Objective:To evaluate the robustness of fully automated adaptive planning for Ethos online adaptive radiotherapy (ART) based on the intelligent optimization engine (IOE).Methods:Clinical data of 11 stage ⅠB cervical cancer patients admitted to Peking Union Medical College Hospital between June 2021 and June 2022 were retrospectively analyzed. Original planning images and iterative cone-beam computed tomography (iCBCT) images of each radiotherapy treatment were acquired, and all patient data were imported into the Ethos simulator. IOE-based 9-field automatic plan generation was performed for 11 patients using Ethos, and the generated plans were sent to online adaptive radiotherapy simulation to obtain each online adaptive radiotherapy plan (273 fractions in total) and complete the simulated treatment. For comparison, manual plan design was performed based on the images and contoured structures used for online adaptive radiotherapy planning, and the manually plans created with evenly divided 9 fields. Dosimetric parameters, plan complexity parameters, and Mobius quality assurance (QA) pass rates were collected to compare and evaluate the robustness of the online adaptive radiotherapy plan in terms of organs at risk (OAR), target volume dosimetric parameters, and plan complexity by using paired t-test or rank sum test. Results:The online adaptive plan of cervical cancer had comparable planning target volume (PTV) coverage compared to the manual plan. For the clinical target volume (CTV) D 99%, online adaptive plan was significantly higher than the manual plan [(45.93±0.36) vs. (45.32±0.31) Gy, P<0.001]. For hot dose area, the maximum point dose (PTV D max) of adaptive plan was significantly higher than the manual plan [(49.89±1.25) vs. (48.48±0.77) Gy, P<0.001], but the PTV D 1% of adaptive plan was significantly lower than the manual plan [(47.22±0.29) vs. (47.59±0.48) Gy, P<0.001]. There was no statistical difference in the conformal index ( P=0.967). And there was significant difference in the homogeneity index, with same medians and less dispersion in adaptive plan ( P<0.001). For OAR dose, bladder D mean, rectal V 40 Gy, small intestine D mean of adaptive plan was slightly higher than that of the manual plan; the rectal D mean, small intestine D 2 cm3 of the adaptive plan was slightly lower than that of manual plan; dosimetric parameters of right and left femoral heads, spinal cord and bone marrow of the adaptive plan were better than those of manual plan. The adaptive plan had more monitor units (MU) than the manual plan, but the complexity of the adaptive plan was significantly lower than that of the manual plan (0.135±0.012 vs. 0.151±0.015, P<0.001). For Mobius γ pass rate (5%/3 mm), both adaptive and manual plans met clinical requirements. Conclusion:Ethos cervical cancer online adaptive plan, which is based on the IOE engine, demonstrates good robustness and ensures the quality of online adaptive plans generated for each treatment fraction.

Objective:To evaluate the automatic optimization performance and clinical feasibility of the intelligent optimization engine (IOE) in the Ethos online adaptive radiotherapy platform.Methods:Clinical data of 11 patients with postoperative cervical cancer treated with Halcyon accelerator were retrospectively analyzed. Manual planning was performed for all patients using the 4 full arc volumetric modulated arc therapy (VMAT) (Manual-4Arc) in Eclipse, with a prescription dose of 45 Gy/25F. Patient images and structures were imported into the Ethos simulator, and appropriate clinical goals were added based on clinical requirements. The target coverage was normalized to 95%. Automatic plan generation was conducted using IOE, resulting in 7, 9, and 12 field intensity modulated radiotherapy (IMRT) plans (IMRT-7F、IMRT-9F、IMRT-12F), as well as 2 and 3 arc VMAT plans (VMAT-2Arc、VMAT-3Arc). Dosimetric index comparisons were made between the Manual-4Arc plans and the 5 groups of IOE-generated plans through one-way analysis of variance. Based on the analysis results, Turky post hoc multiple comparisons were performed to evaluate the automatic optimization performance of IOE.Results:In terms of the high dose area, the IMRT-12F plans showed the lowest D 1% for the planning target volume (PTV), and there were significant differences compared to the Manual-4Arc plans ( P=0.004). Regarding target coverage, all groups produced clinical target volume (CTV) plans that met the clinical requirements. Although the Ethos online adaptive plans were normalized during planning, the PTV coverage was slightly insufficient. For organs at risk (OAR) close to the target, such as the bladder, there were significant differences in V 30 Gy, V 40 Gy, and D mean among the 6 groups of plans. The dose ranking for the bladder was generally as follows: IMRT-12F

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.

Objective:The clinical data of prenatal stillbirth were analyzed in order to increase the understand-ing of the causes of stillbirth.Methods:Prenatal stillbirth cases that terminated pregnancy in Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University from January 2018 to December 2022 were col-lected,and the distribution characteristics of clinical data and the stillbirth causes were analyzed.The causes of death were classified according to the standards developed by the Stillbirth Collaborative Research Network(SCRN)in the United States,and they were divided into clear cause-of-death group and unknown cause-of-death group.The different characteristics of the two groups were compared and analyzed.Results:There were 210 ca-ses of prenatal stillbirth during the study period,and 104 cases met the inclusion criteria.Among them,33 cases(31.7%)had autopsy results,39 cases(37.5%)had genetic results,and 75 cases(72.1%)had placental pathol-ogy.According to the classification of SCRN standard,55 cases(52.9%)were probably related to the cause of death,33 cases(31.7%)were classified as possible,13 cases(12.5%)were probably unrelated,and 3 cases(2.9%)could not be attributed to the cause of death,that is,84.6%(88 cases)in the clear cause of death group and 15.4%(16 cases)in the unknown cause of death group.The rate of placental pathological examination in the clear cause of death group was significantly higher than that in the unknown cause of death group(78.4%).In the classification of causes of death,placental pathological changes accounted for the largest proportion,account-ing for 26.9%(28 cases),followed by pregnancy complications accounting for 25.0%(26 cases),and 15.4%of the cases were still unexplained.Conclusions:Placental pathology is of great significance for clarifying the cause of stillbirth.It is feasible to use SCRN to classify the etiology of stillbirth.Pathological placental conditions account for a relatively high proportion in the classification of stillbirth causes.It is recommended that each case of stillbirth placenta should undergo pathological examination.