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Loap P, Vu Bezin J, De Marzi L, Kirova Y. Determinants of radiation dose to immune cells during breast radiotherapy. Strahlenther Onkol 2024:10.1007/s00066-024-02240-8. [PMID: 38801448 DOI: 10.1007/s00066-024-02240-8] [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: 02/07/2024] [Accepted: 04/17/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The immune system has been identified as an organ at risk in esophageal and lung cancers. However, the dosimetric impact of radiotherapy on immune system exposure in patients treated for breast cancer has never been studied. METHODS A monocentric retrospective dosimetric study included 163 patients treated at the Institut Curie (Paris, France) between 2010 and 2016 with locoregional helical tomotherapy after conservative surgery or total mastectomy. The effective dose to the immune system (EDIC) was calculated based on diverse dosimetric parameters. The clinical and volumetric determinants of EDIC in adjuvant radiotherapy of breast cancer were analyzed. RESULTS The median EDIC for the population was 4.23 Gy, ranging from 1.82 to 6.19 Gy. Right-sided radiotherapy and regional lymph node irradiation were associated with significantly higher EDIC in univariate (4.38 Gy vs. 3.94 Gy, p < 0.01, and 4.27 Gy vs. 3.44 Gy, p < 0.01, respectively) and multivariate analyses (p < 0.01 and p < 0.01). Liver overexposure was the main contributor to EDIC increase in right-sided breast cancer patients (+0.38 Gy [95%CI: +0.30; +0.46]), while the integral total dose increase was the main contributor to EDIC increase in cases of regional node irradiation (+0.63 Gy [95%CI: +0.42; +0.85]). CONCLUSION The EDIC score during adjuvant radiotherapy after breast cancer was statistically significantly higher in the case of right-sided radiotherapy and regional lymph node irradiation. Liver irradiation is the main contributor to immune system exposure in adjuvant irradiation of right-sided breast cancer. Populations in which an association between EDIC and survival would exist have yet to be identified but could potentially include patients treated for triple-negative breast cancer with a poor response to neoadjuvant chemoimmunotherapy.
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Affiliation(s)
- Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France.
| | - Jeremi Vu Bezin
- Department of Radiation Oncology, Institut Curie, Paris, France
| | | | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
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2
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Struikmans H, Petoukhova A, Schreur JHM, Mast ME, Poortmans PM. Is the risk of ischemic heart disease in women after radiotherapy for breast cancer nowadays still (linearly) associated with the mean heart dose? Acta Oncol 2024; 63:175-178. [PMID: 38597665 DOI: 10.2340/1651-226x.2024.34751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/29/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Henk Struikmans
- Department of Radiation Therapy, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - Anna Petoukhova
- Department of Medical Physics, Haaglanden Medical Center, Leidschendam, the Netherlands
| | - Joop H M Schreur
- Cardiology Department, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - Mirjam E Mast
- Department of Radiation Therapy, Haaglanden Medical Center, Leidschendam, The Netherlands.
| | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; Antwerp University, Wilrijk-Antwerp, Belgium
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3
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Fatima H, Abbas P, Alshehri SM. Balancing Innovation and Patient Care in Breast Cancer: Integrating Hypofractionated Proton Therapy With Breast Reconstruction Outcomes. Cureus 2024; 16:e58056. [PMID: 38738134 PMCID: PMC11088419 DOI: 10.7759/cureus.58056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
This review aims to assess the application of hypofractionated proton therapy in breast cancer reconstruction, analyzing its advantages, challenges, and broader implications for patient care. The goal is to comprehensively understand how this innovative approach can be integrated into breast cancer treatment. Proton therapy exhibits superior target coverage and safety, reducing radiation-induced complications and sparing critical organs, but skin toxicity outcomes differ from photon therapy. Tissue expanders are vital in breast reconstruction, employing innovative planning for positive long-term outcomes and highlighting the importance of balancing cancer treatment effectiveness with cosmetic outcomes. Hypofractionated proton therapy and breast cancer reconstruction present promising innovations with notable advantages in target coverage and organ sparing. However, variations in skin toxicity outcomes and the need for a careful balance between treatment effectiveness and cosmetic outcomes underscore ongoing challenges. Future directions should focus on refining treatment protocols, optimizing patient selection criteria, and integrating emerging technologies to enhance therapeutic outcomes while minimizing adverse effects.
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Affiliation(s)
- Hadia Fatima
- Radiation Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Paras Abbas
- Oncology Department, Atomic Energy Cancer Hospital, Nuclear Medicine Oncology and Radiotherapy Institute, Islamabad, PAK
| | - Salem M Alshehri
- Radiation Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
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4
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Stick LB, Nielsen LL, Trinh CB, Bahij I, Jensen MF, Kronborg CJS, Petersen SE, Thai LMH, Martinsen ML, Precht H, Offersen BV. Spot-scanning proton therapy for early breast cancer in free breathing versus deep inspiration breath-hold. Acta Oncol 2024; 63:56-61. [PMID: 38404218 DOI: 10.2340/1651-226x.2024.28591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 12/13/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND PURPOSE Proton therapy for breast cancer is usually given in free breathing (FB). With the use of deep inspiration breath-hold (DIBH) technique, the location of the heart is displaced inferiorly, away from the internal mammary nodes and, thus, the dose to the heart can potentially be reduced. The aim of this study was to explore the potential benefit of proton therapy in DIBH compared to FB for highly selected patients to reduce exposure of the heart and other organs at risk. We aimed at creating proton plans with delivery times feasible with treatment in DIBH. MATERIAL AND METHODS Sixteen patients with left-sided breast cancer receiving loco-regional proton therapy were included. The FB and DIBH plans were created for each patient using spot-scanning proton therapy with 2-3 fields, robust and single field optimization. For the DIBH plans, minimum monitor unit per spot and spot spacing were increased to reduce treatment delivery time. RESULTS All plans complied with target coverage constraints. The median mean heart dose was statistically significant reduced from 1.1 to 0.6 Gy relative biological effectiveness (RBE) by applying DIBH. No statistical significant difference was seen for mean dose and V17Gy RBE to the ipsilateral lung. The median treatment delivery time for the DIBH plans was reduced by 27% compared to the FB plans without compromising the plan quality. INTERPRETATION The median absolute reduction in dose to the heart was limited. Proton treatment in DIBH may only be relevant for a subset of these patients with the largest reduction in heart exposure.
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Affiliation(s)
| | | | - Cecilia Bui Trinh
- The Education of Radiography, University College Lillebælt, Svendborg, Denmark
| | - Ihsan Bahij
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Linh My Hoang Thai
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - May-Lin Martinsen
- The Education of Radiography, University College Lillebælt, Svendborg, Denmark
| | - Helle Precht
- Health Sciences Research Center, University College Lillebælt, Svendborg, Denmark; Institute of Regional Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Radiology, Lillebælt University Hospital of Southern Denmark, Kolding, Denmark
| | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark; Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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5
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Ruan H, Okamoto M, Ohno T, Li Y, Zhou Y. Particle radiotherapy for breast cancer. Front Oncol 2023; 13:1107703. [PMID: 37655110 PMCID: PMC10467264 DOI: 10.3389/fonc.2023.1107703] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/28/2023] [Indexed: 09/02/2023] Open
Abstract
Breast cancer is the most common malignant tumor in female patients. Along with surgery, radiotherapy is one of the most commonly prescribed treatments for breast cancer. Over the past few decades, breast cancer radiotherapy technology has significantly improved. Nevertheless, related posttherapy complications should not be overlooked. Common complications include dose-related coronary toxicity, radiation pneumonia, and the risk of second primary cancer of the contralateral breast. Particle radiotherapy with protons or carbon ions is widely attracting interest as a potential competitor to conventional photon radiotherapy because of its superior physical and biological characteristics. This article summarizes the results of clinical research on proton and carbon-ion radiotherapy for treating breast cancer.
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Affiliation(s)
- Hanguang Ruan
- Department of Radiation Oncology, Gunma University, Maebashi, Japan
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Gunma, Japan
| | - Masahiko Okamoto
- Department of Radiation Oncology, Gunma University, Maebashi, Japan
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Gunma, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University, Maebashi, Japan
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Gunma, Japan
| | - Yang Li
- Department of Radiation Oncology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Yuan Zhou
- Department of Radiation Oncology, Gunma University, Maebashi, Japan
- Gunma University Heavy Ion Medical Center, Gunma University, Maebashi, Gunma, Japan
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6
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Aristei C, Kaidar-Person O, Boersma L, Leonardi MC, Offersen B, Franco P, Arenas M, Bourgier C, Pfeffer R, Kouloulias V, Bölükbaşı Y, Meattini I, Coles C, Luis AM, Masiello V, Palumbo I, Morganti AG, Perrucci E, Tombolini V, Krengli M, Marazzi F, Trigo L, Borghesi S, Ciabattoni A, Ratoša I, Valentini V, Poortmans P. The 2022 Assisi Think Tank Meeting: White paper on optimising radiation therapy for breast cancer. Crit Rev Oncol Hematol 2023:104035. [PMID: 37244324 DOI: 10.1016/j.critrevonc.2023.104035] [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: 02/23/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. < 70% agreement in an online questionnaire identified the following clinical challenges: 1: Nodal RT in patients who have a) 1-2 positive sentinel nodes without ALND (axillary lymph node dissection); b) cN1 disease transformed into ypN0 by primary systemic therapy and c) 1-3 positive nodes after mastectomy and ALND. 2. The optimal combination of RT and immunotherapy (IT), patient selection, IT-RT timing, and RT optimal dose, fractionation and target volume. Most experts agreed that RT- IT combination does not enhance toxicity. 3: Re-irradiation for local relapse converged on the use of partial breast irradiation after second breast conserving surgery. Hyperthermia aroused support but is not widely available. Further studies are required to finetune best practice, especially given the increasing use of re-irradiation.
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Affiliation(s)
- C Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - O Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - L Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M C Leonardi
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - B Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - P Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carita`' University Hospital, Novara, Italy
| | - M Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - C Bourgier
- Radiation Oncology, ICM-Val d' Aurelle, Univ Montpellier, Montpellier, France
| | - R Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - V Kouloulias
- 2nd Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Y Bölükbaşı
- Koc University, Faculty of Medicine, Department of Radiation Oncology, Istanbul, Turkey
| | - I Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - C Coles
- Department of Oncology, University of Cambridge, UK
| | - A Montero Luis
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - V Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - I Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - A G Morganti
- DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy; Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - E Perrucci
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - V Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - M Krengli
- DISCOG, Università di Padova e Istituto Oncologico Veneto - IRCCS
| | - F Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - L Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - S Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - A Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - I Ratoša
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - V Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore e Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - P Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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7
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Lin H, Dong L, Jimenez RB. Emerging Technologies in Mitigating the Risks of Cardiac Toxicity From Breast Radiotherapy. Semin Radiat Oncol 2022; 32:270-281. [DOI: 10.1016/j.semradonc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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Loap P, Orlandi E, De Marzi L, Vitolo V, Barcellini A, Iannalfi A, Dendale R, Kirova Y, Mirandola A. Cardiotoxicity model-based patient selection for Hodgkin lymphoma proton therapy. Acta Oncol 2022; 61:979-986. [PMID: 35668710 DOI: 10.1080/0284186x.2022.2084639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Hodgkin lymphoma (HL) is a highly curable hematological malignancy. Consolidation radiation therapy techniques have made significant progresses to improve organ-at-risk sparing in order to reduce late radiation-induced toxicity. Recent technical breakthroughs notably include intensity modulated proton therapy (IMPT), which has demonstrated a major dosimetric benefit at the cardiac level for mediastinal HL patients. However, its implementation in clinical practice is still challenging, notably due to the limited access to proton therapy facilities. In this context, the purpose of this study was to estimate the benefit of IMPT for HL proton therapy for diverse cardiac adverse events and to propose a general frame for mediastinal HL patient selection strategy for IMPT based on cardiotoxicity reduction, patient clinical factors, and IMPT treatment availability. MATERIAL AND METHODS This retrospective dosimetric study included 30 mediastinal HL patients treated with VMAT. IMPT plans were generated on the initial simulation scans. Dose to the heart, to the left ventricle and to the valves were retrieved to calculate the relative risk (RR) of ischemic heart disease (IHD), congestive heart failure (CHF) and valvular disease (VD). Composite relative risk reduction (cRRR) of late cardiotoxicity, between VMAT and IMPT, were calculated as the weighted mean of relative risk reduction for IHD, CHF and VD, calculated across a wide range of cardiovascular risk factor combinations. The proportion of mediastinal HL patients who could benefit from IMPT was estimated in European countries, based on the country population and on the number of active gantries, to propose country-specific cRRR thresholds for patient selection. RESULTS Compared with VMAT, IMPT significantly reduced average mean doses to the heart (2.36 Gy vs 0.99 Gy, p < 0.01), to the left ventricle (0.67 Gy vs 0.03, p < 0.01) and to the valves (1.29 Gy vs. 0.06, p < 0.01). For a HL patient without cardiovascular risk factor other than anthracycline-based chemotherapy, the relative risks of late cardiovascular complications were significantly lower after IMPT compared with VMAT for ischemic heart disease (1.07 vs 1.17, p < 0.01), for congestive heart failure (2.84 vs. 3.00, p < 0.01), and for valvular disease (1.01 vs. 1.06, p < 0.01). The median cRRR of cardiovascular adverse events with IMPT was 4.8%, ranging between 0.1% and 30.5%, depending on the extent of radiation fields and on the considered cardiovascular risk factors. The estimated proportion of HL patients currently treatable with IMPT in European countries with proton therapy facilities ranged between 8.0% and 100% depending on the country, corresponding to cRRR thresholds ranging from 24.0% to 0.0%. CONCLUSION While a statistically significant clinical benefit is theoretically expected for ischemic heart disease, cardiac heart failure and valvular disease for mediastinal HL patients with IMPT, the overall cardiotoxicity risk reduction is notable only for a minority of patients. In the context of limited IMPT availability, this study proposed a general model-based selection approach for mediastinal HL patient based on calculated cardiotoxicity reduction, taking into consideration patient clinical characteristics and IMPT facility availability.
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Affiliation(s)
- Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France.,Centre de Protonthérapie (CPO), Institut Curie, Orsay, France.,Radiation Oncology Clinical Department, Centro Nazionale di Adronterapia Oncologica (CNAO), Pavia, Italia
| | - Ester Orlandi
- Radiation Oncology Clinical Department, Centro Nazionale di Adronterapia Oncologica (CNAO), Pavia, Italia
| | - Ludovic De Marzi
- Department of Radiation Oncology, Institut Curie, Paris, France.,Centre de Protonthérapie (CPO), Institut Curie, Orsay, France
| | - Viviana Vitolo
- Radiation Oncology Clinical Department, Centro Nazionale di Adronterapia Oncologica (CNAO), Pavia, Italia
| | - Amelia Barcellini
- Radiation Oncology Clinical Department, Centro Nazionale di Adronterapia Oncologica (CNAO), Pavia, Italia
| | - Alberto Iannalfi
- Radiation Oncology Clinical Department, Centro Nazionale di Adronterapia Oncologica (CNAO), Pavia, Italia
| | - Rémi Dendale
- Department of Radiation Oncology, Institut Curie, Paris, France.,Centre de Protonthérapie (CPO), Institut Curie, Orsay, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France.,Centre de Protonthérapie (CPO), Institut Curie, Orsay, France
| | - Alfredo Mirandola
- Radiation Oncology Clinical Department, Centro Nazionale di Adronterapia Oncologica (CNAO), Pavia, Italia
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9
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Gleeson I. Comparing the robustness of different skin flash approaches using wide tangents, manual flash VMAT, and simulated organ motion robust optimization VMAT in breast and nodal radiotherapy. Med Dosim 2022; 47:264-272. [DOI: 10.1016/j.meddos.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
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10
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Kowalchuk RO, Corbin KS, Jimenez RB. Particle Therapy for Breast Cancer. Cancers (Basel) 2022; 14:cancers14041066. [PMID: 35205814 PMCID: PMC8870138 DOI: 10.3390/cancers14041066] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 02/05/2023] Open
Abstract
Particle therapy has received increasing attention in the treatment of breast cancer due to its unique physical properties that may enhance patient quality of life and reduce the late effects of therapy. In this review, we will examine the rationale for the use of proton and carbon therapy in the treatment of breast cancer and highlight their potential for sparing normal tissue injury. We will discuss the early dosimetric and clinical studies that have been pursued to date in this domain before focusing on the remaining open questions limiting the widespread adoption of particle therapy.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Kimberly S. Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Rachel B. Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence:
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11
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Milo MLH, Nyeng TB, Lorenzen EL, Hoffmann L, Møller DS, Offersen BV. Atlas-based auto-segmentation for delineating the heart and cardiac substructures in breast cancer radiation therapy. Acta Oncol 2022; 61:247-254. [PMID: 34427497 DOI: 10.1080/0284186x.2021.1967445] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND This study aimed to develop and validate an automatic multi-atlas segmentation method for delineating the heart and substructures in breast cancer radiation therapy (RT). MATERIAL AND METHODS The atlas database consisted of non-contrast-enhanced planning CT scans from 42 breast cancer patients, each with one manual delineation of the heart and 22 cardiac substructures. Half of the patients were scanned during free-breathing, the rest were scanned during a deep inspiration breath-hold. The auto-segmentation was developed in the MIM software system and validated geometrically and dosimetrically in two steps: The first validation in a small dataset to ensure consistency of the atlas. This was succeeded by a final test where multiple manual delineations in CT scans of 12 breast cancer patients were compared to the auto-segmentation. For geometric evaluation, the dice similarity coefficient (DSC) and the mean surface distance (MSD) were used. For dosimetric evaluation, the RT doses to each substructure in the manual and the automatic delineations were compared. RESULTS In the first validation, a high geometric and dosimetric performance between the automatic and manual delineations was observed for all substructures. The final test confirmed a high agreement between the automatic and manual delineations for the heart (DSC = 0.94) and the cardiac chambers (DSC: 0.75-0.86). The difference in MSD between the automatic and manual delineations was low (<4 mm) in all structures. Finally, a high correlation between mean RT doses for the automatic and the manual delineations was observed for the heart and substructures. CONCLUSIONS An automatic segmentation tool for delineation of the heart and substructures in breast cancer RT was developed and validated with a high correlation between the automatic and manual delineations. The atlas is pivotal for large-scale evaluations of radiation-associated heart disease.
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Affiliation(s)
- Marie Louise H. Milo
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Tine B. Nyeng
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Ebbe L. Lorenzen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Lone Hoffmann
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Denmark
| | - Ditte S. Møller
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Denmark
| | - Birgitte V. Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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12
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Fuglsang Jensen M, Stick LB, Høyer M, Kronborg CJS, Lorenzen EL, Mortensen HR, Nyström PW, Petersen SE, Randers P, Thai LMH, Yates ES, Offersen BV. Proton therapy for early breast cancer patients in the DBCG proton trial: planning, adaptation, and clinical experience from the first 43 patients. Acta Oncol 2022; 61:223-230. [PMID: 34632922 DOI: 10.1080/0284186x.2021.1986229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Danish Breast Cancer Group (DBCG) Proton Trial randomizes breast cancer patients selected on high mean heart dose (MHD) or high lung dose (V20Gy/V17Gy) in the photon plan between photon and proton therapy. This study presents the proton plans and adaptation strategy for the first 43 breast cancer patients treated with protons in Denmark. MATERIAL AND METHODS Forty-four proton plans (one patient with bilateral cancer) were included; 2 local and 42 loco-regional including internal mammary nodes (IMN). Nineteen patients had a mastectomy and 25 a lumpectomy. The prescribed dose was either 50 Gy in 25 fractions (n = 30) or 40 Gy in 15 fractions (n = 14) wherefrom five received simultaneous integrated boost to the tumor bed. Using 2-3 en face proton fields, single-field optimization, robust optimization and a 5 cm range shifter ensured robustness towards breathing motion, setup- and range uncertainties. An anatomical evaluation was performed by evaluating the dose after adding/removing 3 mm and 5 mm tissue to/from the body-outline and used to define treatment tolerances for anatomical changes. RESULTS The nominal and robust criteria were met for all patients except two. The median MHD was 1.5 Gy (0.5-3.4 Gy, 50 Gy) and 1.1 Gy (0.0-1.5 Gy, 40 Gy). The anatomical evaluations showed how 5 mm shrinkage approximately doubled the MHD while 5 mm swelling reduced target coverage of the IMN below constraints. Ensuring 3-5 mm robustness toward swelling was prioritized but not always achieved by robust optimization alone emphasizing the need for a distal margin. Twenty-eight patients received plan adaptation, eight patients received two, and one received five. CONCLUSION This proton planning strategy ensured robust treatment plans within a pre-defined level of acceptable anatomical changes that fulfilled the planning criteria for most of the patients and ensured low MHD.
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Affiliation(s)
| | | | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Petra Witt Nyström
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | | | - Pia Randers
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Linh My Hoang Thai
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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13
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Cui Bono, Proton Radiotherapy? Clin Oncol (R Coll Radiol) 2022; 34:258-260. [DOI: 10.1016/j.clon.2022.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/07/2022] [Accepted: 01/14/2022] [Indexed: 11/19/2022]
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14
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Loap P, De Marzi L, Almeida CE, Barcellini A, Bradley J, de Santis MC, Dendale R, Jimenez R, Orlandi E, Kirova Y. Hadrontherapy techniques for breast cancer. Crit Rev Oncol Hematol 2021; 169:103574. [PMID: 34958916 DOI: 10.1016/j.critrevonc.2021.103574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022] Open
Abstract
Radiotherapy plays a key role in breast cancer treatment, and recent technical advances have been made to improve the therapeutic window by limiting the risk of radiation-induced toxicity or by increasing tumor control. Hadrontherapy is a form a radiotherapy relying on particle beams; compared with photon beams, particle beams have specific physical, radiobiological and immunological properties, which can be valuable in diverse clinical situations. To date, available hadrontherapy techniques for breast cancer irradiation include proton therapy, carbon ion radiation therapy, fast neutron therapy and boron neutron capture therapy. This review analyzes the current rationale and level of evidence for each hadrontherapy technique for breast cancer.
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Affiliation(s)
- Pierre Loap
- Proton Therapy Center, Institut Curie, Orsay, France.
| | | | - Carlos Eduardo Almeida
- Department of Radiological Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Julie Bradley
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | | | - Remi Dendale
- Proton Therapy Center, Institut Curie, Orsay, France
| | - Rachel Jimenez
- Massachusetts General Hospital, Boston, MA, United States
| | - Ester Orlandi
- National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Youlia Kirova
- Proton Therapy Center, Institut Curie, Orsay, France
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15
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Stick LB, Jensen MF, Bentzen SM, Kamby C, Lundgaard AY, Maraldo MV, Offersen BV, Yu J, Vogelius IR. Radiation-Induced Toxicity Risks in Photon Versus Proton Therapy for Synchronous Bilateral Breast Cancer. Int J Part Ther 2021; 8:1-13. [PMID: 35530186 PMCID: PMC9009461 DOI: 10.14338/ijpt-21-00023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study compares photon and proton therapy plans for patients with synchronous bilateral early breast cancer and estimates risks of early and late radiation-induced toxicities. Materials and Methods Twenty-four patients with synchronous bilateral early breast cancer receiving adjuvant radiation therapy using photons, 3-dimensional conformal radiation therapy or volumetric modulated arc therapy, were included and competing pencil beam scanning proton therapy plans were created. Risks of dermatitis, pneumonitis, acute esophageal toxicity, lung and breast fibrosis, hypothyroidism, secondary lung and esophageal cancer and coronary artery events were estimated using published dose-response relationships and normal tissue complication probability (NTCP) models. Results The primary clinical target volume V95% and/or nodal clinical target volume V90% were less than 95% in 17 photon therapy plans and none of the proton plans. Median NTCP of radiation dermatitis ≥ grade 2 was 18.3% (range, 5.4-41.7) with photon therapy and 58.4% (range, 31.4-69.7) with proton therapy. Median excess absolute risk (EAR) of secondary lung cancer at age 80 for current and former smokers was 4.8% (range, 0.0-17.0) using photons and 2.7% (range, 0.0-13.6) using protons. Median EAR of coronary event at age 80, assuming all patients have preexisting cardiac risk factors, was 1.0% (range, 0.0-5.6) with photons and 0.2% (range, 0.0-1.3) with protons. Conclusion Proton therapy plans improved target coverage and reduced risk of coronary artery event and secondary lung cancer while increasing the risk of radiation dermatitis.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren M. Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public, Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claus Kamby
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anni Young Lundgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja Vestmø Maraldo
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Vrou Offersen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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16
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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17
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Thomsen MS, Berg M, Zimmermann S, Lutz CM, Makocki S, Jensen I, Hjelstuen MHB, Pensold S, Hasler MP, Jensen MB, Offersen BV. Dose constraints for whole breast radiation therapy based on the quality assessment of treatment plans in the randomised Danish breast cancer group (DBCG) HYPO trial. Clin Transl Radiat Oncol 2021; 28:118-123. [PMID: 33937532 PMCID: PMC8079332 DOI: 10.1016/j.ctro.2021.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/27/2021] [Accepted: 03/28/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose Quality assessment of the treatment plans in the Danish Breast Cancer Group (DBCG) HYPO trial was carried out based on prospectively reported dosimetric parameters and evidence-based dose constraints for whole breast radiation therapy were derived. Materials and methods From 2009 to 2014, 1882 patients (pts) were randomised between 50 Gy/25fractions (fr) versus 40 Gy/15fr. Doses to CTVp_breast (V95%, V107%-V110%, Dmax, and in addition for 40 Gy plans V105%-V107%), ipsilateral lung (V20Gy/V17Gy), heart (V20Gy/V17Gy, V40Gy/V35Gy), and left anterior descending coronary artery (LADCA) (Dmax) and use of respiratory gated technique were prospectively reported to the DBCG database. After end of accrual, these dosimetric parameters from all plans in the trial were compared to the pre-specified treatment constraints. Results In total, 1854 pts from eight radiation therapy (RT) centres in three countries were treated. No statistically significant differences were found between the results for 40 Gy and 50 Gy plans, except for CTVp_breast hot-spot volume (V107%-V110%). Of the 40 Gy pts, 90% with CTVp_breast > 600 mL and 95% with CTVp_breast ≤ 600 mL had a CTVp_breast hot-spot volume (V105%-V107%) <2%. In 95% of the 50 Gy plans, the CTVp_breast absolute hot-spot volume (V107%-V110%) was <0.5 mL and 1.7 mL for CTVp_breast ≤ 600 mL and > 600 mL, respectively. Compliance was >99% for both heart and lung constraints. Largest deviation from protocol constraints was found for the volume of CTVp_breast covered with 95% of the prescription dose or more (V95%). The CTV dose coverage (V95%) was >94.3% in 95% of the right-sided pts, whereas the figures for 95% of the left-sided pts treated with and without respiratory gating were 93.2% and 88.8%, respectively. Conclusion A high degree of compliance with protocol dose constraints was found for treatment plans in the DBCG HYPO trial. New constraints for dose to organs at risk and high-dose volumes in the breast are suggested for breast-only RT planning.
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Affiliation(s)
- M S Thomsen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - M Berg
- Department of Medical Physics, Lillebaelt Hospital, Vejle, Denmark
| | - S Zimmermann
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - C M Lutz
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - S Makocki
- Dept of Radiation Oncology and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - I Jensen
- Department of Medical Physics, Aalborg University Hospital, Aalborg, Denmark
| | - M H B Hjelstuen
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - S Pensold
- Praxis for Radiotherapy, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany
| | - M P Hasler
- Department of Oncology, Sørlandet Hospital, Kristiansand, Norway
| | - M-B Jensen
- Danish Breast Cancer Cooperative Group, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - B V Offersen
- Department of Experimental Clinical Oncology and Department of Oncology, Aarhus University Hospital, Denmark
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