Kotaro Gomi

Hypofractionated Stereotactic Radiotherapy (HypoFXSRT) for Stage I Non-small Cell Lung Cancer: Updated Results of 257 Patients in a Japanese Multi-institutional Study

Introduction: Hypofractionated stereotactic radiotherapy (HypoFXSRT) has recently been used for the treatment of small lung tumors. We retrospectively analyzed the treatment outcome of HypoFXSRT for stage I non-small cell lung cancer (NSCLC) treated in a Japanese multi-institutional study. Methods: This is a retrospective study to review 257 patients with stage I NSCLC (median age, 74 years: 164 T1N0M0, 93 T2N0M0) were treated with HypoFXSRT alone at 14 institutions. Stereotactic three-dimensional treatment was performed using noncoplanar dynamic arcs or multiple static ports. A total dose of 18 to 75 Gy at the isocenter was administered in one to 22 fractions. The median calculated biological effective dose (BED) was 111 Gy (range, 57–180 Gy) based on α/β = 10. Results: During follow-up (median, 38 months), pulmonary complications of above grade 2 arose in 14 patients (5.4%). Local progression occurred in 36 patients (14.0%), and the local recurrence rate was 8.4% for a BED of 100 Gy or more compared with 42.9% for less than 100 Gy (p < 0.001). The 5-year overall survival rate of medically operable patients was 70.8% among those treated with a BED of 100 Gy or more compared with 30.2% among those treated with less than 100 Gy (p < 0.05). Conclusions: Although this is a retrospective study, HypoFXSRT with a BED of less than 180 Gy was almost safe for stage I NSCLC, and the local control and overall survival rates in 5 years with a BED of 100 Gy or more were superior to the reported results for conventional radiotherapy. For all treatment methods and schedules, the local control and survival rates were better with a BED of 100 Gy or more compared with less than 100 Gy. HypoFXSRT is feasible for curative treatment of patients with stage I NSCLC.

Late toxicity after definitive concurrent chemoradiotherapy for thoracic esophageal carcinoma.

PURPOSE To evaluate late cardiopulmonary toxicities after concurrent chemoradiotherapy (CCRT) for esophageal carcinomas. METHODS AND MATERIALS From February 2002 through April 2005, 74 patients with clinical Stage I-IVB carcinoma of the esophagus were treated with CCRT. Sixty-nine patients with thoracic squamous cell carcinoma were the core of this analysis. Patients received 60 Gy of radiation therapy in 30 fractions over 8 weeks, including a 2-week break, and received 2 cycles of fluorouracil/cisplatin chemotherapy concomitantly. Initial radiation fields included primary tumors, metastatic lymph nodes, and supraclavicular, mediastinal, and celiac nodes areas. Late toxicities were assessed with the late radiation morbidity scoring scheme of the Radiation Therapy Oncology Group/European Organiation for Research and Treatment of Cancer. RESULTS The median age was 67 years (range, 45-83 years). The median follow-up time was 26.1 months for all patients and 51.4 months for patients still alive at the time of analysis. Five cardiopulmonary toxic events of Grade 3 or greater were observed in 4 patients, Grade 5 heart failure and Grade 3 pericarditis in 1 patient, and Grade 3 myocardial infarction, Grade 3 radiation pneumonitis, and Grade 3 pleural effusion. The 2-year cumulative incidence of late cardiopulmonary toxicities of Grade 3 or greater for patients 75 years or older was 29% compared with 3% for younger patients (p = 0.005). CONCLUSION The CCRT used in this study with an extensive radiation field is acceptable for younger patients but is not tolerated by patients older than 75 years.

Treatment of thoracic esophageal carcinoma invading adjacent structures

T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor–node–metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down‐staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post‐CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy. (Cancer Sci 2007; 98: 937–942)

In Vivo Dosimetry of High-Dose-Rate Interstitial Brachytherapy in the Pelvic Region: Use of a Radiophotoluminescence Glass Dosimeter for Measurement of 1004 Points in 66 Patients With Pelvic Malignancy

PURPOSE To perform the largest in vivo dosimetry study for interstitial brachytherapy yet to be undertaken using a new radiophotoluminescence glass dosimeter (RPLGD) in patients with pelvic malignancy and to study the limits of contemporary planning software based on the results. PATIENTS AND METHODS Sixty-six patients with pelvic malignancy were treated with high-dose-rate interstitial brachytherapy, including prostate (n = 26), gynecological (n = 35), and miscellaneous (n = 5). Doses for a total of 1004 points were measured by RPLGDs and calculated with planning software in the following locations: rectum (n = 549), urethra (n = 415), vagina (n = 25), and perineum (n = 15). Compatibility (measured dose/calculated dose) was analyzed according to dosimeter location. RESULTS The compatibility for all dosimeters was 0.98 +/- 0.23, stratified by location: rectum, 0.99 +/- 0.20; urethra, 0.96 +/- 0.26; vagina, 0.91 +/- 0.08; and perineum, 1.25 +/- 0.32. CONCLUSIONS Deviations between measured and calculated doses for the rectum and urethra were greater than 20%, which is attributable to the independent movements of these organs and the applicators. Missing corrections for inhomogeneity are responsible for the 9% negative shift near the vaginal cylinder (specific gravity = 1.24), whereas neglect of transit dose contributes to the 25% positive shift in the perineal dose. Dose deviation of >20% for nontarget organs should be taken into account in the planning process. Further development of planning software and a real-time dosimetry system are necessary to use the current findings and to achieve adaptive dose delivery.

Preliminary Study of Correction of Original Metal Artifacts due to I-125 Seeds in Postimplant Dosimetry for Prostate Permanent Implant Brachytherapy

PurposeWe investigated a subtraction-based reprojection approach to reduce CT metal artifacts due to I-125 seeds and evaluated the clinical implications in postimplant dosimetry for prostate permanent implant brachytherapy.Materials and MethodsThe raw projection data were used to reduce metal artifacts due to I-125 seeds. CT images of the metal parts only were separated from the original CT images by setting the threshold for pixel value to that of the I-125 seeds. Using these images, sinograms of CT images with and without seeds were obtained by inverse Radon transform (iRT), and the sinogram of the metal image was subtracted from that of the original image. Finally, the image was reconstructed using the sinogram by Radon transform (RT). This technique was applied to a prostate phantom and to a patient undergoing prostate permanent implant brachytherapy.ResultsMetal artifacts from I-125 seeds were reduced in both the phantom and patient studies. This technique decreased the density of the inner region of seeds but enhanced the density of the seed edge, thereby facilitating the identification of seed number, orientation, and location.ConclusionThis method reduces metal artifacts from I-125 seeds, and has potential for decreasing the time required for and improving the accuracy of postimplant dosimetry.

Radiation therapy for esophageal cancer: results of the patterns of Care Study in Japan 1995–1997

PurposeTo report the characteristics and treatment process of esophageal cancer patients treated with radiation therapy (RT) in Japan.Methods and materialsThe Patterns of Care Study (PCS) in Japan was conducted in 78 facilities nationwide including 40 academic (A) and 38 nonacademic (B) institutions using the original two-stage cluster sampling. Detailed information was accumulated on patients with cancer in the thoracic esophagus in stage I, II, or III who had received RT between 1995 and 1997.ResultsOf a total of 776 patients, 479 were treated in A institutions and 297 in B institutions. Median age was 67 years; 85.0% were men and 14.3% were women. Patients in stage I disease were more frequently identified in A institutions than in B (18.8% vs. 13.4%; P = 0.001). More than 99% had squamous cell carcinoma by histology, and the main tumors were often located in the midthoracic esophagus (62.2% of all patients). Pretreatment diagnostic modalities such as esophagram, endoscopy, endoscopic ultrasound, and computed tomography were done equally in A and B institutions. Chemotherapy was used for 39.7% of the patients. RT was combined with esophagectomy in the pre- or postoperative setting for 26.8% of the patients. Median fractionation and total external RT dose were 2 Gy and 60 Gy, respectively. Brachytherapy was more frequently used in A institutions than in B (P = 0.001).ConclusionsThis PCS study revealed the background and process of RT for esophageal cancer in Japan and also revealed the differences of the characteristics of patients and treatment procedures among two types of institutions.

SU-FF-T-50: Reduction of Computed Tomography Metal Artifacts Due to I-125 Seeds for Post Implant Analysis in Prostate Permanent Brachytherapy

Purpose: Postimplant analysis in I‐125 permanent brachytherapy for prostate cancer plays important role in improving the techniques of implant. Although American Brachytherapy Society recommends CT based postimplant analysis, the identification of prostate bundle is quite difficult. In addition, metal artifacts from the I‐125 seeds implanted make it more difficult to identify the prostate. Thus accuracy of the dosimetric parameters associated with volume of prostate such as D90 and V100 may be unclear. The purpose of this study is to mitigate CT metal artifacts due to I‐125 seeds to provide more accurate postimplant analysis. Method and Materials: The prostate phantom that was implanted 3 to 10 seeds per a plane was scanned using 16‐detector raw CT. The sinogram was modified by our algorithm that is similar to projection‐interpolation method to CTimages containing artifacts from I‐125 seeds. The regions of projection data existing I‐125 seeds were identified by observing differences of X‐ray intensity between the phantom and the seeds. Then the regions were interpolated to remove the metal artifacts. The new images were reconstructed with the corrected sinogram. We compared these with the CTimages that are corrected by commercially available metal artifact reduction method. Results: The metal artifacts caused by a small number of I‐125 seeds were completely eliminated by our correcting method. On the other hand, the magnitude of the artifact with the commercially available method was insufficient. With regard to many seeds in the same plane, the metal artifact was mitigated by our method although the contrast of images was degraded. Conclusion: Our method would mitigate metal artifacts caused by I‐125 seeds and be helpful to identify prostate. Although some problems have still remained to improve, our approaches would be adapted to clinical field.