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Objective:To analyze the treatment efficacy, safety and dose parameters of optimized hippocampus-avoidance prophylactic cranial irradiation (HA-PCI) in limited-stage small cell lung cancer (LS-SCLC) and explore the corresponding dosimetric parameters under the condition of narrowing the hippocampus avoidance region as hippocampus region plus 2 mm in three dimensions.Methods:Clinical data of patients with LS-SCLC receiving HA-PCI (hippocampus avoidance region defined as hippocampus region plus 2 mm in three dimensions) in Cancer Hospital Chinese Academy of Medical Sciences from August 2014 to June 2020 were retrospectively analyzed. Dose parameters of HA-PCI and adverse events were analyzed using descriptive statistics analysis. Changes of neurocognitive function, such as mini-mental state examination (MMSE) and Hopkins verbal learning test-revised (HVLT-R) scores, were evaluated by analysis of variance and Kruskal-Wallis H test. Overall survival (OS), progression-free survival (PFS) and intracranial PFS (iPFS) were calculated using Kaplan-Meier method. The cumulative incidence of local-regional recurrence (LRR), extracranial distant metastases (EDM), and locoregional recurrence (LR) were investigated under competing risk analysis. Results:A total of 112 patients were included, the median follow-up time was 50 months (95% CI: 45.61-54.38). The median volume of hippocampus was 4.85 ml (range: 2.65-8.34 ml), with the average dose ≤9 Gy in 106 patients (94.6%), ≤8 Gy in 92 patients (82.1%). The median volume of hippocampus avoidance area was 15.00 ml (range: 8.61-28.06 ml), with the average dose ≤12 Gy in 109 patients (97.3%), ≤10 Gy in 101 patients (90.2%). The 2-year cumulative LRR, EDM, LR rates were 16.9%, 23.2% and 28.5%, respectively. The 5-year cumulative LRR, EDM, LR rates were 23.2%, 26.9% and 33.3%, respectively. The 2-year iPFS, PFS and OS rates were 66.1% (95% CI: 57.9%-75.4%), 53.6% (95% CI: 45.1%-63.7%) and 80.4% (95% CI: 73.3%-88.1%), respectively. The most common grade I-Ⅱ adverse events were nausea (33.9%) and dizziness (31.3%), and only 1 patient developed grade Ⅲ nausea and dizziness. MMSE ( n=57) and HVLT-R tests ( n=56) showed no significant decline. Conclusions:Optimized HA-PCI can achieve similar dose limitation with favorable efficacy and light toxicity. No significant decline is observed in short-term neurocognitive function in evaluable patients.
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Objective:To establish the first Mini-Formative Evaluation of Radiation Oncology (Mini-FERO) scale in China and evaluate its preliminary application value in the standardized training for radiation oncology resident physicians.Methods:Based on the educational curriculum and examination requirements for the standardized training for radiation oncology resident physicians, as well as the standardized Mini-Clinical Evaluation Exercise (Mini-CEX) scale commonly used in clinical practice, the Mini-Formative Evaluation of Radiation Oncology (Mini-FERO) scale was developed to facilitate the standardized training for resident physicians in the field of radiation oncology. In this prospective study, a randomization method using a random number table was employed to select a cohort of 26 resident physicians who completed their rotations in Department of Radiation Oncology at the Cancer Hospital, Chinese Academy of Medical Sciences from March 1, 2021 to December 31, 2021. The Mini-FERO scale was administered in the initial, middle, and final stages during the rotation period. The differences in evaluation scores before and after the assessments were analyzed by paired t-test. Furthermore, participating resident physicians and supervising teachers provided satisfaction ratings, and a comprehensive evaluation of the Mini-FERO scale was conducted. Results:The average scores of the three examinations of 26 resident physicians demonstrated a successive improvement, with individual performance in each assessed category also showing progressive enhancement. The second evaluation exhibited a more pronounced score increase compared to the first evaluation, with a mean improvement of (1.43±1.02) points ( t=7.13, P<0.001); while the third evaluation had a mean improvement of (0.41±0.50) points ( t=4.07, P<0.001) compaired to the second evaluation, with a mean difference of (1.02±1.15) points between the two ( t=4.53, P<0.001). The average time required for the assessments was (34.31±24.46) min. Overall satisfaction ratings from the evaluated resident physicians for the Mini-FERO scale were (8.42±0.85) points, and supervising teachers reported an overall satisfaction rating of (8.45±0.85) points. The satisfaction rate was 96% (25/26). Conclusions:In this study, the Mini-FERO scale was successfully developed and validated in the context of clinical teaching practice for radiation oncology resident physicians. The Mini-FERO scale is proven to be a feasible tool for assessing the gradual improvement of resident physicians throughout their learning process in the field of radiation oncology. Importantly, it offers the advantages of short assessment time, thereby avoiding additional burden on supervising teachers. The adoption of the Mini-FERO scale addresses current limitations of lacking of formative evaluation in the standardized training for radiation oncology resident physicians.
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Objective:To evaluate the efficacy and safety of hippocampal avoidance whole-brain irradiation with simultaneous integrated boost in the treatment of brain metastases of lung cancer.Methods:Forty lung cancer patients with brain metastases who received whole-brain radiotherapy with simultaneous integrated boost and hippocampal avoidance in Cancer Hospital, Chinese Academy of Medical Sciences from 2014 to 2020 were enrolled in this study. Brain MRI, survival follow-up and evaluation of side effects were performed before radiotherapy and at 1, 3, 6 and 12 months after radiotherapy, respectively. Overall survival (OS), progression-free survival (PFS) and changes in cognitive function were analyzed. Continuous data were described as Mean ± SD. Categorical data were described by frequency and composition ratio or percentage. Survival analysis was conducted by Kaplan-Meier method. Influencing factors of survival were identified by univariate and multivariate Cox's regression analyses.Results:A total of 40 patients were enrolled in the study. The median follow-up time was 14.2 months and the median OS, PFS and intracranial PFS of all patients were 14.8 months, 6.7 months and 14.8 months, respectively. Multivariate analysis showed that male gender and newly diagnosed stage Ⅳ disease were associated with worse OS and PFS, respectively. The Hopkins verbal learning test-revised (HVLT-R) scores at baseline and 1, 3 and 6 months after radiotherapy were 21.94±2.99, 20.88±3.12, 20.03±3.14, and 19.78±2.98, respectively. The HVLT-R score at 6 months after radiotherapy was decreased by approximately 9.8% compared with the baseline. No grade 3 or above toxic and side effect occurred in the entire cohort.Conclusion:Hippocampal avoidance whole-brain irradiation with simultaneous integrated boost is a safe and effective treatment for brain metastases of lung cancer, which is expected to reduce the impact of radiotherapy on cognitive function.
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Objective:To explore the impacts of comprehensive geriatric assessment (CGA) on setup errors during the radiotherapy of elderly patients with rectal cancer.Methods:A total of 45 patients over 70 years of age and receiving radiotherapy were enrolled in the study. A comprehensive geriatric assessment was conducted before the radiotherapy. The enrolled patients had a median age of 77 years, including 28 male and 17 female cases. Meanwhile, 31 patients were determined to be in a good CGA status and 14 were determined to be in a poor CGA status, and 35 patients received radiotherapy in the prone position and 10 in the supine position. Cone beam CT (CBCT) was used for setup correction during radiotherapy. CBCT was performed daily in the first week and once a week from the second week. By fusing and aligning the CBCT images with simulation CT images according to the lumbar vertebra, setup errors in the left-right ( x axis), cranio-caudal ( y axis), and anterior-posterior ( z axis) directions were obtained. A total of 338 CBCT images were obtained. A generalized linear model was used to evaluate the effects of multiple factors on the setup errors. Results:During the radiotherapy, setup errors of all patients were (0.24±0.19) cm in the left-right direction, (0.33±0.25) cm in the cranio-caudal direction, and (0.19±0.15) cm in the anterior-posterior direction. The setup error in the cranio-caudal direction was more than that in the left-right direction and that in the anterior-posterior direction ( Z=-4.86, -7.72, P< 0.001). The setup error in the left-right direction was greater than that in the anterior-posterior direction ( Z=-2.79, P=0.005). The mean setup errors of the good and poor status groups in the left-right direction were (0.21 ± 0.17) and (0.30 ± 0.22) cm, respectively ( Z=2.16, P=0.031). There was no statistically significant difference in the setup errors between cranio-caudal direction and anterior-posterior direction ( P>0.05). The setup errors in the anterior-posterior direction were (0.17 ± 0.13) and (0.27 ± 0.19) cm, respectively for the prone and supine positions during the radiotherapy ( Z=2.85, P=0.004). There was no statistically significant difference in the setup errors between the left-right direction and the cranio-caudal direction ( P>0.05). Conclusion:The status of CGA elderly patients with rectal cancer affects the setup error in the left-right direction. It may be necessary to clinically adjust the PTV margin.
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Objective:To evaluate the safety and tolerance of sequential thoracic radiotherapy combined with PD-1/PD-L1 inhibitors in patients with extensive-stage small cell lung cancer (ES-SCLC) after induction systemic therapy.Methods:ES-SCLC patients from a phase I trial and a real-world study were enrolled for those who received thoracic radiotherapy after induction systemic treatment (chemotherapy/chemotherapy combined with PD-1/PD-L1 inhibitors) and consolidated with PD-1/PD-L1 inhibitors. These two studies were both approved by the Ethics Committee of Chinese Academy of Medical Sciences Cancer Hospital (Clinical Trials.gov number, NCT03971214, NCT04947774).Results:Between January 2019 and March 2021, a total of 11 patients with ES-SCLC were analyzed, aged 52-73 years, with a median age of 62 years. Among them, five patients (45.5%) received induction chemotherapy and six patients (54.5%) received chemotherapy combined with PD-1/PD-L1 inhibitor, and then all received intensity-modulated thoracic radiotherapy after evaluation of systemic treatment efficacy. Two patients developed treatment-related grade G3-5 toxicity (18.2%, 1 treatment-related pneumonitis and 1 radiation esophagitis). G 1-G 2 hematologic toxicity, pneumonia, and anorexia were common mild toxicities. Only one patient (9.1%) terminated immunotherapy due to immune-related pneumonitis. During a median follow-up time of 12.5 months (range: 3.5-16.4 months), the median disease progression-free survival and overall survival was 7.4 months (95% CI: 6.9-8.0 months) and 14.6 months (95% CI: 9.0-20.2 months), respectively. Conclusions:Sequential thoracic radiotherapy followed by PD-1/PD-L1 inhibitor is safe and feasible in patients with ES-SCLC after induction therapy. Given that both thoracic radiotherapy and immunotherapy benefits the ES-SCLC in survival, this comprehensive treatment modality warrants further investigation.
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Objective:Simultaneous integrated boost radiation technique in limited-stage small cell lung cancer is lack of evidence. This prospective study aims to evaluate whether the simultaneous integrated boost is as efficacious and safe as conventional fractionated radiotherapy.Methods:Patients diagnosed with treatment-naive and confirmed limited-stage SCLC were eligible. Participants were randomly assigned (1: 1) to receive simultaneous integrated boost radiotherapy (PGTV 60.2 Gy/2.15 Gy/28F, PTV 50.4 Gy/1.8 Gy/28F) or conventional fractionated radiotherapy (PTV 60 Gy/2 Gy/30F). The primary endpoint was 2-year progression-free survival, and the secondary endpoints were 2-year overall survival, 2-year local-regional recurrence-free survival and toxicity.Results:Between February 2017 and July 2019, 231 patients were enrolled. We analyzed 216 patients whose follow-up time was more than 2 years or who had died, among whom 106 patients in the conventional fractionated radiotherapy group and 110 patients in the simultaneous integrated boost radiotherapy group. The median follow-up time was 37 months (95% CI: 35.2-38.7). The 2-year progression-free survival rates were 45.2% vs. 38.2%( HR=1.22, 95% CI: 0.87-1.72, P=0.2). The 2-year overall survival rates were 73.5% vs. 60.9%( HR=1.35, 95% CI: 0.90-2.04, P=0.14). The 2-year local-regional recurrence-free survival rates were 68.7% vs. 69.9%( HR=0.98, 95% CI: 0.62-1.56, P=1.0). Multivariate analysis showed that early radiotherapy yielded better 2-year progression-free survival, overall survival and local-regional recurrence-free survival than delayed radiotherapy in two groups ( HR=1.69, 95% CI: 1.18-2.41, P=0.003; HR=1.72, 95% CI: 1.09-2.70, P=0.018; HR=1.66, 95% CI: 1.01-2.73, P=0.046). Tumor staging was an influencing factor of overall survival (stage Ⅲ vs. stage Ⅰ-Ⅱ, HR=3.64, 95% CI: 1.15-11.57, P=0.028). The most common grade 3-4 adverse events were myelosuppression (21.7% vs. 15.4%, P=0.83), radiation pneumonitis (4.7% vs. 2.7%, P=0.44) and radiation esophagitis (3.8% vs. 1.8%, P=0.51). Conclusions:Simultaneous integrated boost radiotherapy yields equivalent efficacy and toxicities to conventional fractionated radiotherapy for limited-stage small cell lung cancer. Early radiotherapy can enhance clinical prognosis.
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Objective:To explore the effect of pretreatment body mass index (BMI) on the prognosis of patients with unresectable locally advanced non-small cell lung cancer (NSCLC) after chemoradiotherapy.Methods:The clinical data of 711 patients with locally advanced NSCLC treated with radiotherapy, sequential chemoradiotherapy or concurrent chemoradiotherapy from January 2013 to December 2017 in Cancer Hospital of Chinese Academy of Medical Science and Peking Union Medical College were retrospectively analyzed. Radiotherapy was performed with intensity-modulated radiotherapy (IMRT) or volumetric-modulated arc therapy (VMAT), and the chemotherapy regimens were paclitaxel+carboplatin, pemetrexed+cisplatin or etoposide+cisplatin. The effects of pretreatment BMI and other clinical factors on overall survival (OS) of patients were analyzed. Survival analysis was performed by using Kaplan-Meier method; univariate and multivariate analyses were performed by using Cox proportional hazards model.Results:According to the World Health Organization (WHO) recommended BMI grouping method for Asian, the median OS time of low BMI group (<18.5 kg/m 2, 23 cases), normal BMI group (18.5-23.9 kg/m 2, 293 cases) and high BMI group (≥24.0 kg/m 2, 395 cases) was 17 months (95% CI 11-29 months), 29 months (95% CI 22-36 months) and 30 months (95% CI 27-34 months), respectively. OS in the low BMI group was poorer than that in the normal BMI group and high BMI group ( χ2 = 11.20, P = 0.004). Maximally selected rank statistics was used to determine the optimal cut-off value of BMI for prediction of survival as 21.31 kg/m 2, according to which patients were divided into low BMI group (BMI<21.31 kg/m 2, 130 cases) and high BMI group (BMI≥21.31 kg/m 2, 581 cases), the median OS time of the two groups was 20 months (95% CI 17-27 months) and 32 months (95% CI 28-35 months), respectively. OS in the low BMI group was poorer than that in the high BMI group ( χ2 = 12.30, P < 0.001). Multivariate analysis showed that age ≥ 65 years old, male, Karnofsky score < 80 points, low BMI, smoking, histological type of squamous cell carcinoma and radiotherapy alone were independent risk factors for OS (all P < 0.05). Conclusions:For patients with unresectable locally advanced NSCLC who received chemoradiotherapy, those with low pretreatment BMI have poor prognosis.
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Objective:To compare the outcomes of watch&wait (W&W) strategy in patients with locally advanced rectal cancer who achieved complete clinical response (cCR) after neoadjuvant therapy, with those who obtained pathological complete response (pCR) after total mesorectal excision (TME).Methods:This is a retrospective cohort analysis study. Patients histologically proven with locally advanced rectal adenocarcinoma (stage Ⅱ-Ⅲ) who had received neoadjuvant chemotherapy were eligible between January 2014 and December 2019. In whom we included patients who had cCR offered management with W&W strategy after completing neoadjuvant therapy and follow-up ≥1 year (W&W group), and patients who did not have cCR but pCR after TME (pCR group). The primary endpoints were 3-year and 5-year overall survival (OS), colostomy-free survival (CFS), disease-free survival (DFS), non-local regrowth disease-free survival (NR-DFS), and organ preservation rate. Kaplan-Meier analysis was used for survival analysis and log-rank test was performed. For comparative analysis, we also derived one-to-one paired cohorts of W&W versus pCR using propensity-score matching (PSM).Results:A total of 118 patients were enrolled, 49 of whom had cCR and managed by W&W, 69 had pCR, with a median follow-up period of 49.5 months (12.1-79.9 months). No difference was observed in the 3-year OS (97.1% vs. 96.7%) and 5-year OS (93.8% vs. 90.9%, P=0.696) between the W&W and pCR groups. Patients managed by W&W had significantly better 3-year and 5-year CFS (89.1% vs. 43.5%, P<0.001), better 3-year DFS (83.6% vs. 97.0%) and 5-year DFS (83.6% vs. 91.2%, P=0.047) compared with those achieving pCR. The 3-year NR-DFS (95.9% vs. 97.0%) and 5-year NR-DFS (92.8% vs. 97.0%, P=0.407) did not significantly differ between the W&W and pCR groups. Local regeneration occurred in six cases, and 87.7% of patients had successful rectum preservation in the W&W group. In the PSM analysis (34 patients in each group), absolutely better CFS (90.1% vs. 26.5%, P<0.001) was noted in the W&W group. A median interval of 17.5 weeks was observed for achieving cCR, while only 23.9% of patients achieved cCR within 5 to 12 weeks from radiation completion. Patients with short-course sequential chemoradiotherapy achieved cCR significantly later when compared with those with long-course concurrent chemoradiotherapy (19.0 vs. 9.8 weeks, P<0.001). Conclusions:The oncological outcomes of W&W strategy in patients with locally advanced rectal cancer are safe and effective, significantly improving the quality of life. Longer interval for cCR evaluation may improve rectal organ preservation rate.
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Oligometastasis is an intermediate status between the locally advanced and wide spread disease. Patients with oligometastasis may obtain long-term survival after local treatment. Stereotactic body radiation therapy (SBRT) can deliver radical ablative doses in a small number of fractions, which is a highly precise local ablation therapy. Approximately half of patients diagnosed with colorectal cancer (CRC) will develop metastases, with the liver and lung as the most common site of involvement. In this article, the safety, local efficacy and prognostic factors of SBRT for liver and lung oligometastases from CRC were illustrated. The highlights of SBRT implementation were also discussed. SBRT is safe and effective for oligometastases from CRC under respiratory motion management and robust quality assurance.
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Objective:To investigate the relationship between gastric filling status and intra-or inter-fractional tumor displacement in patients with adenocarcinoma of the esophagogastric junction (AEG) undergoing preoperative radiotherapy.Methods:From October 2018 to June 2019, 10 patients with locally advanced AEG who received totally neoadjuvant therapy were enrolled in this prospective study. Patients received two markers implanted at the cranial and caudal borders of the tumors under gastroscope and a total of 20 fiducial markers were implanted finally. All patients underwent 4DCT scan under the gastric fasting and filling status. Ten images of 0% to 90% respiratory phase were automatically reconstructed by the system (Pinnacle 3, version 9.1, Philips Medical Systems, Eindhoven, The Netherland). Each patient obtained one hundred sets of images. Results:In the tumors proximal to the chest, gastric filling did not significantly affect intrafractional or interfractional tumor displacements. Nevertheless, in the tumors distal to the chest, the interfractional displacement in the cranio-caudal (CC) direction under the gastric fasting status was significantly larger compared with that under the gastric filling status (6.22±4.67 mm vs. 4.13±3.68 mm, P=0.013). To ensure 95% of the prescribed dose irradiated to at least 90% of the tumor volume during the radiotherapy, the margins of tumors proximal to the chest in the left-right (LR), antero-posterior (AP) and CC directions were 9 mm, 8.5 mm, 12.1 mm under gastric filling status with 300 ml semi-fluid. Six patients diagnosed with gastric cancer with proximal thoracic fiducial markers treated by preoperative radiotherapy were included in the validation group, revealing that the fiducial markers of 93% patients were covered in this margin. Conclusion:During the preoperative radiotherapy in AEG patient, the approach of quantitative gastric filling can be considered.
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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 2 cm 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 (Pinnacle 3 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 2 cm from the main hepatic portal vein, 2-5 cm from the main hepatic portal vein, and>5 cm 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 (all P<0.001). The motion varied at different tumor locations. The longer distance from the main hepatic portal vein, the larger the intrafractional motion (all P<0.05). To cover the 95% population-based confidence interval, the internal target volume (ITV) was suggested to include the expansion of 3.9 mm, 5.2 mm and 7.9 mm in the LR, AP and CC direction. The expansion of 4.3 mm, 4.4 mm and 6.1 mm was delivered within 2 cm from the main hepatic portal vein, and 3.5 mm, 7.3 mm and 9.7 mm>5 cm 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 > 5 cm from the main portal vein in the AP direction was larger than that of inner parts. Conclusion:Liver tumors at different locations require individual external expansion of ITV.
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In China, gastric cancer ranks in the second place in morbidity. Patients were mostly diagnosed as an advanced stage at the first time. Radical resection rate was low and the recurrence rate remained high by surgery alone, which resulted in a poor prognosis. Preoperative chemoradiotherapy served as a local therapy method played an important role in gastric cancer gradually. In recent years, although most patients′ tumor are located at the mid-distal gastric cancer, due to the changes of living habits, the number of patients with gastroesophageal junction adenocarcinoma has gradually increased, and their prognosis are relatively poorer compared with the mid-distal gastric cancer.Large-scale phase III studies have confirmed that preoperative radiotherapy and chemotherapy can improve the rate of downstaging and local control in adenocarcinoma of the gastroesophageal junction. However, mid-distal gastric cancer still lacks phase III evidence and more clinical studies are needed to explore the value of preoperative chemoradiotherapy. This review summarizes the progress of preoperative chemoradiotherapy in adenocarcinoma of esophagogastric junction and mid-distal gastric cancer separately.
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Objective:To investigate the relationship between MRI parameters and clinical prognosis before and after chemoradiotherapy in patients with locally advanced rectal cancer.Methods:Clinical and follow-up data of 96 patients with locally advanced rectal cancer who were initially treated in the Cancer Hospital of Chinese Academy of Medical Sciences from 2015 to 2017 were retrospectively analyzed. All patients received preoperative chemoradiotherapy, followed by delayed radical surgery at 6-13 weeks after radiotherapy. MRI assessment was performed twice around radiotherapy which were within 4 weeks before the treatment and 4-8 weeks after it. Correlation analysis was utilized to determine the association between MRI assessment and 3-year disease-free survival (DFS).Results:Of the all patients, 80 (83%) had T 3 stage, 16(17%) had T 4 stage, 14 (15%) had N 0 stage, and 82 (86%) had N 1-2 stage. Among them, 69(72%) and 58(60%) patients were positive for MRF and EMVI. The median dose of radiotherapy was 50 Gy, and all patients were sensitized by simultaneous capecitabine. After chemoradiotherapy, T-downstage rate of the whole group was 24%, and 50% for the N-downstage rate. The MRF-and EMVI-positive rates were significantly decreased to 37% and 27% after chemoradiotherapy (both P<0.001). Univariate and multivariate analyses showed that N staging and EMVI status change were significantly correlated with the 3-year DFS. Conclusion:MRI after concurrent chemoradiotherapy reveals that positive EMVI throughout the treatment and N 1-N 2 staing are poor prognostic factors of DFS, suggesting the need for improving the treatment.
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Objective To retrospectively analyze the long-term efficacy of and prognostic factors after preoperative chemoradiotherapy combined with total mesorectal excision (TME) in the treatment of 241 patients with locally advanced rectal cancer.Methods A total of 241 patients who were consecutively admitted to our hospital and diagnosed with locally advanced mid-low rectal adenocarcinoma by pelvic magnetic resonance imaging or computed tomography from January 2006 to November 2014 were enrolled as subjects.All patients received preoperative radiotherapy with doses ranging between 42.0 and 50.4 Gy (median dose =50 Gy) and concurrent chemotherapy with capecitabine ±oxaliplatin.Patients received TME (R0 excision) at 4-15 weeks (median time =7 weeks) after chemoradiotherapy.Adjuvant postoperative chemotherapy was given depending on the recovery and preference of each patient.Disease-free survival (DFS),locoregional recurrence (LRR),overall survival (OS),and distant metastasis (DM) rates were calculated by the Kaplan-Meier method and analyzed by the log-rank test.The Cox model was used for multivariate analysis.Results In all the patients,the median follow-up time was 42 months;the 3-year LRR,DFS,OS,and DM rates were 3.8％,76.2％,85.9％,and 20.6％,respectively.The subgroup analysis showed that ypT0-2,ypN-,pCR,and TRG4 were associated with improved DFS (ypT0-2 vs.yp T3-4:86.0％ vs.69.3％,P =0.002;ypN-vs ypN +:88.1％ vs.56.9％,P=0.000;pCR vs.non-pCR:100％ vs.72.4％,P=0.001;TRG4 vs.TR G2-3 vs.TR G0-1:94.9％ vs.73.6％ vs.66.3％,P=0.011).The multivariate analysis revealed that the postoperative ypN status was an independent prognostic factor for DFS (P=0.000).Conclusions For patients with locally advanced mid-low rectal adenocarcinoma,preoperative chemoradiotherapy combined with radical surgery achieves satisfactory outcomes in local control.The major reason for treatment failure lies in distant metastasis.The ypN status after chemoradiotherapy is an independent prognostic factor for DFS.
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<p><b>OBJECTIVE</b>To evaluate the outcome of radical surgery combined with adjuvant radiotherapy for patients aged over 75 years with stage II( or III( rectal cancer.</p><p><b>METHODS</b>From 2000 to 2010, 178 patients aged over 75 years at diagnosis who underwent radical surgery in National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, were selected from 3995 patients with stage II( or III( rectal cancer in the database of the above center and enrolled into this retrospective cohort study, which was approved by ethics committee of the above hospital (ClinicalTrials.gov number, NCT02312284).</p><p><b>RESULTS</b>Median age of patients was 77 years (range 75-87). There were 37 (20.8%), 69 (38.8%), and 72 (40.4%) patients with tumors locating in the high, middle and low rectum respectively; 89(50%) patients of pathological stages II( and III( respectively; 21(11.8%), 137(77%), 19(10.7%), and 1(0.6%) patients with poorly, moderately, well differentiated adenocarcinoma, and mucinous adenocarcinoma respectively. The Charlson/Deyo comorbidity index (CCI) score was 0 in the majority (73.6%) of patients. Fifty-three patients underwent abdominoperineal resection, 116 underwent low anterior resection and 9 underwent Hartmann resection. All the patients received computed tomography-based simulation and treatment planning using an anal marker in a prone or supine position. Patients were treated with linear accelerator by megavoltage photons (6MV), with 2D technique in early years and 3D conformal or simplified intensity-modulated radiotherapy technique later, at a dose of 50 Gy in 25 fractions to the pelvis within an overall treatment time of 35 days. Sixty-one patients (34.3%) received surgery combined with radiation (ART group), in whom 16 received radiation alone 117 patients did not receive radiation(NORT group). The baseline data between ART and NORT group were not significantly different(all P>0.05). There was no significant difference in 5-year overall survival between ART and NORT groups (61.0% vs. 63.0%, P=0.586). The cumulative local relapse was 10.9% and 25.4% in ART and NORT group respectively (P=0.032). Cox multivariate analysis revealed that surgery combined with radiation improved local control significantly(HR=0.27, 95%CI:0.11-0.68, P=0.005).</p><p><b>CONCLUSIONS</b>For elderly patients aged over 75 years with stage II( or III( rectal cancer, radical surgery combined with radiation does not increase the overall survival, but can improve local control rate. It is reasonable to selectively apply adjuvant radiotherapy to the elderly patients in the setting of radical surgery.</p>
Subject(s)
Aged , Aged, 80 and over , Humans , Adenocarcinoma , Radiotherapy , General Surgery , Neoplasm Recurrence, Local , Neoplasm Staging , Radiotherapy, Adjuvant , Rectal Neoplasms , Radiotherapy , General Surgery , Retrospective StudiesABSTRACT
Objective To evaluate the range of motion of gastroesophageal junction (GEJ) adenocarcinoma during preoperative radiotherapy.Methods Fourteen consecutive patients who received preoperative chemoradiotherapy for GEJ adenocarcinoma were included in this study.Fiducial markers were placed on the upper and lower edges of and around the primary tumor under a gastroscope.Eight patients underwent four-dimensional computed tomography to obtain 98 intrafractional images containing 8 fiducial markers at the GEJ.Twelve patients underwent cone-beam computed tomography at the 1 st to 5th,7th,12th,17th,and 22nd courses of radiotherapy to obtain 90 interfractional images.The paired t test was used for difference analysis.Results The intrafractional tumor displacements in left-right (LR),ventro-dorsal (VD),and cranio-caudal (CC) directions were 0.92±0.95 mm,2.27±2.73 mm,and 9.95±5.48 mm,respectively;the motion in CC direction was larger than that in LR or VD direction (P=0.000 or P=0.000);the motion in VD direction was larger than that in LR direction (P=0.000).The interfractional tumor displacements in LR,VD,and CC were 6.56±4.19 mm,5.69±3.29 mm,and 6.49±4.37 mm,respectively;the motion in LR or CC direction was larger than that in VD direction (P=0.031 or P=0.044);there was no significant difference between the motions in LR and CC directions (P=0.956).In order to ensure 95% of prescribed dose to at least 90% of the tumor volume,the margins from GEJ lesion in LR,VD,and CC directions were 19.4 mm,14.6 mm,and 27.2 mm,respectively,which could cover both intrafractional and interfractional tumor displacements during preoperative radiotherapy.Conclusions GEJ tumor has a wide range of movement in preoperative intra-and inter-fractional radiotherapy.This should be considered for precise radiotherapy,and a new method should be selected to limit tumor movement.
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Objective To investigate the effects of different irradiation techniques on dose distribution in target volume and normal tissues after the radical surgery for gastroesophageal junction adenocarcinoma,and to provide the optimal regimen for clinical treatment.Methods A total of 9 patients with gastroesophageal junction adenocarcinoma who underwent radical esophagus-proximal gastrectomy or total gastrectomy were enrolled.The therapeutic regimens of five-field static intensity-modulated radiotherapy (IMRT),volumetric-modulated arc therapy (VMAT),and helical tomotherapy (HT) were designed for each patient,and the dose-volume histogram was used to evaluate the effects of different irradiation techniques on the conformity index (CI) and homogeneity index (HI) of target volume and the surrounding normal tissues. The prescribed dose was 45 Gy at 1.8 Gy/fraction.The patients received oral S-1 as concurrent chemotherapy at a dose of 80 mg/(m 2? d) twice a day during radiotherapy.Results Compared with IMRT and VMAT,HT had better CI and HI of the target volume,as well as a better protective effect on the intestinal tract and bone marrow.Compared with IMRT and HT,VMAT had a lower V20 and V30 for the left kidney and a lower V30 for the heart,while IMRT had lower V5 and V10 for both lungs;V20 and mean dose showed no significant differences between the three techniques.HT had the highest mean sub-field hop count,followed by IMRT and VMAT.Conclusions IMRT, VMAT, and HT can meet the clinical requirements,but besides ensuring the best CI and HI of the target volume,HT has a good protective effect on the intestine and spinal cord and can help to reduce the incidence of adverse events in patients.
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Objective To observe the incidence of adverse reactions and short-term efficacy of S-1 and concurrent intensity-modulated radiotherapy ( IMRT) for locally advanced gastric cancer in a phase Ⅱclinical trial based on the phase I clinical trial.Methods Patients pathologically diagnosed with stage TN (+) gastric adenocarcinoma with local or distal metastasis after R0 resection were enrolled as subjects.IMRT was delivered 5 times per week with a total dose of 45 Gy in 25 fractions.S-1 was orally administered on the day of radiotherapy at a dose of 80 mg/m2 .Results A total of 40 patients, consisting of 6 patients from the phase I trial and 34 patients from the phaseⅡtrial, were enrolled in this study.In those patients, the age ranged between 27 and 73 years ( median age 50 years) and the male-to-female ratio was 3:1.Thirty-nine ( 98%) out of the forty patients completed radiotherapy and thirty-five ( 88%) completed concurrent chemotherapy.The most common grade 3-4 adverse reactions were nausea/anorexia ( 13%) , leukopenia ( 10%) , vomiting ( 8%) , radiation esophagitis ( 5%) , and neutropenia ( 5%) .There was no perioperative death.The 2-year overall survival and disease-free survival rates were 74% and 77%, respectively. Conclusions Postoperative S-1 and concurrent IMRT achieve satisfactory outcomes and tolerable toxicity in patients with locally advanced gastric cancer.
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Objective The aim of this study was to investigate whether the addition of neoadjuvant chemoradiotherapy ( NACRT ) to surgery can improve outcomes better than neoadjuvant chemotherapy in terms of rate of R0 resection, pathological complete response ( pCR ) and side effects. Methods This exploratory study included primary gastric adenocarcinoma patients staged as clinical T4N0 or anyTN1-3. Intensity modulated radiotherapy was delivered of 40 to 50 Gy in 22 to 25 fractions,5 days/week.Concurrent chemotherapy regimens included S-1 or Capecitabine or a combination of Paclitaxel plus Carboplatin.Results Eleven eligible patients were enrolled. R0 and R2 resections were performed in 9 ( 9/11) and 1 patients, respectively.Peritoneal metastasis was found in 1 case during exploratory laparotomy.The pCR was observed in 1 patient with R0 resection ( 1/10 ) . Ten cases completed radiotherapy and 8 cases completed chemotherapy. Nausea ( 3/11 ) , vomit ( 2/11 ) and anorexia ( 2/11 ) were the most common Grade 3 toxicities. Conclusions NACRT showed an acceptable toxicity and promising activity in locally advanced gastric adenocarcinoma.
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Objective To evaluate the effects of electrocautery assisted uvalopalatopharyngoplasty (UPPP) for obstructive sleep apnea and hyponea syndrome(OSAHS) .Methods Patients with OSAHS were randomly divided into two groups ,with 14 cases in each group .Group A was operated on with electrocautery ,while group B was operated on with the traditional method .The operative blood loss ,the operation time ,the tunica albuginea off time ,post operative pain ,surgical outcomes and complications were compared between two groups .Results The operative blood loss and the operation time of group A were much less than in group B (all P0 .05) .Two groups of patients both had no serious complications .Conclusion The advantages of electrocautery assisted UPPP consists of less operative blood loss and less operation time .It deserves to generalize and apply in the future clinical treatments .