Chinese Journal of Radiation Oncology

中华放射肿瘤学杂志

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Chinese Journal of Radiation Oncology

	2022 Vol.31 Issue.6 Published 2022-06-15

	493	Medical physics practice guidelines for Linac-based stereotactic radiotherapy
		National Cancer Center/National Cancer Quality Control Center
		Stereotactic radiotherapy (SRT) has the characteristics of large irradiation dose per fraction, few fraction sessions and sharp dose falloff out of the target volume. During the radiotherapy treatment, the most precise equipments should be used, and the strictest and most standardized operations should be performed. The purpose of this guideline is to establish the minimum level of medical physics support deemed prudent for the practice of linear-accelerator, photon-based (Linac) stereotactic (cranial) radiation therapy (SRT) services in China, aiming to help institutions in China to carry out SRT technology correctly and safely. When using this guideline, each institution should develop clear and detailed standard operating procedures according to their SRT equipment-specific or patient-specific requirements.
		2022 Vol. 31 (6): 493-512 [Abstract] ( 90 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	513	Comparison of clinical efficacy between postoperative simultaneous and sequential integrated boost intensity-modulated radiotherapy for high-grade glioma
		Li Feng, Wang Guohui, Chang Xiaojing, Li Haonan, Liu Huizhi, Ge Xiaohui
		Objective To compare the efficacy and side effects between simultaneous and sequential integrated boost intensity-modulated radiotherapy after operation for high-grade glioma. Methods We retrospectively analyzed 142 patients with high-grade glioma who underwent postoperative radiotherapy from January 2010 to December 2017. All patients were divided into the simultaneous and sequential integrated boost intensity-modulated radiotherapy groups. Concurrent temozolomide chemotherapy was delivered during radiotherapy in two groups. The follow-up outcomes were statistically compared between two groups. Results For the whole group, the median overall survival (OS) was 24 months, the median progression-free survival (PFS) was 17 months, and the median disease-free survival (DFS) was 25 months. In the simultaneous and sequential integrated boost intensity-modulated radiotherapy groups, the median OS were 27.2 and 21.0 months (P=0.950), the median PFS were 21.2 and 15.0 months (P=0.21), and the median DFS were 28.0 and 18.0 months (P=0.171), and the disease control rates were 92.86% and 85.17%(P=0.541), respectively. There was no statistical difference in OS, PFS, DFS, short-term efficacy and side effects between two groups. However, the conformity index in the simultaneous integrated boost intensity-modulated radiotherapy group was better than that in the sequential integrated boost intensity-modulated radiotherapy group (P=0.032). Conclusions Postoperative simultaneous and sequential integrated boost intensity-modulated radiotherapy yield no statistical differences in the survival, short-term efficacy and side effects in the treatment of high-grade glioma. However, the conformity index in the simultaneous integrated boost intensity-modulated radiotherapy group is significantly better, which can be recommended for postoperative radiotherapy of high-grade glioma.
		2022 Vol. 31 (6): 513-518 [Abstract] ( 112 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	519	Analysis of recurrence patterns of early-stage non-small cell lung cancer treated with stereotactic ablative radiotherapy
		Zheng Xiaoli, Ye Ke, Sun Yanan, Fan Chengcheng, Yang Yang, Wang Xiaohui, Liu Yang, Cheng Chen, Ge Hong
		Objective To analyze the failure patterns and influencing factors of stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer (ES-NSCLC). Methods 113 cases of ES-NSCLC treated with SABR from 2012 to 2020 in our hospital were retrospectively analyzed. The failure patterns, recurrence time, recurrence site and influencing factors were analyzed. Kaplan-Meier method was used to calculate the local recurrence rate, regional lymph node recurrence rate and distant metastasis rate. Univariate analysis was performed by Log-rank test, and multivariate analysis was performed by Cox model. Results The median follow-up time was 58 months (range:6-108 months), and a total of 45 patients (39.8%) recurred. The median recurrence time was 36 months. Distant metastasis (DM) occurred in 31 patients (27.4%) and DM alone in 24 patients (21.2%). Local recurrence (LR) was developed in 12 patients (10.6%) and LR alone in 7(6.2%). Regional lymph node recurrence (RR) occurred in 11 patients (9.7%) and RR alone in 6 patients (5.3%). LR combined with RR was observed in 1 case (0.9%), LR combined with DM in 3(2.7%), LR combined with RR and DM in 1(0.9%), and RR combined with DM in 3(2.7%). The 1-, 2-, 3-, 4-and 5-year recurrence rates were 5.4%, 16.6%, 27.5%, 44% and 51.2%, respectively. Univariate and multivariate analyses suggested that EGFR mutation was an influencing factor of high recurrence rate. Conclusion ES-NSCLC patients treated with SABR alone have a high recurrence rate, and DM is the most common mode of failure. Follow-up consolidation therapy is recommended, especially for EGFR mutation-positive NSCLC patients.
		2022 Vol. 31 (6): 519-524 [Abstract] ( 202 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	525	Analysis of the 10-year survival results of patients with esophageal squamous cell carcinoma achieving clinical complete remission after radical radiotherapy
		Li Runxiao, Shen Wenbin, Cao Yankun, Song Chunyang
		Objective To investigate the long-term prognosis and failure mode of patients with esophageal squamous cell carcinoma who achieved clinical complete remission (cCR) after receiving radical radio (chemo) therapy. Methods Clinical data of 183 patients with esophageal squamous cell carcinoma eligible for inclusion criteria who received treatment in our hospital from January 2009 to December 2012 were retrospectively analyzed. The factors that affected the long-term prognosis of patients were identified, and the failure mode of cCR patients and the prognosis after failure were analyzed. SPSS 19.0statistical software was used for data analysis. Results As of the follow-up date, the 1-, 3-, 5-, and 10-year overall survival (OS) rates and disease-free survival (DFS) rates of the entire group were 83.1%,53.4%,36.2%,12.8% and 68.9%,45.9%, 30.5%, 12.0%,respectively. The median OS and DFS were 41.3 months and 33.4 months. The results of multivariate analysis showed that cT staging, cN staging and prescribed dose were the independent factors affecting the OS (P=0.001, <0.001, 0.003);hoarseness, lesion length, cT staging, cN staging and prescribed dose were the independent factors that affected the DFS (P=0.002, 0.033, 0.009,<0.001, 0.003). In the whole group,72 cases (39.3%) had local regional recurrence,58 cases (31.7%) had distant metastasis, and 26 cases (14.2%) had local regional recurrence with distant metastasis. Among 104 patients after treatment failure, the prognosis of patients receiving salvage treatment was significantly better than that of their counterparts receiving maintenance treatment (χ²=39.153, P<0.001). Conclusions The long-term prognosis of patients with esophageal squamous cell carcinoma who achieved cCR after receiving radical radio (chemo) therapy is still unsatisfactory. Clinically, it is necessary to strengthen the clinical observation and follow-up of these patients. The main treatment failure mode of cCR patients is local regional recurrence. Active salvage treatment can significantly improve clinical prognosis of these patients.
		2022 Vol. 31 (6): 525-531 [Abstract] ( 93 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	532	Analysis of treatment results of concurrent and asynchronous radiochemotherapy for early extranodal NK/T cell lymphoma
		Liu Qiulin, Wu Tao, Zhang Jing, Hu Yunfei, Chen Mengxiang, Huang Yunhong
		Objective To compare the efficacy of concurrent and asynchronous radiochemotheray for early extranodal nasal natural killer/T-cell lymphoma (NKTCL). Methods From 2007 to 2020, 278 patients with early NKTCL treated with comprehensive treatment in the Affiliated Tumor Hospital of Guizhou Medical University were recruited. According to the adjusted Nomogram-revised risk index (NRI) prognostic model, there were 49 cases in the good prognostic group without adverse prognostic factors (age>60 years old,increased serum lactate dehydrogenase (LDH), ECOG score ≥2, primary tumor invasion (PTI), Ann Arbor stage Ⅱ,and 229 cases in the poor prognostic group with any adverse prognostic factors. 145 of these cases were treated with concurrent radiochemotherapy, and 133 of them were treated with asynchronous radiochemotherapy. Results The 5-year overall survival (OS) rate of the whole group was 71.0%, and the progression-free survival (PFS) rate was 67.6%. The 5-year OS rate in the good prognostic group was 95.6%, and 65.4% in the poor prognostic group (P<0.001). In the poor prognostic group, the 5-year OS rates of patients with NRI=1(low-and moderate-risk group), NRI=2(moderate-and high-risk group), NRI≥3(high-risk group) were 72.1%, 61.1% and 47.7%, respectively (P=0.007). There was no significant difference in curative effect between the concurrent and asynchronous radiochemotherapy groups. The 5-year OS rates were 70.6% and 69.8%(P=0.783), and the 5-year PFS rates were 67.6% and 65.2%(P=0.631). Further stratified analysis showed that the 5-year OS rates of patients with NRI=1 receiving concurrent and asynchronous radiochemotherapy were 73.1% and 76.5%(P=0.576),62.6% and 69.3%(P=0.427) for those with NRI=2, and 58.1% and 42.3% for those with NRI≥3(P=0.954). Conclusions Comprehensive treatment can significantly improve the prognosis of early NKTCL in the poor prognostic group. In the sequence of radiotherapy and chemotherapy, there is no significant difference in 5-year OS and PFS rates between concurrent and asynchronous radiochemotherapy. Sequential treatment with better tolerance can be adopted for early NKTCL with poor prognosis.
		2022 Vol. 31 (6): 532-538 [Abstract] ( 107 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	539	Analysis of dosimetry and clinical efficacy of intracavitary/interstitial brachytherapy in ⅢB cervical cancer
		Xiu Yuting, Meng Fanxu, Wang Zhuo, Zhao Kangkang, Wang Yunlong, Chen Zhishen, Liu Min, Tian Qi, Liu Juntian, Sun Baosheng
		Objective To compare the dosimetry and efficacy of intracavitary brachytherapy (ICBT) and intracavitary/interstitial brachytherapy (IC+ISBT) based on CT image guidance in the treatment of stage ⅢB cervical cancer. Methods Clinical data of 93 patients with stage ⅢB cervical cancer treated in Department of Radiotherapy of Jilin Cancer Hospital from June 2014 to February 2017 were analyzed retrospectively. According to the results ofGynecological examination and pelvic MRI before brachytherapy, confirming the size of residual tumor and the degree of parauterine infiltration, all patients were divided into the ICBT and IC+ISBT groups. The D90%, D100%, V100% and D2cm³ of bladder and rectum were compared, and the short-term and long-term efficacy was observed between two groups. Results The median follow-up time was 60 months. The 5-year local control rate, distant metastasis-free survival rate and overall survival rate of all patients were 83%, 71% and 68%, respectively. Compared with the ICBT group, HR-CTV D90% in the IC+ISBT group was all more than 85Gy, while there was no significant difference between two groups (P=0.188). The D2cm³ of bladder and rectum in the IC+ISBT group was significantly decreased by 7Gy and 8Gy (both P<0.01), and the distant metastasis-free survival rate was significantly improved (P=0.009). The 5-year local control rate in the HR-CTV volume>60cm³ in the IC+ISBT group was significantly higher than that in the IC group (P=0.029). Conclusion For patients with ⅢB cervical cancer, IC+ISBT can not only ensure target coverage, but also significantly reduce the incidence of distant metastasis and the dose of organs at risk, and significantly improve the local control rate of large tumors.
		2022 Vol. 31 (6): 539-543 [Abstract] ( 103 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	544	Dosimetric study of 6MeV X-ray in different phantoms in a magnetic field
		Hu Birong, Meng Qianqian, Zhong Renming
		Objective To evaluate the effects of orthogonal magnetic fields on the dose distribution of 6MeV X-ray in a uniform water and heterogeneous phantoms. Methods The Monte Carlo simulation software Gate v8.2 was used to investigate the dose distribution of X-ray beams of different field sizes in a uniform water phantom, water-air/bone-water layer phantom and"custom lung model" in the magnetic field strength of 0.0, 0.5, 1.0, 1.5, 3.0 T, respectively. The relationship between the intensity of magnetic field and the dose distribution of X-rays in the phantoms was analyzed. Results The existence of a magnetic field would cause the X-ray to shorten the built-up area in the water phantom;when the field was 10cm×10cm, the maximum dose on the central axis could change by up to 56.22%(3.0 T). The transverse dose distribution of the radiation field in the direction of the vertical magnetic field shifted to one side by up to 43.64%(-44.55%). The average dose of the air layer in the water-air-water phantom could be reduced by 57.4%(3.0 T). In the water-bone-water phantom, the dose at the proximal end of the bone layer was decreased by 16.5%, whereas the dose at the distal end was increased by 22.6%(1.5 T). The dose change in each layer in the customed lung model was positively correlated with the magnetic field strength. Conclusion The existence of the orthogonal magnetic field will cause the change of X-ray dose distribution on the built-up area and both sides of the radiation field in the phantoms, which is more obvious adjacent to the interface of heterogeneous phantom.
		2022 Vol. 31 (6): 544-549 [Abstract] ( 104 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	550	Statistical analysis of duration of each phase of Unity MR-linac in clinical application
		Sun Yingying, Hong Tianhang, Wang Hong, Li Shenglan, Tian Yuan, Huan Fukui, Qin Shirui
		Objective To analyze the duration of each phase of Unity MR-linac in clinical application,aiming to provide reference for clinical optimization of the process time. Methods Clinical data of 55 patients treated with Unity MR-linac were retrospectively analyzed. All patients were divided into the adapt to position (ATP) and adapt to shape (ATS) groups according to the planning method. The duration of each phase in the treatment process, the name and the time of each sequence, the number of beams, segments and total monitor units (MUs) were recorded and compared between two groups. In addition, the set-up time was counted according to different treatment sites. The time of each sequence and set-up time were expressed as the median M (Q₁, Q₃), and the number of beams, segments and total MUs of each plan were described as the mean±SD. Results 42 patients underwent ATP with a total of 305 treatment sessions:setup time was 3(2, 5) min, MR scanning time was 5(4, 7) min, registration time was 3(3, 4) min, adaptive planning time was 8(4, 12) min, beam on time was 8(6, 11) min, and the total time was 30(25, 36) min. 13 patients received ATS with a total of 65 treatment sessions:setup time was 2(2, 3) min, MR scanning time was 7(5, 8) min,registration time was 4(3, 5) min, time of delineation of target and organs at risk was 12(9,16) min, adaptive planning time was 11(10,14) min, beam on time was 10(9,11) min and the total time was 55(49,61) min. The set-up time according to treatment sites was 4(2, 4) min in the head and neck, 2(2, 4) min in the chest, and 3(2, 5) min in the abdomen. The number of fields, segments and total MUs during ATP were 8.1±1.7, 49.9±31.2, 846.75±363.44 in the head and neck, 8.0±2.0, 60.7±13.3, 790.21±279.00 in the chest, and 9.7±2.0, 81.2±22.3, 2007.32±1053.81 in the abdomen, respectively. The number of fields, segments and total MUs during ATS in head and neck of one case were 13, 39, 993.07, and 9.5±1.5, 65.5±6.3, 2763.26±835.41 in the abdomen. Conclusions MR-guided radiotherapy yields huge potential in clinical application. However, there is still much room for the improvement of shortening the process duration.
		2022 Vol. 31 (6): 550-555 [Abstract] ( 103 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	556	Preliminary research on breast cancer organoids as a radiobiological model
		Li Li, Han Zhongbin, Chen Hongsheng, Liang Shanshan, Wang Ruoyu
		Objective To construct breast cancer organoid culture system and conduct histological characterization and preliminary radiobiological characteristics study. Methods Different molecular types of breast cancer cell lines and patient-derived tumor cells were cultured in vitro to form breast cancer organoids and characterize their tissue structure. In addition, Ki-67, ER, PR and Her2 markers were evaluated by immunohistochemical staining. Breast cancer organoids were irradiated with 4Gy and 8Gy. The numbe and diameter changes of breast cancer organoids at 0, 24, 48 and 96h after irradiation were observed to evaluate the irradiation-induced damage to the organoids. Results Breast cancer cell lines and patient-derived tissues formed organoid structures at 6d. HE staining showed the microstructures, and the expression profile of markers was spatially heterogeneous. The expression patterns of markers were similar between patient-derived organoids and original tumor tissues. Irradiation of MCF-7 breast cancer organoids led to growth arrested, and some of the formed organoids collapsed and the proliferating trend gradually recovered from 48h to 96h. MDA-MB-231 breast tumor organoids showed radioresistance, growth arrested, but the structures remained intact, the recovery trend was still not observed at 96h. The tissue-derived organoids from triple-negative patients also showed radiation tolerance. After irradiation, the organoids continued to grow without significant structural changes, whereas the growth trend was significantly smaller than that in the non-irradiated group. Conclusions Breast cancer organoids formed by in vitro culture of breast cancer cells from different sources and different molecular types have microstructure and heterogeneity, which can reflect the expression of source tissue markers and show different radioresistance. Organoids derived from triple-negative breast cancer are more resistant to irradiation.
		2022 Vol. 31 (6): 556-561 [Abstract] ( 107 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	562	Pirfenidone inhibits the polarization of M2 macrophages by down-regulating IRF4 to reduce the occurrence and development of radiation-induced lung fibrosis
		Fang Min, Ying Hangjie, Hang Qingqing, Chen Yamei, Chen Ming
		Objective To explore the preventive and therapeutic effect of pirfenidone (PFD) on radiation-induced lung fibrosis (RILF) and its mechanism. Methods 40 female C57/BL6 mice were randomly divided into 4 groups:negative control group (NC), PFD treatment group (PFD), radiation treatment group (RT) and radiation plus PFD treatment group (RT+PFD). Mice in RT and RT+PFD groups received a single whole lung X-ray consisting of a 50Gy dose of radiation, delivered by small animal radiation research platform (SARRP). PFD at a dose of 300mg/kg was administered orally 2h before irradiation for 150d. HE and Masson staining were used to detect the infiltration of inflammatory cells and the degree of pulmonary fibrosis. Quantitative real-time PCR (qPCR) and Western blotting (WB) were adopted to detect the expression levels of M1/M2 macrophage phenotypic markers. The expression levels of arginase-1(ARG-1), chitinase 3-like protein 3(YM-1) and interferon regulatory factor-4(IRF4) of macrophages stimulated with IL-4 and IL-13 were detected by WB. In addition, immunofluorescence staining was used to detect the expression and translocation of IRF4 in macrophages among different treatment groups. Results HE and Masson staining showed that PFD could significantly inhibit radiation-induced infiltration of inflammatory cells and fibrosis in lung tissues. The M2 macrophages and expression levels of ARG-1 and YM-1 were down-regulated in the RT+PFD group. Cell experiments further confirmed that PFD could significantly inhibit the polarization of macrophages to M2 induced by IL-4+IL-13, which was mainly related to the down-regulation of IRF4. Conclusion PFD has a preventive and therapeutic effect on RILF by inhibiting IRF4 and reducing the polarization of macrophages to M2.
		2022 Vol. 31 (6): 562-568 [Abstract] ( 112 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	569	Hypofractionated radiotherapy of head and neck cancer:research progress and clinical value in COVID-19 pandemic
		Shao Shilong, Li Churong, Chen Sihao, He Shanshan, Zhong Zuxian, Wang Dan, Feng Mei, Zhang Peng, Zhang Shichuan
		Radiotherapy is an essential part of comprehensive treatment, as well as a radical treatment for head and neck cancer (HNC). The COVID-19has continued so far, imposing a great impact on cancer care. Since conventional fractionated radiotherapy (CFRT, 2Gy/F) requires as long as more than six weeks of treatment time, a huge challenge for epidemic control is created for both hospitals and patients. Hypofractionated radiotherapy (Hypo-RT) may be more suitable than CFRT for patients during pandemic by increasing the fraction size, thus reducing fraction number and treatment duration. Early studies have explored the application of Hypo-RT in HNC in palliative setting, which partially proved its safety and effectiveness. Recently, the efforts have been made in definitive treatment using hypofractionated regimen, as well as its combination with systemic treatment and immunotherapy. Indeed, regarding the pandemic of COVID-19, Hypo-RT has been recommended by several expert consensus in the HNC. In this review, relevant research progress was summarized and clinical implication of Hypo-RT in COVID-19 pandemic era was discussed.
		2022 Vol. 31 (6): 569-573 [Abstract] ( 94 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	574	Advances in application of CT/MR and PET/MR for target delineation in glioma
		Liao Taiping, Zhang Chunyin
		Glioma is the most common central nervous system tumor, mainly derived from the interstitial cells of the nervous system, showing diffuse and infiltrative growth, with the characteristics of high morbidity, high postoperative recurrence, high mortality and low cure rate. Currently, radical resection followed by radiotherapy and chemotherapy is the first choice of treatment. Accurate delineation of GTV-T is of significance for precision radiotherapy after surgery. In addition, CT/MR fusion imaging has been commonly used in the delineation of tumor targets in glioma. In recent years, PET/MR has been more and more widely applied in tumors. In this article, the application and differences between PET/MR and CT/MR for target delineation in glioma were reviewed.
		2022 Vol. 31 (6): 574-578 [Abstract] ( 101 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	579	Research progress on radiotherapy combined with immunotherapy for non-small cell lung cancer
		Xu Tongzhen, Liang Jun
		Radiotherapy combined with immunotherapy for non-small cell lung cancer (NSCLC), especially with PD-1/PD-L1 immune checkpoint inhibitors, have fallen under the spotlight in recent years. How to explore the optimal combination modality of radiotherapy and immunotherapy to maximize the benefits for all-stage patients is one of the developing directions of clinical research. This article expounds the effect of radiotherapy on tumor immunology, research progress on radiotherapy combined with immunotherapy for various stages of NSCLC, and the problems existing in radiotherapy combined with immunotherapy.
		2022 Vol. 31 (6): 579-584 [Abstract] ( 106 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	585	Research progress on radiation-induced heart disease in esophageal cancer
		Yang Hongjuan, Sun Yunchuan
		Radiotherapy is one of the main treatment for esophageal cancer. With the development of radiotherapy techniques, prognostic outcomes of esophageal cancer have been gradually improved and radiation-induced heart disease (RIHD) has captivated increasing attention. Radiation-induced heart complications mainly encompass pericardial disease, cardiomyopathy, coronary artery atherosclerosis, valvular heart disease, and arrhythmias, etc. The use of modern radiotherapy techniques is expected to mitigate heart injury and reduce the risk of RIHD. Research progress on the incidence and risk factors of RIHD in esophageal cancer were described as follows.
		2022 Vol. 31 (6): 585-588 [Abstract] ( 82 ) [HTML 1KB] [ PDF 0KB] ( 0 )

	589	Research progress on the role of astrocytes in radiation-induced brain injury
		Zhu Wenjun, Peng Xiaohong, Li Xiaoyu, Luo Na, Tang Wenhua, Fu Min, Zhang Yuanyuan, Yang Feng, Zhou Haiting, Wen Su
		Radiation-induced brain injury (RBI) is one of the complications after radiotherapy for head and neck malignant tumors, which seriously affects the quality of life of patients. The pathophysiological mechanism of RBI is not completely clear. Current studies suggest that it is involved in a variety of cells in the central nervous system (CNS), whereas astrocyte, as the largest number of glial cells in the CNS, plays an important role in maintaining the CNS homeostasis and responding to CNS injury. In this article, the role of astrocytes in RBI was reviewed.
		2022 Vol. 31 (6): 589-593 [Abstract] ( 91 ) [HTML 1KB] [ PDF 0KB] ( 0 )

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