6040 Background: The PRANCIS model has been shown to be robust for identifying patients with recurrent nasopharyngeal carcinoma (rNPC) who are at high risk of treatment-related adverse events from re-irradiation (reRT). Here, we investigate the efficacy of combination doublet gemcitabine-cisplatin (GP) and PD-1 inhibitor (Toripalimab) to down-classify PRANCIS high risk (>252) to low-risk post-3 cycles of treatment, and the survival outcomes of these patients. For patients who converted to low-risk, reRT may be considered (NCT03930498). Methods: Eligibility criteria included diagnosed as local ± regional recurrence after ≥1 year of radical treatment, not suitable for surgery, histologic or clinically diagnosis of NPC, stage rII-IVa (AJCC/UICC 8th), PRANCIS model > 252 points. All patients received 3 cycles of GP + PD-1 inhibitor, then received reRT (GTV, 60-66Gy, 1.8-2.0Gy/f) plus PD-1 inhibitor if got CR/PR (reRT group), or received another 3 cycles of GP+PD-1 inhibitor if got SD (no reRT group), finally all got 4 cycles of PD-1 inhibitor maintenance. Primary end point was 2-year overall survival (OS). Results: Between Mar 2020 to Nov 2023, 68 high-risk patients were recruited (Table 1). After 3 cycles of GP + PD-1 inhibitor, 44 (64.7%) patients got PR (34 down-classify to low-risk and 10 still high-risk) and received full-course reRT, 22 (32.4%) got SD (all high-risk) and kept receiving GP + PD-1 inhibitor, and 2 (2.9%) could not be evaluated due to 1 died of COVID-19 and 1 withdrew after 2 cycles of treatment. 56 (82.4%) patients finished the scheduled treatment, and 12 discontinued chemo-immunotherapy. With a median follow-up time of 32.7 months, the 2-year OS of whole cohort was 67.2%, and 73.8% vs 51.2% ( P = 0.019) in reRT group vs no reRT group. The 2-year progression-free survival (PFS) of whole cohort was 47.9%, and 61.0% vs 24.3% ( P < 0.0001) in reRT group vs no reRT group. The most common ≥grade 3 toxicities included neutropenia (30.9%), lymphopenia (22.1%), and xerostomia (16.2%). The incidences of grade 3 nasopharyngeal necrosis was 5.9%. Two (2.9%) patients died of massive nasal bleeding. Conclusions: Induction chemo-immunotherapy offered the chance of reRT for high-risk rNPC patients and improved their overall survival with acceptable toxicities. Clinical trial information: NCT03930498 . Basic information. Variables Whole cohort reRT group no reRT group Age † , year 52.0 (43.0 - 58.0) 54.5 (42.8 - 58.8) 47.0 (43.0 - 54.8) Sex Male 51 (75.0) 30 (68.2) 21 (87.5) Female 17 (25.0) 14 (31.8) 3 (12.5) rT stage T3 36 (52.9) 28 (63.6) 8 (33.3) T4 32 (47.1) 16 (36.4) 16 (66.7) rN stage N0 36 (52.9) 25 (56.8) 11 (45.8) N1-3 32 (47.1) 19 (43.2) 13 (54.2) rTNM stage III 35 (51.5) 27 (61.4) 8 (33.3) IVa 33 (48.5) 17 (38.6) 16 (66.7) pre-treatment EBV DNA, copy/ml 0 23 (33.8) 14 (31.8) 9 (37.5) >0 41 (60.2) 27 (61.4) 14 (58.3) Missing 4 (5.9) 3 (6.8) 1 (4.2) PRANCIS model † , points 295.3 (264.1 - 321.8) 270.8 (258.1 - 340.5) 309.2 (297.5 - 319.4) † median (IQR).

Objective: To evaluate the effect of individualized nutritional support on protein -energy malnutrition in patients with maintenance hemodialysis Design: Retrospective study Setting: Department of Nephrology, the Seventh Affiliated Hospital of Sun Yat-sen University Subjects: Maintenance hemodialysis patients Interventions: Patients with regular nutritional support received routine nursing and nutritional guidance, while patients with individualized nutritional support had personalized nursing plan with particular emphasis on proper protein intake and restrictions on sodium, potassium, calcium and phosphorus intake. Main outcome measures: Patients' dietary behavior management scores, electrolyte levels and nutritional status indicators at three months post -nursing were compared. Results: After nursing, the scores of self -care, liquid control, low -salt diet, low -potassium diet, and adherence in times of particular difficulty in patients with individualized nutritional support were significantly higher than those with regular nutritional support (P<0.001). Moreover, compared to patients with regular nursing, patients with individualized nutritional support had lower levels of serum calcium, phosphorus and potassium (P<0.001), and their nutrition status indicators, including triceps skinfold thickness, upper arm circumference, levels of albumin and hemoglobin were significantly improved (P<0.001). Conclusion: These data demonstrate that individualized nutritional intervention can effectively regulate diet behaviors of patients, correct the water -electrolyte disorder, and ameliorate protein -energy wasting in patients with maintenance hemodialysis. Further clinical trials addressing long-term impacts of individualized nutrition intervention on patients with maintenance hemodialysis are warranted.

PurposeWe aimed to perform the commissioning and clinical evaluation of myQA SRS detector array for patient-specific quality assurance (PSQA) of stereotactic radiosurgery (SRS)/ stereotactic body radiotherapy (SBRT) plans.MethodsTo perform the commissioning of myQA SRS, its dose linearity, dose-rate dependence, angular dependence, and field-size dependence were investigated. Ten SBRT plans were selected for clinical evaluation: 1) Common clinical deviations based on the original SBRT plan (Plan0), including multileaf collimator (MLC) positioning deviation and treatment positioning deviation were introduced. 2) Compared the performance of the myQA SRS and a high-resolution EPID dosimetry system in PSQA measurement for the SBRT plans. Evaluation parameters include gamma passing rate (GPR) and distance-to-agreement (DTA) pass rate (DPR).ResultsThe dose linearity, angle dependence, and field-size dependence of myQA SRS system exhibit excellent performance. The myQA SRS is highly sensitive in the detection of MLC deviations. The GPR of (3%/1 mm) decreases from 90.4% of the original plan to 72.7%/62.9% with an MLC outward/inward deviation of 3 mm. Additionally, when the setup error deviates by 1 mm in the X, Y, and Z directions with the GPR of (3%/1 mm) decreasing by an average of -20.9%, -25.7%, and -24.7%, respectively, and DPR (1 mm) decreasing by an average of -33.7%, -32.9%, and -29.8%. Additionally, the myQA SRS has a slightly higher GPR than EPID for PSQA, However, the difference is not statistically significant with the GPR of (3%/1 mm) of (average 90.4%% vs. 90.1%, p = 0.414).ConclusionDosimetry characteristics of the myQA SRS device meets the accuracy and sensitivity requirement of PSQA for SRS/SBRT treatment. The dose rate dependence should be adequately calibrated before its application and a more stringent GPR (3%/1 mm) evaluation criterion is suggested when it is used for SRS/SBRT QA.

Background To analysis the clinical outcomes of concurrent chemoradiotherapy (CCRT) alone based on 10-year results for loco-regionally advanced nasopharyngeal carcinoma (LANPC), so as to provide evidence for individualized treatment strategy and designing appropriate clinical trial for different risk LANPC patients. Methods Consecutive patients with stage III-IVa (AJCC/UICC 8th) were enrolled in this study. All patients received radical intensity-modulated radiotherapy (IMRT) and concurrent cisplatin chemotherapy (CDDP). The hazard ratios (HRs) of death risk in patients with T3N0 was used as baseline, relative HRs were calculated by a Cox proportional hazard model to classify different death risk patients. Survival curves for the time-to-event endpoints were analyzed by the Kaplan–Meier method and compared using the log-rank test. All statistical tests were conducted at a two-sided level of significance of 0.05. Results A total of 456 eligible patients were included. With 12-year median follow-up, 10-year overall survival (OS) was 76%. 10-year loco-regionally failure-free survival (LR-FFS), distant failure-free survival (D-FFS) and failure-free survival (FFS) were 72%, 73% and 70%, respectively. Based on the relative hazard ratios (HRs) of death risk, LANPC patients were classified into 3 subgroups, low-risk group (T1-2N2 and T3N0-1) contained 244 patients with HR < 2; medium-risk group (T3N2 and T4N0-1) contained 140 patients with HR of 2 – 5; high-risk group (T4N2 and T1-4N3) contained 72 patients with HR > 5. The 10-year OS for patients in low-, medium-, and high-risk group were 86%, 71% and 52%, respectively. Significantly differences of OS rates were found between each of the two groups (low-risk group vs. medium-risk group, P < 0.001; low-risk group vs. high-risk group, P < 0.001; and medium-risk group vs. high-risk group, P = 0.002, respectively). Grade 3–4 late toxicities included deafness/otitis (9%), xerostomia (4%), temporal lobe injury (5%), cranial neuropathy (4%), peripheral neuropathy (2%), soft tissue damage (2%) and trismus (1%). Conclusions Our classification criteria demonstrated that significant heterogeneity in death risk among TN substages for LANPC patients. IMRT plus CDDP alone maybe suitable for low-risk LANPC (T1-2N2 or T3N0-1), but not for medium- and high-risk patients. These prognostic groupings provide a practicable anatomic foundation to guide individualized treatment and select optimal targeting in the future clinical trials.

Background Ultrahigh dose-rate irradiation (FLASH-IR) was reported to be efficient in tumor control while reducing normal tissue radiotoxicity. However, the mechanism of such phenomenon is still unclear. Besides, the FLASH experiments using high energy X-ray, the most common modality in clinical radiotherapy, are rarely reported. This study aims to investigate the radiobiological response using 6 MV X-ray FLASH-IR or conventional dose-rate IR (CONV-IR). Methods The superconducting linac of Chengdu THz Free Electron Laser (CTFEL) facility was used for FLASH-IR, a diamond radiation detector and a CeBr3 scintillation detector were used to monitor the time structure and dose rate of FLASH pulses. BALB/c nude mice received whole abdominal 6 MV X-ray FLASH-IR or CONV-IR, the prescribed dose was 15 Gy or 10 Gy and the delivered absolute dose was monitored with EBT3 films. The mice were either euthanized 24 h post-IR to evaluate acute tissue responses or followed up for 6 weeks to observe late-stage responses and survival probability. Complete blood count, histological analyses, and measurement of cytokine expression and redox status were performed. Results The mean dose rate of >150 Gy/s and instantaneous dose rate of >5.5 x 10(5) Gy/s was reached in FLASH-IR at the center of mice body. After 6 weeks' follow-up of mice that received 15 Gy IR, the FLASH group showed faster body weight recovery and higher survival probability than the CONV group. Histological analysis showed that FLASH-IR induced less acute intestinal damage than CONV-IR. Complete blood count and cytokine concentration measurement found that the inflammatory blood cell counts and pro-inflammatory cytokine concentrations were elevated at the acute stage after both FLASH-IR and CONV-IR. However, FLASH irradiated mice had significantly fewer inflammatory blood cells and diminished pro-inflammatory cytokine at the late stage. Moreover, higher reactive oxygen species (ROS) signal intensities but significantly reduced lipid peroxidation were found in the FLASH group than in the CONV group in the acute stage. Conclusions The radioprotective effect of 6 MV X-ray FLASH-IR was observed. The differences in inflammatory responses and redox status between the two groups may be the factors responsible for reduced radiotoxicities following FLASH-IR. Further studies are required to thoroughly evaluate the impact of ROS on FLASH effect.

Purpose This study was aimed to investigate long-term survivals and toxicities of early-stage nasopharyngeal carcinoma (NPC) in endemic area, evaluating the role of chemotherapy in stage II patients.Materials and Methods Totally 187 patients with newly diagnosed NPC and restaged American Joint Committee on Cancer/ International Union Against Cancer 8th T1-2N0-1M0 were retrospectively recruited. All received intensity-modulated radiotherapy (IMRT)±chemotherapy (CT) from 2001 to 2010.Results With 15.7-year median follow-up, 10-year locoregional recurrence-free survival, distant metastasis-free survival (DMFS), disease-specific survival (DSS), and overall survival (OS) were 93.3%, 93.5%, 92.9% and 88.2%, respectively. Multivariable analyses showed cervical lymph nodes positive and pre-treatment prognostic nutritional index ≥ 52.0 could independently predict DMFS (p=0.036 and p=0.011), DSS (p=0.014 and p=0.026), and OS (p=0.002 and p < 0.001); Charlson comorbidity index < 3 points could predict DSS (p=0.011); age > 45 years (p=0.002) and pre-treatment lactate dehydrogenase ≥ 240 U/L (p < 0.001) predicted OS. No grade 4 late toxicity happened; grade 3 late toxicities included subcutaneous fibrosis (4.3%), deafness or otitis (4.8%), skin dystrophy (2.1%), and xerostomia (1.1%). No differences on survivals were shown between IMRT+CT vs. IMRT alone in stage II patients, even in T2N1M0 (p > 0.05). Unsurprising, patients in IMRT+CT had more acute gastrointestinal reaction, myelosuppression, mucositis, late ear toxicity, and cranial nerve injury (all p < 0.05) than IMRT alone group.Conclusion Superior tumor control and satisfying long-term outcomes could be achieved with IMRT in early-stage NPC with mild late toxicities. As CT would bring more toxicities, it should be carefully performed to stage II patients.

Purpose To evaluate the long-term local control, failure patterns, and toxicities after individualized clinical target volume (CTV) delineation in unilateral nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT). Methods Unilateral NPC was defined as a nasopharyngeal mass confined to one side of the nasopharynx and did not exceed the midline. From November 2003 to December 2017, 95 patients were retrospectively included. All patients received IMRT. The CTVs were determined based on the distance from the gross tumor. The contralateral para-pharyngeal space and skull base orifices were spared from irradiation. Results There were three local recurrences and eight regional recurrences in 10 patients during an 84-month follow-up. All local recurrences were within PGTVnx, and all in-field recurrences. No recurrences were found in traditional high-risk areas including contralateral the para-pharyngeal space and skull base orifices. The 10-year local-recurrence-free survival, regional-recurrence-free survival and overall survival were 96.2%, 90.5% and 84.7%, respectively. The dosimetry parameters of the tumor-contralateral organs were all lower than the values of the tumor-ipsilateral side (P < 0.05). The late toxicities occurred mainly in the tumor-ipsilateral organs, including radiation-induced temporal lobe injury, impaired visuality, hearing loss and subcutaneous fibrosis. Conclusion Individualized CTV delineation in unilateral NPC could yield excellent long-term local control with limited out-of-field recurrences, reduced dose to tumor- contralateral organs and mild late toxicities, which is worthy of further exploration.

Purpose A recurrent neural network (RNN) and its variants such as gated recurrent unit-based RNN (GRU-RNN) were found to be very suitable for dose-volume histogram (DVH) prediction in our previously published work. Using the dosimetric information generated by nonmodulated beams of different orientations, the GRU-RNN model was capable of accurate DVH prediction for nasopharyngeal carcinoma (NPC) treatment planning. On the basis of our previous work, we proposed an improved approach and aimed to further improve the DVH prediction accuracy as well as study the feasibility of applying the proposed method to relatively small-size patient data. Methods Eighty NPC volumetric modulated arc therapy (VMAT) plans with local IRB's approval in recent two years were retrospectively and randomly selected in this study. All these original plans were created using the Eclipse treatment planning system (V13.5, Varian Medical Systems, USA) with ≥95% of PGTVnx receiving the prescribed doses of 70 Gy, ≥95% of PGTVnd receiving 66 Gy, and ≥95% of PTV receiving 60 Gy. Among them, fifty plans were used to train the DVH prediction model, and the remaining were used for testing. On the basis of our previously published work, we simplified the 3-layer GRU-RNN model to a single-layer model and further trained every organ at risk (OAR) separately with an OAR-specific equivalent uniform dose- (EUD-) based loss function. Results The results of linear least squares regression obtained by the new proposed method showed the excellent agreements between the predictions and the original plans with the correlation coefficient r = 0.976 and 0.968 for EUD results and maximum dose results, respectively, and the coefficient r of our previously published method was 0.957 and 0.946, respectively. The Wilcoxon signed-rank test results between the proposed and the previous work showed that the proposed method could significantly improve the EUD prediction accuracy for the brainstem, spinal cord, and temporal lobes with a p value < 0.01. Conclusions The accuracy of DVH prediction achieved in different OARs showed the great improvements compared to the previous works, and more importantly, the effectiveness and robustness showed by the simplified GRU-RNN trained from relatively small-size DVH samples, fully demonstrated the feasibility of applying the proposed method to small-size patient data. Excellent agreements in both EUD results and maximum dose results between the predictions and original plans indicated the application prospect in a physically and biologically related (or a mixture of both) model for treatment planning.

Objective:To analyze the predicting values of hematological indicators for the pathological response in patients with gastric adenocarcinoma after preoperative neoadjuvant therapy and radical surgery.Methods:The absolute count of neutrophils (NE), lymphocytes (LY) and monocytes (MO) of 102 patients with locally advanced gastric adenocarcinoma in a multi-center randomized phase Ⅲ clinical trial (NCT01815853) from June 2013 to Feburary 2019 were retrospectively analyzed. Patients were divided into the chemotherapy alone group (ChT, 3 cycles of XELOX regimen) and the chemoradiation group (CRT, 1 cycle of induced XELOX regimen and 4500 cGy/25f radiotherapy plus concurrent extenuated 2 cycles of XELOX regimen), 51 cases in each group. The pathological response indicators of tumors after radical surgery included tumor regression grade, pathological complete regression, pathological T stage (ypT), N stage (ypN) and TNM stage (ypTNM).Results:Univariate regression analysis and ROC curves demonstrated a significant association between the absolute neutrophil count (NE) and ypT, lymphocyte-to-monocyte ratio (LMR) and ypN 0, and LMR and ypTNM reduction in the entire cohort of patients. Multivariate regression analysis showed that higher NE (>4.10×10 9/L) was significantly associated with higher probability of ypT reduction ( OR=3.308, P=0.007). Higher LMR (>3.46) was significantly associated with higher ypN 0 probability ( OR=4.276, P=0.005) and better ypTNM reduction ( OR=2.805, P=0.019). In subgroup analysis, higher NE (>4.10) was significantly correlated with higher probability of ypT reduction ( OR=3.750, P=0.030) in the CRT group, and higher LMR (>3.46) was significantly associated with higher ypN 0 probability ( OR=8.500, P=0.050) and the probability of ypTNM stage reduction ( OR=4.000, P=0.026) in the ChT group. Conclusions:Pretreatment NE and LMR in the peripheral blood serve as independent predictors for tumor pathological responses after preoperative treatment, and immune condition is correlated with tumor regression after radical surgery in patients with locally advanced gastric cancer.

PURPOSE:Current guideline recommends a uniform method of delineation of subclinical disease within the primary clinical target volume (CTVp) for all stages of nasopharyngeal carcinoma (NPC). We performed a prospective observational study to investigate the outcomes with a reduced CTVp and radiation dose for early-stage NPC. METHODS AND MATERIALS:Patients with newly diagnosed, biopsy-proven World Health Organization type II-III and American Joint Committee on Cancer/Union for International Cancer Control sixth edition stage T1-2N0-1 disease were enrolled. All patients were treated with intensity modulated radiation therapy alone. We categorized CTVp into CTVp1 (high risk) and CTVp2 (low risk). CTVp1 comprised of gross tumor (on magnetic resonance imaging or contrast-enhanced computed tomography) plus a 5-mm margin (3-mm posteriorly) and was prescribed to 60 Gy in 30 fractions (fr). CTVp2 was generated from CTVp1 plus a 5-mm margin (3 mm posteriorly), excluding the maxillary and cavernous sinuses, and was prescribed to 54 Gy in 30 fr. The prescribed doses to the primary and nodal gross tumor volume (GTVp and GTVn) were 68 Gy in 30 fr and 60 to 66 Gy in 30 fr, respectively. Primary endpoint was local recurrence-free survival. This study was registered in ClinicalTrials.gov, number NCT03839602. RESULTS:From May 2001 to August 2006, 103 patients were recruited and completed IMRT. With a median follow-up of 15.2 years (range, 2.1-18.1 years), only 1 patient had local failure. Ten-year local recurrence-free survival, regional recurrence-free survival, distant metastasis-free survival, and overall survival were 90.3%, 88.3%, 90.3%, and 91.2%, respectively. Among late IMRT-related adverse events, we recorded 2 patients with G1 cranial nerve injury, 3 patients with G3 hearing loss, and 3 patients with G3 subcutaneous fibrosis. No patients had temporal lobe necrosis, brain stem injury, or trismus. CONCLUSIONS:Decreased CTV margins and radiation doses can achieve long-term tumor control with mild late toxicities for patients with early-stage NPC.

目的 目前腮腺肿瘤术后调强放射治疗(intensity modulated radiation therapy,IMRT)临床靶区(clinical target volume,CTV)勾画方法国内外尚未达成共识.本研究旨在探讨借助外科切除原则设定及勾画CTV的方法.方法 选取2010-06-01-2018-06-01中山大学肿瘤防治中心放疗科连续收治的29例腮腺癌术后放疗患者临床资料进行分析.靶区勾画时结合手术记录,根据手术前后临床及影像资料对比,分析测算手术切面及周围各保留组织术前旁开原肿瘤大体外缘的距离,判断各保留组织术前受侵累及的风险,＜5 mm定义为高危临床靶区(CTV-HD),5～10 mm的组织定义为中危靶区(CTV1),＞10～20 mm的组织定义为低危靶区(CTV2),必要时CTV2还包括需要预防照射的区域淋巴结引流区.CTV-HD、CTV1和CTV2的处方剂量分别为64.0～66.0、59.5～61.0和45.0～54.0 Gy.统计靶区及毗邻危及器官剂量分布,并用Kaplan-Meier法进行生存分析,单因素分析采用Log-rank检验,多因素分析采用Cox风险回归模型.结果 茎突、下颌支、二腹肌后腹、颈动脉鞘、茎乳孔对应组织范围被勾画为CTV-HD的比例分别高达31.03％、27.59％、55.17％、37.93％和37.10％.截至2019-03-31,29例患者中位随访时间35(5～98)个月,未发现局部区域复发.所有患者3和5年预期生存率(overall survival,OS)分别为95.7％和81.2％,无复发生存率(recurrence-free survival,RFS)分别为100.0％和100.0％,无远处转移生存率(distant metastasis-free survival,DMFS)分别为87.9％和81.7％.单因素分析结果示,N分期与腮腺肿瘤患者生存预后有关联,P=0.02.Cox风险回归模型未见有统计学意义的独立预后因素.结论 根据个体肿瘤手术切面及周围各保留组织术前与原肿瘤外缘距离判定其术前受侵风险,勾画为不同CTV,给予不同剂量照射,为腮腺肿瘤术后靶区勾画提供了新思路,疗效显示安全可行,值得进一步研究.

目的:调查急诊护士对预防静脉血标本溶血的知信行现状.方法:以问卷星发放问卷的方式将问卷发送至广东省内数家医院急诊科,请急诊科护士完成问卷填写.本问卷为自行设计的问卷,包含个人资料、医院情况及知识、信念行为等部分.结果:急诊护士对预防血标本溶血的知识得分为(15.38±4.084),合格率为56.8％;信念得分为(24.8±3.862);行为得分(42.12±5.035).结论:急诊护士对预防静脉血标本溶血的信念较好,知识掌握欠佳,行为有待提高;护理管理者需继续加强急诊护士对血标本采集的相关培训,降低急诊血标本溶血发生率.

Dear Editor, Intensity-modulated radiotherapy (IMRT) has a distinct advantage of high conformity and is an appropriate technique for treating nasopharyngeal carcinoma (NPC). Previous studies have demonstrated that anatomical changes in the external contour, shape, and location of the target and critical structures are significant and result in dosimetric changes [1, 2]. Patients' quality of life and clinical outcomes might be improved by IMRT replanning [3]. Therefore, replanning strategies should be considered instead of single-planning strategies throughout the entire course of radiotherapy. However, there are substantial controversies on (1) the appropriate time for target redelineation, (2) how to modify the target volumes, and (3) how to evaluate the modified plans. The present study provides a new perspective in replanning with regard to these three aspects. We analyzed the data of 54 patients with newly diagnosed NPC between October 2013 and June 2016. The mean age was 45.5 years (range 18–67 years). All patients had undifferentiated non-keratinized carcinoma. According to the 7th edition of the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) staging system, 6 (11.1%), 17 (31.5%), 29 (53.7%), and 2 (3.7%) patients had stage IVb, IVa, III, and II diseases, respectively. Twenty-four (44.4%) patients received induction chemotherapy and concurrent chemoradiotherapy, 29 (53.7%) received concurrent chemoradiotherapy, and 1 (1.9%) received radiotherapy alone. The median duration of radiotherapy was 47 days (range 41–71 days). The median duration of interruption between two plans was 2 days (range 1–24 days). The baseline clinical characteristics are shown in Table 1. In plan-I radiotherapy, computed tomography simulation (CT-I) was performed for target delineation. The gross target volume of the nasopharynx (GTVnx)-I was defined as all gross lesions determined with clinical and imaging examinations. The high-risk clinical target volume (CTV1-I) was delineated with a 1-cm margin surrounding the GTVnx-I area. The low-risk clinical target volume (CTV2-I) was delineated with a 0.5-cm margin surrounding the CTV1-I. Any metastatic retropharyngeal lymph nodes and cervical lymph nodes were delineated as GTVrpn-I and GTVnd-I [4]. CTVrpn1-I and CTVnd1-I were delineated with a 0.5- and 1.0-cm expansion from the GTVrpn-I and GTVnd-I. CTVrpn2-I and CTVnd2-I were delineated with a 0.5-cm margin surrounding CTVrpn1 and CTVnd1-I, which included the bilateral prophylactically irradiated lymphatic drainage areas. In patients undergoing induction chemotherapy, target volumes were delineated according to the tumor appearance after induction chemotherapy [5]. On the basis of results of previous studies [1, 2], we chose to perform a second CT simulation (CT-II) after the 22nd fraction of radiotherapy, leaving 3 days for radiophysicists to make plan-II. For the first 11 patients, considering the inadequate time for determining adaptive plans, we implemented the plan-II radiotherapy after the 26th fraction. For the following patients, we implemented the plan-II radiotherapy after the 25th fraction. In plan-II radiotherapy, GTVnx/rpn/nd-II was defined as all residual diseases; CTV1/rpn1/nd1-II was the same as CTV1/rpn1/nd1-I; and CTV2/rpn2/nd2-II was not delineated (Fig. 1). Illustration of target delineation in plan-I and plan-II. Magnetic resonance imaging (MRI)-I acquired before plan-I radiotherapy with cross-sectional T2-weighted images, T1-weighted images, and contrast-enhanced T1-weighted (T1 + C) images shows the primary tumor, which locates on the left side of the upper wall and extends into the nasal cavity, left medial pterygoid plate, and navicular fossa. In plan-I radiotherapy, the gross target volume of primary tumor (GTVnx-I) was outlined (red line). Clinical target volume 1-I (CTV1-I) (green line) is delineated with a 1.0-cm margin surrounding GTVnx-I. Clinical target volume 2-I (CTV2-I) (blue line) is delineated with a 0.5-cm margin surrounding CTV1-I. MRI-II acquired after 22 fractions of irradiation shows that the tumor greatly regressed. In plan-II radiotherapy, the residual tumor is delineated as GTVnx-II (red line). The regressing areas of the intracavitary area, the left medial pterygoid plate, and the navicular fossa lesion are included not in GTVnx-II but in CTV1-II (green line), which maintains the same as CTV1-I. CTV2-II is not delineated. GTVnx-I was copied to the CT-II for comparison (purple line) A 3- to 5-mm margin surrounding the above targets was required for the delineation of the planning target volumes (PGTVnx, PGTVrpn, PGTVnd, PCTV1, and PCTV2). Before June 2014, the doses prescribed were as follows: GTVnx/rpn/nd-I, 57 Gy in 26 fractions at 2.19 Gy/fraction; PCTV1/rpn1/nd1-I, 50 Gy in 26 fractions at 1.92 Gy/fraction; PCTV2/rpn2/nd2-I, 46–47 Gy in 26 fractions at 1.77–1.81 Gy/fraction; PGTVnx/rpn/nd-II, 11 Gy in 5 fractions at 2.2 Gy/fraction; PCTV1/rpn1/nd1-II, 10 Gy in 5 fractions at 2.0 Gy/fraction. After June 2014, the doses prescribed were as follows: PGTVnx/rpn/nd-I, 53–54 Gy in 25 fractions at 2.12–2.16 Gy/fraction; PCTV1/rpn1/nd1-I, 47.5 Gy in 25 fractions at 1.90 Gy/fraction; PCTV2/rpn2/nd2-I, 45 Gy in 25 fractions at 1.8 Gy/fraction; PGTVnx/rpn/nd-II, 15–15.5 Gy in 7 fractions at 2.14–2.21 Gy/fraction; PCTV1/rpn1/nd1-II, 13.5 Gy in 7 fractions at 1.93 Gy/fraction. The target delineation and dose prescription of organs at risk (OARs), including the brain stem, spinal cord, and optic chiasm, were performed according to Radiation Therapy Oncology Group (RTOG) 0225 protocol [4]. Under the dose tolerance limit requirements of the RTOG 0225 protocol [4], the dose constraints for OARs were calculated via multiplying the dose tolerance limit (Dtolerance limit) by the percentage of dose of each plan in total dose. The average weights of the patients were 61.2 ± 9.3 kg before radiotherapy and 58.2 ± 9.0 kg after the 22nd fraction of irradiation, without significant weight reduction (P> 0.05). GTVnx, GTVnd-R, volumes of bilateral parotids, and volumes of bilateral submandibular glands showed significant reductions after 22 fractions of irradiation (all P < 0.05), whereas other volume changes were not significant (Additional file 1: Table S1). Nearly 100% of PGTV was irradiated with 95% of the prescription dose of PGTVnx in the two plans. No significant differences in the percentage of the mean dose (Dmean) in the total dose (Dmean%) of PGTVnx, bilateral PGTVrpn, or bilateral PGTVnd were observed between the two plans. Among the evaluated OARs, Dmean% values of the brain stem, spinal cord, optic chiasm, pituitary, oral cavity, oropharynx, hypopharynx, and thyroid gland were significantly different between plan-I and plan-II (P< 0.05) (Additional file 1: Table S2). Adverse events were evaluated based on RTOG acute radiation morbidity scoring criteria. Grade 1–2 adverse events were mainly observed in the skin, oral mucosa, and salivary glands, whereas grade 0 adverse events were mainly observed in the hypopharynx mucosa and larynx mucosa. Grade 3 leukopenia, neutropenia, and thrombocytopenia were observed in 18 (33.30%), 13 (24.07%), and 5 (9.25%) patients, respectively; 1 (1.85%) developed grade 4 neutropenia. The median follow-up period was 30 months (range 3–44 months). Three patients developed distant metastasis, and 4 developed locoregional failure, but none occurred in the regression area. The 3-year overall survival, local recurrence-free survival, and distant metastasis-free survival rates were 93.3%, 90.5%, and 91.4%, respectively. Few studies have described the target redelineation in detail for replanning or modified dose prescription for tumor regression areas. Hansen et al. [6] used the same GTV in plan-II without extending it beyond the skin contour or into adjacent normal structures. Chitapanarux et al. [7] recontoured the GTV-II by removing the air cavity formed due to tumor shrinkage while maintaining the other dimensions of GTV-I. CTV-II was adapted by excluding the air cavity and noninvolved tissues. According to basic research and the results of definitive irradiation for NPC [8], a dose of 60 Gy delivered to subclinical lesions achieved good treatment efficacy. In the present study, upon disappearance/dissolution of tumor areas, the initial location of the tumor were included in CTV1-II, and the total dose delivered to the disappeared part of GTVnx-I after radiotherapy was over 65 Gy. Our follow-up results showed that no recurrence occurred in the regression areas of GTVnx/rpn/nd-I which were delineated as CTV1/rpn1/nd1-II, and the 3-year survival rate was not decreased as compared with previously reported outcomes [9]. CTV2 was not prescribed any dose in plan-II, whereas a total dose of 45–47 Gy in 25–26 fractions was prescribed for CTV2 in plan-I. Historically, the suggested dose for microscopic sterilization was 45–50 Gy at 1.8–2 Gy/fraction [10]. Zhang et al. [11] analyzed prognostic factors of 1302 NPC patients based on a 10-year follow-up and found that the 5- and 10-year survival rates of patients without cervical lymph node metastasis who underwent 40–45 Gy irradiation were similar to those of patients with clinical adenopathy who underwent 50–60 Gy irradiation. The present study showed no recurrence in the CTV2 area. This outcome needs to be confirmed in long-term follow-up. According to the principle of radiobiology, the tumor-killing effect of radiation is related to not only the fractionated dose but also the total dose. Wang et al. [2] and Yang et al. [3] used the same dose fractionation for each target volume in plan-II as that in plan-I, which may facilitate a simple superposition assessment of the doses between plans. Fung et al. [12] used the same dose fractionation, 2.1 Gy/fraction, for plan-I and plan-II over 7 weeks and used a higher dose fractionation, 3.5–3.7 Gy/fraction, for plan-III. The total dose for the three plans was as large as 80.9 Gy in 37 fractions or 84 Gy in 38 fractions, but the efficacy or toxic adverse effects of radiotherapy were not reported. The dose hyperfractionation in plan-II might increase the possibility of late reaction tissue damage and may elicit serious sequelae. In the present study, a higher dose per fraction was prescribed for GTVnx-II and CTV1-II with the intention of increasing the biological effect of radiation and improving therapeutic effect. In conclusion, our adaptive replanning IMRT for patients with NPC provides a new perspective on target redelineation and dose prescription, as it would demonstrate a significant dosimetric and clinical benefits without recurrence and reduction in survival. DHX, WQC, YS: study conception and design; DHX, WQC, YS, SWL: manuscript preparation and editing; DHX, WQC, SWL, RZ, JH, SMH, MLW: data acquisition; DHX, LW: statistical analysis; YS, YFX: quality control of data and algorithms, manuscript review. All authors read and approved the final manuscript. Not applicable. The authors declare that they have no competing interests. The datasets used and/or analyzed during the current study were uploaded onto the Research Data Deposit public platform (http://www.researchdata.org.cn), with the RDD approval number RDDA2018000575. Written informed consent for publication was obtained from all participants. Ethical approval was obtained by the Ethics Committee of Sun Yat-sen University Cancer Center. Written informed consent was obtained from all patients with respect to chemotherapy and/or radiotherapy and clinical data management for research purposes. The authors declare that they have no funding. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background Nasopharyngeal carcinoma (NPC) may be cured with radiation therapy. Tumor proximity to critical structures demands accuracy in tumor delineation to avoid toxicities from radiation therapy; however, tumor target contouring for head and neck radiation therapy is labor intensive and highly variable among radiation oncologists. Purpose To construct and validate an artificial intelligence (AI) contouring tool to automate primary gross tumor volume (GTV) contouring in patients with NPC. Materials and Methods In this retrospective study, MRI data sets covering the nasopharynx from 1021 patients (median age, 47 years; 751 male, 270 female) with NPC between September 2016 and September 2017 were collected and divided into training, validation, and testing cohorts of 715, 103, and 203 patients, respectively. GTV contours were delineated for 1021 patients and were defined by consensus of two experts. A three-dimensional convolutional neural network was applied to 818 training and validation MRI data sets to construct the AI tool, which was tested in 203 independent MRI data sets. Next, the AI tool was compared against eight qualified radiation oncologists in a multicenter evaluation by using a random sample of 20 test MRI examinations. The Wilcoxon matched-pairs signed rank test was used to compare the difference of Dice similarity coefficient (DSC) of pre- versus post-AI assistance. Results The AI-generated contours demonstrated a high level of accuracy when compared with ground truth contours at testing in 203 patients (DSC, 0.79; 2.0-mm difference in average surface distance). In multicenter evaluation, AI assistance improved contouring accuracy (five of eight oncologists had a higher median DSC after AI assistance; average median DSC, 0.74 vs 0.78; P < .001), reduced intra- and interobserver variation (by 36.4% and 54.5%, respectively), and reduced contouring time (by 39.4%). Conclusion The AI contouring tool improved primary gross tumor contouring accuracy of nasopharyngeal carcinoma, which could have a positive impact on tumor control and patient survival. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Chang in this issue.

目的:探讨急诊科各病区护理质量自查小组通过每天1h自查在护理质量管理中的作用.方法:各病区成立护理质控自查小组,每天抽出下班后的1h对本病区的护理质量进行检查.结果:病区护理质控自查小组成立执行后,全科人员对急救仪器的使用与保养、急救技能的掌握、急救药品、耗材的管理、护理文书的书写规范、感控意识、患者满意度等质量达标情况都得到较大程度的提高.结论:病区质控自查小组紧紧抓住了每天自查1h这一关键时刻,不仅护理人员的业务水平提高,工作作风及态度有来明显的提升,对护理质量持续改进有良好的促进作用.

Abstract Background This study aimed to evaluate the clinical and dosimetric factors predictive of acute anal toxicity (AAT) after radiotherapy in prostate cancer (PCa) patients with or without hemorrhoids. Methods We analyzed data from 347 PCa patients (248 cases treated from July 2013 to November 2017 for training cohort and 99 cases treated in 2018 for validation cohort) treated with pelvic radiotherapy at a single institution. Anal canal dose–volume histogram was used to determine the prescribed dose. Univariate and multivariate analyses were used to evaluate the risk of AAT as a function of clinical and dosimetric factors. Results Totally, 39.5% (98/248) and 31.3% (31/99) of the PCa patients developed AAT in training and validation cohorts, respectively. The incidence of AAT was much higher in patients with hemorrhoids than in those without hemorrhoids in both training and validation cohorts. Hemorrhoids and volume received more than 20 Gy (V20) were valuated as independent factors for predicting AAT in training cohort. Similar results were also observed in our validation cohort. The combination of hemorrhoids and high anal canal V20 (> 74.93% as determined by ROC curves) showed the highest specificity and positive predictive values for predicting AAT in both training and validation cohorts. Conclusions AAT occurs commonly in PCa patients with hemorrhoids during and after pelvic radiotherapy. Hemorrhoids and anal canal V20 are independent predictors of AAT. These factors should be carefully considered during treatment planning to minimize the incidence of AAT.

目的:观察封闭式吸痰对急诊观察区内机械通气患者呼吸机相关性肺炎(VAP)发生率的影响.方法:回顾性分析中山大学附属第一医院急诊观察区2017年1月1日-2018年12月30日急诊观察区内机械通气患者的临床资料,依据住院时间患者所用吸痰管的不同,分为开放式吸痰组和封闭式吸痰组.结果:急诊观察区共收治机械通气患者244例,其中开放式吸痰组152例、封闭式吸痰组92例,发生VAP 81例(33.2％).封闭式吸痰组的VAP发生率明显低于开放组(39.5％vs 22.8％,P<0.001).开放式吸痰组鲍曼不动和大肠埃希菌感染的比率显著高于封闭式吸痰组,且耐药菌较多.结论:封闭式吸痰可减少急诊观察区内机械通气患者VAP的发生率和降低耐药菌感染的机会.

Purpose The purpose of this study was to compare the survival and toxicities in cervical esophageal squamous cell carcinoma (CESCC) treated by concurrent chemoradiothrapy with either three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) techniques. Materials and Methods A total of 112 consecutive CESCC patients were retrospectively reviewed. 3D-CRT and IMRT groups had been analyzed by propensity score matching method, with sex, age, Karnofsky performance status, induction chemotherapy, and tumor stage well matched. The Kaplan-Meier method and Cox proportional hazards model were used for overall survival (OS) and progression-free survival (PFS). Toxicities were compared between two groups by Fisher exact test. Results With a median follow-up time of 34.9 months, the 3-year OS (p=0.927) and PFS (p=0.859) rate was 49.6% and 45.8% in 3D-CRT group, compared with 54.4% and 42.8% in IMRT group. The rates of grade ≥ 3 esophagitis, grade ≥ 2 pneumonitis, esophageal stricture, and hemorrhage were comparable between two groups, while the rate of tracheostomy dependence was much higher in IMRT group than 3D-CRT group (14.3% vs.1.8%, p=0.032). Radiotherapy technique (hazard ratio [HR], 0.09; 95% confidence interval [CI], 0.01 to 0.79) and pretreatment hoarseness (HR, 0.12; 95% CI 0.02 to 0.70) were independently prognostic of tracheostomy dependence. Conclusion No survival benefits had been observed while comparing IMRT versus 3D-CRT in CESCC patients. IMRT with fraction dose escalation and pretreatment hoarseness were considered to be associated with a higher risk for tracheostomy dependence. Radiation dose escalation beyond 60 Gy should be taken into account carefully when using IMRT with hypofractionated regimen.

Purpose: To evaluate the long-term locoregional control, failure patterns, and late toxicity after reducing the target volume and radiation dose in patients with locoregionally advanced nasopharyngeal carcinoma patients treated with induction chemotherapy (IC) plus concurrent chemoradiotherapy (CCRT). Methods and Materials: Previously untreated patients with locoregionally advanced nasopharyngeal carcinoma were recruited into this prospective study. All patients received 2 cycles of IC followed by CCRT. The gross tumor volumes of the nasopharynx (GTVnx) and the neck lymph nodes (GTVnd) were delineated according to the post-IC tumor extension and received full therapeutic doses (68 Gy and 62-66 Gy, respectively). The primary tumor shrinkage after IC was included in the high-risk clinical target volume (CTV1) with a reduced dose of 60 Gy. The locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were calculated using the Kaplan-Meier method. The location and extent of locoregional recurrences were transferred to pretreatment planning computed tomography for dosimetry analysis. Results: There were 112 patients enrolled in this study. The average mean dose of post-GTVnx, post-GTVnd (left), post-GTVnd (right), post-CTV1, and post-low-risk clinical target volume (CTV2) was 75.24, 68.97, 69.16, 70.49, and 63.37 Gy, respectively. With a median follow-up of 125.95 months, the 10-year LRRFS, DMFS and OS were 89.0%, 83.3%, and 75.9%, respectively. There were 8 local recurrences and 6 regional recurrences in 12 patients. All 8 of the local recurrences were in-field; among the 6 regional recurrences, 4 were in-field, 1 was marginal, and 1 was out-field. The most common late toxicities were grade 1 to 2 subcutaneous fibrosis, hearing loss, and xerostomia. No grade 4 late toxicities were observed. Conclusions: Reduction of the target volumes according to the post-IC tumor extension and radiation dose to the post-IC tumor shrinkage could yield excellent long-term locoregional control with limited marginal and out-field recurrences and mild late toxicities. (C) 2019 Elsevier Inc. All rights reserved.