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 125 I 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.

This study aimed to analyze the clinical results of radiotherapy for cervical cancer using two-dimensional (2D) intracavitary brachytherapy (ICBT) and computed tomography (CT)-based image-guided brachytherapy (IGBT) at our institution. Patients with stage IB-IVA cervical cancer who received ICBT between April 2008 and April 2014 were included in this study. In total 58 patients were assessed. The first 38 patients received ICBT with the 2D treatment plan (the 2D group), and the remaining 20 patients received CT-based IGBT (the IGBT group). The dose of point A tended to be lower in the IGBT group (mean value, 60.6 Gy vs. 62.5 Gy; p=.07), though the minimum dose to the 90% (D90) of the clinical target volume (CTV) was equivalent in both groups (mean value, 66.0 Gy vs. 66.2 Gy; p=.91). The rectum minimum dose to 2 cc (D2cc) was significantly lower in the IGBT group than in the 2D group (mean value, 61.2 Gy vs. 69.1 Gy; p=.001). With a median follow-up time of 60 months, the 5-year local control rates (LCRs) of the IGBT group and 2D group were 100% and 83%, respectively (p=.12). The 5-year incidence of rectal complications in the IGBT group and the 2D group were 11% and 29%, respectively (p=.26). Our study showed favorable LCR and preferred incidence of rectal complications in patients treated with CT-based IGBT.

PurposeTo identify predictive factors for local control of locally advanced esophageal cancer by chemoradiotherapy, the relationship between clinical features, including macroscopic tumor type, and treatment outcome was analyzed in 83 patients.Materials and methodsMacroscopic tumor type was defined by endoscopy as follows: type 1: protruding type; type 2: ulcerative and localized type; type 3: ulcerative and infiltrative type; type 4: diffusely infiltrative type; and type 5: unclassifiable type. We analyzed the overall survival, cause-specific survival, local progression-free rate, and predictive factors for locally advanced esophageal cancer after chemoradiotherapy.ResultsThe median follow-up period at the time of evaluation was 59months among survivors. The 5-year overall survival, cause-specific survival, and local progression-free rates for type 1 and other types were 37.0% and 23.3% (P=0.4255), 71.8% and 30.3% (P=0.0325), and 100% and 63.3% (P=0.0246), respectively. Macroscopic tumor type (type 1) was the most significant predictive factor of cause-specific survival and local progression-free rates.ConclusionsMacroscopic tumor type 1 was the significant favorable predictive factor for local control. The study results suggested that the macroscopic tumor type was useful in predicting tumor responses.

A 69-year-old man with stage IIIB lung adenocarcinoma received durvalumab following chemoradiotherapy. The prescribed dose was 50Gy in 2Gy fractions, and the maximum spinal cord dose was 40Gy. After three cycles of durvalumab, he experienced bladder and rectal disturbance, muscle weakness in the lower limbs, and sensory loss in the lower body. Magnetic resonance imaging revealed T2 signal hyperintensity involving the thoracic spinal cord. As the thoracic spinal cord with T2 signal hyperintensity matched with the irradiated site, the patient was diagnosed with radiation myelitis. This case report shows the clinical and radiographic features of a case of locally advanced non-small cell lung cancer that demonstrated radiation myelitis following durvalumab administration. The time of onset was very early and the influence of durvalumab was suspected as the cause of myelitis.

We aimed to demonstrate a single institution experience of treatment of pancreatic ductal carcinoma and to identify the role of radiation therapy. We assessed all patients who were diagnosed with pancreatic ductal carcinoma from January 2011 to December 2017. A total of 342 patients were enrolled. Thirteen, 131, 36, and 162 patients had stage I, II, III, and IV disease, respectively (UICC TNM, 7th edition). Among the patients with stages I-III disease, 94 underwent surgery, and the median overall survival (OS) was 33 months. Of patients with stages I-III disease who were not suitable for surgery, 58 patients received chemotherapy, and the median OS was 12 months. Among them, 17 patients received chemoradiotherapy added on chemotherapy and their OS was significantly better than that of patients who received chemotherapy alone. Of patients with stage IV disease, 111 received chemotherapy, and the median OS was 6 months. This study evaluated the demand, role, and outcome of each treatment modality and demonstrated a single institution experience of treatment of pancreatic ductal carcinoma. The demand and role of radiation therapy remained small; however, radiation therapy might have some importance as a local treatment.

Radiation recall is regarded as an acute inflammatory reaction that is triggered by cytotoxic agents within a previously irradiated area, and the most common site is the skin. Gemcitabine-related radiation recall is rare, and most reported cases involving gemcitabine occur in the muscle, unlike those of other chemotherapeutic agents. Here, we report 2 cases of chemotherapy- induced radiation myositis. Combination chemotherapy with gemcitabine and S-1 was performed in both patients after radiation therapy. The irradiation dose to the muscle was quite low compared to the muscle tolerance dose in both cases. To the best of our knowledge, there are no reports on radiation recall with S-1. Therefore, it is unclear whether S-1 is related to myositis in these cases. Although radiation recall with gemcitabine is rare and uncommon, it has the potential to occur in any organ in forms such as myositis or central nervous system necrosis, and careful observation is required for patients who received chemotherapy that includes gemcitabine after radiation therapy.

The aim of this study was to analyse the clinical features of prostate-specific antigen (PSA) bounce and the difference between biochemical failure and large-magnitude PSA bounce. The cases of 352 patients with prostate cancer who underwent brachytherapy were analysed. PSA bounce was defined as an increase in PSA of ≥0.2 ng/ml above an initial PSA nadir, with subsequent decline to or below that initial nadir without treatment. PSA bounce +2 was defined as an increase in PSA of ≥2.0 ng/ml above the nadir with subsequent decline to or below that initial nadir without treatment. We analysed the rates, time to onset, and predictive factors for PSA bounce and PSA bounce +2. The median follow-up period at the time of evaluation was 82 months. One hundred and seventeen patients had PSA bounce; of them, 10 had PSA bounce +2. Biochemical failure occurred in 29 patients. The median times to onset of PSA bounce, PSA bounce +2, and biochemical failure were 20, 17.5 and 51 months, respectively. Younger age at implant and larger prostate volume were significant predictive factors for PSA bounce. Age was a significant factor for PSA bounce +2, and PSA bounce +2 patients were significantly younger than biochemical failure patients. The maximum duration from the date of PSA bounce +2 to the date when PSA level decreased was 12 months. Age at implant, time to onset, and 1-year follow-up after an increase in PSA level of ≥2 ng/ml above nadir level are useful for distinguishing between biochemical failure and PSA bounce +2.

Recently, the diagnosis-specific graded prognostic assessment (DS-GPA) score was adopted to evaluate the prognosis of patients with brain metastasis (BM). DS-GPA for lung cancer (LC) patients includes age, the Karnofsky Performance Status score, number of brain metastases, and the presence of extra-cranial metastases. According to the original report on DS-GPA, the median survival time (MST) was only 3 months for a DS-GPA score of 0-1. Although optimal treatment strategies for patients with good prognosis are well discussed, reports on treatment regimens for patients with poor prognosis are sparse. The purpose of this study was to assess whether other factors affect the survival of LC patients with BM regarded as poor prognosis (DS-GPA, 0-1) who received whole-brain radiotherapy (WBRT). We retrospectively evaluated 123 LC patients with BM who received WBRT at 2 institutions between 2008 and 2015. Patients who underwent craniotomy or stereotactic radiotherapy before WBRT were excluded. Ninety eight patients received only WBRT and 25 received boost irradiation to tumor site after WBRT. The prescribed dose of WBRT was 30–37.5 Gy in 10–15 fractions. Median dose of boost irradiation was 10 Gy in 4 fractions. The evaluated prognostic factors for overall survival (OS) included sex, histology, epidermal growth factor receptor (EGFR) mutation status, previous cytotoxic chemotherapy, previous EGFR-tyrosine kinase inhibitor treatment, size of the maximum lesion, and DS-GPA score (0, 0.5, 1). The Kaplan–Meier method was used to generate survival curves, and the log-rank test was used for statistical comparisons. All factors with a P < 0.05 in univariate analysis were entered into multivariate analysis using the Cox regression model and a confidence interval of 95%. The MST was 6.3 months for all patients. Univariate analysis showed that histology (P=0.007), EGFR mutation status (P=0.03), previous cytotoxic chemotherapy (P=0.003), and DS-GPA score (P < 0.001) were significant prognostic factors for OS. Histology and GPA-score were found to be significant prognostic factors for OS in multivariate analysis, with P = 0.017 and P < 0.0001, respectively. The MST of patients with adenocarcinoma (n=67), small cell carcinoma (n=35), and the others (n=21) were 9.7 months, 5.9 months, and 3.0 months, respectively (p=0.007). Histology affects survival among poor prognosis LC patients with BM and should be considered in addition to DS-GPA to determine a treatment strategy for them.

The purpose of this study was to analyze the clinical results of concurrent chemoradiotherapy (CCRT) with volumetric modulated arc therapy (VMAT) for nasopharyngeal carcinoma (NPC) patients.

Although chemoradiotherapy (CRT) is widely used as a curative treatment for esophageal cancer (EC), little is known about safety and efficacy for elderly patients. The aim of this study is to investigate the long-term results of definitive CRT for elderly patients, here we defined older than 70 years old, with EC. We retrospectively analyzed 133 EC patients treated with definitive CRT at two institutions between 2008 and 2012. There were 50 elderly (median 76, range, 70-85) and 83 nonelderly (median 63, range, 41-69) patients. One patient had adenocarcinoma and 132 patients had squamous cell carcinoma. Clinical stages I/II/III/IV were 7/7/28/8 patients in the elderly and 14/16/33/20 patients in the nonelderly (UICC 6th). Radiotherapy (RT) was administered to a total dose of 50-70 Gy/25-35 fractions (median 60 Gy/30 fractions) with elective nodal irradiation of 40 Gy/20 fractions. The standard chemotherapeutic regimen consisted of two cycles of CDDP 70mg/m2 as the intravenous infusion and 5FU 700mg/m2 as the continuous infusion on 4 days of each cycle during RT. The Kaplan–Meier method was used to generate actual survival curves. The chi-square test was used for statistical comparisons. The median follow-up for survivors was 61 months (range, 8-103 months). Planned RT was accomplished in 48 elderly (96%) and 81 nonelderly (98%) patients (p=0.60). One nonelderly patient discontinued RT because of bleeding from tumor. Two elderly and 1 nonelderly patients interrupted RT more than one week because of toxicities. Only 26 patients (52%) was able to complete standard chemo regimen in the elderly, whereas 65 patients (78%) completed standard chemo regimen in the nonelderly (p<0.01). Complete response (CR) rate was 56% in the elderly and 57% in the nonelderly. The 5-year overall survival rate (OS) was 38% in the elderly and 45% in the nonelderly. There was no significant difference in CR rate and OS according to age and chemotherapeutic dose. Acute toxicities ≥grade 3 were observed in 30 elderly (60%) and in 50 nonelderly patients (60%) (p=0.98). Most common ≥grade 3 toxicity was hematologic toxicity in both groups. Late toxicities ≥grade 3 were observed in 8 elderly (16%) and in 8 nonelderly patients (10%) (p=0.27). Grade 5 toxicity was observed in 4 elderly (interstitial pneumonia in 2 and heart failure in 2 patients) and one nonelderly (esophagobronchial fistula) (p=0.04). Almost all elderly patients were able to complete planned RT. However, standard CDDP/5FU regimen was accomplished in only half of the elderly patients. In addition, elderly patients are more likely to suffer grade 5 toxicities compared to nonelderly. We considered that optimal radiation field and chemotherapeutic regimen should be investigated in case of elderly patients.

Single-photon emission computed tomography/computed tomography (SPECT/CT) demonstrates the precise location of the sentinel lymph nodes (SLNs) in patients with breast cancer. We evaluated the relationship between SLNs and postoperative tangential fields by using SPECT/CT images. Subjects included 72 patients with early breast cancer who underwent SPECT/CT of the SLNs and received whole-breast irradiation with tangential fields after partial mastectomy. The SLN locations evaluated by using SPECT/CT images were entered into the treatment-planning CT image with a 5-mm-diameter sphere. A 15-mm-diameter sphere including the 5-mm treatment margin around the SLNs was defined as PTV-SLN. The PTV-SLN doses with tangential irradiation were evaluated and expressed as the percentage of the prescribed dose. In 69 patients, SLNs were detected by using SPECT/CT; 68 SLNs were located at axillary lymph node Level I, and one was located at Level II. A total of 62 SLNs (90%) were determined to be located inside the tangential fields on the digitally reconstructed radiography (DRR) images. The median doses of SLN center, mean PTV-SLN dose, and PTV-SLN D95 (the minimum dose delivered to 95% of the volume) were 94.1% (range, 15.3–101.9%), 93.7% (range, 29.3–104.0%) and 84.8% (range, 6.8–99.8%). The D95 for the SLNs with treatment margins were ≤90% of the prescribed doses in more than half of the cases. Modification of the individual treatment fields seemed to be necessary to ensure coverage of the SLNs in whole-breast irradiation.

Although chemoradiation therapy (CRT) is widely used as a curative treatment for esophageal cancer (EC), little is known about safety and efficacy for elderly patients. The aim of this study is to investigate the tolerability and outcome of definitive CRT for elderly patients, here we defined older than 70 years old, with EC. We retrospectively reviewed 134 EC patients treated with definitive CRT at two institutions between 2008 and 2012. There were 51 elderly (over 70 years old) and 83 nonelderly (under 69 years old) patients. One patient had adenocarcinoma and 133 patients had squamous cell carcinoma. Clinical stages I/II/III/IV were 7/7/29/8 patients in the elderly and 14/16/33/20 patients in the nonelderly (UICC 6th). Radiation therapy (RT) was administered to a total dose of 50-70 Gy/25-35 fractions (median 60 Gy/30 fractions) with elective nodal irradiation of 40 Gy/20 fractions. The standard chemotherapy regimen consisted of two cycles of CDDP 70mg/m2 as the intravenous infusion and 5FU 700mg/m2 as the continuous infusion on 4 days of each cycle during RT. The median follow-up for survivors was 27 months (range, 5-67 months). Planned RT was accomplished in 49 elderly (96%) and 81 nonelderly (98%) patients (p = 0.62). One nonelderly patient discontinued RT because of bleeding from tumor. Two elderly and 1 nonelderly patients interrupted RT more than one week because of toxicities. Only 26 patients (51%) was able to complete standard chemo regimen in the elderly, whereas 65 patients (78%) completed standard chemo regimen in the nonelderly (p<0.01). Complete response (CR) rate was 55% in the elderly and 57% in the nonelderly. The 2-year overall survival rate (OS) was 61% in the elderly and 67% in the nonelderly. There was no significant difference in CR rate and OS according to age and chemotherapeutic dose. In the patients with stage II/III except T4, there was also no significant difference in CR rate and OS between the elderly and nonelderly. Acute toxicities ≥grade 3 were observed 65% in the elderly and 61% in the nonelderly (p = 0.70). Most common ≥grade 3 toxicity was hematologic toxicity in both groups. Grade 5 toxicity was observed in two elderly patients who completed standard treatment regimen. Almost all elderly patients were able to complete planned RT. However, standard CDDP/5FU regimen was achieved in only half of the elderly patients. Chemotherapeutic dose did not affect CR rate and OS. These results suggest further investigation is required for optimal chemotherapy regimen in elderly patients.

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. (C) 2014 Elsevier Inc.

症例は75歳女性．腰痛を契機に近医においてCTを受け，肝腫瘍を指摘され当科を紹介された．肝機能はChildA（5点）と肝予備能は良好であり，非B非C例であり，非アルコール性脂肪性肝炎による肝硬変の可能性が考えられた．肝関連腫瘍マーカーはAFP 276 ng/ml，PIVKA-II 74 mAU/mlであった．腫瘍は肝細胞癌と診断されたが，門脈右枝，右肝静脈，中肝静脈，下大静脈に近接し囲まれるように存在していた．ラジオ波熱凝固療法（RFA）は危険であると判断し，外科切除は可能と判断されたものの，本人および家族が希望されなかった．そこで肝動脈化学塞栓術（TACE）を施行し，その後に定位放射線療法（SBRT）を施行する方針とした．TACE施行1カ月後にSBRT（45 Gy/5回）を施行した．その後，4年経過した現在も，肝画像診断反復にて再発徴候を認めず，肝関連腫瘍マーカーは陰性を維持している．

Methods: Twenty-one patients with MALT lymphoma of the ocular adnexa were treated with radiotherapy alone at a dose ranging from 30 to 54Gy. The disease arose from the conjunctiva in 15 patients (9 with bilateral involvement), and from the retrobulbar space in 6 patients (1 with bilateral involvement). Results: All patients with MALT lymphoma achieved a CR or unconfirmed CR (CRu). The 5-and 10-year overall survival rates of all patients with MALT lymphoma were 100% and 90%, respectively. The 5-and 10-year cause-specific survival rates were 100% and 100%, respectively. In all patients with delayed toxicity, the radiation dose was more than 40Gy. Conclusions: Excellent local control and survival can be achieved for patients with MALT lymphoma of the ocular adnexa using radiotherapy alone. ACTA MEDICA NAGASAKIENSIA 56: 49－52, 2011

A 79-year-old woman was found to have an abnormal shadow on chest radiography. Computed tomography demonstrated a pleural mass. The F-18 fluorodeoxyglucose positron emission tomography (FDG PET) was performed to determine whether the pleural mass was benign or malignant. The histologic examination of the resected mass showed a unilocular mesothelial cyst of the pleura. The FDG PET findings of a mesothelial cyst of the pleura have not yet been previously reported. The FDG PET findings of a mesothelial cyst in the pleura reflected the microscopic findings of the resected mass. The FDG PET findings, therefore, seem to be useful in the diagnosis of mesothelial cysts.