Minoru Uematsu

Computed tomography-guided frameless stereotactic radiotherapy for stage I non-small cell lung cancer: a 5-year experience☆

PURPOSE Stereotactic radiotherapy (SRT) is highly effective for brain metastases from non-small-cell lung cancers (NSCLCs). As such, primary lesions of NSCLC may also be treated effectively by similar focal high-dose SRT. METHODS AND MATERIALS Between October 1994 and June 1999, 50 patients with pathologically proven T1-2N0 M0 NSCLC were treated by CT-guided frameless SRT. Of these, 21 patients were medically inoperable and the remainder were medically operable but refused surgery. In most patients, SRT was 50-60 Gy in 5-10 fractions for 1-2 weeks. Eighteen patients also received conventional radiotherapy of 40-60 Gy in 20-33 fractions before SRT. RESULTS With a median follow-up period of 36 months (range 22-66), 30 patients were alive and disease free, 3 were alive with disease, 6 had died of disease, and 11 had died intercurrently. Local progression was not observed on follow-up CT scans in 47 (94%) of 50 patients. The 3-year overall survival rate was 66% in all 50 patients and 86% in the 29 medically operable patients. The 3-year cause-specific survival rate of all 50 patients was 88%. No definite adverse effects related to SRT were noted, except for 2 patients with a minor bone fracture and 6 patients with temporary pleural pain. CONCLUSIONS SRT is a very safe and effective treatment for Stage I NSCLC. Additional studies involving a larger patient population and longer follow-up periods are warranted to assess this new treatment for early-stage lung cancer.

Focal, high dose, and fractionated modified stereotactic radiation therapy for lung carcinoma patients: A preliminary experience

Stereotactic radiation therapy is highly effective in the treatment of small brain metastases, regardless of the histology. This suggests that small extracranial malignancies may be curable with similar radiation therapy. The authors developed a novel treatment unit for administering such therapy.

A dual computed tomography linear accelerator unit for stereotactic radiation therapy: A new approach without cranially fixated stereotactic frames

PURPOSE To perform stereotactic radiation therapy (SRT) without cranially fixated stereotactic frames, we developed a dual computed tomography (CT) linear accelerator (linac) treatment unit. METHODS AND MATERIALS This unit is composed of a linac, CT, and motorized table. The linac and CT are set up at opposite ends of the table, which is suitable for both machines. The gantry axis of the linac is coaxial with that of the CT scanner. Thus, the center of the target detected with the CT can be matched easily with the gantry axis of the linac by rotating the table. Positioning is confirmed with the CT for each treatment session. Positioning and treatment errors with this unit were examined by phantom studies. Between August and December 1994, 8 patients with 11 lesions of primary or metastatic brain tumors received SRT with this unit. All lesions were treated with 24 Gy in three fractions to 30 Gy in 10 fractions to the 80% isodose line, with or without conventional external beam radiation therapy. RESULTS Phantom studies revealed that treatment errors with this unit were within 1 mm after careful positioning. The position was easily maintained using two tiny metallic balls as vertical and horizontal marks. Motion of patients was negligible using a conventional heat-flexible head mold and dental impression. The overall time for a multiple noncoplanar arcs treatment for a single isocenter was less than 1 h on the initial treatment day and usually less than 20 min on subsequent days. Treatment was outpatient-based and well tolerated with no acute toxicities. Satisfactory responses have been documented. CONCLUSION Using this treatment unit, multiple fractionated SRT is performed easily and precisely without cranially fixated stereotactic frames.

A new irradiation unit constructed of self-moving gantry-CT and linac.

PURPOSE To improve reproducibility in stereotactic irradiation (STI) without using noninvasive immobilization devices or body frames, we have developed an integrated computed tomography (CT)-linac irradiation system connecting CT scanner and linac via a common treatment couch. METHODS AND MATERIALS This system consists of a linac, a CT scanner, and a common treatment couch. The linac and the CT gantry are positioned on opposite ends of the couch so that, by rotating the treatment couch, linac radiotherapy or CT scanning can be performed. The rotational axis of the linac gantry is coaxial with that of the CT gantry, and the position of the linac isocenter on the couch matches the origin of the coordinate system for CT scanning when the couch is rotated 180 degrees toward the CT side. Instead of the couch moving into the gantry, as in conventional CT, in this case the table is fixed and scanning is accomplished by moving the gantry. We evaluated the rotational accuracy of the common couch and the scan-position accuracy of the self-moving gantry CT. RESULTS The positional accuracy of the common couch was 0.20, 0.18, and 0.39 mm in the lateral, longitudinal, and vertical directions, respectively. The scan-position accuracy of the CT gantry was less than 0.4 mm in the lateral, longitudinal, and vertical directions. CONCLUSION This irradiation system has a high accuracy and is useful for noninvasive STI and for verification of the position of a target in three-dimensional conformal radiotherapy.

Intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy for lung or liver cancers with a fusion of CT and linear accelerator (FOCAL) unit.

PURPOSE To evaluate intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy (SRT) for lung or liver cancers, we checked repeated CT scanning, with a fusion of CT and linear accelerator (FOCAL) unit. METHODS AND MATERIALS The FOCAL unit is a combination of a linear accelerator (Linac), CT scanner, X-ray simulator (X-S), and carbon table, and is designed to achieve CT-guided SRT with daily CT positioning followed by immediate irradiation while patients keep reduced shallow respirations. To evaluate intrafractional tumor position stability, 50 lung or liver lesions in 20 patients were checked by repeated CT scanning just before and after irradiation, and the obtained images were compared. RESULTS There was no case with the intrafractional error judged to be greater than 10 mm. In 68% of cases, the intrafractional positioning errors were negligible (0-5 mm). CONCLUSIONS Using the FOCAL unit, SRT for lung or liver cancers could be performed with intrafractional positioning errors not greater than 10 mm.

Daily positioning accuracy of frameless stereotactic radiation therapy with a fusion of computed tomography and linear accelerator (focal) unit: evaluation of z-axis with a z-marker.

To evaluate quantitative positioning errors of frameless stereotactic radiation therapy with a fusion of computed tomography (CT) and linear accelerator unit, Z-type CT markers were attached to patients, and CT images were obtained before and after daily treatment. In 40 verification tests, geometrical errors were never more than 1 mm.

Entire hemithorax irradiation following complete resection in patients with Stage II–III invasive thymoma

PURPOSE To evaluate the feasibility and efficacy of prophylactic entire hemithorax irradiation (EH) in addition to mediastinal irradiation (MRT) following a complete resection in Stage II-III invasive thymoma. METHODS AND MATERIALS Forty-three patients with invasive thymoma treated with surgery and radiation therapy between 1978 and 1993 were analyzed retrospectively. All 43 patients underwent a complete surgical resection and were judged to have Masaokas Stage II-III invasive thymoma. Of these, 23 patients received EH and MRT (EH-MRT) and the remaining 20 received MRT. Of the 23 patients with EH-MRT, 11 were Stage II and 12 Stage III. Of the 20 with MRT, 11 were Stage II and 9 Stage III. In most cases, EH was 15 Gy per 15 fractions over 3 weeks (without lung compensation calculation). In both the EH-MRT and MRT group, the total radiation doses to the mediastinum were similar with a median of 40 Gy. The median follow-up time after surgery was 63 months and no patients were lost to follow-up. RESULTS Only one of the 23 patients with EH-MRT relapsed. On the other hand, eight of the 20 with MRT relapsed, six of whom died of disease. The pleura was the most common site of failure. At 5 years, the relapse-free rate was 100% for those receiving EH-MRT and 66% for those with MRT (p = 0.03); the overall survival rate was 96% for those with EH-MRT, and 74% for those with MRT (p: not significant). The only significant treatment-related complication was radiation pneumonitis requiring treatment, in one patient who received MRT and three who received EH-MRT, including one death of a 72-year-old man and one 68-year-old woman with severe lung fibrosis. CONCLUSION Except for elderly patients, EH-MRT following a macroscopically complete resection appears to be safe and feasible, and can reduce intrathoracic relapses.

Radiotherapy for cervical cancer with high-dose rate brachytherapy — correlation between tumor size, dose and failure

This is a retrospective analysis of 659 patients with cervical squamous cell carcinoma with a minimum follow-up of 2 years at Keio University Hospital between May 1974 and March 1990. All patients were treated with external radiation (50 Gy) and high-dose rate (HDR) intracavitary brachytherapy (20-34 Gy). The 5-year survival rates in each stage gradually decreased with the advance of the stage (I, 84%; II, 71%; III, 47%; and IVa, 12%). When 366 patients with stage III were classified into three groups according to tumor size, i.e. small (S, 102 patients), medium (M, 145) and large (L, 119), a survival gradient of small > medium > large was demonstrated and the differences between them were significant. At follow-up visits conducted between 1 and 2 months after completion of treatment, 135 patients (20%) had physical indications of residual disease. The larger the tumor size, the more likely was residual disease by 2 months. The patients with residual disease had a significantly higher rate of the pelvic failure than those without it. There was no significant correlation between radiation doses by RALS and pelvic failure rates, except in the stage III-L group. In the stage III-L group, intracavitary doses of 24 Gy or less to point A could be correlated with the higher pelvic failure rate and the lower survival rate, in contrast to doses of 27 Gy or more. The incidence of major rectosigmoid complications was 11.8% with doses of 24 Gy or less to point A, 8.1% with 27 Gy and 19.2% with doses of 30 Gy or more.(ABSTRACT TRUNCATED AT 250 WORDS)

A proposal for treatment of invasive thymoma.

Eleven patients with invasive thymoma were treated with radiotherapy. All patients had gross anterior mediastinal tumors that invaded the adjacent structures, four of whom showed intrathoracic dissemination. Before radiotherapy, only one had macroscopic complete resection of the tumor, and another had partial resection; the other nine patients underwent biopsy only. All 11 patients achieved complete remission after radiotherapy, eight of whom have been free from relapse for 31 to 202 months. Three patients experienced recurrence within the thorax but outside the radiation fields. Even after whole mediastinal irradiation, recurrence could occur in the pleural cavity. Therefore, extended radiation fields including the entire hemithorax is recommended. Intensive combination chemotherapy was administered for two patients with recurrence and they achieved complete remission. A possible role of intensive chemotherapy in induction phase for invasive thymomas is discussed.

Sex ratio in the offspring of male radiologists

RATIONALE AND OBJECTIVES The purpose of this study was to determine if male radiologists predominantly father daughters and, if so, to investigate the association between this skewed sex ratio of offspring and radiation exposure. MATERIALS AND METHODS Questionnaires completed by 586 male radiologists in Japan provided data regarding the radiologists age, length of employment in radiology, if he had ever received radiation doses higher than that recommended by the International Commission on Radiological Protection, the sex of each child fathered, and the birth date of each child. RESULTS As a group, male radiologists tended to father a lower proportion of boys (48.47%) compared with the control group (51.46%), and the relative risk was 1.13 (95% confidence interval [CI]: 1.00, 1.27). Offspring of highly irradiated radiologists, however, had a reduced proportion of males (34.48%), with a significantly (P = .002) increased relative risk of 2.01 (95% CI: 1.29, 3.13). CONCLUSION X-ray exposure may explain the reduced percentage of sons in the offspring of male radiologists.