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Appel S, Bar J, Alezra D, Ben-Ayun M, Rabin-Alezra T, Honig N, Katzman T, Chatterji S, Symon Z, Lawrence YR. Image-guidance triggered adaptive replanning of radiation therapy for locally advanced lung cancer: an evaluation of cases requiring plan adaptation. Br J Radiol 2020; 93:20190743. [PMID: 31670581 PMCID: PMC6948072 DOI: 10.1259/bjr.20190743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/12/2019] [Accepted: 10/28/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Anatomic changes may occur during chemoradiation treatment for lung cancers, requiring adaptive replanning. Here we characterize these cases. METHODS We retrospectively studied lung cancer cases that underwent resimulation and adaptive replanning during 1/2016-3/2019. We compared first and second CT-simulation regarding tumor location, timing of change, tumor volume, anatomical alteration and change in simulation technique. We also compared dosimetric parameters between the plans, recorded local control, and overall survival outcomes. RESULTS Out of 281 patients, 58 underwent replanning (20.6%). Histology included small cell (22.4%) and non-small cell (77.6%). Stage III was in 91.4%. Mean radiation dose of 59.4 Gray (Gy) (range 50-66Gy).Tumor location was peribronchial in 53.5%. Timing of replanning was in the first, second and final third of the treatment course in 26%, 43% and 31% respectively. Changes in gross tumor volume were observed in 74%; mean gross tumor volume was 276.7cc vs 192.7 cc (first vs second simulation, p = 0.001). Anatomical changes were identified in 35.4% including pleural fluid accumulation, atelectasis or pneumothorax alteration. Change in simulation technique was performed in 25.9%, including breath-hold or continuous positive airway pressure.Changes in dosimetric parameters when the same technique was used: lung V20Gy 26% (standard deviation, SD 7.6) vs 25.3% (SD 6.6) (p = 0.36), mean lung dose 15.1 Gy (SD 3.7) vs 14.7Gy (SD 3.3) (p = 0.23), heart V40Gy 10.2% (SD13) vs 7.2% (SD 9.8) (p = 0.037). When simulation technique changed: lung V20Gy 30.8% (SD 8.2) vs 27.3% (SD 8) (p = 0.012), mean lung dose 17.3 Gy (SD 4.4) vs 15.3 Gy (SD 3.8) (p = 0.007), heart V40Gy 11.1% (SD 14.7) vs 6.5% (SD 6.7) (p = 0.014).2 year local control was 60.7% (95% confidence interval, 34.5-79.2%), and median overall survival was 19.7 months. CONCLUSION Adaptive replanning of radiation was performed in a fifth of locally advanced lung cancer patients. In most cases tumor volume decreased, or atelectasis resolved, causing mediastinal shifts, which, if unidentified and left uncorrected, may have led to local failure and increased toxicity. The heart V40Gy was reduced significantly in all cases, but significant reduction in lung doses was evident only if simulation technique was altered. ADVANCES IN KNOWLEDGE In locally advanced lung cancer image-guidance with cone beam CT can detect significant mediastinal shifts and gross tumor volume changes that raise the need for adaptive replanning. Image guidance-triggered adaptive replanning should be added to the armament of advanced radiation treatment planning in locally advanced lung cancer.
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Affiliation(s)
- Sarit Appel
- Radiation Oncology, Institute Of Oncology, Chaim Sheba Medical Center affiliated to Tel Aviv University, Sackler faculty of medicine, Ramat Gan, Israel
| | - Jair Bar
- Medical Oncology, Institute of Oncology, Chaim Sheba Medical Center, affiliated to Tel Aviv University, Sackler faculty of medicine, Ramat Gan, Israel
| | - Dror Alezra
- Radiation Oncology, Institute Of Oncology, Chaim Sheba Medical Center affiliated to Tel Aviv University, Sackler faculty of medicine, Ramat Gan, Israel
| | - Maoz Ben-Ayun
- Radiation Oncology, Institute Of Oncology, Chaim Sheba Medical Center affiliated to Tel Aviv University, Sackler faculty of medicine, Ramat Gan, Israel
| | | | - Nir Honig
- Radiation Oncology, Institute Of Oncology, Chaim Sheba Medical Center affiliated to Tel Aviv University, Sackler faculty of medicine, Ramat Gan, Israel
| | - Tamar Katzman
- Radiation Oncology, Institute Of Oncology, Chaim Sheba Medical Center affiliated to Tel Aviv University, Sackler faculty of medicine, Ramat Gan, Israel
| | - Sumit Chatterji
- Department of Pulmonology, Chaim Sheba Medical Center affiliated to Tel Aviv University, Sackler faculty of medicine, Israel, Ramat Gan, Israel
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Kashani R, Olsen JR. Magnetic Resonance Imaging for Target Delineation and Daily Treatment Modification. Semin Radiat Oncol 2018; 28:178-184. [DOI: 10.1016/j.semradonc.2018.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Bainbridge H, Salem A, Tijssen RHN, Dubec M, Wetscherek A, Van Es C, Belderbos J, Faivre-Finn C, McDonald F. Magnetic resonance imaging in precision radiation therapy for lung cancer. Transl Lung Cancer Res 2017; 6:689-707. [PMID: 29218271 PMCID: PMC5709138 DOI: 10.21037/tlcr.2017.09.02] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/08/2017] [Indexed: 12/25/2022]
Abstract
Radiotherapy remains the cornerstone of curative treatment for inoperable locally advanced lung cancer, given concomitantly with platinum-based chemotherapy. With poor overall survival, research efforts continue to explore whether integration of advanced radiation techniques will assist safe treatment intensification with the potential for improving outcomes. One advance is the integration of magnetic resonance imaging (MRI) in the treatment pathway, providing anatomical and functional information with excellent soft tissue contrast without exposure of the patient to radiation. MRI may complement or improve the diagnostic staging accuracy of F-18 fluorodeoxyglucose position emission tomography and computerized tomography imaging, particularly in assessing local tumour invasion and is also effective for identification of nodal and distant metastatic disease. Incorporating anatomical MRI sequences into lung radiotherapy treatment planning is a novel application and may improve target volume and organs at risk delineation reproducibility. Furthermore, functional MRI may facilitate dose painting for heterogeneous target volumes and prediction of normal tissue toxicity to guide adaptive strategies. MRI sequences are rapidly developing and although the issue of intra-thoracic motion has historically hindered the quality of MRI due to the effect of motion, progress is being made in this field. Four-dimensional MRI has the potential to complement or supersede 4D CT and 4D F-18-FDG PET, by providing superior spatial resolution. A number of MR-guided radiotherapy delivery units are now available, combining a radiotherapy delivery machine (linear accelerator or cobalt-60 unit) with MRI at varying magnetic field strengths. This novel hybrid technology is evolving with many technical challenges to overcome. It is anticipated that the clinical benefits of MR-guided radiotherapy will be derived from the ability to adapt treatment on the fly for each fraction and in real-time, using 'beam-on' imaging. The lung tumour site group of the Atlantic MR-Linac consortium is working to generate a challenging MR-guided adaptive workflow for multi-institution treatment intensification trials in this patient group.
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Affiliation(s)
- Hannah Bainbridge
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Ahmed Salem
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | - Michael Dubec
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Andreas Wetscherek
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Corinne Van Es
- The University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jose Belderbos
- The Netherlands Cancer Institute and The Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Corinne Faivre-Finn
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Fiona McDonald
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
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De Ruysscher D, Faivre-Finn C, Moeller D, Nestle U, Hurkmans CW, Le Péchoux C, Belderbos J, Guckenberger M, Senan S. European Organization for Research and Treatment of Cancer (EORTC) recommendations for planning and delivery of high-dose, high precision radiotherapy for lung cancer. Radiother Oncol 2017; 124:1-10. [PMID: 28666551 DOI: 10.1016/j.radonc.2017.06.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 04/25/2017] [Accepted: 06/05/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To update literature-based recommendations for techniques used in high-precision thoracic radiotherapy for lung cancer, in both routine practice and clinical trials. METHODS A literature search was performed to identify published articles that were considered clinically relevant and practical to use. Recommendations were categorised under the following headings: patient positioning and immobilisation, Tumour and nodal changes, CT and FDG-PET imaging, target volumes definition, radiotherapy treatment planning and treatment delivery. An adapted grading of evidence from the Infectious Disease Society of America, and for models the TRIPOD criteria, were used. RESULTS Recommendations were identified for each of the above categories. CONCLUSION Recommendations for the clinical implementation of high-precision conformal radiotherapy and stereotactic body radiotherapy for lung tumours were identified from the literature. Techniques that were considered investigational at present are highlighted.
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Affiliation(s)
- Dirk De Ruysscher
- Maastricht University Medical Center+, Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, The Netherlands; KU Leuven, Radiation Oncology, Belgium.
| | - Corinne Faivre-Finn
- Division of Cancer Sciences University of Manchester, Christie NHS Foundation Trust, UK
| | - Ditte Moeller
- Aarhus University Hospital, Department of Oncology, Denmark
| | - Ursula Nestle
- Freiburg University Medical Center (DKTK partner site), Department of Radiation Oncology, Germany; Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Coen W Hurkmans
- Catharina Hospital, Department of Radiation Oncology, Eindhoven, The Netherlands
| | | | - José Belderbos
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | | | - Suresh Senan
- VU University Medical Center, Department of Radiation Oncology, Amsterdam, The Netherlands
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Hugo GD, Weiss E, Sleeman WC, Balik S, Keall PJ, Lu J, Williamson JF. A longitudinal four-dimensional computed tomography and cone beam computed tomography dataset for image-guided radiation therapy research in lung cancer. Med Phys 2017; 44:762-771. [PMID: 27991677 DOI: 10.1002/mp.12059] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 11/23/2016] [Accepted: 12/01/2016] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To describe in detail a dataset consisting of serial four-dimensional computed tomography (4DCT) and 4D cone beam CT (4DCBCT) images acquired during chemoradiotherapy of 20 locally advanced, nonsmall cell lung cancer patients we have collected at our institution and shared publicly with the research community. ACQUISITION AND VALIDATION METHODS As part of an NCI-sponsored research study 82 4DCT and 507 4DCBCT images were acquired in a population of 20 locally advanced nonsmall cell lung cancer patients undergoing radiation therapy. All subjects underwent concurrent radiochemotherapy to a total dose of 59.4-70.2 Gy using daily 1.8 or 2 Gy fractions. Audio-visual biofeedback was used to minimize breathing irregularity during all fractions, including acquisition of all 4DCT and 4DCBCT acquisitions in all subjects. Target, organs at risk, and implanted fiducial markers were delineated by a physician in the 4DCT images. Image coordinate system origins between 4DCT and 4DCBCT were manipulated in such a way that the images can be used to simulate initial patient setup in the treatment position. 4DCT images were acquired on a 16-slice helical CT simulator with 10 breathing phases and 3 mm slice thickness during simulation. In 13 of the 20 subjects, 4DCTs were also acquired on the same scanner weekly during therapy. Every day, 4DCBCT images were acquired on a commercial onboard CBCT scanner. An optically tracked external surrogate was synchronized with CBCT acquisition so that each CBCT projection was time stamped with the surrogate respiratory signal through in-house software and hardware tools. Approximately 2500 projections were acquired over a period of 8-10 minutes in half-fan mode with the half bow-tie filter. Using the external surrogate, the CBCT projections were sorted into 10 breathing phases and reconstructed with an in-house FDK reconstruction algorithm. Errors in respiration sorting, reconstruction, and acquisition were carefully identified and corrected. DATA FORMAT AND USAGE NOTES 4DCT and 4DCBCT images are available in DICOM format and structures through DICOM-RT RTSTRUCT format. All data are stored in the Cancer Imaging Archive (TCIA, http://www.cancerimagingarchive.net/) as collection 4D-Lung and are publicly available. DISCUSSION Due to high temporal frequency sampling, redundant (4DCT and 4DCBCT) data at similar timepoints, oversampled 4DCBCT, and fiducial markers, this dataset can support studies in image-guided and image-guided adaptive radiotherapy, assessment of 4D voxel trajectory variability, and development and validation of new tools for image registration and motion management.
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Affiliation(s)
- Geoffrey D Hugo
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - William C Sleeman
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | | | - Paul J Keall
- Radiation Physics Laboratory, The University of Sydney, Camperdown, NSW, Australia
| | - Jun Lu
- University of Mississippi Medical Center, Jackson, MS, 39213, USA
| | - Jeffrey F Williamson
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, 23298, USA
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Tennyson N, Weiss E, Sleeman W, Rosu M, Jan N, Hugo GD. Effect of variations in atelectasis on tumor displacement during radiation therapy for locally advanced lung cancer. Adv Radiat Oncol 2016; 2:19-26. [PMID: 28740912 PMCID: PMC5514234 DOI: 10.1016/j.adro.2016.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/14/2016] [Accepted: 12/02/2016] [Indexed: 11/29/2022] Open
Abstract
Purpose Atelectasis (AT), or collapsed lung, is frequently associated with central lung tumors. We investigated the variation of atelectasis volumes during radiation therapy and analyzed the effect of AT volume changes on the reproducibility of the primary tumor (PT) position. Methods and materials Twelve patients with lung cancer who had AT and 10 patients without AT underwent repeated 4-dimensional fan beam computed tomography (CT) scans during radiation therapy per protocols that were approved by the institutional review board. Interfraction volume changes of AT and PT were correlated with PT displacements relative to bony anatomy using both a bounding box (BB) method and change in center of mass (COM). Linear regression modeling was used to determine whether PT and AT volume changes were independently associated with PT displacement. PT displacement was compared between patients with and without AT. Results The mean initial AT volume on the planning CT was 189 cm3 (37-513 cm3), and the mean PT volume was 93 cm3 (12-176 cm3). During radiation therapy, AT and PT volumes decreased on average 136.7 cm3 (20-369 cm3) for AT and 40 cm3 (−7 to 131 cm3) for PT. Eighty-three percent of patients with AT had at least one unidirectional PT shift that was greater than 0.5 cm outside of the initial BB during treatment. In patients with AT, the maximum PT COM shift was ≥0.5 cm in all patients and >1 cm in 58% of patients (0.5-2.4 cm). Changes in PT and AT volumes were independently associated with PT displacement (P < .01), and the correlation was smaller with COM (R2 = 0.58) compared with the BB method (R2 = 0.80). The median root mean squared PT displacement with the BB method was significantly less for patients without AT (0.45 cm) compared with those with AT (0.8cm, P = .002). Conclusions Changes in AT and PT volumes during radiation treatment were significantly associated with PT displacements that often exceeded standard setup margins. Repeated 3-dimensional imaging is recommended in patients with AT to evaluate for PT displacements during treatment.
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Affiliation(s)
| | | | | | | | | | - Geoffrey D. Hugo
- Corresponding author. Virginia Commonwealth University, 401 College Street, PO Box 980058, Richmond, VA 23298Virginia Commonwealth University401 College StreetPO Box 980058RichmondVA23298
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Cardiac and respiration induced motion of mediastinal lymph node targets in lung cancer patients throughout the radiotherapy treatment course. Radiother Oncol 2016; 121:52-58. [DOI: 10.1016/j.radonc.2016.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 07/02/2016] [Accepted: 07/03/2016] [Indexed: 12/25/2022]
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Liquid fiducial marker performance during radiotherapy of locally advanced non small cell lung cancer. Radiother Oncol 2016; 121:64-69. [PMID: 27443450 DOI: 10.1016/j.radonc.2016.06.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/01/2016] [Accepted: 06/20/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE We analysed the positional and structural stability of a long-term biodegradable liquid fiducial marker (BioXmark) for radiotherapy in patients with locally advanced lung cancer. MATERIAL AND METHODS Markers were injected via endoscopic- or endobronchial ultrasound in lymph nodes and reachable primary tumours. Marker volume and Hounsfield Units (HU) changing rates were estimated using breath-hold CBCT. Inter-fraction variation in marker position relative to gross tumour volume (GTV) position was established, as well as the inter-fraction variation in mediastinal marker registration relative to a carina registration through the treatment. RESULTS Fifteen patients were included and 29 markers analysed. All markers that were in situ at planning were visible through the treatment. Mean HU was 902±165HU for lymph node and 991±219HU for tumour markers. Volume degradation rates were -5% in lymph nodes and -23% in primary tumours. Three-dimensional inter-fraction variation for marker position relative to the GTV position was -0.1±0.7mm in lymph nodes and -1.5±2.3mm in primary tumours. Inter-fraction variations in marker registration relative to carina registration were -0.4±1.2mm in left-right, 0.2±2.0mm in anterior-posterior and -0.5±2.0mm in cranio-caudal directions. CONCLUSIONS The liquid fiducial markers were visible and stable in size and position throughout the treatment course.
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Anatomical landmarks accurately determine interfractional lymph node shifts during radiotherapy of lung cancer patients. Radiother Oncol 2015; 116:64-9. [DOI: 10.1016/j.radonc.2015.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 12/25/2022]
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Respiratory motion variability of primary tumors and lymph nodes during radiotherapy of locally advanced non-small-cell lung cancers. Radiat Oncol 2015; 10:133. [PMID: 26071910 PMCID: PMC4476088 DOI: 10.1186/s13014-015-0435-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/01/2015] [Indexed: 12/25/2022] Open
Abstract
Background and purpose The need for target adjustment due to respiratory motion variation and the value of carina as a motion surrogate is evaluated for locally advanced non-small-cell lung cancer. Material and methods Using weekly 4D CTs (with audio-visual biofeedback) of 12 patients, respiratory motion variation of primary tumors (PT), lymph nodes (LN) and carina (C) were determined. Results Mean (SD) 3D respiratory motion ranges of PT, LN and C were 4 (3), 5 (3) and 5 (3) mm. PT and LN (p = 0.003), and LN and C motion range were correlated (p = 0.03). Only 20 %/5 % of all scans had variations >3 mm/5 mm. Large respiratory motion range on the initial scan was associated with larger during-treatment variations for PT (p = 0.03) and LN (p = 0.001). Mean (SD) 3D relative displacements of PT-C, LN-C and PT-LN were each 6 (2) mm. Variations of displacements >3 mm/5 mm were observed in 28 %/6 % of scans for PT-LN, 20 %/9 % for PT-C, and 20 %/8 % for LN-C. Conclusions Motion reassessment is recommended in patients with large initial motion range. Relative motion-related displacements between PT and LN were larger than PT and LN motion alone. Both PT and C appear to be comparable surrogates for LN respiratory motion.
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Correlation of 18F-FDG PET avid volumes on pre-radiation therapy and post-radiation therapy FDG PET scans in recurrent lung cancer. In regard to Shusharina et al. Int J Radiat Oncol Biol Phys 2014; 90:968-9. [PMID: 25585790 DOI: 10.1016/j.ijrobp.2014.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 06/25/2014] [Accepted: 07/13/2014] [Indexed: 11/21/2022]
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Differential Motion Between Mediastinal Lymph Nodes and Primary Tumor in Radically Irradiated Lung Cancer Patients. Int J Radiat Oncol Biol Phys 2014; 90:959-66. [DOI: 10.1016/j.ijrobp.2014.07.038] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 07/16/2014] [Accepted: 07/25/2014] [Indexed: 11/21/2022]
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