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The aim of the study was to evaluate the clinical feasibility of a 3D-print silica bolus for nasal NK/T-cell lymphoma radiation therapy. Intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) plans were designed using an anthropomorphic head phantom with a 3D-print silica bolus and other kinds of bolus used clinically, and the surface dose was measured by a metal oxide semiconductor field-effect transistor (MOSFET) dosimeter. Four nasal NK/T patients with or without 3D-print silica bolus were treated and the nose surface dose was measured using a MOSFET dosimeter during the first treatment. Plans for the anthropomorphic head phantom with 3D-print bolus have more uniform dose and higher conformity of the planning target volume (PTV) compared to other boluses; the homogeneity index (HI) and conformity index (CI) of the VMAT plan were 0.0589 and 0.7022, respectively, and the HI and CI of the IMRT plan were 0.0550 and 0.7324, respectively. The MOSFET measurement results showed that the surface dose of the phantom with 3D-print bolus was >180 cGy, and that of patients with 3D-print bolus was higher than patients without bolus. The air gap volume between the 3D-print bolus and the surface of patients was

Background: Prostate alignment is subject to interobserver variability in cone-beam CT (CBCT)-based soft-tissue matching. This study aims to analyze the impact of interobserver variability in CBCT-based soft-tissue matching for prostate cancer radiotherapy.Methods: Retrospective data, consisting of 156 CBCT images from twelve patients with intermediate- or high-risk prostate cancer were analyzed in this study. To simulate interobserver variability, couch shifts of 2 mm relative to the resulting patient position of prostate alignment were assumed as potential patient positions (27 possibilities). For each CBCT, the doses of the potential patient positions were recalculated using deformable image registration-based synthetic CT. The impact of the simulated interobserver variability was evaluated using tumor control probabilities (TCPs) and normal tissue complication probabilities (NTCPs).Results: No significant differences in TCPs were found between prostate alignment and potential patient positions (0.944 ± 0.003 vs 0.945 ± 0.003, P = 0.117). The average NTCPs of the rectum ranged from 5.16 (%) to 7.29 (%) among the potential patient positions and were highly influenced by the couch shift in anterior-posterior direction. In contrast, the average NTCPs of the bladder ranged from 0.75 (%) to 1.12 (%) among the potential patient positions and were relatively negligible.Conclusions: The NTCPs of the rectum, rather than the TCPs of the target, were highly influenced by the interobserver variability in CBCT-based soft-tissue matching. This study provides a theoretical explanation for daily CBCT-based image guidance and the prostate-rectum interface matching procedure.Trial registration: Not applicable.

BACKGROUND The aim of this study is to assess the effect of home enteral nutrition (HEN) on the myelosuppression of patients with nasopharyngeal cancer (NPC) during the course of concurrent chemoradiotherapy (CCRT). METHODS A total of 18 outpatients with NPC administered oral nutritional supplementation intervention at home during the course of CCRT were designated as the HEN group, whereas 36 patients with NPC who had previously completed CCRT were retrospectively included as the control group. Patient Generated Subjective Global Assessment, body mass index (BMI), and blood test were evaluated prior to CCRT. During the course of CCRT, blood test was assessed every 2 weeks. RESULTS In male patients, hemoglobin (HB) and red blood cell were decreased (P

Background Partial breast radiotherapy (PBI) has emerged as an option after breast-conserving surgery for early-stage breast cancer patients. Methods A total of 55 patients with early-stage breast cancer between 2009 and 2013 were enrolled in this single-institutional phase II prospective clinical trial. All patients received adjuvant PBI-IMRT after lumpectomy, with the prescription of 48 Gy in 12 fractions at 4 Gy per fraction, 5 days a week. The primary endpoint was ipsilateral breast tumor recurrence (IBTR), the other endpoints were a regional nodal failure (RNF), distant metastasis (DM) rate, disease-free survival (DFS), and overall survival (OS). These endpoints were used to evaluate clinical outcomes. The cosmetic effects and the late toxicity were assessed according to Harvard standard scale and CTCAE 3.0, respectively. Results In our cohorts, the median age was 45.60 years old (range 31 to 65 years) and 29.09% of these patients were post-menopause (n = 16). Most patients were T1 stage (65.45%) or N0 stage (70.91%). 80% of patients were ER-positive, 67.27% PR positive, and 61.82% HER2 negative. At the median follow-up of 9.25 years, RNF was 0% and IBTR occurred in only one patient (1.82%) to the chest wall. Except for one patient (1.82%) had DM to lung and pleura and died from disease progression, the remaining patients were alive at the end of the ten-year follow-up. The ten-year DFS and OS were 94.55% and 98.18%. One patient (1.82%) was diagnosed with endometrial cancer after PBI. Except for 9 patients who declined the cosmetic assessment, the rest of the 46 patients (83.64%) were all rated as good and well-satisfied with the appearance of the irradiated breast. No breast retraction and fibrosis were observed in any of the patients. Additionally, only 4 patients experienced grade 1 late toxicity (7.28%). None had grade 3 or higher late toxicity. Conclusion This is the first study to report the ten-year results of PBI after breast-conserving surgery in Chinese patients. Our study suggested that PBI had durable local control and maintained good cosmetic outcomes with minimal late toxicity at long term follow up for the early-stage breast cancer patients.

Purpose: To analyze the influence of the bladder and rectum filling and the body contour changes on the prostate target dose. Methods: A total of 190 cone-beam CT (CBCT) image data sets from 16 patients with prostate cancer were used in this study. Dose reconstruction was performed on the virtual CT generated by the deformable planning CT. Then, the effects of the bladder filling, rectal filling, and the patient’s body contour changes of the PCTV1 (the prostate area, B1) and PCTV2 (the seminal vesicle area, B2) on the target dose were analyzed. Correlation analysis was performed for the ratio of bladder and rectal volume variation and the variation of the bladder and rectal dose. Results: The mean Dice coefficients of B1, B2, bladder, and rectum were 0.979, 0.975, 0.888 and 0.827, respectively, and the mean Hausdorff distances were 0.633, 1.505, 2.075, and 1.533, respectively. With the maximum volume variations of 142.04 ml for the bladder and 40.50 ml for the rectum, the changes of V100, V95, D2, and D98 were 1.739 ± 1.762 (%), 0.066 ± 0.169 (%), 0.562 ± 0.442 (%), and 0.496 ± 0.479 (%) in PCTV1 and 1.686 ± 1.051 (%), 0.240 ± 0.215 (%), 1.123 ± 0.925 (%), and 0.924 ± 0.662 (%) in PCTV2, respectively. With a 10% increase in the volume of the bladder and rectum, the V75, V70, and V65 of rectum increased at 0.73 (%), 0.71 (%), and 1.18 (%), and the V75, V70, and V65 of bladder changed at −0.21 (%), −0.32 (%), and −0.39 (%), respectively. Conclusion: Significant correlations were observed between the volume variation and the dose variation of the bladder and rectum. However, when a bladder and rectal filling protocol was adopted, the target dose coverage can be effectively ensured based on CBCT guidance to correct the prostate target position.

Objective: To analyse which local set-up errors can be covered by a 5-mm margin for cone beam computed tomography (CBCT)-guided radiotherapy in nasopharyngeal carcinoma (NPC). Methods: 11 regions of interest (ROIs) were registered for 24 NPC patients, with a total of 323 CBCT scans. According to the registration results, clinical target volume–planning target volume (CTV–PTV)/organs at risk-planning risk volume (OAR-PRV) margin analysis; Pearson correlation analysis; Bland–Altman plots; and a receiver operating characteristic (ROC) analysis were used to investigate which local set-up errors of substructure can be represented by the PTVROI. Results: The clinical target volume-PTV/OAR-planning risk volume margins were less than 5 mm for C1ROI-C4ROI, mandible (MROI), and sphenoid sinus (SROI) with respect to PTVROI. C1ROI-C4ROI, MROI, and SROI exhibited significant correlations and consistencies in the mediolateral, superior–inferior, and anteroposterior (AP) directions and significant receiver operating characteristic analysis results in the anteroposterior direction. Conclusion: Only the upper local set-up error of C1ROI-C4ROI, MROI, and SROI can be covered by a 5-mm margin for CBCT-guided NPC radiotherapy with a large ROI. Using these ROIs as an integral reference ROI is better than individual bony landmark. Advances in knowledge: This report is helpful to CBCT registration for NPC radiotherapy in clinical practice.

Interfractional variations of the bladder, rectum and vagina may affect the accuracy of postoperative intensity-modulated radiotherapy in patients with cervical cancer. This study aimed to assess the interfractional variations with daily kV cone-beam computed tomography (CBCT). All the patients were instructed to control the filling status of the bladder and rectum. CBCT images were obtained daily after set-up and the bladder, rectum and vagina were contoured on each CBCT scan. All the contours were transferred to the planning CT following image fusion. Interfractional variations in pelvic organs were assessed with CBCT based on two reference lines, which were identified as A (the midsaggital line across the superior border of pubic symphysis) and B (a parallel line 1.5 cm above line A). The mean volume (range) of the bladder and rectum was 156.5 (1.7-626.5) and 48.2 (11.3-139.7) ml, respectively. The uniform planning target volume (PTV) margin of 10 mm failed to encompass the vagina in 17.3 and 18.1% of the fractions on lines A and B, respectively. The motion of the vagina (standard deviation) was 0.3 (0.3) and 0.1 (0.5) cm on lines A and B, respectively. The anteroposterior dimension and position of the vagina were significantly affected by the filling status of the bladder (P

Background To analyze the feasibility of active breath control (ABC), the lung tumor reproducibility and the rationale for single-breath-hold cone beam CT (CBCT)-guided hypofraction radiotherapy. Methods Single-breath-hold CBCT images were acquired using ABC in a cohort of 83 lung cancer patients (95 tumors) treated with hypofraction radiotherapy. For all alignments between the reference CT and CBCT images (including the pre-correction, post-correction and post-treatment CBCT images), the tumor reproducibility was evaluated via online manual alignment of the tumors, and the vertebral bone uncertainties were evaluated via offline manual alignment of the vertebral bones. The difference between the tumor reproducibility and the vertebral bone uncertainty represents the change in the tumor position relative to the vertebral bone. The relative tumor positions along the coronal, sagittal and transverse axes were measured based on the reference CT image. The correlations between the vertebral bone uncertainty, the relative tumor position, the total treatment time and the tumor reproducibility were evaluated using the Pearson correlations. Results Pre-correction, the systematic/random errors of tumor reproducibility were 4.5/2.6 (medial-lateral, ML), 5.1/4.8 (cranial-caudal, CC) and 4.0/3.6 mm (anterior-posterior, AP). These errors were significantly decreased to within 3 mm, both post-correction and post-treatment. The corresponding PTV margins were 4.7 (ML), 7.4 (CC) and 5.4 (AP) mm. The changes in the tumor position relative to the vertebral bone displayed systematic/random errors of 2.2/2.0 (ML), 4.1/4.4 (CC) and 3.1/3.3 (AP) mm. The uncertainty of the vertebral bone significantly correlated to the reproducibility of the tumor position (P 0.05). Conclusions Using ABC for single-breath-hold CBCT guidance is an effective method to reduce the PTV margin of hypofraction radiotherapy for lung cancer. Using ABC, the tumor position was significantly altered relative to the vertebral position. The reproducibility of the tumor position was affected by the vertebral bone but not by the relative tumor position or the total treatment time.

Background and purpose To evaluate the feasibility and validity of cone beam computed tomography (CBCT) and active breath control (ABC) by long breath-holding in hypofraction radiotherapy of liver tumor. Methods and materials Twenty-four patients received hypofraction radiotherapy of liver tumor with long breath-holding at end-inhale; four prescriptions were used: 6Gy×7 ( n =8), 10Gy×4 ( n =7), 5Gy×9 ( n =6), 4Gy×10 ( n =3). For each fraction, all patients received pre-correction CBCT scans with ABC, some patients received post-correction and post-treatment CBCT. The interfraction and intrafraction liver positioning errors on medial–lateral (ML), cranial–caudal (CC) and anterior–posterior (AP) directions were obtained. The theoretic margin from clinical target volume (CTV) to planning target volume (PTV) was calculated based on post-treatment error. The dosimetric parameters of PTV and normal tissue were compared between ABC and free breathing (FB). Results The interfraction error in liver positioning showed system errors (Σ) of 3.18mm (ML), 6.80mm (CC) and 3.05mm (AP); random error ( σ ) of 3.03mm (ML), 6.78mm (CC) and 3.62mm (AP). These errors were significantly reduced with CBCT guided online correction. The intrafraction systematic error was 0.72mm (ML), 2.21mm (CC), 1.49mm (AP), and random error was 2.30mm (ML), 3.58mm (CC), 2.49mm (AP). Dosimetric parameters such as PTV, the liver's volume included by 23, 30Gy isodose curve (V23, V30), mean dose to normal liver (MDTNL) and mean dose to cord were significantly larger for FB ( P Conclusion Liver radiotherapy with long time breath-holding at end-inhale is an effective method to reduce liver motion, PTV and dose to normal tissue. Interfraction and intrafraction liver positioning errors were substantial. CBCT guided online correction of positioning error is recommended for liver radiotherapy with end-inhale ABC.

Purpose To evaluate the positioning accuracy of four different immobilizations by use of cone-beam computed tomography guidance for radiotherapy of non–small-cell lung cancer (NSCLC). Methods and Materials Sixty-seven patients with NSCLC received conventional or stereotactic body radiotherapy. Of these, 30 were immobilized with a thermoplastic frame (TF), 16 with a thermoplastic frame and active breathing control (TF-ABC), 7 with a stereotactic body frame (SBF), and 14 with a stereotactic body frame and active breathing control (SBF-ABC). Cone-beam computed tomography scans at initial setup and after correction were registered to planning computed tomography. The positional errors in the left-to-right, superior-inferior, and anterior-posterior directions were analyzed. The planning target volume margins were calculated. Results The precorrection systematic and random errors ranged from 1.9 to 4.2 mm for TF, 1.9 to 4.3 mm for SBF, 1.2 to 5.8 mm for TF-ABC, and 2.3 to 3.9 mm for SBF-ABC. The postcorrection systematic and random errors ranged from 0.3 to 1.9 mm for the four immobilizations. The planning target volume margins (conventional vs. stereotactic body radiotherapy) were 15.6 vs. 13.9 mm (TF), 14.9 vs. 14.8 mm (TF-ABC), 14.4 vs. 13.4 mm (SBF), and 9.9 vs. 9.4 mm (SBF-ABC) before correction and 7.3 vs. 6.9 mm (TF), 4.0 vs. 3.8 mm (TF-ABC), 7.5 vs. 7.1 mm (SBF), and 4.5 vs. 4.2 mm (SBF-ABC) after correction. Conclusions The positioning accuracies of SBF and TF were similar. Active breathing control increased positioning error but reduced internal margin. Cone-beam computed tomography online correction improved the positioning accuracy of NSCLC patients.

Background To study the set-up errors, PTV margin and toxicity of cone beam CT (CBCT) guided hypofractionated radiotherapy with active breathing control (ABC) for patients with non-small cell lung cancer (NSCLC) or metastatic tumors in lung. Methods 32 tumors in 20 patients were treated. Based on the location of tumor, dose per fraction given to tumor was divided into three groups: 12 Gy, 8 Gy and 6 Gy. ABC is applied for every patient. During each treatment, patients receive CBCT scan for online set-up correction. The pre- and post-correction setup errors between fractions, the interfractional and intrafractional, set-up errors, PTV margin as well as toxicity are analyzed. Results The pre-correction systematic and random errors in the left-right (LR), superior-inferior (SI), anterior-posterior (AP) directions were 3.7 mm and 5.3 mm, 3.1 mm and 2.1 mm, 3.7 mm and 2.8 mm, respectively, while the post-correction residual errors were 0.6 mm and 0.8 mm, 0.8 mm and 0.8 mm, 1.2 mm and 1.3 mm, respectively. There was an obvious intrafractional shift of tumor position. The pre-correction PTV margin was 9.5 mm in LR, 14.1 mm in SI and 8.2 mm in AP direction. After CBCT guided online correction, the PTV margin was markedly reduced in all three directions. The post-correction margins ranged 1.5 to 2.1 mm. The treatment was well tolerated by patients, of whom there were 4 (20%) grade1-2 acute pneumonitis, 3 (15%) grade1 acute esophagitis, 2 (10%) grade1 late pneumonitis and 1 (5%) grade 1 late esophagitis. Conclusion The positioning errors for lung SBRT using ABC were significant. Online correction with CBCT image guidance should be applied to reduce setup errors and PTV margin, which may reduce radiotherapy toxicity of tissues when ABC was used.

Background Whole brain radiotherapy (WBRT) plus sequential focal radiation boost is a commonly used therapeutic strategy for patients with brain metastases. However, recent reports on WBRT plus simultaneous in-field boost (SIB) also showed promising outcomes. The objective of present study is to retrospectively evaluate the efficacy and toxicities of WBRT plus SIB with image guided intensity-modulated radiotherapy (IG-IMRT) for inoperable brain metastases of NSCLC. Methods Twenty-nine NSCLC patients with 87 inoperable brain metastases were included in this retrospective study. All patients received WBRT at a dose of 40 Gy/20 f, and SIB boost with IG-IMRT at a dose of 20 Gy/5 f concurrent with WBRT in the fourth week. Prior to each fraction of IG-IMRT boost, on-line positioning verification and correction were used to ensure that the set-up errors were within 2 mm by cone beam computed tomography in all patients. Results The one-year intracranial control rate, local brain failure rate, and distant brain failure rate were 62.9%, 13.8%, and 19.2%, respectively. The two-year intracranial control rate, local brain failure rate, and distant brain failure rate were 42.5%, 30.9%, and 36.4%, respectively. Both median intracranial progression-free survival and median survival were 10 months. Six-month, one-year, and two-year survival rates were 65.5%, 41.4%, and 13.8%, corresponding to 62.1%, 41.4%, and 10.3% of intracranial progression-free survival rates. Patients with Score Index for Radiosurgery in Brain Metastases (SIR) >5, number of intracranial lesions