Spontaneous fusion of isthmic spondylolisthesis after discitis: a case report

This is the first case report of a child with isthmic spondylolisthesis and discitis who had spontaneous fusion develop at an unstable level with relief of symptoms after nonoperative treatment. Although the blood culture was negative, the 14-year-old boy with Grade III isthmic spondylolisthesis of L5 was diagnosed with discitis at the L5-S1 level, based on clinical findings, elevated C-reactive protein, plain radiographs, and magnetic resonance imaging scans. The patient was treated with antibiotics for 19 weeks and bed rest for 4 weeks followed by immobilization in a hip spica cast for 8 weeks and a thoracolumbosacral orthosis for an additional 12 weeks. The lumbar back pain improved and there was a decrease in C-reactive protein to the normal range 3 weeks after onset. Forty months from onset, the patient was free from lumbar back or leg pain and his clinical neurologic examination was normal. Plain radiographs showed spontaneous fusion between L5 and the sacrum. This suggests that nonoperative treatment is acceptable even if discitis occurs at an unstable level.     

Radiation therapy for small-cell lung cancer: results of the 1995-1997 patterns of care process survey in Japan

The Patterns of Care Study (PCS) conducted a nationwide audit survey in order to establish the national practice process of radiation therapy for small-cell lung cancer (SCLC) and examined the influence of institutional stratification on the process of care in Japan. The PCS randomly sampled institutions and patients using a two-stage cluster method and surveyed the process of radiation therapy for 174 stage I-III SCLC patients according to the category of institution, stratified as follows: A1, academic institutions treating > or = 300 patients a year; A2, <300 patients; B1, non-academic institutions treating > or = 120 patients a year; and B2, <120 patients. Karnofsky performance status distributions showed significant variance by stratification of institutions (P=0.013). Patients treated on an outpatient basis accounted for 32% in A1, 23% in A2, 8% in B1, but only 5% in B2 (P=0.007). A photon energy > or = 10 MV was used for 87% of patients in A1, 69% in A2, 54% in B1 and 23% in B2 (P=0.001). Contralateral hilus was irradiated for 11% of patients in A1, 17% in A2, 29% in B1 and 3% in B2 (P=0.001). Field size reduction during the treatment course was done for 77% of patients in A1, 54% in A2, 60% in B1 and 42% in B2 (P=0.007). Ninety-two percent of patients received combined chemotherapy and radiation therapy, and the most frequently used drugs were etoposide (91%) and cisplatin (69%). The results of clinical studies on SCLC had favorably penetrated into the clinical practice. However, the stratification of institutions significantly affected the process of radiation therapy in Japan.     

Monte Carlo calculation of depth doses for small field of CyberKnife

PURPOSE: A Monte Carlo (MC) model of CyberKnife was developed as a quality assurance tool. The percentage depth dose (%dd) was verified by using this model. MATERIALS AND METHODS: An MC model was developed with Electron Gamma Shower version 4 (EGS4) in two steps: (1) a model of the CyberKnife treatment head and (2) a model of the collimator and phantom. The bremsstrahlung spectrum was calculated using the first model, and this spectrum was then used to calculate %dds with the second model. The calculated %dds for a large field (60 mm diameter) and three small fields (30, 15, and 5 mm diameter) were compared with those measured with a diamond detector. RESULTS AND DISCUSSION: The MC-calculated and measured %dd-curves for the 60 mm diameter field were in excellent agreement (<1.85%), thus confirming the validity of the model. Discrepancies between the calculated and measured %dd-curves increased with decreasing field size, with considerable discrepancy (11.62%) for the 5 mm diameter field due to lateral electron disequilibrium. Accurate dose can be determined with MC even in small fields. CONCLUSION: The MC technique can provide reliable standard data for accurate dose delivery with high-technology radiotherapies using small beams.     

Second Primary Cancers Following Non-Hodgkin's Lymphoma in Japan: Increased Risk of Hepatocellular Carcinoma

We evaluated the risk of development of second primary cancers, with particular reference to subsequent hepatocellular carcinoma (HCC), in 592 patients diagnosed as non-Hodgkin's lymphoma (NHL), at Osaka Medical Center for Cancer and Cardiovascular Diseases. During 1978–1994, 2,163 person-years of observation were accrued, and 27 of the patients developed a second primary cancer, yielding an observed-to-expected ratio (O/E) of 1.53 [95% confidence interval (CI) = 1.01–2.23]. Significant excess risk was noted for primary liver cancer (PLC; O/E=4.36, 95% CI=1.99–8.28; O =9) and non-lymphocytic leukemia (O/E=26.17, 95% CI=5.26–76.46; O=3). The excess risk of PLC was relatively constant within the first 10 years after the NHL diagnosis. Patients who received chemotherapy as the NHL treatment had a significantly increased risk of PLC (O/E=5.91, 95% CI =2.70–11.23; O=9). Their clinical reports indicated that all nine patients with PLC were diagnosed as HCC, and eight of them had clinical and/or histologic evidence of cirrhosis at the time of HCC diagnosis. None of the nine patients had a history of blood transfusion between the first NHL treatment and the diagnosis of HCC. These findings suggested that Japanese NHL patients might have an increased risk of developing HCC, and they indicated the importance of medical surveillance for liver malignancies, as well as subsequent leukemias. Possible explanations for the excess risk of subsequent HCC are discussed.     

A case of locally advanced rectal carcinoma with liver metastasis treated with a combination of CRT, HAI, and systemic chemotherapy

A 55-year-old man with locally advanced rectal carcinoma and liver metastasis was treated with a combination of chemo-radiotherapy (5-FU suppository 100 mg/day and 63 Gy of RT), hepatic arterial infusion chemotherapy (5-FU 1,000 mg/3 h, biweekly), and systemic chemotherapy (5'-DFUR 800 mg/day + cimetidine 800 mg/day). His rectal tumor was reduced and his symptoms such as pain and bleeding had markedly decreased. The river metastasis did not change during the entire course. HAI and administration of 5-FU suppository, 5'-DFUR, and cimetidine were continued. As of 18 months after the onset of the combination therapy, NC has been maintained, and the general condition of the patient is favorable.     

Radial and lumbar bone mineral density after wrist synovectomy in rheumatoid arthritis

Bone mineral density (BMD) of both radii and lumbar vertebrae was measured by single-photon absorptiometry and dual X-ray absorptiometry, respectively, before and 2.1–4.8 years after a unilateral wrist synovectomy in 10 patients with rheumatoid arthritis. Radial BMD on the operated side significantly increased after synovectomy, while that on the non-operated side did not change. Lumbar BMD significantly decreased after the operation. The grip strength of the operated side increased significantly after synovectomy, while there were no changes in the grip strength on the non-operated side. These findings suggest that wrist synovectomy results in pain relief and improves use, thereby increasing the BMD of the operated radius.     

Radiotherapy for uterine cervical cancer: results of the 1995-1997 patterns of care process survey in Japan

OBJECTIVE: The aim of this study is to establish Japanese national practice patterns for uterine cervical cancer patients who received radiotherapy without surgery. METHODS: The Japanese Patterns of Care Study (JPCS) conducted a national survey of 73 institutions using two-stage cluster sampling, and collected specific information on 591 patients with uterine cervical cancer treated by radiotherapy without planned surgery between 1995 and 1997. RESULTS: The median age of the patients was 70 years. Karnofsky performance status (KPS) was >/=90 for 37%. Most patients (95%) had histology of squamous cell carcinoma. Ten percent were stage I, 29% stage II, 48% stage III and 13% stage IVA. Photon beams of 10-14 MV were the most used for external beam radiotherapy (EBRT). The beam energy utilized varied significantly by institution strata. Midline block was used in approximately 70% of institutions. Intracavitary brachytherapy (ICBT) was performed in 77%. Institution strata correlated significantly with the ICBT application. The majority of patients (89%) were treated with high-dose-rate (HDR) ICBT. The median single point A dose of HDR-ICBT was 600 cGy. The median summated point A dose from EBRT and HDR-ICBT was 5800 cGy (range: 1196-8600). The median overall treatment time including ICBT was 49 days. Twenty-four percent of the patients received chemotherapy. Concurrent chemoradiation was performed in 5%. CONCLUSIONS: The JPCS established the Japanese national practice patterns of care for uterine cervical cancer patients treated with radiotherapy without planned surgery between 1995 and 1997. This survey demonstrated that the institutional strata significantly affected several practice patterns.     

Patterns of care study in Japan

BACKGROUND: The Patterns of Care Study (PCS), started in the 1970's, is a well-known study used for clinical quality assurance (QA) in radiation oncology in the United States. PCS has been introduced in Japan since 1996. METHODS: Three national PCS surveys have been performed by means of external audit to evaluate patterns of care for the patients with carcinoma of any of esophagus and cervix treated with radiation between 1992 and 1994, for those with carcinoma of any of esophagus, cervix, breast, lung and prostate between 1995 and 1997, and for those with any of the five disease sites between 1999 and 2001. In the first PCS, feasibility of the study was confirmed. In the second PCS, two-stage cluster sampling of institutions and patients was performed and national averages for the survey items were calculated as QA measures. In the third PCS, additional imaging data were collected. The Japan/USA PCS workshops were held at San Francisco in 2001 and at Tokyo in 2003. RESULTS: Significant variations in process and structure were observed according to institutional stratification. In academic institutions, external beam energy > or =6 MV for deep-seated tumors of esophagus, lung, prostate and cervix, and brachytherapy for those of cervix and esophagus were used more frequently. There was an average of less than one full-time equivalent radiation oncologist in most non-academic institutions. These variations influenced the outcomes. There were also significant differences between USA and Japan in various aspects, e.g. a difference in radiation dose of 20% for uterine cervix cancer patients. It is higher in the USA. The number of new cancer patients requiring radiation is increasing steeply (120,000 in 2000 and 170,000 in 2005). Based on PCS data, structural guidelines were published and distributed throughout Japan. CONCLUSION: PCS is useful for establishing the clinical QA for radiation oncology as well as other specialties through detailed monitoring and evaluation of their structures, processes and outcomes.