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Zink K, Baumann KS, Theiss U, Subtil F, Lahrmann S, Eberle F, Adeberg S. Organization and operation of multi particle therapy facilities: the Marburg Ion-Beam Therapy Center, Germany (MIT). HEALTH AND TECHNOLOGY 2024; 14:929-938. [PMID: 39219555 PMCID: PMC11358185 DOI: 10.1007/s12553-024-00881-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/23/2024] [Indexed: 09/04/2024]
Abstract
Purpose The Marburg Ion-Beam Therapy Center (MIT) is one of two particle therapy centers in Germany that enables the treatment of patients with both protons and carbon ions. The facility was build by Siemens Healthineers and is one of only two centers worldwide built by Siemens (Marburg, Germany and Shanghai, China). The present report provides an overview of technical and clinical operations as well as research activities at MIT. Methods The MIT was completed in 2011 and uses a synchrotron for accelerating protons and carbon ions up to energies of 250 MeV/u and 430 MeV/u respectively. Three treatment rooms with a fixed horizontal beam-line and one room with a 45 degree beam angle are available. Results Since the start of clinical operations in 2015, around 2.500 patients have been treated at MIT, about 40% with carbon ions and 60% with protons. Currently around 400 patients are treated each year. The majority of the patients suffered from benign and malign CNS tumors (around 40%) followed by head and neck tumors (around 23%). MIT is actively involved in clinical studies with its patients. In addition to clinical operations, there is active research at MIT in the fields of radiation biology and medical physics. The focus is on translational research to improve the treatment of H & N carcinomas and lung cancer (NSCLC). Moreover, intensive work is being carried out on the technical implementation of FLASH irradiation for research purposes. Conclusion The MIT is one of two centers worldwide that were built by Siemens Healtineers and has been successfully in clinical operation since 2015. The service provided by Siemens is guaranteed until 2030, the future after 2030 is currently under discussion.
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Affiliation(s)
- Klemens Zink
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Albrecht-Kossel-Strasse, Marburg, 35043 Germany
- Department of Radiotherapy and Radiooncology, Marburg University Hospital, Baldingerstrasse, Marburg, 35043 Germany
- Institute for Medical Physics and Radiation Protection, University of Applied Sciences Giessen, Wiesenstr. 14, Giessen, 35390 Germany
| | - Kilian Simon Baumann
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Albrecht-Kossel-Strasse, Marburg, 35043 Germany
- Department of Radiotherapy and Radiooncology, Marburg University Hospital, Baldingerstrasse, Marburg, 35043 Germany
- Institute for Medical Physics and Radiation Protection, University of Applied Sciences Giessen, Wiesenstr. 14, Giessen, 35390 Germany
| | - Ulrike Theiss
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Albrecht-Kossel-Strasse, Marburg, 35043 Germany
- Department of Radiotherapy and Radiooncology, Marburg University Hospital, Baldingerstrasse, Marburg, 35043 Germany
| | - Florentine Subtil
- Department of Radiotherapy and Radiooncology, Marburg University Hospital, Baldingerstrasse, Marburg, 35043 Germany
| | - Sonja Lahrmann
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Albrecht-Kossel-Strasse, Marburg, 35043 Germany
| | - Fabian Eberle
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Albrecht-Kossel-Strasse, Marburg, 35043 Germany
- Department of Radiotherapy and Radiooncology, Marburg University Hospital, Baldingerstrasse, Marburg, 35043 Germany
| | - Sebastian Adeberg
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Albrecht-Kossel-Strasse, Marburg, 35043 Germany
- Department of Radiotherapy and Radiooncology, Marburg University Hospital, Baldingerstrasse, Marburg, 35043 Germany
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Cuccia F, Jafari F, D’Alessandro S, Carruba G, Craparo G, Tringali G, Blasi L, Ferrera G. Preferred Imaging for Target Volume Delineation for Radiotherapy of Recurrent Glioblastoma: A Literature Review of the Available Evidence. J Pers Med 2024; 14:538. [PMID: 38793120 PMCID: PMC11122491 DOI: 10.3390/jpm14050538] [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: 03/12/2024] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Recurrence in glioblastoma lacks a standardized treatment, prompting an exploration of re-irradiation's efficacy. METHODS A comprehensive systematic review from January 2005 to May 2023 assessed the role of MRI sequences in recurrent glioblastoma re-irradiation. The search criteria, employing MeSH terms, targeted English-language, peer-reviewed articles. The inclusion criteria comprised both retrospective and prospective studies, excluding certain types and populations for specificity. The PICO methodology guided data extraction, and the statistical analysis employed Chi-squared tests via MedCalc v22.009. RESULTS Out of the 355 identified studies, 81 met the criteria, involving 3280 patients across 65 retrospective and 16 prospective studies. The key findings indicate diverse treatment modalities, with linac-based photons predominating. The median age at re-irradiation was 54 years, and the median time interval between radiation courses was 15.5 months. Contrast-enhanced T1-weighted sequences were favored for target delineation, with PET-imaging used in fewer studies. Re-irradiation was generally well tolerated (median G3 adverse events: 3.5%). The clinical outcomes varied, with a median 1-year local control rate of 61% and a median overall survival of 11 months. No significant differences were noted in the G3 toxicity and clinical outcomes based on the MRI sequence preference or PET-based delineation. CONCLUSIONS In the setting of recurrent glioblastoma, contrast-enhanced T1-weighted sequences were preferred for target delineation, allowing clinicians to deliver a safe and effective therapeutic option; amino acid PET imaging may represent a useful device to discriminate radionecrosis from recurrent disease. Future investigations, including the ongoing GLIAA, NOA-10, ARO 2013/1 trial, will aim to refine approaches and standardize methodologies for improved outcomes in recurrent glioblastoma re-irradiation.
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Affiliation(s)
- Francesco Cuccia
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy (G.F.)
| | - Fatemeh Jafari
- Radiation Oncology Department, Imam-Khomeini Hospital Complex, Teheran University of Medical Sciences, Teheran 1416634793, Iran
| | | | - Giuseppe Carruba
- Division of Internationalization and Health Research (SIRS), ARNAS Civico Hospital, 90100 Palermo, Italy
| | | | | | - Livio Blasi
- Medical Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy;
| | - Giuseppe Ferrera
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy (G.F.)
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Koosha F, Ahmadikamalabadi M, Mohammadi M. Review of Recent Improvements in Carbon Ion Radiation Therapy in the Treatment of Glioblastoma. Adv Radiat Oncol 2024; 9:101465. [PMID: 38770179 PMCID: PMC11103612 DOI: 10.1016/j.adro.2024.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose This article provides an overview of the physical and biologic properties of carbon ions, followed by an examination of the latest clinical outcomes in patients with glioma who have received carbon ion radiation therapy. Methods and Materials According to thee articles that have been reviewed, glioma represents the predominant form of neoplastic growth in the brain, accounting for approximately 51% of all malignancies affecting the nervous system. Currently, high-grade glioma, specifically glioblastoma, comprises 15% of cases and is associated with a high mortality rate. The development of novel drugs for the treatment of high-grade tumors has been impeded by various factors, such as the blood-brain barrier and tumor heterogeneity, despite numerous endeavors. According to the definition of tumor grade established by the World Health Organization, the conventional treatment involves surgical resection followed by adjuvant radiation and chemotherapy. Despite numerous attempts in photon radiation therapy to apply the highest possible dose to the tumor site while minimizing damage to healthy tissue, there has been no success in increasing patient survival. The primary cause of resistance to conventional radiation therapy methods, namely x-ray and gamma-ray, is attributed to the survival of radio-resistant glioma stem cells, which have the potential to trigger a recurrence of tumors. Particle beams, such as protons and carbon ions, can deposit the highest dose to a confined region, thus offering a more accurate dose distribution compared with photon beams. Results Carbon ions exhibit higher linear energy transfer and relative biologic effectiveness compared with photons, potentially enabling them to overcome radio-resistant tumor cells. Conclusions Therefore, it can be hypothesized that carbon ion radiation therapy may show superior efficacy in destroying neoplastic cells with reduced negative outcomes compared with x-ray radiation therapy.
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Affiliation(s)
- Fereshteh Koosha
- Department of Radiology Technology, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdieh Ahmadikamalabadi
- Social Determinants of Health Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Radiology Department, School of Paramedical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Mohadesseh Mohammadi
- Department of Radiology Technology, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Han Y, Geng C, Altieri S, Bortolussi S, Liu Y, Wahl N, Tang X. Combined BNCT-CIRT treatment planning for glioblastoma using the effect-based optimization. Phys Med Biol 2023; 69:015024. [PMID: 38048635 DOI: 10.1088/1361-6560/ad120f] [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: 09/20/2023] [Accepted: 12/04/2023] [Indexed: 12/06/2023]
Abstract
Objective. Boron neutron capture therapy (BNCT) and carbon ion radiotherapy (CIRT) are emerging treatment modalities for glioblastoma. In this study, we investigated the methodology and feasibility to combine BNCT and CIRT treatments. The combined treatment plan illustrated how the synergistic utilization of BNCT's biological targeting and CIRT's intensity modulation capabilities could lead to optimized treatment outcomes.Approach. The Monte Carlo toolkit, TOPAS, was employed to calculate the dose distribution for BNCT, while matRad was utilized for the optimization of CIRT. The biological effect-based approach, instead of the dose-based approach, was adopted to develop the combined BNCT-CIRT treatment plans for six patients diagnosed with glioblastoma, considering the different radiosensitivity and fraction. Five optional combined treatment plans with specific BNCT effect proportions for each patient were evaluated to identify the optimal treatment that minimizes damage on normal tissue.Main results. Individual BNCT exhibits a significant effect gradient along with the beam direction in the large tumor, while combined BNCT-CIRT treatments can achieve uniform effect delivery within the clinical target volume (CTV) through the effect filling with reversed gradient by the CIRT part. In addition, the increasing BNCT effect proportion in combined treatments can reduce damage in the normal brain tissue near the CTV. Besides, the combined treatments effectively minimize damage to the skin compared to individual BNCT treatments.Significance. The initial endeavor to combine BNCT and CIRT treatment plans is achieved by the effect-based optimization. The observed advantages of the combined treatment suggest its potential applicability for tumors characterized by pleomorphic, infiltrative, radioresistant and voluminous features.
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Affiliation(s)
- Yang Han
- Department of Nuclear Science and Technology, Nanjing University of Aeronautics and Astronautics, Nanjing, People's Republic of China
- Department of Physics, University of Pavia, Pavia, Italy
| | - Changran Geng
- Department of Nuclear Science and Technology, Nanjing University of Aeronautics and Astronautics, Nanjing, People's Republic of China
| | - Saverio Altieri
- Department of Physics, University of Pavia, Pavia, Italy
- National Institute of Nuclear Physics, Unit of Pavia, Pavia, Italy
| | - Silva Bortolussi
- Department of Physics, University of Pavia, Pavia, Italy
- National Institute of Nuclear Physics, Unit of Pavia, Pavia, Italy
| | - Yuanhao Liu
- Department of Nuclear Science and Technology, Nanjing University of Aeronautics and Astronautics, Nanjing, People's Republic of China
- Neuboron Medtech. Ltd, Nanjing, People's Republic of China
| | - Niklas Wahl
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute for Radiation Oncology (HIRO) and National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Xiaobin Tang
- Department of Nuclear Science and Technology, Nanjing University of Aeronautics and Astronautics, Nanjing, People's Republic of China
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Ehret F, Wolfgang J, Allwohn L, Onken J, Wasilewski D, Roohani S, Oertel J, Zips D, Kaul D. Outcomes of Isocitrate Dehydrogenase Wild Type Glioblastoma after Re-irradiation. Clin Transl Radiat Oncol 2023; 42:100653. [PMID: 37502699 PMCID: PMC10369398 DOI: 10.1016/j.ctro.2023.100653] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 07/29/2023] Open
Abstract
Purpose Glioblastomas (GBM) are the most common malignant primary brain tumors in adults and have a dismal prognosis. Patients frequently suffer from local tumor recurrences, with limited therapeutic options. Re-irradiation represents a possible intervention, but given the recent 5th edition of the World Health Organization classification of central nervous system tumors, studies in isocitrate dehydrogenase wild type (IDH-wt) cohorts undergoing a second course of radiotherapy remain limited. Herein, we sought to describe our institutional experience and outcomes after GBM IDH-wt re-irradiation. Materials and Methods GBM patients with confirmed IDH-wt status undergoing re-irradiation were included in this single-center, retrospective analysis. Results A total of 88 patients were analyzed. The median clinical and radiographic follow-up periods were 4.6 months and 4.4 months, respectively. Most patients had a Karnofsky performance status of at least 80% (n = 57). The median biologically effective dose and 2 Gy equivalent dose (EQD2) for re-irradiations, assuming an α/β ratio of 10 Gy for GBM, were 51.4 and 42.8 Gy, respectively. In total, 71 deaths were recorded. The median overall survival (OS) was 8.0 months. Multivariable Cox regression of OS revealed a positive influence of gross total resection vs. biopsy or no resection (hazard ratio: 0.43, p = 0.02). The median progression-free survival (PFS) was 5.9 months. The multivariable Cox regression for PFS did not detect any significant factors. No clear evidence of radiation necrosis was recorded during the available follow-up. However, only a minority (n = 4) of patients underwent surgery after re-irradiation, none showing histopathological proof of radiation necrosis. Conclusion The prognosis for recurrent IDH-wt GBM after re-irradiation is poor. Patients who are amenable and able to undergo re-resection may have a favorable OS. A second course of radiotherapy with a moderate cumulative EQD2 and small- to medium-sized planning target volumes appeared safe regarding the occurrence of radiation necrosis.
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Affiliation(s)
- Felix Ehret
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Josy Wolfgang
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
| | - Luisa Allwohn
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
| | - Julia Onken
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Berlin, Germany
| | - David Wasilewski
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Berlin, Germany
| | - Siyer Roohani
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Hospital, Saarland University, Homburg, Germany
| | - Daniel Zips
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Kaul
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Monocentric evaluation of Ki-67 labeling index in combination with a modified RPA score as a prognostic factor for survival in IDH-wildtype glioblastoma patients treated with radiochemotherapy. Strahlenther Onkol 2022; 198:892-906. [PMID: 35612598 PMCID: PMC9515058 DOI: 10.1007/s00066-022-01959-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/24/2022] [Indexed: 11/05/2022]
Abstract
Purpose The prognosis for glioblastoma patients remains dismal despite intensive research on better treatment options. Molecular and immunohistochemical markers are increasingly being investigated as understanding of their role in disease progression grows. O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation has been shown to have prognostic and therapeutic relevance for glioblastoma patients. Other markers implicated in tumor formation and/or malignancy are p53, Alpha thalassemia/mental retardation syndrome X-linked (ATRX), Epidermal Growth Factor Receptor splice variant III (EGFRvIII), and Ki-67, with loss of nuclear ATRX expression and lower Ki-67 index being associated with prolonged survival. For p53 and EGFRvIII the data are contradictory. Our aim was to investigate the markers mentioned above regarding progression-free (PFS) and overall survival (OS) to evaluate their viability as independent prognostic markers for our patient collective. Methods In this retrospective study, we collected data on patients undergoing radiotherapy due to isocitrate dehydrogenase (IDH) wildtype glioblastoma at a single university hospital between 2014 and 2020. Results Our findings confirm Ki-67 labeling index ≤ 20% as an independent prognostic factor for prolonged PFS as well as MGMT promoter methylation for both prolonged PFS and OS, in consideration of age and Eastern Cooperative Oncology Group (ECOG) status, chemotherapy treatment, and total radiation dose for PFS as well as additionally sex, resection status, and receipt of treatment for progression or recurrence for OS. Additionally, Ki-67 labeling index ≤ 20% showed a significant correlation with prolonged OS in univariate analysis. Modification of the recursive partitioning analysis (RPA) score to include Ki-67 labeling index resulted in a classification with the possible ability to distinguish long-term-survivors from patients with unfavorable prognosis. Conclusion MGMT promoter methylation and Ki-67 labeling index were independent predictors of survival in our collective. We see further studies pooling patient collectives to reach larger patient numbers concerning Ki-67 labeling index as being warranted. Supplementary Information The online version of this article (10.1007/s00066-022-01959-6) contains supplementary material, which is available to authorized users.
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The use of radiosensitizing agents in the therapy of glioblastoma multiforme-a comprehensive review. Strahlenther Onkol 2022; 198:507-526. [PMID: 35503461 PMCID: PMC9165247 DOI: 10.1007/s00066-022-01942-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/30/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Glioblastoma is the most common malignant brain tumor in human adults. Despite several improvements in resective as well as adjuvant therapy over the last decades, its overall prognosis remains poor. As a means of improving patient outcome, the possibility of enhancing radiation response by using radiosensitizing agents has been tested in an array of studies. METHODS A comprehensive review of clinical trials involving radiation therapy in combination with radiosensitizing agents on patients diagnosed with glioblastoma was performed in the National Center for Biotechnology Information's PubMed database. RESULTS A total of 96 papers addressing this matter were published between 1976 and 2021, of which 63 matched the subject of this paper. All papers were reviewed, and their findings discussed in the context of their underlining mechanisms of radiosensitization. CONCLUSION In the history of glioblastoma treatment, several approaches of optimizing radiation-effectiveness using radiosensitizers have been made. Even though several different strategies and agents have been explored, clear evidence of improved patient outcome is still missing. Tissue-selectiveness and penetration of the blood-brain barrier seem to be major roadblocks; nevertheless, modern strategies try to circumvent these obstacles, using novel sensitizers based on preclinical data or alternative ways of delivery.
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Relapsing High—Grade Glioma from Peritumoral Zone: Critical Review of Radiotherapy Treatment Options. Brain Sci 2022; 12:brainsci12040416. [PMID: 35447948 PMCID: PMC9027370 DOI: 10.3390/brainsci12040416] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 11/17/2022] Open
Abstract
Glioblastoma (GBM) is the most common and aggressive brain tumor in adults, with a median survival of about 15 months. After the prior treatment, GBM tends to relapse within the high dose radiation field, defined as the peritumoral brain zone (PTZ), needing a second treatment. In the present review, the primary role of ionizing radiation in recurrent GBM is discussed, and the current literature knowledge about the different radiation modalities, doses and fractionation options at our disposal is summarized. Therefore, the focus is on the necessity of tailoring the treatment approach to every single patient and using radiomics and PET/MRI imaging to have a relatively good outcome and avoid severe toxicity. The use of charged particle therapy and radiosensitizers to overcome GBM radioresistance is considered, even if further studies are necessary to evaluate the effectiveness in the setting of reirradiation.
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