Chinese Journal of Radiation Oncology

中华放射肿瘤学杂志

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Chinese Journal of Radiation Oncology

	2017 Vol.26 Issue.10 Published 2017-10-10

	Head and Neck Tumors Abdominal Tumors Thoracic Tumors Physics·Biology·Technique Review Articles Consensus Guideline Meeting Summary

Guideline

	1111	Modern radiation therapy for hodgkin lymphom-target definition and dose guidelines from the international lymphoma radiation oncology group
		Lena Specht,MD,PhD,Joachim Yahalom,MD,Tim Illidge,MD,PhD,Anne Kiil Berthelsen,MD,Louis S.Constine,MD,Hans Theodor Eich,MD,PhD,Theodore Girinsky,MD,Richard T.Hoppe,MD,Peter Mauch,MD,N.George Mikhaeel,MD,Andrea Ng,MD,MPH
		Radiation therapy (RT) is the most effective single modality for local control of Hodgkin lymphoma (HL) and an important component of therapy for many patients. These guidelines have been developed to address the use of RT in HL in the modern era of combined modality treatment. The role of reduced volumes and doses is addressed, integrating modern imaging with 3-dimensional (3D) planning and advanced techniques of treatment delivery. The previously applied extended field (EF) and original involved field (IF) techniques, which treated larger volumes based on nodal stations, have now been replaced by the use of limited volumes, based solely on detectable nodal (and extranodal extension) involvement at presentation, using contrast-enhanced computed tomography, positron emission tomography/computed tomography, magnetic resonance imaging, or a combination of these techniques. The International Commission on Radiation Units and Measurements concepts of gross tumor volume, clinical target volume, internal target volume, and planning target volume are used for defining the targeted volumes. Newer treatment techniques, including intensity modulated radiation therapy, breath-hold, image guided radiation therapy, and 4-dimensional imaging, should be implemented when their use is expected to decrease significantly the risk for normal tissue damage while still achieving the primary goal of local tumor control. The highly conformal involved node radiation therapy (INRT), recently introduced for patients for whom optimal imaging is available, is explained. A new concept, involved site radiation therapy (ISRT), is introduced as the standard conformal therapy for the scenario, commonly encountered, wherein optimal imaging is not available. There is increasing evidence that RT doses used in the past are higher than necessary for disease control in this era of combined modality therapy. The use of INRT and of lower doses in early-stage HL is supported by available data. Although the use of ISRT has not yet been validated in a formal study, it is more conservative than INRT, accounting for suboptimal information and appropriately designed for safe local disease control. The goal of modern smaller field radiation therapy is to reduce both treatment volume and treatment dose while maintaining efficacy and minimizing acute and late sequelae. This review is a consensus of the International Lymphoma Radiation Oncology Group (ILROG) Steering Committee regarding the modern approach to RT in the treatment of HL, outlining a new concept of ISRT in which reduced treatment volumes are planned for the effective control of involved sites of HL.
		2017 Vol. 26 (10): 1111-1118 [Abstract] ( 1068 ) [HTML 1KB] [ PDF 2728KB] ( 0 )

Consensus

	1119	The 2017 edition for staging of nasopharyngeal carcinoma in China (The Chinese 2008 expert consensus on staging revision of nasopharyngeal carcinoma)
		Chinese Committee for Staging of Nasopharyngeal Carcinoma
		The staging of malignant tumors is a fundamental component of treatment selection, prognosis prediction and academic exchange. As“Chinese 2008 staging for nasopharyngeal carcinoma (NPC)”was widely adopted in China from 2009, more and more coordination and exchange of information has been carried out between treatment centers, which has promoted the development of multicenter clinical trials and staging studies. On July 1, 2017, an expert consensus conference was held by the Chinese Committee for Staging of NPC to discuss the revision of Chinese 2008 staging for NPC in Nanping City, Fujian Province. After a full discussion and communication according to evidence-based medicine, a consensus was made. The 8^th edition UICC/AJCC staging system for NPC was more rational because it had incorporated the strengths of the Chinese 2008 and the 7^th edition UICC/AJCC staging systems. Chinese 2008 staging should be revised based on the 8^th edition UICC/AJCC staging system to make an internationally unified staging system. Therefore, the experts strongly recommended Chinese 2017 staging for NPC should be consistent with the 8^th edition UICC/AJCC staging system.
		2017 Vol. 26 (10): 1119-1124 [Abstract] ( 1092 ) [HTML 1KB] [ PDF 2495KB] ( 0 )

Meeting Summary

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		2017 Vol. 26 (10): 1125-1125 [Abstract] ( 717 ) [HTML 1KB] [ PDF 695KB] ( 0 )

	1235


		2017 Vol. 26 (10): 1235-1236 [Abstract] ( 634 ) [HTML 1KB] [ PDF 760KB] ( 0 )

Head and Neck Tumors

	1126	Dosimetric predictors of hypothyroidism in nasopharyngeal cancer patients treated with intensity-modulated radiation therapy
		Qu Yuan,Huang Xiaodong,Tain Yuan,Yi Junlin,Wang Kai,Gao Li,Zhang Ye,Wu Runye,Chen Xuesong,Liu Qingfgeng,Xiao Jianping,Zhang Shiping,Xu Guozhen
		Objective To investigate the mobidity and risk factors for primary hypothyroidism (HT) in nasopharyngeal cancer (NPC) patients treated with intensity-modulated radiotherapy (IMRT). Methods 113 NPC patients with complete clinical information who received IMRT from 2008-2010 were retrospectively analyzed. Thyroid function assessments before and after IMRT were periodically monitored. Various clinical and dosimetric parameters were obtained including D_min,D_max,D_mean,V₃₀,V₃₅,V₄₀,V₄₅,V₅₀,V₅₅,V₆₀,V₆₅,V₇₀(thyroid gland), PD_min,PD_max,PD_mean(pituitary gland).Univariate and multivariate logistic regression analyses were performed to identify predictors of HT. Results After a median follow-up period of 62 months,41 patients (36.3%) had clinical HT,and 28 patients (24.8%) developed subclinical HT. Univariate analysis revealed that younger age,mean dose to the thyroid gland,V₄₀,V₄₅,V₅₀,V₅₅,V₆₀ were correlated with developing HT (all P<0.05).On multivariate analysis including patient,tumor,and treatment variables,younger age (P=0.002) and V₅₀(P=0.002) remained statistically significant. We found that the cutoff value of V₅₀(50%) may be an valuable evaluation marker of HT.Combined with age to predict the HT,the area under ROC curve is 0.728.The endpoint event rate of the patients whose level of V₅₀ is above 50% and age level below 45 years were 79.3%,whlie the date in patients whose level of V₅₀ is below 50% and age level above 45 years was 31.8%. Conclusions Thyroid V₅₀ above 50% is predictive of primary HT after IMRT for NPC patient,Our results suggested that restricting V₅₀<50% during IMRT planning may facilitate the reduction in incidence of HT for the younger patients.
		2017 Vol. 26 (10): 1126-1130 [Abstract] ( 880 ) [HTML 1KB] [ PDF 899KB] ( 0 )

	1131	Expression of PD-1 and PD-L1 in patients with stage Ⅳ_{a nasopharyngeal carcinoma and its clinical significance}
		Han Xiao,Haung Li,Li Wenting. Wang Ruozheng
		Objective To measure the expression levels of PD-1 and PD-L1 in the tumor tissues of patients with nasopharyngeal carcinoma (NPC) and to explore the association of their expression with the clinical characteristics and prognosis of NPC patients. Methods The expression levels of PD-1 and PD-L1 in 65 NPC patients were determined by immunohistochemistry, and an analysis was performed on the association of their expression with clinical characteristics and long-term survival in NPC patients. Comparisons between groups were made by the chi-square test or Fisher′s exact test, and the Pearson’s test was used for correlation analysis. Survival rates were calculated using the Kaplan-Meier method, and the log-rank test was used for survival comparison and univariate prognostic analysis. The Cox model was used for multivariate prognostic analysis. Results Expression of PD-1 and PD-L1 was observed in 88%(57/65) and 89%(58/65) of tumor cell surfaces using a cut-off value of 5%, and 38%(25/65) and 58%(38/65) using a cut-off value of 10%. PD-1 expression was significantly correlated with PD-L1 expression using the cut-off value of 5%(P=0.003), and a non-significant correlation was found between the expression levels of PD-1 and PD-L1 using the cut-off value of 10%(P=0.080). There was no significant association between the positive expression rates of PD-1 and PD-L1 and clinicopathological characteristics (P>0.05). The univariate and multivariate survival analyses showed that using the cut-off value of 10%, the patients with positive PD-L1 expression had significantly reduced progression-free survival (hazard ratio[HR]=2.73, 95% confidence interval[CI]:1.07-6.97, P=0.035) and overall survival (HR=3.95, 95%CI:1.09-14.27, P=0.036) compared with those with negative PD-L1 expression. Conclusions PD-1 and PD-L1 are highly expressed in NPC tissues. The expression of PD-L1 is associated with the poor prognosis in patients with stage IVa NPC, and PD-L1 can better predict the poor prognosis using the cut-off value of 10%.
		2017 Vol. 26 (10): 1131-1136 [Abstract] ( 690 ) [HTML 1KB] [ PDF 2453KB] ( 0 )

	1137	Prognostic analysis of 68 patients with initially diagnosed bone-only metastatic nasopharyngeal carcinoma
		Sang Xuejin,Wang Xiaoyan,Yang Zhining,Huang Baotian,Lin Zhixiong
		Objective To analyze the prognostic factors in patients with initially diagnosed bone-only metastatic nasopharyngeal carcinoma (NPC). Methods We collected the data of 68 patients with initially diagnosed bone-only metastatic NPC admitted to The Affiliated Tumor Hospital of Shantou University Medical College from 1997 to 2015. Forty-nine patients received chemoradiotherapy. The Kaplan-Meier method was used to calculate the overall survival rate;the log-rank test was used for univariate prognostic analysis;the Cox model was used for multivariate prognostic analysis. Results The median follow-up was 95.3 months. The 1-, 2-, 3-, and 5-year overall survival (OS) rates were 53%, 38%, 21%, and 15%, respectively. The median OS time was 13.4 months. The univariate prognostic analysis showed that spinal metastases, the number of bone metastases, lactic dehydrogenase level before treatment, the radiotherapy technology and dose for primary tumor, and the short-term outcome of primary tumor were associated with OS (P=0.02,0.01,0.00,0.02,0.02,0.01). The multivariate prognostic analysis showed that ≤3 bone metastases, dose to primary tumor>65 Gy, and intensity-modulated radiotherapy (IMRT) were favorable prognostic factors for OS (P=0.03,0.02,0.04). Conclusions For patients with initially diagnosed bone-only metastatic NPC, active treatment (IMRT, dose to primary tumor>65 Gy) should be considered for those with ≤3 bone metastases to achieve a complete response of primary tumor.
		2017 Vol. 26 (10): 1137-1140 [Abstract] ( 832 ) [HTML 1KB] [ PDF 779KB] ( 0 )

Thoracic Tumors

	1141	Result of stereotactic radiotherapy of oligometastasis non-small cell lung cancer
		Hu Xiaolong,Li Hongqi,Xu Xiangsheng,Liu Hefei,Wu Weizhang,Xia Tingyi,Wang Yingjie
		Objective To explore the curative effect and adverse reaction of applying stereotactic radiotherapy to primary lesion inside chest cavity of patients with oligometastasis non-small cell lung cancer and rendering radical radiotherapy to all metastases. Methods 43 patients with ≤5 metastases of non-small cell lung cancer received initial treatment during 2009-2015 in our department were analyzed;the stereotactic radiotherapy was adopted to implement radical radiotherapy on primary lesion and all metastases. The average and neutral position BED₁₀ respectively were 101.416 Gy and 102.700 Gy,the number of neutral position chemotherapy period was 4.Kaplan-Meier method, survival analysis, Cox model, multi factor Prognosis analysis were used. Results By the end of January 10,2017 in 36 months’ neutral position follow-up visit,the total effective rate of lesion treatment of 86%;the survival rates after 1,2 and 3 years respectively were 74%, 70% and 51%. Neutral survival time was 48 months, and the progression-free time of neutral position was 15 months. Multi-factor analysis indicated that,ECOG<2 and ECOG≥2(P=0.000),BED₁₀<100 Gy and BED₁₀≥100 Gy (P=0.006) generated obvious influence on survival prognosis. About 90% of the patients only got 1-2 degree of adverse reaction without emerging treatment related death. Conclusions On the premise of systematic therapy of oligometastasis non-small cell lung cancer,combined with radical radiotherapy of primary lesion and metastasis can obviously improve patients’ overall survival and progression-free survival,the adverse reaction is durable.
		2017 Vol. 26 (10): 1141-1146 [Abstract] ( 848 ) [HTML 1KB] [ PDF 827KB] ( 0 )

Abdominal Tumors

	1147	Prognostic value of American Joint Committee on Cancer-tumor regression grading combined with ypTN staging in patients with locally advanced rectal cancer
		Wei Jiawang,Xiao Weiwei,Xi Shaoyan,Chang Hui,Wang Qiaoxuan,Li Liren,Zhang Huizhong,Zeng Zhifan,Ding Peirong,Gao Yuanhong
		Objective To investigate the prognostic value of American Joint Committee on Cancer-tumor regression grading (AJCC-TRG) combined with ypTN stage in patients with locally advanced rectal cancer (LARC),who were treated with neoadjuvant chemoradiotherapy,and to identify the subgroups with the worst prognosis. Methods A total of 263 patients with LARC,including 176 males and 87 females,with a median age of 55 years,were admitted to Sun Yat-sen University Cancer Center from 2004 to 2012.All the patients received neoadjuvant chemoradiotherapy before surgery and underwent total mesorectal excision at 6 to 8 weeks after radiotherapy. All the surgical specimens were reevaluated according to the AJCC (7th edition)-TRG system and ypTN staging criteria. The prognostic prediction by TRG combined with ypTN was evaluated using survival analysis. The Kaplan-Meier method was used to calculate the rates of overall survival (OS),disease-free survival (DFS),local recurrence-free survival (LRFS),and distant metastasis-free survival (DMFS).The log-rank test was used for survival comparison and univariate prognostic analysis. Results The median follow-up was 60.1 months. The 5-year rates of OS,DFS,LRFS,and DMFS for all patients were 80.0%,75.0%,97.0%,and 81.0%,respectively. There were significant differences in OS,DFS,and DMFS between different ypT/TRG subgroups and different ypN/TRG subgroups (all P<0.05).ypT_3-4/TRG 2-3 and ypN_1-2/TRG 2-3 subgroups showed the worst prognosis. The 5-year rates of OS,DFS,and DMFS of the two subgroups were 66.9%/56.0%,52.2%/41.4%,and 60.9%/46.0%,respectively. Conclusions A combination of AJCC-TRG system and ypTN staging can better predict the prognosis of LARC and identify the subgroups with the worst prognosis,which may provide a clinical guidance for postoperative individualized decision on adjuvant therapy for LARC.
		2017 Vol. 26 (10): 1147-1150 [Abstract] ( 886 ) [HTML 1KB] [ PDF 1508KB] ( 0 )

	1151	Clinical value of radiotherapy in 78 patients with pT₃N₀M₀ breast cancer after modified radical mastectomy
		Li Shuai,Wang Shulian,Tang Yu,Jin Jing,Ren Hua,Song Yongwen,Wang Weihu,Liu Yueping,Fang Hui,Liu Xinfan,Yu Zihao,Li Yexiong
		Objective To investigate the value of post-mastectomy radiotherapy (PMRT) in patients with T₃N₀ breast cancer (BC) who were treated with modified radical mastectomy (MRM). Methods A retrospective analysis was performed on the clinical data of BC patients treated with MRM from 1997 to 2014.The inclusion criteria were as follows:(1) female patients;(2) pathological diagnosis of invasive BC;(3) tumor volume greater than 5 cm without axillary lymph node metastasis;(4) the patients who received no neoadjuvant chemotherapy or endocrine therapy and had no distant metastasis or other second primary cancers. A total of 78 patients met the inclusion criteria. Forty patients (51%) received PMRT and sixty-seven patients (86%) received adjuvant chemotherapy. The Kaplan-Meier method was used to calculate overall survival (OS), disease-free survival (DFS)(DFS), and local-regional recurrence (LRR) rates, and survival differences between groups were analyzed by the log-rank test. Results The median follow-up time was 79 months (6-232 months). For all patients, the 5-year OS, DFS, and LRR rates were 89%, 87%, and 2%, respectively. The 5-year DFS, OS and LRR rates for radiotherapy group were 84%, 84% and 0%, respectively, versus 91%(P=0.641), 96%(P=0.126), and 5% for non-radiotherapy group. Only estrogen receptor/progesterone receptor (ER/PR) status and molecular type had significant impacts on DFS (P=0.002 and 0.031, respectively). One patient in non-radiotherapy group had chest wall recurrence. Conclusions MRM is effective in reducing LRR in T₃N₀M₀ BC patients. Only ER/PR status and molecular type significantly influence DFS. Effective systemic therapy may be helpful for some T₃N₀ patients to avoid chest wall and supraclavicular radiotherapy after MRM, but large-sample studies are needed to further confirm this conclusion.
		2017 Vol. 26 (10): 1151-1155 [Abstract] ( 862 ) [HTML 1KB] [ PDF 1024KB] ( 0 )

	1156	Expression of miR-93-5p and miR-27a-3p in rectal cancer tissues and its clinical significance
		Hu Yiran,Hu Peng,Wu Quan,Luo Wenguang,Zhang Hongyan
		Objective To investigate the miRNA expression profiles in rectal cancer tissues and their associations with clinical pathological stage, depth of tumor invasion, and lymph node metastasis, and to evaluate the potential of miRNA as diagnostic and prognostic markers of rectal cancer. Methods Human miRNA microarray was used to profile miRNA expression in rectal cancer tissues and matched adjacent normal tissues (n=71). The up-regulated miR-93-5p and down-regulated miR-27a-3p were screened out, and the top differentially expressed miRNA were validated by quantitative real-time polymerase chain reaction (qRT-PCR). The relationship between the expression of miRNA and clinical parameters was analyzed by ANOVA and Spearman correlation. Results The expression of miR-27a-3p was down-regulated in miRNA microarray, but was up-regulated in qRT-PCR analysis;the data were relatively discrete. The expression of miR-93-5p was up-regulated in both miRNA microarray and qRT-PCR analysis;the expression level of miR-93-5p in rectal cancer tissues was 3.165 times that in adjacent normal tissues (P=0.0058);the expression level was correlated with tumor volume (P=0.004), and was positively correlated with the level of carcinoembryonic antigen (CEA) before treatment (P=0.001) and the number of lymph nodes metastases (r_s=0.534, P=0.005). Conclusions There is a differential miRNA expression pattern between rectal cancer tissues and matched adjacent normal tissues. The miR-93-5p is highly up-regulated in rectal cancer tissues and may serve as a diagnostic and prognostic marker of rectal cancer.
		2017 Vol. 26 (10): 1156-1161 [Abstract] ( 797 ) [HTML 1KB] [ PDF 1576KB] ( 0 )

	1162	Clinical nursing of vaginal adhesions in patients treated with radiotherapy for cervical cancer
		Mai Miaoqing,Chen Peifang,Feng Guirong,Chen Yushan,Hu Lianying
		Objective To explore the nursing method for the prevention and treatment of vaginal adhesions in patients treated with full-dose radiotherapy for cervical cancer. Methods From 2015 to 2016, 80 cervical cancer patients who received radiotherapy were treated with domestic vaginal washing, vaginal local use of"Fufangbao", infection control, diet and sexual rehabilitation guidance, and so on, and the nursing outcome was evaluated. Results Of the 80 patients, 6 were lost during follow-up, resulting in a follow-up rate of 92.5%. Ten, five, and three patients were found to have grade 1, 2, and 3 vaginal toxicity, respectively. The patients with grade 1 vaginal toxicity were not treated with special treatment and were asked to do more vaginal washing. The patients with grade 2 and 3 vaginal toxicity were treated with daily vaginal washing and"Fufangbao" for repairing the vagina;vaginal adhesions disappeared or improved 3 months later. The patients with no vaginal adhesions had regular sexual intercourse and thus had improved quality of life. Conclusions Effective clinical nursing can reduce the incidence of vaginal adhesions and stenosis, improve patients’ quality of life, and promote the harmony of family.
		2017 Vol. 26 (10): 1162-1164 [Abstract] ( 817 ) [HTML 1KB] [ PDF 747KB] ( 0 )

Physics·Biology·Technique

	1165


		2017 Vol. 26 (10): 1165-1166 [Abstract] ( 792 ) [HTML 1KB] [ PDF 960KB] ( 0 )

	1167	Clinical feasibility of atlas-based auto-segmentation software in radiotherapy for cervical cancer
		Sun Yuchen,Zhang Xiaozhi,Li Yi
		Objective To investigate the time efficiency and accuracy of atlas-based auto-segmentation (ABAS) software with different atlas template numbers and layers of computed tomography(CT) scans in delineation of the target tissues of cervical cancer patients receiving radiotherapy. Methods The CT images from 20, 40, 60, 80, 100, and 120 patients with cervical cancer were separately selected as atlas templates for MIM auto-segmentation software, and the CT-based tumor volumes of another 20 patients with cervical cancer were manually contoured by physicians. The quality of contours obtained automatically from the software and manual contouring was compared by one-way analysis of variance (ANOVA), randomized block ANOVA, and least significant difference t test. The impact of atlas template numbers and layers of CT scans on the accuracy and time efficiency of MIM software was analyzed based on the time spent in delineation, dice similarity coefficient, and overlap index. Results Taking manual contouring as the reference, no significant differences were observed in the accuracy and time efficiency of auto-contouring when atlas template numbers ranged from 20 to 120(all P>0.05). The ABAS auto-contouring significantly shortened the time for target contours when the layers of CT scans were less than 65(all P>0.05), but reduced the accuracy of rectal contours (P=0.000), while CT scans with 67 layers achieved the highest accuracy of rectal contours (P=0.037). Conclusions The ABAS software shows an advantage in delineation of the target tissues of cervical cancer patients receiving radiotherapy, and 20 templates are suggested to construct this atlas. The CT scans with 65 layers are recommended for patients when target tissues include the bladder, femur, and spinal cord, and CT scans with 67 layers are recommended for patients when target tissues include the rectum.
		2017 Vol. 26 (10): 1167-1172 [Abstract] ( 878 ) [HTML 1KB] [ PDF 2107KB] ( 0 )

	1173	Comparison of 3DCBCT and 4DCBCT matching results in setup error assessment and correction for breast irradiation after breast-conserving surgery
		Ding Yun,Li Yufeng,Li Qilin,Gao Min,Wei Xiaobo,Huang Jin,Xi Dan,Gu Wendong
		Objective To compare the differences in setup error (SE) assessment and correction between three-dimensional cone-beam computed tomography (3DCBCT) and four-dimensional CBCT(4DCBCT) in breast irradiation patients during free breathing after breast-conserving surgery. Methods Twenty patients with breast cancer after breast-conserving surgery were recruited for external beam breast irradiation and 4DCBCT and 3DCBCT simulation. The target volumes were delineated. Volumetric modulated arc therapy plans were designed using the MONACO v5.10 treatment planning system. 3DCBCT and 4DCBCT images were collected alternately five times each before breast irradiation. The CT images were matched, and the interfraction SEs were acquired. After online setup correction, the residual errors were calculated, and the SEs, systematic errors, and random errors were compared. The paired t test was used for comparison between groups. Results The SEs acquired by 4DCBCT were significantly larger than those acquired by 3DCBCT in three directions (P=0.035,0.018,0.040). After online setup correction, the random errors based on 3DCBCT were significantly smaller than those based on 4DCBCT in left-right and anterior-posterior (AP) directions (0.5±0.39 mm vs. 0.7±0.30 mm, P=0.005;0.9±1.09 mm vs. 1.2±0.48 mm, P=0.000), and the residual errors based on 3DCBCT were also significantly smaller than those based on 4DCBCT in AP direction (0.2±0.33 mm vs. 0.6±0.63 mm, P=0.000). The setup margins based on 4DCBCT was significantly larger than those based on 3DCBCT in AP direction both before and after online setup correction (P=0.002). Conclusions Compared with 3DCBCT, 4DCBCT has more advantages in monitoring the SEs in three directions. Both 3DCBCT and 4DCBCT have similar efficacy in random error correction. The satisfying position repeatability and minimized target volume margins will be achieved by online setup correction.
		2017 Vol. 26 (10): 1173-1176 [Abstract] ( 902 ) [HTML 1KB] [ PDF 774KB] ( 0 )

	1177	A new set of conformity indices for evaluating intensity-modulated radiotherapy or three-dimensional conformal radiotherapy plans
		Zhao Man,Hu Yimin
		Objective To propose a new set of conformity indices (CIs) that may be useful for evaluating whether the prescribed doses to target volume and organs at risk (OAR) in intensity-modulated radiotherapy (IMRT) or three-dimensional conformal radiotherapy (3DCRT) plans meet clinical requirements. Methods A total of 30 patients’ plans were randomly selected from the IMRT or 3DCRT plans for non-small cell lung cancer and analyzed with the newly defined CIs described in this article. The plans to be improved were selected according to the evaluating results, and two schemes were developed to improve these plans. Then, the differences in CI, D_max, D_min, and D_meanof the planning target volume (PTV), V₅ and V₂₀ of the normal lung, V₃₀ and V₄₀ of the heart, and D_max of the spinal cord were investigated with the paired t-test.Results Among the 30 plans, the average volume covered by the prescribed isodose line (V_RI) was 25% larger than the PTV, so the normal lung tissue with a volume approximately 25% of PTVwas given the same dose as the target volume, and the volume covered by the prescribed isodose line in the target V (C) R was only 75% of the volume VR. Ninety-five percent of the target volume received a full prescribed dose;only 5% of the target volume received less than the prescribed dose, but which was still within 90% of the prescribed dose. In the comparison between the original plans and the plans improved using the first scheme, CI₂, CI₄, CI₅, CI₆, and homogeneity index (HI) were not significantly different (P=0.240-0.780), and CI₁ and CI₃ showed significant differences (P=0.002 and 0);D_max, D_min, and D_mean of the PTV, V₅ and V₂₀ of the normal lung, V₃₀ and V₄₀ of the heart, and D_max of the spinal cord were not significantly different (P=0.211-0.964). In the comparison between the original plans and the plans improved using the second scheme, CI₂, CI₄, and CI₅ were not significantly different (P=0.308, 0.308, and 0.106), CI₁, CI₃, CI₆, and HI showed significant differences (P=0.001-0.014);D_max, D_min, and D_mean of the PTV, V₅ and V₂₀ of the normal lung, and D_max of the spinal cord showed significant differences (P=0.008-0.036), and V₃₀ and V₄₀ of the heart were not significantly different (P=0.083 and 0.080). Conclusions The new set of CIs proposed in this paper may be a good tool for evaluating the conformity of the target and the prescribed dose to OAR and thus developing better individualized treatment plans.
		2017 Vol. 26 (10): 1177-1181 [Abstract] ( 871 ) [HTML 1KB] [ PDF 871KB] ( 0 )

	1182	Impact of actual gantry angle on accuracy of intensity-modulated radiotherapy for nasopharyngeal carcinoma
		Sun Yanze,Zhou Gang,Chen Liesong,Qian Jianjun,Zhu Yaqun,Tian Ye
		Objective To investigate the impact of actual gantry angle on the accuracy of intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC). Methods A total of 27 patients with NPC were enrolled in this study. IMRT plans were designed with Pinnacle treatment planning system (TPS),and 8 beams with an interval of 30°(within 0°-360°) were selected for each plan. These plans were divided into plan A and plan B according to the beam parameters. In plan A,the minimum sub-field area was 5 cm²,the minimum number of sub-field monitor unit (MU) was 5,and the maximum sub-field number was 80;in plan B,the minimum sub-field area was 8 cm²,the minimum number of sub-field MUs was 8,and the maximum sub-field number was 60.The gamma passing rate using the criteria of 3%/3 mm and 2%/2 mm at actual and zero degree gantry angles were calculated using Mapcheck 2 device for dose verification,and were compared with the paired t-test. The relationship between the above differences (Δ value) and the beam angle or the beam parameters was also analyzed. Results In plan A with the criteria of 3%/3 mm,the beams were significantly different (P=0.000-0.007) except for at angles of 270°,300°,and 300°,and the mean Δ value was 0.90%;under the criteria of 2%/2 mm,all beams were significantly different (P=0.000-0.019) except for at an angle of 300°,and the mean Δ value was 2.72%.In plan B with the criteria of 3%/3 mm,the beams showed no significant difference (P=0.052-0.639) except for at an angle of 300 °,and the mean Δ value was 0.40%;under the criteria of 2%/2 mm,all beams showed no significant difference (P>0.05) except for at angles of 210°,240°,270°,and 300°,and the mean Δ value was 1.52%.When the plan B parameters were used,the Δ value was reduced;the results of two verification methods were more consistent,so the accuracy was also improved. Conclusions Compared with the validation method at zero degree gantry angle,the validation method at an actual gantry angle is associated with reduced gamma passing rate because of some factors such as gravity,which is not significantly related to the beam angle,but the beam parameters. In the design of IMRT plans for NPC,the total number of sub-fields should be decreased as far as possible,and the minimum sub-field area and the minimum number of MU should be increased,so as to improve the accuracy of treatment plans.
		2017 Vol. 26 (10): 1182-1186 [Abstract] ( 885 ) [HTML 1KB] [ PDF 2189KB] ( 0 )

	1187	Dosimetric comparison of simultaneous integrated boost with intensity-modulated radiotherapy, volumetric modulated arc therapy, and hybrid intensity-modulated radiotherapy in patients with multiple brain metastases
		Sun Tao,Lin Xiutong,Wang Ruozheng,Liu Xiao,Duan Jinghao,Yin Yong
		Objective To evaluate the impact of simultaneous integrated boost (SIB) with different radiotherapy plans on the dosimetry of the target volume and organs at risk (OAR) in patients with multiple brain metastases (MBM), and to provide a basis for the selection of an optimal clinical radiotherapy. Methods Ten patients with MBM who were treated with whole-brain SIB radiotherapy were randomly selected in this analysis. The local imaging data from the enrolled patients were re-planned with dynamic intensity-modulated radiotherapy (dynamic IMRT), dual-arc volumetric modulated arc therapy (dual-arc VMAT), and hybrid-IMRT (h-IMRT). h-IMRT plan was created by inversely optimizing 3 and 4 fixed fields of IMRT based on conformal radiotherapy. Two-tailed Wilcoxon matched pairs signed rank sum test was performed to analyze the differences between the three radiotherapy plans in the conformity index (CI) and homogeneity index (HI) of the planning target volumes (PTV), D_mean and D_max of OAR, monitor units (MU), and delivery time. Results CI of PTVs with VMAT plan was better than that with IMRT and h-IMRT plans (P=0.04,0.00), and no significant difference in HI was observed between the three plans (P>0.05). There were no significant differences in CI and HI between 3 and 4 fields in dynamic IMRT (P>0.05). h-IMRT 3-and 4-field plans had significantly reduced doses to the eye lens and eyeballs than dynamic IMRT and VMAT plans (all P=0.00), and the three plans had similar doses to the brainstem and optic nerve (P>0.05). As for the MHs and delivery time, dynamic IMRT and VMAT plans showed the highest and lowest value, respectively (all P=0.00). Conclusions All the three plans meet the clinical requirements. VMAT shows the highest treatment efficiency. H-IMRT protects the eye lens and eyeballs more effectively while maintaining the doses to the PTV, with reduced MU compared with IMRT. These offer a reference for designing the radiotherapy plan in MBM patients.
		2017 Vol. 26 (10): 1187-1191 [Abstract] ( 849 ) [HTML 1KB] [ PDF 1269KB] ( 0 )

	1192	Evaluation of plan quality between two treatment planning systems for volumetric modulated arc therapy
		Yang Tao,Xu Wei,Xu Shouping,Qu Baolin,Ge Ruigang,Dai Xiangkun,Xie Chuanbin,Cong Xiaohu,Gong Xuan
		Objective To investigate the plan quality between two treatment planning systems (TPSs) for volumetric modulated arc therapy (VMAT). Methods VMAT plans based on Varian Eclipse and Philips Pinnacle TPS were designed for 10 cervical cancer patients (2, 3 Arcs) and 10 prostate cancer patients (1, 2 Arcs). The delivery system of VMAT was Varian ClinaciX machine, and RapidArc was used. The treatment plan quality between the two TPSs was evaluated based on dose distribution, delivery efficiency, and parameter settings. The differences between the two TPSs were compared using paired t-test. Results For cervical cancer patients, the 2-Arc VMAT plans based on the Pinnacle was slightly better than those based on the Eclipse in terms of the conformal index (CI) of planning target volume (PTV), rectum V₃₀ and V₄₀, and bladder V₃₀ and V₄₀, and the homogeneity index (HI) of PTV and PTV₁ as well as CI of PTV₁ in theEclips were slightly better than those in the Pinnacle(P<0.05)Pinnacle were slightly worse than those in the Eclipse (P>0.05). The number of monitor units with 2-Arcs and 3-Arcs plans of the Eclipse was significantly smaller than those in the Pinnacle (P<0.05). For prostate cancer patients, The 1-arc VMAT plans of the Pinnacle TPS were slightly superior to those of the Eclipse TPS in terms of the HI of PTV, rectumV₃₀ and V₄₀, and bladderV₃₀ and V₄₀, but the former was slight inferior to the latter in terms of the CI of PTV (P<0.05). The number of monitor units of 1-arc and 2-Arcs plans showed no significant difference between the two TPSs (P>0.05). Conclusions For patients with cervical cancer and prostate cancer, the VMAT plans based on Varian Eclipse and Philips Pinnacle TPS can achieve a clinically acceptable dose distribution and show a little difference in the treatment plan quality. However, we will still need more cases to further study and determine the performance characteristics of the commercial TPSs for optimizing VMAT.
		2017 Vol. 26 (10): 1192-1198 [Abstract] ( 889 ) [HTML 1KB] [ PDF 848KB] ( 0 )

	1199	Dosimetric sensitivity with MU and MLC errors in IMRT versus VMAT plan for nasopharyngeal carcinoma
		Cheng Yanming,Hu Cairong,Yin Xiaojuan,Zheng Mingzhi,Zhang Xiuchun
		Objective To simulate the possible systematic delivery errors introduced by monitor units (MU) and multi-leaf collimator (MLC) in radiotherapy plans for nasopharyngeal carcinoma (NPC), and to analyze the dosimetric sensitivity of static intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) with these errors. Methods Five IMRT plans were replanned using VMAT modality with the same physical parameters, and then MU errors of 1.25%, 2.50%, and 5.00% were introduced into IMRT and VMAT plans. Meanwhile, to simulate leaf position errors during delivery, MLC position errors (0.25 mm, 0.50 mm, 1.00 mm, 1.50 mm, and 2.00 mm) were introduced by modifying the original plan documents. The types of MLC errors were as follows:(1) the MLC banks moved in the same direction;(2) the MLC banks moved in opposing directions (expand or contract the MLC gaps). The differences in dosimetric sensitivity introduced by MU and MLC errors between IMRT and VMAT plans for NPC were calculated by linear regression analysis. Results With the increase in MU errors, the doses to target and organs at risk (OARs) of IMRT and VMAT plans increased in a linear way, and met R²=0.992-1.000(P<0.05). For MLC errors, the average dosimetric sensitivity for target and OARs of IMRT and VMAT were -0.26%/mm and -0.65%/mm in case of offset errors, 4.87%/mm and 8.68%/mm in case of expansion errors, and -6.04%/mm and -9.88%/mm in case of indentation errors. In addition, the dosimetric sensitivity with the three types of MLC errors was greater for VMAT plan than for IMRT plan. Conclusions MU and MLC errors have a significant effect on the dose distribution of IMRT, and particularly VMAT, for NPC. It is important to execute routine quality assurance of MLC to ensure accurate radiotherapy.
		2017 Vol. 26 (10): 1199-1203 [Abstract] ( 878 ) [HTML 1KB] [ PDF 2039KB] ( 0 )

	1204	Effect of density heterogeneity on absorbed dose with CyberKnife Synchrony Respiratory Tracking System
		Liu Hongyuan,Yang Zhiyong,Liang Zhiwen,Yang Jing,Hu Bin,Cheng Junping,Cao Ting,Li Qin
		Objective To measure the actual absorbed dose of the target in the QUASAR Respiratory Motion Phantom using the CyberKnife Synchrony Respiratory Tracking System, and to evaluatethe effect of density heterogeneity on the absorbed dose of tumor gross target volume (GTV). Methods Nine groups were obtained by making different patterns of QUASAR phantom:rib thickness of 0, 20, and 50 mm, and motion amplitudes of 0, 10, and 15 mm. The nine groups were treated with static computed tomography (CT) in different time phases of four-dimensional CT (4DCT) plan, with the same beam and number of monitor units, and the 4D accumulated dose was calculated. The doses of static and 4D plans were calculated using Ray-tracing and Monte Carlo algorithms, and the absorbed doses of GTV in the nine groups were measured at the same time. Results There were a decrease in calculated absorbed dose of GTV and an increase in deviation between the planned and actual dose, with the increases in simulated rib thickness and motion amplitude. Conclusions The density heterogeneity has an impact on the absorbed dose of GTV. Both static CT and 4DCT plan can evaluate the absorbed dose of GTV in case of small rib thickness and motion amplitude, and 4DCT plan with Monte Carlo algorithm may be the optimal method for evaluation of the absorbed dose of GTV in case of large rib thickness and motion amplitude (deviation<3%)
		2017 Vol. 26 (10): 1204-1208 [Abstract] ( 771 ) [HTML 1KB] [ PDF 1116KB] ( 0 )

	1209	Captopril attenuates lung inflammation through inhibiting the expression of CCL-2 in rats with acute radiation-induced lung injury
		Wang Jun,Lu Hongda,Lei Zhang,Wu Hongbin,Lu Chi
		Objective To explore the inhibitory effect of captopril on acute radiation-induced lung injury in rats and the possible mechanism. Methods Sixty-four female Wistar rats were randomly divided into control group, irradiation group, irradiation+low-dose captopril group, and irradiation+high-dose captopril group. A single dose of 20 Gy was given to the right lung of all rats except those in the control group to establish a rat model of acute radiation-induced lung injury. These rats were sacrificed at 1, 2, 4, and 8 weeks. HE staining was used to observe the pathological changes in lung tissue;RT-PCR and Western blot were used to measure the mRNA and protein expression of CCL-2 in lung tissue;immunohistochemical assay was used to determine the number of monocytes (CD₆₈) in lung tissue. A one-way analysis of variance was performed. Results Captopril significantly reduced lung inflammation in rats with acute radiation-induced lung injury (P<0.05), inhibited the accumulation of monocytes (CD₆₈) in lung tissue (P<0.05), and decreased the content of CCL-2 in lung tissue (P<0.05). Conclusions For rats with acute radiation-induced lung injury, captopril can reduce the expression of CCL-2 to inhibit the accumulation of monocytes in lung tissue and thus attenuate lung inflammation.
		2017 Vol. 26 (10): 1209-1213 [Abstract] ( 653 ) [HTML 1KB] [ PDF 4499KB] ( 0 )

Review Articles

	1214	Progress in stereotactic body radiation therapy combined with immunotherapy for advanced malignancies
		Lu Yi,Huang Minjie,Qiu Jianbo,Zhang Zhanchun
		For advanced pulmonary metastases or melanoma, radiotherapy combined with immune checkpoint inhibitor can block the immunosuppression pathway, enhance the antitumor immune response, and significantly improve survival. Stereotactic body radiation therapy (SBRT) delivers a large dose of radiation to the tumor target with high precision while sparing irradiation of the surrounding normal tissues. It is suggested that SBRT could be the most appropriate radiotherapy modality to be combined with immunotherapy since it induces the expression of a series of cytokines and immune molecules and is more likely to cause intense immune response and exert an abscopal effect than conventional radiotherapy. Previous studies have explored that total dose and fractionation seem to be important parameters for determining the immune response;the timing of radiation with immunotherapy significantly influences the outcome, and tumor infiltrating lymphocytes, the expression level of programmed death-ligand 1, and mismatch repair defect may be important predicators of the outcome. With appropriate radiotherapy dose and fractionation, the optimal timing of radiation with immunotherapy, and effective predictive markers, a combination of SBRT and immunotherapy may eliminate advanced malignancies while activating the systemic immune response to exert an abscopal effect.
		2017 Vol. 26 (10): 1214-1217 [Abstract] ( 940 ) [HTML 1KB] [ PDF 803KB] ( 0 )

	1218	Research progress in tyrosine kinase inhibitor combined with radiotherapy for brain metastases in patients with non-small cell lung cancer
		Kong Yue,Song Zhenbo,Chen Ming
		Brain metastases (BM) are a frequent complication of non-small cell lung cancer (NSCLC), with various treatment strategies. The widespread use of tyrosine kinase inhibitor (TKI) has significantly prolonged the survival of NSCLC patients with epidermal growth factor receptor mutations. This article reviews recent progress in TKI therapy for BM in NSCLC patients and discusses a combination of TKI and radiotherapy.
		2017 Vol. 26 (10): 1218-1221 [Abstract] ( 747 ) [HTML 1KB] [ PDF 812KB] ( 0 )

	1222	Research advances in the association of miRNAs with EGFR mutation, EGFR-TKI, and radiotherapy in non-small cell lung cancer
		Xu Qizhen,Zhang Daxin
		Epidermal growth factor receptor (EGFR) is most popular in targeted therapy for non-small cell lung cancer (NSCLC). In recent years, there have been a great number of molecular biology studies of EGFR. Radiotherapy is well-known as a traditional and important treatment for NSCLC, and the treatment outcome is associated with EGFR mutation and overexpression. Phase Ⅲ trials are needed to evaluate the effect of a combination of radiotherapy and EGFR-tyrosine kinase inhibitor (EGFR-TKI) in the treatment of NSCLC. MicroRNAs (miRNAs) can modulate tumor-associated gene expression and influence the biological process of tumor. Recent studies have demonstrated that miRNAs play a positive or negative role in EGFR mutation, EGFR-TKI treatment, and radiotherapy, which mechanism has been partially clarified. In this article, we review the research advances in the association of miRNAs with EGFR mutation, EGFR-TKI, and radiotherapy, so as to provide the latest evidence for the application of miRNAs in the combination of radiotherapy and EGFR-TKI for the treatment of NSCLC.
		2017 Vol. 26 (10): 1222-1226 [Abstract] ( 781 ) [HTML 1KB] [ PDF 840KB] ( 0 )

	1227	Challenges in synergy between radiation and immunotherapy
		Zhu Xiling,Li Gong
		Radiotherapy (RT) is used as primary treatment for numerous cancers. Although it is usually described as an immunosuppressive modality,there are new preclinical evidences suggesting that RT could have also generated substantial changes in the tumor microenvironment,including triggering an inflammatory process. Some studies established the proof of concept that combining RT with strategies modifying immunology could enhance antitumor effects.
		2017 Vol. 26 (10): 1227-1230 [Abstract] ( 898 ) [HTML 1KB] [ PDF 807KB] ( 0 )

	1231	Research progress in DNA damage checkpoint mechanism
		Zhou Congya,Zhang Dan,Han Suxia
		A damage is a general event in the life of cells and may lead to mutation,cancer,and cell/organ death. DNA damage occurring in different phases of cell cycle can activate different damage checkpoint pathways to halt the progress of cell cycle in order to provide time for DNA damage repair. If DNA damage cannot be repaired,cellular apoptosis may be induced. Therefore,DNA damage checkpoint is of great significance for cell survival after DNA damage. This article summarizes recent research on DNA damage responses,including DNA damage checkpoint,DNA damage repair,transcriptional response,and cell apoptosis. We focus on how the DNA damage checkpoint pathway is activated after DNA damage,as well as the functional mechanism of the DNA damage checkpoint pathway. The review aims to help readers understand the great significance of DNA damage checkpoint pathway,providing a theoretical basis for its application in radiotherapy and chemotherapy for cancer.
		2017 Vol. 26 (10): 1231-1234 [Abstract] ( 828 ) [HTML 1KB] [ PDF 919KB] ( 0 )

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