Chinese Journal of Radiation Oncology

中华放射肿瘤学杂志

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Chinese Journal of Radiation Oncology

	2018 Vol.27 Issue.3 Published 2018-03-15

	Head and Neck Tumors Abdominal Tumors Thoracic Tumors Physics·Biology·Technique Review Articles Consensus Symposium

Consensus

	227	Consensus and contouring atlas for the delineation of clinical target volume in pre-/post-operative image-guided intensity modulated radiotherapy for rectal cancer
		Professional Committee of Radiotherapy for Colorectal Cancer of Chinese Medical Doctor Association;China Society for Radiation Oncology of Chinese Medical Association, Tang Yuan, Jin Jing, Zhu Yuan, Liu Shixin, Yuan Xianglin, Wang Wenling, Wang Xiaohuo, Zhang Zhen, Tian Ye, Gao Yuanhong, Zhang Hongyan, Cai Yong, Chi Yihebali, Jiang Liming, Liu Zheng, Wen Bixiu, Zhang Daxin, Yu Dahai, Wu Junxin, Lin Shaomin, Shi Mei, Li Yexiong
		Objective To establish a Chinese experts’ consensus for the delineation of clinical target volume (CTV) of pre-/post-operative radiotherapy for rectal cancer in the era of three dimensional conformal radiotherapy, and compile a high-resolution contouring atlas. Methods The consensus and contouring atlas for the delineation of CTV of pre-/post-operative radiotherapy for rectal cancer were drafted by referring to international guidelines and treatment experience of domestic radiation centers. The details of draft were discussed and voted on the annual conference of Professional Committee of Radiotherapy for Colorectal Cancer of Chinese Medical Doctor Association. The final consensus was summarized by the steering committee. Results Based on the strength of the evidence and the consistency of experts’ consensus,the grading recommendations for positioning technology,pre-/post-operative radiotherapy target definition, definition of organs at risk (OAR), radiotherapy dose and fraction were delivered. In addition,the atlas of CTV was demonstrated on high-resolution on CT scan images. Conclusions To establish a Chinese experts’ consensus for radiotherapy of rectal cancer,standardize the radiotherapy process and reduce the variance in the delineation of CTV among different hospitals and radiologists.
		2018 Vol. 27 (3): 227-234 [Abstract] ( 1283 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Head and Neck Tumors

	235	Relationship between radiation-induced xerostomia and the volume of parotid glands exposed in radiotherapy for nasopharyngeal carcinoma
		Liu Yang, Ma Jie, Yang Yunli, Li Ling, Zhu Xiaodong
		Objective To evaluate the relationship between the volume of parotid glands and radiation-induced xerostomia in patients with nasopharyngeal carcinoma (NPC). Methods A total of 199 patients with NPC who were admitted to our hospital from 2015 to 2016 were enrolled as subjects. According to the initial volume of parotid glands, all patients were divided into large parotid group and small parotid group. The incidence of xerostomia after radiotherapy and dosimetric parameters were compared between the two groups. Comparison of categorical data was made by χ² test. Comparison of continuous data was made by t-test or nonparametric test. Comparison of dose-volume histogram index was made by nonparametric test. Results There was no difference in the severity of xerostomia between the two groups at 3 and 6 months after radiotherapy. At one year after radiotherapy,the large parotid group had significantly milder xerostomia than the small parotid group (P=0.035).The small parotid group had a higher dose delivered to both parotid glands than the large parotid group. There was no difference in the mean dose to the submandibular gland between the two groups. Conclusions The initial volume of parotid glands is one of the influencing factors for the grade of xerostomia after radiotherapy. Patients with large parotid glands have better recovery from xerostomia after radiotherapy than those with small parotid glands. For patients with small parotid glands, more attention should be paid to reducing the dose to protect parotid glands.
		2018 Vol. 27 (3): 235-239 [Abstract] ( 1062 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	240	Dose analysis of hippocampus in T3,T4 nasopharyngeal carcinoma patients treated with intensity modulated radiotherapy
		Sun Zongwen, Shi lei, Kong yue, Du fenglei, Xie Tieming, Zhu Ziyu, Chen Mengyuan, Hua Yonghong, Hu Qiaoying, Chen Yuanyuan, Chen Ming
		Objective To analyze the exposed dose of hippocampus (HC) of T3,T4 nasopharyngeal carcinoma patients treated with intensity modulated radiotherapy (IMRT). Methods The bilateral HCs were delineated and were divided into head (HH),body (HB) and tail (HT) for 62 nasopharyngeal carcinoma patients treated with IMRT.The dose parameters of HC were then analyzed. Results The mean dose of left and right HC was (1127±704) cGy,(1173±762) cGy. The mean dose of left HH,HB and HT was (1732±1029) cGy,(820±632) cGy,(423±366) cGy (P=0.000);while the mean dose of right HH,HB and HT was (1985±1101) cGy,(837±531) cGy,(432±343) cGy (P=0.000).The exposed dose and the volume exposed in different dose of HH were obviously higher than those of HB and HT.The dose parameters of HH,HB and HT decreased in turn. The involvement of sphenoid sinus,ethmoid sinus and cavernous sinus correlated with high exposed dose of HC. Conclusions The exposed dose of HH,HB and HT was different in nasopharyngeal carcinoma patients treated with IMRT.The exposed dose of HH was the highest,which should be emphasized especially. The involvement of sphenoid sinus,ethmoid sinus and cavernous sinus suggest high exposed dose of HC.
		2018 Vol. 27 (3): 240-244 [Abstract] ( 874 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Thoracic Tumors

	245	Involved field irradiation (IFI) versus elective nodal irradiation (ENI) in combination with concurrent chemotherapy for esophageal thoracic squamous cell cancer:a prospective,randomized,multicenter,controlled study
		Lyu Jiahua, Abulimiti·Yisikandaer, Li Tao, Zhang Xiaozhi, Tian Zhongge, Wang Xiaohu, Chen Long, Lu Bing, Chen Hong, Yang Jie, Wang Qifeng, Zhang Jinrong, Ma Youguo, Liu Rui, Liu Ruifeng, Ayiguli· Hare, Lang Jinyi
		Objective This study was conducted to evaluate treatment-related toxicities,the patterns of failure,overall survival (OS) and progression-free survival (PFS) by comparing IFI with ENI in combination with chemotherapy. Methods Eligible patients were treated with concurrent chemoradiotherapy and randomized into either an IFI or ENI arm. The primary end points wereacute treatment-related toxicities. The secondary end points were patterns of failure,OS and PFS. Kaplan-Meier survival rate of the method for calculating the Logrank test difference method. Results Between April 2012 and October 2016,a total of 228 patients were enrolled from nine centers in china. Grade≥3,Grade≥2 radiation esophagitis and pneumonitis in the IFI arm were significantly lower than that of the ENI arm (P=0.018,0.027).No significant differences were observed in overall failure rates,loco-regional failure,distant failure rates,in-field and out-field lymph node failure between the two arms (P=0.401,0.561,0.510,0.561,0.681).The 1-,2-,3-,4-yearand median OS in the ENI arm and IFI arm were 84.1%,57.3%,39.4%,31.6%,28 months and 83.6%,62.1%,44.5%,31.5%,32 months (P=0.654),respectively. The 1-,2-,3-yearand median PFS in the ENI arm and IFI arm were 71.9%,42.3%,32.7%,20 months and 70.1%,45.0%,35.9%,22 months (P=0.885),respectively. Conclusions Compared to ENI,IFI resulted in decreased radiation pneumonitis and esophagitis without sacrificing loco-regional lymph nodal control,PFS and OS in thoracic ESCC.Clinical Trial Registry Chinese Clinical trail registry,registration number:NCT01551589.
		2018 Vol. 27 (3): 245-249 [Abstract] ( 1065 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	250	Comparison of different treatment modalities in node-positive patients after radical resection for squamous cell carcinoma of the thoracic esophagus
		Shen Wenbin, Gao Hongmei, Zhu Shuchai, Li Teng, Li Shuguang, Li Youmei, Liu Zhikun, Su Jingwei, Li Juan, Xu Jinrui
		Objective To compare the efficacy between different modalities in the treatment of positive lymph nodes after radical resection for squamous cell carcinoma of thoracic esophagus (TESCC),and to explore the best treatment mode. The Kaplan-Meier method was used to calculate survival rates. The log-rank test and Cox model were used for univariate and multivariate prognostic analyses,respectively. Methods A retrospective analysis was performed among 548 patients with TESCC who were admitted to our hospital and had positive lymph nodes after radical resection. The efficacy of different treatment methods was evaluated. Propensity scores (PSM) were used to make 1-to-1 patient matching between different treatment groups to further analyze and figure out the best treatment model for patients. The Kaplan-Meier method was used to calculate the overall survival (OS) and disease-free survival (DFS) rates. The log-rank test was used for survival analysis and univariate prognostic analysis. The Cox regression model was used for multivariate prognostic analysis. Results In all patients,the 1-,3-,and 5-year OS rates were 79.9%,38.1% and 28.5%,respectively,while the 1-,3-,and 5-year DFS rates were 68.5%,39.8% and 32.5%,respectively. After 1-to-1 matching based on PSM,there were no differences in general clinical pathological data between the four groups. After PSM,there were significant differences in 1-,3-,and 5-year OS and DFS rates between the surgery alone group,the postoperative radiotherapy group,the postoperative chemotherapy group,and the postoperative chemoradiotherapy (POCRT) group (P=0.000,0.000).There were significant differences in OS and DFS rates between patients with stage N1,N2,and N3 disease (P=0.000,0.000).The result of the Cox multivariate analysis showed that treatment method and N staging were two independent prognostic factors for OS and DFS (P=0.001,0.000,0.025,0.016). Conclusions Patients with positive lymph nodes after radical resection for TESCC have a poor prognosis. Moreover,the prognosis becomes worse with the increase in metastatic lymph nodes. POCRT may improve the survival in those patients. Prospective studies are needed to further confirm those conclusions.
		2018 Vol. 27 (3): 250-255 [Abstract] ( 805 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	256	Clinical efficacy and prognostic factors of intensity-modulated radiotherapy combined with chemotherapy for limited-stage small cell lung cancer
		Liu Xuan, Zhou Zongmei, Wang Yuxia, Dong Xin, Chen Dongfu, Xiao Zefen, Feng Qinfu, Lyu Jima, Liang Jun, Wang Xiaozhen, Hui Zhouguang, Wang Lyuhua, Li Yexiong, Yin Weibo
		Objective To investigate the clinical efficacy and prognosis of intensity-modulated radiotherapy (IMRT) combined with chemotherapy for limited-stage small cell lung cancer (LS-SCLC). Methods A retrospective analysis was performed on the clinical data of 484 LS-SCLC patients treated with chemoradiotherapy in our center from 2006 to 2014. The patients with partial or complete response to IMRT received prophylactic cranial irradiation (PCI). The Kaplan-Meier method was used to calculate survival rates, and the log-rank test and Cox regression were used for univariate and multivariate analyses, respectively. Results In all the patients, the follow-up rate was 93%;the median overall survival (OS) time was 23.8 months;the 2-, 3-, and 5-year OS rates were 48.7%, 39.8%, and 28.6%, respectively;the median progression-free survival (PFS) time was 14.1 months;the 2-, 3-, and 5-year PFS rates were 34.4%, 30.5%, and 28.3%, respectively. The incidence rates of grade ≥3 bone marrow suppression, grade ≥2 radiation esophagitis, and grade ≥2 radiation pneumonitis were 26.9%, 24.8%, and 18.4%, respectively, in SCLC patients after IMRT. The objective response rate was 84.5%. The univariate analysis showed that age, smoking history, TNM stage, PCI, and the number of chemotherapy cycles before radiotherapy were prognostic factors for OS (P=0.006, 0.001, 0.047, 0.000, and 0.046). The multivariate analysis showed that smoking history and PCI were independent prognostic factors (P=0.001 and 0.000). Conclusions IMRT combined with chemotherapy achieves satisfactory clinical outcomes in the treatment of LS-SCLC. Smoking history and PCI are independent prognostic factors for OS of LS-SCLC patients.
		2018 Vol. 27 (3): 256-260 [Abstract] ( 986 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	261	Efficacy and safety of hyperfractionated versus conventionally fractionated chemoradiotherapy for limited-stage small-cell lung cancer:a meta-analysis
		Tong Shaodong, Wang Hui, Xie Ruilin, Wang Han, Qin Zhaohui, Yao Yuanhu
		Objective To systematically evaluate the differences in efficacy and safety between hyperfractionated and conventionally fractionated radiotherapy for limited-stage small-cell lung cancer (LS-SCLC). Methods A computerized search was performed in PubMed, Embase, Cochrane Library, Web of Science, CBM, Wanfang Data, CNKI, and VIP to collect controlled clinical trials of hyperfractionated versus conventionally fractionated chemoradiotherapy in the treatment of LS-SCLC. The RevMan 5.3 softwarewas used to perform meta-analyses of short-term outcomes, survival data, and adverse events. Results Eight controlled clinical trials involving 1361 patients were enrolled in this study. The results of meta-analysis showed that there were no significant differences in objective response rate or 2-and 5-year overall survival rates between the hyperfractionation group and the conventional fractionation group (odds ratio[OR]=1.31, 95% confidence interval[CI]:0.64-2.69,P=0.46;risk ratio[RR]=1.10, 95%CI:0.98-1.24,P=0.12;RR=1.13,95%CI:0.75-1.69,P=0.56). Compared with the conventional fractionation group, the hyperfractionation group had a significantly higher incidence of grade ≥2 radiation esophagitis (RR=1.74, 95%CI:1.39-2.17,P<0.05). However, there were no significant differences in incidence rates of grade ≥2 radiation pneumonitis or grade >3 hematological toxicity between the two groups (RR=0.73, 95%CI:0.24-2.24,P=0.58;RR=1.18, 95%CI:0.99-1.39,P=0.06). Conclusions In the treatment of LS-SCLC, two fractionation modes show similar short-term efficacy and survival benefits. However, hyperfractionated radiotherapy causes a higher incidence of radiation esophagitis than conventionally fractionated radiotherapy. Given that hyperfractionated radiotherapy is not superior to conventionally fractionated radiotherapy, conventionally fractionated radiotherapy is recommended for treating LS-SCLC.
		2018 Vol. 27 (3): 261-266 [Abstract] ( 933 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	267	Analysis of influencing factors of intrafractional positioning errors in the hypofractionated radiotherapy for pulmonary tumors
		Sun Li, Kong Cheng, Yin Li, Guo Chang, Ming Xuezhong, Zhang Yuanyuan, Xu Yufeng, Feng Pingbai
		Objective Image-guided radiation therapy (IGRT) was performed to investigate the intrafractional body motion and identify the relevant influencing factors during hypofractionated radiotherapy for malignant pulmonary tumors. Methods A total of ninety-six patients with malignant pulmonary tumors receiving hypofractionated radiotherapy in Jiangsu Cancer Hospital were enrolled in this clinical trial. The kilo-voltage cone beam CT (kV-CBCT) was acquired prior to each fraction and matched to the planning CT images to correct the set-up errors. CBCT was performed immediately after the end of treatment to evaluate the intrafractional variation in the mediolateral, anteroposterior and craniocaudal dimensions. The relationship between relevant influencing factors and intrafractional variation was analyzed using multivariate linear regression. Results In the anteroposterior and craniocaudal directions, the intrafractional positioning errors were reduced along with the increase of ordinal number of fraction (P=0.000). In the mediolateral direction,the intrafractional positioning errors were increased along with the longer duration of hypofractionated radiotherapy (P=0.010).The intrafractional positioning errors were decreased over larger body weight (P=0.003).The intrafractional positioning errors were significantly increased when vacuum bag and thermoplastic film were utilized for fixation (P=0.009). Conclusions Certain intrafractional positioning errors occur during hypofractionated radiotherapy. Relevant influencing factors differ in different directions. Relevant influencing factors should be modified to reduce intrafractional positioning variation and improve the treatment accuracy.
		2018 Vol. 27 (3): 267-270 [Abstract] ( 931 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Abdominal Tumors

	271	A dose-effect analysis of organs at risk during preoperative chemoradiotherapy for gastric cancer
		Feng Lingling, Zhang Yujing, Zhang Li, Huang Shaomin, Zhou Zhiwei
		Objective To investigate the clinical and dose-volume factors for damages to organs at risk (OARs) during preoperative chemoradiotherapy for gastric cancer, and to provide a reference for optimization of radiotherapy plans to avoid or reduce damages to OARs. Methods A total of 58 patients with locally advanced gastric adenocarcinoma undergoing neoadjuvant treatment were enrolled as subjects. In those patients, 30 received preoperative chemoradiotherapy combined with surgery and adjuvant chemotherapy, while others received preoperative chemotherapy combined with surgery and adjuvant chemotherapy. The preoperative chemotherapy group received 2-3 cycles of xeloxregimen (capecitabine+oxaliplatin) before surgery and 3-4 cycles of xeloxregimen after surgery (a total of 6 cycles). The preoperative chemoradiotherapy group received preoperative radiotherapy (45 Gy in 25 fractions) combined with 2 cycles of concurrent xeloxchemotherapy at 14-21 days after the first cycle of xeloxregimen, as well as 3 cycles of xeloxchemotherapy after surgery. The analyses of clinical and dose-volume factors for damages to OARs were performed based on laboratory indices and clinical symptoms during the treatment. Results In all the patients, the incidence rates of liver injury (LI), renal injury (RI), and duodenum injury (DI) before surgery were 22%,48%, and 33%, respectively;the incidence rates of LI and RI after treatment were 35% and 49%, respectively. After appropriate treatment, neither LI nor DI affected the treatment of gastric cancer. RI healed without any special treatment. Compared with preoperative chemotherapy, preoperative chemoradiotherapy caused higher incidence of LI (P=0.00,0.03).RI was only associated with glomerular filtration rate before radiotherapy (P=0.08,0.13). A V3.5 of ≤98.96% for the liver reduced LI, while a D2cc of ≤48 Gy for the duodenum reduced DI. Conclusions Preoperative chemoradiotherapy is safe for treating gastric cancer. Compared with preoperative chemotherapy, preoperative chemoradiotherapy does not increase the risk of RI. However,preoperative chemoradiotherapy tends to increase LI.Further studies are needed to improve the treatment method.
		2018 Vol. 27 (3): 271-276 [Abstract] ( 866 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	277	Outcome of radiotherapy for unresectable renal cell carcinoma and renal pelvis and ureter cancer
		Chang Dongshu, Xia Tingyi
		Objective To retrospectively analyze the clinical outcome of radiotherapy for unresectable renal cell carcinoma and renal pelvis and ureter cancer. Methods A total of 29 patients with unresectable renal cell carcinoma or renal pelvis and ureter cancer received radiotherapy from 2006 to 2015. Those patients were 18 males and 11 females aged between 41 and 95 years (median age 76 years). In those patients, 17 had renal cell carcinoma and 12 renal pelvis and ureter cancer;14 had hematuria and 7 low back pain. All patients received dose-escalation radiotherapy, with 17 treated by gamma knife treatment and 12 by helical tomotherapy(HT). For the gamma knife treatment, the 50% isodose line was set as the prescribed dose line;the radiation dose was 3 to 5 Gy per fraction, with a total dose of 40-50 Gy around the planning target volume and 60-70 Gy around the gross tumor volume. HT was performed with a dose of 50/60/70 Gy in 15-20 fractions. Results For the primary lesion, the complete response (CR) and partial response (PR) rates were 17%(5/29) and 69%(20/29), respectively, yielding an overall response rate (CR+PR) of 86%. After treatment, 93% of patients recovered from hematuria and 100% of patients recovered from low back pain. The 3-and 5-year sample sizes were 15 and 11, respectively. The 3-, and 5-year survival rates were 81%, and 81%, respectively, for renal cell carcinoma, and, 69%, and 69%, respectively, for renal pelvis and ureter cancer. During treatment, 25 patients had grade 1-2 digestive system reaction and 20 patients had grade 1-2 bone marrow suppression. The radiation-induced toxicity was reduced by medication. Conclusions Radiotherapy is safe and effective for treating renal cell carcinoma and renal pelvis and ureter cancer. It can improve the local control and overall survival rates. Radiotherapy provides an effective way to treat unresectable renal cell carcinoma and renal pelvis and ureter carcinoma.
		2018 Vol. 27 (3): 277-280 [Abstract] ( 913 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Physics·Biology·Technique

	281	Cardiac dosimetry of deep inspiration breath-hold technique in whole breast irradiation for left breast cancer after breast-conserving surgery
		Chen Siye, Wang Shulian, Tang Yu, Tian Yuan, Qin Shiru, Cui Weijie, Jing Jing, Liu Yueping, Song Yongwen, Fang Hui, Chen Bo, Qi Shunan, ZhangJianghao, Sun Guangyi, Deng Yanbo, Li Yexiong
		Objective To study the effect of deep inspiration breath-hold (DIBH) technique on the heart dose in whole breast irradiation (WBI) for left breast cancer after breast-conserving surgery, and to investigate the anatomical factors for heart dose. Methods Fifteen patients with left breast cancer who received WBI after breast-conserving surgery and met breathing control requirements were prospectively enrolled as subjects. Simulated CT scans were performed during free breathing (FB) and DIBH. The WBI plans were optimized based on DIBH images. The position, volume, and radiation doses to the heart and lung were compared between the status of FB and DIBH. Correlation of heart dose with various anatomical factors was analyzed in FB status. Between-group comparison of categorical data was made by nonparametric Wilcoxon rank test. A two-variable correlation analysis was made by the Pearson method. Results There was no significant difference in heart volume between the status of FB and DIBH (P=0.773).The volume of both lungs was significantly larger in DIBH status than in FB status (P=0.001). The mean and maximum doses and V5-V40 for the heart, left anterior descending coronary artery,left ventricle, right ventricle, and left lung were significantly lower in DIBH status than in FB status (all P<0.05). The greater DIBH increased the lung volume, the greater the mean heart dose decreased. In FB status, the left breast volume, heart-to-lung volume ratio, distance between the inferior margins of breast and heart, and maximum heart margin distance showed a linear correlation with heart dose. Particularly, the heart-to-lung volume ratio and maximum heart margin distance were independently correlated with heart dose. Conclusions DIBH technique in WBI for left breast cancer after breast-conserving surgery significantly reduces heart and lung doses compared with FB. Changes in lung volume are the basis for improving the relative anatomical location of the heart. The heart-to-lung volume ratio and maximum heart margin distance may provide a reference for DIBH technique.
		2018 Vol. 27 (3): 281-288 [Abstract] ( 938 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	289	Feasibility and effectiveness of self-made tiltable treatment couch in minimizing setup errors of radiotherapy for thoracic and abdominal tumors
		Zhang Yanxin, Dai Jianrong, Wu Zhaoxia, Liang Jun, Cao Ying, Fu Guishan
		Objective A self-made tiltable treatment couch was adopted for CT simulation positioning and radiotherapy to evaluate the feasibility and effectiveness to minimize the setup errors. Methods Twenty-two patients with thoracic and abdominal tumors receiving radiotherapy in Department of Radiation Oncology,Peking Union Medical College between March and September 2016 were recruited in this study. All patients were randomly divided into the experimental (n=11) and control groups (n=11).In the study group,the tiltable treatment couch was adopted to switch the patients from the standing position to the supine position,and conventional supine position was utilized in the control group. All patients received CT positioning under spontaneous breathing. Image registration was performed according to the standard recommendations of IGRT group. The image registration data for the translational and rotation errors of CBCT were recorded and analyzed. The setup errors were calculated by four-parameter model between two groups. Results In the experimental group,the translational error of the x direction was (-0.012±0.128) cm with a variation range of (0.29-0.70 cm),(0.272±0.123) cm for the y direction (0.23-0.70 cm) and (0.089±0.105) cm for the z direction (0.14-0.53 cm),respectively. In the control group,the translational error of the x direction was (0.006±0.198) cm (0.27-0.75 cm),(-0.108±0.396) cm for the y direction (0.56-2.08 cm) and (-0.096±0.176) cm for the z direction (0.34-0.89 cm),respectively. Conclusions Application of the self-made tiltable treatment couch can enhance the setup reproducibility and reduce the setup errors,especially in the y direction during radiotherapy for the thoracic and abdominal tumors.
		2018 Vol. 27 (3): 289-294 [Abstract] ( 815 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	295	Utilization rate of gold fiducial markers and reasons for abandonment in CyberKnife stereotactic body radiation therapy
		Xu Fei, Guo Fuxin, Peng Ran, Zhang Xile, Zhuang Hongqing, Jiang Ping, Fan Jinghong, Li Weiyan, Jiang Yuliang, Ji Zhe, Sun Haitao, Cheng Cheng, Wang Junjie
		Objective To investigate the utilization rate of gold fiducial markers and reasons for abandonment of gold fiducial markers in the CyberKnife VSI System, and to provide reference data for implantation of gold fiducial markers and radiotherapy planning. Methods From March to August, 2017, a total of 47 patients had gold fiducial markers implanted or pasted. In those patients, 42 patients had gold fiducial markers implanted, including 32 receiving computed tomography (CT)-guided 3D-printing coplanar template assisted implantation, 1 receiving CT-guided 3D-printing non-coplanar template assisted implantation, 1 receiving CT-guided implantation, and 8 receiving ultrasound-guided implantation. A total of 44 patients received the CyberKnife treatment, including 2 patients who failed to use gold fiducial markers and were treated with spine tracking instead and 3 patients missing the treatment for other reasons. The numbers of utilized and abandoned gold fiducial markers were recorded for calculation of the utilization and abandonment rates. The reasons for abandonment of gold fiducial markers were analyzed and classified. Results A total of 134 gold fiducial markers were implanted into or pasted to the 44 patients. In all the gold fiducial markers, 111 were utilized and 23 abandoned, yielding a utilization rate of 82.8% and an abandonment rate of 17.2%.The reasons for abandonment of gold fiducial markers included large rigidity error (26.1%), unqualified implanted fold fiducial markers (17.4%), displacement of gold fiducial markers (26.1%), and others (30.4%). Conclusions Compared with the CT-guided or ultrasound-guided implantation of gold fiducial markers, the CT-guided 3D-printing coplanar or non-coplanar template assisted implantation of gold fiducial markers requires only two puncture needles for each implantation and implants two gold fiducial markers by a single needle, which reduces the number of puncture needles, risk of puncture-induced injury, and incidence of complications after implantation. Not all the gold fiducial markers implanted by a variety of ways will be utilized. Some gold fiducial markers will be abandoned for different reasons, which should be taken into account during implantation of gold fiducial markers.
		2018 Vol. 27 (3): 295-298 [Abstract] ( 828 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	299	Comparison of positioning accuracy between personalized polyurethane foam with wing boards and negative pressure vacuum bag in radiotherapy for lung cancer
		Zhang Yingting, Liu Bingzhong, Chen Wenfen, Huang Hong, Lin Chengguang
		Objective To compare the positioning accuracy between personalized polyurethane foam with wing boards and negative pressure vacuum bag in radiotherapy for lung cancer using kilovoltage cone beam computed tomography (CBCT). Methods Thirty-nine patients with lung cancer who received chest radiotherapy in our hospital from 2015 to 2016 were enrolled as subjects. In those patients, 20 were immobilized by negative pressure vacuum bags (VB group) and the others by personalized polyurethane foam with wing boards (PF group).CBCT images were acquired weekly and registered with planning CT images. Setup errors in the left-right, superior-inferior, and anterior-posterior directions, three-dimensional (3D) displacement vector, and setup time were recorded. The margin of the planning target volume (PTV) was calculated using the Van Herk formula (2.5∑+0.7σ). Between-group comparison was made by paired t test. Results The PF group had a significant smaller setup error in the y-direction than the VB group (2.54±1.79 vs. 3.19±2.14 mm, P=0.03), while there were no significant differences in setup errors in the x-or z-direction between the two groups (1.80±1.48 vs. 1.90±1.41 mm, P=0.46;2.14±1.75 vs. 2.25±1.75 mm, P=0.35). There were no significant differences in rotational setup errors in the Rx-, Ry-, or Rz-direction between the two groups(1.15°±0.76°vs. 1.15°±0.85°, P=0.50;0.71°±0.60°vs. 0.72°±0.43°, P=0.45;0.62°±0.54° vs. 0.46°±0.30°, P=0.06). The PTV margins in the x-, y-, and z-directions were expanded by 5.56, 8.57, and 7.02 mm, respectively, in the PF group, and by 5.62, 9.27, and 7.23 mm, respectively, in the VB group. The proportion of patients with 3D displacement vectors larger than 5 mm was 40% in the PF group and 45% in the VB group. Conclusions For patients undergoing radiotherapy for lung cancer, personalized polyurethane foam with wing boards can, to a certain extent, reduce the setup error in the superior-inferior direction and PTV margin expansion.
		2018 Vol. 27 (3): 299-302 [Abstract] ( 1252 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	303	Quantitative analysis of γ-H2AX foci formation and dynamic changes in DNA double-strand breaks induced by X-ray radiation
		Dong Jun, Wang Chengtao, Zhang Chun, Ren Yufeng, Zhang Tian, Ooyang Bin, Wang Zhenyu, Gloria C. Li, Fuqiu He, Wen Bixiu
		Objective To quantitatively compare the γ-H2AX foci formation between DNA-PKcs^+/+ and DNA-PKcs^-/-mouse embryonic fibroblast (MEF) cells, and to investigate the dynamic changes in DNA double-strand breaks (DSBs) in human nasopharyngeal carcinoma SUNE-1 cells exposed to X-ray radiation. Methods The expression of DNA-PKcs was determined by Western blot. The γ-H2AX foci formation induced by 5 Gy X-ray radiation was detected by cell immunofluorescence. The ImageJ software was used to quantitatively analyze the γ-H2AX foci formation. Results The expression of DNA-PKcs was silenced in DNA-PKcs^-/-MEF cells and normal in DNA-PKcs^+/+ MEF cells. According to the dynamic analyses of the numbers of γ-H2AX foci/cell and γ-H2AX foci/mm², a similar tendency was observed in DSB formation in DNA-PKcs^+/+ MEF cells, DNA-PKcs^-/-MEF cells, and SUNE-1 cells exposed to X-ray radiation. A large number of γ-H2AX foci formed at 0.5-1.0 h after radiation. DSBs were repaired at 6 h after radiation in DNA-PKcs^+/+ MEF cells and 24 h after radiation in DNA-PKcs^-/-MEF cells and SUNE-1 cells. The peak values of γ-H2AX foci/cell and γ-H2AX foci/mm² were observed at 1.0 and 0.5 h after radiation, respectively. Compared with DNA-PKcs^+/+ MEF cells, DNA-PKcs^-/-MEF cells had different numbers of γ-H2AX foci/cell at 0.5, 1.0, 3.0, 6.0, and 12.0 h after radiation, as well as different numbers of γ-H2AX foci/mm² at 3.0, 6.0, and 12.0 h after radiation. Conclusions Quantitative measurement of the number of γ-H2AX foci/cell or γ-H2AX foci/mm² by cell immunofluorescence provides new insights into the quantitative and dynamic study of DSB damage and repair.
		2018 Vol. 27 (3): 303-308 [Abstract] ( 614 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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		2018 Vol. 27 (3): 309-311 [Abstract] ( 719 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Review Articles

	312	Research progress in replanning during intensity-modulated radiotherapy for nasopharyngeal carcinoma
		Shen Qun, Luo Li, Liu Feng, Xi Xuping
		Intensity-modulated radiotherapy (IMRT) is the first-line treatment for nasopharyngeal carcinoma currently. Previous studies have shown that regression of primary tumor and metastatic lymph nodes or a decrease in body weight causes the contour of normal organs and head-and-neck to shrink during the course of radiotherapy, which may lead to underdose in primary tumor and overdose in organs at risk (OARs) and then adversely affect treatment outcomes. Replanning during the course of radiotherapy can maintain the dose to target volume and reduce the exposure of OARs, which improves outcomes in some patients. For replanning during the course of IMRT, however, the advantages have not been widely recognized and there is still a long way to go before widely accepted timing and frequency of replanning are set up. Further studies are needed to figure out how to identify patients appropriate for plan modification.
		2018 Vol. 27 (3): 312-315 [Abstract] ( 997 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	316	Radiotherapy progress in elderly patients with unresectable esophageal carcinoma
		Yang Xu, Liang Jun
		As the fourth leading cause of cancer death for years,esophageal carcinoma yields a high morbidity in China. In an aging society,the quantity of elderly patients with esophageal carcinoma is ever increasing. However,elderly patients have been excluded in most studies due to more comorbidities,lower performance status grade,worse therapeutic tolerance and other clinical features. Although clinical prognosis of esophageal carcinoma patients has been improved in the past decades, the clinical efficacy in the treatment of esophageal carcinoma in elderly patients is still unsatisfactory. Current options should be combined with novel therapeutic srategies to enhance the clinical efficacy. In this article, the clinical efficacy and adverse events of radiotherapy, radiochemotherapy, targeted therapy or immunotherapy in treating elderly patients with unresectable esophageal carcinoma were retrospectively analyzed.
		2018 Vol. 27 (3): 316-322 [Abstract] ( 906 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	323	Prognostic analysis of extended field intensity-modulated radiation therapy for cervical cancer
		Zhang Feng, Du Xiaomeng, Huang Manni
		In recent decades,accurate radiotherapy has developed rapidly,and the application of intensity-modulated radiation therapy (IMRT) in gynecologic malignancies has increased gradually in the past ten years. Many studies have shown a high rate of occult abdominal aortic lymph node metastasis in patients with advanced cervical cancer,while pelvic and abdominal aortic lymph node status are important prognostic factors in cervical cancer patients. Conventional prophylactic extended field radiotherapy has the characteristics of severe gastrointestinal side effects,and synchronic chemotherapy is also controversial. The optimal dose of radiation therapy for metastatic pelvic and abdominal aortic lymph nodes is still controversial. This paper mainly analyzed the effect of prophylactic extended conformal radiotherapy with concurrent chemotherapy on the prognosis of cervical cancer and the dose-effect relationship of lymph node positive region.
		2018 Vol. 27 (3): 323-326 [Abstract] ( 914 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	327	Research progress on radiomics reproducibility
		Qiu Qingtao, Duan Jinghao, Gong Guanzhong, Yin Yong
		Radiomics has played an irreplaceable role along with the development of precision medicine. In the field of radiomics researches, the stability of imaging features is of vital significance, which is directly linked to the modeling analysis. In this review, we summarized the recent research progress on the reproducibility problems in four crucial steps of the standard workflow of radiomics including imaging acquisition and reconstruction, region of interest (ROI) segmentation, imaging feature extraction and modeling establishment. In addition, the commonly used software related to radiomics was briefly introduced.
		2018 Vol. 27 (3): 327-330 [Abstract] ( 860 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Symposium

	331	Cutaneous adverse events caused byimmune checkpoint inhibitors:classification and management
		Nie Fangfang, Fu Jie
		Immune checkpoint inhibitors (ICPIs) have been successfully used in the treatment of multiple malignancies. However, immune-related adverse events (irAEs) may occur during treatment. Cutaneous adverse event (CAE) is acommon type of irAE. Mild CAEs include maculopapule,lichenoid reaction,bullous pemphigoid,vitiligo,psoriasis, and scleroderma. Severe and even life-threatening CAEs include Steven-Johnson syndromeand toxic epidermal necrolysis. Other CAEs include drug reactionwith eosinophiliaand systemic symptoms,Sweet′s syndrome,alopecia,Grover′s disease, and paraneoplastic syndrome. This paper reviews the treatment of cutaneous adverse events associated with ICPIs.
		2018 Vol. 27 (3): 331-334 [Abstract] ( 790 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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