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Lee SF, Kennedy SKF, Caini S, Wong HCY, Yip PL, Poortmans PM, Meattini I, Kaidar-Person O, Recht A, Hijal T, Torres MA, Cao JQ, Corbin KS, Choi JI, Koh WY, Kwan JYY, Karam I, Chan AW, Chow E, Marta GN. Randomised controlled trials on radiation dose fractionation in breast cancer: systematic review and meta-analysis with emphasis on side effects and cosmesis. BMJ 2024; 386:e079089. [PMID: 39260879 PMCID: PMC11388113 DOI: 10.1136/bmj-2023-079089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVE To provide a comprehensive assessment of various fractionation schemes in radiation therapy for breast cancer, with a focus on side effects, cosmesis, quality of life, risks of recurrence, and survival outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to 23 October 2023). STUDY SELECTION Included studies were randomised controlled trials focusing on conventional fractionation (CF; daily fractions of 1.8-2 Gy, reaching a total dose of 50-50.4 Gy over 5-6 weeks), moderate hypofractionation (MHF; fraction sizes of 2.65-3.3 Gy for 13-16 fractions over 3-5 weeks), and/or ultra-hypofractionation (UHF; schedule of only 5 fractions). DATA EXTRACTION Two independent investigators screened studies and extracted data. Risk of bias and quality of evidence were assessed using the Cochrane Collaboration's tool and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach, respectively. DATA SYNTHESIS Pooled risk ratios (RRs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity was analysed using Cochran's Q test and I2 statistic. Network meta-analysis was used to integrate all available evidence. MAIN OUTCOME MEASURES The pre-specified primary outcome was grade ≥2 acute radiation dermatitis and late radiation therapy related side effects; secondary outcomes included cosmesis, quality of life, recurrence, and survival metrics. RESULTS From 1754 studies, 59 articles representing 35 trials (20 237 patients) were assessed; 21.6% of outcomes showed low risk of bias, whereas 78.4% had some concerns or high risk, particularly in outcome measurement (47.4%). The RR for grade ≥2 acute radiation dermatitis for MHF compared with CF was 0.54 (95% CI 0.49 to 0.61; P<0.001) and 0.68 (0.49 to 0.93; P=0.02) following breast conserving therapy and mastectomy, respectively. Hyperpigmentation and grade ≥2 breast shrinkage were less frequent after MHF than after CF, with RRs of 0.77 (0.62 to 0.95; P=0.02) and 0.92 (0.85 to 0.99; P=0.03), respectively, in the combined breast conserving therapy and mastectomy population. However, in the breast conserving therapy only trials, these differences in hyperpigmentation (RR 0.79, 0.60 to 1.03; P=0.08) and breast shrinkage (0.94, 0.83 to 1.07; P=0.35) were not statistically significant. The RR for grade ≥2 acute radiation dermatitis for UHF compared with MHF was 0.85 (0.47 to 1.55; P=0.60) for breast conserving therapy and mastectomy patients combined. MHF was associated with improved cosmesis and quality of life compared with CF, whereas data on UHF were less conclusive. Survival and recurrence outcomes were similar between UHF, MHF, and CF. CONCLUSIONS MHF shows improved safety profile, cosmesis, and quality of life compared with CF while maintaining equivalent oncological outcomes. Fewer randomised controlled trials have compared UHF with other fractionation schedules, but its safety and oncological effectiveness seem to be similar with short term follow-up. Given the advantages of reduced treatment time, enhanced convenience for patients, and potential cost effectiveness, MHF and UHF should be considered as preferred options over CF in appropriate clinical settings, with further research needed to solidify these findings. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023460249.
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Affiliation(s)
- Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Samantha K F Kennedy
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPO), Florence, Italy
| | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Hospital Authority, Hong Kong
| | - Pui Lam Yip
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong
| | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- GROW-School for Oncology and Reproductive (Maastro), Maastricht University, Maastricht, Netherlands
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Mylin A Torres
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey Q Cao
- Section of Radiation Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wee Yao Koh
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jennifer Y Y Kwan
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Irene Karam
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Adrian W Chan
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Edward Chow
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil
- Latin America Cooperative Oncology Group, Porto Alegre, Brazil
- Postgraduate Program, Department of Radiology and Oncology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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2
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Ba MB, Giudici F, Bellini C, Auzac G, Louvel G, Bockel S, Moukasse Y, Chaffai I, Berthelot K, Vatonne A, Conversano A, Viansone A, Larue C, Deutsch E, Michiels S, Milewski C, Rivera S. Feasibility and Safety of the "One-Week Breast Radiation Therapy" Program. Clin Oncol (R Coll Radiol) 2024; 36:e333-e341. [PMID: 38971686 DOI: 10.1016/j.clon.2024.06.045] [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: 07/28/2023] [Revised: 02/21/2024] [Accepted: 06/13/2024] [Indexed: 07/08/2024]
Abstract
AIMS FAST-Forward and UK-FAST-trials have demonstrated the safety and efficacy of five-fraction breast adjuvant radiation therapy (RT) and have become the standard of care for selected early breast cancer patients. In response to the additional burden caused by the COVID-19 pandemic, we implemented "One-Week Breast RT," an innovative program delivering five-fraction whole breast RT in a complete 5-day workflow. The primary objective of this study was to demonstrate the feasibility and safety of our program. The secondary objective was to evaluate cosmetic results. MATERIAL AND METHODS A total of 120 patients treated from February 2021 to March 2022, received whole breast RT without lymph node irradiation nor boost, with 26 Gy in five fractions over one week. Inverse planning with restricted optimization parameters offers systematic deep inspiration breath-hold aimed to provide treatment plans compliant with FAST-Forward recommendations. Toxicity and cosmetic evaluations were prospectively registered prior (pre-RT), at the end (end-RT), and 6 months after RT (6 months) based on Common Terminology Criteria for Adverse Events v. 4.03 and Harvard scale. RESULTS With a median age of 70 years (interquartile range (IQR): 66-74) and a median follow-up of 6 months (IQR: 6.01-6.25), most patients (93.3%) completed their RT in one week from baseline to the end of the treatment consultation. The most common acute toxicities (at end-RT) were skin-related: radio-dermatitis (72%), induration (35%), hyperpigmentation (8%), and breast edema (16%). The rate of radio-dermatitis decreased from end-RT to 6 months (71.7% vs 5.4%, P< 0.001). No patient experienced grade ≥3 toxicity. At 6 months, cosmetic results were generally good or excellent (94.1%). CONCLUSION This study confirms the feasibility and acute safety of the "One-Week Breast RT" in real life. Favorable toxicity profiles and good cosmetic outcomes are in line with FAST-Forward results. A prospective national cohort, aimed at decreasing treatment burden, maintaining safety, efficacy, and improving RT workflow efficiency with longer follow-up is ongoing.
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Affiliation(s)
- M B Ba
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - F Giudici
- Bureau de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, Paris-Saclay University, F-94805, Villejuif, France
| | - C Bellini
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - G Auzac
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - G Louvel
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - S Bockel
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - Y Moukasse
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - I Chaffai
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - K Berthelot
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - A Vatonne
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - A Conversano
- Gustave Roussy, Surgery Department, F-94805, Villejuif, France
| | - A Viansone
- Gustave Roussy, Medical Oncology Department, F-94805, Villejuif, France
| | - C Larue
- Bureau de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, Paris-Saclay University, F-94805, Villejuif, France
| | - E Deutsch
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France; Université Paris-Saclay, Gustave Roussy, Inserm 1030, 94805, Villejuif, France
| | - S Michiels
- Bureau de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, Paris-Saclay University, F-94805, Villejuif, France
| | - C Milewski
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - S Rivera
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France; Université Paris-Saclay, Gustave Roussy, Inserm 1030, 94805, Villejuif, France.
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3
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Tokuda PJK, Mitsuyoshi T, Ono Y, Kishi T, Negoro Y, Okumura S, Ikeda I, Sakamoto T, Kokubo Y, Ashida R, Imagumbai T, Yamashita M, Tanabe H, Takebe S, Tokiwa M, Suzuki E, Yamauchi C, Yoshimura M, Mizowaki T, Kokubo M. Acute adverse events of ultra-hypofractionated whole-breast irradiation after breast-conserving surgery for early breast cancer in Japan: an interim analysis of the multi-institutional phase II UPBEAT study. Breast Cancer 2024; 31:643-648. [PMID: 38607499 PMCID: PMC11194189 DOI: 10.1007/s12282-024-01577-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The applicability of ultra-hypofractionated (ultra-HF) whole-breast irradiation (WBI) remains unknown in Japanese women. This study aimed to evaluate the safety and efficacy of this approach among Japanese women and report the results of an interim analysis performed to assess acute adverse events (AEs) and determine whether it was safe to continue this study. METHODS We enrolled Japanese women with invasive breast cancer or ductal carcinoma in situ who had undergone breast-conserving surgery, were aged ≥ 40 years, had pathological stages of Tis-T3 N0-N1, and had negative surgical margins. Ultra-HF-WBI was delivered at 26 Gy in five fractions over one week. When the number of enrolled patients reached 28, patient registration was paused for three months. The endpoint of the interim analysis was the proportion of acute AEs of grade ≥ 2 (Common Terminology Criteria for Adverse Events v5.0) within three months. RESULTS Of the 28 patients enrolled from seven institutes, 26 received ultra-HF-WBI, and 2 were excluded due to postoperative infections. No AEs of grade ≥ 3 occurred. One patient (4%) experienced grade 2 radiation dermatitis, and 18 (69%) had grade 1 radiation dermatitis. The other acute grade 1 AEs experienced were skin hyperpigmentation (n = 10, 38%); breast pain (n = 4, 15%); superficial soft tissue fibrosis (n = 3, 12%); and fatigue (n = 1, 4%). No other acute AEs of grade ≥ 2 were detected. CONCLUSIONS Acute AEs following ultra-HF-WBI were within acceptable limits among Japanese women, indicating that the continuation of the study was appropriate.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/surgery
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/pathology
- Mastectomy, Segmental/adverse effects
- Middle Aged
- Aged
- Japan/epidemiology
- Adult
- Radiation Dose Hypofractionation
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Radiotherapy, Adjuvant/adverse effects
- Radiotherapy, Adjuvant/methods
- Aged, 80 and over
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Affiliation(s)
- Peter J K Tokuda
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Takamasa Mitsuyoshi
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Yuka Ono
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Takahiro Kishi
- Department of Radiation Therapy, Osaka Red Cross Hospital, Osaka, Osaka, Japan
| | - Yoshiharu Negoro
- Department of Radiation Oncology, Japanese Red Cross Wakayama Medical Center, Wakayama, Wakayama, Japan
| | - Setsuko Okumura
- Department of Radiation Oncology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Itaru Ikeda
- Department of Radiation Oncology, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Takashi Sakamoto
- Department of Radiation Oncology, Kyoto-Katsura Hospital, Kyoto, Kyoto, Japan
| | - Yumi Kokubo
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Ryo Ashida
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Toshiyuki Imagumbai
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Mikiko Yamashita
- Department of Radiological Technology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hiroaki Tanabe
- Department of Radiological Technology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Sayaka Takebe
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Mariko Tokiwa
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Eiji Suzuki
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Masaki Kokubo
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Ratosa I, Montero A, Ciervide R, Alvarez B, García-Aranda M, Valero J, Chen-Zhao X, Lopez M, Zucca D, Hernando O, Sánchez E, de la Casa MA, Alonso R, Fernandez-Leton P, Rubio C. Ultra-hypofractionated one-week locoregional radiotherapy for patients with early breast cancer: Acute toxicity results. Clin Transl Radiat Oncol 2024; 46:100764. [PMID: 38516338 PMCID: PMC10955656 DOI: 10.1016/j.ctro.2024.100764] [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: 01/17/2024] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Purpose Moderate hypofractionated radiotherapy is the standard of care for all patients with breast cancer, irrespective of stage or prior treatments. While extreme hypofractionation is accepted for early-stage tumours, its application in irradiating locoregional lymph nodes remains controversial. Materials and methods A prospective registry analysis from July 2020 to September 2023 included 276 patients with early-stage breast cancer treated with one-week ultra-hypofractionation (UHF) at 26 Gy in 5 fractions on the whole breast (58.3 %) or thoracic wall (41.7 %) and ipsilateral regional lymph nodes and simultaneous integrated boost (58.3 %). Primary endpoint was assessment of acute adverse events (AEs). Secondarily, onset of early-delayed toxicity was assessed. A minimum 6-month follow-up was required for assessing potential treatment-related early-delayed complications. Acute or late complications attributable to treatment were assessed at inclusion using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 criteria. Results With a median follow-up of 19 months (range 1-49 months), 159 (57.6 %) patients reported AEs, predominantly grade (G) 1 (n = 139, 50.4 %) and G2 (n = 20, 7.8 %). Skin acute toxicity was common (G1/2: 134, G3: 14), while breast oedema occurred in 10 patients (G1: 9, G2: 1), and 15.9 % reported breast pain (G1: 42, G2: 2). Ipsilateral arm oedema was observed in 1.8 % patients. For patients with a follow-up beyond 6 months (n = 213), 23.4 % patients reported G1/G2 skin AEs, 8.8 % had G1/G2 breast/chest wall oedema, and 8.9 % experienced arm lymphedema. There were no cases of brachial plexopathy or G3 toxicity in this group of patients. Conclusions One-week UHF adjuvant locoregional radiation is well-tolerated, displaying low-toxicity profiles comparable to other studies using similar irradiation schedules.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain
| | - Raquel Ciervide
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Beatriz Alvarez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | | | - Xin Chen-Zhao
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Mercedes Lopez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Daniel Zucca
- Department of Medical Physics, HM Hospitales, Madrid, Spain
| | - Ovidio Hernando
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Rosa Alonso
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Carmen Rubio
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
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González-Viguera J, Martínez-Pérez E, Pérez-Montero H, Arangüena M, Guedea F, Gutiérrez-Miguélez C. Hype or hope? A review of challenges in balancing tumor control and treatment toxicity in breast cancer from the perspective of the radiation oncologist. Clin Transl Oncol 2024; 26:561-573. [PMID: 37505372 DOI: 10.1007/s12094-023-03287-2] [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: 05/02/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
The aim of this article is to discuss the challenges and new strategies in managing breast cancer patients, with a specific focus on radiation oncology and the importance of balancing oncologic outcomes with quality of life and post-treatment morbidity. A comprehensive literature review was conducted to identify advances in the management of breast cancer, exploring de-escalation strategies, hypofractionation schemes, predictors and tools for reducing toxicity (radiation-induced lymphocyte apoptosis, deep inspiration breath-hold, adaptive radiotherapy), enhancer treatments (hyperthermia, immunotherapy) and innovative diagnostic modalities (PET-MRI, omics). Balancing oncologic outcomes with quality of life and post-treatment morbidity is crucial in the era of personalized medicine. Radiotherapy plays a critical role in the management of breast cancer patients. Large randomized trials are necessary to generalize some practices and cost remains the main obstacle for many innovations that are already applicable.
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Affiliation(s)
- Javier González-Viguera
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Evelyn Martínez-Pérez
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Héctor Pérez-Montero
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marina Arangüena
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ferran Guedea
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
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Montero A, Ciérvide R, Cañadillas C, Álvarez B, García-Aranda M, Alonso R, López M, Chen-Zhao X, Alonso L, Valero J, Sánchez E, Hernando O, García de Acilu P, Fernandez-Letón P, Rubio C. Acute skin toxicity of ultra-hypofractionated whole breast radiotherapy with simultaneous integrated boost for early breast cancer. Clin Transl Radiat Oncol 2023; 41:100651. [PMID: 37388711 PMCID: PMC10300060 DOI: 10.1016/j.ctro.2023.100651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/18/2023] [Accepted: 06/04/2023] [Indexed: 07/01/2023] Open
Abstract
Background Whole-breast irradiation (WBI) after breast conserving surgery (BCS) is indicated to improve loco-regional control and survival. Former studies showed that addition of tumor bed boost in all age groups significantly improved local control although no apparent impact on overall survival but with an increased risk of worse cosmetic outcome. Even though shortened regimens in 3 weeks are considered the standard, recent studies have shown the non-inferiority of a treatment regimen of 5 fractions in one-week in both locoregional control and toxicity profile, although simultaneous integrated boost (SIB) in this setting has been scarcely studied. Materials and Methods From March-2020 to March-2022, 383 patients with early breast cancer diagnosis and a median age of 56 years-old (range 30-99)were included in a prospective registry of ultra-hypofractionated WBI up to a total dose of 26 Gy in 5.2 Gy/fraction with a SIB of 29 Gy in 5.8 Gy/fraction in 272 patients (71%), 30-31 Gy in 6-6.2 Gy/fraction in 111 patients (29%) with close/focally affected margins. Radiation treatment was delivered by conformal 3-D technique in 366 patients (95%), VMAT in 16patients (4%) and conformal 3-D with deep inspiration breath hold (DIBH) in 4patients (1%). Ninety-three per cent of patients received endocrine therapy and 43% systemic or targeted chemotherapy. Development of acute skin complications was retrospectively reviewed. Results With a median follow-up of 18 months (range 7-31), all patients are alive without evidence of local, regional or distant relapse. Acute tolerance was acceptable, with null o mild toxicity: 182 (48%) and 15 (4%) patients developed skin toxicity grade 1 and 2 respectively; 9 (2%) and 2 (0.5%) patients breast edema grade 1and 2 respectively. No other acute toxicities were observed. We also evaluated development of early delayed complications and observed grade 1 breast edema in 6 patients (2%); grade 1 hyperpigmentation in 20 patients (5%); and grade 1 and 2 breast induration underneath boost region in 10(3%) and 2 patients (0.5%) respectively. We found a statistically significant correlation between the median PTVWBI and presence of skin toxicity (p = 0.028) as well as a significant correlation between late hyperpigmentation with the median PTVBOOST (p = 0.007) and the ratio PTVBOOST/PTVWBI (p = 0.042). Conclusion Ultra-hypofractionated WBI + SIB in 5 fractions over one-week is feasible and well tolerated, although longer follow-up is necessary to confirm these results.
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Affiliation(s)
- Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain
| | - Raquel Ciérvide
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Beatriz Álvarez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Rosa Alonso
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Mercedes López
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Xin Chen-Zhao
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Leyre Alonso
- Department of Medical Physics, HM Hospitales, Madrid, Spain
| | - Jeannete Valero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Ovidio Hernando
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | | | - Carmen Rubio
- Department of Medical Physics, HM Hospitales, Madrid, Spain
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Coles CE, Haviland JS, Kirby AM, Griffin CL, Sydenham MA, Titley JC, Bhattacharya I, Brunt AM, Chan HYC, Donovan EM, Eaton DJ, Emson M, Hopwood P, Jefford ML, Lightowlers SV, Sawyer EJ, Syndikus I, Tsang YM, Twyman NI, Yarnold JR, Bliss JM. Dose-escalated simultaneous integrated boost radiotherapy in early breast cancer (IMPORT HIGH): a multicentre, phase 3, non-inferiority, open-label, randomised controlled trial. Lancet 2023; 401:2124-2137. [PMID: 37302395 DOI: 10.1016/s0140-6736(23)00619-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND A tumour-bed boost delivered after whole-breast radiotherapy increases local cancer-control rates but requires more patient visits and can increase breast hardness. IMPORT HIGH tested simultaneous integrated boost against sequential boost with the aim of reducing treatment duration while maintaining excellent local control and similar or reduced toxicity. METHODS IMPORT HIGH is a phase 3, non-inferiority, open-label, randomised controlled trial that recruited women after breast-conserving surgery for pT1-3pN0-3aM0 invasive carcinoma from radiotherapy and referral centres in the UK. Patients were randomly allocated to receive one of three treatments in a 1:1:1 ratio, with computer-generated random permuted blocks used to stratify patients by centre. The control group received 40 Gy in 15 fractions to the whole breast and 16 Gy in 8 fractions sequential photon tumour-bed boost. Test group 1 received 36 Gy in 15 fractions to the whole breast, 40 Gy in 15 fractions to the partial breast, and 48 Gy in 15 fractions concomitant photon boost to the tumour-bed volume. Test group 2 received 36 Gy in 15 fractions to the whole breast, 40 Gy in 15 fractions to the partial breast, and 53 Gy in 15 fractions concomitant photon boost to the tumour-bed volume. The boost clinical target volume was the clip-defined tumour bed. Patients and clinicians were not masked to treatment allocation. The primary endpoint was ipsilateral breast tumour relapse (IBTR) analysed by intention to treat; assuming 5% 5-year incidence with the control group, non-inferiority was predefined as 3% or less absolute excess in the test groups (upper limit of two-sided 95% CI). Adverse events were assessed by clinicians, patients, and photographs. This trial is registered with the ISRCTN registry, ISRCTN47437448, and is closed to new participants. FINDINGS Between March 4, 2009, and Sept 16, 2015, 2617 patients were recruited. 871 individuals were assigned to the control group, 874 to test group 1, and 872 to test group 2. Median boost clinical target volume was 13 cm3 (IQR 7 to 22). At a median follow-up of 74 months there were 76 IBTR events (20 for the control group, 21 for test group 1, and 35 for test group 2). 5-year IBTR incidence was 1·9% (95% CI 1·2 to 3·1) for the control group, 2·0% (1·2 to 3·2) for test group 1, and 3·2% (2·2 to 4·7) for test group 2. The estimated absolute differences versus the control group were 0·1% (-0·8 to 1·7) for test group 1 and 1·4% (0·03 to 3·8) for test group 2. The upper confidence limit for test group 1 versus the control group indicated non-inferiority for 48 Gy. Cumulative 5-year incidence of clinician-reported moderate or marked breast induration was 11·5% for the control group, 10·6% for test group 1 (p=0·40 vs control group), and 15·5% for test group 2 (p=0·015 vs control group). INTERPRETATION In all groups 5-year IBTR incidence was lower than the 5% originally expected regardless of boost sequencing. Dose-escalation is not advantageous. 5-year moderate or marked adverse event rates were low using small boost volumes. Simultaneous integrated boost in IMPORT HIGH was safe and reduced patient visits. FUNDING Cancer Research UK.
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Affiliation(s)
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Anna M Kirby
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
| | - Clare L Griffin
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Mark A Sydenham
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Jenny C Titley
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Indrani Bhattacharya
- Department of Oncology and Radiotherapy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Murray Brunt
- School of Medicine, University of Keele, Keele, UK; University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - H Y Charlie Chan
- Department of Breast Surgery, Nuffield Health Cheltenham Hospital, Cheltenham, UK
| | - Ellen M Donovan
- Centre for Vision, Speech and Signal Processing, University of Surrey, Guildford, UK
| | - David J Eaton
- Department of Medical Physics, Guy's and St Thomas' Hospitals, London, UK
| | - Marie Emson
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Penny Hopwood
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | | | | | - Elinor J Sawyer
- Guy Cancer Centre School of Cancer and Pharmaceutical Sciences, Guy's and St Thomas' Foundation Trust, Kings College London, London, UK
| | - Isabel Syndikus
- Department of Radiotherapy, Clatterbridge Cancer Centre, Bebington, UK
| | - Yat M Tsang
- Radiotherapy Trials QA Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Nicola I Twyman
- Department of Medical Physics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John R Yarnold
- Department of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, UK
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
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Dzhugashvili M, Veldeman L, Kirby AM. The role of the radiation therapy breast boost in the 2020s. Breast 2023; 69:299-305. [PMID: 36958070 PMCID: PMC10068257 DOI: 10.1016/j.breast.2023.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Given that most local relapses of breast cancer occur proximal to the original location of the primary, the delivery of additional radiation dose to breast tissue that contained the original primary cancer (known as a "boost") has been a standard of care for some decades. In the context of falling relapse rates, however, it is an appropriate time to re-evaluate the role of the boost. This article reviews the evolution of the radiotherapy boost in breast cancer, discussing who to boost and how to boost in the 2020s, and arguing that, in both cases, less is more.
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Affiliation(s)
| | - L Veldeman
- Ghent University/Ghent University Hospital, Ghent, Belgium.
| | - A M Kirby
- Royal Marsden Hospital NHS Foundation Trust & Institute of Cancer Research, UK.
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Vakaet V, Deseyne P, Schoepen M, Stouthandel M, Post G, Speleers B, Van Greveling A, Monten C, Mareel M, Van Hulle H, Paelinck L, De Gersem W, De Neve W, Vandecasteele K, Veldeman L. Prone Breast and Lymph Node Irradiation in 5 or 15 Fractions: A Randomized 2 × 2 Design Comparing Dosimetry, Acute Toxicity, and Set-Up Errors. Pract Radiat Oncol 2022; 12:324-334. [PMID: 35717049 DOI: 10.1016/j.prro.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/20/2021] [Accepted: 01/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Prone whole breast irradiation results in lower dose to organs at risk compared with supine position, especially lung dose. However, the adoption of prone position for whole breast irradiation + lymph node irradiation remains limited and data on lymph node irradiation in 5 fractions are lacking. Although the study was ended prematurely for the primary endpoint (breast retraction at 2 years), we decided to report acute toxicity for prone and supine positions and 5 and 15 fractions. Additionally, dosimetry and set-up accuracy between prone and supine positions were evaluated. METHODS AND MATERIALS A randomized open-label factorial 2 × 2 design was used for an acute toxicity comparison between prone and supine positions and 5 and 15 fractions. The primary endpoint of the trial was breast retraction 2 years after treatment. In total, 57 patients were evaluated. Dosimetry and set-up errors were compared between prone and supine positions. All patients were positioned on either our in -house developed prone crawl breast couch or a Posirest-2 (Civco). RESULTS No difference in acute toxicity between prone and supine positions was found, but 5 fractions did result in a lower risk of desquamation (15% vs 41%; P = .04). Prone positioning resulted in lower mean ipsilateral lung dose (2.89 vs 4.89 Gy; P < .001), mean thyroid dose (3.42 vs 6.61 Gy; P = .004), and mean contralateral breast dose (0.41 vs 0.54 Gy; P = .007). No significant difference in mean heart dose (0.90 vs 1.07 Gy; P = .22) was found. Set-up accuracy was similar between both positions. CONCLUSIONS Unfortunately, the primary endpoint of the trial was not met due to premature closure of the trial. Acceleration in 5 fractions resulted in a lower risk of desquamation. Prone positioning did not influence acute toxicity or set-up accuracy, but did result in lower ipsilateral mean lung dose, thyroid dose, and contralateral breast dose.
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Affiliation(s)
- Vincent Vakaet
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium.
| | - Pieter Deseyne
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Industrial Systems Engineering and Product Design, Kortrijk, Belgium
| | - Michael Stouthandel
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Giselle Post
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Bruno Speleers
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | | | - Christel Monten
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Marcus Mareel
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Hans Van Hulle
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Werner De Gersem
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Katrien Vandecasteele
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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10
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Vakaet V, Van Hulle H, Van de Vijver K, Hilderson I, Naert E, De Neve W, Vandorpe J, Hendrix A, Göker M, Depypere H, Vergauwen G, Van den Broecke R, De Visschere P, Braems G, Vandecasteele K, Denys H, Veldeman L. Safety of pre- or postoperative accelerated radiotherapy in 5 fractions: A randomized pilot trial. Breast 2022; 62:10-15. [PMID: 35091184 PMCID: PMC8800131 DOI: 10.1016/j.breast.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/20/2021] [Accepted: 01/19/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Neo-adjuvant radiotherapy (NART) for breast cancer has shown promising survival results in retrospective trials. However, there are some obstacles such as a chemotherapy delay, an increased overall treatment time (OTT) and the risk of increasing surgical morbidity. Accelerated radiotherapy (RT) in 5 fractions allows to deliver NART in a very short time span and minimizes the delay of surgery and chemotherapy. This trial investigates this NART schedule for safety, feasibility and OTT. MATERIAL AND METHODS Twenty patients eligible for neo-adjuvant chemotherapy (NACT) and breast conserving surgery, were randomized between NART before NACT or NACT and postoperative RT. In both arms, RT treatment was given in 5 fractions to the whole breast with a simultaneously integrated boost (SIB) on the tumor(bed). Lymph node irradiation was given concomitantly in case of lymph node involvement. OTT was defined as the time from diagnosis to last surgery in the intervention group, while in the control group the time between diagnosis and last RT-fraction was used. In the intervention group NACT-delay was defined as time between diagnosis and start of chemotherapy. RESULTS 20 patients were included, and 19 patients completed treatment. OTT was significantly shorter in the intervention group (mean 218 days, range 196-253) compared to the control group (mean 237, range 211-268, p = 0.001). The difference in mean duration from diagnosis to the first treatment was a non-significant 4 days longer (31 vs 27 days, p = 0.28), but the start of NACT after diagnosis was delayed by 21 days (48 vs 27 days, p < 0.001). NART did not result in additional surgery complications. CONCLUSION This pilot trial is the first to report on accelerated NART in 5 fractions with SIB. NART before NACT resulted in a shorter OTT with good safety results.
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Affiliation(s)
- Vincent Vakaet
- Dept. of Human Structure and Repair, Ghent University, Belgium; Dept. of Radiation Oncology, Ghent University Hospital, Belgium.
| | - Hans Van Hulle
- Dept. of Human Structure and Repair, Ghent University, Belgium.
| | - Koen Van de Vijver
- Dept. of Pathology, Ghent University Hospital, Belgium; Dept. of Diagnostic Sciences, Ghent University, Belgium.
| | | | - Eline Naert
- Dept. of Medical Oncology, Ghent University Hospital, Belgium; Dept. of Internal Medicine and Pediatrics, Ghent University, Belgium.
| | | | - Jo Vandorpe
- Dept. of Pathology, Ghent University Hospital, Belgium; Dept. of Diagnostic Sciences, Ghent University, Belgium.
| | - An Hendrix
- Dept. of Human Structure and Repair, Ghent University, Belgium.
| | - Menekse Göker
- Dept. of Gynaecology, Ghent University Hospital, Belgium.
| | - Herman Depypere
- Dept. of Human Structure and Repair, Ghent University, Belgium; Dept. of Gynaecology, Ghent University Hospital, Belgium.
| | | | - Rudy Van den Broecke
- Dept. of Human Structure and Repair, Ghent University, Belgium; Dept. of Gynaecology, Ghent University Hospital, Belgium.
| | - Pieter De Visschere
- Dept. of Diagnostic Sciences, Ghent University, Belgium; Dept. of Radiology and Nuclear Medicine, Ghent University Hospital, Belgium.
| | - Geert Braems
- Dept. of Human Structure and Repair, Ghent University, Belgium; Dept. of Gynaecology, Ghent University Hospital, Belgium.
| | - Katrien Vandecasteele
- Dept. of Human Structure and Repair, Ghent University, Belgium; Dept. of Radiation Oncology, Ghent University Hospital, Belgium.
| | - Hannelore Denys
- Dept. of Medical Oncology, Ghent University Hospital, Belgium; Dept. of Internal Medicine and Pediatrics, Ghent University, Belgium.
| | - Liv Veldeman
- Dept. of Human Structure and Repair, Ghent University, Belgium; Dept. of Radiation Oncology, Ghent University Hospital, Belgium.
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