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Holt E, Mantel A, Cokelek M, Tacey M, Jassal S, Law M, Zantuck N, Yong C, Cheng M, Viotto A, Foroudi F, Chao M. Volumetric arc therapy: A viable option for right-sided breast with comprehensive regional nodal irradiation in conjunction with deep inspiration breath hold. J Med Imaging Radiat Sci 2021; 52:223-237. [PMID: 33771509 DOI: 10.1016/j.jmir.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE Deep inspiration breath hold (DIBH) is an innovative technique routinely used for left-sided breast radiotherapy to significantly reduce harmful dose to the heart and ipsilateral lung. Currently, there is scant literature exploring DIBH for right-sided whole breast and regional nodal irradiation (WB & RNI). The purpose of this study is to examine if DIBH produces a clinically significant reduction in organ at risk (OAR) dose for right-sided WB + RNI, whilst comparatively analysing the use of volumetric arc therapy (VMAT) versus tangential inverse modulated radiotherapy (t-IMRT). METHODS AND MATERIALS Ten patients, previously treated for left sided breast cancer (with a FB and DIBH CT scan), were selected from our database to be retrospectively replanned to the right breast and nodal regions. Planning target volumes (PTV) were marked to include the whole right breast and regional nodes, encompassing the supraclavicular fossa (SCF) and internal mammary nodes (IMN). PTVs and OARs were contoured on the Pinnacle workstation according to the Radiation Therapy Oncology Group (RTOG) guidelines. VMAT and t-IMRT plans were generated to a prescribed dose of 50 Gy in 25 fractions on both the DIBH and FB data sets for dosimetric analysis. RESULTS Coverage of the right breast (mean, D95%) and SCF (D95%) were significantly improved with VMAT in comparison to t-IMRT, with no statistically significant variation on the IMN PTV (D95%). The use of DIBH did not impact PTV coverage compared with FB. VMAT reduced dose to the ipsilateral lung (mean, V20Gy), combined lungs (mean, V20Gy) and liver (D2cc); conversely dose to the heart (mean), left lung (mean, V5Gy) and contralateral breast (mean) were increased. For both techniques DIBH significantly improved dose to OARs including the ipsilateral lung (mean, V20Gy, V5Gy), total lung (mean, V20Gy), heart (mean, V25Gy) and liver (D2cc) when compared to FB. CONCLUSION DIBH could be considered for patients treated with right-sided WB and RNI due to a significant decrease in heart, ipsilateral lung, total lung and liver doses. VMAT significantly improves PTV coverage over t-IMRT whilst reducing dose to the ipsilateral lung and liver, albeit to the detriment of the left lung, contralateral breast and heart. The increase in heart dose can be mitigated by the use of DIBH. We recommend if VMAT is utilised for superior target volume coverage, DIBH should also be implemented to reduce OAR toxicity. RÉSUMÉ: BUT: La retenue respiratoire profonde (DIBH) est une technique innovante couramment utilisée pour la radiothérapie du cÔté gauche du sein afin de réduire de manière significative la dose nocive pour le cŒur et le poumon ipsilatéral (13-15). Actuellement, il existe peu d'ouvrages sur la DIBH pour l'irradiation du sein entier du cÔté droit et des nodules régionaux (WB+RNI). L'objectif de cette étude est d'examiner si la DIBH produit une réduction cliniquement significative de la dose d'organe à risque (OAR) pour la WB+RNI du cÔté droit, tout en analysant comparativement l'utilisation de l'arcthérapie volumétrique (VMAT) par rapport à la radiothérapie par modulation d'intensité tangentielle (t-IMRT). MéTHODOLOGIE ET MATéRIEL: Dix scans tomodensitométriques avec un ensemble de données DIBH et de respiration libre (FB) ont été sélectionnés de manière rétrospective. Les volumes cibles de planification (PTV) ont été marqués pour inclure le sein droit entier et les ganglions régionaux, englobant la fosse supraclaviculaire (SCF) et les ganglions mammaires internes (IMN). Les PTV et les OAR ont été définis sur la station de travail Pinnacle conformément aux directives du groupe de radiothérapie oncologique (RTOG) (17). Les plans t-IMRT et VMAT ont été générés pour une dose prescrite de 50Gy en 25 fractions sur les ensembles de données DIBH et FB pour l'analyse dosimétrique. RéSULTATS: La couverture du sein droit (moyenne, D95%) et du SCF (D95%) a été significativement améliorée avec la VMAT par rapport à la t-IMRT, sans variation statistiquement significative sur la PTV IMN (D95%). L'utilisation de la DIBH n'a pas eu d'impact sur la couverture du PTV par rapport à la FB. La VMAT a réduit la dose dans le poumon ipsilatéral (moyenne, V20Gy), les poumons combinés (moyenne, V20Gy) et le foie (D2cc) ; à l'inverse, la dose dans le cŒur (moyenne), le poumon gauche (moyenne, V5Gy) et le sein controlatéral (moyenne) a été augmentée. Pour les deux techniques, la DIBH a amélioré de manière significative la dose aux OAR, y compris le poumon ipsilatéral (moyenne, V20Gy, V5Gy), le poumon total (moyenne, V20Gy), le cŒur (moyenne, V25Gy) et le foie (D2cc), par rapport à la respiration libre. CONCLUSION La DIBH pourrait être envisagé pour les patients traités par WB+RNI du cÔté droit en raison d'une diminution significative des doses dans le cŒur, le poumon ipsilatéral, le poumon total et le foie. La VMAT améliore considérablement la couverture de la PTV par rapport à la t-IMRT tout en réduisant la dose dans le poumon ipsilatéral et le foie, mais au détriment du poumon gauche, du sein controlatéral et du cŒur. L'augmentation de la dose au cŒur peut être atténuée par l'utilisation de la DIBH. Nous recommandons, si la VMAT est utilisée pour une couverture supérieure du volume cible, de mettre également en Œuvre la DIBH pour réduire la toxicité aux OAR.
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Affiliation(s)
- Emily Holt
- GenesisCare Victoria, Ringwood Private Hospital, VIC, Australia.
| | - Amanda Mantel
- GenesisCare Victoria, Ringwood Private Hospital, VIC, Australia
| | - Margaret Cokelek
- Olivia Newton John Cancer and Wellness Centre, Heidelberg, VIC, Australia
| | - Mark Tacey
- Olivia Newton John Cancer and Wellness Centre, Heidelberg, VIC, Australia; Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia
| | - Sunny Jassal
- Maroondah Hospital, Ringwood East, VIC, Australia
| | - Michael Law
- Maroondah Hospital, Ringwood East, VIC, Australia
| | | | - Charles Yong
- Maroondah Hospital, Ringwood East, VIC, Australia
| | | | - Angela Viotto
- Olivia Newton John Cancer and Wellness Centre, Heidelberg, VIC, Australia
| | - Farshad Foroudi
- Olivia Newton John Cancer and Wellness Centre, Heidelberg, VIC, Australia
| | - Michael Chao
- GenesisCare Victoria, Ringwood Private Hospital, VIC, Australia; Maroondah Hospital, Ringwood East, VIC, Australia.
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2
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Loap P, Kirova Y. Evaluating cardiac substructure radiation exposure in breast rotational intensity modulated radiation therapy: Effects of cancer laterality, fractionation and deep inspiration breath-hold. Cancer Radiother 2020; 25:13-20. [PMID: 33288407 DOI: 10.1016/j.canrad.2020.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/10/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Rotational intensity-modulated radiation therapy currently has a growing role in breast cancer radiation therapy, since this radiation technique reduces cardiac radiation exposure while homogeneously covering target volumes. This study aims to evaluate radiation exposure of cardiac substructures across a broad spectrum of breast cancer cases differing by cancer laterality, fractionation regimen and addition of deep-inspiration breath hold. MATERIALS AND METHODS Cardiac substructures were delineated following guidelines endorsed by the European Society for Radiotherapy and Oncology (ESTRO) for forty-four breast cancer patients having undergone conserving surgery and adjuvant rotational intensity-modulated radiation therapy. Target volumes consisted of the whole breast with a boost, axillary and internal mammary nodes. Patients were treated using free-breathing technique for left-sided or right-sided, normofractionated or hypofractionated helical tomotherapy or volumetric modulated arc therapy, or using deep-inspiration breath hold for left-sided normofractionated volumetric modulated arc therapy. Mean and maximum doses to cardiac substructures were retrieved. Correlations were performed between mean- and maximum radiation doses to cardiac substructures. RESULTS Left-sided and right-sided irradiations were associated with different cardiac substructure exposure patterns despite comparable mean heart dose: 7.21Gy for left-sided normofractionated regimen, 6.28Gy for right-sided normofractionated regimen. Deep-inspiration breath hold reduced mean doses to almost all cardiac substructures for left-sided irradiation, but did not decrease maximum doses to coronary arteries. Correlations between mean- and maximum doses to cardiac substructures were usually moderate, but stronger for right-sided irradiation. CONCLUSION Despite comparable mean heart dose, cardiac substructure radiation exposure patterns with rotational intensity-modulated radiation therapy strongly depend on the breast side, which could trigger clinically different long-term cardiotoxicity events. Deep-inspiration breath hold improves cardiac substructure dosimetry. Mean- and maximum heart dose could probably not be used as surrogate markers for precise cardiac substructure evaluation. In a near future, clinical practice and cardiotoxicity studies could possibly gain by considering cardiac substructure in a more systematic manner, possibly relying on cardiac autosegmentation algorithms.
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Affiliation(s)
- P Loap
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
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Tyran M, Tallet A, Resbeut M, Ferre M, Favrel V, Fau P, Moureau-Zabotto L, Darreon J, Gonzague L, Benkemouche A, Varela-Cagetti L, Salem N, Farnault B, Acquaviva MA, Mailleux H. Safety and benefit of using a virtual bolus during treatment planning for breast cancer treated with arc therapy. J Appl Clin Med Phys 2018; 19:463-472. [PMID: 29959819 PMCID: PMC6123145 DOI: 10.1002/acm2.12398] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose This study evaluates the benefit of a virtual bolus method for volumetric modulated arc therapy (VMAT) plan optimization to compensate breast modifications that may occur during breast treatment. Methods Ten files were replanned with VMAT giving 50 Gy to the breast and 47 Gy to the nodes within 25 fractions. The planning process used a virtual bolus for the first optimization, then the monitors units were reoptimized without bolus, after fixing the segments shapes. Structures and treatment planning were exported on a second scanner (CT) performed during treatment as a consequence to modifications in patient's anatomy. The comparative end‐point was clinical target volume's coverage. The first analysis compared the VMAT plans made using the virtual bolus method (VB‐VMAT) to the plans without using it (NoVB‐VMAT) on the first simulation CT. Then, the same analysis was performed on the second CT. Finally, the level of degradation of target volume coverage between the two CT using VB‐VMAT was compared to results using a standard technique of forward‐planned multisegment technique (Tan‐IMRT). Results Using a virtual bolus for VMAT does not degrade dosimetric results on the first CT. No significant result in favor of the NoVB‐VMAT plans was noted. The VB‐VMAT method led to significant better dose distribution on a second CT with modified anatomies compared to NoVB‐VMAT. The clinical target volume's coverage by 95% (V95%) of the prescribed dose was 98.9% [96.1–99.6] on the second CT for VB‐VMAT compared to 92.6% [85.2–97.7] for NoVB‐VMAT (P = 0.0002). The degradation of the target volume coverage for VB‐VMAT is not worse than for Tan‐IMRT: the median differential of V95% between the two CT was 0.9% for VMAT and 0.7% for Tan‐IMRT (P = 1). Conclusion This study confirms the safety and benefit of using a virtual bolus during the VMAT planning process to compensate potential breast shape modifications.
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Affiliation(s)
- Marguerite Tyran
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Agnes Tallet
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Michel Resbeut
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Marjorie Ferre
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Veronique Favrel
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Pierre Fau
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Julien Darreon
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Laurence Gonzague
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ahcene Benkemouche
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Naji Salem
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Bertrand Farnault
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Hugues Mailleux
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
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4
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Cozzi L, Lohr F, Fogliata A, Franceschini D, De Rose F, Filippi AR, Guidi G, Vanoni V, Scorsetti M. Critical appraisal of the role of volumetric modulated arc therapy in the radiation therapy management of breast cancer. Radiat Oncol 2017; 12:200. [PMID: 29258539 PMCID: PMC5735809 DOI: 10.1186/s13014-017-0935-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
Background The aim of this review is the critical appraisal of the current use of volumetric modulated arc therapy for the radiation therapy management of breast cancer. Both clinical and treatment planning studies were investigated. Material and methods A Pubmed/MEDLINE search of the National Library of Medicine was performed to identify VMAT and breast related articles. After a first order rejection of the irrelevant findings, the remaining articles were grouped according to two main categories: clinical vs. planning studies and to some sub-categories (pointing to significant technical features). Main areas of application, dosimetric and clinical findings as well as areas of innovations were defined. Results A total of 131 articles were identified and of these, 67 passed a first order selection. Six studies reported clinical results while 61 treatment dealed with treatment planning investigations. Among the innovation lines, the use of high intensity photon beams (flattening filter free), altered fractionation schemes (simultaneous integrated boost, accelerated partial breast irradiation, single fraction), prone positioning and modification of standard VMAT (use of dynamic trajectories or hybrid VMAT methods) resulted among the main relevant fields of interest. Approximately 10% of the publications reported upon respiratory gating in conjunction with VMAT. Conclusions The role of VMAT in the radiation treatment of breast cancer seems to be consolidated in the in-silico arena while still limited evidence and only one phase II trial appeared in literature from the clinical viewpoint. More clinical reports are needed to fully proove the expected dosimetric benefits demonstrated in the planning investigations.
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Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.
| | - Frank Lohr
- Radiation Oncology Department, Ospedaliero-Universitaria, Modena, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - A R Filippi
- Department of Radiation Oncology, Osp. S. Luigi Gonzaga University Hospital, Torino, Italy
| | - Gabriele Guidi
- Medical Physics Department, Az. Ospedaliero-Universitaria, Modena, Italy
| | | | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
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5
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Zhang C, Wang X, Li X, Zhao N, Wang Y, Han X, Ci C, Zhang J, Li M, Zhang Y. The landscape of DNA methylation-mediated regulation of long non-coding RNAs in breast cancer. Oncotarget 2017; 8:51134-51150. [PMID: 28881636 PMCID: PMC5584237 DOI: 10.18632/oncotarget.17705] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/24/2017] [Indexed: 12/22/2022] Open
Abstract
Although systematic studies have identified a host of long non-coding RNAs (lncRNAs) which are involved in breast cancer, the knowledge about the methyla-tion-mediated dysregulation of those lncRNAs remains limited. Here, we integrated multi-omics data to analyze the methylated alteration of lncRNAs in breast invasive carcinoma (BRCA). We found that lncRNAs showed diverse methylation patterns on promoter regions in BRCA. LncRNAs were divided into two categories and four subcategories based on their promoter methylation patterns and expression levels be-tween tumor and normal samples. Through cis-regulatory analysis and gene ontology network, abnormally methylated lncRNAs were identified to be associated with can-cer regulation, proliferation or expression of transcription factors. Competing endog-enous RNA network and functional enrichment analysis of abnormally methylated lncRNAs showed that lncRNAs with different methylation patterns were involved in several hallmarks and KEGG pathways of cancers significantly. Finally, survival analysis based on mRNA modules in networks revealed that lncRNAs silenced by high methylation were associated with prognosis significantly in BRCA. This study enhances the understanding of aberrantly methylated patterns of lncRNAs and pro-vides a novel insight for identifying cancer biomarkers and potential therapeutic tar-gets in breast cancer.
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Affiliation(s)
- Chunlong Zhang
- Department of Medical Informatics, Daqing Campus, Harbin Medical University, Daqing, 163000, China
| | - Xinyu Wang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
| | - Xuecang Li
- Department of Medical Informatics, Daqing Campus, Harbin Medical University, Daqing, 163000, China
| | - Ning Zhao
- School of Life Science and Technology, Harbin Institute of Technology, Harbin, 150081, China
| | - Yihan Wang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
| | - Xiaole Han
- Department of Medical Informatics, Daqing Campus, Harbin Medical University, Daqing, 163000, China
| | - Ce Ci
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
| | - Jian Zhang
- Department of Medical Informatics, Daqing Campus, Harbin Medical University, Daqing, 163000, China
| | - Meng Li
- Department of Medical Informatics, Daqing Campus, Harbin Medical University, Daqing, 163000, China
| | - Yan Zhang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150081, China
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6
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Macchia G, Deodato F, Cilla S, Cammelli S, Guido A, Ferioli M, Siepe G, Valentini V, Morganti AG, Ferrandina G. Volumetric modulated arc therapy for treatment of solid tumors: current insights. Onco Targets Ther 2017; 10:3755-3772. [PMID: 28794640 PMCID: PMC5538686 DOI: 10.2147/ott.s113119] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Aim This article discusses the current use of volumetric modulated arc therapy (VMAT) techniques in clinical practice and reviews the available data from clinical outcome studies in different clinical settings. An overview of available literature about clinical outcomes with VMAT stereotactic/radiosurgical treatment is also reported. Materials and methods All published manuscripts reporting the use of VMAT in a clinical setting from 2009 to November 2016 were identified. The search was carried out in December 2016 using the National Library of Medicine (PubMed/Medline). The following words were searched: “volumetric arc therapy”[All Fields] OR “vmat”[All Fields] OR “rapidarc”[All Fields], AND “radiotherapy”[All Fields] AND “Clinical Trial”[All Fields]. Results Overall, 37 studies (21 prospective and 16 retrospective) fulfilling inclusion criteria and thus included in the review evaluated 2,029 patients treated with VMAT; of these patients, ~30.8% had genitourinary (GU) tumors (81% prostate, 19% endometrial), 26.2% head-and-neck cancer (H&NC), 13.9% oligometastases, 11.2% had anorectal cancer, 10.6% thoracic neoplasms (81% breast, 19% lung), and 7.0% brain metastases (BMs). Six different clinical scenarios for VMAT use were identified: 1) BMs, 2) H&NC, 3) thoracic neoplasms, 4) GU cancer, 5) anorectal tumor, and 6) stereotactic body radiation therapy (SBRT) performed by VMAT technique in the oligometastatic patient setting. Conclusion The literature addressing the clinical appropriateness of VMAT is scarce. Current literature suggests that VMAT, especially when used as simultaneous integrated boost or SBRT strategy, is an effective safe modality for all cancer types.
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Affiliation(s)
| | | | - Savino Cilla
- Medical Physics Unit, "Giovanni Paolo II" Foundation, Catholic University of the Sacred Heart, Campobasso
| | - Silvia Cammelli
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Alessandra Guido
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Martina Ferioli
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Giambattista Siepe
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Vincenzo Valentini
- Department of Radiation Oncology, Catholic University of the Sacred Heart, Rome
| | - Alessio Giuseppe Morganti
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Gabriella Ferrandina
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome.,Department of Health Sciences and Medicine, University of Molise, Campobasso, Italy
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