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Wojcieszek P, Szlag M, Głowacki G, Cholewka A, Gawkowska-Suwińska M, Kellas-Ślęczka S, Białas B, Fijałkowski M. Salvage high-dose-rate brachytherapy for locally recurrent prostate cancer after primary radiotherapy failure. Radiother Oncol 2016; 119:405-10. [PMID: 27165612 DOI: 10.1016/j.radonc.2016.04.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 04/15/2016] [Accepted: 04/20/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate high-dose-rate brachytherapy (HDR BT) as a salvage modality for locally recurrent prostate cancer after primary radiotherapy failure. MATERIALS AND METHODS Eighty-three prostate cancer patients, who locally relapsed after radiotherapy, were treated with salvage HDR BT. The schedule was three implantations, every two weeks, with 10Gy per implant, to a total dose of 30Gy. Acute and late toxicity rates were evaluated. Overall survival (OS) and biochemical control were calculated using Kaplan-Meier method. RESULTS Median follow-up after salvage HDR was 41months. The 3-year and 5-year OS were 93% and 86%, respectively. The 3-year and 5-year biochemical disease-free survival (bDFS) were 76% and 67%, respectively. The single factor associated with biochemical control was time to achieve salvage PSA nadir (p-.006). OS was linked significantly with primary nadir level (p-.001) while primary biochemical relapse interval was of borderline significance (p-.07). CONCLUSIONS Salvage HDR BT is a promising treatment option for patients with localized relapse of previously irradiated prostate cancer. Lower PSA nadir after primary radiotherapy and longer primary disease-free interval influence the outcome.
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Affiliation(s)
- Piotr Wojcieszek
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland.
| | - Marta Szlag
- Radiotherapy and Brachytherapy Treatment Planning Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Grzegorz Głowacki
- Radiotherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Agnieszka Cholewka
- Radiotherapy and Brachytherapy Treatment Planning Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Marzena Gawkowska-Suwińska
- III Department of Radiotherapy and Chemotherapy, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Sylwia Kellas-Ślęczka
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Brygida Białas
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Marek Fijałkowski
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
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Philippou Y, Parker RA, Volanis D, Gnanapragasam VJ. Comparative Oncologic and Toxicity Outcomes of Salvage Radical Prostatectomy Versus Nonsurgical Therapies for Radiorecurrent Prostate Cancer: A Meta-Regression Analysis. Eur Urol Focus 2015; 2:158-171. [PMID: 28723532 DOI: 10.1016/j.euf.2015.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 08/20/2015] [Accepted: 09/08/2015] [Indexed: 01/20/2023]
Abstract
CONTEXT In the absence of randomised controlled trials comparing the oncologic, toxicity, and functional outcomes of salvage radical prostatectomy (SRP), salvage high-intensity focused ultrasound (SHIFU), salvage brachytherapy (SBT), and salvage cryotherapy (SCT), controversy exists as to the optimal salvage modality in radiorecurrent prostate cancer. OBJECTIVE We carried out a meta-regression analysis to determine whether there is a difference in oncologic, toxicity, and functional outcomes using data from original publications of salvage modalities in the postradiation setting. EVIDENCE ACQUISITION We performed a systematic review of PubMed/Medline citations according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. We included 63 articles in the analysis (25 on SRP, 8 on SHIFU, 16 on SCT, 14 on SBT). EVIDENCE SYNTHESIS Median values of the following variables were extracted from each study: patient age, length of follow-up, prostate-specific antigen (PSA) before radiotherapy (RT), PSA before salvage therapy, Gleason score before RT, and time interval between RT and salvage therapy. Functional, toxicity, and oncologic outcomes were measured according to rates of impotence, incontinence, fistula formation, urethral strictures, and biochemical recurrence. Meta-regression adjusting for confounders found no significant difference in oncologic outcomes between SRP and nonsurgical salvage modalities. SBT, SCT, and SHIFU appeared to have better continence outcomes than SRP. No significant difference in toxicity outcomes between modalities was found, although limitations such as reporting, selection, and publication bias and between-study heterogeneity must also be considered with these conclusions. CONCLUSIONS Oncologic outcomes are comparable for SRP and all three nonsurgical salvage modalities. We found no significant differences in toxicity outcomes among modalities; however, SRP appears to be associated with worse rates of urinary incontinence than SBT, SCT, and SHIFU. PATIENT SUMMARY We performed a meta-regression analysis to compare oncologic, functional, and toxicity outcomes between salvage radical prostatectomy and nonsurgical salvage modalities. Oncologic and toxicity outcomes appear to be similar; however, all nonsurgical salvage modalities may be associated with better continence outcomes.
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Affiliation(s)
- Yiannis Philippou
- Department of Surgery, Basildon and Thurrock University Hospital, Essex, UK
| | - Richard A Parker
- Health Services Research Unit University of Edinburgh, Edinburgh, UK
| | - Dimitrios Volanis
- Department of Urology, Addenbrooke's University Hospital, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Addenbrooke's University Hospital, Cambridge, UK; Academic Urology Group, Department of Surgery and Oncology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
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3
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Parekh A, Graham PL, Nguyen PL. Cancer Control and Complications of Salvage Local Therapy After Failure of Radiotherapy for Prostate Cancer: A Systematic Review. Semin Radiat Oncol 2013; 23:222-34. [DOI: 10.1016/j.semradonc.2013.01.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Peters M, Moman MR, van der Poel HG, Vergunst H, de Jong IJ, Vijverberg PLM, Battermann JJ, Horenblas S, van Vulpen M. Patterns of outcome and toxicity after salvage prostatectomy, salvage cryosurgery and salvage brachytherapy for prostate cancer recurrences after radiation therapy: a multi-center experience and literature review. World J Urol 2012; 31:403-9. [PMID: 22903773 DOI: 10.1007/s00345-012-0928-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 07/27/2012] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Current salvage treatments for recurrent prostate cancer after primary radiation therapy include radical prostatectomy, cryosurgery and brachytherapy. Because toxicity and failure rates are considerable, salvage treatments are not commonly performed. As most centers perform only one preferred salvage technique, the literature only describes single-center outcomes from a single salvage technique with a limited number of patients. In this overview, five high-volume Dutch centers describe their toxicity and outcome data using different salvage techniques. This provides a view on how salvage is performed in clinical practice in The Netherlands. METHODS A total of 129 patients from five different centers in the Netherlands were retrospectively analyzed. Biochemical failure (BF) was defined as PSA >0.1 ng/ml for the salvage prostatectomy group (n = 44) and PSA nadir + 2.0 ng/ml (Phoenix definition) for the salvage cryosurgery (n = 54) and salvage brachytherapy group (n = 31). Toxicity was scored according to the Common Toxicity Criteria for Adverse events (CTCAE v3.0). RESULTS BF occurred in 25 (81%) patients in the brachytherapy group (mean follow-up 29 ± 24 months), 29 (66%) patients in the prostatectomy group (mean follow-up 22 ± 25 months) and 33 (61%) patients in the cryosurgery group (mean follow-up 14 ± 11 months). Severe (grade >3) genitourinary and gastrointestinal toxicity was observed in up to 30% of patients in all three groups. CONCLUSION This overview shows clinical practice of prostate cancer salvage. Significant failure and toxicity rates are observed, regardless of salvage technique. Patients should be selected with great care before offering these salvage treatment strategies.
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Affiliation(s)
- Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Abstract
Many management options are available to patients with newly diagnosed prostate cancer. Magnetic resonance (MR) imaging plays an important role in initial staging of prostate cancer, but it also aids in tumor detection when there is clinical or biochemical suspicion of residual or recurrent disease after treatment. The purpose of this review is to describe the normal appearances of the prostatic region after different kinds of treatment for prostate cancer and to discuss how these appearances differ from those of recurrent and residual disease. Several MR imaging techniques used in evaluating patients with prostate cancer are described, including conventional MR imaging sequences (mainly T1- and T2-weighted sequences), MR spectroscopic imaging, diffusion-weighted imaging, and dynamic contrast agent-enhanced MR imaging. Clinical considerations, together with the different approaches for interpreting serum prostate-specific antigen values in the posttreatment setting, are also presented. All forms of treatment alter the MR imaging features of the prostatic region to a greater or lesser extent, and it is important to be able to recognize expected posttreatment appearances and distinguish them from the features of recurrent or residual cancer to aid subsequent clinical management.
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Affiliation(s)
- Hebert Alberto Vargas
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Radiology Academic Offices, New York, NY 10065, USA.
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6
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Paparel P, Soulie M, Mongiat-Artus P, Cornud F, Borgogno C. Prostatectomie de rattrapage après échec de radiothérapie externe pour cancer de la prostate localisé : enquête de pratique, indications, morbidité et résultats. Travail du CCAFU sous-comité prostate. Prog Urol 2010; 20:317-26. [DOI: 10.1016/j.purol.2009.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 11/05/2009] [Indexed: 10/20/2022]
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7
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Management of prostate cancer recurrence after definitive radiation therapy. Cancer Treat Rev 2010; 36:91-100. [DOI: 10.1016/j.ctrv.2009.06.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 06/08/2009] [Accepted: 06/21/2009] [Indexed: 11/18/2022]
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8
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Montironi R, Cheng L, Lopez-Beltran A, Mazzucchelli R, Scarpelli M, Kirkali Z, Montorsi F. Joint Appraisal of the Radical Prostatectomy Specimen by the Urologist and the Uropathologist: Together, We Can Do It Better. Eur Urol 2009; 56:951-5. [DOI: 10.1016/j.eururo.2009.08.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 08/18/2009] [Indexed: 12/24/2022]
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9
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van Vulpen M, van den Berg CAT, Moman MR, van der Heide UA. Difficulties and potential of correlating local recurrences in prostate cancer with the delivered local dose. Radiother Oncol 2009; 93:180-4. [PMID: 19700213 DOI: 10.1016/j.radonc.2009.06.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 04/19/2009] [Accepted: 06/28/2009] [Indexed: 10/20/2022]
Abstract
In the previous decades the distinction between a local relapse and distant metastases was difficult to accomplish in an early stage. As a consequence, a failure could only be coarsely related to the original radiotherapy treatment. Currently, due to better imaging and position verification techniques, the actual dose within the prostate can be estimated, taking position uncertainties into account. Furthermore, advanced functional MRI techniques, such as MR spectroscopy (MRS) and dynamic contrast-enhanced MRI (DCE-MRI), increase the chance of localizing a local recurrence within the prostate. With this information the correlation between the actual previously delivered dose and a local relapse can be established, using non-rigid registration of the planning CT and the post-recurrence MRI. The current study describes the possibilities and problems in obtaining this correlation. This serves as a framework for investigating a reliable dose effect relationship in the future.
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Affiliation(s)
- Marco van Vulpen
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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10
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Oncologic Outcome and Patterns of Recurrence after Salvage Radical Prostatectomy. Eur Urol 2009; 55:404-10. [DOI: 10.1016/j.eururo.2008.07.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Accepted: 07/03/2008] [Indexed: 11/19/2022]
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11
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Editorial Comment on: Oncologic Outcome and Patterns of Recurrence after Salvage Radical Prostatectomy. Eur Urol 2009; 55:410-1. [DOI: 10.1016/j.eururo.2008.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Salvage HIFU for recurrent prostate cancer after radiotherapy. Prostate Cancer Prostatic Dis 2008; 12:124-9. [DOI: 10.1038/pcan.2008.53] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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13
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Zacharakis E, Ahmed HU, Ishaq A, Scott R, Illing R, Freeman A, Allen C, Emberton M. The feasibility and safety of high-intensity focused ultrasound as salvage therapy for recurrent prostate cancer following external beam radiotherapy. BJU Int 2008; 102:786-92. [DOI: 10.1111/j.1464-410x.2008.07775.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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van der Poel H, Moonen L, Horenblas S. Sequential treatment for recurrent localized prostate cancer. J Surg Oncol 2008; 97:377-82. [DOI: 10.1002/jso.20967] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Nguyen PL, D'Amico AV, Lee AK, Suh WW. Patient selection, cancer control, and complications after salvage local therapy for postradiation prostate-specific antigen failure. Cancer 2007; 110:1417-28. [PMID: 17694553 DOI: 10.1002/cncr.22941] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Among men who experience prostate-specific antigen (PSA) failure after external beam radiation or brachytherapy (RT), many will harbor occult micrometastases; however, a significant minority will have a true local-only failure and, thus, potentially may benefit from a salvage local therapy. Those most likely to have a local-only failure initially have low-risk disease (PSA < 10 ng/mL, Gleason score < or =6, clinical T1c or T2a tumor status), pretreatment PSA velocity < 2.0 ng/mL per year at the time of initial presentation, interval to PSA failure > 3 years, PSA doubling time > 12 months, negative bone scan and pelvic imaging, and positive rebiopsy. In addition, men with presalvage PSA levels > 10 ng/mL, presalvage T3/T4 disease, or presalvage Gleason scores > or =7 on a rebiopsy sample without significant RT effects are unlikely to be cured by salvage local therapy. Based on a review of all series of post-RT salvage prostatectomy, cryosurgery, and brachytherapy published in English since 1990, morbidity can be substantial. Although urinary incontinence appeared to be greater after salvage prostatectomy (41%) or cryosurgery (36%) than after brachytherapy (6%), patients who received salvage brachytherapy faced a 17% risk of grade 3 or 4 genitourinary complications and a fistula risk that averaged 3.4% across all series. From this review, the authors concluded that prospective randomized studies are needed to determine the relative efficacy of the 3 major local salvage modalities and that additional research is needed to identify factors associated with an increased risk of significant complications to improve patient selection and to augment the benefit/risk ratio associated with attempts to cure local-only recurrences after radiation therapy.
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Affiliation(s)
- Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA.
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16
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Nguyen PL, Chen MH, D'Amico AV, Tempany CM, Steele GS, Albert M, Cormack RA, Carr-Locke DL, Bleday R, Suh WW. Magnetic resonance image-guided salvage brachytherapy after radiation in select men who initially presented with favorable-risk prostate cancer. Cancer 2007; 110:1485-92. [PMID: 17701957 DOI: 10.1002/cncr.22934] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The authors prospectively evaluated the late gastrointestinal (GI) and genitourinary (GU) toxicity and prostate-specific antigen (PSA) control of magnetic resonance imaging (MRI)-guided brachytherapy used as salvage for radiation therapy (RT) failure. METHODS From October 2000 to October 2005, 25 men with a rising PSA level and biopsy-proven, intraprostatic cancer at least 2 years after initial RT (external beam in 13 men and brachytherapy in 12 men) who had favorable clinical features (Gleason score < or =7, PSA < 10 ng/mL, negative pelvic and bone imaging studies), received MRI-guided salvage brachytherapy to a minimum peripheral dose of 137 gray on a phase 1/2 protocol. Estimates of toxicity and cancer control were calculated using the Kaplan-Meier method. RESULTS The median follow-up was 47 months. The 4-year estimate of grade 3 or 4 GI or GU toxicity was 30%, and 13% of patients required a colostomy and/or urostomy to repair a fistula. An interval < 4.5 years between RT courses was associated with both outcomes with a hazard ratio of 12 (95% confidence interval [95% CI], 1.4-100; P = .02) for grade 3 or 4 toxicity and 25 (95% CI, 1.1-529; P = .04) for colostomy and/or urostomy. PSA control (nadir +2 definition) was 70% at 4 years. CONCLUSIONS The current results indicated that MRI-guided salvage brachytherapy in men who are selected based on presenting characteristics and post-failure PSA kinetics can achieve high PSA control rates, although complications requiring surgical intervention may occur in 10% to 15% of patients. Prospective randomized studies are needed to characterize the relative cancer control and toxicity after all forms of salvage local therapy.
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Affiliation(s)
- Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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