Transport of per-/polyfluoroalkyl substances from leachate to groundwater as affected by dissolved organic matter in landfills

The transport of per- and polyfluoroalkyl substances (PFAS) from landfill leachate to surrounding soil and groundwater poses a threat to human health via the food chain or drinking water. Studies have shown that the transport process of PFAS from the solid to liquid phase in the environment is significantly affected by dissolved organic matter (DOM) adsorption. However, the mechanism of PFAS release from landfill solids into leachate and its transport to the surrounding groundwater remains unclear. In this study, we identified the composition of PFAS and DOM components and analyzed the association between DOM components, physicochemical factors, and PFAS concentrations in landfill leachate and groundwater. This study demonstrated that the frequency of PFAS detection in the samples was 100%, and the PFAS concentrations in leachate were greater than in the groundwater samples. Physicochemical factors, such as ammonium-nitrogen (NH4+-N), sodium (Na), calcium (Ca), DOM components C4 (macromolecular humic acid), SUVA254 (aromatic component content), and A240-400 (humification degree and molecular weight), were strongly correlated with PFAS concentrations. In conclusion, PFAS environmental risk management should be enhanced in landfills, especially in closed landfills, or landfills that are scheduled to close in the near future.

Dynamics of magnetization at infinite temperature in a Heisenberg spin chain

Understanding universal aspects of quantum dynamics is an unresolved problem in statistical mechanics. In particular, the spin dynamics of the one-dimensional Heisenberg model were conjectured as to belong to the Kardar-Parisi-Zhang (KPZ) universality class based on the scaling of the infinite-temperature spin-spin correlation function. In a chain of 46 superconducting qubits, we studied the probability distribution of the magnetization transferred across the chain's center, [Formula: see text]. The first two moments of [Formula: see text] show superdiffusive behavior, a hallmark of KPZ universality. However, the third and fourth moments ruled out the KPZ conjecture and allow for evaluating other theories. Our results highlight the importance of studying higher moments in determining dynamic universality classes and provide insights into universal behavior in quantum systems.

Deteriorated bone microarchitecture caused by sympathetic overstimulation in pheochromocytoma and paraganglioma

PURPOSE

Despite the potentially destructive effect of sympathetic activity on bone metabolism, its impact on bone microarchitecture, a key determinant of bone quality, has not been thoroughly investigated. This study aims to evaluate the impact of sympathetic activity on bone microarchitecture and bone strength in patients with pheochromocytoma and paraganglioma (PPGL).

METHODS

A cross-sectional study was conducted in 38 PPGL patients (15 males and 23 females). Bone turnover markers serum procollagen type 1 N-terminal propeptide (P1NP) and β-carboxy-terminal crosslinked telopeptide of type 1 collagen (β-CTX) were measured. 24-h urinary adrenaline (24hUE) and 24-h urinary norepinephrine levels (24hUNE) were measured to indicate sympathetic activity. High-resolution peripheral quantitative computed tomography (HR-pQCT) was conducted to evaluate bone microarchitecture in PPGL patients and 76 age-, sex-matched healthy controls (30 males and 46 females). Areal bone mineral density (aBMD) was measured by dual-energy X-ray absorptiometry (DXA) simultaneously.

RESULTS

PPGL patients had a higher level of β-CTX. HR-pQCT assessment revealed that PPGL patients had notably thinner and more sparse trabecular bone (decreased trabecular number and thickness with increased trabecular separation), significantly decreased volume BMD (vBMD), and bone strength at both the radius and tibia compared with healthy controls. The deterioration of Tt.vBMD, Tb.Sp, and Tb.1/N.SD was more pronounced in postmenopausal patients compared with the premenopausal subjects. Moreover, subjects in the highest 24hUNE quartile (Q4) showed markedly lower Tb.N and higher Tb.Sp and Tb.1/N.SD at the tibia than those in the lowest quartile (Q1). Age-related bone loss was also exacerbated in PPGL patients to a certain extent.

CONCLUSIONS

PPGL patients had significantly deteriorated bone microarchitecture and strength, especially in the trabecular bone, with an increased bone resorption rate. Our findings provide clinical evidence that sympathetic overstimulation may serve as a secondary cause of osteoporosis, especially in subjects with increased sympathetic activity.

Application of deep learning in radiation therapy for cancer

In recent years, with the development of artificial intelligence, deep learning has been gradually applied to clinical treatment and research. It has also found its way into the applications in radiotherapy, a crucial method for cancer treatment. This study summarizes the commonly used and latest deep learning algorithms (including transformer, and diffusion models), introduces the workflow of different radiotherapy, and illustrates the application of different algorithms in different radiotherapy modules, as well as the defects and challenges of deep learning in the field of radiotherapy, so as to provide some help for the development of automatic radiotherapy for cancer.

[Clinical application of split liver transplantation: a single center report of 203 cases]

Objective: To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application. Methods: This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis. Results: The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group (χ2=5.560,P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group (χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion: SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Measurements of All-Particle Energy Spectrum and Mean Logarithmic Mass of Cosmic Rays from 0.3 to 30 PeV with LHAASO-KM2A

We present the measurements of all-particle energy spectrum and mean logarithmic mass of cosmic rays in the energy range of 0.3-30 PeV using data collected from LHAASO-KM2A between September 2021 and December 2022, which is based on a nearly composition-independent energy reconstruction method, achieving unprecedented accuracy. Our analysis reveals the position of the knee at 3.67±0.05±0.15  PeV. Below the knee, the spectral index is found to be -2.7413±0.0004±0.0050, while above the knee, it is -3.128±0.005±0.027, with the sharpness of the transition measured with a statistical error of 2%. The mean logarithmic mass of cosmic rays is almost heavier than helium in the whole measured energy range. It decreases from 1.7 at 0.3 PeV to 1.3 at 3 PeV, representing a 24% decline following a power law with an index of -0.1200±0.0003±0.0341. This is equivalent to an increase in abundance of light components. Above the knee, the mean logarithmic mass exhibits a power law trend towards heavier components, which is reversal to the behavior observed in the all-particle energy spectrum. Additionally, the knee position and the change in power-law index are approximately the same. These findings suggest that the knee observed in the all-particle spectrum corresponds to the knee of the light component, rather than the medium-heavy components.

Stable quantum-correlated many-body states through engineered dissipation

Engineered dissipative reservoirs have the potential to steer many-body quantum systems toward correlated steady states useful for quantum simulation of high-temperature superconductivity or quantum magnetism. Using up to 49 superconducting qubits, we prepared low-energy states of the transverse-field Ising model through coupling to dissipative auxiliary qubits. In one dimension, we observed long-range quantum correlations and a ground-state fidelity of 0.86 for 18 qubits at the critical point. In two dimensions, we found mutual information that extends beyond nearest neighbors. Lastly, by coupling the system to auxiliaries emulating reservoirs with different chemical potentials, we explored transport in the quantum Heisenberg model. Our results establish engineered dissipation as a scalable alternative to unitary evolution for preparing entangled many-body states on noisy quantum processors.

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.

Elevated risk of multimorbidity post-COVID-19 infection: protective effect of vaccination

BACKGROUND

It is unclear how the coronavirus disease 2019 (Covid-19) pandemic has affected multimorbidity incidence among those with one pre-existing chronic condition, as well as how vaccination could modify this association.

AIM

To examine the association of Covid-19 infection with multimorbidity incidence among people with one pre-existing chronic condition, including those with prior vaccination.

DESIGN

Nested case-control study.

METHODS

We conducted a territory-wide nested case-control study with incidence density sampling using Hong Kong electronic health records from public healthcare facilities and mandatory Covid-19 reports. People with one listed chronic condition (based on a list of 30) who developed multimorbidity during 1 January 2020-15 November 2022 were selected as case participants and randomly matched with up to 10 people of the same age, sex and with the same first chronic condition without having developed multimorbidity at that point. Conditional logistic regression was used to estimate adjusted odds ratios (aORs) of multimorbidity.

RESULTS

In total, 127 744 case participants were matched with 1 230 636 control participants. Adjusted analysis showed that there were 28%-increased odds of multimorbidity following Covid-19 [confidence interval (CI) 22% to 36%] but only 3% (non-significant) with prior full vaccination with BNT162b2 or CoronaVac (95% CI -2% to 7%). Similar associations were observed in men, women, older people aged 65 or more, and people aged 64 or younger.

CONCLUSIONS

We found a significantly elevated risk of multimorbidity following a Covid-19 episode among people with one pre-existing chronic condition. Full vaccination significantly reduced this risk increase.

Highly sensitive SERS platform for pathogen analysis by cyclic DNA nanostructure@AuNP tags and cascade primer exchange reaction

The capacity to identify small amounts of pathogens in real samples is extremely useful. Herein, we proposed a sensitive platform for detecting pathogens using cyclic DNA nanostructure@AuNP tags (CDNA) and a cascade primer exchange reaction (cPER). This platform employs wheat germ agglutinin-modified Fe3O4@Au magnetic nanoparticles (WMRs) to bind the E. coli O157:H7, and then triggers the cPER to generate branched DNA products for CDNA tag hybridization with high stability and amplified SERS signals. It can identify target pathogens as low as 1.91 CFU/mL and discriminate E. coli O157:H7 in complex samples such as water, milk, and serum, demonstrating comparable or greater sensitivity and accuracy than traditional qPCR. Moreover, the developed platform can detect low levels of E. coli O157:H7 in mouse serum, allowing the discrimination of mice with early-stage infection. Thus, this platform holds promise for food analysis and early infection diagnosis.

Effect of occlusal stabilisation splint with or without arthroscopic disc repositioning on condylar bone remodelling in adolescent patients

The aim of this study was to investigate the treatment effects of a stabilisation splint (SS) with and without arthroscopic disc repositioning (ADR) on condylar bone remodelling in adolescent patients with anterior disc displacement without reduction (ADDwoR). Cone beam computed tomography and magnetic resonance imaging were used to analyse condylar bone remodelling, condyle position, and disc position. Twenty-two temporomandibular joints of 14 patients who underwent ADR (age range 12-20 years; mean follow-up 12.5 ± 7.8 months) and 21 temporomandibular joints of 14 patients who did not undergo ADR (age range 13-20 years; mean follow-up 11.1 ± 5.1 months) were included. The change in bone volume (P < 0.001), rate of bone volume change (P < 0.001), and change in condyle height (P = 0.031) were significantly greater in patients with ADR than in those without ADR. The changes in posterior joint space (P = 0.013), superior joint space (P = 0.020), and ratio of condyle sagittal position (P = 0.013) were significantly greater in patients with ADR than in those without ADR. All discs in patients who underwent ADR and one disc in those who did not undergo ADR were backward repositioned. In conclusion, in adolescent patients with ADDwoR, ADR with SS therapy achieved better condyle and disc position than SS therapy alone, and also induced bone generation.

Application of natural language processing to post-structuring of rectal cancer MRI reports

AIM

To evaluate a natural language processing (NLP) system for extracting structured information from the free-form text of rectal cancer magnetic resonance imaging (MRI) reports written in Chinese.

MATERIALS AND METHODS

A rule-based NLP model that could extract 11 key image features of rectal cancer was constructed using 358 MRI reports of rectal cancer written between 2015 and 2021. Fifty reports written before 2015 and 50 written after 2021 were used as test datasets, and the reference standard was determined by manual extraction of information by two radiologists. The length and reporting rate of image features in pre-2015 and post-2021 datasets, as well as the accuracy, precision, recall, and F1 score of feature extraction by the NLP system, were compared. The time required for the NLP to extract data was compared with that required by the radiologists.

RESULTS

Reports written after 2021 had longer diagnostic impression sections than reports written before 2015. The reporting rate of key imaging features of rectal cancer was 36.55% before 2015 and 79.82% after 2021. The accuracy, precision, recall, and F1 score of NLP for correct extraction of values from reports were 93.82%, 95.63%, 87.06%, and 91.15%, respectively, for pre-2015 reports, and 92.55%, 98.53%, 94.15%, and 96.29%, respectively, for post-2021 reports. NLP generated all the structured information in <1 second.

CONCLUSIONS

The NLP system with rule-based pattern matching achieved rapid and accurate structured processing of rectal cancer MRI reports. MRI reports with structured templates are more suitable for NLP-based extraction of information.

Utility of metagenomic Next-Generation Sequencing for simultaneously detecting pathogens and neoplasms

Objectives

Clinicians often face the challenge of differentially diagnosing febrile patients who are suspected of infectious diseases, since the clinical manifestations of infection and cancer may overlap. A single test that can detect both pathogens and tumor could provide timely and accurate diagnostic clues to aid the treatment and management of these patients.

Methods

We enrolled eight patients to evaluate the utility of metagenomic Next-Generation Sequencing for simultaneously detecting pathogens and neoplasms using body fluids and tissue samples. Patients were selected by the following criteria: 1) Tumor was not considered upon hospitalization, but mNGS testing indicated neoplasm; 2) Tumor was not excluded, but microbial infection was primarily suspected according to initial clinical assessment.

Results

We detected potential pathogens in five patients, three of whom had progressed into critical infections. Moreover, abnormal chromosomal copy numbers were identified in all patients that indicated presence of neoplasms, which were pathologically confirmed.

Conclusions

Although copy number variations do not render a definitive cancer diagnosis, it can prompt clinicians to conduct more focused diagnostic testing for cancer, potentially saving time and cost. As a result, integrating copy number analysis with pathogen detection in mNGS may help establish rapid and accurate diagnosis for febrile patients.

Tumor resistance to anti-mesothelin CAR-T cells caused by binding to shed mesothelin is overcome by targeting a juxtamembrane epitope

Despite many clinical trials, CAR-T cells are not yet approved for human solid tumor therapy. One popular target is mesothelin (MSLN) which is highly expressed on the surface of about 30% of cancers including mesothelioma and cancers of the ovary, pancreas, and lung. MSLN is shed by proteases that cleave near the C terminus, leaving a short peptide attached to the cell. Most anti-MSLN antibodies bind to shed MSLN, which can prevent their binding to target cells. To overcome this limitation, we developed an antibody (15B6) that binds next to the membrane at the protease-sensitive region, does not bind to shed MSLN, and makes CAR-T cells that have much higher anti-tumor activity than a CAR-T that binds to shed MSLN. We have now humanized the Fv (h15B6), so the CAR-T can be used to treat patients and show that h15B6 CAR-T produces complete regressions in a hard-to-treat pancreatic cancer patient derived xenograft model, whereas CAR-T targeting a shed epitope (SS1) have no anti-tumor activity. In these pancreatic cancers, the h15B6 CAR-T replicates and replaces the cancer cells, whereas there are no CAR-T cells in the tumors receiving SS1 CAR-T. To determine the mechanism accounting for high activity, we used an OVCAR-8 intraperitoneal model to show that poorly active SS1-CAR-T cells are bound to shed MSLN, whereas highly active h15B6 CAR-T do not contain bound MSLN enabling them to bind to and kill cancer cells.

Spectral and conformational characteristics of phycocyanin associated with changes of medium pH

C-phycocyanin (C-PC) is the main component of water-soluble light-harvesting complexes (phycobilisomes, PBS) of cyanobacteria. PBS are involved in the absorption of quantum energy and the transfer of electronic excitation energy to the photosystems. A specific environment of C-PC chromophoric groups is provided by the protein matrix structure including protein-protein contacts between different subunits. Registration of C-PC spectral characteristics and the fluorescence anisotropy decay have revealed a significant pH influence on the chromophore microenvironment: at pH 5.0, a chromophore is more significantly interacts with the solvent, whereas at pH 9.0 the chromophore microenvironment becomes more viscous. Conformations of chromophores and the C-PC protein matrix have been studied by Raman and infrared spectroscopy. A decrease in the medium pH results in changes in the secondary structure either the C-PC apoproteins and chromophores, the last one adopts a more folded conformation.

Involvement of GA3-oxidase in inhibitory effect of nitric oxide on primary root growth in Arabidopsis

Both NO and GAs are essential for regulating various physiological processes and stress responses in plants. However, the interaction between these two molecules remains unclear. We investigated the distinct response patterns of Arabidopsis thaliana Col-0 and GA synthesis functional deficiency mutants to NO by measuring root length. To investigate underlying mechanisms, we detected bioactive GA content using UHPLC-ESI-MS/MS, assessed the accumulation of ROS by chemical staining Arabidopsis roots. We also conducted RNA-seq analysis and compared results between Col-0 and ga3ox1, with and without SNP (as NO donor) treatment. Phenotypic results revealed that the inhibitory effect of NO on primary roots of Arabidopsis was primarily mediated by GA3-oxidase, rather than GA20-oxidase or GA2-oxidase. The content of GA3 decreased in Col-0 treated with SNP, whereas this decrease was not observed in ga3ox1. The deficiency of GA3-oxidase alleviated the buildup of H2 O2 in roots when treated with SNP. We identified 222 DEGs. GO annotation of these DEGs revealed that all top 20 GO terms were related to stress responses. Moreover, three DEGs were annotated to GA-related processes (DDF1, DDF2, EXPA1), and seven DEGs were associated with root development (RAV1, RGF2, ERF71, ZAT6, MYB77, XT1, and DTX50). In summary, NO inhibits primary root growth partially by repressing GA3-oxidase catalysed GA3 synthesis in Arabidopsis. ROS, Ca2+ , DDF1, DDF2, EXPA1 and seven root development-related genes may be involved in crosstalk between NO and GAs.

Causal link between gut microbiota and osteoporosis analyzed via Mendelian randomization

OBJECTIVE

Osteoporosis (OP) is closely associated with gut microbiota (GM), yet the nature of their causal relationship remains elusive. Therefore, this study aims to reverse causality between GM and OP by using population cohorts and two-sample MR (TSMR) analysis.

MATERIALS AND METHODS

In this study, we conducted an extensive genome-wide association study (GWAS) using publicly accessible summary statistics data for GM and OP. Employing rigorous criteria (p < 1*e-5), we identified independent genetic loci that exhibited significant associations with GM relative abundances as instrumental variables (IVs). A causal evaluation was primarily carried out using the inverse variance-weighted (IVW) method, supplemented by additional analyses such as MR-Egger, weighted median, simple mode, and weighted mode.

RESULTS

We unveiled that increased abundances of the family Pasteurellaceae, order Pasteurellales, and genus Ruminococcaceae UCG004 were linked to an increased risk of OP. Conversely, the family Oxalobacteraceae, unknown family id.1000006161, genus Lachnospiraceae NK4A136 group, unknown genus id.1000006162, and order NB1n were associated with a reduced risk of OP. To ensure the reliability of our findings, we conducted quality assessments through Cochrane's Q test and a leave-one-out analysis. Furthermore, the stability and consistency of the results were confirmed by the MR-Egger intercept test, Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) global test, and sensitivity analysis (p > 0.05). Our study reveals the causal relationships between 211 GM taxa and OP, pinpointing specific GM taxa associated with the risk of OP. This research sheds light on the genetic mechanisms that underlie GM-mediated OP and opens up promising avenues for identifying valuable biomarkers and potential therapeutic targets in future OP research.

CONCLUSIONS

This study establishes a substantial GM-OP link with specific taxa being identified, offering biomarkers for early detection, tailored interventions, and improved patient education. These findings enhance OP diagnosis, prevention, and treatment, promising more effective, individualized care and inspiring future research.

Efficacy and Safety of First-line Therapies for Advanced Unresectable Oesophageal Squamous Cell Cancer: a Systematic Review and Network Meta-analysis

AIM

To compare the clinical efficacy and safety of first-line treatments for advanced unresectable oesophageal squamous cell cancer.

MATERIALS AND METHODS

A systematic review and network meta-analysis was carried out by retrieving and retaining relevant literature from databases. The studies were randomised controlled trials comparing first-line treatments for advanced unresectable oesophageal squamous cell cancer. A Bayesian network meta-analysis was used to assess clinical outcomes.

RESULTS

Nine studies including 4499 patients receiving first-line treatments were analysed. For all populations, toripalimab plus chemotherapy tended to provide the best overall survival (hazard ratio 0.58, 95% confidence intervals 0.43-0.78) and sintilimab plus chemotherapy provided the best progression-free survival (0.56, 0.46-0.68). Nivolumab plus chemotherapy presented the best objective response rate (odds ratio 2.45, 1.78-3.42) and camrelizumab plus chemotherapy (0.47, 0.29-0.74) appeared to be the safest. Sintilimab plus chemotherapy (0.55, 0.40-0.75) and nivolumab (0.54, 0.37-0.80) plus chemotherapy had the best overall survival in programmed death ligand 1 (PD-L1) tumour proportion score <1% and ≥1% subgroups. Toripalimab plus chemotherapy (0.61, 0.40-0.93) and pembrolizumab (0.57, 0.43-0.75) were the best in overall survival in combined positive score <10 and ≥10 subgroups, respectively. Toripalimab plus chemotherapy showed the best overall survival in the Asian group; pembrolizumab presented better overall survival in the Asian population than the non-Asian group.

CONCLUSION

Most immunotherapy combined with chemotherapy showed superior clinical benefits and sintilimab plus chemotherapy, toripalimab plus chemotherapy and tislelizumab plus chemotherapy had better comprehensive clinical efficacy. PD-L1 expression detection and ethnicity differences are still of great significance and most suitable regimens varied from each subgroup.

Cytomegalovirus Infection and Alzheimer's Disease: A Meta-Analysis

BACKGROUND

Evidence on the association of cytomegalovirus (CMV) infection with Alzheimer's disease (AD) is scarce and the results are inconsistent.

OBJECTIVE

To investigate the association of CMV infection with the risk of AD.

METHODS

Observational studies on the relationship between CMV infection and AD were identified from PubMed, Embase, Web of Science, and the Cochrane Library until September 30, 2022. The quality of included studies was assessed using the Newcastle-Ottawa Scale. Random-effect meta-analysis was performed using a generic inverse-variance method, followed by sensitivity analyses and subgroup analyses based on study designs, regions, adjustments, and population types.

RESULTS

Our search yielded 870 articles, of which 200 were duplicates and 663 did not meet the inclusion criteria, and finally yielded seven studies with 6,772 participants. No strong evidence was observed in the summary analysis for the association of CMV infection and risk of AD (odds ratio [OR] = 1.33; 95% confidence interval [CI]: 0.88, 2.03, I2 =69.9%). However, subgroup analysis showed that an increased risk of AD was detected in East Asians (OR = 2.39; 95% CI: 1.63, 3.50, I2 = 0.00%), cohort studies (OR = 1.99; 95% CI: 1.35, 2.94, I2 = 28.20%), and studies with confounder adjustment (OR = 2.05; 95% CI: 1.52, 2.77, I2 = 0.00%).

CONCLUSIONS

This meta-analysis provides evidence to support the heterogeneity of the associations between CMV infection and AD. Future studies with larger sample sizes and multi-ethnic populations are necessary.

Proportion of participants with type 2 diabetes achieving a metabolic composite endpoint with once-weekly semaglutide treatment versus comparators: Post hoc pooled analysis from SUSTAIN 1-5, 7-10 and SUSTAIN China

AIM

To compare the proportion of participants with type 2 diabetes (T2D) treated with once-weekly (OW) subcutaneous (SC) semaglutide versus comparators who achieved a composite metabolic endpoint.

MATERIALS AND METHODS

SUSTAIN 1-5, 7-10 and SUSTAIN China trial data were pooled. Participants with T2D (aged ≥18 years) and glycated haemoglobin ≥7.0% (≥53 mmol/mol) who had been randomized to OW SC semaglutide (0.5 or 1.0 mg) or comparator in addition to background medication. Using patient-level data pooled by treatment, proportions of participants achieving the metabolic composite endpoint, defined as glycated haemoglobin <7% (<53 mmol/mol), blood pressure <140/90 mmHg and non-high-density lipoprotein cholesterol <130 mg/dl (<3.37 mmol/L), were evaluated following baseline adjustments. Endpoints were analysed per trial using a binomial logistic regression model with treatment, region/country and stratification factor as fixed effects and baseline value as covariate. Pooled analysis used logistic regression with treatment and trial as fixed effects and baseline value as covariate.

RESULTS

This post hoc analysis included data from 7633 participants across 10 trials. The proportion of participants who achieved the metabolic composite endpoint was significantly higher with OW SC semaglutide 0.5 and 1.0 mg versus comparators (23.7% and 32.0% vs. 11.5%, respectively; p < .0001). Likewise, when the OW SC semaglutide doses were pooled, significantly higher proportions of patients receiving semaglutide achieved the composite metabolic endpoint versus comparators (29.1% vs. 11.4%, respectively; p < .0001).

CONCLUSIONS

Treatment with OW SC semaglutide versus comparators was associated with increased proportions of participants with T2D meeting the composite metabolic endpoint.

Neoantigen cancer vaccines: a new star on the horizon

Immunotherapy represents a promising strategy for cancer treatment that utilizes immune cells or drugs to activate the patient's own immune system and eliminate cancer cells. One of the most exciting advances within this field is the targeting of neoantigens, which are peptides derived from non-synonymous somatic mutations that are found exclusively within cancer cells and absent in normal cells. Although neoantigen-based therapeutic vaccines have not received approval for standard cancer treatment, early clinical trials have yielded encouraging outcomes as standalone monotherapy or when combined with checkpoint inhibitors. Progress made in high-throughput sequencing and bioinformatics have greatly facilitated the precise and efficient identification of neoantigens. Consequently, personalized neoantigen-based vaccines tailored to each patient have been developed that are capable of eliciting a robust and long-lasting immune response which effectively eliminates tumors and prevents recurrences. This review provides a concise overview consolidating the latest clinical advances in neoantigen-based therapeutic vaccines, and also discusses challenges and future perspectives for this innovative approach, particularly emphasizing the potential of neoantigen-based therapeutic vaccines to enhance clinical efficacy against advanced solid tumors.

[Enlightenment of World Health Organization fungal priority pathogens list]

The WHO established the first fungal priority pathogens list (FPPL) in October 2022 to focus on and promote further research and policy interventions to strengthen the global response to fungal infections and antifungal resistance. The FPPL and its formulation process provide new significant insights for managing pathogenic fungi and invasive fungal disease (IFD) in China, necessitating the following key actions: Strengthen public health interventions for IFD. Further, it improves the ability of laboratory testing and clinical supervision for IFD and pathogenic fungi. Increase targeted investment and support for innovative research and development in IFD diagnosis, treatment, and prevention.

[Analysis of public health risks associated with pathogenic fungi in China]

At present, the public health risks caused by pathogenic fungi are greater in China and have attracted great attention from disease control departments. Due to the difficulty in diagnosing fungal infections, the public health risk of pathogenic fungi is currently hidden in the unexplained pneumonia/encephalitis/fever syndrome and is not effectively appreciated. From the public health perspective, the mainly focused fungal pathogens include highly pathogenic fungi (including dimorphic fungi and dematiaceous fungi), pathogenic fungi that cause regional aggregation infections, and drug-resistant pathogenic fungi. However, due to the lack of systematic monitoring data, the disease burden related to pathogenic fungi cannot be accurately quantified and evaluated. Therefore, to effectively reduce the serious harm of fungal infections to the public, systematic monitoring of pathogenic fungi should be carried out nationally.

A comparison of size exclusion chromatography-based tandem strategies for plasma exosome enrichment and proteomic analysis

Proteomic analysis of exosomes from human plasma faces a tremendous challenge mainly due to the low abundance of the exosome itself and the complexity of the plasma matrix. Therefore, enrichment of exosomes from human plasma is an essential and indispensable step for large scale and in depth proteomic analysis. Size exclusion chromatography (SEC) is one of the most extensively used methods for exosome isolation from human plasma and many SEC-based tandem methods were established in order to increase the purity of the enriched exosomes and thus the accuracy of the proteomic analysis. To compare the advantages and disadvantages of the different isolation methods and subsequently to promote the establishment of a standardized method for plasma proteomic research, the capacities of the direct SEC method, the combination of SEC with ultracentrifugation (SEC-UC), ultrafiltration (SEC-UF), and titanium dioxide microspheres (SEC-TiO2) were systematically evaluated for exosome isolation from human plasma and thus proteomic analysis. The results demonstrated that the SEC-based tandem methods were superior to the direct SEC method in the purity of exosomes isolated from human plasma. Additionally, the SEC-UC method possessed the highest number of the total identified proteins and the overlapped proteins with the top 100 exosome markers in comparison with the other methods. The SEC-TiO2 method displayed the biggest capacity for plasma protein deleting. We expect that the research will have more beneficial values in the field of exosome research.

Triple-negative breast cancer: predictive model of early recurrence based on MRI features

AIM

To develop an integrated model based on preoperative magnetic resonance imaging (MRI) features for predicting early recurrence in patients with triple-negative breast cancer (TNBC).

MATERIALS AND METHODS

Women with TNBC who underwent breast MRI and surgery between 2009 and 2019 were evaluated retrospectively. Two breast radiologists reviewed MRI images independently based on the Breast Imaging Reporting and Data System Lexicon (BI-RADS), and classified the breast oedema scores on T2-weighted imaging (WI) as no oedema, peritumoural oedema, prepectoral oedema, or subcutaneous oedema. The relationship between disease-free survival (DFS) and MRI features was analysed by Cox regression, and a nomogram model was generated based on the results.

RESULTS

150 patients with TNBC were included and divided into a training cohort (n=78) and validation cohort (n=72). MRI features including subcutaneous oedema and rim enhancement showed a tendency to worsen DFS in univariate analysis. Multivariate analysis showed that subcutaneous oedema (p=0.049, HR [95% confidence interval {CI} = 8.24 [1.01-67.52]) and rim enhancement (p=0.016, HR [95% CI] = 4.38 [1.32-14.54]) were independent predictors for DFS. In the nomogram, the areas under the curves (AUCs) of the training cohort was 0.808, and that of the validation cohort was 0.875.

CONCLUSION

The presence of subcutaneous oedema or rim enhancement on preoperative breast MRI was shown to be a good predictor of poor survival outcomes in patients with TNBC.

[Report content and prenatal diagnosis of non-invasive prenatal testing for sex chromosome aneuploidy]

Objective: To analyze the report content, the methods and results of prenatal diagnosis of high risk of sex chromosome aneuploidy (SCA) in non-invasive prenatal testing (NIPT). Methods: A total of 227 single pregnancy pregnant women who received genetic counseling and invasive prenatal diagnosis at Drum Tower Hospital Affiliated to the Medical School of Nanjing University from January 2015 to April 2022 due to the high risk of SCA suggested by NIPT were collected. The methods and results of prenatal diagnosis were retrospectively analyzed, and the results of chromosome karyotype analysis and chromosome microarray analysis (CMA) were compared. The relationship between NIPT screening and invasive prenatal diagnosis was analyzed. Results: (1) Prenatal diagnosis methods for 277 SCA high risk pregnant women included 73 cases of karyotyping, 41 cases of CMA and 163 cases of karyotyping combined with CMA, of which one case conducted amniocentesis secondly for further fluorescence in situ hybridization (FISH) testing. Results of invasive prenatal diagnosis were normal in 166 cases (59.9%, 166/277), and the abnormal results including one case of 45,X (0.4%, 1/277), 18 cases of 47,XXX (6.5%, 18/277), 36 cases of 47,XXY (13.0%, 36/277), 20 cases of 47,XYY (7.2%, 20/277), 1 case of 48,XXXX (0.4%, 1/277), 20 cases of mosaic SCA (7.2%, 20/277), 5 cases of sex chromosome structural abnormality or large segment abnormality (1.8%, 5/277), and 10 cases of other abnormalities [3.6%, 10/277; including 9 cases of copy number variation (CNV) and 1 case of balanced translocation]. Positive predictive value (PPV) for SCA screening by NIPT was 34.7% (96/277). (2) Among the 163 cases tested by karyotyping combined with CMA, 11 cases (6.7%, 11/163) showed inconsistent results by both methods, including 5 cases of mosaic SCA, 1 case of additional balanced translocation detected by karyotyping and 5 cases of additional CNV detected by CMA. (3) NIPT screening reports included 149 cases of "sex chromosome aneuploidy"(53.8%, 149/277), 54 cases of "number of sex chromosome increased" (19.5%, 54/277), and 74 cases of "number of sex chromosome or X chromosome decreased" (26.7%, 74/277). The PPV of "number of sex chromosome increased" and "number of sex chromosome or X chromosome decreased" were 72.2% (39/54) and 18.9% (14/74), respectively, and the difference was statistically significant (χ2=34.56, P<0.01). Conclusions: NIPT could be served as an important prenatal screening technique of SCA, especially for trisomy and mosaicism, but the PPV is comparatively low. More information of NIPT such as the specific SCA or maternal SCA might help improving the confidence of genetic counseling and thus guide clinic management. Multi technology platforms including karyotyping, CMA and FISH could be considered in the diagnosis of high risk of SCA by NIPT.

[Research advances on application of pancreatic stone protein in the early diagnosis of sepsis]

Sepsis is a severe life-threatening syndrome characterized by an abnormal host response to infection that can rapidly evolve into septic shock and multiple organ failure. Treatment of sepsis depends on early identification and diagnosis as well as adequate and timely anti-infection and multi-organ functional support. In recent years, pancreatic stone protein has been widely studied as a new biomarker for sepsis. Existing evidence shows that compared with the commonly used inflammatory markers in clinical practice, pancreatic stone protein has higher sensitivity and specificity in the diagnosis of sepsis. It enables the early diagnosis of sepsis and assessment of the severity of septic patients to a certain extent. This article reviews the characteristics, biological functions, diagnostic features, and clinical application of pancreatic stone protein.

Measurement of Ultra-High-Energy Diffuse Gamma-Ray Emission of the Galactic Plane from 10 TeV to 1 PeV with LHAASO-KM2A

The diffuse Galactic γ-ray emission, mainly produced via interactions between cosmic rays and the interstellar medium and/or radiation field, is a very important probe of the distribution, propagation, and interaction of cosmic rays in the Milky Way. In this Letter, we report the measurements of diffuse γ rays from the Galactic plane between 10 TeV and 1 PeV energies, with the square kilometer array of the Large High Altitude Air Shower Observatory (LHAASO). Diffuse emissions from the inner (15°10  TeV). The energy spectrum in the inner Galaxy regions can be described by a power-law function with an index of -2.99±0.04, which is different from the curved spectrum as expected from hadronic interactions between locally measured cosmic rays and the line-of-sight integrated gas content. Furthermore, the measured flux is higher by a factor of ∼3 than the prediction. A similar spectrum with an index of -2.99±0.07 is found in the outer Galaxy region, and the absolute flux for 10≲E≲60  TeV is again higher than the prediction for hadronic cosmic ray interactions. The latitude distributions of the diffuse emission are consistent with the gas distribution, while the longitude distributions show clear deviation from the gas distribution. The LHAASO measurements imply that either additional emission sources exist or cosmic ray intensities have spatial variations.

"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.

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.

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.

[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.