Objective:To discuss the clinical characteristics,intervention timing,diagnosis and treatment plan,and prognosis of one patient with immune thrombotic thrombocytopenic purpura(iTTP),and to provide more clinical evidences for the precise diagnosis and treatment of this rare disease.Methods:The clinical data of one patient with iTTP were collected,who had been previously misdiagnosed with acute infection after receiving a virus-inactivated vaccine.The data included clinical manifestations and ancillary examination informations.The relevant literatures were reviewed.Results:The patient,a 60-year-old male,was admitted with"fever for 6 d."The physical examination results showed scattered red maculopapules on the lower limbs,with only mild thrombocytopenia initially,and the admission PLASMIC score was 5 points.Initially diagnosed with acute infection,the patient was treated with anti-inflammatory,anti-infective,and corticosteroid therapies,but the response was poor.After one week,the re-evaluation results showed a significant decrease in the platelet count,progressing to severe thrombocytopenia,hematuria,dark-colored urine,and neurological and psychiatric symptoms as the disease progressed.The further examination results showed the PLASMIC score was increased to 7 points.After high suspicion of iTTP,therapeutic plasma exchange(TPE)was initiated immediately.The a disintegrin and metalloproteinase with thrombospondin type 1 motif member 13(ADATMS13)activity level was<1%during treatment,and the test for ADAMTS13 inhibitors was positive.The genetic testing results revealed a missense mutation in an iTTP-susceptible gene.After a confirmed diagnosis,the patient was treated regularly with intravenous rituximab,completing four treatment cycles,and followed up to the present;the treatment deemed effective.Conclusion:iTTP is often delayed in the diagnosis due to atypical initial clinical symptoms.Once suspected,the treatment based on TPE and glucocorticoids should be initiated immediately.New drugs like rituximab provide a multidisciplinary treatment strategy option for iTTP.

A 48-year-old female patient received chemotherapy with etoposide and carboplatin combined with whole brain radiotherapy for small cell lung cancer located in the right lung with brain metastasis. An IV infusion of toripalimab 240 mg once per 21 days in the 4th cycle of chemotherapy was combined due to tumor progression, and no radiotherapy was given again. After 7 courses of chemotherapy, the patient received monotherapy with toripalimab. On the 2nd day after the 5th administration of toripalimab, the patient developed obvious fatigue, nausea, vomiting, and repeated fever. Laboratory tests showed decreased corticotropin and cortisol (1.5 μg/L, 3.9 μg/L), increased prolactin (127.6 μg/L), and normal thyroid function. Excluding tumor occupation by pituitary magnetic resonance imaging, it was considered as hypophysitis caused by toripalimab. Symptoms disappeared after hydrocortisone replacement therapy was given. After the 9th administration of toripalimab, the patient developed polyuria, thirst, and nocturia. Laboratory tests showed decreased urine specific gravity and urine osmolality (1.010, 132 mmol/L). Diabetes insipidus as the manifestation of hypophysitis caused by toripalimab was considered. The above symptoms were improved after discontinuation of toripalimab and administration of desmopressin. After more than 3 months of the treatment, symptoms of diabetes insipidus disappeared. Then desmopressin was discontinued and diabetes insipidus did not recur.

A 48-year-old female patient received chemotherapy with etoposide and carboplatin combined with whole brain radiotherapy for small cell lung cancer located in the right lung with brain metastasis. An IV infusion of toripalimab 240 mg once per 21 days in the 4th cycle of chemotherapy was combined due to tumor progression, and no radiotherapy was given again. After 7 courses of chemotherapy, the patient received monotherapy with toripalimab. On the 2nd day after the 5th administration of toripalimab, the patient developed obvious fatigue, nausea, vomiting, and repeated fever. Laboratory tests showed decreased corticotropin and cortisol (1.5 μg/L, 3.9 μg/L), increased prolactin (127.6 μg/L), and normal thyroid function. Excluding tumor occupation by pituitary magnetic resonance imaging, it was considered as hypophysitis caused by toripalimab. Symptoms disappeared after hydrocortisone replacement therapy was given. After the 9th administration of toripalimab, the patient developed polyuria, thirst, and nocturia. Laboratory tests showed decreased urine specific gravity and urine osmolality (1.010, 132 mmol/L). Diabetes insipidus as the manifestation of hypophysitis caused by toripalimab was considered. The above symptoms were improved after discontinuation of toripalimab and administration of desmopressin. After more than 3 months of the treatment, symptoms of diabetes insipidus disappeared. Then desmopressin was discontinued and diabetes insipidus did not recur.

Objective To investigate the acute adverse reactions of craniospinal irradiation with helical tomotherapy in medulloblastoma patients and its risk factors. Methods A total of 20 patients with medulloblastoma who received craniospinal irradiation with helical tomotherapy between October 2012 and September 2016 in Air Force General Hospital were selected. The acute adverse events of 20 patients during the treatment were record. According to National Cancer Institute Common Terminology Criteria Adverse Events (NCI-CTCAE) version 4.0, the adverse reactions were divided into the mild group (grade 0-Ⅱ) and severe group (grade Ⅲ-Ⅳ) adverse reactions. And the risk factors were also analyzed. Results The non-hematological adverse reactions included fatigue (55％), vomiting (45％) and headache (25％). The hematological adverse reactions included leukopenia (95％), thrombocytopenia (55％) and lower hemoglobin (45％), and the incidence of severe adverse reactions was 35％ (7/20), 20％ (4/20) and 0 ( 0/20 ) , respectively . Leukopenia occurred in 18 patients ( 90％) at the beginning of radiotherapy within 2 weeks, and thrombocytopenia occurred in 8 patients (40％) at the beginning of radiotherapy after 2 weeks. Single factor analysis showed that there were no statistical differences in hematological adverse events of gender, age and radiation dose of spinal cord (all P>0.05). The incidence of leukopenia for the patients who received the chemotherapy before the radiotherapy was higher than that for the patients without the chemotherapy before the radiotherapy (P< 0.05). Conclusions The hematological adverse reactions were the major acute adverse events during the craniospinal irradiation with helical tomotherapy in patients with medulloblastoma. Theincidence of leukopenia and thrombocytopenia is common, and the incidence of hematological adverse reactions is higher after the chemotherapy. Thus, the close monitoring of hemogram change and treatment of hematological adverse reactions in time during the radiotherapy should be taken into the consideration.

Objective To introduce the therapeutic procedures of helical tomotherapy based total marrow irradiation(HT-TMI), and validate the feasibility of TMI. Methods At 1 week before bone marrow transplantation,12 patients received TMI conditioning regimen at a prescriptive dose of 12 Gy in 3 times,once daily. Patient immobilization, CT simulation, target delineation, plan design and dosimetric verification were implemented in sequence according to the TMI procedures. The dosimetric paramaters of the target and normal tissues were analysed. The correlation between the dose verification and image-guided results was observed. Results Compared with total body irradiation(TBI), TMI could significantly reduce the irradiation dose to normal tissues. The median dose D50of all normal tissues except the oral cavity were lower than 6 Gy,where The D50of lens,brain,lung and liver are (1.8±0.1) Gy, (5.7±0.2) Gy, (5.2±0.2) Gy, and (4.6±0.2) Gy, respectively. Pass rate of γ Index was larger than 95% with 3mm/3% criterian for each section. The positioning error of head and neck was relatively lower than that of pelvis at x-axis,and was higher at z-axis.Conclusions Helical tomotherapy based TMI is a feasible and reasonable approach,which has evident dosimetric advantage.

Objective To explore the curative effect and adverse reaction of applying stereotactic radiotherapy to primary lesion inside chest cavity of patients with oligometastasis non-small cell lung cancer and rendering radical radiotherapy to all metastases. Methods 43 patients with≤5 metastases of non-small cell lung cancer received initial treatment during 2009-2015 in our department were analyzed;the stereotactic radiotherapy was adopted to implement radical radiotherapy on primary lesion and all metastases. The average and neutral position BED10 respectively were 101416 Gy and 102700 Gy,the number of neutral position chemotherapy period was 4. Kaplan-Meier method, survival analysis, Cox model, multi factor Prognosis analysis were used. Results By the end of January 10,2017 in 36 months' neutral position follow-up visit, the total effective rate of lesion treatment of 86%;the survival rates after 1,2 and 3 years respectively were 74%, 70% and 51%. Neutral survival time was 48 months, and the progression-free time of neutral position was 15 months. Multi-factor analysis indicated that,ECOG<2 and ECOG≥2(P=0000),BED10<100 Gy and BED10≥100 Gy ( P=0006) generated obvious influence on survival prognosis. About 90% of the patients only got 1-2 degree of adverse reaction without emerging treatment related death. Conclusions On the premise of systematic therapy of oligometastasis non-small cell lung cancer, combined with radical radiotherapy of primary lesion and metastasis can obviously improve patients ' overall survival and progression-free survival,the adverse reaction is durable.

Objective To explore the efficacy and security of helical tomotherapy (radical radiotherapy) combined with targeted therapy for stage Ⅳ non-small cell lung cancer (NSCLC).Methods The data of 19 patients with stage Ⅳ NSCLC were retrospectively analyzed.The efficacy and security were observed by SPSS 20.0 statistical software.Results Among 19 patients, there were 6 cases complete remission (CR), 8 cases partial remission (PR), 4 cases stable disease (SD), 2 cases progressive disease (PD).The response (CR+PR) rate was 73.7 ％ (14/19).The 1-and 2-year local control rates were 73.7 ％, 47.4 ％,respectively.The 1-year progression-free survival rate was 31.6 ％.The median survival time was 13 months, and the 1-and 2-year overall survival rates were 52.6 ％, 26.3 ％, respectively.The median survival time of females, non-smokers or targeted therapy synchronous radiotherapy was longer than that of male, smokers or targeted therapy sequential radiotherapy, respectively (21 months vs 8 months, P =0.014;21 months vs 6 months, P =0.007;18 months vs 6 months, P =0.026).There were no significant differences of age, number of metastatical organs or targeted drug categories between two groups (P ＞ 0.05).All patients could tolerate the adverse reactions without treatment-related death.Conclusion The effect of helical tomotherapy combined with targeted therapy for stage Ⅳ NSCLC is desirable.

Objective To seek a optimization method for lung cancer planning with Helical TomoTherapy for reducing the low dose area of total lung.Methods CT images of thirty patients with unilateral lung cancer were selected.Seven plans (Groups A,B,C,D,E,F and G) were generated for each patient using an identical optimization procedure with the conditions that implemented contralateral lung with unblocked (control group),1/4 directional block,1/2 directional block,directional block,1/4 complete block,1/2 complete block and complete block,respectively.The benefits in different schemes of reducing the low dose area of normal lung tissue were estimated,in order to provide a reference treatment plan scheme in clinical.Results Groups B,C,D and E had less influence on the target than that of group A.And there were no statistical difference between the target dosimetric parameters.The median dose and average dose of group F were increased within 0.5 Gy.The conformal index of group G had great influence on the target.The low dose area of total lung were reduced effectively in Groups C,D,E,F and G,the average decrease of V5 and V10 was 8.06％-45.26％ and 6.21％-33.95％,respectively.The V20 decreased by 1.71％-3.78％ in directional block group,while V20 increased in complete block group (2.07％-5.07％).The single treatment time was increased by 8.51％-79.22％.Conclusions The results showed that the low dose area of total lung was higher for the plan without any block limitation.It could reduce the low dose area of total lung with directional block.We should lengthen the blocking arc of contralateral lung with directional block based on the fractional treatment time and the patient's physical condition.A certain arc of contralateral lung with complete block could effectively reduce low dose area.When complete block was used,it is suggested that the arc was no more than half of the contralateral lung.

Objective To study the dose characteristics of Body γ Knife and Tomotherapy treatment plans for hepatocellular carcinoma,and compare their differences between organs at risk (OAR) dose and the range of low dose.Methods CT simulation images of twelve patients with hepatocellular carcinoma were selected,the target volume and OAR were drew by doctor.Body γ Knife and Tomotherapy treatment plans were optimized with their own planning station.The dosimetric characteristics were evaluated by dose volume histograms and were compared.To analyze the difference between the two techniques,the paired t-test was applied.Results The Dmax and Dmean of target with Body γ Knife were higher than Tomotherapy (P =0.002,0.000),but the conformal index of PTV of Tomotherapy was superior to the Body γ Knife (P =0.001).The Dmax of spinal cord and left kidney with Body γ Knife was lower than Tomotherapy (P =0.013,0.012),and it was also in the Dean of stomach and left kidney (P =0.010,0.023).In the volume dose comparison,the V40,V35,V30,V25 and V20 of normal tissue (all Body-PTV) and liver (all liver-GTV) with Body γ Knife were higher than Tomotherapy (P =0.001,0.001,0.001,0.007,0.029),but the V10 and V5 were lower (P =0.019,0.031),the Dmax of stomach,Dmean of right kidney and liver were no statistical difference (P =0.247,0.308,0.401).Conclusions Both treatment plans could meet the clinical dosimetric need,by the same prescription dose,Dmax and Dmean of target of Body γ Knife were higher than Tomotherapy.Tomotherapy had excellent dose-target conformal and could reduce the range of V25-V40 of OAR and normal tissue,but the range of V5-V10 was increased obviously.