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This report presents a new method to characterize the inappropriate positioning of dosimeters based on the dose equivalent Hp(10). The Hp(10) values of medical workers were measured monthly for 12 mo using two personal dosimeters. Using the ratio between the values of Hp(10) recorded from dosimeters worn over and under protective aprons [Hp(10) over and Hp(10) under , respectively], 670 pairs of dosimeter readings were categorized into a proper use group [Hp(10) over /Hp(10) under ≥ 5] and a misuse group [Hp(10) over /Hp(10) under5]. Following personal interviews, the readings in the misuse group were classified into the following six subgroups: "reversed," "sometimes reversed," "both under," "both over," "without apron," and "not specified." Ultimately, the scatter plot of "Hp(10) over - Hp(10) under " vs. Hp(10) over was identified as the most promising tool for clarifying the misuse patterns of dosimeters, as individual readings were mapped to the locations of the corresponding subgroups in the obtained graphs. Our results are expected to facilitate efficient and accurate usage of dosimeters by medical workers.

To improve the homogeneity and conformity of the irradiation dose for postoperative breast cancer including regional lymph nodes, we planned Hybrid volumetric-modulated arc therapy (VMAT), which combines conventional tangential field mainly for the chest area and VMAT mainly for the supraclavicular area and marginal zone. In this study, we compared the dosimetric impact between traditional 3D conformal radiotherapy (3DCRT) and Hybrid VMAT and observed toxicities following Hybrid VMAT. A total of 70 patients indicated between October 2016 and December 2017 were included. The prescribed dose was 50 Gy/25 fractions. For the dosimetric impact, 3DCRT and Hybrid VMAT plans were compared in each patient with respect to the dosimetric parameters. Toxicities were followed using the Common Terminology Criteria for Adverse Events version 4.0. The median follow-up duration was 319 days. For the dosimetric impact, the homogeneity index (HI) and conformity index (CI) of PTV were significantly improved in the Hybrid VMAT plan compared with that in the 3DCRT plan (HI, 0.15 ± 0.07 in Hybrid VMAT vs 0.41 ± 0.19 in 3DCRT, P

This study aimed to investigate whether the use of molecular-targeted agents could affect gastrointestinal (GI) toxicity in palliative radiotherapy (RT) for metastatic bone tumors in the abdominopelvic region. We collected data of patients who received palliative RT for bone metastases in the abdominopelvic region between 2013 and 2014 from six institutions. Data of 395 patients were collected and184 patients received molecularly targeted therapy, of whom 80 received vascular endothelial growth factor (VEGF)-targeted agents. For 556 lesions, 410 sessions of irradiation were undergone. GI toxicity of ≥G3 was observed in 3.8% of patients. The incidence rates of ≥G3 GI toxicity in patients without targeted agents use, in those using VEGF-targeted agents and in those using non-VEGF-targeted agents were 3.8, 7.5 and 1.0%, respectively. Regarding risk factors of the occurrence of ≥G3 GI toxicity, univariate analysis in all patients showed that a history of abdominopelvic surgery was a significant risk factor (P = 0.01), and the use of VEGF-targeted agents showed a trend of high incidence (P = 0.06). In patients using VEGF-targeted agents, both univariate and multivariate analysis showed that combined anticoagulant use (P = 0.03 and 0.01) and agent use between 1 week before and after RT (P = 0.046 and 0.03) were significant risk factors. In conclusion, the history of abdominopelvic surgery was associated with ≥G3 GI toxicity and the use of VEGF-targeted agents showed a trend for high incidence. When using VEGF-targeted agents, caution should be exercised in the combined use of anticoagulants and in the agent use between 1 week before and after RT.

The present study aimed to analyze treatment outcomes after induction chemotherapy followed by chemoradiotherapy (CRT) using volumetric-modulated arc therapy (VMAT) in patients with stage IVA-B oropharyngeal cancer (OPC) or hypopharyngeal cancer (HPC), with long-term observation, including examination of larynx preservation. A total of 60 patients with stage IVA-B OPC or HPC, who underwent induction TPF chemotherapy (a combination regimen consisting of docetaxel, cisplatin, and 5-fluorouracil) followed by CRT using VMAT were analyzed. Overall survival (OS), progression-free survival (PFS), laryngoesophageal dysfunction-free survival (LEDFS), and locoregional control (LRC) were calculated and compared. Univariate and multivariate analyses were performed to determine statistical differences in OS and LEDFS. The median follow-up period at the time of evaluation was 61 months. Twenty-six (43%) patients had OPC and 34 (57%) had HPC. The 5-year OS, PFS, LEDFS, and LRC rates were 57%, 52%, 52%, and 68%, respectively. Response to TPF therapy was the only significant predictive factor of OS and LEDFS in multivariate analyses. Regarding long-term toxicities, grade ≥ 2 late toxicities accounted for 15%. No patients experienced grade ≥ 3 xerostomia, and 5% of all patients developed grade 3 dysphagia. With long-term observation, the OS, PFS, and LEDFS rates were relatively good, and the incidence of late toxicities was low. TPF followed by CRT using VMAT was feasible and more effective in those who responded to induction chemotherapy.

Purpose We aimed to evaluate the magnetic resonance imaging (MRI) appearance changes during stereotactic radiotherapy (SRT) for large sized brain metastases, and analyze the lesions necessitating treatment plan modification. Materials and methods A total of 23 patients (27 lesions, >2 cm in tumor diameter) underwent SRT and all lesions were evaluated the appearance changes which had the necessity of the treatment plan modification. The appearance change of tumor during SRT was evaluated using gadolinium-enhanced MRI. The reasons of the modification were classified into tumor reduction, tumor enlargement, displacement, and shape change. Results Among the 27 lesions, 55.6% required the treatment plan modification. The reasons were tumor reduction in six lesions, tumor enlargement in three lesions, displacement in three lesions, and shape change in three lesions. The planning target volume (PTV) size changed up to 43.0% and the shift of center of PTV was a maximum of 1.7 mm. The pathological status (adenocarcinoma vs others) and timing of steroid administration (prior vs after SRT start) were the predictive factors of tumor changes required the modification. Conclusions As tumor changes might occur even during short period of SRT, the treatment plan evaluation and modification were important in SRT for large brain metastases.

Purpose The detection of intestinal/rectal gas is very important during image-guided radiation therapy (IGRT) of prostate cancer patients because intestinal/rectal gas increases the inter- and intra-fractional prostate motion. We propose a deep convolutional neural network (DCNN) to detect intestinal/rectal gas in the pelvic region. Material and methods We selected 300 anterior-posterior kilo-voltage (kV) X-ray images from 30 prostate cancer patients. Thirty images were randomly chosen for a test set, and the remaining 270 images used as the training set. The intestinal/rectal gas was manually delineated on kV X-ray images and segmented. The training images were augmented by applying artificial shifts and fed into a DCNN. The network models were trained to keep the quality of the output image close to the quality of the input image by pooling and upsampling. The training set was used to adjust the parameters of the DCNN, and the test set was used to assess the performance of the model. The performance of the DCNN was evaluated using a fivefold cross-validation procedure. The dice similarity coefficient (DSC) was calculated to evaluate the detection accuracy between the manual contour and auto-segmentation. Results The DCNN was trained within approximately 17 min with a time step of 20 s/epoch. The training and validation accuracy of the models after 50 epochs were 0.94 and 0.85, respectively. The average ± standard deviation of the DSC for 30 test images was 0.85 ± 0.08. Conclusions The proposed DCNN method can automatically detect the intestinal/rectal gas in kV images with good accuracy.

Background Few studies have assessed hydrogel spacer shrinkage during external-beam radiation therapy following brachytherapy for localized high-risk prostate cancer. This case presentation evaluated the changes in hydrogel spacer appearance by magnetic resonance imaging during external-beam radiation therapy after brachytherapy for prostate cancer and analyzed the effect of this shrinkage on the dose distribution in four cases. Case presentation In all cases, we implanted 125I sources using a modified peripheral loading pattern for seed placement. The prescribed dose for each implant was 110 Gy. After delivering the sources, a hydrogel spacer was injected. All cases underwent external-beam radiation therapy approximately 1–2 months after brachytherapy. The prescribed dose of external-beam radiation therapy was 45 Gy in 1.8-Gy fractions. Magnetic resonance imaging was performed for evaluation on the day following seed implantation (baseline), at external-beam radiation therapy planning, and during external-beam radiation therapy. The median hydrogel spacer volume was 16.2 (range 10.9–17.7) cc at baseline, 14.4 (range, 9.4–16.1) cc at external-beam radiation therapy planning, and 7.1 (range, 2.0–11.4) cc during external-beam radiation therapy. The hydrogel spacer volume during external-beam radiation therapy was significantly lower than that at external-beam radiation therapy planning. The rectum V60–80 (rectal volume receiving at least 60–80% of the prescribed dose of external-beam radiation therapy) during external-beam radiation therapy was significantly higher than that at external-beam radiation therapy planning. Conclusions The potential reduction in hydrogel spacer size during external-beam radiation therapy following brachytherapy can lead to unexpected irradiation to the rectum. This case presentation would be helpful for similar cases.

Introduction: According to several guidelines, stereotactic body radiation therapy (SBRT) for early hepatocellular carcinoma (HCC) can be considered an alternative to other modalities, such as resection, radiofrequency ablation (RFA), and transarterial chemoembolization (TACE), or when these therapies have failed or are contraindicated. This article reviews the current status of SBRT for the treatment of HCC. Areas covered: From the results of many retrospective reports, SBRT is a promising modality with an excellent local control of almost 90% at 2–3 years and acceptable toxicities. Currently there are no randomized trials to compare SBRT and other modalities, such as resection, RFA, and TACE, but many retrospective reports and propensity score matching have shown that SBRT is comparable to the different modalities. Repeated SBRT for intra-hepatic recurrent HCC also resulted in high local control with safety and satisfactory overall survival, which were comparable to those of other curative local treatments. Expert opinion: Despite the good results of SBRT, the conclusions of the comparisons of SBRT and other modalities are still controversial. Further studies, including randomized phase III studies to define that patients are more suitable for each curative local treatment, are needed.

The aim of the current planning study is to evaluate the ability of gadoxetate disodium-enhanced magnetic resonance imaging (EOB-MRI)–guided stereotactic body radiation therapy (SBRT) planning by using intensity-modulated radiation therapy (IMRT) techniques in sparing the functional liver tissues during SBRT for hepatocellular carcinoma. In this study, 20 patients with hepatocellular carcinoma were enrolled. Functional liver tissues were defined according to quantitative liver-spleen contrast ratios ≥ 1.5 on a hepatobiliary phase scan. Functional images were fused with the planning computed tomography (CT) images; the following 2 SBRT plans were designed using a “step-and-shoot” static IMRT technique for each patient: (1) an anatomical SBRT plan optimization based on the total liver; and (2) a functional SBRT plan based on the functional liver. The total prescribed dose was 48 gray (Gy) in 4 fractions. Dosimetric parameters, including dose to 95% of the planning target volume (PTV D 95% ), percentages of total and functional liver volumes, which received doses from 5 to 30 Gy (V5 to V30 and fV5 to fV30), and mean doses to total and functional liver (MLD and fMLD, respectively) of the 2 plans were compared. Compared with anatomical plans, functional image-guided SBRT plans reduced MLD (mean: plan A, 5.5 Gy; and plan F, 5.1 Gy; p p

The long-term outcomes of whole-breast and boost irradiation after breast-conserving surgery (BCS) for patients with breast cancer were retrospectively analyzed. Patients who received whole-breast and boost irradiation after BCS from 1990 to 2002 were included. Boost irradiation was administered to each tumor bed, regardless of the surgical margin status. The median doses of whole-breast and boost irradiation were 45 Gy in 25 fractions (range 36–45 Gy), and 14 Gy in 7 fractions (range 0–14 Gy), respectively. Data for 306 patients were analyzed. With a median follow-up time of 144 months, the 10-year overall survival, disease-free survival, ipsilateral breast tumor recurrence (IBTR), and metachronous contralateral breast cancer (MCBC) occurrence rates were 93.0, 84.1, 2.1, and 4.1 %, respectively. In the multivariate analysis, pT2 was a significant risk factor for IBTR (p = 0.041), while age ≤ 50 years and pT2 were significant risk factors for MCBC occurrence (p = 0.003 and 0.043, respectively). One patient (0.3 %) developed angiosarcoma in the irradiated region 120 months after the completion of radiation therapy. The 12-year outcome of breast-conserving therapy using whole-breast and boost irradiation with doses of 45 and 14 Gy, respectively, was favorable.

Purpose The purpose of this study was to prospectively investigate clinical correlations between dosimetric parameters associated with radiation pneumonitis (RP) and functional lung imaging. Methods and Materials Functional lung imaging was performed using four-dimensional computed tomography (4D-CT) for ventilation imaging, single-photon emission computed tomography (SPECT) for perfusion imaging, or both (V/Q-matched region). Using 4D-CT, ventilation imaging was derived from a low attenuation area according to CT numbers below different thresholds (vent-860 and -910). Perfusion imaging at the 10th, 30th, 50th, and 70th percentile perfusion levels (F10-F70) were defined as the top 10%, 30%, 50%, and 70% hyperperfused normal lung, respectively. All imaging data were incorporated into a 3D planning system to evaluate correlations between RP dosimetric parameters (where fV20 is the percentage of functional lung volume irradiated with >20 Gy, or fMLD, the mean dose administered to functional lung) and the percentage of functional lung volume. Radiation pneumonitis was evaluated using Common Terminology Criteria for Adverse Events version 4.0. Statistical significance was defined as a P value of Results Sixty patients who underwent curative radiation therapy were enrolled (48 patients for non-small cell lung cancer, and 12 patients for small cell lung cancer). Grades 1, 2, and ≥3 RP were observed in 16, 44, and 6 patients, respectively. Significant correlations were observed between the percentage of functional lung volume and fV20 (r=0.4475 in vent-860 and 0.3508 in F30) or fMLD (r=0.4701 in vent-860 and 0.3128 in F30) in patients with grade ≥2 RP. F30∩vent-860 results exhibited stronger correlations with fV20 and fMLD in patients with grade ≥2 (r=0.5509 in fV20 and 0.5320 in fMLD) and grade ≥3 RP (r=0.8770 in fV20 and 0.8518 in fMLD). Conclusions RP dosimetric parameters correlated significantly with functional lung imaging.

Aim To evaluate the response, survival and safety on 3-D conformal radiotherapy (3D-CRT) for major portal vein tumor thrombosis (PVTT) combined with hepatic arterial infusion chemotherapy (HAIC) for advanced hepatocellular carcinoma (HCC). Methods In this retrospective study, 83 advanced HCC patients treated with HAIC who met the following criteria were enrolled: (i) PVTT of the main trunk or first branch of the portal vein; (ii) no extrahepatic metastasis; (iii) Child–Pugh score of 5–7; (iv) performance status of 0 or 1; and (v) no history of sorafenib treatment. The response, overall survival (OS), time to treatment failure (TTF), post-progression survival (PPS) and safety were compared between HAIC combined with 3D-CRT for PVTT (RT group, n = 41) and HAIC alone (non-RT group, n = 42). Results The objective response of PVTT was significantly higher in the RT group (56.1%) than in the non-RT group (33.3%), while that of intrahepatic tumor and OS were not significantly different between groups. Median OS, TTF and PPS were significantly longer in the RT group than in the non-RT group (8.6 and 5.0 months, 5.0 and 2.7 months, and 5.3 and 1.5 months, respectively) among intrahepatic tumor non-responders to HAIC, whereas those were not significantly different between groups among intrahepatic tumor responders to HAIC. By multivariate analysis, the combination of 3D-CRT with HAIC was an independent contributing factor for OS (hazard ratio, 3.2; 95% confidence interval, 1.692–6.021; P

Purpose To consider nonuniform tumor motion within the internal target volume (ITV) by defining time-adjusted ITV (TTV), a volume designed to include heterogeneity of tumor existence on the basis of 4-dimensional computed tomography (4D-CT). Methods and Materials We evaluated 30 lung cancer patients. Breath-hold CT (BH-CT) and free-breathing 4D-CT scans were acquired for each patient. The tumors were manually delineated using a lung CT window setting (window, 1600 HU; level, −300 HU). Tumor in BH-CT images was defined as gross tumor volume (GTV), and the sum of tumors in 4D-CT images was defined as ITV-4D. The TTV images were generated from the 4D-CT datasets, and the tumor existence probability within ITV-4D was calculated. We calculated the TTV80 value, which is the percentage of the volume with a tumor existence probability that exceeded 80% on ITV-4D. Several factors that affected the TTV80 value, such as the ITV-4D/GTV ratio or tumor centroid deviation, were evaluated. Results Time-adjusted ITV images were acquired for all patients, and tumor respiratory motion heterogeneity was visualized. The median (range) ITV-4D/GTV ratio and median tumor centroid deviation were 1.6 (1.0-4.1) and 6.3 mm (0.1-30.3 mm), respectively. The median TTV80 value was 43.3% (2.9-98.7%). Strong correlations were observed between the TTV80 value and the ITV-4D/GTV ratio (R=−0.71) and tumor centroid deviation (R=−0.72). The TTV images revealed the tumor motion pattern features within ITV. Conclusions The TTV images reflected nonuniform tumor motion, and they revealed the tumor motion pattern features, suggesting that the TTV concept may facilitate various aspects of radiation therapy planning of lung cancer while incorporating respiratory motion in the future.

Aim To evaluate the efficacy and safety of stereotactic body radiotherapy (SBRT) in patients with small hepatocellular carcinoma (HCC) who were ineligible for resection or ablation therapies. Methods Overall, 65 patients with 74 HCC (median tumor size, 16 mm) were enrolled. They were treated at the prescribed dose of 48 Gy in four fractions at the isocenter. Child–Turcotte–Pugh (CTP) scoring was used to classify 56 and nine patients into classes A and B, respectively. Local progression was defined as irradiated tumor growth on a dynamic computed tomography follow up. The median follow-up period was 26 months. Tumor responses were assessed according to the modified Response Evaluation Criteria in Solid Tumors. Treatment-related toxicities were evaluated according to the Common Terminology Criteria for Adverse Events version 4.0. Results The 2-year overall survival, progression-free survival and local control rates were 76.0% (95% confidence interval [CI], 65.4–86.7%), 40.0% (95% CI, 27.6–52.3%) and 100% (95% CI, 100%), respectively. At 6–12 months after SBRT, grade 3 or higher toxicities was observed in 15 (23.1%) patients. The incidence of grade 3 or higher toxicities was higher in CTP class B than in class A (P = 0.0127). Conclusion SBRT was effective and relatively safe for patients with small HCC who were ineligible for resection or ablation therapies.

Objective The purpose of this study was to clarify operational situations, treatment planning and processes, quality assurance and quality control with relevance to stereotactic radiotherapy, intensity-modulated radiotherapy and image-guided radiotherapy in Japan. Methods We adopted 109 items as the quality indicators of high-precision radiotherapy to prepare a questionnaire. In April 2012, we started to publicly open the questionnaire on the website, requesting every institution with radiotherapy machines for response. The response ratio was 62.1% (490 out of 789 institutions responded). Results Two or more radiotherapy technologists per linear accelerator managed linear accelerator operation in ∼90% of the responded institutions while medical physicists/radiotherapy quality managers were engaged in the operation in only 64.9% of the institutions. Radiotherapy certified nurses also worked in only 18.4% of the institutions. The ratios of the institutions equipped for stereotactic radiotherapy of lung tumor, intensity-modulated radiotherapy and image-guided radiotherapy were 43.3, 32.6 and 46.8%, respectively. In intensity-modulated radiotherapy planning, radiation oncologists were usually responsible for delineation while medical physicists/radiotherapy quality managers or radiotherapy technologists set up beam in 33.3% of the institutions. The median time required for quality assurance of intensity-modulated radiotherapy at any site of brain, head and neck and prostate was 4 h. Intensity-modulated radiotherapy quality assurance activity had to be started after clinical hours in >60% of the institutions. Conclusions This study clarified one major issue in the current high-precision radiotherapy in Japan. A manpower shortage should be corrected for high-precision radiotherapy, especially in the area relevant to quality assurance/quality control.

The aim of this study was to evaluate portal vein and bile duct toxicity after stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC). We retrospectively reviewed 63 patients who were administrated SBRT once for HCC. The prescribed doses were from 48 Gy in four fractions to 60 Gy in eight fractions. Portal vein thrombosis and bile duct stenosis were evaluated. The dose received by 2% of the volume (D2 ) of the portal vein and bile duct was calculated. Portal vein thrombosis was observed in three patients (4.8%). Common points of these patients were Child-Pugh class B and D2 of the portal vein 40 Gy or more (BED3 ≥200 Gy). Bile duct stenosis was observed in one patient (1.6%). The patient had a history of cholangiocarcinoma and left hepatic lobectomy. Portal vein thrombosis may be necessary to be considered when SBRT for HCC is administrated to patients in higher Child-Pugh class with higher D2 of the portal vein.

This article describes a case of radiation-induced pyogenic vertebral osteomyelitis (PVO) after re-irradiation for para-aortic lymph node metastases in a patient with cervical cancer. A 62-year-old woman was admitted to our hospital with fever and severe back pain 4 months after re-irradiation (initially 56 Gy plus a secondary 50 Gy) of the para-aortic lymph nodes at the level of the fourth lumbar vertebra. Streptococcus group G was detected in a vertebral biopsy specimen and blood cultures. The patient was diagnosed with radiation-induced PVO, and intravenous antibiotic therapy was initiated. Symptoms improved significantly 2 weeks later. The patient was healthy with no evidence of relapse 5 years after the second course of radiotherapy.

AbstactBackground and Aims To compare the tumor control and safety of stereotactic body radiation therapy (SBRT) combined with transcatheter arterial chemoembolization (TACE) for small, solitary, and hypervascular hepatocellular carcinoma (HCC) with TACE alone. Methods Three hundred and sixty-five HCC patients who had solitary, ≤ 3 cm, and hypervascular nodule were treated with TACE. Among them, 30 patients followed by SBRT (SBRT group) and 38 patients without additional therapy and previous HCC treatment (control group) were enrolled in this retrospective cohort study. Local tumor progression, complication, and disease-free survival were compared between these groups. Results There was no difference in clinical background between these groups. Complete response to therapy was noted in 29 (96.3%) patients of the SBRT group, and in only one (3.3%) patient of the TACE group (P

Aim To evaluate the dynamic computed tomography (CT) appearance of tumor response after stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) and reconsider response evaluation criteria for SBRT that determine treatment outcomes. Methods Fifty-nine patients with 67 tumors were included in the study. Of these, 56 patients with 63 tumors underwent transarterial chemoembolization using lipiodol prior to SBRT that was performed using a 3-D conformal method (median, 48 Gy/four fractions). Dynamic CT scans were performed in four phases, and tumor response was evaluated by comparing tumor appearance on CT prior SBRT and at least 6 months after SBRT. The median follow-up time was 12 months. Results The dynamic CT appearance of tumor response was classified into the following: type 1, continuous lipiodol accumulation without early arterial enhancement (26 lesions, 38.8%); type 2, residual early arterial enhancement within 3 months after SBRT (17 lesions, 25.3%); type 3, residual early arterial enhancement more than 3 months after SBRT (19 lesions, 28.4%); and type 4, shrinking low-density area without early arterial enhancement (five lesions, 7.5%). Only two tumors with residual early arterial enhancement did not demonstrate remission more than 6 months after SBRT. Conclusion The dynamic CT appearance after SBRT for HCC was classified into four types. Residual early arterial enhancement disappeared within 6 months in most type 3 cases; therefore, early assessment within 3 months may result in a misleading response evaluation.

The purpose of this phase I trial of S-1 chemotherapy in combination with pelvic radiotherapy for locally recurrent rectal cancer was to determine the maximum tolerated dose (MTD), recommended dose (RD), and dose-limiting toxicity (DLT) of S-1.We enrolled 9 patients between April 2005 and March 2009. Radiotherapy (total dose, 60 Gy in 30 fractions) was given to the gross local recurrent tumor and pelvic nodal metastases using three-dimensional radiotherapy planning. We administered oral S-1 twice a day on days 1-14 and 22-35 during radiotherapy. The dose of S-1 was initially 60 mg/m(2)/day and was increased to determine the MTD and RD for this regimen.DLT appeared at dose level 2 (70 mg/m(2)/day) in 2 patients, who experienced grade 3 enterocolitis and consequently required suspension of S-1 administration for longer than 2 weeks. Hematological toxicity was mild and reversible. At the initial evaluation, complete regression and partial regression were seen in 1 patient (11%) and 2 patients (22%), respectively.This phase I trial of S-1 chemotherapy with pelvic radiotherapy for locally recurrent rectal cancer revealed that the MTD for S-1 was 70 mg/m(2)/day and the RD was 60 mg/m(2)/day.

To determine the efficacy of a definitive radiotherapy protocol using high-dose-rate intracavitary brachytherapy (HDR-ICBT) with a low cumulative dose schedule in nonbulky early-stage cervical cancer patients, we conducted a prospective multi-institutional study.Eligible patients had squamous cell carcinoma of the intact uterine cervix, Federation of Gynecologic Oncology and Obstetrics (FIGO) stages Ib1, IIa, and IIb, tumor size40 mm in diameter (assessed by T2-weighted magnetic resonance imaging), and no pelvic/para-aortic lymphadenopathy. The treatment protocol consisted of whole-pelvis external beam radiotherapy (EBRT) of 20 Gy/10 fractions, pelvic EBRT with midline block of 30 Gy/15 fractions, and HDR-ICBT of 24 Gy/4 fractions (at point A). The cumulative biologically effective dose (BED) was 62 Gy(10) (α/β = 10) at point A. The primary endpoint was the 2-year pelvic disease progression-free (PDPF) rate. All patients received a radiotherapy quality assurance review.Between September 2004 and July 2007, 60 eligible patients were enrolled. Thirty-six patients were assessed with FIGO stage Ib1; 12 patients with stage IIa; and 12 patients with stage IIb. Median tumor diameter was 28 mm (range, 6-39 mm). Median overall treatment time was 43 days. Median follow-up was 49 months (range, 7-72 months). Seven patients developed recurrences: 3 patients had pelvic recurrences (2 central, 1 nodal), and 4 patients had distant metastases. The 2-year PDPF was 96% (95% confidence interval [CI], 92%-100%). The 2-year disease-free and overall survival rates were 90% (95% CI, 82%-98%) and 95% (95% CI, 89%-100%), respectively. The 2-year late complication rates (according to Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer of Grade ≥ 1) were 18% (95% CI, 8%-28%) for large intestine/rectum, 4% (95% CI, 0%-8%) for small intestine, and 0% for bladder. No Grade ≥ 3 cases were observed for genitourinary/gastrointestinal late complications.These results suggest that definitive radiotherapy using HDR-ICBT with a low cumulative dose schedule (BED, 62 Gy(10) at point A) can provide excellent local control without severe toxicity in nonbulky (4-cm) early-stage cervical cancer.

Aim: We investigated the efficacy of hepatic arterial infusion chemotherapy (HAIC) using 5-fluorouracil (5-FU) and systemic interferon (IFN)-α (HAIC-5-FU/IFN) for advanced hepatocellular carcinoma (HCC) with venous tumor thrombosis (VTT) in the hepatic vein trunk (Vv2) or inferior vena cava (Vv3). Methods: Thirty-three patients with HCC/Vv2/3 underwent HAIC with 5-FU (500 mg/body weight/day, into hepatic artery on days 1–5 on the first and second weeks) and IFN-α (recombinant IFN-α-2b 3 000 000 U or natural IFN-α 5 000 000 U, intramuscularly on days 1, 3 and 5 of each week). Three-dimensional conformal radiotherapy (3D-CRT) was used in combination with HAIC-5-FU/IFN in 14 of 33 patients to reduce VTT. Result: The median survival time (MST) was 7.9 months, and 1- and 2-year survival rates were 30% and 20%, respectively. Evaluation of intrahepatic response after two cycles of HAIC-5-FU/IFN showed complete response (CR) in three (9%) and partial response (PR) in seven (21%), with an objective response rate of 30%. Multivariate analysis identified reduction of VTT (P = 0.0006), size of largest tumor (P = 0.013) and intrahepatic response CR/PR (P = 0.030) as determinants of survival. CR/PR correlated significantly with tumor liver occupying rate (P = 0.016) and hepatitis C virus Ab (P = 0.010). Reduction of VTT correlated significantly with radiotherapy (P = 0.021) and platelet count (P = 0.015). Radiotherapy-related reduction in VTT significantly improved survival of 16 patients with Vv3 and non-CR/PR response of HAIC-5-FU/IFN (P = 0.028). Conclusion: As for advanced HCC with VTT of Vv2/3, HAIC-5-FU/IFN responsive patients could obtain favorable survival. Despite ineffective HAIC-5-FU/IFN, the combination with effective radiotherapy to VTT might improve patients' prognosis.

Aim: To analyze the clinical outcome of esophageal varices (EV) after hepatic arterial infusion chemotherapy (HAIC) in patients with advanced hepatocellular carcinoma (HCC) and major portal vein tumor thrombus (Vp3/4). Methods: The study subjects were 45 consecutive patients who received HAIC for HCC with Vp3/4 between January 2005 and December 2009. HAIC comprised the combination therapy of intra-arterial 5-FU with interferon-α (5-FU/IFN) in 23 patients and low-dose cisplatin plus 5-FU (FP) in 22. Radiotherapy (RT) was also provided in 19 patients for portal vein tumor thrombosis. Aggravation rate for EV and overall survival rate were analyzed. Results: The aggravation rates for EV were 47% and 64% at 12 and 24 months, respectively. The survival rates were 47% and 33% at 12 and 24 months, respectively. The response rates to 5-FU/IFN and FP were 35% and 41%, while the disease control rates in these two groups were 57% and 50%, respectively. There were no significant differences in the objective response and disease control between 5-FU/IFN and FP. Multivariate analysis identified size of EV (F2/F3) (HR = 7.554, P = 0.006) and HCC disease control (HR = 5.948, P = 0.015) as significant and independent determinants of aggravation of EV, and HCC disease control (HR = 12.233, P

The aim of this study was to assess the long-term outcomes of combining high-dose-rate intraluminal brachytherapy (IBT) with external beam radiotherapy (EBRT) for superficial esophageal cancer (SEC).From 1992 to 2002, 87 patients with T1N0M0 thoracic esophageal cancer received IBT in combination with EBRT. Of these, 44 had mucosal cancer and 43 had submucosal cancer. For patients with tumor invasion within the lamina propria mucosa, IBT alone was performed (n = 27). IBT boost following EBRT was performed for patients with tumor invasion in the muscularis mucosa or deeper (n = 60). No patient received chemotherapy.The median follow-up time was 94 months. For mucosal cancer, the 5-year locoregional control (LRC), cause-specific survival (CSS) and overall survival (OS) rates were 75, 97 and 84%, respectively, and 49, 55 and 31%, respectively, for submucosal cancer. Tumor depth was a significant factor associated with LRC (p = 0.02), CSS (p0.001) and OS (p0.001) by univariate analysis. Multivariate analysis revealed that tumor depth was the only significant predictor for OS (p = 0.003). Late toxicities of grade 3 or higher in esophagus, pneumonitis, pleural effusion and pericardial effusion were observed in 5, 0, 0 and 1 patients, respectively. Grade ≥3 events of cardiac ischemia and heart failure after radiotherapy were observed in 9 patients, and history of heart disease before radiotherapy was the only significant factor (p = 0.002).There was a clear difference in outcomes of IBT combined with EBRT between mucosal and submucosal esophageal cancers. More intensive treatment should be considered for submucosal cancer.

AIM We conducted a retrospective cohort study to investigate the efficacy of combination therapy with radiotherapy (RT) and zoledronic acid for bone metastases from hepatocellular carcinoma (HCC). Additionally, we investigated the efficacy of zoledronic acid for non-irradiated bone metastases. METHODS This study consisted of 31 patients who had received RT for bone metastases. Twelve of these patients with 23 sites of bone metastases were also treated with zoledronic acid (Z group). In the Z group, 14 sites received RT and nine sites did not. Nineteen patients with 38 sites of bone metastases were not treated with zoledronic acid (non-Z group). In the non-Z group, 22 sites received RT and 16 did not. We compared survival, pain response, time to pain progression, radiographic response, time to radiographic progression, and safety between groups. RESULTS While pain response rates were similar between the two groups, time to pain progression rates of irradiated and non-irradiated bone metastases was significantly lower in the Z (0% and 20% at 6 months, respectively) than in the non-Z group (34% and 66% at 6 months, respectively) (P = 0.045 and P = 0.005). Further, while radiographic response rates were similar between the two groups, time to radiographic progression rate of non-irradiated bone metastases was significantly lower in the Z (29% at 3 months) than in the non-Z group (91% at 3 months) (P = 0.009). No significant side-effects were documented. CONCLUSION Zoledronic acid delayed the pain progression of both irradiated and non-irradiated bone metastases and the radiographic progression of non-irradiated bone metastases from HCC.

The current study was a retrospective questionnaire survey of stage IIIb adenocarcinoma of the uterine cervix treated with high-dose-rate intracavitary brachytherapy combined with external beam radiation therapy in Japan aimed to investigate the optimal dose on the basis of the biological effective dose and prognostic factors.Between 1990 and 2000, 61 patients with stage IIIb adenocarcinoma of the uterine cervix underwent high-dose-rate intracavitary brachytherapy combined with external beam radiation therapy in 19 major hospitals in Japan. This retrospective questionnaire survey was performed by mail including survey charts to be fulfilled by radiation oncologists in these 19 major hospital. Fifty had only adenocarcinoma components and 11 had adenosquamous cell carcinoma components. All patients were treated with high-dose-rate intracavitary brachytherapy combined with external beam radiation therapy. Total biological effective dose (T-BED(10)) was calculated from the sum of the biological effective doses of the external beam radiation therapy and the intracavitary brachytherapy. Thirty-two patients underwent chemotherapy.The 5-year overall survival rate of all patients was 20.2%. Stratified by total biological effective dose, the 5-year overall survival rate was 0% for T-BED(10)75 Gy, 24.7% for T-BED(10) between 75 and 100 Gy and 0% for T-BED(10)110 Gy (P = 0.15). Stratified by histopathology, the 5-year overall survival rate was 22.1% for adenocarcinoma and 13.6% for adenosquamous cell carcinoma (P = 0.43). Stratified by chemotherapy, the 5-year overall survival rate was 20.3% in patients who received chemotherapy and 20.4% in patients who did not receive chemotherapy (P = 0.96).The 5-year overall survival rate of stage IIIb adenocarcinoma of the uterine cervix in this retrospective questionnaire survey was 20.2%. The optimal T-BED(10) and evident prognostic factors were not clear from this questionnaire survey.

Objective: To assess compliance with the radiotherapy protocol of a multi-institutional prospective study (JAROG0401/JROSG04-2), which investigated the efficacy and toxicity of definitive radiotherapy using high-dose-rate intracavitary brachytherapy (HDR-ICBT) for early-stage uterine cervical cancer patients. \nMethods: Individual case reviews (ICRs) were performed on all 60 study participants. Radiotherapy data were submitted to the quality assurance (QA) committee, which performed ICRs on 16 QA items according to previously selected criteria. The items focused on quality of external beam radiotherapy (EBRT), HDR-ICBT and both. Each item was determined to be either acceptable or a deviation. The QA committee performed ICR three times as planned, two during the patient accrual and the final one just after the final patient accrued. The QA results of the first and second reviews were reported back to the investigators after each ICR. \nResults: In 40 cases (67%), all 16 QA items were classified as acceptable. One deviation was found in 16 cases, two deviations were identified in 3 cases and three deviations were noted in 1 case. The most frequently observed deviation was missing the rules for determining point A (10 cases). The items described by quantitative values, such as prescribed doses, certain time intervals and overall treatment time, were well followed. The proportion of deviations gradually decreased during the ICR process. \nConclusions: The present ICR demonstrated the favorable radiotherapy compliance with the JAROG0401/JROSG04-2 protocol. The QA process using ICRs can potentially be used to improve the quality of radiotherapy, including HDR-ICBT in the multi-institutional prospective studies for cervical cancer.

Purpose To examine the effectiveness of concomitant intra-arterial infusion chemotherapy (IAIC) using cisplatin (CDDP) with radiotherapy for Stage III squamous cell carcinoma of the cervix. Materials and Methods We analyzed 29 cases of Stage III squamous cell carcinoma of the uterine cervix treated with radiotherapy and IAIC of CDDP from 1991 to 2006. External-beam therapy was given to the whole pelvis using four opposing parallel fields with an 18-MV linear accelerator unit. A central shield was used after 30–40 Gy with external whole-pelvic irradiation, and the total dose was 50 Gy. High-dose-rate brachytherapy was given with 192Ir microSelectron. The dose at Point A was 6 Gy per fraction, 2 fractions per week, and the total number of fractions was either 3 or 4. Two or three courses of IAIC were given concomitantly with CDDP 120 mg or carboplatin 300 mg. Results We confirmed excellent medicine distribution directly by using computed tomographic angiography. The 5-year overall survival rate for Stage III patients was 62%, the cause-specific survival rate was 70%, and the local relapse-free survival rate was 89%. Local recurrence, distant metastasis, and occurrences of both were 7%, 38%, and 3%, respectively. The incidence of severe acute hematologic adverse reactions (Grade ≥3) was 27% for all patients; however, all recovered without interruption of radiotherapy. Severe nonhematologic effects (Grade ≥3) were 3%, including nausea and ileus. Only 1 patient's radiotherapy was interrupted for a period of 1 week because of ileus. Severe late complication rates (Grade ≥3) for the bladder, rectum, and intestine were 3%, 3%, and 10%, respectively. Conclusion A combination of IAIC and systemic chemotherapy should be considered to improve the prognosis of patients with Stage III squamous cell carcinoma of the cervix.

Purpose To describe patient characteristics and the process of radiotherapy (RT) for patients with esophageal cancer treated between 1999 and 2001 in Japan. Methods and Materials The Japanese Patterns of Care Study (PCS) Working Group conducted a third nationwide survey of 76 institutions. Detailed information was accumulated on 621 patients with thoracic esophageal cancer who received RT. Results The median age of patients was 68 years. Eighty-eight percent were male, and 12% were female. Ninety-nine percent had squamous cell carcinoma histology. Fifty-five percent had the main lesion in the middle thoracic esophagus. Fourteen percent had clinical Stage 0–I disease, 32% had Stage IIA–IIB, 43% had Stage III, and 10% had Stage IV disease. Chemotherapy was given to 63% of patients; 39% received definitive chemoradiotherapy (CRT) without surgery and 24% pre- or postoperative CRT. Sixty-two percent of the patients aged ≥75 years were treated with RT only. Median total dose of external RT was 60 Gy for definitive CRT patients, 60 Gy for RT alone, and 40 Gy for preoperative CRT. Conclusions This PCS describes general aspects of RT for esophageal cancer in Japan. Squamous cell carcinoma accounted for the majority of patients. The standard total external RT dose for esophageal cancer was higher in Japan than in the United States. Chemoradiotherapy had become common for esophageal cancer treatment, but patients aged ≥75 years were more likely to be treated by RT only.

We have conducted nationwide surveys of primary central nervous system lymphoma (PCNSL) treated since 1985. In the present study, we newly collected data between 2000 and 2004 and investigated changes in clinical features and outcome over time. A total of 739 patients with histologically proven PCNSL under going radiotherapy were analyzed. Seventeen institutions were surveyed, and data on 131 patients were collected. These data were compared with updated data that were previously obtained for 466 patients treated during 1985-1994 and 142 patients treated during 1995-1999. Recent trends toward decrease in male/female ratio, increase in aged patients, and increase in patients with multiple lesions were seen. Regarding treatment, decrease in attempts at surgical tumor removal and increases in use of systemic chemotherapy and methotrexate (MTX)-containing regimens were observed. The median survival time was 18, 29, and 24 months for patients seen during 1985-1994, 1995-1999, and 2000-2004, respectively, and the respective 5-year survival rates were 15%, 30%, and 30%. In groups seen during 1995-1999 and during 2000-2004, patients who received systemic or MTX-containing chemotherapy had better prognosis than those who did not. Multivariate analysis of all patients seen during 1985-2004 suggested the usefulness of MTX-containing chemotherapy as well as the importance of age, lactate dehydrogenase level, and tumor multiplicity as prognostic factors. Thus, this study revealed several notable changes in clinical features of PCNSL patients. The prognosis improved during the last 10 years. Advantage of radiation plus chemotherapy, especially MTX-containing chemotherapy, over radiation alone was suggested.

Secondary brain tumors rarely arise after cranial irradiation; among them, meningiomas and glioblastomas are the most common and secondary oligodendroglial tumors the most rare. We present a 48-year-old man who developed an oligodendroglial tumor 38 years after receiving 50 Gy of cranial irradiation to a pineal tumor. He underwent gross total removal of a calcified, ring-enhanced mass in the right temporal lobe. The tumor was histologically diagnosed as anaplastic oligodendroglioma. Our review of previously reported secondary oligodendroglial tumors that developed after cranial irradiation revealed that these rare tumors arose after low-dose cranial irradiation or at the margin of a field irradiated with a high dose. We suggest that secondary oligodendroglial tumors arising after cranial irradiation are more aggressive than primary oligodendrogliomas.

Background: The third Japanese Patterns of Care Study (JPCS) was conducted for esophageal cancer patients receiving radiotherapy (RT). The aim of this study is to analyse the data of the non-surgery group. Methods: Of the 621 patients receiving RT from 1999 to 2001, 385 non-surgical patients were analysed. Results: Median age was 71 years and 85% were male. Karnofsky performance status (KPS) was 80 in 71% and better in T1 cases than in T2–4 cases. Ninety-nine per cent had squamous cell carcinoma and 56% had the main lesion in the middle thoracic esophagus. Twenty-one per cent had T1 disease, 12% T2, 38% T3 and 29% T4. Endoscopic ultrasound was used in 29% and mainly in T1 cases. Endoscopic mucosal resection was performed in 40% of mucosal cancer. Utilization of chemotherapy had remarkably increased compared with the 1995 –1 997 JPCS (61% versus 35%), however was significantly less in T1 cases than in T2–4 cases. The most frequently used agents for concurrent use were 5-fluorouracil and cisplatin. The median total dose of external beam RT (ERT) was 60 Gy and did not differ between T1 and T2 –4 cases and also in comparison with the 1995 –1 997 JPCS. Brachytherapy was used in 10% and mainly in T1 cases. Conclusions: Utilization of chemotherapy had remarkably increased. However the common treatment for T1 cases was RT alone. The standard dose of ERT was 60 Gy in spite of the increase in chemotherapy administration. Moreover, this survey showed significant differences in many parameters of treatment process between T1 and T2–4 cases.

Purpose/Objective To evaluate the outcome of cervical cancer patients unable to undergo conventional intracavitary brachytherapy (ICBT) treated with 3D-conformal radiotherapy (3DCRT) alone using accelerated hyperfractionation (AHF). Methods and materials We reviewed the records of 7 patients who had received definitive radiotherapy with 3DCRT alone using AHF for cervical cancer between 2002 and 2005. FIGO stage was IB (1), IIB (2), IIIA (1), IIIB (2), and IVA (1). The reason we did not perform ICBT was due to patient refusal. In 1 patient with stage IB, a total dose of 65.4 Gy was delivered by local irradiation (LI) only. In 1 patient with stage IIIA, a total dose of 60 Gy was delivered by LI only. In 5 patients with Stage IIB–IV, a median total dose of 70.8 Gy was delivered by combination of whole pelvic irradiation (median dose of 45 Gy) with LI. Median overall treatment time was 42 days. Results Median follow-up for survival patients was 17 months. Out of 7 patients, 6 patients had CR and 1 patient had PR. The response rate was 100%. The 2-year local control rate was 85.7%. Of these patients, 5 are alive without disease and 1 is alive with lung metastasis. Conclusions Our outcomes suggest that 3DCRT using AHF may be a promising as a definitive treatment for cervical cancer when ICBT is not able to be performed.

Our purpose was to apply arterial spin labeling (ASL) magnetic resonance imaging (MRI) to characterize regional cerebral blood flow (rCBF: the CBF values at each voxel / the subject's mean global flow) in patients with transient hypothyroidism after thyroidectomy.Our study included 27 patients who had undergone total thyroidectomy due to thyroid cancer and pre-131I therapy and 24 controls. Patients were evaluated at two points in time: before and after thyroxine replacement. The assessments for the patients and controls consisted of evaluation of ASL of the brain and the severity of depression using 21-question Beck Depression Inventory (BDI). The assessments for the patients also included thyroid hormone lebel. We performed the comparison of rCBF between patients and controls, and investigated the association between rCBF in hypothyroid patients and thyroid hormone level and BDI score.Hypothyroid patients showed a significantly lower rCBF in the cerebellum, the left thalamus and some regions, and showed a significantly higher rCBF in the bilateral frontal gyri and some regions. After thyroxine replacement, patients showed a significantly lower rCBF mostly in the right frontal lobe, and showed a significantly higher rCBF in the left frontal and parietal lobes, although the degree of rCBF changes was lower after thyroxine replacement. In the hypothyroid patients, significant positive relationships were found between free T3 and the rCBF (p0.05 corrected for FDR).This study revealed alterations of rCBF in patients with transient hypothyroidism. ASL is helpful for understanding of the effects of hypothyroidism on the brain.

To evaluate the efficacy of sequential chemoradiotherapy (CRT) for intracranial germinoma by long-term follow-up.We retrospectively evaluated 23 consecutive intracranial germinoma patients without spinal dissemination, who had been treated by sequential CRT. All patients except for one were biopsied or surgically resected before treatment and all patients received both cranial and spinal magnetic resonance imaging. Three cycles of induction chemotherapy composed of etoposide and platinum agents were administered. The prescription of radiotherapy was 24 Gy per 12 fractions. No patients received spinal irradiation.All patients accomplished CRT and achieved complete remission. No severe acute and late toxicities were observed. Median follow-up time was 11.8 years. The 5- and 10-year overall survival rates were 100 and 100 %, and relapse-free survival rates were 96 and 89 %, respectively. Three patients developed intracranial recurrence and all of them were successfully salvaged by additional CRT. All patients were alive without disease at final follow-up.Treatment of 24 Gy of sequential CRT for intracranial germinoma might be promising as an alternative to radiotherapy alone. Spinal irradiation may not be necessary for patients who had no spinal dissemination and who were treated with CRT.

Purpose: The purpose of this study was to analyze the computed tomographic (CT) appearance of radiation injury to the lung and clinical symptoms after stereotactic body radiation therapy (SBRT) and evaluate the difference by the presence of pulmonary emphysema (PE) for small lung cancers. Methods and Materials: In this analysis, 45 patients with 52 primary or metastatic lung cancers were enrolled. We evaluated the CT appearance of acute radiation pneumonitis (within 6 months) and radiation fibrosis (after 6 months) after SBRT. Clinical symptoms were evaluated by Common Terminology Criteria for Adverse Events, version 3.0. We also evaluated the relationship between CT appearance, clinical symptoms, and PE. Results: CT appearance of acute radiation pneumonitis was classified as follows: ( 1 ) diffuse consolidation, 38.5%; ( 2 ) patchy consolidation and ground-glass opacities (GGO), 15.4%; ( 3 ) diffuse GGO, 11.5%; ( 4 ) patchy GGO, 2.0%; ( 5 ) no evidence of increasing density, 32.6%. CT appearance of radiation fibrosis was classified as follows: ( 1 ) modified conventional pattern, 61.5%; ( 2 ) mass-like pattern, 17.3%; ( 3 ) scar-like pattern, 21.2%. Patients who were diagnosed with more than Grade 2 pneumonitis showed significantly less no evidence of increased density pattern and scar-like pattern than any other pattern ( p = 0.0314, 0.0297, respectively). Significantly, most of these patients with no evidence of increased density pattern and scar-like pattern had PE ( p = 0.00038, 0.00044, respectively). Conclusion: Computed tomographic appearance after SBRT was classified into five patterns of acute radiation pneumonitis and three patterns of radiation fibrosis. Our results suggest that SBRT can be also safely performed even in patients with PE.

The purpose of this study is to investigate the incidence of cavernous angioma (CVA) in long-term survivors of childhood embryonal tumors treated by cranial irradiation. Between 1990 and 2012, we treated 25 patients (13 males, 12 females) with embryonal tumors (17 medulloblastomas, 5 primitive neuroectodermal tumors (PNET), 3 pineoblastomas) with craniospinal irradiation. Follow-up ranged from 15.5 to 289.9 months, the irradiation dose to the whole neural axis from 18 to 36 Gy, and the total local dose from 49.6 to 60 Gy. All patients underwent follow-up magnetic resonance imaging (MRI) studies at least once a year, and the diagnosis of posttreatment CVA was based solely on MRI findings. At the time of this writing, 18 were alive and free of the recurrence of the original disease or the development of secondary neoplasms other than CVA; another 2 were alive with medulloblastoma or diffuse astrocytoma. Posttreatment, 14 patients developed CVAs in the course of a median of 56.7 months; 13 of these presented with multiple CVAs. Patients who underwent radiation therapy (RT) at an age younger than 6 years developed multiple CVAs significantly earlier than those treated at a later age (p = 0.0110). Patients with PNET or pineoblastoma developed Zabramski type 1 and 2 CVA significantly earlier than did medulloblastoma patients (p = 0.0042). We attribute the high rate of post-RT CVA in our long-term follow-up study of pediatric patients to the delivery of cranial irradiation for embryonal tumors, especially PNET and pineoblastoma, and recommend the regular, long-term follow-up of patients whose embryonal tumors were treated by cranial irradiation.

Purpose: Results of radiation therapy for primary central nervous system lymphoma (PCNSL) were poor in the 1970 –1980s, with most reported 5-year survival rates being less than 10%. To investigate whether the prognosis of PCNSL patients treated by radiation alone remains still poor, we investigated the results of radiation monotherapy in the 1990s. Methods and Materials: We collected data on 132 patients with histologically proven PCNSL treated by radiation alone in the 1990s from three nationwide or regional multiinstitutional studies conducted by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO) Lymphoma Study Group or the Chubu Radiation Oncology Group. Follow-up data were updated as far as possible. Eleven patients who did not complete planned radiotherapy were included. The data were analyzed in relation to patient and tumor characteristics. The median patient age was 63 years, and the World Health Organization performance status (PS) was 3 or 4 in 40% of the patients. Multiple tumors were seen in 34%. Whole-brain irradiation with or without focal boost was used in 92%. The median radiation dose to the tumor site was 50 Gy (range, 8 –74 Gy). Results: For all 132 patients, the median survival time was 18 months and the 5-year survival rate was 18.0%. For 62 patients with PS 0 –3 and aged 16 – 65 years (i.e., those eligible for the European Organization for Research and Treatment of Cancer 20962 study), the median survival was 26 months and 5-year survival was 24%. The 5-year survival was 25% for patients 63 years old or younger, and 9.8% for those older than 63 years (p 0.0005). The 5-year survival was 22% for patients with PS 0 –2 and 13% for those with PS 3 or 4( p 0.0040). Multivariate analysis confirmed the negative influence of higher age on patient prognosis. Conclusions: The results of radiation monotherapy for PCNSL appear to have improved as compared with those reported previously. The results of new treatment should be evaluated in light of this finding. Since most prospective studies on the combined treatment exclude poor PS and high-age patients, the 5-year survival rate of 30% may not be regarded as a marked improvement over radiation alone. © 2005 Elsevier Inc.

Purpose To report the characteristics and treatment process of esophageal cancer patients treated with radiation therapy (RT) in Japan.

Purpose To evaluate in healthy volunteers the reproducibility of organ position using a voluntary breath-hold method with a spirometer and the feasibility of this method for extracranial stereotactic radiotherapy in a clinical setting. Methods and materials For this study, 5 healthy volunteers were enrolled. After training sessions, they held their breath at the end-inspiration and the end-expiration phase under spirometer-based monitoring. Computed tomography (CT) scans were performed twice at each respiratory phase, with a 10-min interval, on 2 separate days. The total number of CT scans was four at each respiratory phase. After CT volume data were transferred to a three-dimensional treatment-planning system, digitally reconstructed radiographs (DRRs) were calculated for anterior–posterior and left–right beams. Verification was performed with DRRs relative to the diaphragm position, bony landmarks, and the isocenter in each healthy volunteer at each respiratory phase. To evaluate intrafraction reproducibility, we measured the distance between diaphragm position and bony landmarks. To evaluate interfraction reproducibility, we measured the distance between diaphragm position and the isocenter. Reproducibility and setup error were defined as the average value of the differences between each DRR with regard to the first DRR. Results Intrafraction reproducibility of the caudal–cranial direction was 4.0 ± 3.5 mm at the end-inspiration phase and 2.2 ± 2.0 mm at the end-expiration phase. Interfraction reproducibility of the caudal–cranial direction was 5.1 ± 4.8 mm at the end-inspiration phase and 2.1 ± 1.8 mm at the end-expiration phase. The end-expiration phase was more stable than the end-inspiration phase. Conclusions The voluntary breath-hold method with a spirometer is feasible, with relatively good reproducibility. We are encouraged about the use of this technique clinically for extracranial stereotactic radiotherapy.

Purpose To evaluate the quality of radiotherapy (RT) in Japan, we have been carrying out a national survey through patterns-of-care studies (PCSs) since 1996. We present the preliminary results of surgery combined with RT with or without chemotherapy for thoracic esophageal cancer. Methods and materials A Japanese PCS data format for esophageal cancer was established based on one used in the United States and including information used in the surgical registration system in Japan, so that the results in both countries could be compared. An independent panel of radiation oncologists surveyed randomly selected institutions and patients between September 1998 and March 2001. There were 767 esophageal cancer patients, of whom 220 had undergone preoperative or postoperative RT. Results The median age of the 220 patients was 62.3 years (range 31–89); of them, 88.1% were men. Pathologically, 218 patients (99.5%) had squamous cell carcinoma, predominantly located in the middle and lower thoracic esophagus, 41.7% of the patients had Stage III disease; they accounted for 52.6% of patients in nonacademic institutions and for 37.7% of those in academic institutions ( p = 0.016). Sixty-nine patients received preoperative RT; of them, 60.9% received chemotherapy; 145 patients received postoperative RT with or without chemotherapy. The spinal cord of 23 (11.7%) of 196 patients was irradiated with ≥50 Gy. In academic institutions, extended radical "three-field" lymphatic dissection was performed for 72 (48.7%) of 148 patients; however, this sophisticated surgical procedure was done in only 13 (25.5%) of 51 patients in nonacademic settings ( p = 0.004). In all large academic institutions (those treating ≥300 patients annually), ≥6 MV of photon energy was used; 30.5% of nonacademic institutes had linear accelerators of p = 0.001). No deviations occurred in the radiation dose (median 46 Gy), fractionations, or fields between the two types of institutions. Univariate analyses showed that the statistically significant prognostic factors affecting overall survival were stage ( p = 0.001), extended radical "three-field" lymphatic dissection ( p = 0.001), no residual tumor ( p = 0.001), supraclavicular RT ( p = 0.001), mediastinal RT ( p = 0.025), Karnofsky performance status ( p = 0.006) photon energy ( p = 0.011), and stratification of the institutions ( p = 0.001). Multivariate analysis showed that the type of institution ( p = 0.045, risk ratio=0.604), stage ( p 0.029, risk ratio=0.572), no residual tumor ( p = 0.006, risk ratio=0.487), photon energy ( p = 0.043, risk ratio=0.579), and use of chemotherapy ( p = 0.012, risk ratio=1.907) significantly affected overall survival. Conclusion This PCS showed that in Japan important issues are present regarding RT for esophageal cancer that should be solved immediately, namely, treatment strategy, photon energy, and dose applied to the spinal cord. The PCS provided important information on how much improvement in structure and process would be required nationwide for RT of esophageal cancer.