In radiotherapy for thoracic and abdominal tumors, the negative effect of respiratory movement on radiotherapy persist throughout the whole process of radiotherapy. Deep inspiration breath-hold technique (DIBH) is a method of respiratory movement management in radiotherapy, which can reduce the negative effect of respiratory movement upon radiotherapy in the whole process of radiotherapy. Meantime, DIBH technique has its own characteristics and operation requirements compared with other respiratory movement management measures (such as 4D CT, gated technology and tracking, etc.). The aim of this review was to introduce the advantages, disadvantages and the application status of DIBH technique.

Objective: To investigate the current status of breast reconstruction surgery in China and analyze the specific views of Chinese doctors on the relationship between radiotherapy and breast reconstruction surgery. Methods: A total of 110 medical institutions nationwide with more than 200 cases of breast cancer surgery yearly were selected into this questionnaire survey. The questionnaire survey included basic information of the surgeons and their hospitals, information of breast cancer surgeries in 2017, types of reconstruction surgery and specific views on the relationship between radiotherapy and reconstruction surgery. Results: In total, 110 hospitals participated in the survey, 96(87.3%) had undergone breast reconstruction surgery. Reconstruction with implants accounted for 65.7% of the total reconstruction surgery and the proportion of autologous reconstruction was 20.1%. For patients who probably required postoperative radiotherapy, the preferred surgical procedure in the surveyed hospitals was implant based reconstruction surgery. For those who were confirmed to receive postoperative radiotherapy or had undergone radiotherapy after total mastectomy, autologous tissue reconstruction was recommended. Postoperative radiotherapy was a negative factor for immediate breast reconstruction, and most hospitals believed that radiotherapy exerted slight effect on surgery. The proportion of delay-immediate breast reconstruction reached 66% and 86% of hospitals preferred to replace with the prosthesis at 6 months after radiotherapy. Patients with local recurrence after breast-conserving surgery could also receive immediate reconstruction and implant reconstruction was the preferred surgical procedure. Conclusions The proportion of breast reconstruction in China is relatively low and Chinese doctors still lack of technical mastery. In the face of conflict with radiotherapy, the regime selected by Chinese doctors is not in accordance with those recommended by the guideline and consensus, prompting that more professional training should be delivered for Chinese doctors to further promote the development of breast reconstruction in China.

Objective: To investigate the radiotherapy (RT)-induced changes in the brain structural network in patients with nasopharyngeal carcinoma (NPC). Methods: Three-dimensional structural magnetic resonance data (3D-T1W) was adopted to investigate the structural network in 103 patients with NPC before and after receiving RT. The structural networks were then reconstructed using 3D-T1W. The radiation-induced changes in topology properties of small world network were analyzed by using graph theoretical analysis. Results: Patients showed small world properties before and after RT. Compared with the pre-RT group, the global and local efficiency were lower, the shortest path length was longer and the clustering coefficient was less in the post-RT group. In addition, the hub regions in the post-RT group were significantly different from those in the pre-RT group, mainly located in the left rolandic operculum, right inferior frontal gyrus, right parahippocampal gyrus, right lingual gyrus, bilateral supramarginal gyrus, left superior temporal gyrus and temporal pole of the right middle temporal gyrus. Conclusion It is speculated that RT leads to high efficiency of network topology and information transmission, which provides a novel perspective for exploring the RT-induced brain changes, diagnosis of RT-induced injury and evaluation of RT efficacy.

Objective: To analyze the spatial distribution of brain metastases in EGFR-mutant lung cancer and the risk of hippocampal metastasis. Methods: Patients with lung cancer brain metastases diagnosed and treated in the Shanghai Cancer Center Fudan University from 2006 to 2016 were enrolled. The brain metastasis with positive mutation of EGFR gene was screened. The magnetic resonance images of the patients were reviewed and the distribution characteristics of brain metastasis were analyzed. Results: A total of 920 lung cancer patients with brain metastases were screened, 266 of whom had EGFR gene mutation detection, and 131(49%) were identified as EGFR gene mutations. Excluding 17 patients who did not have a head magnetic resonance examination in our hospital, a total of 114 patients and 738 lesions were enrolled in this study. The proportion of brain metastases distributed in each brain region was 22.8%, 19.5%, 22.0%, 13.4%, 3.3%, 16.7%, and 2.2% for frontal, temporal, parietal, occipital lobe, insula, cerebellum, and brainstem, respectively. The number of metastases and cases located in the hippocampus, <5 mm from the hippocampus, <10 mm from the hippocampus, and<15 mm from the hippocampus were 6(0.8%), 10(1.3%), 11(1.4%), and 14(1.8%), 5 cases (4.4%), 8 cases (7.0%), 9 cases (7.9%), and 11 cases (9.6%), respectively. Conclusion EGFR-mutant lung cancer brain metastasis is low risk in the hippocampus and its surrounding 15 mm.

Objective: To compare the overall survival (OS), progression-free survival (PFS) and brain metastasis free survival (BMFS) between the chemo-radiotherapy and surgical treatment for patients with limited stage small cell lung cancer (LS-SCLC). Methods: Clinical data of 69 patients diagnosed with LS-SCLC undergoing surgery in Zhejiang Cancer Hospital between 2000 and 2016 were collected. According to T, N stage, treatment duration, age, gender and whether or not prophylactic cranial irradiation (PCI), 69 patients of 503 LS-SCLC patients who underwent standard radiochemotherapy were assigned into the radiochemotherapy group by using the pair-matched case-control method. Results: Among 138 patients, 69 cases were allocated into the surgery group (24 cases of stage Ⅰ, 14 cases of stage Ⅱ and 31 cases of stage Ⅲ) and 69 cases in the radiochemotherapy group (24 cases of stage Ⅰ, 14 cases of stage Ⅱ and 31 cases of stage Ⅲ). The median OS time was 37.1 months (95%CI: 24.1-50.2 months) in surgery group and 45.0 months (95%CI: 15.8-74.2 months) in the radiochemotherapy group. The 2-and 5-year OS rates were 60% and 45% in the surgery group, and 64% and 45% in the radiochemotherapy group (P=0.846). The median PFS time was 27.1 months (95%CI: 0.00-60.3 months) in the surgery group and 36.2 months (95%CI: 20.9-51.4 months) in the radiochemotherapy group. The 2-and 5-year PFS rates were 52%, and 38% in the surgery group, and 56% and 40% in the chemo-radiotherapy group (P=0.610). The 2-and 5-year BMFS rates were 81% and 76% in the surgery group, and 84% and 80% in the radiochemotherapy group (P=0.774). The 5-year OS rate (62% vs. 40%, P=0.038) and 5-year PFS rate (80% vs.40%, P=0.048) for patients with stage Ⅰ LS-SCLC in the surgery group were significantly higher than those in the radiochemotherapy group. However, the 5-year BMFS rate in patients with stage Ⅰ LS-SCLC did not significantly differ between two groups (92% vs.95%, P=0.816). The 5-year OS rate (41% vs.51%, P=0.946), 5-year PFS rate (65% vs.42%, P=0.280) and 5-year BMFS rate (75% vs.78%, P=0.720) for stage Ⅱ SCLC did not significantly differ between two groups. As for stage Ⅲ SCLC patients, the OS rate (25% vs.48%, P=0.220), 5-year PFS rate (28% vs.36%, P=0.333) and 5-year BMFS rate (76% vs. 74%, P=0.84) did not significantly differ between two groups. Conclusions Surgical treatment can bring survival benefits to patients with stage Ⅰ LS-SCLC. The survival prognosis of stage Ⅱ patients is equivalent between two groups. Patients with stage Ⅲ LS-SCLC receiving radiochemotherapy obtain better survival trend compared with those undergoing surgery. The conclusion remains to be validated by studies with larger sample size or prospective investigations.

Objective: To investigate the salvage strategy and efficacy for patients with locally recurrent esophageal squamous cell carcinoma after definitive radiochemotherapy. Methods: A total of 126 patients who met the inclusion criteria were enrolled in this study and divided into the salvage surgery, salvage radiochemotherapy and best supportive care. Results: Fifty-eight of 126 patients received salvage esophagectomy, 52 underwent salvage radiochemotherapy and the remaining 16 patients received best supportive care. The 1-, 3-, 5-year overall survival rates of patients receiving salvage therapy were 51%, 16% and 4% for the three groups, whereas all patients in the best supportive care group died within 12.0 months (P<0.001). The 1-, 3-, 5-year survival rates in the salvage surgery and salvage radiochemotherapy groups were 48%, 20% and 7%, and 51%, 11% and 3%, respectively (P=0.473). Multivariate analysis by Cox proportional hazard model showed that T staging of recurrent tumors and salvage regimen were the independent prognostic factors in patients with locally recurrent esophageal cancer (both P<0.001). Postoperative infection occurred in 16% of the patients in the salvage surgery group, and the incidence of esophagotracheal fistula and mediastinoesophageal fistula was 10% and 6% in the salvage radiochemotherapy group. Conclusions A survival benefit can be elicited by salvage surgery or salvage radiochemotherapy in patients with locally recurrent esophageal cancer after definitive radiochemotherapy. Nevertheless, extensive attention should be paid to the management of postoperative complications in clinical practice.

Objective: To investigate the locoregional benefit from adjuvant anti-HER-2 target therapy and the possibility of omitting postmastectomy radiation therapy (PMRT) in HER-2 positive breast cancer patients. Methods: Clinical data of 1398 patients diagnosed with HER-2+ breast cancer admitted to our hospital who underwent mastectomy without PMRT from 2009 to 2014 were retrospectively analyzed, and 370 of them received adjuvant anti-HER-2 target therapy mainly with trastuzumab. Results: Anti-HER-2 target therapy significantly improved the disease-free survival (DFS) and overall survival (OS), whereas reduced the locoregional recurrence (LRR) insignificantly. Multivariate analysis demonstrated that anti-HER-2 target therapy improved the locoregional recurrence-free survival (LRRFS)(P=0.06). After propensity score matching, the 5-year LRR rate was 4.4% vs. 6.4%(P=0.070) for those treated with and without anti-HER-2 target therapy. Subgroup analysis revealed that the locoregional control benefit was only significant in patients with pathological Grade Ⅰ-Ⅱtumors (2.5% vs. 5.9%, P=0.046). For patients with pN₁ tumors with and without anti-HER-2 target therapy, the 5-year LRR rate was 8.2% vs. 12.3%(P=0.150). Patients with hormone receptor-positive tumors obtained significant benefit from anti-HER-2 target therapy. The 5-year LRR rate could be less than 5% in patients with favorable risk factors who received anti-HER-2 target therapy. Conclusions Anti-HER-2 target therapy with trastuzumab can improve the LRRFS of patients with HER-2+ breast cancer after mastectomy. Nevertheless, patients with radiotherapy indications have to receive radiotherapy due to relatively high recurrence rate. Newly approved dual HER-2 blockade is a promising approach to further reduce LRR. Subgroup analysis is required to identify the low-risk patients.

Objective: To compare the efficacy of postoperative adjuvant radiotherapy and non-radiotherapy in patients with extrahepatic cholangiocarcinoma and gallbladder carcinoma by a meta-analysis. Methods: The controlled clinical trials of postoperative adjuvant radiotherapy versus non-radiotherapy of extrahepatic cholangiocarcinoma and gallbladder carcinoma were searched from PubMed, EMbase, Cochrane Library, Wanfang database, CNKI, Chongqing VIP and CBM databases. The obtained data were analyzed using RevMan 5.3 and Stata 14.0 statistical software. The difference between two groups was estimated by calculating the odds ratio (OR) with 95% confidence interval (CI). Results: A total of 20 controlled clinical trials involving 1258 extrahepatic cholangiocarcinoma and gallbladder carcinoma patients were included in this meta-analysis. The meta-analysis demonstrated that the 5-year survival rate in the adjuvant radiotherapy group was significantly higher than that in the non-radiotherapy group (OR=1.67, 95%CI: 1.29-2.18, P=0.001). The 5-year survival rates in those with lymph node positive disease (OR=7.44, 95%CI: 1.24-44.72, P=0.03) and positive margins disease (OR=3.43, 95%CI: 1.56-7.75, P=0.002) were significantly enhanced by postoperative adjuvant radiotherapy. The local recurrence rate in the adjuvant radiotherapy group was significantly lower than that in the non-radiotherapy group (OR=0.56, 95%CI: 0.39-0.80, P=0.01), whereas the distant metastasis rate did not significantly differ between two groups (OR=1.22, 95%CI: 0.86-1.73, P=0.27). The incidence rates of acute toxicity and chronic toxicity of grade ≥3 caused by radiotherapy were 0-11.9% and 0-21.7%, respectively. Conclusion Compared with non-radiotherapy, postoperative adjuvant radiotherapy is a safer and more effective postoperative treatment for extrahepatic cholangiocarcinoma and gallbladder carcinoma.

Objective: To explore the poor prognostic factors of patients with cervical stump carcinoma, aiming to provide certain reference for the clinical diagnosis and treatment. Methods: Clinical data of 48 patients with cervical stump carcinoma admitted to the Affiliated Tumor Hospital of Xinjiang Medical University from January 1, 2005 to December 1, 2016 were retrospectively analyzed. A total of 19 patients (40%) withⅠ_A-Ⅱ_A stage cervical stump carcinoma were treated with surgery+ adjuvant therapy and 29 patients (60%) in Ⅱ_B-Ⅳ stage received radiotherapy combined with chemotherapy. The median age of onset was 51 years old. Uterine fibroids were the main cause of subtotal hysterectomy. The average time interval from subtotal hysterectomy to definite diagnosis was 10.76 years. Results: The 1-, 3-, 5-year survival rate was 98%, 83% and 74%, respectively. Univariate analysis demonstrated the time interval from subtotal hysterectomy (P=0.016), tumor diameter (P=0.016), clinical stage (P=0.036), histological grade (P=0.009), lymph node metastasis (P=0.044), parametrial invasion (P=0.046), myelosuppression (P=0.013) and radical surgery (P=0.019) were the poor prognostic factors of cervical stump carcinoma. Conclusions Poor prognosis of patients with cervical stump carcinoma is correlated with tumor diameter, clinical stage, histological grade, lymph node metastasis, parametrial invasion and myelosuppression. Histological grade is an independent risk factor.

Objective: To explore the correlation between microdamage in white matter and radiotherapy dose at early stage after radiotherapy (RT) in patients with nasopharyngeal carcinoma (NPC). Methods: Thirty-three patients who were initially diagnosed with NPC were recruited and received diffusion tensor imaging (DTI) scan and neuro-cognitive scale test within 1 week before RT and the first day after RT. DTI-related characteristic parameters including fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (λ_‖), and radial diffusivity (λ_⊥) were calculated based on whole-brain voxel analysis method. Paired t-test was conducted to evaluate statistical significance between pre-RT and post-RT groups. In the subgroup analysis, all the subjects were divided into 3 groups according to the average dose of temporal lobe, and each group was set with an equal dose interval range. The DTI-related parameters of whole brain pre-RT and post-RT in each group were statistically compared. All the statistical results were corrected by FDR with a threshold of P<0.05 and clusters>100. Results: FA, MD, λ_‖ and λ_⊥in the post-RT group significantly differed compared with those in the pre-RT group (P<0.05). The values of FA, MD, λ_‖ and λ_⊥were 0.455±0.016, (9.893±0.403)×10^-4, (13.441±0.412)×10^-4 and (8.231±0.429)×10^-4, respectively. Subgroup analysis showed that the extent and degree of λ_‖ and λ_⊥ changes were exacerbated with the increase of the average dose of temporal lobe after RT. Particularly in high-dose group, the average dose range was 25-35 Gy and the extent of regions with significant changes was significantly larger than those in the medium-dose (15-25 Gy) and low-dose groups (5-15 Gy)(P<0.05). Conclusions DTI can be utilized to detect" normal" brain tissue microdamage in NPC patients at early stage after RT. The average radiation dose of temporal lobe may be one of the reasons for the severity of cerebral microdamage. In the future, DTI technique may be useful for guiding exposure dose of organs at risk during RT planning and to evaluate the cohort with a high risk of cerebral microdamage at early stage after RT, thereby protecting normal cerebral tissues to the maximum extent.