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Jiang D, Deng D, Xiong Y, Wang D, Gong J, Zhao H, Bao Z, Wei Y, Xie C, Jia L, Liao C, Liu S, Liu H, Wang X. Total marrow lymphoid irradiation IMRT treatment using a novel CT-linac. Eur J Med Res 2023; 28:463. [PMID: 37884978 PMCID: PMC10605975 DOI: 10.1186/s40001-023-01380-4] [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: 03/29/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND A novel CT-linac (kilovolt fan-beam CT-linac) has been introduced into total marrow and lymphoid irradiation (TMLI) treatment. Its integrated kilovolt fan-beam CT (kV FBCT) can be used not only for image guidance (IGRT) but also to re-calculate the dose. PURPOSE This study reported our clinical routine on performing TMIL treatment on the CT-linac, as well as dose distribution comparison between planned and re-calculated based on IGRT FBCT image sets. METHODS 11 sets of data from 5 male and 6 female patients who had underwent the TMLI treatment with uRT-linac 506c were selected for this study. The planning target volumes consist of all skeletal bones exclusion of the mandible and lymphatic sanctuary sites. A planned dose of 10 Gy was prescribed to all skeletal bones exclusion of the mandible in two fractions and 12 Gy in two fractions was prescribed to lymphatic sanctuary sites. Each TMLI plan contained two sub-plans, one dynamic IMRT for the upper body and the other VMAT for the lower extremity. Two attempts were made to obtain homogeneous dose in the overlapping region, i.e., applying two plans with different isocenters for the treatment of two fractions, and using a dose gradient matching scheme. The CT scans, including planning CT and IGRT FBCT, were stitched to a whole body CT scan for dose distribution evaluation. RESULTS The average beam-on time of Planupper is 30.6 min, ranging from 24.9 to 37.5 min, and the average beam-on time of Planlower is 6.3 min, ranging from 5.7 to 8.2 min. For the planned dose distribution, the 94.79% of the PTVbone is covered by the prescription dose of 10 Gy (V10), and the 94.68% of the PTVlymph is covered by the prescription dose of 12 Gy (V12). For the re-calculated dose distribution, the 92.17% of the PTVbone is covered by the prescription dose of 10 Gy (V10), and the 90.07% of the PTVlymph is covered by the prescription dose of 12 Gy (V12). The results showed that there is a significant difference (p < 0.05) between planning V10, V12 and delivery V10, V12. There is no significant difference (p > 0.05) between planned dose and re-calculated dose on selected organs, except for right lens (p < 0.05, Dmax). The actual delivered maximum dose of right lens is apparently larger than the planned dose of it. CONCLUSION TMLI treatment can be performed on the CT-linac with clinical acceptable quality and high efficiency. Evaluation of the recalculated dose on IGRT FBCT suggests the treatment was delivered with adequate target coverage.
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Affiliation(s)
- Dazhen Jiang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Di Deng
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yu Xiong
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Dajiang Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jian Gong
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hongli Zhao
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Zhirong Bao
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yongchang Wei
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Lecheng Jia
- United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, 518045, China
| | - Can Liao
- Shanghai United Imaging Healthcare Co., Ltd, Shanghai, 201807, China
| | - Shuo Liu
- Shanghai United Imaging Healthcare Co., Ltd, Shanghai, 201807, China
| | - Hui Liu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
| | - Xiaoyong Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Köksal M, Özkan O, Holderried T, Heine A, Brossart P, Gawish A, Scafa D, Sarria GR, Leitzen C, Schmeel LC, Müdder T. Optimized Conformal Total Body Irradiation with VMAT Using a Linear-Accelerator-Based Radiosurgery Treatment System in Comparison to the Golden Standard Helical TomoTherapy. Cancers (Basel) 2023; 15:4220. [PMID: 37686498 PMCID: PMC10486387 DOI: 10.3390/cancers15174220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Modern irradiation techniques for optimized conformal TBI can be realized by Helical Tomotherapy (HT) or Volumetric Modulated Arc Therapy (VMAT), depending on the availability of suitable specialized equipment. In this dosimetric planning study, we compared both modalities and addressed the question of whether VMAT with small field sizes is also suitable as a backup in case of HT equipment malfunctions. For this purpose, we retrospectively used planning computed tomography (CT) data from 10 patients treated with HT with a total dose of 8 Gy (n = 5) or 12 Gy (n = 5) for treatment planning for VMAT with a small field size (36 × 22 cm). The target volume coverage, dose homogeneity at target volume, and dose reduction in organs at risk (OAR) (lungs, kidneys, lenses) were analyzed and compared. One patient was irradiated with both modalities due to a device failure of the HT equipment during the study, which facilitated a comparison in a real clinical setting. The findings indicate that in addition to a higher mean dose to the lenses in the 12 Gy group for VMAT and a better dose homogeneity in the target volume for HT, comparably good and adequate target dose coverage and dose reduction in the other OAR could be achieved for both modalities, with significantly longer treatment times for VMAT. In conclusion, after appropriate optimization of the treatment times, VMAT using linear accelerator radiosurgery technology can be used both as a backup in addition to HT and in clinical routines to perform optimized conformal TBI.
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Affiliation(s)
- Mümtaz Köksal
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Oğuzhan Özkan
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Tobias Holderried
- Department of Internal Medicine—Oncology, Hematology and Rheumatology, University Hospital of Bonn, 53127 Bonn, Germany (P.B.)
| | - Annkristin Heine
- Department of Internal Medicine—Oncology, Hematology and Rheumatology, University Hospital of Bonn, 53127 Bonn, Germany (P.B.)
| | - Peter Brossart
- Department of Internal Medicine—Oncology, Hematology and Rheumatology, University Hospital of Bonn, 53127 Bonn, Germany (P.B.)
| | - Ahmed Gawish
- Department of Radiation Oncology, University Hospital of Marburg, 35043 Marburg, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Leonard C. Schmeel
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Thomas Müdder
- Department of Radiation Oncology, University Hospital of Bonn, 53127 Bonn, Germany
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Hao C, Ladbury C, Wong J, Dandapani S. Modern Radiation for Hematologic Stem Cell Transplantation: Total Marrow and Lymphoid Irradiation or Intensity-Modulated Radiation Therapy Total Body Irradiation. Surg Oncol Clin N Am 2023; 32:475-495. [PMID: 37182988 DOI: 10.1016/j.soc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The development of large-field intensity-modulated radiation therapy (IMRT) has enabled the implementation of total marrow irradiation (TMI), total marrow and lymphoid irradiation (TMLI), and IMRT total body irradiation (TBI). IMRT TBI limits doses to organs at risk, primarily the lungs and in some cases the kidneys and lenses, which may mitigate complications. TMI/TMLI allows for dose escalation above TBI radiation therapy doses to malignant sites while still sparing organs at risk. Although still sparingly used, these techniques have established feasibility and demonstrated promise in reducing the adverse effects of TBI while maintaining and potentially improving survival outcomes.
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Affiliation(s)
- Claire Hao
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA.
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Cananoglu M, Hurmuz P, Yeginer M, Ozyigit G. Planning and dosimetric evaluation of three total body irradiation techniques: Standard SSD VMAT, Extended SSD VMAT and Extended SSD Field-in-Field. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2023; 62:73-81. [PMID: 36269391 DOI: 10.1007/s00411-022-00999-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
The aim of this study was to dosimetrically compare three total body irradiation (TBI) techniques which can be delivered by a standard linear accelerator, and to deduce which one is preferable. Specifically, Extended Source to Surface Distance (SSD) Field-in-Field (FiF), Extended SSD Volumetric Modulated Arc Therapy (VMAT), and Standard SSD VMAT TBI techniques were dosimetrically evaluated. Percent depth dose and dose profile measurements were made under treatment conditions for each specified technique. After having generated treatment plans with a treatment planning system (TPS), dose homogeneity and critical organ doses were investigated on a Rando phantom using radiochromic films and optically stimulated luminescence dosimeters (OSLDs). TBI dose of 12 Gy in six fractions was prescribed for each technique. The gamma index (5%/5 mm) was used for the analysis of radiochromic films. Passing rates for Extended SSD FiF, Extended SSD VMAT and Standard SSD VMAT techniques were found to be 90%, 87% and 94%, respectively. OSLD measurements were within ± 5% agreement with TPS calculations for the first two techniques whereas the agreement was found to be within ± 3% for the Standard SSD VMAT technique. TPS calculations demonstrated that mean lung doses in the first two techniques were around 8.5 Gy while it was kept around 7 Gy in Standard SSD VMAT. It is concluded that Standard SSD VMAT is superior in sparing the lung tissue while all three TBI techniques are feasible in clinical practice with acceptable dose homogeneity. In the absence of VMAT-based treatment planning, Extended SSD FiF would be a reasonable choice compared to other conventional techniques.
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Affiliation(s)
- Mert Cananoglu
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Pervin Hurmuz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.
| | - Mete Yeginer
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Gokhan Ozyigit
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
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Ladbury C, Hao C, Yang D, Hui S, Han C, Liu A, Salhotra A, Nakamura R, Rosenthal J, Stein A, Wong J, Dandapani S. Long-term follow up of patients with hematological malignancies treated with total body irradiation using intensity modulated radiation therapy. Front Oncol 2022; 12:1044539. [PMID: 36531001 PMCID: PMC9755353 DOI: 10.3389/fonc.2022.1044539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/18/2022] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND With the advent of modern radiation treatment technologies such as intensity modulated radiation therapy (IMRT), there has been increasing interest in its use for total body irradiation (TBI) conditioning regimens for hematopoietic cell transplantation (HCT) to achieve lower doses to critical organs such as the lungs and kidneys. Although this has been reported on in early studies, long-term safety and efficacy data is limited. METHODS We performed a single institution matched-pair retrospective analysis of patients treated with IMRT TBI and standard TBI between 2010 and 2020 to provide data on long-term outcomes. Patients with hematologic malignancies, who could not tolerate standing for traditional TBI or who received prior radiation received IMRT TBI. Patients were matched based on age, diagnosis, disease status, and year of transplant, and were matched 2:1 to the standard TBI and IMRT TBI cohorts. Patient and treatment characteristics, toxicity, graft-versus-host disease (GVHD), dosimetry, and outcomes were evaluated for each cohort. RESULTS A total of 13 patients met inclusion criteria for the IMRT cohort, leading to 26 patients in the standard TBI cohort. There was no significant difference in relevant clinical factors between the cohorts. Reasons for using IMRT over conventional TBI included being unable to stand (n=5), prior radiation (n=5), and pediatric patient requiring anesthesia (n=3). Among living patients, median follow-up for all patients was 5.1 years in the IMRT TBI cohort and 5.5 years in the standard TBI cohort. The 5-yr estimate of OS was 68% in the IMRT TBI cohort and 60% in the standard TBI cohort (p=0.706). The 5-yr estimate of RFS was 54% in the IMRT TBI cohort and 60% in the standard TBI cohort (p=0.529). There was no clinically significant pneumonitis, nephritis, hypothyroidism, or cataracts reported in the IMRT TBI cohort. 41.7% of patients in the IMRT TBI cohort and 79.2% of patients in the standard TBI cohort experienced Grade II-IV acute GVHD (p=0.023). CONCLUSIONS IMRT TBI appears to lead to favorable long-term outcome and dosimetry, and therefore potentially improved long-term toxicity profile compared to conventional TBI. IMRT TBI warrants further investigation as part of larger prospective trials.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Claire Hao
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Dongyun Yang
- Division of Biostatistics, City of Hope National Medical Center, Duarte, CA, United States
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - An Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Joseph Rosenthal
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
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Hoeben BAW, Pazos M, Seravalli E, Bosman ME, Losert C, Albert MH, Boterberg T, Ospovat I, Mico Milla S, Demiroz Abakay C, Engellau J, Jóhannesson V, Kos G, Supiot S, Llagostera C, Bierings M, Scarzello G, Seiersen K, Smith E, Ocanto A, Ferrer C, Bentzen SM, Kobyzeva DA, Loginova AA, Janssens GO. ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children. Radiother Oncol 2022; 173:119-133. [PMID: 35661674 DOI: 10.1016/j.radonc.2022.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. MATERIAL AND METHODS The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. RESULTS Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. CONCLUSIONS These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.
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Affiliation(s)
- Bianca A W Hoeben
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Montserrat Pazos
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Enrica Seravalli
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Christoph Losert
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Michael H Albert
- Dept. of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Tom Boterberg
- Dept. of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inna Ospovat
- Dept. of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Soraya Mico Milla
- Dept. of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Candan Demiroz Abakay
- Dept. of Radiation Oncology, Uludag University Faculty of Medicine Hospital, Bursa, Turkey
| | - Jacob Engellau
- Dept. of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Gregor Kos
- Dept. of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Stéphane Supiot
- Dept. of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Camille Llagostera
- Dept. of Medical Physics, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giovanni Scarzello
- Dept. of Radiation Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Ed Smith
- Dept. of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Abrahams Ocanto
- Dept. of Radiation Oncology, La Paz University Hospital, Madrid, Spain
| | - Carlos Ferrer
- Dept. of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Søren M Bentzen
- Dept. of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, United States
| | - Daria A Kobyzeva
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Geert O Janssens
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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