Chinese Journal of Radiation Oncology

中华放射肿瘤学杂志

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Chinese Journal of Radiation Oncology

	2019 Vol.28 Issue.4 Published 2019-04-15

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

	241


		2019 Vol. 28 (4): 241-241 [Abstract] ( 283 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Consensus

	242	Consensus on the integrated application of domestic radiotherapy equipment——homogenized IMRT of nasopharyngeal carcinoma:radiotherapy

		Intensity-modulated radiotherapy (IMRT) is the standard radiotherapy technique for nasopharyngeal carcinoma. In recent years,domestic radiotherapy equipment has been gradually recognized in the market,and widely applied in the hospitals at all levels. Radiotherapy technique heavily relies on the combination of modern equipment and multi-disciplinary professionals. Based on the present gaps in the performance between domestic and imported radiotherapy equipment,we drafted this consensus in accordance with the national relevant laws and regulations after referring to relevant guidelines,consensus and professional books at home and abroad,aiming to standardize the basic equipment and technical requirements for the integrated application of domestic radiotherapy equipment in the positioning and planning design of IMRT for nasopharyngeal carcinoma and define the process of diagnosis and treatment,thereby achieving the homogenization of IMRT for nasopharyngeal carcinoma between primary and Grade Ⅲ Level A hospitals and improving clinical benefits for patients.
		2019 Vol. 28 (4): 242-249 [Abstract] ( 569 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Special Feature

	250	Clinical Interpretation of ICRU report No.89—— Target Contouring for Adaptive Brachytherapy of Cervical Cancer
		Cheng Guanghui,Shi Dan
		Brachytherapy plays a key role in the radical radiotherapy of cervical cancer. The time concept was introduced in the 3D brachytherapy according to ICRU report No.89 for cervical cancer treatment.4D brachtherapy, as an adaptive brachytherapy, was formally proposed in this report. In this article, relevant data were searched based on ICRU report No.89 combined with the experience in our center to analyze, summarize and conclude the chapters related to target contouring, aiming to provide evidence for the colleagues who perform the brachytherapy in patients with cervical cancer.
		2019 Vol. 28 (4): 250-257 [Abstract] ( 606 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Head and Neck Tumors

	258	Analysis of clinical efficacy and safety of local radiotherapy in children with stage Ⅳ high-risk neuroblastoma
		Zhou Yuchen,Su Yan,Jiang Chiyi,Cai Siyu,Jin Mei,Zhang Dawei,Zhang Fuquan,Ma Xiaoli
		Objective To retrospectively analyze the clinical efficacy, safety and influencing factors of radiotherapy in children with stage Ⅳ high-risk neuroblastoma (HR-NB). Methods A total of 120 children with HR-NB who were diagnosed and treated with local radiotherapy according to the BCH-HR-NB-2007 protocol in the Oncology Department of Beijing Children's Hospital from January 2014 to December 2017 were enrolled. Among them, 56 children were male and 64 female with a median age of 43 months (9-148 months). The treatment protocol consisted of 4 cycles of CAV chemotherapy, 3 cycles of CVP chemotherapy, surgical resection after 4 cycles, autologous hematopoietic stem cell transplantation after 7 cycles, local radiotherapy at a dose of 15.0-30.6 Gy for 82 cases of primary tumors and 38 cases of primary and metastatic tumors, followed by 13 cis-retinoic acid as maintenance therapy. The entire treatment protocol endured for approximately 18 months. Results The median follow-up time was 21 months. The 3-year local control rate was 84.4%. Before radiotherapy, the 3-year event-free survival rate was 78.4% in children without metastases, significantly higher compared with 30.4% in the residual group (P=0.003). The 3-year event-free survival rate was 66.1% in patients who underwent radiotherapy within 6 months after surgery, significantly higher than 50.6% in their counterparts receiving radiotherapy at 6 months or more after surgery (P=0.018). Among the children with residual metastases before radiotherapy, the progression rate in children who did not receive radiotherapy was 66.6%, significantly higher compared with 20.0% in those receiving radiotherapy (P=0.001). All patients had no radiation-related adverse reactions in the liver, kidney and heart, etc. The incidence rate of grade Ⅲ-IV myelosupression was 24.5% at 1 week post-radiotherapy, and 8% at 2 weeks after radiotherapy. Conclusions Radiotherapy yields definite clinical efficacy in the local control of children with stage Ⅳ HR-NB. Early radiotherapy after surgery and radiotherapy for the metastatic lesions can improve the clinical prognosis. No vital organ injuries are observed during the short-term follow-up. At 2 weeks after radiotherapy, the myelosupression is gradually restored.
		2019 Vol. 28 (4): 258-261 [Abstract] ( 472 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Thoracic Tumors

	262	The influence of concurrent chemoradiotherapy on survival for patients of different ages with stage Ⅳnon-small cell lung cancer——reanalysis of two prospective studies
		Fu Weixu,Ouyang Weiwei,Su Shengfa,Ma Zhu,Li Qingsong,Geng Yichao,Luo Daxian,Yang Wengang,Hu Yinxiang,Li Huiqin,He Zhixu,Lu Bing
		Objective To analyze the survival and toxicity after concurrent chemoradiotherapy in patients of different ages with stage Ⅳ non-small cell lung cancer (NSCLC). Methods Clinical data of 282 NSCLC patients in two prospective studies were retrospectively analyzed,who completed the protocol (at least 2 cycles of chemotherapy and thoracic radiation doses of ≥36 Gy).Among them,44 patients were assigned into in the young group (≤ 45 years old),161 patients in the middle-age group (46-64 years old) and 77 patients in the elderly group (≥ 65 years old).The clinical characteristics of patients among different groups were analyzed by χ² test. The overall survival (OS) was calculated by Kaplan-Meier method. Stratified analysis was performed by Log-rank test. Multi-factor prognosis analysis was conducted by Cox’s proportional hazards regression model. Results The incidence of NSCLC in the male patients in the elderly group was higher than that in the middle-age and young groups. The 1-,2-,3-and 5-year OS did not significantly differ among different groups (P=0.810).The OS did not significantly differ among patients of the same gender,pathological type,T stage,N stage,metastasis status,same chemotherapy cycle,primary tumor dose and comprehensive treatment and short-term response (all P>0.05).The incidence of adverse events did not considerably differ among different groups. Multivariate analysis demonstrated that age was not an independent factor for survival (P>0.05). Conclusion Patients of different ages with stage Ⅳ NSCLC obtain similar survival benefits and adverse events after concurrent chemoradiotherapy.
		2019 Vol. 28 (4): 262-267 [Abstract] ( 398 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	268	Prognostic factors in patients with stage Ⅳ small cell lung cancer:A nomogram prediction model based on different doses of thoracic radiotherapy
		Xu LiMing,Yuan Yajing,Luo Jing,Pang Qingsong,Wang Jun,Yuan Zhiyong,Zhao Lujun,Wang Ping
		Objective To evaluate the effect of different doses of thoracic radiotherapy (TRT) upon the clinical prognosis of patients with extensive-stage (stage Ⅳ) small cell lung cancer (ES-SCLC) and establish a Nomogram prediction model. Methods Clinical data of 144 patients pathologically diagnosed with ES-SCLC undergoing TRT in Tianjin Medical University Cancer Hospital from month,2010 to month,2016 were retrospectively analyzed. Clinical characteristics,treatment data and responses were evaluated. A Nomogram was established by using Cox’s proportional hazard regression model to predict the overall survival (OS).The prediction capability and accuracy were assessed by the concordance index (C-index) and a calibration curve between the model and verification groups. Results The median follow-up time was 31.9 months. The 2-year OS rate was 20.3%.The Nomogram model demonstrated that TRT dose,liver metastases,oligometastases/polymetastases,number of chemotherapy cycle and response to chemotherapy were significantly correlated with clinical prognosis. The calibration curve revealed that the predicted and actual OS were highly consistent. The C-index was calculated as 0.701.In the subgroup analyses,patients with high-dose TRT obtained significantly better OS than their counterparts with low-dose TRT. Conclusion The Nomogram prediction model based on different TRT doses can accurately predict the OS rate of ES-SCLC patients,which is an individualized model for predicting the survival probability.
		2019 Vol. 28 (4): 268-273 [Abstract] ( 463 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	274	Correlation between treatment-related lymphopenia and pathologic response in esophageal squamous cell carcinoma patients undergoing neoadjuvant chemoradiotherapy
		Wang Xiushen,Zhang Xixi,Xi Mian,Bo Shanshan
		Objective To investigate the relationship between treatment-related lymphopenia and pathologic complete response (pCR) to neoadjuvant chemoradiotherapy (CRT) in patients with esophageal squamous cell carcinoma (ESCC). Methods Clinical data of 220 ESCC patients treated with neoadjuvant CRT followed by surgery between 2002 and 2016 were retrospectively analyzed. Absolute lymphocyte count was determined before and at 1 month after neoadjuvant CRT. Treatment-related lymphopenia was graded using Common Terminology Criteria for Adverse Events (CTCAE, 4.0 version). The relationship between lymphopenia, pCR and recurrence was evaluated by chi-square test and Cox’s regression model. Results Ninety-five patients (43.2%) achieved a pCR after neoadjuvant CRT and 71 cases (32.3%) recurred postoperatively. During neoadjuvant CRT, the incidence rates of grade 0,1,2,3,and 4 lymphopenia were 1.8%,6.8%,31.4%,38.2%,and 21.8%,respectively. Patients with grade 4 lymphopenia had a significantly lower pCR rate than those with grade 0-3 lymphopenia (22.9% vs.48.8%,P=0.001). Moreover, grade 4 lymphopenia was significantly associated with a higher risk of recurrence (45.8% vs.28.5%,P=0.023). Multivariate analysis identified that primary tumor length, tumor location and radiation dose were the independent predictors for grade 4 lymphopenia during neoadjuvant CRT (P=0.013,0.001,0.002). Conclusions The incidence of grade 4 lymphopenia in ESCC patients undergoing neoadjuvant CRT is correlated with a low pCR rate and a high risk of recurrence. Lymphopenia can be used as an economic and effective predictor for pCR.
		2019 Vol. 28 (4): 274-279 [Abstract] ( 404 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Abdominal Tumors

	280	Delay in initiating postmastectomy radiotherapy is associated with inferiorsurvival outcomes for locally advanced breast cancer patients treated with neoadjuvant chemotherapy and mastectomy
		Huang Zhou, Wang Shulian,Tang Yu,Rong Qinglin,Zhu Li,Shi Mei,Huang Xiaobo,Shen Liangfang,Cheng Jing,Zhang Jun,Chen Jiayi,Wu Hongfen,Liu Min,Ma Changying,Li Yexiong
		Objective To evaluate the effect of surgery-radiotherapy interval (SRI) on clinical prognosis of locally advanced stage cⅡ-Ⅲ breast cancer patients treated with neoadjuvant chemtherapy and modified radical mastectomy. Methods Clinical data of 1087 breast cancer patients treated with neoadjuvant chemotherapy and modified radical mastectomy from 11 hospitals in China were retrospectively analyzed. The optimal threshold value of SRI upon clinical prognosis was determined by maxstat method. The effect of SRI on clinical prognosis was evaluated by using multivariate Cox regression analysis and propensity score matching (PSM). Results The median follow-up time was 72.9 months. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 68.1% and 81.8%. All patients were divided into SRI≤18 weeks (n=917) and SRI>18 weeks groups (n=170). Multivariate Cox regression analysis demonstrated that hormone receptor status (P<0.001), pathological T stage (P<0.001), pathological N stage (P<0.001) and SRI (P=0.023) were independent influencing factors of DFS. Hormone receptor status (P=0.013), pathological T stage (P=0.006), pathological N stage (P<0.001), endocrine therapy (P=0.013) and SRI (P=0.001) were significantly associated with OS. After balancing the clinical and pathological factors with PSM, patients with SRI< 18 weeks had superior DFS and OS to those with SRI> 18 weeks. Conclusions SRI affects the clinical prognosis of locally advanced breast cancer patients treated with neoadjuvant chemotherapy and modified radical mastectomy. Radiotherapy should be performed within 18 weeks after mastectomy.
		2019 Vol. 28 (4): 280-285 [Abstract] ( 523 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	286	Superiority of breast-conserving surgery plus radiotherapy versus modified mastectomy in patients with stage Ⅰ breast cancer:a propensity score-matching analysis
		Wang Jianyang,Wang Shulian,Song Yongwen,Tang Yu,Jing Hao,Sun Guangyi,Jin Jing,Liu Yueping,Wang Weihu,Fang Hui, Chen Bo,Qi Shunan,Li Ning,Tang Yuan,Lu Ningning,Yu Zihao,Li Yexiong
		Objective To compare the clinical efficacy between breast-conserving surgery (BCS) plus radiotherapy (RT) and modified mastectomy in patients with stage Ⅰ breast cancer in clinical setting. Methods　Clinical data of 6137 patients diagnosed with pT1-2N0 breast cancer from 1999 to 2014 were retrospectively reviewed. Among them, 1296 patients received BCS plus RT (BCS group) and 4841 cases underwent modified mastectomy alone (modified mastectomy group). Kaplan-Meier analysis was used for survival analysis. Log-rank test, single factor analysis and Cox’s proportional hazards regression model were performed. The results were further confirmed with the propensity score-matching (PSM) method.Results Within a median follow-up period of 55.2 months (range,1-222 months),the 5-year locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS),disease-free survival (DFS) and overall survival (OS) were 96.3%, 93.7%, 91.9% and 96.9%, respectively. In the BCS plus RT group, the 5-year DMFS (96.9% vs. 92.9%, P<0.001),DFS (94.9% vs. 91.2%, P=0.005) and OS (99.1% vs. 96.4%,P=0.001) were significantly higher than those in the mastectomy group.Multivariate analysis revealed that postoperative RT was an influencing factor of DMFS (P=0.003,HR=0.621;95%CI:0.455–0.849) and OS (P=0.036;HR=0.623;95%CI:0.401–0.969). For 1252 pairs of patients matched by PSM, the 5-year OS (99.1% vs. 96.1%,P=0.001), DMFS (97.0% vs. 92.2%,P<0.001) and DFS (95.3% vs. 90.2%,P=0.001) in the BCS plus RT group were significantly higher compared with those in the mastectomy group. Conclusion The long-term clinical prognosis of patients with stage Ⅰ breast cancer in the BCS plus RT group is better than that in the mastectomy group. BCS plus RT should be recommended for patients with stage Ⅰ breast cancer.
		2019 Vol. 28 (4): 286-291 [Abstract] ( 456 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Physics·Biology·Technique

	292	Evaluation of the auto-segmentation based on self-registration and Atlas in adaptive radiotherapy for cervical cancer
		Zheng Qingzeng,Wang Yunlai,Zhang Jianchun,Wang Jinyuan,Zhang Huijuan,Yang Guang,Gao Bin,Ju Zhongjian
		Objective To evaluate the accuracy and validate the feasibility of auto-segmentation based on self-registration and Atlas in adaptive radiotherapy for cervical cancer using MIM-Maestro software. Methods The CT scan images and delineation results of 60 cervical cancer patients were obtained to establish the Atlas template database. The planning CT (pCT) and replanning CT (rCT) images were randomly selected from 15 patients for the contouring of clinical target volume (CTV) and organs at risk (OAR) by an experienced radiation oncologist. The rCT images of 15 patients were auto-contoured using Atlas-based auto-segmentation (Atlas group),and mapping contours from the pCT to the rCT images was performed by rigid and deformable image registration (rigid group and deformable group).The time for the three methods of auto-segmentation was also recorded. The similarity of the auto-contours and reference contours was assessed using dice similarity coefficient (DSC),overlap index (OI),the average hausdorff distance (AHD) and the deviation of centroid (DC),and the results were statistically compared among three groups by using one-way analysis of variance. Results The mean time was 89.2 s,22.4 s and 42.6 s in the Atlas, rigid and deformable groups respectively. The DSC, OI and AHD for the CTV and rectum in the rigid and deformable groups significantly differed from those in the Atlas group (all P<0.001). In the rigid and deformable groups, the OI for the intestine significantly differed from that in the Atlas group. The mean DSC for CTV was 0.89 in the rigid and deformable groups, and 0.76 in the Atlas group. The optimal delineation of the bladder, pelvis and femoral heads was obtained in the deformable group. Conclusions All three methods of auto-segmentation can automatically and rapidly contour the CTV and OARs. The performance in the deformable group is better than that in the rigid and Atlas groups.
		2019 Vol. 28 (4): 292-296 [Abstract] ( 446 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	297	Research of obtaining pseudo-CT images based on ultrasound deformation fields in radiotherapy
		Sun Hongfei,Guo Chang,Lin Tao,Gao Liugang,Sui Jianfeng,Xie Kai,Ni Xinye,He Xia
		Objective An improved method for obtaining pseudo-computed tomography (CTps) based on ultrasound deformation field. Methods The three-dimensional image data of computed tomography and ultrasound for three postoperative cervical cancer patients were selected,including the CT (CTsim) and ultrasound (USsim) images obtained during the simulated positioning stage,and the cone beam CT (CBCT) and ultrasound images obtained during the positioning verification stage of the treatment one week later. Binary masks of the OROI and OROW were created and applied in ultrasound image registration;thus,the deformation field was obtained. The deformation field was applied to CTsim images and different pseudo-CT images were obtained. Similarities between these pseudo-CT images and those of CBCT were compared,and registration accuracies between pseudo-CT images under different binary masks and CTsim were discussed. Results The averages of the correlation coefficient between pseudo-CT based on OROI,OROW,no binary mask and CBCT were 0.95,0.82 and 0.64 respectively. The average of the normalized mean square Error were 0.12,0.42 and 0.57 respectively. Conclusion The pseudo-CT based on OROI binary mask matches the best with CTsim and achieves the highest similarity with CBCT.
		2019 Vol. 28 (4): 297-301 [Abstract] ( 399 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	302	*Radiosensitization and micro CT imaging of multifunctional gold nanoparticles in lung adenocarcinoma A549 cell:an in vivo* animal study**
		Yang Chuan,Zhang Guojun,Huang Jianming,Lyu Jiahua,Qin Sheng,Li Tao
		Objective To evaluate the radiosensitization effect and micro CT imaging of multifunctional gold nanoparticles in lung adenocarcinoma A549 tumor-bearing mouse models. Methods The tumor-bearing mice were injected with gold nanoparticles and irradiated with different energy levels of 160 kV and 6 MV X-ray. The tumor volume changes were measured. Intra-tumoral injection of gold nanoparticles was administered and micro CT scan was performed at different time points to observe the imaging and retention time of gold nanoparticles in the tumor tissues. Results The tumor volume did not significantly differ between the control and gold nanoparticles groups (P=0.941). The tumor volume in the 6 MV X-ray combined with gold nanoparticles group was slightly reduced compared with that in the 6 MV X-ray group with no statistical significance (P=0.730).The tumor volume in the 160 kV X-ray combined with gold nanoparticles group was significantly smaller than that in the 160 kV X-ray group (P=0.026).Micro CT scan demonstrated that gold nanoparticles could be deposited in the tumors for 30 d and yielded excellent imaging effect. No gold nanoparticles-induced toxicity was observed. Conclusions Multifunctional gold nanoparticles exert significant radiosensitization effect in the lung adenocarcinoma A549 transplanted tumors irradiated with 160 kV X-ray. Stable CT imaging of the gold nanoparticles-injected tumors can be used as a potential method for mapping and delineating the target area in tumor-guided radiotherapy.
		2019 Vol. 28 (4): 302-308 [Abstract] ( 478 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Review Articles

	309	Research progress on application of machine learning in quality assurance of intensity-modulated radiotherapy
		Li Jiaqi,Zhang Shuming,Wang Hao,Zhang Xile,Li Jun,Shi Chengyu,Sui Jing,Yang Ruijie
		In recent years, the application of machine learning in the field of radiotherapy has been gradually increased along with the development of big data and artificial intelligence technology. Through the training of previous plans, machine learning can predict the results of plan quality and dose verification. It can also predict the multi-leaf collimator (MLC) positioning error and linear accelerator performance. In addition, machine learning can be applied in the quality assurance of intensity-modulated radiotherapy to improve the quality and efficiency of treatment plan and implementation, increase the benefits to the patients and reduce the risk. However, there are many problems, such as difficulty in the selection, extraction and calculation of characteristic value, requirement for large training sample size and insufficient prediction accuracy, which impede its clinical translation and application. In this article, research progress on the application of machine learning in the quality assurance of IMRT was reviewed.
		2019 Vol. 28 (4): 309-313 [Abstract] ( 608 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	314	Research progress on prediction of early response to chemoradiotherapy of esophageal cancer by multimodal imaging and radiomics
		Liao Ye,Zhao Lina,Shi Mei
		Conventional imaging techniques and gastrointestinal endoscopy cannot accurately predict the early clinical efficacy of chemoradiotherapy in the treatment of esophageal cancer, whereas the functional imaging of PET-CT,MRI-DWI and radiomics can reflect the functional metabolism of the tumors prior to the morphological changes, which can compensate for the limitations of conventional diagnostic methods. In this article, the current application of imaging techniques in predicting the early response of chemoradiotherapy for esophageal cancer was reviewed.
		2019 Vol. 28 (4): 314-316 [Abstract] ( 546 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	317	The progress on the delineation of target volume in postoperative intensity-modulated radiotherapy for glioblastoma
		Lin Lin, Zhou Juying
		The standard treatments of glioblastoma include surgery, postoperative radiotherapy and concurrent and adjuvant temozolomide-based chemotherapy. Radiotherapy is directly related to the overall survival rate. Nevertheless, the standard delineation of target volume during radiotherapy remains controversial. In this article, different standpoints upon the range of delineation of tumor volume were analyzed and the recurrence pattern of glioblastoma after radiotherapy was summarized. Besides, the technical causes of the failure to accurately delineate the tumor outline were identified. It is of significance to deliver individualized delineation of target volume by referring to the clinical and pathological characteristics of each patient. Finally, the application prospect of radiotherapy in the treatment of glioblastoma was discussed in this article, aiming to enhance the accuracy of target volume delineation during radiotherapy and maximize the clinical benefits to the patients.
		2019 Vol. 28 (4): 317-320 [Abstract] ( 384 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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