Clinical experience of consolidative radiotherapy for localized metastatic non-small cell lung cancer who showed favorable tumor response after systemic treatment

BACKGROUND

Our study has aimed to assess the effects of consolidative high-dose radiotherapy on clinical outcomes in patients with localized metastatic non-small cell lung cancer (NSCLC) who showed favorable tumor response after systemic treatment.

METHODS

We retrospectively reviewed the medical records of 83 patients with localized metastatic NSCLC, who received systemic therapy followed by consolidative local radiotherapy at the Korea University Guro Hospital between March 2017 and June 2022. In the current study, we defined localized metastatic disease as the presence of one to three metastatic sites at the time of diagnosis. And patients who showed favorable tumor response after systemic treatment, including oligo-progressive disease at the thoracic site which was amenable to curative high-dose local radiotherapy, were included. The planned total dose and fraction size mainly depended on the location of lesions.

RESULTS

The median follow-up time after consolidative radiotherapy was 16 months (range: 5-52 months). The overall 2-year progression-free survival rates were 81.4%. Of 83 patients, only four (4.3%), treated with intensity-modulated radiation therapy, showed an in-field local recurrence. Interestingly, only one patient experienced a local failure among the 20 patients who showed an oligo-progressive disease at the thoracic site on the tumor response evaluation after systemic treatment. Regarding treatment-related pulmonary toxicity, three patients with grade-3 and one patient with grade-4 radiation pneumonitis were presented.

CONCLUSIONS

If the disease is sufficiently controlled and localized by systemic therapy, local consolidative radiotherapy is thought to improves local control rates with acceptable treatment-related toxicities in patients with localized metastatic NSCLC, especially those with oligo-progressive disease.

Risk factor analysis of the development of severe radiation pneumonitis in patients with non-small cell lung cancer treated with curative radiotherapy, with focus on underlying pulmonary disease

BACKGROUND

We aim to identify the multifaceted risk factors that can affect the development of severe radiation pneumonitis (RP) in patients with non-small cell lung cancer (NSCLC) treated with curative high-dose radiotherapy with or without concurrent chemotherapy.

METHODS

We retrospectively reviewed the medical records of 175 patients with stage-I-III NSCLC treated with curative thoracic X-ray radiotherapy at the Korea University Guro Hospital between June 2019 and June 2022. Treatment-related complications were evaluated using the Common Terminology Criteria for Adverse Events (version 4.03).

RESULTS

The median follow-up duration was 15 months (range: 3-47 months). Idiopathic pulmonary fibrosis (IPF) as an underlying lung disease (P < 0.001) and clinical stage, regarded as the concurrent use of chemotherapy (P = 0.009), were associated with a high rate of severe RP. In multivariate analyses adjusting confounding variables, the presence of IPF as an underlying disease was significantly associated with severe RP (odds ratio [95% confidence interval] = 48.4 [9.09-347]; P < 0.001). In a subgroup analysis of stage-I-II NSCLC, the incidence of severe RP in the control, chronic obstructive pulmonary disease (COPD), and IPF groups was 3.2%, 4.3%, and 42.9%, respectively (P < 0.001). The incidence of severe RP was 15.2%, 10.7%, and 75.0% in the control, COPD, and IPF groups, respectively (P < 0.001) in the stage-III NSCLC group.

CONCLUSIONS

This study revealed that IPF as an underlying lung disease and the concurrent use of chemotherapy are associated with a high rate of severe RP. In contrast, COPD did not increase the risk of pulmonary toxicity after receiving curative high-dose radiotherapy.

Role of local ablative treatment in oligometastatic non-small cell lung cancer: a meta-analysis

INTRODUCTION

This meta-analysis analyzed the oncologic role of local ablative treatment (LAT) in oligometastatic nonsmall cell lung cancer.

METHOD

Pubmed, MEDLINE, Embase, and Cochrane Library were searched until October, 2022. Studies comparing LAT with standard care (control) were included. Sensitivity analyses were performed including randomized controlled studies (RCTs). Subgroup analyses were performed according to specific categories and metastatic burden. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Considering the median OS and PFS from landmark studies, 2-year OS and 1-year PFS rates were used to calculate pooled odds ratios (ORs).

RESULTS

A total of 20 studies (four RCTs) encompassing 1750 patients were included. Surgery and radiotherapy (60 and 90% of studies) were mainly used as LATs. Pooled ORs of OS and PFS were 3.492 (95% CI:2.612-4.699, P <0.001) and 3.743 (95% CI: 2.586-5.419, P <0.001), favoring LAT, respectively. Sensitivity analyses, including RCTs showed ORs of 4.111 ( P <0.001) and 4.959 ( P =0.001) regarding OS and PFS, favoring LCT, respectively. Pooled 1-year and 2-year OS rates were 83.8 and 58.4% in LAT arms, whereas 64.4 and 31% in control arms; pooled 1-year and 2-year PFS rates were 64.6 and 32.8% in LAT arms, and 36.1 and 10% in control arms. In subgroup analyses, the pooled ORs were 3.981 ( P <0.001), 3.355 ( P <0.001), and 1.726 ( P =0.373) in synchronous, oligopersistence, and oligoprogression/recurrence subgroups, respectively. Regarding PFS comparison, pooled ORs were 5.631 ( P <0.001), 3.484 ( P <0.001), and 1.777 ( P =0.07), respectively. According to metastatic burden categories, pooled ORs favored LAT arms in both analyses including low-metastatic and high-metastatic burden subgroups.

CONCLUSION

The present study supports the role of LAT in treating nonsmall cell lung cancer oligometastasis. The oligoprogression/recurrence disease could have less LAT benefit than synchronous or oligopersistent disease.

Towards hard-magnetic behavior of CoFe2O4 nanoparticles: a detailed study of crystalline and electronic structures, and magnetic properties

We have used the coprecipitation and mechanical-milling methods to fabricate CoFe₂O₄ nanoparticles with an average crystallite size (d) varying from 81 to ∼12 nm when changing the milling time (t _m) up to 180 min. X-ray diffraction and Raman-scattering studies have proved the samples crystalizing in the spinel structure. Both the lattice constant and residual strain tend to increase when t _m(d) increases (decreases). The analysis of magnetization data has revealed a change in the coercivity (H _c) towards the hard-magnetic properties. Specifically, the maximum H _c is about 2.2 kOe when t _m = 10 min corresponding to d ≈ 29 nm; beyond this t _m(d) value, H _c gradually decreases. Meanwhile, the increase of t _m always reduces the saturation magnetization (M _s) from ∼69 emu g^-1 for t _m = 0 to 35 emu g^-1 for t _m = 180 min. The results collected as analyzing X-ray absorption data have indicated a mixed valence state of Fe^2+,3+ and Co²⁺ ions. We think that the migration and redistribution of these cations between the tetrahedral and octahedral sites together with lattice distortions and defects induced by the milling process have impacted the magnetic properties of the CoFe₂O₄ nanoparticles.

Host Transcriptome Analysis of Ferret Tissues Following Henipavirus Infection

Ferrets are commonly used as experimental models of infection for a variety of viruses due to their susceptibility to human respiratory viruses and the close resemblance of pathological outcomes found in human infections. Even though ferret-specific reagents are limited, the use of ferrets as a preclinical experimental model of infection has gained considerable interest since the publication of the ferret transcriptome and draft ferret genome. These advances have made it feasible to easily perform whole-genome gene expression analysis in the ferret infection model. Here, we describe methods for genome-wide gene expression analysis using RNA sequence (RNAseq) data obtained from the lung and brain tissues obtained from experimental infections of Hendra (HeV) and Nipah (NiV) viruses in ferrets. We provide detailed methods for RNAseq and representative data for host gene expression profiles of the lung tissues that show early activation of interferon pathways and later activation of inflammation-related pathways.

Clinical Outcomes of Stereotactic Ablative Radiotherapy for All Stages of Non-Small Cell Lung Cancer; Definitive versus Consolidative

Background and Objectives: Stereotactic ablative radiotherapy (SABR) is not confined to early stage non-small cell lung cancer (NSCLC) and has a potential role in stage IV disease. We aimed to evaluate the effect of SABR on local control rates and survival outcomes in patients with all stages of NSCLC according to the treatment aim. Materials and Methods: We retrospectively reviewed the medical records of 88 patients with NSCLC who received SABR at the Korea University Guro Hospital between January 2015 and March 2021. Among these, 64 patients with stage I–II NSCLC ineligible for surgery were treated with a definitive aim. Twenty-four patients with stage IV limited metastatic NSCLC showing a favorable response to prior systemic therapy were treated with a consolidative aim. Results: The median follow-up time was 34 (range: 5–88) months. Thirty-one patients developed recurrence (35.2%), with distant metastasis being the most common (25/31, 80.6%). In-field local recurrence occurred in four patients (4/88 patients, 4.5%). For patients treated with definitive SABR, the 3-year overall survival (OS) and disease-free survival (DFS) rates were 91.8% and 58.6%, respectively. In patients treated with consolidative SABR, the 3-year OS and DFS rates were 86.7% and 53.8%, respectively. With respect to treatment-related pulmonary toxicity, grade 3 radiation pneumonitis incidence requiring hospitalization was 2.3% (2/88). Conclusions: Definitive SABR is appropriate for medically inoperable or high surgical risk patients with early stage NSCLC with acceptable treatment-related toxicities. Consolidative SABR improves local control rates and helps achieve long-term survival in patients with limited metastatic NSCLC.

Oncologic outcomes according to the level of disease burden in patients with metachronous distant metastases from uterine cervical cancer: a Korean Radiation Oncology Group study (KROG 18-10)

Objective

This study aimed to evaluate the oncologic outcomes according to disease burden in uterine cervical cancer patients with metachronous distant metastases.

Methods

Between 2005 and 2015, 163 patients with metachronous distant metastases from uterine cervical cancer after receiving a definitive therapy were evaluated at seven institutions in Korea. Low metastatic burden was defined as less than 5 metastatic sites, whereas high metastatic burden was others. Each metastasis site was divided based on the lymph node (LN) and organs affected. The overall survival (OS) and progression-free survival (PFS) were assessed. Cox proportional hazards models, including other clinical variables, were used to evaluate the survival outcomes.

Results

The median follow-up duration was 22.2 months (range: 0.3–174.8 months). Para-aortic LNs (56.4%), lungs (26.4%), supraclavicular LNs (18.4%), and peritoneum (13.5%) were found to be the common metastasis sites. Among 37 patients with a single metastasis, 17 (45.9%) had LN metastases and 20 (54.1%) had organ metastases. The 1- and 2-year OS rates were 73.9% and 55.0%, respectively, whereas the PFS rates were 67.2% and 42.9%, respectively. SCC Ag after recurrence and high metastatic burden were significant factors affecting the OS (p=0.004 and p<0.001, respectively). Distant organ recurrence, short disease-free interval (≤2 years), and high metastatic burden were unfavorable factors for PFS (p=0.003, p=0.011, and p=0.002, respectively).

Conclusion

A favorable oncologic outcome can be expected by performing salvage treatments in selected patients with a long disease-free interval, low metastatic burden, and/or lymphatic-only metastasis.

This multicenter study aimed to evaluate the oncologic outcomes according to disease burden in uterine cervical cancer patients with metachronous distant metastases. Long disease-free interval, low metastatic burden, and/or lymphatic-only metastasis are good prognostic factors for metachronous distant metastatic cervical cancer.

Salvage External Beam Radiotherapy after Incomplete Transarterial Chemoembolization for Hepatocellular Carcinoma: A Meta-Analysis and Systematic Review

Background and objective: Although transarterial chemoembolization (TACE) has been the commonest local modality for hepatocellular carcinoma (HCC), incomplete repsonse occurs especially for tumors with a large size or difficult tumor accessment. The present meta-analysis assessed the efficacy and feasibility of external beam radiotherapy (EBRT) as a salvage modality after incomplete TACE. Materials and Methods: We systematically searched the PubMed, Embase, Medline, and Cochrane databases. The primary endpoint was overall survival (OS), and the secondary endpoints included the response ratem toxicity of grade 3, and local control. Results: Twelve studies involving 757 patients were included; the median of portal vein thrombosis rate was 25%, and the pooled median of tumor size was 5.8 cm. The median prescribed dose ranged from 37.3 to 150 Gy (pooled median: 54 Gy in *EQD2). The pooled one- and two-year OS rates were 72.3% (95% confidence interval (CI): 60.2-81.9%) and 50.5% (95% CI: 35.6-65.4%), respectively; the pooled response and local control rates were 72.2% (95% CI: 65.4-78.1%) and 86.6 (95% CI: 80.1-91.2%) respectively. The pooled rates of grade ≥3 gastrointestinal toxicity, radiation-induced liver disease, hepatotoxicity, and hematotoxicity were 4.1%, 3.5%, 5.7%, and 4.9%, respectively. Local control was not correlated with intrahepatic (p = 0.6341) or extrahepatic recurrences (p = 0.8529) on meta-regression analyses. Conclusion: EBRT was feasible and efficient in regard to tumor response and control; after incomplete TACE. Out-field recurrence, despite favorable local control, necessitates the combination of EBRT with systemic treatments. *Equivalent dose in 2 Gy per fraction scheme.

Strong correlation between flux pinning and epitaxial strain in the GdBa2Cu3O7-x /La0.7Sr0.3MnO3 nanocrystalline heterostructure

The effect of magnetic flux pinning is investigated in GdBa₂Cu₃O₇ (GdBCO) thin films with two different types of ferromagnetic La_0.7Sr_0.3MnO₃ (LSMO) buffers (nanoparticles and a layer) deposited on an STO substrate. Magnetization analyses reveal the presence of multiple flux pinning mechanisms responsible for the improvement in the critical current density of GdBCO films. While core pinning becomes a dominant pinning mechanism in GdBCO films with LSMO nanoparticles, a hybrid effect of magnetic-volume and core-point pinning is observed in GdBCO films with LSMO layers. Examinations of local structures for both LSMO and GdBCO using extended X-ray absorption fine structure spectroscopy (EXAFS) exhibit a close relation between the parameters in the pinning force scaling and the length ratio of the Mn–O bond to the Cu–O bond. This result implies that the origin of core pinning is probably attributed to epitaxial strain induced by lattice mismatch between LSMO and GdBCO. Therefore, an appropriate strain state of LSMO is required for an effective operation of magnetic pinning.

The effect of magnetic flux pinning is investigated in GdBa₂Cu₃O₇ (GdBCO) thin films with two different types of ferromagnetic La_0.7Sr_0.3MnO₃ (LSMO) buffers (nanoparticles and a layer) deposited on an STO substrate.

Modulation of rumen fermentation and microbial community through increasing dietary cation-anion difference in Chinese Holstein dairy cows under heat stress conditions

AIMS

The effect of increasing dietary cation-anion difference (DCAD) on rumen fermentation and ruminal microbial community in dairy cows under heat stress (HS) conditions were evaluated.

METHODS AND RESULTS

This study was performed as a two-period cross-over design during the summer season, with eight lactating dairy cows randomly distributed to either a control DCAD diet (CON: 33·5 mEq/100 g DM) or high DCAD diet (HDCAD: 50·8 mEq/100 g DM). Throughout the present study, the temperature and humidity index (THI; 80·2 ± 4·29) was generally elevated above the threshold (THI = 72) that is reported to cause HS in lactating dairy cows. Rumen liquid samples were collected on 15 and 21 d during each 21 d-period. The absolute concentration of ruminal total volatile fatty acid (TVFA) in HDCAD treatment was significantly (P < 0·05) higher than those in the control, whilst the ruminal pH, NH₃ -N, and VFA molar percentages were unaffected through increasing DCAD. Furthermore, the copy numbers of the cellulolytic bacteria Ruminococcus albus and Ruminococcus flavefaciens in rumen fluid significantly (P < 0·05) rose along with the increment of DCAD. Although the Alpha diversity indexes and the bacterial microbiota structure were unaffected, increasing DCAD significantly (P < 0·05) enriched the phylum Fibrobacteres and genus Fibrobacter in the microflora of rumen fluid, whilst the genera Flexilinea and Dubosiella were the most differentially abundant taxa in the control.

CONCLUSIONS

Increasing DCAD under HS conditions resulted in a greater concentration of total VFA without affecting rumen bacteria diversity or structure, although the enrichment of some cellulolytic/hemicellulolytic bacteria was observed.

SIGNIFICANCE AND IMPACT OF THE STUDY

The present study provides information on the modulation of rumen fermentation and microbial community through the increment of DCAD in Holstein dairy cows under HS conditions.

Physical activity status in relation to quality of life and dietary habits in breast cancer survivors: subset analyses of KROG 14-09 nationwide questionnaire study

PURPOSE

We investigated the relationship of physical activity with dietary habits and quality of life (QoL) in breast cancer survivors in accordance with the recommendations of the American Cancer Society.

METHODS

Data of 928 breast cancer survivors were obtained from the KROG 14-09 study to measure QoL in early phase after adjuvant radiotherapy. According to the extent of physical activity, survivors were divided into four groups: inactivity (0-149 min/week, N = 144), regular activity (150-450 min/week, N = 309), moderate activity (451-900 min/week, N = 229), and marked activity (901-1800 min/week, N = 164) excluding hyperactivity (> 1800 min/week, N = 82) as it is a difficult condition to recommend to survivors. Global physical activity questionnaire, 5-dimensional questionnaire by EuroQoL (EQ-5D-3L), QoL Questionnaire-breast cancer (QLQ-BR23) from EORTC, and dietary habits were surveyed. A linear-to-linear association test for EQ-5D-3L and Kruskal-Wallis analysis for QLQ-BR23 and dietary habit were conducted.

RESULTS

Overall, 15.5% respondents (144/928) were classified as physically inactive. The trends of frequent intake of fruits (p = 0.001) and vegetable (p = 0.005) and reluctance toward fatty food (p < 0.001) were observed in physically active groups. Mobility (p = 0.021) and anxiety (p = 0.030) of EQ-5D-3L, and systemic therapy side effect (p = 0.027) and future perspective (p = 0.008) of QLQ-BR23 were better in physically active groups besides body image (p = 0.003) for the survivors with breast-conserving surgery. However, moderate and marked activities did not further improve QoL than regular activity.

CONCLUSION

Physicians and care-givers have to pay attention to inactive survivors to boost their physical activity, thereby facilitating a better QoL and dietary habit.

Long-term outcomes of immediate autologous breast reconstruction after definite adjuvant therapy in intermediate and locally advanced breast cancer

Background

To analyze oncologic outcomes and reconstruction quality in locally advanced stage breast cancer after performing immediate autologous breast reconstruction (IABR).

Methods

From 2007 to 2014, data of patients aged ≤70 years old with stage II-III breast cancer who received total mastectomy (TM) were extracted from medical records. Exclusion criteria were: previous contralateral breast cancer, follow-up loss before adjuvant therapy completion, and artificial reconstruction. Patients were divided into two groups: (I) TM alone, and (II) TM + IABR. Overall survival (OS) and loco-regional recurrence free survival (LRRFS) were calculated. Times of minor revision, abnormal image findings in breast, and change of breast height were observed.

Results

Sixty-one of 188 patients received IABR after TM. Stage IIIB-C was the most important prognostic factor for OS (P<0.001) and LRRFS (P<0.001). For stage II, five-year TM and TM + IABR OS rates were 96.8% and 100% (P=0.324), respectively. For stage IIIB-C, five-year TM and TM + IABR OS rates were 57.6% and 62.5% (P=0.544), respectively. For stage II, five-year TM and TM + IABR LRRFS were 98.1% and 95.7% (P=0.998), respectively. For stage IIIB-C, five-year TM and TM + IABR LRRFS were 70.8% and 62.5% (P=0.378), respectively. Two major complications were observed after IABR. Minor revisions, abnormal image findings, and change of breast height were common without showing significant relation with adjuvant radiotherapy or tumor stage.

Conclusions

IABR showed feasible oncologic outcomes in 5-year follow-up. Adjuvant radiotherapy had little effect on quality of reconstruction. However, IABR in advanced stage should be cautiously applied considering expected survival and minor problems after IABR.

Sequential simulation computed tomography allows assessment of internal rectal movements during preoperative chemoradiotherapy in rectal cancer

Purposes

The purpose of this study was to assess the internal rectal movement and to determine the factors related to extensive internal rectal movement using sequential simulation computed tomography (CT) images.

Materials and Methods

From 2010 to 2015, 96 patients receiving long-course preoperative chemoradiotherapy were included in our retrospective study. The initial simulation CT (Isim-CT) and follow-up simulation CT (Fsim-CT) for a boost were registered according to the isocenters and bony structure. The rectums on Isim-CT and Fsim-CT were compared on four different axial planes as follows: (1) lower pubis symphysis (AX_VERYLOW), (2) upper pubis symphysis (AX_LOW), (3) superior rectum (AX_HIGH), and (4) middle of AX_LOW and AX_HIGH (AX_MID). The involved rectum in the planning target volume was evaluated. The maximal radial distances (MRD), the necessary radius from the end of Isim-CT rectum to cover entire Fsim-CT rectum, and the common area rate (CAR) of the rectum (CAR, (Isim-CT∩Fsim-CT)/(Isim-CT)) were measured. Linear regression tests for the MRDs and logistic regression tests for the CARs were conducted.

Results

The mean ± standard deviation (mm) of MRDs and CAR <80% for AX_VERYLOW, AX_LOW, AX_MID, and AX_HIGH were 2.3 ± 2.5 and 8.9%, 3.0 ± 3.7 and 17.4%, 4.0 ± 5.2 and 27.1%, and 4.1 ± 5.2 and 25%, respectively. For MRDs and CARs, a higher axial level (AX_VERYLOW/AX_MID-HIGH, P = 0.018 and P = 0.034, respectively), larger bladder volume (P = 0.054 and P = 0.017, respectively), smaller bowel gas extent (small/marked, P = 0.014 and P = 0.001, respectively), and increased bowel gas change (decrease/increase, both P < 0.001) in rectum were associated with extensive internal rectal movement in multivariate analyses.

Conclusions

As a result of following internal rectal movement through sequential simulation CT, the rectum above the pubis symphysis needs a larger margin, and bladder volume and bowel gas should be closely observed.

Abstract P5-16-18: Oncologic outcomes and reconstruction quality of immediate autologous breast reconstruction in intermediate and locally advanced breast cancer

Purpose: We analyzed oncologic outcomes and reconstruction quality in locally advanced stage breast cancer after performing immediate autologous breast reconstruction (IABR).

Methods: From 2007 to 2014, data of patients with stage II-III breast cancer of ≤ 70-years-old who received total mastectomy (TM) from two institutions were extracted. Exclusion criteria were: previous contralateral breast cancer, follow-up loss before adjuvant therapy completion, and artificial reconstruction. Patients were divided into two groups; 1) TM alone and 2) TM+IABR. Overall survival (OS) and loco-regional recurrence free survival (LRRFS) were calculated and minor revision, abnormal volume on CT, and breast height change were observed.

Results: Sixty-one of 188 patients received IABR after TM. Neoadjuvant chemotherapy and postoperative radiotherapy was done in 27 and 80 patients, respectively. Fifty-nine percent, 19.2%, and 21.8% of patients were in stage II, IIIA, and IIIB-C, respectively. Stage IIIB-C was the most important prognostic factor for OS and LRRFS. In a median of 56.8 follow-up months, 5-year TM and TM+IABR OS rate were 96.8% and 100% for stage II (P=0.324) and 57.6%, 95.5% and 91.7% for stage IIIA (P=0.698), and 62.5% for stage IIIB-C (P=0.544), respectively. Five-year TM and TM+IABR LRRFS were 98.1% and 95.7% for stage II (P=0.998)91.1% and 100% for stage IIIA (P=0.277), and 70.8% and 62.5% for stage IIIB-C (P=0.378), respectively. However, two locoregional failures after 5-years were developed in stage IIIB-C of TM+IABR at 71 and 94 months. Minor revisions 3 months of IABR, including two major complications, were done in 49.2%. The reduction of breast height was 21.2% (11/52) and 31.9% (15/47) in about 18 months and about 42 months observations after IABR, respectively. The volume of abnormal imaging was over 10 cc in 27.3% (15/55) on CT of 6 months after IABR. Although minor revisions, abnormal volume on CT, and breast height change were common, they were not related to therapeutic methods, including radiotherapy and tumor stage.

Conclusions: In about 5-years follow-up, IABR did not aggravate oncologic outcomes, and adjuvant radiotherapy was not closely related with quality of reconstruction. It must be considered, however, that absolute oncologic outcomes of advanced stage were not sufficient, and minor problems post-IABR were commonly developed.

Citation Format: Yoon WS, Yang DS, Son GS, Woo SU, Kim D-W, Dhong E-S, Chang YW. Oncologic outcomes and reconstruction quality of immediate autologous breast reconstruction in intermediate and locally advanced breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-18.

Is stereotactic body radiotherapy for ultra-central lung tumor a feasible option? A systemic review and meta-analysis

INTRODUCTION

Ultra-central (UC) tumors, which are generally defined as tumors directly abutting the proximal bronchial tree, are difficult to treat with stereotactic body radiotherapy (SBRT) owing to possible serious complications. This systemic review and meta-analysis analyzed the early experiences and evaluated the efficacy and feasibility of SBRT for UC tumors.

METHODS AND MATERIALS

The present study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systemic searches of the EMBASE, PubMed, MEDLINE, and Cochrane library electronic databases were performed. The primary endpoints were two-year local control (LC), overall survival (OS), and grade ≥3 complication rates. A random-effects model was used to determine the pooled rates of the primary endpoints. Grade 5 complications were descriptively assessed.

RESULTS

Nine studies involving 291 patients with UC tumors who underwent SBRT were included. The pooled two-year LC, two-year OS, and grade ≥3 complication rates were 96.7% (95% confidence interval [CI]: 91.0-98.9), 57.7% (95% CI: 32.0-79.8), and 23.2% (95% CI: 11.8-40.5), respectively. The incidence of grade 5 complication was 0-22% and was 0% in three of eight available studies. Hemorrhage (68.2%) was the commonest fatal complication. The risk factors for fatal hemoptysis included anticoagulant use, excessive maximum irradiation dose, endobronchial involvement, squamous histology, and bevacizumab exposure.

CONCLUSIONS

SBRT for UC tumors confers efficient LC, although the risk of complications was not negligible. Control of possible risk factors of hemorrhage and dose optimization through further studies are warranted.

Clinical Significance of Gender and Body Mass Index in Asian Patients with Colorectal Cancer

Objective: Colorectal cancer is a disease closely associated with anthropometric values. This study aimed to evaluate the clinical relevance of gender and body mass index (BMI) with colorectal cancer using a Korean nationwide cohort. Methods: Data of colorectal cancer cohorts between 2012 and 2013 were acquired from the Health Insurance Review and Assessment Service. All patients underwent surgery due to colorectal cancers. Stage IV patients were excluded due to possible clinical heterogeneity. BMI was classified with the World Health Organization criteria. Results: A total of 31,756 patients were analyzed. The underweight group had 33% higher risk of stage III disease (p<0.001). The overweight and obese groups had 20% and 19% lower risk of stage III (p<0.001 and p=0.002, respectively). The underweight and obese groups had higher risk of longest hospitalization period quartile (≥19 days), with odds ratio of 2.26 (p<0.001) and 1.33 (p<0.001), respectively. The overweight group had a 22% lower risk of the longest hospitalization period quartile (p=0.002). Females had 12% lower risk of distal cancer than males (p<0.001). There was no significant relationship between cancer stage and gender. The proportions of patients who were <50 years and ≥70 years old were higher in the females, and the proportions of patients in their 50s and 60s were higher in the males. Conclusions: Cancer stages and hospitalization period varied depending on BMI. Disease location and the age distribution were affected by gender.

Questionnaire study of the dietary habits of breast cancer survivors and their relationship to quality of life (KROG 14-09)

We evaluated the dietary habits of breast cancer survivors and investigated the relationship with quality of life (QoL), with 1,156 survivors recruited from 17 institutions. We used the Questionnaire Survey of Dietary Habits of Korean Adults (Q-DH-KOR) comprising 25 questions. The following indices were derived as follows: (1) quality of healthy dietary habits (Q-HD)-eight questions on number of meals, regularity, quantity, duration, skipping breakfast, dinner with companion(s), overeating and late-night snacks; (2) habits of nutritional balance (H-NB)-questions on consuming five food categories (grains, fruits, proteins, vegetables and dairy products); and (3) habits of unhealthy foods (H-UF)-questions on consuming three food categories (fatty, instant and fast foods). The times and regularity of meals, frequency of skipping breakfast, dinner with companion(s) and overeating were better in groups with high symptomatic and functional QoL. Symptomatic QoL positively affected Q-HD and H-NB (p < 0.001 and p = 0.024 respectively) and negatively affected H-UF (p = 0.02). Breast cancer survivors more frequently ate from the fruit, protein and vegetable categories than did the control group, with lower H-UF and higher Q-HD values (p < 0.001 and p < 0.001 respectively). Our findings supported the relationship between QoL and dietary habit and showed healthier dietary habits of breast cancer survivors than controls.

The expression of insulin receptor substrate 1 and estrogen receptor as prognostic factor on breast cancer patient

Background

Insulin receptor substrate 1 (IRS-1) has been known to be an associated factor with breast cancer progression. However, there has been little study with respect to the relationship between the expression of IRS-1 and breast cancer prognosis in clinical practice. In this study, we evaluated the impact of the estrogen receptor (ER) and IRS-1 on the recurrence and survival of breast cancer patients.

Methods

We analyzed the pathologic finding of 376 tissue samples from breast cancer patients who received proper treatment between January 1990 and December 2006 using the tissue microarray. We measured the expression of ER and IRS-1 by immunohistochemistry staining and analyzed the difference of recurrence and survival rate in each subgroup of ER and IRS-1.

Results

Our results show that there is a significant difference of disease-free survival (DFS) according to ER and IRS-1 subgroups with both univariate and multivariate analyses. Specifically, ER-positive and IRS-1-positive breast cancer samples showed improved DFS compared to ER-positive and IRS-1-negative breast cancer (adjusted hazard ratio: 2.17; 95% confidence interval: 1.15-4.09; P = 0.01). There was a difference of overall survival according to ER and IRS-1 subgroups by univariate analysis (P = 0.01), but not by multivariate analysis (P = 0.36).

Conclusion

ER and IRS-1 subgroups appear to be critical factors for the prediction of breast cancer recurrence. In particular, we suggest that the patients who have ER-positive and IRS-1-negative breast cancer undergo more aggressive treatment because they have poorer prognoses.

The role of external beam radiotherapy for hepatocellular carcinoma patients with lymph node metastasis: a meta-analysis of observational studies

Purpose

Lymph node metastasis of hepatocellular carcinoma is categorized as advanced in Barcelona Clinic of Liver Cancer staging, and sorafenib is a sole treatment recommended. However, appliance of local treatment including external beam radiotherapy (EBRT) has not been uncommon. We performed a meta-analysis and systemically reviewed current literature to evaluate the efficacy and safety of EBRT.

Methods

PubMed, Medline, Cochrane library, and Embase were systemically searched until December 17, 2017. The primary endpoint of analyses was response rate (RR), and 1-year overall survival and complication rates of grade ≥3 were secondary endpoints. Complications were primarily assessed descriptively.

Results

A total of 8 studies comprising 521 patients were included. The pooled RR was 73.1% (95% confidence interval [CI]: 63.6–80.9), and high-dose EBRT groups had better RR than the low-dose group (82.2% [95% CI: 74.4–88.1] vs 51.1% [95% CI: 40.3–61.7]; P=0.001]. The pooled 1-year overall survival rate was 41.0% (95% CI: 32.9–49.6). Six studies assessed the survival benefit according to RR, and 5 (83.3%) of these 6 studies reported statistically significant survival benefit. The most common grade ≥3 toxicities were thrombocytopenia and gastrointestinal complication, with pooled rates of 3.4% (95% CI: 1.2–9.5) and 3.5% (95% CI:1.7–7.2), respectively.

Conclusion

EBRT showed a pooled RR of 73.1% and was safely performed. EBRT might palliate symptoms through tumor reductions and improve survival. Use of sorafenib combined or sequentially with EBRT can be recommended rather than monotherapy.

External beam radiation therapy to hepatocellular carcinoma involving inferior vena cava and/or right atrium: A meta-analysis and systemic review

PURPOSE

Hepatocellular carcinoma (HCC) involving inferior vena cava (IVC) and/or right atrium (RA) is a very rare but serious disease. The objective of this meta-analysis was to assess efficacy and safety of external beam radiotherapy (EBRT) for HCC involving IVC and/or RA.

MATERIALS AND METHODS

Systematic search of Pubmed, MEDLINE, EMBASE, and Cochrane library published was performed. Primary endpoints were 1-year overall survival (OS) rate and 2-year OS rates. Secondary endpoints were response rate, local control (LC) rate, and grade ≥3 toxicities. According to heterogeneity evaluated with Cochran Q test and I² statistics, meta-analysis was performed using either random or fixed model.

RESULTS

A total of 8 studies and 9 cohorts were included, encompassing 164 patients. Pooled 1- and 2-year OS rates were 53.6% (95% CI: 45.7-61.3%) and 36.9% (95% CI: 27.2-42.4%), respectively. Pooled response rate and LC rate were 59.2% (95% CI: 39.0-76.7%) and 83.8% (95% CI: 78.8-97.1%), respectively. Only one study reported 2 grade ≥3 toxicities, an esophageal rupture and a pulmonary embolism cases. The overall rate of possible grade ≥3 complications was 1.2% (2 of 164).

CONCLUSIONS

EBRT is a feasible and safe option to palliate HCC with IVC and/or RA invasion.

An assessment of quality of life for early phase after adjuvant radiotherapy in breast cancer survivors: a Korean multicenter survey (KROG 14-09)

BACKGROUNDS

Quality of life (QoL) has become a major concern as the survival time of breast cancer increases. We investigated the changes in QoL through comprehensive categorical analysis, for the first three years after breast cancer treatment including radiotherapy.

METHODS

A total of 1156 patients were enrolled from 17 institutions. All survivors were grouped according to a surveillance period of 9-15 months (first year), 21-27 months (second year), and 33-39 months (third year) from the end of radiotherapy. The 5-dimensional questionnaire by the EuroQol group (EQ-5D) and the EORTC Quality of Life Questionnaire; breast cancer specific module (QLQ-BR23) were checked by self-administrated method.

RESULTS

First, second and third year groups comprised 51.0, 28.9, and 21.0%. In EQ-5D-3 L (3-Likert scale) analysis, pain/discomfort and anxiety/depression categories showed lower QoL. In multivariate analyses of EQ-5D-VAS (visual-analogue scale), categories of pain/discomfort and self-care were improved with time; axillary dissection was a significant clinical factor deteriorates pain/discomfort, self-care and usual activities. In QLQ-BR23 analysis, the lowest scored category was sexual activity, followed by sexual enjoyment, future perspective, and hair loss, and the best scored category was breast symptoms. In multivariate analyses, arm symptoms, breast symptoms and body image were improved with time.

CONCLUSIONS

Categories of pain/discomfort and self-care in EQ-5D-VAS, arm/breast symptoms and body image in QLQ-BR23 were improved, while categories of anxiety/depression and future perspective BR23 were not, suggesting necessity of psychosocial support. This research provides comprehensive information on the categorical aspects of QoL and changes during early follow-up after breast cancer treatment.

Abstract P3-12-17: Can radiation dosimetric parameters explain severe skin reaction during adjuvant whole breast irradiation applying field-in-field technique?

Aim: Although modern radiotherapy such as field-in-field technique decreased the radiation toxicity, skin reaction is still frequent and main problem during adjuvant whole breast irradiation. Our study investigated various radiation dosimetric and clinical parameters as the risk factors of severe skin reaction.

Methods: From January 2012 to December 2014, total 219 patients with breast conserving surgery and adjuvant whole breast irradiation were retrospectively reviewed. All patients took both whole breast irradiation (50 Gy/25 fractions) and boost to the tumor bed (10 - 15 Gy). Skin reaction was measured by comparing the photography of radiation field between the first day of whole breast irradiation and boost therapy. For each axilla and inferior fold, the intensity (score 1 to 5) and extent (score 0 to 1) of erythema were recorded and summed. The severe skin reaction was defined as score 5 or 6. The relations of various radiation dosimetric parameters for radiotherapy planning, personal breast characteristics and clinical factors to severe skin reaction were evaluated using the Logistic regression tests.

Results: Total 75 (34%) and 57 (26%) patients showed the severe skin reaction to axilla and inferior fold, respectively. The variables of P &lt; 0.2 in univariate analyses including age, the body mass index, the breast height, the V100, the calculated point dose in radiation planning system, the breast separation, the field size, and the gradient of inferior fold entered the multivariate analyses. Age (P=0.013 (OR = 0.950, 95% CI 0.913 - 0.989)), the body mass index (P = 0.015 (OR = 1.123, 95% CI 1.023 - 1.233)), the calculated axilla point dose (P = 0.091 (OR = 1.064, 95% CI 0.990 - 1.142)), and the gradient of inferior fold (P = 0.073 (OR = 1.029, 95% CI 0.997 - 1.063)) were risk factors for severe axilla skin reaction, whereas age (P = 0.018 (OR = 0.948, 95% CI 0.907 - 0.991)) and the V100 (P &lt; 0.001 (OR = 1.005, 95% CI 1.003 - 1.007)) were for severe inferior fold skin reaction.

Conclusion: In addition to clinical factor and personal breast characteristics, the radiation dosimetric parameters such as calculated point dose and V100 could be another predictive factors of severe skin reaction.

Citation Format: Yoon WS, Lee NK, Lee JA, Yang DS, Kim CY, Son GS, Chang YW. Can radiation dosimetric parameters explain severe skin reaction during adjuvant whole breast irradiation applying field-in-field technique?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-17.

Treatment outcomes of curative radiotherapy in patients with vulvar cancer: results of the retrospective KROG 1203 study

PURPOSE

We evaluated the prognostic factors and clinical outcomes of 56 patients with vulvar cancer treated with curative radiotherapy (RT) or concurrent chemoradiotherapy.

MATERIALS AND METHODS

Overall survival (OS) and disease-free survival (DFS) were assessed retrospectively. Prognostic factors evaluated included age, International Federation of Gynecology and Obstetrics (FIGO) stage, TNM classification, tumor size, treatment modality, RT duration, and RT field. The association between the tumor human papillomavirus (HPV) status and survival was analyzed in 35 patients.

RESULTS

During the median follow-up of 2.8 years (range, 0.3 to 18.9 years), 21 patients (37.5%) experienced treatment failure. Fifteen patients (27%) had local failure: nine (16%) local failure only, three (5%) locoregional failure, two (4%) local and distant failure, and one (2%) locoregional and distant failure. Of 56 patients, seven (13%) had persistent disease at the first follow-up at 2 months and all but one died within a year after completing RT. The 5-year OS and DFS were 51.6% and 44.0%, respectively. In multivariate analysis, clinical size ≥3 cm predicted a poor prognostic factor for DFS (p = 0.040) and age (≥70 years) was poor prognostic for DFS (p = 0.032) and OS (p = 0.048). Patients with HPV-positive tumors tended to have better 5-year OS and DFS, but the differences were not significant statistically.

CONCLUSION

Clinical size ≥3 cm was a significant prognostic factor for DFS. However, age was the most important prognostic factor for DFS and OS in patients treated with curative RT. Further studies are needed to determine which treatment should be considered for old age ≥70 years.

Association of aldehyde dehydrogenase 1 expression and biologically aggressive features in breast cancer

Aldehyde dehydrogenase 1 (ALDH1) has been regarded as a breast cancer stem cell marker. Several studies have reported that ALDH1 expression is associated with poor prognosis in breast cancer. We aimed, therefore, to determine the prognostic value of ALDH1 expression and its association with several biomarkers in breast cancer tissue using immunohistochemistry. Furthermore, we investigated the characteristics of and differences between cellular and stromal expression of ALDH1. We performed tissue microarray (TMA) analysis of 425 breast cancer tissue samples collected during surgery. Immunohistochemical staining was then performed to measure the expression of ALDH1 and other breast cancer biomarkers. Statistical analysis of the relationship between ALDH1 expression and clinicopathologic characteristics was performed for 390 TMA samples. We found that ALDH1 was expressed in 71 cases (18.2%) in the tumor cells and/or stroma. Of these cases, 38 (9.7%) showed ALDH1 expression in tumor cells and 38 (9.7%) showed ALDH1 expression in the stroma. ALDH1 expression was significantly associated with markers of a poor prognosis, such as young age, estrogen receptor negativity, progesterone receptor negativity, a high histological grade, and a high Ki-67 index. However, ALDH1 expression was not associated with p53, transforming growth factor-beta, Gli-1, YKL-40, or sonic hedgehog expression status. With regard to the expression site, the clinical characteristics did not differ between cases of cellular expression and those of stromal expression. However, ALDH1 expression in tumor cells was correlated with hormone receptor status, histological grade, molecular subtype, epidermal growth factor receptor expression status, and cytokeratin 5/6 expression status while stromal expression of ALDH1 was only correlated with hormone receptor status. Overall, these findings suggest that ALDH1 expression in tumor tissue is associated with a biologically aggressive phenotype.

KEYWORDS

ALDH1, biologically aggressive, breast cancer.

The effectiveness of gadolinium MRI to improve target delineation for radiotherapy in hepatocellular carcinoma: a comparative study of rigid image registration techniques

To achieve consistent target delineation in radiotherapy for hepatocellular carcinoma (HCC), image registration between simulation CT and diagnostic MRI was explored. Twenty patients with advanced HCC were included. The median interval between MRI and CT was 11 days. CT was obtained with shallow free breathing and MRI at exhale phase. On each CT and MRI, the liver and the gross target volume (GTV) were drawn. A rigid image registration was taken according to point information of vascular bifurcation (Method[A]) and pixel information of volume of interest only including the periphery of the liver (Method[B]) and manually drawn liver (Method[C]). In nine cases with an indefinite GTV on CT, a virtual sphere was generated at the epicenter of the GTV. The GTV from CT (VGTV[CT]) and MRI (VGTV[MR]) and the expanded GTV from MRI (V+GTV[MR]) considering geometrical registration error were defined. The underestimation (uncovered V[CT] by V[MR]) and the overestimation (excessive V[MR] by V[CT]) were calculated. Through a paired T-test, the difference between image registration techniques was analyzed. For method[A], the underestimation rates of VGTV[MR] and V+GTV[MR] were 16.4 ± 8.9% and 3.2 ± 3.7%, and the overestimation rates were 16.6 ± 8.7% and 28.4 ± 10.3%, respectively. For VGTV[MR] and V+GTV[MR], the underestimation rates and overestimation rates of method[A] were better than method[C]. The underestimation rates and overestimation rates of the VGTV[MR] were better in method[B] than method[C]. By image registration and additional margin, about 97% of HCC could be covered. Method[A] or method[B] could be recommended according to physician preference.

Intraoperative Radiation Therapy for Gallbladder Cancer: Experience at a Single Institution

BACKGROUND/AIMS

To investigate the survival outcome of intraoperative radiation therapy for patients with gallbladder cancer on the basis of experience at a single institution.

METHODOLOGY

The medical records of 8 patients with gallbladder cancer who were treated with intraoperative radiation therapy during surgical resection or palliative surgery were retrospectively analyzed. The primary endpoint was overall survival. The median follow-up time was 20.8 months.

RESULTS

The median survival time was 15.0 months. Overall survival for all patients was 75.0% at 1 year, 37.5% at 3 years, and 25.0% at 5 years. Three patients underwent complete resection, and 5 patients had residual tumor after resection or palliative surgery. The 3-year OS rate for 3 patients with no residual tumor after curative resection was 66.7%, with a mean survival time of 122.6 months, whereas the 3-year OS rate for 5 patients with macroscopic residual diseasewas 0% with a mean survival time of 13.5 months (P = 0.014).

CONCLUSIONS

The results of the present study suggest that intraoperative radiation therapy with or without external beam radiation therapy was safe and beneficial for patients who underwent curative resection with negative margins and allows the possibility of long-term survival.

Abstract P2-02-08: MRI in predicting pathological response of breast cancer after neoadjuvant chemotherapy: Correlation with tumor size and morphology changes

PURPOSE

Contrast enhanced MR imaging is widely used to monitor the response of neoadjuvant chemotherapy (NAC) in breast cancer patients. The objectives of the study are 1) to assess the response of neoadjuvant chemotherapy (NAC) according to molecular biomarker status using MRI, 2) to evaluation of changes in morphological variation, and 3) to compare MR imaging-pathological size discrepancy depending on molecular biomarker status.

MATERIALS AND METHODS

Between May 2007 and March 2012, a total of 47 patients (age range, 34-65 years; mean age, 48 years) underwent NAC prior to surgery. Among them, 34 patients who performed MRI before and after NAC were enrolled. The extent of the lesion is measured by longest diameter. The response to NAC was calculated as reduction rate between pre NAC MRI and post NAC MRI. Histological grading system - Miller and Payne grade - was also recorded. Patients were divided into subgroups based on human epidermal growth factor receptor 2 (HER2), hormone receptors (HRs), and the proliferation marker Ki-67 status. The morphologic changes were classified into 1) concentric reduction, 2) fragmentation, 3) non-mass like, and 4) architectural distortion.

RESULTS

Total of 34 lesions from 34 patients were included. Among them, 12 lesions (35.3%) were pathologically proven to have no residual tumor (Miller and Payne grade 5). The mean MR reduction rate tended to be higher in HER2-positive (62.7%) and triple negative subgroups (61.9%) than HR-positive subgroup (47.7%). The mean MR imaging-pathologic size discrepancy tended to be smaller in triple negative subgroup (0.5cm) than HER2-positive (1.2cm) and HR-positive subgroups (1.4cm). All results showed no statistical significance (P&gt;0.05). Ki-67 expression showed no significant correlations in tumor response (r = 0.17, P = 0.4) and MR imaging-pathologic size discrepancy (r = 0.1, P = 0.6). The majority of morphologic change is concentric reduction (57.6%). MRI is tended to overestimate residual size of the lesion (62.5%)

CONCLUSION

HER2-positive and triple negative subgroups showed relatively better response. Tumors were most likely to response in the manner of concentric reduction. The mean MR imaging-pathologic size discrepancy tended to be smaller in triple negative subgroup. MRI is reliable method in predicting histopathological response to NAC, but is more likely to overestimate the residual size of the lesion.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-02-08.

The relationship between preeclampsia, pregnancy-induced hypertension and maternal risk of breast cancer: a meta-analysis

BACKGROUND

It has long been recognized that some human breast cancers are hormone dependent. Preeclampsia is a syndrome of pregnancy defined by the onset of hypertension and proteinuria and characterized by dysfunction of the maternal endothelium. Many hormonal changes occur with preeclampsia, and we hypothesize that these changes may influence the risk of maternal breast cancer. We also analyzed the relation between pregnancy-induced hypertension (PIH) and maternal risk of breast cancer.

METHODS

Among 13 relevant publications about preeclampsia and six relevant publications about PIH, some studies find preeclampsia associated with a lower risk of breast cancer, but others did not. Therefore, these results are inconclusive. We conducted meta-analysis to evaluate more precisely the relationship between preeclampsia, PIH and maternal risk of breast cancer.

RESULTS

The pooled estimate of the hazard ratio (HR) associated with preeclampsia was 0.86 (95% CI 0.73-1.01), and that associated with PIH was 0.83 (0.66-1.06), both based on the random effects model.

CONCLUSION

Some suggestive but not entirely consistent nor conclusive evidence was found on the association between the history of preeclampsia or PIH with the subsequent risk of breast cancer.

Evaluation of mechanical accuracy for couch-based tracking system (CBTS)

This study evaluated the mechanical accuracy of an in‐house–developed couch‐based tracking system (CBTS) according to respiration data. The overall delay time of the CBTS was calculated, and the accuracy, reproducibility, and loading effect of the CBTS were evaluated according to the sinusoidal waveform and various respiratory motion data of real patients with and without a volunteer weighing 75 kg. The root mean square (rms) error of the accuracy, the reproducibility, and the sagging measurements were calculated for the three axes (X, Y, and Z directions) of the CBTS. The overall delay time of the CBTS was 0.251 sec. The accuracy and reproducibility in the Z direction in real patient data were poor, as indicated by high rms errors. The results of the loading effect were within 1.0 mm in all directions. This novel CBTS has the potential for clinical application for tumor tracking in radiation therapy.

PACS number: 87.55.ne

Treatment outcome of conservative surgery plus postoperative radiotherapy for extremity soft tissue sarcoma

PURPOSE

To evaluate the treatment outcome and prognostic factor of postoperative radiotherapy for extremity soft tissue sarcoma (STS).

MATERIALS AND METHODS

Forty three patients with extremity STS were treated with conservative surgery and postoperative radiotherapy from January 1981 to December 2010 at Korea University Medical Center. Median total 60 Gy (range, 50 to 74.4 Gy) of radiation was delivered and 7 patients were treated with chemotherapy.

RESULTS

The median follow-up period was 70 months (range, 5 to 302 months). Twelve patients (27.9%) sustained relapse of their disease. Local recurrence occurred in 3 patients (7.0%) and distant metastases developed in 10 patients (23.3%). The 5-year overall survival (OS) was 69.2% and disease free survival was 67.9%. The 5-year local relapse-free survival was 90.7% and distant relapse-free survival was 73.3%. On univariate analysis, no significant prognostic factors were associated with development of local recurrence. Histologic grade (p = 0.005) and stage (p = 0.02) influenced the development of distant metastases. Histologic grade was unique significant prognostic factor for the OS on univariate and multivariate analysis. Severe acute treatment-related complications, Common Terminology Criteria for Adverse Events (CTCAE) grade 3 or 4, developed in 6 patients (14.0%) and severe late complications in 2 patients (4.7%).

CONCLUSION

Conservative surgery with postoperative radiotherapy achieved a satisfactory rate of local control with acceptable complication rate in extremity STS. Most failures were distant metastases that correlate with tumor grade and stage. The majority of local recurrences developed within the field. Selective dose escalation of radiotherapy or development of effective systemic treatment might be considered.

Effectiveness of high-dose three-dimensional conformal radiotherapy in hepatocellular carcinoma with portal vein thrombosis

OBJECTIVE

To evaluate the treatment outcome of three-dimensional conformal radiotherapy in hepatocellular carcinoma patients with portal vein thrombosis, concerning survival and treatment response of thrombosis.

METHODS

Forty-five patients with hepatocellular carcinoma who had portal vein thrombosis treated from March 2005 to March 2011 were the subjects of this study. The median total dose was 61.2 Gy (range 38-65 Gy). A daily radiation dose of 1.8-2.5 Gy was administered at a frequency of five fractions per week. The clinical target volume included portal vein thrombosis with or without primary tumour with clinical consideration.

RESULTS

Three of the 45 patients (6.7%) showed complete remission of portal vein thrombosis, 25 patients (55.6%) showed partial response, 14 patients (31%) had stable disease and 3 patients (6.7%) had progressive disease. The median and the 1-year survival rate of the responders (complete remission + progressive disease) were 16.7 months and 63.7%, respectively, and those of the non-responders were 8 months and 28.2%, respectively (P= 0.003). A univariate analysis revealed that thrombosis response, Eastern Cooperative Oncology Group performance status, maximum tumour size, tumour bilaterality, Cancer of the Liver Italian Program stage, Okuda stage, hepatic arterial infusion, hepatitis B 'e' antigen and hepatitis C antibody were statistically significant prognostic factors affecting survival. In a multivariate analysis, thrombosis response, Cancer of the Liver Italian Program stage and Okuda stage were found to be statistically significant. No clinically significant radiation-induced liver disease was noted. One grade 3 late complication (duodenal ulcer) was reported.

CONCLUSIONS

High-dose three-dimensional conformal radiotherapy yielded a response rate of 62.3%. It is a safe and effective treatment prolonging the survival of hepatocellular carcinoma patients with portal vein thrombosis.

Whole breast irradiation for small-sized breasts after conserving surgery: is the field-in-field technique optimal?

BACKGROUND

To determine the optimal whole breast irradiation technique in patients with small-sized breasts, tangential and field-in-field IMRT (FIF) techniques were compared.

METHODS

Sixteen patients with ≤3 cm breast height and ≤350 cc volume were included. Seven patients had 4D CTs performed. The planning target volumes (PTV), editing 5 and 2 mm from the surface on the whole breast, were delineated and called PTV(5) and PTV(2), respectively. Dose-volume histograms of tangential techniques with open beam (OT) and wedge filter (WT), conventional FIF (cFIF), and modified FIF (mFIF) blocking out the lung were produced. Various dose-volume parameters, the dose heterogeneity index (DHtrI), dose homogeneity index (DHmI), and PTV dose improvement (PDI) were calculated.

RESULTS

OT compared with WT showed a significantly favorable V 90 of the heart and lung, and PTV(5)-dose distribution. Comparing OT and cFIF, OT showed significant improvement in the V 95 of PTV(2), whereas cFIF showed significant improvement in the V 95, DHtrI, DHmI, and PDI of the PTV(5). In comparing cFIF and mFIF, mFIF showed improved dose distributions of the heart and lung, while cFIF presented the better V 95, DHtrI, DHmI, and PDI of the PTV(5). Respiratory influences on the absolute dose were mostly within 1 %. The ratio of free breathing and each respiratory phase was similar among OT, cFIF, and mFIF.

CONCLUSIONS

cFIF has favorable dose conformity and is suggested to be an optimal method for small-sized breasts. However, OT for dose coverage close to the skin and mFIF for normal tissue may also be potential alternatives. Respiratory effects are minimal.

The extent and serial pattern of interfractional variation in patients with whole pelvic irradiation: a study using a kilovoltage orthogonal on-board imager

The purpose of this study is to assess the extent and serial pattern of setup error of conventional fractionated whole pelvic irradiation using a kilovoltage on-board imager. The daily on-board images of 69 patients were matched with the digitally reconstructed radiographs of simulation on the basis of pelvic bony structure. The shifts along x- (lateral), y- (longitudinal), and z- (vertical) axes, and the 3D vector, were measured. The shift between an origin of the first fraction and each fraction (Δshift(1st)) and the shift between an isocenter of simulation and each fraction (Δshift(Sim)) were calculated. To evaluate serial changes, the shifts of each fraction were classified into four consecutive sessions, and an ANOVA and chi-square test were used. The systematic error of the Δshift(Sim) and Δshift(1st) were 2.72 and 1.43 mm along the x-axis, 2.98 and 1.28 mm along the y-axis, and 4.26 and 2.39 mm along the z-axis, respectively. The Δshift(Sim) and Δshift(1st) ≥ 5 mm of the 3D vector occurred in 54.3% and 23.1%, respectively. The recommended margins to cover setup error in case of using Δshift(1st) were 3.81, 3.54, and 6.01 mm along x-, y-, and z-axes, whereas those using Δshift(Sim) were 6.39, 6.95, and 9.95 mm, respectively. With the passage of time, the Δshift(1st) ≥ 5 mm of 3D vector and along any axis in supine setup increased from 14.1% for first session to 22.5% for fourth session (p=0.027) and from 10.8% to 18.5% (p = 0.034), respectively. In prone setup, first session was better than others in the Δshift(1st) ≥ 5 mm of 3D vector and along any axis. It is expected that the correction using the on-board images on the first fraction improves geometrical uncertainties and reduces the margin for target coverage. Daily continuous OBI follow-up during conventional fractionated pelvic irradiation can increase the reproducibility and be more effective in the late period.

Protective effect of triphala on radiation induced acute intestinal mucosal damage in Sprague Dawley rats

Aim of the study was to determine protective effect of triphala on radiation-induced rectal mucosal damage. Male Sprague Dawley rats (30) were divided into 5 groups. Rats in group A were sham irradiated and rats in group B underwent only irradiation. Rats in group C were administered triphala 1 g/kg/day orally for 5 consecutive days before irradiation. Rats in group D and E were administered triphala 1 and 1.5 g/kg/day orally for 10 consecutive days, respectively. Rectal mucosal damage was induced by a single fraction of 12.5Gy gamma irradiation (Ir-192) on 5th day. All the rats were autopsied on 11th day and histological changes in surface epithelium, glands, and lamina propria were assessed. Proctitis showed significant improvement in surface epithelium (P < 0.024), glands (P < 0.000) and lamina propria (P < 0.002) in group E compared to group B. Rats in group E showed significantly less change in glands (P < 0.000) compared to rats in group D, All histological variables (surface epithelium, P < 0.001; glands, P < 0.000; lamina propria, P < 0.003) compared to rats in group C. In a Tukey-b test, group E had a significantly recovered grade for glands (P < 0.000) compared to groups B, C and D. Results of the present study showed that high-dose triphala improved radiation-induced damage of glands.

Risk factors related to interfractional variation in whole pelvic irradiation for locally advanced pelvic malignancies

PURPOSE

The goal of the present study was to demonstrate risk factors affecting the interfractional variation in whole pelvic irradiation.

PATIENTS AND METHODS

Daily image acquisitions of 101 patients with locally advanced pelvic malignancy were undertaken using a kilo-voltage orthogonal on-board imager. The baseline deviation (the shift between the initial treatment and each fraction; Value(Base)) and day-to-day variation (the shift between the previous treatment and each fraction; Value(DD)) were measured. The standard deviations (SD) along the x- (right-left), y- (cranial-caudal), and z- (anterior-posterior) axes (SD[x], SD[y], and SD[z], respectively), the 3D vector of the SD (SD[3D]), and the mean of 3D shift (mean[3D]) were calculated in each patient. Various clinical factors, lumbar pelvic balance and rotation, and the shift of 5 consecutive fractions from the initial treatment (Value(5Fx)) were investigated as risk factors.

RESULTS

The prone set-up showed a larger mean(Base)[3D] than in the supine position (p =0 .063). A body mass index (BMI) ≥ 30 kg/m(2) resulted in the largest mean(DD)[3D] (p = 0.078) and SD(DD)[3D] (p = 0.058). All the SD(5Fx) along the x-, y-, and z-axes had moderate linear relationships with SD(Base) and SD(DD) (p < 0.001). The SD(5Fx)[3D] also had a moderate linear relationship with the mean(Base)[3D], mean(DD)[3D], SD(Base)[3D], and SD(DD)[3D] (p < 0.001). In multivariate analysis, the SD(5Fx) had the same significant relationship with SD(Base) and SD(DD) (p < 0.001). A BMI ≥ 30 kg/m(2) was associated with the largest SD(DD)[x] (p = 0.003).

CONCLUSION

Close surveillance through high-quality and frequent image guidance is recommended for patients with extensive variations of the initial five consecutive fractions or obesity.

Radiotherapy for pituitary adenomas: long-term outcome and complications

PURPOSE

To evaluate long-term local control rate and toxicity in patients treated with external beam radiotherapy (EBRT) for pituitary adenomas.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 60 patients treated with EBRT for pituitary adenoma at Korea University Medical Center from 1996 and 2006. Thirty-five patients had hormone secreting tumors, 25 patients had non-secreting tumors. Fifty-seven patients had received postoperative radiotherapy (RT), and 3 had received RT alone. Median total dose was 54 Gy (range, 36 to 61.2 Gy). The definition of tumor progression were as follows: evidence of tumor progression on computed tomography or magnetic resonance imaging, worsening of clinical sign requiring additional operation or others, rising serum hormone level against a previously stable or falling value, and failure of controlling serum hormone level so that the hormone level had been far from optimal range until last follow-up. Age, sex, hormone secretion, tumor extension, tumor size, and radiation dose were analyzed for prognostic significance in tumor control.

RESULTS

Median follow-up was 5.7 years (range, 2 to 14.4 years). The 10-year actuarial local control rates for non-secreting and secreting adenomas were 96% and 66%, respectively. In univariate analysis, hormone secretion was significant prognostic factor (p = 0.042) and cavernous sinus extension was marginally significant factor (p = 0.054) for adverse local control. All other factors were not significant. In multivariate analysis, hormone secretion and gender were significant. Fifty-three patients had mass-effect symptoms (headache, dizziness, visual disturbance, hypopituitarism, loss of consciousness, and cranial nerve palsy). A total of 17 of 23 patients with headache and 27 of 34 patients with visual impairment were improved. Twenty-seven patients experienced symptoms of endocrine hypersecretion (galactorrhea, amenorrhea, irregular menstruation, decreased libido, gynecomastia, acromegaly, and Cushing's disease). Amenorrhea was abated in 7 of 10 patients, galactorrhea in 8 of 8 patients, acromegaly in 7 of 11 patients, Cushing's disease in 4 of 4 patients. Long-term complication was observed in 4 patients; 3 patients with cerebrovascular accident, 1 patient developed dementia. Of these patients, 3 of 4 received more than 60 Gy of irradiation.

CONCLUSION

EBRT is highly effective in preventing recurrence and reducing mass effect of non-secreting adenoma. Effort to improve tumor control of secreting adenoma is required. Careful long-term follow-up is required when relatively high dose is applied. Modern radiosurgery or proton RT may be options to decrease late complications.

Bevacizumab for salvage treatment of metastatic breast cancer: a systemic review and meta-analysis of randomized controlled trials

Although various new agents have been developed for the treatment of patients with metastatic breast cancer (MBC), overall survival rates have changed little in the last half century. We conducted meta-analysis to verify the clinical efficacy of bevacizumab for the salvage treatment of MBC. Event-based hazard ratios (HR) with 95% confidence intervals (95% CIs) were derived, and a test of heterogeneity was applied. Four studies, with a total of 2,860 patients, met the inclusion criteria for analysis. The pooled results of clinical efficacies were: HR for progression free survival 0.69 (95% CI, 0.58-0.81, z = 4.54, P <0.001); HR for overall survival 0.92 (95% CI, 0.82-1.03, z =1.44, P = 0.15); and HR for the clinical objective response rate 1.53 (95% CI, 1.37-1.71, z = 7.37, P < 0.001). In terms of overall survival, subgroup analysis demonstrated statistically significant improvement for the bevacizumab combination in the initial therapy subgroup (HR, 0.878; 95% CI, 0.771-0.999, z = 1.98, P = 0.048). Hypertension and proteinura were more common in the bevacizumab combination arm; however, these toxicities were managed with therapy. In conclusion, meta-analysis suggested benefits of a carefully managed bevacizumab-containing salvage regimen for patients with histologically or cytologically confirmed Her-2 negative MBC who have not received previous cytotoxic therapy. This treatment could improve both progression free survival and overall survival rates.

TGFα and EGFR in ovine preimplantation embryos and effects on development

The present study aimed to assess location and relative amounts of transforming growth factor alpha (TGFalpha) and its receptor (EGFR) in ovine oocytes and preimplantation embryos by using immunohistochemical technique that was graded on a relative scale of 0-3, with 0 representing absence of staining, and 3 exhibiting prominent staining, and to evaluate the effects of TGFalpha/EGF on in vitro development of preimplantation embryos by adding different concentrations of EGF and TGFalpha to culture medium. The results showed that EGFR was abundant in cell plasma membranes in immature and mature oocytes, cumulus cells of immature cumulus-oocyte complexes (COC), fertilized oocytes and at different stages of embryo development. However, the relative amounts in inner cell mass (ICM) (1+) was less than that in trophectoderm (TE) cells (2+) at the blastocysts stage. The staining pattern for TGFalpha was a similar to EGFR. However, the staining for TGFalpha slightly increased in the fertilized oocytes (1-2+) as compared to immature and mature oocytes (1+). TGFalpha was mainly detected in the cytoplasm close to the membrane in both ICM and trophectoderm (TE) cells. The developmental rate of 8-cell stage embryos cultured with 5 ng/ml TGFalpha was increased as compared to other treatments (P<0.05). There was no significant difference in the rate of development of blastocysts cultured with 5 ng/ml TGFalpha, 20 ng/ml EGF, 20 ng/ml EGF+5 ng/ml TGFalpha or the control treatment (P>0.05). In addition, there was no significant difference in the number of cells in blastocyst stage as compared with different treatments (P>0.05). However, TGFalpha alone enhanced cell survival rated (P<0.01) and reduced apoptosis. We concluded that TGFalpha can improve development of ovine preimplantation embryos at the 8-cell and blastocyst stages in vitro.

Locally applied simvastatin promotes fracture healing in ovariectomized rat

Simvastatin solution was injected subcutaneously to the site of fractured tibiae of ovariectomized rats. Afterwards healing quality was evaluated by morphologic, radiographic, biomechanical, histological and histomorphometric methods at 1, 2 and 4 weeks after fracture. Results showed that locally applied simvastatin improved fracture healing.

INTRODUCTION

Many studies have documented an anabolic effect of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, statins, on undisturbed bone. Reports of their effects, however, on fractured skeletal systems have been limited. A study was, therefore, conducted to check the effects of statins on fracture healing.

METHODS

Simvastatin (10 mg/kg/day) was injected subcutaneously to tissue overlying the site of fractured tibiae of ovariectomized rats for a treatment period of 5 days. Vehicle reagent was used as a control. Healing quality was evaluated at 1, 2 and 4 weeks after fracture.

RESULTS

Compared with that in the vehicle group, the callus cross-section area in simvastatin-treated rats was significantly enlarged by 21.3% (p < 0.05) at 1 week and by 21.5% (p < 0.05) at 2 weeks; new woven bone was relatively substantive and arranged more tightly and regularly at 2 and 4 weeks; and maximal load was increased by 57.5% (p < 0.05) at 2 weeks and by 31.4% (p < 0.05) at 4 weeks. Histomorphometrically, simvastatin was associated with a significant (p < 0.05) increase of mineralization width (MLW), mineralization volume (MLV) and mineral apposition rate (MAR).

CONCLUSION

The current study suggests that local application of simvastatin could promote fracture healing in ovariectomized rats.

Dosimetric parameters that predict late rectal complications after curative radiotherapy in patients with uterine cervical carcinoma

BACKGROUND

Late rectal complication (LRC) was a major late complication in patients with uterine cervical carcinoma who were treated with a combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary irradiation (HDR-ICR). For the current study, the authors retrospectively evaluated dosimetric parameters that were correlated with LRC > or = Grade 2 in patients with uterine cervical carcinoma who were treated with curative radiotherapy, and they analyzed the appropriate dose estimates to the rectum that were predictive for LRC > or = Grade 2.

METHODS

Between July 1994 and September 2002, 157 patients who were diagnosed with Stage IB-IIIB cervical carcinoma and were treated with definitive radiotherapy were included. EBRT (41.4-66 grays [Gy] in 23-33 fractions) to the whole pelvis was delivered to all patients, with midline shielding performed after a 36-50.4 Gy external dose. HDR-ICR (21-39 Gy in 6-13 fractions to Point A) was administered at a rate of 2 fractions weekly after midline shielding of EBRT. LRC was scored using Radiation Therapy Oncology Group criteria. The total biologically effective dose (BED) at specific points, such as Point A (BED(Point A)), rectal point (BED(RP)), and maximal rectal point (BED(MP)), was determined by a summation of the EBRT and HDR-ICR components, in which the alpha/beta ratio was set to 3. Analyzed parameters included patient age, tumor size, stage, concurrent chemotherapy, ICR fraction size, RP ratio (dose at the rectal point according to the Point A dose), MP ratio (dose at the maximal rectal point according to the Point A dose), EBRT dose, BED(Point A), BED(RP), and BED(MP).

RESULTS

The 5-year actuarial overall rate of LRC > or = Grade 2 in all patients was 18.4%. Univariate analysis showed that the RP ratio, MP ratio, EBRT dose, BED(Point A), BED(RP), and BED(MP) were correlated with LRC > or = Grade 2 (P < 0.05). Multivariate analysis showed that, of all clinical and dosimetric parameters evaluated, only BED(RP) was correlated with LRC > or = Grade 2 (P = 0.009). The 5-year actuarial rate of LRC > or = Grade 2 was 5.4% in patients with a BED(RP) < 125 Gy(3) and 36.1% in patients with a BED(RP) > or = 125 Gy(3) (P < 0.001).

CONCLUSIONS

BED(RP) was a useful dosimetric parameter for predicting the risk of LRC > or = Grade 2 and should be limited to < 125 Gy(3) whenever possible to minimize the risk of LRC > or = Grade 2 in patients with uterine cervical carcinoma who are treated with a combination of EBRT and HDR-ICR. Cancer 2005.

Structure determination of a lone alpha-helical antifreeze protein from winter flounder

The X-ray crystal structure of a lone alpha-helical antifreeze protein from winter flounder has been determined to 1.5 A using a combination of molecular-replacement and isomorphous-replacement techniques. Molecular replacement involved a multiparameter search using X-PLOR with two 37-mers of alanine in idealized alpha-helical conformations as the search models. Identified were a large number of potential solutions from which the correct solution was not distinguishable. Commitment of the top 1620 solutions to cycles of rigid-body, positional and simulated-annealing refinement identified the correct solution by a small margin in R factor. Low-resolution electron-density maps generated with phasing information from TbNO(3) and LaNO(3) derivatives were consistent with the top molecular-replacement solution. These derivatives also provided a means to filter and compare the large number of other molecular-replacement solutions with reasonable R factor statistics. The structure-solution strategy described herein may prove useful for the determination of other relatively simple alpha-helical X-ray structures.

Development of Respiratory Motion Reduction Device System (RMRDs) for Radiotherapy in Moving Tumors

BACKGROUND

The internal target volume (ITV) for tumors in the abdomen or thorax includes sufficient margin for breathing-related movement of tumor volumes during treatment. Depending on the location of the tumor, the magnitude of the ITV margin extends from 1 to 3 cm, which increases substantially the volume of the irradiated normal tissue, hence resulting in an increase in normal tissue complication probability (NTCP). We developed a simple and handy method which can reduce ITV margins in patients with moving tumors: the respiratory motion reduction device system (RMRDs).

METHODS

The patient's clinical database was structured for moving tumor patients and patient set-up error measurement and immobilization device effects were investigated. The system is composed of the respiration presser device (RPD) utilized in the prone position and the abdominal strip device (ASD) utilized in the supine position, and the analysis program, which enables analysis of patient set-up reproducibility. It was tested for analyzing the diaphragm movement from patients with RMRDs, the magnitude of the ITV margin was determined and the dose-volume histogram (DVH) was computed using treatment planning software. The dose to normal tissue in patients with and without RMRDs was analyzed by comparing the fraction of the normal liver receiving 50% of the isocenter dose.

RESULTS

Average diaphragm movement due to respiration was 16 +/- 1.9 mm in the case of the supine position, and 12 +/- 1.9 mm in the case of the prone position. When utilizing the RMRDs, which was personally developed in our hospital, the value was reduced to 5 +/- 1.4 mm, and in the case in which the belt immobilization device was utilized, the value was reduced to 3 +/- 0.9 mm. In the case where the strip device was utilized, the value was proven to reduce to 4 +/- 0.3 mm. As a result of analyzing the volume of normal liver where 50% of the prescription dose is irradiated in DVH according to the radiation treatment planning, the use of the RMRD can create a reduction of 30% to the maximum. Also by obtaining the digital image, the function of comparison between the standard image, automated external contour subtraction, etc. was utilized to develop a patient set-up reproducibility analysis program that can evaluate the change in patient set-up.

CONCLUSION

Internal organ motion due to breathing can be reduced using RMRDs, which is simple and easy to use in the clinical setting. It can reduce the organ motion-related planning target volume margin, thereby decreasing the volume of irradiated normal tissue.

Short-latency ocular following in humans: sensitivity to binocular disparity

We show that the initial ocular following responses elicited by motion of a large pattern are modestly attenuated when that pattern is shifted out of the plane of fixation by altering its binocular disparity. If the motion is applied to only restricted regions of the pattern, however, then altering the disparity of those regions severely attenuates their ability to generate ocular following. This sensitivity of the ocular tracking mechanism to local binocular disparity would help the observer who moves through a cluttered 3-D world to stabilize objects in the plane of fixation and ignore all others.