant difference in nodal status (P = .032) and "liver reduction rate" >30% (P = .016). In the association between the ≥grade 2 RIHT and DVH, there were significantly differences in V30 and V40 (P = .041, P = .034), respectively. The grade ≥2 RIHT rates differ also significantly by sex (P = .008). Two patients (6.2%) were suspected of RILD.We suggest that RT for remnant liver should be considered the liver V30, V40 to prevent radiation-induced liver dysfunction.

Radiation Therapy for Patients with Bone Metastasis from Uterine Cervical Cancer: Its Role and Optimal Radiation Regimen for Palliative Care

AIM

To determine the role of radiation therapy for patients with bone metastasis from uterine cervical cancer and identify an optimal radiation regimen.

PATIENTS AND METHODS

A total of 20 patients with bone metastases from uterine cervical cancer received radiation therapy to the pelvis. The median total dose of 60.2 Gy in the 2 Gy per fraction-equivalent dose (EQD2) was delivered to cervical tumors of all patients. Thirteen patients underwent chemotherapy during and/or following radiation therapy.

RESULTS

In 18 of 20 patients, the primary tumors disappeared or were markedly reduced after radiation therapy. In all but one of 17 patients with pelvic pain and bleeding, these symptoms disappeared or were remarkably relieved. However, three patients had primary tumor progression at 7, 9, and 15 months after irradiation with total doses of 56.8, 58.4, and 68.3 Gy in EQD2, respectively. Two of these patients had relapses of bleeding and pain. The primary progression-free rate considering all patients was 69% at 1 year and 34% at 2 years. The corresponding overall survival rates were 34% at 1 year, and 8% at 2 years, with an estimated median survival time of 7 months. The number of metastatic bone sites (p=0.027) and administration of chemotherapy (p<0.001) were significant prognostic factors for survival.

CONCLUSION

Radiation therapy is effective for relief of pelvic symptoms in patients with bone metastasis from uterine cervical cancer. For patients who are expected to survive for more than 1 year, almost curative-dose irradiation to primary tumors is recommended.

Radiation therapy for stage IVA uterine cervical cancer: treatment outcomes including prognostic factors and risk of vesicovaginal and rectovaginal fistulas

Purpose

To evaluate the safety and efficacy of radiation therapy for stage IVA uterine cervical cancer and to identify an optimal radiation regimen.

Results

Seventeen of the 28 patients developed recurrence after radiation therapy (local recurrence in 10 and distant metastasis in 12). The local control and distant metastasis-free rates at 3 years in all patients were 61% and 49%, respectively. Fourteen patients died after radiation therapy, and all but 2 died of tumor progression. The disease-free, cause-specific, and overall survival rates at 3 years in all patients were 32%, 49%, and 45%, respectively, and the estimated median survival time was 32 months. Tumor size (P = 0.007) and involvement in the lower third of vagina (P = 0.006) were significant prognostic factors for local control. Older age (P = 0.018) and performance status (P = 0.020) were significant prognostic factors for distant metastasis. The presence of hydronephrosis was the sole significant prognostic factor for survival (P = 0.026). Only 2 patients developed grade 3 late toxicities (vesicovaginal fistula and radiation proctitis, respectively).

Materials and Methods

Twenty-eight patients with stage IVA uterine cervical cancer received radiation therapy. All patients initially received external pelvic irradiation at a median dose of 50.4 Gy in 28 fractions. Twenty patients also received high-dose-rate intracavitary brachytherapy at a median dose of 22 Gy in 4 fractions. These fraction sizes were lower than conventional sizes. The total median dose for all 28 patients was 68.7 Gy.

Conclusions

Radiation therapy is safe and effective for treatment of stage IVA uterine cervical cancer. The reduced radiation dose per fraction may contribute to the prevention of vesicovaginal fistula formation.

Radiation Therapy for Para-Aortic Lymph Node Metastasis from Uterine Cervical Cancer

AIM

To evaluate the efficacy of radiation therapy for para-aortic lymph node metastases from uterine cervical cancer and to identify an optimal radiation regimen.

PATIENTS AND METHODS

A total of 80 metastatic para-aortic lymph nodes, ranging from 11-50 mm (median=20 mm) on computed tomography, in 22 patients with squamous cell carcinoma of the uterine cervix were initially treated with radiation therapy. Total radiation doses for para-aortic lymph node metastases were 40-61.2 Gy (median=50.4 Gy) in 1.8-2 Gy fractions.

RESULTS

Eight out of the 22 patients remained alive at a median follow-up of 32 months. Seven irradiated lymph nodes, 20-50 mm in diameter, in four patients progressed after irradiation at total doses of 44-50.4 Gy. No metastatic lymph nodes administered >50.4 Gy (median=55.8 Gy) exhibited progression after irradiation. All metastatic lymph nodes ≤ 25 mm in diameter irradiated with 50 or 50.4 Gy were controlled. The 3-year lymph node progression-free rates were 78% in the cohort of 22 patients and 89% considering all 80 metastatic lymph nodes. Apart from transient hematological reactions, two patients developed grade 3 or more therapy-related toxicities, including radiation proctitis in one and hemorrhagic cystitis and colitis in another.

CONCLUSION

Radiation therapy can effectively control para-aortic lymph node metastases in patients with uterine cervical cancer. A total dose of 50.4 Gy in 1.8 Gy fractions is sufficient to control metastatic lymph nodes ≤ 25 mm in diameter, whereas a higher dose (approximately 55.8 Gy) may be required for larger nodes.

Chemoradiation as a definitive treatment for cervical lymph node metastases from unknown primary cancer

AIM

To assess the treatment outcomes of chemoradiation for cervical lymph node metastases from an unknown primary site (CUP), and to identify for prognostic factors.

PATIENTS AND METHODS

Thirty patients diagnosed as having CUP, and receiving chemoradiation as a definitive treatment were included in the analysis. Locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) rates were estimated, and the factors affecting treatment outcomes were analyzed.

RESULTS

After a median follow-up period of 25 months for surviving patients, the two- and five-year LRC, DFS, and OS rates were 56%/45%, 46%/36%, and 69%/52%, respectively. On univariate analysis, lower performance status (PS; p=0.001), and limitation of disease to level 2 or 3 lymph nodes (p=0.009) were significantly associated with better DFS. Low PS (p=0.002) was significantly associated with better LRC. No late toxicity of grade 3 or greater was observed.

CONCLUSION

Definitive chemoradiation for CUP was well-tolerated, with improvement of DFS/LRC for those with good PS and disease limited to level 2 or 3 lymph nodes.

Definitive radiation therapy for extramammary Paget's disease

BACKGROUND

Extramammary Paget's disease (EMPD) is frequently inoperable because of old age and/or coexisting disease. We therefore reviewed the efficacy and toxicity of radiation therapy for EMPD.

PATIENTS AND METHODS

Fourteen patients with EMPD underwent definitive radiation therapy. Three patients had regional lymph node metastases before radiation therapy, but none had distant metastasis. Total doses of 52-80.2 Gy (median=60.6 Gy) were delivered to tumor sites in 26-43 fractions (median=33 fractions).

RESULTS

Four patients had developed recurrence at a median follow-up period of 47 months. The 5-year local control and disease-free rates were 71% and 63%, respectively. Two patients died of old age and renal failure at 6 and 51 months, respectively, after irradiation. The 5-year disease-free, cause-specific and overall survival rates were 46%, 100% and 79%, respectively. No therapy-related toxicities of grade 3 or greater were observed.

CONCLUSION

Radiation therapy is effective and safe, and appears to offer a curative treatment option for patients with EMPD.

Reduction cranioplasty for craniocerebral disproportion due to chronic subdural hematoma in infants. A technical report

Advanced craniocerebral disproportion due to chronic subdural hematoma in infants which is resistant to conventional treatments requires reduction cranioplasty as the last resort. The present paper deals with our experience with two such cases originated from head injury. Since the volume of the hematoma cavity was calculated based on the pre-operative CT scans, we devised a mathematical formula to design how the cranial vault could be reconstructed for reduction. This enabled us to pre-determine the extent of cranial reduction which was tailored to each patient. Furthermore, the present methodology is characterized by the modification that the midline bone strip overlying the superior sagittal sinus was shortened at its anterior end and bent down using the posterior end as a hinge. Since the follow-up results were favorable, this technique of reduction cranioplasty is reported in detail.

Gamma-ray induced hepatocarcinogenesis in p53-deficient mice

BACKGROUND

Mutations in the p53 gene are frequent genetic alterations in human hepatocellular carcinoma (HCC), but, little is known of the molecular genetic changes that occur during murine hepatocarcinogenesis.

MATERIALS AND METHODS

To characterize the properties of constitutive p53 deficiency that contribute to liver tumor development, a total of 168 F1 mice of two different strains (C3H, which are susceptible to hepatocarcinogenesis and MSM [Mus. M. molossinus] with a single null p53 allele) were exposed to a single 3-Gy dose of whole-body gamma-irradiation at 4 weeks of age and observed for a period of 360 days. The genotype of the mice and the p53 spectrum of the tumors were investigated by polymerase chain reaction (PCR) analysis.

RESULTS

Thirty-five gamma-ray-induced HCCs were obtained as a result of this experiment. 11 (40%) of the mice with liver tumor were wild-type for p53. All liver tumors examined retained the wild-type p53 allele, indicating that p53 itself may not be a target for radiation-induced alteration. Only two p53-deficient mice in the liver tumor group developed thymic lymphomas. The p53-deficient mice showed no significant differences in the number, size, or growth rate of HCC or in the apparent development of HCC.

CONCLUSION

These results indicate that p53 deficiency does not enhance the rate of development or degree of malignancy of radiation-induced HCC in mice but may instead favor the development of multiple primary cancers.

Transcranial approach for transsphenoidal encephalocele: report of two cases

BACKGROUND

Whereas the transcranial approach has been regarded as the therapy of choice for transethmoidal encephalocele, its feasibility for transsphenoidal encephalocele has remained controversial, particularly in neonates and infants.

CASE REPORT

Two cases of transsphenoidal encephalocele operated transcranially are presented. In the first case, this 6-year-old boy underwent a transpalatal operation with repair of a cleft palate in another hospital before admission. Reoperation via the transcranial route was carried out because of postoperative recurrent meningitis. With partial resection of the anterior wall, the encephalocele could be separated from the underlying tissue, and the interspace was filled with the pericranial flap. He made an uneventful recovery and has been well for the past 3 years. The second was a 3-month-old baby with a large encephalocele filling the nasopharyngeal space. As the cleft palate was absent, the transcranial approach was employed. In this case, the herniated tissue was excised at the lowest level possible. Postoperatively, panhypopituitarism became manifest. Re-evaluation of the preoperative magnetic resonance imaging (MRI) disclosed a small mass far below the dorsum sellae, which turned out to be an anomalous pituitary gland on histologic examination.

CONCLUSIONS

The transcranial approach is considered a valid alternative for the therapy of transsphenoidal encephalocele, particularly when the transpalatal approach is unfeasible. While the anterior wall of the herniated sac may be safely resected, the posterior wall should under no circumstances be sacrificed. The preoperative MRI is essential, as it may provide valuable information as to the location of vital structures within the herniated tissue.

Pairing of DNA fragments containing (GGA:TCC)n repeats and promotion by high mobility group protein 1 and histone H1

Tandemly repeated DNA sequences of (GGA:TCC)n are found in tracts up to 50 base pairs long, dispersed at thousands of sites throughout the genomes of eukaryotes. Here we demonstrate the formation of complexes paired between two DNAs containing such repeats in vitro and show enhancement of the pairing by glutathione S-transferase fusion proteins of high mobility group protein 1 and histone H1. This assembly depends on incubation time at 37 degrees C and concentrations of the proteins and DNA, and the enhancement is inhibited by distamycin and actinomycin D interacting DNA through the minor groove. Structure of the DNA-DNA complex is deduced by comparison of its mobility in gel electrophoresis with those of synthetic markers of heterotetramers. Three synthetic and genomic DNA fragments containing repeats that have different arrangements exhibit different efficiencies of DNA pairing, implying that the pairing is affected by the number of repeat units and the arrangement of repeats in a sequence. Intriguingly, pairing occurs between homologous fragments but not between heterologous DNAs among the three. These results suggest that the repeat-mediated DNA pairing plays a role in organization of higher order architecture of chromatin and possibly chromosome segregation requiring sequence-specific association events of DNA molecules.

The role of active smooth-muscle contraction in the occurrence of chronic vasospasm in the canine two-hemorrhage model

To evaluate the pathogenetic role of alterations in the physical properties of the arterial wall (the passive component) and of active smooth-muscle contraction (the active component) in the occurrence of chronic vasospasm, the temporal profiles of these events were examined using the canine "two-hemorrhage" model. In the in vivo study, the basilar artery was exposed via the transclival approach on Day 0, 2, 4, 7, or 14. Nicardipine, followed by the protein kinase C inhibitor H-7, then papaverine were administered in a cumulative fashion, and the change in the basilar artery diameter induced by the addition of each agent was recorded angiographically. Drug administration markedly reversed the arterial narrowing caused by chronic vasospasm. When the vasodilatory effect of each agent was compared, the dilation induced by nicardipine or papaverine progressively decreased from Day 2 to Day 7, whereas that induced by H-7 increased. The in vitro experiment using arterial segments excised from the basilar artery revealed a progressive increase in arterial stiffness from Day 2 to Day 7. Also, there was a significant decrease in the initial half-circumference of the arterial segment, which was at its maximum on Days 4 and 7. However, the alteration in the initial half-circumference was considerably less than that in the angiographic diameter following subarachnoid hemorrhage. These data indicate that the augmented spontaneous tonus of the smooth muscle plays the predominant role in the occurrence of chronic vasospasm. Thus, the involvement of the protein kinase C-mediated contractile system is strongly suggested.

Effect of antioxidative lactic acid bacteria on rats fed a diet deficient in vitamin E

Lactic acid bacteria, including Bifidobacterium, with antioxidative activity were selected by in vitro screening. The effect of the antioxidative activity was investigated by in vivo experiments using rats that were deficient in vitamin E. In the first stage of screening, 570 strains were examined; intracellular cell-free extracts of 19 strains (16 lactobacilli, 2 streptococci, and 1 lactococci) had antioxidative activity as determined by an assay using rat liver microsomes and thiobarbituric acid. In the second stage of screening, 7 strains of lactobacilli showed over 70% inhibition of oxidation activity. The highest activity was obtained by heterofermentative Lactobacillus sp. SBT 2028. The effect of two strains, Lactobacillus sp. SBT 2028 and Lactobacillus casei ssp. rhamnosus SBT 2257, was evaluated for improvement of the condition of rats fed a diet deficient in vitamin E. Intracellular cell-free extracts of those two strains were also used for in vivo experiments. Hemolysis of red blood cells was inhibited in rats that were administered the extract of Lactobacillus sp. SBT 2028, which proved that the extract improved the vitamin E deficiency status. Antioxidative activity of an extract from L. casei ssp. rhamnosus SBT 2257 determined by hemolysis was relatively weak compared with the activity of Lactobacillus sp. SBT 2028 extract.

Possible involvement of C-kinase in occurrence of chronic cerebral vasospasm after subarachnoid hemorrhage

The present study aimed to examine the turnover of phospholipids such as PI, PC and PE, the time course of PKC activity and the phosphorylation of 20 kDa MLC in the canine BA undergoing chronic VS. The phosphorylation of 20 kDa MLC was not augmented in the spastic BA. Turnover of PC and PE was detectably stimulated on day 7. The cytosolic PKC activity was down-regulated on days 4 and 7, while the membrane PKC activity remained unchanged during these periods. The present results indicate that a process which affected the membrane lipid metabolism, PKC metabolism and PKC activity occurred in spastic BA.

Primary empty sella syndrome caused by an abnormal dilatation of the optic recess

A new variety of primary empty sella syndrome is reported. A partial herniation of the optic chiasm into an enlarged empty sella compressed by a dilated optic recess mimicking a cystic tumor was confirmed at operation. The pathogenesis and the treatment of this type of empty sella syndrome are discussed.

[The effectiveness of FID-CT (functional image of dynamic CT) for the evaluation of early cerebral ischemia]

A computer program was newly developed to display the ischemic area from the serial dynamic CT scan, namely the functional image of the dynamic CT (FID-CT). The principles of FID-CT are as follows; Seven rapid-sequence dynamic CT scans were taken following a peripheral bolus intravenous injection of 40 ml of iopamidol. As the data from each scan can be separated into three consecutive segments, we obtained 21 images during 44 seconds. Time density curves of each pixel were calculated employing Gamma variate fitting method. Eight functional parameters obtained from this curve were displayed with gray-scale pixel by pixel. These eight images were functional images obtained from dynamic CT. Only three or four minutes were required to complete all the calculations. Twenty-two patients were examined with both FID-CT and 123I-SPECT. In each case, the lesion detected by FID-CT was remarkably consistent with that shown by SPECT. Two representative cases were presented. The authors believe that FID-CT is a very useful diagnostic method in the acute stage of cerebral ischemia because the method can be quickly and easily performed and it discloses the ischemic area with fair certainty.

Optimal preprocessing Butterworth-Wiener filter for Tl-201 myocardial SPECT

The optimal frequency characteristic of Butterworth-Wiener filters (BWF) for improving the image quality of 201Tl myocardial SPECT was determined by a phantom experiment. Thirty two projection images of the phantom containing 11.1 MBq of 201Tl with 4 different cold lesions were collected during a 180 degree arc of a gamma camera. A set of the projection images were processed with each of 27 different BWFs, and SPECT images were reconstructed by Shepp-Logan filtered backprojection. The SPECT images were evaluated for their diagnostic ability to visibly detect the cold lesions by four nuclear medicine physicians. The lesion contrasts were used as an adjunctive tool to determine the optimum filter. The optimal combination of the parameters determining BWF characteristics (for the data of about 100 count/pixel at the myocardium) is: 1) cutoff of 0.25/pixel, 2) FWHM of 3 pixels, 3) noise/signal ratio of 0.02. FWHM and noise/signal ratio affected lesion contrast much less than cutoff frequency. Clinical myocardial SPECT images processed with the optimal BWF showed less noise and sharper delineation of the myocardium.

Iodine-123 IMP SPECT before and after bypass surgery in a patient with occlusion of left anterior and middle cerebral arteries with basal abnormal telangiectasis (unilateral Moyamoya disease)

A case of left anterior and middle cerebral arterial occlusion with angiographic features similar to Moyamoya disease was reported. IMP SPECT of the patient revealed the success of bypass surgery clearly. The patient complained of transient right hemiparesis with aphasia 4 times. The cerebral arteriography disclosed occlusions of left anterior and middle cerebral arteries at their proximal portions. Right internal carotid and its branches were normal. I-123 IMP SPECT study showed hypoperfusion in left temporal lobe, basal ganglia with incomplete reperfusion on the delayed (4 hours after injection) SPECT images. After the superficial temporal-middle cerebral artery anastomosis, I-123 IMP SPECT showed improvement of the brain blood flow. I-123 IMP SPECT was very useful in detecting the ischemic areas and evaluating the revascularizing surgery in this case.

[The study of a two-dimensional polar representation of the cardiac SPECT image--a new method of displaying left ventricular wall motion]

A new method was developed to display left ventricular wall motion using two dimensional polar representation of cardiac SPECT image. After intravenous administration of 740 MBq (20 mCi) 99mTc (in vivo labeling of red blood cell), ECG-gated SPECT image of cardiac pool was recorded (32 directions, 180 degrees). The short axis images of left ventricle were constructed at end-diastole (ED) and end-systole (ES). Then the functional images of (ED-ES)/ED were calculated at each compatible slices and displayed in color according the degree of wall motion. In 8 cases with cardiac diseases this method was applied and clinically useful functional images could be obtained. The area of akinesia or hypokinesia are successfully demonstrated clearly separated from the area of normokinesia. We conclude that this method is useful to show left ventricular wall motion and to evaluate the segment and grade of abnormal wall motion of left ventricle.