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Purpose: Current radiation therapy (RT) treatment planning relies mainly on pre-defined dose-based objectives and constraints to develop plans that aim to control disease while limiting damage to normal tissues during treatment. These objectives and constraints are generally population-based, in that they are developed from the aggregate response of a broad patient population to radiation. However, correlations of new biologic markers and patient-specific factors to treatment efficacy and toxicity provide the opportunity to further stratify patient populations and develop a more individualized approach to RT planning. We introduce a novel intensity-modulated radiation therapy (IMRT) optimization strategy that directly incorporates patient-specific dose response models into the planning process. In this strategy, we integrate the concept of utility-based planning where the optimization objective is to maximize the predicted value of overall treatment utility, defined by the probability of efficacy (e.g., local control) minus the weighted sum of toxicity probabilities. To demonstrate the feasibility of the approach, we apply the strategy to treatment planning for non-small cell lung cancer (NSCLC) patients., Methods and Materials: We developed a prioritized approach to patient-specific IMRT planning. Using a commercial treatment planning system (TPS), we calculate dose based on an influence matrix of beamlet-dose contributions to regions-of-interest. Then, outside of the TPS, we hierarchically solve two optimization problems to generate optimal beamlet weights that can then be imported back to the TPS. The first optimization problem maximizes a patient's overall plan utility subject to typical clinical dose constraints. In this process, we facilitate direct optimization of efficacy and toxicity trade-off based on individualized dose-response models. After optimal utility is determined, we solve a secondary optimization problem that minimizes a conventional dose-based objective subject to the same clinical dose constraints as the first stage but with the addition of a constraint to maintain the optimal utility from the first optimization solution. We tested this method by retrospectively generating plans for five previously treated NSCLC patients and comparing the prioritized utility plans to conventional plans optimized with only dose metric objectives. To define a plan utility function for each patient, we utilized previously published correlations of dose to local control and grade 3-5 toxicities that include patient age, stage, microRNA levels, and cytokine levels, among other clinical factors., Results: The proposed optimization approach successfully generated RT plans for five NSCLC patients that improve overall plan utility based on personalized efficacy and toxicity models while accounting for clinical dose constraints. Prioritized utility plans demonstrated the largest average improvement in local control (16.6%) when compared to plans generated with conventional planning objectives. However, for some patients, the utility-based plans resulted in similar local control estimates with decreased estimated toxicity., Conclusion: The proposed optimization approach, where the maximization of a patient's RT plan utility is prioritized over the minimization of standardized dose metrics, has the potential to improve treatment outcomes by directly accounting for variability within a patient population. The implementation of the utility-based objective function offers an intuitive, humanized approach to biological optimization in which planning trade-offs are explicitly optimized., (© 2022 The Authors. Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.)

Accurate nutrient sensing is important for rapid fungal growth and exploitation of available resources. Sulfur is an important nutrient source found in a number of biological macromolecules, including proteins and lipids. The model filamentous fungus Neurospora crassa is capable of utilizing sulfur found in a variety of sources from amino acids to sulfate. During sulfur starvation, the transcription factor CYS-3 is responsible for upregulation of genes involved in sulfur uptake and assimilation. Using a combination of RNA sequencing and DNA affinity purification sequencing, we performed a global survey of the N. crassa sulfur starvation response and the role of CYS-3 in regulating sulfur-responsive genes. The CYS-3 transcription factor bound the promoters and regulated genes involved in sulfur metabolism. Additionally, CYS-3 directly activated the expression of a number of uncharacterized transporter genes, suggesting that regulation of sulfur import is an important aspect of regulation by CYS-3. CYS-3 also directly regulated the expression of genes involved in mitochondrial electron transfer. During sulfur starvation, genes involved in nitrogen metabolism, such as amino acid and nucleic acid metabolic pathways, along with genes encoding proteases and nucleases that are necessary for scavenging nitrogen, were activated. Sulfur starvation also caused changes in the expression of genes involved in carbohydrate metabolism, such as those encoding glycosyl hydrolases. Thus, our data suggest a connection between sulfur metabolism and other aspects of cellular metabolism. IMPORTANCE Identification of nutrients present in the environment is a challenge common to all organisms. Sulfur is an important nutrient source found in proteins, lipids, and electron carriers that are required for the survival of filamentous fungi such as Neurospora crassa. Here, we transcriptionally profiled the response of N. crassa to characterize the global response to sulfur starvation. We also used DNA affinity purification sequencing to identify the direct downstream targets of the transcription factor responsible for regulating genes involved in sulfur uptake and assimilation. Along with genes involved in sulfur metabolism, this transcription factor regulated a number of uncharacterized transporter genes and genes involved in mitochondrial electron transfer. Our data also suggest a connection between sulfur, nitrogen, and carbon metabolism, indicating that the regulation of a number of metabolic pathways is intertwined.

Background: This study investigated the feasibility of using a computer-assisted method to evaluate and differentiate the carotid plaque characteristics in radiation-induced and non-radiation-induced carotid atherosclerosis., Methods: This study included 107 post-radiotherapy (post-RT) nasopharyngeal carcinoma (NPC) patients and 110 subjects with cardiovascular risk factors (CVRFs). Each participant had a carotid ultrasound examination, and carotid plaques and carotid intima-media thickness (CIMT) were evaluated with grey scale ultrasound. The carotid plaque characteristics were evaluated for grey-scale median (GSM) and detailed plaque texture analysis (DPTA) using specific computer software. In DPTA, five different intra-plaque components were colour-coded according to different grey scale ranges. A multivariate linear regression model was used to evaluate the correlation of risk factors and carotid plaque characteristics., Results: Post-RT NPC patients have significantly higher CIMT (748±15.1 µm, P=0.001), more patients had a plaque formation (80.4%, P<0.001) and more plaque locations (2.3±0.2, P<0.001) than CVRF subjects (680.4±10.0 µm, 38.2% and 0.5±0.1 respectively). Among the five intra-plaque components, radiation-induced carotid plaques had significantly larger area of calcification (4.8%±7.7%, P=0.012), but lesser area of lipid (42.1%±16.9%, P=0.034) when compared to non-radiation-induced carotid plaques (3.0%±5.7% and 46.3%±17.9% respectively). Age, radiation and number of CVRF were significantly associated with the carotid atherosclerosis burden (P<0.001). Besides, age was significantly associated with the amount of lipid and calcification within carotid plaques (P<0.001)., Conclusions: Radiation caused more severe carotid artery disease than CVRF with larger CIMT and more prevalent of carotid plaque. Radiation-induced carotid plaques tended to have more intra-plaque calcifications, whereas non-radiation-induced carotid plaques had more lipids. Ultrasound aided by computer-assisted image analysis has potential for more accurate assessment of carotid atherosclerosis., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/qims-20-1012). The authors have no conflicts of interest to declare., (2021 Quantitative Imaging in Medicine and Surgery. All rights reserved.)

Sensing available nutrients and efficiently utilizing them is a challenge common to all organisms. The model filamentous fungus Neurospora crassa is capable of utilizing a variety of inorganic and organic nitrogen sources. Nitrogen utilization in N. crassa is regulated by a network of pathway-specific transcription factors that activate genes necessary to utilize specific nitrogen sources in combination with nitrogen catabolite repression regulatory proteins. We identified an uncharacterized pathway-specific transcription factor, amn-1 , that is required for utilization of the nonpreferred nitrogen sources proline, branched-chain amino acids, and aromatic amino acids. AMN-1 also plays a role in regulating genes involved in responding to the simple sugar mannose, suggesting an integration of nitrogen and carbon metabolism. The utilization of nonpreferred nitrogen sources, which require metabolic processing before being used as a nitrogen source, is also regulated by the nitrogen catabolite regulator NIT-2. Using RNA sequencing combined with DNA affinity purification sequencing, we performed a survey of the role of NIT-2 and the pathway-specific transcription factors NIT-4 and AMN-1 in directly regulating genes involved in nitrogen utilization. Although previous studies suggested promoter binding by both a pathway-specific transcription factor and NIT-2 may be necessary for activation of nitrogen-responsive genes, our data show that pathway-specific transcription factors regulate genes involved in the catabolism of specific nitrogen sources, while NIT-2 regulates genes involved in utilization of all nonpreferred nitrogen sources, such as nitrogen transporters. Together, these transcription factors form a nutrient sensing network that allows N. crassa cells to regulate nitrogen utilization., Competing Interests: The authors declare no competing interest.

Purpose: To introduce a new optimization algorithm that improves DVH results and is designed for the type of heterogeneous dose distributions that occur in brachytherapy. Methods: The new optimization algorithm is based on a prior mathematical approach that uses mean doses of the DVH metric tails. The prior mean dose approach is referred to as conditional value-at-risk (CVaR), and unfortunately produces noticeably worse DVH metric results than gradient-based approaches. We have improved upon the CVaR approach, using the so-called Truncated CVaR (TCVaR), by excluding the hottest or coldest voxels in the structure from the calculations of the mean dose of the tail. Our approach applies an iterative sequence of convex approximations to improve the selection of the excluded voxels. Data Envelopment Analysis was used to quantify the sensitivity of TCVaR results to parameter choice and to compare the quality of a library of 256 TCVaR plans created for each of prostate, breast, and cervix treatment sites with commercially-generated plans. Results: In terms of traditional DVH metrics, TCVaR outperformed CVaR and the improvements increased monotonically as more iterations were used to identify and exclude the hottest/coldest voxels from the optimization problem. TCVaR also outperformed the Eclipse-Brachyvision TPS, with an improvement in PTVD95% (for equivalent organ-at-risk doses) of up to 5% (prostate), 3% (breast), and 1% (cervix). Conclusions: A novel optimization algorithm for HDR treatment planning produced plans with superior DVH metrics compared with a prior convex optimization algorithm as well as Eclipse-Brachyvision. The algorithm is computationally efficient and has potential applications as a primary optimization algorithm or quality assurance for existing optimization approaches., (© 2020 IOP Publishing Ltd.)

Nasopharyngeal carcinoma (NPC) patients treated with Helical Tomotherapy (HT) are commonly set up in an extended neck (EN) or a flexed neck (FN) position. This study investigated the dosimetric and set-up accuracy differences between these 2 set-up positions. Twenty NPC patients treated with HT from each set-up position were retrospectively recruited. HT plans were computed using the same target prescription and organs at risks (OARs) constraints for both set-up positions. The doses parameters of the target volumes and OARs were assessed. Daily megavoltage CT images were retrieved to obtain the set-up errors at 4th (C4) and 7th (C7) cervical levels. The mean values of these parameters were compared between the 2 set-up positions. The dose to NP target in FN group was more conformal than EN group, while the conformity of the neck targets in FN group were significantly lower. For the OARs, the temporal lobe, cerebellum, and hippocampus in FN group received significantly lower doses than the EN. However, the optic structures, brain stem, spinal cord, and parotid glands received higher doses in FN group. The systematic errors at C4 and C7 levels in FN group were larger in all translational directions except the ML direction at C7 level. With regard to radiotherapy of NPC patient using helical tomotherapy, FN position reduced doses to intracranial structures but increased doses to optic structures and other structures when compared with the EN position. In terms of set-up accuracy at the neck region, EN position was relatively better., (Copyright © 2020 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Purpose: A Pareto Navigation and Visualization (PNaV) tool is presented for interactively constructing a high-dose-rate (HDR) brachytherapy treatment plan by navigating and visualizing the multidimensional Pareto surface. PNaV aims to improve treatment planning time and quality and is generalizable to any number of dose-volume histogram (DVH) and convex dose metrics., Methods and Materials: Pareto surface visualization and navigation were demonstrated for prostate, breast, and cervix HDR brachytherapy sites. A library of treatment plans was created to span the Pareto surfaces over a 30% range of doses in each of five DVH metrics. The PNaV method, which uses a nonnegative least-squares model to interpolate the library plans, was compared against pure optimization for 11,250 navigated plans using data envelopment analysis. The visualization of the metric trade-offs was accomplished using numerically estimated partial derivatives to plot the local curvature of the Pareto surface. PNaV enables the user to control both the magnitude and direction of the trade-off during navigation., Results: Proof of principle of PNaV was demonstrated using a graphical user interface with visualization tools to enabled rapid plan selection and a quantitative review of metric trade-offs. PNaV produced deliverable plans with DVH metrics within < 0.4%, 0.6%, and 1.1% (95% confidence interval) of the Pareto surface using plan libraries with nominal plan spacing of 10%, 15%, and 30% in each metric dimension, respectively. The interpolation used for the navigation executed in 0.1 s. The fast interpolation allows for quick and efficient exploration of trade-off options by the physician, after an initial preprocessing step to generate the library., Conclusions: Generation, visualization, and navigation of the Pareto surface were validated for brachytherapy treatment planning. The PNaV method enables efficient and informed decision-making for radiotherapy., (Copyright © 2020 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Introduction: In stereotactic body radiation therapy (SBRT) of solitary liver cancer, organ motion due to respiration is an important factor in the definition of planning target volume (PTV). This study evaluated the potential associations of target motion with gross tumour volume (GTV) size, tumour location, Child-Pugh score and intra-fraction treatment time in SBRT of liver cancer treated by CyberKnife., Methods: Translational motion data of 145 liver cancer patients, who were previously treated by CyberKnife with free breathing under tumour tracking, were recorded in the log files of the motion tracking system and analysed. The factors including target location based on liver segments, Child-Pugh score which was an indication of liver cirrhosis, GTV size and intra-fraction treatment time were recorded and their associations with the magnitude of target movement were evaluated., Results: Target location demonstrated significant association with the translational target motion in the supero-inferior (SI) and left-right (LR) directions but less in antero-posterior (AP) direction. Tumours located at the peripheral segments were more affected than the central segments. Child-Pugh score and GTV size were not significantly associated with target motion in any direction. Longer intra-fraction treatment time generally increased target motion in the SI and LR directions., Conclusion: In SBRT of liver cancer, the target motions in SI and LR directions were correlated with the location of target and treatment time, but not with Child-Pugh score and GTV size. These results should assist in deciding the GTV-PTV margin in SBRT treatment planning for solitary liver cancer., (© 2020 The Royal Australian and New Zealand College of Radiologists.)

Filamentous fungi, such as Neurospora crassa , are very efficient in deconstructing plant biomass by the secretion of an arsenal of plant cell wall-degrading enzymes, by remodeling metabolism to accommodate production of secreted enzymes, and by enabling transport and intracellular utilization of plant biomass components. Although a number of enzymes and transcriptional regulators involved in plant biomass utilization have been identified, how filamentous fungi sense and integrate nutritional information encoded in the plant cell wall into a regulatory hierarchy for optimal utilization of complex carbon sources is not understood. Here, we performed transcriptional profiling of N. crassa on 40 different carbon sources, including plant biomass, to provide data on how fungi sense simple to complex carbohydrates. From these data, we identified regulatory factors in N. crassa and characterized one (PDR-2) associated with pectin utilization and one with pectin/hemicellulose utilization (ARA-1). Using in vitro DNA affinity purification sequencing (DAP-seq), we identified direct targets of transcription factors involved in regulating genes encoding plant cell wall-degrading enzymes. In particular, our data clarified the role of the transcription factor VIB-1 in the regulation of genes encoding plant cell wall-degrading enzymes and nutrient scavenging and revealed a major role of the carbon catabolite repressor CRE-1 in regulating the expression of major facilitator transporter genes. These data contribute to a more complete understanding of cross talk between transcription factors and their target genes, which are involved in regulating nutrient sensing and plant biomass utilization on a global level., Competing Interests: The authors declare no competing interest., (Copyright © 2020 the Author(s). Published by PNAS.)

Objective: In radiotherapy of nasopharyngeal carcinoma (NPC) patients, the brachial plexus (BP) situated at both sides of the neck is often irradiated to high dose. This study was to evaluate different BP delineation methods and analyse the dosimetric consequences when applying BP dose constraints in radiotherapy planning of NPC., Methods: 15 NPC cases radically treated with helical tomotherapy were recruited. Apart from the original treatment plan (Plan A), two new plans (Plans B and C) with additional BP dose constraints were computed using the same planning CT images, structures and planning parameters. Plan B consisted of BP contours based on Radiation Therapy Oncology Group (RTOG)-endorsed atlas; while those in Plan C were based on MR images registered with the planning CT images., Results: The mean BP volume by RTOG method was 19.04 ± 3.50 cm 3 vs 10.44 ± 2.00 cm 3 by CT/MRI method. The mean BP overlapping volume between the two contouring methods was 1.9 cm 3 (0.38-4.03 cm 3 ). There was significant difference between two methods ( p < 0.001). The average D max , D mean , D 5% , D 10% and D 15% of both sides of BP in Plan A were significantly higher than those in both Plan B and Plan C. There were no significant dose differences in the targets and organs at risk (OARs) after applying dose constraints in Plan B and Plan C., Conclusion: RTOG method was recommended since larger BP volume provided better protection. Applying BP dose constraints during tomotherapy plan optimisation for NPC patients could significantly reduce the BP dose ( p < 0.05) without compromising the doses to the targets and other OARs., Advances in Knowledge: This is the first study comparing the delineation method based on RTOG-endorsed atlas with the conventional CT/MRI delineation method for BP in tomotherapy of NPC patients. Our results showed that BP dose could be significantly reduced after applying the dose constraints without compromising the doses to the target volumes and other OARs. The RTOG method was more favoured as it gave a relatively larger BP volume and therefore offered better organ sparing.

Recently, On-Board Imager (OBI) and ExacTrac x-ray 6 degree-of-freedom system (ExacTrac) are increasingly used verification systems in local radiotherapy centers. This study aimed to compare the differences between these two systems in terms of verification accuracy, organ doses, and verification time for head-and-neck (H&N) and pelvic cases. Rando anthropomorphic phantoms of H&N and pelvic regions were positioned with known set-up deviations from the reference position in the linear accelerator. x-Ray verification images were then acquired using both systems. Verification accuracy was evaluated based on the residual positioning error (δD) after image registration. Thermoluminescence dose meters (TLD-100s) were placed in specific locations of the phantoms for the measurement of imaging doses at the organs of interest. Besides, the verification time was also recorded for comparison. Most average detection errors for both systems were within 1 mm. The detection error of ExacTrac was significantly larger than OBI in the H&N region in all directions (p < 0.05), but was significantly lower in the pelvis (p < 0.05). The mean imaging doses to all organs of interest from ExacTrac were significantly lower than OBI (p < 0.05). The mean verification time for ExacTrac was about 10 seconds, which was significantly shorter than the 100 seconds in OBI (p < 0.001). Both verification systems achieved satisfactory performance in the H&N and pelvic regions despite ExacTrac being better in terms of verification time and organ dose. The verification accuracy of Exactrac was better in pelvic region than the H&N region when compared with OBI., (Copyright © 2019. Published by Elsevier Inc.)

Maintenance of cell integrity and cell-to-cell communication are fundamental biological processes. Filamentous fungi, such as Neurospora crassa , depend on communication to locate compatible cells, coordinate cell fusion, and establish a robust hyphal network. Two MAP kinase (MAPK) pathways are essential for communication and cell fusion in N. crassa : the cell wall integrity/MAK-1 pathway and the MAK-2 (signal response) pathway. Previous studies have demonstrated several points of cross-talk between the MAK-1 and MAK-2 pathways, which is likely necessary for coordinating chemotropic growth toward an extracellular signal, and then mediating cell fusion. Canonical MAPK pathways begin with signal reception and end with a transcriptional response. Two transcription factors, ADV-1 and PP-1, are essential for communication and cell fusion. PP-1 is the conserved target of MAK-2, but it is unclear what targets ADV-1. We did RNA sequencing on Δ adv-1 , Δ pp-1 , and wild-type cells and found that ADV-1 and PP-1 have a shared regulon including many genes required for communication, cell fusion, growth, development, and stress response. We identified ADV-1 and PP-1 binding sites across the genome by adapting the in vitro method of DNA-affinity purification sequencing for N. crassa To elucidate the regulatory network, we misexpressed each transcription factor in each upstream MAPK deletion mutant. Misexpression of adv-1 was sufficient to fully suppress the phenotype of the Δ pp-1 mutant and partially suppress the phenotype of the Δ mak-1 mutant. Collectively, our data demonstrate that the MAK-1/ADV-1 and MAK-2/PP-1 pathways form a tight regulatory network that maintains cell integrity and mediates communication and cell fusion., (Copyright © 2018 by the Genetics Society of America.)

Objective: Radiation-induced trismus, which is resulted from damage of the temporomandibular joint (TMJ), is one of the common late complications in nasopharyngeal carcinoma (NPC) patients after radical radiotherapy. This study investigated the radiation induced TMJ changes using ultrasonography in post-radiotherapy (post-RT) NPC patients., Methods: 114 NPC patients, who had completed radiotherapy for more than 4 years, were assessed with the maximum incisal distance (MID) and ultrasonography examination of TMJ from which the maximum disc thickness of the joint disc, the condyle irregularity (CI), joint vascularity (JV) and relative muscle echogenicity were assessed. The same assessments were conducted on 100 age-matched normal subjects. The results were compared among the patients with and without trismus, and the control group. The mean doses to the TMJ were estimated using the treatment planning system and their correlation with the magnitude of MID was also investigated by the Pearson correlation test., Results: 39 out of the 114 patients (34.2%) presented with trismus. The average mean TMJ for all patients was 41.4 Gy, in which patients with trismus was significantly higher than patients without trismus (p = 0.017). The mean MID of patient group was significantly lower than control group (p < 0.001). The mean maximum disc thickness of the patient group was significantly smaller than the control group, whereas the mean CI and JV were significantly higher in patient group. For relative muscle echogenicity, a higher percentage of the control group showed hyperechoic pterygoid muscle than the patient group. The mean total dose to the TMJs for the patient group was 41.4 Gy and there was a mild negative correlation between the mean TMJ dose and the MID (r = -350)., Conclusion: The TMJ in post-RT NPC patients showed reduction of disc thickness, increase of CI and JV. Patients with trismus demonstrated thinner disc thickness and higher JV than those without trismus. Advances in knowledge: Our study was the first cross-sectional comparative study involving over 100 patients and normal subjects that used ultrasound to assess the radiation-induced morphological changes of TMJ. Post-RT TMJ changes characterized by the reduction of disc thickness, increase of CI and JV were detected in the NPC patients. The parameters used in this study were able to detect the morphological differences between the patient group and control group, and therefore can be effectively used to monitor the TMJ condition of post-RT NPC patients.

Background: Pectin is an abundant component in many fruit and vegetable wastes and could therefore be an excellent resource for biorefinery, but is currently underutilized. Fungal pectinases already play a crucial role for industrial purposes, such as for foodstuff processing. However, the regulation of pectinase gene expression is still poorly understood. For an optimal utilization of plant biomass for biorefinery and biofuel production, a detailed analysis of the underlying regulatory mechanisms is warranted. In this study, we applied the genetic resources of the filamentous ascomycete species Neurospora crassa to screen for transcription factors that play a major role in pectinase induction., Results: The pectin degradation regulator-1 (PDR-1) was identified through a transcription factor mutant screen in N. crassa . The Δ pdr - 1 mutant exhibited a severe growth defect on pectin and all tested pectin-related poly- and monosaccharides. Biochemical as well as transcriptional analyses of WT and the Δ pdr - 1 mutant revealed that while PDR-1-mediated gene induction was dependent on the presence of l-rhamnose, it also strongly affected the degradation of the homogalacturonan backbone. The expression of the endo-polygalacturonase gh28 - 1 was greatly reduced in the Δ pdr - 1 mutant, while the expression levels of all pectate lyase genes increased. Moreover, a pdr - 1 overexpression strain displayed substantially increased pectinase production. Promoter analysis of the PDR-1 regulon allowed refinement of the putative PDR-1 DNA-binding motif., Conclusions: PDR-1 is highly conserved in filamentous ascomycete fungi and is present in many pathogenic and industrially important fungi. Our data demonstrate that the function of PDR-1 in N. crassa combines features of two recently described transcription factors in Aspergillus niger (RhaR) and Botrytis cinerea (GaaR). The results presented in this study contribute to a broader understanding of how pectin degradation is orchestrated in filamentous fungi and how it could be manipulated for optimized pectinase production.

In Neurospora crassa, the transcription factor COL-26 functions as a regulator of glucose signaling and metabolism. Its loss leads to resistance to carbon catabolite repression. Here, we report that COL-26 is necessary for the expression of amylolytic genes in N. crassa and is required for the utilization of maltose and starch. Additionally, the Δcol-26 mutant shows growth defects on preferred carbon sources, such as glucose, an effect that was alleviated if glutamine replaced ammonium as the primary nitrogen source. This rescue did not occur when maltose was used as a sole carbon source. Transcriptome and metabolic analyses of the Δcol-26 mutant relative to its wild type parental strain revealed that amino acid and nitrogen metabolism, the TCA cycle and GABA shunt were adversely affected. Phylogenetic analysis showed a single col-26 homolog in Sordariales, Ophilostomatales, and the Magnaporthales, but an expanded number of col-26 homologs in other filamentous fungal species. Deletion of the closest homolog of col-26 in Trichoderma reesei, bglR, resulted in a mutant with similar preferred carbon source growth deficiency, and which was alleviated if glutamine was the sole nitrogen source, suggesting conservation of COL-26 and BglR function. Our finding provides novel insight into the role of COL-26 for utilization of starch and in integrating carbon and nitrogen metabolism for balanced metabolic activities for optimal carbon and nitrogen distribution.

Sterol regulatory element binding proteins (SREBPs) are conserved from yeast to mammalian cells and function in the regulation of sterol homeostasis. In fungi, the SREBP pathway has been implicated in the adaptation to hypoxia and in virulence. In Neurospora crassa and Trichoderma reesei , the SREBP pathway also negatively regulates protein secretion under lignocellulolytic conditions. Here we utilized global transcriptional profiling combined with genetic and physiological analyses to address the regulatory link between the SREBP pathway and protein secretion in N. crassa Our results demonstrated that the function of the SREBP pathway in ergosterol biosynthesis and adaptation to hypoxia was conserved in N. crassa Under lignocellulolytic conditions, the SREBP pathway was highly activated, resulting in the reduced expression of lytic polysaccharide monooxygenases, which require molecular oxygen for catalytic activity. Additionally, activation of the SREBP pathway under lignocellulolytic conditions repressed a set of genes predicted to be involved in the endoplasmic reticulum stress response. Here we show that the inability of a hac-1 mutant, which bears a deletion of the major regulator of the unfolded protein response (UPR), to efficiently produce cellulases and utilize cellulose was suppressed by mutations in the SREBP pathway. The analyses presented here demonstrated new SREBP pathway functions, including linkages to the UPR, and provide new clues for genetic engineering of filamentous fungi to improve their production of extracellular proteins. IMPORTANCE The role of SREBP transcription factors in the regulation of sterol biosynthesis is conserved from humans to yeast. In filamentous fungi, this pathway regulates the secretion of lignocellulolytic enzymes during plant biomass deconstruction. Here we show that the SREBP pathway in Neurospora crassa regulates the production of specific cellulases, lytic polysaccharide monooxygenases that utilize molecular oxygen. Via global transcriptional profile and genetic analyses, a relationship between the SREBP pathway and the unfolded protein response (UPR) pathway was revealed, suggesting a regulatory interplay of these two pathways in the trafficking of plant biomass-degrading enzymes. These findings have implications for our understanding of the cross talk of the SREBP and UPR pathways in other organisms and will guide the rational engineering of fungal strains to improve cellulolytic enzyme production., (Copyright © 2017 Qin et al.)

Purpose  To comprehensively evaluate and compare the degree of carotid atherosclerosis in patients treated with radiotherapy (RT) for nasopharyngeal carcinoma (NPC) and in patients with type 2 diabetes mellitus (DM), and using healthy subjects as controls. Materials and Methods  The present study recruited 69 post-RT NPC patients without conventional cardiovascular risk factors, 70 type 2 diabetic patients without previous RT, and 76 healthy controls without conventional cardiovascular risk factors and previous RT. For each participant, 5 carotid atherosclerotic parameters, namely carotid intima-media thickness (CIMT), carotid arterial stiffness (CAS), presence of carotid plaque, carotid plaque score, and presence of ≥ 50 % carotid stenosis, were assessed using ultrasonography. The differences in these carotid atherosclerotic parameters between study groups were compared using ANCOVA or logistic regression after the adjustment for age and gender. Multiple comparisons were corrected using the Benjamini-Hochberg false discovery rate. Results  Post-RT NPC patients and type 2 diabetics had a significantly higher CIMT, CAS and carotid plaque burden compared to the healthy subjects (corrected P-value, Pcor < 0.05). In addition, carotid atherosclerosis in post-RT NPC patients tended to be more severe with significantly higher CAS and carotid plaque burden than that in type 2 diabetics (Pcor < 0.05). Conclusion  Neck RT for NPC is an independent risk factor of carotid atherosclerosis, and radiation induces more severe carotid atherosclerosis in post-RT NPC patients. Thus, assessment of carotid atherosclerosis using ultrasonography may be necessary for these patients and should be indicated in the routine follow-up of NPC., (© Georg Thieme Verlag KG Stuttgart · New York.)

Autophagy is an important catabolic process in which cells digest and recycle their own cytoplasmic contents for maintaining cellular homeostasis. Interestingly, autophagy could play both pro-death and pro-survival roles in influencing the development of cancer via various signal pathways. As radiotherapy is one of the main treatment modalities for cancer, we reviewed the effect of autophagy modulations on radiosensitivity and radiotherapy efficacy in various cancer types. The future development of autophagy modifications for improving radiotherapy efficacy and cancer prognosis will also be discussed.

The breakdown of plant biomass to simple sugars is essential for the production of second-generation biofuels and high-value bioproducts. Currently, enzymes produced from filamentous fungi are used for deconstructing plant cell wall polysaccharides into fermentable sugars for biorefinery applications. A post-translational N-terminal pyroglutamate modification observed in some of these enzymes occurs when N-terminal glutamine or glutamate is cyclized to form a five-membered ring. This modification has been shown to confer resistance to thermal denaturation for CBH-1 and EG-1 cellulases. In mammalian cells, the formation of pyroglutamate is catalyzed by glutaminyl cyclases. Using the model filamentous fungus Neurospora crassa, we identified two genes (qc-1 and qc-2) that encode proteins homologous to mammalian glutaminyl cyclases. We show that qc-1 and qc-2 are essential for catalyzing the formation of an N-terminal pyroglutamate on CBH-1 and GH5-1. CBH-1 and GH5-1 produced in a Δqc-1 Δqc-2 mutant, and thus lacking the N-terminal pyroglutamate modification, showed greater sensitivity to thermal denaturation, and for GH5-1, susceptibility to proteolytic cleavage. QC-1 and QC-2 are endoplasmic reticulum (ER)-localized proteins. The pyroglutamate modification is predicted to occur in a number of additional fungal proteins that have diverse functions. The identification of glutaminyl cyclases in fungi may have implications for production of lignocellulolytic enzymes, heterologous expression, and biotechnological applications revolving around protein stability., Importance: Pyroglutamate modification is the post-translational conversion of N-terminal glutamine or glutamate into a cyclized amino acid derivative. This modification is well studied in animal systems but poorly explored in fungal systems. In Neurospora crassa, we show that this modification takes place in the ER and is catalyzed by two well-conserved enzymes, ubiquitously conserved throughout the fungal kingdom. We demonstrate that the modification is important for the structural stability and aminopeptidase resistance of CBH-1 and GH5-1, two important cellulase enzymes utilized in industrial plant cell wall deconstruction. Many additional fungal proteins predicted in the genome of N. crassa and other filamentous fungi are predicted to carry an N-terminal pyroglutamate modification. Pyroglutamate addition may also be a useful way to stabilize secreted proteins and peptides, which can be easily produced in fungal production systems., (Copyright © 2017 Wu et al.)

Liver stereotactic body radiation therapy (SBRT) patients differ in both pre-treatment liver function (e.g. due to degree of cirrhosis and/or prior treatment) and radiosensitivity, leading to high variability in potential liver toxicity with similar doses. This work investigates three treatment planning optimization models that minimize risk of toxicity: two consider both voxel-based pre-treatment liver function and local-function-based radiosensitivity with dose; one considers only dose. Each model optimizes different objective functions (varying in complexity of capturing the influence of dose on liver function) subject to the same dose constraints and are tested on 2D synthesized and 3D clinical cases. The normal-liver-based objective functions are the linearized equivalent uniform dose ([Formula: see text]) (conventional '[Formula: see text] model'), the so-called perfusion-weighted [Formula: see text] ([Formula: see text]) (proposed 'fEUD model'), and post-treatment global liver function (GLF) (proposed 'GLF model'), predicted by a new liver-perfusion-based dose-response model. The resulting [Formula: see text], fEUD, and GLF plans delivering the same target [Formula: see text] are compared with respect to their post-treatment function and various dose-based metrics. Voxel-based portal venous liver perfusion, used as a measure of local function, is computed using DCE-MRI. In cases used in our experiments, the GLF plan preserves up to [Formula: see text] more liver function than the fEUD ([Formula: see text]) plan does in 2D cases, and up to [Formula: see text] in 3D cases. The GLF and fEUD plans worsen in [Formula: see text] of functional liver on average by 1.0 Gy and 0.5 Gy in 2D and 3D cases, respectively. Liver perfusion information can be used during treatment planning to minimize the risk of toxicity by improving expected GLF; the degree of benefit varies with perfusion pattern. Although fEUD model optimization is computationally inexpensive and often achieves better GLF than [Formula: see text] model optimization does, the GLF model directly optimizes a more clinically relevant metric and can further improve fEUD plan quality.

Background: In intensity modulated radiotherapy (IMRT) of nasopharyngeal carcinoma (NPC), accurate delineation of the gross tumour volume (GTV) is important. Image registration of CT and MRI has been routinely used in treatment planning. With recent development of positron emission tomography (PET), the aims of this study were to evaluate the impact of PET on GTV delineation and dosimetric outcome in IMRT of early stage NPC patients., Methods: Twenty NPC patients with T1 or T2 disease treated by IMRT were recruited. For each patient, 2 sets of NP GTVs were delineated separately, in which one set was performed using CT and MRI registration only (GTVCM), while the other set was carried out using PET, CT and MRI information (GTVCMP). A 9-field IMRT plan was computed based on the target volumes generated from CT and MRI (PTVCM). To assess the geometric difference between the GTVCM and GTVCMP, GTV volumes and DICE similarity coefficient (DSC), which measured the geometrical similarity between the two GTVs, were recorded. To evaluate the dosimetric impact, the Dmax, Dmin, Dmean and D95 of PTVs were obtained from their dose volume histograms generated by the treatment planning system., Results: The overall mean volume of GTVCMP was greater than GTVCM by 4.4 %, in which GTVCMP was slightly greater in the T1 group but lower in the T2 group. The mean DSC of the whole group was 0.79 ± 0.05. Similar mean DSC values were also obtained from the T1 and T2 groups separately. The dosimetric parameters of PTVCM fulfilled the planning requirements. When applying this plan to the PTVCMP, the average Dmin (56.9 Gy) and D95 (68.6 Gy) of PTVCMP failed to meet the dose requirements and demonstrated significant differences from the PTVCM (p = 0.001 and 0.016 respectively), whereas the doses to GTVCMP did not show significant difference with the GTVCM., Conclusion: In IMRT of early stage NPC, PET was an important imaging modality in radiotherapy planning so as to avoid underdosing the PTV, although its effect on GTV delineation was not significant. It was recommended that PET images should be included in the treatment planning of NPC patients.

Nasopharyngeal carcinoma (NPC) is endemic in southern China, and its incidence in Hong Kong is relatively high. Radiotherapy is the mainstay treatment for NPC due to its relatively high radiosensitivity and deep-seated anatomical position, which is not readily accessible by surgery. Although the technique of radiotherapy in NPC has been advancing and offers promising treatment outcome, complications around the irradiation areas are inevitable and the quality of life of the post-radiotherapy patients is often compromised. Trismus, which is defined as the restricted mouth opening or jaw movement due to the disorder of temporo-mandibular joint (TMJ), is one of the possible late complications for radiotherapy of NPC and is found in 5-17% of the post-radiotherapy (post-RT) patients. Trismus at early stage may only affect the speech, but in severe cases nutritional intake and oral hygiene condition may deteriorate seriously. This article reviewed the possible causes of radiation-induced TMJ damage, the various assessments including imaging modalities and possible treatments. The conclusion is that the availability of simple, yet effective examinations for trismus is essential for delaying the progression and restoring TMJ functions. Although there is no absolutely effective treatment for trismus, many supportive, restorative and palliative management are possible under different clinical situations.

Objective: This study evaluated the potential benefit of a split-parotid delineation approach on the parotid gland in the treatment planning of patients with nasopharyngeal carcinoma (NPC)., Methods: 50 patients with NPC with parapharyngeal space (PPS) and/or level IIa cervical node involvements were divided into three groups: PPS only, level IIa cervical node only and both. Two volumetric-modulated arc therapy plans were computed. The first plan (control) was generated based on the routine treatment-planning protocol, while the second plan (test) was computed with the split-parotid delineation approach, in which a line through the anterolateral margin of the retromandibular vein was created that divided the parotid gland into anterolateral and posteromedial subsegments. For the test plan, the anterolateral subsegment was prescribed, with a dose constraint of 25 Gy in the plan optimization. Dosimetric data of the parotid gland, target volumes and selected organs at risk (OARs) were compared between the control and test plans., Results: The mean dose to the anterolateral subsegment of the parotid gland in all three groups was kept below 25 Gy. The test plan demonstrated significantly lower mean parotid dose than the control plan in the entire gland and the anterolateral subsegment in all three groups. The difference was the greatest in Group 3., Conclusion: The split-parotid delineation approach significantly lowered the mean dose to the anterolateral subsegment and overall gland without greatly compromising the doses to target volumes and other OARs. The effect was more obvious for both PPS and level IIa cervical node involvements than for either of them alone., Advances in Knowledge: It is the first article based on the assumption that parotid gland stem cells are situated at the anterolateral segment of the gland, and applied the split-parotid delineation approach to the parotid gland in the treatment planning of patients with NPC with PPS and level IIa cervical node involvements, so that the function of the post-radiotherapy parotid gland might be better preserved.

Aims: This study aimed to analyze the dose distribution using different dosimetric tools in conducting pretreatment quality assurance for lung cancer stereotactic body radiation therapy (SBRT) plans with flattening filter free (FFF) beams., Methods: Nine patients with lung cancer treated via SBRT were randomly selected, and their treatment plans were generated using the Eclipse treatment planning system (TPS) with FFF beams. For each patient, the same plan was applied to the Delta4 phantom and MatriXX by the TPS, which calculated the dose distribution. The Delta4 and MatriXX phantoms were then used to measure the actual dose distribution at the linear accelerator, and these measured doses were compared to with the calculated doses. Gamma analysis was employed in verifying the correspondence between the dose distributions. The absolute point doses were measured by a 0.016 mL Microchamber with the RW3 phantom and Thorax phantom., Results: The absolute point doses measured by the 0.016 mL Microchamber were within ±3% of the calculated results for the central point of the RW3 and Thorax phantoms. The Delta4 and MatriXX dose distributions agreed well with the measured and calculated doses, over 98%, based on the 3% maximum dose and 3 mm gamma criteria., Conclusions: Both measured and calculated doses for the Delta4 and MatriXX phantoms agreed well for each patient with lung cancer. The absolute point dose measurements using the 0.016 mL Microchamber exhibited excellent agreement with the TPS calculated between the RW3 and Thorax phantoms.

Introduction: Flattening filter-free (FFF) radiation beams have recently become clinically available on modern linear accelerators in radiation therapy. This study aimed to evaluate the dosimetric impact of using FFF beams in intensity-modulated radiotherapy (IMRT) for early-stage upper thoracic oesophageal cancer., Methods: Eleven patients with primary stage upper thoracic oesophageal cancer were recruited. For each patient, two IMRT plans were computed using conventional beams (Con-P) and FFF beams (FFF-P), respectively. Both plans employed a five-beam arrangement and were prescribed with 64 Gy to (planning target volume) PTV1 and 54 Gy to PTV2 in 32 fractions using 6 MV photons. The dose parameters of the target volumes and organs at risks (OARs), and treatment parameters including the monitor units (MU) and treatment time (TT) for Con-P and FFF-P were recorded and compared., Results: The mean D 5 of PTV1 and PTV2 were higher in FFF-P than Con-P by 0.4 Gy and 0.3 Gy, respectively. For the OARs, all the dose parameters did not show significant difference between the two plans except the mean V 5 and V 10 of the lung in which the FFF-P was lower (46.7% vs. 47.3% and 39.1% vs. 39.6%, respectively). FFF-P required 54% more MU but 18.4% less irradiation time when compared to Con-P., Conclusion: The target volume and OARs dose distributions between the two plans were comparable. However, FFF-P was more effective in sparing the lung from low dose and reduced the mean TT compared with Con-P. Long-term clinical studies are suggested to evaluate the radiobiological effects of FFF beams.

Background: Radiotherapy (RT) of the neck is commonly given to nasopharyngeal carcinoma (NPC) patients for preventing cervical lymph node metastasis. However, neck RT may induce the development of carotid atherosclerosis. The mechanisms of radiation-induced carotid atherosclerosis are still unclear and no previous study has investigated the genetic involvement of radiation-induced carotid atherosclerosis. The present study aims to determine the association between genetic polymorphisms and carotid atherosclerosis in patients treated with RT for nasopharyngeal carcinoma., Methods: The present study recruited 128 post-RT NPC patients. Carotid plaque score was assessed using ultrasonography. Thirteen single nucleotide polymorphisms (SNPs) that affect the function of anti-atherosclerotic genes, including SOD2, SOD3, CAT, PON1, PPARG, ADIPOQ, IL10, TGFB1 and NOS3, were genotyped. Association between the 13 SNPs and carotid atherosclerosis was evaluated using multiple regression after adjustment for covariates (PLINK). Multiple testing was corrected using Benjamini-Hochberg step-up false discovery rate controlling procedure., Results: rs662 and rs705379 of PON1 were close to be significantly associated with carotid plaque score (Corrected P value, P cor  =0.0528 and P cor  =0.0842). When the two SNPs were combined together, TC haplotype in rs662-rs705379 of PON1 was significantly associated with higher carotid plaque score (P cor  < 0.05). None of the other SNPs showed significant association with carotid plaque score., Conclusions: TC haplotype in rs662-rs705379 of PON1 is likely to be a genetic risk factor of carotid plaque score. Post-RT NPC patients with the TC haplotype may need earlier and more frequent carotid ultrasound examinations for early detection of carotid atherosclerosis.

Objective: To determine the predictors of the extent of carotid atherosclerosis in patients treated with radiotherapy (RT) for nasopharyngeal carcinoma (NPC)., Methods: The present study investigated 129 post-RT NPC patients. Carotid atherosclerotic parameters, such as carotid intima-media thickness, carotid arterial stiffness and carotid plaque burden (plaque score, the presence of plaque and ≥50% stenosis) were assessed using ultrasonography. The association between carotid atherosclerotic parameters and nine potential predictors, including age, gender, post-RT duration, radiation dose, chemotherapy, diabetes mellitus, hypertension, hypercholesterolemia, and smoking, were determined using multiple regression. The cutoff values of age, post-RT duration and number of cardiovascular risk factors for the presence of carotid plaque or ≥50% carotid stenosis were analyzed using receiver operating characteristic (ROC) curve analysis. Multiple testing was corrected using Benjamini-Hochberg false discovery rate., Results: Age, post-RT duration and number of cardiovascular risk factors were significantly associated with carotid plaque burden (corrected P value, Pcor<0.05). Age of 44.5 years (sensitivity = 99.2% and specificity = 50%, Pcor<0.01) and post-RT duration of 8.5 years (sensitivity = 75.7% and specificity = 64.3%, Pcor<0.001) were the cutoff values for detecting carotid plaque, while post-RT duration of 13.5 years (sensitivity = 66.7% and specificity = 71.6%, Pcor<0.001) and 1.5 cardiovascular risk factors (sensitivity = 40.7% and specificity = 84.3%, Pcor<0.05) were the cutoff values for screening ≥50% carotid stenosis., Conclusions: Age, post-RT duration and number of cardiovascular risk factors are significant predictors of carotid atherosclerosis in post-RT NPC patients. Post-RT NPC patients, who are at least 45 years old, with post-RT duration of 9 years or above, and/or have ≥2 cardiovascular risk factors, are more susceptible to carotid atherosclerosis.

Radiation-induced fibrosis is one of the late complications of radiotherapy (RT) for nasopharyngeal carcinoma (NPC). The aim of this study was to investigate the association between X-ray repair cross-complementing protein 1 and 3 ( XRCC1 and XRCC3 , respectively) gene haplotypes and radiation-induced fibrosis in NPC patients. Genomic DNA was extracted from blood samples of 120 NPC patients previously treated with RT. In total, 12 tag single-nucleotide polymorphisms (SNPs) were selected from the XRCC1 and XRCC3 genes and were genotyped using restriction fragment length polymorphism analysis or unlabeled probe melting analysis. Single-marker and haplotype analyses were performed using multivariate logistic regression analysis. The functional variant rs861539 of XRCC3 may be associated with radiation-induced fibrosis [asymptotic P-value (P asym )<0.05]. No significant association was observed between radiation-induced fibrosis and any of the tag SNPs of XRCC1 and XRCC3 in either single-marker or haplotype analysis after 10,000 permutations [empirical P-value (P emp )>0.05]. Our preliminary results indicated that the rs861539 variant of XRCC3 may be associated with an increased risk of radiation-induced fibrosis; however, a large-scale study is required to confirm this result.

Adaptive radiotherapy (ART) has recently been introduced to restore the planned dose distribution by accounting for the anatomic changes during treatment. By quantifying the anatomic changes in nasopharyngeal carcinoma (NPC) patients, this study aimed to establish an ART strategy for NPC cases. A total of 30 NPC patients treated with helical tomotherapy were recruited. In the pretreatment megavoltage CT images, the anatomic changes of the posterolateral wall of nasopharynx (P-NP), neck region and parotid glands were measured and assessed. One-way repeated measure ANOVA was employed to define threshold(s) at any time-point. The presence of a threshold(s) would indicate significant anatomical change(s) such that replanning should be suggested. A pragmatic schedule for ART was established by evaluating the threshold for each parameter. Results showed the P-NP, parotid gland and neck volumes demonstrated significant regressions over time. Respectively, the mean loss rates were 0.99, 1.35, and 0.39 %/day, and the mean volume losses were 35.70, 47.54 and 11.91% (all P < 0.001). The parotid gland shifted medially and superiorly over time by a mean of 0.34 and 0.24 cm, respectively (all P < 0.001). The neck region showed non-rigid posterior displacement, which increased from upper to lower neck. According to the threshold occurrences, three replans at 9th, 19th and 29th fractions were proposed. This ART strategy was able to accommodate the dosimetric consequences due to anatomic deviation over the treatment course. It is clinically feasible and would be recommended for centers where an adaptive planning system was not yet available.

Objective: Effective immobilization is crucial for the accurate delivery of radiotherapy. This study aimed to compare the effectiveness of the commonly used immobilization systems for different body regions using megavoltage CT (MVCT)., Methods: Daily treatment set-up data from 212 patients treated by helical tomotherapy (Accuray, Sunnyvale, CA) in 6 body regions (52 head and neck, 41 chest, 38 abdomen, 36 pelvis, 18 breast and 27 cranium) were obtained. Based on a verification tool using the pre-treatment MVCT, set-up corrections for each patient were recorded. Mean systematic and random errors of lateral, longitudinal, vertical and roll directions and three-dimensional vectors were compared between immobilization systems of each region., Results: Smaller set-up deviations were observed in the Orfit system (Orfit Industries NV, Wijnegem, Belgium) of the head and neck region, while the performance of immobilization systems for the chest, abdomen and pelvis regions was similar. Larger differences were noted in the breast group, where the prone BodyFIX® system (Medical Intelligence, Medizintechnik GmbH, Schwabmünchen, Germany) was less stable than the supine VacLok® system (CIVCO Medical Solutions, Orange City, IA)., Conclusion: Differences were found between the immobilization systems in the head and neck region, in which the Orfit system was relatively more effective, whereas the VacLok and BodyFIX systems performed similarly in the chest, abdomen and pelvis regions. For the breast case, the supine position with VacLok was much more stable than the prone breast technique. The results provided references for the estimation of clinical target volume-planning target volume margins., Advances in Knowledge: This is the first article on comprehensive comparisons performed in immobilization systems for main body regions that provides some practical recommendations.

Background: The purpose of this study was to evaluate the correlations of thyroid antibody and thyroid hormone in postradiotherapy (post-RT) patients with nasopharyngeal carcinoma (NPC)., Methods: Serum thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), thyroperoxidase antibody (anti-TPO), and thyroglobulin antibody (anti-TG) levels of 55 patients with NPC were taken before RT and at 3, 6, 12, and 18 months after RT. Patients with hypothyroidism at 18 months after RT and those with normal thyroid function were categorized into the hypo and normal groups, respectively. The thyroid antibody levels were compared between the 2 groups, and the correlations of thyroid antibody and thyroid hormone were evaluated for the hypo group., Results: The anti-TPO and anti-TG of the hypo group were higher than the normal group. In the hypo group, there was a positive correlation (r = 0.51) between TSH and anti-TG and a negative correlation between fT4 and anti-TPO (r = -0.55)., Conclusion: There were correlations of the thyroid antibody and thyroid hormone levels in patients with radiation-induced hypothyroidism., (Copyright © 2013 Wiley Periodicals, Inc.)

Introduction: Radiation-induced thyroid dysfunction after radiotherapy for nasopharyngeal cancer (NPC) has been reported. This study investigated the radiation effects of the thyroid and pituitary glands on thyroid function after radiotherapy for NPC., Methods: Sixty-five NPC patients treated with radiotherapy were recruited. Baseline thyroid hormone levels comprising free triiodothyronine (fT3), free thyroxine (fT4) and thyroid-stimulating hormone (TSH) were taken before treatment and at 3, 6, 12 and 18 months. A seven-beam intensity-modulated radiotherapy plan was generated for each patient. Thyroid and pituitary gland dose volume histograms were generated, dividing the patients into four groups: high (>50 Gy) thyroid and pituitary doses (HTHP group); high thyroid and low pituitary doses (HTLP group); low thyroid and high pituitary doses; and low thyroid and pituitary doses. Incidence of hypothyroidism was analysed., Results: Twenty-two (34%) and 17 patients (26%) received high mean thyroid and pituitary doses, respectively. At 18 months, 23.1% of patients manifested various types of hypothyroidism. The HTHP group showed the highest incidence (83.3%) of hypothyroidism, followed by the HTLP group (50%)., Conclusions: NPC patients with high thyroid and pituitary gland doses carried the highest risk of abnormal thyroid physiology. The dose to the thyroid was more influential than the pituitary dose at 18 months after radiotherapy, and therefore more attention should be given to the thyroid gland in radiotherapy planning., (© 2013 The Royal Australian and New Zealand College of Radiologists.)

Purpose: Promoter hypermethylation of tumor suppressor genes may serve as a promising biomarker for the diagnosis of cancer. Cell-free circulating DNA (cf-DNA) shares hypermethylation status with primary tumors. This study investigated promoter hypermethylation of five tumor suppressor genes as markers in the detection of nasopharyngeal carcinoma (NPC) in serum samples., Methods: cf-DNA was extracted from serum collected from 40 NPC patients and 41 age- and sex-matched healthy subjects. The promoter hypermethylation status of the five genes (RASSF1, CDKN2A, DLEC1, DAPK1 and UCHL1) was assessed by methylation-specific PCR after sodium bisulfite conversion. Differences in the methylation status of these five genes between NPC patients and healthy subjects were compared., Results: The concentration of cf-DNA in the serum of NPC patients was significantly higher than that in normal controls. The five tumor suppressor genes - RASSF1, CDKN2A, DLEC1, DAPK1 and UCHL1 - were found to be methylated in 17.5%, 22.5%, 25.0%, 51.4% and 64.9% of patients, respectively. The combination of four-gene marker - CDKN2A, DLEC1, DAPK1 and UCHL1 - had the highest sensitivity and specificity in predicting NPC., Conclusion: Screening DNA hypermethylation of tumor suppressor genes in serum was a promising approach for the diagnosis of NPC., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this study was to investigate the sonographic (US) appearances of submandibular glands in patients with nasopharyngeal carcinoma after external beam radiotherapy (RT) and compare them with those of healthy subjects., Methods: A total of 81 nasopharyngeal carcinoma patients treated with RT and 66 healthy subjects were recruited and underwent submandibular gland US. Bilateral submandibular glands were assessed for their size, echogenicity, echogenicity margin sharpness, and echotexture., Results: The mean ± SD transverse dimension of submandibular glands in patients treated with RT (2.5 ± 0.4 cm) was significantly smaller than that of healthy subjects (3.3 ± 0.4 cm) (p < 0.05). Submandibular glands in patients treated with RT tended to be heterogeneous (72%) with hypoechoic areas (46%) and ill-defined margins (89%). However, there were no statistically significant differences in echogenicity and conspicuity of intraglandular ducts of submandibular glands between patients and healthy subjects., Conclusions: RT-induced changes of the submandibular glands were demonstrated on US., (Copyright © 2012 Wiley Periodicals, Inc.)

This study evaluated the extent of improvement in dose predication accuracy achieved by the Fast Monte Carlo algorithm (MC) compared to the Ray Tracing algorithm (RAT) in stereotactic body radiotherapy (SBRT) of non-small cell lung cancer (NSCLC), and how their differences were influenced by the tumor site and size. Thirty-three NSCLC patients treated with SBRT by CyberKnife in 2011 were recruited. They were divided into the central target group (n = 17) and peripheral target group (n = 16) according to the RTOG 0236 guidelines. Each group was further divided into the large and small target subgroups. After the computation of treatment plans using RAT, a MC plan was generated using the same patient data and treatment parameters. Apart from the target reference point dose measurements, various dose parameters for the planning target volume (PTV) and organs at risk (OARs) were assessed. In addition, the "Fractional Deviation" (FDev) was also calculated for comparison, which was defined as the ratio of the RAT and MC values. For peripheral lung cases, RAT produced significantly higher dose values in all the reference points than MC. The FDev of all reference point doses and dose parameters was greater in the small target than the large target subgroup. For central lung cases, there was no significant reference point and OAR dose differences between RAT and MC. When comparing between the small target and large target subgroups, the FDev values of all the dose parameters and reference point doses did not show significant difference. Despite the shorter computation time, RAT was inferior to MC, in which the target dose was usually overestimated. RAT would not be recommended for SBRT of peripheral lung tumors regardless of the target size. However, it could be considered for large central lung tumors because its performance was comparable to MC.

Monte Carlo (MC) simulation is currently the most accurate dose calculation algorithm in radiotherapy planning but requires relatively long processing time. Faster model-based algorithms such as the anisotropic analytical algorithm (AAA) by the Eclipse treatment planning system and multigrid superposition (MGS) by the XiO treatment planning system are 2 commonly used algorithms. This study compared AAA and MGS against MC, as the gold standard, on brain, nasopharynx, lung, and prostate cancer patients. Computed tomography of 6 patients of each cancer type was used. The same hypothetical treatment plan using the same machine and treatment prescription was computed for each case by each planning system using their respective dose calculation algorithm. The doses at reference points including (1) soft tissues only, (2) bones only, (3) air cavities only, (4) soft tissue-bone boundary (Soft/Bone), (5) soft tissue-air boundary (Soft/Air), and (6) bone-air boundary (Bone/Air), were measured and compared using the mean absolute percentage error (MAPE), which was a function of the percentage dose deviations from MC. Besides, the computation time of each treatment plan was recorded and compared. The MAPEs of MGS were significantly lower than AAA in all types of cancers (p<0.001). With regards to body density combinations, the MAPE of AAA ranged from 1.8% (soft tissue) to 4.9% (Bone/Air), whereas that of MGS from 1.6% (air cavities) to 2.9% (Soft/Bone). The MAPEs of MGS (2.6%±2.1) were significantly lower than that of AAA (3.7%±2.5) in all tissue density combinations (p<0.001). The mean computation time of AAA for all treatment plans was significantly lower than that of the MGS (p<0.001). Both AAA and MGS algorithms demonstrated dose deviations of less than 4.0% in most clinical cases and their performance was better in homogeneous tissues than at tissue boundaries. In general, MGS demonstrated relatively smaller dose deviations than AAA but required longer computation time., (Copyright © 2013 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

In localisation of radiotherapy treatment field, the oncologist is present at the simulator to approve treatment details produced by the therapist. Problems may arise if the oncologist is not available and the patient requires urgent treatment. The development of a tele-localisation system is a potential solution, where the oncologist uses a personal digital assistant (PDA) to localise the treatment field on the image sent from the simulator through wireless communication and returns the information to the therapist after his or her approval. Our team developed the first tele-localisation prototype, which consisted of a server workstation (simulator) for the administration of digital imaging and communication in medicine localisation images including viewing and communication with the PDA via a Wi-Fi network; a PDA (oncologist's site) installed with the custom-built programme that synchronises with the server workstation and performs treatment field editing. Trial tests on accuracy and speed of the prototype system were conducted on 30 subjects with the treatment regions covering the neck, skull, chest and pelvis. The average time required in performing the localisation using the PDA was less than 1.5 min, with the blocked field longer than the open field. The transmission speed of the four treatment regions was similar. The average physical distortion of the images was within 4.4% and the accuracy of field size indication was within 5.3%. Compared with the manual method, the tele-localisation system presented with an average deviation of 5.5%. The prototype system fulfilled the planned objectives of tele-localisation procedure with reasonable speed and accuracy., (© 2012 The Authors. Journal of Medical Imaging and Radiation Oncology © 2012 The Royal Australian and New Zealand College of Radiologists.)

Background and Purpose: Significant tumor shrinkage and weight loss may occur during Intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC). This study aims to evaluate the dosimetric effect of volumetric changes on target volumes and organs at risk (OARs) during IMRT, using reassessment of computed tomography (CT) and magnetic resonance imaging (MRI)., Material and Methods: Nineteen loco-regionally advanced NPC patients treated with IMRT were recruited prospectively. Repeat planning CT and MRI were acquired at 30 and 50 Gy intervals. Recontouring of target volumes and OARs was based on the fused CT-MRI images. Hybrid plans with recontouring were generated. The assessment of volumetric and dosimetric changes was performed by comparing the hybrid plans with the original plan., Results: There was volume reduction of target volumes and parotid glands over the course of IMRT. Relative to the original plan, the hybrid plans demonstrated significantly higher dose to most of target volumes with greater dose inhomogeneity, higher maximum doses to the spinal cord and brainstem, and higher median doses to the parotid glands., Conclusions: Replanning with repeat CT and MRI scans at 30 Gy is essential to keep a satisfactory dose to the target volumes and avoid overdosing the OARs., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

This study compared the oral cavity dose between the routine 7-beam intensity-modulated radiotherapy (IMRT) beam arrangement and 2 other 7-beam IMRT with the conventional radiotherapy beam arrangements in the treatment of nasopharyngeal carcinoma (NPC). Ten NPC patients treated by the 7-beam routine IMRT technique (IMRT-7R) between April 2009 and June 2009 were recruited. Using the same computed tomography data, target information, and dose constraints for all the contoured structures, 2 IMRT plans with alternative beam arrangements (IMRT-7M and IMRT-7P) by avoiding the anterior facial beam and 1 conventional radiotherapy plan (CONRT) were computed using the Pinnacle treatment planning system. Dose-volume histograms were generated for the planning target volumes (PTVs) and oral cavity from which the dose parameters and the conformity index of the PTV were recorded for dosimetric comparisons among the plans with different beam arrangements. The dose distributions to the PTVs were similar among the 3 IMRT beam arrangements, whereas the differences were significant between IMRT-7R and CONRT plans. For the oral cavity dose, the 3 IMRT beam arrangements did not show significant difference. Compared with IMRT-7R, CONRT plan showed a significantly lower mean dose, V30 and V-40, whereas the V-60 was significantly higher. The 2 suggested alternative beam arrangements did not significantly reduce the oral cavity dose. The impact of varying the beam angles in IMRT of NPC did not give noticeable effect on the target and oral cavity. Compared with IMRT, the 2-D conventional radiotherapy irradiated a greater high-dose volume in the oral cavity., (Copyright © 2012 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Adaptive radiotherapy (ART) has been introduced to correct the radiation-induced anatomic changes in head and neck cases during a treatment course. This study evaluated the potential dosimetric benefits of applying a 3-phase adaptive radiotherapy protocol in nasopharyngeal carcinoma (NPC) patients compared with the nonadaptive single-phase treatment protocol. Ten NPC patients previously treated with this 3-phase radiation protocol using Hi-Art Tomotherapy were recruited. Two new plans, PII-ART and PIII-ART, were generated based on the up-to-date computed tomography (CT) images and contours and were used for treatment in phase two (PII; after 25th fraction) and phase three (PIII; after 35th fraction), respectively. To simulate the situation of no replanning, 2 hybrid plans denoted as PII-NART and PIII-NART were generated using the original contours pasted on the PII- and PIII-CT sets by CT-CT fusion. Dosimetric comparisons were made between the NART plans and the corresponding ART plans. In both PII- and PIII-NART plans, the doses to 95% of all the target volumes (D₉₅) were increased with better dose uniformity, whereas the organs at risk (OARs) received higher doses compared with the corresponding ART plans. Without replanning, the total dose to 1% of brainstem and spinal cord (D₁) significantly increased 7.87 ± 7.26% and 10.69 ± 6.72%, respectively (P = 0.011 and 0.001, respectively), in which 3 patients would have these structures overdosed when compared with those with two replannings. The total maximum doses to the optic chiasm and pituitary gland and the mean doses to the left and right parotid glands were increased by 10.50 ± 10.51%, 8.59 ± 6.10%, 3.03 ± 4.48%, and 2.24 ± 3.11%, respectively (P = 0.014, 0.003, 0.053, and 0.046, respectively). The 3-phase radiotherapy protocol showed improved dosimetric results to the critical structures while keeping satisfactory target dose coverage, which demonstrated the advantages of ART in helical tomotherapy of NPC., (Copyright © 2012 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Objectives: Xerostomia is a common post-radiotherapy (post-RT) complication in nasopharyngeal carcinoma (NPC) patients. This study evaluated the relation of post-RT parotid gland changes with the dose received., Methods: Data from 18 NPC patients treated by radiotherapy between 1997 and 2001 were collected. Parotid gland volumes were measured and compared between their pre-RT and post-RT CT images; both sets of CT were conducted with the same scanning protocol. Doppler ultrasound was used to assess the haemodynamic condition of the glands after radiotherapy. Doppler ultrasound results were compared against 18 age-matched normal participants. A questionnaire was used to evaluate the patients' comments of xerostomia condition. Radiotherapy treatment plans of the participants were retrieved from the Eclipse treatment planning system from which the radiation doses delivered to the parotid glands were estimated. The correlations of parotid gland doses and the post-RT changes were evaluated., Results: The post-RT parotid glands were significantly smaller (p<0.001) than the pre-RT ones. They also demonstrated lower vascular velocity, resistive and pulsatility indices (p<0.05) than normal participants. The degree of volume shrinkage and subjective severity of xerostomia demonstrated dose dependence, but such dependence was not definite in the haemodynamic changes., Conclusion: It was possible to predict the gland volume change and subjective severity of xerostomia based on the dose to the parotid glands for NPC patients. However, such prediction was not effective for the vascular changes. The damage to the gland was long lasting and had significant effects on the patients' quality of life.

Background: Hereditary hemochromatosis (HH) is a genetic disorder resulting in increased accumulation of dietary iron. It is associated with various clinical complications such as liver cirrhosis and diabetes. The aim of this study was to explore patients' experiences of living with HH, the diagnosis process, and phlebotomy treatment., Study Design and Methods: An online survey was developed and completed by a total of 210 HH patients across the United States (n = 70), France (n = 50), Ireland (n = 40), and the United Kingdom (n = 50)., Results: Of the 210 patients, 30% were induction patients, 49% were maintenance patients, and 22% had never received phlebotomy. The most common route to diagnosis was by chance (42%), although most patients (87%) reported experiencing symptoms they now associated with HH at the time of diagnosis. Fatigue (60%) and joint pain (50%) were the most frequently reported current symptoms. While 87% of patients felt that treatment with phlebotomy was "quite worthwhile" or "very worthwhile," 52% of induction patients and 37% of maintenance patients experienced side effects "always" or "most of the time" after phlebotomy and 16% of patients would "definitely" or "probably" decide not to receive phlebotomy if alternative options were available., Conclusion: Diagnosis of HH is likely made late in many patients and subsequent phlebotomy treatment, while considered worthwhile by most, leads to concerns over side effects and inconvenience, often impacting patients' lives. Greater efforts to promote awareness of the disease and reduce the treatment burden associated with phlebotomy are required to improve detection and management of this disease., (© 2010 American Association of Blood Banks.)

The product alignment and orientation of the title reaction on the ground potential energy surface of 1 (2)A' have been studied using the quasi-classical trajectory method. The calculations were carried out for case (a) at collision energies of 0.5-20 kcal mol(-1) with the initially rovibrational state of the reagent FCl molecule being at the v = 0 and j = 0 level to especially reveal in detail the dependence of the product integral cross section on collision energy. Further calculations at the collision energy of 15 kcal mol(-1) for case (b) at v = 0-5, and j = 0, and (c) at v = 0, and j = 3, 6, 9 initial states were carried out to reveal the effect of initially vibrational and rotational excitations on stereodynamics, respectively. Possessing final relative velocity k' (defined as a vector in the xz-plane), product alignment perpendicular to the reagent relative velocity vector k (defined as z- or parallel to the z-axis), for case (a) is found to be weaker at all collision energies, for case (b) is found to be vibrationally enhanced by the reactant molecule FCl, but for case (c), rather insensitive to initially rotational excitation. The rotational vector of product molecular orientation pointing to either negative or positive direction of the y-axis in the center of mass frame, e.g. origin of the coordinate system, is enhanced by collision energies regarding to 0.5-20 kcal mol(-1), while it becomes weaker at higher vibrational (v = 0-5) or rotational (j = 0, 3, 6, 9) excitation levels. Effects of collision energies and of rotational excitation at these collision energies, with 15 kcal mol(-1) as an example on the calculated PDDCSs are also shown and discussed. Detailed plots P(φ(r)) in the range of 0 ≤φ(r)≤ 360(o), and P(θ(r), φ(r)) in the ranges of 0 ≤θ(r)≤ 180° and 0 ≤φ(r)≤ 360° at collision energies 0.5-20 kcal mol(-1) have been presented. Overall, results of PDDCSs of the product alignment and product orientation at these collision energies in the title reaction are not very strongly distinguishable., (This journal is © the Owner Societies 2011)

Salivary glands are usually irradiated during radiotherapy for head and neck cancers, which can lead to radiation-induced damage. Radiation-induced xerostomia (oral dryness) is the most common post-radiotherapy complication for head and neck cancer patients and can reduce the patient's quality of life. Accurate and efficient salivary gland assessment methods provide a better understanding of the cause and degree of xerostomia, and may help in patient management. At present, there are different methods for the assessment of salivary gland hypofunction; however, none of them are considered to be standard procedure. This article reviews the value of common methods in the assessment of post-radiotherapy salivary glands.

Purpose: To compare the image quality and dosimetry on the Varian cone beam computed tomography (CBCT) system between software Version 1.4.13 and Version 1.4.11 (referred to as "new" and "old" protocols, respectively, in the following text). This study investigated organ absorbed dose, total effective dose, and image quality of the CBCT system for the head-and-neck and pelvic regions., Methods and Materials: A calibrated Farmer chamber and two standard cylindrical Perspex CT dosimetry phantoms with diameter of 16 cm (head phantom) and 32 cm (body phantom) were used to measure the weighted cone-beam computed tomography dose index (CBCTDIw) of the Varian CBCT system. The absorbed dose of different organs was measured in a female anthropomorphic phantom with thermoluminescent dosimeters (TLD) and the total effective dose was estimated according to International Commission on Radiological Protection (ICRP) Publication 103. The dose measurement and image quality were studied for head-and-neck and pelvic regions, and comparison was made between the new and old protocols., Results: The values of the new CBCTDIw head-and-neck and pelvic protocols were 36.6 and 29.4 mGy, respectively. The total effective doses from the new head-and-neck and pelvic protocols were 1.7 and 8.2 mSv, respectively. The absorbed doses of lens for the new 200° and old 360° head-and-neck protocols were 3.8 and 59.4 mGy, respectively. The additional secondary cancer risk from daily CBCT might be up to 2.8%., Conclusions: The new Varian CBCT provided volumetric information for image guidance with acceptable image quality and lower radiation dose. This imaging tool gave a better standard for patient daily setup verification., (Copyright © 2011 Elsevier Inc. All rights reserved.)

A large fractional dose in radiotherapy produces better radiobiological results, but there is always a concern of radiation-induced damage to the normal tissues, especially peripheral nerves. This study was to evaluate the radiation-induced changes of sciatic nerve treated by stereotactic radiosurgery (SRS) in rabbit. A localization test was performed on 3 rabbits to determine the reference landmarks to the location of the sciatic nerve of rabbit in CT. Another 12 rabbits were irradiated by a dose of 25 Gy at the sciatic nerve using SRS with 5 non-coplanar arcs. The rabbits were randomized into 3 groups and euthanised at 3, 5, and 7 months after radiotherapy, respectively. Apart from the sensory and motor tests performed on the rabbits, segments of the sciatic nerve were prepared for hematoxylin and eosin staining. Histologic and ultra-structural examinations including morphometric analyses were conducted and compared with the control (non-irradiated side). Apart from the loosening of myelin layers at 5 months, no prominent changes were shown at 3 and 5 months after irradiation. At 7 months, despite the fact that the sensation and motor function tests remained intact, ultra-structural examination showed obvious vacuolation, degeneration and necrosis of the axons with myelin fragmentation. In addition, morphometric analysis indicated that, when compared with the control, there was significant reduction in fiber diameter, increase of myelin thickness and decrease of G ratio (P < 0.01). Although it remained functionally intact, a focal single dose of 25 Gy caused significant microscopic damage to the rabbit sciatic nerve at 7 months after irradiation. Escalating doses with large single fractional dose involving peripheral nerves should be carried out with caution.

This study aimed to investigate and compare the sonographic appearances of parotid glands in nasopharyngeal carcinoma patients treated with conventional radiotherapy (RT) or intensity-modulated radiotherapy (IMRT), and to compare them with healthy subjects. Totally 43 patients treated with conventional RT, 38 patients treated with IMRT and 58 healthy subjects were recruited and underwent parotid ultrasonography. Parotid glands were assessed for their size, echogenicity and internal architectures. The mean transverse dimension of parotid glands in patients treated with conventional RT and those treated with IMRT were significantly smaller than that in healthy subjects (p < 0.05). Parotid glands of the IMRT group tended to be hyperechoic (93%), homogenous (62%), without hypoechoic areas (64%) and with marginally-seen intra-parotid ducts (89%), which are similar to those in healthy subjects. Parotid glands in the conventional RT group tended to be hypoechoic (51%), heterogeneous (98%), with hypoechoic areas (94%) and had obviously-seen intra-parotid ducts (64%). For accurate diagnosis, post-RT changes of parotid glands should be noted in ultrasound examination of patients with previous radiotherapy., (Copyright © 2011 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Purpose: Locally recurrent nasopharyngeal carcinoma (NPC) patients can be salvaged by reirradiation with a substantial degree of radiation-related complications. Stereotactic radiotherapy (SRT) is widely used in this regard because of its rapid dose falloff and high geometric precision. The aim of this study was to examine whether the newly developed intensity-modulated stereotactic radiotherapy (IMSRT) has any dosimetric advantages over three other stereotactic techniques, including circular arc (CARC), static conformal beam (SmMLC), and dynamic conformal arc (mARC), in treating locally recurrent NPC., Methods and Materials: Computed tomography images of 32 patients with locally recurrent NPC, previously treated with SRT, were retrieved from the stereotactic planning system for contouring and computing treatment plans. Treatment planning of each patient was performed for the four treatment techniques: CARC, SmMLC, mARC, and IMSRT. The conformity index (CI) and homogeneity index (HI) of the planning target volume (PTV) and doses to the organs at risk (OARs) and normal tissue were compared., Results: All four techniques delivered adequate doses to the PTV. IMSRT, SmMLC, and mARC delivered reasonably conformal and homogenous dose to the PTV (CI <1.47, HI <0.53), but not for CARC (p < 0.05). IMSRT presented with the smallest CI (1.37) and HI (0.40). Among the four techniques, IMSRT spared the greatest number of OARs, namely brainstem, temporal lobes, optic chiasm, and optic nerve, and had the smallest normal tissue volume in the low-dose region., Conclusion: Based on the dosimetric comparison, IMSRT was optimal for locally recurrent NPC by delivering a conformal and homogenous dose to the PTV while sparing OARs., (Copyright © 2011 Elsevier Inc. All rights reserved.)