Takuro Arimoto

The role of radiotherapy in the management of maxillary sinus carcinoma

From 1971 to 1983, a total of 208 patients with maxillary sinus carcinomas were treated at Department of Radiology, Hokkaido University School of Medicine, 38 by Method I (radiation + surgery + intraarterial 5‐fluorouracil [5‐Fu] infusion), and 170 by Method II (radiation + surgery). Radiation doses ranged from 30 to 50 Gy over 3 to 5 weeks in Method I and 52 to 58 Gy over 4 weeks in Method II. Overall actuarial survival rate at 5 years was 45.6%. No statistical difference in survival rates was found between Method I and Method II. With respect to T stage, absolute 5‐year survival rates were 100% (4/4) for T2, 49.5% (52/105) for T3, and 24.4% (11/45) for T4. From our data, no advantage in the use of intra‐arterial 5‐Fu infusion was demonstrated; the local failures in Method I developed earlier and more frequently than in Method II. The ultimate failures for all patients were 46.8%. Since 1980 when treatment planning by using computerized tomography scans and immobilization device was initiated, improvement in survival rate white reducing an incidence of eye complications has been accomplished. Cancer 57:2261–2266, 1986.

Clinical Outcomes of Stereotactic Body Radiotherapy for Small Lung Lesions Clinically Diagnosed as Primary Lung Cancer on Radiologic Examination

PURPOSE Image-guided biopsy occasionally fails to diagnose small lung lesions, which are highly suggestive of primary lung cancer. The aim of the present study was to evaluate the outcome of stereotactic body radiotherapy (SBRT) for small lung lesions that were clinically diagnosed as primary lung cancer without pathologic confirmation. METHODS AND MATERIALS A total of 115 patients were treated with SBRT in 12 institutions. Tumor size ranged from 5 to 45 mm in diameter, with a median of 20 mm. RESULTS The 3-year and 5-year overall survival rates for patients with a tumor size < or =20 mm in diameter (n = 58) were both 89.8%, compared with 60.7% and 53.1% for patients with tumors >20 mm (n = 57) (p <0.0005), respectively. Local progression occurred in 2 patients (3.4%) with a tumor size < or =20 mm and in 3 patients (5.3%) with tumors >20 mm. Among the patients with a tumor size < or =20 mm, Grade 2 pulmonary complications were observed in 2 (3.4%), but no Grade 3 to 5 toxicity was observed. In patients with a tumor size >20 mm, Grades 2, 3, and 5 toxicity were observed in 5 patients (8.8%), 3 patients (5.3%), and 1 patient (1.8%), respectively. CONCLUSION In patients with a tumor < or =20 mm in diameter, SBRT was reasonably safe in this retrospective study. The clinical implications of the high local control rate depend on the accuracy of clinical/radiologic diagnosis for small lung lesions and are to be carefully evaluated in a prospective study.

Reduction of radiation-induced xerostomia in nasopharyngeal carcinoma using CT simulation with laser patient marking and three-field irradiation technique

PURPOSE Tumor control and reduction of postirradiation xerostomia in patients with nasopharyngeal carcinoma (NPC) using the three-field irradiation technique based on the CT-based simulation with laser patient marking was investigated. METHODS AND MATERIALS Seventy-eight patients with NPC were consecutively treated between 1983 and 1993. In 33 patients treated before 1987, target volume was determined using a conventional x-ray simulator with a reference of CT images, and the primary site was treated by the conventional parallel-opposed two-field technique (Group I). In 45 patients treated from 1987, target volume was determined using a CT simulator slice by slice, the treatment field was projected onto the patients skin by a laser beam projector mounted on a C-arm, and the primary site was irradiated by a three-fields (anterior and bilateral) technique (Group II). In Group II, the shape of each field was determined using a beams eye view to reduce the dose to the bilateral parotid glands. The three-field technique reduced the dose to the superficial lobe of parotid gland to about two-thirds of the dose given by the two-field technique. Radiation-induced xerostomia was evaluated by clinical symptoms and radioisotope sialography. RESULTS The 5-year survival rate and disease-free survival rate were 46.6 and 31.2% in Group I, and 46.8 and 46.5% in Group II. A large variation in the volume of parotid glands were demonstrated, ranging from 9 cm3 to 61 cm3 among patients treated with CT simulation. Forty percent of the patients in Group II showed no or mild xerostomia, whereas all of the patients in Group I showed moderate to severe xerostomia (p < 0.01). The radioisotope sialography study showed that the mean secretion ratio by acid stimulation was improved from 3.8% in the Group I to 15.2% in the Group II (p < 0.01). CONCLUSIONS CT simulation was useful to determine the size and shape of each field to reduce the dose to the parotid gland, of which size varies largely among individual patients. The three-field technique based on CT simulation with laser patient markings is suggested to result in superior complication-free survival in terms of salivary dysfunction than did the conventional two-field technique with x-ray simulatior for NPC.

Ipsilateral irradiation for carcinomas of tonsillar region and soft palate based on computed tomographic simulation.

PURPOSE To reduce xerostomia in selected patients with carcinomas of the tonsillar region and soft palate. METHODS AND MATERIALS We evaluated the treatment results of 32 patients with tonsillar region and soft palate carcinoma treated by radical radiotherapy between May 1989 and December 1996. They have a unilateral tumor that did not cross midline and have no contralateral neck lymphnode metastasis and treated with an ipsilateral technique (an anterior oblique and a posterior oblique field). All patients were planned with computed tomographic (CT) simulation and given 65 Gy in 26 fractions in 6.5 weeks with or without 5-15 Gy boost irradiation. The median follow-up was 44 months (4-86 months). RESULTS Five-year overall, cause-specific survival, local control, and regional control rate was 64, 79, 74 and 81%. No failure at the contralateral neck occurred. Moderate or severe symptomatic xerostomia was seen in 3 (9%) patients and ostero-radionecrosis requiring surgery occurred in one (3.3%) of 32 patients. CONCLUSION It is suggested that the ipsilateral technique is indicated in patients who had an unilateral tonsillar region or soft palate carcinoma that did not cross midline and have no contralateral neck lymphnode metastasis.

Analysis of adenoid cystic carcinoma treated by radiotherapy

The records of 41 patients with adenoid cystic carcinoma of the head and neck region who had been treated with radiotherapy were reviewed. Local control was achieved in 72.3% in the cases with primary lesions at 5 years. The prognosis for tumors that arose in the major salivary glands was better than that for tumors that arose in the minor salivary glands; however, the difference was not statistically significant. In the minor salivary glands, early-stage tumors were well controlled with the use of radiation therapy alone. In spite of the high local control rate, the disease-free survival rate of the patients at 10 years was only 20.8%. Lung metastasis determined the prognosis.

A Phase III Comparison of Etoposide/Cisplatin with or without Added Ifosfamide in Small-Cell Lung Cancer

A total of 92 patients with small-cell lung cancer (SCLC) were randomized to receive cisplatin (80 mg/m2, day 1)/etoposide (100 mg/m2, days 1, 3, 5) (PE) or cisplatin (80 mg/m2, day 1)/etoposide (100 mg/m2, days 1, 3, 5)/ifosfamide (2 g/m2, days 1, 2, 3) (PEI) combination chemotherapy. After 2 courses of chemotherapy, patients with limited disease (LD) received chest irradiation of 40-50 Gy. Of the 89 patients who could be wholly evaluated, the overall response rate was 78% for PE and 74% for PEI therapy (NS). For all patients the complete response (CR) rates were 14 versus 21%, respectively, and 22 versus 30% for LD. However, the median survival times for all patients were 55 weeks for PE therapy versus 56 weeks for PEI therapy (NS). The 2-year survival rates were 15 and 17%, respectively, for all patients (NS). There was no difference in the duration of response between PE and PEI therapy in cases with CR or partial response. However, severe leukopenia (< 2,000/mm3) occurred more often after PEI (73%) than after PE (44%) therapy (p < 0.05). These results suggest that PEI is not superior to PE chemotherapy in SCLC. The use of ifosfamide in multimodality treatment regimens needs to be studied further.

Early stage head and neck non-Hodgkin's lymphoma: the effect of tumor burden on prognosis

Treatment results were investigated in 113 previously untreated patients with clinical Stage I and II (Ann Arbor) non‐Hodgkins lymphoma of the head and neck. Fifty‐six Waldeyers ring, 34 other extranodal sites, and 23 cervical nodal lesions were included. The overall relapse‐free survival at 5 years was 41%. Age and Ann Arbor stage influenced relapse‐free survival. The results suggested that the tumor cell burden is a fundamental prognostic factor for patients with Waldeyers ring disease and for patients with only cervical nodal disease. Abdominal relapse was most frequent, followed by generalized relapse. From 1981, patients were randomized in a clinical trial to receive either chemotherapy (cyclophosphamide, vincristine, and prednisone [CVP], five courses) or whole‐abdominal irradiation (25 Gy/20 Fr) as an adjuvant therapy. Patients could not tolerate the whole‐abdominal irradiation well. A significant improvement in survival has been obtained by adjuvant chemotherapy.

High-dose-rate intracavitary irradiation using linear source arrangement for stage II and III squamous cell carcinoma of the uterine cervix

PURPOSE The purpose of this article is to evaluate fractionated high-dose-rate (HDR) intracavitary irradiation using linear source arrangement (LSA) for patients with squamous cell carcinoma of the uterine cervix. MATERIALS AND METHODS The subjects consisted of 217 patients (71 patients with stage II and 146 with stage III disease) who received external beam therapy (EBT) followed by fractionated HDR intracavitary irradiation using LSA between January 1980 and June 1990. In EBT, 40 Gy in 20 fractions (40 Gy/20 Fr) or 39.6 Gy/22 Fr was delivered to the whole pelvis and an additional 10 Gy/5 Fr or 10.8 Gy/6 Fr was delivered to the parametrium. The intracavitary irradiation dose was 30 Gy/6 Fr or 35 Gy/7 Fr with a daily fraction size of 5 Gy and two fractions per week. During the intracavitary treatment, most patients were treated on an out-patient basis. RESULTS Cause-specific 5-year survival rates were 77% for stage II and 50% for stage III. Pelvic failure rates were 13% for stage II and 36% for stage III. In multivariate analyses, improved cause-specific survival was significantly associated with stage II (P = 0.0003), higher pretreatment serum hemoglobin level (P = 0.0015), higher pretreatment serum total protein level (P = 0.0029), and shorter total treatment time (P = 0.0024). The rate of severe (grade 3 or 4) late complication was 2% for the rectum, 1% for the small intestine or sigmoid colon and 1% for the bladder. CONCLUSIONS Fractionated HDR intracavitary irradiation using LSA is an effective treatment for patients with uterine cervical cancer without need for hospitalization.

Scintigraphic evaluation of long-term salivary function after bilateral whole parotid gland irradiation in radiotherapy for head and neck tumour

In 25 patients with head and neck tumour, in whom bilateral whole parotid glands were totally included in the irradiation volume, parotid gland function was estimated and compared with that of 58 non-irradiated parotid glands in 29 patients, by symptomatic grading and radioisotope (RI) sialography. Sequential follow-up by RI sialography has suggested that if the total dose to the parotid gland is less than 52 Gy or if the time-dose fractionation (TDF) value is less than 80, then partial recovery of salivary function can be expected 1 or 2 years after irradiation, even if patients show severe xerostomia during the first 6 months. Long-term recovery rarely occurs in parotid glands which have been irradiated at doses exceeding 55 Gy or with TDF values of 88 or higher. The 50% complication probability (ED50) was less than 33 Gy for subacute xerostomia during the first 6 months and 52.5 Gy for chronic xerostomia after 12 months, respectively. Although a prospective study will be required for confirmation, differences between the dose-response curves of xerostomia at subacute and chronic phases suggest a basis in different biological mechanisms.

Intraoperative radiation therapy to the upper mediastinum and nerve-sparing three-field lymphadenectomy followed by external beam radiotherapy for patients with thoracic esophageal carcinoma

In patients with thoracic esophageal carcinoma, radical dissection of the upper mediastinal lymph nodes often leads to complications such as recurrent laryngeal nerve palsy and subsequent pulmonary disorders. Intraoperative radiation therapy (IORT) to the upper mediastinum and nerve‐sparing three‐field lymphadenectomy followed by external beam radiotherapy has been developed to improve the locoregional control rate without resulting in these major postoperative complications.