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Shouman MA, Fuchs F, Walter F, Corradini S, Westphalen CB, Vornhülz M, Beyer G, Andrade D, Belka C, Niyazi M, Rogowski P. Stereotactic body radiotherapy for pancreatic cancer - A systematic review of prospective data. Clin Transl Radiat Oncol 2024; 45:100738. [PMID: 38370495 PMCID: PMC10873666 DOI: 10.1016/j.ctro.2024.100738] [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: 10/01/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Purpose This systematic review aims to comprehensively summarize the current prospective evidence regarding Stereotactic Body Radiotherapy (SBRT) in various clinical contexts for pancreatic cancer including its use as neoadjuvant therapy for borderline resectable pancreatic cancer (BRPC), induction therapy for locally advanced pancreatic cancer (LAPC), salvage therapy for isolated local recurrence (ILR), adjuvant therapy after radical resection, and as a palliative treatment. Special attention is given to the application of magnetic resonance-guided radiotherapy (MRgRT). Methods Following PRISMA guidelines, a systematic review of the Medline database via PubMed was conducted focusing on prospective studies published within the past decade. Data were extracted concerning study characteristics, outcome measures, toxicity profiles, SBRT dosage and fractionation regimens, as well as additional systemic therapies. Results and conclusion 31 studies with in total 1,571 patients were included in this review encompassing 14 studies for LAPC, 9 for neoadjuvant treatment, 2 for adjuvant treatment, 2 for ILR, with an additional 4 studies evaluating MRgRT. In LAPC, SBRT demonstrates encouraging results, characterized by favorable local control rates. Several studies even report conversion to resectable disease with substantial resection rates reaching 39%. The adoption of MRgRT may provide a solution to the challenge to deliver ablative doses while minimizing severe toxicities. In BRPC, select prospective studies combining preoperative ablative-dose SBRT with modern induction systemic therapies have achieved remarkable resection rates of up to 80%. MRgRT also holds potential in this context. Adjuvant SBRT does not appear to confer relevant advantages over chemotherapy. While prospective data for SBRT in ILR and for palliative pain relief are limited, they corroborate positive findings from retrospective studies.
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Affiliation(s)
- Mohamed A Shouman
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Frederik Fuchs
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center (CCC Munich LMU), University Hospital LMU, Munich, Germany
| | - Marlies Vornhülz
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Georg Beyer
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplant Surgery, University Hospital LMU, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
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Ocanto A, Torres L, Montijano M, Rincón D, Fernández C, Sevilla B, Gonsalves D, Teja M, Guijarro M, Glaría L, Hernánz R, Zafra-Martin J, Sanmamed N, Kishan A, Alongi F, Moghanaki D, Nagar H, Couñago F. MR-LINAC, a New Partner in Radiation Oncology: Current Landscape. Cancers (Basel) 2024; 16:270. [PMID: 38254760 PMCID: PMC10813892 DOI: 10.3390/cancers16020270] [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: 12/17/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Technological advances in radiation oncology are oriented towards improving treatment precision and tumor control. Among these advances, magnetic-resonance-image-guided radiation therapy (MRgRT) stands out, with technological advances to deliver targeted treatments adapted to a tumor's anatomy on the day while minimizing incidental exposure to organs at risk, offering an unprecedented therapeutic advantage compared to X-ray-based IGRT delivery systems. This new technology changes the traditional workflow in radiation oncology and requires an evolution in team coordination to administer more precise treatments. Once implemented, it paves the way for newer indication for radiation therapy to safely deliver higher doses than ever before, with better preservation of healthy tissues to optimize patient outcomes. In this narrative review, we assess the technical aspects of the novel linear accelerators that can deliver MRgRT and summarize the available published experience to date, focusing on oncological results and future challenges.
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Affiliation(s)
- Abrahams Ocanto
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Lisselott Torres
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Miguel Montijano
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Diego Rincón
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Beatriz Sevilla
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Daniela Gonsalves
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Macarena Teja
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Marcos Guijarro
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Luis Glaría
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Raúl Hernánz
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Juan Zafra-Martin
- Group of Translational Research in Cancer Immunotherapy, Centro de Investigaciones Médico-Sanitarias (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain;
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | - Noelia Sanmamed
- Department of Radiation Oncology, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain;
| | - Amar Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA;
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar, Italy;
- University of Brescia, 25121 Brescia, Italy
| | - Drew Moghanaki
- UCLA Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
- GenesisCare, 28043 Madrid, Spain
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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Pérez Haas Y, Ludwig R, Dal Bello R, Tanadini-Lang S, Unkelbach J. Adaptive fractionation at the MR-linac. Phys Med Biol 2023; 68. [PMID: 36596262 DOI: 10.1088/1361-6560/acafd4] [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: 06/22/2022] [Accepted: 01/03/2023] [Indexed: 01/04/2023]
Abstract
Objective. Fractionated radiotherapy typically delivers the same dose in each fraction. Adaptive fractionation (AF) is an approach to exploit inter-fraction motion by increasing the dose on days when the distance of tumor and dose-limiting organs at risk (OAR) is large and decreasing the dose on unfavorable days. We develop an AF algorithm and evaluate the concept for patients with abdominal tumors previously treated at the MR-linac in 5 fractions.Approach. Given daily adapted treatment plans, inter-fractional changes are quantified by sparing factorsδtdefined as the OAR-to-tumor dose ratio. The key problem of AF is to decide on the dose to deliver in fractiont, givenδtand the dose delivered in previous fractions, but not knowing futureδts. Optimal doses that maximize the expected biologically effective dose in the tumor (BED10) while staying below a maximum OAR BED3constraint are computed using dynamic programming, assuming a normal distribution overδwith mean and variance estimated from previously observed patient-specificδts. The algorithm is evaluated for 16 MR-linac patients in whom tumor dose was compromised due to proximity of bowel, stomach, or duodenum.Main Results. In 14 out of the 16 patients, AF increased the tumor BED10compared to the reference treatment that delivers the same OAR dose in each fraction. However, in 11 of these 14 patients, the increase in BED10was below 1 Gy. Two patients with large sparing factor variation had a benefit of more than 10 Gy BED10increase. For one patient, AF led to a 5 Gy BED10decrease due to an unfavorable order of sparing factors.Significance. On average, AF provided only a small increase in tumor BED. However, AF may yield substantial benefits for individual patients with large variations in the geometry.
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Affiliation(s)
- Y Pérez Haas
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - R Ludwig
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - R Dal Bello
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - S Tanadini-Lang
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - J Unkelbach
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
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Webking S, Sandoval ML, Chuong MD, Ucar A, Aparo S, De Zarraga F, Sahin I, Biachi T, Kim DW, Hoffe SE, Frakes JM, Palm RF. Ablative 5-Fraction Stereotactic MRI-Guided Adaptive Radiotherapy for Oligometastatic Pancreatic Adenocarcinoma. Cancer Control 2023; 30:10732748231219069. [PMID: 38038261 PMCID: PMC10693219 DOI: 10.1177/10732748231219069] [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: 09/01/2023] [Revised: 10/24/2023] [Accepted: 11/16/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Metastatic pancreatic ductal adenocarcinoma (PDAC) carries a poor prognosis and significant morbidity from local tumor progression. We investigated outcomes among oligometastatic PDAC patients treated with stereotactic magnetic resonance image-guided ablative radiotherapy (SMART) to primary disease. METHODS We performed a retrospective multi-institutional analysis of oligometastatic PDAC at diagnosis or with metachronous oligoprogression during induction chemotherapy treated with primary tumor SMART. Outcomes of interest included overall survival (OS), progression-free survival (PFS), freedom from locoregional failure (FFLRF), and freedom from distant failure (FFDF). Acute and late toxicity were reported and in exploratory analyses patients were stratified by the number of metastases, SMART indication, and addition of metastasis-directed therapy. RESULTS From 2019 to 2021, 22 patients with oligometastatic PDAC (range: 1-6 metastases) received SMART to the primary tumor with a median follow-up of 11.2 months from SMART. Nineteen patients had de novo synchronous metastatic disease and three had metachronous oligoprogression. Metastasis location most commonly was liver only (40.9%), multiple organs (27.3%), lungs only (13.6%), or abdominal/pelvic nodes (13.6%). All patients received either FOLFIRINOX (64%) or gemcitabine/nab-paclitaxel (36%) followed by SMART (median 50 Gy, 5 fractions) for local control (77%), pain control (14%), or local progression (9%). Additionally, 41% of patients received other metastasis-directed treatments. The median OS from diagnosis and SMART was 23.9 months and 11.6 months, respectively. Calculated from SMART, the median PFS was 2.4 months with 91% of patients having distant progression, and 1-year local control was 68. Two patients (9%) experienced grade 3 toxicities, gastric outlet obstruction, and gastrointestinal bleed without grade 4 or 5 toxicity. CONCLUSION There was minimal morbidity of local disease progression after SMART in this cohort of oligometastatic PDAC. As systemic therapy options improve, additional strategies to identify patients who may derive benefits from local consolidation or metastasis-directed therapy are needed.
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Affiliation(s)
- Samantha Webking
- American University of the Caribbean, Dutch Sint Maarten, Cupecoy
| | - Maria L. Sandoval
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Antonio Ucar
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Santiago Aparo
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | | | - Ibrahim Sahin
- Department of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tiago Biachi
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Dae W. Kim
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah E. Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jessica M. Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Russell F. Palm
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
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Schiff JP, Maraghechi B, Chin RI, Price A, Laugeman E, Rudra S, Hatscher C, Spraker MB, Badiyan SN, Henke LE, Green O, Kim H. A pilot study of same-day MRI-only simulation and treatment with MR-guided adaptive palliative radiotherapy (MAP-RT). Clin Transl Radiat Oncol 2022; 39:100561. [PMID: 36594078 PMCID: PMC9803918 DOI: 10.1016/j.ctro.2022.100561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
We conducted a prospective pilot study evaluating the feasibility of same day MRI-only simulation and treatment with MRI-guided adaptive palliative radiotherapy (MAP-RT) for urgent palliative indications (NCT#03824366). All (16/16) patients were able to complete 99% of their first on-table attempted fractions, and no grades 3-5 toxicities occurred.
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Affiliation(s)
- Joshua P. Schiff
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Borna Maraghechi
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Re-I. Chin
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Alex Price
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Eric Laugeman
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Souman Rudra
- Emory University School of Medicine, Department of Radiation Oncology, Atlanta, GA, USA
| | - Casey Hatscher
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Matthew B. Spraker
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Shahed N. Badiyan
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Lauren E. Henke
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA
| | - Olga Green
- Varian Medical Systems, Palo Alto, CA, USA
| | - Hyun Kim
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO, USA,Corresponding author at: Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
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Auranofin and Pharmacologic Ascorbate as Radiomodulators in the Treatment of Pancreatic Cancer. Antioxidants (Basel) 2022; 11:antiox11050971. [PMID: 35624835 PMCID: PMC9137675 DOI: 10.3390/antiox11050971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/27/2022] [Accepted: 05/11/2022] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer accounts for nearly one fourth of all new cancers worldwide. Little progress in the development of novel or adjuvant therapies has been made over the past few decades and new approaches to the treatment of pancreatic cancer are desperately needed. Pharmacologic ascorbate (P-AscH−, high-dose, intravenous vitamin C) is being investigated in clinical trials as an adjunct to standard-of-care chemoradiation treatments. In vitro, P-AscH− has been shown to sensitize cancer cells to ionizing radiation in a manner that is dependent on the generation of H2O2 while simultaneously protecting normal tissue from radiation damage. There is renewed interest in Auranofin (Au), an FDA-approved medication utilized in the treatment of rheumatoid arthritis, as an anti-cancer agent. Au inhibits the thioredoxin antioxidant system, thus increasing the overall peroxide burden on cancer cells. In support of current literature demonstrating Au’s effectiveness in breast, colon, lung, and ovarian cancer, we offer additional data that demonstrate the effectiveness of Au alone and in combination with P-AscH− and ionizing radiation in pancreatic cancer treatment. Combining P-AscH− and Au in the treatment of pancreatic cancer may confer multiple mechanisms to increase H2O2-dependent toxicity amongst cancer cells and provide a promising translatable avenue by which to enhance radiation effectiveness and improve patient outcomes.
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