Purpose: Although customized three-dimensional (3D) templates have shown advantages in brachytherapy, widespread application is still full of challenges. The present work proposed the use of a commercial 3D standardized template-guided intracavitary/interstitial brachytherapy (IC/ISBT) that could provide simple and reproducible needles’ insertion.
Material and methods: 43 patients received external beam radiotherapy (EBRT) with 45-50.4 Gy and subsequent IC/ISBT with 28 Gy in 4 fractions. In terms of IC/ISBT, 24 patients were treated with 3D standardized templates (ST group), and 19 patients were treated using free-hand implantation (FH group). Consistency of implantation for all needles and dosimetric differences for target and organs at risk (OARs) were then compared between two groups.
Results: The mean variation of tip position between insertions for needles was 1.41 mm and 2.74 mm in ST group and FH group, respectively (p < 0.001). ST group was superior in terms of dosimetric conformity index (CI) and D90 for high-risk clinical target volume (HR-CTV), significantly improving to 23.21% (p < 0.001) and 3.58% (p = 0.031) compared with FH group. The D2cc of the bladder and sigmoid in the ST group were lower than those in the FH group (p < 0.05). Meanwhile, a strong correlation between the volume of HR-CTV and its CI in the ST group (R = 0.865, p < 0.001) was found with Spearman’s correlation analysis.
Conclusions: The implementation of 3D standardized template can potentially improve the precision and consistency in the needle insertion procedure that may replace some customized 3D templates, and achieve clinical satisfied dose distribution in IC/ISBT plans for patients with LACC.
{"title":"Clinical implementation of three-dimensional standardized template-guided brachytherapy for patients with locally advanced cervical cancer","authors":"Yeqiang Tu, Jiahao Wang, Yukai Chen, Yuanyuan Chen, Qiu Tang","doi":"10.5114/jcb.2023.134170","DOIUrl":"https://doi.org/10.5114/jcb.2023.134170","url":null,"abstract":"<b>Purpose:</b><br/>Although customized three-dimensional (3D) templates have shown advantages in brachytherapy, widespread application is still full of challenges. The present work proposed the use of a commercial 3D standardized template-guided intracavitary/interstitial brachytherapy (IC/ISBT) that could provide simple and reproducible needles’ insertion.<br/><br/><b>Material and methods:</b><br/>43 patients received external beam radiotherapy (EBRT) with 45-50.4 Gy and subsequent IC/ISBT with 28 Gy in 4 fractions. In terms of IC/ISBT, 24 patients were treated with 3D standardized templates (ST group), and 19 patients were treated using free-hand implantation (FH group). Consistency of implantation for all needles and dosimetric differences for target and organs at risk (OARs) were then compared between two groups.<br/><br/><b>Results:</b><br/>The mean variation of tip position between insertions for needles was 1.41 mm and 2.74 mm in ST group and FH group, respectively (<i>p</i> < 0.001). ST group was superior in terms of dosimetric conformity index (CI) and D90 for high-risk clinical target volume (HR-CTV), significantly improving to 23.21% (<i>p</i> < 0.001) and 3.58% (<i>p</i> = 0.031) compared with FH group. The D2cc of the bladder and sigmoid in the ST group were lower than those in the FH group (<i>p</i> < 0.05). Meanwhile, a strong correlation between the volume of HR-CTV and its CI in the ST group (<i>R</i> = 0.865, <i>p</i> < 0.001) was found with Spearman’s correlation analysis.<br/><br/><b>Conclusions:</b><br/>The implementation of 3D standardized template can potentially improve the precision and consistency in the needle insertion procedure that may replace some customized 3D templates, and achieve clinical satisfied dose distribution in IC/ISBT plans for patients with LACC.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"10 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139412423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: This survey aimed to understand the practice pattern and attitude of Indian doctors towards prostate brachytherapy.
Material and methods: A 21-point questionnaire was designed in Google form and sent to radiation oncologists practicing in India, using texts, mails, and social media. Responses were collated, and descriptive statistical analysis was performed.
Results: A total of 212 radiation oncologists from 136 centers responded to the survey questionnaire, with majority (66%) being post-specialty training > 6 years. We found that about 44.3% (n = 94) of respondents do not practice interstitial brachytherapy for any site, and majority (83.3%, n = 175) do not practice high-dose-rate (HDR) prostate brachytherapy. Only 2.8% (n = 6) of doctors preferred boost by brachytherapy compared with 38.1% (n = 80) of respondents, who favored stereotactic body radiation therapy (SBRT) boost. When asked about the indication of HDR prostate brachytherapy in Indian setting, 32.5% (n = 67) of respondents favored monotherapy, 46.1% (n = 95) of oncologists thought boost as a good indication, and 21.4% (n = 44) preferred re-irradiation/salvage setting. The most cited reason for prostate brachytherapy not being popularly practiced in India was lack of training (84.8%, n = 179). It was also noted that out of 80 respondents who practiced SBRT for prostate boost, 37 would prefer HDR brachytherapy boost if given adequate training and facilities.
Conclusions: The present survey provided insight on practice of prostate brachytherapy in India. It is evident that majority of radiation oncologists do not practice HDR prostate brachytherapy due to lack of training and infrastructure. Indian physicians are willing to learn and start prostate brachytherapy procedures if dedicated training and workshops are organized.
{"title":"Current status and future readiness of Indian radiation oncologists to embrace prostate high-dose-rate brachytherapy: An Indian Brachytherapy Society survey","authors":"Susovan Banerjee, Soumya Sarkar, Umesh Mahantshetty, Sorun Shishak, Venkatesan Kaliyaperumal, Shyam Singh Bisht, Deepak Gupta, Kushal Narang, Mayur Mayank, V Srinivasan, Vivek Anand, Kanhu Charan Patro, Rajiv Ranjan Prasad, Tejinder Kataria","doi":"10.5114/jcb.2023.134168","DOIUrl":"https://doi.org/10.5114/jcb.2023.134168","url":null,"abstract":"<b>Purpose:</b><br/>This survey aimed to understand the practice pattern and attitude of Indian doctors towards prostate brachytherapy.<br/><br/><b>Material and methods:</b><br/>A 21-point questionnaire was designed in Google form and sent to radiation oncologists practicing in India, using texts, mails, and social media. Responses were collated, and descriptive statistical analysis was performed.<br/><br/><b>Results:</b><br/>A total of 212 radiation oncologists from 136 centers responded to the survey questionnaire, with majority (66%) being post-specialty training > 6 years. We found that about 44.3% (<i>n</i> = 94) of respondents do not practice interstitial brachytherapy for any site, and majority (83.3%, <i>n</i> = 175) do not practice high-dose-rate (HDR) prostate brachytherapy. Only 2.8% (<i>n</i> = 6) of doctors preferred boost by brachytherapy compared with 38.1% (<i>n</i> = 80) of respondents, who favored stereotactic body radiation therapy (SBRT) boost. When asked about the indication of HDR prostate brachytherapy in Indian setting, 32.5% (<i>n</i> = 67) of respondents favored monotherapy, 46.1% (<i>n</i> = 95) of oncologists thought boost as a good indication, and 21.4% (<i>n</i> = 44) preferred re-irradiation/salvage setting. The most cited reason for prostate brachytherapy not being popularly practiced in India was lack of training (84.8%, <i>n</i> = 179). It was also noted that out of 80 respondents who practiced SBRT for prostate boost, 37 would prefer HDR brachytherapy boost if given adequate training and facilities.<br/><br/><b>Conclusions:</b><br/>The present survey provided insight on practice of prostate brachytherapy in India. It is evident that majority of radiation oncologists do not practice HDR prostate brachytherapy due to lack of training and infrastructure. Indian physicians are willing to learn and start prostate brachytherapy procedures if dedicated training and workshops are organized.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"29 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139398542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: To compare dose volume parameters of target and organs at risk in vaginal vault brachytherapy using ovoids or cylinder in post-operative endometrial carcinoma.
Material and methods: The study was done among 25 histologically proven post-operative endometrial carcinoma patients requiring vaginal brachytherapy. All patients underwent both cylinder and ovoids application alternatively on weekly basis. Ovoids size ranged from 2 to 3 cm diameter. Diameters of cylinder ranged between 2.5 and 3.5 cm. Bladder, rectum, urethra, and clinical target volume (CTV) were contoured on CT simulation images. Prescribed dose was 6-7 Gy in 2-3 fractions at 0.5 cm from the surface of applicator.
Results: The mean values of D90, D50, V150, V100, V90, and V50 of CTV were comparable between cylinder and ovoids plans. The mean dose of CTV was significantly higher with cylinder than with ovoids, and D100 was significantly higher with ovoids (mean = 15.63 Gy vs. 14.64 Gy, p = 0.016, and D100 = 37.82% vs. 42.86%, p = 0.042, for cylinder vs. ovoids). In the dosimetry of the vault, D90, D50, V100, V90, V50, and mean of the vault did not show any significant difference between cylinder and ovoids. The V150 was significantly higher with cylinder plans than ovoids, and D100 of the vault was significantly higher with ovoids plans (V150 = 14.81% vs. 6.86%, p = 0.02, and D100 = 37.77% vs. 44.80%, p = 0.029, for cylinder vs. ovoids). D0.1cc, D1cc, D2cc, and mean for the bladder, rectum, and urethra were comparable between the cylinder and ovoid plans.
Conclusions: The present study showed that the dose to organs at risk, most of the dosimetric parameters of CTV, and vault were comparable between the cylinder and ovoid plans. Both applicators provide good reproducibility. The choice of applicator will ultimately depend on the institutional policies and oncologist decision. However, in patients with dog-ear configuration of the vagina, ovoids may be preferred as per ABS guidelines.
{"title":"Comparison of dosimetric analysis of organs at risk and target volumes for ovoids and cylinders in endometrial carcinoma","authors":"Yashaswini BR, Tanvir Pasha, Rekha Reddy, Naveen T, Siddanna R Palled, Uday Krishna, Lokesh V, Sridhar P, Nikhila R, Thejaswini B, Chundru Swaroopa","doi":"10.5114/jcb.2023.134171","DOIUrl":"https://doi.org/10.5114/jcb.2023.134171","url":null,"abstract":"<b>Purpose:</b><br/>To compare dose volume parameters of target and organs at risk in vaginal vault brachytherapy using ovoids or cylinder in post-operative endometrial carcinoma.<br/><br/><b>Material and methods:</b><br/>The study was done among 25 histologically proven post-operative endometrial carcinoma patients requiring vaginal brachytherapy. All patients underwent both cylinder and ovoids application alternatively on weekly basis. Ovoids size ranged from 2 to 3 cm diameter. Diameters of cylinder ranged between 2.5 and 3.5 cm. Bladder, rectum, urethra, and clinical target volume (CTV) were contoured on CT simulation images. Prescribed dose was 6-7 Gy in 2-3 fractions at 0.5 cm from the surface of applicator.<br/><br/><b>Results:</b><br/>The mean values of D<sub>90</sub>, D<sub>50</sub>, V<sub>150</sub>, V<sub>100</sub>, V<sub>90</sub>, and V<sub>50</sub> of CTV were comparable between cylinder and ovoids plans. The mean dose of CTV was significantly higher with cylinder than with ovoids, and D<sub>100</sub> was significantly higher with ovoids (mean = 15.63 Gy vs. 14.64 Gy, <i>p</i> = 0.016, and D<sub>100</sub> = 37.82% vs. 42.86%, <i>p</i> = 0.042, for cylinder vs. ovoids). In the dosimetry of the vault, D<sub>90</sub>, D<sub>50</sub>, V<sub>100</sub>, V<sub>90</sub>, V<sub>50</sub>, and mean of the vault did not show any significant difference between cylinder and ovoids. The V<sub>150</sub> was significantly higher with cylinder plans than ovoids, and D<sub>100</sub> of the vault was significantly higher with ovoids plans (V<sub>150</sub> = 14.81% vs. 6.86%, <i>p</i> = 0.02, and D<sub>100</sub> = 37.77% vs. 44.80%, <i>p</i> = 0.029, for cylinder vs. ovoids). D<sub>0.1cc</sub>, D<sub>1cc</sub>, D<sub>2cc</sub>, and mean for the bladder, rectum, and urethra were comparable between the cylinder and ovoid plans.<br/><br/><b>Conclusions:</b><br/>The present study showed that the dose to organs at risk, most of the dosimetric parameters of CTV, and vault were comparable between the cylinder and ovoid plans. Both applicators provide good reproducibility. The choice of applicator will ultimately depend on the institutional policies and oncologist decision. However, in patients with dog-ear configuration of the vagina, ovoids may be preferred as per ABS guidelines.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"127 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139412087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Eugene T Yap, Mark P Dumago, Carl Jay Jainar, Maureen Bojador, Stellar Marie Cabrera, Gil S Gonzalez, Jocelyn Z Mariano, Aida Bautista, Jhustine Mababangloob, Janell Marie Genson, Teresa Sy Ortin, Warren R Bacorro
Purpose: The aim of the study was to evaluate the safety and clinical outcomes of single application multi-fractionated computed tomography (CT)-guided interstitial high-dose-rate brachytherapy given in four fractions in locally advanced cervical cancer.
Material and methods: Patients with locally advanced cervical cancer stage IIB-IVA treated definitively with external radiation ± weekly cisplatin, followed by single application multi-fractionated CT-guided interstitial high-dose-rate brachytherapy in four fractions were included. Dosimetry data, clinical response, and toxicity records were reviewed.
Results: Between January 2018 and December 2022, twenty-two patients were included. Clinical stage distribution was as follows: IIB – 13.6%, IIIB – 27.3%, IIIC – 22.7%, and IVA – 36.4%. Mean high-risk clinical target volume (HR-CTV) was 66.19 ±32.69 cm3, and HR-CTV D90 dose was 86.8 ±1.7 Gy. 2 cc doses to bladder, rectum, and sigmoid were 84.6 ±2.8 Gy, 71.5 ±2.4 Gy, and 65.6 ±4.0 Gy, respectively. Mean overall treatment time was 66 ±21 days. With a median follow-up of 11.5 months (range, 5-44 months), median survival and local control were not achieved. One-year local control rate, one-year progression-free survival, and one-year overall survival were 82%, 66%, and 78%, respectively. Univariate analysis showed overall treatment time to be the only variable associated with all oncologic outcomes. For acute toxicity, grade 3 toxicity in four patients and grade 4 toxicity of infection in one patient were observed. For late toxicity, grade 3 gastrointestinal toxicity was noted in two patients.
Conclusions: Initial results suggest that single application multi-fractionated CT-guided interstitial brachytherapy given in four fractions in locally advanced cervical cancer seems to be feasible and safe, but additional evidence is needed to generate more validated conclusions.
{"title":"Clinical outcomes of single application multi-fractionated CT-guided interstitial high-dose-rate brachytherapy for locally advanced cervical cancer: A multi-institution initial experience","authors":"Eugene T Yap, Mark P Dumago, Carl Jay Jainar, Maureen Bojador, Stellar Marie Cabrera, Gil S Gonzalez, Jocelyn Z Mariano, Aida Bautista, Jhustine Mababangloob, Janell Marie Genson, Teresa Sy Ortin, Warren R Bacorro","doi":"10.5114/jcb.2023.134169","DOIUrl":"https://doi.org/10.5114/jcb.2023.134169","url":null,"abstract":"<b>Purpose:</b><br/>The aim of the study was to evaluate the safety and clinical outcomes of single application multi-fractionated computed tomography (CT)-guided interstitial high-dose-rate brachytherapy given in four fractions in locally advanced cervical cancer.<br/><br/><b>Material and methods:</b><br/>Patients with locally advanced cervical cancer stage IIB-IVA treated definitively with external radiation ± weekly cisplatin, followed by single application multi-fractionated CT-guided interstitial high-dose-rate brachytherapy in four fractions were included. Dosimetry data, clinical response, and toxicity records were reviewed.<br/><br/><b>Results:</b><br/>Between January 2018 and December 2022, twenty-two patients were included. Clinical stage distribution was as follows: IIB – 13.6%, IIIB – 27.3%, IIIC – 22.7%, and IVA – 36.4%. Mean high-risk clinical target volume (HR-CTV) was 66.19 ±32.69 cm<sup>3</sup>, and HR-CTV D90 dose was 86.8 ±1.7 Gy. 2 cc doses to bladder, rectum, and sigmoid were 84.6 ±2.8 Gy, 71.5 ±2.4 Gy, and 65.6 ±4.0 Gy, respectively. Mean overall treatment time was 66 ±21 days. With a median follow-up of 11.5 months (range, 5-44 months), median survival and local control were not achieved. One-year local control rate, one-year progression-free survival, and one-year overall survival were 82%, 66%, and 78%, respectively. Univariate analysis showed overall treatment time to be the only variable associated with all oncologic outcomes. For acute toxicity, grade 3 toxicity in four patients and grade 4 toxicity of infection in one patient were observed. For late toxicity, grade 3 gastrointestinal toxicity was noted in two patients.<br/><br/><b>Conclusions:</b><br/>Initial results suggest that single application multi-fractionated CT-guided interstitial brachytherapy given in four fractions in locally advanced cervical cancer seems to be feasible and safe, but additional evidence is needed to generate more validated conclusions.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"37 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139398450","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: The use of a hydrogel spacer inserted into recto-vaginal fossa is a valuable strategy to mitigate radiation exposure to the rectum during radiation therapy for female pelvic malignancies. However, when the sigmoid colon is in proximity to the cervix, radiation exposure to the sigmoid colon cannot be adequately mitigated with a hydrogel spacer injected into the recto-vaginal fossa. Here, we presented a case, in which a hydrogel spacer was injected into the meso-sigmoid to protect the sigmoid colon.
Material and methods: A 73-year-old female diagnosed with T3b stage IIIC2r uterine cervical cancer (FIGO 2018) underwent high-dose-rate interstitial brachytherapy consisting of 24 Gy in 4 fractions, following concurrent chemoradiotherapy with external beam radiation therapy of 50 Gy in 25 fractions of whole pelvic radiation therapy. In the initial brachytherapy, the sigmoid colon was in close contact with the uterine cervix. In the second brachytherapy, attempts to create a space between the sigmoid colon and uterine cervix using injected artificial ascites were unsuccessful due to rapid absorption of fluid. In the third and fourth brachytherapy fractions, 5 mL of hydrogel was injected into the meso-sigmoid through a pouch of Douglas under trans-rectal ultrasonography guidance. Dose ratio of sigmoid colon D2cc and high-risk clinical target volume (HR-CTV) D90 of each brachytherapy were evaluated.
Results: Dose ratio of the sigmoid colon D2cc to HR-CTV D90 was 1.03, 0.43, 0.56, and 0.47 in each respective brachytherapy session, indicating dose escalation to HR-CTV whilst achieving acceptable sigmoid dose with hydrogel spacer injected into the meso-sigmoid.
Conclusions: The dose ratio of the sigmoid colon to HR-CTV D90 was decreased by introducing a hydrogel spacer into the meso-sigmoid. In cases where the sigmoid colon is in proximity to the cervical tumor, this novel technique can be considered to achieve better clinical outcomes.
{"title":"Hydrogel spacer injection to the meso-sigmoid to protect the sigmoid colon in cervical cancer brachytherapy: A technical report","authors":"Madoka Sakuramachi, Naoya Murakami, Ayaka Nagao, Kanako Kojima, Yusaku Miyata, Tairo Kashihara, Tomoya Kaneda, Kana Takahashi, Koji Inaba, Kae Okuma, Yuko Nakayama, Hiroyuki Okamoto, Mitsuya Ishikawa, Hiroshi Igaki","doi":"10.5114/jcb.2023.134174","DOIUrl":"https://doi.org/10.5114/jcb.2023.134174","url":null,"abstract":"<b>Purpose:</b><br/>The use of a hydrogel spacer inserted into recto-vaginal fossa is a valuable strategy to mitigate radiation exposure to the rectum during radiation therapy for female pelvic malignancies. However, when the sigmoid colon is in proximity to the cervix, radiation exposure to the sigmoid colon cannot be adequately mitigated with a hydrogel spacer injected into the recto-vaginal fossa. Here, we presented a case, in which a hydrogel spacer was injected into the meso-sigmoid to protect the sigmoid colon.<br/><br/><b>Material and methods:</b><br/>A 73-year-old female diagnosed with T3b stage IIIC2r uterine cervical cancer (FIGO 2018) underwent high-dose-rate interstitial brachytherapy consisting of 24 Gy in 4 fractions, following concurrent chemoradiotherapy with external beam radiation therapy of 50 Gy in 25 fractions of whole pelvic radiation therapy. In the initial brachytherapy, the sigmoid colon was in close contact with the uterine cervix. In the second brachytherapy, attempts to create a space between the sigmoid colon and uterine cervix using injected artificial ascites were unsuccessful due to rapid absorption of fluid. In the third and fourth brachytherapy fractions, 5 mL of hydrogel was injected into the meso-sigmoid through a pouch of Douglas under trans-rectal ultrasonography guidance. Dose ratio of sigmoid colon D<sub>2cc</sub> and high-risk clinical target volume (HR-CTV) D<sub>90</sub> of each brachytherapy were evaluated.<br/><br/><b>Results:</b><br/>Dose ratio of the sigmoid colon D<sub>2cc</sub> to HR-CTV D<sub>90</sub> was 1.03, 0.43, 0.56, and 0.47 in each respective brachytherapy session, indicating dose escalation to HR-CTV whilst achieving acceptable sigmoid dose with hydrogel spacer injected into the meso-sigmoid.<br/><br/><b>Conclusions:</b><br/>The dose ratio of the sigmoid colon to HR-CTV D<sub>90</sub> was decreased by introducing a hydrogel spacer into the meso-sigmoid. In cases where the sigmoid colon is in proximity to the cervical tumor, this novel technique can be considered to achieve better clinical outcomes.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"25 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139412088","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Liqiu Ji, Wenwen Zhang, Shanhu Hao, Zhiguo Wang, Guoxu Zhang
Purpose: To explore the efficacy of CT-guided iodine-125 (125I) radioactive particle implantation for the treatment of pelvic local recurrence of cervical cancer after radiotherapy.
Material and methods: To analyze clinical data of 46 patients with pelvic local recurrence of cervical cancer after radiotherapy, who underwent 125I particle implantation, post-operative follow-up using Kaplan-Meier method to calculate the rate of local control, and observation of complications. Univariate and multi-factorial analyses were performed with log-rank test and Cox regression statistical method to observe changes in serum SCC-Ag and CEA levels.
Results: A total of 57 lesions in 46 patients had a short-term local control rate of 87.72% (50/57) and effective rate of 68.42% (39/57). As of the end of follow-up, the median local progression-free survival time of 46 patients was 12.2 (range, 3.5-32) months, the median overall survival time was 16.3 (range, 3.5-40) months, with 1-year and 2-year OS of 63.04% and 41.30%. Univariate and multi-factorial analyses suggested that local recurrent mass size and recurrence site were the main factors affecting survival. Loco-regional progression-free survival (LPFS) time was 15.5 and 11.25 months in cases with recurrent mass diameter < 3 cm and ≥ 3 cm, respectively (χ2 = 10.83, p = 0.001 < 0.05). In patients with pelvic wall recurrence and central recurrence, the time to LPFS was 15.80 and 10.00 months, respectively (χ2 = 8.833, p = 0.0030 < 0.05). Tumor markers serum SCC-Ag and CEA decreased to different degrees after treatment, and the difference was statistically significant. The median LPFS in the SCC-Ag ≤ 3.5 ng/ml group was significantly higher than that in the SCC-Ag > 3.5 ng/ml group (χ2 = 4.241, p = 0.036 < 0.05). No serious post-operative complications were observed.
Conclusions: CT-guided 125I seed implantation has significant short-term efficacy in the treatment of pelvic local recurrence of cervical cancer after radiotherapy. It can improve the effective rate in patients with initial clinical stage II, especially in those with locally recurrent masses < 3 cm and in those with a recurrence in the pelvic wall.
{"title":"Clinical efficacy analysis of radioactive 125I particle implantation for the treatment of pelvic local recurrence of cervical cancer after radiotherapy","authors":"Liqiu Ji, Wenwen Zhang, Shanhu Hao, Zhiguo Wang, Guoxu Zhang","doi":"10.5114/jcb.2023.134172","DOIUrl":"https://doi.org/10.5114/jcb.2023.134172","url":null,"abstract":"<b>Purpose:</b><br/>To explore the efficacy of CT-guided iodine-125 (<sup>125</sup>I) radioactive particle implantation for the treatment of pelvic local recurrence of cervical cancer after radiotherapy.<br/><br/><b>Material and methods:</b><br/>To analyze clinical data of 46 patients with pelvic local recurrence of cervical cancer after radiotherapy, who underwent <sup>125</sup>I particle implantation, post-operative follow-up using Kaplan-Meier method to calculate the rate of local control, and observation of complications. Univariate and multi-factorial analyses were performed with log-rank test and Cox regression statistical method to observe changes in serum SCC-Ag and CEA levels.<br/><br/><b>Results:</b><br/>A total of 57 lesions in 46 patients had a short-term local control rate of 87.72% (50/57) and effective rate of 68.42% (39/57). As of the end of follow-up, the median local progression-free survival time of 46 patients was 12.2 (range, 3.5-32) months, the median overall survival time was 16.3 (range, 3.5-40) months, with 1-year and 2-year OS of 63.04% and 41.30%. Univariate and multi-factorial analyses suggested that local recurrent mass size and recurrence site were the main factors affecting survival. Loco-regional progression-free survival (LPFS) time was 15.5 and 11.25 months in cases with recurrent mass diameter < 3 cm and ≥ 3 cm, respectively (χ<sup>2</sup> = 10.83, <i>p</i> = 0.001 < 0.05). In patients with pelvic wall recurrence and central recurrence, the time to LPFS was 15.80 and 10.00 months, respectively (χ<sup>2</sup> = 8.833, <i>p</i> = 0.0030 < 0.05). Tumor markers serum SCC-Ag and CEA decreased to different degrees after treatment, and the difference was statistically significant. The median LPFS in the SCC-Ag ≤ 3.5 ng/ml group was significantly higher than that in the SCC-Ag > 3.5 ng/ml group (χ<sup>2</sup> = 4.241, <i>p</i> = 0.036 < 0.05). No serious post-operative complications were observed.<br/><br/><b>Conclusions:</b><br/>CT-guided <sup>125</sup>I seed implantation has significant short-term efficacy in the treatment of pelvic local recurrence of cervical cancer after radiotherapy. It can improve the effective rate in patients with initial clinical stage II, especially in those with locally recurrent masses < 3 cm and in those with a recurrence in the pelvic wall.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"28 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139398504","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Elisa Placidi, Bruno Fionda, Enrico Rosa, Valentina Lancellotta, Antonio Napolitano, Martina De Angeli, Francesco Pastore, Maria Antonietta Gambacorta, Luca Indovina, Luca Tagliaferri, Marco De Spirito
Purpose: Brachytherapy (BT, interventional radiotherapy) is a well-established radiotherapy technique capable of delivering high doses to tumors while sparing organs at risk (OARs). Currently, the clinically accepted dose calculation algorithm used is TG-43. In the TG-186 report, new model-based dose calculation algorithms (MBDCA), such as Elekta’s advanced collapsed cone engine (ACE), have been introduced, although their clinical application is yet to be fully realized. This study aimed to investigate two aspects of TG-186: firstly, a comparison of dose distributions calculated with TG-43 and TG-186 for skin tumors; and secondly, an exploration of the impact of using a water bolus on the coverage of clinical target volume (CTV) and OARs.
Material and methods: Ten treatment plans for high-dose-rate IRT were developed. All plans were initially calculated using the TG-43 algorithm, and were subsequently re-calculated with TG-186. In addition, one of the treatment plans was assessed with both TG-43 and TG-186, using 10 different water bolus thicknesses ranging from 0 to 5 cm. To assess dose variations, the following dose-volume histogram (DVH) parameters were compared: D2cc and D0.01cc for OARs, and V150, V100, V95 and V90 for CTV coverage.
Results and conclusions: The average dosimetric results for CTV and OARs, as calculated by both algorithms, revealed statistically significant lower values for TG-186 when compared with TG-43. The presence of a bolus was observed to enhance CTV coverage for the TG-186 algorithm, with a bolus thickness of 2 cm being the point at which ACE calculations matched those of TG-43. This study identified significant differences in dosimetric parameters for skin tumors when comparing the TG-43 and TG-186 algorithms. Moreover, it was demonstrated that the inclusion of a water bolus increased CTV coverage in TG-186 calculations.
{"title":"Dosimetric impact of applying a model-based dose calculation algorithm for skin cancer brachytherapy (interventional radiotherapy)","authors":"Elisa Placidi, Bruno Fionda, Enrico Rosa, Valentina Lancellotta, Antonio Napolitano, Martina De Angeli, Francesco Pastore, Maria Antonietta Gambacorta, Luca Indovina, Luca Tagliaferri, Marco De Spirito","doi":"10.5114/jcb.2023.134173","DOIUrl":"https://doi.org/10.5114/jcb.2023.134173","url":null,"abstract":"<b>Purpose:</b><br/>Brachytherapy (BT, interventional radiotherapy) is a well-established radiotherapy technique capable of delivering high doses to tumors while sparing organs at risk (OARs). Currently, the clinically accepted dose calculation algorithm used is TG-43. In the TG-186 report, new model-based dose calculation algorithms (MBDCA), such as Elekta’s advanced collapsed cone engine (ACE), have been introduced, although their clinical application is yet to be fully realized. This study aimed to investigate two aspects of TG-186: firstly, a comparison of dose distributions calculated with TG-43 and TG-186 for skin tumors; and secondly, an exploration of the impact of using a water bolus on the coverage of clinical target volume (CTV) and OARs.<br/><br/><b>Material and methods:</b><br/>Ten treatment plans for high-dose-rate IRT were developed. All plans were initially calculated using the TG-43 algorithm, and were subsequently re-calculated with TG-186. In addition, one of the treatment plans was assessed with both TG-43 and TG-186, using 10 different water bolus thicknesses ranging from 0 to 5 cm. To assess dose variations, the following dose-volume histogram (DVH) parameters were compared: D<sub>2cc</sub> and D<sub>0.01cc</sub> for OARs, and V<sub>150</sub>, V<sub>100</sub>, V<sub>95</sub> and V<sub>90</sub> for CTV coverage.<br/><br/><b>Results and conclusions:</b><br/>The average dosimetric results for CTV and OARs, as calculated by both algorithms, revealed statistically significant lower values for TG-186 when compared with TG-43. The presence of a bolus was observed to enhance CTV coverage for the TG-186 algorithm, with a bolus thickness of 2 cm being the point at which ACE calculations matched those of TG-43. This study identified significant differences in dosimetric parameters for skin tumors when comparing the TG-43 and TG-186 algorithms. Moreover, it was demonstrated that the inclusion of a water bolus increased CTV coverage in TG-186 calculations.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"96 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139412085","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: The addition of interstitial (IS) needles to intra-cavitary (IC) brachytherapy applicators is associated with improved outcomes in locally advanced cervical cancers involving parametrial tumor extensions. The purpose of this work was to validate a clinical workflow involving 3D-printed caps for a commercial IC split ring applicator that enable using IS needle trajectories tailored to each treatment.
Material and methods: A dedicated software module was developed in this work allowing users to design patient-specific IS caps without knowledge of computer-aided design (CAD) software. This software module was integrated to 3D Brachy, a commercial software developed by Adaptiiv Medical Technologies Inc. For validation of the workflow, CAD models of ground truth caps with five IS needle trajectories were designed with Fusion 360™, 3D-printed, assembled with a split ring applicator, and CT-scanned with radio-opaque markers. 3D Brachy was then applied to generate a replica based on trajectories reconstructed from the radio-opaque markers. A comparison between ground truth and replicated IS needle trajectories was done using intersection points with planes at the level of the cervix (z = 0 cm) and a representative needle depth (z = 3 cm).
Results: Prototypes of interstitial caps 3D-printed in both BioMed Amber and BioMed Clear SLA resins were tested to be functional both pre- and post-sterilization for IS needles with obliquity angles ≤ 45°. Distance-to-agreement at z = 0 cm and 3 cm as well as deviations in pitch and yaw angles of the five IS needle trajectories were found to have mean values of 3.3 ±2.1 mm, 7.3 ±2.0 mm, 2.9° ±2.3°, and 7.0° ±7.0°, respectively.
Conclusions: The clinical workflow for image-guided adaptive cervical cancer brachytherapy using the Montreal split ring applicator was validated.
目的：在腔内近距离放射治疗器中添加间质（IS）针可改善涉及宫旁肿瘤延伸的局部晚期宫颈癌的治疗效果。材料与方法：这项工作开发了一个专用软件模块，允许用户在不了解计算机辅助设计（CAD）软件的情况下设计患者专用的IS帽。该软件模块与Adaptiiv医疗技术公司开发的商业软件3D Brachy集成。为了验证该工作流程，使用 Fusion 360™ 设计了带有五种 IS 针轨迹的真实帽的 CAD 模型，进行了三维打印，与分瓣环涂抹器组装在一起，并使用不透射线标记进行了 CT 扫描。然后应用 3D Brachy 根据不透射线标记重建的轨迹生成复制品。结果：使用 BioMed Amber 和 BioMed Clear SLA 树脂 3D 打印的间隙帽原型经过测试，在消毒前和消毒后对斜角≤45°的 IS 针均可正常使用。五种IS针轨迹在z = 0 cm和3 cm处的一致性距离以及俯仰角和偏航角偏差的平均值分别为3.3 ±2.1 mm、7.3 ±2.0 mm、2.9° ±2.3°和7.0° ±7.0°。
{"title":"The Montreal split ring applicator: Towards highly adaptive gynecological brachytherapy using 3D-printed biocompatible patient-specific interstitial caps","authors":"Yuji Kamio, Marie-Ève Roy, Lori-Anne Morgan, Maroie Barkati, Marie-Claude Beauchemin, François DeBlois, Borko Basaric, Jean-François Carrier, Stéphane Bedwani","doi":"10.5114/jcb.2023.133676","DOIUrl":"https://doi.org/10.5114/jcb.2023.133676","url":null,"abstract":"<b>Purpose:</b><br/>The addition of interstitial (IS) needles to intra-cavitary (IC) brachytherapy applicators is associated with improved outcomes in locally advanced cervical cancers involving parametrial tumor extensions. The purpose of this work was to validate a clinical workflow involving 3D-printed caps for a commercial IC split ring applicator that enable using IS needle trajectories tailored to each treatment.<br/><br/><b>Material and methods:</b><br/>A dedicated software module was developed in this work allowing users to design patient-specific IS caps without knowledge of computer-aided design (CAD) software. This software module was integrated to 3D Brachy, a commercial software developed by Adaptiiv Medical Technologies Inc. For validation of the workflow, CAD models of ground truth caps with five IS needle trajectories were designed with Fusion 360™, 3D-printed, assembled with a split ring applicator, and CT-scanned with radio-opaque markers. 3D Brachy was then applied to generate a replica based on trajectories reconstructed from the radio-opaque markers. A comparison between ground truth and replicated IS needle trajectories was done using intersection points with planes at the level of the cervix (z = 0 cm) and a representative needle depth (z = 3 cm).<br/><br/><b>Results:</b><br/>Prototypes of interstitial caps 3D-printed in both BioMed Amber and BioMed Clear SLA resins were tested to be functional both pre- and post-sterilization for IS needles with obliquity angles ≤ 45°. Distance-to-agreement at z = 0 cm and 3 cm as well as deviations in pitch and yaw angles of the five IS needle trajectories were found to have mean values of 3.3 ±2.1 mm, 7.3 ±2.0 mm, 2.9° ±2.3°, and 7.0° ±7.0°, respectively.<br/><br/><b>Conclusions:</b><br/>The clinical workflow for image-guided adaptive cervical cancer brachytherapy using the Montreal split ring applicator was validated.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"209 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139398604","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jeremy P. M. Flanagan, William H. F. Udovenya, Melvin A. Astrahan, Daniel McKay, Claire Phillips, John D. McKenzie, Roderick O’Day, Lotte S. Fog
Purpose: Ruthenium-106 brachytherapy is a common treatment for small to medium-sized uveal melanomas. In certain clinical contexts, plaques may be placed eccentrically to tumor center. The effect of plaque decentration, a common radiation dose measurement in radiotherapy: D98%, the percentage of the tumor volume receiving at least 98% of the prescribed dose (a commonly used term in radiation oncology), is unknown. We investigated this using two commonly used plaques (CCA and CCB; Eckert & Ziegler, BEBIG GmbH) in silico.
Material and methods: Using a Plaque Simulator™ (Eye Physics) plaque modelling software, treatment time required to deliver 100 Gy D98% with central plaque placement was calculated for both plaque models, treating tumors with basal dimensions of 10 mm (CCB plaque only) and 7 mm (CCA and CCB plaques), and a range of thicknesses. D98% was calculated for plaque-tumor edge distances of 0-5 mm. Additionally, we defined minimum plaque-tumor edge distances, at which D98% fell by 10% and 5% (safety margins).
Results: D98% decreased as plaque-tumor edge distance decreased, i.e. as plaque eccentricity increased. Minor (< 1 mm) plaque decentration caused minimal D98% changes across tumor thicknesses. Safety margins did not follow a consistent pattern.
Conclusions: Eccentric plaque placement reduces the radiation dose delivered to choroidal tumors. Both tumor (thickness, diameter) and plaque (size, location) characteristics are important D98% modulators. Further investigation of the effect of these characteristics and dose to organs at risk is essential.
{"title":"Quantifying the effect of eccentric ruthenium plaque placement on tumor volume dose","authors":"Jeremy P. M. Flanagan, William H. F. Udovenya, Melvin A. Astrahan, Daniel McKay, Claire Phillips, John D. McKenzie, Roderick O’Day, Lotte S. Fog","doi":"10.5114/jcb.2023.133614","DOIUrl":"https://doi.org/10.5114/jcb.2023.133614","url":null,"abstract":"<b>Purpose:</b><br/>Ruthenium-106 brachytherapy is a common treatment for small to medium-sized uveal melanomas. In certain clinical contexts, plaques may be placed eccentrically to tumor center. The effect of plaque decentration, a common radiation dose measurement in radiotherapy: D<sub>98%</sub>, the percentage of the tumor volume receiving at least 98% of the prescribed dose (a commonly used term in radiation oncology), is unknown. We investigated this using two commonly used plaques (CCA and CCB; Eckert & Ziegler, BEBIG GmbH) <i>in silico</i>.<br/><br/><b>Material and methods:</b><br/>Using a Plaque Simulator™ (Eye Physics) plaque modelling software, treatment time required to deliver 100 Gy D<sub>98%</sub> with central plaque placement was calculated for both plaque models, treating tumors with basal dimensions of 10 mm (CCB plaque only) and 7 mm (CCA and CCB plaques), and a range of thicknesses. D<sub>98%</sub> was calculated for plaque-tumor edge distances of 0-5 mm. Additionally, we defined minimum plaque-tumor edge distances, at which D<sub>98%</sub> fell by 10% and 5% (safety margins).<br/><br/><b>Results:</b><br/>D<sub>98%</sub> decreased as plaque-tumor edge distance decreased, i.e. as plaque eccentricity increased. Minor (< 1 mm) plaque decentration caused minimal D<sub>98%</sub> changes across tumor thicknesses. Safety margins did not follow a consistent pattern.<br/><br/><b>Conclusions:</b><br/>Eccentric plaque placement reduces the radiation dose delivered to choroidal tumors. Both tumor (thickness, diameter) and plaque (size, location) characteristics are important D<sub>98%</sub> modulators. Further investigation of the effect of these characteristics and dose to organs at risk is essential.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"31 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139398376","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: To present a new technique for the treatment of vaginal cuff recurrences using 3D-printed vaginal cylindrical template (3D-PVCT) with curved needle channels in brachytherapy.
Material and methods: Two patients with vaginal cuff tumor treated with external beam radiotherapy and MRI-guided interstitial brachytherapy were selected for the present study. Prior to treatment, a vaginal cylinder with the same size as 3D-PVCT was inserted into the vagina. Magnetic resonance scan was performed to identify target volumes and organs at risk (OARs). By registration techniques, the implantation angle was determined, appropriate needle channels were selected, and the depth of each needle position was recorded. During the actual treatment, patients were under general anesthesia, and real-time guidance of trans-rectal ultrasound was applied referring to a pre-determined treatment plan.
Results: For patient No. 1, 9 needles were inserted into the tumor, with 4 curved needle channels and 5 straight channels. For patient No. 2, 7 needles were inserted into the vaginal cuff tumor, with 6 curved needle channels and 1 straight channel. Doses delivered to volumes of targets and OARs for both patients met the EMBRACE II dose constraints. After follow-up of 15 and 18 months, respectively, both patients showed complete response, with no evidence of tumor recurrence. No significant acute or late toxicities were reported.
Conclusions: With careful pre-planning, 3D-PVCT provides good target coverage and sparing of OARs. The results from these two patients indicate that this approach is very promising due to its flexibility and potential widespread application in the future.
{"title":"3D-printed vaginal cylindrical template with curved needle channels in MRI-guided vaginal cuff brachytherapy","authors":"Zhuang Mao, Hongfu Zhao","doi":"10.5114/jcb.2023.133227","DOIUrl":"https://doi.org/10.5114/jcb.2023.133227","url":null,"abstract":"<b>Purpose:</b><br/>To present a new technique for the treatment of vaginal cuff recurrences using 3D-printed vaginal cylindrical template (3D-PVCT) with curved needle channels in brachytherapy.<br/><br/><b>Material and methods:</b><br/>Two patients with vaginal cuff tumor treated with external beam radiotherapy and MRI-guided interstitial brachytherapy were selected for the present study. Prior to treatment, a vaginal cylinder with the same size as 3D-PVCT was inserted into the vagina. Magnetic resonance scan was performed to identify target volumes and organs at risk (OARs). By registration techniques, the implantation angle was determined, appropriate needle channels were selected, and the depth of each needle position was recorded. During the actual treatment, patients were under general anesthesia, and real-time guidance of trans-rectal ultrasound was applied referring to a pre-determined treatment plan.<br/><br/><b>Results:</b><br/>For patient No. 1, 9 needles were inserted into the tumor, with 4 curved needle channels and 5 straight channels. For patient No. 2, 7 needles were inserted into the vaginal cuff tumor, with 6 curved needle channels and 1 straight channel. Doses delivered to volumes of targets and OARs for both patients met the EMBRACE II dose constraints. After follow-up of 15 and 18 months, respectively, both patients showed complete response, with no evidence of tumor recurrence. No significant acute or late toxicities were reported.<br/><br/><b>Conclusions:</b><br/>With careful pre-planning, 3D-PVCT provides good target coverage and sparing of OARs. The results from these two patients indicate that this approach is very promising due to its flexibility and potential widespread application in the future.<br/><br/>","PeriodicalId":51305,"journal":{"name":"Journal of Contemporary Brachytherapy","volume":"50 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2023-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139398544","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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