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Stewart J, Sahgal A, Zadeh MM, Moazen B, Jabehdar Maralani P, Breen S, Lau A, Binda S, Keller B, Husain Z, Myrehaug S, Detsky J, Soliman H, Tseng CL, Ruschin M. Empirical planning target volume modeling for high precision MRI guided intracranial radiotherapy. Clin Transl Radiat Oncol 2023; 39:100582. [PMID: 36699195 PMCID: PMC9869418 DOI: 10.1016/j.ctro.2023.100582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Purpose Magnetic resonance image-guided radiotherapy for intracranial indications is a promising advance; however, uncertainties remain for both target localization after translation-only MR setup and intrafraction motion. This investigation quantified these uncertainties and developed a population-based planning target volume (PTV) model to explore target and organ-at-risk (OAR) volumetric coverage tradeoffs. Methods Sixty-six patients, 49 with a primary brain tumor and 17 with a post-surgical resection cavity, treated on a 1.5T-based MR-linac across 1329 fractions were included. At each fraction, patients were setup by translation-only fusion of the online T1 MRI to the planning image. Each fusion was independently repeated offline accounting for rotations. The six degree-of-freedom difference between fusions was applied to transform the planning CTV at each fraction (CTVfx). A PTV model parameterized by volumetric CTVfx coverage, proportion of fractions, and proportion of patients was developed. Intrafraction motion was quantified in a 412 fraction subset as the fusion difference between post- and pre-irradiation T1 MRIs. Results For the left-right/anterior-posterior/superior-inferior axes, mean ± SD of the rotational fusion differences were 0.1 ± 0.8/0.1 ± 0.8/-0.2 ± 0.9°. Covering 98 % of the CTVfx in 95 % of fractions in 95 % of patients required a 3 mm PTV margin. Margin reduction decreased PTV-OAR overlap; for example, the proportion of optic chiasm overlapped by the PTV was reduced up to 23.5 % by margin reduction from 4 mm to 3 mm. Conclusions An evidence-based PTV model was developed for brain cancer patients treated on the MR-linac. Informed by this model, we have clinically adopted a 3 mm PTV margin for conventionally fractionated intracranial patients.
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Affiliation(s)
- James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Mahtab M. Zadeh
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bahareh Moazen
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Stephen Breen
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Angus Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Shawn Binda
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Brian Keller
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Corresponding author at: Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
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Wiesmueller M, Wuest W, May MS, Ellmann S, Heiss R, Saake M, Janka R, Uder M, Laun FB. Comparison of Readout-Segmented Echo-Planar Imaging and Single-Shot TSE DWI for Cholesteatoma Diagnostics. AJNR Am J Neuroradiol 2021; 42:1305-1312. [PMID: 33926901 DOI: 10.3174/ajnr.a7112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/23/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The high diagnostic value of DWI for cholesteatoma diagnostics is undisputed. This study compares the diagnostic value of readout-segmented echo-planar DWI and single-shot TSE DWI for cholesteatoma diagnostics. MATERIALS AND METHODS Thirty patients with newly suspected cholesteatoma were examined with a dedicated protocol, including readout-segmented echo-planar DWI and single-shot TSE DWI at 1.5T. Acquisition parameters of both diffusion-weighted sequences were as follows: b=1000 s/mm,2 axial and coronal section orientations, and section thickness of 3 mm. Image quality was evaluated by 2 readers on a 5-point Likert scale with respect to lesion conspicuity, the presence of susceptibility artifacts mimicking cholesteatomas, and overall subjective image quality. Sensitivity and specificity were calculated using histology results as the gold standard. RESULTS Twenty-five cases of histologically confirmed cholesteatomas were included in the study group. Lesion conspicuity was higher and fewer artifacts were found when using TSE DWI (both P < .001). The overall subjective image quality, however, was better with readout-segmented DWI. For TSE DWI, the sensitivity for readers 1 and 2 was 92% (95% CI, 74%-99%) and 88% (95% CI, 69%-97%), respectively, while the specificity for both readers was 80% (95% CI, 28%-99%). For readout-segmented DWI, the sensitivity for readers 1 and 2 was 76% (95% CI, 55%-91%) and 68% (95% CI, 46%-85%), while the specificity for both readers was 60% (95% CI, 15%-95%). CONCLUSIONS The use of TSE DWI is advisable for cholesteatoma diagnostics and preferable over readout-segmented DWI.
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Affiliation(s)
- M Wiesmueller
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.) .,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - W Wuest
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.).,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - M S May
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.).,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - S Ellmann
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.)
| | - R Heiss
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.).,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - M Saake
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.).,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - R Janka
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.).,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - M Uder
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.).,Image Science Institute (M.W., W.W., M.S.M., R.H., M.S., R.J., M.U.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - F B Laun
- From the Institute of Radiology (M.W., W.W., M.S.M., S.E., R.H., M.S., R.J., M.U., F.B.L.)
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Evaluation of the influence of susceptibility-induced magnetic field distortions on the precision of contouring intracranial organs at risk for stereotactic radiosurgery. Phys Imaging Radiat Oncol 2021; 15:91-97. [PMID: 33458332 PMCID: PMC7807629 DOI: 10.1016/j.phro.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022] Open
Abstract
45 data sets (18 on a 1.5 T MR and 27 on a 3 T MR) were evaluated for susceptibility induced distortions. Maximum distortions of up to 1.7 mm were found for organs at risk in standard diagnostic settings. Median distortions ranged between 0.1 and 0.2 mm for all organs at risk. Active shimming was estimated to reduce distortions by a factor of 2.3 to 2.9. A safety margin of 1 mm would have encompassed 99.8% of the distortions.
Background and purpose Magnetic resonance imaging (MRI) is a crucial factor in optimal treatment planning for stereotactic radiosurgery. To further the awareness of possible errors in MRI, this work aimed to investigate the magnitude of susceptibility induced MRI distortions for intracranial organs at risk (OARs) and test the effectiveness of actively shimming these distortions. Materials and methods Distortion maps for 45 exams of 42 patients (18 on a 1.5 T MRI scanner, 27 on a 3 T MRI scanner) were calculated based on a high-bandwidth double-echo gradient echo sequence. The investigated OARs were brainstem, chiasm, eyes, and optic nerves. The influence of active shimming was investigated by comparing unshimmed 1.5 T data with shimmed 3 T data and comparing the results to a model based prediction. Results The median distortion for the different OARs was found to be between 0.13 and 0.18 mm for 1.5 T and between 0.11 and 0.13 mm for 3 T. The maximum distortion was found to be between 1.3 and 1.7 mm for 1.5 T and between 1.1 and 1.4 mm for 3 T. The variation of values was much higher for 1.5 T than for 3 T across all investigated OARs. Active shimming was found to reduce distortions by a factor of 2.3 to 2.9 compared to the expected values. Conclusions Using a safety margin for OARs of 1 mm would have encompassed 99.8% of the distortions. Since distortions are inversely proportional to the readout bandwidth, they can be further reduced by increasing the bandwidth. Additional error sources like gradient nonlinearities need to be addressed separately.
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Implementation of a dedicated 1.5 T MR scanner for radiotherapy treatment planning featuring a novel high-channel coil setup for brain imaging in treatment position. Strahlenther Onkol 2020; 197:246-256. [PMID: 33103231 PMCID: PMC7892740 DOI: 10.1007/s00066-020-01703-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/29/2020] [Indexed: 12/17/2022]
Abstract
Purpose To share our experiences in implementing a dedicated magnetic resonance (MR) scanner for radiotherapy (RT) treatment planning using a novel coil setup for brain imaging in treatment position as well as to present developed core protocols with sequences specifically tuned for brain and prostate RT treatment planning. Materials and methods Our novel setup consists of two large 18-channel flexible coils and a specifically designed wooden mask holder mounted on a flat tabletop overlay, which allows patients to be measured in treatment position with mask immobilization. The signal-to-noise ratio (SNR) of this setup was compared to the vendor-provided flexible coil RT setup and the standard setup for diagnostic radiology. The occurrence of motion artifacts was quantified. To develop magnetic resonance imaging (MRI) protocols, we formulated site- and disease-specific clinical objectives. Results Our novel setup showed mean SNR of 163 ± 28 anteriorly, 104 ± 23 centrally, and 78 ± 14 posteriorly compared to 84 ± 8 and 102 ± 22 anteriorly, 68 ± 6 and 95 ± 20 centrally, and 56 ± 7 and 119 ± 23 posteriorly for the vendor-provided and diagnostic setup, respectively. All differences were significant (p > 0.05). Image quality of our novel setup was judged suitable for contouring by expert-based assessment. Motion artifacts were found in 8/60 patients in the diagnostic setup, whereas none were found for patients in the RT setup. Site-specific core protocols were designed to minimize distortions while optimizing tissue contrast and 3D resolution according to indication-specific objectives. Conclusion We present a novel setup for high-quality imaging in treatment position that allows use of several immobilization systems enabling MR-only workflows, which could reduce unnecessary dose and registration inaccuracies. Electronic supplementary material The online version of this article (10.1007/s00066-020-01703-y) contains supplementary material, which is available to authorized users.
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Kurz C, Buizza G, Landry G, Kamp F, Rabe M, Paganelli C, Baroni G, Reiner M, Keall PJ, van den Berg CAT, Riboldi M. Medical physics challenges in clinical MR-guided radiotherapy. Radiat Oncol 2020; 15:93. [PMID: 32370788 PMCID: PMC7201982 DOI: 10.1186/s13014-020-01524-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 03/24/2020] [Indexed: 12/18/2022] Open
Abstract
The integration of magnetic resonance imaging (MRI) for guidance in external beam radiotherapy has faced significant research and development efforts in recent years. The current availability of linear accelerators with an embedded MRI unit, providing volumetric imaging at excellent soft tissue contrast, is expected to provide novel possibilities in the implementation of image-guided adaptive radiotherapy (IGART) protocols. This study reviews open medical physics issues in MR-guided radiotherapy (MRgRT) implementation, with a focus on current approaches and on the potential for innovation in IGART.Daily imaging in MRgRT provides the ability to visualize the static anatomy, to capture internal tumor motion and to extract quantitative image features for treatment verification and monitoring. Those capabilities enable the use of treatment adaptation, with potential benefits in terms of personalized medicine. The use of online MRI requires dedicated efforts to perform accurate dose measurements and calculations, due to the presence of magnetic fields. Likewise, MRgRT requires dedicated quality assurance (QA) protocols for safe clinical implementation.Reaction to anatomical changes in MRgRT, as visualized on daily images, demands for treatment adaptation concepts, with stringent requirements in terms of fast and accurate validation before the treatment fraction can be delivered. This entails specific challenges in terms of treatment workflow optimization, QA, and verification of the expected delivered dose while the patient is in treatment position. Those challenges require specialized medical physics developments towards the aim of fully exploiting MRI capabilities. Conversely, the use of MRgRT allows for higher confidence in tumor targeting and organs-at-risk (OAR) sparing.The systematic use of MRgRT brings the possibility of leveraging IGART methods for the optimization of tumor targeting and quantitative treatment verification. Although several challenges exist, the intrinsic benefits of MRgRT will provide a deeper understanding of dose delivery effects on an individual basis, with the potential for further treatment personalization.
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Affiliation(s)
- Christopher Kurz
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748, Garching, Germany
| | - Giulia Buizza
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, P.za Leonardo da Vinci 32, 20133, Milano, Italy
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748, Garching, Germany
- German Cancer Consortium (DKTK), 81377, Munich, Germany
| | - Florian Kamp
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Moritz Rabe
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Chiara Paganelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, P.za Leonardo da Vinci 32, 20133, Milano, Italy
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, P.za Leonardo da Vinci 32, 20133, Milano, Italy
- Bioengineering Unit, National Center of Oncological Hadrontherapy (CNAO), Strada Privata Campeggi 53, 27100, Pavia, Italy
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Paul J Keall
- ACRF Image X Institute, University of Sydney, Sydney, NSW, 2006, Australia
| | - Cornelis A T van den Berg
- Department of Radiotherapy, University Medical Centre Utrecht, PO box 85500, 3508 GA, Utrecht, The Netherlands
| | - Marco Riboldi
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748, Garching, Germany.
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Hall WA, Paulson ES, van der Heide UA, Fuller CD, Raaymakers BW, Lagendijk JJW, Li XA, Jaffray DA, Dawson LA, Erickson B, Verheij M, Harrington KJ, Sahgal A, Lee P, Parikh PJ, Bassetti MF, Robinson CG, Minsky BD, Choudhury A, Tersteeg RJHA, Schultz CJ. The transformation of radiation oncology using real-time magnetic resonance guidance: A review. Eur J Cancer 2019; 122:42-52. [PMID: 31614288 PMCID: PMC8447225 DOI: 10.1016/j.ejca.2019.07.021] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 12/11/2022]
Abstract
Radiation therapy (RT) is an essential component of effective cancer care and is used across nearly all cancer types. The delivery of RT is becoming more precise through rapid advances in both computing and imaging. The direct integration of magnetic resonance imaging (MRI) with linear accelerators represents an exciting development with the potential to dramatically impact cancer research and treatment. These impacts extend beyond improved imaging and dose deposition. Real-time MRI-guided RT is actively transforming the work flows and capabilities of virtually every aspect of RT. It has the opportunity to change entirely the delivery methods and response assessments of numerous malignancies. This review intends to approach the topic of MRI-based RT guidance from a vendor neutral and international perspective. It also aims to provide an introduction to this topic targeted towards oncologists without a speciality focus in RT. Speciality implications, areas for physician education and research opportunities are identified as they are associated with MRI-guided RT. The uniquely disruptive implications of MRI-guided RT are discussed and placed in context. We further aim to describe and outline important future changes to the speciality of radiation oncology that will occur with MRI-guided RT. The impacts on RT caused by MRI guidance include target identification, RT planning, quality assurance, treatment delivery, training, clinical workflow, tumour response assessment and treatment scheduling. In addition, entirely novel research areas that may be enabled by MRI guidance are identified for future investigation.
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Affiliation(s)
- William A Hall
- Medical College of Wisconsin, Department of Radiation Oncology, USA.
| | - Eric S Paulson
- Medical College of Wisconsin, Department of Radiation Oncology, USA
| | | | - Clifton D Fuller
- University of Texas, MD Anderson Cancer Center, USA; Netherlands Cancer Institute, the Netherlands
| | - B W Raaymakers
- UMC Utrecht, Department of Radiotherapy, the Netherlands
| | | | - X Allen Li
- Medical College of Wisconsin, Department of Radiation Oncology, USA
| | - David A Jaffray
- Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Laura A Dawson
- Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Beth Erickson
- Medical College of Wisconsin, Department of Radiation Oncology, USA
| | - Marcel Verheij
- Radbound University Medical Center, Nijmegen, the Netherlands
| | - Kevin J Harrington
- The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, UK
| | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Percy Lee
- University of California, Los Angeles, USA
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Kroll C, Dietrich O, Bortfeldt J, Paganelli C, Baroni G, Kamp F, Neppl S, Belka C, Parodi K, Opel M, Riboldi M. Improving the modelling of susceptibility-induced spatial distortions in MRI-guided extra-cranial radiotherapy. ACTA ACUST UNITED AC 2019; 64:205006. [DOI: 10.1088/1361-6560/ab447c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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The Challenges of Using MRI During Radiotherapy. Clin Oncol (R Coll Radiol) 2018; 30:680-685. [DOI: 10.1016/j.clon.2018.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/01/2018] [Accepted: 08/20/2018] [Indexed: 12/29/2022]
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La radiothérapie externe guidée par l’imagerie dans le cancer de la prostate ; comment, quand et pourquoi ? Cancer Radiother 2018; 22:586-592. [DOI: 10.1016/j.canrad.2018.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 06/29/2018] [Indexed: 12/14/2022]
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