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Behzadi ST, Moser R, Kiesl S, Nano J, Peeken JC, Fischer JC, Fallenberg EM, Huber T, Haller B, Klein E, Kiechle M, Combs SE, Borm KJ. Tumor Contact With Internal Mammary Perforator Vessels as Risk Factor for Gross Internal Mammary Lymph Node Involvement in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 119:1455-1463. [PMID: 38458496 DOI: 10.1016/j.ijrobp.2024.02.030] [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: 09/29/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE The identification of internal mammary lymph node metastases and the assessment of associated risk factors are crucial for adjuvant regional lymph node irradiation in patients with breast cancer. The current study aims to investigate whether tumor contact with internal mammary perforator vessels is associated with gross internal mammary lymph node involvement. METHODS AND MATERIALS We included 297 patients with primary breast cancer and gross internal mammary (IMN+) and/or axillary metastases as well as 230 patients without lymph node metastases. Based on pretreatment dynamic contrast-enhanced magnetic resonance imaging, we assessed contact of the tumor with the internal mammary perforating vessels (IMPV). RESULTS A total of 59 patients had ipsilateral IMN+ (iIMN+), 10 patients had contralateral IMN+ (cIMN+), and 228 patients had ipsilateral axillary metastases without IMN; 230 patients had node-negative breast cancer. In patients with iIMN+, 100% of tumors had contact with ipsilateral IMPV, with 94.9% (n = 56) classified as major contact. In iIMN- patients, major IMPV contact was observed in only 25.3% (n = 116), and 36.2% (n = 166) had no IMPV contact at all. Receiver operating characteristic analysis revealed that "major IMPV contact" was more accurate in predicting iIMN+ (area under the curve, 0.85) compared with a multivariate model combining grade of differentiation, tumor site, size, and molecular subtype (area under the curve, 0.65). Strikingly, among patients with cIMN+, 100% of tumors had contact with a crossing contralateral IMPV, whereas in cIMN- patients, IMPVs to the contralateral side were observed in only 53.4% (iIMN+) and 24.8% (iIMN-), respectively. CONCLUSIONS Tumor contact with the IMPV is highly associated with risk of gross IMN involvement. Further studies are warranted to investigate whether this identified risk factor is also associated with microscopic IMN involvement and whether it can assist in the selection of patients with breast cancer for irradiation of the internal mammary lymph nodes.
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Affiliation(s)
- Sophie T Behzadi
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Rebecca Moser
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Sophia Kiesl
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Jana Nano
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Julius C Fischer
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Eva M Fallenberg
- Department of Radiology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Thomas Huber
- Department of Radiology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Haller
- Institute of AI and Informatics in Medicine, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Evelyn Klein
- Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Marion Kiechle
- Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany; Deutsches Konsortium für translationale Krebsforschung (DKTK) - Partner Site Munich, Munich, Germany; Institute of Radiation Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany.
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Frengen J, Vikström J, Mjaaland I, Funderud M, Almberg SS, Dybvik KI, Hjelstuen MHB. Locoregional breast radiotherapy including IMN: optimizing the dose distribution using an automated non-coplanar VMAT-technique. Acta Oncol 2023; 62:1169-1177. [PMID: 37812070 DOI: 10.1080/0284186x.2023.2264488] [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: 05/03/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Volumetric Modulated Arc Therapy (VMAT) offers better conformity, homogeneity and sparing of the heart and ipsilateral lung for locoregional radiotherapy in left-sided breast cancer compared to three-dimensional conformal radiotherapy (3D-CRT). However, conventional coplanar VMAT (cVMAT) can result in higher doses to the normal tissue on the contralateral side. This study investigates a non-coplanar VMAT-technique (ncVMAT) to mitigate this issue. MATERIAL AND METHODS CT series of 20 left sided breast cancer patients were included for planning of locoregional breast radiotherapy including internal mammary nodes (IMN). Three treatment plans; 3D-CRT, cVMAT and ncVMAT, were generated for each patient with a prescription dose of 40.05 Gy in 15 fractions. Both VMAT-techniques consisted of a single arc in the axial plane, while ncVMAT included an additional arc in the sagittal plane. All plans were optimized to cover the clinical target volume (CTV) by 38.05 Gy for the breast and 36.05 Gy for lymph nodes, with as low as possible dose to organs at risk. RESULTS Full CTV coverage was achieved for all plans. Both cVMAT and ncVMAT delivered more conformal and homogeneous target doses than 3D-CRT. Doses to the heart and ipsilateral lung were significantly lower with ncVMAT compared to both cVMAT and 3D-CRT. ncVMAT reduced doses to both the contralateral breast and lung compared to cVMAT and achieved levels similar to 3D-CRT for the contralateral breast and moderately higher doses for the contralateral lung. Delivery of high doses (>30 Gy) to the contralateral side was completely avoided with ncVMAT, contrary to the results for cVMAT and 3D-CRT. CONCLUSION ncVMAT reduced doses to the heart and ipsilateral lung as compared to both cVMAT and 3D-CRT. All contralateral dose metrics were reduced with the novel ncVMAT technique compared to cVMAT, and the mean contralateral breast doses were similar to 3D-CRT.
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Affiliation(s)
- Jomar Frengen
- Department of Radiotherapy, Cancer Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Johan Vikström
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Ingvil Mjaaland
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Marit Funderud
- Department of Radiotherapy, Cancer Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Sigrun Saur Almberg
- Department of Radiotherapy, Cancer Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Kjell Ivar Dybvik
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
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Kaidar-Person O, Fortpied C, Hol S, Weltens C, Kirkove C, Budach V, Peignaux-Casasnovas K, van der Leij F, Vonk E, Valli M, Weidner N, Guckenberger M, Koiter E, Fourquet A, Bartelink H, Struikmans H, Poortmans P. The association of internal mammary and medial supraclavicular lymph node radiation technique with clinical outcomes: Results from the EORTC 22922/10925 randomised trial. Radiother Oncol 2022; 172:99-110. [PMID: 35568284 DOI: 10.1016/j.radonc.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/25/2022] [Accepted: 05/08/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The multicentre EORTC 22922/10925 trial (ClinicalTrials.gov, NCT00002851) was conducted between 1996 and 2004. The trial evaluated the effect of irradiation of the internal mammary and medial supraclavicular lymph node chains (IM-MS) vs no further radiation therapy (RT) on survival and cause of death in breast cancer stage I-III patients. At 15.7 years of median follow-up, a significant reduction of breast cancer specific mortality (BCSM) and any recurrence, not translating in improved overall survival (OS), and low absolute rates of side effects were found. The aim of the current analysis was to evaluate the association of RT techniques of IM-MS lymph node irradiation with long-term outcomes. PATIENTS AND METHODS Three RT techniques were used for IM-MS: a standard technique using a fixed set-up combining photon/electron beams to the IM and tangential fields to the breast or chest wall vs a standard-modified technique with minor adaptation for beam settings vs a more individualised technique based on individual localisation of the IM. Techniques used were fixed per institution over the duration of the trial. We performed an exploratory and descriptive analysis of the outcomes after 15 years follow-up for the three RT techniques. RESULTS Between July 1996 and January 2004, 46 radiation oncology departments from 13 countries accrued 4004 patients. Median follow-up was 15.7 years. The number of patients treated by each technique was 2440 (61%) by standard vs 635 (16%) by standard-modified vs 929 (23%) patients by individualised technique. The absolute improvements of oncological outcomes in terms of disease-free survival (DFS), OS and BCSM with IM-MS RT compared to no IM-MS RT were 6.8%, 4.9% and -5.8% for the individualised technique, vs 1.6%, 2.9% and -4.3% for modified standard and -1.4%, 1.1% and -3% for standard technique, respectively. The increase in 15-year rates of side effects due to IM-MS RT, both scored longitudinally and cross-sectionally, were similar among the techniques. CONCLUSION Even though a straightforward comparison by technique is not possible because of variations in baseline characteristics between institutions, our findings suggest that the use of more individualised RT techniques is associated with higher rates of oncological improvements without increased risks for late side effects.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel; GROW-School for Oncology and Developmental Biology or GROW (Maastro), Maastricht University, The Netherlands.
| | - Catherine Fortpied
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven Faculty of Medicine, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Volker Budach
- Department of Radiation Oncology and Radiotherapy, Comprehensive Cancer Center, Charite University Medicine, Berlin, Germany
| | | | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Ernest Vonk
- Institute for Radiation Oncology RISO, Deventer, The Netherlands
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
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Kundrát P, Rennau H, Remmele J, Sebb S, Simonetto C, Kaiser JC, Hildebrandt G, Wolf U, Eidemüller M. Anatomy-dependent lung doses from 3D-conformal breast-cancer radiotherapy. Sci Rep 2022; 12:10909. [PMID: 35764679 PMCID: PMC9240052 DOI: 10.1038/s41598-022-14149-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 06/02/2022] [Indexed: 12/14/2022] Open
Abstract
This study aims to identify key anatomic features that govern the individual variability of lung doses from breast-cancer radiotherapy. 3D conformal, intensity-modulated and hybrid techniques with 50.4 Gy whole-breast dose were planned for 128 patients. From their CT images, 17 anatomic measures were assessed and tested as predictors for lung dose-volume characteristics. Tangential techniques yielded mean ipsilateral lung doses in the range of 3–11 Gy. This inter-patient variability was explained to almost 40% by central lung distance, and to almost 60% if this measure was complemented by midplane lung width and maximum heart distance. Also the variability in further dose-volume metrics such as volume fractions receiving 5, 20 or 40 Gy could be largely explained by the anatomy. Multi-field intensity-modulated radiotherapy reduced high-exposed lung volumes, but resulted in higher mean ipsilateral lung doses and larger low-dose burden. Contralateral lung doses ranged from 0.3 to 1 Gy. The results highlight that there are large differences in lung doses among breast-cancer patients. Most of this inter-individual variability can be explained by a few anatomic features. The results will be implemented in a dedicated software tool to provide personalized estimates of long-term health risks related to breast-cancer radiotherapy. The results may also be used to identify favourable as well as problematic anatomies, and serve as a quick quantitative benchmark for individual treatment plans.
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Affiliation(s)
- Pavel Kundrát
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. .,Department of Radiation Dosimetry, Nuclear Physics Institute of the CAS, Na Truhlářce 39/64, 180 00, Prague 8, Libeň, Czech Republic.
| | - Hannes Rennau
- Department of Radiation Oncology, Universitätsmedizin Rostock Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Südring 75, 18059, Rostock, Germany
| | - Julia Remmele
- Department of Radiation Oncology, Universität Leipzig Klinik für Strahlentherapie, Stephanstraße 9a, 04103, Leipzig, Germany
| | - Sabine Sebb
- Department of Radiation Oncology, Universitätsmedizin Rostock Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Südring 75, 18059, Rostock, Germany
| | - Cristoforo Simonetto
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Jan Christian Kaiser
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, Universitätsmedizin Rostock Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Südring 75, 18059, Rostock, Germany
| | - Ulrich Wolf
- Department of Radiation Oncology, Universität Leipzig Klinik für Strahlentherapie, Stephanstraße 9a, 04103, Leipzig, Germany
| | - Markus Eidemüller
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
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Noblet C, Duthy M, Coste F, Saliou M, Samain B, Drouet F, Papazyan T, Moreau M. Implementation of volumetric-modulated arc therapy for locally advanced breast cancer patients: Dosimetric comparison with deliverability consideration of planning techniques and predictions of patient-specific QA results via supervised machine learning. Phys Med 2022; 96:18-31. [DOI: 10.1016/j.ejmp.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/10/2022] [Accepted: 02/15/2022] [Indexed: 12/21/2022] Open
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Excluding Lung Tissue from the PTV during Internal Mammary Irradiation. A Safe Technique for OAR-Sparing? Cancers (Basel) 2021; 13:cancers13081951. [PMID: 33919587 PMCID: PMC8073233 DOI: 10.3390/cancers13081951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022] Open
Abstract
Simple Summary The planning treatment volume (PTV) during internal mammary irradiation (IMNI) regularly overlaps with lung tissue and is often in close proximity to the heart. Thus, exclusion of lung tissue from the PTV is a potential technique to spare the organs at risk (OARs) during adjuvant breast cancer irradiation. Using an innovative dose recalculation and accumulation algorithm, we evaluated the safety of exclusion of lung tissue from the PTV. According to our data, exclusion of lung tissue from the PTV to spare the OARs leads to significant dose reduction in the target volume and can, therefore, not be recommended. Abstract The current study aims to determine whether exclusion of lung tissue from planning treatment volume (PTV) is a valid organ at risk (OAR)-sparing technique during internal mammary irradiation (IMNI). Twenty patients with left-sided breast cancer undergoing adjuvant radiotherapy including IMNI after mastectomy or lumpectomy with daily ConeBeam CT (CBCT; median n = 28) were enrolled in the current study. The daily dose distribution of the patients was estimated by recalculating treatment plans on CBCT-scans based on a standard PTV (PTV margin: 5mm-STD) and a modified PTV, which excluded overlapping lung tissue (ExLung). Using 3D-deformable dose accumulation, the dose coverage in the target volume was estimated in dependence of the PTV-margins. The estimated delivered dose in the IMN-CTV was significantly lower for the ExLung PTV compared to the STD PTV: ExLung: V95%: 76.6 ± 22.9%; V90%: 89.6 ± 13.2%, STD: V95%: 95.6 ± 7.4%; V90%: 99.1 ± 2.7%. Daily CBCT imaging cannot sufficiently compensate the anatomic changes and intrafraction movement throughout the treatment. Therefore, to ensure adequate delivery of the prescribed dose to the IMN-CTV, exclusion of lung tissue from the PTV to spare the OARs is not recommended.
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Chang KH, Chang JS, Park K, Chung SY, Kim SY, Park RH, Han MC, Kim J, Kim H, Lee H, Kim DW, Kim YB, Kim JS, Hong CS. A Retrospective Dosimetric Analysis of the New ESTRO-ACROP Target Volume Delineation Guidelines for Postmastectomy Volumetric Modulated Arc Therapy After Implant-Based Immediate Breast Reconstruction. Front Oncol 2020; 10:578921. [PMID: 33194701 PMCID: PMC7606939 DOI: 10.3389/fonc.2020.578921] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/16/2020] [Indexed: 01/07/2023] Open
Abstract
Purpose: The European Society of Radiation & Oncology and Advisory Committee on Radiation Oncology Practice (ESTRO-ACROP) presented new guidelines for clinical target volume (CTV) delineation in post-mastectomy radiation therapy (PMRT) after implant-based immediate breast reconstruction (IBR-i). This study evaluated the dosimetric characteristics, dosimetric accuracy, and delivery accuracy of these guidelines in volumetric modulated arc therapy (VMAT). Methods and Materials: This retrospective study included 15 patients with left breast cancer who underwent mastectomy with tissue expander placement followed by PMRT. An experienced radiation oncologist delineated the CTV twice on the same image datasets based on the ESTRO-ACROP (EA-TVD) and conventional target volume delineation (C-TVD) guidelines. All VMAT plans, which used a double partial arc, were generated using six MV photons. Clinically relevant dose-volume parameters for organs at risk were compared. Dosimetric accuracy of the treatment plans and delivery accuracy were assessed. Results: Target volume of EA-TVD was significantly smaller than that of C-TVD. Although no statistically significant difference was noted in the target coverage between the two VMAT plans, EA-TVD VMAT significantly reduced the mean heart dose (3.99 ± 1.02 vs. 5.84 ± 1.78 Gy, p = 0.000), the maximum left anterior descending coronary artery (LAD) dose (9.43 ± 3.04 vs. 13.97 ± 6.04 Gy, p = 0.026), and the mean LAD dose (4.52 ± 1.31 vs. 6.35 ± 2.79 Gy, p = 0.028) compared with C-TVD VMAT. No significant difference was observed with respect to the total monitor units, plan complexity, and delivery quality assurance. Conclusions: This is the first study to show significant dose reduction for the normal heart and LAD tissue offered by the EA-TVD, while maintaining dosimetric and delivery accuracy, in PMRT after IBR-i in VMAT for left-sided breast cancer patients.
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Affiliation(s)
- Kyung Hwan Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Kwangwoo Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Yeun Chung
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Se Young Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ryeong Hwang Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Cheol Han
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jihun Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hojin Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ho Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Wook Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Chae-Seon Hong
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
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