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Purpose We aimed to investigate manifestations and patterns of care for patients with brain metastasis (BM) from breast cancer (BC) and compared their overall survival (OS) from 2005 through 2014 in Korea.Materials and Methods We retrospectively reviewed 600 BC patients with BM diagnosed between 2005 and 2014. The median follow-up duration was 12.5 months. We categorized the patients into three groups according to the year when BM was initially diagnosed (group I [2005-2008], 98 patients; group II [2009-2011], 200 patients; and group III [2012-2014], 302 patients).Results Over time, the median age at BM diagnosis increased by 2.2 years (group I, 49.0 years; group II, 48.3 years; and group III, 51.2 years; p=0.008). The percentage of patients with extracranial metastasis was 73.5%, 83.5%, and 86.4% for group I, II, and III, respectively (p=0.011). The time interval between BC and BM was prolonged in patients with stage III primary BC (median, 2.4 to 3 years; p=0.029). As an initial brain-directed treatment, whole-brain radiotherapy alone decreased from 80.0% in 2005 to 41.1% in 2014. Meanwhile, stereotactic radiosurgery or fractionated stereotactic radiotherapy alone increased from 13.3% to 34.7% during the same period (p=0.005). The median OS for group I, II, and III was 15.6, 17.9, and 15.0 months, respectively, with no statistical significance.Conclusion The manifestations of BM from BC and the pattern of care have changed from 2005 to 2014 in Korea. However, the OS has remained relatively unchanged over the 10 years.

The benefits of adjuvant radiotherapy (ART) in gallbladder cancer (GBC) treatment remain inconclusive owing to the rarity of GBC and lack of randomized studies.PubMed, Medline, Embase, and Cochrane Library were systematically searched until March 2021. The primary endpoint was overall survival (OS). Comparative clinical studies that reported survival outcomes in GBC patients treated with or without ART were included. The comparability of each study was assessed by considering all possible clinical indicators (group 2: ART arm with poor clinical profile; group 1: ART arm with statistically similar profile or no evidence of having inferior clinical factors compared to non-ART arm).Twenty-one studies involving 6876 GBC patients were reviewed. In pooled analyses of OS, the odds ratio (OR) was 1.26 (p = 0.111) neither favoring ART or non-ART arms. In subgroup analyses considering comparability, the OR significantly favored the ART arm (1.92, p = 0.008) among comparability group 1 studies, whereas it was 1.03 (p = 0.865) in comparability group 2 studies. The pooled rate of 5-year OS in the ART vs. non-ART arms was 44.9% vs. 20.9% in group 1 and 34.1% vs. 40.0% in group 2. With ART, significant reduction in locoregional recurrence (OR 0.21, p = 0.001) but not in distant metastasis (OR 1.32, p = 0.332) was noted.ART not only showed benefits in patients with a similar clinical profile to those treated without ART but also yielded comparable survival in patients with an inferior clinical profile. Our results suggest the more active application of ART in GBC treatment.This study is registered in PROSPERO (CRD42021240624, available at: https://www.crd.york.ac.uk/ ).

Objective Hypofractionated radiotherapy has recently been applied to treat pulmonary metastases of hepatocellular carcinoma. However, there is no definite evidence on its safety and efficacy. We evaluate the clinical outcomes of hypofractionated radiotherapy for oligo pulmonary metastases of hepatocellular carcinoma in the multicenter and retrospective study. Methods From March 2011 to February 2018, 58 patients with fewer than five pulmonary metastases of hepatocellular carcinoma who underwent hypofractionated radiotherapy in nine tertiary university hospitals were analyzed retrospectively. The primary endpoint was the local control rate. The secondary endpoints were overall survival, progression-free survival, prognostic factors affecting the treatment outcomes and treatment-related side effects. Results The local tumor response rate including complete and partial response was 77.6% at 3 months after hypofractionated radiotherapy. The median survival and progression-free survival times were 20.9 and 5.3 months, respectively. The 1-year overall survival and progression-free survival rates were 65.5 and 22.4%, respectively. The good treatment response after hypofractionated radiotherapy (P = 0.001), the absence of intrahepatic tumor (P = 0.004) and Child-Pugh class A (P = 0.010) were revealed as significant prognostic factors for overall survival in the multivariate analysis. A progression-free interval of Conclusions The favorable local control rate and acceptable toxicity indicate the clinical usefulness of hypofractionated radiotherapy for hepatocellular carcinoma patients who have less than five pulmonary metastases.

Background: We analyzed the treatment outcome of breast cancer patients with brain metastases (BM) in Korea to identify the prognostic factors and the role of whole brain radiation therapy (WBRT). Methods: Seven hundred thirty patients of breast cancer with BM treated at 17 institutions in Korea from 2000 to 2014 were analyzed. The median follow-up duration was 12 months. The analysis consisted of three cohorts: in cohort A, a total of 730 patients were included; in cohort B, 538 patients with available follow-up imaging after initial brain-directed treatment; and in cohort C, 54 patients receiving salvage WBRT due to recurrent BM after initial Stereotactic radiosurgery or WBRT. Overall survival (OS) was calculated from BM diagnosis in cohort A or from the last day of salvage WBRT in cohort C. Results: Median OS of cohort A was 15 months. In multivariate analysis, histologic grade 3, extracranial metastasis, number of BM >4, hormone receptor (HR) or HER2 negativity, and shorter time interval to diagnosis of BM were associated with inferior OS. Among 538 patients in cohort B, 201 showed subsequent development of new BM at a median of 11 months after stereotactic radiosurgery or WBRT for the management of initial BM (at 1 year, HR+/HER2- 51.9%, HER2+ 44.0%, and TNBC 69.6%, respectively; p=0.008). Upfront WBRT reduced subsequent development of new BM, which showed the significant difference among molecular subtypes (HR+/HER2-, 42% reduction at 1 year, p4, and involvement of both tentoria increased subsequent development of new BM. Anti-HER2 therapy for HER2+ patients and upfront WBRT significantly reduced risk of new BM. In cohort C, upfront WBRT prolonged the salvage WBRT-free duration (median 6.9 vs. 8.7 months, p=0.058). Median OS was 6.8 months after salvage WBRT. Longer interval to salvage WBRT, controlled primary tumor, high dose of salvage WBRT (BED10 >37.5 Gy), and systemic treatment after salvage WBRT showed better OS. Uncontrolled extracranial systemic disease and salvage WBRT due to local progression without distant intracranial failure showed worse OS. Conclusions: The rates of new BM showed the significant differences among molecular subtypes. Upfront WBRT decreased subsequent development of new BM and this effect was dependent on the molecular subtype as well. Anti-HER2 therapy for HER2+ patients significantly decreased the subsequent development of new BM. On salvage WBRT setting, the patients having high dose of salvage WBRT, stable extracranial systemic disease and subsequent systemic therapy showed better OS. Citation Format: Jae Sik Kim, Kyubo Kim, Wonguen Jung, Kyung Hwan Shin, Seock-Ah Im, Hee-Jun Kim, Yong Bae Kim, Jee Suk Chang, Jee Hyun Kim, Doo Ho Choi, Yeon Hee Park, Dae Yong Kim, Tae Hyun Kim, Byung Ock Choi, Sea-Won Lee, Suzy Kim, Jeanny Kwon, Ki Mun Kang, Woong-Ki Chung, Kyung Su Kim, Won Sup Yoon, Jin Hee Kim, Jihye Cha, Yoon Kyeong Oh, In Ah Kim. Multicenter study for brain metastasis from breast cancer in Korea: The significance of molecular subtype (KROG 1612) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-21-01.

The intestine is a dose-limiting organ in the treatment of intra-abdominal cancer. We previously reported that the extract of mistletoe parasites onWild-type adult AB zebrafish were exposed to 45-50 Gy of photon beam irradiation and/or treated with mistletoe extract orally 1 h before. The main endpoints of the study were survival and degree of deformation of the intestinal villi.The median follow-up period was 10 d post-irradiation (range: 7-11 d). A total of 105 zebrafish were used, including 42 in the radiation alone, 42 in the radiation and mistletoe arms, and 21 control subjects (mistletoe alone, mock-irradiated arm). The rate of both significant deformity and death was 53% in the radiation-alone arm, whereas the corresponding rate was 30% in the radiation and mistletoe arms. Significant deformity-free survival rates at 10 d post-irradiation in the radiation alone, and radiation and mistletoe arms were 44.7% (95% confidence interval [CI]:20-54.3) and 68.4% (95% CI:53.8-86.8), respectively (The radioprotective effect against intestinal toxicity was successfully shown in an adult zebrafish model. This result suggests the possibility of clinical use of mistletoe extract for the treatment of abdominal cancers.

To identify the risk factors leading to new brain metastases (BM) following brain-directed treatment for initial BM resulting from breast cancer (BC). In this multi-institutional study, 538 BC patients with available follow-up imaging after brain-directed treatment for initial BM were analyzed. Tumor molecular subtypes were classified as follows: hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2−, n = 136), HER2-positive (HER2+, n = 253), or triple-negative BC (TNBC, n = 149). In 37.4% of patients, new BM emerged at a median of 10.5 months after brain-directed treatment for initial BM. The 1-year actuarial rate of new BM for HR+/HER2−, HER2+, and TNBC were 51.9%, 44.0%, and 69.6%, respectively (p = 0.008). Initial whole-brain radiotherapy (WBRT) reduced new BM rates (22.5% reduction at 1 year, p 4) (p

Background. We sought to analyze the preferred treatment modality by age and liver function in South Korea. Methods. The Korean Liver Cancer Study Group randomly extracted the data of patients with hepatocellular carcinoma (HCC) enrolled in the Korean Central Cancer Registry from 2008 to 2014 from approximately 50 hospitals nationwide. After excluding distant and lymphatic metastases, the treatment preference for patients with a single lesion (excluding PVT (portal vein thrombosis), hepatic vessels, and bile duct invasion) and with PVT was evaluated in 7559 patients. Patients were grouped by age, and baseline liver function was divided based on the Child–Pugh class (CPC) A, B, and C. Results. For a single HCC, the majority of patients selected transarterial therapy as the initial treatment, followed by surgical resection and local ablative therapy. The surgical resection rate decreased significantly with age ( p < 0.001 ), and the transarterial therapy rate significantly increased ( p < 0.001 ). For CPC C, liver transplantation was significantly increased to 11.5%, and 36.3% of patients received no treatment. In HCC with PVT, the transarterial therapy rate was the highest, followed by the rate of abandonment of treatment. The proportion of no treatment significantly increased with age ( p < 0.001 ). In CPC C, transarterial therapy and systemic therapy were attempted in 15.4% and 5.8% of patients, respectively. Conclusions. Age and liver function have a significant impact on the therapeutic decision-making of HCC patients in Korea. In unfavorable conditions, surgical resection was less favored in patients with single tumors, and no treatment was preferred in patients with PVT.

Introduction: The benefits of adjuvant radiotherapy (ART) for extrahepatic cholangiocarcinoma are uncertain largely because existing publications lack clear comparisons between ART and non-ART arms. Methods: PubMed, Medline, Embase, and the Cochrane library were systematically searched until December 2020. The primary endpoint was overall survival (OS). Sensitivity analysis was performed for studies with reliable comparability (i.e., no favorable prognosticators in the ART arm that could skew the data). Results: Twenty-three studies involving 1,731 patients with extrahepatic cholangiocarcinoma were reviewed. The overall median of all median prescribed doses was 50.4 Gy; brachytherapy or an intraoperative boost of 10–21 Gy was applied in 5 studies. The pooled 1-, 3-, and 5-year OS rates in the non-ART and ART arms were 69.2% versus 81.0%, p = 0.035; 34.3% versus 44.7%, p = 0.025; 25.6% versus 31.7%, p = 0.115, respectively. The corresponding pooled locoregional recurrence rates were 52.1% versus 34.9% (p = 0.014). The pooled rate of grade ≥3 gastrointestinal complications was 9.8%. Sensitivity analysis performed on 14 eligible studies showed that the ART arms had a lower pooled R0 rate (36.8% vs. 63.2%, p = 0.02) and a higher rate of positive lymph nodes (47.4% vs. 34.9%, p = 0.08). The pooled 1-, 3-, and 5-year OS rates in the non-ART versus ART arms of the selected studies were 78.2% versus 84.9%, p = 0.143; 38.5% versus 49.2%, p = 0.026; and 27.8% versus 34.5%, p = 0.11, respectively. Conclusions: ART was shown to improve OS in all studies and in those selected for their reliable comparability.

Purpose Emerging data suggest that higher radiation doses in post-mastectomy radiotherapy may be associated with an increased risk of reconstruction complications. This study aimed to validate previous findings regarding the impact of radiation dose on complications among women with breast cancer using a multi-center dataset. Methods Fifteen institutions participated, and women with breast cancer who received radiotherapy after either autologous or prosthetic breast reconstruction were included. The primary endpoint was major post-radiation therapy complications requiring re-operation for explantation, flap failure, or bleeding control. Results In total, 314 patients were included. Radiotherapy was performed using both conventional fractionation and hypofractionation in various schedules. The range of the radiation therapy dose in Equivalent Dose in 2 Gy fractions (EQD2; α/β = 3.5) varied from 43.4 to 71.0 Gy (median dose: 48.6 Gy). Boost radiation therapy was administered to 49 patients. Major post-radiation therapy complications were observed in 24 (7.6%) patients. In multivariate analysis, an increasing EQD2 per Gy (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.26–1.98; p, Highlights • Radiation dose is associated with the risk of breast reconstruction complications. • We conducted a retrospective multi-center observational study of 314 women in Korea. • Complication-related risk factors were identified using multivariate analysis. • Use of hypofractionated radiation therapy may improve breast reconstruction outcomes. • A prospective multi-center study is under way to further validate our findings.

Purpose The details of breast reconstruction and radiation therapy (RT) vary between institutions; therefore, we sought to investigate the practice patterns of radiation oncologists who specialize in breast cancer. Materials and methods We identified the practice patterns and inter-hospital variations from a multi-center cohort of women with breast cancer who underwent post-mastectomy RT (PMRT) to the reconstructed breast at 16 institutions between 2015 and 2016. The institutions were requested to contour the target volume and produce RT plans for one representative case with five different clinical scenarios and answer questionnaires which elicited infrastructural information. We assessed the inter-institutional variations in RT in terms of the target, normal organ delineation, and dose-volume histograms. Results Three hundred fourteen patients were included; 99% of them underwent immediate reconstruction. The most irradiated material was tissue expander (36.9%) followed by transverse rectus abdominis musculocutaneous flap (23.9%) and silicone implant (12.1%). In prosthetic-based reconstruction with tissue expander, most patients received PMRT following partial deflation. Conventional fractionation and hypofractionation RT were used in 66.6% and 33.4% patients, respectively (commonest: 40.05 Gy in 15 fractions [17.5%]). Furthermore, 15.6% of the patients received boost RT and 53.5% were treated with bolus. Overall, 15 physicians responded to the questionnaires and six submitted their contours and RT plans. There was a significant variability in target delineations and RT plans between physicians, and between clinical scenarios. Conclusion Adjuvant RT following post-mastectomy reconstruction has become a common practice in Korea. The details vary significantly between institutions, which highlights an urgent need for standard protocol in this clinical setting.

External beam radiation therapy (EBRT) and surgery are local treatment modalities for patients with hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT). This meta-analysis aims to evaluate the effectiveness and feasibility of these treatment modalities.PubMed, Medline, Embase, and Cochrane Library databases were systematically searched until April 2021. The primary endpoint was overall survival (OS) of the patients; the adverse effects of the treatment were also investigated.A total of 59 studies involving 9525 patients with HCC and PVT were included in this meta-analysis. All studies were non-randomized series, including seven comparative studies, and the remainder were single-arm studies or studies with comparative groups other than surgery or EBRT. The pooled rates of Child-Pugh class A were 74.6% and 95.3% in the EBRT and surgery arms, respectively, and the pooled main PVT rates were 40.7% and 15.5% in the EBRT and surgery arms, respectively (p 0.001). Pooled 1- and 2-year OS rates of the EBRT arm were 44.1% (95% CI:40.3-48.0) and 21.7% (95% CI:18.9-24.8), respectively. In the subgroup of EBRT studies without main PVT, pooled 1- and 2-year OS rates were 59.9% (95% CI:48.9-70.1) and 30.5% (95% CI:15.2-51.8), respectively. In the surgery arm, the correlation rates were 62.8% (95% CI:55.0-70.0) and 42.5% (95% CI:34.4-51.0), respectively. The pooled 1-, and 2-year OS rates of surgery arm were significantly higher than those of EBRT arm (ps 0.001), and not significantly different with the EBRT subgroup without main PVT (p = 0.762, 0.353, respectively). In studies of surgery accompanied by EBRT, the 1- and 2-year OS rates were 77.1% (95% CI:69.6-83.2) and 45.4% (95% CI:19.8-73.7), respectively. The pooled rates of grade≥3 toxicities ranged from 1.8 to 4.3%, depending on the type.Surgery can yield a favorable survival outcome, whereas EBRT can be widely considered for patients, including those with inferior clinical profiles. Further studies are warranted to determine the possibility of improving the clinical outcomes of surgery accompanied by EBRT.

PurposeExternal beam radiotherapy (EBRT) has been commonly applied as salvage or a combination locoregional modality after transarterial chemoembolization (TACE) for hepatocellular carcinomas (HCCs). This study reports oncologic outcomes and feasibility after application of the two modalities in our center.MethodsForty consecutive patients who underwent EBRT due to incomplete responses of TACE were evaluated. Fourteen patients (35.0%) received stereotactic body radiotherapy (SBRT) and the remaining patients received conventionally fractionated radiotherapy (RT). A majority of patients who underwent SBRT received doses of 27 to 48 Gy in 3–4 fractions (median *EQD2: 57.0 Gy). Conventionally fractionated RT was performed with a median EQD2 of 47.8 Gy.ResultsThe median follow-up duration was 14.4 months (range: 2.6–83.0 months). A majority (77.5%) of patients were regarded as having Child-Pugh grade A. The median tumor size was 3.4 cm (range: 0.8–20.1 cm). Ten patients (25.0%) had thrombosis at a main portal branch. The 1- and 2-year overall survival (OS) and progression-free survival (PFS) rates were 82.2% and 42.1% and 55.8% and 32.1%, respectively. The local control rates were 89.1% and 89.1% at 1 and 2 years, respectively. The albumin level was a significant factor affecting OS (p = 0.002), and the BCLC stage significantly affected PFS (p = 0.001). Intrahepatic, out-of-field recurrence was the main cause of disease progression (60.0%), and distant metastasis developed in 12 patients (30.0%) during follow-up. Non-classic radiation-induced liver disease was seen in five (12.5%) patients, and two (5%) patients experienced grade ≥ 3 hepatic toxicities.ConclusionsEBRT after incomplete TACE was feasible and yielded favorable oncologic outcomes. However, disease progression related to intrahepatic failure remained a hindrance.*EQD2: Equivalent dose in 2 Gy per fraction radiotherapy

We investigated the relationship of physical activity with dietary habits and quality of life (QoL) in breast cancer survivors in accordance with the recommendations of the American Cancer Society. Data of 928 breast cancer survivors were obtained from the KROG 14-09 study to measure QoL in early phase after adjuvant radiotherapy. According to the extent of physical activity, survivors were divided into four groups: inactivity (0–149 min/week, N = 144), regular activity (150–450 min/week, N = 309), moderate activity (451–900 min/week, N = 229), and marked activity (901–1800 min/week, N = 164) excluding hyperactivity (> 1800 min/week, N = 82) as it is a difficult condition to recommend to survivors. Global physical activity questionnaire, 5-dimensional questionnaire by EuroQoL (EQ-5D-3L), QoL Questionnaire–breast cancer (QLQ-BR23) from EORTC, and dietary habits were surveyed. A linear-to-linear association test for EQ-5D-3L and Kruskal–Wallis analysis for QLQ-BR23 and dietary habit were conducted. Overall, 15.5% respondents (144/928) were classified as physically inactive. The trends of frequent intake of fruits (p = 0.001) and vegetable (p = 0.005) and reluctance toward fatty food (p

Government healthcare expenditure is rising in Korea, and the costs incurred by patients in Korea exceed those incurred by patients in other Organization for Economic Co-operation and Development countries. Despite the increasing health expenditure, patient demand for services is increasing as well, so it is now becoming recognized that cancer care needs to be balanced. The most important measure in cancer care optimization is to provide high-quality care while keeping costs sustainable. The Korean Cancer Association considers the current situation of cancer therapy in Korea the foremost issue, which has led to the implementation of the nationwide ‘Right Decisions in Cancer Care’ initiative. This initiative is based on the concepts of medical professionalism in that it should be led by physicians working in the field of oncology, that education should be offered to patients and clinicians, and that it should influence healthcare policy. In this article, we introduce the nationwide ‘Right Decision in Cancer Care’ initiative and highlight the five initial items on its agenda. The agenda is open to expansion and update as the medical environment evolves and additional clinical evidence becomes available.

BACKGROUND To summarize outcomes of reirradiation with intensity-modulated radiotherapy (IMRT) for recurrent or secondary head and neck cancer (HNC). METHODS Primary endpoints were 2-year local control (LC) and overall survival (OS). Studies involving only recurrent nasopharyngeal patients with cancer were excluded. RESULTS A total of 17 studies involving 1635 patients were included. Fourteen (82%) of those were retrospective, and 15 (88%) were from single institution. Reirradiation with IMRT produced pooled 2-year LC and OS rates of 52% (95% confidence interval [CI], 46%-57%) and 46% (95% CI, 41%-50%), respectively. In subgroup analyses, the rate of salvage surgery (

Introduction Radiofrequency ablation (RFA) is a standard ablative modality for small liver malignancies. Stereotactic body radiotherapy (SBRT) has emerged although yet suffers a lack of high-level evidence. We performed meta-analyses and a systematic review to integrate the literature and help in clinical decision-making. Methods Systemic searches were performed of the PubMed, Medline, and EMBASE databases to identify controlled studies comparing RFA and SBRT. Results Eleven studies involving 2238 patients were included. Among them, eight studies were for treating early hepatocellular carcinomas (HCCs) and three for liver metastases. Including HCCs and liver metastases studies, the pooled two-year local control (LC) rate was higher in the SBRT arm (83.8%, 95% confidence interval [CI]: 77.6–88.4) than that in the RFA arm (71.8%, 95% CI: 61.5–80.2) (p = 0.024). Among studies on liver metastases, the pooled two-year LC rate was higher in the SBRT arm (83.6% vs. 60.0%, p Conclusion LC was equivalent between RFA and SBRT for HCC and better for SBRT for the treatment of liver metastases. RFA was associated with better OS for HCC, but discrepancy between LC and OS requires further investigation, as they are local modalities having comparable efficacy.

The etiology and disease patterns of hepatocellular carcinoma (HCC) significantly vary among regions. Modern standard treatments commonly require multidisciplinary approaches, including applications of up-to date medicine and advanced procedures, and necessitate the support of socioeconomic systems. For these reasons, a number of clinical guidelines for HCC from different associations and regions have been presented. External beam radiation therapy was contraindicated for HCC until a few decades ago, but with the development of new technologies, its application has rapidly increased as selective irradiation for tumorous lesions became possible. Most of the guidelines had been opposed or indifferent to radiotherapy in the past, but several guidelines have introduced indications and recommendations for radiotherapy in their updated versions. This review will discuss the characteristics of important guidelines and their contents regarding radiotherapy and will also provide guidance to physicians who are considering applications of locoregional modalities that include radiotherapy.

Background & purpose: The benefits of adjuvant radiotherapy (ART) in gallbladder cancer (GBC) treatment remain inconclusive owing to the rarity of GBC and lack of randomized studies.Methods: PubMed, Medline, Embase, and Cochrane Library were systematically searched until March 2021. The primary endpoint was overall survival (OS). Comparative clinical studies that reported survival outcomes in GBC patients treated with or without ART were included. The comparability of each study was assessed by considering all possible clinical indicators (group 2: ART arm with poor clinical profile; group 1: ART arm with statistically similar profile or no evidence of having inferior clinical factors compared to non-ART arm).Results: Twenty-one studies involving 6876 GBC patients were reviewed. In pooled analyses of OS, the odds ratio (OR) was 1.26 ( p =0.111). In subgroup analyses considering comparability, the OR significantly favored the ART arm (1.92, p =0.008) among comparability group 1 studies, whereas it was 1.03 ( p =0.865) in comparability group 2 studies. The pooled rate of 5-yr OS in the ART vs. non-ART arms was 44.9% vs. 20.9% in group 1 and 34.1% vs. 40.0% in group 2. With ART, significant reduction in locoregional recurrence (OR: 0.21, p =0.001) but not in distant metastasis (OR: 1.32, p =0.332) was noted.Conclusion: ART not only showed benefits in patients with a similar clinical profile to those treated without ART but also yielded comparable survival in patients with an inferior clinical profile. Our results strongly support the more active application of ART in GBC treatment.Protocol registration: This study is registered in PROSPERO (CRD4202124062, available at: https://www.crd.york.ac.uk/).

External beam radiation therapy (EBRT) is commonly used as a palliative treatment for bone metastases of hepatocellular carcinoma (HCC). We planned a hybrid systematic review that meta-analyzed the efficacy and feasibility of EBRT and reviewed the literature to answer specific clinical questions. The PubMed, Medline, Embase, and Cochrane Library databases were searched through 1 December 2021. Primary endpoints were overall survival (OS) and response rate (RR). Secondary endpoints were comparative data, including treatment response and survival related to dose escalation, number of metastases, and fractionation scheme. Formal pooled analyses were performed on the primary endpoints, and the secondary endpoints were systematically reviewed. Complications were also reviewed. Nineteen studies involving 1613 patients with HCC and bone metastases were included. The median OS was 6 months (range: 3–13 months). The pooled one-year OS was 23.1% (95% confidence interval [CI]: 18.4–28.6); pooled pain RR was 81.5% (95% CI: 76.4–85.7) and of pain complete remission was 26.5% (95% CI: 21.7–32.0). Pain response might be related to dose escalation, considering the moderate consistency of results and plausibility, with a low-quality grade of evidence†. Considering the indeterminate results, we cannot suggest that dose escalation is correlated with OS. The oligometastasis status might be related to better OS, considering the high consistency of results and plausibility with low to moderate quality of evidence. Hypofractionated EBRT might yield comparable efficacy to conventional EBRT, with a low-quality grade of evidence. There were few complications of grade ≥3, except for hematologic complications, which ranged from 11.5to 34%. EBRT is an efficient and feasible palliative option. Clinical consideration of hematologic complications is necessary. Future studies are needed to increase the quality of evidence for actual clinical questions. †Reference to a system of the American Society for Radiation Oncology primary liver cancer clinical guidelines.

This study aimed to evaluate the oncologic outcomes according to disease burden in uterine cervical cancer patients with metachronous distant metastases.Between 2005 and 2015, 163 patients with metachronous distant metastases from uterine cervical cancer after receiving a definitive therapy were evaluated at seven institutions in Korea. Low metastatic burden was defined as less than 5 metastatic sites, whereas high metastatic burden was others. Each metastasis site was divided based on the lymph node (LN) and organs affected. The overall survival (OS) and progression-free survival (PFS) were assessed. Cox proportional hazards models, including other clinical variables, were used to evaluate the survival outcomes.The median follow-up duration was 22.2 months (range: 0.3-174.8 months). Para-aortic LNs (56.4%), lungs (26.4%), supraclavicular LNs (18.4%), and peritoneum (13.5%) were found to be the common metastasis sites. Among 37 patients with a single metastasis, 17 (45.9%) had LN metastases and 20 (54.1%) had organ metastases. The 1- and 2-year OS rates were 73.9% and 55.0%, respectively, whereas the PFS rates were 67.2% and 42.9%, respectively. SCC Ag after recurrence and high metastatic burden were significant factors affecting the OS (p=0.004 and p0.001, respectively). Distant organ recurrence, short disease-free interval (≤2 years), and high metastatic burden were unfavorable factors for PFS (p=0.003, p=0.011, and p=0.002, respectively).A favorable oncologic outcome can be expected by performing salvage treatments in selected patients with a long disease-free interval, low metastatic burden, and/or lymphatic-only metastasis.

Purpose There is limited data on radiotherapy (RT) for hepatocellular carcinoma (HCC) in patients with Child-Pugh classification B (CP-B). This study aimed to evaluate the treatment outcomes of fractionated conformal RT in HCC patients with CP-B. Materials and Methods We retrospectively reviewed the data of HCC patients with CP-B treated with RT between 2009 and 2014 at 13 institutions in Korea. HCC was diagnosed by the Korea guideline of 2009, and modern RT techniques were applied. Fraction size was ≤ 5 Gy and the biologically effective dose (BED) ≥ 40 Gy10 (α/β = 10 Gy). A total of 184 patients were included in this study. Results Initial CP score was seven in 62.0% of patients, eight in 31.0%, and nine in 7.0%. Portal vein tumor thrombosis was present in 66.3% of patients. The BED ranged from 40.4 to 89.6 Gy10 (median, 56.0 Gy10). After RT completion, 48.4% of patients underwent additional treatment. The median overall survival (OS) was 9.4 months. The local progression-free survival and OS rates at 1 year were 58.9% and 39.8%, respectively. In the multivariate analysis, non-classic radiation-induced liver disease (RILD) (p < 0.001) and additional treatment (p < 0.001) were the most significant prognostic factors of OS. Among 132 evaluable patients without progressive disease, 19.7% experienced non-classic RILD. Normal liver volume was the most predictive dosimetric parameter of non-classic RILD. Conclusion Fractionated conformal RT showed favorable OS with a moderate risk non-classic RILD. The individual radiotherapy for CP-B could be cautiously applied weighing the survival benefits and the RILD risks.

Hepatocellular carcinoma (HCC) involving the inferior vena cava (IVC) and/or right atrium (RA) is a rare and intractable disease. A standard treatment has not been established yet, owing to the rarity of disease and difficulties in the therapeutic treatment. Herein, we report the case of a patient who had recurrent HCC (after a prior lobectomy) involving both IVC and RA and underwent multimodality treatments including external beam radiotherapy and transarterial chemotherapy, followed by sorafenib treatment. The disease was well controlled with local treatments and sustained for 7 years until last follow-up after the systemic treatments. Our case shows a possibility of long-term survival for patients affected by HCC involving IVC and/ or RA, after a rigorous multimodality treatment strategy. (J Liver Cancer 2019;19:149-153)

Radiation toxicity grades must be reviewed based on existing knowledge-based clinical evidence or be assessed by referencing the clinical research literature to minimize radiation toxicity associated with radiotherapy. The aim of this study was to develop a radiation toxicity prediction system using metarule-guided mining of the clinical research literature to predict radiation pneumonitis and esophagitis in lung cancer patients. A semantic pattern database was built using 100 clinical research articles. Semantic patterns of prognostic factors and toxicity grades were extracted by metarule-guided mining. Feature analysis and correlation investigation of prognostic factors and toxicity grades were performed by using dendrogram and heatmap. A web-based user interface for the prediction system was designed. Patient prognostic factors were used in this prediction system to predict toxicity grade results. Radiation toxicity grades for patients with radiation pneumonitis and esophagitis were calculated through our prediction system. Age and chemotherapy were prognostic factors as were toxicity grades 1–3 and 5 based on the metarule-guided mining system. The odds ratios had similar trends to those in the existing meta-analysis literature. The radiation toxicity prediction system that we developed can potentially be used as a clinical decision support system for patient-specific radiation treatment after weighting of prognostic factors, performing a correlation analysis, and performing a validity evaluation.

Background The purpose of the study was to evaluate the efficacy and safety of stereotactic body radiotherapy (SBRT) for centrally located, primary non–small-cell lung cancer (NSCLC). Materials and Methods Systematic search of 4 databases (PubMed, MEDLINE, EMBASE, and Cochrane Library) was performed for literature published until May 9, 2018. Primary (overall survival [OS] and local control [LC] rates) and secondary (Grade ≥3 toxicity) endpoints were reported. Results Thirteen studies encompassing 599 patients with central NSCLCs were included. Median values of T1 tumor proportion, tumor size, and median survival were 55.3% (range, 0%-75%), 3.3 (range, 2.1-4.1) cm, and 26 (range, 14-68.9) months, respectively. Pooled rates of 1-, 2-, and 3-year OS rates were 84.3% (95% confidence interval [CI], 75.7-90.3), 64.0% (95% CI, 52.9-72.2), and 50.5% (95% CI, 39.4-61.5), respectively. Pooled rates of 1-, 2-, and 3-year LC rates were 89.4% (95% CI, 80.8-94.4), 82.2% (95% CI, 71.7-89.4), and 72.2% (95% CI, 55.0-84.7), respectively. Pooled rate of Grade ≥3 complication was 12.0% (95% CI, 7.3-19.0). Meta-regression analyses showed significant positive relationships between biologically equivalent dose using an α/β of 10 Gy in the linear quadratic model (BED10Gy) and 1- and 2-year LC rates (P Conclusion Our results suggests that SBRT is potent for tumor control in central NSCLC, although complications should be further minimized through optimization of dose-fractionation scheme and accurate planning. Using BED10Gy ≥100 Gy yielded higher LC rates, and dose escalation was related to OS, LC, and complications.

Purpose: Administration of stereotactic body radiation therapy (SBRT) to ultra-central (UC) lung tumors, generally defined as those abutting the proximal bronchial trees, is difficult due to concer...

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. (Gut Liver 2019;13:227-299)

Purpose Sorafenib is recommended as the standard treatment for hepatocellular carcinoma (HCC) of Barcelona Clinic of Liver Cancer stage C (BCLC C). However, local treatment including radiation therapy (LRT) is also widely administered in practice. The aim of our study was to define the role of LRT among BCLC C patients. Patients and methods Of the patients with HCC enrolled the Korean Central Cancer Registry from 2008 to 2014, the Korean Liver Cancer Study Group randomly extracted 10,580 patient data from ~50 hospitals nationwide. Among them, 3,401 patients were categorized to have BCLC C HCC. Among them, patients with information on initial treatments, defined as the first and secondary treatment within 60 days after the first treatment, were selected and classified into three initial treatment groups: LRT, sorafenib, and no treatment. Results Among 3,401 BCLC C HCC patients, 1,486 were included in the study and the remaining patients were excluded as they did not meet the criteria (eg, underwent local treatments without radiotherapy [RT] or received chemotherapy other than sorafenib). Of these, 266 were assigned to LRT (17.9%), 316 to sorafenib (21.3%), and 904 to no treatment group (60.8%). Median survival time of the sorafenib group was shorter than that of the LRT group (3.8 vs 7.6 months, P

Purpose Breast radiotherapy set-up is often uncertain. Actual dose distribution to normal tissues could be different from planned dose distribution. The objective of this study was to investigate such difference in dose distribution according to the extent of set-up error in breast radiotherapy. Materials and methods A total of 50 Gy with fraction size of 2 Gy was given to 30 left breasts with different set-ups applying a deep inspiration breath holding (DIBH) or a free breathing (FB) technique. Under the assumption that errors might come from translational axes of deep or caudal directions, the isocenter was shifted from the original tangential alignment every 2.5 mm to simulate uncertainty of deep and caudal tangential set-up in DIBH and FB. Changes were evaluated for dosimetric parameters for the heart, the left ventricle (LV), the left anterior descending coronary artery (LAD), and the ipsilateral lung. Results On the original plan, mean doses of heart and ipsilateral lung were 2.0 ± 1.1 Gy and 3.7 ± 1.4 Gy in DIBH and 8.4 ± 1.3 Gy and 7.8 ± 1.5 Gy in FB, respectively. The change of dose distribution for the heart in DIBH was milder than that in FB. The deeper the tangential set-up, the worse the heart, LV, LAD, and ipsilateral lung doses, showing as much as 49.4%, 56.4%, 90.3%, and 26.1% shifts, respectively, in 5 mm DIBH setup. The caudal set-up did not show significant dose difference. In multiple comparison of DIBH, differences of mean dose occurred in all 7.5 mm deep set-ups for the heart (p = 0.025), the LV (p = 0.049), and LAD (p = 0.025) in DIBH. Conclusions To correct set-up error over indicated limitation for deep tangential set-up in DIBH at 5 mm action level, mean heart and ipsilateral lung doses are expected to increase approximately 50% and 25%, respectively.

Background This study was to assess the rate of radiotherapy (RT) utilization according to the modality in South Korea to identify the implications of contemporary RT patterns. Methods We collected information from claims and reimbursement records of the National Health Insurance Service from 2010 to 2019. We classified the location of each institution as capital (Seoul, Incheon, and Gyeonggi-do) and non-capital areas. Results The rate of RT utilization in total cancer patients nationwide was 24.5% in 2010, which consistently has increased to 36.1% in 2019 (annual increase estimate [AIE], 4.5%). There was an abrupt increase in patients receiving intensity-modulated RT (IMRT), with an AIE of 33.5%, and a steady decline in patients receiving three-dimensional conformal RT (3DCRT), with an AIE of −7.1%. The commonest RT modality was IMRT (44.5%), followed by 3DCRT and stereotactic RT (SRT) (37.2% and 13.5%) in 2019. An increasing trend of advanced RT (such as IMRT and SRT) utilization was observed regardless of the region, although the AIE in the capital areas was slightly higher than that in non-capital areas. Conclusion The utilization of overall RT application and especially of advanced modalities remarkably increased from 2010 to 2019. We also found gaps in their AIEs between capital and non-capital areas. We should ensure that advanced RT is accessible to all cancer patients across South Korea., Graphical Abstract

PurposeAs the treatment efficacy of systemic therapy for patients with advanced-stage HCC is insufficient, locoregional therapies are performed in the clinical practice. We investigated the efficacy and safety of two most potent therapies, surgery and external beam radiotherapy (EBRT), in patients with HCC involving the IVC and/or right atrium (RA) through comparative meta-analysis.MethodA systematic search of Pubmed, MEDLINE, EMBASE, and the Cochrane library was performed for entries up to July 2020. The primary endpoints were 1- and 2-year overall survival (OS) rates, while secondary endpoints were response rate, local control rate, and grade ≥3 toxicities.ResultsEighteen studies with 22 cohorts were included, encompassing 755 patients. The pooled median OS and 1-and 2-year OS rates were 14.2 months, 55.6%, and 27.4%, respectively. The pooled median OS in the surgery and EBRT arms were 15.3 and 11.7 months, respectively. The pooled 1-year OS rate of the surgery arm was significantly higher than that of the EBRT arm (62.4%, 95% CI: 53.8–70.3 vs. 48.8%, 95% CI: 40.9–56.8; p=0.023). However, the 2-year OS rates were comparable (26.9%, 95% CI: 20.7–34.2 vs. 27.5%, 95% CI: 19.7–37.1; p=0.913). The pooled response and local control rates in the EBRT arm were 74.3% and 87.2%, respectively. In the surgical arm, the perioperative mortality and grade ≥3 complication rates were 0–7.6% and 3.9–67%, respectively. Grade ≥3 complications and radiation-induced liver disease were rarely observed in the EBRT arm.ConclusionsBoth surgery and EBRT are effective treatment options for patients with HCC involving IVC/RA invasion. Outcomes and safety should be further evaluated in well-controlled clinical trials.

BACKGROUND: Ultracentral (UC) tumors, a subset of central lung tumors defined as those that abut the proximal bronchial tree (PBT), have been contraindicated for stereotactic body radiotherapy (SBRT). The present meta-analysis evaluated the efficacy of SBRT for UC and central tumors, and dose-response for local control (LC) of UC tumors. METHODS: Databases including MEDLINE and EMBASE were searched up to March, 2020, to identify studies regarding SBRT for UC and/or central tumors. The primary endpoints were LC and overall survival (OS), while secondary endpoints were grade ≥3 and 5 complications. RESULTS: Fourteen studies including 892 patients were included. In the UC and central tumor groups, the 1-year OS rates were 82.2% and 85.4% (P=0.556), respectively, and the 2-year OS rates were 66.4% and 71.9% (P=0.522), respectively. The 1- and 2-year LC rates in the UC and central tumor groups were 93.9% and 97.8% (P=0.023) and 90.4% and 93.7% (P=0.459), respectively. The pooled grade ≥3 complication rates in the UC and central tumor groups were 9.0% and 4.4% (P=0.06), while the corresponding grade 5 complication rates were 5.7% and 2.1% (P=0.087). The dose-response for LC was shown in the meta-regression (P

Our study aimed to evaluate the benefits of chemoradiotherapy (CRT) after D2 gastrectomy, as compared to adjuvant chemotherapy, alone. PubMed, MEDLINE, Embase, and the Cochrane Library were systematically searched. We applied stepwise analyses that enabled the evaluation of data from randomized controlled trials (RCTs), balanced studies, and all studies separately and in a hierarchical manner. Thirteen controlled studies, including six RCTs involving 2603 patients, were included. Overall pooled analysis revealed a disease-free survival benefit of CRT (odds ratio (OR): 1.264, p = 0.053), which was more evident in the subgroup analysis of RCTs (OR: 1.440, p = 0.006) and balanced studies (OR: 1.417, p &lt, 0.001). Overall survival was insignificantly different in the overall pooled analysis (OR: 1.124, p = 0.347). However, the difference was marginally significant in the subgroup analysis of balanced studies (OR: 1.279, p = 0.055) and significant in the subgroup analysis of studies involving stage &ge, III patients only (OR: 1.663, p = 0.005). Locoregional recurrence (LRR) reduction was noted in the overall pooled analysis (OR: 0.559, p = 0.012, pooled rate: 11.3% vs. 18.1%) and was more robust in the subgroup analyses. Grade &ge, 3 leukopenia was higher in the CRT arm (OR: 1.387, p = 0.004, pooled rate: 26.4% vs. 15.7%). CRT after D2 gastrectomy should be applied for patients with high risk of LRR (e.g., stage &ge, III), along with efforts to reduce leukopenia.