Definitive treatment of lung cancer with radiotherapy is challenging, as respiratory motion and anatomical changes can increase the risk of severe off-target effects during radiotherapy. Online adaptive radiotherapy (ART) is an evolving approach that enables timely modification of a treatment plan during the interfraction of radiotherapy, in response to physiologic or anatomic variations, aiming to improve the dose distribution for precise targeting and delivery in lung cancer patients. The effectiveness of online ART depends on the seamless integration of multiple components: sufficient quality of linear accelerator-integrated imaging guidance, deformable image registration, automatic recontouring, and efficient quality assurance and workflow. This review summarizes the present status of online ART for lung cancer, including key technologies, as well as the challenges and areas of active research in this field.
Humans ; Lung Neoplasms/radiotherapy* ; Radiotherapy Planning, Computer-Assisted/methods*

Objective:To evaluate the feasibility of using bedside ultrasound and serum biomarkers for the prediction of sepsis-induced myocardial dysfunction(SIMD)and mortality in septic shock patients.Methods:The patients diagnosed as septic shock were enrolled in the study from January 2019 to July 2021 in PICU at Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine.Bedside ultrasound results were recorded at day 1, 2, 3, 7 and 10.Blood samples were collected at the same time, markers of myocardial injury were detected, and prognosis was recorded at 28 days.According to the left ventricular ejection fraction (LVEF), children with septic shock were divided into SIMD group and non-SIMD group.Those with LVEF <50% or decreased by ≥10% from baseline level were defined as SIMD.Differences in cardiac ultrasound parameters and biomarkers between two groups were compared.Logistic regression analysis was performed to determine the independent risk factors for SIMD and the independent risk factors for death at 28 days after septic shock.The area under the receiver operating characteristic curve (AUC) was used to evaluate the efficacy of different indicators in predicting SIMD and the death outcome of children with septic shock on 28 days.Results:A total of 57 children were enrolled, including 28 cases in SIMD group and 29 cases in non-SIMD group.Univariate analysis showed that there were statistically significant differences in pediatric critical illness score, N-terminal B-type natriuretic peptide(NT-proBNP), LVEF and left ventricular short axis shortening rate between two groups ( P<0.05). Logistic analysis demonstrated that LVEF( OR=0.890, 95% CI 0.818-0.969, P=0.007)and NT-proBNP ( OR=1.000, 95% CI 1.000-1.000, P=0.015)could independently predict SIMD.There were 42 cases in survival group and 15 in non-survival group according to the prognosis on 28 days.Univariate analysis showed that there were significant differences in pediatric risk mortality score Ⅲ, pediatric sequential organ failure assessment, cardiac troponin I, and mitral annular plane systolic excursion(MAPSE)( P<0.05). Logistic analysis showed that only MAPSE independently predicted mortality( OR=85.670, 95% CI 1.685-4 356.736, P=0.026). Compared with MAPSE(AUC=0.727), MAPSE combined with pediatric risk mortality score Ⅲ, pediatric sequential organ failure assessment, cardiac troponin I(AUC=0.926) could be better to predict the 28 days prognosis of patients with septic shock on 28 days. Conclusion:NT-proBNP increases significantly in the early stage of SIMD.MAPSE shows no difference between SIMD and non-SIMD patients.MAPSE is correlated with the prognosis of patient with septic shock.

OBJECTIVE: To identify the problems in clinical radiotherapy planning for cervical cancer through quantitative evaluation of the radiotherapy plans to improve the quality of the plans and the radiotherapy process. METHODS: We selected the clinically approved and administered radiotherapy plans for 227 cervical cancer patients undergoing external radiotherapy at Sun Yat-sen University Cancer Center from May, 2019 to January, 2022. These plans were transferred from the treatment planning system to the Plan IQ^TM workstation. The plan quality metrics were determined based on the guidelines of ICRU83 report, the GEC-ESTRO Working Group, and the clinical requirements of our center and were approved by a senior clinician. The problems in the radiotherapy plans were summarized and documented, and those with low scores were re-planned and the differences were analyzed. RESULTS: We identified several problems in the 277 plans by quantitative evaluation. Inappropriate target volume selection (with scores < 60) in terms of GTV, PGTV (CI) and PGTV (V_{66 Gy}) was found in 10.6%, 65.2%, and 1% of the plans, respectively; and the PGTV (CI), GTV, and PCTV (D_98%, HI) had a score of 0 in 0.4%, 10.1%, 0.4%, 0.4% of the plans, respectively. The problems in the organs at risk (OARs) involved mainly the intestines (the rectum, small intestine, and colon), found in 20.7% of the plans, and in occasional cases, the rectum, small intestine, colon, kidney, and the femoral head had a score of 0. Senior planners showed significantly better performance than junior planners in PGTV (V_{60 Gy}, D_98%), PCTV (CI), and CTV (D_98%) (P≤0.046) especially in terms of spinal cord and small intestine protection (P≤0.034). The bowel (the rectum, small intestine and colon) dose was significantly lower in the prone plans than supine plans (P < 0.05), and targets coverage all met clinical requirements. Twenty radiotherapy plans with low scores were selected for re-planning. The re-planned plans had significantly higher GTV (D_min) and PTV (V_{45 Gy}, D_98%) (P < 0.05) with significantly reduced doses of the small intestines (V_{40 Gy} vs V_{30 Gy}), the colon (V_{40 Gy} vs V_{30 Gy}), and the bladder (D_35%) (P < 0.05). CONCLUSION Quantitative evaluation of the radiotherapy plans can not only improve the quality of radiotherapy plan, but also facilitate risk management of the radiotherapy process.
Humans ; Female ; Uterine Cervical Neoplasms/radiotherapy* ; Rectum ; Colon ; Kidney ; Organs at Risk

OBJECTIVE: To investigate the accuracy of automatic segmentation of organs at risk (OARs) in radiotherapy for nasopharyngeal carcinoma (NPC). METHODS: The CT image data of 147 NPC patients with manual segmentation of the OARs were randomized into the training set (115 cases), validation set (12 cases), and the test set (20 cases). An improved network based on three-dimensional (3D) Unet was established (named as AUnet) and its efficiency was improved through end-to-end training. Organ size was introduced as a priori knowledge to improve the performance of the model in convolution kernel size design, which enabled the network to better extract the features of different organs of different sizes. The adaptive histogram equalization algorithm was used to preprocess the input CT images to facilitate contour recognition. The similarity evaluation indexes, including Dice Similarity Coefficient (DSC) and Hausdorff Distance (HD), were calculated to verify the validity of segmentation. RESULTS: DSC and HD of the test dataset were 0.86±0.02 and 4.0±2.0 mm, respectively. No significant difference was found between the results of AUnet and manual segmentation of the OARs ( CONCLUSIONS AUnet, an improved deep learning neural network, is capable of automatic segmentation of the OARs in radiotherapy for NPC based on CT images, and for most organs, the results are comparable to those of manual segmentation.
Databases, Factual ; Humans ; Image Processing, Computer-Assisted ; Nasopharyngeal Carcinoma/radiotherapy* ; Nasopharyngeal Neoplasms/radiotherapy* ; Organs at Risk ; Tomography, X-Ray Computed

The clinical data of 2 children with early graft liver dysfunction (EAD) admitted to the Pediatric Intensive Care Unit, Shanghai Children′s Medical Center, Shanghai Jiaotong University School of Medicine were retrospectively analyzed to discussed the therapeutic significance of non-biological artificial liver technology, such as intermittent plasma exchange (PE) combined with continuous veno-venous hemodiafiltration (CVVHDF) in children with EAD.Case 1 was suffering from biliary atresia, and case 2 was suffering from Niemann-Pick disease.Graft liver dysfunction and multiple organ dysfunction occurred in 2 children after liver transplantation.PE and CVVHDF were initiated early in the first two days after liver transplantation.After one-week therapy with intermittent PE plus CVVHDF, acute multiple organ dysfunction were reversed with liver function remarkably improved in the 2 cases.Therefore non-biological artificial liver technique can be tried after liver transplantation in children.This technique contributes to the recovery of liver function and can improve the secondary multi-organ insufficiency.

There is a wide variety of diseases resulting in pediatric right heart failure because of children′s special disease spectrum,the main mechanisms include pressure or volume overload,myocardial lesions and arrhythmia,etc.On the basis of adult studies,tailored treatment should be considered in pediatric patients.

Objective To investigate the risk factors for contact dermatitis in patients with peripherally inserted central catheter (PICC) catheterization.Methods A total of 244 patients with PICC catheterization admitted in the Venous Catheter Nursing Outpatient of Affiliated Hospital of Nanjing University of TCM from June to August 2016 were selected using convenience sampling. A prospective study was performed on those patients for general information, PICC catheter information, PICC care information and contact dermatitis development information. SPSS 21.0 was used to analyze the date.Results A number of 24 patients were observed to have contact dermatitis with an incidence of 9.84%. Single factor analysis showed that gender, age, allergy, dressing type and catheter material correlated to the development of contact dermatitis with PICC. The differences were statistically significant (P<0.05). Multiple factor logistic regression analysis showed that the gender[OR=2.721, 95%CI (1.059-6.994),P=0.038], allergy[OR=5.846, 95%CI (2.030-16.833),P=0.001] and dressing type[OR=4.055, 95%CI (1.472-11.169),P=0.007]were risk factors of contact dermatitis in patients with PICC catheterization.Conclusions For PICC catheterization patients, effective preventive measures aiming at risk factors can reduce the occurrence of contact dermatitis with PICC.

OBJECTIVETo study the correction of algorithm for Varian enhanced dynamic wedge(EDW) factors and compare the dose/monitor unit (MU) deviation measured at the central axis of EDW field with that obtained by manual calculation or using the treatment planning system.

METHODSEDW factors and dose were measured with Thimble ion chamber at 10 cm depth under the water for 6 MV and 10 MV photon on Varian linear accelerator. The corresponding calculations were done with the radiation treatment planning system. An analytic formula, namely the MU Fraction model, was used to calculate the EDW factor, which was corrected with a constant factor. The MU of conventional 2-D planning derived from manual calculating, treatment planning system, and actual measurements were compared.

RESULTSWith the measured results as the standard, the corrected manual calculation deviation of EDW factors was significantly reduced. For photon 6 MV, the maximum deviation reduced from 4.2% to 1.3% for 60° symmetry fields was, and from -4.7% to -1.8% for asymmetric fields. For photon 10 MV, the maximum deviation for all EDW fields was reduced from -3.0% to 1.1%. Comparison of the manual calculations with the measured results showed a MU deviation for symmetric fields within 2%, and more than 5% for some asymmetric fields. The deviation between the calculations of the treatment planning and the measured results was less than 1.5%.

CONCLUSIONConstant factor correction can effectively reduce the deviation of manual calculation. For MU calculation of EDW field in conventional 2-D dimensional treatment planning, the corrected results of symmetric fields meet clinical requirements. While the minimum distance between the field edge and the central axis was less than 4 cm in asymmetric fields, the corresponding special method, measurement or the treatment planning system should be used to calculate the dose/MU.

Objective To evaluate the value of integrated use of bedside lung ultrasound and echo-cardiography in PICU.Methods Two cases with respiratory failure and shock were monitored using inte-grated bedside lung ultrasound and echocardiography.Breathing and circulation support solutions were adopt-ed according to Bedside Lung Ultrasound in Emergency(BLUE)and Fluid Administration Limited by Lung Sonography(FALLS).Results Case 1 with acute lymphoblastic leukemia complicated with severe phneu-monia was measured as “B-profile”throughout both lung fields which interpreted as pulmonary edema ac-cording to the BLUE protocol.He was diagnosed as acute respiratory distress syndrome later and supported by non-invasive ventilation according to the lung ultrasonography.After 4 days,the numbers of B line were sig-nificantly reduced with PaO2/FiO2 >300 mmHg(1 mmHg=0.133 kPa)and the improvement in chest X ra-diography was found,ventilation was weaned accordingly.Case 2 was diagnosed as septic shock and acute re-spiratory distress syndrome with volume resuscitation and mechanical ventilation.According to FALLS proto-col,we ruled out obstructive and cardiogenic shock,and assessed the variation in inferior vena cava diameter and aortic systolic velocity-time integral as a guide to fluid therapy.At the 8th hour in PICU,case 2 recovered from shock.Conclusion Integrated use of bedside lung ultrasound and echocardiography is clinically signifi-cant for the rescue of critically ill patient with respiratory failure and shock.

Fulminant myocarditis is one of the most common diseases causing sudden cardiac death in pediatrics and young adults.The pathophysiology of fulminant myocarditis involves both direct myocyte dysfunction and immune-mediated tissue injury,which result in severe damage in cardiac structure and func-tion.It always rapidly developed into cardiogenic shock in several hours.Despite the high mortality rate,if pa-tient response well to a series of progressive treatment,most of them would get complete resolution.Better understanding of the hemodynamic changes of fulminant myocarditis is the key point of rapid diagnosis and proper interventional treatment.In this article we made a summary introduction of those hemodynamic chan-ges in fulminant myocarditis.