Effects of X-ray volume imaging registration methods on position verification for radiotherapy in treatment of middle/lower-segment esophageal cancer / 中国辐射卫生

@#<b>Objective</b> To compare the set up errors derived from different registration methods of the X-ray volume imaging (XVI) system for radiotherapy in the treatment of middle/lower-segment esophageal cancer, and to provide a reference for radiation treatment of esophageal cancer. <b>Methods</b> We randomly selected 63 patients with middle/lower-segment esophageal cancer, and obtained their reconstructed XVI images at the first therapy to perform automatic registration with gray-value and bone registration methods. We acquired and compared the three translation errors (along <i>x</i> [left to right], <i>y</i> [head to feet], and <i>z</i> [front to back] axes) and three rotation errors (around the <i>x</i>, <i>y</i>, and <i>z</i> axes) derived from the two registration methods. <b>Results</b> Gray-value registration had significantly smaller translation errors along the <i>x</i> and <i>z</i> axes than bone registration (<i>x</i> azes <i>t</i> = −2.78, <i>z</i> azes <i>t</i> = −2.15, <i>P</i> < 0.05), but there was no significant difference along the <i>y</i> axes (<i>P</i> > 0.05). The rotation errors around the three axes were all smaller than 1°, and were smaller with gray-value registration than with bone registration, but without significant differences (<i>P</i> > 0.05). <b>Conclusion</b> We recommend gray-value registration for radiotherapy in the treatment of middle/lower-segment esophageal cancer. Manual verification or fine-tuning is recommended after automatic registration in clinical practice. Besides translation errors, rotation errors should also be paid attention to.

Evolution and Information Analysis of Classical Formulas Guizhi Shaoyao Zhimutang / 中国实验方剂学杂志

The classic formula Guizhi Shaoyao Zhimutang, listed as the 15th formula in the Catalog of Ancient Classic Formulas (First Batch) published in 2018, originated from Synopsis of the Golden Chamber （《金匮要略》） written by ZHANG Zhongjing in the Eastern Han Dynasty. It consists of Cinnamomi Ramulus, Ephedrae Herba, Aconiti Lateralis Radix Praeparata, Anemarrhenae Rhizoma, Paeoniae Radix Alba, Atractylodis Macrocephalae Rhizoma, Saposhnikoviae Radix, Zingiberis Rhizoma Recens, and Glycyrrhizae Radix et Rhizoma, and is effective in dispelling wind, eliminating dampness, dispersing cold, relieving impediment, nourishing Yin, and clearing heat. It is mainly used to treat diseases characterized by wind, cold, and dampness invading the body, combined with heat damaging Yin, such as joint disorders, rheumatism, gout, and knee osteoarthritis. Based on the call for "inheritance of essence and application of ancient knowledge for modern use", this study conducted a comprehensive analysis of historical evolution, composition, formulation principles, processing, dosage, decocting methods, and indications of Guizhi Shaoyao Zhimutang using textual research on ancient and modern literature. When analyzing modern literature, it has been found that this formula is widely used in the treatment of various diseases. It is mainly applied to rheumatic diseases such as rheumatism, rheumatoid arthritis, gout, gouty arthritis, and psoriatic arthritis, as well as orthopedic diseases like knee osteoarthritis, ankylosing spondylitis, sciatica, and knee joint effusion. It can also be used for diseases in other systems, including the endocrine system, gynecology, respiratory system, and circulatory system. The pathological mechanisms involve the invasion of wind, cold, and dampness accompanied by heat pathogens, reflecting the concept of treating different diseases with the same principles in traditional Chinese medicine (TCM). Through the analysis of ancient and modern literature on Guizhi Shaoyao Zhimutang using a literature statistical method, the historical evolution and key formula and syndrome information were clarified to provide a theoretical basis for the development and further research of Guizhi Shaoyao Zhimutang in terms of its formulation and subsequent in-depth studies.

Analysis of clinical characteristics and dosimetric factors on long-term survival in locally advanced thoracic esophageal squamous cell carcinoma / 国际肿瘤学杂志

Objective:To explore the effects of clinical characteristics and dosimetric factors on the survival and prognosis of patients with locally advanced thoracic esophageal squamous cell carcinoma after concurrent chemoradiotherapy (CCRT).Methods:A total of 158 patients with locally advanced thoracic esophageal squamous cell carcinoma undergoing CCRT in Shandong Cancer Hospital, Anyang Cancer Hospital of Henan Province, Tengzhou Central People′s Hospital of Shandong Province and the First Affiliated Hospital of China Medical University from August 2015 to October 2018 were selected as the research subjects. These patients were divided into standard-dose group (50.0-50.4 Gy, n=59) and high-dose group (>50.4 Gy, n=99) according to the radiotherapy dose. The overall survival (OS) and progression-free survival (PFS) of the two groups after treatment were compared. Kaplan-Meier method was used to calculate survival rate and survival comparison was performed by log-rank test. Cox proportional hazard regression model was used to analyze the adverse prognostic factors. The receiver operating characteristic (ROC) curve was used to analyze the predictive value of lung V 30 for patient prognosis. Results:In 158 patients with locally advanced esophageal squamous cell carcinoma, 19 cases (12.03%) had complete remission after CCRT, 103 cases (65.19%) had partial remission, 27 cases (17.09%) had stable disease, 9 cases (5.70%) had progression disease, and the total effective rate was 77.22%. The median OS of 158 patients was 41 months (95% CI: 25-57 months), and the 1- and 3-year OS rates were 76% and 51%, respectively. The median PFS was 24 months (95% CI: 13-35 months), and the 1- and 3-year PFS rates were 60% and 39%, respectively. The 1- and 3-year OS rates in the standard-dose group were 74% and 56%, and those in the high-dose group were 77% and 49%, with no statistically significant difference ( χ2=0.300, P=0.584). The 1- and 3-year PFS rates in the standard-dose group were 62% and 37%, and those in the high-dose group were 59% and 40%, with no statistically significant difference ( χ2<0.001, P=0.990). Univariate analysis showed that the length of the lesion, N stage, clinical stage, short-term efficacy of CCRT, planning target volume (PTV) D max, gross tumor volume (GTV) D mean, V 5, V 10, V 20, V 30, D mean of the left, right and bilateral lung were all the prognostic factors for OS and PFS (all P<0.05). Multivariate analysis showed that the length of the lesion ( HR=2.226, 95% CI: 1.244-3.985, P=0.007), N stage ( HR=2.819, 95% CI: 1.137-6.991, P=0.025), clinical stage ( HR=1.897, 95% CI: 1.079-3.334, P=0.026), short-term efficacy of CCRT ( HR=1.805, 95% CI: 1.250-2.606, P=0.002), left lung V 10 ( HR=0.811, 95% CI: 0.668-0.986, P=0.035), left lung V 30 ( HR=0.617, 95% CI: 0.408-0.933, P=0.022), right lung V 20 ( HR=2.067, 95% CI: 1.010-4.231, P=0.047), bilateral lung V 10 ( HR=1.299, 95% CI: 1.016-1.662, P=0.037) and bilateral lung V 30 ( HR=2.368, 95% CI: 1.142-4.910, P=0.021) were independent prognostic factors affecting OS. N stage ( HR=2.433, 95% CI: 1.201-4.931, P=0.014), short-term efficacy of CCRT ( HR=2.067, 95% CI: 1.391-3.071, P<0.001) and bilateral lung V 30 ( HR=0.113, 95% CI: 0.018-0.719, P=0.021) were independent prognostic factors affecting PFS. The ROC curve for predicting OS and PFS showed that the optimal cut-off value of bilateral lung V 30 was 9.5%. Conclusion:Compared with the standard-dose group, increasing the dose of radiotherapy fails to improve the long-term survival of patients with locally advanced thoracic squamous cell carcinoma. Lesion length, N stage, clinical stage, short-term efficacy of CCRT, left lung V 10 and V 30, right lung V 20 , bilateral lung V 10 and V 30 are independent prognostic factors for OS in patients with locally advanced thoracic squamous cell carcinoma. N stage, short-term efficacy of CCRT and bilateral lung V 30 are independent prognostic factors for PFS. When bilateral lung V 30≤9.5%, the patients′ OS and PFS will benefit from the treatment.

Clinical characteristics and prognosis analyses of metastatic sites symptom as the first manifestation in esophageal carcinoma patients with stage T 1 and T 2 / 肿瘤研究与临床

Objective:To explore the clinical characteristics and prognosis of metastatic sites symptom as the first manifestation in esophageal carcinoma patients with stage T 1 and T 2, and to provide a reference for clinical practice. Methods:The clinical data of 50 esophageal carcinoma patients with stage T 1 and T 2 who had lymph node or distant metastasis as the first symptom in Anyang Tumor Hospital of Henan Province from November 2007 to December 2019 were retrospectively analyzed. Survival analysis was performed by using Kaplan-Meier method. Univariate analysis was performed by using log-rank test. Results:Among 50 patients with esophageal carcinoma, lymph node metastases as the first symptom were found in 42 cases and distant organ metastases as the first symptom were found in 8 cases. The 1-, 3-, 5-year overall survival rates of patients with stage Ⅰ-Ⅱ and stage Ⅲ-Ⅳ were 58.7%, 49.0%, 16.3% and 56.1%, 12.2%, 0, respectively, and there was no statistically significant difference in OS of both groups ( P = 0.094). The 1-, 3-, 5-year overall survival rates of patients with stage N 1 and stage N 2-N 3 were 63.5%, 34.7%, 17.3% and 52.2%, 11.9%, 0, respectively, and there was no statistically significant difference in OS of both groups ( P = 0.083). The 1-, 3-, 5-year overall survival rates were 64.6%, 30.5%, 18.3%, respectively in radiotherapy group and 38.2%, 0, 0, respectively in non-radiotherapy group, and there was a statistically significant difference in OS of both groups ( P = 0.008); the progression-free survival in radiotherapy group was better than that in non-radiotherapy group ( P = 0.028). The 1-, 3-, 5-year overall survival rates were 70.8%, 35.5%, 21.3% and 33.3%, 0, 0 and 35.4%, 0, 0, respectively in concurrent chemoradiotherapy group, radiotherapy group and chemotherapy group, and there was a statistically significant difference in overall survival among three groups ( P = 0.004). The results of univariate analysis showed that radiotherapy ( χ2 = 7.112, P = 0.008) and concurrent chemoradiotherapy ( χ2 = 10.940, P = 0.004) were the main factors affecting the prognosis. Conclusions:Lymph node and distant metastasis could occur in esophageal carcinoma patients with stage T 1 and T 2. Radiotherapy can prolong the progression-free survival time and concurrent chemoradiotherapy could benefit overall survival of these patients.

Study on setup errors for different body carcinoma radiotherapy with image guidance in TOMO-HD / 中国辐射卫生

Objective The literature study the setup errors of head and neck, thoracic, abdominal and pelvic tumors by megavoltage fan-beam CT based image guidance in TOMO-HD to provide the margin enlarging from clinic target volume (CTV) to planning target volume (PTV) in treatment planning system of TOMO-HD. Methods 103 patients with head and neck (30 patients), thoracic (42 patients), abdominal and pelvic (31 patients) carcinoma were enrolled. Megavoltage fan-beam CT based image guidance in tomotherapy-HD was used to acquire CT scan before every treatment. The left-right (X), superior-inferior (Y), anterior-posterior (Z) and rotation (Fy) setup errors of patients can be obtained from the tomography image automatically restructured by the system. Calculating the systematic error and the random error in the three dimensions and check whether the setup data accord with the normal distribution or not, then acquire the data expand in the three directions. Results According to 2593 fan-beam CT scans, the shift errors (µ ± s) in X, Y, Z and Fy (rotation) of three study group were [(−0.31 ± 2.16) mm、(1.09 ± 3.56) mm、(2.36 ± 2.27) mm, (0.29 ± 0.96)°] (head and neck tumor), [(−0.98 ± 2.95) mm、(0.45 ± 6.86) mm、(3.79 ± 2.47) mm, (0.18 ± 0.60)°] (thoracic cancer) and [(−0.86 ± 2.85) mm、(−1.59 ± 6.91) mm、(5.77 ± 2.40) mm, (0.20 ± 0.68)°](abdominal and pelvic carcinoma). The systematic errors (∑) and random errors (σ) in X, Y, Z dimensions of patients with head and neck, thoracic, abdominal and pelvic tumors were (1.06 mm and 1.84 mm), (1.93 mm and 3.43 mm), (2.41 mm and 2.71 mm), (1.10 mm and 2.56 mm), (3.79 mm and 5.46 mm), (1.38 mm and 1.99 mm) and (1.39 mm and 0.87 mm), (4.98 mm and 5.69 mm), (1.19 mm and 2.05 mm), respectively. Conclusion It is recommended as a reference for image guidance in TOMO-HD according to the frequency distribution of setup errors, for patients with head and neck, chest and abdominal and pelvic tumors, the maximum range of motion in three dimensions are (5.00, 5.00, 5.00) mm, (6.63, 17.25, 16.00) mm and (6.49, 16.24, 13.60) mm.

Application of ArcCHECK system in the verification of tomotherapy plan for esophageal cancer / 中华放射肿瘤学杂志

Objective:To explore the application of ArcCheck system in the validation of Helical and Direct tomotherapy plans for esophageal cancer and summarize relevant experience.Methods:The Helical and Direct tomotherapy verification plans were established for 32 patients with esophageal cancer at different positions according to the doctor′s instructions, which were verified by the ArcCHECK system to compare the passing rate of the results.The correlation between the volume of the target area and the passing rate of the planned verification was analyzed. The therapeutic verification plan with a small target volume was made. The target area was placed at the center of ArcCHECK phantom and the area of detectors to statistically compare the verification passing rates.Results:Helical plan showed a significantly higher passing rate than the Direct plan ( P<0.01). The correlation coefficients between the target volume and the passing rate of the Helical and Direct plans were -0.364 and -0.042, and the P values were 0.041 and 0.819, respectively. For the Helical plan, when the 3%/2mm criterion was adopted, there was significant difference between placing the high-dose area at the center of the phantom and the area of detectors ( P=0.005), and the passing rate of the latter was higher. There was no significant difference in the other cases (all P>0.05). Conclusions:The passing rate of the Helical plan is generally higher than that of the Direct plan, which may be related to the angular response of the ArcCHECK detector and the fact that more reference points are not included for calculation due to low-dose radiation. In addition, it may also be related to the higher requirements of Direct plan for tomotherapy dose control system. In the Helical verification plan, when the 3%/3mm criterion is adopted, the larger the target volume, the higher the possibility of lower passing rate, whereas the correlation coefficient between them is relatively low. The high-dose area can be verified by the plans at the center of the phantom or the detection point. With the comprehensive consideration, we suggest putting it at the center of the phantom.

Dosimetric comparison among TomoDirect, Helical Tomotherapy and VMAT in the treatment of upper thoracic esophageal carcinoma / 中华放射医学与防护杂志

Objective To compare the dosimetric difference among TomoDirect (TD) radiotherapy,Helical Tomotherapy(HT) and volumetric modulated arc therapy(VMAT) in the treatment of upper thoracic esophageal carcinoma.Methods A total of 15 patients with cT2-4 N0-1 M0 upper thoracic esophageal squamous cell carcinoma were enrolled.Three plans were generated using the same dose objective for each patient:TD,HT and VMAT.Dose-volume histogram (DVH),homogeneity index (HI),conformal index (CI),dose at organ at risk (OAR),delivery time and monitor unit (MU) were compared among different plans.Results The D2 and D values in the HT and TD plans were significantly lower than those in the VMAT plans.The D98 value in the TD was similar to that in the HT,but lower than that in the VMAT.The HI of HT was significantly better than those of TD and VMAT (F =81.603,P ＜ 0.05).For the CI,there was no significant difference among the three techniques (P ＞ 0.05).For the V15 of lung,HT was significantly higher than TD (t =-2.626,P ＜0.05) and VMAT (t=3.547,P ＜ 0.05).The V20 of lung in TD was similar to that in HT,but higher than that in VMAT (t =2.824,3.052,P ＜ 0.05).The Dmax of spinal cord showed no significant difference among the three techniques.VMAT had a significantly shorter delivery time and lower MU compared with HT and TD (t =21.617,15.693,10.018,7.802,P ＜ 0.05).Conclusions HT and TD could gain a better planning target volume (PTV) coverage and HI than VMAT in the treatment of upper thoracic esophageal carcinoma.However,VMAT achieved the lowest lung V20,the least Mus and the shortest delivery time.HT achieved a better PTV coverage compared with TD,but TD had a lower lung V15 Mus and shorter delivery time compared with HT.

An analysis of setup errors in helical tomotherapy for esophageal cancer patients / 中华放射肿瘤学杂志

Objective To analyze setup errors and guide the calculation of margins from clinical target volume (CTV) and planning target volume (PTV) in esophageal cancer patients treated with tomothcrapy by the MVCT image-guided system.Methods Sixty-four esophageal canccr patients trcated with tomotherapy in our hospital in 2016 were randomly selected.MVCT images were acquired after patients' positioning and co-registered with KVCT images.The setup errors of x,y,and z translations and roll rotation were analyzed with the t-test or one-way ANOVA.Meanwhile,PTV margin was calculated based on the formula of M =2.5 Σ + 0.7δ Results According to the formula,the CTV-PTV margins in the x,y and z directions are slightly different between cancers located in the cervical,upper thoracic,middle thoracic,and lower thoracic segments.In patients with upper thoracic esophageal cancer,the average setnp error in the yaxis was lower when the head-neck-shoulder thermoplastic film fixation was used than when somatic thermoplastic film fixation (P=0.000);the setup errors of z-axis with somatic thermoplastic film fixation in the fifth and sixth weeks were slightly less than those in the first several weeks (P =0.036);the setup errors acquired by three image registration patterns were similar (x-axis P=0.868,y-axis P=0.491,z-axis P=0.169,roll P=0.985).Conclusions In the treatment of patients with esophageal cancer,the setup errors are large,but the MVCT in the TOMO HD system can greatly reduce the setup errors,ensuring the accuracy of each treatment.It is further recommended that in clinical practice,different CTV-PTV margins should be used for the treatments of esophageal cancers located in different segments.Patients with upper thoracic esophageal cancer are advised to use the head-neck-shoulder thermoplastic film fixation.

Effect and prognosis of three dimensional conformal intensity modulated radiotherapy on 468 postoperative local recurrent esophageal squamous cell carcinomas / 中华放射医学与防护杂志

Objective To study the effect of three dimensional conformal intensity modulated radiotherapy and prognostic factors for postoperative local recurrent esophageal squamous cell carcinomas.Methods A total of 468 patieuts with postoperative local recurrent esophageal squamous cell carcinomas were retrospectively analyzed.The median interval between surgery and recurrence was 14.95 months (2-252 months).There were 45 patients with supraclavicular lympy node relapse,291 with mediastinal lymph node relapse,4 with abdominal lymph node relapse,15 with anastomosis relapse,89 with supraclavicular and mediastinal lymph node relapse,11 with anastomosis and mediastinal lymph node relapse,7 with mediastinal and abdominal lymph node relapse,1 with supraclavicular and anastomosis relapse,2 with supraclavicular and abdominal lymph node relapse,3 with anastomosis,mediastinal and supraclavicular lymph node relapse.There were 224 patients who received three-dimensional conformal radiation therapy,and the other 244 patients of intensity-modulated radiation therapy,with a median dose of 59.4 Gy (40-70 Gy).A total of 166 patients received adjuvant chemotherapy.Kaplan-Meier method was used to calculate the survival rate;Log-rank test was used for univariate prognostic analysis;Cox regression test was used for multivariate prognostic analysis.Results The follow-up rate was 95.3％.The recent curative effect in the effective rate was 81.6％,with 41.2％ CR rate.The overall 1,2,3,4 years of survival rates after radiotherapy were 61％,32％,21％,14％ respectively and the median survival time was 17.6 months.Univariate analysis showed that age,.pathologic stage,the number of positive lymph node cleaning,the recurrence area,single or multiple lesions,the size of the lesion,overall response rate,radiation dose,and chemotherapy (x2 =4.814-247.322,P ＜ 0.05) were associated with prognosis.Multivariate analysis showed that age,pathologic stage,the recurrence area,single or multiple lesions,the size of the lesion,overall response rate,radiation dose,and chemotherapy (P ＜0.05) were independent prognostic factors.A total of 370 patients had progressive diseases after radiotherapy,176 had local failure 47.57％ (176/370),148 had distant metastasis 40.00％ (148/370) and 16 had both local and distant failures 4.32％ (16/370).One case died of pneumonia;2 cases died of acute myocardial infarction;1 case died of cerebral hemorrhage;26 cases died of unknown cause (including lost to follow-up).Lung was the most common distant metastatic site.Conclusions Radiotherapy may improve the survival of esophageal squamous cell carcinoma patients with postoperative recurrence.Patients with less than 70 years old,early postoperative stage,single recurrent lesion,initial small lesions,response to radiotherapy,radiation dose of higher than 59.4 Gy,chemoradiation might have better prognosis.