A case of massive hemoptysis caused by lung cancer saved by V-V ECMO and hemostasis achieved by radiotherapy

Massive hemoptysis is one of the fatal complications of lung cancer. There is no established standard treatment method for it, and it often causes sudden suffocation, and some cases may be difficult to save. A 63-year-old man was admitted to the hospital with dyspnea, and developed massive hemoptysis from lung cancer shortly after admission. The tumor had obstructed the right main bronchus and had invaded the right pulmonary artery. Surgery and interventional radiology were judged impossible. The patient was successfully saved by the introduction of Veno-Venous Extra Corporeal Membrane Oxygenation (V-V ECMO), and hemostasis was obtained by radiotherapy. Two months after completion of radiotherapy, he was weaned off the ventilator and discharged on his own. He died of increased peritoneal dissemination and other complications 1 year and 1 month later, but no recurrence of hemoptysis was noted until his death. We experienced a case of massive hemoptysis in which V-V ECMO and radiation therapy succeeded in saving life and stopping bleeding. The use of V-V ECMO by emergency care teams and multimodality therapy, including radiotherapy, were effective for massive hemoptysis from lung cancer.

Long-term follow-up of unresectable adenoid cystic carcinoma of the trachea and bronchus treated with high-dose proton beam therapy: A report of two cases

Adenoid cystic carcinoma (ACC) of the trachea is a rare disease that is slow growing and has a risk of distant metastasis. The standard treatment for ACC of the trachea is surgery, but this tumor is often unresectable. In definitive radiotherapy using photons for unresectable ACC of the trachea, it is sometimes difficult to deliver a sufficient dose to the target without exceeding the tolerable dose to the surrounding normal tissues. Here, we report two cases of ACC of the trachea that received a high dose (74 Gy [relative biological effectiveness]) of proton beam therapy and achieved long-term survival.

Is there any relationship between nurses' perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout?

AIM

The present study is an attempt to investigate the relationship between Corley's model variables in mental health nurses.

BACKGROUND

Based on Corley's model, burnout and moral distress in nurses are, in retrospect, the consequences of the interplay of organizational and individual factors such as perceived organizational justice, moral sensitivity, and moral courage. The relationship between two variables or three variables of Corley's moral distress model has been investigated, but the test of Corley's moral distress model with more variables has not been done. Therefore, this research was proposed with the aim of investigating the relationship between the variables of moral courage and moral sensitivity (as characteristics of nurses), perceived organizational justice (as an antecedent), moral distress, and job burnout (as consequences of moral distress).

METHODS

The study was conducted as a descriptive correlational study involving 500 nurses working in the mental health wards of hospitals. Data collection was conducted using perceived organizational justice scale, moral sensitivity scale, moral courage scale, moral distress scale, and burnout inventory.

RESULTS

The results showed a significant relationship between perceived organizational justice, moral sensitivity, moral courage, and moral distress (< 0.05). Moreover, perceived organizational justice and moral distress had an inverse relationship. Moral sensitivity and moral courage had a direct relationship with moral distress (< 0.05). Furthermore, the results showed inadequate model fitness.

CONCLUSIONS

This study adds to the existing knowledge about the experiences of mental health nurses and their interactions with both organizational and individual factors. It highlights that the connections between perceived organizational justice, moral sensitivity, moral courage, moral distress, and burnout are intricate and multifaceted. As we deepen our understanding of these relationships, it opens the door for the development of interventions and strategies to enhance nurses' well-being and the quality of care they deliver in mental health settings. Moreover, future research and ongoing refinement and expansion of Corley's model will be crucial in addressing the complex challenges within the healthcare sector.

Long-Term Results of a Phase II Study of Accelerated Hyperfractionated Thoracic Radiotherapy with Dose Escalation to 54 Gy for Limited-Stage Small-Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

The combination of accelerated hyperfractionated thoracic radiotherapy (AHF-TRT) of 45 Gy and concurrent chemotherapy is the standard treatment for limited-stage small-cell lung cancer (LS-SCLC). However, the optimal dose and fractionation remain controversial. We herein report the results of a phase II study investigating the utility of dose escalation to 54 Gy on AHF-RT for LS-SCLC.

MATERIALS/METHODS

We enrolled patients ≤80 years old with treatment-naïve confirmed LS-SCLC and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2. The radiation dose was 54 Gy delivered in 36 fractions in 18 treatment days over 3.6 weeks. The chemotherapy regimens were PE (cisplatin and etoposide)- or CE (carboplatin and etoposide)-based. AHF-TRT was given in 2 phases: patients initially received 36 Gy to the gross tumor plus uninvolved mediastinal nodes, followed by a boost to the gross tumor of 18 Gy. All patients were treated with three-dimensional conformal radiation therapy with multiple fields to reduce the elevated dose volume to the surrounding tissues, such as the lungs and esophagus, as much as possible. All patients were evaluated for the overall survival (OS), progression-free survival (PFS), and non-hematological toxicity.

RESULTS

Between 2013 and 2016, a total of 13 patients were enrolled in the present study. All the patients were assessable for the response and toxicity. The median age was 67 (range, 54-78) years old, and 9 patients were male, while 4 were female. Twelve patients had a ECOG performance status of 0. The numbers of patients with Stage IIA, IIB, IIIA, and IIIB disease were one, one, eight, and three, respectively. The median follow-up for all patients was 79 (range, 13-107) months, and that for surviving patients was 90 (range, 79-107) months. The patterns of failure were locoregional-only recurrence in 0% (0 patients), both locoregional and distant in 15.4% (2 patients), and distant-only in 30.8% (4 patients). Recurrence from the elective nodal irradiation area was seen in 0% (0 patients). The 1-, 3-, 5-, and 7-year OS rates were 100%, 76.9%, 53.9%, and 44.9%, respectively, and the median OS was 83.0 months. The 1-, 3-, 5-, and 7-year PFS rates were 76.9%, 53.9%, 53.9%, and 44.9%, respectively, and the median PFS was 83.0 months. No patient experienced a grade ≥3 non-hematological adverse effect, such as esophagitis or pneumonitis, during treatment or follow-up. Grade 2 pneumonitis was observed in 2 patients (15.4%), Grade 2 esophagitis was observed in 12 patients (92.3%), and Grade 2 esophageal pain was observed in 2 patients (15.4%).

CONCLUSION

In this study, AHF-TRT of 54 Gy with concurrent PE- or CE-based regimens resulted in a good OS and PFS without increasing severe toxicity. Although this regimen needs to be evaluated in more patients to fully confirm its efficacy, these outcomes suggest that dose escalation to 54 Gy may be a promising radical treatment for LS-SCLC.

Multi-Institutional Fact-Finding Study: Association between Geriatric Assessment and Reduction in Intensity of Radiotherapy for Elderly Cancer Patients without Metastasis

PURPOSE/OBJECTIVE(S)

Vulnerable patients receive a low-intensity, palliative treatment rather than the standard treatment. Defining vulnerability in terms of standard or reduced radiation intensity can result in appropriate radiotherapy for elderly cancer patients without excessive adverse events and poor outcomes. However, it is difficult to define vulnerability, because radiation oncologists hesitate to include vulnerable patients in clinical trials involving radical radiotherapy. We hypothesized that for elderly cancer patients without metastasis, vulnerability scores, obtained by geriatric assessment (GA), could help in predicting the reduction in radiation intensity determined by radiation oncologists based on their experience.

MATERIALS/METHODS

In this multicenter prospective study, we enrolled cancer patients (70 years or older) without metastasis. The reduction in radiation intensity was categorized into 3 groups as follows: i) standard schedule of radiotherapy, but conversion of irradiation fields, ii) standard irradiation fields, but converted schedule of radiotherapy, and iii) conversion of radiotherapy schedule and irradiation fields. Standard radiotherapy was defined as recommended doses and radiation fields according to the guidelines for the primary tumors analyzed. GA was performed by calculating geriatric 8 (G8) and vulnerable elders survey (VES-13) scores before radiotherapy and 3-5 and 8-16 weeks after completion of radiotherapy. The primary endpoint was to evaluate the correlation between vulnerability assessed by G8 and change in radiation intensity.

RESULTS

Between November 2020 and February 2022, 317 patients were included in this study at 13 centers in Japan. The median age was 77 (range, 70-90) years. The primary cancer sites were head and neck, esophagus, lungs, breasts, pancreas, bladder, uterus, and prostate in 63, 22, 62, 48, 6, 5, 26, and 85 patients, respectively. High-precision radiotherapy was performed for 199 patients (63%). Of the 31 patients (10%) whose radiation intensity was reduced, 14, 9, and 8 patients were provided i, ii, and iii category, respectively. Planned radiotherapy was completed for 312 patients (98%). G8 and VES-13 vulnerability scores were obtained for 201 and 61 patients, respectively, before radiotherapy. The mean G8 and VES-13 scores were 13.3 ± 2.4 and 1.8 ± 1.8, 12.9 ± 2.6 and 2.0 ± 2.0, and 13.4 ± 2.4 and 2.0 ± 1.9 before radiotherapy and 3-5 and 8-16 weeks after completion of radiotherapy, respectively. Multivariate analysis revealed that reduction in radiation intensity was significantly associated with vulnerability assessed using VES-13 (p < 0.001) but not G8 (p = 0.06).

CONCLUSION

An excellent completion rate was obtained for planned radiotherapy, and vulnerability assessed using VES-13, not G8, was associated with the reduction in intensity of radiotherapy.

Proton beam therapy in multimodal treatment for locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus

BACKGROUND

To evaluate proton beam therapy (PBT) in multimodal treatment for locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus (NPSCC).

METHODS

The cases in this study included T3 and T4 NPSCC without distant metastases that were treated at our center using PBT between July 2003 and December 2020. These cases were classified into 3 groups based on resectability and treatment strategy: surgery followed by postoperative PBT (group A); those indicated to be resectable, but the patient refused surgery and received radical PBT (group B); and those declared unresectable based on the extent of the tumor and treated with radical PBT (group C).

RESULTS

The study included 37 cases, with 10, 9 and 18 in groups A, B and C, respectively. The median follow-up period in surviving patients was 4.4 years (range 1.0-12.3 years). The 4-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 58%, 43% and 58% for all patients; 90%, 70% and 80% in group A, 89%, 78% and 89% in group B; and 24%, 11% and 24% in group C. There were significant differences in OS (p = 0.0028) and PFS (p = 0.009) between groups A and C; and in OS (p = 0.0027), PFS (p = 0.0045) and LC (p = 0.0075) between groups B and C.

CONCLUSIONS

PBT gave favorable outcomes in multimodal treatment for resectable locally advanced NPSCC, including surgery followed by postoperative PBT and radical PBT with concurrent chemotherapy. The prognosis for unresectable NPSCC was extremely poor, and reconsideration of treatment strategies, such as more active use of induction chemotherapy, may improve outcomes.

Long-term Outcomes After Moderate Hypofractionated Proton Therapy for Centrally Located Non-small Cell Lung Cancer

BACKGROUND/AIM

To investigate the outcomes of patients with centrally located non-small-cell lung cancer (NSCLC) treated with proton beam therapy (PBT) using moderate hypofractionation.

PATIENTS AND METHODS

Between 2006 and 2019, 34 patients with centrally located T1-T4N0M0 NSCLC who received moderate hypofractionated PBT were retrospectively reviewed.

RESULTS

The median follow-up was 50.8 months (range=5.8-100.4 months). The 3-year overall survival, progression-free survival (PFS), and local control rates were 70.4%, 55.5% and 80.5%, respectively. Grade 2 or 3 lung adverse events (AEs) after PBT were observed in five (14.7%) patients; however, grade 3 radiation pneumonitis was observed in one (2.9%) patient. Notably, no grade 4 or higher AEs were observed. Regarding the correlation between the lung dose and proximal bronchial tree maximum dose and grade 2 or higher lung AEs, a weak correlation was observed between the mean lung dose and AEs (p=0.035). Although the clinical target volume (CTV) was a risk factor for poor PFS, no significant correlation was found between the CTV and lung AEs after PBT.

CONCLUSION

Moderate hypofractionated PBT may be a useful radiotherapy method for centrally located cT1-T4N0M0 NSCLC.

Proton beam therapy for cervical lymph node metastasis in an octogenarian with melanoma of unknown primary: a case report

An 80-year-old man with an approximately 3-cm mass in the right submandibular region presented to our institution. Magnetic resonance imaging revealed enlarged lymph nodes (LNs) in the right neck, and fluorine-18-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) indicated positive FDG accumulation in the right neck LNs only. Excisional biopsy was performed for suspected malignant lymphoma, and the biopsy revealed melanoma. Close examination of the skin, nasal cavity, oral pharyngeal and laryngeal cavities, and gastrointestinal tract were performed. No primary tumor was detected by these examinations, and the patient was diagnosed with cervical LN metastasis from melanoma of unknown primary of clinical stage T0N3bM0 stage IIIC. The patient refused cervical neck dissection because of his age and comorbidity of Alzheimer's disease and instead opted for proton beam therapy (PBT) at a total dose of 69 Gy (relative biological effectiveness) in 23 fractions. He did not receive any systemic therapy. The enlarged LNs shrunk slowly, and FDG PET/CT at 1 year after PBT showed that the right submandibular LN had shrunk from 27 to 7 mm in length, and there was no significant FDG accumulation. At 6 years and 4 months after PBT, the patient is alive without any recurrence.

Effects of lymphopenia on survival in proton therapy with chemotherapy for non-small cell lung cancer

Lymphocytes play an important role in the cancer immune system. In the present study, we aimed to evaluate the associations of lymphopenia during proton beam therapy (PBT) and concurrent chemotherapy with clinical outcomes and to determine whether lung or bone is more influential on lymphopenia during PBT. Data from 41 patients with stage III non-small cell lung cancer (NSCLC) who received PBT of 74 GyE with concurrent chemotherapy between 2007 and 2017 were reviewed retrospectively. The correlation between dosimetry parameters obtained from dose-volume histograms of the bone and lung and lymphopenia during PBT were analyzed. Minimum absolute lymphocyte count (ALCmin) and maximum neutrophil/lymphocyte ratio (NLRmax) were used as indicators of lymphopenia. Bone V5-20 and lung V5-50 were significantly correlated with the ALCmin and NLRmax during PBT. Multivariable analysis showed that the NLRmax, but not the ALCmin, was associated with overall survival (OS), progression-free survival (PFS) and distant metastasis-free survival (DMFS). The 3-year rates of OS, PFS and DMFS of patients with a low (≤ 6.3) versus high (> 6.3) NLRmax were 73.9% vs 44.4% (P = 0.042), 26.1% vs 5.6% (P = 0.022) and 39.1% vs 5.6% (P < 0.001), respectively. Lung V20 was significantly associated with DMFS on multivariable analyses (hazard ratio: 1.094, P = 0.008), whereas bone V5 had no impact on survival outcomes. We concluded that the NLRmax was a better prognostic indicator than the ALCmin, and the lung dose had more influence than the bone dose on the main survival outcomes in stage III NSCLC patients treated with PBT combined with concurrent chemotherapy.

Preliminary Study on Establishing a Heart Rate Variability-based Method for Objectively Evaluating Bone Metastasis Pain

BACKGROUND/AIM

The aim of this study was to establish an objective evaluation method for pain due to bone metastasis, based on heart rate variability (HRV).

PATIENTS AND METHODS

In this prospective study, patients who underwent radiotherapy for painful bone metastases were enrolled. Pain was assessed using a numerical rating scale (NRS), and anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS). Autonomic and physical activities were evaluated by measuring HRV using a wearable device. NRS, HADS, and R-R interval (RRI) values were obtained upon starting, completing, and 3-5 weeks after radiotherapy.

RESULTS

Between July 2020 and July 2021, 11 patients were enrolled. The median average NRS score was 5 (range=2-10). HADS-assessed median anxiety and depression scores were 8 (range=1-13 and 2-21). For patients with an NRS score ≥4, NRS score was significantly associated with low-frequency/high-frequency (LF/HF) component ratio (p=0.03). Heart rate during physical activity was significantly higher than resting heart rate; however, mean resting LF/HF was significantly higher than LF/HF during physical activity. During rest, excluding patients with a HADS depression score ≥7 in an NRS score 1-3, there was a trend for a positive correlation between the NRS score and the mean LF/HF (p=0.07).

CONCLUSION

HRV measurements can objectively evaluate pain due to bone metastasis. However, we must consider that the effects of mental status, such as depression, on LF/HF also affect HRV in patients with cancer with mild pain.

Proton Beam Therapy in Elderly Patients With cT1-3N0M0 Non-small Cell Lung Cancer

BACKGROUND/AIM

To investigate the outcomes of elderly patients with cT1-3N0M0 non-small cell lung cancer (NSCLC) undergoing proton beam therapy (PBT).

PATIENTS AND METHODS

Between 2009 and 2019, 110 patients receiving hypofractionated PBT for cT1-3N0M0 NSCLC were retrospectively reviewed.

RESULTS

The median follow-up was 36.5 months (range=4.9-131.0 months). In the elderly group (80 years or older), the 3-year overall survival and progression-free survival rates were 79.8% and 73.9%, respectively, and the corresponding rates in the younger group were 80.5% and 61.2%, respectively. Grade 3 radiation pneumonitis (RP) was observed in 4.4% patients in the young group, whereas no grade 3 RP was observed in the elderly group. Age was not a risk factor for symptomatic RP. There were no significant differences in the survival and adverse events between the elderly and younger groups.

CONCLUSION

PBT may be a reasonable approach for treating lung cancer in elderly patients with T1-3N0M0 NSCLC.

Hypofractionated Proton Beam Therapy for cT1-2N0M0 Non-small Cell Lung Cancer Patients With Interstitial Lung Disease

BACKGROUND/AIM

To evaluate the outcomes of proton beam therapy (PBT) for early-stage non-small cell lung cancer (NSCLC) in patients with interstitial lung disease (ILD).

PATIENTS AND METHODS

Between 2002 and 2017, 110 patients receiving hypofractionated PBT for cT1-2N0M0 NSCLC were reviewed.

RESULTS

Of the 110 patients, 17 were diagnosed with ILD. The median follow-up period was 37.8 months. No significant difference in the 1-year cumulative rate of grade ≥2 pneumonitis was observed between patients with and those without ILD (17.6% vs. 14.1%, p=0.708). The lung doses were significantly lower in patients with than in those without ILD among patients without grade ≥2 pneumonitis. There were no significant differences in overall survival or local recurrence-free rates according to the presence of ILD.

CONCLUSION

PBT appears to be a feasible and effective treatment for cT1-2N0M0 NSCLC in patients with ILD, but the lung dose should be strictly reduced.

Psychometrics of the moral distress scale in Iranian mental health nurses

BACKGROUND

One of the challenges that nurses often face in ethical decision-making situations is moral distress. Moral distress is caused by the conflict between professional and individual values in decision-making situations. Despite its importance, there is no reliable scale in Persian to measure it. Therefore, this study was conducted to validate the moral distress scale in mental health nurses in Iranian culture and Persian language.

METHODS

This study was conducted in two parts: Translation and cross-cultural adaptation and psychometric analysis. The translation and cross-cultural adaptation process was conducted based on the Polit approach. Next, face validity (qualitative), content validity (quantitative and qualitative), and construct validity were examined. This part of the study was a cross-sectional study. In this step, a demographic questionnaire and the Moral Distress Scale were sent to 500 nurses working in selected educational and medical centers in Iran via online questionnaires. Then, the construct validity of the "Moral Distress Scale" was confirmed by confirmatory factor analysis and the reliability of the instrument was examined by studying the internal consistency with Cronbach's alpha and the internal correlation of the AIC.

RESULTS

The confirmatory factor analysis showed an acceptable ratio of the expressions in 15 items in three factors: Acquiescence to patients' rights violations (6 items), Unethical conduct by caregivers (5 items), and low staffing (4 items) in the scale. The internal consistency of the instrument with Cronbach's alpha was higher than 7.0.

CONCLUSION

The Persian version of moral distress with 15 items of the three factors had validity and reliability. According to the present findings, this scale can be used to study moral distress among nurses working in psychiatric wards. Moral distress leads to burnout, increases risks to patient safety and reduces quality of care. Nurses need to be able to assess and manage moral distress. Therefore, considering the side effects, it is necessary to have a reliable and valid scale that can be studied. Considering that culture has an impact on nurses' moral distress, it is suggested that this instrument be studied in and tested in other languages and cultures.

Efficacy of the pretreatment geriatric nutritional risk index for predicting severe adverse events in patients with head and neck cancer treated with chemoradiotherapy: Efficacy of the pretreatment Geriatric Nutritional Risk Index for predicting severe adverse events

OBJECTIVE

The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established nutritional assessment tool. Although concurrent chemoradiotherapy (CCRT), particularly cisplatin-based CCRT, is a standard treatment for locoregional advanced head and neck squamous cell carcinoma (HNSCC), the predictive factors of adverse events related to CCRT remain to be elucidated. The present study aimed to determine the association between GNRI and CCRT-related adverse events in patients of all ages with head and neck cancer (HNC) who underwent CCRT.

METHODS

We retrospectively analyzed and compared the clinical characteristics and adverse events of 82 patients with HNC treated with CCRT according to their GNRI at the Department of Otolaryngology, Head and Neck Surgery, University of Tsukuba Hospital, between May 2014 and November 2019. The GNRI was calculated according to the equation: 1.489 × serum albumin (g/L) + 41.7 × (body weight/ideal body weight). We compared two groups: low GNRI (GNRI < 98) and normal GNRI (GNRI ≥ 98) groups.

RESULTS

Eighty-two patients were enrolled in this study. There were 61 (76%) and 21 (26%) patients in the normal GNRI group and low GNRI group, respectively. There were significant differences in the incidence of grade ≥ 3 radiation mucositis, radiation dermatitis, and leukopenia between the low GNRI group and the normal GNRI groups.

CONCLUSIONS

Patients with low GNRI scores were more likely to have severe adverse events. Pretreatment GNRI predicted severe CCRT-related adverse events in patients of all ages with HNC undergoing CCRT.

Salvage Photon or Proton Radiotherapy for Oligo-recurrence in Regional Lymph Nodes After Surgery for Non-small Cell Lung Cancer

BACKGROUND/AIM

To evaluate the outcome of definitive salvage radiotherapy (RT) in non-small cell lung cancer (NSCLC) patients with oligo-recurrence in regional lymph nodes after surgery.

PATIENTS AND METHODS

Between January 2003 and December 2016, 33 patients with NSCLC were reviewed from radiotherapy database at our hospital. All patients received photon or proton salvage RT for metastases in the regional lymph nodes.

RESULTS

The median follow-up from salvage RT was 35.2 (range=5.9-89.6) months. Recurrences occurred in 18 (55%) patients, and the 3-year overall and progression-free survival rates were 63.8% and 45.1%, respectively. Regional and local control improved patients' survival and these control rates were increased by use of concurrent chemotherapy (p=0.039) and proton RT (p=0.084). No grade 4 acute or late non-hematologic toxicities were observed.

CONCLUSION

Salvage RT is an effective treatment for NSCLC patients with oligo-recurrence at regional lymph nodes.

Long-term outcomes of high-dose (74 GyE) proton beam therapy with concurrent chemotherapy for stage III nonsmall-cell lung cancer

BACKGROUND

To evaluate the long-term outcomes of high-dose (74 GyE) proton beam therapy (PBT) with concurrent chemotherapy for stage III non-small cell lung cancer (NSCLC).

METHODS

Between July 2007 and March 2018, 45 patients with stage III NSCLC were treated with passive-scattering PBT of 74 GyE and concurrent chemotherapy. Among the 45 patients, the median age was 62 years (range 39-79 years) and 32 patients were men. The clinical stages were stage IIIA in 14 patients and stage IIIB in 31 patients. Thirty-six patients received chemotherapy consisting of cisplatin and vinorelbine.

RESULTS

The median follow-up time was 42.1 months (range 6.4-127.0 months) for all patients and 63.5 months (range 9.4-127.0 months) for the 12 survivors. The 3- and 5-year overall survival rates were 63.7% and 38.8%, respectively, and the median overall survival was 49.1 months. Over the follow-up period, disease recurrence was observed in 32 (71%) patients. The 3- and 5-year progression-free survival rates were 22.2% and 17.7%, respectively, with a median progression-free survival of 13.1 months. In-field control improved survival and the in-field control rate was better in patients with T0-3 tumors (p = 0.023) and stage IIIA/IIIB-N3 disease (p = 0.030). Dosimetric parameters of the heart and lung were not associated with survival. No grade 4 or 5 acute or late non-hematologic toxicities were observed.

CONCLUSIONS

Passive-scattering PBT of 74 GyE with chemotherapy showed favorable survival and a low incidence of severe adverse events in patients with stage III NSCLC.

The role of online ethics consultation on mental health

BACKGROUND

Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice.

RESEARCH OBJECTIVE

To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness.

ETHICAL CONSIDERATIONS

The research was conducted in accordance with the Declaration of Helsinki.

RESEARCH DESIGN

This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan.

PARTICIPANTS

The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users.

FINDINGS

The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive.

DISCUSSION

The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants.

CONCLUSION

This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses' moral distress, building ethics into decision-making.

Swelling of Doubly Magic ^{48}Ca Core in Ca Isotopes beyond N=28

Interaction cross sections for ^{42-51}Ca on a carbon target at 280  MeV/nucleon have been measured for the first time. The neutron number dependence of derived root-mean-square matter radii shows a significant increase beyond the neutron magic number N=28. Furthermore, this enhancement of matter radii is much larger than that of the previously measured charge radii, indicating a novel growth in neutron skin thickness. A simple examination based on the Fermi-type distribution, and mean field calculations point out that this anomalous enhancement of the nuclear size beyond N=28 results from an enlargement of the core by a sudden increase in the surface diffuseness of the neutron density distribution, which implies the swelling of the bare ^{48}Ca core in Ca isotopes beyond N=28.

Are Intraoral Stents Effective for Reducing the Severity of Oral Mucositis During Radiotherapy for Maxillary and Nasal Cavity Cancer?

PURPOSE

The intraoral stent (IOS) is an individualized mouth opening device that can be used during radiotherapy (RT) for head and neck cancer to prevent unnecessary irradiation to normal tissues. The purpose of the present study was to compare the severity of oral mucositis (OM) between patients using and not using an IOS during RT for maxillary and nasal cavity cancer.

PATIENTS AND METHODS

We designed and implemented a retrospective cohort study. The study sample included patients with maxillary and nasal cavity cancer who had undergone RT. The primary predictor variable was IOS application, and the outcome variable was the grade of OM.

RESULTS

The IOS group included 18 patients with an IOS and the control group, 16 patients without an IOS. The parameters of the dose-volume histogram included the median dosage covering 1 mL (D1mL) for the tongue and the mean dosage. The D1mL (36.2 vs 65.4 Gy) and mean dosage (4.9 Gy vs 25.9 Gy) were both significantly lower in the IOS group than in the control group (P < .005). The incidence of OM using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0, were significantly different between the oral stomatitis grade and the use of an IOS (P = .028). A significant difference was found in opioid use between the IOS and control groups (P = .009).

CONCLUSIONS

The use of an IOS decreased the radiation dosage to the tongue, the grade of OM, and opioid usage during RT.

Clinical outcomes of previously untreated patients with unresectable intrahepatic cholangiocarcinoma following proton beam therapy

BACKGROUND

The effectiveness of proton beam therapy (PBT) as initial treatment for patients with unresectable intrahepatic cholangiocarcinoma (ICC) is unclear, particularly as related to ICC histological subtypes. We performed this study to address this gap in knowledge.

METHODS

Thirty-seven patients with unresectable ICC who underwent PBT as their initial treatment were evaluated. Twenty-seven patients had Child-Pugh class A liver function, 11 exhibited jaundice, and 10 had multiple tumors. Nineteen, 7, and 11 tumors were classified as mass forming (MF), periductal infiltrating (PI), and intraductal growth (IG) types, respectively, based on gross appearance in imaging studies. Patients were classified into the curative group (n = 25) and palliative group (n = 12) depending on whether the planning target volume covered all the macroscopic tumors.

RESULTS

The 1- and 2-year overall survival rates were 60.3, and 41.4%, respectively; the median survival time (MST) was 15 months for all patients. The MSTs for curative and palliative groups were 25 and 7 months, respectively. Curative treatment and adjuvant chemotherapy significantly improved overall survival, while the presence of periductal infiltrating type tumors was a negative prognostic factor. In the curative group, the 1- and 2-year local control rates were 100 and 71.5%, respectively, while the 1-, and 2-year progression-free survival rates were 58.5, and 37.6%, respectively. No severe acute toxicities were observed. Three patients experienced grade 3 biliary tract infection, although it was unclear whether this was radiotherapy-related.

CONCLUSION

PBT may yield to improve survival and local tumor control among patients with unresectable ICC.

Three cases of hepatocellular carcinoma treated 4 times with proton beams

HCC may recur following surgery or radiofrequency ablation. Proton beam therapy (PBT) is a type of radiotherapy that achieves excellent local control of HCC without severe toxicity. The present study reported the long-term outcome of 3 HCC patients who each received 4 repeat courses of PBT. All patients had a hepatitis B or C viral infection. A total of 14 lesions were treated using a curative PBT protocol and irradiated liver volumes in each treatment were 7-50% of the total liver volume. Liver function in all cases was considerably preserved until the last follow-up and patient survival was 51-107 months from the first PBT with no local recurrence observed in the 14 lesions. The presented cases indicated that repeated PBT is an effective treatment option for recurrent HCC due to reduced liver damage and superior local treatment compared with other treatment options such as transarterial chemoembolization.

Proton Beam Therapy for Histologically or Clinically Diagnosed Stage I Non-Small Cell Lung Cancer (NSCLC): The First Nationwide Retrospective Study in Japan

PURPOSE

To investigate the efficacy and safety of proton beam therapy (PBT) for the treatment of stage I non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

Six hundred sixty-nine patients with 682 tumors histologically or clinically diagnosed stage I NSCLC according to the seventh edition of Union for International Cancer Control who received passive-scattering PBT from April 2004 and December 2013 in Japan were retrospectively reviewed to analyze survival, local control, and toxicities.

RESULTS

Of 669 patients, 486 (72.6%) were men, with a median age of 76 years (range, 42-94 years). NSCLC was histologically confirmed in 440 patients (65.7%). Clinical T stages included T1a (n = 265; 38.9%), T1b (n = 216; 31.7%), and T2a (n = 201; 29.4%). The total irradiation doses of PBT ranged from 74.4 to 131.3 biological effective dose GyE (median, 109.6 biological effective dose GyE). The median follow-up period was 38.2 months (range, 0.6-154.5 months) for all patients. The 3-year overall survival and progression-free survival rates for all patients were 79.5% and 64.1%, respectively. For patients with stage IA tumors, the 3-year overall survival and progression-free survival rates were 82.8% and 70.6%, respectively, and the corresponding rates for patients with stage IB tumors were 70.8% and 47.3%, respectively. The 3-year local progression-free rates for all, stage IA, and stage IB patients were 89.8%, 93.5%, and 79.4%, respectively. The incidence of grade 2, 3, 4, and 5 pneumonitis was 9.8%, 1.0%, 0%, and 0.7%, respectively. The incidence of grade ≥3 dermatitis was 0.4%. No grade 4 or severe adverse events, other than pneumonitis, were observed.

CONCLUSIONS

PBT appears to yield acceptable survival rates, with a low rate of toxicities.

Concurrent chemoradiotherapy using proton beams for unresectable locally advanced pancreatic cancer

BACKGROUND AND PURPOSE

We investigated clinical outcomes of proton beam concurrent chemoradiotherapy (CCRT) for unresectable, locally advanced pancreatic cancer (LAPC) patients.

MATERIALS AND METHODS

Records from 42 unresectable LAPC patients (21 male and 21 female, 39-83 years old) with IIB/III clinical staging of 1/41 treated by proton beam CCRT were retrospectively reviewed. Twelve patients received a conventional 50 Gray equivalents (GyE) in 25 fractions protocol and 30 others received a higher dose protocol of 54.0-67.5 GyE in 25-33 fractions. Gemcitabine or S-1 (Tegafur, Gimeracil and Oteracil) was used concurrently. Toxicity, overall survival (OS) and local control (LC) were examined.

RESULTS

Acute adverse events of grades 1, 2, 3 and 4 were found in 4, 15, 17 and 2 patients, respectively. All grade 3 and 4 events were hematologic. Late adverse events of grades 1 and 2 were found in 3 and 2 patients, respectively. No late adverse effects of grade 3 or higher were observed. The 1-year/2-year OS rates from the start of CCRT were 77.8/50.8% with median survival time (MST) of 25.6 months. The 1-year/2-year LC rate from CCRT start was 83.3/78.9% with a median time to local recurrence of more than 36 months. Total irradiation dose was the only significant factor in univariate analyses of OS and LC (p = 0.015 and 0.023, respectively).

CONCLUSION

Proton beam CCRT lengthened survival periods compared to previous photon CCRT data and higher dose irradiation prolonged LC and OS for unresectable LAPC patients. Proton beam therapy is therefore safe and effective in these cases.

Possible antithrombotic effects of Angelica keiskei (Ashitaba)

Angelica keiskei Koidzumi (Ashitaba) is a large perennial herb that is native to the Pacific coast of Japan, and it has recently become popular as herbal medicine, dietary supplement and health food in Asian countries. The structures of various constituents isolated from Ashitaba such as chalcones, flavanones and coumarins have been precisely characterized, and many of them have bioactivities. A recent study clarified that Angelica keiskei exerts actions that lead to the prevention of thrombosis. Here, we introduce the possibility that ingesting Ashitaba could help to prevent thrombotic diseases.

A validated proton beam therapy patch-field protocol for effective treatment of large hepatocellular carcinoma

Development of a curative local treatment for large hepatocellular carcinoma (HCC) is an important issue. Here, we investigated the dose homogeneity, safety and antitumor effectiveness of proton beam therapy (PBT) using a patch-field technique for large HCC. Data from nine patients (aged 52-79 years) with large HCC treated with patch-field PBT were investigated. The cranial-caudal diameters of the clinical target volumes (CTVs) were 15.0-18.6 cm (median 15.9). The CTV was divided cranially and caudally while both isocenters were aligned along the cranial-caudal axis and overlap of the cranial and caudal irradiation fields was set at 0-0.5 mm. Multileaf collimators were used to eliminate hot or cold spots. Total irradiation doses were 60-76.4 Gy equivalents. Irradiation doses as a percentage of the prescription dose (from the treatment planning system) around the junction were a minimum of 93-105%, a mean of 99-112%, and a maximum of 105-120%. Quality assurance (QA) was assessed in the cranial and caudal irradiation fields using imaging plates. Acute adverse effects of Grade 3 were observed in one patient (hypoalbuminemia), and a late adverse effect of Grade 3 was observed in one patient (liver abscess). Child-Pugh class elevations were observed in four patients (A to B: 3; B to C: 1). Overall survival rates at 1 and 2 years were 55 and 14%, respectively, with a median overall survival of 13.6 months. No patients showed local recurrence. Patch-field PBT supported by substantial QA therefore is one of the treatment options for large HCC.

Effect of Oral Adsorbent on Blood Metabolites in Hepatic Failure Dogs

AST-120 is a specially synthesized carbonaceous adsorbent for oral use. It mainly adsorbs low to middle molecules in the alimentary tract. In the present study, AST-120 was administered to hepatic failure dogs, and blood metabolites were analyzed by high performance liquid chromatography (HPLC).

Thirty adult mongrel dogs underwent posta-cavae (P-C) shunts with 40% and 70% hepatectomies. They were divided into two groups, the AST group (n= 19) and control group (n=11). The AST group received about 0.5 g/kg of the adsorbent intermittently with diet after the operation. The control group was fed the ordinary diet. Body weight, blood ammonia, plasma bile acids were measured, and blood metabolites were analyzed by the multi-column HPLC system.

P-C shunt dogs with 70% hepatotectomies died within three months showing about 40–50% body weight loss. HPLC analysis of their plasma showed some specific peaks for middle molecules, about 3000–5000 daltons. After administration of the adsorbent, these peaks were not detected, so it was considered that these substances had been adsorbed.

Anti-platelet effects of chalcones from Angelica keiskei Koidzumi (Ashitaba) in vivo

Angelica keiskei Koidzumi (Ashitaba) is a traditional folk medicine that is also regarded in Japan as a health food with potential antithrombotic properties. The ability of the major chalcones, xanthoangelol (XA) and 4-hydroxyderricin (4-HD) extracted from Ashitaba roots to inhibit platelet aggregation activity in vitro was recently determined. However, the anti-platelet activities of Ashitaba chalcones in vivo have remained unclear. The present study examines the anti-platelet effects of Ashitaba exudate and its constituent chalcones using mouse tail-bleeding models that reflect platelet aggregation in vivo. Ashitaba exudate and the major chalcone subtype XA, suppressed the lipopolysaccharide (LPS)-induced shortening of mouse tail bleeding. However, trace amounts of other Ashitaba chalcone subtypes including xanthoangelols B (XB), D (XD), E (XE) and F (XF) did not affect tail bleeding. These results suggest that the major chalcone subtype in Ashitaba, XA, has anti-platelet-activities in vivo.

Impact of moral sensitivity on moral distress among psychiatric nurses

Background:

Moral distress occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Moral distress was found to cause negative feelings, burnout, and/or resignation. Not only external factors such as lack of staff but also internal ones affect moral distress. Moral sensitivity, which is thought of as an advantage of nurses, could effect moral distress, as nurses being unaware of existing ethical problems must feel little distress.

Objectives:

To examine the impact of moral sensitivity on moral distress among psychiatric nurses, and affirm the hypothesis that nurses with higher moral sensitivity will suffer moral distress more than nurses with less moral sensitivity in two different samples.

Ethical consideration:

The study obtained ethical approval from the Research Ethics Committee of the Faculty of Medicine at Mie University (# 1111, 20.4.2010), and by the Turku University Ethics Board (29.5.2012). Permissions to undertake the study was obtained from the in two hospital districts and in one city (§ 48/4.10.2012, § 63/4.9.2012, 51/2012 27.8.2012). Informed consent was not formally obtained, because the questionnaire was anonymously reported by the participants who volunteered to answer. The participants responded voluntarily and anonymously.

Methods:

An anonymous questionnaire containing the Revised Moral Sensitivity Questionnaire and the Moral Distress Scale for Psychiatric nurses was conducted to 997 nurses in 12 hospitals in Japan, and 974 nurses in 10 hospitals in Finland after obtaining of approval by research ethics committees. Data were analyzed using a multi-group structural equation model analysis.

Findings:

A set of analyses imply that the association of moral sensitivity with moral distress is significant and similar between Japan and Finland, whereas the factor structures of moral sensitivity and moral distress may be partially different.

Discussion:

The result of this study may indicate that nurses with high moral sensitivity can sense and identify moral problems, but not resolve them. Therefore, supporting nurses to solve ethical problems, not benumbing them, can be important for better nursing care and prevention of nurses’ resignation.

Conclusion:

Moral sensitivity and moral distress were positively correlated among psychiatric nurses in both Japan and Finland, although the participating nurses from the two countries were different in qualification, age, and cultural background. Nurses with high moral sensitivity suffer from moral distress.

A retrospective study of late adverse events in proton beam therapy for prostate cancer

The efficacy and safety of proton beam therapy (PBT) were retrospectively evaluated in 111 consecutive patients with prostate cancer who underwent definitive PBT between 2008 and 2012. Following exclusion of 18 patients due to treatment suspension, loss to follow-up, and histology, the analysis included 93 patients with a median age of 68 years (range, 49–81 years). A total of 7, 32 and 54 prostate cancer patients were classified as low-, intermediate- and high-risk, respectively, as follows: High-risk, T≥3a or prostate-specific antigen (PSA) ≥20 ng/ml or Gleason Score ≥8; low-risk, T ≤2b and PSA≤10 ng/ml and Gleason Score=6; intermediate-risk, all other combinations. The median initial prostate-specific antigen (PSA) level was 9.75 ng/ml (range, 1.4–100 ng/ml) and the median Gleason score was 7 (range, 6–10). Patients with low-risk disease received 74 GyE (relative biological effectiveness=1.1) in 37 fractions, and those at intermediate or higher risk received 78 GyE in 39 fractions. Complete androgen blockade (CAB) therapy was performed from 6 months prior to PBT for patients with intermediate- or high-risk disease. CAB was continued during PBT and then terminated at the end of PBT for intermediate-risk patients. Patients at high risk continued CAB for 3 years. No combination therapy was used for low-risk patients. All the patients were followed up for >2 years after PBT, and all but one were PSA failure-free. The Common Terminology Criteria for Adverse Events v.4.0 was used to evaluate late adverse events. One patient developed grade 3 non-infectious cystitis and hematuria. Grade 2 urinary frequency was observed in 1 patient, and grade 2 rectal bleeding occurred in 4 patients. Of the 4 patients with grade 2 rectal bleeding, 2 received anticoagulant therapy, but none had diabetes mellitus or another high-risk comorbidity. The median time to occurrence of an adverse event of grade ≥2 was 14 months (range, 3–41 months). Therefore, the present retrospective study revealed that PBT at 78 GyE/39 Fr was well-tolerated and achieved good tumor control in patients with prostate cancer.

Follow-up study of liver metastasis from breast cancer treated by proton beam therapy

Liver metastasis from breast cancer (LMBC) is an incurable, fatal disease with a very poor prognosis. Although various local treatments have been applied, their clinical utility has not been established. The purpose of this study was to investigate the safety and effectiveness of proton beam therapy (PBT) for the treatment of patients with LMGC. A total of 8 female patients (aged 38-63 years) with LMBC who received PBT between 2002 and 2012 were retrospectively reviewed. Patients who had tumors confined to the liver were investigated, whereas patients with extrahepatic tumors were excluded. A total of 5 patients had solitary tumors and 3 had multiple tumors. The total irradiation dose was 66-72.6 Gray equivalent [Gy relative biological effectiveness (RBE)] and 2 patients received concurrent chemotherapy or hormone therapy. The overall and progression-free survival (OS and PFS) rates, local control (LC) rate and adverse effects were investigated. All the patients completed treatment without interruption and late adverse effects of grade >3 were not observed. The OS rate was 88/73/58%, the PFS rate was 50/25/0% and the LC rate was 86/86/86% at 1/3/5 years, respectively. Thus, PBT is a safe treatment and the OS and PFS rates are comparable to those with other local treatments. PBT may be considered as an effective local treatment option for the treatment of LMBC patients.

Registration error of the liver CT using deformable image registration of MIM Maestro and Velocity AI

BACKGROUND

Understanding the irradiated area and dose correctly is important for the reirradiation of organs that deform after irradiation, such as the liver. We investigated the spatial registration error using the deformable image registration (DIR) software products MIM Maestro (MIM) and Velocity AI (Velocity).

METHODS

Image registration of pretreatment computed tomography (CT) and posttreatment CT was performed in 24 patients with liver tumors. All the patients received proton beam therapy, and the follow-up period was 4-14 (median: 10) months. We performed DIR of the pretreatment CT and compared it with that of the posttreatment CT by calculating the dislocation of metallic markers (implanted close to the tumors).

RESULTS

The fiducial registration error was comparable in both products: 0.4-32.9 (9.3 ± 9.9) mm for MIM and 0.5-38.6 (11.0 ± 10.0) mm for Velocity, and correlated with the tumor diameter for MIM (r = 0.69, P = 0.002) and for Velocity (r = 0.68, P = 0.0003). Regarding the enhancement effect, the fiducial registration error was 1.0-24.9 (7.4 ± 7.7) mm for MIM and 0.3-29.6 (8.9 ± 7.2) mm for Velocity, which is shorter than that of plain CT (P = 0.04, for both).

CONCLUSIONS

The DIR performance of both MIM and Velocity is comparable with regard to the liver. The fiducial registration error of DIR depends on the tumor diameter. Furthermore, contrast-enhanced CT improves the accuracy of both MIM and Velocity.

INSTITUTIONAL REVIEW BOARD APPROVAL

H28-102; July 14, 2016 approved.

Proton beam therapy for liver metastases from gastric cancer

Liver metastases from gastric cancer (LMGC) is a non-curable, fatal disease with a 5-year survival rate of <10%. Although various local treatments have been applied, their clinical utility has not been established. The purpose of this study was to investigate the safety and effectiveness of proton beam therapy (PBT) for the treatment of patients with LMGC. A total of nine patients (seven men, two women; aged 56-78 years) with LMGC who received PBT between 2002 and 2012 were retrospectively reviewed. Patients who had tumors confined to the liver were investigated, and patients who had extrahepatic tumors were excluded. Six of the patients had solitary tumors, and three patients had multiple tumors. The total irradiation dose was 64-77 Gy relative biological effectiveness (RBE), and three patients received concurrent chemotherapy. The overall and progression-free survival (OS and PFS) rates, local control (LC) rate, and adverse effects were investigated. All patients completed treatment without interruption, and late adverse effects of higher than Grade 3 were not observed. The OS rates at 1, 3 and 5 years were 100%, 78% and 56%, respectively (median, 5.5 years); the PFS rates were 67%, 40% and 40% (median, 2.6 years); and the LC rates were 89%, 71% and 71%. PBT was demonstrated to be a safe treatment, and the OS and PFS rates were not inferior to those for other types of local treatment. Therefore, PBT should be considered as an effective local treatment option for patients with LMGC.

Frequent somatic mutations in epigenetic regulators in newly diagnosed chronic myeloid leukemia

Although tyrosine kinase inhibitors (TKIs) have significantly improved the prognosis of chronic myeloid leukemia (CML), the ability of TKIs to eradicate CML remains uncertain and patients must continue TKI therapy for indefinite periods. In this study, we performed whole-exome sequencing to identify somatic mutations in 24 patients with newly diagnosed chronic phase CML who were registered in the JALSG CML212 study. We identified 191 somatic mutations other than the BCR-ABL1 fusion gene (median 8, range 1–17). Age, hemoglobin concentration and white blood cell counts were correlated with the number of mutations. Patients with mutations ⩾6 showed higher rate of achieving major molecular response than those<6 (P=0.0381). Mutations in epigenetic regulator, ASXL1, TET2, TET3, KDM1A and MSH6 were found in 25% of patients. TET2 or TET3, AKT1 and RUNX1 were mutated in one patient each. ASXL1 was mutated within exon 12 in three cases. Mutated genes were significantly enriched with cell signaling and cell division pathways. Furthermore, DNA copy number analysis showed that 2 of 24 patients had uniparental disomy of chromosome 1p or 3q, which disappeared major molecular response was achieved. These mutations may play significant roles in CML pathogenesis in addition to the strong driver mutation BCR-ABL1.

Long-term outcomes of proton beam therapy in patients with previously untreated hepatocellular carcinoma

Long-term efficacy of proton beam therapy (PBT) remains unclear for patients with previously untreated hepatocellular carcinoma (HCC). We aimed to study the long-term outcomes of PBT according to Barcelona Clinic Liver Cancer (BCLC) staging classifications in patients with previously untreated HCC. The major eligibility criteria of this observational study were an Eastern Cooperative Oncology Group performance status (PS) 0-2, Child-Pugh grade A or B, previously untreated HCC covered within an irradiation field, and no massive ascites. A total of 66.0-77.0 GyE was administered in 10-35 fractions. Local tumor control (LTC), defined as no progression in the irradiated field, progression-free survival (PFS), and overall survival (OS) were assessed according to BCLC staging. From 2002 to 2009 at our institution, 129 patients were eligible. The 5-year LTC, PFS, and OS rates were 94%, 28%, and 69% for patients with 0/A stage disease (n = 9/21), 87%, 23%, and 66% for patients with B stage disease (n = 34), and 75%, 9%, and 25% for patients with C stage disease (n = 65), respectively. The 5-year LTC and OS rates of 15 patients with tumor thrombi in major vessels were 90% and 34%, respectively. Multivariate analyses revealed that PS (0 versus 1-2) was a significant prognostic factor for OS. No grade 3 or higher adverse effects were observed. PBT showed favorable long-term efficacies with mild adverse effects in BCLC stage 0 to C, and can be an alternative treatment for localized HCC especially when accompanied with tumor thrombi. This study was registered with UMIN Clinical Trials Registry (UMIN000025342).

The frequency of snowline-region planets from four-years of OGLE-MOA-Wise second-generation microlensing

We present a statistical analysis of the first four seasons from a "second-generation" microlensing survey for extrasolar planets, consisting of near-continuous time coverage of 8 deg² of the Galactic bulge by the OGLE, MOA, and Wise microlensing surveys. During this period, 224 microlensing events were observed by all three groups. Over 12% of the events showed a deviation from single-lens microlensing, and for ~1/3 of those the anomaly is likely caused by a planetary companion. For each of the 224 events we have performed numerical ray-tracing simulations to calculate the detection efficiency of possible companions as a function of companion-to-host mass ratio and separation. Accounting for the detection efficiency, we find that 55 - 22 + 34 % of microlensed stars host a snowline planet. Moreover, we find that Neptunes-mass planets are ~ 10 times more common than Jupiter-mass planets. The companion-to-host mass ratio distribution shows a deficit at q ~ 10^-2, separating the distribution into two companion populations, analogous to the stellar-companion and planet populations, seen in radial-velocity surveys around solar-like stars. Our survey, however, which probes mainly lower-mass stars, suggests a minimum in the distribution in the super-Jupiter mass range, and a relatively high occurrence of brown-dwarf companions.