"It just made me feel better": qualitative examination of the implementation of a novel virtual psychosocial support program for adolescents with cancer

PURPOSE

Adolescents with cancer routinely report feelings of isolation and exclusion, including from medical decision-making. To address this problem and support adolescents, we designed and implemented the novel, virtual, weekly Teens4Teens peer support group and patient education program. We examined the views of participating adolescents, program guest speakers, and program moderators as they pertained to the need for the program, its feasibility, acceptability, and perceived impact.

METHODS

We recruited all available adolescents, moderators, and guest speakers who participated in Teens4Teens to take part in audio-recorded, semi-structured interviews. Interviews were transcribed, coded, and analyzed using thematic analysis.

RESULTS

We conducted 21 interviews across participant groups. We identified four broad themes: pathways into the Teen4Teens program, Teens4Teens implementation capacity, perspectives of the positive impact of Teens4Teens, and suggestions to improve Teens4Teens. These themes described a perceived need for adolescent-centered psychosocial programming in pediatric cancer care, provided lessons on how best to build and apply such a program, and highlighted the value of the program for both adolescents' and clinicians' acceptability, feasibility, and perceived utility.

CONCLUSION

Adolescents, guest speakers, and moderators valued Teens4Teens and made suggestions to improve capacity to routinely implement the program. Adolescent-tailored psychosocial programming, such as Teens4Teens, is positioned to be integrated into clinical care with relative ease and may serve to improve the cancer care experience of adolescents and their families. This study has potential to provide researchers and clinicians with valuable information about the content, design, and delivery of virtual peer support programming for adolescents with cancer.

Dose Painting Radiotherapy Guided by Diffusion-Weighted Magnetic Resonance vs. 18F-FDG-PET/CT in Locoregionally Advanced Nasopharyngeal Carcinoma: A Randomized, Controlled Clinical Trial

PURPOSE/OBJECTIVE(S)

This phase II randomized controlled trial aimed at comparing the efficacy and toxicity of diffusion-weighted magnetic resonance imaging (DWI)-guided dose painting radiotherapy (DP-RT), FDG-PET/CT-guided DP-RT, and conventional MRI-based radiotherapy (RT) in locoregionally advanced nasopharyngeal carcinoma (NPC).

MATERIALS/METHODS

A total of 330 patients with stage III-IVa NPC disease were randomly assigned in a 1:1:1 ratio to receive induction chemotherapy followed by concurrent chemoradiotherapy by DWI-guided DP-RT (group A, n = 110), FDG-PET/CT-guided DP-RT (group B, n = 110), or conventional MRI-based RT (group C, n = 110). All patients received volumetric modulated arc therapy (VMAT). In group A, subvolume GTVnx-DWI (gross tumor volume of nasopharynx in DWI) was defined as the areas within the GTVnx (gross tumor volume of nasopharynx) with an apparent diffusion coefficient (ADC) below the mean ADC (ADC < mean). In group B, subvolume GTVnx-PET (gross tumor volume of nasopharynx in PET images) was defined within GTVnx as the SUV50%max isocontour. The doses to GTVnx-DWI in group A and GTVnx-PET in group B were escalated to 75.2 Gy/32 fx in patients with T1-2 disease and to 77.55 Gy/33 fx in those with T3-4 disease in 2.35 Gy per fraction. In group C, planning gross tumor volume of nasopharynx (PGTVnx) was irradiated at 70.4 to 72.6 Gy/32 to 33 fx in 2.2 Gy per fraction. This trial is registered with chictr.org.cn (ChiCTR2200057476).

RESULTS

Group A and B showed significant higher complete response (CR) rates than group C (100%, 100%, and 96.4% for group A, B and C, respectively, p = 0.036). In groups A, B and C, the 1-year local recurrence-free survival (LRFS) rates were 100%, 100%, and 94.5%, respectively (p = 0.002). The 1-year disease-free survival (DFS) rates were 100%, 99.1%, and 92.7%, respectively (p = 0.001). The 1-year distant metastasis-free survival (DMFS) rates were 100%, 99.1%, and 93.6%, respectively (p = 0.004). The 1-year overall survival (OS) rates were 100%, 100%, and 95.4%, respectively (p = 0.006). Group A and B had significantly higher 1-year LRFS, DFS, DMFS, and OS than those in group C. No significant differences were observed in LRFS, DFS, DMFS and OS between group A and B. Group B (PET/CT group) had a higher incidence of grade 3-4 acute ototoxicity (3.6%) than group A (0%) and group C (0%, p = 0.036). No significant differences in other grade 3-4 acute adverse events and late toxic effects were observed among the three groups, and no patient had grade 5 toxicities. Multivariate analysis showed that dose painting (DWI-guided DP-RT and PET/CT-guided DP-RT vs conventional MRI-based RT) was associated with improved LRFS, DFS, DMFS and OS.

CONCLUSION

Both DWI-guided DP-RT and PET/CT-guided DP-RT plus chemotherapy are associated with improved LRFS, DFS, DMFS and OS compared with conventional MRI-based RT among patients with locoregionally advanced NPC. DWI-guided DP-RT does not increase toxicities, but PET/CT-guided DP-RT has higher incidence of acute ototoxicity.

Puerarin protects against acetaminophen-induced oxidative damage in liver through activation of the Keap1/Nrf2 signaling pathway

Puerarin (Pue) is a kind of isoflavone compound extracted from Pueraria lobata, which has significant antioxidant activity. Excessive use of acetaminophen (APAP) can cause oxidative stress in the liver and eventually lead to acute liver injury. The purpose of this study was to investigate the protective effect and the mechanism of puerarin on APAP-induced liver oxidative damage. In in vitro experiments, puerarin significantly increased the cell activity of HepG2 cells, reduced the ROS accumulation, alleviated the oxidative damage and mitochondrial dysfunction. In in vivo studies, our results showed that puerarin enhanced antioxidant activity and alleviated histopathological damage. Further studies showed that puerarin decreased the expression of Keap1, promoted the nuclear migration of Nrf2, and up-regulated the expression of GCLC, GCLM, HO-1 and NQO1. This study demonstrated that puerarin can protect APAP-induced liver injury via alleviating oxidative stress and mitochondrial dysfunction by affecting the nuclear migration of Nrf2 via inhibiting Keap1.

Targeting of endothelial cells in brain tumours

BACKGROUND

Aggressive brain tumours, whether primary gliomas or secondary metastases, are characterised by hypervascularisation and are fatal. Recent research has emphasised the crucial involvement of endothelial cells (ECs) in all brain tumour genesis and development events, with various patterns and underlying mechanisms identified.

MAIN BODY

Here, we highlight recent advances in knowledge about the contributions of ECs to brain tumour development, providing a comprehensive summary including descriptions of interactions between ECs and tumour cells, the heterogeneity of ECs and new models for research on ECs in brain malignancies. We also discuss prospects for EC targeting in novel therapeutic approaches.

CONCLUSION

Interventions targeting ECs, as an adjunct to other therapies (e.g. immunotherapies, molecular-targeted therapies), have shown promising clinical efficacy due to the high degree of vascularisation in brain tumours. Developing precise strategies to target tumour-associated vessels based on the heterogeneity of ECs is expected to improve anti-vascular efficacy.

Improving Dose Volume Histogram (DVH) Based Analysis of Clinical Outcomes Using Modern Statistical Techniques: A Systematic Answer to Multiple Comparisons Concerns

PURPOSE/OBJECTIVE(S)

DVH constraints are essential in the clinical practice of radiation therapy. Historically, DVH constraints were found through sparse sampling of all possible DVH indices to find one that appeared to be most predictive for clinical toxicity. This approach can lead to inconsistent results among studies and to multiple comparison concerns. We aim to solve both problems by examining a full array of DVH indices using statistical methods that account for strong correlations among DVH indices and incorporate radiobiological knowledge constraints.

MATERIALS/METHODS

We extracted a dense array of V%_D indices from a treatment planning system using ESAPI interface, with V%_D corresponding to the volume fraction irradiated to dose D, or higher. We used Fused Lasso as the base model to compensate for correlations among DVH indices because it applies a penalty on the difference between DVH variables with adjacent dose. The base model was augmented with additional constraints based on radiobiological considerations: the positivity constraint (beta_i > 0) which assumes that any tissue irradiation cannot reduce the risk of toxicity, and monotonicity constraint (beta_i+1 > = beta_i) which assumes that higher dose to a fixed volume fraction cannot be associated with a lower risk of toxicity. We called the hybrid model KC-Lasso (Knowledge Constrained Lasso) and applied it to two clinical examples: grade 2 acute rectal toxicity in conventionally fractionated RT for 79 prostate cancer patients (77.4 Gy + MR based boost to 81-83 Gy) and cardiac toxicity in conventionally fractionated RT for 119 locally advanced Non-small Cell Lung Cancer (NSCLC) patients (Median prescribed dose 62 Gy). We further examined alternative data driven models to determine the importance of knowledge constraints.

RESULTS

KC-Lasso detected two distinct dose thresholds for grade 2 rectal toxicity, at 35 Gy and 78 Gy. A threshold of 51 Gy was detected for reduced overall survival due to cardiac irradiation in NSCLC patients. An examination of KC-Lasso models at varying step size suggested that a single mid-range index can be used as a treatment planning constraint while full model can be used for confirmatory, final plan evaluation. Alternative models which lack knowledge constraints show patterns of negative and isolated coefficients which are difficult to interpret and are not likely to be generalizable.

CONCLUSION

A more systematic approach to the analysis of correlations between DVH constraints and clinical toxicity can lead to greater consistency of results among different studies, better understanding of true dose thresholds and results which are more generalizable.

Hollow mesoporous organosilica nanoparticles reduced graphene oxide based nanosystem for multimodal image-guided photothermal/photodynamic/chemo combinational therapy triggered by near-infrared

Developing a nanosystem that can perform multimodal imaging-guided combination therapy is highly desirable but challenging. In this study, we introduced multifunctional nanoparticles (NPs) consisting of graphene oxide-grafted hollow mesoporous organosilica loaded with the drug doxorubicin (DOX) and photosensitizers tetraphenylporphyrin (TPP). These NPs were encapsulated by thermosensitive liposomes that release their contents once the temperature exceeds a certain threshold. Metal oxide NPs grown on the graphene oxide (GO) surface served multiple roles, including enhancing photothermal efficiency, acting as contrast agents to improve magnetic resonance imaging, increasing the sensitivity and specificity of photoacoustic imaging, and catalysing hydrogen peroxide for the generation of reactive oxygen species (ROS). When locally injected, the HMONs-rNGO@Fe3 O4 /MnOx@FA/DOX/TPP NPs effectively enriched in subcutaneous Hela cell tumour of mice. The photothermal/photodynamic/chemo combination therapy triggered by near-infrared (NIR) successfully suppressed the tumour without noticeable side effects. This study presented a unique approach to develop multimodal imaging-guided combination therapy for cancer.

Reinforcement Learning Powered Station Parameter Optimized Radiation Therapy (SPORT): A Novel Treatment Planning and Beam Delivery Technique

PURPOSE/OBJECTIVE(S)

Conventional intensity modulated radiation therapy (IMRT) with a typical 5-20 fixed beams often does not provide sufficient angular sampling required for conformal dose shaping, whereas current volumetric modulated arc therapy (VMAT) discretizes the angular space into equally spaced control points without considering the differential need for intensity modulation of different angles, leading to undersampling at some angles while oversampling at some other angles. Our goal is to develop a node or station parameter optimized radiation therapy (SPORT) strategy with simultaneously optimized angular sampling and beam modulation by leveraging state-of-the-art reinforcement learning and the unique capability of modern digital LINACs in dose delivery through programmable nodal points.

MATERIALS/METHODS

We developed a SPORT optimization framework, in which, the process of programming control points (or station parameters) was formulated as a stochastic dynamic programming problem, which was solved by a reinforcement learning-based algorithm. On-policy reinforcement learning method, namely, state-action-reward-state-action (SARSA) was integrated with deep convolutional neural network to predict station parameters by utilizing the patient's anatomical structures meanwhile considering the delivery capability of a typical digital LINAC machine. Here, the deep convolutional neural network estimated the state-action value by using the quality of the plan with current station parameters when a next potential station parameter was selected. The state-action value was then updated by SARSA learning. The quality of the plan was quantified by dosimetry constraints. The model was assessed by a retrospective study on a cohort of patients underwent head-and-neck radiation therapy. Dosimetric analysis and delivery efficiency comparisons were used to evaluate the performance of the proposed framework.

RESULTS

Our model was used to generate 16 plans unseen in the original training set. All the plans predicted by our model achieved better dose distributions without violating clinical planning constraints. Moreover, instead of using 4 full standard arcs in the original clinically used plans obtained via manual optimization, the predicted plans only used one full standard arc (about 178 control points) plus boost from a few sub-arcs (less than 30 degrees of gantry angles), which significantly improved the efficiency of the beam delivery. We are in the process of integrating the sub-arcs into the full arc by considering the programmable capability of modern LINACs.

CONCLUSION

We demonstrated that a machine learning-based SPORT framework capable of optimizing the spatial sampling and beam modulation simultaneously for modern radiation therapy. The framework not only significantly improves the quality and efficiency of beam delivery, but also has the potential to be incorporated into current clinical workflow to improve the efficiency of dose planning and delivery.

Patient-Specific 3D CT Images Reconstruction from 2D KV Images Via Vision Transformer-Based Deep-Learning

PURPOSE/OBJECTIVE(S)

In some proton therapy facilities, patient alignment relies on two 2D orthogonal kV images, taken at fixed, oblique angles, as no 3D on-the-bed-imaging is available. The visibility of the tumor in kV images is limited since the patient's 3D anatomy is projected onto a 2D plane, especially when the tumor is behind a high-density structure such as bone. This can lead to a large patient setup error. A solution to this problem is to reconstruct the 3D CT image from the kV images obtained in the treatment position.

MATERIALS/METHODS

An asymmetric autoencoder-like network built with vision-transformer blocks was developed. The data was collected from a head and neck patient: 2 orthogonal kV images (1024X1024 voxels), 1 3D CT with padding (512X512X512) acquired from the in-room CT-on-rails before kVs were taken and 2 digitally-reconstructed-radiograph (DRR) images (512X512) based on the CT. We resampled kV images every 8 voxels and DRR and CT every 4 voxels, thus formed a dataset consisting of 262,144 samples, in which the images had a dimension of 128 for each direction. The value of each voxel in CT was normalized to range 0-1 with a uniform shift of 1000 and a denominator of 4000. For kV and DRR, we ranked all voxels value in an ascending order and normalized the values of the first 80% voxels to range 0-0.8 and the rest to range 0.8-1, thus yielding a quasi-Gaussian distribution, which was favorable by the deep neural networks. We further cropped kV and DRR images with a self-supervised bitmap based on the voxels' gradients. In training, both kV and DRR were utilized, and the encoder was encouraged to learn the same feature maps for kV images and its corresponding DRR images with mean-absolute-error (MAE) as the similarity loss. Then the decoder would reconstruct the 3D CT image from the feature maps of the kV images with the CT-on-rails as ground-truth (gCT) and MAE as the reconstruction loss. In testing, only independent kV images were used. The full-size synthetic CT (sCT) was achieved by concatenating the sCTs generated by the model according to their spatial information. The image quality of the sCT was evaluated using MAE and per-voxel-absolute-CT-number-difference volume histogram (CDVH). The proposed network was implemented with PyTorch deep learning library and both distributed data parallel (DDP) and automatic mixed precision (AMP) were applied to saving memory and accelerating the training speed. We used the AdamW optimizer with β1 = 0.9 and β2 = 0.999 and a cosine annealing learning rate scheduler with an initial learning of 1e-7 and 20 warm-up epochs.

RESULTS

The model achieved a MAE of <40HU and the CDVH showed that <5% of the voxels had a per-voxel-absolute-CT-number-difference larger than 185HU. The profile of a typical gCT slice and its corresponding sCT slice exhibited a high agreement, indicating the high similarity between the gCT and sCT.

CONCLUSION

A patient-specific vision-transformer-based network was developed and shown to be accurate and efficient to reconstruct 3D CT images from kV images.

An Efficient Transformer Model for Synthesizing Dual Energy CT from Single Energy Scanner

PURPOSE/OBJECTIVE(S)

Dual-energy CT can be used to optimize radiation treatment. Recently, deep learning has been demonstrated to synthesize high-energy CT images from low-energy ones for dose reduction and lower CT system burden. As the state-of-the-art deep learning architecture, the computation burden of Transformer increases quadratically with the feature size, making the model training resource-demanding or even infeasible. Here, we introduce an efficient transformer for the balance between CT image synthesis quality and computational burden.

MATERIALS/METHODS

The model is a U-shape deep neural network with encoders and decoders built by Transformer blocks. The model input is low-energy 100kVp CT image and the output is high-energy 140kVp one. Each block has a Self Channel Correlation Unit (SCCU) and a Self Spatial Attention Unit (SSAU). Local shortcuts are applied for both units. Under-sampling operation achieved by pixel shuffling is used to obtain multi-scale feature maps, and the transformer block is applied on each feature scale. Symmetric skip connection sending features from shallow layers to deep layers, thus an additional 1 × 1 convolution is used for feature fusion in each decoder. In a SCCU, the feature is first mapped to one Query, one Key, and one Value. Then the Query and the Key tensors perform matrix multiplication to compute cross covariance of feature channels. The channel correlation score can be obtained by normalization of the covariance, and it is used to weight the Value tensor. As a result, the model complexity only increases linearly with the feature size. Besides the channel weighting, we enhance spatial information using SSAU, where the feature is mapped to two tensors. One tensor after activation is used to point-wisely calibrate another tensor. Additional Transformer blocks are cascaded to the last decoder for feature refinement. Because of the structure similarity of low- and high-energy CT images, a global shortcut is used to ease model training. Clinical iodine contrast-enhanced dual energy CT image datasets of 19 patients are used in this study. The dual-energy scanning is performed by a SOMATOM Definition Flash DECT scanner. We split the datasets into training dataset of 15 patients, validation dataset of 1 patient, and testing dataset of 3 patients. The image size is 512 × 512 with pixel size 0.5 × 0.5 mm2.

RESULTS

The U-Net model with 1.95M parameters and 44.87G FLOPS achieved the averaged PSNR value of 44.55 dB (s.t.d. 1.34) and averaged RMSE value of 0.0060 (s.t.d. 0.001). In comparison, our efficient Transformer with 1.408M parameters and 31.375G FLOPS achieved the averaged PSNR value of 44.78 dB (s.t.d. 1.37) and RMSE value of 0.0059 (s.t.d. 0.001), demonstrating our model has better performance with small model size and less computation.

CONCLUSION

The efficient Transformer model allows high-resolution CT image synthesis with small model scale and computation burden from low-energy CT image.

Morin protects chicks with T-2 toxin poisoning by decreasing heterophil extracellular traps, oxidative stress and inflammatory response

1. Fusarium tritici widely exists in a variety of grain feeds. The T-2 toxin is the main hazardous component produced by Fusarium tritici, making a serious hazard to poultry industry. Morin, belonging to the flavonoid family, can be extracted from mulberry plants and possesses anticancer, antioxidant and anti-inflammatory compounds, but whether morin protects chicks with T-2 toxin poisoning remains unclear. This experiment firstly established a chick model of T-2 toxin poisoning and then investigated the protective effects and mechanism of morin against T-2 toxin in chicks.2. The function of liver and kidney was measured by corresponding alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), blood urea nitrogen (BUN), creatinine (Cre) and uric acid (UA) kits. Histopathological changes were observed by haematoxylin-eosin staining. The status of oxidative stress was measured by MDA, SOD, CAT, GSH and GSH-PX kits. The mRNA levels of TNF-α, COX-2, IL-1β, IL-6, caspase-1, caspase-3 and caspase-11 were measured by quantitative real-time PCR. Heterophil extracellular trap (HET) release was analysed by immunofluorescence and fluorescence microplate.3. The model with T-2 toxin poisoning in chicks was successfully established. Morin significantly decreased T-2 toxin-induced ALT, AST, ALP, BUN, Cre and UA, and improved T-2 toxin-induced liver cell rupture, liver cord disorder and kidney interstitial oedema. Oxidative stress analysis showed that morin ameliorated T-2 toxin-induced damage by reducing malondialdehyde (MDA), increasing superoxide dismutase (SOD), catalase (CAT), glutathione (GSH) and glutathione peroxidase (GSH-PX). The qRT-PCR analysis showed that morin reduced T-2 toxin-induced mRNA expressions of TNF-α, COX-2, IL-1β, IL-6, caspase-1, caspase-3 and caspase-11. Moreover, morin significantly reduced the release of T-2 toxin-induced HET in vitro and in vivo.4. Morin can protect chicks from T-2 toxin poisoning by decreasing HETs, oxidative stress and inflammatory responses, which make it a useful compound against T-2 toxin poisoning in poultry feed.

A Machine Learning Method to Predict Pathological Complete Response of Esophageal Cancer after Neoadjuvant Chemoradiotherapy with Clinicohematological Markers and MR Radiomics: A Multi-Center Study

PURPOSE/OBJECTIVE(S)

Nearly 30% of patients with local advanced esophageal cancer achieved pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT), who may benefit from organ-preservation strategy under accurate prediction of pCR. We aimed to develop and validate machine learning models based on clinicohematological markers and MR radiomics to accurately predict pCR of esophageal cancer after nCRT.

MATERIALS/METHODS

In this multi-center study, eligible patients with esophageal cancer who received baseline MR scan (T2-weighted image) and nCRT plus surgery were enrolled between September 2014 and September 2022 at institution 1 (training set) and between December 2017 and August 2021 at institution 2 (testing set). Pre-nCRT and post-nCRT blood test results were collected to calculate hematological markers. Models were constructed by machine learning based on clinicohematological markers and MR radiomics to predict pCR. Area under the curve (AUC) and cut-off analysis were used to evaluate model performances.

RESULTS

Totally 154 patients (81 in the training set and 73 in the testing set) were enrolled. The combined model integrating pre-nCRT monocyte-to-lymphocyte ratio and 6 radiomics features achieved AUC of 0.800 (95% CI 0.671-0.918) in the testing set, with sensitivity of 79.2% (95% CI 62.5%-95.8%), specificity of 83.7% (95% CI 73.5%-93.9%), positive predictive value of 76.0% (95% CI 62.5%-90.0%), and negative predictive value of 89.6% (95% CI 82.0%-95.8%).

CONCLUSION

A machine learning model based on clinicohematological markers and MR radiomics to predict pCR after nCRT for patients with esophageal cancer was developed and validated, providing a novel tool for personalized treatment. It is necessary to further validate in more large datasets.

Polymetastatic Recurrence-Free Survival in Patients with Repeat Oligometastases on the SABR-5 Trial

PURPOSE/OBJECTIVE(S)

To determine polymetastatic recurrence-free survival (PMRFS) in patients with repeat oligometastases (OM) on the SABR-5 trial.

MATERIALS/METHODS

SABR-5 is a prospective, multi-center trial that evaluated the safety of stereotactic ablative radiotherapy (SABR) in patients with 1-5 OM or oligoprogressive lesions. On SABR-5, patients were followed post-SABR according to standardized protocols. Patients with repeat extra-cranial OM after metastasis-directed therapy (MDT; SABR, surgery, or thermoablation) to all initial OM (including those treated before enrolment on SABR-5) were identified. Exclusion criteria included history of multiple primary malignancies and incomplete re-staging. PMRFS was defined as time from presentation of repeat oligometastases to death or presentation of 6 or more progressing metastases, leptomeningeal metastases, lymphangitic carcinomatosis, malignant ascites, or malignant pleural effusion. PMRFS, overall survival (OS), and progression-free survival (PFS) were calculated using the Kaplan-Meier method.

RESULTS

Seventy-six patients with repeat OM were included, of which 44 (58%) received second MDT to all OM. The most common histology in patients who received second MDT was colorectal cancer (10/44 [23%]) and in those who did not was prostate cancer (17/32 [53%]). Patients who did vs. did not receive second MDT had fewer metastases at repeat OM (mean 1.3 vs 2.2; p<0.001) and no difference in time between initial OM and repeat OM (16 vs. 17 months; p = 0.74). For patients who received second MDT, median follow-up from presentation of repeat OM was 2.6 years. Median PFS after first and second MDT were 15 months (95% CI 11-18) and 11 months (95% CI 7-17), respectively. At last follow-up, 22/44 patients (50%) were alive without polymetastatic recurrence. 3-year PMRFS and OS from presentation of repeat OM were 51% (95% CI 33-66%) and 66% (95% CI 47-79%), respectively.

CONCLUSION

Patients presenting with repeat OM after MDT may still have favorable 3-year PMRFS and OS, which may justify exploring aggressive local treatments in this subpopulation. Further randomized trials in this space are needed.

Efficacy and Toxicity of Different Target Volume Delineations of Radiotherapy Based on the Updated RTOG/NRG and EORTC Guidelines in Patients with High Grade Glioma: A Randomized, Controlled Clinical Trial

PURPOSE/OBJECTIVE(S)

Postoperative radiotherapy with concomitant and adjuvant temozolomide (TMZ) is the standard of care for newly diagnosed high grade glioma, but the optimal method for target volume delineations for intensity modulated radiation therapy (IMRT) is still unclear. We hypothesized that compared with the EORTC guidelines, IMRT based on the updated RTOG/NRG guidelines was equally effective, without increasing toxicities for patients with high-grade glioma. The purpose of this randomized phase 2 study was to compare the efficacy and toxicity of IMRT based on different target volume delineations (updated RTOG/NRG versus EORTC guidelines) with concomitant and adjuvant TMZ for patients with high grade glioma.

MATERIALS/METHODS

A total of 302 patients with newly diagnosed high-grade glioma (WHO grade 3-4) were randomly assigned (1:1) to receive postoperative IMRT based on either updated RTOG/NRG guidelines (RTOG/NRG group, n = 151) or EORTC guideline (EORTC group, n = 151), with concomitant and adjuvant TMZ. In the RTOG/NRG group, an initial volume consisting of enhancement, postoperative cavity, plus surrounding edema (or fluid-attenuated inversion recovery [FLAIR] abnormality defined by magnetic resonance imaging [MRI]) and a 2-cm margin received 46 Gy in 23 fractions followed by a boost of 14 Gy in 7 fractions to the area of enhancement plus the cavity and a 2-cm margin. In the EORTC group, a single planning volume was used to deliver 60 Gy in 30 fractions to the area of enhancement and the cavity with a 2-cm margin. The primary end point was overall survival (OS). Secondary end points included progression-free survival (PFS) and toxicities associated with each treatment.

RESULTS

No statistically significant differences were observed between groups for 1-year OS (71.8% for RTOG/NRG group and 69.9% for EORTC group, respectively; P = 0.759) or 1-year PFS (46.7% for RTOG/NRG group and 43.6% for EORTC group, respectively; P = 0.674). Efficacy did not differ by MGMT methylation status. There were no differences in grade 3-4 toxicities (leukopenia, lymphopenia, neutropenia, thrombocytopenia, fatigue, nausea and vomiting) between the two groups. No grade 5 toxicities were observed in both groups. Multivariate analyses showed that tumor MGMT status (methylated vs unmethylated) and WHO grade (grade 3 vs grade 4) were associated with OS and PFS. However, radiation type (RTOG/NRG group vs EORTC), sex, age, and Karnofsky scale did not significantly influence OS or PFS.

CONCLUSION

Compared with EORTC guidelines for postoperative radiotherapy, IMRT based on RTOG/NRG guidelines was equally effective, without increasing toxicities for patients with high-grade glioma. This trial is registered with chictr.org.cn, number ChiCTR2100046667.

High Resolution Imaging with Focused kV X-Rays for Small Animal Radio-Neuromodulation

PURPOSE/OBJECTIVE(S)

High precision radiotherapy for small animal radio-neuromodulation requires conformal treatment to very small targets down to 2.5 mm. A focused kV technique based on novel usage of polycapillary x-ray lenses can focus x-ray beams to <0.2 mm in diameter, which is ideal for such uses. Such application also requires high resolution CT images for treatment planning and setup, which was hard to achieve using conventional x-ray tube. In this work, we demonstrate the feasibility of using a virtual focal spot generated with an x-ray lens to perform high-resolution CBCT acquisition.

MATERIALS/METHODS

The experiment with x-ray lens was set up on an x-ray tabletop system to generate a virtual focal spot. A pinhole image was acquired for the virtual focal spot and compared with the one acquired with the conventional focal spot without the lens. The planar imaging resolution with and without the lens were evaluated using a line pair resolution phantom. The spatial resolution of the two settings were estimated by reconstructing a 0.15-mm wire phantom and comparing its full width half maximum (FWHM). A CBCT scan of a rodent head was also acquired to further demonstrate the improved resolution using the x-ray lens.

RESULTS

Compared to conventional imaging acquisition with a measured x-ray focal spot of 0.395 mm FWHM, the virtual focal spot size was measured at 0.175 mm. The reduction in focal spot size with lens leads to an almost doubled planar imaging resolution and a 26% enhancement in 3D spatial resolution. A realistic CBCT acquisition of a rodent head mimicked the imaging acquisition step for radio-neuromodulation and further showed the improved visualization for fine structures.

CONCLUSION

This work demonstrated that the focused kV x-ray technique was capable of generating small focal spot size of <0.2 mm. The proposed method provides an adaptive imaging platform to acquire x-ray and CBCT images for treatment planning and setup with improved spatial resolution compared to conventional CBCT image acquisition.

Chemoradiotherapy Combined with Nab-Paclitaxel plus Cisplatin in Patients with Locally Advanced Borderline Resectable or Unresectable Esophageal Squamous Cell Carcinoma: A Phase I/II Study

PURPOSE/OBJECTIVE(S)

To evaluate the efficacy and safety of nanoparticle albumin-bound paclitaxel (nab-PTX) plus cisplatin as the regimen of conversional chemoradiotherapy (cCRT) in locally advanced borderline resectable or unresectable esophageal squamous cell carcinoma (ESCC).

MATERIALS/METHODS

Patients with locally advanced ESCC (cT3-4, Nany, M0-1, M1 was limited to lymph node metastasis in the supraclavicular area) were enrolled. All the patients received the cCRT of nab-PTX plus cisplatin. After the cCRT, those resectable patients received esophagectomy; those unresectable patients continued to receive the definitive chemoradiotherapy (dCRT). The locoregional control (LRC), overall survival (OS), progression-free survival (PFS), distant metastasis free survival (DMFS), pathological complete response (pCR), R0 resection rate and adverse events (AEs) were calculated.

RESULTS

A total of 45 patients with ESCC treated from October 2019 to May 2021 were finally included. The median follow-up time was 30.3 months. The LRC, OS, EFS, DMFS at 1and 2 years were 81.5%, 86.6%, 64.3%, 73.2% and 72.4%, 68.8%, 44.8%, 52.7% respectively. 21 patients (46.7%) received conversional chemoradiotherapy plus surgery (cCRT+S). The pCR rate and R0 resection rate were 47.6% and 84.0%. The LRC rate at 1 and 2 years were 95.0%, 87.1% in cCRT+S patients and 69.3%, 58.7% in dCRT patients respectively (HR, 5.14; 95% CI, 1.10-23.94; P = 0.021). The OS rate at 1 and 2 years were 95.2% and 84.2% in resectable patients compared to 78.8% and 54.4% in unresectable patients (HR, 3.41; 95% CI, 1.10-10.61; P = 0.024). The toxicities during chemoradiotherapy were tolerated, the most common grade 3-4 toxicities were radiation esophagitis (15.6%).

CONCLUSION

Nab-PTX plus cisplatin were effective and safe as the regimen of conversional chemoradiotherapy of ESCC. The patients receiving conversional chemoradiotherapy plus surgery (cCRT+S) were prone to have a better survival.

Multi-Institutional Report of Re-Irradiation for Recurrent High-Grade Glioma

PURPOSE/OBJECTIVE(S)

Significant heterogeneity exists with regards to prior published reports of re-irradiation (re-RT) in patients with recurrent high grade glioma (HGG). A multi-institutional database of 10 academic centers across the United States was created to analyze prognostic outcomes for re-RT for recurrent HGG, which included WHO Grade III and Grade IV tumors.

MATERIALS/METHODS

Patients with HGG who had initially received standard radiotherapy (RT) and were subsequently treated with a course of re-RT at recurrence were included in the study. Factors assessed to delineate a significant association with overall survival (OS) and toxicity included age, KPS, number of relapses, dose, use of bevacizumab (BEV) or temozolomide (TMZ), time from prior RT, histology, RT target, re-RT target> 5cm and extent of resection, and MGMT methylation status. The Kaplan-Meier Method was used to estimate OS. Cox proportional hazards regression models were used to identify factors associated with OS. Toxicity outcomes were assessed using logistic regression. Significance was assumed if p<0.05. Data management and decision management software were used for all analyses.

RESULTS

Between 2001 and 2022, 280 patients from 10 academic institutions were treated with re-RT for diagnosis of recurrent HGG. 133 patients (71.1%) had a histologic glioblastoma (GBM) at the time of re-RT, with the remainder having Grade 3 gliomas. Median dose delivered at re-RT was 47 Gy BED10 (IQR 47 - 53 Gy BED10), with the most common regimen being 35 Gy in 10 fractions. 83 patients (56%) had GTV greater than 5 cm treated with re-RT. 183 patients (79%) received concurrent systemic therapy, including 95 (41%) who received concurrent TMZ and 86 (45%) who received concurrent BEV. Median OS for the entire cohort was 10 months. Increasing dose at re-RT was associated with improved OS (OR 0.80 95% CI 0.67-0.95, p = 0.10 per 10 Gy BED10), as was dose greater than 47 Gy BED10, which is equivalent to 35 Gy in 10 fractions (OR 0.70, 95% CI 0.54-0.91). Concurrent TMZ was also associated with improved OS (OR 0.68, 95% CI 0.46-0.83, p < 0.01). 32/143 (22%) patients evaluable for toxicity experienced Grade 2 or greater adverse radiation effect (ARE). Use of BEV was associated with decreased toxicity (OR 0.45, 95% CI 0.21-0.98, p = 0.05). Dose at re-RT (OR 1.07 per 10 Gy BED10, p = 0.78), a GTV > 5cm (OR 1.39, p = 0.44), and the use of concurrent TMZ (OR 1.90, p = 0.10) were not associated with Grade 2 or greater ARE.

CONCLUSION

Higher dose of re-RT and use of concurrent TMZ led to improved OS in recurrent HGG patients without an associated increased rate of ARE. Use of BEV decreased the likelihood of Grade 2 or greater ARE in the re-RT setting for these recurrent HGG patients.

Measurement-induced entanglement and teleportation on a noisy quantum processor

Measurement has a special role in quantum theory1: by collapsing the wavefunction, it can enable phenomena such as teleportation2 and thereby alter the 'arrow of time' that constrains unitary evolution. When integrated in many-body dynamics, measurements can lead to emergent patterns of quantum information in space-time3-10 that go beyond the established paradigms for characterizing phases, either in or out of equilibrium11-13. For present-day noisy intermediate-scale quantum (NISQ) processors14, the experimental realization of such physics can be problematic because of hardware limitations and the stochastic nature of quantum measurement. Here we address these experimental challenges and study measurement-induced quantum information phases on up to 70 superconducting qubits. By leveraging the interchangeability of space and time, we use a duality mapping9,15-17 to avoid mid-circuit measurement and access different manifestations of the underlying phases, from entanglement scaling3,4 to measurement-induced teleportation18. We obtain finite-sized signatures of a phase transition with a decoding protocol that correlates the experimental measurement with classical simulation data. The phases display remarkably different sensitivity to noise, and we use this disparity to turn an inherent hardware limitation into a useful diagnostic. Our work demonstrates an approach to realizing measurement-induced physics at scales that are at the limits of current NISQ processors.

VvBBX44 and VvMYBA1 form a regulatory feedback loop to balance anthocyanin biosynthesis in grape

Anthocyanins are essential for the quality of perennial horticultural crops, such as grapes. In grapes, ELONGATED HYPOCOTYL 5 (HY5) and MYBA1 are two critical transcription factors that regulate anthocyanin biosynthesis. Our previous work has shown that Vitis vinifera B-box protein 44 (VvBBX44) inhibits anthocyanin synthesis and represses VvHY5 expression in grape calli. However, the regulatory mechanism underlying this regulation was unclear. In this study, we found that loss of VvBBX44 function resulted in increased anthocyanin accumulation in grapevine callus. VvBBX44 directly represses VvMYBA1, which activates VvBBX44. VvMYBA1, but not VvBBX44, directly modulates the expression of grape UDP flavonoid 3-O-glucosyltransferase (VvUFGT). We demonstrated that VvBBX44 represses the transcriptional activation of VvUFGT and VvBBX44 induced by VvMYBA1. However, VvBBX44 and VvMYBA1 did not physically interact in yeast. The application of exogenous anthocyanin stimulated VvBBX44 expression in grapevine suspension cells and tobacco leaves. These findings suggest that VvBBX44 and VvMYBA1 form a transcriptional feedback loop to prevent overaccumulation of anthocyanin and reduce metabolic costs. Our work sheds light on the complex regulatory network that controls anthocyanin biosynthesis in grapevine.

[The application of ultrasound in the diagnosis of small bowel volvulus in adults]

Objective: To analyze the ultrasound characteristics of small bowel volvulus among adults and to investigate the value of ultrasound in the diagnosis of small bowel volvulus. Methods: Totally 34 adults with small bowel volvulus confirmed by clinical diagnosis or surgery and who underwent ultrasound examination at Peking Union Medical College Hospital from August 2017 to October 2022 were enrolled, including 19 males and 15 females, aged (55.0±21.8) years (range: 19 to 94 years). The clinical characteristics, CT images and ultrasound images of the patients were retrospectively reviewed, and the ultra, sound features of small bowel volvulus and its diagnostic efficacy were analyzed. Results: Abdominal pain was the typical clinical symptom of all patients. Other symptoms included 21 cases of abdominal distension, 19 cases of nausea and vomiting, and 13 cases of cessation of passage of stool or flatus. Eight patients had signs of peritonitis and 22 patients had abnormal bowel sounds. Twenty patients had a history of abdominal surgery. Twenty-seven patients underwent surgery for intestinal obstruction, and the remaining 7 patients improved after conservative treatment. All cases were evaluated by ultrasound, 11 cases showed a "whirl sign" and were diagnosed as small bowel volvulus, the diagnostic accuracy rate was 32.4% (11/34), ultrasound simultaneously diagnosed intestinal obstruction in 21 cases, 17 cases of abdominal effusion, 4 cases of intestinal wall thickening, 2 cases of abdominal mass, 1 case of intussusception, 1 case of right sided inguinal hernia. CT and ultrasound had a consistent positive discovery in 88.2% (30/34) of all the patients. Conclusion: Ultrasound is valuable in the diagnosis of small bowel volvulus and the evaluation of complications.

The Impact of Intra-Fraction Bowel Motion on Luminal Gastrointestinal Organ at Risk Dosimetry When Using Stereotactic Adaptive Radiotherapy for Abdominal Malignancies

PURPOSE/OBJECTIVE(S)

Daily online adaptive radiotherapy (ART) provides inter-fraction motion management of the luminal gastrointestinal (GI) structures when delivering abdominal SBRT. One potential drawback of ART is the time-consuming process, and intra-fraction GI changes from completion of the ART process to the end of treatment delivery have not been thoroughly evaluated. We explored intra-fraction bowel motion for patients receiving abdominal stereotactic adaptive radiotherapy (sART) MATERIALS/METHODS: Six patients with abdominal malignancies treated with CT-guided sART on a prospective feasibility trial had additional CBCT's acquired post-treatment (pTx-CBCT). All patients were prescribed to 50 Gy/5 fractions (fx), and the constraint for all GI OARs was V33≤0.5 cc. Time from initial CBCT (I-CBCT) used for adaptive planning to pTx-CBCT was collected. The luminal GI OAR (stomach (S), duodenum (D), small bowel (SB), and large bowel (LB)) were retrospectively contoured on pTx-CBCT. The OAR doses were compared between the I-CBCT and pTx-CBCT. The adaptive plan (PA) and initial plan (PI) doses were overlayed on the pTx-CBCT contours. The PA pTx-CBCT OAR doses were then compared to the PI pTx-CBCT OAR doses. A Boolean OAR structure of all GI OARs was evaluated to remove potential differences in structure definitions between providers. The T-test was used to compare differences in instances of D0.5cc ≥ 33 and 50 Gy. Patient charts were reviewed for grades (G) ≥ 3 toxicity.

RESULTS

Thirty fractions (fx) of sART were delivered and pTx-CBCT were acquired in 26 fx. Mean time from I-CBCT to pTx-CBCT acquisition was 66 min (38-98 min). On average at 0.5 cc the PA overdosed the S by 1.74 Gy based on pTx-CBCT anatomy compared to 2.35 Gy by the PI, the D by 0.47 Gy (PA) vs .84 Gy (PI), the SB by 1.14 Gy (PA) vs 1.43 Gy (PI), and the LB by 0.13 Gy (PA) vs 0.60 Gy (PI). The dose to the Boolean OAR structure was on average 2.51 Gy/fx higher than expected when overlaying the PA on the pTx-CBCT compared to 3.38 Gy/fx higher when overlaying the PI on the pTx-CBCT. There was no significant difference in the instance of the PA exceeding D0.5 cc ≥33 Gy vs the PI (p = 0.083), but the PA significantly reduced the instances of D0.5cc≥50 Gy (p = 0.001) compared to the PI. No patient experienced G≥3 toxicity at a median follow-up of 8 months (3-12).

CONCLUSION

These data demonstrate sART led to a significant decrease in dose to GI OARs, particularly for prescription dose or greater, even after accounting for intra-fractional bowel motion. While both the PI and the PA violated the V33 luminal GI OAR constraint in approximately ½ of pTx-CBCTs, the fraction of OARs receiving at least 50 Gy was significantly higher when overlaying the PI compared to the PA. While no G3 toxicities were reported in this small cohort, further studies are needed to characterize if the increased dose to GI OARs over the expected dose is clinically significant.

Effects of magnesium-modified biochar on antibiotic resistance genes and microbial communities in chicken manure composting

Abatement of antibiotic resistance genes (ARGs) in livestock manure by composting has attracted attention. This study investigated the effect of adding magnesium-modified biochar (MBC) on ARGs and microbial communities in chicken manure composting. Twelve genes for tetracyclines, sulfonamides, and macrolides, and mobile genetic elements were measured in the compost pile. The results showed that after 45 days of the composting, the treatment groups of MBC had longer high temperature periods, significantly higher germination indices (GI) and lower phytotoxicity. There were four major dominant phyla (Firmicutes, Actinobacteriota, Proteobacteria, and Bacteroidota) in the compost. The abundance of Firmicutes decreased significantly during the compost cooling period; tetracycline resistance genes demonstrated an extremely significant positive correlation with Firmicutes, showing a trend of the same increase and decrease with composting time; tetT, tetO, tetM, tetW, ermB, and intI2 were reduced in the MBC group; the total abundance of resistance genes in the 2% MBC addition group was 0.67 times that of the control; Proteobacteria and Chloroflexi were also significantly lower than the other treatment groups. Most ARGs were significantly associated with mobile genetic elements (MGEs); MBC can reduce the spread and diffusion of ARGs by reducing the abundance of MGEs and inhibiting horizontal gene transfer (HGT).

A novel bivalent anti-c-MET/PD-1 bispecific antibody exhibits potent cytotoxicity against c-MET/PD-L1-positive colorectal cancer

Previously, we generated a novel bispecific antibody (BsAb) simultaneously targeting both c-MET and PD-1 (PDCD1), which can bridge T cells and c-MET positive tumor cells. However, the specific mechanisms and antitumor activities of the BsAb against c-MET/PD-L1 (CD274) positive colorectal cancer (CRC) is not completely understood. In this study, in addition to the tumor intrinsic mechanism investigation with molecular biology assay in vitro, a humanized mouse model was used to evaluate antitumor activity of the BsAb in vivo. The BsAb could inhibit c-MET/PD-L1+ CRC cell migration and show strong antitumor activity against HCT116 tumors in mice, potentially by inducing the degradation of c-MET protein in a dose and time-dependent manner. The BsAb could suppress the phosphorylation of c-MET downstream proteins GRB2-associated-binding protein 1 (Gab1) and focal adhesion kinase (FAK). Considering the tumor extrinsic mechanism, the BsAb may promote phagocytosis of macrophage. Furthermore, the level of plasma exosomal-c-MET/PD-L1 is able to distinguish CRC patients from healthy controls. In summary, the BsAb exhibited potent anti-tumor activities by two distinguished mechanisms: inhibition of c-MET signal transduction and promotion of macrophage-mediated phagocytosis. Our BsAb may provide a novel therapeutic agent for patients with c-MET/PD-L1+ CRC, and the status of exosomal-c-MET/PD-L1 can serve as a biomarker to predict responsiveness to treatment of our BsAb.

A Model of Type II Collagen-Induced Spondylitis and Arthritis in F1 Hybrid Male Mice

In this study, we tested a new model of ankylosing spondylitis in order to determine its histological and radiological features needed to investigate peripheral arthritis, spondylitis, and formation of the new bone tissues. F1 hybrid male mice (BALB/c×DBA/1), a progeny of spondylitis-susceptible BALB/c male mice and rheumatoid arthritis-susceptible DBA/1 female mice, were immunized intraperitoneally with bovine type II collagen (CII) mixed with adjuvant dimethyldioctadecylammonium bromide. Radiological and histological studies were performed at the peak of swelling, redness, and stiffness. The incidence of peripheral arthritis and spondylitis induced by CII in F1 hybrid mice were 66 and 62%, respectively. X-ray examination revealed bone erosion and spondylitis in the peripheral joints, as well as the formation of new bone tissues in the coccygeal vertebrae and between LIII and LIV vertebrae. The histological study showed lymphocyte and plasma cell infiltration, capillary dilation, congestion, and endochondral ossification of the lumbar vertebrae. This novel model of CII-induced spondylitis in F1 hybrid mice provoked axial and peripheral arthritides inducing chronic inflammation. In this model, the formation of new bone tissue in the stiff spine is characterized by endochondral ossification. The advanced model is an additional and valuable tool for investigation of the autoimmune reactions in spondylitis.

STAT3 promotes migration and invasion of cholangiocarcinoma arising from choledochal cyst by transcriptionally inhibiting miR200c through the c-myb/MEK/ERK signaling pathway

Signal transducer and activator of transcription 3 (STAT3) have been highlighted in cancer regulation. Its roles in Cholangiocarcinoma (CCA) arising from the choledochal cyst (CC) were unclear. Here, we attempted to elucidate the roles of STAT3 in CCA-CC and explore its mechanism. A total of 20 patients with CCA arising from CC, that underwent CC excision in the infant stage were included. The expressions of STAT3, miR200c and c-Myb in clinical samples were assessed by RT-qPCR and/or western blot. Their expression correlations in tumor tissues were evaluated by Pearson correlation analysis. Their roles in CCA cell migration and invasion were investigated by gene silence using siRNA or miRNA inhibitor mediated approach and MEK activator. The expression levels of EMT, metastasis and MEK/ERK pathway-related proteins were checked by western blot. The high expressions of STAT3 and c-Myb, and low expression of miR200c were detected in CCA samples. We defined the transcription inhibition of STAT3 in miR200c expression and the negative correlation between miR200c and c-Myb expression. Silence of STAT3 increased miR200c expression and retarded the migration and invasion of CCA cells, accompanied by decreased levels of Vimentin, N-cadherin, MMP2 and MMP9, and elevated expression of E-cadherin, resulting in inactivating MEK/ERK pathway. MiR200c inhibitor reversed the changes induced by STAT3 silence, which was restored by si-c-Myb. MEK activator significantly reversed the inactivation of the MEK/ERK pathway induced by si-STAT3+miR200c inhibitor+si-c-Myb. In summary, the silence of STAT3 suppressed metastasis and progression of CCA cells by regulating miR200c through the c-Myb mediated MEK/ERK pathway, suggesting STAT3 is the effective target for CCA arising from CC.