Advances in Modern Medicine E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Sprache: Englisch
Advances in Modern Medicine introduces recent advanced medical practices performed at the Kure Medical Center and Chugoku Cancer Center (KMCCCC) - one of the leading hospitals in Japan - to those working in the field of medicine throughout the world, including physicians, surgeons, pharmacists, psychologists, medical engineers, medical technologists, nurses, and students. Readers will be updated on the general trends in modern medicine relevant to a variety of medical specialties performed at KMCCCC. The volume covers topics such as cancer management, acute phase reaction against a national-level disaster, depression management, emergency medicine, hepatobiliary and gastrointestinal diseases, orthopedics, organ transportation, infection control, blood disease, chronic kidney disease, palliative care, dermatology, ophthalmology, pathology, and nursing for cancer patients. Aspiring medical students can learn more about the latest developments in their field of interest, while patients can learn about treatment options available for different diseases.
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Advances in Modern Medicine
Edited By
Kiyomi Taniyama
Wataru Kamiike
BENTHAM SCIENCE PUBLISHERS LTD.
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FOREWORDS
FOREWORD 1
Congratulation on the Publication of “Advances in Modern Medicine”
We congratulate Dr. Kiyomi Taniyama and Dr. Wataru Kamiike on the publication of this excellent eBook entitled “Advances in Modern Medicine.” This publication is the outcome of more than ten years of effort at the Institute for Clinical Research, Kure Medical Center and Chugoku Cancer Center (KMCCCC), one of the major hospitals in the National Hospital Organization (NHO).
NHO is an independent administrative agency that manages 143 hospitals nationwide in Japan. The NHO is entrusted with three missions: providing medical care, promoting clinical research and educating medical care professionals. We are the largest domestic hospital network, providing services from acute to chronic care. There are more than 80 clinical research institutes attached to the hospitals. The Institute for Clinical Research of KMCCCC is one of the most powerful research institutes within NHO.
It has been pointed out recently that the clinical research should be more strenuously promoted in Japan, because domestically clinical research is not as active compared to basic medical research. As such, we are promoting high-quality clinical research including clinical trials with rapid progress by leveraging NHO’s large network. Looking forward, we expect continuous growth at the Institute for Clinical Research of KMCCCC, and hope that KMCCCC will be a leader for clinical research within NHO and also throughout Japan.
FOREWORD 2
Toward Enhancement of Research Activities in Clinical Medicine
This publication was planned to celebrate the 10-year anniversary of the Institute for Clinical Research, Kure Medical Center and Chugoku Cancer Center (KMCCCC). Dr. Kiyomi Taniyama has served as the director of this institute throughout these 10 years. In addition, the publication is intended to commemorate the contributions and dedication of Dr. Wataru Kamiike, the president of KMCCCC, who will retire from his position in July.
The city of Kure, home to Kure Medical Center, used to be one of Japan’s major naval bases. After World War II, operation of the Kure Naval Hospital was taken over by the United Nations. The hospital was transferred to the Japanese government 10 years later and began to serve the Japanese people as a national hospital. Since then, KMCCCC has stood as the leading hospital in the Chugoku-Shikoku region. The role of the center has not been limited to clinical services for people in the Kure area, however. The center has also been expected to enhance and advance research activities in clinical medicine. The Institute for Clinical Research, KMCCCC was established and has functioned for this purpose.
Japan is generally acknowledged as a nation with the highest standards and achievements in scientific research. This is true for basic research such as research to elucidate the molecular mechanism of diseases. However, Japan’s achievements in clinical investigation are somewhat limited. International rankings of research activities have listed Japan 3rd in the field of basic medical sciences, but 18th in clinical medicine.
The National Hospital Organization is expected to encourage each member hospital to enhance its research activities in clinical medicine, including case reports, case-controlled studies, clinical trials, and cohort studies. Progress in medicine has been accomplished only through careful observation of clinical cases. Evidence that is inevitably needed for daily clinical decision making is only possible through documentation of clinical experiences.
We anticipate that the strength of research at the Institute for Clinical Research, KMCCCC, led by Dr. Taniyama, will continue to grow; it is our hope that the institute will contribute significant advancements to the medical sciences well into the future.
FOREWORD 3
10 Glorious Years for the National Hospital Organization Kure Medical Center and Chugoku Cancer Center
I want to express my great appreciation to Dr. Wataru Kamiike, president of national hospital organization (NHO) Kure Medical Center and Chugoku Cancer Center (KMCCCC), for his 10 years of significant contributions to the hospital. In his first five years, he helped me in his role as vice president to reengineer hospital management and in the second five years he managed the hospital as its president. Over the past decade, KMCCCC has made remarkable progress in both clinical and financial performance, which resulted in the hospital being acknowledged as one of the best hospitals among the more than 140 hospitals within the NHO. I believe that our highly advanced medical treatment and diligent nursing by the hospital staff have produced these outstanding results.
Publication of this eBook titled “Advances in modern medicine during the last decade” upon Dr. Kamiike's retirement and the tenth anniversary of Dr. Taniyama as director of the Clinical Research Institute affiliated with KMCCCC is extremely timely.
Dr. Taniyama will serve as the next president of KMCCCC. He has also contributed to the hospital’s distinguished development in both basic and clinical research. He is a highly regarded scientist in the field of clinical pathology not only domestically but also internationally. The memorandum of understanding between KMCCCC and Rajavithi Hospital in Thailand, the Kure International Medical Forum, and other international activities could not have been a great successes without his effort.
I thank everyone who has contributed to this eBook. I hope its publication will be a key milestone for the KMCCCC and that the center continues to grow and contribute to the advancement of modern medicine.
FOREWORD 4
Congratulatory Message for Dr. Kiyomi Taniyama, Kure Medical Center
It is my great honor and pleasure to write this congratulatory message for Dr. Kiyomi Taniyama on the occasion of the publication of his eBook, Advances in Modern Medicine during the Last Decade which coincides with the tenth anniversary of his chairmanship at the Institute for Clinical Research and his appointment as the President of National Hospital Organization Kure Medical Center and Chugoku Cancer Center (KMCCCC).
This eBook has taken up basic science, translational research and modern medicine in relation to both diagnosis and treatment, and reviews the latest cutting-edge therapeutics and diagnostics by KMCCCC's entire staff. I am deeply impressed by the eBook's descriptions of the achievements of the last decade. There is no doubt that this eBook is valuable to medical workers and researchers around the world.
I have known Dr. Taniyama for more than 30 years, since I became a member of the First Department of Pathology at Hiroshima University. Over the years, I have learned much, not only about medicine and pathology but also about social issues. I admire his foresight and action. In addition to his pathology practice and research, he organizes the annual Kure International Medical Forum and collaborates with many medical professionals across Asia. He is a leader and makes the resources of the Pathology Clinic available to cancer patients in Japan. When I, as the President, hosted the 103rd Annual Meeting the Japanese Society of Pathology in April 2014, he chaired the program committee of diagnostic pathology and ensured the great success of the meeting.
I wish Dr. Taniyama and his colleagues in KMCCCC all the best for a bright future. As the Director of Institute of Biomedical & Health Sciences, Hiroshima University, I look forward to our collaboration to achieve our goal of an even better understanding and treatment of our patients and the improvement of human health worldwide.
PREFACE
The National Hospital Organization (NHO) of Japan was rebuilt from the former National Hospitals of Japan 10 years ago in 2004. At almost the same time, Dr. Kiyomi Taniyama obtained his position as the director of the clinical research institute affiliated with the NHO Kure Medical Center and Chugoku Cancer Center (KMCCCC), Kure, Japan. Over the last decade, he has organized his research institute well and obtained many good results with the collaboration of the basic and translational research staff. Because the systems and equipment are often upgraded to keep pace with the latest trends in medicine, remarkable medical advances have been achieved during the last decade in our hospital, which is representative of the progress made in modern medicine, not only in Japan, but also around the world.
On June 30, 2014, Dr. Wataru Kamiike, is going to retire from the president of NHOKMCCCC that is one of the top five hospitals among the 143 NHO hospitals in Japan. Therefore, July in 2014 is a good time to celebrate Dr. Taniyama’s ten-year history as the director of clinical research center and promotion to the next president, as well as the retirement of Dr. Kamiike from the president. Fundamentally, this eBook will be a memorable token of this celebration, but it also represents the latest trends in modern medicine, covering a wide range of fields. As previously mentioned, this eBook will cover basic science, translational research, and modern medicine in relation to both diagnosis and treatment. This eBook will be full of reviews of cutting edge therapies and diagnostic techniques related to the fields of the authors, along with original articles with the latest data obtained by the authors.
List of Contributors
Part 1 TOPICS IN THE MODERN MEDICINE A: CANCER MANAGEMENT
A New Therapeutic Strategy for Advanced Squamous Cell Carcinomas of the Head and Neck
Haruo Hirakawa1,*,Yasuyuki Nishi1,Taisuke Watanabe1,Makoto Tada1,Kiyomi Taniyama2,Wataru Kamiike2Abstract
A concurrent superselective intra-arterial chemoradiotherapy (SIACRT) is a new therapeutic strategy for advanced squamous cell carcinomas of the maxillary sinus and upper gingiva that might enable patients to keep the shape and function as well as improve curability. We have been applying SIACRT since 2008. We will present the results of SIACRT compared to conventional combined therapy at our hospital. SIACRT is promising to preserve patient’s quality of life (QOL) both under and after the treatment without sacrificing a cure rate.
INTRODUCTION
A combination of intra-arterial chemotherapy, radiotherapy (RT), and surgical therapy has been a common therapy for advanced squamous cell carcinomas (SCC) of the maxillary sinus and upper gingiva in Japan for nearly 30 years [1]. The conventional combined therapy (CTx) has remarkably improved the survival rate compared to each therapy alone; however, functional and cosmetic problems remain. The longer patients survived after treatment, the more they suffered from
face deformity and dysfunctions of speech, mastication, and vision, even though they were free of the disease.
A concurrent chemoradiotherapy (CRT) has become a standard therapy for advanced pharyngeal and laryngeal SCC, which enables patients to keep the functions of the larynx and pharynx (i.e., speaking and swallowing) without sacrificing curability [2].
Superselective intra-arterial chemotherapy (SIAC) has more effect on the target lesion without increasing general adverse effect than general chemotherapy. Localized cancer without metastatic lesion is good indication for SIAC [3].
SIACRT, combination of CRT and SIAC, is a new therapeutic strategy for advanced squamous cell carcinomas of the maxillary sinus and upper gingiva that might enable patients to keep the shape and function as well as improve curability [4]. We have been applying SIACRT since 2008. We present the results of SIACRT compared to CTx at our hospital.
PATIENTS AND METHODS
CTx was applied to 9 cases from 2004 to 2010, containing 6 males and 3 females of which the age-range was from 61 to 80.
SIACRT was applied to 10 cases from 2009 to 2012, containing 7 males and 3 females of which the age-range was 57 to 81.
A carcinoma of the upper gingiva involving the maxillary sinus was treated in the same way as a maxillary cancer involving the upper gingiva.
PROTOCOL OF CTX (Fig. 1)
The 1st day, the affected side of the maxillary sinus is opened through transalveolar incision to reduce the volume of the tumor and to examine the frozen section histopathologically if necessary. An indwelling catheter is inserted into the superficial temporal artery under local anesthesia.
Fig. (1)) Protocol of combined therapy. It takes nine weeks to complete.The 2nd day, irradiation, continuous intra-arterial administration of 5 Fluorouracil (5FU), and intra-venous weekly administration of carboplatin (CBDCA) are started. Daily necrotomy of the tumor is performed with the maxillary sinus open till the surgery. Partial or total maxillectomy is performed 2 weeks after a total dose of 40Gy irradiation. A total dose of 10 to 20Gy additional irradiation and weekly administration of CBDCA are started again 1 week after the surgery.
PROTOCOL OF SIACRT (Fig. 2)
Intra-arterial micro-catheter is inserted into a feeding artery of the tumor super-selectively with Seldinger’s method contrasting the tumor. Cisplatin (CDDP) is intra-arterially injected into the tumor through the catheter at the rate of 5 mg a minute. At the same time sodium thiosulfate (STS) was intravenously administered at 200-fold the dose of CDDP in molar quantity to reduce the toxicity of CDDP. Irradiation was started on the same day. Five-day-continuous intra-venous administration of 5FU was started on the next day. CDDP and 5Fu were administered in the same way four weeks later. A total dose of irradiation was 50 to 60 Gy.
Fig. (2)) Protocol of combination of chemoradiotherapy and superselective intra-arterial chemotherapy. It takes 6 weeks to complete.EVALUATION OF THE RESULTS
Patients applied CTx were evaluated by histopathological findings of the surgical specimens and by clinical observation of the local findings.
Patients applied SIACRT to were evaluated by FDG-PET (fluorodeoxyglucose-positron emission tomography) CT and clinical observation of the course.
Response to each therapy was evaluated according to RECIST (Revised Response Evaluation Criteria in Solid Tumors guideline, version 1.1.).
RESULTS
CTX (Table 1)
Seven cases were surviving without disease more than 46 months. Two cases were dead because of refusal of the surgery.
SIACRT (Table 2)
Eight cases that the protocol was applied to properly showed CR and were surviving without disease more than 15 months.
2 cases, which dropped out of the protocol, resulted in PR. Case 2 refused the 2nd administration of intra-arterial chemotherapy. In case 9 the initial 2 courses of SIAC were administered without irradiation.
ADVERSE EVENTS Table 3 AND DAYS OF HOSPITAL TREATMENT (Fig. 3)
SIACRT caused no critical adverse events, preserved both function and appearance, reduced the pain under the treatment, and shortened the period of necessary hospitalization.
DISCUSSION
Advanced SCC of the maxillary sinus and upper gingiva, which is separated from the surrounding tissue by the bone, is good indication of SIAC within the head and neck [3, 4]. SIAC (Fig. 4) has more effect on the target lesion without increasing adverse effect on other organs than general administration (Fig. 5). In SIAC, the concentration of CDDP is high within the lesion and low without the lesion because the drug is diluted out of the lesion. In addition, the simultaneous venous administration of STS eliminates the most toxicity of CDDP before CDDP reaches the kidney and the bone marrow (Fig. 6), that can decrease adverse effect in spite of increasing the dose of CDDP [4]. However we apply this method to aged patients around 80 to reduce the toxicity without increasing the dose.
The application of SIACRT eliminated metastatic lymph node in our two cases, which suggests SIAC might have some effect on the lesion close to the primary cancer.
Fig. (4)) Superselective intra-arterial administration (i.a.) of CDDP. High concentration of CDDP (dark grey) is administered directly to the tumor (T). CDDP is diluted after passing the tumor (light grey). Fig. (5)) Intra-venous administration (i.v.) of CDDP. CDDP is diluted over the whole body. The concentration of CDDP (light grey) is same between the tumor(T) and the whole body. Fig. (6)) Superselective intra- Arterial administration (i.a.) of CDDP with simultaneously intra-venous administration (i.v.) of STS (black).Now we have started to extend the application of SIACRT to advanced SCC of the middle ear and the larynx, separated from the surrounding tissue by the cartilage or the bone.
CONCLUSION
SIACRT is promising to preserve patient’s QOL both under and after the treatment without sacrificing a cure rate. Accumulation of the cases and longer observation are necessary to discuss the long-term prognosis.
CONFLICT OF INTEREST
The authors confirm that they have no conflict of interest to declare for this publication.
ACKNOWLEDGEMENTS
We thank all staffs in Dept. Otorhinolaryngology, Head and Neck Surgery of KMCCCC who supported the present study.
REFERENCES
[1]Sato Y, Morita M, Takahashi HO, Watanabe N, Kirikae I. Combined surgery, radiotherapy, and regional chemotherapy in carcinoma of the paranasal sinuses. Cancer 1970; 25(3): 571-9. [http://dx.doi.org/10.1002/1097-0142(197003)25:3<571::AID-CNCR2820250312>3.0.CO;2-N] [PMID: 5416827][2]Benasso M, Bonelli L, Numico G, et al. Treatment with cisplatin and fluorouracil alternating with radiation favourably affects prognosis of inoperable squamous cell carcinoma of the head and neck: results of a multivariate analysis on 273 patients. Ann Oncol 1997; 8(8): 773-9. [http://dx.doi.org/10.1023/A:1008244110004] [PMID: 9332685][3]Korogi Y, Hirai T, Nishimura R, et al. Superselective intraarterial infusion of cisplatin for squamous cell carcinoma of the mouth: preliminary clinical experience. AJR Am J Roentgenol 1995; 165(5): 1269-72. [http://dx.doi.org/10.2214/ajr.165.5.7572516] [PMID: 7572516][4]Robbins KT, Storniolo AM, Kerber C, Seagren S, Berson A, Howell SB. Rapid superselective high-dose cisplatin infusion for advanced head and neck malignancies. Head Neck 1992; 14(5): 364-71. [http://dx.doi.org/10.1002/hed.2880140505] [PMID: 1399569]The Long-Term Outcomes of Partial Breast Irradiation Using External Beam after Breast Conserving Surgery
Michinori Yamamoto*Abstract
To examine long-term outcomes of a single institution’s cases of partial breast irradiation.
Between January 1990 and March 2001, a total of 104 patients with T1 or T2 breast cancer were treated with partial breast irradiation using external beam after breast-conserving surgery. Ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor occurrence (CBTO) were examined. Median follow-up time was 10.2 years.
IBTR rates at 5, 10 and 15 years were 2%, 6.5% and 13.2%, respectively. CBTO rates at 5, 10 and 15 years were 0%, 1% and 5%, respectively. Failure within radiation field occurred in 1 patient and failure outside radiation field occurred in 7 patients. Of 7 recurrences outside radiation field, 1 recurred diffusely in the skin of the breast, 3 recurred in another portion of the breast and 3 recurred in the breast near the radiation field. The incidence of failure outside radiation field was high compared to that of CBTO, but this difference was not statistically significant (p=0.059).
This study speculates that PBI is a feasible alternative to WBI.
INTRODUCTION
Breast-conserving therapy is an effective treatment method for T1 or T2 breast cancer [1]. In the standard treatment protocol, the surgeon resects a clinically detected tumor and microscopic residual diseases is then eradicated with whole breast irradiation (WBI), which requires a comparatively long treatment period of about five or six weeks. Treatment could be made more convenient for the patient by the adoption of accelerated partial breast irradiation (APBI), which requires only five or six days; this method has been tried and promising results have been published [2-8]. When the radiation field is restricted to the tumor bed, however, there is a risk of ipsilateral breast tumor recurrence (IBTR) outside the radiation field. Holland et al. have studied the multifocality of breast cancer in mastectomy specimens and have reported that 11% to 18% of patients would have had microscopic residual diseases if the primary tumor had been removed with a margin of only 3 to 4 cm [9]. Since breast cancer usually grows slowly, long follow-up was necessary to confirm the hypothesis that APBI is a feasible alternative to WBI. We started partial breast irradiation (PBI) using external beam in 1990; the median follow-up time for these cases is 10.2 years (range, 1 to 221 months). Here, we present the long-term outcomes of our PBI cases and evaluate a risk of IBTR outside the radiation field.
MATERIALS AND METHODS
Patients and Tumor Characteristics
Between January 1990 and March 2001, 109 patients with T1 or T2 breast cancer were treated with PBI after breast-conserving surgery. Of 109 patients, 5 were excluded from this study, since they were lost to follow-up within 5 years (7, 12, 31, 45 and 49 months). The remaining 104 patients’ ages ranged from 30 to 79 years (median: 54 years). Fifty-four lesions were in the right breast and 50 lesions were in the left. Each patient underwent partial resection or quadrantectomy of the breast, the margins of which were negative except in two cases. Only 4 cases were invasive lobular carcinoma, which had a higher frequency of multifocality than invasive ductal carcinoma did. All patients except one also underwent axillary dissection. The pathological TNM-classification of the tumors, (UICC, 2002), are shown in Table 1.
Treatment
The remaining breast was subjected to radiation therapy with electron beam (EB) except in two cases. The EB radiation fields were determined by a radiation oncologist and a surgeon based on the location and extent of the surgical scar and all available clinical records. EB field sizes ranged between 5 x 6 cm2 and 11 x 13 cm2; the most popular field size was 6 x 10 cm2. The EB energies used were 5MeV in 2 cases; 7MeV in 22 cases; 9MeV in 43 cases; 11MeV in 31 cases and 13MeV in 4 cases. The remaining 2 cases, in which the tumors were located in the upper outer quadrant of the breast, were treated with Cobalt-60, while the upper outer quadrant of the remaining breast as well as the axillary and supraclavicular regions were irradiated in an anterior photon beam. Delivered doses ranged between 44 and 52 Gy in 15-25 daily fractions over five weeks in patients with negative margins and 60 and 70 Gy in 30 and 35 daily fractions over six and seven weeks in 2 patients with positive margins. In cases of inpatient treatments, radiation therapy was delivered in daily fractions of 2 Gy, 5 times per week; in cases of outpatient treatments, it was delivered in daily fractions of 2.5 or 3 Gy, 3 times per week, for the sake of the patients’ convenience. Of 104 patients, 89 (86%) were treated with daily fractions of 2 Gy, 5 times per week, to a total dose of 50 Gy.
Four patients also received adjuvant systemic chemotherapy, 79 patients received adjuvant systemic endocrine therapy, and 11 patients received both.
End Points and Statistics
The endpoints analyzed were ipsilateral breast tumor recurrence (IBTR), contralateral breast tumor occurrence (CBTO) and overall survival (OS). IBTR was also divided into the following categories: failure within radiation field (true recurrence), failure outside radiation field (marginal recurrence or failure elsewhere). The timing of these events was measured from the date of initial surgery. Five-year, 10-year and 15-year estimates of the probability of IBTR, OBTO and OS were calculated using the Kaplan-Meier method with comparisons among groups performed using the Generalized Wilcoxon test. Data management and statistical work were performed using StatMate III for Macintosh.
RESULTS
IBTR rates at 5, 10 and 15 years were 2%, 6.5% and 13.2%, respectively (Fig. 1). Of 8 recurrences, 6 occurred more than 5 years after surgery. Failure within radiation field occurred in 1 patient at 163 months and failure outside radiation field occurred in 7 patients at 4, 12, 62, 64, 70, 107 and 185 months. Of 7 recurrences outside radiation field, 1 recurred diffusely in the skin of the breast, 3 recurred in another portion of the breast and 3 recurred in the breast near the radiation field. The incidence of failure within radiation field was significantly lower than that of failure outside radiation field (p=0.01516) (Fig. 2).
Fig. (1)) Local recurrence curve for all patients. Fig. (2)) Local recurrence curves within and outside the radiation field. Fig. (3)) Local recurrence curve outside radiation field and new cancer occurrence curve in contralateral breast.Contralateral breast tumor occurred at 88, 153 and 206 months in 3 of 102 patients, with 2 patients who had already experienced mastectomy for contralateral breast cancer excluded. CBTO rates at 5, 10 and 15 years were 0%, 1% and 5%, respectively. The incidence of failure outside radiation field was higher than that of CBTO, but this difference was not statistically significant (p=0.05862) (Fig. 3).
OS rates at 5, 10 and 15 years were 95%, 89% and 86%, respectively. Eleven patients died at 1, 25, 32, 45, 84, 86, 104, 106, 110, 153, and 198 months. Of these 11 patients, 6 died of breast cancer and 5 died of other causes (1 by suicide, 1 of cholangiocarcinoma, 2 of hepatocellular carcinoma and 1 of idiopathic interstitial pneumonitis).
No patients experienced such complications as symptomatic pneumonitis due to radiation therapy or rib fracture.
DISCUSSION
The incidence of failure within radiation field was significantly lower than that of failure outside radiation field. This outcome confirmed that radiation therapy can eradicate microscopic residual diseases, but there is a significant risk of tumor recurrence if the region of microscopic residual diseases is not included within the radiation field. We had 7 cases of failure outside radiation field; these 3 consist of marginal recurrence.
One problem with this study is the fact that an old radiation technique was used during period before computed tomography (CT) simulation. Specifically, the radiation fields for PBI were determined by a radiation oncologist and a surgeon based on the location and extent of surgical scar and on all available clinical records.
Several studies have compared clinical techniques based on surgical scar location with techniques based on CT simulation [11-14]. Benda et al. have shown that clinical delineation of the tumor bed carries a significant risk of missing the target and recommended CT-based treatment planning [11]. CT-based treatment planning is not infallible, either, however; the lumpectomy cavity is not always detectable in CT images. Smitt et al. have developed cavity visualizing scores (CVSs) to express how visible lumpectomy cavities are in CT: the possible scores are cavity not visualized (CVS1), cavity visualized but margins indistinct (CVS2), cavity visualized with some distinct margins (CVS3), cavity visualized all but one margin distinct (CVS4), and all cavity margins clearly defined (CVS5) [15]. Landis et al. have shown that, even among radiation oncologists who specialize in breast radiotherapy, there can be substantial differences in delineation of the lumpectomy cavity when a technique based on CT simulation is used, especially when cavities have low CVSs [16]. Dzhugashvili et al. have proposed the placement of surgical clips at lumpectomy, which would increase CVS [17]. Both the placement of surgical clips at lumpectomy and the use of CT images based on CT simulation are desirable to determine to radiation field for PBI.
Another problem in PBI is a risk of failure elsewhere. One way to increase the success rate of PBI is to select patients who are good candidates for PBI.
The American Society for Radiation Oncology (ASTRO) has presented guidance for patients and physicians regarding the use of APBI, based on current published evidence complemented by expert opinion, and proposed three patient groups: a suitable group, for whom APBI outside of a clinical trial is acceptable, a cautionary group, for whom caution and concern should be applied when considering APBI outside of a clinical trial, and an unsuitable group, for whom APBI outside of a clinical trial is not generally considered to be warranted [10]. The GEC-ESTRO Breast cancer Working Group also recommended three categories guiding patient selection for APBI: a low-risk group for whom APBI outside the context of a clinical trial is an acceptable treatment option, an intermediate-risk group, for whom APBI is considered acceptable only in the context of prospective clinical trials, a high-risk group, for whom APBI is considered contraindicated [18]. However, the criteria for the selection of good candidates for PBI are not yet completely known. Data from ongoing clinical trials will provide a more scientific foundation for recommendation about selection of patients who are good candidates for PBI.
CONCLUSION
This study speculates that PBI is a feasible alternative to WBI, because the incidence of failure outside radiation field was higher than that of CBTO, but this difference was not statistically significant. In order for PBI to succeed, it is important to select patients who are good candidates for PBI and to determine the radiation field through CT-based planning.
CONFLICT OF INTEREST
The author confirms that he has no conflict of interest to declare for this publication.
ACKNOWLEDGEMENTS
Declared none.
