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Maccauro M, Cuomo M, Bauckneht M, Bagnalasta M, Mazzaglia S, Scalorbi F, Argiroffi G, Kirienko M, Lorenzoni A, Aliberti G, Pusceddu S, Giuseppina C, Matteo GE, Seregni E, Chiesa C. The LUTADOSE trial: tumour dosimetry after the first administration predicts progression free survival in gastro-entero-pancreatic neuroendocrine tumours (GEP NETs) patients treated with [ 177Lu]Lu-DOTATATE. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06863-y. [PMID: 39235614 DOI: 10.1007/s00259-024-06863-y] [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: 12/19/2023] [Accepted: 07/26/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE In Peptide Receptor Radionuclide Therapy (PRRT) with [177Lu]Lu-DOTATATE of gastro-entero-pancreatic neuroendocrine tumours (GEP NETs) a question remains open about the potential benefits of personalised dosimetry. This observational prospective study examines the association of individualized dosimetry with progression free survival (PFS) in G1-G2 GEP NETs patients following the standard [177Lu]Lu-DOTATATE therapeutic regimen. METHODS The analysis was conducted on 42 patients administered 4 times, and on 165 lesions. Dosimetry was performed after the first and the forth cycle, with two SPECT/CT scans at day 1 and 7 after administration. Global mean Tumour absorbed Dose of each patient (GTD) was calculated after cycle 1 and 4 as the sum of lesion doses weighted by lesion mass, normalized by the global tumour mass. Cumulative GTD_TOT was calculated as the mean between cycle 1 (GTD_1) and 4 (GTD_4) multiplied by 4. Patients were followed-up for median 32.8 (range 18-45.5) months, through blood tests and contrast enhanced CT (ceCT). This study assessed the correlation between global tumour dose (GTD) and PFS longer or shorter than 24 months. After a ROC analysis, we stratified patients according to the best cut-off value for two additional statistical analyses. At last a multivariate analysis was carried out for PFS > / < 24 months. RESULTS The median follow-up interval was 33 months, ranging from 18 to 45.5 months. The median PFS was 42 months. The progression free survival rate at 20 months was 90.5%. GTD_1 and GTD_TOT were statistically associated with PFS > / < 24 m (p = 0.026 and p = 0.03 respectively). The stratification of patients on GTD_1 lower or higher than the best cut-off value at 10.6 Gy provided significantly different median PFS of 21 months versus non reached, i.e. longer than 45.5 months (p = 0.004), with a hazard ratio of 8.6, (95% C.I.: [2 - 37]). Using GTD_TOT with the best cut-off at 43 Gy, the same PFS values were obtained as after cycle 1 (p = 0.035). At multivariate analysis, a decrease in GTD_1 and, with lower impact, a higher global tumour volume were significantly associated with PFS < 24 months. We calculated the Tumour Control Probability of obtaining PFS > 24 months as a function of GTD_1. DISCUSSION Several statistical analyses seem to confirm that simple tumour dosimetry with 2 SPECT/CT scans after the first administration allows to predict PFS values after 4 × 7.4 GBq administrations of 177Lu[Lu]-DOTATATE in G1-G2 GEP NETs. This result qualitatively confirms recent findings by a Belgian and a French study. However, dosimetric thresholds are different. This probably comes from different cohort baseline characteristics, since the median PFS in our study (42 m) was longer than in the other studies (28 m and 31 m). CONCLUSION Tumour dosimetry after the first administration of [177Lu]Lu-DOTATATE offers an important prognostic value in the clinical decision-making process, especially for the future as alternative emitters or administration schedule may become available.
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Affiliation(s)
- Marco Maccauro
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Mariarosaria Cuomo
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Matteo Bauckneht
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genova, Genoa, Italy
| | - Matteo Bagnalasta
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Stefania Mazzaglia
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Federica Scalorbi
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giovanni Argiroffi
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Margarita Kirienko
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Alice Lorenzoni
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Gianluca Aliberti
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Sara Pusceddu
- Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | | | - Ettore Seregni
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Carlo Chiesa
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
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Flux G, Gleisner KS, Bardies M. Physics for molecular radiotherapy - The battle between science and simplicity. Phys Med 2024; 124:103413. [PMID: 38880679 DOI: 10.1016/j.ejmp.2024.103413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Affiliation(s)
- Glenn Flux
- Joint Dept of Physics, Royal Marsden Hospital & Institute of Cancer Research, Sutton, UK.
| | | | - Manuel Bardies
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France; Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
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Karimzadeh A, Schatz L, Sauer M, Apostolova I, Buchert R, Klutmann S, Lehnert W. Organ and tumor dosimetry including method simplification for [ 177Lu]Lu-PSMA-I&T for treatment of metastatic castration resistant prostate cancer. EJNMMI Phys 2024; 11:63. [PMID: 39017988 PMCID: PMC11255161 DOI: 10.1186/s40658-024-00668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 07/05/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Internal dosimetry in individual patients is essential for safe and effective radioligand therapy. Multiple time point imaging for accurate dosimetry is time consuming and hence can be demanding for nuclear medicine departments as well as patients. The objectives of this study were (1) to assess absorbed doses to organs at risk and tumor lesions for [177Lu]Lu-PSMA-I&T using whole body SPECT imaging and (2) to investigate possible simplified dosimetry protocols. METHODS This study included 16 patients each treated with 4 cycles of [177Lu]Lu-PSMA-I&T. They underwent quantitative whole body SPECT/CT imaging (3 bed positions) at four time points (TP) comprising 2 h, 24 h, 48 h and 72-168 h post-injection (p.i.). Full 3D dosimetry (reference method) was performed for all patients and dose cycles for organs at risk (kidneys, parotid glands and submandibular glands) and up to ten tumor lesions per patient (resulting in 90 lesions overall). The simplified dosimetry methods (SM) included (1) generating time activity curves for subsequent cycles using a single TP of imaging applying the kinetics of dose cycle 1, and for organs at risk also (2) simple extrapolation from dose cycle 1 and (3) from both, dose cycle 1 and 2. RESULTS Normalized absorbed doses were 0.71 ± 0.32 mGy/MBq, 0.28 ± 0.12 mGy/MBq and 0.22 ± 0.08 mGy/MBq for kidneys, parotid glands and submandibular glands, respectively. Tumor doses decreased from 3.86 ± 3.38 mGy/MBq in dose cycle 1 to 2.01 ± 2.65 mGy/MBq in dose cycle 4. Compared to the full dosimetry approach the SM 1 using single TP imaging at 48 h p.i. resulted in the most accurate and precise results for the organs at risk in terms of absorbed doses per cycle and total cumulated dose. For tumor lesions better results were achieved using the fourth TP (≥ 72 h p.i.). CONCLUSION Simplification of safety dosimetry protocols is possible for [177Lu]Lu-PSMA-I&T therapy. If tumor dosimetry is of interest a later imaging TP (≥ 72 h p.i.) should be used/added to account for the slower kinetics of tumors compared to organs at risk.
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Affiliation(s)
- Amir Karimzadeh
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Linus Schatz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Markus Sauer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ivayla Apostolova
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ralph Buchert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Susanne Klutmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Wencke Lehnert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Turner JH. Theranostics: Timing is Everything. Cancer Biother Radiopharm 2024. [PMID: 38757676 DOI: 10.1089/cbr.2024.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
On stage, and in real life, timing is critical for success. Theranostic cancer care epitomizes the central role of timing in the evolution of efficacious molecular targeted radioligand therapy and its incorporation into routine clinical practice of oncology. Nuclear medicine has returned to its therapeutic roots, having been founded as a medical specialty, over three-quarters of a century ago, with radioiodine therapy of thyroid cancer. The very recent oncologist acceptance of 68Ga/177Lu/225Ac-PSMA effectiveness in treating prostate cancer has re-established the role of the physician in nuclear medicine. This article addresses various important issues in respect of timing related to this resurgence. Training of the required new workforce in technical -omics expertise and physicianly virtues is an urgent priority. Precision in radioligand therapy requires definition of individual radiation absorbed dose (Gy) to tumor and to critical normal organs, preferably prospectively. It is time to abandon one-size-fits-all administration of fixed activities (GBq) in arbitrary cycle intervals and duration. The time has also come to design combination sequenced theranostic-immuno-chemotherapeutic approaches to metastatic cancer to address unmet needs, particularly in pancreatic carcinoma; exploiting the potential of new fibroblast activation protein inhibitor radioligands targeting the tumor microenvironment. Public perception of all things "nuclear," including nuclear medicine, has recently recovered from the general opprobrium and radiophobia of the last half-century. Nuclear is the new green. At last, there have arisen propitious circumstances for the future development of theranostics: The timing is right, now.
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Affiliation(s)
- J Harvey Turner
- Department of Nuclear Medicine, Fiona Stanley Fremantle Hospitals Group, The University of Western Australia, Murdoch, Australia
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Bardiès M, Gabiña PM, Flux G, Platoni P, Koutsouveli E. Symposium on molecular radiotherapy dosimetry: The first of a series? Phys Med 2024; 120:103328. [PMID: 38498956 DOI: 10.1016/j.ejmp.2024.103328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
The EFOMP Special Interest Group for Radionuclide Internal Dosimetry (SIG_FRID) organised its first scientific meeting, the Symposium on Molecular Radiotherapy Dosimetry, in Athens on November 9th-11th 2023. The Symposium was hosted by the Hellenic Association of Medical Physicists and the National and Kapodistrian University of Athens. This meeting gathered more than 180 scientists from 28 countries. Scientific, clinical and regulatory aspects were addressed by 8 invited experts. Two continuous professional development sessions were organised. A special round table gathering medical physics experts, physicians regulatory authority experts and patient representatives addressed the possibilities to increase clinical dosimetry dissemination. The event was supported by companies and a specific industry session allowed sponsors to present their products, innovations and future perspective in this field.
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Affiliation(s)
- Manuel Bardiès
- IRCM, UMR 1194 INSERM, Université de Montpellier and Institut Régional du Cancer de Montpellier (ICM), France & Département de Médecine Nucléaire, Institut Régional du Cancer de Montpellier (ICM), France.
| | - Pablo Minguez Gabiña
- Department of Medical Physics and Radiation Protection, Gurutzeta-Cruces University Hospital /Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Glenn Flux
- Joint Department of Physics, Royal Marsden Hospital and Institute of Cancer Research, Sutton, Surrey, UK
| | - Pola Platoni
- Medical School, National and Kapodistrian University of Athens, 2nd Departement of Radiology, "Attikon" University General Hospital, Athens, Greece
| | - Efi Koutsouveli
- Department of Medical Physics, Hygeia Hospital, Athens, Greece
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Dieudonné A, Bailly C, Cachin F, Edet-Sanson A, Kraeber-Bodéré F, Hapdey S, Merlin C, Robin P, Salaun PY, Schwartz P, Tonnelet D, Vera P, Courbon F, Carlier T. Dosimetry for targeted radionuclide therapy in routine clinical practice: experts advice vs. clinical evidence. Eur J Nucl Med Mol Imaging 2024; 51:947-950. [PMID: 38110711 PMCID: PMC10881593 DOI: 10.1007/s00259-023-06568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Affiliation(s)
- Arnaud Dieudonné
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France.
- Service de Médecine Nucléaire, Centre Henri Becquerel, 76000, Rouen, France.
| | - Clément Bailly
- Department of Nuclear Medicine, University Hospital, Nantes, France
| | - Florent Cachin
- Department of Nuclear Medicine, Jean Perrin Cancer Center, Clermont-Ferrand, France
| | - Agathe Edet-Sanson
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | | | - Sébastien Hapdey
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | - Charles Merlin
- Department of Nuclear Medicine, Jean Perrin Cancer Center, Clermont-Ferrand, France
| | - Philippe Robin
- Department of Nuclear Medicine, University Hospital, Brest, France
| | | | - Paul Schwartz
- Department of Nuclear Medicine, University Hospital, Bordeaux, France
| | - David Tonnelet
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | - Pierre Vera
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | - Frédéric Courbon
- Department of Medical Imaging, Institut Universitaire du Cancer Toulouse - Oncopole, Toulouse, France
| | - Thomas Carlier
- Department of Nuclear Medicine, University Hospital, Nantes, France
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Peters S, Tran-Gia J, Agius S, Ivashchenko OV, Badel JN, Cremonesi M, Kurth J, Gabiña PM, Richetta E, Gleisner KS, Tipping J, Bardiès M, Stokke C. Implementation of dosimetry for molecular radiotherapy; results from a European survey. Phys Med 2024; 117:103196. [PMID: 38104033 DOI: 10.1016/j.ejmp.2023.103196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/13/2023] [Accepted: 12/07/2023] [Indexed: 12/19/2023] Open
Abstract
PURPOSE The use of molecular radiotherapy (MRT) has been rapidly evolving over the last years. The aim of this study was to assess the current implementation of dosimetry for MRTs in Europe. METHODS A web-based questionnaire was open for treating centres between April and June 2022, and focused on 2020-2022. Questions addressed the application of 16 different MRTs, the availability and involvement of medical physicists, software used, quality assurance, as well as the target regions for dosimetry, whether treatment planning and/or verification were performed, and the dosimetric methods used. RESULTS A total of 173 responses suitable for analysis was received from centres performing MRT, geographically distributed over 27 European countries. Of these, 146 centres (84 %) indicated to perform some form of dosimetry, and 97 % of these centres had a medical physicist available and almost always involved in dosimetry. The most common MRTs were 131I-based treatments for thyroid diseases and thyroid cancer, and [223Ra]RaCl2 for bone metastases. The implementation of dosimetry varied widely between therapies, from almost all centres performing dosimetry-based planning for microsphere treatments to none for some of the less common treatments (like 32P sodium-phosphate for myeloproliferative disease and [89Sr]SrCl2 for bone metastases). CONCLUSIONS Over the last years, implementation of dosimetry, both for pre-therapeutic treatment planning and post-therapy absorbed dose verification, increased for several treatments, especially for microsphere treatments. For other treatments that have moved from research to clinical routine, the use of dosimetry decreased in recent years. However, there are still large differences both across and within countries.
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Affiliation(s)
- Steffie Peters
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Sam Agius
- Medical Imaging Department and Radioisotope Unit, Mater Dei Hospital, Msida, Malta
| | - Oleksandra V Ivashchenko
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Jean Noël Badel
- Centre de Lutte Contre le Cancer Léon-Bérard, CREATIS CNRS UMR 5220 INSERM U 1044, Université de Lyon, INSA-Lyon, Lyon, France
| | - Marta Cremonesi
- Unit of Radiation Research, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Jens Kurth
- Department of Nuclear Medicine, Rostock University Medical Center, Rostock, Germany
| | - Pablo Minguez Gabiña
- Department of Medical Physics and Radiation Protection, Gurutzeta-Cruces University Hospital/Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Elisa Richetta
- Medical Physics Department, AO Ordine Mauriziano, Turin, Italy
| | | | - Jill Tipping
- The Christie NHS Foundation Trust, Nuclear Medicine, Manchester, UK
| | - Manuel Bardiès
- IRCM, UMR 1194 INSERM, Université de Montpellier and Institut Régional du Cancer de Montpellier (ICM), France & Département de Médecine Nucléaire, Institut Régional du Cancer de Montpellier (ICM), France
| | - Caroline Stokke
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway.
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Cicone F, Sjögreen Gleisner K, Sarnelli A, Indovina L, Gear J, Gnesin S, Kraeber-Bodéré F, Bischof Delaloye A, Valentini V, Cremonesi M. The contest between internal and external-beam dosimetry: The Zeno's paradox of Achilles and the tortoise. Phys Med 2024; 117:103188. [PMID: 38042710 DOI: 10.1016/j.ejmp.2023.103188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/06/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023] Open
Abstract
Radionuclide therapy, also called molecular radiotherapy (MRT), has come of age, with several novel radiopharmaceuticals being approved for clinical use or under development in the last decade. External beam radiotherapy (EBRT) is a well-established treatment modality, with about half of all oncologic patients expected to receive at least one external radiation treatment over their disease course. The efficacy and the toxicity of both types of treatment rely on the interaction of radiation with biological tissues. Dosimetry played a fundamental role in the scientific and technological evolution of EBRT, and absorbed doses to the target and to the organs at risk are calculated on a routine basis. In contrast, in MRT the usefulness of internal dosimetry has long been questioned, and a structured path to include absorbed dose calculation is missing. However, following a similar route of development as EBRT, MRT treatments could probably be optimized in a significant proportion of patients, likely based on dosimetry and radiobiology. In the present paper we describe the differences and the similarities between internal and external-beam dosimetry in the context of radiation treatments, and we retrace the main stages of their development over the last decades.
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Affiliation(s)
- Francesco Cicone
- Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy; Nuclear Medicine Unit, "Mater Domini" University Hospital, Catanzaro, Italy.
| | | | - Anna Sarnelli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Luca Indovina
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Jonathan Gear
- Joint Department of Physics, Royal Marsden NHSFT & Institute of Cancer Research, Sutton, UK
| | - Silvano Gnesin
- Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland; University of Lausanne, Lausanne, Switzerland
| | - Françoise Kraeber-Bodéré
- Nantes Université, Université Angers, CHU Nantes, INSERM, CNRS, CRCI2NA, Médecine Nucléaire, F-44000 Nantes, France
| | | | - Vincenzo Valentini
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marta Cremonesi
- Unit of Radiation Research, IEO, European Institute of Oncology IRCCS, Milan, Italy
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