Factors Involved in the Choice Between Thoracic and Abdominal Deep Inspiration Breath Holds During Left Breast Cancer Radiotherapy

PURPOSE

Deep inspiration breath hold (DIBH) is used with adjuvant radiation therapy after left breast cancer surgery to reduce radiation dose to the heart. In this study we determined whether thoracic DIBH (T-DIBH) or abdominal DIBH (A-DIBH) should be selected based on patient background.

METHODS

Three-dimensional conformal radiation therapy plans were created under the same conditions using free breathing (FB), T-DIBH, and A-DIBH CT scans of patients who had previously undergone treatment at our hospital.

RESULTS

A-DIBH decreased the left lung dose compared to FB. In comparing T-DIBH and A-DIBH, the heart maximum and left lung doses were significantly lower in A-DIBH. The differences in the heart mean dose (Dmean) between FB, and T-DIBH and A-DIBH were correlated with the cardiothoracic ratio, heart volume, and left lung volume. The difference in the heart Dmean and the left lung dose of T-DIBH and A-DIBH correlated with the forced vital capacity (FVC).

CONCLUSIONS

A-DIBH is preferable over T-DIBH with respect to the heart and left lung doses; however, with respect to the heart Dmean, T-DIBH was more effective in reducing the dose in some cases, and the FVC was a relevant factor in this study.

Effect on Heart and Lung Doses Reduction of Abdominal and Thoracic Deep Inspiratory Breath-hold Assuming Involved-field Radiation Therapy in Patients with Simulated Esophageal Cancer

PURPOSE

The purpose of this study was to evaluate the lung and heart doses in volumetric-modulated arc therapy (VMAT) using involved-field irradiation in patients with middle-to-lower thoracic esophageal cancer during free breathing (FB), abdominal deep inspiratory breath-hold (A-DIBH), and thoracic DIBH (T-DIBH) images.

METHODS

Computed tomography images of A-DIBH, T-DIBH, and FB from 25 patients with breast cancer were used to simulate patients with esophageal cancer. The irradiation field was set at an involved-field, and target and risk organs were outlined according to uniform criteria. VMAT optimization was performed, and lung and heart doses were evaluated.

RESULTS

A-DIBH had a lower lung V20 Gy than FB and a lower lung V40 Gy, V30 Gy, V20 Gy than T-DIBH. The heart all dose indices were lower in T-DIBH than FB, and the heart V10 Gy was lower in A-DIBH than FB. However, the heart D_mean was comparable with A-DIBH and T-DIBH.

CONCLUSIONS

A-DIBH had significant dose advantages for lungs compared to FB and T-DIBH, and the heart D_mean was comparable to T-DIBH. Therefore, when performing DIBH, A-DIBH is suggested for radiotherapy in patients with middle-to-lower thoracic esophageal cancer, excluding irradiation of the prophylactic area.

Dose and organ displacement comparisons with breast conservative radiotherapy using abdominal and thoracic deep-inspiration breath-holds: A comparative dosimetric study

Deep-inspiration breath-hold (DIBH) reduces the radiation dose to the heart and lungs during breast radiotherapy in cancer. However, there is not enough discussion about suitable breathing methods for DIBH. Therefore, we investigated the radiation doses and organ and body surface displacement in abdominal DIBH (A-DIBH) and thoracic DIBH (T-DIBH). Free-breathing, A-DIBH, and T-DIBH computed tomography images of 100 patients were used. After contouring the targets, heart, and lungs, radiotherapy plans were created. We investigated the heart and lung doses, the associations between the heart and left lung displacements, and the thorax and abdominal surface displacements. No significant differences were observed in the target dose indices. However, the heart and lung doses were significantly lower in A-DIBH than in T-DIBH for all the indices; the mean heart and lung doses were 1.69 and 3.48 Gy, and 1.91 and 3.55 Gy in A-DIBH and T-DIBH, respectively. The inferior displacement of the heart and the left lung was more significant in A-DIBH. Therefore, inferior expansion of the heart and lungs may be responsible for the respective dose reductions. The abdominal surface displaced more than the thoracic surface in both A-DIBH and T-DIBH, and thoracic surface displacement was greater in T-DIBH than in A-DIBH. Moreover, A-DIBH can be identified because abdominal surface displacement was greater in A-DIBH than in T-DIBH. In conclusion, A-DIBH and T-DIBH could be distinguished by comparing the abdominal and thoracic surfaces of A-DIBH and T-DIBH, thereby ensuring the implementation of A-DIBH and reducing the heart and lung doses.

Comparing the toxicity and disease control rate of radiotherapy for prostate cancer between salvage settings after high-intensity focused ultrasound therapy and initial settings

The purpose of this retrospective study was to compare the toxicity and disease control rate of radiotherapy for prostate cancer in salvage settings after high-intensity focused ultrasound (HIFU) therapy (HIFU cohort) with those in radical settings (non-HIFU cohort). From 2012 to 2020, 215 patients were identified for this study and 17 were treated in the salvage settings after HIFU. The median follow-up time was 34.5 months (range: 7-102 months, inter-quartile range [IQR]: 16-64 months). Genitourinary (GU) and gastrointestinal (GI) adverse events were evaluated in acute and late periods with Common Terminology Criteria for Adverse Events version 5, and the rates of biochemical-clinical failure free survival (BCFS) and overall survival (OS) were estimated. The cumulative incidence of late GU Grade 2 or greater toxicity after five years was significantly different between the non-HIFU and HIFU cohorts with rates of 7.3% and 26.2%, respectively (P = 0.03). Regarding GI Grade 2 or greater toxicity, there was no significant difference between the two cohorts. The 5y-BCFS was 84.2% in the non-HIFU cohort and 69.5% in the HIFU cohort with no significant difference (P = 0.10) and the 5y-OS was 95.9% and 92.3%, respectively (P = 0.47). We concluded that the possibility of increased late GU Grade 2 or greater should be considered when applying salvage radiotherapy for local recurrence after HIFU.

Examination of the dose distribution of volumetric modulated arc radiotherapy using a high-definition multi-leaf collimator for breast cancer patients with irradiated regional lymph nodes

Background

A high-definition multi-leaf collimator (HD-MLC) with 5- and 10-mm fine MLCs is useful for radiotherapy. However, it is difficult to irradiate the mammary gland and supraclavicular region using a HD-MLC because of the narrow field of volumetric modulated arc radiotherapy (VMAT). Therefore, we aimed to evaluate the dose distribution of the VMAT dose using a HD-MLC in 15 patients with left breast cancer undergoing postoperative irradiation of breast and regional lymph nodes, including the internal mammary node.

Materials and methods

The following four plans were generated: three-arc VMAT using HD-MLC (HD-VMAT), two tangential arcs and one-arc VMAT using HD-MLC (tHD-VMAT), three-dimensional conformal radiotherapy (3DCRT) using HD-MLC, and two-arc VMAT using the Millennium 120-leaf MLC (M-VMAT). We assessed the doses to the target volume and organs at risk.

Results

The target dose distributions were higher for HD-VMAT than 3DCRT. There were no significant differences in the heart mean dose (D_mean) or lung volume receiving 20 Gy (V20 Gy) between HD-VMAT and 3DCRT. The heart D_mean and lung V20 Gy of tHD-VMAT were higher than those of HD-VMAT, and the heart D_mean of M-VMAT was higher than that of HD-VMAT. However, the target doses of tHD-VMAT, M-VMAT, and HD-VMAT were equivalent.

Conclusions

In cases of the mammary gland and regional lymph node irradiation, including the internal mammary node in patients with left breast cancer, HD-VMAT was not inferior to M-VMAT and provided a better dose distribution to the target volume and organs at risk compared with 3DCRT and tHD-VMAT.

Dosimetric study of whole-brain irradiation with high-energy photon beams for dose reduction to the scalp

OBJECTIVE

To evaluate the efficiency of high-energy photons for mitigating alopecia due to whole-brain irradiation (WBRT).

METHODS

Planning CT data from 10 patients who received WBRT were collected. We prepared 4 WBRT plans that used 6 or 15 MV photon beams, with or without use of a field-in-field (FiF) technique, and compared outcomes using a treatment planning system. The primary outcome was dose parameters to the scalp, including the mean dose, maximum dose, and dose received to 50% scalp(D50%). Secondary outcomes were minimum dose to the brain surface.

RESULTS

Using FiF, the mean doses were 24.4-26.0 and 22.4-24.1 Gy, and the maximum doses were 30.5-32.1 and 28.5-30.8 Gy for 6 and 15 MV photon beams, respectively. Without FiF, the mean doses were 24.6-26.9 and 22.6-24.5 Gy, and the maximum doses were 30.8-34.6 and 28.6-32.4 Gy for 6 and 15 MV photon beams. The 15 MV plan resulted in a lower scalp dose for each dose parameter (p < 0.001). Using FiF, the minimum doses to the brain surface for the 6 and 15 MV plans were 28.9 ± 0.440 and 29.0 ± 0.557 Gy, respectively (p = 0.70). Without FiF, the minimum doses to the brain surface for the 6 and 15 MV plans were 28.9 ± 0.456 and 29.0 ± 0.529, respectively (p = 0.66).

CONCLUSION

Compared with the 6 MV plan, the 15 MV plan achieved a lower scalp dose without impairing the brain surface dose.

ADVANCES IN KNOWLEDGE

High-energy photon WBRT may mitigate alopecia of patients who receiving WBRT.

Dosimetric evaluation of the feasibility of stereotactic body radiotherapy for primary lung cancer with lobe-specific selective elective nodal irradiation

More than 10% of all patients treated with stereotactic body radiotherapy (SBRT) for primary lung cancer develop regional lymph node recurrence. We evaluated the dosimetric feasibility of SBRT with lobe-specific selective elective nodal irradiation (ENI) on dose-volume histograms. A total of 21 patients were treated with SBRT for Stage I primary lung cancer between January 2010 and June 2012 at our institution. The extents of lobe-specific selective ENI fields were determined with reference to prior surgical reports. The ENI fields included lymph node stations (LNS) 3 + 4 + 11 for the right upper lobe tumors, LNS 7 + 11 for the right middle or lower lobe tumors, LNS 5 + 11 for the left upper lobe tumors, and LNS 7 + 11 for the left lower lobe tumors. A composite plan was generated by combining the ENI plan and the SBRT plan and recalculating for biologically equivalent doses of 2 Gy per fraction, using a linear quadratic model. The V20 of the lung, D(1cm3) of the spinal cord, D(1cm3) and D(10cm3) of the esophagus and D(10cm3) of the tracheobronchial wall were evaluated. Of the 21 patients, nine patients (43%) could not fulfill the dose constraints. In all these patients, the distance between the planning target volume (PTV) of ENI (PTVeni) and the PTV of SBRT (PTVsrt) was ≤2.0 cm. Of the three patients who developed regional metastasis, two patients had isolated lymph node failure, and the lymph node metastasis was included within the ENI field. When the distance between the PTVeni and PTVsrt is >2.0 cm, SBRT with selective ENI may therefore dosimetrically feasible.

AV-65, a novel Wnt/β-catenin signal inhibitor, successfully suppresses progression of multiple myeloma in a mouse model

Multiple myeloma (MM) is a malignant neoplasm of plasma cells. Although new molecular targeting agents against MM have been developed based on the better understanding of the underlying pathogenesis, MM still remains an incurable disease. We previously demonstrated that β-catenin, a downstream effector in the Wnt pathway, is a potential target in MM using RNA interference in an in vivo experimental mouse model. In this study, we have screened a library of more than 100 000 small-molecule chemical compounds for novel Wnt/β-catenin signaling inhibitors using a high-throughput transcriptional screening technology. We identified AV-65, which diminished β-catenin protein levels and T-cell factor transcriptional activity. AV-65 then decreased c-myc, cyclin D1 and survivin expression, resulting in the inhibition of MM cell proliferation through the apoptotic pathway. AV-65 treatment prolonged the survival of MM-bearing mice. These findings indicate that this compound represents a novel and attractive therapeutic agent against MM. This study also illustrates the potential of high-throughput transcriptional screening to identify candidates for anticancer drug discovery.

Removal efficiency of 66 pharmaceuticals during wastewater treatment process in Japan

Both biological treatment processes including conventional activated sludge (CAS) and biological nutrient removal (BNR) processes, and physico-chemical treatment processes including ozonation process and Title 22 process consisting of coagulation, sedimentation and filtration followed by UV or chlorination disinfection after the above biological processes, were compared from the viewpoint of removal efficiency. 66 pharmaceuticals including antibiotics, analgesics, psychoneurotic agents were measured with SPE-LC/MS/MS. 26 compounds out of 66 were detected in the influent ranging ng/L to microg/L order. Particularly, disopyramide, sulpiride, and dipyridamole that have been rarely detected before in the WWTP, occurred at concentration levels of more than 100 ng/L. The total concentration of the individual pharmaceuticals in the influent was efficiently removed by 80% during the biological treatment. But removal efficiencies of carbamazepine and crotamiton were less than 30%. The total concentration of the individual pharmaceuticals in the effluent from CAS process was 1.5 times higher than that from BNR process. Further, the total concentration of the individual pharmaceuticals in the discharge from WWTPs applying ozonation following activated sludge process was reduced to less than 20%. Physico-chemical treatment train called Title 22 treatment after CAS could not efficiently remove the pharmaceuticals. However, ozonation process followed by biological activated carbon process could efficiently reduce all the residual pharmaceuticals below their quantification limits.

Effects of antihypertensive treatment on platelet function in essential hypertension

To evaluate the effect of antihypertensive therapy on platelet activation in essential hypertension, the plasma levels of beta-thromboglobulin (beta-TG) were examined in 45 patients with essential hypertension and 20 age-matched normotensive control subjects. Hypertensive patients were assigned to monotherapy with one of five different antihypertensive drugs for 6 months, and the change of plasma levels of beta-TG was reexamined after the completion of the monotherapy. The plasma beta-TG increased in hypertensive patients compared with levels in normotensive control subjects. Monotherapy with each drug resulted in sufficient blood pressure control in all hypertensive patients. The plasma beta-TG decreased significantly after monotherapy with an alpha-blocker or an angiotensin-converting enzyme inhibitor (ACEI). The plasma beta-TG increased with the use of a diuretic but did not change with the use of a beta-blocker or calcium antagonist. The platelet activation observed in patients with essential hypertension is reversed by monotherapy with an alpha-blocker or an ACEI. It is possible that these drugs reduce the development of hypertensive vascular complications due to suppression of platelet activation in patients with essential hypertension.

Cerebral black blood MR angiography with the interleaved multi-slab three-dimensional fast spin echo sequence

To overcome the disadvantages of conventional three-dimensional time-of-flight MR angiography (3D-TOF), such as saturation or intravoxel dephasing, black blood MR angiography (BB-MRA) using an interleaved multi-slab 3D fast spin echo sequence was developed and evaluated clinically. In major branches, the contrast-to-noise ratio of the flow was not as good as 3D-TOF in BB-MRA. However, in-plane slow flow and large aneurysm were visualized better on BB-MRA than on 3D-TOF. Furthermore, BB-MRA could provide wider coverage than 3D-TOF. BB-MRA using interleaved multi-slab 3D fast spin echo is now feasible and complementary to 3D-TOF.

[Study of two cases of active pulmonary tuberculosis complicated by lung cancer]

In this study, we report on two patients diagnosed with active pulmonary tuberculosis who later developed complications of lung cancer. In both instances, lung cancer was not detected until after cessation of tuberculostatic drugs. Both patients were initially considered to be experiencing exacerbation of pulmonary tuberculosis. Patient 1 was a 77-year-old female. A roentgenogram of her chest revealed a cavitary lesion with infiltration into the right lung field. Her sputum tested positive for acid-fast bacilli. Although she was treated with isoniazid (INH), rifampicin (RFP) and streptomycin sulfate (SM), the RFP and INH treatments had to be discontinued due to liver dysfunction. Her general condition was deteriorated, and pleural effusion appeared on a subsequent chest roentgenogram. Primary squamous-cell lung cancer was confirmed by conducting a transbronchial biopsy. Patient 2 was a 59-year-old male. A roentgenogram of his chest revealed multiple cavitary lesions with infiltration into the bilateral lung field. His sputum also tested positive for acid-fast bacilli. Although he was treated with INH, RFP and SM, INH and RFP treatment had to be discontinued due to liver dysfunction and high fever. The shadow infiltrating the left lung field subsided, but a massive shadow appeared in the right lung field. Primary small-cell lung cancer was confirmed after conducting a sputum cytology. The patients was then administered cisplatin and etoposide. Patient 1 was diagnosed with lung cancer five months after being admitted to the hospital, and Patient 2 ten months after admission. Both patients succumbed due to lung cancer at seven and 26 months, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of acyl-CoA: cholesterol acyltransferase activity by cyclodepsipeptide antibiotics

The effect was studied of the fungal cyclodepsipeptide antibiotics beauvericin and seven distinct enniatins on acyl-CoA: cholesterol acyltransferase (ACAT) activity. In an enzyme assay using rat liver microsomes, all the compounds were found to inhibit ACAT activity. The drug concentration that caused 50% inhibition (IC50 value) of the enzyme activity was determined to be 3.0 microM for beauvericin, indicating that the compound is one of the most potent ACAT inhibitors of microbial origin. Enniatins exhibited much higher IC50 values of 22 to 110 microM. More hydrophobic enniatins showed more potent inhibitory activity. Furthermore, the ACAT inhibitory activity was evaluated as inhibition of cholesteryl ester formation in a cell assay using J774 macrophages. Calculation of the ratio, CD50 value (the drug concentration causing 50% cell damage)/IC50 value of cholesteryl ester formation, indicated that beauvericin shows the highest specificity. These data indicate that beauvericin is one of the most potent and specific ACAT inhibitors of microbial origin.

[Clinical backgrounds of six cases of childhood tuberculosis]

Clinical backgrounds of six children who entered Matsue National chest Hospital due to pulmonary tuberculosis and tuberculous pleuritis were investigated and the following results were obtained. 1) Of six children five had not received BCG vaccination. 2) There were two children who developed tuberculosis after the completion of chemoprophylaxis. 3) None was detected by the examination of the household of the source cases. 4) Both patients and doctors were responsible for the delay in detecting the source, which ranged between five and seventeen months in total. 5) Among the source cases there were two patients who were smear-negative but culture-positive. In view of the above observations it is suggested that BCG vaccination is important for the prevention of tuberculosis in children and that follow-up examinations should be continued after the completion of chemoprophylaxis. It should also be emphasized that early detection of the source case is imperative for the prevention of tuberculosis.

Stimulation of the reticuloendothelial system of mice by muramyl dipeptide

Muramyl dipeptide (MDP), a part of bacterial cell wall peptidoglycans, was active as adjuvant and stimulated the reticuloendothelial system (RES) of mice to increase its phagocytic function. A series of analogs of MDP was tested for their adjuvant activity and RES-stimulating activity. Sex differences were observed in the adjuvant activity and RES-stimulating capacity of some MDP analogs. A stereochemically highly specific structure required for MDP to exert adjuvant activity was also required for its RES-stimulating activity. Based on this close correlation among the structure, adjuvant activity, and RES-stimulating capacity of MDP, we infer that macrophages may play an important role in the expression of adjuvant activity of MDP.

Application of magnification radiography to the biliary system

Magnification radiography was applied for the diagnosis of the biliary tract diseases including cancer. Our X-ray unit was consisting of HITACHI DR-155-23 U-6M-55P and 0.1 mm focal-spot tube, FFD 80 cm giving a magnification of x2 with the conditions of 60 kVp, 20 mA, 0.8 sec. Intensifying screens such as Kyokko LH II (for a standard sized subject) or DuPont Q II (for an obese subject) were used in combination with Fuji RX films. We confirmed a high diagnostic value in revealing early lesions of this sytem. The skin dose test indicated that this technique was routinely applicable with safety for clinical use.