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von der Burchard C, Miura Y, Stanzel B, Chhablani J, Roider J, Framme C, Brinkmann R, Tode J. Regenerative Retinal Laser and Light Therapies (RELITE): Proposal of a New Nomenclature, Categorization, and Trial Reporting Standard. Lasers Surg Med 2024. [PMID: 39210705 DOI: 10.1002/lsm.23833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/25/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Numerous laser and light therapies have been developed to induce regenerative processes in the choroid/retinal pigment epithelium (RPE)/photoreceptor complex, leaving the neuroretina undamaged. These therapies are applied to the macula for the treatment of various diseases, most prominently diabetic maculopathy, retinal vein occlusion, central serous chorioretinopathy, and age-related macular degeneration. However, the abundance of technologies, treatment patterns, and dosimetry protocols has made understanding these therapies and comparing different approaches increasingly complex and challenging. To address this, we propose a new nomenclature system with a clear categorization that will allow for better understanding and comparability between different laser and light modalities. We propose this nomenclature system as an open standard that may be adapted in future toward new technical developments or medical advancements. METHODS A systematic literature review of reported macular laser and light therapies was conducted. A categorization into a standardized system was proposed and discussed among experts and professionals in the field. This paper does not aim to assess, compare, or evaluate the efficacy of different laser or dosimetry techniques or treatment patterns. RESULTS The literature search yielded 194 papers describing laser techniques, 50 studies describing dosimetry, 272 studies with relevant clinical trials, and 82 reviews. Following the common therapeutic aim, we propose "regenerative retinal laser and light therapies (RELITE)" as the general header. We subdivided RELITE into four main categories that refer to the intended physical and biochemical effects of temperature increase (photothermal therapy, PTT), RPE regeneration (photomicrodisruption therapy, PMT), photochemical processes (photochemical therapy, PCT), and photobiomodulation (photobiomodulation therapy, PBT). Further, we categorized the different dosimetry approaches and treatment regimens. We propose the following nomenclature system that integrates the most important parameters to enable understanding and comparability: Pattern-Dosimetry-Exposure Time/Frequency, Duty Cycle/Irradiation Diameter/Wavelength-Subcategory-Category. CONCLUSION Regenerative retinal laser and light therapies are widely used for different diseases and may become valuable in the future. A precise nomenclature system and strict reporting standards are needed to allow for a better understanding, reproduceable and comparable clinical trials, and overall acceptance. We defined categories for a systematic therapeutic goal-based nomenclature to facilitate future research in this field.
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Affiliation(s)
- Claus von der Burchard
- Department of Ophthalmology, University of Kiel, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Yoko Miura
- Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
- Department of Ophthalmology, University of Luebeck, University Medical Center of Schleswig-Holstein, Luebeck, Germany
| | - Boris Stanzel
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Johann Roider
- Department of Ophthalmology, University of Kiel, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Carsten Framme
- Hannover Medical School, University Eye Clinic, Hannover, Germany
| | - Ralf Brinkmann
- Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
- Medical Laser Center Luebeck, Luebeck, Germany
| | - Jan Tode
- Hannover Medical School, University Eye Clinic, Hannover, Germany
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Seifert E, Tode J, Pielen A, Theisen-Kunde D, Framme C, Roider J, Miura Y, Birngruber R, Brinkmann R. Algorithms for optoacoustically controlled selective retina therapy (SRT). PHOTOACOUSTICS 2022; 25:100316. [PMID: 34926158 PMCID: PMC8649889 DOI: 10.1016/j.pacs.2021.100316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/19/2021] [Accepted: 11/09/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Selective Retina Therapy (SRT) uses microbubble formation (MBF) to target retinal pigment epithelium (RPE) cells selectively while sparing the neural retina and the choroid. Intra- and inter-individual variations of RPE pigmentation makes frequent radiant exposure adaption necessary. Since selective RPE cell disintegration is ophthalmoscopically non-visible, MBF detection techniques are useful to control adequate radiant exposures. It was the purpose of this study to evaluate optoacoustically based MBF detection algorithms. METHODS Fifteen patients suffering from central serous chorioretinopathy and diabetic macula edema were treated with a SRT laser using a wavelength of 527 nm, a pulse duration of 1.7 µs and a pulse energy ramp (15 pulses, 100 Hz repetition rate). An ultrasonic transducer for MBF detection was embedded in a contact lens. RPE damage was verified with fluorescence angiography. RESULTS An algorithm to detect MBF as an indicator for RPE cell damage was evaluated. Overall, 4646 irradiations were used for algorithm optimization and testing. The tested algorithms were superior to a baseline model. A sensitivity/specificity pair of 0.96/1 was achieved. The few false algorithmic decisions were caused by unevaluable signals. CONCLUSIONS The algorithm can be used for guidance or automatization of microbubble related treatments like SRT or selective laser trabeculoplasty (SLT).
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Affiliation(s)
- Eric Seifert
- Medizinisches Laserzentrum Lübeck GmbH, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
| | - Jan Tode
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Amelie Pielen
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Dirk Theisen-Kunde
- Medizinisches Laserzentrum Lübeck GmbH, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
| | - Carsten Framme
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Johann Roider
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Straße, 24105 Kiel, Germany
| | - Yoko Miura
- Medizinisches Laserzentrum Lübeck GmbH, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
- Institut für Biomedizinische Optik, Universität zu Lübeck, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
| | - Reginald Birngruber
- Institut für Biomedizinische Optik, Universität zu Lübeck, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
| | - Ralf Brinkmann
- Medizinisches Laserzentrum Lübeck GmbH, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
- Institut für Biomedizinische Optik, Universität zu Lübeck, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
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Podlipec R, Mur J, Petelin J, Štrancar J, Petkovšek R. Method for controlled tissue theranostics using a single tunable laser source. BIOMEDICAL OPTICS EXPRESS 2021; 12:5881-5893. [PMID: 34692222 PMCID: PMC8515989 DOI: 10.1364/boe.428467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/07/2021] [Accepted: 08/13/2021] [Indexed: 06/13/2023]
Abstract
Tissue diseases and related disorders need to be first recognized using diagnostic methods and then later treated by therapeutic methods-a joint procedure called theranostics. One of the main challenges in the field of retinal therapies remains in the success of the treatment, typically improving the local metabolism, by sparing the surrounding tissue and with the immediate information of the laser effect. In our study, we present a concept for real-time controlled tissue theranostics on a proof-of-concept study capable of using a single tunable ps laser source (in terms of irradiance, fluence, and repetition rate), done on ex-vivo human retinal pigment epithelium. We have found autofluorescence intensity and lifetime imaging diagnostics very promising for the recognition and quantification of laser effects ranging from selective non-destructive molecular tissue modification to complete tissue ablation. The main novelty of our work presents the developed algorithm for optimized theranostics based on the model function used to quantify laser-induced tissue changes through the diagnostics descriptors, fluorescence lifetime and fluorescence intensity parameters. This approach, together with the operation of the single adaptable laser source, can serve as a new theranostics method in personalized medicine in the future not only limited to treat retinal diseases.
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Affiliation(s)
- Rok Podlipec
- Laboratory of Biophysics, Condensed Matter Physics Department, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia
- Helmholtz-Zentrum Dresden-Rossendorf e.V., Ion Beam Center, Bautzner Landstraße 400, Dresden 01328, Germany
| | - Jaka Mur
- Faculty of Mechanical Engineering, University of Ljubljana, Aškerčeva 6, Ljubljana, Slovenia
| | - Jaka Petelin
- Faculty of Mechanical Engineering, University of Ljubljana, Aškerčeva 6, Ljubljana, Slovenia
| | - Janez Štrancar
- Laboratory of Biophysics, Condensed Matter Physics Department, Jožef Stefan Institute, Jamova cesta 39, Ljubljana, Slovenia
| | - Rok Petkovšek
- Faculty of Mechanical Engineering, University of Ljubljana, Aškerčeva 6, Ljubljana, Slovenia
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Kim U, Kwon M, Jung G, Kim Y, Lee Y, Im S, Cense B, Lee H, Ohm WS, Joo C. Optical dosimeter for selective retinal therapy based on multi-port fiber-optic interferometry. BIOMEDICAL OPTICS EXPRESS 2021; 12:4920-4933. [PMID: 34513233 PMCID: PMC8407823 DOI: 10.1364/boe.434812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/07/2021] [Indexed: 06/13/2023]
Abstract
Selective retinal therapy (SRT) employs a micro-second short-pulse lasers to induce localized destruction of the targeted retinal structures with a pulse duration and power aimed at minimal damage to other healthy retinal cells. SRT has demonstrated a great promise in the treatment of retinal diseases, but pulse energy thresholds for effective SRT procedures should be determined precisely and in real time, as the thresholds could vary with disease status and patients. In this study, we present the use of a multi-port fiber-based interferometer (MFI) for highly sensitive real-time SRT monitoring. We exploit distinct phase differences among the fiber ports in the MFI to quantitatively measure localized fluctuations of complex-valued information during the SRT procedure. We evaluate several metrics that can be computed from the full complex-valued information and demonstrate that the complex contour integration is highly sensitive and most correlative to pulse energies, acoustic outputs, and cell deaths. The validity of our method was demonstrated on excised porcine retinas, with a sensitivity and specificity of 0.92 and 0.88, respectively, as compared with the results from a cell viability assay.
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Affiliation(s)
- Uihan Kim
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- These authors contributed equally to this work
| | - Minsung Kwon
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- These authors contributed equally to this work
| | - Gyeongyeon Jung
- Department of Research, Lutronic Corporation, 219 Sowon-ro, Goyang, 10534, Republic of Korea
| | - Youngnam Kim
- Department of Research, Lutronic Corporation, 219 Sowon-ro, Goyang, 10534, Republic of Korea
| | - Yunam Lee
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seonghun Im
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Barry Cense
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Optical and Biomedical Engineering Laboratory, Department of Electrical, Electronic & Computer Engineering, The University of Western Australia, Perth, WA 6009, Australia
| | - Hyungsuk Lee
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Won-Suk Ohm
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Chulmin Joo
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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Lee S, Wei S, Guo S, Kim J, Kim B, Kim G, Kang JU. Selective retina therapy monitoring by speckle variance optical coherence tomography for dosimetry control. JOURNAL OF BIOMEDICAL OPTICS 2020; 25:1-9. [PMID: 32061065 PMCID: PMC7019183 DOI: 10.1117/1.jbo.25.2.026001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 01/29/2020] [Indexed: 05/29/2023]
Abstract
SIGNIFICANCE Selective retina therapy (SRT) selectively targets the retinal pigment epithelium (RPE) and reduces negative side effects by avoiding thermal damages of the adjacent photoreceptors, the neural retina, and the choroid. However, the selection of proper laser energy for the SRT is challenging because of ophthalmoscopically invisible lesions in the RPE and different melanin concentrations among patients or even regions within an eye. AIM We propose and demonstrate SRT monitoring based on speckle variance optical coherence tomography (svOCT) for dosimetry control. APPROACH M-scans, time-resolved sequence of A-scans, of ex vivo bovine retina irradiated by 1.7-μs duration laser pulses were obtained by a swept-source OCT. SvOCT images were calculated as interframe intensity variance of the sequence. Spatial and temporal temperature distributions in the retina were numerically calculated in a 2-D retinal model using COMSOL Multiphysics. Microscopic images of treated spots were obtained before and after removing the upper neural retinal layer to assess the damage in both RPE and neural layers. RESULTS SvOCT images show abrupt speckle variance changes when the retina is irradiated by laser pulses. The svOCT intensities averaged in RPE and photoreceptor layers along the axial direction show sharp peaks corresponding to each laser pulse, and the peak values were proportional to the laser pulse energy. The calculated temperatures in the neural retina layer and RPE were linearly fitted to the svOCT peak values, and the temperature of each lesion was estimated based on the fitting. The estimated temperatures matched well with previously reported results. CONCLUSION We found a reliable correlation between the svOCT peak values and the degree of retinal lesion formation, which can be used for selecting proper laser energy during SRT.
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Affiliation(s)
- Soohyun Lee
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Shuwen Wei
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Shoujing Guo
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | | | | | - Gihoon Kim
- Lutronic Center, Goyang, Republic of Korea
| | - Jin U. Kang
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
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Bliedtner K, Seifert E, Brinkmann R. Towards Automatically Controlled Dosing for Selective Laser Trabeculoplasty. Transl Vis Sci Technol 2019; 8:24. [PMID: 31807369 PMCID: PMC6890396 DOI: 10.1167/tvst.8.6.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/09/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose Selective laser trabeculoplasty (SLT) is a treatment option for open-angle glaucoma; however, it lacks an instant evidence for successful irradiation. So far ophthalmologists use the visible appearance of permanent champagnelike bubbles (macro bubbles) as an indicator for appropriate pulse energy. We hypothesize that micro bubbles, which start energetically far below the appearance of macro bubbles, already trigger the therapeutic benefit. Here we present two methods to capture the onset of these micro bubbles. Methods The trabecular meshwork of freshly enucleated porcine eye globes was irradiated with a series of 15 pulses with a pulse duration of 1.7 μs and with increasing energy at a repetition rate of 100 Hz per each spot of 200 μm in diameter. An optical and an optoacoustic method have been developed and appropriate algorithms investigated towards the real-time detection of the onset of micro bubbles. Results Both observation methods are capable of detecting micro bubble nucleation. Threshold radiant exposures were found at 310 ± 137 mJ/cm2. By combination of both methods a sensitivity and specificity of 0.96 was reached. Conclusions In case that the therapeutically demanded pressure reduction is already achieved with these micro bubbles, which needs to be proven clinically, then the methods presented here can be used in an automatic feedback loop controlling the laser irradiation. This will unburden the clinicians from any dosing during SLT. Translational Relevance Automatic real-time pulse energy dosing based on the formation of micro bubbles in SLT significantly improves and facilitates the treatment for the physician.
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Affiliation(s)
| | | | - Ralf Brinkmann
- Medical Laser Center Lübeck, Lübeck, Germany.,Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany
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Seifert E, Tode J, Pielen A, Theisen-Kunde D, Framme C, Roider J, Miura Y, Birngruber R, Brinkmann R. Selective retina therapy: toward an optically controlled automatic dosing. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-12. [PMID: 30392199 DOI: 10.1117/1.jbo.23.11.115002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/04/2018] [Indexed: 06/08/2023]
Abstract
Selective retina therapy (SRT) targets the retinal pigment epithelium (RPE) with pulsed laser irradiation by inducing microbubble formation (MBF) at the intracellular melanin granula, which leads to selective cell disruption. The following wound healing process rejuvenates the chorio-retinal junction. Pulse energy thresholds for selective RPE effects vary intra- and interindividually. We present the evaluation of an algorithm that processes backscattered treatment light to detect MBF as an indicator of RPE cell damage since these RPE lesions are invisible during treatment. Eleven patients with central serous chorioretinopathy and four with diabetic macula edema were treated with a SRT system, which uses a wavelength of 527 nm, a repetition rate of 100 Hz, and a pulse duration of 1.7 μs. Fifteen laser pulses with stepwise increasing pulse energy were applied per treatment spot. Overall, 4626 pulses were used for algorithm parameter optimization and testing. Sensitivity and specificity were the metrics maximized through an automatic optimization process. Data were verified by fluorescein angiography. A sensitivity of 1 and a specificity of 0.93 were achieved. The method introduced in this paper can be used for guidance or automatization of microbubble-related treatments like SRT or selective laser trabeculoplasty.
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Affiliation(s)
- Eric Seifert
- Medizinisches Laserzentrum Lübeck GmbH, Lübeck, Germany
| | - Jan Tode
- Universitätsklinikum Schleswig-Holstein, Klinik für Ophthalmologie, Arnold-Heller-Strasse, Kiel, Germany
| | - Amelie Pielen
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Carsten Framme
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Hannover, Germany
| | - Johann Roider
- Universitätsklinikum Schleswig-Holstein, Klinik für Ophthalmologie, Arnold-Heller-Strasse, Kiel, Germany
| | - Yoko Miura
- Medizinisches Laserzentrum Lübeck GmbH, Lübeck, Germany
- Universität zu Lübeck, Institut für Biomedizinische Optik, Lübeck, Germany
| | | | - Ralf Brinkmann
- Medizinisches Laserzentrum Lübeck GmbH, Lübeck, Germany
- Universität zu Lübeck, Institut für Biomedizinische Optik, Lübeck, Germany
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Fountoukidou T, Raisin P, Kaufmann D, Justiz J, Sznitman R, Wolf S. Motion-invariant SRT treatment detection from direct M-scan OCT imaging. Int J Comput Assist Radiol Surg 2018. [PMID: 29520526 DOI: 10.1007/s11548-018-1720-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Selective retina therapy (SRT) is a laser treatment targeting specific posterior retinal layers. It is focused on inducing damage to the retinal pigment epithelium (RPE), while sparing other retinal tissue compared to traditional photocoagulation. However, the targeted RPE layer is invisible with most imaging modalities and induced SRT lesions cannot be monitored. In this work, imaging scans acquired from an experimental setup that couples the SRT laser beam with an optical coherence tomography (OCT) beam are analyzed in order to evaluate the treatment as they occur. METHODS We isolated a small part of the time-resolved scan corresponding to the end of the treatment, for which we have microscopic evidence of the SRT outcome. We then use a convolutional neural network to correspond each scan to the treatment result. We explore which aspects of the scan convey more valuable information for a robust therapy evaluation. By only using this adequately small part, we can achieve an online estimation, while being resilient to eye movement. RESULTS The available dataset consists of time- resolved OCT scans of 98 ex vivo porcine eyes, treated with different energy levels. The proposed method yields high performance in the task of predicting whether the applied energy was adequate for SRT treatment, by focusing on the immediate OCT signal acquired during treatment time. CONCLUSIONS We propose a strategy toward online noninvasive SRT treatment assessment, able to provide a satisfying evaluation of a treatment status, that therefore could be used for the planning of the treatment continuation.
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Affiliation(s)
| | | | - Daniel Kaufmann
- Engineering and Information Technology, Berner Fachhochschule, Biel/Bienne, Switzerland
| | - Jörn Justiz
- Engineering and Information Technology, Berner Fachhochschule, Biel/Bienne, Switzerland
| | | | - Sebastian Wolf
- Inselspital, University Hospital of Bern, Bern, Switzerland
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