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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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Esophageal cancer is a malignant tumor of the digestive system that has a high incidence in China. The traditional treatment methods include surgery, radiotherapy, and chemotherapy, but the long-term efficacy is not good and the side effects are obvious. As a traditional physical therapy, hyperthermia has no significant toxic and side effects. Studies have shown that hyperthermia can increase the sensitivity of esophageal cancer to radiotherapy and chemotherapy, and its combined use in the treatment of esophageal cancer can prolong the survival and improve the quality of life. In addition, the innovation of materials and technologies brings new breakthroughs to tumor hyperthermia.
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Objective:To evaluate the pancreatic subclinical dysfunction after intensity-modulated radiation therapy (IMRT) for gastric cancer by analyzing biochemical indexes and pancreatic volume changes, and to reduce the dose of pancreas by dosimetric prediction and dose limitation.Methods:30 patients with gastric cancer who received 45 Gy postoperative adjuvant radiotherapy were retrospectively selected. The pancreas was delineated and its dose and anatomical relationship with planning target volume (PTV) were evaluated. Fasting blood glucose, serum lipase and amylase, and pancreatic volume changes before and after radiotherapy were analyzed. The correlation between the changes of biochemical indexes and volume and pancreatic dose was evaluated by Pearson analysis. The threshold of the dosimetric prediction was obtained by receiver operating characteristic (ROC) curve. Finally, the feasibility of dosimetric limitation in IMRT was assessed.Results:The pancreatic volume of 30 patients was 37.6 cm 3, and 89.0% of them were involved in PTV. D mean of the pancreas was 45.92 Gy, and 46.45 Gy, 46.46 Gy and 45.80 Gy for the pancreatic head, body and tail, respectively. The fasting blood glucose level did not significantly change. The serum lipase levels were significantly decreased by 66% and 77%(both P<0.001), and the serum amylase levels were significantly declined by 24% and 38%(both P<0.001) at 6 and 12 months after radiotherapy. Pancreatic volumes of 22 patients was decreased by 47% within 18 months after radiotherapy. ROC curve analysis showed that pancreatic V 45Gy had the optimal predictive value for the decrease by 1/3 of serum lipase and amylase levels at 6 months and serum amylase level at 12 months after radiotherapy, and the cut-off value was V 45Gy<85%. Pancreatic D mean yielded the optimal predictive value for the decrease by 2/3 of serum lipase level at 12 months after radiotherapy, and the cut-off value was D mean<45.01 Gy. After" whole pancreas" and" outside PTV pancreas" dose limit, V 45Gy of the pancreas was decreased by 11% and 7%, D mean of the pancreas was declined by 2% and 2%, and D mean of the pancreatic tail was decreased by 3%, respectively. Conclusions:Serum lipase and amylase levels significantly decline at 6 and 12 months after adjuvant radiotherapy for gastric cancer, and pancreatic volume is decreased significantly within 18 months after radiotherapy. Pancreatic V 45Gy<85% and D mean<45.01 Gy are the dose prediction values for the decrease of serum lipase and amylase levels. The dose can be reduced to certain extent by dosimetric restriction.
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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 evaluate whether the decrease in peripheral blood monocyte count was a potential predictor for neutropenia in patients with nasopharyngeal carcinoma and cervical cancer.Methods:The medical records of 95 patients with nasopharyngeal carcinoma and cervical carcinoma who received intensity-modulated radiation therapy (IMRT) combined with paclitaxel liposomes and platinum (TP) synchronous chemotherapy and presented with neutropenia in the Second Affiliated Hospital of Soochow University from January 2017 to December 2018 were retrospectively analyzed. Paired sample t-test was used to assess whether the number of days when the monocytes initially dropped/decreased to lowest level/eventually increased to normal value was significantly less than those of the neutrophils. In addition, the chi-square test was performed to determine the correlation between the degree of reduction in the absolute neutrophil count (ANC) and baseline absolute monocyte count (AMC). Results:The change trend of AMC was consistent with that of ANC in the two cycles of concurrent chemotherapy. The number of days when AMC initially decreased/decreased to the lowest level/finally increased to normal value was significantly less than that of ANC (4 d vs. 6 d, 4 d vs. 10 d, P<0.001; 5 d vs. 6 d, 6 d vs. 9 d, 7 d vs. 12 d, P<0.001). However, no correlation was found between the baseline level of monocytes and the degree of subsequent neutropenia [(AMC<0.4×10 9) vs.( AMC≥0.4×10 9)=32 vs. 63, P=0.172]. Conclusions:Decreased monocyte count is an important potential predictor for neutropenia and a significant indicator for guiding the next monitoring of neutrophil count and treatment with granulocyte colony-stimulating factor.
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Surgical resection is the main radical treatment of early and mid-stage primary liver cancer (PLC), but the high postoperative recurrence rate is the main factor affecting the curative effect. With recent advancement in techniques, the efficacy and safety of radiation therapy for PLC have been widely proven. In this review, we will investigate the combination of surgery and radiation therapy, covering the topics of preoperative or postoperative radiotherapy for PLC with portal vein tumor thrombus, postoperative adjuvant radiotherapy in PLC with narrow surgical margin or microvascular invasion, stereotactic body radiation therapy as a bridge to liver transplantation, radiotherapy in conversion to resectability for intrahepatic inoperable PLC. Despite radiation therapy is one of the effective therapeutic options for PLC, there is still a compelling need for prospective, randomized, controlled phase Ⅲ trials to acquire high-levelclinical evidence for confirming the role of radiation therapy in the treatment of PLC.
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Hepatocellular carcinoma (HCC) is prone to invading portal vein system known as portal vein tumor thrombus (PVTT). PVTT is one of the main reasons for poor prognosis of HCC because of its rapid progress and lack of effective treatments, and the optimal treatment strategy remains controversial. With recent advances in techniques, the efficacy and safety of radiation therapy for PVTT has been improved. The optimization of individualized radiotherapy and multimodality treatment is the future direction of research. In this review, we will investigate the current state and future opportunities of radiation therapy and multimodality treatment for HCC with PVTT.
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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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Radiotherapy is an important component of multidisciplinary comprehensive treatment of malignant tumors. However, the existence of non-neoplastic complications may increase the acute and late adverse reactions of radiotherapy and affect the smooth implementation of radiotherapy. This paper reviews the effects of various common non-neoplastic complications (including diabetes, HIV infection, and inflammatory bowel disease) on radioactive normal tissue damage in tumor patients.
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Acute radiation-induced intestinal injury is the common complication in patients following abdominal and pelvic radiotherapy. However, no effective clinical prevention and treatment interventions are available. As the probiotics and symbiotic bacteria, many species of the genus Lactobacillus are normally present in the gastrointestinal tract and beneficial for the intestinal health. Preclinical studies have reported that the genus Lactobacillus can prevent and treat acute radiation-induced intestinal injury by protecting crypt stem cells, maintaining intestinal barrier and exerting the antioxidant effect, etc. Clinical trials have prompted that oral administration of adequate complex probiotics containing Lactobacillus spp.at one week before radiotherapy contributes to preventing radiation-induced diarrhea. In addition, oral intake of the genus Lactobacillus has the tendency to treat radiation-induced diarrhea and mitigate acute radiation proctitis. At present, no relevant adverse events have been reported.
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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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Recently,the relationship between intestinal flora and its metabolites and tumorigenesis,inflammatory bowel diseasesas well as radiation-induced intestinal injury has captivated widespread attention from researchers.Accumulated evidence derived from nuclear accident investigation,animal model experiment and clinical research has proven the role of intestinal flora and its metabolites as the biomarkers to evaluate the radiation dose and severity of radiation-induced intestinal injury.This article reviews the relationship between intestinal flora and its metabolites and radiation-induced intestinal injury,aiming to provide theoretical reference for assessing the risk of radiation-induced intestinal injury.
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Objective To evaluate and predict the pelvic dose by analyzing two pelvic contour definitions and identify the influencing factors of the pelvic dose in postoperative IMRT for cervical cancer,aiming to provide reference for postoperative pelvis-sparing IMRT for cervical cancer.Methods Sixty cervical cancer patients receiving postoperative IMRT with unrestricted pelvic dose were selected.Two sets of pelvic contours (pelvic anatomy and pelvic Mell) were delineated as per the anatomical and Mell methods.The dose relationship between two methods was analyzed after redesigning the treatment plan by limiting dose of pelvic anatomy.The correlation analysis was performed by Pearson's correlation method.The factors affecting the pelvic anatomy dose were identified by Logistic multivariate regression analysis and a dose prediction model was subsequently established.Results The volumes of pelvic anatomy and pelvic Mell were 925.82 cm3 and 1 141.20 cm3(P=0.000).There was a significant correlation between them (r＞0.622,P=0.000).The dose of pelvic anatomy was significantly higher than that of pelvic Mell.The relationship of V10,V20 and V30 between them was y =-8 + 1.01x,y =-13 + 1.05x and y =-4 + 0.9x,respectively.The dose limits of pelvic Mell recommended by literatures (V10＜90％,V20＜75％,V30＜60％)were translated into V10 ＜ 97％,V20 ＜ 83％ and V30 ＜ 70％,respectively.The pelvic anatomy dose was significantly reduced after dose limiting.The V10,V20,V30 and Dmean were significantly decreased by 3.64％,12.69％,12.02％ and 6.93％(P=0.000,0.000,0.000),respectively.Multivariate analysis showed that the overlapping volume of pelvic anatomy within PTV was an independent influencing factor of pelvic anatomy dose (P＜0.05).Patients with a relative overlapping volume of less than 18％ could easily meet the dose limiting requirement.Conclusions Both two pelvic contour definitions can be applied in postoperative pelvis-sparing IMRT for cervical cancer.Use of pelvic dose limiting can significantly reduce the IMRT dose.The overlapping volume of the pelvis within PTV is an independent influencing factor of pelvic dose.Patients whose overlapping volume within the PTV relative to pelvis is less than 18％ can easily meet the dose limiting requirement.
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Objective@#To evaluate and predict the pelvic dose by analyzing two pelvic contour definitions and identify the influencing factors of the pelvic dose in postoperative IMRT for cervical cancer, aiming to provide reference for postoperative pelvis-sparing IMRT for cervical cancer.@*Methods@#Sixty cervical cancer patients receiving postoperative IMRT with unrestricted pelvic dose were selected. Two sets of pelvic contours (pelvic anatomy and pelvic Mell) were delineated as per the anatomical and Mell methods. The dose relationship between two methods was analyzed after redesigning the treatment plan by limiting dose of pelvic anatomy. The correlation analysis was performed by Pearson’s correlation method. The factors affecting the pelvic anatomy dose were identified by Logistic multivariate regression analysis and a dose prediction model was subsequently established.@*Results@#The volumes of pelvic anatomy and pelvic Mell were 925.82 cm3 and 1141.20 cm3(P=0.000). There was a significant correlation between them (r>0.622, P=0.000). The dose of pelvic anatomy was significantly higher than that of pelvic Mell. The relationship of V10, V20 and V30 between them was y=-8+ 1.01x, y=-13+ 1.05x and y=-4+ 0.9x, respectively. The dose limits of pelvic Mell recommended by literatures(V10<90%, V20<75%, V30<60%) were translated into V10<97%, V20<83% and V30<70%, respectively. The pelvic anatomy dose was significantly reduced after dose limiting. The V10, V20, V30 and Dmean were significantly decreased by 3.64%, 12.69%, 12.02% and 6.93%(P=0.000, 0.000, 0.000), respectively. Multivariate analysis showed that the overlapping volume of pelvic anatomy within PTV was an independent influencing factor of pelvic anatomy dose (P<0.05). Patients with a relative overlapping volume of less than 18% could easily meet the dose limiting requirement.@*Conclusions@#Both two pelvic contour definitions can be applied in postoperative pelvis-sparing IMRT for cervical cancer. Use of pelvic dose limiting can significantly reduce the IMRT dose. The overlapping volume of the pelvis within PTV is an independent influencing factor of pelvic dose. Patients whose overlapping volume within the PTV relative to pelvis is less than 18% can easily meet the dose limiting requirement.
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Objective@#To compare the efficacy of postoperative adjuvant radiotherapy and non-radiotherapy in patients with extrahepatic cholangiocarcinoma and gallbladder carcinoma by a meta-analysis.@*Methods@#The controlled clinical trials of postoperative adjuvant radiotherapy versus non-radiotherapy of extrahepatic cholangiocarcinoma and gallbladder carcinoma were searched from PubMed, EMbase, Cochrane Library, Wanfang database, CNKI, Chongqing VIP and CBM databases. The obtained data were analyzed using RevMan 5.3 and Stata 14.0 statistical software. The difference between two groups was estimated by calculating the odds ratio (OR) with 95% confidence interval (CI).@*Results@#A total of 20 controlled clinical trials involving 1258 extrahepatic cholangiocarcinoma and gallbladder carcinoma patients were included in this meta-analysis. The meta-analysis demonstrated that the 5-year survival rate in the adjuvant radiotherapy group was significantly higher than that in the non-radiotherapy group (OR=1.67, 95%CI: 1.29-2.18, P=0.001). The 5-year survival rates in those with lymph node positive disease (OR=7.44, 95%CI: 1.24-44.72, P=0.03) and positive margins disease (OR=3.43, 95%CI: 1.56-7.75, P=0.002) were significantly enhanced by postoperative adjuvant radiotherapy. The local recurrence rate in the adjuvant radiotherapy group was significantly lower than that in the non-radiotherapy group (OR=0.56, 95%CI: 0.39-0.80, P=0.01), whereas the distant metastasis rate did not significantly differ between two groups (OR=1.22, 95%CI: 0.86-1.73, P=0.27). The incidence rates of acute toxicity and chronic toxicity of grade ≥3 caused by radiotherapy were 0-11.9% and 0-21.7%, respectively.@*Conclusion@#Compared with non-radiotherapy, postoperative adjuvant radiotherapy is a safer and more effective postoperative treatment for extrahepatic cholangiocarcinoma and gallbladder carcinoma.
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Objective@#To compare the efficacy between hypofractionated radiotherapy versus conventionally fractionated radiotherapy in post-mastectomy breast cancer by a meta-analysis.@*Methods@#The controlled clinical trials of comparing hypofractionated radiotherapy versus conventionally fractionated radiotherapy in post-mastectomy breast cancer were searched from PubMed, EMbase, Cochrane Library, Wanfang database, VIP, CNKI, and CBM databases. The obtained data were analyzed using RevMan 5.3 and Stata 14.0 software. The differences between two groups were estimated by calculating the odds ratio (OR) with 95% confidence interval (CI).@*Results@#A total of 19 controlled clinical trials involving 2652 post-mastectomy breast cancer patients were selected in this meta-analysis according to the inclusion and exclusion criteria. The meta-analysis results demonstrated that no statistical significance was observed in the tumor-free survival (OR=1.10, 95%CI: 0.78-1.56, P=0.59), overall survival (OR=1.18, 95%CI: 0.92-1.53, P=0.19), locoregional recurrence (OR=1.01, 95%CI: 0.68-1.51, P=0.96), distant metastasis (OR=1.14, 95%CI: 0.82-1.59, P=0.43), skin toxicity (OR=1.01, 95%CI=0.80-2.16, P=0.96), cardiac toxicity (OR=1.17, 95%CI: 0.71-1.93, P=0.53) and pulmonary toxicity (OR=0.78, 95%CI: 0.44-1.37, P=0.38) between two groups.@*Conclusions@#Hypofractionated radiotherapy and conventionally fractionated radiotherapy post-mastectomy yield similar clinical efficacy, both of which are safe and efficacious radiotherapy patterns. However, the findings remain to be validated by large-scale randomized clinical trials with long-term follow-up of the advanced stage complications.
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Objective To compare the efficacy between hypofractionated radiotherapy versus conventionally fractionated radiotherapy in post-mastectomy breast cancer by a meta-analysis.Methods The controlled clinical trials of comparing hypofractionated radiotherapy versus conventionally fractionated radiotherapy in post-mastectomy breast cancer were searched from PubMed,EMbase,Cochrane Library,Wanfang database,VIP,CNKI,and CBM databases.The obtained data were analyzed using RevMan 5.3 and Stata 14.0 software.The differences between two groups were estimated by calculating the odds ratio (OR) with 95％ confidence interval (CI).Results A total of 19 controlled clinical trials involving 2652 post-mastectomy breast cancer patients were selected in this meta-analysis according to the inclusion and exclusion criteria.The meta-analysis results demonstrated that no statistical significance was observed in the tumor-free survival (OR =1.10,95 ％ CI:0.78-1.56,P =0.59),overall survival (OR =1.18,95 ％ CI:0.92-1.53,P =0.19),locoregional recurrence (OR=1.01,95％CI:0.68-1.51,P=0.96),distant metastasis (OR=1.14,95％CI:0.82-1.59,P=0.43),skin toxicity (OR=1.01,95％CI=0.80-2.16,P=0.96),cardiac toxicity (OR=1.17,95％CI:0.71-1.93,P=0.53) and pulmonary toxicity (OR=0.78,95％CI:0.44-1.37,P=0.38) between two groups.Conclusions Hypofractionated radiotherapy and conventionally fractionated radiotherapy post-mastectomy yield similar clinical efficacy,both of which are safe and efficacious radiotherapy patterns.However,the findings remain to be validated by large-scale randomized clinical trials with long-term follow-up of the advanced stage complications.
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Objective To compare the effect between the supine and prone patient positions upon target dose coverage during intensity-modulated radiotherapy (IMRT) for rectal cancer, aiming to provide clinical reference for the selection of position for rectal cancer patients. Methods Twenty-four patients diagnosed with rectal cancer receiving postoperative adjuvant radiotherapy were selected and divided into the supine (n=12) and prone position groups(n=12). Before and during the IMRT(1-4 weeks),all patients received CT scans, which were defined as:Plan,1W,2W,3W and 4W,respectively. The organs at risk were delineated based on CT scan images. Plan,1W, 2W, 3W and 4W CT scan images were fused. The CTV and PTV from Plan CT scan were copied to the 1-4W CT scan images,and the therapeutic plans from Plan CT scan were copied as well. The target dose coverage was assessed and the failure rate of target dose coverage was calculated. The couch-position data for each patient during each cycle of IMRT were recorded by using the MOSAIQ network and the overall deviation (S) of couch position was calculated. Results The failure rates of CTV and PTV target dose coverage in the prone position group were higher than those in the supine position group (18.60% VS 0%, 69.76% VS 53.65%).The S value was significantly correlated with the target dose coverage (r=-0.683,P=0.000). The S value in the prone position group was(1.23±0.76) cm,significantly greater than(0.28±0.18) cm in the supine position (P=0.001),and the most significant deviation was noted in the y (head and foot) and z (frontal and dorsal) directions (P=0.003 and 0.003). Compared with the supine group,the V5and V10 of the small intestine were significantly less (P=0.003 and 0.004) and the chronic toxicity (NTCPC) was considerably reduced(P=0.041) in the prone position group. Conclusions A better target dose coverage can be maintained during IMRT with a supine position during rectal cancer IMRT, whereas the positioning repeatability is worsened with a prone position due to use of the belly board, thereby affecting the target dose coverage. Although the prone position combined with belly board can reduce the tolerated dosage of the small intestine,effective measures should be taken to guarantee the patient positioning repeatability.
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Objective To explore the clinical efficacy of Ilizarov technique for infected-bone defect in lower extremity.Methods From January 2013 to December 2016,data of 31 consecutive patients with lower limb infected bone defect were retrospectively analyzed.There were 23 males and 8 females,with an average age of 35.8 years (range,5-57 years).16 cases of infected bone defect were on femur while the other 15 were on tibia.The infected bone defects were developed from blood-borne osteomyelitis in 3 cases,from open fracture (according to Gustlio classification,Gustilo Ⅱ 8,Ⅲ a 5,Ⅲ b 4) surgery in 17 cases (12 cases after external fixation and 5 cases after internal fixation),and from closed fracture surgery of plate or intramedullary nail fixation in 11 cases.Soft-tissue defects were observed in 5 cases,including 1 femur and 4 tibia.The previous operations were performed with an average operation time of 3.2 (range,2-5 times) and treatment duration of 9.6 months (range,3-21 months).The operation process was one stage debridement,external fixation,combined with bone osteotomy and transportation.Bone transportation started 7 to 10 days after osteotomy with a speed of 1 mm/d,and 0.25 mm/time.Healing rate and complications were recorded during the follow-up period and were assessed by Paley fracture healing score.Results The length of bone defect after debridement was 6.9 cm (range,3-13.5 cm).There were 27 cases positive in bacterial culture,who were treated by sensitive antibiotics.The other 4 cases were negative and treated by broad-spectrum antibiotics.The bone lengthening speed was 0.76 mm/d (range,0.56-0.86 mm/d).All bone and soft-tissue defects healed,with average bone healing time of 11.5 months (range,6-18.5 months).All patients were followed-up for 12 to 48 months (average,25.5 months).Pin infection appeared in 11 cases (8 cases on femur and 3 cases on tibia)who were cured by oral antibiotics,serial dressing and debridement.Axial displacement was presented in 4 cases on femur and were corrected by external fixation adjustment.No recurrent infection was observed and the limb length restored normal.Postoperative complications in femur were 106.3％ (17/16) comparing 46.7％ (7/15) in tibia.According to Paley fracture healing score,12 cases were excellent,14 were good and 5 were fair,yielding an excellent to good rate of 83.9％ (26/31).Conclusion Ilizarov technique is an effective way in the treatment of infected-bone defects.The complication rates on femur observed in this study were slightly higher than that on tibia.
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Objective To evaluate the feasibility and clinical efficacy of preoperative simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) combined with neoadjuvant chemotherapy of capecitabine in patients with locally-advanced low rectal cancer.Methods Between 2015 and 2016,26 patients admitted to 301 Hospital who were diagnosed with locally-advanced low rectal cancer,which was located within 5 cm from the anal verge,were enrolled in this investigation.Dose fractionation pattern was delivered:58.75 Gy in 25 fractions (2.35 Gy/fraction) for rectal cancer and lymph node metastasis and 50 Gy in 25 fractions for the pelvic lymphatic drainage area and simultaneously combined with capecitabine chemotherapy (825 mg/m2,bid d 1-5 weekly).One cycle of capecitabine (1 250 mg/m2,twice daily,d 1-14)was given at one week after the completion of chemoradiotherapy (CRT).Total mesorectal excision (TME)was performed at 6 to 8 weeks after the completion of CRT.The primary endpoints included pathological complete response rate (ypCR) and sphincter-preserving rate.The secondary endpoints included acute toxicity,tumor downstaging rate and postoperative complications.Results Twenty-six patients successfully completed neoadjuvant CRT,25 of them underwent surgical resection and one patient failed to receive surgery due to pxrianal edema.Postoperative ypCR rate was 32％ (8/25),the sphincter-preserving rate was 60％ (15/25),the tumor downstaging rate was 92％ (23/25) and the R0 resection rate was 100％.During the period of CRT,grade 1 and 2 adverse events occurred in 24 patients,grade 3 radiation dermatitis was noted in 2 cases.No ≥ grade 4 acute adverse event was observed.Postoperative complications included ureteral injury in one case and intestinal obstruction in one patient.Conclusions Preoperative SIB-IMRT combined with neoadjuvant chemotherapy of capecitabine is a feasible and safe treatment for patients with locallyadvanced low rectal cancer,which yields expected ypCR rate,R0 resection rate and sphincter-preserving rate.Nevertheless,the long-term clinical benefits remain to be elucidated.Clinical Trial Registry Chinese Clinical Trial Registry,registration number:ChiCTR-ONC-12002387.