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Yan O, Wang S, Wang Q, Wang X. FLASH Radiotherapy: Mechanisms of Biological Effects and the Therapeutic Potential in Cancer. Biomolecules 2024; 14:754. [PMID: 39062469 PMCID: PMC11275005 DOI: 10.3390/biom14070754] [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: 05/21/2024] [Revised: 06/11/2024] [Accepted: 06/15/2024] [Indexed: 07/28/2024] Open
Abstract
Radiotherapy is an important treatment for many unresectable advanced malignant tumors, and radiotherapy-associated inflammatory reactions to radiation and other toxic side effects are significant reasons which reduce the quality of life and survival of patients. FLASH-radiotherapy (FLASH-RT), a prominent topic in recent radiation therapy research, is an ultra-high dose rate treatment known for significantly reducing therapy time while effectively targeting tumors. This approach minimizes radiation side effects on at-risk organs and maximally protects surrounding healthy tissues. Despite decades of preclinical exploration and some notable achievements, the mechanisms behind FLASH effects remain debated. Standardization is still required for the type of FLASH-RT rays and dose patterns. This review addresses the current state of FLASH-RT research, summarizing the biological mechanisms behind the FLASH effect. Additionally, it examines the impact of FLASH-RT on immune cells, cytokines, and the tumor immune microenvironment. Lastly, this review will discuss beam characteristics, potential clinical applications, and the relevance and applicability of FLASH-RT in treating advanced cancers.
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Affiliation(s)
| | | | | | - Xin Wang
- Division of Abdominal Tumor Multimodality Treatment, Department of Radiation Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China; (O.Y.); (S.W.); (Q.W.)
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Chow JCL, Ruda HE. Mechanisms of Action in FLASH Radiotherapy: A Comprehensive Review of Physicochemical and Biological Processes on Cancerous and Normal Cells. Cells 2024; 13:835. [PMID: 38786057 PMCID: PMC11120005 DOI: 10.3390/cells13100835] [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: 04/09/2024] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
The advent of FLASH radiotherapy (FLASH-RT) has brought forth a paradigm shift in cancer treatment, showcasing remarkable normal cell sparing effects with ultra-high dose rates (>40 Gy/s). This review delves into the multifaceted mechanisms underpinning the efficacy of FLASH effect, examining both physicochemical and biological hypotheses in cell biophysics. The physicochemical process encompasses oxygen depletion, reactive oxygen species, and free radical recombination. In parallel, the biological process explores the FLASH effect on the immune system and on blood vessels in treatment sites such as the brain, lung, gastrointestinal tract, skin, and subcutaneous tissue. This review investigated the selective targeting of cancer cells and the modulation of the tumor microenvironment through FLASH-RT. Examining these mechanisms, we explore the implications and challenges of integrating FLASH-RT into cancer treatment. The potential to spare normal cells, boost the immune response, and modify the tumor vasculature offers new therapeutic strategies. Despite progress in understanding FLASH-RT, this review highlights knowledge gaps, emphasizing the need for further research to optimize its clinical applications. The synthesis of physicochemical and biological insights serves as a comprehensive resource for cell biology, molecular biology, and biophysics researchers and clinicians navigating the evolution of FLASH-RT in cancer therapy.
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Affiliation(s)
- James C. L. Chow
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1X6, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Harry E. Ruda
- Centre of Advance Nanotechnology, Faculty of Applied Science and Engineering, University of Toronto, Toronto, ON M5S 3E4, Canada;
- Department of Materials Science and Engineering, University of Toronto, Toronto, ON M5S 3E4, Canada
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Shiraishi Y, Matsuya Y, Fukunaga H. Possible mechanisms and simulation modeling of FLASH radiotherapy. Radiol Phys Technol 2024; 17:11-23. [PMID: 38184508 DOI: 10.1007/s12194-023-00770-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 01/08/2024]
Abstract
FLASH radiotherapy (FLASH-RT) has great potential to improve patient outcomes. It delivers radiation doses at an ultra-high dose rate (UHDR: ≥ 40 Gy/s) in a single instant or a few pulses. Much higher irradiation doses can be administered to tumors with FLASH-RT than with conventional dose rate (0.01-0.40 Gy/s) radiotherapy. UHDR irradiation can suppress toxicity in normal tissues while sustaining antitumor efficiency, which is referred to as the FLASH effect. However, the mechanisms underlying the effects of the FLASH remain unclear. To clarify these mechanisms, the development of simulation models that can contribute to treatment planning for FLASH-RT is still underway. Previous studies indicated that transient oxygen depletion or augmented reactions between secondary reactive species produced by irradiation may be involved in this process. To discuss the possible mechanisms of the FLASH effect and its clinical potential, we summarized the physicochemical, chemical, and biological perspectives as well as the development of simulation modeling for FLASH-RT.
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Affiliation(s)
- Yuta Shiraishi
- Graduate School of Health Sciences, Hokkaido University, N12 W5 Kita-Ku, Sapporo, Hokkaido, 060-0812, Japan
- Faculty of Health Sciences, Japan Healthcare University, 3-11-1-50 Tsukisamu-Higashi, Toyohira-Ku, Sapporo, Hokkaido, 062-0053, Japan
| | - Yusuke Matsuya
- Faculty of Health Sciences, Hokkaido University, N12 W5 Kita-Ku, Sapporo, Hokkaido, 060-0812, Japan
| | - Hisanori Fukunaga
- Faculty of Health Sciences, Hokkaido University, N12 W5 Kita-Ku, Sapporo, Hokkaido, 060-0812, Japan.
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Shiraishi Y, Matsuya Y, Kusumoto T, Fukunaga H. Modeling for predicting survival fraction of cells after ultra-high dose rate irradiation. Phys Med Biol 2023; 69:015017. [PMID: 38056015 DOI: 10.1088/1361-6560/ad131b] [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: 06/09/2023] [Accepted: 12/06/2023] [Indexed: 12/08/2023]
Abstract
Objective. FLASH radiotherapy (FLASH-RT) with ultra-high dose rate (UHDR) irradiation (i.e. > 40 Gy s-1) spares the function of normal tissues while preserving antitumor efficacy, known as the FLASH effect. The biological effects after conventional dose rate-radiotherapy (CONV-RT) with ≤0.1 Gy s-1have been well modeled by considering microdosimetry and DNA repair processes, meanwhile modeling of radiosensitivities under UHDR irradiation is insufficient. Here, we developed anintegrated microdosimetric-kinetic(IMK)model for UHDR-irradiationenabling the prediction of surviving fraction after UHDR irradiation.Approach.TheIMK model for UHDR-irradiationconsiders the initial DNA damage yields by the modification of indirect effects under UHDR compared to CONV dose rate. The developed model is based on the linear-quadratic (LQ) nature with the dose and dose square coefficients, considering the reduction of DNA damage yields as a function of dose rate.Main results.The estimate by the developed model could successfully reproduce thein vitroexperimental dose-response curve for various cell line types and dose rates.Significance.The developed model would be useful for predicting the biological effects under the UHDR irradiation.
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Affiliation(s)
- Yuta Shiraishi
- Graduate school of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo, Hokkaido, 060-0812, Japan
- Faculty of Health Sciences, Japan Healthcare University, 3-11-1-50 Tsukisamu-higashi, Toyohira-ku, Sapporo, Hokkaido, 062-0053, Japan
| | - Yusuke Matsuya
- Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo, Hokkaido, 060-0812, Japan
- Nuclear Science and Engineering Center, Japan Atomic Energy Agency, 2-4 Shirakata, Tokai, Ibaraki, 319-1195, Japan
| | - Tamon Kusumoto
- National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, 263-8555, Japan
| | - Hisanori Fukunaga
- Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo, Hokkaido, 060-0812, Japan
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Sunnerberg JP, Zhang R, Gladstone DJ, Swartz HM, Gui J, Pogue BW. Mean dose rate in ultra-high dose rate electron irradiation is a significant predictor for O 2consumption and H 2O 2yield. Phys Med Biol 2023; 68:165014. [PMID: 37463588 PMCID: PMC10405361 DOI: 10.1088/1361-6560/ace877] [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: 02/09/2023] [Revised: 06/27/2023] [Accepted: 07/18/2023] [Indexed: 07/20/2023]
Abstract
Objective. The objective of this study was to investigate the impact of mean and instantaneous dose rates on the production of reactive oxygen species (ROS) during ultra-high dose rate (UHDR) radiotherapy. The study aimed to determine whether either dose rate type plays a role in driving the FLASH effect, a phenomenon where UHDR radiotherapy reduces damage to normal tissues while maintaining tumor control.Approach. Assays of hydrogen peroxide (H2O2) production and oxygen consumption (ΔpO2) were conducted using UHDR electron irradiation. Aqueous solutions of 4% albumin were utilized as the experimental medium. The study compared the effects of varying mean dose rates and instantaneous dose rates on ROS yields. Instantaneous dose rate was varied by changing the source-to-surface distance (SSD), resulting in instantaneous dose rates ranging from 102to 106Gy s-1. Mean dose rate was manipulated by altering the pulse frequency of the linear accelerator (linac) and by changing the SSD, ranging from 0.14 to 1500 Gy s-1.Main results. The study found that both ΔH2O2and ΔpO2decreased as the mean dose rate increased. Multivariate analysis indicated that instantaneous dose rates also contributed to this effect. The variation in ΔpO2was dependent on the initial oxygen concentration in the solution. Based on the analysis of dose rate variation, the study estimated that 7.51 moles of H2O2were produced for every mole of O2consumed.Significance. The results highlight the significance of mean dose rate as a predictor of ROS production during UHDR radiotherapy. As the mean dose rate increased, there was a decrease in oxygen consumption and in H2O2production. These findings have implications for understanding the FLASH effect and its potential optimization. The study sheds light on the role of dose rate parameters and their impact on radiochemical outcomes, contributing to the advancement of UHDR radiotherapy techniques.
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Affiliation(s)
- Jacob P Sunnerberg
- Thayer School of Engineering at Dartmouth College, Hanover, NH, United States of America
| | - Rongxiao Zhang
- Thayer School of Engineering at Dartmouth College, Hanover, NH, United States of America
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - David J Gladstone
- Thayer School of Engineering at Dartmouth College, Hanover, NH, United States of America
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Harold M Swartz
- Geisel School of Medicine at Dartmouth College, Hanover, NH, United States of America
| | - Jiang Gui
- Geisel School of Medicine at Dartmouth College, Hanover, NH, United States of America
| | - Brian W Pogue
- Thayer School of Engineering at Dartmouth College, Hanover, NH, United States of America
- University of Wisconsin—Madison, Madison, WI, United States of America
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Camazzola G, Boscolo D, Scifoni E, Dorn A, Durante M, Krämer M, Abram V, Fuss MC. TRAX-CHEMxt: Towards the Homogeneous Chemical Stage of Radiation Damage. Int J Mol Sci 2023; 24:ijms24119398. [PMID: 37298351 DOI: 10.3390/ijms24119398] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
The indirect effect of radiation plays an important role in radio-induced biological damages. Monte Carlo codes have been widely used in recent years to study the chemical evolution of particle tracks. However, due to the large computational efforts required, their applicability is typically limited to simulations in pure water targets and to temporal scales up to the µs. In this work, a new extension of TRAX-CHEM is presented, namely TRAX-CHEMxt, able to predict the chemical yields at longer times, with the capability of exploring the homogeneous biochemical stage. Based on the species coordinates produced around one track, the set of reaction-diffusion equations is solved numerically with a computationally light approach based on concentration distributions. In the overlapping time scale (500 ns-1 µs), a very good agreement to standard TRAX-CHEM is found, with deviations below 6% for different beam qualities and oxygenations. Moreover, an improvement in the computational speed by more than three orders of magnitude is achieved. The results of this work are also compared with those from another Monte Carlo-based algorithm and a fully homogeneous code (Kinetiscope). TRAX-CHEMxt will allow for studying the variation in chemical endpoints at longer timescales with the introduction, as the next step, of biomolecules, for more realistic assessments of biological response under different radiation and environmental conditions.
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Affiliation(s)
- Gianmarco Camazzola
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research GmbH, 64291 Darmstadt, Germany
- Quantum Dynamics and Control Division, Max Planck Institute for Nuclear Physics, 69117 Heidelberg, Germany
- Department of Physics and Astronomy, Heidelberg University, 69120 Heidelberg, Germany
| | - Daria Boscolo
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research GmbH, 64291 Darmstadt, Germany
| | - Emanuele Scifoni
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics (INFN), 38123 Povo, Italy
| | - Alexander Dorn
- Quantum Dynamics and Control Division, Max Planck Institute for Nuclear Physics, 69117 Heidelberg, Germany
| | - Marco Durante
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research GmbH, 64291 Darmstadt, Germany
- Institute for Condensed Matter Physics, Technical University of Darmstadt, 64289 Darmstadt, Germany
| | - Michael Krämer
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research GmbH, 64291 Darmstadt, Germany
| | - Valentino Abram
- Department of Mathematics, University of Trento, 38123 Povo, Italy
| | - Martina C Fuss
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research GmbH, 64291 Darmstadt, Germany
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Chappuis F, Tran HN, Zein SA, Bailat C, Incerti S, Bochud F, Desorgher L. The general-purpose Geant4 Monte Carlo toolkit and its Geant4-DNA extension to investigate mechanisms underlying the FLASH effect in radiotherapy: Current status and challenges. Phys Med 2023; 110:102601. [PMID: 37201453 DOI: 10.1016/j.ejmp.2023.102601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 05/01/2023] [Indexed: 05/20/2023] Open
Abstract
FLASH radiotherapy is a promising approach to cancer treatment that offers several advantages over conventional radiotherapy. With this novel technique, high doses of radiation are delivered in a short period of time, inducing the so-called FLASH effect - a phenomenon characterized by healthy tissue sparing without alteration of tumor control. The mechanisms behind the FLASH effect remain unknown. One way to approach this problem is to gain insight into the initial parameters that can distinguish FLASH from conventional irradiation by simulating particle transport in aqueous media using the general-purpose Geant4 Monte Carlo toolkit and its Geant4-DNA extension. This review article discusses the current status of Geant4 and Geant4-DNA simulations to investigate mechanisms underlying the FLASH effect, as well as the challenges faced in this research field. One of the primary challenges is to accurately simulate the experimental irradiation parameters. Another challenge is the temporal extension of the simulations. This review also focuses on two hypotheses to explain the FLASH effect - namely the oxygen depletion hypothesis and the inter-track interactions hypothesis - and discusses how the Geant4 toolkit can be used to investigate them. The aim of this review is to provide an overview of Geant4 and Geant4-DNA simulations for FLASH radiotherapy and to highlight the challenges that need to be overcome in order to better study the FLASH effect.
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Affiliation(s)
- Flore Chappuis
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Hoang Ngoc Tran
- Univ. Bordeaux, CNRS, LP2I Bordeaux, UMR 5797, F-33170 Gradignan, France
| | - Sara A Zein
- Univ. Bordeaux, CNRS, LP2I Bordeaux, UMR 5797, F-33170 Gradignan, France
| | - Claude Bailat
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Sébastien Incerti
- Univ. Bordeaux, CNRS, LP2I Bordeaux, UMR 5797, F-33170 Gradignan, France
| | - François Bochud
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Laurent Desorgher
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland.
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Lin B, Huang D, Gao F, Yang Y, Wu D, Zhang Y, Feng G, Dai T, Du X. Mechanisms of FLASH effect. Front Oncol 2022; 12:995612. [PMID: 36212435 PMCID: PMC9537695 DOI: 10.3389/fonc.2022.995612] [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: 07/16/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
FLASH radiotherapy (FLASH-RT) is a novel radiotherapy technology defined as ultra-high dose rate (≥ 40 Gy/s) radiotherapy. The biological effects of FLASH-RT include two aspects: first, compared with conventional dose rate radiotherapy, FLASH-RT can reduce radiation-induced damage in healthy tissue, and second, FLASH-RT can retain antitumor effectiveness. Current research shows that mechanisms of the biological effects of FLASH-RT are related to oxygen. However, due to the short time of FLASH-RT, evidences related to the mechanisms are indirect, and the exact mechanisms of the biological effects of FLASH-RT are not completely clear and some are even contradictory. This review focuses on the mechanisms of the biological effects of FLASH-RT and proposes future research directions.
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Affiliation(s)
- Binwei Lin
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Dan Huang
- Department of Radiology Mianyang Central Hospital, Mianyang, China
| | - Feng Gao
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Yiwei Yang
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Dai Wu
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Yu Zhang
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Gang Feng
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Tangzhi Dai
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
| | - Xiaobo Du
- National Health Commission (NHC) Key Laboratory of Nuclear Technology Medical Transformation, Mianyang Central Hospital, Department of Oncology, Mianyang Central Hospital, Mianyang, China
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Jansen J, Beyreuther E, García-Calderón D, Karsch L, Knoll J, Pawelke J, Schürer M, Seco J. oChanges in Radical Levels as a Cause for the FLASH effect: Impact of beam structure parameters at ultra-high dose rates on oxygen depletion in water. Radiother Oncol 2022; 175:193-196. [PMID: 36030933 DOI: 10.1016/j.radonc.2022.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/15/2023]
Abstract
The influence of different average and bunch dose rates in electron beams on the FLASH effect was investigated. The present study measures O2 content in water at different beam pulse patterns and finds strong correlation with biological data, strengthening the hypothesis of radical-related mechanisms as a reason for the FLASH effect.
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Affiliation(s)
- Jeannette Jansen
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Elke Beyreuther
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiation Physics, Dresden, Germany
| | - Daniel García-Calderón
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, Ruprecht-Karls-University, Heidelberg, Germany
| | - Leonhard Karsch
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Jan Knoll
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, Ruprecht-Karls-University, Heidelberg, Germany
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Michael Schürer
- National Center for Tumor Diseases Dresden (NCT/UCC), Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Joao Seco
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, Ruprecht-Karls-University, Heidelberg, Germany.
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