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Milano MT, Marks LB, Olch AJ, Yorke ED, Jackson A, Bentzen SM, Constine LS. Comparison of Risks of Late Effects From Radiation Therapy in Children Versus Adults: Insights From the QUANTEC, HyTEC, and PENTEC Efforts. Int J Radiat Oncol Biol Phys 2024; 119:387-400. [PMID: 38069917 DOI: 10.1016/j.ijrobp.2023.08.066] [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: 04/13/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 05/19/2024]
Abstract
Pediatric Normal Tissue Effects in the Clinic (PENTEC) seeks to refine quantitative radiation dose-volume relationships for normal-tissue complication probabilities (NTCPs) in survivors of pediatric cancer. This article summarizes the evolution of PENTEC and compares it with similar adult-focused efforts (eg, Quantitative Analysis of Normal Tissue Effects in the Clinic [QUANTEC] and Hypofractionated Treatment Effects in the Clinic [HyTEC]) with respect to content, oversight, support, scope, and methodology of literature review. It then summarizes key organ-specific findings from PENTEC in an attempt to compare NTCP estimates in children versus adults. In brief, select normal-tissue risks within developing organs and tissues (eg, maldevelopment of musculoskeletal tissue, teeth, breasts, and reproductive organs) are primarily relevant only in children. For some organs and tissues, children appear to have similar (eg, brain for necrosis, optic apparatus, parotid gland, liver), greater (eg, brain for neurocognition, cerebrovascular, breast for lactation), less (ovary), or perhaps slightly less (eg, lung) risks of toxicity versus adults. Similarly, even within the broad pediatric age range (including adolescence), for some endpoints, younger children have greater (eg, hearing and brain for neurocognition) or lesser (eg, ovary, thyroid) risks of radiation-associated toxicities. NTCP comparisons in adults versus children are often confounded by marked differences in treatment paradigms that expose normal tissues to radiation (ie, cancer types, prescribed radiation therapy dose and fields, and chemotherapy agents used). To add to the complexity, it is unclear if age is best analyzed as a continuous variable versus with age groupings (eg, infants, young children, adolescents, young adults, middle-aged adults, older adults). Further work is needed to better understand the complex manner in which age and developmental status affect risk.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Arthur J Olch
- Radiation Oncology Program, Children's Hospital Los Angeles/Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ellen D Yorke
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Søren M Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
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2
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Constine LS, Marks LB, Milano MT, Ronckers CM, Jackson A, Hudson MM, Marcus KJ, Hodgson DC, Hua CH, Howell RM, Marples B, Yorke E, Olch A, Bentzen SM. A User's Guide and Summary of Pediatric Normal Tissue Effects in the Clinic (PENTEC): Radiation Dose-Volume Response for Adverse Effects After Childhood Cancer Therapy and Future Directions. Int J Radiat Oncol Biol Phys 2024; 119:321-337. [PMID: 37999712 DOI: 10.1016/j.ijrobp.2023.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 11/25/2023]
Abstract
Pediatric Normal Tissue Effects in the Clinic (PENTEC) is an international multidisciplinary effort that aims to summarize normal-tissue toxicity risks based on published dose-volume data from studies of children and adolescents treated with radiation therapy (RT) for cancer. With recognition that children are uniquely vulnerable to treatment-related toxic effects, our mission and challenge was to assemble our group of physicians (radiation and pediatric oncologists, subspecialists), physicists with clinical and modeling expertise, epidemiologists, and other scientists to develop evidence-based radiation dosimetric guidelines, as affected by developmental status and other factors (eg, other cancer therapies and host factors). These quantitative toxicity risk estimates could serve to inform RT planning and thereby improve outcomes. Tandem goals included the description of relevant medical physics issues specific to pediatric RT and the proposal of dose-volume outcome reporting standards to inform future studies. We created 19 organ-specific task forces and methodology to unravel the wealth of data from heterogeneous published studies. This report provides a high-level summary of PENTEC's genesis, methods, key findings, and associated concepts that affected our work and an explanation of how our findings may be interpreted and applied in the clinic. We acknowledge our predecessors in these efforts, and we pay homage to the children whose lives informed us and to future generations who we hope will benefit from this additional step in our path forward.
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Affiliation(s)
- Louis S Constine
- Departments of Radiation Oncology and; Pediatrics, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York.
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Cécile M Ronckers
- Division of Childhood Cancer Epidemiology (EpiKiK) and the German Childhood Cancer Registry (DKKR), Johannes Gutenberg University of Mainz, Germany
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa M Hudson
- Department of Oncology, Division of Cancer Survivorship, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Karen J Marcus
- Department of Radiation Oncology, Dana Farber/ Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Arthur Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, California
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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Lucas JT, Abramson ZR, Epstein K, Morin CE, Jaju A, Lee JW, Lee CL, Sitaram R, Voss SD, Hudson MM, Constine LS, Hua CH. Imaging Assessment of Radiation Therapy-Related Normal Tissue Injury in Children: A PENTEC Visionary Statement. Int J Radiat Oncol Biol Phys 2024; 119:669-680. [PMID: 38760116 DOI: 10.1016/j.ijrobp.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 05/19/2024]
Abstract
The Pediatric Normal Tissue Effects in the Clinic (PENTEC) consortium has made significant contributions to understanding and mitigating the adverse effects of childhood cancer therapy. This review addresses the role of diagnostic imaging in detecting, screening, and comprehending radiation therapy-related late effects in children, drawing insights from individual organ-specific PENTEC reports. We further explore how the development of imaging biomarkers for key organ systems, alongside technical advancements and translational imaging approaches, may enhance the systematic application of imaging evaluations in childhood cancer survivors. Moreover, the review critically examines knowledge gaps and identifies technical and practical limitations of existing imaging modalities in the pediatric population. Addressing these challenges may expand access to, minimize the risk of, and optimize the real-world application of, new imaging techniques. The PENTEC team envisions this document as a roadmap for the future development of imaging strategies in childhood cancer survivors, with the overarching goal of improving long-term health outcomes and quality of life for this vulnerable population.
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Affiliation(s)
| | - Zachary R Abramson
- Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Katherine Epstein
- Division of Radiology and Medical Imaging, UC Department of Radiology, Cincinnati, Ohio
| | - Cara E Morin
- Division of Radiology and Medical Imaging, UC Department of Radiology, Cincinnati, Ohio
| | - Alok Jaju
- Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Chang-Lung Lee
- Department of Radiation Oncology and; Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Ranganatha Sitaram
- Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stephan D Voss
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Louis S Constine
- Department of Radiation Oncology, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
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Hua CH, Bentzen SM, Li Y, Milano MT, Rancati T, Marks LB, Constine LS, Yorke ED, Jackson A. Improving Pediatric Normal Tissue Radiation Dose-Response Modeling in Children With Cancer: A PENTEC Initiative. Int J Radiat Oncol Biol Phys 2024; 119:369-386. [PMID: 38276939 DOI: 10.1016/j.ijrobp.2023.11.038] [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: 07/14/2023] [Revised: 11/07/2023] [Accepted: 11/19/2023] [Indexed: 01/27/2024]
Abstract
The development of normal tissue radiation dose-response models for children with cancer has been challenged by many factors, including small sample sizes; the long length of follow-up needed to observe some toxicities; the continuing occurrence of events beyond the time of assessment; the often complex relationship between age at treatment, normal tissue developmental dynamics, and age at assessment; and the need to use retrospective dosimetry. Meta-analyses of published pediatric outcome studies face additional obstacles of incomplete reporting of critical dosimetric, clinical, and statistical information. This report describes general methods used to address some of the pediatric modeling issues. It highlights previous single- and multi-institutional pediatric dose-response studies and summarizes how each PENTEC taskforce addressed the challenges and limitations of the reviewed publications in constructing, when possible, organ-specific dose-effect models.
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Affiliation(s)
- Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yimei Li
- Department of Biostatics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Ajithkumar T, Avanzo M, Yorke E, Tsang DS, Milano MT, Olch AJ, Merchant TE, Dieckmann K, Mahajan A, Fuji H, Paulino AC, Timmermann B, Marks LB, Bentzen SM, Jackson A, Constine LS. Brain and Brain Stem Necrosis After Reirradiation for Recurrent Childhood Primary Central Nervous System Tumors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:655-668. [PMID: 38300187 DOI: 10.1016/j.ijrobp.2023.12.043] [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: 05/12/2023] [Revised: 12/19/2023] [Accepted: 12/26/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Reirradiation is increasingly used in children and adolescents/young adults (AYA) with recurrent primary central nervous system tumors. The Pediatric Normal Tissue Effects in the Clinic (PENTEC) reirradiation task force aimed to quantify risks of brain and brain stem necrosis after reirradiation. METHODS AND MATERIALS A systematic literature search using the PubMed and Cochrane databases for peer-reviewed articles from 1975 to 2021 identified 92 studies on reirradiation for recurrent tumors in children/AYA. Seventeen studies representing 449 patients who reported brain and brain stem necrosis after reirradiation contained sufficient data for analysis. While all 17 studies described techniques and doses used for reirradiation, they lacked essential details on clinically significant dose-volume metrics necessary for dose-response modeling on late effects. We, therefore, estimated incidences of necrosis with an exact 95% CI and qualitatively described data. Results from multiple studies were pooled by taking the weighted average of the reported crude rates from individual studies. RESULTS Treated cancers included ependymoma (n = 279 patients; 7 studies), medulloblastoma (n = 98 patients; 6 studies), any CNS tumors (n = 62 patients; 3 studies), and supratentorial high-grade gliomas (n = 10 patients; 1 study). The median interval between initial and reirradiation was 2.3 years (range, 1.2-4.75 years). The median cumulative prescription dose in equivalent dose in 2-Gy fractions (EQD22; assuming α/β value = 2 Gy) was 103.8 Gy (range, 55.8-141.3 Gy). Among 449 reirradiated children/AYA, 22 (4.9%; 95% CI, 3.1%-7.3%) developed brain necrosis and 14 (3.1%; 95% CI, 1.7%-5.2%) developed brain stem necrosis with a weighted median follow-up of 1.6 years (range, 0.5-7.4 years). The median cumulative prescription EQD22 was 111.4 Gy (range, 55.8-141.3 Gy) for development of any necrosis, 107.7 Gy (range, 55.8-141.3 Gy) for brain necrosis, and 112.1 Gy (range, 100.2-117 Gy) for brain stem necrosis. The median latent period between reirradiation and the development of necrosis was 5.7 months (range, 4.3-24 months). Though there were more events among children/AYA undergoing hypofractionated versus conventionally fractionated reirradiation, the differences were not statistically significant (P = .46). CONCLUSIONS Existing reports suggest that in children/AYA with recurrent brain tumors, reirradiation with a total EQD22 of about 112 Gy is associated with an approximate 5% to 7% incidence of brain/brain stem necrosis after a median follow-up of 1.6 years (with the initial course of radiation therapy being given with conventional prescription doses of ≤2 Gy per fraction and the second course with variable fractionations). We recommend a uniform approach for reporting dosimetric endpoints to derive robust predictive models of late toxicities following reirradiation.
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Affiliation(s)
- Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals, Cambridge, United Kingdom.
| | - Michele Avanzo
- Division of Medical Physics, Centro di Riferimento Oncologico Aviano IRCCS, Aviano, Italy
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Derek S Tsang
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Arthur J Olch
- Department of Radiation Oncology and Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Hiroshi Fuji
- National Center for Child Health and Development, Tokyo, Japan
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen, West German Cancer Center, Essen, Germany
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Soren M Bentzen
- Division of Biostatistics and Bioinformatics, Department of Radiation Oncology, and University of Maryland Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York; Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
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Journy N, Bolle S, Brualla L, Dumas A, Fresneau B, Haddy N, Haghdoost S, Haustermans K, Jackson A, Karabegovic S, Lassen-Ramshad Y, Thariat J, Wette MR, Botzenhardt S, De Wit I, Demoor-Goldschmidt C, Christiaens M, Høyer M, Isebaert S, Jacobs S, Henriksen LT, Maduro JH, Ronckers C, Steinmeier T, Uyttebroeck A, Van Beek K, Walsh L, Thierry-Chef I, Timmermann B. Assessing late outcomes of advances in radiotherapy for paediatric cancers: Study protocol of the "HARMONIC-RT" European registry (NCT 04746729). Radiother Oncol 2024; 190:109972. [PMID: 37922994 DOI: 10.1016/j.radonc.2023.109972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Neige Journy
- National Institute for Medical Research (INSERM) U1018 Center for Research in Epidemiology and Population Health, Laboratory of "Radiation Epidemiology, Clinical Epidemiology and Cancer Survivorship", Paris-Saclay University, Gustave Roussy Cancer Campus, Villejuif, France.
| | - Stéphanie Bolle
- Department of Radiotherapy, Gustave Roussy Cancer Campus, Villejuif, France; West German Proton Therapy Centre Essen (WPE), Hufelandstr. 55, Essen 45147, Germany
| | - Lorenzo Brualla
- West German Proton Therapy Centre Essen (WPE), Hufelandstr. 55, Essen 45147, Germany
| | - Agnès Dumas
- Inserm, Aix Marseille University, IRD, ISSPAM, SESSTIM (Economic and Social Sciences of Health and Medical Information Processing), Marseille, France
| | - Brice Fresneau
- National Institute for Medical Research (INSERM) U1018 Center for Research in Epidemiology and Population Health, Laboratory of "Radiation Epidemiology, Clinical Epidemiology and Cancer Survivorship", Paris-Saclay University, Gustave Roussy Cancer Campus, Villejuif, France; Department of Paediatric Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Nadia Haddy
- National Institute for Medical Research (INSERM) U1018 Center for Research in Epidemiology and Population Health, Laboratory of "Radiation Epidemiology, Clinical Epidemiology and Cancer Survivorship", Paris-Saclay University, Gustave Roussy Cancer Campus, Villejuif, France
| | - Siamak Haghdoost
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden; University of Caen Normandy, Advanced Resource Center for HADrontherapy in Europe (ARCHADE), 14000 Caen, France
| | - Karin Haustermans
- Department of Radiation Oncology, UZ Leuven & Department of Oncology, KU Leuven, Leuven 3000, Belgium
| | - Angela Jackson
- National Institute for Medical Research (INSERM) U1018 Center for Research in Epidemiology and Population Health, Paris-Saclay University, Villejuif, France; National Institute for Medical Research (INSERM) U1018 Center for Research in Epidemiology and Population Health, Paris-Saclay University, Gustave Roussy Cancer Campus, Villejuif, France
| | - Sanja Karabegovic
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Yasmin Lassen-Ramshad
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - Juliette Thariat
- Centre Régional Francois Baclesse, Avenue Du General Harris 3, Caen Cedex 5 14076, France; Université de Caen Normandie, ENSICAEN, CNRS/IN2P3, LPC Caen UMR6534, F-14000 Caen, France
| | - Martina Roxanne Wette
- Department of Particle Therapy - University Hospital Essen, West German Cancer Centre (WTZ), Hufelandstrasse 55, Essen 45147, Germany; West German Proton Therapy Centre Essen (WPE), Hufelandstr. 55, Essen 45147, Germany
| | - Suzan Botzenhardt
- Department of Particle Therapy - University Hospital Essen, West German Cancer Centre (WTZ), Hufelandstrasse 55, Essen 45147, Germany
| | - Inge De Wit
- Department of Radiation Oncology, UZ Leuven & Department of Oncology, KU Leuven, Leuven 3000, Belgium
| | - Charlotte Demoor-Goldschmidt
- National Institute for Medical Research (INSERM) U1018 Center for Research in Epidemiology and Population Health, Laboratory of "Radiation Epidemiology, Clinical Epidemiology and Cancer Survivorship", Paris-Saclay University, Gustave Roussy Cancer Campus, Villejuif, France; Centre Régional Francois Baclesse, Avenue Du General Harris 3, Caen Cedex 5 14076, France; Centre Hospitalier Universitaire d'Angers, Rue Larrey 4, Angers 49 000, France
| | - Melissa Christiaens
- Department of Radiation Oncology, UZ Leuven & Department of Oncology, KU Leuven, Leuven 3000, Belgium
| | - Morten Høyer
- Aarhus University (AU), Nordre Ringgade 1, Aarhus C 8000, Denmark
| | - Sofie Isebaert
- Department of Radiation Oncology, UZ Leuven & Department of Oncology, KU Leuven, Leuven 3000, Belgium
| | - Sandra Jacobs
- Department of Paediatric Oncology, UZ Leuven, Leuven 3000, Belgium; Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Louise Tram Henriksen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - John H Maduro
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Cecile Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Theresa Steinmeier
- Department of Particle Therapy - University Hospital Essen, West German Cancer Centre (WTZ), Hufelandstrasse 55, Essen 45147, Germany; West German Proton Therapy Centre Essen (WPE), Hufelandstr. 55, Essen 45147, Germany
| | - Anne Uyttebroeck
- Department of Paediatric Oncology, UZ Leuven, Leuven 3000, Belgium
| | - Karen Van Beek
- Department of Radiation Oncology, UZ Leuven & Department of Oncology, KU Leuven, Leuven 3000, Belgium
| | - Linda Walsh
- Department of Physics, University of Zürich, Winterthurerstrasse 190, 8057 Zürich, Switzerland
| | | | - Beate Timmermann
- University Hospital Essen (UK Essen), Hufelandstrasse 55, Essen 45147, Germany; Department of Particle Therapy - University Hospital Essen, West German Cancer Centre (WTZ), Hufelandstrasse 55, Essen 45147, Germany; West German Proton Therapy Centre Essen (WPE), Hufelandstr. 55, Essen 45147, Germany
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