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Sharma DN, Sharma S, Gupta A, Saini SK, Subramani V. Low-dose radiation therapy for COVID-19 pneumonia: Comparison of dosimetry and life-time attributable risk of cancer with conventional AP-PA fields and bone marrow sparing VMAT. J Cancer Res Ther 2024; 20:943-948. [PMID: 39023602 DOI: 10.4103/jcrt.jcrt_656_24] [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: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 07/20/2024]
Abstract
PURPOSE Low-dose radiation therapy (LDRT) to lungs did show encouraging results in COVID-19 patients in some clinical trials. However, there has been some concern regarding the long-term risk of radiation-induced cancer (RIC). Compared to the conventional AP-PA field technique, volumetric modulated arc therapy (VMAT) can potentially reduce the dose to the marrow and other organs at risk (OARs) and thus minimize the risk of cancer. We designed a dosimetry study to study if VMAT can reduce the exposure to the marrow and other OAR doses and curtail the estimated life-time attributable risk (LAR) of cancer. METHODS AND MATERIALS We retrieved the computed tomography scan data of 10 patients (aged 40-60 years, median 48 years) who have been already treated for any malignancy in the region of the thorax. A dose of 1.0 Gy in single fraction was prescribed to both lungs. All the organs were delineated as per the established guidelines. The dosimetry achieved by the two plans was compared to find the difference. Mean OAR doses were used to estimate the LAR for both plans and compared. RESULTS Planning target volume coverage parameters like conformity index and homogeneity index were significantly better with VMAT (P value < 0.05 for all). The mean dose to most OARs was significantly lower with VMAT (P value < 0.05 for all). The mean dose to the marrow was significantly lower with VMAT (59.05 vs 81.9 cGy with P value < 0.05). The overall LAR was significantly lower with VMAT as compared to the conventional plan (0.357% vs 0.398%, P value < 0.05). CONCLUSION Compared to the conventional technique, VMAT provides better OAR dosimetry for lung irradiation (a prescription dose of 1.0 Gy or more) in COVID-19 pneumonia. VMAT significantly reduces the risk of RIC. We therefore suggest if lung LDRT is used for COVID-19 patients, VMAT is the preferred technique for a prescription dose of ≥1.0 Gy.
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Affiliation(s)
- Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
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Verhaegen F, Butterworth KT, Chalmers AJ, Coppes RP, de Ruysscher D, Dobiasch S, Fenwick JD, Granton PV, Heijmans SHJ, Hill MA, Koumenis C, Lauber K, Marples B, Parodi K, Persoon LCGG, Staut N, Subiel A, Vaes RDW, van Hoof S, Verginadis IL, Wilkens JJ, Williams KJ, Wilson GD, Dubois LJ. Roadmap for precision preclinical x-ray radiation studies. Phys Med Biol 2023; 68:06RM01. [PMID: 36584393 DOI: 10.1088/1361-6560/acaf45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 12/30/2022] [Indexed: 12/31/2022]
Abstract
This Roadmap paper covers the field of precision preclinical x-ray radiation studies in animal models. It is mostly focused on models for cancer and normal tissue response to radiation, but also discusses other disease models. The recent technological evolution in imaging, irradiation, dosimetry and monitoring that have empowered these kinds of studies is discussed, and many developments in the near future are outlined. Finally, clinical translation and reverse translation are discussed.
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Affiliation(s)
- Frank Verhaegen
- MAASTRO Clinic, Radiotherapy Division, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
- SmART Scientific Solutions BV, Maastricht, The Netherlands
| | - Karl T Butterworth
- Patrick G. Johnston, Centre for Cancer Research, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Anthony J Chalmers
- School of Cancer Sciences, University of Glasgow, Glasgow G61 1QH, United Kingdom
| | - Rob P Coppes
- Departments of Biomedical Sciences of Cells & Systems, Section Molecular Cell Biology and Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, The Netherlands
| | - Dirk de Ruysscher
- MAASTRO Clinic, Radiotherapy Division, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Sophie Dobiasch
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine and Klinikum rechts der Isar, Germany
- Department of Medical Physics, Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Germany
| | - John D Fenwick
- Department of Medical Physics & Biomedical Engineering University College LondonMalet Place Engineering Building, London WC1E 6BT, United Kingdom
| | | | | | - Mark A Hill
- MRC Oxford Institute for Radiation Oncology, University of Oxford, ORCRB Roosevelt Drive, Oxford OX3 7DQ, United Kingdom
| | - Constantinos Koumenis
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kirsten Lauber
- Department of Radiation Oncology, University Hospital, LMU München, Munich, Germany
- German Cancer Consortium (DKTK), Partner site Munich, Germany
| | - Brian Marples
- Department of Radiation Oncology, University of Rochester, NY, United States of America
| | - Katia Parodi
- German Cancer Consortium (DKTK), Partner site Munich, Germany
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching b. Munich, Germany
| | | | - Nick Staut
- SmART Scientific Solutions BV, Maastricht, The Netherlands
| | - Anna Subiel
- National Physical Laboratory, Medical Radiation Science Hampton Road, Teddington, Middlesex, TW11 0LW, United Kingdom
| | - Rianne D W Vaes
- MAASTRO Clinic, Radiotherapy Division, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Ioannis L Verginadis
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jan J Wilkens
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine and Klinikum rechts der Isar, Germany
- Physics Department, Technical University of Munich (TUM), Germany
| | - Kaye J Williams
- Division of Pharmacy and Optometry, University of Manchester, Manchester, United Kingdom
| | - George D Wilson
- Department of Radiation Oncology, Beaumont Health, MI, United States of America
- Henry Ford Health, Detroit, MI, United States of America
| | - Ludwig J Dubois
- The M-Lab, Department of Precision Medicine, GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Kolahdouzan K, Chavoshi M, Bayani R, Darzikolaee NM. Low-Dose Whole Lung Irradiation for Treatment of COVID-19 Pneumonia: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2022; 113:946-959. [PMID: 35537577 PMCID: PMC9077801 DOI: 10.1016/j.ijrobp.2022.04.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Studies dating back to a century ago have reported using low-dose radiation therapy for the treatment of viral and bacterial pneumonia. In the modern era, since the COVID-19 pandemic began, several groups worldwide have researched the applicability of whole lung irradiation (WLI) for the treatment of COVID-19. We aimed to bring together the results of these experimental studies. METHODS AND MATERIALS We performed a systematic review and meta-analysis searching PubMed and Scopus databases for clinical trials incorporating WLI for the treatment of patients with COVID-19. Required data were extracted from each study. Using the random-effects model, the overall pooled day 28 survival rate, survival hazard ratio, and intubation-free days within 15 days after WLI were calculated, and forest plots were produced. RESULTS Ten studies were identified, and eventually, 5 were included for meta-analysis. The overall survival hazard ratio was calculated to be 0.85 (0.46-1.57). The pooled mean difference of intubation-free days within 15 days after WLI was 1.87, favoring the WLI group (95% confidence interval, -0.02 to 3.76). The overall day 28 survival rate of patients receiving WLI for the 9 studies with adequate follow-up data was 74% (95% confidence interval, 61-87). Except for 2 studies, the other 8 studies were assessed to have moderate to high risk of bias, and there were many differences among the designs of the studies, included patients, primary endpoints, outcome measurement methods, and reporting of the results. CONCLUSIONS Despite a mild improvement in intubation-free days, WLI had no significant effect on patients' overall survival. Currently, we cannot recommend routine use of WLI for the treatment of patients with moderate-to-severe COVID-19.
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Affiliation(s)
- Kasra Kolahdouzan
- Department of Radiation Oncology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran,Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Chavoshi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Bayani
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran,Department of Radiation Oncology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Nima Mousavi Darzikolaee
- Department of Radiation Oncology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran,Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran,Cancer Institute, Imam Khomeini Hospital Complex, Tehran, Iran,Corresponding author: Nima Mousavi Darzikolaee, MD
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Piras A, Venuti V, D’Aviero A, Cusumano D, Pergolizzi S, Daidone A, Boldrini L. Covid-19 and radiotherapy: a systematic review after 2 years of pandemic. Clin Transl Imaging 2022; 10:611-630. [PMID: 35910079 PMCID: PMC9308500 DOI: 10.1007/s40336-022-00513-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/12/2022] [Indexed: 02/08/2023]
Abstract
Introduction Following the Covid-19 pandemic spread, changes in clinical practice were necessary to limit the pandemic diffusion. Also, oncological practice has undergone changes with radiotherapy (RT) treatments playing a key role.Although several experiences have been published, the aim of this review is to summarize the current evidence after 2 years of pandemic to provide useful conclusions for clinicians. Methods A Pubmed/MEDLINE and Embase systematic review was conducted. The search strategy was "Covid AND Radiotherapy" and only original articles in the English language were considered. Results A total of 2.733 papers were obtained using the mentioned search strategy. After the complete selection process, a total of 281 papers were considered eligible for the analysis of the results. Discussion RT has played a key role in Covid-19 pandemic as it has proved more resilient than surgery and chemotherapy. The impact of the accelerated use of hypofractionated RT and telemedicine will make these strategies central also in the post-pandemic period.
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Affiliation(s)
- Antonio Piras
- Radioterapia Oncologica, Villa Santa Teresa, Palermo, Italy
| | - Valeria Venuti
- Radioterapia Oncologica, Università degli Studi di Palermo, Palermo, Italy
| | - Andrea D’Aviero
- Radiation Oncology, Mater Olbia Hospital, Olbia, Sassari Italy
| | | | - Stefano Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | - Luca Boldrini
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica - Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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Sanmamed N, Alcantara P, Gómez S, Bustos A, Cerezo E, Gaztañaga M, Doval A, Corona J, Rodriguez G, Cabello N, Duffort M, Ortuño F, de Castro J, López A, Fuentes M, Sanz A, Vazquez M. Low-dose radiation therapy in the management of COVID-19 pneumonia (LOWRAD-Cov19). Final results of a prospective phase I-II trial. Radiother Oncol 2022; 171:25-29. [PMID: 35367528 PMCID: PMC8968128 DOI: 10.1016/j.radonc.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/14/2022] [Accepted: 03/25/2022] [Indexed: 12/15/2022]
Abstract
Background and purpose Material and methods Results Conclusions
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Affiliation(s)
- Noelia Sanmamed
- Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain; Investigation Institute, Clinico San Carlos Hospital, Madrid, Spain.
| | - Pino Alcantara
- Investigation Institute, Clinico San Carlos Hospital, Madrid, Spain; Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain; Faculty of Medicine. Complutense University of Madrid, Spain
| | - Sara Gómez
- Radiology Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Ana Bustos
- Radiology Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Elena Cerezo
- Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Miren Gaztañaga
- Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain; Investigation Institute, Clinico San Carlos Hospital, Madrid, Spain
| | - Anxela Doval
- Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Juan Corona
- Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain; Faculty of Medicine. Complutense University of Madrid, Spain
| | - Gabriel Rodriguez
- Medical Physics Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Noemi Cabello
- Internal Medicine Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Mercedes Duffort
- Internal Medicine Department, Infanta Leonor Hospital, Madrid, Spain
| | | | | | - Amanda López
- Investigation Institute, Clinico San Carlos Hospital, Madrid, Spain
| | - Manuel Fuentes
- Preventive Department, Clinico San Carlos Hospital, Madrid, Spain
| | - Alvaro Sanz
- Medical Oncology Department, Rio Hortega Hospital, Valladolid, Spain
| | - Manuel Vazquez
- Radiation Oncology Department, Clinico San Carlos Hospital, Madrid, Spain; Investigation Institute, Clinico San Carlos Hospital, Madrid, Spain; Faculty of Medicine. Complutense University of Madrid, Spain
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The Role of Ionizing Radiation for Diagnosis and Treatment against COVID-19: Evidence and Considerations. Cells 2022; 11:cells11030467. [PMID: 35159277 PMCID: PMC8834503 DOI: 10.3390/cells11030467] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 02/06/2023] Open
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic continues to spread worldwide with over 260 million people infected and more than 5 million deaths, numbers that are escalating on a daily basis. Frontline health workers and scientists diligently fight to alleviate life-threatening symptoms and control the spread of the disease. There is an urgent need for better triage of patients, especially in third world countries, in order to decrease the pressure induced on healthcare facilities. In the struggle to treat life-threatening COVID-19 pneumonia, scientists have debated the clinical use of ionizing radiation (IR). The historical literature dating back to the 1940s contains many reports of successful treatment of pneumonia with IR. In this work, we critically review the literature for the use of IR for both diagnostic and treatment purposes. We identify details including the computed tomography (CT) scanning considerations, the radiobiological basis of IR anti-inflammatory effects, the supportive evidence for low dose radiation therapy (LDRT), and the risks of radiation-induced cancer and cardiac disease associated with LDRT. In this paper, we address concerns regarding the effective management of COVID-19 patients and potential avenues that could provide empirical evidence for the fight against the disease.
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Ganesan G, Ponniah S, Sundaram V, Kumar Marimuthu P, Pitchaikannu V, Chandrasekaran M, Thangarasu J, Kannupaiyan G, Ramamoorthy P, Thangaraj B, Sasipriya Govindaraj H, Vaishnavi Raguram S. Whole lung Irradiation as a Novel treatment for COVID-19: Final Results of the Prospective Randomized trial (WINCOVID trial). Radiother Oncol 2021; 167:133-142. [PMID: 34958809 PMCID: PMC8709793 DOI: 10.1016/j.radonc.2021.12.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022]
Abstract
Background and purpose The ability of low dose radiotherapy (LDRT) to control the unprecedented cytokine release associated with COVID-19 pathogenesis has been an area of widespread research since the COVID pandemic. It has not been studied adequately whether the anti-inflammatory effect of LDRT provides additional benefit when used concurrently with steroids amongst other standard pharmacologic therapy. Material and methods 51 RT-PCR positive COVID-19 patients were recruited between November 2020 and July 2021. 34 patients were allotted to receive 0.5 Gy single session LDRT along with standard pharmacologic therapy while 17 patients received standard pharmacologic therapy alone. All had SpO2 <94% on room air, respiratory frequency >24/min and SpO2/FiO2 (SF) ratio between >89 but <357. All patients underwent a baseline CT scan. They were followed up for 28 days during when serial SF ratio, blood biomarkers (CRP, Serum ferritin, IL-6), Absolute lymphocyte count (ALC), repeat CT scan were performed at pre-defined time points. Results LDRT showed a statistically significant early improvement in oxygenation, an early time to clinical recovery, early hospital discharge and better radiological resolution compared to control group. There was no statistically significant difference between the two groups with respect to ALC or blood biomarkers at any of the measured time points. The 28-day mortality rate did not show statistically significant difference between the two groups. Conclusion LDRT can be considered for selected oxygen-dependent moderate to severe COVID-19 patients for rapid relief of respiratory distress. It can be safely combined with standard pharmacologic treatment in such patients for added clinical benefit.
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Affiliation(s)
- Govindaraj Ganesan
- Harshamitra Super-Specialty Cancer Centre and Research Institute, Trichy, Tamilnadu, India.
| | - Sasipriya Ponniah
- Harshamitra Super-Specialty Cancer Centre and Research Institute, Trichy, Tamilnadu, India
| | | | | | | | | | | | | | - Prabhu Ramamoorthy
- Harshamitra Super-Specialty Cancer Centre and Research Institute, Trichy, Tamilnadu, India
| | - Brindha Thangaraj
- Harshamitra Super-Specialty Cancer Centre and Research Institute, Trichy, Tamilnadu, India
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Kapoor R, Welsh JS, Dhawan V, Javadinia SA, Calabrese EJ, Dhawan G. Low-dose radiation therapy (LDRT) for COVID-19 and its deadlier variants. Arch Toxicol 2021; 95:3425-3432. [PMID: 34302492 PMCID: PMC8308081 DOI: 10.1007/s00204-021-03124-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/20/2021] [Indexed: 12/11/2022]
Abstract
Coronavirus variants are gaining strongholds throughout the globe. Despite early signals that SARS-CoV-2 coronavirus case numbers are easing up in the United States and during the middle of a (not so easy) vaccination roll out, the country has passed a grim landmark of 600,000 deaths. We contend that these numbers would have been much lower if the medical community undertook serious investigations into the potential of low doses of radiation (LDRT) as a mainstream treatment modality for COVID-19 pneumonia. LDRT has been posited to manifest anti-infectious and anti-inflammatory properties at doses of 0.3-1.0 Gy via the activation of the Nrf-2 pathway. Although some researchers are conducting well-designed clinical trials on the potential of LDRT, the deep-rooted, blind, and flawed acceptance of the Linear No-Threshold (LNT) model for ionizing radiation has led to sidelining of this promising therapy and thus unimaginable numbers of deaths in the United States.
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Affiliation(s)
- Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, CT USA
| | - James S. Welsh
- Edward Hines Jr VA Hospital, Hines, IL USA
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL USA
| | - Vikas Dhawan
- COVID 19 Facilities, Command Hospital (Western Command), Chandimandir, Panchkula, Haryana India
| | - Seyed Alireza Javadinia
- Clinical Research Development Unit, Hospital Research Development Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Edward J. Calabrese
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA USA
| | - Gaurav Dhawan
- Sri Guru Ram Das University of Health Sciences, Amritsar, India
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Shuryak I, Kachnic LA, Brenner DJ. In Reply to Welsh et al. Int J Radiat Oncol Biol Phys 2021; 111:576-577. [PMID: 34473976 PMCID: PMC8403552 DOI: 10.1016/j.ijrobp.2021.05.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Igor Shuryak
- Department of Radiation Oncology, Center for Radiological Research, Columbia University Irving Medical Center, New York, New York
| | - Lisa A Kachnic
- Department of Radiation Oncology, Center for Radiological Research, Columbia University Irving Medical Center, New York, New York
| | - David J Brenner
- Department of Radiation Oncology, Center for Radiological Research, Columbia University Irving Medical Center, New York, New York
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Welsh JS, Bevelacqua J, Mortazavi SMJ, Sacks B. In Regard to Shuryak et al. Int J Radiat Oncol Biol Phys 2021; 111:574-576. [PMID: 34473975 PMCID: PMC8403553 DOI: 10.1016/j.ijrobp.2021.05.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 01/09/2023]
Affiliation(s)
- James S Welsh
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, Illinois; Department of Radiation Oncology, Edward Hines, Jr. VA Hospital, Hines, Illinois
| | | | - S M J Mortazavi
- Medical Physics and Engineering Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bill Sacks
- FDA (retired medical officer), Gaithersburg, Maryland
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