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Purpose: This study aimed to investigate cumulative incidence and risk factors associated with chronic pulmonary infection (CPI) development after radiotherapy for lung cancer., Materials and Methods: We retrospectively analyzed 1,872 patients with lung cancer who received radiotherapy for lung cancer from 2010-2014, had a follow-up period of ≥ 3 months after radiotherapy, and did not have CPI at the time of radiotherapy. CPI was defined as pulmonary tuberculosis, non-tuberculous mycobacterial pulmonary disease, chronic pulmonary aspergillosis, or pulmonary actinomycosis. The cumulative incidence of CPI and overall survival (OS) were estimated using the Kaplan-Meier method, and a multivariable Cox proportional hazards analysis was performed to identify risk factors associated with CPI development., Results: The median follow-up period was 2.3 years with OS rates of 55.6% and 37.6% at 2 and 5 years, respectively. CPI developed in 59 patients at a median of 1.8 years after radiotherapy, with cumulative incidence rates of 1.1%, 3.4%, 5.0%, and 6.8% at 1, 3, 5, and 7 years, respectively. A lower body mass index, interstitial lung disease, prior pulmonary tuberculosis, larger clinical target volume, history of lung cancer surgery or radiation pneumonitis, and use of inhaled corticosteroids were independent risk factors for CPI development., Conclusion: The long-term survival rate of lung cancer patients receiving radiotherapy was not low, but the cumulative incidence of CPI gradually increased to 6.8% at 7 years after radiotherapy. Therefore, close monitoring of CPI development is required in surviving patients with risk factors.

Purpose: This study aimed to report the clinical outcomes following selective neck irradiation (SNI) with lower elective radiation therapy (RT) dose in treating nasopharyngeal cancer (NPC) patients., Materials and Methods: A total of 347 NPC patients received definitive RT according to our SNI policy and were retrospectively analyzed. The clinical target volumes (CTVs) were subdivided into CTV at high risk (CTV-HR) and CTV at low risk (CTV-LR). The typical doses to gross tumor volume (GTV), CTV-HR, and CTV-LR were 68.4-70.0 Gy, 54.0-60.0 Gy, and 36.0 Gy., Results: With the median follow-up of 68.1 months (range, 2.3 to 197.1 months), the 5-year rates of loco-regional control and progression-free survival in all the patients were 85.0% and 70.8%, respectively. Thirty patients developed regional failure and the regional control rates at 3 and 5 years were 92.6% and 91.4%, respectively. The sites of regional failure in relation to the target volume were exclusively inside GTV/CTV-HR in 20, inside and outside GTV/CTVHR in three, and exclusively outside GTV/CTV-HR in seven, which were 5.7%, 0.9%, and 2.0% of total patients, respectively., Conclusion: The clinical outcomes by the current SNI policy were feasible and comparable to those following classic elective nodal irradiation policy.

Introduction: The International Association for the Study of Lung Cancer's lung cancer staging project has recently proposed a new subclassification of pN1-2 based on multiplicity of involved nodal stations and presence of skip metastasis. The authors investigated whether this new subclassification agrees with the ypN categories after trimodality therapy for initially N2 disease., Methods: From March 2001 until June 2014, trimodality therapy consisting of preoperative thoracic radiation therapy concurrent with weekly platinum-based doublet chemotherapy and surgical resection was successfully undertaken in 508 patients after histopathologic confirmation of N2 disease. Data on 481 patients were analyzed and compared with special focus on the current and new pN classification., Results: The median duration of overall survival (OS) was 58 months, and the 5-year OS rate of all patients was 48.8%: 62.6% in ypN0; 45.5% in ypN1; 37.6% in ypN2; and 0% in ypN3. Comparisons between neighboring ypN categories showed significant difference between ypN0 and ypN1 (p = 0.028) but not between other categories. The 5-year OS rates according to new ypN subclassification were 48.2% in ypN1a, 39.0% in ypN1b, 52.8% in ypN2a1, 37.9% in ypN2a2, and 32.1% in ypN2b. Although the OS rate of ypN2a1 was numerically higher than those of ypN1b and ypN2b, comparisons between neighboring ypN categories revealed no significant difference., Conclusions: The current study was specifically intended to investigate whether ypN categories after trimodality therapy agree with International Association for the Study of Lung Cancer's new pN subclassification. Through the current study, the authors have confirmed that ypN downstaging to ypN0-1 from initial N2 stage is a favorable factor with respect to OS and raised the need for refinement of ypN subcategorization after trimodality therapy., (Copyright © 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Retrospective analyses were done on 19 lacrimal adenoid cystic carcinoma (ACC) patients who underwent curative treatment between 1997 and 2013. Nine patients (47.4%) had T1-2 disease and ten (52.6%) had T4 disease. Surgical procedures were globe-preserving tumor resection in 11 patients (57.9%), incisional biopsy in five (26.3%), and orbital exenteration was undertaken in three (15.8%). Residual tumor burdens were R0/1 in 12 patients (63.2%) and R2 in seven (36.8%). Radiation therapy (RT) was recommended to all patients, and 16 (84.2%) completed RT (median 60 Gy). After median follow-up of 57.5 months, seven (36.8%) developed progression and three (15.8%) died. Local recurrence occurred in four patients (21.1%), distant metastasis in one (5.3%), and combined local recurrence and distant metastasis in two (10.5%). Progression-free survival and overall survival rates at 5-years were 64.5% and 82.6%, respectively. Among 12 patients following R0/1 resection, two (16.7%) developed local recurrence and none died, while among seven following R2 resection, five (71.4%) developed progression and three (42.9%) died. RT following R0/R1 resection could reduce progression. Globe-preserving surgery and RT seemed optimal strategy for T1-2 disease. Careful attention should to be paid to minimize residual tumor burden at surgery and effort for safe radiation dose escalation would be desired.

Purpose: The Korean Society of Radiation Oncologists (KOSRO) conducted the Patterns of Care Study (PCS) of radiotherapy (RT) for spine metastases in 2009. The current study was conducted to investigate current practice patterns and compare them with the results of the PCS., Materials and Methods: The survey questionnaire was composed of 10 questions regarding general information and seven questions for each of two clinical scenarios., Results: Fifty-four members of the KOSRO answered at least one question on the web-based questionnaire. The yearly number of patients treated who underwent palliative spine RT was greater than 200 in 14 (25.9%), 51 to 100 in 13 (24.1%), and 31 to 50 in 11 respondents (20.4%). Scenario 1 described a patient presenting with cord compressive spine metastasis in multiple bones and liver metastasis from non-small cell lung cancer. Thirty gray (Gy) in 10 fractions was chosen by 35 respondents (64.8%). Scenario 2 described a case of a single spine metastasis without progression after targeted therapy. Thirty Gy in 10 fractions was chosen by 19 respondents (35.2%), and a single fraction or less than four fractions of stereotactic ablative radiotherapy (SABR) were selected by 18 respondents (33.3%). When compared with the 2009 PCS, practice patterns of Korean radiation oncologists had not changed significantly over 5 years, except that SABR emerged as a new treatment modality in the selected population., Conclusion: The 2014 PCS demonstrated that multiple fraction RT is still preferred in a considerable proportion of Korean radiation oncologists.

Purpose: The authors developed a video image-guided real-time patient motion monitoring (VGRPM) system using PC-cams, and its clinical utility was evaluated using a motion phantom., Methods: The VGRPM system has three components: (1) an image acquisition device consisting of two PC-cams, (2) a main control computer with a radiation signal controller and warning system, and (3) patient motion analysis software developed in-house. The intelligent patient motion monitoring system was designed for synchronization with a beam on/off trigger signal in order to limit operation to during treatment time only and to enable system automation. During each treatment session, an initial image of the patient is acquired as soon as radiation starts and is compared with subsequent live images, which can be acquired at up to 30 fps by the real-time frame difference-based analysis software. When the error range exceeds the set criteria (δ(movement)) due to patient movement, a warning message is generated in the form of light and sound. The described procedure repeats automatically for each patient. A motion phantom, which operates by moving a distance of 0.1, 0.2, 0.3, 0.5, and 1.0 cm for 1 and 2 s, respectively, was used to evaluate the system performance. The authors measured optimal δ(movement) for clinical use, the minimum distance that can be detected with this system, and the response time of the whole system using a video analysis technique. The stability of the system in a linear accelerator unit was evaluated for a period of 6 months., Results: As a result of the moving phantom test, the δ(movement) for detection of all simulated phantom motion except the 0.1 cm movement was determined to be 0.2% of total number of pixels in the initial image. The system can detect phantom motion as small as 0.2 cm. The measured response time from the detection of phantom movement to generation of the warning signal was 0.1 s. No significant functional disorder of the system was observed during the testing period., Conclusions: The VGRPM system has a convenient design, which synchronizes initiation of the analysis with a beam on/off signal from the treatment machine and may contribute to a reduction in treatment error due to patient motion and increase the accuracy of treatment dose delivery.

Herein is reported our experience of radiation therapy using a real-time tumor-tracking and gated radiotherapy (RTRT) system for inoperable pancreatic cancer. Three unresectable pancreatic cancer patients were treated with intraoperative electron beam radiation therapy, at the time of open biopsy, and postoperative external beam radiation therapy using an RTRT system with a 2.0 mm diameter gold ball implanted into the pancreas. The total BED'salpha/beta=10 was intended to be equivalent to that of delivering 60 Gy by 2.0 Gy/fraction, while the actual dose schedules were individualized. The movement of the pancreas was analyzed based on the 3-dimensional marker positions during the RTRT. The side effects and tumor responses were evaluated. During the RTRT course, the average movement of markers in the x (left to right), y (cranial to caudal) and z (dorsal to ventral) directions were 3.0 mm (1.7- 5.2 mm), 5.2 mm (3.5 - 6.8 mm) and 3.5 mm (2.7 - 5.1 mm), respectively. During and after the course of postoperative radiation therapy, no acute side effects of RTOG grade II or higher were detected. The objective tumor responses, as evaluated by CT scans 3 months after the treatment, were 2 partial responses and no response in one patient. Using the RTRT technique the margin of treatment planning and the possible errors in target localization were reduced, and the 3-dimensional movement of the internal marker implanted in the pancreas was able to be analyzed.

Simple Summary: Spinal metastases can cause instability, making it difficult for clinicians to decide on the best treatment. While guidelines exist for stable and unstable spinal metastases, those with intermediate instability (a SINS of 7–12) pose a clinical challenge. This study examines risk factors that might require surgical intervention following initial radiotherapy in these patients. We analyzed data from 469 patients with spinal metastases treated between 2019 and 2021. Our findings show that patients with primary tumors in the lung, liver, or kidney, higher Bilsky grades of spinal cord compression, lytic bone lesions, and higher radiation doses are more likely to need surgery. These results suggest that the careful evaluation of these factors can help us to develop better treatment strategies for patients with intermediate spinal instability. Background: One important determinant in choosing a treatment modality is spinal instability. Clear management guidelines are suggested for stable and unstable spinal metastatic lesions, but lesions in the intermediate instability category (SINS [spinal instability neoplastic score] score of 7–12) remain a clinical dilemma. This study aims to analyze the risk factors necessitating surgical intervention after radiotherapy (RT) in patients with those lesions. Methods: A multicenter cohort of 469 patients with spinal metastases of intermediate instability who received radiotherapy (RT) as the initial treatment between 2019 and 2021 were retrospectively enrolled. All patients were neurologically intact at the time of RT. According to the performance of surgical intervention after RT, various clinical and radiographic risk factors for surgical intervention were compared between surgery and non-surgery groups using uni- and multivariate analyses. A recursive partitioning analysis (RPA) was performed using significant determinants identified in multivariate analysis. Results: The mean age at the time of RT was 59.9 years and there were 198 females. The lung was the most common primary site. During the mean follow-up duration of 18.2 months, surgical treatment was required in 79 (17.9%) of patients. The most common surgical method was decompressive laminectomy with stabilization (62.0%), followed by vertebrectomy with stabilization (22.8%) and stabilization only (15.2%). The mean SINS for the total cohort was 9.0. Multivariate regression analyses revealed that the primary tumor site of the lung, liver, and kidney, higher Bilsky grades of ESCC, lytic bone lesions, and higher EQD210 were significant risk factors for surgical intervention after RT. Among them, Bilsky grade, primary tumor type of the lung, liver, and kidney, and EQD210 were the most important determinants for expecting the probability of surgical intervention on RPA. Conclusions: Surgical intervention was performed in 17.9% of patients with intermediate instability after RT as the initial treatment. The primary tumor site of the lung, liver, and kidney, higher Bilsky grade of ESCC, and EQD210 were the most important determinants for expecting the probability of surgical intervention. Therefore, the optimal treatment strategy needs to be devised by carefully evaluating the risk of surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Interest in the oligometastatic prostate cancer (OMPC) is increasing, and various clinical studies have reported the benefits of metastasis-directed radiation therapy (MDRT) in OMPC. However, the recognition regarding the adopted definitions, methodologies of assessment, and therapeutic approaches is diverse among radiation oncologists. This study aims to evaluate the level of agreement for issues in OMPC among radiation oncologists. Methods: We generated 15 key questions (KQs) for OMPC relevant to definition, diagnosis, local therapies, and endpoints. Additionally, three clinical scenarios representing synchronous metastatic prostate cancer (mPC) (case 1), metachronous mPC with visceral metastasis (case 2), and metachronous mPC with castration-resistance and history of polymetastasis (case 3) were developed. The 15 KQs were adapted according to each scenario and transformed into 23 questions with 6–9 per scenario. The survey was distributed to 80 radiation oncologists throughout the Republic of Korea. Answer options with 0.0–29.9%, 30–49.9%, 50–69.9%, 70–79.9%, 80–89.9%, and 90–100% agreements were considered as no, minimal, weak, moderate, strong, and near perfect agreement, respectively. Results: Forty-five candidates voluntarily participated in this study. Among 23 questions, near perfect (n = 4), strong (n = 3), or moderate (n = 2) agreements were shown in nine. For the case recognized as OMPC with agreements of 93% (case 1), near perfect agreements on the application of definitive radiation therapy (RT) for whole metastatic lesions were achieved. While ≥70% agreements regarding optimal dose-fractionation for metastasis-directed RT (MDRT) has not been achieved, stereotactic body RT (SBRT) is favored by clinicians with higher clinical volume. Conclusion: For the case recognized as OMPC, near perfect agreement for the application of definitive RT for whole metastatic lesions was reached. SBRT was more favored as a MDRT by clinicians with a higher clinical volume. [ABSTRACT FROM AUTHOR]

Purpose Perspectives of radiation oncologists on oligometastatic disease was investigated using multi-layered survey. Materials and Methods Online survey on the oligometastatic disease was distributed to the board-certified regular members of the Korean Society for Radiation Oncology. The questionnaire consisted of four domains: five questions on demographics; five on the definition of oligometastatic disease; four on the role of local therapy; and three on the oligometastatic disease classification, respectively. Results A total of 135 radiation oncologists participated in the survey. The median length of practice after board certification was 22.5 years (range, 1 to 44 years), and the vast majority (94.1%) answered affirmatively to the clinical experience in oligometastatic disease management. Nearly two-thirds of the respondents considered the number of involved organs as an independent factor in defining oligometastasis. Most frequently perceived upper limit on the numerical definition of oligometastasis was 5 (64.2%), followed by 3 (26.0%), respectively. Peritoneal and brain metastasis were nominated as the sites to be excluded from oligometastastic disease by 56.3% and 12.6% of the participants, respectively. Vast majority (82.1%) agreed on the role of local treatment in the management of oligometastatic disease. Majority (72%) of the participants acknowledged the European Society for Radiotherapy and Oncology (ESTRO)-European Organisation for Research and Treatment of Cancer (EORTC) classification of oligometastatic disease, however, only 43.3% answered that they applied this classification in their clinical practice. Underlying reasons against the clinical use were 'too complicated' (66.0%), followed by 'insufficient supporting evidence' (30.0%), respectively. Conclusion While most radiation oncologists supported the role of local therapy in oligometastatic disease, there were several inconsistencies in defining and categorizing oligometastatic disease. Continued education and training on oligometastatic disease would be also required to build consensus among participating caregivers. [ABSTRACT FROM AUTHOR]

Simple Summary: Adenoid cystic carcinoma (ACC) is known to have distinctive clinical features. It tends to metastasize to the lungs and spread through the nerves. As the nasal cavity and paranasal sinuses are close to cranial nerves, ACC arising in such areas presents explicit challenges for treatment. This study reported the treatment patterns and outcomes of sixty-one patients with sinonasal ACC who were treated at a single institution. Patients with more extensive disease underwent radiation therapy as the mainstay of treatment, and these showed worse treatment outcomes when compared to those who were able to undergo surgery and postoperative radiation therapy. The difference in treatment outcomes may be attributed to worse clinical features, such as extensive disease and involvement of cranial nerves, rather than treatment modality. As patients with ACC tend to survive for many years, the balance between risk and benefit needs to be thoroughly considered before determining the initial treatment. This study aimed to present the treatment patterns and outcomes for adenoid cystic carcinoma (ACC) arising in the nasal cavity and paranasal sinus. Sixty-one sinonasal ACC patients were retrospectively reviewed: 31 (50.8%) underwent surgery followed by postoperative radiation therapy (S+PORT), and 30 (49.2%) received definitive radiation therapy (D(C)RT). T4 disease was significantly more frequent in the D(C)RT group (25.8% vs. 80.0%, p < 0.001), where all T4b disease patients underwent D(C)RT. The 5-year local failure-free survival (LFFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival were 61.8% versus 37.8% (p = 0.003), 64.8% versus 38.1% (p = 0.036), 52.6% versus 19.3% (p = 0.010), and 93.2% versus 73.4% (p = 0.001) in the S+PORT and D(C)RT groups, respectively. The absolute differences in 5-year rates of LFFS, DMFS, and PFS between the two groups were smaller in the T3–4 subgroup. The univariate analysis showed that T4b disease, neurologic symptoms, longest diameter of tumor, radiological evidence of nerve involvement, and undergoing D(C)RT were associated with worse clinical outcomes, but the significance disappeared in the multivariate analysis, except for in the case of radiological evidence of nerve involvement. In conclusion, most patients with extensive disease underwent upfront D(C)RT and generally exhibited inferior clinical outcomes when compared to those with less extensive disease and who underwent S+PORT. [ABSTRACT FROM AUTHOR]

This study aimed to compare oncologic outcomes between definitive radiation therapy (RT) and upfront surgical resection in patients with sinonasal squamous cell carcinoma (SCC). Between 2008 and 2021, 155 patients with T1-4b, N0-3 sinonasal SCC were analyzed. The 3-year overall survival (OS), local progression-free survival (LPFS), and overall progression-free survival (PFS) were evaluated using the Kaplan Meier method and compared using a log-rank test. A pattern of regional neck lymph node (LN) failure and treatment-related toxicity profiles were investigated. A total of 63 and 92 patients underwent upfront RT (RT group) and surgical resection (Surgery group), respectively. The RT group included significantly more patients with T3-4 disease than the Surgery group (90.5% vs 39.1%, P <.001). The rates of 3-year OS, LPFS, and PFS in the RT and Surgery groups were 68.6% versus 81.7% (P =.073), 62.3% versus 73.8% (P =.187), and 47.4% versus 66.1% (P =.005), respectively. However, the corresponding rates in patients with T3-4 disease were 65.1% versus 64.8% (P =.794), 57.4% versus 56.8% (P =.351), and 43.2% versus 46.5% (P =.638), respectively, demonstrating no statistically significant differences between the 2 treatment modalities. Among the 133 N0 patients, regional neck LN progression was observed in 17 patients, and the most common sites of regional neck LN failure were ipsilateral levels Ib (9 patients) and II (7 patients). The 3-year neck node recurrence-free rate in cT1-3N0 patients was 93.5%, while that in cT4N0 patients was 81.1% (P =.025). Upfront RT may be considered in selected patients with locally advanced sinonasal SCC, as we have demonstrated similar oncologic outcomes to those of surgery. Prophylactic neck treatment in T4 disease requires further investigation to evaluate its efficacy. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the feasibility of combining helical tomotherapy (HT) and intensity‐modulated proton therapy (IMPT) in treating patients with nasopharynx cancer (NPC). From January 2016 to March 2018, 98 patients received definitive radiation therapy (RT) with concurrent chemotherapy (CCRT). Using simultaneous integrated boost and adaptive re‐plan, 3 different dose levels were prescribed: 68.4 Gy in 30 parts to gross tumor volume (GTV), 60 Gy in 30 parts to high‐risk clinical target volume (CTV), and 36 Gy in 18 parts to low‐risk CTV. In all patients, the initial 18 fractions were delivered by HT, and, after rival plan evaluation on the adaptive re‐plan, the later 12 fractions were delivered either by HT in 63 patients (64.3%, HT only) or IMPT in 35 patients (35.7%, HT/IMPT combination), respectively. Propensity‐score matching was conducted to control differences in patient characteristics. In all patients, grade ≥ 2 mucositis (69.8% vs 45.7%, P = .019) and grade ≥ 2 analgesic usage (54% vs 37.1%, P = .110) were found to be less frequent in HT/IMPT group. In matched patients, grade ≥ 2 mucositis were still less frequent numerically in HT/IMPT group (62.9% vs 45.7%, P = .150). In univariate analysis, stage IV disease and larger GTV volume were associated with increased grade ≥ 2 mucositis. There was no significant factor in multivariate analysis. With the median 14 month follow‐up, locoregional and distant failures occurred in 9 (9.2%) and 12 (12.2%) patients without difference by RT modality. In conclusion, comparable early oncologic outcomes with more favorable acute toxicity profiles were achievable by HT/IMPT combination in treating NPC patients. [ABSTRACT FROM AUTHOR]

Background: Oesophageal cancer with airway invasion presents a challenge for therapy and often has serious complications. We analysed the clinical outcomes of radiation therapy (RT) in patients with clinical T4b oesophageal cancer with airway invasion.Methods: We retrospectively reviewed the medical records of 73 patients with oesophageal cancer who had clinical T4 disease and who received RT between January 1994 and June 2017. Among them, 47 patients with clinical T4b disease with airway invasion were included in this study; 31 had gross invasion on bronchoscopy and 16 had extrinsic compression with mucosal change. We investigated the survival outcomes, clinical courses, and toxicities.Results: The median survival (MS) time was 9 months. The 1- and 2-year overall survival (OS) rates were 41.4 and 27.4%, respectively. The MS times for patients treated with curative or palliative aims were 15 and 4 months, respectively (p = 0.001). Seven patients (14.9%) had fistulae at diagnosis; after RT, three had no change in size, three closed, and one had increased. Newly developed oesophageal fistulae after treatment were observed in 13 patients (27.7%). The median time to a newly developed fistula was 3 months (range, 1-15). Among them, a fistula was closed in only one patient. Death from aspiration pneumonia occurred in one patient who had a fistula at diagnosis and in nine patients who newly developed fistulae after treatment. Severe oesophageal bleeding causing death occurred in two patients. Patients with gross invasion on bronchoscopy had a higher risk of developing a fistula than did patients with mucosal change (37.5% vs. 25.0%, respectively).Conclusions: Even for clinical T4b disease with airway invasion, RT with a curative aim showed acceptable survival outcomes in patients with good performance status and no distant metastasis at initial diagnosis. However, the risk of fistula development associated with fatal events remains high. Further study is warranted to decrease the risks of treatment and improve clinical outcomes.Trial Registration: Retrospectively registered. [ABSTRACT FROM AUTHOR]

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Background The purpose of this study was to investigate whether adjuvant radiotherapy (RT) is efficacious for regional control and survival in patients with pN0 oral tongue cancer. Methods Clinicopathological features of 166 patients with pN0 oral tongue cancer were compared between those who underwent adjuvant RT to the neck (neck RT-positive) and those who did not (neck RT-negative). Study endpoints were isolated regional recurrence and 3-year regional recurrence-free survival (RRFS). Propensity score matching was also performed. Results Cox regression analysis did not reveal any significant predictor of isolated regional recurrence, including RT field. Three-year RRFS showed modest improvement in neck RT-positive group compared to neck RT-negative group before (92.2% vs 91.9%) and after propensity analysis (93.8% vs 83.3%), without statistical significance (log-rank P = .85 and .37, respectively). Conclusion Despite more frequent unfavorable factors, the neck RT-positive group had a comparable oncologic outcome to the neck RT-negative group, suggesting that a marginal benefit in regional control might be expected from extending the RT field to the neck for pN0 oral tongue cancer. [ABSTRACT FROM AUTHOR]

Purpose: Radiation pneumonitis (RP) has been a challenging obstacle in treating stage III lung cancer patients. Beam angle optimization (BAO) technique for Tomotherapy was developed to reduce the normal lung dose for stage III non-small cell lung cancer (NSCLC). Comparative analyses on plan quality by 3 different Intensity-modulated radiation therapy (IMRT) methods with BAO were done.Materials and Methods: Ten consecutive stage IIIB NSCLC patients receiving linac-based static IMRT (L-IMRT) with total 66 Gy in 33 fractions to the PTV were selected. Two additional Tomotherapy-based IMRT plans (helical beam (TH-IMRT) and static beam (TD-IMRT)) were generated on each patient. To reduce the normal lung dose, Beam angles were optimized by using complete and directional block functions in Tomotherapy based on knowledge based statistical analysis. Plan quality was compared with target coverage, normal organ sparing capability, and normal tissue complication probability (NTCP). Actual beam delivery times and risk of RP related with planning target volume (PTV) were also evaluated.Results: The best PTV coverage measured by conformity index and homogeneity index was achievable by TH-IMRT (0.82 and 1.06), followed by TD-IMRT (0.81 and 1.07) and L-IMRT (0.75 and 1.08). Mean lung dose was the lowest in TH-IMRT plan followed by TD-IMRT and L-IMRT, all of which were ≤20 Gy. TH-IMRT plan could significantly lower the lung volumes receiving low to medium dose levels: V5~30 when compared to L-IMRT plan; and V5~20 when compared to TD-IMRT plan, respectively. TD-IMRT plan was significantly better than L-IMRT with respects to V20 and V30 and there was no significant difference with respect to V40 among three plans. The NTCP of the lung was the lowest in TH-IMRT plan, followed by TD-IMRT and L-IMRT (6.42% vs. 6.53% vs. 8.11%). Beam delivery time was the shortest in TD-IMRT plan followed by L-IMRT. As PTV length increased, NTCP and Mean lung dose proportionally increased significantly in all three plans.Conclusion: Advantageous profiles by TH-IMRT could be achieved by BAO by complete and directional block functions. Current observation could help radiation oncologists to make wise selection of IMRT method for stage IIIB NSCLC. [ABSTRACT FROM AUTHOR]

Objective: The present study was conducted to determine the preventive efficacy of vitamin C/E complex supplementation for radiotherapy (RT)-induced xerostomia in patients with head and neck cancer.Study Design: Prospective, double-blinded, randomized, placebo-controlled study.Setting: A single tertiary referral institution.Subjects and Methods: The trial group (n = 25) received antioxidant supplements (100 IU of vitamin E + 500 mg of vitamin C) twice per day during RT, while the control group (n = 20) received an identical placebo. Pre-RT and 1 and 6 months post-RT, patient-reported xerostomia questionnaires, observer-rated xerostomia score, and salivary scintigraphy were serially obtained to compare xerostomia severity between the 2 groups.Results: The trial group showed greater improvements in xerostomia questionnaire and score at 6 months post-RT when compared with those at 1 month post-RT (P = .007 and .008, respectively). In contrast, the control group showed no changes between 1 and 6 months post-RT. By salivary scintigraphy, there was no difference in maximal accumulation or ejection fraction between the 2 groups. However, the trial group maintained significantly better oral indices at the prestimulatory (P = .01) and poststimulatory (P = .009) stages at 1 month post-RT, compared with the control group. At the final follow-up, there was no difference in overall survival and disease-free survival between the 2 groups.Conclusions: Our data suggest that short-term supplementation with an antioxidant vitamin E/C complex exerts a protective effect against RT-induced xerostomia. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of concurrent chemoradiation therapy (CCRT) with 40 Gy followed by consolidation chemotherapy for localized extranodal natural killer (NK)/T-cell lymphoma (ENKTL), nasal type.Methods and Materials: From August 2004 to August 2012, 62 patients with newly diagnosed stage IE to IIE ENKTL underwent CCRT followed by consolidation chemotherapy. The median RT dose was 40 Gy. Cisplatin, 30 mg/m(2), was administered weekly during the RT course. Responders to CCRT were encouraged to undergo consolidation chemotherapy. Three different consolidation chemotherapy regimens were used consecutively: VIPD (etoposide, ifosfamide, cisplatin, and dexamethasone); VIDL (etoposide, ifosfamide, and dexamethasone followed by intramuscular injection of l-asparaginase); and MIDLE (methotrexate, etoposide, ifosfamide, mesna, and l-asparaginase).Results: The median follow-up period was 49 months (range 8-112). After completion of CCRT, 56 patients (90.3%) had a complete response, 4 (6.4%) had a partial response, 1 (1.6%) had stable disease, and 1 patient (1.6%) had progressive disease (PD). Consolidation chemotherapy was recommended to 61 patients, after excluding the patient with PD, but was actually delivered to 58. Of these 58 patients, 56 (96.5%) had a complete response and 2 (3.5%) had PD. During the follow-up period, 17 patients (including 3 with PD) experienced progression. The median interval to progression was 11 months (range 1-61). Local failure developed in 6 patients, of whom, 2 had developed progression outside the RT field. For all patients, the 3-year overall survival, progression-free survival, and local control rates were 83.1%, 77.1%, and 92.4%, respectively. Grade ≥3 nonhematologic toxicity developed in only 3 patients (4.8%).Conclusions: Excellent clinical outcomes were achieved using CCRT with 40 Gy followed by consolidation chemotherapy. Additional investigation, however, is warranted to confirm our findings. [ABSTRACT FROM AUTHOR]

Purpose: To assess the impact of imaging, surgical, histopathologic and patient-related factors on the risks of recurrence and overall survival (OS) in stage IIIA-N2 non-small cell lung cancer (NSCLC) patients undergoing definitive resection after neoadjuvant concurrent chemoradiotherapy (CCRT). Methods: We retrospectively examined 104 consecutive patients with stage IIIA-N2 NSCLC who received neoadjuvant CCRT followed by surgery between 2008 and 2011. While reviewing the clinical and surgical data, we also assessed histopathologic and imaging (CT and PET/CT) factors. Disease-free survival (DFS) and OS were estimated with predictors for recurrence and survival. Results: The 3-year OS for patients with and without recurrence was 37.1 and 63.3 %, respectively ( p < 0.001). Size decrease of target lesion(s) ≥36 % on post-neoadjuvant CCRT CT ( p = 0.048) and viable tumor size on surgical specimen <9.4 mm ( p = 0.035) were related to longer OS. Regarding shorter DFS, tumor size on post-neoadjuvant CCRT CT ( p = 0.046), SUV of the primary tumor ( p = 0.011), male gender ( p = 0.023), total tumor size on surgical specimen ( p = 0.041) and viable tumor size on surgical specimen ( p = 0.043) were the significant predictors. Conclusions: OS is prolonged with greater extent of size decrease of target lesion(s) on post-neoadjuvant CCRT CT and smaller viable tumor size on surgical specimen. Larger tumor size on post-neoadjuvant CCRT CT, higher SUV, male gender, larger total tumor size and larger viable tumor size on surgical specimen may herald the higher probability of recurrence and the necessity of more attention. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate the prognostic significance of the tumor volume reduction rate (TVRR) measured during adaptive definitive radiation therapy (RT) in patients with oropharyngeal cancer. Methods We reviewed the RT records of 59 patients with oropharyngeal cancer who were treated with definitive RT with or without concurrent chemotherapy between January 2006 and October 2010. Adaptive replanning was performed in all patients during RT. The pre-RT and mid-RT gross tumor volumes (GTVs) of the primary and the metastatic lymph nodes were measured and analyzed for their possible impacts on locoregional control. Results After the median follow-up period of 41.3 months (range, 9.3-73.5 months) for survivors, there were 10 treatment failures (8 locoregional recurrences and 2 distant metastases). The locoregional control rate at 3 years in all the patients was 84.1%. The mean pre-RT and mid-RT total GTVs were 27.5 cm3 (±17.9 cm3) and 16.9 cm3 (±12.1 cm3), and the mean GTV reduction rate was 37.9% (±22.6%), respectively. The patients who achieved locoregional control had a higher TVRR than those with locoregional failure ( p = .010), and those with the TVRR >35% achieved significantly higher locoregional control at 3 years (94.4% vs 72.4%; p = .018). On multivariate analysis when adjusted with other clinical prognostic factors, the TVRR was found to be a significant factor affecting the locoregional control (hazard ratio = 0.136; 95% confidence interval = 0.022-0.852; p = .033). Conclusion The TVRR measured during adaptive RT proved a significant prognosticator on locoregional disease control in patients with oropharyngeal cancer, based on which a few therapeutic modifications may be considered. © 2013 Wiley Periodicals, Inc. Head Neck 36: 499-504, 2014 [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to understand the practice patterns of palliative radiation therapy for bone metastasis in Korea among Korean radiation oncologists by survey and to determine the decision factors affecting the prescription of radiation therapy fractionation schedules. Methods: An Internet-based survey was performed from October 5 to October 23, 2009, among 177 active full members of the Korean Society for Radiation and Oncology (KOSRO). The survey questionnaire included general information about the respondent, three types of clinical scenario, depending on the life expectancy of the patients, and the decision factors that affected the prescription of a radiation therapy schedule. Results: The most prescribed schedule was 30 Gy in 10 fractions regardless of the life expectancy of the patient. Also, it was found that a single fraction was seldom prescribed routinely in Korea. An increasing number prescribed fewer than 10 fractions as the life expectancy shortened; however, the prescription rate of a single fraction was still low. The general performance (and/or accompanying diseases) of patients and the life expectancy were the most considered factors in deciding the prescription of radiation therapy. Conclusions: Despite the abundant evidence supporting the equivalence of single- and multi-fraction radiation therapy, still, most Korean radiation oncologists continue to prescribe multi-fraction schedules depending on the general performance and life expectancy of the patients. Thus, we confirmed that there was a gap between evidence and practice, and treatment prescriptions can be strongly affected by decision factors other than published literature results. [ABSTRACT FROM AUTHOR]

This study evaluated the toxicity associated with radiation techniques on curative re-irradiation (re-RT) in patients with thoracic recurrence of non-small cell lung cancer (NSCLC). From 2011 to 2019, we retrospectively reviewed the data of 63 patients with salvage re-RT for in-field or marginal recurrence of NSCLC at two independent institutions. Re-RT techniques using X-ray beams and proton beam therapy (PBT) were also included. Re-RT had a 2-year overall survival (OS) and local progression-free survival of 48.0% and 52.0%, respectively. Fifteen patients experienced grade 3 or higher toxicity after re-RT. The complication rates were 18.2% (4/22) and 26.8% (11/41) in PBT patients and X-ray patients, respectively. Airway or esophageal fistulas occurred in seven patients (11.1%). Fistulas or severe airway obstruction occurred in patients with tumors adjacent to the proximal bronchial tree and esophagus, who underwent hypofractionated radiotherapy (RT) or concurrent chemotherapy, and with a higher dose exposure to the esophagus. In conclusion, salvage re-RT was feasible even in patients with local recurrence within the previous RT field. PBT showed similar survival outcomes and toxicity to those of other techniques. However, thoracic re-RT should be performed carefully considering tumor location and RT regimens such as the fraction size and concurrent chemotherapy. [ABSTRACT FROM AUTHOR]

We report the results of radiotherapy for abdominal lymph node metastasis from hepatocellular carcinoma (HCC). From 1998 to 2004, 45 cases were treated with radiotherapy (RT), with a dose between 30 and 55 Gy. The radiation response, overall survival, prognostic factors, and complications were evaluated. Thirty-nine cases were able to be evaluated for response: 10 cases showed complete response; 21 cases showed a partial response; and 8 cases showed stable disease. The overall response rate was 79.5%. The response rate was 87.5% for patients receiving ≥40 Gy10 (biologically effective dose, α/β = 10) and 42.9% for patients receiving <40 Gy10 ( P = 0.02). The median survival time was 10 months for responders and 6 months for nonresponders ( P = 0.01). The absence of other concurrent distant metastasis and controllable primary HCC were significant prognostic factors. RT induced gastric or duodenal ulcer development in nine patients. All of these patients had received more than 50 Gy10, and these complications were not detected among patients receiving <50 Gy10 (0% vs 37.5%, P < 0.01). RT was an effective treatment modality, and the absence of concurrent distant metastasis and controllable primary tumor were significant prognostic factors. However, considering the high rate of RT-induced morbidity, 40 Gy10 to 50 Gy10 might be the optimal RT dose. [ABSTRACT FROM AUTHOR]

We aimed to define the role of cyclophosphamide, vincristine, doxorubicin, prednisone (CHOP) followed by involved field radiotherapy (IFRT) for treating localized primary gastric diffuse large B-cell lymphoma (DLBCL). Newly diagnosed patients with localized primary gastric DLBCL were to receive four cycles of CHOP followed by IFRT of 40.0 Gy. At 1 year after the completion of treatment, patients filled out the EORTC Quality of Life Questionnaire specified for stomach cancer (QLQ-C30-STO22). Fifty evaluable patients (25 men, 25 women) were included. The median age was 54.5 years (range, 21 - 73 years. The overall response rate to the CHOP was 94% (95% confidence interval [CI], 87 - 100) in the intent-to-treat population. Forty-one of the 50 patients (82%; 95% CI, 71 - 93) achieved complete remission (CR). After the completion of radiotherapy, five patients who were in PR following chemotherapy eventually attained CR. The overall complete response rate was thus 92% (95% confidence interval, 84 - 99). With a median follow-up period of 30 months, the 2-year progression-free and overall survival rate was 92% and 92%, respectively. The gastric function was well preserved with negligible stomach-related symptoms at 1 year after the completion of treatment. This organ-preserving combined treatment is highly effective and well tolerated for the patients with localized gastric DLBCL. [ABSTRACT FROM AUTHOR]

Simple Summary: Systemic hematologic markers such as the neutrophil–lymphocyte ratio (NLR) are attracting attention in a simple blood test predicting survival and treatment outcomes in various solid cancers. In our study including 40 patients with anaplastic thyroid cancer (ATC) who underwent radiotherapy, we found that high NLR before and after radiotherapy was associated with poor survival. This study result means that host immunity has an important role in patients with ATC, which can be important information for designing future investigations on the impact of immune system modulating therapy in ATC. The neutrophil–lymphocyte ratio (NLR) is a marker of systemic inflammation, and its elevation has recently been associated with poor survival in many solid cancers. Leukocyte elevation and lymphocyte reduction are associated with a poor response to radiotherapy (RT). This study aimed to assess the prognostic value of NLR before and after RT for anaplastic thyroid carcinoma (ATC). This retrospective study analyzed 40 patients with ATC who received RT with available complete blood cell count data from November 1995 through May 2020 at Samsung Medical Center (Seoul, Korea). Patients were classified into two groups according to the NLR before and after RT. The median overall survival (OS) was 8.9 months (range, 3.5–18.2) in the low NLR group (<3.47) and 5.2 months (range, 2.7–7.5) months in the high NLR group (≥3.47). The association between NLR and OS was also observed in multivariable Cox regression analysis (hazard ratio, 3.18; 95% confidence interval, 1.15–8.85; p = 0.026). The OS curves differed significantly according to post-RT NLR (p = 0.036). A high NLR before and after RT may be significantly associated with poor OS in patients with ATC who receive RT. [ABSTRACT FROM AUTHOR]

Simple Summary: Intensity-modulated proton therapy (IMPT) is expected to reduce toxicity more effectively than intensity-modulated radiation therapy (IMRT) in treating oropharynx cancer (OPC) patients. Because of long waiting before starting IMPT, authors began IMRT first and then determined whether to continue IMRT or to switch into IMPT at time of adaptive re-plan, based on the rival plan comparison in 148 OPC patients. Early clinical outcomes were analyzed and compared between IMRT alone and IMRT/IMPT combination groups through propensity score matching method. We found that, with comparable oncologic outcomes, more favorable acute toxicity profiles (mucositis and need for analgesic use) were achieved following IMRT/IMPT combination than IMRT alone. Purpose: To report the early clinical outcomes of combining intensity-modulated radiation therapy (IMRT) and intensity-modulated proton therapy (IMPT) in comparison with IMRT alone in treating oropharynx cancer (OPC) patients. Materials and Methods: The medical records of 148 OPC patients who underwent definitive radiotherapy (RT) with concurrent systemic therapy, from January 2016 till December 2019 at Samsung Medical Center, were retrospectively reviewed. During the 5.5 weeks' RT course, the initial 16 (or 18) fractions were delivered by IMRT in all patients, and the subsequent 12 (or 10) fractions were either by IMRT in 81 patients (IMRT only) or by IMPT in 67 (IMRT/IMPT combination), respectively, based on comparison of adaptive re-plan profiles and availability of equipment. Propensity-score matching (PSM) was done on 76 patients (38 from each group) for comparative analyses. Results: With the median follow-up of 24.7 months, there was no significant difference in overall survival and progression free survival between groups, both before and after PSM. Before PSM, the IMRT/IMPT combination group experienced grade ≥ 3 acute toxicities less frequently: mucositis in 37.0% and 13.4% (p < 0.001); and analgesic quantification algorithm (AQA) in 37.0% and 19.4% (p = 0.019), respectively. The same trends were observed after PSM: mucositis in 39.5% and 15.8% (p = 0.021); and AQA in 47.4% and 21.1% (p = 0.016), respectively. In multivariate logistic regression, grade ≥ 3 mucositis was significantly less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.027 and 0.024, respectively). AQA score ≥ 3 was also less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.085 and 0.018, respectively). Conclusions: In treating the OPC patients, with comparable early oncologic outcomes, more favorable acute toxicity profiles were achieved following IMRT/IMPT combination than IMRT alone. [ABSTRACT FROM AUTHOR]

Purpose: The study purpose was to report failure patterns in Masaoka-Koga stage II to IV type C thymic epithelial tumor (TET) after postoperative radiation therapy (PORT) and to evaluate the suitability of PORT target volume confined to the "tumor bed only with margin."Methods and Materials: A retrospective review of 53 patients with stage II to IV type C TET was performed. The clinical outcomes, failure patterns in relation to PORT target volume, and prognostic factors were analyzed.Results: During a median follow-up period of 69 months, 14 deaths and 25 recurrences were observed. The 5-year rates of overall survival, disease-specific survival, and freedom from recurrence were 81.0%, 91.5%, and 49.7%, respectively. The failure patterns in relation to PORT target volume were in-field failure in 2 patients (3.8%), marginal in 2 (3.8%), and out of field in 23 (43.4%), respectively. The most common failure site was the pleura (12 patients), followed by the lung parenchyma (8 patients). Relapse involving the regional lymph nodes was observed in 6 patients, of whom 4 had synchronous distant failure and only 2 had isolated ipsilateral supraclavicular lymph node failure.Conclusions: The policy of PORT target volume confined to only the tumor bed seems reasonable in treating patients with stage II to IV type C TET. The development of a more effective systemic therapy regimen is warranted. [ABSTRACT FROM AUTHOR]

Purpose: Reirradiation for locally recurrent nasopharyngeal carcinoma (NPC) is challenging because prior radiation dose delivered in the first course is often close to the tolerance limit of surrounding normal structures. A delicate balance between achieving local salvage and minimizing treatment toxicities is needed. However, high-level evidence is lacking because available reports are mostly retrospective studies on small series of patients. Pragmatic consensus guidelines, based on an extensive literature search and the pooling of opinions by leading specialists, will provide a useful reference to assist decision-making for these difficult decisions.Methods and Materials: A thorough review of available literature on recurrent NPC was conducted. A set of questions and preliminary draft guideline was circulated to a panel of international specialists with extensive experience in this field for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the whole panel for review and reconsideration. The current guideline was based on majority voting after repeated iteration for final agreement.Results: The initial round of questions showed variations in clinical practice even among the specialists, reflecting the lack of high-quality supporting data and the difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of reirradiation (including patient selection, targets contouring, dose prescription, and constraints).Conclusion: This paper provides useful reference on radical salvage treatment strategies for recurrent NPC and optimization of reirradiation through review of published evidence and consensus building. However, the final decision by the attending clinician must include full consideration of an individual patient's condition, understanding of the delicate balance between risk and benefits, and acceptance of risk of complications. [ABSTRACT FROM AUTHOR]

Purpose: To reduce radiation doses to the tongue, a patient-specific semi-customized tongue displacement device (SCTDD) was developed using a 3D printer (3DP) for head and neck (H&N) radiation therapy (RT). Dosimetric characteristics of the SCTDD were compared with those of a standard mouthpiece (SMP).Materials and Methods: The SCTDD consists of three parts: a mouthpiece, connector with an immobilization mask, and tongue displacer, which can displace the tongue to the contralateral side of the planning target volume. Semi-customization was enabled by changing the thickness and length of the SCTDD. The instrument was printed using a 3DP with a biocompatible material. With the SCTDD and SMP, two sets of planning computed tomography (CT) and tomotherapy plans were obtained for seven H&N cancer patients. Dosimetric and geometric characteristics were compared.Results: Using the SCTDD, the tongue was effectively displaced from the planning target volume without significant tongue volume change compared to the SMP. The median tongue dose was significantly reduced (29.6 Gy vs. 34.3 Gy). The volumes of the tongue receiving a dose of 15 Gy, 30 Gy, 35 Gy, 45 Gy, and 60 Gy were significantly lower than using the SMP.Conclusion: The SCTDD significantly decreased the radiation dose to the tongue compared to the SMP, which may potentially reduce RT-related tongue toxicity. [ABSTRACT FROM AUTHOR]

• Radiation esophagitis has been frequent and annoying side effect in high dose thoracic radiation therapy. • Contralateral esophagus-sparing intensity modulated radiation therapy (CES-IMRT) has been proposed to mitigate this problem. • Impact of CES-IMRT on esophagitis frequency and severity and failure pattern was investigated in definitive CCRT setting. • CES-IMRT seems effective in alleviating radiation esophagitis without additional risk of marginal failure. Radiation esophagitis is frequent and annoying toxicity in high dose thoracic radiation therapy. Contalateral esophagus sparing intensity modulated radiation therapy (CES-IMRT) has been proposed to mitigate this problem, and this is to report the impact of CES-IMRT in definitive concurrent chemoradiotherapy (dCCRT) for lung cancer patients. From January 2021 till May 2023, 183 stage III non-small cell lung cancer patients underwent dCCRT. Esophagus was located within 1 cm from internal target volume in 159 patients. We comparatively evaluated the frequency and severity of esophagitis by pain-killer usage, analgesic quantification algorithm (AQA) score, and failure patterns in 159 CES-necessary patients. All patients underwent dCCRT (66 Gy in 30 fractions with concurrent chemotherapy). Actual CES-IMRT application was determined based on the discretion of responsible radiation oncologists: CES-applied in 41 patients; and CES-unapplied in 118. CES-applied patients experienced pain events less frequently (pain-killer usage: 53.7 % vs. 77.1 %, p = 0.008) and less severely (AQA score of 2–3: 39.0 % vs. 68.6 %, p = 0.002). On multivariate analyses, overlapping volume of esophagus and planning target (HR = 1.32, 95 % CI 1.12–1.55, p = 0.001) and CES-IMRT application (HR = 0.31, 95 % CI 0.13–0.76, p = 0.010) were associated with AQA score of 2–3 less frequently. There were no differences in failure pattern, progression-free survival, and overall survival. CES-IMRT application resulted in less frequent and less severe pain events without compromising oncologic outcomes. Further studies, preferably in a randomized fashion, would be desired. [ABSTRACT FROM AUTHOR]

Purpose: To report treatment outcomes after combined-modality therapy in patients with Stage I/II head-and-neck (HN) diffuse large B cell lymphoma (DLBL). Methods and Materials: Eighty-six eligible patients received sequential chemotherapy and involved-lesion radiation therapy from 1995 to 2006. After a median of four cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or rituximab-plus-CHOP chemotherapy, a median of 41.4 Gy was delivered to the known initial gross lesion with adequate margin (2 to 3 cm). Results: After a median follow-up of 57 months, eight treatment failures were observed: distant metastasis in 8 patients; and locoregional failure in 4 patients. Among the 4 patients with locoregional failure, 3 presented with in-field failures, and 1 both in-field and out-of-field failure (contralateral neck). Rates of overall survival (OS) and freedom from progression (FFP) at 10 years were 74.1% and 88.9%, respectively. There was no severe side effect except 1 patient with Grade 3 mucositis during and after completion of radiation therapy. Multivariate analyses showed that absence of B symptom (p = 0.022) and normal lactate dehydrogenase (p = 0.017) were related to favorable OS, age >60 years (p = 0.033) was related to favorable FFP, and international prognostic index of 0 or 1 was related to favorable OS (p = 0.003) and FFP (p = 0.03). Conclusion: This study demonstrated that patients with Stage I/II HN DLBL did not need whole-neck irradiation. Involved-lesion radiation therapy might reduce radiation toxicity with favorable treatment results. [Copyright &y& Elsevier]

• First to report outcomes of early esophageal SCC treated with moderate hypofractionated RT alone. • The 5-year local control rate and cancer specific survival were acceptable. • Tumor length ≥ 3 cm and cT2 stage was prognostic for the incidence of G ≥ 2 esophageal toxicities. • Surgically unfit early ESCC patients may benefit from short course RT. To report the feasibility of hypofractionated radiation therapy (RT) alone for early stage esophageal squamous cell carcinoma (ESCC) patients. The oncologic outcomes of 60 cT1-2 N0 ESCC patients who received hypofractionated RT (54 ∼ 60 Gy by 3.0 Gy per fraction) from 2004 to 2018 were retrospectively evaluated. The 5-year rates of local control (LC), progression-free survival, cancer-specific survival, and overall survival were 81.1 %, 44.2 %, 73.7 %, and 54.5 %, respectively. In Cox regression analysis, tumor length < 3 cm was correlated with favorable LC (HR 0.167, p = 0.090), and the 5-year LC rates were 95.7 % and 72.0 % in < 3 cm and ≥ 3 cm subgroups, respectively (p = 0. 053). Grade ≥ 2 esophagitis was observed in 44 patients (73.3 %) and grade ≥ 2 esophageal strictures developed in five (8.3 %), respectively. The patients with ≥ 3 cm tumor more frequently suffered from grade ≥ 2 esophagitis (13/24 vs. 31/36, p = 0.006) and grade ≥ 2 esophageal stricture (0/24 vs. 5/36, p = 0.056), respectively. The patients with cT2 tumor suffered from grade ≥ 2 esophagitis more frequently than those with T1 tumor (29/44 vs. 15/16, p = 0.03). Hypofractionated RT alone, with the merit of short treatment course, could be used as feasible option in treating the early stage ESCC patients who are unfit for surgical resection or chemoradiation. Especially, tumor length < 3 cm seems a good indication of this treatment scheme based on favorable LC rate with low incidence of esophageal toxicities. [ABSTRACT FROM AUTHOR]

Purpose: The treatment of nasopharyngeal carcinoma requires high radiation doses. The balance of the risks of local recurrence owing to inadequate tumor coverage versus the potential damage to the adjacent organs at risk (OARs) is of critical importance. With advancements in technology, high target conformality is possible. Nonetheless, to achieve the best possible dose distribution, optimal setting of dose targets and dose prioritization for tumor volumes and various OARs is fundamental. Radiation doses should always be guided by the As Low As Reasonably Practicable principle. There are marked variations in practice. This study aimed to develop a guideline to serve as a global practical reference.Methods and Materials: A literature search on dose tolerances and normal-tissue complications after treatment for nasopharyngeal carcinoma was conducted. In addition, published guidelines and protocols on dose prioritization and constraints were reviewed. A text document and preliminary set of variants was circulated to a panel of international experts with publications or extensive experience in the field. An anonymized voting process was conducted to rank the proposed variants. A summary of the initial voting and different opinions expressed by members were then recirculated to the whole panel for review and reconsideration. Based on the comments of the panel, a refined second proposal was recirculated to the same panel. The current guideline was based on majority voting after repeated iteration for final agreement.Results: Variation in opinion among international experts was repeatedly iterated to develop a guideline describing appropriate dose prioritization and constraints. The percentage of final agreement on the recommended parameters and alternative views is shown. The rationale for the recommendations and the limitations of current evidence are discussed.Conclusions: Through this comprehensive review of available evidence and interactive exchange of vast experience by international experts, a guideline was developed to provide a practical reference for setting dose prioritization and acceptance criteria for tumor volumes and OARs. The final decision on the treatment prescription should be based on the individual clinical situation and the patient's acceptance of optimal balance of risk. [ABSTRACT FROM AUTHOR]

Abstract Purpose Target delineation in nasopharyngeal carcinoma (NPC) often proves challenging because of the notoriously narrow therapeutic margin. High doses are needed to achieve optimal levels of tumour control, and dosimetric inadequacy remains one of the most important independent factors affecting treatment outcome. Method A review of the available literature addressing the natural behaviour of NPC and correlation between clinical and pathological aspects of the disease was conducted. Existing international guidelines as well as published protocols specified by clinical trials on contouring of clinical target volumes (CTV) were compared. This information was then summarized into a preliminary draft guideline which was then circulated to international experts in the field for exchange of opinions and subsequent voting on areas with the greatest controversies. Results Common areas of uncertainty and variation in practices among experts experienced in radiation therapy for NPC were elucidated. Iterative revisions were made based on extensive discussion and final voting on controversial areas by the expert panel, to formulate the recommendations on contouring of CTV based on optimal geometric expansion and anatomical editing for those structures with substantial risk of microscopic infiltration. Conclusion Through this comprehensive review of available evidence and best practices at major institutions, as well as interactive exchange of vast experience by international experts, this set of consensus guidelines has been developed to provide a practical reference for appropriate contouring to ensure optimal target coverage. However, the final decision on the treatment volumes should be based on full consideration of individual patients' factors and facilities of an individual centre (including the quality of imaging methods and the precision of treatment delivery). [ABSTRACT FROM AUTHOR]

Background Endoscopic findings of extranodal natural killer/T-cell lymphoma (ENKTL), nasal type, are heterogeneous, but not fully understood. The objective of this study was to evaluate the role of nasal endoscopic examination and its implications for treatment of stage I/II ENKTL. Methods This retrospective study included 60 consecutive patients diagnosed with stage I/II ENKTL, nasal type, from 2000 to 2011. Results The endoscopic findings were classified into early (45%) and advanced (55%) lesions. Furthermore, the primary tumor extent assessed by endoscopy was significantly correlated with the radiologic imaging ( p < 0.001). The results of univariate analysis showed that the patients with advanced lesions had worse overall survival ( p = 0.004) and disease-free survival ( p = 0.001) than those with early lesions. In multivariate analysis, advanced lesions on nasal endoscopy was an independent prognostic factor ( p = 0.024; hazard ratio 5.29; 95% confidence interval, 1.25-22.39). Conclusion We found that nasal endoscopic findings were important prognostic factors in stage I/II ENKTL, nasal type, suggesting that comprehensive endoscopic evaluation of primary tumor should be performed in this setting. [ABSTRACT FROM AUTHOR]

Purpose: To compare treatment results between the use of two different radiation fields including and excluding remnant stomach and suggest new target volumes excluding remnant stomach after subtotal gastrectomy (STG) in patients with stomach cancer. Methods and Materials: We retrospectively analyzed 291 patients treated with adjuvant chemoradiotherapy after STG and D2 dissection at the Samsung Medical Center, Seoul, South Korea. Eighty-three patients registered from 1995 to 1997 underwent irradiation according to the INT 0116 protocol that recommended the inclusion of remnant stomach within the target volume (Group A). After this period, we excluded remnant stomach from the target volume for 208 patients (Group B). Median follow-up was 67 months. Results: Treatment failure developed in 93 patients (32.0%). Local and regional recurrence rates for Group A vs. Group B were 10.8% vs. 5.3% (p = not significant) and 9.6% vs. 6.3% (p = not significant), and recurrence rates for remnant stomach were 7.2% vs. 1.4% (p = 0.018), respectively. Overall and disease-free survival rates were not different between the two groups. Grade 3 or 4 vomiting and diarrhea developed more frequently in Group A than Group B (4.8% vs. 1.4% and 6.0% vs. 1.9%, respectively; p = 0.012; p < 0.001). Conclusion: Exclusion of remnant stomach from the radiation field had no effect on failure rates or survival, and a low complication rate occurred in patients treated excluding remnant stomach. We suggest that remnant stomach be excluded from the radiation target volume for patients with stomach cancer who undergo STG and D2 dissection. [Copyright &y& Elsevier]

Purpose: To investigate the incidence, clinical characteristics, and risk factors of pelvic insufficiency fracture (PIF) after pelvic radiotherapy (RT) in cervical cancer. Methods and Materials: Medical records and imaging studies, including bone scintigraphy, CT, and MRI of 557 patients with cervical cancer who received whole-pelvic RT between January 1998 and August 2005 were reviewed. Results: Eighty-three patients were diagnosed as having PIF after pelvic RT. The 5-year cumulative incidence of PIF was 19.7%. The most commonly involved site was the sacroiliac joint. Pelvic pain developed in 48 patients (57.8%) at diagnosis. Eleven patients (13.3%) needed admission or narcotics because of severe pain, and others had good relief of symptoms with conservative management. In univariate analysis, age ≥55 years (p < 0.001), anteroposterior/posteroanterior parallel opposing technique (p = 0.001), curative treatment (p < 0.001), and radiation dose ≥50.4 Gy (p = 0.005) were the predisposing factors for development of PIF. Concurrent chemotherapy (p = 0.78) was not significant. Multivariate analysis showed that age ≥55 years (p < 0.001), body weight <55 kg (p = 0.02), curative treatment (p = 0.03), and radiation dose ≥50.4 Gy (p = 0.04) were significant predisposing factors for development of PIF. Conclusion: The development of PIF is not rare after pelvic RT. The use of multibeam arrangements to reduce the volume and dose of irradiated pelvic bone can be helpful to minimize the risk of fracture, especially in elderly women with low body weight. [Copyright &y& Elsevier]

Abstract: Purpose: This study was performed to quantitate the positional change of the uterus during the period of radiotherapy (RT). Methods: For 13 patients who received RT with the use of small bowel displacement system (SBDS) for uterine cervix cancer, CT scans were taken before the beginning of RT. Three more weekly CT scans were subsequently performed during the RT period. The position of the uterus on each set of CT images was defined and compared to that on the initial CT images. The difference was quantified by measuring the parameters as follows: the change of uterus border in superior (D S), right lateral (D R), left lateral (D L), anterior (D A) and posterior (D P) direction measured on images taken before and during treatments. The change of uterus volume was also measured, and the correlation between the uterus volume reduction and uterus mobility was tested. Results: The most prominent interfractional positional changes were in the cranio-caudal direction. Among the three sets of comparisons, the largest mean values for D S, D R, D L, D A and D P were −0.77±1.87, −0.29±1.02, −0.3±1.25, −0.20±1.13 cm, and −0.55±1.21 cm, respectively. The average target volume reductions were 6.4% (p =0.1335), 11.7% (p =0.0138) and 27.2% (p =0.0192) in the 1st, 2nd and 3rd week of treatment, respectively. Significant correlation between D S and uterus volume reduction (p =0.002) was found. Conclusions: The average interfractional positional changes of the uterus with the use of SBDS were relatively small, while the inter-patient deviations were large. The significant target volume reductions and inter-patient deviations of uterus mobility need to be accounted for when conformal radiation therapy for cervical cancer is performed. [Copyright &y& Elsevier]

Purpose: This study evaluated the treatment results of external beam radiotherapy administered in six fractions per week and high-dose-rate (HDR) brachytherapy for the treatment of cervical cancer.Methods and Materials: From July 2000 to July 2003, 43 patients were enrolled in this study. The patients received 45 Gy from a 10-MV photon beam using four-field box or anterior-posterior beams. Parametrial regions and the pelvic side walls were boosted with up to 50.4 Gy using a midline block. The daily fraction dose was 1.8 Gy administered in six-weekly fractions, from Monday to Saturday. HDR brachytherapy was also delivered at doses of 24 Gy to point A in six fractions twice a week. The median follow-up time was 37 months (range, 9-60 months).Results: The median overall treatment time was 51 days for all patients (range, 44-62 days). Thirty-four patients (79.1%) achieved complete remission and 8 (18.6%) achieved partial remission after radiotherapy. Locoregional recurrence occurred in 5 patients (11.6%), and a distant metastasis was encountered in 6 patients (13.9%). The 3-year overall survival, locoregional, and distant metastasis-free survival rates were 74.7%, 87.8%, and 84.7%, respectively. Grade 2 and 3 late rectal complications were encountered in 3 (6.5%) and 1 (2.2%), respectively. There were no Grade 3 late bladder complications.Conclusions: Six fractions per week of external beam radiotherapy and HDR brachytherapy is an effective treatment for patients with a carcinoma of the uterine cervix and can be used as a possible alternative to concomitant chemoradiotherapy in elderly patients or in patients with co-morbidity. [ABSTRACT FROM AUTHOR]

Abstract: Objective. : To evaluate the reproducibility of small bowel displacement system (SBDS) volumetrically using weekly CT throughout a regimen of radiotherapy for the treatment of cervical cancer. Methods. : From October 2004 to January 2005, 10 consecutive patients who received pelvic radiation therapy for uterine cervical carcinoma with the SBDS were included in this study. With the patient laid prone on the conventional simulator table, the Styrofoam compression device is placed under the lower abdomen of the patient. Next, CT scan images, first two sets of without and with the SBDS, followed by with SBDS once a week for 3 weeks consecutively after the beginning of radiotherapy, were taken. Radiation planning was performed using standard pelvic box fields in 3-dimensional radiation treatment planning system. In each CT sets, we measured the identified organ volumes and the volume of small bowel irradiated in treatment portals. We used the regression analysis to know the correlation of the volume of small bowel irradiated according to the volume variation of bladder during radiotherapy. Results. : The mean small bowel volume with SBDS of 10 patients during radiotherapy was reduced by 60.5% (from 32.5% to 78.2%), comparing to the small bowel volume without SBDS. The variation of small bowel volume reduction in each patient was ranged from 7.3% to 38.5% (mean: 20.5%). In spite of using the SBDS, the volume reduction of small bowel irradiated was affected significantly by the volume of bladder during radiotherapy. The variation of small bowel irradiated for five patients who had more than 10% small bowel volume variation was significantly correlated with the volume of bladder, but not for five patients less than 10% small bowel volume variation. Conclusion. : We confirm that in spite of the variation of bladder volume during radiotherapy, the SBDS is an effective method that can be used to displace the small bowel continuously away from the irradiated field for cervical cancer. [Copyright &y& Elsevier]

Purpose: To evaluate the feasibility of real-time monitoring of a fiducial marker in/near the digestive tract and to analyze the motion of organs at risk to determine a reasonable internal margin. Methods and Materials: We developed two methods to insert a fiducial marker into/near the digestive tract adjacent to the target volume. One method involves an intraoperative insertion technique, and the other involves endoscopic insertion into the submucosal layer of the normal digestive tract. A fluoroscopic real-time tumor-tracking radiotherapy system was used to monitor the marker. Results: Fourteen markers (2 in the mediastinum and 12 in the abdomen) were implanted intraoperatively in 14 patients with no apparent migration. Seventeen of 20 markers (13/14 in the esophagus, 1/2 in the stomach, and 3/4 in the duodenum) in 18 patients were implanted using endoscopy without dropping. No symptomatic adverse effects related to insertion were observed. The mean/standard deviation of the range of motion of the esophagus was 3.5/1.8, 8.3/3.8, and 4.0/2.6 mm for lateral, craniocaudal and anteroposterior directions, respectively, in patients with intrafractional tumor motion less than 1.0 cm. Conclusion: Both intraoperative and endoscopic insertions of a fiducial marker into/near the digestive tract for monitoring of organs at risk were feasible. The margin for internal motion can be individualized using this system. [Copyright &y& Elsevier]

Purpose: To evaluate the response to local radiotherapy (RT) for unresectable hepatocellular carcinoma (HCC) and to analyze the dose–response relationship and the treatment-related morbidities. Methods and materials: Between 1998 and 2002, 59 patients who were treated with localized RT were evaluated. RT was delivered with a curative intent, and the radiation dose was 30–55 Gy (biologic effective dose of 39.0–70.2 Gy10 using the α/β ratio of 10 Gy) with 2–3 Gy as a daily dose. The tumor response was evaluated by the change in maximum tumor size on serial CT scans, and the morbidity was evaluated by the Common Terminology Criteria for Adverse Events v3.0. Results: An objective tumor response was achieved in 39 of 59 patients (66.1%) with complete response (CR) in 5 patients and partial response (PR) in 34 patients. More than 50 Gy10 had a significant response; CR or PR was 72.8% with >50 Gy10 and 46.7% with ≤50 Gy10 (p = 0.0299). The 2-year overall survival rate after RT was 27.4% (median survival time: 10 months), and this was affected by the tumor response (p = 0.0640); the 2-year overall survival rate after RT was 50.0% for CR and 21.8% for PR. There was no Grade 3 or 4 acute toxicity, and 3 patients (5.1%) developed gastric or duodenal ulcer. Conclusions: Radiotherapy for unresectable HCC resulted in 66.1% of tumor response with acceptable toxicity, and the radiation dose seems to be a significant prognostic factor in RT response for HCC. [Copyright &y& Elsevier]

: PurposeTo provide a rationale for the use of local radiotherapy (RT) for the treatment of low-grade mucosa-associated lymphoid tissue lymphoma of the stomach (MLS). In addition, the clinicopathologic characteristics were analyzed.: Methods and materialsThe data of 72 patients with MLS, who underwent radical surgery between 1991 and 2001, were retrospectively reviewed. The depth of invasion into the gastric wall and the pattern of lymph node spread according to pathologic grade were analyzed.: ResultsThe patient age range was 24–77 years (median, 51 years). Of the 72 patients, 45 (62.5%) had low-grade and 27 (37.5%) had high-grade MLS; 44 (61%) had Stage I and 28 (39%) Stage II. The tumors were confined to the mucosa or submucosa in 43 patients (58.9%). Sixty-seven percent of low-grade tumors and 48% of high-grade tumors were confined to the mucosa and submucosa. Lymph node involvement was identified in 24.4% of the low-grade MLS patients and 63.0% of the high-grade MLS patients. In the low-grade group, lymph node involvement was limited to the perigastric lymph nodes in all cases except for one. One patient with tumor infiltration beyond the serosa had extensive lymph node involvement into the paraaortic and omental lymph nodes.: ConclusionLocal RT to the stomach and regional lymphatics can be applied preferably instead of gastrectomy in patients with low-grade MLS who are negative for Helicobacter pylori or are refractory to anti-H. pylori therapy. The timing of RT and the exclusion criteria for RT should be determined in the future. [Copyright &y& Elsevier]