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Use of Normal Tissue Complication Probability Models in the Clinic
Open accessAbstract
The Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) review summarizes the currently available three-dimensional dose/volume/outcome data to update and refine the normal tissue dose/volume tolerance guidelines provided by the classic Emami et al. paper published in 1991. A "clinician's view" on using the QUANTEC information in a responsible manner is presented along with a description of the most commonly used normal tissue complication probability (NTCP) models. A summary of organ-specific dose/volume/outcome data, based on the QUANTEC reviews, is included.
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“A seminal paper by Emami et al. ( 6 ) summarized normal-tissue tolerances to external photon irradiation as they were known in 1991, and these data have been gradually updated and expanded through other initiatives such as Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) and Hypofractionated Treatment Effects in the Clinic (HyTEC) ( 25 , 26 ).”
From Normal-Tissue Tolerance to Radiopharmaceutical Therapies, the Knowns and the Unknowns (2021) · cites this paper as [25]
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Lyman, J. T. (1985) · Radiation Research · doi:10.2307/3576626 · Cited by 1,160
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- Jolles, 1939, Area factor in skin reaction, Br Emp Cancer Campaign Rep, 16
- Niemierko, 1999, A generalized concept of equivalent uniform dose (EUD), Med Phys, 26, 1100
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“showed that no more than 55% of the volume of the bilateral whole kidney should receive a dose greater than 12 Gy [9].”
BackgroundSmall bowel protection in IMRT for rectal cancer
Koeck, J., Kromer, K., Lohr, F., Baack, T., Siebenlist, K., Mai, S., Büttner, S., Fleckenstein, J., & Wenz, F. K. (2017) · Strahlentherapie und Onkologie · doi:10.1007/s00066-017-1107-z · Cited by 12
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Stoppel, G., Eich, H.-T., Matuschek, C., Kortmann, R., Meyer, F., Martinsson, U., Nilsson, K. L., Kristensen, I. F., Vordermark, D., Willich, N. A., et al. (2017) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2017.09.026 · Cited by 12
Bernhardt, D., Sterzing, F., Adeberg, S., Herfarth, K. K., Katayama, S., Foerster, R., Rieber, J., König, L., Debus, J., & Rieken, S. (2018) · Cancer Management and Research · doi:10.2147/cmar.s148395 · Cited by 12
Chaikh, A., Ojala, J., Khamphan, C., Garcia, R., Giraud, J.-Y., Thariat, J., & Balosso, J. (2018) · Radiation Oncology · doi:10.1186/s13014-018-1005-2 · Cited by 12
“OARs TD50 (Gy) a [29, 36] Endpoint EUDmax (Gy) NTCP ≤1% EUDmax (Gy) NTCP ≤5% Dose limits [37, 38] (in 3DCRT)”
BackgroundMukai, Y., Matsuyama, R., Koike, I., Kumamoto, T., Kaizu, H., Homma, Y., Takano, S., Sawada, Y., Sugiura, M., Yabushita, Y., et al. (2019) · Medicine · doi:10.1097/md.0000000000016673 · Cited by 12
“quantitative analyses of normal tissue effects in the clinic([14]) indicates that for conventional fractionation, mean dose to a whole, unresected liver should be <30 to 32Gy to prevent from classic radiation-induced liver disease (RILD).([15]) Also, it is widely used that the volume of liver received 30Gywas set to k…”
BackgroundRadiomics for radiation oncologists: are we ready to go?
Vaugier, L., Ferrer, L., Mengue, L., & Jouglar, E. (2020) · BJR|Open · doi:10.1259/bjro.20190046 · Cited by 12
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Pinnix, C. C., Gunther, J. R., Fang, P. Q., Bankston, M. E., Milgrom, S. A., Boyce-Fappiano, D. R., Lee, H. J., Nair, R. K., Steiner, R. E., Strati, P., et al. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.13935 · Cited by 12
“RESULTS The cohort comprised 42 patients with ESFHL (median [range] age at diagnosis, 35 [18-74] years; 18 [43%] women; 24 [57%] with stage II disease).”
BackgroundZhang, Y., Song, M., Geng, J., Zhu, X., Li, S., Li, Y., Cai, Y., & Wang, W. (2021) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2021.06.017 · Cited by 12
Personalized Radiation Therapy (PRT) for Lung Cancer
Jin, J., & Kong, F. (2015) · Advances in experimental medicine and biology · doi:10.1007/978-3-319-24932-2_10 · Cited by 12
“During 2008–2010, the American Society of Therapeutic Radiology and Oncology (ASTRO) and American Association of Medical Physicists (AAPM) sponsored a Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) to determine the best NTCP models for each organ [15].”
BackgroundMethodMendez, L. C., Louie, A. V., Moreno, C., Wronski, M., Warner, A., Leung, E., Sakuraba, R. K., Helito, J. K., de Rezende, A. C. P., de Carvalho, Í. T., et al. (2018) · Radiation Oncology · doi:10.1186/s13014-018-1069-z · Cited by 12
Mondlane, G., Ureba, A., Gubanski, M., Lind, P. A., & Siegbahn, A. (2018) · Radiation Oncology · doi:10.1186/s13014-018-1151-6 · Cited by 12
Hou, T.-C., Dai, K.-Y., Wu, M.-C., Hua, K., Tai, H.-C., Huang, W., & Chen, Y.-J. (2019) · OncoTargets and Therapy · doi:10.2147/ott.s205803 · Cited by 12
“The latest statement released in 2010 recommended maintaining the V20 at <30–35% and mean lung dose between 20 and 23 Gy in order to lower the risk of pneumonitis to <20%.(25) However, the association between calculated dosimetry and normal organ outcome was estimated mainly using results of definitive RT and 3Dconfor…”
MethodRadiation pneumonitis after definitive chemoradiation and durvalumab for non-small cell lung cancer
Voong, K. R., & Naidoo, J. (2020) · Lung Cancer · doi:10.1016/j.lungcan.2020.08.022 · Cited by 12
Held, T., Herpel, C., Schwindling, F. S., Christ, L., Lang, K., Regnery, S., Eichkorn, T., Hommertgen, A., Jaekel, C., Krisam, J., et al. (2021) · Radiation Oncology · doi:10.1186/s13014-021-01803-8 · Cited by 12
“Dose constraints for normal tissues and organs will be respected according to the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) [20, 21].”
MethodShin, H. S., Lee, S. H., Jun, B. G., Kim, H. S., Kang, S. H., Park, J. Y., Choi, S. I., Cheon, G. J., Kim, Y. D., Yoo, J., et al. (2022) · European Journal of Gastroenterology & Hepatology · doi:10.1097/meg.0000000000002442 · Cited by 11
Güzelöz, Z., Ayrancıoğlu, O., Aktürk, N., Güneş, M., & Alıcıkuş, Z. A. (2023) · Current Oncology · doi:10.3390/curroncol30100632 · Cited by 11
“According to normal tissue dose limitations, the mean dose to the liver was aimed to be below 30–32 Gy [18].”
BackgroundFeasibility and constraints of Bragg peak FLASH proton therapy treatment planning
Lövgren, N., Kristensen, I. F., & Petersson, K. (2024) · Frontiers in Oncology · doi:10.3389/fonc.2024.1369065 · Cited by 11
Multi-institutional experimental validation of online adaptive proton therapy workflows
Bobić, M., Choulilitsa, E., Lee, H., Czerska, K., Christensen, J. B., Mayor, A., Safai, S., Winey, B. A., Weber, D. C., Lomax, A., et al. (2024) · Physics in Medicine and Biology · doi:10.1088/1361-6560/ad6527 · Cited by 11
Amini, A., Zaha, V. G., Hamad, E. A., Woodard, P. K., Rimner, A., Chang, J. Y., Chun, S. G., Donington, J. S., Edelman, M. J., Gubens, M. A., et al. (2024) · Journal of Thoracic Oncology · doi:10.1016/j.jtho.2024.09.1433 · Cited by 11
Vošmik, M., John, S., Dvořák, J., Mohelníková-Duchoňová, B., Melichar, B., Lohynská, R., Ryška, A., Banni, A. M., Krempová, J., & Sirák, I. (2024) · Oncology and Therapy · doi:10.1007/s40487-024-00309-z · Cited by 11
The Red Journal's Top 10 Most Downloaded Articles of 2011
Zietman, A. L. (2012) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/s0360-3016(12)00746-8 · Cited by 11
Owen, D. R., Boonstra, P. S., Viglianti, B. L., Balter, J. M., Schipper, M. J., Jackson, W., Naqa, I. E., Jolly, S., Haken, R. K. T., Kong, F., et al. (2018) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2018.05.049 · Cited by 11
Hardisty, M., Wright, T., Campbell, M., Burke, M., Atenafu, E. G., Cawricz, M., Caldwell, C., Yee, A., Sahgal, A., & Whyne, C. M. (2020) · Clinical & Experimental Metastasis · doi:10.1007/s10585-020-10049-9 · Cited by 11
“MRI), therapy (specifically radiation’s effect, modelled using normal tissue complication probability [NTCP [59]), and other factors (i.”
BackgroundKapitanova, I., Biswas, S., Divekar, S., Kemmerer, E. J., Rostock, R. A., Forster, K. M., Grimm, R. J., Scofield, C. J., Grimm, J., Emami, B., et al. (2021) · Radiation Oncology · doi:10.1186/s13014-021-01822-5 · Cited by 11
Zhang, X., Yang, D., Jiang, Y. H., Huang, L., Wang, C., Tao, D., Liu, X., Lei, Y., Wu, Y., & Zhou, W. (2021) · Journal of Inflammation Research · doi:10.2147/jir.s328955 · Cited by 11
Baltazar, F., Tessonnier, T., Haberer, T., Debus, J., Herfarth, K. K., Tawk, B., Knoll, M., Abdollahi, A., Liermann, J., & Mairani, A. (2023) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2023.109872 · Cited by 10
Cicone, F., Gleisner, K. S., Sarnelli, A., Indovina, L., Gear, J. I., Gnesin, S., Kraeber‐Bodéré, F., Delaloye, A. B., Valentini, V., & Cremonesi, M. (2023) · Physica Medica · doi:10.1016/j.ejmp.2023.103188 · Cited by 11
“…contouring of normal tissues, the use of conventional fractionation only, and no information about DVHs, this was used as reference until a panel of experts focusing on Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) was formed and their work published in 2010 [104,105].”
MethodSchreiber, D. P., Chhabra, A. M., Rineer, J., Nabhani, T., Katsoulakis, E., Morkos, R., Rotman, M. Z., & Schwartz, D. A. (2013) · Clinical Genitourinary Cancer · doi:10.1016/j.clgc.2013.07.008 · Cited by 11
Investigation of stereotactic radiotherapy dose using dosimetry film and Monte Carlo simulations
Kairn, T., Crowe, S., Kenny, J., & Trapp, J. (2011) · Radiation Measurements · doi:10.1016/j.radmeas.2011.06.024 · Cited by 11
“It should be noted, however, that all doses to critical structures calculated using both methods are below levels linked to a 3-5% of necrosis or neuropathy (Marks et al., 2010).”
MethodRadiation myelitis after hypofractionated radiotherapy with concomitant gefitinib
Lewitzki, V., Andratschke, N. H., Kuhnt, T., & Hildebrandt, G. (2015) · Radiation Oncology · doi:10.1186/s13014-015-0334-7 · Cited by 11
“Using data of the QUANTEC review [15], we could”
Nour, A. A., Alaradi, A., Mohamed, A., Altuwaijri, S., & Rudat, V. (2013) · Radiation Oncology · doi:10.1186/1748-717x-8-207 · Cited by 11
“For the evaluation of treatment plans tolerance doses for the organs at risk as described by the Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) review [2] were used.”
MethodInaba, K., Okamoto, H., Wakita, A., Nakamura, S., Kobayashi, K., Harada, K., Kitaguchi, M., Sekii, S., Takahashi, K., Yoshio, K., et al. (2014) · Journal of Radiation Research · doi:10.1093/jrr/rru052 · Cited by 11
“Radiation effects to the kidneys and liver were recently summarized in the QUANTEC study [6, 7, 8].”
BackgroundKouloulias, Kouvaris, J., Zygogianni, A., Mosa, E., Georgakopoulos, I., Theodosiadis, P. G., Antypas, C. E., Platoni, K., Tolia, M., Beli, I., et al. (2013) · Head & Neck Oncology · Cited by 11
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Mattes, M. D., Zhou, Y., Berry, S. L., & Barker, C. A. (2016) · Radiation Oncology Journal · doi:10.3857/roj.2015.01592 · Cited by 11
“The higher mean lung dose for the 3D-CRT plans would also be associated with an approximately 5% increased risk of symptomatic pneumonitis compared to the other techniques [24].”
ResultLewis, G. D., Agrusa, J. E., Teh, B. S., Gramatges, M. M., Kothari, V., Allen, C. E., & Paulino, A. C. (2018) · Practical Radiation Oncology · doi:10.1016/j.prro.2018.01.007 · Cited by 11
Ciabatti, S., Ntreta, M., Buwenge, M., Gaudiano, C., Sessagesimi, E., Romani, F., Angelini, A. L., Cammelli, S., Macchia, G., Deodato, F., et al. (2019) · Medical dosimetry · doi:10.1016/j.meddos.2019.01.008 · Cited by 11
Khattab, M. H., Sherry, A. D., Whitaker, R. M., Wharton, D. M., Weaver, K. D., Chambless, L. B., Cmelak, A. J., & Attia, A. A. (2019) · Neurosurgery · doi:10.1093/neuros/nyz219 · Cited by 11
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Use of radiomics in the radiation oncology setting: Where do we stand and what do we need?
Schick, U., Lucia, F., Bourbonne, V., Dissaux, G., Pradier, O., Jaouen, V., Tixier, F., Visvikis, D., & Hatt, M. (2020) · Cancer/Radiothérapie · doi:10.1016/j.canrad.2020.07.005 · Cited by 11
Hundvin, J. A., Fjellanger, K., Pettersen, H. E. S., Nygaard, B., Revheim, K., Sulen, T. H., Ekanger, C., & Hysing, L. B. (2020) · Acta Oncologica · doi:10.1080/0284186x.2020.1828619 · Cited by 11
Ahmad, I., Chufal, K. S., Bhatt, C. P., Miller, A., Bajpai, R. C., Chhabra, A., Chowdhary, R. L., Pahuja, A. K., & Gairola, M. (2020) · BJR|Open · doi:10.1259/bjro.20200007 · Cited by 11
Dzierma, Y., Schürmann, M., Melchior, P., Nuesken, F. G., Oertel, J., Rübe, C., & Hendrix, P. (2021) · Frontiers in Oncology · doi:10.3389/fonc.2021.628007 · Cited by 11
“Besides these plan quality parameters, the doses in the critical sensitive brain structures based on the QUANTEC recommendations (38) as well as the PTV are determined.”
MethodWaheed, A., Butt, S., Ishtiaq, A., Mansha, M., Mehreen, S., Raza, M., & Yousaf, M. (2021) · Cureus · doi:10.7759/cureus.15732 · Cited by 11
“Malfunctioning organs can be symptomatic or asymptomatic (subclinical) [23].”
BackgroundRecurrent spinal cord compression due to extramedullary hematopoiesis in thalassemia patient
Abbarh, S., Al-Mashdali, A. F., Abdelrazek, M., Gurusamy, V. M., & Yassin, M. A. (2022) · Medicine · doi:10.1097/md.0000000000029334 · Cited by 12
“Our patient received ten radiotherapy sessions of 2000 cGy with complete resolution of symptoms during the first episode, which was well below the spinal cord radiation tolerance dose, estimated at 5000 cGy.([31]) Hence, he was offered reirradiation during recurrence.”
MethodMeasuring out-of-field dose to the hippocampus in common radiotherapy indications
Auerbach, H., Dzierma, Y., Schürmann, M., Rübe, C., & Rübe, C. E. (2023) · Radiation Oncology · doi:10.1186/s13014-023-02242-3 · Cited by 11
“For plan evaluation, we used our in-house dose-volume histogram (DVH) criteria based on the Quantec guidelines [21].”
MethodThoracolumbar spinal cord tolerance to high dose conformal proton–photon radiation therapy
Chowdhry, V. K., Liu, L., Goldberg, S. I., Adams, J., Bernstein, K. D. A., Liebsch, N. J., Niemierko, A., Chen, Y., & DeLaney, T. F. (2016) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2016.01.002 · Cited by 11
Yavaş, G., Yavaş, Ç., Kerimoğlu, Ö. S., & Çelık, Ç. (2014) · International Journal of Gynecological Cancer · doi:10.1097/igc.0000000000000298 · Cited by 11
“Furthermore, the correlations between dosimetric parameters are technique dependent, and readers should carefully assess the similarity of their treatment technique to the historical reports before using any of these limits as clinical constraints.(28) There are some shortcomings of the current study that should be me…”
MethodTas, B., Bilge, H., & Ozturk, S. (2016) · Journal of Medical Physics · doi:10.4103/0971-6203.181635 · Cited by 11
de Dios, N. R., Sanz, X., Foro, P., Membrive, I., Reig, A., Ortiz, A., Jiménez, R., & Algara, M. (2016) · Clinical & Translational Oncology · doi:10.1007/s12094-016-1544-7 · Cited by 11
“Dose restrictions to the OARs were set according to standard limits [18, 19].”
BackgroundZeman, E. M., Schreiber, E. C., & Tepper, J. E. (2014) · Elsevier eBooks · doi:10.1016/b978-1-4557-2865-7.00027-8 · Cited by 11
“Determining appropriate dose constraints for normal structures from clinical data is critical; compilations of so-called “tolerance doses” for different normal tissue effects are generated periodically as clinical data accrues and have most recently been aggregated in the Quantitative Analyses of Normal Tissue Effects…”
BackgroundTreating lung cancer with dynamic conformal arc therapy: a dosimetric study
Peterlin, P., Stanič, K., Méndez, I., & Strojnik, A. (2017) · Radiation Oncology · doi:10.1186/s13014-017-0823-y · Cited by 11
“Treatment planning restrictions used in our department generally follow QUANTEC [9].”
Sminia, P., Lammertsma, A. A., Greuter, M. J. W., Wiegman, M., de Lange, F., Fluiter-Zeeman, M. D., Franken, K., Vegter, A., Spilt, A., & van de Kamer, J. B. (2018) · doi:10.25030/ncs-026 · Cited by 11
Reinartz, G., Baehr, A., Kittel, C., Oertel, M., Haverkamp, U., & Eich, H. T. (2021) · Cancers · doi:10.3390/cancers13061390 · Cited by 10
Yadav, S., Jiang, F., Kurkowska, S., Saelee, R., Morley, A., Feng, F. Y.-C., Aggarwal, R. R., Lawhn-Heath, C. A., Uribe, C., & Hope, T. A. (2024) · Journal of Nuclear Medicine · doi:10.2967/jnumed.123.267208 · Cited by 11
Janke, F., Stritzke, F., Dvornikovich, K., Franke, H., Angeles, A. K., Riediger, A. L., Ogrodnik, S. J., Gerhardt, S., Regnery, S., Schröter, P., et al. (2024) · International Journal of Cancer · doi:10.1002/ijc.35152 · Cited by 10
“28 For photon re-RT by VMAT, the total dose ranged between 54 to 60 Gy delivered in five fractions per week of 2 Gy.”
Descriptive overview of AI applications in x-ray imaging and radiotherapy
Damilakis, J. E., & Stratakis, J. (2024) · Journal of Radiological Protection · doi:10.1088/1361-6498/ad9f71 · Cited by 12
“Traditionally, outcome modelling in radiotherapy relied on domain knowledge-based features such as dose-volume metrics, including equivalent uniform dose (EUD), TCP, and NTCP [84].”
Meng, X., Ju, Z., Sakai, M., Li, Y., Musha, A., Kubo, N., Kawamura, H., & Ohno, T. (2025) · Radiotherapy and Oncology · doi:10.1016/j.radonc.2025.110709 · Cited by 10
A Review of Online Adaptive Radiation Therapy
Lŭ, L., Zhang, Z., & Qi, P. (2024) · Applied Radiation Oncology · doi:10.37549/aro-d-24-00037 · Cited by 10
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Radiation Therapy for Benign Disease
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Self-citationExperimental dosimetry in conformal breast teletherapy compared with the planning system
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“…rectal dose volume parameters over time on late rectal and urinary toxicity after high-dose intensity-modulated radiotherapy for prostate cancer: A 10-years single centre experience ValéRiE FOnTEynE1, SiMin SaDEGHi1, PiET OST1, FRank VanPaCHTEnBEkE1, PHiliPPE VUyE1, niCOlaaS lUMEn2 & GERT DE…”
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Clinical risk factors for late intestinal toxicity after radiotherapy: a systematic review protocol
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“Previous studies have focused on investigating radiation dosimetric factors that play a direct role in the development of intestinal injuries, aiming to establish a predictive model of Normal Tissue Complication Probability (NTCP) with radiation parameters [20-23].”
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“The simultaneous transition from Emami to QUANTEC dose constraints posed an additional complexity during the initial IMRT implantation [9,10].”
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Metadata
- Authors
- Marks, L. B., Yorke, E. D., Jackson, A., Ten Haken, R. K., Constine, L. S., Eisbruch, A., Bentzen, S. M., Nam, J., & Deasy, J. O.
- Affiliations
- University of North Carolina at Chapel Hill (US)
- Memorial Sloan Kettering Cancer Center (US)
- University of Rochester Medicine (US)
- University of Michigan (US)
- University of Wisconsin–Madison (US)
- Washington University in St. Louis (US)
- Corresponding author
- Marks, Lawrence B.
- ORCID
- Venue
- International Journal of Radiation Oncology*Biology*Physics
- Publisher
- Elsevier BV
- Published
- 2010-03
- Volume
- 76
- Issue
- 3
- Pages
- S10-S19
- ISSN
- 0360-3016 (ISSN-L)
- PMC
- PMC4041542
- OpenAlex
- W2046701188
- Cited by
- 1,826
- References
- 30
- Citations by year
- 2026: 92 · 2025: 110 · 2024: 125 · 2023: 132 · 2022: 130 · 2021: 160 · 2020: 138 · 2019: 146 · 2018: 164 · 2017: 122 · 2016: 108 · 2015: 102 · 2014: 112 · 2013: 87 · 2012: 55
- FWCI
- 56.07
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- International Journal of Radiation Oncology*Biology*Physics (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Lance Armstrong Foundation
- Armstrong Foundation
- National Institutes of Health
- National Cancer Institute (CA69579, R29CA069579, R29CA085181, R01CA069579, R01CA129182, R01CA085181, CA85181)
- Topics
- Physical Sciences › Physics and Astronomy › Radiation › Advanced Radiotherapy Techniques
- Physical Sciences › Physics and Astronomy › Radiation › Radiation Therapy and Dosimetry
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Effects of Radiation Exposure
- Keywords
- normal tissue complication probability, QUANTEC, normal tissue tolerance, NTCP models
- MeSH terms
- Adult, Child, Dose-Response Relationship, Radiation, Humans, Models, Biological, Organ Specificity, Radiation Injuries, Radiation Tolerance, Models, Statistical, Practice Guidelines as Topic, Radiation Oncology, Dose Fractionation, Radiation
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