[The identification of a novel reassortant H3N2 avian influenza virus based on nanopore sequencing technology and genetic characterization]

Objective: To identify a novel reassortant H3N2 avian influenza virus using nanopore sequencing technology and analyze its genetic characteristics. Methods: The positive samples of the H3N2 avian influenza virus, collected from the external environment in the farmers' market of Guangzhou, were cultured in chicken embryos. The whole genome was sequenced by targeted amplification and nanopore sequencing technology. The genetic characteristics were analyzed using bioinformatics software. Results: The phylogenetic trees showed that each gene fragment of the strain belonged to the Eurasian evolutionary branch, and the host source was of avian origin. The HA gene was closely related to the origin of the H3N6 virus. The NA gene was closely related to the H3N2 avian influenza virus from 2017 to 2020. The PB1 gene was closely related to the H5N6 avian influenza virus in Guangxi Zhuang Autonomous Region and Fujian Province from 2016 to 2022 and was not related to the PB1 gene of the H5N6 avian influenza epidemic strain in Guangzhou. The other internal gene fragments had complex sources with significant genetic diversity. Molecular characteristics indicated that the strain exhibited the molecular characteristics of a typical low pathogenic avian influenza virus and tended to bind to the receptors of avian origin. On important protein sites related to biological characteristics, this strain had mutations of PB2-L89V, PB1-L473V, NP-A184K, M1-N30D/T215A, and NS1-P42S/N205S. Conclusions: This study identified a novel reassortant H3N2 avian influenza virus by nanopore sequencing, with the PB1 gene derived from the H5N6 avian influenza virus. The virus had a low ability to spread across species, but further exploration was needed to determine whether its pathogenicity to the host was affected.

Strictureplasty may lead to increased preference in the surgical management of Crohn's disease: a case-matched study

BACKGROUND

Resection and strictureplasty are the two surgical modalities used in the management of Crohn's disease (CD). The objective of this study was to compare morbidity and clinical recurrence between patients who underwent strictureplasty and patients who underwent resection.

METHODS

Patients with CD who underwent strictureplasty between January 2012 and December 2022 were enrolled. The patients were well matched with patients who underwent resection without strictureplasty. Patient- and disease-specific characteristics, postoperative morbidity, and clinical recurrence were also analyzed.

RESULTS

A total of 118 patients who underwent a total of 192 strictureplasties were well matched to 118 patients who underwent resection. The strictureplasty group exhibited significantly less blood loss (30 ml versus 50 ml, p < 0.001) and stoma creation (2.5% versus 16.9%, p < 0.001). No significant difference was found regarding postoperative complications or length of postoperative stay. At the end of the follow-up, the overall rate of clinical recurrence was 39.4%, and no difference was observed between the two groups. Postoperative prophylactic use of biologics (odds ratio = 0.2, p < 0.001) was the only protective factor against recurrence.

CONCLUSION

Strictureplasty does not increase the risk of complications or recurrence compared with resection. It represents a viable alternative to resection in selected patients, and as such, it should have a broader scope of indications and greater acceptance among surgeons.

[Incidence of hypogammaglobulinaemia in children with steroid-dependent/frequently relapsing nephrotic syndrome treated with rituximab and its association with severe infections]

Objective: To investigate the incidence and influencing factors of hypogammaglobulinemia (HGG) in children with steroid-dependent/frequently relapsing nephrotic syndrome (SDNS/FRNS) treated with rituximab (RTX), and its relationship with the risk of severe infections. Methods: The clinical data of children with SDNS/FRNS treated with RTX at the Department of Pediatrics of the First Affiliated Hospital of Zhengzhou University from December 2020 to January 2023 were retrospectively analyzed. RTX treatment was performed using a B-cell-guided regimen (a single dose of 375 mg/m2, a maximum of 500 mg/dose, and an additional one dose when reassessment of peripheral blood CD19+B cells≥1%). Patients were divided into HGG and non-HGG groups according to the presence or absence of HGG during the follow-up period. A multivariate logistic regression model was used to analyze the influencing factors of HGG, and the predictive value of each influencing factor on HGG was assessed by plotting the receiver operating characteristic (ROC) curve. Results: A total of 59 SDNS/FRNS children (48 males and 11 females) were included, and aged [M (Q1, Q3)] 9.4 (6.5, 12.2) years at the time of the first RTX treatment, with a median application of 3 (2, 4) doses of RTX. During the follow-up period of 15.5 (9.9, 22.8) months, the HGG was present in 16 (27.1%) children, of which seven persisted for more than 1 year. Compared with non-HGG group, HGG group had a shorter duration of the disease [3.3 (2.1, 3.6) vs 4.6 (2.4, 8.0) years, P=0.030], younger age at the time of the first RTX treatment [6.2 (5.6, 7.4) vs 11.3 (8.8, 13.3) years, P<0.001], and lower serum IgG levels [5.9 (4.9, 6.4) vs 7.5 (6.1, 8.2) g/L, P<0.001]. Multivariate logistic regression analysis showed that young age at the time of the first RTX treatment (OR=0.52, 95%CI: 0.35-0.78, P=0.002) was an influencing factor of HGG. The area under the curve (AUC) for age at first RTX treatment to predict HGG was 0.887 (95%CI: 0.778-0.955, P<0.001), with an optimal cut-off value of 8.3 years. During the follow-up period, six children (10.2%) developed severe infectious, and there was no statistically significant difference in the incidence of serious infections between the HGG and non-HGG groups [12.5% (2/16) vs 9.3% (4/43), P=1.000]. Conclusions: HGG is frequent in children with SDNS/FRNS treated with RTX, and nearly half of HGG persists for more than 1 year. The possibility of HGG is greater in those≤8.3 years at the first RTX treatment, but HGG does not increase the risk of severe infections in children.

[Thoughts and suggestions on digital services to enhance the level of vaccination management]

With the development of information technology and the increasing demand for vaccination services among the people, it is a definite trend to enhance the quality of vaccination services through digitization. This article starts with a clear concept of digital services for vaccination, introduces the current development status in China and abroad, analyzes the advantages and disadvantages of existing models in leading regions, takes a glean from the summation, and proposes targeted solutions. This study suggests establishing a departmental coordination mechanism for data interconnection and sharing, formulating data standards and functional specifications, enhancing the functionalities of the immunization planning information system, strengthening data collection and analytical usage, and intensifying appointment management and science and health education to provide expert guidance for the construction of digital vaccination services across the country in the future.

[Current status of vaccination services for adults in urban and rural areas of nine provinces in China from 2019 to 2021]

Objective: To understand the current situation of vaccination services for adults in China, explore how to establish a stable and efficient vaccination service system for adults, and provide reference for formulating corresponding policies. Methods: The vaccination information systems of nine provinces in China were used to obtain information on urban and rural vaccination of influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPV23), and human papillomavirus vaccine (HPV) from 2019 to 2021. The indicator, vaccination rate/full vaccination rate, was used for statistical description. Results: The vaccination rate/full vaccination rate of the three vaccines in eastern China was generally higher than that in central and western China. The vaccination rate/full vaccination rate in urban areas was generally higher than that in rural areas. From 2019 to 2021, the vaccination rates of influenza vaccine among people aged 60 years and above in urban and rural areas were 2.96%, 6.29%, 6.14% and 1.29%, 2.58%, 2.94%, respectively. The vaccination rates of the PPV23 among people aged 60 years and above in urban and rural areas increased year by year, with rates of 0.38%, 1.05%, 1.15% and 0.14%, 0.49%, 0.59%, respectively. From 2019 to 2021, the HPV coverage of female adults aged 27-45 years in urban and rural areas increased year by year, with rates of 0.46%, 0.93%, 1.88% and 0.17%, 0.40%, 1.08%, respectively. Conclusion: The vaccination rates of influenza vaccine,PPV23 vaccine and HPV vaccine for adults in China are relatively low, with higher rates in the eastern region than in the central and western regions, and higher rates in urban areas than in rural areas. It is recommended to formulate corresponding health and economic policies and explore a suitable vaccination service system for adults in China to improve vaccination rates.

[Considerations for the development of adult vaccination in China]

Adult vaccination is an important component of the life-course immunization for all. Strengthening adult vaccination in China contributes to shrinking immunization gaps between regions and groups, enhancing the overall immunity of our population, and promoting health equity and social prosperity. Chinese adults bear the heavy burden of vaccine preventable diseases such as influenza, pneumococcal diseases and shingles, and have low coverage of vaccines against those diseases, so it is necessary to make efforts to improve adult vaccination development. This article focuses on elaborating the values of adult vaccination, introducing the current status of adult vaccination abroad, and analyzing the challenges and existing foundations for China to provide adult vaccination, and makes suggestions for the building and development of adult vaccination.

Tests of Light-Lepton Universality in Angular Asymmetries of B^{0}→D^{*-}ℓν Decays

We present the first comprehensive tests of the universality of the light leptons in the angular distributions of semileptonic B^{0}-meson decays to charged spin-1 charmed mesons. We measure five angular-asymmetry observables as functions of the decay recoil that are sensitive to lepton-universality-violating contributions. We use events where one neutral B is fully reconstructed in ϒ(4S)→BB[over ¯] decays in data corresponding to 189  fb^{-1} integrated luminosity from electron-positron collisions collected with the Belle II detector. We find no significant deviation from the standard model expectations.

Daily self-weighing compared with an active control causes greater negative affective lability in emerging adult women: A randomized trial

Age-related weight gain prevention may reduce population overweight/obesity. Emerging adulthood is a crucial time to act, as rate of gain accelerates and health habits develop. Evidence supports self-weighing (SW) for preventing weight gain; however, how SW impacts psychological states and behaviors in vulnerable groups is unclear. This study assessed daily SW effects on affective lability, stress, weight-related stress, body satisfaction, and weight-control behaviors. Sixty-nine university females (aged 18-22) were randomized to daily SW or temperature-taking (TT) control. Over 2 weeks, participants completed five daily ecological momentary assessments with their intervention behavior. A graph of their data with a trendline was emailed daily, with no other intervention components. Multilevel mixed models with random effect for day assessed variability in positive/negative affect. Generalized linear mixed models assessed outcomes pre- and post-SW or TT and generalized estimating equations assessed weight-control behaviors. Negative affective lability was significantly greater for SW versus TT. While general stress did not differ between groups, weight-related stress was significantly higher and body satisfaction was significantly lower post-behavior for SW but not TT. Groups did not significantly differ in the number or probability of weight-control behaviors. Caution is advised when recommending self-weighing to prevent weight gain for emerging adults.

Pharmacological activity and clinical progress of Triptolide and its derivatives LLDT-8, PG490-88Na, and Minnelide: a narrative review

Triptolide, a compound isolated from a Chinese medicinal herb, has potent antitumor, immunosuppressive, and anti-inflammatory properties. Due to its interesting structural features and diverse pharmacological activities, it has attracted great interest by the Society of Organic Chemistry and Pharmaceutical Chemistry. However, its clinical potential is greatly hampered by limited aqueous solubility and oral bioavailability, and multi-organ toxicity. In recent years, various derivatives of Triptolide have made varying degrees of progress in the treatment of inflammatory diseases, autoimmune diseases, and cancer. The most researched and potentially clinically valuable of them were (5R)-5-hydroxytriptolide (LLDT-8), PG490-88Na (F6008), and Minnelide. In this review, we provide an overview of the advancements made in triptolide and several of its derivatives' biological activity, mechanisms of action, and clinical development. We also summarized some prospects for the future development of triptolide and its derivatives. It is hoped to contribute to a better understanding of the progress in this field, make constructive suggestions for further studies of Triptolide, and provide a theoretical reference for the rational development of new drugs.

Precise Measurement of the D_{s}^{+} Lifetime at Belle II

We measure the lifetime of the D_{s}^{+} meson using a data sample of 207  fb^{-1} collected by the Belle II experiment running at the SuperKEKB asymmetric-energy e^{+}e^{-} collider. The lifetime is determined by fitting the decay-time distribution of a sample of 116×10^{3} D_{s}^{+}→ϕπ^{+} decays. Our result is τ_{D_{s}^{+}}=(499.5±1.7±0.9)  fs, where the first uncertainty is statistical and the second is systematic. This result is significantly more precise than previous measurements.

[Analysis on the vaccination coverage of 13-valent pneumococcal conjugate vaccine in China from 2017 to 2021]

Objective: To explore the vaccination coverage of the 13-valent pneumococcal conjugate vaccine (PCV13) in China from 2017 to 2021. Methods: Using the reported number of PCV13 administrated doses from 2017 to 2021 and the population data from 31 provinces in China, which were collected by the Immunization Program Information System and summarized data at different levels (prefecture, provincial, and national). Collecting batch release data of PCV13 during the same period through the official website of the National Institutes for Food and Drug Control. The average coverage level of PCV13 was calculated by comparing the number of PCV13 vaccinations reported annually to the number of births in that year, and the spatial auto-correlation analysis was conducted in 2021 at the prefecture level. The coverage of PCV13 vaccination was estimated by the total vaccine doses administered each year divided by the number of newborn in the year, as of the administrated dose number per 100 people. Results: From March 2017 to December 2020, the total batch release of PCV13 was 20.06 million, with a total of 71.54, 384.75, 475.45, and 10.8886 million doses each year. During the same period, PCV13 reported doses were 20.2369 million and the vaccination doses from 2017 to 2021 were 4.08, 170.46, 407.52, 599.77, and 8.4185 million doses, respectively. From 2017 to 2021, the ratio of PCV13 doses administrated per 100 infants in each year was 0.25, 10.26, 23.81, 38.16, and 69.90 doses per 100 people, respectively. The range of the ratio in each province increased from 3.85 doses in 2017 to 264.41 doses per 100 people in 2021. The spatial auto-correlation analysis results showed that based on prefecture-level cities, there was spatial clustering in a certain area of PCV13 coverage from 2017 to 2021, and the spatial correlation in 2021 was the highest. The hotspot analysis showed that the hotspot areas with high coverage levels of PCV13 were concentrated in Jiangsu, Zhejiang, Shanghai, Fujian and their surrounding areas. The cold spots with low vaccine coverage were concentrated in Yunnan, Qinghai, Tibet, and their surrounding areas. Conclusion: The average coverage level of PCV13 is low in China with significant regional differences.

Prognostic and Predictive Significance of Tumor Immune Microenvironment in Breast Ductal Carcinoma In Situ

PURPOSE/OBJECTIVE(S)

This study aims to identify the role of different subtypes of tumor infiltrating lymphocytes (TILs) in ductal carcinoma in situ (DCIS) in predicting risk of recurrence and benefit of whole breast irradiation (WBI).

MATERIALS/METHODS

Immunohistochemical stain for CD3, CD4, CD8, FOXP3 and CD20 were carried in a well characterized DCIS cohort who received breast-conserving surgery (BCS) from Jan 2009 to Dec 2018. All the TILs subtypes were evaluated by the average numbers of touching-TILs which defined as TILs touching or within one lymphocyte cell thickness from the malignant ducts' basement membrane. The optimal cut-off values of TILs subtypes were selected by the X-tile.

RESULTS

In total, 167 patients were enrolled in this analysis with 114 patients received WBI. After a median follow-up of 67 months, 15 IBTR events occurred with 6 invasive-IBTRs. Nine out of 15 IBTRs occurred outside of the original quadrant (elsewhere failure event, EFE). CD3+ lymphocytes were the predominant cell subtype while Treg showed the lowest levels. High abundance of TILs subtypes was associated with high tumor grade, presence of microinvasion, high Ki67 index, ER negativity and HER2 positivity. For various TILs subtypes, the multivariate analyses showed that dense CD4+ TILs (HR = 9.84, 95% CI 2.43-39.91, p<0.01) and dense Treg (HR = 4.22, 95% CI 1.24-14.36, p = 0.02) were independent prognostic factors for higher IBTR. As the infiltration of TIL subsets was correlated with one another, we also analyzed the relationship between IBTR and the ratios of different TILs subtypes. By adjusted by clinicopathological parameters, high ratios of CD4+/CD8+, Treg/CD4+ and Treg/CD8+ were found to be independent prognostic factors for higher IBTR (HR = 11.31, 95% CI 3.14-40.76, p<0.01; HR = 3.09, 95% CI 1.05-9.11, p = 0.04; HR = 7.14, 95% CI 1.98-25.73, p<0.01). Consistent with the results of IBTR, the 5-y rate of invasive-IBTR and EFE was both significantly associated with the high CD4+/CD8+, Treg/CD4+ and Treg/CD8+ TILs ratios (all p<0.01). WBI reduced the rate of 5y-IBTR risk from 8.4% to 1.3% (p = 0.02) in the low Treg/CD8+ group, but there was no benefit of WBI in the high group. With respect to EFE, WBI significantly reduced the rate from 2.8% to 0.0% (p = 0.03) in the low Treg/CD8+ group while not in the high group. The benefits of WBI in reducing IBTR and EFE were not significant difference between different CD4+/CD8+ and Treg/CD4+ groups.

CONCLUSION

Assessment of overall TILs provides a tool for comprehensive evaluation of the DCIS immune microenvironment. Patients with pro-tumoral immune infiltrate (high Treg, high ratios of CD4+/CD8+, Treg/CD4+ and Treg/CD8+) in tumor microenvironment show an increased risk of IBTR and less benefit from breast radiotherapy.

Evaluation of immunogenicity of enterobactin conjugate vaccine for the control of Escherichia coli mastitis in dairy cows

Mastitis is the most common disease of dairy cows that incurs severe economic losses to the dairy industry. Currently, environmental mastitis pathogens are a major problem for most dairy farms. A current commercially available Escherichia coli vaccine does not prevent clinical mastitis and production losses, likely due to antibody accessibility and antigenic variation issues. Therefore, a novel vaccine that prevents clinical disease and production losses is critically needed. Recently a nutritional immunity approach, which restricts bacterial iron uptake by immunologically sequestering conserved iron-binding enterobactin (Ent), has been developed. The objective of this study was to evaluate the immunogenicity of the keyhole limpet hemocyanin-enterobactin (KLH-Ent) conjugate vaccine in dairy cows. Twelve pregnant Holstein dairy cows in their first through third lactations were randomized to the control or vaccine group, with 6 cows per group. The vaccine group received 3 subcutaneous vaccinations of KLH-Ent with adjuvants at drying off (D0), 20 (D21), and 40 (D42) days after drying off. The control group was injected with phosphate-buffered saline (pH 7.4) mixed with the same adjuvants at the same time points. Vaccination effects were assessed over the study period until the end of the first month of lactation. The KLH-Ent vaccine did not cause any systemic adverse reactions or reduction in milk production. Compared with the control group, the vaccine elicited significantly higher levels of serum Ent-specific IgG at calving (C0) and 30 d postcalving (C30), mainly its IgG2 fraction, which was significantly higher at D42, C0, C14, and C30 d, with no significant change in IgG1 levels. Milk Ent-specific IgG and IgG2 levels in the vaccine group were significantly higher on C30. Fecal microbial community structures were similar for both control and vaccine groups on the same day and shifted directionally along the sampling days. In conclusion, the KLH-Ent vaccine successfully triggered strong Ent-specific immune responses in dairy cows without significantly affecting the gut microbiota diversity and health. The results show that Ent conjugate vaccine is a promising nutritional immunity approach in control of E. coli mastitis in dairy cows.

A Cascaded Deep Learning-Based Cardiac Substructures Segmentation Frame and on Non-Gated Non-Enhanced Planning CT Scans in Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

To develop a deep learning-based segmentation frame for cardiac substructures especially coronary arteries (CAs) on non-gated non-enhanced planning computed tomography (CT) scans in breast cancer (BC) patients.

MATERIALS/METHODS

Non-gated non-enhanced CT scans of 39 BC patients receiving adjuvant radiotherapy (RT) were collected. Cardiac substructures were manually labelled, including four chambers, left main (LM), left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA). The training, validation, and test sample is 28, 7 and 4, respectively. A cascaded network, using nnUNet as the backbone, is proposed to use chambers as prior information to constrain the segmentation of CAs. The mean Dice similarity coefficient (DSC), 95th percentile Hausdorff distance (HD95) and average symmetrical surface distance (ASSD) were used as geometric metrics. Dosimetric parameters of cardiac substructures was calculated based on the segmentation frame and manually labeled contouring, respectively. The data of cardiac examination including ultrasonography, electrocardiogram before and during the follow-up after RT were retrospectively collected. The cardiac event was any symptomatic heart disease or new-onset abnormality in the cardiac examination after RT.

RESULTS

The mean DSC of heart, atriums and ventricles of the proposed frame was 0.93, 0.90, and 0.93, respectively. As shown in Table 1, compared with direct segmentation (as baseline), the proposed frame had a better performance in terms of HD95, ASSD, and the mean dose (Dmean) absolute error for all CAs. Compared to the dosimetric parameters of the heart collected based on the manual labelled contours, the relative errors of D5, D95, and V15Gy for LAD was 4.3±7.8%, 11.7±5.9%, and 14.6±13.0% collected based on the direct segmentation contours and 2.4±4.4%, 3.9±3.1%, 8.5±6.9% collected based on the auto-segmented contours, respectively. Multivariate analysis showed that increased V15Gy of LAD was an independent cardiac toxicity risk factor ([HR] = 1.07, 95% CI 1-1.15, p = 0.0387).

CONCLUSION

We developed a cascaded network for cardiac substructures segmentation with dosimetric validation on non-enhanced CT scans in breast cancer radiotherapy. This is the first attempt to use chambers as prior information for CAs' segmentation and had a superior stable performance. Accurate segmentation will help radiation oncologists to better evaluate DVHs based on substructures and thus to estimate cardiovascular risk. An optimized cardiac substructure-based dosimetric constrain may be proposed accordingly.

Identification and Dosimetric Analysis of Axillary Substructures Associated with Breast Cancer Related Lymphedema

PURPOSE/OBJECTIVE(S)

It has been hypothesized that substructures in the axillary region may be involved in the development of upper limb lymphedema in breast cancer patients. We aimed to compare dosimetric parameters of different substructures to identify risk regions and dose indicators related to the development of lymphedema.

MATERIALS/METHODS

A total of 486 patients with breast cancer treated with axillary node dissection (ALND) and regional node irradiation (RNI) between 2017 and 2020 were analyzed. Ten axillary substructures were retrospectively contoured, and dose-volume histogram (DVH) parameters (maximum dose [Dmax], Dmean, Dmin, V5 Gy, V10 Gy, V15 Gy, V20 Gy, V25 Gy, V30 Gy, V35 Gy, V40 Gy, V45 Gy and V50 Gy) were evaluated. EQD2 using α/β = 3 was applied for hypofractionation.

RESULTS

The cumulative incidence of lymphedema was 32.5% during the median follow-up of 25 month (IQR 15-35). Higher BMI (≥21.77 kg/m2, hazard ratio [HR]1.6, 95% CI 1.1-2.3, p = 0.019) and higher number of dissected lymph nodes (≥13, HR 1.8, 95% CI 1.1-3.0, p = 0.026) were baseline risk factors associated with breast cancer related lymphedema (BCRL). A cohort of 196 patients was obtained by 1:1 propensity score matching based on the above two factors (154 treated with 50 Gy/25 fractions [Fx] and 42 with 40.05 Gy/15Fx). The optimal metric was axillary-lateral thoracic vessel juncture (ALTJ) Dmean ≥36.84 Gy (HR 3.7, 95% CI 1.6-8.6, p = 0.002). Other significant risk factors are Medial of Axillary Nodes level I(ALN-I-M) Dmin <9.19 Gy (HR 2.3, 95% CI 1.4-3.7, p = 0.001) and Posterior of Axillary Nodes level II(ALN-II-P) Dmax <52.75 Gy (HR 2.0, 95% CI 1.2-3.5, p = 0.015). A nomogram incorporated the above three parameters was created to predict the risk of lymphedema with reasonable accuracy confirmed by both self-training (area under curve [AUC], 0.76; 95% CI, 0.67-0.84) and internal validation (AUC 0.66; 95% CI, 0.50-0.80).

CONCLUSION

A mean dose of 36.84 Gy of ALTJ may be a suggested dose limit for patients indicated RNI after ALND, especially when patients with higher BMI and higher dissected nodes. Ideally, avoidance of ALTJ may be realized without compromising dose coverage to high-risk nodal region. Confirmation of this finding in future prospective studies is needed.

Does Dual Anti-HER2 Therapy Increase Early Cardiac Toxicity in Comparison with Trastuzumab Alone in Breast Cancer Patients Receiving Adjuvant Radiotherapy? A Multicenter Retrospective Study

PURPOSE/OBJECTIVE(S)

Adjuvant trastuzumab in combination with RT has proved its safety in terms of cardiac events. Dual anti-HER2 therapy with pertuzumab is currently standard adjuvant therapy in N+ and high-risk N0 early breast cancer (BC) patients. Our study aims to find if it increases early cardiac toxicity compared with trastuzumab alone in BC patients receiving adjuvant radiotherapy.

MATERIALS/METHODS

Operable BC patients who received adjuvant radiotherapy (RT) and trastuzumab with or without pertuzumab between January 2017 and September 2020 in 7 Chinese centers were retrospectively reviewed. The cardiac examination included ultrasonography, electrocardiogram (ECG), NT-proBNP, and cTnI before RT and during follow-up. The cardiac event was any new-onset symptomatic heart disease or abnormality in the cardiac examination after RT.

RESULTS

In total, 711 patients with a median age of 52 years were included, of whom 567 (79.7%) patients were treated with trastuzumab-only and 144 (20.3%) patients received dual anti-HER2 therapy. Adjuvant RT was given concurrently in 140/144 (97.2%) of dual anti-HER2 therapy and 562/567 (99.1%) of trastuzumab alone, respectively. With a median follow-up of 11 months, no patients developed symptomatic heart diseases. Among patients with normal baseline, 17 (2.4%), 86 (12.1%), 18 (2.5%) and 14 (7.3%) developed new-onset diastolic dysfunction, left ventricular ejection fraction (LVEF) decline, abnormal ECG, and abnormal NT-proBNP, respectively. No significant difference was found between the trastuzumab-only and dual anti-HER2 cohort in the incidence of all kinds of new-onset cardiac events (all p > 0.1). Multivariate analysis showed that left-sided (vs right-sided) RT significantly increased the risk of ECG abnormality (HR = 2.32, 95% CI 1.62-3.32, p<0.001). Increased age was an independent risk factor for diastolic dysfunction (HR = 1.1, 95% CI 1.02-1.18, p = 0.0098). Dosimetric analysis showed that patients who developed any cardiac events had increased mean heart dose (397.67±251.08 vs 344.87±236.75 cGy, p = 0.032). A significant increase in risk of cardiac events was found in patients with mean heart dose > 450 cGy (HR = 1.55, 95% CI 1.17-2.05, p = 0.0024), V5 > 26% (HR = 1.51, 95% CI 1.09-2.09, p = 0.013), and V30 > 5.5% (HR = 1.49, 95% CI 1.09-2.04, p = 0.0117), respectively. Further analysis was done in the subgroup of patients treated with left-sided RT, internal mammary nodes RT, or anthracyclines, no difference in risk of cardiac events was found between trastuzumab alone and dual anti-HER2 therapy in concurrent with RT (all p > 0.05).

CONCLUSION

Compared with trastuzumab-only, dual anti-HER2 therapy does not increase early cardiac toxicity in combination with adjuvant RT in BC patients. Cardiac radiation exposure remains the primary risk factor associated with early cardiac toxicity.

Convolution Neural Network-Based Automatic Scoring of Coronary Artery Calcification and Its Value to Identify the Risk of Radiation-Induced Cardiac Toxicity on Radiotherapy Planning CT Scans in Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

To develop an automatic scoring of coronary artery calcification (CAC) on breast cancer radiotherapy (RT) planning computed tomography (CT) scans, and to explore its predictive value of CAC for radiation-induced cardiac toxicity.

MATERIALS/METHODS

Planning CT scans of 668 breast cancer patients from two prospective clinical trials (NCT02942615, NCT03829553) were retrospectively reviewed. In total, 34 CTs containing CAC were identified. The training and test samples were 29 and 5, respectively. We proposed a two-stage model for CAC segmentation task with nnU-Net as backbone. The segmentation results were processed by threshold extraction and region growth algorithm. We also employed transfer learning to automatically identify calcification of left anterior descending artery (LAD), right coronary artery (RCA), left circumflex artery (LCX), and left main coronary artery (LM) based on a public dataset of 430 cases from Stanford University. The data of cardiac examination of these 34 patients before and during the follow-up after RT were collected. The cardiac event was any symptomatic heart disease or new-onset abnormality in the cardiac examination after RT.

RESULTS

The mean dice coefficients (DSC) and 95% Harsdorf distance (95HD) of test samples were 0.992 and 0.599 mm, respectively. The mean absolute error (MAE) of CAC Angaston score between ground truth (GT) and predictions was 0.532. The detailed consistency parameters of 5 test samples were shown in Table 1. After 1:2 propensity score matching (PSM), 21 patients had CAC and 42 patients had no CAC were selected. The number of patients with CAC scores of 1 to 10, 11 to 100, and greater than 100 was 10, 9 and 2, respectively. During median follow-up of 9.2 months (range, 1-42.7), 90.5% and 38.1% of patients in CAC cohort and no CAC cohort developed cardiac event (p<0.001). Patients with CAC had significantly increased cardiac events (HR = 2.4; 95% CI, 1.22-4.75; p = 0.0117). The risk of cardiac events increased with CAC scores ([HR]1-10 = 2.1, 95% CI 0.9-4.9; [HR]11-100 = 2.5, 95% CI 1.0-5.9; [HR]>100 = 4.0, 95% CI 0.9-17.4).

CONCLUSION

Our primary results showed that this two-stage segmentation model is capable of achieving automatic CAC scoring which might assist to predict the risk of post-RT cardiac events in breast cancer patients.

Dosimetry Comparison of Incidental Irradiation to the Low Axilla in Whole Breast Irradiation Using IMRT and IMPT Therapy

PURPOSE/OBJECTIVE(S)

It has been hypothesized that incidental dose to low axilla contributes to regional control in patients receiving whole breast irradiation (WBI), especially in patients with limited metastatic sentinel nodes who were spared from subsequent axillary dissection. We aimed to compare axillary dose between intensity-modulated radiotherapy (IMRT) and intensity-modulated proton radiotherapy (IMPT).

MATERIALS/METHODS

Dosimetric comparisons between IMRT and IMPT were conducted in 15 patients treated with WBI without planned regional node irradiation (RNI). The prescribed dose was 40.05 Gy (RBE)/15 Fx. Axillary lymph nodes levels I, II (ALN I, ALN II) and rotter's lymph nodes (RN) were contoured and evaluated.

RESULTS

The dose to the axilla was generally low for IMPT, with mean dose to ALN I, ALN II, and RN of 896.31, 194.64, and 2111.58 cGy (RBE), respectively. The mean V90% and V50% of ALN I was higher for IMRT (11.5 cm3, 22.9% of structure volume, p < 0.0001; 36.1 cm3, 66.6%, p < 0.0001) compared to IMPT (1.1 cm3, 2.0%; 8.1cm3, 15.9%). Similar finding was found in other low axilla. Mean dose to total ALN caudal to axillary vein was 936.6 cGy (RBE) in IMPT compared to 2407.3 cGy in IMRT (p < 0.0001). Within all substructures of axilla, mean dose to RN was the highest, but it remains lower in IMPT than in IMRT [2111.58 cGy (RBE) versus 3510.88 cGy, p < 0.0001].

CONCLUSION

WBI treated with IMPT leads to a significant reduction of axilla dose compared to IMRT. In clinical scenarios like Z0011 or likewise requiring incidental irradiation to the low axilla without additional RNI, contouring should be modified based on individual risk.

A Modified Robust Nomogram for Predicting the Probability of Pelvic Lymph Node Invasion in Localized Prostate Cancer

PURPOSE/OBJECTIVE(S)

Improved predictive models for the risk of pelvic lymph node invasion (LNI) in localized prostate cancer (PCa) is important in decision making of pelvic lymph node dissection (PLND) or whole pelvic RT (WPRT). We aimed to establish a nomogram with improved robustness (Ruijin model) based on pre-treatment information.

MATERIALS/METHODS

Continuous localized PCa patients with detailed prostate tumor biopsy information, treated with laparoscopic radical prostatectomy and PLND between 2013 and 2022 in single institution were retrospectively reviewed. A multivariable logistic regression model was fitted and represented the basis for a coefficient-based nomogram of predicting LNI. Comparisons between the Ruijin model and the Roach formula were conducted using the receiver operating characteristic-derived area under the curve (AUC), calibration plot, and decision-curve analyses (DCAs).

RESULTS

In total, 624 patients with median age (69.5 year) were included in this analysis. The median number of pelvis lymph nodes removed was 6 (range: 2-30). LNI was found in 35 (5.6%) patients. In the multivariable logistic regression model, total prostate-specific antigen (OR = 1.008, P = 0.025), percentage of cores with the highest-grade PCa (OR = 14.822, P<0.001), clinical stage (III vs. I-II: OR = 7.733, P = 0.008), and biopsy Gleason Grading Group (G3 vs G1-2: OR = 3.152, P = 0.082; G4 vs G1-2: OR = 3.065, P = 0.083; G5 vs G1-2: OR = 5.262, P = 0.008;) were included and formed the basis for the nomogram. The predictive accuracy of Ruijin nomogram in our cohort was 87.7%. Using a cutoff of 4% based on Ruijin nomogram, 395 (63%) PLND would be spared and LNI would be missed in only two (0.5%) patients. The sensitivity, specificity, and negative predictive value associated with the 4% cutoff were 94.3%, 66.7%, and 99.5%, respectively. As compared with the Roach formula, the Ruijin model showed higher AUC (87.7% vs 80.9%, Z = -2.013, P = 0.044), better calibration characteristics, and a higher net benefit at DCA.

CONCLUSION

We developed a novel nomogram for predicting the LNI in localized PCa patients with detailed biopsy information. PLND or WPRT could be avoided in patients with a risk of LNI <4%, so as to spare more than 60% of unnecessary pelvic nodal treatment with a cost of missing only 0.5% LNIs.

Quality Assurance of Protocol Compliance in a Multicenter Randomized Trial Investigating the Role of Hypofractionated Comprehensive Reginal Nodal Irradiation in Node-Positive Breast Cancer (HARVEST)

PURPOSE/OBJECTIVE(S)

The HARVEST trial (NCT03829553) is a phase III, multicenter, randomized clinical trial to explore efficacy and safety of hypofractionated irradiation (HFI) involving regional nodal irradiation (RNI, including internal mammary nodes, IMN) in N+ breast cancer patients treated with mastectomy or breast conserving surgery (BCS). Current study aims to analyze the dosimetric quality assurance so as to evaluate the compliance to the trial protocol.

MATERIALS/METHODS

Eligible patients were randomly assigned (1:1) to receive conventional fractionated irradiation (CFI: 50 Gy/25Fx) or HFI (40.05 Gy/15Fx), which is delivered to ipsilateral chest wall or whole breast (CW/WB) with tumor bed boost (HFI: 10.68 Gy/4Fx; CFI: 10 Gy/5Fx) and comprehensive RNI (supra/infraclavicular nodes and IMN in each patient, lower axilla if indicated) by using IMRT technique. The plan quality was evaluated based on dose distribution, dose volume histogram (DVH) and field parameters. The target coverage, including planning target volume of CW/WB (PTV1) and tumor bed (PTV2) and doses of the organs at risk (OARs) were evaluated. The LQ model was used to convert doses of OARs in HFI group using α/β = 3 Gy (EQD23) for comparison.

RESULTS

Between Feb 21, 2019 and Feb 14, 2022, 801 patients were enrolled at 8 centers with 401 and 400 in CFI and HFI group, respectively. There were 182 patients received BCS and 387 patients were with more than three positive lymph nodes. In the CFI group, the D90 and V45 of PTV1 reached the prescribed dose in 70.6% and 96.0% of the patients, respectively. In the HFI group, the D90 and V36 of PTV1 reached the prescribed dose in 87.8% and 95.5% of the patients, respectively. When the tumor bed was irradiated, the D90 of PTV2 reached the prescribed dose in 95.6% in the CFI group and 100% in the HFI group, respectively. The mean D90 of PTV1 and PTV2 were 50.09±0.65 Gy and 60.63±0.91 Gy in CFI group while 40.11±0.56 Gy and 50.79±2.03 Gy in HFI group. For OARs constraints, protocol compliance was all above 95% (heart: 95.3%; ipsilateral lung: 95.5%; contralateral lung: 97.1%; humeral head: 98.2% and spinal cord: 100%) with no significant difference between CFI and HFI groups. For patients with left-sided breast cancer, the Dmean of the heart was 5.10±1.75 Gy vs. 4.59±1.86 Gy (EQD23) in CFI and HFI groups (p = 0.51), respectively. No significant differences in Dmean of the heart (1.45±0.71 Gy vs. 1.33±0.77 Gy (EQD23), p = 0.40) was found either between two groups in right-sided patients. The differences were significant in the Dmean of the ipsilateral lung (13.37±1.99 Gy vs. 11.17±3.50 Gy (EQD23), p<0.01), contralateral lung (0.88±0.73 Gy vs. 0.74±0.61 Gy (EQD23), p<0.01) and the ipsilateral humeral head (15.27±7.62 Gy vs. 13.05±6.19 Gy (EQD23), p<0.01) and the Dmax of spinal cord (21.40±8.82 Gy vs. 19.47±7.99 Gy (EQD23), p = 0.05) between CFI and HFI groups.

CONCLUSION

A high degree of compliance with protocol dose constraints was found for treatment plans in the HARVEST trial and doses to the most of OARs decreased in HFI group.

Establishing a Risk Stratification Model to Identify Clinically High-Risk N0 Breast Cancer Who Could Benefit from Regional Nodal Irradiation: A Single Institute Analysis

PURPOSE/OBJECTIVE(S)

The adverse clinical features for pN0 BC patients significantly varies and there is no established clinical risk stratification system to identify those "high-risk" pN0 BC patients who might benefit from RNI. The purpose of this real-world study was to investigate the risk factors for developing recurrence among patients with pathological T1-3N0 breast cancer (BC) treated with breast-conserving surgery (BCS) followed by whole breast irradiation alone (WBI) and identify those clinically high-risk BCs who could benefit from regional nodal irradiation (RNI).

MATERIALS/METHODS

Female BC patients treated from 2009 to 2016 were retrospectively reviewed. The disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan-Meier method, and survival differences were compared with the log-rank test. Univariate and multivariate analysis was performed using Cox logistic regression analysis. An external validation was conducted by using SEER database.

RESULTS

A total of 622 BC patients treated with BCS+WBI alone were included. With a median follow-up of 82 months, the 7-year OS and DFS for the entire cohort was 97% and 91%, respectively. Multivariable Cox analysis indicated that tumor size (p = 0.006), tumor location (p = 0.033), lymphovascular invasion (LVI) status (p = 0.0028) and Ki-67 index (p = 0.051) were independent risk factors for DFS, while only tumor size was the only independent risk factors for OS (p = 0.029). A scoring system was developed using these four factors and the 7-year DFS and OS were 97% and 96% for patients with 0-1 risk factors, 95% and 82% for patients with ≥2 risk factors (p<0.0001 for DFS, and p = 0.0063 for OS). Based on tumor size and tumor location, an external validation by demonstrated that the 7-year OS was 90% and 88% for patients with 0-1 risk factor, which was significantly better than those defined as high-risk BC patients (82%, p<0.0001).

CONCLUSION

By using our institute database, we establish a risk stratification system for identifying sub-group of pN0 BC patients, who are at high risk for developing recurrence. The results of our study support tailored RT decision-making according to individual risks, which needed to be confirmed in further studies.

Treatment Outcomes and Prognostic Factors of Chemotherapy Combined with Radiotherapy for Patients with Stage I-II Nasal-Type Natural Killer/T-Cell Lymphoma

PURPOSE/OBJECTIVE(S)

The purpose of this study was to assess the treatment outcome and the potential prognostic factors for patients with stage I-II nasal ENKTL treated with radiotherapy (RT) combined chemotherapy (CT).

MATERIALS/METHODS

From July, 2005 to January, 2019, 118 eligible patients were retrospective included in the study. Among the 118 patients, 84 were male and 34 were female. The median age was 45 years (range: 14-77 years). According to the Ann Arbor staging system, 66 patients had stage I disease (Primary tumor invasion (PTI) was present in 29 patients), and 52 patients had stage II disease. B symptoms were observed in 61 patients. The Eastern Cooperative Oncology Group (ECOG) performance score was 0 to 1 in 88 patients. Cervical lymph node involvement was observed in 51 patients. The primary lesions were located in the nasal cavity in 92 cases and in the Waldeyer ring in 26 cases. Five patients had received RT followed by CT (RT + CT), 20 patients had received CT followed by RT (CT + RT), 90 patients had received CT followed by RT, again followed by CT (CT+RT+CT), and 3 patients had received concurrent chemoradiotherapy (CRT) (1 patient received CRT + CT, other 2 patients received CT+CRT+CT). Patients were irradiated with a median dose of 50 Gy (range, 24-61.2). All patients received chemotherapy, 91 received non-anthracycline-based chemotherapy, whereas 27 patients received anthracycline-based chemotherapy. The median number of courses of chemotherapy was four (range: 1-10). Patients were scored as having low-risk disease (n = 50), intermediate-risk disease (n = 60) or high-risk disease (n = 8) according to the prognostic index of natural killer cell lymphoma (PINK).

RESULTS

Among the 118 patients, after initial therapy, the complete response (CR) rate was 82.2% (n = 97), and the partial response (PR) rate was 11.0% (n = 13). The stable disease (SD) rate was 2.5% (n = 3), and the progressive disease (PD) rate was 4.2% (n = 5). With a median follow-up of 43 months (range, 4-201) after irradiation, the 3-year PFS and OS were 76.9% and 82.9%, respectively. The 3-year OS rate was 75.0% for RT + CT, 70.0% for CT + RT, 87.1% for CT + RT+ CT, and 50.0% for CRT (P = 0.052). Three-year OS and PFS were 88.6% and 83.4%, respectively, for non-anthracycline-based chemotherapy regimen compared to 61.6% (P = 0.001) and 58.4% (P = 0.003), respectively, for the anthracycline-based chemotherapy regimen. Three-year OS and PFS were 84.0% and 79.0%, respectively, for patients receiving high-dose RT (≥50 Gy, n = 111) compared to 71.4% (P = 0.076) and 71.4% (P = 0.228), respectively, for low-dose RT (<50 Gy, n = 7). In multivariate analysis, adverse factors associated with OS in our study were chemotherapy regimen and response to RT and CT (P = 0.047, <0.001).

CONCLUSION

Radiotherapy combined with chemotherapy reported promising response rate and a favorable survival for patients with stage I-II nasal ENKTL. Anthracycline-based chemotherapy regimen and no remission after RT and CT were adverse factors of OS.

Improving Interfraction Robustness for IMPT Treatment Planning for Lung Cancer Using Multiple-CT Incorporated Robust Optimization

PURPOSE/OBJECTIVE(S)

Dose deterioration due to motion-induced density variation is a major concern in intensity-modulated proton therapy (IMPT) for lung cancer. Robust optimization is capable to address the intrafraction motion issue but not the interfraction variation. This study aims to investigate the potential of a new robust optimization technique of IMPT in mitigating the interfraction variation of lung cancer patients.

MATERIALS/METHODS

Two optimization techniques were used to create an IMPT plan for a lung cancer case, one was conventional robust optimization (ROcon) considering the perturbation of 3 mm setup uncertainty and 3.5% range uncertainty, and the other was multiple-CT incorporated robust optimization (ROmul) considering one more perturbation quantified using the end-of-inhalation-phase (T0) and end-of-exhalation-phase (T50) CTs. The ROcon plan was optimized on the average-intensity-projection (AIP) planning CT (pCT), and the ROmul plan was optimized on the AIP, T0, and T50 pCTs. The dose prescription was 40 Gy (RBE) in 5 fractions. The patient underwent a verification 4DCT (vCT) scan on six successive days. Both plans were recalculated on the T0 pCT, T50 pCT, and AIP vCT. The dose to the target and organ at risk of the ROcon and ROmul plans on pCT and vCT were compared.

RESULTS

Compared with the ROcon plan, the ROmul plan reduced the deviation of target coverage by greater than 50% in presence of intrafraction motion (ROmul:0.38-0.88%, ROcon:1.90-2.23%) and interfraction variation (ROmul: 0.62-1.63% vs ROcon:0.50-2.75%) while meeting the dose criteria on the planning AIP CT. As for the dose to the organ at risk, the ROmul plan had a slightly high lung V20 (0.3%) than did the ROcon plan on the AIP pCT. The deviations in lung V20 of the ROmul plan (mean 0.15%) on the vCTs were similar to that of the ROcon plan (mean 0.17%).

CONCLUSION

This study indicates that dose variation of an IMPT plan can be reduced in presence of interfraction variation along the treatment course by combining conventional robust optimization and novel multiple-CT optimization using only the planning CT.

Nodal Response to Neo-Adjuvant Systemic Therapy Predicts Prognosis of cN3c Breast Cancer Patients Receiving Multidisciplinary Therapy

PURPOSE/OBJECTIVE(S)

cN3c breast cancer with ipsilateral supraclavicular (SCV) lymph nodal (SCLN) metastasis has a dismal prognosis. We investigated the survival outcomes, patterns and risks of recurrence in those patients after multidisciplinary therapy, as well as the predictors of candidates for SCV area boosting.

MATERIALS/METHODS

Consecutive cN3c breast cancer patients without distant metastases from January 2009 to December 2020 in our institution were retrospectively reviewed. Based on nodal response to neoadjuvant therapy (NAT), patients were categorized into three groups: clinical complete response (cCR) not achieved in SCLN (Group A, n = 66), SCLN cCR but axillary node (ALN) did not achieve pathological complete response (pCR, Group B, n = 34), cCR in SCLN and pCR in ALN (Group C, n = 13).

RESULTS

The median follow-up time was 32.7 months (range, 21.9-53.3months). The 5-year overall survival (OS) and recurrence-free survival (RFS) rates were 64.6% and 43.7% respectively. Multivariate analysis showed cumulative SCV dose and ypT stage, ALN response and SCV response to NAT were significantly associated with OS and RFS respectively. The 3-year for patients receiving the cumulative SCV dose of ≥60 Gy versus <60 Gy was 81.3% versus 69.0% (P = 0.042). Compared with Group A or B, Group C showed significantly improved RFS (3y-RFS: 53.8% vs 73.6% vs 100%, p = 0.003) and a numerically longer OS (3y-OS: 73.4% vs 86.7% vs 100%, p = 0.089). Meanwhile, Group C showed the lowest rate of DM as first failure (37.9 % vs 23.5% vs 0 in group A, B and C, respectively, p = 0.010). In patients of Group A, the 3-year OS rates for patients receiving the cumulative SCV dose of ≥60 Gy versus <60 Gy was 78.0% versus 57.3% (p = 0.029).

CONCLUSION

Nodal response to NAT is an independent prognostic factor for survival and pattern of failure. cN3c breast cancer patients with SCLN cCR and ALN pCR after NAT are potentially curable. A cumulative SCV dose of ≥60 Gy is positively associated with improved OS, especially in patients of SCLN without achieving cCR. Our data supports the perspective of optimizing radiotherapeutic strategy based on nodal response.