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Deng X, Lin D, Yu L, Xu X, Zhang N, Zhou H, Sheng H, Yin B, Lin F, Xu S, Li D, Fang J, Lu X, Lin J. The role of postoperative radiotherapy in pediatric patients with grade II intracranial ependymomas: a population-based, propensity score-matched study. Cancer Manag Res 2018; 10:5515-5524. [PMID: 30519099 PMCID: PMC6233483 DOI: 10.2147/cmar.s181900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose The main objectives of this study were to clarify the efficacy of postoperative radiotherapy (PORT) for pediatric intracranial grade II ependymomas (EPNs) and to explore whether various characteristics are associated with different outcomes in patients with and without PORT. Patients and methods Data from patients younger than 18 years diagnosed with grade II intracranial EPNs and treated by surgery, with or without PORT, were obtained from the Surveillance, Epidemiology, and End Results (SEER) database (1973–2013 data set). Propensity score-matched analysis was conducted to balance clinical variables. Patient characteristics were stratified and analyzed. Results In total, data from 632 patients with grade II EPNs treated by cancer-directed surgery with or without PORT were obtained from the SEER database. Multivariable Cox analysis in the matched cohort suggested that undergoing PORT (overall survival [OS], P=0.020; cancer-specific survival [CSS], P=0.031), undergoing gross total resection (GTR; subtotal resection [STR] vs GTR; OS, P<0.001; CSS, P<0.001), and older age (OS, P<0.001; CSS, P<0.001) were the independent predictors of superior prognosis. Stratified analysis demonstrated that patient characteristics, including infratentorial location, younger age, and STR, were associated with benefit from PORT, while the survival advantage was not detected in patients who underwent GTR. Conclusion Propensity score-matched analysis using SEER data indicates survival advantages of PORT. Given the strong prognostic associations with extent of resection and patient age, we recommend PORT for younger patients treated by STR.
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Affiliation(s)
- Xiangyang Deng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Dongdong Lin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Lisheng Yu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Xingxing Xu
- Department of Physiology, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Nu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Hui Zhou
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Hansong Sheng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Fengchun Lin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Shangyu Xu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Dandong Li
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Junhao Fang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Xiangqi Lu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Jian Lin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
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Laprie A, Hu Y, Alapetite C, Carrie C, Habrand JL, Bolle S, Bondiau PY, Ducassou A, Huchet A, Bertozzi AI, Perel Y, Moyal É, Balosso J. Paediatric brain tumours: A review of radiotherapy, state of the art and challenges for the future regarding protontherapy and carbontherapy. Cancer Radiother 2015; 19:775-89. [PMID: 26548600 DOI: 10.1016/j.canrad.2015.05.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Brain tumours are the most frequent solid tumours in children and the most frequent radiotherapy indications in paediatrics, with frequent late effects: cognitive, osseous, visual, auditory and hormonal. A better protection of healthy tissues by improved beam ballistics, with particle therapy, is expected to decrease significantly late effects without decreasing local control and survival. This article reviews the scientific literature to advocate indications of protontherapy and carbon ion therapy for childhood central nervous system cancer, and estimate the expected therapeutic benefits. MATERIALS AND METHODS A systematic review was performed on paediatric brain tumour treatments using Medline (from 1966 to March of 2014). To be included, clinical trials had to meet the following criteria: age of patients 18 years or younger, treated with radiation, and report of survival. Studies were also selected according to the evidence level. A secondary search of cited references found other studies about cognitive functions, quality of life, the comparison of photon and proton dosimetry showing potential dose escalation and/or sparing of organs at risk with protontherapy; and studies on dosimetric and technical issues related to protontherapy. RESULTS A total of 7051 primary references published were retrieved, among which 40 clinical studies and 60 papers about quality of life, dose distribution and dosimetry were analysed, as well as the ongoing clinical trials. These papers have been summarized and reported in a specific document made available to the participants of a final 1-day workshop. Tumours of the meningeal envelop and bony cranial structures were excluded from the analysis. Protontherapy allows outstanding ballistics to target the tumour area, while substantially decreasing radiation dose to the normal tissues. There are many indications of protontherapy for paediatric brain tumours in curative intent, either for localized treatment of ependymomas, germ-cell tumours, craniopharyngiomas, low-grade gliomas; or panventricular irradiation of pure non-secreting germinoma; or craniospinal irradiation of medulloblastomas and metastatic pure germinomas. Carbon ion therapy is just emerging and may be studied for highly aggressive and radioresistant tumours, as an initial treatment for diffuse brainstem gliomas, and for relapse of high-grade gliomas. CONCLUSION Both protontherapy and carbon ion therapy are promising for paediatric brain tumours. The benefit of decreasing late effects without altering survival has been described for most paediatric brain tumours with protontherapy and is currently assessed in ongoing clinical trials with up-to-date proton devices. Unfortunately, in 2015, only a minority of paediatric patients in France can receive protontherapy due to the lack of equipment.
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Affiliation(s)
- A Laprie
- Université Paul-Sabatier, Toulouse, France; Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France.
| | - Y Hu
- GCS-Étoile-France-Hadron, Lyon, France
| | - C Alapetite
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France
| | - C Carrie
- GCS-Étoile-France-Hadron, Lyon, France; Centre Léon-Bérard, Lyon, France
| | - J-L Habrand
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France; Université Paris Sud, Orsay, France; Archade-France-Hadron, Caen, France; Centre François-Baclesse, Caen, France; Gustave-Roussy, Villejuif, France
| | - S Bolle
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France; Impact-France-Hadron, Nice, France
| | - P-Y Bondiau
- Centre Antoine-Lacassagne, Nice, France; CHU de Bordeaux, Bordeaux, France
| | - A Ducassou
- Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France
| | - A Huchet
- Hôpital des Enfants, Toulouse, France
| | - A-I Bertozzi
- Périclès-France-Hadron, Toulouse, France; Université Grenoble Alpes, Grenoble, France
| | - Y Perel
- Université Grenoble Alpes, Grenoble, France
| | - É Moyal
- Université Paul-Sabatier, Toulouse, France; Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France
| | - J Balosso
- GCS-Étoile-France-Hadron, Lyon, France; CHU de Grenoble, Grenoble, France
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Weber DC, Wang Y, Miller R, Villà S, Zaucha R, Pica A, Poortmans P, Anacak Y, Ozygit G, Baumert B, Haller G, Preusser M, Li J. Long-term outcome of patients with spinal myxopapillary ependymoma: treatment results from the MD Anderson Cancer Center and institutions from the Rare Cancer Network. Neuro Oncol 2014; 17:588-95. [PMID: 25301811 DOI: 10.1093/neuonc/nou293] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Spinal myxopapillary ependymomas (MPEs) are slowly growing ependymal gliomas with preferential manifestation in young adults. The aim of this study was to assess the outcome of patients with MPE treated with surgery, radiotherapy (RT), and/or chemotherapy. METHODS The medical records of 183 MPE patients (male: 59%) treated at the MD Anderson Cancer Center and 11 institutions from the Rare Cancer Network were retrospectively reviewed. Mean patient' age at diagnosis was 35.5 ± 15.8 years. Ninety-seven (53.0%) patients underwent surgery without RT, and 86 (47.0%) were treated with surgery and/or RT. Median RT dose was 50.4 Gy. Median follow-up was 83.9 months. RESULTS Fifteen (8.2%) patients died, 7 of unrelated cause. The estimated 10-year overall survival was 92.4% (95% CI: 87.7-97.1). Treatment failure was observed in 58 (31.7%) patients. Local failure, distant spinal relapse, and brain failure were observed in 49 (26.8%), 17 (9.3%), and 11 (6.0%) patients, respectively. The estimated 10-year progression-free survival was 61.2% (95% CI: 52.8-69.6). Age (<36 vs ≥36 y), treatment modality (surgery alone vs surgery and RT), and extent of surgery were prognostic factors for local control and progression-free survival on univariate and multivariate analysis. CONCLUSIONS In this series, treatment failure of MPE occurred in approximately one third of patients. The observed recurrence pattern of primary spinal MPE was mainly local, but a substantial number of patients failed nonlocally. Younger patients and those not treated initially with adjuvant RT or not undergoing gross total resection were significantly more likely to present with tumor recurrence/progression.
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Affiliation(s)
- Damien C Weber
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Yucai Wang
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Robert Miller
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Salvador Villà
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Renata Zaucha
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Alessia Pica
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Philip Poortmans
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Yavuz Anacak
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Gokhan Ozygit
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Birgitta Baumert
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Guy Haller
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Matthias Preusser
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Jing Li
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
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