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Fiandra C, Zara S, Richetto V, Rossi L, Leonardi MC, Ferrari P, Marrocco M, Gino E, Cora S, Loi G, Rosica F, Ren Kaiser S, Verdolino E, Strigari L, Romeo N, Placidi L, Comi S, De Otto G, Roggio A, Di Dio A, Reversi L, Pierpaoli E, Infusino E, Coeli E, Licciardello T, Ciarmatori A, Caivano R, Poggiu A, Ciscognetti N, Ricardi U, Heijmen B. Multi-centre real-world validation of automated treatment planning for breast radiotherapy. Phys Med 2024; 123:103394. [PMID: 38852364 DOI: 10.1016/j.ejmp.2024.103394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/29/2024] [Accepted: 06/01/2024] [Indexed: 06/11/2024] Open
Abstract
PURPOSE To present the results of the first multi-centre real-world validation of autoplanning for whole breast irradiation after breast-sparing surgery, encompassing high complexity cases (e.g. with a boost or regional lymph nodes) and a wide range of clinical practices. METHODS The 24 participating centers each included 10 IMRT/VMAT/Tomotherapy patients, previously treated with a manually generated plan ('manplan'). There were no restrictions regarding case complexity, planning aims, plan evaluation parameters and criteria, fractionation, treatment planning system or treatment machine/technique. In addition to dosimetric comparisons of autoplans with manplans, blinded plan scoring/ranking was conducted by a clinician from the treating center. Autoplanning was performed using a single configuration for all patients in all centres. Deliverability was verified through measurements at delivery units. RESULTS Target dosimetry showed comparability, while reductions in OAR dose parameters were 21.4 % for heart Dmean, 16.7 % for ipsilateral lung Dmean, and 101.9 %, 45.5 %, and 35.7 % for contralateral breast D0.03cc, D5% and Dmean, respectively (all p < 0.001). Among the 240 patients included, the clinicians preferred the autoplan for 119 patients, with manplans preferred for 96 cases (p = 0.01). Per centre there were on average 5.0 ± 2.9 (1SD) patients with a preferred autoplan (range [0-10]), compared to 4.0 ± 2.7 with a preferred manplan ([0,9]). No differences were observed regarding deliverability. CONCLUSION The automation significantly reduced the hands-on planning workload compared to manual planning, while also achieving an overall superiority. However, fine-tuning of the autoplanning configuration prior to clinical implementation may be necessary in some centres to enhance clinicians' satisfaction with the generated autoplans.
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Affiliation(s)
- C Fiandra
- University of Turin, Department of Oncology, Turin, Italy.
| | - S Zara
- Tecnologie Avanzate, Turin, Italy
| | - V Richetto
- Medical Physics Unit, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - L Rossi
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M C Leonardi
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - P Ferrari
- Department of Health Physics, Provincial Hospital of Bolzano (SABES-ASDAA), Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Bolzano-Bozen, Italy
| | - M Marrocco
- Radiation Oncology, Campus Biomedico University, Rome, Italy
| | - E Gino
- SC Fisica Sanitaria AO Ordine Mauriziano di Torino, Turin, Italy
| | - S Cora
- U.O.C. Fisica Sanitaria, Ospedale "San Bortolo", AULSS8, Vicenza, Italy
| | - G Loi
- Department of Medical Physics, 'Maggiore della Carità' University Hospital, Novara, Italy
| | - F Rosica
- U.O.C. Fisica Sanitaria, ASL Teramo, Italy
| | - S Ren Kaiser
- S.C. Fisica Sanitaria, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy
| | | | - L Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - N Romeo
- UOC Radioterapia. Azienda Sanitaria Provinciale di Messina. Ospedale "San Vincenzo", Taormina, Italy
| | - L Placidi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - S Comi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - G De Otto
- S.C. Fisica Sanitaria Firenze-Empoli Azienda USL Toscana Centro, Italy
| | - A Roggio
- Medical Physics Department, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - A Di Dio
- Medical Physics Unit, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - L Reversi
- Ospedali Riuniti di Ancona - Medical Physics Department, Ancona, Italy
| | - E Pierpaoli
- UOC Fisica Sanitaria, Area Vasta 5 Asur P.O. Mazzoni, Ascoli, Italy
| | - E Infusino
- Medical Physics Dept IRCCS Regina Elena National Cancer Institute, Rome
| | - E Coeli
- U.O.C. di RADIOTERAPIA Azienda ULSS 9 Scaligera del Veneto, Legnago (VR), Italy
| | - T Licciardello
- SC Fisica Sanitaria, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - A Ciarmatori
- UOC Fisica Medica e Alte Tecnologie, AST Pesaro Urbino, Pesaro, Italy
| | - R Caivano
- UOC di Radioterapia Oncologica e Fisica Sanitaria, IRCCS CROB Rionero in Vulture, Potenza, Italy
| | - A Poggiu
- SSD Fisica Sanitaria AOU Sassari, Italy
| | - N Ciscognetti
- ASL2 liguria - Dipartimento di diagnostic, SSD fisica sanitaria, Savona, Italy
| | - U Ricardi
- University of Turin, Department of Oncology, Turin, Italy
| | - B Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Zhang Y, Fu W, Brandner E, Percinsky S, Moran M, Huq MS. Minimizing normal tissue low dose bath for left breast Volumetric Modulated Arc Therapy (VMAT) using jaw offset. J Appl Clin Med Phys 2024:e14365. [PMID: 38760907 DOI: 10.1002/acm2.14365] [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: 09/08/2023] [Revised: 02/22/2024] [Accepted: 04/02/2024] [Indexed: 05/20/2024] Open
Abstract
PURPOSE With proper beam setup and optimization constraints in the treatment planning system, volumetric modulated arc therapy (VMAT) can improve target dose coverage and conformity while reducing doses to adjacent structures for whole breast radiation therapy. However, the low-dose bath effect on critical structures, especially the heart and the ipsilateral lung, remains a concern. In this study, we present a VMAT technique with the jaw offset VMAT (JO-VMAT) to reduce the leakage and scatter doses to critical structures for whole breast radiation therapy. MATERIALS AND METHODS The data of 10 left breast cancer patients were retrospectively used for this study. CT images were acquired on a CT scanner (GE, Discovery) with the deep-inspiration breath hold (DIBH) technique. The planning target volumes (PTVs) and the normal structures (the lungs, the heart, and the contralateral breast) were contoured on the DIBH scan. A 3D field-in-field plan (3D-FiF), a tangential VMAT (tVMAT) plan, and a JO-VMAT plan were created with the Eclipse treatment planning system. An arc treatment field with the x-jaw closed across the central axis creates a donut-shaped high-dose distribution and a cylinder-shaped low-dose volume along the central axis of gantry rotation. Applying this setup with proper multi-leaf collimator (MLC) modulation, the optimized plan potentially can provide sufficient target coverage and reduce unnecessary irradiation to critical structures. The JO-VMAT plans involve 5-6 tangential arcs (3 clockwise arcs and 2-3 counterclockwise arcs) with jaw offsets. The plans were optimized with objective functions specified to achieve PTV dose coverage and homogeneity; For organs at risk (OARs), objective functions were specified individually for each patient to accomplish the best achievable treatment plan. For tVMAT plans, optimization constraints were kept the same except that the jaw offset was removed from the initial beam setup. The dose volume histogram (DVH) parameters were generated for dosimetric evaluation of PTV and OARs. RESULTS The D95% to the PTV was greater than the prescription dose of 42.56 Gy for all the plans. With both VMAT techniques, the PTV conformity index (CI) was statistically improved from 0.62 (3D-FiF) to 0.83 for tVMAT and 0.84 for JO-VMAT plans. The difference in the homogeneity index (HI) was not significant. The Dmax to the heart was reduced from 12.15 Gy for 3D-FiF to 8.26 Gy for tVMAT and 7.20 Gy for JO-VMAT plans. However, a low-dose bath effect was observed with tVMAT plans to all the critical structures including the lungs, the heart, and the contralateral breast. With JO-VMAT, the V5Gy and V2Gy of the heart were reduced by 32.7% and 15.4% compared to 3D-FiF plans. Significantly, the ipsilateral lung showed a reduction in mean dose (4.65-3.44 Gy) and low dose parameters (23.4% reduction for V5Gy and 10.7% reduction for V2Gy) for JO-VMAT plans compared to the 3D-FiF plans. The V2Gy dose to the contralateral lung and breast was minimal with JO-VMAT techniques. CONCLUSION A JO-VMAT technique was evaluated in this study and compared with 3D-FiF and tVMAT techniques. Our results showed that the JO-VMAT technique can achieve clinically comparable coverage and homogeneity and significantly improve dose conformity within PTV. Additionally, JO-VMAT eliminated the low-dose bath effect at all OARs evaluation metrics including the ipsilateral/contralateral lung, the heart, and the contralateral breast compared to 3D-FiF and tVMAT. This technique is feasible for the whole breast radiation therapy of left breast cancers.
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Affiliation(s)
- Yongqian Zhang
- Department of Radiation Oncology, University of Pittsburgh School of Medicine and UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Weihua Fu
- Department of Radiation Oncology, University of Pittsburgh School of Medicine and UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Edward Brandner
- Department of Radiation Oncology, University of Pittsburgh School of Medicine and UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Sharon Percinsky
- Department of Radiation Oncology, University of Pittsburgh School of Medicine and UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Mary Moran
- Department of Radiation Oncology, University of Pittsburgh School of Medicine and UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - M Saiful Huq
- Department of Radiation Oncology, University of Pittsburgh School of Medicine and UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
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Chan RCK, Ng CKC, Hung RHM, Li YTY, Tam YTY, Wong BYL, Yu JCK, Leung VWS. Comparative Study of Plan Robustness for Breast Radiotherapy: Volumetric Modulated Arc Therapy Plans with Robust Optimization versus Manual Flash Approach. Diagnostics (Basel) 2023; 13:3395. [PMID: 37998531 PMCID: PMC10670672 DOI: 10.3390/diagnostics13223395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/03/2023] [Accepted: 11/04/2023] [Indexed: 11/25/2023] Open
Abstract
A previous study investigated robustness of manual flash (MF) and robust optimized (RO) volumetric modulated arc therapy plans for breast radiotherapy based on five patients in 2020 and indicated that the RO was more robust than the MF, although the MF is still current standard practice. The purpose of this study was to compare their plan robustness in terms of dose variation to clinical target volume (CTV) and organs at risk (OARs) based on a larger sample size. This was a retrospective study involving 34 female patients. Their plan robustness was evaluated based on measured volume/dose difference between nominal and worst scenarios (ΔV/ΔD) for each CTV and OARs parameter, with a smaller difference representing greater robustness. Paired sample t-test was used to compare their robustness values. All parameters (except CTV ΔD98%) of the RO approach had smaller ΔV/ΔD values than those of the MF. Also, the RO approach had statistically significantly smaller ΔV/ΔD values (p < 0.001-0.012) for all CTV parameters except the CTV ΔV95% and ΔD98% and heart ΔDmean. This study's results confirm that the RO approach was more robust than the MF in general. Although both techniques were able to generate clinically acceptable plans for breast radiotherapy, the RO could potentially improve workflow efficiency due to its simpler planning process.
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Affiliation(s)
- Ray C. K. Chan
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; (R.C.K.C.); (Y.T.Y.L.); (Y.T.Y.T.); (B.Y.L.W.); (J.C.K.Y.)
| | - Curtise K. C. Ng
- Curtin Medical School, Curtin University, GPO Box U1987, Perth, WA 6845, Australia;
- Curtin Health Innovation Research Institute (CHIRI), Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
| | - Rico H. M. Hung
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China;
| | - Yoyo T. Y. Li
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; (R.C.K.C.); (Y.T.Y.L.); (Y.T.Y.T.); (B.Y.L.W.); (J.C.K.Y.)
| | - Yuki T. Y. Tam
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; (R.C.K.C.); (Y.T.Y.L.); (Y.T.Y.T.); (B.Y.L.W.); (J.C.K.Y.)
| | - Blossom Y. L. Wong
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; (R.C.K.C.); (Y.T.Y.L.); (Y.T.Y.T.); (B.Y.L.W.); (J.C.K.Y.)
| | - Jacky C. K. Yu
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; (R.C.K.C.); (Y.T.Y.L.); (Y.T.Y.T.); (B.Y.L.W.); (J.C.K.Y.)
| | - Vincent W. S. Leung
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; (R.C.K.C.); (Y.T.Y.L.); (Y.T.Y.T.); (B.Y.L.W.); (J.C.K.Y.)
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Carr MA, Gargett M, Stanton C, Zwan B, Byrne HL, Booth JT. A method for beam's eye view breath-hold monitoring during breast volumetric modulated arc therapy. Phys Imaging Radiat Oncol 2023; 25:100419. [PMID: 36875326 PMCID: PMC9975298 DOI: 10.1016/j.phro.2023.100419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Background and purpose Deep inspiration breath-hold (DIBH) is a technique that is widely utilised to spare the heart and lungs during breast radiotherapy. In this study, a method was developed to validate directly the intrafraction accuracy of DIBH during breast volumetric modulated arc therapy (VMAT) via internal chest wall (CW) monitoring. Materials and methods In-house software was developed to automatically extract and compare the treatment position of the CW in cine-mode electronic portal image device (EPID) images with the planned CW position in digitally reconstructed radiographs (DRR) for breast VMAT treatments. Feasibility of this method was established by evaluating the percentage of total dose delivered to the target volume when the CW was sufficiently visible for monitoring. Geometric accuracy of the approach was quantified by applying known displacements to an anthropomorphic thorax phantom. The software was used to evaluate (offline) the geometric treatment accuracy for ten patients treated using real-time position management (RPM)-guided DIBH. Results The CW could be monitored within the tangential sub-arcs which delivered a median 89% (range 73% to 97%) of the dose to target volume. The phantom measurements showed a geometric accuracy within 1 mm, with visual inspection showing good agreement between the software-derived and user-determined CW positions. For the RPM-guided DIBH treatments, the CW was found to be within ±5 mm of the planned position in 97% of EPID frames in which the CW was visible. Conclusion An intrafraction monitoring method with sub-millimetre accuracy was successfully developed to validate target positioning during breast VMAT DIBH.
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Affiliation(s)
- M A Carr
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, The University of Sydney, Sydney, New South Wales, Australia
| | - M Gargett
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - C Stanton
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - B Zwan
- Central Coast Cancer Centre, Gosford Hospital, Gosford, New South Wales, Australia
| | - H L Byrne
- ACRF Image-X Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - J T Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, The University of Sydney, Sydney, New South Wales, Australia
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Fogliata A, Parabicoli S, Paganini L, Reggiori G, Lobefalo F, Cozzi L, Franzese C, Franceschini D, Spoto R, Scorsetti M. Knowledge-based DVH estimation and optimization for breast VMAT plans with and without avoidance sectors. Radiat Oncol 2022; 17:200. [PMID: 36474297 PMCID: PMC9724419 DOI: 10.1186/s13014-022-02172-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To analyze RapidPlan knowledge-based models for DVH estimation of organs at risk from breast cancer VMAT plans presenting arc sectors en-face to the breast with zero dose rate, feature imposed during the optimization phase (avoidance sectors AS). METHODS CT datasets of twenty left breast patients in deep-inspiration breath-hold were selected. Two VMAT plans, PartArc and AvoidArc, were manually generated with double arcs from ~ 300 to ~ 160°, with the second having an AS en-face to the breast to avoid contralateral breast and lung direct irradiation. Two RapidPlan models were generated from the two plan sets. The two models were evaluated in a closed loop to assess the model performance on plans where the AS were selected or not in the optimization. RESULTS The PartArc plans model estimated DVHs comparable with the original plans. The AvoidArc plans model estimated a DVH pattern with two steps for the contralateral structures when the plan does not contain the AS selected in the optimization phase. This feature produced mean doses of the contralateral breast, averaged over all patients, of 0.4 ± 0.1 Gy, 0.6 ± 0.2 Gy, and 1.1 ± 0.2 Gy for the AvoidArc plan, AvoidArc model estimation, RapidPlan generated plan, respectively. The same figures for the contralateral lung were 0.3 ± 0.1 Gy, 1.6 ± 0.6 Gy, and 1.2 ± 0.5 Gy. The reason was found in the possible incorrect information extracted from the model training plans due to the lack of knowledge about the AS. Conversely, in the case of plans with AS set in the optimization generated with the same AvoidArc model, the estimated and resulting DVHs were comparable. Whenever the AvoidArc model was used to generate DVH estimation for a plan with AS, while the optimization was made on the plan without the AS, the optimizer evidentiated the limitation of a minimum dose rate of 0.2 MU/°, resulting in an increased dose to the contralateral structures respect to the estimation. CONCLUSIONS The RapidPlan models for breast planning with VMAT can properly estimate organ at risk DVH. Attention has to be paid to the plan selection and usage for model training in the presence of avoidance sectors.
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Affiliation(s)
- Antonella Fogliata
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Sara Parabicoli
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Lucia Paganini
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Giacomo Reggiori
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Francesca Lobefalo
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Luca Cozzi
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| | - Ciro Franzese
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| | - Davide Franceschini
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Ruggero Spoto
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Marta Scorsetti
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, Humanitas Research Hospital IRCCS, Milan-Rozzano, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
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van Gysen K, Kneebone A, Le A, Wu K, Haworth A, Bromley R, Hruby G, O'Toole J, Booth J, Brown C, Pearse M, Sidhom M, Wiltshire K, Tang C, Eade T. Evaluating the utility of knowledge-based planning for clinical trials using the TROG 08.03 post prostatectomy radiation therapy planning data. Phys Imaging Radiat Oncol 2022; 22:91-97. [PMID: 35602546 PMCID: PMC9117914 DOI: 10.1016/j.phro.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 10/27/2022] Open
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