Chinese Journal of Radiation Oncology

中华放射肿瘤学杂志

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Chinese Journal of Radiation Oncology

	2021 Vol.30 Issue.2 Published 2021-02-15

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

Head and Neck Tumors

	109	Analysis of psychological distress in elderly patients with head and neck cancer receiving radiotherapy
		Bao Ruizhi, Yi Junlin, Liu Qingfeng, Chen Xuesong, Wu Runye, Huang Xiaodong, Wang Kai, Qu Yuan, Zhang Shiping, Luo Jingwei, Xiao Jianping, Zhang Ye
		Objective To evaluate the psychological pain of patients with head and neck cancer aged ≥60 years old before and after intensity-modulated radiotherapy (IMRT). Methods Distress Thermometer (DT)(Chinese version) was used to investigate the degree and problems of psychological pain before and after IMRT for 85 elderly patients with head and neck cancer. The results before and after IMRT were compared by paired t-test. Relevant factors were identified by Logistic regression analysis. Results The median age in the cohort was 66 years old (60-85 years old). The incidence rates of psychological pain were 73% and 87% before and after IMRT (P<0.001). The corresponding incidence rates of severe distress were 6% and 34%(P<0.001). The main distress problems before IMRT were memory loss/attention deficit, worry, oral pain, economic problems, stress, sleep problems, and dry nose. The significantly-increased distress problems after IMRT were oral pain, constipation, eating, nausea, and dry nose. Logistic regression analysis showed gender (OR=5.520, 95%CI 1.437-21.212, P=0.013), pre-treatment PG-SGA score (OR=1.220, 95%CI 1.048-1.421, P=0.010) and medical insurance (OR=0.230, 95%CI 0.053-0.995, P=0.049) were the relevant factors of the severe psychological distress before IMRT. Occupation (OR=2.286, 95%CI 1.291-4.050, P=0.005) and medical insurance (OR=0.089, 95%CI 0.029-0.276, P<0.001) were the relevant factors of severe psychological distress after IMRT. Conclusion The incidence rate of distress is high in elderly patients with head and neck cancer before IMRT, which can be aggravated after IMRT, primarily the treatment-related physical pain problems.
		2021 Vol. 30 (2): 109-113 [Abstract] ( 195 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Thoracic Tumors

	114	Long-term outcomes and failure patterns of prophylactic cranial irradiation in limited-stage small cell lung cancer patients managed with modern chemoradiotherapy and diagnostic methods
		Liu Xuan, Zhou Zongmei, Xiao Zefen, Feng Qinfu, Chen Dongfu, Lyu Jima, Liang Jun, Bi Nan, Wang Xin, Deng Lei, Zhang Tao, Wang Wenqing, Wang Xiaozhen, Hui Zhouguang, Wang Lyuhua
		Objective To evaluate the clinical efficacy and failure patterns of prophylactic cranial irradiation (PCI) in patients with limited-stage small cell lung cancer (LS-SCLC) on the basis of modern chemoradiotherapy and diagnostic techniques. Methods In this retrospective study, clinical data of 201 LS-SCLC patients treated with chemotherapy (EP/CE regimens,≥4 cycles) and intensity-modulated radiotherapy (IMRT) in Cancer Hospital of Chinese Academy of Medical Sciences from 2006 to 2014 were reviewed. All patients were primarily managed with concurrent or sequential chemoradiotherapy and achieved complete response (CR) or partial response (PR). Ninety percent of patients were revaluated for brain metastasis (BM) by MRI and 10% by CT scan. Long-term survival and failure patterns were compared between the PCI (n=91) and non-PCI groups (n=110). Results The median follow-up time was 77.3 months (95%CI 73.0-81.5 months). The median overall survival (OS), 2-and 5-year OS rates were 58.5 months, 72.5% and 47.7% in the PCI group, and 34.5 months, 61.7% and 35.8% in the non-PCI group (P=0.075). The median progression-free survival (PFS), 2-and 5-year PFS rate were 22.0 months,48.0% and 43.4% in the PCI group, significantly higher than 13.9 months, 34.4% and 26.7% in the non-PCI group (P=0.002). The 2- and 5-year cumulative incidence of BM were 6.6% and 12.2% in the PCI group, and 30.0% , 31.0% in the non-PCI group (P=0.001). The median time and rate of BM as an isolated first site of relapse were 11.9 months and 4.4% in the PCI group, and 8.7 months and 25.5% in the non-PCI group (P＜0.001). Multivariate analysis showed that response after chemoradiotherapy (P＜0.001) and PCI (P=0.033) were the independent prognostic factors for PFS. Stratified analysis demonstrated that PCI significantly improved the 5-year PFS in patients who achieved CR (72.7% vs. 48.0%, P=0.013), while it did not improve the 5-year PFS in patients who obtained PR (26.1% vs. 20.2%, P=0.213).Conclusion In the new era of standard chemoradiotherapy and more accurate diagnostic methods for BM, PCI was associated with improved PFS and lower incidence of BM in LS-SCLC patients.
		2021 Vol. 30 (2): 114-119 [Abstract] ( 204 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	120	Impact of radiotherapy-related factors on survival in non-small cell lung cancer complicated with malignant pleural effusion based on propensity score matching
		Li Qingsong, Ouyang Weiwei, Su Shengfa, Ma Zhu, Geng Yichao, Yang Wengang, Hu Yinxiang, Li Huiqin, Li Xiaoyang, Chen Xiaxia, Lu Bing
		Objective To analyze the radiotherapy-related factors affecting the survival of non-small cell lung cancer (NSCLC) patients complicated with malignant pleural effusion (MPE)(MPE-NSCLC). Methods From 2007 to 2019, 256 patients pathologically diagnosed with MPE-NSCLC received primary treatment. Among them, 117 cases were enrolled in this study. All patients were divided into two groups according to the radiation dose (<63Gy and≥63Gy). Propensity score matching (PSM) was performed to further adjust the confounding factors (Calipers value=0.1). The impact of radiotherapy-related factors on the overall survival (OS) was analyzed by Kaplan—Meier method, log-rank test and Cox’s regression model. Results Primary tumor radiotherapy significantly prolonged the OS (P<0.001). The radiation dose escalation (36.0-44.1Gy, 45.0-62.1Gy, 63.0-71.1Gy) of primary tumor significantly prolonged the OS (P<0.001). The corresponding median OS were 5, 13 and 18 months, respectively. Before the PSM,univariate analysis suggested that radiation dose ≥63Gy, gross tumor volume (GTV)<157.7cm³ and stations of metastatic lymph node (S-mlN)≤5 were significantly associated with better OS (all P<0.05) and T4N3 was significantly associated with worse OS (P=0.018). After the PSM,univariate analysis indicated that radiation dose ≥63Gy was significantly associated with better OS (P=0.013) and S-mlN ≤5had a tendency to prolong the OS (P=0.098). Prior to the PSM, multivariate analysis showed that radiation dose ≥63Gy was an independent favorable factor of OS (HR=0.566,95%CI 0.368-0.871,P=0.010) and GTV<157.7cm³had a tendency to prolong the OS (HR=0.679,95%CI 0.450-1.024,P=0.065). After the PSM, multivariate analysis revealed that radiation dose ≥63Gy was still an independent favorable factor of OS (HR=0.547,95%CI 0.333~0.899,P=0.017). No ≥grade 4 radiation toxicity occurred. The incidence rates of grade 3 radiation esophagitis and pneumonitis were 9.4% and 5.1%, respectively. Conclusion For MPE-NSCLC, radiotherapy dose of primary tumor may play a key role in improving OS on the basis of controllable MPE.
		2021 Vol. 30 (2): 120-126 [Abstract] ( 190 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Abdominal Tumors

	127	Preoperative three dimensional conformal radiotherapy and volumetric modulated arc therapy concurrently combined with chemotherapy for locally advanced rectum cancer:a five-year follow-up study
		Xiao Lin, Deng Wenjing, Wei Jiawang, Xiao Weiwei, Wang Qiaoxuan, Zeng Zhifan, Liu Mengzhong, Gao Yuanhong
		Objective To compare 5-year overall survival (OS) and disease free survival (DFS) between preoperative three dimensional conformal radiotherapy (3DCRT) and volumetric medulated arc therapy (VMAT) concurrently combined with chemotherapy for locally advanced rectum cancer (LARC), and analyze the value of induction and/or consolidation chemotherapy in these circumstances. Methods 334 patients with LARC treated with preoperative 3DCRT (172 cases) and VMAT (162 cases) concurrently combined with chemotherapy, main protocol XELOX (capecitabine plus oxaplatin), and subsequent surgery in Sun Yat-sen University from May 2007 to April 2013 were retrospectively analyzed. The radiation prescription dose for VMAT group was 50Gy 25 fractions for planning target volume1(PTV1), and 46Gy 25 fractions for PTV2. The radiation prescription dose for 3DCRT group was 46Gy 23 fractions for PTV2. One hundred and eighty-five cases of all received preoperative concurrent chemoradiotherapy (namely, CCRT group), 149 cases received preoperative concurrent chemoradiotherapy plus median 2 courses (1-7 courses) induction and/or consolidation chemotherapy (namely, CCRT±induction chemotherapy±consolidation chemotherapy group), whose main chemotherapy protocol was XELOX. Difference of 5-year OS and DFS between 3DCRT and VMAT group was compared. The rate differences of acute toxicity during chemoradiotherapy, postoperative complications, ypCR, and survival between CCRT group and CCRT±induction chemotherapy±consolidation chemotherapy group were analyzed. Results After a median follow-up of 62.3 months (2.4-119months) for the 334 patients, no any significant difference for 5-year OS (79.0% vs. 83.2%, P=0.442) and 5-year DFS (77.0% vs. 82.1%, P=0.231) between 3DCRT and VMAT group was observed. There was no any significant difference for the Grade 3hematological toxicity (7.0% vs. 12.1%,P=0.114) and non-hematological toxicity (14.1% vs. 16.8%,P=0.491) during chemoradiotherapy, postoperative complications (17.3% vs. 17.4%,P=0.971), ypCR rate (25.4% vs. 30.2%,P=0.329), 5-year OS (80.5% vs. 82.0%,P=0.714) and 5-year DFS (78.8% vs. 81%,P=0.479) between CCRT group and CCRT±induction chemotherapy±consolidation chemotherapy group. Conclusions Compared with 3DCRT, the physics advantage of VMAT technique does not significantly convert into clinical benefits and improve 5-year OS and DFS, even further boosting radiation dose to the gross tumor volume. It is safe for median 2 courses of induction and/or consolidation chemotherapy before and or after preoperative concurrent chemoradiotherapy in the treatment of LARC, though it does not significantly improve ypCR rate and survival.
		2021 Vol. 30 (2): 127-133 [Abstract] ( 207 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Physics·Technique·Biology

	134	The clinical application of magnetic resonance-guided radiotherapy
		Liu Biaoshui, Guo Xuan, Ding Shouliang, Wang Bin, Li Yongbao, Xia Yunfei, Ouyang Yi, Huang Xiaoyan, Lin Chengguang
		Objective To investigate the clinical feasibility of the Unity radiotherapy system guided by magnetic resonance imaging. Methods Twenty-four patients were enrolled and received a total of 384 fractions of treatment at Unity system. According to the treatment site, all patients were divided into head-neck, abdomen-thorax, pelvic, spine and limb groups. The patients were set-up without external laser. And then, the time required at different stages in online treatment process and the registration error of each fraction were separately calculated. The geometric deformations of MR images were weekly measured by using MR geometric deformation phantom. At last, the Arccheck was used to perform the dose verification of reference plan, online plan and offline plan. Results The mean duration of radiotherapy in the five groups were 29.1, 27.6, 26.6, 25.6 and 32.0min, respectively. The set-up errors in the left-right, superior-inferior and anterior-posterior direction in the five groups were:head-neck group (0.08±0.06cm, 0.16±0.13cm, 0.08±0.05cm), abdomen-thorax group (0.23±0.18cm, 0.50±0.47cm, 0.12±0.1cm), pelvic group (0.25±0.19cm, 0.32±0.25cm, 0.11±0.09cm), spine group (0.46±0.38cm, 0.26±0.26cm, 0.13±0.07cm) and limb group (0.33±0.30cm, 0.34±0.23cm, 0.08±0.06cm), respectively. In the central region, the geometric deformation of MR was less than 0.3mm, and that of the sphere with a diameter of 500mm was less than 2.1mm. The meanγ pass rate of the reference plan, online plan and offline plan were 97.92%, 97.84% and 94.58%, respectively. Conclusions MR-guided radiotherapy has great potential for clinical application, whereas the process of Unity system is relatively complex. The synergy of different departments has a great impact on the treatment, which needs further optimization.
		2021 Vol. 30 (2): 134-139 [Abstract] ( 179 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	140	Preliminary clinical application of stereotactic body radiotherapy (SBRT) for lung cancer based on MRI-guided radiotherapy system
		Li Zhenjiang, Li Chengqiang, Li Yukun, Wang Wei, Liu Xijun, Zhu Jian1, Li Baosheng, Lu Jie, Yin Yong
		Objective To observe the feasibility of magnetic resonance (MR)-guided stereotactic body radiotherapy (SBRT) for non-small cell lung cancer, and analyze the dosimetric differences in the presence or absence of magnetic field. Methods Three patients with non-small cell lung cancer were prospectively treated with MR-guided linac (MR linac) for SBRT, and the dose was calculated with or without magnetic field models. The differences of dose distribution with or without magnetic field models were compared. At the same time, the target coverage, plan pass rate and treatment time were described, and the complexity of the conventional accelerator backup plan and the magnetic field model were compared. Results The treatment time of 3 patients was (36.67±6.11) min, and the average time of online adaptive planning was (14.4±1.7) min, which was basically tolerated by patients. The treatment plan pass rate (3%/3mm) was 98.9%, the Gamma pass rate (3%/3mm) of the online plan during treatment was 98.5% and the target coverage was 99.1%, which met the clinical needs. The dose in the low dose area of the lung was slightly lower than that in the case without magnetic field, whereas the dose in ribs and skin was slightly higher than that in the plan without magnetic field. The number of machine unit (MU) for online adaptive plan was slightly higher than that of the reference plan, and the number of MU for the conventional accelerator standby treatment plan was significantly lower than that of the MR linac plan under the same target coverage. The follow-up results showed that there was no adverse reaction, and the short-term efficacy was partially relieved. Conclusions In the case of considering the influence of magnetic field, the treatment plan meeting the clinical needs can be obtained. It is proven that SBRT radiotherapy for lung cancer guided by magnetic resonance accelerator is feasible, whereas the treatment time and process are complex.
		2021 Vol. 30 (2): 140-145 [Abstract] ( 185 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	146	Characterization of imaging distortion of high-field magnetic resonance imaging-guided linear accelerator (MR-Linac) and its influencing factors
		Wang Bin, Liu Hongdong, Liu Biaoshui, Li Yongbao, Ding Shouliang, Huang Xiaoyan
		Objective To characterize the imaging distortion of the 1.5T magnetic resonance imaging-guided linear accelerator (MR-Linac) and to analyze the influence of MR-Linac and peripheral devices on the geometric distortion. Methods Specialized MRI imaging distortion phantom and analysis software were applied. The baseline of imaging distortion within diameter spherical volume (DSV) around the center of the magnet was established. The influence of the beam generation system, mechanical system and peripheral devices on the imaging distortion was analyzed. The long-term stability of imaging distortion was tested on the MR-Linac. Results Imaging distortion of the MR-Linac was increased with the increasing distance to the center of the magnet. Within DSV 400mm, few test points surpassed 1mm imaging distortion in 3D directions. However, imaging distortion surpassed 2mm in part of region within DSV 400-500mm, with the largest distortion over 7mm. Imaging distortion of the MR-Linac remained unchanged within 7 months after installation. And the influence of the MR-Linac and peripheral devices on the imaging distortion was only observed in the overall largest distortion within DSV 400-500mm. Conclusions Cautions should be taken during the application of high-field MR-Linac in patients whose tumor location is over 20 cm from the ISO center. Imaging distortion of the MR-Linac remains stable within 7 months after installation. The influence of the MR-Linac and peripheral devices on the imaging distortion is trivial, which can be neglected in clinical practice.
		2021 Vol. 30 (2): 146-150 [Abstract] ( 171 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	151	Evaluation of the feasibility of Gd-based contrast clearance difference to delineate subvolume target in radiotherapy for primary and metastatic brain tumors
		Wang Yinxing, Gong Guanzhong, Su Ya, Wang Lizhen, Lu Jie, Yin Yong
		Objective To evaluate the feasibility of delineating subvolume target in radiotherapy for brain tumors using Gd-based contrast clearance difference. Methods Twenty-six patients with malignant brain tumors were scanned with MRI. The first and second acquisitions of standard T₂-weighted images (T₂WI) and T₁-weighted images (T1WI) were performed at 5min and 60min after injection of contrast agent. Delayed contrast extravasation (DCEM) MRI computed by Brainlab comprised regions of contrast agent clearance representing active tumors and regions of contrast accumulation representing non-tumor tissues. Based on T₂WI images,14 patients with liquefaction necrosis were divided into group A, and 12 patients without liquefaction necrosis into group B, respectively. Then, gross target volume (GTV) was delineated on T1WI images. Based on the GTV, active tumor (GTV_tumor) and non-tumor regions (GTV_non-tumor) were delineated on T₁WI-DCEM fusion images, while liquefaction necrosis (GTV_liquefaction) and non-liquefaction (GTV_{non-liquefaction}) were delineated on T₁-T2WI fusion images. Finally, the differences between different subvolumes were compared by paired t-test. Results In group A, the GTV_{non-liquefaction} and GTV_liquefaction were (13.65±18.15) cm³ and (6.30±7.57) cm³. The GTV_tumor was (10.40±13.52) cm³ and the GTV_non-tumor was (9.55±14.57) cm³. The GTV_{non-liquefaction} was significantly increased by 16.3% on average compared with the GTV_tumor (P<0.05). The GTV_non-tumor was significantly increased by 16.3% on average compared with the GTV_liquefaction (P<0.05). In group B, The GTV_non-tumor was significantly reduced by 68.8% on average compared with the GTV_tumor (P<0.05). Conclusions Compared with T₂WI, DCEM has advantages in identifying the liquefaction area and can clearly differentiate the subvolume of active tumors from non-liquefaction necrosis. DCEM provides evidence for guiding the delineation of subvolume in primary and metastatic brain tumors.
		2021 Vol. 30 (2): 151-155 [Abstract] ( 148 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	156	Comparison of dose distributions among five radiotherapy apparatuses in stereotactic body radiation therapy for pancreatic cancer SBRT Group of Radiation Oncology Committee of Shanghai Medical Association
		Cao Yangsen, Zhang Jianying, Li Tingting, Qiu Jianjian, Zhang Libo, Zhuang Yayun, Su Yang, Guo Xiaojing, Zhang Huojun
		Objective To compare the dose distribution among CyberKnife, Tomotherapy, Edge, Triology and γ-knife in stereotactic body radiation therapy (SBRT) for pancreatic cancer. Methods Clinical data of 10 panreatic cancer patients receiving CyberKinife treatment were retrospectively analyzed. The treatment plans were designed by five apparatuses from five centers according to the uniform requirement. All plans were transferred to MIM system for the extraction of parameters, which mainly included Dmin, Dmean and Dmax of PTV, conformity index (CI), new conformity index (nCI), homogeneity index (HI), gradient index (GI), coverage, Dmax and dose-volume of the stomach and bowel. Results The best CI and nCI were obtained in Triology (P<0.001), and the worst HI was found in γ-knife (P<0.001). The best GI was found in CyberKnife, followed by γ-knife and Tomotherapy, and Edge showed the worst GI (P<0.001). The highest Dmin of PTV was found in both Edge and Triology, while lower Dmin of PTV was found in CyberKnife and Tomotherapy (P<0.001). Additionally, γ-knife provided the highest Dmean and Dmax of PTV (P<0.001). Regarding the organs at risk, the lowest Dmax and D5cm³ of the bowel (P<0.001), Dmax of the stomach (P=0.003), Dmax(P=0.001), D5cm³ (P<0.001) and D10cm³ (P=0.005) of the duodenum, Dmax(P<0.001) and D0.35cm³ (P<0.001) of the spinal cord were found in CyberKnife. The highest Dmax of the bowel was found in γ-knife. Furthermore, the highest D5cm³ of the duodenum was demonstrated in Edge (P<0.001) and Tomotherapy provided the highest Dmax(P<0.001) and D0.35cm³ of the spinal cord (P<0.001). Conclusions All five radiotherapy apparatuses can meet the requirement of SBRT for pancreatic cancer. More rapid dose fall-off could be obtained via CyberKnife and γ-knife. Triology and Edge provide better target conformity. CyberKnife can better protect the gastrointestinal tract.
		2021 Vol. 30 (2): 156-163 [Abstract] ( 219 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	164	A comparative study of dose distribution of prostate IMRT between IMRT and VMAT models using knowledge-based planning
		Bi Suyan, Dai Zhitao, Ding Zhen, Sun Xingru, Yuan Qingqing, Chen Zhijian, Ren Hua
		Objective To compare the dosimetric difference between knowledge-based planning (KBP) volumetric modulated arc therapy (VMAT) and intensity-modulated radiotherapy (IMRT) models for predicting the dose distribution during IMRT, aiming to investigate the feasibility of VMAT model to predict the IMRT plans. Methods Fifty prostate cancer patients who had completed radiotherapy were selected. Manual planning was performed on each selected patient to generate the corresponding IMRT and VMAT plans. The IMRT and VMAT manual plans of the 40 randomly-selected patients were adopted to generate the KBP VMAT and IMRT models. The remaining 10 patients were utilized to predict IMRT plans. VMAT library-derived IMRT model (V-IMRT) and IMRT library-derived IMRT model (I-IMRT) were generated. Dosimetric parameters related to organ-at-risks (OARs) and planning target volume (PTV) were statistically compared among the manual IMRT (mIMRT), V-IMRT and I-IMRT plans. Results Compared with the mIMRT plan, I-IMRT could significantly better control Dmax of the PTV (P=0.039), whereas V-IMRT and I-IMRT plans could better protect the bladder and bilateral femoral heads (both P<0.05). V-IMRT plan could better protect the Dmax of bilateral femoral heads and the D15% of the right femoral head (both P<0.05), whereas no significant difference was observed in other OARs and PTV (all P>0.05). Conclusions Compared with the manual plans, KBP IMRT plan has significant advantages in protecting the OARs. KBP VMAT and IMRT models are both feasible in clinical practice, which yield equivalent accuracy for predicting IMRT plan.
		2021 Vol. 30 (2): 164-169 [Abstract] ( 219 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	170	Effect of selection of statistical uncertainty of control points in Monaco planning system on dose calculation in nasopharyngeal carcinoma
		Wu Siyu, Huang Xiaoyan, Cao Wufei, Chen Li
		Objective To explore the influence of the selection of statistical uncertainty of control points in Monaco planning system on the dose distribution of nasopharyngeal carcinoma (NPC), aiming to provide the statistical uncertainty of single control point in Monte Carlo calculation which satisfies clinical needs. Methods First, nine 10cm×10cm square fields with an equal interval of gantry angle were designed and five cases of 9-field intensity-modulated radiotherapy (IMRT) and five cases of single-arc volumetric-modulated arc therapy (VMAT) plans were randomly selected, Then, quality assurance (QA) verification plan using patient CT as QA phantom was created. Second, the grid spacing was selected as 3 mm during the calculation of dose distribution of QA plan. The statistical uncertainties of single control point were selected as 1%, 2%, 3%, 4% and 5%, respectively. Last, the deviation of dose distribution between different statistical uncertainties and 1% statistical uncertainty was analyzed. Results For a square field and single IMRT field, the dose deviation of center point was almost 7% while the statistical uncertainty was selected 4%. For 9-field IMRT and single-arc VMAT, the dose deviation of center point was ≤ 1.5% and the average dose deviation of PTV was ≤ 0.3% when the statistical uncertainty of control points was changed from 1% to 5%. The percentage of the point dose deviation of the coronary plane of ≤ 1% was greater than 99% when the statistical uncertainty was ≤ 3% for 9-filed IMRT and 4% for single-arc VMAT. Conclusions For the Monaco treatment planning system based on Monte Carlo calculation, the changes in the statistical uncertainty of control point from 1% to 5% exert significant effect upon the single field. In clinical application, the statistical uncertainty of control point should be ≤ 3% for 9-field IMRT and ≤ 4% for single-arc VMAT.
		2021 Vol. 30 (2): 170-174 [Abstract] ( 208 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	175	Study on the effect of 4D-CT special reconstruction image on the evaluation of cardiac structure dose in radiotherapy for breast cancer
		Su Ming, Gong Guanzhong, Qiu Xiaoping, Li Qian, Tong Ying, Yin Yong
		Objective To evaluate the effect of different reconstruction images on cardiac dose evaluation by comparing the differences between 4D-CT series and special reconstruction images in evaluating the dose-volume index of cardiac structures. Methods ECG 4D-CT series were scanned in 15 female patients with left breast cancer. The images of 0-95% 20 phases were reconstructed at an interval of 5% cardiac cycle. The maximum intensity projection (MIP), minimum intensity projection (MinIP), average intensity projection (AIP) and sum intensity projection (SIP) images were obtained by special reconstruction of 4D-CT series. Left ventricle (LV) and left anterior descending coronary artery (LADCA) were delineated on 4D-CT and special reconstruction series, respectively. The intensity-modulated radiation therapy plan of the left breast cancer was designed on the basis of 0% phase, and the cumulative dose (Dose-cumulate) of 20 phases was obtained by deformation registration. The doses of 0% phase were deformed and registered to MIP, MinIP, AIP and SIP images to obtain the corresponding dose distribution. The dose-volume indexes of LV and LADCA based on different CT images were compared. Results In the evaluation of dose-volume index of LV, compared with 4D-CT series, the change rates of V5Gy, V30Gy, V40Gy, Dmax and Dmean on MIP images were 3.8%, 2.0%, 0.9%, 3.8% and 1.7%, respectively. There was significant difference in V5 and Dmax between MIP and 4D-CT (both P<0.05). Compared with 4D-CT, the change rates of Dmax on MinIP, SIP and AIP images were 2.5%, 3.1% and 1.5%, respectively (all P<0.05). In the evaluation of dose-volume index of LADCA, only the change rate of Dmax on four special reconstructed images was<5%(P<0.05). Conclusions In the dose-volume evaluation of LV, the V30Gy, V40Gy and Dmean obtained by MIP are basically equivalent to those obtained by 4D-CT series, which can be used to substitute 4D-CT series to evaluate the dose-volume. The special reconstruction image of LADCA can not replace 4D-CT series.
		2021 Vol. 30 (2): 175-179 [Abstract] ( 185 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	180	Nomenclature standardization of radiotherapy in cervical cancer
		Zheng Wanjia, Mai Xiuying, You Yiqi, Huang Sijuan, Tao Yalan, Chi Feng, Cao Xinping, Lin Chengguang, Huang Xiaoyan, Yang Xin
		Objective To standardize the naming of organ at risk (OAR) and target area during cervical cancer radiotherapy based on AAPM TG-263. Methods After self-programming of Matlab software to implement the reading and resolution of radiotherapy structure files, the naming of each substructure was automatically output, recorded and restored. After naming all substructures, the structure names were classified by keywords. According to TG-263, a standard naming conversion table of OAR and target area was developed, and the classified structure names were standardized through procedures. Finally, the standardized named radiotherapy structure files were output and imported into the treatment planning system (TPS). Results The radiation structure of 144 patients with cervical cancer was successfully transformed and displayed correctly in TPS. Before the transformation, the naming of OAR and target area lacked of uniform norms and standards, and the naming of the same structure significantly differed. After the transformation, 43 naming methods of OAR and 74 naming methods of the target area were unified into 20 and 8 naming methods, which were more convenient for staff understanding and communication. Conclusion The standardization of cervical cancer radiotherapy structure naming can reduce the inconsistency of naming and provide reference for the standardized naming of pelvic tumors.
		2021 Vol. 30 (2): 180-185 [Abstract] ( 180 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	186	Effect of body mass index on setup errors in intensity-modulated radiotherapy for cervical cancer
		Li Yaning, Lin Chengguang, Yang Xin
		Objective To investigate the effect of body mass index (BMI) on setup errors in intensity-modulated radiotherapy for cervical cancer and explore the optimal position for patients with different BMI without taking into account the rotation error and the changes in target area and adjacent organs. Methods A total of 90 patients were divided into three groups according to their BMI:light weight group (BMI≤18.4 kg/m²), normal weight group (18.5 kg/m²≤BMI≤23.9 kg/m²) and overweight group (BMI≥24 kg/m²). Thirty patients were assigned into each group including15 patients in the supine position and 15 patients in the prone position. In total, 2250 sets of CBCT scan data of 90 patients were obtained. The setup errors were recorded and analyzed in each group. The margins of the optimal position were calculated according to the formula of MPTV=2.5+0.7. Results When BMI was not taken into account, there was no significant difference in the setup errors between the supine and prone positions in the x, y and z directions (all P>0.05). When BMI was considered, the setup error in the supine position were significantly smaller than those in the prone position in the x and y directions in the light weight group, whereas there was no significant difference in the setup errors between the supine and prone positions in the z direction (P>0.05). The corresponding MPTV in the supine position was 4.76, 4.27 and 5.73mm, respectively. In the normal weight group, there was no significant difference in the setup errors between the supine and prone positions in the x and y directions (both P>0.05), whereas the setup error in the prone position was smaller than that in the supine position in the z direction. The corresponding MPTV in the prone position were 6.42, 10.21 and 4.91mm, respectively. In the overweight group, there was no significant difference in the setup errors between the supine and prone positions in the x and z directions (all P>0.05), whereas the setup error in the prone position was smaller than that in the supine position in the y direction. The corresponding MPTV in the prone position were 5.88, 5.26 and 5.32mm, respectively. Conclusions Without taking into account the rotation error and the changes in target area and adjacent organs, when the BMI≤18.4, the supine position is recommended. When the BMI≥18.5, it is better to choose the prone position.
		2021 Vol. 30 (2): 186-190 [Abstract] ( 204 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	191	miR-203a regulates bladder cancer cell proliferation and radiosensitivity by targeting CDK6
		Wang Lei, Qiao Qingdong, Huang Haihang, Li Haoran, He Yunfeng
		Objective To investigate the expression of miR-203a in bladder cancer (BC) cell lines (RT-112, T24, 5637, UM-UC-3) and evaluate the effects on BC cell proliferation and radiosensitivity. Methods Mir-203a mimics, mir-203a inhibitor, CDK6siRNA, CDK6 expression plasmid and corresponding negative controls were transfected into BC cells. Quantitative real-time PCR was used to detect the expression of miR-203a in BC cell lines and human bladder epithelial immortalized cell line (SV-HUC-1). CCK8 assay was used to investigate the regulation of miR-203a and cyclin-dependent kinases 6(CDK6) on the proliferation of BC cells. Colony formation assay was performed to assess the effect of miR-203a and CDK6 on the radiosensitivity of BC cells. The target gene of miR-203a was confirmed by luciferase reporter assay. The effect of miR-203a on CDK6 protein expression was detected by Western blot. Multi-group comparison was performed by one-way ANOVA and two-group comparison was conducted by t-test. Results Compared with the SV-HUC-1 cells, the expression levels of miR-203a in RT-112, T24, 5637 and UM-UC-3 cells were significantly down-regulated (all P<0.05). Compared with NC group, overexpression of miR-203a significantly inhibited the proliferation of BC cells, whereas knockdown of miR-203a significantly promoted the proliferation of BC cells (both P<0.05). Compared with NC group, overexpression of miR-203a significantly increased the sensitivity of BC cells to radiotherapy, whereas knockdown of miR-203a significantly weakened the sensitivity of BC cells to radiotherapy (both P<0.05). CDK6 was the target of miR-203a. Compared with NC group, overexpression of miR-203a significantly down-regulated the expression level of CDK6 protein, whereas knockdown of miR-203a significantly up-regulated the expression level of CDK6 protein (both P<0.05). After overexpression of CDK6 in T24 and UM-UC-3 cells transfected with miR-203a mimics, the cell proliferation ability was significantly increased, whereas the sensitivity to radiotherapy was significantly decreased compared with mir-203a mimics (both P<0.05). After CDK6 was silenced in RT-112 and 5637 cells transfected with miR-203a inhibitor, the proliferation ability of cells was significantly decreased, whereas the sensitivity to radiotherapy was remarkably increased compared with miR-203a inhibitor group (both P<0.05). Conclusion miR-203a can serves as a tumor suppressor gene to inhibit the proliferation of BC cells and enhance the radiosensitivity of BC cells.
		2021 Vol. 30 (2): 191-197 [Abstract] ( 197 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	198	LncRNA LINC00261 regulates radiosensitivity of nasopharyngeal carcinoma and tumor formation in nude mice by down-regulating miR-620 expression
		Fu Gaoshang, Zhang Ke, Xu Yanxia, Xu Ying, Zhang Xuexi, Lian Lixia
		Objective To investigate the effect of LINC00261 on the radiosensitivity of nasopharyngeal carcinoma and tumor formation and its underlying mechanism in nude mice. Methods qRT-PCR was used to detect the relative expression levels of miR-620 and LINC00261 in radiosensitive and radioresistant nasopharyngeal carcinoma tissues. After the 6-10B and HNE-3 cells were irradiated with 0, 2, 4, 6, and 8 Gy ⁶⁰Coγ-ray, the relative expression levels of miR-620 and LINC00261 were measured by qRT-PCR. After over-expression or silencing of LINC00261 and inhibition of miR-620 expression, the cells were irradiated with 4 Gy ⁶⁰Coγ-ray. Clone formation assay was performed to detect the radiosensitivity of nasopharyngeal carcinoma cells. Flow cytometry was used to detect cell apoptosis. Western blot was utilized to detect the expression levels of Cleaved caspase-3 and Cleaved caspase-9 proteins. Luciferase reporter assay was adopted to analyze the targeting relationship between LINC00261 and miR-620. The changes in tumor formation were observed in tumor-bearing nude mice. Results Compared with the radiosensitive tissues, the expression of LINC00261 was significantly down-regulated, whereas that of miR-620 was significantly up-regulated in radioresistant tissues (both P<0.05). After different doses of irradiation, the expression of LINC00261 was significantly down-regulated, whereas that of miR-620 was significantly up-regulated in 6-10B and HNE-3 cells (both P<0.05). After overexpression of LINC00261 and interference with miR-620 expression, the expression levels of Cleaved caspase-3 and Cleaved caspase-9 were significantly up-regulated (both P<0.05), the cell apoptosis rate was remarkably increased (P<0.05) and the cell survival fraction was significantly enhanced in 6-10B and HNE-3 cells (P<0.05). LINC00261 targetedly regulated the expression of miR-620. Overexpression of miR-620 could attenuate the radiosensitization and pro-apoptotic effects of LINC00261 overexpression on nasopharyngeal carcinoma cells. LINC00261 overexpression could significantly reduce the tumor formation weight of nasopharyngeal carcinoma in nude mice (P<0.05). Conclusion Overexpression of LINC00261 can increase the radiosensitivity of nasopharyngeal carcinoma cells probably by targeted regulation of miR-620 expression.
		2021 Vol. 30 (2): 198-203 [Abstract] ( 191 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Review Articles

	204	Application of MR-guided radiotherapy for pancreatic cancer
		Zeng Liang, Zhong Renming
		Radiotherapy is a vital treatment method for pancreatic cancer. However, the therapeutic effect of radiotherapy is significantly limited by the influence of pancreatic motion. More efficient radiotherapy for pancreatic cancer depends upon the improvement of motion management and high-quality image guidance. The emerging MR-guided radiotherapy (MRgRT) can perform functional imaging with high soft tissue resolution and no additional radiation. Multiple researches have demonstrated that MRgRT has significant advantages in terms of precise delineation of target area and organ at risk, motion management and adaptive radiotherapy, which assists radiotherapy to play a better role in the treatment of pancreatic cancer. In this paper,the application of MRgRT in pancreatic cancer was reviewed and prospected.
		2021 Vol. 30 (2): 204-207 [Abstract] ( 181 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	208	Research progress and controversies of individualized local treatment of breast ductal carcinoma in situ
		Xu Feifei, Chen Jiayi, Cao Lu
		With the widespread adoption of screening mammography, the incidence of ductal carcinoma in situ (DCIS) has been dramatically increased. The spectrum of local treatment advances from mastectomy to breast conservation surgery plus whole breast irradiation (WBI), and hypofractionated WBI or accelerated partial breast irradiation. Although the efficacy of WBI on reducing local recurrence is clear, such benefit in the low-risk DCIS is still controversial. Further studies are required to establish a more precise local recurrence risk stratification system for better tailoring local treatment in patients with DCIS. In this review, the latest advances and controversies in surgery, radiation therapy and local recurrence risk stratification system for patients with DCIS were summarized.
		2021 Vol. 30 (2): 208-212 [Abstract] ( 182 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	213	Research progress on the mechanism of radiation-induced lung injury
		Ying Hangjie, Chen Yamei, Chen Mengyuan, Fang Min, Chen Ming
		Radiation-induced lung injury (RILI) is a common complication in thoracic cancer patients through radiotherapy, which can be divided into the early-stage radiation-induced pneumonitis (RP) and late-stage radiation-induced lung fibrosis (RILF). At present, glucocorticoids are mainly adopted in the clinical treatment of RP. However, there has been no effective medical treatment for RILF. RILF patients will eventually die from respiratory failure. The exact mechanism of RILI remains unclear. Current studies have proposed that its possible pathogenesis might consist of genetic heterogeneity, oxidative stress and cell damage. In this review, studies related to the pathogenesis of RILI were summarized.
		2021 Vol. 30 (2): 213-216 [Abstract] ( 198 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	217	Research progress on application of 3D printing technique in radiotherapy
		Hou Yanjie, Yu Jiangping, Wang Junjie
		Three-dimensional (3D) printing technique has been improving the industrial process from uniform pipeline production procedure in manufacture into individualized production with distributed network. 3D printing technique also provokes these changes in the field of medicine, especially in orthopedics, stomatology and radiology. The role of 3D printing technique has been increasingly highlighted in tumor radiotherapy. Current studies and application mainly focus on personalized tissue compensato (bolus), brachytherapy (high-dose post-loading and particle implantation therapy), 3D printing personalized phantom and individualized fixtures, etc. In this article, research progresses on the application of 3D printing technique in radiotherapy at home and abroad were reviewed.
		2021 Vol. 30 (2): 217-220 [Abstract] ( 233 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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