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Putz F, Bock M, Schmitt D, Bert C, Blanck O, Ruge MI, Hattingen E, Karger CP, Fietkau R, Grigo J, Schmidt MA, Bäuerle T, Wittig A. Quality requirements for MRI simulation in cranial stereotactic radiotherapy: a guideline from the German Taskforce "Imaging in Stereotactic Radiotherapy". Strahlenther Onkol 2024; 200:1-18. [PMID: 38163834 PMCID: PMC10784363 DOI: 10.1007/s00066-023-02183-6] [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: 09/01/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024]
Abstract
Accurate Magnetic Resonance Imaging (MRI) simulation is fundamental for high-precision stereotactic radiosurgery and fractionated stereotactic radiotherapy, collectively referred to as stereotactic radiotherapy (SRT), to deliver doses of high biological effectiveness to well-defined cranial targets. Multiple MRI hardware related factors as well as scanner configuration and sequence protocol parameters can affect the imaging accuracy and need to be optimized for the special purpose of radiotherapy treatment planning. MRI simulation for SRT is possible for different organizational environments including patient referral for imaging as well as dedicated MRI simulation in the radiotherapy department but require radiotherapy-optimized MRI protocols and defined quality standards to ensure geometrically accurate images that form an impeccable foundation for treatment planning. For this guideline, an interdisciplinary panel including experts from the working group for radiosurgery and stereotactic radiotherapy of the German Society for Radiation Oncology (DEGRO), the working group for physics and technology in stereotactic radiotherapy of the German Society for Medical Physics (DGMP), the German Society of Neurosurgery (DGNC), the German Society of Neuroradiology (DGNR) and the German Chapter of the International Society for Magnetic Resonance in Medicine (DS-ISMRM) have defined minimum MRI quality requirements as well as advanced MRI simulation options for cranial SRT.
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Affiliation(s)
- Florian Putz
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Michael Bock
- Klinik für Radiologie-Medizinphysik, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Daniela Schmitt
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Christoph Bert
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Maximilian I Ruge
- Klinik für Stereotaxie und funktionelle Neurochirurgie, Zentrum für Neurochirurgie, Universitätsklinikum Köln, Cologne, Germany
| | - Elke Hattingen
- Institut für Neuroradiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Christian P Karger
- Abteilung Medizinische Physik in der Strahlentherapie, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
- Nationales Zentrum für Strahlenforschung in der Onkologie (NCRO), Heidelberger Institut für Radioonkologie (HIRO), Heidelberg, Germany
| | - Rainer Fietkau
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johanna Grigo
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel A Schmidt
- Neuroradiologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Bäuerle
- Radiologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andrea Wittig
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Würzburg, Würzburg, Germany
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Maksoud Z, Schmidt MA, Huang Y, Rutzner S, Mansoorian S, Weissmann T, Bert C, Distel L, Semrau S, Lettmaier S, Eyüpoglu I, Fietkau R, Putz F. Transient Enlargement in Meningiomas Treated with Stereotactic Radiotherapy. Cancers (Basel) 2022; 14:cancers14061547. [PMID: 35326697 PMCID: PMC8946188 DOI: 10.3390/cancers14061547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Accurate assessment of treatment efficacy is a prerequisite for the improvement in therapeutic outcomes in clinical trials. However, it is very challenging to accurately track the size of meningiomas after radiotherapy, because of their complex shapes and often slow growth. Measuring the whole tumor volume as opposed to simple diameter measurements to assess treatment efficacy, therefore, is very promising but little is known on expected volumetric changes of meningiomas following radiotherapy. Therefore, in this study, we meticulously investigated volumetric changes in meningiomas following radiotherapy incorporating volumetric measurements from 468 MRI studies and evaluated newly proposed RANO volumetric criteria in the context of radiotherapy. We found that temporary tumor enlargement after radiotherapy overall was rare but occurred significantly more frequently after high than after low single doses of radiation, represented an important differential diagnosis to tumor progression and would have skewed results in a clinical trial if not accounted for. Abstract To investigate the occurrence of pseudoprogression/transient enlargement in meningiomas after stereotactic radiotherapy (RT) and to evaluate recently proposed volumetric RANO meningioma criteria for response assessment in the context of RT. Sixty-nine meningiomas (benign: 90%, atypical: 10%) received stereotactic RT from January 2005–May 2018. A total of 468 MRI studies were segmented longitudinally during a median follow-up of 42.3 months. Best response and local control were evaluated according to recently proposed volumetric RANO criteria. Transient enlargement was defined as volumetric increase ≥20% followed by a subsequent regression ≥20%. The mean best volumetric response was −23% change from baseline (range, −86% to +19%). According to RANO, the best volumetric response was SD in 81% (56/69), MR in 13% (9/69) and PR in 6% (4/69). Transient enlargement occurred in only 6% (4/69) post RT but would have represented 60% (3/5) of cases with progressive disease if not accounted for. Transient enlargement was characterized by a mean maximum volumetric increase of +181% (range, +24% to +389 %) with all cases occurring in the first year post-RT (range, 4.1–10.3 months). Transient enlargement was significantly more frequent with SRS or hypofractionation than with conventional fractionation (25% vs. 2%, p = 0.015). Five-year volumetric control was 97.8% if transient enlargement was recognized but 92.9% if not accounted for. Transient enlargement/pseudoprogression in the first year following SRS and hypofractionated RT represents an important differential diagnosis, especially because of the high volumetric control achieved with stereotactic RT. Meningioma enlargement during subsequent post-RT follow-up and after conventional fractionation should raise suspicion for tumor progression.
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Affiliation(s)
- Ziad Maksoud
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Manuel Alexander Schmidt
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Yixing Huang
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Sandra Rutzner
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Sina Mansoorian
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Luitpold Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Sabine Semrau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Ilker Eyüpoglu
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
- Department of Neurosurgery, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitaetsstraße 27, 91054 Erlangen, Germany; (Z.M.); (Y.H.); (S.R.); (S.M.); (T.W.); (C.B.); (L.D.); (S.S.); (S.L.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.A.S.); (I.E.)
- Correspondence: ; Tel.: +49-9131-853-4080
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Extracranial temporal bone paragangliomas: Re-defining the role of otologic surgery within the scope of function-preserving multimodal concepts. Am J Otolaryngol 2022; 43:103212. [PMID: 34536923 DOI: 10.1016/j.amjoto.2021.103212] [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: 07/26/2021] [Accepted: 09/05/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The aim of this study was to present our concept in the management of extracranial temporal bone paragangliomas and demonstrate the outcome after primary surgical management of the middle ear component, with an individualized indication for adjuvant radiotherapy. MATERIALS AND METHODS The records of all patients treated for extracranial jugulotympanic paragangliomas by means of primary surgical management between 2010 and 2021 were studied retrospectively. RESULTS Twenty-nine patients made up our study sample (mean age 58.8 years). 15 cases were managed solely by means of surgery. Out of the remaining 14 cases with reduction of the middle ear component, adjuvant irradiation was performed in 11 cases, whereas a wait-and-scan strategy was adopted at the patient's request in three cases. No further growth was detected in our study cases. CONCLUSION Our protocol seems to be associated with an acceptable quality of life and a satisfactory oncologic outcome.
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Bürkel F, Jost T, Hecht M, Heinzerling L, Fietkau R, Distel L. Dual mTOR/DNA-PK Inhibitor CC-115 Induces Cell Death in Melanoma Cells and Has Radiosensitizing Potential. Int J Mol Sci 2020; 21:ijms21239321. [PMID: 33297429 PMCID: PMC7730287 DOI: 10.3390/ijms21239321] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
CC-115 is a dual inhibitor of the mechanistic target of rapamycin (mTOR) kinase and the DNA-dependent protein kinase (DNA-PK) that is currently being studied in phase I/II clinical trials. DNA-PK is essential for the repair of DNA-double strand breaks (DSB). Radiotherapy is frequently used in the palliative treatment of metastatic melanoma patients and induces DSBs. Melanoma cell lines and healthy-donor skin fibroblast cell lines were treated with CC‑115 and ionizing irradiation (IR). Apoptosis, necrosis, and cell cycle distribution were analyzed. Colony forming assays were conducted to study radiosensitizing effects. Immunofluorescence microscopy was performed to determine the activity of homologous recombination (HR). In most of the malign cell lines, an increasing concentration of CC-115 resulted in increased cell death. Furthermore, strong cytotoxic effects were only observed in malignant cell lines. Regarding clonogenicity, all cell lines displayed decreased survival fractions during combined inhibitor and IR treatment and supra-additive effects of the combination were observable in 5 out of 9 melanoma cell lines. CC-115 showed radiosensitizing potential in 7 out of 9 melanoma cell lines, but not in healthy skin fibroblasts. Based on our data CC-115 treatment could be a promising approach for patients with metastatic melanoma, particularly in the combination with radiotherapy.
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Affiliation(s)
- Felix Bürkel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany; (F.B.); (T.J.); (M.H.); (R.F.)
| | - Tina Jost
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany; (F.B.); (T.J.); (M.H.); (R.F.)
| | - Markus Hecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany; (F.B.); (T.J.); (M.H.); (R.F.)
| | - Lucie Heinzerling
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054 Erlangen, Germany;
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany; (F.B.); (T.J.); (M.H.); (R.F.)
| | - Luitpold Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054 Erlangen, Germany; (F.B.); (T.J.); (M.H.); (R.F.)
- Correspondence: ; Tel.: +49-9131-85-32312
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Putz F, Weissmann T, Oft D, Schmidt MA, Roesch J, Siavooshhaghighi H, Filimonova I, Schmitter C, Mengling V, Bert C, Frey B, Lettmaier S, Distel LV, Semrau S, Fietkau R. FSRT vs. SRS in Brain Metastases-Differences in Local Control and Radiation Necrosis-A Volumetric Study. Front Oncol 2020; 10:559193. [PMID: 33102223 PMCID: PMC7554610 DOI: 10.3389/fonc.2020.559193] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022] Open
Abstract
Background: While the role of stereotactic radiotherapy for brain metastases is increasing, evidence on the comparative efficacy and safety of fractionated stereotactic radiotherapy (FSRT) and single-session radiosurgery (SRS) is scarce. Methods: Longitudinal volumetric analysis was performed in a consecutive cohort of 120 patients and 190 brain metastases (>0.065 cm3 in volume / > ~5 mm in diameter) treated exclusively with FSRT (n = 98) and SRS (n = 92), respectively. A total of 972 tumor segmentations was used, averaging 5.1 time points per metastasis. Progression was defined using a volumetric extension of the RANO-BM criteria. Local control and radionecrosis were compared for lesions treated with FSRT and SRS, respectively. Results: Metastases treated with FSRT were significantly larger at baseline (mean, 4.66 vs. 0.40 cm3, p < 0.001). Biologically effective dose (BED) for metastases (α/β = 12, linear-quadratic-cubic model) was significantly associated with local control, whereas BED for normal brain (α/β = 2, linear-quadratic model) was significantly associated with radionecrosis. Median time to local progression was 22.9 months in the FSRT group compared to 14.5 months in the SRS group (p = 0.022). Overall radionecrosis rate at 12 months was 3.4% for FSRT and 14.8% for SRS (p = 0.010). Radionecrosis °IV requiring resection with histologic proof of radiation necrosis also was significantly reduced in the FSRT group (FSRT 0.0% vs. SRS 3.9%, p = 0.041). In multivariate analysis, FSRT was associated with reduced risk of progression (HR 0.47, p = 0.015) and reduced risk of radionecrosis (HR 0.18, p = 0.045). Conclusions: This volumetric study provides initial evidence that the improvements in therapeutic ratio expected for FSRT in larger brain metastases, might equally extend into the domain of smaller metastases, traditionally less considered for fractionated treatment. FSRT might constitute an important tool to further increase local control and reduce radionecrosis risk in stereotactic radiotherapy for brain metastases, that should be assessed in randomized intervention trials.
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Affiliation(s)
- Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dominik Oft
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hadi Siavooshhaghighi
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Irina Filimonova
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Charlotte Schmitter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Veit Mengling
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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