• Radiation Oncology Journal
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• v.24 no.3
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• pp.171-178
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• 2006

[ $\underline{Purpose}$ ]: To determine the efficacy and safety of concurrent chemotherapy and radiation therapy with high-dose-rate brachytherapy for cervical cancer. $\underline{Materials\;and\;Methods}$: From January 2001 to December 2002, 30 patients with cervical cancer were treated with concurrent chemotherapy (cisplatin and 5-FU) and definitive radiation therapy. The median age was 58 (range $34{\sim}74$) year old. The pathology of the biopsy sections was squamous cell carcinoma in 29 patients and one was adenocarcinoma. The distribution to FIGO staging system was as follows: stage IB, 7 (23%); IIA, 3 (10%); IIB, 12 (40%); IIIA, 3 (10%); IIIB, 5 (17%). All patients received pelvic external beam irradiation (EBRT) to a total dose of $45{\sim}50.4\;Gy$ (median: 50.4 Gy) over $5{\sim}5.5$ weeks. Ir-192 HDR intracavitary brachytherapy (ICBT) was given after a total dose of 41.4 Gy. HDR-ICBT was performed twice a week, with a fraction point A dose of 4 Gy and median dose to point A was 28 Gy (range: $16{\sim}32\;Gy$) in 7 fractions. The median cumulative biologic effective dose (BED) at point A (EBRT+ICBT) was $88\;Gy_{10}$ (range: $77{\sim}94\;Gy_{10}$). The median cumulative BED at ICRU 38 reference point (EBRT+ICBT) was $131\;Gy_3$ (range: $122{\sim}140\;Gy_3$) at point A, $109\;Gy_3$ (range: $88{\sim}125\;Gy_3$) at the rectum and $111\;Gy_3$ (range: $91{\sim}123\;Gy_3$) at the urinary bladder. Cisplatin ($60\;mg/m^2$) and 5-FU ($1,000\;mg/m^2$) was administered intravenously at 3 weeks interval from the first day of radiation for median 5 (range: $2{\sim}6$) cycles. The assessment was performed at 1 month after completion of radiation therapy by clinical examination and CT scan. The median follow-up time was 36 months (range: $8{\sim}50$ months). $\underline{: The complete response rate after concurrent chemoradiation therapy was 93.3%. The 3-yr actuarial pelvic control rate was 87% and 3-yr actuarial overall survival and disease-free survival rate was 93% and 87%, respectively. The local failure rate was 13% and distant metastatic rate was 3.3%. The crude rate of minor hematologic complications (RTOG grade 1-2) occurred in 3 patients (10%) and one patient had suffered from severe leukopenia (RTOG grade 4) during concurrent treatment. Acute minor enterocolitis (RTOG grade 1-2) occurred in 11 patients (37%) and one patient (3%) was suffered from colon perforation during radiation therapy. Late colitis of RTOG grade 1 occurred in 5 patients (15%). Acute cystitis of RTOG grade 1 occurred in 12 patients (40%) and late cystitis of RTOG grade 2 occurred in one patient (3%). No treatment related death was seen. $\underline{Conclusion}$: The results of this study suggest that the concurrent chemoradiation therapy with HDR brachytherapy could be accepted as an effective and safe treatment for cervical cancer.

• Radiation Oncology Journal
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• v.28 no.4
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• pp.231-237
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• 2010

Purpose: We investigated the effect of location changes in the inferior border of the belly board (BB) aperture by adding a bladder compression device (BCD). Materials and Methods: We respectively reviewed data from 10 rectal cancer patients with a median age 64 years (range, 45~75) and who underwent computed tomography (CT) simulation with the use of BB to receive pelvic radiotherapy between May and September 2010. A CT simulation was again performed with the addition of BCD since small bowel (SB) within the irradiated volume limited boost irradiation of 5.4 Gy using the cone down technique after 45 Gy. The addition of BCD made the inferior border of BB move from symphysis pubis to the lumbosacral junction (LSJ). Results: Following the addition of BCD, the irradiated volumes of SB and the abdominopelvic cavity (APC) significantly decreased ($174.3{\pm}89.5mL$ vs. $373.3{\pm}145.0mL$, p=0.001, $1282.6{\pm}218.7mL$ vs. $1,571.9{\pm}158mL$, p<0.001, respectively). Bladder volume within the treated volume increased with BCD ($222.9{\pm}117.9mL$ vs. $153.7{\pm}95.5mL$, p<0.001). The ratio of irradiated bladder volume to APC volume with BCD ($33.5{\pm}14.7%$) increased considerably compared to patients without a BCD ($27.5{\pm}13.1%$) (p<0.001), and the ratio of irradiated SB to APC volume decreased significantly with BCD ($13.9{\pm}7.6%$ vs. $24.2{\pm}10.2%$, p<0.001). The ratios of the irradiated SB volume and irradiated bladder volume to APC volume negatively correlated (p=0.001). Conclusion: This study demonstrated that the addition of BCD, which made the inferior border of BB move up to the LSJ, increased the ratio of the bladder to APC volume and as a result, decreased the irradiated volume of SB.

• Radiation Oncology Journal
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• v.13 no.2
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• pp.157-162
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• 1995

Lung cancer study group at Asan Medical Center has conducted the second prospective study to determine the efficacy and feasibility of MVP chemotherapy with concurrent hyperfractionated radiotherapy for Patients with stage III unresectable non-small cell lung cancer(NSCLC). All eligible Patients with stage III unresectable NSCLC were treated with hyperfractionated radiotherapy(120 cGy/fx BID. 6480 cGy/54fx) and concurrent 2 cycles of MVP(Mitomycin C $6mg/m^2,$ d2 & d29.Vinblastine $6mg/m^2,$ d2 & d29, Cisplatin $60mg/m^2,$ dl & d28) chemotherapy. Between Aug. 1993 and Nov. 1994, 62 patients entered this study; $6(10\%)$ had advanced stage IIIa and $56(90\%)$ had IIIb disease including 11 with pleural effusion and 10 with supraclavicular metastases. Among 62 patients, $48(77\%)$ completed planned therapy. Fourteen patients refused further treatment during chemoradiotherapy. Of 46 patients evaluable for response, $34(74\%)$ showed major response including $10(22\%)$ with complete and $24(52\%)$ with partial responses. Of 48 patients evaluable for toxicity, $13(27\%)$ showed grade IV hematologic toxicity but treatment delay did not exceed 5 days Two patients died of sepsis during chemoradiotherapy. Severe weight loss(more than $10\%)$ occurred in 9 patients$(19\%)$ during treatment. Nine patients$(19\%)$ developed radiation pneumonitis Six of these patients had grade 1 (mild) Pneumonitis with radiographic changes within the treatment fields Three other patients had grade 11 Pneumonitis, but none of these patients had continuous symptoms after steroid treatment. Concurrent chemoradiotherapy for patients with advanced NSCLC was well tolerated with acceptable toxicity and achieved higher response rates than the first study, but rather low compliance $rate(77\%)$ in this study is worrisome. We need to improve nutritional support during treatment and to use G-CSF to improve leukopenia and if necessary. supportive care will be given as in patients, Longer follow-up and larger sample size is needed to observe survival advantage.

• Journal of Chest Surgery
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• v.38 no.2 s.247
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• pp.157-163
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• 2005

Background: Clinical outcomes of esophageal cancer have not been satisfactory in spite of the development of surgical skills and protocols of adjuvant therapy. We analyzed the results of corrective surgical patients for esophageal cancer from January 1992 to July 2002. Material and Method: Among 129 patients with esophageal cancer, this study was performed in 68 patients who received corrective surgery. The ratio of sex was 59 : 9 (male : female) and mean age was $61.07\pm7.36$ years old. Chief complaints of this patients were dysphagia, epigastric pain and weight loss, etc. The locations of esophageal cancer were 4 in upper esophagus, 36 in middle, 20 in lower, 8 in esophagogastric junction. 60 patients had squamous cell cancer and 7 had adenocarcinoma, and 1 had malignant melanoma. Five patients had neoadjuvant chemotherapy. Result: The postoperative stage I, IIA, IIB, III, IV patients were 7, 25, 12, 17 and 7, respectively. The conduit for replacement of esophagus were stomach (62 patients) and colon (6 patients). The neck anastomosis was performed in 28 patients and intrathoracic anastomosis in 40 patients. The technique of anastomosis were hand sewing method (44 patients) and stapling method (24 patients). One of the early complications was anastomosis leakage (3 patients) which had only radiologic leakage that recovered spontaneously. The anastomosis technique had no correlation with postoperative leakage, which stapling method (2 patients) and hand sewing method (1 patient). There were 3 respiratory failures, 6 pneumonia, 1 fulminant hepatitis, 1 bleeding and 1 sepsis. The 2 early postoperative deaths were fulminant hepatitis and sepsis. Among 68 patients, 23 patients had postoperative adjuvant therapy and 55 paitents were followed up. The follow up period was $23.73\pm22.18$ months ($1\~76$ month). There were 5 patients in stage I, 21 in stage 2A, 9 in stage IIB, 15 in stage III and 5 in stage IV. The 1, 3, 5 year survival rates of the patients who could be followed up completely was $58.43\pm6.5\%,\;35.48\pm7.5\%\;and\;18.81\pm7.7\%$, respectively. Statistical analysis showed that long-term survival difference was associated with a stage, T stage, and N stage (p<0.05) but not associated with histology, sex, anastomosis location, tumor location, and pre and postoperative adjuvant therapy. Conclusion: The early diagnosis, aggressive operative resection, and adequate postoperative treatment may have contributed to the observed increase in survival for esophageal cancer patients.

• Journal of Chest Surgery
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• v.34 no.12
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• pp.917-923
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• 2001

Background : Bronchial sleeve resection for centrally located primary lung cancer is a lung-parenchyma-sparing operation in patients whose predicted postoperative lung function is expected to diminished markedly. Because of its potential bronchial anastomotic complications, it is considered to be an alternative to pneumonectomy. However, since sleeve lobectomy yielded survival results equal to at least those of pneumonectomy, as well as better functional results, it became and accepted standard procedure for patients with lung cancer who have anatomically suitable tumors, regardless of lung function. In this study, from analyzing of occurrence rate of postoperative complication and survival rate, we wish to investigate the validity of sleeve resection for primary lung cancer. Material and Method : From January 1989 to December 1998, 45 bronchial sleeve resections were carried out in the Department of Thoracic Surgery of Seoul National University Hospital. We included 40 men and 5 women, whose ages ranged from 23 to 72 years with mean age of 57 years. Histologic type was squamous cell carcinoma in 35 patients, adenocarcinoma in 7, and adenosquamous cell carcinoma in 1 patients. Right upper lobectomy was peformed in 24 patients, left upper lobectomy in 11, left lower lobectomy in 3, right lower lobectomy in 1, right middle lobecomy and right lower lobectomy in 3, right upper lobectomy and right middle lobecomy in 2, and left pneumonectomy in 1 patient. Postoperative stage was Ib in 11, IIa in 3, IIb in 16, IIIa in 13, and IIIb in 2 patients. Result: Postoperative complications were as follows; atelectasis in 9, persistent air leakage for more than 7 days was in 7 patients, prolonged pleural effusion for more than 2 weeks in 7, pneumonia in 2, chylothorax in 1, and disruption of anastomosis in 1. Hospital mortality was in 3 patients. During follow-up period, bronchial stricture at anastomotic site were found in 7 patients under bronchoscopy, Average follow-up duration of survivals(n=42) was 35.5$\pm$29 months. All of stage I patients were survived, and 3 year survival rate of stage II and III patients were 63%, 21%, respectively. According to Nstage, all of N0 patients were survived and 3 year survival rates of Nl and N2 were 63% and 28% respectively. Conclusion: We suggest that this sleeve resection, which is technically demanding, should be considered in patients with centrally located lung cancer, because ttlis lung-saving operation is safer than pneumonectomy and is equally curative.

• Journal of Chest Surgery
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• v.40 no.1 s.270
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• pp.37-44
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• 2007

Background: It is known that long-term survival rate in patients underwent bronchial sleeve lobectomy for primary lung cancer is at least equal to that in patients underwent pneumonectomy, and bronchial sleeve lobectomy is performed in patients with suitable tumor location even in patients have adequate pulmonary function. Sleeve pneumonectomy is performed when carina was invaded by tumor or tumor location was near to the carina. We performed this study to know our results of sleeve resection for primary lung cancer. Material and Method: We analyzed retrospectively the medical records of 45 patients who underwent sleeve lobectomy or sleeve pneumonectomy for primary lung cancer by one thoracic surgeon from May 1990 to July 2003 in Department of Thoracic & Cardiovascular Surgery, College of Medicine, Kyung Hee University. Follow-up loss was absent and last follow-up was performed in April 5, 2005. Kaplan-Meyer method and log-lank test were used to know long-term survival rate and p-value. Result: Mean age was 60 years old and male to female ratio 41:1. Histologic types were squamous cell carcinoma were 39, adenocarcinoma were 4, and others were 2 patients. Pathologic stages were I 14, II 14, and III 17 patients. Nodal stages were N0 23, N1 13, and N2 9 patients. Types of operation were sleeve lobectomy 40 and sleeve pneumonectomy 5 patients. Operative mortality was 3 patients and its cause was respiratory complications. Early complications were pneumonia 4, atelectasis 8, air leakage more than 7 days 6, and atrial fibrillation 4 patients. In 19 patients tumor was recurred. Local recurrence was 10 and systemic metastasis was 9 patients. Overall 5, 10-year survival rate were 54.2%, 42.5%. The 5, 10-year survival rates according to the pathologic stage were 83.9%, 67.1% in stage I, 55%, 47.1% in II, 33.3%, 25% in III, and significance difference was present between stage I and III. The 5, 10-year survival rate according to the lymph node involvement were 63.9%, 54.6% in N0, 53,8%, 46.5% in N1, 28.5%, 14.2% in N2, and significance difference was present between N0 and N2. Conclusion: Because bronchial sleeve lobectomy for primary lung cancer could be performed safely and shows acceptable long-term survival rate, it could be considered primary in case of suitable tumor location if complete resection is possible. Although sleeve pneumonectomy for primary lung cancer shows somewhat high operative mortality rate, it could be considered in view of curative treatment.

• Radiation Oncology Journal
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• v.19 no.3
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• pp.275-286
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• 2001

Purpose : To setup procedures of quality assurance (OA) for implementing intensity modulated radiation therapy (IMRT) clinically, report OA procedures peformed for one patient with prostate cancer. Materials and methods : $P^3IMRT$ (ADAC) and linear accelerator (Siemens) with multileaf collimator are used to implement IMRT. At first, the positional accuracy, reproducibility of MLC, and leaf transmission factor were evaluated. RTP commissioning was peformed again to consider small field effect. After RTP recommissioning, a test plan of a C-shaped PTV was made using 9 intensity modulated beams, and the calculated isocenter dose was compared with the measured one in solid water phantom. As a patient-specific IMRT QA, one patient with prostate cancer was planned using 6 beams of total 74 segmented fields. The same beams were used to recalculate dose in a solid water phantom. Dose of these beams were measured with a 0.015 cc micro-ionization chamber, a diode detector, films, and an array detector and compared with calculated one. Results : The positioning accuracy of MLC was about 1 mm, and the reproducibility was around 0.5 mm. For leaf transmission factor for 10 MV photon beams, interleaf leakage was measured $1.9\%$ and midleaf leakage $0.9\%$ relative to $10\times\;cm^2$ open filed. Penumbra measured with film, diode detector, microionization chamber, and conventional 0.125 cc chamber showed that $80\~20\%$ penumbra width measured with a 0.125 cc chamber was 2 mm larger than that of film, which means a 0.125 cc ionization chamber was unacceptable for measuring small field such like 0.5 cm beamlet. After RTP recommissioning, the discrepancy between the measured and calculated dose profile for a small field of $1\times1\;cm^2$ size was less than $2\%$. The isocenter dose of the test plan of C-shaped PTV was measured two times with micro-ionization chamber in solid phantom showed that the errors upto $12\%$ for individual beam, but total dose delivered were agreed with the calculated within $2\%$. The transverse dose distribution measured with EC-L film was agreed with the calculated one in general. The isocenter dose for the patient measured in solid phantom was agreed within $1.5\%$. On-axis dose profiles of each individual beam at the position of the central leaf measured with film and array detector were found that at out-of-the-field region, the calculated dose underestimates about $2\%$, at inside-the-field the measured one was agreed within $3\%$, except some position. Conclusion : It is necessary more tight quality control of MLC for IMRT relative to conventional large field treatment and to develop QA procedures to check intensity pattern more efficiently. At the conclusion, we did setup an appropriate QA procedures for IMRT by a series of verifications including the measurement of absolute dose at the isocenter with a micro-ionization chamber, film dosimetry for verifying intensity pattern, and another measurement with an array detector for comparing off-axis dose profile.

• Tuberculosis and Respiratory Diseases
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• v.43 no.4
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• pp.500-518
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• 1996

Background : The solitary pulmonary nodule(SPN) presents a diagnostic dilemma to the physician and the patient. Many clinical characteristics(i.e. age, smoking history, prior history of malignancy) and radiological characteristics( i.e. size, calcification, growth rate, several findings of computed tomography) have been proposed to help to determine whether the SPN was benign or malignant. However, most of these diagnostic guidelines are based on the data collected before computed tomography(CT) has been introduced and lung cancer was not as common as these days. Moreover, it is not well established whether these guidelines from western populations could be applicable to Korean patients. Methods : We had a retrospective analysis of the case records and radiographic findings in 114 patients presenting with SPN from Jan. 1994 to Feb. 1995 in Seoul National University Hospital, a tertiary referral hospital. Results : We observed the following results ; (1) Out of 113 SPNs, the etiology was documented in 94 SP IS. There were 34 benign SP s and 60 malignant SPNs. Among which, 49 SPNs were primary lung cancers and the most common hi stologic type was adenocarcinoma. (2) The average age of patients with benign and malignant SPNs was $49.7{\pm}12.0$ and $58.1{\pm}10.0$ years, respectively( p=0.0004), and the malignant SPNs had a striking linear propensity to increase with age. (3) No significant difference in the hi story of smoking was noted between the patients with benign SPNs($13.0{\pm}17.6$ pack- year) and those with malignant SPNs($18.6{\pm}25.1$ pack-year) (p=0.2108). (4) 9 out of 10 patients with prior history of malignancy had malignant SPNs. 5 were new primary lung cancers with no relation to prior malignancy. (5) The average size of benign SPNs($3.01{\pm}1.20cm$) and malignant SPNs($2.98{\pm}0.97cm$) was not significantly different(p=0.8937). (6) The volume doubling time could be calculated in 22 SPNs. 9 SPNs had the volume doubling time longer than 400 days. Out of these, 6 were malignant SPNs. (7) The CT findings suggesting malignancy included the lobulated or spiculated border, air- bronchogram, pleural tail, and lymphadenopathy. In contrast, calcification, central low attenuation, cavity with even thickness, well-marginated border, and peri nodular micronodules were more suggestive for benign nodule. (8) The diagnostic yield of percutaneous needle aspiration and biopsy was 57.6%(19/33) of benign SPNs and 81.0%(47/58) of malignant SPNs. The diagnostic value of sputum analysis and bronchoscopic evaluations were relatively very low. (9) 42.3%(11/26) of SPNs of undetermined etiology preoperatively turned out to be malignant after surgical resection. Overall, 75.4%(46/61) of surgically resected SPNs were malignant. Conclusions : We conclude that the likelihood of malignant SPN correlates the age of patient, prior history of malignancy, some CT findings including lobulated or spiculated border, air-bronchogram, pleural tail and lymphadenopathy. However, the history of smoking, the size of the nodule, and the volume doubling time are not helpful to determent whether the SPN is benign or malignant, which have been regarded as valuable clinical parameters previously. We suggest that aggressive diagnostic approach including surgical resection is necessary in patient with SPNs.