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Sreenivasa S, Wösle M, Gager Y, Vordermark D, Grajewski L, Krause L, Ciernik IF. Impact of tumour volume and treatment delay on the outcome after linear accelerator-based fractionated stereotactic radiosurgery of uveal melanoma. Br J Ophthalmol 2024; 108:457-464. [PMID: 36894300 PMCID: PMC10894830 DOI: 10.1136/bjo-2022-322750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/19/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND/AIMS Primary radiation therapy is used to treat malignant uveal melanoma (UM). We report our single-centre experience with fractionated radiosurgery (fSRS) with a linear accelerator (LINAC) after specific adaptation for small target volumes with HybridArc. METHODS From October 2014 to January 2020, 101 patients referred to Dessau City Hospital with unilateral UM underwent fSRS with 50 Gy given in five fractions on five consecutive days. Primary endpoints were local tumour control, globe preservation, metastasis and death. Potential prognostic features were analysed. Kaplan-Meier analysis, Cox proportional hazards model and linear models were used for calculations. RESULTS The median baseline tumour diameter was 10.0 mm (range, 3.0-20.0 mm), median tumour thickness 5.0 mm (range, 0.9-15.5 mm) and median gross tumour volume (GTV) 0.4 cm³ (range, 0.2-2.6 cm³). After a median follow-up of 32.0 months (range, 2.5-76.0 months), 7 patients (6.9%) underwent enucleation: 4 (4.0%) due to local recurrence and 3 (3.0%) due to radiation toxicities, and 6 patients (5.9%) revealed tumour persistence with a GTV exceeding 1.0 cm³. Of 20 patients (19.8%) who died, 8 (7.9%) were tumour-related deaths. Twelve patients (11.9%) suffered from distant metastasis. GTV showed an impact on all endpoints, and treatment delay was associated with reduced odds of eye preservation. CONCLUSION LINAC-based fSRS with static conformal beams combined with dynamic conformal arcs and discrete intensity-modulated radiotherapy results in a high tumour control rate. The tumour volume is the most robust physical prognostic marker for local control and disease progression. Avoiding treatment delay improves outcomes.
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Affiliation(s)
- Shanthala Sreenivasa
- Department of Radiation Oncology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - Markus Wösle
- Department of Radiation Oncology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - Yann Gager
- Department of Research and Development, PathoNext GmbH, Leipzig, Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Luise Grajewski
- Department of Ophthalmology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - Lothar Krause
- Department of Ophthalmology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - I Frank Ciernik
- Department of Radiation Oncology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
- Department of Radiation Oncology, Martin Luther Universität Halle-Wittenberg, Halle (Saale), Germany
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Kornhuber C, Ensminger S, Hübsch P, Janich M, Leucht CA, Vordermark D, Dietzel CT. Feasibility of a simultaneously integrated boost concept for hypofractionated stereotactic radiotherapy of unresected brain metastases. Radiat Oncol 2023; 18:88. [PMID: 37217934 DOI: 10.1186/s13014-023-02266-9] [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: 01/07/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND In stereotactic radiotherapy, dose is prescribed to an isodose surrounding the planning target volume (PTV). However, the desired dose inhomogeneity inside the PTV leaves the specific dose distribution to the gross tumor volume (GTV) unspecified. A simultaneously integrated boost (SIB) to the GTV could solve this shortcoming. In a retrospective planning study with 20 unresected brain metastases, a SIB approach was tested against the classical prescription. METHODS For all metastases, the GTV was isotropically enlarged by 3 mm to a PTV. Two plans were generated, one according to the classical 80% concept with 5 times 7 Gy prescribed (on D2%) to the 80% PTV surrounding isodose (with D98%(PTV) ≥ 35 Gy), and the other one following a SIB concept with 5 times 8.5 Gy average GTV dose and with D98%(PTV) ≥ 35 Gy as additional requirement. Plan pairs were compared in terms of homogeneity inside GTV, high dose in PTV rim around GTV, and dose conformity and gradients around PTV using Wilcoxon matched pairs signed rank test. RESULTS The SIB concept was superior to the classical 80% concept concerning dose homogeneity inside GTV: Heterogeneity index of GTV was in the SIB concept (median 0.0513, range 0.0397-0.0757) significantly (p = 0.001) lower than in the 80% concept (median 0.0894, range 0.0447-0.1872). Dose gradients around PTV were not inferior. The other examined measures were comparable. CONCLUSION Our stereotactic SIB concept better defines the dose distribution inside PTV and can be considered for clinical use.
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Affiliation(s)
- Christine Kornhuber
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stephan Ensminger
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Patrick Hübsch
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Martin Janich
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Chris Andre Leucht
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Christian T Dietzel
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
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Guberina M, Sokolenko E, Guberina N, Dalbah S, Pöttgen C, Lübcke W, Indenkämpen F, Lachmuth M, Flühs D, Chen Y, Hoffmann C, Deuschl C, Jabbarli L, Fiorentzis M, Foerster A, Rating P, Ebenau M, Grunewald T, Bechrakis N, Stuschke M. Feasibility, Method and Early Outcome of Image-Guided Volumetric Modulated Arc Radiosurgery Followed by Resection for AJCC Stage IIA–IIIB High-Risk Large Intraocular Melanoma. Cancers (Basel) 2022; 14:cancers14194729. [PMID: 36230660 PMCID: PMC9562629 DOI: 10.3390/cancers14194729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/28/2022] Open
Abstract
Simple Summary The aim of this trial was to define one optimal contemporary treatment procedure for large intraocular melanoma. Radiosurgery is a highly effective treatment in cancer. In this trial, all consecutive patients with large intraocular melanoma treated with multimodality treatment, comprising 4D image-guided volumetric modulated arc radiosurgery procedure followed by resection, were evaluated. In the short-term follow-up there was no clinical toxicity due to external beam radiation therapy, and no local tumor recurrence. In 98% of the cases, the eye bulb could be maintained with partial residual visual acuity in the mean follow-up of 18 months. The outcome estimates one optimal treatment procedure for high-risk, large intraocular melanoma, with excellent results in the first follow-up. Abstract The main objective of this prospective observational study was the characterization of the feasibility and early outcome of image-guided (IG) volumetric modulated arc (VMAT) radiosurgery (SRS) followed by resection for patients with large intraocular melanoma. Our study included consecutive patients with unfavorable-risk melanoma, enrolled in an ophthalmic oncology center. IG-VMAT-SRS was applied by high-resolution 4D image guidance and monitoring. Current stereotactic technique parameters were evaluated for comparison. Side effects and eye function, based on a 5-point CTC assessment score, were quantified. In patients with tumors located more than 0.7–1 mm apart from the optic nerve, partial to complete volume-sparing of the optic nerve head could be achieved. In 95.5% of this subgroup, the vitality of the optic nerve and vision could be preserved by the multimodality-treatment approach (mean follow-up: 18 months (7.5–36 months)). The advanced technology of stereotactic radiotherapy demonstrated the achievability of steep dose gradients around the high-dose volume, with 4D-IG-VMAT dose application. These results enforce IG-VMAT-SRS followed by resection as one of the major therapeutic options for patients with large intraocular melanoma. The combination of 4D-IG high-precision SRS and resection provides an effective treatment for large intraocular melanoma, with few side effects, and enables an eye bulb and even vision preserving modus operandi.
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Affiliation(s)
- Maja Guberina
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Hufeland Str. 55, 45147 Essen, Germany
- Correspondence: ; Tel.: +49-201-723-2321
| | - Ekaterina Sokolenko
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Nika Guberina
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Sami Dalbah
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Christoph Pöttgen
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Wolfgang Lübcke
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Frank Indenkämpen
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Manfred Lachmuth
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Dirk Flühs
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Ying Chen
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Christian Hoffmann
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Cornelius Deuschl
- Institute of Diagnostic, Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Leyla Jabbarli
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Miltiadis Fiorentzis
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Andreas Foerster
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Philipp Rating
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Melanie Ebenau
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Tobias Grunewald
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Nikolaos Bechrakis
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Hospital Essen, West German Cancer Center, University Duisburg-Essen, Hufeland Str. 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Hufeland Str. 55, 45147 Essen, Germany
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Biltekin F, Yazici G. Dosimetric comparison and secondary malignancy risk estimation for linac-based and robotic stereotactic radiotherapy in uveal melanoma. Med Dosim 2021; 46:364-369. [PMID: 34011456 DOI: 10.1016/j.meddos.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 11/24/2022]
Abstract
It was aimed to investigate the dosimetric differences among linac-based and robotic stereotactic radiotherapy (SRT) techniques for the treatment of uveal melanoma and to evaluate secondary malignancy risks for these different SRT techniques. Ten patients who received robotic SRT with CyberKnife were retrospectively included in this study. A total dose of 54 Gy in three fractions was prescribed to the planning target volume (PTV). For each patient, non-coplanar micro-multileaf collimator based dynamic conformal arc (DCA), intensity-modulated radiotherapy (IMRT) and circular cone based DCA (cDCA) plans were generated. During the analysis dose-volume histogram (DVH) parameters, homogeneity index, new conformity index, the volume received more than or equal to 30% and 50% of the prescribed dose were compared. Additionally, secondary malignancy risk for each technique was estimated using the risk factors recommended by The International Commission on Radiological Protection. Robotic SRT plans provided a high degree of conformity within the PTV and better normal tissue sparing compared to linac-based treatment plans. However, dose distribution was more heterogeneous in robotic SRT plans than that in linac-based techniques. Estimated secondary malignancy risk was also found as 3.4%, 1.4%, 1.4% and 1.6% for robotic SRT and linac-based IMRT, DCA, cDCA plans, respectively. Treatment parameters of uveal melanoma patients planned with robotic SRT had superior conformity and organ-at-risk (OAR) sparing compared with those planned with the linac-based system. However, estimated secondary malignancy risk was almost two-times higher in robotic SRT than that in linac-based techniques.
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Affiliation(s)
- Fatih Biltekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.
| | - Gozde Yazici
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
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Zimmermann L, Kneifel C, Grajewski L, Ciernik IF, Krause L. Treatment of radiation-induced maculopathy with fluocinolone acetonide. Graefes Arch Clin Exp Ophthalmol 2020; 258:2535-2539. [PMID: 32661701 DOI: 10.1007/s00417-020-04804-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/04/2020] [Accepted: 06/13/2020] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Chronic macular oedema is a well-known presentation of radiation-induced maculopathy (RM) following external beam photon therapy, plaque radiotherapy and proton beam radiotherapy for choroidal tumours. Current therapies vary in respect of efficacy and clinical benefit. The potential of fluocinolone acetonide (FAc) slow-release implants is unknown. We hypothesised that local continuous delivery of low-dose corticosteroids might improve symptoms of RM. METHODS Five-two male and three female-patients from 37 to 68 years presented with RM following 106Ru-plaque brachytherapy or stereotactic radiation therapy (STx) with photons using a hypofractionated schedule of 5 × 10 Gy. All were treated with triamcinolone injections in first line and proofed to be refractory to steroids. In addition, two patients had received Ozurdex® implants as a second-line treatment, though without any clinical benefit. FAc slow-release implants were injected, and patients were followed up to monitor clinical improvement. RESULTS All patients responded to therapy by means of a decrease in macular oedema. In four of five (80%) patients, visual acuity improved, and one patient showed stable visual acuity. No toxic effects or complications were observed. CONCLUSION Slow-release implants of FAc are a promising therapeutic potent steroid treatment option to benefit anatomical structures of the fovea and visual function. Slow-release implants with FAc reduce the frequency of intravitreal injections and the therapeutic burden.
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Affiliation(s)
- Lena Zimmermann
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany.
| | - Christiane Kneifel
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany
| | - Luise Grajewski
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany
| | - Ilja F Ciernik
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Strahlentherapie und Radioonkologie, Dessau, Germany.,University of Zürich, Zürich, Switzerland
| | - Lothar Krause
- Akademisches Lehrkrankenhaus der Medizinischen Hochschule Brandenburg Theodor Fontane, Städtisches Klinikum Dessau, Klinik für Augenheilkunde, Auenweg 38, 06847, Dessau, Germany
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Wösle M. The superficially averaged dose gradient at the target volume's boundary: A two-dimensional formulation and solution of anisotropic dose gradient problems. Z Med Phys 2019; 30:70-86. [PMID: 31843265 DOI: 10.1016/j.zemedi.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/29/2019] [Accepted: 09/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Dose conformity and steepness of dose fall-off at a target volume's boundary are important quality criteria in treatment planning to predict complication rates in normal tissue and critical structures. Several dose gradient measures are in use; ICRU Report 91 recommends one of two gradient metrics for reporting. All of the common gradient indices are one-dimensional, although dose gradient problems are at least two-dimensional and anisotropic. Four of ten investigated gradient indices show false characteristics on the mean value of the physical dose gradients. Anisotropic dose gradient measures can be the basis of clinical therapeutic decisions if tumours are surrounded by organs at risk with various tolerance dose values. To close this information gap, the author presents a mathematical description and solution of anisotropic dose gradient problems. MATERIALS AND METHODS The new two-dimensional dose gradient measure is called the superficially averaged dose gradient (SADG). The particular informative content of the ten common dose gradient indices was assessed by classification and analysing their properties. The correlations between all of the dose gradient measures were investigated for linac-based stereotactic radiosurgery of 13 brain metastases. RESULTS From all of the one-dimensional dose gradient indices, the approximated SADG* showed the best correlation on the SADG. Here, Pearson's correlation coefficient was 1.000 and the relative errors were in a range of -0.2 to 2.9%. Distributions of anisotropic dose gradients were graphically represented by dose gradient-solid angle histograms. CONCLUSIONS Two-dimensional dose gradient measures such as the SADG are urgently required for lesions that are located in non-homogeneous normal tissue. The quality of each present and future dose gradient measure concerning the description of anisotropic dose gradient problems is now verifiable by use of the SADG. Through the SADG, the influences of collimation types on the dose fall-off at the target volume's boundary can be investigated. The algorithm for determining the SADG should be implemented in treatment planning systems to utilise the formalism for all users. The dose gradient indices recommended in ICRU Report 91 overestimate and underestimate physical dose gradients, respectively.
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Affiliation(s)
- Markus Wösle
- Klinik für Strahlentherapie und Radioonkologie, Städtisches Klinikum Dessau, Dessau-Roßlau, Germany.
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Ciernik IF, Wösle M, Krause L, Krayenbuehl J. Optimizing radiosurgery with photons for ocular melanoma. Phys Imaging Radiat Oncol 2018; 6:83-88. [PMID: 33458394 PMCID: PMC7807539 DOI: 10.1016/j.phro.2018.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 05/26/2018] [Accepted: 06/01/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND PURPOSE Photon radiotherapy has been established for the treatment of ocular melanoma (OM). Here we investigate the planning qualities of two different planning approaches, a combination of dynamic conformal arcs (DCA) complemented with multiple non-coplanar static intensity-modulated (IMRT) fields (DCA-IMRT), and volumetric modulated arc therapy (VMAT) in combination with automated planning (AP). MATERIALS AND METHODS Thirteen consecutive patients treated for ocular melanoma with curative intent on a Linac-based radiosurgery system were analyzed. Fractionated stereotactic radiosurgery (fSRS) was applied using 50 Gy in 5 fractions using the combination of DCA-IMRT. Plans were reviewed and the thirteen cases were compared to plans obtained with optimized automated VMAT based on a set of 28 distinct patients treated with DCA-IMRT who were selected to generate the AP model for the prediction of dose volume constraints. RESULTS Overall, plan quality of DCA-IMRT was superior to AP with VMAT. PTV coverage did not exceed 107% in any case treated with DCA-IMRT, compared to seven patients with VMAT. The median PTV covered by >95% was 98.3% (91.9%-99.7%) with DCA-IMRT, compared to 95.1% (91.5%-97.9%) (p < 0.01) with VMAT. The median mean dose delivered to the treated eye was 22.4 Gy (12.3 Gy-33.3 Gy) with DCA-IMRT compared to 27.2 Gy (15.5 Gy-33.7 Gy) (p < 0.01). Dose to the ipsilateral lacrimal gland and the ipsilateral optic nerve were comparable for DCA-IMRT and VMAT, however, the dose to the lens was lower with DCA-IMRT compared to VMAT. CONCLUSIONS The combination of multiple arcs complemented with multiple IMRT fields sets the gold standard for fSRS of ocular melanoma for photon therapy.
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Affiliation(s)
- I Frank Ciernik
- Department of Radiotherapy and Radiation Oncology, Dessau City Hospital, Dessau, Germany.,University of Zürich, Zürich, Switzerland
| | - Markus Wösle
- Department of Radiotherapy and Radiation Oncology, Dessau City Hospital, Dessau, Germany
| | - Lothar Krause
- Department of Ophthalmology, Dessau City Hospital, Dessau, Germany
| | - Jérôme Krayenbuehl
- Department of Radiation Oncology, University Hospital, Zürich, Switzerland
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