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We report a case of pulmonary metastasis from hilar cholangiocarcinoma successfully treated by stereotactic body radiotherapy. The patient was a 70-year-old woman who underwent extended left hemi-hepatectomy with bile duct reconstruction for hilar cholangiocarcinoma at the age of 67. Pathological diagnosis indicated a well-differentiated adenocarcinoma. We followed up the patient without adjuvant chemotherapy. Nineteen months after the initial resection, a solitary pulmonary metastasis was detected in the right upper lobe. The patient received gemcitabine plus cisplatin(GC)therapy. After 4 courses of GC therapy, the size of the pulmonary metastasis was unchanged. Therefore, we performed a thoracoscopic wedge resection. Pathological diagnosis indicated that the pulmonary metastasis originated from the cholangiocarcinoma. Fifteen months after the pulmonary resection, another solitary pulmonary metastasis was detected in the left lower lobe. As the patient refused further chemotherapy, we performed stereotactic body radiotherapy(SBRT)(50 Gy/4 Fr). An adverse event of Grade 1 radiation pneumonitis was observed. The metastasis disappeared after SBRT. Twenty-eight months after SBRT and 70 months after the initial surgery, the patient is alive without recurrence.

A 24-year-old man with acute lymphoblasticleukemia underwent allogeneicperipheral blood stem cell transplantation (allo-PBSCT)from a human leukocyte antigen-matched sibling after myeloablative conditioning, with a regimen including total body irradiation(TBI)(12 Gy/6 fractions), 6 years ago. The patient developed extensive chronic graft-versus-host disease(cGVHD)of the skin, mouth, liver, and gut four months after allo-PBSCT. Treatment with cyclosporine and prednisolone was necessary to control the cGVHD. Six years after allo-PBSCT, the patient experienced odynophagia and was diagnosed with cervical esophageal squamous cell carcinoma(cT1bN1M0, cStage II B). Because we considered laryngeal preservation, risk of anastomotic leakage, and infection related to the operation, the patient was planned to receive chemoradio- therapy with 5-fluorouracil and cisplatin. Regarding irradiation, the patient received radiotherapy(50.4 Gy/28 fractions)for a primary tumor and lymph node without an elective nodal area. The patient achieved complete response and remained disease- free without any treatment-related complications for 3 years.

Iodine-131 (I-131) has been used for the ablation of residual thyroid remnants and cancer cells in well-differentiated thyroid cancers. It has also been used for metastatic well-differentiated thyroid cancers, especially lung and bone metastases. For small lung metastases, I-131 treatment has curative potential, particularly in young patients. Suppression of the thyroid stimulating hormone is also important for prolonging the survival of thyroid cancer patients. Strontium-89 (Sr-89) chloride has a mechanism similar to calcium, and it has been used for the treatment of bone metastases, especially osteoblastic metastases. It has been reported to have analgesic effects in an average of 76% of cases, and it is more effective if used in the early bone metastatic phase. Ibritumomab tiuxetan (Zevalin) is an anti-CD20 mouse monoclonal antibody labeled with Yttrium-90 (Y-90). It is used for treatment-resistant low grade or follicular B-cell non-Hodgkin's lymphomas and mantle lymphomas. Recently, radium-223 (Ra-223) has been used for bone metastases from castration resistant prostate cancers, and in a phase III trial, it has been proven to prolong survival of these patients. Cancer therapy using unsealed radioisotopes has been thought to be promising because it exhibits more targeted therapy than external beam irradiation. Therefore, if many more ideal targeting agents are developed in the future, this treatment might be used more commonly. As many agents such as I-131, Sr-89, and Ra-223 are available for treating bone metastasis, the combined use of other treatments such as high precision radiotherapy, bisphosphonates, hormonal agents, and molecular targeted agents should be investigated.

The rate of severe late adverse effects has decreased with the highly accurate administration of radiation therapy; however, the total number of patients who suffer from late effects has not decreased because of the increased total number of patients and better survival rates. Late adverse effects, occurring more than a few months after irradiation, include the extension and collapse of capillaries, thickening of the basement membrane, and scarring of tissue due to loss of peripheral vessels. The main causes of these late effects are the loss of stromal cells and vascular injury. This is in contrast to early reactions, which occur mainly due to the reorganization of slow-growing non-stem cell renewal systems such as the lung, kidney, heart, and central nervous system. In addition, the patient's quality of life is impaired if acute reactions such as mouth or skin dryness are not alleviated. Most adverse effects are radiation dose dependent, and the thresholds differ according to the radiosensitivity of each organ. These reactions occur with a latency period of a few months to more than 10 years. Understanding the clinical and pathological status, through discussion with radiation oncologists, is the essential first step. Some of the late effects have no effective treatment, but others can be treated by steroids or hyperbaric oxygen therapy. An appropriate decision is important.

We report multidisciplinary treatment of 3 patients with lymph node recurrence after curative gastrectomy. Case 1: A 71- year-old woman had a history of distal gastrectomy with D2 lymphadenectomy for the treatment of advanced gastric cancer. Para-aortic lymph node metastasis was observed 36 months after surgery. Complete response( CR) was achieved after concurrent chemoradiotherapy with S-1 plus radiation. Case 2: A 51-year-old man had a history of total gastrectomy with D2 lymphadenectomy for the treatment of advanced gastric cancer. Right cervical lymph node metastasis was observed 48 months after surgery. CR was achieved after concurrent chemoradiotherapy with S-1 plus radiation. Case 3: A 68-year-old man had a history of distal gastrectomy with D2 lymphadenectomy followed by neoadjuvant chemotherapy for the treatment of advanced gastric cancer. CR was achieved after sequential treatment with irinotecan( CPT-11) plus cisplatin( CDDP), radiation, and 5-fluorouraci(l 5-FU) plus Leucovorin therapy for lymph node recurrence near the head of the pancreas. These cases suggest that the combination of systemic chemotherapy and local radiation therapy might be effective for the treatment of lymph node recurrence in patients with gastric cancer.

Our first report mentioned the analysis results of the safety and efficacy of trigger point (TP) therapy by Neovitacain® injection (NV) in the daily clinical treatment of myofascial pain in cancer patients. This time, we report additional considerations regarding the following points; (1) Injection sites: they were concentrated on both sides of the spine, indicating that TPs could be easily formed on the points and near them to support the body's weight when patients were supine. (2) Correlation between VAS and FS: VAS and FS were positively correlated in every measurement period. (3) Patient satisfaction: many patients made several comments expressing feelings of satisfaction from this treatment. The comments were considered to reflect the patients' candid feelings. Therefore, all comments were classified according to the degree of patients' feeling of satisfaction. It may be possible to obtain much higher patient satisfaction by hearing out the voice of the patients. Judging from this study, TP therapy by NV for myofascial pain in cancer patients relieved the total pain of cancer patients. TP therapy has potential for obtaining high patient satisfaction.

Special use-results surveillance was conducted to examine the safety and efficacy of trigger point (TP) therapy by Neovitacain ®injection (NV) in the daily clinical treatment of myofascial pain in cancer patients. The case report forms of 175 patients were collected from 43 nationwide facilities and all of them were analyzed in terms of safety and efficacy. This treatment deeply impressed both patients and physicians; 75.4% and 78.3% respectively, over "the good". In addition, as the results of Wilcoxon's signed rank sum test for pain assessment (VAS, FS), both "Cumulative effect before and after treatment" and "Immediate effect before and after each administration" were confirmed to show a highly significant difference (p<0. 0001). Side effects were observed in five of 175 cases (2. 9%) but none of them were serious. Judging from the results of this study, TP therapy with NV was considered to be very useful for the treatment of myofascial pain in cancer patients.

Among various altered fractionation regimens, hyperfractionated radiotherapy (HFRT) has been considered effective to raise survival rate(SR)as well as local control rate(LCR)in head and neck cancers. We reviewed our results of HFRT (117 cases) treated between 1995 and 2004 and compared with those of conventionally fractionated radiotherapy (CFRT; 80 cases) treated during the same period. By disease site, naso-/oro-/hypopharynx/larynx were 5/23/44/45 vs. 10/6/10/54. There were more advanced-stage cases in HFRT group (stage I/II/III/IV = 19/36/23/35 vs. 42/16/8/ 14). Median RT dose were 72 Gy vs. 66 Gy. In 71 cases, chemotherapy was added (HF/CF = 54/17). In stage III and IV cases, there was a borderline significant difference in LCR (at 5 years; 44.3% for HFRT group vs. 24.5% for CFRT group; p = 0.0502), and a tendency in SR(at 5 years; 50.7% for HFRT group vs. 16.7% for CFRT group; p = 0.1210). By disease site, LCR of HFRT group was higher in hypopharynx(p = 0.0005)and oropharynx(p = 0.0003), and SR of HFRT group was higher in hypopharynx(p = 0.0023). Acute toxicity was heavy but in most cases it was tolerable and there were no severe late toxicities. From our data, it was suggested that HFRT might be effective in certain kinds of head and neck cancers.

Radiation therapy (RT) for prostate cancer has been developing dramatically during the past 10 years in Japan as well as in USA. There are several ways to treat prostate cancer by RT. As for external-beam RT (EBRT), a more sophisticated technique beyond 3-dimensional conformal RT called intensity modulated RT was developed and has been in use in many Japanese RT centers. It can raise the total radiation dose and is expected to increase the biochemical control rate. As for brachytherapy, a low-dose-rate seed implant using iodine-125 was initiated in 2003 and has become widespread throughout Japan in only a few years. High-dose-rate brachytherapy using iridium-19 2 has also been used in more advanced cases combined with EBRT. Brachytherapy offers an ideal RT dose concentration and can avoid rectal complications. As for particle therapy, we have carbon and proton in several institutions in Japan. Particles have the merit of good dose distributions and for carbons, relative biological effectiveness. Furthermore, some centers are considering the stereotactic hypofractionated RT due to the relatively low alfa-beta ratio of prostate cancer. Recent reports showed that after a certain period of followup, the biochemical control rate was similar either with external beam high-quality RT, brachytherapy, heavy ion RT and surgery. Therefore, the choice of treatment should depend on the adverse effects, quality of life, medical costs, and the lifestyle of the patient. The merits and demerits of each treatment modality were discussed. Longer follow-up is still necessary and informed consent is mandatory when choosing a treatment modality.

Radiotherapy has been widely used in breast cancer in many situations. These are breast irradiation of breast conserving therapy,post mastectomy regional irradiation,irradiation for regional lymph nodes recurrence,breast irradiation of inoperable locally advanced cases,palliative irradiation of brain metastasis,bone metastasis and so on. The relationship among radiotherapy,surgery and systemic therapy has to be considered in those situations. In breast conserving therapy, the usefulness of breast irradiation is well established. Otherwise, a local controllability depend on a grade of residual tumor cell has not been understand. The authors conducted the survey of 941 cases of positive surgical margins and found that doses more than 60 Gy has a tendency for better local control in post menopausal cases. To reduce patient's burden,3 weeks short course irradiation (Canadian protocol) or accelerated partial breast irradiation have been introduced in breast irradiation. A subgroup which has no need to irradiate to conserving breast had not been identified. The timing between postoperative chemotherapy and irradiation is another point that has to be considered. To reduce distant metastasis,chemotherapy first has been considered better. As for post mastectomy regional irradiation, improvement of local and systemic control has been widely known these days. A timing of systemic therapy and irradiation is a point has to consider. In inoperable or far advanced T 4 tumors, breast irradiation with concurrent chemotherapy must be considered in stead of surgery. We have to know a big shortage in Japanese cancer treatment situation that we have few radiation oncologists or medical physicists in Japan. We have to educate those specialists to catch up with increasing cancer patients.

We present two cases of liver metastases from breast cancer treated by radiofrequency ablation (RFA) for elongation of life. Case 1: A 50-year-old woman was treated by left mastectomy (stage IIIa) in December 2002. In April 2004, she was treated with a combination therapy of weekly paclitaxel and trastuzumab for multiple liver metastases, left supraclavicular lymph node metastases, and multiple bone metastases. After 16 courses of weekly paclitaxel and trastuzumab, liver metastases decreased significantly in size. Because liver metastases recurred during a continuation of weekly paclitaxel and trastuzumab, we performed RFA and chemotherapy using a hepatic artery infusion of docetaxel for liver metastasis. The aggravation spread to the liver lesion and she died after 20 months from liver metastases. Case 2: A 65-year-old woman was treated by left mastectomy (stage IIA) in 1984, and the distant metastasis was not found through the course after an operation. She was noted with a liver function aberration in another hospital in March 2005. We scanned it, and it was diagnosed as multiple liver and bone metastases from breast cancer. Because she did not hope for an anticancer drug treatment for multiple liver metastases, we performed RFA in May 2005. After the second RFA was performed, she does not show any new lesion to the liver for 10 months.

We evaluated the efficacy and feasibility of low-dose gemcitabine concurrent with radiation as adjuvant therapy. Nine cases of locally far advanced unresectable pancreatic cancer were enrolled in this study. Intraoperative radiation was carried out in every case using eight or ten centimeter cones with a radiation dose of twenty to twenty five Gy. Postoperative radiation was two Gy per day on weekdays for five weeks. Low-dose gemcitabine (40 mg/m2) once a week was administered prior to radiation. A grade 3 adverse event occurred in three cases. CA19-9 decreased 60.1% and DUPAN-2, 52.6%. CT scan confirmed a necrotic change and a decrease of the tumor size. Average survival time was ten months. Peritoneal dissemination was the recurrence pattern. In conclusion, low-dose gemcitabine concurrent with radiation therapy may contribute to local control of the disease. However, peritoneal dissemination must be overcome to prolong survival.

Gemcitabine (GEM) concurrent with radiation is clinically not well defined. We herein report four cases of chemo-radiotherapy against locally advanced pancreatic cancer using low-dose GEM concurrent with extra-beam radiation. A total of eight cases entered the study. Three were resected and five were non-resected cases. Intraoperative radiation was carried out in every case using an 8 or 10 centimeter cone with a radiation dose of 25 Gy. Postoperative radiation was 2 Gy per day on weekdays for 5 weeks. Four cases were concurrent with low-dose GEM (40 mg/m2) twice a week, whereas the other four were radiation only. With the use of GEM concurrent with radiation, tumor markers decreased more than 80 percent regardless of the tumor resection. CT scan confirmed a necrotic change and the decrease of the tumor size. In conclusion, low dose GEM concurrent with radiation therapy may be a promising therapeutic choice for the local control of advanced pancreatic cancers.

At the present time, surgery and standard radiotherapy are considered equally effective to control prostate cancer (PC) though previous randomized controlled trials (RCTs) this failed to show this. Therefore, it is important to inform patients of the treatment toxicity as well as treatment effect in selecting treatment options. Dose escalation studies have been done to enhance the biochemical control rate of PC. RCTS are necessary to evaluate the optimal doses in each risk group. Long-term follow-up is necessary both for biochemical control and normal tissue toxicity. Hormone manipulation has been considered standard treatment for high risk groups. Combined with radiotherapy, it is used neoadjuvantly and/or adjuvantly and has been shown to raise the biochemical control rate compared with radiotherapy alone and even overall survival in some RCTs. The timing and length of hormone therapy and the total dose of radiotherapy need to be determined. Brachytherapy is a promising modality in concentrating the dose to the target volume. The treatment results for the present time depend largely on the skills of the operators. But in future, it will be considered a standard treatment. The treatment results for prostate cancer have been improving owing to the continuing efforts to enhance the therapeutic ratio.

We report a case of recurrent breast cancer with chronic renal failure in a 58-year-old female. She could be treated on an outpatient basis under good general condition for most of her remaining life by chemoradiotherapy in combination with hemodialysis. Modification of the chemoradiotherapy procedures and collaboration of medical staff including the doctor in charge of home medical care and her family was indispensable in keeping her hospital stay as short as possible.

Radiotherapy can be done on an outpatient basis depending on the patient's cancer stage, radiation method, concurrent therapy, treatment purpose and general condition. Daily treatment time takes only about 1 minute, but the patient has to come 5 times a week for about 6 weeks for radical treatment and about 3 weeks for palliative treatment. If treated with radiotherapy alone, most patients suffer no severe adverse effects in their daily life. Therefore, radiotherapy can be done on an outpatient basis only if the patient is able to come frequently to the clinic for several weeks. Breast cancer patients commonly undergo radiotherapy in the outpatient clinic, such as breast conserving therapy, postoperative therapy and radiotherapy for local recurrence after mastectomy. Prostate cancer is also commonly treated with radical radiotherapy, postoperative therapy and radiotherapy for local recurrence after prostatectomy. Usually, postoperative irradiation for other cancers and radiotherapy for bone metastases are also undergone on an outpatient basis. During outpatient treatment, it is important to predict and avoid severe normal tissue reactions to radiotherapy, such as myelosuppression and/or pneumonitis, before they are apparent by watching the patient carefully.

We analyzed 58 cases of advanced or recurrent cervical cancer treated with intra-arterial infusion chemotherapy (IAIC) with or without radiotherapy. Two separate IAIC regimens were administered since 1985: group I consisted of 5-FU + MMC +/- ADR (30 patients) and group II consisted of CDDP + MMC +/- 5-FU (28 patients). The tip of a catheter was placed in the bifurcation of the abdominal aorta (1 way method: 45 patients regimen II: 15) between 1977-1984. We have used selective catheterization (2 ways method: 9) since 1995 in order to get good drug distribution. However we experienced grade 4 toxic effect of cutaneous and pain with this method, so we have used a 3 ways method (4 patients) since 1998. The two-year survival rete was 60% with the 1 way method, and 67% with the 2 ways method and regimen II. Severe adverse effects (grade 3 + 4) were found in 53, 56, 0%, respectively, by each of the three methods (1, 2, 3 ways) hematologically, 13, 22, 0% in gastrointestinally, 0, 44, 0% in cutaneously and 0, 56, 0% in pain or neurotoxicity. These data suggest that IAIC by the 3 ways method is a useful treatment for advanced or recurrent cervical cancer. However, one should check the blood flow distribution periodically, and control concentration of drugs.

The conventional treatment for patients with locally advanced esophageal cancer has been surgery or radiotherapy. The indication of the treatment depends on the location of the primary tumor, tumor stage, resectability of the lesion and operability of the patient. Radiotherapy is used in a case refusing surgery, medical contraindications to surgery, extensive locoregional disease or poor general condition. The survival rate by surgery alone or radiotherapy alone is poor. Thus, single modality therapy is not a standard treatment, but combined multimodal therapy including chemotherapy is a standard approach for locally advanced esophageal cancer. Further studies of optimization of multimodal therapies which are surgery and/or radiotherapy combined with chemotherapy are needed to improve the results in the treatment of esophageal cancer.

The efficacy of intraoperative radiotherapy (IORT) for the local recurrence of rectal cancer was evaluated. Operations were performed for a total of 43 patients with local recurrence of rectal cancer, and among them 13 cases received IORT. These patients were divided into two groups those with a suspicion of cancer remaining in the surgical margin macroscopically (EW+ group) or those with no such suspicion (EW- group). The length of pain relieving period and total survival between the IORT and no IORT groups in EW- patients showed no statistical difference. Though the same result was found in EW+ patients, in the patients whose area of positive surgical margin was less than 10 cm2 and given IORT, the pain relief period was prolonged compared with the no IORT patients such as 270 days v.s. 218 days. IORT did not show efficacy in terms of the survival period, but if the local remnant area was small, it was beneficial for the patients in terms of the pain period.

We analyzed 52 cases of advanced or recurrent cancer of the cervix treated by intra-arterial infusion chemotherapy (IAIC) with or without radiotherapy. IAIC regimen was separated into two groups: Group I consisted of 5-FU + MMC +/- ADR (30 cases) and group II of CDDP + MMC +/- 5-FU (22 cases). The tip of the catheter was placed in the bifurcation of abdominal aorta or the bilateral internal iliac arteries (7 cases). The overall response rate (CR + PR) was 71%, 87% in patients given radiotherapy, 50% in those without radiotherapy, and 100% in primary cases. The five-year survival rate was 20% in primary cases, 14% in recurrent cases, 3% in Group I and 38% in Group II (p = 0.00182) by chemotherapy regimen. Severe (more than grade III) hematological acute side effect was 48% for all cases, but recovered by interruption of drugs. In 7 cases in which the tip of the catheter was placed in internal iliac arteries, there were severe skin ulcers in 2 cases and severe pain of leg or gluteal region requiring narcotics in 2 cases. These data suggest that IAIC mainly with cisplatin with or without radiotherapy is one of the effective treatments for advanced or recurrent cervix cancer. But we should check the blood flow distribution periodically, and control the concentration of drugs.

We analyzed 97 cases of various advanced or recurrent pelvic tumors which were cervix, rectal, ovarian and other tumors treated by intra-arterial infusion chemotherapy (IAIC) with or without radiotherapy. The IAIC regimen was separated into two groups: group I consisting of 5-FU + MMC +/- ADR (54 cases) and group II consisting of CDDP + MMC +/- 5-FU (43 cases) from 1985. The catheter was placed in the bifurcation of abdominal aorta, and from 1990, the catheters were placed in bilateral internal iliac arteries (8 cases). The overall response rate (CR + PR) was 65%, 74% in patients receiving radiotherapy, and 47% in those without radiotherapy. There were no significant differences between each primary site and presence of radiotherapy combination in survival rate. Two-year survival rate and 5-year survival rate was 32% and 15% for all cases, and 65% and 33% for CR cases, respectively. A significantly better survival rate was obtained in patients with CR. Five-year survival rate was 4% in group I, and 35% in group II (p = 0.00216) by chemotherapy regimen. Severe (more than grade III) hematological acute side effects were 45% for all cases. In 8 cases in which the catheters were placed in internal iliac arteries, there were severe skin ulcers in 2 cases, and severe pain of leg or gluteal region requiring narcotics in 3 cases. These data suggest that IAIC mainly with cisplatin with or without radiotherapy is one of the effective treatment for advanced or recurrent pelvic tumors. Also, we should check blood flow distribution periodically, and control the concentration of drugs.

As predictors of tumor response by radiotherapy, tumor with or without c-myc amplification and DNA histogram pattern were analyzed and evaluated for patients' prognosis. There was no relation between c-myc amplification and DNA ploidy pattern in this study. These factors also showed no relation to response rate and survival. But all of the tumors with c-myc amplification and aneuploid pattern exhibited a complete response by radiotherapy. The tumors with c-myc amplification and aneuploid pattern may be more radiosensitive than without amplification and diploid. These data suggested that c-myc amplification and ploidy pattern might be a predictive parameter before radiotherapy.

Considering the relationship between tumor lethal dose and normal tissue tolerance: the therapeutic ratio, radiation oncologists have been performed the radiotherapy for cancer patient. The basic principle of radiotherapy is to have a good result (curability), to be tolerable in side effects and to have a comfortable life after radiation. Radiotherapy is the important strategy for an early stage of cancer with conserving the function and structure, and for an advanced or a recurrent stage of cancer with contributing to improve the quality of life. Recently, advantage of radiation tools and supportive care of cancer treatment, have been able to decrease the incidence of late injuries and complications. Radiotherapy must be planned on basis of considering therapeutic ratio and should be performed with optimum radiation in the multimodal treatment for cancer.

Radiation therapy has now an increasing role in the treatment of rectal cancer. Formerly it was used for the palliation of recurrent or residual tumors, but now it is more frequently used for preoperative purposes. Preoperative radiotherapy has the following advantages. It often makes unresectable tumors resectable, prevents tumor seeding during the operation, treats the lateral involvement by the tumor, and makes resectable tumors resected more conservatively. So far we've treated 22 patients with advanced stage rectal cancer by preoperative radiotherapy. Their 3 year local control rate and survival rate was 79% and 86%, respectively, with 9% complication rate. And as for the anal cancers preoperative irradiation and more conservatively, definitive irradiation with doses more than 60 Gy are quite worthwhile both in terms of local control and complication. Both for rectal and anal cancers radiotherapy seems quite promising modality in local tumor control and the patient's quality of life. Further clinical trials are necessary.

Twenty cases of metastatic bone tumors were treated with Elcatonin together with irradiation, achieving pain relief in 47.3% of cases, improved bone scintigrams in 16.7% of cases and radiographic improvement of invaded bone in 7.7% of cases. It has reported that calcitonin is effective for pain relief in 50% of cases but for the radiographic improvement of bone lesions in only 0-10%. The life quality of patients with bone metastases is controversial since treatment techniques for advanced oncological patients has progressed remarkably. The pain relief obtained with calcitonin contributes significantly to improving the quality of life for such patients when administered in combination with conventional treatment modes.