Yu-Chin Lin

Concurrent image-guided intensity modulated radiotherapy and chemotherapy following neoadjuvant chemotherapy for locally advanced nasopharyngeal carcinoma.

BackgroundTo evaluate the experience of induction chemotherapy followed by concurrent chemoradiationwith helical tomotherapy (HT) for nasopharyngeal carcinoma (NPC).MethodsBetween August 2006 and December 2009, 28 patients with pathological proven nonmetastatic NPC were enrolled. All patients were staged as IIB-IVB. Patients were first treated with 2 to 3 cycles of induction chemotherapy with EP-HDFL (Epirubicin, Cisplatin, 5-FU, and Leucovorin). After induction chemotherapy, weekly based PFL was administered concurrent with HT. Radiation consisted of 70 Gy to the planning target volumes of the primary tumor plus any positive nodal disease using 2 Gy per fraction.ResultsAfter completion of induction chemotherapy, the response rates for primary and nodal disease were 96.4% and 80.8%, respectively. With a median follow-up after 33 months (Range, 13-53 months), there have been 2 primary and 1 nodal relapse after completion of radiotherapy. The estimated 3-year progression-free rates for local, regional, locoregional and distant metastasis survival rate were 92.4%, 95.7%, 88.4%, and 78.0%, respectively. The estimated 3-year overall survival was 83.5%. Acute grade 3, 4 toxicities for xerostomia and dermatitis were only 3.6% and 10.7%, respectively.ConclusionHT for locoregionally advanced NPC is feasible and effective in regard to locoregional control with high compliance, even after neoadjuvant chemotherapy. None of out-field or marginal failure noted in the current study confirms the potential benefits of treating NPC patients by image-guided radiation modality. A long-term follow-up study is needed to confirm these preliminary findings.

Image-guided intensity modulated radiotherapy with helical tomotherapy for postoperative treatment of high-risk oral cavity cancer

BackgroundThe aim of this study was to assess the treatment results and toxicity profiles of helical tomotherapy (HT) for postoperative high-risk oral cavity cancer.MethodsFrom December 6, 2006 through October 9, 2009, 19 postoperative high-risk oral cavity cancer patients were enrolled. All of the patients received HT with (84%) or without (16%) chemotherapy.ResultsThe median follow-up time was 17 months. The 2-year overall survival, disease-free survival, locoregional control, and distant metastasis-free rates were 94%, 84%, 92%, and 94%, respectively. The package of overall treatment time > 13 wk, the interval between surgery and radiation ≤ 6 wk, and the overall treatment time of radiation ≤ 7 wk was 21%, 84%, and 79%, respectively. The percentage of grade 3 mucositis, dermatitis, and leucopenia was 42%, 5% and 5%, respectively.ConclusionsHT achieved encouraging clinical outcomes for postoperative high-risk oral cavity cancer patients with high compliance. A long-term follow-up study is needed to confirm these preliminary findings.

Ultrasonographic differentiation between Kikuchi's disease and lymphoma in patients with cervical lymphadenopathy

PURPOSE Kikuchis disease, or histiocytic necrotizing lymphadenitis, is a self-limited necrotizing lymphadenitis. Clinically, it resembles lymphoma. We want to compare the sonographic features between Kikuchis disease and lymphoma in patients with cervical lymphadenopathy. MATERIALS AND METHODS The study protocol was approved by the institutional review board. Two hundred and twenty six cervical lymph nodes (137 nodes from 21 Kikuchis disease patients and 89 nodes from 20 malignant lymphoma patients) were examined. The demographic and ultrasonographic characteristics of lymph nodes were collected and analyzed. RESULTS The Kikuchis disease patients (mean age, 24.2 years; range, 8-57 years) were younger than those with lymphoma (mean age, 54 years; range, 13-81 years). There was no difference in laterality of nodes (p=0.19). The nodal distribution demonstrated most enlarged neck lymph nodes located at level II, III and V. The ranges of short-axis and long-axis length were 6.5±2.3mm (mean±SD) versus 13.4±5.1mm and 13.4±5.0mm versus 21.2±9.2mm for Kikuchis disease versus lymphoma (p<0.01), respectively. The S/R ratio of Kikuchis disease nodes was 0.5±0.2 compared to 0.7±0.2 in lymphoma nodes (p<0.01). Eighty-seven of 137 nodes (63.5%) of Kikuchis disease, and eight of 89 nodes (9%) of malignant lymphoma had signs of cortical widening (p<0.01). Seventy-six nodes (55.5%) of Kikuchis disease and twenty-eight nodes (31.5%) of malignant lymphoma were matted (p<0.01). Forty-five of 89 nodes among lymphoma and twenty-four among 137 of Kikuchis disease had features of micronodular reticular echotexture (p<0.01). All nodes exhibited hypoechogenicity except one lymphomatous node demonstrated isoechogenicity, and there was no difference in sharpness of border and presence of echogenic hilum between the two diseases (p>0.05). CONCLUSION Analysis of basic ultrasonographic characteristics (size, shape, rims, matting and echotexture) helps differentiate cervical lymph nodes in patients with Kikuchis disease and lymphoma. Cervical lymphadenopathies in patients with Kikuchis disease have smaller size, less round, less micronodular reticular echotexture, and more signs of matting and cortical widening than those with lymphoma examined under ultrasound.

Risk factors for second primary neoplasia of esophagus in newly diagnosed head and neck cancer patients: a case–control study

BackgroundThe prevalence of esophageal neoplasia in head and neck (H&N) cancer patients is not low; however, routine esophageal surveillance is not included in staging of newly-diagnosed H&N cancers. We aimed to investigate the risk factors for synchronous esophageal neoplasia and the impact of endoscopy on management of H&N cancer patients.MethodsA total of 129 newly diagnosed H&N cancer patients who underwent endoscopy with white-light imaging, narrow-band imaging (NBI) with magnifying endoscopy (ME), and chromoendoscopy with 1.5% Lugol’s solution, before definite treatment were enrolled prospectively.Results60 esophageal lesions were biopsied from 53 (41.1%) patients, including 11 low-grade, 14 high-grade intraepithelial neoplasia and 12 invasive carcinoma in 30 (23.3%) patients. Alcohol consumption [odds ratio (OR) 5.90, 95% confidence interval (CI) 1.23-26.44], advanced stage (stage III and IV) of index H&N cancers (OR 2.98, 95% CI 1.11-7.99), and lower body mass index (BMI) (every 1-kg/m2 increment with OR 0.87, 95% CI 0.76-0.99) were independent risk factors for synchronous esophageal neoplasia. NBI with ME was the ideal screening tool (sensitivity, specificity, and accuracy of 97.3%, 94.1%, and 96.3%, respectively, for detection of dysplastic and cancerous esophageal lesions). The treatment strategy was modified after endoscopy in 20 (15.5%) patients. The number needed to screen was 6.45 (95% CI 4.60-10.90).ConclusionsNBI-ME surveillance of esophagus should be done in newly-diagnosed H&N cancer patients, especially those with alcohol drinking, lower BMI, and advanced stage of primary tumor.

Initial outcomes of an integrated outpatient-based screening program for oral cancers

OBJECTIVE To evaluate the feasibility of an integrated outpatient-based screening program for oral cancer. STUDY DESIGN An automated system was used to refer high-risk patients presenting to the outpatient clinic for oral cavity examination. The outcomes between the screened and concurrently symptomatic cohorts were compared to assess the programs effectiveness at identifying oral cancers. RESULTS Among the 38,693 candidates flagged as high-risk patients by our automated referral system, a total of 8037 participants were recruited to our screened cohort; 1664 patients were identified with positive lesions, and 302 patients underwent a biopsy. Five patients were diagnosed with oral cancer and 121 with dysplastic precancers. The symptomatic cohort comprised 157 patients with oral cancers and 61 with precancers. The screening program identified earlier stages of oral cancers than in the symptomatic cohort. CONCLUSION Automated outpatient-based oral cancer screening programs may be a practicable strategy to identify precancerous lesions or early-stage cancers in high-risk adults.

Prognostic impact of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in nasopharyngeal carcinoma: A retrospective study of 180 Taiwanese patients

Nasopharyngeal cancer (NPC) is an endemic disease in Taiwan. Prognostic factors the anatomical TNM stage are important for its prognostic stratification. An elevated neutrophil‐to‐lymphocyte ratio (NLR) has been reported to be associated with poor prognosis in various solid tumours. In this study, we analysed the prognostic impact of the NLR in NPC in Taiwan.

Long Term Outcome of Routine Image-enhanced Endoscopy in Newly Diagnosed Head and Neck Cancer: a Prospective Study of 145 Patients.

Synchronous second primary tumors (SPTs), especially esophageal squamous cell neoplasia (ESCN), in patients with head and neck squamous cell carcinoma (HNSCC) are not uncommon. Image-enhanced endoscopy (IEE) screening may identify SPTs while there is no evidence to support its benefit. We prospectively recruited an adult cohort with newly-diagnosed HNSCC for IEE screening of upper gastrointestinal (UGI) tract neoplasia. 145 HNSCC patients were recruited. 22 (15.2%) patients had synchronous UGI tract neoplasia, including 20 ESCNs and 2 gastric adenocarcinoma. At a median follow-up of 2.72 (±1.73) years, the 3-year overall survival (OS) rate was 0.71. HNSCC patients with synchronous ESCN/UGI tract neoplasia had poorer prognosis than those without (multivariate analysis, hazard ratio [HR] 2.75/2.79, 95% confidence interval [CI] 1.11~6.82/1.15~6.80, p = 0.03/0.02). HNSCC patients with advanced (stage III&IV) ESCN had worst survivals (p < 0.001). Among those with synchronous ESCNs, hypopharyngeal cancers were associated with poorer prognosis when compared with oral cancers (HR 2.36, 95% CI 1.08~5.15, p = 0.03). IEE screening for UGI SPTs in HNSCC patients could be used for risk stratification and prognosis prediction. HNSCC patients with advanced ESCN had the worst prognosis. Further studies are needed to demonstrate the survival benefits from IEE screening.

Clinical effectiveness, toxicity, and failure patterns of helical tomotherapy for postoperative oral cavity cancer patients

Background The outcome of postoperative high- and intermediate-risk oral cavity cancer (OCC) patients receiving helical tomotherapy (HT) remains limited. Materials and methods Between November 2006 and November 2012, 53 postoperative high- and intermediate-risk OCC patients treated with HT were enrolled. Results The 4-year locoregional, local, and regional control rates were 66%, 76.4%, and 94.3%, respectively. The 4-year locoregional control rates of oral tongue and buccal mucosa cancer were 88.3% and 37.1%, respectively (P=0.012). Eleven (20.8%) patients experienced locoregional failure. In-field failure occurred in six of 53 (11.3%) in the primary area and three of 53 (5.7%) in the regional lymph-node area. No marginal failure was noted. Two of 53 (3.8%) experienced out-of-field failure. The rates of grade 3 dermatitis, mucositis, and dysphagia were 11%, 34%, and 13%, respectively. No grade 3 xerostomia was noted. Grade 2 xerostomia was 33% at month 6 and declined to 0 at month 48. A rate of 56% of grade 2 trismus at month 6 was noted, and declined to around 30% after 2 years. No grade 3 trismus was noted after 2 years. Conclusion HT as a postoperative modality provided satisfying results, especially for xerostomia and trismus, and was impressive in high- and intermediate-risk OCC patients receiving postoperative HT.

Image-guided intensity-modulated radiotherapy for refractory bilateral breast cancer in a patient with extensive cutaneous metastasis in the chest and abdominal walls

Treatment for bilateral breast cancer with chest wall and abdominal skin invasion normally involves conventional radiotherapy (RT); however, conventional RT provides inadequate target volume coverage and excessive treatment of large volumes of normal tissue. Helical tomotherapy (HT) has the ability to deliver continuous craniocaudal irradiation that suppresses junction problems and provides good conformity of dose distribution. A 47-year-old female with stage IV bilateral breast cancer with chest wall and pectoralis major muscle invasion, lymphadenopathy, bilateral pleural effusion, and multiple bone metastases received chemotherapy and target therapy beginning in January 2014; 4 months after the initiation of chemotherapy, computed tomography revealed progression of chest and abdominal wall invasion. A total dose of 70.2 Gy was delivered to both breasts, the chest wall, the abdominal wall, and the bilateral supraclavicular nodal areas in 39 fractions via HT. The total planning target volume was 4,533.29 cm3. The percent of lung volume receiving at least 20 Gy (V20) was 28%, 22%, and 25% for the right lung, left lung, and whole lung, respectively. The mean dose to the heart was 8.6 Gy. Follow-up computed tomography revealed complete response after the RT course. Grade 1 dysphagia, weight loss, grade 2 neutropenia, and grade 3 dermatitis were noted during the RT course. Pain score decreased from 6 to 1. No cardiac, pulmonary, liver, or intestinal toxicity developed during treatment or follow-up. Concurrent HT with or without systemic treatment could be a safe salvage therapy for chemorefractory locally advanced breast cancer patients with extensive cutaneous metastasis.

Helical Tomotherapy Reduces Pain Efficiently for Circuited Pleural Metastasis of Nasopharyngeal Carcinoma-A Case Report

Nasopharyngeal carcinoma (NPC) with pleural circulative metastasis is difficult to treat due to the cylinder shape and close critical organs. Helical tomotherapy (HT) is a new type of CT-based rotational intensity modulated radiotherapy with highly conformal dose distributions and critical organs sparing. HT could be helpful in this kind of difficult situation.A 38-year-old male Asian nasopharyngeal carcinoma patient with pleural and liver metastasis was treated. Thirty-six Gy was delivered to bilateral pleural and mediastinum metastatic sites with HT. After HT treatment, pain was controlled by narcotics successfully. Pain scale decreased from 10 to 0. Tumor volume decreased from 629 ml to 158 ml. HT reduced V20 by more than 50% for each lung and reduced the mean lung dose by 22.2% and 33.8% in the right lung and left lung when compared with the IMRT technique, respectively.For palliative treatment, HT provides impressive ability for irregularly shaped metastatic sites and reduces painful sensation successfully.[Therapeut Radiol Oncol 2011; 18(4): 341-345]