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Saripalli AL, Lee B, Adams W, Bhandare N, Venkatesulu BP, Yoo RK, Price J, Harmon GA, Block AM, Friedman N, Harkenrider MM, Major EJ, Small W, Wagner RH, Welsh JS, Solanki AA. Multi-institutional Development and Validation of Contouring Guidelines for Para-aortic Elective Nodal Irradiation in Prostate Cancer Based on Patterns of Involvement on Targeted Molecular Imaging Positron Emission Tomography/Computed Tomography. Int J Radiat Oncol Biol Phys 2023; 117:630-640. [PMID: 37201758 DOI: 10.1016/j.ijrobp.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/07/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Molecular imaging better identifies anatomic regions of metastatic spread of prostate cancer compared with conventional imaging, resulting in para-aortic (PA) nodal metastases being increasingly identified. Consequently, some radiation oncologists electively treat the PA lymph node region in patients with gross or high risk of PA nodal involvement. The anatomic locations of at-risk PA lymph nodes for prostate cancer are unknown. Our objective was to use molecular imaging to develop guidelines for the optimal delineation of the PA clinical target volume (CTV) in patients with prostate cancer. METHODS AND MATERIALS We conducted a multi-institutional retrospective cohort study of patients with prostate cancer undergoing 18F-fluciclovine or 18F-DCFPyL prostate-specific membrane antigen positron emission tomography (PET)/computed tomography (CT). Images of patients with PET-positive PA nodes were imported into the treatment planning system, avid nodes were contoured, and measurements were taken in relation to anatomic landmarks. A contouring guideline that encompassed the location of ≥95% of PET-positive PA nodes was created using descriptive statistics and then validated in an independent data set. RESULTS Five hundred fifty-nine patients had molecular PET/CT imaging in the development data set (78% 18F-fluciclovine, 22% prostate-specific membrane antigen). Seventy-six patients (14%) had evidence of PA nodal metastasis. We determined that expanding the CTV to 1.8 cm left of the aorta, 1.4 cm right of the inferior vena cava (IVC), 7 mm posterior to the aorta/IVC or to the vertebral body, and superiorly to the T11/T12 vertebral interface, with the anterior border 4 mm anterior to the aorta/IVC and inferior border at the bifurcation of the aorta/IVC, resulted in coverage of ≥95% of PET-positive PA nodes. When the guideline was used in the independent validation data set (246 patients with molecular PET/CT imaging, of whom 31 had PA nodal metastasis), 97% of nodes were encompassed, thereby validating our guideline. CONCLUSIONS We used molecular PET/CT imaging to determine the anatomic locations of PA metastases to develop contouring guidelines for creating a prostate cancer PA CTV. Although the optimal patient selection and clinical benefits of PA radiation therapy remain uncertain, our results will aid in delineating the optimal target when PA radiation therapy is pursued.
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Affiliation(s)
- Anjali L Saripalli
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Brian Lee
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - William Adams
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Niranjan Bhandare
- Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Bhanu P Venkatesulu
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Ryan K Yoo
- Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Jennifer Price
- Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Grant A Harmon
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Alec M Block
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Nicholas Friedman
- Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Erica J Major
- Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - William Small
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Robert H Wagner
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - James S Welsh
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Abhishek A Solanki
- Department of Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr VA Hospital, Hines, Illinois.
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Francolini G, Garlatti P, Di Cataldo V, Triggiani L, Simoni N, Detti B, Lorenzetti V, Colombo F, Morelli V, Ganovelli M, Caprara L, Orsatti C, Burchini L, Frosini G, Bertini N, Loi M, Simontacchi G, Greto D, Desideri I, Meattini I, Livi L. Pattern of recurrence after stereotactic body radiotherapy for para-aortic oligo-recurrent prostate cancer, a multicentric analysis. LA RADIOLOGIA MEDICA 2023; 128:1423-1428. [PMID: 37597125 DOI: 10.1007/s11547-023-01701-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND M1a disease represents an intermediate status between loco-regional relapse and bone metastatic disease. Metastasis directed therapy (MDT), through stereotactic body RT (SBRT) may be offered to patients, aiming to exclusively treat sites of macroscopic relapse and avoiding wide prophylactic treatment volumes. This appears as a viable treatment, especially after the rise of PSMA tailored treatment approaches. MATERIALS AND METHODS Data about patients treated in two different institutions were retrieved from a prospectively collected dataset. All included patients were affected by oligo-recurrent M1a disease after definitive RT or radical prostatectomy, defined as ≤ 3 nodal lesions situated above aortic bifurcation and below renal arteries. Both castration resistant PCa (CRPC) and castration sensitive (CSPC) PCa patients were included. All imaging methods were allowed to detect recurrence (CT scan, Choline or PSMA PET/CT).All sites of recurrences were treated with SBRT. RESULTS Median PFS was 10 months (95% CI 8-17). Twelve patients died, with a median OS of 114 months (95% CI 85-114). Out of the 83 recurrences, 2 (2.4%), 11 (13.25%), 36 (43.37%) and 15 (18%) patients had respectively prostate bed only, pelvic nodal, para-aortic or distant relapse. Furthermore, 19 (22.9%) patients experienced a biochemical only relapse with negative imaging at re-staging. DISCUSSION MDT conferred a remarkable PFS outcome in a mixed cohort of CSPC and CRPC patients with m1a disease, with an optimal safety profile. Prospective trials are needed in order to compare MDT and ENRT for these patients, allowing to select the best treatment option.
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Affiliation(s)
- Giulio Francolini
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Pietro Garlatti
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Vanessa Di Cataldo
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Nicola Simoni
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126, Parma, Italy
| | - Beatrice Detti
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Victoria Lorenzetti
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Federico Colombo
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126, Parma, Italy
| | - Vittorio Morelli
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Michele Ganovelli
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Luisa Caprara
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Carolina Orsatti
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Luca Burchini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Giulio Frosini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Niccolò Bertini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Mauro Loi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gabriele Simontacchi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Daniela Greto
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Icro Meattini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Lorenzo Livi
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
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Murray J, De Meerleer G. How High Should We Go for Para-aortic Lymph Node Radiation Therapy? Int J Radiat Oncol Biol Phys 2023; 117:641-643. [PMID: 37739609 DOI: 10.1016/j.ijrobp.2023.06.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Julia Murray
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom.
| | - Gert De Meerleer
- Department of Radiotherapy, University Hospitals Leuven, Leuven, Belgium
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Zapatero A, Conde Moreno AJ, Barrado Los Arcos M, Aldave D. Node Oligorecurrence in Prostate Cancer: A Challenge. Cancers (Basel) 2023; 15:4159. [PMID: 37627187 PMCID: PMC10453311 DOI: 10.3390/cancers15164159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/12/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Within the oligometastatic state, oligorecurrent lymph node disease in prostate cancer represents an interesting clinical entity characterized by a relatively indolent biology that makes it unique: it can be treated radically, and its treatment is usually associated with a long period of control and excellent survival. Additionally, it is an emergent situation that we are facing more frequently mainly due to (a) the incorporation into clinical practice of the PSMA-PET that provides strikingly increased superior images in comparison to conventional imaging, with higher sensitivity and specificity; (b) the higher detection rates of bone and node disease with extremely low levels of PSA; and (c) the availability of high-precision technology in radiotherapy treatments with the incorporation of stereotaxic body radiotherapy (SBRT) or stereotaxic ablative radiotherapy (SABR) technology that allows the safe administration of high doses of radiation in a very limited number of fractions with low toxicity and excellent tolerance. This approach of new image-guided patient management is compelling for doctors and patients since it can potentially contribute to improving the clinical outcome. In this work, we discuss the available evidence, areas of debate, and potential future directions concerning the utilization of new imaging-guided SBRT for the treatment of nodal recurrence in prostate cancer.
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Affiliation(s)
- Almudena Zapatero
- Health Research Institute, University Hospital La Princesa, 28006 Madrid, Spain
| | | | | | - Diego Aldave
- University Clinical Hospital of Valladolid, 47003 Valladolid, Spain;
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Li M, Fan Y, Trapp C, Schmidt-Hegemann NS, Ma J, Buchner A, Lu S, Xu B, Stief C, Wang X, Zhou C, Belka C, Rogowski P. Elective nodal radiotherapy with a gapless radiation field junction for oligorecurrent prostate cancer after previous radiotherapy. Clin Transl Radiat Oncol 2022; 39:100571. [PMID: 36605290 PMCID: PMC9807861 DOI: 10.1016/j.ctro.2022.100571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/26/2022] Open
Abstract
Purpose To evaluate the feasibility of subsequent elective nodal radiotherapy (ENRT) for nodal recurrences after previous radiotherapy with a defined planning approach for a gapless radiation field junction. Methods Patients with 1) previous radiotherapy of prostate or prostatic fossa and subsequent pelvic ENRT or 2) previous pelvic radiotherapy and subsequent ENRT to paraaortic lymph nodes (LN) and gapless junction of both radiation fields were analyzed. The cumulative maximum dose (Dmax-cum) and the maximum cumulative dose in 1 cc (D1cc-cum) were estimated. Absolute toxicity and the toxicity exceeding baseline were evaluated. Results Twenty-two patients with PSMA-PET/CT-staged nodal oligorecurrence after prior radiotherapy were treated with pelvic (14 patients) or paraaortic ENRT (9 patients). One patient was treated sequentially at both locations. Median time between first and second RT was 20.2 months. Median doses to the lymphatic pathways and to PET-positive LN were 47.5 Gy and 64.8 Gy, respectively. The planning constraint of an estimated Dmax-cum ≤ 95 Gy and of D1cc-cum < 90 Gy were achieved in 23/23 cases and 22/23 cases, respectively. Median follow-up was 33.5 months. There was no additional acute or late toxicity ≥ grade 3. Worst acute toxicity exceeding baseline was grade 1 in 68.2% and grade 2 in 22.7% of patients. Worst late toxicity exceeding baseline was grade 1 in 31.8% and grade 2 in 18.2% of patients. Conclusion ENRT for nodal recurrences after a previous radiotherapy with gapless junction of radiation fields seems to be feasible, applying the dose constraints Dmax-cum ≤ 95 Gy and D1cc-cum < 90 Gy without grade 3 acute or late toxicities exceeding baseline.
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Key Words
- ADT, androgen deprivation therapy
- CTCAE, common terminology criteria for adverse events
- CTV, clinical target volume
- D1cc-cum, maximum cumulative dose in 1 cc
- Dmax-cum, cumulative maximum dose
- ENRT
- ENRT, elective nodal radiotherapy
- EQD2, equivalent dose in 2 Gy fractions
- Gapless radiation field junction
- IGRT, image-guided radiotherapy
- IMRT, intensity-modulated radiotherapy
- LN, lymph nodes
- Nodal oligorecurrence
- OAR, organs at risk
- PSA, prostate-specific antigen
- PSMA-PET/CT
- PSMA-PET/CT, prostate-specific membrane antigen positron emission tomography/computed tomography
- RT, radiotherapy
- Reirradiation
- SBRT, stereotactic body radiotherapy
- SIB, simultaneous integrated boost
- VMAT, volumetric modulated arc therapy
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6
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Zilli T, Achard V, Dal Pra A, Schmidt-Hegemann N, Jereczek-Fossa BA, Lancia A, Ingrosso G, Alongi F, Aluwini S, Arcangeli S, Blanchard P, Conde Moreno A, Couñago F, Créhange G, Dirix P, Gomez Iturriaga A, Guckenberger M, Pasquier D, Sargos P, Scorsetti M, Supiot S, Tree AC, Zapatero A, Le Guevelou J, Ost P, Belka C. Recommendations for radiation therapy in oligometastatic prostate cancer: An ESTRO-ACROP Delphi consensus. Radiother Oncol 2022; 176:199-207. [PMID: 36228761 DOI: 10.1016/j.radonc.2022.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Oligometastatic prostate cancer is a new and emerging treatment field with only few prospective randomized studies published so far. Despite the lack of strong level I evidence, metastasis-directed therapies (MDT) are widely used in clinical practice, mainly based on retrospective and small phase 2 studies and with a large difference across centers. Pending results of ongoing prospective randomized trials, there is a clear need for more consistent treatment indications and radiotherapy practices. MATERIAL AND METHODS A European Society for Radiotherapy and Oncology (ESTRO) Guidelines Committee consisting of radiation oncologists' experts in prostate cancer was asked to answer a dedicated questionnaire, including 41 questions on the main controversial issues with regard to oligometastatic prostate cancer. RESULTS The panel achieved consensus on patient selection and routine use of prostate-specific membrane antigen positron emission tomography (PSMA PET) imaging as preferred staging and restaging imaging. MDT strategies are recommended in the de novo oligometastatic, oligorecurrent and oligoprogressive disease setting for nodal, bone and visceral metastases. Radiation therapy doses, volumes and techniques were discussed and commented. CONCLUSION These recommendations have the purpose of providing standardization and consensus to optimize the radiotherapy treatment of oligometastatic prostate cancer until mature results of randomized trials are available.
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Affiliation(s)
- Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, Geneva University, Geneva, Switzerland.
| | - Vérane Achard
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Andrea Lancia
- Department of Radiation Oncology, Policlinico San Matteo Pavia Fondazione IRCCS, Pavia, Italy
| | - Gianluca Ingrosso
- Department of Radiation Oncology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Negrar di Valpolicella, Italy; University of Brescia, Brescia, Italy
| | - Shafak Aluwini
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Stefano Arcangeli
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Pierre Blanchard
- Université Paris Saclay, Villejuif, France; Inserm U1018 Oncostat, Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Antonio Conde Moreno
- Radiation Oncology Department, Hospital Universitario y Politécnico La Fe, Valencia, CEU Cardenal Herrera University, Castellón, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Madrid, Spain; Department of Radiation Oncology, Hospital La Luz, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea, Villaviciosa de Odón, Madrid, Spain
| | - Gilles Créhange
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Piet Dirix
- Department of Radiation-Oncology, Iridium Network, Antwerp, Belgium
| | - Alfonso Gomez Iturriaga
- Biocruces Health Research Institute, Cruces University Hospital, Basque Country University (UPV/EHU), Barakaldo, Bizkaia, Spain
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France; CRIStAL UMR CNRS 9189, Lille University, Lille, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest René Gauducheau, Saint-Herblain, France
| | - Alison C Tree
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Almudena Zapatero
- Department of Radiation Oncology, Health Research Institute, University Hospital La Princesa, Madrid, Spain
| | - Jennifer Le Guevelou
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Piet Ost
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Iridium Network, GZA ziekenhuizen, Wilrijk, Belgium
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital Munich, Munich, Germany
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