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.11 Published 2021-11-15

	Abdominal Tumors Thoracic Tumors Review Articles Physics·Technique·Biology

Thoracic Tumors

	1105	Effect of Onodera's prognostic nutritional index on the prognosis of esophageal squamous cell carcinoma after intensity-modulated radiotherapy
		Yan Ke, Zhao Hanjun, Deng Wenzhao, Wang Xiaobin, Du Xingyu, Shen Wenbin, Zhu Shuchai
		Objective To investigate the relationship between Onodera's prognostic nutritional index (PNI) and prognosis of patients with esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy or radiotherapy, aiming to provide a convenient, effective and accurate predictive indicator for evaluating the long-term survival of patients after treatment. Methods Clinical data of 231 ESCC patients treated with definitive chemoradiotherapy or radiotherapy at the Fourth Hospital of Hebei Medical University from 2013 to 2015 were retrospectively analyzed. The PNI values of each patient at different radiotherapy periods were calculated and the ROC curve was used to determine the optimal cutoff value of PNI before radiotherapy, 231 patients were divided into the better-nourishment group (n=86) and worse-nourishment group (n=145). Kaplan-Meier method was used for survival analysis. Cox proportional hazards model was utilized to analyze the relationship between different nutritional status and prognosis. The short-term clinical efficacy and incidence of acute toxicities were statistically compared between two groups. Results The mean values of PNI before, at week 3, week 6 and 1 month after radiotherapy were48.68±5.08,39.68±4.87,43.74±4.89 and48.31±4.92, respectively. The optimal cutoff value of pretreatment PNI was 49.25, the area under the curve (AUC) was 0.655, the sensitivity and specificity were 68.6% and 60.9%, respectively. The 5-year overall survival (OS) and progression-free survival (PFS) rates in the better-nourishment group (PNI≥49.25) were 36.0% and 31.3%, significantly better than 19.3% and 18.6% in the worse-nourishment group (PNI<49.25)(P=0.001,P=0.039). Multivariate analysis showed PNI before the therapy was an independent prognostic factor for OS (P=0.021). Stratified analysis demonstrated that Stage Ⅰ/Ⅱ and concurrent chemotherapy patients in the better-nourishment group all obtained significantly better OS than their counterparts in the worse-nourishment group (P=0.007,P=0.004). In addition, the Objective response rate in the better-nourishment group was significantly higher than that in the worse-nourishment group (P=0.047), whereas the incidence of ≥3 grade radiation esophagitis was lower than that in the worse-nourishment group (P=0.060). Conclusions Pretreatment PNI is a convenient and reliable indicator for predicting the long-term survival of ESCC patients after definitive chemoradiotherapy or radiotherapy. Patients with higher PNI have relatively better prognosis and radiotherapy tolerance, especially in those with early stage or concurrent chemotherapy.
		2021 Vol. 30 (11): 1105-1110 [Abstract] ( 140 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1111	Study of application of radiomics model in predicting radiation pneumontis in patients with lung cancer and esophageal cancer
		Yu Jiaqi, Zhang Zhen, Ren Kai, Wang Wei, Liu Ying, Li Qian, Ye Zhaoxiang, Zhao Lujun
		Objective To analyze and explore the common radiomics features of radiation pneumonitis (RP) in patients with lung cancer and esophageal cancer, and then establish a prediction model that can predict the occurrence of RP in two types of cancer after radiotherapy. Methods Clinical data of 100 patients with stage Ⅲ lung cancer and 100 patients with stage Ⅲ esophageal cancer who received radical radiotherapy were retrospectively analyzed. The RP was graded by imaging data and clinical information during follow-up, and the planning CT images were collected. The whole lung was used as the volume of interest to extract radiomics features. The radiomics features,clinical and dosimetric parameters related to RP were analyzed, and the model was constructed by machine learning. Results A total of 1691 radiomics features were extracted from CT images. After ANOVA and LASSO dimensionality reduction in lung cancer and esophageal cancer patients, 8 and 6 radiomics features associated with RP were identified, and 5 of them were the same. Using the random forest to construct the prediction model,lung cancer and esophageal cancer were alternately used as the training and validation sets. The AUC values of esophageal cancer and lung cancer as the independent validation set were 0.662 and 0.645. Conclusions It is feasible to construct a common prediction model of RP in patients with lung cancer and esophageal cancer. Nevertheless, it is necessary to further expand the sample size and include clinical and dosimetric parameters to increase its accuracy, stability and generalization ability.
		2021 Vol. 30 (11): 1111-1116 [Abstract] ( 140 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1117	Study of the value of SPECT lung perfusion imaging in optimizing lung cancer radiotherapy plan for lung function protection
		Liu Ji, Hao Meili, Tan Ye, Jiang Xiaohong, Lu Haijun
		Objective To evaluate the application value of SPECT lung perfusion imaging in guiding radiotherapy path, optimizing the radiotherapy plan for lung cancer and protecting lung function during radiotherapy for locally advanced non-small cell lung cancer. Methods In this study, 84 patients with stage Ⅲ non-resectable non-small cell lung cancer were randomly divided into the control group (n=44) and observation group (n=40). In the control group, radiotherapy plan based on conventional CT images was delivered, and two plans based on the lung function information suggested by conventional CT and SPECT lung perfusion imaging:P1 and P2 were given in the observation group. All patients in the observation group were finally treated according to the P2 plan. The incidence of radiation pneumonitis, and changes in lung function before and after radiotherapy were statistically compared between two groups. The dose-volume parameters of P1 and P2 were statistically compared. Results After the plan was optimized, the incidence of radiation pneumonitis in the observation group was significantly reduced and the decline of lung function was significantly improved (bothP≤0.001). The functional dose parameters were significantly improved in the P2 plans (bothP<0.05), whereas the irradiation dose of organs at risk did not significantly change (P>0.05). Conclusion SPECT lung perfusion imaging optimizes the intensity-modulated radiotherapy plan, which can reduce the functional lung dose and increase the tumor radiotherapy dose without increasing the irradiation dose of other organs at risk.
		2021 Vol. 30 (11): 1117-1121 [Abstract] ( 135 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Abdominal Tumors

	1122	Dosimetric evaluation, acute toxicity and short-term efficacy of postmastectomy hypofractionated internal mammary chain irradiation with electrons
		Zhang Yuanyuan, Zhang Tingting, Tang Yu, Jing Hao, Fang Hui, Song Yongwen, Chen Bo, Tang Yuan, Jin Jing, Liu Yueping, Lu Ningning, Qi Shunan, Li Ning, Li Yexiong, Wang Shulian
		Objective To investigate the dosimetric characteristics, acute toxicity and short-term efficacy of postmastectomy hypofractionated internal mammary (IM) chain irradiation with electrons in patients with high-risk breast cancer. Methods A total of 155 patients with breast cancer who underwent modified mastectomy between November 2018 and January 2020 were selected. Among them, 137(88.4%) patients were classified as stage Ⅲ and 18(11.6%) as stage Ⅱ. All patients received standard chemotherapy, endocrine therapy and anti-Her2 targeted therapy. CTVim was divided into three subregions:CTVim1, CTVim2 and CTVim3, which represented the first, second and third intercostal IM, respectively. The planning target volume of subraclavicular region (PTVsc) was delineated. CTVcw and CTVim were irradiated with 6-15MeV electron at 43.5Gy in 15 fractions over 3 weeks. Moreover, PTVsc was irradiated with 6MV X-ray at 43.5Gy in 15 fractions over 3 weeks using two-dimensional radiotherapy (2DRT) or three-dimensional radiotherapy (3DRT). The dosimetric characteristics of CTVim, PTVsc, lung, heart, left anterior descending coronary artery (LAD) and right coronary artery (RA) were evaluated, and the acute toxicity and short-term efficacy were analyzed. Results The mean dose (Dmean) of CTVim was (43.3±2.6)Gy, D95% was (30.5±8.3)Gy, V90% was (85.0±10.5)% and V80% was (91.0±7.4)%, respectively. The corresponding parameters of CTVim1 were significantly lower than those of CTVim2 and CTVim3(allP<0.001). Body mass index exerted no significant effect on IM dose (P>0.05). Compared with 2DRT, 3DRT for SC significantly increased theDmean of CTVim[(43.4±2.6)Gy vs.(41.4±2.3)Gy,P=0.021], and the hot spot within PTVsc[V110%:(26.7±17.5) cm³ vs.(12.5±8.4) cm³,P=0.018; V120%:(6.1±5.3) cm³ vs.(2.0±2.6) cm³,P=0.023]. TheDmean of the ipsilateral lung was (9.8±1.9)Gy, and V20Gy was (19.7±4.7)%. TheDmean of heart was (3.3±1.7)Gy in the whole group,(4.7±1.4)Gy for the left-sided breast cancer and (2.6±1.2)Gy for the right-sided breast cancer, respectively. TheDmean of LAD for the left-sided breast cancer was (13.9±4.9)Gy. TheDmean of RA for the right-sided breast cancer was (7.5±3.7)Gy. The incidence rates of ≥ grade 2 acute radiation dermatitis, esophagitis and pneumonitis were 19.3%, 4.5% and 2.6%, respectively. With a median follow-up time of 20.5 months (range:9.9-41.8 months), 2 cases of chest wall recurrence, 2 regional lymph node recurrence, 6distant metastases and 1death were reported. Conclusions When hypofractionated internal mammary chain is irradiated by electrons after mastectomy, the doses to the lung, heart and coronary artery are low, and the acute toxicities are mild. However, the dose to CTVim1 is inadequate. Although short-term efficacy is high, long-term follow-up is warranted.
		2021 Vol. 30 (11): 1122-1128 [Abstract] ( 112 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1129	Prognostic analysis of early stage extranodal natural-killer/T cell lymphoma
		Shen Jiafeng, Wu Tao, Liu Qiulin, Zhang Jing, Hu Yunfei, Chen Mengxiang, Huang Yunhong, Lu Bing
		Objective To analyze the efficacy and prognostic factors of radiotherapy combined with asparaginase/peaspartase-based chemotherapy regimen in the treatment of early stage extranodal natural-killer/T cell lymphoma of the upper aerodigestive tract (UADT ENKTCL). Methods 267 early stage UADT ENKTCL patients were treated in Guizhou Cancer Hospital from October 2003 to February 2020. Among them, 229 patients received radiotherapy or radiotherapy combined with menpartaminase/permenidase-based chemotherapy regimen and 38 patients were treated with radiotherapy or chemotherapy alone. The overall survival (OS) and progression-free survival (PFS) were calculated by Kaplan-Meier method, log-rank test was conducted for univariate analysis and Cox regression model was performed for multivariate analysis. Results The 5-year OS and PFS were 67.2% and 61.5% in all patients. The 5-year OS and PFS in patients treated with radiotherapy combined with chemotherapy, radiotherapy alone and chemotherapy alone were 71.7%, 35% and 49%(allP<0.001), and 66.4%, 35% and 28%(allP<0.001), respectively. According to the NRI risk stratification, 246 patients treated with radiotherapy and chemotherapy were divided into the favourable and the unfavourable prognosis groups. The 5-year OS was 93.3% and 64.3%(P<0.001) and the 5-year PFS was 91.1% and 56.7%(P<0.001) in two groups. For patients receiving radiotherapy with a dose ≥50Gy and<50Gy, the 5-year OS was 72.4% and 55.7%(P<0.001), and the 5-year PFS was 68.3%,and 36.5%(P<0.001). In the unfavourable prognosis group, the 5-year OS of patients receiving ≥ 4 and<4 cycles of chemotherapy was 65.5% and 59.2%(P=0.049), and the 5-year PFS was 60.7% and 50.6%(P=0.018). Univariate analysis showed that stage Ⅱ, ECOG≥2, primary tumor invasion, radiotherapy alone, NRI≥1(Nomogram-revised risk index), EBV-DNA≥2750 copies/ml, radiotherapy dose < 50Gy, and<4 cycles of chemotherapy were associated with unfavorable 5-year OS and PFS (allP<0.05),and CHOP-like regimen was the risk factor of unfavorable 5-year PFS (P<0.05). Multivariate analysis demonstrated that primary tumor invasion, ECOG≥2, and radiotherapy dose <50Gy were associated with unfavorable OS and PFS (allP<0.05), and stage Ⅱ was the risk factor of unfavorable 5-year OS (P<0.05). Conclusions The prognosis of early stage low-risk UADT ENKTCL of is favourable. Sufficient dose of extended involved-field radiotherapy is an important curative modality in early stage UADT ENKTCL. Compared with radiotherapy alone, radiotherapy combined with chemotherapy can significantly improve the prognosis of early stage UADT ENKTCL patients in the unfavourable prognosis group. Full-course chemotherapy can significantly prolong the long-term survival in the unfavorable prognosis group. The chemotherapy containing asparaginase can significantly enhance the prognosis of patients with early stage UADT ENKTCL.
		2021 Vol. 30 (11): 1129-1135 [Abstract] ( 137 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1136	Comparison of different delineation methods of clinical target volume of internal mammary lymph node for patients after internal mammary lymph node dissection
		Wang Xue, Wang Wei, Li Jianbin, Zheng Gang, Zhang Wenyu
		Objective To compare the differences of postoperative clinical target volume of internal mammary lymph node (CTVImlN) by different delineation methods, and to explore the reasonable method of CTVImlN delineation after internal mammary lymph node dissection (ImlND). Methods A total of 20 breast cancer patients who had undergone modified radical mastectomy(MRM) with ImlND on the affected side and had complete preoperative and postoperative CT images were selected. The CTV (CTVpr-I, CTVpr-a) of both sides of ImlN were delineated on preoperative CT images according to RTOG guideline. On postoperative CT images, three different methods including deformation image registration (DIR) method, visual contrast method and precise measurement method, were employed to delineate the postoperative CTVImlN of the affected side. The targets were named as CTVDIR, CTVV and CTVM, respectively. The central displacement, target volume, degree of inclusion (DI) and conformity index (CI) of CTVpr-a, CTVV, CTVM and CTVDIR were compared. Results The central displacement of CTVV, CTVM and CTVDIR from CTVpr-a was 2.17cm, 1.44cm and 1.25cm,respectively. The target volume of CTVpr-a, CTVpr-I,CTVV, CTVM and CTVDIR was 2.10cm³, 2.17cm³, 2.04cm³, 1.88cm³ and 2.07cm³ respectively. There was no significant difference in the target volume (all P>0.05). The CI values of CTVV-CTVpr-a and CTVM-CTVpr-a were both 0.16, and that of CTVDIR-CTVpr-a was 0.43. The CI value of CTVDIR was significantly higher than those of CTVV and CTVM (both P<0.01). The DI values of CTVV-CTVpr-a, CTVM-CTVpr-a and CTVDIR-CTVpr-a were 0.26, 0.24 and 0.58, respectively. The DI value of CTVDIR was significantly higher than those of CTVV and CTVM (both P<0.01). Conclusions It is difficult to accurately delineate the CTVImlN for patients after ImlND. However, the spatial position fitness of the target region delineated by DIR method is better than those by visual contrast and precise measurement methods.
		2021 Vol. 30 (11): 1136-1141 [Abstract] ( 130 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1142	Four-dimensional computed tomography scan analysis of liver tumor motion treated with abdominal compression during stereotactic treatment
		Zhao Ying, Tang Yuan, Liu Wenyang, Li Ning, Lei Junqin,Chen Silin, Shi Jinming, Ma Huiying, Zeng Qiang, Song Yongwen, Wang Shulian, Ren Hua, Liu Yueping, Fang Hui, Lu Ningning, Tang Yu, Qi Shunan, Yang Yong, Chen Bo, Li Yexiong, Jin Jing
		Objective To explore the motion and influencing factors of implanted gold markers in guiding liver stereotactic body radiation therapy (SBRT) using abdominal compression. Methods Twenty patients with oligometastatic colorectal cancer or primary hepatocellular carcinoma from January 2016 to December 2019 were included. All patients were treated with SBRT under abdominal compression, with 1-3 gold markers were implanted within 2cm from the lesion before positioning. Four-dimensional computed tomography (4DCT) scan was used for treatment planning. The respiratory cycle was divided into 0-90% respiratory phase images based on the respiratory signal, which were reconstructed by the system (Pinnacle³ version 9.1;Philips Medical System, Madison, WI, USA), and cone beam CT validation images before radiation exposure were obtained. The liver volume was divided into 3 parts:within 2cm from the main hepatic portal vein, 2-5cm from the main hepatic portal vein, and>5cm from the main hepatic portal vein. The motion of different tumor locations was evaluated. Results The average intrafractional motion amplitude was (2.63±2.81)mm in the cranial-caudal (CC) direction,(1.35±1.23)mm in the anterior-posterior (AP) direction, and (0.76±0.88)mm in the left-right (LR) direction, respectively. The average interfractional motion amplitude was (3.45±3.06)mm,(2.64±2.60)mm, and (2.23±2.07)mm, respectively. Both the intra-or inter-fractional motion amplitudes in the CC direction were the highest, followed by those in the AP and LR direction (allP<0.001). The motion varied at different tumor locations. The longer distance from the main hepatic portal vein, the larger the intrafractional motion (allP<0.05). To cover the 95% population-based confidence interval, the internal target volume (ITV) was suggested to include the expansion of 3.9mm, 5.2mm and 7.9mm in the LR, AP and CC direction. The expansion of 4.3mm, 4.4mm and 6.1mm was delivered within 2cm from the main hepatic portal vein, and 3.5mm,7.3mm and 9.7mm>5cm from the main hepatic portal vein, respectively. The expansion varied significantly depending on the tumor location, whereas the motion in the CC direction was the largest regardless of the tumor location. The longer distance of the tumor from the main portal vein, the larger expansion in the CC direction. The expansion of tumor > 5cm from the main portal vein in the AP direction was larger than that ofinner parts. Conclusion Liver tumors at different locations require individual external expansion of ITV.
		2021 Vol. 30 (11): 1142-1147 [Abstract] ( 133 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1148	Analysis of different prognostic effects of nadirs of neutrophils and lymphocytes during concurrent chemoradiotherapy for cervical cancer
		Yang Li, Xu Zhiyuan, Wang Qian, Xiao Xiangyu
		Objective To evaluate the effects of the nadirs of neutrophils and lymphocytes during concurrent chemoradiotherapy (CCRT) on clinical prognosis of patients with cervical cancer,aiming to provide reference data for clinicians. Methods Clinical data of FIGO (2018)ⅠB1-ⅣA cervical cancer patients treated with radical CCRT inthe University of Hong Kong-Shenzhen Hospital,from January 2015 to September 2019 were analyzed. Routine blood test was performed weekly. The overall survival (OS) was calculated by Kaplan-Meier methodand analyzedby log-rank test.Univariate andMultivariate prognostic analysis were performed by Cox proportional hazards model. Results A total of 87 patients were included. The cutoff values of absolute neutrophil count nadir (ANCn) and absolute lymphocyte count nadir (ALCn) for predicting OS were determined by receiver operating characteristic curve. Compared with the ANCn of ≤2.14×10⁹/L (n=76), patients with the ANCn of > 2.14×10⁹/L (n=11) had lower 2-year OS rate (54.5% vs. 88.9%,P=0.035). Compared with ALCn of > 0.2×10⁹/L (n=49), patients with ALCn of ≤0.2×10⁹/L (n=38) obtained lower 2-year OS rate (75.3% vs. 90.8%,P=0.008). Multivariate analysis showed that ANCn (>2.14×10⁹/L vs. ≤2.14×10⁹/L)(HR=4.487,95%CI:1.404-14.344,P=0.011),ALCn (≤0.2×10⁹/L vs. >0.2×10⁹/L)(HR=5.814,95%CI:1.822-18.554,P=0.003),concurrent chemotherapy cycle (5-6 cycles vs. 0-4 cycles)(HR=0.204,95%CI:0.060-0.696,P=0.011) and the mean body radiation dose (HR=1.296,95%CI:1.125-1.493,P<0.001) were significantly associated with OS. Patients with the ANC of > 5.19×10⁹/L before CCRT were more likely to have ANCn of > 2.14×10⁹/L during CCRT and those with the ALC of < 2.05×10⁹/L before CCRT was more likely to have ALCn of ≤0.2×10⁹/L during CCRT. Conclusions Peripheral ANCn and ALCn during CCRT have different prognostic effects and influencing factors. Clinical prognosis of cervical cancer patients may be improved by closely monitoring routine blood parameters and optimizing treatment modality during CCRT.
		2021 Vol. 30 (11): 1148-1153 [Abstract] ( 132 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1154	Evaluation of clinical efficacy and safety of single-channel intracavitary applicator for uterine cervical cancer:3-year long-term results of a prospective randomized phase Ⅱ clinical trial
		Li Dan, Huang Rong, Wen En, Wu Zhouxue, Lin Sheng, He Lijia, Ren Peirong, Shang Changling, Xiang Li, Yang Hongru, Wu Jingbo
		Objective To evaluate the 3-year survival outcomes and late injury between the self-designed patent single-channel applicator, which was modified from the traditional tandem applicator and wrapped with a oval-shield alloy around the source channel and standard Fletcher-type applicator in the high-dose-rate brachytherapy for cervical cancer. Methods Patients initially diagnosed with cervical cancer in the Affiliated Hospital of Southwest Medical University from December 2011 to April 2017 were enrolled and randomly assigned into the external beam radiotherapy (EBRT)+ single-channel intracavitary applicator group (the patent single-channel group) and EBRT+the Fletcher applicator group. The whole pelvis irradiation was delivered with 6-MV photons via a four-field box variant or anterior and posterior parallel fields. Five to six fractions of intracavitary brachytherapy were performed at a dose of 7Gy at point A once a week after 30Gy (Equivalent Dose in 2Gy at point A:80-90Gy). Chemotherapy was given with intravenous injection of cisplatin at a dose of 40mg/m² once weekly during EBRT. Clinical efficacy and safety were evaluated after corresponding treatment. Results In total, 150 eligible cases were assigned into the Fletcher applicator group and 149 cases into the patent single-channel group. Up to December 2020, all patients had been followed up for 3 years, and the median duration of follow-up was 61 months. In the Fletcher group, the 3-year overall survival, progression-free survival and locoregional failure-free survival was 76.3%, 78.1% and 75.4%, and 83.8%, 80.3% and 85.5% in the single-channel group, respectively. In the Fletcher group, the cumulative rate of grade 3-4 late rectal complications was 3.3% and 6.7% in the single-channel group (P=0.122). The cumulative rate of grade 3-4 bladder complications was 1.3% in the Fletcher group and 0.7% in the single-channel group (P=1.000). Conclusion The self-designed patent single-channel intracavitary applicator yields equivalent long-term clinical efficacy and safety to the standard Fletcher-type three-channel applicator in the HDR brachytherapy for uterine cervical cancer.
		2021 Vol. 30 (11): 1154-1158 [Abstract] ( 143 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Physics·Technique·Biology

	1159	Meta-analysis of dosimetric comparison between volumetric-modulated arc therapy and intensity-modulated radiotherapy for breast cancer after modified radical mastectomy
		Gao Yan, Zhong Heli, Li Zhuangling, Zhang Guangwei, Li Longxing, Shi Yabin, Li Xianming
		Objective To compare the dosimetric differences between volumetric-modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT) on planning target volume (PTV) and organ-at-risk (OAR) for breast cancer after modified radical mastectomy, aiming to provide evidence-based reference for clinical practice. Methods According to strict inclusion and exclusion criteria, literature search was performed in PubMed, Cochrane Library, FMRS, CNKI, Wanfang Data and VIP full text databases from the inception of databases up to March 2020. The controlled clinical trials of dosimetric comparison between VMAT and IMRT for breast cancer following modified radical mastectomy were selected. The meta-analysis was performed using Stata14software. Results The meta-analysis included 281 patients from 13 observational studies. Compared with IMRT, VMAT significantly increased the PTV dose coverage D95%(P<0.001) and significantly improved the PTV homogeneity index (HI,P<0.001) and conformity index (CI,P=0.004). Compared with IMRT, VMAT more effectively decreased the ipsilateral lung V20Gy (WMD=1.332,P=0.027) and contralateral lung V10Gy (P=0.003). There were no significant differences in theDmean, V5Gy, V10Gy and V30Gy of the ipsilateral lung,Dmean and V5Gy of the contralateral lung,Dmean,V10Gy and V30Gy of the heart between VMAT and IMRT (allP>0.05). Compared with VMAT, IMRT reduced the cardiac V5Gy (P=0.001). However, sensitivity analysis of included literature on cardiac V5Gy showed that the P value was reversed, indicating that the stability of the results was poor. VMAT significantly shortened the delivery time (P<0.001) and the number of monitor units (P<0.001) compared to IMRT. Conclusion Compared with IMRT, VMAT can achieves superior target dose coverage, HI and CI, better protection for the ipsilateral and contralateral lung, fewer monitor units and shorter delivery time.
		2021 Vol. 30 (11): 1159-1166 [Abstract] ( 118 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1167	Tolerance and dosimetric study of multi-leaf collimator leaf position accuracy for dynamic intensity-modulated radiotherapy
		Yang Jiming, Ma Min, Wu Yong, Ren Jiangping
		Objective To evaluate the dosimetric effect of multi-leaf collimator (MLC) position error on dynamic intensity-modulated radiotherapy (dMLC-IMRT), aiming to provide guidance for the establishment of MLC quality control accuracy and operation tolerance. Methods In the phantom study, the virtual water phantom established in the treatment planning system (TPS), and three dynamic sliding window test fields with gap width of 5mm, 10mm and 20mm were designed. Clinical treatment plans of 7 common tumor types were extracted, including nasopharyngeal carcinoma, glioma, lung cancer, esophageal cancer, cervical cancer, prostate cancer, and breast cancer, with 6 cases in each. MLC errors were introduced into the copy from original plan to generate the simulation plans. MLC errors included systematic open/close error, systematic deviation error and random error. The dosimetric differences between the original and simulation plans were compared. Results The phantom study showed that the symbol of dose deviation was the same as that of systematic open/close error, and the value was increased with the increase of MLC error and decreased with the increase of gap width. The results of patient study showed that the systematic open/close error had a significant effect on dosimetry, the target volume dose sensitivities of different plans were 7.258-13.743%/mm, and were negatively correlated with the average field width. The dosimetric deviation caused by the systematic shift error below 2mm was less than 2%. The dosimetric change caused by the random error below 2mm could be neglected in clinical treatment. Conclusions The minimal gap width should be limited in TPS, whereas the quality control of MLC should be strengthened. In addition, for the dynamic intensity-modulated treatment technology, 2mm random error was suggested to be the operation tolerance during treatment delivery, and 0.2mm alignment accuracy on each side (or 0.4mm unilateral) is recommended to be the MLC quality control accuracy to ensure the dose accuracy of radiotherapy for different tumors.
		2021 Vol. 30 (11): 1167-1172 [Abstract] ( 137 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1173	Implementation and assessment of software based on ESAPI compilation structure
		Wang Zhiqun, Yang Bo, Zhang Jie, Yu Lang, Wang Bei, Li Wenbo, Zhu Gao, Wang Xiaoshen, Lan Maoying, Wang Xingliu, Zhou Zongkai, Zhu Weihua, Zhang Zhen, Hu Ke, Zhang Fuquan, Qiu Jie
		Objective To help clinicians simplify the post-processing operations of structures by developing rapid processing software for target area and organs at risk structures based on ESAPI. Methods SmartStructure script software was developed based on ESAPI, verified and evaluated in clinical work. 10 cases of rectal cancer receiving neoadjuvant radiotherapy, 10 breast cancer treated with postoperative radiotherapy, 10 cervical cancer receiving postoperative radiotherapy, 10 nasopharyngeal carcinoma receiving radical radiotherapy and 10 lung stereotactic body radiotherapy (SBRT) were selected, and different types of tumors had different post-processing operations of structures. In each case, three methods were used for post-processing of structures. In the control group (manual group), normal manual processing was employed. In the experimental group 1(SmaStru-N group), scripts without templates were utilized. In the experimental group 2(SmaStru-P group). scripts combined with templates were adopted. The processing time of the three methods was compared. Clinicians scored the scripting software from multiple aspects and compared the feeling scores of scripting software and manual operation. Results All three methods can be normally applied in clinical settings. The error rate in the manual group was 7.0%, 3.0% in the SmaStru-N group 0% in the SmaStru-P group, respectively. Compared with the manual method, SmaStru-N shortened the processing time of target area and organs at risk by 60.9% and 93.3% for SmaStru-P. In addition, SmartStructure was superior to manual method in terms of using feeling scores. Clinicians gave lower score for the"applicability" and"simplicity", and higher score on the"accuracy" and"efficiency". Conclusions Compared with conventional manual structure processing method, SmartStructure software can rapidly and accurately process all structures of the target area and organs at risk, and its advantages become more obvious with the increasing number of structures that need to be processed. SmartStructure software can meet clinical requirements, reduce the error rate, elevate processing speed, improve the working efficiency of clinicians, providing basis for the development of adaptive radiotherapy.
		2021 Vol. 30 (11): 1173-1177 [Abstract] ( 141 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1178	Application of auto-importing of CT images and structures into treatment planning system based on UiBot software
		Li Bing, Cheng Zhiyao, Guo Wei, Mao Ronghu, Lou Zhaoyang, Cheng Xiuyan, Ge Hong
		Objective To build a systemic and automatic importing scheme for importing CT images and structures into the treatment planning systems (TPSs) of Eclipse and Monaco. Methods Based on two TPSs of Eclipse and Monaco, the files of CT images and structures were automatically transported from OAR auto-delineation system to the importing directory of these two TPSs using batch script in Windows system. Following the standard importing procedures of these two TPSs, the automatically importing script of CT images and structures were developed using the application of UiBot. Finally, the CT images and structures were imported into these two TPSs opportunely. Results By comparing the importing time using script and manual methods, the script not only achieved auto-importing CT images and structures into TPSs, but also yielded almost the same efficiency to manual method. The number of imaging layers in most patients was between 130 and 180, and the average manual and automatic importing time within this interval was 76s and 75s. Conclusions Automatic scripts can be developed by using the automation function of UiBot combined with the actual problems of radiotherapy and repeated workflow. The efficiency of radiotherapy work can be significantly improved. Manual and time costs can be saved. It provides a novel alternative for the automation of radiotherapy procedures.
		2021 Vol. 30 (11): 1178-1182 [Abstract] ( 257 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1183	Preliminary observation of new immobilization for total skin irradiation with helical tomotherapy
		Xu Senkui, Yao Wenyan, Hu Jiang, Xia Yunfei, Kang Dehua, Tao Yalan, Jiang Xiaobo, Lu Jie, Lin Chengguang
		Objective To preliminarily observe the feasibility of different immobilization techniques for total skin irradiation (TSI) using helical tomotherapy. Methods Three eczema scrophuloderma patients treated with TSI in Sun Yat-sen University Cancer Center were immobilized with low-temperature thermoplastic in a prone position, diving suit combined with negative pressure vacuum bag in a supine position, low-temperature thermoplastic combined with vacuum bag in a supine position,respectively. Different immobilization effects were observed. The conformity index (CI) of the target area, heterogeneity index (HI) of the target area, and the mean dose (Dmean) of the target area were calculated. Results Three immobilization methods could achieve satisfactory immobilization effects, and all the dosimetric parameters of radiation treatment plans met the clinical requirements. The average set-up errors in the left and right, head and foot, and abdomen and back directions of three patients were (0.26±3.40)mm,(-2.63±4.63)mm and (6.13±4.86)mm, respectively. The CI, HI andDmean were0.56±0.09,1.186±0.059 and (2586.56±63.28)cGy. Conclusions Low-temperature thermoplastic or diving suits can be combined with vacuum bags for immobilization in TSI. The epidermal dose can be increased with bolus through the dose-building effect, which can provide a safe and reliable method for TSI in helical tomotherapy.
		2021 Vol. 30 (11): 1183-1187 [Abstract] ( 163 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1188	miR-205-5p/E2F1signal axis is involved in the regulation of radiosensitivity of glioma cells through suppressing the classical Wnt/β-catenin signaling pathway
		Zhou Youdong, Luo Ran, Liu Yanting,Dong Yuanxun, Ma Jinyang, Hu Huojun, Wang Xuguang, Guo Jinman, Huang Song, Yuan Gao, Fu Changtao, Wang Lei, Gao Yan
		Objective To explore the mechanism of miR-205-5p/E2F1signal axis in regulating the glioma U251, U87 radiotherapy resistance. Methods X-ray gradual ascending and intermittent induction method was used to irradiate the glioma U251 cells to establish U251/TR, U87/TR radiation-resistant cell lines. Then, the morphology, migration, invasion and proliferation abilities of cells (U251/TR, U87/TR radiation-resistant cells and U251, U87 radiation-sensitive cells) were analyzed. Luciferase gene detection system and point mutation technique were employed to analyze the mechanism of miR-205-5p and E2F1 gene activity on U251 and U87 radiation-resistant cell lines. Results Compared with the radiation-sensitive U251 cells, the radiation-resistant cells U251/TR, U87/TR showed increased proliferation activity, enhanced migration and invasion abilities and decreased apoptosis under X-ray irradiation. miR-205-5p mimics transfection could down-regulate the expression of E2F1 factor in U251/TR cells, inhibit cell proliferation, invasion and migration and increase the radiosensitivity of U251/TR cells. miR-205-5p mimics transfection combined with with E2F1down-regulation exerted anti-tumor effect and decreased cell tolerance by suppressing the Wnt/β-catenin signaling pathway activity. Conclusions The glioma radiation-resistant cell line U251/TR, U87/TR can be established by X-ray gradual ascending and intermittent induction method. The miR-205-5p/E2F1signal axis exerts tumor-suppressing effect through the classical Wnt/β-catenin signaling pathway, which can be used as an therapeutic target to increase the radiosensitivity of glioma.
		2021 Vol. 30 (11): 1188-1194 [Abstract] ( 142 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1195	Effect of down-regulation of lncRNA LINC00263 targeting miR-4458 on regulating radiosensitivity of breast cancer SK-BR-3 cells
		Wen Lanlan, Wang Dongjuan, Dong Hui, Zhao Jiwei, Zhu Cuimin, Lin Pingping, Liu Lanfang, Li Qingshan
		Objective To evaluate the effect of down-regulating lncRNA LINC00263 targeting miR-4458 on the proliferation, migration, invasion and radiosensitivity of breast cancer SK-BR-3 cells. Methods The expression differences of LINC00263 in breast cancer tissues, adjacent tissues, normal breast epithelial cells and breast cancer cells were determined by qRT-PCR. Transfection of LINC00263shRNA in breast cancer SK-BR-3 cells down-regulated the expression of LINC00263, and the cloning experiment was used to detect the radiosensitivity. Breast cancer SK-BR-3 cells were treated with 6Gy irradiation. CCK-8 assay was employed to detect cell proliferation. Flow cytometry was adopted to detect cell apoptosis. Transwell chamber test was performed to detect cell migration and invasion. Western blot was used to detect the expression levels of C-Caspase-3 and C-Caspase-9, MMP-2 and MMP-9 proteins. Bioinformatics software predicted that LINC00263 and miR-4458had complementary binding sites, and the luciferase reporter system was utilized determine the targeting relationship between LINC00263 and miR-4458. LINC00263shRNA and miR-4458 inhibitor were co-transfected into breast cancer SK-BR-3 cells, and 6Gy irradiation was given to detect the changes in cell proliferation, apoptosis, invasion and migration. Results The expression level of LINC00263 in breast cancer tissues was higher than that in adjacent tissues. The expression level of LINC00263 in breast cancer cells was higher compared with that in normal breast epithelial cells. The radiosensitivity of breast cancer SK-BR-3 cells was increased after transfection of LINC00263shRNA. Transfection of LINC00263shRNA and radiation exerted a synergistic effect, jointly inhibited breast cancer cell proliferation, migration and invasion, promoted cell apoptosis, up-regulated the expression levels of C-Caspase-3 and C-Caspase-9 proteins in cells, and down-regulated those of MMP-2 and MMP-9 proteins. Down-regulation of LINC00263 targetedly up-regulated miR-4458 expression. miR-4458 inhibitor reversed the inhibitory effect of LINC00263shRNA combined with radiation on the proliferation, migration, invasion and apoptosis promotion of breast cancer SK-BR-3 cells. Conclusion Down-regulating lncRNA LINC00263 targeting miR-4458 inhibits the proliferation, migration and invasion of breast cancer SK-BR-3 cells, and improves cell radiosensitivity.
		2021 Vol. 30 (11): 1195-1201 [Abstract] ( 139 ) [HTML 1KB] [ PDF 0KB] ( 0 )

Review Articles

	1202	Current treatment of recurrent nasopharngeal carcinoma
		He Meilin, Yi Junlin
		On the basis of intensity-modulated radiotherapy (IMRT)-based comprehensive treatment, the 5-year overall survival rate of initially-treated nasopharngeal carcinoma patients without recurrence and metastasis has reached 80%, local regional control rate has exceeded 90%,whereas approximately 10%-15% of patients will suffer from local and/or nodal recurrence after initial treatment. The factors affecting the decision-making of re-treatment mainly include the causes of local and/or nodal recurrence of nasopharngeal carcinoma after initial treatment, selection of re-treatment, side effects and efficacy after re-treatment. This article summarizes the recent progress on these issues above.
		2021 Vol. 30 (11): 1202-1208 [Abstract] ( 114 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1209	Practice and prospect of radiotherapy and immunotherapy for lung cancer
		Shang Shijie, Chen Dawei, An Cui, Wang Ruiyang, Wu Meng, Yu Jinming
		In recent years, immunotherapy has become the hottest topic in the field of oncology. Both the Keynote189 study and the Keynote407 study have confirmed that progression-free survival is significantly prolonged in patients who have been benefited from immune checkpoint blockades in lung cancer. In an article published in The New England Journal of Medicine in 2012, a case report of radiation abscopal effects caused by immunization combined with conventional radiotherapy has attracted great attention in the field of oncology. The Pacific study, published in 2017, expanded the indications for immunotherapy from advanced to locally-advanced non-small cell lung cancer. The second analysis of Keynote001, published in the Lancet Oncology in the same year, suggested that radiation therapy may mediate the immune memory effects, whereas the mechanism and time window are still unclear. With the publication of PEMBRO-RT study and several pieces of work by our team in recent years, various details of radiotherapy combined with immunotherapy (iRT) have become more mature. In clinical practice, iRT is involved in the full treatment of lung cancer. However, iRT is not a hodgepodge or stew that needs further refinement and sorting. In this article, the principles, efficacy in clinical practice, and exploration of the details of iRT were discussed.
		2021 Vol. 30 (11): 1209-1215 [Abstract] ( 151 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1216	Research progress on application of simultaneous integrated boost intensity-modulated radiotherapy in esophageal carcinoma
		Wang Lan, Wang Yamin, Liu Lihong, Liu Shutang, Han Chun, Yu Jinming
		In recent years, unconventional fractionated radiotherapy has shown increasing advantages in the treatment of multiple system tumors. Simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) involves the delivery of standard-fraction doses of radiotherapy to different areas, achieving the delivery of higher doses of radiotherapy per fraction to the high-risk gross tumor volume (GTV) without sacrificing the irradiation dose to the normal tissues. The dosimetric advantages of SIB-IMRT have been widely recognized. At present, the local control,survival advantage, indication population and the optimal upper limit of single fraction of SIB-IMRT for esophageal carcinoma are still unclear. This article reviews the application of SIB-IMRT in esophageal carcinoma.
		2021 Vol. 30 (11): 1216-1220 [Abstract] ( 142 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	1221	Research progress on stereotactic body radiotherapy for oligometastatic breast cancer
		Song Yuchun, Wang Shulian
		Distant metastasis is the leading cause of death for breast cancer patients, and advanced metastatic breast cancer is mainly considered incurable. Oligometastasis is an"intermediate stage" between local primary tumor and extensive metastasis. As a local treatment approach, radiotherapy plays an important role in the management of oligometastatic breast cancer. The development of stereotactic body radiotherapy (SBRT) allows the delivery of ablative doses to the targets without exceeding the dose constraints of organs-at-risk. Studies have shown that SBRT is safe and effective, with local control rates of more than 80% for breast cancer oligometastasis to the bone, lung, liver, brain, and lymph nodes. However, how to screen the true oligometastasis remains controversial. Randomized clinical trials will be essential to confirm whether SBRT can improve the survival outcomes.
		2021 Vol. 30 (11): 1221-1225 [Abstract] ( 131 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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