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Wang J, Dong T, Meng X, Li W, Li N, Wang Y, Yang B, Qiu J. Application and dosimetric comparison of surface-guided deep inspiration breath-hold for lung stereotactic body radiotherapy. Med Dosim 2024:S0958-3947(24)00027-X. [PMID: 38910070 DOI: 10.1016/j.meddos.2024.05.003] [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: 04/08/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/25/2024]
Abstract
Respiratory motion management is the crucial challenge for safe and effective application of lung stereotactic body radiotherapy (SBRT). The present study implemented lung SBRT treatment in voluntary deep inspiration breath-hold (DIBH) with surface-guided radiotherapy (SGRT) system and evaluated the geometric and dosimetric benefits of DIBH to organs-at-risk (OARs), aiming to advising the choice between DIBH technology and conventional free breathing 4 dimensions (FB-4D) technology. Five patients of lung SBRT treated in DIBH with SGRT at our institution were retrospectively analyzed. CT scans were acquired in DIBH and FB-4D, treatment plans were generated for both respiratory phases. The geometric and dosimetry of tumor, ipsilateral lung, double lungs and heart were compared between the DIBH and FB-4D treatment plans. In terms of target coverage, utilizing DIBH significantly reduced the mean plan target volume (PTV) by 21.9% (p = 0.09) compared to FB-4D, the conformity index (CI) of DIBH and FB-4D were comparable, but the dose gradient index (DGI) of DIBH was higher. With DIBH expanding lung, the volumes of ipsilateral lung and double lungs were 2535.1 ± 403.0cm3 and 4864.3 ± 900.2cm3, separately, 62.2% (p = 0.009) and 73.1% (p = 0.009) more than volumes of ipsilateral lung (1460.03 ± 146.60cm3) and double lungs (2811.25 ± 603.64cm3) in FB-4D. The heart volume in DIBH was 700.0 ± 146.1cm3, 11.6% (p = 0.021) less than that in FB-4D. As for OARs protection, the mean dose, percent of volume receiving > 20Gy (V20) and percent of volume receiving > 5Gy (V5) of ipsilateral lung in DIBH were significantly lower by 33.2% (p = 0.020), 44.0% (p = 0.022) and 24.5% (p = 0.037) on average, separately. Double lungs also showed significant decrease by 31.1% (p = 0.019), 45.5% (p = 0.024) and 20.9% (p = 0.048) on average for mean dose, V20 and V5 in DIBH. Different from the lung, the mean dose and V5 of heart showed no consistency between DIBH and FB-4D, but lower maximum dose of heart was achieved in DIBH for all patients in this study. Appling lung SBRT in DIBH with SGRT was feasibly performed with high patient compliance. DIBH brought significant dosimetric benefits to lung, however, it caused more or less irradiated heart dose that depend on the patients' individual differences which were unpredictable.
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Affiliation(s)
- Jiaxin Wang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Tingting Dong
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Xiangyin Meng
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Wenbo Li
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Nan Li
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Yijun Wang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China
| | - Bo Yang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China.
| | - Jie Qiu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, China.
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Renner A, Gulyas I, Buschmann M, Heilemann G, Knäusl B, Heilmann M, Widder J, Georg D, Trnková P. Explicitly encoding the cyclic nature of breathing signal allows for accurate breathing motion prediction in radiotherapy with minimal training data. Phys Imaging Radiat Oncol 2024; 30:100594. [PMID: 38883146 PMCID: PMC11176922 DOI: 10.1016/j.phro.2024.100594] [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: 02/07/2024] [Revised: 05/17/2024] [Accepted: 05/25/2024] [Indexed: 06/18/2024] Open
Abstract
Background and purpose Active breathing motion management in radiotherapy consists of motion monitoring, quantification and mitigation. It is impacted by associated latencies of a few 100 ms. Artificial neural networks can successfully predict breathing motion and eliminate latencies. However, they require usually a large dataset for training. The objective of this work was to demonstrate that explicitly encoding the cyclic nature of the breathing signal into the training data enables significant reduction of training datasets which can be obtained from healthy volunteers. Material and methods Seventy surface scanner breathing signals from 25 healthy volunteers in anterior-posterior direction were used for training and validation (ratio 4:1) of long short-term memory models. The model performance was compared to a model using decomposition into phase, amplitude and a time-dependent baseline. Testing of the models was performed on 55 independent breathing signals in anterior-posterior direction from surface scanner (35 lung, 20 liver) of 30 patients with a mean breathing amplitude of (5.9 ± 6.7) mm. Results Using the decomposed breathing signal allowed for a reduction of the absolute root-mean square error (RMSE) from 0.34 mm to 0.12 mm during validation. Testing using patient data yielded an average absolute RMSE of the breathing signal of (0.16 ± 0.11) mm with a prediction horizon of 500 ms. Conclusion It was demonstrated that a motion prediction model can be trained with less than 100 datasets of healthy volunteers if breathing cycle parameters are considered. Applied to 55 patients, the model predicted breathing motion with a high accuracy.
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Affiliation(s)
- Andreas Renner
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
| | - Ingo Gulyas
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Martin Buschmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Gerd Heilemann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
| | - Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Martin Heilmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Joachim Widder
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Image and Knowledge Driven Precision Radiation Oncology, Department of Radiation Oncology, Medical University of Vienna, Austria
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Petra Trnková
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
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Lu W, Hong LX, Yamada N, Berry SL, Song Y, Choi W, Cerviño LI, Tang X, Mechalakos JG, Romesser PB, Powell S, Li G. Comparison of setup accuracy of optical surface image versus orthogonal x-ray images for VMAT of the left breast using deep-inspiration breath-hold. J Appl Clin Med Phys 2023; 24:e14117. [PMID: 37535396 PMCID: PMC10691624 DOI: 10.1002/acm2.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/25/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023] Open
Abstract
To compare the setup accuracy of optical surface image (OSI) versus orthogonal x-ray images (2DkV) using cone beam computed tomography (CBCT) as ground truth for radiotherapy of left breast cancer in deep-inspiration breath-hold (DIBH). Ten left breast DIBH patients treated with volumetric modulated arc therapy (VMAT) were studied retrospectively. OSI, 2DkV, and CBCT were acquired weekly at treatment setup. OSI, 2DkV, and CBCT were registered to planning CT or planning DRR based on a breast surface region of interest (ROI), bony anatomy (chestwall and sternum), and both bony anatomy and breast surface, respectively. These registrations provided couch shifts for each imaging system. The setup errors, or the difference in couch shifts between OSI and CBCT were compared to those between 2DkV and CBCT. A second OSI was acquired during last beam delivery to evaluate intrafraction motion. The median absolute setup errors were (0.21, 0.27, 0.23 cm, 0.6°, 1.3°, 1.0°) for OSI, and (0.26, 0.24, 0.18 cm, 0.9°, 1.0°, 0.6°) for 2DkV in vertical, longitudinal and lateral translations, and in rotation, roll and pitch, respectively. None of the setup errors was significantly different between OSI and 2DkV. For both systems, the systematic and random setup errors were ≤0.6 cm and ≤1.5° in all directions. Nevertheless, larger setup errors were observed in some sessions in both systems. There was no correlation between OSI and CBCT whereas there was modest correlation between 2DkV and CBCT. The intrafraction motion in DIBH detected by OSI was small with median absolute translations <0.2 cm, and rotations ≤0.4°. Though OSI showed comparable and small setup errors as 2DkV, it showed no correlation with CBCT. We concluded that to achieve accurate setup for both bony anatomy and breast surface, daily 2DkV can't be omitted following OSI for left breast patients treated with DIBH VMAT.
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Affiliation(s)
- Wei Lu
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Linda X. Hong
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Nelson Yamada
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Sean L. Berry
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Yulin Song
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Wookjin Choi
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Laura I. Cerviño
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiaoli Tang
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - James G. Mechalakos
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Paul B. Romesser
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Simon Powell
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Guang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Zeng C, Fan Q, Li X, Song Y, Kuo L, Aristophanous M, Cervino LI, Hong L, Powell S, Li G. A Potential Pitfall and Clinical Solutions in Surface-Guided Deep Inspiration Breath Hold Radiation Therapy for Left-Sided Breast Cancer. Adv Radiat Oncol 2023; 8:101276. [PMID: 38047221 PMCID: PMC10692299 DOI: 10.1016/j.adro.2023.101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/18/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Deep inspiration breath hold (DIBH) is an effective technique to spare the heart in treating left-sided breast cancer. Surface-guided radiation therapy (SGRT) is increasingly applied in DIBH setup and motion monitoring. Patient-specific breathing behavior, either thoracically driven or abdominally driven (A-DIBH), should be unaltered, online identified, and monitored accordingly to ensure reproducible heart-sparing treatment. Methods and Materials Sixty patients with left-sided breast cancer treated with SGRT were analyzed: 20 A-DIBH patients with vertical chest elevation (VCE ≤ 5 mm) were prospectively identified, and 40 control patients were retrospectively and randomly selected for comparison. At simulation, both free-breathing (FB) and DIBH computed tomography (CT) were acquired, guided by a motion surrogate placed around the xiphoid process. For SGRT treatment setups, the region of interest (ROI) was defined on the CT chest surface, and the surrogate-based setup was a backup. For all 60 patients, the VCE was measured as the average of the FB-to-DIBH elevations at the breast and xiphoid process, together with abdominal elevation. In the 40-patient control group, A-DIBH patients (VCE ≤ 5 mm) were identified. Of the 20 A-DIBH patients, 10 were treated with volumetric modulated arc therapy plans, and 10 patients were treated with tangent plans. Clinical DIBH plans were recalculated on FB CT to compare maximum dose (DMax), 5% of the maximum dose (D5%), mean dose (DMean), and V30Gy, V20Gy, and V5Gy of the heart and lungs and their significance. Results In the 20 A-DIBH patients, VCE = 3 ± 2 mm, surrogate motion (9 ± 6 mm), and abdomen motion of 14 ± 5 mm are found. Heart dose reduction from FB to DIBH is significant (P < .01): ∆DMax = -8.4 ± 9.8 Gy, ∆D5% = -2.4 ± 4.4 Gy, and ∆DMean = -0.6 ± 0.9 Gy. Six out of 40 control patients (15%) are found to have VCE ≤ 5 mm. Conclusions A-DIBH (VCE ≤ 5 mm) patient population is significant (15%), and they should be identified in the SGRT workflow and monitored accordingly. A new abdominal ROI or an abdominal surrogate should be used instead of the conventional chest-only ROI. Patient-specific DIBH should be preserved for higher reproducibility to ensure heart sparing.
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Affiliation(s)
- Chuan Zeng
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Qiyong Fan
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Xiang Li
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yulin Song
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Licheng Kuo
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michalis Aristophanous
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura I. Cervino
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Linda Hong
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon Powell
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Guang Li
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Nikovia V, Chinis E, Gkantaifi A, Marketou M, Mazonakis M, Charalampakis N, Mavroudis D, Orfanidou KV, Varveris A, Antoniadis C, Tolia M. Current Cardioprotective Strategies for the Prevention of Radiation-Induced Cardiotoxicity in Left-Sided Breast Cancer Patients. J Pers Med 2023; 13:1038. [PMID: 37511651 PMCID: PMC10381791 DOI: 10.3390/jpm13071038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/11/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Breast cancer (BC) is the most common malignancy in females, accounting for the majority of cancer-related deaths worldwide. There is well-established understanding about the effective role of radiotherapy (RT) in BC therapeutic strategies, offering a better local-regional control, prolonged survival, and improved quality of life for patients. However, it has been proven that conventional RT modalities, especially in left-sided BC cases, are unable to avoid the administration of high RT doses to the heart, thus resulting in cardiotoxicity and promoting long-term cardiovascular diseases (CVD). Recent radiotherapeutic techniques, characterized by dosimetric dose restrictions, target volume revision/modifications, an increased awareness of risk factors, and consistent follow-ups, have created an advantageous context for a significant decrease inpost-RT CVD incidence. AIM This review presents the fundamental role of current cardioprotective strategies in the prevention of cardiotoxic effects in left-BCRT. MATERIAL AND METHODS A literature search was conducted up to January 2023 using the Cochrane Central Register of Controlled Trials and PubMed Central databases. Our review refers to new radiotherapeutic techniques carried out on patients after BC surgery. Specifically, a dose evaluation of the heart and left anterior descending coronary artery (LADCA) was pointed out for all the included studies, depending on the implemented RT modality, bed positioning, and internal mammary lymph nodes radiation. RESULTS Several studies reporting improved heart sparing with new RT techniques in BC patients were searched. In addition to the RT modality, which definitely determines the feasibility of achieving lower doses for the organs at risk (OARs), better target coverage, dose conformity and homogeneity, and the patient's position, characteristics, and anatomy may also affect the evaluated RT dose to the whole heart and its substructures. CONCLUSIONS Modern BC RT techniques seem to enable the administration of lower doses to the OARs without compromising on the target coverage. The analysis of several anatomical parameters and the assessment of cardiac biomarkers potentiate the protective effect of these new irradiation modalities, providing a holistic approach to the radiation-associated risks of cardiac disease for BC patients. Despite technological advances, an inevitable cardiac radiation risk still exists, while adverse cardiac events may be observed even many years after RT. Studies with longer follow-ups are required in order to determine the effectiveness of modern breast RT techniques.
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Affiliation(s)
- Vasiliki Nikovia
- Medical School, University of Crete, Vassilika, 71110 Heraklion, Greece
| | - Evangelos Chinis
- Medical School, University of Crete, Vassilika, 71110 Heraklion, Greece
| | - Areti Gkantaifi
- Radiotherapy Department, Theagenio Anticancer Hospital of Thessaloniki, 54639 Thessaloniki, Greece
| | - Maria Marketou
- Cardiology Department, University General Hospital of Heraklion, Heraklion, 71110 Heraklion, Greece
| | - Michalis Mazonakis
- Department of Medical Physics, Faculty of Medicine, University of Cret, Iraklion, P.O. Box 2208, 71003 Heraklion, Greece
| | | | - Dimitrios Mavroudis
- Department of Medical Oncology, University General Hospital of Heraklion, 71500 Heraklion, Greece
| | | | - Antonios Varveris
- Department of Radiotherapy, University Hospital/Medical School, University of Crete, Vassilika, 71110 Heraklion, Greece
| | - Chrysostomos Antoniadis
- Department of Radiotherapy, University Hospital/Medical School, University of Crete, Vassilika, 71110 Heraklion, Greece
| | - Maria Tolia
- Department of Radiotherapy, University Hospital/Medical School, University of Crete, Vassilika, 71110 Heraklion, Greece
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Nguyen D, Reinoso R, Farah J, Yossi S, Lorchel F, Passerat V, Louet E, Pouchard I, Khodri M, Barbet N. Reproducibility of surface-based deep inspiration breath-hold technique for lung stereotactic body radiotherapy on a closed-bore gantry linac. Phys Imaging Radiat Oncol 2023; 26:100448. [PMID: 37252251 PMCID: PMC10213090 DOI: 10.1016/j.phro.2023.100448] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/31/2023] Open
Abstract
Background and purpose Tumor motion and delivery efficiency are two main challenges of lung stereotactic body radiotherapy (SBRT). The present work implemented the deep inspiration breath hold technique (DIBH) with surface guided radiation therapy (SGRT) on closed-bore linacs and investigated the correlation between SGRT data and internal target position. Materials and methods Thirteen lung SBRT patients treated in DIBH using a closed-bore gantry linac and a ring-mounted SGRT system were retrospectively analysed. Visual coaching was used to achieve DIBH with a ± 1 mm threshold window in the anterior-posterior direction. Three kV-CBCTs were added to the treatment workflow and examined offline to verify intra-fraction tumor position. Surface-based DIBH was analysed using SGRT treatment reports and an in-house python script. Data from 73 treatment sessions and 175 kV-CBCTs were studied. Correlations between target and surface positions were studied with Linear Mixed Models. Results Median intra-fraction tumor motion was 0.8 mm (range: 0.7-1.3 mm) in the anterior-posterior direction, 1.2 mm (range: 1-1.7 mm) in the superior-inferior direction, and 1 mm (range: 0.7-1.1 mm) in the left-right direction, with rotations of <1° (range: 0.6°-1.1°) degree in all three directions. Planned target volumes and healthy lung volumes receiving 12.5 Gy and 13.5 Gy were reduced on average by 67% and 54%, respectively. Conclusions Lung SBRT in DIBH with the ring-mounted SGRT system proved reproducible. The surface monitoring provided by SGRT was found to be a reliable surrogate for internal target motion. Moreover, the implementation of DIBH technique helped reduce target volumes and lung doses.
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Affiliation(s)
- Daniel Nguyen
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Rebeca Reinoso
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Jad Farah
- Vision RT Ltd., Dove House, Arcadia Avenue, London N3 2JU, United Kingdom
| | - Sena Yossi
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Fabrice Lorchel
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Victor Passerat
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Estelle Louet
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Isabelle Pouchard
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Mustapha Khodri
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
| | - Nicolas Barbet
- ORLAM’s Group, Department of Radiation Oncology, Mâcon, Villeurbanne, Lyon, France
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