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.10 Published 2020-10-15

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

Guidelines

	813	Quality assurance of helical tomotherapy
		National Cancer Center/ National Cancer Quality Control Center
		Helical Tomotherapy combines a form of intensity-modulated radiation therapy (IMRT) with the accuracy of computed tomography (CT) scanning technology in one machine. HT is one of the most advanced radiotherapy equipments at present. Considering the difference from the quality assurance of conventional linear accelerators, this guideline was proposed by National Cancer Center/National Cancer Quality Control Center, and multiple medical institutions participated in the formulation of this guideline. The guideline includes the acceptance items, operating rules and emergency plans, etc. The test methods, tolerances and frequencies of HT quality assurance are clarified. According to the actual situation of domestic medical institutions, the guideline provides recommended testing items, mainly including mechanical accuracy, dosimetric parameters, laser system, couch motion accuracy, MVCT imaging system quality control testing and clinical treatment plan verification, etc., making the guideline highly operable. This guideline can provide clinical phycicians with technical guidance on quality assurance, make quality assurance work rule-based, and improve the accuracy and precision of radiotherapy. It has instructive implications for medical institutions to establish standardized HT quality assurance system.
		2020 Vol. 29 (10): 813-821 [Abstract] ( 185 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Head and Neck Tumors

	822	Discussion of the 8^th edition of AJCC/UICC staging system from the clinical stage Ⅲ nasopharyngeal carcinoma
		Hong Yingji, Li Mei, Yang Zhining, Xue Yajie, Gao Xiaoying, Lin Zhixiong
		Objective To evaluate the 8^th edition of AJCC/UICC staging system for stage Ⅲ nasopharyngeal carcinoma (NPC) by the survival analysis. All patients were treated with intensity-modulated radiotherapy (IMRT). Methods Among 1351 treatment-naïve NPC patients who received radiotherapy/chemoradiotherapy in our hospital from December 2008 to October 2014, 742 and 784 cases were classified as clinical stage Ⅲ based on the criteria of the 7^th and 8^th edition of AJCC/UICC staging systems, respectively. These patients were classified into three subgroups according to the 7^th and 8^th edition of AJCC/UICC staging systems:T3N0-1 as G1(n=226, n=245), T1-2N2 as G2(n=180, n=187) and T3N2 as G3(n=336, n=352). The 5-year overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS) and local-regional recurrence-free survival (LRRFS) were analyzed with Kaplan-Meier method. The differences among different groups were evaluated by log-rank test. Results There were 93.6% patients evaluated by the 8^th AJCC/UICC staging system remained the same cohort with those by the 7^th AJCC/UICC staging system. The 5-year OS, PFS, DMFS and LRRFS of the 8^th and 7^th staging systems were 84.8% and 85.4%, 76.2% and 77.0%, 80.4% and 81.3%, 89.8% and 90.6%, respectively (all P>0.05). The OS, PFS or DMFS significantly differed among three subgroups classified by the 8^th staging system (all P<0.001). In addition, statistical significance was observed between G1 and G2, and between G1 and G3(both P<0.05), whereas no statistical significance was noted between G2 and G3(P=0.183, 0.310, 0.248). Conclusions The distribution features and clinical endpoints of clinical stage Ⅲ defined by the 8^th AJCC/UICC staging system are similar to those defined by the 7^th AJCC/UICC staging system. The distribution of survival risk significantly differs among different subgroups. N2 plays a major role in assessing the survival risk of patients with stage Ⅲ NPC. In the era of IMRT plus chemotherapy, the effect of local tumors on clinical prognosis has been diminished. The 8^th AJCC/UICC staging system remains to be further improved.
		2020 Vol. 29 (10): 822-826 [Abstract] ( 186 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	827	The role of concurrent chemotherapy in intensity-modulated radiotherapy for patients with stage Ⅲ nasopharyngeal carcinoma
		Wu Zheng, Wang Lei, Xie Dehuan, Lyu Shaowen, Su Yong
		Objective To investigate the clinical efficacy of concurrent chemotherapy in intensity-modulated radiotherapy (IMRT) for patients with stage Ⅲ nasopharyngeal carcinoma (NPC). Methods Clinical data of 251 patients with stage Ⅲ NPC treated with IMRT alone or concurrent chemoradiotherapy (CCRT) at Sun Yat-sen University Cancer Center from February 2001 to December 2008 were retrospectively analyzed. The prognostic factors of NPC were analyzed and the efficacy of CCRT was assessed. The survival rate was calculated by Kaplan-Meier method. The differences between two groups were analyzed by log-rank test. The prognostic factors were analyzed by Cox model. Results The 10-year locoregional-free survival (LRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) for NPC patients were 88.6%, 81.1%, 68.8% and 75.1%, respectively. Univariate and multivariate analyses demonstrated that N staging and nasopharyngeal tumor volume were the most important prognostic factors, and concurrent chemotherapy significantly improved PFS and OS (both P<0.05). In T3N0-1 patients, there was no significant difference in survival indexes between IMRT alone and CCRT (10y-LRFS:93.8% vs. 93.2%, P=0.933;10y-DMFS:80.9% vs. 86.8%, P=0.385;10y-PFS:70.6% vs. 77.7%, P=0.513;10y-OS:71.8% vs. 83.6%, P=0.207). For T1-3N2 patients, CCRT was significantly better than radiotherapy alone in LRFS, PFS, and OS (10y-LRFS:87.3% vs. 66.7%, P=0.016;10y-PFS:70.2% vs. 41.0%, P=0.003;10y-OS:78.5% vs. 51.7%, P=0.008), whereas there was an increasing trend in DMFS (10y-DMFS:80.3% vs. 66.4%, P=0.103). Conclusions Concurrent chemotherapy can improve clinical prognosis of stage Ⅲ NPC patients, and the most survival benefits are obtained in the N2 group. Individualized treatment options should be delivered based on the risk of treatment failure.
		2020 Vol. 29 (10): 827-832 [Abstract] ( 195 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	833	Comprehensive evaluation of stereotactic radiotherapy plan for treatment of multiple brain metastatic tumors based on volume-modulated arc therapy and CyberKnife-6D Skull technology
		Li Guoquan, Hu Bin, Zhang Tian, Liang Zhiwen, Hu Tao, Zhang Sheng, Peng Zhenjun
		Objective By comparing the comprehensive differences between volume-modulated arc therapy (VMAT)-and CyberKnife-6D Skull (CK-6D Skull) tracking technology-based stereotactic radiotherapy (SRT) plans in the treatment of multiple brain metastatic tumors, and explore the advantages of multi-target intracranial technology. Methods Clinical data of 42 patients with more than 2 brain metastases who received STR between January 2017 and August 2018 were retrospectively analyzed. For each patient, two radiotherapy plans were designed by selecting CK-6D Skull and VMAT technologies. The quality of VMAT and CK-6D Skull was compared by calculating the gradient index (GI), dose sag volume and organ at risk (OAR) of target area. The total number of monitor unit and single treatment time were recorded to compare the execution efficiency of these two technologies. Results The GI of intracranial 2-target and 3-target plans of CK-6D Skull technology was significantly superior to that of VMAT technology (P<0.05). The GI did not significantly differ between the 4-target and the 5-target groups (P>0.05). The contribution of these two technologies to the maximum dose of OAR was not significantly different (P>0.05), whereas the treatment time of VMAT technology was shorter (P<0.05). Conclusions Both technologies can meet the requirements of clinical SRT for multiple brain metastatic tumors. From the perspective of treatment plan and implementation, SRT based on CK-6D skull technology is recommended for patients with less than 4 intracranial metastatic tumors, and VMAT-based SRT is considered for those with > 4 metastatic tumors. Patients with poor physical condition and difficulty in maintaining a fixed position for a long time shall give priority to VMAT technology. More differences between these two technologies in the implementation of SRT for intracranial multiple brain metastases remain to be elucidated by more case data for statistical analysis.
		2020 Vol. 29 (10): 833-836 [Abstract] ( 163 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	837	Patterns of regional spread and the value of elective neck treatment for oral mucosal melanoma
		Sun Shiran, Huang Xiaodong, Zhang Ye, Zhang Shiping, Wang Kai, Qu Yuan, Wu Runye, Liu Qingfeng, Chen Xuesong, Xiao Jianping, Luo Jingwei, Xu Guozhen, Gao Li, Yi Junlin
		Objective To investigate the patterns of regional lymphatic spread and the value of elective neck treatment (ENT) in oral mucosal melanoma (OMM). Methods In this retrospective analysis, 61 OMM patients with no distant metastasis treated in Cancer Hospital of Chinese Academy of Medical Sciences between 1984 and 2016 were recruitred. The regional lymph node distribution of cN+ disease, the value of ENT in cN0 disease, the failure patterns and prognostic factors were retrospectively analyzed. Results Overall, 55.7% of the patients were clinical/pathological cN+. The most frequently involved locations were the level Ⅰ b (76%), followed by level Ⅱ and level Ⅲ. For cN0 patients, the 5-year regional failure-free survival rate was 91.7% in patients who received at least ipsilateral level Ⅰ b-Ⅲ ENT and 52.4% in patients who did not receive at least ipsilateral level Ⅰ b-Ⅲ ENT (P=0.036). The regional failure rate was 6% for patients treated with at least ipsilateral leve Ⅰ b-Ⅲ ENT, while in their counterparts who did not receive at least ipsilateral level Ⅰ b-Ⅲ ENT was 46%(P=0.035). For the regional failure pattern, the most frequently failure sites were level Ⅰ b (93%), level Ⅱ(50%) and level Ⅲ(36%). Conclusions The cervical lymph node metastasis rate is relatively high in OMM patients. The pathway of regional LN spread follows a regular pattern. The most frequently involved regions for clinical/pathological cN+ and regional failure are both level Ⅰ b-Ⅲ. Elective treatment including at least ipsilateral level Ⅰ b-Ⅲ ENT should be recommended for OMM patients with cN0.
		2020 Vol. 29 (10): 837-841 [Abstract] ( 180 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Thoracic Tumors

	842	Prognostic analysis of intensity-modulated radiotherapy for cervical and upper thoracic esophageal carcinoma
		Shen Wenbin, Xu Jinrui, Li Shuguan, Cao Yankun, Li Youmei, Zhu Shuchai
		Objective To analyze the clinical prognosis of patients with cervical and upper thoracic esophageal squamous cell carcinoma treated with radical intensity-modulated radiotherapy (IMRT) with or without chemotherapy, and to explore the significance of elective lymph node irradiation (ENI). Methods A retrospective analysis was performed on 309 patients with cervical and upper thoracic esophageal squamous cell carcinoma who underwent IMRT with or without chemotherapy in the Department of Radiology, the Fourth Hospital of Hebei Medical University. The prognostic factors were analyzed and patients receiving different irradiation methods were assigned into different group. The curative effect, toxicity and side effects were analyzed among different groups. Results The 1-, 3-and 5-year overall survival (OS) and progression-free survival (PFS) were 76.7%, 37.4%, 19.3% and 59.7%, 27.4% and 14.4%, respectively, with median values of 26.8 and 15.5 months. Multivariate analysis showed that gender, cTNM staging and chemotherapy were the prognostic factors affecting the OS (P=0.003, P<0.001, P=0.022), and gender, cTNM stage and radiation mode were the prognostic factors affecting the PFS (P=0.016, P<0.001, P=0.008). After propensity score matching (PSM), the 1-, 3-, and 5-year OS and PFS were 77.2%, 39.3%, 20.0%, and 62.0%, 29.3%, and 15.4%, respectively, with median values of 27.1 and 18.2 months. Multivariate analysis showed that gender, cTNM staging and chemotherapy were the prognostic factors affecting the OS (P=0.026, P<0.001, P=0.017);cTNM staging and irradiation mode were the prognostic factors affecting the PFS (P<0.001, P=0.008). A subgroup analysis of chemotherapy showed that patients receiving 3-4 cycles of chemotherapy were preferred. The side effects of the patients were mainly grade 0 to 2, which could be tolerated. Conclusions IMRT combined with or without chemotherapy is an efficacious treatment for patients with cervical and upper thoracic esophageal squamous cell carcinoma;ENI can improve the PFS of patients.
		2020 Vol. 29 (10): 842-848 [Abstract] ( 168 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	849	Prognostic value of peripheral blood CD⁺₈T lymphocytes for stage Ⅲ-Ⅳ non-small cell lung cancer patients treated with chemoradiotherapy
		Wang Haojie, Wang Lixue, Ouyang Weiwei, Ma Zhu, Li Qingsong, Yang Wengang, Li Huiqin, Su Shengfa, Lu Bing
		Objective To explore the changes of CD⁺₈ T cells in stage Ⅲ-Ⅳ non-small cell lung cancer (NSCLC) patients before and after radiochemotherapy and evaluate its clinical value in predicting survival. Methods A total of 795 patients with stage Ⅲ-Ⅳ NSCLC who completed CD⁺₈ T cell testing from January 2011 to December 2017 were recruited (249 patients completed 1-3 tests within 6 months after treatment). The survival difference of patients with different levels of CD⁺₈ T cells and the prognostic value of the changes in the CD⁺₈ T cell level were analyzed. The survival analysis was performed by Kaplan-Meier method and log-rank test or univariate analysis. The multivariate survival analysis was conducted by Cox’s regression model. Results Before treatment, the levels of CD⁺₈ T cells in the peripheral blood did not significantly differ among patients with different clinical factors. The survival time of stage Ⅲ NSCLC patients with CD⁺₈ T cell levels of<26.44% was significantly prolonged (P=0.043). After treatment, the levels of CD⁺₈ T cells were significantly higher than those before treatment. The levels were similar within 1-3 months, decreased after 4-6 months but still significantly higher than those before treatment. The median survival time of patients with CD⁺₈cell levels of<43.90% after treatment was 22 months, significantly longer than 16 months of those with CD⁺₈cell levels of ≥43.90%(P=0.032). Stratified analysis demonstrated no significant difference in the survival time at 1 month and 2-3 months after treatment (P>0.05), whereas the survival time significantly differed at 4-6 months (P=0.001). The multivariate survival analysis showed that CD⁺₈ cell levels of<43.90% after treatment was an independent prognostic factor (HR=0.714, P=0.031). Conclusions The effect of CD⁺₈ T cells on prognosis of patients with stage Ⅲ-Ⅳ NSCLC is limited. After treatment, CD⁺₈ T cell levels are increased significantly. A certain increase in the CD⁺₈ T cell levels can prolong the survival time. The detection of CD⁺₈ T cell subtypes plays a more significant role.
		2020 Vol. 29 (10): 849-854 [Abstract] ( 175 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Abdominal Tumors

	855	Preliminary clinical observation of efficacy and safety of stereotactic body radiation therapy in combination with targeted therapy for metastatic renal cell carcinoma
		Liu Yang, Dong Pei, Huang Sijuan, Cao Wufei, Liu Boji, Lin Maosheng, Jiang Xiaobo, Lin Chengguang, Liu Zhuowei, Han Hui, Li Yonghong, Liu Mengzhong, Zhou Fangjian, He Liru
		Objective To evaluate the preliminary clinical efficacy and safety of stereotactic body radiation therapy (SBRT) in combination with targeted therapy for metastatic renal cell carcinoma (mRCC). Methods Clinical data of 58 patients with mRCC who were treated with SBRT in combination with targeted therapy in Sun Yat-sen University Cancer Center from June 2013 to December 2018 were retrospectively analyzed. Among them, 79.3% patients were classified as intermediate or high risk according to International Metastatic Renal Cell Carcinoma Database Consortium Criteria. The median biologically equivalent dose (BED) was 147 Gy (67 to 238 Gy). Results Overall, 32, 13, 7, 5 and 1 patients received SBRT for 1, 2, 3, 4 and 6 metastatic sites (105 lesions) and 71.4% of them were bone lesions. Targeted therapy was continued during SBRT. With a median follow-up of 9.4 months (range 2.7 to 40.1 months), 18 patients died. The 1-year local control rate was 97.4%. The 1-year progression-free survival was 50.3%. The 1-and 2-year overall survival was 72% and 53%. Approximately 85% patients experienced pain relief after SBRT. Patients who achieved complete or partial response after SBRT obtained better overall survival than those with stable disease or disease progression (1-year overall survival:83% vs. 48%,P=0.021). In the whole cohort, 6 cases developed Grade Ⅲ adverse events, 4 of which were Grade Ⅲ myelosuppression, 1 case of Grade Ⅲ neuropathy and 1 case of radiation-induced skin injury. Conclusion Preliminary study reveals that combined use of targeted therapy and SBRT is an efficacious and safe treatment of advanced mRCC.
		2020 Vol. 29 (10): 855-858 [Abstract] ( 170 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	859	Clinical evaluation of deep learning-based clinical target volume auto-segmentation algorithm for cervical cancer
		Ma Chenying, Zhou Juying, Xu Xiaoting, Guo Jian, Han Miaofei, Gao Yaozong, Wang Zhanglong, Zhou Jingjie
		Objective To validate the feasibility of a deep learning-based clinical target volume (CTV) auto-segmentation algorithm for cervical cancer in clinical settings. Methods CT data sets from 535 cervical cancer patients were collected. CTVs were delineated according to RTOG and JCOG guidelines, reviewed by experts, and then used as reference contours for training (definitive 177, post-operative 302) and test (definitive 23, post-operative 33). Four definitive and 6 post-operative cases were randomly selected from the testing cohort to be manually delineated by junior, intermediate, senior doctors, respectively. Dice coefficient (DSC), mean surface distance (MSD) and Hausdorff distance (HD) were used for test and comparison between auto-segmentation and RO delineation. Meantime, auto-segmentation time and manual delineation time were recorded. Results Auto-segmentation models of dCTV1, dCTV2 and pCTV1 were trained with VB-Net and showed good agreement with reference contours in the testing cohorts (DSC, 0.88,0.70,0.86 mm;MSD,1.32,2.42,1.15 mm;HD,21.6,22.4,20.8 mm). For dCTV1, the difference between auto-segmentation and all three groups of doctors was not significant (P>0.05). For dCTV2 and pCTV1, auto-segmentation was better than the junior and intermediate doctors (both P<0.05). Auto-segmentation time consumption was considerably shorter than that of manual delineation. Conclusions Deep learning-based CTV auto-segmentation algorithm for cervical cancer achieves comparable accuracy to manual delineation of senior doctors. Clinical application of the algorithm can contribute to shortening doctors′ manual delineation time and improving clinical efficiency. Furthermore, it may serve as a guide for junior doctors to improve the consistency and accuracy of cervical cancer CTV delineation in clinical practice.
		2020 Vol. 29 (10): 859-865 [Abstract] ( 168 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Physics·Biology·Technique

	866	Dosimetric study of particle radiotherapy for glioma patients
		Lu Yan, Wang Weiwei, Xing Ying, Gao Jing, Kong Lin, Lu Jiade
		Objective To investigate the dosimetric difference between glioma patients treated by particle (proton+carbon ion) and photon radiotherapy. Methods Twelve previously-treated glioma patients were selected, and given with the same total dose of 60.00 Gy [RBE]. Two types of planning target volumes (PTVs) including PTV-ion and PTV-photon were expended from clinical target volumes according to range uncertainty and patient setup errors. Based on PTV-ion, proton plans with sequential carbon ion boost (particle plan) were created. Following the same prescription, two types of photon intensity-modulated radiotherapy (IMRT) plans were established to achieve similar target coverage and compare the dose of organs at risk. Results Target coverages of three types of plans had no statistical difference (all P>0.05). The median integral dose of normal brain of all patients receiving particle plan was merely 44.90% of the minimum number from photon plans (P<0.001). Compared with the minimum number from photon plans, particle radiotherapy decreased the mean dose of brain stem[(6.83±6.22) Gy[RBE] vs. (15.10±10.11) Gy[RBE], P=0.001)], the maximum dose of chiasm[(47.76±20.80) Gy[RBE] vs. (49.59±20.52) Gy[RBE], P=0.009)] and the mean dose of contralateral hippocampus (0.26±9.08) Gy[RBE] vs. (16.28±11.14) Gy[RBE], P=0.002), respectively. Conclusions Particle radiotherapy can achieve similar target coverage while maintaining lower normal tissue doses to the photon radiotherapy. Photon planion can increase the doses to adjuvant normal tissues.
		2020 Vol. 29 (10): 866-871 [Abstract] ( 182 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	872	Study on dosimetric changes between initial and second treatment plans in IMRT for large volume NSCLC
		Ren Jianxin, Yin Yong, Gong Guanzhong, Yao Xinsen, Han Zhujun, Su Ming, Quan Hong
		Objective To evaluate the cumulative dose of the target volume and organs at risk (OARs) in intensity-modulated radiation therapy (IMRT) for large volume non-small cell lung cancer (NSCLC) based on rigid and deformation registration methods. The dosimetric changes between the initial and second treatment plans were compared. Methods Thirty patients treated with IMRT for large volume NSCLC with twice 4DCT scans acquired before radiotherapy and after 20 fractions of radiotherapy were recruited. The initial treatment plan (Plan1) based on the average density projection CT (CT1-avg) of the first 4DCT images and the second treatment plan (Plan2) based on the average density projection CT (CT2-avg) of the second 4DCT images were calculated. Then, the dose distributions of Plan1 and Plan2 were accumulated based on rigid and deformation registration methods to obtain Planrig and Plandef, respectively. Finally, the volume changes of gross tumor volume (GTV) and OARs between two CT scans were compared. The dose-volume parameters between Plan1 and other plans (including Plan2, Planrig and Plandef) were also statistically compared. Results Compared with the initial CT scan, the mean volume of GTV and heart on the second CT was decreased by 44.2% and 5.5%, respectively, while the mean volume of ipsilateral lung, contralateral lung and total lung was increased by 5.2%, 6.2% and 5.8%, respectively (all P<0.05). Compared with Plan1, the D95%, D98% and V100% of target volume IGTV (GTV fusion of 10 4DCT phases) and PTV in Plan2 did not significantly change (all P>0.05), and those in Planrig and Plandef were decreased (all P<0.05). The dose-volume parameters of spinal-cord, heart, ipsilateral lung and total lung in Plan2, Planrig and Plandef were significantly lower than those in Plan1(all P<0.05). Among them, the V30Gy and Dmean of heart were decreased by 27.3%, 16.5%, 15.3% and 15.2%, 6.6%, 5.6%, respectively. The V20Gy and Dmean of total lung were decreased by 15.6%, 4.5%, 3.7% and 15.7%, 6.2%, 5.1%, respectively. Some dose-volume parameters (including D95% and D98% of target volume, V40Gy of heart, V20Gy and Dmean of the ipsilateral lung and the total lung) of Plandef were higher than those in Planrig (all P<0.05). The Dice similarity coefficients (DSCs) of OARs after deformation registration were significantly higher than those after rigid registration (P<0.05). Conclusions The dose-volume parameters of OARs significantly differ between Plan1 and Plan2. Hence, all these parameters have a large degree of deviation in predicting radiation-induced injury of OARs. Nevertheless, the dose-volume parameters obtained by deformation registration can enhance the prediction accuracy.
		2020 Vol. 29 (10): 872-876 [Abstract] ( 166 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	877	Comparison of setup errors between deep inspiration breath hold and free breathing for whole breast irradiation
		Yu Shufei, Chen Siye, Wang Shulian, Tang Yu, Li Minghui, Song Yongwen, Jin Jing, Liu Yueping, Fang Hui, Chen Bo, Qi Shunan, Li Ning, Tang Yuan, Lu Ningning, Li Yexiong
		Objective To compare the setup errors between deep inspiration breath hold (DIBH) and free breathing (FB) for breast cancer patients who were treated with whole breast irradiation (WBI) after breast conserving surgery (BCS). Methods In this retrospective analysis, 30 breast cancer patients receiving WBI following BCS using DIBH in National Cancer Center/ Chinese Academy of Medical Sciences, an 30 patients treated with WBI using FB were enrolled as comparator.The kilovoltage cone-beam computed tomography (CBCT) was performed to evaluate and reduce setup errors. The optimal margins from clinical target volume (CTV) to planning target volume (PTV) for DIBH were estimated. The differences of setup errors between two techniques were compared using independent two-sample t-test. Results A total of 318 sets of CBCT images were acquired, with (5.1±1.1) sets per patient on average. The setup errors along the three translational directions (laternal, longitudinal and vertical) were (2.1±1.6) mm,(2.6±1.7) mm and (2.5±2.1) mm for DIBH, and (2.2±1.7) mm,(3.1±2.5) mm and (3.3±2.3) mm for FB, respectively. Compared with FB, DIBH significantly reduced setup errors in the longitudinal (P=0.015) and vertical (P=0.004) directions, whereas the setup errors in the lateral direction did not significantly differ (P=0.294). The optimal margins from CTV to PTV using DIBH were 6.2 mm, 7.3 mm and 7.8 mm, respectively.In the DIBH group, treatment fractions at the beginning and higher body mass index (BMI) did not associate with larger set-up deviation. Conclusions DIBH technique yields less setup errors than FB for breast cancer patients treated with WBI after BCS. The CTV-PTV margins of 6-8 mm are recommended for DIBH.
		2020 Vol. 29 (10): 877-881 [Abstract] ( 216 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	882	Dosimetric comparison between CT-guided free-hand intracavity/interstitial adaptive brachytherapy and conventional point-A brachytherapy in the treatment of cervical cancer
		Wang Yanhong, Ye Weijun, Zhan Shizhao, Ouyang Yi, Cao Xinping
		Objective To analyze the dosimetric differences between CT-guided free-hand intracavity/interstitial brachytherapy[image-guided adaptive brachytherapy (IGABT)] and conventional point-A plan (CP) in the treatment of cervical cancer. Methods Twenty-six cervical cancer patients who received four cycles of IGABT in Sun Yat-sen University Cancer Center were enrolled in this study. Two sets of CT images were obtained before and after applicator adjustment to aid in the design of CP and IGABT plans. The high-risk clinical target volume (HRCTV), point A, and organs at risk (bladder, rectum, and sigmoid colon) were defined on CT images. CP and IGABT plans were designed on CT images. Parameter differences between CP and IGABT plans were analyzed with paired t-test and Wilcoxon test. Results According to the coverage index (CI) of CP, plans were divided into two groups:in group A (CI≥0.90), 20 CP and corresponding IGABT plans were included, and 84 CP and corresponding IGABT plans in group B (CI<0.90). The mean volume of HRCTV and mean tumor diameter in group A were significantly smaller than those in group B (46.7 cm³ vs. 62.1 cm³, P<0.001 and 3.1 cm vs. 4.4 cm, P<0.001). Compared with CP, IGABT significantly improved the value of D90% in all plans and group B, whereas lowered the bladder dose. IGABT also reduced the dose of sigmoid colon in group A. IGABT significantly improved conformal index and dose homogeneity index. Conclusions IGABT can significantly improve the target coverage, conformal index and dose homogeneity index, protect organs at risk. Compared with CP, IGABT has advantages in the treatment of patients with bulky tumor.
		2020 Vol. 29 (10): 882-887 [Abstract] ( 179 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	888	Research on robust optimization method of intensity-modulated proton therapy
		Han Rongcheng, Pu Yuehu, Kong Haiyun, Li Xiufang, Wu Chao
		Objective To propose a new robust optimization method, known as modified worst case method, was proposed, which can enable users to control the trade-off between nominal plan quality and plan robustness. Methods In each iteration of the plan optimization process, the dose value of each voxel in nine scenarios, which corresponded to a nominal scenario and eight perturbed scenarios with range or set-up uncertainties, were calculated and the maximum of deviations of each scenario voxel dose from that of the nominal scenario was included as an additive robust optimization term in the Objective function. A weighting factor probust was used to this robust optimization term to balance the nominal plan quality and plan robustness. Results The robust optimization methods were implemented and compared in an in-house developed robust optimization module. When probust=0.8, compared with conventional optimization, the ΔD95% of CTV was reduced from 9.8 Gy to 7.6 Gy. When probust was reduced from 1 to 0, ΔD95% was increased from 7.0 Gy to 9.8 Gy, whereas the D95% and Dmax of CTV, and the D5% and Dmax of organs at risk (OAR) in the nominal scenario were reduced. Conclusions The proposed modified worst case method can effectively improve the robustness of the plan to the range and set-up uncertainties. Besides, the weighting factor probust in this method can be adopted to control the trade-off between nominal plan quality and plan robustness.
		2020 Vol. 29 (10): 888-893 [Abstract] ( 187 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	894	LncRAN MEG3 regulates the radiosensitivity of cervical cancer cells by targeting miR-181a-5p
		Hou Ge, Wang Cheng, Li Ruping, Xiao Chenhu, Chu Alan, Liu Zongwen
		Objective To evaluate the effect of long-chain non-coding RNA MEG3(LncRNA MEG3) on the radiosensitivity of cervical cancer cells, and to explore its underlying mechanism. Methods The expression of LncRNA MEG3 in cervical cancer cells was detected by qRT-PCR. In the overexpression control group (transfected with pcDNA 3.1), LncRNA MEG3 overexpression group (transfected with pcDNA 3.1-LncRNA MEG3), miR-NC inhibition group (transfected with anti-miR-NC), miR-181a-5p inhibition group (transfected with anti-miR-181a-5p), LncRNA MEG3+miR-NC overexpression group (co-transfected with pcDNA3.1-LncRNA MEG3 and anti-miR-NC), LncRNA MEG3+miR-181a-5p overexpression group (co-transfected with pcDNA 3.1-LncRNA MEG3 and anti-miR-181a-5p), all plasmids were transfected into SiHa cells by liposome method. The cell survival fraction was assessed by colony formation assay. The cell apoptosis rate was evaluated by flow cytometry. The cell fluorescence activity was assessed by dual luciferase reporter assay. The expression levels of PTEN, p-Akt and Akt proteins were detected by Western blot. Results Compared with the radiosensitive group, the expression of LncRNA MEG3 was significantly down-regulated in radiation-resistant cervical cancer tissues (P<0.05), and its expression level was positively correlated with the sensitivity of cervical cancer cells. Overexpression of LncRNA MEG3 or inhibition of miR-181a-5p could significantly enhance the irradiation sensitivity and promote the apoptosis of cervical cancer cell line SiHa (both P<0.05). The fluorescence activity of wild-type LncRNA MEG3 cells was inhibited by miR-181a-5p. Overexpression of miR-181a-5p reversed the irradiation sensitization and pro-apoptosis effect of LncRNA MEG3 and the regulation of the PTEN/Akt signaling pathway on cervical cancer cell. Conclusion LncRNA MEG3 can enhance the sensitivity of cervical cancer cells to radiation exposure, probably by targeting the miR-181a-5p and regulating the PTEN/Akt signaling pathway, which will provide a new direction for improving clinical prognosis of cervical cancer patients.
		2020 Vol. 29 (10): 894-900 [Abstract] ( 198 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	901	Study of the relationship between radiation-induced taste cell injury and radiation mode in mice
		Bu Shanshan, Xu Gang, Wang Zhonghou, Liu Hongxiang, Wang Xiushen
		Objective To investigate the relationship between radiation mode and radiation-induced taste cell injury in mouse models. Methods The head and neck of adult C57/bl mice were exposed to 8 Gy irradiation for 1, 2 and 3 times and sacrificed at 2, 4, 7 and 14 d after irradiation. Frozen sections of taste papilla tissues were treated with specific markers by immunohistochemical staining. The changes of proliferative cells and the number of type Ⅱtaste cells at different time points under different radiation modes were observed. The effect of different radiation dose patterns upon the taste cells was assessed. Results The count of proliferative cells was decreased significantly on the 2^nd day after radiation, and rapidly recovered to normal level on the 4^th day after radiation, which was not correlated with the dose mode. The number of type Ⅱ taste cells was decreased on the 2^nd day of the first 8 Gy radiation, decreased to the lowest on the 4^th day of the second and third 8 Gy radiation, and rose slowly on the 7^th day. Conclusions Radiation can initially decrease and subsequently increase the number of proliferative cells to normal range. Besides, it can gradually repair the type Ⅱ taste cell injury. After high-dose irradiation, the decrease of progenitor cells with proliferative function leads to a synchronous decrease in the number of taste function cells, which may be the reason why taste dysfunction cannot be recovered for a long time after radiotherapy.
		2020 Vol. 29 (10): 901-903 [Abstract] ( 175 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Review Articles

	904	Consensus and disputes on the adjuvant therapy for non-small cell lung cancer with positive surgical margins
		Yuan Meng, Men Yu, Kang Jingjing, Sun Xin, Zhao Maoyuan, Yang Xu, Bao Yongxing, Hui Zhouguang
		For non-small cell lung cancer (NSCLC) patients with positive surgical margins, the survival rates can be dramatically decreased. However, high-level evidence is lacking in the standard adjuvant treatment for NSCLC patients with positive surgical margins. In this article, consensus and disputes on the adjuvant therapy for NSCLC patients with positive surgical margins were reviewed.
		2020 Vol. 29 (10): 904-908 [Abstract] ( 186 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	909	Research progress on clinical efficacy of postoperative radiotherapy for resectable pathological stage ⅢA-N2 non-small cell lung cancer
		Tian Cuimeng, Li Baolan
		With the development of modern radiotherapy technology, the significance of postoperative radiotherapy in treating resectable stage ⅢA-N2 non-small cell lung cancer has been emphasized. At present, the value of postoperative radiotherapy has been controversial due to the lack of large-size prospective randomized controlled studies. A large number of retrospective studies have confirmed that the efficacy of postoperative radiotherapy is significantly correlated with different clinicopathological characteristics. In this article, the influencing factors of the efficacy of postoperative radiotherapy were analyzed, and the subgroup of patients receiving clinical benefits was discussed, aiming to achieve precise postoperative radiotherapy.
		2020 Vol. 29 (10): 909-912 [Abstract] ( 185 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	913	Advances in radiotherapy for breast cancer in 2018
		Xie Jinrong, Cao Lu, Chen Jiayi
		In 2018, studies of radiotherapy for breast cancer mainly focus on three aspects:shorten course of radiotherapy:efficacy and safety of weekly hypofractionated whole breast irradiation (FAST and FAST FORWARD) and dose escalated intensity-modulated radiotherapy to whole breast (IMPORT HIGH);reduction in treatment volume:safety and efficacy of APBI (NSABP/RTOG 0413 and RAPID), and individualize radiotherapy decision:optimization of definition of low-risk breast cancer using clinicopathologic parameters, genomic assays and molecule subtypes. The individualized radiotherapy will be the mainstream orietation of development.
		2020 Vol. 29 (10): 913-918 [Abstract] ( 171 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	919	Research progress on application of image registration methods in target volume delineation of breast tumor bed
		Xie Xin, Dai Jianrong
		Accurate delineation of breast tumor bed and its target volume is of great importance in the planning of postoperative radiotherapy. Registration of different medical images and radiotherapy-oriented CT images can provide more comprehensive information, which can assist radiation oncologists to delineate the target contours. Image registration methods can be divided into the rigid and non-rigid types according to geometrical transformation property. Due to complex and non-rigid deformation of soft tissues, it is difficult to utilize rigid registration to strictly align the non-rigid structures. Non-rigid registration tends to achieve better results. In this article, the application of two types of registration methods in target volume delineation of breast tumor bed was reviewed and the existing problems in clinical practice were analyzed and the research direction of non-rigid registration was prospected.
		2020 Vol. 29 (10): 919-924 [Abstract] ( 172 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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