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Ji MC, Li ZJ, Li K, Wang YX, Yang B, Lv LL, Su Y, Zhang ZW, Huo ZC, Qi Q, Lu YC, Cui ZQ, Liu YB. Dosimetric risk factors for radiation esophagitis in patients with breast cancer following regional nodal radiation. World J Clin Cases 2024; 12:2995-3003. [PMID: 38898857 PMCID: PMC11185373 DOI: 10.12998/wjcc.v12.i17.2995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/25/2024] [Accepted: 04/22/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Radiation esophagitis (RE) is one of the most common clinical symptoms of regi-onal lymph node radiotherapy for breast cancer. However, there are fewer studies focusing on RE caused by hypofractionated radiotherapy (HFRT). AIM To analyze the clinical and dosimetric factors that contribute to the development of RE in patients with breast cancer treated with HFRT of regional lymph nodes. METHODS Between January and December 2022, we retrospectively analysed 64 patients with breast cancer who met our inclusion criteria underwent regional nodal intensity-modulated radiotherapy at a radiotherapy dose of 43.5 Gy/15F. RESULTS Of the 64 patients in this study, 24 (37.5%) did not develop RE, 29 (45.3%) developed grade 1 RE (G1RE), 11 (17.2%) developed grade 2 RE (G2RE), and none developed grade 3 RE or higher. Our univariable logistic regression analysis found G2RE to be significantly correlated with the maximum dose, mean dose, relative volume 20-40, and absolute volume (AV) 20-40. Our stepwise linear regression analyses found AV30 and AV35 to be significantly associated with G2RE (P < 0.001). The optimal threshold for AV30 was 2.39 mL [area under the curve (AUC): 0.996; sensitivity: 90.9%; specificity: 91.1%]. The optimal threshold for AV35 was 0.71 mL (AUC: 0.932; sensitivity: 90.9%; specificity: 83.9%). CONCLUSION AV30 and AV35 were significantly associated with G2RE. The thresholds for AV30 and AV35 should be limited to 2.39 mL and 0.71 mL, respectively.
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Affiliation(s)
- Mei-Chen Ji
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Zhi-Jia Li
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Ke Li
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Yun-Xiao Wang
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Bo Yang
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Lin-Lin Lv
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Ying Su
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Zhi-Wei Zhang
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Zhong-Chao Huo
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Qing Qi
- Oncology Center, The Affiliated Hospital of Hebei University of En-gineering, Handan 056002, Hebei Province, China
| | - Yong-Chang Lu
- General Surgery Department, Handan First Hospital, Handan 056002, Hebei Province, China
| | - Zhi-Qiang Cui
- Department of Breast Surgery, The Affiliated Hospital of Hebei University of Engineering, Handan 056002, Hebei Province, China
| | - Yan-Bao Liu
- School of Clinical Medicine, Hebei University of Engineering, Handan 056002, Hebei Province, China
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Sharmin S, Sultana R, Mollah NU, Rasheed MO, Anika AS, Rassell M. Association of Radiation-Induced Acute Esophagitis With Dosimetric Parameters of Oesophagus in Breast Carcinoma Patients Receiving Supraclavicular Nodal Irradiation. Cureus 2024; 16:e60778. [PMID: 38903289 PMCID: PMC11188969 DOI: 10.7759/cureus.60778] [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: 04/26/2024] [Accepted: 05/20/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION We conducted this investigation to ascertain the dosimetric properties such as the mean and maximum radiation dosage during radiotherapy as well as the extent of radiation exposure to the esophagus. These factors can potentially impact the development of esophagitis in breast cancer patients undergoing supraclavicular radiation. METHODOLOGY From January to June 2023, an observational study was conducted at Bangabandhu Sheikh Mujib Medical University in Bangladesh. The patients received radiation therapy (40.05 Gy in 15 parts) to the chest wall and supraclavicular node for three weeks. We were able to guess the following from the dose volume histogram (DVH) data: the length of the esophagus in the treatment area (i.e., the size of the esophagus that was visible on the planning CT scan), the maximum dose (Dmax), the mean dose (Dmean), and the volume of the 10Gy (V10Gy) and 20Gy (V20Gy) doses that were given to the esophagus. During radiotherapy, patients were checked on once a week, and the radiotherapy oncology group was used to evaluate and grade esophagitis Results: Patients with left-sided breast cancer showed a higher Dmean, Dmax, and length of the esophagus compared to those with right-sided breast cancer. Specifically, the Dmean was 6.7 (±2.1) Gy, the Dmax was 39.2 (±1.5) Gy, and the length of the esophagus was 6.1 (±1.2) Gy. Patients with left breast cancer had elevated V10Gy and V20Gy values for the esophagus, but the difference was not statistically significant. The incidence of V10Gy for right-sided breast cancer and left-sided breast cancer was 4.2% (±2.6%) and 19.8% (±9.2%), respectively. The V20Gy was 2.4% (±0.9%) for right-sided breast cancer and 13.09% (±5.0%) for left-sided breast cancer Conclusion: In conclusion, there is a strong association between the mean oesophageal dose and radiation to the left supraclavicular region following surgery in women with breast cancer and acute esophagitis. We can reduce esophageal toxicity by prescribing dose restrictions and performing precise delineation of the esophagus.
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Affiliation(s)
- Sadia Sharmin
- Department of Clinical Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Rokaya Sultana
- Department of Clinical Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Nazir Uddin Mollah
- Department of Clinical Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Mamun O Rasheed
- Department of Clinical Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Afsana Sharmin Anika
- Department of Clinical Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Md Rassell
- Department of Surgical Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
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Wang DQ, Zhang N, Dong LH, Zhong YH, Wu HF, Zhong QZ, Jin J, Hou XR, Jing H, Tang Y, Hu C, Song YW, Liu YP, Qi SN, Tang Y, Lu NN, Chen B, Zhai YR, Zhang WW, Li N, Fang H, Li YX, Wang SL. Dose-Volume Predictors for Radiation Esophagitis in Patients With Breast Cancer Undergoing Hypofractionated Regional Nodal Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:186-197. [PMID: 37001764 DOI: 10.1016/j.ijrobp.2023.03.060] [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: 12/10/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE Our objective was to assess the incidence and dose-volume predictors of radiation esophagitis (RE) in patients with breast cancer undergoing hypofractionated regional nodal irradiation. METHODS AND MATERIALS Eligible patients who received intensity modulated radiation therapy (RT) at the chest wall, the supraclavicular/infraclavicular fossa, level II axilla, and/or the internal mammary chain after mastectomy were included. The prescribed dose was 43.5 Gy in 15 fractions. RE was evaluated weekly during RT and at 1 and 2 weeks, followed by 3 and 6 months after RT, and was graded according to National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0. The esophagus was contoured from the lower border level of the cricoid cartilage to the lower margin of the aortic arch. Esophageal total volume, mean dose, maximum dose, and the relative volumes (RV) and absolute volumes (AV) receiving at least 5 to 45 Gy by 5-Gy increments (RV5-RV45 and AV5-AV45) were evaluated. Univariable and multivariable logistic regression analyses were performed to determine risk factors for RE, and receiver operating characteristic curves were obtained to identify the thresholds of esophageal dosimetric parameters. RESULTS In total, 298 patients were included between May 8, 2020, and January 5, 2022 (minimum post-RT follow-up: 6 months). Grade 2 and 3 RE incidence was 40.9% (122/298) and 0.3% (1/298), respectively. No grade 4 or 5 RE was observed. Esophageal RV20-RV40 and AV35-AV40 were significantly associated with the risk of grade ≥2 RE after adjusting for tumor laterality and internal mammary nodal irradiation. RV25 and AV35 were optimum dose-volume predictors for grade ≥2 RE at thresholds 20% for RV25 (35.9% vs 60.9%; P = .04) and 0.27 mL for AV35 (31.0% vs 54.6%; P = .04). CONCLUSIONS RE is common in patients with breast cancer undergoing hypofractionated regional nodal irradiation. Maintaining the upper esophageal V25 at <20% and V35 at <0.27 mL may decrease the risk of RE.
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Affiliation(s)
- Dan-Qiong Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Zhang
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Li-Hua Dong
- Department of Radiation Oncology, First Hospital, Jilin University, Changchun, China
| | - Ya-Hua Zhong
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, China
| | - Hong-Fen Wu
- Department of Radiation Oncology, Cancer Hospital of Jilin Province, Changchun, China
| | - Qiu-Zi Zhong
- Department of Radiation Oncology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Xiao-Rong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Beijing, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Rui Zhai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Mohammed Amin SS, Faraj KA, Kamangar TM, Yarahmadi M. Comparison of esophagus dose in breast cancer patients undergoing supraclavicular irradiation with and without esophagus countering. J Cancer Res Ther 2023; 19:S603-S607. [PMID: 38384025 DOI: 10.4103/jcrt.jcrt_771_22] [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: 04/09/2022] [Accepted: 07/13/2022] [Indexed: 02/23/2024]
Abstract
CONTEXT Esophagus toxicity and the risk of esophageal cancer are linked to radiation dose to the esophagus in breast cancer patients undergoing supraclavicular irradiation. AIMS The aim of this study was to evaluate the impact of esophagus contouring on the dose received in the esophagus in breast cancer patients undergoing supraclavicular irradiation. SETTING AND DESIGN This study included 30 treatment plans for breast cancer patients who received 50 Gy/25 fractions (2 Gy/fraction/day) using 3D-conformal radiation therapy (3D-CRT) to the whole breast or chest wall and supraclavicular. METHODS AND MATERIALS Our study included two groups: the non-sparing group was the treatment plan in which the esophagus was not delineated and the esophagus sparing group was generated, in which the plans were modified to spare the esophagus. The maximum dose, mean dose, and percentage of esophagus volume received, 5, 10, 15, and 20 Gy, respectively (V5, V10, V15, and V20), were used to evaluate both groups. STATISTICAL ANALYSIS One-way analysis of variance was used. A P value <0.05 was considered statistically significant. RESULTS The esophagus sparing group plans show a reduction in the esophageal mean dose Dmean (5.72 ± 5.15) Gy when compared to the non-sparing group (7.83 ± 3.31) Gy. Likewise, the maximum dose, V5, V10, V15, and V20 were reduced in the esophagus sparing group. All dosimetric parameters were significantly higher (P < 0.05) in patients with left breast cancer for both groups. CONCLUSION Our results suggest that it is possible to reduce the dose to the esophagus by considering the esophagus during treatment planning while maintaining plan quality. This reduction could lead to the greatest predicted decrease in acute esophagitis and esophageal cancer.
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Affiliation(s)
- Soma S Mohammed Amin
- Department of Anesthesia, College of Health and Medical Technology in Sulaimani, Sulaimaniyah Polytechnic University, Sulaimaniyah, Iran
| | - Kharman A Faraj
- Department of Physics, College of Science, University of Sulaimani, Sulaimaniyah, Iran
| | - Tara Molanaie Kamangar
- Cancer and Immunology Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mehran Yarahmadi
- Cancer and Immunology Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Amin SSM, Faraj KA, Ali JS, Rahim HAH, Yarahmadi M. Prediction Factors of Radiation Esophagitis in Breast Cancer Patients Undergoing Supraclavicular Radiotherapy. J Med Phys 2023; 48:38-42. [PMID: 37342603 PMCID: PMC10277297 DOI: 10.4103/jmp.jmp_84_22] [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: 09/16/2022] [Revised: 01/13/2023] [Accepted: 01/28/2023] [Indexed: 06/23/2023] Open
Abstract
Purpose The aim of this study was to investigate demographic and dosimetric parameters which may link with esophagitis in patients with breast cancer receiving three-dimensional conformal radiotherapy to the supraclavicular fossa. Materials and Methods We examined 27 breast cancer patients with supraclavicular metastases. All patients were treated with radiotherapy (RT) with a prescribed dose of 40.5 Gy in 15 fractions for 3 weeks. Esophagitis was recorded weekly and esophagus toxicity was evaluated and graded according to the tadiation therapy oncology group. The following factors were examined regarding their correlation with grade 1 or worse esophagitis by univariate and multivariate analyses: age, chemotherapy, smoking history, maximum dose (Dmax), mean dose (Dmean), esophagus volume receiving 10 Gy (V10), esophagus volume receiving 20 Gy (V20), and length of esophagus in the treatment field. Results Of 27, 11 (40.7%) patients developed no esophageal irritation throughout therapy. Approximately half of the patients 13/27 (48.1%) had maximum grade 1 esophagitis. 2/27 (7.4%) patients had grade 2 esophagitis. The incidence of grade 3 esophagitis was (3.7%). Dmean, Dmax, V10, and V20 were 10.48 ± 5.10 Gy, 38.18 ± 5.12Gy, 29.83 ± 15.16, and 19.32 ± 10.01, respectively. Our results showed that Dmean, V10, and V20 were the significant factors for the development of esophagitis, whereas esophagitis was not significantly associated with the chemotherapy regimen, age, and smoking status. Conclusions We found that Dmean, V10, and V20 correlated significantly with acute esophagitis. However, the chemotherapy regimen, age, and smoking status did not affect esophagitis development.
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Affiliation(s)
- Soma Saeed Mohammed Amin
- Department of Anesthesia, College of Health and Medical Technology in Sulaimani, Sulaimani Polytechnic University, Sulaimaniyah, Iraq
| | - Kharman Akarm Faraj
- Department of Physics, College of Science, University of Sulaimani, Sulaimaniyah, Iraq
| | - Jalil Salih Ali
- Department of Radiotherapy, Medical Physics Zhianawa Cancer Center, Sulaimaniyah, Iraq
| | | | - Mehran Yarahmadi
- Cancer and Immunology Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Lapen K, King C, Braunstein LZ, Khan AJ, Kamrava MR, Gillespie EF, Cook KA. A Comparison of Patient- and Clinician-Reported Acute Toxic Effects During Radiation Therapy for Primary Breast Cancer. Int J Radiat Oncol Biol Phys 2022; 114:301-309. [PMID: 35675851 PMCID: PMC10281649 DOI: 10.1016/j.ijrobp.2022.05.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Evidence suggests that cancer treatment-related toxic effects are underreported by clinicians. We sought to compare patient- and clinician-reported acute toxic effects among patients undergoing radiation therapy for primary breast cancer and to determine factors associated with patient-clinician discordance. METHODS AND MATERIALS Patient responses from a weekly Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events based assessment were matched to clinician assessments of acute toxic effects during treatment. Weighted κ statistics were used to evaluate agreement between patient and clinician assessments. Linear regression, logistic regression, and generalized estimating equation models were used to identify covariates associated with discordance. RESULTS Overall, 842 patient-clinician assessment pairs from 376 unique patients were analyzed. Total symptom burden score was higher for patients than clinicians (4.7 vs 2.3, P < .01). Dermatitis, pruritis, pain, and edema items were classified as having minimal agreement (κ of 0.25, 0.23, 0.20, and 0.25, respectively). Fatigue (κ 0.17) and psychosocial (0.03) patient-clinician pairs were found to have no agreement. The linear regression demonstrated that assessments by patients who identified as Black or African American were associated with a 0.13-point decrease in discordance (95% confidence interval, -0.25 to -0.01), while time from the start of treatment was associated with increased discordance (95% confidence interval, 0.07-0.12). CONCLUSIONS For patients undergoing breast radiation therapy, discordance in patient and clinician symptom reporting is high and increases as treatment progresses. The mechanism of reduced discordance among Black or African American patients warrants further investigation. Prospective studies are needed to determine whether interventions for lower severity symptoms, which are commonly overlooked by clinicians, can reduce symptom burden and improve patient quality of life during radiation therapy.
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Affiliation(s)
- Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Caroline King
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mitchell R Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kiri A Cook
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon.
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Ranger A, Dunlop A, Hansen VN, Princewill G, Landeg S, Donovan EM, Harris EJ, McNair HA, Haviland J, Kirby AM. A Randomised Phase II Clinical Trial Comparing the Deliverability and Acute Toxicity of Wide Tangent versus Volumetric Modulated Arc Therapy to the Breast and Internal Mammary Chain. Clin Oncol (R Coll Radiol) 2022; 34:526-533. [PMID: 35597698 DOI: 10.1016/j.clon.2022.03.020] [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: 08/09/2021] [Revised: 02/18/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
AIMS Inclusion of the internal mammary chain in the radiotherapy target volume (IMC-RT) improves disease-free and overall survival in higher risk breast cancer patients, but increases radiation doses to heart and lungs. Dosimetric data show that either modified wide-tangential fields (WT) or volumetric modulated arc therapy (VMAT) together with [AQ1]voluntary deep inspiration breath hold (vDIBH) keep mean heart doses below 4 Gy in most patients. However, the impact on departmental resources has not yet been documented. This phase II clinical trial compared the time taken to deliver IMC-RT using either WT and vDIBH or VMAT and vDIBH, together with planning time, dosimetry, set-up reproducibility and toxicity. MATERIALS AND METHODS Left-sided breast cancer patients requiring IMC-RT were randomised to receive either WT(vDIBH) or VMAT radiotherapy. The primary outcome was treatment time, powered to detect a minimum difference of 75 min (5 min/fraction) between techniques. The population mean displacement, systematic error and random error for cone beam computed tomography chest wall matches in three directions of movement were calculated. Target volume and organ at risk doses were compared between groups. Side-effects, including skin (Radiation Therapy Oncology Group), lung and oesophageal toxicity (Common Terminology Criteria for Adverse Events v 4.03) rates, were compared between the groups over 3 months. Patient-reported outcome measures, including shoulder toxicity at baseline, 6 months and 1 year, were compared. RESULTS Twenty-one patients were recruited from a single UK centre between February 2017 and January 2018. The mean (standard deviation) total treatment time per fraction for VMAT treatments was 13.2 min (1.7 min) compared with 28.1 min (3.3 min) for WT(vDIBH). There were no statistically significant differences in patient set-up errors in between groups. The average mean heart dose for WT(vDIBH) was 2.6 Gy compared with 3.4 Gy for VMAT(vDIBH) (P = 0.13). The mean ipsilateral lung V17Gy was 32.8% in the WT(vDIBH) group versus 34.4% in the VMAT group (P = 0.2). The humeral head (mean dose 16.8 Gy versus 2.8 Gy), oesophagus (maximum dose 37.3 Gy versus 20.1 Gy) and thyroid (mean dose 22.0 Gy versus 11.2 Gy) all received a statistically significantly higher dose in the VMAT group. There were no statistically significant differences in skin, lung or oesophageal toxicity within 3 months of treatment. Patient-reported outcomes of shoulder toxicity, pain, fatigue, breathlessness and breast symptoms were similar between groups at 1 year. CONCLUSION VMAT(vDIBH) and WT(vDIBH) are feasible options for locoregional breast radiotherapy including the IMC. VMAT improves nodal coverage and delivers treatment more quickly, resulting in less breath holds for the patient. This is at the cost of increased dose to some non-target tissues. The latter does not appear to translate into increased toxicity in this small study.
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Affiliation(s)
- A Ranger
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - A Dunlop
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - V N Hansen
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - G Princewill
- The Royal Marsden NHS Foundation Trust, London, UK
| | - S Landeg
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - E J Harris
- The Institute of Cancer Research, London, UK
| | - H A McNair
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - J Haviland
- The Institute of Cancer Research, London, UK
| | - A M Kirby
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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Comparison of dose volumetric parameters of oesophagus in the radiation treatment of carcinoma breast with and without oesophagus delineation. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396921000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Aim:
There are only limited studies available in literature that discuss methods to reduce the oesophageal dose and acute oesophagitis during breast cancer radiotherapy. The aim of this study is to compare dose volumetric parameters of oesophagus in radiation treatment of breast with and without oesophagus delineation.
Methods:
Treatment plans of 44 patients, who underwent chest wall and supraclavicular fossa irradiation, were selected for the study. Oesophagus was later delineated and treatment replanned using three-dimensional conformal radiotherapy (3DCRT) considering oesophagus as an organ at risk (OAR). The dose prescribed was 40 Gy/15 fractions to the planning target volume (PTV). Dose volumetric parameters of oesophagus such as maximum dose (Dmax), mean dose (Dmean), the percentage of oesophagus volume receiving ≥15Gy (V15), ≥25Gy(V25), ≥33Gy(V33) and ipsilateral lung volume parameters V4, V8 and V16 were compared with already executed plans in which oesophagus was not delineated.
Results:
Contouring the oesophagus as an OAR as a part of the radiotherapy treatment for Carcinoma Breast resulted in statistically significant reduction in dose to the oesophagus. No statistically significant change was found in the ipsilateral lung volume parameters. No compromise in plan quality was required as evident from the statistically non-significant differences in Homogeneity index and Conformity index.
Findings:
3DCRT planning with oesophagus delineation can be considered as a method to reduce oesophageal dose and the acute oesophageal toxicity during radiotherapy for carcinoma breast.
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Dzul S, Ninia J, Jang H, Kim S, Dominello M. Predictors of Acute Radiation Dermatitis and Esophagitis in African American Patients Receiving Whole Breast Radiotherapy. Pract Radiat Oncol 2021; 12:52-59. [PMID: 34710629 DOI: 10.1016/j.prro.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE/OBJECTIVES Adjuvant whole breast radiotherapy following breast conserving surgery is standard of care in the management of early stage breast cancer. Two of the most common acute toxicities of breast radiotherapy are radiation esophagitis (RE) and radiation dermatitis (RD). African Americans are at higher risk for experiencing treatment-related toxicity and are often under-represented in clinical trials. METHODS An institutional database was developed to include all African American patients with history of breast cancer or DCIS undergoing adjuvant radiotherapy at a single institution from 2013-2019. Records were reviewed to identify patient age, BMI, radiation dose, prone vs supine position, inclusion of boost, and inclusion of regional nodal irradiation (RNI). Radiation treatment plans were reviewed to identify breast size as well as dosimetric parameters to the breast and esophagus. Medical records were reviewed to identify which patients were prescribed silvadene or mylanta-lidocaine during or immediately following their course of radiotherapy which was used as a surrogate for Grade 2 or higher dermatitis (G2RD) and esophagitis (G2RE), respectively. RESULTS 272 patients were included in the final analysis. On univariable analysis, morbidly obese patients were more likely to develop G2RD while hypofractionated radiotherapy was associated with lower rates of G2RD. On multivariable analysis, increasing breast volume was associated with higher rates of G2RD. For the subset of patients receiving RNI, 19% of patients experienced G2RE with the best predictor on multivariable analysis being Dmean to the esophagus. CONCLUSION Radiation dermatitis and esophagitis are common toxicities in African American patients undergoing adjuvant breast radiotherapy. Breast size, irrespective of patient's BMI, was associated with worse rate of dermatitis. Prone position and hypofractionated radiation reduced rates of G2RD. Dmean to the esophagus was the dosimetric parameter best correlating with G2RE. These results may be used to help select patients are at higher risk for G2 or higher toxicity during radiotherapy.
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Affiliation(s)
- Stephen Dzul
- Wayne State University School of Medicine, Detroit, MI.
| | - James Ninia
- Wayne State University School of Medicine, Detroit, MI
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Adjuvant Trastuzumab Emtansine (T-DM1) and Concurrent Radiotherapy for Residual Invasive HER2-positive Breast Cancer: Single-center Preliminary Results. Am J Clin Oncol 2021; 43:895-901. [PMID: 33027084 DOI: 10.1097/coc.0000000000000769] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The treatment of nonmetastatic HER2-positive breast cancer with residual invasive disease using concurrent Trastuzumab emtansine (T-DM1) and radiotherapy appears to be an effective option. Our aim was to evaluate the acute side effects of this treatment regime. METHODS Fourteen patients were treated between March 2019 and April 2020 concurrent T-DM1 and radiotherapy. Left ventricular ejection fraction was assessed at baseline, before and after radiotherapy. All toxicities were evaluated using Common Terminology Criteria of Adverse Events (CTCAE) version 3.0. RESULTS The median age was 55 years (range 36 to 72). All patients received total dose of 50 Gy for the breast/ chest wall, 10 patients got lymph node irradiation, 4 patients received an additional tumor bed boost. The most common side effect was grade 1 radiodermatitis. A reversible grade 2 left ventricular ejection fraction decrease occurred in 2 patients. During our examination 3 patients showed alanine aminotransferases increase after the cycle 4 of T-DM1, 1 patient had grade 1, 1 patient grade 2, and 1 patient grade 3 alanine aminotransferase increases. CONCLUSIONS The acute toxicity rate especially focusing on skin and cardiac toxicity were assumed acceptable in our cohort. To safely administer this concomitant treatment, further examination and prospective data are needed.
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Yaney A, Ayan AS, Pan X, Jhawar S, Healy E, Beyer S, Lindsey K, Kuhn K, Tedrick K, White JR, Bazan JG. Dosimetric parameters associated with radiation-induced esophagitis in breast cancer patients undergoing regional nodal irradiation. Radiother Oncol 2020; 155:167-173. [PMID: 33157173 DOI: 10.1016/j.radonc.2020.10.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND/PURPOSE Rates of acute esophagitis in breast cancer patients undergoing regional nodal irradiation (RNI) are under-reported. We set to identify esophageal dose-volume constraints associated with grade 2 esophagitis (G2E). We hypothesized that the G2E rate was higher with intensity modulated radiation therapy (IMRT) vs. 3D conformal radiation therapy (3DCRT). MATERIALS/METHODS We identified patients that received RNI (50 Gy/25 fractions) from 1/2013 to 6/2019. We retrospectively contoured the esophagus in a consistent manner and recorded esophageal mean dose, max dose, and V10-V50. Our primary endpoint was the G2E rate. Receiver operating characteristics curves analysis (e.g., Youden's J statistic) were used to determine the cutpoints for the dosimetric parameters which were then tested in logistic regression models. RESULTS We identified 531 patients (50% left-sided; 41% IMRT; 16.2% G2E). G2E was significantly higher in IMRT vs. 3DCRT patients (23.6% vs. 10.9%, p < 0.0001). All esophageal dosimetric parameters were significantly associated with G2E after adjusting for age and laterality. The cutpoints for esophageal mean dose, V10 and V20 were 11 Gy, 30%, and 15%, respectively. The associations between the dichotomized dose-volume parameters and G2E were OR = 3.82 (95% CI 2.28-6.40, p < 0.0001) for esophageal mean dose, OR = 5.37 (95% CI 3.01-9.58, p < 0.0001) for esophageal V10, and OR = 3.23 (95% CI 1.93-5.41, p < 0.0001) for esophageal V20. CONCLUSION In patients receiving RNI with modern techniques, we found that G2E occurs in >15%, and more frequently with IMRT. These data strongly support the routine contouring of the esophagus in RNI planning, and our constraints should be incorporated in future prospective protocols of RNI.
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Affiliation(s)
- Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Ahmet S Ayan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Xueliang Pan
- Department of Biomedical Informatics, The Ohio State University, Columbus, USA.
| | - Sachin Jhawar
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Erin Healy
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Kylee Lindsey
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Karla Kuhn
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Kayla Tedrick
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Julia R White
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Jose G Bazan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
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Bazan JG, Healy E, Beyer S, Kuhn K, DiCostanzo D, Smith TL, Jhawar S, White JR. Clinical Effectiveness of an Adaptive Treatment Planning Algorithm for Intensity Modulated Radiation Therapy Versus 3D Conformal Radiation Therapy for Node-Positive Breast Cancer Patients Undergoing Regional Nodal Irradiation/Postmastectomy Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 108:1159-1171. [PMID: 32711036 DOI: 10.1016/j.ijrobp.2020.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Clinical trials support adjuvant regional nodal irradiation (RNI) after breast-conserving surgery or mastectomy for patients with lymph node-positive breast cancer. Advanced treatment planning techniques (eg, intensity modulated radiation therapy [IMRT]) can reduce dose to organs at risk (OARs) in this situation. However, uncertainty persists about when IMRT is clinically indicated (vs 3-dimensional conformal radiation therapy [3DCRT]) for RNI. We hypothesized that an adaptive treatment planning algorithm (TPA) for IMRT adoption would allow OAR constraints for RNI to be met when 3DCRT could not without significantly changing toxicity and locoregional recurrence (LRR) patterns. METHODS AND MATERIALS Since 2013, all RNI patients also underwent an adaptive TPA that began with 3DCRT and then changed to IMRT when OAR constraints (mean heart dose ≤500 cGy; ipsilateral lung V20 ≤35%) could not be met. Patients received 2 Gy/d to the prospectively contoured target volumes (including internal mammary nodes). We retrospectively evaluated the dosimetry and clinical outcomes of the treatment groups (IMRT vs 3DCRT). The primary endpoint was the cumulative incidence of LRR as the site of first recurrence, and we specifically address patterns of failure based on dose to the posterior supraclavicular nodal region (SCL-post). RESULTS Two hundred forty patients (60% stage III; mean 4.0 + nodes) underwent an adaptive-TPA for RNI after mastectomy (74%) or breast-conserving surgery (26%), resulting in 168 patients treated with 3DCRT and 72 patients treated with IMRT. There were 7 LRRs (2 IMRT, 5 3DCRT) resulting in 4-year LRR of 2.8% for IMRT versus 1.8% for 3DCRT (P = .99). Three patients (2 IMRT, 1 3DCRT) had SCL nodal failures (1 in the SCL-post). CONCLUSIONS An adaptive TPA for use of IMRT when 3DCRT does not meet critical OAR constraints resulted in rare high-grade toxicity and no difference in failure patterns between patients treated with IMRT and 3DCRT. These data should provide reassurance that IMRT maintains the therapeutic ratio by preserving cancer control outcomes without excess toxicity when 3DCRT fails to meet OAR constraints.
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Affiliation(s)
- Jose G Bazan
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio.
| | - Erin Healy
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Karla Kuhn
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Tamara L Smith
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sachin Jhawar
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Julia R White
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
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Drobin K, Marczyk M, Halle M, Danielsson D, Papiez A, Sangsuwan T, Bendes A, Hong MG, Qundos U, Harms-Ringdahl M, Wersäll P, Polanska J, Schwenk JM, Haghdoost S. Molecular Profiling for Predictors of Radiosensitivity in Patients with Breast or Head-and-Neck Cancer. Cancers (Basel) 2020; 12:cancers12030753. [PMID: 32235817 PMCID: PMC7140105 DOI: 10.3390/cancers12030753] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 02/07/2023] Open
Abstract
Nearly half of all cancers are treated with radiotherapy alone or in combination with other treatments, where damage to normal tissues is a limiting factor for the treatment. Radiotherapy-induced adverse health effects, mostly of importance for cancer patients with long-term survival, may appear during or long time after finishing radiotherapy and depend on the patient’s radiosensitivity. Currently, there is no assay available that can reliably predict the individual’s response to radiotherapy. We profiled two study sets from breast (n = 29) and head-and-neck cancer patients (n = 74) that included radiosensitive patients and matched radioresistant controls.. We studied 55 single nucleotide polymorphisms (SNPs) in 33 genes by DNA genotyping and 130 circulating proteins by affinity-based plasma proteomics. In both study sets, we discovered several plasma proteins with the predictive power to find radiosensitive patients (adjusted p < 0.05) and validated the two most predictive proteins (THPO and STIM1) by sandwich immunoassays. By integrating genotypic and proteomic data into an analysis model, it was found that the proteins CHIT1, PDGFB, PNKD, RP2, SERPINC1, SLC4A, STIM1, and THPO, as well as the VEGFA gene variant rs69947, predicted radiosensitivity of our breast cancer (AUC = 0.76) and head-and-neck cancer (AUC = 0.89) patients. In conclusion, circulating proteins and a SNP variant of VEGFA suggest that processes such as vascular growth capacity, immune response, DNA repair and oxidative stress/hypoxia may be involved in an individual’s risk of experiencing radiation-induced toxicity.
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Affiliation(s)
- Kimi Drobin
- Affinity Proteomics, Science for Life Laboratory, Department of Protein Science, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH – Royal Institute of Technology, Tomtebodavägen 23, 171 65 Stockholm, Sweden; (K.D.); (A.B.); (M.-G.H.); (U.Q.); (J.M.S.)
| | - Michal Marczyk
- Yale Cancer Center, Department of Internal Medicine, Yale University School of Medicine, 06511 New Haven, CT, USA;
- Department of Data Science and Engineering, Silesian University of Technology, 44-100 Gliwice, Poland; (A.P.); (J.P.)
| | - Martin Halle
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden;
- Reconstructive Plastic Surgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Daniel Danielsson
- Department of Clinical Science, Intervention and Technology, Division of ENT Diseases, Karolinska Institutet, 14186 Stockholm, Sweden;
- Department of Oral and Maxillofacial Surgery, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Anna Papiez
- Department of Data Science and Engineering, Silesian University of Technology, 44-100 Gliwice, Poland; (A.P.); (J.P.)
| | - Traimate Sangsuwan
- Centre for Radiation Protection Research, Department of Molecular Biosciences, The Wenner-Gren Institute Stockholm University, 10691 Stockholm, Sweden; (T.S.); (M.H.-R.)
| | - Annika Bendes
- Affinity Proteomics, Science for Life Laboratory, Department of Protein Science, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH – Royal Institute of Technology, Tomtebodavägen 23, 171 65 Stockholm, Sweden; (K.D.); (A.B.); (M.-G.H.); (U.Q.); (J.M.S.)
| | - Mun-Gwan Hong
- Affinity Proteomics, Science for Life Laboratory, Department of Protein Science, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH – Royal Institute of Technology, Tomtebodavägen 23, 171 65 Stockholm, Sweden; (K.D.); (A.B.); (M.-G.H.); (U.Q.); (J.M.S.)
| | - Ulrika Qundos
- Affinity Proteomics, Science for Life Laboratory, Department of Protein Science, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH – Royal Institute of Technology, Tomtebodavägen 23, 171 65 Stockholm, Sweden; (K.D.); (A.B.); (M.-G.H.); (U.Q.); (J.M.S.)
| | - Mats Harms-Ringdahl
- Centre for Radiation Protection Research, Department of Molecular Biosciences, The Wenner-Gren Institute Stockholm University, 10691 Stockholm, Sweden; (T.S.); (M.H.-R.)
| | - Peter Wersäll
- Department of Radiotherapy, Karolinska University Hospital, 17176 Stockholm, Sweden;
| | - Joanna Polanska
- Department of Data Science and Engineering, Silesian University of Technology, 44-100 Gliwice, Poland; (A.P.); (J.P.)
| | - Jochen M. Schwenk
- Affinity Proteomics, Science for Life Laboratory, Department of Protein Science, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH – Royal Institute of Technology, Tomtebodavägen 23, 171 65 Stockholm, Sweden; (K.D.); (A.B.); (M.-G.H.); (U.Q.); (J.M.S.)
| | - Siamak Haghdoost
- Centre for Radiation Protection Research, Department of Molecular Biosciences, The Wenner-Gren Institute Stockholm University, 10691 Stockholm, Sweden; (T.S.); (M.H.-R.)
- University of Caen Normandy, Department of medicine, Cimap-Laria, Advanced Resource Center for HADrontherapy in Europe (ARCHADE), 14076 Caen, France
- Correspondence:
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