Thoracic Cancer Patients Research Articles

Cardiac Monitoring for Thoracic Radiotherapy: Survey of Practice Patterns in the United States

American Society of Clinical Oncology (ASCO)'s 2017 Guideline on Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers identified patients receiving thoracic radiation (TRT) ≥ 30 Gy (heart in field) at increased risk for developing radiation induced heart disease (RIHD). ASCO encouraged clinicians to actively screen and monitor for baseline modifiable cardiac risk factors and therapy-induced cardiotoxicity in this high-risk population, which would include a majority of lung and esophageal patients obtaining definitive TRT. Further, coronary artery calcium (CAC) is an independent risk factor for adverse cardiac events that can be mitigated with preventative medical therapy. CAC is easily identified on non-contrast thoracic CT simulation scans, yet it is unclear whether ROs are aware of the clinical implications of CAC seen on simulation scans. We sought to assess ROs practice patterns, experiences, and perceptions of cardiac screening and monitoring for TRT patients. A 28-question survey was emailed to United States ROs 3 times from September 2018 to January 2019. Responses were collected on Survey Monkey and descriptive statistics were used to report results. Of the 162 respondents from 42 states, 94% treat non-breast thoracic cancers to doses ≥ 45 Gy with heart in the field, 51% practice in academic settings, and 62% have an average of 1-5 thoracic cancer patients actively on treatment. While 22% have access to a Cardio-Oncology program, 81% were not aware of the ASCO cardiac monitoring guidelines. Only 24% agreed with these guidelines, whereas 41% thought they should be more specific and 35% were not sure. The most significant reported barrier to cardiac monitoring in asymptomatic patients was lack of strong evidence for type and timing of cardiac monitoring tests (69%). The majority (56%) did not monitor cardiac changes after RT. When monitoring, 38% prefer ECHO, yet 72% were unsure or had no preference as to which type of ECHO to order. While 62% agreed that RIHD could occur in any section of the heart in the RT field and that the earliest expected time-point that cancer survivors would be symptomatic from RIHD was <2years (27%), 2-5 years (41%) or 5-10 yrs (26%), 72% would NOT reduce tumor coverage and 67% would NOT reduce RT dose in order to minimize RT heart dose since the priority was cancer control. If CAC was evident on CT sim scans, 68% had never thought about what actions to take or did not take any actions, whereas 38% would refer to internist or cardiologist. Only 7% reported having ongoing clinical trials for cardiac monitoring at their centers. This survey highlights a critical gap in knowledge about cardiac monitoring and potentially missed opportunities for preventive medical management in a high risk population that may have competing life-threatening cardiac risks. Future studies focusing on timing and detection of RIHD may elucidate the utility of cardiac monitoring for TRT patients.

Severe Radiation Induced Dermatitis after IMRT or Proton Therapy for Thoracic Cancer Patients

Severe Radiation Induced Dermatitis after IMRT or Proton Therapy for Thoracic Cancer Patients

Fixed‐jaw technique to improve IMRT plan quality for the treatment of cervical and upper thoracic esophageal cancer

The purpose of this study was to investigate the potential advantages of the fixed‐jaw technique (FJT) over the conventional split‐field technique (SFT) for cervical and upper thoracic esophageal cancer (EC) patients treated with intensity‐modulated radiotherapy. The SFT and FJT plans were generated for 15 patients with cervical and upper thoracic EC. Dosimetric parameters and delivery efficiency were compared. An area ratio (AR) of the jaw opening to multileaf collimator (MLC) aperture weighted by the number of monitor units (MUs) was defined to evaluate the impact of the transmission through the MLC on the dose gradient outside the PTV50.4, and the correlation between the gradient index (GI) and AR was analyzed. The FJT plans achieved a better GI and AR (P < 0.001). There was a positive correlation between the GI and AR in the FJT (r = 0.883, P < 0.001) and SFT plans (r = 0.836, P < 0.001), respectively. Moreover, the mean dose (Dmean), V5Gy–V40Gy for the lungs and the Dmean, V5Gy–V50Gy for the body‐PTV50.4 in the FJT plans were lower than those in the SFT plans (P < 0.05). The FJT plans demonstrated a reduction trend in the doses to the spinal cord PRV and heart, but only the difference in the heart Dmean reached statistical significance (P < 0.05). The FJT plans reduced the number of MUs and subfields by 5.5% and 17.9% and slightly shortened the delivery time by 0.23 min (P < 0.05). The gamma‐index passing rates were above 95% for both plans. The FJT combined with target splitting can provide superior organs at risk sparing and similar target coverage without compromising delivery efficiency and should be a preferred intensity‐modulated radiotherapy planning method for cervical and upper thoracic EC patients.

Bio-physic constraint model using spatial registration of delta 18F-fluorodeoxyglucose positron emission tomography/computed tomography images for predicting radiation pneumonitis in esophageal squamous cell carcinoma patients receiving neoadjuvant chemoradiation.

PurposeThis study integrated clinical outcomes and radiomics of advanced thoracic esophageal squamous cell carcinoma patients receiving neoadjuvant concurrent chemoradiotherapy (NACCRT) to establish a novel constraint model for predicting radiation pneumonitis (RP).Patients and methodsWe conducted a retrospective review for thoracic advanced esophageal cancer patients who received NACCRT. From 2013 to 2018, 89 patients were eligible for review. Staging workup and response evaluation included positron emission tomography/computed tomography (PET/CT) scans and endoscopic ultrasound. Patients received RT with 48 Gy to gross tumor and 43.2 Gy to elective nodal area in simultaneous integrated boost method divided in 24 fractions. Weekly platinum-based chemotherapy was administered concurrently. Side effects were evaluated using CTCAE v4. Images of 2-fluoro-2-deoxyglucose PET/CT before and after NACCRT were registered to planning CT images to create a region of interest for dosimetry parameters that spatially matched RP-related regions, including V10, V20, V50%, V27, and V30. Correlation between bio-physic parameters and toxicity was used to establish a constraint model for avoiding RP.ResultsAmong the investigated cohort, clinical downstaging, complete pathological response, and 5-year overall survival rates were 59.6%, 40%, and 34.4%, respectively. Multivariate logistic regression analysis demonstrated that each individual set standardized uptake value ratios (SUVRs), neither pre- nor post-NACCRT, was not predictive. Interestingly, cutoff increments of 6.2% and 8.9% in SUVRs (delta-SUVR) in registered V20 and V27 regions were powerful predictors for acute and chronic RP, respectively.ConclusionSpatial registration of metabolic and planning CT images with delta-radiomics analysis using fore-and-aft image sets can establish a unique bio-physic prediction model for avoiding RP in esophageal cancer patients receiving NACCRT.

The usefulness of a bilateral trans-cervical pneumomediastinal approach for mediastinoscopic radical esophagectomy: a right transcervical approach is an available option.

We investigated the merits and demerits of right cervical open surgery with right trans-cervical pneumomediastinal approach in mediastinoscopic esophagectomy. Ten thoracic esophageal cancer patients were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. The average number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without using the right trans-cervical pneumomediastinal approach, it might be impossible to successfully remove some of the right cervical and upper mediastinal paraesophageal lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes lymph nodes. Regarding surgical complications, one case of bilateral recurrent nerve palsy as well as two cases on the right and two cases on the left were noted. Although the rate of recurrent nerve palsy should still be reduced, a bilateral (especially right-sided) trans-cervical pneumomediastinal approach is an available option for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

Effect of complementary Integrative Oncology on anxiety, depression and quality of life in thoracic cancer patients: A pilot study

PurposeThoracic-cancer (TC) patients have an extensive toll taken in terms of health-related quality of life (HRQL). Integrative Oncology (IO) is recognized as a valid complement to any Standard-Therapy treatment to improve outcomes in TC patients. The objective of this pilot-study was to evaluate the effect of adding IO (acupuncture, Cognitive-Behavior Therapy and mindfulness) in terms of depression, anxiety and HRQL. MethodsTC patients who attended the Thoracic Oncology-Unit from July to September 2018 were invited to participate. A total of 16 patients were included in the study, 8 patients were required to attend 5 weekly sessions of IO and 8 patients were invited as controls. Anxiety, depression and HRQL were measured at baseline and after completing 5 sessions of IO or 5 weeks, using the HADS scale and the QLQ-C30 scale. ResultsA total of 8 patients in the IO group attended the 5 sessions and 8 patients were followed as controls. Compliance with the therapies was high, none of the patients dropped out from the study. A tendency for improvement in anxiety, fatigue, pain and dyspnea was observed in patients attending IO, though not statistically significant likely due to sample size. ConclusionsIO therapies are well accepted among TC patients. Larger studies are necessary with robust sample sizes to improve conclusions regarding outcome improvements.

Technical Note: Density correction to improve CT number mapping in thoracic deformable image registration.

To improve the accuracy of computed tomography (CT) number mapping inside the lung in deformable image registration with large differences in lung volume for applications in vertical CT imaging and adaptive radiotherapy. The deep inspiration breath hold (DIBH) CT image and the end of exhalation (EE) phase image in four-dimensional CT of 14 thoracic cancer patients were used in this study. Lung volumes were manually delineated. A Demons-based deformable registration was first applied to register the EE CT to the DIBH CT for each patient, and the resulting deformation vector field deformed the EE CT image to the DIBH CT space. Given that the mass of the lung remains the same during respiration, we created a mass-preserving model to correlate lung density variations with volumetric changes, which were characterized by the Jacobian derived from the deformation field. The Jacobian determinant was used to correct the lung CT numbers transferred from the EE CT image. The absolute intensity differences created by subtracting the deformed EE CT from the DIBH CT with and without density correction were compared. The ratio of DIBH CT to EE CT lung volumes was 1.6 on average. The deformable registration registered the lung shape well, but the appearance of voxel intensities inside the lung was different, demonstrating the need for density correction. Without density correction, the mean and standard deviation of the absolute intensity difference between the deformed EE CT and the DIBH CT inside the lung were 54.5±45.5 for all cases. After density correction, these numbers decreased to 18.1±34.9, demonstrating greater accuracy. The cumulative histogram of the intensity difference also showed that density correction improved CT number mapping greatly. Density correction improves CT number mapping inside the lung in deformable image registration for difficult cases with large lung volume differences.

PACE: A Probabilistic Atlas for Normal Tissue Complication Estimation in Radiation Oncology.

In radiation oncology, the need for a modern Normal Tissue Complication Probability (NTCP) philosophy to include voxel-based evidence on organ radio-sensitivity (RS) has been acknowledged. Here a new formalism (Probabilistic Atlas for Complication Estimation, PACE) to predict radiation-induced morbidity (RIM) is presented. The adopted strategy basically consists in keeping the structure of a classical, phenomenological NTCP model, such as the Lyman-Kutcher-Burman (LKB), and replacing the dose distribution with a collection of RIM odds, including also significant non-dosimetric covariates, as input of the model framework. The theory was first demonstrated in silico on synthetic dose maps, classified according to synthetic outcomes. PACE was then applied to a clinical dataset of thoracic cancer patients classified for lung fibrosis. LKB models were trained for comparison. Overall, the obtained learning curves showed that the PACE model outperformed the LKB and predicted synthetic outcomes with an accuracy >0.8. On the real patients, PACE performance, evaluated by both discrimination and calibration, was significantly higher than LKB. This trend was confirmed by cross-validation. Furthermore, the capability to infer the spatial pattern of underlying RS map for the analyzed RIM was successfully demonstrated, thus paving the way to new perspectives of NTCP models as learning tools.

Efficacy of preserving the residual stomach in esophageal cancer patients with previous gastrectomy.

There is no consensus concerning whether the residual stomach should be preserved after esophagectomy for thoracic esophageal cancer patients with previous distal or segmental gastrectomy. The purpose of this retrospective study was to assess the efficacy of preserving the residual stomach after esophagectomy in patients with previous gastrectomy. Between 2000 and 2015, 45 consecutive thoracic esophageal cancer patients with previous distal or segmental gastrectomy underwent esophagectomy followed by colon reconstruction. Patients were assigned to two groups according to how the residual stomach was treated (preservation group, n = 11; resection group, n = 34). We compared surgical outcomes and alterations of nutrition status, including the skeletal muscle area, between the two groups. In addition, we investigated the distribution of abdominal lymph node metastases in the resection group. Operative time and blood loss tended to be lower in the preservation group compared to the resection group. However, the difference did not reach statistical significance. The rate of patients decreasing skeletal muscle area after surgery was significantly higher in the resection group (88% vs 50%, P = 0.03). There were no patients with metastatic abdominal lymph nodes when the previous gastrectomy had been performed for gastric cancer and the esophageal cancer was located at the upper or middle esophagus in the resection group. Preservation of the residual stomach after esophagectomy in esophageal cancer patients with previous gastrectomy may influence the postoperative nutrition status and can be selectively approved.

Radiosensitivity nomogram based on circulating neutrophils in thoracic cancer.

To evaluate the prediction ability of neutrophils and develop a nomogram on radiosensitivity in thoracic cancer patients. We retrospectively reviewed 398 lung and esophageal cancers patients who received external-beam radiotherapy or concurrent chemoradiotherapy as first-line therapy. Logistic regression model showed that patients with low levels of neutrophil counts and/or TGF-β1 exhibited better radiation sensitivity. Furthermore, a nomogram was created to predict radiotherapy sensitivity. The combination of neutrophil count and TGF-β1 level was an independent prognostic factor for lung and esophageal cancers patients. The study developed a nomogram based on the levels of circulating neutrophils and TGF-β1. The prediction value in radiosensitivity and protumorigenic effect of neutrophils might owe to N2 tumor-associated neutrophils.

A post-processing method based on interphase motion correction and averaging to improve image quality of 4D magnetic resonance imaging: a clinical feasibility study.

Nine patients (seven pancreas, one liver, and one lung) were recruited. 4D-MRI was performed using two prototype k-space sorted techniques, stack-of-stars (SOS) and koosh-ball (KB) acquisitions. Post-processing using MoCoAve was implemented for both methods. Image quality score, apparent SNR (aSNR), sharpness, motion trajectory and standard deviation (σ_GTV) of the gross tumor volumes were compared between original and MoCoAve image sets. All subjects successfully underwent 4D-MRI scans and MoCoAve was performed on all data sets. Significantly higher image quality scores (2.64 ± 0.39 vs 1.18 ± 0.34, p = 0.001) and aSNR (37.6 ± 15.3 vs 18.1 ± 5.7, p = 0.001) was observed in the MoCoAve images when compared to the original images. High correlation in tumor motion trajectories in the superoinferior direction (SI: 0.91 ± 0.08) and weaker in the anteroposterior (AP: 0.51 ± 0.44) and mediolateral (ML: 0.37 ± 0.23) directions, similar image sharpness (0.367 ± 0.068 vs 0.369 ± 0.072, p = 0.805), and minimal average absolute difference (0.47 ± 0.34 mm) of the motion trajectory profiles was found between the two image sets. The σ_GTV in pancreas patients was significantly (p = 0.039) lower in MoCoAve images (1.48 ± 1.35 cm3) than in the original images (2.17 ± 1.31 cm3). MoCoAve using interphase motion correction and averaging has shown promise as a post-processing method for improving k-space sorted (SOS and KB) 4D-MRI image quality in thoracic and abdominal cancer patients. The proposed method is an image based post-processing method that could be applied to many k-space sorted 4D-MRI methods for improved image quality and signal-to-noise ratio while preserving image sharpness and respiratory motion fidelity. It is a useful technique for the radiotherapy planning community who are interested in using 4D-MRI but aren't satisfied with their current MR image quality.

Perioperative Venous Thromboembolism (VTE) Prophalaxis in Thoracic Cancer Patients: Chinese Experts Consensus

【中文题目：胸部恶性肿瘤围术期静脉血栓栓塞症预防 中国专家共识（2018版）】.

Thalidomide (THD) alleviates radiation induced lung fibrosis (RILF) via down-regulation of TGF-β/Smad3 signaling pathway in an Nrf2-dependent manner

Radiation-induced lung fibrosis (RILF) is a complication of radiotherapy in thoracic cancer patients. Thalidomide (THD) has a therapeutic effect on fibrotic and inflammatory disorders. The purpose of the current study was to investigate the therapeutic effect of THD on RILF in mice and better understand the underlying regulatory mechanisms of the therapeutic effect. We found that THD mitigated the fibrosis caused by irradiation in mice. The action of THD on RILF was related to the elevation of low levels reactive oxygen species (ROS), which inhibited the transforming growth factor‑β (TGF‑β)/Smad3 signaling pathway through activation of nuclear factor (erythroid-derived 2)-like 2 (Nrf2). Analysis of the therapeutic effect of THD using Nrf2-/- mouse model confirmed the role of Nrf2 in vivo. In addition, no radioprotective effect of THD on thoracic cancer cell lines was observed. In conclusion, these data showed that THD attenuated RILF in mice, which was mediated by Nrf2-dependent down-regulation of the TGF-β/Smad3 pathway, suggesting THD as a potential novel agent for RILF prevention.

RA07.09: THE EFFICACY OF ASSESSING METASTATIC LYMPH NODES BY COMPUTED TOMOGRAPHY IN ADVANCED ESOPHAGEAL CANCER WITH NEOADJUVANT CHEMOTHERAPY

Abstract Background Although various modalities including CT, endoscopy, and positron emission tomography (PET) have been used to predict pathological tumor response (pTR) to neoadjuvant chemotherapy (NACT) or prognosis in esophageal cancer patients, an optimal method of response evaluation remains to be established. Methods A total of 97 non-T4 thoracic esophageal cancer patients who underwent curative surgery after NACT from 2011 to 2014 with both measurable primary tumors (PT) and metastatic lymph nodes (LNs) by CT (≥ 10mm in short axis or ≥ 5mm in short axis with SUV-max ≥ 2.5) were analyzed. Patients with ≥ 50% decrease in size of the PT (two-direction measurement) and ≥ 30% decrease in size of LNs (sum of short diameter based on RECIST criteria) were defined as PT- and LNs-responders, respectively. Results The median reduction rate of PT and LNs were 62.0% (5.5–93.4) and 26.7% (60.9–13.6), respectively. Of 97 patients, 62 (69%) and 45 patients (45%) were classified as PT- and LNs-responders respectively. The concordance rate between CT response of PT and LNs was 66% (P = 0.01). CT response of PT was correlated with pTR (P&lt;0.0001) while CT response of LNs was associated with pT (P = 0.0011), pN(P = 0.0004), and pTR (P &lt; 0.0001). Receiver operating characteristic (ROC) curves demonstrated the highest accuracy (AUC 0.75), sensitivity (88.9%) and specificity (60.9%) at the reduction rate of 53% (P = 0.007) which was approximated to the cutoff value we used. In univariate analysis of recurrence free survival (RFS), pT, pN, pM, CT response of both PT and LNs, and pTR were significantly correlated with RFS. Multivariate analysis further identified CT response of LNs (HR 2.68 P = 0.003) and pTR (HR 2.72 P = 0.022) to be independently associated with RFS. When classified into three groups by histological grade and CT response of LNs [group A (grade2–3/LNs-responders), group B (grade1a-1b/LNs-nonresponders), and group C (others)], 2-year RFS were 83% in the groupA, 59% in groupC and 29% in groupB (P &lt; 0.0001), respectively. Conclusion In locally-advanced esophageal cancer patients with NACT followed by surgery, CT response of PT and LNs significantly correlated with pTR. Especially, CT response of LNs was important to predict prognosis in addition to pTR. Disclosure All authors have declared no conflicts of interest.

Effect of respiratory guidance on internal/external respiratory motion correlation for synchrotron-based pulsed heavy-ion radiotherapy

Having implemented an audio-visual biofeedback (BFB) method for respiratory-gated radiotherapy of synchrotron-based pulsed heavy-ion beam delivery with tracking of external abdominal wall motion, this study evaluated the feasibility of the respiratory guidance method on thoracic and abdominal cancer patients, and the internal/external respiratory motion consistency under respiratory guidance maneuvers due to its interactive intervention in free breathing (FB). A total of 42 breathing traces from seven lung and breast cancer patients and corresponding fluoroscopy movies under FB, standard breath hold (stBH) and representative breath hold (reBH) guidance maneuvers were analyzed. Diaphragm motions were measured manually on a frame-by-frame basis. Mean absolute deviation (MAD) values of the measured external motion curves were calculated for the FB and guidance maneuvers, and the internal/external motion consistencies were compared with a linear fit. Compared with FB, the MAD values were reduced significantly with respiratory guidance maneuvers. The mean internal/external correlations of the first treatment fraction were determined to be 0.96 ± 0.03, 0.97 ± 0.02, and 0.97 ± 0.03 for the FB, stBH and reBH guidance maneuvers, respectively, and were 0.95 ± 0.03, 0.97 ± 0.03, and 0.98 ± 0.02 for the second treatment fraction. No phase shift between the two breathing signals was observed, and good reproducibility of consistency of breathing guidance between the two fractions was achieved. These results demonstrated that treatment precision could be improved for cancer patients with audio-visual BFB, and a strong correlation between diaphragm motion and abdominal wall motion was obtained. The use of audio-visual BFB improved the regularity of both internal and external motions, allowing confident use of the audio-visual BFB method by tracking of the external abdominal wall motion to synchrotron-based heavy-ion radiotherapy.

Research progress in radiation-induced lung injury

Radiation-induced lung injury (RILI) is a severe complication which commonly occurs after radiotherapy in patients diagnosed with thoracic cancer patients. RILI includes acute radiation-induced pneumonitis and fibrosis. RILI not only limits the radiotherapy dose, but also affects subsequent clinical efficacy and quality of life of patients. The mechanism underlying RILI has been mainly investigated in animal models. Multiple cells, cytokines and molecules participate in the regulation of immune response, eventually leading to the incidence of RILI. No guidelines or standards have been established for the treatment of RILI, which primarily depend upon clinical experience and professional recommendations. In this article, recent RILI-related studies have been summarized to unravel the pathophysiological changes, clinical symptoms, imaging findings, clinical diagnosis and treatment of RILI. Key words: Radiation-induced lung injury; Mechanism; Thoracic neoplasm/radiotherapy

A longitudinal study of muscle strength and function in patients with cancer cachexia.

Patients with cancer frequently experience an involuntary loss of weight (in particular loss of muscle mass), defined as cachexia, with profound implications for independence and quality of life. The rate at which such patients' physical performance declines has not been well established. The aim of this study was to determine the change in muscle strength and function over 8weeks in patients with already established cancer cachexia, to help inform the design and duration of physical activity interventions applicable to this patient group. Patients with thoracic and gastrointestinal cancer and with unintentional weight loss of > 5% in 6months or BMI < 20 plus 2% weight loss were included. Physical and functional assessments (baseline, 4weeks, 8weeks) included isometric quadriceps and hamstring strength, handgrip, standing balance, 10-m walk time and timed up and go. Fifty patients (32 male), mean ± SD age 65 ± 10years and BMI 24.9 ± 4.3kg/m2, were recruited. Thoracic cancer patients had lower muscle strength and function (p < 0.05). Despite notable attrition, in patients who completed all assessments (8 thoracic and 12 gastrointestinal), there was little change in performance over 8weeks (p > 0.05). Baseline variables did not differentiate between completers and non-completers (p > 0.05). More than a third of patients with established cancer cachexia in our study were stable over 8weeks, suggesting a subgroup who may benefit from targeted interventions of reasonable duration. Better understanding the physical performance parameters which characterise and differentiate these patients has important clinical implications for cancer multidisciplinary team practice.

Development and evaluation of screening dysphagia tools for observational studies and routine care in cancer patients.

Background and aimsDysphagia can be associated with significant morbidity in cancer patients. We aimed to develop and evaluate dysphagia screener tools for use in observational studies (phase 1) and for routine symptom monitoring in clinical care (phase 2).MethodsVarious dysphagia or odynophagia screening questions, selected after an expert panel reviewed the content, criterion, and construct validity, were compared with either functional assessment of cancer therapy ‐ esophageal cancer (FACT‐E) Swallowing Index Cut‐Off Values or to questions adapted from the Patient Reported Outcomes for Common Terminology Criteria for Adverse Events. Sensitivity, specificity, and patient acceptability were assessed.ResultsIn Phase 1 (n = 178 esophageal cancer patients), the screening question “How are you currently eating?” had the highest sensitivities and specificities against various Swallowing Index Cut‐Off Value cut‐offs, with the best optimal cutoff associated with weight loss (80% sensitivity and 75% specificity). In phase 2 (255 head and neck, gastro‐esophageal, and thoracic cancer patients), a single question screener (“Do you experience any difficulty or pain upon swallowing?”) versus a Patient Reported Outcomes for Common Terminology Criteria for Adverse Events–like gold standard generated sensitivities between 86% and 94% and specificities between 93% and 100%. This screening question (+/− follow‐up questions) had a median completion time of under 2 minutes, and >90% of patients were willing to complete the survey electronically, did not feel that survey made clinic visit more difficult, and did not find the questions upsetting or distressful.ConclusionOur results demonstrate that these screener tools (“How are you currently eating?”, “Do you experience any difficulty or pain upon swallowing?”) can effectively screen dysphagia symptoms without increasing cancer outpatient clinic burden, both in observational studies and for routine clinical monitoring.

Long-term survival of the middle and lower thoracic esophageal cancer patients after surgical treatment through left or right thoracic approach.

Esophageal cancer is one of the most prevalent malignancies with a high incidence and mortality in China, the main treatment for esophageal cancer at present is still surgery-based multimodality treatment, and surgery is still the most effective measure. However, the modes of surgical treatment for esophageal cancer have been diverse. The surgical approaches can be mainly divided into the left thoracic approach and right thoracic approach in China. The long-term survival of the patients treated through right approach was reported better than that through left thoracic approach, but until now no statistically significant difference was found between two approaches, especially, for those with middle and lower thoracic esophageal cancer without suspected upper mediastinal lymph node metastasis in preoperative examinations, no definite conclusion have been made on selection of the approach, therefore, this studies try to compare the long-term survival between two approaches . The data of 402 cases with complete resection and two-field lymph node dissection from January, 2011 to December, 2011 in the Cancer Hospital, Chinese Academy of Medical Sciences was retrospectively reviewed and analyzed. Propensity score matching (PSM) analysis and life-table in SPSS 22.0 and Stata 14.0 were used to analyze the survival. Totally, 402 cases were surgically treated either via left or right thoracic approach. The overall 5-year survival rate of this series was 38%, it was 37% in 281 cases surgically treated through left approach, and 39% in 121 cases through right approach (P=0.908). The 5-year survival of 256 patients without suspected lymph node metastasis in the upper mediastinum based on the preoperative examinations surgically treated through left approach was 38% versus 43% of 88 cases through right approach (P=0.404). After PSM, the 5-year survival of 110 cases surgically treated through left approach was 32% versus 40% of another matched 110 cases through right approach (P=0.146). for the patients without suspected lymph node metastasis in the upper mediastinum based on preoperative examinations, the 5-year survival of 88 surgically treated through left approach was 33% versus 44% of another matched 88 cases through right approach (P=0.239). For the middle and lower thoracic esophageal cancer patients, whether or not who has suspected lymph node metastasis in the upper mediastinum based on preoperative CT and EUS, the surgical treatment through right thoracic approach can achieve better but not significantly better overall survival than that through left thoracic approach. Further prospective randomized clinical trials are still needed to verify this disputed issue on approach selection.

Principal component analysis-based imaging angle determination for 3D motion monitoring using single-slice on-board imaging.

Through-plane motion introduces uncertainty in three-dimensional (3D) motion monitoring when using single-slice on-board imaging (OBI) modalities such as cine MRI. We propose a principal component analysis (PCA)-based framework to determine the optimal imaging plane to minimize the through-plane motion for single-slice imaging-based motion monitoring. Four-dimensional computed tomography (4DCT) images of eight thoracic cancer patients were retrospectively analyzed. The target volumes were manually delineated at different respiratory phases of 4DCT. We performed automated image registration to establish the 4D respiratory target motion trajectories for all patients. PCA was conducted using the motion information to define the three principal components of the respiratory motion trajectories. Two imaging planes were determined perpendicular to the second and third principal component, respectively, to avoid imaging with the primary principal component of the through-plane motion. Single-slice images were reconstructed from 4DCT in the PCA-derived orthogonal imaging planes and were compared against the traditional AP/Lateral image pairs on through-plane motion, residual error in motion monitoring, absolute motion amplitude error and the similarity between target segmentations at different phases. We evaluated the significance of the proposed motion monitoring improvement using paired t test analysis. The PCA-determined imaging planes had overall less through-plane motion compared against the AP/Lateral image pairs. For all patients, the average through-plane motion was 3.6mm (range: 1.6-5.6mm) for the AP view and 1.7mm (range: 0.6-2.7mm) for the Lateral view. With PCA optimization, the average through-plane motion was 2.5mm (range: 1.3-3.9mm) and 0.6mm (range: 0.2-1.5mm) for the two imaging planes, respectively. The absolute residual error of the reconstructed max-exhale-to-inhale motion averaged 0.7mm (range: 0.4-1.3mm, 95% CI: 0.4-1.1mm) using optimized imaging planes, averaged 0.5mm (range: 0.3-1.0mm, 95% CI: 0.2-0.8mm) using an imaging plane perpendicular to the minimal motion component only and averaged 1.3mm (range: 0.4-2.8mm, 95% CI: 0.4-2.3mm) in AP/Lateral orthogonal image pairs. The root-mean-square error of reconstructed displacement was 0.8mm for optimized imaging planes, 0.6mm for imaging plane perpendicular to the minimal motion component only, and 1.6mm for AP/Lateral orthogonal image pairs. When using the optimized imaging planes for motion monitoring, there was no significant absolute amplitude error of the reconstructed motion (P=0.0988), while AP/Lateral images had significant error (P=0.0097) with a paired t test. The average surface distance (ASD) between overlaid two-dimensional (2D) tumor segmentation at end-of-inhale and end-of-exhale for all eight patients was 0.6±0.2mm in optimized imaging planes and 1.4±0.8mm in AP/Lateral images. The Dice similarity coefficient (DSC) between overlaid 2D tumor segmentation at end-of-inhale and end-of-exhale for all eight patients was 0.96±0.03 in optimized imaging planes and 0.89±0.05 in AP/Lateral images. Both ASD (P=0.034) and DSC (P=0.022) were significantly improved in the optimized imaging planes. Motion monitoring using imaging planes determined by the proposed PCA-based framework had significantly improved performance. Single-slice image-based motion tracking can be used for clinical implementations such as MR image-guided radiation therapy (MR-IGRT).