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Objective:To retrospectively analyze prognostic factors and patterns of recurrence in locally advanced gastric cancer patients receiving chemoradiotherapy (CRT) after radical gastrectomy, aiming to provide reference for postoperative CRT of locally advanced gastric cancer.Methods:Clinical data of 171 patients with curatively resected gastric carcinoma who received postoperative CRT in our hospital between 2008 and 2020 were retrospectively analyzed. The disease-free survival and overall survival (OS) rates were calculated by Kaplan- Meier method. Univariate prognostic analysis was performed by log- rank test. Multivariate prognostic analysis was conducted by Cox model. Results:The median follow-up duration was 63 months. The follow-up rate was 93.6%. 31.0% and 66.7% of the enrolled patients were classified in pathological stage Ⅱ and Ⅲ. The acute grade 3 or 4 gastrointestinal and hematological toxicity rates were 8.8% and 9.9%, respectively. In total, 166 patients completed the entire CRT regimen. No toxicity-related death occurred. Regarding patterns of recurrence, 17 patients had locoregional recurrence, 29 had distant metastasis and 12 had peritoneal metastasis. The 1-, 3-and 5-year overall survival (OS) rates were 83.7%, 66.3%, and 60.0%, while the 1-, 3-and 5-year disease-free survival rates were 75.5%, 62.7%, and 56.5%, respectively. In the multivariate analysis, pathological T stage, perineural invasion and lymph node ratio (LNR) were found to be the independent predictors of OS.Conclusions:Postoperative intensity-modulated radiation therapy and chemotherapy are well tolerated, with acceptable toxicities and encouraging locoregional tumor control and long-term survival. LNR can be used as an independent prognostic indicator for OS. Adjuvant CRT should be considered for all patients with a high risk of locoregional recurrence.
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Objective:To investigate and analyze the current status of multimodality therapy for resectable gastric cancer, aiming to provide reference for optimizing the multimodality treatment strategy for gastric cancer.Methods:Clinical data of patients diagnosed with gastric adenocarcinoma undergoing radical gastrectomy in the Second Affiliated Hospital of Soochow University were retrospectively analyzed. Clinical characteristics, preoperative medical comorbidities, pathological features, surgical and perioperative status and clinical efficacy were recorded. The gap between the diagnosis and treatment procedures and the standard guidelines was analyzed. The changes in the multimodality treatment patterns for gastric cancer were understood.Results:A total of 265 patients were included in this study. All patients were divided into two cohorts: early[2008] and late[2013] cohorts. In the early cohort, 127 patients were assigned, and 138 cases in the late cohort. In the early cohort, 67 patients (52.8%) underwent D 2 lymph node dissection, significantly less than 83 patients (60.1%) in the late cohort ( P<0.01). In the early and late cohorts, the proportion of patients with the number of lymph node dissection of ≥15 was 5.5% and 52.8%( P<0.01). The median number of lymph node dissection was increased from 6 to 16. The proportion of patients receiving neoadjuvant chemotherapy in the early and late cohorts was 2.4% and 3.6%( P=0.55). In the early cohort, the proportion of patients treated with postoperative chemotherapy and postoperative adjuvant chemoradiotherapy was 62.6% and 2.4%, significantly higher compared with 58.0% and 8.0% in the late cohort ( P=0.04). In addition, the proportion of patients receiving postoperative chemotherapy in the early cohort was 62.2%( n=79) and 58.0%( n=80) in the late cohort ( P=0.48). Conclusions:Although the level of radical gastrectomy has been continuously improved and standardized in China, which still lags behind the standard D 2 radical gastrectomy in Japan and South Korea. Adjuvant therapies including postoperative adjuvant radiotherapy can bring clinical benefits. However, the proportion of patients receiving adjuvant therapy is still low, and the multimodality therapy of gastric cancer should be widely applied.
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Objective:To explore the method of improving the accuracy of dose calculation of treatment plan in radiotherapy for patients with metal implants.Methods:A CT simulator with metal artifact reduction technique (MAR) was utilized to scan the CIRS intensity-modulated phantom with metal rods and 8 patients with steel nails implanted in the centrum for radiotherapy. Radiotherapy plans were designed using conventional CT images, MAR images and density-filled images. The dose calculation errors between single field and intensity-modulated radiotherapy (IMRT) plan were compared. The effect of mental implants and their artifacts on the irradiation dose of IMRT plan was evaluated.Results:In the conventional CT images of the phantom, when the incident path of the field failed to pass through the metal region, the dose calculation error for a single field was 3.85%, and the range of dose error for the field was 4.46%-74.11% when passing through the metal region. IMRT planning errors might exceed the clinically acceptable range when the incident path of the field passed through the metal region, and the errors tended to increase with the increase of dose weight of this field. After processing the images with density filling and artifact reduction techniques, the errors of the single field were 1.23% and 0.89%-4.73%, respectively, and the dose error of IMRT was 1.84%. The error of IMRT plan was 1.88% if density filling technique alone was employed to process the metal region. Due to the influence of metal implants and their artifacts, the minimum dose, average dose and prescription dose coverage actually received in the tumor target area were lower than IMRT plan results based on conventional CT images. The dosimetric difference of organs at risk was not statistically significant.Conclusions:In the radiotherapy plan based on conventional CT images, there may be a large dose calculation error when the incident path of field passes through the metal region. If the metal material is known, density filling of the metal region in the planning system can effectively improve the accuracy of dose calculation. Metal artifact reduction technique can significantly improve the image quality and further reduce dose calculation error, which should be a routine technique for CT machines equipped with this function to perform simulated localization of patients with metal implants.
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Objective:According to the SIOPE (2018) guidelines, the whole brain target of patients undergoing craniospinal irradiation was delineated and the underdose of sub-structures which were not delineated in original plan was verified, aiming to provide evidence for the risk of whole brain recurrence of craniospinal irradiation and accumulate experience for the clinical application of SIOPE guidelines.Methods:Twelve children who underwent craniospinal irradiation were selected. As per the SIOPE guidelines in 2018, the CTV sub (including the superior orbital fissure, foramen rotundum, foramen ovale, jugular foramen, hypoglossal canal, internal auditory meatus and optic nerve) were delineated based on the original CTV old (whole brain plus sieve plate) to form PTV new. A rough PTV (PTV rough) was formed by giving a margin of 15 mm forward-downward (skull base) and 3 mm in the other directions. CRT old and IMRT old plans were designed based on PTV old. CRT new and IMRT new plans were designed based on PTV new. CRT rough plan was designed based on PTV rough. The omission of sub-structures based on CTV old and the underdose of CTV sub in each plan were evaluated. Results:A total of 78.6% of superior orbital fissure, 71.99% of foramen rotundum, 96.76% of foramen ovale, 88.5% of jugular foramen, 97.71% of hypoglossal canal, 99.48% of internal auditory meatus and 100% of optic nerve volume were missed based on CTV old. The target dose coverage of CTV sub based on CRT old and IMRT old was only 91.70% and 89.83%, respectively. The underdose was observed in 16.66%, 3.57%, 20.83%, 1.78% and 1.19% of sub-structures in CRT old, CRT new, IMRT old, IMRT new and CRT rough plans, respectively. Of the underdose of all sub-structures, 38.36% and 46.58% occurred in CRT old and IMRT old plans, respectively. Among them, the least and the most significant underdose occurred in foramen rotundum (0%) and foramen ovale (36.66%), respectively. Conclusions:As per the SIOPE guidelines, traditional brain tissue delineation (including sieve plate) is likely to omit part of the target during the cranial target definition of craniospinal irradiation. The most significant underdose occurs in foramen ovale, and more obvious in the IMRT plan. The plan based on the delineation of sub-structures can significantly improve the underdose. When AP-PA irradiation is adopted, a rough PTV is recommended to obtain approximate target dose coverage and organ of risk sparing, whereas it requires further clinical verification.
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Objective To analyze the clinical characteristics of children with low grade glioma (LGG) and evaluate their survival status and quality of life in LGG pediatric patients after postoperative radiotherapy.Methods Clinical data of 27 LGG children aged ≤ 14 years admitted to Department of Radiation Oncology of our hospital from January 2011 to December 2017 were retrospectively analyzed.The 5-year overall survival (OS) and progression-free survival (PFS) were estimated with the Kaplan-Meier method.The quality of life was evaluated by body mass index (BMI),WeeFIM and enrollment situation.Results The 5-year OS and PFS of 27 pediatric patients were 92％ and 87％.BMI was measured in 25 children who were still alive and the results showed that 1 child was slightly emaciated,3 were overweight and 21 were normal.The total score of WeeFIM was＞ 108 in 21 cases and＜ 90 in 4 cases.In terms of social role-playing assessment,5 cases delayed enrollment for≥ 2 years,2 cases had good adaptation except the difficulties due to lameness,7 of them had poor study performance,but had no communication barrier.Conclusions Children with LGG can obtain relatively excellent OS and PFS after postoperative radiotherapy.Part of the children with long-term survival may experience a declined quality of life,which is mainly manifested with a decline in motor and cognitive functions.
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Objective@#To analyze the clinical characteristics of children with low grade glioma (LGG) and evaluate their survival status and quality of life in LGG pediatric patients after postoperative radiotherapy.@*Methods@#Clinical data of 27 LGG children aged≤14 years admitted to Department of Radiation Oncology of our hospital from January 2011 to December 2017 were retrospectively analyzed. The 5-year overall survival (OS) and progression-free survival (PFS) were estimated with the Kaplan-Meier method.The quality of life was evaluated by body mass index (BMI), WeeFIM and enrollment situation.@*Results@#The 5-year OS and PFS of 27 pediatric patients were 92% and 87%. BMI was measured in 25 children who were still alive and the results showed that 1 child was slightly emaciated, 3 were overweight and 21 were normal. The total score of WeeFIM was> 108 in 21 cases and< 90 in 4 cases. In terms of social role-playing assessment, 5 cases delayed enrollment for≥ 2 years, 2 cases had good adaptation except the difficulties due to lameness, 7 of them had poor study performance, but had no communication barrier.@*Conclusions@#Children with LGG can obtain relatively excellent OS and PFS after postoperative radiotherapy. Part of the children with long-term survival may experience a declined quality of life, which is mainly manifested with a decline in motor and cognitive functions.
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Objective To investigate the construction and application in practice of information process management system in the treatment of acute ischemic stroke (AIS).Methods From August 2017 to November 2017,the clinical data of the 597 patients with suspected stroke received green channel treatment for stroke and incorporated into the information process management system at the Cerebrovascular Disease Center,Changhai Hospital,the Second Military Mcdical University were analyzed retrospectively.The operation status and operational efficiency of each link in the AIS treatment process were evaluated.The performance assessment indicators for stroke nurses and visiting doctors were developed.The accuracy and missed diagnosis of stroke determined by the stroke nurses were calculated.The operation ability of stroke nurses was evaluated by the doctor's arrival at triage desk to establishment of intravenous access time and signing of informed consent to rt-PA bolus time,with less than 10 min as the standard.The emergency response capability of consultation physicians was evaluated by calling consultation physician to arriving at the triage desk and establishing venous channel to transport to the CT room time,with less than 5 min as the standard.The standard-reaching rate was calculated.Results A total of 597 patients were prechecked as suspected stroke.Among them,549 patients with stroke were judged by doctors,430 established venous access,443 were transported to CT room,441 completed CT scan,and 52 were treated with venous thrombolysis.In the process,the median time of patients to hospital to doctor to triage desk,doctor to triage desk to establishment of venous channel,establishment of venous channel to transportion to CT room to completion of CT scan,completion of CT scan to rt-PA bolus,patients to hospital to completion of CT scan and patients to hospital to rt-PA bolus was 3 (1,5),8 (3,16),3 (2,5),3 (2,9),9 (3,22),20(10,30) and 27 (19,55) min,respectively.The stroke nurses determined the accuracy and misdiagnosis rate of stroke were 92.0％ (549/597) and 8.4％ (50/597) respectively.The standard-reaching rate of doctor to triage desk to establishment of venous channel,signing informed consent to rt-PA bolus time were 82.1％ (353/430) and 80.8％ (42/52) respectively.The standard-reaching rates of calling consultation doctor to doctor to triage desk,establishment of venous channel to transportion to CT room time were 94.5％ (564/597) and 91.4％ (405/443) respectively.Conclusion A process management system centered on "time management" may help analyze the efficiency of various links and personnel in the AIS treatment process,and optimize the process continuously.
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Objective To analyze the effects of quality supervision and continuous improvement system on optimizing in-hospital diagnosis and treatment process in patients with acute ischemic stroke (AIS).Methods From September 2013 to May 2016,424 consecutive patients with AIS treated with intravenous thrombolysis and/or endovascular therapy in Changhai Hospital,the Second Military Medical University were enrolled retrospectively.They were analyzed according to the annual running process (the first year[from September 2013 to August 2014],the second year[from September 2014 to August 2015],and the third year[from September 2015 to May 2016]).The spend time and delay (DTN>60 min,DTP>90 min) rate of each treatment process in the first,second,and third year (time from door-to-imaging[DTI],door-to-needle[DTN],imaging-to-needle (ITN),door-to-groin puncture (DTP) and imaging-to-groin puncture (ITP) were compared.Taking the time periods (>median) of having significant differences of the spend time of the treatment processes as the dependent variables in the first,second,and third year,the influence of the years and treatment modalities on delay was observed.The difference of constituent ratio of the reasons for delay in intravenous thrombolysis and endovascular therapy (objective reasons/other reasons) in different years were analyzed.Results (1) DTIs were 23.0 (11.0,42.0) min,22.0 (10.1,39.0) min,and 13.0 (6.0,27.0) min,respectively,and DTNs were 50.0 (30.0,77.1) min,45.0 (30.0,70.2) min,and 36.0 (24.0,57.0) min,respectively in the first,second,and third year.The spending time was shortened year by year.There were significant differences among the different years (all P0.05).(2) The DTN delay rates were 33.3% (40/120),20.7% (29/140),and 8.1% (9/111),respectively in the first,second,and third year.There were significant differences among the 3 years (x2=22.111,P0.05).(4) During the three years,the delay of intravenous thrombolysis was mainly due to objective reasons.The constituent ratio of other reasons caused delay of intravenous thrombolysis was decreased year by year.There was no other reasons for delay in the third year).There was no significant difference in the constituent ratio of the delay reasons in endovascular treatment (x2=3.622,P=0.164).Conclusion Under the existing process and resource allocation,setting the DTN target time and implementing continuous quality improvement are conducive to the effective implementation of brain CT scan and continuous optimization of intravenous thrombolysis in the processes in AIS patients with the first diagnosis.
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Objective To analyze the effect of the changes of hospital diagnosis and treatment mode on the treatment time in patients with acute ischemic stroke before and after the establishment of Cerebrovascular Disease Center. Methods A total of 103 consecutive patients with acute ischemic stroke admitted to the Department of Neurology,Changhai Hospital,the Second Military Medical University between June 2008 and December 2012 were enrolled retrospectively. Thirty-one of them were excluded because of incomplete medical records. Finally,72 patients were enrolled as a control group and received series diagnosis and treatment mode. A total of 210 consecutive patients with acute ischemic stroke admitted to the Cerebrovascular Disease Center,Changhai Hospital,the Second Military Medical University from September 2013 to February 2015 were enrolled retrospectively. Thirteen patients were excluded (4 patients with recurrent transient ischemic attack were treated with recombinant tissue-type plasminogen activator,9 without complete data were treated with intravenous thrombolysis),197 were enrolled as an observation group finally,and they were received series diagnosis and treatment mode. The patients of both groups were visited within 4. 5 h after onset and received rt-PA treatment. The time-consuming changes of each time period from onset-to-door,door-to-imaging,imaging-to-needle,door-to-needle,and onset-to-needle time between the control group and the observation group were compared and analyzed. Results Compared with the control group,the door-to-imaging,imaging-to-needle,door-to-needle and onset-to-needle time were significantly shorter in the observation group. There were significant difference between the 2 groups (24 ± 12 min vs. 60 ± 20 min,27 ± 12 min vs. 62 ± 31 min,51 ± 17 min vs. 122 ± 52 min,and 153 ± 69 min vs. 230 ± 81 min,all P 0. 05). Conclusion The establishment of cerebral vascular disease center and the improvement of the processes have shortened the treatment time in patients with acute ischemic stroke within time window. The time from onset-to-door is still longer,and the propaganda and education of stroke should be strengthened.
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Objective To assess the differences in delineation of organs at risk (OAR) and dosimetry between junior and senior physicians during intensity-modulated radiation therapy (IMRT) for nasopharyngeal carcinoma (NPC) and to evaluate the role of specific training in reducing the differences.Methods Sixteen patients newly diagnosed with NPC were selected in the study.The OAR was delineated separately by three junior physicians and three senior physicians,and the geometric and dosimetric differences were assessed relative to the reference OAR.Delineation was performed again for the two OARs with the biggest difference after specific training in the two groups of physicians,and the differences were evaluated again.The difference was determined by paired t test.Results The maximum dose differences (Dmax) of OAR in the junior and senior physicians were (2.33 ± 12.06) ％ (-48.06％-137.82％) and (0.09 ± 4.72) ％ (-49.54％-42.96％),respectively (P =0.039),and the difference in the optic chiasm was the greatest ((5.85 ± 19.63) ％ ∶ (1.36 ± 4.64) ％,P =0.042).The mean dose differences (Dmean) of OAR in the junior and senior physicians were (3.10 ± 8.07)％ (-46.76％-59.76％) and (-0.93 ± 2.03) ％ (-45.54％-35.69％),respectively (P =0.021),and the difference in the parotid gland was the greatest ((13.23 ± 13.39) ％ ∶ (3.20 ± 6.71) ％,P =0.002).In the secondary delineation after training,the Dmax of the optic chiasm in the junior and senior physicians was (1.68 ± 3.34)％ and (1.50 ± 1.87) ％,respectively (P =0.841),and the difference in junior physicians was reduced significantly compared with before training ((1.68 ± 3.34) ％ ∶ (5.85 ± 19.63) ％,P =0.048) ; the Dmean of the parotid gland in the junior and senior physicians was (2.46 ± 3.06) ％ and (1.35 ± 3.00) ％,respectively (P =0.2 7 4),significantly reduced compared with before training ((2.46 ± 3.0 6) ％ ∶ (13.23 ± 13.39)％,P=0.002; (1.35 ± 3.00)％ ∶ (3.20 ± 6.71) ％,P =0.033).Conclusions The differences in delineation of OAR lead to dose uncertainties during IMRT for NPC,and specific training can improve the accuracy of delineation.
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Objective To study the appropriate neck irradiation volume for neck lymph nodenegative nasopharyngeal carcinoma patients by Meta-analysis.Methods The related references published from Jan 1990 to Jun 2013 were searched in Pubmed,Embase,Cochrane and Wangfang Databases.The qualified references for enrollment criteria were screened and the relative data were collected.The OR (Odds ratio) value by fixed effect model was used to evaluate the data for patients who received radiotherapy between the upper neck and whole neck irradiation.The endpoints including 5-year neck local control rate (LCR),neck-in-irradiation LCR,and neck-outsides-irradiation LCR.Results Five qualified references were screened and belonged to respective research.There enrolled 1 333 patients,including 970 patients who received the upper neck irradiation and 363 patients who received the whole neck irradiation,respectively.The forest plots revealed that there were no significant differences for 5-year neck LCR,neckin-irradiation LCR,and neck-outsides-irradiation LCR for patients received radiotherapy between the upper neck and whole neck irradiation.These OR values were 0.89 (95％ CI:0.41-1.94),1.29 (95％ CI:0.58-2.88) and 0.42 (95％ CI:0.07-2.36),respectively.Conclusions The Meta-analysis results suggest that irradiation to the upper neck for neck lymph node-negative nasopharyngeal carcinoma can be appropriate.