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Chicas-Sett R, Castilla Martinez J, Hernández Blanquisett A, Zafra J, Pastor-Peidro J. Stereotactic ablative radiotherapy for acquired resistance to EGFR therapy in metastatic non-small cell lung cancer. Front Oncol 2023; 12:1092875. [PMID: 36727053 PMCID: PMC9884815 DOI: 10.3389/fonc.2022.1092875] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/12/2022] [Indexed: 01/17/2023] Open
Abstract
The advent of targeted therapy has transformed the treatment paradigm and survival of patients with metastatic non-small cell lung cancer (NSCLC) with driver mutations. The development of acquired resistances during treatment with tyrosine kinase inhibitors (TKIs) impedes a prolonged survival in many patients. This fact is leading to the use of locally ablative therapies such as stereotactic ablative radiotherapy (SABR) to counter these resistances. SABR is a non-invasive treatment that can be delivered in multiple locations and has already proven effective in oligometastatic disease. Clinical evidence suggests that the combination of SABR with TKIs prolongs progression-free survival (PFS) in metastatic NSCLC patients with mutations in epidermal growth factor receptor (EGFR), with international guidelines recommending their use in unfavorable scenarios such as oligoprogressive disease. In this publication, we have reviewed the available evidence on EGFR-TKIs resistance mechanisms and the combination of SABR with TKI in metastatic NSCLC with EGFR mutations. We also describe the utility and clinical recommendations of this combination in oligometastatic and oligoprogressive disease.
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Affiliation(s)
- Rodolfo Chicas-Sett
- Department of Radiation Oncology, ASCIRES GRUPO BIOMEDICO, Valencia, Spain,*Correspondence: Rodolfo Chicas-Sett,
| | | | | | - Juan Zafra
- Group of Translational Research in Cancer Immunotherapy, Health and Medical Research Center (CIMES), Institute of Biomedical Research in Malaga (IBIMA), Malaga, Spain,Department of Radiation Oncology, Virgen de la Victoria University Hospital, Malaga, Andalusia, Spain,Faculty of Medicine, University of Malaga, Malaga, Andalusia, Spain
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Ablative Radiotherapy as a Strategy to Overcome TKI Resistance in EGFR-Mutated NSCLC. Cancers (Basel) 2022; 14:cancers14163983. [PMID: 36010982 PMCID: PMC9406789 DOI: 10.3390/cancers14163983] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Most patients with EGFR-mutated NSCLC who receive treatment with targeted therapy will eventually develop resistance, meaning the therapy will lose its efficacy. Prior studies have shown a benefit to continuing to treat patients on TKI therapy despite limited progression of one or more sites of metastatic disease in EGFR-mutated NSCLC. Based on the data reviewed here, the use of radiation therapy to sites of disease progression is both efficacious and carries a low risk for side effects, with the added benefit of allowing patients to continue on TKI therapy. Abstract Tyrosine kinase inhibitor (TKI) therapy is the recommended first-line treatment for metastatic non-small-cell lung cancer (NSCLC) positive for epidermal growth factor receptor (EGFR) gene mutation. However, most individuals treated with TKI therapy for EGFR-mutant NSCLC will develop tumor resistance to TKI therapy. Therapeutic strategies to overcome TKI resistance are the topic of several ongoing clinical trials. One potential strategy, which has been explored in numerous trials, is the treatment of progressive sites of disease with stereotactic body radiation treatment (SBRT) or stereotactic radiosurgery (SRS). We sought to review the literature pertaining to the use of local ablative radiation therapy in the setting of acquired resistance to TKI therapy and to discuss stereotactic radiation therapy as a strategy to overcome TKI resistance.
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Deng R, Liu J, Song T, Xu T, Li Y, Duo L, Xiang L, Yu X, Lei J, Cao F. Primary lesion radiotherapy during first-line icotinib treatment in EGFR-mutated NSCLC patients with multiple metastases and no brain metastases: a single-center retrospective study. Strahlenther Onkol 2022; 198:1082-1093. [PMID: 35819466 DOI: 10.1007/s00066-022-01971-w] [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: 10/04/2021] [Accepted: 06/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The most frequent mode of progression in the majority of non-small cell lung cancer (NSCLC) patients treated with Epidermal growth factor - receptor tyrosine kinase inhibitors (EGFR-TKIs) is failure to respond to treatment at the primary lesion, suggesting that concurrent radiotherapy (CRT) to the primary lesion (CPRT) during first-line treatment with EGFR-TKI may be a novel therapeutic approach with a potential of additional benefit for metastatic NSCLC. Therefore, this study investigated the progression-free survival (PFS) and safety of CPRT during first-line icotinib treatment in NSCLC patients with EGFR mutations. METHODS EGFR-mutant NSCLC patients diagnosed with limited multiple metastases were treated with first-line icotinib. The decision to treat the primary lesions with radiation largely depended on the patient's preference. The study endpoints included PFS, toxicity, progression pattern, and acquisition of the T790M mutation. RESULTS The median PFS in the CPRT and Non-CPRT groups was 13.6 and 10.6 months (hazard ratio [HR] 0.23, 95% confidence interval [CI] 0.15-0.37, P < 0.001). Subgroup analysis showed that the results were statistically significant with 14.7 and 11.5 months for the 19del mutation (HR 0.20, 95% CI 0.10-0.40, P < 0.001) and 12.9 and 9.9 months for the L858R mutation (HR 0.25, 95% CI 0.13-0.48, P < 0.001). There were no reports of interstitial pneumonia associated with treatment at grade 4 or above. Patients who received CPRT during first-line icotinib treatment had the potential to decrease the primary lesion progression (P < 0.05) without increasing newly metastatic lesions (P > 0.05). The proportion of acquired T790M mutations was 26.7% and 45.7% in both groups (P > 0.05). CONCLUSION This study suggests that CPRT is a viable option for patients with EGFR-sensitive mutations in NSCLC with limited multiple metastases during first-line icotinib treatment, which can significantly improve PFS with acceptable toxicities. Data on progression patterns and T790M mutations suggest the need to further investigate the benefits of radiation treatment from a molecular perspective.
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Affiliation(s)
- Rui Deng
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Jinkun Liu
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
- Jinzhou Medical University, 121000, Jinzhou, Liaoning, China
| | - Tongjun Song
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
- Hubei University of Medicine, 442000, Shiyan, Hubei, China
| | - Tao Xu
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Yong Li
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
- Institute of Cancer Research, Renmin Hospital, Hubei University of Medicine, 442000, Shiyan, Hubei, China
| | - Long Duo
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Longchao Xiang
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Xiongjie Yu
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Jinhua Lei
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Fengjun Cao
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China.
- Institute of Cancer Research, Renmin Hospital, Hubei University of Medicine, 442000, Shiyan, Hubei, China.
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Hu C, Wu S, Deng R, Wu Y, Pan Y, Shu L, Wu F. Radiotherapy with continued EGFR-TKIs for oligoprogressive disease in EGFR-mutated non-small cell lung cancer: A real-world study. Cancer Med 2022; 12:266-273. [PMID: 35666038 PMCID: PMC9844634 DOI: 10.1002/cam4.4894] [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: 02/13/2022] [Revised: 04/29/2022] [Accepted: 05/11/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC) develops resistance to tyrosine kinase inhibitors (TKIs). Here, we evaluated the efficacy of radiotherapy and continuation of TKIs in patients with advanced NSCLC with oligoprogression after EGFR-TKIs. METHODS From January 2011 to January 2019, 33 patients with EGFR-mutated NSCLC on TKIs were treated by radiotherapy and continuation of TKIs for oligoprogressive disease. The primary endpoints were median progression-free survival 1 (mPFS1), mPFS2, and median overall survival (mOS). PFS1 was measured from the start of EGFR-TKIs therapy to the oligoprogression of the disease. PFS2 was measured from the date of oligoprogression to the further progression of the disease, while OS was calculated from oligoprogression to death from any cause or was censored at the last follow-up date. RESULT The mPFS1, mPFS2, and mOS were 11.0 (95% CI, 4.4-17.6), 6.5 (95% CI, 1.4-11.6) and 21.8 (95% CI, 14.8-28.8) months, respectively. Univariate analysis showed that EGFR mutation type (p = 0.024), radiotherapy method (p = 0.001), and performance status (p = 0.017) were significantly correlated with PFS2. Univariate analysis showed that sex (p = 0.038), smoking history (p = 0.031), EGFR mutation type (p = 0.012), and radiotherapy method (p = 0.009) were significantly correlated with OS. Multivariate analysis suggested that radiotherapy method (p = 0.001) and performance status (p = 0.048) were prognostic factors for PFS2, and radiotherapy method (p = 0.040) was a prognostic factor for OS. CONCLUSION Radiotherapy with continued TKIs is effective for EGFR-mutated NSCLC with oligoprogression, and it should be conducted as soon as possible. T790M+ patients have higher sensitivity to radiotherapy, and patients with good performance status and stereotactic body radiation therapy have better PFS2 and OS.
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Affiliation(s)
- Chunhong Hu
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina
| | - Sixuan Wu
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina,Department of Internal Medicine OncologyThe First Affiliated Hospital of University of South ChinaHengyangHunan ProvinceChina
| | - Renfang Deng
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina,Department of OncologyZhuZhou Second HospitalZhuZhouHunanChina
| | - Yuanqiang Wu
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina
| | - Yue Pan
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina
| | - Long Shu
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina
| | - Fang Wu
- Department of OncologyThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina,Hunan Cancer Mega‐Data Intelligent Application and Engineering Research CentreChangshaHunanChina,Hunan Key Laboratory of Tumor Models and Individualized MedicineThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina,Hunan Key Laboratory of Early Diagnosis and Precision Therapy in Lung CancerThe Second Xiangya Hospital, Central South UniversityChangshaHunanChina
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Chen Y, Wei J, Cai J, Liu A. Combination therapy of brain radiotherapy and EGFR-TKIs is more effective than TKIs alone for EGFR-mutant lung adenocarcinoma patients with asymptomatic brain metastasis. BMC Cancer 2019; 19:793. [PMID: 31399067 PMCID: PMC6688250 DOI: 10.1186/s12885-019-6005-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 07/31/2019] [Indexed: 02/01/2023] Open
Abstract
Background The treatment strategy for brain metastasis (BM) in patients with epidermal growth factor receptor (EGFR) -mutant lung adenocarcinoma (LAC) remains controversial. In the present study, we compared the efficacy of brain radiotherapy (RT) in combination with tyrosine kinase inhibitors (TKIs) and TKIs alone for advanced LAC patients with EGFR mutations and BM. Methods We retrospectively studied 78 patients diagnosed with EGFR-mutant LAC who developed BM. These patients were divided into two groups: 49 patients in the combination treatment group who received brain RT in combination with EGFR-TKIs (including 23 patients with asymptomatic BM before RT); 29 patients in the TKI group who received EGFR-TKI targeted therapy alone (including 22 patients with asymptomatic BM before TKI treatment). Results The median intracranial progression-free survival (iPFS) of the combination treatment group was longer than that of the TKI alone group (21.5 vs. 15 months; P = 0.036). However, there were no significant differences in median progression-free survival (PFS, 12 vs. 13 months; P = 0.242) and median overall survival (mOS, 36 vs. 23 months; P = 0.363) between the two groups. Further analysis of asymptomatic BM showed that both the median iPFS and the mOS of the combination treatment group were significantly longer than for the TKI alone group (iPFS, 21.5 vs. 14.8 months, P = 0.026; mOS, 36 vs. 23 months, P = 0.041). Cox multivariate regression analysis found no independent adverse predictors of iPFS in all patients. Conclusions The synchronous combination of brain RT and TKIs was superior to EGFR-TKIs alone for EGFR-mutant LAC patients with BM. The combination treatment group exhibited longer iPFS, while the PFS and OS were not significantly different between the two groups. In addition, the combination treatment could result in better iPFS and OS in those with asymptomatic BM. Therefore, addition of brain RT was useful for intracranial metastatic lesions.
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Affiliation(s)
- Yanxin Chen
- Department of oncology, The second affiliated hospital of Nanchang University, Jiangxi province, Nanchang, 330006, China.,Jiangxi key laboratory of clinical translational cancer research, The second affiliated hospital of Nanchang University, Jiangxi province, Nanchang, 330006, China
| | - Jianping Wei
- Department of oncology, The second affiliated hospital of Nanchang University, Jiangxi province, Nanchang, 330006, China
| | - Jing Cai
- Department of oncology, The second affiliated hospital of Nanchang University, Jiangxi province, Nanchang, 330006, China
| | - Anwen Liu
- Department of oncology, The second affiliated hospital of Nanchang University, Jiangxi province, Nanchang, 330006, China. .,Jiangxi key laboratory of clinical translational cancer research, The second affiliated hospital of Nanchang University, Jiangxi province, Nanchang, 330006, China.
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Zhuang H. Research progress on the impact of radiation on TKI resistance mechanisms in NSCLC. J Cancer 2018; 9:3797-3801. [PMID: 30405851 PMCID: PMC6216000 DOI: 10.7150/jca.26364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/23/2018] [Indexed: 11/21/2022] Open
Abstract
Resistance to tyrosine kinase inhibitor (TKI) therapy is often accompanied by various genetic alterations, and radiation is an important weapon for changing the DNA of tumor cells. In radiotherapy combined with TKI therapy for non-small cell lung cancer (NSCLC), the two treatment strategies affect and interact with each other, resulting in complex tumor resistance mechanisms. Accordingly, tumor progression management after radiotherapy combined with TKI therapy should be different from that after TKI therapy alone. However, current clinical practice is entirely based on the resistance mechanisms of simple TKI therapy. Therefore, it is imperative to investigate the impact of radiation on the mechanism of TKI resistance. However, due to the complexity of the resistance mechanisms under the combined effect of both therapies, such studies remain extremely challenging and time-consuming.
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Affiliation(s)
- Hongqing Zhuang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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Hochmair M. Medical Treatment Options for Patients with Epidermal Growth Factor Receptor Mutation-Positive Non-Small Cell Lung Cancer Suffering from Brain Metastases and/or Leptomeningeal Disease. Target Oncol 2018; 13:269-285. [PMID: 29700687 PMCID: PMC6004273 DOI: 10.1007/s11523-018-0566-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Brain metastases and/or leptomeningeal disease (LMD) with associated central nervous system (CNS) metastases are known complications of advanced epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). It is important, therefore, to assess the activity of EGFR tyrosine kinase inhibitors (TKIs) versus such CNS complications. This review explores the literature reporting the intracranial activity of EGFR TKIs, and finds that there is evidence for varying efficacy of the approved agents, erlotinib, gefitinib, afatinib, and osimertinib in patients with CNS metastases. Other EGFR TKIs in development, such as AZD3759, may have a future role as therapeutic options in this setting. Emerging evidence indicates that the second- and third-generation EGFR TKIs, afatinib and osimertinib, effectively penetrate the blood-brain barrier, and therefore represent viable treatment options for CNS lesions, and can reduce the risk of CNS progression. These agents should therefore be considered as first-line treatment options in patients with EGFR mutation-positive NSCLC who have brain metastases and/or LMD. While there are currently no prospective data comparing the intracranial efficacy of second- and third-generation EGFR TKIs in this setting, CNS activity and protection offered by different EGFR TKIs should be an additional consideration when making decisions about the optimal sequence of treatment with EGFR TKIs in order to maximize survival benefit in individual patients.
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Affiliation(s)
- Maximilian Hochmair
- Department of Respiratory and Critical Care Medicine and Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria.
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Zhu Q, Sun Y, Cui Y, Ye K, Yang C, Yang D, Ma J, Liu X, Yu J, Ge H. Clinical outcome of tyrosine kinase inhibitors alone or combined with radiotherapy for brain metastases from epidermal growth factor receptor (EGFR) mutant non small cell lung cancer (NSCLC). Oncotarget 2017; 8:13304-13311. [PMID: 28076323 PMCID: PMC5355097 DOI: 10.18632/oncotarget.14515] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/27/2016] [Indexed: 01/05/2023] Open
Abstract
This study compared treatment outcomes between TKI monotherapy and TKI administration combined with brain radiotherapy (TKI + RT) in 133 non-small cell lung cancer (NSCLC) patients with brain metastasis (BM). We also evaluated the association of different epidermal growth factor receptor (EGFR) mutation subtypes with treatment outcome. To screen for potential variables affecting cranial progression free survival (PFS) and overall survival (OS), we performed univariate and multivariate analysis based on Cox proportional-hazards models. Median cranial PFS and OS were longer for the TKI + RT group (n = 67) than TKI alone group (n = 66). Intracranial metastasis correlated with a better median OS than extracranial metastasis. For patients with exon 21 mutations, TKI + RT yielded a better median OS and cranial PFS than TKI alone. However, there were no significant differences in median OS and cranial PFS between the two treatment groups for patients with exon 19 deletions. Thus EGFR-mutant NSCLC patients with BM could benefit more from TKI + RT than from TKI monotherapy, especially when they suffer from exon 21 mutations. However, TKI + RT confers no advantage over TKI treatment alone for patients with exon 19 deletions. These results underscore the urgent need to develop individualized disease management strategies in clinical practice.
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Affiliation(s)
- Qianqian Zhu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Yanan Sun
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Yingying Cui
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Ke Ye
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Chengliang Yang
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Daoke Yang
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Jie Ma
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Xiao Liu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, 250117, Shandong Province, China
| | - Hong Ge
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
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