All-in-One Online Radiotherapy for Nasopharyngeal Carcinoma: Preliminary Results of Treatment Time, Contouring Accuracy, Treatment Plan Quality and Patient Compliance

PURPOSE/OBJECTIVE(S)

To explore the feasibility of Fan-beam CT (FBCT)-based all in one (AIO) online workflow for nasopharyngeal carcinoma (NPC) in radical radiotherapy setting, and to preliminarily describe the timing of different steps in the process, contouring accuracy of regions of interest (ROIs), target coverage, organs at risk (OARs) dose and patient compliance.

MATERIALS/METHODS

From March 16, 2022 to January 04, 2023, 25 NPC patients (22/25 diagnosed as phase III/IV disease according to 8th edition of the AJCC/UICC staging system) consecutively treated with AIO radiotherapy were prospectively enrolled. All patients received mask fixation and MRI simulation scan in advance. Primary gross tumor volume (GTVp) of nasopharynx was automatically delineated by AI and edited manually on MRI images. AIO online workflow started with an integrated KV-level CT in a CT-integrated linear accelerator. After that GTVp was registrated to CT images and other ROIs was contoured automatically and then modified manually as needed. Subsequently automatic treatment plan was calculated and optimized until the dose of target and OARs was evaluated satisfactory by physicians and physicists. Finally, treatment was delivered using volumetric modulated arc treatment (VMAT), with prescribed dose of 6996 cGy/ 33 fractions to the GTVp.

RESULTS

Twenty-four patients (24/25, 96%) completed the AIO radiotherapy workflow successfully, with average treatment time of 28.3 min (range: 19.9-42.4 min). the AI-assisted ROIs automatically contouring took 1.55 min in average (range: 1.32-1.77 min), with an average DICE of 97.7% compared with modified contouring, and the average DICE was 95.7% for clinical tumor volume 1 (CTV1), 88.6% for CTV2, 73.6% for GTVn (cervical lymph node), 99.3% for 30 OARs. The automatic treatment plan averagely needed 3.5 min, and the pass rate of radiotherapy planning was 91.7% (22/24). The target coverage for PTVs for GTVp, CTV1, and CTV2 was 99.3%, 99.8%, 98.0% respectively. As for the dose of OARs, the average Dmax of brainstem was 5,583cGy; the Dmax of spinal cord was 3,467cGy; the Dmean of parotid was 3,285 cGy. The average monitor units of all patients was 643 MU and the delivery took 2.93 min. Patient compliance with respect to AIO workflow and total treatment time was excellent.

CONCLUSION

The AIO online radiotherapy was promising for NPC patients, with clinically acceptable AI assisted ROIs contouring and treatment planning, as well as favorable patient compliance to the AIO online workflow.

First Implementation of Full-Workflow Automation for Online Adaptive Radiotherapy of Nasopharyngeal Carcinoma

PURPOSE/OBJECTIVE(S)

The aim of this work is to established the technical characteristics and implementation procedures of an artificial intelligence (AI)-powered radiotherapy workflow that enables full-process automation for online adaptive radiotherapy (ART); and evaluate its feasibility and performance implemented for ART of nasopharyngeal carcinoma (NPC).

MATERIALS/METHODS

This single center, prospective study has been approved by the ethical committee of the institution. The online ART workflow was developed based on a CT-integrated linear accelerator. During the course of radiotherapy, the patient underwent daily pre-treatment fan-beam CT (FBCT) scan. Then the FBCT was automatically registered to the original planning CT and used to assess the need for the patient to implement ART according to radiation oncologist's discretionary. The online ART workflow incorporates critical radiotherapy procedures from re-simulation, auto-segmentation by integrating image fusion and deep learning method, auto-replanning, beam delivery, and in vivo quality assurance (QA) into one scheme, while the patient is on the treatment couch during the whole process.

RESULTS

From 2th April 2022 to 5th January 2023, 20 patients with newly-diagnosed, non-metastatic NPC were enrolled in this study. Only one-time online ART was performed for each patient, because that the appropriate timing for triggering online ART was explored in parallel with this study. According to radiation oncologists' discretionary, the median fraction for performing online ART was at 21 fractions (interquartile range, 19-24 fractions). All patients were well tolerated and successfully completed the treatment. For tumor targets contouring, minor revisions were required for automated contours of the primary gross tumor volume (GTVp) and clinical target volumes (CTVs, including CTV1 and CTV2), with the mean DSC between before and after revision of 0.91±0.042, 0.94 ± 0.042 and 0.91 ± 0.061, respectively; and much more revisions for the automated contours of cervical lymph nodes GTV (GTVn), with the mean DSC of 0.74 ± 0.28. The automated contours of normal tissues were clinically acceptable with little modifications. Median time consuming for auto-segmentation and revision was 9.5 minutes (min). For treatment planning, 18 automated plans (90%) were passed at their first auto-optimization and two plans (10%) were passed after further optimization of the dose coverage of CTVs by physicist; and the median time consuming for auto-planning was 6.2 min. Time consuming for other procedures were as follows: re-simulation, 2.3 min; plan evaluation, 3.3 min; beam delivery, 4.6 min; and the duration of the entire process was 25.9 min, range from 19.4 min to 32.5 min.

CONCLUSION

We successfully established an AI-powered online ART workflow for adaptive radiotherapy of NPC, and confirmed that current auto-segmentation and auto-replanning methods are powered enough to support the clinical application of its online ART.

Advances in health-promoting effects of natural polysaccharides: Regulation on Nrf2 antioxidant pathway

Natural polysaccharides (NPs) possess numerous health-promoting effects, such as liver protection, kidney protection, lung protection, neuroprotection, cardioprotection, gastrointestinal protection, anti-oxidation, anti-diabetic, and anti-aging. Nuclear factor erythroid 2-related factor 2 (Nrf2) antioxidant pathway is an important endogenous antioxidant pathway, which plays crucial roles in maintaining human health as its protection against oxidative stress. Accumulating evidence suggested that Nrf2 antioxidant pathway might be one of key regulatory targets for the health-promoting effects of NPs. However, the information concerning regulation of NPs on Nrf2 antioxidant pathway is scattered, and NPs show different regulatory behaviors in their different health-promoting processes. Therefore, in this article, structural features of NPs having regulation on Nrf2 antioxidant pathway are overviewed. Moreover, regulatory effects of NPs on this pathway for health-promoting effects are summarized. Furthermore, structure-activity relationship of NPs for health-promoting effects by regulating the pathway is preliminarily discussed. Otherwise, the prospects on future work for regulation of NPs on this pathway are proposed. This review is beneficial to well-understanding of underlying mechanisms for health-promoting effects of NPs from the view angle of Nrf2 antioxidant pathway, and provides a theoretical basis for the development and utilization of NPs in promoting human health.

[Application progress of home self-sampling for human papillomavirus and human immunodeficiency virus testing]

Self-sampling is a method by which the subject collects the own specimens for disease detection. It has the advantages of strong privacy, convenient and simple operation, free time and place, etc. It can improve the compliance of people in remote areas, affected by traditional concepts, limited by working hours and underdeveloped transportation and medical treatment to participate in disease detection and screening. With the development of "Internet+health care" and "Internet+nursing service", home-based self-sampling testing will become a developing situation for disease detection and screening. Human immunodeficiency virus and Human papillomavirus infection bring a heavy burden to individuals and society. In the absence of effective and widespread primary prevention, secondary prevention, namely "early detection, early diagnosis and early treatment" is an effective measure to control the adverse consequences. At present, there are many researches on HPV and HIV self-sampling test, whose test results are highly reliable and highly accepted in the population, and is of great significance for improving the coverage rate of cervical cancer screening and the diagnosis rate of HIV carriers.

[Clinical manifestations of 10 cases of imported human Zika virus disease in Jiangmen city of China]

Objective: To study the clinical manifestations and detection method for imported patients of Zika virus disease. Method: The records of symptoms, signs and laboratory results were collected and analyzed. The specimen of blood, saliva and urine from patients were collected. Results: Two of ten patients had mild fever. The visible cutaneous maculopapular rash of the trunk and extremities was observed in all patients. Seven patients were observed congestive conjunctivitis and only one patient gave an account of itching. No patient had symptoms of myalgia or arthralgia. The laboratory results of patients were normal except two patients had mild leucopenia and another one had thrombocytosis. The Zika virus RNA was detected in urine samples for a longest period. The detection rates of Zika virus RNA from the samples of blood, saliva and urine that collected in seventh day after disease onset were 0, 5, 8 cases, respectively. Conclosion: Epidemiology history, maculopapular rash, congestive conjunctivitis and Zika virus RNA being detected in urine can be considered as the important clinical criterion for making a definite diagnosis as Zika virus disease.

Concordant expression of proto-oncogene promyelocytic leukemia and major histocompatibility antigen HLA class I in human hepatocellular carcinoma

Many malignant cancer cells downregulate human leukocyte antigen (HLA) class I antigen expression to evade T cell recognition. However, hepatocellular carcinoma (HCC) is exceptional to the general findings in cancer cells, and the mechanisms for its upregulation remain unclear. It has been reported that promyelocytic leukemia (PML) proto-oncogene controls the transcription of multiple class I antigen presentation genes in murine cancer cells. To find out the functional role of PML gene on the increased HLA class I antigen expression in HCC cells, we analyzed the expression of proto-oncogene PML and multiple class I antigen presentation genes in HCC specimens obtained in China. The results showed concordant changes of proto-oncogene PML and cell surface HLA-A expression in 44 paraffin-embedded HCC tissues. Furthermore, co-upregulated expression of PML genes and class I antigen presentation genes could be detected in 9 of 15 fresh HCC tissues by reverse transcription polymerase chain reaction (RT-PCR). In addition, studies using HCC cell lines showed that increased expression of HLA class I molecules paralleled with PML upregulation were detected in QGY-7701 HCC cell line with RT-PCR, western blot, and flow cytometry, and that the overexpression of exogenous PML in a low-expression class I cell line BEL-7405 could induce the expression of multiple class I antigen-presenting molecule genes and slightly but significantly increase the expression of cell surface HLA class I molecules. In conclusion, the expression of proto-oncogene PML and HLA class I molecules were concordantly upregulated and the expression of PML gene might be one of the mechanisms that leads to the increased expression of class I antigen in HCC.

An immunoelectron microscopic study of peptide substances in the rat neurohypophysis

The ultrastructural localization of peptide substances, such as vasopressin (VP), substance P (SP), enkephalin (ENK) and somatostatin (SRIF), and the distribution of peptidergic nerves in rat neurohypophysis were studied by immunoelectron microscopy. The results show that VP, SP, ENK and SRIF immunoreactive products are located in large granular vesicles (110-150 nm in diameter), at the periphery of microvesicles and on the outer membrane of mitochondria. The VP-, SP-, ENK- and SRIF- containing nerve fibers are distributed at the periphery of capillaries and in the vicinity of pituicytes. VP- and ENK-positive nerve terminals form axo-axonic synapses with negative terminals. VP- and ENK-terminals are pre- or postsynaptic elements. Axo-axonic synapses formed by two SRIF- positive terminals were also found. In addition, ENK- and SP-positive terminals with pituicytes form synaptoid structures respectively. The authors have discovered VP-positive pituicytes for the first time.