51
|
Seppälä J, Heikkilä J, Myllyoja K, Koskela K. Volumetric modulated arc therapy for synchronous bilateral whole breast irradiation - A case study. Rep Pract Oncol Radiother 2015; 20:398-402. [PMID: 26549999 DOI: 10.1016/j.rpor.2015.05.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/13/2015] [Accepted: 05/24/2015] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The treatment planning of bilateral breast irradiation (BBI) is a challenging task. The overlapping of tangential fields is usually unavoidable without compromising the target coverage. The purpose of this study was to investigate the technical feasibility and benefits of a single isocentre volumetric modulated arc therapy (VMAT) in BBI. METHODS AND MATERIALS Two women with bilateral breast cancer were included in this case study. The first patient (Pat#1) underwent a bilateral breast-conserving surgery and sentinel lymph node biopsy. The second patient (Pat#2) underwent a bilateral ablation and axillary lymph node dissection. Planning target volumes (PTV) and organs at risk were delineated on CT images. VMAT plans were created with four (two for both sides, Pat#1) or two (one for each breast, Pat#2) separate VMAT fields. Subsequently, traditional tangential field plans were generated for each patient and the dosimetric parameters were compared. RESULTS The treatment times of the patients with VMAT were less than 15 min with daily CBCT imaging. When compared to the standard tangential field technique, the VMAT plans improved the PTV dose coverage and dose homogeneity with improved sparing of lungs and heart. With traditional field arrangement, the overlapping of the tangential fields was inevitable without significantly compromising the target coverage, whereas with VMAT the hotspots were avoided. The patients were treated with the VMAT technique and no acute skin toxicity was observed with either of the patients. CONCLUSIONS A single isocentre VMAT technique has been implemented clinically for BBI. With the VMAT techniques, the dose delivery was quick and the hotspots in the field overlapping areas were avoided. The PTV dose coverage was superior in VMAT plans when compared with conventional tangential technique plans.
Collapse
Affiliation(s)
- Jan Seppälä
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Janne Heikkilä
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Kimmo Myllyoja
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | | |
Collapse
|
52
|
Depauw N, Batin E, Daartz J, Rosenfeld A, Adams J, Kooy H, MacDonald S, Lu HM. A novel approach to postmastectomy radiation therapy using scanned proton beams. Int J Radiat Oncol Biol Phys 2015; 91:427-34. [PMID: 25636765 DOI: 10.1016/j.ijrobp.2014.10.039] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/13/2014] [Accepted: 10/17/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Postmastectomy radiation therapy (PMRT), currently offered at Massachusetts General Hospital, uses proton pencil beam scanning (PBS) with intensity modulation, achieving complete target coverage of the chest wall and all nodal regions and reduced dose to the cardiac structures. This work presents the current methodology for such treatment and the ongoing effort for its improvements. METHODS AND MATERIALS A single PBS field is optimized to ensure appropriate target coverage and heart/lung sparing, using an in-house-developed proton planning system with the capability of multicriteria optimization. The dose to the chest wall skin is controlled as a separate objective in the optimization. Surface imaging is used for setup because it is a suitable surrogate for superficial target volumes. In order to minimize the effect of beam range uncertainties, the relative proton stopping power ratio of the material in breast implants was determined through separate measurements. Phantom measurements were also made to validate the accuracy of skin dose calculation in the treatment planning system. Additionally, the treatment planning robustness was evaluated relative to setup perturbations and patient breathing motion. RESULTS PBS PMRT planning resulted in appropriate target coverage and organ sparing, comparable to treatments by passive scattering (PS) beams but much improved in nodal coverage and cardiac sparing compared to conventional treatments by photon/electron beams. The overall treatment time was much shorter than PS and also shorter than conventional photon/electron treatment. The accuracy of the skin dose calculation by the planning system was within ±2%. The treatment was shown to be adequately robust relative to both setup uncertainties and patient breathing motion, resulting in clinically satisfying dose distributions. CONCLUSIONS More than 25 PMRT patients have been successfully treated at Massachusetts General Hospital by using single-PBS fields. The methodology and robustness of both the setup and the treatment have been discussed.
Collapse
Affiliation(s)
- Nicolas Depauw
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia.
| | - Estelle Batin
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Julianne Daartz
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anatoly Rosenfeld
- Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia
| | - Judith Adams
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hanne Kooy
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon MacDonald
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hsiao-Ming Lu
- Francis H. Burr Proton Therapy Center, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
53
|
Doyen J, Bondiau PY, Bénézéry K, Chand MÈ, Thariat J, Leysalle A, Gérard JP, Habrand JL, Hannoun-Lévi JM. [Current situation and perspectives of proton therapy]. Cancer Radiother 2015; 19:211-9; quiz 231-2, 235. [PMID: 25840776 DOI: 10.1016/j.canrad.2014.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/26/2014] [Indexed: 12/25/2022]
Abstract
Proton beam therapy is indicated as a treatment for some rare tumours and paediatric tumours because the technique allows a good local control with minimal toxicity; the growing number of centres that use proton beam therapy is associated with an increase of dosimetric and clinical data for other malignant tumours as well. This paper reviews potential indications of proton beam therapy. A systematic review on Medline was performed with the following keywords proton beam therapy, cancer, heavy particle, charged particle. No phase III trial has been published using proton beam therapy in comparison with the best photon therapy, but numerous retrospective and dosimetric studies have revealed an advantage of proton beam therapy compared to photons, above all in tumours next to parallel organs at risk (thoracic and abdominal tumours). This could be accompanied with a better safety profile and/or a better tumoural control; numerous phase 0, I, II, III and IV studies are ongoing to examine these hypotheses in more common cancers. Use of proton beam therapy is growing for common cancers within clinical trials but some indications could be applied sooner since in silico analysis showed major advantages with this technique.
Collapse
Affiliation(s)
- J Doyen
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - P-Y Bondiau
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - K Bénézéry
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - M-È Chand
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - J Thariat
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - A Leysalle
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - J-P Gérard
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - J-L Habrand
- Département de radiothérapie, centre François-Baclesse, 3, avenue du Général-Harris, 14076 Caen cedex 05, France
| | - J-M Hannoun-Lévi
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France.
| |
Collapse
|
54
|
Flejmer AM, Nyström PW, Dohlmar F, Josefsson D, Dasu A. Potential Benefit of Scanned Proton Beam versus Photons as Adjuvant Radiation Therapy in Breast Cancer. Int J Part Ther 2015. [DOI: 10.14338/ijpt-14-00013.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
55
|
Koppelmans V, Vernooij MW, Boogerd W, Seynaeve C, Ikram MA, Breteler MM, Schagen SB. Prevalence of Cerebral Small-Vessel Disease in Long-Term Breast Cancer Survivors Exposed to Both Adjuvant Radiotherapy and Chemotherapy. J Clin Oncol 2015; 33:588-93. [DOI: 10.1200/jco.2014.56.8345] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Adjuvant radiotherapy and chemotherapy for breast cancer have been related to transient ischemic attacks and stroke. To date, no studies have investigated the relationship between these adjuvant therapies and subclinical cerebral small-vessel disease in survivors of breast cancer. We compared white matter lesion (WML) volume and prevalence of brain infarctions and cerebral microbleeds (CMBs) between breast cancer survivors exposed to adjuvant radiotherapy and chemotherapy (aRCeBCSs) for primary disease and a population-based reference group. Patients and Methods Multimodal magnetic resonance imaging (1.5 T) was performed in 187 aRCeBCSs who received primary breast cancer treatment on average more than 20 years before this study and 374 age-matched reference women without a history of cancer. WML volume was segmented using fully automated software. Experienced raters reviewed all scans for cortical infarctions, lacunar infarctions, strictly lobar CMBs, and deep/infratentorial CMBs with or without lobar CMBs. Within the aRCeBCS group, we also analyzed the association between relative radiotherapy exposure to the carotid artery and prevalence of WML volume and CMBs. Results The aRCeBCS group had a higher prevalence of both total CMBs and CMBs in a deep/infratentorial region than the reference group. No between-group differences were observed in the prevalence of infarctions or WML volume. Exposure of the carotid artery to radiation was not associated with WML volume or CMBs. Conclusion More CMBs were found in the aRCeBCS group than in the population-based controls. These vascular lesions potentially mark cerebrovascular frailty that could partially explain the well-documented association between chemotherapy and cognitive dysfunction. No support was found for a radiotherapy-related origin of CMBs.
Collapse
Affiliation(s)
- Vincent Koppelmans
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| | - Meike W. Vernooij
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| | - Willem Boogerd
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| | - Caroline Seynaeve
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| | - M. Arfan Ikram
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| | - Monique M.B. Breteler
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| | - Sanne B. Schagen
- Vincent Koppelmans, University of Michigan, School of Kinesiology, Ann Arbor, MI; Vincent Koppelmans, Meike W. Vernooij, Caroline Seynaeve, and M. Arfan Ikram, Erasmus University Medical Center, Rotterdam; Vincent Koppelmans, Willem Boogerd, and Sanne B. Schagen, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; and Monique M.B. Breteler, German Center for Neurodegenerative Diseases and University of Bonn, Institute for Medical Biometry, Informatics, and
| |
Collapse
|
56
|
Plastaras JP, Berman AT, Freedman GM. Special Cases for Proton Beam Radiotherapy: Re-irradiation, Lymphoma, and Breast Cancer. Semin Oncol 2014; 41:807-19. [DOI: 10.1053/j.seminoncol.2014.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
57
|
Merino Lara TR, Fleury E, Mashouf S, Helou J, McCann C, Ruschin M, Kim A, Makhani N, Ravi A, Pignol JP. Measurement of mean cardiac dose for various breast irradiation techniques and corresponding risk of major cardiovascular event. Front Oncol 2014; 4:284. [PMID: 25374841 PMCID: PMC4205812 DOI: 10.3389/fonc.2014.00284] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/30/2014] [Indexed: 12/04/2022] Open
Abstract
After breast conserving surgery, early stage breast cancer patients are currently treated with a wide range of radiation techniques including whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) using high-dose rate (HDR) brachytherapy, or 3D-conformal radiotherapy (3D-CRT). This study compares the mean heart’s doses for a left breast irradiated with different breast techniques. An anthropomorphic Rando phantom was modified with gelatin-based breast of different sizes and tumors located medially or laterally. The breasts were treated with WBI, 3D-CRT, or HDR APBI. The heart’s mean doses were measured with Gafchromic films and controlled with optically stimulated luminescent dosimeters. Following the model reported by Darby (1), major cardiac were estimated assuming a linear risk increase with the mean dose to the heart of 7.4% per gray. WBI lead to the highest mean heart dose (2.99 Gy) compared to 3D-CRT APBI (0.51 Gy), multicatheter (1.58 Gy), and balloon HDR (2.17 Gy) for a medially located tumor. This translated into long-term coronary event increases of 22, 3.8, 11.7, and 16% respectively. The sensitivity analysis showed that the tumor location had almost no effect on the mean heart dose for 3D-CRT APBI and a minimal impact for HDR APBI. In case of WBI large breast size and set-up errors lead to sharp increases of the mean heart dose. Its value reached 10.79 Gy for women with large breast and a set-up error of 1.5 cm. Such a high value could increase the risk of having long-term coronary events by 80%. Comparison among different irradiation techniques demonstrates that 3D-CRT APBI appears to be the safest one with less probability of having cardiovascular events in the future. A sensitivity analysis showed that WBI is the most challenging technique for patients with large breasts or when significant set-up errors are anticipated. In those cases, additional heart shielding techniques are required.
Collapse
Affiliation(s)
- Tomas Rodrigo Merino Lara
- Radiotherapy Unit, School of Medicine, Pontificia Universidad Católica de Chile , Santiago , Chile ; Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Emmanuelle Fleury
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Shahram Mashouf
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Joelle Helou
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Claire McCann
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Anthony Kim
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Nadiya Makhani
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Ananth Ravi
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Jean-Philippe Pignol
- Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada ; Department of Radiation Oncology, Erasmus MC , Rotterdam , Netherlands
| |
Collapse
|
58
|
Abstract
Proton beam therapy, the most common form of heavy-particle radiation therapy, is not a new invention, but it has gained considerable public attention because of the high cost of installing and operating the rapidly increasing number of treatment centers. This article reviews the physical properties of proton beam therapy and focuses on the up-to-date clinical evidence comparing proton beam therapy with the more standard and widely available radiation therapy treatment alternatives. In a cost-conscious era of health care, the hypothetical benefits of proton beam therapy will have to be supported by demonstrable clinical gains. Proton beam therapy represents, through its scale and its cost, a battleground for the policy debate around managing expensive technology in modern medicine.
Collapse
Affiliation(s)
- Timur Mitin
- Timur Mitin, Massachusetts General Hospital, Boston, MA.
| | | |
Collapse
|
59
|
Shah C, Badiyan S, Berry S, Khan AJ, Goyal S, Schulte K, Nanavati A, Lynch M, Vicini FA. Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy. Radiother Oncol 2014; 112:9-16. [PMID: 24813095 DOI: 10.1016/j.radonc.2014.04.009] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 04/06/2014] [Accepted: 04/18/2014] [Indexed: 12/12/2022]
Abstract
Breast cancer radiotherapy represents an essential component in the overall management of both early stage and locally advanced breast cancer. As the number of breast cancer survivors has increased, chronic sequelae of breast cancer radiotherapy become more important. While recently published data suggest a potential for an increase in cardiac events with radiotherapy, these studies do not consider the impact of newer radiotherapy techniques commonly utilized. Therefore, the purpose of this review is to evaluate cardiac dose sparing techniques in breast cancer radiotherapy. Current options for cardiac protection/avoidance include (1) maneuvers that displace the heart from the field such as coordinating the breathing cycle or through prone patient positioning, (2) technological advances such as intensity modulated radiation therapy (IMRT) or proton beam therapy (PBT), and (3) techniques that treat a smaller volume around the lumpectomy cavity such as accelerated partial breast irradiation (APBI), or intraoperative radiotherapy (IORT). While these techniques have shown promise dosimetrically, limited data on late cardiac events exist due to the difficulties of long-term follow up. Future studies are required to validate the efficacy of cardiac dose sparing techniques and may use surrogates for cardiac events such as biomarkers or perfusion imaging.
Collapse
Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Summa Health System, Akron, United States
| | - Shahed Badiyan
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, St. Louis, United States
| | - Sameer Berry
- Department of Radiation Oncology, Summa Health System, Akron, United States
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey & Rutgers Robert Wood Johnson Medical School, New Brunswick, United States
| | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey & Rutgers Robert Wood Johnson Medical School, New Brunswick, United States
| | - Kevin Schulte
- Department of Radiation Oncology, Summa Health System, Akron, United States
| | - Anish Nanavati
- Department of Oncology, Georgetown University School of Medicine, Washington DC United States
| | - Melanie Lynch
- Department of Radiation Oncology, Summa Health System, Akron, United States
| | - Frank A Vicini
- Michigan Healthcare Professionals/21st Century Oncology, Farmington Hills, United States.
| |
Collapse
|
60
|
Grau C. The model-based approach to clinical studies in particle radiotherapy – A new concept in evidence based radiation oncology? Radiother Oncol 2013; 107:265-6. [DOI: 10.1016/j.radonc.2013.06.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 06/28/2013] [Indexed: 12/29/2022]
|