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Eertink JJ, Bahce I, Waterton JC, Huisman MC, Boellaard R, Wunder A, Thiele A, Menke-van der Houven van Oordt CW. The development process of 'fit-for-purpose' imaging biomarkers to characterize the tumor microenvironment. Front Med (Lausanne) 2024; 11:1347267. [PMID: 38818386 PMCID: PMC11138661 DOI: 10.3389/fmed.2024.1347267] [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: 11/30/2023] [Accepted: 04/24/2024] [Indexed: 06/01/2024] Open
Abstract
Immune-based treatment approaches are successfully used for the treatment of patients with cancer. While such therapies can be highly effective, many patients fail to benefit. To provide optimal therapy choices and to predict treatment responses, reliable biomarkers for the assessment of immune features in patients with cancer are of significant importance. Biomarkers (BM) that enable a comprehensive and repeatable assessment of the tumor microenvironment (TME), the lymphoid system, and the dynamics induced by drug treatment can fill this gap. Medical imaging, notably positron emission tomography (PET) and magnetic resonance imaging (MRI), providing whole-body imaging BMs, might deliver such BMs. However, those imaging BMs must be well characterized as being 'fit for purpose' for the intended use. This review provides an overview of the key steps involved in the development of 'fit-for-purpose' imaging BMs applicable in drug development, with a specific focus on pharmacodynamic biomarkers for assessing the TME and its modulation by immunotherapy. The importance of the qualification of imaging BMs according to their context of use (COU) as defined by the Food and Drug Administration (FDA) and National Institutes of Health Biomarkers, EndpointS, and other Tools (BEST) glossary is highlighted. We elaborate on how an imaging BM qualification for a specific COU can be achieved.
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Affiliation(s)
- Jakoba J. Eertink
- Department of Medical Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Idris Bahce
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
- Department of Pulmonary Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - John C. Waterton
- Centre for Imaging Sciences, University of Manchester, Manchester, United Kingdom
| | - Marc C. Huisman
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ronald Boellaard
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Andreas Wunder
- Department of Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach and der Riss, Germany
| | - Andrea Thiele
- Department of Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach and der Riss, Germany
| | - Catharina W. Menke-van der Houven van Oordt
- Department of Medical Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
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2
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Oei EHG, Runhaar J. Imaging of early-stage osteoarthritis: the needs and challenges for diagnosis and classification. Skeletal Radiol 2023; 52:2031-2036. [PMID: 37154872 PMCID: PMC10509094 DOI: 10.1007/s00256-023-04355-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
In an effort to boost the development of new management strategies for OA, there is currently a shift in focus towards the diagnosis and treatment of early-stage OA. It is important to distinguish diagnosis from classification of early-stage OA. Diagnosis takes place in clinical practice, whereas classification is a process to stratify participants with OA in clinical research. For both purposes, there is an important opportunity for imaging, especially with MRI. The needs and challenges differ for early-stage OA diagnosis versus classification. Although it fulfils the need of high sensitivity and specificity for making a correct diagnosis, implementation of MRI in clinical practice is challenged by long acquisition times and high costs. For classification in clinical research, more advanced MRI protocols can be applied, such as quantitative, contrast-enhanced, or hybrid techniques, as well as advanced image analysis methods including 3D morphometric assessments of joint tissues and artificial intelligence approaches. It is necessary to follow a step-wise and structured approach that comprises, technical validation, biological validation, clinical validation, qualification, and cost-effectiveness, before new imaging biomarkers can be implemented in clinical practice or clinical research.
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Affiliation(s)
- Edwin H. G. Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, PO-Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Jos Runhaar
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, PO-Box 2040, 3000 CA Rotterdam, the Netherlands
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3
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Chauvie S, Mazzoni LN, O’Doherty J. A Review on the Use of Imaging Biomarkers in Oncology Clinical Trials: Quality Assurance Strategies for Technical Validation. Tomography 2023; 9:1876-1902. [PMID: 37888741 PMCID: PMC10610870 DOI: 10.3390/tomography9050149] [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: 08/16/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
Imaging biomarkers (IBs) have been proposed in medical literature that exploit images in a quantitative way, going beyond the visual assessment by an imaging physician. These IBs can be used in the diagnosis, prognosis, and response assessment of several pathologies and are very often used for patient management pathways. In this respect, IBs to be used in clinical practice and clinical trials have a requirement to be precise, accurate, and reproducible. Due to limitations in imaging technology, an error can be associated with their value when considering the entire imaging chain, from data acquisition to data reconstruction and subsequent analysis. From this point of view, the use of IBs in clinical trials requires a broadening of the concept of quality assurance and this can be a challenge for the responsible medical physics experts (MPEs). Within this manuscript, we describe the concept of an IB, examine some examples of IBs currently employed in clinical practice/clinical trials and analyze the procedure that should be carried out to achieve better accuracy and reproducibility in their use. We anticipate that this narrative review, written by the components of the EFOMP working group on "the role of the MPEs in clinical trials"-imaging sub-group, can represent a valid reference material for MPEs approaching the subject.
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Affiliation(s)
- Stephane Chauvie
- Medical Physics Division, Santa Croce e Carle Hospital, 12100 Cuneo, Italy;
| | | | - Jim O’Doherty
- Siemens Medical Solutions, Malvern, PA 19355, USA;
- Department of Radiology & Radiological Sciences, Medical University of South Carolina, Charleston, SC 20455, USA
- Radiography & Diagnostic Imaging, University College Dublin, D04 C7X2 Dublin, Ireland
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4
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Arduino A, Pennecchi F, Katscher U, Cox M, Zilberti L. Repeatability and Reproducibility Uncertainty in Magnetic Resonance-Based Electric Properties Tomography of a Homogeneous Phantom. Tomography 2023; 9:420-435. [PMID: 36828386 PMCID: PMC9961522 DOI: 10.3390/tomography9010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
Uncertainty assessment is a fundamental step in quantitative magnetic resonance imaging because it makes comparable, in a strict metrological sense, the results of different scans, for example during a longitudinal study. Magnetic resonance-based electric properties tomography (EPT) is a quantitative imaging technique that retrieves, non-invasively, a map of the electric properties inside a human body. Although EPT has been used in some early clinical studies, a rigorous experimental assessment of the associated uncertainty has not yet been performed. This paper aims at evaluating the repeatability and reproducibility uncertainties in phase-based Helmholtz-EPT applied on homogeneous phantom data acquired with a clinical 3 T scanner. The law of propagation of uncertainty is used to evaluate the uncertainty in the estimated conductivity values starting from the uncertainty in the acquired scans, which is quantified through a robust James-Stein shrinkage estimator to deal with the dimensionality of the problem. Repeatable errors are detected in the estimated conductivity maps and are quantified for various values of the tunable parameters of the EPT implementation. The spatial dispersion of the estimated electric conductivity maps is found to be a good approximation of the reproducibility uncertainty, evaluated by changing the position of the phantom after each scan. The results underpin the use of the average conductivity (calculated by weighting the local conductivity values by their uncertainty and taking into account the spatial correlation) as an estimate of the conductivity of the homogeneous phantom.
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Affiliation(s)
- Alessandro Arduino
- Istituto Nazionale di Ricerca Metrologica, Strada delle Cacce 91, 10135 Torino, Italy
- Correspondence:
| | - Francesca Pennecchi
- Istituto Nazionale di Ricerca Metrologica, Strada delle Cacce 91, 10135 Torino, Italy
| | | | - Maurice Cox
- National Physical Laboratory, Teddington TW11 0LW, UK
| | - Luca Zilberti
- Istituto Nazionale di Ricerca Metrologica, Strada delle Cacce 91, 10135 Torino, Italy
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5
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Hegazy R, Azzam H. Value of apparent diffusion coefficient factor in correlation with the molecular subtypes, tumor grade, and expression of Ki-67 in breast cancer. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00881-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Breast cancer is known to be the most common cancer in women; in the last decade, contrast-enhanced magnetic resonance imaging has become an important tool in the diagnosis of cancer breast. Numerous studies have analyzed associations between imaging and histopathological features as well as the proliferation potential of breast cancer. The purpose of this study was to evaluate the relationship between the apparent diffusion coefficient (ADC) and expression of Ki-67 as well as tumor molecular subtype in breast cancer.
Results
No significant difference between the mean ADC value of tumors of grade I, II, and III was found. However, there was a significant difference between the mean ADC value of tumors of molecular type A and molecular type B (P = 0.000), HER2 overexpression (P = 0.018), and TN (P = 0.000), respectively. However, there was no significant difference between molecular type B, HER2 overexpression and TN. Also, no significant difference was found between the Ki-67 value of tumors of grade I, II, and III. Yet there was a significant difference between the mean ADC value of tumors of molecular type A and molecular type B (P = 0.000), HER2 overexpression (P = 0.014), and TN (P = 0.000), respectively. However, there was no significant difference between molecular type B, HER2 overexpression, and TN.
Conclusions
There is a significant inverse correlation between ADC values and Ki-67 expression. DWI and Ki-67 could be a good discriminator between tumors of molecular subtype A from other subtypes, yet it did not show a correlation with the tumor grade.
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Jha AK, Mithun S, Purandare NC, Kumar R, Rangarajan V, Wee L, Dekker A. Radiomics: a quantitative imaging biomarker in precision oncology. Nucl Med Commun 2022; 43:483-493. [PMID: 35131965 DOI: 10.1097/mnm.0000000000001543] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cancer treatment is heading towards precision medicine driven by genetic and biochemical markers. Various genetic and biochemical markers are utilized to render personalized treatment in cancer. In the last decade, noninvasive imaging biomarkers have also been developed to assist personalized decision support systems in oncology. The imaging biomarkers i.e., radiomics is being researched to develop specific digital phenotype of tumor in cancer. Radiomics is a process to extract high throughput data from medical images by using advanced mathematical and statistical algorithms. The radiomics process involves various steps i.e., image generation, segmentation of region of interest (e.g. a tumor), image preprocessing, radiomic feature extraction, feature analysis and selection and finally prediction model development. Radiomics process explores the heterogeneity, irregularity and size parameters of the tumor to calculate thousands of advanced features. Our study investigates the role of radiomics in precision oncology. Radiomics research has witnessed a rapid growth in the last decade with several studies published that show the potential of radiomics in diagnosis and treatment outcome prediction in oncology. Several radiomics based prediction models have been developed and reported in the literature to predict various prediction endpoints i.e., overall survival, progression-free survival and recurrence in various cancer i.e., brain tumor, head and neck cancer, lung cancer and several other cancer types. Radiomics based digital phenotypes have shown promising results in diagnosis and treatment outcome prediction in oncology. In the coming years, radiomics is going to play a significant role in precision oncology.
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Affiliation(s)
- Ashish Kumar Jha
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital
- Homi Bhabha National Institute (HBNI), Deemed University, Mumbai
| | - Sneha Mithun
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital
- Homi Bhabha National Institute (HBNI), Deemed University, Mumbai
| | - Nilendu C Purandare
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital
- Homi Bhabha National Institute (HBNI), Deemed University, Mumbai
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Science, New Delhi, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital
- Homi Bhabha National Institute (HBNI), Deemed University, Mumbai
| | - Leonard Wee
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
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7
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Springer E, Cardoso PL, Strasser B, Bogner W, Preusser M, Widhalm G, Nittka M, Koerzdoerfer G, Szomolanyi P, Hangel G, Hainfellner JA, Marik W, Trattnig S. MR Fingerprinting-A Radiogenomic Marker for Diffuse Gliomas. Cancers (Basel) 2022; 14:cancers14030723. [PMID: 35158990 PMCID: PMC8833555 DOI: 10.3390/cancers14030723] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/22/2022] [Accepted: 01/28/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Advanced MR imaging (MRI) of brain tumors is mainly based on qualitative contrast images. MR Fingerprinting (MRF) offers a novel approach. The purpose of this study was to use MRF-derived T1 and T2 relaxation maps to differentiate diffuse gliomas according to isocitrate dehydrogenase (IDH) mutation. (2) Methods: Twenty-four patients with histologically verified diffuse gliomas (14 IDH-mutant, four 1p/19q-codeleted, 10 IDH-wildtype) were enrolled. MRF T1 and T2 relaxation times were compared to apparent diffusion coefficient (ADC), relative cerebral blood volume (rCBV) within solid tumor, peritumoral edema, and normal-appearing white matter (NAWM), using contrast-enhanced MRI, diffusion-, perfusion-, and susceptibility-weighted imaging. For perfusion imaging, a T2* weighted perfusion sequence with leakage correction was used. Correlations of MRF T1 and T2 times with two established conventional sequences for T1 and T2 mapping were assessed (a fast double inversion recovery-based MR sequence ('MP2RAGE') for T1 quantification and a multi-contrast spin echo-based sequence for T2 quantification). (3) Results: MRF T1 and T2 relaxation times were significantly higher in the IDH-mutant than in IDH-wildtype gliomas within the solid part of the tumor (p = 0.024 for MRF T1, p = 0.041 for MRF T2). MRF T1 and T2 relaxation times were significantly higher in the IDH-wildtype than in IDH-mutant gliomas within peritumoral edema less than or equal to 1cm adjacent to the tumor (p = 0.038 for MRF T1 mean, p = 0.010 for MRF T2 mean). In the solid part of the tumor, there was a high correlation between MRF and conventionally measured T1 and T2 values (r = 0.913, p < 0.001 for T1, r = 0.775, p < 0.001 for T2), as well as between MRF and ADC values (r = 0.813, p < 0.001 for T2, r = 0.697, p < 0.001 for T1). The correlation was weak between the MRF and rCBV values (r = -0.374, p = 0.005 for T2, r = -0.181, p = 0.181 for T1). (4) Conclusions: MRF enables fast, single-sequence based, multi-parametric, quantitative tissue characterization of diffuse gliomas and may have the potential to differentiate IDH-mutant from IDH-wildtype gliomas.
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Affiliation(s)
- Elisabeth Springer
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
- Institute of Radiology, Hietzing Hospital, 1130 Vienna, Austria
| | - Pedro Lima Cardoso
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
| | - Bernhard Strasser
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
| | - Wolfgang Bogner
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
- Correspondence: ; Tel.: +431-40-400-64710
| | - Matthias Preusser
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, 1090 Vienna, Austria;
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Mathias Nittka
- Siemens Healthineers, 91052 Erlangen, Germany; (M.N.); (G.K.)
| | | | - Pavol Szomolanyi
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
- Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, 84104 Bratislava, Slovakia
| | - Gilbert Hangel
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
- Department of Neurosurgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Johannes A. Hainfellner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Wolfgang Marik
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria;
| | - Siegfried Trattnig
- High-Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (E.S.); (P.L.C.); (B.S.); (P.S.); (G.H.); (S.T.)
- Christian Doppler Laboratory for Clinical Molecular MR Imaging, Medical University of Vienna, 1090 Vienna, Austria
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8
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Meseguer E, Barberá-Tomás D, Benito-Amat C, Díaz-Faes AA, Martí-Bonmatí L. What do biomarkers add: Mapping quantitative imaging biomarkers research. Eur J Radiol 2021; 146:110052. [PMID: 34839166 DOI: 10.1016/j.ejrad.2021.110052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/11/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To understand the contribution of the concept of "biomarker" to quantitative imaging research. METHOD The study consists of a bibliometric and a network analysis of quantitative imaging biomarkers research based on publication data retrieved from the Web of Science (WoS) for the period 1976-2017. Co-authorship is used as a proxy for scientific collaboration among research groups. Research groups are disambiguated and assigned to an institutional sector and to a medical specialty or academic discipline. Co-occurrence maps of specialties are built to delineate the collaborative network structure of this emerging field. RESULTS Two very distinct growth patterns emerged from the 5432 publications retrieved from WoS. Scientific production on «quantitative imaging biomarkers» (QIB) began 20 years after the first publications on «quantitative imaging» (QI). The field of QIB has exhibited rapid growth becoming the most used term since 2011. Among the 12,882 institutions identified, 56% include the term QIB and 44% include the term QI; among the 14,734 different research groups identified, 60% include the term QIB and 40% the term QI. QIB is characterized by a well-established community of researchers whose largest contributors are in medical specialties (radiology 17%, neurology 16%, mental 10%, oncology 10%), while QI shows a more fragmented and diverse community (radiology 13%, engineering 13%, physics 10%, oncology 9%, neurology 6%, biology 4%, nuclear 3%, computing 3%). This suggests a qualitative difference between QIB and QI networks. CONCLUSIONS Adding biomarkers to quantitative imaging suggests that medical imaging is rapidly evolving, driven by the efforts to translate quantitative imaging research into clinical practice.
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Affiliation(s)
- Enrique Meseguer
- INGENIO (CSIC-UPV), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
| | - David Barberá-Tomás
- INGENIO (CSIC-UPV), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
| | - Carlos Benito-Amat
- INGENIO (CSIC-UPV), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
| | - Adrián A Díaz-Faes
- INGENIO (CSIC-UPV), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
| | - Luis Martí-Bonmatí
- Medical Imaging Department and Biomedical Imaging Research Group, Hospital Universitario y Politécnico and Health Research Institute La Fe, Av. Fernando Abril Martorell 106, 46026 Valencia, Spain
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9
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Bruixola G, Remacha E, Jiménez-Pastor A, Dualde D, Viala A, Montón JV, Ibarrola-Villava M, Alberich-Bayarri Á, Cervantes A. Radiomics and radiogenomics in head and neck squamous cell carcinoma: Potential contribution to patient management and challenges. Cancer Treat Rev 2021; 99:102263. [PMID: 34343892 DOI: 10.1016/j.ctrv.2021.102263] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/06/2021] [Accepted: 07/23/2021] [Indexed: 12/12/2022]
Abstract
The application of imaging biomarkers in oncology is still in its infancy, but with the expansion of radiomics and radiogenomics a revolution is expected in this field. This may be of special interest in head and neck cancer, since it can promote precision medicine and personalization of treatment by overcoming several intrinsic obstacles in this pathology. Our goal is to provide the medical oncologist with the basis to approach these disciplines and appreciate their main uses in clinical research and clinical practice in the medium term. Aligned with this objective we analyzed the most relevant studies in the field, also highlighting novel opportunities and current challenges.
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Affiliation(s)
- Gema Bruixola
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Elena Remacha
- Quantitative Imaging Biomarkers in Medicine (QUIBIM SL), Valencia, Spain
| | - Ana Jiménez-Pastor
- Quantitative Imaging Biomarkers in Medicine (QUIBIM SL), Valencia, Spain
| | - Delfina Dualde
- Department of Radiology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Alba Viala
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Jose Vicente Montón
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Maider Ibarrola-Villava
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain; CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Andrés Cervantes
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain; CIBERONC, Instituto de Salud Carlos III, Madrid, Spain.
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10
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Leiner T, Bennink E, Mol CP, Kuijf HJ, Veldhuis WB. Bringing AI to the clinic: blueprint for a vendor-neutral AI deployment infrastructure. Insights Imaging 2021; 12:11. [PMID: 33528677 PMCID: PMC7855120 DOI: 10.1186/s13244-020-00931-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/16/2020] [Indexed: 12/30/2022] Open
Abstract
AI provides tremendous opportunities for improving patient care, but at present there is little evidence of real-world uptake. An important barrier is the lack of well-designed, vendor-neutral and future-proof infrastructures for deployment. Because current AI algorithms are very narrow in scope, it is expected that a typical hospital will deploy many algorithms concurrently. Managing stand-alone point solutions for all of these algorithms will be unmanageable. A solution to this problem is a dedicated platform for deployment of AI. Here we describe a blueprint for such a platform and the high-level design and implementation considerations of such a system that can be used clinically as well as for research and development. Close collaboration between radiologists, data scientists, software developers and experts in hospital IT as well as involvement of patients is crucial in order to successfully bring AI to the clinic.
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Affiliation(s)
- Tim Leiner
- Department of Radiology
- E.01.132, Utrecht University Medical Center, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
| | - Edwin Bennink
- Image Sciences Institute, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Christian P Mol
- Image Sciences Institute, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Hugo J Kuijf
- Image Sciences Institute, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Wouter B Veldhuis
- Department of Radiology
- E.01.132, Utrecht University Medical Center, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
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11
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Alberich-Bayarri A, Sourbron S, Golay X, deSouza N, Smits M, van der Lugt A, Boellard R. ESR Statement on the Validation of Imaging Biomarkers. Insights Imaging 2020; 11:76. [PMID: 32500316 PMCID: PMC7272524 DOI: 10.1186/s13244-020-00872-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/17/2022] Open
Abstract
Medical imaging capable of generating imaging biomarkers, specifically radiology and nuclear medicine image acquisition and analysis processes, differs from frequently used comparators like blood or urine biomarkers. This difference arises from the sample acquisition methodology. While different analysis methodologies and equipment provide slightly different results in any analytical domain, unlike blood or urine analysis where the samples are obtained by simple extraction or excretion, in radiology the acquisition of the sample is heterogeneous by design, since complex equipment from different vendors is used. Therefore, with this additional degree of freedom in medical imaging, there is still risk of persistent heterogeneity of image quality through time, due to different technological implementations across vendors and protocols used in different centres. Quantitative imaging biomarkers have yet to demonstrate an impact on clinical practice due to this lack of comprehensive standardisation in terms of technical aspects of image acquisition, analysis algorithms, processes and clinical validation.The aim is establishing a standard methodology based on metrology for the validation of image acquisition and analysis methods used in the extraction of biomarkers and radiomics data. The appropriate implementation of the guidelines herein proposed by radiology departments, research institutes and industry will allow for a significant reduction in inter-vendor & inter-centre variability in imaging biomarkers and determine the measurement error obtained, enabling them to be used in imaging-based criteria for diagnosis, prognosis or treatment response, ultimately improving clinical workflows and patient care. The validation of developed analytical methods must be based on a technical performance validation and clinical validation.
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Gadoxetic acid-enhanced MR imaging for hepatocellular carcinoma: molecular and genetic background. Eur Radiol 2020; 30:3438-3447. [PMID: 32064560 DOI: 10.1007/s00330-020-06687-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/03/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023]
Abstract
Gadoxetic acid-enhanced magnetic resonance imaging (MRI) plays important roles in diagnosis of hepatic lesions because of its superiority in the detectability of small lesions, its differentiation ability, and its utility for the early diagnosis of hepatocellular carcinoma (HCC). In HCC, expression of organic anion transporting polypeptide (OATP) 1B3 correlates with the enhancement ratio in the hepatobiliary phase. Gadoxetic acid-enhanced MRI, an indirect molecular imaging method, reflects OATP1B3 expression in HCC. OATP1B3 expression gradually decreases from the dysplastic nodule stage to advanced HCC. Decreased expression is a sensitive marker of multistep hepatocarcinogenesis, especially in the early stages. Hypervascular HCCs commonly show hypointensity in the hepatobiliary phase corresponding to a decrease in OATP1B3; however, approximately 10% of HCCs show hyperintensity due to OATP1B3 overexpression. This hyperintense HCC shows less aggressive biological features and has a better prognosis than hypointense HCC. Hyperintense HCC can be classified into a genetic subtype of HCC with a mature hepatocyte-like molecular expression. OATP1B3 expression and the less aggressive nature of hyperintense HCC are regulated by the molecular interaction of β-catenin signaling and hepatocyte nuclear factor 4α, a tumor suppressor factor. Gadoxetic acid-enhanced MR imaging has the potential to be an imaging biomarker for HCC. KEY POINTS: • The hepatobiliary phase is a sensitive indirect indicator of organic anion transporting polypeptide1B3 (OATP1B3) expression in hepatocellular carcinoma (HCC). • The OATP1B3 expression, namely, enhancement in the hepatobiliary phase, decreases from the very early stage of hepatocarcinogenesis, contributing to early diagnosis of HCC. • HCC showing hyperintensity on the hepatobiliary phase is a peculiar genetic subtype of HCC with OATP1B3 overexpression, a less aggressive nature, and mature hepatocyte-like molecular/genetic features.
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Abstract
Non-invasive magnetic resonance imaging (MRI) techniques are increasingly applied in the clinic with a fast growing body of evidence regarding its value for clinical decision making. In contrast to biochemical or histological markers, the key advantages of imaging biomarkers are the non-invasive nature and the spatial and temporal resolution of these approaches. The following chapter focuses on clinical applications of novel MR biomarkers in humans with a strong focus on oncologic diseases. These include both clinically established biomarkers (part 1-4) and novel MRI techniques that recently demonstrated high potential for clinical utility (part 5-7).
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Affiliation(s)
- Daniel Paech
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Heinz-Peter Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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14
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Smith EE, Biessels GJ, De Guio F, de Leeuw FE, Duchesne S, Düring M, Frayne R, Ikram MA, Jouvent E, MacIntosh BJ, Thrippleton MJ, Vernooij MW, Adams H, Backes WH, Ballerini L, Black SE, Chen C, Corriveau R, DeCarli C, Greenberg SM, Gurol ME, Ingrisch M, Job D, Lam BY, Launer LJ, Linn J, McCreary CR, Mok VC, Pantoni L, Pike GB, Ramirez J, Reijmer YD, Romero JR, Ropele S, Rost NS, Sachdev PS, Scott CJ, Seshadri S, Sharma M, Sourbron S, Steketee RM, Swartz RH, van Oostenbrugge R, van Osch M, van Rooden S, Viswanathan A, Werring D, Dichgans M, Wardlaw JM. Harmonizing brain magnetic resonance imaging methods for vascular contributions to neurodegeneration. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2019; 11:191-204. [PMID: 30859119 PMCID: PMC6396326 DOI: 10.1016/j.dadm.2019.01.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Many consequences of cerebrovascular disease are identifiable by magnetic resonance imaging (MRI), but variation in methods limits multicenter studies and pooling of data. The European Union Joint Program on Neurodegenerative Diseases (EU JPND) funded the HARmoNizing Brain Imaging MEthodS for VaScular Contributions to Neurodegeneration (HARNESS) initiative, with a focus on cerebral small vessel disease. METHODS Surveys, teleconferences, and an in-person workshop were used to identify gaps in knowledge and to develop tools for harmonizing imaging and analysis. RESULTS A framework for neuroimaging biomarker development was developed based on validating repeatability and reproducibility, biological principles, and feasibility of implementation. The status of current MRI biomarkers was reviewed. A website was created at www.harness-neuroimaging.org with acquisition protocols, a software database, rating scales and case report forms, and a deidentified MRI repository. CONCLUSIONS The HARNESS initiative provides resources to reduce variability in measurement in MRI studies of cerebral small vessel disease.
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Affiliation(s)
- Eric E. Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Geert Jan Biessels
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - François De Guio
- Department of Neurology, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Frank Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Simon Duchesne
- CERVO Research Center, Quebec Mental Health Institute, Québec, Canada
- Radiology Department, Université Laval, Québec, Canada
| | - Marco Düring
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universität LMU, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Richard Frayne
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
- Seaman Family MR Centre, Foothills Medical Centre, Calgary, Alberta, Canada
| | - M. Arfan Ikram
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Eric Jouvent
- Department of Neurology, Lariboisière Hospital, University Paris Diderot, Paris, France
| | - Bradley J. MacIntosh
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Department of Medical Biophysics, Sunnybrook Research Institute, University of Toronto, Ontario, Canada
| | - Michael J. Thrippleton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Meike W. Vernooij
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hieab Adams
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Walter H. Backes
- Department of Radiology & Nuclear Medicine, School for Mental Health & Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lucia Ballerini
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Sandra E. Black
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Chen
- Memory Aging and Cognition Centre, Department of Pharmacology, National University of Singapore, Singapore
| | - Rod Corriveau
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Charles DeCarli
- Department of Neurology and Center for Neuroscience, University of California at Davis, Davis, CA, USA
| | - Steven M. Greenberg
- J. Philip Kistler Stroke Research Center, Stroke Service and Memory Disorders Unit, Massachusetts General Hospital, Boston, MA, USA
| | - M. Edip Gurol
- J. Philip Kistler Stroke Research Center, Stroke Service and Memory Disorders Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Ingrisch
- Department of Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany
| | - Dominic Job
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Bonnie Y.K. Lam
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Lenore J. Launer
- National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer Linn
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Cheryl R. McCreary
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Seaman Family MR Centre, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Vincent C.T. Mok
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Leonardo Pantoni
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - G. Bruce Pike
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Joel Ramirez
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Department of Medical Biophysics, Sunnybrook Research Institute, University of Toronto, Ontario, Canada
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Yael D. Reijmer
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jose Rafael Romero
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- Framingham Heart Study, Framingham, MA, USA
| | - Stefan Ropele
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Natalia S. Rost
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Perminder S. Sachdev
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
| | - Christopher J.M. Scott
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Department of Medical Biophysics, Sunnybrook Research Institute, University of Toronto, Ontario, Canada
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Mukul Sharma
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Neurology) McMaster University, Hamilton, Ontario, Canada
| | - Steven Sourbron
- Imaging Biomarkers Group, Department of Biomedical Imaging Sciences, University of Leeds, Leeds, UK
| | - Rebecca M.E. Steketee
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Richard H. Swartz
- Department of Medicine (Neurology), University of Toronto, Toronto, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Robert van Oostenbrugge
- Department of Neurology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Matthias van Osch
- C.J. Gorter Center for high field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sanneke van Rooden
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Stroke Service and Memory Disorders Unit, Massachusetts General Hospital, Boston, MA, USA
| | - David Werring
- University College London Queen Square institute of Neurology, London, UK
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universität LMU, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
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Kang KJ, Jung KH, Choi EJ, Kim H, Do SH, Ko IO, Oh SJ, Lee YJ, Kim JY, Park JA. Monitoring Physiological Changes in Neutron-Exposed Normal Mouse Brain Using FDG-PET and DW-MRI. Radiat Res 2019; 193:54-62. [PMID: 31682543 DOI: 10.1667/rr15405.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We monitored a physiological response in a neutron-exposed normal mouse brain using two imaging tools, [18F]fluro-deoxy-D-glucose positron emission tomography ([18F]FDG-PET) and diffusion weighted-magnetic resonance imaging (DW-MRI), as an imaging biomarker. We measured the apparent diffusion coefficient (ADC) of DW-MRI and standardized uptake value (SUV) of [18F]FDG-PET, which indicated changes in the cellular environment for neutron irradiation. This approach was sensitive enough to detect cell changes that were not confirmed in hematoxylin and eosin (H&E) results. Glucose transporters (GLUT) 1 and 3, indicators of the GLUT capacity of the brain, were significantly decreased after neutron irradiation, demonstrating that the change in blood-brain-barrier (BBB) permeability affects the GLUT, with changes in both SUV and ADC values. These results demonstrate that combined imaging of the same object can be used as a quantitative indicator for in vivo pathological changes. In particular, the radiation exposure assessment of combined imaging, with specific integrated functions of [18F]FDG-PET and MRI, can be employed repeatedly for noninvasive analysis performed in clinical practice. Additionally, this study demonstrated a novel approach to assess the extent of damage to normal tissues as well as therapeutic effects on tumors.
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Affiliation(s)
- Kyung Jun Kang
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
| | - Ki-Hye Jung
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
| | - Eun-Ji Choi
- College of Veterinary Medicine, Konkuk University, Seoul, Korea 05029
| | - Hyosung Kim
- College of Veterinary Medicine, Konkuk University, Seoul, Korea 05029
| | - Sun Hee Do
- College of Veterinary Medicine, Konkuk University, Seoul, Korea 05029
| | - In Ok Ko
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
| | - Se Jong Oh
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
| | - Yong Jin Lee
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
| | - Jung Young Kim
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
| | - Ji-Ae Park
- Division of Applied RI, Korea Institute Radiological and Medical Sciences, Seoul, Korea 01812
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Integrating molecular nuclear imaging in clinical research to improve anticancer therapy. Nat Rev Clin Oncol 2019; 16:241-255. [PMID: 30479378 DOI: 10.1038/s41571-018-0123-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Effective patient selection before or early during treatment is important to increasing the therapeutic benefits of anticancer treatments. This selection process is often predicated on biomarkers, predominantly biospecimen biomarkers derived from blood or tumour tissue; however, such biomarkers provide limited information about the true extent of disease or about the characteristics of different, potentially heterogeneous tumours present in an individual patient. Molecular imaging can also produce quantitative outputs; such imaging biomarkers can help to fill these knowledge gaps by providing complementary information on tumour characteristics, including heterogeneity and the microenvironment, as well as on pharmacokinetic parameters, drug-target engagement and responses to treatment. This integrative approach could therefore streamline biomarker and drug development, although a range of issues need to be overcome in order to enable a broader use of molecular imaging in clinical trials. In this Perspective article, we outline the multistage process of developing novel molecular imaging biomarkers. We discuss the challenges that have restricted the use of molecular imaging in clinical oncology research to date and outline future opportunities in this area.
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Camps-Herrero J. Diffusion-weighted imaging of the breast: current status as an imaging biomarker and future role. BJR Open 2019; 1:20180049. [PMID: 33178933 PMCID: PMC7592470 DOI: 10.1259/bjro.20180049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022] Open
Abstract
Diffusion-weighted imaging (DWI) of the breast is a MRI sequence that shows several advantages when compared to the dynamic contrast-enhanced sequence: it does not need intravenous contrast, it is relatively quick and easy to implement (artifacts notwithstanding). In this review, the current applications of DWI for lesion characterization and prognosis as well as for response evaluation are analyzed from the point of view of the necessary steps to become a useful surrogate of underlying biological processes (tissue architecture and cellularity): from the proof of concept, to the proof of mechanism, the proof of principle and finally the proof of effectiveness. Future applications of DWI in screening, DWI modeling and radiomics are also discussed.
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Affiliation(s)
- Julia Camps-Herrero
- Head of Radiology Department, Breast Unit. Hospital Universitario de la Ribera, Alzira, Spain
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19
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Giganti F, Tang L, Baba H. Gastric cancer and imaging biomarkers: Part 1 - a critical review of DW-MRI and CE-MDCT findings. Eur Radiol 2018; 29:1743-1753. [PMID: 30280246 PMCID: PMC6420485 DOI: 10.1007/s00330-018-5732-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 08/13/2018] [Accepted: 08/28/2018] [Indexed: 12/17/2022]
Abstract
Abstract The current standard of care for gastric cancer imaging includes heterogeneity in image acquisition techniques and qualitative image interpretation. In addition to qualitative assessment, several imaging techniques, including diffusion-weighted magnetic resonance imaging (DW-MRI), contrast-enhanced multidetector computed tomography (CE-MDCT), dynamic-contrast enhanced MRI and 18F-fluorodeoxyglucose positron emission tomography, can allow quantitative analysis. However, so far there is no consensus regarding the application of functional imaging in the management of gastric cancer. The aim of this article is to specifically review two promising biomarkers for gastric cancer with reasonable spatial resolution: the apparent diffusion coefficient (ADC) from DW-MRI and textural features from CE-MDCT. We searched MEDLINE/ PubMed for manuscripts published from inception to 6 February 2018. Initially, we searched for (gastric cancer OR gastric tumour) AND diffusion weighted magnetic resonance imaging. Then, we searched for (gastric cancer OR gastric tumour) AND texture analysis AND computed tomography. We collated the results from the studies related to this query. There is evidence that: (1) the ADC is a promising biomarker for the evaluation of the aggressiveness (T and N stage), treatment response and prognosis of gastric cancer; (2) textural features are related to the degree of differentiation, Lauren classification, treatment response and prognosis of gastric cancer. We conclude that these imaging biomarkers hold promise as effective additional tools in the diagnostic pathway of gastric cancer and may facilitate the multidisciplinary work between the radiologist and clinician, and across different institutions, to provide a greater biological understanding of gastric cancer. Key Points • Quantitative imaging is the extraction of quantifiable features from medical images for the assessment of normal or pathological conditions and represents a promising area for gastric cancer. • Quantitative analysis from CE-MDCT and DW-MRI allows the extrapolation of multiple imaging biomarkers. • ADC from DW-MRI and CE- MDCT-based texture features are non-invasive, quantitative imaging biomarkers that hold promise in the evaluation of the aggressiveness, treatment response and prognosis of gastric cancer.
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Affiliation(s)
- Francesco Giganti
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK. .,Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, 3rd Floor, Charles Bell House, 43-45 Foley St, London, W1W 7TS, UK.
| | - Lei Tang
- Department of Radiology, Peking University Cancer Hospital, Beijing, China
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Karageorgis A, Lenhard SC, Yerby B, Forsgren MF, Liachenko S, Johansson E, Pilling MA, Peterson RA, Yang X, Williams DP, Ungersma SE, Morgan RE, Brouwer KLR, Jucker BM, Hockings PD. A multi-center preclinical study of gadoxetate DCE-MRI in rats as a biomarker of drug induced inhibition of liver transporter function. PLoS One 2018; 13:e0197213. [PMID: 29771932 PMCID: PMC5957399 DOI: 10.1371/journal.pone.0197213] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/28/2018] [Indexed: 12/12/2022] Open
Abstract
Drug-induced liver injury (DILI) is a leading cause of acute liver failure and transplantation. DILI can be the result of impaired hepatobiliary transporters, with altered bile formation, flow, and subsequent cholestasis. We used gadoxetate dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), combined with pharmacokinetic modelling, to measure hepatobiliary transporter function in vivo in rats. The sensitivity and robustness of the method was tested by evaluating the effect of a clinical dose of the antibiotic rifampicin in four different preclinical imaging centers. The mean gadoxetate uptake rate constant for the vehicle groups at all centers was 39.3 +/- 3.4 s-1 (n = 23) and 11.7 +/- 1.3 s-1 (n = 20) for the rifampicin groups. The mean gadoxetate efflux rate constant for the vehicle groups was 1.53 +/- 0.08 s-1 (n = 23) and for the rifampicin treated groups was 0.94 +/- 0.08 s-1 (n = 20). Both the uptake and excretion transporters of gadoxetate were statistically significantly inhibited by the clinical dose of rifampicin at all centers and the size of this treatment group effect was consistent across the centers. Gadoxetate is a clinically approved MRI contrast agent, so this method is readily transferable to the clinic. Conclusion: Rate constants of gadoxetate uptake and excretion are sensitive and robust biomarkers to detect early changes in hepatobiliary transporter function in vivo in rats prior to established biomarkers of liver toxicity.
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Affiliation(s)
- Anastassia Karageorgis
- Safety and ADME Translational Sciences, Drug Safety and Metabolism, AstraZeneca, Gothenburg, Sweden
- * E-mail:
| | - Stephen C. Lenhard
- Bioimaging, Platform Technology and Sciences, GlaxoSmithKline, King of Prussia, Pennsylvania, United States of America
| | - Brittany Yerby
- Research Imaging Sciences, Amgen, Thousand Oaks, California, United States of America
| | - Mikael F. Forsgren
- Center for Medical Image Science and Visualization (CMIV), Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Wolfram MathCore, Linköping, Sweden
| | - Serguei Liachenko
- National Center for Toxicological Research, Division of Neurotoxicology, United States Food and Drug Administration, Jefferson, Arkansas, United States of America
| | - Edvin Johansson
- Personalised Healthcare and Biomarkers, Imaging group, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Gothenburg, Sweden
| | - Mark A. Pilling
- Biostatistics, Quantitative Biology, Discovery Sciences, Innovative Medicines and Early Development, AstraZeneca R&D, Cambridge, United Kingdom
| | - Richard A. Peterson
- Safety Assessment, GlaxoSmithKline, Research Triangle Park, Durham, North Carolina, United States of America
| | - Xi Yang
- National Center for Toxicological Research, Division of Systems Biology, United States Food and Drug Administration, Jefferson, Arkansas, United States of America
| | - Dominic P. Williams
- Safety and ADME Translational Sciences, Drug Safety and Metabolism, AstraZeneca, Cambridge, United Kingdom
| | - Sharon E. Ungersma
- Research Imaging Sciences, Amgen, Thousand Oaks, California, United States of America
| | - Ryan E. Morgan
- Department of Comparative Biology and Safety Sciences, Amgen Inc., Thousand Oaks, California, United States of America
| | - Kim L. R. Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of N orth Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Beat M. Jucker
- Bioimaging, Platform Technology and Sciences, GlaxoSmithKline, King of Prussia, Pennsylvania, United States of America
| | - Paul D. Hockings
- Antaros Medical, BioVenture Hub, Mölndal, Sweden
- MedTech West, Chalmers University of Technology, Gothenburg, Sweden
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Quantitative Imaging and Imaging Biomarkers: The Search for Generalizability in Radiology. J Thorac Imaging 2018; 33:69-70. [PMID: 29461430 DOI: 10.1097/rti.0000000000000321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Sardanelli F. Trends in radiology and experimental research. Eur Radiol Exp 2017; 1:1. [PMID: 29708170 PMCID: PMC5909338 DOI: 10.1186/s41747-017-0006-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/15/2017] [Indexed: 12/19/2022] Open
Abstract
European Radiology Experimental, the new journal launched by the European Society of Radiology, is placed in the context of three general and seven radiology-specific trends. After describing the impact of population aging, personalized/precision medicine, and information technology development, the article considers the following trends: the tension between subspecialties and the unity of the discipline; attention to patient safety; the challenge of reproducibility for quantitative imaging; standardized and structured reporting; search for higher levels of evidence in radiology (from diagnostic performance to patient outcome); the increasing relevance of interventional radiology; and continuous technological evolution. The new journal will publish not only studies on phantoms, cells, or animal models but also those describing development steps of imaging biomarkers or those exploring secondary end-points of large clinical trials. Moreover, consideration will be given to studies regarding: computer modelling and computer aided detection and diagnosis; contrast materials, tracers, and theranostics; advanced image analysis; optical, molecular, hybrid and fusion imaging; radiomics and radiogenomics; three-dimensional printing, information technology, image reconstruction and post-processing, big data analysis, teleradiology, clinical decision support systems; radiobiology; radioprotection; and physics in radiology. The journal aims to establish a forum for basic science, computer and information technology, radiology, and other medical subspecialties.
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Affiliation(s)
- Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano and Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan Italy
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Joseph J, Tomaszewski MR, Quiros-Gonzalez I, Weber J, Brunker J, Bohndiek SE. Evaluation of Precision in Optoacoustic Tomography for Preclinical Imaging in Living Subjects. J Nucl Med 2017; 58:807-814. [PMID: 28126890 DOI: 10.2967/jnumed.116.182311] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/15/2016] [Indexed: 12/12/2022] Open
Abstract
Optoacoustic tomography (OT) is now widely used in preclinical imaging; however, the precision (repeatability and reproducibility) of OT has yet to be determined. Methods: We used a commercial small-animal OT system. Measurements in stable phantoms were used to independently assess the impact of system variables on precision (using coefficient of variation, COV), including acquisition wavelength, rotational position, and frame averaging. Variables due to animal handling and physiology, such as anatomic placement and anesthesia conditions, were then assessed in healthy nude mice using the left kidney and spleen as reference organs. Temporal variation was assessed by repeated measurements over hours and days both in phantoms and in vivo. Sensitivity to small-molecule dyes was determined in phantoms and in vivo; precision was assessed in vivo using IRDye800CW. Results: OT COV in a stable phantom was less than 2.8% across all wavelengths over 30 d. The factors with the greatest impact on signal repeatability in phantoms were rotational position and user experience, both of which still resulted in a COV of less than 4% at 700 nm. Anatomic region-of-interest size showed the highest variation, at 12% and 18% COV in the kidney and spleen, respectively; however, functional SO2 measurements based on a standard operating procedure showed an exceptional reproducibility of less than 4% COV. COV for repeated injections of IRDye800CW was 6.6%. Sources of variability for in vivo data included respiration rate, degree of user experience, and animal placement. Conclusion: Data acquired with our small-animal OT system were highly repeatable and reproducible across subjects and over time. Therefore, longitudinal OT studies may be performed with high confidence when our standard operating procedure is followed.
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Affiliation(s)
- James Joseph
- Department of Physics and Cancer Research U.K. Cambridge Institute, University of Cambridge, United Kingdom
| | - Michal R Tomaszewski
- Department of Physics and Cancer Research U.K. Cambridge Institute, University of Cambridge, United Kingdom
| | - Isabel Quiros-Gonzalez
- Department of Physics and Cancer Research U.K. Cambridge Institute, University of Cambridge, United Kingdom
| | - Judith Weber
- Department of Physics and Cancer Research U.K. Cambridge Institute, University of Cambridge, United Kingdom
| | - Joanna Brunker
- Department of Physics and Cancer Research U.K. Cambridge Institute, University of Cambridge, United Kingdom
| | - Sarah E Bohndiek
- Department of Physics and Cancer Research U.K. Cambridge Institute, University of Cambridge, United Kingdom
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25
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Mahmood F, Johannesen HH, Geertsen P, Hansen RH. Repeated diffusion MRI reveals earliest time point for stratification of radiotherapy response in brain metastases. Phys Med Biol 2017; 62:2990-3002. [PMID: 28306548 DOI: 10.1088/1361-6560/aa5249] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An imaging biomarker for early prediction of treatment response potentially provides a non-invasive tool for better prognostics and individualized management of the disease. Radiotherapy (RT) response is generally related to changes in gross tumor volume manifesting months later. In this prospective study we investigated the apparent diffusion coefficient (ADC), perfusion fraction and pseudo diffusion coefficient derived from diffusion weighted MRI as potential early biomarkers for radiotherapy response of brain metastases. It was a particular aim to assess the optimal time point for acquiring the DW-MRI scan during the course of treatment, since to our knowledge this important question has not been addressed directly in previous studies. Twenty-nine metastases (N = 29) from twenty-one patients, treated with whole-brain fractionated external beam RT were analyzed. Patients were scanned with a 1 T MRI system to acquire DW-, T2*W-, T2W- and T1W scans, before start of RT, at each fraction and at follow up two to three months after RT. The DW-MRI parameters were derived using regions of interest based on high b-value images (b = 800 s mm-2). Both volumetric and RECIST criteria were applied for response evaluation. It was found that in non-responding metastases the mean ADC decreased and in responding metastases it increased. The volume based response proved to be far more consistently predictable by the ADC change found at fraction number 7 and later, compared to the linear response (RECIST). The perfusion fraction and pseudo diffusion coefficient did not show sufficient prognostic value with either response assessment criteria. In conclusion this study shows that the ADC derived using high b-values may be a reliable biomarker for early assessment of radiotherapy response for brain metastases patients. The earliest response stratification can be achieved using two DW-MRI scans, one pre-treatment and one at treatment day 7-9 (equivalent to 21 Gy).
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Affiliation(s)
- Faisal Mahmood
- Radiotherapy Research Unit (RRU), Department of Oncology, University of Copenhagen, Herlev and Gentofte Hospital, Herlev, Denmark
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26
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O'Connor JPB, Aboagye EO, Adams JE, Aerts HJWL, Barrington SF, Beer AJ, Boellaard R, Bohndiek SE, Brady M, Brown G, Buckley DL, Chenevert TL, Clarke LP, Collette S, Cook GJ, deSouza NM, Dickson JC, Dive C, Evelhoch JL, Faivre-Finn C, Gallagher FA, Gilbert FJ, Gillies RJ, Goh V, Griffiths JR, Groves AM, Halligan S, Harris AL, Hawkes DJ, Hoekstra OS, Huang EP, Hutton BF, Jackson EF, Jayson GC, Jones A, Koh DM, Lacombe D, Lambin P, Lassau N, Leach MO, Lee TY, Leen EL, Lewis JS, Liu Y, Lythgoe MF, Manoharan P, Maxwell RJ, Miles KA, Morgan B, Morris S, Ng T, Padhani AR, Parker GJM, Partridge M, Pathak AP, Peet AC, Punwani S, Reynolds AR, Robinson SP, Shankar LK, Sharma RA, Soloviev D, Stroobants S, Sullivan DC, Taylor SA, Tofts PS, Tozer GM, van Herk M, Walker-Samuel S, Wason J, Williams KJ, Workman P, Yankeelov TE, Brindle KM, McShane LM, Jackson A, Waterton JC. Imaging biomarker roadmap for cancer studies. Nat Rev Clin Oncol 2017; 14:169-186. [PMID: 27725679 PMCID: PMC5378302 DOI: 10.1038/nrclinonc.2016.162] [Citation(s) in RCA: 670] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Imaging biomarkers (IBs) are integral to the routine management of patients with cancer. IBs used daily in oncology include clinical TNM stage, objective response and left ventricular ejection fraction. Other CT, MRI, PET and ultrasonography biomarkers are used extensively in cancer research and drug development. New IBs need to be established either as useful tools for testing research hypotheses in clinical trials and research studies, or as clinical decision-making tools for use in healthcare, by crossing 'translational gaps' through validation and qualification. Important differences exist between IBs and biospecimen-derived biomarkers and, therefore, the development of IBs requires a tailored 'roadmap'. Recognizing this need, Cancer Research UK (CRUK) and the European Organisation for Research and Treatment of Cancer (EORTC) assembled experts to review, debate and summarize the challenges of IB validation and qualification. This consensus group has produced 14 key recommendations for accelerating the clinical translation of IBs, which highlight the role of parallel (rather than sequential) tracks of technical (assay) validation, biological/clinical validation and assessment of cost-effectiveness; the need for IB standardization and accreditation systems; the need to continually revisit IB precision; an alternative framework for biological/clinical validation of IBs; and the essential requirements for multicentre studies to qualify IBs for clinical use.
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Affiliation(s)
- James P B O'Connor
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Manchester, Manchester, UK
| | - Eric O Aboagye
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Judith E Adams
- Department of Clinical Radiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Hugo J W L Aerts
- Department of Radiation Oncology, Harvard Medical School, Boston, MA
| | - Sally F Barrington
- CRUK and EPSRC Comprehensive Imaging Centre at KCL and UCL, Kings College London, London, UK
| | - Ambros J Beer
- Department of Nuclear Medicine, University Hospital Ulm, Ulm, Germany
| | - Ronald Boellaard
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Sarah E Bohndiek
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Cambridge, Cambridge, UK
| | - Michael Brady
- CRUK and EPSRC Cancer Imaging Centre, University of Oxford, Oxford, UK
| | - Gina Brown
- Radiology Department, Royal Marsden Hospital, London, UK
| | - David L Buckley
- Division of Biomedical Imaging, University of Leeds, Leeds, UK
| | | | | | | | - Gary J Cook
- CRUK and EPSRC Comprehensive Imaging Centre at KCL and UCL, Kings College London, London, UK
| | - Nandita M deSouza
- CRUK Cancer Imaging Centre, The Institute of Cancer Research, London, UK
| | - John C Dickson
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Caroline Dive
- Clinical and Experimental Pharmacology, CRUK Manchester Institute, Manchester, UK
| | | | - Corinne Faivre-Finn
- Radiotherapy Related Research Group, University of Manchester, Manchester, UK
| | - Ferdia A Gallagher
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Cambridge, Cambridge, UK
| | - Fiona J Gilbert
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Cambridge, Cambridge, UK
| | | | - Vicky Goh
- CRUK and EPSRC Comprehensive Imaging Centre at KCL and UCL, Kings College London, London, UK
| | - John R Griffiths
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Cambridge, Cambridge, UK
| | - Ashley M Groves
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Steve Halligan
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Adrian L Harris
- CRUK and EPSRC Cancer Imaging Centre, University of Oxford, Oxford, UK
| | - David J Hawkes
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Otto S Hoekstra
- Department of Radiology and Nuclear Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Erich P Huang
- Biometric Research Program, National Cancer Institute, Bethesda, MD
| | - Brian F Hutton
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Edward F Jackson
- Department of Medical Physics, University of Wisconsin, Madison, WI
| | - Gordon C Jayson
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | - Andrew Jones
- Medical Physics, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Dow-Mu Koh
- CRUK Cancer Imaging Centre, The Institute of Cancer Research, London, UK
| | | | - Philippe Lambin
- Department of Radiation Oncology, University of Maastricht, Maastricht, Netherlands
| | - Nathalie Lassau
- Department of Imaging, Gustave Roussy Cancer Campus, Villejuif, France
| | - Martin O Leach
- CRUK Cancer Imaging Centre, The Institute of Cancer Research, London, UK
| | - Ting-Yim Lee
- Imaging Research Labs, Robarts Research Institute, London, Ontario, Canada
| | - Edward L Leen
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Jason S Lewis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yan Liu
- EORTC Headquarters, EORTC, Brussels, Belgium
| | - Mark F Lythgoe
- Centre for Advanced Biomedical Imaging, University College London, London, UK
| | - Prakash Manoharan
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Manchester, Manchester, UK
| | - Ross J Maxwell
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | - Kenneth A Miles
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Bruno Morgan
- Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
| | - Steve Morris
- Institute of Epidemiology and Health, University College London, London, UK
| | - Tony Ng
- CRUK and EPSRC Comprehensive Imaging Centre at KCL and UCL, Kings College London, London, UK
| | - Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Hospital, London, UK
| | - Geoff J M Parker
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Manchester, Manchester, UK
| | - Mike Partridge
- CRUK and EPSRC Cancer Imaging Centre, University of Oxford, Oxford, UK
| | - Arvind P Pathak
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew C Peet
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Shonit Punwani
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Andrew R Reynolds
- Breakthrough Breast Cancer Research Centre, The Institute of Cancer Research, London, UK
| | - Simon P Robinson
- CRUK Cancer Imaging Centre, The Institute of Cancer Research, London, UK
| | | | - Ricky A Sharma
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Dmitry Soloviev
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Cambridge, Cambridge, UK
| | - Sigrid Stroobants
- Molecular Imaging Center Antwerp, University of Antwerp, Antwerp, Belgium
| | - Daniel C Sullivan
- Department of Radiology, Duke University School of Medicine, Durham, NC
| | - Stuart A Taylor
- CRUK and EPSRC Cancer Imaging Centre at KCL and UCL, University College London, London, UK
| | - Paul S Tofts
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Gillian M Tozer
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Marcel van Herk
- Radiotherapy Related Research Group, University of Manchester, Manchester, UK
| | - Simon Walker-Samuel
- Centre for Advanced Biomedical Imaging, University College London, London, UK
| | | | - Kaye J Williams
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Manchester, Manchester, UK
| | - Paul Workman
- CRUK Cancer Therapeutics Unit, The Institute of Cancer Research, London, UK
| | - Thomas E Yankeelov
- Institute of Computational Engineering and Sciences, The University of Texas, Austin, TX
| | - Kevin M Brindle
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Cambridge, Cambridge, UK
| | - Lisa M McShane
- Biometric Research Program, National Cancer Institute, Bethesda, MD
| | - Alan Jackson
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Manchester, Manchester, UK
| | - John C Waterton
- CRUK and EPSRC Cancer Imaging Centre in Cambridge and Manchester, University of Manchester, Manchester, UK
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27
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Oei EHG. Quantitative musculoskeletal imaging biomarkers. Quant Imaging Med Surg 2017; 6:621-622. [PMID: 28090440 DOI: 10.21037/qims.2016.12.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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28
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Affiliation(s)
- Michael Skwarski
- Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Geoff S Higgins
- Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
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29
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Abstract
Imaging biobanks as defined by the European Society of Radiology are "organised databases of medical images, and associated imaging biomarkers (radiology and beyond), shared among multiple researchers, linked to other biorepositories". Oncologic imaging biobanks are developed mainly for research purposes. These biobanks may be developed in academic centers, or with the support of industry. The awareness of their importance is gradually increasing in the oncologic community. It is difficult to determine which oncologic domain of research will benefit from the implementation of imaging biobanks. One of the most foreseeable applications could be the correlation between imaging phenotype and genotype. For this reason imaging biobanks should be embedded in wider biobanks networks, as for example the European-based Biobanking and BioMolecular resources Research Infrastructure.
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Affiliation(s)
- Emanuele Neri
- Department of Translational Research & New Technologies in Medicine & Surgery, University of Pisa, Pisa, Italy
| | - Daniele Regge
- Department of Surgical Sciences, University of Torino, Turin, Italy.,Department of Radiology, Candiolo Cancer Institute – FPO, IRCCS, Candiolo, Torino, Italy
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30
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Sullivan DC, Obuchowski NA, Kessler LG, Raunig DL, Gatsonis C, Huang EP, Kondratovich M, McShane LM, Reeves AP, Barboriak DP, Guimaraes AR, Wahl RL. Metrology Standards for Quantitative Imaging Biomarkers. Radiology 2015; 277:813-25. [PMID: 26267831 PMCID: PMC4666097 DOI: 10.1148/radiol.2015142202] [Citation(s) in RCA: 283] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Although investigators in the imaging community have been active in developing and evaluating quantitative imaging biomarkers (QIBs), the development and implementation of QIBs have been hampered by the inconsistent or incorrect use of terminology or methods for technical performance and statistical concepts. Technical performance is an assessment of how a test performs in reference objects or subjects under controlled conditions. In this article, some of the relevant statistical concepts are reviewed, methods that can be used for evaluating and comparing QIBs are described, and some of the technical performance issues related to imaging biomarkers are discussed. More consistent and correct use of terminology and study design principles will improve clinical research, advance regulatory science, and foster better care for patients who undergo imaging studies.
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Affiliation(s)
- Daniel C. Sullivan
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Nancy A. Obuchowski
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Larry G. Kessler
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - David L. Raunig
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Constantine Gatsonis
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Erich P. Huang
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Marina Kondratovich
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Lisa M. McShane
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Anthony P. Reeves
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Daniel P. Barboriak
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Alexander R. Guimaraes
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
| | - Richard L. Wahl
- From the Department of Radiology, Duke University Medical Center, Box 2715, Durham, NC 27710 (D.C.S., D.P.B.); Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Public Health, University of Washington, Seattle, Wash (L.G.K.); Department of Informatics, ICON Medical, Washington, Pa (D.L.R.); Center for Statistical Sciences, Brown University, Providence, RI (C.G.); National Cancer Institute, Bethesda, Md (E.P.H., L.M.M.); Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Md (M.K.); Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY (A.P.R.); Department of Radiology, Oregon Health & Science University, Portland, Ore (A.R.G.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.L.W.)
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31
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Beaumont H, Souchet S, Labatte JM, Iannessi A, Tolcher AW. Changes of lung tumour volume on CT - prediction of the reliability of assessments. Cancer Imaging 2015; 15:17. [PMID: 26521238 PMCID: PMC4628325 DOI: 10.1186/s40644-015-0052-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/02/2015] [Indexed: 11/12/2022] Open
Abstract
Background For oncological evaluations, quantitative radiology gives clinicians significant insight into patients’ response to therapy. In regard to the Response Evaluation Criteria in Solid Tumours (RECIST), the classification of disease evolution partly consists in applying thresholds to the measurement of the relative change of tumour. In the case of tumour volumetry, response thresholds have not yet been established. This study proposes and validates a model for calculating thresholds for the detection of minimal tumour change when using the volume of pulmonary lesions on CT as imaging biomarker. Methods Our work is based on the reliability analysis of tumour volume measurements documented by the Quantitative Imaging Biomarker Alliance. Statistics of measurements were entered into a multi-parametric mathematical model of the relative changes derived from the Geary-Hinkley transformation. The consistency of the model was tested by comparing modelled thresholds against Monte Carlo simulations of tumour volume measurements with additive random error. The model has been validated by repeating measurements on real patient follow ups. Results For unchanged tumour volume, relying on a normal distribution of error, the agreement between model and simulations featured a type I error of 5.25 %. Thus, we established that a threshold of 35 % of volume reduction corresponds to a partial response (PR) and a 55 % volume increase corresponds to progressive disease (PD). Changes between −35 and +55 % are categorized as stable disease (SD). Tested on real clinical data, 97.1 % [95.7; 98.0] of assessments fall into the range of variability predicted by our model of confidence interval. Conclusions Our study indicates that the Geary Hinkley model, using published statistics, is appropriate to predict response thresholds for the volume of pulmonary lesions on CT.
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Affiliation(s)
- Hubert Beaumont
- MEDIAN Technologies - Sciences, 1800 route des crêtes Les Deux Arcs Bat B, Valbonne, 06560, France.
| | - Simon Souchet
- Université d'Angers - Mathematics, Angers, 49000, France.
| | | | - Antoine Iannessi
- Centre Anticancer Antoine Lacassagne - Radiology, Nice, 06100, France.
| | - Anthony William Tolcher
- START - South Texas Accelerated Research Therapeutics, LLC - Clinical Research, San Antonio, TX, USA.
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Abstract
In March 2014 the European Society of Radiology (ESR) established a dedicated working group (ESR WG on Imaging Biobanks) aimed at monitoring the existing imaging biobanks in Europe, promoting the federation of imaging biobanks and communication of their findings in a white paper. The WG provided the following statements: (1) Imaging biobanks can be defined as "organised databases of medical images and associated imaging biomarkers (radiology and beyond) shared among multiple researchers, and linked to other biorepositories". (2) The immediate purpose of imaging biobanks should be to allow the generation of imaging biomarkers for use in research studies and to support biological validation of existing and novel imaging biomarkers. (3) A long-term scope of imaging biobanks should be the creation of a network/federation of such repositories integrated with the already-existing biobanking network. The aim of the WG was to investigate the existence, consistency, geographical distribution and type of imaging biobanks in Europe. A survey among ESR members resulted in the identification of 27 imaging biobanks, mostly disease-oriented and designed for research and clinical reference. In 80 % access to imaging biobanks is restricted. Key points • Imaging biobanks are "shared databases of imaging biomarkers, linked to biorepositories".• Exploitation of traditional and imaging biobanks is meaningful for "personalised medicine".• A European imaging biobank network would significantly boost research in the imaging domain.
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Magnetic Resonance Fingerprinting - a promising new approach to obtain standardized imaging biomarkers from MRI. Insights Imaging 2015; 6:163-5. [PMID: 25800993 PMCID: PMC4376817 DOI: 10.1007/s13244-015-0403-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 11/29/2022] Open
Abstract
Current routine MRI examinations rely on the acquisition of qualitative images that have a contrast “weighted” for a mixture of (magnetic) tissue properties. Recently, a novel approach was introduced, namely MR Fingerprinting (MRF) with a completely different approach to data acquisition, post-processing and visualization. Instead of using a repeated, serial acquisition of data for the characterization of individual parameters of interest, MRF uses a pseudo randomized acquisition that causes the signals from different tissues to have a unique signal evolution or ‘fingerprint’ that is simultaneously a function of the multiple material properties under investigation. The processing after acquisition involves a pattern recognition algorithm to match the fingerprints to a predefined dictionary of predicted signal evolutions. These can then be translated into quantitative maps of the magnetic parameters of interest. MR Fingerprinting (MRF) is a technique that could theoretically be applied to most traditional qualitative MRI methods and replaces them with acquisition of truly quantitative tissue measures. MRF is, thereby, expected to be much more accurate and reproducible than traditional MRI and should improve multi-center studies and significantly reduce reader bias when diagnostic imaging is performed. Key Points • MR fingerprinting (MRF) is a new approach to data acquisition, post-processing and visualization. • MRF provides highly accurate quantitative maps of T1, T2, proton density, diffusion. • MRF may offer multiparametric imaging with high reproducibility, and high potential for multicenter/ multivendor studies.
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