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Ödén J, Eriksson K, Pavoni B, Crezee H, Kok HP. A Novel Framework for Thermoradiotherapy Treatment Planning. Int J Radiat Oncol Biol Phys 2024; 119:1530-1544. [PMID: 38387812 DOI: 10.1016/j.ijrobp.2024.02.012] [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: 04/27/2023] [Revised: 01/24/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024]
Abstract
PURPOSE Thermoradiotherapy combines radiation therapy with hyperthermia to increase therapeutic effectiveness. Currently, both modalities are optimized separately and in state-of-the-art research the enhanced therapeutic effect is evaluated using equivalent radiation dose in 2-Gy fractions (EQD2). This study proposes a novel thermoradiotherapy treatment planning framework with voxelwise EQD2 radiation therapy optimizing including thermal radiosensitization and direct thermal cytotoxicity. METHODS AND MATERIALS To demonstrate proof-of-concept of the planning framework, 3 strategies consisting of 20 radiation therapy fractions were planned for 4 prostate cancer cases with substantially different temperature distributions: (1) Conventional radiation therapy plan of 60 Gy combined with 4 hyperthermia sessions (RT60 + HT), (2) standalone uniform dose escalation to 68 Gy without hyperthermia (RT68), and (3) uniform target EQD2 that maximizes the tumor control probability (TCP) accounting for voxelwise thermal effects of 4 hyperthermia sessions without increasing normal tissue doses (RTHT + HT). Assessment included dose, EQD2, TCP, and rectal normal tissue complication probability (NTCP), alongside robustness analyses for TCP and NTCP against parameter uncertainties. RESULTS The estimated TCP of around 76% for RT60 without hyperthermia was increased to an average of 85.9% (range, 81.3%-90.5%) for RT60 + HT, 92.5% (92.4%-92.5%) for RT68, and 94.4% (91.7%-96.6%) for RTHT + HT. The corresponding averaged rectal NTCPs were 8.7% (7.9%-10.0%), 14.9% (13.8%-17.1%), and 8.4% (7.5%-9.7%), respectively. RT68 and RTHT + HT exhibited slightly enhanced TCP robustness against parameter uncertainties compared with RT60 + HT, and RT68 presented higher and less robust rectal NTCP values compared with the other planning strategies. CONCLUSIONS This study introduces an innovative thermoradiotherapy planning approach, integrating thermal effects into EQD2-based radiation therapy optimization. Results demonstrate an ability to achieve enhanced and uniform target EQD2 and TCP across various temperature distributions without elevating normal tissue EQD2 or NTCP compared with conventional methods. Although promising for improving clinical outcomes, realizable enhancements depend on accurate tumor- and tissue-specific data and precise quantification of hyperthermic effects, which are seamlessly integrable in the planning framework as they emerge.
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Affiliation(s)
- Jakob Ödén
- RaySearch Laboratories AB, Stockholm, Sweden.
| | | | | | - Hans Crezee
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - H Petra Kok
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
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Herrera TD, Ödén J, Lorenzo Polo A, Crezee J, Kok HP. Thermoradiotherapy Optimization Strategies Accounting for Hyperthermia Delivery Uncertainties. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02960-2. [PMID: 39019236 DOI: 10.1016/j.ijrobp.2024.07.2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 06/13/2024] [Accepted: 07/04/2024] [Indexed: 07/19/2024]
Abstract
PURPOSE The combined effect of hyperthermia and radiation therapy can be quantified by an enhanced equivalent radiation dose (EQDRT). Uncertainties in hyperthermia treatment planning and adjustments during treatment can impact achieved EQDRT. We developed and compared strategies for EQDRT optimization of radiation therapy plans, focusing on robustness against common adjustments. METHODS AND MATERIALS Using Plan2Heat, we computed preplanning hyperthermia plans and treatment adjustment scenarios for 3 cervical cancer patients. We imported these scenarios into RayStation 12A for optimization with 4 different strategies: (1) conventional radiation therapy optimization prescribing 46 Gy to the planning target volume (PTV), (2) nominal EQDRT optimization using the preplanning scenario, targeting uniform 58 Gy in the gross tumor volume (GTV), keeping organs at risk doses as in plan 1, (3) robust EQDRT optimization, as plan 2 but adding adjusted scenarios for optimization, and (4) library of plans (4 plans) with strategy 2 criteria but optimizing on 1 adjusted scenario per plan. We calculated for each radiation therapy plan EQDRT distributions for preplanning and adjusted scenarios, evaluating each combination of GTV coverage and homogeneity objectives. RESULTS EQDRT95% increased from 49.9 to 50.9 Gy in strategy 1 to 56.1 to 57.4 Gy in strategy 2 with the preplanning scenario, improving homogeneity by ∼10%. Strategy 2 demonstrated the best overall robustness, with 62% of all GTV objectives within tolerance. Strategy 3 had a higher percentage of coverage objectives within tolerance than strategy 2 (68% vs 54%) but a lower percentage for uniformity (44% vs 71%). Strategy 4 showed a similar EQDRT95% and homogeneity for adjusted scenarios than strategy 2 for a preplanning scenario. D0.1% (radiation dose received by the 0.1% most irradiated volume) for organs at risk was increased by strategies 2 to 4 by up to ∼6 Gy. CONCLUSIONS EQDRT optimization enhances EQDRT levels and uniformity compared with conventional optimization. Better overall robustness is achieved by optimizing the preplanning hyperthermia plan. Robust optimization improves coverage but reduces homogeneity. A library of plans ensures coverage and uniformity when dealing with adjusted hyperthermia scenarios.
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Affiliation(s)
- Timoteo D Herrera
- Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands.
| | - Jakob Ödén
- RaySearch Laboratories AB, Stockholm, Sweden
| | | | - Johannes Crezee
- Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - H Petra Kok
- Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
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Overgaard J, Ccm Hulshof M, Dahl O, Arcangeli G. ESHO 1-85. Hyperthermia as an adjuvant to radiation therapy in the treatment of locally advanced breast carcinoma. A randomized multicenter study by the European Society for Hyperthermic Oncology. Radiother Oncol 2024; 196:110313. [PMID: 38670266 DOI: 10.1016/j.radonc.2024.110313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The ESHO protocol 1-85 is a multicenter randomized trial initiated by the European Society for Hyperthermic Oncology with the aim to investigate the value of hyperthermia (HT) as an adjuvant to radiotherapy (RT) in treatment of locally advanced breast carcinoma. The trial is one of the largest studies of hyperthermia in radiotherapy but has not been previously published. PATIENTS AND METHODS Between February 1987 and November 1993, 155 tumors in 151 patients were included. Tumors were stratified according to institution and size (T2-3/T4) and randomly assigned to receive radiotherapy alone (2 Gy/fx, 5 fx/wk) to a total dose of 65-70 Gy, incl. boost, or the same radiotherapy followed once weekly by hyperthermia (aimed for 43 °C for 60 min). Radiation was given with high voltage photons or electrons. The primary endpoint was persistent complete response (local control) in the treated area. RESULTS A total of 146 tumors in 142 patients were evaluable, with a median observation time of 19 (range 1-134) months. Seventy tumors were randomized to RT alone and 76 to RT + HT. Size was T4 in 92, and T2-3 in 54 tumors, respectively. The compliance to RT was good with all but 4 patients fulfilling the planned RT treatment. The tolerance to HT was fair, but associated with moderate to severe pain and discomfort in 15 % of the treatments. In 84 % of the heated patients a least one heat treatment achieved the target temperature, but the temperature variation was large. Addition of heat did not significantly increase the acute nor late radiation reactions. Overall, the 5-year actuarial local failure rate was 57 %. Univariate analysis showed a significant influence of hyperthermia (RT alone 68 % versus RT + HT 50 %, p = 0.04, and T-size (T4 75 % versus T2-3 36 %, p < 0.01). A Cox multivariate analysis showed the same factors to be the only significant prognostic parameters: hyperthermia (HR: 0.61 [0.38-0.98], and small tumor strata (HR: 0.46 [0.26-0.92]. Consequentially, more patients given RT + HT (36 %) survived without disease (DFS), than after RT alone (19 %), p = 0.021) CONCLUSION: A randomized multicenter trial investigating the addition of a weekly hyperthermia treatment to radiotherapy of patients with locally advanced breast cancer significantly enhanced the 5-year tumor control and yielded more patients surviving free from cancer. The results substantiate the potential clinical benefit of hyperthermic oncology.
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Affiliation(s)
- Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
| | - Maarten Ccm Hulshof
- Amsterdam University Medical Centers, Department of Radiotherapy, University of Amsterdam, the Netherlands
| | - Olav Dahl
- Department of Oncology and Medical Physics, Haukeland University, Hospital, Bergen, Norway.
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Mei X, Kok HP, Rodermond HM, van Bochove GGW, Snoek BC, van Leeuwen CM, Franken NAP, Ten Hagen TLM, Crezee J, Vermeulen L, Stalpers LJA, Oei AL. Radiosensitization by Hyperthermia Critically Depends on the Time Interval. Int J Radiat Oncol Biol Phys 2024; 118:817-828. [PMID: 37820768 DOI: 10.1016/j.ijrobp.2023.09.048] [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: 07/21/2023] [Revised: 09/20/2023] [Accepted: 09/23/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Hyperthermia is a potent sensitizer of radiation therapy that improves both tumor control and survival in women with locally advanced cervical cancer (LACC). The optimal sequence and interval between hyperthermia and radiation therapy are still under debate. METHODS AND MATERIALS We investigated the interval and sequence in vitro in cervical cancer cell lines, patient-derived organoids, and SiHa cervical cancer hind leg xenografts in athymic nude mice and compared the results with retrospective results from 58 women with LACC treated with thermoradiotherapy. RESULTS All 3 approaches confirmed that shortening the interval between hyperthermia and radiation therapy enhanced hyperthermic radiosensitization by 2 to 8 times more DNA double-strand breaks and apoptosis and 10 to 100 times lower cell survival, delayed tumor growth in mice, and increased the 5-year survival rate of women with LACC from 22% (interval ≥80 minutes) to 54% (interval <80 minutes). In vitro and in vivo results showed that the sequence of hyperthermia and radiation therapy did not affect the outcome. CONCLUSIONS Shortening the interval between hyperthermia and radiation therapy significantly improves treatment outcomes. The sequence of hyperthermia and radiation therapy (before or after) does not seem to matter.
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Affiliation(s)
- Xionge Mei
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - H Petra Kok
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Hans M Rodermond
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gregor G W van Bochove
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Barbara C Snoek
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Caspar M van Leeuwen
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Nicolaas A P Franken
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Timo L M Ten Hagen
- Precision Medicine in Oncology (PrMiO), Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johannes Crezee
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Louis Vermeulen
- Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands; Oncode Institute, Amsterdam, The Netherlands
| | - Lukas J A Stalpers
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arlene L Oei
- Department of Radiation Oncology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands; Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands; Cancer Biology and Immunology, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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González-Viguera J, Martínez-Pérez E, Pérez-Montero H, Arangüena M, Guedea F, Gutiérrez-Miguélez C. Hype or hope? A review of challenges in balancing tumor control and treatment toxicity in breast cancer from the perspective of the radiation oncologist. Clin Transl Oncol 2024; 26:561-573. [PMID: 37505372 DOI: 10.1007/s12094-023-03287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
The aim of this article is to discuss the challenges and new strategies in managing breast cancer patients, with a specific focus on radiation oncology and the importance of balancing oncologic outcomes with quality of life and post-treatment morbidity. A comprehensive literature review was conducted to identify advances in the management of breast cancer, exploring de-escalation strategies, hypofractionation schemes, predictors and tools for reducing toxicity (radiation-induced lymphocyte apoptosis, deep inspiration breath-hold, adaptive radiotherapy), enhancer treatments (hyperthermia, immunotherapy) and innovative diagnostic modalities (PET-MRI, omics). Balancing oncologic outcomes with quality of life and post-treatment morbidity is crucial in the era of personalized medicine. Radiotherapy plays a critical role in the management of breast cancer patients. Large randomized trials are necessary to generalize some practices and cost remains the main obstacle for many innovations that are already applicable.
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Affiliation(s)
- Javier González-Viguera
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Evelyn Martínez-Pérez
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Héctor Pérez-Montero
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marina Arangüena
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ferran Guedea
- Radiation Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
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Aristei C, Kaidar-Person O, Boersma L, Leonardi MC, Offersen B, Franco P, Arenas M, Bourgier C, Pfeffer R, Kouloulias V, Bölükbaşı Y, Meattini I, Coles C, Luis AM, Masiello V, Palumbo I, Morganti AG, Perrucci E, Tombolini V, Krengli M, Marazzi F, Trigo L, Borghesi S, Ciabattoni A, Ratoša I, Valentini V, Poortmans P. The 2022 Assisi Think Tank Meeting: White paper on optimising radiation therapy for breast cancer. Crit Rev Oncol Hematol 2023:104035. [PMID: 37244324 DOI: 10.1016/j.critrevonc.2023.104035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. < 70% agreement in an online questionnaire identified the following clinical challenges: 1: Nodal RT in patients who have a) 1-2 positive sentinel nodes without ALND (axillary lymph node dissection); b) cN1 disease transformed into ypN0 by primary systemic therapy and c) 1-3 positive nodes after mastectomy and ALND. 2. The optimal combination of RT and immunotherapy (IT), patient selection, IT-RT timing, and RT optimal dose, fractionation and target volume. Most experts agreed that RT- IT combination does not enhance toxicity. 3: Re-irradiation for local relapse converged on the use of partial breast irradiation after second breast conserving surgery. Hyperthermia aroused support but is not widely available. Further studies are required to finetune best practice, especially given the increasing use of re-irradiation.
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Affiliation(s)
- C Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - O Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - L Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M C Leonardi
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - B Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - P Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carita`' University Hospital, Novara, Italy
| | - M Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - C Bourgier
- Radiation Oncology, ICM-Val d' Aurelle, Univ Montpellier, Montpellier, France
| | - R Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - V Kouloulias
- 2nd Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Y Bölükbaşı
- Koc University, Faculty of Medicine, Department of Radiation Oncology, Istanbul, Turkey
| | - I Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - C Coles
- Department of Oncology, University of Cambridge, UK
| | - A Montero Luis
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - V Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - I Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - A G Morganti
- DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy; Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - E Perrucci
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - V Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - M Krengli
- DISCOG, Università di Padova e Istituto Oncologico Veneto - IRCCS
| | - F Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - L Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - S Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - A Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - I Ratoša
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - V Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore e Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - P Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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Real World Analysis of Quality of Life and Toxicity in Cancer Patients Treated with Hyperthermia Combined with Radio(chemo)therapy. Cancers (Basel) 2023; 15:cancers15041241. [PMID: 36831583 PMCID: PMC9954584 DOI: 10.3390/cancers15041241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 02/18/2023] Open
Abstract
Hyperthermia (HT) in combination with radio(chemo)therapy (RCT) is a well-established cancer treatment strategy. This report analyses the quality of life (QoL), toxicity and survival outcomes in patients with different tumor entities who received HT in combination with RCT. The primary endpoint of this study was the assessment of QoL scale items 3 and 12 months after treatment in patients who were treated with palliative intent and curative intent, respectively. The secondary endpoints of this study were acute toxicities, 1-year overall survival (OS), and local progression-free survival (LPFS). Patients treated with curative intent experienced significant improvement in emotional functioning (EF), social functioning (SF), financial difficulties (FI) and insomnia (SL) 12 months after treatment. Patients had significantly improved FI and pain (PA) three months after palliative treatment. Acute toxicity of grade 3 or more was 26% during treatment and 4% after three months. The 1-year OS rates were 90% (95% CI: 79-96%) and 44% (95% CI: 31-59%) for patients treated with curative and palliative RCT combined with HT, respectively. Moreover, the 1-year LPFS rates were 94% (95% CI: 84-98%) for patients treated with curative intent and 64% (95% CI: 50-77%) for palliative patients. In summary, combined RCT and HT stabilized or improved QoL scale items for both curative and palliative indications.
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Brummelhuis ISG, Crezee J, Witjes JA. Evaluation of thermal dose effect in radiofrequency-induced hyperthermia with intravesical chemotherapy for nonmuscle invasive bladder cancer. Int J Hyperthermia 2023; 40:2157498. [PMID: 36755433 DOI: 10.1080/02656736.2022.2157498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
PURPOSE In nonmuscle invasive bladder cancer (NMIBC) patients who fail standard intravesical treatment and are unfit or unwilling to undergo a radical cystectomy, radiofrequency (RF)-induced hyperthermia combined with intravesical chemotherapy (RF-CHT) has shown promising results. We studied whether higher thermal dose improves clinical NMIBC outcome. METHODS AND MATERIALS The cohort comprised 108 patients who started with RF-CHT between November 2013 and December 2019. Patients received intravesical mitomycin-C or epirubicin. Bladder hyperthermia was accomplished with an intravesical 915 MHz RF device guided by intravesical thermometry. We assessed the association between thermal dose parameters (including median temperature and Cumulative Equivalent Minutes of T50 at 43 °C [CEM43T50]) and complete response (CR) at six months for patients with (concomitant) carcinoma in situ (CIS), and recurrence-free survival (RFS) for patients with papillary disease. RESULTS Median temperature and CEM43T50 per treatment were 40.9 (IQR 40.8-41.1) °C and 3.1 (IQR 0.9-2.4) minutes, respectively. Analyses showed no association between any thermal dose parameter and CR or RFS (p > 0.05). Less bladder spasms during treatment sessions was associated with increased median temperature and CEM43T50 (adjusted OR 0.01 and 0.34, both p < 0.001). CONCLUSIONS No significant association between thermal dose and NMIBC outcome was found. Possibly thermal dose effect in patients of the current cohort exceeds a certain threshold value. On the other hand, occurrence of bladder spasms had a thermal dose limiting effect. We advise to treat patients with temperatures >40.5 °C for at least 45 min while respecting individual tolerability, including occurrence of bladder spasms.
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Affiliation(s)
- Iris S G Brummelhuis
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes Crezee
- Department of Radiotherapy, Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
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Androulakis I, Sumser K, Machielse MND, Koppert L, Jager A, Nout R, Franckena M, van Rhoon GC, Curto S. Patient-derived breast model repository, a tool for hyperthermia treatment planning and applicator design. Int J Hyperthermia 2022; 39:1213-1221. [DOI: 10.1080/02656736.2022.2121862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Ioannis Androulakis
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kemal Sumser
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Melanie N. D. Machielse
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Linetta Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Remi Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Martine Franckena
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Gerard C. van Rhoon
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
- Department of Radiation Science and Technology, Delft University of Technology, Delft, The Netherlands
| | - Sergio Curto
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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Kok HP, van Rhoon GC, Herrera TD, Overgaard J, Crezee J. Biological modeling in thermoradiotherapy: present status and ongoing developments toward routine clinical use. Int J Hyperthermia 2022; 39:1126-1140. [PMID: 35998930 DOI: 10.1080/02656736.2022.2113826] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Biological modeling for anti-cancer treatments using mathematical models can be very supportive in gaining more insight into dynamic processes responsible for cellular response to treatment, and predicting, evaluating and optimizing therapeutic effects of treatment. This review presents an overview of the current status of biological modeling for hyperthermia in combination with radiotherapy (thermoradiotherapy). Various distinct models have been proposed in the literature, with varying complexity; initially aiming to model the effect of hyperthermia alone, and later on to predict the effect of the combined thermoradiotherapy treatment. Most commonly used models are based on an extension of the linear-quadratic (LQ)-model enabling an easy translation to radiotherapy where the LQ model is widely used. Basic predictions of cell survival have further progressed toward 3 D equivalent dose predictions, i.e., the radiation dose that would be needed without hyperthermia to achieve the same biological effect as the combined thermoradiotherapy treatment. This approach, with the use of temperature-dependent model parameters, allows theoretical evaluation of the effectiveness of different treatment strategies in individual patients, as well as in patient cohorts. This review discusses the significant progress that has been made in biological modeling for hyperthermia combined with radiotherapy. In the future, when adequate temperature-dependent LQ-parameters will be available for a large number of tumor sites and normal tissues, biological modeling can be expected to be of great clinical importance to further optimize combined treatments, optimize clinical protocols and guide further clinical studies.
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Affiliation(s)
- H P Kok
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - G C van Rhoon
- Department of Radiation Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Radiation Science and Technology, Delft University of Technology, Delft, The Netherlands
| | - T D Herrera
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - J Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J Crezee
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
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11
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Riesterer O, Ademaj A, Puric E, Eberle B, Beck M, Gomez S, Marder D, Oberacker E, Rogers S, Hälg RA, Kern T, Schwenne S, Stein J, Stutz E, Timm O, Zschaeck S, Weyland MS, Veltsista PD, Wyler S, Wust P, Scheidegger S, Bodis S, Ghadjar P. Tetramodal therapy with transurethral resection followed by chemoradiation in combination with hyperthermia for muscle-invasive bladder cancer: early results of a multicenter phase IIB study. Int J Hyperthermia 2022; 39:1078-1087. [PMID: 35993234 DOI: 10.1080/02656736.2022.2109763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND Transurethral resection of bladder tumor (TUR-BT) followed by chemoradiation (CRT) is a valid treatment option for patients with muscle-invasive bladder cancer (MIBC). This study aimed to investigate the efficacy of a tetramodal approach with additional regional hyperthermia (RHT). METHODS Patients with stages T2-4 MIBC were recruited at two institutions. Treatment consisted of TUR-BT followed by radiotherapy at doses of 57-58.2 Gy with concurrent weekly platinum-based chemotherapy and weekly deep RHT (41-43 °C, 60 min) within two hours of radiotherapy. The primary endpoint was a complete response six weeks after the end of treatment. Further endpoints were cystectomy-free rate, progression-free survival (PFS), local recurrence-free survival (LRFS), overall survival (OS) and toxicity. Quality of life (QoL) was assessed at follow-up using the EORTC-QLQ-C30 and QLQ-BM30 questionnaires. Due to slow accrual, an interim analysis was performed after the first stage of the two-stage design. RESULTS Altogether 27 patients were included in the first stage, of these 21 patients with a median age of 73 years were assessable. The complete response rate of evaluable patients six weeks after therapy was 93%. The 2-year cystectomy-free rate, PFS, LRFS and OS rates were 95%, 76%, 81% and 86%, respectively. Tetramodal treatment was well tolerated with acute and late G3-4 toxicities of 10% and 13%, respectively, and a tendency to improve symptom-related quality of life (QoL) one year after therapy. CONCLUSION Tetramodal therapy of T2-T4 MIBC is promising with excellent local response, moderate toxicity and good QoL. This study deserves continuation into the second stage.
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Affiliation(s)
- Oliver Riesterer
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Adela Ademaj
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland.,Doctoral Clinical Science Program, Medical Faculty, University of Zürich, Zurich, Switzerland
| | - Emsad Puric
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Brigitte Eberle
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Marcus Beck
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Silvia Gomez
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Dietmar Marder
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Eva Oberacker
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Susanne Rogers
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Roger A Hälg
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland.,Institute of Physics, Science Faculty, University of Zurich, Zurich, Switzerland
| | - Thomas Kern
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Sonja Schwenne
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jürgen Stein
- Department of Urology, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - Emanuel Stutz
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olaf Timm
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Sebastian Zschaeck
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mathias S Weyland
- ZHAW School of Engineering, Zurich University of Applied Science, Zurich, Switzerland
| | - Paraskevi D Veltsista
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stephen Wyler
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Peter Wust
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stephan Scheidegger
- ZHAW School of Engineering, Zurich University of Applied Science, Zurich, Switzerland
| | - Stephan Bodis
- Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland.,Department of Radiation Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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De-Colle C, Beller A, Gani C, Weidner N, Heinrich V, Lamprecht U, Gaupp S, Voigt O, Dohm O, Zips D, Müller AC. Radiotherapy and hyperthermia for breast cancer patients at high risk of recurrence. Int J Hyperthermia 2022; 39:1010-1016. [PMID: 35902116 DOI: 10.1080/02656736.2022.2103593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
PURPOSE To evaluate the long-term efficacy of combined radiotherapy (RT) and hyperthermia (HT) in a large mono-institutional cohort of breast cancer (BC) patients affected by recurrent, newly diagnosed non-resectable or high risk resected tumor. MATERIALS AND METHODS Records of BC patients treated with RT + HT between 1995 and 2018 were retrospectively analyzed. RT doses of 50-70 Gy concurrent to a twice per week superficial HT were applied. For HT, a temperature between 41 and 42 °C was applied for approximately 1 h. Primary endpoint was local control (LC), secondary endpoints comprised toxicity, overall survival (OS), and progression-free survival (PFS). RESULTS A total of 191 patients and 196 RT + HT treatments were analyzed. In 154 cases (78.6%) RT + HT was performed for patients with recurrent BC. Among these, 93 (47.4% of the entire cohort) had received RT prior to RT + HT. Median follow up was 12.7 years. LC at 2, 5, and 10 years was 76.4, 72.8, and 69.5%, respectively. OS at 2, 5, and 10 years was 73.5, 52.3, and 35.5%, respectively. PFS at 2, 5, and 10 years was 55.6, 41, and 33.6%, respectively. Predictive factors for LC were tumor stage, distant metastases, estrogen/progesterone receptor expression, resection status and number of HT fractions. At multivariate analysis tumor stage and receptor expression were significant. No acute or late toxicities higher than grade 3 were observed. CONCLUSION Combined RT + HT offers long-term high LC rates with acceptable toxicity for patients with recurrent, newly diagnosed non-resectable or resected BC at high risk of relapse.
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Affiliation(s)
- Chiara De-Colle
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Anna Beller
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Vanessa Heinrich
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Ulf Lamprecht
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stephan Gaupp
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Otilia Voigt
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Oliver Dohm
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site Tübingen, Tübingen, Germany
| | - Arndt-Christian Müller
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany.,Clinic of Radiation Oncology, Ludwisburg Hospital, Ludwisburg, Germany
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13
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Kok HP, Crezee J. Validation and practical use of Plan2Heat hyperthermia treatment planning for capacitive heating. Int J Hyperthermia 2022; 39:952-966. [PMID: 35853733 DOI: 10.1080/02656736.2022.2093996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Capacitive devices are used for hyperthermia delivery, initially mainly in Asia, but nowadays also increasingly in Europe. Treatment planning can be very useful to determine the most effective patient-specific treatment set-up. This paper provides a validation of GPU-based simulations using Plan2Heat for capacitive hyperthermia devices. METHODS Validation was first performed by comparing simulations with an analytical solution for a spherical object placed inside a uniform electric field. Resolution was 5, 2.5 or 1 mm. Next, simulations for homogeneous and inhomogeneous phantom setups were performed for Thermotron RF8 and Celsius TCS capacitive heating devices at 2.5 mm resolution. Also different combinations of electrode sizes were evaluated. Normalized SAR profiles were compared to phantom measurements from the literature. Possible clinical use of treatment planning was demonstrated for an anal cancer patient, evaluating different treatment set-ups in prone and supine position. RESULTS Numerical and analytical solutions showed excellent agreement. At the center of the sphere, the error was 5.1%, 2.9% and 0.2% for a resolution of 5, 2.5 and 1 mm, respectively. Comparison of measurements and simulations for both Thermotron RF8 and Celsius TCS showed very good agreement within 5% for all phantom set-ups. Simulations were capable of accurately predicting the penetration depth; a very relevant parameter for clinical application. The patient case illustrated that planning can provide insight by comparing effectiveness of different treatment strategies. CONCLUSION Plan2Heat can rapidly and accurately predict heating patterns generated by capacitive devices. Thus, Plan2Heat is suitable for patient-specific treatment planning for capacitive hyperthermia.
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Affiliation(s)
- H P Kok
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - J Crezee
- Amsterdam UMC Location University of Amsterdam, Radiation Oncology, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Cancer Biology and Immunology, Amsterdam, The Netherlands
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