Po-Ming Wang

Impact of magnetic resonance imaging versus CT on nasopharyngeal carcinoma: Primary tumor target delineation for radiotherapy

Our aim was to assess the capacity of CT versus MRI for delineating to the primary tumor extent of nasopharyngeal carcinoma (NPC) in treated patients.

Comparison of surgery or radiotherapy on complications and quality of life in patients with the stage IB and IIA uterine cervical cancer.

OBJECTIVES To compare the long-term complications and quality of life of patients with stage IB and stage IIA uterine cervical carcinoma treated by surgery or radiotherapy. METHODS From August 2003 to May 2004, 202 patients with uterine cervical carcinoma were treated with surgery or radiotherapy at two institutions and were enrolled in this study upon follow-up at least 2 years post treatment. All patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and complications Questionnaire. RESULTS Constipation (p<0.001), flushing (p<0.001), dysuria (p<0.001), urinary incontinence (p<0.01), dysparia (p<0.05) and vaginal dryness (p<0.05) were statistically higher in the surgery treated group, while diarrhea (p<0.001), bloody stools (p<0.001) and abdominal pain (p<0.01) were higher in the radiotherapy group. Using factor analysis and introducing personal conditioned variables, pelvic neural dysfunction was significantly higher in surgery group and intestinal dysfunction was higher in radiotherapy group. There was no difference in sexual dysfunction between these two modalities. Comparison of EORTC QLQ-C30 showed that the majority of issues had minimal differences between these two treatment modalities, except social functioning (p<0.05; higher in radiotherapy group), constipation (p<0.001; higher in surgery group) and diarrhea (p<0.01; higher in radiotherapy group). CONCLUSIONS In early stage uterine cervical cancer patients, surgery or radiotherapy resulted in different complications, whereas long-term quality of life showed few differences between these two different modalities. These data were helpful for physicians in regards to the changes of patients, and moreover, for rehabilitation and supportive care of the patients after treatment.

Assessment of a model based optimization engine for volumetric modulated arc therapy for patients with advanced hepatocellular cancer

BackgroundTo evaluate in-silico the performance of a model-based optimization process for volumetric modulated arc therapy (RapidArc) applied to hepatocellular cancer treatments.Patients and methods45 clinically accepted RA plans were selected to train a knowledge-based engine for the prediction of individualized dose-volume constraints. The model was validated on the same plans used for training (closed-loop) and on a set of other 25 plans not used for the training (open-loop). Dose prescription, target size, localization in the liver and arc configuration were highly variable in both sets to appraise the power of generalization of the engine. Quantitative dose volume histogram analysis was performed as well as a pass-fail analysis against a set of 8 clinical dose-volume objectives to appraise the quality of the new plans.ResultsQualitative and quantitative equivalence was observed between the clinical and the test plans. The use of model-based optimization lead to a net improvement in the pass-rate of the clinical objectives compared to the plans originally optimized with standard methods (this pass-rate is the frequency of cases where the objectives are respected vs. the cases where constraints are not fulfilled). The increase in the pass-rate resulted of 2.0%, 0.9% and 0.5% in a closed-loop and two different open-loop validation experiments.ConclusionsA knowledge-based engine for the optimization of RapidArc plans was tested and lead to clinically acceptable plans in the case of hepatocellular cancer radiotherapy. More studies are needed before a broad clinical use.

Mini-Nutritional Assessment Predicts Functional Status and Quality of Life of Patients With Hepatocellular Carcinoma in Taiwan

This study aimed to determine the possibility of using the Mini-Nutritional Assessment (MNA) to evaluate the quality of life and functional status in patients with hepatocellular carcinoma (HCC). The study recruited 300 outpatients with HCC from a teaching hospital in Central Taiwan to serve as subjects. All subjects were interviewed with a structured questionnaire for rating the nutritional status with the MNA (long-form and short-form), and for evaluating quality of life and functional status with Global Quality of Life (GQL) and Global Functional Status (GFS), respectively, of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 version-3. Cancer staging and liver cirrhosis indicators, blood biochemical indicators, and self-rated health status and mobility were used as reference standards. Results showed that based on the strength of the correlation and association with the reference standards, both the long-form and short-form of the MNA performed better than GQL and GFS in predicting quality of life and functional status of patients with HCC. These results suggest that the MNA is suitable for identifying the risk of deteriorating quality of life or functional status, in addition to identifying the risk of malnutrition, in patients with HCC.

Radiation treatment with volumetric modulated arc therapy of hepatocellular carcinoma patients. Early clinical outcome and toxicity profile from a retrospective analysis of 138 patients

BackgroundTo report early outcome and toxicity for inoperable patients with hepatocellular carcinoma (HCC) treated with volumetric modulated arc therapy (VMAT).MethodsOne hundred and thirty eight patients were retrospectively analysed. Dose prescription ranged from 45 to 66Gy with conventional fractionation regime. Based on AJCC staging, 88.4% presented stage III or IV. Two-thirds (69.6%) were Child-Pugh stage A, the remaining were stage B. According to Barcelona Clinic Liver Cancer staging, 72.5% of patients were classified as stage C.ResultsMedian age was 66 years, median tumor volume was 516cm3 (28 to 3620cm3). The most patients (83%) were treated with 60Gy. Median follow-up time was 9 months. One-year overall survival rate was 45% (100% for AJCC stage I, 83% for stage II, 45% for stage III and 28% for stage IV), median survival was 10.3 months (95% C.I. 7.2-13.3). Local control was achieved in 94% (of 109 assessable patients), stable disease in 29%, partial response in 53%, complete response in 11%, and progression in 6%. Radiation-induced liver disease was observed in 34 patients (25%). Gastrointestinal grade 3 toxicity was modest with a total of 17 (12.3%) cases for all endpoints.ConclusionsClinical results could suggest to introduce VMAT as an appropriate technique for the patients with HCC.

Chromosome aberrations induced in human lymphocytes after partial-body irradiation.

Chromosomal aberrations in peripheral blood lymphocytes obtained from two patients before and after they received one fraction of partial-body irradiation for palliative treatment were analyzed. Blood samples were taken 30 min and 24 h after radiation treatment. The yield of dicentrics obtained from case A 30 min after a partial-body (about 21%) treatment with 8 Gy was 0.066/cell, while the yield obtained 24 h after radiation treatment was 0.071/cell. The fraction of irradiated lymphocytes that reached metaphase at 52 h was 0.08 as evaluated by mixing cultures of in vitro irradiated and unirradiated blood. The yield of dicentrics for blood from case B 30 min after 6 Gy partial-body (about 24%) irradiation was 0.655/cell, while the yield 24 h after irradiation was 0.605/cell. The fraction of irradiated cells was 0.29. Estimation of doses and irradiated fractions for the two cases using the method proposed by Dolphin and the Qdr method is discussed. Although there was no significant difference between the mean yields of dicentrics per cell obtained 30 min and 24 h after radiation treatment, the data obtained at 24 h seemed more useful for the purpose of dose estimation. When a higher dose (8 Gy) was delivered to a smaller percentage of the body, underestimation of the dose was encountered.

Preliminary Results of Three-Dimensional Conformal Radiotherapy and Thalidomide for Advanced Hepatocellular Carcinoma

Purpose : The purpose of this study was to evaluate the response and therapeutic results of advanced hepatocellular carcinoma (HCC) treated with three-dimensional conformal radiotherapy (3D-CRT) and thalidomide. Materials and Methods : From October 1999 to September 2002, thirty-three advanced HCC patients who had been treated with 3D-CRT and thalidomide were reviewed. The mean age was 61.36 years old (range: 36-80 years old). Three-dimensional CRT was delivered at 1.5 Gy per fraction using 6 or 10 MV photons, twice a day and 5 days a week for a total dose of 45- 75 Gy. The mean treatment volume was 369.59 ml (range: 32.54-2094.82 ml). The dosage of thalidomide was 200 mg/day in 25 patients, 300 mg/day in 5 patients, and 400 mg/day in 3 patients. Results : Sixty-four percent [21/33; 1 complete response (CR), 20 partial response (PR)] of patients responded in 淯T field?and 12.1% (4/33; 4 PR) of patients responded in 烋on-irradiated lesion? When therapeutic outcome was determined by the different tumor patterns, the responses of 淯T field?for the recurrent tumor, huge mass, HCC with metastatic lesions and multiple lesions were 80.0% (8/10; 1 CR, 7 PR), 71.4% (5/7; 5 PR), 61.5% (8/13; 8 PR), and 0% (0/3; 2 SD and 1 PD), respectively (p = 0.234). Furthermore, the responses of 烋on-irradiated lesion?for the recurrent tumor, huge mass, HCC with metastatic lesions and multiple lesions were 10.0% (1/10; 1 PR), 14.3% (1/7; 1 PR), 15.4% (2/13; 2 PR), and 0% (0/3; all 3 PD), respectively (p = 0.778). The mean and median survival times were 327 and 242 days, respectively. The adverse effects of 3D-CRT and thalidomide include constipation (26/33, 78.8%), drowsiness and sedation (15/33, 45.5%), skin rash (11/33, 33.3%), lower extremity edema (20/33, 60.6%), peripheral neuropathy (2/33, 6.1%), dizziness (1/33, 3.0%), orthostatic hypotension (1/33, 3.0%), leukopenia (5/33, 15.2%), transient elevation in liver function tests (9/33, 27.3%), and epigastralgia (8/33, 24.2%). Conclusions : Our experience concluded that 3D-CRT combined with thalidomide might be a safe and effective treatment modality for unresectable HCC patients. The preliminary data showed quite promising result. It is valuable to study the potential role of 3D-CRT combined with thalidomide in the treatment strategy for HCC at various stages.

Preliminary Results of Fractionated Stereotactic Radiotherapy in Patients with Advanced Hepatocellular Carcinoma

Purpose: The treatment result of advanced hepatocellular carcinoma failed from previous TACE is often unsatisfactory. To minimize the acute and late adverse effects of liver irradiation and preserve maximal normal liver tissue, fractionated stereotactic radiotherapy (R/T) is used in our institute. Materials & Methods: Twenty-three patients with advanced hepatocellular carcinoma received fractionated stereotactic radiotherapy with 55Gy in 22 fractions. All patients were assessable for side effects and response. Results: The mean regression of turner volume was 29% at 1 month after completion of R?T, 41% at 2 months and 55% at 3 months. In 17 patients with elevated serum alpha-fetoptein (AFP), 15 (88%) were found to have response in the first month after R/T, 10 (59%) had regression of more than 50% of the original level at the first month after R/T. Conclusion: For patients with advanced hepatocellular carcinoma, the fractionated stereotactic radiotherapy is a feasible modality and deserves further follow-up for outcome and toxicity.

Radiotherapy of Conjunctival Lymphoma with A Specially Designed Lens Block

Purpose:To evaluate and discuss the therapeutic results and technique of conjunctival lymphoma. Materials and Methods: This retrospective study was to review the 10 patients with conjunctival lymphoma treated at National Taiwan University Hospital from 1988 to 1996. There were 8 men and 2 women. The range of age was 32 - 75 years old, mean: 59.1 years old. Most of the patients presented with conjunctival mass, reddish eyes and forelgn body sensation. The conjunctival lesions in all patients were treated with a single anterior field which covered the entire conjunctiva, using 3 MeV to 10 MeV electron beam. Total dose of 30 Gy to 50 Gy was delivered in 15 to 25 fractions over 23 to 33 days. In all cases, a specially designed lead shield was used to protect the lens. The follow-up time ranged from 24 months to 124 months. Results: All patients were doing well with no sign of active localized or distant disease till the closing date of the study. Moreover, the complications, including decreased visual acuity, cataract and photophobia, were minimal. Conclusion: Lymphoma clinically localized to conjunctiva as the initial presentation can be cured by radiation therapy with a dosage of 30 Gy to 40 Gy. The complications of radiation therapy can be minimized with sophisticated treatment technique and well protection of the highly radiosensitive lens.

Treatment Results of Oral Tongue Cancer

Purpose: To evaluate the therapeutic results of oral tongue cancer patients treated with curative intent at the National Taiwan University Hospital. Materials and Methods: From 1977 to 1994, 161 oral tongue cancer patients were treated by different modalities, including surgery alone (85 patients), radiotherapy alone (40 patients) and surgery followed by radiotherapy (36 patients). Patients were grouped according to the American Joint Committee on Cancer (AJCC) staging system. Among these 161 patients, 33 (20%) were categorized as stage I; 53 (33%) stage II; 37 (23%) stage III and 38 (24%) stage IV. All of them were squamous cell carcinoma with a male to female ratio of approximately 4:1. The treatment results of primary control, neck node control, outcomes and complications were analyzed. Results: More than four fifths of the lesions were located on the lateral border of the tongue and less than 5% were either on the dorsum or undersurface. Primary control rates of Ti and T2 diseases in the OP alone group were 90% and 86%, respectively. The T3 patients of OP+REF group had better primary control rate as 67%. Primary control of T4 disease was very poor hi our three treatment groups. Even for the early disease, patients receiving surgical resection of primary tumor without further neck treatment have a higher risk (28%) of neck failure. Five-year survival rates of stage Ⅲ patients were: R/T alone, 17%; OP alone, 24%; OP+R/T, 61%. Eighty-four percent and 72% recurrence in T3/T4 and T1/T2, respectively, occurred within one year after treatment. Overall, 86% recurrence occurred within the first 2 years. Sixteen patients (10%) showed evidence of distant metastasis; most commonly presented in the lung (75%). The risk of osteonecrosis was similar between OP+R/T group (6%) and R/T alone group (3%). Conclusion: In our study, surgery can control primary tumors effectively in Ti and T2 lesions. Advanced (T3 and T4) disease is unlikely to be cured by radiation therapy or surgery alone and therefore is best managed by a planned combination of surgery and radiation therapy. For stageⅢ group, five-year survival rate was significantly improved (p＜O.O5) for patients who were treated with surgery and postoperative radiotherapy. When the primary lesion is treated by simple excision, neck failure is not uncommon and adjuvant radiotherapy to the neck lymphatics may decrease its occurrence. There was 14% of recurrence occurred beyond the first 2 years which indicated that a long period of follow-up was important for tongue cancer patients.