Purpose: To examine, retrospectively, national-wide clinical data of patients with localized extranodal non-Hodgkin's lymphoma (NHL) who were treated by radiation therapy with or without chemotherapy. Materials and Methods: The survey was carried out at 25 radiation oncology institutions in Japan in 1998. In 1999, according to the REAL classification, central pathological review conducted at Aichi cancer center was carried out for the data from 7 radiation oncology institutions. The 5-year progression free survival rates (PFS) were calculated to identify prognostic factors.
Results: 1) Survey: Data from 1, 141 patients with stage I and II NHL were recruited from 1988 through 1992. Of them, 787 patients, who were treated using definitive radiotherapy with or without chemotherapy for intermediate and high-grade lymphomas in Working Formulation, constituted the core of this study. Primary tumors arose mainly from extra-nodal organs (71%) in the head and neck (Waldeyer's ring: 41%, thyroid gland: 7%, nasal cavities: 5%, oral cavities: 4%, sinus: 3%, orbital structures: 3%, skin: 2% and etc.). The median age of 60 years for patients with extra-nodal NHL was higher than that of 56 years for patients with nodal NHL (p<0.01). Female were dominant in incidence of extra-nodal NHL arising from the thyroid gland, skin and gastrointestinal tract. The percentage of stage I to the extra-nodal NHL from orbit, sino-nasal presentation was higher than that of other NHLs. The percentage of stage II to the extra-nodal NHL from Waldeyer's ring and thyroid gland was higher than that of other NHLs.
2) Central pathological review was carried out for pathological data from 79 patients (Waldeyer's ring: 45, thyroid gland: 19, sinonasal cavities: 15). Of these, diffuse large B cell lymphoma (DLBCL) composed 63% of all patients, mucosa associated lymphoid tissue lymphoma (MALT-L): 16%, Natural Killer/T cell lymphoma (NK/T-L): 11%, and mantle cell lymphoma: 5% in REAL, respectively. In the case of Waldeyer's ring, DLBCL was dominant (80%) in incidence. In the case of thyroid gland. MALT-L was 52% of the total and in the case of sinonasal cavity NK/'I-L was 60% of the total in incidence. According to the REAL classification, the 5-year PFS rates for patients with DLBCL, MALT-L, NK/T-L and mantle cell lymphoma were 64%, 83%, 50% and 25%, respectively (p<0.06). On the other hand, according to the Working Formulation, the 5-year PFS rates for patients with follicular lymphoma, diffuse small cleaved cell lymphoma, diffuse mixed cell lymphoma, diffuse large cell lymphoma and immunoblastic lymphoma were 71%. 57%, 79%. 56% and 50%, respectively (p<0.73). The 5-year PFS rates for patients with Waldeyer's ring NHL, thyroid NHL and sinonasal NHL were 61%, 49% and 74%, respectively (p=0.34). The 5-year PFS rates for patients treated with radiation therapy alone and combined modality were 36% and 75%, respectively (p<0.01). The 5-year PFS rates for patients with low grade of IPI and low-intermediate grade were 70% and 59%, respectively (p<0.01). There was no difference of PFS according to the dose and fields of radiotherapy.
Conclusion: The central pathological review was very important in conducting the multi-center clinical trials and multi-institutional surveys. The REAL classification and IPI were useful in predicting the survival of patients with localized extra-nodal NHL.

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To compare late changes of normal tissue treated either by high dose rate (HDR) or low dose rate (LDR) interstitial brachytherapy.
Materials and Methods: For HDR group, 22 oropharynx cancer patients who were treated by HDR Ir-192 interstitial brachytherapy with/without external beam radiotherapy in Osaka (Osaka Medical Center for Cancer & Cardiovascular Diseases and Osaka University Hospital) during June 1994 through April 2000 and came to the follow-up clinics during July 2000 through December 2000 were studied. For LDR group, 26 oropharynx cancer patients who were treated by LDR Ir-192 interstitial brachytherapy with/without external beam radiotherapy in Nancy (Centre Alexis Vautrin) during February 1989 through July 1998 and came to the follow-up clinics during April 1999 through July 1999 were studied. The standard HDR schedules were 54 Gy/9 fr/5-6 days for monotherapy and 18-24 Gy/3-4 fr/2-3 days following 45 Gy external beam radiotherapy. The standard LDR schedules were 65 Gy/5-6 days for monotherapy and 15-25 Gy/2-3 days following 50 Gy external beam radiotherapy. For evaluation of the late changes, we scored the mucosal and muscular changes inside the treated volume using the modified Dische score system and the RTOG/EORTC late radiation morbidity scoring scheme.
Results: For 6 items of the modified Dische score system, no significant difference was found between HDR and LDR groups. For the remaining 2 items (pallor, mobility impairment of faucial pillars), LDR group showed higher scores (p=0.010, 0.002). LDR group showed a trend toward higher scores for the RTOG/EORTC scheme (p=0.059).
Discussion: Some predict late effects by HDR interstitial brachytherapy to be severer than by LDR because no dose-rate effects can be expected. Our study, however, showed at least equivalent or even milder late changes by HDR. Appropriate fractionation schedule and extra geometrical sparing effects by optimized dose distribution of HDR group might result in milder late changes.
Conclusion: With our standard HDR schedule, late changes by HDR were not severer than those by LDR.

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Our experiences of stereotactically-guided conformal treatment using micro-multileaf collimator (m-MLC) for ethmoid tumor was reported, and the usefulness of stereotactically-guided conformal treatment for ethmoid tumor was evaluated. Three patients with ethmoid tumor were treated with stereotacticallyguided conformal treatement using m-MLC postoperatively. The volume of these planning target volume (PTV) were 30.0ml, 18.8ml, and 20.0ml, respectively. Total dose was 45 Gy with fraction size of 3 Gy. Non-coplanar static conformal treatment with 6 fields collimated with m-MLC were made for each case. Eyes, optic nerves, and optic chiasma were defined as the organs at risk. Each plan was arranged that PTV was covered with 80% isodose surface and dose of the organs at risk was restricted under 70% dose. Ninetynine percent of PTV volume was covered with 80% isodose surface in all cases. The doses of all organs at risk were restricted under 70% dose in 2 cases. In the other case, only 7% of ipsilateral eye received 70-80% dose. The maximum doses within PTV in each case were 103-109%. Stereotactically-guided conformal treatment using m-MLC is useful to restrict the dose of organs at risk adjacent to PTV, while covering PTV with adequate dose. Radiation therapy for ethmoid sinus can be performed safely with fractionated stereotactically-guided conformal radiotherapy using m-MLC.

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Purpose: Postoperative radiotherapy has been delivered with wedged tangential fields, optimized isodose distribution without inhomogeniety corrections in a single central-axis. Three-dimensional radiation treatment planning systems (3D-RTPS) is now available and its utility for breast irradiation should be evaluated. We evaluated MLC segment technique whether it improves dose uniformity within target volume and reduces the dose delivered in normal tissue.
Methods and Materials: Twenty-four consecutive patients with breast cancer undergoing lumpectomy and adjuvant breast radiotherapy were treated in our hospital from April to September 2000. Using 3D-RTPS, standard wedge technique and MLC segment technique were evaluated according to the following parameters; maximum absorbed dose in field, dose conformity in PTV (volume of PTV with dose outside 95-105% of the prescribed dose), absorbed dose in ipsilateral lung (volume with dose larger than 100% of the prescribed dose), and absorbed dose in contralateral breast (maximum dose and mean dose).
Results: Significant improvement in the doses PTV and critical structures were achieved using MLC segment technique. Compared with standard wedge technique, MLC segment technique decreased 6% of the maximum absorbed dose, improved 50% of dose homogeneity within the planning target volume, and decreased 50% of the maximum dose and 25% of mean dose to the contralateral breast. The ipsilateral lung volume receiving more than 100% of the prescribed dose was not significantly changed.
Conclusion: MLC segment technique can significantly improve dose uniformity within PTV and decrease the maximum dose in the field and the dose of critical structures. It is suggested that customized 3D treatment planning for breast irradiation should be clinically applied to improve treatment outcome.

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Purpose: To evaluate the efficacy of radiotherapy for portal tumor emboli of hepatocellular carcinoma.
Materials and Methods: Twenty-four patients with portal tumor emboli of hepatocellular carcinoma who were treated with radiotherapy from August 1995 to December 1999 were retrospectively studied. Patients were classified according to the degree of portal tumor emboli (Vp2: 3, Vp3: 14, Vp4: 7) and liver damage (A: 8, B: 11, C: 4, unknown: 1). The responses were classified as effective, no change, or progression. The liver function between pre-and post-radiotherapy was compared.
Results: The responses were effective for 12 cases (75%) and no change for 4 cases (25%). Cause specific survival rate at 1 year and 50% survival time was 24.4% and 6.3 months, respectively. Cause specific survival rate at 1 year for liver damage A and Vp3 were 60% and 38% respectively. 50% survival time for liver damage A and Vp3 were 11 months and 11.3 months respectively. Prolongation of the prognosis over 6 months was observed in a few cases of liver damage B. Liver function with local irradiation was generally tolerable.
Conclusions: Radiotherapy for portal tumor emboli of hepatocellular carcinoma was useful as one of multimodality treatments for advanced hepatocellular carcinoma. This treatment sometimes expected prolongation of the prognosis for hepatocellular carcinoma with portal tumor emboli.

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Obstructive jaundice is a rare complication of metastatic nasophayngeal carcinoma (NPC). The effect of local radiotherapy (RT) has been rarely reported. The authors report a 52-year-old female treated with curative radiotherapy for a T2aN I NPC who developed liver and hepatic hilar lymph node (HHLN) metastasis 34 months after initial therapy. Obstructive jaundice occurred 2 months after the disclosure of HHLN metastasis. Since endo-nasal biliary drainage (ENBD) and percutaneous transhepatic cholangiography and drainage (PTCD) were both unsuccessful, local RT 30.4 Gy in fractions of I.6 Gy was given. The obstructive jaundice was markedly improved until her death 3 months after RT. Only common toxicity criteria (CTC) grade I nausea was noted during RT. This report revealed that local RT could he a helpful choice in treating obstructive jaundice due to metastatic HHLN m patients with NPC.

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A 76-year-old man with postoperative local recurrent parotid gland cancer was treated by brachytherapy with 13 ¹⁹⁸Au grains because of no shrinkage of the tumor after chemotherapy and external radiotherapy. After treatment the tumor shrank markedly with pain relief. However, after 11 months, a new lesion was found at the near of the primary tumor, so we inserted 10 ¹⁹⁸Au grains again.
The tumor shrank markedly with formation of a skin ulcer and necrosis at the inserted part.
The tumor regrew with multiple lung metastases. Two years and 9 months since the beginning of treatment, he died of respiratory insufficiency.
During the overall treatment time, he could be treated on an outpatient basis except only 16 days when isolated in the isotope room for brachytherapy, and obtained an improvement of his prognosis and QOL. Interstitial brachytherapy with ¹⁹⁸Au grains was seemed to be a useful therapeutic method for aged or weak patients because of the easy suitable insertion with a little suffering.

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case of T3N2b tongue cancer treated by radiotherapy is presented. The case was a 33 year-old male whose chief complaint was contact pain at the left border of the tongue. Physical examination revealed a huge mass on the left border of the tongue which was 47×31×25mm in size. There were 3 palpable lymph nodes that were elastic but hard. One lymph node was 20×20mm and the others were 10×10mm in size. This tumor was histologically confirmed as a well differentiated squamous cell carcinoma. Therefore, the oral surgeon proposed the treatment plan of a subtotal glossectomy and left radical neck dissection. The patient refused the surgical operation for the tongue, though he accepted the surgical operation for the neck. So it was treated as follows:(1) External radiotherapy for the tongue, upper and middle neck.(2) High dose rate (HDR) interstitial radiotherapy for the tongue.(3) Left radical neck dissection. External irradiation dose was 39 Gy/18 fr/25 days. We used a concomitant electron boost (field in the field technique) for the left upper jugular lymph node that was growing rapidly during the term of external radiotherapy. Hyperfractionated HDR interstitial radiation dose was 48 Gy/8 fr/7 days with volume implantation. Two metastatic lymph nodes were histologically confirmed at radical neck dissection. There is no recurrence in primary and neck regions three years after radiotherapy.

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Recently, the impact of the overall treatment time on local tumor control has been reported by several authors. However, we in Japan have a long radiotherapy break because of the two large national holiday seasons in April-May & December-January. Therefore, a national survey on the current status of salvage radiotherapy on holidays was performed in 2001. Fifty-three % of the all institutes performed salvage radiotherapy on holidays. However, there are several problems to be solved, and a national consensus and an authorized proposal by the JASTRO are waited.

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