{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,16]],"date-time":"2026-05-16T03:19:53Z","timestamp":1778901593253,"version":"3.51.4"},"reference-count":41,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2026,1,15]],"date-time":"2026-01-15T00:00:00Z","timestamp":1768435200000},"content-version":"vor","delay-in-days":14,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100012166","name":"National Key Research and Development Program of China","doi-asserted-by":"publisher","award":["2023YFC2414502"],"award-info":[{"award-number":["2023YFC2414502"]}],"id":[{"id":"10.13039\/501100012166","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["82472117"],"award-info":[{"award-number":["82472117"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["aapm.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Applied Clin Med Phys"],"published-print":{"date-parts":[[2026,1]]},"abstract":"Abstract<\/jats:title>\n \n Objective<\/jats:title>\n Extended\u2010field intensity\u2010modulated radiotherapy (EF\u2010IMRT) used for elective nodal irradiation (ENI) in upper thoracic esophageal cancer frequently results in excessive intermediate\u2010to\u2010low\u2010dose pulmonary irradiation. This study presented a practical and reproducible planning strategy (segmented Jaw\u2010locking IMRT, SJL\u2010IMRT) for optimizing dose distributions to ENI target volumes, and assessed its impact on plan complexity and lung parenchyma sparing.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n In a paired planning study (\n n<\/jats:italic>\n \u00a0=\u00a040), EF\u2010IMRT and SJL\u2010IMRT plans were generated per patient under identical target coverage objectives. SJL\u2010IMRT partitioned the longitudinal ENI volume into cervical\u2010supraclavicular and upper\u2010mediastinal segments via coordinated orthogonal collimators, and multi\u2010leaf collimator (MLC)\u2010defined apertures locked within each segment. The evaluation was based on multifaceted criteria, including metrics for: (i) plan complexity: the aperture\u2010based edge\u2010area metric (EAM) and the sequence\u2010level modulation complexity score (MCS); (ii) dosimetry: conformity index (CI), homogeneity index (HI), gradient measure (GM), pulmonary parameters (mean lung dose [MLD], V\n 5<\/jats:sub>\n \u223cV\n 30<\/jats:sub>\n ), and spinal cord maximum dose (D\n max<\/jats:sub>\n ); (iii) radiobiological effects: tumor control probability (TCP) and normal tissue complication probability (NTCP). The delivery accuracy of SJL\u2010IMRT and EF\u2010IMRT was validated with a PTW OCTAVIUS 729 2D ionization chamber array and RW3 phantom, using\n \u03b3<\/jats:italic>\n analysis (3.0%\/3.0\u00a0mm criterion, global normalization, 10% dose threshold). Statistical analysis was performed using Wilcoxon signed\u2010rank test.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Both SJL\u2010IMRT and EF\u2010IMRT satisfied prescription dose objectives for planning target volume (PTV). No significant differences were observed in CI and HI (\n p\u00a0<\/jats:italic>\n =\u00a00.347 and\n p\u00a0<\/jats:italic>\n =\u00a00.173, respectively). SJL\u2010IMRT demonstrated lower geometric complexity and simpler sequencing: EAM 8.610\u00a0\u00b1\u00a02.951\u00a0vs. 20.824\u00a0\u00b1\u00a04.944 (paired \u0394\u00a0=\u00a0\u221212.214;\n p\u00a0<\/jats:italic>\n =\u00a00.00195) and MCS 0.243\u00a0\u00b1\u00a00.015\u00a0vs. 0.203\u00a0\u00b1\u00a00.036 (paired \u0394\u00a0=\u00a0+0.040;\n p\u00a0<\/jats:italic>\n =\u00a00.0193), respectively. Compared with EF\u2010IMRT, SJL\u2010IMRT (i) reduced gradient measures (GM) by 0.215\u00a0cm (\n p\u00a0<<\/jats:italic>\n \u00a00.01), indicating a steeper dose fall\u2010off; (ii) decreased MLD by 1.62\u00a0Gy (left) and 2.64\u00a0Gy (right); (iii) lowered left lung V\n 5<\/jats:sub>\n and V\n 20<\/jats:sub>\n by 19.96%, 3.63%, right lung V\n 5<\/jats:sub>\n and V\n 20<\/jats:sub>\n by 25.27%, 3.05%, respectively (all\n p\u00a0<<\/jats:italic>\n \u00a00.01); (iv) exhibited a marginally higher mean\n \u03b3<\/jats:italic>\n passing rate (99.4\u00a0\u00b1\u00a00.72%\u00a0vs. 98.8\u00a0\u00b1\u00a00.75%,\n p\u00a0<\/jats:italic>\n =\u00a00.048), no dose cold\/hot spots in the 2\u2010cm feathered overlap, and a more compact high\u2010dose area; (v) demonstrated a longer mean delivery time (10.9\u00a0vs. 8.8\u00a0min,\n p\u00a0<\/jats:italic>\n =\u00a00.021) and higher total monitor units (MUs: 2893\u00a0vs. 2066;\n p\u00a0<\/jats:italic>\n =\u00a00.026). (vi) translated these dosimetric gains into significant NTCP reductions for both lungs (left \u22121.30%, right \u22121.29%;\n p\u00a0<<\/jats:italic>\n \u00a00.01). TCP values were numerically higher for SJL\u2010IMRT, but these differences were not statistically significant; D\n max<\/jats:sub>\n to the spinal cord followed the same pattern.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n SJL\u2010IMRT reduces plan complexity (EAM\u2193, MCS\u2191) and lowers intermediate\u2010to\u2010low lung dose compared with EF\u2010IMRT for ENI in upper thoracic esophageal cancer, without compromising target coverage, supporting SJL\u2010IMRT as a pragmatic approach to improving dosimetric quality and delivery simplicity. Confirmation in larger cohorts is warranted.<\/jats:p>\n <\/jats:sec>","DOI":"10.1002\/acm2.70467","type":"journal-article","created":{"date-parts":[[2026,1,16]],"date-time":"2026-01-16T02:24:21Z","timestamp":1768530261000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Segmented jaw\u2010locking in IMRT for upper thoracic esophageal cancer: A plan complexity\u2010driven approach to lung dose reduction"],"prefix":"10.1002","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5985-5308","authenticated-orcid":false,"given":"Shi","family":"Cao","sequence":"first","affiliation":[{"name":"Department of Radiation Oncology Taizhou People's Hospital Affiliated to Nanjing Medical University Taizhou Jiangsu China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Guang\u2010Zhi","family":"Sun","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology Taizhou People's Hospital Affiliated to Nanjing Medical University Taizhou Jiangsu China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jun\u2010Yi","family":"Gao","sequence":"additional","affiliation":[{"name":"Department of Radiology Taizhou People's Hospital Affiliated to Nanjing Medical University Taizhou Jiangsu China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiang","family":"Dai","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology Taizhou People's Hospital Affiliated to Nanjing Medical University Taizhou Jiangsu China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hao","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology Taizhou People's Hospital Affiliated to Nanjing Medical University Taizhou Jiangsu China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chao\u2010Min","family":"Chen","sequence":"additional","affiliation":[{"name":"Institute of Medical Instruments School of Biomedical Engineering Southern Medical University Guangzhou Guangdong China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wan\u2010Song","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology Taizhou People's Hospital Affiliated to Nanjing Medical University Taizhou Jiangsu China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yi\u2010Hai","family":"Fang","sequence":"additional","affiliation":[{"name":"Department of Medical Engineering Zhujiang Hospital Southern Medical University Guangzhou Guangdong China"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2026,1,15]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.21147\/j.issn.1000\u20109604.2021.05.01"},{"issue":"12","key":"e_1_2_10_3_1","first-page":"881","article-title":"Esophageal cancer committee of the chinese anti\u2010cancer association. guidelines for radiotherapy of esophageal cancer in China (2023 edition)","volume":"29","year":"2020","journal-title":"Chin J Radiat Oncol."},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1093\/dote\/doad006"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2022.10.036"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000002824"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13014\u2010018\u20101191\u2010y"},{"issue":"14","key":"e_1_2_10_8_1","first-page":"3374","article-title":"Factors related to the occurrence of symptomatic acute radiation pneumonitis in elderly patients with esophageal cancer treated with intensity modulated radiotherapy","volume":"43","author":"Yang M","year":"2023","journal-title":"Chin J Gerontol."},{"issue":"9","key":"e_1_2_10_9_1","first-page":"16646","article-title":"Associated factors of radiation pneumonitis induced by precise radiotherapy in 186 elderly patients with esophageal cancer","volume":"8","author":"Cui Z","year":"2015","journal-title":"Int J Clin Exp Med"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.prro.2016.02.004"},{"key":"e_1_2_10_11_1","first-page":"1","article-title":"Dosimetric comparison and biological evaluation of fixed\u2010jaw intensity\u2010modulated radiation therapy for T\u2010shaped esophageal cancer","volume":"16","author":"Chen H","journal-title":"Radiat Oncol."},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.21037\/apm\u201023\u2010594"},{"issue":"4","key":"e_1_2_10_13_1","first-page":"81","article-title":"Clinical application of intensity modulated radiation therapy based on orthogonal double\u2010layer grating","volume":"36","author":"Chen GX","year":"2021","journal-title":"Chin J Med Equip"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2021.05.005"},{"key":"e_1_2_10_15_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12885\u2010024\u201012825\u20102"},{"key":"e_1_2_10_16_1","doi-asserted-by":"publisher","DOI":"10.1002\/acm2.12704"},{"key":"e_1_2_10_17_1","volume-title":"Precision Radiotherapy Planning Design for Tumors","author":"Wang RZ","year":"2014"},{"key":"e_1_2_10_18_1","doi-asserted-by":"crossref","unstructured":"Winnewisser Niklas et\u00a0al.How shapley value and its generalizations can help in the analysis of complex engineering systems and what next.International Symposium on Integrated Uncertainty in Knowledge Modelling and Decision Making.Singapore: Springer Nature Singapore 2025.","DOI":"10.1007\/978-981-96-4603-6_8"},{"key":"e_1_2_10_19_1","doi-asserted-by":"crossref","unstructured":"Bui Quang\u2010Thinh et\u00a0al.Novel Distances for Fermatean Fuzzy Sets in Multi\u2010attribute Decision\u2010Making using covering\u2010based rough sets.international symposium on integrated uncertainty in knowledge Modelling and Decision Making.Singapore: Springer Nature Singapore 2025.","DOI":"10.1007\/978-981-96-4603-6_6"},{"key":"e_1_2_10_20_1","doi-asserted-by":"publisher","DOI":"10.1002\/acm2.12055"},{"issue":"11","key":"e_1_2_10_21_1","first-page":"1167","article-title":"Study on the dosimetric effect and tolerance of dynamic multi\u2010leaf collimator accuracy on intensity\u2010modulated radiotherapy","volume":"30","author":"Yang JM","year":"2021","journal-title":"Chin J Radiat Oncol."},{"key":"e_1_2_10_22_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2020.07.002"},{"key":"e_1_2_10_23_1","doi-asserted-by":"publisher","DOI":"10.3389\/fonc.2019.00674"},{"issue":"4","key":"e_1_2_10_24_1","first-page":"1286","article-title":"Rationale for using field feathering and junction shifting techniques in radiotherapy","volume":"62","author":"Karger C P","year":"2005","journal-title":"Int J Radiat Oncol Biol Phys."},{"key":"e_1_2_10_25_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.phro.2021.02.002"},{"key":"e_1_2_10_26_1","first-page":"71","article-title":"Implementation of aperture\u2010based complexity metrics of MLC opening based on the IMRT technique for central nervous system (CNS) and breast cases","volume":"21","author":"Ambalinggi M","year":"2024","journal-title":"Iran J Med Phys"},{"key":"e_1_2_10_27_1","doi-asserted-by":"publisher","DOI":"10.1088\/2057\u20101976\/ac82c6"},{"key":"e_1_2_10_28_1","doi-asserted-by":"publisher","DOI":"10.1002\/acm2.14432"},{"key":"e_1_2_10_29_1","first-page":"26","volume-title":"The ICRU Report 83: Prescribing, Recording, and Reporting Photon Beam Intensity Modulated Radiation Therapy (IMRT)","author":"The International Commission on Radiation Units and Measurements","year":"2010"},{"issue":"14","key":"e_1_2_10_30_1","first-page":"1","article-title":"Lung stereotactic body radiation therapy (SBRT) dose gradient and PTV volume: a retrospective multi\u2010center analysis","volume":"12","author":"Hoffman D","year":"2019","journal-title":"Radiat Oncol."},{"key":"e_1_2_10_31_1","doi-asserted-by":"publisher","DOI":"10.1088\/1361\u20106560\/ad48f6"},{"key":"e_1_2_10_32_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejmp.2007.07.001"},{"key":"e_1_2_10_33_1","doi-asserted-by":"publisher","DOI":"10.1016\/0360\u20103016(94)00475\u2010Z"},{"key":"e_1_2_10_34_1","doi-asserted-by":"publisher","DOI":"10.1088\/0031\u20109155\/53\/3\/014"},{"key":"e_1_2_10_35_1","doi-asserted-by":"publisher","DOI":"10.1120\/jacmp.v15i3.4641"},{"key":"e_1_2_10_36_1","unstructured":"IAEA (International Atomic Energy Agency).Commissioning of radiotherapy treatment planning systems: testing for typical external beam treatment techniques.2008."},{"key":"e_1_2_10_37_1","doi-asserted-by":"publisher","DOI":"10.1002\/mp.12810"},{"key":"e_1_2_10_38_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00362\u2010012\u20100443\u20104"},{"key":"e_1_2_10_39_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13014\u2010023\u201002332\u20102"},{"key":"e_1_2_10_40_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1470\u20102045(21)00718\u2010X"},{"key":"e_1_2_10_41_1","unstructured":"National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: esophageal and esophagogastric junction cancers. Version 4.2025 2025."},{"key":"e_1_2_10_42_1","doi-asserted-by":"publisher","DOI":"10.1093\/jrr\/rrac021"}],"container-title":["Journal of Applied Clinical Medical Physics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/aapm.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/acm2.70467","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/aapm.onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/acm2.70467","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/aapm.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/acm2.70467","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,17]],"date-time":"2026-02-17T13:09:28Z","timestamp":1771333768000},"score":1,"resource":{"primary":{"URL":"https:\/\/aapm.onlinelibrary.wiley.com\/doi\/10.1002\/acm2.70467"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":41,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1]]}},"alternative-id":["10.1002\/acm2.70467"],"URL":"https:\/\/doi.org\/10.1002\/acm2.70467","archive":["Portico"],"relation":{},"ISSN":["1526-9914","1526-9914"],"issn-type":[{"value":"1526-9914","type":"print"},{"value":"1526-9914","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]},"assertion":[{"value":"2025-09-16","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-12-29","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-01-15","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70467"}}