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Steybe D, Voss PJ, Metzger MC, Schmelzeisen R, Poxleitner P. Virtual tumor mapping and margin control with 3-D planning and navigation. Innov Surg Sci 2024; 9:17-24. [PMID: 38826628 PMCID: PMC11138405 DOI: 10.1515/iss-2021-0009] [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: 03/17/2021] [Accepted: 03/20/2024] [Indexed: 06/04/2024] Open
Abstract
Computer technology-based treatment approaches like intraoperative navigation and intensity-modulated radiation therapy have become important components of state of the art head and neck cancer treatment. Multidirectional exchange of virtual three-dimensional patient data via an interdisciplinary platform allows all medical specialists involved in the patients treatment to take full advantage of these technologies. This review article gives an overview of current technologies and future directions regarding treatment approaches that are based on a virtual, three-dimensional patient specific dataset: storage and exchange of spatial information acquired via intraoperative navigation allow for a highly precise frozen section procedure. In the postoperative setting, virtual reconstruction of the tumor resection surface provides the basis for improved radiation therapy planning and virtual reconstruction of the tumor with integration of molecular findings creates a valuable tool for postoperative treatment and follow-up. These refinements of established treatment components and novel approaches have the potential to make a major contribution to improving the outcome in head and neck cancer patients.
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Affiliation(s)
- David Steybe
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Medical Center – University of Freiburg, Freiburg, Germany
| | - Pit J. Voss
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Medical Center – University of Freiburg, Freiburg, Germany
| | - Marc C. Metzger
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Medical Center – University of Freiburg, Freiburg, Germany
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Medical Center – University of Freiburg, Freiburg, Germany
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Medical Center – University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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2
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Brown K, Ghita M, Prise KM, Butterworth KT. Feasibility and guidelines for the use of an injectable fiducial marker (BioXmark ®) to improve target delineation in preclinical radiotherapy studies using mouse models. F1000Res 2023; 12:526. [PMID: 38799243 PMCID: PMC11116939 DOI: 10.12688/f1000research.130883.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Preclinical models of radiotherapy (RT) response are vital for the continued success and evolution of RT in the treatment of cancer. The irradiation of tissues in mouse models necessitates high levels of precision and accuracy to recapitulate clinical exposures and limit adverse effects on animal welfare. This requirement has been met by technological advances in preclinical RT platforms established over the past decade. Small animal RT systems use onboard computed tomography (CT) imaging to delineate target volumes and have significantly refined radiobiology experiments with major 3Rs impacts. However, the CT imaging is limited by the differential attenuation of tissues resulting in poor contrast in soft tissues. Clinically, radio-opaque fiducial markers (FMs) are used to establish anatomical reference points during treatment planning to ensure accuracy beam targeting, this approach is yet to translate back preclinical models. METHODS We report on the use of a novel liquid FM BioXmark ® developed by Nanovi A/S (Kongens Lyngby, Denmark) that can be used to improve the visualisation of soft tissue targets during beam targeting and minimise dose to surrounding organs at risk. We present descriptive protocols and methods for the use of BioXmark ® in experimental male and female C57BL/6J mouse models. RESULTS These guidelines outline the optimum needle size for uptake (18-gauge) and injection (25- or 26-gauge) of BioXmark ® for use in mouse models along with recommended injection volumes (10-20 µl) for visualisation on preclinical cone beam CT (CBCT) scans. Injection techniques include subcutaneous, intraperitoneal, intra-tumoral and prostate injections. CONCLUSIONS The use of BioXmark ® can help to standardise targeting methods, improve alignment in preclinical image-guided RT and significantly improve the welfare of experimental animals with the reduction of normal tissue exposure to RT.
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Affiliation(s)
- Kathryn Brown
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
| | - Mihaela Ghita
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
| | - Kevin M Prise
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
| | - Karl T Butterworth
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
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3
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Opbroek TJ, Willems YC, Verhaegen F, de Ridder R, Hoge C, Melenhorst J, Bakers F, Grabsch HI, Buijsen J, van Limbergen EJ, Canters RA, Berbée M. BioXmark® liquid fiducials to enable radiotherapy tumor boosting in rectal cancer, a feasibility trial. Clin Transl Radiat Oncol 2022; 38:90-95. [PMID: 36407490 PMCID: PMC9668658 DOI: 10.1016/j.ctro.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
Abstract
BioXmark® is a novel liquid fiducial marker for image-guided radiotherapy. The marker remained stable during chemoradiotherapy in 96% of rectal cancer cases. The fiducial allows for image tracking on CT-based imaging modalities. Marker visibility was good using CT-based imaging without any relevant artifacts. The marker is easy to inject without marker related adverse events.
Background and purpose Dose-escalation in rectal cancer (RCa) may result in an increased complete response rate and thereby enable omission of surgery and organ preservation. In order to implement dose-escalation, it is crucial to develop a technique that allows for accurate image-guided radiotherapy. The aim of the current study was to determine the performance of a novel liquid fiducial marker (BioXmark®) in RCa patients during the radiotherapy course by assessing its positional stability on daily cone-beam CT (CBCT), technical feasibility, visibility on different imaging modalities and safety. Materials and methods Prospective, non-randomized, single-arm feasibility trial with inclusion of twenty patients referred for neoadjuvant chemoradiotherapy for locally advanced RCa. Primary study endpoint was positional stability on CBCT. Furthermore, technical aspects, safety and clinical performance of the marker, such as visibility on different imaging modalities, were evaluated. Results Seventy-four markers from twenty patients were available for analysis. The marker was stable in 96% of the cases. One marker showed clinically relevant migration, one marker was lost before start of treatment and one marker was lost during treatment. Marker visibility was good on computed tomography (CT) and CBCT, and moderate on electronic portal imaging (EPI). Marker visibility on magnetic resonance imaging (MRI) was poor during response evaluation. Conclusion The novel liquid fiducial marker demonstrated positional stability. We provide evidence of the feasibility of the novel fiducial marker for image-guided radiotherapy on daily cone beam CT for RCa patients.
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4
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Steybe D, Poxleitner P, Voss PJ, Metzger MC, Schmelzeisen R, Bamberg F, Kim S, Russe MF. Evaluation of computed tomography settings in the context of visualization and discrimination of low dose injections of a novel liquid soft tissue fiducial marker in head and neck imaging. BMC Med Imaging 2021; 21:157. [PMID: 34702192 PMCID: PMC8549337 DOI: 10.1186/s12880-021-00689-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background Intraoperative incorporation of radiopaque fiducial markers at the tumor resection surface can provide useful assistance in identifying the tumor bed in postoperative imaging for RT planning and radiological follow-up. Besides titanium clips, iodine containing injectable liquid fiducial markers represent an option that has emerged more recently for this purpose. In this study, marking oral soft tissue resection surfaces, applying low dose injections of a novel Conformité Européenne (CE)-marked liquid fiducial marker based on sucrose acetoisobutyrate (SAIB) and iodinated SAIB (x-SAIB) was investigated. Methods Visibility and discriminability of low dose injections of SAIB/x-SAIB (10 µl, 20 µl, 30 µl) were systematically studied at different kV settings used in clinical routine in an ex-vivo porcine mandible model. Transferability of the preclinical results into the clinical setting and applicability of DE-CT were investigated in initial patients.
Results Markers created by injection volumes as low as 10 µl were visible in CT imaging at all kV settings applied in clinical routine (70–120 kV). An injection volume of 30 µl allowed differentiation from an injection volume of 10 µl. In a total of 118 injections performed in two head and neck cancer patients, markers were clearly visible in 83% and 86% of injections. DE-CT allowed for differentiation between SAIB/x-SAIB markers and other hyperdense structures. Conclusions Injection of low doses of SAIB/x-SAIB was found to be a feasible approach to mark oral soft tissue resection surfaces, with injection volumes as low as 10 µl found to be visible at all kV settings applied in clinical routine. With the application of SAIB/x-SAIB reported for tumors of different organs already, mostly applying relatively large volumes for IGRT, this study adds information on the applicability of low dose injections to facilitate identification of the tumor bed in postoperative CT and on performance of the marker at different kV settings used in clinical routine.
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Affiliation(s)
- David Steybe
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Marc Christian Metzger
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Suam Kim
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Frederik Russe
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Wang W, Hansen AE, Sun H, Fliedner FP, Kjaer A, Jensen AI, Andresen TL, Henriksen JR. Carbohydrate based biomarkers enable hybrid near infrared fluorescence and 64Cu based radio-guidance for improved surgical precision. Nanotheranostics 2021; 5:448-460. [PMID: 34055574 PMCID: PMC8156217 DOI: 10.7150/ntno.60295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/04/2021] [Indexed: 01/15/2023] Open
Abstract
Increasing numbers of lung tumors are identified at early disease stages by diagnostic imaging in screening programs, but difficulties in locating these during surgical intervention has prevented an improved treatment outcome. Surgical biomarkers that are visible on diagnostic images, and that provide the surgeon with real-time image guidance during the intervention are thus highly warranted to bridge diagnostic precision into enhanced therapeutic outcome. In this paper, a liquid soft tissue marker for near infrared fluorescence and radio-guidance is presented. The biocompatible marker is based on the carbohydrate ester, sucrose acetate isobutyrate, ethanol, and a multifunctional naphthalocyanine dye, which enable near infrared fluorescence image-guided resection at short, medium and long tissue depths. Naphthalocyanine dyes have high quantum yields and may further act as chelators of radionuclides. Upon injection of the liquid marker, a gel-like depot is formed in situ at the site of injection, wherein the fluorescent dye and radionuclide is retained. The radiolabeled markers were optimized for minimal fluorescence quenching and high retention of the positron emission tomography radionuclide 64Cu. The performance of the radiolabeled marker was tested in vivo in mice, where it displayed high photostability over a period of 4 weeks, and high retention of 64Cu for 48 hours. The retention and biodistribution of 64Cu was quantified via PET/CT, and the fluorescence emission by an in vivo imaging system. The presented data demonstrate proof-of-concept for naphthalocyanine markers as multimodal imaging agents that can bridge the precision of diagnostic imaging into surgical interventions.
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Affiliation(s)
- Wenbo Wang
- Technical University of Denmark, Department of Health Technology, Building 423, 2800 Lyngby, Denmark.,Center for Nanomedicine and Theranostics, Technical University of Denmark, 2800 Lyngby, Denmark
| | - Anders E Hansen
- Technical University of Denmark, Department of Health Technology, Building 423, 2800 Lyngby, Denmark.,Center for Nanomedicine and Theranostics, Technical University of Denmark, 2800 Lyngby, Denmark
| | - Hongmei Sun
- School of Bioengineering and Food, Key Laboratory of Fermentation Engineering, (Ministry of Education), Key Laboratory of Industrial Microbiology in Hubei, National '111' Center for Cellular Regulation and Molecular Pharmaceutic, Hubei province Cooperative Innovation Center for Industrial Fermentation, Hubei University of Technology, Wuhan 430068, China
| | - Frederikke P Fliedner
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Rigshospitalet and University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Rigshospitalet and University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Andreas I Jensen
- Technical University of Denmark, The Hevesy Laboratory, Department of Health Technology, 4000 Roskilde, Denmark.,Center for Nanomedicine and Theranostics, Technical University of Denmark, 2800 Lyngby, Denmark
| | - Thomas L Andresen
- Technical University of Denmark, Department of Health Technology, Building 423, 2800 Lyngby, Denmark.,Center for Nanomedicine and Theranostics, Technical University of Denmark, 2800 Lyngby, Denmark
| | - Jonas R Henriksen
- Technical University of Denmark, Department of Health Technology, Building 423, 2800 Lyngby, Denmark.,Center for Nanomedicine and Theranostics, Technical University of Denmark, 2800 Lyngby, Denmark
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Fach M, Fliedner FP, Kempen PJ, Melander F, Hansen AE, Bruun LM, Köster U, Sporer E, Kjær A, Andresen TL, Jensen AI, Henriksen JR. Effective Intratumoral Retention of [ 103 Pd]AuPd Alloy Nanoparticles Embedded in Gel-Forming Liquids Paves the Way for New Nanobrachytherapy. Adv Healthc Mater 2021; 10:e2002009. [PMID: 33763995 DOI: 10.1002/adhm.202002009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/10/2021] [Indexed: 12/31/2022]
Abstract
Local application of radioactive sources as brachytherapy is well established in oncology. This treatment is highly invasive however, due to the insertion of millimeter sized metal seeds. The authors report the development of a new concept for brachytherapy, based on gold-palladium (AuPd) alloy nanoparticles, intrinsically radiolabeled with 103 Pd. These are formulated in a carbohydrate-ester based liquid, capable of forming biodegradable gel-like implants upon injection. This allows for less invasive administration through small-gauge needles. [103 Pd]AuPd nanoparticles with sizes around 20 nm are prepared with radiolabeling efficiencies ranging from 79% to >99%. Coating with the hydrophobic polymer poly(N-isopropylacrylamide) leads to nanoparticle diameters below 40 nm. Dispersing the nanoparticles in ethanol with water insoluble carbohydrate esters gives "nanogels", a low viscosity liquid capable of solidifying upon injection into aqueous environments. Both nanoparticles and radioactivity are stably retained in the nanogel over 25 days (>99%) after formation in aqueous buffers. Animals bearing CT26 murine tumors are injected intratumorally with 25 MBq of the 103 Pd-nanogel, and display tumor growth delay and significantly increase median survival times compared with control groups. Excellent retention in the tumor of both the 103 Pd and the nanoparticle matrix itself is observed, demonstrating a potential for replacing currently used brachytherapy seeds.
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Affiliation(s)
- Matthias Fach
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
| | - Frederikke P. Fliedner
- Department of Clinical Physiology Nuclear Medicine & PET and Cluster for Molecular Imaging Department of Biomedical Sciences Rigshospitalet and University of Copenhagen Blegdamsvej 3B Copenhagen 2100 Denmark
| | - Paul J. Kempen
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
| | - Fredrik Melander
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
| | - Anders E. Hansen
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
- Department of Clinical Physiology Nuclear Medicine & PET and Cluster for Molecular Imaging Department of Biomedical Sciences Rigshospitalet and University of Copenhagen Blegdamsvej 3B Copenhagen 2100 Denmark
| | - Linda M. Bruun
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
| | - Ulli Köster
- Institut Laue‐Langevin 71 Avenue des Martyrs Grenoble 38042 France
| | - Emanuel Sporer
- The Hevesy Laboratory DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark (DTU) Frederiksborgvej 399 Roskilde 4000 Denmark
| | - Andreas Kjær
- Department of Clinical Physiology Nuclear Medicine & PET and Cluster for Molecular Imaging Department of Biomedical Sciences Rigshospitalet and University of Copenhagen Blegdamsvej 3B Copenhagen 2100 Denmark
| | - Thomas L. Andresen
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
| | - Andreas I. Jensen
- The Hevesy Laboratory DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark (DTU) Frederiksborgvej 399 Roskilde 4000 Denmark
| | - Jonas R. Henriksen
- DTU Health Technology Center for Nanomedicine and Theranostics Technical University of Denmark Ørsteds Plads 345C Lyngby 2800 Denmark
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Steybe D, Russe MF, Ludwig U, Sprave T, Vach K, Semper-Hogg W, Schmelzeisen R, Voss PJ, Poxleitner P. Intraoperative marking of the tumour resection surface for improved radiation therapy planning in head and neck cancer: preclinical evaluation of a novel liquid fiducial marker. Dentomaxillofac Radiol 2021; 50:20200290. [PMID: 32915672 DOI: 10.1259/dmfr.20200290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate a novel liquid fiducial marker for intraoperative marking of the tumour resection surface in oral cancer patients to facilitate precise postoperative delineation of the interface between the tumour resection border and reconstructed tissue for intensity-modulated radiation therapy. METHODS A total of 200 markers were created by injecting the volumes of 10 µl, 20 µl, 30 µl, 40 µl and 50 µl of a liquid marker composed of sucrose acetoisobutyrate (SAIB) and iodinated sucrose acetoisobutyrate (x-SAIB) into the soft tissue of porcine mandible segments. Visibility of the resulting markers was quantified by threshold-based segmentation of the marker volume in CT- and CBCT imaging and by a comparison of signal intensities in MRI. RESULTS Even the lowest volume of SAIB-/x-SAIB investigated (10 µl) resulted in a higher visibility (CTSoft tissue: 88.18 ± 13.23 µl; CTBone: 49.55 ± 7.62 µl; CBCT: 54.65 ± 12.58 µl) than observed with the incorporation of titanium ligature clips (CTSoft tissue: 50.15 ± 7.50 mm3; CTBone: 23.90 ± 3.39 mm3; CBCT: 33.80 ± 9.20 mm3). Markers created by the injection of 10 µl and 20 µl could reliably be delineated from markers created by the injection of higher volumes. CONCLUSION SAIB/x-SAIB, which has recently become available as a Conformité Européenne (CE)-marked fiducial marker, provides an option for fast and reliable production of markers with excellent visibility in imaging modalities used in oral cancer radiation therapy (RT) planning routine.
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Affiliation(s)
- David Steybe
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Frederik Russe
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ute Ludwig
- Medical Physics, Department of Radiology, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kirstin Vach
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Wiebke Semper-Hogg
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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8
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Hansen AE, Henriksen JR, Jølck RI, Fliedner FP, Bruun LM, Scherman J, Jensen AI, Munck af Rosenschöld P, Moorman L, Kurbegovic S, de Blanck SR, Larsen KR, Clementsen PF, Christensen AN, Clausen MH, Wang W, Kempen P, Christensen M, Viby NE, Persson G, Larsen R, Conradsen K, McEvoy FJ, Kjaer A, Eriksen T, Andresen TL. Multimodal soft tissue markers for bridging high-resolution diagnostic imaging with therapeutic intervention. SCIENCE ADVANCES 2020; 6:eabb5353. [PMID: 32875113 PMCID: PMC7438096 DOI: 10.1126/sciadv.abb5353] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/07/2020] [Indexed: 05/11/2023]
Abstract
Diagnostic imaging often outperforms the surgeon's ability to identify small structures during therapeutic procedures. Smart soft tissue markers that translate the sensitivity of diagnostic imaging into optimal therapeutic intervention are therefore highly warranted. This paper presents a unique adaptable liquid soft tissue marker system based on functionalized carbohydrates (Carbo-gel). The liquid state of these markers allows for high-precision placement under image guidance using thin needles. Based on step-by-step modifications, the image features and mechanical properties of markers can be optimized to bridge diagnostic imaging and specific therapeutic interventions. The performance of Carbo-gel is demonstrated for markers that (i) have radiographic, magnetic resonance, and ultrasound visibility; (ii) are palpable and visible; and (iii) are localizable by near-infrared fluorescence and radio guidance. The study demonstrates encouraging proof of concept for the liquid marker system as a well-tolerated multimodal imaging marker that can improve image-guided radiotherapy and surgical interventions, including robotic surgery.
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Affiliation(s)
- Anders E. Hansen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Jonas R. Henriksen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Rasmus I. Jølck
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Frederikke P. Fliedner
- Dept. of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Dept. of Biomedical Sciences, Copenhagen University Hospital (Rigshospitalet) and University of Copenhagen, Copenhagen, DK-2200, Denmark
| | - Linda M. Bruun
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Jonas Scherman
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund SE-222 42, Sweden
| | - Andreas I. Jensen
- DTU Health Technology, The Hevesy Laboratory, Technical University of Denmark, Roskilde DK-4000, Denmark
| | - Per. Munck af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund SE-222 42, Sweden
| | - Lilah Moorman
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederiksberg DK-1870, Denmark
| | - Sorel Kurbegovic
- Dept. of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Dept. of Biomedical Sciences, Copenhagen University Hospital (Rigshospitalet) and University of Copenhagen, Copenhagen, DK-2200, Denmark
| | - Steen R. de Blanck
- Department of Oncology, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Klaus R. Larsen
- Department of Respiratory Medicine, Copenhagen University Hospital (Bispebjerg and Frederiksberg Hospital), Copenhagen DK-2400, Denmark
| | - Paul F. Clementsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Anders N. Christensen
- DTU Compute, Section for Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Mads H. Clausen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Wenbo Wang
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Paul Kempen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Merete Christensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Niels-Erik Viby
- Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Gitte Persson
- Department of Oncology, Herlev-Gentofte Hospital, Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen DK-2200, Denmark
| | - Rasmus Larsen
- DTU Compute, Section for Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Knut Conradsen
- DTU Compute, Section for Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Fintan J. McEvoy
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederiksberg DK-1870, Denmark
| | - Andreas Kjaer
- Dept. of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Dept. of Biomedical Sciences, Copenhagen University Hospital (Rigshospitalet) and University of Copenhagen, Copenhagen, DK-2200, Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederiksberg DK-1870, Denmark
| | - Thomas L. Andresen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
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9
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de Ridder M, Gerbrandy LC, de Reijke TM, Hinnen KA, Hulshof MCCM. BioXmark® liquid fiducial markers for image-guided radiotherapy in muscle invasive bladder cancer: a safety and performance trial. Br J Radiol 2020; 93:20200241. [PMID: 32463291 DOI: 10.1259/bjr.20200241] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE This study evaluated the performance of the novel liquid fiducial marker (BioXmark®) in IGRT for bladder cancer. METHODS 20 patients with muscle invasive bladder cancer were entered in this prospective, single center, Phase I-II study. The novel BioXmark® liquid markers were injected around the tumor using a flexible cystoscopy. Visibility and stability of the markers were evaluated on planning-CT and CBCT. Prospectively defined threshold for success was set at a visibility of 75%. RESULTS In total, 76 markers were implanted in 20 patients. Of those, 60 (79% 95% CI ± 9%) were visible on CT scan. Due to the learning curve of the technique, the visibility improved in the last 75% of patients (86% visibility) compared to the first 25% of patients with 58% visibility. Concerning stability of the BioXmark® marker, all visible markers after CT acquisition were still detectable at the last CBCT without displacement. In 15/20 (75%) of the patients, three or more markers were visible on CT. No BioXmark® related adverse events were reported. CONCLUSION The success rate of this novel fiducial marker was 79%, which is above the prospectively defined threshold rate. A distinct learning curve of the injection of the liquid marker was seen over the study period. The marker showed sustained visibility and positional stability during treatment phases and also appears to be safe and easy to inject. ADVANCES IN KNOWLEDGE This novel liquid BioXmark® marker seems to be a very promising tool in daily-adaptive IGRT for bladder preserving chemoradiotherapy in muscle invasive bladder cancer.
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Affiliation(s)
- Mischa de Ridder
- Department of radiation oncology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of radiation oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lara C Gerbrandy
- Department of urology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Theo M de Reijke
- Department of urology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Karel A Hinnen
- Department of radiation oncology, Amsterdam UMC, Amsterdam, The Netherlands
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Evaluation of a Novel Liquid Fiducial Marker, BioXmark ®, for Small Animal Image-Guided Radiotherapy Applications. Cancers (Basel) 2020; 12:cancers12051276. [PMID: 32443537 PMCID: PMC7280978 DOI: 10.3390/cancers12051276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/17/2022] Open
Abstract
BioXmark® (Nanovi A/S, Denmark) is a novel fiducial marker based on a liquid, iodine-based and non-metallic formulation. BioXmark® has been clinically validated and reverse translated to preclinical models to improve cone-beam CT (CBCT) target delineation in small animal image-guided radiotherapy (SAIGRT). However, in phantom image analysis and in vivo evaluation of radiobiological response after the injection of BioXmark® are yet to be reported. In phantom measurements were performed to compare CBCT imaging artefacts with solid fiducials and determine optimum imaging parameters for BioXmark®. In vivo stability of BioXmark® was assessed over a 5-month period, and the impact of BioXmark® on in vivo tumour response from single-fraction and fractionated X-ray exposures was investigated in a subcutaneous syngeneic tumour model. BioXmark® was stable, well tolerated and detectable on CBCT at volumes ≤10 µL. Our data showed imaging artefacts reduced by up to 84% and 89% compared to polymer and gold fiducial markers, respectively. BioXmark® was shown to have no significant impact on tumour growth in control animals, but changes were observed in irradiated animals injected with BioXmark® due to alterations in dose calculations induced by the sharp contrast enhancement. BioXmark® is superior to solid fiducials with reduced imaging artefacts on CBCT. With minimal impact on the tumour growth delay, BioXmark® can be implemented in SAIGRT to improve target delineation and reduce set-up errors.
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Cunningham DP, Skinner OT. Determination of the lateral extent of the subcutaneous wound bed in canine cadavers after closure of skin defects to replicate tumor excision. Vet Surg 2020; 49:728-735. [PMID: 32073170 DOI: 10.1111/vsu.13397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/03/2019] [Accepted: 01/18/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the extent of subcutaneous involvement after primary closure of experimental skin defects. STUDY DESIGN Experimental study. ANIMALS Eight large, mixed breed dog cadavers. METHODS Standardized, circular skin defects with diameters of 2, 4, 6, or 8 cm were created at the lateral thorax or abdomen by using a matrix to ensure even distribution, with eight defects of each diameter. The wound beds were covered in 60% barium sulfate paste prior to primary closure. Computed tomography and a dedicated viewing program were used to measure the distance from the edge of the subcutaneous defect to the incision at set intervals along the incision. RESULTS The mean ± SD maximum lateral extension was 6.4 ± 1.9, 14.1 ± 4.9, 18.5 ± 6.9, and 26.0 ± 9.6 mm for 2-, 4-, 6-, and 8-cm defects, respectively. Extension >2 cm from the incision occurred in zero of eight, one of eight, five of eight, and six of eight defects after closure of 2-, 4-, 6-, and 8-cm defects, respectively. Extension >3 cm from the incision occurred in zero of eight, zero of eight, two of eight, and five of eight defects after closure of 2-, 4-, 6-, and 8-cm defects, respectively. CONCLUSION The lateral extent of the subcutaneous wound bed extended past previously recommended revision margins of 2 to 3 cm in some defects measuring greater than 4 cm in diameter. CLINICAL SIGNIFICANCE Surgeons and radiation oncologists should consider the potential extent of the subcutaneous defect when planning revision therapy, especially after large resections.
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Affiliation(s)
- Devin P Cunningham
- University of Missouri College of Veterinary Medicine Veterinary Health Center, Columbia, Missouri
| | - Owen T Skinner
- University of Missouri College of Veterinary Medicine Veterinary Health Center, Columbia, Missouri
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12
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Osman SOS, Russell E, King RB, Crowther K, Jain S, McGrath C, Hounsell AR, Prise KM, McGarry CK. Fiducial markers visibility and artefacts in prostate cancer radiotherapy multi-modality imaging. Radiat Oncol 2019; 14:237. [PMID: 31878967 PMCID: PMC6933910 DOI: 10.1186/s13014-019-1447-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In this study, a novel pelvic phantom was developed and used to assess the visibility and presence of artefacts from different types of commercial fiducial markers (FMs) on multi-modality imaging relevant to prostate cancer. METHODS AND MATERIALS The phantom was designed with 3D printed hollow cubes in the centre. These cubes were filled with gel to mimic the prostate gland and two parallel PVC rods were used to mimic bones in the pelvic region. Each cube was filled with gelatine and three unique FMs were positioned with a clinically-relevant spatial distribution. The FMs investigated were; Gold Marker (GM) CIVCO, GM RiverPoint, GM Gold Anchor (GA) line and ball shape, and polymer marker (PM) from CIVCO. The phantom was scanned using several imaging modalities typically used to image prostate cancer patients; MRI, CT, CBCT, planar kV-pair, ExacTrac, 6MV, 2.5MV and integrated EPID imaging. The visibility of the markers and any observed artefacts in the phantom were compared to in-vivo scans of prostate cancer patients with FMs. RESULTS All GMs were visible in volumetric scans, however, they also had the most visible artefacts on CT and CBCT scans, with the magnitude of artefacts increasing with FM size. PM FMs had the least visible artefacts in volumetric scans but they were not visible on portal images and had poor visibility on lateral kV images. The smallest diameter GMs (GA) were the most difficult GMs to identify on lateral kV images. CONCLUSION The choice between different FMs is also dependent on the adopted IGRT strategy. PM was found to be superior to investigated gold markers in the most commonly used modalities in the management of prostate cancer; CT, CBCT and MRI imaging.
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Affiliation(s)
- Sarah O. S. Osman
- Centre of Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland BT7 1NN UK
- Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Emily Russell
- Centre of Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland BT7 1NN UK
| | - Raymond B. King
- Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Karen Crowther
- Radiotherapy Department, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Suneil Jain
- Centre of Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland BT7 1NN UK
- Clinical Oncology, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Cormac McGrath
- Radiological Sciences and Imaging, Belfast Health and Social Care Trust, Forster Green Hospital, Belfast, UK
| | - Alan R. Hounsell
- Centre of Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland BT7 1NN UK
- Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Kevin M. Prise
- Centre of Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland BT7 1NN UK
| | - Conor K. McGarry
- Centre of Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland BT7 1NN UK
- Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
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Schneider S, Aust DE, Brückner S, Welsch T, Hampe J, Troost EGC, Hoffmann AL. Detectability and structural stability of a liquid fiducial marker in fresh ex vivo pancreas tumour resection specimens on CT and 3T MRI. Strahlenther Onkol 2019; 195:756-763. [PMID: 31143995 DOI: 10.1007/s00066-019-01474-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/03/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To test the detectability of a liquid fiducial marker injected into ex vivo pancreas tumour tissue on magnetic resonance imaging (MRI) and computed tomography (CT). Furthermore, its injection performance using different needle sizes and its structural stability after fixation in formaldehyde were investigated. METHODS Liquid fiducial markers with a volume of 20-100 µl were injected into freshly resected pancreas specimens of three patients with suspected adenocarcinoma. X‑ray guided injection was performed using different needle sizes (18 G, 22 G, 25 G). The specimens were scanned on MRI and CT with clinical protocols. The markers were segmented on CT by signal thresholding. Marker detectability in MRI was assessed in the registered segmentations. Marker volume on CT was compared to the injected volume as a measure of backflow. RESULTS Markers with a volume ≥20 µl were detected as hyperintensity on X‑ray and CT. On T1- and T2-weighted 3T MRI, marker sizes ranging from 20-100 µl were visible as hypointensity. Since most markers were non-spherical, MRI detectability was poor and their differentiation from hypointensities caused by air cavities or surgical clips was only feasible with a reference CT. Marker backflow was only observed when using an 18-G needle. A volume decrease of 6.6 ± 13.0% was observed after 24 h in formaldehyde and, with the exception of one instance, no wash-out occurred. CONCLUSIONS The liquid fiducial marker injected in ex vivo pancreatic resection specimen was visible as hyperintensity on kV X‑ray and CT and as hypointensity on MRI. The marker's size was stable in formaldehyde. A marker volume of ≥50 µL is recommended in clinically used MRI sequences. In vivo injection is expected to improve the markers sphericity due to persisting metabolism and thereby enhance detectability on MRI.
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Affiliation(s)
- Sergej Schneider
- Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany. .,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstraße 74, PF 41, 01307, Dresden, Germany.
| | - Daniela E Aust
- Institute of Pathology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan Brückner
- Medical Department 1, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Hampe
- Medical Department 1, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Esther G C Troost
- Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstraße 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), partner site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden; and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Aswin L Hoffmann
- Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstraße 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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