Kuei-Li Lin

The early result of whole pelvic radiotherapy and stereotactic body radiotherapy boost for high-risk localized prostate cancer

Purpose: The rationale for hypofractionated radiotherapy in the treatment of prostate cancer is based on the modern understanding of radiobiology and advances in stereotactic body radiotherapy (SBRT) techniques. Whole-pelvis irradiation combined with SBRT boost for high-risk prostate cancer might escalate biologically effective dose without increasing toxicity. Here, we report our 4-year results of SBRT boost for high-risk localized prostate cancer. Methods and Materials: From October 2009 to August 2012, 41 patients newly diagnosed, high-risk or very high-risk (NCCN definition) localized prostate cancer were treated with whole-pelvis irradiation and SBRT boost. The whole pelvis dose was 45 Gy (25 fractions of 1.8 Gy). The SBRT boost dose was 21 Gy (three fractions of 7 Gy). Ninety percent of these patients received hormone therapy. The toxicities of gastrointestinal (GI) and genitourinary (GU) tracts were scored by Common Toxicity Criteria Adverse Effect (CTCAE v3.0). Biochemical failure was defined by Phoenix definition. Results: Median follow-up was 42 months. Mean PSA before treatment was 44.18 ng/ml. Mean PSA level at 3, 6, 12, 18, and 24 months was 0.94, 0.44, 0.13, 0.12, and 0.05 ng/ml, respectively. The estimated 4-year biochemical failure-free survival was 91.9%. Three biochemical failures were observed. GI and GU tract toxicities were minimal. No grade 3 acute GU or GI toxicity was noted. During radiation therapy, 27% of the patient had grade 2 acute GU toxicity and 12% had grade 2 acute GI toxicity. At 3 months, most toxicity scores had returned to baseline. At the last follow-up, there was no grade 3 late GU or GI toxicity. Conclusions: Whole-pelvis irradiation combined with SBRT boost for high-risk localized prostate cancer is feasible with minimal toxicity and encouraging biochemical failure-free survival. Continued accrual and follow-up would be necessary to confirm the biochemical control rate and the toxicity profiles.

Primary Angiosarcoma of the Breast

We report on a 39 year old woman with a biopsy diagnosed angiosarcoma of the breast. Surgical treatment consisted of a modified radical mastectomy with axillary lymph node dissection (level I and II). The size of the tumor was 4.5 x 3.5 x 2.3 cm with G II grading. In addition the patient was put on postoperative chemotherapy (EC). Soft tissue sarcomas of the breast are very rare tumors (0.04 to < 1 % of all malignant breast tumors). The etiology of most of the vascular neoplasias of the breast is therapy associated such as preexisting surgery and radiotherapy. We found a primary angiosarcoma of the breast and tried to demonstrate aspects of the morphological diagnosis, prognosis and treatment of this disease.

Speculation of Intrafractional Motion Errors in Patients with Prostate Cancer during Pelvis RapidArc Radiotherapy

Purpose: To evaluate the intrafractional motion errors in patient with prostate cancer received pelvis irradiation during RapidArc radiotherapy.Materials and Methods: A total of eighteen high risk group prostate cancer patients were treated prostate and pelvis lymph nodes by RapidArc radiotherapy then boost dose by Cyberknife. All patients had kV cone beam computerized tomography (CBCT) scans in their first three fractions of treatment. During these treatments, the CBCT scans were registered to planning CT simulation images as reference to perform registration procedure based on soft tissue windows matched with clinical tumor volume (CTV). The errors of isocenter position were corrected by couch shifted. The second and third CBCT images were immediately acquired before and after RapidArc treatment. These errors of isocenter position on the left-right (LR), superior–inferior (SI) and anterior–posterior (AP) directions were analyzed retrospectively.Results: Under RapidArc technique with a shortened treatment delivery time (about 3 min), the residual systemic and random errors in pre and post-radiation treatment revealed limited. Based on the paired 2^(nd) and 3^(rd) CBCT images, the intrafractional errors (mean ± SD) in LR-SI-AP directions were -0.4 ± 0.8, -0.2 ± 1.0, 0.1 ± 0.8 mm. No intrafractional error differences in three axes, except borderline significant in LR direction (p= 0.046). Isotropic planning margins created with the linear addition of internal margin to clinical tumor volume was respectively 3.6, 4.4, 4.5 mm in LR-SI-AP axes and 2.5, 3.2, 3.3 mm if generated with quadrature addition.Conclusion: Use of the faster RapidArc technique with accurate kV CBCT images online verification for prostate cancer pelvis radiotherapy, the intrafractional motion errors were limited. These speculated intrafractional errors could be applied to improve the accuracy of radiation delivery and a smaller PTV margin might be adopted.

A Case Report: Urachal Adenocarcinoma

Urachal adenocarcinoma is an extremely rare neoplasm and usually associated with poor prognosis. We report a case of urachal adenocarcinoma in one 44-year-old woman. She presented painless hematuria. Cystoscopic examination and transurethral biopsy showed an urachal tumor. After undergoing laparoscopic partial cystectomy with lymph nodes dissection, the patient received postoperative radiation therapy. The clinical presentation, radiological, histopathological findings, treatment methods and correlated literature are discussed and reviewed here.

Lymphoepithelial Carcinoma of the Sublingual Gland Associated with EBV Infection: A Case Report

Purpose: Lymphoepithelial carcinoma (LEC) is a subtype of undifferentiated carcinoma, which is originated from squamous cell. Lymphoepithelial carcinoma is a rare tumor of the major salivary gland, especially in sublingual gland. In moat cases, LEC affected the parotid gland. There are high incidences in Greenlandic Eskimos and Southeastern Asians with strongly associated with Epstein-Barr virus infection. To our knowledge, there is no case of LEC in sublingual gland reported in the medical literature. Materials and Methods: We report the first case of LEC of the sublingual tumor of a 37-year-old Taiwanese man. The initial presentation was a mass over the submental area. PET/CT scan showed there was only a locoregional disease, which was limited in the left mouth floor and submental lymph node. Naopharynx was not involved at the same time. Serological studies showed elevated titer of Epstein-Barr virus: capsid antigen IgG and IgA antibodies. Immunohistochemical stain of LMP-1 also showed the positive result. The patient underwent excision and lymphodectomy followed by definite radiotherapy. Result: Complete remission of LEC of the sublingual gland was achieved by the definite radiotherpy. The patient remained alive without any recurrence or metastasis after 20-month of follow-up. Conclusion: LEC of the salivary gland is a radiosensitive disease and has a better prognosis among the undifferentiated carcinoma at the head and neck region. High rates of locoregional control were achieved by radiotherapy. Therefore, radiotherapy is appropriate locoregional therapy for patents in the early stage or after surgical intervention.

Radiotherapy for the Treatment of Giant Cell Tumor of the Spine: A Report of 3 Cases and Review of the Literature

Optimal treatment for giant cell tumors of the spine remains challenging. Surgical excision remains the initial treatment of choice, but the potential spinal cord injury may limit the extent of resection. Between 2001 and 2003, we report 3 patients diagnosed with giant cell tumor of spine treated with post-operative radiotherapy. Surgery consisted of subtotal resection of tumor. The involved vertebrae were then irradiated with doses ranging from 4500 to 6120 cGy. All patients tolerated the treatment well with no severe or chronic complications. Two of the 3 patients are alive with no evidence of disease. One is alive with recurrent disease upon regular MRI follow-up 24 months after treatment, although it is not clinically apparent. Our experience shown adjuvant radiotherapy after conservative surgery is a reasonable treatment alternative for tumors that cannot be completely excised or in which surgery would result in significant morbidity. Although there is no clear dose response, review of the literature suggest doses ranged from 3500 to 4500 cGy are safe and effective in controlling giant cell tumor.

Small Cell Neuroendocrine Carcinoma of Ethmoid Sinus: Case Report and Literature Review

Malignant tumors arising in the paranasal sinuses account for 0.2 to 0.8% of all cancers. Squamous cell carcinoma is by far the most common malignant tumor. Primary small cell neuroendocrine carcinoma of ethmoid sinus is an uncommon and distinctive tumor with an aggressive clinical behavior. Besides, its morphological and immuno-histo-chemical features are similar to those of small cell carcinoma of lung. The need for a multi-disciplinary treatment approach combining surgery or radiotherapy and chemotherapy is indicated in treating these aggressive tumors. We report a case of 40-year-old man who has small cell neuroendocrine carcinoma of ethmoid sinus with invasion of upper aspect of right maxillary sinus and medial aspect of right orbit. The patient was treated with surgery and adjuvant radiotherapy followed by systemic chemotherapy. Neither local recurrence nor distant metastasis was noted during follow-up of 6 months. The optimal treatment and the immuno-histo-chemical characteristics are discussed.

Choroid Plexus Carcinoma of the Lateral Ventricle: Case Report and Review

Primary carcinoma of choroid plexus are rare and found most frequently in children than in adults. In children, the choroid plexus carcinoma are located predominantly in the lateral ventricles, while adults in the fourth ventricle. This report is about a 53 year old male with primary carcinoma located in the lateral ventricle with CSF metastases, which was treated with total tumor excision of choroids plexus followed by post-operative cranial spinal irradiation. This paper aims at the possibilities and limitations of the treatment of primary carcinoma of choroids plexus.