Chinese Journal of Radiation Oncology

中华放射肿瘤学杂志

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Chinese Journal of Radiation Oncology

	2020 Vol.29 Issue.9 Published 2020-09-15

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

Guidelines

	705	Quality control and quality assurance of afterloading equipment
		National Cancer Center/ National Cancer Quality Control Center
		Compared with external beam radiotherapy, afterloading radiotherapy has its unique dose advantage and plays an irreplaceable role in radiotherapy. At present, the number of hospitals and institutions carrying out afterloading radiotherapy is ever increasing in China, whereas the quality control and quality assurance of afterloading equipment are still at a low level. A comprehensive and easy-to-use guiding document is urgently required to meet the current precision requirement of afterloading radiotherapy. During the drafting of this guideline, relevant domestic and foreign literatures were referenced and the actual clinical situation was considered. The content of this guideline not only includes the quality control and quality assurance requirements of afterloading equipment, but also lists specific testing procedures for each requirement, which provides practical reference for large-scale hospitals implementing afterloading radiotherapy. This guideline plays a critical role in standardizing the development and improving the therapuetic outcome of afterloading radiotherapy.
		2020 Vol. 29 (9): 705-711 [Abstract] ( 186 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Consensus

	712	Chinese expert consensus on three-dimensional image guided brachytherapy for cervical cancer
		The Brachytherapy Group of China Society for Radiation Oncology, The Gynecological Oncology Group of Chinese Association for Therapeutic Radiation Oncologists, The Brachytherapy Special Committee of Chinese Anti-Cancer Association
		In recent years, image-guided brachytherapy (IGBT) for cervical cancer has been rapidly developed in China. IGBT can improve local control and survival rates in patients with locally advanced cervical cancer compared with the two-dimensional technology. Dose volume histogram parameters for the high risk clinical target volume (HR-CTV), intermediate risk clinical target volume (IR-CTV) and organs at risk should be calculated, reported, and adopted to explore the relationship with local control rate and incidence of complications. The volume and topography of residual tumor at the initiation of IGBT is significantly correlated with local control rate. The residual tumor should be assessed by the combination of MRI, ultrasound images and gynecological examinations. The appropriate implant with intracavitary applicator supplemented with interstitial needles can improve the dose distribution in the target area. Target delineation, dose assessment and quality control should be conducted strictly according to the principles and consensus. To standardize its application, the Chinese expert consensus was jointly formulated by Brachytherapy Group of China Society for Radiation Oncology, the Gynecological Oncology Group of Chinese Association for Therapeutic Radiation Oncologists, and the Brachytherapy Special Committee of Chinese Anti-Cancer Association in light of the national conditions in China.
		2020 Vol. 29 (9): 712-717 [Abstract] ( 224 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	718	Chinese expert consensus on standardized application of two-dimensional brachytherapy for cervical cancer
		Brachytherapy Group of China Society for Radiation Oncology, Gynecological Oncology Group of Chinese Association for Therapeutic Radiation Oncologists, Brachytherapy Special Committee of Chinese Anti-Cancer Association
		Brachytherapy is an essential part of radical radiotherapy for cervical cancer. At present, two-dimensional brachytherapy is the most frequently adopted approach in China. To standardize the application and implementation of two-dimensional brachytherapy for cervical cancer, the expert consensus was jointly formulated by Brachytherapy Group of China Society for Radiation Oncology (CSTRO), Gynecological Oncology Group of Chinese Association for Therapeutic Radiation Oncologists (CATRO) and Brachytherapy Special Committee of Chinese Anti-Cancer Association (CACA).
		2020 Vol. 29 (9): 718-720 [Abstract] ( 153 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	721	Expert consensus on brachytherapy for recurrent cervical cancer
		Jiang Ping, Zhang Fuquan, Cheng Guanghui, Wang Ruoyu, Sun Baosheng, Wang Tiejun, Zhang Yunyan, Qu Ang, Wang Junjie
		The main treatment options for cervical cancer include surgery and/or radiotherapy combined with chemotherapy. Radiotherapy consists of external beam radiotherapy and brachytherapy (BT). BT contains high-dose-rate (HDR-BT) and low-dose-rate brachytherapy (LDR-BT). The prognosis of cervical cancer is relatively good. However, some patients experience substantial treatment failures, such as intra-pelvic and/or extra-pelvic recurrences. Recurrent cervical cancer (RCC) has poor prognosis due to lack of effective and safe approach. In 2002, Professor Wang Junjie introduced CT-guidance into the field of LDR-BT, and fully applied 3D printing technology in BT in 2015, which met the requirement of preoperative LDR-BT planning, and significantly improving the precision, quality and efficiency of BT. In 2018, Professor Wang Junjie proposed the concept of stereotactic ablation brachytherapy (SABT). Chinese experts have attempted to treat RCC with BT for nearly two decades and accumulated certain clinical experience. Based on the 3D-printing template (3D-PT) assisted CT-guidance, the standard and consensus of BT for RCC were established, including the indications, dosimetric requirements, technological procedures and radiation protection, etc. At present, there is still a lack of phage Ⅲ clinical and evidence-based medicine for the treatment of RCC with 3D-PT guidance, which requires prospective multi-center, randomized studies to improve the evidence-based level of BT.
		2020 Vol. 29 (9): 721-729 [Abstract] ( 208 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Special Feature

	730	Recommendation of radiotherapy for gynecological cancer during the COVID-19 epidemic
		Yan Junfang, Hu Ke, Hou Xiaorong, Li Gaofeng, Jiang Ping, Zhang Fuquan
		With the outbreak of COVID-19 around the globe, the epidemic prevention and control in China will take a long-term trend. As the main treatment of gynecological malignant tumor, rational application of radiotherapy bring patients with both “epidemic prevention” and “anti-tumor” benefits. This recommendation combined the domestic epidemic prevention guidelines, foreign literature related to epidemic prevention and gynecological tumor treatment, and the experiences of Peking Union Medical College Hospital during the prophase of epidemic period, aiming to provide guidance for the clinical work for radiotherapy and gynecological departments during COVID-19 crisis from the perspectives of gynecological radiotherapy principles, clinical trials, MDT and academic activities.
		2020 Vol. 29 (9): 730-733 [Abstract] ( 203 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Investigation Research

	734	An investigation report of radiotherapy centers in Beijing during the COVID-19 pandemic
		Radiation Oncology Therapeutics Branch of Beijing Medical Association, Society of Radiotherapy Specialists (Technicians) of Beijing Medical Doctors Association, Sun Xiansong, Hu Ke, Zhang Fuquan, Li Gaofeng
		Objective An investigation on the prevention and control measures taken by radiotherapy centers of various hospitals in Beijing during the COVID-19 pandemic was conducted. The experience was summarized to provide reference for further work. Methods Electronic questionnaires were distributed to each radiotherapy center through members of the radiation oncology therapeutics branch of Beijing medical association and members of Society of Radiotherapy Specialists (Technicians) of Beijing Medical Doctors Association. Statistical analysis was performed based on the feedback results of electronic questionnaires. Results All forty radiotherapy centers in Beijing returned the questionnaires by the end of April 10, 2020. Except for the suspension of treatment in one center due to COVID-19 pandemic, all radiotherapy centers have taken corresponding prevention and control measures and continued to carry out radiotherapy. No COVID-19 infection of patients or medical staffs occurred during this pandemic. Conclusions During the COVID-19 pandemic, all radiotherapy centers attach great importance to optimizing the clinical process and adopt reasonable prevention and control measures. On the basis of efficient prevention and control measures, radiotherapy is delivered to fulfill the treatment demands of cancer patients.
		2020 Vol. 29 (9): 734-738 [Abstract] ( 214 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Head and Neck Tumors

	739	Early screening of high-risk patients with radiation-induced hypothyroidism in nasopharyngeal carcinoma by hematological examination
		Zhou Ling, Zhu Chaonan, Chen Jia, Huang Shuang, Tao Changjuan, Shen Wei, Chen Ming, Yu Zhonghua, Chen Yuanyuan
		Objective To analyze the relationship between hematological examination combined with clinical factors and radiation-induced hypothyroidism (HT) in patients with nasopharyngeal carcinoma (NPC). Methods Clinical data of 206 patients with NPC who received radiotherapy in Cancer Hospital of University of Chinese Academy of Sciences between January 2015 to August 2018 were retrospectively analyzed. The correlation between general clinical data, hematological examination and HT was analyzed to establish a hematological prediction model. Results Univariate analysis showed that sex, N-stage, thyroid volume, average dose, V20Gy, V25Gy, V30Gy, V35Gy, V40Gy, V45Gy, fibrinogen content, cholinesterase and neutrophil count were closely associated with the incidence of HT. Multivariate analysis showed that thyroid volume, fibrinogen content and cholinesterase were the independent predictors of HT. Conclusion The combination of sex, N-stage, thyroid volume, dose parameters, fibrinogen content, cholinesterase, neutrophil percentage and neutrophil count can predict the incidence of HT (AUC=0.777).
		2020 Vol. 29 (9): 739-743 [Abstract] ( 215 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	744	A phase Ⅱ trial of comprehensive treatment based on radiotherapy in leptomeningeal metastasis
		Yang Siran, Liu Qingfeng, Xiao Jianping, Zhang Hongmei, Bi Nan, Zhang Ye, Ma Yuchao, Wang Kai, Chen Xuesong, Zhao Ruizhi, Wu Xi, Li Junling, Yi Junlin, Wang Shulian, Li Yexiong
		Objective To evaluate the efficacy and safety of comprehensive treatment based on radiotherapy for patients with leptomeningeal metastases (LM) in this prospective study. Methods A total of 93 patients diagnosed with LM admitted to our hospital undergoing whole brain radiotherapy (WBRT) or craniospinal irradiation (CSI) with or without simultaneous boost from 2014 to 2017 were enrolled. The dynamic changes of clinical signs and symptoms, enhanced magnetic resonance imaging (MRI), cerebrospinal fluid cytology and liquid biopsy detection were recorded. The primary endpoint was overall survival (OS),the secondary endpoints were local control (LC), intracranial progress-free survival (IPFS), brain metastasis specific survival (BMSS) and toxicity. Results The major primary disease was non-small cell lung cancer. The whole cohort received WBRT with boost (40 Gy in 20 fractions (f) for WBRT and 60Gy in 20 f for boost), focal radiation to LM, WBRT and CSI (40 Gy in 20 f or 50Gy in 25 f for WBRT and 36 Gy in 20 f for CSI). For 20 patients, tumor cells were identified and intrathecal chemotherapy was performed. Sixty-three patients received target therapy. The median follow-up time was 33.8 months. The 1-year OS, LC and IPFS was 62.4%, 77.2% and 52.6%, respectively. The median survival time was 15.9 months, and the median BMSS was 42.2 months.Treatment-related grade 3–4 adverse events were rare and only 8 cases was observed to have grade 3 hematological toxicity. Conclusion Reasonable comprehensive treatment including precise radiotherapy, intrathecal chemotherapy and targeted therapy can be well tolerated and prolong the survival time of LM patients.
		2020 Vol. 29 (9): 744-750 [Abstract] ( 180 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Thoracic Tumors

	751	Effect of CD⁺₄ T cells and CD⁺₄/CD⁺₈ in peripheral blood on survival of patients with stage Ⅳ non-small cell lung cancer—Establishment of a Nomogram prediction model
		Wang Lixue, Wang Haojie, Ouyang Weiwei, Yang Wengang, Ma Zhu, Li Qingsong, Li Huiqin, Chen Xiaxia, Li Xiaoyang, Geng Yichao, Su Shengfa, Lu Bing
		Objective To explore the possibility of CD⁺₄ T cells and CD⁺₄/CD⁺₈ ratio in peripheral blood to predict the survival of patients with stage Ⅳ non-small cell lung cancer (NSCLC), and to establish a Nomogram prediction model. Methods The influence of CD⁺₄ T cells and CD⁺₄/CD⁺₈ ratio on the clinical factors and survival of 682 patients pathologically diagnosed with stage Ⅳ NSCLC with no history of cancer treatment was retrospectively analyzed and the Nomogram prediction model was established. Combined with the changes of immune cells levels in 110 patients after treatment, the prognostic and predictive values of CD⁺₄ T cells and CD⁺₄/CD⁺₈ ratio were verified. Countable data were analyzed by t-test. The survival rate was calculated by Kaplan-Meier method, log-rank test or univariate analysis. The multivariate analysis was performed by Cox regression model. Results Univariate analysis demonstrated that CD⁺₄> 43.15% before treatment significantly prolonged the survival. By multivariate analysis of Cox regression model, CD⁺₄>43.15% was an independent prognostic factor to prolong survival for stage Ⅳ NSCLC. The Nomogram model was established and verified that the predicted and actual overall survivals were highly consistent. Further analysis showed that 43.15% as the critical value of CD⁺₄T cell level significantly prolonged survival when CD⁺₄ expressed at a high-level before treatment, after treatment, before and after treatment, or combined with CD⁺₄/CD⁺₈>1.65. Conclusions The baseline level of CD⁺₄ T cells before treatment in peripheral blood is an independent prognostic factor for stage Ⅳ NSCLC. The CD⁺₄/CD⁺₈ ratio before treatment has limited value in predicting the prognosis.
		2020 Vol. 29 (9): 751-756 [Abstract] ( 176 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Abdominal Tumors

	757	Correlation between nutritional status and toxicity of concurrent chemoradiotherapy in patients with rectal cancer
		Fu Xiaowei, Teng Lihua, Shen Jinwen, Peng Qi, Zhang Na, Zhu Yuan, Xie Shuping
		Objective To analyze the correlation between nutritional status and acute toxicity induced by concurrent chemoradiotherapy in patients with rectal cancer. Methods A total of 115 patients with rectal cancer who underwent concurrent chemoradiotherapy in Zhejiang Cancer Hospital from March 2018 to August 2019 were prospectively selected. Nutritional risk was assessed by NRS 2002 and PG-SGA nutritional screening tools before, during and after radiotherapy. The acute toxicity was assessed by RTOG and CTCAE 3.0 scoring criteria. The correlation between nutritional status and the acute toxicity of chemoradiotherapy was analyzed by Spearman′s correlation analysis. Results The nutritional risk of the cohort was gradually increased from the beginning of chemoradiotherapy to the fourth week of chemoradiotherapy, and then decreased gradually. Spearman′s correlation analysis showed that NRS 2002 and PG-SGA scores were positively correlated with acute hematological toxicity (r=0.26, P<0.05;r=0.31, P<0.01), upper gastrointestinal toxicity (r=0.51, P<0.01;r=0.63, P<0.01), proctitis (r=0.23, P<0.05;r=0.45, P<0.01) and fatigue (r=0.47, P<0.01;r=0.64, P<0.01) in patients with rectal cancer undergoing chemoradiotherapy. The correlation coefficients between PG-SGA and various toxicities were higher than those of NRS 2002. Stratified analysis showed that patients with stage Ⅱ-Ⅲ B, age<65 years and postoperative adjuvant chemoradiotherapy, nutritional status was significantly associated with the severity of toxicity (all P<0.05). Conclusions Patients with rectal cancer has a high risk of malnutrition during concurrent chemoradiotherapy. The higher the risk of malnutrition, the greater the acute toxicity of chemoradiotherapy. Therefore, dynamic nutrition assessment and nutritional support should be strengthened for rectal cancer patients during chemoradiotherapy.
		2020 Vol. 29 (9): 757-761 [Abstract] ( 182 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	762	Clinical efficacy of concurrent chemoradiotherapy for cervical adenocarcinoma and salvage treatment of residual lesions
		Ma Jiabin, Hu Ke, Zhang Fuquan
		Objective To evaluate the clinical efficacy of concurrent chemoradiotherapy for cervical adenocarcinoma, and to analyze the treatment and evaluate the prognosis of patients with residual lesions after definitive radiotherapy. Methods Clinical data of 109 patients with locally advanced cervical adenocarcinoma treated from January 2005 to February 2016 were analyzed retrospectively. The prescription dose of external irradiation was 50.4Gy,28 fractions, and the point A dose of brachytherapy was 30-36Gy,5-7 fractions. Cisplatin or paclitaxel was used as concurrent chemotherapy regimen. Clinical efficacy was evaluated after concurrent chemoradiotherapy. Patients with clinical partial remission (PR) after treatment might receive salvage surgery and/or chemotherapy and/or radiotherapy. The survival analysis was performed with Kaplan Meier method. Results The median follow-up period was 48 months, and the 3-year and 5-year overall survival rates were 74.1% and 58.5%, respectively. After concurrent chemoradiotherapy, 72 patients (66.1%) achieved clinical complete remission, and 31 patients (28.4%) obtained PR. After receiving salvage treatment, the 3-year overall survival rate and progression-free survival rate of PR patients were 53.1% and 40.5%, respectively. Only 4 patients (3.7%) and 2 patients (1.8%) had grade 3 or greater urinary and gastrointestinal toxicity after definitive treatment. Conclusion For patients with cervical adenocarcinoma who have clinical residual lesions after primary treatment, salvage treatment should be actively taken in order to improve survival outcomes.
		2020 Vol. 29 (9): 762-766 [Abstract] ( 166 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	767	Relationship between the radiation dose of different anatomic bony sites and neutrophil toxicity in three-dimensional radiotherapy concurrent chemotherapy for cervical cancer
		Zhang Baozhong, Liu Zhiyan, Xu Liming, Wang Jing, Cao Yuanjie, Hou Hailing, Chai Yanlan
		Objective To investigate the correlation between radiation dose of the pelvic bone marrow of different anatomical bony sites and the incidence of neutrophil toxicity during the three-dimensional radiotherapy concurrent chemotherapy for cervical cancer. Methods Clinical data of 117 cervical cancer patients who received three-dimensional radiotherapy concurrent chemotherapy from 2016 to 2018 were retrospectively analyzed. The dosimetric parameters included Dmean, V5Gy, V10Gy, V20Gy, V30Gy, V40Gy and V50Gy. The correlation between the dosimetric parameters and the lowest neutrophil count was analyzed by linear regression analysis. Clinicopathological features and dosimetric parameters were included into the multivariate regression analysis model. Results The incidence rates of neutrophil toxicity (grade 1-4) were 10.3%, 27.4%, 11.1% and 10.3%, respectively. The linear regression analysis showed that the Dmean and V50Gy of lumbosacral vertebrae (LS), the Dmean, V5Gy, V10Gy, V20Gy, V30Gy, V40Gy and V50Gy of the ilium were significantly correlated with the grade 2-4 neutrophil toxicity (P=0.035、<0.001、<0.001、=0.001、=0.003、=0.001、<0.001、<0.001、<0.001). Multivariate analysis demonstrated that the V20Gy, V30Gy and V50Gy of the LS, the Dmean, V5Gy, V10Gy, V20Gy and V30Gy of the ilium were significantly correlated with thegrade 2-4 neutrophil toxicity (P=0.046、0.038、0.049、0.041、0.039、0.029、0.036、0.029). Conclusion During the process of three-dimensional radiotherapy concurrent chemotherapy for cervical cancer, the volume of medium-and high-dose of LS and the volume of low-and medium-dose of ilium are significantly correlated with the risk of neutrophil toxicity.
		2020 Vol. 29 (9): 767-771 [Abstract] ( 159 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Physics·Biology·Technique

	772	Mitigation of interplay effects with layer repainting techniques in intensity-modulated proton therapy for early-stage non-small cell lung cancer
		Shang Haijiao, Pu Yuehu, Liu Chenbin, He Xiaodong, Wang Yuenan
		Objective The purpose of current study was to evaluate the interplay effects in intensity-modulated proton therapy (IMPT) for lung cancer and compare the results of different Iso-energy layer repainting techniques in the mitigation of interplay effects. Methods Eight patients with lung cancer who underwent 4DCT were retrospectively selected. A robust CTV-based IMPT plan was generated for each based on commercial TPS, considering patient setup errors ±5 mm, range uncertainties ±3.5%, and CTV time structure motion in 4DCT image. Monte Carlo dose engines were used for all IMPT plans in the final dose calculation. The 4D static dose (4DSD) and 4D dynamic dose (4DDD) were calculated using a hybrid deformable algorithm and simulated proton delivery system for interplay effects. An index[ΔI(ROI,DVH)] was developed to quantitatively evaluate the interplay effects. We applied Iso-energy layer repainting techniques with different numbers of repainting (3, 4, 5, 6, 7) to the robust IMPT plans and evaluated the difference in the mitigation of interplay effects based on the ΔI(ROI,DVH)index. Results Due to interplay effects, the mean values of target coverage, conformity and homogeneity index reduced by 13.7%, 12.7% and 24.6%, respectively. The mean values of lung V5Gy and V20Gy improved by 0.8%,3.4% and 2.6%. Compared to the IMPT plans without layer repainting, Multiple iso-energy layers repainting techniques improved the mean values of CTV coverage by 4.5%,3.8%,3.8%,3.6% and 5.7%, respectively. The average values of lung V20Gy reduced by 1.5%,1.8%,1.7%,1.6% and 1.9%, respectively. Conclusions In the robust CTV-based IMPT plans, the interplay effects degraded the target dose distribution but were mitigated using iso-energy layer repainting techniques. We recommended to use the layer repainting technique according to the characteristics of the patient.
		2020 Vol. 29 (9): 772-778 [Abstract] ( 175 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	779	Impact of accelerator operating errors on γ passing rate during dose verification of volumetric modulated arc therapy for pelvic tumors
		Yuan Qingqing, Li Yanlong, Wang Dajiang, Quan Hong, Li Guangjun, Bai Sen
		Objective To investigate the impacts of gantry rotation angle errors, monitor unit (MU) errors, collimator and multi-leaf collimator (MLC) position errors upon the γ passing rate of dose verification in volumetric modulated arc therapy (VMAT). Methods Ten patients with rectal cancer and 10 patients with uterine tumors were selected. The operating errors of accelerator parameters were introduced during the VMAT execution. By comparing the γ passing rates during dose verification between the simulating and original plans, the impact and sensitivity of the operating errors of each accelerator parameter on γ passing rate were analyzed. Results When the γ criteria were set as 3%/3mm, 3%/2mm and 2%/2mm, the γ passing rate decreasing gradient was less than 7.0% after the introduction of gantry rotation angle, MU and collimator position errors, respectively. However, after the reverse, opposite, and co-directional motion errors of the MLC blades on both sides were introduced,the γ passing rate decreasing was less than 19.13 %, 18.53%, 0.19 %; 19.87%, 20.01%, 0.42 % and 23.11%, 23.45%,0.65 % for absolute dose verification, respectively. Conclusion During VMAT, the reverse and opposite motion errors of MLC blades exert more significant effect on the γ passing rate compared with the gantry rotation angle errors, MU errors, collimator position errors and co-directional motion errors of the MLC blades. When the γ criteria of 3%/3mm, 3%/2mm and 2%/2mm are adopted, the impact of accelerator operating errors upon the γ passing rate is strengthened in sequence. Therefore, when performing dose verification for a specific patient, appropriate γ criteria should be chosen and absolute dose verification should be taken as the reference index to evaluate the consistency between the calculated and measured dose distribution.
		2020 Vol. 29 (9): 779-783 [Abstract] ( 177 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	784	*Preliminary study of in vivo* dose measurement of intensity-modulated radiotherapy for cervical cancer**
		Tan Xia, Luo Huanli, Wang Ying, Zhong Mingsong, Liu Xianfeng, Li Shi, Tian Xiumei, Li Guang, Li Bo, Shen Zhengwen, Xu Yingchao, Jin Fu
		Objective To monitor and evaluate in vivo dose changes of intensity-modulated radiotherapy (IMRT) in patients with cervical cancer in a real-time manner. Methods Twelve patients with cervical cancer admitted to our hospital were enrolled in this study. The in vivo doses were monitored by PerFRACTION^TM. Electronic portal imaging device (EPID) were collected in each treatment fraction for two-dimensional in vivo dose verification[γ index and dose difference (DD) index]. Log files were recorded for three-dimensional in vivo dose verification (γ index). The correlation between in vivo dose and treatment duration was analyzed by Pearson correlation analysis. Results A total of 206 sets of EPID images and corresponding Log files were collected. The three-dimensional in vivo dose verification γ_1%/1mm of all patients was not correlated with treatment fraction (P>0.05). Among them, the absolute difference of γ_1%/1mm of 94.66% fractions was< 1%. The mean DD3% of two-dimensional in vivo dose verification of all patients was negatively correlated with treatment fraction (P<0.05). Among which, the average γ_3%/3mm of 9 patients was>89% in the treatment fractions, and the average γ_3%/3mm of 98.57% fractions of these 9 patients was>93%. The other 3 patients had an average γ_3%/3mm ranged from 38% to 100%. CBCT images showed that the bladder volume of these 3 patients was significantly decreased with the relative changes by 82.08%, 84.41% and 73.59%, respectively, and the target area was retracted significantly with the relative changes by 38.12%, 59.79% and 24.46%, respectively. Conclusion Combined with γ index and DD index, PerFRACTION^TM can monitor the mechanical stability of accelerator and MU delivery accuracy during treatment fractions, and monitor the changes of in vivo dose in patients with cervical cancer, which can improve the safety and quality assurance of IMRT for cervical cancer patients and provide guidance for patients with adaptive radiotherapy.
		2020 Vol. 29 (9): 784-789 [Abstract] ( 145 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	790	Research on automatic segmentation of female bowel based on Dense V-Network neural network
		Wu Qingnan, Guo Wen, Wang Jinyuan, Gu Shanshan, Yang Wei, Zhang Huijuan, Wang Yunlai, Quan Hong, Liu Jie, Ju Zhongjian
		Objective To resolve the issue of poor automatic segmentation of the bowel in women with pelvic tumors, a Dense V-Network model was established, trained and evaluated to accurately and automatically delineate the bowel of female patients with pelvic tumors. Methods Dense Net and V-Net network models were combined to develop a Dense V-Network algorithm for automatic segmentation of 3D CT images. CT data were collected from 160 patients with cervical cancer, 130 of which were randomly selected as the training set to adjust the model parameters, and the remaining 30 were used as test set to evaluate the effect of automatic segmentation. Results Eight parameters including Dice similarity coefficient (DSC) were utilized to quantitatively evaluate the segmentation effect. The DSC value, JD,ΔV, SI, IncI, HD (cm), MDA (mm), and DC (mm) of the small intestine were 0.86±0.03,0.25±0.04,0.10±0.07,0.88±0.05,0.85±0.05,2.98±0.61,2.40±0.45 and 4.13±1.74, which were better than those of any other single algorithm. Conclusion Dense V-Network algorithm proposed in this paper can deliver accurate segmentation of the bowel organs. It can be applied in clinical practice after slight revision by physicians.
		2020 Vol. 29 (9): 790-795 [Abstract] ( 242 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	796	Establishment of C57BL/6 mouse models with radiation-induced cardiopulmonary dysfunction
		Yan Rui, Song Jianbo, Cai Honghong, Guo Min, Xu Xianhai, Zhang Yarong, Yu Yang, Li Sijin
		Objective To establish the C57BL/6 mouse models of radiation-induced cardiopulmonary dysfunction. Methods Twenty-four male C57BL/6 mice were randomly divided into the control and irradiation groups. Mice in the irradiation group were irradiated with 20 Gy electron beam and bred for 6 months after irradiation. Cardiac function was assessed using ultrasonography. The partial pressure of oxygen was detected by blood gas analysis. Cell apoptosis was observed by Tunel assay. Myocardial and pulmonary fibrosis was assessed by Masson staining. Results The LVEF in the irradiation group was (68.60±10.92)%, significantly less compared with (81.75±8.79)% in the control group (P< 0.01). The apoptotic index of heart in the irraiation group was (23.90±6.60)%, considerably higher than (3.25±3.38)% in the control group (P< 0.01). The CVF of heart in the irradiation group was (15.42±5.72)%, significantly higher than (1.45±0.64)% in the control group (P< 0.01). The PaO₂ level in the irradiation group was (86.10±7.60) mmHg, significantly lower compared with (107.16±9.01) mmHg in the control group (P< 0.01). The apoptotic index of lung in the irradiation group was (27.90±8.94)%, significantly higher than (2.50±3.55)% in the control group (P<0.01). The CVF of lung in the irradiation group was (17.76±5.77)%, remarkably higher than (2.50±3.55)% in the control group (P< 0.01). Conclusion Radiation can induce cardiopulmonary apotosis and fibrosis remodeling, which leads to cardiopulmonary dysfunction, suggesting the successful establishment of C57BL/6 mouse model of radiation-induced cardiopulmonary dysfunction.
		2020 Vol. 29 (9): 796-798 [Abstract] ( 178 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Review Articles

	799	Research progress on influencing factors of radiation-induced oral mucositis
		Yin Yan, Zhang Jingping
		Radiation-induced oral mucositis (RIOM) is a common toxicity in patients receiving radiotherapy for head and neck cancer. RIOM not only significantly affects the oral function of patients, but also affects the short-term and long-term quality of life. In severe cases, it can reduce the tumor control rate and thus impact the survival of patients. The influencing factors of RIOM has been intensively studied, whereas the conclusions of some studies are inconsistent. In this article, the research progresses on the influencing factors of RIOM in recent years were summarized, aiming to provide the basis for the prevention and management of RIOM.
		2020 Vol. 29 (9): 799-803 [Abstract] ( 171 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	804	Research progress on hypothyroidism after radiotherapy in breast cancer
		Zhao Xuran, Wang Shulian
		Radiotherapy has improved the locoregional control and overall survival for patients with breast cancer. Breast/chest wall and supraclavicular fossa are the common sites of irradiation. During radiotherapy, the thyroid gland will be inevitably irradiated at a certain dose, which might increase the risk of hypothyroidism in the long-term survivors. The irradiation dose to the thyroid gland cannot be evaluated by traditional two-dimensional radiation technique. The hypothyroidism induced by radiation has been largely ignored. With the development of radiotherapy and application of three-dimentional conformal radiotherapy and intensity-modulated radiotherapy in breast cancer, how to choose appropriate radiation technique and how to limit the dose irradiated to the thyroid gland remain to be urgently resolved. This review systematically summarized the clinical characteristics, pathogenesis, risk factors and monitoring of hypothyroidism induced by radiotherapy, aiming to help clinicians to make the optimal decision in radiation technique selection and treatment plan evaluation.
		2020 Vol. 29 (9): 804-808 [Abstract] ( 180 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	809	Research progress on microscopic extension in defining clinical target volume
		Wang Xiaohang, Geng Jianhao, Zhang Siyuan, Zhu Xianggao, Wang Weihu
		Microscopic extension (subclinical lesion) is the key factor for defining clinical target volume in radiotherapy. In this article, the research progresses on microscopic extension or extracapsular extension in esophageal cancer, lung cancer, hepatocellular carcinoma, prostate cancer, bladder cancer, rectal cancer, breast cancer, non-melanoma skin cancer and metastatic lymph nodes were reviewed. These results provide important basis for the definition of clinical target volume. However, a series of questions remain to be properly resolved.
		2020 Vol. 29 (9): 809-812 [Abstract] ( 167 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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