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Fabian A, Domschikowski J, Letsch A, Schmalz C, Freitag-Wolf S, Dunst J, Krug D. Use and Reporting of Patient-Reported Outcomes in Trials of Palliative Radiotherapy: A Systematic Review. JAMA Netw Open 2022; 5:e2231930. [PMID: 36136335 PMCID: PMC9500555 DOI: 10.1001/jamanetworkopen.2022.31930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Approximately 50% of all patients with cancer have an indication for radiotherapy, and approximately 50% of radiotherapy is delivered with palliative intent, with the aim of alleviating symptoms. Symptoms are best assessed by patient-reported outcomes (PROs), yet their reliable interpretation requires adequate reporting in publications. OBJECTIVE To investigate the use and reporting of PROs in clinical trials of palliative radiotherapy. EVIDENCE REVIEW This preregistered systematic review searched PubMed/Medline, EMBASE, and the Cochrane Center Register of Controlled Trials for clinical trials of palliative radiotherapy published from 1990 to 2020. Key eligibility criteria were palliative setting, palliative radiotherapy as treatment modality, and clinical trial design (per National Institutes of Health definition). Two authors independently assessed eligibility. Trial characteristics were extracted and standard of PRO reporting was assessed in adherence to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. The association of the year of publication with the use of PROs was assessed by logistic regression. Factors associated with higher CONSORT-PRO adherence were analyzed by multiple regression. This study is reported following the PRISMA guidelines. FINDINGS Among 7377 records screened, 225 published clinical trials representing 24 281 patients were eligible. Of these, 45 trials (20%) used a PRO as a primary end point and 71 trials (31%) used a PRO as a secondary end point. The most prevalent PRO measures were the Numeric Rating Scale/Visual Analogue Scale (38 trials), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire C30 (32 trials), and trial-specific unvalidated measures (25 trials). A more recent year of publication was significantly associated with a higher chance of PROs as a secondary end point (odds ratio [OR], 1.04 [95% CI, 1.00-1.07]; P = .03) but not as primary end point. Adherence to CONSORT-PRO was poor or moderate for most items. Mean (SD) adherence to the extension adherence score was 46.2% (19.6%) for trials with PROs as primary end point and 31.8% (19.8%) for trials with PROs as a secondary end point. PROs as a primary end point (regression coefficient, 9.755 [95% CI, 2.270-17.240]; P = .01), brachytherapy as radiotherapy modality (regression coefficient, 16.795 [95% CI, 5.840-27.751]; P = .003), and larger sample size (regression coefficient, 0.028 [95% CI, 0.006-0.049]; P = .01) were significantly associated with better PRO reporting per extension adherence score. CONCLUSIONS AND RELEVANCE In this systematic review of palliative radiotherapy trials, the use and reporting of PROs had room for improvement for future trials, preferably with PROs as a primary end point.
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Affiliation(s)
- Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Justus Domschikowski
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anne Letsch
- Department of Haematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Juergen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
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Ferro M, Deodato F, Ferro M, Panza G, Buwenge M, Pezzulla D, Cilla S, Boccardi M, Romano C, Arcelli A, Cammelli S, Zamagni A, Morganti AG, Macchia G. A SHort course Accelerated RadiatiON therapy (SHARON) dose-escalation trial in older adults head and neck non-melanoma skin cancer. Br J Radiol 2022; 95:20211347. [PMID: 35451856 PMCID: PMC10996410 DOI: 10.1259/bjr.20211347] [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: 12/05/2021] [Revised: 02/01/2022] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To assess feasibility and safety of a SHort-course Accelerated RadiatiON therapy (SHARON) regimen, in the treatment of non-melanoma skin cancers (NMSC) in older patients. METHODS Old patients (age ≥ 80 years) with histological confirmed non-melanoma skin cancers were enrolled. The primary endpoint was to determine the maximum tolerated dose (MTD). Radiotherapy regimen was based on the delivery of four radiotherapy fractions (5 Gy per fraction) with a twice daily fractionation in two consecutive days. Three different level of dose were administered: 20 Gy (one cycle), 40 Gy (two cycles) and 60 Gy (three cycles). RESULTS Thirty patients (median age: 91 years; range: 80-96) were included in this analysis. Among fourteen patients who completed the one cycle, only one (7%) experimented acute G4 skin toxicity. Twelve patients reported an improvement or resolution of baseline symptoms (overall palliative response rate: 85.8%). Nine and seven patients underwent to two and three RT cycles, respectively: of these, no G3 toxicities were recorded. The overall response rate was 100% when three cycles were delivered. The overall six-month symptom-free survival was 78.7% and 77.8% in patients treated with one course and more courses, respectively. CONCLUSIONS Short-course accelerated radiotherapy in older patients with non-melanoma skin cancers is well tolerated. High doses seem to be more effective in terms of response rate. ADVANCES IN KNOWLEDGE This approach could represent an option for older adults with NMSC, being both palliative (one course) or potentially curative (more courses) in the aim, accordingly to the patient's condition.
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Affiliation(s)
- Milena Ferro
- Radiation Oncology Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
- Istituto di Radiologia, Università Cattolica del Sacro
Cuore, Rome,
Italy
| | - Marica Ferro
- Radiation Oncology Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
| | - Giulia Panza
- Università Cattolica del Sacro Cuore,
Rome, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di
Bologna, Bologna,
Italy
- Department of Experimental, Diagnostic, and Specialty Medicine
- DIMES, Alma Mater Studiorum Bologna University,
Bologna, Italy
| | - Donato Pezzulla
- Radiation Oncology Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
| | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
| | - Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di
Bologna, Bologna,
Italy
- Department of Experimental, Diagnostic, and Specialty Medicine
- DIMES, Alma Mater Studiorum Bologna University,
Bologna, Italy
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di
Bologna, Bologna,
Italy
- Department of Experimental, Diagnostic, and Specialty Medicine
- DIMES, Alma Mater Studiorum Bologna University,
Bologna, Italy
| | - Alice Zamagni
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di
Bologna, Bologna,
Italy
- Department of Experimental, Diagnostic, and Specialty Medicine
- DIMES, Alma Mater Studiorum Bologna University,
Bologna, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di
Bologna, Bologna,
Italy
- Department of Experimental, Diagnostic, and Specialty Medicine
- DIMES, Alma Mater Studiorum Bologna University,
Bologna, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital,
Università Cattolica del Sacro Cuore,
Campobasso, Italy
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Morganti AG, Macchia G, Cellini F, Deodato F, Zamagni A, Siepe G, Buwenge M. A "SHort course Accelerated RadiatiON therapy" (SHARON) During and Beyond the COVID-19 Pandemic. Front Oncol 2022; 12:823445. [PMID: 35280809 PMCID: PMC8904873 DOI: 10.3389/fonc.2022.823445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Alessio G Morganti
- Radiation Oncology, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy.,Dipartimento di Medicina Specialistica Diagnostica e Sperimentale (DIMES), Alma Mater Studiorum - Bologna University, Bologna, Italy
| | - Gabriella Macchia
- Gemelli Molise Hospital, Radiotherapy Unit, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Deodato
- Gemelli Molise Hospital, Radiotherapy Unit, Università Cattolica del Sacro Cuore, Campobasso, Italy.,Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alice Zamagni
- Dipartimento di Medicina Specialistica Diagnostica e Sperimentale (DIMES), Alma Mater Studiorum - Bologna University, Bologna, Italy
| | - Giambattista Siepe
- Radiation Oncology, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy
| | - Milly Buwenge
- Radiation Oncology, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy.,Dipartimento di Medicina Specialistica Diagnostica e Sperimentale (DIMES), Alma Mater Studiorum - Bologna University, Bologna, Italy
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Deressa BT, Tigeneh W, Bogale N, Buwenge M, Morganti AG, Farina E. Short-Course 2-Dimensional Radiation Therapy in the Palliative Treatment of Esophageal Cancer in a Developing Country: A Phase II Study (Sharon Project). Int J Radiat Oncol Biol Phys 2019; 106:67-72. [PMID: 31622698 DOI: 10.1016/j.ijrobp.2019.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/29/2019] [Accepted: 10/03/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Patients with locally advanced and metastatic esophageal cancer are usually affected by cancer-related symptoms, which worsen their performance status and quality of life. The aim of this study was to determine the efficacy of short-course accelerated radiation therapy for symptomatic palliation in a low resourced setting where only a 2-dimensional radiation therapy (RT) technique was available. METHODS AND MATERIALS A phase II trial based on Simon's 2-stage design was planned. A total dose of 12 Gy in 4 fractions, twice per day, over 2 days, ≥8 hours apart, using a 2-dimensional conventional RT technique was delivered with a Cobalt 60 unit (Equinox, Best Theratronics, Ottawa, Ontario). Symptoms were graded using the International Atomic Energy Agency scoring system. RESULTS A total of 17 patients were treated (male/female = 10/7; median age, 50.0 years; range, 27-78 years; histology: 6 adenocarcinomas and 11 squamous cell carcinomas; tumor site: 4 gastresophageal junction and 13 esophagus). The most frequent baseline symptoms were dysphagia or regurgitation (100%), odynophagia (76%), and chest or back pain (53%). At 1 month after RT, all patients were alive with palliative response rates (complete plus partial) for dysphagia, regurgitation, odynophagia, and chest or back pain of 76%, 82%, 69%, and 56%, respectively. No patients presented acute ≥G3 toxicity. CONCLUSIONS Short-course accelerated radiation therapy treatment, planned and delivered using a conventional 2-dimensional RT technique, was effective and well tolerated for the symptomatic palliation of locally advanced or metastatic esophageal cancer. This schedule may be useful for RT centers in developing countries to reduce treatment times, costs, and patient waiting times before treatment.
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Affiliation(s)
- Biniyam Tefera Deressa
- Radiotherapy Department, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia; Department of Clinical Oncology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Netsanet Bogale
- Radiotherapy Department, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Eleonora Farina
- Radiation Oncology Unit, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy.
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Cilla S, Deodato F, Ianiro A, Macchia G, Picardi V, Buwenge M, Cammelli S, Zamagni A, Valentini V, Morganti AG. Partially ablative radiotherapy (PAR) for large mass tumors using simultaneous integrated boost: A dose-escalation feasibility study. J Appl Clin Med Phys 2018; 19:35-43. [PMID: 30220111 PMCID: PMC6236838 DOI: 10.1002/acm2.12427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/12/2018] [Indexed: 12/22/2022] Open
Abstract
Purpose This study aimed to assess the feasibility to plan and deliver highly heterogeneous doses to symptomatic large tumors using volumetric modulated arc therapy (VMAT) and simultaneous integrated boost (SIB) during a short course palliative accelerated radiotherapy. Methods A patient with a large symptomatic chordoma infiltrating the right gluteal region was selected. A modified SIB treatment was implemented to irradiate the central volume of the tumor (boost target volume, BTV) up to 10 Gy/fraction in a dose escalation trial while maintaining the remaining tumor volume (planning target volume, PTV) and the surrounding healthy tissues within 5 Gy/fraction in twice daily fractions for two consecutive days. Four SIB plans were generated in the dual‐arc modality; a basal dose of 20 Gy was prescribed to the PTV, while the BTV was boosted up to 40 Gy. For comparison purposes, plans obtained with a sequential boost (SEQ plans) were also generated. All plans were optimized to deliver at least 95% of the prescription dose to the targets. Dose contrast index (DCI), conformity index (CI), integral dose (ID), and the irradiated body volumes at 5, 10, and 20 Gy were evaluated. Results At equal targets coverage, SIB plans provided major improvement in DCI, CI, and ID with respect to SEQ plans. When BTV dose escalated up to 200% of PTV prescription, DCI resulted in 66% for SIB plans and 37% for SEQ plans; the ID increase was only 11% for SIB plans (vs 27% for SEQ plans) and the increase in healthy tissues receiving more than 5, 10, and 20 Gy was less than 2%. Pretreatment dose verification reported a γ‐value passing rate greater than 95% with 3%(global)‐2 mm. Conclusion A modified SIB technique is dosimetrically feasible for large tumors, where doses higher than the tolerance dose of healthy tissues are necessary to increase the therapeutic gain.
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Affiliation(s)
- Savino Cilla
- Medical Physics Unit, Fondazione di Ricerca e Cura Giovanni Paolo II - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Fondazione di Ricerca e Cura Giovanni Paolo II - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Anna Ianiro
- Medical Physics Unit, Fondazione di Ricerca e Cura Giovanni Paolo II - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Fondazione di Ricerca e Cura Giovanni Paolo II - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Picardi
- Radiation Oncology Unit, Fondazione di Ricerca e Cura Giovanni Paolo II - Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology Department, DIMES Università di Bologna - Ospedale S.Orsola Malpighi, Bologna, Italy
| | - Silvia Cammelli
- Radiation Oncology Department, DIMES Università di Bologna - Ospedale S.Orsola Malpighi, Bologna, Italy
| | - Alice Zamagni
- Radiation Oncology Department, DIMES Università di Bologna - Ospedale S.Orsola Malpighi, Bologna, Italy
| | - Vincenzo Valentini
- Radiation Oncology Unit, Fondazione di Ricerca e Cura Giovanni Paolo II - Università Cattolica del Sacro Cuore, Campobasso, Italy.,Radiation Oncology Department, Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessio G Morganti
- Radiation Oncology Department, DIMES Università di Bologna - Ospedale S.Orsola Malpighi, Bologna, Italy
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Capuccini J, Macchia G, Farina E, Buwenge M, Genovesi D, Caravatta L, Nguyen NP, Cammelli S, Cilla S, Wondemagegnhu T, Uddin AFMK, Aziz Sumon M, Cellini F, Valentini V, Deodato F, Morganti AG. Short-course regimen of palliative radiotherapy in complicated bone metastases: a phase i–ii study (SHARON Project). Clin Exp Metastasis 2018; 35:605-611. [DOI: 10.1007/s10585-018-9931-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/13/2018] [Indexed: 12/25/2022]
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Results of a Phase II Study of Short-Course Accelerated Radiation Therapy (SHARON) for Multiple Brain Metastases. Am J Clin Oncol 2015. [DOI: 10.1097/coc.0b013e3182a0e826] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Ferro M, Cilla S, Macchia G, Deodato F, Pierro A, Digesu' C, Ferrandina G, Ciuffreda M, Sallustio G, Morganti AG. On the cutting edge of intensity modulated radiotherapy and simultaneous integrated boost (IMRT-SIB): The case of a patient with 8 brain metastases. Rep Pract Oncol Radiother 2015; 20:316-9. [PMID: 26109921 DOI: 10.1016/j.rpor.2014.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 09/02/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Patients with multiple brain metastases, especially those with more than 3 lesions, usually undergo to palliative whole brain (WB) radiotherapy (RT). METHODS A breast cancer patient with 8 brain metastases was treated on the brain by a radical RT regimen. Prescription doses were according to the simultaneous integrated boost-intensity modulated radiation therapy (SIB-IMRT) technique with all lesions as well brain irradiated simultaneously in 20 daily fractions. Doses of 40.0 Gy (2.0 Gy/fraction) and 50.0 Gy (2.5 Gy/fraction) were prescribed to the whole brain and to eight individual metastases, respectively. RESULTS Mean volume of the eight metastases was 8.1 cc (range: 3.8-10.1 cc). For all lesions, the volume receiving 95% of prescribed dose was 100% and dose homogeneity was within 3%. Moreover, maximum doses were less than 105% of prescribed dose, while average mean dose to lesions was 50.6 Gy (range: 49.7-51.5 Gy). Whole brain mean dose was 45.2 Gy. Maximum doses to brainstem and optic chiasma were limited to 44.5 Gy and 42.9 Gy, respectively, while maximum doses to eyes, lens and optic nerves were limited to 9.2 Gy, 4.9 Gy and 41.0 Gy, respectively. From a clinical point of view, subsequent MRI brain controls showed a complete clinical response. Forty months after treatment the patient is disease free and shows no late brain and skin toxicities. CONCLUSION This case demonstrates the technical feasibility of a SIB-IMRT treatment in patients with more than 3 brain metastases.
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Affiliation(s)
- Marica Ferro
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Antonio Pierro
- Radiology Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Cinzia Digesu'
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Ferrandina
- Gynecology Oncology Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Matteo Ciuffreda
- Radiology Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Giuseppina Sallustio
- Radiology Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Alessio G Morganti
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy ; Department of Radiotherapy, Policlinico Universitario "A. Gemelli", Università Cattolica del Sacro Cuore, Roma, Italy
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