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Wang J, Wu Y, Zhang W, Chen Y, Liu Q, Jing S, Zhang J, Wu F, Wang J, Qiao X. Elective nodal irradiation versus involved-field irradiation for stage II-IV cervical esophageal squamous cell carcinoma patients undergoing definitive concurrent chemoradiotherapy: a retrospective propensity study with 8-year survival outcomes. Radiat Oncol 2023; 18:142. [PMID: 37641149 PMCID: PMC10464095 DOI: 10.1186/s13014-023-02332-2] [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: 10/18/2022] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Definitive concurrent chemoradiotherapy (dCCRT) is suggested as the standard treatment for cervical esophageal squamous cell carcinoma (CESCC). This retrospective propensity study compared the 8-year survival outcomes and acute treatment toxicities of these patients treated with elective nodal irradiation (ENI) versus involved-field irradiation (IFI). MATERIALS AND METHODS Patients with stage II-IV CESCC treated with dCCRT at the Fourth Hospital of Hebei Medical University between January 1, 2007 and December 31, 2020 were enrolled in the study. All the patients were restaged according to the American Joint Commission 8th edition criteria. The propensity score matching (PSM) was used to minimize the effects of treatment selection bias and potential confounding factors including sex, age, ECOG score, clinical T stage, clinical N stage, clinical TNM stage and radiation dose between the ENI group and IFI group. Survival and the prognostic factors were evaluated. RESULTS The 131 eligible patients underwent ENI (60 patients, 45.8%) or IFI (71 patients, 54.2%). The median follow-up time was 91.1 months (range, 23.8-182.0 months) for all the patients. The median OS, 1-, 3-, 5-, and 8-year OS rates were 44.4 months, 87.8%, 55.1%, 38.3%, and 27.2%, respectively. After PSM, there were 49 patients in each group. The median OS, 1-, 3-, 5-, and 8-year OS rates for ENI and IFI group were 32.0 months, 83.7%, 48.5%, 38.5% and 31.1% versus 45.2 months, 89.8%, 52.5%, 37.5%, 26.1%, respectively (P = 0.966; HR 0.99, 95% CI 0.61-1.61). Similar locoregional control was obtained in both groups. The tendency of leukocytopenia and neutropenia was higher in ENI than in IFI (59.2% vs. 38.8%; P = 0.068 and 30.6% vs. 14.3%; P = 0.089) at the end of dCCRT. CONCLUSION Cervical esophageal squamous cell carcinoma patients undergoing definitive concurrent chemoradiotherapy has a satisfactory prognosis with organ conservation. The involved-field irradiation might be a better alternative owing to similar overall survival outcomes and local control with less toxicity of myelosuppression.
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Affiliation(s)
- Jianing Wang
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Yajing Wu
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Wei Zhang
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Yujia Chen
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Qing Liu
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Shaowu Jing
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Jiandong Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Fengpeng Wu
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China
| | - Jun Wang
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China.
| | - Xueying Qiao
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, 050011, China.
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Liao S, Wei W, Zhang S, Zeng T, Chen H, Zheng W, Chen C, Ji Z, Zheng B. Modified method to improve the diagnostic efficiency of 18F-FDG PET/CT in regional lymph node metastasis of esophageal squamous cell carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1549. [PMID: 34790755 PMCID: PMC8576671 DOI: 10.21037/atm-21-4926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/22/2021] [Indexed: 12/24/2022]
Abstract
Background Regional lymph node (LN) metastasis is a significant factor influencing the treatment choice of esophageal squamous cell carcinoma (ESCC). The performance PET/CT as an imaging evaluation method for regional LNs in ESCC, is unsatisfactory due to the lack of logical criterion. We explored how a modified criterion improved the diagnostic value of 18F-FDG PET/CT in regional LN metastasis. Methods The data from 111 patients with ESCC were analyzed retrospectively. All patients underwent preoperative PET/CT examination, resection of the cancer, and regional LN dissection. The PET/CT images were interpreted by two experienced diagnosticians. LNs were allocated to five subregions. Each LN was diagnosed by two diagnostic criteria of PET/CT (traditional criterion and the modified criterion) one by one across the same field, and the accuracy of PET/CT was determined using the histopathologic results as the reference standard. Results A total of 4,847 LNs were dissected, of which 147 were confirmed as metastases by postoperative pathology. A total of 656 LNs were screened by 18F-FDG PET/CT imaging. The determination of all 656 LNs by PET/CT was compared with the pathological results. The diagnostic accuracy of the modified and traditional criteria for the five subregions (paraesophageal, neck, upper mediastinal, middle-lower mediastinal and ventral subregions) was: 74.60% vs. 61.90%, 86.44% vs. 81.36%, 90.26% vs. 70.78%, 96.19% vs. 75.09%, and 87.91% vs. 85.71%, respectively. Conclusions The modified diagnostic criterion had better diagnostic efficiency because it combined PET and CT imaging data.
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Affiliation(s)
- Siqin Liao
- PET/CT Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wenwei Wei
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shuliang Zhang
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Taidui Zeng
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hao Chen
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wei Zheng
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Chun Chen
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhongyou Ji
- PET/CT Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bin Zheng
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou, China
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Ishida Y, Sakanaka K, Fujii K, Itasaka S, Mizowaki T. Intensity-modulated radiotherapy for cervical esophageal squamous cell carcinoma without hypopharyngeal invasion: dose distribution and clinical outcome. JOURNAL OF RADIATION RESEARCH 2019; 60:517-526. [PMID: 31083715 PMCID: PMC6640902 DOI: 10.1093/jrr/rrz019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/01/2019] [Indexed: 05/13/2023]
Abstract
Hypopharyngeal invasion would be a key finding in determining the extent of the irradiation fields in patients with cervical esophageal squamous cell carcinoma (CESCC). This study aimed to investigate the clinical outcomes of chemoradiotherapy using simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) omitting upper cervical lymph nodal irradiation in CESCC without hypopharyngeal invasion, and the dosimetric superiority of SIB-IMRT to 3D conformal radiotherapy (3DCRT). We retrospectively identified 21 CESCC patients without hypopharyngeal invasion [clinical Stage I/II/III/IV (M1LYM); 3/6/5/7] (UICC-TNM 7th edition) who underwent chemoradiotherapy using SIB-IMRT between 2009 and 2015. SIB-IMRT delivered 60 Gy to each primary tumor and the metastatic lymph nodes, and 48 Gy to elective lymph nodal regions, including Levels III and IV of the neck, supraclavicular, and upper mediastinal lymphatic regions, in 30 fractions. The overall survival rate, locoregional control rate, and initial recurrence site were evaluated. 3DCRT plans were created to perform dosimetric comparisons with SIB-IMRT. At a median follow-up of 64.5 months, the 5-year locoregional control and overall survival rates were 66.7% and 53.4%, respectively. Disease progressed in eight patients: all were locoregional progressions and no patients developed distant progression including upper cervical lymph nodal regions as initial recurrence sites. The planning study showed SIB-IMRT improved target coverage without compromising the dose to the organs at risk, compared with 3DCRT. In conclusion, omitting the elective nodal irradiation of the upper cervical lymph nodes was probably reasonable for CESCC patients without hypopharyngeal invasion. Locoregional progression remained the major progression site in this population.
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Affiliation(s)
- Yuichi Ishida
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Sho-goin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Katsuyuki Sakanaka
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Sho-goin Kawahara-cho, Sakyo-ku, Kyoto, Japan
- Corresponding author: Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Sho-goin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan. Tel: +81-75-751-3762; Fax: +81-75-771-9749;
| | - Kota Fujii
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Sho-goin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Satoshi Itasaka
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Sho-goin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Sho-goin Kawahara-cho, Sakyo-ku, Kyoto, Japan
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Xu HY, Wu SX, Luo HS, Chen CY, Lin LX, Huang HC. Analysis of definitive chemo-radiotherapy for esophageal cancer with supra-clavicular node metastasis based on CT in a single institutional retrospective study: a propensity score matching analysis. Radiat Oncol 2018; 13:200. [PMID: 30326912 PMCID: PMC6192107 DOI: 10.1186/s13014-018-1145-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/01/2018] [Indexed: 11/10/2022] Open
Abstract
Background The prognostic value of supra-clavicular lymph node (SCLN) metastases in esophageal cancer (EC) is still not clear. Method From January 2009 to December 2015, a survival analysis was performed to retrospectively identify the prognostic value of SCLN metastasis on survival on 751 patients with EC treated with definitive chemo-radiotherapy (dCRT). Results The median follow-up duration for living patients was 56.6 months. The median overall survival (OS) for all patients was 16.6 months. Patients with SCLN metastasis had a much poorer prognosis for OS (χ2 = 17.342, P < 0.001), distant metastasis-free survival (DMFS) (χ2 = 24.793, P < 0.001) and progression-free survival (PFS) (χ2 = 25.802, P < 0.001) than those without SCLN metastasis. The same results were found after propensity score matching. Nonetheless, the prognosis of patients with cervical or upper thoracic EC metastasis in SCLN was better than those of patients with middle or lower thoracic EC metastasis in SCLN for OS (χ2 = 4.516, P = 0.038), DMFS (χ2 = 8.326, P = 0.004) and PFS (χ2 = 6.255, P = 0.012). Univariate analysis showed that gender, middle or lower thoracic EC with SCLN metastasis, tumor length, tumor diameter, concurrent chemo-radiotherapy (CCR) and number of lymph nodes were prognostic factors for PFS. Gender, age, middle or lower thoracic EC with SCLN metastasis, tumor diameter, tumor length, and number of lymph nodes were prognostic factors for DMFS. According to the multivariate analysis, only middle or lower thoracic EC with SCLN metastasis and number of lymph nodes were independent prognostic factors for DMFS and PFS. Conclusion For patients with cervical or upper thoracic EC, metastasis in SCLN should be considered to be regional lymph nodes and treated with curative intent if the total number of lymph nodes is limited. However, for patients with middle or lower thoracic EC, metastasis should be considered to be a higher level N stage or M1 stage, and it is thus necessary to provide consolidation chemotherapy after dCRT.
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Affiliation(s)
- Hong-Yao Xu
- Department of Radiotherapy, Shantou Central Hospital (The Affiliated Shantou Hospital of Sun Yat-sen University), Shantou, 515031, China.
| | - Sheng-Xi Wu
- Department of Radiotherapy, Shantou Central Hospital (The Affiliated Shantou Hospital of Sun Yat-sen University), Shantou, 515031, China
| | - He-San Luo
- Department of Radiotherapy, Shantou Central Hospital (The Affiliated Shantou Hospital of Sun Yat-sen University), Shantou, 515031, China
| | - Chu-Yun Chen
- Department of Radiotherapy, Shantou Central Hospital (The Affiliated Shantou Hospital of Sun Yat-sen University), Shantou, 515031, China
| | - Lian-Xing Lin
- Department of Radiotherapy, Shantou Central Hospital (The Affiliated Shantou Hospital of Sun Yat-sen University), Shantou, 515031, China
| | - He-Cheng Huang
- Department of Radiotherapy, Shantou Central Hospital (The Affiliated Shantou Hospital of Sun Yat-sen University), Shantou, 515031, China
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Identification of risk factors and the pattern of lower cervical lymph node metastasis in esophageal cancer: implications for radiotherapy target delineation. Oncotarget 2018; 8:43389-43396. [PMID: 28118614 PMCID: PMC5522154 DOI: 10.18632/oncotarget.14761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/10/2017] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy remains the important therapeutic strategy for patients with esophageal cancer (EC). At present, there is no uniform opinion or standard care on the range of radiotherapy in the treatment of EC patients. This study aimed to investigate the risk factors associated with lower cervical lymph node metastasis (LNM) and to explore the distribution pattern of lower cervical metastatic lymph nodes. It could provide useful information regarding accurate target volume delineation for EC. We identified 239 patients who initial diagnosed with esophageal squamous cell carcinoma. The clinicopathological factors related to LNM were analyzed and the locations of the lower cervical metastatic lymph nodes were transferred onto computed tomography images. The lower cervical area was further divided into four subgroups areas. The results showed that the incidence of lower cervical LNM was 37.2 % (89 of 239) and 94.4 % (84 of 89 patients) patients had subgroup II and/or subgroup III region LNM. Of those patients, 151 nodes were considered to be clinical metastatic in the lower cervical region and 96% nodes were located in group II and group III. Based on the present study, prophylactic irradiating to lower cervical areas is recommended for patients with deeper tumor invasion, the mediastinal level 1, 2, and 4 station LNM and the more number of LNM. The atlas showed that, for the lower cervical area, the subgroup II and III region should be precisely covered in the target volume and the subgroup I and IV may be spared for minimizing the toxicity.
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Regional hyperthermia combined with radiotherapy for esophageal squamous cell carcinoma with supraclavicular lymph node metastasis. Oncotarget 2018; 8:5339-5348. [PMID: 28029663 PMCID: PMC5354912 DOI: 10.18632/oncotarget.14148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/24/2016] [Indexed: 11/25/2022] Open
Abstract
To assess the efficacy and toxicity of Intensity-modulated radiotherapy (IMRT) and hyperthermia for upper and middle thoracic esophageal squamous cell carcinoma (UMT-ESCC) with supraclavicular lymph node metastasis. A total of 50 patients with UMT-ESCC with supraclavicular lymph node metastasis were evaluated in this retrospective study. All patients received IMRT. Hyperthermia was delivered simultaneously with irradiation, in 45 minutes twice a week for 5-6 weeks. Hyperthermia included supraclavicular lymph node metastasis. Forty-four patients (88.0%) received concurrent chemoradiotherapy based on cisplatin regimens. The most common types of hematological toxicities were anemia (62.0%) and leukopenia (60.0%). Most of these events were grade 1-2 and transient. The 3-year progression-free survival (PFS) rate and overall survival (OS) rate were 34.9% and 42.5%, respectively. Cox regression revealed that tumor length and number of supraclavicular lymph node metastasis were two independent predictors of OS (tumor length: HR=3.65, p=0.008; nodal stage: HR=8.07, p=0.019). The IMRT combined with supraclavicular regional hyperthermia has low toxicity and well tolerated with excellent local control in UMT-ESCC with supraclavicular lymph node metastasis.
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Xing J, Luo Y, Wang X, Gao M, Sun M, Ding X, Fan T, Yu J. Anatomic distribution of supraclavicular lymph node in patients with esophageal cancer. Onco Targets Ther 2016; 9:5803-5808. [PMID: 27703379 PMCID: PMC5036650 DOI: 10.2147/ott.s111800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Definitive chemoradiation therapy remains the standard of care for patients with localized esophageal carcinoma who choose nonsurgical management. However, there is no consensus regarding delineation of the nodal clinical target volume (CTVn), especially for lower cervical lymph nodes. This study aimed to map the location of metastatic supraclavicular lymph nodes in thoracic esophageal carcinoma patients with supraclavicular node involvement and generate an atlas to delineate the CTVn for elective nodal radiation of esophageal squamous cell carcinoma. PATIENTS AND METHODS In this study, the supraclavicular regional lymph node was further divided into four subgroups. The locations of the involved supraclavicular nodes for all patients were then transferred onto a template computed tomography (CT) image. A volume probability map was then generated with nodal volumes, and was displayed on the template CT to provide a visual impression of nodal frequencies and anatomic distribution. RESULTS We identified 154 supraclavicular nodal metastases based on CT image in 96 patients. Of these, 29.2% were located in group I region, 59.7% in group II region, 10.4% in group III region, and 0.7% in group IV region. CONCLUSION On the basis of our study, we suggest that the appropriate radiation field of CTVn should include the group I and II regions and the CTVn exterior margin along the lateral side of the internal jugular vein may be suitable.
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Affiliation(s)
- Jun Xing
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University
| | - Yijun Luo
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University; School of Medical and Life Sciences, Shandong Academy of Medical Sciences, University of Jinan, Jinan, People's Republic of China
| | - Xiaoli Wang
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University; School of Medical and Life Sciences, Shandong Academy of Medical Sciences, University of Jinan, Jinan, People's Republic of China
| | - Min Gao
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University
| | - Mingping Sun
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University
| | - Xiuping Ding
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University
| | - Tingyong Fan
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University
| | - Jinming Yu
- Department of Radiation Oncology and Radiology, Shandong Cancer Hospital Affiliated to Shandong University
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Hoeben A, Polak J, Van De Voorde L, Hoebers F, Grabsch HI, de Vos-Geelen J. Cervical esophageal cancer: a gap in cancer knowledge. Ann Oncol 2016; 27:1664-74. [PMID: 27117535 DOI: 10.1093/annonc/mdw183] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 04/20/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The aim of this systematic review is to provide an overview of the diagnosis, treatment options and treatment-related complications of cervical esophageal carcinoma (CEC) and to subsequently provide recommendations to improve quality of care. DESIGN Studies were identified in PubMed, EMBASE and Web of Science. A total of 107 publications fulfilled the inclusion criteria and were included. RESULTS CEC is uncommon, accounting for 2%-10% of all esophageal carcinomas. These tumors are often locally advanced at presentation and have a poor prognosis, with a 5-year overall survival of 30%. Tobacco and alcohol consumption seem to be the major risk factors for developing CEC. Surgery is usually not possible due to the very close relationship to other organs such as the larynx, trachea and thyroid gland. Therefore, the current standard of care is definitive chemoradiation (dCRT) with curative intent. Treatment regimens used to treat CEC are adapted by established regimens in lower esophageal squamous cell carcinoma and head and neck squamous cell carcinoma. However, dCRT may be accompanied by severe side-effects and complications. Several diagnostic and predictive markers have been studied, but currently, there is no other biomarker than clinical stage to determine patient management. Suggestions to improve patient outcomes are to determine the exact radiation dose needed for adequate locoregional control and to combine radiotherapy with optimal systemic therapy backbone. CONCLUSION CEC remains unchartered territory for many practising physicians and patients with CEC have a poor prognosis. To improve the outcome for CEC patients, future studies should focus on the identification of new diagnostic biomarkers or targets for radiosensitizers, amelioration of radiation schedules, optimal combination of chemotherapeutic agents and/or new therapeutic targets.
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Affiliation(s)
- A Hoeben
- Department of Internal Medicine, Division of Medical Oncology
| | - J Polak
- Department of Internal Medicine, Division of Medical Oncology
| | | | - F Hoebers
- Department of Radiation Oncology (MAASTRO Clinic)
| | - H I Grabsch
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands Department of Pathology & Tumour Biology, Leeds Institute of Cancer Studies and Pathology, University of Leeds, Leeds, UK
| | - J de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology
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