1
|
Deng B, Kong W, Han C, Zhou C, Li J, Song D, Lin Y. Study of long-term effects of pelvic radiotherapy on the function of bone marrow in recurrent cervical cancer patients. Int J Med Sci 2024; 21:2000-2010. [PMID: 39113881 PMCID: PMC11302553 DOI: 10.7150/ijms.95900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
Purpose: To study the effects of prior pelvic radiotherapy on bone marrow suppression in recurrent cervical cancer patients during chemotherapy. Methods and materials: The cases of 129 patients with recurrent cervical cancer were reviewed, of which 77 patients had pelvic radiotherapy history and another 52 patients with no pelvic radiotherapy history were used as control group. All patients received a chemotherapy regimen of paclitaxel combined with carboplatin (TC) per 21 days for 5-6 times. Hematologic toxicity, including count of red blood cell, white blood cell and neutrophil cell and platelet, was defined by using Common Terminology Criteria for Adverse Events (version 4.0). The relationship between age, body mass index, disease free survival, pathological types, FIGO stages, radiotherapy methods and the degree of bone marrow suppression during chemotherapy was statistically analyzed, respectively, for all recurrent cervical cancer patients. Results: Among 77 patients with previous radiotherapy history, 73 recurrent patients (94.8%) had bone marrow suppression followed by chemotherapy. Recurrent cervical cancer patients without prior radiotherapy (n=52) showed a lower risk of bone marrow suppression followed by chemotherapy (n=39, 75.0%, P < 0.05). The probability of severe bone marrow suppression (grade III-IV) after chemotherapy in recurrent cervical patients with or without history of radiotherapy was 41.6% and 13.5%, respectively (P < 0.05). In univariate analysis, radiotherapy methods were associated with the incidence of grade III-IV bone marrow suppression in recurrent cervical cancer patients (P=0.005). In multivariate analysis, radiotherapy methods and extended-field radiotherapy were the risk factor of grade III-IV bone marrow suppression (χ2=16.975, P=0.001). No significant differences in the counts of white blood cell, hemoglobin and platelet were observed before chemotherapy at relapse between patients with and without prior radiotherapy. Reduction of white blood cell counts, absolute value of neutrophil cell and platelet counts composited majority type of grade III and IV bone marrow suppression. Conclusions: The prior pelvic radiotherapy significantly increased the incidence of bone marrow suppression during chemotherapy in recurrent cervical cancer patients. When treating recurrent cervical cancer patients with chemotherapy who had prior radiotherapy, especially for those experienced external beam radiation therapy, essential attention and timely intervention are recommended to ensure completion of chemotherapy and clinical efficacy.
Collapse
Affiliation(s)
- Boer Deng
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100006, P.R. China
| | - Weimin Kong
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100006, P.R. China
| | - Chao Han
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100006, P.R. China
| | - Chunxiao Zhou
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jing Li
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100006, P.R. China
| | - Dan Song
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100006, P.R. China
| | - Yuxuan Lin
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing 100006, P.R. China
| |
Collapse
|
2
|
Robinson M, Muirhead R, McGowan DR, Chu KY, Jacobs C, Hawkins MA. Differential Response of Pelvic Bone Marrow Fluorodeoxyglucose Uptake in Patients Receiving Concurrent Chemoradiotherapy. Clin Oncol (R Coll Radiol) 2023; 35:e622-e627. [PMID: 37339923 DOI: 10.1016/j.clon.2023.06.001] [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: 07/28/2022] [Revised: 05/01/2023] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
AIMS Irradiation of pelvic bone marrow (PBM) at the level of the typical low dose bath of intensity-modulated radiotherapy delivery (10-20 Gy) is associated with an increased risk of haematological toxicity, particularly when combined with concurrent chemotherapy. Although sparing of the whole of the PBM at a 10-20 Gy dose level is unachievable, it is known that PBM is divided into haematopoietically active and inactive regions that are identifiable based on the threshold uptake of [18F]-fluorodeoxyglucose (FDG) seen on positron emission tomography-computed tomography (PET-CT). In published studies to date, the definition of active PBM widely used is that of a standardised uptake value (SUV) greater than the mean SUV of the whole PBM prior to the start of chemoradiation. These studies include those looking at developing an atlas-based approach to contouring active PBM. Using baseline and mid-treatment FDG PET scans acquired as part of a prospective clinical trial we sought to determine the suitability of the current definition of active bone marrow as representative of differential underlying cell physiology. MATERIALS AND METHODS Active and inactive PBM were contoured on baseline PET-CT and using deformable registration mapped onto mid-treatment PET-CT. Volumes were cropped to exclude definitive bone, voxel SUV extracted and the change between scans calculated. Change was compared using Mann-Whitney U testing. RESULTS Active and inactive PBM were shown to respond differentially to concurrent chemoradiotherapy. The median absolute response of active PBM for all patients was -0.25 g/ml, whereas the median inactive PBM response was -0.02 g/ml. Significantly, the inactive PBM median absolute response was shown to be near zero with a relatively unskewed distribution (0.12). CONCLUSIONS These results would support the definition of active PBM as FDG uptake greater than the mean of the whole structure as being representative of underlying cell physiology. This work would support the development of atlas-based approaches published in the literature to contour active PBM based on the current definition as being suitable.
Collapse
Affiliation(s)
- M Robinson
- Department of Clinical Oncology, Oxford University Hospitals NHS Trust, Oxford, UK; Department of Oncology, University of Oxford, Oxford, UK.
| | - R Muirhead
- Department of Clinical Oncology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - D R McGowan
- Department of Oncology, University of Oxford, Oxford, UK; Department of Medical Physics and Clinical Engineering, Oxford University Hospitals NHS Trust, Oxford, UK
| | - K-Y Chu
- Department of Clinical Oncology, Oxford University Hospitals NHS Trust, Oxford, UK; Department of Oncology, University of Oxford, Oxford, UK
| | - C Jacobs
- Department of Clinical Oncology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - M A Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| |
Collapse
|
3
|
Iorio GC, Spieler BO, Ricardi U, Dal Pra A. The Impact of Pelvic Nodal Radiotherapy on Hematologic Toxicity: A Systematic Review with Focus on Leukopenia, Lymphopenia and Future Perspectives in Prostate Cancer Treatment. Crit Rev Oncol Hematol 2021; 168:103497. [PMID: 34666186 DOI: 10.1016/j.critrevonc.2021.103497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/06/2021] [Accepted: 10/10/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Hematologic toxicity (HT), particularly leukopenia, is a common side-effect of oncologic treatments for pelvic malignancies. Pelvic nodal radiotherapy (PNRT) has been associated with HT development mainly through incidental bone marrow (BM) irradiation; however, several questions remain about the clinical impact of radiotherapy-related HT. Herein, we perform a systematic review of the available evidence on PNRT and HT. MATERIALS AND METHODS A comprehensive systematic literature search was performed through EMBASE. Hand searching and clinicaltrials.gov were also used. RESULTS While BM-related dose-volume parameters and BM-sparing techniques have been more thoroughly investigated in pelvic malignancies such as cervical, anal, and rectal cancers, the importance of BM as an organ-at-risk has received less attention in prostate cancer treatment. CONCLUSIONS We examined the available evidence regarding the impact of PNRT on HT, with a focus on prostate cancer treatment. We suggest that BM should be regarded as an organ-at-risk for patients undergoing PNRT.
Collapse
Affiliation(s)
| | - Benjamin Oren Spieler
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Turin, Turin, Italy
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
4
|
Nilsson MP, Johnsson A, Scherman J. Sarcopenia and dosimetric parameters in relation to treatment-related leukopenia and survival in anal cancer. Radiat Oncol 2021; 16:152. [PMID: 34399812 PMCID: PMC8365937 DOI: 10.1186/s13014-021-01876-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/04/2021] [Indexed: 12/21/2022] Open
Abstract
Background Treatment-related white blood cell (WBC) toxicity has been associated with an inferior prognosis in different malignancies, including anal cancer. The aim of the present study was to investigate predictors of WBC grade ≥ 3 (G3+) toxicity during chemoradiotherapy (CRT) of anal cancer. Methods Consecutive patients with locally advanced (T2 ≥ 4 cm—T4 or N+) anal cancer scheduled for two cycles of concomitant 5-fluorouracil and mitomycin C chemotherapy were selected from an institutional database (n = 106). All received intensity modulated radiotherapy (IMRT; mean dose primary tumor 59.5 Gy; mean dose elective lymph nodes 45.1 Gy). Clinical data were extracted from medical records. The highest-grade WBC toxicity was recorded according to CTCAE version 5.0. Pelvic bone marrow (PBM) was retrospectively contoured and dose-volume histograms were generated. The planning CT was used to measure sarcopenia. Dosimetric, anthropometric, and clinical variables were tested for associations with WBC G3+ toxicity using the Mann–Whitney test and logistic regression. Cox proportional hazard regression was used to assess predictors for overall survival (OS) and anal cancer specific survival (ACSS). Results WBC G3+ was seen in 50.9% of the patients, and 38.7% were sarcopenic. None of the dosimetric parameters showed an association with WBC G3+ toxicity. The most significant predictor of WBC G3+ toxicity was sarcopenia (adjusted OR 4.0; P = 0.002). Sarcopenia was also associated with an inferior OS (adjusted HR 3.9; P = 0.01), but not ACSS (P = 0.07). Sensitivity analysis did not suggest that the inferior prognosis for sarcopenic patients was a consequence of reduced doses of chemotherapy or a prolonged radiation treatment time. Patients who experienced WBC G3+ toxicity had an inferior OS and ACSS, even after adjustment for sarcopenia. Conclusions Sarcopenia was associated with increased risks of both WBC G3+ toxicity and death following CRT for locally advanced anal cancer. In this study, radiation dose to PBM was not associated with WBC G3+ toxicity. However, PBM was not used as an organ at risk for radiotherapy planning purposes and doses to PBM were high, which may have obscured any dose–response relationships. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01876-5.
Collapse
Affiliation(s)
- Martin P Nilsson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23, 221 85, Lund, Sweden.
| | - Anders Johnsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23, 221 85, Lund, Sweden
| | - Jonas Scherman
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
5
|
Stieb S, Lee A, van Dijk LV, Frank S, Fuller CD, Blanchard P. NTCP Modeling of Late Effects for Head and Neck Cancer: A Systematic Review. Int J Part Ther 2021; 8:95-107. [PMID: 34285939 PMCID: PMC8270107 DOI: 10.14338/20-00092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Anna Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisanne V. van Dijk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, University Medical Center–Groningen, Groningen, the Netherlands
| | - Steven Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre Blanchard
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiotherapy, Gustave Roussy Cancer Campus, Universite Paris-Saclay, Villejuif, France
| |
Collapse
|
6
|
Robinson M, Muirhead R, Jacobs C, Cooke R, Chu KY, Van den Heuvel F, Ng S, Virdee P, Strauss V, Hawkins M. Response of FDG avid pelvic bone marrow to concurrent chemoradiation for anal cancer. Radiother Oncol 2019; 143:19-23. [PMID: 31506182 PMCID: PMC7077746 DOI: 10.1016/j.radonc.2019.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 11/16/2022]
Abstract
Chemoradiation suppression of active bone marrow shown in on-treatment FDG-PET. No suppression shown in un-irradiation bone marrow. Volumes of active bone marrow receiving 20 Gy are associated with blood count nadirs.
Background and purpose To determine if suppression of active bone marrow, as defined on FDG PETCT, is seen in on-treatment imaging of anal cancer patients receiving concurrent chemoradiation. Methods and materials Scans from 26 patients participating in the ART trial (full title: Anal squamous cell carcinoma: Investigation of functional imaging during chemoRadioTherapy), a single center observational study with FDG PETCT prior to radiotherapy and at fraction 8–10 of concurrent chemoradiation were analysed. Active bone marrow was contoured in both the pelvis and un-irradiated thoracic spine. SUV and volume of active bone marrow after 8–10 fractions of treatment were compared to baseline. Dose metrics to pelvic active bone marrow were extracted and compared to reduction in SUV/active bone marrow volume and to blood count nadir using linear regression. Results Suppression of active bone marrow is seen in the pelvis by a reduction in mean SUV and volume of active bone marrow after 8–10 fractions of treatment. Suppression is not seen in un-irradiated thoracic spine. Dose metrics were associated with reduced SUV and reduced volume of active bone marrow. Volume of active bone marrow receiving <20 Gy was associated with WCC/ANC nadir. 20 Gy was identified as the most likely clinically meaningful dose threshold for toxicity. Volume of active bone marrow receiving <20 Gy correlated to WCC and ANC with an increase of 100 cc being associated with an increase of 0.4 and 0.3 respectively. Conclusion The effect of concurrent chemoradiation in suppression of active bone marrow is seen in on-treatment FDG PETCT scans. Chemotherapy appears well tolerated after 2 weeks of treatment.
Collapse
Affiliation(s)
- Maxwell Robinson
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | - Rebecca Muirhead
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | - Clare Jacobs
- Department of Oncology, Oxford University Hospitals NHS Trust, UK
| | - Rosie Cooke
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | - Kwun-Ye Chu
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | | | - Stasya Ng
- Oncology Clinical Trials Office, University of Oxford, UK
| | - Pradeep Virdee
- Centre for Statistics in Medicine, University of Oxford, UK
| | | | - Maria Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK.
| |
Collapse
|
7
|
Palma G, Monti S, Conson M, Pacelli R, Cella L. Normal tissue complication probability (NTCP) models for modern radiation therapy. Semin Oncol 2019; 46:210-218. [PMID: 31506196 DOI: 10.1053/j.seminoncol.2019.07.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
Mathematical models of normal tissue complication probability (NTCP) able to robustly predict radiation-induced morbidities (RIM) play an essential role in the identification of a personalized optimal plan, and represent the key to maximizing the benefits of technological advances in radiation therapy (RT). Most modern RT techniques pose, however, new challenges in estimating the risk of RIM. The aim of this report is to schematically review NTCP models in the framework of advanced radiation therapy techniques. Issues relevant to hypofractionated stereotactic body RT and ion beam therapy are critically reviewed. Reirradiation scenarios for new or recurrent malignances and NTCP are also illustrated. A new phenomenological approach to predict RIM is suggested.
Collapse
Affiliation(s)
- Giuseppe Palma
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Serena Monti
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Laura Cella
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy.
| |
Collapse
|
8
|
Cheng Y, Ma Y, Zheng J, Deng H, Wang X, Li Y, Pang X, Chen H, He F, Wang L, Wang J, Wan X. Impact of Chemotherapy Regimens on Normal Tissue Complication Probability Models of Acute Hematologic Toxicity in Rectal Cancer Patients Receiving Intensity Modulated Radiation Therapy With Concurrent Chemotherapy From a Prospective Phase III Clinical Trial. Front Oncol 2019; 9:244. [PMID: 31024846 PMCID: PMC6465593 DOI: 10.3389/fonc.2019.00244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/18/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose: To determine whether there are differences in bone marrow tolerance to chemoradiotherapy (CRT) between two chemotherapy regimens according to FOWARC protocol and how chemotherapy regimens affect radiation dose parameters and normal tissue complication probability (NTCP) modelings that correlate with acute hematologic toxicity (HT) in rectal cancer patients treated with intensity modulated radiation therapy (IMRT) and concurrent chemotherapy. Materials and Methods: One hundred and twenty-eight rectal cancer patients who received IMRT from a single institution were recruited from Chinese FOWARC multicenter, open-label, randomized phase III trial. We assessed HT in these patients who were separated into two groups: Oxaliplatin (L-OHP) + 5- fluorouracil (5FU) (FOLFOX, 70 of 128) and 5FU (58 of 128). The pelvic bone marrow (PBM) was divided into three subsites: lumbosacral spine (LSS), ilium (I), and lower pelvic (LP). The endpoint for HT was grade ≥3 (HT3+) and grade ≥2 (HT2+) leukopenia, neutropenia, anemia and thrombocytopenia. Logistic regression was used to analyze the association between HT2+/HT3+ and dosimetric parameters. Lyman-Kutcher-Burman (LKB) model was used to calculate NTCP. Results: Sixty-eight patients experienced HT2+: 22 of 58 (37.9%) 5FU and 46 of 70 (65.7%) FOLFOX (p = 0.008), while twenty-six patients experienced HT3+: 4 of 58 (6.9%) 5FU and 22 of 70 (31.4%) FOLFOX (p = 0.016). PBM and LP dosimetric parameters were correlated with HT2+ in the 5FU group but not in the FOLFOX group. No PBM dosimetric parameters were correlated with HT3+ in both groups. For PBM, NTCP at HT3+ was 0.32 in FOLFOX group relative to 0.10 in 5FU subset (p < 0.05). Conclusion: Patients receiving FOLFOX have lower BM tolerance to CRT than those receiving 5FU. Low-dose radiation to the PBM is predictive for HT2+ in patients who received 5FU. NTCP modeling in FOLFOX group predicts much higher risk of HT3+ than 5FU group.
Collapse
Affiliation(s)
- Yikan Cheng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan Ma
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian Zheng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hua Deng
- Department of Radiation Oncology, Banner-University Medical Center Phoenix, Phoenix, AZ, United States
| | - Xueqin Wang
- Department of Statistical Science, Southern China Center for Statistical Science, School of Mathematics, Sun Yat-sen University, Guangzhou, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yewei Li
- Department of Statistical Science, Southern China Center for Statistical Science, School of Mathematics, Sun Yat-sen University, Guangzhou, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Xiaolin Pang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haiyang Chen
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fang He
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lei Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Colorectal Surgery, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianping Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Colorectal Surgery, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangbo Wan
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Department of Radiation Oncology, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
9
|
Faivre JC, Peiffert D, Vendrely V, Lemanski C, Hannoun-Levi JM, Mirabel X, Stanbury T, Salleron J, Guillemin F. Prognostic factors of colostomy free survival in patients presenting with locally advanced anal canal carcinoma: A pooled analysis of two prospective trials (KANAL 2 and ACCORD 03). Radiother Oncol 2018; 129:463-470. [PMID: 30172453 DOI: 10.1016/j.radonc.2018.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/30/2018] [Accepted: 08/09/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND To carry out a prognosis study of the prospective studies KANAL 2 and ACCORD 03 in order to highlight new prognostic factors of colostomy-free survival in patients with locally advanced anal canal carcinoma. PATIENTS AND METHODS KANAL 2 and ACCORD 03 were phase 2 and phase 3 multicenter trials with same inclusion criteria: anal canal squamous cell carcinoma of ≥4 cm or pelvic node involvement treated with conformal radiotherapy (45 Gy/25 fractions plus a boost) and concomitant fluorouracyl and cisplatin at weeks 1 and 5. A multivariate analysis of potential factors (patients, tumors, and treatments) was carried out through Cox proportional hazard model. Results were presented as hazard ratio (HR). RESULTS 387 patients were included. In multivariate analysis, age over 55 years (HR = 0.62, p = 0.013), the increase of circumferential tumor spread (between 1/3 and 2/3 and more than 2/3 compared to less than 1/3) (respectively 1.97, p = 0.015 and 2.94, p < 0.001), the skin ulceration (1.57, p = 0.03), the inguinal node involvement (1,98, p < 0.001) and the total radiotherapy dose above 60 Gy (between 60 and 65 Gy (HR = 0.37, p < 0.001) and >65 Gy (HR = 0.61, p = 0.028)) were associated with colostomy-free survival. CONCLUSION Our study highlights new favorable prognostic factors such as circumferential tumor damage of less than two thirds, age over 55 years, dose escalation boost irradiation and possibly a total radiation dose between 60 and 65 Gy (but the BED dose depends on the overall treatment time). These results could be considered for better selection or stratification of the target population in future trials.
Collapse
Affiliation(s)
- Jean-Christophe Faivre
- Radiation Department, Institut de Cancérologie de Lorraine Alexis-Vautrin, Vandœuvre-lès-Nancy, France; EA 4360 APEMAC, Université de Lorraine, Nancy, France.
| | - Didier Peiffert
- Radiation Department, Institut de Cancérologie de Lorraine Alexis-Vautrin, Vandœuvre-lès-Nancy, France; EA 4360 APEMAC, Université de Lorraine, Nancy, France
| | - Véronique Vendrely
- Radiation Department, Centre Hospitalier Universitaire de Bordeaux - Hôpital Haut-Lévêque, Pessac, France
| | - Claire Lemanski
- Department of Radiation Oncology, Institut de Cancérologie de Montpellier - Val d'Aurelle, University of Montpellier, France
| | - Jean-Michel Hannoun-Levi
- Radiation Department, Centre Antoine Lacassagne, Nice, France; Université de Nice, Sophia Antipolis, France
| | - Xavier Mirabel
- Radiation Department, Centre Oscar Lambret, Lille, France
| | | | - Julia Salleron
- Biostatistics and Epidemiology Department, Institut de Cancérologie de Lorraine - Alexis-Vautrin, Vandœuvre-lès-Nancy, France
| | - Francis Guillemin
- EA 4360 APEMAC, Université de Lorraine, Nancy, France; Inserm CIC 1433 Clinical Epidemiology, and Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
| |
Collapse
|
10
|
Jones CM, Adams R, Downing A, Glynne-Jones R, Harrison M, Hawkins M, Sebag-Montefiore D, Gilbert DC, Muirhead R. Toxicity, Tolerability, and Compliance of Concurrent Capecitabine or 5-Fluorouracil in Radical Management of Anal Cancer With Single-dose Mitomycin-C and Intensity Modulated Radiation Therapy: Evaluation of a National Cohort. Int J Radiat Oncol Biol Phys 2018; 101:1202-1211. [PMID: 29859793 DOI: 10.1016/j.ijrobp.2018.04.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE Chemoradiation therapy (CRT) with mitomycin C (MMC) and 5-fluorouracil (5-FU) is established as the standard of care for the radical treatment of patients with anal squamous cell carcinoma (ASCC). The use of the oral fluoropyrimidine-derivative capecitabine is emerging as an alternative to 5-FU despite limited evidence of its tolerability and toxicity. METHODS AND MATERIALS A national cohort evaluation of ASCC management within the United Kingdom National Health Service was undertaken from February to July 2015. The toxicity rates were prospectively recorded. For the present analysis, we report data from ASCC patients who underwent intensity modulated RT and a single dose of MMC with either 5-FU (5-FU/MMC) or capecitabine (capecitabine/MMC). All were treated with radical intent and intensity modulated radiation therapy (IMRT) was delivered in accordance with UK guidance. RESULTS Of the 242 patients received from 40 centers across the United Kingdom, 147 met the inclusion criteria; 52 of whom were treated with capecitabine/MMC and 95 with 5-FU/MMC. No treatment-related deaths and no overall difference were found in the proportion of patients experiencing any grade ≥3 toxicity between the capecitabine and 5-FU groups (45% vs 55%; P = .35). However, significantly fewer patients in the capecitabine/MMC group experienced grade 3 hematologic toxicity (4% vs 27%; P = .001). A lower proportion of patients completed their planned chemotherapy course in the capecitabine cohort, although this did not reach statistical significance (81% vs 90%; P = .21). The median RT duration was 38 days (interquartile range 38-39) for both groups. No difference was found in the 1-year oncologic outcomes. CONCLUSIONS Capecitabine/MMC resulted in similar levels of grade 3/4 toxicity overall compared with 5-FU/MMC as CRT for ASCC, although differences were found in the patterns of observed toxicities, with less hematologic toxicity with capecitabine. Further studies of capecitabine/MMC are required to understand the acute toxicity profile and long-term oncologic outcomes of this combination with intensity modulated RT for ASCC.
Collapse
Affiliation(s)
- Christopher M Jones
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom; Radiotherapy Research Group, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard Adams
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; Velindre Hospital, Cardiff, United Kingdom
| | - Amy Downing
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom
| | - Rob Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Mark Harrison
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Maria Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - David Sebag-Montefiore
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom; Radiotherapy Research Group, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Duncan C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Rebecca Muirhead
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Oxford, United Kingdom.
| |
Collapse
|
11
|
Christophides D, Appelt AL, Gusnanto A, Lilley J, Sebag-Montefiore D. Method for Automatic Selection of Parameters in Normal Tissue Complication Probability Modeling. Int J Radiat Oncol Biol Phys 2018; 101:704-712. [PMID: 29681482 DOI: 10.1016/j.ijrobp.2018.02.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/08/2018] [Accepted: 02/26/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To present a fully automatic method to generate multiparameter normal tissue complication probability (NTCP) models and compare its results with those of a published model, using the same patient cohort. METHODS AND MATERIALS Data were analyzed from 345 rectal cancer patients treated with external radiation therapy to predict the risk of patients developing grade 1 or ≥2 cystitis. In total, 23 clinical factors were included in the analysis as candidate predictors of cystitis. Principal component analysis was used to decompose the bladder dose-volume histogram into 8 principal components, explaining more than 95% of the variance. The data set of clinical factors and principal components was divided into training (70%) and test (30%) data sets, with the training data set used by the algorithm to compute an NTCP model. The first step of the algorithm was to obtain a bootstrap sample, followed by multicollinearity reduction using the variance inflation factor and genetic algorithm optimization to determine an ordinal logistic regression model that minimizes the Bayesian information criterion. The process was repeated 100 times, and the model with the minimum Bayesian information criterion was recorded on each iteration. The most frequent model was selected as the final "automatically generated model" (AGM). The published model and AGM were fitted on the training data sets, and the risk of cystitis was calculated. RESULTS The 2 models had no significant differences in predictive performance, both for the training and test data sets (P value > .05) and found similar clinical and dosimetric factors as predictors. Both models exhibited good explanatory performance on the training data set (P values > .44), which was reduced on the test data sets (P values < .05). CONCLUSIONS The predictive value of the AGM is equivalent to that of the expert-derived published model. It demonstrates potential in saving time, tackling problems with a large number of parameters, and standardizing variable selection in NTCP modeling.
Collapse
Affiliation(s)
- Damianos Christophides
- Leeds Cancer Centre, St. James's University Hospital, Leeds, United Kingdom; Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom.
| | - Ane L Appelt
- Leeds Cancer Centre, St. James's University Hospital, Leeds, United Kingdom; Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom; Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Arief Gusnanto
- Department of Statistics, University of Leeds, Leeds, United Kingdom
| | - John Lilley
- Leeds Cancer Centre, St. James's University Hospital, Leeds, United Kingdom
| | - David Sebag-Montefiore
- Leeds Cancer Centre, St. James's University Hospital, Leeds, United Kingdom; Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom
| |
Collapse
|
12
|
Radiation Therapy in Anal Cancer. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_48-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
13
|
Warren S, Hurt CN, Crosby T, Partridge M, Hawkins MA. Potential of Proton Therapy to Reduce Acute Hematologic Toxicity in Concurrent Chemoradiation Therapy for Esophageal Cancer. Int J Radiat Oncol Biol Phys 2017; 99:729-737. [PMID: 29280467 PMCID: PMC5612280 DOI: 10.1016/j.ijrobp.2017.07.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/19/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Radiation therapy dose escalation using a simultaneous integrated boost (SIB) is predicted to improve local tumor control in esophageal cancer; however, any increase in acute hematologic toxicity (HT) could limit the predicted improvement in patient outcomes. Proton therapy has been shown to significantly reduce HT in lung cancer patients receiving concurrent chemotherapy. Therefore, we investigated the potential of bone marrow sparing with protons for esophageal tumors. METHODS AND MATERIALS Twenty-one patients with mid-esophageal cancer who had undergone conformal radiation therapy (3D50) were selected. Two surrogates for bone marrow were created by outlining the thoracic bones (bone) and only the body of the thoracic vertebrae (TV) in Eclipse. The percentage of overlap of the TV with the planning treatment volume was recorded for each patient. Additional plans were created retrospectively, including a volumetric modulated arc therapy (VMAT) plan with the same dose as for 3D50; a VMAT SIB plan with a dose prescription of 62.5 Gy to the high-risk subregion within the planning treatment volume; a reoptimized TV-sparing VMAT plan; and a proton therapy plan with the same SIB dose prescription. The bone and TV dose metrics were recorded and compared across all plans and variations with respect to PTV and percentage of overlap for each patient. RESULTS The 3D50 plans showed the highest bone mean dose and TV percentage of volume receiving ≥30 Gy (V30Gy) for each patient. The VMAT plans irradiated a larger bone V10Gy than did the 3D50 plans. The reoptimized VMAT62.5 VT plans showed improved sparing of the TV volume, but only the proton plans showed significant sparing for bone V10Gy and bone mean dose, especially for patients with a larger PTV. CONCLUSIONS The results of the present study have shown that proton therapy can reduced bone marrow toxicity.
Collapse
Affiliation(s)
- Samantha Warren
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, United Kingdom
| | | | - Thomas Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff, United Kingdom
| | - Mike Partridge
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, United Kingdom
| | - Maria A Hawkins
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, United Kingdom.
| |
Collapse
|
14
|
Meier T, Mascia A, Wolf E, Kharofa J. Dosimetric Comparison of Intensity-Modulated Proton Therapy and Volumetric-Modulated Arc Therapy in Anal Cancer Patients and the Ability to Spare Bone Marrow. Int J Part Ther 2017; 4:11-17. [PMID: 31773004 DOI: 10.14338/ijpt-17-00017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/07/2017] [Indexed: 11/21/2022] Open
Abstract
Purpose Intensity-modulated radiation therapy (IMRT) has been used to spare organs at risk (OARs) in the definitive treatment of anal cancer. However, treatment continues to result in significant hematologic toxicity. In a cooperative trial assessing IMRT (RTOG 0529), the rate of grade 2+ and grade 3+ hematologic toxicity was 73% and 58%, respectively. Intensity-modulated proton therapy (IMPT) has the potential to decrease the integral bone marrow dose and dose to other OARs compared with photon therapy. Patients and Methods Computed tomography datasets of 9 patients with anal cancer previously treated with IMRT, volumetric arc therapy (VMAT), or tomotherapy at our institution were used for comparison. Both VMAT and IMPT plans were created for each patient. The IMPT plans were created using a multi-field optimized, split-target technique. The dose to OARs, including bone marrow, bladder, small bowel, large bowel, femoral heads, and genitalia, were compared using a paired t test. Results The mean bone marrow dose was 17.42 Gy with IMPT plans and 30.76 Gy with VMAT plans (P < .0001). The absolute volume of bone marrow spared 10 and 20 Gy was significantly less with the proton plans. IMPT also showed significant sparing of other OARs, including the small and large bowel, femoral heads, and genitalia. The mean planning target volume receiving at least 95% of the prescribed dose (V95) was similar with IMPT and VMAT plans, 99% and 98%, respectively. Conclusion IMPT can decrease the mean bone marrow dose compared with VMAT plans by minimizing the low dose spill associated with standard photon treatment. Prospective studies assessing proton therapy for anal cancer are ongoing to evaluate the potential for improvement in hematologic toxicity and the acute tolerance of therapy.
Collapse
Affiliation(s)
- Teresa Meier
- University of Cincinnati Medical Center, Department of Radiation Oncology, Cincinnati, OH, USA
| | - Anthony Mascia
- University of Cincinnati Medical Center, Department of Radiation Oncology, Cincinnati, OH, USA
| | - Eric Wolf
- University of Cincinnati Medical Center, Department of Radiation Oncology, Cincinnati, OH, USA
| | - Jordan Kharofa
- University of Cincinnati Medical Center, Department of Radiation Oncology, Cincinnati, OH, USA
| |
Collapse
|
15
|
Franco P, Arcadipane F, Ragona R, Mistrangelo M, Cassoni P, Racca P, Morino M, Numico G, Ricardi U. Hematologic toxicity in anal cancer patients during combined chemo-radiation: a radiation oncologist perspective. Expert Rev Anticancer Ther 2017; 17:335-345. [PMID: 28277103 DOI: 10.1080/14737140.2017.1288104] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Hematologic toxicity is an important side effect occurring in patients affected with anal cancer, undergoing combined radio-chemotherapy, with consistent clinical meaningfulness. Areas covered: Since more than a half of bone marrow is comprised within the pelvic region, the radiation dose received by this functional compartment is crucial. Modern imaging modalities may provide a useful tool to identify bone marrow and new delivery technology may enhance the radiation oncologist's possibility to selectively spare these structures, potentially decreasing acute hematologic toxicity profile in this setting. Expert commentary: Correlation between dose to pelvic structures and acute hematologic toxicity has been studied in several oncological settings, mainly on a retrospective frame. Different dose metrics were found to be correlated including mean doses and different points within the dose-volume histogram ranging from low to medium-high doses. Several imaging modalities were used to identify bone marrow both morphological and functional. Several clinical endpoints were used. In general, accounting for bone marrow during the treatment planning process may be important to decrease the acute hematologic toxicity profile during concurrent chemo-radiation in anal cancer patients. The most appropriate strategy to address this issue need further investigation and deserve validation in a prospective clinical framework.
Collapse
Affiliation(s)
- Pierfrancesco Franco
- a Department of Oncology, Radiation Oncology , University of Turin , Turin , Italy
| | - Francesca Arcadipane
- a Department of Oncology, Radiation Oncology , University of Turin , Turin , Italy
| | - Riccardo Ragona
- a Department of Oncology, Radiation Oncology , University of Turin , Turin , Italy
| | | | - Paola Cassoni
- c Department of Medical Sciences , University of Turin , Turin , Italy
| | - Patrizia Racca
- d Department of Oncology , Oncological Centre for Gastrointestinal Neoplasm, AOU Città della Salute e della Scienza , Turin , Italy
| | - Mario Morino
- b Department of Surgical Sciences , University of Turin , Turin , Italy
| | - Gianmauro Numico
- e Department of Oncology , Medical Oncology, AO SS Antonio e Biagio e Cesare Arrigo , Alessandria , Italy
| | - Umberto Ricardi
- a Department of Oncology, Radiation Oncology , University of Turin , Turin , Italy
| |
Collapse
|
16
|
Schernberg A, Escande A, Rivin Del Campo E, Ducreux M, Nguyen F, Goere D, Chargari C, Deutsch E. Leukocytosis and neutrophilia predicts outcome in anal cancer. Radiother Oncol 2017; 122:137-145. [DOI: 10.1016/j.radonc.2016.12.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/28/2016] [Accepted: 12/04/2016] [Indexed: 12/25/2022]
|
17
|
Durrant L, Robinson M, Hawkins MA, Van den Heuvel F, Muirhead R. Quantifying target-specific motion in anal cancer patients treated with intensity modulated radiotherapy (IMRT). Radiother Oncol 2016; 121:92-97. [PMID: 27576432 PMCID: PMC5100804 DOI: 10.1016/j.radonc.2016.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/08/2016] [Accepted: 08/13/2016] [Indexed: 02/07/2023]
Abstract
Background and purpose Intensity modulated radiotherapy requires all target areas to be treated by a single radiotherapy plan. In anal cancer, the pelvic nodes, inguinal nodes and primary tumour represent three different targets. We aim to calculate target-specific motion in anal cancer radiotherapy, when delivered using a single pelvic online auto-match. Materials and methods Twenty consecutive patients treated using IMRT at a single institution were studied. CBCTs were retrospectively re-matched around the inguinal nodes and primary tumour. Match values were recorded relative to origin, defined as pelvic CBCT auto-match. Systematic and random errors were quantified to determine target-specific motion and suggested margins calculated using van Herk formulae. Results The suggested margins to cover the independent motion of the inguinal and anal targets for LR, CC and AP set up around the inguinal nodes were 1.5 mm, 2.7 mm and 2.8 mm; and the primary tumour were, 4.6 mm, 8.9 mm and 5.2 mm respectively. Conclusions Target-specific set up will likely result in reduced treatment volumes and as such reduced toxicity. This is the first time a relationship has been described between pelvic bones, inguinal nodes and primary tumour. The PLATO study will prospectively assess the toxicity and outcomes of this target-specific margins strategy.
Collapse
Affiliation(s)
- Lisa Durrant
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | - Maxwell Robinson
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | - Maria A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK
| | | | - Rebecca Muirhead
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, UK.
| |
Collapse
|